Maternal mortality has been one of the biggest health stories of 2017.

A superb and evolving series of articles written by ProPublica in collaboration with NPR has focused a spotlight on the rising US maternal mortality rate. The latest piece is Nearly Dying In Childbirth: Why Preventable Complications Are Growing In U.S.

Each year in the U.S., 700 to 900 women die related to pregnancy and childbirth. But for each of those women who die, up to 70 suffer hemorrhages, organ failure or other significant complications. That amounts to more than 1 percent of all births. The annual cost of these near deaths to women, their families, taxpayers and the health care system runs into billions of dollars…

Better care could have prevented or alleviated many of these complications, experts say…

Why have we allowed this to happen?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We turned toward the goal of reducing interventions before we secured low rates of maternal mortality.[/pullquote]

Yes, allowed; with the exception of cardiac complications, none of these complications are new, and we’ve been treating them successfully for decades. We haven’t forgotten what to do; we’ve just stopped doing it and women are injured and dying as a result.

In my view, we’ve committed the medical equivalent of the classic football receiver’s mistake. We started heading up the field before securing the ball. The receiver is so excited to reach the goal line that he turns toward it assuming that making the catch is a foregone conclusion. In obstetrics, we’ve turned toward the goal of reducing interventions, assuming that the catch — a safe outcome to pregnancy — is a foregone conclusion. In football, losing focus and dropping the ball results in missed opportunities to score. In obstetrics, losing focus and dropping the ball results in preventable injuries and deaths.

How can we improve maternal health in 2018? We can start by returning to fundamentals.

1.Focus on outcome, not process

If we want to decrease maternal morbidity and maternal mortality, we need to focus on what’s causing them.

The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. That reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before.

2. Stop obsessing about C-section rate; it’s not a metric of maternal health

Sadly, we’ve allowed the natural childbirth industry to dictate our priorities with disastrous results. The natural childbirth industry is focused on what will benefit them; in other words, they are focused on reducing C-section rates and interventions rates and providing employment opportunities for midwives, doulas and childbirth educators. The bedrock assumption of the natural childbirth industry is that childbirth is inherently safe. Unfortunately, childbirth is inherently dangerous and it is ONLY C-sections and interventions that prevent injuries and deaths.

Do iatrogenic injuries from interventions occur? Of course they do, but as a glance at the chart above demonstrates, that’s not what’s injuring and killing pregnant and postpartum women. If we want to prevent severe maternal morbidity and mortality, we have to focus on what’s causing it.

3. Improve access to health care in general and prenatal care in particular

Chronic diseases, complications of pregnancy, obesity and advanced maternal age pose serious risks to pregnant women. Management of chronic diseases (high blood pressure, heart disease, kidney disease, etc.) before pregnancy is critical to improving pregnancy outcomes. Managing obesity related problems like adult onset diabetes is also very important.

Good prenatal care allows providers to anticipate and prepare for potential complications and have staff and services in place before disaster strikes.

4. Increase high risk specialists

We’ve experienced a tremendous increase in high risk pregnancies without a concomitant increase in perinatologists (specialists in high risk pregnancies). Too many women die because they don’t have access to the doctors who are best prepared to treat them.

5. Create more obstetric ICUs

Critically ill obstetric patients are often transferred to the ICU, but the ICU doctors don’t have experience with the physiology of pregnancy or the pathophysiology of complications. In contrast, the dramatic decrease in perinatal mortality over the past 50 years reflects the creation specialty units for the care of critically ill newborns (NICUs) and a rating systen for hospital nurseries (levels I, II, and III) to facilitate triage and transport of critically ill newborns to hospitals that have the experts and equipment to to treat them. We need a similar system of ICUs, rating systems and triage for critically ill pregnant women.

6. Research cardiac complications of pregnancy

No one really understands why cardiac disease has become the leading cause of maternal mortality. We won’t find out unless we fund and perform the research that will answer that question.

7. Have high index of suspicion for complications

In order to prevent complications, you have to understand who is at greatest risk and take appropriate steps to address the risk factors. In order to treat complications, you must recognize when they are happening, the earlier the better. The natural childbirth industry has deformed our efforts to do both by pretending that complications are rare and interventions and treatments are dangerous. They’ve made a concerted effort to undermine trust between doctors and patients, encouraging women to refuse testing, refuse interventions and lie about risk factors. They are wrong, dead wrong. Childbirth is and has always been, in every time, place and culture a leading cause of death of young women.

The pernicious effect of the natural childbirth industry can best be understood by analogizing to firefighting. Fire, like childbirth, is entirely natural. Fire, like childbirth, injures and kills. Imagine a “natural” firefighting industry that counsels people: fires are rare; don’t bother taking precautions, don’t pull the fire alarm until the house has almost burned to the ground; don’t tell firefighters about the presence of highly flammable fluids within the house; and make the firefighters wait to use hoses until efforts at putting out the fire by spitting on it have been exhausted. Would it be any surprise if injuries and deaths from fire increased as a result?

