Breastfeeding, medicalization and the pernicious rise of quasi-science

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How can we explain the unmerited veneration of breastfeeding in contemporary society?

The predicted benefits of raising breastfeeding rates have failed to appear; tens of thousands of infants are harmed each year; and breastfeeding promotion hasn’t saved money, only wasted it. Nonetheless breastfeeding is still promoted aggressively.

Like the formula industry before it, the breastfeeding industry has invaded hospitals to promote itself, not the health or wellbeing of babies and mothers.

Why?

The celebration and promotion of breastfeeding is a case study in the pernicious rise of quasi-science.

Everyone is familiar with pseudoscience. It is sham science, from the Greek pseudo for “fake.” Breastfeeding promotion isn’t pseudoscience, but it isn’t real science, either. I propose the term quasi (also Greek) for “nearly” to identify something that appears to be science — and may even invoke some scientifically valid claims — but ultimately isn’t real science because it violates the most critical principle of science: it is non-falsifiable.

How did breastfeeding promotion become quasi-science?

It’s all about the breastfeeding industry and market share. While they claim to abhor the tactics of the formula industry, no one could have copied those despised tactics more assiduously than the lactation profession. They recognized early on that it’s all about marketing!

Breastfeeding as natural is adequate for marketing breastfeeding goods and services to lay people, but the holy grail for the breastfeeding industry was to supplant the formula industry in hospitals. What better way to promote breastfeeding could there be than to give it both the imprimatur of medicine and exclusive access to new mothers recovering in hospitals?

But doctors weren’t likely to believe that just because something is natural it must be good. So lactation professionals chose a marketing technique they knew physicians were likely to understand: they medicalized infant feeding. The language and authority of science was once used to promote formula feeding as best; lactation professionals now use the language and authority of science to promote breastfeeding as best.

The Baby Friendly Hospital Initiative, created by the World Health Organization in conjunction with La Leche League, instituted elaborate medical practices around breastfeeding and justified its intrusiveness with claims of major medical benefits.

Breastfeeding saves lives!
Every woman can breastfeed!
Formula supplementation interferes with breastfeeding!
Pacifiers cause “nipple confusion”!
Long periods of skin-to-skin contact facilitate breastfeeding!
Mandating mother/baby rooming in makes it easier to breastfeed!

This was the first indication that breastfeeding was quasi-science, not real science. The lactation profession literally fabricated “science” to support its goals.

It is shocking to reflect that those claims were confidently made in the ABSENCE of any scientific evidence to support them. It was fully a decade before anyone attempted scientific investigation of the specific claims and by then nearly every scientific investigation was undertaken for the purpose of supporting the existing claims, not testing them.

That speaks to the non-falsifiability of medical claims about breastfeeding. Of course lactation professionals and the scientists they enlisted in their cause did not understand at the time that they were violating a basic principle of science. To the contrary, they were so sure that breastfeeding is always so much better than formula feeding that they embarked on scientific investigation merely to prove what they already believed to be true.

And at first, they found the scientific evidence they “knew” they would find. Small observational studies suggested that breastfeeding did indeed have significant benefits. Those findings were publicized far and wide and became the basis for aggressive breastfeeding marketing and promotion efforts.

But those small observational studies did not correct for socio-economic status, a critical flaw when studying something that is as socio-economically patterned as breastfeeding. Women of higher educational socio-economic status are much more likely to breastfeed. Therefore, the purported benefits of breastfeeding might actually be benefits of wealth and access to healthcare.

The past decade has witnessed a thorough debunking of nearly every claim made about the benefits of breastfeeding. When studies are corrected for maternal socio-economic status, the benefits of breastfeeding evaporate. Unfortunately, the lactation profession has made the deliberate choice to ignore that the scientific evidence they repeatedly quote was debunked long ago. That’s another reason why breastfeeding promotion is quasi-science: it doesn’t change as the scientific evidence changes. It relies on real science, but real science that has been superseded by better science.

The lactation profession has chosen not merely to ignore the fact that their favorite scientific claims have been bebunked, but, more ominously, they have chose to ignore the large and growing body of scientific evidence that breastfeeding promotion is harmful to babies, actually injures and in some cases kills them. That, too, speaks to the non-falsifiability of claims about breastfeeding promotion.

