Nothing in my nearly 30 years as a mother equips me to understand this.

Baby is eight weeks old now and doing fine, but it was a traumatic time. Went into spontaneous labor at 42 weeks and continued with homebirth as planned for 12 hours. Plenty of dilatations [sic] and effective contractions but descent was lacking and I was struggling to cope with contractions on top of one another. Waaay different to last time. Anyway, to cut a long story short, hospital transfer, c-section, meconium aspiration syndrome, severe asphyxia, hypoxic ischemic encephalitis [sic], persistent pulmonary hypotension [sic] of the newborn, sepsis and pneumonia. Baby was taken to a a nicu 70 miles away for ventilation and cooling….

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Baby suffered meconium aspiration, severe asphyxia, hypoxic ischemic encephalopathy, persistent pulmonary hypertension, sepsis and pneumonia.[/pullquote]

The mother transferred to the hospital NOT because her baby was dying; no one had a clue about that. She transferred for her own comfort. It was a bonus that the baby was rescued from near death.

And it’s not over yet.

…[B]aby Seth will need checks up until the age of 2 because of the possibility of brain damage and cerebral palsy.

But she’s proud. Proud of what? Proud that she risked his life in the first place? Proud that she didn’t kill him? Proud that her narcissism resulted in his brain damage that might be permanent?

She ought to be ashamed, not proud.

I, like most mothers, would do anything to spare my children pain or injury. Who could possibly be proud of causing her child to suffer both?

When I started the predecessor of this blog more than a decade ago I was a lone voice in the wilderness. Now my views — including the notion that natural childbirth is a deeply anti-feminist effort to exert control over women — are generating ever more attention in academic circles.

The latest paper to focus on controlling women through the rhetoric of natural childbirth is Pushing Ecstasy: Neoliberalism, Childbirth, and the Making of Mama Economicus written by Kate Rossiter and published in the journal Women’s Studies. It is Rossiter’s contention that birth has been commodified not merely to make money, but to discipline women.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural childbirth disempowers women by forcing them to erase their non-maternal selves.[/pullquote]

Rossiter was inspired to explore the ways that natural childbirth advocacy controls women after she did everything “right” and had a terrifying birth experience nonetheless.

In 2011, I gave birth to my daughter unmedicated, at home, and assisted by a midwife—just as I had planned. She was healthy. I was healthy. It was, in the order of things, the “perfect” birth. Perfect, except that the birth was over- whelming, painful, and frightening, and I came away from the experience feeling as though I had fallen short—had failed, or been failed. When I expected to feel exultant, empowered, and proud, I simply felt empty, sad, and numb. Why had I expected ecstasy, and why did this failed promise indicate my overall failure as a mother? …

Sounds familiar, right?

Rossiter blames the usual suspects:

…I engage three key texts—midwife Elizabeth Davis and doula Debra Pascali-Bonaro’s Orgasmic Birth, physician Sarah Buckley’s Ecstatic Birth: Nature’s Hormonal Blueprint for Labor, and spiritualist Jeanice Barcelo’s website Birth of a New Earth—that illuminate and exemplify the underlying tenets of the ecstatic (or orgasmic) birth movement.

Her description of their rhetoric is spot on:

Through a critical analysis of these three aforementioned texts, I argue that the discourse of the ecstatic birth movement, under the guise of supportive instruction, provides an extremely compelling (and ultimately constraining) construction of the “good mother” as expressed through the birth experience…

I aim to trouble and challenge the underlying politics of the ecstatic birth movement, and to capture the oppressive impact that this discourse has on birthing women.

Rossiter’s analysis follows that of Foucault, arguing that consumerism can be used to control people.

My analysis takes seriously Foucault’s assertion that the body—and discourses about the body and bodily practice—is a critical site for the production and manifestation of particular kinds of power relations.

Natural childbirth discourse is a way to exert power over women, ultimately constraining their choices to those favored by the powerful.

Rossiter postulates the existence of Mama Economicus, the female analogue of Homo Economicus:

…Foucault argues that there are two important facets of the neoliberal construction of homo economicus: first, homo economicus is, at heart, an “entrepreneur of himself [sic]” and therefore invested in schemas of his or her own self-improvement; second, the goal of neoliberal production is not to earn a wage, but rather to engage in consumptive gratification.

Rossiter notes, as I have noted, that the original goals of the natural childbirth movement were valuable but the goals gave been transmuted. It started as an effort to wrest control from the patriarchy; has become an effort to enforce control by society by convincing women to discipline themselves:

…Thus, what on the surface may appear to be an ethic of care that empowers women in their choice-making ability is in fact a tactic that individuates and ultimately disempowers women in terms of their ability to operate outside self-managerial, consumerist frameworks.

It is a source of oppression.

…Anthropologist Gail Landsman points to the ways in which the contemporary discourse of pregnancy and childbirth places total responsibility for the health and wellbeing of children in the hands of the mother, demanding that women do everything right. Specifically, Landsman looks at the rigid instructions for self-care (and self-deprivation) in pregnancy, which contribute to stigmatizing and painful forms of mother-blame in mothers of children with disabilities.

Consumerism is deployed to exert control over women, “the making of mama economicus“:

…[U]nderlying this appeal is, in fact, a highly constraining model of self-regulation where women’s lives and routines are governed by a series of practices necessary for getting it [birth] right… [G]etting it right is not simply a matter of having an enjoyable, fulfilling birth, but in fact is critical to the act of good motherhood…

Rossiter notes:

…[T]his discourse juxtaposes two images of the birthing mother: one wild, and one under technocratic gaze; one pure and authentic, and one living uncritically and irresponsibly within contemporary culture. Paradoxically, in order to access this wild self, the mother must work very hard to regulate herself and her surroundings in order to ensure that her ecstatic potential is realized… This is a mother who, through her diligent preparedness has optimized her natural capacity to birth … This is the mother who forgets herself in the face of her baby’s needs, and, crucially, enjoys this erasure of her non-maternal self…

And it pathologizes women who refuses to go along:

This model holds no place for alternate reactions, such as ambivalence, grief, or anger. Rather, the implicit correlation is that deviation from the ideal of the ecstatic mother marks some kind of failure or pathology—suggesting that the birth circumstances were not optimal, or the mother’s hormonal system is somehow faulty, or that she herself is not a natural mother.