8. Drill for common complications (hemorrhage, pre-eclampsia)

Once you recognize complications, you must treat them as expeditiously as possible. That means having easy access to interventions, medications, and transfusions and lots of practice using them. In life threatening complications, every second counts. Practice reduces the time needed. Fire fighters drill. Doctors and midwives must drill, too.

9. Provide extra monitoring for black women

Maternal morbidity and mortality disproportionately affect black women. Therefore, it only makes sense to given them extra time, extra attention, easier access to care, greater funding for care and more research on the specific complications that they are likely to experience. Instead, we do the opposite, obsessing about the “birth plans” of privileged women and brainstorming on marketing techniques to attract them.

10. Prioritize improving outcomes for the disadvantaged over catering to the whims of the privileged

To go back to the firefighting analogy: if we ignore fire traps in poor neighborhoods, fail to build and maintain fire hydrants, and place fire stations miles away, should we be surprised that there are more fires and more deaths among the most vulnerable?

Then why are we surprised that pretending pregnancy complications are rare, having a low index of suspicion for them, failing to drill for them, and demonizing the people who are experts in treating them has led to an increase in preventable injuries and deaths, particularly among the most vulnerable?

Becoming a mother is an experience like no other.

As Alexandra Sacks, MD wrote in The New York Times:

The process of becoming a mother, which anthropologists call “matrescence,” has been largely unexplored in the medical community. Instead of focusing on the woman’s identity transition, more research is focused on how the baby turns out. But a woman’s story, in addition to how her psychology impacts her parenting, is important to examine, too…

The process is joyful, but the joy is not unalloyed. In addition to welcoming a beloved new child, women giving birth for the first time are experiencing a change in identity, a sudden weight of tremendous responsibility, the reality of motherhood vs. the fantasy, and possible ambivalence at the change.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural childbirth, breastfeeding and attachment parenting aren’t merely unnecessary; they have nothing to do with mother-infant bonding at all.[/pullquote]

In other words, even in the best and easiest cases, matrescence is a fraught process. So why have we allowed the Maternal Guilt Industry to make it harder by promoting the holy trinity of maternal suffering: pain, fear and anguish?

What is the Maternal Guilt Industry?

As I wrote last week, the Maternal Guilt Industry encompasses the professional and lay advocates of natural childbirth, lactivism and attachment parenting. The bedrock principle of the Maternal Guilt Industry is this: children’s wellbeing can only be ensured by mothers’ suffering.

It starts with the well known imperative to endure the agonizing pain of labor and not dare to abolish it with an epidural. The imperative to embrace suffering continues with the extraordinary pressure to breastfeed exclusively. It is reinforced by attachment parenting, which recommends that a mother erase her identity and limit herself to continuous physical proximity to her child. And it is made possible by the guilt and shame heaped on women who refuse to comply.

As Dr. Sacks writes:

There’s also the ideal mother in a woman’s mind. She’s always cheerful and happy, and always puts her child’s needs first. She has few needs of her own. She doesn’t make decisions that she regrets. Most women compare themselves to that mother, but they never measure up because she’s a fantasy. Some women think that “good enough” (a phrase coined by the pediatrician and psychoanalyst Donald Winnicott) is not acceptable, because it sounds like settling. But striving for perfection sets women up to feel shame and guilt.

In my view, the Maternal Guilt Industry sets women up to feel guilt and shame in order to push sales of their products and services.

As Chavi Eve Karkovsky, MD wrote in a fantastic piece for Slate entitled Sorry You Were Tricked Into a C-Section; What disapproving friends don’t understand about cesarean births:

You’d think any woman who has recently had major abdominal surgery and has a newborn to care for would have enough to deal with, but too often there’s more. This is what I see a fair amount of the time: A woman who has had a cesarean birth gets comments from her friends—online friends, IRL friends—mostly congratulations, but also messages of regret. Coming from everywhere are intimations that the surgery wasn’t warranted, suggestions that something underhanded occurred. Her friends and relatives point out that the cesarean birth rate in this country is too high. It can’t be the case that all of those surgeries are necessary.

So her friends and relatives tell her, outright or through subtext, that she must have been snookered. She was fooled and then underwent some shady butchery. Perhaps the fate of her child was held hostage: “Something might happen to the baby,” she was told, and under these manipulations, she allowed herself to be cut. But, her friends say, it wasn’t right.

That’s the Maternal Guilt Industry, natural childbirth branch, at work. But when it comes to guilt and shame, the natural childbirth branch has nothing on the lactivism branch. The Baby Friendly Hospital Initiative, which is not baby friendly and is downright mother hostile, grossly exaggerates the benefits of breastfeeding and ignores the risks in order to shame women into breastfeeding.

