One of the greatest ironies of the anti-vaccine movement is that its proponents imagine themselves to be deep, incisive thinkers when they are the exact opposite. Their beliefs reflect immature cognitive errors and a spectacular failure of critical thinking.

There are a lot of different definitions of critical thinking, including:

[Critical thinking is] thinking about one’s thinking in a manner designed to organize and clarify, raise the efficiency of, and recognize errors and biases in one’s own thinking.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Anti-vaxxers never ask themselves what they DON’T know.[/perfectpullquote]

Critical thinking is often contrasted with traditional education techniques like lectures and memorization. Whereas lectures and memorization result in students who remember the important dates of the Revolutionary War, for example, critical thinking leads to students who understand why the war happened.

In my view there are four pillars to critical thinking and those pillars can be expressed as self-directed questions.

1. What do I know?

2. How do I know it?

3. What don’t I know?

4. How can I learn it?

What do I know?

Both critical thinkers and uncritical thinkers like anti-vaxxers are clear on what they know. The differences are encompassed by answers to the other three questions.

How do I know what I know?

For uncritical thinkers like anti-vaxxers, the answer is simple and concise. They “know” that vaccines are harmful because someone else told them so. They like to dress it up in their own minds by insisting that they “did their research,” but what they really mean is that they ignored experts and chose to believe random people on the internet.

Anti-vaxxers have never seen the inside of a laboratory or a medical library, the places where real medical research occurs. Most have never read a single scientific paper beyond the abstract and wouldn’t understand one if they did. They lack basic knowledge of immunology, statistics and the scientific method. They have the cognitive maturity of a four year old who imagines that addition and subtraction reflect the sum total of knowledge in mathematics. They are so limited in their understanding of science that they don’t even understand their limitations.

Anti-vaxxers imagine themselves as bold thinkers because they reject the assertions of experts without realizing that reflexively rejecting experts is the same as reflexively embracing them. Neither involves thinking; both are responses to authority.

In contrast, critical thinkers know what they know by reading authoritative texts and scientific literature. In addition to reading expert literature that confirms their beliefs, they are fully conversant with the scientific literature that questions their beliefs or contradicts them.

The breadth of knowledge of vaccine experts exceeds that of anti-vaxxers by orders of magnitude.

What don’t I know?

This is where the rubber hits the road in critical thinking. Critical thinkers always ask themselves what they don’t know, recognizing that gaps in knowledge can lead to faulty reasoning.

Anti-vaxxers never ask themselves what they don’t know. Their cognitive immaturity (and their vanity) leads them to imagine that they know everything worth knowing.

That cognitive immaturity is reflected in their style of argument, best captured by the phrase: “but what about?”. They parachute on to skeptic blogs and Facebook pages and offer what they believe to be devastating rejoinders: “But what about this out of date paper?” “But what about the blathering of this anti-vaxxer who once taught an extension course at Harvard?” “But what about the fact that cases of this disease dropped between epidemics before the existence of vaccines?”

They lack the critical thinking skills to answer their own questions. Since they have no understanding of the scientific method, they can’t appreciate that a single, out of date paper is meaningless; only the breadth of the entire literature matters. Since they are incapable of reading that literature, they have no idea what their preferred paper actually shows; they only know what some other anti-vaxxers told them it shows. They don’t even know if the paper was contradicted by subsequent research or even retracted due to violating principles of scientific reporting. Since they have no understanding of statistics they are ignorant of the fact that disease incidence can fall from one year to the next without it being evidence that the disease is disappearing. And although they claim to reject arguments from authority they are quick to embrace arguments from anti-vax celebrities.

How can I learn what I don’t know?

Anti-vaxxers don’t know what they don’t know so they are unlikely to ask themselves this question spontaneously. However, as soon as they engage with people who know a great deal more (which is nearly everyone who has professional education and training), they become aware that there’s lots they don’t know.

Critical thinkers will attempt to remedy their deficits. They will do background research in science and statistics; they will review the entire literature; they will seek out help reading and interpreting scientific papers. Anti-vaxxers, who are cognitively immature, will respond immaturely — accusing anyone who knows more of being a shill for the pharmaceutical industry. It’s the intellectual equivalent of calling your opponent a poopy-head.

Anti-vaccine advocacy reflects a spectacular failure of critical thinking because it is missing one of the pillars: interrogating oneself to determine what you don’t know, not merely what you do know. Anti-vaxxers flatter themselves by imagining that they are engaged in deep thinking when they haven’t been thinking at all, just dumbly imbibing, believing and repeating nonsense from other equally ignorant fools.

Raw water. It’s the latest health craze, and no, I’m not making it up.

According to the Washington Post:

Hold your canteen under a natural spring and you’ll come away with crystal clear water, potentially brimming with beneficial bacteria as well as minerals from the earth.

That’s what proponents of the “raw water” movement are banking on: selling people on the idea of drinking water that contains the things they say nature intended without the chemicals, such as chlorine, often used in urban water treatment processes.

In some areas of the country, including the West Coast, it has become a high-dollar commodity — water captured in glass bottles and sold straight to you.

“Naturally probiotic. Perfected by nature,” boasts Live Water, which sells raw water sourced from Oregon’s Opal Spring.

It signals a rise of what I call “raw stupidity,” to distinguish it from highly processed stupidity.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Raw stupidity arises spontaneously from deeply held, nonsensical beliefs.[/pullquote]

What’s the difference?

Highly processed stupidity does not arise spontaneously but requires technology for propagation. Anti-vax is the classic example; indeed it’s the stupidity equivalent of Cheetos. The anti-vax movement has existed for more than 200 years, but it didn’t really take off until the advent of computers, Wi-Fi and Facebook.

No one wakes up one morning and says, “I think vaccines, which I know absolutely nothing about, lead to unusual diseases, which I also know absolutely nothing about.” Most anti-vaxxers adopt views they have acquired from proselytizing of other, equally ignorant anti-vaxxers. The primary mode of transmission is through websites and Facebook groups.

Moreover, highly processed stupidity seeks to claim the mantle of science and technology by invoking the copy-paste skills of its advocates who faithfully reproduce long lists of scientific citations that they have never read and wouldn’t understand if they did read. Andrew Wakefield is its avatar, a “scientist” who faked his science for profit and lost his medical license as a result.

The raw water craze, in contrast, is raw stupidity. Like most raw stupidity, it arises spontaneously from two deeply held nonsensical beliefs:

1. If it’s natural, it must be good.
2. It’s true if I can see it with my unaided eyes.

Everyone knows that nature is benevolent, that lions lie down with lambs, that the population of the earth used to be much larger and decreased steadily with the advent of technology, and that health is all about eating as nature intended.

The paradigmatic example of raw stupidity is flat eartherism. Obviously the earth is flat because it looks flat. Obviously the earth can’t be round because the people in Australia would fall off.

