Natural childbirth and confident idiots

Nerd laughing

The trouble with ignorance is that it feels so much like expertise.

So says psychology professor Dr. David Dunning. He ought to know.

In 1999, in the Journal of Personality and Social Psychology, my then graduate student Justin Kruger and I published a paper that documented how, in many areas of life, incompetent people do not recognize — scratch that, cannot recognize — just how incompetent they are, a phenomenon that has come to be known as the Dunning-Kruger effect. Logic itself almost demands this lack of self-insight: For poor performers to recognize their ineptitude would require them to possess the very expertise they lack. To know how skilled or unskilled you are at using the rules of grammar, for instance, you must have a good working knowledge of those rules, an impossibility among the incompetent…

Or, for instance, to know how knowledgeable or ignorant you are about childbirth, you have to have a good working knowledge of modern obstetrics including both normal and abnormal childbirth. Paradoxically:

What’s curious is that, in many cases, incompetence does not leave people disoriented, perplexed, or cautious. Instead, the incompetent are often blessed with an inappropriate confidence, buoyed by something that feels to them like knowledge.

When it comes to childbirth, we call these people midwives, doulas and childbirth educators. Not all, fortunately, have an inappropriate level of confidence in their own incompetence, but a significant proportion of midwives (including 100% of homebirth midwives) and an astoundingly large proportion of doulas and childbirth educators suffer from the of delusion believing themselves “knowledgeable” after having done “their research.” The world of celebrity natural childbirth and homebirth advocates is filled with what Dunning calls “confident idiots.” These include, but are in no way limited to, Ina May Gaskin, Ricki Lake, Barbara Harper of Waterbirth International, Jan Tritten of Midwifery Today, Jennifer Margulis, Jen Kamel of VBACFacts, Milli Hill of Positive Birth, and doula Teri Shilling, former president of Lamaze International, of My OB Said What??!!

How do people become confident idiots?

Very young children … carry misbeliefs that they will harbor, to some degree, for the rest of their lives. Their thinking, for example, is marked by a strong tendency to falsely ascribe intentions, functions, and purposes to organisms. In a child’s mind, the most important biological aspect of a living thing is the role it plays in the realm of all life. Asked why tigers exist, children will emphasize that they were “made for being in a zoo.” Asked why trees produce oxygen, children say they do so to allow animals to breathe… This purpose-driven misconception wreaks particular havoc on attempts to teach one of the most important concepts in modern science: evolutionary theory. Even laypeople who endorse the theory often believe a false version of it. They ascribe a level of agency and organization to evolution that is just not there…

Hence natural childbirth and natural parenting advocates claim that women are “perfectly evolved” for childbirth or that women who are breastfeeding “always” have enough breastmilk.

This idea of evolution misses the essential role played by individual differences and competition between members of a species in response to environmental pressures: Individual cheetahs who can run faster catch more prey, live longer, and reproduce more successfully; slower cheetahs lose out, and die out—leaving the species to drift toward becoming faster overall. Evolution is the result of random differences and natural selection, not agency or choice.

Similarly, childbirth and breastfeeding have always been, and are still governed by random differences and natural selection. Some pregnancies are too short and the baby dies; some pregnancies are too long and the baby dies. The idea that “the baby knows when to be born” is paradigmatic example of the purpose driven misbelief; it’s just as foolish as imagining that a cheetah knows that if it runs faster it will catch more prey. These purpose driven misbeliefs are behind many of the most egregious claims of natural childbirth advocates, from “breech is just a variation of normal” to “you can’t grow a baby too big to birth vaginally.”

The confident idiots of the natural childbirth world also suffer from motivated reasoning.

Some of our most stubborn misbeliefs arise not from primitive childlike intuitions or careless category errors, but from the very values and philosophies that define who we are as individuals. Each of us possesses certain foundational beliefs — narratives about the self, ideas about the social order—that essentially cannot be violated: To contradict them would call into question our very self-worth. As such, these views demand fealty from other opinions. And any information that we glean from the world is amended, distorted, diminished, or forgotten in order to make sure that these sacrosanct beliefs remain whole and unharmed.

