Are you one of those who think that Nature gave a woman breasts, not that she might feed her children, but as pretty little hillocks to give her bust a pleasing contour? Many, indeed, of our present-day ladies do try to dry up and repress that sacred fount of the body, the nourisher of the human race, … lest it should take off from the charm of their beauty.

It may be a bit flowery, but the quote accurately expresses the anxiety of contemporary lactivists over the sexualization of breasts leading women to ignore their most important function, providing milk for newborns.

Therefore, you may be surprised to learn that the quote comes from Rome in AD 150.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The lactivist project is dystopian in its efforts to indocrinate, regulate and measure the behavior of women.[/pullquote]

How about this quote bemoaning the fact that rich mothers refuse to breastfeed while poor mothers do so eagerly?

Most mothers of any condition either cannot or will not undertake the troublesome task of suckling their own child… The Mother who has only a few Rags to cover her Child loosely, and little more than her own Breast to feed it, sees it healthy and strong, and very soon able to shift for itself; while the puny Insect, the Heir and Hope of a rich Family lies languishing.

That’s William Cadogan writing in 1750.

Or this quote about indigenous women, closer to nature, and therefore better able to nurture their infants.

The ideal nursing mothers are the cow among animals and the peasant mother among our own kind, who do not think about it all, but get on with the job, and in this matter an ounce of faith is worth a ton or more of science and book-lore.

Lindsey W Batten writing in 1838.

Indeed, as Pam Carter notes in her chapter Breast Feeding and the Social Construction of Heterosexuality, or ‘What Breasts are Really for’ from the book Sex, Sensibility and the Gendered Body the purported conflict between the sexualization of breasts and the proper use of breasts has been going on for at least two millennia and probably far longer:

While some attribute this conflict to ‘Hollywood’ or ‘modern civilisation’ it is clear that it has earlier manifestations within Western culture.

It has little to do with what benefits babies. The anxiety about breastfeeding reflects the anxiety about the role of women within society.

Concern about breast feeding constitutes concern about women’s behaviour… At the heart of the breast feeding ‘problem’ is a preoccupation with the failure of women to use their breasts in ways which are deemed natural…

Sound familiar? It should; I’ve been writing the same thing for years.

How dare I (or anyone) question the benefits of breastfeeding? According to lactivists, anyone who questions breastfeeding must hate breastfeeding.

But as Carter suggests:

Perhaps the fact that raising questions about such a taken-for-granted good thing looks like a hostile act should alert us to an arena which warrants further scrutiny.

Breastfeeding is a proxy for attitudes about women’s emancipation from stay at home motherhood.

…Despite the preoccupation in the breast-feeding literature with the inadequate behaviour of women, there is almost no recognition that breast feeding is constructed within gendered social relations. Women are always present within discussions about breast feeding but are presented as unproblematic natural beings. In that respect women are strangely invisible…

There is an assumption that breast feeding is always in women’s interests, that in itself it is a form of resistance to patriarchy. But there is little attempt to look at breast feeding from the point of view of women themselves nor at the impact of the powerful linkages which are made between good mothering and breast feeding. There are limited opportunities for women to articulate a different perspective…

One sentence from the chapter struck me forcefully:

So the naturalness of breast feeding is endorsed by science and controlled by medicine through various surveillance techniques.

What is the Baby Friendly Hospital Initiative if not an attempt to control women’s behavior through various surveillance techniques? The contemporary lactivist project is dystopian in its efforts to indocrinate, regulate and measure the behavior of women.

It is dystopian in its use of public shaming — mandatory visits of lactation consultants, formula consent forms, and public condemnation of bottle feeding.

It is also dystopian in that it flagrantly ignores — indeed denies the existence of — the harms to babies physical health and women’s mental health from equating breastfeeding with good mothering.

We are encouraged to imagine — with no evidence whatsoever — that a society in which every woman breastfeeds is a better society but the key question is never asked, let alone addressed. Better for whom?

Controlling women by controlling their breasts is not better for babies and it’s not better for mothers. It is only better for those who want to keep women in their traditional, biologically determined, misogynistic place.

Yesterday I wrote about the tendency of anti-vax mothers to view themselves as heroes. Though they view themselves as rebelling against “the system,” the truth is that they are merely submitting to a different system, characterized by deeply valued fantasies including the illusion of control of the health of their children and the radical uniqueness of their children, almost always in conjunction with ignorance of science, medicine and statistics.

While researching for that post I came across a fascinating book, The Paradox of Natural Mothering By Chris Bobel, an associate professor of Women’s Studies. In Bobel’s view, natural mothering isn’t just a paradox, it is a plethora of paradoxes:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Though natural mothers imagine themselves as transgressive advocates for social change, in reality they are both privileged and self-absorbed.[/pullquote]

It is a movement of radical simplicity that promotes rabid consumerism … albeit for non-traditional products.

It venerates a highly romanticized “natural” form of parenting that not only was never practiced by our foremothers, but is thoroughly modern.

It stresses feminist empowerment through total submission to a traditionally gendered division of labor.

It isn’t so much a paradox as it is an oxymoron.

Natural mothering may resist certain capitalist and technological prescriptions for family life, but it does not resist essentialized, even romanticized, conceptions of women that manifest themselves in a rigid sexual division of labor.

In truth, natural mothering reflects the three P’s: purchasing, patriarchy and privilege.

Purchasing

Bobel notes:

For many of the natural mothers, consumerism is a key feature of what they regard as mainstream culture. Typically, natural mothers perceive themselves as fervent critics of American consumption practices. They assert that every individual must make a pledge to live simply if the planet and its inhabitants are to survive. Moreover, consumerism sustains the capitalist system, which is increasingly dependent on mothers who work outside the home. When a mother refuses to “buy into” the notion that her worth is established by a paycheck or a job title, she performs an act of resistance. Furthermore, when she is home, she is “freed up” to construct a lifestyle less dependent on the goods and services designed to assist overly busy people who do not have time to cook, sew, garden, and build.

