Another study has found exclusive breastfeeding dramatically increases the risk of newborn hospital readmission.

We’ve known for sometime that aggressive breastfeeding promotion has significant risks including hypernatremic neonatal dehydration and jaundice induced brain damage (kernicterus); indeed 90% of cases of kernicterus are associated with breastfeeding. Closing well baby nurseries in order to force infants to room in with mothers has additional harms: babies being smothered in or falling from mothers’ hospital beds.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Infants treated with phototherapy had a 72% reduction in risk of readmission. Infants allowed unrestricted access to formula had a 76% reduction in risk of readmission.[/pullquote]

In January I reported on Health Care Utilization in the First Month After Birth and Its Relationship to Newborn Weight Loss and Method of Feeding by Flaherman et al., which appears to be the first study to quantify the harms of aggressive breastfeeding promotion.

Exclusively breastfed newborns had higher readmission rates than those exclusively formula fed for both vaginal (4.3% compared to 2.1%) (p<0.001) and Cesarean deliveries (2.1% compared to 1.5%) (p=0.025). Those exclusively breastfed also had more neonatal outpatient visits compared to those exclusively formula fed for both vaginal (means of 3.0 and 2.3, p<0.001) and Cesarean deliveries (means of 2.8 and 2.2, p<0.001)

In addition to the pain and suffering of the newborns and anguish of the parents, a tremendous amount of money was spent.

…[S]ince the cost of a neonatal readmission has been estimated at $4548.27 a potential savings of $7.8 million might be realized for a cohort similar to ours if the readmission rate of exclusively breastfed newborns approximated that of newborns exclusively formula fed.

To put that in perspective, with 4 million births each year and more than 75% hospital breastfeeding rates, that means we should expect 60,000 excess newborn hospital admissions at a cost of more than $240,000,000 each and every year. And that doesn’t even count the downstream impact of brain injuries, a consequence that was beyond the purview of this study.

A new study Efficacy of Subthreshold Newborn Phototherapy During the Birth Hospitalization in Preventing Readmission for Phototherapy was undertaken to determine whether prophylactive phototherapy could reduce the risk of hospital readmission for severe neonatal jaundice.

As the authors explain:

To estimate the efficacy of subthreshold phototherapy for newborns with total serum bilirubin (TSB) levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold during the birth hospitalization in preventing readmissions for phototherapy, and to identify predictors of readmission for phototherapy.

Phototherapy works! But the authors serendipitously found a far simpler intervention that also dramatically reduces the risk of readmission: formula!

Among 25 895 newborns with qualifying TSB [total serum bilirubin] levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold, 4956 (19.1%) received subthreshold phototherapy and 241 of these (4.9%) were readmitted for phototherapy compared with 2690 of 20 939 untreated newborns (12.8%) (unadjusted odds ratio [OR], 0.35; 95% CI, 0.30-0.40). In a logistic regression model, adjustment for confounding variables, including gestational age, race/ethnicity, formula feedings per day, and the difference between the TSB level and the phototherapy threshold, strengthened the association (OR, 0.28; 95% CI, 0.19-0.40)… Subthreshold phototherapy was associated with a 22-hour longer length of stay (95% CI, 16-28 hours).

Formula supplementation was equally effective:

Newborns who received formula feedings had lower adjusted odds of readmission for phototherapy compared with exclusively breastfed newborns (OR, 0.58; 95% CI, 0.47-0.72 for >0 to to <2 formula feedings per day; OR, 0.24; 95% CI, 0.21-0.27 for 6 formula feedings per day).

Infants treated with phototherapy had a 72% reduction in risk of readmission. Infants allowed unrestricted access to formula had a 76% reduction in risk of readmission.

Contemporary pediatricians are rediscovering what our ancient foremothers learned long ago: supplementation in the days after birth improves outcomes.

Our ancient foremothers supplemented with prelacteal feeds. Prelacteal feeding — feeding babies supplements like water, tea and honey in the early days of breastfeeding — is common in indigenous and rural cultures around the world.

So why have lactivists, who promote breastfeeding as beneficial precisely because it was the practice of our foremothers, discarded this “ancient wisdom”? First, it doesn’t comport with their belief in the near magical properties breastfeeding. Second, studies have demonstrated that prelacteal feeding is associated with higher infant mortality.

That’s not surprising since the supplements are often contaminated with harmful bacteria, and therefore compare unfavorably with exclusive breastfeeding for women who produce enough breastmilk. But supplements probably compare favorably with death from insufficient breastmilk production. Since insufficient breastmilk in the early days after birth is relatively common, prelacteal feeding became a widespread practice the world over.

Are we actively and aggressively ignoring what indigenous mothers have known for centuries, that a significant proportion of babies cannot survive and thrive without initial supplementation?

Are we risking babies’ lives and brain function because lactivists and breastfeeding professionals have become obsessed with promoting the process of exclusive breastfeeding, privileging it over the outcome of healthy babies?

Sure, we could prophylactically treat large numbers of breastfed infants with phototherapy in order to reduce the risk of life threatening side effects of aggressive breastfeeding promotion: severe jaundice and hospital readmission. But as the authors note:

Phototherapy is generally considered a low-risk intervention. Still, it can cause physical separation of the mother and the newborn, potentially interfere with breastfeeding and bonding, increase inpatient hospitalization costs, and increase the hospital length of stay…

Or we could just allow babies unrestricted access to formula, an equally effective intervention that is far easier to employ, far less expensive, and would have the added bonus of treating newborn hunger, thus reducing suffering for both babies and mothers.

Breastfeeding is causing otherwise mentally healthy women to lose their minds.

Consider this piece from the Today Show.

Donna Freydkin writes:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Like mass hysteria, it appears to be contagious, directly transmitted by lactation professionals who suffer from their own version of Breastfeeding Derangement Syndrome.[/pullquote]

Then my glorious globes failed me. No milk came out. Not a trickle. Not a drip. Not a sprinkle. We got Alex’s tongue clipped and I’d attach him, but it was akin to walking a cat on a leash. Pretty much futile. The nurses gave him formula (to my disgust but whatever, the kid had to eat) and I wore a La Leche League hair shirt of guilt.

It sounds like she experienced primary lactation failure. It would never have harmed her child since she had easy access to formula and clean water with which to prepare it, but it definitely harmed her psychological health:

I made myself crazy. Actually, I owe an apology to the word crazy. I, in fact, became deranged with guilt.

