I watched the web cast of the NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights, which is occurring this week. Dr. Michael Socol, chief of OB-GYN at Northwestern, distilled the problem down to its essence. He said (I am paraphrasing) that if it were possible for women to sign a binding consent giving up their right to sue in the event of uterine rupture, there would be no need for the conference. Every doctor would be offering a VBAC to every eligible patient.It is liability that is driving the restriction of VBAC. Successful lawsuits have led malpractice insurers to void a doctors’ malpractice policies for presiding over VBACs.

Unfortunately, the law does not allow patients to sign away their right to file malpractice suits. Since that is the case, doctors have stopped doing VBACs.

During the question and answer session, a woman (it looked like Henci Goer, but the lighting was too poor to be sure) made the typically sanctimonious comment that patients should be “informed” that doctors would putting their liability concerns ahead of the patients’ well being. The comment accomplished nothing beyond demonstrating that the woman had no understanding of the issues involved.

Let me make it easier for VBAC activists to understand:

What would you do if your health insurance company made a rule that anyone who attempts a VBAC would automatically void their health insurance policy and lose all coverage forever. In other words, you’d be on the hook for your $15,000 hospital stay and your baby’s hospital stay. Not only that, your well baby visits to the pediatrician would no longer be covered. Your older child’s epilepsy medications would no longer be covered, nor would his occupational therapy. Your husband would have to pay for the medication used to control his blood pressure. You’d be out at least an additional $10,000 each and every year forever.

On the other hand, if you consented to an elective repeat C-section, everything would be covered and you would not lose any insurance benefits.

What would you do then? Would you be willing to void your health insurance policy and threaten the financial security of your family in order to have a vaginal delivery? Is a vaginal delivery worth paying $15,000 out of pocket AND all your health expenses for the rest of your life, totaling hundreds of thousands of dollars?

And if it’s not worth voiding your health insurance policy and being personally responsible for tens or even hundreds of thousands of dollars, why is it worth voiding a doctors’ malpractice policy?

Homebirths advocates are touting a reported increase in homebirths from 2004-2006. They ought to look at the actual numbers a bit more closely before they get excited. They don’t seem to realize that the homebirth rate in 2006 is exactly the same as it was in 2000. Homebirths still represent only a minuscule proportion of births in the US.

According to Trends and Characteristics of Home and Other Out-of-Hospital Births in the United States, 1990–2006:

In 2006, there were 38,568 out-of-hospital births in the United States, including 24,970 home births and 10,781 births occurring in a freestanding birthing center. After a gradual decline from 1990 to 2004, the percentage of out-of-hospital births increased by 3% from 0.87% in 2004 to 0.90% in 2005 and 2006. A similar pattern was found for home births. After a gradual decline from 1990 to 2004, the percentage of home births increased by 5% to 0.59% in 2005 and remained steady in 2006… About 61% of home births were delivered by midwives. Among midwife-delivered home births, one-fourth (27%) were delivered by certified nurse midwives, and nearly three-fourths (73%) were delivered by other midwives.

In other words:

From 2004 to 2005 out of hospital births (planned plus unplanned) increased from 0.87% of births to 0.90% of births; there was no increase from 2005-2006. Among births at home from 2004-2005 (planned plus unplanned) there was an increase from 0.56% to 0.59%; there was no increase from 2005-2006. But the homebirth rate dropped from 2000-2004, so the purported “increased” homebirth rate in 2006 is actually unchanged from the homebirth rate in 2000.

addendum: This graph makes it easier to see what happened.

The helicopter parent is dead. Long live the snowplow parent!

We’ve all heard of helicopter parents, mothers and fathers who hovers over a child’s every decision and action. Evidently helicopter parents have evolved into the snowplow parent s “who determinedly clears a path for their child and shove aside any obstacle they perceive in the way.”

So says Craig Lambert in an article in this month’s issue of Harvard Magazine. The article, Nonstop: Today’s superhero undergraduates do 3,000 things at 150%, detailing the frenetic pace and relentless ambition of today’s undergraduates is by turns horrifying and depressing.

