Sometimes, the most mundane practices can give us insight into our deepest beliefs. Such is the case with marketing of products. For example, the current obsession with “green” products may or may not improve the environment, but it does tell us what ideas have captured the attention of the American public.

Marketing involves various tactics. The best tactic is to market based on the true virtues of the product. So, for example, if a laundry detergent is the best at removing grass stains, you can market it as “best at removing grass stains” and that will attract certain buyers.

Of course, not every product has virtues that are worth marketing. So often times marketers resort to other strategies, appealing to instincts and preconceived ideas of potential buyers. Take Cheetos for example. There is absolutely nothing nutritionally redeeming about Cheetos. No one is going to be able to market them as “good for you”. So the marketers did the next best thing. Appealing to an inate belief among buyers that “natural” is better, they’ve now brought out a product called “All Natural Cheetos”. Cheetos are just as bad for you as they ever were, but the marketers have blunted this perception by appealing to unconscious beliefs about natural products.

How did the marketers of All Natural Cheetos hit upon this strategy? In Packaging as a Vehicle for Mythologizing the Brand in the journal Consumption, Markets and Culture, Knaizeva and Belk identify “Myths of the World in the Past” that influence the “stories” found on packaging.

Packaging narratives depict the modern world as a deeply distorted reflection of what it originally was – the garden before agro-chemical technology. While the values of the past include family, tradition, authenticity, peace, and simplicity, the current era is associated with broken family ties that need to be restored, scientific “advances” that pose threats, constant pressure on the well-being of humans, and unnecessary complexity in everyday life.

The authors pay particular attention to the concept of “naturalness”:

Naturalness appears as a rich emotional construct that connects with positive contemporary images of nature… People do not want to remember that nature can also be destructive as in deadly hurricanes and poisonous mushrooms … In a natural health context, Thompson also finds nature to be a positively framed powerful mythic construction; and his informants attribute magical, regenerative powers to nature. They firmly believe that aligning with what nature has to offer for one’s health lets them assert control over their lives and bodies versus losing control by being complicit in a scientized medical system.

We can see here the spiritual treatment of nature that … pervades alternative medicine, vegetarianism, voluntary simplicity philosophies, the natural childbirth movement, and dietary beliefs linking food to health with a resulting reverence for magical, harmonious, whole, natural foods free of herbicides, pesticides, and genetic modification. These beliefs are in turn linked to puritanical American beliefs that we must take responsibility for our bodies, work hard to perfect our health, cleanse our environment and system of pollutants, and choose the foods that will make us healthy…

Ultimately, these myths are joined in service of the over-arching myth, that of the “enobled and empowered”

consumer:

… [A]ll the significance attached by storytellers to the products transforms otherwise powerless consumers into the powerful marketplace players. As a result, newly empowered consumers can temporarily escape imposed world conditions by shaping their personal myths and servicing their individual lives. Thus, myths of the past are meaningfully used to serve the present.

Marketers exploit these myths precisely because they have so much resonance for consumers. It is these same myths that undergird contemporary health fads such as “alternative” medicine, “natural” childbirth, and fears of an obesity epidemic.

 the myth of idealized nature
the myth of the idealized past
the myth that are health choices will necessarily make us healthy
the myth that making the prescribed choices empowers people

Unfortunately, those myths are nothing more than wishful thinking. There is no such thing as “alternative” health, “natural” childbirth bears no resemblance to childbirth in nature, and healthy choices like eating and exercising to be thin do not necessarily make us healthy.

Whether we choose to respond to these marketing ploys is far less important than examining the assumptions that underlie them. Sometimes our most accepted beliefs, the ones we take for granted, have no basis in fact.

There’s a new wrinkle in the healthcare debate. It’s called “paying doctors for performance” commonly abbreviated as P4P.

On the face of it, who could object to P4P? A doctor will be paid based on his performance. The better the quality of medicine he practices, the more patients he saves and improves, the more he will be paid. Oh, wait, that’s not what P4P really means. According to proponents, in P4P, the physicians who will be most highly compensated are “physicians who are perceived to be delivering higher quality for lower cost ….”