What purpose does mama economicus serve? She is a woman bound to her children and bound to her home?

…The work of motherhood here is twofold. First, it is the work of her own self-regulation qua enjoyment. She works on herself so that she may better perform the work of motherhood, which promises unceasing joy and happiness. Perhaps more importantly, though, through her own self-regulation—and by extension the management of her children for whom she has utter responsibility—she relieves the state and other broad structural forces of social responsibility.

Women could reject these restrictions but:

… [They are] presented as extremely compelling and deeply gratifying, perhaps more so than any other form of work. The work of assuming total responsibility for herself and her offspring is her birthright, should she so choose. As exemplified by the ecstatic birth discourse, the work of motherhood is constructed as so deeply fulfilling and gratifying that even labor—a quintessentially agonizing feature of motherhood—is refigured as orgasm.

At a stroke women are disciplined into restricting themselves to motherhood and relieving society of any responsibility toward mothers or children.

Mothers sacrifice. It has ever been thus.

Whether it is sacrificing sleep to soothe a fretful baby, sacrificing the last piece of cake to please a hungry child, or sacrificing tremendous amounts of money to send a teenager to college, sacrifice is part and parcel of motherhood.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural parenting posits that the body of the good mother must be literally interposed between children and omnipresent threats to health and brain function.[/pullquote]

Nontheless, we are undergoing a profound change in beliefs about maternal sacrifice. The philosophy of natural parenting has transmuted maternal sacrifice from episodic to the central purpose of motherhood. That change has been harmful for mothers and without being beneficial for babies and children. That’s not surprising since natural parenting isn’t about children and what’s good for them; it’s about mothers and how they ought to behave.

Yesterday I wrote about natural parenting’s problematization of infant/child safety. There has never been a safer time or place to be an infant and small child than 2016 in industrialized countries. Ironically, there has never been greater anxiety about the physical, emotional and intellectual status of those same infants and small children.

Why the disconnect? Natural parenting problematizes infant/child health and safety in order to enforce a “regime of truth” regarding the appropriate role of mothers. The problematizing of safety offers the justification for the central premise of natural parenting.

And the central premise is this: constant sacrifice is the definitive feature of good mothering. But not just any sacrifice is required. Women must sacrifice their bodies. The body of the mother must be literally interposed between children and omnipresent threats to health.

As sociologist Pam Lowe explains in her fascinating book Reproductive Health and Maternal Sacrifice:

…At its heart, maternal sacrifice is the notion that ‘proper’ women put the welfare of children, whether born, in utero, or not yet conceived, over and above any choices and/or desires of their own. The idea of maternal sacrifice acts as a powerful signifier in judging women’s behaviour. It is valorized in cases such as when women with cancer forgo treatment to save a risk to their developing foetus, and it is believed absent in female substance users whose ‘selfish’ desire for children means they are born in problematic circumstances…

But not just any sacrifice will do.

Never mind that perinatal mortality, infant mortality, and child mortality are at historic lows, vaccine preventable diseases have been nearly vanquished, malnutrition and vitamin deficiencies are rare and foods and medications are safer than ever because of government oversight. In the cosmology of natural parenting, infants and small children face unprecedented, omnipresent technological threats to their physical health as well as their emotional and intellectual development. The only thing that can ameliorate those threats is the mother’s physical body.

• Natural parenting rejects pain relief in labor, insisting that good mothers sacrifice their physical comfort, willingly enduring hours of agony to protect their babies from the “dangers” of epidurals.
• Natural parenting rejects formula, insisting that good mothers sacrifice their physical comfort, sleep, body boundaries, and even mental health to breastfeeding because “breast is best.”
• Natural parenting rejects jarred baby food, insist in that good mothers sacrifice time and effort in sourcing organic, GMO free foods, and hand preparing them to protect children from “toxins.”
• Natural parenting rejects routine pediatric preventive care like vaccines, insist if that the mother who sacrifices her time and “does her research” is the best guardian of infant health, and, in any case breastfeeding is protective against all microbial threats.
• Natural parenting rejects putting babies down, insisting that good mothers sacrifice their physical comfort, and need for separation and recuperation, because only close physical contact with the mother’s body protects the bond between parent and child.
• Natural parenting rejects placing babies to sleep in their own rooms, insist if that good mothers sacrifice sleep, privacy and the opportunity for sexual intimacy because only unremitting physical contact through every hour of the day can ensure infant and child wellbeing.

Sunna Simmonardottir expands upon these observations in Constructing the attached mother in the “world’s most feminist country”:

…Within the discourse of attachment and bonding, the ideal Icelandic mother is constructed as being constantly present, happy, and content with her role, happily breastfeeding and fully understanding of her child’s needs. Her body is not her own but shared with her infant, even after birth, for heat, nourishment, and comfort… [M]others are instructed to direct all their physical and emotional capacities at their children and … the maternal body and mind is subject to disciplinary practises… In this way, both attachment and bonding (or lack thereof) are constructed simultaneously as the problem, as well as the solution for mothers…

The maternal body is imagined as always functioning perfectly; all problems are therefore ascribed to the mother’s mind.

