An industry devoted to ignoring, demeaning and ridiculing women's pain

There's something perverse about an entire industry predicated on the concept that excruciating pain is good for women. I'm talking, of course, about the "natural" childbirth industry, and the books, blogs, courses, videos and celebrities that comprise it. The "natural" childbirth industry isn't always sure that the pain of labor exists, but they are sure that if it does, it's desirable that women feel it.

The unalterable bedrock of "natural" childbirth advocacy is that women should refuse effective pain relief in labor. The "ideal" situation is for women to embrace their pain and pretend that it is "good pain." Of course, there is no such thing as "good pain": they just made that up. The pain of contractions and the pain of vaginal distention do not differ in any way from any other kind of pain. It is not carried by different nerves, it is not conducted through the action of different neurotransmitters, it is not routed to different areas in the brain. It is exactly the same as any other kind of pain. So the take home message of NCB is that the excruciating pain of childbirth should be ignored.

And not merely ignored. What's worse is that the NCB movement pretends that women are improved by experiencing the agonizing pain of childbirth, although they cannot think of any other instance in which human beings are improved by agonizing pain. The irony is that "natural" childbirth advocates have beliefs that are strikingly similar to the Victorian clergymen who opposed anesthesia in childbirth when it was first introduced in the second half of the nineteenth century. The clergymen believed that is was wrong to abolish labor pain with anesthesia because God intended for women to feel the pain. NCB advocates appear to believe that it is wrong to abolish labor pain because "Nature" intended for women to feel the pain. There is precisely zero concern for the effect of that pain on a woman herself.

The "natural" childbirth movement routinely demeans women who do not want to tolerate the pain. They are portrayed as weak, as "giving in," as uneducated and uncaring because they don't understand the "risks." Or worse. The ultimate insult, implied, but not always stated is that "authentic" women can and should accept the pain, and that, therefore, women who opt for an epidural are somehow less womanly.

There is one strain of "natural" childbirth advocacy that simply denies the reality of the pain. In this view, the pain of childbirth is psychosomatic in the true sense of the word. It does not reflect actual neurologic signals, but rather the social conditioning of women by a medical, technocratic culture. Pain is a manifestation of the fact that the woman has not "educated" herself that the pain doesn't exist, doesn't "trust" birth, and, once again, is not an "authentic" woman.

There is another strain of "natural" childbirth advocacy that acknowledges that the pain exists but that it can and should be "managed" in ways that are "natural" and inherently ineffective. The goal is not to abolish the pain; that would be wrong. The goal is to tolerate the pain so that the incentive to abolish it will be reduced. Hence the emphasis on hypnosis, water, and labor support. The pain is real, the pain is severe, and it is acceptable to reduce the pain. But it is only acceptable to reduce the pain in ways that involve no technology, and it is never acceptable to actually abolish the pain.

The "support" people in the "natural" childbirth movement exist primarily for indoctrination. The childbirth educator exists to convince women that pain is good for her, and pain relief is bad. The primary function of a doula is to interfere with a woman's desire for pain relief. At every point, the doula counsels the laboring mother that she does not "need" pain relief, that she's doing "great" and she "can do it," with "it" being enduring labor without an epidural.

At the fringes of the "natural" childbirth movement is a group that not only denies the existence of the pain, but inverts it. Childbirth is not painful, it is pleasurable. No remotely plausible physiologic explanation is advanced for this claim, beyond the inane observation that the tissues that produce the pain of childbirth could, in different circumstances produce sexual pleasure. The explanation makes as much sense as the claim that kicking a man in the groin could induce orgasm because sexual pleasure can be produced by contact in the same area.

Why are "natural" childbirth advocates so invested in the idea that women "should" experience excruciating pain in labor? Why are they invested in the idea that women benefit from experiencing labor pain? Why do they direct the bulk of their efforts, both before and during labor, to pressuring women to forgo effective pain relief? Why do these efforts include misinformation about the "risks" of epidurals, and insinuations about the fitness of the laboring women as a mother, and even insinuations about her fitness as a woman?

I don't know all the answers to these questions, but I do know this: it is inherently wrong to ignore the pain of women and to pretend that agonizing pain is good for them.

Orgasmic birth and other fairy tales

With apologies to Hans Christian Andersen:

Early in this century there lived a Mother who was so exceedingly fond of feeling superior to other mothers that she was constantly searching for ways to distinguish herself from them. She claimed to be the best, most natural, most authentic mother in the world. She took no interest in current events, did not work, and only socialized with other mothers in order to boast of her superior birth, breastfeeding, parenting style.

Now one fine day a swindler, calling herself Midwife, arrived. She declared that she could facilitate the most magnificent birth that one could imagine; better than a homebirth, better than an unassisted birth … an orgasmic birth! Not only was the birth perfect in every way - unassisted, in water, videotaped and painless - but it culminated in the greatest orgasm ever. Even better the orgasm had the special power of being invisible to everyone who was not a super awesome, all natural, authentic woman.