Students today routinely sprint through jam-packed daily schedules, tackling big servings of academic work plus giant helpings of extracurricular activity in a frenetic tizzy of commitments. They gaze at their Blackberries … to field the digital traffic: e-mail and text messages, phone calls, Web access, and their calendars. Going or gone are late-night bull sessions with roommates and leisurely two-hour lunches …

There’s a wide consensus that today’s undergraduates make up the most talented, accomplished group of polymaths ever assembled in Harvard Yard: there’s nothing surprising about meeting a first-chair cellist in the Harvard-Radcliffe Orchestra who is also a formidable racer for the cycling club, or a student doing original research on interstellar dark matter who organized a relief effort in sub-Saharan Africa…

The paradox is that students now live in such a blur of activity that idle moments for such introspection are vanishing. The French film director Jean Renoir once declared, “The foundation of all civilization is loitering,” saluting those unstructured chunks of time that give rise to creative ideas. If Renoir is right, and if Harvard students are among the leaders of the future, then civilization is on the precipice …

What’s driving this frenetic activity? Relentless ambition that starts surprisingly early:

Busy parents book them into things constantly—violin lessons, ballet lessons, swimming teams. … Dingman [dean of freshmen] notes that, “Starting at an earlier age, students feel that their free time should be taken up with purposeful activities…

Home life has changed in ways that would seem to undercut children’s development of autonomy. There was a time when children did their own homework. Now parents routinely “help” them with assignments … Youngsters formerly played sports and games with other children on a sandlot or pickup basis, not in leagues organized, coached, and officiated by adults … Once, college applicants typically wrote their own applications, including the essays; today, an army of high-paid consultants, coaches, and editors is available to orchestrate and massage the admissions effort.

Parents have created this culture. As Lambert explains, ” The strategizing starts early; today’s parents groom their children for high achievement in ways that set in motion the culture of scheduled lives and nonstop activity… “

While “snowplow parents” seem to be a new phenomenon, I suspect that are just a variation on a phenomenon as old as recorded history: wealthy parents ensuring children’s success by paving the way with money and social connections. The prep school has been replaced by the public high school with multiple AP courses, the European grand tour has been replaced by the summer trips to far off lands, the social clubs replaced with the National Honor Society as the reward for extensive tutoring, special courses and advanced summer programs. Money, copious amounts of it, is usually required.

Sure anyone can go to public school, but very few can afford to live in the communities with the best schools; schools are usually funded by property taxes and estate sized homes for wealthy families provide an excellent tax base. Those fabulous summer trips to work on a dig in Egypt or study intensive Italian in Florence cost a fortune. And tutors, special courses and advanced study at college programs designed for high school students don’t come cheap.

It used to be that money and social connections assured a child’s success. Now actual merit is required, but money and social connections pave the way just as they always did. An outstanding athlete requires talent, but talent can honed with private coaches and exclusive leagues. To become a brilliant scientist requires brilliance, but a summer working in the award winning lab of Dad’s medical colleague gives a teen an undeniable advantage. And woe to the child who has not devoted serious time to “social action,” time that children of modest means must spend at work in order to help their families make ends meet.

Not only do parents script their children’s lives and pay for every possible advantage, they run roughshod over anyone and anything that dares to stand in the way. It’s bad enough that they will not back teachers in ensuring good behavior in schools, but it is ridiculous that they expect to be able to call a college to “check up” on their sophomore, and it is downright harmful that some come along to job negotiations or try to amend grades in law school.

Snowplow parents forget that their principle job is not to make sure that a child is successful, but to make sure that a child becomes a competent adult; the success will follow if it is merited. Any parent who is calling their child’s law school professor has no faith that the child can perform even the most basic tasks of adulthood, hardly surprising since the parents never taught them how.

