One of the things I like best in writing about contemporary mothering issues is the cross-fertilization betweeen academic theory found in journals and lived reality represented by media articles and blog posts by and about mothers. The average natural childbirth advocate or lactivist has little idea how her preferred rhetoric, which she believes was promulgated by childbirth and breastfeeding professionals, has actually been shaped by professors. Similarly, women struggling under the crushing imperatives mandated by those professionals have little idea how — fortunately — their anguish is fueling the writing of other academics.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”[W]e should not treat breastfeeding as a baseline in a sense that implies that women who formula feed are harming their babies.”[/pullquote]

Breastfeeding is a case in point. Most contemporary language on breastfeeding can be traced back to an academic paper written in 1996, Watch your language by Diane Wiessinger.

When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a “special bonus”; but she may clamor for help if she knows how much she and her baby stand to lose. She is less likely to use artificial baby milk just “to get him used to a bottle” if she knows that the contents of that bottle cause harm.

But now a philosophy professor cautions that the use of risk based language around formula is not morally justified. In a new paper in the Journal of Medical Ethics, Fiona Woollard asks, Should we talk about the ‘benefits’ of breastfeeding? The significance of the default in representations of infant feeding.

In an accompanying blog post, Prof. Woollard explains why she wrote the paper.

She was attending a meeting of breastfeeding professionals:

… Then the speaker adds, almost as an aside, “Of course, we know that it is really ‘the harms of formula’ not ‘the benefits of breastfeeding’.” There is a general nodding of heads. It seems to be accepted by almost everyone in the room that this is something that we know. It is ‘known’ that any differences in outcomes between babies fed with infant formula and breastfed babies should be described as ‘harms of formula’.

Woollard begs to differ.

As a philosopher, I feel a sort of territorial annoyance. This is a deeply complex philosophical question. It is not something that we should confidently claim to know as if there were a simple answer.

In her paper she explains why talking about the “harms” of formula is NOT morally justified.

She, too, traces the use of risk language to Weissinger’s piece. And she opposes the use of such language on both philosophical and practical grounds:

Given the detrimental effects that shame surrounding formula use can have on the well-being of new mothers and their neonates, we have strong reasons to avoid the unjustified use of morally loaded terms to describe infant-feeding decisions. There is significant sociological evidence connecting decisions to use formula and feelings of shame, guilt and failure… The use of morally loaded terms … also gives the impression that such guilt and shame is appropriate. If guilt and shame is seen as appropriate, then its effects on maternal well-being may be wrongly dismissed as morally unimportant.

Where did Weissinger go wrong in her invocation to use shaming language around formula feeding?

Wiessinger appeals to an allegedly standard use of language surrounding health to argue that we should treat breastfeeding as the default and formula feeding as deficient and dangerous. She states: “Health comparisons use a biological, not a cultural, norm, whether the deviation is harmful or helpful…

Even if breastfeeding is the biological norm, it is far from obvious that it should be the moral baseline from which the morally loaded calculations of harm and benefit are calculated…

Why not?

Because breastfeeding deeply implicates the mother’s body and agency, positioning breastfeeding as the moral baseline is problematic even if it is the biological norm. To do so takes the mother’s body and agency for granted. It does not fit with our use of the concepts of harm and benefit in other situations…

Woollard reviews a variety of moral accounts of harm and shows why they lead to the conclusion that formula feeding does not cause “harm.”

For example:

If I were to push “Joe” into traffic on a busy highway and he gets hit by a car, I have harmed Joe. But if Joe runs into traffic and I don’t stop him, I haven’t harmed him. Moreover, if a car is heading is our direction and I don’t step in front of Joe to protect him at the expense of myself, I certainly haven’t harmed Joe.

Similarly, if I were to deliberately expose “Sammy” to a diarrheal illness and he gets sick, I have harmed him. But if Sammy gets a diarrheal illness that might possibly been prevented by breastfeeding, I haven’t harmed him. Moreover, if Sammy gets a diarrheal illness because I don’t use my body to offer him the potential protection of breastfeeding, I haven’t harmed him, either.

Therefore, from a moral perspective, not breastfeeding cannot and should not be described as a harm.

Interestingly, Woollard does not question the scientific evidence on the benefits of breastfeeding. Either she is unaware or in the interests of brevity has decided not to mention the fact that the scientific evidence on the benefits of breastfeeding is weak, conflicting and riddled with confounding variables. She does not mention that the promised benefits of increasing the breastfeeding rate have failed to appear and that breastfeeding has risks (of dehydration, jaundice, starvation and death) as well as benefits. She proceeds under the assumption that breastfeeding is indeed beneficial, but even then a mother who doesn’t breastfeed is NOT harming her child.

Woollard concludes:

When it comes to descriptions of maternal behaviour, we should reject the assumption that there has to be a single appropriate default for infant feeding. Breastfeeding is normal and should not be stigmatised or seen as a lifestyle choice that can only be accommodated under ideal circumstances. The phrase ‘breast is best’ should be avoided. But we should not treat breastfeeding as a baseline in a sense that implies that women who formula feed are harming their babies. Extreme care should be taken before using morally powerful terms such as ‘risk’, ‘harm’ and ‘danger’. Where possible, neutral terms such as ‘difference’ should be used, accompanied by clear information about the outcomes presented non-comparatively.

I strongly agree and I sincerely hope that breastfeeding professionals will take note!

In 1558, John Knox penned The First Blast of the Trumpet Against the Monstrous Regiment of Women. Knox, a Protestant, was lamenting the fact that the Protestant Reformation was being stymied in both England and Scotland by Catholic monarchs. Yet it wasn’t their Catholicism that he blamed; it was the fact that they were women.

