Defensive medicine works.

A recent study shows that obstetricians who have higher C-section rates are far less likely to be sued than those who have low C-section rates. Why?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is a potential solution but insurers won’t pay for it.[/pullquote]

There are two possible reasons: obstetricians who have higher C-section rates may have better outcomes and obstetricians who aggressively try to prevent bad outcomes are less likely to be sued when a bad outcome does occur.

This has important implications for those attempting to reduce the practice of defensive medicine.

According to Wikipedia:

Defensive medicine … refers to the practice of recommending a diagnostic test or treatment that is not necessarily the best option for the patient, but … to protect the physician against the patient as potential plaintiff …

There’s a lot of handwringing about defensive medicine among those who wish to reform healthcare. They aren’t so much scandalized by the possibility of patients receiving unneeded treatment (although they are concerned about it) as they are horrified by the increased cost of potentially unnecessary treatments. It is an article of faith among reformers that defensive medicine could be eliminated resulting in decreased spending and no impact on the quality of medical care. They may be wrong.

The paper is Physician spending and subsequent risk of malpractice claims: observational study published in the BMJ.

Across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. For example, among internists, the probability of experiencing an alleged malpractice incident in the following year ranged from 1.5% (95% confidence interval 1.2% to 1.7%) in the bottom spending fifth ($19 725 (£12 800; €17 400) per hospital admission) to 0.3% (0.2% to 0.5%) in the top fifth ($39 379 per hospital admission). In six of the specialties, a greater use of resources was associated with statistically significantly lower subsequent rates of alleged malpractice incidents…

The results were especially striking in obstetrics:

Increasing average risk adjusted caesarean rates for each obstetrician year was associated with decreases in the probability that an obstetrician experienced an alleged malpractice incident in the subsequent year. For example, the average adjusted caesarean rate for each obstetrician increased from 5.1% in the bottom fifth of obstetrician years to 31.6% in the top fifth, whereas the probability an obstetrician experienced an alleged malpractice incident in the subsequent year decreased from 5.7% (95% confidence interval 4.6% to 6.8%) in the bottom fifth of caesarean delivery rates to 2.7% (1.9% to 3.6%) in the top fifth. In within physician analyses, which relied on variation in risk adjusted caesarean rates within the same obstetrician over time, greater caesarean rates continued to be negatively correlated with the probability of facing an alleged malpractice incident in the subsequent year (increased risk adjusted caesarean rate from the bottom fifth to the top fifth was associated with a −1.5 percentage point (95% confidence interval to −3.6 to −0.6) change in malpractice claims in the subsequent year).

I created the following graph to illustrate the results.

Obstetricians know this and if affects the threshold for performing a C-section. Consider that the most dreaded possible outcome for any obstetrician is the preventable loss of a baby or mother. The second most dreaded outcome is a malpractice lawsuit. Is it any surprise then that obstetricians are willing to perform C-sections when there is any doubt about the baby’s wellbeing?

Doctors blame lawyers.

Law professor Sandra Johnson writing in Regulating Physician Behavior: Taking Doctors’ “Bad Law” Claims Seriously notes:

Doctors frequently claim that the very law intended to improve the lot of their patients is instead making the doctors provide poor care. These “bad law” claims are levied against malpractice litigation that makes doctors practice “defensive medicine”; … against antitrust laws that prevent doctors from organizing themselves in ways that would produce more cost-effective and accessible care; and against regulations that impede important medical research. These “bad law” claims assert that the law’s effort to promote patient health and well-being has actually caused significant harm.

Healthcare reformers blame doctors:

Medicine’s complaints … [have come] to be characterized as the work of a self serving guild, rather than a profession motivated by altruism and armed with expertise, or at least as the work of the recalcitrant “bad apples” who continued to resist improvements that the more enlightened among them embraced. These narratives marginalized physicians’ … claims and diminished them as a source of legitimate information about the effectiveness of reform efforts.

Rather than addressing the substance of doctors’ arguments, experts and lay people have denied that there the complaints are legitimate, ascribing them to greed and self interest. Yet in the case of medical liability, as in other areas of medical “reform,” doctors are often right.

We tell obstetricians “Make sure all babies are born perfect or we will try to destroy you professionally and economically in malpractice suits!” and then piously express shock and horror that obstetricians will perform C-sections in order to guarantee perfect babies.

There is a potential solution to this problem but insurers and reformers don’t want to pay for it:

It has been shown repeatedly that doctors who have good relationships with patients are less likely to get sued by those patients regardless of outcome. But creating a relationship with a patient — being available, listening to and thinking about patient concerns, answering any and all questions and making sure patients understand the answers — takes lots of time. Insurers won’t pay for physician time; they pay for physician procedures. Moreover, insurers and reformers are constantly pressuring doctors to be more “efficient,” in other words to spend less time with each patient.

And so we end up with a system where more C-sections = fewer law suits.

Defensive medicine works, but building patient relationships also works. Insurers will pay for defensive medicine but they won’t pay for building relationships between doctors and patients.

Who’s really at fault for the increase in defensive medicine?

A new paper in The Proceedings of the National Academy of Science is getting a lot of buzz.

According to the BBC, Caesarean births ‘affecting human evolution’:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is no cliff-edge in fitness. A mother who needs a C-section for a  7 pound baby could subsequently deliver an 8 pound baby vaginally.[/pullquote]

Researchers estimate cases where the baby cannot fit down the birth canal have increased from 30 in 1,000 in the 1960s to 36 in 1,000 births today.

Historically, these genes would not have been passed from mother to child as both would have died in labour.

Researchers in Austria say the trend is likely to continue, but not to the extent that non-surgical births will become obsolete.

In other words C-sections, by saving the lives of babies and mothers who would otherwise die and allowing for the persistence of genes for overly large fetal heads and overly small maternal pelves.