Snowplow parents believe they are helping their children, but in many cases they are hurting them. They are depriving them of the opportunity of gaining competence by overcoming disappointment or by striving to reach goals instead of having the goals slid to within easy reach. How will these children make their way in the world when their parents are gone? How will these children learn to value themselves for who they are instead of what they achieve? And how will these children handle the disappointment of realizing that it may not always be possible to achieve what they desire?

Parents should be active and involved in their children’s lives. And parents sometimes have to run interference for children, particularly when children are young and vulnerable to the whims of teachers and coaches who may be cruel or unfair. But that does not require a snowplow, it doesn’t even require a shovel. It requires a more subtle tool such as a broom, one that gets smaller and smaller as the years pass until it finally fades away altogether.

A child in college should be competent enough to manage anything that comes along outside the realm of a true disaster like sexual harassment on the part of a professor, or a roommate who is mentally ill, in other words, very rare occurrences. If a parent cannot trust a child to manage on his own at college or beyond, then something is wrong, not with the child, but with the parent, who failed to ensure that the child gradually learned to handle the basic tasks of adulthood.

Homebirth advocates like to tout the many “advantages” of giving birth at home. High on the list is limiting exposure to hospital acquired infections, and since only your “own germs” are in your home, you are protected. Yes, you are protected from hospital acquired infections, but the most dangerous infectious agents are actually those that live inside the mother, not the ones in the hospital. Consider that for newborns both Group B strep and herpes virus represents potentially deadly threats. And both Group B strep and herpes virus are infectious agents carried by the mother. In other words, the most deadly infectious threat to the baby is the mother herself.

For mothers, the most common infectious risk is a uterine infection. Once again the infectious agent is usually a bacteria living in the vagina. Homebirth advocates like to fling accusations about women who contract life threatening sepsis at home and are fond of pointing out horror stories like the unfortunate woman in Florida who ended up losing parts of multiple limbs due to Group A strep (“flesh eating” bacteria) sepsis. But what they don’t realize is that approximately 90% of cases of Group A strep sepsis are acquired outside the hospital because the bacteria lives in the community. Usually it is harmless, but when it invades a wound (like the raw surface of the inside of the uterus after birth), the results can be disastrous.

It appears that this has happened in a small Texas town. According to the local paper:

A few weeks ago, a perfectly healthy Katy gave birth to daughter Arielle, only to experience an intense and prolonged pain after the birth.

… Doctors at Kingwood Medical Center eventually discovered the new mom had a Streptococcal A infection that had aggressively invaded her body.

As a result, Katy has experienced multiple organ failure and is unconscious. Surgery last week involved the removal of several sepsis organs. She is currently on a ventilator and is receiving dialysis.

Katy had had an eight hour, drug-free, intervention free labor and delivered a 10 pound baby girl … in a planned homebirth.

Of course, the result may not have been any different had Katy given birth in the hospital, since she would have brought the bacteria in with her. And that is the important point to keep in mind. While hospital acquired infections are a serious problem for the elderly and the immuno-compromised, they are far less common in obstetric care. During childbirth, the bacteria and viruses that pose the greatest threat to babies and mothers are those carried by the mother herself. Homebirth does not offer protection against serious neonatal and maternal infections, because the most dangerous “germs” are “your own germs at home.”

Katy has no health insurance. A variety of events are being held to raise money for her and her family. Find out more here.

What do episiotomy and Cesarean section have to do with Hitler? Nothing, actually, but it did catch your attention. Perhaps it was simply to catch your attention that Dr. Michael Klein entitled his editorial in this month’s edition of the journal Birth What Do Episiotomy and Cesarean Have to Do with Copernicus, Galileo, and Newton? Episiotomy and Cesarean section have nothing to do with Copernicus, Galileo and Newton, either.

Yet I suspect that the title was more than a cheap bid for attention. Rather, it was an example of the ludicrous grandiosity of Dr. Klein and certain other critics of modern obstetrics: he actually believes that he should be included in the pantheon of scientific immortals, among Copernicus, Galileo and Newton. In other words, Dr. Klein suffers from the “conceit of the brilliant heretic.”

