ACOG was wrong about episiotomies, wrong about hormone replacement therapy and now it’s wrong about breastfeeding

Cutting the branch your sitting on

I was very fortunate in my OB-GYN training. I did my internship and residency at Boston’s Beth Israel Hospital, a Harvard hospital. I prize that training, but over the past 35 years I’ve discovered that some of things I was taught were wrong. Three of the principles of obstetrics and gynecology that were accepted as conventional wisdom when I was trained were actually untrue.

In the 1990’s we finally recognized we were wrong about episiotomies; they were not beneficial but actually harmful. In the 2000’s we finally recognized we were wrong about hormone replacement therapy (HRT); it was not beneficial but actually harmful. In both cases, it took years to change clinical practice but eventually the scientific evidence forced us to back away from defending the status quo.

 How many babies have to be injured, starved or allowed to die before ACOG admits they’re wrong about breastfeeding.

In 2018 we have copious data that we have been wrong about breastfeeding; sadly, just as in the case of episiotomies and HRT, ACOG (the American College of Obstetricians and Gynecologists) is resisting the acknowledgement that what we thought was an unalloyed good doesn’t have the benefits we’ve claimed and can actually be harmful in some cases.

In a recent newsletter, ACOG published a remarkably fact free attack on the Fed Is Best Foundation:

In May 2017, an organization called the “Fed is Best” (FIB) Foundation issued an open letter to obstetric care providers that outlines concerns about the safety of exclusive breastfeeding, and has caused some expectant mothers to question breastfeeding as the optimal feeding method for the health of the mother and baby. Although FIB describes itself as a non-profit volunteer organization and appears to cite peer-reviewed literature, many of the assertions that FIB makes misrepresent the findings of referenced studies…

ACOG believes that parents must have accurate, current, evidence-based information on which to base their infant feeding decisions, not on sensationalized headlines. FIB’s inflammatory anecdotes and misleading portrayal of evidence threatens to undermine and confuse mothers about well-established knowledge and breast-feeding protocols.

Inflammatory anecdotes, ACOG?

You mean the seizure and subsequent death of Jillian Johnson’s baby from dehydration only 12 hours after she was reassured by hospital personnel that her son was getting enough breastmilk and discharged home?

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You mean the appalling before and after photos of Mandy Dukovan’s baby, emaciated on breastmilk but thriving on formula?

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Fed Is Best misrepresents the findings of referenced studies?

Care to explain how the findings of these papers were misrepresented?

Taken together, these papers demonstrate that insufficient breastmilk is common (up to 15% of first time mothers), formula supplementation makes successful breastfeeding more likely, pacifiers prevent SIDS, extended skin to skin contact lead to babies falling from their mothers’ hospital beds or suffocating while in them, and the latest results from the PROBIT studies show no impact on IQ at age 16. In addition, we know that the leading cause of jaundice induced brain damage (kernicterus) is breastfeeding.

In what way has Fed Is Best misrepresented the findings of these up to the minute papers? They haven’t misrepresented them at all.

ACOG, you seem certain that breastfeeding is the optimal feeding method for every infant. If it’s optimal why is there no correlation between breastfeeding rates and infant mortality rates? Why, given that the breastfeeding rate has tripled in the past 45 years, have the savings in lives and healthcare dollars predicted by breastfeeding advocates, failed to materialize?

And what’s up with the ugly insinuations? Fed Is Best describes itself as a non-profit volunteer organization? Do you have any evidence they are anything other than that? They appear to cite peer-reviewed literature? How can one “appear” to cite the scientific literature? This is nothing more than a thinly veiled attempt at the “shill gambit”, a claim beloved of quacks and charlatans, that medical providers with whom they disagree are hiding the fact that they are on an industry payroll. It’s wrong the peddlers of pseudoscience use it and it is wrong of you to insinuate it about Fed Is Best.

ACOG, it took you years to admit that you had been wrong about episiotomies for decades. It was hard to give up on something that had become embedded in clinical practice, especially because it seemed to make so much sense. ACOG, for years you promoted hormone replacement therapy despite the fact that the evidence in its favor was relatively weak and had not yet been confirmed by longterm studies. It seemed to make so much sense that you rushed to incorporate it into clinical practice. Now, ACOG, you are refusing to admit that you have been wrong about breastfeeding. It seemed to make so much sense that something natural would have great benefits and low failure rates so, in response to high pressure lobbying by the breastfeeding industry, you incorporated its promotion into clinical practice even though the data was weak, conflicting and riddled by confounders.