The foundational belief of natural childbirth, lactivism and natural parenting is: “My birth, feeding and parenting choices make me a better mother than everyone else.” Many natural childbirth advocates literally cannot tolerate any evidence that threatens this foundational belief. Hence the epidemic of deleting and banning that afflicts natural childbirth websites and message boards.

How can we combat the epidemic of misbeliefs promoted by natural childbirth advocates? Dunning advocates a general strategy that can be applied to natural childbirth advocacy:

For individuals, the trick is to be your own devil’s advocate: to think through how your favored conclusions might be misguided; to ask yourself how you might be wrong, or how things might turn out differently from what you expect. It helps to try practicing what the psychologist Charles Lord calls “considering the opposite.” To do this, I often imagine myself in a future in which I have turned out to be wrong in a decision, and then consider what the likeliest path was that led to my failure. And lastly: Seek advice. Other people may have their own misbeliefs, but a discussion can often be sufficient to rid a serious person of his or her most egregious misconceptions.

Of course natural childbirth advocates have already cleverly “immunized” their followers against such a strategy. According to them, you should never ask yourself how you might be wrong because questioning birth inevitably leads to poor outcomes. “Trust birth!” sounds better than “Don’t think!” but it means exactly the same thing.

How can you protect yourself against the confident idiots in the world of natural childbirth?

1. The first step is to recognize that those who know the least often think they know the most. That’s why professional qualifications are so important. The people who know the most about childbirth are obstetricians. That doesn’t mean that they know everything, or that they are always right, but it does mean that they have a strong foundation from which to assess claims about childbirth.

2. Be wary of anyone who claims that formal education is unnecessary, or that obstetricians don’t follow the scientific evidence. Be wary of anyone who tells you what birth is like in the hospital when they have never worked in a hospital.

3. Be wary of anyone who makes claims about what is or is not normal in pregnancy without having extensive experience in caring for women who have pregnancy complications.

4. Don’t “trust” any natural process.

5. Ignore anyone who cannot tolerate dissent and deletes comments that call their claims into question.

6. Resist the temptation to succumb to flattery. Choices about birth and breastfeeding do not have much, if any, impact on whether children will become healthy, happy and competent adults. Anyone who tells you that the “right” choices make you a better mother is a confident idiot. Don’t let the desire to feel superior to other mothers make you a confident idiot, too.

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  • sdsures

    What you don’t know CAN kill you, eh?

  • Kris Hawkins

    It seems as though this site should be a closed forum for doctors and nurses to self congratulate one another while making fun of their patients and giving one another verbal hand jobs…. I wonder why people don’t trust you all? It is no wonder it takes years to find a good doctor. Look at how many of you are self congratulating assholes? What do you tell yourself when you screw up and someone dies or has severe complications?

    • Who?

      What they do:
      They tell themselves they may have made a mistake. Their bosses, employers and registration boards, not to mention insurers, go over the outcome and what led to it with a fine tooth comb. When an understanding of the full picture is reached, protocols, processes and systems are reviewed and revised if necessary. They respect the decisions of their employers, insurers and licensing boards.

      What they don’t do:
      They don’t tell themselves the patient wasn’t meant to live, or wasn’t meant to be well. They don’t refuse to participate in reviews. They don’t adamantly maintain that they are right and that everyone else is wrong. And if the death or injury is their fault, they are retrained, disciplined or lose their professional rights.

      Next question. Make it a harder one, will you?

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  • Sue

    I see much the same attitude in the anti-vaxers, homeopaths and those promoting populist diets (fructose-is-poison, seed oils are ”poison” etc).

    There is a certain hubris that combines lack of insight with scientific ignorance, and the assumption that, if they don’t know about something, it mustn’t exist.

    There is the typical “medicine doesn’t really know much about how the body works”, which may be true for consciousness or causes of certain rare diseases, but it isn’t true for how the kidney works, or how the uterus contracts.

    I’m looking forward to the end of this ”everyone’s opinion is valid” era, so we can go back to the appreciation of specialist expertise.

    (Another opportunity to refer to this lovely essay by academic philosopher Patrick Stokes:
    https://theconversation.com/no-youre-not-entitled-to-your-opinion-9978)

    • Who?

      I always smile at how an idea is dropped like a hot potato when a new idea comes along.