The central premise of the attachment parenting branch, that maternal infant bonding is fragile, uncertain and contingent on following the admonitions of the natural childbirth and breastfeeding branches, completes the trifecta of pain and fear with the anguish that new mothers have ruined their babies before they are even a week old.

Why have we allowed the Maternal Guilt Industry to blight new motherhood?

It’s certainly not because we believe in their medical or psychological claims. Unmedicated vaginal birth has no benefit for babies and substantial risk of injury and death. The benefits of breastfeeding in industrialized countries are so trivial as to be meaningless (a few less colds and episodes of diarrheal illness across the entire population of infants in their first year). And maternal infant bonding is not uncertain and contingent; it happens spontaneously in every situation except severe abuse and neglect (and bonding often takes place even then).

We’ve allowed it to happen because doctors have been too busy taking care of people to worry about the aggressive tactics the Maternal Guilt Industry uses to promote itself.

We’ve allowed the Maternal Guilt Industry to frame the issues and made only half-hearted efforts to debunk their nonsensical claims.

We’ve allowed the Maternal Guilt Industry to portray their products and services as “feminist” when they are the opposite: sexist, retrograde and aimed at controlling women, not increasing their freedom.

We’ve allowed natural childbirth charlatans (most doulas and childbirth educators) into hospitals and let them spread the poison that eats away at the self-esteem of new mothers.

We’ve committed the unpardonable sin of letting a private organization, the Baby Friendly Hospital Initiative, have free reign inside a hospital. To my knowledge, no other private organization has been allowed to do so for the obvious reason that private organizations are committed to what benefits them, not what benefits patients.

We’ve allowed attachment parenting gurus to proclaim their beliefs, contradicted by scientific evidence, without attempting to publicly debunk them.

In short, we’ve repeated the same mistakes with the Maternal Guilt Industry that we committed with the Anti-Vax Industry and women and children are suffering pain, fear and anguish as a result.

New motherhood is hard enough; we should not allow the Maternal Guilt Industry to make it harder.

It’s time to force the Lamaze certified childbirth educators out of hospitals and replace them with science based childbirth educators. The Baby Friendly Hospital Initiative should be ended immediately; it causes far more harm than good since the benefits of breastfeeding are trivial. Most importantly, we should spend time educating women about the actual scientific evidence about mother-infant bonding and emphasize in the strongest possible terms that there are many, many ways to be a good mother and that natural childbirth, breastfeeding and attachment parenting aren’t merely unnecessary; they have nothing to do with mother-infant bonding at all!

Why do good mothers feel so bad? Because suffering is integral to contemporary mothering ideology.

Yesterday I wrote about hyper-maternalism as a more accurate term than natural mothering or attachment parenting. Natural mothering and attachment parenting are really marketing terms designed to romanticize maternal suffering and hide the true purpose: manipulating women. Hyper-maternalism is a more accurate description because it captures the belief that mere mothering is not enough; hyper-mothering is required.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Maternal suffering is not an unfortunate side effect of natural mothering or attachment parenting; it’s a requirement.[/pullquote]

Today I’d like to talk about the holy trinity of maternal suffering: pain, fear and anguish.

The key point I want to make is this: Maternal suffering is not an unfortunate side effect of natural mothering or attachment parenting; it’s a critical feature.

It’s a deliberate exploitation of the fact that most mothers are willing to endure any form of pain in any amount to spare their children. What’s unique about hyper-maternalism is the belief that mothers ought to suffer pain for trivial reasons or for no reason at all. Maternal pain is often portrayed as beneficial for children without any evidence to support the claim.

Maternal suffering is mandated even for “good” mothers. Their suffering may be limited to physical pain of childbirth and breastfeeding, plus fear of “toxins,” vaccine “injuries” and suboptimal intellectual achievement and that’s if they are lucky. Those who do not tick all the boxes of hyper-maternalism experience the pain of trying to tick the boxes, compounded by anguish that they “failed” and thereby short changed their beloved children.

1. Pain

This is the sine qua non of maternal suffering.

It starts with the well known imperative to endure the agonizing pain of labor and not dare to abolish it with an epidural. Most people do not realize that avoiding pain medication was not originally part of the natural childbirth ideology. Grantly Dick-Read insisted that women would not have to endure childbirth pain if they understood that their purpose was to reproduce. The Lamaze method was originally touted as pain relief. Natural childbirth was about being awake and aware during birth without pain. Indeed, both Dick-Read and Lamaze explicitly allowed pain relief in labor and the advent of the epidural several decades later meant that women could fully experience birth without pain.

