Vaginal birth may be natural but it can also be very damaging. It has long been known that C-section reduces the risk of subsequent urinary incontinence. Now a new study provides evidence that C-section also protects the nerves responsible for pelvic sensation.

The study is The impact of pregnancy and childbirth on pelvic sensation: a prospective cohort study just published in the prestigious journal Nature.

The authors note:

Pelvic organ prolapse, urinary, bowel and sexual dysfunction, collectively termed pelvic floor dysfunction (PFD) is estimated to affect one in three women in high and middle income countries with a significant public health cost…

This is the first study to report the effect of pregnancy and mode of delivery on sensory function of the pudendal nerve.

We hypothesised sensory nerves are unaffected by pregnancy and injured following vaginal birth. Our primary objective was to investigate the effect of mode of delivery on pelvic sensation…

What did they study?

One hundred and fifty nulliparous women were recruited from antenatal clinics between 10 and 40 weeks gestation…

Women were assessed in the third trimester (antenatal), at 3 and 6 months postnatal…

The primary outcome measure was proportional change in sensation following a normal vaginal delivery (NVD), assisted vaginal delivery (AVD) and caesarean section (CS).

Secondary outcome measures were baseline sensation in pregnancy compared to non-pregnant normative data and proportional change in sensation across the postnatal period.

Among other findings, the authors report:

At 3 months postnatal vaginal and clitoral vibration sensation in women delivered by CS showed greater recovery to antenatal levels than following a NVD or AVD. By 6 months postnatal sensation in the NVD group was comparable to the CS group, but the same recovery was not evident in the AVD group.

In other words, C-section protected pelvic nerves while vaginal birth damaged them. The greatest damage occurred after assisted vaginal birth with forceps.

Our results indicate that women who underwent CS did not experience any deterioration in pudendal nerve sensory function, suggesting CS is neuroprotective for sensory nerves. Women who had a NVD showed slow recovery at 3 months postnatal and demonstrated enough recovery to restore function to CS levels by 6 months postnatal, suggesting nerve damage in this group is transient. AVD was associated with the greatest reduction in sensory nerve function and less recovery of function by 6 months postnatal than a CS or NVD, suggesting AVD causes profound and potentially irreversible nerve damage.

The authors conclude that women should be counseled about the risk of vaginal delivery causing impairment of pelvic sensation and the neuro-protective effect of C-sections.

The bottom line is that maternal request C-sections make a great deal of sense for women anxious to avoid either incontinence, sexual dysfunction or both!

Natural childbirth advocates profess confusion that the promotion of “normal, physiological” birth is disrespectful to women who make different choices. To help them understand why their rhetoric is hurtful, hateful and utterly self referential, I offer a thought experiment. Let’s apply the philosophy of “normal” birth to sex.

Below is a paraphrase of a natural childbirth position paper, Promoting, Supporting, and Protecting Normal Birth.

Promoting, Supporting, and Protecting Normal Sex
by The Institute for Safe and Healthy Sex

Sex in the 21st century is characterized by choices and practices directly antithetical to normal, natural and physiologic processes. Nature designed sex to occur only between one man and one woman, within the context of a permanent pair-bonded relationship, and always leading to pregnancy. In contrast to what we know about the physiologic process of sex, society now countenances homosexual relationships, sex outside of marriage or even outside of a relationship and artificial contraception. These practices are alarming because there is no research demonstrating that choices like homosexuality, oral sex and contraception respect and facilitate normal physiology.

The normal, natural, physiologic process of sex involves a sequence of interacting events: the male erection, vaginal lubrication, ejaculation, etc. It is exquisitely orchestrated by male and female hormones and facilitated by the missionary position. Restriction to the missionary position helps men and women tolerate increasing levels of oxytocin (the love hormone), and this ultimately ensures not only that sex will progress, but they will benefit from the release of endorphins, nature’s narcotic.

The Institute for Safe and Healthy Sex encourages men and women to be confident in their ability to have heterosexual sexual intercourse. The Institute further encourages health-care providers and policy makers to understand and trust the normal, natural process of heterosexual intercourse and to promote, support, and protect men’s and women’s confidence and their ability to have heterosexual intercourse without the unnatural distractions of abnormal sexual practices or artificial contraception.

The Institute of Safe and Healthy Sex has identified six care practices, that promote, support, and protect normal heterosexual intercourse:

Practice #1: We must recognize and acknowledge that Nature designed sex to occur only between one man and one woman. Moreover Nature designed individuals in binary — either male or female. Gender fluidity and transgenderism are both unnatural.

Practice #2: Sex should be restricted to only heterosexual, monogamous, long term relationships (ideally marriage), because that is the only physiologic situation.

Practice #3: No artificial interference with fertility.

Practice #4: All sex should have to potential for conception. Accordingly, there should be no homosexual sex, no oral or anal sex and no masturbation.