      And some of the thinking is really odd. I had someone tell me the other day how much they were enjoying their ‘sugar free’ jam. How, I asked, fearing the worst, could jam be sugar free? Surely jam is made of fruit, which has sugar in it? Remember, I nudged, when you weren’t eating fruit because of the sugar? Silly me, turned out it was sucrose free jam: that is, made without adding granulated sugar. Who knows they may well add coconut sugar, stevia, maple syrup or honey, all of which are Good because they are Not Sucrose.

    • sdsures

      “I’m looking forward to the end of this ”everyone’s opinion is valid” era, so we can go back to the appreciation of specialist expertise.”

      Me, too! But the thing is, not everyone’s opinion is valid, and it might take an earthquake or some other horrible disaster for people to realize this basic fact.

      http://theconversation.com/no-youre-not-entitled-to-your-opinion-9978

  • Just the other day I had yet another person tell me on my blog that I should ‘do my research’ for having the audacity to suggest that birth was risky and should be treated medically, with an abundance of caution.

  • araikwao

    I heart this post. The cognitive psychology aspect of the stories we read here always fascinates me – both the mothers and the birth attendants. FWIW, I had a little chat with a professor of psychiatry and psychotherapy about the way women think and feel about childbirth (particularly wrt a study, as yet unpublished, that showed within 6 weeks of birth, women’s feelings about the birth polarised, e.g. if they thought it was good immediately post, it was rated “very good” by 6 weeks post, etc).
    He offers this perspective: childbirth is a time where there is blurred boundaries between 3 generations – issues (whether positive or negative) from the woman’s relationship with her own mother, what she expects of the baby (e.g. it will look at me lovingly and be solving quadratic equations on arrival into the world), and all the hopes of how the mother is going to do things/make things better for this generation, not repeat their mistakes. When things don’t go as expected, it does often get channelled into “evil hospital/sue the obstetrician”, and probably explains rather neatly why women may seek out and totally romanticise “their homebirth”, because it’s another opportunity to make things “better” as per the above.
    Feel free to dismiss that all as psychobabble or whatever, I just found the perspective interesting, and wondered if you might too. Sorry if my recall is incomplete our inadequate

  • Felicitasz

    I stop after the third or so paragraph to note my aha!-experience: I have never thought about what is behind this phenomenon, and the post is a fascinating insight indeed. Thank you.

  • Guest

    “6. Resist the temptation to succumb to flattery. Choices about birth and breastfeeding do not have much, if any, impact on whether children will become healthy, happy and competent adults. Anyone who tells you that the “right” choices make you a better mother is a confident idiot. Don’t let the desire to feel superior to other mothers make you a confident idiot, too.”
    I love this piece. During the first year of my first child I thought I was doing better than other moms and felt superior to them (in other aspects than bf and nb) and yes I feel idiot when I remember!

  • Mishimoo

    They’re branching out into more high risk areas, unfortunately. One of my friends sent me the link for this: http://www.transbirth.com/ – most of the midwives are CPMs and DEMs, with a few CNMs. Yay! *sighs*

    • Dr Kitty

      I think it is wonderful that there are people actively trying to help Trans people access supportive, welcoming care.

      I do think they should also be trying to make sure it is good quality, safe and appropriate care- which means CPMs probably aren’t best placed to provide it.

      I would imagine there would be some trans men for whom the idea of an unmedicated labour and vaginal birth is about the furthest thing from empowering they can imagine, and who might actively seek elective CS.

      • Alcharisi

        Although things are slowly getting better, I’d say a lot of folks in the trans* community probably have really good reasons to be suspicious of the medical establishment. Now, this DOESN’T mean they should have substandard care–far from it! What it does mean is that substandard providers, well-meaning or otherwise, have a significant opportunity to exploit the trans* community’s having been ill-served, unfortunately.

      • Mishimoo

        That’s exactly my take on it too – I don’t want incompetent buffoons to capitalise on transpeople or non-binary people by putting them in danger after taking advantage of their past negative experiences with the medical system. It’s not fair to them and it’s not fair to their babies. I also don’t think that the “real” women stuff that quite frequently goes along with the NCB beliefs would be very healthy for people who experience gender dysphoria.