The irony is that there is virtually no aspect of natural mothering that does not require the purchase of expensive products and services. As sociologist Norah MacKendrick explains in her paper More Work for Mother; Chemical Body Burdens as a Maternal Responsibility:

The ideology of intensive mothering infuses spaces of consumption by urging mothers to buy with the best interests of the child in mind. Consumption is therefore entangled with other routine activities that parents — and mothers in particular — view as integral to securing a child’s future outcomes. Indeed, women’s transition to motherhood is marked by the consumption of specific material goods…

Eggs must be cage-free, clothes must be unbleached cotton and homeopathic treatments must be devoid of GMO’s. And all of it must be organic and therefore quite expensive. Natural childbirth requires a midwife, doula and rented inflatable tub, not to mention books and courses. Breastfeeding requires a lactation consultant, lactation cookies, herbal supplements and specialized clothing designed for ease in breastfeeding. The list of products that are required for radical simplicity is quite long and constantly growing.

It’s difficult to avoid the conclusion that natural mothering, touted as a rejection of contemporary consumer culture, is merely a niche form of the very same consumer culture that is purportedly being rejected. In other words, just as the women who feed their children McDonald’s take out, let them play with plastic toys, and allow them to watch TV are obviously responding to rampant consumerism, natural mothering advocates who hire doulas, treat everything with homeopathic remedies, and wear their babies in slings are unwittingly responding to the exact same consumerism they claim to deplore, carefully curated to appeal specifically to them.

Patriarchy

As Bobel explains in the section Putting Family First and Mom Last: Natural Mothering and Accommodating Patriarchy, natural mothering requires an almost complete capitulation to the misogyny of the patriarchy:

…[N]atural mothers do not resist patriarchal constructions of motherhood. While they make the fairly radical claim that female productivity must be ascribed social value, they do not resist the most fundamental assumptions about what it means to he a woman in the contemporary age. Natural mothering, rooted in biologically determinist understandings of gender, reifies a male-centered view of role-bound women. The “natural” in natural mothering may liberate mothers from a mechanized and commodified experience of their maternity, but it reproduces a gendered experience that subordinates their needs to those of child and husband and models that experience for their children…

Natural mothering, then, adapts to patriarchal notions about women and men, including … the preeminence of biology as shaper of human destiny. It accepts a standard that rationalizes women’s inferior social position…

Women are taught to seek “feminist” empowerment through submission to traditional gender norms.

Privilege

Privilege is a sine qua non of natural mothering and not merely the economic privilege that allows natural mothers to purchase expensive specialty products. One must have access to a highly technological lifestyle in order to give meaning to rejecting it. That’s why unmedicated vaginal birth is an “achievement” for a suburban white women, but not for a woman of color living in an African village without access to epidurals.

Moreover:

Natural mothers … enjoy a privileged position in which their alternative lifestyle is possible. That is, it is because they enjoy a secure economic status, solidified by their racial, educational, and class status, that they can afford to take the social risks involved in nonmainstream practices. In this sense, their privilege serves as a sort of safety net, protecting them from a nasty fall should they, for instance, he challenged for nursing their toddler in a public place or refusing conventional medical treatment for an illness. Being white and middle-class, they are less likely to come under attack. A poor woman of color spotted breastfeeding an older child could risk censure and certainly judgment. A mother receiving state benefits is required to vaccinate her children; waiving vaccinations is not an option. An immigrant woman known to use herbal remedies to treat illness risks a scolding by her family physician.

Though natural mothers imagine themselves as transgressive advocates for social change, in reality they are both privileged and self-absorbed.

The most striking thing about the paradigm of natural mothering as a politicized lifestyle is the specific way in which it is realized. Rather than taking to the streets, running for local office, or dedicating their lives to grassroots community organizing, these women strive to effect social change through the day-to-day practice of mothering outside the mainstream.

But they are not effecting social change, they are reifying their own privilege and passing it on to their children to the exclusion of other children.

Natural mothering — promoted as radical simplicity, parenting just like our foremothers and offering feminist empowerment — is in fact the complete opposite. It is a form of consumerism, confirms traditional misogynistic gender roles, and reflects and reinforces privilege.

A new paper in Clinics in Mother and Child Health, Intensive Mothering and Vaccine Choice: Reclaiming the Lifeworld from the System, provides fascinating insight into how anti-vaccine mothers view themselves.

What brings families to the decision to delay or refuse vaccination? What informs their choices? How do vaccination choices fit into broader trends in pregnancy, birth, and childrearing?

Anti-vax mothers believe:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]She is a superhero keeping her child safe from corrupt experts shilling for greedy corporations.[/pullquote]

[S]ome mothers “have wrested control of their personal lives away from institutions and experts and others who claim to ‘know best’ and returned it to the site of the individual family…this hard­won control does not rest with the individual; rather, it is surrendered to nature. The natural mothers exalt nature as a force to be trusted and respected.”

Of course we are not talking about all mothers. Privilege is the sine qua non of natural mothering. But for these women:

In our current milieu, the good mother is an intensive mother;… intensive mothers often tend toward holistic, natural styles of care over efficient and scientized approaches to family management and decision making. While not all intensive mothers are natural mothers, we suggest a connection between the centering of children’s needs and desires of intensive mothering, paired with prioritization of naturalness and distrust of the medical system, come together …

As I have argued repeatedly in the past, natural mothering reflects a new domesticity as well as submission to traditional gender roles. The natural mother has no time to work since she has been convinced that her “work” is keeping her child safe in a dangerous world filled with evil experts who are merely shills for industry, engaging in profitable efforts to harm children.

…Natural mothers choose to dedicate their full attention to intensive mothering, but are marked by three specific elements including a commitment to simple living, attachment parenting, and cultural feminist theory. Natural mothers use their “intuition as a practical guide, […] their notions of mothering at odds with mainstream notions about the proper way to raise a family.”.