Practice #5: Sex should be restricted to the missionary position because it affords the best possibility for conception, which is what Nature intended.

Practice #6: There should be no artificial components to heterosexual intercourse. Synthetic lubricants, vibrators and sex toys interfere with the physiologic sex that nature intended.

The goal of the Institute for Safe and Healthy Sex preparation for sex is that men and women have confidence in their inherent ability to have normal, heterosexual intercourse. In Institute for Safe and Healthy Sex sex education classes, men and women learn to understand and trust normal, natural, physiologic sex and avoid homosexual tendencies, non-normal sexual practices, and artificial contraception. The Institute for Safe and Healthy Sex encourages all men and women to attend sex education classes that promote the six care practices described above and that increase their confidence in their ability to have sex normally.

The mission of the Institute of Safe and Healthy Sex the is to promote, support, and protect normal sex through education and advocacy. The Institute for Safe and Healthy Sex was launched to support initiatives that provide credible, relevant, and useful information about normal sex to young men and women and to advance the agenda of promoting, supporting and protecting normal sex.

Offensive, right?

The promotion of normal birth every bit as offensive as the promotion of normal sex.

Breastfeeding rates have risen dramatically over the past 50 years and NONE of the predicted benefits for infant health have come to pass.

Why not?

Because breastfeeding is SOCIALLY patterned (breastfeeding is closely associated with higher socio-economic status) and most of the purported benefits of breastfeeding are actually benefits of maternal wealth, education and access to healthcare.

Lately the focus has been on claiming maternal benefits of breastfeeding. But those probably don’t exist either because breastfeeding is also MEDICALLY patterned. Women who are more likely to have difficulty breastfeeding for medical reasons are also more likely to develop serious illness later in life.

That’s the message from a new evaluation of claims that breastfeeding protects against maternal heart disease. The paper is Adverse Pregnancy Outcomes: The Missing Link in Discovering the Role of Lactation in Cardiovascular Disease Prevention published in Journal of the American Heart Association.

The authors reference a paper published earlier this year that received a lot of media attention:

[T]he January 2022 issue of the Journal of the American Heart Association (JAHA) included the article by Tschiderer and colleagues titled, “Breastfeeding Is Associated With a Reduced Maternal Cardiovascular Risk: Systematic Review and Meta‐Analysis Involving Data from 8 Studies and 1 192 700 Parous Women.”1 The compilation and synthesis of data from over 1 million women is a valuable contribution to the literature. The primary findings were that a history of any duration of breastfeeding was associated with 11% to 17% reduction in the relative risks of later life adverse cardiovascular outcomes … for coronary heart disease; HR, 0.88 … for stroke; and HR, 0.83 … for fatal CVD),1 after accounting for reproductive and sociodemographic factors.

That study did not account for an important confounding variable, adverse pregnancy outcomes like pre-eclampsia, gestational diabetes or premature birth.

These pregnancy complications are established risk factors for both future CVD in women and also  for difficulty breastfeeding.

In other words reduced breastfeeding doesn’t cause future maternal cardiovascular disease, it predicts it.

Prepregnancy obesity, chronic conditions, and certain APOs [adverse pregnancy outcomes], especially preeclampsia and preterm delivery, can interfere with breastfeeding initiation and lead to delayed onset of lactogenesis and earlier cessation, as well as increased CVD risk in later life.

The implications don’t merely undercut the claimed benefit of breastfeeding in preventing maternal cardiac disease, they undercut the unquestioned assumptions about breastfeeding that have been promoted by the lactation profession.

Lactation professionals assume — and have aggressively advocated the idea — that every woman is biologically capable of successful breastfeeding. To the extent that women experience difficulty breastfeeding, lactation professionals ascribe it to malingering (“perceived insufficient breastmilk”), formula advertising or infant anatomical abnormalities (tongue-ties).

But difficulty breastfeeding has biological markers (breastmilk sodium concentrations), genetic markers and associations with adverse pregnancy outcomes.

…Maternal and neonate medical complications related to clinical outcomes (ie, prematurity) and physiologic effects (ie, delayed onset of lactogenesis) of APOs are recognized barriers to lactation success… Thus, the findings of a consistent protective association between lactation and adverse CVD outcomes based on the summary risk estimates … leave open the question of reverse causation, effect modification, or confounding.

Just as we find that nearly all predicted infant benefits of breastfeeding disappear when maternal socio-economic status is taken into account, we may find that nearly all predicted maternal benefits of breastfeeding disappear when maternal adverse pregnancy outcomes are taken into account. That’s because the same factors that lead to maternal chronic diseases also lead to breastfeeding difficulties.

In order to understand what is going on, we need a massive realignment in the way that we think about breastfeeding:

Difficulty breastfeeding is NOT the result of cultural and psychological factors but rather of MEDICAL factors.

Instead of blaming “society” and women themselves for breastfeeding difficulties we should be exploring the biology of insufficient breastmilk and its implications for women’s health overall.