Consider the Baby Friendly Hospital Initiative. Descibing its founding statements Lowe notes:

Whilst it suggests that the purpose of the BFI is to support parents in making informed decisions, the outcome of their deliberations should be an increase in breastfeeding… That women might have different needs and priorities and could make an informed choice not to breastfeed is not considered seriously. As the name ‘baby friendly’ implies, women’s position is assumed to be synonymous with what experts deem to be ‘best’ for their baby…

Indeed:

The underlying assumption behind BFI, and many other breastfeeding campaigns, is that women who decline breastfeeding only do so through ignorance or as the dupes of formula marketing campaigns. Palmer is typical of this position. She suggests that infant feeding companies as well as ill-informed experts have contributed to a loss of faith in breastfeeding… “[W]hilst women should have a choice, they should all be informed that formula milk is signicantly detrimental to their baby’s health.” This is hardly a neutral position and is not necessarily based on the evidence…

In other words, a mother who is not willing to constantly use her body in a never ending pageant of maternal sacrifice is pathologized as ignorant, emotionally immature and selfish: a “bad” mother.

Why has constant maternal bodily sacrifice come to be defining characteristic of the “good mother”?

Simmonardottir postulates:

When older structures of oppression start to disintegrate, new structures develop and become “regimes of truth.” Within the discourse of attachment certain “truths” become scientifically sanctioned and reasonable, while conflicting discourses are made to seem inappropriate or even unnatural. Within the discourse of attachment and bonding, the ideal Icelandic mother is constructed as being constantly present, happy, and content with her role, happily breastfeeding and fully understanding of her child’s needs. Her body is not her own but shared with her infant, even after birth, for heat, nourishment, and comfort… [M]others are instructed to direct all their physical and emotional capacities at their children and how the maternal body and mind is subject to disciplinary practises.

The inevitable and desired result is that women are forced back into the home.

The political, legal and economic emancipation of women in industrialized countries is arguably one of the greatest achievements of the 20th Century. It allowed women to leave the home and seek their own destiny. Seismic social changes generate backlash. Natural parenting is part of that backlash.

By imagining a world full of omnipresent, never ending dangers to infant/child health and insisting that only mothers can protect their children from these dangers and only by constant bodily sacrifice,  women can be disciplined into returning home, not for the original sexist justification that women are inferior but for a new sexist justification — that sacrifice of the maternal body is best for babies.

There has never been a safer time or place to be an infant and small child than 2016 in industrialized countries. Ironically, there has never been greater anxiety about the physical, emotional and intellectual status of those same infants and small children.

Why is there an extraordinary disconnect between reality and anxiety? You can thank the cultural conceit of “natural parenting” for problematizing infant and child health … at the very same historical moment when infant and child health are extraordinarily good.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural parenting problematizes infant safety in order to pathologize women who don’t conform.[/pullquote]

Perinatal mortality, infant mortality, and child mortality are at historic lows. Vaccine preventable diseases have been nearly vanquished. Rates of sudden infant death syndrome are falling. Congenital defects like heart disease can be treated. Malnutrition and vitamin deficiencies are rare. Foods and medications are safer than ever because of government oversight.

But you’d never know that if you are part of the natural parenting culture, which justifies its intrusiveness into maternal choice by promoting fear in regard to infant and child health. Natural parenting advocates inflate risks of rare events to monstrous proportions or invent theoretical risks that have never been seen in real life.

For example, childbirth is inherently dangerous, but has been made dramatically safer by the liberal use of obstetric interventions. Yet to hear natural childbirth advocates tell it, childbirth is inherently safe and any dangers that exist are caused by technology.

Obstetricians are desperate to prevent brain injuries from lack of oxygen. Natural childbirth advocates pretend that the placenta is a miracle organ that never deviates from perfection and that “drugs” used to control labor pain threaten neonatal health.

Infant formula has never been safer or more nutritious. Yet to hear lactivists tell it, breastmilk is lifesaving and formula is deadly.

Vaccines have never been safer or more effective (as evidenced by the bottoming out of incidences of childhood diseases), but anti-vaxxers utterly ignore both medicine and history in denying the public health triumph of universal vaccination. Instead they obsess about rare or even fabricated vaccine injuries.

Food has never been safer. Natural parenting advocates have never been more afraid of food, wasting money on organic produce, blithering about GMOs, and dosing their children with unregulated supplements.

Pediatrics has never been safer or more effective at preventing disease and suffering. Natural parenting advocates have never been more sure that nonsense — homeopathy, cranio-sacral therapy, and herbal preparations — is the key to good health.

Why is there such a tremendous disconnect between reality and belief? Two reasons: privilege and problematizing.

The privilege issue is distressingly blatant. The only fears that count in the world of natural parenting are the fears of Western, white, well off parents.

Poor children and children of color face a plethora of truly life-threatening issues including hunger, lack of access to healthcare and gun violence. Poor children and children of color die each and every day because of these problems, but many privileged Western, white well off parents could care less. They oppose life saving free school meals, Obamacare and sensible gun regulations. Instead they are preoccupied by birth plans, brelfies and baby slings, though none of those do or could save lives.

What’s even more outrageous is that they are so insulated by privilege that they actually believe they are promoting safety by fetishizing birth, breastfeeding, organic food, vaccine opposition and homeopathy.

Using and misusing the language of science, natural parenting advocates problematize infant and child safety.

The natural childbirth industry of midwives, doulas and childbirth educators claim it is evidence based when the truth is that it is based on no evidence at all. They publish papers in industry trade papers disguised as scientific journals like the Lamaze International’s Birth: Issues in Perinatal Care.

Lactivists howl that low breastfeeding rates compromise infant health despite the fact that breastfeeding rates have no correlation at all with infant health. Infant mortality rates dropped precipitously through the 20th century despite the fact that for most of that time period breastfeeding rates dropped like a rock. Indeed, the countries with the highest infant mortality rates in the world have the highest breastfeeding rates.

Attachment parenting advocates have hijacked attachment theory (which postulates that children need only a “good enough” mother) in order to problematize infant attachment. The truth is that mother-infant attachment happens spontaneously, easily and is not contingent on any specific behaviors. In contrast, attachment parents obsess about promoting “bonding” through ritualized behaviors like baby wearing.

