Prepare yourself!

Next week is World Breastfeeding Week. Prepare yourself for an onslaught of articles, and podcasts and tweets rhapsodizing about the benefits of breastfeeding as well as an onslaught of images of breastfeeding stunts — breastfeeding in uniform, in evening gowns or naked outdoors — ironically designed to “normalize” breastfeeding. Prepare yourself for a disingenuous effort to convince you that breastfeeding is a critical issue of public health when it is nothing more than the choice between two excellent ways to nourish an infant (formula being the other).

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Can lactivists promote breastfeeding by sticking to the facts?[/pullquote]

I’d like to offer a challenge to lactivists: Can they promote breastfeeding by sticking to the facts or do they reflexively resort to grossly exaggerating the benefits?

Will they stick to the truth that the ONLY proven benefits of breastfeeding for term infants are 8% fewer colds and episodes of diarrheal illness across the entire population of infants across the first year?

Will they acknowledge that breastfeeding has no discernible impact on the vast majority of term infants?

Or will they roll out a long list of “benefits” that are based on weak or conflicting data or based on studies that were discredited long ago because they failed to take into account the impact of maternal socio-economic status on infant outcomes?

I’m going to guess that lactivists will not be able to keep themselves from exaggerating the benefits. Why not? Because it is difficult to make the case that breastfeeding is critical when you acknowledge the scientific reality that it isn’t.

Perhaps they’ll surprise me and stick to the truth; we’ll see.

Lactivists are constantly nattering on about “normalizing” breastfeeding. They are absolutely convinced that baring their breasts on Facebook and Twitter will encourage more women to breastfeed their babies.

In their view, breastfeeding fell out of favor due to a concerted assault by formula companies on women’s comfort with breastfeeding. In other words, it was social pressure that convinced women to switch to formula feeding and it is social pressure that will convince them to return to breastfeeding.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If you care about your baby’s health, there is no greater gift you can give her than vaccines.[/pullquote]

Homebirth advocates are constantly nattering on about “normalizing” childbirth. They are absolutely convinced that baring their bulging vaginas on YouTube will encourage more women to have homebirths.

In their view, homebirth fell out of favor due to a concerted assault by obstetricians on women’s innate “trust” of birth by “playing the dead baby card.” In other words, it was social pressure that convinced women to switch to hospital birth and it is social pressure that will convince them to return to homebirth.

Let’s take them at their word, but let’s apply it to something that has exponentially greater benefits than breastfeeding or unmedicated vaginal birth: vaccination!

In contrast to breastfeeding, which has never been shown to save the life of a single term baby, and in contrast to unmedicated vaginal birth, which in nature has an appalling death rate, vaccination saves literally hundreds of thousands of lives a year. Anti-vaccine advocacy has become popular among people who value defying medical authority over scientific evidence. It has been endlessly promoted by charlatans and celebrities who play on parents worst fears.

Anti-vax advocacy has become a social identity for its proponents; they gather in echo chamber communities on social media ruthlessly deleting and banning anyone who offers real scientific data. In other words, it is social pressure that convinces many parents to forgo vaccination for their children and perhaps social pressure will convince them to return to vaccinating, thereby protecting their children and everyone else’s children from deadly disease.

Let’s normalize vaccination!

Let’s do it by filling social media with pictures of ourselves embracing our newly vaccinated babies and children with the hashtag #vaccinesarelove because vaccines ARE love. If you care about your baby’s health, there is no greater gift you can give her than vaccines. Vaccination saves far more lives than breastfeeding, than unmedicated vaginal birth, than carseats or nearly any other safety measure that you can name.

Feel free to post your pictures here or on The Skeptical OB Facebook page. Flaunt how much you love your happy, healthy babies and flaunt your knowledge of science at the very same time!

Imagine that I published a paper crowing that the US had reduced the use of chemotherapy.

Chemotherapy is expensive, arduous and has a plethora of terrible complications up to and including death. We would save lots of money and prevent lots of serious complications. A victory, right? Wrong!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lowering death rates is an achievement; lowering intervention rates is not.[/pullquote]

You don’t have to a rocket scientist to understand that simply reducing the use of chemotherapy is meaningless in and of itself. It might be meaningful be but ONLY if the death rate from cancer held steady or dropped. If the cancer death rate rose, the reduced use of chemotherapy wouldn’t be an achievement; it would be an indictment of skewed priorities. At worst, it would reflect an appalling eagerness to save money instead of lives.

There’s a principle being illustrated here: chemotherapy is a process not an outcome. Improving outcomes is an achievement. Changing process is not.

The same thing goes for rates of intervention in childbirth. That’s why I despair when I see papers like the one published today in JAMA, Temporal Trends in Late Preterm and Early Term Birth Rates in 6 High-Income Countries in North America and Europe and Association With Clinician-Initiated Obstetric Interventions.