I am a passionate advocate of breastfeeding and breastfed my four children. Nonetheless, I am disturbed at the way that breastfeeding is wielded by breastfeeding activists (lactivists)  to criticize other women. New studies confirm that many of the purported benefits of breastfeeding have been grossly overstated. The scientific literature shows that while breastfeeding has real benefits, the benefits are actually quite small.

Lactivism is just one aspect of the growing cult of “total motherhood”.  The article Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign by Joan Wolf describes how lactivism is a  facet of a new moralism that has redefined the role of the mother to promote the personal preferences of a select group of women.

… [T]otal motherhood obligates mothers to be experts in everything their children might encounter, to become lay pediatricians, psychologists, consumer products – safety inspectors, toxicologists, educators, and more. Mothers are expected not only to protect their children from immediate threats but also to predict and prevent any circumstance that might interfere with putatively normal development. Total motherhood is a moral code in which mothers are exhorted to optimize every dimension of children’s lives, beginning with the womb, and its practice is frequently cast as a trade-off between what mothers might like and what babies and children must have. When mothers have wants, such as a sense of bodily, emotional, and psychological autonomy, but children have needs, such as an environment in which anything less than optimal is framed as perilous, good mothering is construed as behavior that reduces even minuscule or poorly understood risks to offspring, regardless of potential cost to the mother. (my emphasis)

Breastfeeding has particular significance within this newly defined moral universe:

Breast-feeding is an integral part of the total motherhood discourse. Dubbed “America’s pediatrician” and credited with coining the term “attachment parenting” — which promotes mothers’ constant physical and emotional attachment to their babies — Dr. William Sears is perhaps the country’s best-known breast-feeding advocate. Virtually all of his advice to women takes as its point of departure babies’ needs and the necessity of breast-feeding, and mothers’ well-being is addressed largely through these demands… Sears contends that breast-feeding is better for a baby’s brain, eyes, ears, mouth, throat, kidneys, appendix, urinary tract, joints and muscles, skin, growth, and bowels as well as its respiratory, heart, circulatory, digestive, immune, and endocrine system. The benefits he attributes to breast-feeding are both more extensive and less scientifically defensible than those of the NBAC. “You are doing the most important job in the world,” he tells mothers. “Nothing matters more than this.”

The corrosive nature of such moralizing is on display in public health campaigns designed to promote breastfeeding and in the way that lactivists talk about and treat other women.

… [W]omen’s needs — to work, control their bodies, or sustain an identity independent of their children — become “weaknesses in individual maternal character, to be corrected through educational messages”. This kind of reasoning, which implies that either ignorance, cowardice, or selfishness is behind a mother’s decision not to do what is best for her baby, rests firmly on assumptions about total motherhood in a risk society…

Any woman is free to choose the principles of “total motherhood” for herself and her family. The problem occurs when these women and their supporters assert that what is best for themselves and their families is objectively required either for health reasons or emotional reasons. Lactivists need to understand that their way of looking at the world, and the role of mothers in the world, is only one of many possible ways. While it might currently be a popular view, particularly among Western, white, relatively well educated and relatively well off women, that does not privilege it above other possible ways of understanding the role and obligations of mothers. The “risk society”, “total motherhood” and the view of breastfeeding as a proxy for good mothering are cultural fads, no different than the cultural fads that once considered breastfeeding primitive and ignorant. Lactivists have no right to lie to women about the risks and benefits of breastfeeding, and they have no right to present their view of mothering as superior to anyone else’s view.

Anti-cesarean activists love to point out that the World Health Organization has recommended that the C-section rate should be 10-15%. Unfortunately, the WHO appears to have pulled those numbers out of thin air. Its own data shows that a 15% C-section rate does not result in the lowest possible levels of either neonatal mortality or maternal mortality. Indeed, Dr. Marsden Wagner, who has probably done more than anyone to promote the idea of a 15% C-section rate as ideal, is a co-author of a study that actually demonstrates the opposite.