The natural intensive mother exists in contradiction to the “bad other mother” who “goes with the flow of the mainstream, doesn’t question conventional wisdom, ignorant, duped by powerful, child hostile, expert and institution dependent culture.”. Natural intensive mothers are parenting from an individualist approach; prioritizing their children’s needs within institutions and advocating for them when necessary. To do so successfully, parents invest a significant amount of time into the labor of knowledge consumption and research, talking with friends and family, sharing information online and on the internet, all while centering their children’s uniqueness.

They are heroes!

Though they view themselves as rebelling against “the system,” the truth is that they are merely submitting to a different system, characterized by deeply valued fantasies including the illusion of control of the health of their children and the radical uniqueness of their children, almost always in conjunction with ignorance of science, medicine and statistics.

In the individualist view, “disease prevention is a process of personal risk assessment, lifestyle adjustment and individual choice.” More specifically, risk assessment is an individual choice for each parent for each child, which evaluates benefits of vaccines, and severity of disease (if the parents choose not to vaccinate, and the child does get sick), along with an assessment of vaccine risk informed by family history, views of children as vulnerable and perfect, and maternal instinct or intuition. These risk assessments and vaccine choices are informed by the knowledge gathered from friends and family, advocacy organizations, and natural living publications.

Only they can keep their children safe! They are heroes!!

Parents who choose to delay or refuse vaccination often focus on natural living as a way to prevent illness and keep their children healthy and safe. These practices are time and labor intensive, but mothers view the work as worthy efforts for the benefit of her child. Privileging the vulnerable, perfect and natural state of their child, mothers rely on natural solutions like breastfeeding and good nutrition, a diet of organic and unprocessed foods, and limiting social contact to manage and control risk.

Although anti-vax mothers are viewed, quite appropriately, as anti-science, that is not how they view themselves:

Although anti/alt­vaxxers are often cast as anti­science by the larger pro­vaxx community and within mainstream parenting groups, they do not experience themselves to be anti­science. In fact, many of the conversations we observed, particularly on the anti/alt­vaxx and natural pages, but even within vaccine debates on mainstream parenting pages, mothers who are defending their choice to deviate from the CDC vaccine schedule do so with what they refer to as “evidence based research” and draw from what they believe to be scientific research. In addition to the natural knowledge production raised above, some of the more popular pages from which alt/anti­vaxx mothers draw their sources from include the Living Whole website, the Healthy Home Economist website, the Sears family website, all of which report on vaccine injury, toxicity, and corruption within big pharma. Overwhelmingly, mothers believe themselves to be informed and to be making the best choices for their children, based on evidence­based research and of course, instinct.

Ultimately:

Natural intensive mothering, a distrust of systematized institutions, and the prominence of individualist choice come together as a reclaiming of the lifeworld space of the family from the system: its unnaturalness, its subjugation of traditional knowledge, its corruption, its judgments, and its privileging of the collective over the individual.

Anti-vax mothers imagine themselves as superheroes!

Trust breasts?

It’s not the motto of the lactivist movement, but it could be. If breastfeeding advocates are sure of anything, they’re sure that breasts are the one organ system in the body that never, ever fails. In their view, if breastfeeding isn’t working for you and your baby, there are myriad possible reasons, but it is never the fault of your breasts.

Baby nursing for hours at a time yet still frantic with hunger and not gaining weight?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Don’t trust breasts. Trust women![/pullquote]

A reasonable person might conclude that you aren’t making enough breastmilk. But lactivists aren’t reasonable people. Since breasts are perfect, you surely have enough milk but:

• You are “misperceiving” the amount of breastmilk you are producing.
• You are ignorant of normal infant behavior. All babies cry like that.
• Babies don’t really need to gain steadily. You’re misled by the way that formula fed infants grow.

See, it’s all your head! Because you can trust breasts to work perfectly.

Except that it’s not all in your head. The scientific evidence shows that up to 15% of first time mothers don’t produce enough milk to fully nourish an infant in the early days.

So if you aren’t producing enough breastmilk, especially in the first few days before your milk comes in, a reasonable person might suggest small amounts of formula to tide your baby over, but lactivists aren’t reasonable people. Their “solution” it to flog your breasts and yourself more.

• You should just nurse more; breastfeeding depends on supply and demand.
• Pump in between nursing sessions; getting rest is not important.

See, you should just try harder! Because you can trust breasts to work perfectly.

Except that trying harder is not guaranteed to work. Breastfeeding may depend on supply and demand, but so does insulin production. In people with type I diabetes, the pancreas no longer responds to supply and demand as it should. Advising women whose babies are hungry and nursing constantly to just breastfeed or pump more is the equivalent of advising diabetics to just eat more sugar. If an organ is not producing optimally, stressing it more doesn’t work.

Experiencing excruciating pain while breastfeeding?

A reasonable person might conclude that having the force of a vacuum applied to the sensitive tissue of nipple and areola can be profoundly painful, especially early on, but breastfeeding advocates aren’t reasonable people. They’re sure that your pain is your fault!

• Adjust the baby’s latch. You must be putting him on the breast the wrong way.
• You aren’t getting enough proper support. If the previous generation had breastfed they would help you.
• Hire a lactation consultant. She will show you what you are doing wrong.

See, you must be doing it wrong! Because you can trust breasts to work perfectly.

Wait, what? The lactation consultant says that there is nothing wrong with the latch?

Well, then the baby must broken! Maybe he or she has a tongue tie.

While tongue tie can cause pain while breastfeeding, it is relatively uncommon and certainly never cut in nature. Though tongue tie surgery seems simple, it is quite painful for many babies, especially the repeated sweeping of the wound to prevent the tie from reforming during healing.

