I knew this day was coming, but I’m pleased that it has arrived sooner than I expected. Lactation professionals are backpedaling as fast as they can.

I’ve been writing for years that lactation professionals in general, and Baby Friendly USA in particular, have been ignoring scientific evidence in favor of personal biases. Babies and mothers are suffering (and in the case of babies, dying) as a result.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The scientific evidence shows: Fed Is Best![/pullquote]

Along comes Marsha Walker, IBCLC to confirm it.

Walker essentially proves the contention of the JAMA paper that she is commenting upon. That paper found that the World Health Organization reviewed the latest evidence on breastfeeding and then proceeded to IGNORE it.

Specifically, the WHO noted but ignored the scientific evidence that pacifiers reduce the incidence of SIDS, that pacifiers do NOT interfere with breastfeeding and that early judicious formula supplementation does NOT interfere with breastfeeding. In addition, the WHO recommended policies for which there is NO EVIDENCE, including mandatory rooming in of babies and mothers, skin-to-skin beyond the first hour after birth, and the use of donor milk instead of formula for term infants.

The authors conclude that in both cases, stakeholder bias was allowed to take precedence over the actual scientific evidence.

This is a powerful critique (and confirmation of much of what I’ve been writing for years) but Walker tries to justify ignoring the scientific evidence that she doesn’t like. We don’t need high quality evidence for breastfeeding policies because breastfeeding is natural!

The use of the GRADE method and systematic reviews in this synopsis may not necessarily represent the best framework for evaluating interventions for an essentially normal process. Breastfeeding is not a medical problem…

This is so disingenuous that I wonder if Walker actually believes it. I doubt that she would accept scientific evidence that contradicts what she believes about breastfeeding UNLESS it was evidence of the highest quality. So to argue that it can be ignored BECAUSE it is the highest quality is bizarre.

The response by Bass, one of the authors of the original paper, is devastating:

Her statement that the synopsis used the GRADE method is inaccurate because that evidence assessment method was actually used by the World Health Organization (WHO)2 and is widely used and respected because of its rigorous approach to evidence rating. Suggesting that a lower level of evidence was warranted because breastfeeding is not a medical problem reflects confusion concerning the purpose of the BFHI guideline: to analyze the best manner to support breastfeeding, not to judge the value of breastfeeding.

Furthermore:

This resistance to evidence that challenges BFUSA compliance criteria can inadvertently result in unsafe outcomes including sudden unexpected postnatal collapse4 and newborn falls, which have been associated with BF designation…

But Walker is hardly the only lactation professional attempting to backpedal as fast as she can.

Prof. Amy Brown is arguably the fastest backpeddler of them all.

In her latest piece for HuffPo, Brown is shocked, shocked to discover that some women cannot produce enough breastmilk. This represents a complete about face from articles she has written in the past.

In May of 2016, in the cruelly title article Why Fed Will Never Be Best Brown claimed:

Physiologically speaking only around 2% of women should be unable to breastfeed …

[T]he reason why we are struggling so much with breastfeeding is for most not initially a physiological issue…

As recently as December 2018, Brown had the temerity to suggest that women who alert others to the risks of insufficient breastmilk should be ignored:

Try not to pay too much attention to breastfeeding horror stories. People like to share stories – it makes them feel better – without thinking about the consequences for you.

There’s no mention in that piece of what Brown just discovered: some of those horror stories are true.

But give Brown credit for smartly performing an about face. Now not only is insufficient breastmilk much more common that Brown previously acknowledged, it’s the fault of doctors!

Given the breadth and depth of medical knowledge, why do women still not have answers if they can’t breastfeed?

How lovely that after years of repeatedly being informed by women that they weren’t breastfeeding because they had inadequate milk supply, Prof. Brown has suddenly discovered that some women have inadequate milk supply. For years women have struggled with shame, guilt and self-hatred induced by lactation professionals like Brown who refused to listen and berated them instead. I wonder if she plans on apologizing for her years of gaslighting these suffering women and treating them cruelly. Somehow I doubt it.

What’s the take away message from all this lactivist backpedaling?

First, as I and the Fed Is Best founders have been writing for years, contemporary breastfeeding promotion efforts like the Baby Friendly Hospital Iniaitive IGNORE the scientific evidence.

Second, babies and mothers have been harmed by the lactivist insistence on placing their personal biases above the scientific evidence.

Third, lactation professionals aren’t going to back down without a fight.

Whether it’s Marsha Walker pathetically insisting that we can ignore high quality scientific evidence because breastfeeding is natural or Amy Brown brazenly insisting that the problem of insufficient breastmilk — a problem whose existence she denied until yesterday — is both real and the fault of doctors, lactation professionals will maintain breast is best for every baby and every mother. It doesn’t matter to them both scientific evidence and real world experience show that’s a lie. That’s why you should ignore lactation professionals who ignore scientific evidence.

The final take away message is the most important of all:

Fed Is Best!

Lactation professionals don’t think much of women and their ability to make decisions; they are sure that women who choose to formula feed are ignorant dupes.

In Reproductive Health and Maternal Sacrifice, sociologist Pam Lowe offers an excellent description of lactivism in general and the Baby Friendly Hospital Initiative in particular.

And:

The underlying assumption behind BFI, and many other breastfeeding campaigns, is that women who decline breastfeeding only do so through ignorance or as the dupes of formula marketing campaigns. Palmer is typical of this position. She suggests that infant feeding companies as well as ill-informed experts have contributed to a loss of faith in breastfeeding… “[W]hilst women should have a choice, they should all be informed that formula milk is signicantly detrimental to their baby’s health.” This is hardly a neutral position and is not necessarily based on the evidence…

But is that really why some women don’t breastfeed?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation professionals resolutely ignore factors beyond women’s control, preferring to blame mothers or society.[/pullquote]

The answer makes a big difference in assessing the ethics of breastfeeding promotion so it’s worth giving serious thought to the way we attribute causes to behavior, known in psychology (not suprisingly) as attribution theory.

