Category Archives: Birth

Dr. Amy and Conspiracy Theories

tinfoil hatA friend pointed out this 2012 article by Amy Tuteur about skepticism versus denialism. It’s a worthy topic, and I’m right with her (or perhaps more accurately with her cited material from Andrew Dart) regarding vaccine and evolution “skepticism.” But I take issue with her broad brush getting paint on me when she states, “Though it isn’t as obvious, natural childbirth and homebirth advocates are denialists, too.”

I’m a natural childbirth and homebirth advocate in part because I’m a skeptic! (The other major impetus for me is gender equality and bodily autonomy.) Look, I realize there are loonies in the natural/home birth camps. There are people so out there that Koi-Assisted Birth was greeted not simply with “Great satire!” but with many readers taking it as real. But there are plenty of advocates interested in evidence-based medicine and freedom of choice. Take someone who questions the benefit of routine continuous electronic fetal monitoring. That’s a reasonable question to ask when the intervention was introduced on the guess that it would be helpful, then later research showed it may result in worse outcomes. When you equate a skeptic about that issue with a crank who believes against all evidence that the earth is 6,000 years old, you’re being both inaccurate and insulting.

Here’s a rundown of the most glaring logical problems in Dr. Tuteur’s article.

Universal statements – Note the lack of “some” or “many,” or “the most extreme,” preceding the terms natural childbirth advocate and homebirth advocate. The existence of a single skeptical, reasonable advocate of natural childbirth upsets her argument.

False Dilemma – she gives the impression that a person either supports typical hospital birth, or is a loony conspiracy theorist who ignores all evidence that homebirth is imperfect. There’s no intimation that some people might occupy a middle ground.

Equivocation – Tuteur quotes Dart’s discussion of conspiracy theories, then uses an unexplained, idiosyncratic definition of “conspiracy theory” to assert that natural childbirth advocates are conspiracy theorists. Under her implicit redefinition of “conspiracy theory,” anyone who acknowledges unconscious bias (such as the possibility that a doctor might intervene quicker if he wants to get to a golf game) is evoking a conspiracy theory.  She also redefines conspiracy theory to include the realization that medical schools often teach by tradition, rather than strictly keeping to the latest evidence-based practice. The normal definition of “conspiracy theory” hinges on deliberate plotting. Dr. Amy’s special definition includes totally unconscious, unplanned behavior. I guess if she used the real definition, she couldn’t include natural childbirth advocates under Dart’s definition of denialists.

Guilt by association: “And natural childbirth and homebirth advocates share key attitudes with vaccine rejectionists, creationists and other denialists.” First she lumps natural childbirth and homebirth advocates together, then further assumes that homebirth advocates universally support poorly trained CPMs, and don’t care about any evidence that they might be less safe. Through this chain of association, suddenly a mother who gave birth in a freestanding birth center because she was worried about unnecessary interventions is equated with believers in a global conspiracy to give kids autism with vaccines.

Personally I get the impression that “The Skeptical O.B.” is herself a bit of a denialist, that she believes typical hospital birth with lots of interventions is the best, safest practice, and that no evidence will ever be good enough to dissuade her. So rather than searching out the best evidence about these practices and questioning her own biases, she targets people who do question, and paints us all as crazed fringe ideologues who don’t care about dead babies.

I admit I am biased toward natural childbirth and questioning medical interventions. But, I at least try to remember that I have that bias and attempt to embrace the foundation of skepticism – watching out for my own perceptual foibles. If there is solid, evidence-based consensus that the benefits outweigh the risks for routine continuous electronic fetal monitoring, routine episiotomy, or nil by mouth during labor, I would be interested in seeing it, and if it’s convincing I would change my mind about the desirability of these procedures. Being willing to change your mind is what skepticism is all about, while protecting your current beliefs at all costs is denialism – even if your beliefs are culturally mainstream.

(For the record, I’m a natural childbirth advocate and homebirth advocate in that I believe in making these options available to women, I am skeptical of some of the typical hospital practices, and I was personally more comfortable birthing outside a hospital, where I felt my providers’ approach to birth dovetailed with mine. I’m 100% in favor of making CNM-attended homebirth a common option. I am not personally as comfortable with CPMs, and unattended childbirth scares the hell out of me. But I still think women have the right to do either, though they should have access to the risks and benefits information as best we have right now.)

