Amy Tuteur on Birth, Natural Parenting, and Push Back
Mar 18 2019

Push-Back-199x300.jpg Obstetrician gynecologist Amy Tuteur and author of Push Back, talks about the book with EconTalk host Russ Roberts. Tuteur argues that natural parenting--the encouragement to women to give birth without epidurals or caesarians and to breastfeed--is bad for women's health and has little or no benefit for their children.

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Explore audio highlights, further reading that will help you delve deeper into this week’s episode, and vigorous conversations in the form of our comments section below.

READER COMMENTS

Drew B
Mar 18 2019 at 12:46pm

I’m a huge fan of EconTalk. I’ve been listening for years but have never made a comment. This week’s episode got me pretty fired up. Amy comes at the argument from the opposite perspective of mine, and it was valuable for me to check my bias at the door and listen with an open-mind, granted there were times I felt frustrated, even angry. She made many fair points about the pressure placed (full-disclosure, I am a man and my wife has given birth to 5 children naturally) on women to have natural child-births and to breast feed. We should not be a culture of coersion and pressure. Some women can’t breastfeed and some women are not in a position to have a natural birth. Her main point is that women should not be shamed if they don’t have a natural birth; I couldn’t agree more! However, Amy really failed to show dignity to the natural childbirth movement and her tone and words were at times at odds with her desire to “support women.” My wife and i have been on the other end of the argument where doctors we pure bullies in regards to not honoring my wife’s wishes to have a natural birth. The shaming that occurs from the medical estblishment can be just as pernicious and anti-women as she purports the natural child birth movement to be. It breaks my heart that women are shamed for not breast feeding or getting an epidural, but Amy is completely blind to the fact that women on the other end are also bullied and shamed which I have watched first hand. Her characterization of the natural child-birth movement was essentially a straw-man, painting a very-ugly depiction of the movement as essentially a movement of shaming. Her tie to Dick-Reid was pretty ridiculous and irrelevant as if the natural child-birth movement today is just trying to enslave women. As a supportive husband of my wife who desired to have natural childbirths, I find it very offensive. Both sides have valid points to make and there should be a broader dialogue, but Amy failed to elevate the discussion. I actually agreed with her on many points and i am glad she was able to share her viewpoint, but her condescending tone was tough to handle.

Russ, as always, you were a great host!

Harry Robinson
Mar 19 2019 at 8:23am

I think the three main topics, C-sections, epidurals and breastfeeding should also be separated.

With breastfeeding, I often found that the mother’s vanity appeared to get in the way of them doing what’s best for the child. They’re more concerned about what their breasts will look like as a result of breastfeeding then the health of the baby, not caring or considering the tremendous benefits it provides.

The manufacturers of the various baby formulas have done a good job at promoting their products and young women’s lack of chemistry, physiology and biological knowledge negates their ability to make sound judgments on the matter.

I think what my wife once said has had a profound influence on me. She said, “I think we have to have socialism, women are not responsible enough to stop having babies they cannot afford.”

Even in the age of very good birth control methods, the poor continue to have babies at record numbers.

These same women are then left to determine the fate of their children both in nutrition and medical care such as the administering of vaccinations.

It appears to me the commercial interests are taking advantage of women through various methods of phycological persuasion.

Hazel Meade
Mar 19 2019 at 12:01pm

Nobody is pressuring women to have natural childbirths. On the contrary, the medical establishment pressures women into inductions and C-sections, which are now 30% of all births in the US. Inductions and C-sections are convenient for doctors and hospitals because they can be scheduled and women can be quickly “processed” – moving them out of delivery rooms faster so that fewer delivery rooms are needed. Epidurals also increase the rate of C-sections for the simple reason that it confines the woman to the bed, so she cannot get up and walk around to help the baby move down the birth canal. I’ve been through this whole process twice, and have experienced this first hand. The first was with a traditional gynecologist who pressured me into an induction at 39 weeks and then a Cesarean. The second time was with a midwife that let me go to 42 weeks and try for a VBAC , which was successful. I would opt for the midwife over the traditional gynocologist and recommend the same to others as the midwife allowed me to make my own decisions. if anything, they bent over backward to conform to the medical establishments rules – they were not pressuring me to do a natural childbirth. In fact, i gave birth in the hospital with an induction and an epidural after I was in active labor. They were merely more willing to allow me to try for a natural birth instead of being eager to get me hooked up to pitocin and epidurals as fast as they could.

 

 

 

James
Mar 20 2019 at 3:32pm

While I’m perfectly sympathetic to the idea that cesareans are over done, I want to push pack a little bit on your comment and say that there are very real risks of postterm pregnancy (eg. baby growing to large to exit birthing canal) and prolonged labor (eg. infection, lack of oxygen to baby). Perhaps they’re overemphasized, but surely some of the 30% was legitimate medical need and not out of convenience.

Justin
Mar 18 2019 at 1:19pm

I enjoyed this conversation.

I will say I went through the process with my wife for our first child at the hospital, our second child was born at a mid wife/natural care clinic and the hospital with meds was awful from start to finish.

The irony being the hospital was extremely pushy about breastfeeding because it has strict regulatory standards it must uphold to maintain WHO happy baby accreditation, none of that was going on at the mid-wife clinic it was all about what does the mom and baby need to be most comfortable and happy that is available (obviously they don’t have anesthesia available but they do have formula).

So while I’m sure our experience was unique it was the exact opposite of what is described in this podcast about the guilt, shaming, and misery involved in midwifery.

When I reflect on it now it felt like the mid wife clinic was a small business that was very interested in our safety and happiness as a customer with an acceptable outcome, where the hospital was terrible service but also an acceptable outcome.

Largely I agree with the premise of the author, and we would not have sought the mid wife option for our second child if the hospital care was not so poor.

Steve Bacharach
Mar 18 2019 at 1:19pm

Thanks for this episode.  My wife was made to carry some guilt from friends and family for bottle feeding and having C-sections.  She resented it.

Charles Hickenlooper
Mar 18 2019 at 3:36pm

What about the economics of child birthing? If there is greater risk and doctors’ time spent on natural vaginal births, shouldn’t these births cost more than anesthetized and Cesarean births?  Yet, (I may be wrong here) it seems to me that natural births are cheaper? Why? Also, where was the discussion about incentives for doctors preferring C-sections? (more monetary compensation and less time expended)

Why the non sequitur about Grantly Dick-Read? Yes, he was an imperfect person. But, that has nothing to do with whether his ideas are any good or not. Why not just discuss the fallacies of his ideas?

Isn’t pain relative to each individual?  My wife had two horrible birthing experiences in the hospital  in the early 1970s with anesthetics and ob/gyns. (In those days the social pressure was to have anesthesia.) My wife was so disgusted that she had our next four children all natural at home in a water bed comfortably on her side with a very experienced midwife who knew how to turn a breech prior to birth and deal with a cord wrapped twice around a child’s neck. My wife learned that episiotomies are mostly unnecessary. And fetal heart monitors gave false indications because the mother must lie still in a certain position which constricted the blood supply vessel to the unborn infant thus slowing the heart rate.  What she discovered is that recovery pain after a natural  birth is SO much less than recovering from the pain suppressed by anesthesia. She prefers the term labor rather than pain. She likens it to working out. Working out is painful. But it is a good pain. Mothers go into labor. Labor is painful. But it is a good pain. My wife exercised a great deal to prepare for each birth. I’ve read fit people tend to handle pain much better than unfit people.

In the 1970s almost all our close relatives, friends, neighbors, and church members were horrified that my wife chose to birth our children at home. (Talk about social pressure and scare tactics!) Since that time home like birthing rooms and midwives have become available in hospital settings. I applaud this development. I’m sure my wife would choose to have our children born in today’s hospitals.

Oh, how the pendulum has swung in the last half century or so. Back in the 1950s, 1960s, and 1970s baby formula was a must, NOT breast feeding. Women who breast fed were deemed socially inferior.

 

szymon moldenhawer
Mar 18 2019 at 4:05pm

Ah, how pendulum swings in 1890’s wise Germanic doctors were teaching teaching that scientific way to raise children was teach them sleep separate from birth, discipline them when they cried (by corporal punishments to a new born baby) showing affection to children especially boys  by fathers was viewed scientifically proven to be  perniciously feminizing.  Sleeping with children was unsanitary  then it swung the other extreme that good Dr is now militating against.  In the end nothing will substitute for common sense healthy skepticism   whenever anyone claims to full and correct knowledge of of the best way to do whatever.

ThomasL
Mar 18 2019 at 4:30pm

I asked our doctor once, as my wife and I were pacing the halls, about 12h into labor for our daughter–how common my wife’s “no non-medically necessary interventions” take was, and he said that in his experience, about 80% of women just want in and out as quickly as possible, and are in favor of epidural, inducement, C-section, whatever it takes to make that happen.

