Homebirth advocates exult that the proportion of planned homebirths in the US has been rising from miniscule to slightly more than miniscule. Too bad they never point out the endless stream of preventable homebirth deaths that result.

I noted earlier this month that there are so many homebirth deaths that I can barely keep track. There was an additional homebirth death just this past weekend.

First, though, I’d like to update the information on a death that I mentioned in the above post:

A baby who died in Phoenix last week whose mother, a doula, had a previous HBAC. I have not been able to establish whether the caregiver knew that the baby was dead before birth or was not expecting it.

It turns out that I had written about the mother before. She runs the Big Baby Project, which I wrote about here.

In a bio for a this piece and the follow up piece she wrote for a birth website, Cherise Sant is described as:

…Mother, Doula, Childbirth Educator, Placenta Crafter, and Creator of the marvelous “Big Baby Project” (a website full of empowering vaginal births of babies 9 lbs and over).

Sant is a purveyor of the standard homebirth trope.

Disappointment with her first birth:

I had resisted an induction but eventually caved to the pressure I was receiving from my obstetrician. The ultimate result was a healthy baby boy born via cesarean and my broken heart and body.

A successful hospital VBAC:

My second birth was an empowering vaginal birth in the hospital, but I was met with mistrust, abandonment and even violence though I had carefully chosen my provider and a “natural birth friendly” hospital.

Then the successful HBAC and total lack of awareness that the baby was possibly borderline IUGR:

We had a boy! As I’d pulled him up, I immediately could tell that he was little!! My smallest baby for sure, and yes he weighed in at 5 pounds, 15.9 oz. Later I would marvel that I changed course on a path to VBAC and didn’t have planned cesareans at 39 weeks. I couldn’t imagine how small and fragile he would have been 2 ½ weeks prior.

But if he was IUGR, he was not getting stronger in the two weeks after 39 weeks. He was struggling to survive despite a placenta that was depriving him of adequate oxygen and nutrients.

Sant had dodged a bullet, but she didn’t realize it.

This time around she was not so lucky. This baby was stillborn.

According to a post left on the Big Baby Project Facebook page, the baby died during labor:

This wonderful woman, Cherise Sant, who has been a support and strength to many, including this community, recently lost her sweet babe during childbirth. Please help them if you can. Look at her photos and let their story touch you. Spread the love!

Cherise Sant is a doula who headed up the Big Baby Project though she hadn’t had a big baby herself, she spent countless hours helping all women to have a wonderful birthing experience, no matter how big their baby was measuring.

She is very involved in the birthing and natural living communities.

She has been a strength and inspiration. I hope we can reach out to her now!

In other words, she inspired other women to play Russian Roulette by holding a figurative gun to their babies’ heads just like she did.

Inevitably, there is the obligatory plea for money accompanied by a heartbreakingly beautiful picture of a stillborn baby.

This baby lost his mother’s game of Russian Roulette. Perhaps his death may serve as an inspiration to women contemplating homebirth not to play Russian roulette with their babies’ lives.

*****

But, tragically that’s not all for March.

A Connecticut mother played Russian Roulette and her baby lost, too.

She was laboring at home at 41 1/2 weeks.

Her uterus ruptured and the baby died. The mother survived.

Her “midwives” are a CPM and a lay midwife.

This will be yet another opportunity for CPMs to practice “letting go.” It couldn’t be letting go of babies lives could it? It could.

As Lana Muniz writes:

Homebirth midwives “value the art of letting go.” Letting go of what, exactly? The lives of babies born at homebirths.

We know this because it’s written in the MANA Statement of Values and Ethics right on their website,

“… We value the art of letting go and acknowledge death and loss as possible outcomes of pregnancy and birth.”

It’s a disturbing statement coming from an organization that claims homebirth is safe, even though it’s 4 times more deadly than hospital birth.

Muniz provided chilling quotes from Professional Ethics in Midwifery Practice by Illysa Foster and Jon Lasser:

We value the acceptance of death as a possible outcome of birth. We value our focus as supporting life rather than avoiding death…

We place the emphasis of our care on supporting life (preventive measures, good nutrition, emotional health, etc.) and not pathology, diagnosis, treatment of problems, and heroic solutions in an attempt to preserve life at any cost of quality.

In other words, they place the emphasis on what they can provide (and bill for) and NOT diagnosis, NOT treatment of problems, NOT heroic solutions (all things they cannot provide and therefore cannot profit from).

They can provide preventive measures for playing Russian Roulette (nutrition, emotional health), but if you’re the unlucky mother with a bullet in the chamber when she figuratively fires into her baby, they not only can’t fix it, but, apparently, they don’t even think it is worth trying.

This is what “ethics” looks like in the world of homebirth midwifery. It’s a farce, just as their education and training is a farce.

*****

If you’re a mother thinking about homebirth, think again.

Do you really want to play Russian Roulette with your baby’s life? No doubt you think this couldn’t happen to you, but, then these mothers thought that too and now they are burying their babies.

It looks like I’m not the only one shocked by the response of UK midwives to the Morecambe Bay Report that places the blame for the preventable deaths of 11 babies and 1 mother squarely on midwives and their pursuit of “normal birth.”

According to the author of the report, Dr. Bill Kirkup:

All showed evidence of the same problems of poor clinical competence, insufficient recognition of risk, inappropriate pursuit of normal childbirth and failures of team-working.

In fact:

The midwives at Furness general were so cavalier they became known as “the musketeers”.

In an interview with reporter Shaun Lintern in yesterday’s Health Service Journal, Dr. Kirkup expressed his disappointment with the response (or, more accurately, the lack of response) from professional bodies. He singled out midwives in particular:

…[He] had also been “concerned” by some comments online which he described as “defensive.”

This included blogs by midwives suggesting the report was anti-midwives or against normal birth, while on social media relatives of those who suffered poor care at Morecambe Bay had been accused of “midwife bashing” and “retrospective negativity.”

This is a direct reference to last weeks’ Twitter chat held by WeMidwives that I wrote about in Being a UK midwife means you never have to say you’re sorry.

Indeed, midwifery leaders like Cathy Warwick and Sheena Byrom and their colleagues have been holding an impromptu master class on shirking responsibility, such as the Twitter response when Lintern tweeted highlights of the Kirkup interview and Sheena Byrom disparaged them as concerned with “blame.”

