Natural childbirth advocates often imply that shoulder dystocia is not big deal when successfully resolved. But the consequences of shoulder dystocia don’t end when the baby is born safely. Rachel Acosta and her son have been living with the consequences of his shoulder dsytocia: a brachial plexus nerve injury leading to a partially paralyzed arm known as Erb’s palsy. She is suffering terrible regret and wrote to tell me her story, hoping that she might prevent other babies from being injured and other women from feeling responsible as a result.

No natural childbirth advocate or OB-GYN ever mentioned brachial plexus injuries.

It was not in the 2008 What To Expect it was not in my silly birth plan book I bought. In fact no one ever said (my peers, SAHMs, or doctors or hippy friends for lack of better word) ever said: if the baby gets stuck he could die of brain damage or have a permanently damaged arm.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural birth advocates made it seem like doctors are referees trying to foul you out so they can slice you open.[/pullquote]

Natural birth people I met consistently made it seem like doctors are referees trying to foul you out so they can slice you open. The Business of Being Born scared me.

I sat in front of a doctor and asked him how do I avoid a C-section. The doctor asked, “What did your first baby weigh? Did you tear, did he have shoulder dystocia?”

He recommended I have a C-section. No explanation. If only he had said, “Babies get stuck and die; a second labor is not always shorter or easier than the first.”

Maybe I would have understood if only I was thinking straight and was less guarded.

I joined a baby wearing group. I hired a doula for $450. I asked around for a low intervention OB and he was recommended by all the AP and baby wearers and natural birth people.

I attended the natural birthing class and apparently my interest in the subject made the doula say, “Are you sure you don’t want a home birth? You’re a great candidate!” Now I shudder at that thought. The saving grace was that I was in a hospital with trained professionals when the shoulder dystocia happened.

Apparently desire is the only thing you need to be a home birth candidate. I was obese, had a history of large babies and a previous shoulder dystocia. And in Ohio, home birth is illegal. I should have known then that the doula was wonky.

Wonderful people were telling me big babies are born easily and flawlessly. They said there were so many pros for vaginal delivery, but they were all cancelled out by shoulder dystocia:

No major surgery if I go vaginal:

The consequence but now I have a grade 2 cystocele. My bladder bulges out; it’s visible and I can’t barely hold urine in. I have to have procedure to fix the prolapse.

Speaking of surgery my son will have nerve transfer surgery from his Erb’s palsy brachial plexus injury if he doesn’t meet the next few milestones. That’s a major surgery for a little 1 year old. That certainly cancels out a pro of avoiding a C-section.

Better bonding skin to skin:

Bullshit! They were trying to get my child to breathe and I did not hold him for the longest time. It’s hard to bond with a baby who was perfect and that you were supposed to protect but you didn’t research enough. It’s hard to bond with a baby who’s arm is completely limp because of my choice. It’s hard to bond with a baby when you regret being a diva I did not know my demands were stupid; that’s a source of my postpartum depression.

Being able to go home sooner if you have a vaginal birth:

No that was canceled out we had to wait for him to be cleared to leave.

Faster recovery time, my favorite!

The vaginal birth canceled that out because my second was 11.5 lbs (sad I can not even be proud when I say his weight) so I got a third degree tear.

Lastly vaginal birth is not traumatic.

No, that was cancelled out. What’s really traumatic is almost losing your baby from your defiance fueled by ignorance.

I got postpartum depression. I had tons of stitches. I still have to have surgery and my bonus prize for begging and begging for a vaginal is a beautiful baby with arm issues that are slowly resolving, but I am one of the lucky ones.

I really want to raise awareness of Erb’s palsy. Often we look for the positive stories, but had I only heard one negative story of big babies I would have never risked my child’s arm use. Even if someone told me “your child will not have arm use for just one day,” I still would not risk it.

That’s not all:

In my overzealous search for this stupid ideal birth I alienated the women in my husband’s family who had medically necessary C-sections (breech and twins and emergency). But when I turned to the natural birth people who had encouraged me, they kept asking me “well, did you have an epidural??”

“Did you try squatting?”

“You’re overweight; were you eating a lot of sugar?” Somehow the latter become important only they wanted to discredit my story.

Every thing I have shared was turned around and used against me as if everything that saved my sons life and mine was an error and my fault.

My birth plan seems so narcissistic when I read it now. One source of my depression was the stupid affirmation, “your body would not make a baby to big to birth.”

The birth plan said “only intermittent monitoring so I can have free movement.” But I couldn’t move I could only screech and hold my breath and beg for my husband to punch me so I can pass out. I did get a regional epidural only because I lost all energy from just the hours of being alive and in pain. My doula kept blaming me, saying, “When you tense up your pain will be higher.”

I have to clarify I absolutely did try squatting and every position to open me up laying down with the hospital tray table elevated to lay in between my legs to open me up.

Once I had reviewed the epidural I could actually make sentences and I felt so bad about getting it even though I could feel the pain and could move; I felt like a sell out.

My doula told me that I could have done it had I been mentally stronger, even though I had been “strong” enough to push out a 11.5 lb 22.5 inch baby. She implied that the shoulder dystocia and 3rd degree tear happened because I had caved from the pain.

But it’s funny and sad that now I’ve met some very nice women in the Erb’s palsy group. There’s even one from my state and we go to the same brachial plexus center. She had a home birth and a brachial plexus injury more severe than my son’s injury. She really saved my life and my marriage when she told me that no epidural plus free movement does not always equal no shoulder dystocia. Because she had done just that in her home and still encountered a consequence of it a shoulder dystocia and brachial plexus injury. When I heard she had done everything I attempted to do and still got I thought to myself that the epidural and the doctor were my SAVING GRACE.

For months when I put my son onesies over his head and I had trouble I would think back to the terror that childbirth was. How he was stuck and we were coded and they saved him but his arms didn’t work symmetrically. My poor little guy he was trying to be born safely and here I was making deals against his survival

The shocking part I have received more sympathy from the doctor than anyone else even though he had recommended a C-section.

