Nov 12 2009
“The mother is the factory”
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.
In Holistic obstetrics: the origins of “natural childbirth” in Britain, O Moscucci, PMJ 2003;79:168-173, Dr. Ornella Moscucci explains the backdrop against which the philosophy of “natural” childbirth was promulgated:
Health policy became the subject of intense public debate in the aftermath of the Boer war, when Britain’s near defeat at the hands of a barely trained army focused the attention on the physical fitness of new recruits… Adherents to the new science of eugenics on the other hand blamed heredity. In their view, health policy should aim to prevent reproduction among “low quality” human stock .., and encourage reproduction among “good” stock…
The development of “natural childbirth” owed much to the activities of physicians and health professionals who were in sympathy with the aims of reform eugenics…
[T]hese health reformers were concerned about the differential birth rate—the tendency of poorer, less healthy sections of society to have larger families than their “betters”. Thus, as well as endorsing plans for the sterilisation and detention of “degenerates”, they also sought to encourage the middle classes to have more children… Female education and employment were seen as a particular evil, insofar as they led women to regard motherhood a burden and to neglect hearth and home…
One obvious way to reverse the falling birth was to entice women of “superior stock” back into the home, where they would fulfill their functions as wives and mothers. Health reformers took up the challenge by developing an ideology of childbirth that emphasised the “naturalness” of pregnancy and birth. This ideology functioned at a number of levels. It was prescriptive, in that it rooted woman’s social role in her biological capacity for reproduction… Motherhood was not only a woman’s supreme fulfilment and reward, but also her civic duty…
Read himself stated:
“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.
Moscucci writes:
Whether women experienced pain or not depended on cultural attitudes to childbirth rather than on some property inherent to parturition. Dick-Read … claimed that primitives experienced easy, painless labours. This was because in primitive societies the survival value of childbirth was fully appreciated and labour was regarded as nothing more than “hard work” in the struggle for existence. In civilised societies on the other hand a number of cultural factors conspired to distort woman’s natural capacity for painless birth, producing in woman a fear of childbirth that hindered normal parturition…
To eliminate pain, the fear-tension-pain cycle must be broken … Women had to be “tactfully, gradually and carefully initiated into the job they were about to perform”. Education in the “facts” of natural childbirth and instruction in the methods of relaxation were the chief weapons in the battle against fear… According to Dick-Read, these psychological techniques would not only eliminate pain, but also shorten labour and reduce the need for surgical interference.
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 fabrications.
219 Responses to ““The mother is the factory””
Oh, hehe at first I didn’t get it. It’s a Glenn Beck parody. (sorry, sarcasm)
It must be because I learned in middle school that the whole guilt by association argument is highly suspect in critical thinking. Although it is used with great success by Fox and MSNBC. “I’m just saying, isn’t it interesting?”
Otherwise, you could discredit the american labor movement by it’s association with Lenin and Stalin. You could discredit modern psychotherapy by quoting some of Freud’s looney ideas. (and I don’t want to even go into the whole lobotomy and shock therapy fiasco).
As a supporter of great medically based prenatal care and hospital birth (my children were adopted, but I want my friends and family to be safe). I have to say, arguments like this may seem effective but there are more credible ways to make your point.
Your other recent piece on home birth vs hospital birth seemed much more credible.
Of course, it is historically interesting to know that Grantly Dick-Read shared the eugenic obsession with middle-class procreation fashionable in his day. However, I think you would do better, in a forum that presents itself as ‘science-based medicine’, to move away from the rehashed ad hom, and address his claims directly by reference to the scientific literature.
For example – what, if any, impact does fear and/or tension have on pain perception? Can pain be reduced with information and/or relaxation techniques? If you address yourself to these questions, then we can have the scientific discussion.
It would also really help if you would define your terms. “Natural childbirth” covers a lot of ground. Specifically in relation to your theme, you will find some who argue that the pain of labour has a role in the production of oxytocin, and others who argue that self-hypnosis can and should be used for a painfree labour. Two very different positions in relation to the issue of labour pain.
I would totally agree with you on the natural fallacy. Natural doesn’t automatically = better. At the same time, a reasonable starting position for evidence-based maternity care is that “any interference with the natural process of pregnancy and childbirth should…be shown to do more good than harm.” and that “the onus of proof rests on those who advocate any intervention.” (Enkin et al, Guide to Effective Care in Pregnancy and Childbirth).
Wow, where to start!
Amy says, “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.”
Is giving birth through a vagina without pain medication really an invention?
Was there any research done at the time that showed that the primary reason why middle and upper class women were not having as many children was because of fear of the pain of childbirth, or were there perhaps other factors involved?
What did birth look like at this time for middle and upper class women compared to the lower class women? Were they all birthing in hospital? If there was a sudden movement urging naturalness of pregnancy and birth, what had been the prevailing attitude towards pregnancy and birth amongst those three groups?
This article is seriously lacking important contextual detail.
Amy quotes Moscucci, “To eliminate pain, the fear-tension-pain cycle must be broken … Women had to be “tactfully, gradually and carefully initiated into the job they were about to perform”. Education in the “facts” of natural childbirth and instruction in the methods of relaxation were the chief weapons in the battle against fear… According to Dick-Read, these psychological techniques would not only eliminate pain, but also shorten labour and reduce the need for surgical interference.”
How would this be incompatible with a woman being educated, employed, or independent? I don’t see it as a call for women to give up university books, marry young and produce a child every other year, or for women to more closely emulate primitive women in all aspects of their lives, but rather to learn from them that pregnancy and birth should not be viewed as terrifying and extraordinarily painful by default. Additionally, is there something wrong with a doctor recommending techniques that he observed shortened labour and reduced the need for surgical interference? Doesn’t sound like a bad idea to me, especially when the techniques are not harmful physically or mentally.
As a woman with low-risk pregnancies who has given birth naturally twice using hypnobirthing techniques, I can say that going into birth without fear and using relaxation most certainly helped me cope with the pain and birth easily. Was I merely duped by racist and sexist fabrications? Would a medicated or surgical birth be more feminist and non-racist? I will not be having more children besides these two, and my decision is certainly not based on how painful I found my labours and births.
“Was I merely duped by racist and sexist fabrications?”
Hynobirthing???? Someone defiantly duped you.
“Natural” childbirth advocacy has virtually nothing to do with childbirth in nature. It is a modern philosophy that was created from whole cloth less than 100 years ago.
Advocates like to claim that “natural” childbirth is based on science. Nothing could be farther from the truth. I think it is very important to go back to the origins of the philosophy in order to understand that it was made up by white men to control white women. Grantly Dick-Read, Lamaze, Bradley, etc. denied that it is a philosophy and insisted that it is based on science. Starting from Grantly Dick-Read and extending to the present day, though, there has been no effort by those who promulgated the philosophy to subject its fundamental principles to scientific testing.
StatlerWaldorf:
“Is giving birth through a vagina without pain medication really an invention?”
There is very little about “natural” childbirth that recapitulates childbirth in nature.
“Natural childbirth” as practiced in first world countries virtually always involves prenatal care, blood pressure monitoring , urine dipsticks for protein and sugar, listening to the fetal heartrate, routine weights, measurement of hematocrit, blood type, Rh status, checking for evidence of previous exposure to viral diseases and sexually transmitted diseases, a prescribed diet, prenatal vitamins, etc. etc. etc. None of these things occur in nature; they are not natural. So pregnancy, as managed in the natural childbirth movement (and make no mistake, it is managed) bears absolutely no relationship to pregnancy in nature.
Let’s take a look at labor and delivery then. That’s not natural either. It always involves the use of technology such as blood pressure measurement and fetal heartrate monitoring. Most midwives carry medication and resuscitation equipment, decidedly non-natural. In fact, there really isn’t much about childbirth that is natural, either. There are only two things that hark back to nature in the natural childbirth movement, the decision to forgo pain medication and the refusal to have an episiotomy. In the case, of the perineum, the expectation is always that any significant tears will be repaired with sutures, so that’s not natural either.
Essentially, the movement that touts itself (falsely) as the “natural” childbirth movement is really the childbirth with pain and without episiotomy movement. Calling yourself the “painful childbirth movement” doesn’t really sound that great. Natural childbirth sounds so much better.
And of course that doesn’t even address one of my favorite questions: If “natural” childbirth is so natural, why must it be taught by special instructors in lengthy courses?
Plonit:
“For example – what, if any, impact does fear and/or tension have on pain perception?”
Virtually none. Grantly Dick-Read simply made it up.
I didn’t claim that it did. Only that this is the terrain for scientific debate, not Dick-Read’s ideology.
I didn’t know about this history. Eugenics has stained some of the most important names of the 20th century, so I’m not surprised to find it here.
However, I want to second Plonit’s question: what do you mean when you say “natural childbirth”? Does it mean without drugs or surgery? Or without fetal monitoring?
When I had my children, the prebirth education given at the hospital focused on techniques to deal with pain, not deny it. These were very helpful in letting me approach the difficulty of labor with a sense of active participation. This attitude, and the supportive attention of CNMs, allowed me to get through the pain of labor without medication or panic.
While the natural childbirth movement is relatively modern and may indeed have had some of its roots in sexism, I disagree with some of the premises in the article above.
* Painful labor as punishment for being an uppity woman is a 20th century conceit.
Not true. This idea actually predates recorded history, and is commonplace even (ironically) in societies which the eugenicists would have deemed “primitive”. There are many, many societies which have not only held this belief, but used it explicitly as justification for subjugating women. Women have difficult, painful labors. Ergo, they are being punished by the gods. And they are likely to die in childbirth, so it’s best not to get too attached to them anyway. It even turns up in the book of Genesis, where it is punishment for Eve’s sin.
* Hysteria was invented by sexist male doctors trying to encourage women back into the home.
Also not true. While the sexist male doctors clearly were trying to use the concept that way, they didn’t come up with it on their own. Not only did the concept precede them by millenia, but they didn’t even come up with the idea of using it to hoodwink women into staying in the home. “Hysteria” is a Greek word; the ancient Greeks believed that psychological disorders in women were the result of a wandering uterus. Hysteria, indeed.
* Women should be able to put up with the pain.
Again, a very old idea, held by every group which didn’t think it necessary to actually ask women for their opinions on the matter. Unfortunately, there is a tendency to minimize the amount of pain relief considered if nobody thinks it important to ask the patient for their opinion, moreso if the patient can’t offer an opinion anyway. For instance, the adoption of pain relief in NICUs has been slow. Of course, aggravating this in the early 20th Century was a philosophy, commonplace at the time (and well described in the article), that people in general should be able to tolerate herculean trials without complaint. Again, this is not novel to the 20th Century, but it was experiencing a bit of a comeback after the relative decadence of the Victorian period.
I’m disinclined to think that these men were basing their views on pain relief on sexism, at least consciously, but the eugenics argument has merit. They may have felt that those women better suited to childbearing (certainly there are women who give birth very easily and with almost no pain) would thus produce more offspring, encouraging that trait. Still, I don’t think it should be implied that they made all of this up in a vacuum. They based this on *established views*, which is why it was so easily accepted by those who read their work. It was entirely consistent with what people already believed.
Dacks:
“Eugenics has stained some of the most important names of the 20th century, so I’m not surprised to find it here.”
It did not merely “stain” the philosophy of natural childbirth, it was the raison d’etre.
“Natural” childbirth is the affectation of a particular segment of society. It is embraced by Western, white, relatively well off women with a high school or some college education. It is not at all popular among women of color or women who reside in non-Western countries. That, of course, calls into question the designation “natural” since most women are not interested in it and don’t believe in its fundamental principles.
“Natural” childbirth is a bunch of white men telling white women that the pain of childbirth is all in their heads or that they are “improved” by suffering agonizing pain. It is in keeping with the early 20th Century view of women as subject to “nervous” disorders located in the uterus (e.g. hysteria).
Most importantly, it has no basis in science. “Natural” childbirth is not better, healthier, safer or superior in any way.
“This attitude, and the supportive attention of CNMs, allowed me to get through the pain of labor without medication or panic.”
But what made you choose that as a goal?
Calli Arcale:
“Still, I don’t think it should be implied that they made all of this up in a vacuum.”
If I implied that, I did not intend to. It was made up in keeping with the prevailing view of women and people of color, and owing more than a little to traditional belief that labor pain is punishment for women’s sins.
Amy, you still haven’t defined “natural” childbirth.
Dacks:
“you still haven’t defined “natural” childbirth.”
It is a philosophy that places a premium on avoiding pain medication in childbirth and considers refusing pain medication to be “empowering” and an “achievement.” The conceit of the “natural” childbirth movement is that it recapitulates childbirth in nature, but it bears almost no resemblance to childbirth in nature. In its contemporary incarnation it claims to be based on scientific evidence, but it never has been and it is not based on science now.
This is nip picky but when arguing against a certain method try, defining your terms. Some jargon is acceptable within professional journals, or blogs, but to the broader public “natural childbirth” does not have such a distinct definition (as you later use in the comments).
I have meet women who would easily tell you that using lamaze in a hospital setting is natural childbirth or going without an epidermal unless necessary, or to avoiding inducing labor if possible. I don’t think it is your intention to paint them all with the same brush. But I assure you they will feel painted.
Plonit:
“For example – what, if any, impact does fear and/or tension have on pain perception?”
Amy Tuteur – Virtually none. Grantly Dick-Read simply made it up.”
Virtually none? Source? I have not idea why all the cognitive therapists and pain clinics spend so much time on reducing anxiety and stress in chronic pain patients then.
I can see that childbirth as it is today has been greatly reformed since my mom gave birth to me in 1965 (stories, I don’t claim to remember it;) and even before that. There have been advances in medicine, but there have also been big advancements in the culture of how mom’s are prepared and treated. Whichever side of the debate you are on, it’s reasonable to believe that reform is at least partly due to the push for “natural childbirth”. Just as more recent improvements in hospice care and pain management are at least in part due to Jack Kevorkian and assisted suicide. The medical establishment was forced to look at themselves and say “look, we can do better.” and they have.
By arguing in such a general manner against a vaguely defined historical technique you unfortunately seem to be setting yourself against a lot of the improvements that have occurred in the last fifty years.
Look, if we look back on the literature for “anti-natural childbirth” or pro medical establishment or SBM of 1942 we could probably find some pretty appalling stuff. It just doesn’t prove much.
If you insist on pursuing the against home birth argument. (And I can think of a lot of topics that would be less redundant, such as advances in prenatal care, the impact and limitations of prenatal care, gardisal, health insurance, etc.) Perhaps an illustration of the typical hospital delivery TODAY. In my experience a lot of childbirth woo is based solely on false impressions and horror stories from many years ago.
“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.”
“It is a philosophy that places a premium on avoiding pain medication in childbirth and considers refusing pain medication to be “empowering” and an “achievement.” The conceit of the “natural” childbirth movement is that it recapitulates childbirth in nature, but it bears almost no resemblance to childbirth in nature. In its contemporary incarnation it claims to be based on scientific evidence, but it never has been and it is not based on science now.”
Which is it – that childbirth is not painful, or that medication isto be avoided at all costs? And do this cover all of what you see as “natural” childbirth?
BTW, my “goal” was to have a healthy baby, but getting there without medication or fear seems like a reasonable approach, if it is possible.
Amy Tuteur, MD “It is a philosophy that places a premium on avoiding pain medication in childbirth and considers refusing pain medication to be “empowering” and an “achievement.” The conceit of the “natural” childbirth movement is that it recapitulates childbirth in nature, but it bears almost no resemblance to childbirth in nature.”
Slant, Slant, Slant.
I’m sorry I know I’m picking on you now and I’m going to walk away from the computer. But, please. I don’t even know what you are arguing against now. not using pain medication? A suggestion that a doctor should listen to a patient that would prefer not to use pain medication unless necessary? It is so hard to read when everything is slanted.
If it’s any comfort, I also dislike Micheal Moore’s approach even though I agree with almost all his politics.
I’m stopping now.
SO?
I guess that’s my reaction to this post. So what? Lots of philosophies that we like now were founded on shady premises way back when. Who really cares now? And what does this have to do with science at all?
What do you have against women who want to birth without pain relief? Is there science proving that it’s dangerous to birth without pain relief?
I’ll admit my bias here. I’ve had 3 births. The first I got an epidural. Then I proceeded to have vaginal exams performed on me without warning or consent. And I was administered Pitocin without my knowledge or consent (reviewed my records later). And I seriously injured my tailbone while pushing on my back. All and all a painful and humiliating experience, with a long recovery time afterwards. I went on to have two drug-free births. My experience WAS empowering and my recovery time after my drug-free births was minimal.
More than anything, as a birthing woman I am a human being and a consumer of obstetric services. I have a right to give birth with or without drugs. Unless you have scientific evidence to the contrary I’m not sure what the point is in spreading your hate for “natural child birth.”
So Grantly Dick-Read had some biases? So what? Apparently you do too.
Sorry, but I’m afraid you haven’t convinced me, Amy, at least not with this post. Insufficient historical context is given to be convincing, and none of these ideas is new. Various “back to nature” movements have existed since…well…since the rise of cities and city-states. Moreover, even if you are right and eugenics was the raison d’etre for the home birth movement, it would not be a good argument as to whether home birth is unsafe. After all, creationists try to discredit “Darwinism” will point out that its adherents point out that eugenicists used “Darwinism” as a justification for their movement, even though evolution does not refer to artificial selection. Even if it were true that Hitler channeled Darwin as the inspiration for the Holocaust, that would not say one thing about the scientific merits of Darwin’s theory of evolution by natural selection. Your first post was far more convincing.
And Calli is absolutely right. Each and every concept you attribute to the home birth movement is actually very ancient. None of them originated with the home birth movement, although certainly you do provide evidence that the movement appropriated them for their own uses. Heck, the idea that painful childbirth is a punishment on “uppity” women is enshrined in Judaism and Christianity along with the concept of original sin. It’s right there in Genesis, written nearly 3,000 years ago. Painful childbirth was the penalty for Eve’s having tasted of the fruit from the tree of the knowledge of good and evil.
David:
“Sorry, but I’m afraid you haven’t convinced me, Amy, at least not with this post.”
The limitations of the blog format is that I can only write one post at a time. I intend to expand upon the topic over time.
My central claims in this post are:
1. “Natural” childbirth is a philosophy, and not based in science.
2. The origins of the philosophy of “natural” childbirth are in racist and sexist notions about childbirth, not in any empirical observations of childbirth.
“Heck, the idea that painful childbirth is a punishment on “uppity” women is enshrined in Judaism and Christianity along with the concept of original sin. It’s right there in Genesis, written nearly 3,000 years ago. Painful childbirth was the penalty for Eve’s having tasted of the fruit from the tree of the knowledge of good and evil.”
And that is part of my argument. Grantly Dick-Read and other originators of “natural” childbirth were the products of centuries of racist and sexist notions about women, pain and punishment. Dick-Read did not observe painless childbirth, he made it up.
Does this prove that “natural” childbirth is just an affectation of Western, white women? No, of course not. However, I thinking is important to start with a historical overview because “natural” childbirth cannot be understood without understanding its history.
BTW, homebirth is just one subset of the “natural” childbirth movement, and not even the most radical one. The latest fad is unassisted homebirth, without a provider of any kind.
Dacks:
“Which is it – that childbirth is not painful, or that medication isto be avoided at all costs?”
One of the hallmarks of pseudoscience is that it is often contradictory on its face. Internal contradictions are simply ignored.
Childbirth is painless. Childbirth is very painful, but the pain can be managed with the right attitude. Not only is childbirth not painful, it is actually pleasurable. Childbirth is orgasmic! All of these claims co-exist within the “natural” childbirth movement.
NDL:
“And what does this have to do with science at all?”
“Natural” childbirth itself has virtually nothing to do with science. It is a philosophy based on empirical claims that are false or made up. I’m simply starting my indictment of “natural” childbirth at the beginning, when its pioneers first fabricated their claims.
StatlerWaldorf:
“Is giving birth through a vagina without pain medication really an invention?”
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The question still stands Amy.
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“There is very little about “natural” childbirth that recapitulates childbirth in nature.
“Natural childbirth” as practiced in first world countries virtually always involves prenatal care, blood pressure monitoring , urine dipsticks for protein and sugar, listening to the fetal heartrate, routine weights, measurement of hematocrit, blood type, Rh status, checking for evidence of previous exposure to viral diseases and sexually transmitted diseases, a prescribed diet, prenatal vitamins, etc. etc. etc. None of these things occur in nature; they are not natural. So pregnancy, as managed in the natural childbirth movement (and make no mistake, it is managed) bears absolutely no relationship to pregnancy in nature.
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There may be a small fringe of people who want a pregnancy free from any monitoring, but that is not a belief that the majority of “natural birthers” share. I’d also like to point out that Grantly Dick-Read never suggested that naturalness in pregnancy and birth should be free of prenatal care or medical expertise.
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Let’s take a look at labor and delivery then. That’s not natural either. It always involves the use of technology such as blood pressure measurement and fetal heartrate monitoring. Most midwives carry medication and resuscitation equipment, decidedly non-natural. In fact, there really isn’t much about childbirth that is natural, either. There are only two things that hark back to nature in the natural childbirth movement, the decision to forgo pain medication and the refusal to have an episiotomy. In the case, of the perineum, the expectation is always that any significant tears will be repaired with sutures, so that’s not natural either.