Knox used “monstrous” and “regiment” in an archaic sense to mean “unnatural” and “rule,” arguing that female dominion over men was against God and nature. He lamented that the future of the Protestant faith lay solely in the hands of a female monarchy largely hostile to its precepts. Echoing the era’s widespread assumption that women were inferior to men, capable only of domestic acts such as bearing children, Knox placed blame on the “abominable empire of wicked women” for the trials and tribulations of the Reformation.

No doubt it made perfect sense to Knox and his readers, but from our vantage point in the 21st Century, it’s easy to see that it was misogyny pure and simple. Women who dared seek more out of life than reproduction (or, as the in the case of queens, were forced by circumstance to do so) were unnatural and therefore monstrous. “Natural” women were meant to be home pregnant, breastfeeding or both.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is a gathering backlash to the philosophies of natural childbirth and lactivism that condemn women who make different choices as “unnatural.” [/pullquote]

Curiously, the injunction to limit oneself to natural pursuits applied only to women. Men who sought to do more than reproduce and hunt to feed themselves and their families — men who sailed ships, waged technological warfare, built cathedrals, wrote religious tomes — were to be praised for rising above their base, animal nature.

Sadly, contemporary midwives and lactation consultants are the intellectual heirs of Knox’s misogyny. Women who refuse to be limited by biology in giving birth to and feeding their infants in the “natural” way are portrayed as monstrous — either lacking in feminine feeling, possessing deficient bodies, too stupid (in need of “education” and “support”) to know better or all three.

Knox meant The Monstrous Regiment of Women as a marketing tool. He was selling his services as a Protestant reformer by tying the old religion of Catholicism to the “unnatural” rule of women. Those who let themselves be led by women were being led to Hell. Better to be led by men who know the way to Heaven.

Midwives and lactation consultants are also selling their services. They do so by tying the lifesaving technology of modern medicine — epidurals, C-sections and infant formula — to “unnatural” women. Indeed the technology itself is portrayed as male and patriarchal despite the fact that in 2018 the majority of obstetricians are women and the majority of women happily avail themselves of that technology. In other words, those who let themselves be led by technology are being led to the hell of a traumatic birth or a child sickened by lack of breastmilk. Better to be led by women, midwives and lactation consultants, who know the way to the heaven of empowering birth and empowering breastfeeding.

When midwives claim that the only healthy, safe birth (and not coincidentally the only one they can provide) is birth as nature intended, they are implying that women who choose otherwise are monstrous. When lactation consultants insist that we can’t improve upon breastfeeding (not coincidentally the only form of feeding they are selling) because it’s natural, they are implying that women who choose otherwise are monstrous.

Things didn’t turn out well for John Knox. Shortly after The Monstrous Regiment of Women was published, the Catholic, English Queen Mary died and was succeeded by the Protestant Queen Elizabeth. She was familiar with his condemnation of “unnatural” women and she wasn’t amused.

Though not the intended target of Knox’s First Blast, Queen Elizabeth took great offense at the publication, and in 1559, repeatedly refused Knox passage to Scotland through England. Knox attempted to apologize to the queen …

Ultimately he was allowed to return and he had learned his lesson:

Having endured the controversy of The First Blast, Knox went on to play a key role in Scotland’s opposition to the Catholic monarchy, solidifying Scotland as a Protestant, and Presbyterian, nation for centuries to come. As for his second and third blasts, it would seem that the “Trumpet of the Scottish Reformation” learned an important lesson. Neither was ever sounded.

He never stopped being a misogynist, but at least he stopped writing about it.

Midwives and lactation consultants need to learn the same lesson. It’s a very bad idea to criticize the people on whom you depend for employment. There is a gathering backlash to the philosophies of natural childbirth and lactivism, philosophies that condemn women who make different choices as “unnatural.” That backlash comes as women recognize that midwives and doulas aren’t leading them to heaven, but rather to a hell of excruciating labor pain, frustrating breastfeeding attempts that harm their babies, and being relegated back into the home.

Elizabeth, a subtle and brilliant queen, resented the misogyny of labeling her as “unnatural” because she chose to rule rather than to marry. Similarly, ever more women are coming to resent the misogyny of midwives and lactation consultants who seek to control women by labeling those who use and even choose technology by labeling them as “unnatural,” too. Admonishing women to pursue the natural has always been a hallmark of misogyny; it was true in 1558 and it’s just as true in 2018.

When my children were small, there was rarely a day that passed without someone whining, ”It’s not fair!”

I would inevitably respond with some variation of, “Who said life was fair?”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Believing you are entitled to a “healing” birth makes as much sense as believing you are entitled to a “healing” diet that will finally make you thin.[/pullquote]

Sometimes I would expand on that admonition by explaining that anyone who expected that everything would always be fair was destined to be sorely and repeatedly disappointed. The difference between a happy life and an unhappy life is not whether you experienced unfairness; everyone does. The difference is how you deal with it. You have to learn to accept it and move on. That didn’t mean that you have to be happy about it, just that you can’t let yourself become weighed down by sadness and anger.

That’s how I explained it to children. The adult version is this: you have to be unbelievably entitled to imagine that you are owed fairness.

I am reminded of this whenever I read about a woman’s quest for a “healing” birth, as I did yesterday. Joni Edelman wrote:

His birth was supposed to be peaceful, swimming into the world in our kitchen, surrounded by his family, welcomed with cake and champagne. He was supposed to come out easily and heal me from the trauma of my previous labor and dystocia. His birth was supposed to be a lot of things that it was not.

This birth was supposed to “heal” her from a previous disappointing birth?

Where did she get the idea that she was entitled to the birth of her dreams? Where did she get the idea that if she didn’t get that ideal birth the first time, she is entitled to get it on the next go round? I’d be willing to bet she acquired that outsize sense of entitlement from the natural childbirth industry.