At first blush, the paper appears persuasive, but there’s a very serious problem here and I was not surprised to find that there were no obstetricians among the authors. That’s because the authors don’t seem to understand feto-pelvic disproportion:

The maternal pelvis is not a basketball hoop; the shape matters nearly as much as the size.

A very common cause of feto-pelvic disproportion is the position of the baby, not the size.

Both the baby’s size and the size of the mother’s pelvis are greatly affected by nutrition. Indeed, the apparent increase in feto-pelvic disproportion is far more likely to be due to improved nutrition than evolutionary pressure occurring over the minute time period of less than 100 years.

When you take these factors into account, the paper, Cliff-edge model of obstetric selection in humans by Mitterroecker et al. is not merely incorrect; it is foolish.

According to the authors:

The strikingly high incidence of obstructed labor due to the disproportion of fetal size and the mother’s pelvic dimensions has puzzled evolutionary scientists for decades. Here we propose that these high rates are a direct consequence of the distinct characteristics of human obstetric selection. Neonatal size relative to the birth-relevant maternal dimensions is highly variable and positively associated with reproductive success until it reaches a critical value, beyond which natural delivery becomes impossible. As a consequence, the symmetric phenotype distribution cannot match the highly asymmetric, cliff-edged fitness distribution well: The optimal phenotype distribution that maximizes population mean fitness entails a fraction of individuals falling beyond the “fitness edge” (i.e., those with fetopelvic disproportion). Using a simple mathematical model, we show that weak directional selection for a large neonate, a narrow pelvic canal, or both is sufficient to account for the considerable incidence of fetopelvic disproportion. Based on this model, we predict that the regular use of Caesarean sections throughout the last decades has led to an evolutionary increase of fetopelvic disproportion rates by 10 to 20%.

The authors reference “the obstetric dilemma,” the observation that there are two opposing evolutionary pressures on the relationship between the mother’s pelvis and the size of the baby’s head. In simple terms, a large head is an evolutionary advantage for a baby, but a large pelvis is an evolutionary disadvantage for the mother since it interferes with her ability to walk and run.

Not only are the needs of the mother and baby directly opposed at the time of birth, but the contribution of the father’s genes means that there is no coordination between the size of the mother’s pelvis and the size of the baby’s head, particularly if the father had a large head at birth.

The authors postulate an obstetric “fitness” function, D:

Successful labor requires the match of the neonatal head and shoulder dimensions with the dimensions of the maternal pelvic inlet, midplane, and outlet. Consider an idealized variable, D, that represents the difference between the size of the neonate and the size of the maternal pelvic canal. A negative value indicates a pelvic canal that can accommodate the newborn, whereas fetopelvic disproportion occurs if D > 0. In practice, this composite quantity cannot be inferred from the usual clinical measurements, but it is conceivable that D can be expressed as a function of a finite set of appropriate morphological measurements.

Using this idealized variable D, the authors created a mathematical model.

We present a mathematical model that explains the high rates of fetopelvic disproportion by the dis- crepancy between a wide symmetric phenotype distribution and an asymmetric, “cliff-edged” fitness function.

But there is no cliff-edge in fitness. There is are multiple factors that can be combined kaleidoscopically to lead to a variety of outcomes. To put it is real world terms: A mother who has feto-pelvic disproportion with an 7 pound baby and requires a C-section could subsequently deliver an 8 pound baby is a successful vaginal birth.

How can that be?

1. The maternal pelvis is not a hoop.

The pelvis is a bony passage with an inlet and an outlet having different dimensions and a multiple bony protuberances jutting out at various places and at multiple angles. The baby’s head does not pass through like a ball going through a hoop. The baby’s head must negotiate the bony tube that is the pelvis, twisting this way and that to make it through.

You can see what I mean in the illustration above (from Shoulder Dystocia Info.com). There are bony protuberances that jut into the pelvis from either side (the ischial spines) and the bottom of the sacrum and the coccyx, located in the back of the pelvis, jut forward. How does the baby negotiate these obstacles? During labor, the dimension of the baby’s head occupies the largest dimension of the mother’s pelvis. But because of the multiple obstacles, the largest part of the mother’s pelvis is different from top to middle to bottom. Therefore, the baby is forced to twist and turn its head in order to fit.

This illustration (from the textbook Human Labor & Birth) shows what happens. We are looking up from below and the fetal skull is passing through the mother’s pelvis. The lines on top of the skull demarcate the different bones of the fetal skull.

Clearly there is a great deal of potential for a mismatch between the size of the pelvis and the size of the baby’s head. Over time, babies have evolved so that the bones of the skull are not fused and can slide over each other, reducing the diameter of the head. This is called “molding” and accounts for the typical conehead of the newborn. But there is a limit to the amount of molding that the head can undergo and ultimately, the baby may not fit through.

2. One of the most common causes of feto-pelvic disproproportion is the position of the baby, not the size of its head.

The illustration above shows the baby’s head entering the pelvis in the optimal position, but babies don’t always cooperate. If the head is in anything other than the ideal position the fit will be even tighter. That’s why babies in the OP position (facing frontwards) and babies with asynclitic heads (the head titled to one side) are much more difficult to deliver vaginally. Their heads no longer in the smallest possible diameter. It’s like trying to put on a turtleneck face first  instead of starting from the back of your head. It’s much more difficult.

And it’s far more difficult (and sometimes impossible) to deliver a baby vaginally if it presents brow first or face first. Moreover, 3-4% of babies are breech, meaning bottom or feet are coming first. The head is less likely to fit if the feet come first.

3. Genes are not the only determinants of the size of the baby’s head and the size of the maternal pelvis. Nutrition plays a critical role.