Think about how painful biting your tongue it; now imagine cutting it. A reasonable person might conclude pumping and bottle feeding, or formula feeding from a bottle were excellent alternatives to subjecting a baby to searing surgical pain, but lactivists aren’t reasonable people.

• He must have an anterior tongue tie. Cut it.
• She must have a posterior tongue tie. Cut that, too.
• Maybe it’s a lip tie. Just keep cutting.

See, it’s the baby’s fault, never the fault of your breasts!

Ready to give up on the painful, frustrating, exhausting process of breastfeeding because your child is starving? A reasonable person might sympathize with your suffering and recommend formula to alleviate it, but breastfeeding advocates aren’t reasonable people:

• You don’t care about your baby.
• Where did you get the idea that your pain, exhaustion and mental health matter? They don’t.
• Who says you need to return to work?
• You’re obviously a dupe of the formula industry.

Blame formula manufacturers! Blame capitalism! Blame society!

But whatever you do, don’t blame breasts because they’re perfect.

Ridiculous, right? But many women fall for it and end up feeling guilty, anguished and blaming themselves.

I have a better solution:

Don’t trust breasts; trust women.

You know whether breastfeeding is right for your baby and yourself. Don’t let breastfeeding advocates convince you otherwise.

Tobacco executives tried to convince people to ignore horror stories about lung cancer.

Car company executives tried to convince people to ignore the horror stories about exploding Pintos.

Pharmaceutical executives tried to convince people to ignore the horror stories about Vioxx.

Now lactation professionals are trying to convince people to ignore breastfeeding horror stories.

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…

What Brown really means is: ignore breastfeeding horror stories. People share them without thinking of the consequences for ME!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When Brown tells you to ignore breastfeeding horror stories, she’s really telling you to ignore breastfeeding brain injuries and deaths. Don’t![/pullquote]

The tobacco executives, car company executives and pharmaceutical executives feared they would lose money, market share and status if people learned about the risks of their product, so they hid them. What’s a few dead people compared to their profitability? Brown and other lactation professionals fear they will lose money, market share and status if people learn the risks about their product — breastfeeding — so they hide them. What’s a few dead and brain damaged babies compared to their profits and prestige?

Make no mistake, when Brown tells you to ignore breastfeeding horror stories, she’s really telling you to ignore breastfeeding deaths, brain injuries, neonatal and maternal suffering.

She wants you to ignore Christie del Castillo-Hegyi’s horror story of her son who sustained permanent brain injuries from dehydration due to insufficient breastmilk.

She wants you to ignore Monica Thompson’s horror story of suffocating her daughter to death in her hospital bed trying to breastfeed.

She wants you to ignore Jillian Johnson’s horror story of losing her son to profound dehydration 12 hours after leaving the hospital which had assured her that her baby was receiving enough breastmilk.

She wants you to ignore the fact that the scientific literature is burgeoning with papers* detailing the high rate of insufficient breastmilk especially in the early days after birth (up to 15% of first time mothers) and the brain-threatening, life-threatening consequences. We are experiencing a dramatic increase in neonatal hypernatremic dehydration, hypoglycemia and kernicterus (severe jaundice). Exclusive breastfeeding is associated with tens of thousands of newborn hospital readmissions per year at a cost of hundreds of millions of dollars.

Brown, like other breastfeeding professionals, fears that mothers will learn the single most important fact about breastfeeding: like pregnancy, it has risks as well as benefits.

She and they are terrified of the impact of the Fed Is Best Foundation:

The Fed Is Best Foundation is a non-profit, volunteer organization of health professionals and parents who study the scientific literature on infant feeding and real-life infant feeding experiences of mothers through clinical practice and social media connections. We work to identify dangerous gaps in current breastfeeding protocols, guidelines, and education programs, and provide families and health professionals the most up-to-date scientific research, education and resources to practice safe infant feeding with breast milk, formula, or a combination of both. We provide safe, brain-protective infant feeding education for breastfeeding, mixed-feeding, formula-feeding, pumped-milk-feeding and tube-feeding mothers and families to prevent feeding complications to babies that have become too common in today’s “Breast is Best” world.

Breastfeeding professionals treat Fed Is Best like Voldemort: it’s the organization that must not be named!

They strive to diminish it by labeling it a social media campaign, refusing to acknowledge its 501(c)3 charitable status, its physician advisers and its tremendous resonance with ordinary mothers (its Facebook membership exceeds La Leche League).

That lactivist terror is expressed in the most recent issue of Clinical Lactation devoted to breastfeeding’s “bad press”:

Over the past few years, we have seen a distinct risk in social media campaigns that have claimed that breastfeeding harms babies. The gist of these campaigns is that we should focus on the fact that babies are fed, not on how they are fed …

In this special issue, we want to equip you to address the challenges presented by these negative social media campaigns …

It is replete with articles like these:

Debunking the Misunderstandings of the Baby-Friendly Hospital Initiative and Designation Requirements

Sensational headlines and messages surrounding breastfeeding in the media are leaving the public confused. There are also myths being circulated about the Baby-Friendly Hospital Initiative (BFHI) that are causing some to question the value and safety of its practices.

The False and the Furious by Kimberly Seals-Allers

…Negative social media campaigns have highlighted the “dangers” of breastfeeding and used extremist language to brand breastfeeding supporters. This article suggests some specific strategies for addressing gaps in our current system and countering the negative information…

Is Exclusive Breastfeeding Dangerous? By Marsha Walker

Social media has been alight with descriptions of exclusive breastfeeding being dangerous, resulting in significant and severe negative outcomes in infants whose mothers wished to breastfeed. This backlash has been led by a campaign that uses inflammatory anecdotes and misleading and inaccurate interpretation of research to bolster its assault on breastfeeding…

What Do Women Lose if They Are Prevented From Meeting Their Breastfeeding Goals? by Amy Brown:

Many women stop breastfeeding before they are ready, often leading to feelings of anxiety, guilt, and anger. Critics of breastfeeding promotion blame breastfeeding advocates for this impact, claiming that if the focus were merely on feeding the baby, with all methods equally valued and supported, maternal mental health would be protected. Established health impacts of infant feeding aside, this argument fails to account for the importance of maternal breastfeeding goals, or the physical and emotional rewards breastfeeding can bring…

Amy Brown bemoaning breastfeeding disappointment is like the fashion industry bemoaning negative body image.

