Yesterday I wrote about the new ACOG recommendations for postpartum care and the fact that they are cheap, low tech window dressing for expensive, high tech problems. The most obvious example is the recommendation to screen for postpartum depression.
Screening for postpartum depression is literally the first mandate in the long list of recommendations.
Screen for postpartum depression and anxiety with a validated instrument.
Postpartum depression and anxiety are serious, and in some cases life threatening, mental health conditions. Screening for it is easy and cheap. But what’s the point of screening for it if the majority of women who have it can’t access treatment because it is expensive and not covered by most insurance?
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The stark reality is that mental health care after pregnancy is available only to the privileged: well off and well insured.[/pullquote]
Just last month California radio station WQED asked: To Screen or Not to Screen? Doctors Debate Post Partum Depression Testing.
Lawmakers will begin debate next month on a bill that would require doctors to screen new moms for mental health problems – once while they’re pregnant and again, after giving birth.
But a lot of doctors don’t like the idea. Many obstetricians and pediatricians are afraid to screen new moms for depression and anxiety.
“What are you going to do with those people who screen positive?” said Laura Sirott, an OB/GYN who practices in Pasadena. “Some providers have nowhere to send them.”
It’s a serious problem:
Of women who screen positive for postpartum depression, 78 percent don’t get mental health treatment, according to a 2015 study review published in the journal Obstetrics & Gynecology.
There are three primary reasons why women don’t get treatment for postpartum depression.
1. They can’t access it because there is no provider in their area trained in reproductive psychiatry, the mental health care of pregnant and breastfeeding women.
2. They can’t access it because insurance doesn’t cover it and out of pocket costs are exhorbitant.
3. They can’t access it because they can’t get the childcare, transportation and/or time off from work to see a mental health professional.
The stark reality is that mental health care after pregnancy is available only to the privileged: well off and well insured. Mandating postpartum depression and anxiety screening will likely help them and no one else, further exacerbating the gulf in health outcomes between the privileged and the less privileged. The new ACOG recommendations ignores this reality.
ACOG also ignores ways that we could prevent or mitigate postpartum depression. The most important of these would be to back off on aggressive breastfeeding promotion.
As I noted yesterday, the lead author of the new recommendations made this odious comment:
The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”
She was slandering obstetricians but the reality is that lactation professionals, of which Dr. Stuebe is one, are the guilty parties. They treat babies like kings and mothers like cows.
Despite the fact that the benefits of breastfeeding for term babies in industrialized countries are trivial (limited to 8% fewer colds and 8% fewer episodes of diarrheal illness across all infants in their first year), lactation professionals evince complete disregard for maternal well being.
Maternal autonomy is ignored in the effort to pressure every woman to breastfeed regardless of her own health, needs and priorities. Maternal exhaustion is not merely ignored, it is promoted by closing well baby nurseries, recommending the barbaric practice of triple feeding (nursing, pumping and supplementing) and insisting, despite scientific evidence to the contrary, that anything that makes life easier for new mothers — i.e. formula, pacifiers — must not be allowed.
Worst of all, women’s mental health is viewed as irrelevant. Lactation professionals are much more concerned with whether treatments for postpartum depression are compatible with breastfeeding than with whether they are the best possible treatment for the mother’s psychological condition. Women are encouraged to continue dispensing breastmilk even when they are inexorably approaching complete psychological collapse.
Postpartum depression and anxiety are very serious problems and they require very serious — and expensive — treatment. ACOG can congratulate themselves on recommending screening but until they tackle the problems of prevention and access to treatment, it’s nothing more than window dressing.
One of the bigger issues I see is a lack of consensus on whose role it is to treat ppd and ppa. For many uncomplicated cases, six months on an SSRI is effective treatment. Ideally, this would be in conjunction with talk therapy, but that’s often not happening for the reasons you stated. Most OB-GYNs should be able to manage the medication side, again, absent of any major conplications. Seems barriers to more OBs taking on care is how it gets billed to insurance (does it fall under postpartum?) and a general reluctance of providers to take responsibility to treat it being that mental health is not a large part of their medical training. Perhaps it should be, at least pertaining to perinatal mood disorders.
I live in Washington, DC, where virtually no psychiatrists or therapists work with insurance. The reimbursements for out-of-network are trivial. I am spending a fortune treating my PPD/PPA.