It is well known that the average size of babies is getting bigger, just as the average size of adults is getting bigger, as a result of improved nutrition. For most of the past hundred thousand years or so, humans lived a substistence existence and stunting of growth was common at all ages. Now, very few people starve in industrialized countries. Indeed, people are far more likely to be obese that at any time in human history. Obese babies have trouble surviving birth not merely because their heads might be bigger, but also because their shoulders are bigger and can get stuck during the process of birth (shoulder dystocia), a potentially deadly complication.

In contrast, better nutrition (and pregnancy delayed far beyond the teenage years) means that women who give birth are likely to have a larger pelvis and one that is not constrained by nutritional deficiencies like rickets.

Given these factors, the authors’ conclusions are fanciful.

The authors give a nod to other factors:

The success of labor is … influenced … by numerous other factors, including flexibility of the pelvic ligaments, orientation of the neonate, and efficiency of uterine contractions. However, as long as these factors are statistically independent of the discrepancy between neonatal and maternal dimensions, the selection gradient and evolutionary trajectory of D can be modeled independently of other factors.

That’s yet another faulty assumption. These factors are intimately intertwined. For example, the orientation of the baby is dependent of the shape of the mother’s pelvis. And the strength of the uterine contractions may be dependent on the size of the baby; a distended uterus may be less likely to contract effectively.

That’s why a mother who has a C-section for feto-pelvic disproportion with a 7 lb baby might subsequently deliver an 8 pound baby vaginally. That would be impossible if the cliff-edge theory of fitness were true.

And that doesn’t even take into account that C-sections have only become routinely survivable in the past 80 years or so, not even a blink in the eye of evolution and far too short a period of time for evolutionary pressures to have produced changes like those proposed.

Are C-sections changing the maternal pelvis? Maybe, but this paper doesn’t show it.

Indeed it doesn’t show anything at all.

I’ve written before that the philosophy of natural childbirth is the philosophy of a cult.

Like most cults, has its own mythology, in this case a mythology that is both racist and sexist. The cult was started by Grantly Dick-Read, author of Childbirth Without Fear, and a eugenicist who was preoccupied with visions of “race suicide” as non-white people became an ever larger part of the population of first world countries. Dick-Read thought that white women of the “civilized” races were being diverted by the quest for economic and political equality, when they really should be home spitting out babies. He believed that it was fear of the excruciating pain of labor that discourage these women from having more children. He fabricated out of whole cloth the bizarre notion that “primitive” (read: black) women gave birth without pain because they didn’t fear childbirth and understood that their primary role was to reproduce.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The vicious response to those who question the principle of natural childbirth advocacy.[/pullquote]

To this day, natural childbirth advocates fantasize that they are emulating exotic brown foreigners and becoming better at birth than they are themselves. There is no historical basis to the claim that unmedicated vaginal birth is safest, and no scientific basis for the claim that it is superior in any way to childbirth with pain relief. No matter; cult membership requires belief regardless of inconvenient facts.

The fundamental principles of natural childbirth advocacy are cultural constructs:

• Birth is depicted as inherently safe though it is actually inherently dangerous.
• Birth is depicted as an individual achievement thought it is purely a matter of luck.
• While historically a bad birth experience involved a dead baby, dead mother or both, a bad birth experience is now depicted as one in which a mother’s birth plan was not fulfilled in all details.

In other words, natural childbirth is a cult. As defined by Google, a cult is:

a system of religious veneration and devotion directed toward a particular figure or object.

In the case of natural childbirth, the object of the cult is unmedicated childbirth without interventions. Unmedicated vaginal birth is understood by cult members to be venerated with trust, worshipped with affirmations, and often viewed as more important that the ostensible purpose of childbirth, a live, healthy baby.

And, like all cults, it reacts viciously to criticism.

How else to explain the nauseating, gut churning cruelty of natural childbirth advocates toward James Titcombe?

James and his wife Hoa lost their newborn son Joshua to midwifery negligence followed by a brazen attempt at cover up. Throughout his multi-year quest to learn the truth about Joshua’s death and hold the midwives accountable for it, James was subjected to vicious attacks by the natural childbirth community.

His sin? He dared question the cult of natural childbirth.

You might think his status as the father of a dead baby would protect him; you would be wrong.

Despite the fact that James was fully vindicated and received a royal honor from Queen Elizabeth for his relentless quest on behalf of victims of midwifery negligence, any time he questions the fundamental principles of the natural childbirth cult, he is subjected to viciousness from natural childbirth advocates.

The latest example occurred over the past few days. Apparently James dared to question the notion that vaginal birth is empowering.

Professional homebirth advocate and author Milli Hill responded by accusing him of being an enemy of women and their choices:

What had James done to arouse Hill’s wrath?

He had dared question the notion that vaginal birth is inherently empowering when he pointed out, commenting about a VBAC birth story, that babies die when their mothers ignore medical advice for C-section in pursuit of a vaginal birth.

The mother who wrote the story, Michelle Quashie, did feel empowered by her vaginal birth and she’s entitled to feel whatever she wants. But, there is every reason to question a cult of birth that privileges process over outcome and leads to preventable deaths of babies as a result.

For that matter, a woman who fits into a size 2 dress is entitled to feel proud that she can do so. That doesn’t change the fact that there is every reason to question the cultural constructs that women should be judged by their weight, that thinness is superior, and that leads to women starving themselves literally to death to meet these cultural “achievements” set by the fashion and entertainment industries.

My invocation of empowerment through weight loss is deliberate. For many years, the fashion and entertainment industries turned a blind eye to the harm they did to women by setting arbitrary standards of beauty through thinness. Ultimately, though, they began to understand that the drive to achieve thinness could lead vulnerable young women to death through anorexia. There is a growing effort to temper the cultural message that thin is superior, and emphasize instead that different weights are healthy for different women.