She developed what I’ve begun to think of as Breastfeeding Derangement Syndrome. It happens when women who otherwise think clearly completely lose perspective about the limited benefits of breastfeeding.

It is a situational disorder; it depends on social milieu.

…We lived on the Upper West Side of Manhattan, the ground zero of mommy wars, where the women I met at playgroups competed for the Golden Globe in Parenting Decisions. One bragged about growing her own organic fruits so she could make her child’s food from scratch. Another schooled me on powering through nursing issues, telling me to drink lactation tea and just keep trying and trying and trying because I could do it!

All the moms I met — all of them — insisted that breast was best, that formula was second to arsenic when it came to baby nutrition, and that they would practice child-led weaning, even it if meant nursing until their kids were doing college tours. I nodded as I shamefacedly mixed Earth’s Best powder with warm water in my bottle and fed it to my kid, who guzzled it down like it was the world’s greatest sake.

It is characterized by deep feelings of guilt and shame. Its sufferers are nearly prostrate with intrusive thoughts that they are bad mothers, that their babies are being harmed. And like many psychological illnesses, it is impervious to reality. The truth is their babies aren’t suffering; their babies aren’t merely doing better than they were while breastfeeding; they’re thriving, chubby, happy and hitting developmental milestones on target or early.

Why are so many women developing Breastfeeding Derangement Syndrome? Like mass hysteria, it appears to be contagious, directly transmitted by lactation professionals who suffer from their own version of Breastfeeding Derangement Syndrome. Lactation professionals have acquired a monopoly — through La Leche League, the Baby Friendly Hospital Initiative, and a variety of health organizations captured by the lobbying efforts of LLL and the BFHI — over the dissemination of information about breastfeeding. That has allowed their delusions to go mainstream.

In reality, breastfeeding in industrialized countries has trivial benefits, but lactation professionals promote their delusion that the benefits of breastfeeding are massive.

In reality, breastfeeding, like all natural processes, has a significant failure rate (up to 15% of first time mothers in the early days after birth), but lactation professionals promote their delusion that breastfeeding failure is rare.

In reality, breastfeeding has no impact on mother-infant bonding because it is the fact of being fed that promotes bonding, not how the baby is fed. But lactation professionals promote their delusion that breastfeeding is necessary for bonding.

In reality, there are a myriad of possible breastfeeding problems, and not all are amenable to treatment. But lactation professionals promote their delusion that any difficulties with breastfeeding are due to lack of maternal will or lack of support.

Breastfeeding Derangement Syndrome causes lactation professionals — who are ostensibly medical providers subject to ethical guidelines — to behave in ways that are grossly unprofessional, bullying and shaming new mothers while simultaneously muzzling or drowning out other providers. Pediatricians, neonatologists and obstetricians are desperately trying to draw attention to the very real harms, including neonatal brain injures and death, from aggressive breastfeeding promotion not to mention maternal mental health issues.

Prevention is the key to relieving the suffering from Breastfeeding Derangement Syndrome. The Baby Friendly Hospital Initiative must be ended; no outside special interest group should be allowed to make hospital policy. Simultaneous efforts must be made to root out Breastfeeding Derangement Syndrome from the lactation profession. Lactation consultants’ training should involve neonatologists and pediatricians to educate them about the very real limitations and risks of breastfeeding, and mental health professionals to root out their tendency to bully and shame mothers who can’t or don’t wish to breastfeed.

Obstetricians and pediatricians have a special role to play: offering unbiased information about the limited benefits and real risks of breastfeeding, instead of the propaganda many are forced to offer now. Obstetricians and pediatricians should also offer reassurance.

Freydkin credits her obstetrician with helping her regain perspective:

This would have gone on indefinitely until I had a checkup with my OBGYN, Dr. Andrea M. Dobrenis, a doctor both witty and wise.

She commented on what a big, healthy baby Alex was, and asked how feedings were going. I immediately kicked into my prepared remarks, not even catching my breath as I ranted apologetically about why I was such a failure as a mother, despite the breasts that should be performing their milk-producing function. She told me to please take a breath and calm down. And here’s what she said: “Donna, do you have access to clean drinking water? Do you have access to quality formula? Is your son thriving? You’ll be fine. Stop beating yourself up and enjoy your time with your baby.”

Freydkin’s story is more poignant than most. At the same time she was struggling with breastfeeding guilt and shame her husband was dying of brain cancer.

…To overcompensate for being a working mom who excelled at interviews with Meryl Streep and Brad Pitt but who was a flop at feeding her son, I spent hours at farmers markets buying certified organic produce, which I would then meticulously steam and turn into baby food — saved only in glass containers, due to BPA fears. His sheets were fair-trade organic cotton. As were his clothes. I fixated on everything but what mattered — spending intimate time with my husband, who was undergoing chemotherapy for brain cancer, and our son.

Breastfeeding Derangement Syndrome blighted the Freydkin’s early days of motherhood, just as it does for many new mothers. That’s a tragedy, one that — fortunately — we have the power to prevent.

California is about to experiment on its mothers and babies.

Ordinarily we would look with horror on a state’s desire to experiment on its own people. Yet when the purported justification is preventive care, we suspend our distaste under the theory that preventive care is always a good thing; as a result people get hurt or even die. Sadly, we have not yet learned our lesson from other preventive care debacles like those with hormone replacement therapy (HRT) and the PSA test.

According to NPR:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Its proponents are sure that it will lead to improved outcomes and money saved; the proponents of routine HRT, routine PSA testing, and the 39 week rule were also sure. They were wrong.[/pullquote]

Many women who don’t need a C-section often get one anyway, according to the data — and it varies from hospital to hospital. Even for low-risk cases, Lang says, several California hospitals are delivering 40 percent of babies by C-section. At one hospital, it’s 78 percent…

… Performing it when it’s not needed exposes a woman to unnecessary risks: infection, hemorrhage, even death.

Studies also have found that babies delivered by C-section are more likely to have complications and spend more time in the neonatal intensive care unit.

That’s not quality health care, Lang says, and that’s why Covered California is telling hospitals they need to reduce their C-section rates to 23.9 percent or lower, for low-risk births.

What will happen if they don’t?

Starting in less than two years, if the hospitals haven’t met certain designated targets for safety and quality, they’ll risk being excluded from the “in-network” designation of health plans sold on the state’s insurance exchange…

… Covered California is telling hospitals that if don’t play by the rules, they’ll be benched

Surely a massive experiment like this is based on solid data that definitively shows two things: that lower C-section rates cause better outcomes and that blunt efforts to lower C-section rates don’t lead to increased deaths and injuries. Nope. It’s based entirely on studies that show a correlation of lower C-section rates with acceptable outcomes in some settings. To my knowledge, there are no large scale studies of what happens when insurers pressure hospitals to lower C-section rates.