I had worried about the cost of a c-section as if I were refused coverage by insurance and thought of the horror stories of how costly a c-section bill would be. But weekly physical therapy visits for 9 months combined with 3 trips Cincinnati Children’s Hospital brachial plexus clinic is not cheap either.

I feel like the doubt that is spread online is insidious and I treated my doctors like biased referees in a ball game instead of guardians of my child’s life and mine.

 

There’s a critical difference between midwifery/breastfeeding research on the one hand and real scientific research on the other. Indeed, midwifery/breastfeeding research has more in common with Big Pharma research than it does with actual science.

What’s the difference?

Scientific research seeks to learn, specifically to learn how the human body works and how to maximize healthy outcomes. Midwifery/breastfeeding research, like Big Pharma research, seeks to justify the product that they are already selling.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Midwifery/breastfeeding research, like Big Pharma research, seeks to justify the product that they are already selling.[/pullquote]

Don’t believe me?

The hallmark of Big Pharma research is that it always shows that the drug being tested is safe, efficacious and worthy of being prescribed routinely. No doubt Big Pharma does research that shows that it’s drugs aren’t safe, don’t work and shouldn’t be prescribed, but that research is never allowed to reach the light of day.

Search any midwifery journal for whichever years you choose and you will find that anything a midwife can do is safe, efficacious and worthy of being prescribed routinely. You will never find a paper that calls into question any aspect of contemporary natural childbirth advocacy.

Similarly, if you search any breastfeeding journal, you will find that every single article concludes that breastfeeding is safest, always better than formula and therefore worthy of being forced on every mother and baby. You won’t find papers that call into question the assumed superiority of breastmilk.

That difference extends to professional conferences.

Attend obstetric conferences and you will find countless sessions on “controversies in obstetrics.” When is induction appropriate? What’s the right C-section rate? What’s the best way to prevent postpartum infections? In those sessions there are always people on both sides of the controversy, arguing their point of view vigorously and the attendees are encouraged to make their own decisions based on what they have heard.

Attend any midwifery conference, in contrast, and it is a festival of mutual support and midwifery promotion. There are no controversies in midwifery because everyone agrees a priori that midwifery care is the ideal, vaginal birth is the goal, and safe outcomes are secondary and perhaps not even mentioned.

There are no controversies in breastfeeding either. Everyone in the profession agrees a priori that breastfeeding is the one and only spectacularly superior way for every mother to nourish every child. Everyone agrees that the central focus of breastfeeding research should be finding new benefits and. New ways to promote it and no one is discussing any drawbacks.

This reflects a profound difference in focus.

Scientific research always starts with the null hypothesis: the new technique/drug/intervention is no better than the old. The object of scientific research is to determine if the null hypothesis is true or false. Either conclusion is acceptable since the point is to learn.

Midwifery/breastfeeding research starts with the conclusion: unmedicated vaginal birth/breastfeeding is superior and worthy of being promoted and sold. It bears a striking resemblance to Big Pharma research which starts with the conclusion that the product under study is great and should be marketed as such.

That’s why it’s nearly impossible to take most of midwifery/breastfeeding research seriously. It isn’t research if the conclusion has been determined in advance.

There’s another important difference in midwifery/breastfeeding research and real scientific research and that is the arrow of time.

Real scientific research looks forward and believes that we can often do better than nature, cure more disease, save more lives. Midwifery/breastfeeding research, in contrast, always looks backward to prehistory, believing that we can’t possibly improve on nature and ignoring the fact that infant and maternal mortality in nature are astronomically high.

That means that we should approach midwifery/breastfeeding research the same way we approach Big Pharma research, alert for conflicts of interest and aware that the research was designed to reach a predetermined conclusion. That doesn’t mean that all midwifery/breastfeeding research is wrong; just like Big Pharma research, there is plenty that is correct. But no one should think that either is real scientific research.

Natural childbirth advocates and lactivists don’t do nuance. For them, everything is black or white. You’re either with them or against them.

Consider the response of The Academy of Breastfeeding Medicine to my comments on their recent piece It’s time to disarm the formula industry.

The piece itself is a classic example of rallying the faithful by invoking an outside enemy. Rather than take responsibility for the shaming and humiliation of women and the outrageous exaggerations of the purported benefits of breastfeeding, both integral to lactivism, professional lactivists try to divert attention from their own deceptions and deficiencies by blaming their failures on “the other.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If you aren’t agreeing, you’re “bullying.”[/pullquote]

When I tried to direct them back on track — demanding scientific evidence that their claim that if more women breastfed we could save hundreds of infant lives and billions of healthcare dollars — they invoked their favorite logical fallacy, false dichotomy.

What is a false dichotomy? It’s when a range of possible options is deliberately reduced to only two extremes. In the case of breastfeeding, the range is everything between “breastfeeding is the perfect way for every mother to feed every child” and “breastfeeding is a terrible way for every mother to feed every child.” The false dichotomy is presenting the extremes as the only two options.

How does it work? In the case of the ABM, whenever I ask for scientific evidence for the claim that breastfeeding has tremendous public health benefits, ABM members respond by accusing me of hating breastfeeding or trying to sabotage it.

Dr. Casey Rosen-Carole writes:

However, I would hope that you can at least agree that advertising campaigns designed to undermine a woman’s confidence in her own body are sadly off-target and should not be tolerated. After all, aren’t we all on the side of our patients, not industry?

False dichotomy: if you’re not with us in demonizing formula, you are against the wellbeing of babies.

Dr. Anne Eglash writes:

Have you ever thought about what your diet will look like when/if you are 90 years old? How would you feel if the doctor of your nursing home/assisted living (or maybe you will be lucky enough to stay at home with in home care) puts you on a formula diet of 6 servings of Ensure or Glycerna per day, as opposed to 5 servings of fruits and veggies, lean proteins, whole grains, and healthy fats each day? If you believe that Ensure or Boost is a good substitute for a healthy balanced diet, that would explain why you believe that a diet of infant formula can lead to equal health outcomes as breastfeeding.