As I mentioned a few weeks ago, when a hospital staff can delay the hard stuff that can actually bring a skyhigh blood pressure down because breastfeeding, the “not quite real since it won’t kill you” attitude to a thing like PPD doesn’t surprise me at all.
Last week, I was left to wonder just how much well-meaning but truly self-absorbed right now people can influence a new mother. Again, it was about my friend with the 30 weeker. Her SIL had had her first baby a month earlier and was constanly complaining how hard it was, how the baby was playing tricks on her by crying for 20 minutes and only calming down if held, how terrible it was that she had to have a c-section before the due date… Really, lady? You’re whining about it to a woman whose baby cries alone in her box in the NICU and she can’t hold her? Who had a c-section not two weeks before the due date but at 30 weeks? I know everyone is the most important in their own eyes but really! Anyone wondering when she needed to be away from home, my friend came to my door and not theirs? And mind you, as far as I can say, she doesn’t have a depression, at least not yet. When well-meaning relatives lecture her about the benefits of breastfeeding, she knows it’s rubbish. As she says, are they a bloody sept or something? But it’s discouraging anyway. I can easily see how this would make a PPD even worse – and that’s without even starting with the medical pressure.
BTW, looks like there’s going to be no breastfeeding for her. When they tried to wean her off ONE of the heavy drugs, the BP went back to new heights. Not compatible. But she says that when she told the sect that she was pumping and dumping just in case it could work and she was doing it for herself because she wanted to try at least this after giving birth so soon and in fear, she got rewarded with a new lecture and horror of how she demeaned breastfeeding. WTF?
Demeaned breastfeeding? By keeping the option open? WTF are these people on? I hope her BP settles again and her idiot relatives STFU.
I actually know one of the family sect. She’s a very kind woman but big into all things natural and never saying “no” to her kid in a way he can construct it as an actual prohibition because positive upbringing and all this. She also took great pains to build a supply so I think it’s a matter of affirming the brilliance of her own choice – if she put forth so much effort, it must have been worth it and if it was worth it, surely it would be worth it for this baby as well? People are so deep into the liquid gold thing that the idea of a mother deciding to give it a try but for herself and not because she thinks it’s going to make baby immune to all the nasty stuff sounds like blasphemy.
I have to say, in my experience with one of the country’s largest nonprofit healthcare providers, the OB-GYNs and labor and delivery nurses acted like moms Must Breastfeed at All Costs, while the pediatricians embraced formula use because they just wanted to see baby grow. The OB-GYN side aggressively propagandized triple feeding, while the pediatric staff thought that was nuts. The pediatric staff also screened me for PPD at each well baby visit, and they were the ones that caught it. In my experience, natural parenting has absolutely infiltrated women’s health to the point that women are no longer the priority. I would love to find an OB that didn’t see me as a “wrapper” after I got pregnant.
That would be the point of the “fourth trimester” – just as post-operative care is as important as pre-operative and operative.
OBGYN (known as O&G in Aus and UK) is about womens’ health, not just extraction of babies.
Our pediatrician with our first, who I loved, always made it a point to tell me that I was doing awesome and my baby was lucky to have me at every visit. It meant the world to me when I was in the haze of being a new mom and worrying that I was messing everything up. He also said “you make the baby fit into your life, you don’t change your life to fit the baby”. He encouraged us to take the baby swimming early because it was a great way to bond and when I asked about supplementing from birth he said it was totally reasonable. I love that man
My daughter is 4 and the only meat she will eat is hotdogs. The pediatrician said that’s fine, hotdogs are a perfectly acceptable meat source for a 4 year old and eventually she will expand her food selection. I love her so much for saying that!
Pick your battles.
You could try to insist that your 4 yo eat kale and fresh caught seafood, and let them go hungry. Or you could feed them food they will eat and try to introduce variety when you can.
I live in hope that my boyo will eat kale again when he’s older. He didn’t mind it until he turned 3
I’m pretty old and have never cared for kale.
Adolescent growth spurt hunger cured my kids of fussy eating. I think they just got bored with eating huge quantities of the same thing. They both now-as adults-prepare and consume a wide range of foods and don’t seem to be delayed or stunted by their earlier fussiness.
My only suggestion is don’t have things in the house you don’t want them to eat-when they are fussy/low appetite they fill up fast, you want the food they eat to count as much as possible.
