Even those who can’t tell the difference between a t-test and a chi-square are familiar with a basic principle of epidemiology: correlation does not equal causation. Just because Event A happened before Disease B, it does not mean that A caused B.

For example, in last 100 years deaths from infectious diseases has declined precipitously. During the same time span, the recreational use of marijuana has also increased. Yet no one would suggest that the decline in infectious disease deaths was caused by smoking marijuana.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]One experiment or even a few experiments is not enough to determine causation.[/pullquote]

So if correlation does not equal causation, what does?

To determine if Event A caused Disease B, we need to investigate whether it satisfies Hill’s Criteria. These are 9 criteria, most of which much be satisfied before we can conclude that Event A is not merely correlated with Disease B, but Event A actually causes Disease B.

Who was Hill and why should we care about his criteria?

… These criteria were originally presented by Austin Bradford Hill (1897-1991), a British medical statistician as a way of determining the causal link between a specific factor (e.g., cigarette smoking) and a disease (such as emphysema or lung cancer)… [T]he principles set forth by Hill form the basis of evaluation used in all modern scientific research… Hill’s Criteria simply provides an additional valuable measure by which to evaluate the many theories and explanations proposed within the social sciences.

What are the criteria?
1. Temporal relationship: It may sound obvious, but if Event A causes Disease B, Event A must occur before Disease B. If smoking causes lung cancer than smoking must precede the development of lung cancer. The is the only absolutely essential criterion, but it is NOT sufficient. Lay people often erroneously assume that because it’s the only essential criterion, it is the only criterion that counts. For example, anti-vaccine parents often point to the fact that childhood vaccinations usually occur before the onset of autism, but that does not mean that vaccination causes autism. Learning to walk usually precedes autism, too, but obviously learning to walk does not cause autism.

2. Strength: This is measured by statistical tests, but can be thought of as similar to the closeness of the relationship. Is Disease B always preceded by Event A? Sometimes? Only rarely? Does Event A always cause Disease B? Sometimes? Only rarely? Lung cancer is not always preceded by cigarette smoking, but it usually is. Cigarette smoking does not always lead to lung cancer, but it often leads to lung cancer. In other words, the relationship is fairly strong.

In the case of vaccines and autism, vaccines usually precede the diagnosis. However, most children who receive vaccines don’t develop autism. Thus the relationship is weaker.

3. Dose-response relationship: If cigarette smoking causes lung cancer, we would expect that smoking more cigarettes would increase the risk of lung cancer, which it does. In contrast, there appears to be no dose-response relationship between the number of vaccinations and the risk of developing autism.

4. Consistency: Have the findings that purported to show a relationship been replicated by other scientists, in other populations and at other times? If studies fail to consistently show the relationship, causation is very unlikely.

This is a critical point. One experiment or even a few experiments is NOT enough to determine causation. A large number of experiments that consistently show the same result is required; that’s exactly what we find in the case of cigarettes and lung cancer. This is particularly important for anti-vaxxers to note. The fact that a few studies claim to have shown that vaccination causes autism is meaningless when a very high proportion of studies show that there is not even a correlation between vaccination and autism.

5. Plausibility: In order to claim causation, you MUST offer a plausible mechanism. In the case of cigarette smoking, certain components of the smoke are known to cause damage to the cells inside the lungs, and cellular damage has been shown to lead to cancer. In contrast, no one has yet offered a plausible explanation for how vaccines “cause” autism. In fact, no one can even agree on the specific component that is supposedly responsible.

6. Consideration of alternative explanations: This is self explanatory. In the case of vaccination and autism, there is a very simple alternative explanation. Autism cannot be diagnosed before the age of 2 and most vaccines are given before the age of 2.

7. Experiment: If you alter Event A do you still get Disease B. In the case of smoking, if you quite smoking, the risk of lung cancer goes down. In the case of vaccines and autism, if you forgo vaccination, the risk of autism remains unchanged.

8. Specificity: Is Event A the only thing that leads to Disease B? This is the least important of the criterion. If it is present, it is a very powerful indicator of causation. For example, among young women who developed a rare form of vaginal cancer, all of them were found to have been exposed to DES (diethylstilbestrol) while in utero. That is a highly specific effect.

However, even if the relationship is not highly specific, that does not preclude causation. Though there are non-smokers who get lung cancer, it does not change the fact that the other criteria show that smoking causes lung cancer.

9. Coherence: The explanation of action must comport with the known laws of science. If the purported mechanism of causation violates the law of gravity, for example, then it isn’t acceptable. That’s why religious arguments against evolution are wrong. They are “incoherent” since they invoke forces outside science.

What do Hill’s criteria look like in action?

In the case of cigarette smoking and lung cancer, 8 out of 9 Hill’s Criteria are satisfied. In contrast, in the case of vaccines and autism, only 2, possibly 3 criteria are satisfied. This is why we can say that the scientific evidence shows that vaccines do not cause autism.

While it is true that vaccinations usually precede the diagnosis of autism, that is an essential criterion, but not enough. The fact that there is no dose-response relationship, that the few studies that showed a purported relationship cannot be replicated and that studies in which people who were not vaccinated did not have a lower incidence of autism, demonstrates that vaccines do not cause autism.

They utterly changed the nature of infectious disease. Communicable diseases that had previously wiped out wide swathes of the population could be controlled with simple injections. Deaths dropped dramatically.