  • MJ

    I think this post highlights some of the things that lay people don’t realise is part of an academic scientific education, including the social sciences. We are taught – we are required – to provide objective evidence for our arguments, to anticipate and acknowledge limitations of our claims, and what’s more, to respectfully and objectively critique the existing evidence. That’s why I’m fairly nonplussed when someone flounces in with an ideology and a messiah-complex and courageously declares that ‘You’re all wrong about everything’. They don’t realise that we have probably examined that possibility more thoroughly and critically than they ever could, and we’re also not actually horrified by the notion of being wrong about some things. Because that’s the very proposition that science is based on.

  • The Bofa, Being of the Sofa

    2. Be wary of anyone who claims that formal education is unnecessary, or
    that obstetricians don’t follow the scientific evidence. Be wary of
    anyone who tells you what birth is like in the hospital when they have
    never worked in a hospital.

    What if they worked in the hospital … as a janitor?

    Wasn’t there a midwife who used to post here who claimed she had all this hospital experience and it turns out she had been a janitor?

    • Echidna Lactation Consultant

      Jan I. Tor, CPM

      • The Bofa, Being of the Sofa

        Yeah, that’s what I was thinking…

    • Bombshellrisa

      I know Patricia Couch CPM worked in L&D for years-part of the cleaning staff. She is in Oregon

  • Burgundy

    I have a story to tell.
    Last Saturday night, as I lay down with my 2-year old on my bed, I heard commotions from the next room. “On my god, my water broke!” one person cried. “It is ok, lie down on the bed and we will get the baby out”, said my daughter. “It hurts and the baby won’t come out!!”
    “Maybe change your position and do some cartwheel will help!” chimed the other person. “Drink some water!” “Take deep breath!” :”Walk around!”
    Finally, one person barked at the group, “Everyone get out, I will take care it”.
    After 10 seconds of silence, the boy cried loudly and proudly, “I GAVE BIRTH TO A HORSE!!”.
    It was my older daughter and her friends (age ranging from 7 to 10 years old) playing; yet, this scenario was very similar to many home-birth stories that I read on-line.
    Confident idiots are scary.

    • Samantha06

      If he had said, ” I gave birth to a unicorn”, he would have been right on the mark..

  • Bugsy

    “5. Ignore anyone who cannot tolerate dissent and deletes comments that call their claims into question.”

    This. x100. As soon as we told our NCB that we don’t let our vaccinated kid play with unvaccinated children (including her own preschooler), she cut us out of her life. Tolerance apparently doesn’t go far in a black-and-white world.

  • Amy M

    I would include in the NCB foundational belief that the birth, feeding and parenting choices not only “make me a better mother than everyone else” but also “make me who I am as a person.” A person is going to cling pretty hard to an idea if her entire self-worth is built on it.

    And, since the women who think like that tend to find each other and form groups, based on all thinking and behaving the same way, their social status is also dependent on maintaining those beliefs. That’s some pretty powerful motivation to act like you know what you are talking about.

    This explains the phenomenon of shunning anyone who has had a homebirth disaster, very neatly. The group can’t maintain that everything they believe and hold dear (about the safety of homebirth) is true, if they allow a member to stick around who has lost a baby because said baby was born at home. They can’t even be compassionate, because it would still force them to reexamine their beliefs. Easier to shun, and sweep under the rug, than lose one’s identity, social standing and possibly source of income.

    • Bugsy

      Well-said. My NCB friend was fond of saying that her likeminded mommy group “rejuvenated” her. And yet she was constantly judging anyone from the group who criticized her and/or didn’t fit their mold for perfect parenting. It didn’t seem very rejuvenating to me.

      • Dr Kitty

        Oh no, it does, if she literally meant that her group made her young again, and so she behaved like a middle school mean girl…

        • Bugsy

          Lol, that’s one way to look at it! 🙂

        • Amy M

          Do you think all the nasty gossiping gave her zits?

  • Samantha06

    I love this post! Spot on, Dr. Amy! I think it cuts right through the heart of the garbage NCBers promote.. a concise guide for women looking for answers.

    • Roadstergal

      I love it, too. It just gets right to the heart of so many things.