Lots of people don’t like kale or broccoli, but Dem and I like both and both kids liked it into their early toddler years. Tastes change of course, but it would be nice to have my favorite green veggies eaten by the younger generation.
They’ll be back for it-time is on your side! Keep making, eating and enjoying it, and sooner or later they will come.
LOL! I am glad to know that because my 18 month old has an obsession with processed meats. 🙂
OT – My sister-in-law is being induced tomorrow at 40 weeks. Baby predicted to be 10lb plus. We’re in the UK. Any advice, please? How long they should expect everything to take, process, warning signs, etc. I won’t be there so I’m concerned with managing my parents’ anxiety as much as anything else – they lost their first and never got over it, so I want to be able to be cool, calm and collected when my mother (understandly) starts panicking, but also well-informed in case my SIL and brother need advice.
This is the guidance American OBs get
http://opqic.org/acog-practice-bulletin-173-fetal-macrosomia/
The high estimate by itself doesn’t warrant much difference in care. If she’s being induced, something else might be in play too.
Thank you! I’m not aware of any other factors influencing the recommendation to induce, but that doesn’t mean that there isn’t something I don’t know about (am getting most of my info through little bro who tends to garble stuff). Daft question, but what counts as a “prolonged” second stage, or is it a case-by-case thing?
Here’s another ACOG quote
https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery
So if your SIL is a first timer, 3 hours is the point where people should start to at least consider throwing in the towel on a no-instrument vaginal birth. And I would think at that point if the midwives refused to consider changing tactics, that’s the time to start making noise about getting an OB in there.
Thank you! Baby born by c-section in the end. I don’t know the details but they are apparently both well – baby looks lovely, pink and contented in the first photos.
FWIW (I’m in the U.S.) – I was induced at 41 weeks. Went in 8pm Monday night to get induction started. Cervadil that night to get cervix ready. Pitocin started at 6:30am Tuesday. Epidural around 1:30pm. Started pushing about 7:30pm. 9pm decision made that baby wasn’t making progress and heart rate was dipping during pushing (not emergency level, they were willing to let me try pushing for another hour) so we decided it was time to go to a C-section. Baby was at an angle and wouldn’t have made it out on her own, so the extra hour of pushing wouldn’t have mattered. Baby born 11:03pm Tuesday night.
Everyone is different though. There was another lady that got induced at the same time as me and she had her baby Tuesday afternoon, probably a good 8 hours before me.
And honestly if you’ve been reading this blog for any length of time, you are probably already pretty well-informed to give logical advice.
Thank you! Ended in a c-section this morning. Mum and baby both doing great.
Congratulations! Best wishes for a quick recovery for your SIL. How much did baby weigh?
Thank you! He was actually a whisker under 10 lb, but massive head and shoulders. 🙂
Congrats! Glad to hear everyone is doing well.
Well, as someone who had ppd twice I disagree. Yes I’m privileged to afford treatment/have good insurance.
But:
1. I think just knowing that there is an explanation for what you are feeling is helpful and a weight off. I think having a medical explanation but no treatment is better than not realizing you have a medical condition and feeling like you are crazy, a horrible person, etc. Reading books/belonging to message boards would be better than nothing. And for me meds were the answer. Talking to a therapist didn’t do much and I didn’t even bother the 2nd time. OB prescribed meds and I was good. Doesn’t Medicare cover antidepressants? So maybe treatment isn’t completely inaccessible for all low income women.
2. BF pressure is obviously not the sole/main cause of PPD. Cause is mainly unknown, correct? So changing this is not going to prevent all or even most PPD. That doesn’t mean it doesn’t need changing, but it’s not going to eliminate the need for ppd screening.
I don’t think Dr. T is saying that removing breastfeeding pressure negates the need for screening, just that it might be a more practical step for reducing PPD?
You’re absolutely right that breastfeeding pressure isn’t a universal factor in PPD; it wasn’t an issue with mine (although the general culture of attachment parenting came into it). Anecdotally, though, I have seen many women at my postpartum support group really struggling with feelings of “failure” around breastfeeding.
Between Kid 2 and Kid 3, I switched the kids to a new pediatrician practice. The former one was wonderful, but it was about an hour’s drive away, and hauling a 4-year-old, a near-2-year-old, and a newborn an hour each way for all those newborn appointments ranked…low…on my List Of Things I Wanted To Experience.
