The deadly UK midwifery Campaign for Normal Birth has been thoroughly discredited by harrowing reports of dozens of perinatal and maternal deaths, nearly £2 bn in liability payments, and the shocking admission that the UK is paying more to support the babies injured by maternity providers than to actually provide care. In response to the demise of the Campaign for Normal Birth, UK midwives are pressing a potentially deadly “Campaign for Normal Post-Birth.”

And just as the Campaign for Normal Birth was based on the self-serving lie that unmedicated vaginal birth is “best,” the new campaign is based on the self-serving lie that babies and mothers suffer irreparable harm if separated in the first few hours and days after birth.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]UK midwives are always promoting themselves while piously pretending that they have the best interests of babies and mothers at heart.[/pullquote]

Consider this presentation by Michele Upton discussing the ATAIN initiative (Avoiding Term Admissions Into Neonatal units) at a recent midwifery conference. The foundational lie is front and center:

There is overwhelming evidence that separation of mother and baby so soon after birth interrupts the normal bonding process, which can have a profound and lasting effect on maternal mental health, breastfeeding, long-term morbidity for mother and child.

That is a bald-faced lie though no doubt Upton believes it. There is precisely ZERO evidence for those claims. Everything we know about maternal-infant bonding tells us that it is spontaneous and is NOT contingent on specific behaviors. There is ZERO evidence that brief periods of separation have ANY effect on maternal mental health, breastfeeding or long term morbidity for mother and child.

In fact, there’s a mountain of data demonstrating the opposite. Multiple generations of infants were born while their mothers were fully anesthetized and spent most of their hospitalization in the newborn nursery. There is no evidence that had any impact on bonding, maternal mental health or long term morbidity for mother or child. But I guess if you have no regard for the truth, you might as well make your lie spectacular.

That’s what UK midwives did with their foundational lie for the Campaign for Normal Birth. As articulated by Midwifery Prof. Soo Downe:

Most women, in every country across the world, would prefer to give birth as physiologically as possible. For most women and babies, this is also the safest way to give birth, and to be born, wherever the birth setting. If routine interventions are eliminated for healthy women and babies, resources will be freed up for the extra staff, treatments and interventions that are needed when a laboring woman and her baby actually need help. This will ensure optimal outcomes for all women and babies, and sustainable maternity care provision overall.”

There is precisely ZERO evidence that “most women” would prefer to give birth without interventions. Indeed, when allowed access to pain relief in labor, more than 60% of women choose it. There is ZERO evidence that avoiding interventions is the safest way to give birth. Midwives were in charge of birth for most of human existence. They avoided interventions and perinatal and maternal mortality rates were astronomical. And if the evidence from the campaign itself shows anything, it shows that the Campaign for Normal Birth led to preventable deaths, coverups and massive liability payments.

What’s going on here? Why are midwives promoting programs that harm babies and mothers?

The key to understanding midwives behavior is this: they are always promoting themselves while piously pretending (even to themselves) that they have the best interests of babies and mothers at heart. They believe wholeheartedly, despite all the evidence to the contrary, that midwives are the key to optimal maternity care.

The real issue is midwives’ desperation to keep control over patient care. The Campaign for Normal Birth was based on the self-serving lie that keeping obstetricians away from women was “best.” The campaign for “normal” post-birth is based on the self-serving lie that keeping pediatricians away from babies is “best.”

Upton explains that although the birth rate in the UK decreased from 2011-2014, the admission of term newborns to neonatal units increased dramatically. She notes that hypoglycemia and jaundice (both preventable sequelae of aggressive breastfeeding promotion) are among the major reasons for admission. She fails to draw the obvious conclusion that relentless promotion of exclusive breastfeeding is harming babies.

Her discussion of hypoglycemia is particularly chilling.

Noting that 30% of babies admitted for hypoglycemia were admitted at less than 4 hours of age, of whom half were less than an hour of age, Upton concludes that these admissions could have been avoided by … NOT testing for low blood sugar! If you don’t take a temperature you can’t find a fever, right? It seems never to have occurred to her that midwives were testing these babies because they showed SIGNS of hypoglycemia like hypotonia, lethargy, poor feeding, jitteriness and seizures.

Upton reveals the real goal of promoting “normal” post-birth in this slide:

Unthinkable not to have service and staffing models which keep mothers and babies together.

Actually, what’s unthinkable is the self-serving notion that midwives can and should handle of aspect of care for every mother and baby regardless of who is injured or dies in the process.

Childbirth is inherently dangerous. There is no greater risk of death in the entire 18 years of childhood than on day of birth. Babies die from birth injuries and difficulties making the transition to life outside the uterus. Midwives couldn’t prevent those deaths during the milennia in which they maintained control of childbirth and there’s no evidence that they can prevent those deaths now. Only obstetricians and pediatricians can do that.

Keeping doctors away from babies as a matter of principle may be best for midwives but it is definitely not best for babies and mothers. Indeed, it is deadly!

I’ve written a great deal about midwives’ reflexive demonization of C-sections, but even I didn’t think they’d stoop to this.

Ginger Breedlove, CNM, former President of the American College of Nurse Midwives, and current Senior Vice President of Clinical Operations at Baby+Company, a birth center consortium, posted this tweet on Feb. 9.

We lost a highly admired Certified Nurse-Midwife to complications post c-section last night, never able to meet her first child. Explain how we are losing SO MANY WOMEN post C-Section in the 21st CENTURY! In 1978 when I worked L/D 9.6/100,000. Today 26.4!

Based on her tweet you might think that her midwifery colleague died as a direct result of an unnecessary C-section. But that’s not what happened.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]What could midwifery care have done to save the life of the midwife who recently died? Not a damn thing.[/pullquote]

According to a fundraising page set up by midwives who chose to help, not exploit the tragedy:

On February 9, 2018, a month before her due date, W. developed abdominal pain while working in the clinic. She was sent to the hospital for evaluation. Labs were normal, but the NST was ominous. She was rushed for cesarean section. The baby boy did well and was admitted to the NICU for observation … W. was awake in recovery room, and saw pictures of her baby boy. However, she unexpectedly suffered a sudden cardiac arrest in the recovery room and was unable to be revived. It is suspected she suffered from an amniotic fluid embolism.

From the description, it sounds as though W. may have suffered a concealed abruption, which seriously compromised her baby. If it were an abruption it could have killed her son and potentially killed her. This was a necessary — indeed a lifesaving — Cesarean.

Breedlove wants to know why we are losing “SO MANY WOMEN” post C-section in the 21st CENTURY.”