It wasn’t until the early 1980’s, after natural childbirth advocates had achieved their original goals — no sedation, support people in labor and delivery rooms, no perineal shaving or enemas — that they deliberately moved the goalposts. The natural childbirth industry (midwives, doulas, childbirth educators) couldn’t offer epidurals so they demonized them instead, insisting that they are dangerous to babies (they aren’t). The point was further emphasized when Michel Odent fabricated the notion that pain is required for women to bond with their babies (a bald faced lie).

The requirement for pain is responsible in part for viewing C-sections with horror. C-sections bypass the suffering of labor, but they also mitigate future pain from perineal tears, sexual dysfunction and incontinence. The only thing worse than a C-section is a maternal request C-section chosen to prevent pain and painful side effects. How dare a woman imagine that she can be a mother without excruciating pain?

The imperative to endure pain continues with the relentless quest to breastfeed exclusively. Many women experience significant pain while breastfeeding, particularly in the early weeks. Lactivists respond by either telling women that they must be breastfeeding wrong, recommending that they purchase more support services or insisting that good mothers endure pain, despite the fact that the benefits of breastfeeding in industrialized countries are trivial.

2. Fear

In the entire history of the human race, childhood has never been safer. Ironically, contemporary parenting “experts” would have you believe that children are continuously threatened with serious harm and death from infant formula, vaccines and imaginary “toxins” among other threats. These “experts” problematize not merely the safety of children, but even routine developmental tasks. Our ancestors fed their children, provided basic care and hoped for the best. Today’s mothers are encouraged to believe that they can and should be experts on both pediatrics and nutrition with special emphasis on nutrition, immunology and toxicology. They cannot obtain relief from these pervasive fears because they are taught that real experts like obstetricians and pediatricians are not to be trusted.

Above all, they are warned that the mother-infant bond, which has always been understood to develop spontaneously, is frightfully tenuous and contingent on specific, ritualized parenting behaviors. And if all that weren’t bad enough, mothers are being instructed that their children’s brain development depends on the quality of their love. Women are continuously encouraged to be fearful because fearful women are easily manipulated.

3. Anguish

Obviously mothers will be anguished if their children are unhealthy or unhappy. What’s unusual about hyper-maternalism is that mothers are encouraged to be anguished even when their children are healthy and happy. They are supposed to be anguished if they did not have a vaginal birth, if they opted for a C-section or if they did not breastfeed exclusively for an extended period of time.

The responsibility for any and every bad outcome is reflexively pinned on mothers, especially when the actual cause is unknown such as in the case of autism. Mothers are encouraged to believe that bad outcomes could have been avoided if only they had refused vaccines, if only they had removed “toxins” from their child’s diet, if only they enforced rigid restriction diets. It is their “fault” that their children are autistic despite the fact that autism is know to have a large genetic component.

Ironically, real mental anguish, such as postpartum depression or maternal mental illness is dismissed out of hand. Weighed down by depression, crying all day, unable to sleep at night? That’s not an excuse to stop breastfeeding. Doctor recommends psychiatric medication to treat your depression and it’s potentially incompatible with breastfeeding? Don’t you dare stop breastfeeding; stop the medication instead.

The other source of anguish, arguably accounting for the largest share, is guilt and shame. The terms are often used interchangeably in regarding motherhood, although they do have specific meanings. As Jean-Anne Sutherland explains in Mothering, Guilt and Shame:

The notion of maternal guilt is so pervasive in our culture as to be considered a ‘natural’ component of motherhood. To read a popular press book or piece of social scientific research on motherhood is to read about guilt. That mothers experience guilt and shame in relation to their roles as mothers is the most prevalent finding in mothering research …

What’s the difference between guilt and shame?

… [A] mother would be describing guilt if she expressed a negative self-evaluation regarding behavior stemming from a specific task. However, her experience would be labeled shame if she described herself, in relation to others, as having not met an idealized self-image.

In other words, a mother might feel guilty that she had a C-section instead of a vaginal birth or fed her infant with formula instead of exclusively breastfeeding. Either could cause her to be ashamed that she is not a “good” mother. Both are significant sources of anguish for mothers and are often elicited by others specifically for the purpose of making new mothers feel awful.

It’s hardly surprising that good mothers feel so bad. Every mother is forced to endure the holy trinity of maternal suffering.

Why do good mothers feel so bad?

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. That belief, along with our intense love for our children, has been used to control us.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Why do good mothers feel so bad?[/pullquote]

This mothering ideology, the dominant mothering ideology in contemporary culture, is often described as natural mothering or attachment parenting, but I’d like to suggest a new — more accurate, less romantic — term: hyper-maternalism.

Natural mothering and attachment parenting are really marketing terms designed to romanticize maternal suffering and hide the true purpose: manipulating women. They are deliberately misleading; natural mothering, although often presented as a recapitulation of mothering in nature, bears little resemblance to the way our foremothers cared for their children. Attachment parenting is meant to evoke attachment theory, but actually has nothing to do with it. It problematizes mothering by presenting the mother-infant bond not as spontaneous, as has been understood throughout history, but as fragile and contingent on specific ritualized behavior like “baby-wearing.”