Feminism and mothering

Once upon a time, women didn’t have options.  We were expected to learn domestic arts while living in our father’s house, then to be “given away” by him to another man, whose house we would keep and whose children we would bear.  Our sexuality was tightly controlled through shame and restriction of freedom.  Clergy thought that the pain we often feel in childbirth was only our due as daughters of Eve, and to alleviate it was a sin.

Feminism started by asking, “Can’t women enjoy what men have?”  We’ve made huge strides toward that goal.  Women can get an education and choose a career path just like men.  Women compete in the job market and do work that was once considered only for men.  Women own their own property, make their own financial decisions, and are more frequently the primary breadwinners in their households.  We now have legal and social freedom to express our sexuality, along with the access to birth control that makes that freedom practical to exercise.  We’re still fighting for equality and freedom in many areas, from wage equity to abortion access, but we’ve come a long way.

And yet, it seems to me that “female things” are still considered second-best, even by many feminists.  Is it feminist to buy into the idea that the roles traditionally reserved for males are desirable, powerful, and of value, while the roles traditionally reserved for females are undesirable, disenfranchising, and without value?  As part of our (relatively) newfound freedom, women wear pants, work for a wage, and need not be shackled to our fertility – roles and behaviors that once belonged only to men.   But if a man wants to become a nurse, or be the primary caregiver to children, he’s laughed at, or assumed to be marking time until he can find real employment.  God forbid a man want to wear a dress or other traditionally feminine clothing – at best, he’ll be laughed at.

Is it possible we’re ready for a new wave of feminism that is about valuing traditionally female things as much as male things?  On one level, the availability of baby formula is feminist because it frees women from the need to be close to their babies all the time.  But wouldn’t it be more radically empowering to also have a default assumption that workplaces need to accommodate female reproductive biology by routine availability of long maternity leave, and on-site daycare and excellent pumping facilities to facilitate breastfeeding?  Shouldn’t we see going back to work and staying home with a baby as equally challenging and empowering options?  If femaleness is equal to maleness, caring for young children should be seen as just as exhilarating and valuable as being a high-ranking executive.

On one level, the availability of pain relief in labor is a decidedly feminist victory.  But even modern hospital practices can be horribly misogynistic, betraying an underlying assumption that a woman in labor is by definition a hysterical, dangerous, incompetent who must be managed and directed by the more capable medical staff.  Doctors and nurses all too frequently talk down to, bully, and even physically assault laboring mothers in the name of protecting their babies.  And that’s another problem – discussions of where and how to birth so often focus only on the outcomes for the baby, ignoring not only the comfort and autonomy of the women involved, but even their health risks.  The message is loud and clear: “Your needs are not significant; you are only valuable as a vessel for a baby,” and isn’t that an attitude we’ve been trying to do away with?

Nursing in public is a big debate currently, but I don’t think many in the “anti” faction appreciate how big a feminist issue this is.  Acceptance of nursing in public is about female empowerment on two levels.  First, it diminishes the objectification of women.  For so long, breasts have been all about sexuality and the male gaze.  To acknowledge that they aren’t just about arousing the prurient interest of men is to elevate women beyond being mere sex objects.  Second, nursing in public is vital to allowing mothers full access to social life.  As more women are nursing, trying to do the best thing for their babies, more women will be out and about and need to nurse.  Only someone who hasn’t nursed an infant would ever say, “Just time your excursions for when the baby doesn’t need to nurse,” or “Just pump some milk and use a bottle,” or “Just sit on a public toilet for 20 minutes and nurse.”  These are not practical solutions.  What is practical is to get over our societal perversion about breasts and allow mothers full access to life outside their homes by supporting, or at least ignoring, public nursing.

And that leads to my final thought – the Mommy Wars are largely due to a double bind women are put in.  Nursing is a great example.  All the experts say it’s important for your baby’s health to breastfeed.  Women get hammered with the message that they need to nurse to avoid exposing their babies to unnecessary risk.  But society leaves all the onus on the moms; when it comes to actual, broad-based cultural support for these allegedly vital behaviors, our institutions suddenly get very silent.  All the messages to moms are “YOU need to do this for your baby,” never “here is what WE’RE doing to help you help your baby.”  Those on-site daycares, pumping facilities, and welcoming places for nursing in public are few and far between.  This leaves mothers with all the burden of giving perfect infant care, without any of the necessary support.  So moms feel guilty, frustrated, and angry.  And then we accuse each other of being negligent or intolerant, selfish or holier-than-thou.

Is it possible to truly value women’s choices, no matter what?  To find power and worth in mothering just as much as we do in employment?  To give women real options, with any decision being greeted with respect and care?  To turn all that guilt-induced infighting into demands for societal support?  I think these goals are just as important as fighting for equal pay and safeguarding control over our fertility.