They became ubiquitous and virtually mandatory. The companies that manufactured them became extraordinarily wealthy and developed into large multinational conglomerates.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is easy for lay people to believe that antibiotics work, but it requires specialized knowledge to understand how vaccines work.[/pullquote]

But there were side effects. Some recipients suffered serious medical consequences. Some even died. Yet despite these dire consequences, they have remained a cornerstone of medical practice.

What are they?

If you thought I was talking about vaccines you are mistaken. I am referring to antibiotics. I want to talk about a curious paradox. Antibiotics and vaccines are the two most powerful and effective weapons against infectious diseases. Yet antibiotics are accepted without demur and vaccines are the subject of a variety of conspiracy theories. Why should they be viewed so differently?

Both are highly effective. Both are delivered by injection (though they can be delivered in other ways). Both have serious side effects including death. Both are manufactured by large multinational corporations who profit from their sale. So why are vaccines the subject of hysterical pseudo-scientific conspiracy theories, while antibiotics are not merely accepted as necessary, but actively sought, sometimes even when they are not needed?

There are four critical differences and those differences shed light on the nature of pseudo-scientific conspiracy theories. The differences tell us why certain conspiracy theories flourish and others are rejected out of hand.

The first difference is the ease of explanation. The workings of antibiotics are, on their face, easy to understand. Antibiotics kill bacteria by poisoning them. Everyone understands what a poison is and how it can be effective. We routinely poison weeds in our lawns, and mice in our homes. Poisons figure prominently in crime shows and detective novels. When patients are told that antibiotics will cure them by poisoning the bacteria that are making them sick, patients have no trouble understanding or envisioning how the antibiotics will do the job.

In contrast, the explanation of how vaccines work is rather complex. It requires familiarity with the notion of the immune system in general and antibodies in particular, how antibodies function in the body, and how they are created. This is not information that can be acquired in the course of every day life. We have no direct experience with eliciting antibodies to fight disease. Antibodies are certainly not subjects for TV shows or novels. Understanding vaccination, therefore, requires specialized knowledge not easily obtained.

The second difference is the time scale. Antibiotics work quickly, in hours or days at the most. We are sick, we take antibiotics, we get well. It is easy to credit the role of antibiotics in curing illness because they are temporally connected. Cure reliably follows the administration of antibiotics. It is easy to believe that the antibiotics cause the cure.

In contrast, vaccines act over long periods of time. Pertussis vaccine is give in infancy. Years go by and those infants become young children who never develop pertussis. The connection between vaccination and wellness is not directly apparent.

Third, there is something fundamentally different between curing a disease and preventing it. Curing a disease allows for certainty on the part of the person being cured. Connecting the absence of a disease with a maneuver designed to prevent it is not apparent to most people. There are other possible explanations besides vaccination for why a child does not get pertussis. He or she may never have been exposed. Some children who are exposed do not get the disease, even if they haven’t been vaccinated.

Fourth, there is a difference in apparent effectiveness. The reality is that a given antibiotic will never be 100% effective, but there are almost always alternatives. If penicillin does not do the trick, another antibiotic may be more effective. Ultimately, though, the patient is cured by antibiotics, whether it is the initial antibiotic, a subsequent antibiotic or a combination of antibiotics.

No vaccination is 100% effective, either, but there is usually one and only one vaccine for a particular disease. If the vaccine fails, the person gets the disease and there is no other vaccine that can be administered to prevent it.

These differences can be readily summarized: it is easy for lay people to believe that antibiotics work, but it requires specialized knowledge to understand how vaccines work. That’s why it’s not a coincidence that vaccine conspiracies flourish among those who lack basic knowledge of science, immunology and statistics. They literally cannot understand the issues involved. And if they can’t understand it, there is lots of room to disbelieve it and to substitute conspiracy theories for the truth.

 

This piece first appeared in November 2010.

The most over-used word in natural childbirth discourse is “empowerment.” But an equally important concept, one that is rarely spoken aloud but is central to natural childbirth advocacy, is victimization. To a greater or less extent, natural childbirth advocates take it for granted that they are victims … of men, of doctors (almost always portrayed as men), of other women, and just about everyone else in the universe.

They are victims, dammit, and that’s why they are traumatized. And anyone who questions or rejects their exalted victim status is promptly accused of re-victimizing them.

The celebration of their “victimization” serves several important roles in the natural childbirth cosmology. First, and foremost, it guarantees moral superiority. As Sommer and Baumeister explain in the book The human quest for meaning”

… [C]laiming the victim status provides a sort of moral immunity. The victim role carries with it the advantage of receiving sympathy from others and thereby prevents [one’s own behavior] from impugning one’s character…

In the world of natural childbirth, being a victim means never having to say you’re sorry, even when your behavior is obnoxious and disrespectful.

Second, the insistence on “victimization” serves to simplify the world by creating a false dichotomy. For natural childbirth advocates, women giving birth are either empowered or victimized. Not only is there no middle ground, but the possibility that women might feel neither empowered nor victimized is not even recognized.

Freud purportedly said, “Sometimes a cigar is just a cigar.” That aphorism applies to the way that most women view childbirth. Giving birth is just the process whereby a child emerges from inside the mother. It has no meaning beyond that and certainly does not have anything to do with the way the mother views her agency within the world at large. In contrast, in NCB advocacy, the actual birth of a child is secondary to the mother’s feelings about her performance during that birth.

