Yesterday I wrote about the ways in which midwives and lactation consultants treat childbearing women like children. Society at large is also guilty of infantilizing women. The paradigmatic example is formula advertising.

Formula advertising restrictions go back to 1981 and the Nestle debacle in Africa. Nestle and other formula companies engaged in the brutally unethical promotion of infant formula powder to women who had access to only contaminated water with which to prepare it. Tens of thousands of infants died as a result.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Though adult women are trusted to determine whether or not to smoke cigarettes or consume alcohol, it is assumed they cannot be trusted to determine whether or not they wish to breastfeed.[/perfectpullquote]

The problem was the water and the solution was two fold: mandate truth in advertising about the dangers of preparing formula with contaminated water and increase Africans’ access to clean water. Instead, breastfeeding advocates seized upon this as a way to promote breastfeeding, a tactic they have continued to this day, more than 35 years after the fact.

A central pillar of lactivist efforts has been to restrict formula advertising. The World Health Organization’s Code of Marketing of Breast-milk Substitutes first published in 1981 pulls no punches about what it’s trying to accomplish. Even the title disparages the use of formula.

The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have for many years emphasized the importance of maintaining the practice of breast-feeding—and of reviving the practice where it is in decline—as a way to improve the health and nutrition of infants and young children. Efforts to promote breast-feeding and to overcome problems that might discourage it are a part of the overall nutrition and maternal and child health programmes of both organizations and are a key element of primary health care as a means of achieving health for all by the year 2000.

To that end:

Manufacturers and distributors of infant formula should ensure that each container as a clear, conspicuous, and easily readable and understandable message printed on it, or on a label which cannot readily become separated from it, in an appropriate language, which includes all the following points: (a) the words “Important Notice” or their equivalent; (b) a statement of the superiority of breast- feeding; (c) a statement that the product should be used only on the advice of a health worker as to the need for its use and the proper method of use; (d) instructions for appropriate preparation, and a warning against the health hazards of inappropriate preparation. Neither the container nor the label should have pictures of infants, nor should they have other pictures or text which may idealize the use of infant formula…

The following guidelines have also been put in place:

No advertising of such products to the public;
No use of baby pictures on packaging to idealize infant formula;
No free samples or gifts to mothers or health workers;
No promotion of such products in health facilities
No contact of mothers by company representatives.

Further refinements have involved banning marketing displays in stores and prohibiting the use of discount coupons to purchase formula as well as prohibiting the use of formula purchases in frequent shopper programs.

The advertising and marketing of infant formula is subject to greater restrictions than cigarette or alcohol advertising, both of which pose far more risk to life and health than formula. The rationale behind restrictions on cigarette and alcohol marketing is to prevent children — who are assumed to be far more impressionable and to lack the analytic powers of adults — from being tempted to use an addictive substance. The restrictions on cigarette and alcohol advertising are NOT designed to prevent adults from accessing either substance.

When it comes to formula marketing, women are assumed to be so limited in intelligence and judgment that they must be treated as children. Though adult women are trusted to determine whether or not to smoke cigarettes or consume alcohol, it is assumed they cannot be trusted to determine whether or not they wish to breastfeed. They must be pressured into it.

Since the promulgation of the WHO Code, we’ve learned a great deal about the fact that the benefits of breastfeeding are far more limited than what we originally thought. With the exception of premature infants, there is no correlation between breastfeeding rates and mortality rates. The only fully documented benefits of breastfeeding for term infants are an 8% reduction in colds and an 8% reduction in episodes of diarrheal illness across the entire population of infants in their first year. Moreover, despite the manipulative language of breastfeeding advocates, there are no “harms” of infant formula and there are real risks (hospital readmission, brain damage, death) to aggressive breastfeeding promotion.

Ironically, there are no restrictions on the marketing of “natural” and “homeopathic” remedies for infants even though they are useless at best and toxic at worst. For example, while draconian restrictions on formula marketing were being enforced, Hyland’s homeopathic teething preparations were implicated in adverse outcomes, including 10 infant deaths. Finally in 2017 the FDA recalled the products because the manufacturer had mislabeled the amounts of belladonna alkaloids they contained.

Think about that: the US government believes that mothers are adults capable of judging dangers of alternative infant remedies, some of which are toxic, but so incapable of judging the “dangers” of formula that they must be protected from formula marketing as if they were children.

Women are either capable of making safety decisions or they are not. If they are capable of determining whether or not to consume cigarettes or alcohol then they are capable of determining whether or not to breastfeed or use formula. There should be no special restrictions on formula advertising or marketing. To allow them, or worse to promote them, is to demean women.

We treat children differently than we treat adults.

• We presume we know better than they what they need.
• We believe we have an obligation to guide them on the right path.
• We know we understand risks better than they do.
• To the extent they disagree, we ascribe it to immaturity and lack of knowledge.
• We are sure that if they “understood” what was at stake, they would want what we want.
• We accuse them of being inordinately swayed by outside pressures.
• We feel obliged to force them to do things they don’t want to do “for their own good.”

All these reactions are perfectly appropriate if we are talking about a seven year old. They may even be appropriate if we are talking about a seventeen year old, although they may not. Surely, though, they are an inappropriate as a way to treat adult women.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is unacceptable to treat women like children even for “their own good.”[/pullquote]

Which begs the question:

Why do midwives and lactation consultants treat women like children?

Consider how midwives treat women who wish to have maternal request C-sections instead of vaginal births:

Most midwives assume that vaginal birth is better than C-section except in rare circumstances.

They imagine they have an obligation to guide women (“support them”) toward vaginal birth.

They believe they understand the risks better than women do even though they habitually ignore many of the risks that are most relevant to women like future incontinence and sexual dysfunction.