It surely wasn’t from an obstetrician; obstetricians don’t care about how a baby is born just that a healthy baby is born to a healthy mother. I suspect it wasn’t her partner; he was probably thrilled to be a father and considered the method of birth to be irrelevant (to the extent that he considered it at all). I doubt it was her parents or in-laws who were disappointed with her either.

The natural childbirth industry sold her (through their books, websites, childbirth courses, midwives and doulas) a birth that would make her dreams come true and then it didn’t happen. That might have made her question whether giving the industry so much money for promises they couldn’t keep was really worth it.

How convenient (and profitable) for them that they could double down and offer her more books, websites, childbirth courses, midwifery care and doula services to help her “heal” from the disappointment of her first birth, the disappointment that they themselves caused by convincing her that she was entitled to the birth of her dreams.

How convenient for them that at no point are they (or she) forced to re-evaluate validity of the books, websites, childbirth courses, midwifery care and doula services from which they earn their income. They are always correct. She can just try again and this time it will happen!

It’s like the fashion industry. The same people who spend millions marketing the idea that thin women are better, make millions more by marketing the products that will supposedly make you thin. And if a woman’s self-image and self-confidence are undermined because she failed to achieve the ideal weight, it’s her fault for failing, not their fault for creating an unrealistic sense of entitlement.

The idea that a woman is entitled to a “healing” birth makes as much sense as the idea that she is entitled to a “healing” diet that will finally make her thin. Not everyone can be thin and imagining that you are entitled to be thin will just make you miserable. Not everyone can have the birth that midwives, doulas and childbirth educators promise; imagining that you are entitled to such a birth will just make you miserable.

Life isn’t fair. Those who are mature enough to accept that reality deal with their disappointment and move on. Those who aren’t have another baby hoping they will finally get their “healing” birth.

Whose birth experience counts?

Many midwives would answer everyone’s because a “healthy baby isn’t enough.”

They would agree with this mother mourning her lost birth experience:

I don’t have to feign gratitude, because I lost something that was important to me…

I don’t have to be thankful just because things didn’t end tragically.

I’m allowed to grieve what I lost, even now, because it was important to me, and I lost it.

She had wanted a homebirth:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Whose birth experience counts?[/pullquote]

His birth was supposed to be peaceful, swimming into the world in our kitchen, surrounded by his family, welcomed with cake and champagne. He was supposed to come out easily and heal me from the trauma of my previous labor and dystocia. His birth was supposed to be a lot of things that it was not.

I do not want to hear, “Well, you’re lucky he’s healthy,” ever…

Those midwives would encourage Edelman to grieve for her birth as she has done because a desired birth experience reflects a woman’s deepest needs and fears. Providing that experience — an empowering experience that allows her to be in control of her body and feel that her providers have really listened to her —is the ethical obligation of every midwife … UNLESS, of course, she wants a C-section. Then she should be ignored.

According to the BBC:

Women at 75% of UK maternity units are being denied their right to choose a Caesarean, the BBC’s Victoria Derbyshire programme has been told.

NICE guidance says women should be allowed to opt for a planned Caesarean even if it is not for medical reasons.

In this midwife led system, providers are denying women who choose C-sections the birth experience they request.

Birthrights, the human rights in childbirth charity, used a Freedom of Information request to ask 153 trusts providing maternity care how they applied the guidance.

Of the 146 that replied:

26% fully complied with the guidelines
47% partially complied
15% refused maternal requests outright
12% did not seem to have a clear position

This is in direct violation of official policy:

Under the guidelines, women requesting a Caesarean with no other medical reason “should be offered appropriate discussion and support – but ultimately, if they are making an informed choice, a Caesarean should be offered”.

But in many cases the denial occurs without listening to the mother’s request.

[Birthrights] said it had been told trusts had even been telling women they would not be allowed to elect a Caesarean, either when they had been being booked on to maternity care or in a letter before they had even been spoken to.

And even when the request is considered, these women have to jump through hoops that aren’t required for anyone else:

Gill Walton, chief executive of the Royal College of Midwives said: “Women must be given the information to explore their views and feelings about Caesarean birth, to enable them to come to an informed decision about their preferred type of birth.

“This information should reflect the individual woman’s current and previous medical, obstetric and psychological history.”

Are women required to “explore their views and feelings about vaginal birth” before being allowed to have one? I doubt it. Are women required to “explore their views and feelings about homebirth” before being allowed to have one? I’ll bet it never comes up.

Apparently, for women who want a maternal request C-section a healthy baby is supposed to be more than enough.

Why the difference? Because idea that a “healthy baby isn’t enough” is a ploy designed by midwives to wrest market share from obstetricians. Since obstetricians place the highest value on a healthy mother and a healthy baby, midwives encourage women to place the highest value on a fulfilling birth experience … but ONLY if that birth experience fulfills midwives’ needs as well.

Does your ideal birth experience include a vaginal birth? That’s fine; midwives will keep those evil obstetricians — who think a health baby is enough — away so they can’t diagnose any complications that might interfere with your experience.

Does your ideal birth experience include a homebirth? That’s the best! It allows midwives full autonomy and requires more midwives. The midwife/patient ratio at homebirth is supposed to be 2:1 instead of 1:many at hospitals or midwifery led units. And not only will no midwife question whether you are making an informed choice, they’ll happily ignore any and all risk factors that make homebirth a dangerous idea.

Does your ideal birth experience include an epidural? So sad. Midwives will try to convince you that unmedicated birth is better and more empowering. And if that doesn’t work, they will drag their feet in ordering the epidural until it is too late for you to get it.

