In light of the fact that the Echo comment system is being discontinued in a few weeks, I’ve been forced to move the comments to a new system. I also took the opportunity to move to a new server, which allows more options in blog design.

The switch is imperfect. Although all the blog posts imported correctly, there are many, many problems with imported comments. I’ve been working for the past week on trying to fix the problems, but I’ve decided to bite the bullet and switch. I intend to continue working to recover as many of the 130,000+ comments that I can. They are not lost; I have them all. The problem is getting them to display correctly in the blog. In addition, sometimes the comments imported successfully and display correctly, but the comment count does not appear. Finally, any comments posted over the weekend were not imported and are missing.

I apologize in advance for these problems and for any problems you have in signing up for the new comment system. Many of you may already be signed up with Disqus and others will be able to sign in with Facebook and Twitter.

Please let me know about any problems you are having with commenting and I will do my best to fix them.

The folks at the Royal College of Obstetricians and Gynecologists should be profoundly ashamed of themselves. They have participated in the creation of new clinical guidance that is fundamentally unethical.

I’m referrering to Making sense of commissioning Maternity Services in England, produced in collaboration with the Royal College of Midwives and the National Childbirth Trust. It is fundamentally unethical because it focuses on process instead of outcome. It reads like a full employment plan for midwives and childbirth educators, since that is basically what it is.

The chief goal of any maternity service or any maternity provider is simple and straightforward. The chief goal is to deliver healthy babies to healthy mothers. PERIOD. Anything else is untterly inappopriate and smacks of self-interest, not concern with patients. Indeed, this document is an object lesson in the venality and self-absorption of contemporary advocates of natural childbirth. It is in their interest to increase their employment options, but increasing employment options for a particular group has no place in a document that purports to be about patient care.

To understand what I mean, try a thought experiment:

Imagine if a group of lawyers, paralegals and casket manufacturers called for replacing death row appeals with paralegal counseling on will preparation for the condemned man. And for good measure imagine that they recommended withholding legal services of many people who have been charged with murder entirely on the grounds that they are probably guilty anyway.

Sounds reprehensible, right? But it’s no different than the document in which the RCOG participated.

• Both promote saving money above improving outcomes.
• Both promote responses that are based on cost rather than on efficacy.
• Both promote replacing more highly trained professionals with extenders who cost less and are capable of less.
• Both take no account of the needs, wishes and outcomes of the receivers of services.
• Both are transparent attempts to line the pockets of the extenders and others who benefit when the patient loses services.
• Both are fundamentally unethical because they replace the best interests of recipients of services with the economic interests of government, extenders and providers of ancillary services.

It would be one thing if the British maternity system was a shining beacon of best outcomes. Then, perhaps, it might be reasonable to consider ways to provide the same outstanding outcomes with less money. That’s not the case in the UK. Mortality rates are average to high (London mortality rates in particular, are unacceptably high and rising) and multiple hospital systems are facing multiple massive lawsuits precipitated by deaths that occurred when midwives insisted on managing patients who should have been transferred to doctors.

The Hippocratic oath covers this type of situation:

Primum non nocere. First, do no harm.

The RCOG seems to have forgotten that Hippocrates was referring to the patients, not to the economic interests of midwives, childbirth educators, or the government.

Addendum: For more on this subject, check out Pauline Hull’s press release

On its website, Midwifery Today features a timeline entitled The History of Midwifery and Childbirth In America. The timeline extends from 1660 to the late 1990’s. It contains interesting tidbits of information about childbirth practices, interspersed with general historical events. It seems quite comprehensive with the exception of one curious omission. It barely mentions mortality statistcs.

To my mind, the history of childbirth is a continuing effort to master its inherent dangers. Childbirth is and has always been, in every time, place and culture, one of the leading causes of death of young women and the leading cause of death of newborns. Indeed, the primary purpose of a childbirth attendant is to increase the chance that the mother will live, at least, and hopefully the baby will live too.