The belief in the beneficial properties of raw water is similar. It couldn’t possibly be more natural than bubbling up direct from the ground, right? It’s clear; you can’t see any bacteria or parasites so there aren’t any bacteria or parasites. So what if large animals or even people defecate nearby? Everyone knows that feces contains only beneficial bacteria because it comes directly from inside all natural fauna.

In addition to raw stupidity and highly processed stupidity, there’s an amalgamation involving both.

Consider the wisdom of Kelly Brogan, MD holistic psychiatrist. What’s a holistic psychiatrist? It’s a pro-wrestler of healthcare, a fraud who profits from the gullible.

Goodbye to germ theory! Can we really maintain the childish illusion that there are a handful of identified “bad germs” out there trying to kill us?

Brogan is obviously invoking raw stupidity: we can’t see bacteria and even if we could they would be beneficial because they are natural. On the other hand, Brogan transmits her stupidity almost exclusively through technology and invokes the imprimatur of science by constantly alluding to her medical degree. It’s the clever combination of both raw stupidity and the highly processed stupidity of someone like Andrew Wakefield that makes her particularly dangerous.

It’s hard to know what to do about either raw stupidity or highly processed stupidity. As Einstein supposedly said:

Only two things are infinite, the universe and human stupidity, and I’m not sure about the former.

Perhaps we should just take the natural approach and let only the fittest survive. Those who are stupid enough to buy raw water or believe a quack like Kelly Brogan are swimming in the shallow end of the gene pool as it is. Unfortunately, there’s no drug to treat stupidity; sadly, we’re limited to hoping it will burn itself out.

Every maternal death is an extraordinary tragedy, but Erica Garner’s death seems particularly bitter in its irony.

According to NPR:

She entered the public eye in July 2014 when her father, Eric Garner, died after being put in a chokehold by a New York City police officer. Eric Garner was seen on video saying, “I can’t breathe” 11 times before he died.

Why did Erica Garner die? She died because she couldn’t breathe.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]She died because she couldn’t breathe.[/pullquote]

Erica Garner had been in a coma since Dec. 23, when she had an asthma attack that triggered a heart attack, according to the New York Daily News.

“When her son was born in August, she named her newborn after her father,” the newspaper reports. “Garner suffered her first heart attack shortly after the delivery, with doctors saying the pregnancy stressed her already enlarged heart.”

Eric Garner became an icon in the Black Lives Matter movement. Now Erica Garner appears destined to become a icon in the effort to reduce black maternal mortality. In many ways, she is emblematic of the current crisis of black maternal mortality.

Prior to 1999, Erica Garner’s death would not have been included in maternal mortality statistics for two reasons. First, occurring as it did four months after the birth of her son, it would have been considered a “late” maternal death; US mortality statistics which included deaths up to 42 days after delivery. Second, Garner did not die of a pregnancy complication but of pre-existing diseases (heart disease and asthma). Indeed, researchers have found that anywhere from 75-100% of the recently reported increase in US maternal mortality is the result of expanding the classification of maternal deaths.

Erica Garner’s death is emblematic of US maternal deaths in several other ways. She was black and black women die at 3X the rate of other American women.

She appears to have had pre-existing heart disease (an “enlarged” heart). Heart disease is the leading cause (and fastest growing cause) of maternal mortality in the US. What causes an enlarged heart and how did it contribute to Garner’s death?

An enlarged heart can reflect a dilatation of the chambers of the heart (dilated cardiomyopathy) or an increase in the size of the heart muscle (hypertrophic cardiomyopathy).

According to the American Heart Association:

Dilated cardiomyopathy (DCM) is the most common type, occurring mostly in adults 20 to 60. It affects the heart’s ventricles and atria, the lower and upper chambers of the heart, respectively.

Frequently the disease starts in the left ventricle, the heart’s main pumping chamber. The heart muscle begins to dilate, meaning it stretches and becomes thinner. Consequently, the inside of the chamber enlarges. The problem often spreads to the right ventricle and then to the atria.

As the heart chambers dilate, the heart muscle doesn’t contract normally and cannot pump blood very well…

Often, cause of dilated cardiomyopathy isn’t known. Up to one-third of the people of those who have it inherit it from their parents.

Some diseases, conditions and substances also can cause the disease, such as:
Coronary heart disease, heart attack, high blood pressure, diabetes …
Complications during the last month of pregnancy or within 5 months of birth

Dilated cardiomyopathy that develops at the end of pregnancy or within 5 months postpartum is known as peripartum cardiomyopathy.

Alternatively, an enlarged heart can be a pre-existing condition that occurred independent of pregnancy.

Hypertrophic cardiomyopathy (HCM) is very common and can affect people of any age. It affects men and women equally. It is a common cause of sudden cardiac arrest in young people, including young athletes…

Hypertrophic cardiomyopathy occurs if heart muscle cells enlarge and cause the walls of the ventricles (usually the left ventricle) to thickenHypertrophic cardiomyopathy usually is inherited. It’s caused by a change in some of the genes in heart muscle proteins. HCM also can develop over time because of high blood pressure or aging. Diseases such as diabetes or thyroid disease can cause hypertrophic cardiomyopathy. However, the cause of the disease isn’t known.

Peripartum cardiomyopathy usually leads to heart failure (inability of the heart to pump effectively) and not a heart attack (myocardial infarction or MI). Hypertrophic cardiomyopathy can lead to an MI when the enlarged heart’s increased need for oxygen can’t be met by the ineffectively beating heart. Of course it is impossible to know what happened to Garner simply based on news reports since mainstream media sources tend to use terms like heart attack, heart failure and cardiac arrest interchangeably even though they mean very different things.

The proximate cause of Garner’s death was not pregnancy or cardiovascular disease, but asthma. Pre-existing chronic health conditions like asthma are the second leading cause of US maternal deaths.`A severe asthma attack leads to a decrease in oxygen because the patient literally cannot breathe. Garner’s heart was already compromised twice over, first by the enlargement and then by any damage sustained as a result of the heart attack that occurred in the days after her baby’s birth. It seems as though her heart simply could not tolerate any additional damage and she suffered a cardiac arrest. Although she was resuscitated at a hospital, she had sustained severe brain damage and died as a result.

Erica Garner could be the face of American maternal mortality. She was black; her death took place months after delivery; she suffered from heart disease and asthma and they combined to kill her.

Is her death emblematic of systemic racism? That’s difficult to say. So far there have been no accusations of poor medical care. She died of the diseases that probably existed prior to her pregnancy. It may be impossible to determine if racism was a factor in the development of those diseases.

A mother puts Mountain Dew in her baby’s bottles, by age 2 the child is suffering massive tooth decay. Who’s to blame?