At Kid 3’s first appointment, they handed me a PPD screen as part of their standard newborn visit. I made politely approving noises while explaining that yes, I had it, yes, my OB was aware, and yes, I was being treated. The nurse said they’d instituted in a few years before because the doctors in the practice figured, correctly, that most new moms see the pediatrician more often than their OB in those first couple of months, and that way they could provide moms with resource info for treatment.
I wish more OB offices were more on top of screening, and also wish that good treatment was easier for, well, EVERYONE to come by, but kudos to the pediatricians who decided to at least screen and then provide info on local resources.
Yes! My Pediatrician’s office does this and my pediatrician has been really good about checking in with me at each appointment about how I’m feeling.
My baby’s pediatrician asks me each time if I have “any mommy depression”. The wording strikes me as weird but that might just be me.
That really makes me cringe. “Mummy depression” sounds really condescending as though it’s not legitimate depression. What is wrong with asking proper screening questions like: “How is your mood?”; “Do you struggle to find happiness in things that would usually bring you joy?”; “Do you feel helpless?”; “Do you feel worthless?”. Asking if a woman has any “mummy depression” is not only condescending, it’s virtually worthless as a screening question.
My pediatrician uses the Edinburg screening at each visit. I was also contacted twice by my insurance company’s maternity nurse (who had checked in with me during pregnancy) and screened twice post partum by my OB. I feel a bit over screened, TBH, but as someone with a history of anxiety I am glad I have people checking in. I also have fantastic insurance, and STILL had to pay out of pocket for some mental health care I sought during pregnancy. I knew that I have a lot of risk factors for PPD/PPA and consider it money well spent, but I know many people are not in that position. Time though is a universal challenge—I am on maternity leave and have not been seeing my mental health provider (I had planned at least a few check in appointments, even though I am feeling pretty good) because between baby, PT, and one or two much needed social activities I just cannot handle bringing my baby (who hates the car) out every week.
I’m lucky that my spouse works for the feds and was able to buy a fairly good insurance. We both need to see people in the psych department.
So about 3 years after I was married, we were planning on getting pregnant and under the advice of my OB/GYN and PCP I swapped antidepressant in hopes of using one that had more data on pregnancy and lactation.
The important thing we learned from that attempt was that antidepressant makes me agitated and paranoid. Before I had even reached a full therapeutic dose, I called my PCP and she switched me back to my current drug.
A few years pass and we were ready to try. This time, my PCP and OB/GYN both agreed that my current drug had no known concerns for pregnancy or breastfeeding so I should stay on it.
I share this story because most patients in the US with mental health issues are cared for successfully by a PCP and OB/GYN during pregnancy and lactation. I think reproductive psychiatrists could be very helpful for women with complicated mental illnesses – but for most of us, our PCP and OB/GYNs sees lots of people with common mental illness.
The biggest help for me was the fact that my PCP (who is also my son’s doctor) was totally onboard with me stopping pumping when Spawn came home from the NICU. She said pointblank that breastmilk had been important when he was a tiny micropreemie – but he would do great on formula now that he was a big, healthy boy.
When I had PPA (basically that low level anxiety is my natural brain, exacerbated by sleep deprivation as this happened before the hormonal stuff was supposed to kick in) low dose zoloft helped take the edge off enough. I wish though that someone had told me then about the magic of a 5 hour unbroken stretch of sleep and that nightime formula would be my friend.
Preach!
I’m not suggesting that family physicians can handle any and all postpartum depression and anxiety cases but could they not be an important resource to help with a lot of them? At least in our practice, we do postpartum depression screens as part of our well child checks. (I know this has its limitations, e.g. a different caregiver besides mom may bring the child, the child may not be brought at all for care, etc.) We also do OB in our clinic and do them at the postpartum visit. Is it really necessary for all moms with postpartum mood disorders to see a specialist? I manage PPD and PPA all the time and I have more flexibility to see them more often than a psychiatrist would. I also often have the benefit of having the whole family as patients which allows me insight into family and social issues that another provider might not have. Obviously if a case is beyond my capabilities, I would refer them. I don’t suggest that this would fix all the barriers listed above but I think FP’s have a role to play in this.