Consider the way he begins his essay:

Like those who thought the world was flat and the sun revolved around the earth, believers in routine episiotomy considered its use as based on “normal science,” as defined by Thomas Kuhn, and fully accepted within the obstetrical/gynecological community — a discipline that saw birth as inherently abnormal, and whose scientific questions were based on this conception of reality as the only framework for legitimate inquiry…

In the early 1980s, I pondered how to get funded for a randomized controlled trial of an accepted procedure that I thought was inappropriate when applied routinely. Later I struggled to get the episiotomy trial published when the dominant culture
wanted the results buried. In this context, I thought about how strongly held beliefs came about and the critical importance of timing. And then I discovered
“paradigm shift,” as coined by Kuhn.

So obstetricians who used episiotomies were flat-earthers, awaiting the arrival of a man of extraordinary brilliance like Michael C. Klein, MD, CCFP. But when the great man appeared in their midst, those ignorant obstetricians did not recognize his brilliance (possibly because it was blocked by the size of his enormous ego). Fortunately, he can soothe himself by comparing their response to those who refused to recognize the seminal insights of Copernicus, Galileo and Newton. He, too, was persecuted for his earth shattering insights.

Sound familiar? It’s the “conceit of the brilliant heretic” that refuge of crackpots everywhere. I have written about it before. As explained in The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession by Paul Wolpe, Klein believes:

[His view] is the inevitable (or desirable) next step in the history of medicine, and like other heroes of medical history who were initially rejected by the orthodoxy of the day … [he] is simply ahead of his time. Innovation is always initially resisted … [People like Klein] portray themselves as mavericks, leaders, with every expectation that soon all of medicine will, by necessity, follow in their footsteps.

It is a conceit of monumentally embarrassing proportions. Klein imagines that his work on episiotomy is of equal importance to the theory of the Earth revolves around the sun. Klein dares to equate the way obstetricians treated his hypothesis with the persecution of Copernicus and Galileo. Really, Dr. Klein? Did anyone threaten to kill you for your beliefs? Did they threaten to excommunicate you from your religion? What, after all, did they do to you? Evidently they failed to recognize your genius, in your mind a sin every bit as monstrous as the threats to Galileo’s life.

By the way, Dr. Klein, including Newton betrays a deficit in your knowledge of history. Newton was not persecuted. He was a founding Fellow of the British Royal Society, which as the name implies, was blessed with a royal patron, no less than the king himself. You can’t get recognition more official than that. But I guess the temptation to compare himself to Newton was too great for Dr. Klein to resist, regardless of historical inaccuracy.

I’m going to go out on a limb here and assert that Dr. Klein’s finding that routine episiotomy might increase the risk of severe perineal tears is NOT equivalent to the insight that the sun is at the center of the galaxy, even if it were true; and his findings have not been reproduced often enough to be sure that he is correct. Indeed, recent scientific evidence suggests that the decline in episiotomies has not been followed by the decline in perineal tears in the magnitude that his finding predicts.

I’m also going to give Dr. Klein a bit of friendly advice. If he intends to be taken seriously, and not laughed off the stage at future professional meetings, he ought to stop comparing himself to the immortals of science. He is not one of them. He should be profoundly embarrassed that he dared to mention his own name in association with theirs.

I’ve got news for Dr. Klein. His findings are not earth shattering. They have not changed much of anything in modern obstetrics, let alone ushered in a new paradigm. They are a few paltry observations on the possible consequences of a minor surgical procedure, nothing more and possibly a lot less.

One of the big problems with science is that you do the experiment and it doesn’t support your thesis. What to do? Slice and dice the data to make it look better, of course.

That’s just what happened in a study that purports to show that acupuncture alleviates depression in pregnancy. This would be an important finding if it were true, since some pregnant women suffer from depression and are wary of the risks of taking antidepressants in pregnancy.