To the extent that women disagree, they ascribe this to lack of knowledge about the “real” (often rare, sometimes merely theoretical) risks.

They are sure (and they constantly reassure each other on social media) that women want what they wish to give even if the women themselves appear not to realize it.

To the extent that women disagree, they imagine that they are “socialized” to fear the pain of birth or swayed by obstetricians playing the “dead” baby card.

That’s how they justify their pressuring women to avoid C-sections, avoid interventions, and justify actively seeking to limit women’s access to epidurals.

But that’s nothing compared to lactation consultants:

Lactation consultants have codified treating women like children into the oxymoron of the Baby Friendly Hospital Initiative. It’s an oxymoron because it isn’t friendly to babies. It actually harms them by increasing hospital readmissions for dehydration and jaundice and by increasing infant deaths within the hospital from falls from or being smothered in maternal beds.

The baseline assumption of the BFHI is that women can’t be trusted to know what’s best for themselves and their babies. They must be subjected to a rigidly curated propaganda offensive.

Lactation consultants are sure (despite scientific evidence to the contrary) that breast is best for every mother and baby. They are so sure that they have enshrined their belief in the phrase “breast is best” and plastered it to the walls of midwives’ offices and hospital corridors. They endlessly harangue women about the “benefits” of breastfeeding, most of which have proven illusory.

Lactation consultants believe they understand the risks of formula feeding better than mothers do, but most of those presumed risks are based on poorly done epidemiological research riddled with confounders and have not occurred in real world experience.

To the extent that women wish to use formula, lactation consultants ascribe their desire to ignorance, lack of “support” and marketing by formula companies (despite the fact that they have banned marketing by formula companies).

Lactation consultants seek to restrain women who wish to use formula by placing stumbling blocks in their way: locking up formula in hospitals, forcing them to sign formula consent forms, limiting what health professionals are allowed to tell them on the topic.

Lactation consultants have gone so far as to fabricate risks that don’t even exist such as the “risk” of nipple confusion from a bottle and the “risk” of formula supplementation even though research shows that formula supplementation prevents hospital readmission and leads to increased rates of extended breastfeeding.

Lactation consultants are sure that their tactics are justified by an obligation to force women to breastfeed for “their own good” and their babies’ health.

But women are not children and it is completely inappropriate to imagine that they are. Women are adults capable of determining what is best for themselves and their children.

It follows therefore:

Women should not be pressured into avoiding interventions and epidurals or pressured into having a vaginal birth

Women who don’t find empowerment through their reproductive functions don’t need to be educated or “supported” into making choices that are different than the ones they articulate.

The arbiter of clinical practice MUST be scientific evidence, not intuition and certainly not providers seeking validation of their own choices by patients mirroring them back.

This applies equally to breastfeeding. As between breastfeeding and formula feeding there is no “best” way to feed a baby.

Midwives and lactation consultants need to hold themselves to a higher standard than what they currently embrace. It is completely unacceptable to treat women like children even “for their own good.”

Most breastfeeding scientists and much of the public often consider epidemiologic associations of breastfeeding to represent causal effects that can inform public health policy and guidelines. However, the emerging picture of breastfeeding research is difficult to reconcile with good scientific principles. The field needs radical reform.

If that paragraph seems familiar to readers of scientific journals it is because it is a paraphrase of the lead paragraph of John Ioannidis’ new paper The Challenge of Reforming Nutritional Epidemiological Research.

Most nutrition epidemiological research is nonsense and breastfeeding epidemiological research is a subset of nutrition research.

Ioannidis writes:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We should ignore hasty statements of causal inference and advocacy to public policy made by breastfeeding researchers.[/pullquote]

In recent updated meta-analyses of prospective cohort studies, almost all foods revealed statistically significant associations with mortality risk…

Assuming the meta-analyzed evidence from cohort studies represents life span–long causal associations, for a baseline life expectancy of 80 years, eating 12 hazelnuts daily (1 oz) would prolong life by 12 years (ie, 1 year per hazelnut), drinking 3 cups of coffee daily would achieve a similar gain of 12 extra years, and eating a single mandarin orange daily (80 g) would add 5 years of life. Conversely, consuming 1 egg daily would reduce life expectancy by 6 years, and eating 2 slices of bacon (30 g) daily would shorten life by a decade, an effect worse than smoking. Could these results possibly be true? Authors often use causal language when reporting the findings from these studies (eg, “optimal consumption of risk-decreasing foods results in a 56% reduction of all-cause mortality”). Burden-of-disease studies and guidelines endorse these estimates. Even when authors add caveats, results are still often presented by the media as causal.

Breastfeeding studies are exactly the same. The breastfeeding equivalent of claiming 12 hazelnuts a day would prolong life by 12 years is claiming that breastfeeding could save 800,000 lives per year. That’s equally nonsensical. It’s based on a mathematical model that has never been validated. Even when formula companies engaged in their unethical campaign to promote formula in Africa, the actual death toll at the peak year of formula promotion was 65,000. That represents 65,000 preventable tragedies, but nowhere near what we might expect if breastfeeding researchers’ claims were true.

Since then according to Paul Gertler whose research established the 65,000 peak death toll:

…[T]he annual death toll has dropped to about 25,000, driven by improved access to clean water in the Southern Hemisphere.

That’s just 3% of the number claimed by breastfeeding researchers.

How do good people end up making such bad claims?

These implausible estimates of benefits or risks associated with diet probably reflect almost exclusively the magnitude of the cumulative biases in this type of research, with extensive residual confounding and selective reporting. Almost all nutritional variables are correlated with one another; thus, if one variable is causally related to health outcomes, many other variables will also yield significant associations in large enough data sets. With more research involving big data, almost all nutritional variables will be associated with almost all outcomes. Moreover, given the complicated associations of eating behaviors and patterns with many time-varying social and behavioral factors that also affect health, no currently available cohort includes sufficient information to address confounding in nutritional associations.

