Vaccine rejectionism is based on a profound lack of knowledge about immunology, statistics and science. Virtually every single empirical claim of vaccine rejectionism is factually false, but parents who lack even the most basic understanding of immunology are often incapable of evaluating those empirical claims. Indeed, those parents most likely to proclaim themselves “educated” on the topic are generally the most ignorant.

A new paper on a recent measles outbreak, Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated, provides insight into the erroneous beliefs eagerly adopted by gullible and credulous parents.

… They reported substantial skepticism of the government, pharmaceutical industry, and medical community. They believed vaccination was unnecessary, because most vaccine preventable diseases had already been reduced to very low risk by improvements in water, sanitation, and hygiene and were best prevented by “natural lifestyles,” including prolonged breastfeeding and organic foods. In contrast to the immunity produced by disease, they felt that vaccines could damage the immune system while producing a number of other immediate and long-term adverse health conditions, particularly those involving the child’s neurologic system.

The paper highlights yet another false empirical claim of vaccine rejectionism. To the extent that they consider the impact of their actions on others, vaccine rejectionists falsely believe that no others can or will be harmed by their refusal to vaccinate their children. In the San Diego measles outbreak, fully 25% of the children who became ill were too young to be fully vaccinated. In addition, 48 children too young to be fully vaccinated had to be quarantined because of known exposure to an affected child. Although only a small number of children was ultimately affected (12 cases of measles), the total cost of the outbreak was over $175,000 of which $125,000 was born by the taxpayers.

It is instructive to explore the way in which the disease spread:

On January 13, 2008, the 7-year-old male index patient returned from Switzerland, asymptomatic but incubating measles. He transmitted infection to his 9-year-old unvaccinated sister and 3-year-old unvaccinated brother. On January 24, 2008, after 2 days of fever and conjunctivitis, the index patient attended charter school A. Forty-one of the 377 students (11%) at charter school A were unvaccinated for measles because of personal beliefs, and 2 children became infected. The next day … the index patient was taken to pediatric clinic A … No respiratory precautions were taken, 6 children were exposed, 5 were unvaccinated, and 4 were infected (3 infants too young for vaccination and a 2-year-old whose parents had intentionally delayed measles vaccination)…

…The index patient’s sister infected 2 schoolmates and exposed an unknown number of children at a dance studio. One infected classmate of the index patient infected his own younger brother and exposed 10 children at a pediatric clinic, 18 children and adults at a clinical laboratory, and an unknown number at 2 grocery stores and a circus. Another infected classmate of the index patient exposed an unknown number at an indoor amusement facility. Four secondary patients from clinic A returned to the same clinic while symptomatic on 4 separate days … thus exposing 37 children. Of these same 4 patients, 1 exposed an additional 95 children in a preschool on 2 consecutive days, 6 patients at an outpatient laboratory, and 47 children at a swimming-instruction facility; the second patient exposed children in the same swimming class; the third patient exposed 55 students in a school and 10 persons at an outpatient laboratory; and the fourth patient potentially exposed 166 passengers on an airplane flight to Hawaii.

Ultimately 73 children, including intentionally unvaccinated children and children too young to be vaccinated, were quarantined for 21 days each because of significant exposure to measles.

The San Diego outbreak was a small exposure in a city with high vaccination rates. Therefore, the outbreak was easily contained. But there would have been no outbreak at all if it weren’t for the vaccine rejectionists. The outbreak was brought into the community by an intentionally unvaccinated child and initially spread by other intentionally unvaccinated children. Even though the outbreak was easily contained, one quarter of children who became ill were too young to be vaccinated, and the taxpayers spent $125,000 containing an outbreak that was entirely avoidable.

Vaccine rejectionists don’t hurt just their own children, they hurt everyone else’s children and they cost the taxpayers large sums of money to contain the results of their gullibility. San Diego ought to present a bill for $125,000 to the parents of the intentionally unvaccinated child who introduced measles into the city. Perhaps compelling vaccine rejectionists to put their money where their mouth is might make them think twice about exposing the rest of us to preventable diseases.

Waterbirth has become a central component of “natural” childbirth dogma, despite the fact that for primates giving birth underwater is entirely unnatural. You don’t need a medical degree to appreciate the idiocy of birth in water. The most critical task for the newborn is to take its first breath. Inhaling a mouthful of fecally contaminated water instead of air is profoundly dangerous. Not surprisingly, as the popularity of waterbirth has grown, the number of neonatal deaths directly attributable to it has grown as well.

A new paper in the American Journal of Forensic Medical Pathology discusses the tragic case of a term newborn who died of Pseudomonas pneumonia and sepsis as a result of waterbirth. The authors review the existing literature on fatalities associated with waterbirth and the underlying processes leading to neonatal death.

The case report:

A normally formed 42-week gestation male infant was born underwater in a birthing tank to a 29-year-old primigravida mother. The Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. The infant was covered with thick meconium and demonstrated intercostal recession with peripheral cyanosis. He was transferred to hospital where his respiratory status worsened and a chest x-ray demonstrated generalized opacity. Presumed sepsis was treated with broad-spectrum antibiotics. There was no evidence of hyponatremia. Despite maximal therapy he developed respiratory failure with disseminated intravascular coagulation and died at 4 days of age.

… Death was due to extensive P. aeruginosa pneumonia and sepsis associated with meconium aspiration and water birth.

