An alternate world of internal legitimacy

I read this paragraph last night and have been thinking about it ever since.

[They]have built an alternative world of internal legitimacy that mimics all the features of the mainstream research world — the journals, the conferences, the publications, the letters after the names — and some leaders have gained access to policy-making positions. Mixing an environmentally inflected critique of [obstetrics] and Big Pharma with a libertarian individualist account of health has been a resonant formulation for some years now, with support flowing in from both the Left and the Right.

This is a description of vaccine rejectionists, but it applies equally well to natural childbirth and homebirth advocates.

The paragraph appears in the paper The Legitimacy of Vaccine Critics: What Is Left after the Autism Hypothesis? by Anna Kirkland, published in Journal of Health Politics, Policy and Law in October 2011.

In both cases, vaccine rejection and NCB and homebirth advocacy, the paragraph provides a succinct explanation for how and why a movement based on pseudoscience has gained a hold on its followers and why those followers appear impervious to the massive amount of scientific evidence arrayed against their claims. What really resonated for me was the description of the alternate world, for it often seems that NCB and homebirth advocates do inhabit an alternate world that has nothing to do with obstetrics, science or statistics.

As I have written countless times, most of what homebirth advocates think they “know” is factually false, yet they don’t realize it. That’s because their alternate world mimics all the features of the mainstream scientific world.


  • Journals: The premier journal of the NCB and homebirth communities is Birth, published on behalf of Lamaze International. Although it is technically a peer review journal, it is made up in large part of papers written by editorial board, which includes such luminaries of the NCB and homebirth movements as Eugene Declercq, Marc J.N.C. Keirse, Michael Klein, and Marian F. MacDorman. Birth is where you send your paper if you can’t get it published in a real medical journal, and it carries little influence in the world of obstetrics, as its impact factor of 1.82 attests. For comparison, the impact factor of Obstetrics and Gynecology is 4.39.

    There is also a plethora of non-peer review journals including The Journal of Perinatal Education, another Lamaze production, and Midwifery Today, one of the many facets of the Ina May Gaskin empire.

  • Conferences: NCB and homebirth advocates love conferences, ranging from meetings of professional organizations like the Midwives Alliance of North America, through single purpose conferences like The Homebirth Consensus Summit, to festivals of ignorance like the Trust Birth Conference. Unlike traditional scientific conferences where all viewpoints are heard on vigorous disagreements aired, NCB and homebirth conferences are heavily censored to remove dissenting views with the express purpose of creating an echo chamber for non-scientific claims.
  • Letters after names: NCB and homebirth advocates try to confer legitimacy on themselves by adding letters after their names. The CPM (certified professional midwife) “credential” is the premier example of a made up designation meant to impress the faithful and to fool outsiders, but there are countless other combinations including LCCE – Lamaze Certified Childbirth Educator, CD(DONA)- certified doula (Doulas of North America), and my personal favorite, CHBE – Certified Happiest Baby Educators.
  • Libertarian individualist account of health: Homebirth advocates like to invoke all sorts of made up rights, like the “birth as a human right,” and the “right” to be attended by the provider of one’s choice. Homebirth advocates decry government interference in birth choices, yet, ironically, spend a great deal of time lobbying for government involvement in paying for favored birth choices and providers.

As Kirkland explains about vaccine rejectionists:

[They] share an internally bounded world in which both individuals and ideas enjoy legitimacy, but undercut the groups’ external legitimacy … (emphasis in original)

NCB and homebirth advocates are shocked that their assertions about childbirth are greeted with disbelief and even contempt by mainstream medical practitioners. Their predilection for conspiracy theories leads them to envision a massive conspiracy among doctors and hospitals, and it simply never occurs to them that they exist in an echo chamber which mirrors their own nonsensical claims back to them.

Kirkland asks a question about vaccine rejectionists that can also be asked about NCB and homebirth advocates:

Under what conditions could we imagine leaders reporting back at a later conference that the right study had finally been done and proved them wrong?

When will we see Ina May Gaskin acknowledge that homebirth increases the risk of perinatal death?

When will we hear the leaders of Lamaze International acknowledge that the Fear-Tension-Pain cycle was made up Grantly Dick-Read and has little to no basis in science?

When will Marsden Wagner publicly acknowledge that there does not exist, nor did there ever exist, scientific data to support his assertion of an optimal C-section rate of 10-15%?

The answer to all three, of course, is never.

NCB and homebirth advocates occupy an alternate world of internal legitimacy, which means never having to face dissent, never having to respond to real scientific evidence, and never having to acknowledge that most of what they promote is factually false.