The secondary purpose of a childbirth attendant is to comfort the mother as she endures the excruciating pain of labor. The history of childbirth has also been a continuing effort to master the pain of childbirth. That’s another curious omission from the Midwifery Timeline. It makes no mention of chloroform, general anesthesia or epidurals, arguably among the most important advances in the history of childbirth.

I suspect that the reason for these glaring omissions reflects the direct entry midwifery obsession with process. The outcome, whether or not the mother or baby lived, is virtually irrelevant.

Perhaps another reason why the timeline is silent on the issue of mortality statistics is that they illustrate the spectacular success of modern American obstetrics. For hundreds of years midwives presided over childbirth and had almost no impact on the appalling rates of maternal and neonatal mortality. It was only with the advent of modern obstetrics that the mortality rates began to fall.

I thought it might be interesting to look at the statistics that the Midwifery Today timeline left out. I took as the starting point the timeline itself. It faithfully chronicles the movement of birth from the home to the hospital starting in 1900. In every decade, it reports the ever increasing percentage of hospital births. Yet it is silent on massive declines in maternal and infant mortality that occurred simultaneously. For each point in the timeline where the percentage of hospital deliveries is mentioned, I looked up the corresponding maternal and neonatal mortality rates. The above graph is the result.

As the percentage of births in the hospital rose, the maternal and neonatal mortality plunged. The graph is a powerful way of demonstrating that the association is dramatic. During the 1900’s, for the first time in history, using the tools of modern obstetrics, the terrible inherent dangers of childbirth were mastered. Could we do even better? No doubt, and the search continues to make birth even safer than it is today. As Dr. Atul Gawande wrote in his New Yorker article (The Score, How childbirth went industrial), “Nothing else in medicine has saved lives on the scale that obstetrics has.” The graph makes that very clear indeed.

Infant and maternal mortality rates abstracted from CDC on Infant and Maternal Mortality in the United States: 1900-1999. Although neonatal mortality is a much better measure of obstetric practice, neonatal mortality figures were not collected in the earlier part of the century. Therefore, infant mortality statistics are used as a proxy, albeit imperfect.

Homebirth, and natural childbirth advocates insist that “Peace on Earth Begins With Birth.”

That’s not what my research shows. I’ve discovered an astounding fact about natural childbirth and attachment parenting: both are risk factors for tyranny, mass murder and a variety of other ills.

Consider:

Of history’s greatest tyrants, men such as Hitler, Torquemada, Henry VIII, Attila the Hun, etc., nearly all were born vaginally. The only potential exception is Julius Caesar, reputedly born by way of the eponymous Caesarean section.

Almost all of history’s greatest tyrants were breastfed … exclusively.

The long term effect of giving birth without pain medication is dreadful. 100% of the children born to women who gave birth before the advent of anesthesia in the mid-nineteenth century are now dead.

Vaginal birth is a risk factor for Communism: Marx, Engels, Lenin, and Stalin were all born vaginally.

Breastfeeding is a risk factor for plague. Nearly 100% of people who died of the Black Death were breastfed.

Attachment parenting played a major role in imperialist expansion in the US. Fully 100% of the invaders who displaced the Native American population of this continent were born vaginally. Moreover, fully 100% of the Native Americans who were unable to resist the advent of the invaders were breastfed.

Breastfeeding is a risk factor for violent behavior. Almost all Viking marauders were breastfed.

Nearly all slave-holding Americans, plantation owners and the entire Confederate army were born vaginally.

Not a single Crusader was born to a woman who had an epidural in labor.

Vaginal birth is a risk factor for anti-social behavior. Roman emperors Caligula and Nero, as well as Jack the Ripper and Lizzie Borden (who committed patricide AND matricide) were born vaginally.

Breastfeeding leads to transmission of disease. Typhoid Mary was breastfed.

Hospital birth promotes technological progress. Desk top computers, iPhones, Skype and Twitter did not exist until the proportion of US births occurring in hospitals rose above 90%.

