Yesterday I posted a link to a piece about “doing your own research.”

Unless you’re an expert in the field you’re “researching,” you’re almost certainly not able to fully understand the nuance and complexity of the topic. Experts have advanced degrees, published research, and years of experience in their sub-field. They know the body of evidence and the methodologies the researchers use. And importantly, they are aware of what they don’t know.

Inevitably several people wrote to complain about individual doctors who were wrong. For example:

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]There is a big difference between an individual doctor being wrong and the fundamental principles of medicine being wrong.[/perfectpullquote]

The problem with these narratives is that there are plenty of situations where doctors misdiagnose patients or give them no diagnosis at all. Then we need to do our own layman’s research.

To understand why that observation misses the point, consider these situations:

1. The salesperson at the local Ford dealer tells you that the car you are considering is very reliable. You do “your own research” and learn from Consumer Reports that there are many other cars that are more reliable. You buy a different car.

vs.

Having done “your own research” you conclude that the combustion engine never works, all car dealers are frauds and walking from place to place is more reliable and practical than driving.

2. The provider you use to host your website is expensive, has poor design tools and has frequent outages that leave your website offline. You do “your own research” and learn of other providers that have better records. You switch to a one of those and find your website is now online all the time and you are saving money to boot.

vs.

Having done “your own research” you conclude that the internet is a scam and that no one could make money through a website.

3. Your 2nd grader is having terrible trouble learning to read. The teacher counsels patience but you do “your own research” and learn that children who are having trouble reading often have a learning disability like dyslexia. When you take your child for neuropsychological testing you’re told that she is indeed dyslexic. With proper tutoring to compensate for the disability she learns to read and loves it. You conclude that not every teacher is knowledgeable about learning disabilities.

vs.

Having done “your own research” you decide schools pressure children and that you will “unschool” your daughter, letting her learn to read in her own time. By age 11 she still can’t read but other mothers in Facebook unschooling groups reassure you that it’s nothing to worry about.

Can you see the difference?

“Your own research” can allow you to compare various purveyors of the same product, whether that product is a car, an internet provider or a teacher.

But “your own research” CANNOT determine whether the fundamental principles underlying the product — be it cars, the internet or education — are true or false. That requires advanced education and experience, both of which most lay people lack.

Part of the problem is that the language that laypeople use elides the fact that there are two types of “research.” There is the “research” of surveying other people’s experience to determine what is the best choice to meet your needs. That’s very different from real research that determine fundamental scientific principles.

There is nothing wrong with SURVEYING the experiences of people who have similar needs or similar problems. When determining whether a car or a web host is reliable, it is extremely helpful to survey the experiences others had with many different cars or web hosts. When trying to determine whether your child has a learning disability it can be extremely helpful to learn about the varied experiences of other children who had similar difficulties learning how to read.

But that’s very different from “doing your own research” to determine whether the underlying principles of combustion engines or the internet or unschooling are correct.

That’s true for medicine, too. There’s nothing wrong with SURVEYING the experiences of others who have similar needs or problems to determine whether your doctor’s diagnosis is correct or whether his recommendations are right for you. But there is simply no way for a non-expert to do “your own research” to determine whether the fundamental principles of medicine are true.

So while you can note that your child was diagnosed with autism 6 months after receiving the MMR vaccine, and you can SURVEY other parents of children with autism to learn if they had similar experiences, you CANNOT do “your own research” to determine whether vaccines cause autism. Only scientists and statisticians can do that.

While you can discover a lump in your own breast and SURVEY others who also found lumps in their breasts to justify demanding a mammogram when your provider is reluctant to order one, you CANNOT “do your own research” to determine whether or not you have breast cancer. Only doctors — internists, radiologists, pathologists and oncologists — can do that.

While you can decide that you’d like to have a certified nurse midwife as your provider for pregnancy and SURVEY others for midwives they liked and with whom they felt comfortable, you CANNOT “do your own research” to determine whether refusing birth interventions is safe. Only obstetricians and statisticians can do that.

The bottom line is that there is a big difference between an individual doctor being wrong and the fundamental principles of medicine being wrong. Doing “your own research” (surveying others) can help you determine the former but never the latter.

I’ve been writing for more than a decade about babies and mothers whose lives have been sacrificed on the altar of the British midwifery’s “Campaign for of Normal Birth.” Radical midwifery theorists believe “normal” birth is birth without pain relief or interventions of any kind, even interventions designed to ensure safety.

Parliament has now issued a critique of British maternity care including the ideology of “normal” birth. Despite careful, measured language, the report is scathing.

According to The safety of maternity services in England:

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]Maternity care can not be safe until the ideology of normal birth has been eliminated.[/perfectpullquote]

Since shocking failures were uncovered at the University Hospitals of Morecambe Bay NHS Foundation Trust there has been a concerted effort to improve the safety of maternity services in England. However, major concerns have since been raised at the Shrewsbury and Telford Hospital NHS Trust and East Kent Hospitals University NHS Foundation Trust. There can be no complacency when it comes to improving the safety of maternity services and it is imperative that lessons are learnt from patient safety incidents.