The philosophy of natural parenting is a “regime of truth” that has little to do with infants and children and a great deal to do with controlling women’s bodies and women’s lives.

As Sunna Simmonardottir writes in Constructing the attached mother in the “world’s most feminist country”:

…[T]he discourse on attachment has become another site for the medicalization of motherhood and maternal emotion… The role for women as mothers within attachment theory is considered to be narrow and conservative, promoting beliefs that are contrary to the interests of women. Cleary states that any feminist consideration of attachment theory should be mindful of the way it “not only describes but actively prescribes the nature of our psychological lives and ills”. This prescriptive nature of attachment theory has in turn led to the objectification and pathologization of women and presented women with the need to monitor themselves when it comes to their behavior toward their children.

By promoting fear about their children’s well-being, the philosophy of natural parenting causes women to tightly regulate their behavior so it conforms with the “rules” of natural parenting and to pathologize and blame themselves when they fail in conforming to those rules. Hence the outpouring of guilt and recrimination for epidurals, C-sections, formula feeding and other deviations from natural parenting diktat.

In other words, natural parenting problematizes infant safety in order to pathologize women who don’t conform.

• Natural childbirth problematizes pain relief in childbirth in order to pathologize women who don’t accept that pain ought to be part of mothering.
• Lactivism problematizes infant formula in order to pathologize women who don’t breastfeed.
• Attachment parenting problematizes maternal independence in order to pathologize women who think there is more to life than mothering.

Why has natural parenting become popular despite the fact that it imagines threats to children that don’t exist?

Simmonardottir notes:

… According to Hays, the answer lies in the way the theory fits so neatly with our pre-existing cultural beliefs about the appropriate role of the mother and “operates so effectively as a means to keep women in their place”. Attachment theory “makes sense” for us as it taps into pre-existing ideas about the essential nature of men and women as well as the biological and evolutionary purpose of women’s reproductive abilities, where the relationship between mother and child is made to seem biologically determined but not socially constructed and historically specific…

And, of course, it reinforces the privilege of the privileged:

Additionally, it is important to acknowledge how middle-class, hetero-normative, and Anglo-centric norms of child rearing are assumed within the discourse of attachment theory, making it impossible for certain groups of women to discursively position themselves within the narrative of “good mothering”…

The bottom line is that children are not facing unprecedented threats to health that can only be ameliorated by natural parenting; they’ve never been healthier. Natural parenting problematizes infant/child health and safety in order to enforce a “regime of truth” regarding the appropriate role of women, robbing women of the opportunity to make the choices for themselves and their families that they deem best.

This is the 201st piece I’ve posted in 2016, but I’ve been privileged to be able to write for othe publications as well.

These are my ten most popular pieces of the year:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Skeptical OB blog and Facebook page reached more then 7 million people in 2016![/pullquote]

1. Closing Newborn Nurseries Isn’t Good for Babies or Moms on TIME.com. 68,090 shares

I’m deeply disappointed to learn that the hospitals in my state, Massachusetts, are closing their newborn nurseries. It’s a submission to the entreaties of breastfeeding activists (lactivists), and doesn’t accomplish its stated aim. Most importantly, it’s unsafe…

2. Why is American Home Birth So Dangerous? in The New York Times Sunday Review. 29,825 shares

IS home birth safe? That depends on where you ask the question…

But there are places in the world where home birth is relatively safe, like the Netherlands, where it is popular at 16 percent of births. And in Canada, where it appears safest of all, several studies have demonstrated that in carefully selected populations, there is no difference between the number of babies who die at home or in the hospital.

In contrast, home birth in the United States is dangerous. The best data on the practice comes from Oregon, which in 2012 started requiring that birth and death certificates include information on where the birth occurred and who attended it. The state’s figures show that that year, the death rate for babies in planned home births with a midwife was about seven times that of births at a hospital…

3. Dunning Kruger nation and the disaparagment of expertise. 18,399 shares

We live in Dunning Kruger nation.

What do I mean?

A variety of very loud “confident idiots” — anti-vaxxers, homebirth advocates, climate change deniers — actually think they know more than the experts in the respective fields…

4. How the natural childbirth industry sets mothers up for guilt and shame 11,385 shares

…[F]or today’s new mothers, the expectations for childbirth and breast-feeding are higher than ever. Women are supposed to have the most authentic possible experience: They should reject pain relief; eliminate C-sections; embrace midwives, doulas and childbirth educators; and even defy standard obstetric recommendations when they conflict with those goals.

Two powerful forces have arisen to push this dogma. First, the crunchy natural-birth subculture has slowly morphed into an industry, mainly catering to the most privileged women in society. Second, a cabal of natural-birth activists — online, on the air and even inside hospitals — has formed to shame pregnant women who eschew the right-thinking path. For these forces, childbirth has become less about having a baby and more about having an experience. And those who don’t have “the perfect birth” can’t possibly be good mothers.

5. What if we’re doing breastfeeding all wrong?. 8526 shares

It is an article of faith among them that formula supplementation interferes with breastfeeding, dooms exclusive breastfeeding and causes dangerous alterations to infant gut flora. What if they’re flat out wrong? And what if babies are being injured and even die because we aren’t recapitulating nature? …

6. The ultimate appeal of anti-vaccine advocacy: it flatters the ignorant. 8152 shares

One of the most attractive aspects of anti-vaccine advocacy, indeed of all alternative health, is that no particular knowledge is necessary to declare yourself an expert.

It doesn’t matter that you don’t have even the most basic knowledge of science and statistics. It doesn’t matter that you don’t have any understanding at all of the complex fields of immunology or virology. Your personal experiences count for more than the collective wisdom of doctors, scientists and public health officials. Hence Jenny McCarthy, a B movie actress with no training of any kind in science is touted by herself and others as an “expert” on vaccines. Hence Modern Alternative Mother Kate Tietje and similarly undereducated mommy bloggers parade themselves as “experts” on vaccination…

7. Seeing toxins everywhere is just another form of privilege. 7616 shares

It is axiomatic among quacktivists — anti-vaccine activists, organic food devotees, natural parenting advocates — that our world is filled with toxins.