Most of us would have no qualms about blaming the mother who put the soda in the baby’s bottles. The mother did not intend that the child’s teeth should rot, but she bears responsibility nonetheless.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There’s nothing beautiful about the preventable death of a baby.[/pullquote]

A mother fails to put her toddler in a car seat for a trip to the grocery store. Along the way the car is hit by another driver, the baby is ejected through the windshield and dies on the pavement. Who’s to blame?

Most of us would have no qualms about blaming the mother who failed to put the child in a car seat. The mother did not intend for the toddler to die, but she bears responsibility nonetheless.

A mother decides to give birth outside the hospital despite having a history of two previous C-sections. Her uterus ruptures during labor and the baby dies. Who’s to blame?

According to homebirth advocates: no one.

Terall was hoping to have a natural birth since both of her sons were c-section births and extremely hard on her body. Terall did the research and found the perfect Birthing Center for her. They respected her birthing plan and she was confident in the facility… On her due date, 12/28, she went into labor at the center. Her contractions became more severe. In the midst of a contraction Terall felt a huge burst in her stomach…there was an excruciating pain that never went away…almost like a constant contraction. Something was severely wrong.

…[W]hen the midwife checked their son’s heartbeat there was none to be found. Terall was rushed by ambulance to the closest hospital…but it was too late. Terall’s uterus ruptured due to scars from her previous c-sections and dislodged the baby and the placenta causing their son to lose oxygen and blood flow. Terall was rushed into the operating room to stop her internal bleeding…

Who’s to blame?

The mother feels guilty:

…She said “I am so sorry. I thought I was making the right choice, I thought having you naturally in a tub, without drugs would be best. I wanted you to hear beautiful music when you entered this world. I didn’t know, sweetie….

But instead of accepting responsibility for choosing to attempt a VBAC outside of a hospital, she  blames those who performed her previous C-sections:

I didn’t know that having c sections with your brothers would come back to haunt me and ultimately kill you. I didn’t know my scar tissue was going to rupture and force you out of my womb…. Mommy didn’t know… I didn’t know. I will always love you my perfect boy. I am grateful for Love Song, Memories fade and this…these photographs will be all I will ever have of my baby.”

From the comments:

You are not to blame; it wasn’t something that you saw coming!!

And:

This was NOT your fault, it wasn’t because you choose vbac. You choose the option you thought wss safest and had the lowest risks. Please do not blame yourself for doing what you thought was best.

And:

Please do not allow the enemy to to fill your mind with lies. This is not your fault.

I shared the story on my Facebook page under the comment “Another baby who didn’t have to die” and got this in response:

Your … a piece of shit for taking this beautiful sad story and turning it into propaganda. Things happen. I feel terrible for the loss of this family. But, this ob is a shitty person who needs to have her license revoked vbac is common it has its risks just like any birth. I fully plan on vbac with my next.

There’s nothing beautiful about the preventable death of a baby whether that death occurs at homebirth or when a child is ejected through the windshield during an accident. I suspect that the same people who are counseling this mother not to blame herself because she “didn’t see it coming,” would not be so sanguine about the dead child ejected through the windshield. Obviously that mother didn’t see that coming either, but that would not have absolved her of blame.

What does it mean to blame someone for a bad health outcome?

A 2015 paper, Who can blame who for what and how in responsibility for health?, attempts to answer the question.

The concept of personal responsibility for health forms part of the political and philosophical landscape of professional health care, and yet it is poorly understood. Responsibility can be presented as a tripartite concept consisting of (1) a moral agent having (2) responsibilities understood as obligations and (3) being held responsible for them, that is being blamed in failing to meet them.

In the case of the child with rotten teeth, we believe that her mother is a moral agent who shirked the obligation of protecting the child’s teeth by putting Mountain Dew in baby bottles and should be held responsible for the massive tooth decay.

In the case of baby who died on the pavement, we believe that his mother is a moral agent who ignore her obligation of protecting the child by putting him in a car seat and should be held responsible in part for the child’s death.

What’s supposedly different about homebirth?

It can’t be that homebirth supporters believe that the mother is not a moral agent. And it can’t be because they believe the mother has no moral obligation to consider the baby’s survival; these are the same folks who experience spasms of indignation over women who don’t attend assiduously to prenatal nutrition.

It can’t be the fact that the mother never anticipated the outcome. The mother who failed to put her baby in a car seat for a trip to the grocery store never anticipated that she would be involved in an auto accident along the way.

The problem seems to occur for homebirth advocates in connecting the failure to meet obligation to responsibility for the outcome. Yes, the mother had an obligation to consider injury or death of the baby as a consequence of her choice, but, uniquely in this situation, we aren’t supposed to blame her for ignoring that obligation.

But the attempt to assert that the mother is not responsible when a baby dies at homebirth is deeply undercut by the notion that she deserves praise if the VBAC attempt is successful and the baby survives. Praise is the flip side of blame. In order for someone to be eligible for praise in the healthcare setting, they must be acknowledged to be moral agents with healthcare obligations that they have fulfilled. Therefore, they must be eligible for blame when they fail to fulfill those same obligations.

So who’s to blame when a baby dies at homebirth? The mother is to blame … no matter how desperately homebirth advocates wish to pretend otherwise.

What if in response to a famine in Sub-Saharan Africa, an international aid organization sent sterling silverware?

When questioned, the organization replied that most wealthy Americans don’t eat with plastic utensils and prefer sterling, so why shouldn’t the poor have what the wealthy have?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s soft bigotry to imagine that what dying black women need is what wealthy white women want.[/pullquote]

Outrageous, right? The quality of the utensils makes no difference when people are starving. They desperately need food, utensils be damned. It’s a form of soft bigotry to imagine that what starving black Africans need is what wealthy white Americans want.

It’s the same form of soft bigotry that animates the obsession with C-section rates and breastfeeding rates. The biggest problem in contemporary obstetrics today, in the US as well as around the world, is that women and babies who need high tech care are dying due to lack of it. To obsess about C-section rates and breastfeeding rates among those starving for high tech care is every bit as ugly as obsessing about flatware for those starving for food.

This thread pontificating on intervention rates by Dr. Neel Shah is an example of the ugly obsession.

British physician Matthew Fenech wrote to Shah:

Agree with a lot of what Neel is writing, especially relative lack of attn paid to postpartum period. But assertion that HCPs “cause harm by intervening too much, too soon” is entirely unsubstantiated, & adds to the toxic ‘anti-medical’ feeling that sadly colours this discussion.

I could have written that tweet. Indeed, I have been writing to and about Dr. Shah in the same vein for years. He’s decided to ignore me; I don’t blame him. When you don’t have the evidence to argue with someone, it is better to ignore them and he lacks the evidence to argue with me.

He’s still responding to Dr. Fenech, however.