Consider Weiner’s attribution theory of controllability. It sounds complicated, but it’s not hard to understand:

Weiner’s achievement attribution has three categories:

stable theory (stable and unstable)
locus of control (internal and external)
controllability (controllable or uncontrollable)

Stability influences individuals’ expectancy about their future; control is related with individuals’ persistence on mission; causality influences emotional responses to the outcome of task.

The theory is often represented graphically like this:

Each factor is vital to the outcome, whether that outcome is a grade on a test or a winner of a race. The key to success for a paticular individual will depend on the mix of controllable vs. uncontrollable factors, but only the controllable factors can be improved by effort or undermined by lack of support.

So, for example, a student’s grade on a particular test can be attributed to intellectual ability, effort at studying, difficulty of the test and luck (not feeling ill on the day of the test, for example).

If a student gets a bad grade on a test and wants to do better next time, he can study harder and get tutoring support, but he cannot change his innate intellectual ability and he cannot control external factors like illness that can impact his performance.

It is perfectly reasonable for a teacher to chide this student for not trying hard enough, or to blame herself for not making the lesson clear enough, but she should not berate the student for inherent lack of intelligence or other factors over which he has no control.

What does this have to do with breastfeeding?

I’ve modified the chart to encompass the factors involved in successful breastfeeding:

A mother who breastfeeds successfully will have adequate milk supply, and extend the effort (and endure the sleeplessness and possible discomfort) to teach the baby how to breastfeed and ensure that he or she is getting enough. She will also have the support she needs and not be swayed by the marketing efforts of formula companies. Finally, she will have a baby that is able to breastfeed and she herself will be healthy enough to breastfeed (no serious childbirth complications, etc).

Each of these factors is essential to ensuring successful breastfeeding and that has important implications for how we attribute “fault” when a woman cannot breastfeed or chooses not to do so.

In my view, the critical (and dangerous) problem with contemporary lactivist efforts, especially the Baby Friendly Hospital Initiative, is that they fail to take into account ALL factors and ascribe outsize influence to only two.

Consider the ability to produce adequate milk supply, the sine qua non of successful breastfeeding. There is a biological limit to what many women can produce. Some women will have inadequate supply in the first few days; some women will always have inadequate supply; some women will develop inadequate supply as the baby’s growth outstrips their ability to produce more milk.

How do lactation professionals deal with this critical factor?

They lie about it to each other and to their patients. Although it is a biological FACT that up to 15% of first time mothers will be UNABLE to produce enough breastmilk, particularly in the early days after birth, lactation professionals insist that insufficient breastmilk is vanishingly rare.

This is the central difference between “Breast Is Best” advocates and “Fed Is Best” advocates. Because they lie to themselves and each other about the non-modifiable factors that are necessary for successful breastfeeding, lactation professionals are left only with blaming mothers and the wider society.

We would consider it both ignorant and insensitive for a teacher to demand that an intellectually challenged student perform as well on a test as a student with an extraordinarily high IQ. We would consider it cruel in the extreme for the teacher to berate the intellectually challenged student by declaring that if he just studied harder, he could have done as well as the genius.

Lactation professionals (most of whom fall squarely in the “Breast Is Best” camp) sadly behave as ignorantly and insensitively as the worst teacher. Because they lie about the true incidence of insufficient breastmilk, they demand that women with insufficient supply provide the same amount of milk as women who have adequate supply. They cruelly insist that those with inadequate supply would have more if they just tried harder or if they were cognizant of the many (mostly debunked) benefits of breastfeeding or if they weren’t gullible dupes of formula companies.

They also ignore the role of other factors beyond women’s control like a baby who is a poor nurser, excruciating nipple pain, or other medical problems that can impact supply. Rather bizarrely, they imagine that all women and all babies face the exact same challenges, all of which they insist could be overcome.

Furthermore, it is almost impossible to overestimate the impact that lactation professionals attribute to maternal effort and social factors. They are obsessed beyond reason with the idea that women who don’t breastfeeding successfully or choose not to breastfeed at all are either personally lazy, lacking in crucial support or under the influence of formula companies.

Whose “fault” is it when a woman doesn’t breastfeed?

According to attribution theory, it can be no one’s fault. It can be the result of factors beyond a woman’s control including simple luck. But in the echo chamber that is lactivism, it MUST be someone’s fault, either the lazy mother or the lack of societal support or the marketing of formula.

As a result, lactation professionals spend most of their efforts on nonsense: “educating” women about breastfeeding, banning formula marketing, and (most importantly for them) promoting greater employment for more lactation professionals to offer more “support.” To my knowledge, not a single one is engaged in investigating the uncontrollable biological factors that have such a critical impact.

When you fail to correctly attribute the cause of a particular behavior, you can’t modify it and you can’t offer real support; you can only produce guilt, shame and self-hatred among new mothers.

In that, lactation professionals have no peer.

There has never been any confusion about the meaning of “infant formula,” but lactation professionals are engaged in a campaign to rebrand it in shaming, ableist language. It started in 1996 with the publication of lactation consultant Diane Weissinger’s “Watch Your Language”:

“Artificial feeding, which is neither the same nor superior, is therefore deficient, incomplete, and inferior.”
This rebranding has been promoted enthusiastically by lactation professionals and their organizations. It has led — as it was intended to do — to feelings of shame, guilt and self-hatred among women who can’t or don’t wish to breastfeed.

We call upon lactation professionals and their organizations to immediately end the use of shaming, ableist language in all their efforts.

Such language has no place in the ethical provision of medical care including breastfeeding support.

Sign the petition HERE.

Years ago, when I was working for a large health maintenance organization, I received a curious letter. It had come to their attention that my forceps rate (0%) was well below the average for obstetricians in our institution. I pointed out that my C-section rate was only 16% and I hadn’t left a single baby inside a mother. I asked if this were a problem? No one seemed to know.

At another point I got a notification that I had ordered more ultrasounds for my OB and GYN patients than average for that month. This time I asked whether any of the ultrasounds had been unnecessary? No one seemed to know … or care. It was just something they were required to measure.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The composite index DOESN’T tell us whether an individual hospital is a safe place to give birth.[/pullquote]

I mention these anecdotes because they illustrate the dangers of simply compiling statistics and comparing them. My employers wanted to know if I was delivering patients appropriately, but my forceps rate couldn’t tell them that. They wanted to know if I was ordering unnecessary ultrasounds but comparing my ordering rate to my colleagues in a given month couldn’t tell them that, either.