But toxicophobia, fear of toxins, is really just another form of privilege. Only those in wealthy, industrialized societies who have access to copious food and clean water, and are protected from epidemics of infectious disease have the leisure time and financial resources to indulge in internet fantasies of being poisoned by toxins…

8. The theology of quackery; how pseudoscience has become a secular religion. 7606 shares

…It seems to me that for a large proportion of people, particularly people on the political Left, pseudoscience has become a secular religion, complete with creation myth, demons and ultimate salvation.

Don’t get me wrong: there’s plenty of pseudoscience on the political Right, too. But often that is motivated by adherence to standard religious philosophy, the idea that the Bible is the world of God and that anything that contradicts it cannot be allowed to be true. On the Left, where many abjure religion, quackery has become the new religion…

9. Why do anti-vaxxers think “nature intended” for them to survive? 5470 shares

…In reality nature doesn’t “intend” anything. Nature doesn’t “intend” the sun to shine; it shines because nuclear fusion is occurring inside it. Nature doesn’t “intend” the tides to rise and fall; it happens because of the moon’s gravity acting on the oceans. Nature doesn’t intend for people to survive or succumb to infectious diseases; it happens because bacteria and viruses attack people in order to feed and reproduce themselves.

Nature no more “intends” for people to survive infectious diseases than it “intends” for people to survive having a limb bitten off by a tiger. True, your survival might be aided by blood clotting factors that staunch the bleeding and antibodies that combat infection, but it’s equally likely that you’ll die in spite of your body’s defenses against traumatic injury and hemorrhage…

10. Vaccination is far more baby friendly than breastfeeding. 4344 shares

There’s a simple thing that every mother can do to keep her baby as healthy as possible. That’s why we should have a ten step hospital based program to support it.

No, it’s not breastfeeding; it’s vaccination, which saves a thousand times more lives in practice than breastfeeding ever could in theory.

This post also generated the most comments of the year, 2711 and counting.

My most popular meme of the year was this:

It reached 733,100 people on Facebook.

Overall the blog plus The Skeptical OB Facebook page reached more than 7 million people in 2016!

Of course, the most important thing I wrote this year was my book PUSH BACK: Guilt in the Age of Natural Parenting, published in hardcover, kindle and audio editions. The paperback version will be out on January 10, 2017.

It was a very good year!

Apparently my book PUSH BACK: Guilt in the Age of Natural Parenting made Professor Laura Freidenfelds feel stung. Unfortunately it did not make her feel curious enough to reexamine her assumptions about midwifery and childbirth.

In Nurse-Midwives are With Women, Walking a Middle Path to a Safe and Rewarding Birth, Freidenfelds writes:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Freidenfelds piece is profoundly disappointing because when challenged on her personal beliefs she responded as a partisan, not as a person interested in the truth.[/pullquote]

Recently, obstetrician and blogger Amy Tuteur published Push Back: Guilt in the Age of Natural Parenting, in which she made fun of women stupid enough to believe that they might have a better birth experience without an epidural, and excoriated anyone who would refuse any of the bells and whistles of modern obstetrics.

Her title was a response to journalist Jennifer Block’s, Pushed: The Painful Truth about Childbirth and Modern Maternity Care, an exposé of callous obstetricians who damaged women and their babies with the thoughtless overuse of standard obstetric interventions such as the induction agent cytotec and the drastic overuse of major abdominal surgery (cesarean section).

Made fun of women?
Stupid enough to believe they might have a better birth experience without an epidural?
Bells and whistles?
Callous obstetricians?
Thoughtless overuse?

In other words, instead of giving some thought to the idea that privileged, white women swallowed wholesale the fake news and propaganda of the natural childbirth industry, Freidenfelds decides to double down by repeating it all and insisting it’s true.

Curiously, Freidenfelds doesn’t deign to provide any scientific evidence to rebut my scientific claims. She seems to find truthiness of natural childbirth propaganda more persuasive than the truth of historical and scientific evidence.

Instead she offers an intellectually lazy compromise: a highly romanticized view of nurse midwives as a middle way:

In fact, there is someone ready and willing to escort birthing women along that middle path: the nurse-midwife. Calm and sensible, evidence-based and gentle, she is too easily effaced by the competing romantic dreams of natural bliss and technological perfection. We need to notice that she’s there, and we need to figure out how to connect her services to more women.

Seriously, Professor Freidenfelds? Calm? Gentle?

Freidenfeld then proceeds to regurgitate the fake history of midwifery as turf war in which evil obstetricians sought to steal the livelihood of “calm, gentle” midwives.

Sadly, Freidenfelds doesn’t bother to address the questions I raise in PUSH BACK regarding the racist, sexist origins of the philosophy of natural childbirth, the implicit biological essentialism and the remarkable elitism of the movement.

Specifically:

What distinguishes midwifery from obstetrics? Is it truly a difference in outlook or merely midwives clawing for market share

In the paper What is gender? Feminist theory and the sociology of human reproduction sociologists Annandale and Clark criticize contemporary midwifery:

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

Should women be reduced to their reproductive organs and does reproduction mean the same thing to every woman?

Annandale and Clark explain that much of contemporary midwifery imagines that:

… reproduction is still centred for women and put on the agenda as if it were central to all women’s lives. This may serve to lock women into reproductive roles which may be politically problematic since the centrality of reproduction, contraception and childbirth to biomedicine is transferred to women’s experiences. This may be the reality of their experience, but equally importantly, it may not…

Are midwives with all women or just privileged white women?