She seems completely unaware that there’s a range of options between those two starkly opposing choices.

Dr. Eglash is so angry that I dare question the perfection of breastfeeding that she is reduced to libeling me:

You know as well as those of us reading this blog that your rants are analogous to those of anti-climate change individuals, choosing to ignore carefully evaluated science, for your own personal gains. Breastfeeding specialists don’t become wealthy from their research and support of breastfeeding. Much of our time spent advocating to improve infant and maternal health is done thru volunteerism. You, on the other hand, can easily rake in money by promoting large multinational corporations.

In this laughably fallacious view, you either promote breastfeeding or a are a corporate shill for the formula industry. Eglash seems to be incapable of even imaging that a physician could promote breastfeeding and choose it for her own children as I did, while recognizing that it isn’t the right choice for every mother and every baby.

Dr. Melissa Bartick, who has made extraordinary claims about the public health benefits of breastfeeding that she has been unable to substantiate with scientific evidence insists:

I would like to see Amy Tuteur obtain grant funding and conduct actual scientific research and publish it in a peer review journal so she would understand how it is actually done and what goes into this process. She has repeatedly demonstrated that she has no such understanding of science.

Because in the world devoid of nuance that lactivists inhabit you either agree with Dr. Bartick and her compatriots or you don’t understand science. It seems to have never occurred to her that I disagree precisely because I DO understand science and she hasn’t provided any.

The natural childbirth industry is also a world devoid of nuance.

I was recently interviewed by Medscape (a division of WebMD) and they titled the interview Ob/Gyn Wants Women to Stop Feeling Guilty About the Birthing Process. That title is made up of simple words, easy to understand, but members of the natural childbirth industry affect not to understand them.

Deborah Gedel-Beer, CNM writes:

As a nurse-midwife I find this “interview” disturbing and degrading. Instead of supporting services which help to educate and empower women, Dr. Tuteur expresses a patronizing point of view and pretends to reference this with scientic articles.

False dichotomy: if you don’t promote guilt among childbearing women, you oppose education and empowerment. That false dichotomy is especially ironic because I believe that making women feel guilty about their childbirth choices is the OPPOSITE of educating and empowering them.

New Zealand nurse midwife Robin Jones insists:

Dr. Tuteur is well known in childbirth circles for her unswerving belief in the superiority of obstetric care for women (as opposed to midwifery or any other sort of care). As a professional with strong beliefs she should know better than to take her experiences of her own four births and extrapolate these into data that she then applies to all other women. She could try to appreciate that for most women (who do not have her extensive pro-obstetric socialisation) the emotional content of their pregnancy/labour/birth experiences are dependent on their outcome vs their expectations, which will have been influenced by factors not at all under their control (such as their care providers preferences that they may not be aware of).

False dichotomy: either you want women to feel guilty about their childbirth choices or you think obstetric care is perfect.

Nurse Practitioner Holly E goes even further:

Dr. Tuteur is one of many people who find it inconvenient to witness the emotional fallout that occurs when the women she (sexually) violated and coerced are in recovery. Yes, women, the doctor said stop having feelings!

False dichotomy: if you aren’t making women feel guilty about not choosing unmedicated vaginal birth, you are promoting sexual violation and coercion!

Childbirth educator Amy Haas says:

Here’s the problem. There is a long history with this particular retired physician. She has bashed, bullied, belittled, and just been down right nasty to anyone who attempted to have an intellectual conversation with her about research, that differs from her opinion. She is known as a spin doctor in our industry. Fellow researchers stopped attempting to even communicate with her a long time ago, because there was no logical conversation that one could have. If she did not bash you, her cohort would. Promoting someone with such a skewed point of view ends up invalidating the few points she might have. All of this is not about guilt, but control. Her way or the highway. This is not the way to have a professional discourse about health care matters.

False dichotomy: if you aren’t agreeing, you’re “bullying.” Their way or the highway.

In the world of lactivism and natural childbirth, there is no nuance and no shades of gray, but in the real world, there are a range of choices available to women.

For professional lactivists and natural childbirth advocates you’re either with them or against them.

I’m neither because I’m with BABIES and WOMEN.

If you can, head over to Medscape to read the comments on an interview with me, OB/Gyn Wants Women to Stop Feeling Guilty About Birthing Process. How evil of me! Natural childbirth advocates are appalled and fall back on a rather nonsensical whine, the same whine I see whenever I appear in a major media publication:

“How dare you take Dr. Tuteur seriously:

1.Just because she is a Harvard educated, Harvard trained obstetrician-gynecologist?

2. Just because she has written for The New York Times, The Washington Post, The London Times, TIME.com, etc.?

3. Just because she has been invited to speak by a variety of physician organizations including ACOG itself?

4. Just because HarperCollins published her book, PUSH BACK: Guilt in the Age of Natural Parenting that highlights the fact that natural childbirth is a business and is a deeply sexist, retrograde philosophy.

You shouldn’t let her express her views; the natural childbirth industry despises her because we can’t rebut her factual claims so we are reduced to flinging ad hominems!”

You’d think after 10 years of ineffectual whining, natural childbirth advocates would give it up and try a different tactic, but apparently they can’t think of a different tactic.

Lactivists don’t trust women to make their own decisions about infant feeding choices. Hence they have come up with a never ending series of coercive and shaming tactics promote breastfeeding over formula. The Baby Friendly Hospital Initiatve insists that women must be “educated” about the benefits of breastfeeding, deprived of access to formula, forced to endure the attentions of lactation consultants and deprived of formula gifts. This week The Lancet even suggested that the ban on formula advertising in industrialized countries should be extended to a ban from social media.