But Byrom is hardly alone in her desperate efforts to avoid accountability both for the specific tragedies at Morecambe Bay and for the midwifery philosophy of promoting normal birth that led to these tragedies (and others).

What methods have UK midwives used?

1. Ignoring the report

The report has been greeted in the midwifery community with the sound of silence. Cathy Warwick of the Royal College of Midwives has perfected the art of using a lot of words to say absolutely nothing. In  posts on her blog, such as this, she has issued meaningless platitudes and resolutely refused to discuss the core issues in the report.

2. Self-pity

Monday’s piece by an anonymous midwife in The Guardian (I loved being a midwife but bullying, stress and fear made me resign) is a sickening example of how midwives think everything is about themselves and their feelings, patients be damned. See the midwife turn the poor outcome* of a baby at her hands because she failed to recognize the severity of fetal distress into a tale of HER suffering:

The fetal heart is bad – but not bad enough to act. You continue this dance for hours until suddenly the heart trace is terrible – this baby is in real trouble. You press the emergency bell and the world runs into the room. You roll the woman this way and that, attach name bands and tape up earrings, you hold her hand as she is anaesthetised and whisper that the baby will be out soon. You knew something was wrong, but you didn’t have the words and no one listened.

Apparently the fetal heart rate was bad enough to act, but the midwife lacked the clinical competence to recognize it. She “didn’t have the words”??!! What does that even mean? How hard is it tell someone, ” the fetal heart rate indicates this baby is in distress”? Not hard at all, but the midwife didn’t do it.

3. Decrying a culture of “fear”

This is the meme of the moment in midwifery. Midwives are wailing about being held to standards, subject to scrutiny, and forced to use checklists.  What fear are they fighting. They’re fighting the fear of preventable maternal and neonatal deaths, the very things that these measures are designed to prevent.

This stunningly immoral and reflects a preoccupation with midwives’ “experience” over patients health and wellbeing.

4. Insisting that it is critical to “avoid blame”

This is the classic maneuver of anyone who fears accountability, but there are some situations in which blame is not merely appropriate, but absolutely necessary for the well being of all.

Imagine a drunk driver who killed a small child in an accident that occurred precisely because he was drunk. What if he told the judge that he should be allowed to go on his merry way because he didn’t intend the child should die, and therefore it is critical to “avoid blame”? We’d be rightly appalled.

The same principle applies to midwives who didn’t mean for babies and mothers to die preventable deaths because they were too committed to “normal birth” to call for interventions. They were to blame. Their philosophy of promoting “normal birth” is deadly and it is appropriate that we blame it and change it.

5. Insisting that problems can only be solved by “positivity” not negativity

That is just stupidity.

6. Banishing the deaths at Morecambe Bay to the “past”

Deaths due to drunk driving, faulty pharmaceuticals, and even intentional murder are all in the past, too. That doesn’t mean would shouldn’t look at them, learn from them, and hold those responsible for them to account.

7. Bullying on social media

Dr. Kirkup specifically noted the bullying that James Titcombe has been subjected to by midwives who think their professional autonomy is more important than whether other people’s babies live or die. He may not even be aware that WeMidwives chose to forward their “concerns” to his employer, the Care Quality Commission. What were they “concerned” about? He quoted me, whom they despise and fear (rightly so, since I intend to hold them to account). It is obviously pointless to bully me, so they tried to bully him.

and, most importantly,

8. Refusing to apologize

How hard is it to say, “We’re sorry. We allowed our preference for ‘normal birth’ to interfere with our ethical obligation to protect the health and well being of mothers and babies.”?

Apparently it’s very hard because it would require acknowledging the central moral and empirical defect at the heart of contemporary midwifery culture, the obsession with “normal birth.” Midwives have convinced themselves that normal birth isn’t merely better for them, it’s better for their patients. Acknowledging the many preventable deaths that followed ineluctably from this deadly philosophy would mean a wholesale attitude readjustment. Instead of viewing themselves as “guardians of normal birth” they’d be relegated to what they are in reality, mid-level maternity providers who are legally and ethical required to call high level providers like obstetricians, pediatricians and anesthesiologists even when it means sacrificing autonomy.

Unfortunately, for midwives, self-justification and preservation of their own autonomy takes precedence.

I consider myself a very cynical person, but even I am shocked by the brazen behavior of UK midwives. Not only do they feel no remorse for the preventable deaths at the hands of their colleagues, they feel free to flaunt their lack of remorse on social media. Not only do they refuse to be held accountable, they feel free to criticize anyone who dares hold them accountable. Not only do they refuse to recognize the full breadth of human suffering that took place at Morecambe Bay, they feel free to compound that suffering by chastising and bullying the sufferers.

To Cathy Warwick, Sheena Byrom and other UK midwifery leaders I say this:

Have you no shame??!!

*Edited 3/25/15 10 PM from “died” to “poor outcome” to reflect the fact that the midwife does not disclose what happened to the baby.

Everyone knows that breastfeeding provides benefits to babies. That’s true even in first world countries where the threat of pathogen contamination of the water used to prepare formula is nearly nonexistent.

Those benefits are so small, however, that they are measured in individual IQ points, and fewer episodes of mild neonatal illness like colds and diarrhea.

Nonetheless,among ambitious privilege parents in first world societies, incredible social pressure is brought to bear to force exclusive breastfeeding in the first six months. This pressure has been stimulated in large part by the efforts of lactivists (breastfeeding activists) and the breastfeeding industry, comprised of lactation consultants, and hospital credentialing agencies like the oxymoronically named Baby-Friendly Hospital initiative.

As a result, many infants are starving. Stories of breastfeeding failure abound and countless women are tormenting themselves and their babies, taking herbs, supplements, pumping around the clock, and refusing to supplement with formula in an effort achieve and maintain exclusive breastfeeding.

Which raises the question:

What are the long term consequences in brain function and other areas for babies whose mothers do not produce adequate milk and who, therefore, starve for weeks at a time?

The answer to that question, to my knowledge, is unknown.

We know that dehydration as a result of inadequate breastmilk can cause serious health problems in neonates.

Neonatal hypernatremic dehydration associated with breast-feeding malnutrition: a retrospective survey:

Hypernatremic dehydration in neonates is a potentially devastating condition. Recent reports have identified breast-feeding malnutrition as a key factor in its pathophysiology.