We’ve been here before — many times.

When I finished my residency 30 years ago, it was standard of care to prescribe hormone replacement therapy for all post-menopausal women. Many physicians were well aware at the time that the data showed only a correlation between HRT and lower mortality from heart disease. We were equally aware that there was no data to tell us what the side effects of years of HRT might be.

No matter. We were told that HRT would lead to better fewer cardiac deaths and would surely save money. Sadly, the exact opposite happened. HRT did not cause fewer cardiac deaths (no money saved there) and actually increased the rate of breast cancer (a very expensive side effect).

A similar debacle occured with PSA (prostate specific antigen) testing. Since increased PSA is associated with prostate cancer, doctors began recommending routine PSA screening, despite the fact that there were no large scale, long term studies demonstrating benefit. It was preventive medicine; so surely it would cause better outcomes and save money. Wrong again.

According to the National Cancer Institute:

Until about 2008, some doctors and professional organizations encouraged yearly PSA screening for men beginning at age 50. Some organizations recommended that men who are at higher risk of prostate cancer, including African American men and men whose father or brother had prostate cancer, begin screening at age 40 or 45. However, as more was learned about both the benefits and harms of prostate cancer screening, a number of organizations began to caution against routine population screening…

It turned out that many prostate cancers did not grow fast enough to threaten a man’s life. Removing such cancers led to the dreaded side effects treatment: incontinence and erectile dysfunction without saving any lives. It didn’t save money, either.

In order to lower the induction rate we are currently engaged in an experiment on mothers and babies. The 39 weeks rule (no elective inductions before 39 weeks) has been enforced for several years. It was promised that it would lead to a lower neonatal mortality from late prematurity, though many obstetricians suspected that it would actually lead to higher stillbirth rates. The preliminary data was not encouraging.

Changes in the patterns and rates of term stillbirth in the USA following the adoption of the 39-week rule: a cause for concern? was presented at the 2016 annual meeting of the Society for Maternal-Fetal Medicine.

Between 2007 and 2013 in the USA, the implementation of the 39-week rule achieved its primary goal of reducing the proportion of term births occurring before the 39th week of gestation. During the same period the rate of USA term stillbirth increased significantly. Assuming 3.5 million term USA births per year, more than 300 more term stillbirths occurred in the USA in 2013 as compared to 2007…

A new, large study, Association of Temporal Changes in Gestational Age With Perinatal Mortality in the United States, 2007-2015, shows that the 39 week rule has changed the distribution of gestation age at birth — reducing births at 37-38 weeks and increasing births at 39 weeks — but has NOT had the promised impact on death rates.

I graphed the change in gestational age distribution:

What happened to infant deaths?

The overall perinatal mortality rate decreased from 9.0 per 1000 births in 2007 to 8.6 per 1000 births in 2015 (P < .001).

Perinatal mortality decreased at gestational ages of 20 to 27 and 39 to 40 weeks but showed annual adjusted relative increases of 1.0% (95% CI, 0.6%-1.4%) at 34 to 36 weeks, 2.3% (95% CI, 1.9%-2.8%) at 37 to 38 weeks, and 4.2% (95% CI, 1.5%-7.0%) at 42 to 44 weeks.

Stillbirth rates increased at gestational ages of 20 to 27, 28 to 31, 32 to 33, 34 to 36, 37 to 38, and 42 to 44 weeks and remained unchanged at 41 weeks. Neonatal mortality rates decreased at gestational ages of 20 to 27 and 28 to 31 weeks; increased at 34 to 36, 37 to 38, and 42 to 44 weeks; and remained unchanged at 41 weeks.

That’s almost exactly the opposite of what was predicted. Neonatal mortality at 34-36 weeks and 37-38 weeks did NOT drop; it actually INCREASED. Moreover, stillbirths INCREASED, too.

Why did the overall perinatal mortality rate drop? NOT because of the 39 week rule, but because of improvements in the care of extremely premature infants (21-27 weeks).

What went wrong? Once again correlation was confused for causation and a measure designed to save lives at 34-38 weeks actually led to increased deaths.

And now we’re about to embark on a similar experiment to lower C-section rates.

So far, the prospect of exclusion, plus the coaching for hospitals on how to reduce the rates, have functioned as an effective motivator.

By 2020, Covered California’s Lang believes all hospitals will either have met the target or be on their way.

“It’s a quality improvement project,” Lang says, “but with a deadline.”

Its proponents are sure that it will lead to improved outcomes and money saved … exactly the proponents of routine HRT, routine PSA testing, and implementation of the 39 week rules were sure that those were quality improvements. They were wrong.

California is embarking on a massive experiment on mothers and babies. Let’s hope they don’t inadvertently injure and kill them as a result.

A new piece on NPR suggests that it’s okay to risk a baby’s death in order to bed share.

The piece asks Is Sleeping With Your Baby As Dangerous As Doctors Say? and answers by suggesting that the “right” kind of parents can bed share while the “wrong” kind of parents cannot.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Is the relative risk irrelevant? Is it only the absolute risk that counts? Who gets to decide?[/pullquote]

Parents who drink or do drugs shouldn’t be sleeping with their babies because they could roll over onto their child. Babies who are born premature or whose parents smoke shouldn’t sleep in the parents’ bed because of potential respiratory problems. Suffocation can also happen when babies sleep on sofas because babies can be trapped between a parent and the cushions…

But what about the “right” kind of parents?

So far, only two studies have looked at this question. And doctors and families need to be careful with how they interpret these studies, says Robert Platt, a biostatistician at McGill University, who analyzed the studies for the AAP.

“The evidence is quite thin or weak,” he says. In both studies, the number of SIDS cases is small. One study of 400 SIDS had 24 cases in which that baby had shared the bed in the absence of parental hazards, and in the other study, there were just 12 of these cases out 1,472 SIDS deaths. In the latter study, some information about the parent’s drinking habits was missing and had to be estimated.

Nevertheless, the two studies came to similar conclusions. For babies older than 3 months of age, there was no detectable increased risk of SIDS among families that practiced bed-sharing, in the absence of other hazards.

Nevertheless? Pro-tip for the folks at NPR: when a study is underpowered, the results are not valid. You cannot use them to make recommendations. But let’s imagine for the moment that these statistics are accurate.