Essentially, the movement that touts itself (falsely) as the “natural” childbirth movement is really the childbirth with pain and without episiotomy movement. Calling yourself the “painful childbirth movement” doesn’t really sound that great. Natural childbirth sounds so much better.
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That’s cute Amy, and you are great at cute responses.
Natural childbirth has never been about giving birth exactly like our primitive ancestors did, but rather making use of medical intervention when necessary, and otherwise letting nature take its course when there is no evidence that mother or baby are in danger. The female human body has its own mechanisms for birthing, just like all animals on this planet. If these mechanisms supposedly don’t exist and the majority of females are faulty when it comes to labour and birth, then our species could never have survived long enough for modern medicine to be invented to help secure lower maternal and infant mortality rates. Just because medical equipment is present at a birth, doesn’t mean a birth can’t be natural.
Natural birth could be defined ideally as spontaneous onset of labour, freedom of physical movement, absence of fear or intrusions to aid relaxation and efficient progression of labour and reduce pain, and vaginal birth of the baby in whatever position feels best for the mother and baby. This does not rule out prenatal care or the presence of medical equipment and experienced attendants to deal with any medical emergencies or non-emergency necessary procedures like suturing tears. A natural birth can still occur in the absence of some of those ideals, for example, induction could still be followed by a “natural” birth – the definition may be different for different people. A cesarean birth would not be deemed a natural birth.
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“And of course that doesn’t even address one of my favorite questions: If “natural” childbirth is so natural, why must it be taught by special instructors in lengthy courses?”
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What about the lengthy childbirth courses and books that educate thoroughly on medicated medicalized childbirth? (Like your pregnancy and birth “how-to” book Amy.) When women turn up at the hospital they are often instructed what to do by the medical personnel. No worries if you want to anesthetize your body because the people outside of your body and the machines will tell you what’s going on and what to do.
After having given birth unmedicated once with coached pushing and once without, I can personally say that my body knows how to expel a baby without someone bellowing instructions.
StatlerWaldorf:
“If these mechanisms supposedly don’t exist and the majority of females are faulty when it comes to labour and birth, then our species could never have survived long enough for modern medicine to be invented to help secure lower maternal and infant mortality rates”
No, that’s yet another pseudoscientific claim that is integral to “natural” childbirth.
The fact is that human reproduction, like reproduction throughout the animal kingdom, has a tremendous (and entirely natural) amount of wastage. We’ve all seen nature shows about sea turtles who lay hundreds of eggs, with the result that only a few baby turtles survive the treacherous walk across the beach to the safety of the ocean. We know that some animals, like salmon, give up their own lives in the process of reproduction.
There is a tremendous amount of wastage in human reproduction also. The miscarriage rate for established pregnancies is 20%. That means that 1 in 5 pregnancies will not survive to result in a live birth. Pregnancy and childbirth also have a “wastage” rate. In nature, many women and babies did not survive the process. That is a natural part of human reproduction.
The fact that “we are still here” only tells us that in every generation, the number of people who lived exceeded the number who died. It doesn’t tell us anything about the ratio. So, for example the population will grow at a certain rate if each couple has 3 surviving children. It does not matter whether the couple had 3 children, all of whom survived, or 10 children, 7 of whom died.
Dr Tuteur, I have to disagree with you in some things.
There is nothing wrong, in my mind, with a woman wanting to give birth to a child with a few interventions as possible. The “natural childbirth” people have different viewpoints, but the major one is that a woman should have the RIGHT to give birth the way she wants to, provided that the health and safety of the fetus and herself are not compromised.
As a CNM, I had the job of helping women give birth (I did NOT deliver babies…I was not a delivery person supplying goods, I was a professional assisting a woman with a natural body function). There were times when interventions…from as simple as pelvic exam to as complex as a c-section with total hysterectomy…were necessary. Bad fetal tracing? IV fluids, oxygen, continuous monitoring are all appropriate. Patient uncomfortable and requesting an epidural? Appropriate, once she has given informed consent, which entails also offering other options for pain management, from a hot shower, to walking, to IV pain medication.
But many times, as a nurse and as a midwife, I saw women undergoing unnecessary interventions. Why should a woman laboring normally and comfortable, with a responsive fetal tracing, have to lie in bed if she wanted to be up and walking around?
Why shouldn’t a woman be able to refuse an epidural if she really didn’t want one (I had a physician threaten a patient and yell at her when she complained about how rough he was…he was so used to epiduralized women that his exams were very rough and he refused to use local for her epis repair “because it’s all her fault she feels anything”.)
Why should a woman who comes in 9 cm dilated and ready to deliver have to agree to an epidural “so I can make the delivery…I’m at the golf course. Just tell her she has to have the epidural and not to push.” (We let the resident do that delivery because we refused to call anesthesia; the patient didn’t want an epidural, she wanted to deliver the baby!)
In our area, there is one hospital with an 98% epidural rate for women, with a nearly 50% c/s rate. This is not a high risk hospital. It is Yuppie Hospital. The woman come in at 1 cm with every 10-20 minute contractions, and Dr Friendly says, well, let’s just get you delivered. We’ll start the epidural, and then the pit and you won’t be in pain any more and you can have your baby during the day instead of at night. These women aren’t educated on natural childbirth OR the risks of the medical procedures. I’ve been to the childbirth classes (as a coach for friends…and yes, I kept my mouth shut, as hard as it was. They loved their doctor). They teach “being a good patient” essentially. NOT the normal stages of labor, other ways to cope with labor contractions besides an epidural.
Your bias as an interventionalist OB is showing. I don’t think, from your postings, that you would ever work with a CNM, as my gynecologist does. You seem to think that your way of delivering patients is the only right way, and scorn all other ways.
Adam_y said,
“Hynobirthing???? Someone defiantly duped you.”
Have you practiced hypnobirthing and then applied the techniques while giving birth? Have you looked at any research on self-hypnosis for pain management?
Here is a recent study that used similar techniques as hypnobirthing for helping kids cope with stomach pain. “Soothing imagery may help rid some kids of stomach pain” – http://www.nlm.nih.gov/medlineplus/news/fullstory_90528.html
With Pediatrics abstract here – http://pediatrics.aappublications.org/cgi/content/abstract/124/5/e890
If this is science-based medicine, then lets talk about the science behind pain reduction or elimination. I would argue that there are non-pharmacological ways to manage pain.
Plonit asks,
“For example – what, if any, impact does fear and/or tension have on pain perception?”
Now these are interesting scientific questions!
Dr Tuteur, I have to disagree with you in some things.
There is nothing wrong, in my mind, with a woman wanting to give birth to a child with a few interventions as possible. The “natural childbirth” people have different viewpoints, but the major one is that a woman should have the RIGHT to give birth the way she wants to, provided that the health and safety of the fetus and herself are not compromised.
As a CNM, I had the job of helping women give birth (I did NOT deliver babies…I was not a delivery person supplying goods, I was a professional assisting a woman with a natural body function). There were times when interventions…from as simple as pelvic exam to as complex as a c-section with total hysterectomy…were necessary. Bad fetal tracing? IV fluids, oxygen, continuous monitoring are all appropriate. Patient uncomfortable and requesting an epidural? Appropriate, once she has given informed consent, which entails also offering other options for pain management, from a hot shower, to walking, to IV pain medication.
But many times, as a nurse and as a midwife, I saw women undergoing unnecessary interventions. Why should a woman laboring normally and comfortable, with a responsive fetal tracing, have to lie in bed if she wanted to be up and walking around?
Why shouldn’t a woman be able to refuse an epidural if she really didn’t want one (I had a physician threaten a patient and yell at her when she complained about how rough he was…he was so used to epiduralized women that his exams were very rough and he refused to use local for her epis repair “because it’s all her fault she feels anything”.)
Why should a woman who comes in 9 cm dilated and ready to deliver have to agree to an epidural “so I can make the delivery…I’m at the golf course. Just tell her she has to have the epidural and not to push.” (We let the resident do that delivery because we refused to call anesthesia; the patient didn’t want an epidural, she wanted to deliver the baby!)
In our area, there is one hospital with an 98% epidural rate for women, with a nearly 50% c/s rate. This is not a high risk hospital. It is Yuppie Hospital. The woman come in at 1 cm with every 10-20 minute contractions, and Dr Friendly says, well, let’s just get you delivered. We’ll start the epidural, and then the pit and you won’t be in pain any more and you can have your baby during the day instead of at night. These women aren’t educated on natural childbirth OR the risks of the medical procedures. I’ve been to the childbirth classes (as a coach for friends…and yes, I kept my mouth shut, as hard as it was. They loved their doctor). They teach “being a good patient” essentially. NOT the normal stages of labor, other ways to cope with labor contractions besides an epidural.
Your bias as an interventionalist OB is showing. I don’t think, from your postings, that you would ever work with a CNM, as my gynecologist does. You seem to think that your way of delivering patients is the only right way, and scorn all other ways.
Additionally: since this is a SBM site, where are all the studies that show epiduralized, continuously monitored births have better outcomes than ambulatory, unmedicated births?
Amy Tuteur said,
“StatlerWaldorf“If these mechanisms supposedly don’t exist and the majority of females are faulty when it comes to labour and birth, then our species could never have survived long enough for modern medicine to be invented to help secure lower maternal and infant mortality rates”
No, that’s yet another pseudoscientific claim that is integral to “natural” childbirth.
—————————————————————–
Actually, this is a claim I have made and I am not the official spokesperson for “natural childbirth”.
I would argue that emphasizing the smaller percentage of disfunction in female birth mechanisms and de-emphasizing the larger percentage of normally functional female birth mechanisms is integral to modern obstetrics and gynecology.
“Childbirth is painless.
Childbirth is very painful, but the pain can be managed with the right attitude.
Not only is childbirth not painful, it is actually pleasurable. Childbirth is orgasmic!…”
These are contradictory claims, certainly. But they are distinct, and one could examine the validity of each one. (Personally, I can’t see how you can argue against using pain management techniques, but that’s just my opinion)
By lumping the outlandish claims in with more nuanced claims, you are doing exactly what CAMers do all the time – for instance, mixing advice about vitamins and exercise in with advice on balancing chakras.
I read this blog for reasoned discussions of medical topics, not for propaganda. This post gave me some interesting info about the motives of one of the founders of “natural” childbirth, but it doesn’t tell me anything about what this practice actually entails, and what the risks and benefits might be.
StatlerWaldof:
“I would argue that emphasizing the smaller percentage of disfunction in female birth mechanisms and de-emphasizing the larger percentage of normally functional female birth mechanisms is integral to modern obstetrics and gynecology.”
And that’s another pseudo-scientific claim of “natural” childbirth advocacy.
Childbirth is and has always been, in every time place and culture, a leading cause of death of young women and the most dangerous day of the 18 years of childhood is the day of birth.
Childbirth is inherently dangerous, not inherently safe. The mortality rates are extraordinarily high, considering that it is a routine bodily function. For example, in the absence of modern obstetrics, approximately 40,000 American women would die each year in childbirth. That would rival breast cancer as a cause of death.
The limitations of the blog format is that I can only write one post at a time. I intend to expand upon the topic over time.
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Actually, that is not true, since all your posts have already been posted at homebirthdebate. There is nothing preventing you from uploading your entire corpus at once, other than the tolerance of your hosts.
Dacks:
“I read this blog for reasoned discussions of medical topics, not for propaganda.”
“Natural” childbirth is a form of woo. That makes it an excellent topic of discussion for this blog.
I realize that vaccine rejectionism, CAM, etc. are more widely understood to be pseudoscience, but that’s just because skeptics have not paid much attention to “natural” childbirth. Hopefully, we can change that.
Amy,
So by your agument, you are against birth contreol as well, as it’s philosophical origins in eugenics are well documented.
I really, really don’t understand your level of contempt for those who seek and choose natural childbirth. THose that choose this path beleive that birth can be a transformative experience, akin to a religous experience and is a rite of passage. Many ancient cultures believe this (and actually, they DID use drugs on occassion when needed), and still do.
Thus, some women feel that something vital is missing from highly medicalized birth (the definition if which, is dependant on each individual woman).
You may well scoff at this notion, and from the few posts I have read from you, I will even expect it. But I would love to see you scoff in the face of the many aborginal midwives that I know (who have excellent records, btw).
Don’t you see, that people want to reclaim the SIGNIFICANCE of birth in their lives, which is not just about getting a baby. Ask any woman who has given birth what the most important days of their lives were, and they will invairably tell you about the day their children were born. For better or for worse. Some women feel that unmedicated is the best way for them to experience it. SOme women want to have more of a say in what is happening to them on these days.
We can look at sceince for safety and we can all be strong proponents of evidence based practice, but looking at childbirth only through this lens is a mistake.
It is like looking at a baptism in the same way you look at the quick shower.
If people would read the paper that Dr Amy cited, the meanings of the terms will have more context.
My understanding of what “natural childbirth” means to most people is that there is some default childbirth process that in the absence of unnatural interventions a woman will go through. Presumably, that is the childbirth process that “primitive” women go though because they don’t have access to unnatural interventions.
I think that Dr Amy’s point is that the motivation for the “back to nature” childbirth in the 1920’s and 30’s was due to the perception of an unacceptably high mortality during childbirth and the desire to return to the halcyon days of “natural childbirth”; a time that never existed. It was imagined to exist because there was no good data. People didn’t record all the infant deaths because there were so many. Infant and maternal mortality in hospital births is now lower than it has ever been. There is no “natural childbirth” at any time or place in the history of humanity that people can point to with a demonstrated lower mortality.
Most women going through childbirth will survive as will most babies even with no intervention. “Most” is not good enough. 90% is not good enough. 99% is not good enough. 99.9% is not good enough. Distinguishing between 99% and 99.9% can’t be done by an individual. Distinguishing between small risks is hard, people tend to go with their “gut”, and if they “feel” safe. Feeling safe and being safe are two completely different things (as we all know). Feeling safe and having a 90% successful outcome might feel better than feeling unsafe and having a 99.9% successful outcome. In 1000 births, the 900 women who felt safe and had a successful outcome might feel better about their experience than did the 999 women who felt unsafe and had a successful outcome, but those 99 unsuccessful outcomes outweigh (at least to me) those feelings. They are not my feelings, so it is easy for me to discount them.
Feeling unsafe is what drives people to quacks. That is why quacks try to demonize SBM. Doubt is their product. Getting people to feel unsafe is what gets quacks their bread and butter.
What I find interesting is the perceived association of a vegetarian diet with femininity and consumption of meat with masculinity. Red meat has heme, which tends to increase oxidative stress and reduce NO levels. Vegetables have nitrate which is reduced to nitrite and NO. Low NO increases testosterone levels, high NO reduces them. Estrogen increases NO levels.
I think that higher NO levels would tend to reduce the complications of pregnancy and childbirth. A major cause of death was puerperal fever (systemic Strep infection). The way that physiology deals with that is through sepsis, which generates gigantic quantities of NO, which acts to prevent Strep from forming a biofilm. Anemia (through hemorrhaging) reduces hemoglobin levels and increases NO levels (NO destruction is proportional to the product of the NO concentration and the hemoglobin concentration).
edgar:
“THose that choose this path beleive that birth can be a transformative experience, akin to a religous experience and is a rite of passage. Many ancient cultures believe this”
No, that’s yet another claim made up by “natural” childbirth advocates. In ancient cultures, childbirth was viewed (not surprisingly) with fear. It was understood that both mother and baby could and often did die.
Far from being viewed as transformative, it was often viewed as unclean and women were banished from society until they were completely recovered from it. Hence the Christian practice of “churching” a woman who was barred from church for a specified period after childbirth and the Jewish practice of “benching gomel” in thanks for surviving a potentially deadly event.
Many issues have been brought up by this post, I think beyond the scope of the original article (and no, we will not allow the upload of massive amounts of previously written articles).
It seems to me this was more a commentary on the sub-culture advocating for “natural” childbirth, specifically the notion that either women should experience the pain of birth, or that if properly done there should be no pain. I don’t think it’s fair to criticize the post for not addressing a host of other related but distinct issues (like the scientific evidence for or against medicating pain in childbirth). But I suppose Amy could have been more explicit in her post as to it’s scope and context.
To add some evolutionary context – Homo sapiens recently evolved massive brains, which put a great deal of pressure on pregnancy and delivery, forcing a host of compromises and trade-offs. These compromises are imperfect – one of which is that delivery is pushed to the limits of tolerance.
A high complication rate was balanced against giving birth to younger and more helpless infants, for example.
Therefore the naturalistic fallacy is particularly pernicious with regard to childbirth.
But there are many nuances to the issue of childbirth that were not addressed in the post itself, some of which were clarified in the comments.
One further point I wish to make is that, as one commenter pointed out, the evidence does support the notion that emotional state does affect pain perception. In fact, a recent study found that looking at a picture of a pretty person decreased reported pain perception.
But while such techniques are potentially useful (and perhaps an unintended consequence of the original motivation) it is not necessarily true that they are sufficient. I guess much depends upon the goals of the woman giving birth – and that brings us back to the actual purpose of this post.
Amy,
the two are not mutually exclusive. Yes they viewed childbirth with fear because of death, but it is also a ceremonial rite of passage. I work in Indian country and have done extensice MCH work. You are flat out wrong about that, it is not a made up concept but is an integral part of spiritual knowlege.
Perhaps we should call the process “minimal medical intervention childbirth”. About the only thing humans in developed regions do that is “natural” is breathe. In my region women consider giving birth using IV sedation “natural childbirth”.
Dr. Tuteur, you seem to have a deeply biased view against anyone who wants a birth with as little intervention as possible. Most just want a little control and modern obstetrics as practiced in the hospital setting doesn’t support this (at least as practiced everywhere I’ve ever worked). You have cherry-picked to support your bias.
Also, considering his philosophy isn’t Mr. Dick-Read’s name apropos!
edgar:
“an integral part of spiritual knowlege.”
Do you have any references to share with us that support this claim?
I’m not convinced that the same people espouse all of them, or at least in as self-contradictory manner. After all, there is a very wide range of natural childbirth advocacy, and it doesn’t even consistute a spectrum. It may be a bit of a strawman to allege that all of them use all of these claims simultaneously.
BTW, it is quite possible that some proponents actually did witness painless, drug-free childbirth. As I mentioned earlier, some women are blessed with this capacity. It is not common, but it does exist. My father had many Hmong women among his patients, and he witnessed this among them.
momkat:
“you seem to have a deeply biased view against anyone who wants a birth with as little intervention as possible.”
Actually, I would describe my personal philosophy as Burger King childbirth: have it your way.
There is a big difference, though, between choosing various aspects of giving birth and making claims about origins and safety.
The philosophy of “natural” childbirth is woo. It utterly misrepresents the history of childbirth in nature, the history of obstetrics, the safety or lack thereof of childbirth, and the safety of obstetric interventions.
At this point, the philosophy of “natural” childbirth is little more than elevating the personal preferences of a segment of Western, white women to an “ideal” or “achievement” to which all women should aspire. Worse than that, the supposed “scientific” nature of “natural” childbirth has been used by some women to brow beat others, the implication (and often the outright assertion) made that women who choose “natural” childbirth are better mothers.
It has contributed to a climate of mistrust between women and their providers. Most of what “natural” childbirth advocates think they know about the risks of childbirth is factually false, and that makes communicating with them and obtaining informed consent very difficult.
In many ways, “natural” childbirth is the OB equivalent of vaccine rejectionism. It has fostered a culture of fear and mistrust that has benefited no one except those women who believe that they have proved themselves to be better mothers by foregoing pain medication.
Edgar wrote:
I think that this is the key point in the debate. From what I’ve read of Amy’s writing (and if I’m wrong Amy, please correct me), the most important thing is delivering a healthy baby and ensuring that the mother stays healthy as well. Everything else is secondary, including ‘significance’. Anything that increases the risk to mother or baby, for whatever reason, is therefore dangerous.
Calli Arcale:
“My father had many Hmong women among his patients, and he witnessed this among them.”
The reaction to labor appears to be in large part culturally determined. Therefore, no one should confuse lack of screaming with lack of pain.
There are some women who have relatively painless childbirth. As expected, this is a random phenomenon occurring in women of all ethnic and cultural groups. In contrast, claims of orgasmic childbirth and even claims of painless childbirth due to the techniques of “natural” childbirth are restricted almost entirely to Western, white women of the past few decades who have read the “natural” childbirth literature.
This is interesting as history, so far as it goes, but I’m pretty sure that it has little to nothing to do with why people choose to forgo pain relief medications today.
My wife and I were considering childbirth without pain relief for a while. For medical reasons, we ended up not being able to pursue that route, but no one — not the midwives, not the nurses, not the OB/GYN, not my wife’s mother who had had two kids without medication, not any of the books we read — made any claim that childbirth would be painless. They did say that the pain was manageable for most women, and they did say that giving birth was a normal bodily function that only rarely goes wrong and requires additional medical attention. (At which time, of course, everyone was agreed that we would seek and receive such attention immediately, which is indeed exactly what happened.)
You are right that “natural childbirth” as it is practiced today is not, strictly speaking, the kind of childbirth our savannah ancestors experienced in their “natural” habitat. On the other hand, eating a banana in New York in the middle of winter is a highly technologically mediated experience, too. But I think we all recognize that that experience is decidedly more “natural,” in some way, than eating a banana popsicle with artificial flavoring.