The authors found:

Between 2006 and 2014, late preterm and early term birth rates declined in the United States, and an association was observed between early term birth rates and decreasing clinician-initiated obstetric interventions. Late preterm births also decreased in Norway, and early term births decreased in Norway and Sweden. Clinician-initiated obstetric interventions increased in some countries but no association was found with rates of late preterm or early term birth.

ABC News reported:

The rate of cesarean sections and induced births in the U.S. has declined, reversing a decades-long trend of increased rates of obstetric interventions, according to a study published today in the Journal of the American Medical Association.

Researchers from multiple institutions … found measurable drops in the amount of obstetric interventions taking place in babies delivered both late pre-term (34-36 weeks of pregnancy) and early term (37-38 weeks of pregnancy). Researchers found there was a decrease in obstetric interventions from 33 percent in 2006 to 21 percent in 2014 for early-term infants and a slight decrease — from 6.8 percent to 5.7 percent — for infants born in late pre-term births during this time period.

Dr. David Hackney is quoted:

It always feels good to have a long-standing public health and educational campaign [of decreasing medical interventions],” he said. You “can actually see the change in … public health findings.”

Wrong, wrong, wrong!

No one should feel good about anything until they determine how many babies were injured or died to reach those lower intervention rates. I find it utterly appalling that no one even looked. Crowing about process while ignoring outcomes reflects two deeply disturbing trends: the pressure to save money and the obsession with “unhindered” birth.

The pressure to save money is at least understandable; we don’t have unlimited money to spend on healthcare. But the glorification of birth without interventions has no basis in science. It reflects the values of the midwifery and natural childbirth communities who demonize interventions they cannot provide because that is how THEY profit.

Dr. Jennifer Spong wrote an editorial accompanying the JAMA piece. The title, Improving Birth Outcomes Key to Improving Global Health, sounds promising. Our goal should be improving birth outcomes and thereby improving global health. Sadly Dr. Spong barely mentions outcomes and only in the last lines:

However, physicians cannot become too devoted to decreasing late preterm and early term birth rates. For pregnancies in which there is a complication and when delivery will optimize the pregnancy outcome, delivery should occur and will require an obstetrical intervention.

That’s because decreasing early birth rates is NOT an appropriate outcome. The outcome of childbirth can only be measure by death and injury rates and no one has bothered to do that here.

It saddens me that I have to repeat the obvious:

Any birth that results in a preventable injury or preventable death is a failure REGARDLESS of whether it is a vaginal birth at term without interventions.

Obstetricians have a legal and ethical obligation to maximize health in mothers and babies; they have no obligation to minimize interventions or maximize term births.

Even those who can’t tell the difference between a t-test and a chi-square are familiar with a basic principle of epidemiology: correlation does not equal causation. Just because Event A happened before Disease B, it does not mean that A caused B.

For example, in last 100 years deaths from infectious diseases has declined precipitously. During the same time span, the recreational use of marijuana has also increased. Yet no one would suggest that the decline in infectious disease deaths was caused by smoking marijuana.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]One experiment or even a few experiments is not enough to determine causation.[/pullquote]

So if correlation does not equal causation, what does?

To determine if Event A caused Disease B, we need to investigate whether it satisfies Hill’s Criteria. These are 9 criteria, most of which much be satisfied before we can conclude that Event A is not merely correlated with Disease B, but Event A actually causes Disease B.

Who was Hill and why should we care about his criteria?

… These criteria were originally presented by Austin Bradford Hill (1897-1991), a British medical statistician as a way of determining the causal link between a specific factor (e.g., cigarette smoking) and a disease (such as emphysema or lung cancer)… [T]he principles set forth by Hill form the basis of evaluation used in all modern scientific research… Hill’s Criteria simply provides an additional valuable measure by which to evaluate the many theories and explanations proposed within the social sciences.

What are the criteria?
1. Temporal relationship: It may sound obvious, but if Event A causes Disease B, Event A must occur before Disease B. If smoking causes lung cancer than smoking must precede the development of lung cancer. The is the only absolutely essential criterion, but it is NOT sufficient. Lay people often erroneously assume that because it’s the only essential criterion, it is the only criterion that counts. For example, anti-vaccine parents often point to the fact that childhood vaccinations usually occur before the onset of autism, but that does not mean that vaccination causes autism. Learning to walk usually precedes autism, too, but obviously learning to walk does not cause autism.

2. Strength: This is measured by statistical tests, but can be thought of as similar to the closeness of the relationship. Is Disease B always preceded by Event A? Sometimes? Only rarely? Does Event A always cause Disease B? Sometimes? Only rarely? Lung cancer is not always preceded by cigarette smoking, but it usually is. Cigarette smoking does not always lead to lung cancer, but it often leads to lung cancer. In other words, the relationship is fairly strong.