Even the “right” parents can still smother an infant less than 3 months old.

And for babies younger than 3 months?

“I would probably say there may be an increased for this group,” Platt says. “And if there is an increased risk, it’s probably not of comparable magnitude to some of these other risk factors,” such as smoking and drinking alcohol.

NPR includes a chart that attempts to distinguish when it’s okay to risk a baby’s death from when it’s not.

The chart implies that tripling the risk of a baby’s death by bed sharing in the “right” situation is acceptable because the absolute risk is low — 1 in 16,4000. In other words, it purportedly doesn’t matter how much a particular maternal action increases the risk of death as long as the absolute risk is low.

Is that what we really believe?

Consider the case of infants and car seats. According to the Insurance Institute for Highway Safety, from 1975 to 2013, infant fatalities fell from 6/100,000 (1 in 16,7000) to 1.3/100,000 (1 in 76,900) while car seat use rose to 99% of children under age 1. So the risk of death from to a baby riding in a car without a car seat is LOWER than the risk of death from bed sharing.

If it’s the absolute risk that counts and not the increase in relative risk than mothers who don’t strap their babies into car seats are better mothers than those who bed share, right? If it’s only the absolute risk that counts — as implied by breastfeeding researchers — that’s the inevitable conclusion.

How about formula feeding? Breastfeeding decreases the risk of SIDS, but the absolute risk is low in any case. Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies was referenced by Dr. Platt above.

Here’s a chart from the study:

Notice that the absolute risk of SIDS from formula feeding without bed sharing is LOWER that the absolute risk of breastfeeding with bed sharing. So are mothers who formula feed without bed sharing better mothers than those who breastfeed and bed share? If it’s the absolute risk that counts — as implied by breastfeeding researchers — that’s the inevitable conclusion.

How about homebirth? The absolute risk of death from homebirth with an American homebirth midwife was found to be 5.6/1000 (1 in 179) in a 2012 analysis of Oregon state data. That’s more than 100X higher than the risk of death from bed sharing while breastfeeding. If it’s the absolute risk of death that counts, those women are monsters.

The NPR piece suggests:

…[A]ll bed-sharing is not the same. It doesn’t add the same amount of risk for all families. And so perhaps recommendations about it shouldn’t be the same? Maybe they should be tailored for each family and their circumstances?

How ironic! Those who insist that bed sharing recommendations should be tailored to individual families are often the same people who think that infant feeding recommendations should NOT be tailored for each family and their circumstances; they believe that every family should received the same recommendation that breastfeeding is best for every baby even though that’s obviously untrue.

But let’s get back to the original question: when is it okay to risk a baby’s death? Is the relative risk irrelevant? Is it only the absolute risk that counts? Who gets to decide?

Please share your thoughts in the comment section.

Another day, another piece demonizing C-sections.

How the C-Section Went From Last Resort to Overused was written by Rebecca Onion and appears on Slate. We don’t even get to the body of the piece before the first falsehood appears. The subtitle is: The history of the surgery is rife with horror, but today, 1 in 3 American babies are delivered via the procedure, twice what the World Health Organization recommends.

There’s just one problem. The World Health Organization’s recommendation is fake news.

It is this fake news that forms the heart of Onion’s piece:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The WHO’s optimal C-section rate less than 15% is no different from Wakefield’s claim that vaccines cause autism. Both are lies in the service of ideology.[/pullquote]

C-sections remained extremely rare throughout the 19th century. Even after the mid-20th-century advent of antibiotics and blood transfusions, which rendered the surgery much safer, the national rate of C-sections remained low. Then, the procedure exploded. Between 1965 and 1987, it rose 455 percent. Today, despite the work of the birth-reform movement of the ’70s and ’80s, 1 in 3 babies are still delivered by C-section. That’s twice the recommendation set by the World Health Organization, which states that a 10–15 percent rate is the ideal, since a rate higher than that has been assessed to have no effect on mortality rates, even as it pushes up medical costs and increases other risks for both mother and baby.

We live in a world where we have stopped battling over ideas, and started battling over facts themselves. Facts no longer inform beliefs; ideology begets lies masquerading as “facts” in service to a predetermined conclusions. We call this fake news.

One of the original examples of fake news is the World Health Organization’s recommended C-section rate. The WHO “optimal” C-section rate of 10-15% is a bald faced lie. It was fabricated from whole cloth apparently by a single physician; there was NEVER any evidence to support the lie when it was first released in 1985 and it has been thoroughly debunked repeatedly in the past 30 years. No matter.

The WHO’s claim that the optimal C-section rate is less than 15% is no different than Andrew Wakefield’s claim that vaccines cause autism.

I don’t say that lightly.

Wakefield’s claim has been used, as he intended, to call the safety, efficacy and desirability of vaccines into question and to demonize them. The WHO’s optimal C-section rate has been used, as Marsden Wagner its fabricator apparently intended, to call the safety, efficacy and desirability of C-sections into question and to demonize them.

Both claims were made up to serve the interests of the individuals who fabricated them.
Both NEVER had any support in the scientific evidence.
Both have been repeatedly debunked.
Both are fervently believed by some people despite the lack of evidence.
Both cause serious harm and very little good.

Marsden Wagner, a pediatrician who served as the European Head of Maternal and Child Health for the World Health Organization, appears to have been the driving force behind fabricating and publicizing the fake news optimal C-sections rate. Wagner, without any evidence of any kind, convened a conference of like mind health professionals in 1985 and they simply declared the optimal rate of less than 15% by fiat.

Many years later, Wagner inadvertently acknowledged that the “optimal” C-section rate was simply made up. In his 2007 paper Rates of caesarean section: analysis of global, regional and national estimates:

… [T]his paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health. (my emphasis)

Wagner had been touting an optimal C-section rate under 15% for 22 years before he even bothered to check whether it had any basis in reality. And although Wagner ended up “confirming” the fabricated optimal rate, the data showed the opposite. There were only 2 countries in the world that had C-section rates of less than 15% AND low rates of maternal and neonatal mortality. Those countries were Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, EVERY other country in the world with a C-section rate of less than 15% had unacceptable levels of perinatal and maternal mortality.

In 2009, the World Health Organization surreptitiously withdrew the target rate. Buried deep in its handbook Monitoring Emergency Obstetric Care, you can find this:

Although the WHO has recommended since 1985 that the rate not exceed 10-15 per cent, there is no empirical evidence for an optimum percentage … the optimum rate is unknown …

In 2015 researchers from Harvard and Stanford — including Neel Shah, MD and Atul Gawande, MD, put a stake through its heart in the paper Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality.