"What a splendid idea," thought the Mother. "If I had such a birth I could prove that I was the best mother ever, much better than those C-section, formula feeding, unattached mothers."

So the next time the Mother got pregnant, she gave the swindler Midwife large sums of money to pay for the Midwife's books and videos and the two week course at her Farm. Day after day the Midwife went home with more money.

Now the Mother was eager to know give birth and have a giant orgasm. She was, however, somewhat uneasy. "Suppose," she thought secretly, "suppose I don't have an orgasm at the exact moment of birth. That would mean I am not an awesome, all natural, authentic woman. That cannot be," she thought, but all the same I will watch videos of orgasmic birth. "I will best be able to see how a birth orgasm looks. After all, I am the best mother and most authentic woman possible."

So the Mother and her best friend downloaded videos of orgasmic birth from YouTube and watched them together with the Midwife.

The best friend opened her eyes wide. "Shit!" she thought. "I see only women in pain, screaming their heads off at the moment of birth." But she did not say so.

The swindler Midwife begged the best friend to come nearer and asked her how she liked the videos. "Are not the births painless, and see how rapturous is the orgasm," she said. The best friend stared and stared. She saw nothing of the kind because there was nothing of the kind. But she did not dare to say she saw no orgasm. "Nobody must find out,"' thought she. "I must never confess that I could not see it."

Instead the best friend said:

"Oh, it is beautiful - most excellent, to be sure. Such a painless birth, such rapturous orgasm. I am now a believer in Orgasmic Birth." To the Mother the best friend said, "That birth was truly orgasmic."

Two and a half weeks after her due date, the Mother started having contractions and was looking forward to experiencing painless labor. Accompanied by the Midwife, a doula, the best friend, her college roommate, her husband and her preschool age children, the mother labored in the kiddie pool in her living room. After 4 hours of contractions, painful and getting more painful, the mother was only dilated to 2 centimeters.

"Is not the labor painless?" said the swindler Midwife. "Notice the pleasurable 'waves', the glorious 'tightenings'." The doula, best friend, the college roommate and the husband looked at the Midwife and nodded. Each thought that the other could see that the labor was painless and pleasurable.

"What can this mean?" said the Mother to herself. "This is terrible. Am I so unnatural? Am I not authentic? This is disastrous," she thought. But aloud she said, "Oh, the labor is painless and the 'tightenings' are wonderful." She would not, she could not, admit that the contractions were painful, when her doula, her best friend, her college roommate and her husband were watching. "Magnificent." "Excellent." "Exquisite," went from mouth to mouth and everyone was pleased.

Everyone sat up all that night waiting for the labor to progress. By 8 AM, the Mother was entering transition, vomiting into the kiddie pool and screaming with every contraction.

The Midwife issued inspiring statements. "You are doing great," she said. "You are having a painless labor," she said. "Let's tweet your birth progress to your Twitter list. Oh, and could you move a little to the left so that you are not obscuring the videographer's view of me."

"Magnificent," cried the doula, the friend, the roommate and the husband, even as the Mother retched and grunted. Nothing would have persuaded them to admit they were watching a labor that was far from painless, for fear they would be thought unnatural or inauthentic.

And so the moment of birth approached. The doula, the best friend, the college roommate and the husband cheered and cried, "Oh, how painless is the labor. How soothing the waters of the kiddie pool." No one dared to admit that mother appeared to be in agony and was screaming for the pain to stop.

"Soon it will be time for my orgasm," the mother thought to herself in scattered moments of rationality.

Finally the baby was crowning and the Mother was screaming, "Get it out of me. Get it out of me now!"

The head was born and then … nothing. "Surely I will split apart in agony," the mother thought.

The swindler Midwife paled. "Push!" she screamed. "Your baby is stuck!"

"Fuck," she was heard to mutter under her breath, "another shoulder dystocia."

The Midwife twisted the baby this way and that. The doula, the best friend and the roommate were screaming, "Push!" and the preschool age children were crying hysterically. The husband was dialing 911.

With an ear splitting howl, the mother pushed with all her might. The baby emerged limp and blue into the hands of the Midwife. It's right arm dangled at a unnatural angle. The mother fell back into the kiddie pool hemorrhaging into the dirty water.

"Don't cut the cord," screamed the Midwife. The doula tried to perform CPR. The best friend burst into tears. The college roommate ran to open the door for the ambulance crew. The husband was heard pleading, "Breathe, baby, please breathe."

The EMTs bagged the baby who was still unconscious and wrapped him carefully preparing for transport to the hospital.

"Wait," shouted the Midwife, "there hasn't been any skin to skin contact. She needs to nurse that baby first!" The EMTs ignored the Midwife and barreled through the door, with the husband grabbing his car keys to follow.

Several hours later, the profoundly anemic Mother was finally settled into bed after passing out several times. The husband had called from the hospital. The baby had regained consciousness and was now intubated and doing well. His arm still dangled limply at his side.