Does your ideal birth experience include a maternal request C-section? Too bad for you! C-sections don’t do a damn thing for midwives’ need for autonomy and control. Therefore you can’t have one. Shut up and be glad you got a vaginal birth that you didn’t want!

In other words, the “healthy baby isn’t enough” crowd is a bunch of hypocrites. It isn’t your birth experience that matters; it’s theirs.

Let’s stop that hypocrisy. Let’s agree:

Her baby, her body, HER choice and none of the midwife’s business.

Because a woman who wants a maternal request C-section should be treated exactly the same as a woman who wants a homebirth — with respect. Every woman’s birth experience counts!

US maternal mortality has rightly captured the nation’s attention. Perhaps the most shocking fact about it is that so many of the women who die during and in the aftermath of pregnancy die from preventable causes.

Why?

Everyone involved in the care of pregnant women seems to have forgotten the single most important thing about childbirth: it is inherently dangerous and has always been a leading cause of death of young women. Not surprisingly, providers can’t diagnose a complication if they don’t think of it.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]What if normal birth meant avoiding complications not avoiding interventions?[/pullquote]

Obviously obstetricians and midwives need to do a better job of warning women about postpartum complications. Healthcare websites need to do a better job, too.

As Nina Martin reports in the latest installment in the ProPublica/NPR series on US maternal mortality, Trusted Health Sites Spread Myths About a Deadly Pregnancy Complication, most trusted healthcare websites are failing to provide accurate information about postpartum preeclampsia.

The large majority of deaths occur after delivery, often from strokes.

But you’d never know it from the incomplete, imprecise, outdated and sometimes misleading information published by some of the most trusted consumer health sites in the country.

What’s especially disturbing about postpartum preeclampsia is that it often occurs when women are no longer being monitored: after discharge from the hospital and before the 6 week postpartum check. That’s why it is critical that women themselves know how to recognize the symptoms. What do leading internet health websites have to say on the topic?

After reading reports about Beyoncé, ProPublica took a look at how top health sites discuss preeclampsia. We sent screenshots and links to Tsigas, one of the leading experts on the condition in the U.S., for review last week.

Virtually every site we asked her to look at contained some problematic language, Tsigas noted in her written comments. Her biggest area of concern: A number of sites flubbed how they explained postpartum preeclampsia — sometimes mentioning it only in passing, or sometimes failing to mention it entirely…

ProPublica only looked at mainstream medical sites that are presumably maintained or overseen by physicians. But many women often look to natural childbirth websites for information about pregnancy. How do they do?

1. The Childbirth Connection, which describes itself as promoting “safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families,” has NO information on postpartum preeclampsia.

2. Lamaze International, which claims its “education and practices are based on the best, most current medical evidence available,” has NO information on postpartum preeclampsia.

3. Evidence Based Birth, which claims to offer “evidence that empowers,” offers NO information on postpartum preeclampsia.

They aren’t offering women the information they need, either.

What if we used childbirth educators, the people whose job it is to educate women about childbirth, for that very purpose? At the moment, most childbirth educators think their job is to promote “normal birth.” But what if normal birth meant avoiding complications not avoiding interventions?

At the moment, childbirth educators teach women about what to expect during labor and delivery. That’s entirely appropriate. They also spend an inordinate amount of time teaching women that they should avoid epidurals, C-sections, and other childbirth interventions. But if we truly face a crisis in maternal mortality, shouldn’t they be spending that time in trying to avert it?

Let’s reform childbirth education to include the information that women need to protect themselves and their babies from death and serious disability.

Let’s give women:

Information on pregnancy complications like preeclampsia and premature labor. What should they worry about and what should they ignore? Who should they contact when they are concerned?

Information on stillbirth. How much should the baby be expected to move? When should they be concerned about lack of movement? What can they do to encourage the baby to move when they are concerned? When should they insist on fetal monitoring to assess the baby?

Information on postpartum complications like hemorrhage and postpartum preeclampsia. How much bleeding is too much bleeding? What should they do if they begin to hemorrhage? What are the signs of postpartum preeclampsia? Where can they go to get their blood pressure checked besides the doctor’s office? When should they insist on being seen by an obstetrician instead of a midwife or nurse practitioner?

Information on heart complications. Cardiac complications are the leading cause of maternal mortality and women should be taught to recognize their onset. What should they do if they feel unusually weak and short of breath? How quickly should they be seen and by whom?

Information on blood clots. Blood clots are a major, often preventable cause of maternal death. They typically arise in the leg. What are the signs and symptoms? What can women do to prevent blood clots? A blood clot can kill if it breaks off and reaches the lungs (pulmonary embolus). What should women do if they feel chest pain or sudden onset of shortness of breath?

Everyone has a role to play in preventing maternal deaths. Obstetricians and midwives have the primary role, and purveyors of childbirth information have a role, too. Up until now childbirth educators have not been recruited to the effort despite the fact that their mandate is to educate women. Let’s change that. Let’s train childbirth educators to prevent death rather than to prevent interventions!

“You’d look so beautiful if you just lost the extra weight!”

“I admire your confidence for being willing to wear that!”

“Is that your wedding picture? The frame is amazing!”

Those are the kind of passive-aggressive “compliments” that you get from frenemies, the women who insist they are your friends but never miss a chance to undermine you. They aren’t really friends, but rather rivals who cloak their rivalry under the guise of friendship.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Frenemommy is a vampire of self-esteem; she can only get hers by sucking out yours.[/pullquote]

But if you think a frenemy can be harmful to your self-esteem, just wait! One day she will have children and then she will be a frenemommy. No enemy can be as soul destroying as a frenemommy. They are everywhere and it’s not an exaggeration to say that they are destroying the experience new motherhood. So many good mothers feel so bad and frenemommies are the reason.