It is important to measure, but you have to be sure you are measuring the right thing in the right way.

That was my concern when I read the breathless report in USA Today, The secret number maternity hospitals don’t want you to know, and why we’re revealing it.

It is extremely important to measure maternal complication rates. But are the people at USA Today measuring the right thing in the right way?

It’s not clear to me that they are.

According to the article:

[I]n the United States – the most dangerous country in the developed world to give birth – maternity hospitals’ childbirth complication rates are a well-guarded secret.

Many hospitals know them. So do many state health agencies, insurance companies and researchers. But they fear the complication rates are too complex for regular folks to understand.

In truth, no one knows what they mean.

There are certainly questions about the data. Some hospitals are more likely to treat patients with health problems, so childbirth complication rates are difficult to compare. Some of the best-equipped hospitals in the country may have higher complication rates because mothers who are very sick get referred there.

But there’s more to it than that: How useful is the method they used, a “composite index”? How valuable is it to compare one hospital to another or any hospital to a mean value? What is it we really want to know and do the measurements chosen by USA Today tell us what we want to know?

We want to know several things that are extremely difficult to measure:

Is the complication rate for a given mix of patients appropriate?
Has every complication that could have been avoided been avoided?
Has the hospital staff caused complications?
And were the complications that occurred appropriately treated?

Where did the USA Today “secret number” come from?

More than a decade ago, the U.S. Centers for Disease Control and Prevention created a method for calculating how often women giving birth endure severe complications using diagnosis and procedure codes that hospitals record in patient billing records.

The resulting “severe maternal morbidity rate” is like a composite score of things that can go wrong at the hospital before, during or after delivery – heart attacks, strokes, blood transfusions, hysterectomies and other emergencies that can permanently harm or even kill a new mother.

The first problem is the inclusion of blood transfusions (often a minor complication) with far more serious complications.

[T]he CDC method uses blood transfusions as an indicator that a woman may have hemorrhaged. But it’s impossible from billing data to know whether the woman received one unit or many units of blood.

Some experts say that could inflate the rate. Others note that transfusions are counted for all hospitals and a blood transfusion is not part of a routine childbirth.

No it’s not routine, but it’s also not an indicator of severe complications. It would be far better to look at the rate for women who got 3 units of blood or more. A transfusion that large is a good indicator of a severe complication. So right off the bat, the composite index is almost certainly inaccurate in modeling severe complications.

The next problem: in order for any measurement to have meaning, we must adjust case mix so we are comparing like to like:

[S]ome hospitals have higher rates because they are specialty facilities where doctors send the riskiest cases. Some serve more poor mothers, who often get less consistent prenatal care. Others serve larger numbers of black mothers, who tend to have higher rates of certain health problems, such as hypertension, that can lead to serious complications.

What about just looking at the outliers? The article is accompanied by this graph:

Complication rates are distributed in a bell curve (a “normal distribution”) with a very long tail. (You can’t really see that because of the editorial decision to lump all hospitals over 5% together creating a spike at the end.) A normal distribution with a long tail has particular implications in public health.

As the authors of The “Long Tail” and Public Health: New Thinking for Addressing Health Disparities explain:

The prevailing approaches to improving population health emphasize “shifting the mean” through prevention efforts that target large groups at high risk or through mass environmental control interventions that encourage small but universal changes in individual behavior. This approach has led to the search for “blockbuster” public health interventions that can have the largest effects on determinants of population health and individual behavior…

In a compelling critique, Frohlich and Potvin argue that the prevailing population approach may have the unintended consequence of exacerbating health disparities. Disease risk, they point out, varies not just by behavioral risk factors but also by socially defined groups that vary in their exposure to fundamental risks, for example, low education and low socioeconomic status. Broadly targeted population interventions that focus primarily on behavioral determinants may not be as effective under these conditions or with these groups…

And that’s why simply comparing the composite index of one hospital to the composite index of another hospitals is not particularly helpful. Any hospital that is within the bell curve has an acceptable complication rate. Most hospitals in the long tail probably serve vulnerable populations and their complication rates may be more closely tied to socio-economic factors than to hospital competence.

But that’s not particularly eye catching when compared to a “secret number that hospitals don’t want you to know.”

So what does the USA Today composite index tell readers?

Not much that is useful for them.

No one should decide where to give birth based on the composite index since direct comparisons aren’t really possible and all hospitals in the normal distribution are probably as safe as the others in the normal distribution.

The hospitals in the long tail very likely serve high risk populations and the problem is not necessarily that they are providing poor care; they may be providing exactly the same care as the hospitals in the normal distribution but that isn’t enough for vulnerable populations.

The USA Today composite index can highlight facilities that deserve additional scrutiny but unfortunately it the CAN’T tell us whether an individual hospital is a safe place to give birth.

Dr. Gabrielle Colleran, why are you lying to women about breastfeeding?

According to attendees at a recent meeting of La Leche League Ireland, you claimed — falsely — that women who give birth but don’t breastfeed have a 4X increased risk of heart attack. The truth is that the scientific literature shows NO consistent relationship between breastfeeding and maternal cardiovascular disease.

You apparently claimed — in a remarkably vile and vicious falsehood — that both SIDS and childhood leukemia are twice as common in exclusively formula fed children, adding piously that this is very difficult information for parents.

It’s also a lie.

According to a recent comprehensive review of the breastfeeding literature, 3,500 mothers would need to breastfeed 3,500 babies to prevent one SIDS death. Moreover, pacifiers are MORE protective against SIDS than breastfeeding!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Dr. Colleran, apologize and set the record straight. That’s the ethical thing to do![/pullquote]

The same review cautions that the association between breastfeeding and childhood leukemia is NOT firmly established and even if it were, 12,500 women would have to breastfeed 12,500 babies for more than 6 months to prevent one CASE.