"You pushed out a 10 pound baby with no help at all," crowed the Midwife, "and you had an orgasm, too." The doula, the best friend, and the roommate nodded.

From the doorway a little child suddenly gasped out, "But, Mama," he said," it looked like it really hurt."

The Midwife, the doula, the best friend, and the roommate stared at the child. Her little boy's words seemed to rouse the Mother from her near stuporous state. "What can this mean?" said the Mother to herself. "I did not have an orgasm. I was in agony. Am I so unnatural? Am I not authentic? This is disastrous," she thought. The Mother made up her mind.

"Oh, no, honey," she managed to whisper, "I enjoyed it. I had an orgasm."

She drew herself up and smiled proudly, and the doula, the best friend, the college roommate and the Midwife nodded enthusiastically.

The swindler Midwife collected her multi-thousand dollar fee and headed for the door. "Sorry to run," she called over her shoulder," but I've got to help the videographer with the footage. A little judicious editing, and we'll have yet another orgasmic birth video. Check for it on YouTube tonight."

I am so not judging you

How many times have we heard this? A lactivist, birth activist, attachment parenting proponent who insists:

Honestly, I don't understand why other mothers think that I am judging them. If they want to raise their children by doing whatever is easiest for them instead of what's best for their babies, that's their decision and I don't question it. I understand that some women love their jobs more than their children, and, after all, who wouldn't if she had some fancy-pants career where she made tons of money. It probably makes more sense to her to put money ahead of her children's well being.

Take my next door neighbor, for example. She makes oodles of money practicing law and leaves her baby each and every day in the care of strangers. I am impressed that her baby welcomes her home by reaching out to her, smiling and giggling. Fortunately, nature designed babies to recognize their mothers, no matter how little time those mothers spend caring for their children.

I'll admit that I finder it harder to understand how women who aren't even working give up on breastfeeding so easily, or refuse to allow their children to sleep in the family bed. What's so valuable about their time or convenience anyway? But I keep my opinion to myself. I don't let on that I am perfectly aware that there is no such thing as a breastfeeding difficulty that can't be overcome with enough love and dedication. When other women claim they had a low milk supply or that breastfeeding was excruciatingly painful, I merely feel sad that they never had the unique opportunity to bond with their children that only breastfeeding offers.

And when it comes to childbirth, how can I possibly judge other women who haven't taken the time to educate themselves the way that I have? I've read Henci Goer's book three times, and Ina May Gaskin is my idol. Everyone knows that the first step to becoming educated on a topic is to join an internet message board. If I hadn't joined the message boards at Mothering.com, I probably wouldn't have known that birth is inherently safe and that all that stuff about "risk" was made up by doctors trying to steal business from midwives.

The uneducated women who don't understand this can't be blamed for acting like birth is some sort of disease and needs to take place in a hospital. Of course they give in and get an epidural at the drop of a hat because they don't realize that there's a difference between good pain and bad pain. And they don't even understand the real risks of epidurals.

Oh, and don't accuse me of looking down on women who've had C-sections. Sure, they didn't actually give birth, and they have missed out on the peak experience of a woman's life, but is that their fault? I know that almost all C-sections are unnecessary, but those poor women actually think that the C-section "saved" their baby's life.

I don't judge them, but I do think that I have a responsibility to open their eyes to the ways in which they have been misled. It would be wrong for me to refrain from enlightening them merely because it might hurt their feelings. Women need to understand that anyone who thinks her C-section was "medically necessary" is being duped by those who seek to medicalize childbirth for their own benefit.

Many women don't realize it, but if they had more encouragement, they'd happily do what's best for their babies. That's why I tell my birth story to everyone, whether they want to hear it or not. It may seem unbelievable, but it's often the very first time they've heard that they could have been empowered like me if only they'd made the same decisions I made.

And let's face it, women don't get enough encouragement to breastfeed. Some women actually think that a baby who is fed artificial milk (formula) can be as healthy as a baby fed with breast milk as nature intended. I consider it my duty to broadcast the dangers of formula feeding far and wide. It's unfortunate that we have to scare mothers into doing what's best by exaggerating the benefits of breastfeeding, but everyone knows that the ends justify the means.

Please do not accuse me of judging those other mothers who don't love their children as much as I love mine. I'm well aware that different ways of mothering are right for different families. Of course women who are obsessed with their own convenience find that bottle feeding is right for them and their families. Obviously women who have been duped by doctors into fearing birth are going find that hospital birth is right for them. And inevitably those who aren't really attached to their children are not going to be comfortable with attachment parenting.

I just want to be clear:

To those women who haven't really given birth because they've had a C-section, to those women who gave in to the pain and got an epidural, to anyone who doesn't understand that only breastfed babies are truly bonded to their mothers ...

I am so not judging you.


This piece is satire.