What is the cause behind these incontrovertible facts?

First, we’ve known for centuries that deep seated prejudice is “imbibed with mother’s milk.” I’ve never heard of anyone imbibing hatred with Similac, so the obvious solution is to promote formula feeding.

Second, as Dr. Michel Odent has insisted, oxytocin is the love hormone and some women clearly don’t have enough love. The solution is oxytocin supplements. Fortunately, pitocin has the exact same chemical composition of oxytocin, so it seems clear that, to be on the safe side, all labors should be induced or augmented with pitocin.

Finally, epidurals ought to be mandatory in labor. The mothers of the greatest tyrants in history gave birth without pain relief and look what happened as a result.

It’s time to acknowledge that “Peace on Earth begins with Interventions in Birth!”

This piece is (obviously) satire.

Republican Rep. Todd Akin of Missouri reminds me of certain natural childbirth advocates.

When asked whether he opposes abortion in cases of rape, Akin declared:

If it’s a legitimate rape, the female body has ways to try to shut that whole thing down.

Akin ought to win an award for cramming the largest amount of ignorance into the fewest possible words.

I don’t know where he got the idea that women can turn off ovulation or prevent conception or prevent implantation or a fertilized egg, but I do know where he got the idea that not all rapes are “legitimate.” It comes from an old line of legal “reasoning” that claims that most women who are raped were “asking for it,” were tramps, or actually enjoyed it. Evidently, “legitimate” rape occurs only when a virgin (or a married woman who has only had sex with one partner, her husband) is assaulted by a stranger. Oh, and for most of American history the woman has to be white, and the man is preferably of a different race.

Fortunately, almost everyone recognizes that distinguishing “legitimate” rape from any other form of rape is morally abhorrent and downright outrageous.

Why does this remind me of certain natural childbirth advocates? Though not nearly as morally egregious, natural childbirth advocates have a bad habit of trying to distinguish “legitimate” births for all other births.

Consider this fairly representative comment thread from Mothering.com:

C section mamas – do you still say you “gave birth”?

… I want opinions from c section mamas on this because I was on yahoo and one lady was throwing a *bleep* fit at how some women who have had c sections will say that they “gave birth”. She was really irate because she doesn’t think that c section mamas have the right to say that they “gave birth” because they didn’t physically push the baby out of their vaginas.

The replies included:

Honestly, I don’t feel like I gave birth. I remember thinking it sounded so absurd after DD was born when someone would say to me “You need to take care of yourself too, you just gave birth!”… I’ve talked to other friends that have had c-sections and they feel the same way. There’s a baby there. And you were pregnant and the baby was inside you. But there is a huge disconnect in your brain about how the baby got here

And:

… I don’t say that I “gave birth”, but I say that I had a baby or that my babies were born.

And:

I dont say i gave birth, i say he was born, i dont feel i gave birth, I laboured, but i didnt birth him, the doctor with the scalpel did

In other words, according to certain natural childbirth advocates, only a vaginal birth is a “legitimate” birth.

Their “reasoning” is just as pathetically flawed as that of Rep. Akin. Tragically, there is no single “legitimate” way to be raped. Similarly, there is no single “legitimate” way to be give birth.

In both cases, those who choose to distinguish “legitimate” from other forms have an ulterior motive. In the case of Rep. Akin, his motive is to force his view of moral behavior on everyone else. In the case of natural childbirth advocates, it is to force their idiosyncratic view of birth on other women.

Hi, I’m Jen, lay nuclear physicist. I just returned from the gynecologist and I am so pissed off.

I went for a routine annual visit and exam and I am completely fed up with the way that gynecologists pathologize menstruation.

Here’s what happened:

As soon as I got into the exam room, the nurse asked me when was the first day of my last menstrual period. I couldn’t give her an exact date because I’ve only had my period 5 times in the last year (just a variation of normal).