Becoming a mother is a simultaneously entrancing and frightening experience. You are overwhelmed with love for your impossibly beautiful newborn and frightened to death that you might harm him or her by accident or by ignorance. You are incredibly vulnerable … and along comes Frenemommy.

Frenemommy says:

“Hey, it’s still a vaginal birth even if you did have the epidural!”

And the amazing experience that had your husband looking at you as if you were a goddess is suddenly diminished.

“Your daughter is so smart for a formula fed baby!”

And your pride in your daughter is tainted by guilt that you short-changed her.

“How wonderful that your baby recognizes his mama even though you spend so much time at work!”

And your hard won confidence that you were successfully transitioning back to the job you love is blasted to smithereens.

Frenemommies aren’t just restricted to the people whom you know personally. There are professional frenemommies who write books on childbirth, breastfeeding and attachment parenting, offer their advice for free on blogs and websites, and diligently patrol Twitter and Facebook, gathering followers, belittling anyone who makes different choices, and wallowing in outrage at perceived slights. Sadly, many midwives, doulas and lactation consultants are also professional frenemommies. Under the guise of “helping” you, they undermine your self-esteem at every turn.

Why? Because Frenemommy considers you a threat and won’t feel comfortable until you are docilely occupying the place she assigns for rivals: in awe of her achievements and in doubt about your own. Frenemommy is fundamentally insecure. She is like a vampire of self-esteem; she can only get hers by sucking out yours.

Every mother needs mom friends, old friends who have become mothers like her or new friends made through her children. Most women find mom friends invaluable; they’re the women with whom you can share your child’s every milestone, your deepest concerns about your child’s wellbeing and your fears about your adequacy as a mother. Your mom friends have either been there/done that and can provide reassurance that your children will turn out fine or they are at the same stage you are, worrying about the same things, simultaneously seeking and giving reassurance.

Mom friends revel in your birth stories whether they mirror theirs or not. Mom friends couldn’t care less whether you breastfeed or formula feed, just whether your baby is thriving and you are getting enough sleep. A mom friends drops by with her kids to hold your colicky baby while you make dinner for your older kids and calls you at 6 AM with a migraine knowing you’ll take her kids for the day so she can rest and recover. Mom friends freely offer love and support and you gladly give love and support in return.

How can you tell the difference between a mom friend and a frenemommy?

1. A mom friend makes you feel good when you were feeling bad; a frenemommy makes you feel bad when you were feeling good.

A mom friend is thrilled that you got relief from your epidural; a frenemommy “sympathizes” with you over the loss of your natural birth.

2. A mom friend looks at things from your perspective; a frenemommy looks at everything from her perspective.

A mom friend anxiously waits to hear if you got a good night’s sleep after topping off your baby with a few ounces of formula after breastfeeding; a frenemommy “supports” you in pumping 3 times in the middle of the night instead.

3. A mom friend encourages you to take time for yourself and if she’s an especially good friend, she watches your baby so you can do it. A frenemommy insists she’s envious that your baby survived an evening with a babysitter; her baby is too attached to get along without her even for a few hours.

4. A friendly parenting professional asks how she can help you achieve your goals; a professional frenemommy tells you how you can mirror hers.

A friendly lactation consultant knows its more important to supplement a hungry baby with formula than to risk dehydration and failure to thrive. A frenemommy lactation consultant insists that your pediatrician is wrong when he advises supplementation.

5. A mom friend supports you; a frenemommy gaslights you when you question her “support.”

A frenemommy tells you that your excruciating birth wasn’t painful and then further gaslights you by insisting that you merely thought it was painful because you were afraid. A frenemommy tells you insufficient breastmilk is rare then gaslights you about your baby’s hospitalization for dehydration arguing it wouldn’t have happened if you weren’t tricked by formula companies. A frenemommy insists that you don’t have to feel bad about your “failures” because it wasn’t really your fault; you didn’t get enough “support.”

How can you protect yourself from frenemommies? First you must recognize them, and then you need to understand their motivations. But the most important thing by far is to ignore them. Like frenemies of all kinds, they aren’t your friends no matter how hard they pretend they are.

Why have midwives hit out with such vehemence at the ARRIVE Trial that found elective induction at 39 weeks lowers the risk of C-section? Because they recognize that this represents a crossroads for contemporary midwifery.

The foundation of contemporary midwifery is:

1. The belief that childbirth interventions inevitably lead to more interventions, often culminating in a C-section and therefore a bad ‘experience.’

2. The quest for a better childbirth experience is justified by the fact that “scientific evidence shows” that it is also a safer experience.

The ARRIVE Trial demonstrated the opposite; childbirth interventions can actually be safer even when performed without a medical indication.

Hence the crossroads. One direction would confirm the claim that midwifery is about adherence to scientific evidence; the other would represent a rejection of scientific evidence in favor of doctrine. Sadly, it looks like midwifery leaders are searching desperately for any fig leaf that would cover a naked rejection of high quality science in favor of doctrine.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When there’s a choice between scientific evidence and power over women, midwives don’t hesitate to abandon science in order to preserve their power.[/perfectpullquote]

This struggle is not surprising if you recognize that contemporary midwifery (midwifery as practiced in the past 50 years) isn’t a medical discipline. It’s just unreflective defiance of obstetrics. And it seeks to rescue women from the purportedly patriarchal hegemony of technology not to free them, but to oppress them under an matriarchal hegemony of midwives.

This assessment of midwifery was made by two influential feminist scholars in a 1996 landmark paper, What is gender? Feminist theory and the sociology of human reproduction. The paper is long and filled with academic jargon, but its central claim is:

… [T]he lived experience of midwifery … is revealed only as the largely unresearched antithesis of obstetrics. An alternative is called into existence in powerful and convincing terms, while at the same time its central precepts (such as ‘women controlled’, ‘natural birth’) are vaguely drawn and in practical terms carry little meaning.