The dominant mothering ideology

In my last post, I wrote about Harmony Newman's PhD thesis Cross-Cultural Framing Strategies of the Breastfeeding Movement and Mothers’ Responses. What I found most compelling about Newman's explication of lactivism is her claim that lactivism can only be understood within the framework of the dominant mothering ideology, intensive mothering. As she explains:

... [I]ntensive mothering is a belief system that demands that mothers provide unlimited amounts of care, attention and affection to their children. This dominant discourse of motherhood has been described as one that sees mothers as “selfless” and “sacrificial)". That is, mothers are expected to focus primarily, if not exclusively, on their children’s needs rather than on their own desires and needs. Furthermore, mothers are increasingly being held responsible not only for the health and well being of their children, but also for their cognitive and intellectual development, and their overall short-term and long-term success in life.

Lactivism is best understood as a product of this ideology:

Breastfeeding fits within this dominant intensive mothering ideology as it is constructed as the ultimate infant feeding method—the healthiest way to feed a child and one of the best ways for an infant and mother to bond. Breastfeeding very often requires a considerable amount of time from the mother, as she is the only one who can provide the child this sustenance. A breastfeeding (and/or pumping) mother must also have dedication to persevere through the physical struggles that she may encounter. We see activists in the breastfeeding movement draw on this ideology in the construction of their persuasive arguments, encouraging mothers to fear for their children’s future health and possibly even feel responsible for failing to best protect their children if they do not breastfeed.

Newman points out that while all mothers are aware of the dominant ideology and most believe in it (hence the fact that it is the dominant ideology), there is wide variation in how rigidly mothers follow the prescriptions that flow from the ideology.

The strictly committed women believed that motherhood could not be understood in any way other than according to the dominant standards. In contrast, other mothers were resistant to the idea that one conception of motherhood should be applied to all women. These women were much more flexible in their ideological commitment to intensive mothering.

Those who are rigidly committed to intensive motherhood believe and behave in different ways than those women who have a more flexible commitment.

The women committed to intensive motherhood as ideal had a very particular conceptualization of what “good” motherhood meant. The mothers with a strict commitment described characteristics of good mothers as those who are “selfless” and “present.” ...

These women are explicit in their construction of a good mother as someone who puts herself on the backburner, first addressing any needs her children might have. [Some] even [argue] that mothers who do not align with this ideology of selflessness should be considered “bad mothers.”...

This perspective—that “good” motherhood requires an unending amount of attention, affection, and selflessness—is a very demanding expectation for mothers. These women strictly believed in the standards of intensive mothering and expected those behaviors (and sacrifices) both from themselves and other mothers.

In contrast:

... [W]omen with a flexible commitment to the dominant standards of motherhood tended to agree that there was not one cut-and-dried way to parent. Instead, 65 percent of these women argued that mothers needed to figure out what sort of parenting style worked best for them and their children...

These women are critical of the idea that there are ... rigid rules for parenting... [T]hey believe that different parents, children, and situations call for flexibility, and spontaneity in figuring out what the most appropriate response should be.

I consider Newman's most important insight to be the recognition that contemporary mothering reflects one ideology out of many possible ideologies. The contemporary mothering ideology is not "The Truth," but rather simply the currently popular viewpoint, differing dramatically from mothering ideologies of the past and possibly of the future as well. There is not one "right" way to approach mothering and what is right from one family may be inappropriate for another.

I would expand on Newman's characterization of the flexibly committed mother to include another variation. It is possible to be personally committed to the ideology of intensive mothering for one's own family, while being flexible in expectations of other mothers.

When I write about breastfeeding, lactivists often insist that my personal commitment to breastfeeding my four children is at odds with my medical advice to others. I don't see any conflict. My commitment to breastfeeding is part of my personal commitment to intensive mothering. It would be fair to say that I raised my children in accordance with all the major principles of intensive mothering, particularly the commitment to always being present. BUT, and this is a very important but, my commitment to intensive mothering does not extend to belief that intensive mothering is the "right" way or the only way to raise children. It was right for me and my family; that doesn't mean that it is right for everyone. Moreover, I now have the advantage of seeing how my children and other children are turning out. It is more obvious to me than ever that there are many ways to raise happy, healthy, well adjusted children.

There's nothing wrong with the dominant ideology of intensive mothering. There is something wrong with insisting that the dominant ideology is the only correct ideology.

How lactivists try to scare women and why it doesn't work

In a fascinating PhD dissertation, sociology graduate student Harmony Newman explains the strategies of the lactivist movement. Cross-Cultural Framing Strategies of the Breastfeeding Movement and Mothers’ Responses portrays lactivism as a social movement with the avowed goal of increasing breastfeeding rates. Lactivism exists in both the US and Canada, but the Canadian effort has been more successful. Newman looks at the strategies ("framing") in both countries to determine if there is a difference. I found the dissertation valuable for the way in which Newman explains the American lactivist movement.