In Acupuncture for Depression During Pregnancy, the authors set out to investigate whether acupuncture could alleviate symptoms of depression:

Qualified participants were randomized to acupuncture specific for depression, acupuncture not specific for depression, or prenatal massage…

Acupuncture specific for depression was tailored individually to address each participant’s depression-related patterns of disharmony according to the principles of traditional Chinese medicine and following a published standardized treatment manual.26 Acupuncture not specific for depression was also standardized and needles were inserted in real acupuncture points that did not address depression-relevant patterns of disharmony according to traditional Chinese medicine…

Swedish massage was provided in a standardized fashion and included effleurage and pétrissage strokes…

There were 141 participants in the study, randomized as follows: 46 received acupuncture specific for depression, 48 received acupuncture not specific for depression and 40 received massage. Response to treatment was defined as a more than 50% reduction on the Hamilton Rating Scale for Depression, as well as a HRDS score between 7-14. In other words, the patients were still depressed, but their symptoms had decreased markedly. Remission was defined as achieving an HRDS score of less than 7.

Did acupuncture specific for depression result in remission of depression. The authors acknowledge that it did not.

Remission rates were not significantly different between the group receiving acupuncture specific for depression (16 of 46, 34.8%) and the combined control groups (26 of 88, 29.5%; number needed to treat 19.1); the remission rates for the groups receiving acupuncture not specific for depression and prenatal massage did not differ (11 of 40, 27.5%; and 15 of 48, 31.2%, respectively; number needed to treat 26.7). Acupuncture specific for depression remission rates did not differ from either the group receiving acupuncture not specific for depression (P=.47; number needed to treat 13.7) or prenatal massage (P=.72; number needed to treat 28.3).

But did acupuncture for depression produce an improvement in symptoms (a response)? The authors claim that it did, stating:

Response rates were significantly higher for the group receiving acupuncture specific for depression (29 of 46, 63.0%) than for the combined control groups (39 of 88, 44.3%; P<.04)... The control interventions did not differ from each other, 15 of 40 (37.5%) for the group receiving acupuncture not specific for depression and 24 of 48 (50%) for the group receiving prenatal massage; P=.24)...

But on closer inspection, the data does not support the authors’ claims. Yes, the data show that acupuncture specific for depression produced a statistically significant higher rate of response than non-specific acupuncture (63% vs. 37%). And the data also show that acupuncture for depression produced a statistically significant higher rate of response than found in a group created by combining non-specific acupuncture + massage (63% vs, 44%). But, the difference between the response rate for acupuncture specific for depression and massage was not statistically significant (63% vs. 50%; P=0.20).

In other words, acupuncture specific for depression produced an effect that was not different from that of one of the controls. But by creating a group that combined non-specific acupuncture (ineffective) with massage (effective), they were able to create a composite that was ineffective, and then they compared the experimental group with the composite. But that doesn’t change the fact that acupuncture for depression was no better than massage.

Have the authors shown that acupuncture specific for depression is effective for treating depression in pregnant women? I don’t think so. If it offers no advantage over massage, we can forget about acupuncture and simply offer depressed pregnant women a day at the spa. It is no less effective and probably far more enjoyable.

Folks, you are the first to know: I quit Science Based Medicine. What a relief!

The osteopathic medical student who writes Mom’s Tinfoil Hat is obsessed with the process of birth and thinks that you should be, too. In dispensing advice on choosing an OB provider, she doesn’t even mention the most important characteristic, the skill level and professional reputation of the provider. Instead she concentrates on the atmospherics.

Step 1 for choosing a provider:

Episiotomy: Do you employ them? Routinely? Under what circumstances?

It is up to you, but this would be my main litmus test.

The main litmus test?

Let’s step back a minute and consider why you choose any obstetric provider. As I have written many times in the past, anyone can deliver a baby if there are not going to be complications. All you have to do is hold out your hands and make sure the baby doesn’t hit the floor. Dads, policemen and taxi drivers do it on a regular basis.

The reason to choose a professional provider is because childbirth is inherently dangerous and many complications do not announce themselves until they occur during the process of birth. You choose a provider to prevent, diagnose and manage complications, limiting the possibility of severe injury or death of the baby or mother. So the last thing that you should care about is whether the provider promises not to cut an episiotomy. The chief priority ought to be the baby’s and mother’s lives, not the mother’s perineum.