I’m planning to do FM obstetrics (starting my family medicine residency in July) and I know that PPD and PPA management is one of the expected competencies for a family physician. My residency program has a robust psychiatry component and so I know I’m going to get the training I need to manage mild to moderate postpartum mood disorders, and where I am training there’s a specialized clinic for more complex cases. But then I am in Canada and access to this care isn’t as limited as it would be in for-profit systems.
It seems like there’s a very wide variability of how much family physicians will do with regards to psychiatric or postpartum concerns. In the US it seems like people see specialists for a lot of stuff that here in Canada would be routinely managed at the family physician level.
I teach at a rural family medicine residency and we do a lot of our own management for a wide variety of things. It’s not that we don’t have access to specialists, but the wait times to get in are often quite long so by the time I’m referring someone, it’s because I’ve really exhausted a lot of treatment options or workup. For our patients to get to a subspecialist, they’d have to drive a couple of hours and for many, that’s just not practical. We try to do as much for our patients as we safely can. Where I went to medical school was much closer to a large city and the FPs there did a lot of referring. In the US, how much family docs do on their own is often a reflection of their training and their location. Good luck and good for you for choosing primary care! We’ve had quite a few Canadian residents in our program in the past few years. It’s nice to hear how things differ to the north.
Hear, hear!
My OB gives all of her patients the Edinburgh questionnaire at their six-week postpartum visit. I had postpartum depression with my first kid. She said something along the lines of wow, your score is really high (no surprise there), gave me a prescription for Zoloft, reminded me about the hospital’s postpartum support group, and recommended I get therapy.
Which all sounds great, except…
(1) Our local hospital’s support group only met during the weekday, which was inaccessible to me. I ended up driving 40 minutes across town to another hospital that had an evening group.
(2) Zoloft may be the go-to breastfeeding-friendly antidepressant, but I knew from previous experience that it causes odd side effects in me. The typical wait to see a psychiatrist in my city is nine months(!!). I got lucky, though, and the nurse who ran the support group was able to make some calls and get me in right away with someone who worked with me to find medication that worked.
(3) When you’re in the midst of a mental heath crisis, being turned loose to “get therapy” is basically useless. Who has the time and energy to seek out therapists, call people, find out if they take insurance, etc.? That’s assuming there’s even anyone in your area with a background in perinatal issues. I never did get therapy for my PPD.
I had reasonable insurance, a budget for co-pays, and a fair bit of experience navigating mental health care issues. There were still a ton of barriers. (And don’t even get me started on prenatal mental health…)
One thing I think OBs could do right now is cultivate relationships with local psychiatrists and therapists. At least have a list of names for your patients to call.
My OB office has a therapist who is in their office. She is not a part of their practice but rents a room in the office and is specifically a therapist for postpartum and family issues. I ended up using her and she was great. My doctor even told me that the doctors use her when they struggle and it helped me feel like I was not weak because I needed a therapist.
My ob’s junior partner had/has ppd. Her child is 2 now.
My family physician has a therapist on staff now. They can see you for regular appointments or refer you out for care. It’s been great. Now if only the OB office would do the same.
I was given the Edinburgh questionnaire at a 1 week postpartum appointment after a full term stillbirth. Screening is good, but that questionnaire was completely and totally inappropriate in my case. I politely gave the questionnaire back to the nurse and told her I was not going to fill it out, and asking me to fill it out was thoughtless. Apparently she didn’t understand why I wouldn’t want fill out a questionnaire that starts with “I have been able to laugh and see the funny side of things…” Two minutes later my ob and a midwife were both in the room trying to evaluate my mental status and making me fear they were going to put me on a 72 hour hold. When I reassured them I was fine they did not seem convinced. At that point I insisted they read the first two questions out loud. I asked if they thought it would be appropriate to ask any parent who just buried a child a few days ago these questions. At that point everyone slipped back into we don’t want to think about your loss mode and shoved me out the door. It was a completely waste of my time and money as none of my medical questions ever got addresses.
Oh my goodness, I am so sorry for your loss and so sorry you had to deal with medical providers not listening to you as an individual.
The mental health care system in the US is a disaster. Another issue that simply screening won’t help is that even people who do have access don’t often tell the truth because there are a handful of incidents, including one high profile case, where the doctor the person reached out for help in appropriately called CPS. Now there is an appropriate time to call CPS. I have done it myself more than once, but simply having a mental illness should never be a reason to call, and yet parents everywhere are terrified of exactly that.
