It is a curious fact, seldom remarked upon, that all diseases purportedly caused by vaccination share certain common characteristics. Chief among these characteristics is that the cause of the disease purportedly caused by vaccination is presently unknown.

Vaccine rejectionists never claim that a particular vaccine causes heart disease, gall bladder disease, bone abnormalities or any of the myriad diseases for which causes are already known. Vaccine rejectionists always insist that vaccines cause autism, vague “damage to the immune system” or unspecified neurologic injury.

The characteristics of the vaccines themselves may vary (live attenuated, killed), the route of administration may vary (oral, injection), the characteristics of the diseases that they are designed to prevent may vary (everything from smallpox, to polio, to pertussis), but the characteristics of the diseases they supposedly cause are always the same.

Even the purported active agent may vary. The harmful ingredient might be the vaccine itself, the preservative, a contaminant, combinations of vaccines, the list is endless. But the purported harms always idiopathic, are particular dreaded, are typically diagnosed within years of childhood vaccinations, and are perceived to be on the increase.

In “All manner of ills”: The features of serious diseases attributed to vaccination, authors Leask, Chapman and Robbins explain:

The anti-vaccination movement claim many negative consequences from vaccination. High profile controversies have promoted hypotheses that vaccines were responsible for serious and dreaded diseases or disabilities with uncertain causes. Examples include encephalopathy from the pertussis vaccine in the UK in the 1970s and, more recently in the UK, autism from the measles-mumps-rubella (MMR) vaccine and, in France, multiple sclerosis from the hepatitis B vaccine…

Parental anxieties about fearful, mysterious diseases that threaten children foment receptive audiences for such claims. These causal attributions do not rely on the strength of evidence for asserting causal association but share a number of epidemiological and societal features in addition to the uncertain or idiopathic origin of the named diseases…

What are these characteristics?

Idiopathic nature (unknown cause):

Anti-vaccination writings tend to attribute causal connections between vaccination and diseases with idiopathic origin. Autism, asthma, multiple sclerosis, cancers, diabetes and Gulf War Syndrome have all baffled science and draw intense media interest when new claims about their origin arise. Their power comes from the suggestion that danger lurks in the familiar, with the sub-text that vaccines are modern day Trojan horses, promising prevention but disguising hidden threats.

Apparent rise in incidence:

Along with having idiopathic origin, diseases like autism and asthma appear to have increased in incidence in recent decades. Anti-vaccinationists allege this increase coincides with more vaccination.

… [C]onditions like autism lack concrete biochemical or clinical parameters, making them more prone to shifts in diagnostic criteria. The ongoing reappraisal of the diagnostic criteria for the autistic spectrum of disorders over recent decades has led to substantial uncertainty over whether a true increase in incidence exists or whether such diagnostic shifts represent an artifactual increase.

Dreaded outcomes:

Many of the ills attributed to vaccination have lethal, insidious or dreaded consequences. SIDS, autoimmune disorders and developmental disability are a few examples. Such qualitative components of dreaded diseases reduce the acceptability of even minute risks. Anti-vaccine groups or individuals appear to select fearful diseases for attribution to vaccines because of the potential impact of these messages. Dreaded diseases attract news media attention thus increasing the opportunity for the amplifications of the claims…

Temporal relationship to vaccination:

Some of the diseases most often attributed to vaccines become apparent in early childhood when many vaccines are given. In such cases, parents understandably search for an agent of blame, scouring their memories for events shortly before the illness. When parents apply post hoc ergo propter hoc (after therefore because of) reasoning, vaccination can become a compelling causal candidate. Reassurances exonerating vaccines are often met with dismay by those committed to their theory. For parents who may feel guilt, albeit unwarranted, about their child’s problem, vaccination is a graspable external cause…

These features are intuitively appealing to vaccine rejectionists because they do not rely on scientific understanding, but appeal to “common sense.” In the words of sociologist Peter Bearman, writing in the current issue of Social Psychology Quarterly (Just-so Stories: Vaccines, Autism, and the Single-bullet Disorder), vaccine rejectionists tell “just so stories,” stories with simple explanations for complex phenomena.

This explains in part why theories of vaccine rejectionism are evidence-resistant. It seems not to matter how many studies disprove the purported link between vaccines and diseases like autism. Autism is a dread disease, with unknown and complex causes and an apparently rising incidence. It is far more reassuring to pretend that autism has a simple and easily addressed cause, than to acknowledge that it can strike any child, cannot be prevented and cannot be cured.

These findings have implications for the way in which we as a society address vaccine rejectionism. The most straightforward course is to provide more education on vaccination and the science underlying vaccination. When people truly understand immunology, they do not invoke spurious relationships between vaccines and dread diseases.