Third, the insistence on “victimization” presupposes a sexist, retrograde view of women. Only men are doctors and scientific knowledge and technology are inherently male. In the world of natural childbirth, there are no women doctors or scientists. Science is “too hard” for mere women and since they can’t be expected to know or understand science, they are free to reject it. Women must glorify the functions of their bodies because they have no achievements of their intellects.

This belief has its highest expression in homebirth advocacy. Medical school? Too hard. Midwifery master’s degree? Too hard. College? Too hard. Solution? Give yourself a pretend “degree” to masquerade as a professional because meeting real professional requirements is too hard.

Who has convinced natural childbirth advocates that they are victims? Strangely enough, it is male doctors, the exact same people who have purportedly victimized them. From Grantly Dick-Read, the father of natural childbirth, who believed implicitly in the inferiority of women, through Bradley and Lamaze, right down to Odent (who fears that viewing a wife giving birth will render a man impotent) the leading exponents of women’s victimology are men who view women as capable of being nothing more than victims.

This faux sense of victimization has led natural childbirth advocates to create faux “empowerment.” In the world of natural childbirth advocacy, you can be “empowered” by being obnoxious and disrespectful to healthcare professionals, and no one can hold you to account because you are a “victim.” You can be empowered by pretending that reading books written by laypeople makes you “educated.” You can be empowered by ignoring medical advice. And, with homebirth, you can be empowered by hiding from anyone and anything that might not agree with your assessment that your ignorance, defiance and denial mark you as “educated.”

When you are victim, the fact anyone others don’t agree with you, or validate your feelings of victimization, is viewed as a form of re-victimization. Doctor thinks he knows more about obstetrics than you? He’s victimizing you with his technocratic hegemony. Nurse asks you if you would like an epidural? She’s victimizing you by attempting to destroy your opportunity to be empowered. Other women bottle feed? They are victimizing you by refusing to validate your decision to breastfeed.

Victimization is central to natural childbirth advocacy. Indeed natural childbirth advocacy cannot exist without encouraging and validating victimization.

 

Adapted from a piece that first appeared in April 2011.

Yesterday I wrote about childbirth injuries. They’re common, lead to life long disability and distress and are a subject of deep embarrassment for many women.

I discussed the two most serious forms of childbirth injury: obstetric fistula, a hole between the vagina and the bladder or rectum or both; and severe vaginal tears that can result in the vagina and rectum becoming one passage. It’s not difficult to envision why either of those injuries lead to incontinence since urine and stool are released directly into the vagina and then dribble out.

As I explained, such injuries are now relatively uncommon. Fistulas are usually the result of prolonged obstructed labor and with the easy availability of C-sections they are rare. Vaginal tears, including severe vaginal tears, are still common but carefully repairing them with extensive suturing generally prevents incontinence.

Many readers might have wondered: I only had a minor childbirth injury so why am I incontinent?

The reason is because childbirth causes injuries that may not be visible, or the repair of a visible injury may be inadequate.

To understand the problem you need to understand how we achieve continence in the first place.

Outflow from both the bladder and the rectum is controlled by sphincters. A sphincter is a ring of muscle that can open and close in response to conscious or unconscious signals.

Babies are incontinent of both urine and stool, but neither is constantly dribbling. That’s because unconscious signals keep both the bladder and rectum closed until they are full. Only then will the appropriate sphincter open, releasing the contents. Then the sphincter will close until the organ is once again full.

Over time toddlers acquire the mature neurological function need to take conscious control of the bladder and anal sphincters. When continent children and adults feel the urge to void they can override the unconscious signals for the sphincters to open. In other words, they can “hold it.” But in order for them to do so, the sphincters themselves must be undamaged. Childbirth can lead to invisible injuries to the sphincters.

There’s a critical distinction to keep in mind. Bowel incontinence is nearly always the result of an injury that can be repaired while incontinence of urine may be the result of an injury that cannot be easily repaired.

The image below shows a third degree vaginal tear. You can see the muscles of the vagina have torn as well as the sphincter around the anus. Unless the sphincter is repaired, the woman will have permanent bowel incontinence. It’s relatively easy to tell the difference between the vaginal muscles and the anal sphincter in the picture, but in real life it can be quite difficult.

If there is any question, the provider should put a finger in the anus to determine if the sphincter is intact. If it has been torn, it can be repaired with sutures. An inexperienced provider may fail to recognize that the sphincter has been torn and may repair only the vaginal muscles. If you were to look at the repaired area with a mirror, it would look perfectly normal, but because the sphincter has been torn, there is no way to prevent the contents of the rectum from leaking out or being expelled. If that’s the cause of the bowel incontinence, it must be completely repaired, typically requiring surgery.

Urinary incontinence is different.

Urinary continence is controlled by the urethral sphincter. As shown in the image below, the sphincter’s ability to close off the bladder depends in large part on the relationship between the bladder and the urethra. The bladder is held in place by the ligaments and muscles of the pelvic floor. Vaginal birth (and to a lesser extent pregnancy itself) can stretch these ligaments and muscles causing the bladder to fall. The sphincter is still intact so urine doesn’t dribble out. But when the pressure on the bladder is increased by coughing, sneezing or physical exercise urine may escape. This is known as stress urinary incontinence and is the most common form of incontinence in women of childbearing age.