There are a variety of reasons why women — particularly women of color — do not receive safe maternity care. Sadly, one of the most important reasons is because the maternity system is riddled with the ideology of “normal” birth, an ideology that prioritizes the process of birth over safe outcomes.

Referring to previous reports about the safety of maternity care, the Parliamentary report noted:

The report of the Morecambe Bay investigation describes the “pursuit of normal childbirth ‘at any cost’” Similar themes have emerged from the interim Ockenden report into Shrewsbury and Telford. When she came before us, Donna Ockenden said that the review had:

“Spoken to hundreds of women who said to us that they felt pressured to have a normal birth […] at that trust, there was a multi-professional, not midwife-led, focus on normal birth pretty much at any cost.”

Indeed:

…[W]e were shocked to hear from Clotilde Rebecca Abe that a mum she supported was made to feel like a failure by her midwife, because she opted for a caesarean section. Clotilde told us that the woman “felt like a failure because she felt that she had let the midwife down”. ‘Anecdotal evidence like this suggests that, in some cases at least, there is still clinician-led pressure for women to choose vaginal delivery, even when this may not be in their best interests.

Michelle Hemmington simply and eloquently argued that rather than the method of delivery, the outcome of the birthing process must be the focus, with all professionals working together:

“Consultants, registrars, and midwives all need to be working together and to be joined up. At the end of the day, the outcome is to have a safe, healthy, positive experience of birth and to come home with a baby. They should all be working together to achieve that.”

The privileging of process over outcome manifests in many ways but two are particularly critical: withholding pain relief from and discouraging lifesaving interventions for women in labor.

As columnist Sonia Sodha explains in The Guardian:

When it comes to childbirth, this predisposition to disbelieve women in pain and to underemphasise their medical needs has been particularly toxic, allowing an ideology to take hold that so-called normal non-medicalised birth is best, regardless of what a woman herself thinks or feels…

Despite several government reports exploring the death toll of normal birth ideology, it is still an integral part of British midwifery care:

…[W]hile the RCM formally dropped this language in 2017, it lives on strongly in some parts of the midwifery profession. There are still midwifery conferences that promote “normal birth”. The University of Central Lancashire – a major midwifery training centre – still runs a course on “normal birth”…

The Parliamentary report notes in its conclusions:

…[Maternity] organisations need to work hard to stamp out the damaging ideological focus on “normality at any costs”, which caused such huge loss and suffering at Morecambe Bay and Shrewsbury and Telford – and may exist in other trusts today. We heard that senior leaders in maternity services no longer use the term ‘normal birth’ and we urge an end to the use of this unhelpful and potentially damaging term.

When it comes to safety and pain relief:

…[W]omen must be fully and impartially informed about the safety risks associated with all birthing options. Women should also be provided with clear information about the likelihood of interventions.

Timely and appropriate pain relief is also an essential part of safe and personalised care, and we believe that every woman giving birth in England should have a right to their choice of pain relief during birth …

Finally:

We recommend that NHS England and Improvement establish a working group … to develop a set of actions for maternity services to consider in order to ensure no woman feels pressured to have a vaginal delivery and is always informed clearly what the safest option is for her birth…

Ultimately, maternity care can not be safe until the ideology of normal birth has been eliminated.

In the 21st Century United States we speak disparagingly of superstition. Superstition is supposedly a feature of backward, primitive cultures, not our culture.

According to Wikipedia:

Superstition is a pejorative term for any belief or practice that is considered irrational or supernatural: for example, if it arises from ignorance, a misunderstanding of science or causality, a positive belief in fate or magic, or fear of that which is unknown.

But contemporary industrialized cultures have supersitions, too. We just call them “science denialism.”

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]Unlike traditional superstitions which merely leave you looking foolish, the superstition of anti-vax can leave you dead.[/perfectpullquote]

Like traditional superstition, science denialism is usually irrational, involving a misunderstanding of science or causality.

Like traditional superstition, science denialism seeks to explain observed phenomena in a way comprehensible to those without advanced education.

And like traditional superstition, science denialism often gives believers the illusion that they have more control over bad things that could happen to them than they really do.

Superstitions include things like avoiding black cats, walking under ladders and opening umbrellas indoors. That’s supposed to prevent bad luck. But since there is no way that those phenomena could cause bad luck in the first place, avoidance as a preventative merely gives the comforting illusion of control over the uncontrollable. Only the unsophisticated could possibly believe that and even they have trouble defending these beliefs in a rational way.

Science denialism, in contrast, is imagined by its believers, including sophisticated believers, to be true.

There are other significant differences:

Unlike superstitions that are generally spread by word of mouth, science denialism is spread by technology — talk radio, FoxNews and especially social media like Facebook and Twitter.