Not knowing how many kids we will have (baby three is due soon, and God-willing, won’t be the last), the C-section route is not a win unless it is truly necessary, since repeated C-sections take quite a toll.  Of course, making provision for having a large family is rarely considered these days…

Mark
Mar 18 2019 at 5:12pm

I was bothered by Dr. Tuteur’s lack of rigor and science in her responses. I googled her name to find her book and a few things popped up:
– My concern about her lack of scientific rigor seems to be a common issue
– The “natural” movement really does dislike her
– She hasn’t been a practicing OB for about 15 years

I’m not sure why I should believe a medical blogger who thinks that “big lactation” is out for women over the many medical studies showing benefits to breast feeding. Or why the “natural” movement needs such a stern rebuke given that the movement is so small and (according to science) relatively safe. Dr. Tuteur certainly doesn’t give much evidence in the interview and if book reviews are any indication, the book doesn’t either.

All that aside, the least I expected from Econtalk was some talk about…econ. Why aren’t the costs of a C-section vs natural birth discussed? C-sections both cost more for the operation itself as well longer hospital stays and longer recoveries. Breastfeeding is cheaper than formula and there are studies showing reduced incidence of asthma, respiratory illnesses, and common childhood diseased. Presumably that would translate into fewer days off work and better economic outcomes for the primary child rearing parent. Certainly there should be some benefit for the cost? Dr. Tuteur alludes to saving children’s lives, but infant mortality has monotonically dropped since the 1990’s while C-section rates have both gone down and gone up.

I agree that moralizing “natural” birth is not a good thing and some cultural push back is probably warranted. And women should certainly be making informed choices about their health and their children’s health. But “making informed choices” is also the talking points for not vaccinated children. The rhetoric without evidentiary basis is problematic, and it seems that Dr. Tuteur is better at the rhetoric part.

Andrew
Mar 18 2019 at 8:13pm

With my wife currently pregnant with our third child, I was excited to listen to this one.  Well, it certainly didn’t confirm my priors.

When my wife was pregnant with our first child, she stated her desire to have a natural child birth.  I was against it at first.  Medical technology has advanced greatly leading to historically low infant and mother mortality, why would we shun this technology and have birth as though it was hundreds of years ago?  She convinced me to go with her to a birthing class that taught the Bradley method.  I was more than skeptical, especially after finding out the class would be held in a strangers basement, but over the course of the class I was converted.

My wife went on to have a healthy baby, and a relatively smooth, natural birth.  We had a similar experience with our second child, and hope to repeat it in a few months.  With that background on my biases, a few comments on the episode:

My wife gave birth naturally, twice.  Most of our friends who have had children around the same time did not.  A scientific study that is not, but I don’t really see a big move towards natural birth.  If anything, our experience was the opposite of the one stated by the guest.  We were pressured both socially and by doctors to have a more modern birth experience, with inducement and epidural.
I do see women pressured to breastfeed, and have had many family members and friends who could not, and they did indeed feel terribly about it.  I agree with the doctor here, although I do think that breast feeding does have some benefits, is worth some effort, and maybe even a visit to a lactation consultant.  That said, reducing the stigma on formula would be a great thing.
I certainly don’t think that people should be dictating to  mothers how to go about giving birth, but I do think that the medical community and others should arm mothers and fathers with facts to allow them to make educated decisions on how they choose to give birth.  I do include fathers in there – and I don’t think that is a bad thing.  In general, a mothers medically guided opinion should rule, but anything can happen in labor, and a father should be prepared to make a choice should their wife be unable.
One thing taught in the Bradley class that helped convince me was that medical interventions sometimes cause additional medical interventions.  Bradley wants mothers to wait to go into labor, rather than being induced, with the idea that the mother and baby know what they are doing and when they are ready.  So, for example, a mother could be pressured into induction.  Because the mother and baby were not actually ready, the labor is long and hard.  This long/hard labor leads to additional stresses on baby and mother, which forces the hand of doctors at some point who then push a C-Section to save baby and or mother.  the doctor may then say,  thank goodness for modern technology, it saved the baby and mother, when maybe the reality is, the baby could have been born vaginally with less complication if the mother’s body was allowed to determine when the baby was ready to arrive.

Overall, I agree with the Dr. Tuteur that the opinions of Mother-in-Laws outsiders are not super helpful and can add to the stresses of one of the most stressful situations in life.  The world would benefit greatly if we all were a little less judgmental.  However, I do think the medical community should do a bit better than just, “mother knows best”.  If there are no studies that can prove what types of birth, mode of baby feeding, etc. are medically best and should at least be aimed for, then it appears there is work to do in that area.

Josh Rogan
Mar 18 2019 at 9:43pm

As a big fan of econ talk, this episode surprised me as Russ seemed to be less skeptical than usual. I do wonder if it had something to do with the fact it was a woman talking about something men today are “not allowed” to have an opinion. It’s the exact same argument used in the pro-choice movement.

Many times in the episode Russ decided to make a point of using the wrong pronoun (by including himself) when referring to his wife’s birth. This is the primary evidence that Russ was extra careful (to a literal fault) not to offend or stretch his role in the birth of his child. I sympathize with the rationale. Most good people would attempt to do that in personal conversations as to not minimize the fact women have a more stressful experience. This episode is not a personal conversation, but rather a public discussion of ideas. Minimizing the role of childbirth to only one side is ultimately harmful. It should be a dialogue between two parents who want the best possible outcome for their child.

I would have more sympathy for the lack of push back but I know there have been many episodes offering opposing positions to these exact topics. I am glad he had an opposing viewpoint on but I wish he remained his usual skeptical self.

Dr Golabki
Mar 19 2019 at 1:01pm

I’m sympathetic to Amy’s position, and I think she raised some interesting points. In particular I thought the point on deulahs was interesting. It seems like there’s pressure to provide/subsidize non-essential care based on the false assertion that it’s benefiting disadvantaged people, when in reality it is a nice perk for privileged people. It’s an interesting point that strikes me as at least partially true.

 

That said I do not think Amy was very fair mind. I’ll list a few examples…

She continually targeted arguments against the most extreme possible position someone supporting natural birth/parenting could take. I didn’t hear Junger say “all children must sleep in the same room as their parents”. My takeaway was, if you 5 year cries themselves to sleep for 2 hours every night, it’s not because you are a bad parent, and you shouldn’t worry that letting them sleep in your bed is going to scar them for life. My kids have always slept well, but I know this exact issue was a great source of stress for my mother when I was a baby.
She held herself to a different standard of evidence than her opponents. She repeatedly mentioned that medical benefits of breast milk do not appear in large studies, so we shouldn’t take them seriously. But, then casually implied lactation consultants were causing mothers to commit suicide. I kind of doubt there’s a large well controlled trial on that.
She made a fair number of arguments that just don’t make sense. She argued that it’s inconsistent  to favor natural child birth/parenting, unless we also want to have men become hunter gathers. That’s like saying it’s inconsistent to read a paper book, unless you also want to throw your smart phone in the garbage. Obviously that’s absurd.

Deborah
Mar 20 2019 at 10:35am

I had the same reaction as you and others to the lack of scientific rigour and logic in Amy Tuteur’s arguments. This was a problem throughout the podcast, and became extreme when she started talking about breastfeeding.

But she also did a really poor job of explaining what a doula does (it’s more than washcloths and cheerleading). A doula supports a woman throughout pregnancy, childbirth, and in the postnatal period, throughout the process of becoming a mother — no matter what the woman’s choices are or what the particular outcomes of childbirth is.  There have been studies showing evidence that this support is not just a nice perk, but actually reduces the rate of c-sections (not through arguing against a c-section when the decision is being made, but by simply supporting a woman in non-medical ways before and during labour). And, not surprisingly, it’s women who have less family support and fewer economic resources who benefit the most, over the entire perinatal period, from having a doula.

I don’t know the specifics of the doula program in NY she was talking about (in NY?). I work as a doula in Canada (and before that I had a career in public health). Nobody would ever suggest that having a doula replaces prenatal medical care or technology. A doula can in fact help a woman access the medical and parenting resources and information that are available. Given the way Tuteur approached all the other topics, I suspect she may have gotten the facts wrong on the NY program as well.

Cynthia
Mar 19 2019 at 7:48pm

As a mother to a 3 year old and 7 year old I enjoyed the discussion and it is nice to hear another professional women push back on the pressure women feel today when it comes to being mothers. I notice a number of commenters state they haven’t noticed the trends discussed, but where I live in Southern California I can personally relate to most of the examples Dr. Tuteur gave.

What I took from the discussion is that women should be allowed to choose what they think is best without being shamed.  Right now the trend is to give birth naturally and exclusively breast feed and her reasoning against those trends is a point of view that isn’t heard very often. I am one of those women who cried when I had to give my son formula when he was less than a week old. I felt like a failure and looking back on it I see how ridiculous that was.

Maybe the reason I felt more pressure from other moms than my doctors is because I would confide in my doctors how I really felt. I told my OB I was afraid of the pain of childbirth and she understood. I told my pediatrician how I struggle to breastfeed and he reassured me in a hushed tone that his babies who had both formula and breast milk were sometimes his healthier babies. I also got loads of free samples from his office since I was one of the only moms who used formula, according to the nurse.

But when I’m with other moms I usually keep quiet about my scheduled c-section and supplementing with formula, unless I meet someone else who had a similar experience. The moms who never had to give their children formula and/or delivered their babies naturally proudly bring up these facts in conversations. Somehow it ends up with the rest of us feeling bad.