The maximum stretching of ligaments and muscles occurs at the time of vaginal birth. In the aftermath, the ligaments and muscles can regain some of their tone. That’s why incontinence in the first few days or weeks after birth can eventually resolve. If you are incontinent of urine at your 6 week check up, you should definitely tell your provider. He or she may suggest that you wait a little longer to see if you recover more muscle tone. Alternatively your provider may recommend Kegel exercises or pelvic physical therapy to strengthen the muscles of the pelvic floor.

How do childbirth interventions affect childbirth injuries? On the one hand, C-sections can prevent many childbirth injuries entirely. On the other hand, interventions like forceps can dramatically increase the risk of childbirth injuries. That’s not surprising when you consider that it is the passage of the baby’s head that leads to the injuries. When you apply forceps to the head, the effective size is increased and the risk of injury is increased, too. Forceps rotations (turning the baby’s head from an incorrect position to a correct position with the forceps) increases the risk of childbirth injury even more.

How about episiotomies?

The rationale for episiotomy is the belief that cutting through the perineal muscles to enlarge the vaginal opening would reduce both the stretching of the muscles and prevent major tears. Unfortunately, that’s not what happens. Cutting into the perineal muscles appears to increase the risk of severe tears; that’s why routine episiotomy is no longer recommended.

There is one exception, though. A mediolateral episiotomy (a cut angled toward the side) reduces the risk of childbirth injuries. Mediolateral episiotomies are much more painful than typical (median) episiotomies so they are rarely used.

So the role of childbirth interventions is paradoxical. C-sections reduce the risk of childbirth injuries, while vaginal delivery increases the risk of injury and forceps and episiotomy increase that risk even further. Women should be counseled about the risks of vaginal delivery in the same way they are counseled about the risks of C-section.

Moreover, efforts to decrease the C-section rate by replacing C-sections with forceps deliveries are not necessarily in women’s best interest. Yes, surgery has real risks, but the risk of incontinence (not to mention pelvic pain and sexual dysfunction) is one that cannot and should not be ignored.

It should be up to individual women to decide, based on their personal priorities, which mode of birth they prefer. A woman who prioritizes avoiding childbirth injuries should be able to choose a C-section in the absence of other medical indications.

Childbirth is inherently dangerous for babies and for mothers and the risk of death is not the only risk. The right to bodily autonomy means that women should weigh the risks for themselves, and that vaginal birth should be recognized not as a goal, but as an option with significant downsides.

Cosmopolitan Magazine recently published an amazing piece on childbirth injuries, Millions of Women Are Injured During Childbirth. Why aren’t doctors diagnosing them?

Why do childbirth injuries occur?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Childbirth injuries are common, lead to life long disability and distress and are a subject of deep embarrassment for many women.[/pullquote]

The single greatest cause is a mismatch between the size of the baby and the size of the passage it must negotiate during birth. There are two different points at which the mismatch can cause problems. The first is during passage of the head through the maternal bony pelvis. The second point is when the head exists the vaginal opening.

Most people imagine that the pelvis is like a hoop that the baby’s head must pass through, and indeed doctors often talk about it that way. However, the reality is far more complicated. The pelvis is a bony passage with an inlet and an outlet having different dimensions and a multiple bony protuberances jutting out at various places and at multiple angles. The baby’s head does not pass through like a ball going through a hoop. The baby’s head must negotiate the bony tube that is the pelvis, twisting this way and that to make it through.

You can see what I mean in the illustration above (from Shoulder Dystocia Info.com). There are bony protuberances that jut into the pelvis from either side (the ischial spines) and the bottom of the sacrum and the coccyx, located in the back of the pelvis, jut forward. How does the baby negotiate these obstacles? During labor, the dimension of the baby’s head occupies the largest dimension of the mother’s pelvis. But because of the multiple obstacles, the largest part of the mother’s pelvis is different from top to middle to bottom. Therefore, the baby is forced to twist and turn its head in order to fit.

What happens when the baby’s head doesn’t fit? The bones of the mother’s pelvis may break or split to accommodate the baby. That’s why a woman might end up with a fractured coccyx or a separated public symphysis, both extremely painful.

If the bones don’t break or split (and sometimes even if they do), the tissues of the vagina can be squeezed so hard between the baby’s head and the mother’s pelvis that the blood flow to the area is actually stopped. If that goes on for more than a few minutes, the tissue of the mother’s vagina will begin to die resulting in a hole (fistula) in the vagina. If the hole is toward the front of the vagina it will open into the bladder and if it is toward the back it will open into the rectum; there can be holes in the front and the back simultaneously.

In either case, waste products leak into the vagina and dribble out of it rendering the woman incontinent and reeking of urine and/or stool for the rest of her life. Fortunately, easy access to C-sections means that it is rare for women to push for multiple hours with no progress and obstetric fistula is therefore uncommon in industrialized countries today.

What happens when the baby’s head is too big to fit through the vaginal opening? The vagina tears to accommodate it. If the vaginal tear is small, it will heal by itself. If the vaginal tear extends into surrounding structures it will not heal unless it is sutured properly.

Perineal tears are classified by severity from first to fourth degree. First degree tears are small do not need to be stitched. Second degree tears extend into the tissue immediately surrounding the vagina; they ought to be stitched but the results are not catastrophic if they are not stitched.

Third and fourth degree tears are more serious. The illustration of the fourth degree tear below make it easy to see why they MUST be stitched or the woman will be left with bowel incontinence. Third and fourth degree tears can only be diagnosed by someone with considerable obstetric experience and they will NOT heal by themselves. They must be repaired by someone with extensive experience in repairing them.

