AmyTuteurMD's Open Salon Blog

Dr. Amy interview on homebirth and natural childbirth

Mon, 2 Aug 2010 08:08:02 -0400

If you've ever wondered what I sound like,now is your chance to find out by listening to Podcast Beyond Belief, a weekly podcast produced by a consortium of skeptical parent bloggers. In the latest epidsode, episode 22, they interviewed me for an hour on the topic of alternative birth claims and practices. You can download the podcast here, or you can download it directly from the podcast section of iTunes. Let me know what you think.

EC: the excrement obsession

Fri, 9 Jul 2010 04:07:57 -0400

Freud would have a field day with these people.

I'm talking about proponents of EC, elimination communication, the goofiest obsession of the many goofy obsessions of the natural childbirth (NCB) and attachment parenting (AP) crowd. They began obsessing about excrement when cloth diapers came back into vogue, arguing that cloth diapers are better for babies and better for the environment. It turns out that neither of these claims are true. Indeed, those busily preening themselves for their prescience in rejecting disposal diapers forgot to include the environmental impact of sanitizing reusable cloth diapers, an impact that may be worse than the problem of landfills containing used Pampers and Huggies.

As is typical of the oneupsmanship characteristic of the NCB and AP types, fretting over what will catch your baby's excrement is now passe. Proving your maternal superiority now means rejecting diapers altogether in favor of rigorously and continuously observing your baby for any signs of imminent excrement release and immediately holding him or her over a pot to catch the excrement. As Diaper Free Baby explains:

Full time EC'ing families are committed to trying to stay aware of as many of baby's eliminations as they can. To this end, they may choose not to use diapers or other waterproof backup, as this can muffle a parent's awareness of when a baby is about to or has already eliminated, and catches may be easier with trainers or underpants. Full-time EC'ers figure out what works to help them catch eliminations when they are out and about, traveling, or EC'ing at night. They recognize that, like other aspects of parenting, EC progress is not always linear, but they recognize the value of process over results, and have a full toolbox of options to choose from to adjust to each of baby's developmental milestones and stages.

"EC parents speak out" (not surprisingly since EC is all about them, not about their babies). According to "Rachel, mom to Simon, began EC at birth":

By the time Simon was three and a half months old he had proven to us that EC is more than just 'parent training.' He started signaling his need to pee by making his own imitation of our 'sss' cue! We were delighted to be in such two way communication with him.

Evidently Rachel had trouble recognizing smiling and cooing as two way communication. Sarabeth, mom to Ben, began EC at 2 1/2 months" says:

Doing EC with Ben has completely changed our relationship for the better. Before we started EC, it seemed like he often cried for no reason. With EC, I finally have an important tool to help meet his needs, and he is 100% happier.

There's nothing like a relationship based on excrement, is there? And "Megan, mom to Noe, began EC at 8 months":

Responding to your baby's elimination patterns provides many wonderful opportunities for you and your baby to communicate and to become more in-tune.

Poor Megan must be sorely lacking quality communication with her baby if she thinks excrement is a highlight. How does a parent practice EC? First she must assiduously observe her baby to determine when he or she is preparing to "eliminate":

... [Y]our own intuition will naturally develop around your baby's elimination. Listening to and trusting your intuition is an important part of parenting. With a little time and practice, it can also become a very reliable tool for anticipating your baby's elimination... [T]here are a few concrete ways you will know your intuition is telling you that your baby needs to eliminate. For example: * a sudden thought along the lines of "She needs to pee." * wondering or questioning, "Does he need to go?" * "seeing" or "hearing" the word "pee" or cueing sound (see below) * "just knowing" that your baby needs to pee * feeling the urge to pee yourself * feeling a warm wet spreading over your lap or other area while baby is dry

Then mother and baby must assume the position:

When you think your baby needs to eliminate, hold her in a gentle and secure manner over your preferred receptacle. This could be the toilet, sink, potty, bucket, diaper, tree, or any other appropriate place... Generally, she will be more or less in a deep squat, cradled in your arms with her back to your tummy. The main thing is to keep her secure and to think about your aim ;). Once your baby is comfortably in position, make a specific cueing sound to "invite" your baby to pee or poop. In most places where EC is practiced culturally, caregivers use a watery sound such as "psss". This sound, along with a particular position, is used to signal or stimulate the baby's elimination. When you are starting out, make your cueing sound every time you notice your baby peeing. Within a few days, your baby will associate the sound with the act of eliminating. By practicing EC consistently, your baby will learn to release her bladder at will upon hearing the cueing sound and/or being held in the potty position.