What was mothering really like in nature?

Women have always been integral to the survival of small hunter-gatherer bands. They spent hours each day as the gatherers. They spent additional hours laboriously preparing food (grinding grain, for example) and may have sewed the clothing that allowed humans to expand into colder climates. In a very real sense, mothering was an interstitial task, taking place in the gaps while performing other tasks that required attention and energy.

Hyper-maternalism, in contrast, imagines mothering performed instead of other tasks. It is not something that you do while doing everything else; it’s something you do to the exclusion of everything else. It is not natural; it has nothing to do with the way our foremothers raised children, but rather it is an unnatural exaggeration of specific tasks of mothering. Nothing illustrates this better than our cultural pre-occupation over working mothers vs. stay a home mothers. Working is often presented as slighting the traditional role of mother when the reality is that up until the last 200 years or so, all mothers were working mothers.

Hyper-maternalism always and inevitably means more work for mothers, and often more suffering, too. It is the mothering equivalent of the feminine mystique postulated by Betty Friedan.

In her book, The Feminine Mystique:

Friedan shows that advertisers tried to encourage housewives to think of themselves as professionals who needed many specialized products in order to do their jobs, while discouraging housewives from having actual careers, since that would mean they would not spend as much time and effort on housework and therefore would not buy as many household products, cutting into advertisers’ profits.

Hyper-maternalism has also spawned an industry of books, classes, services and specialized products to perform natural mothering, while simultaneously discouraging mothers from having actual careers. That must be discouraged since it would lead to two outcomes the industry considers undesirable: women would not buy the books, classes, services and specialized products and women would acquire economic freedom from manipulation.

Similarly, attachment parenting has nothing to do with the way our foremothers raised their children. The mother-infant bond, to the extent that it was considered at all, was assumed to be the inevitable result of caring for children; mother and child love each other simply because they belong to each other. But in attachment parenting, mothering isn’t enough; hyper-mothering is required. Attachment parenting advocates insist that mother-infant interactions must be prodded and controlled in a series of ritualized behaviors (skin to skin at birth, breastfeeding only, baby wearing) otherwise children will presumably end up “detached.”

As Charlotte Faircloth notes in the essay The Problem of ‘Attachment’: the ‘Detached’ Parent in the book Parenting Culture Studies:

It hardly seems controversial to say that, today, we have a cultural concern with how ‘attached’ parents are to their children. Midwives encourage mothers to try ‘skin-to-skin’ contact with their babies to improve ‘bonding’ after childbirth, a wealth of experts advocate ‘natural’ parenting styles which encourage ‘attachment’ with infants…

Previously a mother’s love for her child had been romanticized and ascribed to inherent characteristics of women, mother love has now been medicalized, requiring participation in rituals prescribed by experts.

Ultimately hyper-maternalism is a more accurate description of contemporary mothering ideology because it captures the belief that mere mothering is not enough; hyper-mothering is required. Women must erase themselves and embrace their own pain, exhaustion and battered mental health. Women must submerge their identities in mothering, ignoring their own intellect, talents, needs and ambitions. The alternative is implied to be beloved children profoundly damaged by our selfishness.

Why do good mothers feel so bad?

It’s not an accident. It’s a direct result of the ideology of hyper-maternalism.

Once again, the natural parenting crowd rushes to demonstrate what I’ve written. This time they’re demonstrating how cultural constructions of both women and nature are used to promote the misogynist belief that mothers ought to suffer.

Both professional lactivist Dr. Jack Newman and artist Natalie Lennard have expropriated the Virgin Mary to make their sexist points. That’s not surprising. Religion is one of the most powerful sources for culturally constructed views about women, nature and the “need” for suffering. That’s why it has been traditionally used to keep women in their place.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]You know what else was never seen in nature? Men mainsplainin’ breastfeeding to women and profiting from it.[/perfectpullquote]

This is hardly the first time that the Virgin Mary has been used in this way. Indeed, La Leche League was created explicitly in order to convince women to breastfeed so they wouldn’t go to work. It is named for a statue of Mary nursing Jesus, Nuestra Senora de la Leche.

In the book La Leche League: At the Crossroads of Medicine, Feminism, and Religion, Jule DeJager Ward explains that the La Leche League was:

…founded in 1956 by a group of Catholic mothers who sought to mediate in a comprehensive way between the family and the world of modern technological medicine…

The League’s presentations and literature carry a strong suggestion that breast feeding is obligatory. Their message is simple: Nature intended mothers to nurse their babies; therefore, mothers ought to nurse…

Emulating the tradition of using religion to convince mothers they must suffer, Dr. Jack Newman offers this bit of idiocy:

I have many photos of paintings of mothers breastfeeding. Not one of them shows a nipple shield. At our clinic one day last week, 5 out 16 of the mothers were using a nipple shield. I am appalled. There is nothing that can be done with a nipple shield that cannot be done better by a skilled helper without one …

Wait a minute while I pick myself up off the floor and catch my breath from laughing so hard.

