Dr. Alison Stuebe of the Academy of Breastfeeding Medicine has had something of an epiphany.

Six years ago, I wrote a blog reflecting on Diane Wiessinger’s seminal essay, “Watch your language.” “There are no benefits of breastfeeding,” I wrote. “There are risks of formula feeding.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]For years the breastfeeding industry has insisted that all women will make enough breastmilk and all along they’ve known it was a lie.[/pullquote]

That post remains the most-viewed piece I’ve ever written, with more than 74,000 views as of this writing. I’ve taken the lesson to heart. I’ve published a peer-reviewed study on the increased risk of hypertension among women with curtailed breastfeeding, and I’ve flipped odds ratios in teaching slides and review articles to frame associations as the “risk of not breastfeeding” or the “risk of formula,” rather than the “benefits of breastfeeding.”

…[W]hen we talk about risks of formula, we will motivate mothers to “clamor for help,” and thereby increase breastfeeding rates and improve the health of mothers and babies.

Weissinger’s piece is a paean to viciousness and inadvertently revealing. Weissinger writes:

All of us within the profession want breastfeeding to be our biological reference point. We want it to be the cultural norm; we want human milk to be made available to all human babies, REGARDLESS OF OTHER CIRCUMSTANCES. A vital first step toward achieving those goals is within immediate reach of every one of us. All we have to do is … watch our language.(my emphasis)

“We want,” “cultural norm,” “regardless of other circumstances.” This is language beloved of tobacco companies and other industries seeking to manipulate the public into buying their products. It is the language of business, not the language of healthcare.

Stuebe was impressed nonetheless:

It’s a compelling logical argument. And yet, I’ve been unable to find empirical evidence that it is true. To generate that evidence, we’d need to compare outcomes among mothers and babies counseled that formula increase risk with outcomes among those told that breastfeeding improves health and wellbeing. To my knowledge – and please let me know if there is a peer-reviewed study out there! – such a study has not been done.

What caused Stuebe’s change of heart? It wasn’t just that shaming language is ineffective at increasing breastfeeding rates. Stuebe was confronted by the inherent racism and classism of lactivism that elevates the personal preferences of upper middle class white women to norms that are used to criticize poor women and women of color.

… In her spectacular keynote address at Breastfeeding and Feminism, Kimberly Seals Allers used a baby bottle with the head of Darth Vader to frame a discussion about how “risks of formula” might be perceived among women of color. For a mother worried that her teenage son might be gunned down for walking down the street wearing a hoodie, “risks of formula” seem pretty trivial…

You don’t say.

In a breastfeeding context, messaging that formula feeding increases childhood leukemia risk is unhelpful for the 22% of employed women who return to the workforce by 10 days postpartum, or for the mother who lives 3 hours from the nearest lactation consultant. If the purpose of risk-based language is to motivate mothers to clamor for help, there has to be help within clamoring distance.

And that doesn’t even take into account that the claim about leukemia is almost certainly untrue.

Then there is an inconvenient fact that Stuebe and colleagues have been deliberately ignoring for years. Stuebe now acknowleges:

… a substantial proportion of infants born in the US require supplementation. Delayed onset of lactogenesis is common, affecting 44% of first-time mothers in one study, and 1/3 of these infants lost >10% of their birth weight. This suggests that 15% of infants — about 1 in 7 breastfed babies — will have an indication for supplementation. If we counsel women prenatally that Just One Bottle will permanently alter the infant gut, then we set up 1 in 7 mothers to believe the horse is out of the barn in the first week of life. A mother might even conclude that the damage has been done, so she might was well wean altogether.

This is a stunning, ugly admission. For years the breastfeeding industry has insisted that all women will make enough breastmilk and all along they’ve known it was a lie.

If that weren’t bad enough, Stuebe and colleagues have deliberately condemned 1 in 7 infants to starve for days by pretending that “Just One Bottle” of formula will damage the infant gut when we have yet to determine the normal state of the infant gut let alone harmful variations.

Stuebe is reassessing her efforts to promote shaming language in light of its ineffectiveness, inherent racism and classism, and its basis in a spectacular lie. Those are good reasons to reassess, but shaming language around breastfeeding should never have been promoted for a very simple reason: it is UNETHICAL. If patient autonomy means anything it means that all people have the right to ignore healthcare providers’ recommendations without fear of bullying and crude attempts at manipulation.

The fundamental problem with shaming language around breastfeeding is that it is CRUEL and cruelty has no place in healthcare.

Stuebe ends her piece with this:

And until we have evidence that risk-based language improves the wellbeing of mothers and children, we might do well to reconsider our rhetoric. It’s past time to conduct the research that’s needed to sort the real risks and benefits of risk-based language.

But she should have ended it with an apology.

Stuebe and her colleagues should beg forgiveness for the suffering they have caused to starving infants. They should beg forgiveness for the suffering they have caused women with their deliberate lie that all women make enough breastmilk. They should beg forgiveness for the suffering they have caused by placing the needs of the breastfeeding industry above the needs of their patients.

In other words, Stuebe and colleagues should beg forgiveness for their unspeakable, unethical cruelty.

I posted the image above on Facebook and got the following response:

You want to spend 10 months carrying a fetus to a live birth… You should be expected to breastfeed to at least 2 years, you should be expected to baby wear – PERIOD. You should also demand paid maternity leave, expect an extra stipend for staying home with your child and have the support group of other Moms and professionals so new Moms don’t feel isolated…

I’ve been a hardcore feminist for over 20 years… You don’t demean or belittle the huge and amazing aspects of womanhood and motherhood to get equality – because then you are making women act like men. You support, praise, expect and demand monetary value for what women do – to gain equality. Don’t make women feel they need to sublimate or cast off their Motherly instincts to be equal- that is just as damaging as the Patriarchy’s demand to pigeon hole women.