Breastfeeding-Associated Hypernatremia: Are We Missing the Diagnosis?:

The incidence of breastfeeding-associated hypernatremic dehydration among 3718 consecutive term and near-term hospitalized neonates was 1.9%, occurring for 70 infants…

Conclusion. Hypernatremic dehydration requiring hospitalization is common among breastfed neonates…

Fatal Hypernatremic Dehydration in Exclusively Breast-Fed Newborn Infants Due To Maternal Lactation Failure

In this case report, we describe unrecognized fatal hypernatremic dehydration in two exclusively breast-fed neonates due solely to failure of maternal lactation. We further describe epidemiologic and etiologic features of such deaths …

Fortunately, severe complications like death, seizures and permanent disability are relatively uncommon in first world countries, because most mothers will ultimately offer formula supplementation or will seek medical care and a pediatrician will strongly recommend formula supplementation.

The overwhelming number of babies who are getting inadequate breast milk will ultimately survive to get formula supplementation, but they (and their mothers) suffer greatly in the meantime.

I wrote last week about the mother who ultimately resorted to using her friend as a wet nurse after her baby languished for nearly a month without adequate food.

She wrote:

… I tried to be cheerful, but when we were alone, I wept, lashed out at my husband, and spiralled into exhausted, muddy irrationality, panicked about failing the precious boy we had only just met. There was very little distinction between day and night. Time took on a strange new cast. I nursed and pumped and nursed and pumped and nursed some more. I remember my husband singing to our crying son while I soaked my breasts in bowls of warm, salty water. I remember cooling my breasts with cabbage leaves, drinking herbal tinctures, pumping and pumping and pumping. I remember hoping each new lactation consultant was going to be The One. I remember hoping the midwife would drop by, or at least return a call. The baby was wetting nappies, but he needed to nurse constantly, and never got a full belly on which he (and I) could rest for a few hours.

Today on Gawker, another mother writes:

… I’d existed practically shirtless from the moment the baby was born, nursing her every time she whimpered or stirred. I gave her the smallest amount of formula I could soothe her with at a given time, having read that every ounce of formula I gave would be an ounce my body wouldn’t make. I was taking all the herbs all of the other lactation consultants had prescribed, pumping every time I had a spare moment. I was doing everything anyone had ever suggested might help. I was desperate to feed her. I was more determined to figure this out than I had ever been about anything in my life…

But my baby was hungry all the time. And very thin.

What happens to infant brains as a result of short term starvation?

It’s shocking that, as far as I know, there is no research on this question. We devote reams of scientific journals and endless pages of parenting websites to debating the subtle value of the additional antibodies in breastmilk, or the possible existence of unknown long chain fatty acids that may promote brain development in the critical early weeks of the neonatal period, but we devote no effort to determining the effect of the tremendous metabolic insult of starvation — lack of calories, lack of fluid, increased serum sodium, etc. — that occurs in those same critical early weeks of the neonatal period in a significant portion of infants whose mothers are attempting to breastfeed them exclusively.

We know that a significant proportion of women (5% or more) cannot produce enough breastmilk to fully nourish an infant. We know that, as a result, a significant proportion of babies spend days, or even weeks, starving, losing weight, hungry (and screaming) for hours at time, unable to settle or sleep.

That cannot be good for the developing neonatal brain.

Does it impede neonatal brain development? Do these infants lose IQ points?

We have no idea.

So why are we pressuring women into exclusive breastfeeding when have no clue whether we are consigning a significant proportion of infants not merely to weeks of misery but possibly a lifetime of subtle (or not so subtle) cognitive effects?

Bullies always go for what they perceive as the weakest link.

UK Midwives are very upset with me, upset with what I’ve written and even more upset because it’s all true.

Recently I’ve written:

1. Hypocrite! Midwife Sheena Byrom, who has publicly treated a loss parent viciously, edits a book about compassion:

Byrom ought to be ashamed of herself for the derisive way that she dismissed the father of a baby who died as a result of midwifery incompetence. But that would involve kindness, compassion and respect, something in woefully short supply among UK midwives.

Imagine my surprise, then, to find that Byrom has edited a book about kindness, compassion and respect in maternity care.

Apparently, what she means is kindness, compassion and respect for those who agree with her and vicious, disrespectful neglect of anyone else who dares criticize Byrom and her colleagues.

2. Being a UK midwife means you never have to say you’re sorry:

In the wake of the Morecambe Bay Report, which investigated the deaths of 11 babies and a mother and placed blame squarely on a midwifery culture that valued “normal birth” above all else, you might think that UK midwives would be in a mood of somber reflection about their deadly philosophy.

You would be wrong.

Yesterday I entered the weekly Twitter chat at the hashtag #WeMidwives hosted by the Royal College of Midwives (RCM). If I hadn’t been there myself, I would not have believed the smugness, meanness, utter lack of reflection and inability to tolerate criticism that characterized the Royal College of Midwives and it’s members.

Apparently, no matter how many dead babies, no matter how many dead mothers, being a UK midwife means you never have to say you’re sorry.

3. Midwives are wrong to fight fear in childbirth; it’s a lifesaving gift.

UK midwives’ desire to “fight fear” in childbirth is both grossly hypocritical and stunningly immoral. They want women to fear everything they can’t provide and they want women to ignore the legitimate, protective fear that they or their babies will be injured or die in life threatening emergencies that are all too common in childbirth.

4. And I’ve been participating quite vigorously in the comment section on The Guardian piece I loved being a midwife but bullying, stress and fear made me resign:

… I have never seen midwives or their defenders address is that “normal birth” is a construct of midwives, created for the benefit of midwives without any input from the majority of women. It is wrong for a provider to privilege process over outcome. A safe outcome should be the sine qua non of maternity care. A particular way of giving birth should NEVER be the goal except when a specific individual woman chooses it as HER goal.

Her body, her baby, her birth, NOT —- as it is now — her body, her baby, and the unmedicated vaginal birth that the midwife prefers, which never requires calling in anyone who might not support the midwife.

UK Midwives are very unhappy but apparently incapable of rebutting my claims or addressing my arguments.

Instead, they appear to be pressuring James Titcombe, whose baby died at the hands of midwives in Morecambe Bay, by sending the Twitter conversation about their unhappiness with his associations directly to his employer.

It appears that he tweeted a link to something I wrote. It’s hard to tell because he deleted it in response to their reaction.