Pious concern for women’s feelings is difficult to take seriously when it comes from the very people who make women feel anxious, guilty and anguished for failure to breastfeed. In the case of the fashion industry, idealized representations of the female body lead to self hatred when women’s bodies don’t meet the fashion industry norm. In the case of the breastfeeding industry, idealized representations of breastfeeding lead to self hatred when women’s bodies don’t meet the breastfeeding norm.

Professional lactivists are right about one thing, though. The Fed Is Best campaign is making tremendous headway against the breastfeeding industry refusal to acknowledge the risks of breastfeeding.

Unfortunately, as the special issue of Clinical Lactation illustrates, lactivists are still missing the point. Instead of publishing a special issue about publicity around breastfeeding injuries and deaths, they could have published a special issue about preventing breastfeeding injuries and deaths. But that would involve caring about babies more than profits, something that appears beyond them.

Instead, like the tobacco executives, car company executives and pharmaceutical executives before them, they will just tell people to ignore the horror stories while they ignore them, too.

 

* Recent publications:

• United States Preventive Services Task Force (USPSTF) guidelines
• Interventions Intended to Support Breastfeeding: Updated Assessment of Benefits and Harms
• Unintended Consequences of Current Breastfeeding Initiatives
• The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature
• Health Care Utilization in the First Month After Birth and Its Relationship to Newborn Weight Loss and Method of Feeding
• The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial

Yesterday I wrote about the new JAMA review of the World Health Organization’s Baby Friendly Hospital Initiative.

I reported that although the review is couched in careful language, the conclusions are devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.

I noted that the review suggest that the BFHI has changed its definition of “exclusive breastfeeding.”

[The Institutional Guidance] national monitoring definition of exclusive breastfeeding is now receiving “only breastmilk during the previous day.”

I was startled by this claim since the breastfeeding professionals at the WHO had already gone on record that babies who are injured and die because of insufficient breastmilk are not a priority:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s still business as usual at the BFHI where the babies who suffer, are brain-injured and die from insufficient breastmilk are not a top priority.[/pullquote]

When asked whether WHO plans to inform mothers of the risks of brain injury from insufficient breast milk, and that temporary supplementation can prevent complications, Dr. Rollins responded that this recommendation was not identified as a “top priority.”

Therefore, I was especially heartened by this purported change since it would be both brain- and life- saving. It would be an acknowledgement that early judicious formula supplementation not only saves lives, but it doesn’t harm breastfeeding, and it would make it possible for women who supplemented babies before their milk came in to still claim they were exclusively breastfeeding.

This change would reduce the number babies who suffered brain injuries and died because of the breastfeeding profession’s reflexive demonization of early formula supplementation. It would alleviate the suffering of hundreds of thousands of babies who endure desperate hunger in their early days because the BFHI has substituted lactivists’ personal beliefs and wishful thinking for scientific evidence.

Alas, in carefully examining the multiple documents that were cited in the review, I can find no evidence that the BFHI has changed its definition at all.

Indeed, the current World Health Organization definition of exclusive breastfeeding is:

Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or solids are given – not even water – with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines.

As far as I can determine, in the hundreds of pages of both evidence and guidance documentation, there is only one instance of exclusive breastfeeding being defined as only breastmilk in the previous day. That occurs in a chart in Protecting, promoting and supporting BREASTFEEDING IN FACILITIES providing maternity and newborn services:

This chart illustrates the impact of additional foods or fluids at 3 months of age on breastfeeding. Exclusive breastfeeding is mentioned more than 100 times through the document but this is the only use of the purportedly revised definition that I could find.

Like many of the charts and analyses in the document, it tracks the impact of various interventions on breastfeeding, NOT on babies. It’s almost as if the BFHI cares more about promoting breastfeeding than whether babies live or die!

As far as I can determine (feel free to correct me if you find evidence otherwise), there has been NO change in the definition of exclusive breastfeeding, NO recognition of the widespread prevalence of insufficient breastmilk (up to 15% of first time mothers in the early days of breastfeeding), NO acknowledgement of the suffering, brain injuries and deaths due to insufficient breastmilk, not to mention the literally tens of thousands of newborn hospital readmissions that result.

It’s still business as usual at the BFHI where the babies who suffer, are brain-injured and die from insufficient breastmilk are not a top priority.

Last week I noted that the editor of premier breastfeeding journal declared that it is time for a critical review of the Baby Friendly Hospital Initiative and its Ten Steps.

The editor’s key point:

What is needed in my opinion is not a rigid categorical defense of a magic (holy?) 10 but an intellectually rigid evaluation of the individual steps and their possible various combinations (not necessarily of all 10) that are both safe and efficacious.

Perhaps he was thinking about a new evaluation of the BFHI guidelines that was just published in the Journal of the American Medical Association. The JAMA Network has produced a Clinical Guideline Synopsis of World Health Organization Baby-Friendly Hospital Initiative Guideline and 2018 Implementation Guidance.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The review is couched in careful language, the conclusions devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.[/pullquote]

The review notes three major revisions in the evidence guidelines [EG]:

1. Recommendations around skin to skin care

The benefit of early skin-to-skin care (SSC) for glucose homeostasis (blood glucose level at 75-100 minutes after birth: meaningful difference, 10.49 mg/dL … 95% CI, 8.39-12.59), thermoregulation (a slight increase in axillary temperature at 90-150 minutes after birth: meaningful difference, 0.30°C; 95% CI, 0.13-0.47), and any breastfeeding at age 1 to 4 months (relative risk [RR], 1.24; 95% CI, 1.07-1.43) was cited. The EG recognizes the potential for sudden infant collapse during unobserved SSC in the first 2 hours of life, citing rates of 1.6 to 5 cases per 100 000 live births with mortality rates of 0 to 1.1 per 100000 livebirths. This is addressed by a recommendation for close observation for at least the first 2 hours after delivery coupled with vigilance to assess and manage signs of distress and prevent the infant from being hurt unintentionally.