I might have thought that the conference attendee was exaggerating or misunderstood the utterly false claims, but then I saw with my own eyes on the LLL Ireland Facebook page a snippet of video from your talk in which you claim, brazenly and falsely, that giving babies formula often leads to allergies. I shared the LLL Ireland post on my Facebook page and — surprise! — LLL Ireland deleted it.

Dr. Colleran, multiple people have asked you on Twitter to provide scientific references for your claims. As far as I can determine, you blocked each and every one of them. You blocked me even before I asked you.

I can’t imagine clearer sign that you KNOW your claims were lies than the fact that you block anyone who asks for proof and that LLL Ireland deleted the video evidence.

Dr. Colleran, we in medicine have a long and sordid history of lying to patients “for their own good.” As recently as the 1960’s doctors told cancer patients with a straight face and a clear conscience that they did not have cancer. Had those doctors been asked, they almost certainly would have justified their behavior by pointing out that patients given a cancer diagnosis often lost hope; it would be better for them to believe they had a less serious illness while the doctors treated them with chemotherapy without their consent.

This is paternalism.

Dr. Colleran, I know you are a pediatric radiologist, but I can tell you that we in obstetrics have a disturbing history of lying to patients “for the good of the baby.” While the current distrust of obstetricians by some patients has been assiduously fanned by midwives, doulas and natural childbirth experts, it could never have taken hold if obstetricians hadn’t already abused the trust of some patients. Natural childbirth advocates contemptuously refer to such behavior as “playing the dead baby card.” Even though it happens much less often than natural childbirth advocates believe, it does happen.

This is yet another, even less justified, form of paternalism.

Women have been in the forefront of holding doctors to account for paternalism. Some of the most well known legal cases that created informed consent law were brought by women. Furthermore, the natural childbirth movement itself was critical in changing paternalistic hospital practices around childbirth, empowering women as consumers of healthcare to whom hospitals and doctors now market medical services.

I doubt that they fought so aggressively against doctors lying to them “for their own good” so that lactation professionals could take up where other doctors left off — lying to women about the “risks” of not breastfeeding and the “risks” of infant formula.

Dr. Colleran, I suspect that you think you can hide from me and I will give up and go away. You don’t know me very well.

You owe new mothers clarification of and references for your outrageous claims. And if you can’t find references for your claims — because you know they don’t exist — you owe an apology to the attendees of the conference for misleading them. They believed you because you are a doctor. If you lied to them, they will take those lies and repeat them to patients “for their own good.” Both mothers and babies will be harmed.

You also owe an apology to new mothers, many of whom struggle with breastfeeding precisely because people like you apply tremendous pressure with fabricated claims of “benefits” of breastfeeding and “risks” of formula. No doubt you believe you are doing it “for their own good” or “for the good of the baby.”

But just as that doesn’t absolve doctors of the past for lying to patients, it most certainly doesn’t absolve you.

Dr. Colleran, apologize and set the record straight. That’s the ethical thing to do!

You might think I’d be happy about the censoring of anti-vaccine propaganda by social media. Over the years I’ve written extensively and in scathing terms about the ignorance, arrogance, and immorality of the anti-vax movement. There is no scientific evidence to support its claims; its promoters are quacks and charlatans; and it harms the most vulnerable among us.

And yet … I’m deeply uncomfortable.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The remedy for false speech is more speech, not enforced silence.[/pullquote]

I’ve also acknowledged the critical role played by social media in the rising popularity of what is basically a superstition. Just as there is no empirical support for fearing the number 13, there is no empirical support for the phobia around vaccination, a corollary of needle phobia.

The anti-vax movement has been around since the inception of vaccination over 200 years ago. It has been active in the US since colonial times. But, let’s face it, it’s a lot harder to spread conspiracies when you have to mimeograph crudely typed claims. It’s so much easier — an more persuasive — to congregate in the virtual space of social media to give support and encouragement to even the most bizarre beliefs.

And yet … I fear the consequences.

I have no doubt that censoring anti-vax propaganda on social media will be effective and will probably save lives. A sense of solidarity with others is critical for anti-vaxxers in defying nearly all doctors, scientists and public health officials in the world.

And yet … I worry that the cure might be worse than the disease.

Why? Because social media companies should not be in the business of deciding what people can read and say. Today it may be anti-vax propaganda; tomorrow it may be climate science, abortion science or something equally controversial.

Don’t get me wrong: I understand that Facebook, Twitter and Pinterest are private companies and therefore have complete discretion over the content they allow on their platforms. There is no question that it is legal for social media companies to censor speech.

I recognize that this is entirely different from government censorship, which is largely forbidden because of the First Amendment.

I’m generally not a fan of slippery slope arguments, yet I worry that we are at the top of a slope that is very slippery indeed.

Wait! Isn’t anti-vax propaganda unique in that it represents a public health problem? We’ve observed that rising fears around vaccination have led to declining immunization rates. We know that when rates decline below a certain point (different for each disease), the diseases will begin to reappear. We predicted the current outbreaks of measles and pertussis right down to the locations where they were most likely to appear.

But can we really argue that anti-vax propaganda represents a bigger health threat than climate change denial? Anti-vax propaganda makes it difficult to protect the most vulnerable among us — infants, the elderly and the immunocompromised. Climate change denial makes is nearly impossible to protect nearly ALL of us who are going to be profoundly impacted (possibly with deadly effect) by man made climate change. Yet Facebook, Twitter and Pinterest aren’t thinking about censoring climate denial.

Can we really argue that anti-vax propaganda represents a bigger public health problem than gun violence? To date, anti-vax propaganda sickens hundreds and kills very few. Widespread availability of guns kill tens of thousands of vulnerable, defenseless Americans (many of them children) EVERY year. Yet no social media platform is thinking about censoring gun rights talk.

So anti-vax propaganda is NOT unique as a form of speech that threatens public health.

Indeed, anti-vax propaganda is a subset of the massive industry of “alternative” health. Just about everything that travels under the imprimatur of alternative health is also propaganda — lacking scientific support, fabricating claims, harming individuals directly as well as by keeping them from getting real medical care.