Moreover:

…[T]he literature is shaped by investigators who report nonprespecified results that are possible to analyze in very different ways. Consequently, meta-analyses become weighted averages of expert opinions.

That’s precisely what has happened with breastfeeding research. Researchers continue to make absurd claims about the benefits of breastfeeding based on extrapolations from small studies with multiple confounding variable; this despite the fact that they can find NO EVIDENCE in real life that their claims are true. There is no evidence that breastfeeding rates are correlated in any way with infant mortality and there’s no evidence that increasing breastfeeding rates leads to corresponding declines in infant deaths.

Okay, so perhaps nutrition and breastfeeding researchers have exaggerated various risks and benefits, but what’s the harm?

Nutritional research may have adversely affected the public perception of science. Resources for some of these studies could have been better spent on unambiguous, directly manageable threats to health such as smoking, lack of exercise, air pollution, or climate change. Moreover, the perpetuated nutritional epidemiologic model probably also harms public health nutrition. Unfounded beliefs that justify eating more food, provided “quality food” is consumed, confuse the public and detract from the agenda of preventing and treating obesity.

The harm is even larger in breastfeeding research because breastfeeding has risks as well as benefits. Aggressive efforts to increase breastfeeding rates have led to tens of thousands of neonatal hospital readmissions for dehydration and jaundice, some of which have culminated in infant brain injuries and deaths.

To the extent that nutritional epidemiological research has revealed anything at all, it has demonstrated that there is no such thing as a nutrition “silver bullet.” There is no food, herb or supplement or combination of food, herbs and supplements that magically assures health. That goes for breastfeeding, too. Despite what breastfeeding researchers claim, breastfeeding is NOT a silver bullet for infant health and in many circumstances formula feeding may actually be healthier.

Ioannidis concludes:

Reform has long been due. Data from existing cohorts should become available for reanalysis by independent investigators. Their results should be presented in their totality for all nutritional factors measured, with standardized methods and standardized exploration of the sensitivity of conclusions to model and analysis choices. Readers and guideline developers may ignore hasty statements of causal inference and advocacy to public policy made by past nutritional epidemiology articles. Such statements should be avoided in the future.

The same goes for breastfeeding. Readers and guideline developers should IGNORE hasty statements of causal inference and advocacy to public policy made by past breastfeeding epidemiology articles. And breastfeeding researchers should avoide such claims in the future. They are not true and they may even be harmful.

One of the things I like best in writing about contemporary mothering issues is the cross-fertilization betweeen academic theory found in journals and lived reality represented by media articles and blog posts by and about mothers. The average natural childbirth advocate or lactivist has little idea how her preferred rhetoric, which she believes was promulgated by childbirth and breastfeeding professionals, has actually been shaped by professors. Similarly, women struggling under the crushing imperatives mandated by those professionals have little idea how — fortunately — their anguish is fueling the writing of other academics.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”[W]e should not treat breastfeeding as a baseline in a sense that implies that women who formula feed are harming their babies.”[/pullquote]

Breastfeeding is a case in point. Most contemporary language on breastfeeding can be traced back to an academic paper written in 1996, Watch your language by Diane Wiessinger.

When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a “special bonus”; but she may clamor for help if she knows how much she and her baby stand to lose. She is less likely to use artificial baby milk just “to get him used to a bottle” if she knows that the contents of that bottle cause harm.

But now a philosophy professor cautions that the use of risk based language around formula is not morally justified. In a new paper in the Journal of Medical Ethics, Fiona Woollard asks, Should we talk about the ‘benefits’ of breastfeeding? The significance of the default in representations of infant feeding.

In an accompanying blog post, Prof. Woollard explains why she wrote the paper.

She was attending a meeting of breastfeeding professionals:

… Then the speaker adds, almost as an aside, “Of course, we know that it is really ‘the harms of formula’ not ‘the benefits of breastfeeding’.” There is a general nodding of heads. It seems to be accepted by almost everyone in the room that this is something that we know. It is ‘known’ that any differences in outcomes between babies fed with infant formula and breastfed babies should be described as ‘harms of formula’.

Woollard begs to differ.

As a philosopher, I feel a sort of territorial annoyance. This is a deeply complex philosophical question. It is not something that we should confidently claim to know as if there were a simple answer.

In her paper she explains why talking about the “harms” of formula is NOT morally justified.

She, too, traces the use of risk language to Weissinger’s piece. And she opposes the use of such language on both philosophical and practical grounds:

Given the detrimental effects that shame surrounding formula use can have on the well-being of new mothers and their neonates, we have strong reasons to avoid the unjustified use of morally loaded terms to describe infant-feeding decisions. There is significant sociological evidence connecting decisions to use formula and feelings of shame, guilt and failure… The use of morally loaded terms … also gives the impression that such guilt and shame is appropriate. If guilt and shame is seen as appropriate, then its effects on maternal well-being may be wrongly dismissed as morally unimportant.

Where did Weissinger go wrong in her invocation to use shaming language around formula feeding?

Wiessinger appeals to an allegedly standard use of language surrounding health to argue that we should treat breastfeeding as the default and formula feeding as deficient and dangerous. She states: “Health comparisons use a biological, not a cultural, norm, whether the deviation is harmful or helpful…

Even if breastfeeding is the biological norm, it is far from obvious that it should be the moral baseline from which the morally loaded calculations of harm and benefit are calculated…

Why not?