He writes:

1/ There IS a toxic “anti-medical” faction in the public debate to improve childbirth…they are wrong. Medicine saves lives.
But there’s an equally toxic faction that lacks the humility to recognize the limits & pitfalls of medicine–even in the face of overwhelming evidence:

He continues with this:

2/ To my colleagues who do not believe mothers are harmed when medical intervention is used “too much too soon,” start with global picture. No country on earth sees benefit to c-section rates above about 19%
(note long tail, indicating countries > 50%) https://jamanetwork.com/journals/jama/fullarticle/2473490

But that’s not what the accompanying graph show (it’s labeled neonatal mortality but the one for maternal mortality is similar). Indeed it shows the OPPOSITE. Extraordinarily high C-section rates are perfectly compatible with low maternal and neonatal mortality rates. For example, Italy, which has a C-section rate over 40% has some of the lowest maternal and neonatal mortality rates in the world.

Shah’s thread ends with this:

8/ @MattFenech83 not alone in view that harm from too much is “unsubstantiated”
I look forward to debating Baha Sibai at 2018 @ACOG_AM & making the case: increasing vaginal deliveries globally will improve safety + long-term health of our mothers & babies annualmeeting.acog.org/wp-content/upl…

Increasing vaginal deliveries globally is as likely to improve safety and long term health as sending sterling silver utensils to famine areas and for the exact same reason. It responds to the desperate need of a suffering group by sending NOT what the suffering need, but what the privileged want.

Consider the United States. We are and have always been in the midst of a crisis of black maternal and neonatal mortality. Medically complex black women and their babies are dying for lack of access to high risk obstetric and neonatal care. The leading causes of death for pregnant women are cardiac disease and chronic pre-existing diseases; the leading causes of death for newborns are prematurity and congenital anomalies.

What do they need? They need greater access to high tech care, more perinatologists, obstetric ICUs, extra monitoring and extra training for health professionals in managing complications.

What are we offering them? Efforts to lower the C-section rate and extremely aggressive efforts to promote breastfeeding. How will lowering the C-section rate improve outcomes for black women dying of cardiac disease and chronic pre-existing disease? It won’t. How will increasing breastfeeding rates improve outcomes for black babies dying of prematurity and congenital anomalies? It won’t.

This recent article in the Washington Post, aptly titled A pregnant woman went to the ‘hospital from hell’ short of breath. Six hours later, she was dead, illustrates the problem.

Somesha Ayobo weighed 520 pounds and had been diagnosed with pre-eclampsia.

After Ayobo arrived at UMC, the medical staff quickly confirmed that her breathing trouble was severe, according to Health Department records. The amount of oxygen in her blood was just 61 percent of normal levels: She and her baby were effectively suffocating.

Ayobo, whom the records do not name but refer to as “Patient #90,” was given oxygen that restored her blood to normal levels…

Then she languished in the ER for 6 hours until she had a cardiac arrest.

…[S]he was rushed to the main operating room in a last-ditch effort to save her baby.

Once there, the medical staff realized they did not have appropriate equipment for neonatal care, according to the report. They again moved Ayobo, this time to the labor and delivery unit’s operating room, on a different floor.

The result:

Ayobo was dead. Her death certificate, reviewed by The Post, lists four possible causes, a catalogue of overlapping debilities that in some combination killed her: cardiopulmonary arrest, hypoxia, pulmonary edema and morbid obesity.

Phoenix lay with tubes snaking from her tiny body in the hospital’s neonatal intensive care unit. She was transferred that night to Children’s National Medical Center in Northwest Washington.

The baby died several days later.

Ayobo and her daughter died preventable deaths because they didn’t receive the high tech care that they needed; indeed it appears that they received virtually no care at all for 6 hours.

Don’t get me wrong. I’m not arguing that there are no iatrogenic complications to C-sections and I’m not arguing that a 32% C-section rate is necessary. I find such a high rate difficult to understand since I had a C-section rate of 16% when I practiced obstetrics. My point is that high C-section rates and low breastfeeding rates don’t kill very many (if any) mothers and babies while literally hundreds of women and thousands of babies are dying in the US due to lack of high tech care.

It is immoral to focus on the lowering the C-section rate or raising the breastfeeding rate — obsessions of privileged, white natural childbirth advocates — instead of focusing on preventing the deaths of black mothers and babies. It’s the soft bigotry of imaging that what white women want is what black women need. Like sending sterling silverware to the starving, it’s grotesque.

Nothing demonstrates the incredible privilege and mind boggling self-absorption of Western, white natural childbirth advocates than the belief that giving birth at home is an accomplishment.

The (undoubtedly privileged) folks at Sammiches & Psych Meds credulously report this mother’s unassisted homebirth, This Home Birth Story Proves Just How F**king Strong Moms Are:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women like Marissa who have homebirths are not f**king strong, they’re just f**king privileged and they dont’ even have the decency to acknowledge it.[/pullquote]

In the photo, Marissa looks gorgeous – you would never guess she just endured a 36-hour, drug-free labor …

Then what? When the magic moment was upon them, Marissa trusted her body and let it do the pushing as she sat on the toilet after attempting to remain in bed and couldn’t because it “felt too ‘unnatural.’” The head descended and as she felt that uncomfortable ‘ring of fire’ feeling, she stood up, held onto a towel rack and delivered her baby.

Marissa boasts:

“I’ve never felt so powerful and accomplished in my entire life. Our bodies are truly amazing!!” Ain’t that the damn truth!

No, it’s not the truth; it is so selfish and clueless as to be ugly.

Why isn’t birth an accomplishment for the hundreds of thousands of women do the exact same thing every day, or die trying as in the image above from Afghanistan? Those are black women, brown women, poor women. They have no choice but to labor in excruciating pain at home without possibility of relief and die in agony if the baby doesn’t fit, or bleed to death from massive hemorrhage, or suffocate, racked by the seizures of eclampsia. Just how f**king strong are they?

According to NATO of Canada:

Afghanistan has the highest infant mortality rate in the world with 117.23 deaths per 1 000 live births! The maternal mortality rate is the 22nd highest in the world with 460 deaths per 100 000 live births. This is certainly an improvement from 1 400 deaths per 100 000 live births in 2008 when the Taliban was in power, but it is not nearly enough of an improvement.

Are Afghan women empowered by birth? Hardly, but they don’t count because the “accomplishment” is not giving birth and surviving. It’s having access to excellent health care and state of the art pain relief and then refusing it.

How about the women who are permanently disabled by childbirth? How about Esther?

Esther gave birth to her second child, Manuel, less than one year ago. She was encouraged to stay at home to deliver the baby, where she labored for three days with the help of a traditional birth attendant. Fortunately, she gave birth to a lively baby boy. However, after four days she noticed she was leaking urine and was unable to control it…

Her husband decided that he couldn’t tolerate the smell of Esther in the house, so he left her and went away to Uganda with their cattle. Her in-laws asked her to leave the house and so she was forced to return home with her mother.