In contrast to superstitions, science denialism is often about technology.

Denialists invoke conspiracies in which agents of technology use that technology to harm a gullible public.

The ultimate superstition of our time is is anti-vaccine advocacy.

Anti-vax has many of the classic attributes of superstitions:

All anti-vaxxers have a friend, a friend of a friend, or a Facebook friend whose child was completely normal until he or she received a vaccine or multiple vaccines.

But the key feature of contemporary superstitions like anti-vax is technological privilege. Anti-vaxxers invariably have no personal experience of nature. Anti-vax beliefs can only take root and flourish in societies that are capable of nearly eradicating diseases by vaccination. No one who has personal experiences of diseases like tetanus, diphtheria, polio, pertussis and measles could be ignorant enough to believe they aren’t dangerous or were disappearing before the advent of vaccines.

Only those who have no direct experience of nature as it existed before technology — not “nature” imagined as lovely vacation spots — could be gullible enough to imagine that nature creates perfection or cares whether you live or die. “Nature is red in tooth and claw” is more than poetry. Evolution, by definition, involves the survival of the fittest, which sounds nicer than acknowledging that most animals (humans included) ended up as dinner for other animals, possibly before but often after being weakened by injury, disease or age.

Survival of the fittest means that in a world dependent on natural immunity, massive numbers of people died of vaccine preventable diseases, particularly childhood diseases. Even those fit enough to reach adulthood could be carried off at any moment by smallpox, plague or even flu … or now by COVID.

Anti-vax is the quintessential contemporary superstition: it is based on misunderstanding of both science and causality, is propagated by technological media, and imparts a false sense of control over bad outcomes where no control exists. But unlike traditional superstitions which merely left you looking foolish, the superstition of anti-vax can leave you dead.

What’s wrong with anti-vaxxers?

Why do they cling to absurd and nonsensical conspiracies despite the fact that they’ve never been right in the entire 200 year history of the anti-vax movement?

The dirty little secret:

They’re psychologically weak and emotionally needy; anti-vax eases their sense of powerlessness and fills a desperate desire to feel both clever and important.

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]Anti-vax belief reflects psychological neediness.[/perfectpullquote]

According to Medical conspiracy theories: cognitive science and implications for ethics:

Anti-vaxxers are anxious:

Humans are natural intention seekers, but this tendency is especially enhanced under conditions of anxiety… [M]agical thinking becomes especially preponderant in the face of uncertainty. Superstitious behavior that also “connects the dots” by establishing causal relationships amongst unrelated phenomena, becomes more prominent in times of difficulties.

Anti-vaxxers feel powerless:

People who make a connection between vaccines and autism are frequently parents of autistic children themselves. There is no known cause or cure for autism, so in those cases, feelings of powerlessness are considerable, and this feeds more into the theory that there is a conspiracy at play.

Anti-vaxxers are desperate to feel important:

…[I]t has been empirically established that conspiracy theories are related to “collective narcissism.”

Not surprisingly, since anti-vax reflects emotional needs — anxiety, powerlessness and collective narcissism — it is unlikely to be ameliorated by education efforts. That’s why education attempts often backfire.

Unfortunately, it is extremely difficult to address the anxiety and sense of powerlessness that fuels belief in anti-vax. That requires government intervention and in the current political environment such intervention is unlikely.

What about the tendency toward collective narcissism? That may be easier to address.

Indeed it has been addressed with remarkable success in the case of drunk driving.

People drink and drive for deep psychological reasons and are unlikely to respond to education attempts. But they have responded to a concerted effort against collective narcissism. Drunk driving used to be viewed by drunk drivers as “cool.” Mothers Against Drunk Driving nearly single handedly changed drunk driving from “cool” to socially unacceptable. Instead of being a source of self-esteem, drunk driving has become a source of shame.

Anti-vax is the intellectual equivalent of drunk driving. It’s seen by its adherents as a sign that they are “cool”: smarter, more knowledgeable and more realistic than others. We should be working to change anti-vax beliefs from a source of self-esteem to a source of shame.

How?

First we must emphasize that anti-vax isn’t a sign of intellectual strength; it’s a sign of emotional neediness. Anti-vaxxers aren’t smarter; they’re just anxious. They aren’t more realistic; they just feel powerless. Those who believe anti-vax celebrities aren’t more knowledgeable; they’re just more gullible.

Second, we must emphasize that liberty does not give people the right to hurt others. Just as there is no “right” to drive drunk and inadvertently harm or kill others, there is no “right” to go out into society unvaccinated and inadvertently harm or kill others.

Finally, we must work to stigmatize anti-vax beliefs.

In addition to “Friends don’t let friends drive drunk!” we should cultivate the belief that “Friends don’t let friends spout anti-vax nonsense!” Anti-vaxxers — like drunk drivers — aren’t cool. They’re pathetic and they must be stopped.