Increasing breastfeeding rates is certainly a noble motivation, but the tactics that have been adopted can be called into question, both on ethical grounds, and on performance grounds. The aim of lactivist tactics is to scare women into breastfeeding by inflating the benefits and concomitantly exaggerating the so called "risks" of formula feeding. Not only is this framing strategy disingenuous, it is a failure since it has not made any difference in breastfeeding rates.

Newman explains this strategy:

Through the active construction of formula feeding as a dangerous behavior, breastfeeding activists intend to change mothers’ health beliefs and behaviors such that they feel compelled to breastfeed rather than formula feed their children...

Specifically:

Fifty-nine percent of the documents sampled used a “baby-saving” approach in their endorsement of breastfeeding, which is more than twice as much as any other approach. In this argument, activists make the case that breastfeeding is a key ingredient in raising a healthy child and preventing a variety of illnesses, even death. Activists created three versions of the baby-saving frame, including a scare tactics approach, a focus on the child’s emotional health, and an emphasis on the mental development of the child.

Scare tactics represent the most common approach:

[Scare tactics] attempt to increase the urgency with which mothers should accept breastfeeding as the preferred infant feeding method by linking the failure to breastfeed with serious health risks, including the possibility of death (i.e., SIDS)...

Even though these arguments are portrayed as absolute, scientific fact, these arguments are better understood as a rhetorical strategy to persuade mothers of the health threats to their children (c.f., Best’s (1990) work on the construction of the child-victim). In contrast to this absolutist presentation, the evidence is more accurately described as suggestive and inconclusive...

Lactivists also invoke emotional and intellectual benefits:

... This framing strategy, which constructs breastfeeding as an “act of love,” puts another layer of pressure on mothers to breastfeed insofar as mothers might interpret the reverse of this argument to mean that those who fail to breastfeed their child somehow love their children less than mothers who breastfeed. Statements such as these, however, have very little evidentiary support...

And:

[An] information sheet on the benefits of breastfeeding contends that one of the “Costs of Not Breastfeeding” is a “3- to 11- point IQ deficit in formula-fed babies; [and] Less educational achievement noted with formula-fed children.” This push for parents to be concerned with the intelligence and learning capacity of their child resonates in a contemporary climate where education is key to accessing successful careers. However, this argument is certainly contestable. Although some research makes the claim that breastfeeding increases IQ, other research suggests that the relationship between breastfeeding and intelligence is much more complicated ...

These strategies are scientifically suspect because they depend on the erroneous assumption that correlation means causation. It is true that breastfeeding is associated with a variety of benefits, but there is no evidence that breastfeeding itself leads to health, emotional or cognitive benefits. Breastfeeding rates are closely related to economic and educational achievement, both known to be important confounding factors. It could be the observed benefits can be ascribed to improved access to health care, and educational opportunities, rather than to breastfeeding itself.

These strategies are also ethically fraught because they deliberately misrepresent the state of the literature. Virtually none of the purported benefits are established science, but rather suggestive results of selected studies, much of which is contradicted by other scientific studies. In addition, even if the benefits are real, most are quite small, and not even clinically relevant.

Why have these scare tactics failed to increase breastfeeding rates? In large part it is because the scare tactics do not comport with what women have seen and experienced. Almost all women know many formula fed babies who grew into happy, healthy, intelligent children. Indeed, many women who consider themselves happy, healthy and intelligent were formula fed babies. Since it is difficult to reconcile lactivists' claims with the life experience of these women, it follows that many conclude that the lactivist's claims are false and nothing more than scare tactics.

Ultimately, the lactivists' plan to scare women into breastfeeding is so transparent a tactic, it is doomed to failure.

A midwife resents UC. Oh, the irony!

Navelgazing Midwife, Barbara Herrera, continues her evolution as a clinician. She has gone from someone who had a UC (and nearly lost her child in the process), to a CPM, to a student CNM. During that time, her philosophy has evolved as well. Consider her current feelings toward those who reject the use of a midwife at homebirth (The UC Oxymoron):

I’m sure that part of it has to do with many UCer’s arrogance about their knowledge and abilities to avert complications or use wishful thinking to eliminate anything negative from happening at all. The puffed out chests, bragging that they don’t need anybody sours my desire to offer assistance – because I am “anybody.” So, if they don’t need anybody, don’t need anybody!

What's striking to me is that Herrera recognizes that her changing views reflect her increased knowledge, but fails to understand that obstetricians' view reflect the fact that they know more than midwives, indeed far more than CPMs who are undereducated and undertrained.

Homebirth advocates complain that obstetricians will not work with CPMs. It is ironic that they fail to see that obstetricians view CPMs in the same way that she views those who choose UC. Paraphrasing Herrera:

I’m sure that part of it has to do with many CPMs arrogance about their knowledge and abilities to avert complications or use wishful thinking to eliminate anything negative from happening at all. The puffed out chests, bragging that they don’t need an obstetrician sours an obstetricians' desire to offer assistance.