WeMidwives

@JamesTitcombe of course. But this person is extreme & opinions personal & damaging. Suggest discuss your liaison with @CareQualityComm

And:

WeMidwives ‏@WeMidwives 2h2 hours ago

@JamesTitcombe @CareQualityComm think it would be wise to read @MidwiferyAction & listen to MWs in UK, not Obs in USA

So WeMidwives thinks it is perfectly acceptable to threaten a loss parent. That’s bad enough.

Why are they threatening him anyway? Because they think he can pressure me to stop.

They don’t know me very well, do they?

Let me state unequivocally (since they did “report” him by sending the tweet to his employer) that James Titcombe has nothing to do with what I’ve written in the past week about UK midwives. I don’t consult him; he doesn’t consult me; he has no control over what I write.

And let me publicly apologize to him for being a target of the wrath that UK midwives have for me. If they have a problem with me, they can address me directly.

Elsewhere in the Twitter feed, they claim:

we aren’t prepared to associate with this person-has no respect or credibility in UK

If that were the case, they wouldn’t be worried about me, and they are worried enough to threaten an innocent bystander.

Maybe someone familiar with the UK medical system can help me out here.

How can these midwives be so brazen as to pressure a loss parent publicly on social media?

Is their union so powerful that it doesn’t matter how they treat people?

Is anyone powerful enough to hold UK midwives to account for the deaths at their hands and for their outrageous, bullying behavior?

Or will the babies and mothers who die at the hands of UK midwives be buried twice, once in coffins in the ground and again by obliterating their deaths from public consciousness?

The meme of the moment in UK midwifery is “fight fear.” It is both hypocritical and immoral.

It’s the keystone of today’s piece in The Guardian by an anonymous midwife, I loved being a midwife, but bullying, stress and fear made me resign and at heart of the new book by UK midwives Sheila Byrom and Soo Downe, The Roar Behind the Silence.

I’ve already written about Byrom’s personal hypocrisy in editing a book about kindness, compassion and respect in maternity care, when she is on public record as treating with utter contempt a parent whose baby died at the hands of her colleagues. But the book itself is an example of the hypocrisy that is at the heart of contemporary UK midwifery theory. UK midwives are among the biggest fear-mongers around.

Before we look at what UK midwives mean by “fight fear,” it is worth considering the advice of security consultant Gavin de Becker who wrote the book The Gift of Fear.

True fear is a gift.
Unwarranted fear is a curse.
Learn how to tell the difference.

Or as this post on a Psychology Today blog explains:

Fear is helpful and safety-oriented whereas worry and anxiety are not helpful and related to phantom ‘possible’ events that often don’t happen. To that degree, worry and anxiety are distracting away from real fear signals that could help …

In other words, fear can be extremely beneficial in helping us avoid danger, while anxiety, generally related to possible events that don’t often happen, is harmful and may actually impede our ability to avoid real harm.

Indeed, fear of death (of the baby or mother) in childbirth has been the impetus for the interventions that have saved and continue to save hundreds of thousands of lives each and every year. In contrast, anxiety about interventions, from epidurals to C-sections, ruins the birth experience for many women and puts them and their babies at risk of injury and death.

What do UK midwives want to fight when they say “fight fear”?

Do they want to fight fear of epidurals?

Absolutely not. They encourage women to fear epidurals, wailing, “Drugs!” and emphasizing complications that are in reality less likely to occur than being killed by a lightning strike.

Do they want to fight fear of childbirth interventions?

Absolutely not. They encourage women to fear childbirth interventions by constantly invoking the dreaded “cascade of interventions.”

Do they want to fight fear of C-sections?

Are you kidding? Their efforts to demonize C-sections are notorious, and they don’t consider themselves restricted to the truth. From “C-sections interfere with bonding” (they don’t) to “C-sections change neonatal DNA” (they don’t), to the supposed “crisis” in maternity care represented by a C-section rate over 30%, no one can touch midwives when it comes to inspiring and creating fear.

So what do UK midwives really mean when they claim they want to fight fear?

Here’s what Sheena Byrom and Soo Downe have to say in the section ‘Fear as a driving principle of maternity care design and delivery’:

…For midwives and obstetricians, fear of recrimination, litigation, negative media exposure and loss of livelihood potentially contributes to defensive practice…

Of course, none of these things — recrimination, litigation, negative media exposure and loss of livelihood — occur UNLESS a baby or mother is injured or dies in childbirth.

The fear that UK midwives want to fight is PROTECTIVE fear of death of a mother or baby in childbirth.

They lament:

In maternity services in England, this issue has been exacerbated since the publication of the Mid Staffordshire Trust public enquiry, with a subsequent increase in internal and external service reviews and a fear of bad publicity of imposed special measures.

Why was the Mid Staffordshire inquiry undertaken?

According to The Guardian:

An estimated 400-1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital, a small district general hospital in Staffordshire. The report being published on 6 February 2013 of the public inquiry chaired by Robert Francis QC will be the fifth official report into the scandal since 2009, and Francis’s second into the hospital’s failings.

The often horrifying evidence that has emerged means “Mid Staffs” has become a byword for NHS care at its most negligent. It is often described as the worst hospital care scandal of recent times. In 2009 Sir Ian Kennedy, the chairman of the Healthcare Commission, the regulator of NHS care standards at the time, said it was the most shocking scandal he had investigated.

What did the Mid Staffordshire Trust report (Francis Report) find?

The very first sentence of the Executive Summary lays it out quite plainly:

Between 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area.

Byrom and Downe don’t lament the hundreds of unnecessary deaths that occurred in “conditions of appalling care.” They don’t even mention the hundreds of people who died unnecessarily, enduring horrific suffering. No, Byrom and Downe lament the extra supervision and scrutiny that were put in place to prevent another similar episode.

Byrom and Downe’s book went to press before the recent publication of the Morecambe Bay Report, often compared to the Mid Staffordshire report, which found that 11 babies and one mother died preventible deaths at the hands of midwives:

[M]idwifery care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care… [W]e heard that midwives took over the risk assessment process without in many cases discussing intended care with obstetricians, and we found repeated instances of women inappropriately classified as being at low risk and managed incorrectly. We also heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care…

Why did this happen? Because the midwives did NOT fear the inherent deadly dangers of childbirth. It is this fear that they are fighting.