Because breastfeeding deeply implicates the mother’s body and agency, positioning breastfeeding as the moral baseline is problematic even if it is the biological norm. To do so takes the mother’s body and agency for granted. It does not fit with our use of the concepts of harm and benefit in other situations…

Woollard reviews a variety of moral accounts of harm and shows why they lead to the conclusion that formula feeding does not cause “harm.”

For example:

If I were to push “Joe” into traffic on a busy highway and he gets hit by a car, I have harmed Joe. But if Joe runs into traffic and I don’t stop him, I haven’t harmed him. Moreover, if a car is heading is our direction and I don’t step in front of Joe to protect him at the expense of myself, I certainly haven’t harmed Joe.

Similarly, if I were to deliberately expose “Sammy” to a diarrheal illness and he gets sick, I have harmed him. But if Sammy gets a diarrheal illness that might possibly been prevented by breastfeeding, I haven’t harmed him. Moreover, if Sammy gets a diarrheal illness because I don’t use my body to offer him the potential protection of breastfeeding, I haven’t harmed him, either.

Therefore, from a moral perspective, not breastfeeding cannot and should not be described as a harm.

Interestingly, Woollard does not question the scientific evidence on the benefits of breastfeeding. Either she is unaware or in the interests of brevity has decided not to mention the fact that the scientific evidence on the benefits of breastfeeding is weak, conflicting and riddled with confounding variables. She does not mention that the promised benefits of increasing the breastfeeding rate have failed to appear and that breastfeeding has risks (of dehydration, jaundice, starvation and death) as well as benefits. She proceeds under the assumption that breastfeeding is indeed beneficial, but even then a mother who doesn’t breastfeed is NOT harming her child.

Woollard concludes:

When it comes to descriptions of maternal behaviour, we should reject the assumption that there has to be a single appropriate default for infant feeding. Breastfeeding is normal and should not be stigmatised or seen as a lifestyle choice that can only be accommodated under ideal circumstances. The phrase ‘breast is best’ should be avoided. But we should not treat breastfeeding as a baseline in a sense that implies that women who formula feed are harming their babies. Extreme care should be taken before using morally powerful terms such as ‘risk’, ‘harm’ and ‘danger’. Where possible, neutral terms such as ‘difference’ should be used, accompanied by clear information about the outcomes presented non-comparatively.

I strongly agree and I sincerely hope that breastfeeding professionals will take note!

In 1558, John Knox penned The First Blast of the Trumpet Against the Monstrous Regiment of Women. Knox, a Protestant, was lamenting the fact that the Protestant Reformation was being stymied in both England and Scotland by Catholic monarchs. Yet it wasn’t their Catholicism that he blamed; it was the fact that they were women.

Knox used “monstrous” and “regiment” in an archaic sense to mean “unnatural” and “rule,” arguing that female dominion over men was against God and nature. He lamented that the future of the Protestant faith lay solely in the hands of a female monarchy largely hostile to its precepts. Echoing the era’s widespread assumption that women were inferior to men, capable only of domestic acts such as bearing children, Knox placed blame on the “abominable empire of wicked women” for the trials and tribulations of the Reformation.

No doubt it made perfect sense to Knox and his readers, but from our vantage point in the 21st Century, it’s easy to see that it was misogyny pure and simple. Women who dared seek more out of life than reproduction (or, as the in the case of queens, were forced by circumstance to do so) were unnatural and therefore monstrous. “Natural” women were meant to be home pregnant, breastfeeding or both.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There is a gathering backlash to the philosophies of natural childbirth and lactivism that condemn women who make different choices as “unnatural.” [/pullquote]

Curiously, the injunction to limit oneself to natural pursuits applied only to women. Men who sought to do more than reproduce and hunt to feed themselves and their families — men who sailed ships, waged technological warfare, built cathedrals, wrote religious tomes — were to be praised for rising above their base, animal nature.

Sadly, contemporary midwives and lactation consultants are the intellectual heirs of Knox’s misogyny. Women who refuse to be limited by biology in giving birth to and feeding their infants in the “natural” way are portrayed as monstrous — either lacking in feminine feeling, possessing deficient bodies, too stupid (in need of “education” and “support”) to know better or all three.

Knox meant The Monstrous Regiment of Women as a marketing tool. He was selling his services as a Protestant reformer by tying the old religion of Catholicism to the “unnatural” rule of women. Those who let themselves be led by women were being led to Hell. Better to be led by men who know the way to Heaven.

Midwives and lactation consultants are also selling their services. They do so by tying the lifesaving technology of modern medicine — epidurals, C-sections and infant formula — to “unnatural” women. Indeed the technology itself is portrayed as male and patriarchal despite the fact that in 2018 the majority of obstetricians are women and the majority of women happily avail themselves of that technology. In other words, those who let themselves be led by technology are being led to the hell of a traumatic birth or a child sickened by lack of breastmilk. Better to be led by women, midwives and lactation consultants, who know the way to the heaven of empowering birth and empowering breastfeeding.

When midwives claim that the only healthy, safe birth (and not coincidentally the only one they can provide) is birth as nature intended, they are implying that women who choose otherwise are monstrous. When lactation consultants insist that we can’t improve upon breastfeeding (not coincidentally the only form of feeding they are selling) because it’s natural, they are implying that women who choose otherwise are monstrous.

Things didn’t turn out well for John Knox. Shortly after The Monstrous Regiment of Women was published, the Catholic, English Queen Mary died and was succeeded by the Protestant Queen Elizabeth. She was familiar with his condemnation of “unnatural” women and she wasn’t amused.