This is not the first time that Herrera has expressed resentment of those who don't think they need a midwife. Over 2 years ago, she wrote:

When I am hired to be someone’s midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life. As a consultant, one that differs from an interior designing consultant, I am being asked to take the lives of two people in my hands and to accept the consequences of the outcome whether that is a spritz of champagne or a cell in a prison. I’ve had a long time to adjust my considerations with my practice – and they might change again (I’d be shocked if they didn’t!). I see women as individuals, listen to their needs and concerns and if we both feel we could work together, I’m game to give it a go. If I find a woman lied to me about her medical or obstetric history, if she hides behaviors she doesn’t want me to know about or if she continually jabs at me questioning my concerns with her pregnancy (and all of these have happened in the last 2 years), I’m going to send her on her way. She is a liability I don’t need to take on… a risk to my profession and life.

She failed to see the irony that time, too.

How many homebirth advocates does it take to change a light bulb?

Ten:

One to teach the course "Empower yourself by changing your own light bulb."

One to whisper affirmations encouraging the light bulb to be in the correct position.

One to photograph the event.

One to twitter the event live.

One to fill the fishy pool. (Note: professional electricians claim that standing in water while changing a light bulb is dangerous, but they just say that to ruin your light bulb changing experience.)

One to call 911 if you get electrocuted while standing in water while changing the light bulb.

One to reassure you that people get electrocuted changing light bulbs even when they are not standing in water, so you shouldn't let the warnings of those stupid electricians scare you.

One help you eat while changing the light bulb in order to keep up your strength.

One to tell you to turn the bulb only when you get the urge.

And finally, one to actually change the light bulb and pretend to have an orgasm while doing it.

Surprise! Fruits and vegetables don't prevent cancer

Last week I wrote about the evidence that vitamins don't prevent cancer. Now a new study demonstrates that the fruits and vegetables that contain those vitamins don't prevent cancer.

The study, Fruit and Vegetable Intake and Overall Cancer Risk in the European Prospective Investigation Into Cancer and Nutrition (EPIC), by Buffetta et al. appears in the latest issue of the Journal of the National Cancer Institute. The study has two major strengths. It is large (over 400,000 people) and prospective, meaning that it followed people over time instead of depending on long term recall of dietary habits. The editors of JNCI have responsibly included a summary for the press, to be sure that the results are reported correctly:

... Paolo Boffetta, M.D., M.P.H., of the Mount Sinai School of Medicine in New York, and colleagues analyzed data from the EPIC study (European Prospective Investigation into Cancer and Nutrition), which included 142,605 men and 335,873 women recruited for the study between 1992 and 2000. The participants were from 23 centers in ten Western European countries–Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain,Sweden and the United Kingdom. Detailed information on their dietary habit and lifestyle variables was obtained. After a median follow-up of 8.7 years, over 30,000 participants were diagnosed with cancer.

The authors found a small inverse association between high intake of fruits and vegetables and reduced overall cancer risk. Vegetable consumption also afforded a modest benefit but was restricted to women. Heavy drinkers who ate many fruits and vegetables had a somewhat reduced risk, but only for cancers caused by smoking and alcohol.

Most importantly, the press summary explains the interpretation of the findings.

The authors caution against attributing any risk reduction to diet and they conclude that any cancer protective effect of these foods is likely to be modest, at best.

In this population, a higher intake of fruits and vegetables was also associated with other lifestyle variables, such as lower intake of alcohol, never-smoking, short duration of tobacco smoking, and higher level of physical activity, which may have contributed to a lower cancer risk," they write.

In other words, the tiny observed benefits are more likely to be due to confounding factors than to represent any protective effect of fruits and vegetables.

In an accompanying editorial, Dr. Walter Willet, from the Department of Nutrition at the Harvard School of Public Health that the data suggesting a cancer protective effect of fruits and vegetables was never strong.

During the 1990s, enthusiasm swelled for increasing consumption of fruits and vegetables with the expectation that this would substan­tially reduce the risk of many cancers. Potential reductions as large as 50% were suggested. The National Cancer Institute’s 5-A-Day program was developed in 1991 to promote increasing the average consumption of fruits and vegetables to five or more servings per day ... However, the evidence for a large preventive effect of fruits and vegetables came primarily from case–control studies, which can be readily biased by differences in recall of past diet by patients with cancer and healthy control subjects. Even more problematic, participation rates in surveys have fallen sharply over the past 50 years so that those who agree to be interviewed as control subjects are likely to overrepre­sent health conscience persons who smoke less, exercise more, and eat more fruits and vegetables compared with those who do not participate...

Yet despite the weak evidence, lay people and professionals alike embraced the conclusions enthusiastically. Why? As a society we have a disturbing tendency to promote simple (and often unproven) answers to complex issues. It would be wonderful if cancer, a complex and multifaceted disease, could be prevented by eating fruits and vegetables. Such a simple answer sounds (and is) too good to be true, and should have been greeted with skepticism instead of uncritical acceptance.