If social media platforms are censoring anti-vax propaganda, shouldn’t they also be censoring fake cancer cures, outlandish restriction diets, and invocations to ingest supplements that are useless in the best case scenario and deadly in the worst case? If the justification for censoring anti-vax propaganda is that it is both unscientific and harmful, shouldn’t social media platforms be regulating ALL unscientific and harmful speech?

Who decides what is harmful enough to merit censorship? Who decides what is unscientific enough to merit being suppressed?

I suspect that I would have these concerns regardless of who was president, but if Donald Trump has done anything, he has alerted us to how very thin the veneer of democratic civilization really is.

Trump has made the previously theoretical risk of autocracy into an all too real risk. He has engaged in political vilification of disfavored people, disfavored political beliefs and disfavored public health organizations. If he were to “encourage” social media platforms to censor disfavored political speech under threat of tax or other financial penalties on the grounds that it is “harmful”, how would we differentiate that from censoring anti-vax propaganda?

Anti-vax propaganda is not hate speech but I wonder if we should treat it similarly. First Amendment advocates have always argued that the remedy for hate speech (which arguably harms, maims and kills more people than anti-vax propaganda) is MORE speech. As Supreme Court Justice Louis Brandeis wrote in the concurrence to Whitney v. California:

…[N]o danger flowing from speech can be deemed clear and present, unless the incidence of the evil apprehended is so imminent that it may befall before there is opportunity for full discussion. If there be time to expose through discussion the falsehood and fallacies, to avert the evil by the processes of education, the remedy to be applied is more speech, not enforced silence.

Brandeis was writing about what the government should and should not do, not private entities. As I acknowledged above, they are legally entitled to censor anti-vax propaganda. But that doesn’t mean that they should or that we ought to encourage them to do so.

There is no doubt in my mind that censoring anti-vax propaganda on social media will improve public health. My fear is that it will imperil intellectual freedom in the process.

The worst thing about contemporary lactivist culture is not that advocates of “Breast Is Best” disagree with advocates of “Fed Is Best.” The worst thing is that contemporary lactivist culture is a culture of contempt.

As I wrote last week, it often seems as if the unifying factor among lactation professionals — the concept around which they bond with each other — is not support for breastfeeding; it is contempt for women who don’t breastfeed. They appear to find fellowship in exacerbating and then celebrating the suffering of women whom they condemn as “minimal” mothers for not breastfeeding.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The contempt for “Fed Is Best” is a special kind of vicious.[/pullquote]

Because lactation professionals have contempt for those with whom they disagree, they continually exhibit what political scientist Arthur C. Brooks calls:

…a noxious brew of anger and disgust. And not just contempt for other people’s ideas, but also for other people. In the words of the philosopher Arthur Schopenhauer, contempt is “the unsullied conviction of the worthlessness of another.”

Brooks is writing about contemporary political culture but I was struck by the resemblance to contemporary breastfeeding culture. At its heart is fundamental attribution error (which Brooks calls motive attribution asymmetry):

the assumption that your ideology is based in love, while your opponent’s is based in hate — suggests an answer… Each side thinks it is driven by benevolence, while the other is evil and motivated by hatred — and is therefore an enemy with whom one cannot negotiate or compromise.

However, in this case I believe lactation professionals suffer from fundamental attribution error while “Fed Is Best” advocates do not.

Based on their writings, contemporary lactation professionals (and most definitely their leaders) believe that their ideology is driven by love for babies and the “opposition” is driven by hate for breastfeeding. Lactation professionals like Amy Brown, Lucy M. Sullivan, Kimberly Seals Allers and Jack Newman believe themselves to be benevolent while I, Christie del Castillo-Hegyi and Jody Seagraves-Daly are evil and should be ignored let alone compromised with. In contrast, I haven’t found a single “Fed Is Best” advocate who hates breastfeeding. And we have spent an inordinate amount of time desperately trying to speak with and inform lactation professionals.

The examples are too numerous to count, but here’s what I’ve observed in the past month alone.

Two weeks ago I left a comment on a post on Dr. Jack Newman’s Facebook page:

Dr. Newman, since you are so sure breastfeeding has substantial benefits, can you please show us any impact that changing breastfeeding rates have had on term infant mortality or any metrics of major term infant morbidity. To my knowledge, the only impact breastfeeding has had on these parameters is a dramatic increase in the rate of neonatal hospital readmission. Indeed exclusive breastfeeding is now the leading risk factor for readmission. So I see the risks, but I can’t find the benefits. Can you show us the population data that supports your claims?

It’s a simple request, respectfully presented. Dr. Newman contemptuously deleted it.

Last week I came across this contemptuous screed from Maureen Minchin, a lactation professional (with no training in science or medicine) who has a self-published book on — I’m not kidding — breastfeeding and immunology. In response to a woman who complained about her lack of sympathy and concern for women who cannot breastfeed, Maureen produced this and it’s a special kind of vicious:

… I am sorry that you had such a hard time with your first, and understand your rage, and your decision to go with formula for your second, and I am glad that worked out so well for you. It doesn’t for some other people, and that’s the point: we can’t know ahead of time which children will be badly affected, but some will, in every country, some will die in every country, and all will develop differently from what they would have done if breastfed. That’s just biological fact…

You have been the victim of what I have been working – mostly gratis – to remedy for decades: poor education and clinical practice about infant feeding, not just breastfeeding. It’s a shame you never had an enjoyable breastfeeding experience and that your son was put at risk. But as you say, environment also matters, and I’m sure he’s had the best you can provide…

I am not in the business of making people feel guilty and it upsets me if mothers tell me they are hurt by hearing truths that need to be told. Partly because it means the mother is so focussed on her own history and family that she cannot see the much bigger picture, and truly believes that in order to avoid upsetting those already victims of formula culture in WEIRD [Western, educated, and from industrialized, rich, and democratic] nations, we should stay silent and allow more families everywhere to be affected by it…

You cannot be so self-centred as to think that the feelings of those already formula feeding matter more than the lives and health of others…

I would be happy to supply you with a free copy of my books should you undertake to read them in full, cover to cover…

All best wishes, Maureen

Last night I saw this from Meg Nagle, the Milk Meg:

“Fed” is not best. Fed is the minimum…

Could there be anything more cruel than telling a mother who loves her baby desperately and is already suffering shame and guilt over the inability to breastfeed that she is giving her child only the “minimum”?