Why? To take power over women from male obstetricians and transfer it to female midwives:

If we conceive of power as a fundamentally male preserve we are led to gloss over ways in which women may exert power over others, including other women.In these terms, as recent institutional reforms stimulate community midwifery midwives may begin to consider the notion of affinity with women embedded in such concepts as ‘continuity of care’… as masking the potential exploitation of midwives by their clients.

The ARRIVE Trial strikes at the heart of midwifery doctrine in two ways. First, it shows that the claim that interventions should be avoided because they lead to more interventions is wrong. Second, and more importantly, if midwives continue to demonize interventions even when safe or safer, they make it clear that their recommendations were never about what is best for babies and mothers, but what is best for midwives.

It’s hardly surprising then, with so much at stake, that they have panicked.

1. They’ve advanced a series of reasons to ignore the results of the ARRIVE Trial, some nonsensical, and most equally applicable to studies that they have embraced such as The Birthplace Study of homebirth.

2. They’ve claimed, with no justification whatsoever, that studies done with obstetricians as primary providers aren’t applicable to midwives though they had absolutely no trouble accepting the results of studies using obstetricians as primary providers that demonstrated the risks of episiotomy.

3. They’ve insisted, with no justification whatsoever, that the study — which is nothing more than the scientific evidence on the risks and benefits of elective induction — will disempower women by “forcing” them to have elective inductions.

4. And led by Milli Hill, they’ve claimed that science is some sort of anti-feminist plot.

Hill’s post is a masterpiece of propaganda that would make a certain American President proud.

Step 1: Demonize the opposition by misrepresenting their views.

If we start from the standpoint that women’s bodies are entirely unfit for purpose …

Step 2: Portray freedom for others as oppression for you.

… then the obvious mental leap from the results of the ARRIVE trial is to recommend it as standard across the board.

Step 3: Insist that only those who are arrogant would dare disagree.

There is an arrogance about the ARRIVE trial that has long pervaded maternity care, a patriarchal approach that never stops to question whether there is a limit to ‘doctor knows best’.

Step 4: Invoke the specter of a police state.

To use Margaret Atwoods analogy from The Handmaid’s Tale, “Nothing changes instantaneously: in a gradually heating bathtub you’d be boiled to death before you knew it.”

Step 5: Do not, under any circumstances, address the facts.

It’s all done for the same reason the American President does it: to whip followers into blinding anger over their “oppression” so they can ignore unpalatable truths.

The reaction of midwifery leaders to the ARRIVE Trial reveals that contemporary midwifery is largely unreflective defiance of obstetrics. Its purpose is to wrest power over women from obstetricians so that midwives can enjoy that power instead. Sadly, when there’s a choice between scientific evidence and power over women, midwives don’t hesitate to abandon science in order to preserve their power. If that’s not anti-feminist, I don’t know what is.

When my boys were small and were angry with me, they would respond with what they considered a devastating insult: “You are a poopy-head.”

Needless to say, it rarely produced the desired response. Instead I laughed.

I was reminded of that when I came across Milli Hill’s latest tweet berating loss father James Titcombe:

[S]ince you regularly align yourself with the ideology of Amy Tuteur, I consider it a great compliment that you find my ideological perspective unhelpful.

Needless to say, neither James nor I is devastated. I don’t know what James did when he read it, but I laughed.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is NO right way to have a baby.[/pullquote]

I also reflected that Hill, as usual, has got it completely backward. I have been deeply affected by the ideology of James Titcombe, not the other way round. His experience, and that of other bereaved mothers and fathers, helped me recognize radical midwifery theory for the arrogant, self-dealing, deadly philosophy that it is. And that in turn led to me to read more deeply about biological essentialism, feminism and medical ethics.

To the extent that James Titcombe might be aligned with “the philosophy of Amy Tuteur,” it’s worth spelling out exactly what that it. It can be summed up as follows:

Her baby, her body, HER choice!

My ideology is informed by my political liberalism. I believe that each individual has a different concept of the “good life,” generally knows best what will make him or her happy and should be allowed to pursue it to the extent that it doesn’t actively harm others.

So, for example, despite the fact that I happily raised four children within a permanent heterosexual relationship and consider it the ideal family arrangement, each individual has a different conception of the “good life.” It might be more, less or no children; marriage, cohabitation, celibacy; homosexuality or bisexuality.

Each individual knows far better than I what will make him or her happy; they aren’t in need of more “education” if they make a choice that is different from mine. And each individual should be allowed to pursue his or her aims to the extent that it doesn’t actively harm others.

As another example, despite the fact that I had four vaginal births (two with epidurals and two without), breastfed all my children, and considered that optimal, other women have different ideas about optimal childbearing and feeding. It might be adoption, elective C-section or gestational surrogacy. For those experiencing labor, they might view the pain as empowering or excruciating. For those who have the option to breastfeed, they might view it as difficult, distasteful or triggering.

Each woman knows far better than I what will make her happy; she isn’t in need of more “education” so she will make the same choices I made. And she should be allowed to pursue her aims to the extent that it doesn’t actively harm others.

As a result, I view the dichotomy beloved of midwives — between the technocratic and the midwifery model of childbirth — as both antiquated and fallacious. In my reading of contemporary childbearing/rearing philosophy, the central dichotomy is between biological essentialism and equality feminism.

It is the difference between viewing women as all having the same need for expression of their reproductive capacities vs. individual women — like individual men — as having different needs. It is the difference between postulating that all women are empowered by using their reproductive organs vs. acknowledging that many women find the use of their intellects and talents far more empowering than the use of their uteri, vaginas and breasts.

What does that mean in practice?