The authors reviewed the literature:

Underwater birth has been promoted as a means of improving the quality of delivery… While the benefits of immersion are said to include increased comfort and relaxation for mother and infant, with greater maternal autonomy, fewer injuries to the birth canal, reduced need for analgesia, with decreased instrumentation and operative intervention, this has been disputed with no clear advantages or disadvantages over conventional births being demonstrated. In addition, other reports of underwater births have documented significant morbidity and even death. Problems have included infections, near drowning/drowning, hyponatremia/water intoxication, seizures, infections, respiratory distress, fevers, hypoxic brain damage, and cord rupture with hemorrhage.

Natural childbirth advocates have a terrible habit of inventing scientific “facts” and waterbirth is a classic example. According to NCB advocates, newborns will not attempt to breathe while immersed in warm water and will wait to take a first breath until they are in direct contact with air. That theory has no basis in neonatal physiology.

It has been postulated that newborns will not breath or swallow while immersed in warm water, and that respiration will only be initiated on exposure to cold air. This has been used to support assertions that drowning and aspiration of water cannot occur with underwater delivery. However, animal studies have demonstrated that this reflex can be over-ridden, and given that respiratory movements occur in utero, it is difficult to see why this process would not continue in a neonate delivered into water. The documentation of cases of near drowning and respiratory distress with apparent aspiration of fluid would also be supportive of the occurrence of breathing under water. In addition, the finding of hyponatremia in certain of these infants would be in keeping with inhalation of fresh water, as lowered sodium levels have resulted from fresh water drowning.

It is ironic that NCB advocates, the self appointed guardians of “physiologic birth” would embrace a practice that is profoundly non-physiologic. Not surprisingly, the consequences can be devastating. Neonates can and do inhale copious amounts of fecally contaminated water during waterbirth. Indeed, they have been found to inhale such large quantities of water that the water dilutes the concentration of sodium in the bloodstream to fatally low levels (hyponatremia). Even small amounts of inhaled water can introduce significant amounts of bacteria into the neonatal lungs leading to pneumonia and other infections as the authors explain:

Sepsis has also arisen from underwater deliveries, ranging from umbilical and ear infections to septicemia and pneumonia. The source of such infections has been contamination of birthing tubs, hoses, and taps with virulent organisms such as P. aeruginosa and Klebsiella pneumoniae. These bacteria have been found despite careful cleaning of systems between deliveries. Lethal Legionella infection has occurred in an underwater birth reported from Japan and other organisms such as amoeba and Mycobacterium avium have been found in spa baths…

The bottom line is that waterbirth kills babies.

As the death of a newborn from entirely preventable factors is of great concern, parents who elect to have an underwater delivery must be appraised of the risks that characterize an aquatic birth, and should have access to resuscitation equipment to enable rapid suctioning of the airway.

The avoidable tragedies of waterbirth cast a harsh light on the fundamental weakness of “natural” childbirth philosophy. “Natural” childbirth advocates pick and choose desired elements of “natural” birth without regard to whether those elements are truly natural. Despite the claims of NCB advocates that their philosophy is “evidence based,” they routinely ignore scientific evidence and make recommendations without ever performing safety testing on those recommendations. Moreover, they are not above fabricating scientific “facts” to bolster claims that have no scientific support. Finally, and most egregiously, babies die as a result of their “advice” and they don’t know and apparently don’t care.

In the ongoing battle known as the mommy wars, participants tend to treat different styles of mothering as interchangeable choices. The assumption is that a woman chooses to adopt attachment parenting, or chooses to value work outside the home. Hence the arguments often boil down to identifying which women are making the best “choice.”

In a thought provoking chapter of a new book, Parenthood and Mental Health: A Bridge between Infant and Adult Psychiatry, (Tyano et al., 2010 John Wiley & Sons, Ltd), Joan Raphael-Leff, of the Faculty for Psychoanalytic Research, UCL/Anna Freud Centre in London, proposes that women approach mothering with specific psychological orientations. She divides these orientations into four different groups: facilitators, regulators, recipricators and conflicted. I’m intrigued with the idea that mothering style reflects specific psychological orientations and I find her descriptions spot on.

According to Raphael-Leff, the different orientations to mothering manifest themselves during pregnancy. She concentrates in particular on facilitators and regulators.

The facilitator:

… treats pregnancy as the culmination of her feminine experience. Throwing herself wholeheartedly into the process, she dons maternity clothes early, ‘communes’ with her baby, reveling in the special attention. She plans as natural a birth as possible, wishing to minimize the traumatic ‘caesura’ that will reunite her with her familiar baby.

The regulator views pregnancy as:

… an unavoidable means of getting a … baby. She resents being treated as an ‘incubator’, prey to comments by strangers. Childbirth is imagined as a dreaded, exhausting and painful event to be mitigated by medical intervention… Their elevated incidence of elected Caesarean sections indicates preference for predictability and a way of bypassing the potentially humiliating experience of vaginal birth.

Not surprisingly, a woman’s psychoanalytic orientation has a profound impact on her mothering.

For facilitators:

Enveloped in the maternal body, the infant rediscovers mother’s voice, her wake/sleep rhythms, cadences of breathing and kinetic patterns of stillness and movement. Some experiences are new: the feel and fit of mother’s fleshy contours, the taste of breast milk and odours of her breath, armpit, vaginal excretions, her bodily warmth, unmuffled immediacy and differing smooth silkiness/rough edges of her caress . . .

Feeling mothering is her vocation, the Facilitator mother adapts herself to her baby, convinced that only she, the biological mother primed by pregnancy, can fathom her infant’s needs. Hence as exclusive carer, she maintains close bodily contact, treating every gurgle as a communication that must be responded to.