The bottom line is that breastfeeding promotion is quasi-science (nearly science but not real science) because:

It’s central claims were enunciated before they were tested.
It promotes real scientific evidence, but evidence that has been debunked.
It doesn’t change when the scientific evidence changes.
It ignores scientifically documented harms.

And most importantly:

It’s central claim is non-falsifiable; the breastfeeding industry will never admit that breastfeeding is NOT best for every mother and every baby.

Although it is not science, it is nearly science, and that has fooled us, but no longer.

It’s time for doctors, nurses and hospital administrators to boot the Baby Friendly Hospital Initiative out of hospitals as unceremoniously as they booted out the formula industry and for the same reason. They are there to promote themselves, not the health and wellbeing of babies and mothers.

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  • CSN0116

    This post is timely as I embark on an institutional battle of my own. Currently, the U.S. clinical guideline paper for management of monochorionic pregnancies (put out by SMFM) is over six-years-old, which is an eternity in the world of fetal therapy innovation.

    Most egregious within the current (dated) guidelines is the recommendation NOT to perform MCA-PSV Doppler screening for twin anemia-polycythemia (TAPS), a complication of monochorionics that occurs spontaneously in up to 6% of these pregnancies and carries a sky-high mortality and serious morbidity rate if not treated.

    Even *MORE* egregious than SMFM’s statement not to bother looking for it is the fact that they use a single citation to support the very profound statement that affects patients every day – the citation they use to tell people not to perform the screening actually SUPPORTS and recommends routine MCA-PSV Doppler screening and shows a 100% survival rate when screening was performed and antenatal interventions used.

    So, this highly influential body puts forth this shit recommendation and doesn’t even have to courtesy to fact check and place an appropriate citation (because there really isn’t one) when dicking around with the literal lives of women. Nonetheless, it is now the law of the land and MCA-PSV Doppler screening is withheld from monochorionic patients, even after they request it, on the daily. Babies are born with chronic polycythemia and anemia, unable to breathe on their own, brain dead, etc. from the ravage of the disease while in utero.

    When called out for the inappropriateness of the recommendation and its “supporting evidence,” or the fact that women have the right to have access to a test that can not only save their babies, but also allows THEM to make decisions about their own health care – the supporters double down (we just don’t know enough about it, those tests can read wrong, it just adds unnecessary stress, it can make us deliver babies too early for no reason, etc.). They will not change with the science. They will not right their wrong.

    I am living this literal post just in a different arena. Ugh.

    • mabelcruet

      On a similar note, we have NICE in the UK-National Institute for Health and Care Excellence, a body that provides advice and guidance for health professionals. A few years ago, NICE produced guidelines stating explicitly that parents of stillborn children should not be encouraged to hold or see their baby. This appeared to be based solely on one observational study that surveyed mothers of stillborn infants and relied on them self-reporting mental health issues, PTSD and depression. The study itself was appallingly bad-this was a postal survey, not face to face interviews, and self reported so it wasn’t based on a clinical diagnosis of mental health issues, and most importantly, it didn’t adjust for pre-existing mental health issues. The conclusion they reached was that mothers who held their stillborn baby were at increased risk of mental health issues. NICE appeared to take this and run with it, and announced that parents should not be encouraged to see their baby after stillbirth.

      Just like that we were back in the 1950s when babies were whisked away and the mother told to forget about them and go home and try again. The various stillbirth charities, the miscarriage association, Babyloss, etc all appealed to NICE to look again, even the study authors said that wasn’t their conclusion, it was that mothers who wanted to see their baby should be supported to do so, and mothers who really didn’t want to see their baby should not be pressured into it, but that the opportunity should be suggested after some time, as mothers state of mind could change rapidly after baby loss. Eventually NICE modified it to say parents should receive ongoing support, and more attention should be paid to maternal mental health history as that could potentially highlight those mums at greater risk of PTSD or whatever. It was only because these very high profile charities, who have far more experience with bereaved parents than anyone else, put a lot of pressure on them very publicly to wise the hell up.