Everything about the way human beings live is artificial in some way; artifice is our great evolutionary advantage, after all. But not all innovation is necessarily good — or, to put it another way, not all innovation interacts with our biology and evolutionary history in a way that produces outcomes beneficial to our physical and psychological well-being. In the case of the banana, we can see that using technology to bring us nutritious food in the winter seems to be a net plus for the organism, while the banana popsicle may be somewhat less so. And the fact that the banana is somewhat more “natural” is important here, because human being evolved to eat fruit (even if it’s been shipped to us by complicated, decidedly non-natural means), and not popsicles.
The case of pain relief is interesting in this regard. Pain is unpleasant, and yet often we seek it out. Marathon runners are, in their way, doing the same thing that women who forgo pain relief in childbirth are: deliberately seeking out a difficult and painful but ultimately rewarding personal challenge. (And, incidentally, getting somewhat closer to the experience of our ancestors, who were long-distance runners and persistence hunters.) There’s something in the human organism that craves that experience, and I think that psychological need is a reasonable thing to balance against the convenience of pain relief.
You’re making a historical argument here that the idea of forgoing pain medication at birth is rooted in “racist and sexist notions about childbirth, not in any empirical observations of childbirth.” I’m just not sure that’s true. It may be that this fellow had such notions AND championed “natural childbirth.” But as David pointed out, that’s mere guilt by association.
In fact, most people interested in “natural” childbirth today simply note THROUGH EMPIRICAL OBSERVATION that the painful labor of birth can be very psychologically rewarding for women who want it and are prepared for it, while on the other hand also noting THROUGH EMPIRICAL OBSERVATION that childbirth can be dangerous in a small number of cases and that it’s nice to have all the safeguards that modern medicine can provide. Not sure there’s anything particularly sexist, racist, or, indeed, problematic about that.
One further point I wish to make is that, as one commenter pointed out, the evidence does support the notion that emotional state does affect pain perception. In fact, a recent study found that looking at a picture of a pretty person decreased reported pain perception.
But while such techniques are potentially useful (and perhaps an unintended consequence of the original motivation) it is not necessarily true that they are sufficient. I guess much depends upon the goals of the woman giving birth – and that brings us back to the actual purpose of this post.
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And yet knowledge of how emotional state mediates pain perception is useful – regardless of the goals of the woman giving birth.
Sometimes the anaesthetist is tied up in theatre and cannot attend immediately. Some women will find that epidural analgesia does not provide the level or consistency of relief from pain and/or sensation that they hoped for. Some women are advised against epidural analgesia (for example, if they have low platelets). A precipitate labour may make epidural analgesia impractical. These are women for whom unmedicated labour is a goal, but who may be helped nonetheless by caregivers who have some understanding of the ways in which environment and support may help reduce pain perception.
Anything that increases the risk to mother or baby, for whatever reason, is therefore dangerous.
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At the time when Dick-Read was writing, the forms of pain-relief used in childbirth did increase the risk to mother and baby. Indeed, contemporary critics of Dick-Read acknowledged that “With increased emotional support to the patient, the analgesic drug requirements can
be reduced to levels of greater safety to the mother and infant; that is the principal advantage offered by the program.”
http://www.psychosomaticmedicine.org/cgi/reprint/14/6/431.pdf
Plonit:
“environment and support may help reduce pain perception.”
Possibly, but that doesn’t explain, for example, why the Royal College of Midwives has designated unmedicated childbirth as “normal” and has made it a priority to convince women that they should have a “normal” birth.
I’m not arguing against other forms of pain relief, just as I would never argue against other forms of pain relief for cancer or other types of pain. I would never suggest, though, that other forms of pain relief could be or should be a substitute for effective pain medication.
Amy Tuteur
“Actually, I would describe my personal philosophy as Burger King childbirth: have it your way.
There is a big difference, though, between choosing various aspects of giving birth and making claims about origins and safety”. ….on to the whole comment
This is much better. You show who you are talking about, why you are addressing this issue, what approach you think is appropriate. The only thing I would change is using specific methods instead of saying “natural childbirth” Because to you that may mean one thing, to the audience another.
In your original post it really did not come through to me that you were talking about a particular ideology being dishonest or using popular misconceptions to sell an idea. It sounded more like “they’re based on eugenics, racism and sexism, they must be bad”.
As an aside, as someone who trusted one reproductive endocrinologist too much, some climate of distrust is good, too much is bad. It’s just finding the right balance.
Possibly, but that doesn’t explain, for example, why the Royal College of Midwives has designated unmedicated childbirth as “normal”.
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Are you referring to the Maternity Care Working Party consensus statement, which is also supported by the Royal College of Obstetricians and Gynaecologists. The statement can be downloaded from the RCOG here -> http://www.rcog.org.uk/files/rcog-corp/uploaded-files/JointStatmentNormalBirth2007.pdf
Plonit’s comment concerning the problems with pain medication and access to them really hit home for me.
I had two medicated births and one unmedicated birth. I chose the unmedicated birth because the epidurals in my first two did not work. The first worked on the left side only and only for an hour or so. The second time it didn’t work at all- maybe ‘took the edge off for an hour or so- but it caused a BP rise and some other issues.
So, with my third, I decided for a natural birth and was able to walk around and be on all fours. I really think this helped bring my labor time down from 14 and 17 hours (my first two births respectively) to only 4 hours.
I don’t like being lumped with the candles and incense birthers or with those who preach about their births or tell people how they should birth. I just did what was good for me, and it worked out. I actually had a lot of fun with my third birth; I enjoyed taking classes which would probably be seen as woo since they involved hypnosis and some other crazy stuff, but they were very relaxing and I feel they really helped me.
All that aside, I don’t think it is right for people to preach to other moms about how they SHOULD give birth. In that sense, I agree with a lot of the things Amy has said here…but I think she clarified better in her comments than she did in the post itself.
Thank you for this post, Amy. I was glad to learn more about how the natural childbirth movement got started.
I’ve attended a lot of labors both with and without pain meds. Some women have practically no pain, may not even realize they are in labor until it is far advanced, and I know of one who just thought she had to “go” and dropped her baby in the toilet. Other women experience pain that they can control with LaMaze breathing and other techniques. Other women have intolerable pain. Whatever we do should take cognizance of these wide variations, and the individual’s preferences should be honored unless there are evidence-based reasons to do otherwise.
Two things about natural childbirth bother me:
(1) It is based on ideology rather than on scientific evidence of benefit.
(2) Some women who try for a drug-free birth are made to feel like failures when the pain becomes intolerable and they have to ask for meds.
I was taught that natural childbirth was safer for the baby, and that sometimes the drugs given to women made the newborn groggy. Although I never saw any evidence that temporary grogginess had any significant impact on outcome. There are two patients in childbirth. I always thought that the needs of both mother and child should be considered, and that pain relief could be provided with no serious danger to the baby.
The outpouring of comments demonstrates how much this subject is involved with emotions rather than evidence.
Another interesting historical note: the idea that women “should” suffer in childbirth held sway until Queen Victoria set a precedent by accepting chloroform for the delivery of her seventh child in 1853. She loved it, and other women were encouraged to follow suit.
“It has fostered a culture of fear and mistrust that has benefited no one except those women who believe that they have proved themselves to be better mothers by foregoing pain medication.”
This war appears to be emotional for you, not scientific. Why do you care if someone wants to forego pain meds and what that “says” about them? Is it dangerous to not use pain meds? Does infant or maternal mortality rate increase?
Harriet:
“Some women who try for a drug-free birth are made to feel like failures when the pain becomes intolerable and they have to ask for meds.”
When I was practicing, I spent a lot of time counseling women to have reasonable expectations and even more time counseling women that no one should ever feel like a failure for asking for pain relief for intolerable pain.
“the idea that women “should” suffer in childbirth held sway until Queen Victoria set a precedent by accepting chloroform for the delivery of her seventh child in 1853. She loved it, and other women were encouraged to follow suit.”
That’s right. Another interesting historical note is the genesis of twilight sleep. Many people, doctors and women, were conflicted about whether totally removing pain with chloroform violated the biblical injunction about bringing forth children in pain. Twilight sleep (morphine and scopolomine) was supposed to represent a compromise: women would feel the pain, but not remember it. It was wildly popular among women.
Twilight sleep was largely opposed by doctors who ultimately gave way in response to women clamoring for it. Indeed, national organizations arose in Britain demanding pain relief for women in labor.
No, that certainly wasn’t the case among these women. For one thing, it was true regardless of whether they were raised in a Laotian refugee camp or in St Paul, Minnesota. For another, some of them were not so lucky, and did have painful labors. There was also no cultural taboo about screaming.
One of his patients actually gave birth in a toilet. She had confused the onset of labor with the urge to move her bowels — it felt very much the same to her. The child had a mild concussion from hitting the toilet bowl, but was otherwise fine, and recovered from the concussion with no ill effects.
His Somali patients were not like this, and they most certainly came from a culture which expected them to conceal pain. (Heck, some of them had even undergone genital mutilation at puberty. Without anesthesia. Any pain was to be accepted.)
I realize my father’s experience as a family practice doc is little more than a collection of anecdotes, but there did seem to be such a strong correlation to Hmong women, specifically, regardless of their personal cultural values, that there is probably something physiologic going on. I’ve also talked to European women lucky enough to have rapid, relatively painless (not completely) and uncomplicated childbirth. It’s certainly not a common feature of women. But it happens enough, that I wonder if one of these 1940s physicians may have had an unusually high percentage of such patients and then made a dangerously wrong conclusion.
Addendum: the “dangerous wrong conclusion” I’m referring to is concluding that women *can* have easy childbirth; if they can’t, it’s because they’re doing it wrong (rather than because they and their child* weren’t blessed with the appropriate genes).
*I include “their child” since some of the major events of birth are controlled by the placenta, and so the child’s genes are a factor in how well the birth goes.
Calli Arcale:
“There was also no cultural taboo about screaming.”
I practiced for several years at a neighborhood health center in the local Chinatown. I cared for hundreds of women from all parts of Southeast Asia and China. My colleagues were all almost all from China or Southeast Asia. They were the ones who made it very clear to me that our patients suffered just as much as other women and they taught me about the various cultural constraints in different societies.
I had an American patient (a WASP) in early labor who was screaming and overreacting. I lost my cool (the one and only time in my career), yelled at her, and insulted her. Sort of like administering a verbal slapping to get her attention. She calmed right down, stopped screaming, and had a nice normal labor and delivery. I was afraid she would report me to the hospital commander, but instead she came to my office afterwards for the sole purpose of thanking me for helping her get control of herself. I’m not proud of what I did, but it sure worked! I’ve often wondered if there was any “nice” way I could have accomplished the same thing. It’s hard to sit down and reason nicely with someone who is hysterical and out of control.
Then you will surely understand that Asian culture is not homogenous, and that though influential people within the Chinese government may wish for Han Chinese to be the dominant ethnic group, they do actually not comprise an ethnic majority. (Perhaps this is not coincidental to our discussion, considering what ethnic Han had done to the Hmong over the course of several centuries.)
He also had other Asian patients. He did not observe the same things in them that he observed in Hmong patients. Surely you appreciate that this fairly small (and, until roughly the time of the Vietnam war, quite isolated) ethnic group may not be identical to the rest of southeast Asia?
BTW, cultural attitudes towards pain can hardly explain why so many Hmong women would be completely dialated in under fifteen minutes. (Dialation is one of the main sources of labor pain, other than uterine contractions, and women who dialate more easily will certainly experience less pain.)
It is dilated and dilatation.
Precipitate labour is often experienced as very traumatic.
the result of women insisting on increased education, enlarged roles outside the home and greater political participation was that their ovaries shriveled
So that’s what happened to them, They couldn’t stand the pressure of a degree and a full-time job. Registering to vote must have been the last straw.
I have to agree with Amy here on most points, and only wished she had the time to elaborate. For those unfamiliar with the concepts, it may seem strained, but it is not. Historically, society has often/always tried to control women by controlling various aspects of reproduction. Some readers may not be old enough to or may not have had the specific education to remember Griswold v CT, the US Supreme Court case that “legalized” contraception.
From contraception, to abortion, to “natural” childbirth, law and medicine have frequently been subverted as tools for the control of women by anyone other than themselves.
The eugenics movement of the late 19th-mid 20th century had wide-ranging effects, even excluding Naziism. US immigration policy (the Johnson Immigration Act), sterilization policies (Buck v. Bell)—all of these were part of a misguided attempt to “improve the race”. While the concepts Amy refers to may not have been “novel” at the time, their use as tools of eugenics was, and knowing the origins of these practices is important in understanding their current use.
Any medical practice needs to be examined in the light of evidence/science—hence “SBM”, but to examine them ahistorically is a mistake.
Harriet Hall
I had an American patient (a WASP) in early labor who was screaming and overreacting. I lost my cool (the one and only time in my career), yelled at her, and insulted her. Sort of like administering a verbal slapping to get her attention.
Harriet, reading this comment immediately brought back two stories.
1) My mom (actually a woman of great patience) used to comment of being in labor with my brother (24 hours) while a woman in the bed nearby screamed and carried on. It was one of the few times I ever heard her criticize someone without saying “bless her heart”. She said she really wanted to give that woman “a talking to.” So, she would probably thank you for your actions.
2) Recently my sister had surgery. Unfortunately, she got a migraine post-op. Having seen her with these, I know how bad they are for her. She also from pain from the surgery. Apparently, she was acting a bit whimpery when the nurse aid came to help her to the bathroom and the (young) nurse aid felt that she should tell my sister that “sometimes you just have to buck up.”
Now, I’ve watched my sister (who’s a nurse anesthetist) care for my terminally ill mother and my terminally ill father (and as mean and surly patients go my father hit the top of the scale many times.) My sister does not whimper at any little thing and she has done alot more “bucking up” than most folks have.
So my first thought means it may not hurt to say “get a grip” when needed. The second is a precaution against unwise use of the same.
# Peter Lipsonon
“From contraception, to abortion, to “natural” childbirth, law and medicine have frequently been subverted as tools for the control of women by anyone other than themselves. ”
What? I’m just curious was the over use of Lobotomy’s in the 1930′s thru 1950′s a “subversion” of medicine or a misuse? And does science based medicine take no responsibility in traditional medicine’s role in promoting the “male establishment”? Really does that all lay at the feet alternative medical groups?
What’s your point? I pointed out that law and medicine have been used to control women. Are you disagreeing or did i fail the clarity test?
Peter:
“knowing the origins of these practices is important in understanding their current use.”
I strongly agree.
When I was in training, I naively thought that women’s health was about science based medicine. That, of course, is what it should be about, but it is still mired in cultural attitudes toward women, childbirth, fertility, even lactation.
What I find fascinating is how many different cultural and philosophical viewpoints have been brought to bear on the subject of childbirth. A great deal of what many people accept as “conventional wisdom” owes its origins to sexist assumptions about women’s roles, faulty empirical claims about childbirth in nature, women’s attempts to claim superiority over other mothers, and outright distortions of fact about obstetrics and obstetrical interventions.
The philosophy of “natural” childbirth can and does only flourish in first world countries with extraordinarily low neonatal and maternal mortality. Only in such societies can “natural” childbirth advocates make claims that would be considered outlandish in most of the world.
In the past 100 years, neonatal mortality has dropped 90% and maternal mortality has dropped 99%. Obstetricians have done such a good job of making childbirth safe that some women can now pretend that it is inherently safe.
Anecdote: In my direct experience and in reading about the experiences of other women, in certain parent peer groups childbirth method is a moving goalpost litmus test. Peer group inclusion/status depends on adherence to natural childbirth protocols, which get progressively ratcheted up to the point where “success” eludes all but the most alpha members of these subcultures.
Women who have unmedicated hospital births are then criticized for giving birth in a hospital. Women who have homebirth with a midwife are criticized for not having an totally unassisted birth. Women who gave birth completely alone in a nartual geothermal spring might still be imperfect because they forgot to eat the placenta….and so it goes. Women regularly beat each other up over how they gave birth.
A healthy outcome for mother and baby is treated as incidental because the mythology teaches that human childbirth is always inherently safe. If something goes awry, it’s because the mother wasn’t positive enough, or the medical technocracy forced her to begin the cascade of interventions that lead inevitably to surgical birth. I have even heard the term “birthrape” used to describe c-section.
Addressing culturally-based childbirth mythology is absolutely appropriate on SBM, and I’m very glad that Dr Amy is bringing this issue to SBM.
Peter – as to lack of clarity. I can’t say if what I read is what you meant.
You actually said that law and medicine have been subverted to control women (not used).
To me “subvert” (to overthrow something established or existing). suggest undermining the established medical process. From a historical context I would say (feel free to point to sources if you think I’m wrong) that both the established medical process and the “natural childbirth” ideology at that time were quite less than perfect in the “controlling women” category. Thus my question whether SBM takes any responsibility in the treatment or mistreatment of women (men, the mentally ill, people of color).
So (in my interpretation) to point out the short comings of your opponents history and ignore your own is not actually putting things in historical context it is trying to use a historical skeleton in the closet to discredit your opponent. I find that tactic unconvincing and disingenuous.
Like I said in a former post. I found Amy’s later comment (s) a much more solid argument. It is one I think most “on the fence” readers would find more convincing and interesting.
Amy – “In the past 100 years, neonatal mortality has dropped 90% and maternal mortality has dropped 99%. Obstetricians have done such a good job of making childbirth safe that some women can now pretend that it is inherently safe.”
Right on there. We Americans can be a spoiled lot.
Tangentially, In the realm of parenting I am often amazed at the lengths we parents will go to to “foster development” in young children. The Attachment parenting movement has some positive attributes but it can also definitely go overboard and start “best mom” competitions. And I’ll never forget a friendly mom trying to introduce my 4 yo son (who has cleft lip and palate, and at that time could say only 3 consonants) to spanish and seeming surprised that he didn’t know what Casa meant. God Lord.
I think it is a cautionary tale that shows that some very odious ideas have been advocated in the name of science. But true science should never be in the service of oppression and should speak out against it. If a scientific pronouncement just doesn’t sound right, like in the past it was thought that caregivers shouldn’t talk to babies, it should be questioned and further studied.
Anthropologist Underground:
“Women who have unmedicated hospital births are then criticized for giving birth in a hospital. Women who have homebirth with a midwife are criticized for not having an totally unassisted birth. Women who gave birth completely alone in a nartual geothermal spring might still be imperfect because they forgot to eat the placenta….and so it goes.”
I know that it may sound unbelievable to those who are not familiar with the “natural” childbirth culture, but this is only a slight exaggeration.
Consider these real comments from multiple women on the unassisted childbirth message board on Mothering.com from a thread counseling a woman that there will almost never be a reason for her to abandon unassisted childbirth and seek medical care.:
I’m such a uc’er.. I didn’t go to the docs for a pp hemorrhage
I’m such a uc’er.. I didn’t hear the heartbeat until 37 weeks
I’m such a uc’er.. I sung l.o.u.d songs whist having waves
I’m such a ucer…I check my own cervix.
I’m such a ucer…I had to guess at my due date.
I’m such a UCer that I managed/healed a postpartum intrauterine infection on my own, with herbs and supplements…never really occurred to me to call a doc or go to ER.
Or the most horrifying of the many horrifying comments on Mothering.com:
“I don’t think you failed at unassisted childbirth because your baby didn’t make it.”
Ahh…got it, michelle. I struggled to find a word there, and picked “subvert” even though I wasn’t happy with it…but not for the same reason you brought up.
It is, indeed, important to recognize our own faults/complicity, as long as we are careful to remember that previous and current faults do not permanently damage the “brand”—IOW, we mustn’t succumb to the “medicine was wrong before” fallacy.
Richard:
“I think it is a cautionary tale that shows that some very odious ideas have been advocated in the name of science.”
The irony is that women have been encouraged to believe that by embracing “natural” childbirth, they are liberating themselves from oppression. There are some very interesting papers by third wave feminists pointing out that a return to nature is not likely to be liberating for most women.
Regarding the various accusations of the use of ad hominem and/or guilt by association, starting with micheleinmichigan, Plonit, David Gorski, etc. I think both are unfounded criticisms. It’s not as if Amy has said “Read liked to push down old ladies, so obviously nothing he said is true or reasonable.” That’s a logical fallacy because there is no reason to believe that Read’s bad behavior makes him automatically wrong on everything (or even any specific thing). I thought Amy was clear in her assertion that Read’s association with eugenics had a direct impact on his work. This is not a character attack, but a claim that his work is based on unsound and outdated principles. Maybe Amy is correct, maybe not, but it is no more an ad hominem attack than is saying “Andrew Wakefield’s now infamous study should be viewed with extreme skepticism since his methods and motives have been called into question.”
Moreover, the guilt by association accusation is completely backward. The flawed argument we’re given for comparison is “Hitler justified his beliefs using ‘Darwinism’ ergo ‘Darwinism’ is bad.” Amy did not say “Read justified his beliefs using ‘Eugenics’ ergo ‘Eugenics’ is bad.” More like “Read based his work on ‘Eugenics’, which is bad, ergo his work is questionable.” This is not a fallacy. A work of science based on false or unsound principles should be suspect. From a moral perspective, a work of science based on principles we find morally wrong should be morally suspect. (i.e. It’s content may be factually true, but it’s application might still be immoral or unethical.) Again, Amy may be wrong, but she is not guilty of trying to invoke guilt by association.