After my pelvic exam (which was totally unnecessary since it turned out to be fine) the gynecologist started in with all sorts of scare tactics. Instead of accepting that periods are not library books — they’re not due on a certain day, he insists that I am at risk for something called polycystic ovarian syndrome (PCOS). That’s right; I’m supposed to believe that my body is defective!

This is the difference between the medical model of menstruation and the lay menstrual midwifery model. Menstrual midwives are trained in holistic care and they know that women are PERFECTLY DESIGNED to menstruate. Sure, I only get 4 or 5 periods a year, but my body is just as perfectly designed as the next woman. Women have been having periods without the help of gynecologists for thousands of years and we are still here.

And yes, I do have painful periods menstrual rushes, but I am not going to dull the joy of my body working perfectly just to get rid of the pain rushes. Even if my periods were painful, it would be pain with a purpose and if I had pain, I’d hire a menstrual doula to support me as I writhed in bed.

The doctor wants me to have blood drawn for hormone tests, but I refused. I know what would happen if the results came back abnormal; I’d have to have more blood tests and maybe even interventions into my menstrual cycle. Once you let gynecologists start the cascade of interventions, who knows where it will end? If I don’t let him do the test, then he can’t tell me my hormone levels are abnormal.

Even though I refused the testing, the gynecologist wouldn’t let it drop. You are not going to believe what he said next. He actually commented on the amount of body hair that I have. At first I thought I hadn’t heard him correctly. All I could think was: My GYN said WHAT??!!

And that’s not the worst of it. I know I am overweight, but he actually pointed it out and claimed that PCOS can lead to excessive weight gain.

Then he started in with the typical scare tactics claiming that women with PCOS are at greater risk for high blood pressure, diabetes, and endometrial cancer. But the worst was when he played the “no baby card.” If I don’t diagnose and treat PCOS, I might be unable to conceive and end up with no baby! He thinks he can scare me but I know better.

First of all, I could have periods every 28 days if I wanted to. All I have to do is practice menstrual affirmations (I will get my period; I am made for menstruation; My body is not broken.) and get a cranio-sacral adjustment. Oh, and I could eat more kale.

Second, I have a friend whose gynecologist told her that she might have PCOS, but when the blood tests came back, they were normal. He made her worry for nothing. I don’t want to go through that.

Third, my gynecologist, like all gynecologists, is in the pocket of Big Pharma. He just wants to prescribe some sort of medication like birth control pills to regulate my period. I bet he makes a thousand dollars every time he writes a prescription for the Pill.

Fourth, my gynecologist wants to regulate my period for his own convenience. It’s easier for him if I have regular periods and he doesn’t want to be bothered by my extremely heavy cycles, my persistent anemia and by the fact that I complained that I have been trying to conceive for three years without success.

Well, I’ll show him! I’ll get pregnant even though I have only 4 or 5 periods a year. Then I’ll be able to relax. Surely even gynecologists know that women are perfectly designed for pregnancy and no one has ever had a miscarriage.

This piece is satire.

Compare and contrast:

Mother #1

… So yes, I had preeclampsia and I needed to have my baby in the hospital just in case something went wrong.

This isn’t the part of my story that makes me angry.

The diagnosis does not make me angry.

Ok I am angry about my diagnosis, but that’s my placenta’s fault not the hospitals.

I am angry with the hospital because of the cookie cutter way in which they treated the diagnosis of preeclampsia.

Is all they saw was a woman showing signs of preeclampsia who was 38 weeks pregnant, full term in their eyes. And as far as they were concerned I needed to deliver that baby right then and there, not 2 days from then, not 12 hours from then, right then.

They could see no reason to compromise. No benefit to staying pregnant even a day longer…

They could not accept that I was not trying to put me or my baby at risk by refusing an immediate induction but that I needed ONE night to both change gears and accept what was happening mentally AND GET SOME FUCKING SLEEP so that I could come to the hospital refreshed and ready to have a baby, not so exhausted that I don’t know how I even found the energy to do what I did.