      • CSN0116

        WOW! And thank you for sharing!

        We know that our initial efforts will go unacknowledged, and so we are planning for future appeals. We have a large gathering of the patient population who has been affected by the current guideline, and we may need to eventually mobilize them. Over here in the U.S., you’d think somebody like the March of Dimes would maybe give a damn, but they really don’t touch anything “rare.” We’ve tried some stuff with them in the past and unless it’s a population-wide problem, they don’t really give you the time of day.

        But both my issue and the one you describe share one thing in common: no fact checking and far too much emphasis on one notion.

        This has my head constantly reeling, asking: These guidelines are not created and passed in a vacuum. Several people sit in a room and draft them. Then they must go through peer review process. Is nobody paying attention with topics so serious? Nobody checking citations? Or are people just too afraid to dissent? Either scenario sucks but each is influenced by a different ignorance.

        Methodologically, neither one of these guidelines should have made it through. Who is dropping the ball, and most importantly – why are they? What fatal flaw needs fixing to stop this from happening?

        • mabelcruet

          I’ve no idea who signed off on that ridiculous ‘don’t see your baby’ recommendation. I don’t know of a single midwife or obstetrician who supported it-its frankly horrific denying parents the choice to see their baby, and it went against absolutely everything we know about bereavement support and making memories: care pathways in place, getting bereavement services up to scratch, getting quiet accommodation for loss parents away from the main delivery suite so they aren’t upset by seeing other peoples babies. I know that various medical bodies also complained to NICE but they were basically ignored-it was only when charities got involved and got some very high profile publicity going on that the advice got watered down (not withdrawn, just watered down). We didn’t find out who passed it for inclusion, or what they were-NICE guidance is supposed to be evidence based and multiprofessional with lay members as well on the various panels, and its supposed to be sent to stakeholders first (hospitals mainly), but this just appeared. I actually wondered if one of the authors of the study had pushed it through, but when the authors complained and said the guidance misrepresented their conclusion, it sounds like it wasn’t. It was all very secretive really, completely inappropriate for such a sensitive area. NICE are supposed to develop their guidance with advice and support from stakeholders, but none of the bereavement or baby charities had a clue it was happening, and you’d think issues about stillbirths would be discussed with the main stillbirth charities, or is that too sensible for quangos?

        • PeggySue

          I sometimes think these things are passed without any scrutiny from medical types. Marketers…

        • mabelcruet

          I’m obviously not an obstetrician, but monochorionic twins come my way not infrequently, either after selective termination because of severe TTTS (horrific choice for the parents to make), or after intervention (laser treatment is working, sort of, but not for every case), or because one twin dies, and its usually the recipient of the twin-to-twin transfusion pair. Even if they both survive, its mandatory to examine the placenta-many centres do injection studies (I was involved in a project years ago with Nick Fisk where his research fellows were looking at mapping anastomoses-they did it via Dopplers during pregnancy, then we injected the vessels in different colours after delivery, mapped out arteries and veins and see if it matched up-we used different colour of gelatin ink for arteries and veins on each side so that we could see where the vessels went).

          It made for some very pretty multicoloured placentas, and it definitely helped-initially when they started doing laser oblation of chorionic anastomoses, they zipped up and down the chorionic plate at the vascular equator and closed all the anastomoses, but it became very quickly evident that some of those connections were necessary.

          The microscopic appearance of a TTTS placenta is striking-the donor side is a horrible, ischaemic, infarcted shrivelled up tiny thing, and the recipient is a huge, oedematous, swollen, hydropic bag with massive immature villi. The recipient is actually more likely to die because a fetus can withstand fairly severe hypoxia, and a hypoxic fetus is stressed, and that makes their lungs mature up a bit better, so if they are delivered prematurely, they have a bit more of a chance. The poor recipients become hydropic and go into heart failure because of polycythaemia, and that is more dangerous.