Esther “trusted her body” exactly the same way that Marissa did. If anything, her experience was much more difficult because it lasted longer and she had no choice but to endure it. How f**king strong is Esther? How powerful and accomplished is she while leaking urine into her vagina from an obstetric fistula?

Oh, right, we’ve already established that black, brown and poor women from developing countries don’t accomplish anything by giving birth without medical care because it is the refusal of medical care that’s the “accomplishment” not the birth itself.

Lest you think that maternal morbidity and mortality are problems only in the developing world, reading the ProPublica/NPR series on US maternal mortality should set you straight. The most recent piece is How Hospitals Are Failing Black Mothers:

Researchers have found that women who deliver at these so-called “black-serving” hospitals are more likely to have serious complications — from infections to birth-related embolisms to emergency hysterectomies — than mothers who deliver at institutions that serve fewer black women…

ProPublica did its own analysis …

We, too, found the same broad pattern identified in previous studies — that women who hemorrhage at disproportionately black-serving hospitals are far more likely to wind up with severe complications, from hysterectomies, which are more directly related to hemorrhage, to pulmonary embolisms, which can be indirectly related…

This is not the developing world, and it isn’t the world of rural poverty.

We found, for example, that SUNY Downstate, where 90 percent of the women who give birth are black, has one of the highest complication rates for hemorrhage across all three states. On average, 34 percent of women who hemorrhage while giving birth at New York hospitals experience significant complications. At SUNY Downstate, it’s 62 percent.

Just how f**king strong are those black women suffering hemorrhages, hysterectomies and death?

Oops, I forgot; they don’t count because they’re black and many are poor. In order to be “f**king strong, you must be white, privileged and have easy access to the highest quality medical care.

Many people have professed themselves to be shocked by the ProPublica/NPR series, but there’s nothing new there. Black women have been dying in the US for lack of high risk obstetrical care for decades.

Why has no one been paying attention? Because the provision of obstetric care has been warped by the natural childbirth industry of privileged white women. They believe that when it comes to obstetric care “less is more.” They believe that refusing obstetric care is a sign of power, when, in reality, it is nothing more than a sign of privilege.

Black women don’t fit that narrative. For them, less isn’t more; it isn’t even enough to save their lives.

Their tragedies have been ignored. The public health discussion has been dominated by those who decry the C-section rate and the rate of other interventions, the obsessions of the privileged.

Homebirth is the designer handbag of birth. Owning a designer handbag doesn’t make a woman powerful or accomplished; it simply a sign of status for those women who already have power and privilege. Women like Marissa are not f**king strong, they’re just f**king privileged and they don’t even have the decency to acknowledge it.

It’s time for another year end round up. These were the most popular posts of the year, starting with the most popular:

Ten Month Mamas cheer a mother to her baby’s death

Homebirth, like most of alternative health, is about two things. Not mother and baby; don’t be silly! It’s about defiance and denial.

Homebirth especially is about defiance. Women routinely risk their baby’s lives — the greater the risk, the better — while flaunting their transgressiveness before their peers. That’s why there are so many Facebook groups built around the specific complication they are defying. Groups like Ten Month Mamas and its secret section…

Melissa Cheyney and the Midwives Alliance of North America finally acknowledge their hideous death rates

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Pseudoscience is deadly![/pullquote]

I’ve been writing about homebirth for more than a decade. For most of that time, the Midwives Alliance of North America (MANA) and Melissa Cheyney, the Director of Research for MANA have insisted that their data show that homebirth is safe.

In every category — with risks or without — homebirth increases the risk of fetal/neonatal death substantially and often enormously.
In the meantime, the publicly available data on CDC Wonder has made it possible for me to demonstrate that homebirth deaths rates have been 3-7X higher than comparable risk hospital birth. Amos Grunebaum, MD and colleagues have published several papers using the same data and confirming my analysis. The most comprehensive analysis of homebirth death rates was performed by Judith Rooks, CNM MPH for the state of Oregon. Rooks found that homebirth midwives had a perinatal death rate 800% higher than comparable risk hospital birth!

Now, MANA and Cheyney have finally relented and published their own data that shows that PLANNED birth at home or in a birth center (generally just a rented home without special equipment) in the US has death rates EVEN WORSE than we imagined…

If stop signs work, why should my refusal to stop hurt you?

If vaccines work, why should my refusal to vaccinate my children hurt your children?

In the world of anti-vax, this is supposed to be an incisive, penetrating question. Of course, in the world of anti-vax, there’s not a whole lot of thinking going on. To understand the foolishness of the question, it helps to think about a similar issue.

Joe has done his research and decided that stop signs don’t work.
If stop signs work, why should my refusal to stop hurt you? …

Modern Alternative Mama and the ugliest parenting post I’ve ever read

…Kate seems to have forgotten the most monumental parenting mistake she ever made. Six years ago, when her daughter was only 3, her son was todder and she was expecting her third child, she wrote the ugliest parenting post I have ever read. It put her on the map, garnering national attention.

It was a vicious attack on her little girl, titled Mom Confession: I Think I Love My Son a Little Bit More, published on the parenting website Babble. The title, while bad enough, does not convey the full repulsiveness of the piece…

Babies die because lactation consultants lie

…[P]eremptory treatment of mothers by lactation consultants — ignoring their concerns about starving babies, in particular — has been going on for decades, but everything changed when Jillian Johnson shared the story of her son Landon’s death from dehydration due to insufficient breastmilk (If I Had Given Him Just One Bottle, He Would Still Be Alive). The issue rose to public consciousness in a way that it never had before, prompting new attention and hopefully a wholesale review of relentless effort to promote breastfeeding…

Alternative health, Dunning Kruger and the Tuteur Corollary

I’ve spent the last few days wrangling with anti-vaxxers on the Skeptical OB Facebook page. I wasn’t arguing with them since a doctor can no more argue immunology with anti-vaxxers than a mathematician can argue calculus with a four year old. Neither knows enough to come to grips with the actual subject.

Most four year olds would be quick to tell you that they don’t understand calculus, but most anti-vaxxers aren’t nearly so self aware. As victims of the Dunning Kruger effect, they actually think they know what they are talking about…

Pity The Milk Meg, whose self esteem resides in her breasts

… For all we know, Meg, you might be an abysmal mother, regardless of the fact that you shove your breast into your child’s mouth on a regular basis. Ask any child, teenager or adult; I’ve yet to meet anyone who thinks infant feeding has anything to do with good or bad mothering.

Please, Meg, find another source for your self-esteem that is more realistic and less fragile. Resting your self esteem on your ability to lactate makes as much sense as resting your self esteem on your blood count. It’s not merely foolish; it’s pathetic.