I had even signed all the leaving Against Medical Advice paperwork that they shoved in my face so I could not sue them should I start seizing in those 12 hours that I was away from the hospital. But they couldn’t let it go.

And the fuckers bullied me into that induction by calling me an hour after I left to tell me my bloodwork was changing. Had I not been so exhausted, had I not already been fighting them for 2 days, had I just been in a better place mentally I would have questions WHAT was changing and what it meant.

But I was tired of fighting and I gave in….

And that, my friends, is why I desperately tried to stay out of the hospital system while I was pregnant. Why I so desperately wanted a homebirth. Why I was so upset with the way the induction was handled.

Everyone says that once you have the baby it doesn’t matter how he came into the world because you got a healthy baby in the end.

I disagree.

Mother #2

… This pregnancy i switched from an ob practice to a midwife practice. 1st appt with them was everything i was looking for. But when i found out i had GD they act like they couldn’t let me vbac at all. One midwife the one i liked scheduled my c section for me without me and it’s on my due date. Another midwife said i can’t go past 39 weeks.

Then:

So im 36.5 weeks with GD. And my chances of vbac are slowly decreasing. Im currently on meds only at bedtime to controll my fasting numbers. They might not let me go past either 39 or 40 weeks i have to go into labor by then or its a rsc for me.

But at 39 weeks and 6 days:

My angel passed the day before i was suppose to get my c section… I was high risk with GD so im mad at the fact they didnt induce me earlier before she passed…

And, inevitably:

I’m devastated i know this could’ve been prevented.

So, natural childbirth advocates, what’s an obstetrician to do when confronted by a patient with risk factors for a serious complication? Please tell me because I and other obstetricians want to know.

Natural childbirth advocates have been caught, proverbially, with their pants down. After making the specter of posttraumatic stress disorder a centerpiece of their efforts to promote natural childbirth, they are shocked to discover that it is natural childbirth itself that may cause post traumatic stress disorder (PTSD) after birth.

Hypocrites take your mark! Set! Go!

The first hypocrite around the bend is Penny Simkin, physical therapist, childbirth educator and all around popularizer of the notion that modern obstetrics causes PTSD and natural childbirth prevents it.

Not surprisingly, she is now struggling mightily to discredit a new study that claims that unmedicated childbirth is a cause of posttraumatic stress disorder after birth. Step 1: discredit the paper.

The paper is Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion. The impact of pain on symptoms of posttraumatic stress disorder is just one of many findings noted in the study:

The prevalence of post-partum PTSD was 3.4% (complete PTSD), 7.9% nearly complete PTSD, and 25.9% significant partial disorder. Women who developed PTSD symptoms had a higher prevalence of “traumatic” previous childbirth, with subsequent depression and anxiety. They also reported more medical complications and “mental crises” during pregnancy as well as anticipating more childbirth pain and fear. Instrumental or cesarean deliveries were not associated with PTSD. Most of the women who developed PTSD symptoms delivered vaginally, but received fewer analgesics with stronger reported pain. Women with PTSD reported more discomfort with the undressed state, stronger feelings of danger, and higher rates of not wanting additional children.

None of these findings is unexpected. Indeed, there is a substantial amount of research suggesting that labor pain can be a source of trauma:

It has been suggested that the intense experience of pain can lead to an event perceived as traumatic. In their study of individuals injured in traumatic events, Schreiber and Galai found that the sensation of pain rather than the injury
itself caused the perception of a traumatic event. Melzack reported that the experience of pain in childbirth is associated with traumatic memories long after the birth itself, with others reporting that many prefer to have the next birth by cesarean
section due to the memory of painful childbirth even 3 years after the birth [6]. In a survey of 28 women requesting cesarean section, all had memories of a traumatic birth, including 50% who had an emergency cesarean section. The repercussions of post-traumatic symptoms after childbirth are varied, with some reporting avoidance of sex and fear of having further children.