I’m sorry for the people who have felt pressured by the medial community during their pregnancy and child birth experiences. I think none of us enjoy the feeling of being pressured to do something that doesn’t feel right and I think that is the point to be taken from this podcast.

 

A woman and a regular listener
Mar 19 2019 at 10:49pm

I gave birth, natural birth, at home two years ago. I wasn’t pressured to do it, but it came so fast that we didn’t have time to go back to the hospital. My midwife was suggesting a natural birth but I was literally begging for an epidural in our home bed. I honestly wish I didn’t do it the natural way because the pain was so great that I cannot imagine having another child. (To an earlier comment about fitter people tend to tolerate pain better. I exercise regularly, have a normal weight and I was in my mid twenties. The pain was absolutely excruciating.)

 

Now, breastfeeding. I can confidently say I hated every single moment of breastfeeding. It is not just inconvenience. My boobs were constantly in pain. (Milk production irregularities) I was essentially chained to my baby because nobody else could feed her. I tired pumping, it felt awful as well. I felt like a cow. However I kept pressing on. Because everything I read is saying breastfeeding is SO GREAT that it’s like the best thing I can give my baby. I had to keep going. I resent it to this day. The social pressure is real.

 
I actuall have a headache from typing this response. All in all, I am SO GLAD somebody is offering an alternative view.  Everybody is different.

Keivan
Mar 20 2019 at 6:07am

As a huge fan of this podcast,  I was somewhat disappointed with this episode, mainly due to the noncommittal attitude of the guest on issues that in my mind have objective answers.

In several occasions in the course of the talk,  as soon as Amy seemed to be running out of arguments, she kept changing the topic and switched to a different line of defence. Example: in the part of discussion related to the value of baby formulas, she suddenly brings up the argument that it is mother’s every right to decide whether she’d like to breastfeed or go for the alternative. Fair enough as a point (and I happen to agree with her on this point), but I’d like to bring the previous discussion which presumably has an objective answer to its conclusion before embarking on a completely independent argument. I also felt that Ross had several opportunities to push back on several occasions, but did not follow up on them.

liane
Mar 20 2019 at 12:53pm

I am surprised and yet not surprised by the comments here on this site. Because this is an economics forum, I expected less comments about tone and attitude, and yet I’m not surprised that there are tone police of Dr. Amy — she is after all a female and expected to be a lot more deferential and polite. And many of the responses weren’t objective or factual, but rather seemed more a result of offended listeners who aren’t armed with information but had differing opinions and experiences.  On the one hand, I find it amusing that the men who have commented have strong opinions about whether there is or is not pressure to have natural childbirths, but I am far from shocked. It’s in the parenting magazines, women’s magazines, blogs, newspapers, mom groups, and childbirth classes. I could go on. To this day and despite that its been refuted and debunked, well respected newspapers and magazines still quote the outdated and incorrect statistic from the WHO that there should be a 15-20% cesarean rate, or demonize hospitals that have 30% rates (studies have shown that cesarean rates have no correlation with the quality of medical care). Thanks to documentaries like “The Business of Being Born” people still spread the myth of a “cascade of interventions” or an epidural will lead to a cesarean despite recent studies proving that epidurals do not increase c-section rate and that induction at 39 weeks actually reduces cesareans and stillbirths. I’ve lost friends because I didn’t agree that it was necessary or beneficial to breastfeed until 18 months. And there is such perceived status of breastfeeding that people will lie about how long they did it. Are there studies about women expressing depression or committing suicide because of their inability to breastfeed or have a natural birth? Maybe. But there are certainly an avalanches of anecdotes that support this. Many women have emotional stories about their so-called “failed homebirths” or have resentment when their friends lord over them about their perfect natural births. Even the men are doing in here. There is an economic side to this, but to demonize doctors or cesarean is to absolve the insurance industry. Midwives charge $4-6k. That’s about 10 percent less than what I paid for my hospital delivery of my first, and 30% less than what the hospital charged for a cesarean after a vaginal attempt for my second. But this “premium” is for expertise and safety and the ability to perform surgery and handle medical emergencies. If there are pressures from medical doctors for their patients to accept “medicalized” labors and deliveries, don’t you think they have good medical reasons, or do you really believe that it’s because they’re trying to “process women” quickly or trying to make a 4:30 tee time because that’s what Rikki Lake said? And before you answer, ask yourself how many babies have died in an attempted homebirth because a woman watched The Business of Being Born and believed that homebirth was just as safe as delivering in a hospital with a staffed and prepped OR. Or if you don’t want to answer that, at least have data to back up your rebuttles of Dr. Amy’s arguments.

Tyler Wells
Mar 20 2019 at 12:57pm

I echo the dismay of many of the commentators on the tone of this podcast.  Dr. Tuteur, in my view, had some interesting points but this podcast lacked the normal healthy skepticism and intellectual rigor of an Econtalk podcast.  Dr. Tuteur  came across as preaching instead of informing and, in my view, cherry-picked and even invented science when it served her purpose.  A couple of her more egregious quotations include:

Amy Tuteur

“And, look around the world: the countries with the highest breastfeeding rates have the highest infant mortality rates. And the countries with the lowest infant mortality rates have the lowest breastfeeding rates.”

So should we presume that the only (or even a primary) difference between countries with high and low infant mortality rates is rates of breastfeeding?  I doubt that very much.

Russ Roberts

“So, the idea that kids should sleep in their own room because it’s good for them, they’ll get better sleep habits, he suggests is actually not true… most cultures in the world, the idea of making your kids sleep in their own room would be seen as a sign of cruelty.”

Amy Tuteur: “Well, I want to address that, because I think it’s nonsense. It’s nonsense on a number of different levels. First of all, the idea that there was one universal culture in pre-history and that all people did the same thing, and parented the same way is just completely bizarre.”

She either missed the point or ignored it.  Only one facet of parenting was addressed, infants sleeping in their own room.  And yes, throughout human prehistory virtually all children would have slept in the same room as their parents as it would have been rare to have a house with more than one room, especially one for sleeping.  That doesn’t mean you need to sleep in the same room as your child, but it would have been nice if she would have addressed the point, or even have declined to address it, instead of dismissing the idea with terms like “nonsense” and “bizarre.”

As I see it, a potentially interesting topic was poorly dealt with.  A missed opportunity for Econtalk.

Doug Iliff
Mar 20 2019 at 2:49pm

Yeah, Russ was a little soft on her, and Amy was pretty judgmental herself at times, but in general it was a mildly useful episode when it comes to encouraging mothers to resist intimidation.  Here’s a family physician perspective based on delivering 1500 babies over 40 years with no stillbirths; a 15% C-section rate; being a covering physician for a birthing center staffed by midwives; and practicing through fads and fancies of Bradley, Lamaze, LeBoyer, La Leche, and doolas.

I got to where I told moms to not speak to another woman for the remainder of her pregnancy, because their well-meaning friends would describe a panoply of catastrophes which I had not encountered in my career.  Of course, they knew I was joking, but they got the point.  Other women drove these fads, and they had to remain skeptical.  Many women presented for prenatal care with extensive plans for a well-designed delivery; I encouraged them to keep an open mind, because the “The best-laid schemes o’ mice and men/Gang oft agley” once the pain starts.
Epidurals are not risk-free, but they are wonderful for pain relief.  Commonly they would cause transient drops in blood pressure, and rarely persistent headaches requiring a blood patch to seal a cerebrospinal fluid leak.  Both problems are manageable.
The perception of pain is highly dependent on fear.  The reason Lamaze worked well for many women (like Russ, my wife had four “natural” childbirths with tolerable levels of discomfort) was that their expectations were prepared beforehand.  And like Russ, I’m skeptical about the efficacy of my contribution to the birthing process.
I had many women committed to “natural” childbirth who opted for an epidural when the pain became intolerable, and I never felt anyone involved in the process made them feel guilty.  Maybe Kansas is less doctrinaire than Boston or Los Angeles.  Sometimes I recommended an epidural during an arrest of descent, figuring the pain relief might allow enough relaxation to renew progress, and sometimes it did.  If it didn’t, they were already anesthetized for C-section.
The breastfeeding clinics in our hospitals were consistently helpful and supportive to women, no matter what they chose.  Again, it’s Kansas.
I have heard many comments from OB nurses over the years that some obstetricians don’t seem to be patient with the process of labor, and have a quick trigger-finger when it comes to C-sections.  Economically, it is certainly true that operative deliveries have a high income/hassle ratio.  And many women facing repeat sections (our hospitals, like Amy said, don’t do VBACs due to lack of in-house anesthetists) seemed to like the predictability and convenience, too.  Maybe that’s why 90% of private clinic Brazilian deliveries are operative.
I can’t see any reason not to at least gently encourage all women to try breastfeeding.  If all the kids get is colostrum in the hospital, fine.  Formula is a great product, but it is very expensive, and breast milk is free.  Here’s another tip: once a baby is six months old, growing normally, and consuming some variety of meats and vegetables, there is no evidence that formula is superior to whole or 2% milk.  The recommendation to continue formula to twelve months is, in my opinion, the result of “follow the money” collusion between manufacturers and the American Academy of Pediatrics.
I’ve had many women foregoing epidurals who called me bad names, usually accompanied by exhortations to “Get it OUUUT.”  When it finally was out, and the baby was hollering in their arms, they seemed to forget the pain.  And they were very sorry for abusing me.  A healthy baby seemed to heal all wounds, natural or operative.
There is a small risk to delivering at home or in a birthing center.  It’s undeniable.  I know of at least a couple of babies who would have lived if they had been delivered in a hospital.  I’m not taking a moral stance one way or another– just stating a fact.