Apparently the only women who count in Freidenfeld’s world view are privileged white women. Natural childbirth advocates are overwhelmingly Western, white, and well off. Certified nurse midwives are overwhelmingly Western, white and well off. I find it quite shocking that in a country that struggles with high black perinatal mortality and high black maternal mortality, Freidenfelds doesn’t even bother to give lip service to the many women of color, women of other nationalities, and women with pre-existing medical conditions and pregnancy complications whose have no interest in and cannot be helped in any way by the philosophy of natural childbirth.

Instead of addressing these fundamental issues of gender, race and class Freidenfelds expresses her surprise that despite my support for nurse midwives (the most highly trained, best midwives in the world), I don’t see them as the solution to all obstetric problems:

If Amy Tuteur and I can agree on the value of nurse-midwives’ practice, why aren’t we both looking to nurse-midwives as model practitioners? In her book and in our conversation, Tuteur insisted that the high false positive rate from obstetricians’ use of continuous fetal monitoring, which leads to a high c-section rate, is unavoidable if we want to save babies. I suggested that it is, in fact, avoidable: all she and her obstetrician colleagues have to do is walk down the hall and ask the nurse-midwives to teach them how to use intermittent monitoring effectively. Tuteur chose to ignore me, and simply insisted that obstetricians know best. She was not about to give ground in public to anyone called a “midwife,” even someone she privately recognizes is fully competent.

Why aren’t nurse midwives model practitioners?

Because not everyone who needs care is a healthy, privileged white woman. Indeed nurse midwives can’t “be with” and can’t care for the many women who are most in need — women with serious medical issues.

Because most women consider a healthy baby more important than avoiding a C-section or treating birth as a piece of performance art.

Because while Freidenfelds may blithely ignore the risks of childbirth, childbirth is inherently dangerous.

Because it is laughably easy to tell obstetricians what they should and should not do when you bear no responsibility for dead babies and dead mothers.

It seems obvious to me that not every woman is a member of the white elite. It seems obvious to me that the white elite should not assume that their needs and desires are the model that all other women seek to emulate. It seems obvious to me that a movement based on biological essentialism is deeply anti-feminist. And as a physician it seems obvious to me that the steep declines in perinatal and maternal mortality is due to the liberal use of obstetric interventions not midwifery, which had existed for millennia before the advent of obstetrics and presided over astronomical rates of perinatal and maternal mortality.

Freidenfelds piece is profoundly disappointing because when challenged on her personal beliefs she responded as a partisan, not as a person interested in the truth.

There’s an eye opening thread on allnurses.com entitled Home births gone wrong.

American women thinking about homebirth should read it. You can’t give informed consent unless you understand the very real risks of your baby dying at homebirth.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Then there was baby that the midwife dropped on the bathroom floor and fractured the baby’s skull but didn’t bring him in until he started seizing.[/pullquote]

It starts off with this question from a NICU nurse:

Do you see this often in your facility? In 2.5 years we have had 2 babies die and 2 be severely disabled from home birth… Recently we had a mom who was told she needed a C section by two different physicians at two different facilities for a breech baby and low fluid and she refused, signed out AMA and attempted a home birth with midwives. The baby of course became stuck with the body born and required a 13 minute code. We cooled her immediately for 72 hours and she spent two weeks on a vent. She just now is extubated but will require a trach because she can’t cough or swallow or gag so secretions just build up. She is more or less vegetative and on a slew of anti seizure meds. This stuff just really makes it hard for me to sleep! I feel like these poor innocent babies end up paying for their parents risky stupid decisions…

Other nurses respond:

Yes! There is a group of midwives in my area that deliver at home and at their birthing center that we see come in with their patients quite often. One of their patients was a similar story to yours. The baby was known to be frank breech a couple days before delivery but the midwives allowed mom to labor at home. Baby got stuck, was coded and died anyway (the baby was essentially dead when mom arrived at the hospital). Beautiful perfect baby who I’m convinced would still be alive if mom got a C-section. Overheard the midwife tell the parents that the baby obviously wasn’t meant to live.

We also had another baby that they removed from the birthing pool too slowly and the kid was an aspiration pneumonia/PPHN/whole body cooling.

Then there was baby that the midwife dropped on the bathroom floor and fractured the baby’s skull but didn’t bring him in until he started seizing.

And this:

We had one mom that was GBS positive and the local birthing center in town told her to shove a garlic clove up her hooha to kill the bacteria and the kid went into RDS about 4 hours after birth. The midwife told them just to drive the kid to the ER and when they got there the baby was sating in the 40’s and HR about 90. Totally blue and limp. GBS sepsis. When we were down in the ER trying to resuscitate the kid the mom asked me “when can I put him to breast again?”. I wanted to slap her. Then we went to get an emergency line into place and the parents tried to decline antibiotics because their midwife told them antibiotics were terrible for babies and not necessary. He ended up on HFOV maxed out on dopamine and dobutamine within an inch of death. Thankfully he lived…

And a maternal death:

Just during my short time in the OR we had 3 failed home births that ended catastrophically. One was a mom with placenta accreta who pushed against a 10lb baby for hours. We sectioned her in the main OR; She bled out right in front of us with her husband standing by her side. Hands down the worst case I’ve ever participated in. Baby made it…

Another maternal death:

I swear, the time has come to write a book to blow the lid off this “natural health” movement. I remember in clinical practice a mother who came in with HELLP and was stable, but due to the influence of her -non nurse- “all natural” midwife would not let us push IV fluids or magnesium. We lost her and the baby in a totally preventable seizure. Someone needs to write a book about all the ways the “natural health” community spews pseudoscience that at best helps nothing and in the worst cases, delays treatment till it’s too late.

And this:

It is hard not to get angry when parents who choose to forgo a hospital birth because of the big, bad medical establishment suddenly want us to do “everything medically possible to save my baby” regardless of how detrimental it is to the infant and in some cases completely futile. The hospital is spending millions of dollars to put their baby on ECMO and body cooling for a baby that is, without a doubt, going to be dinged (a NICU term) and possibly unsaveable when perhaps a few quiet conversations and some different choices could have resulted in a 2-3 day hospital stay and a healthy infant.