Whereas regulators believe:

… mothering is a ‘learned skill’, acquirable by others. Since to her neonates do not discriminate between people, she introduces co-carers early on, establishing a routine which reduces unpredictability, provides continuity between nurturers, and differentiates between ‘valid’ crying and ignorable ‘noise’. Hence, proximity is not an issue. The main goal is to ‘socialize’ the asocial, presocial or even antisocial infant and regulate his or her desires. To this end the baby must adapt to the household regime.

Inevitably, different orientations lead to different views of work outside the home.

… To maintain their self esteem, Regulators need to engage meaningfully with adults outside the home, whereas Facilitators dread separation from the baby. Wishing to provide full-time exclusive care, they return to work reluctantly of economic necessity or job stipulations. Conversely, Regulators resent economic dependence, and the slow ‘mommy-track’ which penalizes career advancement and salary growth.

Mothers of both psychoanalytic orientations experience distress when mothering does not go according to plan.

… [A] Facilitator mother experiences ‘primary maternal preoccupation’ … before and during the months following childbirth. Her identity becomes primarily that of a mother. Holding a distinct mothering philosophy, she strives towards her maternal ideal of devotion, suspending her subjectivity by adapting to the baby, intuitively facilitating, holding and dedicating herself in unconscious identification with both maternal ideal and vicariously gratified baby-self… Facilitating mothers feel devastated if unable to breastfeed. Desperation over minor lapses of maternal perfection induces irreparable guilt, remorse and anxious over-involvement. Self-reproach for ‘ruining’ the ideal may escalate to depression, hopelessness and, in extreme cases, even suicide.

In contrast, regulators may feel:

… ‘primary maternal persecution’. In-depth exploration of their subjective experience boils down to feeling trapped. If the sense of exploitation persists, feeling undermined, and at the mercy of a potentially greedy/spiteful infant, hostility must be managed. Most Regulator mothers do this efficiently. More breastfeed today than in the past – health-education stresses both infantile immunity and maternal benefits … Intake is regulated by schedule, and feeding bottles are introduced early to ensure shared care. This allows the mother to replenish herself by spending time in an enriching social world, protecting her from risks of ruptured defences and/or surrendering to ‘sentimentality’.

What I find most compelling in Raphael-Leff’s analysis is the idea that different styles of mothering are not “choices” and do not reflect specific philosophies. Rather, different styles of mothering reflect the different psychological needs of the mother. If that is the case, the mommy wars are worse than pointless, because there is no “right” way to mother. There is only the ongoing effort by mothers to balance their psychological needs against the needs of their children.

Attachment parenting does not reflect the needs of the child; it reflects the needs of the mother. Natural childbirth, exclusive breastfeeding, the family bed are not objectively “better” for babies and are neither feminist nor rebellious. They are comforting and satisfying to women who have a particular psychological orientation to attachment.

Similarly, rejection of natural childbirth or exclusive breastfeeding is not “selfish” or unwomanly. It is the best way for women who have a deep and real need for regular involvement in the world of work and who would feel trapped by attachment parenting.

Taking a woman’s psychological orientation into account is not a radical idea. We do not expect all marriages to be the same and we do not expect all friendships to be the same. We understand that these relationships only succeed when they meet the particular psychological needs of the participants.

There is no basis for believing that there is only one way to conduct the mother-child relationship. While it is critically important that the relationship meet the psychological needs of the developing child, a successful mother-child relationship should also meet the psychological needs of the mother. And since mothers differ in their psychological needs, we should anticipate and celebrate many permutations of successful mother-child relationships.

I’ve written a series of posts over the past several weeks that point out what is wrong with the factual and philosophical claims of the “natural” childbirth movement. Several commenters have suggested that I have exaggerated the dogmatism and self-righteousness of NCB activists.

Fortunately, the Unnecessarean has reprinted a post from NCB activist Rachel that helpfully demonstrates the ignorance, self-righteousness and pathetic immaturity of NCB activists. Just consider the following quotes.

There’s a disturbing trend in feminist discourse that goes something like this:

… * the advocacy groups go a bit too far in their encouragement of the better/healthier practices and women begin to feel that their choices are now being curtailed in the opposite direction
* a backlash ensues in which we seem to feel that we have to deny the often well-documented and undeniable benefits of this thing the advocacy groups are fighting for.

Hence you see feminists denying that breastmilk is nutritionally better than formula, or that births with fewer medical interventions are, generally speaking, safer for mothers and babies. And this puts us in a really strange and irrational position, because we’re having to deny facts that are well-established through mountains of research.

No, Rachel, you seem to have missed the key point. There are NOT mountains of research that prove NCB claims. There is some research that is equivocal and contradicted by lots of other research. Indeed, what feminists are pointing out is that the very claim that breastfeeding and NCB are superior is NOT supported by the scientific evidence. Rather, those unsupported claims are being used to force women into a specific philosophic vision of motherhood.

I’ve been told that by merely noting that natural childbirth was an empowering experience for me I’m oppressing women for whom natural childbirth was not an option. And I’m sorry, but that’s bullshit, and that silences me and delegitimizes my experience.

No, Rachel, it’s not bullshit. The rest of us call it “being polite.” Your claim makes about as much sense (and reflects the same level of immaturity) as whining that people shouldn’t feel bad when you repeatedly announce that your children are the smartest and the best. The rest of us don’t need to know that you think your children are better than ours, no matter how fervently you believe it. Similarly, the rest of us don’t need to know that you think your birth experience was better than ours. To paraphrase the immortal words of Mad Magazine: “If we wanted your unsolicited opinion, we’d ask for it.”