But cults like natural childbirth cannot even tolerate questioning, let alone criticism.

Imagine if a father who lost his daughter to anorexia was subjected to taunting by the fashion industry that his efforts to prevent future tragedies were efforts to efforts to harm women.

Heartless, vicious and ugly are just a few word that come to mind to describe such behavior.

The same words — heartless, vicious and ugly — describe Milli Hill’s taunting of James Titcombe.

Women are entitled to their feelings, but the rest of us are entitled to question the cultural constructs on which those feelings are based. And no one is more entitled to question those cultural constructs than those who have lost precious children as a result.

Grow up and grow a heart, Milli Hill, and stop taunting James Titcombe.

If you want to argue about the principles of natural childbirth advocacy, feel free to argue with me — but apparently you don’t get as much joy out of intellectual debate as you do from heartless cruelty.

This came from the VBAC group set up in the wake of the implosion of Jen Kamel’s VBAC group.

You may recall that the group imploded after they cluelessly boasted about their VBAC rupture rates, not realizing that they were 70% higher than typically quoted rates. Someone asked Kamel to comment on the fact that the rate was so high and she responded by deleting the question. It went downhill from there.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”Fighting the doctor for my vbac!”[/pullquote]

At least one new group was set up to support women in ignoring medical advice in attempting a VBAC. Cassandra was part of that group. When she cancelled her scheduled C-section she received nothing but support.

40+6 today! Yesterday was my scheduled c-section that I declined. Fighting the doctor for my vbac! She gave me the run around; clinic director called and did the same. They treated me like I was ridiculous for having hope that I could go into labor even by my 41 week mark tomorrow. Lost my plug all day yesterday. Started contractions at 6am this morning! Been consistent & getting stronger!

Group members cheered her on:

S: Good for you, Keep up the strength and your vbac goal…

H: Good for you for standing your ground!! You’re on your way to a successful vbac!! Rock it Mama 🙂 …

A: You go momma! You got this! …

H: Of course they called … they are losing money if you don’t submit to unnecessary surgery. 😏 …

B: Doing fantastic honey. Good luck 💕💕💕💕

J: GO YOU! Determined mama, you WILL GET THIS VBAC!!! …

D: You’ve got this! Listen to your body & believe that you were born with the ability to birth a baby! …

Cassandra announces that she’s heading in to the hospital.

M Own your VBAC girl go get it!! …

S: I went into labor at 40+6. Baby was born ten minutes after midnight on 41 even. Go get it, mama!

A: Good for you girl. Your body. Your birth! You got this …

M: Good for you sweetheart! Don’t ever let someone dictate what will be done to your body! You continue to advocate for yourself. I’m so happy for you and proud of you!

J: Go mama! You’re amazing and brave for standing up to them and fighting for your vbac! Congrats!!!!!

And then this:

We got to the hospital and they couldn’t find a heartbeat. Did several tests and there are no signs of life.

She continues:

She was perfect on Tuesday for the biophysical scan. Thursday labored all day. When they told me no heartbeat my labor stalled. I am still laboring… We are devastated that we won’t get to raise our baby girl but I am thankful for the small blessing through this tragedy… We don’t know why this happened but we are thankful for Catalrina’s life and know that we will see her again one day in heaven.

Ultimately the baby was born vaginally. Cassandra got her VBAC just like her cheerleaders predicted. Sadly, her baby was dead, just like her doctor feared.

You can contribute to her GoFundMe campaign here.

I wasn’t going to write about corrosive nature of breastfeeding “support” again today, but then I read a new paper that brilliantly explains how the lactation professionals who claim to be providing information and support abuse their position as health providers to shame and blame.

The paper Getting the Green Light: Experiences of Icelandic Mothers Struggling with Breastfeeding, written by Sunna Simmonardottir was published today in Sociology Research Online. Simmonardottir is writing about the experience of Icelandic women and the pressure they feel from midwives who are the main lactation professionals. However, the experience of these women is identical that that of American women and lactation consultants.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation professionals embrace a hierarchical relationship where they can shame women at will.[/pullquote]

Simmonardottir focuses specifically on whether the “support” they receive is remotely supportive and describes a critical principle:

The interaction between women who struggle with breastfeeding and health care professionals can sometimes be problematic and fraught with conflict and many women tend to feel that they did not get the help they needed and even felt that their feelings and experiences were not acknowledged. It is therefore extremely valuable to examine the role of health care professionals working ‘in the field’ as they possess the power to define and promote the dominant scientific discourses that women have to contend with as well as provide them and their infant feeding actions with the professional stamp of approval.

Lactation professionals including LCs and midwives are typically extremely critical of the supposedly tyrannical behavior of physicians, especially as regards the technocratic model of birth and the emphasis on authoritative knowledge. Ironically, they have become the very professionals they detested, advancing a technocratic view of breastfeeding and touting their authorative knowledge.

The technocratic model of breastfeeding postulates extraordinary scientifically determined health benefits for breastfeeding, although:

… when it comes to measuring the impact breastfeeding actually has, the conclusions are at best contradictory and ‘for every study linking it to better health, another finds it to be irrelevant, weakly significant, or inextricably tied to other unmeasured or unmeasurable factors’. Nevertheless, the assumed multitude of benefits and the supposed risk reduction of breastfeeding have become ‘scientific truths’ that have achieved dominance world-wide and are rarely questioned or contested.

So the choice to breastfeed is not really a choice at all:

…[T]he decision to breastfeed in an Icelandic context [and among privileged, white American women] is not really a ‘decision’, per se. Mothers are simply expected to breastfeed and the assumption that all mothers would want to breastfeed (for some length of time at least) is completely taken for granted. Exclusive breastfeeding is constructed as a pillar of successful bonding and attachment and absolutely paramount when it comes to promoting the close primary relationship between mother and child.