I recently posted a series of memes on my Facebook page. They’re united by the theme: Conventional Medicine Wins!

For example:

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]Why isn’t this woman’s experience proof that alternative medicine works?[/perfectpullquote]

No one calling 911 begs for a chiropractor of a homeopath.

No one treats a venous snake bite with essential oils.

Alternative medicine cannot cure fractured bones.

In an effort to dispute my claims, a woman posted her fabulous experience with alternative health. It’s a classic example of how the unsuspecting come to believe in quackery.

She wrote:

I was diagnosed with several auto immune diseases at age 11. Juvenile rheumatoid arthritis. The medication they gave me methotrexate and plaquinel had bad side effects and lowered my immune system so every time somebody sneezed I was sick for a week it was terrible.

My good friend’s mother runs in alternative Health care Center – center for natural healing. I can tell you that I was able to slowly get off almost 9 medication and I ate very healthy- I juiced, as well as others things. Never in my life had I been pain and medication free. It helped me tremendously and my blood work showed that!

That’s proof, right? Not really.

Why isn’t this woman’s experience proof that alternative medicine can successfully treat juvenile rheumatoid arthritis?

Because nearly 60% of those who suffer JRA will eventually go into remission.

According to the paper Disease progression into adulthood and predictors of long-term active disease in juvenile idiopathic arthritis:

At 30-year follow-up, 59% of the patients were in clinical remission off medication, 7% were in remission on medication and 34% had active disease. 70% of the patients were in the same category of disease activity at 15 and 30 years…

Indeed the goal of JRA treatment — the same treatment the commentor found so unpleasant — isn’t merely to treat symptoms. The goal is to achieve remission. Ironically, the methotrexate and plaquinel, the treatments she thought were unnecessary and unnecessarily toxic, were almost certainly the reason she achieved remission. The alternative medicine “treatments” made no difference at all.

I share this story not to make fun of the commentor. She didn’t know about the natural history of JRA. Therefore she was easy prey for those who sell snake oil.

There is another lesson here. Like most people who are gullible enough to be persuaded by alternative remedies, she didn’t know what she didn’t know. It’s not difficult to find out the natural history of JRA and the high rate of remission with treatment. A simple Google search will bring it up.

Why didn’t the commentor ever check? Probably because she thought that her personal experience was enough; it never occurred to her that she needed to know the actual science. And because she didn’t know, she was vulnerable to those who would take her money and offer nonsense in return.

Contrary to the beliefs of its adherents, anti-vaccine advocacy isn’t about vaccines. It’s about the political philosophy of neoliberalism and the American predilection for paranoia.

Neoliberalism places a premium on individual responsibility and minimizes the value of collective action. We see this in whose who venerate private industry and derogate goverment support. But we also see its impact in public health where collective action is absolutely required.

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]Anti-vax flourishes because neoliberalism derides the value of collection action to promote health.[/perfectpullquote]

Vaccination works through collective action. We cannot vaccinate 100% of the population since some are allergic or immunocompromised and infants are too young for some vaccinations. Vaccination works through herd immunity. Vaccines dramatically reducing the chance that an infected person will encounter an unprotected person.

Imagine that little Ainsley comes in close contact with 10 children per day. Now imagine that Ainsley develops diphtheria. Who is likely to catch diphtheria from Ainsley? If 99% of children are vaccinated and the vaccine is 95% effective, the odds are low that any of the 10 children she comes in contract with could get diphtheria. Thus, the outbreak of diphtheria ends with Ainsley (though it may end poor Ainsley’s life).

Now imagine that only 50% of children are vaccinated against diphtheria. That means that half the children are likely to be susceptible, and therefore diphtheria is almost certain to be transmitted. And since the children who catch diphtheria from Ainsley are going to expose additional children who aren’t vaccinated, the disease begins to spread like wild fire.

The effectiveness of vaccines depends on collective action, precisely the kind of action that is devalued in neoliberal philosophy.

But vaccines have been a spectacular success. How could anyone doubt their efficacy and safety?

To privilege individual over collective action, neoliberalism takes advantage of the paranoid style in American thinking, the belief that bad things are caused by conspiracies. Rather than acknowledge the role of chance, misunderstanding and just plain stupidity in government or industry blunders, the paranoid style leads people to believe that there is no such thing as mistakes, only deliberate, nefarious plots.

A tiny fraction of children WILL be harmed by vaccines. Indeed, vaccine consent forms inform parents of the rare risk of brain injury or death. Those afflicted with the paranoid style imagine that pharmaceutical companies deliberately allow injuries that could easily be prevented and have hidden the scale of those injuries. In addition, there are children who suffer from conditions, like autism, whose cause is still unknown. Those afflicted with the paranoid style look for someone to blame and vaccines, because of their ubiquity, are easy to blame.

It is hardly surprising then that neoliberal thinking, which places all responsibility for health and wellbeing on individuals, has led to the anti-vaccination movement, which venerates individual action, especially action in defiance of authority.