Finally, to the “so what?” or “this is older than Read” posts of Plonit, Calli, NDL, David Gorski, etc. How is this any different from arguing “The anti-vax movement is much older than Andrew Wakefield, so why should we care that he published a highly suspect study that injected new life into the modern anti-vax movement?” Quoting from Amy: “That was written in 1942 by Grantly Dick-Read, widely considered to be the father of modern natural childbirth.” That’s the “so what?” right there. You might disagree with her statement (and then you should say so). But if it’s a true statement (from my recent experience, his name does seem to arise quite often in natural childbirth literature), then it’s hard to understand “so what?” coming from the same SBM community that cares so much about discrediting Wakefield and his ilk.
She did, actually.
What disturbed me about this post was again what I mentioned above. It has an echo that disturbs me, namely the echo of creationists who point to eugenicists who justified their practices using Darwin’s theory as though such arguments discredit Darwin. That echo reverberates still, even some 70 comments on. Maybe it’s my history refuting creationists, but these kinds of arguments are very difficult to make in such a way that they don’t come across as guilt by association.
You know what this means, don’t you? If Darwin was responsible for eugenics and eugenics was responsible for the home birth movement, then Darwin must have been responsible for the home birth movement!
Just after I posted my first reply (still awaiting moderator approval), David Gorski posted
“It has an echo that disturbs me, namely the echo of creationists who point to eugenicists who justified their practices using Darwin’s theory as though such arguments discredit Darwin.”
I’d like to argue again that this is not the same thing. In David’s comment, Darwin’s reputation is soiled by the actions of people apparently misusing his theory. I agree that this is a logical fallacy. However, Amy is not attempting to soil Read’s reputation by associating him with eugenics. Rather, Amy’s argument seems to be that Read’s theory is fundamentally based on eugenics and is therefore suspect. Agree or not, you cannot rightly make the claim that this is guilt by association. It is logic. If a premise in an argument is suspect, the conclusion is also suspect.
You may argue that Read’s work was not based on eugenics, or that it was but eugenics is OK, or that eugenics is not OK and formed a basis for Read’s ideas but his ideas are still sound, but you can’t rightly dismiss Amy’s argument out of hand as fallacious.
David:
“It has an echo that disturbs me, namely the echo of creationists who point to eugenicists who justified their practices using Darwin’s theory as though such arguments discredit Darwin.”
There’s a critical difference.
Eugenicists invoked Darwin to support their claims, but Darwin did not invoke eugenics to support evolution. In contrast, eugenicists did not invoke “natural” childbirth to support their claims. Dick-Read invoked eugenics to support “natural” childbirth.
Evolution stands on its own, regardless of who tries to appropriate for their own purposes. “Natural” childbirth does not stand on its own. It was created specifically to convince white women to have more children. It is not based on science of any kind and most of its empirical claims are false.
I’m not suggesting that “natural” childbirth is tarred by being associated with eugenics. I’m claiming that “natural” childbirth is a corollary of eugenics and its origins cannot be understood apart from eugenics.
Peter Lipson
It is, indeed, important to recognize our own faults/complicity, as long as we are careful to remember that previous and current faults do not permanently damage the “brand”—IOW, we mustn’t succumb to the “medicine was wrong before” fallacy.
Yes, I’m in complete agreement with you there. I have no desire to subscribe to that fallacy. I do in fact think that medicine has done (and continues to do) an admiral job of improving upon their ethical standards and compassionate treatment of patients.
No one is saying that it is based on science, least of all me.
However, the use of association as an argument to poison the well is what I’m talking about. As has been said before, many sciences now considered legitimate now were tainted by the eugenics movement, in particular psychology and psychiatry. By pointing out that the homebirth movement is based on eugenics, it is that association that is being used to poison the well, and poisoning the well and guilt by association are logical fallacies:
http://www.nizkor.org/features/fallacies/guilt-by-association.html
http://www.nizkor.org/features/fallacies/poisoning-the-well.html
I’ll grant that I should have spelled out that poisoning the well was probably the more appropriate fallacy to invoke than guilt by association, but frequently they are related. My bad.
Actually, saying that about Wakefield is an ad hominem argument if that’s all that’s said. That’s why I almost never just say that about Wakefield. For it not to be strictly an ad hominem attack, you have to explain why his methods and motives have been called into question, along with evidence to back up that explanation.
One should also note that the ad hominem argument is sometimes justified, but it’s very hard to do without its being a logical fallacy.
I find it interesting that the majority of parenting experts are men. Regardless if they’re on the crunchy side of the spectrum to the extreme mainstream (from Dr. Gordon, to Dr. Sears to Dr. Dobson to Gary Ezzo). That the father of Natural Childbirth was a man doesn’t surprise me at all.
I remember the first time I saw someone discuss Dick-Read saying that childbirth pain was “all in our heads” due to the expectation of pain, that it was a modern construct. I knew right a way that it was a load of poop. As Evangelical Christianity was my form of teen rebellion, I knew the bible well enough to know of Eve’s punishment. So right then and there I could dismiss it. Now they have that show “I didn’t know I was pregnant” that show these women writhing in pain without knowing they’re pregnant and in labour.
Regardless, I think Dr. Amy is just bringing the fact that these movements started due to fear (fear due to Xenophobia, feminism etc) and constructed false premises to try and guilt women back to the home and total motherhood.
David:
“By pointing out that the homebirth movement is based on eugenics, it is that association that is being used to poison the well”
I’m going to respectfully disagree.
My claim is that “natural” childbirth is not based on science. It doesn’t really matter what it is based on if it is not based on science. It happens to be based on eugenics, which we agree is bad, but I could have said it was based on a desire to spare the women of the world unnecessary pain, which we would agree is good, but that wouldn’t change the claim.
Surely if I had written a piece claiming that Grantly Dick-Read fabricated the central tenets of “natural” childbirth, the obvious questions would be “why ?” and “how did he choose the tenets that he did ?”. I answered those questions in advance, not in an attempt to poison the well, but because I believe my claim is almost unintelligible without some attempt to explain the reasons for his behavior.
A problem with a lot of alternative birth advocates and adherents is their failure to learn history or what a technology is. Every time I hear some babble about how great childbirth was in the past before the rise of the evil OBs or how Lamaze, teas, and hypnobirth are “natural,” I bang my head against my desk.
Our current system of child birth, partially the hospital aspect, involved because previously paradigms, like midwifery failed to produce the desired results. Women demanded many of the changes that we have today. Pain medication, hospital births, and the rise of O.B.s all have origins in the failure of midwifery to provide safe births. Not knowing the history, alternative birth advocates are freed to spin happy stories about childbirth before the evil people in white coats and conjure up conspiracy theories about how doctors are out to get them for their money, all unfashioned to evidence.
As for technology, Lamaze, teas, and all the natural child birth interventions are technologies, as manufactured as lasers, surgical tools, or pills. Due to their less than high-tech appearance, most fail to recognize them what for they are.
Just curious to know why Amy’s profile on SBM appears to be taken verbatim from her profile on the homebirthdebate.com site except for SBM’s omission of this sentence “She left the practice of medicine to raise her four children.” Was this omission an oversight or intentional?
Other non-practicing physicians on SBM are listed as retired, such Harriet Hall and Wallace Sampson.
I am curious about how long Amy practiced medicine and was she a board certified OB/GYN?
Thanks.
Actually, looking back over the quotes you cited in your original article, I’m now less sure of what you meant than before. The reason is that concept that the “right stock” needs to breed while the “wrong stock” seems to breed too much is also a rather old concept that predates the modern eugenics movement. Heck, Plato advocated a form of eugenics. Darwin merely provided a scientific theory that those who already believed that could point to in order to justify their views.
In any case, “eugenics” is an incredibly broad term encompassing practices that date back to the dawn of civilization, and to my mind you did not adequately define the term for purposes of your characterization of Dick-Read’s beliefs. Plonit pointed out that you probably didn’t adequately define the “home birth” movement, and, I submit, the same criticism applies to your linking him to the eugenics movement, as there wasn’t just one “eugenics movement” and at various times in various places the term “eugenics” encompassed many different practices. Depending on who’s talking about it, eugenics can include anything from simply encouraging more children when birthrates fall, to permitting the termination of pregnancies based on prenatal testing showing severe deformities or even genetic defects (yes, that is eugenics), to full-out negative eugenics such as forced sterilization or the T4 Nazi euthanasia program. Because the last of these is what people tend to remember when they think of eugenics, it’s very important to be precise in what you mean by eugenics if you are to avoid appearing to poison the well. Not all forms of eugenics are equally worthy of revulsion, but the blanket term “eugenics” conjures up in most people’s minds the Nazi vision of eugenics and racial hygiene.
So perhaps it would help me if you could enumerate specifically which specific eugenics beliefs and practices Dick-Read embraced and advocated.
#David Gorski
“Actually, saying that about Wakefield is an ad hominem argument if that’s all that’s said.”
I guess we would have to settle on a definition of an ad hominem argument. I have something in mind along the lines of the Wikipedia definition that it “is an argument which links the validity of a premise to a characteristic or belief of a person advocating the premise.”
I grant that my hypothetical statement is a weak argument in need of evidence to back it up, but I don’t think it qualifies as ad hominem in the sense above. There is a difference between a logically fallacious argument and a logical argument with insufficient evidence. The latter can be strengthened with more evidence, while the former cannot.
If I said “Bob cheated on his taxes last year. Can you really believe the evidence of a person like that?” then I have engaged in an ad hominem argument. It redirects the argument from the topic at hand to (probably) unrelated characteristics of that person. Unless I can provide some strong evidence that his tax-cheating is relevant to the truth or falsity of his argument, I am in an indefensible position.
If I said “There is strong evidence that Bob faked most of the data he used to support that argument,” you would be right to ask for more evidence, but I don’t see that this is ad hominem. It may be that, if I am correct, Bob will suffer harm to his reputation, but I am not directly attacking his character. Rather, I am claiming that he faked a particular set of data that he is using to support his argument. If my claim is true, it certainly does call into question Bob’s argument. Attacking the premises of an argument is fundamental to good debate and is certainly not a fallacy.
Also, on the topic of well-poisoning, I think my argument applies with little modification. (Well-poisoning is just a type of ad hominem after all.) It did not appear that Amy dropped the “E” word just for the negative emotional response it might cause, but instead to give pertinent information critical to her argument. (You may disagree on this point of course.)
I’ll end with an example… With a little modification, I think that your comparison of Amy’s argument to creationist anti-Darwin arguments has all the trappings of an attempt to poison the well. I know that you only intended to give your personal aversion to using an argument involving eugenics (and I certainly understand your point), but let’s pretend for a while that I did make the statement that Amy’s argument “has an echo that disturbs me, namely the echo of creationists who point to eugenicists who justified their practices using Darwin’s theory as though such arguments discredit Darwin” and therefore (the hypothetical part) she is wrong.
I think that’s a textbook case of poisoning the well. The creationist argument has no bearing whatsoever on the current argument (aside from my personal association of the two). It would be quite reasonable for you to infer that I only mentioned it to try to associate the (presumably negative) “C” word with Amy or her position in an attempt to move the argument away from a logical discussion to an emotional one. (Please let me clarify that I’m not accusing you of this. It just seemed like an apropos hypothetical.)
First off, I never said Amy was wrong, only that she hadn’t convinced me with this post that the link to eugenics was enough to discredit the home birth movement as being hopelessly linked with eugenics. You can disagree if you like, but I’ve studied the eugenics and racial hygiene movements; so I found the linkage to have been argued with inadequate precision. I also note that I agreed with Amy’s central premise, namely that the home birth movement is not based on science. And, as you pointed out, I merely used the creationist example because it’s something from my experience in skepticism. You can agree or disagree that the example is appropriate or relevant or not. I could equally have chosen to use the example of Holocaust deniers, because I have long refuted Holocaust denial online, but clearly that example would have been so inflammatory as to be a true (and rather blatantly offensive) poisoning of the well. It’s the same reason that I only rarely use the example of Holocaust denial when I compare various pseudoscience and conspiracy theories, even though they use the same bogus arguments.
Oh, please. Of course that’s exactly what you’re doing, but rather cleverly I will admit. Nice hypothetical. I salute you
Seriously, just be direct next time. Coyness is far more annoying to me than being told I’m wrong about something (which, while momentarily annoying, can at least lead to the furthering of my knowledge and education) in online debates and discussions, and, besides, it fools no one. Remember, I “grew up” on Usenet. I’m used to “full body contact” online debate. I’ve been at it since the mid-1990s in various contexts. I can handle it, and when I can’t I admit errors (usually).
Well, the mother is the factory, etymologically.
The word mother comes from mater/metra/matria/matris , from ‘matrix’.
The matrix described the womb as an effective synonym. It’s meaning is a source for the origin of another object. Thus a matrix is more ‘universal’ but when used in reference to a woman, it was basically only the womb (or the person with the womb).
Basically, the matrix (or womb) is a source or factory, as per the understanding in days of profound antiquity.
That’s what’s been taught in word-origins, relating to the topic at hand, and I thought I’d put it there. Of course some thing ma means breast and that ‘ter’ was a simple designatory suffix/
Here’s the opening graf of a good piece on the underlying sexist assumptions regarding “overcivilized women” and childbirth: http://muse.jhu.edu/login?uri=/journals/american_quarterly/v052/52.2briggs.html
WRT Steve Novella’s comments about how evolving big brains has really made giving birth quite problematic for modern humans, I want to point out that this is especially true when a small-boned mother is made pregnant by a large-boned father, as was often the case when Native American women were made pregnant by European or American white men (Lewis and Clark actually discussed this in their written history of their famous expedition) and when 19th-century Irish immigrant women, whose bodies and bones were made even more fragile by poverty’s poor diets, got pregnant by American white males.
This latter scenario was such a problem in turn-of-the-century Boston in the pre-Caesarian era that hospitals would try to save the mother’s life by aborting the fetus inside her; otherwise, the mother would die after weeks of agony from being ripped apart from the inside, and the fetus’ head would be so crushed from being forced through the woman’s narrow birth canal that it would often suffer brain damage, if not be killed outright.
Considering all of the things that can kill a pregnant woman — eclampsia, gestational diabetes, a fetus with a head too large for the birth canal, etc. — it’s amazing that women did (usually) survive.
# David Gorski
“First off, I never said Amy was wrong, only that she hadn’t convinced me with this post that the link to eugenics was enough to discredit the home birth movement as being hopelessly linked with eugenics.”
Yes. I agree with this summary. That is indeed why I did not accuse you of saying Amy was wrong and I attempted to make it clear in my post. I’ll confess I did write a draft of a comment that had you as the well-poisoning culprit, but when I reread your comments I realized you had not actually committed this error. As I took it, you were merely expressing a distaste for using eugenics in the argument. (I intended to convey as much in my comment.) However, as I had already invested the time in laying out the well-poisoning example as a contrast to Amy’s argument, I modified it to be hypothetical and left it in. I hoped it would illustrate the difference between true well poisoning and what (to my understanding) Amy’s argument contained. Just before submitting, I chickened out a little (worried that you might think I was being coy, ironically) and added a quick disclaimer at the very end. It had the opposite effect I intended apparently. Here is your salute back.
I maintain my original stance. Whatever other attributes Amy’s post does or does not have, I am unconvinced by the the above accusations that her argument involves ad hominem, well poisoning and/or guilt by association fallacies.
Thank you, though, for the useful lesson in online debate technique. (Now THAT’S coyness!)
“What do you have against women who want to birth without pain relief?”
I hope these women also have dentistry without pain relief.
Otherwise they would be merely ascribing some magical effect to the pain of childbirth. Tooth decay is entirely natural, yet only a moron would accept it without treatment.
My wife was not pleased that some stupid women tried to insist that she could have birth without pain relief. As it was she had extremely painful deliveries. Not because she was tricked, but because the babies’ heads were too big to get out (literally, they had to be C-sectioned or her or the baby would have died).
And it’s the insistence of the fanatics that no woman needs pain relief in labour that is the problem. If they want to inflict pain on themselves, then they are welcome to i.
anthropologist said:
“Women who have unmedicated hospital births are then criticized for giving birth in a hospital. Women who have homebirth with a midwife are criticized for not having an totally unassisted birth. Women who gave birth completely alone in a nartual geothermal spring might still be imperfect because they forgot to eat the placenta….and so it goes. Women regularly beat each other up over how they gave birth.”
Exactly! And I applaud Dr. Amy for trying to arm women with the facts regarding these decisions, it’s so much peer pressure that I don’t think it’s going to change soon. I have watched women do stupid stupid things in regards to “NCB”.
I do not see any mention here of ACOG’s position on the subject, including this 63 page report issued in 2005 http://images.ibsys.com/2005/0504/4450560.pdf which states “A Department of Health and Human Services expert working group on cesarean delivery rates, which included ACOG representatives, discussed the Healthy People 2010 objectives and developed evidence-based cesarean delivery rate goals for the year 2010.” The report goes on to say “The expert working group proposes the following cesarean delivery rate benchmarks:
1. Nulliparous women at 37 weeks of gestation or greater with singleton fetuses with vertex presentations: The national 1996 cesarean delivery rate for this group was 17.9%; the expert working group goal at the 25th percentile for this group is 15.5%.
2. Multiparous women with one prior low-transverse cesarean delivery at 37 weeks of gestation or greater with singleton fetuses with vertex presentations: The national 1996 VBAC rate for this group was 30.3%; the expert working group goal at the 75th percentile is 37%.”
Oops, that was supposed to be posted under the c-section article.
David:
“First off, I never said Amy was wrong, only that she hadn’t convinced me with this post that the link to eugenics was enough to discredit the home birth movement as being hopelessly linked with eugenics.”
Well, we’re going to have to agree to disagree on this one, because, I think have mischaracterized my argument based on your initial impression.
1. Your above statement appears to an observation about the structure of my argument: you acknowledge the truth of the premise, but you feel that the structure of the argument is invalid. (Correct me if I am wrong in this impression).
2. Specifically, you believe my argument to have invalid structure because it rests on “poisoning the well.”
3. Poisoning the well has been described as a fallacy of relevance. A detail about the opponent (true or false) is introduced into the argument in order to bias listeners against the opponent.
Or, as the Nizkor reference you cited states:
“Unfavorable information (be it true or false) about person A is presented.
Therefore any claims person A makes will be false. ”
The fallacy exists because the information about the opponent is irrelevant to the truth about the opponents claims.
In the case of my post, such an argument would follow the structure:
Grantly Dick-Read was a eugenicist.
Therefore any claims Grantly Dick-Read made are false.
4. But that is not the structure of my argument. My argument is:
Grantly Dick-Read made up the central premises of natural childbirth.
Therefore, the central premises of natural childbirth are not based on science.
In addition, I said:
Grantly Dick-Read made up the central premises of natural childbirth because he had a separate agenda.
That does not make my argument “poisoning the well” since is not part of the logical structure of the argument.
@Provaxmom: You and anthropologist have hit it exactly. Unfortunately, for many women, childbirth IS a competition – who can give birth the best. As a midwife, I saw that all the time and it drove me NUTS! I did my best to interject the reality of life into the 3-4 page birth plans that some of our patients would being us. (We used to say that the longer the birth plan, the quicker the patient would be c/sectioned). We used to stress at almost every visit that the ultimate goal was a healthy mother and healthy baby, and HOW the baby was born was not as important as that goal.
Perhaps because of the groups I worked with, and my previous nursing experience (along with growing up in a house where my GP grandfather would sit at the table and tell ‘work stories’ of the patients he’d had that day), I always knew emergenies could happen, and happen fast. So, I always tried to keep a balance between intervention and unnecessary intervention.
Pain medication (for example) can be underused, used appropriately, or over used. During my second labor (induced for severe pre-eclampsia, on MgSO4), my OB suggested that I have some pain medication. Since I felt I was in control, I declined. He looked at me, said “Dawn, your BP is 190/110; you ARE having some pain medication”. We discussed a minimal dose and I accepted it. It decreased the pain enough that my BP went down, and I went on to deliver with no other pain medication. I would have been very upset if it had been forced upon me, however (or if the dose had been different from that agreed upon). Yes, I was a nurse so my MD could use medicalese when talking with me. But from observation of him, he always, if possible, involved the patient fully in the decision making. (OTOH, in an emergency, I knew no doctor who could move faster!)
But I would still like to see evidence that a medicated hospital birth is safer than an unmedicated one.
David:
“So perhaps it would help me if you could enumerate specifically which specific eugenics beliefs and practices Dick-Read embraced and advocated.”
Sure.
The fundamental premise of Grantly Dick-Read’s philosophy of natural childbirth is that “primitive” women have no pain in childbirth.
As Clare Hanson explains in Save the Mothers? Representations of Pregnancy in the 1930s:
“… One of Read’s principal arguments is that pregnancy and childbirth are not inherently burdensome or painful. He distinguishes between primitive women, defined as those ‘whose mental development has not attained a state of civilisation’, and cultured women who have for centuries been imbued with fear and told that ‘labour entails peril and agony’. For Read, ‘racial experience’ impacts on the experience of pregnancy and childbirth, and it is the ‘primitive’ approach which he favours. He argues that Nature (sic) never intended pregnancy to be an illness, and describes the primitive woman continuing her work during pregnancy, so that ‘the child develops while she herself lives a full and natural existence . . . the child then is born – small, hard and easily’…”
Patricia Jasen explains the thinking that influenced Read in Race, Culture, and the Colonization of Childbirth in Northern Canada:
“Theories of racial difference are one of the oldest and most enduring features of European imperialism. They were inspired and perpetuated, in good part, by the desire to assess the level of European civilization and racial progress in comparison with more ‘primitive’, or less enlightened, peoples, and the history of ideas regarding aboriginal women and childbirth needs to be examined with this context in mind… [T]he notion that women in ‘savage lands’ were fundamentally different from European women gained a wide following through the myth of painless childbirth… [I]ts increasing acceptance during the nineteenth century, … makes sense only in light of the fact that this image of the aboriginal woman satisfied a growing preoccupation, in European and Euro-American cultures, with both the anatomy of race and the politics of sexual difference.”