Toward this end, they recognize no limits in encouraging fear of epidurals, fear of childbirth interventions, fear of C-sections (all of which, not coincidentally, they cannot provide), but they abhor fear of the very real risk of DEATH and serious injury in childbirth (which, not coincidentally, they can’t prevent).

UK midwives’ desire to “fight fear” in childbirth is both grossly hypocritical and stunningly immoral. They want women to fear everything they can’t provide and they want women to ignore the legitimate, protective fear that they or their babies will be injured or die in life threatening emergencies that are all too common in childbirth.

UK midwives are the equivalent of an auto manufacturer touting a car that doesn’t have seat belt, air bags or other safety devices:

It costs less!
Crashes are rare!
Seatbelts interfere with freedom of movement!
Seatbelts could trap you in the event of a car fire!
Fight fear of being killed in a car crash!

Most of us are savvy enough to recognize that such an auto manufacturer would have only its bottom line in mind and would be encouraging anxiety over unlikely possible events while discouraging the protective fear that saves lives by being prepared for a car crash.

Similarly, we should be savvy enough to recognize that UK midwives have only their own benefit in mind when encouraging anxiety over epidurals, interventions and C-section, while discouraging the protective fear of death and injury that saves lives by being prepared for life threatening events in childbirth.

As de Becker said, fear is a gift, unwarranted fear is a curse and everyone must learn how to tell the difference.

UK midwives discourage life saving fear, substitute unwarranted anxieties in its place, and women and babies die because midwives cannot or will not recognize the difference.

Talk about hypocrisy!

UK midwife Sheena Byrom, whom I’ve called out for viciousness in the past, has edited a new book The Roar Behind the Silence: Why kindness, compassion and respect matter in maternity care

The UK is experiencing a crisis in midwifery. The recently released Morecambe Bay Report decried a midwifery culture which allowed 11 babies and 1 mother to die preventable deaths at the hands of midwives and then participated in a cover up.

All showed evidence of the same problems of poor clinical competence, insufficient recognition of risk, inappropriate pursuit of normal childbirth and failures of team-working,” Kirkup said. (my emphasis)

These failures were compounded by a culture of silence in which midwives protected each other rather than mothers and babies.

James Titcombe is one of the loss parents who has tirelessly fought for justice for his son Joshua; the baby died of a treatable infection when midwives refused to call a pediatrician despite pleas from his parents that he was obviously ill.

Sheena Byrom has publicly treated James Titcombe with unspeakable contempt.

Byrom and colleagues were having a public Twitter confab on the use of social media during and after birth (just like nature intended, no doubt). Byrom tweeted that hospital policies appeared to be dictated by risk and “all this talk about risk. Not comfortable with it.”

James entered the Twitter stream to point out that childbirth is indeed quite dangerous. He should know. His son died as a result of an infection acquired during birth.

A chilling response from Byrom and colleagues followed:

Highlights include:

oh James-don’t let’s get on that roll again …

and:

getting out of bed in the morning has risks

Yes, James, how could you be so tiresome, always going on about the risks of childbirth and the babies who die as a result? Sheena is so over that.

Byrom ought to be ashamed of herself for the derisive way that she dismissed the father of a baby who died as a result of midwifery incompetence. But that would involve kindness, compassion and respect, something in woefully short supply among UK midwives.

Imagine my surprise, then, to find that Byrom has edited a book about kindness, compassion and respect in maternity care.

Apparently, what she means is kindness, compassion and respect for those who agree with her and vicious, disrespectful neglect of anyone else who dares criticize Byrom and her colleagues.

I left a comment on the Amazon UK website.

Nearly twenty colleagues, as well as Byrom herself, rushed to her defense in comments on my review.

No one denied the truth of the allegations that she had treated a loss parent contemptuously. How could they? The proof exists in black and white.

No one offered a defense of Byrom’s disrespectful comments to Mr. Titcombe. How could they? There is no defense for that type of behavior.

No one suggested that she retract her comments and offer Mr. Titcombe a public apology. Of course not. That would mean a UK midwife taking responsibility for her own actions.

Instead they offered her their unqualified support … in the exact same way that the midwives who let babies and mothers die at Morecambe Bay offered each other unqualified support.

I left a follow up comment:

The fact that Byrom’s colleagues defend her is just another example of the problem. Her treatment of a loss parent was, and continues to be, hideous. No one, including Byrom herself has claimed that the cruel, disrespectful statements I quoted are untrue. She said them and she meant them and assumed that no one of any importance would notice.

A culture where midwives protect each other while they let babies die or speak cruelly and disrespectfully to parents who don’t agree with them is an unacceptable culture. UK midwives need to hold each other to account. That’s what ethical professionals do. Byrom should apologize to Mr. Titcombe and should be kind, compassionate and respectful to ALL parents, not just the ones who agree with her views on childbirth. Otherwise there will continue to be tragedies like the horror at Morecambe Bay.

I realize that in the scheme of UK midwifery I am an unimportant critic across the pond, but I can’t let Ms. Byrom’s hideous treatment of Mr. Titcombe go unchallenged. I feel compelled to call attention to the babies and mothers that UK midwives have tried to bury twice, first in coffins in the ground and then by refusing to learn from their deaths or be held accountable.

Ms. Byrom and her colleagues have apparently learned NOTHING from multiple tragedies.

A post about Midwifery reflections on the Kirkup report could best be summarized as “mistakes were made but not by us.”

Ms. Byrom’s response shows that she is part of the problem, not part of the solution:

Protecting normal birth is a midwife’s core function …

No! Protecting MOTHERS and BABIES is a midwife’s core function. Privileging process over outcome is unethical and immoral. It is just this attitude that led to the deaths at Morecambe Bay and the years of effort to cover up those deaths.

Unless and until midwives like Sheena Byrom acknowledge their complicity in a dysfunctional midwifery culture in which midwives place their interests above the health and lives of mothers and babies, innocents will continue to die.

How about it, Ms. Byrom? Will you please publicly apologize to Mr. Titcombe and acknowledge that your contemptuous treatment has no place in contemporary midwifery?

I’ll be waiting.

Not surprisingly, the authors of a new study on breastfeeding and IQ led with the information likely to generate the best headline, Breastfeeding ‘linked to higher IQ’:

A long-term study has pointed to a link between breastfeeding and intelligence.