Ironically, the same people who are quick to see nefarious economic motives to public health projects like vaccination, are willfully blind to the economic motives of those who promote quackery. Anti-vax is nothing if not a money making enterprise; profits are high because unlike pharmaceutical companies that have to demonstate efficacy and safety, anti-vaxxers simply monetize nonsense — books, websites, supplements, immune “boosters” and detoxes.

Anti-vax flourishes not because many are being injured by vaccines; they aren’t. It flourishes because neoliberalism derides the value of collection action to promote health, lays complete responsibility for health and wellbeing on individuals and promotes a paranoid style of thinking.

Anti-vax advocacy dismisses collective action in favor of individual action (or inaction). As a result people die, while anti-vaxxers arrogantly trumpet ignorance and celebrity anti-vax advocates laugh all the way to the bank.

Is there anyone more gullible than a COVID denier?

Hundreds of thousands of Americans are dead and deniers are still not sure the disease is dangerous. Mask use prevented million of cases but they wouldn’t wear them. New vaccines are dramatically effective with few reported side effects but they won’t take them.

Why are they so gullible?

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]Ironically COVID deniers are even more passive than the believers in experts whom they despise.[/perfectpullquote]

Because instead of trusting government, public health experts or pharmaceutical companies, they place their trust in … DOUBT. In other words, they fall for a technique formulated by Big Tobacco back when it was lying about the fact that tobacco smoking causes cancer.

In the late 1960’s, a tobacco company executive circulated a memo among his colleagues. He was attempting to counter the large and growing body of research that demonstrated that smoking caused lung cancer and other serious illnesses.

Doubt is our product since it is the best means of competing with the “body of fact” that exists in the mind of the general public. It is also the means of establishing a controversy. Within the business we recognize that a controversy exists. However, with the general public the consensus is that cigarettes are in some way harmful to the health. If we are successful in establishing a controversy at the public level, then there is an opportunity to put across the real facts about smoking and health.

The memo is startling for its insight. Simply put, tobacco companies did not have to refute the scientific evidence about smoking and cancer; merely creating doubt in the mind of the American consumer was all that was necessary to maintain or increase demand for cigarettes.

COVID deniers don’t have to refute the scientific evidence about the disease; merely creating doubt among others makes it possible to undermine scientists, public health authorities and the pharmaceutical industry.

Indeed the technique of promoting doubt has become so successful that many individuals refuse to trust science, government or industry but have no problem trusting random strangers on social media who encourage doubt.

‘Trusting blindly can be the biggest risk of all’: organised resistance to childhood vaccination in the UK (Hobson-West, Sociology of Health & Illness Vol. 29 No. 2 2007, pp. 198–215) explains how it is accomplished.

A primary way this is achieved … is to construct risk as unknowns… In the realist account, uncertainty and unknowns may be recognised but are usually framed as temporary phases that are overcome by more research. For the [antivaxxers], there is a more fundamental ignorance about the body and health and disease that will not necessarily be overcome by more research. Interestingly, this ignorance is constructed as a collective – ‘we’ as a society do not know the true impact of mass vaccination or the causes of health and disease.

Agreement with doctors (or any expert) is constructed as a negative and refusal to trust is constructed as a positive cultural attribute:

Clear dichotomies are constructed between blind faith and active resistance and uncritical following and critical thinking. Non-vaccinators or those who question aspects of vaccination policy are not described in terms of class, gender, location or politics, but are ‘free thinkers’ who have escaped from the disempowerment that is seen to characterise vaccination…

Anyone who trust experts is imagined as gullible, while those who trust doubt are lauded.

…[Antivaxxers] construct trust in others as passive and the easy option. Rather than trust in experts, the alternative scenario is of a [person] who becomes the expert themselves, through a difficult process of personal education and empowerment …

The truth, of course, is the opposite. Those who trust experts avoid death, disease and longterm disability while those who trust random people on social media become ill and may even die.

Ironically COVID deniers are even more passive than the believers in experts whom they despise. They don’t trust experts who offer empirical evidence but they will trust doubt even when there’s no empirical evidence to support it.

Trusting experts blindly isn’t the biggest risk of all. Trusting doubt is a far bigger risk and a far more dangerous choice.

It has long been known that C-sections are safer for babies than vaginal birth. Now a new study on maternal request C-sections shows that they may be safer for mothers.

As the Times of London explains, Cesarean section no riskier for mother or baby:

Women who plan to have a caesarean section are no more likely to suffer poor medical outcomes for mother and baby following birth than those who opt for a vaginal delivery, a study has found.

The Canadian research, which looked at more than 400,000 low-risk pregnancies, found hints that women popularly characterised as “too posh to push” might even be better off.

Why might that be? Because although a C-section is surgery, vaginal birth has many risks for mothers as well as for babies.

