Dr. Melissa Bartick uses make-believe math to avoid blame for deaths during skin-to-skin care

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Melissa Bartick, MD has a forthcoming paper in the journal Pediatrics entitled Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after Birth. She claims her data show that the Baby Friendly Hospital Initiative cannot possibly be blamed for sudden unexpected infant deaths (SUID) due to smothering during skin-to-skin care (SCC) because death rates dropped as the proportion of Baby Friendly Hospitals increased.

Dividing one unreliable number by another unreliable number cannot yield a reliable result.

In Massachusetts, births in Baby-Friendly facilities rose from 2.8% to 13.9% and skin-to-skin care rose from 50% to 97.8%. SUID prevalence decreased from 2010-2016 compared with 2004-2009: OR 0.32 (95% CI 0.13, 0.82).

There’s just one problem. The data show nothing of the kind because the data have been noted to be unreliable.

A chart from the paper makes it clear:

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How did Dr. Bartick “calculate” that the Massachusetts SUID prevalence decreased over time? She divided one unreliable number (it is literally listed as unreliable) by another unreliable number and expects us to believe that the resulting number is magically reliable. Seriously?

This is just the most egregious misrepresentation in a paper full of them. For example, Dr. Bartick appears to be responding to the paper Trends in the Incidence of Sudden Unexpected Infant Death in the Newborn: 1995-2014 (her first reference).

That paper found:

Death records for 1995-2014 indicate that, although SUID rates in the postneonatal period have declined subsequent to the 1992 American Academy of Pediatrics sleep position policy change, newborn SUIDs have failed to decrease, and the percentage of SUIDs attributed to unsafe sleep conditions has increased significantly in both periods; 29.2% of the neonatal cases occurred within the first 6 days of life.

It’s central claim is that while SUID from 6 days of age to one year of age has decreased dramatically, SUID from birth to 6 days has not decreased and has come to represent an ever larger proportion of total SUID deaths.

So why does she restrict her paper to 2004 and after? Compare the graph she supplies of sudden deaths by year, to the one in the earlier paper and you can see why.

Her graph:

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The graph from the earlier paper:

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The blue line shows the prevalence of sudden unexpected infant deaths in the neonatal period. The orange line shows SUID in the postneonatal period. It’s pretty hard to argue, as Bartick is trying to do, that as the Baby Friendly Hospital Initiative in general and skin-to-skin care in particular has become more widespread, early SUID deaths have decreased.

Dr. Bartick’s use of make-believe math is the sign of a far deeper problem than math illiteracy.

Why is she resisting the existing scientific evidence in this area as well as — not coincidentally — resisting the scientific evidence that bed-sharing is deadly? Sadly, she and her lactation colleagues appear to be more interested in protecting professionalized breastfeeding support and its attendant practices than in protecting babies.

It is a fundamental violation of medical ethics to protect a process instead of protecting patients. Nonetheless, contemporary lactation professionals view their mission as protecting, promoting and supporting breastfeeding. Their ethical obligation — in contrast — is to protect babies, promoting safe infant feeding, and support mothers.

By pledging their allegiance to the process of breastfeeding instead of babies and mothers, lactation professionals are making a terrible mistake. It’s all the more mystifying when you consider that skin-to-skin care has little to nothing to do with breastfeeding itself. SSC is a method to protect premature babies in low resource settings where there is no access to temperature controlled incubators. To my knowledge, there has never been any evidence that term babies need or particularly benefit from it. Yet lactation professionals are so rigid in their thinking that they feel compelled to mindlessly defend anything that touches upon breastfeeding.

They’re hardly the first medical professionals to make a mistake by refusing to recognize the harm they cause. Most famously, in the 1840’s Semmelweis proposed hand washing to reduce puerperal sepsis and his colleagues not merely ignored him, they got angry at him.

…[D]octors were offended by the implication that they were dirty and needed to wash more, or that doctors could be somehow at fault for their patients’ demise…

Lactation professionals, like Dr. Semmelweis’ colleagues are offended by the implication that THEY could be harming babies in their aggressive efforts to protect, promote and support breastfeeding.