Way to miss the point, Pamela!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]In natural parenting, the only good mothers are powerless mothers.[/pullquote]

I’ve been a hardcore feminist for more than 50 years and feminism is all about situating women’s worth in their intellect, talents and character, not their reproductive organs. Natural parenting, in contrast, believes that women (but not men) must be reduced to recapitulating their lowly status in nature.

Feminism is all about autonomy for women, letting them make their own decisions. It is most emphatically NOT about using pregnancy and infancy as excuses to restrict, control and disempower women.

Wake up, Pamela! Natural parenting has nothing to do with what’s good for babies and everything to do with fear of women’s emancipation. Those who are afraid of women holding political and economic power think they can force them back into the home by setting up so many rules around motherhood that the only “good” mothers are powerless mothers. And you’ve fallen for it, Pamela.

• When was the last time you saw people claiming that “good” fathers demonstrate their love for their wives and children by killing game animals and dragging them home?
• When was the last time you saw men escorted out of the delivery room because traditional societies do not allow fathers at childbirth?
• Where are the restrictions on what men can consume, justified by the desire to keep their sperm safe for maximum fertility?
• When was the last time you saw fathers harassing each other over who is the more natural father?

Never, right? And that’s not a coincidence.

It would be bad enough if Pamela were just a random vicious natural parenting advocate, but Pamela is a nurse. A nurse who had this to say about infant formula:

Can’t argue with facts- even when you may feel guilt about a failure.

Chemical compounds, synthetic ingredients and hard to digest vitamin and mineral sludge isn’t normal, isn’t great… It is abnormal and inferior nutrition- which thankfully is enough to allow a baby to survive on it.

You know what’s normal, Pamela, my friend? Women who can’t produce enough breastmilk to fully nourish an infant (5-15% or women) is normal, too. And that normally leads to dehydration, seizures and death. It’s so normal that it happens every day around the world.

The “Nature” of our pre-historic ancestors was not the Garden of Eden; it was a garden of horrors. Get bitten by a predator … die. Bleed excessively in childbirth … die. Get a childhood illness … die. The NORMAL life expectancy in nature was only 35 years. It’s entirely unnatural to live to 70, 80 or 90 as people do now.

Why, Pamela, do you get to pick and choose what aspects of life in nature women must be forced to recapitulate? There were no nurses receiving monetary compensation for careers outside the home in nature. So why is it okay for you to have a career? There were no people living in houses, using central heating and air conditioning and driving to their jobs in cars in nature. So why is it okay for you to live in a house with central heating, wear clothes and drive a car?

Most importantly, there were no people using computers to communicate with others across the country and around the world. What are you doing on the internet promoting the virtues of natural parenting, Pamela, when the internet is entirely unnatural?

Open your eyes, Pamela. Natural parenting is not about parenting in nature since that was filled with disease, disability and death. Natural parenting is a way of judging women by the functions of their reproductive organs, reducing women to nothing more than the chattel of men.

It may be natural, but it sure as hell isn’t feminist.

Meg Heket is holding a pity party for herself and her friends.

Writing in Whole Woman, Heket, an unassisted birth advocate and sister of Janet Fraser (My dead baby was not as traumatic as my birth rape), addresses women she believes destroyed a large, private Facebook group of unassisted birth and homebirth advocates.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]One of THEIR administrators became distraught at the endless parade of preventable deaths.[/pullquote]

You know who you are. You’re sitting in your ivory tower laughing and high-fiving one another. You’re saying JOB WELL DONE! You think you saved a bunch of women from themselves and each other, but your greatest achievement to date is actually showcasing your cult like hysteria on the world stage.

You must seriously be unhinged to think that taking over a large, happy group and dismantling it in this way is an acceptable thing to do. Unhinged, and deluded. Who died and made you the crusaders for the world?

Those 12k women didn’t want you to save them. They wanted to be amongst friends to talk about their pregnancies and births, the good, the bad, and the varicose veins. They had that right, and you did NOT have the right to interrupt them in this narcissistic, grandstanding way…

You may think that this is a giant win for your posse, but actually it is a really convincing nail in your coffin. People everywhere, even many who supported your cause, are utterly disgusted and disillusioned by this. They don’t think you’re brave, they don’t think you saved anyone, they don’t think you had any INTENTION of saving anyone. They know exactly what you are though. You’re all thoughtless, gutless cowards. That’s what cyber-bullying is. It’s gutless and cowardly. You can hide behind your keyboard avidly typing away, never having to face up to the victims, but remember your own important memories on the internet and how easily they could vanish?

What happened?

To be honest, I don’t really know. Contrary to what many natural childbirth advocates believe, I’m not omniscient or omnipotent. I’ve been otherwise occupied publicizing my book so I was not following the drama as it unfolded in real time. I only found out about it afterward when I was publicly blamed for it.

As far as I can determine, a number of safe birth advocates (many, perhaps most, of whom are my Facebook followers) infiltrated a private group supporting unassisted homebirth, home VBAC and unassisted home VBAC. The group is notorious for the steady stream of infant deaths. There are so many deaths that I can’t keep track, but it appears that the group averages several preventable infant deaths each month. In one week last summer there were 6 (!!) deaths.

Nearly all these deaths occur because members ignore the advice of medical professionals and are encouraged to so so by group members and administrators. Babies die and their deaths are subsequently expunged or rationalized (“babies die in the hospital, too”). If all else fails, members resort to shrugging their shoulders and insisting that dead babies happen, the homebirth equivalent of “whatever!”

Earlier this week yet another baby died. In the wake of this death, an administrator of Meg’s* group made one of the infiltrators an administrator, too. She tried to ban medical advice; other administrators tried to ban her and the group imploded and has been closed.

The mother had been encouraged by group members to “rock her home VBAC waterbirth.” She was still being heartily encouraged when she started labor at 43+ weeks.

She was supported throughout her “beautiful” labor and birth by a homebirth midwife (CPM) and doula, both utterly clueless that the baby had died during labor.