And:
“… [T]he myth of painless childbirth acquired an unprecedented following on both sides of the Atlantic around the middle of the nineteenth century and achieved a new level of abstraction from reality. The growing preoccupation with racial hierarchy and degeneracy did not preclude a belief that primitivism and health were somehow linked, and many Europeans and Euro-Americans sought to internalize the qualities of ‘wildness’… which would counter the ill effects of civilized life. Outdoor sport would help preserve the qualities of ‘natural man’, but even more urgent was the quest for the ‘natural woman’. There was a common fear that through some accident (or logic) of evolution, women of superior breeding experienced the most pain and debility in childbearing — that civilization, or over-civilization, made them less fit for reproduction. The survival of the race seemed to depend on alleviating this suffering and countering the growing reluctance, on the part of middle- and upper-class women, to undertake the maternal role.”
Laura Briggs, in The Race of Hysteria: “Overcivilization” and the “Savage” Woman in Late Nineteenth-Century Obstetrics and Gynecology, also describes the racist and sexist notions that were fundamental to Read’s theory:
“[O]vercivilized” women avoided sex and were unwilling or incapable of bearing many (or any) children, “savage” women gave birth easily and often, and were hypersexual. This is the discourse that was slightly later termed “race suicide.”Late nineteenth-century gynecological and obstetrical literature did more than simply naturalize opposition to white women’s political struggles by insisting that contraceptive use, abortion, education, and participation in the professional workforce could cause nervous illness. It also reconceptualized these forms of white women’s struggle for social and political autonomy from white men as a racial threat. That is, by insisting that white women were becoming sterile and weak while non-white women remained fertile and strong, it encoded white women’s transgressive behavior as a danger to the future of “the race.” That this was indeed the implicit trajectory of the concern about white women’s nervous weakness and childlessness is suggested by the subsequent development of eugenics. When Edward Clarke wrote of the shriveling ovaries of educated women, in other words, he tapped into the same discourse that found expression in immigration restriction acts and, four decades later, in Lothrop Stoddard’s rantings in The Rising Tide of Color Against White World Supremacy. The neurasthenic narrative shared with racist eugenics a concern about white women’s low birth rate and the fertility of non-white women.”
Dawn:
“But I would still like to see evidence that a medicated hospital birth is safer than an unmedicated one.”
No one made that claim.
“Natural” childbirth advocates claim that an unmedicated birth is safer than one with pain relief. Therefore, you need to provide evidence for that claim.
“But I would still like to see evidence that a medicated hospital birth is safer than an unmedicated one.”
This request follows the same lines as “prove to me vaccines are safe.” It’s a study that can’t be done. You cannot ask a group of 10,000 women to go into L&D and agree to refuse all meds just to satisfy the needs of a study. It’s unethical. Just like we cannot ask a group of 10,000 babies to not vax so we can prove their rates of autism are the same as the vax’d. In both cases, you’re knowingly putting people at risk.
In attempting to tie today’s philosophy and practice of natural childbirth with the historical eugenics movement it is interesting to make a comparison to the development of modern birth control and Margaret Sanger’s (founder of Planned Parenthood) apparent support of negative eugenics. It’s an interesting aside, but so what? Whatever the opinions of its founder, Planned Parenthood has been a positive influence in helping increase women’s access to contraception. Today’s advocates of birth control are not necessarily advocates of eugenics, the same goes for today’s advocates of natural childbirth. Some go so far as to label the current obstetric standard of care regarding prenatal genetic testing for Down’s syndrome as a form of eugenics. History is filled with otherwise admirable persons advocating either positive or negative eugenics. The practices of prenatal genetic testing, birth control and natural childbirth can stand upon their own merits. They are all venues providing choices that women did not have historically. For that we should be grateful.
wales:
“Today’s advocates of birth control are not necessarily advocates of eugenics, the same goes for today’s advocates of natural childbirth.”
No one said that they were. The issue is that the fundamental premise of “natural” childbirth, that the pain of labor is culturally determined, is factually false. Read believed it because he was a eugenicist, but that’s not what makes it false.
“If this is science-based medicine, then lets talk about the science behind pain reduction or elimination. I would argue that there are non-pharmacological ways to manage pain.”
Yeah I know but its still being duped to think that hypnotherapy actually works. What you are describing and the original post is a part of the placebo effect. Calling it anything else is hopping onto the woo woo train.
Amy said,
“My central claims in this post are:
1. “Natural” childbirth is a philosophy, and not based in science.
2. The origins of the philosophy of “natural” childbirth are in racist and sexist notions about childbirth, not in any empirical observations of childbirth.”
Is it just me, or does Amy’s post not show any actual science to refute that natural childbirth philosophy is not based in science?
Amy,
I was not implying that discussing “natural” childbirth is propaganda. As a layperson, it is slowly dawning on me that obstetricians battle just as much woo as other doctors (maybe more), thus your frustration with “natural” childbirth.
But you seem to assume that everyone who tries to manage labor in a non-medicated way is motivated by a wacko philosophy developed by a eugenicist more than half a century ago. Buried deep in my subconscious may be a little voice that told me to be more “natural,” but my recollection of my labors (and the few others I have witnessed – all in the context of a hospital setting) was the security of knowing that a full range of interventions were available if necessary, with a conscious choice to choose fewer interventions if possible.
It seems that the issuing of birthing has become as contentious and unhitched from reality as vaccinating. The science of vaccination is pretty well sown up, but the science of obstetrics is still evolving (thus your interesting post on the changing rate of C-sections.) I look forward to a discussion of “natural” childbirth that focuses on its effects more than its philosophy.
Yes StatlerWaldorf, it is just you.
David:
“First off, I never said Amy was wrong, only that she hadn’t convinced me with this post that the link to eugenics was enough to discredit the home birth movement as being hopelessly linked with eugenics.”
Amy Tuteur: “Well, we’re going to have to agree to disagree on this one, because, I think have mischaracterized my argument based on your initial impression.”
I’m not good at all the logical fallacy arguments, etc. My background is in design and marketing and I have sat in enough meetings to absorb various ways to get people to buy things that they may need (or don’t need).
Amy, I am assuming that you wanted to convince some audience that the “natural birth” ideology is questionable, perhaps that that SBM birth has more to offer.
You seem caught up with whether you were right or whether people misinterpreted you. My (rhetorical) question would be, do you want to be right or do you want to be convincing?
When I was working with writers (obviously I’m not a writer myself) if two people out of say 5 or 10 misinterpreted the ad (brochure, report) text or said gee, I don’t get the point. I’d send it back to the writer after discussing possible points of confusion.
If some people found it offensive, polarizing, etc. I would certainly seriously consider if that was going to do more harm than good. Because that kind of reputation can be harmful to a brand. (One can dispute whether it has been harmful for Fox and MSNBC, they are making lots of money but they do very little convincing outside their target markets).
I personally found your first article to be a call to emotion without a call to logic or reason. Maybe it’s because you hit the eugenics, but didn’t follow through on how they relates to “natural birth” current practices and concerns. Maybe it was the minute you hit the eugenics you raised a big question about your reliability and the rest of the article just did not overcome that. That is my first impression and as they say in marketing, you never get a second chance to make a first impression. To me, a call to emotion is contradictory to promoting a method based on reason (SBM). It could undermine the brand.
I have to admit in marketing, I always felt pretty yecky about campaigns that were fear or anger based. I’m sure I would make a horrible political ad person. I always tended toward using emotion to make a connection (and stick in the memory) and reason to convince and ease of use to encourage action.
My opinion is that there is too much stirring the pot (singing to the choir) type blogging these days. That’s one reason I like SBM.org. I often find it a welcome retreat.
So that’s free (unrequested) advice from someone who actually used to make her company a reasonable amount of money per hour. You know what they say about free advice. It’s worth every penny.
Dawn:
“But I would still like to see evidence that a medicated hospital birth is safer than an unmedicated one.”
Amy Tuteur “No one made that claim.
“Natural” childbirth advocates claim that an unmedicated birth is safer than one with pain relief. Therefore, you need to provide evidence for that claim.”
and ProVaxMom’s comment unquoted
My take – rephrasing
I think the evidence to look at is the safety (for mom and baby) of using pain medication in a hospital for the comfort of mom.
When you are saying that mom is working with O.B for optimal levels of safety and comfort, then the use of pain medication does not have to be safer than no pain medication, it only has to be as safe (to mom and baby). I’m pretty sure such studies exist. I don’t have access.
Anecdotally, second hand. My sister (the nurse anesthetist) has mentioned that adequate pain medication can (not always) play a part in managing patient health in terms of blood pressure, heart rate.
I can’t shake the feeling that you’re battling a bit of a nasty, nasty straw man here. Not everyone who chooses a “lower intervention” birth (that’s what I called it because of the many connotations you discuss) does so because of woo or because of the natural fallacy or because of womanly oneupsmanship or because we want a “spiritual experience.”
I chose a lower-intervention birth because many of the interventions offered are NOT based in science. I chose it because I read the Cochrane report. I chose it because I wanted to avoid an unnecessary C-section. I chose it because I really, really wanted to leave the hospital the next day and hang with my brand-new daughter, which I could do since I didn’t tear, wasn’t cut, didn’t have an epidural that left my back tingling or in pain. And I chose a doctor who would work with me and explain my options as we went along. I didn’t have some fantasy birth in mind, but I also didn’t want to be rushed through. My OB (fantastic) and I discussed that an epidural might help or hinder labor, depending on when it’s administered.
I think a more helpful discussion would go through interventions one by one and discussing why or why not their use is indicated. It’s easy to beat up this crazy natural birther in your head; much harder to argue on the scientific merits.
Which is far more a racist premise than a eugenic one. The quotes you provide, in fact, are only fairly weakly linked to serious eugenics per se and appear far more strongly linked to the casual racism of the time, where such fears were expressed about the excessive fecundity of the lower classes and “less civilized” races frequently. I hate to say it, but your quotes, rather than helping to convince me, have made me doubt more than I did after originally reading your post that there actually was a strong, explicit connection between the origin of the home birth movement and the eugenics movement, although I have no doubt that there was a lot of racism and glorification of “primitive” savages as more fit than the “civilized.”
So, yeah, I buy that the concept that “primitive” women have no pain in childbirth is a disgustingly racist concept, but there were a lot of concepts that held sway back in the first half of the 20th century that are now considered disgustingly racist. Your argument would have more force if you had been more precise right from the beginning in asserting that the concepts behind the home birth movement go back to racism and bigotry towards “primitive” people and an idealized (and equally racist) notion of the “noble savage” living “in harmony with nature.” The eugenics argument, at least as you’ve presented it thus far, strikes me as the weakest part of the historical association you are trying to make, especially since, after reading the reference you cite, I came away with far more of an impression that Dick-Read’s views derived more from a romanticized concept of “nature” and how a woman’s role was to be a baby factory than from clearly eugenic considerations.
Did Dick-Read have any actual ties with eugenicists of the early 20th century, other than thinking that the “lesser races” were outbreeding civilized white people?
daedalus2u, would you care to elaborate?
———————————————————-
Here is an excerpt from Amy’s book How Your Baby Is Born (1994)
“The advantages of an epidural are obvious: You can experience a pain-free labor while remaining awake and fully aware. There are disadvantages, though, and these are not trivial. Epidural anesthesia, if given too early in labor (before 4 cm. dilation) can slow the progress of labor significantly, often so much so that an intervention that will strengthen the contractions, such as Pitocin, is required. Epidural anesthesia can also anesthetize the nerves that control the diameter of blood vessels and thereby regulate blood pressure. After an epidural is administered, you may experience a temporary drop in blood pressure, which may decrease blood flow to the baby. This condition can be corrected with extra intravenous fluid or medication, if necessary.
Finally, an epidural can also anesthetize the nerves that control muscles, which may hamper your ability to push when the time comes. If the baby is small and your pelvis is large, this will be of no consequence; you will be able to push the baby out anyway. But if the fit is tight, this diminution of your strength may make it very difficult to push the baby out.
The rate of forceps and vacuum-assisted deliveries is much higher in women who have received epidural anesthesia, due to the temporary loss of muscular strength. Because the amount of anesthetic flowing through the catheter can be regulated, if the amount is lowered, you will regain some or all of your muscle strength. Of course, you will also regain some pain. The trade-off, then, is increased pain for increased muscle power. If you are anxious to avoid forceps or vacuum, this may be the right trade-off for you.”
So, there is enough science identifying the pitfalls of epidurals and the interventions that can stem from having epidurals, but there is no science supporting the natural birth belief that unmedicated birth is often better for mother and baby? Natural birth is based on nothing more than false ideology rooted in classism, racism and sexism?
Actually, you did rather strongly imply that very argument (otherwise, why play up the eugenics angle?), although, I’ll grant you, you did not make it explicitly. Again, lack of precision.
And, after your most recent comments, I’m not as sure as I was before that I actually buy that Dick-Read was a serious eugenicist, although it’s obvious that he was clearly a racist and a sexist who made up a lot of stuff about how “primitive” women don’t feel pain at childbirth. The link being made to the eugenics movement appears rather fuzzy and based on racist notions widely in vogue at the time. The odd thing is, the racism and sexism are disgusting enough and produce fantastical enough ideas from Dick-Read without overplaying the eugenics angle.
Which is not, per se, strictly a eugenics concept.
Well, let me depart with, for the first time I can think of, my sincere sympathies to the SMB leadership. You must be feeling right now about like the Republican Party leaders two weeks after they nominated Sarah Palin.
What are you talking about? I love Sarah Palin. Obama should have received the same media trashing, but didn’t. Now look where we are.
Amy said,
““Natural” childbirth does not stand on its own. It was created specifically to convince white women to have more children. It is not based on science of any kind and most of its empirical claims are false.”
Yes, it is racist to claim that “primitive” women birth without pain. My confusion is that I don’t see how it relates to natural childbirth today. I’m still wondering how trying to convince white middle and upper class women that birth could be painless would increase the birth rate when there were clearly many more important reasons for the lower birth rate, like women studying longer, marrying later, working outside of the home, use of contraception methods etc. The natural childbirth movement still exists, yet around the world many governments are using financial incentives to try to increase the birth rates in their countries, not the promise of pain-free labour and birth.
So please, detail specifically what your definition of natural childbirth is and how you feel it still manifests itself in eugenics ideology. Are there in fact two definitions? Natural childbirth in Grantly Dick-Read’s time, and the current form of natural childbirth? If we see your complete definition of natural childbirth we can then tackle the question of whether there is or isn’t any science supporting it.
I wonder why no one addressed the point brought up by Plonit, that Amy HAS followed up on this line of thought on numerous previous blog posts. In fact, so far, all her content is simply reposts of what she’s posted elsewhere.
apteryx said,
“Well, let me depart with, for the first time I can think of, my sincere sympathies to the SMB leadership. You must be feeling right now about like the Republican Party leaders two weeks after they nominated Sarah Palin.”
No kidding!
That was a rather low blow, and uncalled for.
I typed in haste, and worded my last comment poorly, I see. And Amy and Provaxmom correctly took me to task for it. Sorry.
What I meant was, there is no SBM reason to push every woman to have medical interventions for birth. There are certainly studies that show that for some women they are very appropriate. But, as StatlerWaldorf shows in her quote from Amy’s book, they also have risks. So women should have the ability to seek the level of intervention they desire as long as there are no medical reasons to increase interventions.
What I also meant to ask, and I hope this is worded better, is there any literature that shows that women and babies do better if they all receive the same interventions? I recall reading (and I am at work so don’t have my books at hand) that in England there is/was a set routine–admission, AROM, pit, delivery within so many hours or you are c/sectioned. Some studies of the practice showed women and infants benefited (fewer IUFD’s IIRC) while others showed a higher rate of C/S, post delivery infections and higher admissions to NICU, mostly due to TTNB. So, in this case, the studies show mixed results to the benefits of the procedures.
I hope that clarifies my question. I always felt Dick-Read was a bit of a quack, as was Lamaze and Boyier (sp?) but they all had good ideas. A woman who is more aware of the processes of labor and her choices copes better with labor, whether it is medicated or not. Education is key. (I am old enough to recall the end of twilight sleep, full shaves, enemas, and strapping down awake fully alert women’s hands during delivery “so they don’t touch anything”. I don’t miss those days.)
As disclosed on Amy’s profile at her other site (but not here, why?) Amy left the practice of medicine to raise her 4 kids. I am sure that is a full time job, which could account for the rehashing of previously published articles.
I am still wondering why the discrepancy in profile treatment at SBM concerning Amy v. other retired physicians. In my opinion the SBM profiles should be consistent with regard to disclosing the status of physicians, i.e. student, licensed and practicing or retired.
Amy posted an excellent article pointing out that natural childbirth is not SBM, and giving some of the history of the movement’s development. Since this is a controversial subject with high emotions, the discussion has been derailed and Amy has been attacked in every little detail. It is similar to what happened when I tried to write about the actual evidence for the medical risks and benefits of circumcision.
Those who can’t support their beliefs with evidence resort to fighting back with whatever weapons they can find. Tactics like questioning Amy’s credentials and comparing her to Sarah Palin are beneath contempt.
If you have information showing that the natural childbirth movement was originated because scientic evidence showed it was safer, please share it. If you have information showing that unmedicated childbirth has better outcomes than childbirth with analgesia, please share it. Please, more light, less heat!
Stepping away from arguments about logical fallacy, I personally am glad that Amy has taken up this issue. While I understand that some have had a negative emotional reaction to the eugenics connection, I found the post enlightening (though short) and I look forward to more information on the topic.
As a father for nearly seven months, I can still remember the frustration and confusion my wife and I experienced trying to sift through information on childbirth. Pseudoscience seems to have permeated much of the popular literature and it is difficult to disentangle the true science.
A concrete example is the Hypnobirthing book raised earlier in the comments. I was only able to read a few pages in before I put the book down in disgust. We got rid of our copy, so I can’t double-check this, but I’ll try to remember what I read. I think the author made some good points about the historical forced use of anesthetic during labor (which I did not fact check). Soon after, however, she made the dubious claim that the reason so many experience pain in childbirth is fear. (Women are designed for childbirth, after all. There should be no pain.) I can’t remember if it was in the Hypnobirthing book or elsewhere that I read that childbirth should be a pleasurable experience if its treated with the right attitude. This sounds very like the theory Amy has attributed to Dick-Read.
Not only is it not at all liberating to lay the blame of pain on the woman, I did not find any reasonable evidence that it is true. With so many body parts stretching, (tearing?), contracting and shifting I need some extraordinary evidence to be convinced that birth should not be painful. (I think Steve touched on some evolutionary reasons why we should actually expect it to be painful.)
Without scientific evidence to back it up, claims such as these are incredibly harmful. They place an unattainable ideal on laboring mothers and only increase their suffering when they do feel pain and wonder what they’re doing wrong. I can still remember the utter look of defeat on my wife’s face when, after many hours of intensely painful labor with no progress, she finally opted for an epidural. I have never seen her suffer so much in all the time I’ve known her and it broke my heart to see that she felt she had failed in some way.
Please, let’s sort the science from the pseudoscience. I honestly believe I will follow where the evidence leads (maybe not always as easy to do as I think). If Grantly Dick-Read’s work truly was based strongly on the premises presented in Amy’s post and if those premises do not have scientific merit, I want to know. As I said earlier, the name Grantly Dick-Read arose frequently in my attempts to research childbirth. I’ll grant that his conclusion may be correct even if his premises are not, but this requires the advancement of a different argument based on different premises, which should be made explicit and should be tested scientifically.
Thank you for your post, Amy. I look forward to seeing you further your argument.
David:
“Which is far more a racist premise than a eugenic one.”
With all due respect, this reminds me of “moving the goalposts.” First, you wanted to claim that I was poisoning the well; now you want to discuss whether I correctly identified the “poison.”
As I said above, we’re going to have to agree to disagree. I understand the point you are trying to make, but I think you are wrong.
Thanks, Harriet.
This is par for the course for me. “Natural” childbirth has a lot of similarities with vaccine rejectionism in that it is more than a matter of science for its adherents; it can be part of a self-image of being “better,” smarter and more “educated” than everyone else. When that self-image is threatened, especially when it is threatened by scientific evidence or even historical evidence of which they were unaware, its proponents lash out.
Am I reading this correctly? A request for clarification of Ms. Tuteur’s professional status is deemed a “weapon” and a “tactic” “beneath contempt”? How can “science based” individuals believe that the verification of fact is beneath contempt? This is decidedly unscientific.
Requests for full disclosure of an expert’s current professional status are not unusual and should not be construed as such on a “science based” site. If one of the editors or Ms. Tuteur herself would address the issue of her professional status it would not be necessary to repeat the question. When medically trained individuals are holding themselves out as experts their professional status should be divulged.