Unfortunately, not everyone will respond to scientific information. Given the seductive nature of vaccine rejectionism, physicians and public health officials should also address the underlying errors of thought that occur among vaccine rejectionists. Complex diseases do not have simple causes, just because the incidence of a disease is rising and vaccination has risen does not mean that vaccines cause autism, just because a disease is diagnosed after vaccination does not mean that vaccination caused the disease.

Vaccine rejectionists need to heed H.L. Menken’s famous dictum: For every complex problem there is an answer that is clear, simple, and wrong.

For the complex problem of autism and similar diseases, vaccination is the answer that is clear, simple … and tragically wrong.

Who controls childbirth? That’s the title of an insightful, beautifully written piece in the July issue of the magazine Self. As the subtitle explains:

A holistically minded movement says women should—and that doctors are going about it all wrong. An expectant mom [author Taffy Brodesser-Akner] reexamines which side she’s on.

Brodesser-Akner begins by explaining that her current second pregnancy reflects either extreme optimism or profound amnesia since she was so traumatized by her first birth. She had a serious adverse reaction to the medication Stadol, an arrested labor, a variety of interventions, a C-section and a healthy baby.

The author’s “holistically minded” friends and acquaintances were quick to blame her everything that happened:

… [P]eople who hear my story ask about [doulas and birthplans]. Did I consider a home birth? A midwife instead of an obstetrician? How about The Bradley Method, childbirth training designed to promote unmedicated, spontaneous vaginal births? The answer is no…

The women who ask me about my preparations for my first son’s birth—who imply with these questions that I could have prevented what happened to me if I’d been more diligent—are part of an informal movement of women who are trying to “take back” their birth—take it back from the hospital, the insurers and anyone else who thinks he can call the shots…

But that view represents a profound misunderstanding of childbirth and of history.

As Judith Walzer-Levitt explains in Under the Shadow of Maternity: American Women’s Responses to Death and Debility Fears in Nineteenth-Century Childbirth, until very recently, women did not wonder who controls childbirth. They wrote their wills and hoped not to die.

Maternity, the creation of new life, carried with it the ever-present possibility of death. The shadow that followed women through life was the fear of the ultimate physical risk of bearing children. Young women perceived that their bodies, even when healthy and vigorous, could yield up a dead infant or could carry the seeds of their own destruction… Nine months’ gestation could mean nine months to prepare for death. A possible death sentence came with every pregnancy.

Childbirth was deemed a glorious success if both mother and baby survived it and neither was permanently damaged in the process. Those bad old days were not so long ago, but with the striking success of modern obstetrics, the reality of childbirth has receded from women’s lives. Instead of viewing childbirth as the inherently dangerous process that it is, some women pretend that it is controllable. Of course if you’ve convinced yourself that childbirth can be controlled, it is only a small step to demanding that women exercise that control.

Once you believe that you can control childbirth, your expectations can be unlimited. All birth plans are really nothing more than a mother’s expectations writ large. The author of a birth plan expects to have a vaginal delivery, minimal interventions, and no pain relief. That’s possible because the author also expects to have a relatively short labor, an optimally position baby, an optimally sized baby, a perfectly functioning uterus, and a baby who wouldn’t dare suffer from lack of oxygen during the process. And evidently, merely thinking positive will make it so.

The author explains:

I told four doulas my story. One spoke of how I had to “vindicate” my last birth. Another extolled aromatherapy and how it might have helped me dilate. All four agreed on one thing: What had happened was partially the fault of the doctors and nurses, but it mostly happened because I didn’t trust that my body would be able to give birth. “When you trust yourself again,” one said, “you’ll be able to dilate.”

To understand the why such a view is absurd, it is worth examining a related question: who controls pregnancy?

Imagine a woman who writes a “pregnancy plan” specifying her expectations as follows: she expects to get pregnant the first month she tries, will have no morning sickness, will not have a miscarriage, will not get gestational diabetes or develop pregnancy induced hypertension. She will not have premature labor, an excessively small baby or an excessively large one, go into labor on her due date and give birth to a boy.

Crazy, isn’t it? Why is it crazy? Because we know that these things are not under the control of anyone. We know that “trusting yourself” will not prevent miscarriage; fully one in five documented pregnancies end in miscarriage and “trust” has no power to change that. “Trust” can’t prevent morning sickness, pregnancy induced hypertension or premature labor. And, of course, “trust” cannot determine the baby’s gender and no amount of wishing will make it so.

No one asks “who controls pregnancy?” because pregnancy is not controllable by anyone, let alone the mother. And childbirth is exactly the same. No one controls it, so it is worse than pointless to debate who ought to control it, far worse. Pretending that childbirth can be controlled is a recipe for disappointment, because the disappointment stems from failed expectations. And when your expectations are unreasonable, you are bound to be disappointed.