Breastfeeding can reduce SIDS risk nearly as much as pacifier use can

…[F]or every 10 non-breastfed babies who were going to die of SIDS, five of them would survive if all of them used pacifiers.

Breastfeeding your baby is nearly as good as a pacifier!

New mother commits suicide over breastfeeding pressure

…Postpartum depression, like all clinical depression, is a multifactorial problem. No one can say for certain what causes it. But we can say for certain that bullying makes it worse. And contemporary breastfeeding advocacy is BY DESIGN a form of bullying.

Yet another homebirth death and yet another wall of denial

…Why did this happen? It happened because R’s mother chose homebirth with undereducated, undertrained, ideologically brainwashed midwives.

It happened because magical thinking — positive affirmations, having no fear — has NO impact on the incidence of complications and death.

It happened because intermittent Doppler monitoring is not as accurate as electronic fetal monitoring…

Autism, bleach and pre-rational beliefs about illness

Yes, this woman is dosing her autistic daughter with BLEACH. Why? Because a quack declared that autism is caused by parasites and that ingesting bleach and bleach enemas can kill those parasites. This was posted in a Facebook group that has thousands of members dedicated to treating autism with bleach.

You don’t need to be a physician to know that bleach is toxic and these parents are literally poisoning her daughter. This is the worst kind of medical child abuse imaginable and sadly her ignorant parents are abusing her not because they don’t care about her but because they do…

Ina May Gaskin and the racism of natural childbirth advocacy

…[T]his is just the latest effort in which natural childbirth advocates in general and Ina May Gaskin in particular engage in medical colonialism, expropriating the tragedies of Black women to advance a philosophy created by and for Western, relatively well-off white women.

Natural childbirth advocates in general and Ina May Gaskin in particular engage medical colonialism.
It goes all the way back to Grantly Dick-Read, the founder of the natural childbirth movement, who was a racist and a eugenicist …

If there’s a theme that unites these twelve posts, it is this: pseudoscience is deadly!

Maternal mortality has been one of the biggest health stories of 2017.

A superb and evolving series of articles written by ProPublica in collaboration with NPR has focused a spotlight on the rising US maternal mortality rate. The latest piece is Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S.

Each year in the U.S., 700 to 900 women die related to pregnancy and childbirth. But for each of those women who die, up to 70 suffer hemorrhages, organ failure or other significant complications. That amounts to more than 1 percent of all births. The annual cost of these near deaths to women, their families, taxpayers and the health care system runs into billions of dollars…

Better care could have prevented or alleviated many of these complications, experts say…

Why have we allowed this to happen?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We turned toward the goal of reducing interventions before we secured low rates of maternal mortality.[/pullquote]

Yes, allowed; with the exception of cardiac complications, none of these complications are new, and we’ve been treating them successfully for decades. We haven’t forgotten what to do; we’ve just stopped doing it and women are injured and dying as a result.

In my view, we’ve committed the medical equivalent of the classic football receiver’s mistake. We started heading up the field before securing the ball. The receiver is so excited to reach the goal line that he turns toward it assuming that making the catch is a foregone conclusion. In obstetrics, we’ve turned toward the goal of reducing interventions, assuming that the catch — a safe outcome to pregnancy — is a foregone conclusion. In football, losing focus and dropping the ball results in missed opportunities to score. In obstetrics, losing focus and dropping the ball results in preventable injuries and deaths.

How can we improve maternal health in 2018? We can start by returning to fundamentals.

1.Focus on outcome, not process

If we want to decrease maternal morbidity and maternal mortality, we need to focus on what’s causing them.

The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. That reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before.

2. Stop obsessing about C-section rate; it’s not a metric of maternal health

Sadly, we’ve allowed the natural childbirth industry to dictate our priorities with disastrous results. The natural childbirth industry is focused on what will benefit them; in other words, they are focused on reducing C-section rates and interventions rates and providing employment opportunities for midwives, doulas and childbirth educators. The bedrock assumption of the natural childbirth industry is that childbirth is inherently safe. Unfortunately, childbirth is inherently dangerous and it is ONLY C-sections and interventions that prevent injuries and deaths.

Do iatrogenic injuries from interventions occur? Of course they do, but as a glance at the chart above demonstrates, that’s not what’s injuring and killing pregnant and postpartum women. If we want to prevent severe maternal morbidity and mortality, we have to focus on what’s causing it.

3. Improve access to health care in general and prenatal care in particular

Chronic diseases, complications of pregnancy, obesity and advanced maternal age pose serious risks to pregnant women. Management of chronic diseases (high blood pressure, heart disease, kidney disease, etc.) before pregnancy is critical to improving pregnancy outcomes. Managing obesity related problems like adult onset diabetes is also very important.

Good prenatal care allows providers to anticipate and prepare for potential complications and have staff and services in place before disaster strikes.

4. Increase high risk specialists

We’ve experienced a tremendous increase in high risk pregnancies without a concomitant increase in perinatologists (specialists in high risk pregnancies). Too many women die because they don’t have access to the doctors who are best prepared to treat them.

5. Create more obstetric ICUs

Critically ill obstetric patients are often transferred to the ICU, but the ICU doctors don’t have experience with the physiology of pregnancy or the pathophysiology of complications. In contrast, the dramatic decrease in perinatal mortality over the past 50 years reflects the creation specialty units for the care of critically ill newborns (NICUs) and a rating systen for hospital nurseries (levels I, II, and III) to facilitate triage and transport of critically ill newborns to hospitals that have the experts and equipment to to treat them. We need a similar system of ICUs, rating systems and triage for critically ill pregnant women.

6. Research cardiac complications of pregnancy

No one really understands why cardiac disease has become the leading cause of maternal mortality. We won’t find out unless we fund and perform the research that will answer that question.

7. Have high index of suspicion for complications

In order to prevent complications, you have to understand who is at greatest risk and take appropriate steps to address the risk factors. In order to treat complications, you must recognize when they are happening, the earlier the better. The natural childbirth industry has deformed our efforts to do both by pretending that complications are rare and interventions and treatments are dangerous. They’ve made a concerted effort to undermine trust between doctors and patients, encouraging women to refuse testing, refuse interventions and lie about risk factors. They are wrong, dead wrong. Childbirth is and has always been, in every time, place and culture a leading cause of death of young women.

The pernicious effect of the natural childbirth industry can best be understood by analogizing to firefighting. Fire, like childbirth, is entirely natural. Fire, like childbirth, injures and kills. Imagine a “natural” firefighting industry that counsels people: fires are rare; don’t bother taking precautions, don’t pull the fire alarm until the house has almost burned to the ground; don’t tell firefighters about the presence of highly flammable fluids within the house; and make the firefighters wait to use hoses until efforts at putting out the fire by spitting on it have been exhausted. Would it be any surprise if injuries and deaths from fire increased as a result?