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]The right to choose a C-section should be respected not merely for ethical reasons, but because they are safer.[/perfectpullquote]

The paper is Birth outcomes following cesarean delivery on maternal request: a population-based cohort study just published in the Canadian Medical Association Journal.

Women may prefer CDMR [Cesarean Delivery on Maternal Request] for many reasons, including scheduling convenience, anxiety regarding labour pain, perceptions that the quality of obstetrical care is better for women who have cesarean deliveries, and concerns about possible urinary incontinence and sexual maternal care and obstetricianbased antenatal care.

It has been difficult to study outcomes of CMDR because they make up such a small proportion of births, for example less than 4% of C-sections in Ottawa. This study is especially compelling because it includes so many women.

A total of 422 210 pregnancies met our inclusion criteria, of which 1827 (0.4%) and 420 383 (99.6%) were categorized as planned CDMR and planned vaginal delivery (including unplanned cesarean deliveries), respectively.

Our cohort included 46 533 cesarean deliveries, of which 1827 (3.9%) were planned CDMR, and 44 706 (96.1%) were unplanned cesarean deliveries. The proportion of all deliveries that were planned CDMR was 0.5% in the first and last fiscal years of our study (2012/13 and 2017/18) and the proportion remained stable across all fiscal years.

Who chooses CMDR? Women who are in a higher risk category than average.

Planned CDMR was associated with late maternal age (≥ 35 yr), being White, living in a neighbourhood of a higher educational quintiles, gaining more than the recommended weight in pregnancy, nulliparity, conception by in vitro fertilization, anxiety, not attending prenatal classes, delivering at a hospital that provides maternal level IIc or III care and receiving antenatal care from obstetricians.

How did the authors evaluate outcomes?

The primary outcome was the Adverse Outcome Index (AOI), a composite of 10 adverse events related to labour and delivery. 33,34 The AOI is reported as the percentage of individual patients with at least 1 adverse event relative to the total number of deliveries. As the AOI may be influenced by dominant outcomes, it cannot be used as an exclusive measure of quality and safety. For this reason, we also measured the Weighted Adverse Outcomes Score (WAOS) and the Severity Index (SI). The WAOS reflects a combination of the frequency and severity of events, and the SI evaluates the severity of adverse events among the pregnancies with an adverse event.

What were the results?

Overall, the AOI was lower in women with planned CDMR (3.8%) than those with planned vaginal deliveries (8.3%) (Table 3). The frequencies of adverse maternal and neonatal outcomes were both lower for women with planned CDMR than those with planned vaginal deliveries. The most common maternal adverse outcomes were unanticipated operative procedures (1.2%, n = 21) for women who planned CDMR, and third-or fourth-degree perineal tear (3.3%, n = 13 686) for women who planned vaginal deliveries. Admission or transfer to the neonatal intensive care unit (NICU) was the most common neonatal outcome for both the planned CDMR and planned vaginal delivery groups…

The WAOS was lower in women with planned CDMR than in those with planned vaginal deliveries (mean difference [MD] −1.28, 95% CI −2.02 to −0.55) (Figure 2), largely because of a lower neonatal WAOS score (MD −1.35, 95% CI −2.00 to −0.69). There was no statistically significant difference in the overall severity of adverse outcomes as measured by the SI between women with planned CDMR and planned vaginal deliveries (MD 3.6, 95%CI −7.4 to 14.5). However, the severity of maternal outcomes was greater for planned CDMR than planned vaginal deliveries (MD 20.1, 95% CI 10.6 to 29.7).

These graphs illustrate the results:

The authors conclude:

…[W]e found that planned CDMR was accompanied by a decreased risk of adverse outcomes. The AOI and WAOS were lower for women with planned CDMR than women with planned vaginal deliveries, and the risk of adverse outcomes was lower after adjusting for confounding factors.

What about previous studies that claimed to show that C-sections are riskier for mothers? Most did NOT look at C-sections on maternal request but on C-sections for which the authors could not find a medical indication on the birth certificate. But it is only by checking the medical record that they could know whether there was a medical indication or not.

The results confirm what we’ve always known: childbirth is inherently dangerous. It has a natural neonatal mortality rate of approximately 7% and a natural maternal mortality rate of approximately 1%. Although modern obstetrics mitigates the risk, vaginal birth is still dangerous. For example, in this study:

– 14 women in the vaginal delivery group died compared to zero in the CMDR group.
– 100 women in the vaginal delivery group sustained a uterine rupture, but none in the CMDR group.
– And 13,686 women in the vaginal delivery group suffered a 3rd or 4th degree tear compared to zero in the CMDR group.

Does this mean that C-sections are always safer than vaginal birth? No, because this study looked only at non-emergency C-sections that were chosen in advance. C-sections done for medical indications are more dangerous than those done electively and the comparison with vaginal birth might yield different results.