Previous BFHI guidelines recommended continuing the practice of SSC throughout the hospital stay while rooming-in. As there are no studies that specifically demonstrate that SSC confers benefits beyond the early hours of life in term newborns, this practice, when coupled with rigid compliance with breastfeeding exclusivity, has raised safety concerns about unmonitored SSC, particularly overnight by an exhausted or sedated mother. The new guideline focuses on immediate (within 10 minutes of birth) and early SSC (10 minutes-23 hours) without explicitly advocating for ongoing SSC beyond that time. It notes the need for safety vigilance during SSC and that hospital resources may be inadequate to safely perform the task beyond the immediate period. The EG also notes that while there are many benefits to rooming-in, many mothers prefer not to and rooming-in “probably makes little to no difference to any breastfeeding at 6 months”.

Take home messages:

• There is no evidence of benefit of skin-to-skin in term babies beyond the early hours.
• Even those benefits are trivial.
• Unmonitored SSC increases the risk of neonatal death.
• Rooming in makes essentially no difference to breastfeeding at 6 months.

2. Formula supplementation

While supportive of breastfeeding exclusivity, the IG [Implementation Guidance] recognizes that supplementation may be necessary for some infants because of inadequate milk supply and maternal choice. The IG mentions the need for vigilance for the risk for late preterm newborns of jaundice, hypoglycemia, and feeding problems. The EG also cites a Cochrane review of randomized controlled trials demonstrating that “addition of artificial milk in the first few days after birth probably makes little or no difference to the success and duration of breastfeeding at discharge” (RR, 1.02; 95% CI, 0.97-1.08) and the IG national monitoring definition of exclusive breastfeeding is now receiving “only breastmilk during the previous day.” A recommendation was also added to provide donor milk to healthy full-term newborns who required supplementation without providing cost-benefit evidence to support this practice in term infants.

Take home messages:

• Formula use may be necessary because of inadequate milk supply.
• There is no evidence that judicious formula use in the first few days has any impact on breastfeeding.
• There is no evidence to support a recommendation of donor breast milk for term infants.

3. Pacifier use

Consistent with evidence that pacifiers reduce the risk of sudden infant death syndrome (SIDS) and high-QOE that pacifiers do not interfere with breastfeeding outcomes, the draft IG had pro- posed eliminating pacifier restrictions. Despite evidence that mothers value using pacifiers, this change was not included in the final IG. Instead, advice to counsel mothers about hygiene risks was added without mentioning the reduced risk of SIDS associated with pacifier use.

Take home messages:

• Pacifiers prevent SIDS.
• Pacifiers do not interfere with breastfeeding.
• The new guidance ignores this scientific evidence.

The authors note that the BFHI is not the only way or even the best way to support breastfeeding:

Institutional and public health clinicians should consider using the EG to develop their own policies whenever a specific recommendation in the IG is inconsistent with evidence or does not seem applicable to local circumstances.

A notable shift of emphasis that will foster local innovation is the IG conclusion that BFHI designation is not the only worthy public policy option for breast feeding support. Consistent with the US Preventative Services Task Force evidence report, the draft for public comment stated “While the designation of baby-friendly is one way to recognize facilities that provide appropriate care, designation is not the most effective strategy to achieve sustainable improvement in the quality of maternity care.”

Though the review is couched in careful language, the conclusions are devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.

Earlier this week I wrote about the new GateHouse Media expose of homebirth midwifery, Failure to Deliver. It features many tragic stories about preventable infant death including the tale of homebirth midwife Christy Collins. After repeatedly ignoring Danielle Yeager’s serious pregnancy complications — more than 2 weeks past her due date and no amniotic fluid:

Collins took the Doppler wand and placed it on Yeager’s belly, moving it around until they could hear the whoosh-whoosh-whoosh of the heart.

It sounded different this time. Slow. Dangerously slow. A number appeared on the monitor: 90 beats per minute. Not the normal, healthy fetal heart rate of 120-160 bpm.

“At that point, I said, ‘We need to go,’” Brooks [the baby’s father] recalled.

Although they were in a clinic connected to Spring Valley Hospital near the heart of Las Vegas, Collins instructed them to meet her at Centennial Hills Hospital, more than 16 miles north. It’s about a half-hour trek.

By the time Yeager arrived at the other hospital, it was too late. Despite an emergency C-section and extensive neonatal resuscitation efforts, baby Gavin Michael was dead.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Even among homebirth midwives who routinely lie about their role in preventable deaths, Christy Collins stands out.[/pullquote]

There are two things that make the story of Christy Collins particularly damning: 1. She had been prohibited from practicing midwifery in California so she simply moved to another state. 2. Nearly every claim she made to Gatehouse Media was shown — through texts, recollections of the parents, and recollections of the medical professionals — to be a lie.

Now her husband Chuck is publicly lying on her behalf.