I also came across this last night:

Who is Gabrielle Colleran? She’s a pediatric radiologist and I read that she claimed that fat is laid down during pregnancy for breastfeeding. This fat supposedly poses a risk if not “used up” by producing breastmilk. According to Dr. Colleran, women who were pregnant but did not breastfeed are 4 times more likely to have a heart attack.

That’s news to me so I reached out for clarification. I was already blocked even though I had never heard of her and her theories previously. It’s hard to imagine anything more contemptuous than preemptively blocking another physician who might ask for proof of your claims.

The world would be a better place is lactation professionals would heed Brooks’ call for better quality disagreements:

What we need is not to disagree less, but to disagree better. And that starts when you turn away the rhetorical dope peddlers — the powerful people on your own side who are profiting from the culture of contempt. As satisfying as it can feel to hear that your foes are irredeemable, stupid and deviant, remember: When you find yourself hating something, someone is making money or winning elections or getting more famous and powerful. Unless a leader is actually teaching you something you didn’t know or expanding your worldview and moral outlook, you are being used.

Lactation professionals should engage with “Fed Is Best” advocates. They owe it to women and babies to respond to challenges to their core beliefs because their core beliefs may be wrong and even harmful.

And “Breast Is Best” partisans need to reject the powerful people on their own side who profiting from the culture of contempt. As satisfying as it can be to hear that women who don’t breastfeeding are lazy, self-absorbed, bad mothers and as enjoyable as it can feel to hear that medical professionals who question the benefits of breastfeeding are irredeemable, stupid, deviant trolls, remember:

When you find yourself hating those who believe “fed is best” someone is making money. Is your goal to enrich your leaders or is it to help babies and mothers? Sadly, you can’t have both.

There are many ironies embedded within the philosophy of natural mothering.

Chief among them are the mindless embrace of mothering in nature without acknowledging the natural death toll and the fact that our ancient foremothers would have cut off their right arms for the lifesaving medical technology privileged white women ostentatiously reject in performative social media displays.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Children, like plants, are tropic. Plants grow toward the sun. Children grow toward those who love them.[/pullquote]

But in my view, having written about the subject for more than a decade, the cruelest irony is that “natural” mothering is based on the medicalization of love.

What do I mean?

Before the past century in highly industrialized societies, the bond between mother and child was understood as spontaneous and not contingent on any specific practices. Children, like plants, are tropic. Plants grow toward the sun. Children grow toward those who love them.

Natural mothering advocates, in contrast, imagine mother-infant attachment to be a fraught process constantly shadowed by the looming risk that mother and child will fail to bond. Therefore, they have medicalized it.

The Wikipedia definition of medicalization postulates two central claims:

Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment…

Medicalization is studied from a sociologic perspective in terms of the role and power of professionals, patients, and corporations, and also for its implications for ordinary people whose self-identity and life decisions may depend on the prevailing concepts of health and illness.

In other words, a natural process previously understood to have no medical component comes to be defined as a medical condition to be studied and treated. And the process of medicalization transfers power from individuals to “experts.”

Natural mothering has medicalized love, a process previously understood to have no medical component. Medicalizing the mother-infant bond has empowered self-appointed experts like midwives, doulas, lactation consultants and attachment parenting gurus. With their books, courses and social media sites, they have become the arbiters and mediators of mother-child relationships.

I find the principles of the technocratic model of childbirth, described by sociologist Robbie Davis-Floyd, to be an excellent template for the technocratic model of love.

I would paraphrase David-Floyd as follows:

Despite its pretensions to scientific rigor, natural mothering ideology is less grounded in science than in its wider cultural context; it embodies the biases and beliefs about women of the society that created it. Its hegemony is founded in scientization, effected by technology, and carried out through institutions governed by paternalistic ideologies in a profit-driven economic context.

Within the technocratic model of love, midwives, doulas, lactation consultants and attachment parenting “experts” claim scientific rigor (although they lack it), proselytize through technology like the internet (though they claim to despise technology), and monetize everything that isn’t nailed to the floor.

The tenets of the technocratic model of love include:

The body as machine

In contrast to the previous view of mother-infant bonding as primarily spiritual — thereby encompassing the love between mothers and adopted children, the love of children for mothers who never breastfed them (indeed in wealthy families they may have been breastfed by others) and the fierce love between infants and other family members — natural mothering advocates have reduced it to mechanical behaviors that they claim are necessary preconditions to attachment. Natural mothering experts have insisted that unmedicated vaginal birth, breastfeeding, and continuous physical proximity are the necessary preconditions for love.

The patient as object

Natural parenting experts don’t view mothers as individuals. It seems not to cross their minds that different mothers may have different needs, desires and attachment styles. Instead, mothers are viewed as the objects to be molded by aggressive education efforts in conjunction with selling them books, courses, and accessories.

Babies, too, are viewed as objects to be acted upon, each in exactly the same way as all others. Unmedicated vaginal birth is supposed to be “best” for every baby even though when unmedicated vaginal birth was the only method of birth perinatal mortality was astronomical. Breastfeeding is supposed to be “best” for every baby, even though when breastfeeding was the only method of feeding available infant mortality was astronomical. Baby wearing and the family bed are supposed to be “best” for every baby despite the fact that generations of babies fully bonded to mothers, fathers, grandparents and hired caregivers without either.

Diagnosis and treatment from the outside in

Although natural mothering experts purportedly celebrate maternal instinct, close examination reveals that maternal instinct is only promoted to the extent that it differs with recommendations of medical professionals. In reality, it is entirely ignored when the mother’s instinct conflicts with the ideology (and profits) of natural parenting experts. Maternal request C-sections are viewed with horror by midwives and doulas; formula is viewed with horror by lactation consultants; playpens and strollers are viewed with horror by attachment parenting advocates. Natural parenting experts routinely prescribe behaviors and choices to mothers instead of trusting mothers to make good decisions by themselves.