Though not the intended target of Knox’s First Blast, Queen Elizabeth took great offense at the publication, and in 1559, repeatedly refused Knox passage to Scotland through England. Knox attempted to apologize to the queen …

Ultimately he was allowed to return and he had learned his lesson:

Having endured the controversy of The First Blast, Knox went on to play a key role in Scotland’s opposition to the Catholic monarchy, solidifying Scotland as a Protestant, and Presbyterian, nation for centuries to come. As for his second and third blasts, it would seem that the “Trumpet of the Scottish Reformation” learned an important lesson. Neither was ever sounded.

He never stopped being a misogynist, but at least he stopped writing about it.

Midwives and lactation consultants need to learn the same lesson. It’s a very bad idea to criticize the people on whom you depend for employment. There is a gathering backlash to the philosophies of natural childbirth and lactivism, philosophies that condemn women who make different choices as “unnatural.” That backlash comes as women recognize that midwives and doulas aren’t leading them to heaven, but rather to a hell of excruciating labor pain, frustrating breastfeeding attempts that harm their babies, and being relegated back into the home.

Elizabeth, a subtle and brilliant queen, resented the misogyny of labeling her as “unnatural” because she chose to rule rather than to marry. Similarly, ever more women are coming to resent the misogyny of midwives and lactation consultants who seek to control women by labeling those who use and even choose technology by labeling them as “unnatural,” too. Admonishing women to pursue the natural has always been a hallmark of misogyny; it was true in 1558 and it’s just as true in 2018.

When my children were small, there was rarely a day that passed without someone whining, ”It’s not fair!”

I would inevitably respond with some variation of, “Who said life was fair?”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Believing you are entitled to a “healing” birth makes as much sense as believing you are entitled to a “healing” diet that will finally make you thin.[/pullquote]

Sometimes I would expand on that admonition by explaining that anyone who expected that everything would always be fair was destined to be sorely and repeatedly disappointed. The difference between a happy life and an unhappy life is not whether you experienced unfairness; everyone does. The difference is how you deal with it. You have to learn to accept it and move on. That didn’t mean that you have to be happy about it, just that you can’t let yourself become weighed down by sadness and anger.

That’s how I explained it to children. The adult version is this: you have to be unbelievably entitled to imagine that you are owed fairness.

I am reminded of this whenever I read about a woman’s quest for a “healing” birth, as I did yesterday. Joni Edelman wrote:

His birth was supposed to be peaceful, swimming into the world in our kitchen, surrounded by his family, welcomed with cake and champagne. He was supposed to come out easily and heal me from the trauma of my previous labor and dystocia. His birth was supposed to be a lot of things that it was not.

This birth was supposed to “heal” her from a previous disappointing birth?

Where did she get the idea that she was entitled to the birth of her dreams? Where did she get the idea that if she didn’t get that ideal birth the first time, she is entitled to get it on the next go round? I’d be willing to bet she acquired that outsize sense of entitlement from the natural childbirth industry.

It surely wasn’t from an obstetrician; obstetricians don’t care about how a baby is born just that a healthy baby is born to a healthy mother. I suspect it wasn’t her partner; he was probably thrilled to be a father and considered the method of birth to be irrelevant (to the extent that he considered it at all). I doubt it was her parents or in-laws who were disappointed with her either.

The natural childbirth industry sold her (through their books, websites, childbirth courses, midwives and doulas) a birth that would make her dreams come true and then it didn’t happen. That might have made her question whether giving the industry so much money for promises they couldn’t keep was really worth it.

How convenient (and profitable) for them that they could double down and offer her more books, websites, childbirth courses, midwifery care and doula services to help her “heal” from the disappointment of her first birth, the disappointment that they themselves caused by convincing her that she was entitled to the birth of her dreams.

How convenient for them that at no point are they (or she) forced to re-evaluate validity of the books, websites, childbirth courses, midwifery care and doula services from which they earn their income. They are always correct. She can just try again and this time it will happen!

It’s like the fashion industry. The same people who spend millions marketing the idea that thin women are better, make millions more by marketing the products that will supposedly make you thin. And if a woman’s self-image and self-confidence are undermined because she failed to achieve the ideal weight, it’s her fault for failing, not their fault for creating an unrealistic sense of entitlement.

The idea that a woman is entitled to a “healing” birth makes as much sense as the idea that she is entitled to a “healing” diet that will finally make her thin. Not everyone can be thin and imagining that you are entitled to be thin will just make you miserable. Not everyone can have the birth that midwives, doulas and childbirth educators promise; imagining that you are entitled to such a birth will just make you miserable.

Life isn’t fair. Those who are mature enough to accept that reality deal with their disappointment and move on. Those who aren’t have another baby hoping they will finally get their “healing” birth.

Whose birth experience counts?

Many midwives would answer everyone’s because a “healthy baby isn’t enough.”

They would agree with this mother mourning her lost birth experience:

I don’t have to feign gratitude, because I lost something that was important to me…

I don’t have to be thankful just because things didn’t end tragically.

I’m allowed to grieve what I lost, even now, because it was important to me, and I lost it.

She had wanted a homebirth:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Whose birth experience counts?[/pullquote]

His birth was supposed to be peaceful, swimming into the world in our kitchen, surrounded by his family, welcomed with cake and champagne. He was supposed to come out easily and heal me from the trauma of my previous labor and dystocia. His birth was supposed to be a lot of things that it was not.

I do not want to hear, “Well, you’re lucky he’s healthy,” ever…

Those midwives would encourage Edelman to grieve for her birth as she has done because a desired birth experience reflects a woman’s deepest needs and fears. Providing that experience — an empowering experience that allows her to be in control of her body and feel that her providers have really listened to her —is the ethical obligation of every midwife … UNLESS, of course, she wants a C-section. Then she should be ignored.

According to the BBC:

Women at 75% of UK maternity units are being denied their right to choose a Caesarean, the BBC’s Victoria Derbyshire programme has been told.