But the study DOES mean that women who choose CMDR are making a request that isn’t merely consistent with their right to bodily autonomy but is certainly safer for their babies and also safer for themselves. The right to choose a C-section should be respected not merely for ethical reasons, but — as this paper demonstrates — for medical reasons as well.

Medical patients are uniquely vulnerable.

Ill, in pain and immersed in a system where the professionals seem to speak a foreign language, hospitalized individuals require special ethical and legal protections to make sure healthcare providers do not take advantage of them.

That’s especially true for unconscious individuals who are incapable of speaking for themselves. There is a specific ethical and legal standard used for making healthcare decisions about unconscious individuals, the substituted judgment standard. It requires that healthcare professionals choose NOT what the providers believe to be in the best interest of the patient but — as far as can be known — what the patient would choose for herself.

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]An infant’s benefit should NEVER be the determining standard for the mother’s medical care.[/perfectpullquote]

Therefore, it is appalling that a group of lactation professionals had the temerity to violate those ethical and legal principles to force an unconscious woman to breastfeed. Those professionals are so woefully ignorant about their ethical and legal violations that — amazingly — they published a paper to report them.

The paper is Who Makes the Choice: Ethical Considerations Regarding Instituting Breastfeeding in a Mother Who Has Compromised Mental Capacity. The answer is both simple and obvious to anyone with a basic understanding of medical ethics: the providers are REQUIRED to choose what the patient would have chosen for herself. But that’s not what the lactation professionals decided; they decided to FORCE the patient to breastfeed.

According to the authors:

A 25-year-old G4P3003 pregnant female was brought to the emergency department after being struck by a motor vehicle as a pedestrian. There was minimal past medical history available and no record of prenatal care in the electronic medical record, except report of her being ‘‘6 months’’ pregnant.

The mother had sustained a head injury, a fractured leg and there was evidence that the fetus was compromised by an abruption of the placenta.

On ultrasound, fetal biometry con- firmed an approximate 35 weeks of gestation with a weight of ~2,500 g, and a hematoma in the amniotic fluid with a thickened placenta consistent with abruption. The fetal heart rate was 75 beats per minute with minimal variability, and no fetal movement was seen on ultrasound. The patient was taken for an emergency cesarean delivery and exploratory laparotomy. A viable male infant was delivered with APGARS of 2 & 2 was brought to the neonatal intensive care unit (NICU) for care.

The decision to treat the abruption with surgical delivery of the baby (as well as the other treatment decisions) are entirely consistent with what any patient herself would choose since the abruption puts the mother’s life in danger.

In contrast, the authors have absolutely no reason to believe that this woman would have breastfed. No matter. They simply decided they could force her to do so.

The Lactation Medicine physician reviewed maternal medications, noted her history of illicit substance use, lack of prenatal care, homelessness, and placement of two prior children in foster care through Child Protective Services. Through network record sharing with other hospitals, the provider noted that the mother had provided breast milk to a prior child.

“Providing breastmilk” is not the same as breastfeeding; it sounds like something she was pressured to do during a previous maternity hospitalization. There is precisely zero evidence that this poor, homeless, substance abusing woman struggling desperately to survive would have chose to breastfeed this baby. But the well-educated, well-off lactation professionals thought they knew better.

How SHOULD the providers have determined what to do in this situation?

According to Substituted decision making and the dispositional choice account published in the Journal of Medical Ethics.

…[T]he surrogates should attempt to reconstruct the decisions the patient herself would have made, if she were capable, in the circumstances at hand… This standard is commonly justified by the principle of respect for autonomy. It has been suggested that when the patients are incapable of making the relevant decisions, their autonomy can still be indirectly respected by reconstruction, to the greatest possible extent, of the autonomous decisions they would have made if they had been able to make decisions.

The lactation professionals — in contrast — used a wholly inappropriate standard: the best interest of the baby.

The first question is if breastfeeding is the best option for the baby.

You don’t have to have a degree in medical ethics to know that not only is that not the first question; it isn’t an appropriate question at all. We don’t make medical decisions for one patient by what is best for ANOTHER patient.

As breastfeeding is the physiological norm and prevents infant morbidity and mortality one could argue that infants have an ethical right to human milk.

Even if the physiological claims were true — and there’s no evidence that they are true for 35 weekers — the authors are on extremely dangerous philosophical grounds when they imply that the baby’s interests are more important than the mother’s interests. The infant’s benefit should NEVER be the determining standard for the mother’s medical care; that would be both unethical and illegal.

An infant has no “ethical rights” vis a vis the mother’s body. If they did, mothers could be forced to give up kidneys or other organs to their offspring and their behavior could be regulated on an ongoing basis by society if it determines that certain behaviors are in the best interest of their children.

It’s difficult to imagine that the authors don’t know this. Had the mother told them she didn’t want to breastfeed, they would be REQUIRED to respect her wishes regardless of what they deemed in the best interest of the baby. Had the baby’s father or grandmother told them that the mother didn’t want to breastfeed they also would have been REQUIRED to respect the mother’s wishes.