Authority vested in experts, not in mothers

The central conceit of natural parenting is that its practitioners are recapitulating mothering in nature. But mothering in nature did not rely on books, courses and social media interactions. However books, courses and social media interactions are the only way for experts to maintain control of patients, and the expert considers HER oversight and control over birth, breastfeeding and early parenting to be mandatory.

Supervaluation of science, even non-existent “science”

Natural mothering experts believe that invocation of science enhances their authority and hides their paternalism. They’re not forcing women to forgo epidurals; science “shows” epidurals are dangerous (it does not). they’re not forcing women to breastfeed; science shows breastfeeding has massive health benefits (it does not).

Aggressive intervention with emphasis on short term goals

Is there anything more aggressive than the unsafe, unethical Baby Friendly Hospital Initiative? Is there any program more focused on irrelevant, short term goals — increasing rates of exclusive breastfeeding at discharge — at the expense of the health of both mothers and babies than the BFHI?

Expert hegemony, a profit driven system, and intolerance of other choices

That’s self-explanatory.

In truth, the ultimate irony of natural mothering is that it has come to embody everything it claimed to resent about the medicalization of birth. It is based on a technocratic model of mother-infant love rather than a spiritual model and, as such, it benefits natural mothering experts at the expense of babies and mothers.

Let’s have a round of applause for lactivist Charlotte Young, the Analytical Armadillo and founder of Milk Matters UK. She briefly ventured out of her social media echo chamber and — asked to demonstrate that the benefits of breastfeeding are real — promptly scurried back.

Young illustrates in the most emphatic way possible that no mother should worry her baby missed out on the benefits of breastfeeding. They are clearly so trivial that even a committed lactivist who presumably has command of the breastfeeding literature CAN’T find any evidence that they occur.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Asked to provide data that the claimed benefits of breastfeeding really exist Charlotte Young, the Analytical Armadillo, couldn’t.[/pullquote]

Nonetheless she deserves credit for being willing to at least sniff the air outside the echo chamber. Other lactation professionals like Prof. Amy Brown, Lucy Martinez Sullivan, Kimberly Seals Allers and Dr. Jack (“formula is like a condom”) Newman can’t even manage that. Sure, they tell themselves that they block and ban me because I’m a “troll,” and maybe they even believe it. But the real reason they block me is because I keep asking an uncomfortable question that they cannot answer:

If breastfeeding has the benefits claimed by lactivists, why can’t we detect them in large populations?

It is lactivists themselves who have handed me the means I use to easily discredit them. They have created and aggressively promoted mathematical models (and even a “calculator”) that to purport to show how many diseases could be prevented and lives and healthcare dollars saved if more women breastfed. It’s a nifty method for pressuring new mothers and — even more importantly! — pressuring governments to subsidize lactation professionals.

Lactivists failed to consider that their models could be applied as easily to the past as to the future. When you put in data for the years since 1973, when breastfeeding rates in the US reached their nadir, the calculator makes grandiose predictions for the diseases prevented, and lives and healthcare dollars that should have been saved by now. Yet, to their shock and dismay, lactation professionals can’t find them. In technical terms that means that they never bothered to validate their models and that their models are obviously and fatally flawed.

But back to the Analytical Armadillo. In writing a recent piece decrying gaslighting and strawmen, Young gives a masterclass in — you guessed it — gaslighting and strawmen. I’ll let you read it for yourself and you will see that it doesn’t even make sense. I posted it on the Skeptical OB Facebook page with the comment:

AA, which part of “You-are-hurting-babies-and-mothers!” are you having trouble understanding?

Instead of ignoring women’s pain and concerns (gaslighting), why not try LISTENING to what THEY are saying instead?

Young promptly appeared with what she presumably regards as a witty rejoinder:

You might need to read it again, I’m not sure you’ve entirely understood – perhaps you were triggered, half my client base are formula feeders…

I asked a simple question and she promptly scurried back to her burrow:

[C]an you show any population data for term babies in industrialized countries that demonstrates ANY detectable benefit in rates of mortality and severe morbidity from increased breastfeeding rates?

This is the part that I want women who feel fearful or guilty about using formula to pay close attention to: these are simple questions that Young cannot answer. If breastfeeding truly had the benefits lactation professionals claim, she should be inundating me with data.

Instead she is trying to baffle her followers with bullshit.

That’s because she alerted her Facebook followers to the fact that I was discussing her piece. I’ve included the link because you must read it; it is comedy gold! Lots of snark, not a single piece of data.

Where’s the evidence that increased breastfeeding has reduced the incidence of any serious disease? Young can’t find any.

Where’s the evidence that increased breastfeeding has saved lives of term babies? Young can’t find any?

Where’s the evidence that increased breastfeeding has saved healthcare dollars? Once again Young comes up short.

And if Charlotte Young, the Analytical Armadillo and founder of Milk Matters UK, can’t manage to find ANY evidence that increased breastfeeding rates have had ANY detectable impact on term infant mortality or serious morbidity, you know that it doesn’t.

So thank you, AA, for dropping by. You’ve (inadvertently) offered yet more comfort and support to women who might be feeling fearful or guilty for giving their babies formula, and yet more encouragement for women who want to formula feed but are holding back.

You’ve demonstrated in the clearest way possible that most of purported “benefits” of breastfeeding exist only in lactivists’ imaginations, not in real life. That’s a public service!

Lactation professionals are easily triggered by any positive discussion of formula feeding.

What does that mean?

To be triggered is to experience a strong reaction of shock, anger or fear in response something another person said or wrote. For example, many lactation professionals seem to have experienced tremendous shock, anger and fear in response to Nathaniel Popper’s NYTimes piece extolling the unanticipated joy of formula feeding his baby.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Defensive Lactation Professionals welcome the process of getting offended and are attracted to media which triggers them.[/pullquote]

Their overwrought response — accusing the father of controlling his wife, claiming that the piece was created by a formula company algorithm, blaming the patriarchy for his wife’s difficult with breastfeeding — illustrate their extreme defensiveness.