The doula posted this:

Hey mamas! REALLY need some encouragement. I just attended the most beautiful n saddest birth! Mothered laboured perfectly, baby sounded healthy, heart tones strong! This was her VBAC moment!!! An hour upon delivery (Mam pushing) we started having a hard time getting a good FHT reading, got it a few times then everything sounded normal — 150’s. Got it again 2 minutes before birth, upon coming out the baby had no heart rate … And even with the amazing crew who worked on her we lost her!…

One can never forget those images of a baby born into this world and taken to another in a moment … she never took her first breast! … There was no sign of distress … just one moment here … and one moment gone …”

Not exactly. The baby almost certainly suffocated and died during the last hour of labor. She wasn’t there one moment and gone the next. She suffered for a long time, but the midwife failed to recognize the signs since there was no fetal monitor to show them.

What does Meg Heket have to say about this baby’s death? Absolutely nothing, of course. She’s far more concerned with what she believes was stolen from her than the life that was stolen from that poor baby.

Who stole Meg’s group? She and other supporters of unassisted homebirth and home VBAC have utterly missed the point of what happened. One of THEIR administrators became distraught at the endless parade of preventable deaths and sought to stop it by changing the leadership of the group, hoping to end the shockingly ignorant medical advice, the mindless cheering of dangerous stunts, and the deliberate efforts to bury dead babies twice, once in tiny coffins in the ground, and again by being expunged from the memory of the group.

I regret that the group was destroyed in the process. That is not my way. If you know anything about me at all, you know that my way is confrontation. I want to confront the lies, not censor them. That’s why I’m constantly offering to debate those that disagree with me.

Meg Heket and her colleagues may be irresponsible, but they are entitled to private support groups even when those groups are echo chambers for ignorance and dangerous medical advice. I don’t blame Heket for being angry, but, as usual, she is missing the point.

The issue is not the women who infiltrated the group. The issue is that the group is enabling preventable infant deaths, so many that even stalwart members are sickened. Yet that’s not even on the radar of Heket and her colleagues.

She ends her article with this:

To the women who love VBAC. You are not alone. You will regroup. You will find your feet, and your voices, and you will be bigger and better and stronger than ever before. Your network may be scattered, but it isn’t gone, I know this because you are working, driven by kindness, not a deranged craving for control and power, flying under the false banner of bravery and care. You are the ones who will rise from these flames…

You stole VBAC, but you wait, it will be back, and you will fade angrily, hopelessly, into insignificance.

I don’t doubt that the irresponsible VBAC group will be back, although those who opposed it will not be fading into insignificance. Their voice is growing. The irresponsibility of Heket and colleagues is being made manifest and we can hope that THEY will fade angrily, hopeless, into insignifance. When that happens there will be fewer dead babies and that can only be a good thing.

*Clarification: Although Meg has been an administrator of some VBAC groups, she was not an administrator of this particular group, just a member.

“The operation was a success but the patient died.”

It’s an old joke, but there’s an element of truth to it. Technical prowess in providing medical care is meaningless if the patient does not survive and get better. In medicine outcome is far more important than process.

That’s why efforts to reduce C-section rates are terribly misguided. C-section is a process and measuring rates tell us nothing about the quality of obstetric care. If we want to measure the quality of the care we need to look at perinatal and maternal mortality (outcomes), but that’s hard. So insurers and public health authorities have made a much easier (and potentially lethal) decision. They’re going to measure the C-section rate, then punish hospitals and providers who don’t meet an optimal rate.

According to Southern California Public Radio:

[pullquote align=”right” cite=”” link=”” color=”#FF111E” class=”” size=””]Soon we’ll be able to say, “The vaginal birth was a success but the baby died.”[/pullquote]

California’s health insurance exchange will use the threat of exclusion from its approved provider networks as a way to motivate hospitals and doctors to reduce the number of medically unnecessary Cesarean sections.

Beginning in 2019, insurance companies that contract with Covered California must either exclude from their networks any hospitals that don’t meet the federal government’s 2020 target C-section rate or explain why they aren’t, according to the new contract approved by the exchange’s board last week…

“This is going to catch people’s attention and focus the considerable quality improvement activities of hospitals on this area,” says Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative.

But there is a very large, indeed a deadly problem with this approach. The C-section rate is NOT and has never been a measure of quality.

In other words, we’re soon going to be able to say, ‘The vaginal birth was a success, but the baby died.’

Medicine is practiced one on one. A health care provider cares for each individual patient with her specific history, symptoms, physical examination and laboratory values in mind.

How do we know if the provider gave the best possible care?

Did the patient survive? Did she get well? If not, the people caring for her failed. Perhaps no one could have done better, but it is a failure nonetheless.

We can measure healthcare quality in the aggregate, of course. We can look at mortality rates and morbidity rates in response to specific treatments, but that tells us nothing about whether each patient got the treatment she needed and no one got treatment that they didn’t need.

Medicine is both art and science.

It is firmly grounded in science, of course, but there are large gaps in our knowledge (what causes cancer? what causes pre-eclampsia? what causes schizophrenia?) and those gaps are bridged by the art of medical care.

I learned that practicing obstetrics. One incident in particular is burned into my memory. I was on call one evening when a patient phoned to say that she was 25 weeks pregnant and had noticed pain running up the inside of her leg for the past two days. I advised her to meet me at the hospital for an exam because I wanted to make sure that she didn’t have a blood clot in her leg (deep venous thrombosis or DVT).

Pregnancy is a hypercoagulable state, meaning that pregnant women are more prone than average to develop blood clots. Blood clots in the leg are not dangerous in themselves, but pieces can break off and get stuck in the lung circulation. That’s known as a pulmonary embolus and it has a very high death rate.

The patient came in and I examined her leg; she had none of the many potential signs associated with DVT, but when I asked her to point out where she felt the pain, she traced the exact path followed by the vein on its way from her foot to her thigh. I was suspicious despite very little clinical evidence so I asked the radiologist to scan her leg … and he refused!

