Friday, January 04, 2008

What's the difference between "natural" and "normal"?

One of the overarching themes of homebirth advocacy is that if it occurs naturally, it must be normal. Still pregnant at 43 weeks? That happens naturally, so the baby must "know" when to be born. Labor stalled at 7 cm for 5 hours? No problem, just keep waiting for labor to naturally pick up. If you visit homebirth advocacy "support" sites, you come away with the impression that virtually any deviation that occurs naturally is just a variation of normal. You can ignore your due date, your blood pressure, your glucose tolerance, whether or not you are colonized with group B strep, virtually that occurs naturally during pregnancy.

Obviously, though, homebirth advocates do not really believe that everything that is natural is normal. Many babies are naturally born prematurely, some very prematurely, and that clearly is not normal. So how do homebirth advocates determine whether something that occurs naturally is actually normal?

A simple response might be to claim that anything that happens fairly frequently is normal. By that definition, though, miscarriage is normal. Miscarriage is probably the most common deviation from average pregnancy, occuring in at least 20% of pregnancies. Almost every woman will have a miscarriage during her reproductive life. I doubt that homebirth advocates would claim that miscarriage is "normal" despite its relatively common occurrence.

Death in childbirth, while much less frequent, is still relatively common in nature. More than 1% of all births in nature result in the death of the baby, the mother or both. Death, like miscarriage, is clearly a natural result of human reproduction, but homebirth advocates would not consider that normal, either.

Since frequency of natural events does not make them normal, it must have something to do with outcome. A miscarriage is a pregnancy that ends without a baby, and the baby is the objective of human reproduction. Death of the mother or the baby obviously means that the pregnancy has ended without a baby or without a mother to care for that baby. That can't be normal, either. So anything that kills the baby or the mother cannot be normal.

But wait! That can't be right, because homebirth advocates are willing to tolerate high levels of risk of death. Postdates pregnancies increase the risk of death of the baby, yet homebirth advocates claim that going weeks beyond the due date is normal. Ruptured membranes for longer than 24 hours increases the risk of infection and increases the risk of death for the baby, yet homebirth advocates routinely counsel each other to wait until labor starts naturally. Indeed, homebirth advocates are often contemptuous of obstetricians' fear of neonatal death and their consequent willingness to "intervene" in the natural process in order to prevent deaths.

By the same token, homebirth advocates are absurdly intolerant of harmless or relatively harmless deviations from "natural". Bottlefeed your baby, which has never killed anyone, and you are treated as a virtual child abuser; expose your baby to a dramatically increased risk of death by refusing "unnatural" GBS prophylaxis and you are a "mama" who is glorified by other homebirth advocates. Have an "unnatural" epidural in labor, which has a neonatal mortality rate of zero and a maternal mortality rate less than the chance of death from a lightening strike, and you have put the entire mother-child bond at risk; refuse C-section and end up with a brain damaged baby and you are supported as a "mama" who trusted her body.

Homebirth advocates have no rational distinction between "natural" and "normal". They just make it up as they go along, simply to justify their personal preferences. Any deviation from average pregnancy is "normal" if they think it is acceptable (usually because they don't understand the risk) or if they don't want the intervention (testing, induction, C-section) that goes along with an acknowledgement that the deviation is abnormal. Any "intervention" in the natural process of labor is not normal if homebirth advocates don't approve of it. So an epidural in labor is not normal, but sticking factory produced metal needles into your body (acupuncture) is somehow "natural" and giving birth to a baby in a plastic kiddie pool is "natural", too.

While most empirical claims of homebirth advocacy are false, many philosophical claims are purely arbitrary. The designation "normal" has nothing to do with how often a childbirth deviation from average occurs or whether the deviation can lead to death; it is simply an expression of approval. The only basis for determining whether a natural deviation is called "normal" is the personal preferences of homebirth advocates.

This arbitrary designation does important psychological work; by definition homebirth advocates' preferences represent the standard for "normal" and everyone else's preferences can be disregarded as "abnormal". Since homebirth advocates choices are "normal" and those of anyone who disagrees are "abnormal", they can congratulate themselves for being superior mothers. That's the beauty of homebirth advocacy; you don't have to worry whether or not you are a good mother, you can be sure you are. Just define everything that you do as "normal" and you're all set.


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