# wales
This is the Science-Based Medicine blog. As I understand modern science, an argument stands or falls on its own merits regardless the credentials of the argument’s source. You may have legitimate reasons for wanting clarification of Amy’s credentials, but science should not be one of them.
That’s what I was asking for — an actual debate on the scientific merits (or lack thereof) of various elements of “natural childbirth.” For instance, intermittent fetal monitoring versus continuous monitoring? Outcomes of epidural anesthesia? Use of pitocin and other labor-inducing drugs?
Instead we have a bizarre argument about the origins of a “movement.”
More science, less art, please.
Is the current natural childbirth movement that we have today the same one that Grantly Dick-Read started? Do they share some similar features, but not the same basis of existence?
Harriet Hall, I quoted the risks of epidural stated in birth literature in a post above, and in light of those, it seems logical that unmedicated labour and birth can proceed with fewer complications for mother and baby. If one wants to say that the mortality rate is the key, then I would say fine – the mortality rate may be similar for medicated and unmedicated births, but surely one must consider the fact that other medicines and procedures must sometimes be used to combat the negative effects of epidurals and there is increased incidence of episiotomy, instrumental delivery and c-section after epidural. I don’t think that is a desirable outcome, despite the live baby. There likely would have been a live baby without an epidural. Of course women should have the choice to take epidural pain relief, but what is so crazy about women who don’t want to?
Someone’s professional background and current professional activities definitely influence other’s perceptions of their credibility, especially when they have been posting on topics in a way that is perceived to lack credibility. You are right, it is better to stick to discussing the science though.
With all due respect, uh, no, that’s not “moving the goalposts.” Moving the goalposts is when someone sets a standard of evidence and then, when it’s met, demands more evidence. I deal with anti-vaccinationists a lot; they’re masters of moving the goalposts. For instance, David Kirby once said that, if thimerosal in vaccines was a major cause of autism, then autism rates should start falling by 2005 after thimerosal was removed from vaccines in late 2001. If that didn’t happen, he said, then the concept that thimerosal causes autism would have to be reexamined. 2005 came and went with no decline. He came up with some excuse to say that, really, it should be the end of 2007 before we can tell if autism rates are falling. 2007 came and went. Now he’s saying it’s 2011.
That‘s moving the goalposts. I merely pointed out that the linkage to eugenics was rather weak and asked for more information. After reviewing that information, I still found the link to eugenics to be pretty weak but conceded that the link to racism was very strong. I then wondered why the weaker linkage was even mentioned when the stronger linkage would have sufficed.
I second that request–with one additional observation.
Harriet, with all due respect, it was Amy who started out with the heat by emphasizing the racism and sexism of the originator of the home birth movement in her post. Her first two posts used scientific evidence that could be analyzed. That was better.
wales said,
“A request for clarification of Ms. Tuteur’s professional status is deemed a “weapon” and a “tactic” “beneath contempt”?”
In the context, yes. Don’t tell me you “just wanted to know.” You were obviously looking for information that could be used to discredit what she said. It shouldn’t matter whether Amy is the world’s greatest board-certified OB or a kid in junior high school. What matters is the content of her post.
And you know perfectly well she is Doctor Tuteur. Your calling her “Ms.” appears to be another contemptuous tactic.
A quick observation: I am not a proponent of home birth. In fact, I took little interest in this debate until you joined SBM. That’s why I’m cautioning you to be careful with that broad brush stroke when you label seemingly anyone who challenges you as being an advocate of home birth. I suspect that’s not what you meant, but it certainly came off to me as though that’s what you meant.
The topic of the post was that the natural childbirth movement was not originally based on evidence.
The evidence for and against interventions is the subject for another post.
Agreed. I was only skimming because wales has not been contributing much worth reading; so I missed that obvious bit of intentional contempt. It’s the very same thing when anti-vaxers call me “Mr.” Gorski. Now, if we were in England, that might be appropriate, given that I’m a surgeon. Well, actually not. I have a Ph.D. too. In any case, it’s a transparent attempt to show contempt.
Knock it off, wales. That’s every bit as uncalled-for as the Sarah Palin comparison.
I hate to say it, but your quotes, rather than helping to convince me, have made me doubt more than I did after originally reading your post that there actually was a strong, explicit connection between the origin of the home birth movement and the eugenics movement (my italics)
++++++++++++++
Can I just clarify this, since the terms frequently get elided in discussion.
The above post is about the origins of the “natural birth movement”, which is something different from the “home birth movement”. There may be considerable overlap (Venn diagram fashion) but there are also important distinctions. Midwifery care is another term to throw in the mix.
For example, someone currently having a home birth in the UK attended by a midwife working for the NHS would receive the same standard of care (wrt to monitoring, labour progress, reasons for referral) as someone receiving midwife-led care in hospital. Certainly, entonox is used a lot at homebirths, psychoprophylaxis rather less (in fact, I’m not sure anyone still knows what it is!)
On the other hand, Dick-Read certainly presumes that psychoprophylaxis can and should be used in an institutional (hospital or ‘maternity home’) context. E.g. in describing his preferred management of labour “Having arrived at the maternity home [something akin to a GP unit, or cottage hospital] a hot bath and an enema are given in most cases; this procedure is advantageous from all points of view.” p.187 demonstrates that he does not imagine the typical woman labouring at home.
And I have to add this gem! “In spite of all teachings to the contrary, I am persuaded that women are best lying down towards the end of the first stage of labour” p. 188.
Anyway, enough quotes of the man himself. What is clear is that while Dick-Read was certainly an originator of early ‘natural childbirth movement’ it is less clear that his ideas carry much if any weight in the current ‘natural childbirth movement’.
So, a definition of terms would be helpful here. The National Childbirth Trust (the forerunner of which was set up to teach Dick-Read’s methods) would make an interesting case study – since they certainly don’t teach psychoprophylaxis now.
Trying to get an answer about why the editors of SBM chose to cut and past Tuteur’s bio from her website while extracting one telling sentence is like pulling teeth. A lot of words here, but no legitimate response. I go back to my comments about expert credibility on other posts here. Full disclosure confirms credibility, for discerning readers.
An attempt to distract by focusing on my form of address and the psychological ramifications thereof. Let’s skip the delusions of telepathic mind reading powers and use the military model, confining ourselves to last names only. Anyone want to address why Tuteur should be treated any differently than Hall or Sampson with regard to disclosure of professional status?
As far as letting scientific argument stand on its own merits, that isn’t much science evident in this post. Hence my focus on credibility.
# wales
“As far as letting scientific argument stand on its own merits, that isn’t much science evident in this post. Hence my focus on credibility.”
Why not call attention to the sparseness of evidence and leave it at that? If you believe Amy is guilty of attempting an argument by authority, state your case and refrain from personal attacks.
Exactly, nathan. Exactly.
No, calling you out for acting like a jerk.
wales,
When acceptance of some claim requires acceptance of the credibility of a particular source, source credibility is relevant.
For example, if I claim that I saw you molesting a squirrel, and if there were no other witnesses present, and if I could not produce any physical evidence to support my claim, it would be appropriate for you to raise concerns regarding my credibility as a witness.
However, when claims are based upon the scientific literature, the speaker’s credentials are not necessarily relevant. Others can read that same literature to see if it has been fairly represented or not.
Which of Dr. Tuteur’s claims above do you feel rest solely upon her personal testimony?
As you know wales, we count on you as a heckler in the gallery. Sometimes you throw tomatoes. Sometimes eggs. Whatever is within reach.
Nathan, no attacks were made. Requests were made for factual information regarding SBM’s disclosure policy. I will drop my request for information for the moment. The silence speaks volumes. It appears to me that SBM’s omission of pertinent information from Tuteur’s bio is an attempt to foster the impression that Tuteur is a practicing physician, for what reasons I cannot tell.
Why does it matter to you whether Dr. Tuteur is a practicing physician? Dr. Hall is no longer in practice, but you don’t pull this crap with her. Ditto Dr. Sampson. He’s been retired for a while.
Arguments on SBM should stand or fall on their own merits, not on whether or not the blogger making them is a practicing physician. You are concentrating far too much on the person rather than the argument, your attacks bordering on being ad hominem (i.e., Dr. Tuteur must not be practicing physician any longer, so she must be wrong) rather than evidence-based.
And I say this as someone who had a bit of a problem with this post.
Why does it matter? Because SBM has pasted Tuteur’s bio, while omitting a pertinent sentence in that bio, and continued to refuse to answer why. Hall’s and Sampson’s bios disclose their retired status, no need to question. My inquiries have been about SBM’s discrepancies regarding disclosure policies and lack of response to those questions, not Tuteur’s comments. Your comments strike me as another ruse to avoid answering the question. Apparently the answer is that there is no disclosure policy.
hey what happened to your poisoning the well comment? change your mind? anyhow, please point to where I said Tuteur was wrong about anything. that has not been my point at all.
An example of the powerful cultural influence of the natural childbirth movement is a comment upthread which included the phrase “despite a live baby.”
Dr. Amy is not making an argument from authority, and her credentials are not relevant to her argument. That said, I would like to point out that very bright, well-educated women become mothers all the time. Some leave careers to raise children. That doesn’t invalidate their intelligence or education. Full disclosure: I am a stay-home parent.
I am well aware of the common cultural phenomenon of educated mothers. Please don’t attribute concepts to me (such as motherhood invalidating intelligence or education) which I never uttered nor believe in.
Most of us wrote our own bio; there is no overall bio “policy,” thus no consistency. Both Amy’s and my bio have prominent links to our websites. The information that Amy has left the practice of medicine is prominent on her home page. I don’t see that as trying to hide anything. It does not qualify as non-disclosure.
I didn’t specify how long I have been retired (is it important for you to know that?), nor did I mention when my family practice board certification expired, nor what score I got on the last board recertification exam, nor how much CME I have done since retiring.
Wales is just trying to stir up trouble. I bet if he agreed with Amy’s post he wouldn’t have asked the question.
Thanks for clarification on the policy. Frankly I don’t see what there is to agree or disagree with. You either believe Dick-Read was a promoter of eugenics or not. It seems rather irrelevent to me.
# wales
“It seems rather irrelevent to me.”
That’s fine. I tried to make the point above (somewhat verbosely) that it does not seem irrelevant to me.
Summary: Dick-Read’s and similar apparent childbirth pseudoscience exist in our culture today. I suspect from my personal experience, though I do not have evidence to submit, that this is quite harmful. This seems a perfectly relevant topic for an SBM post.
Dawn wrote:
“”What I meant was, there is no SBM reason to push every woman to have medical interventions for birth. There are certainly studies that show that for some women they are very appropriate. But, as StatlerWaldorf shows in her quote from Amy’s book, they also have risks. So women should have the ability to seek the level of intervention they desire as long as there are no medical reasons to increase interventions.”"
First, I don’t think Dr. Amy is advocating meds for everyone. She has said several time it’s about giving women the correct information when they make a decision. I gather from her posts, and I feel the same, that many moms today are making NCB decisions and do not have all the facts. Yet they think they do. They are being misinformed. (again, much like the vax thing!)
As evidenced by her book that has been quoted, ObGyns are honest and upfront about the risks and side effects of choosing medications. I don’t believe the same can be said for the NCB crowd. (and I’m lumping them all into one group, just that there are varying degrees)
I confess to being rather disappointed at the turn this thread has taken. Instead of a discussion of the philosophical underpinnings of the “natural” childbirth movement and the lack of a scientific basis for both the origins of natural childbirth and the contemporary natural childbirth movement, it got derailed into ad hominem attacks and structural minutiae.
The bottom line remains the same. The origins of natural childbirth are not scientific. Indeed, many of Read’s fundamental claims are the exact opposite of what science shows us.
Even today, although the movement has thrown off its eugenicist overtones, it still is not based on science, but rather philosophy. Consider, for example, the Lamaze Approach to Birth as explained on their website:
“Birth is normal, natural and healthy.
The experience of birth profoundly affects women and their families.
Women’s inner wisdom guides them through birth.
Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth.
Women have the right to give birth free from routine medical interventions.
Birth can safely take place in homes, birth centers and hospitals.
Childbirth education empowers women to make informed choices in health care, to assume responsibility for their health and to trust their inner wisdom.”
If that isn’t woo, I don’t know what is.
The Lamaze Approach to Birth embodies empirical claims that are factually false. Birth is not inherently “healthy”. Women have no “inner wisdom” and birth is not “guided” by anything. Homebirth is not safe. And counseling women to “trust their inner wisdom” is not a method of empowering women, but rather a bit of magical thinking that diverts women from learning the truth about childbirth.
These are the issues I’d like to discuss.
I’d like to say one last thing on the subject of disclosure. Harriet raises some good points above, all of those pieces of information would be pertinent to understanding a non-practicing physician’s credentials, especially continuing education. It is remarkable that Amy has remained mute on the subject. If the contributors here write their own profiles then she is the only one who can shed light on the rationale for disclosing her retired status on her other site but omitting it from the SBM profile.
Weak troll is weak. But we are happy to keep it as a lawn gnome, and for the sake of the googles.
PS I’d like to commend Harriet for her consistency in stating her retired status up front on SBM and her personal site. She sets a good example.
Again Amy Tuteur, what is your complete definition of natural birth. Thoroughly discussing how science does or does not support natural birth beliefs will take many posts, so they will need to be taken in turn.
To address some of your points above from the Lamaze website: How exactly do you plan to refute some of those items scientifically? Do you want to claim that the human animal has no instincts for birth and that birth is inherently abnormal, unhealthy and unnatural? If people can feel spiritual about various aspects of life, why not when it comes to birth? Is there something illogical about being positive about one’s ability to birth with little or no medical intervention and saving feelings of fear or anxiety for when there is an actual problem with the birth?
@wales
To contrast Dr. Hall’s disclosure on her retired status as “a good example” implies that Dr. Tuteur is setting a bad example.
Step away from the computer before you embarrass yourself even more.
Dr. Tuteur, thank you for the history lesson. I had never read about the beginnings of the “natural childbirth” before. Now it makes more sense to me, having dealt with the philosophy before.
Is this post laying the groundwork/history out for future posts?
wales, did you happen to read the Credentials page on my website? The disclaimer at the top says “Disclaimer: I’m putting this page on the website only because people keep asking me for my credentials. I don’t think credentials mean much. There are Harvard-educated MDs and PhDs with impressive credentials who have written reams of nonsense, and there are people like James Randi who didn’t go to college but whose writings are consistently reliable and rigorously based on fact and reason. I hope no one accepts anything I write just because I’m an MD. Writings should be judged on their own merits: on what they say, not on who wrote them.”
If you approve of my disclosures, perhaps you will approve of this one too.
I don’t know how long Amy has been retired, and I don’t need to know. I don’t know how many CME credits she earns each year, and I don’t need to know. Someone could have lots of CME credits but not have benefitted from them. I can tell from what Amy writes that her knowledge is up to date.
I have not practiced medicine since retiring from the Air Force in 1989. That’s over 20 years. I don’t think that necessarily impacts on my judgment or on the content of my writing. But if you are going to pick on someone, it would be a lot easier to pick on me.
storkdok there is no reason for embarrassment. In my opinion Harriet’s example is a good one for professionals in all arenas, not just medicine. In fact in some professions it is standard practice for retired individuals to add a “retired” designation to their title, as in the military; or indicating retired status by including the year the designation was awarded, as with the Chartered Financial Analyst designation (CFA). The CFA Institute states that including the year of CFA designation to indicate retired CFA status makes a dignified statement of fact and does not imply that the retired member is active and practicing. This is not a personal issue, but a professional one that deserves some thought. In my commendation of the good example I intended no reference to a specific bad example, but your point is well taken.
StatlerWaldorf:
“Do you want to claim that the human animal has no instincts for birth and that birth is inherently abnormal, unhealthy and unnatural?”
Before any claims, we have to agree on the desired endpoint. When it comes to a physiologic process, the desired endpoint is, at a minimum, to be alive at the end of it. Therefore, the desired endpoint of childbirth is a live mother and a live baby; anything else is a failure.
Here are my claims:
1. Childbirth is inherently dangerous. Considering that it is a physiologic process, it has a massive risk of death. It appears that in nature, childbirth has a maternal mortality rate of 1,000/100,000 (compared to a death rate of approximately 10/100,000 with modern obstetrics) and a neonatal death rate of approximately 70/1000 (compared to a death rate of 7/1000 with modern obstetrics.
There is no physiologic process that comes anywhere close to these extraordinary death rates. In fact, there are many serious diseases that don’t have death rates that high.
2. Human beings have no “instinct” for delivering a healthy baby to a healthy mother. Either they live or die; instinct has nothing to do with it. Human reproduction has tremendous wastage. Women have no “instinct” for preventing miscarriage (the rate is 20% of confirmed pregnancies, and much higher for even earlier pregnancies).
Similarly, there is no “instinct” for avoiding massive maternal hemorrhage, eclamptic seizures, or any other cause of maternal mortality. There is no “instinct” for preventing premature labor, postdates pregnancy, abruption, placenta previa, or any other complication leading to neonatal death.
There is no “instinct” for preventing cephalo-pelvic disproportion leading to a labor that goes on for an agonizing 3 days or more ending in the death of both baby and mother. There is no “instinct” for preventing breech birth with a trapped head or nuchal arms. There is no “instinct” for preventing cord prolapse around a double footling breech.
I could go on and on, but I think you get the idea. The entire concept of “instinct” or “inner wisdom” reducing maternal and neonatal mortality is nothing more than magical thinking of the most ridiculous kind.
Harriet I don’t consider my comments “picking on” Amy. I have no reason to “pick on” you. You have disclosed your professional status. Despite the fact that you don’t place much emphasis on credentials, apparently many do, as illustrated by your comment “people keep asking me for my credentials”. Imagine that. I am glad to hear that others are interested in credentials. In any case, thanks for elaborating.
storkdoc:
“Is this post laying the groundwork/history out for future posts?”
Absolutely. That’s the primary purpose of this post. In order to have a discussion of the science of childbirth, we need to put to rest the non-scientific claims of the “natural” childbirth. The primary claim that childbirth in nature is inherently safe is contradicted by all the existing scientific evidence. The other important fundamental claim that childbirth in nature is painless is also contradicted by all the existing scientific and historical evidence.
Virtually everything else in the philosophy of “natural” childbirth rests on one or both of these faulty premises. I plan to explore individual claims in detail, but I consider the historical background invaluable.
wales, if you are “glad to hear that others are interested in credentials,” that must mean you think they are important. Please explain what you mean.
weing,
I really wish you’d ask about Dr. Tuteur’s credentials one more time. She’s obviously hiding something. You are just the person to sort her.
If she fails to answer to your satisfaction, please repeat your question again and again. Speculate concerning why she fails to engage with you. Phrases that you might find useful: “smells fishy in here, ” or “something’s rotten in the state of Denmark.
Don’t forget: credentials. Keep asking. Over and over. Never mind that the repetition might be driving the rest of us to drink. Just do it.
DOOOOOO EEEEEEEET!!!!!!!
Remember: credentials.
Did I sai weing? I means “wales.”
@wales
This is the second out of three posts by Dr. Tuteur that you keep harping on about her credentials.
Personally, the way I see it, since she is retired, that removes a lot of potential bias, as she is not making any money from the practice of medicine. She is not in competition with other practitioners for patients.
So the only conclusion I can come up with is that you are trying to discredit her because she is not actively practicing medicine.
Please explain why it is so important.
I wasn’t asking for credentials, I was asking what is the rationale for the discrepancy in levels of disclosure.
Which is even worse. It implies a coverup.
“The primary claim that childbirth in nature is inherently safe is contradicted by all the existing scientific evidence. The other important fundamental claim that childbirth in nature is painless is also contradicted by all the existing scientific and historical evidence.”
Interesting. When our guinea pig got pregnant, the vet said only young guinea pigs (I think she said <7 months old) can give birth naturally, without dystocia. If they are older than that, they have an extremely high rate of dystocia and maternal/fetal death if they don't have a C-section. When our guinea pig gave birth, she squealed. Didn't sound happy or painless to us. But I couldn't ask her, as I am not Dr. Dolittle.
So much for nature. And I'm glad I didn't have to do a C-section on the guinea pig.
storkdoc you do like to infer those implications, no? Each reader will infer as he/she is prone to. I don’t know about a “cover-up” (do you?) but I do think it is misleading not to disclose the retired status on the SBM profile, especially for future readers who have not had the pleasure of perusing this particular thread. If it is so unusual for retired physicians to disclose their professional status then why have other SBM physicians done so? And why do other professions have retired designations? In order to accurately represent themselves and not to mislead. Since you have repeated your claims of implications, I will state that representing oneself as a physician without disclosing retired status implies a practicing physician, which is an inaccurate portrayal in this case. Really, I did not intend to beat a dead horse but apparently I am the only reader here who believes this is an important issue. Accuracy, transparency, disclosure, call it what you will, it is the gist of my emphasis on this topic.
I do have another obligation to attend to for the rest of the evening. Adieu for now.
Dr Benway, if that iiissss your real name. (I’ve always wanted to say that.) and wales.
Credentials, smentials. Anybody using the web (except my cat) is perfectly capable of goggling any of the bloggers or doing whatever credential search they think is appropriate (It’s the lack of opposable thumbs. Sad really. She’s quite gifted with actionscript).