Exactly. We tell women to reach out, and when they do we scream for the cops. This is a rational fear, and it prevents new mothers from getting help.
This is especially true because symptoms of postpartum OCD can seem very alarming if you don’t know what to look for. Women with PPOCD will often have what are known as “intrusive thoughts” of harming their children. The thoughts can be very detailed and vivid. So uninformed providers may think the women have postpartum psychosis with infanticidal thoughts when in reality women with PPOCD are not at danger of acting on their thoughts. And PPOCD is actually pretty common.
Luckily my health system now has an immediate visit option for peripartum women. Like if I call, the patient is seen within a couple of hours. It is great! And my city has an excellent Mother-Baby inpatient psychiatric program.
Intrusive thoughts can happen in all the anxiety disorders, so they’re actually fairly common. The interesting thing is that in my observation just giving these thoughts a name helps people cope with them. We have people in my group say things like “I’m having these terrible thoughts and I don’t understand. My rational mind knows I’m being ridiculous, but I can’t help it”. And then we say that what they’re describing sounds like intrusive thoughts, and that they’re a common symptom on anxiety disorders, and that they should tell their doctor or therapist about the thoughts, because there are ways of treating anxiety disorders and that they don’t have to life with those thoughts. And then they come back and say something like “This is really a real thing? It’s not just me? There’s a way to treat this? I’m so relieved.” I think it’s also easier to tell a doctor “I’m having awful intrusive thoughts”, then having to describe the thoughts themselves, and that actually makes the threat of CPS involvement less worrisome for many.
I agree, people do get a ton of relief just from a correct diagnosis. Mothers of infants, in particular, are so relieved that their thoughts are not some ominous sign that they are about to go crazy and kill their babies. Knowing what the thoughts are is half the battle- like literally it reduces their misery by half just that.
This is why I don’t like the Edinburgh Postnatal Scale. It seldom seems to serve as a productive path to finding out what matters. I give it to all postpartum women, because it’s required in my system. I don’t even give it, the woman gets it automatically at check-in. But it never gives me half as much information as making meaningful eye contact, asking “Well [pause] has it all gone like you expected it would?”, and then shutting my mouth and listening.
ETA: although obviously if the doc is not going to ask at all, the Edinburgh is better than nothing.
Wow! You are the first person to give me an explanation and a name for something that really bothered me when my first was born. I had horrible instrutive thoughts and no one ever told me this was a sign of anxiety. It’s been 7 years now and we are all doing fine. I got my anxiety under control and even managed to get off my meds without any problem. But no one, not once, told me the name for what was happening.
Thank you!
I used to have the same. It’s horrible. Mine have receded, glad yours is also no longer a burden to you.
Exactly. I was screened with my first child, and I most definitely had antenatal depression, but lied on the questionnaire because I was afraid of the stigma and repercussions. I ended up medicated 3 months after baby was born, but in hindsight I was struggling long before he was born.
I was terrified to go to the doctor and be completely honest since my PPD made me so angry that I was on the edge of not having control. I was never physically angry with my kids or husband but I was still afraid that they would get CPS involved. Thankfully, they listened, empathized, and gave me medication with a two week check up and a phone number should I need anything from them. It made a huge difference that they didn’t treat me as crazy or under qualified to take care of my kids but with great empathy and resources.
I am currently reading Otis Brawley’s “How we do harm”. He talks a lot about how we have to balance the benefit with the potential downsides of every intervention and treatment including screenings, guidelines, and recommendations from medical organizations.
If you haven’t read it, I can’t recommend it enough. He says ‘You can actually harm people by using science that appears to make sense, as opposed to science that has been proven correct in a clinical trial”. All I could think when I read this was how applicable it is to breastfeeding promotion. It doesn’t matter that breastfeeding is “natural” it is wrong for us to assume that natural is automatically better. We should be VERY skeptical of breastfeeding recommendations (i.e. EBF for 6 months, no pacifiers, etc) have not been shown in a clinical trial to provide more benefit than harm.
He also says that when someone says guidelines are “evidence based” we should ask “says who?”. I never thought about it but, unless I missed something, the organization that wrote the BFHI guidelines is the same organization that charges hospitals 5 figure fees to get and maintain certification.
Sorry for the ramblings, again, I highly recommend his book.