But that’s hardly the only indication of a ‘Defensive Lactation Professional’ (DLP for short).

Victim Mentality

If there is one thing Defensive Lactation Professionals are sure of it’s that they are victims.

They are victims of evil multi-national formula companies who (they imagine) quake at the thought of women actually breastfeeding their babies.

They are victims of a culture that — despite spending millions of dollars to promote breastfeeding and engaging in massive public health campaigns to support breastfeeding — is secretly hostile to breastfeeding.

They are victims of pediatricians and nurses who care more about whether a baby lives or dies than whether it is breastfed.

Therefore, Defensive Lactation Professionals see any positive discussion of formula as an opportunity to recite their ever-lengthening list of ever more arcane “benefits” of breastfeeding. How many times have you seen a perfectly reasonable discussion of formula feeding sabotaged by a DLP with the immortal words, “You could have breastfed if you’d had more support!”?

Facebook and Twitter are dangerous places for Defensive Lactation Professionals. They are always alert for the worst, as it is full of evil women who desire nothing more than to eradicate breastfeeding. In their view, it is a harsh environment of victims (themselves), victimizers (everyone else), and occasional rescuers (other DLPs who send them hugs).

But social media is also a place where like attracts like, so it only makes sense that DLPs attract people like them, united in their shared contempt for formula feeders. When you’re in a social situation and everyone is expressing relief at how much better their babies are growing, how much easier it is to formula feed, and how they can share the burden with partners and family members, it’s so comforting to band together with other DLPs to accuse formula feeders of laziness, selfishness and not caring enough to give their babies the very “best.”

Arrogance

The arrogance of DLPs is often a very subtle and indirect way of expressing cruelty without openly acknowledging it.

Consider this exchange with Doula Maddie on Twitter.

A physician and cancer survivor responded to Maddie’s insistence that everyone can breastfeed, writing:

Hi.I had a double mastectomy for breast cancer age 28. I’m fascinated to hear that ALL women can breastfeed. I would really value your insight into how I could have achieved better for my 3 bottlefed children given my total absence of mammary tissue?

And Maddie, in a response that should win an Oscar for “Cruelty in a Supporting Role” immediately responded with this:

IF you want to …

It’s accompanied by a picture of a baby nursing from a women’s breast with the feeding tube of a supplemental nursing system taped along side the nipple.

Which part of ‘double mastectomy’ did Maddie fail to understand? The doctor has NO breast tissue and NO nipples. What exactly would that SNS be taped to?

Passive Aggressiveness

Defensive Lactation Professionals seem superficially to acknowledging the reality of insufficient breastmilk, breastfeeding pain and demanding jobs incompatible with pumping, but are experts in passive aggressive “suggestions.” For example, they may ask if you have hired a lactation consultant, pumped after every feeding and taken medication to boost supply, but they don’t care about the answer. Regardless of your personal circumstances, and regardless of the fact that you’ve already tried all their suggestions, they are “sure” that you could have breastfed if you’d only tried harder.

In the online environment, within minutes their behaviour will escalate. They will ascribe non-existent negative intentions to neutral statements, sulk, pout, withdraw, bungle, make excuses, and lie. Their talent at sending mixed messages catches others off-guard. One minute they’re having a civil conversation, then they’re offended, then they claim to enjoy the debate, then they are angry. Their behaviour appears very schizophrenic as they battle with their inner demons on the public stage of the internet forum or Facebook page.

A common theatrical performance of a DLP is to post in a discussion of the merits of formula feeding:

“I’m leaving this terrible page; you are all shills for formula companies!”

… and then staying. That’s unfortunate; actually leaving would have produced a sigh of relief from everyone else.

Attention Seeking

This behaviour has a self-defeating, almost masochistic quality. It is as if Defensive Lactation Professionals welcome the process of getting offended and are attracted to media which triggers them. They actively seek out formula support forums, blogs and advocates where they enjoy arguing. They tell themselves they are “informing” others.

To compound the negativity of this outlook, Defensive Lactation Professionals are experts in inflaming others. They have a knack for dragging others into the emotional maelstrom they create, keeping them off-balance with their talent for moving the goalposts. “You could have breastfed!” “But antibodies!” “Why not donor milk?”

They are also masters of manipulation, which can make interactions with them infuriating. It is almost as if they want to offend people, only to prove to themselves that they are being persecuted. Their talent for high drama draws other Defensive Lactation Professionals to them like moths to a flame. They gain short-term pleasure from feeling sorry for themselves or eliciting pity from each other.

But when formula feeders respond with real life experiences or with scientific evidence that undermines their claims, Defensive Lactation Professionals respond by …

Deleting, Blocking and Banning

This behavior is the truest indication of their defensiveness. Rather than gracefully acknowledging that breast is NOT best for every baby and every mother, they delete testimony from women whose babies were hospitalized, suffered brain injuries or even died as a result of insufficient breastmilk.

Rather than addressing the large and growing body of evidence that most of the purported benefits of breastfeeding disappear when corrected for maternal education and socio-economic class, they block other professionals who present that data.

When faced with the papers detailing how the Baby Friendly Hospital Initiative ignores the scientific evidence on pacifiers, formula supplementation and the fact the exclusive breastfeeding is the single greatest risk factor for newborn hospital readmission, Defensive Lactation Professionals delete the “offending” evidence and ban the commentor from their Facebook page.

This is particularly insupportable in a group of people who claim to be professionals. No real professional blocks another professional from asking them to address the scientific evidence. No real academic shies away from public disagreement, refusing to venture into scientific conferences where they can be challenged, preferring to huddle within their social media echo chambers rebuffing attempts at engagement.

You could create a bingo card with these DLP traits: victim mentality; arrogance; passive aggressiveness; attention seeking; deleting, blocking and banning. Next time you encounter a Defensive Lactation Professional, have a mental image of this bingo card and see how many traits you can spot.

Popcorn optional.

 

Some may have already recognized that this is a riff on an old piece from the Alpha Parent.