Within the scientific community, it has been known for quite some time that the protective effect of fruits and vegetables had been vastly overstated. As Willet explains:

... In the late 1990s, the results of large prospec­tive cohort studies of diet and cancer began to accrue, and these did not confirm the strong inverse associations found in most case–control studies. Furthermore, a series of analyses that pooled the data from prospective studies for specific cancer sites confirmed the weak and non-statistically significant associations. In a comprehensive 2007 review, these findings led to the reversal of conclusions for strong benefits of fruits and vegetables for many cancer sites that had been considered convincing or probable in a similar earlier review 10 years before.

That message has not reached the general public and even many healthcare providers.

Fortunately, there was no harm done, and there was possibly a benefit in a decrease in cardiovascular disease as a result. Nonetheless, it is yet another example of a disturbing trend in preventive medicine, the tendency to issue public health recommendations on the basis of weak data. As a result, public health recommendations are often modified or even withdrawn after only a few short years, leading to distrust of science in general and the medical profession in particular.

Brave has nothing to do with it; it's all about ignorance

Morgan McLaughlin McFarland, in a guest post at Bring Birth Home entitled Brave Has Nothing to Do With It, helpfully illustrates the self aggrandizing ignorance that is the hallmark of homebirth advocacy. She is annoyed:

"When hearing the news that I had my last baby at home and am planning to have this one at home as well, the first response from most people is, "You're so brave."

This has to be one of the most irritating things that people say to homebirthers. The implication is that birth is dangerous and that we are willing to take on a tremendous risk to do it anywhere but a hospital.

It negates the research and planning that we’ve done to come to this decision. It makes the choice about balls, not brains. After all, homebirth is "dangerous." Hospital birth is "safe." Therefore, it must be bravado alone that would lead a woman to choosing such an option. Right?"

Research? Now that's a hoot. In the homebirth community, what passes for "research" is being impressed by the bibliography salad cited by professional homebirth advocates who don't understand (and probably have not even read) the papers that they cite.

Let's see what McLaughlin has "learned" from her "research."

"Over 30% of women in the US have cesarean sections, while overwhelming research has led the World Health Organization to set an ideal standard rate of cesarean sections at 10-12%, with 15% being the rate where more harm is being done instead of good."

Hey, Morgan, you just made that up. Marden Wagner, then at the WHO, pulled the 15% number out of thin air. There has been NO research, none, zip, zero, nada, to support the 15% recommendation, a point that Wagner himself has publicly acknowledged."

"Kenneth C Johnson and Betty-Anne Daviss’s Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416 (18 June), found that the outcomes of planned homebirths for low risk mothers were the same as the outcomes of planned hospital births for low risk mothers, with a significantly lower incident of interventions in the homebirth group."

See what happens when you don't read and analyze the study? You don't know what it actually shows. The Johnson and Daviss study actually shows that homebirth with a CPM has nearly triple the rate of neonatal mortality of low risk hospital birth. Guess you didn't pick up the bait and switch. J & D compared low risk homebirths to high risk hospital births. Funny what you learn when you do real research.

"The Netherlands, where 36% of babies are born at home, has lower maternal and neonatal mortality rates than the US."

The Netherlands has the highest perinatal mortality rate in Europe! The US has a lower perinatal mortality rate than Denmark, the UK and the Netherlands. By the way, according to the World Health Organization, the correct statistic for international comparisons is perinatal mortality (neonatal mortality plus late stillbirths). That's because countries like The Netherlands like to boost their international rankings in neonatal mortality by pretending that premature babies born alive are stillbirths and not live births. I guess you didn't learn that basic fact in your "research."

"Call me stubborn, because I wasn’t willing to accept out of hand the culturally held belief that hospitals are safer."

No, I'd call you ignorant, so ignorant that you actually think you know what you are talking about. You've done no research. You've read no papers. You lack even the most basic understanding of science and statistics. You don't even realize that virtually everything you've written is factually false.

"Call me an idealist, because I believe that birth can be a positive, safe, and empowering experience for child and mother."

No, once again I'd call you ignorant. Birth is inherently dangerous. It is and has always been a leading cause of death of young women and babies in every time, place and culture. "Believing" birth is safe just shows that you don't know much about birth.

"Call me a nonconformist, because I choose to birth at home in defiance of a powerful technocratic system."

No, I'd call you ignorant, and self aggrandizing to boot. Only a fool would proudly risk her baby's life to "defy the system."

"But brave? Don’t call me brave. “Brave” has nothing to do with it."

That's right. Brave has absolutely nothing to do with it. It's all about ignorance.