It means:

There is NO “right way” to have a baby. Some women find unmedicated vaginal birth empowering; others find it disempowering; still others feel something in between. All views are philosophically and morally equivalent.

Therefore, it follows that women who don’t find empowerment through their reproductive functions are NOT suffering from lack of knowledge or false consciousness. They don’t need to be educated or “supported” into making choices that are different than the ones they articulate.

It does NOT mean that births involving technology are to be favored. It means that NO specific form of birth is to be favored.

It does NOT mean that having a healthy baby is all that counts. It means that for some women having a healthy baby will be all that counts, and some women will find that a healthy baby is NOT compensation for being traumatized by labor or traumatized by their caregivers.

It means that the arbiter of clinical practice MUST be scientific evidence, not intuition and certainly not providers seeking validation of their own choices by patients mirroring them back.

It means that the arrogance of believing ‘doctor knows best’ should NOT be substituted by the arrogance of ‘nature knows best.’

It applies equally to breastfeeding. As between breastfeeding and formula feeding there is NO right way to feed a baby. Both choices are philosophically and morally equivalent.

That, in brief, is the ideology of Amy Tuteur.

Milli Hill — as well as Sheena Byrom, Hannah Dahlen, and the international clique of radical midwifery theorists — might disagree with it or even despise it; that’s their choice. But they have no right to mischaracterize it.

There’s one pregnancy intervention that everyone — midwives, doulas, childbirth educators, obstetricians — can agree on: promoting optimal nutrition.

We encourage women to get all the calories necessary to grow a baby as well as the full daily requirement of vitamins and minerals. We assume that will improve pregnancy outcomes by improving the health of mothers and babies. We haven’t stopped to consider that there’s more to improved nutrition than what is obvious on the surface. What if nutrition it is making childbirth more dangerous because babies are bigger?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]For most of human existence, babies were probably much smaller than they are today.[/pullquote]

Midwives and natural childbirth advocates are known to bewail the high modern C-section rate by pointing out that childbirth can’t possibly required a 32% surgical delivery rate or our species could not have survived. Leaving aside for the moment their faulty understanding of evolution, they have failed to consider a more basic reality. Childbirth today is very different from childbirth in nature because the human diet is very different from our diet in nature. For most of human existence, babies were probably much smaller than they are today.

That has important implications for both mothers and babies. On the plus side, mothers are healthier with higher blood counts and therefore better able to withstand the rigors of labor and subsequent blood loss. Furthermore, nutritional rickets, which often led to contracted maternal pelvis making it impossible to deliver a term baby, is almost non-existent in industrialized countries.

On the minus side, the risk that a baby will grow too large to fit through the maternal pelvis leading to obstructed labor and the death of mother and baby has almost certainly increased. In modern societies we bypass that deadly result with C-sections.

A 2012 study in the Journal of Pediatrics shows that newborn size has been increasing.* Eighty year trends in infant weight and length growth: the Fels Longitudinal Study found:

Infants born after 1970 were ~450g heavier and ~1.4cm longer at birth, but demonstrated slower growth to one year, than infants born before 1970. Growth trajectories converged after one year of age.

Recent birth cohorts may be characterized not only by greater birth size, but also by subsequent catch-down growth. Trends over time in human growth do not increase monotonically, and growth velocity in the first year may have declined compared with preceding generations.

Newborn infants born in the years after 1970 are an average of 1 pound heavier than those born in the 40 years prior to 1970. Why?

[F]actors that have been responsible include changes in maternal biology and health (including a reduction in smoking prevalence and improved nutrition unrelated to maternal BMI or heights), an improvement in socioeconomic status and living conditions, and reductions in poverty and better provision of, and access, to health care and education.

Once these bigger babies are born, however, their growth rate is slower than babies of previous generations resulting in a convergence of size at the age of 1 year. This observation further strengthens the hypothesis that it is something about pregnancy, not babies, that has changed.

Another possible downside of increased neonatal size is that a bigger baby may be more likely to outstrip a placenta’s oxygenating capacity making that baby more vulnerable to distress in labor or stillbirth. The US stillbirth rate has not risen; indeed it has gone down, but that has happened in parallel with a dramatic increase in C-section rates and induction rates, allowing for rescue of babies that would otherwise die.

The hypothesis that improved nutrition has made childbirth more dangerous is speculative, of course, but it could explain a lot of observations that confound midwives and other natural childbirth advocates. It explains why intervention rates have risen: pregnancy itself has become more dangerous to both mothers and babies. It explains the results of studies like the newly published ARRIVE trial that showed that inductions not only improve outcomes but lead to lower C-section rates (a 39 week baby is both easier to deliver and less likely to experience fetal distress than a 40, 41 or 42 week baby). It may also explain why we are hearing more about postpartum pain, incontinence and discomfort during sex and long term incontinence and pelvic prolapse.

Who could disagree with the idea of improving nutrition for pregnant women? No one, but that doesn’t mean it isn’t an intervention. And it’s an intervention that may have made childbirth more difficult and dangerous — a consequence we haven’t considered because other inverventions have allowed us to avoid the potentially deadly results.

 

*That trend seems to have reversed in the past two decades with babies becoming slightly smaller, but still bigger than one hundred years ago.

In February I wrote about new data presented at the Society for Maternal Fetal Medicine annual meeting that showed that elective induction at 39 weeks improves outcomes.