The paper is Rates of caesarean section: analysis of global, regional and
national estimates (Paediatric and Perinatal Epidemiology, 2007; 21:98–113.) The article explicitly acknowledges that the 15% C-section rate recommendation was made without any data to support it. This paper is actually the first paper that attempts to compare international C-section rates with maternal and neonatal mortality.

Since publication of the WHO consensus statement in 1985, debate regarding desirable levels of CS has continued; nevertheless, this paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health.

The data regarding C-section rates below 10% is stark:

…[T]he majority of countries with high mortality rates have CS rates well below the recommended range of 10–15%, and in these countries there appears to be a strong ecological association between increasing CS rates and decreasing mortality.

How about the data on C-section rates above 15%? The authors claim:

Interpretation of the relationship between CS rates and mortality in countries with low mortality rates is more ambiguous; nevertheless, the sum total of the evidence presented here supports the hypothesis that, as has been argued previously, when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits.

Not exactly. Indeed, not even close. The data show that low maternal mortality and low neonatal mortality are associated almost exclusively with high and very high C-section rates.

The article contains a variety of charts that make this clear. Of note, the charts are of an unusual kind. Rather than graphing C-section rates against mortality rates, the authors chose to graph the log (logarithm) of C-section rates against the log of mortality rates. A log-log graph has the advantage of exposing tiny differences when all the values are bunched close together, but all the values are not bunched together in this situation. C-section rates occur along a broad range, and mortality rates occur along a broad range. As a consequence, the log-log graph magnifies the effect of tiny differences and minimizes the effect of large differences. Therefore, you need to be very careful in interpreting the graphs.

This is an adaptation of the chart that appears in the paper comparing C-section rate to maternal mortality (the authors claim that graphing C-section rate against neonatal mortality produces a similar result). The area representing a C-section rate of 10-15% has been highlighted in yellow. The horizontal blue line represents a mortality rate of 15%. Lower mortality rates are below the blue line and higher mortality rates are above the blue line.

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The data themselves are quite clear. There are only 2 countries in the world that have C-section rates of less than 15% AND low rates of maternal and neonatal mortality. Those countries are Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, EVERY other country in the world with a C-section rate of less than 15% has higher than acceptable levels of maternal and neonatal mortality. There nothing ambiguous about that.

The authors claim:

Although below 15% higher CS rates are unambiguously
correlated with lower maternal mortality; above this range, higher CS rates are predominantly correlated with higher maternal mortality.

No, that’s not what it shows at all. It shows that only countries with  high C-section rates have low levels of maternal and neonatal mortality. A high C-section rate does not guarantee low maternal and neonatal mortality because C-section rate is not the only factor. For example, Latin America (represented on the chart by open diamonds) has a high rate of C-sections performed for social reasons, but does not have a low level of maternal mortality.

The bottom line is this: The only countries with low rates of maternal and neonatal mortality have HIGH C-section rates (except Croatia and Kuwait). The average C-section rate for countries with low maternal and neonatal mortality is 22%, although rates as high as 36% are consistent with low rates of maternal and neonatal mortality.

The authors claims are not supported by their own data. There is simply no support for a C-section rate of 15%, since virtually none of the countries with low rates of maternal and neonatal mortality have a C-section rate of 15% or below, and most have rates that are far higher. There is also no support for the claim that “the sum total of the evidence presented here supports the hypothesis that … when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits”. When C-sections are performed for medical indications, there is no evidence that rising C-section rates lead to rising rates of maternal or neonatal mortality.

The authors own data indicate that a C-section rate of 15% is unacceptably low, and that the average should be at least 22%, with rates as high as 36% yielding low levels of maternal and neonatal mortality.

You may have read recently about the widely publicized study by Swain and colleagues claiming that mothers who had C-sections respond to their baby’s cry differently than mothers who had vaginal deliveries (Maternal brain response to own baby-cry is affected by cesarean section delivery, Swain et al., Journal of Child Psychology and Psychiatry, 2008). The study shows nothing of the kind, and the authors have been utterly irresponsible in the way that they have publicized their findings.