They found:

The optimal cesarean delivery rate in relation to maternal and neonatal mortality was approximately 19 cesarean deliveries per 100 live births.

According to the press release that accompanied the paper:

“This suggests on a policy level that benchmarks for C-section rates on country-wide level should be reexamined and could be higher than previously thought.”

The graphs they created are quite impressive:

These graphs show that C-section rate below 19% lead to preventable maternal and neonatal deaths. In other words, they show that the WHO “optimal” rate, far from being optimal, is actually deadly. They also show that C-section rates above 19% are NOT harmful. There appears to be NO increased risk of either maternal or neonatal mortality for rates as high as 55%.

Why is the WHO continuing to disseminate fake news? Why are they demonizing C-sections?

Because they honestly believe — in the absence of any scientific evidence and in the face of their claims having been debunked — that C-sections are “bad.” It’s the same reason that anti-vaxxers disseminate fake news about vaccines and demonize them. They honestly believe — in the absence of any scientific evidence and in the face of their claims having been debunked — that vaccines are “bad.”

Both are wrong. Sadly, it is women and babies who pay the price for their fake news.

Kavin Senapathy, writing in Self reports Giving Birth Made Me Question the Informed Consent Process During Childbirth.

The issue: should we obtain informed consent for vaginal birth? After all vaginal birth is natural, not a medical procedure.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We must counsel women about the risks of vaginal birth for the same reason we counsel them about the risks of unprotected sexual intercourse.[/pullquote]

I would pose the question a bit differently. Are doctors ethically required to counsel women about the risks of vaginal birth when they counsel women about the risks of C-sections, forceps and vacuum? The answer is yes and the reason is the same as the ethical imperative to counsel women about the risks of unprotected intercourse: so she can protect herself.

Kavin had a forceps birth for her first child.

My daughter is a perfectly healthy first-grader now, and I haven’t suffered permanent damage to my pelvic floor structures…

All that being said, I don’t know whether I would have opted for a C-section for my daughter’s delivery, but I do wish that I had made a choice in advance of giving birth about which procedure to use in the event of an emergency—a choice informed by a more extensive lay understanding of potential outcomes and risk factors.

She reviews themes I’ve discussed repeatedly.

There are significant risks to vaginal birth:

With vaginal deliveries, there is a real possibility not only of vaginal tearing, but pelvic floor problems that can manifest as urinary incontinence, anal sphincter injury and fecal incontinence, and pelvic organ prolapse.

The meta-analysis in PLOS Medicine found that vaginal delivery is associated with greater risk of urinary incontinence (14.9% incidence after vaginal delivery, compared to 8.93% incidence after C-section) and pelvic organ prolapse (5.99% for vaginal delivery, compared to 1.81% for C-sections) in the mother. According to ACOG, the risks of tearing and urinary and fecal incontinence are higher with assisted vaginal delivery.

The absolute risk of vaginal delivery complications is much higher than the absolute risk for C-section complications:

Here is where an extensive understanding of the various risks might come into play. While an unplanned hysterectomy due to complications from a C-section is generally viewed as much worse and more traumatic than urinary incontinence, the number of women who have the former is significantly lower than the number of women walking around with permanent pelvic floor damage. Ask a woman to weigh a 0.07% risk of unplanned hysterectomy to a significantly higher risk of spending the rest of her life peeing a little when she laughs, coughs, sneezes, runs, lifts, and other general life activities, and her answer might not be so obvious.

Kavin asks doctors for their opinions. Not surprisingly, those who treat injuries from vaginal birth think informed consent ought to be necessary:

Hans Peter Dietz, M.D., Ph.D., professor of obstetrics and gynecology at the University of Sydney, tells SELF that informed consent for emergency procedures can often be overlooked in the time leading up to the delivery. And that’s in stark contrast to the way we treat many other medical procedures. “When I propose a surgical procedure, we talk for at least half an hour, and sometimes several times,” about nuances surrounding individual risk factors and potential outcomes, he explains. But “in obstetrics it’s totally different. We’ve been totally backwards in terms of applying those rules of consent.”

But that view is not shared by all obstetricians:

“Informed consent is not obtained for vaginal birth,” Aaron Caughey, M.D., professor and chair of the Department of Obstetrics and Gynecology at Oregon Health Science University, and vice chair of the ACOG Committee on Practice Bulletins-Obstetrics, tells SELF via email. “Informed consent is an ethical concept designed to respect patients’ moral right to bodily integrity by protecting them from unwanted medical treatment or intervention, but giving birth vaginally is a natural physiologic process that by definition is not medical treatment.”

Dr. Caughey offers three reasons why informed consent is not necessary: vaginal birth does not involve a threat to bodily integrity; vaginal birth is entirely natural; and vaginal birth is not an illness.

I respectfully disagree with Dr. Caughey on all three reasons.

First, continence and sexual function are important aspects of bodily integrity. Vaginal birth can impair or destroy both. If the purpose of informed consent is to respect the right to bodily integrity and vaginal birth has a much higher absolute risk of permanently impairing bodily integrity than C-section, then we are ethically mandated to tell women about those risks and how she can avoid them.

Second, the natural vs. technological dichotomy is irrelevant for obtaining informed consent. For example, when a patient faces a cancer diagnosis, the option to forgo debilitating treatment is a critical option and widely recognized as ethically appropriate. Some patients, prefer to leave their fate to nature. They reject chemotherapy, radiotherapy or surgery and hope they can cure themselves with herbs, supplements or prayer. It is just as important to counsel patients about the risks of allowing nature to take its course as it is to counsel them about the risks of treatment.

Finally, the dichotomy between health and illness is also irrelevant. There’s nothing wrong with a person’s health when she chooses to have unprotected sexual intercourse. And there certainly isn’t anything more natural than the desire to have unprotected intercourse. Nonetheless we consider providers ethically mandated to counsel women about the risks of unprotected pregnancy and sexually transmitted diseases. We believe it imperative to counsel women about different methods of birth control as well as condoms to prevent disease with or without other contraceptive methods.

The bottom line is that providers are always ethically mandated to inform women about risks when they face choices of how to protect themselves. It doesn’t matter if the course of action is the biological default; it doesn’t matter if it’s only the refusal of treatment; and it doesn’t matter if it has nothing to do with illness. Women deserve the information about the risks of vaginal birth for the same reason they deserve the information about the risks of unprotected intercourse. They can’t protect themselves unless they have accurate and complete information.