I remember the anguish, the confusion as to why her client, someone that Christy had grown close to, had refused to be seen by specialists after an abdominal assault incident. Or the car accident, or bleeding that followed. It was obvious that the client did not trust the medical community, but Christy did, and gave every chance short of force to make that happen. Multiple ultrasounds, a cancelled perinatologist appointment by the client who accused my wife of trying to subject her to ‘the dead baby flag,’ refusals of hospital induction, refusal to stay at the hospital, and blaming my wife’s urgency for putting stress and pressure on her, as she believed it was preventing her from going into labor. Many other parts of her care were above and beyond a typical client of Christy’s, not just because it was needed, but because the client declined a higher level of monitoring. There were no statutes in that state protecting a midwife from abandonment charges after 36 weeks if the care of a noncompliant client was dropped or transferred. I remember Christy staying in the hospital room after the passing for many many hours, making sure those parents knew their son, helping them cope in the days that followed. In the week that followed (something else missing in your reporting), the client had told my wife that the reason she kept saying she wanted more time was because she KNEW. She knew something was wrong and she wanted more time with her baby while he was still alive. It seems nearly impossible that ANY mother wouldn’t immediately jump into action if their midwife told them that their baby needed to come out. It doesn’t make sense. When the client’s mother found out about California in the weeks that followed, she even went as far to try and have Christy arraigned again for practicing in Nevada. Christy again, had to appear in court only to be told by the judge what she had already been legally advised, that her practice in Nevada was NOT in violation of any part of her legal issue in California.

I suppose if you are committed to lying, it hardly makes sense to worry about how monstrous the lies are, but it does make sense to worry about the existence of documentary evidence proving that it is a monstrous lie. And I have that documentary evidence. I was the one who originally reported the tragedy of Gavin Michael’s preventable death and identified Christy Collins as the midwife responsible.

It wasn’t that hard after Collins crowd sourced Yeager’s complications on Facebook, asking Jan Tritten, the editor of Midwifery Today to solicit advice from other homebirth midwives:

…[W]hat do we truly feel are the risks compared to a woman whose water has been broken and so baby/cord has no cushion there either. Cord compression only? True possibility of placenta being done although it looks good? Can anyone share stories/opinions? …

Do you see any evidence that Collins was trying to convince Yeager to go to the hospital immediately? Me, neither.

In the wake of Gavin Michael’s death, Collins immediately took to social media to share the midwife’s story without acknowledging that SHE was the midwife:

The midwife was ON TOP OF THIS SITUATION

I asked Christy on her own Facebook page whether she was the primary midwife in the case. She lied:

No, I’m not, but enough details had been passed around to select midwives to realize it was not what got created on Jan’s page, and it was NOT Jan. Someone needed to say something …

I asked for the identity of the midwife and Christy lied again.

I’m sorry, you know I can’t do that. Coming to the defense of others is something I will do if I feel that their actions were defensible. With what I have heard, and with what others posted, they were. It was presented by the midwife poorly, but the actions taken up to that point and past appear to have been within OB protocol …

Chuck is now lying when he says that Christy repeatedly urged Danielle to go to the hospital. How do I know? Back in 2014 I quoted the text that Christy sent to Danielle on the day after the baby’s death. In it she acknowledges that she actually advised Danielle to ignore the perinatologist who warned that the baby might die.

I wish I could go back in time, and have said stronger words – enough to make you hate me, and fell you had no choice but to go into the hospital the day before. I could’ve lived with you hating me, over this feeling of devastation.

I know we say that we don’t know if it would’ve been any different; maybe he would’ve been very sick, but alive. I don’t know. But I wish I wouldn’t pushed much hard and said the things that we never want to hear the ‘experts’ say…

Instead of … telling you to “be prepared that the perinatologist doing the NST is likely to tell you that your baby could die if he doesn’t come out;” those should have been MY words. You might have been really pissed at me for pushing you into a corner where you felt you didn’t have a choice, but … I wouldn’t care… I am angry at myself for being the midwife who tried to be as firm but gentle as possible when advising to go in when I could’ve waved the dead baby flag…

I wanted so badly to see a change in fluid … while you just wanted time/space to think … If I hadn’t agreed, and used the words “your baby could die because of this …”, maybe he would still be here…

Back in 2014 Christy told Danielle that she blamed herself for the baby’s death:

I blame me. I would rather have you hate me for pushing you harder into a bad birth experience … so you could hold a live baby instead.

Midwifery implies choices. Informed consent. Informed refusal. No woman would refuse an induction if she knew what having a dead baby felt like. In the future, I’ll pressure until my client hates me. I won’t care.

She promised she would learn from her role in Gavin Michael’s preventable death, but, of course, she lied about that, too.

I’ve argued repeatedly in the past that aggressive breastfeeding promotion in general and the Baby Friendly Hospital Initiative in particular are scientific failures. They ignore the scientific evidence in favor of the personal beliefs of lactation professionals — exaggerating the benefits of breastfeeding, hiding the risks (dehydration, jaundice, brain injures and deaths) and demonizing pacifiers and judicious formula supplementation as harmful when in fact they are lifesaving.

But aggressive breastfeeding promotion, particularly the Baby Friendly Hospital Initiative is also a moral failure. A new paper in Current Sociology, Social roles and alienation: Breastfeeding promotion and early motherhood, explains:

…The article argues that the effort to rigidly impose a moral code as the role [of mothering] is taken on has potentially alienating effects, as it limits the scope for the agent to appropriate and identify with it. An approach to health promotion which instead trusts women to exercise situated moral judgement about infant care, rather than subjecting them to an externally imposed moral code, would reduce the emotional strain and potential for alienation in early motherhood.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Baby Friendly Hospital Initiative treats women not as ethically valuable in themselves but instead as the means for achieving breastfeeding targets.[/pullquote]

Our views about motherhood have recently undergone substantial change:

Motherhood has undergone significant transformation in recent decades, as the expectation of individual autonomy has reshaped gender and family life. Women now expect to become mothers not because of biological destiny, coercion, or social duty, but instead as an aspect of a self-directed life. Motherhood is expected to be taken on only when it is understood as integral to the agent’s realization of her intentions and values.

At the same time, the practices of mothering, particularly in the early stages, have become the focus of intense public interest. Cultural ambiguity about the value of full-time mothering has shifted public debates away from the question of whether mothers should engage in paid employment at all, to a focus on the quality of maternal caregiving.