The study itself suffers from so many serious problems that it is hard to know where to begin. The study is too small to draw any conclusions, let alone the conclusions drawn by the authors. We don’t know if there is any validity to the image of brain activity that the authors were looking at. There is no evidence that this image is correlatedin any way with maternal care taking.

These problems are easier to under stand in the following thought experiment:

Suppose I asked my children to toss coins. My son tossed a coin 6 times and got 6 heads, and my daughter tossed a coin 6 times and got 6 tails. Then suppose I wrote a study claiming that gender determines whether a coin lands heads or tails. Wait a minute, you’d say, your study doesn’t prove anything, and you’d be right. My study would prove nothing for the exact same reasons that the Swain study proves nothing.

First, my study, like the Swain study, is underpowered. I haven’t included enough coin tosses for my son or my daughter. We know from probability theory that if I repeated the experiment with my son tossing the coin 6000 times and my daughter tossing the coin 6000 times, they would get the exact same proportion of heads to tails; they would both get 50:50. My results are not valid because I didn’t include enough coin tosses.

Swain and his co-authors looked at the brain imaging patterns of 6 women who had vaginal deliveries and found that they were different from the 6 women who had C-sections. Just like the heads-tails study, the results could simply reflect the fact that the study is far too small.

Second, drawing the conclusion in my coin experiment that gender determines the result of a coin toss rests on the assumption that correlation equals causation. However, we know from the rules of statistics that correlation does not demonstrate causation. Correlation means that two events appear to be related. Causation means that one event caused the other. In my coin toss experiment, gender and coin toss result appeared to be correlated, but that does not mean that gender caused the coins to land heads or tails. It was just a coincidence.

Similarly, in the Swain study, the two different modes of birth appeared to be correlated with brain image, but that does not mean that the mode of birth cause the specific brain image pattern. It could just have easily been coincidence.

Third, my study claiming that gender determines the result of a coin toss would have rest on another flawed assumption, that there is something fundamentally different, beyond appearance, between a coin landing heads and a coin landing tails. In reality, though, there is no difference; it’s just a matter of chance whether a coin lands heads or tails.

Similarly, Swain and colleagues have made a seriously flawed assumption that the two different brain image patterns they observed reflect a fundamental difference in the actual reaction of the mother, not just a matter of chance. In reality, the authors present no evidence that the brain image pattern has anything to do with the mother’s response to her baby’s cry.

This study shows nothing. It could potentially represent an interesting finding that deserves more investigation, or it could be entirely the result of chance. It is extremely irresponsible for the authors to claim that they showed that mode of delivery determines a mother’s response to an infant. It is no better than a coin toss study claiming that gender determines the result of a coin toss.

The New York Times carried an article in the August 29, 2008 edition asking if the media should be blamed for Gardasil hype. Gardasil, the vaccine that it touted as preventing cervical cancer, has progressed through three stages of media frenzy. First, there was the initial burst of publicity surrounding its introduction, then there was the burst of publicity surrounding efforts of conservatives to discourage its use, now there is the all too predictable burst of publicity asking whether early reports on Gardasil were overly optimistic.

The irony is that nothing about Gardasil or its use has changed. We have the same information now that we possessed when the vaccine was introduced. Did the media overhype the introduction of Gardasil? Yes, it did, but that’s because it appears that no one read the scientific literature before writing about it.

Were the media improperly influenced by the Gardasil marketing campaign? The marketing campaign made claims that, thus far, are only extrapolations from existing data. The manufacturer did not lie, but the manufacturer does not yet know what the long term protective effect of the vaccine will be. The fact that the media looked to the marketing campaign for information was improper. Scientific claims can only be evaluated by looking at the scientific evidence. A marketing campaign does not provide a complete view of the scientific evidence.

Cervical cancer is caused by certain strains of the human papilloma virus. The virus also causes genital warts and pre-cancerous changes in the cervix. The vaccine causes the body to produce antibodies against the virus. Initial testing has been very promising; women who received the vaccine did not develop genital warts and did not have detectable levels of virus on testing. In contrast, some women who received the placebo did develop genital warts, and the virus could be detected on tests.