There’s no question in my mind, ACOG, that you will eventually be forced to acknowledge that you have been wrong about breastfeeding just like you were wrong about episiotomies and hormone replacement therapy. The only question is how many babies have to be injured, starved or allowed to die before you acknowledge your mistake.

  • yentavegan

    Is it at all possible that on some instinctive level, without the need to turn the physical act of nursing a newborn into a course of study requiring a masters/doctorate degree, that left to her own resources, a mother knows when breastfeeding is going well and when it isn’t. Can I be so bold as to compare breastfeeding with passing a bowel movement? We all know , without much science or fanfare, when the act of emptying one’s bowels is smooth hassle free endeavor. Compare that to any numbers of times that try as one might, a little science is required to get the job done. And things don’t go haywire in a vacuum. All things being equal , a mother knows what she knows.

  • Emily

    I’d like to speak out in defense of the episiotomy I had in 2016. It was much preferable to tearing sideways (which my OB caught quickly). Recovery was fine and my skidmark from the small abrasion in my labia hurt much more than my perineum.

    • I think Dr. Tuteur was referring to routine episiotomies, although she can correct me if I’m wrong.

    • Allison

      They’re very necessary, in certain situations. But for a long time, they were performed as a matter of course, whether needed or not, and when they aren’t needed, they tend to cause most of the problems that they’re intended to prevent.

      • MaineJen

        Yes, my mother described them as being routine back in the 70s-80s. By the late 2000s when I asked my OB, she said they are not done routinely any more, and if she feels it’s necessary during delivery, she always talks to the mom about it first.

    • Alyssa Higgins

      Any medical advice or procedure is the wrong choice when it’s blindly applied to all patients regardless of the risk or the needs of the particular patient. We don’t perform blanket tonsillectomies on every single patient despite the benefits to those who need them.

      Many mother report being coerced– or even “surprised”– into an episiotomy or other procedures that aren’t medically necessary in their particular circumstance– many times for the comfort and convenience of the doctor over the well being of the patients. I’m happy to hear that you had a beneficial experience and a responsive OB who performed a procedure as needed for your best health and treatment.

  • mabelcruet

    OT, but Jackie Smith, CEO of the nursing and midwifery council has resigned-2 days before the Professional Standards Authority is due to publish its report into their handling of the issues surrounding the maternal and infant deaths at Barrow in Furness. The report is expected to be very critical (harassing and bullying a loss father, spending a quarter of a million pounds redacting documents about him, monitoring his social media accounts, taking 8+ years to begin to investigate the midwives responsible for the deaths.

    • Amazed

      Resigned or retired? I get more than a little annoyed when these chicks in leadership retire with considerable pensions (usually before an investigation or trial) and this gets touted as a great success of the system getting rid of a ledership that encourages practicing in a dubious way. And the Barrow midwives seemed to excel in this.

      • mabelcruet

        Resigned, effective July (sounds like she gave 3 months notice). The report is out and it’s not good-very carefully worded but clear that the NMC is unfit for purpose. Meanwhile, there has been a resounding silence from all the usual suspects and their hangers-on on Twitter. Jackie Smith is being heaped with praise for how she has revolutionized midwifery revalidation and improved the NMC, despite the report saying exactly the opposite. She has apologized for failings, but that’s not going to bring dead babies and mothers back, but the absolute tone deafness of her supporters doesn’t bode well for the future.

        • Lilly de Lure

          I agree with Amazed, sounds very like an “I’ll resign before I’m sacked and keep my pension thankyouverymuch” move to me *grrr*. Btw, for those who are interested, the report itself is here:

          https://www.professionalstandards.org.uk/docs/default-source/publications/nmc-lessons-learned-review-may-2018b2851bf761926971a151ff000072e7a6.pdf?sfvrsn=34177220_0

          • Amazed

            Oh God! As someone who makes their living by working with texts, each time I see “Lessons Learned” on the very first page, I shudder. Usually, it means bombastic rhethorics and little else.

            And yes, I have only seen the title this far. I’ll have a look but I’m unfavourably inclined already.

            It’s misleading, it’s shifting of focus. Lessons truly learned usually don’t need to shout this phrase from the roof-tops. They prove it. In the content.

            ETA: Thanks for the link!

  • lawyer jane

    Shorter ACOG: We’re mad that your more effective use of rhetoric is threatening our rhetoric; and we’re also unwilling to examine the underlying evidence. Breast is best, nah nah nah, fingers in ears, we can’t hear you!

    I mean, it’s indisputably true that Fed is Best heavily pushes anecdotes about breastfeeding harms. But the stories are true. And more importantly, FIB also cites research to back up its positions. But I think what must be most threatening to ACOG is that many of the FIB organizers and members are health-care professionals who see the harm done by the ideological push to breastfeeding/baby friendly hospitals.