Lactation professionals insists that every woman can breastfeed if she wants, so there’s no point in studying why women don’t breastfeed or stop breastfeeding beyond analyzing their “excuses.” Lactation professionals, like the physicians they despise. strikingly ignore what women tell them — breastfeeding can be difficult, painful and provide inadequate milk supply — and substitute their authoritative knowledge that women don’t understand the benefits of breastfeeding and aren’t receiving adequate support to breastfeed.

Breastfeeding is constructed natural and therefore, women aren’t breastfeeding successfully must be “broken.” Therefore, they must endure techlogical efforts to fix them.

This idea that women have a ‘natural ability’ to breastfeed is culturally very strong but at the same time is counteracted with messages about the possible ‘faults’ that the women possess. They are discursively situated as both ‘natural’ and ‘unnatural’ at the same time, and in order to successfully breastfeed they have to rectify those unnatural faults often by going through quite technical processes, involving a range of breastfeeding aids such as breast pumps, artificial breasts and finger- or syringe feeding systems.

Lactation professionals routinely abuse their power as health providers to confer or deny approval to women.

The power dynamics of this particular relationship between mother (patient) and expert are clearly hierarchical, where the latter is in a position to shame and even scold, and the former feels that she has lost her subject status and is even treated like a child …

Many of the women described how the health care professionals had expressed very negative views towards formula and others had a hard time getting information on formula feeding from health care professionals, who wouldn’t comment on practical information, like quantity, the number of feeds and so on… Many of the mothers associate health care professionals with being judged and having to explain and justify their infant feeding practices.

The outcomes can be heartbreaking:

Should a mother exercise her own agency and decide for herself that the best thing for her would be to give up on trying to breastfeed, she runs the risk of being constructed as the villain, the selfish mother who didn’t want to inconvenience herself for the sake of her child. The biggest sin according to this cultural script of good mothering is not trying hard enough and giving up without a fight. The women want an outsider, especially a health care professional to tell them that they have done enough and that they have passed the test, but for some of the women no one ever does.

Lactation professionals insist that they aren’t forcing women to breastfeed or to continue to breastfeed when it isn’t working, but that’s not true.

The notion of freedom and choice does however become debatable when we consider the culture that they inhabit, where almost all women initiate breastfeeding and the notion of ‘giving up’ on breastfeeding means that you have failed your child and your identity as a ‘good mother’ is challenged.

Ironically, lactation professionals have merely replace the despised medical patriarchy with a new matriarchy based on what is “natural.”

The discursive shift from the ‘medical’ to the ‘natural’ has been successfully implemented without any recognition of the fact that the ‘natural’ is also a cultural category, and has no intrinsic meaning. The unequal power relations between patient (female) and physician (male) that were once so strongly criticized have not been discarded, but simply re-imagined and reproduced within current health care systems. By proclaiming that all women have a ‘natural’ ability to breastfeed, for as long as they wish, the experiences of a large number of women are marginalized and pathologized and essentialist understandings of women as a homogenous group are sustained.

Yesterday I wrote about lactivist-splainin’ and compared it to mansplainin’.

Lactivist-splainin’ occurs when a lactivist explains to formula feeders why they choose not to breastfeed. The fundamental problem is the same as in mansplainin’: a group of people so enamoured of their own opinions that they never listen to anyone else.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Those who truly wish to offer support take ownership of their behavior and then ask how they can do better.[/pullquote]

Lactivist-splainin’ shares another important trait with mansplainin’. When confronted, the splainers insist that they were just trying to be helpful.

Point out the biological essentialism of lactivism — demeaning formula feeders for not using their breasts is no different from demeaning gay people for not having heterosexual intercourse — and the splainers insist that they were just offering “support.”

Point out the misogyny of lactivism — judging women by the function of their reproductive organs — and the splainers insist that they were just offering “support.”

Point out the sheer obnoxiousness of campaigns like “Breast is Best” and the Baby Friendly Hospital Initiative — imagine a health facility where any woman fearing an unwanted pregnancy was forced to navigate staff and signage that proclaim that “Pregnancy is Best” and boasting they are a Pregnancy Friendly hospital — and the splainers insist they they were just offering “support” (just like the anti-abortion crowd whines that it is only offering support.)

But they’re not offering support; they offering lactivist-splainin’ instead of support.

How can we tell the difference? It’s pretty easy.

Support depends on the perception of the recipient NOT the feelings of the donor. In a medical setting, support always starts with listening to the patient, emphathizing with her feelings and perceptions, determining her desires, and helping her achieve HER goals, not yours.

Lactivist-splainers ignore all of them.

Consider this thought experiment:

Imagine if a 35 year old woman came to you requesting a tubal ligation. She and her husband have been happily married for 10 years and have decided they don’t want children.

Would you tell her that she was made to have children? That’s biological essentialism.

Would you tell her that she will never know her true power as a woman unless she gives birth? That’s misogyny.

Would you force her to listen to a lecture or sign a “contract” acknowledging that remaining childless is an inferior option? That’s obnoxious.

When she became frustrated and angry that you weren’t considering her goals and feelings would you angrily declare that you were just offering “support,” that surely she would want children if she only knew more about them?

No one would consider those actions to be “support” and rightfully so. They are directed toward the goals of the provider, NOT the goals of the patient.

There’s also a quick and dirty way to tell the difference between lactivist-splainers and those who offer support:

What do they do when informed that their efforts do not feel remotely supportive?

Those who truly wish to offer support take ownership of their behavior and then ask how they can do better. In contrast, the splainers immediately become defensive and insist that those who are upset are at fault for misunderstanding.