Why? Because breastfeeding is “better” for babies even though lactivists can’t point to even a single term baby who died from properly prepared formula.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Only hypocrites would fail to ban homebirth advertising.[/pullquote]

Surely, then, they should be desperate to apply the same reasoning to homebirth in the US. So why aren’t lactivists calling for a never ending series of coercive and shaming tactics to promote hospital birth over homebirth? Why aren’t they insisting that women must be educated about the benefits of hospital birth, deprived of access to homebirth and forced to endure counseling from hospital consultants? Shouldn’t lactivists be supporting a ban on all advertising by homebirth midwives as well as banning them from social media? After all, babies die each and every week at the hands of poorly educated, poorly trained CPMs (certified professional midwives) and doulas.

Why don’t they call for a ban on homebirths? Because they’re hypocrites. They aren’t worried about the well being of babies; they adore having their own choices ratified as superior.

Shouldn’t lactivists be calling for a ban on anti-vax activism? The harms of anti-vaccine advocacy are several orders of magnitude greater than the purported harms of formula. Children die as a result of vaccine refusal and the harms extend beyond unvaccinated children to other people’s babies too young to be vaccinated and immunocompromised children for whom any exposure to a vaccine preventable illness poses a deadly threat.

Shouldn’t we start by banning Dr. Bob Sears, Dr. Joe Mercola, and Jennifer Margulis (among others) from the Internet and social media? Shouldn’t their books be removed from print and their supplement stores banned from their websites? Shouldn’t every mother be visited repeatedly by a vaccine consultant to hammer the benefits of vaccines into her silly little head? Shouldn’t it be impossible to get a vaccine exemption? Shouldn’t unvaccinated children be banned from leaving the house until they can demonstrate they are up to date on immunizations?

Why stop there? If we are mandated to prevent formula feeding, shouldn’t we be mandated to prevent chiropractic, homeopathy and any form of alternative health? Shouldn’t chiropractors, homeopaths and herbalists be banned from advertising in on TV, in newspapers, on the Internet or social media? Should their books be taken out of print? Shouldn’t we be sending anti-quackery consultants to every home to educate everyone about the dangers of quackery?

I’m going to guess that the same folks who gleefully support bans of formula advertisements would be horrified by bans on advertising by homebirth midwives, chiropractors and homeopaths. I’m willing to bet that the woman who are adamant that formula should be locked up in hospitals would howl if they were deprived of access to homebirth or if they were compelled to endure vaccines consultants hammering away at their resistance to vaccines.

Why? Because they’re hypocrites. They aren’t worried about anyone’s well being. They simply want their personal choices to breastfeed to be held up as the ideal to which other women should aspire.

What about existing bans on tobacco advertising? They are only defensible to the extent that tobacco represents a unique threat to health, responsible for literally millions of deaths each year.

Formula doesn’t harm term babies. Lactivists can’t even point to one death from properly prepared formula, let alone thousands or millions of deaths.

But if we’re going to ban formula advertisements, we should immediately ban advertising by homebirth midwives and doulas, as well as chiropractors, homeopaths, herbalists and all other purveyors of alternative health.

Anything else would be hypocrisy, right?

I just finished reading The Lancet’s new editorial on breastfeeding with its recommendation to ban all formula advertising. I have some advice for the editors:

Stop infantilizing women and mind your own business!

The piece, No ifs, no buts, no follow-on milk, is a masterpiece of elitist nonsense.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Trust women to make their OWN decisions.[/pullquote]

…[T]he International Code of Marketing of Breast-Milk Substitutes was drafted in 1981 amid widespread concern about the advertising and promotion of infant formula, particularly in settings where mothers lacked access to the clean drinking water and sterilisation equipment needed to safely prepare formula milk. The Code prohibits direct advertising of breastmilk substitutes to mothers, claims that formula milk provides health benefits, and gifts or free supplies to health-care workers and facilities…

Strikingly, it is high-income countries (including the USA, Australia, and much of western Europe) … that have the fewest legal protections—and some of the lowest breastfeeding rates, particularly beyond 6 months…

And the consequences of that are … nothing, zip, zero, nada. Many of these countries have the lowest infant mortality rates in the world and there is ZERO EVIDENCE that even a single term baby has ever been harmed by formula feeding.

You’d never know that to read the hysterical pronouncements of The Lancet:

From tobacco, to sugar, to formula milk, the most vulnerable suffer when commercial interests collide with public health. Robust advertising regulation—covering all milk products for children up to 3 years, and banning social media promotion—is the next step to protect them.

That is pure bombast.

Tobacco kills millions around the world each year. Sugar doesn’t kill anyone and infant formula does not harm term babies. Why put them in the same category? Because condemning infant formula (and sugar) is a contemporary cultural conceit based on the firmly held belief that the less privileged should adopt the preoccupations of their betters.

Privileged, Western, white women are preoccupied with producing children who look perfect on paper, racking up achievements that position them to compete in a modern economy. They are obsessed with the idea that breastfeeding produces superior children despite a lack of scientific evidence that it provides significant benefits. They have made breastfeeding into a form of virtue signaling.

What is virtue signaling?

Virtue signaling is the popular modern habit of indicating that one has virtue merely by expressing disgust or favor for certain political ideas, cultural happenings, or even the weather…

Celebrities who publicly express panic about the environment without knowing much about science are virtue signaling. So are those who seize on current events to publicize their supposedly virtuous feelings …

Breastfeeding selfies are a form of virtue signaling, equally beloved of celebrities and ordinary women. “Normalizing breastfeeding” is a form of virtue signaling, as well as decrying formula feeding. Advocating bans on formula advertising and formula gifts are yet another form of virtue signaling that benefits no one except those signaling their virtue.

The Lancet is signaling its virtue in advocating a ban of advertising and formula gifts in industrialized despite a complete lack of evidence that either practice has any impact on breastfeeding rates in those countries. But that’s not the worst aspect of such bans. The worst part is that they treat women like idiots who must, for their own good, be manipulated by their betters.