It is a curious fact, never acknowledged by natural childbirth advocates, that the “disappointment” of a C-section or the “failure” to avoid pain medication are not universal responses. As research has shown, both are profoundly dependent on race, class and national origin. A sense of disappointment or failure is almost exclusive to white, middle class women from first world countries. Most women around the world and most women in the US don’t feel disappointment in having a C-section or take away a sense of failure from choosing pain relief.

Indeed, most women have no expectations beyond giving birth to a healthy baby. The route does not matter to them, and the particulars of how labor progresses do not matter, either. They don’t view birth as a piece of performance art, with a predetermined script, and shame the only appropriate response for those who flub their intricately choreographed parts.

Merely asking “who controls childbirth?” indicates a view that ignores reality. For the reality is that no one controls childbirth, not mothers, not doctors, not insurance companies, no one. Just like pregnancy, childbirth is uncontrollable.

How would we react to a woman who blames herself for morning sickness or a provider who counseled that “trusting” pregnancy is all that is needed to prevent a miscarriage. We’d be shocked, saddened and possibly angered that anyone could blame a woman for a her own morning sickness or for the miscarriage of a deeply wanted pregnancy. And if offered the opportunity to comfort such a woman, most of us would assure her that she should not blame herself; it was not her fault; there was nothing she could have done to prevent those things.

Similarly, when natural childbirth advocates insist that “trusting” childbirth will obviate the need for pain medication or will prevent a C-section, we should also be shocked, saddened and possibly angered by the impulse to assign blame when no blame is warranted.

Who controls childbirth? No one, and if we want to protect women from disappointment and a sense of failure we’d do better to acknowledge that reality and stop pretending that wishing can make things so.

Homebirth midwives are constantly carping that they not treated like medical professionals. If they expect to be viewed as professionals, they need to start acting like professionals and they could start in the state of New York.

New York State, like most states, requires written practice agreements between midwives and the obstetricians who have agreed to cover their patients in cases that go beyond the scope of midwives’ practice. Yet, as an article in The New York Times explains, the midwives view this as an unnecessary burden.

Laura Sheperis, president of the New York Association of Licensed Midwives, said that New York State had 800 to 900 practicing midwives, more than any other state, and that about 10 percent of them were having trouble getting written practice agreements, which must be renewed every year.

Therefore, they promoting a bill in the State Assembly that would abolish the requirement.

Not surprisingly, obstetricians are opposing the bill:

The obstetricians’ group has argued that written agreements are needed to keep women safe. Suppose a woman is giving birth in a hospital, attended by a midwife without a practice agreement, and the woman starts to hemorrhage, Donna Montalto, executive director of the New York division of the congress of obstetricians, said Thursday.

“What obstetrician who has never seen the patient, doesn’t know the midwife, and happens to be at home at their son’s baseball game is going to say, ‘Sure, I’ll come in and take care of your patient,’ ” Ms. Montalto said.

The midwives are indignant that they are not going to be allowed to dump their patients in local emergency rooms when complications develop. It hasn’t occurred to them that professionals do not dump mistakes and complications on other professionals without prior agreement.

Imagine Dr. Jones saying to the patient in his office: “Wow, it looks like you’re having trouble breathing, but I’m not a lung specialist. So why don’t you drive to the pulmonologist across town. He’s the expert. I bet he’ll be able to help you.”

Or how about internist examining a patient who has been injured and remarking: “Whoa, look at all that blood. What? You accidentally chopped your finger off. I don’t do stitches, you know, so you’re on your own. I’m sure they’ll be able to help you at the ER.”

It’s not just medical professionals who make arrangements for the care of their patients. Can you imagine a dentist who stops in the middle of a root canal and says: “This one looks too hard for me. I heard that there’s a dental surgeon who works at the local hospital. Just head over there and have him finish it.”

It’s not just care providers who need to make agreements with other professionals in order to count on their cooperation. A caterer plan an elaborate menu for a client and then at the last moment find herself overwhelmed. She’s not entitled to tell the client to call Martha Stewart to take over the preparations just because Martha Stewart is a better caterer. If she expects Martha Stewart to come to her rescue, she must get Martha Stewart’s agreement in advance.

Homebirth midwives whine that they should be free to dump patients in emergency rooms because doctors are supposed to take care of emergencies. But doctors don’t dump on other doctors. They call ahead to tell the emergency room what is going on. They have formal and informal support arrangements with specialists. And when doctors cover for each other, they provide detailed information on complicated patients, so if those patients require care the covering doctor will be prepared to provide that care without wasting time gathering background information.

If homebirth midwives want to provide safe care, they MUST have formal practice arrangements with obstetricians or they should not practice. If they want to be treated like professionals, they must behave like professionals. And that means meeting the standards that an individual obstetrician demands in exchange for coverage. No doctor would cover for another doctor he did not trust. Midwives should not expect that a doctor should cover for a midwife he does not trust.