The research in Brazil traced nearly 3,500 babies, from all walks of life, and found those who had been breastfed for longer went on to score higher on IQ tests as adults.

Experts say the results, while not conclusive, appear to back current advice that babies should be exclusively breastfed for six months.

But the study, Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil, which shows that breastfeeding might have an impact on IQ of up to 3.76 points also demonstrates that just about anything else has a far greater impact on IQ than breastfeeding.

Consider this graph showing the impact of breastfeeding on IQ stratified by family income:

The graph shows several interesting things:

1. Breastfeeding for less than a month has no impact on IQ
2. Breastfeeding for more than a year has no impact on IQ in infants from high income families.
And, most importantly, the impact of breastfeeding on IQ is dwarfed by the impact on IQ of

Maternal education

Birth weight

Family income

(All graphs shows babies that were breastfed for 6 months.)

Arguably, if a mother wants to have the greatest impact on her baby’s IQ, she should go back to work rather than breastfeed.

The BBC piece acknowledges the contribution of many variables to IQ:

Regarding the findings – published in The Lancet Global Health – they stress there are many different factors other than breastfeeding that could have an impact on intelligence, although the researchers did try to rule out the main confounders, such as mother’s education, family income and birth weight.

Dr Bernardo Lessa Horta, from the Federal University of Pelotas in Brazil, said his study offers a unique insight because in the population he studied, breastfeeding was evenly distributed across social class – not something just practised by the rich and educated.

Most of the babies, irrespective of social class, were breastfed – some for less than a month and others for more than a year.

Those who were breastfed for longer scored higher on measures of intelligence as adults.

They were also more likely to earn a higher wage and to have completed more schooling…

Dr Horta believes breast milk may offer an advantage because it is a good source of long-chain saturated fatty acids which are essential for brain development.

But experts say the study findings cannot confirm this and that much more research is needed to explore any possible link between breastfeeding and intelligence.

In Brazil the impact of income of breastfeeding rates is very different than in higher income countries. In the US, for example, breastfeeding is correlated with family income; the higher the family income, the greater the likelihood that an infant will be breastfed. In Brazil, breastfeeding rates were highest at either end of the income spectrum, the very poor were as likely to breastfeed as the very rich. Indeed 80% of the children in the study were breastfed at for at least a full month. And that raises an important question.

In this study, the authors assume that breastfeeding in an independent variable that depends almost entirely on maternal desire. But in a country where breastfeeding is the norm, it may be that the duration of breastfeeding reflects the success of breastfeeding. In other words, women who breastfed for only a short duration stopped not because they didn’t want to continue, but because their babies were showing signs of malnutrition. The fact that babies breastfed for less than a month had lower IQ scores at age 30 might be a reflection of malnutrition in the early weeks, not a lack of breastmilk.

This is a good study. The authors followed a large cohort of infants through adulthood. They carefully controlled for confounding variables. They showed that breastfeeding up to 12 months (but not longer) has a small but measurable impact not merely on IQ, but also on educational attainment and income. But the study also has some significant limitations. The authors did not control for the most important confounding variable, parental IQ. They assumed that income and educational attainment were proxies for IQ, but they did not demonstrate that. One third of the study participants were lost to follow up and they may differ in important ways from those who were available for follow up.

Ultimately, though, the authors showed that the impact of breastfeeding on IQ pales in significance to the impact of everything from birth weight to maternal educational attainment to family income.

The take away message should be:

If you want to improve your future child’s IQ, you should stay in school, work hard and get good prenatal care so you can have a larger infant. If you want to improve your child’s IQ slightly beyond that, you can breastfeed. But it may not be only the breastfeeding that impacts IQ but whether the mother can produce enough breastmilk. Breastfeeding a baby who isn’t getting enough to eat may actually be far worse than not breastfeeding at all.

In the wake of the Morecambe Bay Report, which investigated the deaths of 11 babies and a mother and placed blame squarely on a midwifery culture that valued “normal birth” above all else, you might think that UK midwives would be in a mood of somber reflection about their deadly philosophy.

You would be wrong.

Yesterday I entered the weekly Twitter chat at the hashtag #WeMidwives hosted by the Royal College of Midwives (RCM). If I hadn’t been there myself, I would not have believed the smugness, meanness, utter lack of reflection and inability to tolerate criticism that characterized the Royal College of Midwives and its members.

Apparently, no matter how many dead babies, no matter how many dead mothers, being a UK midwife means you never have to say you’re sorry.

The topic of the chat was the latest in deadly midwifery philosophy, the RCM Better Births Initiative.

The Better Births initiative started in May 2014 with the aim of developing service-led and evidence-informed resources for maternity care in the UK covering the antenatal, intrapartum and the postnatal periods.

The three themes that we are focussing [sic] on are:

1 The promotion of normal births for majority of the women and normalisation for all women, achieving normality…

In other words, it is the new iteration of the Campaign for Normal Birth, yet another example of MIDWIFE-centered care.

What about MOTHER-centered care? Don’t be naive. UK midwives apparently believe that if it is good for them, it must follow that it is good for mothers. They seem intellectually incapable of differentiating their interests from their ethical obligations to women and babies.

What is normal birth? It is never explicitly defined, but the fundamental RCM belief appears to be that if a midwife can do it, it’s normal and if only a doctor (obstetrician, pediatrician, anesthesiologist) can do it, it’s abnormal and to be abhorred and eliminated.

You can follow nearly the entire chat on Twitter at #WeMidwives. The topic was “What does better births look like for you and why?” The narcissism of a group of health professionals placing their vision of birth above the mother’s needs and desires is truly mind boggling, not to mention thoroughly unethical.

Below are a few exchanges that will give the flavor of the discussion:

Me: @MidwivesRCM Shouldn’t focus be on what better birth looks like to MOTHERS, not midwives? #WeMidwives

RCM: (No response.)

Me: When will RCM acknowledge that Campaign for Normal Birth led to the Morecambe Bay horror? #WeMidwives

Everyone else: (No response.)

James Titcombe (father of a baby who died at Morecambe Bay): How will better births ensure this type of culture doesn’t develop again? #WeMidwives

Newberry Doula: Inappropriate care fm all levels of staff is more likely in overstretched systems IMO. OBs failed too #WeMidwives

Only one midwife had the integrity to state the obvious:

Geraldine Butcher: @MidwivesRCM @WeMidwives hi need to listen to what we don’t want to hear as well as what we do #wemidwives

The rest of the conversations were meaningless platitudes …

Or worse:

And, of course, the inevitable:

And the chilling:

Why won’t the Royal College of Midwives or its members apologize for the deaths that occurred at their hands?