 

gw
Mar 27 2019 at 8:53am

Breastfeeding is only free if you consider women’s effort and time are free. If I didn’t have to stay home and breastfeed I could be returning to work earlier and make a six figure salary. If I didn’t have to breastfeed, I didn’t have to deal with discomfort in my body caused by milk production.

Monika S Pitchford
Mar 21 2019 at 6:13pm

I really appreciate that you covered this topic. Thank you.  For the most part I agreed with Dr. Tutuer that women should not be shamed or guilted for their birthing choices nor how they feed their infants.

Re the question of Lamaze – I suspect the benefit of Lamaze mirrors the benefits of controlled breathing in general: it’s useful to help a person remain calm and “in the present” rather than panic in a high stress/high pain situation.  These breathing techniques *ARE* taught to soldiers, though perhaps not in the US, that I don’t know. But breathing techniques are taught to some high level operatives (per an instructor who I do not have permission to name).

Monika S Pitchford
Apr 8 2019 at 2:15am

Russ- I hope you see this article:

 

NYTimes: The Latest in Military Strategy: Mindfulness The Latest in Military Strategy: Mindfulness https://nyti.ms/2U1CK4x

KeinG
Mar 21 2019 at 8:48pm

Russ, long time listener and prolific referrer of Econtalk.  But I have to say this episode was not one of my favorites. I’m data-driven as a trained economist, so I respect that approach. Also understand how studies can be of more or less value depending on sample size, sample source and rigor of analysis. I found Dr Tuteur’s vacillation between an insistence on rigor and reliance on opinion, depending on how well the data agreed with her to be annoying. To be honest I disagree with her philosophically, but at least I’ll happily acknowled that rather than condescendingly assuring you I’m in the right.

[Comment edited with commenter’s permission—Econlib Ed.]

Andy McGill
Mar 24 2019 at 8:25pm

Sad to see such an important issue treated so badly.  This demonizing the other side as selfish, profit-seeking, and hateful of women is shocking when almost every person who ever lived cared so much for babies and mothers.  I understand that both sides do this and have been doing it for many decades.

Does anybody have a good objective summary of what happened with formula companies in Africa in the 1970s?

The elephant in the room was why modern women don’t want to breastfeed.  The guest obviously danced around the main reasons besides inability to produce sufficient nutrition.

 

gw
Mar 27 2019 at 8:59am

Many women do not enjoy the breastfeeding experience, myself included. It’s uncomfortable, sometimes painful, and it disrupts my sleep.

bogwood
Mar 30 2019 at 9:59pm

I was also expecting more on the economics surrounding childbirth.  Is it an insurable event?   Pregnancy  can be prevented.  Why should society support children when each child, particularly each American child is an ecological hand grenade?  The present insurance system is like a  variable rate house loan.  It enables the entry into parenthood but then the real costs start and we end up with subprime children, higher risks of Adverse Childhood Experiences and higher risk of single parent households.   Fewer government subsidies might help.  It is only fair to pay for your own children.  One part of Obamacare that would not be missed is the OB portion.

Scott Heddle
Apr 1 2019 at 11:16am

Oh, where to start?

It’s too bad that she didn’t spend her time talking about science instead of her agenda politics.  I counted 7 times she used fallacious arguments.  I counted 5 times she used non-sequitor arguments. She was truly one of your worst guests.

 

In addition, you didn’t push back on her as much as you have on other guests.  Why?

 

So bad.  Really a disappointing episode.

Don’t take it too hard though.  I love the show and find it 99% mindblowingly awesome.

ThomasL
Apr 2 2019 at 12:32am

Looking over the transcript I noticed the comment about breathing techniques not working to control pain.

I think that is just a misconception.  We learned those techniques too (admittedly, only one or two of which my wife used), but those classes and three kids naturally delivered later, I cannot recall anyone at any point ever claiming that breathing a certain was was going to deaden the pain.

It was about focus, remembering to breathe if tempted to panic or during exertion–it is actually quite easy to forget in either case–and in certain cases how to control the urge to push when you aren’t actually ready to do so yet (so the claim went, a sudden, sustained puff when the urge to push comes can help relieve some of the pressure).

That last one about pushing is kind of unique to this situation, but using some kind of controlled breathing technique to aid focus, avoid panic, or help physical exertion is not at all unique to birth.

Emma
Apr 17 2019 at 10:16pm

Thank you so much for having this conversation. As a mother of two young kids (who are happy and healthy) I have felt this pressure non-stop since I became pregnant with my first child. Actually as a woman, I have felt this pressure since before even becoming pregnant. I will spare you the gory details but epidurals and formula were the right choices for our family and I faced no shortage of pressure and shame as a result.

Comments are closed.


DELVE DEEPER

This week's guest:

This week's focus:

Additional ideas and people mentioned in this podcast episode:

A few more readings and background resources:

A few more EconTalk podcast episodes:

 


AUDIO HIGHLIGHTS
TimePodcast Episode Highlights
0:33

Intro. [Recording date: February 20, 2019.]

Russ Roberts: My guest is obstetrician and gynecologist, author and blogger, Amy Tuteur.... Her book, which is the subject of today's conversation, is Push Back: Guilt in the Age of Natural Parenting.... So, tell us about your background, as an observer of all these issues related to childbirth and parenting.

Amy Tuteur: So, I'm an obstetrician-gynecologist, as you mentioned. I'm also the mother of four children, now all adults. So, I had my children back in the 1980s and 1990s. But even then, the pressure on women to have a natural childbirth, to breastfeed, and to parent in certain ways was getting started. But, now, it is much worse. And I really feel very badly for a lot of young women who are struggling with the pressure--mostly because it's unnecessary. So many of the things that people are upset about--for example, when I used to be practicing, I used to visit a woman the day after her baby was born; and she would be very, very upset about the fact that she had an epidural--which she hadn't planned on. Or had a C-section [Caesarian Section] that she hadn't planned on. And no matter how much I tried to point out that the reason we were doing this was because she should have a healthy baby and she should be healthy herself, she would be inconsolable. And, I began to wonder why it is that new mothers feel that way; and who is making them feel that way; and what can we do to help them.

Russ Roberts: I want to talk about a different--we are going to go through the different aspects of what you call natural parenting--the pressure to not have a C-section, to have a vaginal birth; the pressure to breastfeed; the--and then the issue of what you write about as attachment parenting and how close the child, the infant, should be to the parent at all times versus independence.

Amy Tuteur: Right.

Russ Roberts: So, I want to go through those one by one. Let's start with the C-section. There is a large--there has been an increase in C-sections in the United States. And the rate--I think in your book you quote a number of, roughly a third of all births or C-section births. And, as a--we had four children. That's not the right pronoun. My wife gave birth to four children. But I was a participant. In, of course, many ways. And one of the ways was that we, neither of us wanted a C-section. And felt there was pressure from parents that we had talked to, from their doctors; sometimes from the nurses--that a C-section was often just an easy way to deal with it. And that mothers who wanted to try longer and to go through labor were often not listened to, at least we were in at the time. So, give us your thoughts on that. Talk about the rate of caesarian section, and why you think that we should be more open to C-sections than we are culturally.

Amy Tuteur: So, before we get into the attitude toward C-section, I feel like I need to say that when I was practicing, I had a 16% C-section rate. Which is really quite low. Although I acknowledge that where I am practicing now, it would probably be higher, because the changes in the rules about vaginal birth after C-section.

Russ Roberts: When you say "rules," do you mean legal restrictions? Or hospital-imposed rules? Or what?

Amy Tuteur: Well, there are legal and insurance restrictions. But they come about because we knew, right from the very beginning that vaginal birth after C-section had a increased risk, compared to vaginal birth in women who hadn't had a previous C-section. And that risk includes the rupture of the uterus and the potential death of the baby. And even the death of the mother. And although women signed consent forms saying that they understood that that could happen, when it began to happen, these women sued. And they won. They sued claiming that they--although they had been told that it could happen, they didn't really understand that it could happen. And, insurance companies paid out a lot of money. And as a result, they directed the doctors and the hospitals that they, um, that they covered, to have certain restrictions on vaginal birth after caesarian. And the American College of Obstetrician-Gynecologists codified some of these restrictions. And they included the ability to perform a C-section within 30 minutes. Which meant that the doctors involved--like, the obstetrician and the anesthesiologist--had to be in the hospital at the time that the woman was in labor. And a lot of community and rural hospitals don't have an anesthesiologist in the hospital 24 hours a day. And so, those hospitals stopped doing vaginal birth attempts after C-section, because they couldn't meet the standards.

6:22

Russ Roberts:

Russ Roberts: So, that's one of the reasons that C-section rates are higher for second, third births, that--etc.--that after an original C-section, now those were increasingly C-section also, is what you are saying.