Curiously, Breedlove has already publicly acknowledged the reasons:

I believe the most profound reason – and the least talked about – is institutional racism and inequities in health care for marginalized populations, specifically African Americans. Most African Americans live down south, and that’s where the majority of maternal deaths are located. Access to care is limited. Government funding for agencies and facilities providing services to rural or uninsured populations has been on the decline for quite some time.

Other issues include increases in obesity, pre-existing hypertension, women who have chronic stress, and other variables that influence a woman’s health prior to and during pregnancy…

Notice that the C-section rate is NOT one of the reasons for the increased maternal mortality rate, no matter how much midwives try to imply that it is.

Breedlove deliberately left out the most important reason for maternal (and perinatal) mortality: physiological childbirth is inherently dangerous.

What about amniotic fluid embolism as a cause of death?

As the chart indicates, it is relatively unusual.

How about the overall trend for US maternal mortality?

As this graph from a recent Mother Jones article about maternal mortality demonstrates, it is indeed rising and that is a bad thing.

But how does it compare to the overall trend of maternal mortality in the past century?

See the tiny “x” to the right of the graph. That’s how today’s maternal mortality rate would appear if added to this graph. That puts it in perspective.

Breedlove, of course, seems to think that midwifery care is the answer to everything.

The next day, in response to news of a birth center opening in the UK, she tweeted this:

… @CallTheMidwife1 @BBC We need more Midwifery integration in US hospitals and all settings with seamless team based care to improve outcomes and #growmidwives @ACNMmidwives @neel_shah Why am I in ED right now with 11 week postpartum Mom and she has been dismissed for concerns expressed now for weeks?

How has midwifery care impacted the maternal death rate? As we can see from the Mother Jones graph, it hasn’t impacted it at all.

For most of human existence midwives were the exclusive providers of childbirth care and both maternal and perinatal death rates were astronomical. In the past 100 years midwives haven’t discovered anything or invented anything that served to decrease the mortality rate. The truth, a truth that midwives are loath to acknowledge even to themselves, is that physiological birth kills women and the interventions of modern obstetrics — especially C-sections — save tens of thousands of maternal lives in the US each year.

What could midwifery care have done to save the life of the midwife who recently died? Not a damn thing.

She was probably receiving midwifery care when she developed a serious complication that threatened her baby’s (and her) life. Her midwives handed her off to obstetricians because there wasn’t anything they could do about what was happening. How ugly then to blame obstetricians for being unable to do what midwives could never do, save her life.

Almost as ugly as exploiting her death to demonize C-sections.

Yesterday I wrote about the way in which bullying can masquerade as science. I used the example of the now discredited “science” of eugenics to draw parallels with the contemporary “science” of natural mothering.

Today I’d like to draw several more parallels between eugenics and contemporary breastfeeding research.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Both reflect moral panic.[/pullquote]

1. Both reflect moral panic.

A moral panic is a widespread fear, most often an irrational one, that someone or something is a threat to the values, safety, and interests of a community or society at large. Typically, a moral panic is perpetuated by news media, fueled by politicians, and often results in the passage of new laws or policies that target the source of the panic. In this way, moral panic can foster increased social control.

In eugenics, the moral panic was explicit and loudly discussed. It was the widespread fear on the part of white Anglo-Saxon Protestant elites that “inferior” immigrants (Catholics, Jews, Southern Europeans, Asians) as well as native born Black people might acquire positions of political and economic power thereby threatening the stranglehold held by elites.

The moral panic masqueraded as science. At the the Second International Congress of Eugenics, titled Eugenics, Genetics, and the Family in 1923, papers included Pedigrees of Pauper Stocks” in England, “Individual and Racial Inheritance of Musical Traits” or “Heritable Factors in Human Fitness and Their Social Control.”

The opening address was given by Henry F. Osborn, president of the vaunted American Museum of Natural History:

In the US we are slowly waking to the consciousness that education and environment do not fundamentally alter racial values. We are engaged in a serious struggle to maintain our historic republican institutions through barring the entrance of those unfit to share in the duties and responsibilities of our well-founded government…

In breastfeeding the source of the moral panic is carefully not discussed. La Leche League International — the original lactivist organization and impetus behind nearly every current iteration of lactivism as well as the driving force behind the recommendations of the World Health Organization and the CDC — was started by those who feared the erosion of traditional “family values” that immured women in the home, relegating them to childrearing. At nearly the same time as feminist Betty Friedan was articulating “the problem that has no name,” the widespread unhappiness of American mothers, La Leche League was insisting it wasn’t a problem but a privilege and a moral imperative.

Friedan wrote:

The problem lay buried, unspoken, for many years in the minds of American women. It was a strange stirring, a sense of dissatisfaction, a yearning that women suffered in the middle of the twentieth century in the United States. Each suburban wife struggled with it alone. As she made the beds, shopped for groceries, matched slipcover material, ate peanut butter sandwiches with her children, chauffeured Cub Scouts and Brownies, lay beside her husband at night—she was afraid to ask even of herself the silent question—“Is this all?”

… Over and over women heard in voices of tradition … that they could desire no greater destiny than to glory in their own femininity.

La Leche League was begun explicitly as a voice of tradition, in a deliberate effort to keep mothers of young children out of the workforce, telling them that they could desire no greater destiny than to glory in breastfeeding their children.

Alas for LLL, they were not able to stop the tide of women’s emancipation. Indeed they were forced to acknowledge women’s participation in the wider world and bury the story of their origins. They settled for the next best thing: pressuring women to breastfeed and making them feel bad if they didn’t. Their moral panic over the dreadful consequences of women working was transmuted to a moral panic over the purportedly dreadful consequences not breastfeeding.

2. Both rest on a bedrock, unalterable, non-falsifiable central principle.

Eugenics rested on the bedrock assumption that white Anglo-Saxon Protestant elites represent the apogee of human evolution. The history of the world was taken as “proof” of that concept. If WASP elites held the levers of power around the world it must because of their inherent superiority. Evidence was then compiled to bolster such “proof.” To my knowledge, across the breadth of eugenics “research” there was never a paper or study that showed that supposedly “inferior” races were actually equal or superior. It is precisely the non-falsifiability of its central principle that proves that eugenics was never science.

Lactivism rests on the bedrock assumption that breastfeeding represents the apogee of human evolution. The fact that “we are still here” is taken as “proof” of that concept. If breastfeeding is the way that women fed their babies since the beginning of humanity, it must be because of the inherent superiority of breastmilk and breastfeeding. Contemporary breastfeeding “research” involve compiling data to support the central premise and ignoring data that does not. To my knowledge, across the breadth of breastfeeding “research” there has never yet been a paper or study that showed that formula was superior, let alone equal to breastfeeding. It is precisely the non-falsifiability of its central principle that makes it clear that breastfeeding research is not science.