In the case of vaccines and autism, vaccines usually precede the diagnosis. However, most children who receive vaccines don’t develop autism. Thus the relationship is weaker.

3. Dose-response relationship: If cigarette smoking causes lung cancer, we would expect that smoking more cigarettes would increase the risk of lung cancer, which it does. In contrast, there appears to be no dose-response relationship between the number of vaccinations and the risk of developing autism.

4. Consistency: Have the findings that purported to show a relationship been replicated by other scientists, in other populations and at other times? If studies fail to consistently show the relationship, causation is very unlikely.

This is a critical point. One experiment or even a few experiments is NOT enough to determine causation. A large number of experiments that consistently show the same result is required; that’s exactly what we find in the case of cigarettes and lung cancer. This is particularly important for anti-vaxxers to note. The fact that a few studies claim to have shown that vaccination causes autism is meaningless when a very high proportion of studies show that there is not even a correlation between vaccination and autism.

5. Plausibility: In order to claim causation, you MUST offer a plausible mechanism. In the case of cigarette smoking, certain components of the smoke are known to cause damage to the cells inside the lungs, and cellular damage has been shown to lead to cancer. In contrast, no one has yet offered a plausible explanation for how vaccines “cause” autism. In fact, no one can even agree on the specific component that is supposedly responsible.

6. Consideration of alternative explanations: This is self explanatory. In the case of vaccination and autism, there is a very simple alternative explanation. Autism cannot be diagnosed before the age of 2 and most vaccines are given before the age of 2.

7. Experiment: If you alter Event A do you still get Disease B. In the case of smoking, if you quite smoking, the risk of lung cancer goes down. In the case of vaccines and autism, if you forgo vaccination, the risk of autism remains unchanged.

8. Specificity: Is Event A the only thing that leads to Disease B? This is the least important of the criterion. If it is present, it is a very powerful indicator of causation. For example, among young women who developed a rare form of vaginal cancer, all of them were found to have been exposed to DES (diethylstilbestrol) while in utero. That is a highly specific effect.

However, even if the relationship is not highly specific, that does not preclude causation. Though there are non-smokers who get lung cancer, it does not change the fact that the other criteria show that smoking causes lung cancer.

9. Coherence: The explanation of action must comport with the known laws of science. If the purported mechanism of causation violates the law of gravity, for example, then it isn’t acceptable. That’s why religious arguments against evolution are wrong. They are “incoherent” since they invoke forces outside science.

What do Hill’s criteria look like in action?

In the case of cigarette smoking and lung cancer, 8 out of 9 Hill’s Criteria are satisfied. In contrast, in the case of vaccines and autism, only 2, possibly 3 criteria are satisfied. This is why we can say that the scientific evidence shows that vaccines do not cause autism.

While it is true that vaccinations usually precede the diagnosis of autism, that is an essential criterion, but not enough. The fact that there is no dose-response relationship, that the few studies that showed a purported relationship cannot be replicated and that studies in which people who were not vaccinated did not have a lower incidence of autism, demonstrates that vaccines do not cause autism.

They utterly changed the nature of infectious disease. Communicable diseases that had previously wiped out wide swathes of the population could be controlled with simple injections. Deaths dropped dramatically.

They became ubiquitous and virtually mandatory. The companies that manufactured them became extraordinarily wealthy and developed into large multinational conglomerates.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is easy for lay people to believe that antibiotics work, but it requires specialized knowledge to understand how vaccines work.[/pullquote]

But there were side effects. Some recipients suffered serious medical consequences. Some even died. Yet despite these dire consequences, they have remained a cornerstone of medical practice.

What are they?

If you thought I was talking about vaccines you are mistaken. I am referring to antibiotics. I want to talk about a curious paradox. Antibiotics and vaccines are the two most powerful and effective weapons against infectious diseases. Yet antibiotics are accepted without demur and vaccines are the subject of a variety of conspiracy theories. Why should they be viewed so differently?

Both are highly effective. Both are delivered by injection (though they can be delivered in other ways). Both have serious side effects including death. Both are manufactured by large multinational corporations who profit from their sale. So why are vaccines the subject of hysterical pseudo-scientific conspiracy theories, while antibiotics are not merely accepted as necessary, but actively sought, sometimes even when they are not needed?

There are four critical differences and those differences shed light on the nature of pseudo-scientific conspiracy theories. The differences tell us why certain conspiracy theories flourish and others are rejected out of hand.