In other words, EC is a form of operant conditioning. The parent attempts to condition the baby to urinate or defecate in response to specific visual and auditory signals. If that sounds familiar, it's probably because it is. It's the same way that pets are housebroken. In essence, EC is nothing more than "housebreaking" a baby.

EC is about, by and for parents. The parent wants the baby to urinate and defecate in a pot and attempts to condition the baby to do so. It stands in explicit contrast to a child centered approach to toilet training that elicits the child's understanding and point of view. In fact, "elimination communication" is a misnomer. It does not involve communication of any kind, since the child is incapable of expressing his views on the subject. It treats children like dogs. Show the dog/baby what you expect, disregard what the dog/baby might prefer, bestow approval or disappointment on the dog/baby until he or she learns to do it your way.

In one way EC is about communication, but not in the way its proponents assert. Adopting EC communicates that the mother thinks her child's bodily functions can be used as weapons in the war of maternal superiority. It communicates that the mother considers that her need to be au courant within her mothering community takes precedence over her child's developmental needs. It communicates that the mother thinks that housebreaking her baby is an appropriate form of parenting.

EC explicitly ignores a child's needs. Instead of allowing a baby to follow the rhythms of its own body, EC implies that urination and defecation must be closely regulated, with the constant parental scrutiny that implies. It conditions the child to believe that even her bodily functions are property of her parents and that urination and defecation must be performed on demand, at the risk of parental disapproval.

Ultimately, it demonstrates the astounding gullibility of certain women and their desperation to claim superiority over other mothers. Proponents of EC are busily housebreaking their babies with the same techniques that they would use for a dog and bragging to each other about it.

Is a baby the "best ally of masculine domination"?

Mon, 7 Jun 2010 08:06:59 -0400

French feminist Elisabeth Badinter’s new book atop the French bestseller list is a full bore assault on the concept of the “good mother.” In Le Conflit: la femme et la mère (Conflict: The Woman and the Mother), Badinter argues that the biological essentialism implicit in current notions of motherhood reduces women’s freedom and limits professional success.

According to a New York Times review:

… [Badinter] contends that the politics of the last 40 years have produced three trends that have affected the concept of motherhood, and, consequently, women’s independence. … “[E]cology” and the desire to return to simpler times; second, a behavioral science based on ethology, the study of animal behavior; and last, an “essentialist” feminism, which praises breastfeeding and the experience of natural childbirth, while disparaging drugs and artificial hormones, like epidurals and birth control pills.

All three trends, Ms. Badinter writes, “boast about bringing happiness and wisdom to women, mothers, family, society and all of humankind.” But they also create enormous guilt in a woman who can’t live up to a false ideal…

Ms. Badinter … says that the baby has now become “the best ally of masculine domination.”

Badinter decries a philosophy that effectively relegates a woman to the home, sacrificing her health, independence and autonomy in an effort to live up to a socially constructed ideal:

... The “green” mother, she says, is pushed to give birth at home, to refuse an epidural as the reflection of “a degenerated industrial civilization” that would deprive her of “an irreplaceable experience,” to breast-feed for both ethological and environmental reasons (plastic baby bottles) and to use washable rather than disposable diapers — in other words, to discard the inventions “that have liberated women.”

Indeed, for most of human existence, women's lives, roles, ambitions and possibilities have been severely limited. Women were defined by their biology. The central role of women's lives was asserted to be biologic reproduction, in other words pregnancy, childbirth and lactation. The current concept of the “good mother” rests on this essentialism. Hence the inordinate emphasis placed on the physical process of birth, and the few physical aspects of parenting like lactation. The various prescriptions for “good mothering” combine to reinforce the notion that a woman is determined by her biology, that her destiny is to live out that biologic role, that her highest calling is to live out that role, and that the role must be lived in strict adherence to biologic limitations.

This essentialism dictates that women must reject technology (since it has been the traditional purview of men), that women must emphasize the physical aspects of parenting, that women are improved by suffering biologic pain, that any deviation from the biologic constraints of childbirth (having a C-section instead of a vaginal delivery, for example) is anathema and robs a woman of her fundamental reason for being, that a woman's natural place and the place where she is most fulfilled is within the home, and that parenting requires intensive physical interaction which renders work outside the home virtually impossible.