3. Both enlist the mainstream media and government in furtherance of their goals.

As a general rule, science has no goal beyond the increase in knowledge. In contrast, both eugenics and breastfeeding “science” have twin goals of alerting us to the “danger” we face and forcing the government to act to prevent it. Eugenics blared its warnings through journals, conferences and the mainstream media. Lactivists blare their warnings through journals, conferences and the mainstream media. Rarely a day passes without a story in the media claiming that breastfeeding increases intelligence, improves immunity, and prevents disease. Almost none of those stories have solid scientific evidence behind them and as time has gone by the claims have become ever more theoretical and attenuated.

There is no existing evidence that increasing breastfeeding rates improves mortality for term infants so breastfeeding researchers tout mathematical models that have never been verified. The claim that breastfeeding increases intelligence has been gutted by studies that correct for maternal education and socio-economic status, so now we are treated to studies that claim to show that breastfeeding increases scores on subtests or increases white matter volume in the brain, with the false implication that these are proxies for intelligence. There is no evidence that breastfeeding has a meaningful impact on diseases of children so the focus has turned to claiming that breastfeeding has an impact of disease of breastfeeding mothers.

The ultimate aim is to bring government in on the side of lactivists, and they have been quite successful so far. From mandated labeling of formula falsely proclaiming that breast is best for every baby and every mother, to government sponsored programs to increase breastfeeding rates, to official recommendations from government organizations, the breastfeeding industry has been successful in “making breastfeeding great again” with the promise that increased breastfeeding rates will improve health and save money.

4. Both always return to the naturalistic fallacy.

The naturalistic fallacy is often referred to as the “is/ought fallacy,” the belief that whatever is today is what ought to be always. Eugenicists justify their hold on political and economic power by insisting that the mere fact that they hold the power means that that is the best possible way for the world to be ordered. Lactivists justify their relentless promotion of breastfeeding, even in the face of mounting harm, by insisting that the mere fact that all women breastfed prior to the advent of formula means that breastfeeding must be better than formula.

The eugenicists were spectacularly wrong, but make no mistake, they believed their “science” with complete fervor. It did not occur to them that their views were self-dealing masquerading as science. I don’t doubt that breastfeeding researchers believe their “science” with equal fervor. It does not occur to them that their views are self-dealing masquerading as science. They could learn an important lesson from the disaster that was eugenics “research.”

Its leaders have always felt that they are using science to improve society. Nature is a brilliant arbiter in ordering the natural world and can rarely be improved upon. It should, however, be supported by policies that give deference to the natural.

Defenders claims that it’s not matter of ideology. Countless studies have shown the dangers, and many of the current ills of society almost certainly stem from interfering with nature’s plan, a plan crafted by hundreds of thousands of years of evolution. Why would we ignore the processes that nature has created? Why would we put ourselves at risk with beliefs that these choices don’t matter or, worse yet, that we should protect everyone’s feelings by pretending that all choices are equal?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural childbirth and lactivism are based on science in the same way that eugenics is based on science.[/pullquote]

In order to prevent a future that is even worse than the present, professional societies have been created, books and journals are published, courses are taught, conferences are held and policies are promulgated. Do these policies make some people uncomfortable? Yes, they do. Do they mean pain and suffering of some individuals? Yes, but the suffering is brief and the benefits are more than worth the effort. But above all else, it must be emphasized that this is what science tells us we should do.

Think I’m talking about natural mothering — natural childbirth, breastfeeding and attachment parenting? Think again.

I’m talking about the eugenics movement. The parallels of the natural mothering movement to the eugenics movement are striking.

• Both were undertaken by those whose traditional hold on power was being threatened.
• Both reinscribe (eugenics) traditionally held power or returned it (natural childbirth and lactivism) to its “rightful” holders.
• Both are appeals to nature and rely on the naturalistic fallacy.
• Both insist that evolution has created the best possible outcome.
• Both berate those who believe differently as inferior and defective.
• Both were or are embraced by academia.

Adam S. Cohen explains the prominent role of Harvard University in the eugenics movement:

In August 1912, Harvard president emeritus Charles William Eliot addressed the Harvard Club of San Francisco on a subject close to his heart: racial purity. It was being threatened, he declared, by immigration…

The former Harvard president was an outspoken supporter of another major eugenic cause of his time: forced sterilization of people declared to be “feebleminded,” physically disabled, “criminalistic,” or otherwise flawed…

He also lent his considerable prestige to the campaign to build a global eugenics movement…

None of these actions created problems for Eliot at Harvard, for a simple reason: they were well within the intellectual mainstream at the University. Harvard administrators, faculty members, and alumni were at the forefront of American eugenics—founding eugenics organizations, writing academic and popular eugenics articles, and lobbying government to enact eugenics laws.

Similarly, natural mothering advocates deeply believe that childbirth, breastfeeding and mothering itself are being threatened by lazy women and greedy doctors who would rather use technology than respect the natural order.

The case for eugenics, as its supporters understood it, was remarkably simple. Nature had created a world in which Anglo-Saxon Protestant white males had achieved dominance over other races. That must be what nature intended.

Frank W. Taussig, whose 1911 Principles of Economics was one of the most widely adopted economics textbooks of its time, called for sterilizing unworthy individuals, with a particular focus on the lower classes. “The human race could be immensely improved in quality, and its capacity for happy living immensely increased, if those of poor physical and mental endowment were prevented from multiplying,” he wrote. “Certain types of criminals and paupers breed only their kind, and society has a right and a duty to protect its members from the repeated burden of maintaining and guarding such parasites.”

The case for natural mothering is remarkably simple, too. Nature has created a world in which women suffer agony in childbirth, babies die of insufficient breastmilk, and women are denied access to the wider world by being relegated to childcare. That must be what nature intended.

Supporters of eugenics insisted it was based on science, but eugenics is merely bullying masquerading as science.  Most of the scientific evidence touted by its supporters was “discovered” by eugenicists themselves.

One of Harvard’s most prominent psychology professors was a eugenicist who pioneered the use of questionable intelligence testing. Robert M. Yerkes, A.B. 1898, Ph.D. ’02 … developed a now-infamous intelligence test that was administered to 1.75 million U.S. Army enlistees in 1917. The test purported to find that more than 47 percent of the white test-takers, and even more of the black ones, were feebleminded. Some of Yerkes’s questions were straightforward language and math problems, but others were more like tests of familiarity with the dominant culture: one asked, “Christy Mathewson is famous as a: writer, artist, baseball player, comedian.”

In other words, the studies were poorly done, deeply biased and designed to arrive at a pre-determined conclusion … just like most of the literature on natural childbirth and breastfeeding.