Why aren’t childbirth injuries diagnosed? I offered my take in the piece:

We have a new cultural view of childbirth that tremendously minimizes how physically and emotionally difficult it is.

Indeed, until relatively recently, childbirth was recognized not merely as deadly, but also as disfiguring and disabling. A historian Judith Walzer Leavitt wrote in Under the Shadow of Maternity: American Women’s Responses to Death and Debility Fears in Nineteenth-Century Childbirth:

In the past, the shadow of maternity extended beyond the possibility and fear of death. Women knew that if procreation did not kill them or their babies, it could maim them for life. Postpartum gynecological problems – some great enough to force women to bed for the rest of their lives, others causing milder disabilities – hounded the women who did not succumb to their labor and delivery. For some women, the fears of future debility were more disturbing than fears of death. Vesicovaginal and rectovaginal fistulas .., which brought incontinence and constant irritation to sufferers; unsutured perineal tears of lesser degree, which may have caused significant daily discomforts; major infections; and general weakness and failure to return to prepregnant physical vigor threatened young women in the prime of life.

What changed between then and now? Quite a few things:

The widespread medicalization of childbirth dramatically reduced the death rates for both babies and women. In the past 100 years, modern obstetrics dropped the neonatal mortality rate 90% and the maternal mortality rate nearly 99%. Childbirth began to be seen as safe.

The medicalization of childbirth dramatically reduced the risk of the most debilitating childbirth injuries. The most devastating injuries, obstetric fistulas, have been rendered exceedingly rare by the easy availability of C-sections, and the more common injuries are easily prevented by the simple expedient of suturing vaginal tears.

Midwives and the natural childbirth industry romanticized childbirth in order to claw back market share. Midwives and other natural childbirth advocates resented what they derided as the “technocratic” model of birth, which they contrasted with the midwifery model which places a premium on avoiding the childbirth interventions that they coincidentally cannot provide.

We’ve ended up with a situation where physicians ignore postpartum pain, incontinence and sexual dysfunction because they are pre-occupied with preventing deaths, and midwives and natural childbirth advocates pretend childbirth injuries don’t exist because those injuries belie their reflexive worship of birth without interventions.

The truth about childbirth injuries is that they are common, can be prevented to a certain extent with the liberal use of obstetric interventions, can lead to life long disability and distress and are a subject of deep embarrassment for many women.

I’ve been quoted extensively in the mainstream media about breastfeeding.

In nearly every case I mention that I breastfed four children relatively easily and I (and they) enjoyed it. Nonetheless I caution that the benefits of breastfeeding have been grossly exaggerated and that what passes for breastfeeding “science” is generally based on data that is weak, conflicting and plagued by confounding variables that render the conclusions meaningless.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is no possibility that breastfeeding “science” will ever show that breast is not best; and that means it isn’t science at all.[/pullquote]

Inevitably commenters complain that I am ignoring the science, but what they don’t realize is that lactivist “science” shares a very important trait with major forms of pseudoscience. Just like creation “science,” the central tenet of lactivist “science” is considered unfalsifiable.

Why is that important?

Science always starts with a hypothesis and then tests it to see if it is true. The possibility always exists that the hypothesis is false. The conclusion of scientific testing is drawn from data gathered in the course of experiments and studies. It is not known a priori.

Creationism, the belief that the universe was created by an intelligent designer, is considered unfalsifiable by its adherents. They start with the conclusion that a Creator was necessary for our current existence and then arrange any experimental data to lead to that conclusion, carefully editing the data so that anything that could falsify the conclusion is excluded.

For creationists, there is no possibility that the conclusion is wrong since they start with the conclusion and, working backwards, do whatever is necessary to arrive at it. There is no possibility that creation “science” will ever conclude that creationism is false and that means that creationism is not science.

Lactivist breastfeeding “science” also starts with a conclusion and works backward to justify it. The central tenet of breastfeeding “science” is that breast is best, despite the copious scientific evidence that in many cases it is not best at all and may even be deadly. Nonetheless, all data is manipulated until it can be forced to fit the predetermined conclusion.

When data is conflicting, as it often is in lactivist breastfeeding research, the data that don’t show breast is best is either excluded or dismissed out of hand. Confounding variables like maternal education and socio-economic status aren’t removed by correction so that the benefits to children that come from being wealthy and having access to better health insurance can be erroneously ascribed to breastfeeding. Startling facts about breastfeeding — the historically high mortality rates of exclusively breastfed infants prior to the 20th century and that fact countries with the highest contemporary breastfeeding rates have the highest mortality rates — are simply ignored. There is no possibility that lactivist breastfeeding “science” will ever show that breast is not best; and that means it isn’t science at all.

But how is it possible that breast isn’t necessarily best?

It’s possible for the exact same reason that “natural immunity,” so beloved of anti-vaccine advocates, isn’t best. Technology can do better and there’s a massive amount of evidence to support the fact that it actually DOES better than nature. Natural is not best.

Just because something is natural doesn’t make it better:

Nearsightedness is entirely natural but it is not better than vision corrected with glasses or contacts.

Naturally acquired immunity is by definition entirely natural but cannot stave off death from vaccine preventable diseases in a substantial number of cases. Survivors of various plagues through the ages could have boasted of their naturally acquired immunity but there were often very few other people left to appreciate it since they had died before naturally acquired immunity could save them. Most of them could have been saved by vaccine acquired immunity.