“While I was pregnant I did a ton of research …”

No, you didn’t Rachel. You read tons of propaganda and because you can’t tell the difference between propaganda and research, you pretend that it is research. Did you read Williams Obstetrics? Did you read the top 100 or so scientific papers in obstetrics? If not, you haven’t done research. Reading Henci Goer on childbirth is like reading Eric Carle on very hungry caterpillars. It’s pleasant; it’s fun; but it’s not research.

My decision was based on the fact that, all other things being equal, natural childbirth is healthier for the mother and the baby than any of the other options. This is a non-normative, purely descriptive, well-documented fact.

Wrong again, Rachel. Why? Because “all other things” are not equal. Because emergencies in childbirth are common, not rare. Because childbirth is, in every time, place and culture a leading cause of death of young women and the leading cause of death of children.

And for me, personally, taking the natural route was also a defiant act of standing up to the bullying and the smirking and the micromanaging and the distrust of women’s bodies that’s so prevalent in the medical industry. It was me saying “Fuck you and your patriarchal fucking attitude toward my body and my mental toughness and my instinctive knowledge of how to birth my own fucking baby.”

See, that’s the immaturity I have been talking about. You think that risking your baby’s life is an act of defiance. It’s difficult to imagine anything more selfish, self-serving and childish than putting your baby’s life on the line to make a point.

And I took on natural childbirth, which was tough and painful and stressful and one of the hardest things I’ve ever done, and I fucking kicked its ass, and it was an incredibly empowering experience.

Well, then you’ve got to get out more, Rachel, and rack up some actual achievements. You’re proud of yourself because you did what any woman in the world could do if she felt like it? Are you proud of yourself because you did what your dog could do? Did you consider it an achievement for your dog when she gave birth without intervention? If it’s not an achievement for your dog, why on earth is it an achievement for you?

You “kicked its ass.” I’ve got news for you Rachel. Labor is not a person; it is a bodily function that happens without your control. Do you routinely kick digestion’s ass, too? How about urination? Are you proud of yourself when those things happen without intervention?

But my point is that silencing people when they talk about the flaws of our overly-medicalized, patriarchal approach to childbirth or about their personal experience of natural childbirth is not the answer.

Sorry, Rachel, but you cannot justify your desire to proclaim your superiority as striking a blow against the patriarchy. If the patriarchy is paying attention, it is laughing at your ignorance and immaturity. You are not promoting the cause of feminism. Indeed by insisting that there is one “right” way to be a mother and a woman, you are actively working against feminism, which exists to provide women opportunities to go far beyond any single view of motherhood or womanhood.

Rachel, you’re just another insecure NCB activist, with limited education, and limited professional success. You’re trying to feel better about yourself by pretending that reading propaganda is “research”, performing bodily functions is an “achievement”, and ignoring medical advice is “defiance.” And you’re being obnoxious in the process.

addendum: Apparently it isn’t enough for Jill at the Unnecessarean to remove comments that she doesn’t like. In a sign that she’s really afraid, she’s now trying to block my access to the website (which, of course, is easy to get around). The claims that she and her guests make are obviously so indefensible, even to Jill, that she wants to keep me from reading them and exposing them for the falsehoods that they are.

The folks over at the Journal of Midwifery and Women’s Health have a problem. They are obsessed with labeling birth. They are absolutely, positively certain that their view of birth is THE TRUTH, and want to give their view an adjective that proclaims to everyone (most especially themselves) that their view is the safest, best, healthiest way to have a baby. First they called it “natural” birth as if everyone who deviated from their prescription were somehow having artificial births or producing plastic babies.

In addition “natural” birth is a problematic description because the philosophy of “natural” childbirth bears absolutely no resemblance to childbirth in nature. Last I checked, childbirth in nature did not involve prenatal visits, blood pressure checks, periodic weighing. It also didn’t involve intermittent fetal monitoring, kiddie pools and neonatal resuscitation.

So midwives invented a new description used only by them and their acolytes: “normal” birth. But as Holly Powell Kennedy recognizes in an editorial in this month’s issue, calling their view of “normal” implies that anyone who doesn’t do it their way is abnormal.

… It is a word that dichotomizes—if you are not “normal,” then you must be abnormal, atypical, disordered, unhealthy, or irregular—and who wants those labels?

This issue doesn’t present much of problem for most of us. Normal birth is pretty simple: the baby that was once inside is now outside, and most importantly, the baby is healthy. That’s all there is to “normal” birth for most women. But that’s unacceptable to midwives like Kennedy, who in the tradition of birth activists, is obsessed with the process and considers the outcome almost irrelevant.

I propose that “normal” is commonly used by midwives as a way to describe a process that counters the common and escalating interventions in many birth settings. A more fitting term might be “physiologic”— that which reflects the innate capacity of a woman’s body to reproduce without intervention—and which most women would be able to achieve when left alone to find their strength, and supported as needed in the process.

There you have it: everything that is wrong with contemporary midwifery wrapped up in two somewhat clumsy sentences. Why is this sentence appalling? Let me count the ways.

1. “commonly used by midwives”

The definition that counts is the one that midwives select. There are no objective criteria.

2. “counters”

The correct views of midwives are oppositional. Whatever is common in current obstetrical practice is to be opposed. Do common practices save lives? Who cares? It’s about the process, not the outcome.