8. Drill for common complications (hemorrhage, pre-eclampsia)

Once you recognize complications, you must treat them as expeditiously as possible. That means having easy access to interventions, medications, and transfusions and lots of practice using them. In life threatening complications, every second counts. Practice reduces the time needed. Fire fighters drill. Doctors and midwives must drill, too.

9. Provide extra monitoring for black women

Maternal morbidity and mortality disproportionately affect black women. Therefore, it only makes sense to given them extra time, extra attention, easier access to care, greater funding for care and more research on the specific complications that they are likely to experience. Instead, we do the opposite, obsessing about the “birth plans” of privileged women and brainstorming on marketing techniques to attract them.

10. Prioritize improving outcomes for the disadvantaged over catering to the whims of the privileged

To go back to the firefighting analogy: if we ignore fire traps in poor neighborhoods, fail to build and maintain fire hydrants, and place fire stations miles away, should we be surprised that there are more fires and more deaths among the most vulnerable?

Then why are we surprised that pretending pregnancy complications are rare, having a low index of suspicion for them, failing to drill for them, and demonizing the people who are experts in treating them has led to an increase in preventable injuries and deaths, particularly among the most vulnerable?

Becoming a mother is an experience like no other.

As Alexandra Sacks, MD wrote in The New York Times:

The process of becoming a mother, which anthropologists call “matrescence,” has been largely unexplored in the medical community. Instead of focusing on the woman’s identity transition, more research is focused on how the baby turns out. But a woman’s story, in addition to how her psychology impacts her parenting, is important to examine, too…

The process is joyful, but the joy is not unalloyed. In addition to welcoming a beloved new child, women giving birth for the first time are experiencing a change in identity, a sudden weight of tremendous responsibility, the reality of motherhood vs. the fantasy, and possible ambivalence at the change.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural childbirth, breastfeeding and attachment parenting aren’t merely unnecessary; they have nothing to do with mother-infant bonding at all.[/pullquote]

In other words, even in the best and easiest cases, matrescence is a fraught process. So why have we allowed the Maternal Guilt Industry to make it harder by promoting the holy trinity of maternal suffering: pain, fear and anguish?

What is the Maternal Guilt Industry?

As I wrote last week, the Maternal Guilt Industry encompasses the professional and lay advocates of natural childbirth, lactivism and attachment parenting. The bedrock principle of the Maternal Guilt Industry is this: children’s wellbeing can only be ensured by mothers’ suffering.

It starts with the well known imperative to endure the agonizing pain of labor and not dare to abolish it with an epidural. The imperative to embrace suffering continues with the extraordinary pressure to breastfeed exclusively. It is reinforced by attachment parenting, which recommends that a mother erase her identity and limit herself to continuous physical proximity to her child. And it is made possible by the guilt and shame heaped on women who refuse to comply.

As Dr. Sacks writes:

There’s also the ideal mother in a woman’s mind. She’s always cheerful and happy, and always puts her child’s needs first. She has few needs of her own. She doesn’t make decisions that she regrets. Most women compare themselves to that mother, but they never measure up because she’s a fantasy. Some women think that “good enough” (a phrase coined by the pediatrician and psychoanalyst Donald Winnicott) is not acceptable, because it sounds like settling. But striving for perfection sets women up to feel shame and guilt.

In my view, the Maternal Guilt Industry sets women up to feel guilt and shame in order to push sales of their products and services.

As Chavi Eve Karkovsky, MD wrote in a fantastic piece for Slate entitled Sorry You Were Tricked Into a C-Section; What disapproving friends don’t understand about cesarean births:

You’d think any woman who has recently had major abdominal surgery and has a newborn to care for would have enough to deal with, but too often there’s more. This is what I see a fair amount of the time: A woman who has had a cesarean birth gets comments from her friends—online friends, IRL friends—mostly congratulations, but also messages of regret. Coming from everywhere are intimations that the surgery wasn’t warranted, suggestions that something underhanded occurred. Her friends and relatives point out that the cesarean birth rate in this country is too high. It can’t be the case that all of those surgeries are necessary.

So her friends and relatives tell her, outright or through subtext, that she must have been snookered. She was fooled and then underwent some shady butchery. Perhaps the fate of her child was held hostage: “Something might happen to the baby,” she was told, and under these manipulations, she allowed herself to be cut. But, her friends say, it wasn’t right.

That’s the Maternal Guilt Industry, natural childbirth branch, at work. But when it comes to guilt and shame, the natural childbirth branch has nothing on the lactivism branch. The Baby Friendly Hospital Initiative, which is not baby friendly and is downright mother hostile, grossly exaggerates the benefits of breastfeeding and ignores the risks in order to shame women into breastfeeding.

The central premise of the attachment parenting branch, that maternal infant bonding is fragile, uncertain and contingent on following the admonitions of the natural childbirth and breastfeeding branches, completes the trifecta of pain and fear with the anguish that new mothers have ruined their babies before they are even a week old.

Why have we allowed the Maternal Guilt Industry to blight new motherhood?

It’s certainly not because we believe in their medical or psychological claims. Unmedicated vaginal birth has no benefit for babies and substantial risk of injury and death. The benefits of breastfeeding in industrialized countries are so trivial as to be meaningless (a few less colds and episodes of diarrheal illness across the entire population of infants in their first year). And maternal infant bonding is not uncertain and contingent; it happens spontaneously in every situation except severe abuse and neglect (and bonding often takes place even then).

We’ve allowed it to happen because doctors have been too busy taking care of people to worry about the aggressive tactics the Maternal Guilt Industry uses to promote itself.

We’ve allowed the Maternal Guilt Industry to frame the issues and made only half-hearted efforts to debunk their nonsensical claims.

We’ve allowed the Maternal Guilt Industry to portray their products and services as “feminist” when they are the opposite: sexist, retrograde and aimed at controlling women, not increasing their freedom.

We’ve allowed natural childbirth charlatans (most doulas and childbirth educators) into hospitals and let them spread the poison that eats away at the self-esteem of new mothers.

We’ve committed the unpardonable sin of letting a private organization, the Baby Friendly Hospital Initiative, have free reign inside a hospital. To my knowledge, no other private organization has been allowed to do so for the obvious reason that private organizations are committed to what benefits them, not what benefits patients.

We’ve allowed attachment parenting gurus to proclaim their beliefs, contradicted by scientific evidence, without attempting to publicly debunk them.

In short, we’ve repeated the same mistakes with the Maternal Guilt Industry that we committed with the Anti-Vax Industry and women and children are suffering pain, fear and anguish as a result.

New motherhood is hard enough; we should not allow the Maternal Guilt Industry to make it harder.