Amy Tuteur: Correct. That's right. But I think it's important to go back a little to the history of the natural childbirth movement, to really situate the whole C-section issue within the movement itself. Now, most people don't realize that the natural childbirth movement was created in the 1930s and 1940s by Grantly Dick Read, who was a British obstetrician. He was also a eugenicist. And he was preoccupied--as were many eugenicists in the 1930s--with the problem of what he called 'white race suicide.' He bemoaned the fact that white women of the so-called 'better classes' were having fewer children, while women of color, of the lower classes, were having more children. And he felt that upper class white people would be drowned in a sea of their--what he felt--were their inferiors. And he--

Russ Roberts: He was a racist. He was a terrible racist. Got it.

Amy Tuteur: Yeah. He was a racist. He was a misogynist--

Russ Roberts: How does that tie into the Natural Birth, thing, though? The natural parenting?

Amy Tuteur: Well, so, he thought that the reason that women were not--women of the better classes--were not having enough children was that they were, first of all, too educated. They were what he referred to as overcivilized. And also that they were afraid of the pain. And, to fix that fear of the pain, it told them it was all in their head. He said that primitive women gave birth easily; had no complications; and had no pain. So, to the extent that women had pain or complications, it was because they were over-educated and over-civilized.

Russ Roberts: This is something you call in the book, which I phrase--I like quite a bit--paleo-fantasy. That romanticization of pre-history and our primitive ancestry.

Amy Tuteur: Right. But, he did it with a purpose. It wasn't that he didn't understand what childbirth had been like in nature. He wanted women to feel bad if they didn't give birth to children--a lot of them. And easily. And, that--the movement in the United Kingdom crossed to the United States in the 1950s where it got a somewhat different spin. And that was because medicine had become very paternalistic, both toward women and toward men. But women rebelled first. And, one of the things that they were unhappy about was that the only anaesthesia available was anaesthesia that put you to sleep. And, they wanted to be awake for the birth; and they were willing to accept the pain. And that's fine. You know--if that's what women wanted. And, the natural childbirth movement, as it crossed to the United States, it was responsible for a lot of important and valuable changes. Natural childbirth advocates asked, 'Why can't husbands and partners be in the delivery room?' And, doctors at first responded, 'Well, they can't.' And women said, 'Well, why not?' And doctors said, 'Well, actually we don't know. We always did it that way; but we don't know why we did it that way. We'll change.' And so, a lot of things changed, in the 1960s, 1970s, and 1980s. Also, what changed is the development of epidural anesthesia. And the improvement of safety of Caesarian sections. It is important for people to understand that up until the 1930s, C-sections were extremely dangerous. They were considered a bad thing. So, a lot of women would have vaginal births and their babies would die. After anaesthesia became better, and then definitely after introduction of spinal and epidural anaesthesia, C-sections became safe. And anesthesia became safe. So, there was no longer a medical reason to avoid c-sections. And, not surprisingly, the c-section rate grows. Because all the doctors wanted to save all the babies they possibility could.

Russ Roberts: But it does pose--impose a much different post partum, after-birth experience for the women involved, in terms of recovery and ability to be with the child. So, talk about that.

Amy Tuteur: Well, again, it all depends on how you frame it. It's certainly a much better recovery than if your baby dies. And that was the choice. Now, what also happened during that time period was the reemergence of midwifery as a profession. And, there have always been midwives; and they have always struggled to make birth safer. But, the reemergence of midwives had more to do with differentiating themselves from obstetricians. And so midwives began to promote what they could do as good and natural, and demonize what doctors could do as bad and harmful. And vaginal birth is a great thing, but it's not the right thing for everyone. There's actually a high rate of infant mortality and maternal mortality; and C-sections--in fact, Atul Gawande actually wrote about this--C-sections have saved more lives than almost any other surgical procedure. They've been an amazing success. Are there too many? Yes, there are potentially too many. But, of course, the problems with having too few are much bigger than the problems with having too many. And, you know, you don't want to have a C-section--it's surgery--that's fine, you don't want to have a C-section. But, you shouldn't feel bad if you do have a C-section. That's what's really changed. Not so much that women are disappointed, but they feel they've done something wrong. And they haven't done anything wrong. And they are told that they have missed out on a certain kind of experience. And they haven't really missed out. In the entire history of human existence, no woman said, 'What I really want is to have an agonizing, painful, near-death experience when I have a baby.'

Russ Roberts: And it puts my child at risk, on top of it.

Amy Tuteur: It definitely puts my child at risk. But what's happened, and it's kind of like what's happened with vaccines, is that neo-natal mortality and maternal mortality are now, fortunately, very rare. And so people have gotten the wrong idea--that childbirth is relatively safe. It's not inherently safe. Obstetrics has made it safe. C-sections have made it safe. Anaesthesia has made it safe. So, you can't really say what we want to do is go back to unhindered childbirth because it was awesome when it was unhindered childbirth. No: It was horrific when there was unhindered childbirth. And what we're looking for now is a balance: Are we at the right place? I don't think we're at the right place. But, we need practical solutions, not demonizing c-sections, and definitely not demonizing women who have c-sections.

14:31

Russ Roberts: Let me ask a question of you as a practitioner; and it's not an easy question to answer; but, certainly there are births you attended where a C-section was called for unequivocally to save the life of the child or the mother. There certainly were times when a C-section was a risk that was being endured to gain something that was very remote, that safety. And then there's the gray areas, the in-between cases where it's hard to know whether a C-section is the definitive response to the risk that the mother and child are facing. As a practitioner, how many times, or how often, or how agonizing was that middle situation where it wasn't clear what the right thing to do is? I ask this because, our first--'our,' again the wrong pronoun--my wife's first delivery of our daughter, our doctor was--it was in the middle of the night; he hadn't arrived yet. There was a monitor of the baby's heart rate, my daughter's heart rate. It was going to very low levels when contractions were occurring. And the attending nurse--it was either an attending nurse or an attending, very young, inexperienced doctor--said, 'I think we need a C-section. Sign these forms.' And, we, like you point out, we were emotionally, culturally against a C-section. Whether that was right or wrong. But there was a lot of pressure on us, and we were not sure what to do. And very shortly thereafter the doctor came, and said, 'Oh, that's just the contraction. Don't worry about that.' And my wife had a very painful, but a vaginal birth; and mother and daughter were fine. That kind of moment, where it's not clear what the right thing to do is: Is that common? Or, in other words: How much leeway is there in trying to decide? I mean, I assume, as an economist, it's not usually--it's usually not open and shut. To use a bad metaphor. It's hard to know what the right thing to do is at any one time. And I think the legal system encourages doctors toward--I worry that the legal system encourages doctors toward c-section. So, what are your thoughts?

Amy Tuteur: Well, the real issue is that we have a technical problem. We know that childbirth can be dangerous for babies, because every time the uterus contracts, the baby has to, figuratively, hold its breath. It cuts off the blood flow to the baby. That's not really a problem if the placenta is functioning well. But, you might imagine that, in a baby that isn't getting enough oxygen through the placenta between contractions, each contraction, it causes the baby to hold its breath and it doesn't have enough, for lack of a better term, enough breath to hold. It begins to suffer oxygen deprivation. We could eliminate a significant proportion of unnecessary C-sections if we could measure the baby's oxygen content. But, the baby is inaccessible to us. We really can't measure the baby's oxygen content. All we can do is listen to the baby's heartbeat. Now, imagine if you had a problem, a medical problem, and you went to your doctor; and the only thing your doctor could do was listen to your heartbeat. Obviously, if your heartbeat was really, really slow, your doctor would know that you were in terrible trouble. And if your heartbeat was normal, your doctor would be relatively safe in assuming that you were okay. But if it were somewhere in the middle, and there was nothing else the doctor could do to figure it out, both you and the doctor would be in a very difficult situation.

Russ Roberts: Yup.

Amy Tuteur: And that's the situation that we're in now, where we know some babies will be harmed by labor; we know what some of the signs are. But we don't know the thing we really want to know, which is: Is the baby getting enough oxygen? So, we have this very imperfect test, to measure the baby's heart rate. And the thing about that test is that it has a really high false-positive rate. In other words, it will show distress even when the baby is not in distress. But it also has a really low false-negative rate. So, if it shows that the baby is fine, the baby is definitely fine. So, then the question becomes: If it suggests that the baby is in trouble, what should you do if you can't actually figure it out? And, that is really a value judgment. And it depends on the patient's values and the doctor's experience. An experienced physician might be willing to wait and see what happens, reasoning that if things are going badly, they'll get worse; and they can intervene then. But, a lot of parents don't want to wait and see. They don't want to risk their baby's health or their baby's brain function. And they're--when they are told that the baby might be at risk, they say, 'You know what? I'd rather help[?] the baby. I'd rather have a baby who is completely intellectually intact.' And therefore, the number of c-sections has risen. Because, when you can't be sure, a lot of people feel it's better to over-treat, because the consequences of undertreating are so devastating.

20:48

Russ Roberts: So, your point, which I think is easily missed--you just sort of alluded to it briefly a few minutes ago, which I think is worth emphasizing, is that until, maybe, certainly it started at the beginning of the 20th century but certainly before the 20th century--childbirth was a terrible cause of death--of not just infant mortality of children that didn't survive or died before delivery, but of maternal mortality. And that transformation is one of the great achievements of human history.