Why?

He explained that the insurance company was trying to reduce the incidence of emergency DVT scans to “improve quality” and he would not get reimbursed for a negative scan. We argued and I ultimately threatened to write in the chart that he was refusing a scan that I thought necessary and if the patient died, he should be held responsible.

He gave in and he found that she had a blood clot so extensive that it extended from her ankle to deep in her pelvis. It almost certainly would have killed her had it not been immediately treated with blood thinners.

A measure designed to improve “quality” inevitably led to poor quality care, because measuring process is not a substitute for measuring outcome.

That’s especially true for C-sections. Except in rare instances (massive hemorrhaging, for example) we have literally NO WAY to determine in advance whether a woman is going to need a C-section. We have NO WAY to predict if her baby is definitely suffering from oxygen deprivation. We have NO WAY to predict if a breech baby is going to die if delivered vaginally. We have NO WAY to tell if a woman with a previous C-section will rupture her uterus (potentially killing her baby) if she tries for a vaginal delivery in a subsequent pregnancy.

What’s the optimal C-section rate? We don’t know.

For years the World Health Organization recommended an “optimal” C-section rate of 10-15% despite the fact that the countries with low perinatal and maternal mortality rates had an average C-section rate of 22% and rates as high as 42% were consistent with excellent outcomes.

A recent study found the a minimum C-section rate of 19% is necessary to ensure low rates of perinatal and maternal mortality. There is precious little evidence that higher rates are dangerous.

That hasn’t stopped public health officials from pretending that they know the optimal C-section rate. In the case of low risk pregnancies:

The federal government has set a goal of reducing C-sections in these low-risk situations to 23.9 percent by 2020. The national rate was 26.9 percent in 2013, according to the Centers for Disease Control and Prevention.

Such specificity ought to mean that public health officials can tell us IN ADVANCE exactly which C-sections made up the 3% difference, but they have literally no idea.

And if they can’t tell in advance, how will obstetricians be able to tell?

They won’t.

Obstetricians will have to guess, risking the lives of individual babies and mothers, leading inevitably to preventable deaths.

Why?

Repeat after me: the C-section rate is not a measure of quality!

There have been many highlights in my professional life, but rarely has one filled me with as much glee as this one: Modern Alternative Mama, Katie Tietje, hate reviewed my book!

She and her followers are trying to drive down the ratings for PUSH BACK: Guilt in the Age of Natural Parenting.

And the best part is that Tietje didn’t even bother to read it, just like she never reads the scientific literature.

Behold!

Wow. I really don’t even know where to begin with this.

“Dr” Amy has taken something — the ‘natural’ parenting movement — that she never understood, never bothered or cared to understand, and twisted it into something so far from what it actually is, it’s unrecognizable.

I don’t know a single mother who cares more about her “experience” in birth than her baby’s safety. Nor any who would refuse truly needed medical interventions. “Dr” Amy shares anecdotes of mothers who have supposedly done this, to their baby’s detriment. Mothers I know are grateful for interventions where necessary — but I also know many who have had interventions pushed upon them without medical reason. Many felt bullied, and ended up with postpartum depression, or even PTSD. That’s a problem.

“Dr” Amy paints a beautiful picture of a sharply reduced maternal and perinatal mortality rate. What she fails to mention is that these rates were at an all-time low in the 1980s, but as birth has become more medicalized, they have risen — actually, have tripled — in the last 30 years. There’s a point where intervention is too much! And yes, we are overusing it now, and the results are sometimes tragic for mom and baby. “Dr” Amy conveniently ignores this, because it doesn’t fit her narrative.

Even more insulting is “Dr” Amy’s insistence that the entire natural child birth and natural parenting movement is driven solely by white men and money. Wow! Actually, modern obstetrics were driven largely by white men. There’s also not much money to be had by midwives, doulas, lactation consultants, etc. These people aren’t rich. Their salaries sure don’t compare to the salaries of obstetricians. Neither do the amounts women pay for birth pools and other supplies compare to what they pay for a simple dose of Tylenol in the hospital. The real money is clearly in the ‘mainstream’ system. (I personally paid less out of pocket for an out-of-hospital birth than I did for a hospital birth, even with good insurance. Although money wasn’t the motivator either way.)

Then “Dr.” Amy attacks natural because it’s really all about “privilege.” (It’s honestly dizzying how many random objections she comes up with. It sounds like the same tirade that the ‘natural’ people launch against the mainstream, simply turned around. It sounds more like butthurt than legitimate objections.)

And then “Dr.” Amy talks about how women are trapped in motherhood and men are pushed out, and women’s choices aren’t respected. This is so blatantly false — it just proves she’s never bothered to talk to anyone outside her tiny little world and try to understand who they are and what they want.

Plus, although “Dr” Amy rants and raves about the necessity of women having options and respecting women’s choices, she does not follow her own advice. She attacks women who don’t choose as she feels is necessary in this book. And, she commonly goes around the internet and trolls natural child birth groups. She maintains a blog called “Hurt by Home Birth” to highlight stories of babies who were injured or died during home births (regardless of cause). She has a group called “Fed Up with Natural Childbirth” where she and other women take screenshots of posts in ‘natural’ groups and mock the women, or even seek their personal information and call the police or children’s services on these women, often over nothing much. Recently, she used fake Facebook profiles to pretend to be a natural birth advocate, become an admin in a large natural parenting group, and dismantle the group entirely.

“Dr” Amy is someone who is closed-minded, refuses to understand a world outside her own, and will stop at nothing to belittle, demean, attack, and punish anyone who dares to stand up to her. She is a bully of the worst kind. This book is just one more step in her infantile tirade against a group of people she doesn’t understand. It’s just pathetic at this point.

When it comes to professional accomplishments, it doesn’t get much better than this!