Breastfeeding is entirely natural but that doesn’t make it better than formula. Women can naturally fail to produce enough breastmilk and their babies can naturally die as a result. It is entirely possible that an infant formula could be devised that is actually superior to breastmilk in the same way that vaccines are superior to natural immunity. When you know more about death and disease, you can defeat entirely natural causes of death.

Real science tells us that the benefits of breastfeeding for term infants in the US are trivial. Breastmilk is neither magical nor mysterious just as immunity is neither magical or mysterious. We can mimic it and we can even improve upon it.

But lactivist breastfeeding “science,” like Creation “science,” won’t admit that possibility. That’s why neither are science at all.

“We’re still here!”

It’s a favorite declaration of those attempting to justify natural parenting practices:

Childbirth without interventions must be optimal because we’re still here.

Homebirth must be safe because we’re still here.

Exclusive breastfeeding must be best because we’re still here.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Looking at those today alive today though their parents never used seatbelts, we might conclude that seatbelts are unnecessary because “we’re still here.”[/pullquote]

But “we’re still here” doesn’t merely fail to justify natural parenting practices, it is actually a form of cognitive bias, a way of thinking that inevitably leads us to erroneous conclusions.

Specifically, “we’re still here” is a form of survivorship bias, a bias so subtle that it is often difficult for its practitioners to recognize.

Rational Wiki defines survivorship bias as:

… a cognitive bias that occurs when someone tries to make a decision based on past successes, while ignoring past failures.

Rational Wiki offers an excellent example of survivorship bias:

Suppose you’re trying to help the military decide how best to armor their planes for future bombing runs. They let you look over the planes that made it back, and you note that some areas get shot heavily, while other areas hardly get shot at all. So, you should increase the armor on the areas that get shot, right?

Wrong! These are the planes that got shot and survived. It stands to reason that on some planes, the areas where you don’t see any damage did get shot, and they didn’t survive. So those are the areas you reinforce…

Dead men (and planes) may tell no tales, but the fact that they are dead provides valuable information for the survivors.

The planes that returned from the bombing runs aren’t the safest planes; they’re the ones that were merely lucky enough to get hit in the places least likely to cause catastrophic damage.

For example, imagine that every plane that returned was shot somewhere in the fuselage, but never in the fuel tank. In contrast, every plane that was shot in the fuel tank failed to survive because a shot to the fuel tank inevitably led to explosion of the entire plane.

If you were to repair the returning planes and send them out on another bombing run a substantial proportion would once again fail to return because this time they might get hit in the fuel tank. Surviving the first bombing run because they were not shot in the fuel tank would not have made them more likely to avoid getting shot in the fuel tank the second time.

In other words, the pilots who survived the first bombing run were simply luckier than the ones who failed to return.

Consider a more common example.

Most of us above a certain age traveled in cars throughout our entire childhoods without ever using a seatbelt and we’re still here. For many years cars didn’t even have seatbelts yet the population of the US continued to increase. Does that mean seatbelts are useless?

Of course not! The many children who died from being ejected in car accidents are testament to the fact that failure to wear a seatbelt is dangerous. The dramatically lower death rates for children in accidents in the 2010’s compared to the 1960’s makes it clear that wearing a seatbelt is much safer than not wearing one. But if we only looked at people alive today even though their parents never used seatbelts, survivorship bias would lead us to conclude that seatbelts are unnecessary.

Dead children leave no descendants; their millions of potential descendants are not here but we don’t notice precisely because they are absent. We are the remainder.

How does this apply to natural parenting?

The claim that childbirth without interventions is safe because “we are still here” makes as much sense as claiming that not wearing seatbelts in the 1960’s was safe because “we are still here.”

The claim that homebirth is safe because for most of human existence women gave birth at home and “we are still here” makes as much sense as claiming that putting babies to sleep on their stomachs instead of their backs is safe because “we are still here.”

The claim that breastmilk must be better than formula because “we are still here” is like claiming riding without a bicycle helmet must be better than using a helmet because “we are still here.”

But billions of potential people are NOT here today precisely because their parents died in childbirth, at homebirth, or from being exclusively breastfed by women who didn’t produce enough milk for them to survive.

We who are “still here” are the remainder, representing nothing more than luck, not inherent safety.

In a new post, the folks at Lamaze are crowing about homebirth statistics that purport to demonstrate the “popularity” of homebirth Look at Home Birth Trends – The Results May Surprise You!.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lamaze is a special interest lobbying group that depends on convincing women that its prescriptions for childbirth are the ones you should buy.[/pullquote]

• 58% increase in the number of home and birth center births in the period of 2004 to 2014. In 2014, over 56,000 births took place out of the hospital.
• Since 2004, there has been a rapid increase primarily in the number of white non-Hispanic mothers choosing home birth.
• By 2014, there is a significant number of states who have home birth rates over 1%, primarily clustered in the Northwest, some of the Midwest and in Maine,Vermont and Pennsylvania.
• In 2014, Certified Professional Midwives (CPM) attend almost half of all out of hospital births. Certified Nurse Midwives/Certified Midwives (CNM/CM) attend just about one quarter of the out of hospital births. 27% of births were attended by “Others” which probably indicates situations where home birth midwifery is illegal or alegal. Dr. Declercq assures us that the “Others” are not taxi drivers!
• In 2014, 98% of CPM attended home births were planned to be at home, and 99% of CNM attended home births were planned to occur at home.