It’s time to force the Lamaze certified childbirth educators out of hospitals and replace them with science based childbirth educators. The Baby Friendly Hospital Initiative should be ended immediately; it causes far more harm than good since the benefits of breastfeeding are trivial. Most importantly, we should spend time educating women about the actual scientific evidence about mother-infant bonding and emphasize in the strongest possible terms that there are many, many ways to be a good mother and that natural childbirth, breastfeeding and attachment parenting aren’t merely unnecessary; they have nothing to do with mother-infant bonding at all!

Why do good mothers feel so bad? Because suffering is integral to contemporary mothering ideology.

Yesterday I wrote about hyper-maternalism as a more accurate term than natural mothering or attachment parenting. Natural mothering and attachment parenting are really marketing terms designed to romanticize maternal suffering and hide the true purpose: manipulating women. Hyper-maternalism is a more accurate description because it captures the belief that mere mothering is not enough; hyper-mothering is required.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Maternal suffering is not an unfortunate side effect of natural mothering or attachment parenting; it’s a requirement.[/pullquote]

Today I’d like to talk about the holy trinity of maternal suffering: pain, fear and anguish.

The key point I want to make is this: Maternal suffering is not an unfortunate side effect of natural mothering or attachment parenting; it’s a critical feature.

It’s a deliberate exploitation of the fact that most mothers are willing to endure any form of pain in any amount to spare their children. What’s unique about hyper-maternalism is the belief that mothers ought to suffer pain for trivial reasons or for no reason at all. Maternal pain is often portrayed as beneficial for children without any evidence to support the claim.

Maternal suffering is mandated even for “good” mothers. Their suffering may be limited to physical pain of childbirth and breastfeeding, plus fear of “toxins,” vaccine “injuries” and suboptimal intellectual achievement and that’s if they are lucky. Those who do not tick all the boxes of hyper-maternalism experience the pain of trying to tick the boxes, compounded by anguish that they “failed” and thereby short changed their beloved children.

1. Pain

This is the sine qua non of maternal suffering.

It starts with the well known imperative to endure the agonizing pain of labor and not dare to abolish it with an epidural. Most people do not realize that avoiding pain medication was not originally part of the natural childbirth ideology. Grantly Dick-Read insisted that women would not have to endure childbirth pain if they understood that their purpose was to reproduce. The Lamaze method was originally touted as pain relief. Natural childbirth was about being awake and aware during birth without pain. Indeed, both Dick-Read and Lamaze explicitly allowed pain relief in labor and the advent of the epidural several decades later meant that women could fully experience birth without pain.

It wasn’t until the early 1980’s, after natural childbirth advocates had achieved their original goals — no sedation, support people in labor and delivery rooms, no perineal shaving or enemas — that they deliberately moved the goalposts. The natural childbirth industry (midwives, doulas, childbirth educators) couldn’t offer epidurals so they demonized them instead, insisting that they are dangerous to babies (they aren’t). The point was further emphasized when Michel Odent fabricated the notion that pain is required for women to bond with their babies (a bald faced lie).

The requirement for pain is responsible in part for viewing C-sections with horror. C-sections bypass the suffering of labor, but they also mitigate future pain from perineal tears, sexual dysfunction and incontinence. The only thing worse than a C-section is a maternal request C-section chosen to prevent pain and painful side effects. How dare a woman imagine that she can be a mother without excruciating pain?

The imperative to endure pain continues with the relentless quest to breastfeed exclusively. Many women experience significant pain while breastfeeding, particularly in the early weeks. Lactivists respond by either telling women that they must be breastfeeding wrong, recommending that they purchase more support services or insisting that good mothers endure pain, despite the fact that the benefits of breastfeeding in industrialized countries are trivial.

2. Fear

In the entire history of the human race, childhood has never been safer. Ironically, contemporary parenting “experts” would have you believe that children are continuously threatened with serious harm and death from infant formula, vaccines and imaginary “toxins” among other threats. These “experts” problematize not merely the safety of children, but even routine developmental tasks. Our ancestors fed their children, provided basic care and hoped for the best. Today’s mothers are encouraged to believe that they can and should be experts on both pediatrics and nutrition with special emphasis on nutrition, immunology and toxicology. They cannot obtain relief from these pervasive fears because they are taught that real experts like obstetricians and pediatricians are not to be trusted.

Above all, they are warned that the mother-infant bond, which has always been understood to develop spontaneously, is frightfully tenuous and contingent on specific, ritualized parenting behaviors. And if all that weren’t bad enough, mothers are being instructed that their children’s brain development depends on the quality of their love. Women are continuously encouraged to be fearful because fearful women are easily manipulated.

3. Anguish

Obviously mothers will be anguished if their children are unhealthy or unhappy. What’s unusual about hyper-maternalism is that mothers are encouraged to be anguished even when their children are healthy and happy. They are supposed to be anguished if they did not have a vaginal birth, if they opted for a C-section or if they did not breastfeed exclusively for an extended period of time.

The responsibility for any and every bad outcome is reflexively pinned on mothers, especially when the actual cause is unknown such as in the case of autism. Mothers are encouraged to believe that bad outcomes could have been avoided if only they had refused vaccines, if only they had removed “toxins” from their child’s diet, if only they enforced rigid restriction diets. It is their “fault” that their children are autistic despite the fact that autism is know to have a large genetic component.

Ironically, real mental anguish, such as postpartum depression or maternal mental illness is dismissed out of hand. Weighed down by depression, crying all day, unable to sleep at night? That’s not an excuse to stop breastfeeding. Doctor recommends psychiatric medication to treat your depression and it’s potentially incompatible with breastfeeding? Don’t you dare stop breastfeeding; stop the medication instead.

The other source of anguish, arguably accounting for the largest share, is guilt and shame. The terms are often used interchangeably in regarding motherhood, although they do have specific meanings. As Jean-Anne Sutherland explains in Mothering, Guilt and Shame:

The notion of maternal guilt is so pervasive in our culture as to be considered a ‘natural’ component of motherhood. To read a popular press book or piece of social scientific research on motherhood is to read about guilt. That mothers experience guilt and shame in relation to their roles as mothers is the most prevalent finding in mothering research …

What’s the difference between guilt and shame?

… [A] mother would be describing guilt if she expressed a negative self-evaluation regarding behavior stemming from a specific task. However, her experience would be labeled shame if she described herself, in relation to others, as having not met an idealized self-image.

In other words, a mother might feel guilty that she had a C-section instead of a vaginal birth or fed her infant with formula instead of exclusively breastfeeding. Either could cause her to be ashamed that she is not a “good” mother. Both are significant sources of anguish for mothers and are often elicited by others specifically for the purpose of making new mothers feel awful.

It’s hardly surprising that good mothers feel so bad. Every mother is forced to endure the holy trinity of maternal suffering.