Sure, it’s helpful if people post something about themselves and give us context. But the indignation to serve your purpose (which is, I’m sure, world domination) is transparent.
Really you are basically trusting (or not, so very visibly) what anyone says online about credentials anyway. If you use the web at all you should always be cognizant of the fact that the 15 year old bubbly teen may actually be a 50 year old hairy male, or the other way around (or any combination of the two, with a mustache).
What are you going to do next? demand the Hawaiian birth certificate? Is Amy Tuteur really from Kenya? (That’s what my cat told me. She got an email from her cousin.)
Signed Michele in Michigan – Original Designer of the Mackinaw Bridge, Dr of Extraordinary Benevolence and Superhero (D.S.S.)
I’m not a REAL doctor. I have a master’s degree (or not).
(Who is focusing more on the therapeutic value of posting than actually believing that anyone will be convinced by any argument reasoned or unreasoned that doesn’t include loads of cash or possibly Halloween Reese’s peanut butter cups.)
Dr Tuteur writes:
“The primary claim that childbirth in nature is inherently safe is contradicted by all the existing scientific evidence. The other important fundamental claim that childbirth in nature is painless is also contradicted by all the existing scientific and historical evidence.”
I have to say, again, that this representation of the claims of natural childbirth advocates is pretty strange to hear. There is, no doubt, a tremendous amount of New Age silliness wrapped up in the natural childbirth movement, but when our family was working on deciding how to give birth, no one we spoke to who advocated for “natural” or unmedicated birth ever suggested that childbirth was either painless or “inherently safe.”
Indeed, both the home birth midwife-RNs we met with and the birth center RNs we met with (not to mention the OBs that worked with both practices) were very concerned with “risking out” anyone who didn’t have a very high likelihood of a simple, normal birth.
We did a lot of research ourselves and came to the conclusion (based on, for example, the recent Dutch study and the British Columbia study — sorry, I would link them but it’s late and I’m lazy) that a home birth or birth center birth seemed to be about as safe, statistically, as a hospital birth, but only for VERY LOW RISK PATIENTS working with a trained nurse-midwife. I know Dr. Tuteur probably disagrees with this, but the Royal College of Obstetricians and Gynaecologists in the UK, for example, considers these kinds of birth situations appropriate as long as there’s adequate medical infrastructure on hand and as long as parents are adequately counseled on emergency scenarios beforehand.
Anyway, the point is that everyone we talked to was very concerned with risk — indeed, obsessed with monitoring and managing risk — and no one ever told us that the process was without danger or inherently safe. And no one disparaged science, either. We were, in fact, all counting on science-based medicine to do a good job sorting out low- and high-risk pregnancies. (Which, for the most part, it does!)
So to me this whole argument is a more than a little strange. I know you quote some mothering message board posts above, but I don’t think that’s typical of where the professionals are at. At least, that wasn’t our experience, anecdotally.
Finally, Dr. Tuteur, I just wanted to say that even though we disagree, I think, on a few points, I’m sorry you’ve been subjected to weird harassment and trolling. That’s not cool.
thehandsomecamel,
Are you a certified camel? Do you have an ID with a camel picture? Do you have a diploma from camel school? Have you won a camel beauty contest? One hump or two? You didn’t disclose that information; you must be hiding something. How can you expect us to read what you write if you haven’t disclosed that information?
Sorry, I couldn’t resist poking fun at wales.
I like your name and I’m not going to ask you what it means.
I suppose we should be gentle with wales. He’s obviously stroked out the midbrain nucleus of STFU, poor lad.
It is easy to dig into the history of “modern obstetrics” (treating that like a monolithic entity) and find fairly astounding quotes to demonstrate that obstetricians have viewed childbirth as inherently pathological (rather than a risk factor for pathology, which is a rather different thing). The writings of DeLee are a total gift for those who dislike Amy Tuteur’s ideas, but share her rhetorical approach.
One doesn’t have to venerate the normal physiology of birth, nor think it is always safe and healthy, to realize that it does have a central place in any science-based discussion. In particular, I would go back to the statement of Enkin et al quoted up thread ““any interference with the natural process of pregnancy and childbirth should…be shown to do more good than harm.” and that “the onus of proof rests on those who advocate any intervention.” This is simply good evidence-based medicine, taking the physiology as the default and demanding evidence that specific interventions improve on it.
Obviously, there are practices (medical and cultural) that significantly reduce maternal mortality. For example, legal regulated abortion in clean environments (septic environments, in the case of surgical abortion) may reduce the rate of fatal septic abortion (one of the largest contributors to maternal mortality). The ability to induce labour with synthetic hormones or do safe caesarean section surely reduces eclampsia fatalities. Corticosteriods for lung maturation during preterm labour has made a massive difference to the survival of preterm neonates. Anti-D prophylaxis has almost entirely eliminated rhesus disease. However, these are not the practices of modern obstetrics that are ‘controversial’.
It is rather routine poorly-evidenced “prophylactic” practices which are unlikely to be beneficial to mother and babies, or have been shown to be detrimental, that cause the most ‘friction’ between ‘modern obstetrics’ and its critics. Observe, for example, where the discussion about cEFM vs. intermittent auscultation ended up in the previous thread. (Basically, Amy Tuteur conceeds that intermittent auscultation is the better standard screening test for fetal wellbeing in labour, but defends cEFM on the grounds that it is cheaper, and without recourse to any health economic evaluation and, in any case, it is the fault of the evil hospital administrators).
@Dr Benway on 13 Nov 2009 at 11:00 pm I support your demand that Wales continue to press the case of credentials; but I want more. Specifically, we should be provided birth certificates, fingerprints and dental records.
thehandsomecamel:
“based on, for example, the recent Dutch study and the British Columbia study — sorry, I would link them but it’s late and I’m lazy”
When did you do that research? Those studies have only been published very recently.
Moreover, those studies are the only ones that show homebirth to have a comparable mortality rate to low risk hospital birth. Why accept those and ignore all the others and well as ignore the state, national and international statistics that show homebirth to have an increased rate of neonatal mortality?
Why accept those and ignore all the others and well as ignore the state, national and international statistics that show homebirth to have an increased rate of neonatal mortality?
+++++++++++
Perhaps because they allow intention to treat analysis (i.e. include the transfers and exclude the unintentional homebirth)? This will more accurately reflect outcomes according to planned place of birth than raw data that doesn’t adjust for these known confounders?
Plonit,
Your comment is filled with so many false factual claims that it is difficult to know where to start. I guess we should go in order, but before we do, I want to make a general comment.
The widespread acceptance of modern obstetrics is based on the abject failures of midwifery. Modern obstetrics received wide and enthusiastic acceptance because midwifery had appallingly high rates of neonatal and maternal mortality. I realize that midwifery has since been reborn to copy virtually all of modern obstetrics and to work only in conjunction with obstetricians. Without that change, the neonatal and maternal mortality rates would still be appalling.
1.”It is easy to dig into the history of “modern obstetrics” (treating that like a monolithic entity) and find fairly astounding quotes”
I did not randomly dig into the history of “natural” childbirth. I presented the fundamental principles of “natural’ childbirth as proclaimed by its founder. And I quote the current fundamental principles of Lamaze, probably the largest entity supporting natural childbirth in the US.
2. “obstetricians have viewed childbirth as inherently pathological (rather than a risk factor for pathology, which is a rather different thing).”
If you consider death pathological (and I do) childbirth IS inherently pathological.
Do you consider miscarriage pathological? Does the fact that it happens “naturally” and in 1 out of 5 pregnancies make it non-pathological? No, it doesn’t. Childbirth, with an inherently high rate of both neonatal and maternal death remains a leading cause of death of young women in every place and culture (even first world countries) and the leading cause of infant death almost everywhere.
3. “any interference with the natural process of pregnancy and childbirth should…be shown to do more good than harm.” and that “the onus of proof rests on those who advocate any intervention.”
By that definition, the “package” that is modern obstetrics has been astoundingly successful. Modern obstetrics has reduced the neonatal mortality rate by 90% and the maternal mortality rate by 99% in its first 100 years. Midwifery has reduced the maternal mortality rate by 0% and the neonatal mortality rate by 0%.
4. “fatal septic abortion (one of the largest contributors to maternal mortality)”
No, septic abortion is NOT one of the largest contributors to maternal mortality.
According to Loudon, writing about maternal mortality in the UK from 1872-1876, septic abortion accounted for only 4% of a maternal mortality rate of 400/100,000.
5. “It is rather routine poorly-evidenced “prophylactic” practices”
Obstetrics is preventive medicine. Sure, our ability to handle life threatening emergencies gets most of the press, but it is our ability to prevent them that has made the difference.
[Just as an aside: Midwives are constantly complaining about "poorly-evidence" obstetric practices, but, to my knowledge, there is not a single practice that is exclusive to midwifery that has ANY evidence to support it at all.]
6. “Basically, Amy Tuteur conceeds that intermittent auscultation is the better standard screening test for fetal wellbeing in labour, but defends cEFM on the grounds that it is cheaper, and without recourse to any health economic evaluation”
Do not put words into my mouth. What I said was that under controlled experimental conditions a rigorously defined protocol for intermittent auscultation appears to have a lower false positive rate than cEFM. No one has studied it under real life conditions. Moreover, as you yourself acknowledged, since its implementation in the UK, there has been no decrease in the C-section rate and no obvious cost savings.
Plonit:
“Perhaps because they allow intention to treat analysis (i.e. include the transfers and exclude the unintentional homebirth)? This will more accurately reflect outcomes according to planned place of birth than raw data that doesn’t adjust for these known confounders?”
That can’t be the reason since many papers and international statistics include intention to treat. More importantly, studies that do not include intention to treat are unfairly biased IN FAVOR of homebirth. Had they included intention to treat, homebirth would have looked even worse in comparison.
With the exception of the two recent papers, there is no scientific evidence that shows homebirth to be as safe as hospital birth for comparable risk women.
“It appears that in nature, childbirth has a maternal mortality rate of 1,000/100,000 (compared to a death rate of approximately 10/100,000 with modern obstetrics) and a neonatal death rate of approximately 70/1000 (compared to a death rate of 7/1000 with modern obstetrics.”
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source?
1. DeLee is not random either, but a pretty central figure in the history of modern obstetrics. If you want to confine your definition ‘natural childbirth’ to belief in psychoprophylaxis mixed up with the racist and sexist attitudes of the day, thenwe could agree that natural childbirth is a lot of tosh. You appear to want to extend your critique beyond that.
2. “If you consider death pathological (and I do) childbirth IS inherently pathological.”
Only in the same sense that “Life is a terminal disease”. Pregnancy and childbirth are not inherently pathological, but clearly have a greater potential to become pathological than the non-pregnant state. I think you have rather proved my point that “obstetricians have viewed childbirth as inherently pathological (rather than a risk factor for pathology, which is a rather different thing).”
3. “Modern obstetrics has reduced the neonatal mortality rate by 90% and the maternal mortality rate by 99% in its first 100 years”
I don’t dispute that obstetrics has made a significant contribution to declines in maternal and neonatal mortality (in fact, I gave several examples of areas in which that is very clear). I dispute that you can simply attribute the entire decline in maternal and neonatal mortality over a 100 year period to obstetrics without further evidence – since correlation is not evidence of causation. As for “the package of obstetrics”, you appear to suggest that gratitude for the clear successes of obstetrics precludes criticism of other parts of the package that may be harmful.
4. On septic abortion, you are quite right. Not the largest by a long stretch, but still certainly signifiant – I got carried away. But of course, I also mentioned the success of obstetrics in intervening to end pregnancy complicated by pre-eclampsia, the virtual elimination of rhesus disease and the use of corticosteroids, to which I could have added many more examples. So, there is no need to conclude that I don’t value obstetrics or that I don’t understand its huge successes.
5. “Obstetrics is preventive medicine. Sure, our ability to handle life threatening emergencies gets most of the press, but it is our ability to prevent them that has made the difference.”
Whether it makes a difference depends on the specific prophylaxis proposed, surely. Some interventions will improve the health of pregnant women and improve outcomes, others do not. The point is to distinguish between them.
6. When I patiently explained (by analogy with breast cancer screening) how intermittent auscultation was as good for babies, but better for mothers than cEFM, your response was
“Tell it to the people who run the hospitals. Obstetricians have no control over nursing staffing. We must work in the situations that exist, not the ones we wish for.”
Which I took to mean that if you had the staff available to provide the superior form of monitoring, you would favour that.
IndianaFran,
There are two ways to ascertain childbirth associated mortality in nature. One is to look at historical data. The other is to look at contemporary data from countries with limited or no access to modern obstetrics.
Irvine Loudon is probably the premier historian of childbirth pre and post modern obstetrics. Discussing his paper Maternal mortality in the past and its relevance to developing countries today, American Journal of Clinical Nutrition, Vol. 72, No. 1, 241S-246s, July 2000, he explained the basis for historical maternal mortality rates.
“The important work was by Wrigley and Schofield, who wrote a population history of England [Wrigley EA, Schofield RS. The population history of England. A reconstruction. Cambridge: Cambridge University Press, 1981]. They found maternal mortality rates were certainly higher at 400–500 per 100000 births throughout the 19th century. It was a bit higher at the beginning of the 19th century and was up to perhaps 1000 per 100000 births in the early part of the 18th century. I have a graph in my book [Loudon I. Death in childbirth. Oxford: Clarendon Press, 1992] that shows maternal mortality stretching back in history and, as you go back, it goes up very slightly and then we lose track because there really are no data as yet. Nevertheless, a dramatic fall in maternal mortality did not occur until 1937.”
As for contemporary data, a 2002 report of the Population Reference Bureau quoted a maternal mortality rate in sub-Saharan Africa of 967/100,000.
Similar historical and contemporary statistics exist for neonatal mortality.
Plonit:
“If you want to confine your definition ‘natural childbirth’ to belief in psychoprophylaxis mixed up with the racist and sexist attitudes of the day, thenwe could agree that natural childbirth is a lot of tosh.”
I think the Lamaze Approach to Birth accurately characterizes contemporary “natural” childbirth. Did you have a different definition in mind?
“I dispute that you can simply attribute the entire decline in maternal and neonatal mortality over a 100 year period to obstetrics without further evidence”
There is actually a great deal of evidence on this point. The decline in maternal and neonatal mortality can be graphed by year against the introduction of various interventions and steep drops can be seen with the introduction of each new intervention. Interestingly, the impact of nutrition and public sanitation on maternal mortality has been very small. Public sanitation has had a bigger impact on neonatal mortality.
“Some interventions will improve the health of pregnant women and improve outcomes, others do not. The point is to distinguish between them.”
I don’t disagree. My point is that childbirth without interventions has an appallingly high rate of neonatal and maternal mortality. Many different interventions are absolutely necessary to ensure low population rates of neonatal and maternal mortality including prenatal care, access to C-section, blood banking, antibiotics (prophylactic and therapeutic), etc.
Does that mean that every woman needs every intervention? No, of course not. Does that mean that every intervention is necessarily beneficial? No, again. However, the assumption that avoiding interventions is either desirable or beneficial has no basis in the scientific evidence.
Oh Dear, Upon rereading I realized Dr. Benway was being facetious in his support of wales comments. That is what happens when I skim posts.
My comment does stand for wales. Though is lacks a certain je ne sais quoi without the Dr Benway reference.
Benway, Joe, Harriet & others have taken the “credentials” ball and run with it. I can only surmise that some SBM readers are not paying much attention to what they’re reading. The comments implying a preoccupation with credentials are inaccurate. Astute readers will discern that my point (preoccupation if you will) was about disclosure of professional status. While credentials are important, that topic was a sidebar in response to Harriet’s comments about credentials.
If a retired physician is blogging as an expert on at least four different websites, half of which disclose his/her retired status, half of which do not, is the discrepancy due to sloppiness or is it intentional? If intentional, what is the purpose? Food for thought. Unfortunately I don’t have more time to spend on this engaging topic today.
wales,
Do you have any comments on what I wrote?
If not then it appears that your efforts to refocus the discussion on who I am is a poorly veiled attempt to divert attention from the substance of the piece.
What, specifically, do you find to be factually incorrect in this piece? Anything?
Irvine Loudon is probably the premier historian of childbirth pre and post modern obstetrics.
++++++++
I totally agree, I wish you would read his book! He has a very interesting discussion about the growth of obstetrics vis-a-vis midwifery in the US.
“If a retired physician is blogging as an expert on at least four different websites, half of which disclose his/her retired status, half of which do not, is the discrepancy due to sloppiness or is it intentional? If intentional, what is the purpose?”
Who cares? (other than Wales) If the purpose is to conceal information, you don’t put the information on half the websites.
Would wales have read the post differently if Amy’s retired status had been mentioned in her SBM bio? If so, doesn’t that amount to an ad hominem prejudice?
IMHO, Wales is just making troll noises because he has nothing substantive to add to the discussion.
Did you have a different definition in mind?
+++++++++
My impression, based on your writings at homebirthdebate, is that you regard any truck with home birth, midwifery or criticism of obstetric practice, as “NBA” (aka Natural Birth Advocacy). That seems too broad a definition to me. If you want to confine yourself to the teaching programme/mission statement of Lamaze, then we can talk about the content of that.
The decline in maternal and neonatal mortality can be graphed by year against the introduction of various interventions and steep drops can be seen with the introduction of each new intervention.
+++++++++++++
The two dramatic improvements in maternal mortality noted by Irvine Loudon are sulfonamides in 1937 (quickly followed by antibiotics) and blood transfusions, immediately post-war. These can be considered gifts from general medicine to obstetrics. And these innovations were as keenly embraced by midwives as by doctors, in places where midwifery was mainstream practice.
What Loudon’s work also shows is a rather dramatic spike in maternal mortality in the late C19th (from c. 400/10000 in 1890 to c. 650/10000 in 1895) partly attributable to the obstetric fashion for heavy anaesthesia and consequent use of high forceps, in the era before antibiotics and blood transfusions. The widespread practice of heavy anaesthesia and forceps in births which may otherwise have been uncomplicated were described by one observer in 1936 as “little short of murder” (Topping, “Maternal mortality and public opinion” _Public Health_ 1936;9:342–9).
However, the assumption that avoiding interventions is either desirable or beneficial has no basis in the scientific evidence.
++++++++
I think the assumption more commonly made is that interventions should be based on good evidence, and their use not extended beyond that which the evidence can support. (e.g. induction to prevent prolonged pregnancy can be justified by research evidence as having a small but statistically significant benefit beyond 41 weeks of pregnancy, but cannot be so supported prior to 41 weeks – nonetheless many obstetricians are performing inductions prior to 41 weeks for ‘postdates’).
I will reply directly to your question Amy, though you have not responded to mine. One correction, it’s not about who you are, but about why you chose different disclosures for different sites.
As for factual accuracy, I don’t know. I haven’t paid much attention to the facts and figures here or attempted to verify them as I lost interest in the topic when it appeared to be a repetitive argument about eugenics, racism and sexism. Aside from that, you seem to make the argument that there is no legitimate science based rationale for natural child birth. I note Statler Waldorf’s Nov 13 comment at 11:49 am that details the risks of medical interventions during labor such as epidurals and pitocin. Much has been written about the cascade effect in medicine, as well as the risk of hospital acquired infections. Thus there does seem to be a science based rationale for natural childbirth for those wanting to avoid the risks of multiple medical interventions and home based birth to avoid risk of hospital acquired infection. This seems like an acceptable choice, especially for low risk pregnancies with (dare I say it? ) a credentialed midwife.
I will continue to read with interest when I return to my desk later tonight.
for anyone who cares, I have taken the discussion of homebirth safety statistics and evidence back over to the original post, where it seems more pertinent.
I did fact check on one subject, Amy. Upon first read I doubted the veracity of your comment that “Childbirth……remains a leading cause of death of young women in every place and culture (even first world countries)”
In the CDC table of US 2004 leading causes of death for females http://www.cdc.gov/Women/lcod/04all.pdf I was surprised to find that pregnancy complications (not childbirth per se) is listed among the top ten causes of death in young women, albeit at the lower rankings and at low rates. Note that the table’s “pregnancy complications” definition includes childbirth as a subset of the definition, so the actual childbirth maternal mortality figures would be lower.
In age group 15-19 “pregnancy complications” (not childbirth per se) are ranked as 7th leading cause of death, with a rate of 0.9%
In age group 20-24 pregnancy complications are ranked as 6th leading cause of death, with a rate of 2.7%
In age group 25-34 pregnancy complications are ranked as 7th leading cause of death, with a rate of 2.3%
Pregnancy complications are not listed in the top ten causes of death for the age group 35-44, which is interesting. Perhaps the numbers are too small, or this age group received better prenatal care.
It would be nice to have the childbirth figures isolated from the pregnancy complications figures. Perhaps they would not be significant enough to be included in the top ten causes of death. I also wonder what percentage of pregnancy complications in the younger age group are attributable to pre-existing conditions such as obesity.
What is it about childbirth that gets everyone so riled up?
Pregnancy and delivery is a HUGE DEAL. I used to say about pregnant women that if the same physiological alterations were present in any other condition, we’d be taking it very seriously indeed (ASA 3, at least) instead of making it into a time of magic and fairy dust and “listening to the wisdom of my body”.