First we heard that the singer Adele, a smart, powerful woman, found the pressure to breastfeed “fu**ing ridiculous.”

Now comes evidence that even Kim Kardashian is vulnerable to that same intolerable pressure. Kardashian, another extroardinarily powerful woman, could not bring herself to own her decision to stop breastfeeding her son Saint. Instead she blamed her two year old for “forcing” her to quit.

[pullquote align=”right” cite=”” link=”” color=”#B71705″ class=”” size=””]She blamed her two year old for “forcing” her to quit.[/pullquote]

According to Yahoo News, North West Forced Kim Kardashian To Stop Breastfeeding Baby Saint:

…Kim has now admitted that she was forced to stop breastfeeding Saint because her two-year-old daughter, North, was getting too jealous…

Speaking on her sister’s chat show Kocktails With Khloe, Kim explained: “North West stopped that for me. You’ll die when I tell you what she did. First of all she’d cry so much and try to pull him off me.

Kim quit and then North had a change of heart:

“She said to me this weekend: ‘Mummy, I’m not mad anymore. You can feed baby brother and I won’t cry.’ And I was like: ‘Honey, the milk’s all dried up.’”

I don’t believe for an instant that North “forced” Kim to quit. Toddlers are often jealous of baby siblings and are not shy about expressing that jealousy. I’ve heard everything from “let’s send the baby back to the hospital!” to “let’s throw the baby in the trash!”

It never occurred to me, nor to any other mother of young children, to take directions from a toddler on how to treat a baby. I suspect that if North had begged her mother to put the baby in the closet, she wouldn’t have done it. And I suspect that if North begs her mother not to go out for work or celebrity appearances, Kardashian does not give in. It is not credible that she stopped breastfeeding Saint because North made her do it.

Kardashian stopped breastfeeding Saint because SHE wanted to stop breastfeeding. Perhaps she found it painful; perhaps she found it inconvenient; perhaps she wanted her body back; or perhaps she had no specific reason at all. It ought to be her choice to use her breasts when and how she wishes to use them.

But it’s not. The breastfeeding industry, including lactation consultants, La Leche League, and the so-called Baby Friendly Hospital Iniative have struggling mightily to thoroughly moralize breastfeeding. They’ve exaggerated the benefits far beyond what the scientific evidence shows. They conjured speculative “risks” to formula feeding. Most importantly, they’ve drummed it into everyone’s heads that the “good” mother breastfeeds.

Not every mother can breastfeed (5-15% of women don’t make enough breastmilk) and not every mother wants to breastfeed or breastfeed for an extended amount of time. But the pressure to breastfeed is crushing. Adele couldn’t bear it and apparently Kim Kardashian can’t bear it, either.

The ultimate irony is that breastfeeding has nothing to do with being a good mother. Breastfeeding is one of two excellent ways to feed an infant. Two generations of Americans were raised nearly entirely on infant formula and infant health parameters improved steadily during that time period. Breastfeeding is integral to the philosophy of attachment parenting, but the psychologists who elucidated Attachment Theory never looked at what an infant was fed, merely that it was fed. They found that mother-infant attachment occurred spontaneously when the “good enough” mother met the baby’s needs for food, protection and love. No special foods or parenting behaviors are required.

You know the pressure to breastfeed has become intolerable with Kim Kardashian is afraid to own her own decision to stop. If powerful women like Kardashian are being crushed by the pressure, average women don’t stand a chance.

We’ve got to push back against the breastfeeding industry that has moralized breastfeeding and return women’s breasts to women’s control.

See the shark?

The shark embodies nature. It’s vicious, deadly, and unconcerned with anything other than its own wellbeing.

Nature is about survival of the fittest … generally by killing both prey and competitors. So how did “natural” come to mean “safe” and “gentle”?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Anti-vaxxers who prefer “natural immunity” are unwitting dupes to the advertising industry, as are those who purchase “natural remedies” or organic food.[/pullquote]

It hasn’t happened by accident. It reflects a highly successful effort on the part of the advertising industry to trick us and we’ve fallen for it.

In Packaging as a Vehicle for Mythologizing the Brand in the journal Consumption, Markets and Culture, Knaizeva and Belk identify “Myths of the World in the Past” that influence the “stories” found on packaging.

By examining stories printed on the food packages that make use of a popular claim of naturalness, we offer a conceptual framework showing how corporations attempt to graft new myths onto old archetypes. We propose that by revisiting traditional mythology, contemporary commercial storytellers collectively create a grand postmodern marketplace myth—that of an empowered and ennobled consumer. We treat packaging narratives as cultural productions and explore them as vehicles for mythologizing the brand. Our findings reveal mythical themes exploited by companies in their packaging stories and messages they convey.

What did they find?

Packaging narratives depict the modern world as a deeply distorted reflection of what it originally was – the garden before agro-chemical technology. While the values of the past include family, tradition, authenticity, peace, and simplicity, the current era is associated with broken family ties that need to be restored, scientific “advances” that pose threats, constant pressure on the well-being of humans, and unnecessary complexity in everyday life.

The authors pay particular attention to the concept of “naturalness”:

Naturalness appears as a rich emotional construct that connects with positive contemporary images of nature… People do not want to remember that nature can also be destructive as in deadly hurricanes and poisonous mushrooms … In a natural health context, Thompson also finds nature to be a positively framed powerful mythic construction; and his informants attribute magical, regenerative powers to nature. They firmly believe that aligning with what nature has to offer for one’s health lets them assert control over their lives and bodies versus losing control by being complicit in a scientized medical system.

Something unfortunate happens when we hear the word “natural.” It’s almost as if the very word disarms our innate skepticism. The irony is that while natural has come to mean “gentle” and “safe’, nature itself if neither.

In other words, advertisers have appealed to our vanity by conditioning us to believe that we are empowered and ennobled consumers. They’ve rewritten history to depict pre-technological Garden of Eden, where nature had magical regenerative properties. And like lemmings, many of us have followed advertisers off an entirely natural cliff.