Homebirth midwives, like all midwives, cannot practice safely without doctors. That is a limitation of their restricted education and restricted clinical experience. No doctor is obligated to fix their mistakes and take care of their complications simply because they don’t know how. Just like a caterer cannot demand that another caterer bail her out, or a dentist cannot demand that another dentist bail him out, midwives cannot ethically demand that an obstetricians bail them out.

Professionals can’t demand back up from other professionals. They have to earn the trust required by such an agreement and they have to fulfill the obligations that any agreement would include. If midwives want to be treated like professionals they need to behave like professionals. Step one would be to recognize their professional obligations to patients and to other providers.

Child centered parenting is a relatively new phenomenon, made possible by the increased security and increased leisure of contemporary life. Where once it was commonplace to send even young children out to work to contribute to the family’s support, childhood is now acknowledged as a protected space.

The change in philosophy has led to a change in the expectations about mothers. After World War II mothers, who were previously held responsible for raising healthy children with good manners, were also tasked with raising emotionally secure adults. This responsibility was seen as requiring a “child centered” approach, giving pride of place to children’s needs over mothers’ needs.

So far, so good. But in the intervening years, the purported responsibilities of mothering have grown dramatically, notably expressed as a commitment to “intensive mothering” also known as attachment parenting. Among those responsibilities is one entirely new claim, the notion that mothers are not responsible merely for physical health, acculturation and emotional security, but are also responsible for a child’s brain development. Whereas there is copious scientific evidence to support assigning the health and socialization tasks to mothers, there is little to none supporting the notion that mothers exercise substantial control over children’s brain development. No matter. An virtual industry has arisen to promote the idea that only mothers can develop a child’s brain.

Canadian sociologist Glenda Wall details the new responsibility in her paper Mothers’ experiences with intensive parenting and brain development discourse.

Over the 1990s and into the current decade government agencies, non-profit foundations, and child-rearing experts undertook to educate parents and the public in general about the importance of spending ample, one-on-one quality time with children in order to stimulate brain development and future brain potential…

The claims being made in the advice literature that has resulted, while presented as fact, have been the subject of some scientific debate. Several authors suggest, among other things, that there is in fact little evidence in the field of neurology to support the claim that ‘extra enrichment’ … has any beneficial effect on future intelligence or success.

Despite scientific critiques however, the brain development advice itself borrows from the language and authority of neuroscience to frame children’s brains as technologically complex machines that need the correct inputs in order to attain maximum efficiency at a later time …

Wall explains how this new responsibility has put increased pressure on mothers.

Parents and caregivers are cast as the engineers and programmers charged with the task of making the correct inputs, and the potential consequences of neglecting to give children what they need in this regard are portrayed as dire…

In other words, there are now new ways for mothers to screw up and bring opprobrium down on themselves. Not only are mothers blamed for children’s poor manners and psychological issues, but they are now held to be at fault if their children are not intellectually superior.

Wall’s critique is insightful, not merely because she explores the lack of evidence for our new found belief that mothers are responsible for optimal brain development. Wall also casts light on the cultural assumptions that buttress this belief: the assumption that we exercise far more control over health and development than we actually do, and the assumption that parents should do more than aspire to intellectual and professional success for children, they should consciously plan for it.

In an age of intensive, and child-centered parenting, the imperative for parents to plan for, control, and manage the lives of their children to optimize their future chances … The institutional practices that have grown up around prenatal education and planning, the promises made in the marketing of educational toys, and the promotion of lessons, and various types of cultural enrichment all contribute to a cultural understanding that parents (and especially mothers) have a duty, and the ability, to control and shape the lives of their children to a very fine degree.

These assumptions have profound implications for mothers and children.

The view of childhood embedded in brain development discourse is certainly one of children as highly malleable, as parental projects full of potential, but potential that can only be activated with appropriate and intensive parental inputs. Children’s current happiness is also emphasized less in this discourse than is their future potential for success.. Rather it is desirable only in so far as it contributes to potential success, and coincides with parental behavior that promotes brain development. At the same time childhood intelligence has become elevated as an important virtue (over and above happiness) and manifestations of it are more likely to be seen as evidence of good parenting.

Hence the moralizing and hectoring that is so common among attachment parenting proponents. Everything they champion – breastfeeding, babywearing, etc. – is not merely a choice, but it is supposedly a demonstration of commitment to raising smarter, more successful children. In other words, mothering has become a competition.

The focus on intelligence in brain development discourse is linked to an implicit endorsement of competition in this regard between children and between parents. As Nadesan notes … the brain development turn in the 1990s accelerated a trend in parental desires to have children who exceed the norm intellectually…

Proponents of attachment parenting need to look carefully at the assumptions underlying their philosophy and stop the hectoring and moralizing that seem to flow from their philosophy.