3. “innate capacity”

What is that supposed to mean? Every woman has the “innate capacity” to get pregnant, but that doesn’t mean that she can. Every women has the “innate capacity” to carry a pregnancy to term but that doesn’t prevent miscarriage. Every woman has the “innate capacity” to have a vaginal delivery, but that doesn’t mean that the baby will fit or that the baby will live through the process.

4. “reproduce without intervention”

Ahh, there’s that obsession with process again. And what’s wrong with interventions anyway? It’s as if Kennedy and other midwives oppose any interventions on the principle that they are inherently bad. No attempt is made to discern if the interventions are helpful or even if they are requested by a woman herself.

5. “most woman would be able to achieve”

Would the baby be alive at the end of this achievement? Would the mother be alive? Kennedy doesn’t say. It’s the process that counts, not the outcome.

6. “strength”

Oh, please, please stop the bullshit! Strength? Birth has precisely NOTHING to do with strength, either physical or spiritual. It depends on three things: the pelvis, the passenger (the baby) and the power (strength of uterine contractions). If the pelvis is too small, the baby won’t fit, and all the “strength” in the world won’t make a whit of difference. If the baby is too big, won’t fit and all the “strength” in the world is useless. If the uterine contractions are not forceful enough, the baby won’t come out and both mother and baby will die in the process, and, you guessed it, strength is irrelevant.

The stupidity doesn’t end there.

I suggest that our culture has situated childbirth fully in risk …

How sad for all those women and babies buried in graveyards around the world. They didn’t die because of the risks of childbirth. They were tricked!

Fear of birth has become the foundation of childbearing in US culture. We do not usually fear things that are normal …

Last I heard, most people fear death and there’s nothing more normal than death. Childbirth is one of the top 10 causes of death of young women in EVERY time, place and culture, including our own. Out of the 18 years of childhood, the day with the highest risk of death is the day of birth. Stop pretending that women fear birth and acknowledge reality: women fear that they or their babies could die and that fear is completely justified.

We live in … a culture that deifies technology and control, with no room for uncertainty of any kind or for less than perfect outcomes.

Yes, we live in a culture where we don’t like to wonder whether our babies will live or die and we certainly don’t like them to die or be rendered brain damaged. Evidently people like Kennedy, for whom the process is more important than the outcome, are willingly to risk “less than perfect outcomes” so they can brag out their “normal” births.

The problem here is not birth, it is midwives. This piece unwittingly reveals the profoundly unscientific, biased and self aggrandizing nature of contemporary midwifery. Midwifery is obsessed with labeling women, dividing them into those who give birth following the preapproved directives and those who do not. Midwifery is obsessed with insulting women who do not adhere to its principles. The language used, words like “natural” and “normal,” is deliberately and profoundly judgmental. Midwifery is obsessed with process; the outcome is virtually irrelevant and never even mentioned in the editorial. Midwifery is based on opinion, not science; in the entire editorial scientific evidence is not mentioned even once.

Midwives have appointed themselves arbiters of birth. They define, they judge, they pontificate. They are mean and they are wrong.

There’s something perverse about an entire industry predicated on the concept that excruciating pain is good for women. I’m talking, of course, about the “natural” childbirth industry, and the books, blogs, courses, videos and celebrities that comprise it. The “natural” childbirth industry isn’t always sure that the pain of labor exists, but they are sure that if it does, it’s desirable that women feel it.

The unalterable bedrock of “natural” childbirth advocacy is that women should refuse effective pain relief in labor. The “ideal” situation is for women to embrace their pain and pretend that it is “good pain.” Of course, there is no such thing as “good pain”: they just made that up. The pain of contractions and the pain of vaginal distention do not differ in any way from any other kind of pain. It is not carried by different nerves, it is not conducted through the action of different neurotransmitters, it is not routed to different areas in the brain. It is exactly the same as any other kind of pain. So the take home message of NCB is that the excruciating pain of childbirth should be ignored.

And not merely ignored. What’s worse is that the NCB movement pretends that women are improved by experiencing the agonizing pain of childbirth, although they cannot think of any other instance in which human beings are improved by agonizing pain. The irony is that “natural” childbirth advocates have beliefs that are strikingly similar to the Victorian clergymen who opposed anesthesia in childbirth when it was first introduced in the second half of the nineteenth century. The clergymen believed that is was wrong to abolish labor pain with anesthesia because God intended for women to feel the pain. NCB advocates appear to believe that it is wrong to abolish labor pain because “Nature” intended for women to feel the pain. There is precisely zero concern for the effect of that pain on a woman herself.

The “natural” childbirth movement routinely demeans women who do not want to tolerate the pain. They are portrayed as weak, as “giving in,” as uneducated and uncaring because they don’t understand the “risks.” Or worse. The ultimate insult, implied, but not always stated is that “authentic” women can and should accept the pain, and that, therefore, women who opt for an epidural are somehow less womanly.

There is one strain of “natural” childbirth advocacy that simply denies the reality of the pain. In this view, the pain of childbirth is psychosomatic in the true sense of the word. It does not reflect actual neurologic signals, but rather the social conditioning of women by a medical, technocratic culture. Pain is a manifestation of the fact that the woman has not “educated” herself that the pain doesn’t exist, doesn’t “trust” birth, and, once again, is not an “authentic” woman.