      One thing I have been working on – and I don’t claim to be good at it, it’s just a goal I have in mind – is to feel _good_ about finding out I’m wrong about something when presented with convincing evidence. In a ‘hey, I have learned something new by keeping an open mind!’ sense. It just reminds me that the best scientists I’ve ever worked with have been the ones who are ready to say “I don’t know” when they don’t know. I strive to emulate them.

      • Samantha06

        I hear you! It’s difficult for me sometimes too but with more hands-on stuff in the hospital. I’m not a “scientific” person, per say. I hated statistics and I don’t always understand studies and so forth. I have learned so much from the people on this blog who can interpret studies and so forth. It’s satisfying to see them shoot down the NCBers who try to fit the studies to coincide with their beliefs!

      • Montserrat Blanco

        The other thing that defines scientists is that we are happy to change our “beliefs”. I am more than happy to find out something has changed with a new scientific discovery. And I am more than happy to change my practice accordingly.

        • Who?

          And it is this that makes science so vulnerable to attack from the certainty crowd: whether they are claiming climate change is a fraud, that vaccines are useless or worse or that they were kidnapped and probed by little green men, they know it with absolute unwavering certainty, which is comforting to an element in the community.

          Scientists say they believe, they keep researching, on the whole they are not dogmatic about their beliefs, and they are ready to adjust when they learn more. All of which is alarming if you just want to ‘know’ and move on.

  • Young CC Prof

    Nobody’s posting here, they’re all busy with the proof-by-example GmaGardner on a post from last January.

    But I really think that’s a good point, about how the whole “trust birth” slogan can short-circuit a woman’s ability to see through the BS. Essentially, they’re telling people that questions are, in and of themselves, dangerous. Which is pretty freaking scary.

    • Amy Tuteur, MD

      Exactly!

    • moto_librarian

      She truly is Dunning-Kruger personified. I guess I shouldn’t be surprised that she is wiling to play fast and loose with her patients given that she admits to delivering her own premature baby (34 weeks) at home. But hey, the baby only needed bili therapy for jaundice, so we’re all good.

      • Roadstergal

        I’m still staggered by the layers of condescension and sexism and various other flavors of bullshit bundled in that ‘tight vagina’ comment.

        • moto_librarian

          She does not want to get into an argument with me about this topic.

          • The Bofa, Being of the Sofa

            Oh come on, moto, say it (just because it’s too funny not to): “She doesn’t want to get into an argument with [you] about tight vaginas.”

            I think it sounds better that way.

          • Wishful

            Can someone link to that post or at least give a title? I wanna read it…

          • anon13

            title is Homebirth Midwives reveal 450% higher death rate. If you look to the right at the “latest comments” you may be able to click on it.

      • fiftyfifty1

        “She truly is Dunning-Kruger personified”
        Or at least the Motivated Reasoning part. Because at this point she really is *rejecting* knowledge, not just being unaware of its existance. She knows childbirth is dangerous. She talks about one of her patients with severe fetal distress who had to be driven to the hospital by her husband while the mother had to stay on all fours while she (midwife) kept her hand inside her to push the baby’s head up off of the prolapsed cord. Mom luckily made it to the hospital in time to have an emergency CS. This sort of case is PROOF of the lifethreatening danger inherent in even the lowest risk birth. But she chooses to ignore it.

      • Samantha06

        And she had the gall to say she had 3 “zero-risk” home births including a 36 weeker! Good grief!

    • Samantha06

      Which is so insulting and demeaning to women. It assumes that women are delicate creatures who need to be “shielded” from the realities of childbirth and the grossly unethical promotion of their agenda because their income depends on it. Then they top off their humiliation by absolving themselves of all responsibility for a bad outcome by throwing up their hands and saying, “you knew the risks, you need to own your choices!”

    • Trixie

      Oh geez, is that still going? C’mon, grandma, time to get off the internet and get that garden ready for winter!

    • Dr Kitty

      I think we should stop replying to her there.
      If she wants to play she can do it on the front page, like a big girl.

      I for one am sick of trawling through old replies trying to find her most recent piece of idiocy.

      • The Bofa, Being of the Sofa

        It’s not so much that it is an old thread, but the fact that the comments are buried in the middle of everything