It is often said that randomized controlled studies (RCTs) are the gold standard in healthcare.

As David Shaywitz explains in a piece in Forbes Will Real World Performance Replace RCTs As Healthcare’s Most Important Standard?:

The value of RCTs lies in the random, generally blinded, allocation of patients to treatment or control group, an approach that when properly executed minimizes confounders (based on the presumption that any significant confounder would be randomly allocated as well), and enables researchers to discern the efficacy of the intervention (does it work better – or worse – than controls) and begin to evaluate the safety and side-effects.

But sometimes there is a mismatch between the results of clinical trials and actual real world experience. The intervention performs much better in scientific studies than in the general public. Why?

The subjects who enroll in clinical trials … may not be representative of either the larger population or of the patients who are likely to receive the intervention currently under study; groups underrepresented in clinical trials include the elderly, minorities, and those with poor performance status (the most debilitated).

This begins to get at what may be the most significant limitations of clinical trials: the ability to generalize results. The issue is that clinical trials, by design, are experiments, often high-stakes experiments from perspective of the subjects … as well as the sponsors, who often invest considerable time and capital in the trial. Clinical trial subjects tend to be showered with attention and followed with exceptional care, and study investigators generally do everything in their power to make sure subjects receive their therapy (whether experimental or control) and show up for their follow-up evaluations. Study personnel strive to be extremely responsive to questions and concerns raised by subjects.

But in real practice, YMMV, as they say on the interwebs — your mileage may vary; adherence is less certain, evaluation can be less systematic, and follow-up more sporadic…

That’s why real world evidence (RWE) is becoming increasingly important in assessing healthcare interventions.

Consider our experience with birth control methods. Early on it became apparent that birth control methods performed much better in scientific studies than in real world use. That’s because, depending on the difficulty of using the method, people don’t always use it properly or regularly or both.

This slide demonstrates the difference between the two:

How each method works in practice is much more important to the individual than how it works in theory. As a result, when providers discuss the risks and benefits of various forms of contraception, we use real world experience as the basis of our discussions.

The same principle applies even when randomization is not possible because it is unethical. Scientific studies are very valuable, but real world experience is possibly even more important.

Consider the case of homebirth. One of the most widely quoted papers on the topic is the Birthplace Study that found in a carefully selected population, subjected to much more stringent eligibility requirements than those in the real world, and followed much more carefully than real world patients, homebirth increased the risk of poor outcomes compared to hospital birth for first time mothers and was essentially equal for mothers having a second, third or higher order child. That’s good to know, but just as in the case of contraception, real world experience is more important than theoretical results.

So how do the outcome of homebirth and hospital birth compare in the real world? The British National Health Service almost certainly knows since they collect the data, but they won’t tell the public. I’m willing to bet that if the real world data showed homebirth in the UK to be as safe as hospital birth it would have been released years ago. The fact that it is not available suggests that in the real world homebirth, which the government has been aggressively supporting as a way of saving money, is significantly more dangerous than hospital birth.

Just as in the case of contraception, real world data is far more relevant and far more accurate than data from the best studies. We would never counsel patients on the risks and benefits various forms of birth control using theoretical effectiveness. Therefore, no one should be counseling women on the risks of homebirth using the Birthplace Study.

When it comes to breastfeeding, the dichotomy between scientific study results and real world experience is massive. The theoretical benefits of breastfeeding — based on extrapolation of small studies that assume causality — are large. The real world benefits of breastfeeding are almost non-existent. There is no real world evidence of which I am aware that shows that increasing breastfeeding rates saves any term babies or any money in actual practice. For example, there seems to have been no impact on infant mortality or healthcare expenditure despite the fact that the US breastfeeding rate has tripled in the past 45 years. Countries with the highest breastfeeding rates have the highest infant mortality rates while countries with the lowest infant mortality rates have the lowest breastfeeding rates.

What are we to think of situations in which the interested parties suppress real world evidence while aggressively promoting scientific studies? The drug Vioxx offers an instructive example. In scientific studies, Vioxx had tremendous benefits and few risks. But then reports began to come in to the manufacturer that in real world experience Vioxx increased the risk of heart attack and stroke. The manufacturer tried to suppress that evidence and many people were harmed as a result.

Homebirth is treated by its advocates the same way as Vioxx was treated by its manufacturer. Real world evidence of harm isn’t released to the public. Breastfeeding is treated by its advocates the same way Vioxx was treated by its manufacturer. Although the information on neonatal hypernatremic dehydration, kernicterus, infants smothering in or falling from their mothers’ hospital beds in the wake of closure of well baby nurseries is available from a variety of databases and published in scientific papers, lactation professionals simply ignore it. Over and over again they cite theoretical mathematical models created by Drs. Melissa Bartick and Alison Stuebe, and completely ignore both real world harms and lack of real world benefits.

So which is more important in health care: scientific studies or real world evidence?

Shaywitz offers his view:

…[A]t its best, real world evidence provides an opportunity to evaluate medical interventions on what arguably matters most – real world performance …

Real world evidence is not always available, but when it is — as in the case of homebirth and breastfeeding — it must take a central place, equal or superior to evidence from scientific studies. Partisans are going to resist, but that’s all the more reason to make sure that individual women have access to it. As with birth control methods, women can not make informed medical decisions in the absence of real world evidence.

A new paper published this month in the Canadian Medical Association Journal, Mode of delivery after a previous cesarean birth, and associated maternal and neonatal morbidity, shows that attempted vaginal birth after C-section (VBAC) significantly increases the risk of poor maternal and neonatal outcome.

Absolute rates of severe maternal morbidity and mortality were low but significantly higher after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery (10.7 v. 5.65 per 1000 deliveries, respectively; adjusted RR 1.96, 95% CI 1.76 to 2.19). Adjusted rate differences in severe maternal morbidity and mortality, and serious neonatal morbidity and mortality were small (5.42 and 7.09 per 1000 deliveries, respectively; number needed to treat 184 and 141, respectively).

The study confirms what we’ve known for sometime. Successful VBAC is safer than elective repeat C-section, which is much safer than failed VBAC.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Should we be so desperate to lower the C-section rate?[/pullquote]

The authors explain:

Vaginal birth after cesarean delivery is increasingly contentious as rates of cesarean delivery rise and prior cesarean delivery serves as the most common single indication for a cesarean delivery. Planning mode of delivery for women with a previous cesarean delivery is challenging both for the patient and the care provider. An elective repeat cesarean delivery is associated with an increased risk of surgical complications, as well as an increased risk of abnormal placentation in subsequent pregnancies. On the other hand, attempted vaginal birth after cesarean delivery is associated with a higher risk of uterine rupture and other maternal and infant complications.In addition, a substantial proportion of women attempting a vaginal birth after cesarean delivery will require an emergency cesarean delivery, which increases the risk of maternal and infant complications.