The first difference is the ease of explanation. The workings of antibiotics are, on their face, easy to understand. Antibiotics kill bacteria by poisoning them. Everyone understands what a poison is and how it can be effective. We routinely poison weeds in our lawns, and mice in our homes. Poisons figure prominently in crime shows and detective novels. When patients are told that antibiotics will cure them by poisoning the bacteria that are making them sick, patients have no trouble understanding or envisioning how the antibiotics will do the job.

In contrast, the explanation of how vaccines work is rather complex. It requires familiarity with the notion of the immune system in general and antibodies in particular, how antibodies function in the body, and how they are created. This is not information that can be acquired in the course of every day life. We have no direct experience with eliciting antibodies to fight disease. Antibodies are certainly not subjects for TV shows or novels. Understanding vaccination, therefore, requires specialized knowledge not easily obtained.

The second difference is the time scale. Antibiotics work quickly, in hours or days at the most. We are sick, we take antibiotics, we get well. It is easy to credit the role of antibiotics in curing illness because they are temporally connected. Cure reliably follows the administration of antibiotics. It is easy to believe that the antibiotics cause the cure.

In contrast, vaccines act over long periods of time. Pertussis vaccine is give in infancy. Years go by and those infants become young children who never develop pertussis. The connection between vaccination and wellness is not directly apparent.

Third, there is something fundamentally different between curing a disease and preventing it. Curing a disease allows for certainty on the part of the person being cured. Connecting the absence of a disease with a maneuver designed to prevent it is not apparent to most people. There are other possible explanations besides vaccination for why a child does not get pertussis. He or she may never have been exposed. Some children who are exposed do not get the disease, even if they haven’t been vaccinated.

Fourth, there is a difference in apparent effectiveness. The reality is that a given antibiotic will never be 100% effective, but there are almost always alternatives. If penicillin does not do the trick, another antibiotic may be more effective. Ultimately, though, the patient is cured by antibiotics, whether it is the initial antibiotic, a subsequent antibiotic or a combination of antibiotics.

No vaccination is 100% effective, either, but there is usually one and only one vaccine for a particular disease. If the vaccine fails, the person gets the disease and there is no other vaccine that can be administered to prevent it.

These differences can be readily summarized: it is easy for lay people to believe that antibiotics work, but it requires specialized knowledge to understand how vaccines work. That’s why it’s not a coincidence that vaccine conspiracies flourish among those who lack basic knowledge of science, immunology and statistics. They literally cannot understand the issues involved. And if they can’t understand it, there is lots of room to disbelieve it and to substitute conspiracy theories for the truth.

This piece first appeared in November 2010.

The most over-used word in natural childbirth discourse is “empowerment.” But an equally important concept, one that is rarely spoken aloud but is central to natural childbirth advocacy, is victimization. To a greater or less extent, natural childbirth advocates take it for granted that they are victims … of men, of doctors (almost always portrayed as men), of other women, and just about everyone else in the universe.

They are victims, dammit, and that’s why they are traumatized. And anyone who questions or rejects their exalted victim status is promptly accused of re-victimizing them.

The celebration of their “victimization” serves several important roles in the natural childbirth cosmology. First, and foremost, it guarantees moral superiority. As Sommer and Baumeister explain in the book The human quest for meaning”

… [C]laiming the victim status provides a sort of moral immunity. The victim role carries with it the advantage of receiving sympathy from others and thereby prevents [one’s own behavior] from impugning one’s character…

In the world of natural childbirth, being a victim means never having to say you’re sorry, even when your behavior is obnoxious and disrespectful.

Second, the insistence on “victimization” serves to simplify the world by creating a false dichotomy. For natural childbirth advocates, women giving birth are either empowered or victimized. Not only is there no middle ground, but the possibility that women might feel neither empowered nor victimized is not even recognized.

Freud purportedly said, “Sometimes a cigar is just a cigar.” That aphorism applies to the way that most women view childbirth. Giving birth is just the process whereby a child emerges from inside the mother. It has no meaning beyond that and certainly does not have anything to do with the way the mother views her agency within the world at large. In contrast, in NCB advocacy, the actual birth of a child is secondary to the mother’s feelings about her performance during that birth.

Third, the insistence on “victimization” presupposes a sexist, retrograde view of women. Only men are doctors and scientific knowledge and technology are inherently male. In the world of natural childbirth, there are no women doctors or scientists. Science is “too hard” for mere women and since they can’t be expected to know or understand science, they are free to reject it. Women must glorify the functions of their bodies because they have no achievements of their intellects.

This belief has its highest expression in homebirth advocacy. Medical school? Too hard. Midwifery master’s degree? Too hard. College? Too hard. Solution? Give yourself a pretend “degree” to masquerade as a professional because meeting real professional requirements is too hard.