Amy Tuteur: Absolutely.

Russ Roberts: It's just under-appreciated. Give us some feel for what the magnitudes used to be. Again, in semi-modern times. Not ancient times.

Amy Tuteur: Well, in terms of maternal mortality, which is still higher than we would like it, but much, much lower than it was: If maternal mortality were now at the same rate now that it was, say, in 1900, approximately 45,000 women would die each year in childbirth. And that's equivalent to the number of women who die each year of breast cancer. And we all recognize breast cancer as a terrible scourge. So--

Russ Roberts: How many women die now of, in maternal, in childbirth?

Amy Tuteur: In the United States, between 700 and 800 women a year. Which is more than we would like--

Russ Roberts: wish it were lower. Yeah.

Amy Tuteur: But that's a far cry from 45,000.

Russ Roberts: Now, I should just mention that: There's been a recent uptick--not small. The word, 'uptick,' is not the right word. A spike in maternal mortality in the United States. And, that, we could spend the whole rest of the time on that. Because it's complicated--to me, looking at it from the outside. It seems to me a change in how it's been measured--

Amy Tuteur: Absolutely--

Russ Roberts: and the way that states [nations?--Econlib Ed.] report maternal mortality. I don't think the United States has become more dangerous place for women to give birth. And one of the challenges of measuring maternal mortality is that a woman who dies 6 months after childbirth can be classified as an example of maternal mortality. Because of a coroner's decision and the way that was kept track as changed over time--

Amy Tuteur: Right--

Russ Roberts: So it's quite complicated. I just want to mention that for listeners. This is the kind of issue that we like to talk about here: how data can be, quite, a lot more complicated than it appears. The other issue is that, the United States has a very high rate of deliveries of women, 40 and 45 and older, which are more dangerous.

Amy Tuteur: Yeah. So, that seems to be less of an issue. It's certainly a problem. But, I think the important thing is to look at what women are dying of. So, the--the shape of the problem has changed dramatically. In 1900, women were dying primarily of hemorrhage. Of infection. And of pre-eclampsia. In 2019, women are dying primarily of cardio-vascular disease, including congenital heart disease. And, pre-existing chronic conditions, like kidney disease, diabetes, other things. And so, what you find is that women are dying of high-tech problems that require high-tech solutions. And, you think about how we lowered infant mortality: One of the things that we did is we developed a triage system: different levels of nurseries. We have Level 1, 2, and 3. And, we transfer babies to Level 3 Nurseries if they are very sick, because those nurseries have specialized care. And that's dramatically improved neo-natal mortality. We have nothing like that for mothers. And we should be putting together something like that for mothers. We should have more peri-natologists, more maternity ICUs [Intensive Care Units]. Because, those are the women who are dying. And they are dying from lack of technology. So, one of the things that I find very upsetting is that, although we can argue whether, um, childbirth has been medicalized too much, when it comes to the issue of maternal mortality, the women who are dying are dying because they lack access to that technology. And it's bizarre--and very unfortunate--to claim that we could reduce maternal mortality if we lowered the C-section rate. Or lowered the intervention rate. Because, those things have--are exactly the opposite of what is going on. And, that's a phenomenon that I have referred to, and others have referred to as 'Medical Colonialism,' in that we have been expropriating, or activists have been expropriating the tragedies of underserved women to advocate for what privileged women want. So, you find something like, New York State, promoting doulas, in response to the maternal mortality situation.

Russ Roberts: Explain what a doula is.

Amy Tuteur: A doula is--it comes from the Greek word for slave. And it's basically a woman who helps other women cope with childbirth. Who supports them through childbirth. Both by giving encouragement and also by, you know, cold washcloth for their brow, cheerleading when they are pushing. Things like that.

Russ Roberts: Counting, for their Lamaze breath.

Amy Tuteur: Right. Right. But the, the sad thing, the tragic thing, is that, while doulas are very good, and they can definitely improve the experience of childbirth, the women who are dying are not dying from bad experiences. They are dying from heart disease. They are dying from kidney disease. And, it seems perverse to offer these women who are suffering a amenity that privileged women would really enjoy.

Russ Roberts: Yeah. Um. Let's--I agree.

27:25

Russ Roberts: Let's move to the epidural issue. A lot of people believe--and I know you do not, so I want to hear your take--a lot of people believe that an epidural puts the baby at some risk. And therefore it's better to have a "natural childbirth." And that that pain relief is just unnecessary.

Amy Tuteur: Well, unnecessary for whom? You know, I happen to think, as a physician and as a human being, that treating pain is the cornerstone of what any person should do for any other person. If somebody wants to be in pain, that's okay. But, um, you know, all pain relief has risks. Why is this the only form of pain relief where anybody talks about the risks? And why is it that those risks are magnified? So, for example, the risk of--the risk of a baby being harmed by an epidural is purely theoretical. The risk of a baby being harmed by attempted vaginal birth after a Caesarian is both very real and orders of magnitude greater than any theoretical risk of epidurals. So, why are natural childbirth advocates promoting VBACs [Vaginal Birth After Cesareans], but demonizing epidurals? It doesn't make sense, if what they are really talking about is the risk.

Russ Roberts: A VBAC is a Vaginal Birth After a Cesarean.

Amy Tuteur: Correct.

Russ Roberts: So, what are your thoughts on the risk? You said it was theoretical? Or hypothetical?

Amy Tuteur: There's really no risk. I mean, you know, one of the things that I always find very interesting is that women obstetricians don't believe any of this stuff. Because it's nonsense. Women obstetricians have epidurals in droves. They have C-sections at much higher rate than average. They don't believe,and their experience tells them, that these things are not bad things. They are just choices. And, one of the reasons that they've been portrayed as bad things is, sadly, because of the reemergence of midwifery. Midwives can't give epidurals. Midwives can't do C-sections. And so they've demonized them. In the United Kingdom, where midwives can administer Nitrous Oxide--laughing gas--for pain relief in labor, they consider that perfectly compatible with a natural childbirth, even though that's a drug.

Russ Roberts: That's interesting.

30:09

Russ Roberts: Let's talk about breastfeeding, because that's another area where there's been a lot of emotional, cultural issues that interface with actual science to the best of our knowledge, which is, of course, imperfect. There's a lot of pressure on women, you suggest in your book, to breastfeed rather than to administer formula. Why is that a mistake?

Amy Tuteur: Well, I often say that the key thing to know about breastfeeding is that the moralization of breastfeeding parallels the monetization of breastfeeding. Sometimes it's an advantage to be old--like I am. I'm 60 years old. And I remember a time before formula--before breastfeeding was magical. When it was just a way that you could feed your baby. A good way, but it didn't have all these supposed benefits. And then came the profession of lactation consultants. Which are good things. They are very helpful to women who are trying to breastfeed. But, instead of concentrating on helping women who want to breastfeed to do so, they are constantly seeking to increase market share. They want every woman to breastfeed. And that's, honestly, none of their business, how another woman uses her body. If a woman wants to breastfeed--great. I mean, I breastfed my four children. I enjoyed it. They thrived. It was a great experience. But that doesn't me the ideal that other women should aspire to. Other women have different preferences, different life histories that may make them feel differently about breastfeeding. But we've crushed that under the notion that breastfeeding has such massive benefits that no good mother should avoid doing it. And, theoretically, it's possible that breastfeeding has all sorts of massive benefits. Certainly there were small studies that suggested it might. But we've already done the big study that shows that it doesn't have big benefits. You know, two entire, nearly entire generations of Americans were raised on formula. Nothing happened that was bad. And, if you look at, um, breastfeeding rates, they've gone up dramatically since the 1970s. In 1973 I think we bottomed out with a breastfeeding initiation rate of 24%. Now, over 80% of women are leaving the hospital claiming that they are going to exclusively breastfeed. And in that time, there's been absolutely no impact on the infant mortality of term babies, and no impact on major parameters of infant illness and hospitalization for term babies. The only proven benefit has been for premature babies who have immature digestive systems. So, at this point, honestly, we are just lying to women. In order to get them to breastfeed, we tell them it has benefits that it doesn't have.

Russ Roberts: And the benefits, we're told, are better immunity against disease, better nutrition, healthier--whatever.

Amy Tuteur: Right, but then you should be able to see it. It's not that it couldn't have those benefits. But if it did have those benefits then the breastfeeding rates should at least be related in some way to infant mortality and infant morbidity--which is sickness. And, look around the world: the countries with the highest breastfeeding rates have the highest infant mortality rates. And the countries with the lowest infant mortality rates have the lowest breastfeeding rates.

Russ Roberts: But as you would point out--and you do in the book--there are lots of other factors. And so, those kind of crude comparisons are not definitive. They are provocative--

Amy Tuteur: It's not that they are not definitive. It just shows that people have been deceiving women. Don't tell women--if you look at the Lancet papers on breastfeeding or the World Health Organization, they say 823,000 lives could be saved each year if more women breastfed. Well, in the first place, those are not in industrialized countries, so why that should matter to American women is an issue. And in the second place, it isn't even true. Because, babies don't die of lack of breastfeeding. They die of prematurity; they die of congenital anomalies; they die of dirty water. But, breastfeeding is not going to save that many lives. And it's wrong to keep insisting that it will.