Natural immunity? We had that for most of human existence and the average lifespan was 35 years.

Natural childbirth? Among the most deadly events in a woman’s life and the deadliest event in a baby’s life.

Natural remedies? If natural remedies actually worked, our lifespan in nature would have been 70 years, not 35 years.

None of that would be surprising if we recognized the shark as an embodiment of nature. Like the shark, nature doesn’t care if you get smallpox and die. It doesn’t care if half (or more) of your children die in childbirth. It doesn’t care to provide us with natural remedies.

Yes, nature provides some plants and animals with natural poisons used to kill competitors or predators. Penicillin existed to provide protection for a species of mold. We hijacked it to protect ourselves. But no one should imagine that nature created penicillin for us.

Anti-vaxxers who prefer “natural immunity” are unwitting dupes to the advertising industry, as are those who purchase “natural remedies” or organic food. They’ve been deliberately tricked into imagining themselves as empowered and ennobled by their choices when, in reality, they’ve been reduced to compliant sheep who can be manipulated into buying food, books and other products that are worthless or worth far less than the premium being charged for them.

Nature is the shark — conscienceless, vicious, and deadly. We should acknowledge the brilliance of the advertising industry in creating a group of consumers who’d rather believe in the fantasy of safe and gentle nature created by advertisers who are flattering them than the evidence of their own eyes.

It’s great for business, but terrible for health.

It’s the central conceit at the heart of contemporary lactivism, and it serves as a justification for the shaming tactics so beloved of lactivists.

It’s the fantasy that the formula industry has been waging war on breastfeeding and it’s a lie.

[pullquote align=”right” cite=”” link=”” color=”#AA0F0B” class=”” size=””]Women use formula for the same reason that women use birth control; it allows them to determine when and how they wish to use their reproductive organs.[/pullquote]

Don’t get me wrong; formula manufacturers are trying to make money. And, yes, decades ago they engaged in deceptive practices to convince women in developing countries to formula feed; but there was never a similar campaign in industrialized countries for a very simple reason — women there couldn’t or wouldn’t breastfeed long before formula even existed.

Formula was not created as a substitute for breastfeeding; it was created as a substitute for the raw animal milk women were already using as a substitute for breastfeeding.

As Jacqueline Wolf explains in the chapter Saving Babies and Mothers: Pioneering Efforts to Decrease Infant and Maternal Mortality, in the book Silent Victories: The History and Practice of Public Health in Twentieth Century:

The custom of feeding cows’ milk via rags, bottles, cans and jars to babies rather than putting them to the breast became increasingly common in the last quarter of the nineteenth century progressed… In 1912, disconcerted physicians complained bitterly that the breastfeeding duration rate had declined steadily since the mid-nineteenth century “and now it is largely a question as to whether the mother will nurse her baby at all. A 1912 survey in Chicago … corroborated the allegation. Sixty-one percent of those women fed their infants at least some cows’ milk within weeks of giving birth.

And the results were deadly:

The late nineteenth century urban milk supply killed tens of thousands of infants each year. Unpasteurized and unrefrigerated as it journeyed from rural dairy farmer to urban consumer for up to 72 hours. cows’ milk was commonly spoiled and bacteria-laden. Public health officials dramatically charged that in most U.S. cities, milk contained more bacteria than raw sewage …

Those death rates did not start falling until cows’ milk was replaced by infant formula, which more closely matches the composition of human milk, is uncontaminated and is very convenient to buy, store and use.

It’s a very important, albeit inconvenient truth about breastfeeding:

There were always large numbers of women who couldn’t or wouldn’t breastfeed.

Why? The answer is another inconvenient truth about breastfeeding:

Many women find breastfeeding to be difficult, painful and inconvenient. Others may wish to breastfeed but don’t make enough milk to fully nourish a growing baby.

Infant formula finally made the widespread use of breastmilk supplements safe. Formula manufacturers didn’t need to convince women to forgo breastfeeding; they just made it safe to do so.

But wait! Why do formula manufacturers still advertise extensively in industrialized countries? It’s for the same reason that birth control manufacturers advertise: to claim market share.

Manufacturers of various formulations of The Pill, condoms and diaphragms aren’t engaged in a war on pregnancy. Women themselves WANT to regulate their fertility. They don’t want to subject themselves to a dozen pregnancies across a reproductive life and they don’t want to raise a dozen children. No one needs to convince women to prevent pregnancy; the market for birth control encompasses just about every woman of reproductive age in every country. The issue for women is not IF they are going to use birth control, but WHICH form of birth control they are going to use. That’s why purveyors of birth control advertise.

Formula manufacturers advertise for the same reason. The issue is not IF women are going to use breastmilk substitutes; many will choose to do so regardless. The issue is which brand to use. It’s the same reason why formula companies give free samples of their product. Contrary to the lactivist fantasy that formula samples are aimed at seducing women away from breastfeeding, the industry is not worried about IF women will use formula; it’s concerned about WHICH formula brand they are going to use.

Lactivists have used this fantasy of formula manufacturers warring against breastfeeding to justify their tactics of grossly exaggerating the benefits of breastfeeding, pretending there are “risks” to formula feeding, invoking shaming language to pressure women into breastfeeding, and coming up with Orwellian programs like the “Baby Friendly Hospital Inititiative” to force new mothers to breastfeed. And, in doing so, they are engaged in a war against women.

Women use formula for the same reason that women use birth control; it allows them to determine when and how they wish to use their reproductive organs. Lactivists oppose formula for the same reason that religious fundamentalists oppose birth control. Fundamentalists believe no woman should have sex unless there is a chance for pregnancy and lactivists believe no woman should give birth unless she plans to breastfeed.

In both cases, what is at stake is not the wellbeing of babies, but the rights of women.

Once again Consumer Reports deserves a big fat “F” for its series on C-sections.

Why? Because it starts with a conclusion and works backward to support it.