I know Trevathan used to talk about pain during delivery as adaptive (which is to say– NORMAL) to make sure that women had help during a very risky time for both mother and infant. Hypotheses about the pelvis and the switch from baby being born face up vs face down (and thus unable to be assisted by the mother herself) creating the necessity of help during labor abound…
But I will say I’ve read a few studies about the up-regulation of pain receptors in the cervix as pregnancy reaches it’s end which makes me think seriously about Trevathan’s hypothesis.
Childbirth is SUPPOSED to hurt. It’s supposed to scare you and make you look for a safe place to have your baby, and people to help you… if there is any “instinct” about human birth at all that would be it. Preventing infant mortality in even nulliparous women save for a few failures of the natural painful delivery process leading to women birthing in toilets etc.
Re: maternal mortality rates. The first link for this topic in google connects with a very informative site that collates figures from UNICEF, 2002. In addition to listing mortality rates by country, bar graphs are available correlating the rates with other country statistics. Here’s the link:http://www.nationmaster.com/correlations/hea_mat_mor-health-maternal-mortality
According to this site, maternal mortality correlates highly with probability of dying before 5 (78%), probability of not reaching 40 (70%), expected duration of education for females (64%).
Correlations with birth attendants is weaker. The correlation with skilled attendant at delivery is 59%, births with health staff is 55% (inverse.) The site does not list any correlation of maternal mortality with access to doctors (physicians per 1,000 people.)
I know almost nothing about statistics, but this seems to me to indicate that the rate of maternal mortality may have more to do with factors related to general health than with access to particular birth attendants.
manixter:
“Childbirth is SUPPOSED to hurt. It’s supposed to scare you and make you look for a safe place to have your baby, and people to help you… if there is any “instinct” about human birth at all that would be it.”
Yes, that is what bioanthropologist Wanda Trevathan (also trained as a midwife) and paleoanthropologist Karen Rosenberg suggest.
As they wrote in a Scientific American article in a special issue devoted to human evolution (2003):
“Today virtually all women in all societies seek assistance at delivery… So, though rare exceptions do exist, assisted birth comes close to being a universal custom in human cultures.
Knowing this—and believing that this practice is driven by the difficulty and risk that accompany human birth—we began to think that midwifery is not unique to contemporary humans but instead has its roots deep in our ancestry. Our analysis of the birth process throughout human evolution has led us to suggest that the practice of midwifery might have appeared as early as five million years ago, when bipedalism constricted the size and shape of the pelvis and birth canal.”
And:
“The triple challenge of big-brained infants, a pelvis designed for walking upright, and a rotational delivery in which the baby emerges facing backward is not merely a contemporary circumstance. For this reason, we suggest that natural selection long ago favored the behavior of seeking assistance during birth because such help compensated for these difficulties.”
Trevathan and Rosenberg speculate that the pain of childbirth was adaptvei in that it frightened women and caused them to seek assistance, and that assistance increased the chance that they and their offspring would survive.
Dacks:
“I know almost nothing about statistics, but this seems to me to indicate that the rate of maternal mortality may have more to do with factors related to general health than with access to particular birth attendants.”
Actually, there’s copious scientific evidence that maternal mortality is directly related to skilled assistance in childbirth. Moreover, the existing scientific evidence suggests that it is related minimally, if at all, to general maternal health.
The Population Reference Bureau statistics show:
Sub-Saharan Africa 45% receive skilled care;967maternal deaths per 100,000 births
South Asia 59%/430
East Asia and Pacific 73%/189
Middle East and North Africa 77%/175
Latin America and Caribbean 83%/146
Central & East Europe/CIS(Russia)/Baltic 97%/45
North America 100%/9
In addition, as Loudon wrote in the paper I cited above:
“There is overwhelming evidence that social and economic conditions were very weak determinants of the levels of maternal mortality, whereas the standard of obstetric care was a very strong determinant. In situations in which nutritional status is so low that it approaches starvation, however, this may not be true. Under the conditions of poverty and associated malnutrition that were seen in parts of developed countries in the 19th and first half of the 20th century, it was care at parturition and not malnutrition and other concomitants of poverty that determined the level of maternal mortality. Although it can be argued that social status and standards of maternal care were not wholly independent variables, because the rich could buy what they thought was the best maternal care and the poor could not, the reduction in maternal mortality in the past was generally independent of the economic status of the mothers.”
Amy Tuteur
There are two ways to ascertain childbirth associated mortality in nature….
They found maternal mortality rates were certainly higher at 400–500 per 100000 births throughout the 19th century.
—————————–
19th century England is nature?
Dr. Amy, would you please provide the links to the statistics cited in your comment?
Trying to find the statistics Dr. Amy referred to in her last post, I found this table at Population Reference Bureau. (You can find the download link on this page, under Skilled Care at Delivery and Maternal Deaths) :http://www.prb.org/Home/Publications/GraphicsBank/ReproductiveHealth.aspx
Here are the figures:
percent of births attended by skilled attendants/number of maternal deaths per 100,000 births, 1996-2004
Sub-Saharan Africa :42/940
South Asia: 36/ 560
Middle East and North Africa: 76/220
Latin American and Caribbean: 87/190
East Asia and Pacific: 86/110
Central, Eastern Europe: 93/64
So, South Asia has 6% fewer attended births, yet 380 fewer deaths per 100,000 than Southern Africa. And Latin America and East Asia have virtually the same percentage of attended births, with somewhat different outcomes.
This says to me that, though access to obstetric care is certainly an important factor in decreasing maternal mortality, it may be outweighed in certain countries by other general health factors. And, again, I’m only describing what the figures suggest to me, having no background in this area.
Dr. Tuteur:
“When did you do that research? Those studies have only been published very recently.”
Yes, that’s true! Our baby was born just 12 days ago, and he was premature, so we were making our decisions about childbirth only in the last four or five months.
“Moreover, those studies are the only ones that show homebirth to have a comparable mortality rate to low risk hospital birth. Why accept those and ignore all the others and well as ignore the state, national and international statistics that show homebirth to have an increased rate of neonatal mortality?”
Hmmm. That’s an interesting question. My wife grew up in Holland, and so was very comfortable with the idea of home birth. I was less so. So we looked into it. And a lot of the raw statistics I was able to find, including from California, where we were living when we started thinking about this, did indeed indicate an elevated risk when comparing all home births to all low-risk hospital births.
But “home birth” is a very broad category, and there are, it seems to me, a huge number of variables at play that determine whether that home care is likely to be decent or terrible. What I liked about the study of the Dutch system in particular was that it seemed to indicate that the Dutch are able to pull it off successfully because they try to regulate those variables. Their midwives are highly trained, they have an obstetric community that works very carefully with them, they have good access to nearby emergency care, and in any event fully a third of Dutch women who start out to have a home birth end up transporting to hospital, which indicated to me that they weren’t dogmatic about avoiding medical care.
So my wife and I compromised: we would try for a home birth, but we would do everything in our power to adopt that Dutch model. We did our prenatal care with a CNM rather than a lay midwife, and her practice (as well as, I think, California law) required us to coordinate care with an OB/GYN. We researched hospitals as well as midwives in order to be prepared for a hospital delivery. And we were re-assured by our midwife’s transport-to-hospital rate, which was about double that of other midwives we interviewed (suggesting, to me, prudence rather than dogmatism).
In the end, we decided to go with a hospital birth center instead of home birth for practical reasons (we had moved to another state). And then ultimately when my wife developed eclampsia even that plan had to be thrown out the window, and she ended up delivering in emergency C-section. So, you know, we’re certainly people who are grateful for scientific medicine and its wonders.
But I think there’s a part of my wife (and, hell, me too!) that’s sad that we didn’t get to see our son born, that we didn’t get to welcome him into the world. I know your primary interest is, as you mentioned above, one live mother and one live baby at the end of the day. And I certainly wouldn’t want any other attitude in a doctor. But for the parents, I think, it’s sad when you miss out on that experience — painful, grunty, weird, and potentially hazardous though it might be. So I’ve got some understanding, I think, of what the “natural childbirth” people are trying to get at, even if many of them are New Age hippies.
Anyway, thanks for asking — sorry to have diverted the discussion in this thread to another topic.
Dacks, that isn’t what the data says. The data is completely consistent with there being essentially no effect of general maternal health provided there is sufficiently skilled birth assistance. I think that is what Dr Amy is saying.
With sufficient sufficiently skilled help available, maternal death rates are very low, even for women not in good health.
There very likely is an effect of maternal health on maternal death rate in the absence of skilled assistance. If a woman is in good health and nutritional status, she will be able to survive blood loss that would be fatal if she wasn’t. In a hospital, she whould survive in either case.
Daedalus2u,
I am confused. The data concerns maternal death, not maternal health. My conclusion, which may be wrong, is that the death rates, in some areas, do not correspond with access to skilled providers. Therefore there must be some other factors that affect the numbers of deaths in a particular country, which would be stronger determinants than percentage of births attended by skilled attendants.
Daedalus2u,
The other site that I mentioned earlier, NationMaster, makes explicit correlations between maternal mortality and other health factors. For the 2 related to access to health professionals, the correlations are considered weak:
http://www.nationmaster.com/plot/hea_mat_mor/peo_wom_ski_att_at_del/flag
http://www.nationmaster.com/plot/hea_mat_mor/hea_bir_wit_hea_sta/flag
I can not vouch for the validity of their statistics, but they give their source as UNICEF, 2002.
Dacks, the data doesn’t show what the maternal death rate was in births attended by skilled attendants vs. what was the death rate in births not attended by skilled attendants. All we are seeing is the total death rate.
If skilled attendants reduce the death rate to zero, and all the deaths are due to births that are not attended, then a factor of 2 in the unattended death rate between Sub Saharan Africa and South Asia would completely explain the difference.
What ever effect a skilled attendant has, it can’t have any effect in the births where such an attendant was not present. Without looking at an explicit comparison, data on averages can’t show what the unaveraged differences are.
“Dacks, the data doesn’t show what the maternal death rate was in births attended by skilled attendants vs. what was the death rate in births not attended by skilled attendants. All we are seeing is the total death rate.”
Granted.
“If skilled attendants reduce the death rate to zero, and all the deaths are due to births that are not attended, then a factor of 2 in the unattended death rate between Sub Saharan Africa and South Asia would completely explain the difference.”
Ok, I’m still not getting what you are saying. The death rates are given per 100,000 live births, so 560 in South Asia is directly comparable to 940 in South Africa. If the rate of attended births were the same, this would be notable. However, the rate of attended births in South Asia is higher than the rate in South Africa. This seems like an anomaly to me.
Correction: the rate of attended births in Southeast Asia is LOWER, yet the rate of maternal deaths is also lower, by a large margin.
daedalus2u’
I think I understand your argument: all of the deaths in South Africa and South Asia can easily be attributed to unattended births, and that is quite likely. So, what else causes the difference in these two rates? I don’t know what it is, but it must be something other than attended births.
In addition, Tuteur’s posts rely on a strawman and false dichotomy. It is certainly interesting to explore the origins of the natural childbirth movement, but you can’t throw out the entire, very broad movement based on the racism of one man, even its supposed founder. Even if some of the philosophy was sexist in 1942, it certainly doesn’t invalidate every single claim and study done after the year 2000. Her subsequent posts did that, maybe based on information not presented here, I don’t know.
IIRC, Queen Victoria was unable to get chloroform for one of her births because her doctors and her culture believed that it was necessary to experience childbirth pain. She was succesful subsequently. Somebody mentioned the Genesis reference as well. In other words, the belief that women “should” experience pain in childbirth goes back millenia (and I agree, ridiculous). The hysteria of the uterus, birth control debates, and the laying in hospitals of the ’20s are also informative of the politics of birth that encompass many different factors in the attempt to subjugate women. The natural childbirth movement is relatively recent because the option for pain medication and intervention simply didn’t exist before. Painless childbirth was promoted by Lamaze in the ’70s and by hypnobirthers today, but is still a fringe viewpoint. The mainstream cultural view of labor without drugs is that of extreme pain. And there is certainly sexism in some circles of the natural childbirth movement going back decades. To claim that there was none of that sexism, that childbirth has never been used as a method to control women in the era of forced twilight sleep for example, in the entire history of obstetrics is simply wrong too. (This was not stated outright, simply my impression.)
A few of the comments seem very emotional to me and I can’t figure out why anyone would even care or bother to post about a few women refusing pain meds. However, a science based approach to the subject of pain management in childbirth would focus on the alleged risks and/or side effects of the medications in epidurals (or lack thereof) versus the benefits (or lack thereof). Some women base their decisions on these risk/benefit scenarios. Some women base their decisions on philosophy. Since there is usually not any harm to forgoing pain medication of which I am aware, I can’t fathom what exactly would be wrong in letting individual women decide if they would like drugs based on philosophy, in the absence of a clear scientific answer. Tuteur’s venom towards such women is confusing to me. I do understand that some of them have a superior attitude or may believe they have failed if needing an epidural, so perhaps that is the source of the venom. I agree, the holier than thous are annoying, on all sides of the debate. Many more of them simply try to avoid ***unnecessary*** medication and/or interventions in any aspect of their lives, not just childbirth.
In particular, Tuteur’s attitude towards midwives, who every single day help women around the world safely deliver their babies, many in places where there *are* no obstetricians, is disturbing. She may help convince more women if her positions weren’t so extreme and her attitude so condescending.
It seems to me, based on my limited knowledge, that there is at least room for debate on a science based medicine site that doctors overuse procedures, surgeries, and medications all the time with limited scientific evidence. There has been a lot of discussion elsewhere on that lately with regards to the health care debate, the sky rocketing cost of health care, and the pay per service model we have. Individual doctors also often go against guidelines set by their very own professional organizations, including obstetricians. Medical based obstetrics is not immune to these controversies, certainly not historically speaking or even today. Science makes mistakes. Doctors make mistakes. The process is such that they are corrected, even if politics make this difficult.
Now for the false dichotomy… I’ve been reading the site for a few days now and this is my first post. Maybe I haven’t read enough past posts, but it does seem odd to me that the choice is either “science has all the answers and no corrupting factors” or “people who believe in anything natural or question anything in medicine are quacks.” I understand that the constant struggle between science/ technology and nature goes back to the very beginning of time. Tuteur would have us believe that it’s either birth in the back woods by yourself (the purely natural model) or have a scheduled elective c-section at 39 weeks (the purely medical model). In reality, there is lots of middle ground. I expected a science based medicine website to question and explore many broad issues relating to different conflicting studies in medical journals, the best evidence for preventing/treating disease, etc, rather than constantly attacking the quacks and then congratulating each other for their superiority. At least, that’s how it reads to a layperson. I will continue to read and hope I’m wrong.
Oh, and Tuteur has at least four times tried to link natural childbirth advocates with anti vaccination quacks. This is also untrue for many of them. Women happen to have many different opinions with many different biases and reasons for their feelings. Yes, there is a lunatic fringe who believe that anything medical is bad, including hospitals, c-sections, vaccines, presciption meds. But this is a minority and again simply a strawman designed to not have to address an argument on its merits.
zoe237,
It is ironic that you accuse Amy of strawmen and false dichotomy, because your comments commit exactly those fallacies.
You said “there is usually not any harm to forgoing pain medication of which I am aware, I can’t fathom what exactly would be wrong in letting individual women decide if they would like drugs based on philosophy, in the absence of a clear scientific answer. Tuteur’s venom towards such women is confusing to me.”
I didn’t see any evidence of venom, or any suggestion that women shouldn’t decide whether to take drugs.
You said “Tuteur would have us believe that it’s either birth in the back woods by yourself (the purely natural model) or have a scheduled elective c-section at 39 weeks (the purely medical model).”
She never suggested any such thing. You are apparently reading what you want to think she wrote rather than what she actually wrote.
You certainly haven’t read this blog long enough if you think any of the authors are suggesting that science has all the answers. All we say is that science is the best way of looking for answers. Not final answers, but a best approximation that is always open to revision when there is new evidence.
“I didn’t see any evidence of venom, or any suggestion that women shouldn’t decide whether to take drugs. ”
I hope that she is not implying that all women who desire a “natural” childbirth (without pain medication) are stupid, unscientific, or putting their babies at risk for the sake of an “experience.” I don’t know and don’t care personally. But it’s not very convincing to newly pregnant women.
“You certainly haven’t read this blog long enough if you think any of the authors are suggesting that science has all the answers. All we say is that science is the best way of looking for answers. Not final answers, but a best approximation that is always open to revision when there is new evidence.”
Yes, only reading for the past week or two. Most of the posts I’ve seen are attacking anti-vaxers or complementary or alternative medicine, but I see now from the search button there are some discussing non-evidence based medicine. I appreciate that. I’m not alternative, so the CAM stuff isn’t really on my radar, but did have recent knee surgery for which I couldn’t find a lot of peer reviewed evidence of long term benefit (although I still did it). Obstetrics always remind me that doctors need to be aware of their own biases and possible conceit. I’m not sure why this appears to be such a passionate issue online.
And that there are always things that science cannot answer- philosophical, moral, ethical questions.
Zoe wrote:
“A few of the comments seem very emotional to me and I can’t figure out why anyone would even care or bother to post about a few women refusing pain meds.”
For the most part, I really don’t care what other women do irt NCB. Go out in the woods, have your baby, eat the placenta, have a nice day. If your baby dies, while sad, that doesn’t affect me & my family (unlike the vax issue which I am extremely passionate about).
But this is what does bother me–I have two small children, so I’m active in the circles of parents w/small kids. You know–talking at daycare & bday parties, things like that. I am extremely annoyed at the NCB mom-types who look down their noses at me based on my choices. With both kids I was induced at 41+ weeks, so when asked “hey, aren’t you due soon?” and I’d reply “being induced Monday if nothing happens before then!” and then hit with an “oh.” And just that smug look that makes me want to smack them. Then into their dissertation about how *they* had NCB, blah blah blah. When asked about my birthplan (and I don’t do birthplans) I’d just say “Oh, don’t have one, I know my options, we’ll just see what happens and keep our choices open” I’d get a lecture on the importance of writing out a birthplan. And on and on and on.
It’s like the NCB crowd clings to this little bit of knowledge (now shown to be false) and hang on to it with this air of superiority. They’ll be the first to start ranting about how women should have choices, but heaven forbid you make a choice that they don’t agree with!
But this is what does bother me–I have two small children, so I’m active in the circles of parents w/small kids. You know–talking at daycare & bday parties, things like that. I am extremely annoyed at the NCB mom-types who look down their noses at me based on my choices. With both kids I was induced at 41+ weeks, so when asked “hey, aren’t you due soon?” and I’d reply “being induced Monday if nothing happens before then!” and then hit with an “oh.” And just that smug look that makes me want to smack them. Then into their dissertation about how *they* had NCB, blah blah blah. When asked about my birthplan (and I don’t do birthplans) I’d just say “Oh, don’t have one, I know my options, we’ll just see what happens and keep our choices open” I’d get a lecture on the importance of writing out a birthplan. And on and on and on.
It’s like the NCB crowd clings to this little bit of knowledge (now shown to be false) and hang on to it with this air of superiority. They’ll be the first to start ranting about how women should have choices, but heaven forbid you make a choice that they don’t agree with!
I won’t disagree with the above, but I feel as if it is part of a larger problem, and it cuts across the board, what i call the Mommy wars.
It is not a hallmark of NBC, but is in fact a symptom in our society in which mothers judge everything that other do?
Breastfeeding, formula feeding, epidural, no epidural, home birth, hosital birth, day care, stay at home, ages and stages comparisons, etc, etc, ect, ad nuseum.
The judgment comes from all around in equal measure.
>”For the most part, I really don’t >care what other women do irt >NCB. Go out in the woods, have >your baby, eat the placenta, have >a nice day. If your baby dies, >while sad, that doesn’t affect me >& my family (unlike the vax issue >which I am extremely passionate >about).”
This common, 99% inaccurate characterization of natural childbirthers is just as judgemental imo. OTOH, I mostly see the mommy wars manifest themselves online- sahm vs. wohm, hospital, home, bf vs. ff, irl, the moms I know don’t really care what the other does wrt birth choices. Occassionally I have run into the stuck up ncb types, and they give everyone else a bad name, definitely. I’ve also run into the mainstream moms who think that anybody who goes med free is nuts or risking their baby’s safety.
Zoe237, “sahm vs. wohm, hospital, home, bf vs. ff, irl”
huh, I am so behind on the mommy wars. I don’t even know what most of these acronyms mean. But I’m concerned it might be
contagious.
Hi, Amy, nice to see you here.
Now we have added one more to our mosaic. Fantastic!
Greetings from the phoneman.
ama
Amy,
here are the references you asked for:
http://www.britannica.com/EBchecked/topic/66765/birth-rite
http://www.enotalone.com/article/5127.html
Here is a conference that was hosted by IHS and NMAI about birthing practices in American Indians/Alaska native and sharing that knowledge.
http://www.naho.ca/english/midwifery/agendaApril24.pdf
http://books.google.com/books?id=p154G4UMSxsC&pg=PA251&lpg=PA251&dq=katsi+Cook&source=bl&ots=mHc7Lwd6zZ&sig=6xogcQh9CJivw02fTbhHrCAVqr4&hl=en&ei=KCkES6THEJHIlAeupujfAQ&sa=X&oi=book_result&ct=result&resnum=5&ved=0CBYQ6AEwBDgK#v=onepage&q=katsi%20Cook&f=false
See the section on Midwifery on birth as ceremony.
http://www.nmai.si.edu/livingvoices/vol1/track7.html