Russ Roberts: Well, in the poorer countries that don't have access to clean water, breastfeeding--a crude switch, just simply nothing else changes but formula is used less and breastfeeding is used more--that could save lives because that water issue. But it wouldn't be the breastfeeding per se. It's that the water is the problem.

Amy Tuteur: Well, and not only that: It's all well and good to breastfeed your baby till two; and then the baby has to still drink the dirty water. And then the baby will die. So, if we really want to save lives in those countries, we should help them with water purification.

Russ Roberts: I agree with that.

36:05

Russ Roberts: You mentioned a study, and you talk about it in the book, of siblings. Obviously, as you point out, many studies that purported to show that the benefits of breastfeeding were flawed because the sample of people who chose to breastfeed in the past was not a perfect match--control--with the people who weren't breastfeeding--

Amy Tuteur: Correct--

Russ Roberts: Classic problem in economics and epidemiology and elsewhere. But, there was a study that was somewhat more controlled, which is of siblings. Can you talk about that?

Amy Tuteur: Yeah. The Colen study was published in 2014. And it was a very elegant study. And it looked at 10 years of data in New York State. And it looked at the difference between, within families, between children who were bottle fed and breast fed. And there was no difference. All the parameters that seemed to be different for, if you looked as a group, of all children who were breastfed compared to all children who were bottle fed, on 11 different measures, like asthma and IQ [Intelligence Quotient] and you name it--every single one of the advantages that supposedly accrued from breast feeding disappeared.

Russ Roberts: And not surprisingly, breast feeding advocates have suggested that study is flawed.

Amy Tuteur: Right. But, you know, I think that the important thing here--we can get into the weeds with the scientific evidence, but the important thing is: This is an issue of choice for women. This is not just about what is good for babies. And, the fact of the matter is that the benefits of breastfeeding are so trivial that you can't even measure them. I mean, we can't find them in any large population. And, if that's the case, why are we pressuring women to use their bodies in an approved way? Shouldn't it be up to women to weigh the risks and benefits? I mean, why do we have something like the Baby-friendly Hospital Initiative, which goes into hospitals and pressures women to breastfeed? That, to me, is completely unethical.

Russ Roberts: Well, you talk about the self-interest of lactation consultants--you mentioned a minute ago. The irony, of course, is the original claim, was that formula has been foisted on women by the profiteering of multinational corporations. And now, you are suggesting that that's being overwhelmed by the self-interest of licensed and trained lactation experts.

Amy Tuteur: Well, the fact of the matter is, formula was not foisted on people by formula companies. Formula companies met the need for--women were already not breastfeeding. They were feeding their children cow's milk and various other concoctions instead of breastfeeding. And those babies died at a massive rate. We found infant feeding bottles from ancient Egypt. There have always been women who can't or don't wish to breastfeed. Formula fills the need. Did formula companies do a terrible thing in Africa in the 1970s? Absolutely. They did. And formula companies should be demonized for that. But that doesn't mean we should demonize formula. And that doesn't mean that we should pressure women in 2019 to breastfeed to punish formula companies for what they did in 1970. Every woman should be able to make her own decision. You know, people--lactation consultants talk a lot about the benefits of breastfeeding. Well, what about the benefits of trusting mothers to do what they think is best for their babies? What about the benefits of not pressuring them? I don't understand why that doesn't end up on our radar somewhere.

Russ Roberts: Well, I just want to mention: At one point I think you talk about the claim that 'a single bottle of formula is harmful to a baby's health.' This just seems to go against common sense. It reminds me of--I may have mentioned this before, but I think it's a tragic story; I think it's informative of human nature. Adelle Davis, the nutrition advocate and expert, died of cancer. And when she got cancer, she attributed it to a bag of potato chips she had eaten as a child, or in her youth.

Amy Tuteur: Right. Right.

Russ Roberts: And, that just--I mean, that's human nature to find things that allow us to keep our narratives intact. But the idea that one bottle of formula is going to lead to a disaster--but that is the claim. Is that correct?

Amy Tuteur: Well, yes. And it's part of a larger effort. Lactation professionals are well aware that the benefits that they predicted for breastfeeding have not come to pass. So, now they are predicting ever-more arcane benefits. And the latest thing is that formula ruins the micro biome of the infant gut. And that formula somehow changes the genetics of babies--the epigenetics of babies. Those things are both unproven, but also they are acknowledgement that the other benefits that they've been touting all this time have not come to pass.

Russ Roberts: Yeah, and of course it's possible that, as you say, the rise in breastfeeding in the 1970s and 1980s and 1990s and into today will lead to children who will live much longer: 'All the problems of formula and breastfeeding are going to show up in old age.' It's conceivable. I think it's unlikely. And with you: I think you want to focus more on the infant morbidity and mortality. But, it's conceivable that these kind of benefits could be there. But, as you point out, finding evidence--there's no real reason to think it's the case.

Amy Tuteur: Right. And, in the meantime, we're just flattening women. We're just telling them, 'This is what you have to do, and if you don't do it, you're a bad mother.' And women are literally committing suicide over this, over these, essentially non-existent benefits. Because they are being pressured. And, you know, one of the things that I've come to wonder about, and animates all that I do now, is: Why do good mothers feel so badly about themselves? And the reason is because there is a whole bunch of people whose profession is to make them feel badly about themselves. You know, make them feel badly if they don't breastfeed. Make them feel bad if they had a C-section. Make them feel bad if they had an epidural. How on earth is this helpful to babies, let alone to mothers? I don't see it.

43:17

Russ Roberts: Well, there is another issue--it came up in our earlier episode with Emily Oster on how to deal with pregnancy and what's the evidence on the right behaviors during pregnancy. And I want to let listeners know: I expect to have Emily on in the next few months, on her new book, Cribsheet--good title--

Amy Tuteur: yeah--

Russ Roberts: which is what we know about the child-raising process, once the birth has happened. And one of the issues that came up with Emily before is that, there would be issues like, should women have a glass of wine while they are pregnant. Should they drink caffeine? One of the things that matters in the health of the baby is the mental wellbeing of the mother. And, driving perspective of moms, or moms after childbirth, is not the best thing. It comes with a cost. That's all I'll say. As an economist, it's--

Amy Tuteur: Well, it more than comes with a cost. It suggests that what's going on here is not what we see on the surface. I mean, most people don't realize that like natural childbirth, both breastfeeding and the attachment parenting movement, were started by people who were explicitly trying to force women back into the home. [?] began in the late 1950s and came out of a traditionalist Catholic mothers' group, where the women, in this suburb, were upset that some mothers of young children were going to work. And they reasoned that if they convinced women to breastfeed, they'd have to stay at home. And so, the history of lactivism has always been about getting women to stay home. And, over the years--what you told them had to change. Because our sensibilities had to change--

Russ Roberts: yeah--

Amy Tuteur: So, it used to be, well, breastfeeding is good. You should stay home and do it. Now it's: You better breastfeed, or your child will be mentally defective and [?] it may be penitentiary. But, again, it's an effort to manipulate women. And attachment parenting--which, in its most popular inception is, by Dr. Bob Sears--Bob Sears was the medical director--I mean, Bill Sears. Bob Sears is his son, the anti-vaccination person. Bill Sears was the Medical Director of LaLeche League. And he and his wife believed, and they wrote in their first book, which is something like The Christian Guide to Parenting and Childbirth--they said that attachment parenting was given to them by God. They prayed on it and they received it from God as the way that God wants the family to be ordered, with the husband as the head and wife solely occupied with caring for him and the children. And I don't think that you can really ignore that these things were created to control women, and that they still are attempting to control women. That's a bad thing, in my view.

Russ Roberts: Well, I want to come to attachment parenting next. But, before we do, it's important to mention for people who have never fathered or mothered a child, that not every woman can breastfeed. On a physical basis, to produce enough milk to sustain the health of the child--I think most people just assume that this just a question of convenience. If you are working, it's hard to breastfeed. You have to pump milk and store it, or bring your baby to work, or get home for lunch; or whatever. But this is not what we're talking about. It's relevant; but, what we're talking about is the fact that--

Amy Tuteur: Well, right. But the reason they assume that--they don't assume it. They were told that by the lactation profession. If you read official lactation literature, it says that the incidence of insufficient breast milk is rare. But it's not rare. It's common. Just like miscarriages are common, because pregnancy isn't perfect, insufficient breast milk is common because breastfeeding isn't perfect. And yet, there's no acknowledgement of that. And so that the women who were told that breastfeeding is natural and there's not going to be any problem so long as they were committed to it and loved their baby enough, when they find themselves with insufficient breast milk, they blame themselves. They consider themselves freaks. I mean, imagine if we told women, when they had a miscarriage, that it was their fault? There's enough grief that comes from having a miscarriage without blaming women for it. And, what we've done with breastfeeding, we've said that women who are having problems, it's their fault. It's lack of, insufficient--it's lack of devotion, and lack of concern, and laziness. And, honestly, I can't think of anything more cruel than that. Because, it's not true.