“Everybody knows” that the C-section rate is too high, and Consumer Reports is no different, but as is the case with many pieces of conventional wisdom, what “everybody knows” is not necessarily true.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We should use metrics to evaluate the quality of healthcare, but our metrics should be OUTCOMES not processes.[/pullquote]

To hear Consumer Reports tell it, obstetric care begins and ends with C-sections and our priority should be reducing their number. But C-sections are a procedure, not an outcome, and our focus should always be on outcomes. Curiously while the Consumer Reports series on C-section focuses a great deal on variation in C-section rates between hospitals, it utterly ignores the real metric by which we should judge hospital quality — perinatal mortality.

One of the reasons I left the practice of medicine is because of short sighted, simplistic views of patient care beloved on large healthcare organizations and healthcare journalists. I once was notified that my rate of ordering ultrasounds the previous month was higher than average. When I asked the executives in charge of compiling such statistics whether any of the ultrasounds I had ordered that month were unnecessary, they couldn’t tell me and seemed shocked that I even bothered to ask.

I was once notified that my forceps rate was “too low.” That was truly mystifying since my C-section rate was low also (16%) and I hadn’t left a single baby inside a single woman. Instead of being lauded for a vaginal delivery rate of 84%, I was chastised for an operative delivery rate of nearly 0%. That doesn’t make any sense at all.

Of course we need to use metrics to evaluate the quality of healthcare, but our metrics should be OUTCOMES not processes. When we look at the C-section rate and ask if it is too high, what we OUGHT to be asking is whether any C-sections were recognized as unnecessary in advance not whether they were recognized as unnecessary in hindsight.

To understand what I mean, consider biopsies for breast lumps. We know that 80% of breast lumps are benign, but we biopsy 100% of breast lumps. In other words, we have an “unnecessary” breast biopsy rate of 80% … or do we? The fact that 80% are “unnecessary” can only be known in hindsight; it is impossible to say beforehand which biopsies are safe to skip. We don’t don’t judge breast cancer care by the breast biopsy rate and we shouldn’t. We judge breast cancer care by the survival rate.

Just as we should never judge breast cancer care by how many biopsies were actually cancerous, we should never judge obstetric care by the C-section rate. We should judge obstetric care by the survival rate, but obstetrics has become such a victim of its own success that Consumer Reports starts with the completely irresponsible assumption that all hospitals have the same perinatal mortality rates and therefore, we don’t even need to check them. And that is very, very wrong.

When you choose a hospital for obstetric care, you should choose based on which hospital will give your baby and you the best chances of coming through the process of childbirth without injury or death. For better or for worse, there is no consistent relationship between C-section rates and outcomes. While that may mean that higher C-section rates are not better, it ALSO means that lower C-section rates aren’t better, either. Why? Because the ideal C-section rate is the one where all women and babies who NEED a C-section get one, and not too many women and babies who don’t need a C-section end up with one anyway. Notice that I did not say that there would be NO unnecessary C-sections. Given the current state of technology that can only imperfectly tell us in advance which C-sections are necessary, it is better to do many unnecessary C-sections in order not to miss any necessary ones.

When it comes to C-sections, the current Demonizer-in-Chief is Dr. Neel Shah, who practices in the same place where I trained and practiced, Boston’s Beth Israel Deaconess Medical Center.

While a number of factors can increase the chance of having a C-section—being older or heavier or having diabetes, for example—the biggest risk “may simply be which hospital a mother walks into to deliver her baby,” says Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, who has studied C-section rates in this country and around the world.

His private remarks to me on the topic of C-sections were particularly irresponsible.

Shah responded on Twitter to a piece I wrote for TIME questioning his sloppy, poorly sourced support for homebirths published in the New England Journal of Medicine. He appeared to be entirely unaware of the published literature on the dramatically increased death rate at American homebirth, and equally unaware that homebirth in the US is typically attended by a second, inferior class of midwife, one who does not meet the basic education and training standards in any other industrialized country. The analogy I used in my TIME piece is that hospitals are like seat belts; most of the time you aren’t going to get into an accident, but if you do, seat belts saved lives.

Shah, clearly stung by my criticism, had this to say:

[H]ospitals are not seatbelts; they are airbags that explode in your face 1 out of every 3 times you get in the car.

Holy hyperbole! Shah implies that 100% of C-sections are unnecessary, and are performed merely because the system is malfunctioning spectacularly. At a MINIMUM, fully half of those C-sections he derides are medically necessary and a substantial proportion are literally life saving. Yet Dr. Shah implies that obstetricians are performing C-sections for reasons that aren’t merely illegitimate, but are a travesty exploding in the face of unsuspecting mothers.

It makes for good copy, but it is irresponsible medicine.

Dr. Shah knows as well as I do that the increase in C-section rates have been driven by the fact that our knowledge has eclipsed our technology. We know that vaginal birth can be dangerous and even deadly to a substantial proportion of infants. Indeed, Dr. Shah was a co-author on a recent paper that showed that a MINIMUM C-section rate of 19% is needed to be sure that rates of perinatal and neonatal mortality are low. That means that in order to ENSURE that all babies are born healthy, nearly 1 in 5 MUST be delivered by C-section.

Which 1 in 5 babies needs a C-section to be born safely? We can’t always tell in advance because the things that we need to know are inaccessible to us. To reduce C-sections for fetal distress we need to know the oxygen content of a fetus’ blood during labor, but we don’t have the technology to determine that. To reduce C-sections for breech, we need to know which babies’ heads will get trapped by their mothers’ pelvis, killing them, but we don’t have any technology to determine that. To reduce C-sections for cephalo-pelvic disproportion (a baby too big to fit) we need to know whether the diameter of a baby’s head can mold enough to fit through his mother’s pelvis, but we don’t have the technology to determine that, either. When we have those technologies, we will reliably be able to reduce the percentage of unnecessary C-sections to zero.