Banning ads and gifts rests on ugly assumptions

1. The ugly assumption that women are morons. Despite decades of incessant blathering about the purported benefits of breastfeeding, women who can’t or choose not to breastfeed are imagined as unaware of the benefits.

2. The ugly assumption that women are silly creatures easily manipulated by industry. The editors of The Lancet imagine that women aren’t smart enough to form and maintain their own philosophies on parenting. They are so flighty that a packet of powder will entice them away from plans to breastfeed.

3. The ugly assumption that women are incapable of protecting themselves and their babies from evil corporations and need their betters to do it for them.

Given that the benefits of breastfeeding in industrialized countries are trivial, the editors have no business dictating to women how they should use their breasts. Given that women are intelligent, there is no need for endless hectoring in an effort to force them to breastfeed. Given that women are capable of protecting themselves from industry, there is no reason to infantilize them by banning formula advertising and gifts.

My advice to the editors of the Lancet (and to the breastfeeding industry itself) is simple:

Keep your virtue signaling to yourself, mind your own business and trust women to make their OWN decisions not the decisions that you prefer.

In a recent piece on HuffPo, Dr. Neel Shah bemoans The Massive Marketing Failure of Motherhood.

He writes:

While over $500 billion is spent annually on healthcare during the last nine months of life, less than $50 billion is spent on the arguably higher leverage first nine months of life.

Might that be because people like Dr. Shah see obstetric care as the perfect opportunity to save money by demonizing C-sections?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The solution to imperfect technology is not forgoing technology; it is improving technology.[/pullquote]

Indeed, according to Shah:

… Over the last generation of American moms, we have misguidedly attempted to make childbirth safer by intervening much more than strictly necessary, delivering one in three human beings through C-sections (a form of major abdominal surgery). Although these surgeries are sometimes lifesaving, since the 1970’s C-sections have become 500 percent more common while our rates of childbirth complications have not improved. In fact, they have actually gotten worse. Nearly half of the C-sections we perform appear unnecessary in retrospect …

Oh, the horror! One in three human beings are delivered by C-section. It’s almost like insisting that one in three human beings need eyeglasses … Oh, wait! One in three people DO need eyeglasses. That’s because the human body is constantly failing in important ways. Childbirth has more failure and more deadly failure than most bodily processes.

What’s the solution to our childbirth dilemma? It’s not obsessing over C-section rates. Though people like Dr. Shah appear to believe that they are thinking creatively about maternity care in condemning the current C-section rate, they aren’t. In fact, obsessing about the C-section rate is the opposite of thinking “outside the box”; at this point, it is the box.

What would thinking outside the box involve?

As Dr. Shah correctly notes, we don’t spend too much money on maternity care. The truth is that we don’t spend nearly enough.

Consider the problem of maternal mortality. In light of repeated adjustments to death certificates, it is unclear whether US maternal mortality is actually rising or whether we are finally capturing cases of maternal mortality that we previously missed. In any case, it is not falling.

Many of the causes of increased maternal mortality are out of our control. Childbirth evolved to occur in women in their teens and twenties, but in our culture childbearing is routinely postponed to the thirties and even forties. The cultural imperative to delay pregnancy means that childbearing women routinely enter pregnancy with pre-existing medical conditions, including conditions that would have been incompatible with survival in the past. Women with high blood pressure, diabetes and serious chronic illness now routinely get pregnant and routinely suffer high rates of pregnancy complications.

One of the great ironies of contemporary maternity care is that we have failed to apply what we learned in caring for sick infants to caring for sick pregnant/postpartum women. We have developed a system of triage to direct very sick newborns to the specialized care that they need. We grade newborn nurseries by the services they can provide, from Level I that provides only basic care to Level III that can provide advanced life sustaining support. When a seriously compromised baby is born in a hospital with a Level I nursery, the baby is immediately transferred to a regional facility with a Level III nursery.

There is nothing similar for pregnant/postpartum women. Most hospitals don’t have an obstetric ICU and there is a woeful under-supply of perinatologists trained to care for critically ill mothers. There’s no system in place to seamlessly transfer critically ill mothers to facilities where they can get the lifesaving care that they need. If we are serious about reducing maternal mortality, we would start creating and grading obstetric ICUs and arranging immediate transfer of critically ill pregnant women.

Another key to improving maternity care lies in Dr. Shah’s own words: half the C-sections we perform appear unnecessary in retrospect.

The problem is not that a 30% C-section rate is “too high.” After all, 30% of Americans are nearsighted and we aren’t advocating saving money by lowering the rate of vision correction. What’s the difference between the two? We have sophisticated and highly accurate ways of determining who needs vision correction. When an optometrist tells you that you need glasses, you definitely need glasses. But when an obstetrician tells you that you need a C-section, often you do not. That’s because we are incapable of accurately measuring the risk that your baby will be injured or die during labor.

We know that many babies die during labor for lack of oxygen but we don’t know how to accurately measure a fetus’ oxygen level. We are forced to resort to crude methods like measuring the baby’s heart rate to determine if it is at risk, and therefore are forced to perform C-sections that turn out to be unnecessary in retrospect. We know that some babies will die during breech birth because their heads will get trapped but we have no way of predicting in advance which babies will get stuck and therefore we recommend routine C-section for breech even though we know that nearly all of those C-sections are unnecessary. We know that some babies, particularly large babies, will suffer serious complications from shoulder dystocia, up to and including death, but we don’t know how to determine which babies will suffer shoulder dystocia so we are forced to recommend C-section in many cases where it is unnecessary.

Natural childbirth advocates like to pretend that the solution to imperfect technology is no technology. Since electronic fetal heart rate monitoring has a high false positive rate, we should just stop using it. Since most breech babies will fit, we should just stop doing C-sections for breech. Since most big babies won’t be harmed by shoulder dystocia, we should simply stop worrying about it.