NICE guidance says women should be allowed to opt for a planned Caesarean even if it is not for medical reasons.

In this midwife led system, providers are denying women who choose C-sections the birth experience they request.

Birthrights, the human rights in childbirth charity, used a Freedom of Information request to ask 153 trusts providing maternity care how they applied the guidance.

Of the 146 that replied:

26% fully complied with the guidelines
47% partially complied
15% refused maternal requests outright
12% did not seem to have a clear position

This is in direct violation of official policy:

Under the guidelines, women requesting a Caesarean with no other medical reason “should be offered appropriate discussion and support – but ultimately, if they are making an informed choice, a Caesarean should be offered”.

But in many cases the denial occurs without listening to the mother’s request.

[Birthrights] said it had been told trusts had even been telling women they would not be allowed to elect a Caesarean, either when they had been being booked on to maternity care or in a letter before they had even been spoken to.

And even when the request is considered, these women have to jump through hoops that aren’t required for anyone else:

Gill Walton, chief executive of the Royal College of Midwives said: “Women must be given the information to explore their views and feelings about Caesarean birth, to enable them to come to an informed decision about their preferred type of birth.

“This information should reflect the individual woman’s current and previous medical, obstetric and psychological history.”

Are women required to “explore their views and feelings about vaginal birth” before being allowed to have one? I doubt it. Are women required to “explore their views and feelings about homebirth” before being allowed to have one? I’ll bet it never comes up.

Apparently, for women who want a maternal request C-section a healthy baby is supposed to be more than enough.

Why the difference? Because idea that a “healthy baby isn’t enough” is a ploy designed by midwives to wrest market share from obstetricians. Since obstetricians place the highest value on a healthy mother and a healthy baby, midwives encourage women to place the highest value on a fulfilling birth experience … but ONLY if that birth experience fulfills midwives’ needs as well.

Does your ideal birth experience include a vaginal birth? That’s fine; midwives will keep those evil obstetricians — who think a health baby is enough — away so they can’t diagnose any complications that might interfere with your experience.

Does your ideal birth experience include a homebirth? That’s the best! It allows midwives full autonomy and requires more midwives. The midwife/patient ratio at homebirth is supposed to be 2:1 instead of 1:many at hospitals or midwifery led units. And not only will no midwife question whether you are making an informed choice, they’ll happily ignore any and all risk factors that make homebirth a dangerous idea.

Does your ideal birth experience include an epidural? So sad. Midwives will try to convince you that unmedicated birth is better and more empowering. And if that doesn’t work, they will drag their feet in ordering the epidural until it is too late for you to get it.

Does your ideal birth experience include a maternal request C-section? Too bad for you! C-sections don’t do a damn thing for midwives’ need for autonomy and control. Therefore you can’t have one. Shut up and be glad you got a vaginal birth that you didn’t want!

In other words, the “healthy baby isn’t enough” crowd is a bunch of hypocrites. It isn’t your birth experience that matters; it’s theirs.

Let’s stop that hypocrisy. Let’s agree:

Her baby, her body, HER choice and none of the midwife’s business.

Because a woman who wants a maternal request C-section should be treated exactly the same as a woman who wants a homebirth — with respect. Every woman’s birth experience counts!

US maternal mortality has rightly captured the nation’s attention. Perhaps the most shocking fact about it is that so many of the women who die during and in the aftermath of pregnancy die from preventable causes.

Why?

Everyone involved in the care of pregnant women seems to have forgotten the single most important thing about childbirth: it is inherently dangerous and has always been a leading cause of death of young women. Not surprisingly, providers can’t diagnose a complication if they don’t think of it.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]What if normal birth meant avoiding complications not avoiding interventions?[/pullquote]

Obviously obstetricians and midwives need to do a better job of warning women about postpartum complications. Healthcare websites need to do a better job, too.

As Nina Martin reports in the latest installment in the ProPublica/NPR series on US maternal mortality, Trusted Health Sites Spread Myths About a Deadly Pregnancy Complication, most trusted healthcare websites are failing to provide accurate information about postpartum preeclampsia.

The large majority of deaths occur after delivery, often from strokes.

But you’d never know it from the incomplete, imprecise, outdated and sometimes misleading information published by some of the most trusted consumer health sites in the country.

What’s especially disturbing about postpartum preeclampsia is that it often occurs when women are no longer being monitored: after discharge from the hospital and before the 6 week postpartum check. That’s why it is critical that women themselves know how to recognize the symptoms. What do leading internet health websites have to say on the topic?

After reading reports about Beyoncé, ProPublica took a look at how top health sites discuss preeclampsia. We sent screenshots and links to Tsigas, one of the leading experts on the condition in the U.S., for review last week.

Virtually every site we asked her to look at contained some problematic language, Tsigas noted in her written comments. Her biggest area of concern: A number of sites flubbed how they explained postpartum preeclampsia — sometimes mentioning it only in passing, or sometimes failing to mention it entirely…

ProPublica only looked at mainstream medical sites that are presumably maintained or overseen by physicians. But many women often look to natural childbirth websites for information about pregnancy. How do they do?

1. The Childbirth Connection, which describes itself as promoting “safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families,” has NO information on postpartum preeclampsia.

2. Lamaze International, which claims its “education and practices are based on the best, most current medical evidence available,” has NO information on postpartum preeclampsia.

3. Evidence Based Birth, which claims to offer “evidence that empowers,” offers NO information on postpartum preeclampsia.

They aren’t offering women the information they need, either.

What if we used childbirth educators, the people whose job it is to educate women about childbirth, for that very purpose? At the moment, most childbirth educators think their job is to promote “normal birth.” But what if normal birth meant avoiding complications not avoiding interventions?