What other factors might you use to judge a provider. The blog author suggests among others:

During labor, can I eat and/or drink? Can I have access to a tub for labor, or a shower, or walking, or a birth ball, or my own clothing, or (fill in the blank)? Can I bring a doula to my labor? How many support people can I have, and what are the visitation rules in general? Can my support person spend the night with me in labor and after the baby is born? Do you require an I.V.?

What do all these factors have in common? They are all about atmosphere. They make about as much sense as choosing a provider because of the color of the office walls or the type of magazines in the waiting room. Sure they might make you feel more comfortable, but they will do nothing to protect you in the event of an emergency.

Of course, “natural” childbirth advocates like to pretend that they will not have complications, and as long as you are pretending, you might as well pretend that wearing your own clothes is more important than the skill level of the provider.

This is a classic example of the “natural” childbirth obsession with process over outcome. Most obstetric providers (obstetricians and CNMs) are obsessed with outcome. The goal is the birth of a healthy baby to a healthy mother. All efforts are governed by that goal.

In contrast, “natural” childbirth advocates are obsessed with the “birth experience” and not just any birth experience, either. It must be the pre-approved, highly stylized experience that they have idealized. No pain relief, a birth ball, and, as the blog author emphasizes above all else, a perineum untouched by the provider, except, of course to sew up the lacerations that occurred spontaneously.

How should women who care about the outcome choose a provider? The first step is to make sure the provider is qualified. What is her training? How long has she been in practice? How many deliveries has she done (this is especially critical in choosing a CPM since they usually have paltry clinical experience)? Has the provider been disciplined by the relevant professional board? Has the provider been found guilty of malpractice or paid out a settlement? All obstetricians will be sued once or twice and insurance companies often force settlements. However, alarm bells should ring if the provider has been sued six times and paid out multiple claims.

It is also important to find out about the hospital, if you are choosing a hospital. Does the hospital have a level three nursery? Is there a pediatrician or neonatologist available around the clock in case the baby is born with a problem like difficulty breathing? Has the hospital been downgraded by JACHO, the hospital accreditation board? Have there been any maternal deaths at the hospital and under what circumstances did they occur? This can often be difficult to find out because hospitals usually insist that patients and families cannot discuss a legal settlement if a case is settled.

In other words, the most important factor is safety. What level of safety can the provider and hospital be counted on to provide? Only after that has been ascertained can the atmospherics be considered.

Like many “natural” childbirth advocates, the blog author displays an astounding amount of denial about the risks of childbirth and complete indifference to what training is required to be a good, safe provider. She asserts in the comment section:

I mean, if I was going to get a complicated and rarely performed procedure done, I would probably want to ask my surgeon about his experience and skill level – how many of these procedures have you done, and what were the outcomes? But, with a relatively common, non technical event, like a physiologically normal vaginal delivery, I think practice patterns for common interventions, informed consent, and basic practical questions (can my partner spend the night in the post partum room?) make much more sense…

No ob/gyn can finish a residency without doing a serious number of deliveries, vaginal and cesarean. I don’t think skill level is a big issue there.

First there is the assumption that complications will not occur. Second there is the assumption that skill means merely technical skill. Sure any obstetrician can do a vaginal delivery or C-section, but the skill that counts far more is clinical judgment, knowing how to prevent, diagnose and manage complications. All obstetricians are essentially equal when it comes to most clinical skills, but they are not equal when it comes to judgment.

I’m not suggesting that the atmospherics are irrelevant. They can make a big difference to the mother’s comfort level and certainly deserve consideration. However, they take a back seat to safety concerns. Once you have found competent providers, you can choose between them based on the atmospherics. Dwelling on your intact perineum is cold comfort if your baby dies of a preventable cause.