But the solution to imperfect technology is not forgoing technology; it is improving technology. We need to spend tens of millions of dollars (or more) perfecting a way to determine fetal oxygen levels during labor. We need to spend tens of millions of dollars (or more) perfecting a way to determine whether a specific baby in a specific position will fit through a specific pelvis. When we create such technologies, the C-section rate will drop precipitously because we learn in advance which C-sections are unnecessary and stop doing them.

Our perinatal and maternal mortality rates are as high as they are because childbirth is inherently dangerous. Our C-section rate is as high as it is because our technology is relatively primitive. Demonizing C-sections is not the answer and demonizing imperfect technology is simply foolish. The “market failure” alluded to by Dr. Shah is not the high C-section rate; it is the low rate of investment in more sophisticated technology.

Obsessing about the C-section rate is not thinking outside the box; it is the box.

Natural childbirth advocates employ birth affirmations as a form of magical thinking. They appear to believe that if they just wish hard enough, they can affect the likelihood of the unmedicated vaginal birth that they are supposed to want.

That’s nonsense, of course. But birth affirmations are also anti-feminist. They are anti-feminist because they assume that a woman’s virtue resides in her vagina, because they ignore women’s needs and desires, and because they arise from philosophies that seek to immure women back into the home.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]A woman’s virtue does not reside in her vagina.[/pullquote]

My feminist mothering affirmations rest on the opposite premises:

• A woman’s virtue resides in her mind, talents and character. Whether or not a baby transits her vagina is no more important than whether or not she wears glasses.
• Women’s needs — for pain relief in labor, for control of whether their breasts are used to feed their babies, for participation in the world beyond mothering — are more important than any purported benefits from natural childbirth, breastfeeding or attachment parenting. Whether or not a woman chooses to adhere to these philosophies is her decision, based on what she thinks is best for her children, not what other people, ignoring scientific evidence, think is best for her children.
• Women — and society — benefit when they are encouraged to use the full range of their talents in the wider world, and women — and society — are harmed when women are immured in the home, forced to restrict themselves to childcare.

Here are my top ten feminist mothering affirmations:

1. It makes no difference how my baby is born.

Over the course of your son or daughter’s childhood, you will have many occasions to ponder how your actions impact your child’s life and you will second guess yourself many times, wondering if you had handled a specific situation differently might your child have been happier or more successful. Whether your baby was born vaginally or by C-section should never be one of them. It will make absolutely, no difference to your child how he or she emerged from your womb (or, in the case of an adopted child, even if he or she emerged from your womb). There is no reason for you to worry or obsess about how your baby is born.

2. There is no reason for me to suffer.

Some lucky women have a manageable amount of pain in labor and don’t need any relief. Most, however, have an unmanageable amount of pain and desperately seek relief. There is NO REASON to forgo pain relief when you are in pain. It is not safer, healthier or better in any way for your baby or for you to withstand hours of excruciating pain.

3. I am not in competition with other women.

Admittedly this is hard to believe when your friends, acquaintances and casual strangers demand details of your birth so they can compare their “performance” to your “performance,” but it’s true. It’s nobody’s business how you choose to give birth to your child and they don’t deserve to comment upon or even to know those private details.

Childbirth is not a performance that ought to be rated or compared. Childbirth is a bodily function like vision. Sometimes it works well; sometimes it needs help. No one judges women who wear glasses or contacts for nearsightedness even though their eyes don’t work “as nature intended.” Nearsightedness just happens, is no one’s fault and implies nothing about the overall health or quality of a woman’s body. Similarly, childbirth complications just happen, are no one’s fault and imply nothing about the overall health or quality of a woman’s body.

4. I am not guaranteed a healthy baby, so I need to consult with the professionals who can help me ensure my baby’s health.

Human reproduction, like all reproduction, has a high degree of “wastage,” which is another way of saying that death is a common complication of pregnancy. For example, 1 in 5 established pregnancies will end in miscarriage. No amount of wishing and hoping will change that. Similarly, in nature, nearly 10% of pregnancies will end in the death of the baby, the mother or both. Fortunately, the interventions of modern obstetrics can prevent the vast majority of those deaths, but only if you avail yourself of those interventions and the expertise of the people trained to use them.

5. I will not trust birth, because birth is not trustworthy.

Trusting birth makes about as much sense as trusting vision. No amount of trusting will prevent nearsightedness, so refusing eye exams in favor of trusting vision is stupid in the extreme. That goes double for childbirth, which is far more deadly than nearsightedness.

6. I will carefully analyze the motives of those who declare that any particular way of giving birth is “better” than any other.

When you take the time to analyze the advice and recommendations of “birth workers” like midwives, doulas and childbirth educators, ask yourself if they profit when you follow their advice. That does not mean that their advice is necessarily wrong, but it can and too often does compromise their recommendations. Instead of recommending what is good for you and your baby, they may be recommending what is good for their wallet.

Similarly, you should analyze the advice and recommendations of friends and acquaintance looking at how they benefit if you do what they suggest. Are they anxious for you to validate their birth choices by making the same choices? If so, feel free to ignore them.

7. I will not take pregnancy advice or care from anyone who won’t take responsibility for that advice or care.

If a homebirth midwife doesn’t carry insurance, and makes you sign a document declaring that the responsibility for any and all outcomes in yours, she is signaling that even she doesn’t believe that she is educated enough or trained enough to take responsibility your baby’s life or for your life. Real professionals take legal and ethical responsibility for their work; amateurs and hobbyists never do.

8.My baby does not care whether he or she is breastfed or bottlefed.

It makes literally no difference to the baby how he or she gets fed, only that he or she gets fed. Yes, breastfeeding does have some advantages, but those advantages are small and in industrialized countries those benefits are trivial.