There is another strain of “natural” childbirth advocacy that acknowledges that the pain exists but that it can and should be “managed” in ways that are “natural” and inherently ineffective. The goal is not to abolish the pain; that would be wrong. The goal is to tolerate the pain so that the incentive to abolish it will be reduced. Hence the emphasis on hypnosis, water, and labor support. The pain is real, the pain is severe, and it is acceptable to reduce the pain. But it is only acceptable to reduce the pain in ways that involve no technology, and it is never acceptable to actually abolish the pain.

The “support” people in the “natural” childbirth movement exist primarily for indoctrination. The childbirth educator exists to convince women that pain is good for her, and pain relief is bad. The primary function of a doula is to interfere with a woman’s desire for pain relief. At every point, the doula counsels the laboring mother that she does not “need” pain relief, that she’s doing “great” and she “can do it,” with “it” being enduring labor without an epidural.

At the fringes of the “natural” childbirth movement is a group that not only denies the existence of the pain, but inverts it. Childbirth is not painful, it is pleasurable. No remotely plausible physiologic explanation is advanced for this claim, beyond the inane observation that the tissues that produce the pain of childbirth could, in different circumstances produce sexual pleasure. The explanation makes as much sense as the claim that kicking a man in the groin could induce orgasm because sexual pleasure can be produced by contact in the same area.

Why are “natural” childbirth advocates so invested in the idea that women “should” experience excruciating pain in labor? Why are they invested in the idea that women benefit from experiencing labor pain? Why do they direct the bulk of their efforts, both before and during labor, to pressuring women to forgo effective pain relief? Why do these efforts include misinformation about the “risks” of epidurals, and insinuations about the fitness of the laboring women as a mother, and even insinuations about her fitness as a woman?

I don’t know all the answers to these questions, but I do know this: it is inherently wrong to ignore the pain of women and to pretend that agonizing pain is good for them.

In my last post, I wrote about Harmony Newman’s PhD thesis Cross-Cultural Framing Strategies of the Breastfeeding Movement and Mothers’ Responses. What I found most compelling about Newman’s explication of lactivism is her claim that lactivism can only be understood within the framework of the dominant mothering ideology, intensive mothering. As she explains:

… [I]ntensive mothering is a belief system that demands that mothers provide unlimited amounts of care, attention and affection to their children. This dominant discourse of motherhood has been described as one that sees mothers as “selfless” and “sacrificial)”. That is, mothers are expected to focus primarily, if not exclusively, on their children’s needs rather than on their own desires and needs. Furthermore, mothers are increasingly being held responsible not only for the health and well being of their children, but also for their cognitive and intellectual development, and their overall short-term and long-term success in life.

Lactivism is best understood as a product of this ideology:

Breastfeeding fits within this dominant intensive mothering ideology as it is constructed as the ultimate infant feeding method—the healthiest way to feed a child and one of the best ways for an infant and mother to bond. Breastfeeding very often requires a considerable amount of time from the mother, as she is the only one who can provide the child this sustenance. A breastfeeding (and/or pumping) mother must also have dedication to persevere through the physical struggles that she may encounter. We see activists in the breastfeeding movement draw on this ideology in the construction of their persuasive arguments, encouraging mothers to fear for their children’s future health and possibly even feel responsible for failing to best protect their children if they do not breastfeed.

Newman points out that while all mothers are aware of the dominant ideology and most believe in it (hence the fact that it is the dominant ideology), there is wide variation in how rigidly mothers follow the prescriptions that flow from the ideology.

The strictly committed women believed that motherhood could not be understood in any way other than according to the dominant standards. In contrast, other mothers were resistant to the idea that one conception of motherhood should be applied to all women. These women were much more flexible in their ideological commitment to intensive mothering.

Those who are rigidly committed to intensive motherhood believe and behave in different ways than those women who have a more flexible commitment.

The women committed to intensive motherhood as ideal had a very particular conceptualization of what “good” motherhood meant. The mothers with a strict commitment described characteristics of good mothers as those who are “selfless” and “present.” …

These women are explicit in their construction of a good mother as someone who puts herself on the backburner, first addressing any needs her children might have. [Some] even [argue] that mothers who do not align with this ideology of selflessness should be considered “bad mothers.”…

This perspective—that “good” motherhood requires an unending amount of attention, affection, and selflessness—is a very demanding expectation for mothers. These women strictly believed in the standards of intensive mothering and expected those behaviors (and sacrifices) both from themselves and other mothers.

In contrast:

… [W]omen with a flexible commitment to the dominant standards of motherhood tended to agree that there was not one cut-and-dried way to parent. Instead, 65 percent of these women argued that mothers needed to figure out what sort of parenting style worked best for them and their children…

These women are critical of the idea that there are … rigid rules for parenting… [T]hey believe that different parents, children, and situations call for flexibility, and spontaneity in figuring out what the most appropriate response should be.

I consider Newman’s most important insight to be the recognition that contemporary mothering reflects one ideology out of many possible ideologies. The contemporary mothering ideology is not “The Truth,” but rather simply the currently popular viewpoint, differing dramatically from mothering ideologies of the past and possibly of the future as well. There is not one “right” way to approach mothering and what is right from one family may be inappropriate for another.

I would expand on Newman’s characterization of the flexibly committed mother to include another variation. It is possible to be personally committed to the ideology of intensive mothering for one’s own family, while being flexible in expectations of other mothers.

When I write about breastfeeding, lactivists often insist that my personal commitment to breastfeeding my four children is at odds with my medical advice to others. I don’t see any conflict. My commitment to breastfeeding is part of my personal commitment to intensive mothering. It would be fair to say that I raised my children in accordance with all the major principles of intensive mothering, particularly the commitment to always being present. BUT, and this is a very important but, my commitment to intensive mothering does not extend to belief that intensive mothering is the “right” way or the only way to raise children. It was right for me and my family; that doesn’t mean that it is right for everyone. Moreover, I now have the advantage of seeing how my children and other children are turning out. It is more obvious to me than ever that there are many ways to raise happy, healthy, well adjusted children.