Unassisted birth advocate Rixa Freeze ponders how different women can view epidurals very differently:

Epidural + empowerment are two words that don’t always get put together in the same sentence, even among women who gladly choose epidurals for pain relief. For me–huge caveat that I’m speaking about my own thought processes here, not generalizing myself onto all women–an epidural is the opposite of empowerment. Not just emotionally or psychologically, but in the literal sense, too, because an epidural causes full or partial paralysis from the waist down. The thought of losing sensation, of literally being unable to walk or move, isn’t something I would look forward to in labor. To me, labor = movement. I cannot imagine having a contraction without moving in response to it.

She views epidurals as disempowering because they limit movement and sensation, yet there are many women who find them empowering because they eliminate pain. Dr JaneMaree Maher of the Centre for Women’s Studies & Gender Research at Monash University in Australia,offers a very different way of conceptualizing pain and empowerment, one that resonates with the majority of women. In her article The painful truth about childbirth: contemporary discourses of Caesareans, risk and the realities of pain , she observes:

… Pain will potentially push birthing women into a non-rational space where we become other; ‘screaming, yelling, self-centered and demanding drugs’. The fear being articulated is two-fold; that birth will hurt a lot and that birth will somehow undo us as subjects. I consider this fear of pain and loss of subjectivity are vitally important factors in the discussions about risks, choices and decisions that subtend … reproductive debates, but they are little acknowledged. This is due, in part, to our inability to understand and talk about pain.

As she explains:

… [W]hen we are in pain, we are not selves who can approximate rationality and control; we are other and untidy and fragmented. When women give birth, they are physically distant from the sense of control over the body that Western discourses of selfhood make central; they are very distant from the discourses of choice that frame the caesarean rates debate. I am not suggesting here that women become irrational in childbirth … I am however suggesting that we continue to frame birthing experiences and decisions as if that model of subjectivity were the relevant one and in so doing, we move further away from articulating the realities of birthing, of pain and of the ways in which women engage.

So epidurals, as the most effective form of pain relief, give women control over their own bodies and control over the way in which they behave. This allows women to represent themselves to others in the ways in which they wish to be seen, instead of pushing them into a “non-rational” space.

While women like Rixa value the ability to move above all else, and therefore consider forgoing an epidural empowering, most women value the ability to control their own bodies and control the way that they behave. For them, pain is disempowering because it robs them of the control they value, and robs them of the ability to articulate other desires or even speak.

The bottom line is that there is nothing inherently empowering about pain or pain relief. It depends on what each individual woman values and wishes to control. Wanting to move in labor is no more or less important than wanting to be comfortable in labor. Women who choose epidurals find them very empowering.

“Natural” childbirth advocate like to declare to all that they are “educated” about childbirth. However, the only way to be truly educated is to read the scientific literature. Therefore, I highly recommend two posts about reading scientific papers that I found in a rather surprising place.

Consider the following quotes:

Start with the abstract, a short summary of what the article contains. The abstract will give you a brief overview of the article and its contents. Keep in mind that abstracts are not comprehensive, and are written by the study authors. They are in a sense similar to theatrical trailers. You can often get the basic gist of what the article is about from the abstract, but just like a well-done movie trailer can make a bad movie look good, you can’t gauge the quality of an article by the abstract alone. Read the whole thing! (emphasis in the original)

And:

… The biases that we have act as a filter that alters our reactions to the research. If we already have our minds made up that induction of labor = bad, then any research on labor induction is going to be seen through that filter. Any research that seems to place induction in a favorable light will be seen has highly suspicious. Any minor flaws will be exaggerated. Any research showing bad outcomes from inductions will likely get a “free pass” and flaws may be overlooked….

… I have, over the years, seen the best and worst of research used to back up various points, ignoring the quality (of lack of it!) as long as it agrees with them. This is a normal human tendency, and one that is at the heart of many discussions about the available research.

It sounds like I could have written either of them, but I didn’t. They come from Andrea Lythgoe and Amy Romano writing on the Lamaze website Science and Sensbility. Bravo to them for acknowledging that being educated starts with reading the scientific literature.