It’s pretty obvious to us that the supporters of eugenics were merely seeking to consolidate their hold on the levers of power and the perquisites of wealth, but it wasn’t obvious to many at the time. It ought to be obvious to us that the supporters of natural childbirth, lactivism and attachment parenting are seeking to bolster their power, employment opportunities and self esteem but, sadly, it still has the imprimatur of science.

Ultimately, most supporters of eugenics realized their spectacular error.

Today, the American eugenics movement is often thought of as an episode of national folly—like 1920s dance marathons or Prohibition—with little harm done …

The truth is that eugenics caused tremendous harm through forced sterilization of “mental defectives” and immigration quotas crafted to keep out “undesirables.”

A few years ago, correspondence was discovered from 1941 in which Otto Frank pleaded with the U.S. State Department for visas for himself, his wife, and his daughters Margot and Anne. It is understood today that Anne Frank died because the Nazis considered her a member of an inferior race, but few appreciate that her death was also due, in part, to the fact that many in the U.S. Congress felt the same way.

It’s hardly surprising that eugenics was harmful; it was bullying masquerading as science.

The harm caused by the natural mothering movement is less serious, but more pervasive. Women who choose epidurals or undergo C-sections have been convinced that they are “defective”; women who can’t breastfeed (or choose not to) are derided as lazy; and women who dare to imagine a life beyond childrearing are jeered as “unnatural.”

The next time someone tells you that natural childbirth, lactivism and attachment parenting are “based on science,” remember: people used to believe that eugenics was based on science, too.

Pardon my profanity, but what the fuck is wrong with people?

That was my thought when I read a paper published yesterday in JAMA Pediatrics. The paper is Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome; A Systematic Review and Meta-analysis by MacMillan et al.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It sounds like a particularly ghastly joke, but sadly it isn’t.[/pullquote]

In this systematic review and meta-analysis of 6 studies comprising 549 patients, rooming-in was associated with a reduction in the need for pharmacologic treatment and a shorter hospital stay when rooming-in was compared with standard neonatal intensive care unit admission for neonatal abstinence syndrome.

Wait, what? We can save money on the care of drug addicted newborns by forcing their mothers — mothers who may lose custody — to room in with them and take care of them? Do the authors of the paper, and the people who reviewed and published it have any idea just how screwed up that is?

Consider the problem:

Neonatal abstinence syndrome (NAS) is a collection of signs and symptoms of newborn opioid withdrawal after intrauterine exposure. Other descriptions of the syndrome include neonatal opioid withdrawal syndrome and neonatal withdrawal syndrome. Neonatal abstinence syndrome manifests 24 to 96 hours after delivery with increased muscle tone, tremors, sweating, vomiting, diarrhea, and other symptoms. Between 1999 and 2013, the incidence of NAS in the United States increased from 1.5 to 6.0 cases per 1000 births,3 with a mean cost in 2012 of $93 400 per newborn stay.

So let me see if I get this straight: Opioid addicted newborns cost a lot of money because they need specialized care for their suffering: increased muscle tone, tremors, sweating, vomiting and diarrhea. The incidence of newborn abstinence syndrome is rising because the incidence of maternal opioid addiction is rising.

There are lots of ways we could address this issue. We could provide greater oversight of the pharmaceutical industry to prevent opioid addiction; we could provide better care for those addicted to opioids; we could provide specialized treatment programs for pregnant opioid addicts. Those measures would work by decreasing the number of infants forced to endure opioid withdrawal after birth. Apparently that’s too hard. The “solution” the researchers offer is to force opioid addicted the mothers — the same people who made their children deathly ill because they couldn’t pry themselves from the grip of addiction — to provide the highly specialized care their babies need despite the fact that they themselves are still recovering from childbirth.

It sounds like an particularly ghastly joke, but it isn’t.

Opioid-exposed newborns are typically cared for in neonatal intensive care units (NICUs), and standardized scoring systems, such as the modified Finnegan system, are used to quantify NAS symptoms and to adjust medications used in treatment. Paradoxically, studies have found that opioid-exposed newborns in NICUs experience more severe withdrawal, longer length of stay (LOS), and increased pharmacotherapy compared with newborns who room in. In rooming-in care, infant and mother remain together 24 hours a day unless separation is indicated for medical reasons or safety concerns. More maternal time at the infant bedside improves NAS outcomes but is harder to accomplish in a typical NICU. Neonatal intensive care units may be poor settings for newborns with NAS because of increased sensitivity to high clinical activity levels…

The excessive sensory stimuli present in a busy NICU is especially jarring for newborns withdrawing from opioids? You don’t say! We could provide one-on-one care is a quieter setting off the main NICU but that would be even more expensive.

Hey, I know how we could provide one-on-one care in a quieter setting and save money, too. Just let their addicted mothers take care of them in the privacy of their own rooms while they are recovering the the exhaustion and agony of childbirth!

While rooming-in may be effective for NAS, potential risks include unintentional suffocation, falling from an adult bed, or undertreated NAS after hospital discharge.

No fooling!

What did the authors find in their literature review?

This systematic review and meta-analysis demonstrates that rooming-in is associated with decreased need for pharmacologic treatment of NAS and shorter LOS. The results of several included studies suggest that rooming-in is associated with reduced hospital costs, but the significant heterogeneity across studies precluded quantitative analysis. Because of variable reporting, we were unable to draw formal conclusions about the role of rooming-in on other secondary outcomes of interest. The findings of 2 studies suggested that breastfeeding increases with rooming-in. There was no evidence that rooming-in for NAS was associated with a significant increase in hospital readmission. Reporting of adverse events was insufficient to draw any conclusions about an association between rooming-in and these outcomes.

In other words, the studies showed a decreased use of pharmacologic treatement that the authors interpreted to mean a decreased need for treatment and a shorter length of stay. The authors couldn’t tell if any money was saved and the study was too small to draw conclusions about adverse events.

It seems never to have occurred to the authors that the Dickensian premise of the study — that opioid addicted mothers should be employed for free to care for their suffering opioid addicted newborns so we can save money on skilled caregivers — is absolutely grotesque.

What was the impact on the mothers themselves? Surely you jest. It never occurred to anyone to check because no one cares.

Whatever happened to basic human compassion? It’s apparently less important than the drive to save money.

Midwives are panicking over a new study.