          But, and I’m getting to my point!-even I, as a pathologist, know that MCA Dopplers are useful-they are good at predicting which baby is likely to be acidotic at birth, we use it for assessing fetal growth failure, there’s loads of data to back that up. It’s a useful, non-invasive, non-stress test and the machine does all the calculations. It doesn’t need to be done on every baby, but if you have a high risk pregnancy, and monochorionic diamniotic twins are high risk, then why isn’t it recommended?

          I know there are some differences between the American Colleges and the UK Royal College of Obstetrics and Gynaecology, but our lot are doing Dopplers routinely-see page 6

          (https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14188

          • CSN0116

            Unfortunately, the 2016 NICE guidelines have always been interpreted to do MCA screening only when the pregnancy is otherwise complicated. Our UK moms struggle like hell to get the testing routinely. This, of course, makes no sense as a monochorionic pregnancy can test great on all other major measures, but TAPS can still be present. Then, in March of 2019 they doubled down and stuck to their opinion:

            “The committee therefore made a recommendation to screen for TAPS in monochorionic twin sets who had additional complications (that had potential to increase the chance of developing TAPS) only. The committee decided that in cases where there were complicated monochorionic pregnancies it was beneficial to screen for TAPS because the risk of complications including fetal death and neonatal morbidity and mortality would outweigh the harms of intervention including preterm birth and in utero transfusion. Given the seriousness of the outcomes the committee decided that strong recommendations were warranted for this group despite the limited evidence base.”

            See page 10

            https://www.nice.org.uk/guidance/GID-NG10063/documents/evidence-review-3?fbclid=IwAR3OJxicylbkc76BsKYchrPyyJzlGknfPDxDzRGwku9hPD42F8St-vTNDRY

          • mabelcruet

            I’ve always worked in a trust with a feto-maternal medicine unit attached, so I suppose I see a biased sample (all the complicated ones, rather than the less complicated twins). Any case that I’ve had come my way is usually accompanied by masses of scan data. Maybe my O+G colleagues are ignoring the NICE recommendations and using their own judgement. I know that over the years there has a lot of criticism about NICE and about how they are some form of gatekeeper rationing access to expensive care, and sometimes that seems to be the case.

        • Sarah

          I think March of Dimes are probably very busy campaigning against pre 39 week sections…

    • Merrie

      I know nothing about this issue, but this sounds awfully alarmingly similar to the nonsense spouted by the “natural” types about lots of more common procedures like ultrasounds, fetal monitoring in labor, and others–too many false positives, unnecessary stress, etc.

  • Amazed

    OT: I think we can use attitude to natural birth, feeding methods, and vaccination as a method for detection who had put forth some strenuous efforts into their college and university studied and who either cheated or studied something that was basically an intellectual entertainment for those with money.

    Given what my education cost me mentally and physically, how hard it was to gather the knowledge I have now (a process that hasn’t stopped when I graduated), I could never be this arrogant to think I know as much as doctors and scientists just because I can google and read abstracts or even books written by professionals for laypeople.

    However, my own studies have given me enough of a perspective. The simple answer of the question who is the greatest mass murderer of 20th century cuts it.

    Now, we have a bunch of lazy cheaters deafening us.

  • mabelcruet

    OT-get ready for more knee-jerk ‘caesarean section is evil’ glee from the usual suspects:

    https://www.theguardian.com/science/2019/apr/12/caesarean-babies-have-lower-level-of-good-gut-bacteria-study-shows

    • Ozlsn

      I am still very dubious about the whole gut microbiome thing. It just has the feel that epigenetics did about a decade ago – very much a buzzword with everything and the kitchen sink being ascribed to it and the actual in depth studies getting lost in the noise. Maybe it does have a lifelong effect but it seems likely that other factors also play a role (and not having pulled up the actual paper I don’t know what they did and didn’t look at.)

      Either way I’d rather have the C-section with the healthy if a bit more prone to respiratory infections child than the vaginal delivery of a stillborn child, which were basically my options.

      • mabelcruet

        It’s an interesting field, but its still at a very early stage and a lot of it is very hypothetical. To use potential issues about the microbiome to base maternity care on is very worrying. We simply don’t know enough yet to say if changes in the microbiome are significant or not: given that we do know that certain babies need to be delivered quickly otherwise their brain or life is risk, it makes no sense whatsoever to compare immediate serious known potential outcomes with some nebulous, unquantified and currently unquantifiable risk.