Who has convinced natural childbirth advocates that they are victims? Strangely enough, it is male doctors, the exact same people who have purportedly victimized them. From Grantly Dick-Read, the father of natural childbirth, who believed implicitly in the inferiority of women, through Bradley and Lamaze, right down to Odent (who fears that viewing a wife giving birth will render a man impotent) the leading exponents of women’s victimology are men who view women as capable of being nothing more than victims.

This faux sense of victimization has led natural childbirth advocates to create faux “empowerment.” In the world of natural childbirth advocacy, you can be “empowered” by being obnoxious and disrespectful to healthcare professionals, and no one can hold you to account because you are a “victim.” You can be empowered by pretending that reading books written by laypeople makes you “educated.” You can be empowered by ignoring medical advice. And, with homebirth, you can be empowered by hiding from anyone and anything that might not agree with your assessment that your ignorance, defiance and denial mark you as “educated.”

When you are victim, the fact anyone others don’t agree with you, or validate your feelings of victimization, is viewed as a form of re-victimization. Doctor thinks he knows more about obstetrics than you? He’s victimizing you with his technocratic hegemony. Nurse asks you if you would like an epidural? She’s victimizing you by attempting to destroy your opportunity to be empowered. Other women bottle feed? They are victimizing you by refusing to validate your decision to breastfeed.

Victimization is central to natural childbirth advocacy. Indeed natural childbirth advocacy cannot exist without encouraging and validating victimization.

Adapted from a piece that first appeared in April 2011.

Yesterday I wrote about childbirth injuries. They’re common, lead to life long disability and distress and are a subject of deep embarrassment for many women.

I discussed the two most serious forms of childbirth injury: obstetric fistula, a hole between the vagina and the bladder or rectum or both; and severe vaginal tears that can result in the vagina and rectum becoming one passage. It’s not difficult to envision why either of those injuries lead to incontinence since urine and stool are released directly into the vagina and then dribble out.

As I explained, such injuries are now relatively uncommon. Fistulas are usually the result of prolonged obstructed labor and with the easy availability of C-sections they are rare. Vaginal tears, including severe vaginal tears, are still common but carefully repairing them with extensive suturing generally prevents incontinence.

Many readers might have wondered: I only had a minor childbirth injury so why am I incontinent?

The reason is because childbirth causes injuries that may not be visible, or the repair of a visible injury may be inadequate.

To understand the problem you need to understand how we achieve continence in the first place.

Outflow from both the bladder and the rectum is controlled by sphincters. A sphincter is a ring of muscle that can open and close in response to conscious or unconscious signals.

Babies are incontinent of both urine and stool, but neither is constantly dribbling. That’s because unconscious signals keep both the bladder and rectum closed until they are full. Only then will the appropriate sphincter open, releasing the contents. Then the sphincter will close until the organ is once again full.

Over time toddlers acquire the mature neurological function need to take conscious control of the bladder and anal sphincters. When continent children and adults feel the urge to void they can override the unconscious signals for the sphincters to open. In other words, they can “hold it.” But in order for them to do so, the sphincters themselves must be undamaged. Childbirth can lead to invisible injuries to the sphincters.

There’s a critical distinction to keep in mind. Bowel incontinence is nearly always the result of an injury that can be repaired while incontinence of urine may be the result of an injury that cannot be easily repaired.

The image below shows a third degree vaginal tear. You can see the muscles of the vagina have torn as well as the sphincter around the anus. Unless the sphincter is repaired, the woman will have permanent bowel incontinence. It’s relatively easy to tell the difference between the vaginal muscles and the anal sphincter in the picture, but in real life it can be quite difficult.

If there is any question, the provider should put a finger in the anus to determine if the sphincter is intact. If it has been torn, it can be repaired with sutures. An inexperienced provider may fail to recognize that the sphincter has been torn and may repair only the vaginal muscles. If you were to look at the repaired area with a mirror, it would look perfectly normal, but because the sphincter has been torn, there is no way to prevent the contents of the rectum from leaking out or being expelled. If that’s the cause of the bowel incontinence, it must be completely repaired, typically requiring surgery.

Urinary incontinence is different.

Urinary continence is controlled by the urethral sphincter. As shown in the image below, the sphincter’s ability to close off the bladder depends in large part on the relationship between the bladder and the urethra. The bladder is held in place by the ligaments and muscles of the pelvic floor. Vaginal birth (and to a lesser extent pregnancy itself) can stretch these ligaments and muscles causing the bladder to fall. The sphincter is still intact so urine doesn’t dribble out. But when the pressure on the bladder is increased by coughing, sneezing or physical exercise urine may escape. This is known as stress urinary incontinence and is the most common form of incontinence in women of childbearing age.