And this:

Almost 50% of our unit’s cooling babies were patients of these midwives and we have seen some absolutely clear cut negligence from them, yet they keep on practicing and consistently producing poor outcomes.

And this:

In my area we have a lay midwife that has lost creditably with the nursing staff long ago. When her patients come in they are train wrecks. Pushing for 5 hours against a 8 cm cervix, push with a FHR in the 90s…turns out that was the moms HR….baby had no heart rate when she come in by rescue for “exhaustion”, and a PP pt that was allowed to slowly bleed out for 6 hours before being brought in because she was “dizzy & couldn’t hold the baby to breastfeed”. They only gave her apple juice thinking it was her blood sugar. Turns out she had a cervical tear and retained placenta. These are just a few examples….and each time it happens, we have to wait for charting, prenatals and other information because she “has to gather my thoughts”.

And a baby with what sounds like an internal decapitation:

I’ve seen terrible things roll into triage when homebirth goes wrong. We had a woman come in who reported her water broke over a week ago but her midwife told her it was fine and to stay home. She was so infected you could barely stand in her room because of the foul odor. And baby was long dead. We had another mom roll in with her homebirth midwife who had been pushing for 12 hours and upon exam was found to have a closed cervix and the fetal heart tones were in the 50s. One more horror story, we had a home birth midwife attempt a delivery that ended with a severe shoulder dystocia which she attempted to resolved herself for nearly 30 minutes before coming to the hospital, at which time baby was long gone and the spinal column was detached from the aggressiveness the midwife had used to attempt to deliver the baby…

There’s plenty more in the following pages.

Thinking about homebirth? Think again.

Apparently many Donald Trump supporters, like Trump himself, believe that women should be punished for having abortions. I have a better, more just, more effective suggestion:

Punish men for abortions!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women don’t create unwanted pregnancies; men do.[/pullquote]

After all, it’s the man’s fault; there’s no way a woman can find herself with an unwanted pregnancy without a man being responsible for it.

Christina Cauterucci at Slate wrote about the beliefs of Trump supporters.

In an online survey, 39 percent of 2,000 self-identified Donald Trump voters reported that they thought women should be punished for seeking abortions if the procedure is ever banned in the U.S. A full 60 percent of those polled said abortion should be illegal; 18 percent of all the poll’s Trump voters said it should be illegal without exceptions for rape, incest, or to save a pregnant woman’s life…

Anti-choicers are enraptured with the notion of punishment for abortion:

Anti-choice legislators pass laws requiring women to listen to state-sponsored misinformation and wait days between requesting an abortion and getting one, revealing a fundamental mistrust of women’s capacity to make their own decisions. Laws in many states make women travel to clinics more than 100 miles away for multiple appointments, separated by days, costing them unnecessary time and money. Restrictions on when women can get abortions force some women to carry to term fetuses with no chance of surviving outside the womb. Women are charged with felonies and incarcerated in the U.S. for trying to induce abortions on their own.

But that’s so inefficient!! Why punish a woman for an unwanted pregnancy when she didn’t want it in the first place? It makes so much more sense to punish the man who made it happen.

Think of the advantages:

It is far simpler: All it takes is a simple paternity test on the products of conception. Quick! Easy! Painless!

It is foolproof: Let’s face it, there are lots of things that women can do to avoid being punished for having an abortion. The biggest problem with state abortion restrictions — requiring unnecessary ultrasounds, forcing women to listen to lies about abortion, or mandating two clinic visits instead of one — is that they can be evaded if a woman travels to another state. But if all she has to do is name the father and bring back the products of conception for testing, we can punish the appropriate man every time!

It is true justice: Women don’t create unwanted pregnancies; men do. Punishing women for having abortions is like punishing women for getting stabbed. Ethics demands that we punish the man who did the stabbing not the victim, right? By the same reasoning, ethics demands that we punish the man who caused the unwanted pregnancy, not the woman who is, in truth, the victim of the unbridled sexual appetites of a man.

It will be much more effective: Women who get pregnant through rape or incest can’t avoid getting pregnant, but the men who commit those crimes could certainly avoid them if they chose. How better to prevent rape and incest in particular, and unwanted pregnancies in general, than holding the perpetrators to account?

How would we punish the men we identify in this way?

Obviously they should be forced to walk a public gauntlet of abortion protesters and be subjected to vicious criticism. What’s good for the goose is good for the gander, right?

Beyond that, their names should be published so that everyone they know should witness their shame; they should pay for the abortion; and then they should pay a large fine above and beyond.

I know it sounds harsh, but if we are really committed to ending unwanted pregnancies that result in abortion, this would go a long way toward making men take responsibility for their irresponsible behavior.

To kick off the campaign, I suggest that all anti-choice politicians, starting with Donald Trump himself, publicly confess to any abortions they have been responsible for in the past and submit their DNA to be used in the event that they cause future unwanted pregnancies.

Let Trump and other anti-choice male politicians publicly acknowledge their part in unwanted pregnancies (if any), accept the public humiliation and pay the fines to demonstrate their sincerity and, in the process, set an edifying example.

Given their profound commitment to ending abortion, anti-choice politicians should greet the plan to punish men for abortions with unrestrained enthusiasm.

Of course, if they reject such a plan we’ll be left to conclude that anti-choice politicians don’t want to prevent abortions; they just want to punish women for having sex.

A new study claiming to show that female doctors provide better care than male doctors is a paradigmatic example of the way that scientific research has been perverted by contemporary journalism. In an effort to provide click-bait headlines, scientists are grossly exaggerating the clinical significance of their findings and thereby misleading the public.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Is a difference in mortality rate of 0.7% clinically meaningful?[/pullquote]

The paper is Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians published in this week’s edition of the Journal of the American Medical Association (JAMA).