According to the Society for Maternal Fetal Medicine, where the data was presented last week:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Interventions improve birth outcomes and letting nature take its course in pregnancy is far from the best decision.[/pullquote]

In a study with more than 6,100 pregnant women across the country, researchers randomly assigned half of the women to an expectant management group (waiting for labor to begin on its own and intervening only if problems occur) and the other half to a group that would undergo an elective induction (inducing labor without a medical reason) at 39 weeks of gestation. Results include:

• Lower rates of cesarean birth among the elective induction group (19%) as compared to the expectant management group (22%)
• Lower rates of preeclampsia and gestational hypertension in the elective induction group (9%) as compared to the expectant management group (14%)
• Lower rates of respiratory support among newborns in the induction group (3%) as compared to the expectant management group (4%)

“Safe reduction of the primary cesarean is an important strategy in improving birth outcomes,” said William Grobman, MD, MBA, who presented today’s findings and is professor in obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine. The research presented is part of, “A Randomized Trial of Induction Versus Expectant Management,” more commonly referred to as the ARRIVE Trial, which was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

You can read the brief presentation here:

…Women in the IOL [induction of labor] group delivered significantly earlier than those in the EM [expectant management] group (39.3 weeks (IQR 39.1 – 39.6) vs. 40.0 weeks (IQR 39.3 – 40.7), p<.001). The primary perinatal outcome occurred in 4.4% of the IOL group and 5.4% of the EM group (RR 0.81, 95% CI 0.64 – 1.01; p = .06). Need for neonatal respiratory support was significantly less frequent in the IOL group (Table). The frequency of CD was significantly lower in the IOL group (18.6% vs. 22.2%, RR 0.84, 95% CI 0.76 – 0.93), as was preeclampsia/gestational hypertension (Table). A priori baseline subgroup analyses showed no differences by race/ethnicity, maternal age > 34 years, BMI > 30 kg/m2, or modified Bishop score < 5 (all P-values for interaction > .05) for either the primary perinatal outcome or CD. IOL at 39 weeks in low-risk nulliparous women results in a lower frequency of CD without a statistically significant change in the frequency of a composite of adverse perinatal outcomes.

This is not surprising. It confirms a variety of studies that have been published in the last 6 years. The central reality of the timing of labor is this, which graphs the risk of stillbirth against the length of pregnancy.

Contrary to the claims of natural childbirth advocates that babies are “not library books due on a certain date,” there is an optimal time to be born and the death rate rises on both sides of that optimal time.

We’ve known that elective induction decreases perinatal mortality:

Stock, Sarah J., Evelyn Ferguson, Andrew Duffy, Ian Ford, James Chalmers, and Jane E. Norman. “Outcomes of elective induction of labour compared with expectant management: population based study.” BMJ 344 (2012): e2838.

Induction improves maternal and neonatal outcomes:

Gibson, Kelly S., Thaddeus P. Waters, and Jennifer L. Bailit. “Maternal and neonatal outcomes in electively induced low-risk term pregnancies.” American Journal of Obstetrics & Gynecology 211, no. 3 (2014): 249-e1.

Induction lowers the risk of C-section:

Mishanina, Ekaterina, Ewelina Rogozinska, Tej Thatthi, Rehan Uddin-Khan, Khalid S. Khan, and Catherine Meads. “Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis.” Canadian Medical Association Journal 186, no. 9 (2014): 665-673.

Obstetricians have been discussing the wisdom of recommending routine 39 week inductions for years. The issue was debated at the 2016 ACOG annual meeting, with Dr. Errol Norwitz recommending routine induction:

“Nature is a terrible obstetrician,” he said, referring to the “continuum” of pregnancy and birth: the large number of zygotes that never implant, the 75 percent lost before 20 weeks, and stillbirth.

And, he said, the risk of stillbirth and neurological injuries rises after 39 weeks. “Stillbirth is a hugely underappreciated problem,” he said. “There are anywhere between 25,000 to 30,000 stillbirths a year in the United States.”

And Dr. Grobman himself explored the issue in a 2016 commentary in The New England Journal of Medicine.

In this issue of the Journal, Walker et al. … report the results of a trial in which more than 600 women who were at least 35 years of age were randomly assigned to labor induction between 39 weeks 0 days and 39 weeks 6 days of gestation or to expectant management. This study was powered to detect at least a 36% relative difference between the two groups in the frequency of cesarean delivery. A total of 32% of the women assigned to the induction group, as compared with 33% of the women assigned to the expectant-management group, underwent a cesarean delivery (relative risk, 0.99; 95% confidence interval, 0.87 to 1.14). There were no significant differences between the groups in other adverse maternal or perinatal outcomes, but such outcomes were uncommon…

The authors note the need for “a larger trial to test the effects of induction on stillbirth and uncommon adverse neonatal outcomes.” I am the principal investigator of such a trial (ClinicalTrials.gov number, NCT01990612), which is currently under way …

It is this study that is being reported now.

Midwives are appalled and nurse midwives have rushed to reaffirm their support of “normal physiologic birth”:

ACNM President Lisa Kane Low, PhD, CNM, FACNM, FAAN cautioned against any rush to change practice … “ACNM has consistently noted there are a number of potentially negative implications when we disrupt the normal physiological processes of labor and birth,” Kane Low said. Research related to the longer-term effects of induction of labor is emerging, but is still insufficient to determine its full impact. Additionally, spontaneous labor offers substantial benefits to the mother and her infant, as ACNM has affirmed in its Consensus Statement on Physiological Birth.

She wrote on Facebook:

What’s missing is the focus on process …

Wait, what? Induction at 39 weeks improves multiple outcomes — lowers the C-section rate, lowers the rate of pre-eclampsia, lowers the need for newborn respiratory support — and Kane Low thinks we should focus on process instead of outcomes? Really?

I’m not surprised midwives are panicking about this study. It undermines the entire raison d’etre of contemporary midwifery theory, the belief that birth in nature is better than birth with interventions. This study shows in the clearest way possible that interventions improve birth outcomes and letting nature take its course in pregnancy is far from the best decision.

Of course, everyone except contemporary midwives have known that since the beginning of recorded history. Midwives were in charge of childbirth for more than 1,000 generations and the perinatal and maternal mortality rates were hideous throughout. It took modern obstetrics only 3 generations to drop the neonatal mortality rate by 90% and the maternal mortality rate by more than 90%.

Midwives did a terrible job when childbirth was midwife-led and childbirth is just as dangerous as it has ever been. Indeed, in every time, place and culture, childbirth has been a leading cause of death of young women and THE leading cause of death in the 18 years of childhood. No matter. Contemporary midwives believe that increasing their market share and profits depends of pretending that childbirth is safe and that obstetricians (the folks who reduced neonatal and maternal mortality by 90%) are the ones who made it dangerous. Many of them even believe it.

Midwives have proceeded to whip up a moral panic over the issue of C-sections and interventions. As I noted last week:

A moral panic is a widespread fear, most often an irrational one, that someone or something is a threat to the values, safety, and interests of a community or society at large…

This moral panic serves to reinforce and strengthen the social authority of midwives. They fear they are losing control of childbirth and they are desperate to gain it back.