There’s nothing wrong with the dominant ideology of intensive mothering. There is something wrong with insisting that the dominant ideology is the only correct ideology.

In a fascinating PhD dissertation, sociology graduate student Harmony Newman explains the strategies of the lactivist movement. Cross-Cultural Framing Strategies of the Breastfeeding Movement and Mothers’ Responses portrays lactivism as a social movement with the avowed goal of increasing breastfeeding rates. Lactivism exists in both the US and Canada, but the Canadian effort has been more successful. Newman looks at the strategies (“framing”) in both countries to determine if there is a difference. I found the dissertation valuable for the way in which Newman explains the American lactivist movement.

Increasing breastfeeding rates is certainly a noble motivation, but the tactics that have been adopted can be called into question, both on ethical grounds, and on performance grounds. The aim of lactivist tactics is to scare women into breastfeeding by inflating the benefits and concomitantly exaggerating the so called “risks” of formula feeding. Not only is this framing strategy disingenuous, it is a failure since it has not made any difference in breastfeeding rates.

Newman explains this strategy:

Through the active construction of formula feeding as a dangerous behavior, breastfeeding activists intend to change mothers’ health beliefs and behaviors such that they feel compelled to breastfeed rather than formula feed their children…

Specifically:

Fifty-nine percent of the documents sampled used a “baby-saving” approach in their endorsement of breastfeeding, which is more than twice as much as any other approach. In this argument, activists make the case that breastfeeding is a key ingredient in raising a healthy child and preventing a variety of illnesses, even death. Activists created three versions of the baby-saving frame, including a scare tactics approach, a focus on the child’s emotional health, and an emphasis on the mental development of the child.

Scare tactics represent the most common approach:

[Scare tactics] attempt to increase the urgency with which mothers should accept breastfeeding as the preferred infant feeding method by linking the failure to breastfeed with serious health risks, including the possibility of death (i.e., SIDS)…

Even though these arguments are portrayed as absolute, scientific fact, these arguments are better understood as a rhetorical strategy to persuade mothers of the health threats to their children (c.f., Best’s (1990) work on the construction of the child-victim). In contrast to this absolutist presentation, the evidence is more accurately described as suggestive and inconclusive…

Lactivists also invoke emotional and intellectual benefits:

… This framing strategy, which constructs breastfeeding as an “act of love,” puts another layer of pressure on mothers to breastfeed insofar as mothers might interpret the reverse of this argument to mean that those who fail to breastfeed their child somehow love their children less than mothers who breastfeed. Statements such as these, however, have very little evidentiary support…

And:

[An] information sheet on the benefits of breastfeeding contends that one of the “Costs of Not Breastfeeding” is a “3- to 11- point IQ deficit in formula-fed babies; [and] Less educational achievement noted with formula-fed children.” This push for parents to be concerned with the intelligence and learning capacity of their child resonates in a contemporary climate where education is key to accessing successful careers. However, this argument is certainly contestable. Although some research makes the claim that breastfeeding increases IQ, other research suggests that the relationship between breastfeeding and intelligence is much more complicated …

These strategies are scientifically suspect because they depend on the erroneous assumption that correlation means causation. It is true that breastfeeding is associated with a variety of benefits, but there is no evidence that breastfeeding itself leads to health, emotional or cognitive benefits. Breastfeeding rates are closely related to economic and educational achievement, both known to be important confounding factors. It could be the observed benefits can be ascribed to improved access to health care, and educational opportunities, rather than to breastfeeding itself.

These strategies are also ethically fraught because they deliberately misrepresent the state of the literature. Virtually none of the purported benefits are established science, but rather suggestive results of selected studies, much of which is contradicted by other scientific studies. In addition, even if the benefits are real, most are quite small, and not even clinically relevant.

Why have these scare tactics failed to increase breastfeeding rates? In large part it is because the scare tactics do not comport with what women have seen and experienced. Almost all women know many formula fed babies who grew into happy, healthy, intelligent children. Indeed, many women who consider themselves happy, healthy and intelligent were formula fed babies. Since it is difficult to reconcile lactivists’ claims with the life experience of these women, it follows that many conclude that the lactivist’s claims are false and nothing more than scare tactics.

Ultimately, the lactivists’ plan to scare women into breastfeeding is so transparent a tactic, it is doomed to failure.

Navelgazing Midwife, Barbara Herrera, continues her evolution as a clinician. She has gone from someone who had a UC (and nearly lost her child in the process), to a CPM, to a student CNM. During that time, her philosophy has evolved as well. Consider her current feelings toward those who reject the use of a midwife at homebirth (The UC Oxymoron):

I’m sure that part of it has to do with many UCer’s arrogance about their knowledge and abilities to avert complications or use wishful thinking to eliminate anything negative from happening at all. The puffed out chests, bragging that they don’t need anybody sours my desire to offer assistance – because I am “anybody.” So, if they don’t need anybody, don’t need anybody!

What’s striking to me is that Herrera recognizes that her changing views reflect her increased knowledge, but fails to understand that obstetricians’ view reflect the fact that they know more than midwives, indeed far more than CPMs who are undereducated and undertrained.