Jack Newman has never seen a painting of the Virgin Mary breastfeeding with a nipple shield and he therefore concludes that nipple shields are never needed? Seriously? We’re supposed to believe that a woman who had a virgin birth is a perfect role model for human physiology?

You know what else was never seen in nature? Men mainsplainin’ breastfeeding to women and profiting from it. The very idea would have horrified Mary and her contemporaries. Women helped other women learn to breastfeed, no money exchanged and men had absolutely nothing to do with it. If Jack Newman thinks nipple shields are not necessary because they weren’t used in the Middle Ages, then he ought to be horrified by the notion that he is making money browbeating women into breastfeeding. There is absolutely nothing natural about what he does and he ought to stop immediately.

There was no internet, no Facebook, no books, no blogs and no videos in nature, either. Why does Dr. Newman finds it perfectly appropriate to use technology to profit from breastfeeding — something that never occurred in the entire history of the human race — yet is horrified by the idea of using technology to help women reduce pain in breastfeeding? It’s obvious: good mothers are supposed to suffer and Dr. Newman, a man, considers himself an appropriate arbiter of just how much suffering is required.

Natalie Lennard tries to make the same nonsensical point with her artwork, The Creation of Man. Apparently Lennard has used Photoshop to create a composite of a woman giving birth in the natural childbirth approved manner and an old painting of the birth of Jesus. Lennard fancies herself transgressive when she is nothing more than another gullible woman credulously quoting the charlatan Ina May Gaskin:

“The human species is no more unsuited to give birth than any other of the 5000 species of mammals on the planet. The birth-giving woman is the central agent in the ancient drama of bringing forth new life”. – Ina May

Every year we celebrate a natural birth, a story that takes place in the most primitive surroundings. Mary, giving birth to the Son of God in a stable … Yet how is it that beyond Julius Garibaldi’s 1891 painting of Mary and Joseph slumped in raw exhaustion, we have never seen a ‘real’ depiction of birth biology, particularly of Mary in upright, ecstatic primal instinct that such an environment would have helped facilitate?

Risking controversy to use universal characters to portray the ultimate ‘birth undisturbed’ amongst other mammals in a dim and lowly environment, suggests to modern woman that often in birth, less is more…

Ecstatic primal instinct? No one in Mary’s time thought birth was ecstatic. That’s a conceit created by Western, white women who have easy access to medical care and who pretend to themselves that they are oh so impressive for refusing it. Once again we are supposed to believe that a woman who had a virgin birth is an appropriate model for human physiology.

Back in Mary’s time there were no women artists, no Photoshop and no internet. If Lennard believes that women should give birth the way that she imagines Mary did, why doesn’t she live the rest of her life the way that Mary did?

Obviously, the invocation of Mary by Dr. Newman and Ms. Lennard is absurd in the extreme, but the purpose behind it is as ancient as the Bible; the purpose is to control women. It’s all about convincing women that suffering is the lot of women in general and necessary for mothering in particular. There’s a bitter irony to portraying nature as the touchstone for how much women ought to suffer, yet discarding it to use technological means to convince women to suffer naturally.

These efforts aren’t just ironic; they’re ludicrous. If you’re using the Virgin Mary to make your point about the physiology of mothering, you need to re-evaluate your point.

It’s the largest study of its kind and it was supposed to save lives. According to StatNews:

It was supposed to be a breakthrough moment in global health.

Atul Gawande, the physician and writer, was applying a simple tool he championed — the checklist — to improve birth outcomes in a rural part of India with some of the world’s highest infant mortality rates.

But his closely watched study, the BetterBirth Trial, has produced a disappointing result: Despite increased adherence to best practices, outcomes for babies and mothers did not improve with the use of a checklist and coaching on its implementation, according to data published Wednesday in the New England Journal of Medicine.

What happened?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Kudos to Gawande et al. for undertaking the study and especially for publishing the result that the study failed.[/pullquote]

Tl/dr version: They changed process, but they didn’t save lives. Why? Because you can’t save lives unless you medicalize childbirth with lots of C-sections.

The paper is Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India by Gawande and many colleagues.

The study took place in Uttar Pradesh, which has hideous rates of perinatal and maternal mortality:

Uttar Pradesh is a high-priority region for national and international public health organizations owing to its persistently high neonatal mortality (32 per 1000 live births) and maternal mortality (258 per 100,000 births). The government of Uttar Pradesh permitted the trial to proceed in 38 districts, in which we identified 320 eligible facilities. We considered a facility to be eligible if it was designated as a primary health center, community health center, or first referral unit; had at least 1000 deliveries annually; had at least three birth attendants with training of at least the level of an auxiliary nurse midwife; had no other concurrent quality-improvement or research programs; and had district and facility leadership willing to participate. The final trial sample included 120 facilities across 24 districts.