    • AnnaPDE

      Plus, FIB’s conclusion isn’t that breastfeeding is bad or anything – just that the baby’s intake should be monitored and if necessary supplemented, where “necessary” means a hungry baby, and not waiting until complications arise. And they actively provide very effective breastfeeding support.
      So yeah, the argument against it doesn’t really stick for anyone who wants babies to be healthy or breastfed. The only reason to be against FIB is if the particular fetish is 100% EXCLUSIVE breastfeeding and pretending that works and is healthiest for everyone .

  • Jessica

    The letter is so frustrating. Not only does it hurt babies and their moms, it’s counterproductive. Fed Is Best helped me maintain breastfeeding my almost four-month-old. I had delayed onset of milk production (colostrum stopped on day 3, milk came in late on day 5), and I was able to recognize the warning signs (12 hours with no wet diaper, brick dust, fussy feeding) and supplement in time to avoid jaundice or significant weight loss. Once my milk came in, I was able to exclusively breastfeed until recently (with more help from them troubleshooting feeding issues that turned out to be reflux), and am now mostly breastfeeding (with the occasional formula top off because I make 29-30 ounces of milk a day and he wants 30-31). This is a win for my son and me and for breastfeeding, so why do they have a problem with it?

    • Empress of the Iguana People

      I hear that. Fortunately for my boyo, he got enough to wet diapers, but he still lost a lot of weight in 3 days until I started supplementing him. My milk didn’t come in until day 5, either. Once it did, I made more than enough.

      • MelJoRo

        We had almost the same experience. I was supplanting, just not enough. In hindsight I wish I had looked up how formula a EFF baby would drink each day and started there. But I basically supplemented in secret with the BFHI hospital I was at, and everyone told me he was fine. The day after hospital discharge we hit 10% loss and his bilirububen jumped, but fortunately my milk was flowing well and my Ped was super on top of watching his intake and labs.

  • CSN0116

    ACOG (and their cousin SMFM) can go to hell. Their 10-year outdated recommendations regarding proper management of MCDA twin pregnancies are something I fight daily. Their “guidelines” allow physicians to neglect best practices (practices the rest of the developed world has been doing for a decade!) and babies die every. single. day as a result, and with no civil/malpractice ramifications, because the guidelines by which a doctor is held accountable are so loose and antiquated …just as they wish to keep them.

    Their breastfeeding statement has the potential to harm many more than poor MCDA care, I know, but they’re just shit all the way around. Politics, not patients. I despise the organization.

    • Daleth

      Yikes! I had mono-di twins. They’re at school right now. What’s wrong with ACOG’s recommendations on them?

      • CSN0116

        They don’t make the recommendation for MFM-level care (so it’s up to an OB to refer or not, despite the fact that few OBs have the equipment or skill necessary to properly conduct and interpret modi screenings); they minimize the risk of twin anemia-polycythemia sequence (TAPS); and they do not recommend routine TAPS screening. These three errors result in utter carnage. All other developed nations control for these things.

        • Daleth

          Oh, that’s awful. I didn’t know. I got referred straight from hospital midwives to MFM at 9 weeks when an ultrasound showed mono-di twins. They tested us up the wazoo throughout my pregnancy.

          • CSN0116

            I had great wrap around care too. A high risk OB and MFM coordinated my care. But MANY do not even make it to an MFM. Moms then don’t receive bi weekly ultrasounds, or they are read wrong, or TTTS is seen but a referral made too late, or the bi weekly scans are discontinued by week 24 because “the threat of TTTS is gone by then”. Oh, I could go on. Failure to even recognize TAPS is the most egregious injustice currently peddled by ACOG, though. I see red and white dead babies on the near daily 🙁

          • Daleth

            Oh, that is so awful.

        • guest

          Wow. I was referred to an MFM for a di-di pregnancy.

    • Kristi Berry Pedler

      There’s a reason despite being board certified, I refuse to be an ACOG member.

  • BeatriceC

    I am furious. Poor MrC had to hear me rant all day yesterday. I’m working on my own letter to ACOG, but I’m having trouble finding the words to appropriately convey my disgust.

    • CSN0116

      Just use the word “fuck” a lot..

  • Empress of the Iguana People

    ACOG can bite me. Actually, no, they may not. I’m still touched out after weaning my son cold turkey 3 1/2 years ago. My ff’d daughter is every bit as healthy and even taller than her brother was at 23 months. He dropped 11% in his first 2 1/2 days because colostrum was supposed to be enough. Until the grandmotherly NP in our family doctors’ office recommended a little supplementation.