Homebirth advocates complain that obstetricians will not work with CPMs. It is ironic that they fail to see that obstetricians view CPMs in the same way that she views those who choose UC. Paraphrasing Herrera:

I’m sure that part of it has to do with many CPMs arrogance about their knowledge and abilities to avert complications or use wishful thinking to eliminate anything negative from happening at all. The puffed out chests, bragging that they don’t need an obstetrician sours an obstetricians’ desire to offer assistance.

This is not the first time that Herrera has expressed resentment of those who don’t think they need a midwife. Over 2 years ago, she wrote:

When I am hired to be someone’s midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life. As a consultant, one that differs from an interior designing consultant, I am being asked to take the lives of two people in my hands and to accept the consequences of the outcome whether that is a spritz of champagne or a cell in a prison. I’ve had a long time to adjust my considerations with my practice – and they might change again (I’d be shocked if they didn’t!). I see women as individuals, listen to their needs and concerns and if we both feel we could work together, I’m game to give it a go. If I find a woman lied to me about her medical or obstetric history, if she hides behaviors she doesn’t want me to know about or if she continually jabs at me questioning my concerns with her pregnancy (and all of these have happened in the last 2 years), I’m going to send her on her way. She is a liability I don’t need to take on… a risk to my profession and life.

She failed to see the irony that time, too.

Last week I wrote about the evidence that vitamins don’t prevent cancer. Now a new study demonstrates that the fruits and vegetables that contain those vitamins don’t prevent cancer.

The study, Fruit and Vegetable Intake and Overall Cancer Risk in the European Prospective Investigation Into Cancer and Nutrition (EPIC), by Buffetta et al. appears in the latest issue of the Journal of the National Cancer Institute. The study has two major strengths. It is large (over 400,000 people) and prospective, meaning that it followed people over time instead of depending on long term recall of dietary habits. The editors of JNCI have responsibly included a summary for the press, to be sure that the results are reported correctly:

… Paolo Boffetta, M.D., M.P.H., of the Mount Sinai School of Medicine in New York, and colleagues analyzed data from the EPIC study (European Prospective Investigation into Cancer and Nutrition), which included 142,605 men and 335,873 women recruited for the study between 1992 and 2000. The participants were from 23 centers in ten Western European countries–Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain,Sweden and the United Kingdom. Detailed information on their dietary habit and lifestyle variables was obtained. After a median follow-up of 8.7 years, over 30,000 participants were diagnosed with cancer.

The authors found a small inverse association between high intake of fruits and vegetables and reduced overall cancer risk. Vegetable consumption also afforded a modest benefit but was restricted to women. Heavy drinkers who ate many fruits and vegetables had a somewhat reduced risk, but only for cancers caused by smoking and alcohol.

Most importantly, the press summary explains the interpretation of the findings.

The authors caution against attributing any risk reduction to diet and they conclude that any cancer protective effect of these foods is likely to be modest, at best.

In this population, a higher intake of fruits and vegetables was also associated with other lifestyle variables, such as lower intake of alcohol, never-smoking, short duration of tobacco smoking, and higher level of physical activity, which may have contributed to a lower cancer risk,” they write.

In other words, the tiny observed benefits are more likely to be due to confounding factors than to represent any protective effect of fruits and vegetables.

In an accompanying editorial, Dr. Walter Willet, from the Department of Nutrition at the Harvard School of Public Health that the data suggesting a cancer protective effect of fruits and vegetables was never strong.

During the 1990s, enthusiasm swelled for increasing consumption of fruits and vegetables with the expectation that this would substan­tially reduce the risk of many cancers. Potential reductions as large as 50% were suggested. The National Cancer Institute’s 5-A-Day program was developed in 1991 to promote increasing the average consumption of fruits and vegetables to five or more servings per day … However, the evidence for a large preventive effect of fruits and vegetables came primarily from case–control studies, which can be readily biased by differences in recall of past diet by patients with cancer and healthy control subjects. Even more problematic, participation rates in surveys have fallen sharply over the past 50 years so that those who agree to be interviewed as control subjects are likely to overrepre­sent health conscience persons who smoke less, exercise more, and eat more fruits and vegetables compared with those who do not participate…

Yet despite the weak evidence, lay people and professionals alike embraced the conclusions enthusiastically. Why? As a society we have a disturbing tendency to promote simple (and often unproven) answers to complex issues. It would be wonderful if cancer, a complex and multifaceted disease, could be prevented by eating fruits and vegetables. Such a simple answer sounds (and is) too good to be true, and should have been greeted with skepticism instead of uncritical acceptance.

Within the scientific community, it has been known for quite some time that the protective effect of fruits and vegetables had been vastly overstated. As Willet explains:

… In the late 1990s, the results of large prospec­tive cohort studies of diet and cancer began to accrue, and these did not confirm the strong inverse associations found in most case–control studies. Furthermore, a series of analyses that pooled the data from prospective studies for specific cancer sites confirmed the weak and non-statistically significant associations. In a comprehensive 2007 review, these findings led to the reversal of conclusions for strong benefits of fruits and vegetables for many cancer sites that had been considered convincing or probable in a similar earlier review 10 years before.

That message has not reached the general public and even many healthcare providers.

Fortunately, there was no harm done, and there was possibly a benefit in a decrease in cardiovascular disease as a result. Nonetheless, it is yet another example of a disturbing trend in preventive medicine, the tendency to issue public health recommendations on the basis of weak data. As a result, public health recommendations are often modified or even withdrawn after only a few short years, leading to distrust of science in general and the medical profession in particular.