They’ve helpfully included a graph to illustrate the trend:

That looks impressive until you realize that they’ve left out the rate of hospital birth. I’ve added hospital birth and the resulting graph is far less impressive. Indeed, out of hospital birth is an uncommon fringe practice which has grown to become … an uncommon fringe practice.

Lamaze is so desperate to pretend that homebirth is popular that they’ve included UNPLANNED out of hospital births in the mix. Dr. Gene Declercq insists that the 27% of out of hospital births attended by “Others” were not attended by taxi drivers, but he has absolutely no way to know that. These aren’t even necessarily term births and it is far more likely that those births happened by the side of the road or were attended by EMTS.

That’s doesn’t capture the full extent of Lamaze and Declercq’s duplicity.

First, the death rates are conveniently excluded. The aim is to promote homebirth by convincing women that “everyone” is doing it because it is both safe and delightful. Including the death rates would have been a bummer since a recent study in NEJM showed that PLANNED out of hospital birth at term has double the death rate of comparable risk hospital birth and the best homebirth data, out of Oregon in 2012, show that planned homebirth with a licensed homebirth midwife has a death rate 800% higher than comparable risk hospital birth!

Second, Lamaze has gone on the record as dismissing the bulk of the studies that show that homebirth has a death rate up to 800% higher than hospital birth because they are based on birth certificate data. As recently as March of this year, a Lamaze blogger wailed about Flaws In Recent Home Birth Research May Mislead Parents, Providers. Apparently, parents and providers are supposed to ignore the appalling death rates at homebirth because they are based on birth certificate data and birth certificate data is supposedly unreliable.

Because the number of home births in the U.S. is small, the inclusion of … unplanned, unattended home births in the “home midwife” category is likely to have an appreciable effect on the negative outcomes examined here.

Yet today’s post claims just the opposite about the reliability of birth certificate data.

In 2014, 98% of CPM attended home births were planned to be at home, and 99% of CNM attended home births were planned to occur at home.

Which is it Lamaze? Is birth certificate data unreliable, in which case you should not be making claims about the increased popularity of homebirth, or is it reliable, in which case you must acknowledge the appalling death rate at homebirth?

Let’s leave aside the duplicity for a moment and ask a more fundamental question: why are midwives and other birth workers in general, and Lamaze in particular so desperate to promote homebirth when it is a fringe practice rejected by more than 99% of women? Shouldn’t they be supporting women’s choices, not trying to change them?

Homebirth is exponentially more popular among midwives, birth workers and organizations like Lamaze that represent them than it is among women because the benefits of homebirth accrue to the workers and organizations and the risks are carried nearly entirely by women and babies.

• Midwives et al. love homebirth because they profit from it; it costs a fortune (as much as $5000 or more out of pocket).
• They love it because it gives them autonomy to do what they want; there are no safety standards of any kind.
• They love it because it allows them to worship at the altar of “normal birth” the holy grail of natural childbirth advocacy.
• They love it because they bear no responsibility for outcomes. Your baby ends up brain damaged or dead? Don’t look to them for help; they don’t bother to carry malpractice insurance to protect mothers and babies because it cuts into their profits.

Lamaze is desperate to pretend homebirth is popular because it is a special interest lobbying group that depends in large part on convincing women that its prescriptions for childbirth are the ones you should buy.

Lamaze couldn’t care less that homebirth kills babies; indeed they actively try to suppress and discredit the growing body of scientific papers that repeatedly demonstrate the deadly risks of homebirth. They figure you’re gullible enough to believe their crude and dishonest attempts to manipulate you. And if your baby is injured or dies as a result? It’s not their problem; it’s yours.

They’ll add your baby’s birth certificate to their statistics to claim that homebirth is popular, and ignore her death because birth certificates are “inaccurate.”

Don’t get me wrong. I’m a big fan of sexual abstinence for high school students. Most aren’t ready for sexual activity, aren’t careful enough, and don’t properly weigh the consequences.

Despite my strong support of abstinence, I am fervently opposed to abstinence-only sex education.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The ends don’t justify the means.[/pullquote]

Don’t get me wrong. I’m a big fan of breastfeeding, having successfully and happily breastfed 4 children. But despite my strong support of breastfeeding, I am fervently opposed to the Baby Friendly Hospital Initiative for exactly the same reasons I oppose abstinence-only sex education.

What are those reasons?

1. Both programs present personal values and beliefs under the guise of science.

Promoters of abstinence-only sex education insist that their views reflect the scientific evidence — indeed abstinence is safer than even the best protected sexual activity. Lactivists insist that their views are also bolstered by scientific evidence — all things being equal, breastfeeding has slight advantages over formula feeding.

While there may be some scientific support for their claims, they aren’t fooling anyone. The primary purpose of abstinence-only sex education is to promote the personal/religious belief that abstinence is morally superior to sexual activity of teenagers.

Similarly, the primary purpose of the BFHI is to promote the personal belief of lactivists that “good mothers breastfeed.”

2. Both programs use censorship to compel desired behaviors.

More than anything, advocates of abstinence only programs want to hide the ways in which teenage sexual activity can be made safe; they misrepresent and censor information about the effectiveness of condoms and other forms of birth control — how to get them and how to use them.

Similarly, the BFHI promotes censorship, going so far as to muzzle nurses and doctors from discussing the risks and downsides of breastfeeding.

3. Both programs pervert science.

Abstinence only programs routinely misrepresent the science on the effectiveness of condoms in preventing sexually transmitted diseases and the effectiveness of all contraceptives in preventing pregnancy.