Quiverfull Families

No time for a full-on, researched post today, as my 3yo has a horrific UTI and dealing with that is a full-time job.

But as I drove to the pediatrician today, I was listening to Godless Bitches interviewing Vyckie of No Longer Quivering.  She mentioned how she had felt she was “turning over her reproductive life to God.”

How come it’s always the reproductive life, and really, only the woman’s reproductive life that gets turned over to God?  As far as the man’s reproductive life, I’m pretty sure the quiverfull husbands don’t sit passively and wait for Yahweh to levitate semen out of them and into their wives.  They get to decide if they’re feeling frisky or if they’re just too tired after work, without being guilty of thwarting God’s will.  It’s only the incubators women who have to turn all decision-making over to the Almighty.

One wonders why it’s just reproduction too.  Wouldn’t any of these statements be just as valid?

I’m turning my nutritional life over to God.  If He wants me to be hungry, how can I disobey Him by eating?

I’m turning my dental life over to God.  It’s in His power to kill the plaque on my teeth, and if He doesn’t, it would be usurping His power to go to the dentist and get a cleaning.

I’m turning my economic life over to God.  If He wills me to have food and shelter, He will make it so.  I dare not contravene His will by making my own decisions to get a job and earn money.  (This one is particularly appealing, seeing as Jesus actually instructed his followers to live like this!)

All this leaves aside the question why Yahweh needs a man to reverse his vasectomy or even sleep with his wife in order to allow for Yahweh’s desired impregnation to occur, given that He’s omnipotent and has a proven track record of knocking up chicks with minimal spousal contribution.

Unassisted Childbirth

Believe it or not, some people do this on purpose.  They give birth at home, with no trained professionals helping them.  I think this trend is largely a reaction to our prevailing culture surrounding birth, where women go to the doctor, do what s/he says, give birth in a hospital, and probably have at least one medical intervention along the way.  This setup leaves a lot to be desired, and there is a counter-movement that celebrates birth as a normal function, and emphasizes respect for the mother.  This school of thought argues that birth has been over-medicalized, doctors treat pregnancy and childbirth as a disease, technology and intervention are revered (even when research shows that they cause more harm than good), and women are treated as dangerous baby-vessels from whom the fetus must be rescued, often resulting in contemptuous treatment of laboring mothers, sometimes even going so far as performing medical procedures without informed consent.

To a very large extent, I agree with this backlash against hospital birth.  I’m a big believer in free-standing birth centers, where practitioners tend to be more aware of evidence-based practice and more respectful of women.  I also think states should have straightforward processes for licensing and regulating midwives who attend home births.  For low risk pregnancies, particularly for women who have already given birth at least once, home birth is just as safe as hospital birth, and is preferable for many families.

My sense is that unassisted childbirth may often be prompted by a mother’s reluctance to subject herself to the standard practices at a hospital, combined with a lack of other options.  I suspect a good portion of mothers who chose UC would be happy to birth at home with a midwife, if that option were available.

But it also seems that some people have just reacted so strongly against the medicalized version of birth that they’ve landed in La-la Land, where birth is a breathlessly venerated spiritual experience, labor and delivery can be risk-free if only you eat right and exercise during pregnancy, and the presence of any person who wasn’t there when the baby was made is unacceptably interventionist, invasive, and disruptive to the natural process.  This is where it gets dangerous.  Birth may be a normal function, but especially in humans, it is a time of crisis, when things can and do go wrong.  Humans are unique in that our pelvic openings are only barely big enough to allow our babies through.  Pregnancy isn’t a disease, but it is a burden on the mother’s body.  Labor doesn’t have to be an emergency, but it does present health challenges to mother and baby that can become emergencies.

There isn’t a lot of research on unassisted childbirth, because it’s so fringe that there aren’t populations to study.  There’s some data on a religious sect that practiced UC, and of course there’s information from developing countries where women simply don’t have access to healthcare.  In both cases, lack of medical care during pregnancy and childbirth are associated with much higher levels of maternal and infant mortality.  UC proponents argue that these situations aren’t analogous because  good nutrition and healthy practices during pregnancy make UC safe.  However, at least one review of historical data shows that poverty and nutrition had almost no effect on maternal mortality rates in childbirth, and the WHO urges better access to medical care as the best way to save the lives of women and babies in underdeveloped areas.