Badinter posits that the philosophy of the “good mother” has arisen to stem the rising tide of women’s professional success. However, it is worth asking who is threatened by that professional success. Is it men, who fear the loss of their traditional dominance as Badinter implies, or is it women who have not achieved professional success and therefore discount its value? Women who lack professional achievements may have fallen back on valorizing biological functions like childbirth and breastfeeding because those are the only "achievements" they are ever going to have. In other words, is this just the latest iteration of the “mommy wars”?

Regardless of its origin, biological essentialism, expressed as an emphasis on the physical aspects of mothering, does serve to limit the autonomy of women. By positing a very specific vision of the “good mother,” proponents of essentialism limit women’s choices within relationships, within the home and even within the professional world. Badinter exhorts feminists to reject biological essentialism.

… I’m convinced that the way feminism has been evolving will lead it to a dangerous dead end. I continue to think that gender equality comes with sharing roles and duties.

Man dies of uterine cancer; who's to blame?

Fri, 28 May 2010 08:05:11 -0400

May you never be an interesting case.

That's a cautionary proverb familiar to medical professionals. While it's bad to get sick, it's much worse to get sick with something uncommon or unusual. The more fascinating a case is for doctors, the more difficult it is for patients. Difficult to diagnose, difficult to treat, and often difficult to survive.

Kenneth Liew was doubly unfortunate. He was an interesting medical case and an interesting legal case. Now he's dead and a jury is currently deliberating who, if anyone, is at fault.

Kenneth Liew was really, really unlucky. He was unlucky because he had serious kidney disease that necessitated debilitating dialysis treatments three times each week. He was unlucky because it took 10 years for a matching kidney to be found to give him in transplant. He was unlucky because after he received his kidney and after it was working well, an autopsy revealed that the kidney came from a woman who, though she died of a stroke, had unknowingly had uterine cancer as well. He was unlucky because there is not a single case like his in the whole world, so no one knew the odds that the cancer would be transmitted. He was unlucky because he died of cancer only seven months after receiving the transplant.

Despite being exhorted by her dying husband to forgive the doctor, Mr. Liew's widow ignored his wishes and sued just about everyone she could think of including the doctor and New York University Medical Center where the transplant occurred. Eight years after Mr. Liew died, the jury has finally received the case.

First and foremost, this case has been a nightmare for Mr. Liew and his family. But secondarily, this case also represents a doctor's worst nightmare. The doctor, transplant surgeon Thomas Diflo, lost a patient through a freak accident that no one could have known about or predicted and now he's being blamed. I would feel sympathy for the doctor no matter what, but I am especially saddened because the doctor was one of my classmates in medical school.

Mrs. Liew is sure that somebody is to blame for something and that she deserves $3 million dollars in compensation, but it is not clear who is to blame or what they are to blame for:

· Did anyone know of the donor's uterine cancer? Both sides agree that no one knew or could have known that the donor had uterine cancer.
· Was the patient informed that the donor had cancer? Both sides agree that the transplant surgeon informed the donor approximately 2 months after the he received the kidney.
· Should the kidney have been removed immediately thereafter? Both sides acknowledge that there was no way to predict the chances of Mr. Liew developing metastatic uterine cancer. There had literally never been a similar case in the history of medicine. Therefore, the doctor left the decision up to the patient, advising him that based upon what is known about transplants and cancer and based upon the fact that uterine cancer does not metastasize to the kidney, the chance that Mr. Liew would develop metastatic uterine cancer was low. Mr. Liew's widow argues that the doctor should have advised that the kidney be removed immediately.
· Would removal of the kidney have made any difference? It's unlikely. Whatever was transmitted to Mr. Liew from the donor kidney had already been transmitted.
· What caused Mr. Liew's death? That's not clear. Mr. Liew died of cancer, but the metastatic cancer was so poorly differentiated that no one can tell what type of organ it came from originally. It could have been uterine cancer transmitted by the kidney, but it also could have been cancer that developed spontaneously in Mr. Liew.

So if no one could have known about the uterine cancer in advance, if removing the kidney would not have made a difference and if it is not completely clear what kind of cancer killed Mr. Liew, why are Dr. Diflo and NYU being sued? They are being sued because something bad happened and someone must be blamed. It wasn't anyone's fault; no one did anything wrong, but you can't get any compensation for bad luck. Therefore someone, anyone, must be blamed and must be made to pay.

The jury has the case now, and within a few days we will find out if they agree.

Who is helped by opposition to female "nicking"?

Fri, 7 May 2010 08:05:04 -0400

The American Academy of Pediatrics new position paper on female genital mutilation (FGM) has been greeted with howls of protest. When I scanned the newspaper, website and blog reports on the issue, I thought that the AAP had lost its ethical moorings and recommended FGM. But reading the actual position paper, I learned that the AAP was recommending something very different, and that the storm of protest reflects a preoccupation with our own moral certitude at the expense of the health and well being of young girls.