So far, so good. The vaccine appears to offer excellent protection against the HPV virus, and appears to prevent the development of genital warts. Does the vaccine prevent cervical cancer? No one knows, because it takes many years for cervical cancer to develop after exposure to HPV, and the vaccine has not been around for many years. Theoretically, it will prevent cervical cancer, but only if the strains in the vaccine are the only strains that can cause cancer, and only if protection is long lasting. We have little or no information on these issues.

Did the media overhype Gardasil? Of course it did. The media, like the manufacturer, claimed that Gardasil will prevent cervical cancer, but no one actually knows if that is true. It will take years to determine whether Gardasil prevents cervical cancer.

But wait; does that mean that the manufacturer should be prohibited from claiming that Gardasil can prevent cervical cancer? Does that mean that girls should not receive the vaccine? Those are difficult ethical questions. Gardasil probably does prevent cervical cancer, but we won’t know definitively for a decade or more. In the meantime young women who forgo the vaccine because it hasn’t been proven to prevent cervical cancer might be forgoing protection against a deadly disease. We know the virus causes cancer. We know that the vaccine helps the body fight off the virus. Logically, we expect that the vaccine will prevent cervical cancer.

How sure do we need to be before we should recommend widespread use of the vaccine? The government decided that given all the available evidence, the projected benefits appear to outweigh any risks, and they are probably right. However, the truth is that no one really knows if Gardasil prevents cervical cancer.

Who said: “the mother is the factory, and by education and care she can be made more efficient in the art of motherhood”?

That was written in 1942 by Grantly Dick-Read, widely considered to be the father of modern natural childbirth. Most people don’t realize that natural childbirth was invented by a man to convince middle and upper class women that childbirth pain is in their minds, thereby encouraging them to have more children. Read’s central claim was that “primitive” women do not have pain in childbirth. In contrast, women of the upper classes were “overcivilized” and had been socialized to believe that childbirth is painful.

Grantly Dick-Read’s theory of natural childbirth grew out of his belief in eugenics. He was concerned that “inferior” people were having more children than their “betters” portending “race suicide” of the white middle and upper classes. Read believed that women’s emancipation led them away from the natural profession of motherhood toward totally unsuitable activities. Since their fear of pain in childbirth might also be discouraging them, so they must be taught that the pain was due to their false cultural beliefs. In this way, women could be educated to have more children.

According to Read: “Woman fails when she ceases to desire the children for which she was primarily made. Her true emancipation lies in freedom to fulfil her biological purposes”..

The comparisons between “overcivilized” white women and “primitive” women who gave birth easily was not merely the product of racism, but reflected the anxiety that men felt about women’s emancipation. This anxiety was expressed in medicine generally, and in obstetrics and gynecology particularly, by the fabrication of claims about the “disease” of hysteria and the degeneration of women’s natural capabilities in fertility and childbirth compared to her “savage” peers. Simply put, the result of women insisting on increased education, enlarged roles outside the home and greater political participation was that their ovaries shriveled, they suddenly began to experience painful childbirth and they developed the brand new disease of “hysteria”, located in the uterus itself.

Pain in childbirth served a very important function in this racist and sexist discourse: it was the punishment that befell women who became too educated, too independent and left the home. The idea that “primitive” women had painless childbirth was fabricated to contrast with the painful childbirth of “overcivilized” women.

Grantly Dick-Read was issuing a warning to women of a certain social class: if you step beyond the roles prescribed for women, you will be punished with painful labor. And if you have had painful labor, you should understand it as a punishment for ignoring your “natural” duty to stay home and procreate.

In light of this, the contemporary popularity of natural childbirth is more than a bit ironic. The central claims of natural childbirth, that childbirth is not inherently painful, and that if you “prepare” properly, your birth will be painless, too, were utter fabrications. Read would be delighted that these fabrications have been embraced by many women and that his philosophy has been propagated so successfully that most women don’t even realize that the central tenets of natural childbirth are racist and sexist lies.