NPR is typical of news outlets hyping the findings:

In a study that is sure to rile male doctors, Harvard researchers have found that female doctors who care for elderly hospitalized patients get better results. Patients cared for by women were less likely to die or return to the hospital after discharge.

Previous research has shown that female doctors are more likely to follow recommendations about prevention counseling and to order preventive tests like Pap smears and mammograms.

But the latest work, published Monday in JAMA Internal Medicine, is the first to show a big difference in the result that matters most to patients: life or death.

According to the paper:

Elderly hospitalized patients treated by female internists have lower mortality and readmissions compared with those cared for by male internists. These findings suggest that the differences in practice patterns between male and female physicians, as suggested in previous studies, may have important clinical implications for patient outcomes.

What did the researchers do?

We analyzed a 20% random sample of Medicare fee-for-service beneficiaries 65 years or older hospitalized with a medical condition and treated by general internists from January 1, 2011, to December 31, 2014. We examined the association between physician sex and 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital fixed effects …

So far, so good.

What did they find?

… Patients treated by female physicians had lower 30-day mortality (adjusted mortality, 11.07% vs 11.49%; adjusted risk difference, –0.43%; 95% CI, –0.57% to –0.28%; P < .001; number needed to treat to prevent 1 death, 233) and lower 30-day readmissions (adjusted readmissions, 15.02% vs 15.57%; adjusted risk difference, –0.55%; 95% CI, –0.71% to –0.39%; P < .001; number needed to treat to prevent 1 readmission, 182) than patients cared for by male physicians, after accounting for potential confounders…

The study is methodologically sound. The authors carefully chose the subjects and carefully corrected for a large number of confounding variables. The differences are statistically significant but the authors fail to pay careful attention to the most important question: Are the results clinically significant?

Put another way, is a difference in adjusted mortality rates of 0.47% clinically meaningful?

I doubt it.

What’s the difference between statistical significance and clinical significance?

A biostatistician explains:

In clinical research is not only important to assess the significance of the differences between the evaluated groups but also it is recommended, if possible, to measure how meaningful the outcome is (for instance, to evaluate the effectiveness and efficacy of an intervention). Statistical significance does not provide information about the effect size or the clinical relevance. Because of that, researchers often misinterpret statistically significance as clinical one…

That is what has happened here. The authors have claimed that there is a statistically significant difference in death rates and readmission rates between female and male physicians; that’s true. But they’ve gone on to imply that this finding is the same as a clinically significant difference and that’s false.

What is the clinical significance of these findings?

The authors haven’t done all the appropriate calculations to determine clinical significance and have not provided the information we need to calculate them.

They do provide the number needed to treat (i.e. 233 to prevent one death), but they don’t provide the Cohen’s effect size, nor the standard deviations that we could use to calculate the Cohen’s effect size for ourselves.

There’s another aspect of clinical significance that hasn’t been considered: are 30 day mortality and readmission rates a good measure of effect? Most people do not choose their doctor by calculating the odds of surviving 30 days after admission to the hospital, nor should they.

The authors hype their findings by extrapolating them. According to NPR:

The study’s authors estimate “that approximately 32,000 fewer patients would die if male physicians could achieve the same outcomes as female physicians every year.”

But the authors provide no evidence that their findings in Medicare patients admitted to the hospital could be extrapolated to other elderly, hospitalized patients, let alone younger patients, outpatients or doctors from specialities other than internal medicine.

The claim is an excellent example of the way that scientific research is perverted by the need to publish and to publicize.

The research paper yielded an interesting finding whose clinical significance is uncertain, has yet to be replicated, and should not be extrapolated. Then the authors proceeded to hype their findings in order to get attention for them. In the process, they have made claims that don’t bear scrutiny and essentially mislead the American public.

That behavior may be good for getting tenure, but it’s not good for patients.

Is there anything more pathetic than an anti-vaxxer who imagines that she’s knowledgeable?

They’re like automatons, cheerfully repeating nonsense that impressed them. And they’re boring. They all say the same stupid stuff.

Here’s a list of stupid stuff anti-vaxxers say, and what it means to smart, truly educated people who are listening.

1. Do your research!

Anti-vax to English translation: Read the same anti-vax fake news sites I’ve read.

2. There has never been an randomized controlled trial (RCT) of vaccines vs. placebo!

Anti-vax to English translation: I don’t understand that there are many different forms of scientific evidence. While RCTs are the gold standard when it is ethical to use them, there are many other tests of validity when it is not ethical to perform an RCT.

3. I’m not anti-vaccine; I’m pro safe vaccines!

Anti-vax to English translation: I’m an anti-vaxxer.

4. Watch this YouTube video!

Anti-vax to English translation: I know so little about science that I don’t understand that citing YouTube is a mark of gullibility.

5. Here’s link to a scientific paper that shows vaccines are harmful!

Anti-vax to English translation: I never read this paper (nor any other scientific paper) and I have no idea what it shows.

6. It’s a conspiracy!

Anti-vax to English translation: I’m so gullible that I actually imagine that nearly all doctors, research scientists, and public health officials IN THE WORLD, are plotting to harm all children including THEIR OWN.

7. Big Pharma!

Anti-vax to English translation: I don’t understand that vaccines are so unprofitable for pharmaceutical companies that the government must provide special benefits in order to induce the pharmaceutical companies to continue to produce them.

8. Too many vaccines at once are harmful!

Anti-vax to English translation: I don’t realize that a baby is exposed to more antigens in an afternoon at the playground than if he were to received all possible vaccines at once.

9. There are more vaccines than ever AND more cases of autism than ever!

Anti-vax to English translation: I don’t understand that correlation is not causation. The breastfeeding rate has not been this high for nearly a century. By my reasoning breastfeeding causes autism.

10. I’m educated about vaccines

Anti-vax to English translation: I’m an idiot.

The sad fact is that most of what anti-vaxxers think they “know” is factually false and they know so little about immunology, science or statistics that they are profoundly ignorant of their ignorance.