The accompanying press release noted:

Results include:

• Lower rates of cesarean birth among the elective induction group (19%) as compared to the expectant management group (22%)
• Lower rates of preeclampsia and gestational hypertension in the elective induction group (9%) as compared to the expectant management group (14%)
• Lower rates of respiratory support among newborns in the induction group (3%) as compared to the expectant management group (4%)

This was in keeping with previous studies that showed that elective induction decreases perinatal mortality:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Given the large body of evidence, women who want to be induced at 39 weeks gestation or thereafter should be accorded that option.[/pullquote]

Stock, Sarah J., Evelyn Ferguson, Andrew Duffy, Ian Ford, James Chalmers, and Jane E. Norman. “Outcomes of elective induction of labour compared with expectant management: population based study.” BMJ 344 (2012): e2838.

And studies that showed that induction improves maternal and neonatal outcomes:

Gibson, Kelly S., Thaddeus P. Waters, and Jennifer L. Bailit. “Maternal and neonatal outcomes in electively induced low-risk term pregnancies.” American Journal of Obstetrics & Gynecology 211, no. 3 (2014): 249-e1.

Mishanina, Ekaterina, Ewelina Rogozinska, Tej Thatthi, Rehan Uddin-Khan, Khalid S. Khan, and Catherine Meads. “Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis.” Canadian Medical Association Journal 186, no. 9 (2014): 665-673.

In other words, contrary to the claims of natural childbirth advocates that babies are “not library books due on a certain date,” there is an optimal time to be born and poor outcomes rise on both sides of that optimal time.

But as I acknowledged at the time, we hadn’t yet seen the completed paper. Yesterday that paper was published in The New England Journal of Medicine titled Labor Induction versus Expectant Management in Low-Risk Nulliparous Women.

They found:

The primary perinatal outcome [a composite score of neonatal injury and death] occurred in 4.3% of the neonates in the induction group and in 5.4% in the expectant-management group (relative risk, 0.80; 95% CI, 0.64 to 1.00; P=0.049 [P

And:

The percentage of women who underwent cesarean delivery was significantly lower in the induc- tion group than in the expectant-management group (18.6% vs. 22.2%; relative risk, 0.84; 95% CI, 0.76 to 0.93; P<0.001). This finding did not change materially after adjustment for previous pregnancy loss. Women assigned to induction of labor were also significantly less likely than women assigned to expectant man- agement to have hypertensive disorders of pregnancy (9.1% vs. 14.1%; relative risk, 0.64; 95% CI, 0.56 to 0.74; P<0.001) and to have extensions of the uterine incision during cesarean delivery …

They concluded:

In summary, we found that elective labor induction at 39 weeks of gestation did not result in a greater frequency of perinatal adverse outcomes than expectant management and resulted in fewer instances of cesarean delivery. These results suggest that policies aimed at the avoidance of elective labor induction among low-risk nulliparous women at 39 weeks of gestation are unlikely to reduce the rate of cesarean delivery on a population level; the trial provides information that can be incorporated into discussions that rely on principles of shared decision making.

Two other recently published papers confirm advantages of induction.

Nonmedically Indicated Induction of Labor Compared with Expectant Management in Nulliparous Women Aged 35 Years or Older found:

In nulliparous women aged ≥ 35 years, NMII [nonmedically indicated induction] was associated with decreased odds of cesarean delivery at 37 to 39 weeks’ gestation and decreased odds of NICU admission at 40 weeks’ gestation compared with expectant management.

Elective induction of labor at 39 weeks among nulliparous women: The impact on maternal and neonatal risk showed:

Mathematical modeling revealed that eIOL at 39 weeks resulted in lower population risks as compared to EM [expectant management] with induction of labor at 41 weeks. Specifically, eIOL at 39 weeks resulted in a lower cesarean section rate, lower rates of maternal morbidity, fewer stillbirths and neonatal deaths, and lower rates of neonatal morbidity.

Not surprisingly, midwives who routinely demonize interventions are panicking.

Hannah Dahlen’s reaction is priceless — a whole lot of words that say nothing.

Dahlen, like many other midwives, believes in the faulty Panglossian paradigm that if something is natural, it must be best. In the context of evolution the Panglossian paradigm imagines that everything that exists in nature today is the product of intense natural selection and represents the perfect solution to a particular evolutionary problem.

But as evolutionary biologist Stephen J. Gould pointed out, an existing natural feature may not be the result of evolutionary pressure at all; it may be an incidental feature of a solution to an entirely different problem or it may represent the limits of genetic adaptation.

For example, it would undoubtedly be evolutionarily advantageous to have eyes in the back of our heads yet we never developed them. Instead technology gave us mirrors, which we can use to escape our biological limitations and see behind us. Two eyes don’t represent the best of all possible outcomes, merely the outcome that we have.

In the case of childbirth, each birth involves an evolutionary compromise between the neurological advantages of a larger neonatal brain and the potentially deadly consequences of a larger neonatal brain leading to obstructed labor.

The brain continues to grow throughout pregnancy. Babies born at later gestational ages have bigger heads and are more neurologically mature but also more likely to die in labor. Babies born at earlier gestational ages have small heads which gives them a tremendous advantage in childbirth. The optimal time to be born is when the baby’s head is as large as possible before it becomes too big to fit. That optimal time appears to be at 39 weeks.

The same thing applies to the size of babies relative to the function of the placenta. Some placentas last longer than others. The longer a baby remains inside the mother, the more neurologically mature and fitter it will be. However the longer a baby remains inside the mother, the greater the chance that its growth will outstrip the placenta’s ability to supply oxygen. If the baby stays inside longer than the placenta can function, the baby is stillborn. The optimal time to be born is immediately before the baby’s growth starts to outstrip the placenta’s ability to supply oxygen. That optimal time also appears to be at 39 weeks.

You could make a very good argument that all women should be induced at 39 weeks of pregnancy in order to optimize perinatal outcomes and decrease the C-section rate. No doubt ACOG and other professional organizations will resist that conclusion for the time being. However, given the large body of evidence, women who want to be induced at 39 weeks or thereafter should be accorded that option.