At the moment, childbirth educators teach women about what to expect during labor and delivery. That’s entirely appropriate. They also spend an inordinate amount of time teaching women that they should avoid epidurals, C-sections, and other childbirth interventions. But if we truly face a crisis in maternal mortality, shouldn’t they be spending that time in trying to avert it?

Let’s reform childbirth education to include the information that women need to protect themselves and their babies from death and serious disability.

Let’s give women:

Information on pregnancy complications like preeclampsia and premature labor. What should they worry about and what should they ignore? Who should they contact when they are concerned?

Information on stillbirth. How much should the baby be expected to move? When should they be concerned about lack of movement? What can they do to encourage the baby to move when they are concerned? When should they insist on fetal monitoring to assess the baby?

Information on postpartum complications like hemorrhage and postpartum preeclampsia. How much bleeding is too much bleeding? What should they do if they begin to hemorrhage? What are the signs of postpartum preeclampsia? Where can they go to get their blood pressure checked besides the doctor’s office? When should they insist on being seen by an obstetrician instead of a midwife or nurse practitioner?

Information on heart complications. Cardiac complications are the leading cause of maternal mortality and women should be taught to recognize their onset. What should they do if they feel unusually weak and short of breath? How quickly should they be seen and by whom?

Information on blood clots. Blood clots are a major, often preventable cause of maternal death. They typically arise in the leg. What are the signs and symptoms? What can women do to prevent blood clots? A blood clot can kill if it breaks off and reaches the lungs (pulmonary embolus). What should women do if they feel chest pain or sudden onset of shortness of breath?

Everyone has a role to play in preventing maternal deaths. Obstetricians and midwives have the primary role, and purveyors of childbirth information have a role, too. Up until now childbirth educators have not been recruited to the effort despite the fact that their mandate is to educate women. Let’s change that. Let’s train childbirth educators to prevent death rather than to prevent interventions!

“You’d look so beautiful if you just lost the extra weight!”

“I admire your confidence for being willing to wear that!”

“Is that your wedding picture? The frame is amazing!”

Those are the kind of passive-aggressive “compliments” that you get from frenemies, the women who insist they are your friends but never miss a chance to undermine you. They aren’t really friends, but rather rivals who cloak their rivalry under the guise of friendship.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Frenemommy is a vampire of self-esteem; she can only get hers by sucking out yours.[/pullquote]

But if you think a frenemy can be harmful to your self-esteem, just wait! One day she will have children and then she will be a frenemommy. No enemy can be as soul destroying as a frenemommy. They are everywhere and it’s not an exaggeration to say that they are destroying the experience new motherhood. So many good mothers feel so bad and frenemommies are the reason.

Becoming a mother is a simultaneously entrancing and frightening experience. You are overwhelmed with love for your impossibly beautiful newborn and frightened to death that you might harm him or her by accident or by ignorance. You are incredibly vulnerable … and along comes Frenemommy.

Frenemommy says:

“Hey, it’s still a vaginal birth even if you did have the epidural!”

And the amazing experience that had your husband looking at you as if you were a goddess is suddenly diminished.

“Your daughter is so smart for a formula fed baby!”

And your pride in your daughter is tainted by guilt that you short-changed her.

“How wonderful that your baby recognizes his mama even though you spend so much time at work!”

And your hard won confidence that you were successfully transitioning back to the job you love is blasted to smithereens.

Frenemommies aren’t just restricted to the people whom you know personally. There are professional frenemommies who write books on childbirth, breastfeeding and attachment parenting, offer their advice for free on blogs and websites, and diligently patrol Twitter and Facebook, gathering followers, belittling anyone who makes different choices, and wallowing in outrage at perceived slights. Sadly, many midwives, doulas and lactation consultants are also professional frenemommies. Under the guise of “helping” you, they undermine your self-esteem at every turn.

Why? Because Frenemommy considers you a threat and won’t feel comfortable until you are docilely occupying the place she assigns for rivals: in awe of her achievements and in doubt about your own. Frenemommy is fundamentally insecure. She is like a vampire of self-esteem; she can only get hers by sucking out yours.

Every mother needs mom friends, old friends who have become mothers like her or new friends made through her children. Most women find mom friends invaluable; they’re the women with whom you can share your child’s every milestone, your deepest concerns about your child’s wellbeing and your fears about your adequacy as a mother. Your mom friends have either been there/done that and can provide reassurance that your children will turn out fine or they are at the same stage you are, worrying about the same things, simultaneously seeking and giving reassurance.

Mom friends revel in your birth stories whether they mirror theirs or not. Mom friends couldn’t care less whether you breastfeed or formula feed, just whether your baby is thriving and you are getting enough sleep. A mom friends drops by with her kids to hold your colicky baby while you make dinner for your older kids and calls you at 6 AM with a migraine knowing you’ll take her kids for the day so she can rest and recover. Mom friends freely offer love and support and you gladly give love and support in return.

How can you tell the difference between a mom friend and a frenemommy?

1. A mom friend makes you feel good when you were feeling bad; a frenemommy makes you feel bad when you were feeling good.

A mom friend is thrilled that you got relief from your epidural; a frenemommy “sympathizes” with you over the loss of your natural birth.

2. A mom friend looks at things from your perspective; a frenemommy looks at everything from her perspective.

A mom friend anxiously waits to hear if you got a good night’s sleep after topping off your baby with a few ounces of formula after breastfeeding; a frenemommy “supports” you in pumping 3 times in the middle of the night instead.

3. A mom friend encourages you to take time for yourself and if she’s an especially good friend, she watches your baby so you can do it. A frenemommy insists she’s envious that your baby survived an evening with a babysitter; her baby is too attached to get along without her even for a few hours.