What did they do?

Studies have previously shown that, when well implemented at a small scale, the WHO Safe Childbirth Checklist improves facility-based birth attendants’ adherence to evidence-based care. We performed a large cluster-randomized trial of coaching-based implementation of the checklist (the BetterBirth program) in Uttar Pradesh, India… We hypothesized that this intervention, implemented at the facility (cluster) level, would result in a reduction in a composite outcome of stillbirth, early neonatal death, maternal death, or maternal severe complications during days 0 to 7.

In other words, they attempted to change process in order to improve outcomes. It was a failure.

We found no significant difference between intervention and control facilities in our primary outcome (15.1% in the intervention group and 15.3% in the control group; relative risk, 0.99; 95% confidence interval, 0.83 to 1.18; P=0.90) or in any secondary outcomes… We found no significant differences between the trial groups in the rates of follow-up care required for women or newborns, hysterectomy, blood transfusion, or interfacility transfer (referral) for women or newborns…

Despite being effective in changing process, no lives were saved.

Kudos to Gawande et al. for undertaking the study and especially for publishing the result that the study failed.

Although it is tempting to extrapolate the results from small scale studies to make policy (that’s pretty much the only thing that breastfeeding researchers do, for example), you don’t know if large scale interventions will work unless you try them and see.

Why didn’t it work?

Because childbirth is very dangerous and women and babies die as a result of complications, not because of provider behavior. The only truly effective way to save lives in childbirth is to medicalize it. The most important factor is easy access to C-sections.

An accompanying editorial notes:

The trial facilities were predominantly health centers, not hospitals… Moreover, the “skilled birth attendants” providing care in this trial did not necessarily have the skills necessary to save the life of a mother, fetus, or newborn. (A skilled birth attendant is often defined as having the ability to conduct a normal vaginal delivery.) In both trial groups, the birth attendant was usually a nurse; physicians performed only 14% of deliveries.

Cesarean delivery is often required to prevent maternal, fetal, or newborn death; analyses of multinational data have shown that rates of cesarean delivery of 15 to 20% are associated with the lowest rates of maternal, fetal, and neonatal death…

What can we learn from this study?

… Because many complications are not predictable, it would be ideal if all births occurred in well-equipped, well-stocked facilities with appropriately trained staff. Preeclampsia cannot be diagnosed or treated if blood pressures are not measured; fetal distress cannot be diagnosed if the fetal heart rate is not auscultated and cannot be treated if cesarean sections are not performed. Reductions in maternal, fetal, and newborn mortality require substantial organization, resources, and skills and will not happen in health systems without these features.

In other words, childbirth is dangerous and only liberal use of medical interventions saves lives.

Although the study was undertaken in the developing world, it has important implications for efforts in the industrialized world, particularly for the purveyors of natural childbirth.

1. It proves yet again that childbirth is inherently dangerous. This wasn’t childbirth in nature; it was far improved beyond that with skilled birth attendants and health facilities. Regardless, rates of perinatal and maternal mortality are hideous.

2. It calls into question the popular idea that childbirth has been “over-medicalized.”

3. It demonstrates that the two most important factors in reducing infant and child death are C-sections and obstetricians and you can’t have the former without the latter.

Reactions to the study results indicate that natural childbirth advocates routinely ignore scientific evidence. The StatNews piece included this mind boggling quote from Katy Kozhimannil, a public health researcher and natural childbirth advocate.

Sometimes when you put evidence-based practices into the world, the world is stronger than those practices.

Apparently cognitive dissonance is hard even for those who ought know better. The world isn’t “stronger” than evidence based practices; practices that don’t work in the world obviously aren’t evidence based.

The bottom line is this: childbirth is inherently dangerous. If we want to save lives we must medicalize it.

Most advocates of natural mothering — natural childbirth, breastfeeding, attachment parenting — believe that they have the best interests of children at heart. They don’t understand that they have fallen prey to the Maternal Guilt Industry that seeks to control mothers by generating and manipulating the fear that they will inadvertently harm their children.

I’m not talking about the women who make choices based on what is best for their families and themselves; they do have the best interests of their children at heart. I’m talking about the advocates, professional and lay, who proselytize on how all women should raise all children.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The operating principle of the Maternal Guilt Industry is this: children’s wellbeing can only be ensured by mothers’ suffering.[/pullquote]

The attempt to control and manipulate women through love for their children is such a fixture of our culture that it is as invisible to us as the air we breathe.