AP proponents assume that they can enhance the neurodevelopment of their own children and disparage mothers who refuse to optimize the neurodevelopment of their children. Yet there is really no evidence that mothers’ choices enhance neurodevelopment and hence no basis to assume that mothers who make different choices don’t care about their child’s intelligence.

AP proponents assume that children in their role as future adults are in competition with one another and that mothers should strive to give their children competitive advantages. They also assume that parents are in competition with each other and that a child’s achievements are weapons in that competition. The parent with the smartest child wins.

Of course it takes many years to find out whose child is the smartest and no one wants to wait. Because of their implicit belief in their ability to control outcomes, AP proponents don’t bother to wait. They simply compete on the basis that their children are going to be smarter than those of women who make different choices!

Attachment parenting is a parenting philosophy, but it is also a reflection of cultural assumptions and simple human competitiveness. AP proponents believe that they are fashioning superior children and have contempt for those who make different parenting choices. They assume, imply and often flat out assert that mothers who make different choices don’t care to give their children a competitive advantage. It hasn’t occurred to them that many mothers know that AP practices don’t give children a competitive advantage and indeed reject the notion that raising children has anything to do with competition.

Freud would have a field day with these people.

I’m talking about proponents of EC, elimination communication, the goofiest obsession of the many goofy obsessions of the natural childbirth and attachment parenting crowd. They began obsessing about excrement when cloth diapers came back into vogue, arguing that cloth diapers are better for babies and better for the environment. It turns out that neither of these claims are true. Indeed, those busily preening themselves for their prescience in rejecting disposal diapers forgot to include the environmental impact of sanitizing reusable cloth diapers, an impact that may be worse than the problem of landfills containing used Pampers and Huggies.

As is typical of the oneupsmanship characteristic of the NCB and AP types, fretting over what will catch your baby’s excrement is now passe. Proving your maternal superiority now means rejecting diapers altogether in favor of rigorously and continuously observing your baby for any signs of imminent excrement release and immediately holding him or her over a pot to catch the excrement. As Diaper Free Baby explains:

Full time EC’ing families are committed to trying to stay aware of as many of baby’s eliminations as they can. To this end, they may choose not to use diapers or other waterproof backup, as this can muffle a parent’s awareness of when a baby is about to or has already eliminated, and catches may be easier with trainers or underpants.

Full-time EC’ers figure out what works to help them catch eliminations when they are out and about, traveling, or EC’ing at night. They recognize that, like other aspects of parenting, EC progress is not always linear, but they recognize the value of process over results, and have a full toolbox of options to choose from to adjust to each of baby’s developmental milestones and stages.

“EC parents speak out” (not surprisingly since EC is all about them, not about their babies). According to “Rachel, mom to Simon, began EC at birth”:

By the time Simon was three and a half months old he had proven to us that EC is more than just ‘parent training.’ He started signaling his need to pee by making his own imitation of our ‘sss’ cue! We were delighted to be in such two way communication with him.

Evidently Rachel had trouble recognizing smiling and cooing as two way communication.

Sarabeth, mom to Ben, began EC at 2 1/2 months” says:

Doing EC with Ben has completely changed our relationship for the better. Before we started EC, it seemed like he often cried for no reason. With EC, I finally have an important tool to help meet his needs, and he is 100% happier.

There’s nothing like a relationship based on excrement, is there?

And “Megan, mom to Noe, began EC at 8 months”:

Responding to your baby’s elimination patterns provides many wonderful opportunities for you and your baby to communicate and to become more in-tune.

Poor Megan must be sorely lacking quality communication with her baby if she thinks excrement is a highlight.

How does a parent practice EC? First she must assiduously observe her baby to determine when he or she is preparing to “eliminate”:

… [Y]our own intuition will naturally develop around your baby’s elimination. Listening to and trusting your intuition is an important part of parenting. With a little time and practice, it can also become a very reliable tool for anticipating your baby’s elimination… [T]here are a few concrete ways you will know your intuition is telling you that your baby needs to eliminate. For example:

* a sudden thought along the lines of “She needs to pee.”
* wondering or questioning, “Does he need to go?”
* “seeing” or “hearing” the word “pee” or cueing sound (see below)
* “just knowing” that your baby needs to pee
* feeling the urge to pee yourself
* feeling a warm wet spreading over your lap or other area while baby is dry

Then mother and baby must assume the position:

When you think your baby needs to eliminate, hold her in a gentle and secure manner over your preferred receptacle. This could be the toilet, sink, potty, bucket, diaper, tree, or any other appropriate place… Generally, she will be more or less in a deep squat, cradled in your arms with her back to your tummy. The main thing is to keep her secure and to think about your aim ;).