It is too soon to change clinical practice based on these findings; we haven’t yet seem the complete paper. Moreover, extraordinary claims require extraordinary evidence.

I suspect that evidence will be forth coming. It makes sense considering what we know about pregnancy and about C-sections. The most common indications for a first C-section are a baby too big to fit or possible fetal distress. Babies are smaller at 39 weeks than anytime thereafter (they gain approximately a half pound a week at this stage) and the placenta is usually in optimal condition. It’s hardly surprising that babies are more likely to fit and less likely to experience fetal distress.

Given the amount of evidence that already exists, we should share this information with pregnant women so they can decide for themselves if they wish to be induced at 39 weeks. Medical ethics demands that we share what we know with our patients, not withhold the information in order to pressure women into a decision the provider might prefer. That goes for midwives as well as obstetricians.

I predict that going forward we will hear a lot from midwives about “nuance” and putting the findings “in perspective.” They are going to do everything they can to ignore the scientific evidence for as long as they can. Their profits depend on it, but more importantly, their fundamental beliefs depend on it and most people don’t give those up without a tremendous fight.

In a brilliant deduction, lactivist Prof. Amy Brown has come to the amazing conclusion that women who are bullied by lactivists are harmed by the bullying.

There’s a simple solution to the problem: lactivists could stop using lies about breastfeeding — specifically the claim that insufficient breastmilk is rare and the massively exaggerated claims of benefits — to bully new mothers.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is the breastfeeding industry that is bullying women and the breastfeeding industry that must stop.[/pullquote]

Nah. That might require someone like Brown to take responsibility for her own bullying and she enjoys it too much to much to stop. Instead she has euphemized bullying, turning it into “breastfeeding trauma.” And I’ll give you three guesses what she thinks is the cure.

Good for you, you got it on one: that’s right, more breastfeeding support from breastfeeding professionals.

Brown is now traveling the world with a new lecture series. The title betrays her bias at the outset: “Breastfeeding Trauma? How can we recognize and support women who were unable to meet their goals?”

The real question is: how can we stop lactivists from bullying new mothers? But that would require taking responsibility for bullying tactics. Brown would prefer to dump responsibility on new mothers for feeling bad about inability to meet “their breastfeeding goals,” when it is the breastfeeding industry that has created and relentlessly promoted those goals.

Brown displays her dogmatism at the outset:

The goal is not the preservation of infant health, nor the preservation of women’s mental health. The goal is always and only to promote breastfeeding.

Brown’s research is spot on when it comes to identifying the feelings of women who could not meet relentless lactivist pressure to breastfeed:

Who’s to blame for these feelings of guilt, failure and shame? Everybody in the universe except the lactivists that applied the outsize pressure in the first place, grossly exaggerating the benefits, and lying about the the nearly 15% incidence of insufficient breastmilk among first time mothers.

It’s the patriarchy!

It’s capitalism!

It’s society!

It’s the formula industry!

But those can’t be the causes because breastfeeding “trauma” is new and the patriarchy, capitalism, society and the formula industry have been around for hundreds of years.

What has changed? The emergence of a profession that monetizes breastfeeding and applies tremendous pressure to breastfeed while simultaneously lying about the failure rate and exaggerating the benefits. It is the breastfeeding industry that is bullying women and the breastfeeding industry that must stop.

In my view, this is the most important slide in Brown’s deck:

It is meant to illustrate the failure of British women to meet breastfeeding goals, but it inadvertently shows something else: that lactivists exaggerate the benefits of breastfeeding to bully women.

Ghana is the country with the best breastfeeding record. In 2015 the infant mortality rate of those breastfed babies was 43.1/1000. The UK is the country with the worst breastfeeding rate. The infant mortality rate of those formula fed babies was 3.6/1000. The country with the best breastfeeding rate had an infant mortality rate 1000% HIGHER than the country with the worst breastfeeding rate. In other words, breastfeeding has virtually nothing to do with infant health.

If Amy Brown really wanted to reduce breastfeeding trauma, she would share that information with new mothers, but that will never happen. The truth is that in industrialized countries it doesn’t really matter to your baby whether or not you breastfeed; it only matters to the breastfeeding industry.

O tempora, O mores!

Oh, the times! Oh, the customs!

Cicero famously wrote these words more than 2000 years ago to deplore the breakdown of traditional values. He was referring to the political corruption of his day, but it has been used repeatedly since then to deplore any departure from the supposedly “good old days.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The discourse of natural mothering reflects moral panic at the possibility that women could control their own destinies.[/pullquote]

It could serve equally well as the motto of the present day natural parenting movement that is forever bemoaning the loss of traditional mothering values. Those are the values that characterized the “good old days” when women were immured in the home, restricted to reproduction and child rearing, unable to use their intellects and talents, and forcibly deprived of political and economic power.

I would argue that contemporary discussions of mothering is a moral panic. It is the emodiment of horror at the possibility that women can control their own destinies.

What is a moral panic?

A moral panic is a widespread fear, most often an irrational one, that someone or something is a threat to the values, safety, and interests of a community or society at large. Typically, a moral panic is perpetuated by news media, fueled by politicians, and often results in the passage of new laws or policies that target the source of the panic. In this way, moral panic can foster increased social control.

Moral panics are often centered on people who are marginalized in society due to their race or ethnicity, class, sexuality, nationality, or religion. As such, a moral panic often draws on known stereotypes and reinforces them…

Women were at the center of the most famous moral panic in American history, the Salem Witch Trials.

Accusations of witchcraft were directed first at women who were social outcasts of the society after a couple of local girls were afflicted with unexplained fits. After the initial arrests, accusations spread to other women in the community who expressed doubt about the accusations or who behaved in ways that did not seem supportive of guilt.

This particular moral panic served to reinforce and strengthen the social authority of local religious leaders, since witchcraft was perceived as a violation of and threat to Christian values, laws, and order.

A moral panic involves a target group that is vilified for ignoring social norms, authority figures that are threatened by the deviation and attempt to reassert control, a compliant media that amplifies the concerns of the threatened authority figures, and a political system willing to encode the authority figures’ wishes in policy positions and laws.

In the case of natural mothering, the target group is women who dare to pursue a life beyond exclusive child rearing, and the authority figures are both general and particular. The general authority figures are the keepers of “traditional” values such as religious figures and the particular authority figures are those who used to control social norms around childbirth, breastfeeding and parenting. Both can only regain their authority by browbeating women back into the home, reduced to obsessing the minutia of childbearing and rearing, instead of engaging with the wider world.

It is not an accident that the philosophies of natural childbirth and lactivism were created in response to religious concerns.