Semmelweis’ colleagues managed to convince themselves for several more decades that puerperal sepsis had nothing to do with them, while women died because they didn’t wash their hands. It wasn’t until the 1880’s that everyone was forced to admit that hand washing protected patients because doctors could and did carry harmful bacteria.

Unfortunately, Dr. Bartick and her colleagues are responding to the burgeoning scientific literature detailing the harms of aggressive breastfeeding promotion just as Semmelweis’ colleagues responded to his discovery. They are desperately trying to protect their egos rather than their patients.

  • mabelcruet

    OT a little, but the interim Ockenden Report into the deaths at Shrewsbury and Telford Maternity Service has been leaked-it sounds identical to Morecombe Bay, the same poor team-working, the same territorial protection by midwives, the pursuit of normality rather than appropriate care, and topped off with what was called a ‘distinct lack of kindness and respect’ to bereaved parents, with non-cooperation, non-disclosure of investigation results, failure to learn. Some of the deaths happened well after the report from Morecombe Bay had been released amid huge publicity, so it seems like no one has learned anything.

    • Anna

      Its horrible. I think its a mistake to focus on individual midwives though (not saying you are, but I suspect the investigations will to some degree) when the universities are teaching them “midwives are the guardians of normal birth” “trust birth” “Drs know nothing”.

      • mabelcruet

        In Morecombe Bay, action was only taken against specific midwives following the report’s publication, and the Nursing and Midwifery council was censured for the way they had handled it: the compounded the distress caused to the families. So I suspect that when individual cases are investigated in S&T, similar charges might be brought against those liable. But it’s a far wider issue than just the odd incompetent bad-apple midwife-I think its a fundamental problem in that midwifery training seems to be very politicised, and teaches a ‘them vs us’ mentality. Normal birth is the province of midwives, therefore we don’t need no useless doctors, they are just out to take over your cases and undermine you. When I’ve been to morbidity and mortality meetings, I get the sense that a woman being transferred to obstetric care is somehow seen as a failure.

        But I’m a little reassured by the response to Caroline Flint-she was a past president of the Royal College of Midwives who made a comment at a conference that doctors were useless and we don’t need obstetricians. There was a backlash against that, with many midwives saying that was inappropriate and that they worked in conjunction with their medical colleagues.

  • mabelcruet

    Skin to skin care sounds nice, but it has risks and it shouldn’t be undertaken lightly or without consideration, even the AAP agrees that. In Sweden, where all their hospitals are BFHI, the sudden post-natal collapse (SUPC) rate is 10 times that of other countries where the baby-friendly practices aren’t as well embedded. As far as I know, its a practice that was adopted in low-resource areas and countries to try and ameliorate for the lack of incubators and specialist neonatal units, so why is it being forced on mothers and babies who aren’t going to benefit particularly, and who may be increasing the risk of harm for no reason?

    • Anna

      As midwives tell it skin to skin is soooo important and, when the baby is well I think its wonderful, why not. With my 5th baby though they had to take her after a very quick skin to skin hold and I’m so grateful they did because she ended up needing considerable help and I’d much rather she be getting it than losing brain cells for “the golden hour”. I notice in birth trauma groups though women feel like they failed or that bonding was destroyed because they didn’t have skin to skin. Its been indoctrinated into Australian women that skin to skin is PARAMOUNT for bonding, breastfeeding and regulating body temp, breathing etc that some women actually believe the hospital wronged them by taking the baby to the resus table, especially if the baby did come round quickly. If I had a dollar for every “birth story” where the woman says “my baby was fine, but they took her away to NICU for no reason!” – well, I’d have a lot more dollars than I do now.