Once your baby is comfortably in position, make a specific cueing sound to “invite” your baby to pee or poop. In most places where EC is practiced culturally, caregivers use a watery sound such as “psss”. This sound, along with a particular position, is used to signal or stimulate the baby’s elimination. When you are starting out, make your cueing sound every time you notice your baby peeing. Within a few days, your baby will associate the sound with the act of eliminating. By practicing EC consistently, your baby will learn to release her bladder at will upon hearing the cueing sound and/or being held in the potty position.

In other words, EC is a form of operant conditioning. The parent attempts to condition the baby to urinate or defecate in response to specific visual and auditory signals. If that sounds familiar, it’s probably because it is. It’s the same way that pets are housebroken. In essence, EC is nothing more than “housebreaking” a baby.

EC is about, by and for parents. The parent wants the baby to urinate and defecate in a pot and attempts to condition the baby to do so. It stands in explicit contrast to a child centered approach to toilet training that elicits the child’s understanding and point of view. In fact, “elimination communication” is a misnomer. It does not involve communication of any kind, since the child is incapable of expressing his views on the subject. It treats children like dogs. Show the dog/baby what you expect, disregard what the dog/baby might prefer, bestow approval or disappointment on the dog/baby until he or she learns to do it your way.

In one way EC is about communication, but not in the way its proponents assert. Adopting EC communicates that the mother thinks her child’s bodily functions can be used as weapons in the war of maternal superiority. It communicates that the mother considers that her need to be au courant within her mothering community takes precedence over her child’s developmental needs. It communicates that the mother thinks that housebreaking her baby is an appropriate form of parenting.

EC explicitly ignores a child’s needs. Instead of allowing a baby to follow the rhythms of its own body, EC implies that urination and defecation must be closely regulated, with the constant parental scrutiny that implies. It conditions the child to believe that even her bodily functions are property of her parents and that urination and defecation must be performed on demand, at the risk of parental disapproval.

Ultimately, it demonstrates the astounding gullibility of certain women and their desperation to claim superiority over other mothers. Proponents of EC are busily housebreaking their babies with the same techniques that they would use for a dog and bragging to each other about it.

French feminist Elisabeth Badinter’s new book atop the French bestseller list is a full bore assault on the concept of the “good mother.” In Le Conflit: la femme et la mère (Conflict: The Woman and the Mother), Badinter argues that the biological essentialism implicit in current notions of motherhood reduces women’s freedom and limits professional success.

According to a New York Times review:

… [Badinter] contends that the politics of the last 40 years have produced three trends that have affected the concept of motherhood, and, consequently, women’s independence. … “[E]cology” and the desire to return to simpler times; second, a behavioral science based on ethology, the study of animal behavior; and last, an “essentialist” feminism, which praises breastfeeding and the experience of natural childbirth, while disparaging drugs and artificial hormones, like epidurals and birth control pills.

All three trends, Ms. Badinter writes, “boast about bringing happiness and wisdom to women, mothers, family, society and all of humankind.” But they also create enormous guilt in a woman who can’t live up to a false ideal…

Ms. Badinter … says that the baby has now become “the best ally of masculine domination.”

Badinter decries a philosophy that effectively relegates a woman to the home, sacrificing her health, independence and autonomy in an effort to live up to a socially constructed ideal:

… The “green” mother, she says, is pushed to give birth at home, to refuse an epidural as the reflection of “a degenerated industrial civilization” that would deprive her of “an irreplaceable experience,” to breast-feed for both ethological and environmental reasons (plastic baby bottles) and to use washable rather than disposable diapers — in other words, to discard the inventions “that have liberated women.”

Indeed, for most of human existence, women’s lives, roles, ambitions and possibilities have been severely limited. Women were defined by their biology. The central role of women’s lives was asserted to be biologic reproduction, in other words pregnancy, childbirth and lactation. The current concept of the “good mother” rests on this essentialism. Hence the inordinate emphasis placed on the physical process of birth, and the few physical aspects of parenting like lactation. The various prescriptions for “good mothering” combine to reinforce the notion that a woman is determined by her biology, that her destiny is to live out that biologic role, that her highest calling is to live out that role, and that the role must be lived in strict adherence to biologic limitations.

This essentialism dictates that women must reject technology (since it has been the traditional purview of men), that women must emphasize the physical aspects of parenting, that women are improved by suffering biologic pain, that any deviation from the biologic constraints of childbirth (having a C-section instead of a vaginal delivery, for example) is anathema and robs a woman of her fundamental reason for being, that a woman’s natural place and the place where she is most fulfilled is within the home, and that parenting requires intensive physical interaction which renders work outside the home virtually impossible.

Natural childbirth and homebirth advocates ought to take a look at their biologic essentialism and question it. Vaginal birth, for example, is only “ideal” if one believes that women allowing themselves to be restricted by biology is ideal. The rejection of technology only makes sense if one believes that women are not capable of understanding, creating and mastering technology, the valorization of ignorance and inexperience (direct entry midwifery as superior to “medwifery”) only makes sense if you believe that being a doctor or a CNM requires a type of thinking that is beyond women.