The AAP position paper attempts to deal with a specific problem and that problem is not female genital mutilation. The AAP is unalterably opposed to FGM, which it refers to as female genital cutting:

The American Academy of Pediatrics:

1. Opposes all forms of FGC that pose risks of physical or psychological harm.

2. Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.

3. Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.

4. Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

The problem that the AAP has identified is that in the face of opposition to FGM, American parents of certain religious backgrounds are opting to send their daughters out of the country for FGM or to have lay practitioners illegally perform FGM here. The position paper asks a very important question: is there anything that American pediatricians can do to divert parents from making other arrangements to amputate the clitoris of their daughters?

The AAP paper explains the cultural significance of FGM:

When parents request a ritual genital procedure for their daughter, they believe that it will promote their daughter’s integration into their culture, protect her virginity, and, thereby, guarantee her desirability as a marriage partner. In some societies, failure to ensure a daughter’s marriageable status can realistically be seen as failure to ensure her survival… Parents are often unaware of the harmful physical consequences of the custom, because the complications of FGC are attributed to other causes and are rarely discussed outside of the family.

Obviously the ideal is for the pediatrician to educate the parents about those harms. But what is the pediatrician's responsibility to a young girl when he cannot persuade her parents to forgo FGM. Is the pediatrician permitted to offer a ritual mimicking the procedure in an attempt to forestall a more radical procedure? The AAP says yes.

Some physicians, including pediatricians who work closely with immigrant populations in which FGC is the norm, have voiced concern about the adverse effects of criminalization of the practice on educational efforts. These physicians emphasize the significance of a ceremonial ritual in the initiation of the girl or adolescent as a community member and advocate only pricking or incising the clitoral skin as sufficient to satisfy cultural requirements. This is no more of an alteration than ear piercing. A legitimate concern is that parents who are denied the cooperation of a physician will send their girls back to their home country for a much more severe and dangerous procedure or use the services of a non–medically trained person in North America…

Most American commentators strongly disagree. This piece from the NY Times is typical:

Georganne Chapin, executive director of an advocacy group called Intact America, said she was “astonished that a group of intelligent people did not see the utter slippery slope that we put physicians on” with the new policy statement. “How much blood will parents be satisfied with?”

The human rights organization Equality Now has reacted with outrage:

FGM is a form of gender-based violence and discrimination that is performed on girls to control their sexuality in womanhood, guarantee their acceptance into a particular community, and safeguard their virginity until marriage. Taina Bien-Aime, Equality Now's Executive Director explains, "Encouraging pediatricians to perform FGM under the notion of 'cultural sensitivity' shows a shocking lack of understanding of a girl's fundamental right to bodily integrity and equality. The AAP should promote awareness-raising within FGM-practicing immigrant communities about the harms of the practice, instead of endorsing an internationally recognized human rights violation against girls and women."

No doubt the commentators feel justified in their self-righteous condemnation of any attempt at compromise, but they've failed to ask the most important question: Is there anything we can do to protect girls whose parents will not forgo FMG? That question can only be addressed with empirical answers, not moral arguments.

Will offering to mimic the procedure with a ritual "nicking" reduce the incidence of traditional FMG and the health problems that go with it? Research suggests that the answer is not clear. Data from the World Health Organization shows that substituting ritual nicking has reduced the incidence of traditional FMG in countries where it is commonly practiced. On the other hand, evidence from Scandinavia has shown that harsh penalties (including the threat of loss of child custody) is also effective at reducing FGM.

It is all well and good for FGM activists to proclaim that compromise is unacceptable, but does that position help the girls it is intended to protect? At the moment, the response of activists appears to little more than flaunting a sense of moral superiority, but that moral superiority, no matter how admirable, does nothing for the girls facing some form of FGM.

Obviously, as the AAP strenuously insists, the ideal is to prevent any form of FGM, ritualized or otherwise. But if that goal cannot be reached is it morally unacceptable to offer a medically harmless compromise? It is difficult to make a compelling moral argument against anything that will reduce the overall incidence of real FGM.

Let's not lose sight of the real question asked by the AAP. The question is not whether we should oppose FGM. We should and the AAP strongly opposes it. The question is whether anything can be done to prevent the serious health and psychological problems due to FGM by replacing it with a ritually acceptable, but medically harmless compromise. It is a reasonable question, and the AAP's response deserves serious consideration.