      • PeggySue

        I have to say that if I hear either “epigenetics” or “microbiome” my brain just turns off and my eyes glaze over. I can’t even really understand the CONCEPT of epigenetics, and the notion that something as changeable as the “gut microbiome” determines Very Important Stuff just kind of makes me suspicious.

        • Kerlyssa

          Epigenetics is like inheriting a laptop from your mom, and she had all these settings that she set on the software that you have to deal with now. Some you can turn off, or will turn themselves to another setting after a while or after a few user changes, but most you don’t even know about- the mah jong game that boots every time you start the computer has a bunch of silent companions. And, yeah, you don’t have Admin access, and the laptop’s actually been used and handed down for millions of years. Good luck!

          • AnnaPDE

            This explanation is absolutely excellent.

        • mabelcruet

          I’ve mentioned this before, but Hannah Dahlen purports to be an epigenetics specialist (it’s all over her personal website and her professional profile on her university website). She has this thing she calls the EPIIC hypothesis, chairs a ‘research’ group and produces papers on it, plus she goes around various midwife conferences describing it. As far as I can see, she is midwife trained. She’s not a geneticist (either clinical or molecular), or a biologist, or anything in that field. The research papers that I’ve accessed of hers tend to be highly speculative, to put it mildly, basically I get the impression that she has decided a conclusion (that intervention is bad and natural is good), and twists the data to fit. She takes little snippets of genuine genetic papers on epigenetics-usually the conclusions at the end where authors say things like ‘more research is needed but it is possible that X may have a lifelong impact on Y’ and presents that as fact. She strips out all of the proper scientific caution and provisos and presents it as ‘this is so’.

          I do a lot of genetics in my area (congenital syndromes, fetal dysmorphology mostly, not molecular genetics), so I think I have a reasonable grasp of it. But epigenetics is a wholly different beast-its complicated, it’s complex, it’s new and potentially very significant , but it still is at the beginning of being unravelled. We simply do not know enough about it to use it as a reason to modify current medical practices, particularly those practices where intervention is needed to reduce known risks. But Hannah Dahlen is touting this theory around and it’s becoming the new buzzword-I don’t want to impugn the scientific literacy of midwives, but I suspect that most of them don’t do a lot of molecular genetics, and only have a general overview of the subject. But she is presenting ‘epigenetics’ as a done deal, and that means parents may be getting inaccurate information from midwives and making choices on a very shaky foundation.

    • Sarah

      Wow, a whole 100 babies!

  • mabelcruet

    I think one of the strongest arguments that it is quasi-science is the reaction caused when their views are challenged. They turn extraordinarily hostile, aggressive, verbally abusive-maybe this is partly due to lack of moderation being online and not being face-to-face, but some of the breast feeding lactivists come out with language that has no place in scientific and professional circles. I’m not a prude by any means, but seeing Dr Tuteur being called a Nazi-bitch cunt for questioning their beliefs shows me these are not scientific and evidence based realists, this is a cult with believers. I’ve seen heated discussion in some conferences, but nothing remotely as aggressive or offensive as lactivists.

    • rational thinker

      I studied cults because my husband joined one. He had to live in a house with ten other men they didnt allow him to stay with me. I eventually had to fake join so I could get him out, that took me 2 years of pretending to believe in thieircrap. I saw a lot of shit over there and they committed one manslaughter and got away with it..

      • TheApe

        My god, two years?! The idea of being in a cult for a day is even too much for me. You certainly have more bravery than me, that’s for sure. I hope your husband is recovering.

  • Christine O’Hare

    Fascinating that they complain about the medicalization of birth, but at the same time medicalize breastfeeding to the extreme.

  • TheApe

    Jesus, I didn’t realized that this was such a issue. I thought the whole breastfeeding promotion was to show women that they shouldn’t be ashamed of it (which I agree), but never realized the ugly side of it. I don’t understand how these people can go so far like this.

    From what of I have read so far from this site has really opened my eyes. Keep up the good work.