Badinter posits that the philosophy of the “good mother” has arisen to stem the rising tide of women’s professional success. However, it is worth asking who is threatened by that professional success. Is it men, who fear the loss of their traditional dominance as Badinter implies, or is it women who have not achieved professional success and therefore discount its value?

It is noteworthy that large numbers of natural childbirth and homebirth advocates appear to be drawn from a particular education level. Almost all have high school degrees, some have college degrees, very few have advanced degrees, and almost none have professional degrees or professional careers. Women who lack professional achievements may have fallen back on valorizing biological functions like childbirth and breastfeeding because those are the only “achievements” they are ever going to have. In other words, is this just the latest iteration of the “mommy wars”?

Regardless of its origin, biological essentialism, expressed as an emphasis on the physical aspects of mothering, does serve to limit the autonomy of women. By positing a very specific vision of the “good mother,” proponents of essentialism limit women’s choices within relationships, within the home and even within the professional world. Badinter exhorts feminists to reject biological essentialism.

… I’m convinced that the way feminism has been evolving will lead it to a dangerous dead end. I continue to think that gender equality comes with sharing roles and duties.

The reason that the majority of women reject natural childbirth advocacy and homebirth advocacy is not because they have a fundamentally different view of birth; it is because they have a fundamentally different view of WOMEN. Most women in first world countries reject the notion that they should be defined, limited and controlled by their biology.

Breech vaginal increases the risk of neonatal injury and death, not a lot, but an additional 6 will die and additional babies will be injured out of every 1000 breech delivery. And that’s only if breech vaginal delivery is restricted to a minority of patients who are carefully selected for specific characteristics: baby in the frank breech position at that start of labor (legs folded up against the body, head flexed on the chest and below a certain estimate weight).

In other words, in order to be safe, breech vaginal delivery needs to monitored very closely with ultrasound at the beginning of labor and careful attention to the progress of the labor. Therefore it is foolish to show up pushing in an attempt to avoid a C-section for breech, and it is reckless in the extreme to recommend to a patient that she show up pushing in order to avoid a C-section. Unfortunately, that’s what happened to this blogger’s cousin:

She had an uneventful pregnancy until the very end, when she found out her baby was breech. All along, they’d been having midwife care and were planning a home birth. … [T]hey sought out one of the only doctors in the state who would permit a breech vaginal birth. He did an ultrasound and attempted a version…then told her that she should show up at the hospital at 8cm and that they would allow her to attempt a vaginal birth at that time.

Evidently she and her doctor conspired to circumvent the rules of the hospital by having her show up when it was “too late” to perform a C-section. And she did avoid a C-section, and gave birth to a brain damaged baby as a result.

…She shows up fully dilated, and as she is wheeled into the OR, two feet emerge first. Bad. At that point, the clock starts. Owen’s vitals degrade and it quickly becomes clear that the cord is wrapped around his neck twice and his head is far too big to make it through the birth canal. The Dr. had to reach in and physically pull him out, breaking his shoulder in the process…

… [H]is brain had gone 9 minutes without oxygen. They rushed him to the NICU, and his brain began to swell so they put him on hypothermic treatments. They lower his body temperature and cool his brain for 72 hours in hopes of helping stop the brain injury and give it time to recover….

How is the baby doing now?

… [T]hey removed the body cooler and brought his body back to body temperature. They switched ventilators, and he took a few breathes on his own. All his vitals have stabilized, he is pinking up, gaining weight, and having plenty of wet diapers. But they don’t know if his brain has any activity.

The blogger is having trouble making sense of this:

… It’s just been so hard, because he was a perfectly healthy and perfect baby boy. He has loving parents. But the birth trauma just seems so unfair…

Unfair? No, not unfair, but a known complication of breech vaginal birth. The mother played Russian roulette with her baby’s brain function and she lost, or rather the baby lost.

Was it worth it? The mother avoided a uterine scar and the baby is saddled with serious disabilities for the rest of his life, however long that may be. Had that mother opted for a C-section, either electively or when she showed up in early labor and an ultrasound revealed that the baby was in an unfavorable position, she would not be standing vigil in the NICU hoping that her baby’s brain damage is only “minor” and not severe. She would be home with her new baby bemoaning he “unnecessarean” and whining about how she lost her perfect birth. Instead, she had a perfect birth and ended up with a lifetime of contemplating how she grievously injured her perfect baby.

Amid the hoopla surrounding the publication of the politically motivated Amnesty International Report on maternal mortality and the cynical Ina May Gaskin’s Safe Motherhood quilt memorializing mothers who died of iatrogenic childbirth complications, a curious thing has been happening: American maternal mortality has dropped for the second year in a row.