The maximum stretching of ligaments and muscles occurs at the time of vaginal birth. In the aftermath, the ligaments and muscles can regain some of their tone. That’s why incontinence in the first few days or weeks after birth can eventually resolve. If you are incontinent of urine at your 6 week check up, you should definitely tell your provider. He or she may suggest that you wait a little longer to see if you recover more muscle tone. Alternatively your provider may recommend Kegel exercises or pelvic physical therapy to strengthen the muscles of the pelvic floor.

How do childbirth interventions affect childbirth injuries? On the one hand, C-sections can prevent many childbirth injuries entirely. On the other hand, interventions like forceps can dramatically increase the risk of childbirth injuries. That’s not surprising when you consider that it is the passage of the baby’s head that leads to the injuries. When you apply forceps to the head, the effective size is increased and the risk of injury is increased, too. Forceps rotations (turning the baby’s head from an incorrect position to a correct position with the forceps) increases the risk of childbirth injury even more.

How about episiotomies?

The rationale for episiotomy is the belief that cutting through the perineal muscles to enlarge the vaginal opening would reduce both the stretching of the muscles and prevent major tears. Unfortunately, that’s not what happens. Cutting into the perineal muscles appears to increase the risk of severe tears; that’s why routine episiotomy is no longer recommended.

There is one exception, though. A mediolateral episiotomy (a cut angled toward the side) reduces the risk of childbirth injuries. Mediolateral episiotomies are much more painful than typical (median) episiotomies so they are rarely used.

So the role of childbirth interventions is paradoxical. C-sections reduce the risk of childbirth injuries, while vaginal delivery increases the risk of injury and forceps and episiotomy increase that risk even further. Women should be counseled about the risks of vaginal delivery in the same way they are counseled about the risks of C-section.

Moreover, efforts to decrease the C-section rate by replacing C-sections with forceps deliveries are not necessarily in women’s best interest. Yes, surgery has real risks, but the risk of incontinence (not to mention pelvic pain and sexual dysfunction) is one that cannot and should not be ignored.

It should be up to individual women to decide, based on their personal priorities, which mode of birth they prefer. A woman who prioritizes avoiding childbirth injuries should be able to choose a C-section in the absence of other medical indications.

Childbirth is inherently dangerous for babies and for mothers and the risk of death is not the only risk. The right to bodily autonomy means that women should weigh the risks for themselves, and that vaginal birth should be recognized not as a goal, but as an option with significant downsides.

Cosmopolitan Magazine recently published an amazing piece on childbirth injuries, Millions of Women Are Injured During Childbirth. Why aren’t doctors diagnosing them?

Why do childbirth injuries occur?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Childbirth injuries are common, lead to life long disability and distress and are a subject of deep embarrassment for many women.[/pullquote]

The single greatest cause is a mismatch between the size of the baby and the size of the passage it must negotiate during birth. There are two different points at which the mismatch can cause problems. The first is during passage of the head through the maternal bony pelvis. The second point is when the head exists the vaginal opening.

Most people imagine that the pelvis is like a hoop that the baby’s head must pass through, and indeed doctors often talk about it that way. However, the reality is far more complicated. 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.

What happens when the baby’s head doesn’t fit? The bones of the mother’s pelvis may break or split to accommodate the baby. That’s why a woman might end up with a fractured coccyx or a separated public symphysis, both extremely painful.

If the bones don’t break or split (and sometimes even if they do), the tissues of the vagina can be squeezed so hard between the baby’s head and the mother’s pelvis that the blood flow to the area is actually stopped. If that goes on for more than a few minutes, the tissue of the mother’s vagina will begin to die resulting in a hole (fistula) in the vagina. If the hole is toward the front of the vagina it will open into the bladder and if it is toward the back it will open into the rectum; there can be holes in the front and the back simultaneously.

In either case, waste products leak into the vagina and dribble out of it rendering the woman incontinent and reeking of urine and/or stool for the rest of her life. Fortunately, easy access to C-sections means that it is rare for women to push for multiple hours with no progress and obstetric fistula is therefore uncommon in industrialized countries today.

What happens when the baby’s head is too big to fit through the vaginal opening? The vagina tears to accommodate it. If the vaginal tear is small, it will heal by itself. If the vaginal tear extends into surrounding structures it will not heal unless it is sutured properly.

Perineal tears are classified by severity from first to fourth degree. First degree tears are small do not need to be stitched. Second degree tears extend into the tissue immediately surrounding the vagina; they ought to be stitched but the results are not catastrophic if they are not stitched.

Third and fourth degree tears are more serious. The illustration of the fourth degree tear below make it easy to see why they MUST be stitched or the woman will be left with bowel incontinence. Third and fourth degree tears can only be diagnosed by someone with considerable obstetric experience and they will NOT heal by themselves. They must be repaired by someone with extensive experience in repairing them.

Why aren’t childbirth injuries diagnosed? I offered my take in the piece:

We have a new cultural view of childbirth that tremendously minimizes how physically and emotionally difficult it is.