9. Both the baby’s needs and my needs matter when it comes to infant feeding.

Yes, breastfeeding can be difficult and stressful in the first few days and weeks, and it is great to persevere through those difficulties if breastfeeding is important to you. But the baby’s hunger and suffering count for a lot, and if you feel your baby is suffering from hunger, you should feel free to feed the baby formula. Your pain and suffering count, too. If your nipples are raw and bleeding, if you have horrible pain when nursing, if you start crying every time the baby cries with hunger, dreading nursing, it is perfectly healthy and acceptable to use formula instead, either for supplementing or exclusively.

10. I will not judge my mothering by the performance of my body.

You mother with your entire body. Your arms hold and embrace your children. Your hands guide. Your lips kiss. Your brain plans and worries, and your metaphorical heart loves your child. Your uterus, vagina and breasts are trivial when compared to the other body parts, so it makes no sense to judge your mothering by whether you had a vaginal birth or breastfed your children.

Mothering is hard. I know; I have four children and I have spent countless hours caring and worrying, wishing I could carry their burdens, smooth their paths, and absorb their hurts. My children are adults now, and no doubt there are many things that they think I could have done better, but they never, ever give any thought to their route of delivery or to whether or for how long they are breastfed.

Don’t judge yourself on these issues, and don’t let anyone judge you. It isn’t simply doesn’t matter and it’s anti-feminist.

 

Adapted from a piece that first appeared in August 2014.

Imagine if I said the following:

The proportion of parents refusing vaccines has steadily increased over the past decades. Let’s stop debating whether refusing vaccines is safe and instead engage in examination of the factors that may make vaccine refusal safer.

I’d be roundly and appropriately condemned by pediatricians, immunologists and public health officials even though vaccine refusal has grown tremendously to affect as much as 20% of children.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There’s nothing subjective about the fact that homebirth with a CPM leads to preventable infant deaths. [/pullquote]

Why?

Because we understand that vaccine refusal stems from lack of knowledge about how vaccines work or the dangers of vaccine preventable illnesses, and a fraud committed by Dr. Andrew Wakefield falsely connecting vaccines to autism. It is the responsibility of medical professionals to meet this knowledge deficit with accurate information, correcting myths and misapprehensions with scientific data.

We are also coming to understand that vaccine refusal is closely tied with privilege, defiance and a faux sense of empowerment. Nothing screams privilege louder than ostentatiously refusing something that poor women around the world are desperate to have. Anti-vax parents glory in defying authority, imagining that it marks them as “educated.” Similarly vaccine refusal is viewed by anti-vax parents as an empowering form of rugged individualism, marking out their own superiority from those pathetic “sheeple” who accept medical authority because they haven’t done “their own research.”

So why are some obstetricians insisting that we need to examine the factors that may make homebirth safer when it has risen from a fringe of a fringe practice (0.87% of births) to a fringe practice (1.5% of births)? That’s the terrible mistake made by Ellen L. Tilden, PhD, CNM; Jonathan M Snowden, PhD; Aaron B Caughey, MD, PhD; Melissa J. Cheyney, PhD, CPM, LDM in their Medscape commentary Making Out-of-Hospital Birth Safer Requires Systems Change.

They write:

… [O]ut-of-hospital births have steadily increased over the past decade, up 72% from 0.87% of US births in 2004 to 1.5% in 2014. This trend shows no sign of reversing; disengaging with the debate over whether out-of-hospital birth is safe and instead engaging examination of the factors that may make out-of-hospital birth safer is of critical import. Formally including home and birth center care in US maternity care systems will improve outcomes for the growing numbers of women seeking care outside of the hospital. In parallel, increasing the availability of physiologic birth in-hospital may decrease the number of women choosing out-of-hospital birth as a means of avoiding unnecessary intervention, with the added benefit of reducing iatrogenic maternal morbidity for the predominance of low- to moderate-risk women who choose hospital birth.

Why should we take that approach to a dangerous fringe practice when we would appropriately condemn pediatricians like Dr. Bob Sears who take that approach to vaccine refusal, a dangerous practice that is widespread.

I have deep sympathy for Dr. Caughey and his obstetric colleagues who are daily forced to witness the tragic outcomes of homebirths attended by CPMs, counterfeit midwives who can’t be bothered to meet the international standards for midwifery practice. Obstetricians are desperate to save the lives of babies endangered by incompetent practitioners, and mothers who have been fed a steady diet of mistruths, half truths and outright lies by the homebirth industry.

But American homebirth is MORE dangerous than vaccine refusal; an approach that attempts to straddle the homebirth fence is unlikely to address the deadly risk it poses.

Why?

Because homebirth, just like vaccine refusal, is based on misinformation, privilege, defiance and a faux sense of empowerment. CPMs are just like vaccine charlatans, spreading lies about the inherent dangers of childbirth, and encouraging potential clients to imagine themselves as smarter than and superior to the sheeple who merely follow the medical advice of their obstetricians.

The authors write:

What one deems “safe” is inherently subjective, involving a series of judgments and a relative weighing of multiple (and sometimes conflicting) factors.

That is spectacularly wrong! There’s nothing subjective about the fact that vaccines don’t cause autism and there’s nothing subjective about the fact that homebirth with a CPM does lead to preventable neonatal deaths.

There’s no more reason to validate homebirth advocates’ fanciful view that childbirth is inherently safe than there is to validate anti-vax’ parents fanciful view that vaccines cause autism.

There’s every reason, in fact, to meet misinformation with accurate scientific evidence, and to make it clear to mothers contemplating homebirth that it poses a serious risk to their babies.

The subjective issue is NOT whether homebirth with a CPM is safe; it isn’t. The subjective issue is how an individual balances the various risks and benefits to make her own choice. Some women may find any increased risk to the baby anathema, whereas some will find the increased hospital risk of C-section deeply problematic. It is the right and prerogative of women to make their own informed medical decisions. But accurate scientific data is required for informed decision making and it’s the ethical obligation of obstetricians to provide it.