That’s what has happened in the Twitter discussion I referenced yesterday, when called out Prof. Amy Brown for the biological essentialism of claiming:

We are animals. Mammals. Did you not realize? Or are breasts the animal bit? …

She and her many lactivist colleagues have continued arguing — over and over and over again — that they only offer support.

But if they truly offered support they’d be asking what they could do to improve, not incessantly splainin’ that they do everything right and that women who feel pressured and bullied into breastfeeding are at fault for their own despair.

I’ve written before about mansplainin’. Mansplainin’ occurs when a man condescendingly explains something to a woman assuming he has a superior understanding since he is a man.

The founders of the natural childbirth movements were mansplainers, assuming that as male physicians they had a better understanding of what women feel during childbirth than women themselves. The fundamental problem with mansplainers is they are so enamored of the sound of their own voices that they never stop to listen. If they listened, truly listened, to women they would realize that women are not merely their intellectual equals, but have specialized knowledge that they as men could never have.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When a lactivist explains to formula feeders why they choose not to breastfeed.[/pullquote]

I’d like to introduce a new term: lactivist-splainin’.

Lactivist-splainin’ occurs when a lactivist explains to formula feeders why they choose not to breastfeed. The fundamental problem is the same as in mansplainin’: a group of people so enamoured of their own opinions that they never listen to anyone else.

In the past few days I’ve had the typical lactivist-splainin’ experience, when a group of lactivist imagined they would taunt me and then couldn’t address my arguments about the misogynism at the heart of contemporary lactivism. So they fell back on lactivist-splainin’as if their experience of pressuring women to breastfeed gives them greater knowledge of women who choose formula than those women themselves.

For example, this tweet comes from British psychology professor Dr. Amy Brown. It’s a perfect example of the biological essentialism at the heart of lactivism: the believe that women should be defined by and limited to their biology.

We are animals. Mammals. Did you not realize? Or are breasts the animal bit? …

You may remember Dr. Brown from my piece The naked misogyny of pressuring women to breastfeed in which I took her to task for ignoring the results of her own research that 80% of women stop breastfeeding because of pain and difficulty and instead lactivist-splained that they really stop breastfeeding because of lack of understanding and support.

I pointed out to Dr. Brown that insisting that women ought to breastfeed, whether they want to or not, because they have breasts is like insisting that gay women ought to have penetrative intercourse, whether they want to or not, because they have vaginas.

Dr. Brown starts back pedaling.

I’ve never told women to do anything. Just supported.

Really? And what do women think about such “support”? They don’t feel supported; they feel bullied.

A new paper, The emotional and practical experiences of formula-feeding mothers, joins a long list of previous papers in pointing out that lactivist “support” isn’t supportive in the least :

…Given the widespread knowledge of the many merits of breastfeeding among mothers, the moral statuses of those who decide not to breastfeed, or who are unable to, are left in jeopardy. Assuming that every new parent desires the “best” for their infant, the “breast is best” slogan becomes a profoundly moralistic message, rather than a promotional tool to simplify the scientific evidence about the benefits of breastfeeding. This is amplified further by expert claims about the “riskiness” of choosing formula. In this manner, the pro-breastfeeding discourse has become intertwined with broader ideologies of the concept of optimal parenting. This can lead to considerable pressure to conform to infant feeding guidelines in pregnancy and an emotional burden for those who do not manage to adhere to current recommendations in the postnatal period.

That’s not support; that’s bullying.

But lactivist-splainers wouldn’t know how their efforts are received because they aren’t listening to women who can’t or don’t want to breastfeed, or ignoring them when they do listen:

Compared with the large literature on breastfeeding and despite the high percentage of infants receiving formula and the potentially grave consequences for maternal and infant health and wellbeing arising from negative feeding experiences, there is very limited evidence regarding the opinions and experiences of formula-feeding mothers… To our knowledge, no study has explored emotional and practical factors simultaneously nor quantified them in a large sample.

What would lactivist-splanners learn if they ever stopped talking and started listening?

…[A] high percentage of mothers experienced negative emotions including guilt (67%), stigma (68%), and the need to defend their decision (76%) to use formula.

The primary source of these negative feelings was internal, but:

These negative emotions were secondarily driven by health professionals. These feelings may occur as a result of not conforming to health professionals’ recommendations or stem from a perception that health professionals judge formula to be an inferior option. Such conclusions are further reinforced by data revealing that the majority of mothers in this study felt unsupported by health professionals and were more likely to rely on the internet for infant feeding information than seek advice from them…

The Baby Friendly Hospital Initiative is recognized as promoting these negative outcomes:

While the BFHI message is critically important in developing countries or high-risk situations (prematurity, very low birth weight) where the relevance for child survival is undisputed, it may be internalized differently among affluent or low-risk populations. The evidence presented here suggests that the current approach to infant feeding promotion and support in higher-income countries may be paradoxically related to significant issues with emotional well-being and may need to be situationally modified…

In other words, while breastfeeding can be lifesaving in developing countries, the benefits are far smaller in places like the US and the UK. In industrialized countries, lactivist efforts do not improve outcomes for babies but instead they damage mothers’ mental health.

And that’s not surprising since regardless of the claims of Dr. Brown and her colleagues, they are not providing support, they are deliberately bullying. Lactivism is often more about making lactivists feel superior for their choices by demeaning women who make different choices.

Dr. Amy Brown and her colleagues need to stop lactivist-splainin’ and start listening. Based on her responses, I’m not hopeful that she or they give a damn.

Let’s try a thought experiment.

Imagine if I asked if erectile dysfunction is real or is it socially constructed. I might write something like this:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Bures exemplifies a culturally mediated response that has existed since time out of mind: ignoring women’s symptoms.[/pullquote]

Erectile dysfunction is widely accepted to be a real disorder and there is an entire industry devoted to treating it with everything from medications to mechanical devices. But does erectile dysfunction reflect biological causes or is it figment of our sex ambivalent culture and men’s embrace of traditional gender roles?