This woman wasn’t merely unconscious, she was a member of a vulnerable economic class and was rendered even more vulnerable by having no family members to speak for her. And because of her profound vulnerability the authors had no compunction in ignoring what she might want.

And she made it clear what she wanted when she regained consciousness:

The mother in our case made the decision to stop breastfeeding due to nipple pain and engorged breasts… The mother then became engorged when she declined pumping due to nipple pain. She required multiple interventions to prevent mastitis…

Even now the authors – engaged in massive self-deception — fail to understand that their behavior was profoundly unethical.

Our case discusses the decision to initiate pumping for a comatose mother using biomedical ethical principles: (1) beneficence (breastfeeding is likely be good for the infant and mother); (2) nonmaleficence (breastfeeding might cause undue stress for a critically ill mother: there are risks of complications); (3) patient autonomy (preserving the choice to lactate preserved the mother’s ability to self-determination and avoidance of provider assumptions and bias); and (4) justice (attending to biopsychosocial features of the care, including potential biases, to promote a fair decision-making process). We believe beneficence, nonmaleficence, and justice may be met while preserving patient autonomy best by initiating pumping for comatose mothers.

But forcing a woman to breastfeed does NOT respect patient autonomy. Moreover, justice requires treating this poor homeless woman exactly the way they would have treated a well-educated, well-off woman who had a supportive family. I doubt they would have dared to substitute their judgment for hers had they thought she had the ability to hold them to account for what they did — using the fact that she was unconscious to force her to breastfeed.

Patching up False Dichotomies in the Birth Subculture by anthropologist Jessie K. Tougas should be required reading for all midwifery students.

Some birth scholars (Melissa Cheyney, Robbie Davis-Floyd, and Elizabeth Davis) have argued that there are two models of birth that value different kinds of knowledge. They assert that the “technocratic” model has been adopted by “mainstream” culture, which values reason and scientific knowledge. Meanwhile, the “countercultural” birth subculture, which has adopted a “holistic” model, values intuition and “body knowledge” instead…

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]Beware anyone who promotes intuition over empirical facts — in politics or in midwifery.[/perfectpullquote]

But it’s a false dichotomy:

…[T]he dichotomy between reason and scientific knowledge on the one hand, and intuition and “body knowledge” on the other, is also inaccurate. Feminist epistemology also warns that this dichotomization undercuts a diversity of thinking styles by limiting them to just two.

Moreover radical midwifery theorists do not behave like they value women’s intuition over their own education and training which they presume to be empirical knowledge.

…[A]lthough birth activists use their connection to the “alternative health arena … to position themselves as avant-garde, counter-cultural and discriminated against,” they nonetheless “make appeals to science in order to stress the benefits of their preferred practices” and their ideas have become hegemonic since the introduction of “normal birth” campaigns in the U.K. and North America …

That’s especially true when it comes to making money:

While birth activists perceive “women requesting birth interventions as being conditioned by consumerist values,” they themselves profit from … “natural birth” product placement and … commercial support services…[B]y presenting a certain kind of birth as radically different from the mainstream kind of birth, the “natural birth” industry can profit from various products and services that are deemed necessary to “achieve” the counter-cultural birth, since it cannot be easily learned through free mainstream sources. This in turn may also explain why the birth subculture is largely composed of white, middle-class women who can afford these products and services.

Midwifery hypocrisy is a real issue. In my view, however, there’s an even deeper problem with privileging intuition, a problem best illustrated by contemporary radical conservatism.

Radical conservatism also privileges intuition over facts. Although racism is still endemic in the US, conservative white people “feel” that people of color get better treatment than they do. Although Black people are under-represented in the professions, on corporate boards and among tenured faculty, many white conservatives “feel” it is white people who face discrimination. Although Black men are literally being shot to death in the streets and are merely trying to survive, it is white conservative men who “feel” that people of color are trying to replace them.

Contemporary radical conservatism has hit upon a incredibly powerful way to privilege intuition over facts. They label facts as “fake news.” Simply put, if something doesn’t “feel” to them to be true, it simply can’t be true. Intuition reigns supreme.

They’re not the only ones.

Anti-vaxxers trust their “intuition” that vaccines are dangerous and treat vaccine science as fake news bought and paid for by Big Pharma.

Wellness charlatans trust their “intuition” that disease can be cured by eating right and buying supplements and that contemporary medicine is fake news bought and paid for by the medical industry.

And midwives trust their “intuition” that childbirth is inherently safe, their “intuition” that pain relief is harmful and their “intuition” that unmedicated vaginal birth is best.

But as even a cursory investigation of contemporary radical conservatism shows, “intuition” is just another name for prejudice — often ugly and almost always unjustified.

We should be very wary of anyone who promotes intuition over empirical facts. That’s just as true for midwifery as it is for politics.