      • mabelcruet

        There are babies who finish off gestating in a plastic box for weeks and months on end, and they bond perfectly well with their parents-the whole bonding lie is just that, a lie. You don’t bond specifically by breast feeding, using organic cloth diapers, or tying them in a sling that you drag around 24/7. Children are pre-programmed to bond to caregivers: care doesn’t have to be perfect-as long as the baby is fed, feels secure with parents/caregivers who are sensitive and responsive to their needs, and interacts with them, that’s enough to create an intimate bond.

        I always get a bit of a chill whenever I see babies lying face down on mum’s chest for skin-to-skin, particularly when they are a newborn. The first breath of air you take and you’re squished face down-I know there are people around who are monitoring the baby, but it seems odd to me that parents are told to always put their baby on their back to sleep, so how come its OK for a brand-new, fresh-out-of-the-box baby to lie face down immediately? And it’s not a huge stretch to think of a scenario-the midwife has left the room to see to someone else, the partner has gone outside to make a few phonecalls to friends and family, and the mum is drowsy from labouring for hours and falls asleep with baby face down. I appreciate that I see a very select group of cases, but I can’t help thinking that its mostly luck that I don’t see many more of these. We had a waterbirth delivery which went horribly wrong last week-that case is going to drag on and on, and its such a pointless death, utterly preventable and should never have happened.

        There was a big discussion online recently in a medical forum I was reading, all about paediatric resuscitation after delivery and whether the cord should be cut or not. Admittedly, I’m not a clinician and I don’t know the stats, but if a baby is born with poor Apgars and needs to be resuscitated, surely the best way to do that is to get the baby to a firm surface (not a bouncy mattress) that is well lit with space for equipment and for personnel to manoeuvre (like the resuscitare unit that sits in the corner of most delivery rooms). Yes, delayed clamping for a minute is good if you can give it a minute, but appropriate resuscitation shouldn’t be held up for that. There seems to be a myth that as long as the cord is intact, the placenta will resuscitate the baby.

        • rational thinker

          Was the water birth death a home birth or hospital.

          • mabelcruet

            Stand-alone midwife led unit, about 10 minutes from nearest hospital (maybe 20 with traffic)

          • rational thinker

            When are they gonna learn. How many babies have to die or suffer brain damage before they stop and realize hey this is really dangerous.

          • mabelcruet

            Nominally low risk, first pregnancy. She’d had one scan at 20 weeks and nothing further. Apparently she put on about 60lb during pregnancy, but was never tested for glucose tolerance. There was minimal record keeping about estimated fetal weight-comments were made about healthy eating but there was nothing in the notes about potential fetal macrosomia, and no referral for scans prior to delivery. Even as a non-obstetric, non-midwife, it was very obvious to me where the errors were made and where intervention would have undoubtedly saved the baby’s life. I honestly think its territorial, that some staff are very much ‘my client, my way’ and see referral for specialist input as a failure rather than good clinical care. It’s like once you’re considered to be low risk, you’re always low risk, no matter what else happens.

  • JDM

    How did Dr. Bartick “calculate” that the Massachusetts SUID prevalence
    decreased over time? She divided one unreliable number (it is literally
    listed as unreliable) by another unreliable number and expects us to
    believe that the resulting number is magically reliable. Seriously?

    It’s the non-computer version of GIGO. Usually folks like to run dubious numbers through a computer so they can “black box” their result, but Dr. Bartick shows you don’t even need the black box.

  • Christine O’Hare

    Wow, talk about an example of, “Lies, damned lies, and statistics.”

    I remember that I was very closely supervised during initial skin to skin/nursing immediately following my c-section. Despite that supervision, I was still the one to ask for someone to take the baby because I could no longer keep my eyes open after 21 hours of labor, pushing, c-section, medication and no longer felt safe holding the baby. Thankfully no one questioned this request, along with the request that my clearly hungry baby be given formula that night (which she pounded 30ml’s in record time – clearly that stomach size stuff is nonsense). However without the supervision, my knowledge of the dangers (thanks to SOB) and my request to stop when I felt unsafe – things could have been very different given my level of exhaustion and medication.