Simkin is already on record insisting that it is “suffering” not pain that leads to PTSD.

She discounts the benefit of pain relief in labor:

An enormous industry exists in North America to manufacture and safely deliver pain relieving medications for labor. Hospital maternity departments are designed with elimination of pain as a primary consideration, complete with numerous interventions and protocols to keep the pain management medications from causing serious harm. When staff believe that labor pain equals suffering, they convey that belief to the woman and her partner, and, instead of offering support and guidance for comfort, they offer pain medication…

What an amazing coincidence that Simkin disparages the service that she is incapable of providing (pharmacologic pain relief) and instead offers the service that she can charge money for (doula services).

For Simkin, the implication is straight forward. Pain does not cause PTSD. Therefore, anesthesiologists cannot prevent PTSD. It is “suffering” that causes PTSD and doulas can relieve “suffering.”

And what is suffering?

Simkin insists that it is “suffering” that leads to PTSD and suffering is whatever the sufferer says it is:

One’s perception of the event is what defines it as traumatic or not. As it pertains to childbirth, “Birth trauma is in the eye of the beholder”, and whether others would agree is irrelevant to the diagnosis.

Unless, of course, the beholder says it is unrelieved pain that is traumatic.

That’s why Simkin is trying to discredit the new paper. The study found that untreated pain is among a variety of factors associated with PTSD after childbirth:

There were more natural births (noninterventional) in the PTSD group than in the control group. A significantly smaller number of women who developed PTSD symptoms received analgesia during delivery compared to the control group (chi-square P = 0.000).

Moreover, the extent to which women were supported during labor made no difference:

No relationship was found between the development of PTSD symptoms after childbirth and being accompanied by someone during labor or the extent to which the accompanying person gave support.

But, but, but … these results are unacceptable. Simkin insists that the paper actually showed that the etiology of PTSD after childbirth is complex and multi-factorial:

Furthermore, these women had numerous other factors that are associated with PTSD. Before accepting natural birth as the major cause of PTSD after childbirth, please check the … other factors, which were as prevalent, or nearly so, as lack of pain relief as a cause of PTSD… [F]or example, 80 percent of the women with PTSD also had discomfort with being undressed; previous mental health problems in previous pregnancy or postpartum; and complications, emotional crises, and high fear of childbirth in their current pregnancy. All these factors have been reported in many studies to be instrumental in the development of PTSD.

Yes, all these factors have been reported to be involved in the development of PTSD, suggesting that characteristics of the women who develop PTSD are more important than their actual experience in labor or their perception of what caused the trauma. Trauma isn’t in the eyes of the beholder, it’s in the psychological disposition of the beholder.

Hence the hypocrisy. The papers that Simkin has cited for years in her assertion that it is the modern obstetric experience that leads to PTSD found exactly the same thing that this new paper found: that PTSD reflects the predisposition of the patient, not her experience. Simkin ignored those findings and insisted that childbirth educators and doulas could prevent PTSD by changing a woman’s experience by:

• Recommend that the woman/couple learn about labor, maternity care practices, and master coping techniques for labor…
• Recommend a Birth Plan…
• [A] process in which she was respected, nurtured, and aided…
• [N]o supportive person wants a woman to have pain medication that she had hoped to avoid. A previously agreed-upon “code word” provides a safety net for a woman who is highly motivated to have an unmedicated birth.

Simkin can’t have it both ways. Either the etiology of PTSD after childbirth is complex, multi-factorial, and affected by psychological predisposition or it isn’t.

I happen to think she is right that this is precisely what the new paper shows, but it is also precisely what everything else she has been citing in support of her own theories shows. PTSD after childbirth has more to do with the patient than her experience. Hence we cannot conclude that unmedicated childbirth leads to PTSD, but we also cannot conclude that a poor childbirth experience leads to PTSD or that childbirth educators and doulas can prevent it.