48:28

Russ Roberts: So, let's talk about that. And I agree with you. Let's talk about attachment parenting. And I want to mention that--I want to set this up with--just let you react to this. We had Sebastian Junger on late last year. And there were many interesting things that came out of his book, Tribe. But, one of the themes of that book is that it's cruel to make small children sleep in their own room, because we evolved, of course, probably, in situations where parents and children slept close to one another, because there was a lot of physical danger through most of human history. So, you wouldn't go put your kid out on a--15, 20, 30 yards away. You'd keep 'im close. Because otherwise they'd get eaten by a sabretooth tiger. So, his claim is that--and I found this very poignant, and I know you're a skeptic on some of this, so I want you to react to it--

Amy Tuteur: Oh, yes--

Russ Roberts: Hang on. So, I'm just going to finish this example, though, because it's juicy. His claim is that the attachment that children have for their teddy bear, their stuffed animal, is this desperate attempt by a small human being to find the source of comfort in a world where they've been shoved out of the family bed. So, the idea that kids should sleep in their own room because it's good for them, they'll get better sleep habits, he suggests is actually not true; and in particular he suggests that in most cultures in the world, the idea of making your kids sleep in their own room would be seen as a sign of cruelty. So, talk about attachment parenting generally; and then tell us why--

Amy Tuteur: Well, I want to address that, because I think it's nonsense. It's nonsense on a number of different levels. First of all, the idea that there was one universal culture in pre-history and that all people did the same thing, and parented the same way is just completely bizarre. And, you know, if there was anything I learned from practicing medicine, it was that people in different parts of the world--because when you practice medicine in a city like Boston where I am, you meet people from all over the world--that there are a zillion different ways to raise children. Just like there are a zillion different ways to conduct marriages, and whole bunch of different ways to relate to your parents--you know, your adult--when you are an adult to relate to your parents. There's all sorts of different ways. And, one is not better than the other. I saw people from other cultures parent their children in ways that I would never parent, who raised happy, healthy, well-adjusted people. And, it seemed to me that the key, in looking at all these different cultures, was that children need to be loved, and need to know that they are loved. And that, all the rest is just commentary.

Russ Roberts: Yeah--so, sending them off to their own room is like saying, 'I don't love you.'

Amy Tuteur: Well, that's ridiculous--

Russ Roberts: By the way: All my kids, most of my kids, slept in their own room. They did in the mornings, sometimes, crawl into bed with us. But we did put them in their own rooms. So, I'm just--just to get that on the record.

Amy Tuteur: Well, I mean--my husband and I had basically what you would call a family bed, because we let anybody crawl in who wanted to. That worked well for some children. For other children, they were disgusted that we took up too much room. And went back to their own beds. But, you know, that's another thing about this, that: Not only the idea that all ancient culture was homogeneous across the entire world and across 50,000 years of human pre-history. It's that all children need the same thing: That, you know, what's good for one child will be good for all children. And, one of the great things about having more than one child--and I don't know if you and your wife also felt this way--is that you learn that everything is not your fault. That, children are born with their own personalities, and their own needs; and that the challenge of parenting is meeting the need of the child in front of you. Not some theoretical child, and not some pre-historic child, but the actual child standing there who needs something specific from you. And that might be something very different from what his brother or sister needs from you.

Russ Roberts: So, you have four kids. We have four kids, also. All of ours, it turns out, are the same. Exactly the same personalities, needs. Actually, the only thing they have in common is that they don't listen to EconTalk with any regularity. So, I can actually talk about them as much as I want. But, our kids were--yeah. One of the blessings of having more than one child, and even more than two, is the variety of personality, [?] skills, gifts, shortcomings, challenges, handicaps. It's an incredible--and I think they all came from the same parents. I'm pretty sure. Not 100%; but of course, it can't be. But I'm pretty confident that they are still from the same urn of genes. But it just comes out differently.

Amy Tuteur: Right. And so, you know, this idea that there's some Ur-child that we're all parenting is ridiculous. And, I also encourage people to consider: Why is there natural mothering, but no natural fathering? Why aren't people saying, 'You know, what children really need is for their fathers to go out and hunt big animals with spears?' And--

Russ Roberts: Well, we've had some guests who hinted[?] that as being a healthy thing. I'm just going to leave that alone.

Amy Tuteur: Right. But, for example, you know, we--one of the things that we do nowadays is have fathers in the delivery room when children are born. No indigenous, or virtually no indigenous cultures have fathers involved in childbirth. They are--women are banished to some hut or room or something far away from the men so they won't contaminate the men with the blood. And, when they are healed, then they can come back. So, why is it that we're not seeking to re-emulate that and banish women to birthing huts, and yet we're supposed to be, you know, re-emulate the family bed?

Russ Roberts: I have to say--I think my favorite moment in your book is when you talk about the husband who is there in the delivery room to support his wife, and she's in terrible pain; and she demands and epidural; and the husband says--it reminds me of the scene in Young Frankenstein. This is two, a couple of episodes in the last few months with this, where Gene Wilder says, 'No matter what I do, no matter how hard I beg: Don't open that door.' Well, similarly, this couple had decided, in advance, when they had their faculties fully about them, that they would not get an epidural. And they--*ahem* the wrong pronoun--would have a natural childbirth. And then, when confronted with the actual experience--and I should mention my wife had four natural childbirths; very pleased with that--she is; it was her choice--but, many women choose not to. And this woman, in the throes of labor, decided she wanted an epidural. And her husband said, 'Well, honey, you know we just decided--when you were calm--that this was not a good idea. So, I'm just--we shouldn't do this.' And at some point, as this conversation continued--I think the quote is, the mother turned to the doctor and, speaking of the husband, said, 'Kill him.'

Amy Tuteur: Yes. Yes.

Russ Roberts: Which, a number of women have confessed to me that they have said things in the middle of labor that they regret. That might be one of them; might not be. I don't know. But the idea of the husband being there is different, yes. Not common.

Amy Tuteur: Well, and that kind of incident really encapsulates so much of what is wrong with these movements. I mean, where else in, you know, in higher breadth of human existence would somebody ask you to decide whether or not you needed pain medication before you experienced the pain? And yet, that's what we tell women to do. And, you know, you talk about your wife had four natural childbirths. Well, I had four children, two with epidurals, two without. And so I can speak to the difference. And the difference was, the pain.

Russ Roberts: Yeah.

Amy Tuteur: That was the difference.

Russ Roberts: That reminds me of when we would go to classes before our children were born, and they would teach Lamaze to my wife and I. And I, of course, was a participant, because I was going to be her coach and help her with her breathing. And, you know, I--she found a place during her births and deliveries to get through it. I don't know if Lamaze had anything to do with those at all. But I expressed skepticism beforehand, because I said, 'If you could really control pain by breathing, they'd teach it to soldiers.' Or other people. The fact that it's only taught for childbirth suggests that it probably doesn't work.

Amy Tuteur: Right. It doesn't work. It absolutely doesn't work. And, it's--frankly, I think it's encouraging women to torture themselves, and embracing them for doing it. I mean, if you need a fallback and you are afraid of an epidural--fine; don't have an epidural. But don't tell me that this is empowering women. Why is it that women are the only ones empowered by pain and not men?

58:50

Russ Roberts: One thing we didn't get to talk about, which I didn't want to miss--and I apologize to come back a little, circle back onto this--is that you suggest that this is not something I'm aware of--that there is a black market [i.e., an illicit market--Econlib Ed.]--in your book you mention this--that there is a black market in breast milk. Is this true?

Amy Tuteur: Oh, absolutely.

Russ Roberts: And how does that work?

Amy Tuteur: Well--

Russ Roberts: What's the price? Do you know? Do you have a feel on the street?

Amy Tuteur: Well, there's also exchanges of breast milk. I mean, what has happened is that we have made women so panicked that, if their children don't get breast milk, that they will somehow be harmed, that women are reaching out to other women--either people that they know online who will share breast milk with them, or a black market in breast milk. First of all, when you pay, it's incredibly expensive. There are milk banks--real milk banks--where the milk is pasteurized, in which, I think it's like $8 an ounce or more. I mean, it's extraordinarily expensive. But when you, when there's an exchange over the Internet--you know, disease can be passed in breast milk. HIV [Human Immunodeficiency Virus] can be passed--the virus that causes AIDS [Acquired Immune Deficiency Syndrome]--is passed in breast milk. And, also, when people have looked--they've done some studies about, they've bought breast milk off the Internet--most of it is not breast milk. A lot of it is adulterated cow's milk.

Russ Roberts: Is it illegal? Is it illegal to sell your breast milk?

Amy Tuteur: You know what? I don't know. I don't know. But I do think that it shows you where we are as a culture, where women are willing to spend a fortune to buy the bodily fluids of other women for fear that their children are being deprived of something. That's--you know, that, I think, tells us more about where we are on the issue of breastfeeding than anything else. Because, the fact is, breastfeeding is not a health issue. It's a lifestyle choice. I mean, I breastfed. My kids enjoyed it. I enjoyed it. I had no trouble doing it. But that doesn't change the fact that the health benefits are trivial. And we should stop torturing women by implying that if their children don't get breast milk, that they are ruined for life. 'You,' what I say to women when I talk to them is, 'You will ruin your children. And your children will tell you that you have ruined them. But it will not have anything to do with birth or breastfeeding or anything like that.' All the things that you are encouraged to worry about are entirely irrelevant.


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