As a result:

Time-intensive mothering practices, especially breastfeeding, have become an important focus of status claims for both stay-at-home and employed mothers.

Ironically, at the same moment that women have been freed from the expectation to have children for no better reason than because it is their biological destiny and therefore must be best, women who choose to have children are still prisoners of the expectation they will breastfeed because it is their biological destiny and therefore must be best.

It’s hardly surprising then that so many good mothers feel so bad about breastfeeding:

Breastfeeding tends to be experienced as emotionally intense, in positive and negative ways. Sustained breastfeeding is generally understood to depend on self-control, in the form of maternal self-sacrifice and concentrated effort, if it is to be ‘successful’. Most women are fully aware of the message that ‘breast is best’, but tend to act in ways which take account of various other considerations.

Then they are shamed for daring to take other considerations into account.

The expectation that good mothers will breastfeed is a feature of the Baby Friendly Initiative. This is a programme for promoting breastfeeding as ‘the golden standard of care’ in maternity centres and amongst health professionals caring for mothers and infants following birth…

Women have not been imagined as decision-makers in this initiative, but instead as passive recipients of information, training and support.

That is a serious moral defect:

Health promotion strategies like this tend to assume that target populations are likely to comply with moral pressure. Such behaviourist expectations take little account of human agency, autonomy, or the indeterminacy of the social world… Such utilitarianism treats agents not as ethically valuable in themselves but instead as the means for achieving public health targets.

In other words, women are treated as objects to be acted upon, not as individuals capable of making their own decisions.

What’s the harm?

When pressure is brought to bear on women to breastfeed in the first hours, days and weeks after giving birth, the role becomes rigidly defined. This undermines agency, the ability to ‘take and make’ motherhood, developing some command over the role through interpretation and improvisation.

That accounts for the plethora of recent articles in which women detail how they and their babies suffered under pressure to breastfeed. It also accounts for the popularity of the Fed Is Best movement; not only is being fully fed with formula better for babies than starving on breastmilk, using formula to ease the stress of new motherhood is better for mothers than struggling to breastfeed.

Even breastfeeding professionals have been forced to address women’s suffering, but sadly they interpret it through the lens of breastfeeding promotion. They’ve defined breastfeeding “trauma” as the disappointment of being unable to breastfeed when the reality is that breastfeeding trauma is a result of treating women as merely the means to reach breastfeeding targets, instead of compassionately as individuals with their own needs, desires and moral agency.

Her baby, her body, her breasts, her choice!

It took 40 years from the time that Heliobacter pylori was identified as the cause of stomach ulcers for doctors to acknowledge it. That’s because the conventional wisdom was that acid caused stomach ulcers and the conventional wisdom was so deeply entrenched (entire careers had been staked upon it) and people with ulcers, denied effective treatment, died as a result.

Today’s conventional wisdom is that breastfeeding has major health benefits and that promoting it aggressively through the Ten Steps of The Baby Friendly Hospital Initiative (BFHI) is the key to improving infant health. It has been the conventional wisdom for nearly 30 years despite the fact that there is little evidence that breastfeeding has major health benefits for term babies, copious evidence that aggressive breastfeeding promotion has major risks and no evidence that the BFHI even works in improving breastfeeding rates.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”[T]he 10 steps should not be treated as the equivalent of the Ten Commandments …”[/pullquote]

No matter. Entire careers, indeed an entire profession (lactation consultant) have been staked upon promoting the Ten Steps of the BFHI.

That’s why it is remarkable to see Arthur I Eidelman, the editor of the premier breastfeeding journal Breastfeeding Medicine, highlight the need for review of the BFHI in general and the Ten Steps in particular.

I find the author’s use of scare quotes particularly telling:

One cannot argue with the recent “success” of the Baby-Friendly Hospital Initiative (BFHI) that was established in 1992 in response to a call to action for support of breastfeeding by the 45th World Health Assembly…

In 2011, in only two states was there >20% BFHI penetration. In 20 states there were no Baby-Friendly facilities. Seven years later, in 2018, 40% of the birthing facilities in 12 states were certified as Baby-Friendly. Most striking, >1 million births (roughly 25%) of the annual US birth cohort were taking place in such facilities…

But recent studies do not support claims of either safety or effectiveness of the BFHI.

Eidelman does not necessarily agree, but:

Careful reading of the two recent reviews confirms that the authors are demanding the same standards of evidence thatare required for any other care plan, procedure, or medication. What they are more than implying is that the 10 steps should not be treated as the equivalent of the Ten Com-
mandments that were chiseled in stone at Mount Sinai and that each of the steps be evaluated separately for evidence-based conclusions.

He notes:

In fact the WHO itself has acknowledged this and recently published a revised set of guidelines for the 10 steps, modifying among other things its previous restrictive policy as to the use of pacifiers, bottles, and teats.

Although he neglects to mention that these restrictions were put in place without any evidence to back them and have resulted in significant suffering for babies and mothers.

His conclusion is powerful nonetheless:

What is needed in my opinion is not a rigid categorical defense of a magic (holy?) 10 but an intellectually rigid evaluation of the individual steps and their possible various combinations (not necessarily of all 10) that are both safe and efficacious.

There is one issue, though, on which I strongly disagree. Eidelman insists:

The measure of success of any initiative should not be the number of certified institutions per se but the actual breastfeeding rates that will meet our healthy people objectives.

Actually it should be neither since both are measure of process, not outcome. The measure of success of any public health initiative is improvement in health OUTCOMES such as reduction of deaths, reduction of illness and reduction of healthcare spending.

The BFHI and the Ten Steps have been around for nearly 30 years, and with the exception of premature infants, they’ve been unable to demonstrate any improvement in health outcomes at all.

That should be a glaring signal that the conventional wisdom about breastfeeding is wrong.