Cognitive dissonance:

…[H]ow do we square two dissonant cognitions when one of them is the belief that we are decent people and the other is the knowledge that we have inflicted pain on an innocent victim?

Ask any kid who wallops a younger brother. “I’m decent, but I hit him,” the argument runs, “therefore he must have deserved it.” It’s the most vicious of circles. Aggression begets self-justification, which begets more aggression, and thus do the authors lead us, one small step at a time, down the road to Abu Ghraib and to all those deeds throughout the ages whose doers were never the monsters we’d prefer them to be but just decent people like us.

And at the end of the day, when the time comes for decent people to tell their story, self-justification is left holding the pen.

According to The Advantages of Not Saying You Are Sorry in Scientific American:

Given that apologies offer a relatively simple way to mend relations and heal wounds for victims and offenders, why do people refuse to apologize? Beyond escaping punishment, there may be some psychological benefits to standing one’s ground. For example, adopting a self-righteous stance may feed one’s need for power. If the act of apologizing restores power to the victim, it may also simultaneously diminish the power of the transgressor. Thus actively denying any wrongdoing may allow the offender to retain the upper hand…

A second possible benefit of standing one’s ground in the face of an accusation is saving face. No one wants to admit to being a hypocrite. Inherent in an apology is the admission that one’s behavior failed to align with personal values and morals, as people generally don’t apologize for actions they believe are right and just. Thus when we admit that we are wrong, we expose the fact that we may talk the talk, but we do not walk the walk…

So rather than apologizing for a deadly philosophy and catastrophic failures that resulted in multiple deaths, the RCM and UK midwives have doubled down by refusing to reflect, refusing to take responsibility, refusing to express remorse. Instead they figuratively put their fingers in their ears, blocking those who ask uncomfortable questions in an effort to pretend that criticism doesn’t exist and there is no need to think about past errors. Hence the Twitter chat ended with the RCM praising its members and “celebrating your efforts :)”.

What the RCM fails to recognize is that babies and mothers will continue to die at the hands of their members as long as they continue to evade responsibility for the fatalities that have already occurred as a result of a midwife-centered philosophy that values process over outcome and gives pride of place to midwives’ needs and desires while ignoring those of mothers and babies.

Commentor Cordy, a midwifery student, advised, “don’t be worried she is 1 we are many.”

Here’s my advice:

Be worried!

I may be one, but my voice is transmitted around the globe thousands of times each day. And I’m not the only one. Brave parents, like James Titcombe, battling heartache but faithful to the memory of their precious loved ones will not stop until midwives accept responsibility for their actions and their philosophy.

Be worried!

Your behavior is unethical, immoral, self-serving and harms innocents. I don’t know how many babies and mothers will have to die before midwives will be held to account, but I do know that the day of reckoning is coming.

In the summer of 2000 I was diagnosed with a brain tumor.

I had developed double vision because a meningioma, a benign tumor, was pressing on cranial nerve VI, the one that controlled the movement of my left eye. The tumor was small, but it was located in an awkward place near the center of my brain. That meant that surgery to remove the tumor would likely damage the nerves that controlled sensation in my face and my hearing on the left side.

Surgery was, until shortly before that point, the only option for treatment. However, as a physician I had access to those who knew about the latest treatment options. A dear friend, a neuro-radiologist, told me about stereo-tactic (“gamma knife”) radiosurgery, which is not surgery at all, but a one day course of radiation to kill the tumor.

I consulted a neurosurgeon, widely reputed to be one of the best in the US, to find out what he recommended. He recommended surgery.

I asked him:

Which treatment had the highest cure rate?

He told me that surgery had a cure rate of 85% and the gamma knife had a cure rate of 95%.

Which treatment had the highest complication rate?

He told me that surgery would likely lead to loss of sensation on the left side of my face and deafness in my left ear. The gamma knife had no complications beyond local irritation.

If the gamma knife treatment failed, would that make subsequent surgery more risky?

He told me that it would have no effect.

So I asked him why he was recommending surgery if the gamma knife had a higher cure rate and a lower complication rate. He replied honestly:

“I don’t do the gamma knife.”

In other words, he was recommending what was best for him, not what was best for me. It could have been worse; had he believed that he couldn’t successfully perform the surgery or offer the gamma knife, he could have told me not to worry, my brain tumor didn’t need any treatment at all.

And that could be the unethical motto at the heart of contemporary midwifery theory: If she can’t do it, you don’t need it.

Consider the midwifery stories that have appeared in the news within the past few weeks.

1. An update from the inquest into the death of Australian homebirth advocate Caroline Lovell.

A Melbourne mother who died after the home birth of her daughter pleaded with her husband to call an ambulance because she felt she was going to die, the Victorian Coroners Court has heard…

Paramedic Marie Daley noted that Nick Lovell had told her at the scene that his wife had grabbed him by his shirt, looked him in the eye and pleaded with him for help,

“‘Nick I’m telling you, you need to call an ambulance, I’m going to die’…

But midwife Gaye Demanuele did not call an ambulance.

The inquest had previously heard that the now unregistered midwife Gaye Demanuele believed Ms Lovell was panicking and did not identify any physical symptoms, which she expressed to Mr Lovell when his wife started hyperventilating…

… [T]he obstetrician at the Austin on the night, Dr Claire Petterson, estimat[ed] Ms Lovell lost three litres of blood. The midwives estimated Ms Lovell had lost 400 millilitres in the birthing pool.

The midwife did know how to manage postpartum hemorrhage, so she insisted that the patient was not having a postpartum hemorrhage.

2. The failure of British midwives to consult a pediatrician for Joshua Titcombe as detailed in the Morecambe Bay Report. Joshua was seriously ill with an infection, but midwives insisted that he was fine. They couldn’t care for a neonatal infection so they insisted that there was no infection.

3. The New Zealand midwife who missed the homebirth (how often have we heard that story?) and then when the patient complained about severe perineal pain, the midwife insisted that the tear would heal itself if the patient was “ladylike” just kept her legs together The midwife didn’t know how to suture a tear so she insisted that the tear did not need to be sutured.