Everyone agrees that the cesarean section rate in the US is too high. Critics claim that it is high because doctors make money from C-sections (false, most obstetricians get paid the same amount regardless of how the baby is delivered) or because it is more convenient for obstetricians (false, nothing is more convenient than every patient having an uncomplicated vaginal delivery). No one seems to realize that the rising C-section rate is a direct response to what patients demand, which is a perfect outcome and massive financial compensation if the outcome is not perfect. Efforts to lower the C-section rate have to start with patient expectation and demands.

In our legal system, there is no possible justification for not doing a C-section when there is any element of doubt, no matter how tiny. Unless and until people stop penalizing doctors for not doing C-sections, they will continue to do them in ever increasing numbers. They really have no choice.

How can we modify patient expectations and demands? The most practical response would be to institute no fault compensation for a baby who dies or is permanently impaired. No fault compensation has the added advantage of being more ethical. The current system requires that getting help caring for a profoundly impaired child is completely dependent on being able to blame a medical provider for the impairment. Parents who care for children who are impaired due to genetic problems (no one’s fault) are forced to struggle without any assistance, while parents whose children may be less disabled receive lottery size awards as long as they can convince a jury that someone is at fault.

The bottom line is that you cannot say to obstetricians, “Give me a perfect baby or I will try to destroy you professionally and economically” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.

Obviously every single C-section with a medical indication should be done. Moreover, what is unnecessary in hindsight is not knowable in advance. Nonetheless, a C-section rate of 32% cannot be medically justified if the normal parameters for medical justification are used. Unfortunately, the typical parameters are not used.

Let’s look at another medical issue for comparison. Ovarian cancer is one of the most dangerous problems an OB-GYN is likely to encounter and early ovarian cancer does not cause symptoms. We could prevent virtually all ovarian cancer. How? We could remove every woman’s ovaries at the age of 40.

We don’t do that, and there are many reasons why. First, it would almost certainly lead to more deaths than it would prevent. Second, the law of diminishing returns applies to removing ovaries. As the rate of removal gets higher, the chance that you are actually doing some good gets smaller. Third, women understand that ovarian cancer is generally a random occurrence; it certainly is not the doctor’s fault. Therefore, the overwhelming majority of women who are diagnosed with ovarian cancer do not sue claiming that someone should have figured it out sooner.

The contrast with obstetrics could not be more glaring. Women do not understand that hypoxic brain damage can be a random occurrence; women believe that a bad obstetric outcome must be someone’s fault. Therefore, they will sue if there is anything wrong with a baby and the only effective legal defense for a doctor is to show that a C-section was performed, and was performed as soon as humanly possible.

Virtually every American obstetrician is sued. Most are sued several times. An obstetrician must assume that she will be sued for every bad outcome, and therefore, she must take whatever steps she can to preserve a legal defense. Of course, the only acceptable legal defense is a C-section.

Obstetricians win most lawsuits. The cases were without merit to begin with. We might conclude that the system works because most doctors who did nothing wrong are found not liable. However, another way to look at the high proportion of physician victories is that it tells us the system is totally dysfunctional. Most lawsuits occur in the absence of any legal wrong, yet they are allowed to proceed anyway.

Lawsuits do not file themselves; patients file them, and they are an expression of patient expectations. The large number of obstetric malpractice suits, and particularly the large number of suits without merit, are a direct expression of patient expectations. They expect a perfect baby and they believe they ought to punish any doctor who doesn’t present them with a perfect baby.

As the C-section rate rises, the percentage of unnecessary C-sections rise and that is a bad thing. Logically speaking we are not going to recommend a C-section rate of 100% even though a C-section rate of 100% would guarantee that everything was done to ensure a perfect baby. So where do we draw the line?

We determine where we draw the line in direct response to patient expectations. When patients demand a perfect baby or else, they have essentially drawn the line at a 100% C-section rate and doctors are merely attempting to respond to that. If patients stopped filing large numbers of lawsuits without merit, the C-section rate would drop in response to their acknowledgement that a perfect baby is not guaranteed.
 
There are too many C-sections being done in the US countries because American women demand a very high C-section rate, while simultaneously insisting that they want a low C-section rate. To those complaining I say: If you want to lower the C-section rate, start by looking in the mirror!