The philosophy of natural childbirth arose from the moral panic instigated by Grantly Dick-Read and his peers, who feared “race suicide” as Christian, white people of the “better” classes were engulfed in a tide of black and brown people who reproduced at a faster rate. He believed that the key to preserving the white race was to convince white women to have more children. They weren’t cooperating because they feared the pain of childbirth so he told them the pain was all in their heads; they weren’t cooperating because they thought there was more to life than childbearing and rearing so they needed to be re-educated.

He famously wrote:

The mother is the factory, and by education and care she can be made more efficient in the art of motherhood.

And, in case you didn’t get the point:

Woman fails when she ceases to desire the children for which she was primarily made. Her true emancipation lies in freedom to fulfil her biological purposes.

The language has changed, but the moral panic behind natural childbirth advocacy has not.

According to this position statement in the Journal of Perinatal Education, a Lamaze publication:

… The use of obstetric interventions in labor and birth has become the norm in the United States. More than half of all pregnant women receive synthetic oxytocin to induce or augment labor, which demands additional interventions to monitor, prevent, or treat side effects. Nationally, one third of women deliver their babies via cesarean, a major abdominal surgery with potential for serious short- and long-term health consequences. For the mothers these consequences include, but are not limited to, postoperative infections, chronic pain, future cesarean births, and placental complications that can lead to hemorrhage, hysterectomy, and rarely, death. Infant risks include respiratory distress, and in subsequent pregnancies maternal risks include increased likelihood of preterm birth and associated morbidity and mortality.

O tempora, O mores!

Never mind that these interventions save the lives of thousands of mothers and tens of thousands of babies each year in the US alone. The interventions threaten the authority of midwives (who can’t perform many of them) and they sever the link between childbearing and the excruciating pain that is deemed to be women’s punishment. When midwives insist that we must “preserve” physiologic birth they mean we must preserve their traditional authority.

Midwives and natural childbirth professionals like doulas and childbirth educators subvert science to reinforce the sense of moral panic, insisting that physiologic birth is better, healthier and safer when it is none of those things. There is no limit to what they will say to demonize C-sections and epidurals so they can maintain their power and authority over birth.

Similarly, the founders of La Leche League were religious fundamentalists who were in a moral panic about mothers of small children returning to the workforce. In the book La Leche League: At the Crossroads of Medicine, Feminism, and Religion, Jule DeJager Ward explains that the La Leche League was founded in 1956:

… by a group of Catholic mothers who sought to mediate in a comprehensive way between the family and the world of modern technological medicine. . . . [A] central characteristic of La Leche League’s ideology is that it was born of Catholic moral discourse on family life. . . . The League has very strong convictions about the needs of families. The League’s presentations and literature carry a strong suggestion that breast feeding is obligatory. Their message is simple: Nature intended mothers to nurse their babies; therefore, mothers ought to nurse.

La Leche League reflected traditional Catholic family values about the subservient role of women and their relegation to the home.

While the language of lactivism has changed, the moral panic has not.

Consider these tenets of contemporary LLL philosophy:

Mothering through breastfeeding is the most natural and effective way of understanding and satisfying the needs of the baby.

Mother and baby need to be together early and often to establish a satisfying relationship and an adequate milk supply.

In the early years the baby has an intense need to be with his mother which is as basic as his need for food…

The message is hardly subtle: the woman who leaves her baby to work is an inferior mother.

Lactivists have recruited the media to their moral panic:

No country in the world supports breastfeeding moms like they should, according to a new report released Tuesday by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF).

WHO and UNICEF recommend mothers breastfeed infants within the first hour of birth, exclusively for six months and continue breastfeeding, while adding complementary foods, until the child is at least 2-years-old. Breastfeeding has a host of health benefits, most notably improving a baby’s immunity…

By comparing breastfeeding rates around the world, the groups found rates nowhere near 100% in its Global Breastfeeding Scorecard, released at the start of World Breastfeeding Week.

O tempora, O mores!

Why do women “fail” to meet the WHO guidelines?

The “key reason” is the need to return to work away from their babies, the report says.

There it is again, the demonization of mothers who work outside the home.

Just give the lactivists more money and authority and they will put women back into their place:

The groups are asking for lower and middle-income countries to invest $4.70 per newborn ($5.7 billion) in initiatives, such as access to breastfeeding counseling and improving breastfeeding practices in hospitals, to increase the global rate of 6-month exclusive breastfeeding to 50% by 2025.

Of course the $5.7 billion could be used to extend maternity leave, but that wouldn’t shore up the power and authority of the breastfeeding industry.

The moral panic around contemporary childbirth and breastfeeding practices are no that different from the Salem Witch Trials. The driving force behind both is desperation to return to a subservient role for women and to bolster the authority of the avatars of traditional mothering values.

And that puts me in mind of a another foreign language phrase: plus ça change, plus c’est la même chose.

The more things change, the more they stay the same.

What if we created a special geographic area, a new state, for those who don’t want to vaccinate? We could carve out a piece of an existing state with low population like Wyoming or Idaho and call it Quackistan!

I can see the real estate brochures now:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]What happens in Quackistan stays in Quackistan.[/pullquote]

Come live in an unspoiled wilderness — with soaring mountains, pristine lakes and abundant wildlife — together with those who share your philosophy that natural is best! Never again worry about government intrusion into healthcare decisions. There are no vaccinations in Quackistan, no “allopathic” doctors; you can have a homebirth (it’s actually your only choice), breastfeed freely anywhere and everywhere and homeschool every child who survives. Reject technology for an all natural lifestyle!

Best of all, the cost of living is in Quackistan is extremely low. Home prices start at only $10,000 for a family of 6. How can they keep prices so affordable? It’s easy: there’s no central heating (build a fire in your hearth), no running water (fetch it from the pristine lakes), no toilets (outhouse in the back yard) and a single bedroom for your family bed.

There’s no need to buy costly health insurance because there are no hospitals in Quackistan; our ancestors lived for tens of thousands of years and we are still here! Obviously hospitals are unnecessary. There are also no pharmaceuticals; you can grow your own healing herbs. Best of all, detoxing is free. Just drink the water from the pristine lakes and streams and the vomiting and diarrhea from giardia will clean you out in no time.

Quackistan is so healthy because toxins and GMOs are banned from supermarkets. In fact, supermarkets themselves are banned. Grow your own food or shoot it on the hoof! It’s up to you; you — not the government — are the boss in Quackistan.

Of course, whatever happens in Quackistan — whether it’s diphtheria, hemorrhage in childbirth or a stroke from untreated high blood pressure — stays in Quackistan. The surrounding states are refusing to treat the residents of Quackistan because they have no health insurance, but we don’t need to worry since everyone is going to be healthy all the time just like our Paleolithic ancestors. And if they’re not, remember that only the fittest survive!