Indeed, until relatively recently, childbirth was recognized not merely as deadly, but also as disfiguring and disabling. A historian Judith Walzer Leavitt wrote in Under the Shadow of Maternity: American Women’s Responses to Death and Debility Fears in Nineteenth-Century Childbirth:

In the past, the shadow of maternity extended beyond the possibility and fear of death. Women knew that if procreation did not kill them or their babies, it could maim them for life. Postpartum gynecological problems – some great enough to force women to bed for the rest of their lives, others causing milder disabilities – hounded the women who did not succumb to their labor and delivery. For some women, the fears of future debility were more disturbing than fears of death. Vesicovaginal and rectovaginal fistulas .., which brought incontinence and constant irritation to sufferers; unsutured perineal tears of lesser degree, which may have caused significant daily discomforts; major infections; and general weakness and failure to return to prepregnant physical vigor threatened young women in the prime of life.

What changed between then and now? Quite a few things:

The widespread medicalization of childbirth dramatically reduced the death rates for both babies and women. In the past 100 years, modern obstetrics dropped the neonatal mortality rate 90% and the maternal mortality rate nearly 99%. Childbirth began to be seen as safe.

The medicalization of childbirth dramatically reduced the risk of the most debilitating childbirth injuries. The most devastating injuries, obstetric fistulas, have been rendered exceedingly rare by the easy availability of C-sections, and the more common injuries are easily prevented by the simple expedient of suturing vaginal tears.

Midwives and the natural childbirth industry romanticized childbirth in order to claw back market share. Midwives and other natural childbirth advocates resented what they derided as the “technocratic” model of birth, which they contrasted with the midwifery model which places a premium on avoiding the childbirth interventions that they coincidentally cannot provide.

We’ve ended up with a situation where physicians ignore postpartum pain, incontinence and sexual dysfunction because they are pre-occupied with preventing deaths, and midwives and natural childbirth advocates pretend childbirth injuries don’t exist because those injuries belie their reflexive worship of birth without interventions.

The truth about childbirth injuries is that they are common, can be prevented to a certain extent with the liberal use of obstetric interventions, can lead to life long disability and distress and are a subject of deep embarrassment for many women.

I’ve been quoted extensively in the mainstream media about breastfeeding.

In nearly every case I mention that I breastfed four children relatively easily and I (and they) enjoyed it. Nonetheless I caution that the benefits of breastfeeding have been grossly exaggerated and that what passes for breastfeeding “science” is generally based on data that is weak, conflicting and plagued by confounding variables that render the conclusions meaningless.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is no possibility that breastfeeding “science” will ever show that breast is not best; and that means it isn’t science at all.[/pullquote]

Inevitably commenters complain that I am ignoring the science, but what they don’t realize is that lactivist “science” shares a very important trait with major forms of pseudoscience. Just like creation “science,” the central tenet of lactivist “science” is considered unfalsifiable.

Why is that important?

Science always starts with a hypothesis and then tests it to see if it is true. The possibility always exists that the hypothesis is false. The conclusion of scientific testing is drawn from data gathered in the course of experiments and studies. It is not known a priori.

Creationism, the belief that the universe was created by an intelligent designer, is considered unfalsifiable by its adherents. They start with the conclusion that a Creator was necessary for our current existence and then arrange any experimental data to lead to that conclusion, carefully editing the data so that anything that could falsify the conclusion is excluded.

For creationists, there is no possibility that the conclusion is wrong since they start with the conclusion and, working backwards, do whatever is necessary to arrive at it. There is no possibility that creation “science” will ever conclude that creationism is false and that means that creationism is not science.

Lactivist breastfeeding “science” also starts with a conclusion and works backward to justify it. The central tenet of breastfeeding “science” is that breast is best, despite the copious scientific evidence that in many cases it is not best at all and may even be deadly. Nonetheless, all data is manipulated until it can be forced to fit the predetermined conclusion.

When data is conflicting, as it often is in lactivist breastfeeding research, the data that don’t show breast is best is either excluded or dismissed out of hand. Confounding variables like maternal education and socio-economic status aren’t removed by correction so that the benefits to children that come from being wealthy and having access to better health insurance can be erroneously ascribed to breastfeeding. Startling facts about breastfeeding — the historically high mortality rates of exclusively breastfed infants prior to the 20th century and that fact countries with the highest contemporary breastfeeding rates have the highest mortality rates — are simply ignored. There is no possibility that lactivist breastfeeding “science” will ever show that breast is not best; and that means it isn’t science at all.

But how is it possible that breast isn’t necessarily best?

It’s possible for the exact same reason that “natural immunity,” so beloved of anti-vaccine advocates, isn’t best. Technology can do better and there’s a massive amount of evidence to support the fact that it actually DOES better than nature. Natural is not best.