You’d probably think I was nuts. Then you’d have some idea how I (and many other women) feel about author Frank Bures’ piece in Slate Is PMS real? Or is it a figment of our menstruation fearing culture?

Bures was researching culture specific syndromes:

Eventually this path led me back to my own culture, and to our own syndromes that don’t occur in other cultures. Premenstrual syndrome was near the top of this list. And much of what I read suggested that PMS was not caused by a tide of hormones wreaking havoc on a woman’s psyche, as I’d always believed…

He claims that PMS is social constructed:

… meaning it’s an imaginary condition foisted on women by society, which is another way of saying PMS is “not real.” Yet just because something is a social construction does not mean we don’t experience it—it simply means that our “real” physiological symptoms can have roots in our mind as well as our body.

Bures is wrong.

Part of the problem is that Bures conflates “culturally constructed” and “culturally mediated.” For example, Bures quotes several studies to support his contention.

Others have elaborated on PMS’s problematic nature as an evidence-based biological condition. Researchers Lisa Cosgrove and Bethany Riddle found that women who endorsed traditional gender roles experienced more menstrual distress. “One of the most striking results,” they wrote, “was that PMS discourse has gained such cultural currency that women often expect to have PMS.” Another study found that patients “firmly believed that PMS is biologically based, and they rejected situational attributions for their distress.” In another experiment, women who were misled to believe they were premenstrual experienced more symptoms of PMS than those who were actually premenstrual but who were misled to believe they were not.

But these studies don’t demonstrate that PMS is culturally constructed, merely that the way women experience and talk about their symptoms can be culturally mediated. The fact that the response varies among cultures is not proof that the syndrome itself exists only in the minds of its sufferers.

Indeed, the response to any condition, be it premenstural syndrome or erectile dysfunction is inevitably culturally mediated. A striking example occurs in the case of leprosy. The term “leper” originally meant someone who was suffering from leprosy (Hansen’s disease), a disfiguring condition that has long been met with social rejection. The term has come to mean a person who is avoided or rejected for moral or social reasons and that’s particularly apt when you consider that Hansen’s disease is not particularly contagious. Nonetheless, it was culturally perceived as punishment and in many ways people feared it more than an illness like tuberculous, which is far more common, more contagious and more deadly.

Yes, the response to leprosy has been culturally mediated, but that doesn’t mean that leprosy itself isn’t an organic syndrome. Similarly, while the response to PMS may be culturally mediated, it doesn’t mean that it is any less an organic syndrome than leprosy itself.

Ironically, in arguing that PMS is culturally constructed as opposed to culturally mediated, Bures exemplifies a different culturally mediated response that has existed since time out of mind, the culturally mediated response of men in discounting women’s symptoms, especially pain.

Bures alludes to this history before unwittingly adding to it. Bures explains:

In our own culture, the underlying idea behind PMS can be traced back 2,500 years to Hippocrates, the father of Western medicine, who believed that certain moods and physical disorders in women were caused by “hysteria” or the “wandering uterus,” meaning the organ literally drifted around the body, pulled by the moon, lodging in wrong places, blocking passages, causing pressures. Cures included marriage and intercourse, which supposedly worked. This notion endured for eons. But by the early 1900s, medical theories around “hysteria” were beginning to crumble. In 1908, at the meeting of the Societé de Neurologie in Paris, Joseph Babinski argued that hysteria was “the consequence of suggestion, sometimes directly from a doctor, and more often culturally absorbed.”

Hyster is the Latin word for uterus. Women’s ailments were traditionally classed as hysteria and thought to be caused by the uterus. But the fact that hysteria does not exist does NOT mean that the symptoms they were meant to describe did not exist. Hysteria provided a scientific sounding nomenclature by which to dismiss women’s real physical and psychiatric symptoms.

The diagnosis of hysteria may have disappeared but the cultural impulse to ignore women’s symptoms persists to this day. It is well established that women’s symptoms, particularly pain, are notoriously undertreated when compared to men’s symptoms. Women in agony are deemed to be “hysterical” while men are simply treated with the relevant medication or procedure.

Sadly, Bures is committing the same error in questioning the existence of PMS.

The not so hidden subtext of natural parenting is that physical choices make a mother, not emotional choices.

Specifically, natural parenting fetishizes physical proximity of mother and child. The child must spend hours trying to pass through the mother’s body (short cuts by C-section not allowed); skin to skin contact in the first hour is imagined to be critical (although there is precious little evidence to support that claim); the mother must feed her baby using her body, she must wear her baby on her body and she must sleep with her baby physically next to her in the same bed.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Good mothering is not about physical closeness, but about emotional closeness.[/pullquote]

In other words, human mothers are assumed to be no different than animal mothers. If it’s good for puppy, or a kitten, or a kit or a joey, it’s good for an infant.

But the truth is very different. Human beings have a much richer existence than physical needs and their fulfillment. Human connections are not based on instinct, but on emotional connection. Good mothering, therefore, is not about physical closeness, but about emotional closeness. That’s why physical choices like natural childbirth, breastfeeding, baby wearing and the family bed are completely irrelevant.

Good mothering is actively embracing the role of caretaker, confidante, educator and moral guide that mothering entails. It means worrying, planning, consulting, advising and ultimately letting go. Should he be the youngest in kindergarten or wait a year and be the oldest? How should she handle the playground teasing? Am I expecting too much from him or does he have a learning disability? Should I let her go to the dance with the older boy or is she still too vulnerable?