Tilden et al. start their piece with a quote:

Birth is as safe as life gets. – Harriette Hartigan, direct-entry midwife

That is abject nonsense from a charlatan, no different from Andrew Wakefield’s contention that vaccines cause autism.

Health care providers MUST respect patient choice, but we MUST NOT pander to charlatans and their acolytes by validating lies. If we do, we won’t stop preventable deaths at homebirth; we’ll encourage them.

You can’t make this stuff up.

I woke up this morning to find that Gaye Demanuele, the midwife who watched Caroline Lovell bleed to death at her homebirth, extolling a piece by Henci Goer’s “rebuttal” of my Washington Post piece How the natural birth industry sets mothers up for guilt and shame.

I wrote:

…[T]he crunchy natural-birth subculture has slowly morphed into an industry, mainly catering to the most privileged women in society. Second, a cabal of natural-birth activists — online, on the air and even inside hospitals.

Goer, a stalwart of the natural childbirth industry, who makes her money selling books about natural childbirth, takes to her new website, selling her natural childbirth videos ($5 per video, $25 for a yearly subscription), to disagree.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]C’mon Henci, you may think your followers are gullible and stupid, but no one is that stupid![/pullquote]

As with most things that come from the industry, it’s an exercise in mendacity.

Goer starts with a dig:

Amy Tuteur has managed to score a commentary in the Washington Post … You would think that the inflammatory rhetoric would have given the Post’s editors a clue that they should get their fact checkers on the case. If they had, they would have realized that the piece cherry picks bits out of context, distorts and sensationalizes the data, and just plain makes statements that are factually incorrect, but perhaps the “Dr.” in front of her name gave her an automatic pass…

Goer appears to be oblivious to the fact the piece is adapted from my new book PUSH BACK: Guilt in the Age of Natural Parenting. I’ve done quite a few print pieces and radio interviews to promote the book. The Washington Post CHOSE to post an excerpt from the book and THEY chose this excerpt.

Poor Henci. She whines that the “Dr.” In front of my name gives me an automatic pass. She’s apparently disgusted that someone would take the word of a Harvard educated, Harvard trained obstetrician gynecologist who’s written for The New York Times, TIME.com, The London Times and a variety of other publications instead of Goer, who has NO formal training in midwifery, medicine or anything else. Goer is a legend in her own mind, a self-appointed “expert” in the obstetrical literature. Who else considers her an expert? No one.

I’ve written about Goer and her mendacity for years and first challenged her to a debate in 2008.

Her lies back then were legion:

“…The blanket accusation that U.S. direct-entry midwives have less training than other midwives in industrialized countries requires no denial because it is fatuous.”

“… If Amy Tuteur is saying that our perinatal mortality rate is low, that is just not true.”

And my personal favorite:

“I don’t know if you ran across that thread while surfing this Forum, but some of us–including me–theorize that “Dr. Amy” is a disinformation strategy of the American College of Ob/Gyns. We can’t prove it, of course.”

So much for Goer’s vaunted “research” skills.

Goer ended up banning me from her message board; it was far easier than acknowledging that I was telling the truth and she was trying to deceive women.

Goer tries the same disinformation tactics in her “rebuttal.”

I wrote in WaPo:

A study in Oregon found that the death rate for babies delivered in planned home births with midwives in 2012 was roughly seven times that of hospital-born babies.

And Goer inexplicably replies:

Tuteur appears to be referring to Snowden (2015). After adjustment for maternal characteristics and medical conditions, the odds ratio for perinatal death in planned out-of-hospital birth was 2.4 times that of planned hospital birth, amounting to an absolute difference of 1.5 more deaths per 1000. Nowhere is there a mention of a 7-fold greater mortality rate.

No, I’m referring to the Rooks 2012 dataset from Oregon and I’d be willing to bet serious money that Goer knows exactly what I’m talking about.

She knows as well as I do that the Rooks data shows that planned homebirth with a licensed homebirth midwife had a death rate 800% higher than comparable risk hospital birth and there’s no way she can rebut that data. Instead she choose to substitute a study on a different group (including birth centers) done 3 years later which reached NO conclusion about homebirth itself.

I guess she figures her readers are so gullible that they won’t notice.

I wrote:

The Midwives Alliance of North America . . . is a major professional organization for American midwives but requires no educational credentials of its roughly 450 members beyond a high school diploma.

And Goer nonsensically replies with:

MANA has nothing to do with the training or credentialing of direct-entry midwives …

I didn’t say it did. I said it requires no educational credentials beyond a high school diploma and it doesn’t.

I guess Goer figures natural childbirth advocates are stupid as well as gullible.

I wrote:

Lamaze’s website states, adding with a note of pity that an epidural still might be needed if a mother ‘can’t move beyond [her] fear of labor pain.’ Rather than teaching strictly the facts about childbirth, Lamaze promotes one particular vision of labor as normal and therefore good.

And Goer tries this whopper:

Tuteur’s quote is taken out of context.

Says the person who wrote The Thinking Women’s Guide to a Better Birth. It’s an implicit insult to women who don’t follow her precepts but no doubt Goer would claim that the title is taken out of context.

In what context is it appropriate to claim that epidurals are for a women who ‘can’t move beyond [her] fear of labor pain?

In what context is it appropriate to promote “normal” birth as better than any other form of birth?

C’mon Henci, you may think your followers are gullible and stupid, but no one is that stupid!

Goer is a paper tiger. She fancies herself an “expert” in obstetric research yet she won’t appear in any forum where the people who do most of the obstetric research (obstetricians) could question her on her claims. She deletes and bans people from her websites when she can’t address their substantive claims. She has point blank refused to publicly debate me because she knows her arguments would be eviscerated in short order.

She’s exactly what I rail about when I criticize the natural childbirth industry, an industry that puts personal beliefs ahead of scientific facts, and uses shame and guilt in order to profit.