Breastfeeding is hard

Yet another paper on the benefits of breastfeeding (real and purported) was released today (Bartick and Reinhold, The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis) in the ongoing, well meaning but basically futile effort to "educate" (i.e. bully) women into higher rates of exclusive breastfeeding. Using highly fanciful methods, Bartick and Reinhold "estimate" that the US could save 900 infant lives and $13 billion if 90% of US women breastfed. These numbers are grossly misleading since not even a single US infant death (let alone 900 per year) has ever been attributed to not breastfeeding and since the purported savings are primarily the "lost wages" of the 900 dead infants.

But let's leave aside for the moment, the fact that the figures on which Bartick and Reinhold based their claims are profoundly suspect. Let's look at their potential motivation.

Breastfeeding advocates like to pretend that women stop breastfeeding because of lack of education, because hospitals give out formula, because of lack of professional support, because of lack of peer support, etc. etc. etc. All this pretending reflects the profound unwillingness of breastfeeding advocates to avoid addressing the real reasons that women stop breastfeeding or fail to start in the first place. The dirty little secret about breastfeeding is that starting is hard, painful, frustrating and inconvenient. And continuing breastfeeding is hard, sometimes painful, and incredibly inconvenient especially for women who work, which in 2010 is most women.

Any article such as this virtually requires the author to demonstrate her bona fides, so let me get that out of the way. I have four children, I breastfed them all nearly exclusively until they weaned themselves. I breastfed even when I was working up to 70 hours a week and was on call every 3rd night. I always had access to an office that could be locked, a state of the art breast pump, and a fair degree of control over my own schedule. I never contemplated doing anything else, but that doesn't change the fact that it was hard, painful in the early stages and incredibly inconvenient. I did it despite the difficulties.

Breastfeeding advocates insist on eliding or ignoring these difficulties. And because they insist on ignoring the experiences of women, their well meaning attempts at encouraging breastfeeding are almost complete failures. Education efforts, counseling efforts and banning of formula gift bags have made little or no difference in breastfeeding rates. Bartick and Reinhold's latest paper on the purported economic benefits of breastfeeding, even if true (and there is a great deal of extrapolation that is probably not true) is destined to have an equally negligible effect.

I don't really understand why breastfeeding activists refuse to acknowledge the reality of breastfeeding. They prefer to sugarcoat it with little maxims like "breast milk is always available," breast milk is always the perfect temperature," and "breast feeding saves money." Those statements are true, but they ignore the very real challenges in initiating and maintaining breastfeeding.

Perhaps breastfeeding activists fear that women will not attempt breastfeeding if they are informed honestly about the difficulties. Yet it appears that the opposite is true. By not acknowledging these difficulties up front, breast feeding activists set women up for failure, when those women encounter pain, frustration and inconvenience.

Breastfeeding is a learned behavior. It is not instinctual on the part of the mother and although a baby has the instinct to suckle, latching on properly and actually getting milk requires practice. A new mother and a new baby may get frustrated very quickly when things do not proceed smoothly.

New mothers are often emotionally labile, due to the effect of hormones. A baby screaming desperately in hunger (and all babies begin to screaming desperately within seconds of realizing they are hungry) can upset even an experienced mother. It's much worse for a new and inexperienced mother who can easily become frantic to satisfy the baby, fearing that the baby is starving. Prior to the advent of formula, there was no choice but to stick with the first inexperienced attempts. Now, with formula at hand and able to satisfy an infant in seconds, it may seem pointless or even cruel (not to mention harrowing to the mother) to force a baby to figure out breastfeeding.

Initiating breastfeeding is often painful. Cracked and bleeding nipples are every bit as unpleasant as it sounds. Countless new mothers tell stories of bursting into tears whenever the baby starts to cry, in anticipation of the pain of nursing. For most women, the pain disappears over time, but it can take days or even weeks. Breastfeeding advocates like to blame women themselves for their pain, insisting that they are positioning the baby in the wrong way. The truth is that women can do everything right, and still have pain. It simply has to be ignored until it goes away and it is hardly surprising that some women do not want to wait that long.
Maintaining breastfeeding while working is incredibly difficult. During the typical work day, a woman may need to pump twice or more, each session taking 20-30 minutes and requiring a clean and private place to pump, a breast pump, and a refrigerator to store the milk. Professional women may be able to assemble these resources, but the average working woman has neither the facilities, nor the time to pump at work.

The demographics of breastfeeding reflect the fact that it is difficult. Breastfeeding is associated with higher levels of maternal education and higher income levels. Successful and long term breastfeeding require a willingness to delay personal gratification, and a willingness to shoulder burdens in exchange for long term benefits. Those traits are closely associated with higher levels of education and professional success. Economic success also makes it easier to continue breastfeeding because women don't have to work, enjoy extended maternity leaves, have private space at the workplace in which to pump and can afford high quality equipment.

Should we encourage breastfeeding? Of course, we should, but we should not forget that the health benefits are relatively small and the difficulties can be large. We should stop spending money on trying to convince women to breastfeed, since most efforts are ineffective. Instead, we should devote smaller sums to providing counseling to women who truly want to breastfeed and leave everyone else alone.