It is kissing the boo-boos, helping them face the fears, stepping aside and allowing them to talk to the doctor in private when they are old enough. It is piano lessons, orthodontia, religious services, holiday celebrations. It is not responding when she says “I hate you” and never failing to respond when you see him teasing another child. It is hard, damn hard, with weeks or months that leave you exhausted or emotionally drained. Yet it is also rewarding at the deepest level, forging a bond to last a lifetime, launching a happy young adult into the world.

Natural parenting advocates, therefore, are not the best parents since children don’t particularly care how their physical needs are met. Breast or bottle? The baby doesn’t care as long as she is fed. Natural childbirth? Meaningless. Baby wearing? It depends on the baby and on the mother. Extended breastfeeding? Irrelevant in the long run (and often in the short run, too).

How do we know a woman is a good mother? We know because she cares; she cares about her children and cares about the impact that she is having on those children. To love a child is to tend an emotional connection. Specific physical choices have nothing to do with love, because there are a myriad of ways to foster and emotional connection and express a mother’s love.

My fundamental objection to the philosophies that travel under the designation “natural parenting” is that they privilege physical proximity over emotional closeness. They elevate animal instincts over human connection. It might be great for ducklings, baby badgers or lion cubs, but it hardly fulfills the needs of a human infant.

That’s not surprising when you consider that natural parenting has nothing to do with what children need and everything to do with how mothers want to see themselves. Natural parenting is a boring recipe; add the right inputs, get the right outputs. Real parenting is the work of a master chef, using the ingredients available, bringing out their inherent strengths, fashioning something new, intriguing and sublime every time.

Sadly, instead of viewing mothering as a service they willingly give their children, natural parenting advocates view mothering as a social identity that they construct for themselves, boosting their own egos in the process. That’s why discussions about natural childbirth, breastfeeding and attachment parenting are such a source of discord between women. None of those discussions are about the best way to mother a baby; they’re all about who is the best mother. It may seem like a trivial difference, but it is an immense difference and most women recognize it as such.

The most critical ingredient of good mothering is love. A child who is loved has the advantage over any other child, regardless of the specific parenting choices his mother made. It’s time to acknowledge and value the power of emotional connection and stop judging other women based on physical choices, which in the final analysis have little if any impact on children.

The hallmark of homeopathy is the belief that tiny doses of medicinal substances have big effects. It’s like insisting that the less salt you put in water, the more salty the water will taste. In other words, it defies common sense, is scientifically unfounded, and has been thoroughly debunked.

Even more inane than the concept of homeopathy are its proponents’ attempts to explain how it works. Homeopathy is, perhaps, the paradigmatic pseudoscience, and like most pseudosciences, it invokes science while at the same time ignoring the scientific evidence.

One of the best (and inadvertently funniest) examples can be found on the Huffington Post. Dana Ullman has written How Homeopathic Medicines Work: Nanopharmacology At Its Best.

Pseudoscience advocates have learned the benefits of clothing pseudoscience in “scientese,” language that sounds scientific but makes no sense. “Nano” sounds scientific, so Ullman insists that homeopathy is “nanopharmacology.’ As Ullman breathlessly explains:

Although the word “nano” also means one-billionth of a size, that is not its only definition. In fact, “nano” derives from the word “dwarf,” and “nano” is the only word in the English language that is used on common parlance as denoting extremely small AND yet extremely powerful.

Sounds cool and so scientific, doesn’t it? Just a few minor problems, though. First, nano does not mean powerful and has nothing to do with power. Second, there is a scientific discipline of nanopharmacology and it means something very different than what Ullman pretends it means.

Nanopharmacology is not about tiny amounts of medication. Nanopharmacology involves assembling tiny particles into medications or medication delivery systems. So nanopharmacology might involve the delivery of chemotherapy drugs directly to cancer cells, not the use of tiny amounts of chemotherapy to cure cancer.

In other words, nanopharmacology refers to the size of the medication delivery system, NOT the dilution of the medication.

How does homeopathy work? Well, it doesn’t work; copious scientific evidence has thoroughly debunked homeopathy. Ullman ignores that point to speculate on various possibilities, each more ridiculous than the last.

Scientists at several universities and hospitals in France and Belgium have discovered that the vigorous shaking of the water in glass bottles causes extremely small amounts of silica fragments or chips to fall into the water. Perhaps these silica chips may help to store the information in the water, with each medicine that is initially placed in the water creating its own pharmacological effect.

Or, perhaps these silica fragments do nothing. Certainly it doesn’t help water “store information” since that is a chemical impossibility.

Or maybe it’s the bubbles:

Further, the micro-bubbles and the nano-bubbles that are caused by the shaking may burst and thereby produce microenvironments of higher temperature and pressure.

If it’s not the silica fragments or the bubbles, maybe it’s the waves:

Normal radio waves simply do not penetrate water, so submarines must use an extremely low-frequency radio wave. The radio waves used by submarines to penetrate water are so low that a single wavelength is typically several miles long!

If one considers that the human body is 70-80 percent water, perhaps the best way to provide pharmacological information to the body and into intercellular fluids is with nanodoses. Like the extremely low-frequency radio waves, it may be necessary to use extremely low (and activated) doses for a person to receive the medicinal effect.

Of course every self-respecting quack must invoke, and profoundly misinterpret, quantum mechanics:

Quantum physics does not disprove Newtonian physics; quantum physics simply extends our understanding of extremely small and extremely large systems. Likewise, homeopathy does not disprove conventional pharmacology; instead, it extends our understanding of extremely small doses of medicinal agents.

But quantum physics is involves sub-atomic particles of very small size, NOT small numbers of particles.

Homeopathy is nothing more than pseudoscience, and a particularly inane pseudoscience at that. It is not involve nanopharmacology. However, we can say that belief in homeopathy is evidence of mega-stupidity, best defined as startling gullibility combined with a profound deficit of scientific knowledge.

 

This piece first appeared in December 2009.