Some UC supporters say, “birth is safe and normal, otherwise our species wouldn’t be here!”  But they’re profoundly misunderstanding evolution, which only requires a process to be good enough to pass along genes.  Natural selection has resulted in a system where women can get pregnant very frequently, so that despite the peril that an upright stance and a big brain causes, enough babies survive to carry on the species.  I don’t know about you, but “a lot of babies die, but enough survive” isn’t an ambitious enough goal for me.

Some supporters of unassisted childbirth claim that it’s unnatural to have birth attendants.  Aside from engaging in the naturalistic fallacy, this argument fails because it’s just not true.  As far as we’ve been able to determine, mothers have sought help from others during birth for as long as we’ve been a distinct species.  For humans, having birth attendants is what’s natural, while closing oneself up in a separate dwelling and giving birth in the presence of only one’s husband is profoundly unnatural – a behavior emerging only in our modern culture.

Now, I consider UC to be overly risky and poorly rationalized, but I still think women have the right to do it.  Just as I’m pro-choice regarding abortion, I believe that a woman has a right to decide what kind of medical care she will receive, and to reject medical interventions, even if others would find her decision foolish.  I do have an issue with parents UCing and then failing to have the newborn checked out by a medical professional, though.  In some jurisdictions this might even fall under child neglect laws, and regardless I don’t feel comfortable with parents simply looking at a newborn and saying, “Gee, she looks like she’s doing OK.”  Again, birth is a tough process that can introduce a lot of life-threatening conditions, some of which will not be apparent to a layperson.  I remember when a friend had her baby a little early, we were all remarking how chubby and healthy she looked – we were sure she was just fine – only to find out that she had some kidney problems that required immediate intervention.

In the end, that is the biggest problem with UC – hubris.  People look at the few areas where doctors have embraced stupid birth practices that aren’t supported by the evidence, and take away the message that parents are just as capable of coping with the crisis of birth as any hospital.  Often their gamble turns out OK – the birth will be a normal, complication-free event, and no particular knowledge or expertise in medicine will be required.  But the problem is that no one can predict with certainty which births will become problematic, and if you have no one present who has training in recognizing and dealing with such situations, you’re headed for disaster.

The Cynical O.B.

I was really excited to see a blog called “The Skeptical O.B.”  Having read The Thinking Woman’s Guide to a Better Birth, I knew that standard O.B. practices are often more about intuition and tradition than evidence-based medicine.  I thought it would be so cool to see an actual O.B. looking at the risk/benefit analysis on interventions like induction, epidural, and c-section.

Whoops!  Boy is my face red.  The blog could better be named, “The Hidebound Ideologue Against Natural Birth.”  Now, I am interested in skepticism of natural birth practices as well as hospital practices.  You don’t automatically get a pass from me because you’re doing something crunchy.  But god damn, Amy Tuteur is so vituperative, condescending, and obnoxious in her approach, and so obviously devoted to propping up standard hospital practices, that I can’t read her blog even if it might offer some interesting info on homebirth safety or midwifery guilds run amok.

Amy typically storms into each post with a haughty and self-assured stance, declaring her position to be self-evidently correct and everyone else to be feeble-minded.  Most recently, she announced “The largest, most comprehensive study ever done of homebirth has released its results and there’s nothing left to argue about: homebirth increases the risk of perinatal death.”  The study she’s citing though, states almost the opposite take-home message in its Conclusions:

The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.

In my experience of her work, this is representative.  She is the opposite of a skeptic – she decides on her position, and then twists and cherry-picks evidence to support it.  It also doesn’t help matters that she is absolutely vile and superior to any commenter who dares to question her pronouncements and offer counter-evidence.  In other circumstances, I’d be very interested in her information about the Midwives Alliance of North America keeping their statistics on births secret, and appearing to require almost a loyalty oath before giving someone access to it.  But a.) I don’t trust her to give me all the information, and b.) I don’t want to don a bile-proof jumpsuit to wade through her excoriating commenters who offer other perspectives.

This was such a wasted opportunity.  In my opinion, all birth practices need a good review based on the most recent evidence available.  Honestly, I probably agree with Dr. Amy on a lot of things.  I think unassisted childbirth is a terrifying new trend that exposes mothers and babies to too much risk.  But I think that it’s useful to look at the hospital practices and insurance structure that drive women to birth without any attendant whatsoever, and try to reform our institutions so mothers can feel safe and secure in a hospital, or have access to a well-trained, licensed midwife.  Dr. Amy thinks the answer is to sneer and call these mothers fools.