4. Oregon homebirth midwife Joanna Jech who ignored a mother’s pre-eclampsia, and when the patient went into labor and the fetal heart rate became undetectable, waited 19 minutes before calling 911. The baby was stillborn at the hospital. The midwife would have been required to transfer care of the patient to a physician if she diagnosed pre-eclampsia so she simply insisted that the patient didn’t have pre-eclampsia. She couldn’t treat fetal distress in labor so ignored it for 19 minutes before calling for emergency assistance.

These incidents, though they involved different midwives at different times and in different countries share a glaring ethical lapse: if the midwife couldn’t provide the appropriate care, she insisted that the patient didn’t need it.

As the story of my brain tumor indicates, this ethical lapse is not restricted to midwives, but in the case of midwives has seemingly become part of the professional ethos. The midwifery commitment to “normal birth” is a commitment to what benefits THEM, not what is safest for their patients. Their efforts to demonize obstetrical interventions benefits THEM, not mothers or babies. Their portrayal of the C-section rate as a medical crisis benefits THEM, not mothers or babies.

No doubt many of the midwives believe that “normal birth” is better, safer and healthier despite the fact that there is no scientific evidence to support that claim. It’s a classic example of “where you stand depends on where you sit.” Midwives need to confront their unethical behavior by acknowledging that their commitment to “normal birth” is a commitment to personal benefit, a factor that has no place in the ethical provision of health care.

Elisa Albert wrote a powerful piece for The Guardian entitled My friend breastfed my baby.

The writing is lyrical, the author’s anguish is palpable and the story has a happy ending.

Unfortunately, Albert never questions the real cause of her misery, her unflective acceptance of the anti-feminist propaganda of the natural parenting movement.

Albert had an unintentionally unassisted homebirth of a healthy son because her midwife failed to show up (how many times have we heard that story?).

…I gave birth at home, after a 13-hour posterior, or back-to-back, labour, which the long-practising, well-respected midwife did not bother to attend…

She had difficulty breastfeeding. Her son languished for an entire month, underfed most of that time.

At a week-and-a-half old, my baby began to lose weight. Breastfeeding was not going well. This was not abnormal, we were reassured… One lactation consultant offered advice that was contradicted by a second, whose advice was contradicted by a third. I should use a breast pump every two hours. I should supplement with formula. I should neither pump nor supplement; I should let him get so hungry he would do whatever it took to latch properly. Around and around we went.

Albert sunk into despair:

The imperative to feed my baby from myself blotted out the sun.

She was touchingly grateful when her best friend breastfed her baby.

I handed the baby to her and collapsed into a nearby chair to sob and thank her and sob and thank her, over and over again. The baby drank and drank and drank. His latch was indeed shallow, but she had a surfeit of compensatory milk…

The baby was no doubt grateful to finally eat his fill. Albert spent the next 3 months working strenuously toward exclusively breastfeeding her baby.

I supplemented with formula until I got nursing on track, which took three months, biweekly follow-ups, a hospital-grade rental pump, and a level of determination and commitment I was proud to discover I had…

At no point in what were literally months of misery did Albert ever question the toxic, anti-feminist assumptions that were the real cause of her anguish. Sadly, her story will probably contribute the to the anguish of other mothers who find themselves in the same situation.

Why did Albert, undoubtedly an otherwise sensible woman, come to feel that breastfeeding was so important that it “blotted out the sun”?

It’s pretty simple actually. She believed the New Age version of age old sexism: that a woman’s worth resides in her uterus, vagina and breasts.

I was supposed to accept that, because breastfeeding was exceedingly difficult, I could not do it. I was supposed to concede to that potent cocktail of bad advice that devalues the functional power of the female body. To which I said, and still say: no.

“Valuing the functional power of the female body” is profoundly retrograde. We should be valuing the power of the female mind and character, and relegating reproductive choices to what they are: personal choices that tell us NOTHING about whether a woman is a good woman or even a good mother.

Ms. Albert does not question the absurd propaganda of the lactivist movement that refuses to recognize that not all woman and not all babies can successfully breastfeed and the wholesale rewriting of history to blame formula use on formula manufacturers.

For most of human history, wet nurses were exceedingly common. The best of the best made an excellent living as highly prized employees. Sisters and good friends nursed each other’s babies as a matter of convenience. But 100 years of aggressive formula marketing has effectively erased the tradition of women helping each other in this way.

No, for most of human history, babies who had trouble breastfeeding were not rescued by wet nurses; they died. Wet nurses were not exceedingly common. They were an affectation of privileged women who didn’t want to breastfeed, an aristocracy who hired other women (or used slaves) to do offload what they viewed as an animal function onto lesser beings whom they viewed as closer to animals.

Formula was invented NOT as a substitute for breastfeeding, but as a substitute for everything under the sun, much of it dangerous, that was being used to feed infants who couldn’t successfully breastfeed, or whose mothers had died in childbirth.

Formula companies never had to market aggressively because the need for formula is so high. The marketing that formula companies do is NOT to convince women to bottlefeed, it is to convince women who were going to bottlefeed anyway to choose one brand over another.

Albert does not question the fact that lactivism gives short shrift to infant suffering. Her baby was starving, literally since babies should not lose weight. That suffering could have been entirely averted by using formula as soon as it became apparent that Albert was not producing enough breastmilk. But lactivism insists that there is no amount of infant agony (and that’s what hunger is for infants) that is not justified by the purported benefits of breastmilk, which in first world countries are actually trivial.

Albert no doubt views her story as one of female triumph where one woman assisted another until she, through months of misery and perseverence, ultimately breastfed her infant exclusively.

But there is another way to look at this story, one that I suspect is closer to the truth:

It’s a triumph of the toxic propaganda of the breastfeeding industry, the one that makes 100% of its income from convincing women to breastfeed. It’s a story of infant starvation and suffering that could have been averted by feeding the baby formula. It is a story of maternal misery and feelings of inadequacy that rests entirely on the exaggeration of the small benefits of breastfeeding, and the sexist belief that women should be judged by the function of their reproductive organs.

This is not a story of the power of women. It is a story of their loss of power to a philosophy that harms women and harms babies, and is so insidious that even women as sophisticated as Albert fail to recognize for it for what it is: yet another way to make money by inducing women’s anxiety about their bodies.