The BFHI is in some ways more egregious. It bans formula supplementation despite the fact that judicious formula supplementation has been shown to increase breastfeeding rates. It bans pacifiers despite the fact that there is no evidence they interfere with breastfeeding and a growing body of evidence that they reduce the risk of SIDS (sudden infant death syndrome). It countenances the closure of well baby nurseries and mandated 24 hour rooming in despite the fact that there is no evidence that these practices increase breastfeeding rates and copious evidence that they violate everything we know about the safe care of infants and mothers.

4. Neither program works.

There’s no evidence that abstinence only programs leads to lower rates of teen sexual activity, and precious little evidence (most of it weak and riddled with confounding variables) that the BFHI does anything to increase breastfeeding rates.

5. Both programs deprive people of choice.

Both abstinence only programs and the BFHI are about forcing people to make program approved choices. Want to make a different choice? Too bad for you. The people who run the programs think they are better equipped and more entitled to make choices FOR you than you are yourself.

6. Both programs are punitive.

It doesn’t take a rocket scientist to figure out that teens deprived of accurate information about protecting themselves from sexually transmitted diseases and pregnancy are going to be at higher risk for sexually transmitted diseases and pregnancy. Too bad; they deserved it.

It doesn’t take a rocket scientist to figure out that depriving women of accurate information about the risks of breastfeeding is going to lead to infant hospitalizations for dehydration, jaundice and the permanent injuries and deaths that result. You don’t have to be a rocket scientist to know that when you close well baby nurseries and force women to violate every principle of safe infant sleep, some babies are going to die from falling out of their mothers hospital beds or being smothered by the bedding or their mothers bodies when she falls asleep from exhaustion and narcotics. But apparently brain-damaged and dead infants are a price that lactivists are willing to pay to promote breastfeeding.

7. They violate the fundamental principle of bodily autonomy.

People have a right to control their own bodies!

For teens that means that they have a right to accurate information about preventing sexually transmitted diseases and pregnancy and information about how to access those methods.

For new mothers that means they have a right to decide whether they wish to use their breasts to feed their babies and a right to parent their children consistent with their personal values which may not be the values that lactivists hold dear.

8. Both programs are unethical.

They subvert science, rely on censorship, deprive people of accurate information and violate bodily autonomy.

It’s pretty obvious in the case of abstinence only sex education programs, but while it may be more subtle, it is equally pernicious for the BFHI.

Advocates of abstinence only programs and advocates of the BFHI both think they hold the moral high ground and that the ends justify the means.

They’re wrong on both counts.

From the Book of Ruth (Bader Ginsburg):

Globalization and automation oppressed the blue collar workers and they cried unto the Lord. “We are suffering mightily.” Prosperity had left them, but had promised to return.

When the blue collar workers saw that prosperity delayed returning, they gathered together, and said unto them themselves, “Come, let us make a demagogue with golden hair that shall go before us; as for American values of justice, fairness and equality, the principles that brought us up out of the land of Britain and into the sun, we do not know what has become of them.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]She dwelt in the Court Supreme near the river Potomac: and the children of America came up to her for judgment.[/pullquote]

They said unto each other “Break off the golden principles which are in the ears of your wives, your sons, and your daughters, and bring them.” So all the people broke off the principles of justice, fairness and equality. They took the remains of their golden principles, and fashioned them into hatred of Muslims, hatred of Mexicans, hatred of anyone who did not look just like them, and molded them into Donald, the Golden Calf.

Then they said, “This is your god, O America, that will bringing you out of the land of Despair!”

Lo, Ruth, a prophetess, judged America at that time. She dwelt in the Court Supreme near the river Potomac: and the children of America came up to her for judgment.

Ruth sent and called CNN and The New York Times before her, and said unto them:

Hath not our Founding Father Alexander Hamilton commanded us to avoid faction, saying, “By a faction, I understand a number of citizens, whether amounting to a majority or a minority of the whole, who are united and actuated by some common impulse of passion, or of interest, adversed to the rights of other citizens, or to the permanent and aggregate interests of the community.”

And Ruth said unto to America, “I can’t imagine what this place would be — I can’t imagine what the country would be — with Donald the Golden Calf as our president.”

And the Elders of Media mounted their high horses and cried, “Go, get down. You have corrupted yourself! Only men like Antonin Scalia have leave to flaunt their partisanship. Only the entire Court in Bush v. Gore is allowed to make a mockery of the separation of the Court and the Executive Branch.”

But the prophetess Ruth would not relent:

“Donald the Golden Calf has no consistency about him. He says whatever comes into his head at the moment. He really has an ego. … How has he gotten away with not turning over his tax returns? The press seems to be very gentle with him on that.”

Donald the Golden Calf is an affront to Our Founding Fathers who are wroth in their graves, rending their clothes and hair, crying out, “They have turned aside quickly out of the way in which we led them. They have made themselves a golden idol, and worship it saying, ‘Bigotry is our God, that made America Great and will make it Great again!”

But the prophetess Ruth rallied the people putting them in mind of conservative philosopher Edmund Burke who chastised, “The only thing necessary for the triumph of evil is for good men to do nothing.”

Hear, O America, the words of our Founders, “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the Pursuit of Happiness.”

Yea, we have been vouchsafed the prophetess Ruth, a Justice who begs us to cast down the false idol of Donald the Golden Calf and the evil that he preaches.

We must listen!