The question is: should this matter to our desperate efforts to lower the C-section rate?

We are currently living through a moral panic about the C-section rate. To hear partisans of “normal” birth tell it, the current C-section rate of 32% is nothing short of a medical scandal even though there is considerable evidence that C-section rates of over 40% are entirely compatible with low rates of maternal and neonatal mortality and morbidity. Nevertheless we are continually exhorted that the C-section rate must be reduced.

One of the ways to reduce the current C-section rate would be to increase the rate of attempted VBAC. VBAC rates were essentially 0% back when all incisions on the uterus were vertical. Because of the high risk of uterine rupture in a subsequent labor, the mantra of “once a Cesarean, always a Cesarean” held sway. As horizontal incisions on the uterus became standard of care, and the rupture rate dropped dramatically, VBAC became quite popular. When I was practicing I, like my colleagues, offered a VBAC to every woman with one previous C-section. Nearly 80% of the attempted VBACs were successful.

In the 1990’s large scale data collection, along with spectacular malpractice settlements, demonstrated that the risk of ruptured uterus after a previous horizontal uterine incision was dramatically smaller, it was emphatically not zero. This study confirms those findings.

The authors note:

The evaluation and interpretation of risks associated with attempted vaginal birth after cesarean delivery presents a challenge because risk perspectives vary widely. Both the relative increase in rates of severe maternal and neonatal morbidity and mortality after attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery and the absolute difference in these rates need to be weighed carefully before a decision is made about whether the excess risks are acceptable or high. In additional, women planning large families need to be cognizant of the risks of morbid placentation in subsequent pregnancies, because such risks increase with repeated cesarean deliveries. These inputs into decision-making may also be affected by desire for vaginal birth, the severity of the outcomes in question and other personal valuations. Health care providers need to help women to contextualize risks better so that they are able to make informed and personalized decisions.

There is nothing wrong with a high C-section rate in and of itself. A high C-section rate is perfectly compatible with low rates of maternal and neonatal mortality and morbidity. Every woman should be counseled that successful VBAC is safer than elective C-section, which is much safer than failed VBAC. However, the chance of successful VBAC varies from women to woman and from pregnancy to pregnancy and that, too, will be a factor in decision making.

Different women will assess the importance of individual risks differently. The job of obstetricians is NOT to lower the C-section rate but rather to deliver healthy babies to healthy mothers while respecting women’s right to make decisions about their own bodies. It is never appropriate to privilege a process — in this case vaginal birth — over the outcome.

I was very fortunate in my OB-GYN training. I did my internship and residency at Boston’s Beth Israel Hospital, a Harvard hospital. I prize that training, but over the past 35 years I’ve discovered that some of things I was taught were wrong. Three of the principles of obstetrics and gynecology that were accepted as conventional wisdom when I was trained were actually untrue.

In the 1990’s we finally recognized we were wrong about episiotomies; they were not beneficial but actually harmful. In the 2000’s we finally recognized we were wrong about hormone replacement therapy (HRT); it was not beneficial but actually harmful. In both cases, it took years to change clinical practice but eventually the scientific evidence forced us to back away from defending the status quo.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””] How many babies have to be injured, starved or allowed to die before ACOG admits they’re wrong about breastfeeding.[/pullquote]

In 2018 we have copious data that we have been wrong about breastfeeding; sadly, just as in the case of episiotomies and HRT, ACOG (the American College of Obstetricians and Gynecologists) is resisting the acknowledgement that what we thought was an unalloyed good doesn’t have the benefits we’ve claimed and can actually be harmful in some cases.

In a recent newsletter, ACOG published a remarkably fact free attack on the Fed Is Best Foundation:

In May 2017, an organization called the “Fed is Best” (FIB) Foundation issued an open letter to obstetric care providers that outlines concerns about the safety of exclusive breastfeeding, and has caused some expectant mothers to question breastfeeding as the optimal feeding method for the health of the mother and baby. Although FIB describes itself as a non-profit volunteer organization and appears to cite peer-reviewed literature, many of the assertions that FIB makes misrepresent the findings of referenced studies…

ACOG believes that parents must have accurate, current, evidence-based information on which to base their infant feeding decisions, not on sensationalized headlines. FIB’s inflammatory anecdotes and misleading portrayal of evidence threatens to undermine and confuse mothers about well-established knowledge and breast-feeding protocols.

Inflammatory anecdotes, ACOG?

You mean the seizure and subsequent death of Jillian Johnson’s baby from dehydration only 12 hours after she was reassured by hospital personnel that her son was getting enough breastmilk and discharged home?

You mean the appalling before and after photos of Mandy Dukovan’s baby, emaciated on breastmilk but thriving on formula?

Fed Is Best misrepresents the findings of referenced studies?

Care to explain how the findings of these papers were misrepresented?

• The revised 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
• Health Care Utilization in the First Month after Birth and Its Relationship to Newborn Weight Loss and Method of Feeding
• The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature
• The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial
• Breastfeeding during infancy and neurocognitive function in adolescence: 16-year follow-up of the PROBIT cluster-randomized trial

Taken together, these papers demonstrate that insufficient breastmilk is common (up to 15% of first time mothers), formula supplementation makes successful breastfeeding more likely, pacifiers prevent SIDS, extended skin to skin contact lead to babies falling from their mothers’ hospital beds or suffocating while in them, and the latest results from the PROBIT studies show no impact on IQ at age 16. In addition, we know that the leading cause of jaundice induced brain damage (kernicterus) is breastfeeding.

In what way has Fed Is Best misrepresented the findings of these up to the minute papers? They haven’t misrepresented them at all.

ACOG, you seem certain that breastfeeding is the optimal feeding method for every infant. If it’s optimal why is there no correlation between breastfeeding rates and infant mortality rates? Why, given that the breastfeeding rate has tripled in the past 45 years, have the savings in lives and healthcare dollars predicted by breastfeeding advocates, failed to materialize?