The folks in Quackistan will elect their own officials, but it seems to me that Gwyneth Paltrow would make a great choice for governor. Joe Mercola would be an excellent director of Health and Human Services, Aviva Romm could be in charge of Maternal and Child Health and Kelly Brogan could run all the mental health facilities. They’re quacks already! Obviously they would have to repudiate their medical degrees and licenses first but I for one can’t wait to see how they keep the state’s inhabitants healthy with their positive thinking and rejection of conventional medicine. There will be no more cancer or heart disease, no newborn or maternal deaths, and no mental illness, either!

The greatest innovation of course will be the complete absence of vaccines. What about whooping cough, measles and tetanus? There won’t be any because everyone knows they were all disappearing long before the advent of vaccines. When was the last time anyone saw a case of tetanus in the general population? It has become so rare in modern times with great nutrition that there’s no need to worry about it.

So how about it folks? Who wants to live in Quackistan? Surely all the anti-vaxxers, homebirth advocates and GMO opponents will be rushing to move there, finally free to live their most cherished values.

Wait, what? No one wants to move there because they depend on the herd immunity of the people who do vaccinate? No one wants to move there because they rely on hospitals to rescue them from homebirths? No one wants to move there because they don’t want to live like our Paleolithic ancestors who died in droves and had an average life expectancy of 35 years?

I don’t believe it. They would never pass up the chance to inscribe their most cherished motto on the license plates of their bicycles and electric cars: Live Unvaxxed or Die!

We get it, men. You think C-sections are “bad” and you think it is your responsibility to protect us silly women from — heaven forefend — actually choosing to have one. That’s paternalistic enough, but you really cross a line when you start mansplainin’ urinary incontinence and sexual dysfunction to the women who endure them.

The recent outburst of mansplainin’ was precipitated by publication of the paper Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. Note that the paper is only concerned with long term risks and does not consider short term risks and benefits. The principal finding of the paper is that the long term risks of vaginal birth (pelvic organ prolapse and urinary incontinence) dwarf the potentially deadly long term risks of C-section. For example, the risk of pelvic organ prolapse is 10,000% (yes 10,000%) higher than the risk of placenta accreta in a subsequent pregnancy.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Can you imagine a male physician telling a man that incontinence and impotence are no big deal?[/pullquote]

In reviewing the paper, Swedish obstetrician and professor Stefan Hansson had the temerity to write, and The Conversation had the audacity to publish, this:

Women are well aware of the discomfort and embarrassment associated with urinary incontinence and have an understandable fear of sexual dysfunction. But despite the reported findings that suggest decreased risk with a caesarean delivery, these problems are manageable, treatable and, importantly, not life threatening.

Pardon my language but WTF??!!

Can you imagine a physician telling a man facing treatment for prostate cancer that incontinence and impotence are no big deal?

The reason it’s called incontinence is precisely because it ISN’T manageable. Urine spurts out when you cough or sneeze because childbirth has damaged the muscles of the pelvic floor, the muscles that hold the bladder and uterus in alignment to each other.

When these muscles are damaged, the pelvic organs can slip through the middle of the pelvic floor. This is known as prolapse. When a pelvic organ like the bladder prolapses, it distorts the relationship between the sphincter that controls release of urine from the bladder into the urethra. Although the sphincter itself has not been damaged, it nonetheless prevents the woman from “holding” urine. It works well enough that urine doesn’t constantly dribble out of the urethra, but when the intra-abdominal pressure is dramatically increased as occurs during coughing and sneezing, urine squirts out (stress urinary incontinence).

When the muscles of the pelvic floor are damaged, the uterus can prolapse into the vagina or even through it to protrude outside the vagina. That can make sexual intercourse difficult and painful

In both cases, the damage may not be immediately apparent. It may not appear until menopause when ligaments are weakened by the lack of estrogen and the pelvic organs begin to drop between the muscles. A woman who has had no problem for 20+ years after the births of her children may gradually develop uterine prolapse and/or incontinence as she enters menopause. And both will last for the rest of her life which is typically decades more.

What does Dr. Hansson mean when he says that urinary incontinence and uterine prolapse can be “managed”? He means they can be camouflaged by various measures including wearing bulky incontinence pads or putting a pessary (similar to a very large diaphragm) into the vagina to literally hold the uterus up though obviously that can’t be done during intercourse. He means that women can make it a point to immediately identify the location of the ladies room wherever they go and position themselves near it. He means that women can undergo painful surgery (generally including hysterectomy) to return the bladder to natural function.

Hansson continues:

There are, however, life-threatening risks associated with a caesarean delivery on subsequent pregnancies, including increased risk of miscarriage, stillbirth and problems with the placenta – such as placenta praevia (the placenta covering the birth canal), placenta accreta (when the placenta grows too deep into the wall of the uterus) and placental abruption (where the placenta partially or completely separates from the womb before the baby is born).

Yes, the consequences of a C-section for subsequent pregnancies can be life threatening, but women are entitled to know and entitled to base decisions on the fact that the risks of pelvic organ prolapse and incontinence dwarf the risk of deadly outcomes in subsequent pregnancies.

Hansson isn’t the only man to fail to mention the relative risk of pelvic organ prolapse to accreta in a subsequent pregnancy. Neel Shah, MD offered his thoughts in a long Twitter thread, including:

The most compelling long-term risks of cesareans have a common mechanism–uterine scarring–which can cause some uteri to rupture and others to hemorrhage uncontrollably in future pregnancies with deadly consequences.

And:

This worries me in the U.S. where … placental disorders caused by uterine scarring are “one of the most morbid obstetricians will encounter” and we are seeing “dramatically increased incidence”

But here’s the issue, Dr. Shah. I doesn’t really matter what you are worried about. Women are fully functional human beings perfectly capable of and completely entitled to weighing the risks and benefits for themselves … and choosing maternal request C-section if that’s what they prefer.

Perhaps most offensive example of mansplainin’ came when Dutch obstetrician Jos H.A. Vollenbergh reached out to me on Twitter to share his thoughts about my icon array illustrated above:

This sounds like a ‘Keep Your Love Tract Honeymoon Fresh – Have A Caesarean’ tract.
Not really my favourite…

Way to mansplain’ women’s sexual dysfunction to women, Dr. Vollenbergh! You should be ashamed of that remark and you should have apologized when I called you on it.

I have no particular love for maternal request C-sections. I never had one, wouldn’t want one and did virtually none when I was practicing. But it’s NOT my decision; the decision belongs to each woman choosing for herself.

Urinary incontinence and sexual dysfunction are life altering complications of vaginal birth. They are not easily manageable and for most women the only truly effective treatment is surgery. It is only right that the woman whose life will be altered gets to decide how.

And we definitely don’t need men deciding for us based on what they think is best.