4. A friendly parenting professional asks how she can help you achieve your goals; a professional frenemommy tells you how you can mirror hers.

A friendly lactation consultant knows its more important to supplement a hungry baby with formula than to risk dehydration and failure to thrive. A frenemommy lactation consultant insists that your pediatrician is wrong when he advises supplementation.

5. A mom friend supports you; a frenemommy gaslights you when you question her “support.”

A frenemommy tells you that your excruciating birth wasn’t painful and then further gaslights you by insisting that you merely thought it was painful because you were afraid. A frenemommy tells you insufficient breastmilk is rare then gaslights you about your baby’s hospitalization for dehydration arguing it wouldn’t have happened if you weren’t tricked by formula companies. A frenemommy insists that you don’t have to feel bad about your “failures” because it wasn’t really your fault; you didn’t get enough “support.”

How can you protect yourself from frenemommies? First you must recognize them, and then you need to understand their motivations. But the most important thing by far is to ignore them. Like frenemies of all kinds, they aren’t your friends no matter how hard they pretend they are.

Why have midwives hit out with such vehemence at the ARRIVE Trial that found elective induction at 39 weeks lowers the risk of C-section? Because they recognize that this represents a crossroads for contemporary midwifery.

The foundation of contemporary midwifery is:

1. The belief that childbirth interventions inevitably lead to more interventions, often culminating in a C-section and therefore a bad ‘experience.’

2. The quest for a better childbirth experience is justified by the fact that “scientific evidence shows” that it is also a safer experience.

The ARRIVE Trial demonstrated the opposite; childbirth interventions can actually be safer even when performed without a medical indication.

Hence the crossroads. One direction would confirm the claim that midwifery is about adherence to scientific evidence; the other would represent a rejection of scientific evidence in favor of doctrine. Sadly, it looks like midwifery leaders are searching desperately for any fig leaf that would cover a naked rejection of high quality science in favor of doctrine.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When there’s a choice between scientific evidence and power over women, midwives don’t hesitate to abandon science in order to preserve their power.[/perfectpullquote]

This struggle is not surprising if you recognize that contemporary midwifery (midwifery as practiced in the past 50 years) isn’t a medical discipline. It’s just unreflective defiance of obstetrics. And it seeks to rescue women from the purportedly patriarchal hegemony of technology not to free them, but to oppress them under an matriarchal hegemony of midwives.

This assessment of midwifery was made by two influential feminist scholars in a 1996 landmark paper, What is gender? Feminist theory and the sociology of human reproduction. The paper is long and filled with academic jargon, but its central claim is:

… [T]he lived experience of midwifery … is revealed only as the largely unresearched antithesis of obstetrics. An alternative is called into existence in powerful and convincing terms, while at the same time its central precepts (such as ‘women controlled’, ‘natural birth’) are vaguely drawn and in practical terms carry little meaning.

Why? To take power over women from male obstetricians and transfer it to female midwives:

If we conceive of power as a fundamentally male preserve we are led to gloss over ways in which women may exert power over others, including other women.In these terms, as recent institutional reforms stimulate community midwifery midwives may begin to consider the notion of affinity with women embedded in such concepts as ‘continuity of care’… as masking the potential exploitation of midwives by their clients.

The ARRIVE Trial strikes at the heart of midwifery doctrine in two ways. First, it shows that the claim that interventions should be avoided because they lead to more interventions is wrong. Second, and more importantly, if midwives continue to demonize interventions even when safe or safer, they make it clear that their recommendations were never about what is best for babies and mothers, but what is best for midwives.

It’s hardly surprising then, with so much at stake, that they have panicked.

1. They’ve advanced a series of reasons to ignore the results of the ARRIVE Trial, some nonsensical, and most equally applicable to studies that they have embraced such as The Birthplace Study of homebirth.

2. They’ve claimed, with no justification whatsoever, that studies done with obstetricians as primary providers aren’t applicable to midwives though they had absolutely no trouble accepting the results of studies using obstetricians as primary providers that demonstrated the risks of episiotomy.

3. They’ve insisted, with no justification whatsoever, that the study — which is nothing more than the scientific evidence on the risks and benefits of elective induction — will disempower women by “forcing” them to have elective inductions.

4. And led by Milli Hill, they’ve claimed that science is some sort of anti-feminist plot.

Hill’s post is a masterpiece of propaganda that would make a certain American President proud.

Step 1: Demonize the opposition by misrepresenting their views.

If we start from the standpoint that women’s bodies are entirely unfit for purpose …

Step 2: Portray freedom for others as oppression for you.

… then the obvious mental leap from the results of the ARRIVE trial is to recommend it as standard across the board.

Step 3: Insist that only those who are arrogant would dare disagree.

There is an arrogance about the ARRIVE trial that has long pervaded maternity care, a patriarchal approach that never stops to question whether there is a limit to ‘doctor knows best’.

Step 4: Invoke the specter of a police state.

To use Margaret Atwoods analogy from The Handmaid’s Tale, “Nothing changes instantaneously: in a gradually heating bathtub you’d be boiled to death before you knew it.”

Step 5: Do not, under any circumstances, address the facts.

It’s all done for the same reason the American President does it: to whip followers into blinding anger over their “oppression” so they can ignore unpalatable truths.

The reaction of midwifery leaders to the ARRIVE Trial reveals that contemporary midwifery is largely unreflective defiance of obstetrics. Its purpose is to wrest power over women from obstetricians so that midwives can enjoy that power instead. Sadly, when there’s a choice between scientific evidence and power over women, midwives don’t hesitate to abandon science in order to preserve their power. If that’s not anti-feminist, I don’t know what is.