And what’s up with the ugly insinuations? Fed Is Best describes itself as a non-profit volunteer organization? Do you have any evidence they are anything other than that? They appear to cite peer-reviewed literature? How can one “appear” to cite the scientific literature? This is nothing more than a thinly veiled attempt at the “shill gambit”, a claim beloved of quacks and charlatans, that medical providers with whom they disagree are hiding the fact that they are on an industry payroll. It’s wrong the peddlers of pseudoscience use it and it is wrong of you to insinuate it about Fed Is Best.

ACOG, it took you years to admit that you had been wrong about episiotomies for decades. It was hard to give up on something that had become embedded in clinical practice, especially because it seemed to make so much sense. ACOG, for years you promoted hormone replacement therapy despite the fact that the evidence in its favor was relatively weak and had not yet been confirmed by longterm studies. It seemed to make so much sense that you rushed to incorporate it into clinical practice. Now, ACOG, you are refusing to admit that you have been wrong about breastfeeding. It seemed to make so much sense that something natural would have great benefits and low failure rates so, in response to high pressure lobbying by the breastfeeding industry, you incorporated its promotion into clinical practice even though the data was weak, conflicting and riddled by confounders.

There’s no question in my mind, ACOG, that you will eventually be forced to acknowledge that you have been wrong about breastfeeding just like you were wrong about episiotomies and hormone replacement therapy. The only question is how many babies have to be injured, starved or allowed to die before you acknowledge your mistake.

You’re a good mother; your children show you that you are.

Your baby greets you with a thousand watt smile when you pick her up from her nap. She loves to be in your arms when she feels happy and she needs to be in your arms when she feels ill.

Your toddler can’t get enough of your snuggles. You’re the first person he wants to see every day, which for him means cuddling with you in bed at 5 AM as you desperately try to get a few more minutes of sleep.

Your pre-schooler thrives on your praise. “Watch me, Mama, watch me!,” he calls whenever he learns a new skill. And you’re the one he runs to when he is sad, or angry or frustrated.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We’ve been socialized to believe that children’s happiness and success can only be purchased with the coin of maternal suffering.[/pullquote]

Your children love you, need you and cry for you.

You’re a good mother … so why do you feel so bad?

Because the dominant mothering ideology in contemporary culture, often described as attachment parenting or natural mothering, is designed to make you feel inadequate.

When you stop and think about it, your children themselves aren’t the ones who make you feel bad. They are happy, healthy, growing and thriving. It is other adults who make you feel bad, everyone from acquaintances to Facebook friends to the experts who write the parenting books that you consult. They make you feel inadequate, like you are failing to meet your children’s most important needs, that no matter how much you do, you are never doing enough.

It’s not an accident. It is a product of our beliefs about women. While many of us proudly declare ourselves feminists, we have failed to question fundamentally anti-feminist beliefs about motherhood, sacrifice and how the differing needs of women and children ought to be negotiated. We don’t question them because we have been socialized to believe that children’s happiness and success can only be purchased with the coin of maternal suffering.

It starts with the deep, powerful love we feel toward our children.

As Jana Malamud Smith explains in A Potent Spell: Mother Love and the Power of Fear, our love, as well as our terror of loss, leaves us vulnerable to being manipulated:

The mother’s fears of child loss and the derivative fears of harming children or caring for them inadequately have been continually manipulated, overtly and subtly, even aroused gratuitously, to pressure, control and subdue women for a very long time — possibly millennia.

And it seems as if there are dangers everywhere.

Ironically, there has arguably never been a better time to be a mother. The specter of dying while giving life has dramatically receded. No longer do women have to fear the consequences of traumatic birth injuries. It is the rare mother who has to bury a child. We can ensure our children are healthy, well educated and equipped with the resources to succeed in life and yet we still feel bad.

But you’d never know that if you are part of the natural parenting culture, which justifies its intrusiveness into maternal choice by promoting fear in regard to infant and child health. Natural parenting advocates inflate risks of rare events to monstrous proportions or invent theoretical risks that have never been seen in real life.

For example, childbirth is inherently dangerous, but has been made dramatically safer by the liberal use of obstetric interventions. Yet to hear natural childbirth advocates tell it, childbirth is inherently safe and any dangers that exist are caused by technology.

Infant formula has never been safer or more nutritious. Yet to hear lactivists tell it, breastmilk is lifesaving and formula is deadly.

Vaccines have never been safer or more effective (as evidenced by the bottoming out of incidences of childhood diseases), but anti-vaxxers utterly ignore both medicine and history in denying the public health triumph of universal vaccination. Instead they obsess about rare or even fabricated vaccine injuries.

By promoting fear about children’s well-being, the philosophy of natural parenting causes women to tightly regulate their behavior so it conforms with the “rules” of natural parenting and to pathologize and blame themselves when they fail in conforming to those rules. Hence the outpouring of guilt and recrimination for epidurals, C-sections, formula feeding and other deviations from natural parenting diktat.

The conceit behind natural parenting is that women can only be successful mothers if they lose themselves. Their pain doesn’t count; their suffering doesn’t count; their time doesn’t count. Yet neither mothers nor children are benefiting as a result.

Natural parenting — natural childbirth, lactivism and attachment parenting — were all created by religious fundamentalists who believed that women belong in the home and must be pressured to return to it.

Grantly Dick-Read, the father of natural childbirth, famously said: “Woman fails when she ceases to desire the children for which she was primarily made. Her true emancipation lies in freedom to fulfil her biological purposes …”

The founders of La Leche League wished to convince mothers of small children that they should not work. Promoting breastfeeding seemed the ideal way to pressure them to stay home.

And Bill and Martha Sears wrote: “We have a deep personal conviction that this is the way God wants His children parented.” And just in case you didn’t get the point: “Now as the church submits to Christ, so also wives should submit to their husbands in everything …”

Don’t get me wrong, mothering requires sacrifice. Mothers sacrifice money, time, convenience and indulgences in order to raise children. But it does NOT require maternal suffering. There is precisely zero evidence that women who suffer in labor or breastfeed or practice attachment parenting have children who are happier or more successful. There’s no reason to feel bad for being unable to or refusing to conform to the “rules” of natural parenting.

So if suffering is not integral to raising happy, healthy children, why are natural parenting advocates exhorting women to suffer? Why do good mothers feel so bad?

Because one of the central unexamined assumptions of our culture is that women deserve to suffer. When your children show you that you are a good mother, you deserve to feel good. Don’t let acquaintances, Facebook friends, parenting “experts” — those who profit from or rest their self esteem on the tenets of natural parenting — make you feel bad.

Happy Mother’s Day!