In the meantime, we do the best with what we have. Obstetricians perform unnecessary (in retrospect) C-sections because we often CAN’T tell in advance the difference between the necessary C-sections and the unnecessary ones. Not surprisingly, we try to err on the side of caution. The Consumer Reports C-section series deserves a big fat “F” because it is utterly irreponsible. It insists that there are too many C-sections being done but offers NO GUIDANCE on how to determine in advance which C-sections are the unnecessary ones. It presumes that the C-section rate is a quality metric when it is anything but. And it is based on the premise that our goal should be a reduction of the C-section rate when our goal ought to be the best possible rates of perinatal and maternal mortality.

The series doesn’t help mothers, doesn’t help babies, doesn’t help obstetricians, but does sell magazines. I guess that’s the point.

In the dystopian novel 1984, George Orwell introduced the idea that vocabulary has the power to control thought. In 1984, the government, in an effort to control citizens and force them into submission, subverts the meaning of common words and phrases to promote approved views.

This type of language manipulation is also known as “doublespeak,” as Wikipedia explains:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There’s nothing “baby friendly” about letting an infant starve.[/pullquote]

… Doublespeak may take the form of euphemisms (e.g., “downsizing” for layoffs, “servicing the target” for bombing, making the truth less unpleasant, without denying its nature. It may also be deployed as intentional ambiguity, or reversal of meaning (for example, naming a state of war “peace”). In such cases, doublespeak disguises the nature of the truth, producing a communication bypass.

The Baby Friendly Hospital Initiative (BFHI) is an outstanding example of doublespeak. In 2016, the breastfeeding industry, in an effort to control women and force them to use their breasts in the lactivist approved manner, subverts the meaning of “baby friendly” to promote breastfeeding.

The BFHI torments mothers, muzzles doctors and nurses, and, unconscionably, it bullies babies in an effort to ensure ideological conformity.

What do I mean?

Anything that is baby friendly would take into account the needs of babies, and if babies need anything at all, they need to eat.

Hunger is probably the most elemental of infant drives and, as anyone who has seen an infant scream from hunger would probably agree, is experienced by the baby as suffering. For most mothers, myself included, the sound of their own infant crying is piercing in its intensity and distress. I remember being surprised by this when my first child was born. I had spent my entire professional life surrounded by crying babies and it had never bothered me, yet I found my son’s crying unbearable and always rushed to determine what was wrong and fix it in any way possible.

It is a biological FACT that at least 5-15% of women will not make enough breastmilk to fully nourish a growing baby. If that rate sounds high to you or incompatible with the survival of the human race, consider this: the natural rate of miscarriage of established pregnancies is 20% and we’ve survived and thrived despite a high death rate of embryos. A rate of inadequate breastmilk production of 5-15% is comparable. And that doesn’t even include those mothers whose milk comes in late.

What happened to those babies prior to the advent of infant formula? They starved to death.

Exclusive breastfeeding rates of 100%, as occurs in nature, aren’t very baby friendly at all.

Along comes the BFHI, airily ignoring the biological reality of breastfeeding, and focusing instead on ideological conformity. The BFHI is all about promoting a process. But being “baby friendly” should be about the outcome for babies, not the process. There is nothing baby friendly about letting a baby starve.

Healthy infants are equipped to survive a short period without much nutrition. That’s why most babies lose a little weight in the first two days. But after that point, a baby who isn’t receiving an adequate amount of breastmilk begins to starve. And that’s what happens to those 5-15% of babies whose mothers don’t produce enough breastmilk and the additional babies whose mothers’ milk comes in late. They starve with all the agony that implies.

When a baby continues to lose weight beyond the first few days, the baby’s body begins to digest itself. That’s what weight loss is, the baby breaking down its own cells to supply its brain, heart and other vital organs with nutrients. The baby becomes dehydrated and its sodium level begins to rise; seizures, brain damage, and death can be the result. Bilirubin, a waste product, can built up. If the bilirubin level gets high enough (kernicterus) the baby’s skin color becomes orange and permanent brain damage may occur.

That’s bad enough, but the worst part is that the baby FEELS that she is starving and she suffers. She screams from hunger until she is too exhausted or too weak to cry. She can’t sleep because hunger wakes her up to scream some more.

What’s baby friendly about that? NOTHING!

What can a woman do if she suspects that her newborn is starving? Not much, if she’s in a “baby friendly” hospital. Infant formula, which would ease the baby’s suffering and has been shown to preserve not harm the breastfeeding relationship, is off limits. A mother must subject herself to a mandatory lecture from nurses and or lactation consultants. She may need to beg for formula or send a family member out to buy it. She is the object of official scorn. All the while her baby is suffering.

Nurses and doctors are muzzled; they can’t counsel her about formula supplementation until the baby is seriously ill. All the while her baby is suffering.

We KNOW that this will happen to 5-15% of babies yet, under pressure from the breastfeeding industry, doctors and hospitals have caved to this distinctly baby unfriendly policy. Why? Not because it’s good for babies; not because it’s good for mothers; they submit because the BFHI credential is good for MARKET SHARE.

The ultimate irony? There’s no evidence that the BFHI has much if any impact on breastfeeding rates.

What should we do?

It seems to me that a good first step would be to force the program to change its name to more accurate “Breastfeeding Friendly” Hospital Initiative. Instead of hiding the true motivation in doublespeak designed to manipulate women, let’s be honest about who really benefits: lactivists and their organizations.

Let’s also make the program mother friendly by ending the hectoring lectures to mothers, ending the muzzling of doctors and nurses, making formula easily accessible, and re-opening well baby nurseries so new mothers can rest and heal from childbirth.

Most importantly, let’s make babies’ wellbeing the centerpiece of hospital care by ending the mandatory starvation the agony that goes with it for a substantial proportion of babies.

There’s nothing baby friendly about letting an infant scream in hunger. The BFHI makes babies suffer. That MUST stop.