In light of yesterday’s post about “birth defeat,” I thought it might be worthwhile to revisit the issue of whether “trauma” is in the eye of the beholder or whether it is reasonable to expect people to put disappointments in perspective. I’ve written several times about feelings of depression, inadequacy and even trauma regarding the issue of weight.

It seems to me that being “traumatized” by a birth that did not go exactly as planned is no different from being “traumatized” by not reaching an idealized weight. There is nothing wrong with a little disappointment, but reacting as if it is a defeat represents a complete loss of perspective on what is important.

All “trauma” is not equal, and not everything that is viewed as “traumatic” by specific individuals is worthy of that designation.

Many American women are “traumatized” by being unable to meet an idealized weight and dress size. Just like there are some women who think that an unmedicated vaginal delivery is an “achievement”, there are other women who think that wearing a size 2 is an achievement. We live in a society that venerates women who wear a size 2, looks down on a woman who is a size 12, and despises and feels sorry for women who are a size 22.

But women’s feelings about weight are not objectively “true.” They are a product of cultural stereotypes, and as such, should be questioned. Similarly, women’s feelings of “trauma” over a C-section are not objectively “true,” either. They are also a product of cultural stereotypes, in this case the stereotypes created by NCB advocates.

Women who are a size 2 aren’t inherently better or superior in any way to women who are not. While the individual woman may have bought into the cultural stereotype of what a woman “should” look like, and while she may diet obsessively to get there and stay that way, and while she may feel “empowered” and happy because she is a size 2, that does not mean the rest of us should agree with her. It also does not mean that the rest of us should aim to be a size 2, should feel empowered by being a size 2 or should sympathize with her over the disappointment of having to wear a size 4.

Women who have an unmedicated vaginal birth aren’t inherently better or superior in any way to women who don’t. While the individual woman may have bought into the NCB stereotype of how a woman “should” give birth, and while she may plan obsessively to follow the stereotype, and while she may feel “empowered” and happy because she has an unmedicated vaginal birth, that does not mean the rest of us should agree with her. It also does not mean that the rest of us should aim to have an unmedicated vaginal birth, should feel empowered by having an unmedicated vaginal birth or should offer sympathy over the “disappointment” of having a C-section.

There are many, many women who are depressed about their weight. I would guess, in fact, that there are far more women depressed about their weight than their birth experience. That’s not surprising, because the obsession with being thin reflects the values of the dominant culture, while obsession with unmedicated childbirth reflects the values of a small subculture.

What is the appropriate response to a woman who feels depressed about her weight? Is being depressed the appropriate response to being a size 4 or 6 or 8?

If a woman sought psychotherapy for being a size 4 or 6 or 8, should the therapist counsel her that the disappointment of being size 6 instead of size 2 is a reasonable response, that her sense of self worth should be dependent on her weight and that the best thing to do would be to make determined efforts to become a size 2 in the future?

Or might the therapist suggest instead exploring what being thin “means” to this woman? Might the therapist suggest questioning the cultural stereotype that thin=good woman? Might the therapist might suggest that the depression over being a size 4 or 6 or 8 is actually not about weight, but about feelings of low self esteem that affect the woman’s entire life, but are currently expressed through disappointment about weight?

What is the difference between being “traumatized” about not matching the cultural ideal of being a size 2 vs. not matching the subcultural ideal of having a unmedicated vaginal delivery? The woman who is depressed about being a size 4 has “chosen” to adopt the value of being thin every bit as much as the woman who has “chosen” to adopt the value of venerating unmedicated childbirth. It is based on what she has seen, what she has read, what she believes is important.

Does that mean that if we do not sympathize with her all too real feelings of self doubt or even “trauma” that we are mean people who trivialize other people’s feelings? Or does it mean that we are demonstrating an appropriate response to obsession with cultural stereotypes that have no objective validity and ought to be questioned?

Adapted from a post that first appeared on Homebirth Debate in January 2008.