Maternal mortality, which reached an all time high of 15.1 per 100,000 dropped to 12.7 per hundred thousand in 2007. This strongly suggests that the previous increase in maternal mortality was not driven by lack of access to health care, since access has not increased. Moreover, it completely undermines that claims of natural childbirth advocates like Ina May Gaskin that the rising rates of C-sections and interventions have increased maternal mortality. The C-section rate, and presumably the rate of interventions, has continued to rise while maternal mortality has dropped.

Of course we have known all along that the bulk of the apparent “increase” in maternal mortality represents enhanced data collection, not a change in maternal deaths. Death certificates were revised in 1999 and in 2003 in order to more clearly establish which female deaths were maternal deaths. Prior to those modifications public health experts estimated that a significant proportion of maternal deaths were left uncounted because state documents did not require specifying the relationship of death to any recent pregnancy. The deaths were recorded, but the fact that they may have been associated with pregnancy were not. That’s why I’ve made the line for mortality rate discontinuous.

Could we decrease maternal mortality even further? Almost certainly. The latest statistics do not obviate the need to find ways to reduce maternal mortality. However, successfully reducing maternal mortality involves addressing the real causes. Based on the available data, neither access nor intervention rates appears to be the cause.

Advocates insist that homebirth is safe, but they don’t want anyone to look too closely. Hence the effort to resist coroner’s investigations by claiming that the a baby who dies during homebirth is not a person and therefore its death is not worthy of evaluation

The latest homebirth advocate to make this argument is Australian midwife Lisa Barrett of Homebirth: A Midwife Mutiny. Lisa is a vociferous opponent of Australia’s attempts to regulate homebirth, claiming that women have a “right” to give birth at home. What about the rights of babies injured or killed by homebirth? Apparently they don’t have any rights if the midwife can convince everyone that the baby was born dead.

The case is the typical homebirth tragedy, the kind that demonstrates that “trusting birth” is no substitute for emergency personnel and equipment. According to ABC News:

A coronial inquest has started into a home birth, but the coroner must first determine if the baby was alive.

The inquest heard Tate Spencer-Koch had a partial water birth at her parents’ home in 2007 but died from complications after getting stuck during the delivery.

Deputy South Australian Coroner Anthony Schapel must first determine if the baby was alive at birth and therefore a person under the law, before any full inquest can be held.

The court was told there had to be some sign of life, such as a heartbeat or a breath, once the birthing was completed.

All the ingredients for the typical “trust birth” fatality were present:

homebirth: check

birth pool: check

shoulder dystocia: check

midwife who didn’t anticipate the complication: check

absence of anyone skilled in expert resuscitation: check

Midwife Lisa Barret is claiming that the death should not be a coroner’s case because she was so inept at resolving the shoulder dystocia (40 minutes until delivery of the shoulders) that the baby died before the entire body was born. And because she was incapable of saving the life of an otherwise healthy baby, as opposed to merely rendering it brain damaged, she should escape investigation A news story explains:

… Common law holds a baby is alive, and therefore legally a person, if it has been “fully extruded” from its mother and breathes independently.

A 2005 NSW decision extended that definition to include babies who display a heartbeat or are breathing due to medical intervention.

This week, Mr Schapel was told Tate’s head was birthed 40 minutes before the rest of her body. Midwife Lisa Barrett said Tate never drew breath …

Unfortunately for Barrett, the paramedic reports that the baby did show signs of life:

… paramedic Alice Rowlands said officers detected electrical heart rhythms but no pulse.

Yesterday, Amay Cacas, counsel assisting the Coroner, said those rhythms were enough to justify an inquest.

“We have a fully-developed baby, a mother going into labour naturally and, right up until the head crowns, a good heartbeat,” she said. “Then, 40 minutes later, we have a completely unresponsive child with only the electrical rhythm.

“That rhythm means there is a possibility a heartbeat was present upon full extrusion, albeit weak or slow.”

The coroner accepted that argument:

South Australia’s Deputy Coroner will proceed with an inquest into a baby’s death during a home birth.

He has ruled the child was alive when she was delivered. Deputy Coroner Anthony Schapel ruled there was no evidence that the newborn took a breath or had a mechanical heartbeat when she was born.

But he ruled that electrical activity detected in her heart by ambulance workers after the delivery could be considered “the last vestige of her human existence”.

There are good reasons why a stillbirth should not be investigated in the same way as a neonatal death. However, that should not allow homebirth midwives to escape investigation simply because their mismanagement was so extensive that the baby died instead of being born alive and brain damaged.

In this case, the issue was mooted by the revelation that the paramedic found objective evidence that the baby was briefly alive after the body was born, but similar claims have been made in other homebirth deaths. The law should be amended to require investigation into any homebirth death that occurs in a baby with a normal fetal heart rate at the onset of labor. Otherwise, the more egregious the mismanagement by the homebirth midwife, then less likely it is that the mismanagement will be acknowledged and remedied.