Just because something is natural doesn’t make it better:

Nearsightedness is entirely natural but it is not better than vision corrected with glasses or contacts.

Naturally acquired immunity is by definition entirely natural but cannot stave off death from vaccine preventable diseases in a substantial number of cases. Survivors of various plagues through the ages could have boasted of their naturally acquired immunity but there were often very few other people left to appreciate it since they had died before naturally acquired immunity could save them. Most of them could have been saved by vaccine acquired immunity.

Breastfeeding is entirely natural but that doesn’t make it better than formula. Women can naturally fail to produce enough breastmilk and their babies can naturally die as a result. It is entirely possible that an infant formula could be devised that is actually superior to breastmilk in the same way that vaccines are superior to natural immunity. When you know more about death and disease, you can defeat entirely natural causes of death.

Real science tells us that the benefits of breastfeeding for term infants in the US are trivial. Breastmilk is neither magical nor mysterious just as immunity is neither magical or mysterious. We can mimic it and we can even improve upon it.

But lactivist breastfeeding “science,” like Creation “science,” won’t admit that possibility. That’s why neither are science at all.

“We’re still here!”

It’s a favorite declaration of those attempting to justify natural parenting practices:

Childbirth without interventions must be optimal because we’re still here.

Homebirth must be safe because we’re still here.

Exclusive breastfeeding must be best because we’re still here.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Looking at those today alive today though their parents never used seatbelts, we might conclude that seatbelts are unnecessary because “we’re still here.”[/pullquote]

But “we’re still here” doesn’t merely fail to justify natural parenting practices, it is actually a form of cognitive bias, a way of thinking that inevitably leads us to erroneous conclusions.

Specifically, “we’re still here” is a form of survivorship bias, a bias so subtle that it is often difficult for its practitioners to recognize.

Rational Wiki defines survivorship bias as:

… a cognitive bias that occurs when someone tries to make a decision based on past successes, while ignoring past failures.

Rational Wiki offers an excellent example of survivorship bias:

Suppose you’re trying to help the military decide how best to armor their planes for future bombing runs. They let you look over the planes that made it back, and you note that some areas get shot heavily, while other areas hardly get shot at all. So, you should increase the armor on the areas that get shot, right?

Wrong! These are the planes that got shot and survived. It stands to reason that on some planes, the areas where you don’t see any damage did get shot, and they didn’t survive. So those are the areas you reinforce…

Dead men (and planes) may tell no tales, but the fact that they are dead provides valuable information for the survivors.

The planes that returned from the bombing runs aren’t the safest planes; they’re the ones that were merely lucky enough to get hit in the places least likely to cause catastrophic damage.

For example, imagine that every plane that returned was shot somewhere in the fuselage, but never in the fuel tank. In contrast, every plane that was shot in the fuel tank failed to survive because a shot to the fuel tank inevitably led to explosion of the entire plane.

If you were to repair the returning planes and send them out on another bombing run a substantial proportion would once again fail to return because this time they might get hit in the fuel tank. Surviving the first bombing run because they were not shot in the fuel tank would not have made them more likely to avoid getting shot in the fuel tank the second time.

In other words, the pilots who survived the first bombing run were simply luckier than the ones who failed to return.

Consider a more common example.

Most of us above a certain age traveled in cars throughout our entire childhoods without ever using a seatbelt and we’re still here. For many years cars didn’t even have seatbelts yet the population of the US continued to increase. Does that mean seatbelts are useless?

Of course not! The many children who died from being ejected in car accidents are testament to the fact that failure to wear a seatbelt is dangerous. The dramatically lower death rates for children in accidents in the 2010’s compared to the 1960’s makes it clear that wearing a seatbelt is much safer than not wearing one. But if we only looked at people alive today even though their parents never used seatbelts, survivorship bias would lead us to conclude that seatbelts are unnecessary.

Dead children leave no descendants; their millions of potential descendants are not here but we don’t notice precisely because they are absent. We are the remainder.

How does this apply to natural parenting?

The claim that childbirth without interventions is safe because “we are still here” makes as much sense as claiming that not wearing seatbelts in the 1960’s was safe because “we are still here.”

The claim that homebirth is safe because for most of human existence women gave birth at home and “we are still here” makes as much sense as claiming that putting babies to sleep on their stomachs instead of their backs is safe because “we are still here.”

The claim that breastmilk must be better than formula because “we are still here” is like claiming riding without a bicycle helmet must be better than using a helmet because “we are still here.”

But billions of potential people are NOT here today precisely because their parents died in childbirth, at homebirth, or from being exclusively breastfed by women who didn’t produce enough milk for them to survive.

We who are “still here” are the remainder, representing nothing more than luck, not inherent safety.