As Jana Malamud Smith explains in A Potent Spell: Mother Love and the Power of Fear:

[S]tarting in Colonial America, a deep grammar of threat, stable beneath ever-changing “facts,” links and relinks child safety to maternal “acceptance” of constricted, submissive “feminine” behavior, deference to authority and her willingness to stay close to home.

It has ever been thus:

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.

What’s new is the latest iteration, the Maternal Guilt Industry, seeks not merely to control women but to make them pay for the privilege.

Malamud Smith’s starting point is what many mothers feel in their bones.

We know that most mothers … feel they will sacrifice even their lives on their children’s behalf. Part of the reason is love. Part is love’s corollary: each mother knows that it would be difficult, if not unbearable, to choose otherwise. How could we live with ourselves if we believed we had not given all to save a child?

When you are willing to give your life to protect your child, how much easier is it to give your aspirations, identity and freedom? The Maternal Guilt Industry seeks to deprive women of all three.

Understanding the depth of a mother’s feelings about child loss is central to comprehending how women who are mothers live in the world… [C]onsciously and, particularly, preconsciously, many women anticipate and fear, often with very good reason, that should they challenge their social role, should they defy the explicit or implicit rules of their environment, they might unwittingly damage their children.

The operating principle of the Maternal Guilt Industry is this: children’s wellbeing can only be ensured by mothers’ suffering.

• You must suffer the agonizing pain of labor, and must not dare to expunge it with pain relief, or your child will be harmed and it will be your fault.
• You must endure any discomforts of breastfeeding, any inconvenience and any disruption of your ability to work, or your child will be harmed and it will be your fault.
• You must carry your child constantly and sacrifice any private time, even when you are sleeping, or your child will be harmed and it will be your fault.
• You must spend endless hours shopping for and hand preparing food for your child, as well as presiding over complex food restriction diets, or your child will be harmed and it will be your fault.
• You must buy the books, services and accoutrements of natural parenting (natural childbirth classes, lactation consultant services, fancy child slings and wraps) or your child will be harmed and it will be your fault.
• You must never consider your own needs, desires and ambitions or your child will be harmed and it will be your fault.

The originators of natural mothering were quite explicit in invoking the trade off between mothers’ desires to escape from traditional gender roles and the harm that would supposedly come to their children as a result. Grantly Dick-Read created the philosophy of natural childbirth explicitly because he feared white women of the “better” classes would not have enough children to rule the world; the founders of La Leche League were explicit in proclaiming that by convincing women to breastfeed they could keep them from going to work; Dr. William Sears of attachment parenting is quite explicit in asserting that “God” wants women to stay in constant physical proximity to their children and maintain a state of subservience.

The saddest aspect of the Maternal Guilt Industry is not that it profits from women’s misery and seeks to maintain that misery in order to continue to profit. The saddest aspect is that women have been recruited as the primary enforcers of the mandatory misery of other women:

Sure midwives profit from convincing women to endure childbirth without pain relief, but they genuinely believe that pain makes women better mothers. They don’t seem to understand that they have been co-opted into enforcing gender stereotypes and oppressing other women.

Sure lactation consultants profit from convincing women to breastfeed, but they genuinely believe that breastfeeding makes women better mothers. They don’t seem to understand that they have been co-opted into enforcing gender stereotypes and oppressing other women.

Sure the purveyors of fancy slings and wraps and attachment parenting books profit from their philosophy, but they genuinely believe that continuous, close physical proximity to their babies makes women better mothers. They don’t seem to understand that they have been co-opted into enforcing gender stereotypes and oppressing other women.

As Malamud Smith notes in regard to parenting “experts”:

The authorities’ admonitions have often harshly and incorrectly punished mothers by suggesting that their children’s suffering or death is a consequence of their behavior — usually any behavior deemed to be ambitious, sexual or independent.

It’s easy for us to laugh at past efforts:

… Richard Kissam, MD [wrote] in The Nurse’s Manual and Young Mother’s Guide (1834), “If the mind of the mother be withdrawn from her child to other pleasures, her milk will be less nutritious and less in quantity.” Milk loses its basic life-sustaining characteristics if a mother lets herself think private, pleasurable thoughts? The notion was terrible science, but a powerful way to make mothers feel guilty and ashamed when their attention inevitably wandered …

It’s much harder to recognize that the present drive to force all women to breastfeed is no different. The claim that breast is best is terrible science, but a powerful way to make mothers feel guilty and ashamed if they use formula.

The ultimate irony is that the women of the Maternal Guilt Industry (and it is mostly women) imagine themselves as independent and transgressive, bucking the hegemony of patriarchal medicine. The reality is that they are oblivious in knuckling under to the traditional patriarchy of enforced gender norms. Maternal suffering is not a requirement for happy children; but it is a requirement for making women easy to control. And when it comes to controlling contemporary women, the Maternal Guilt Industry has no peer.

The BBC is touting a new study claiming that paying women to breastfeed is effective. What it really shows it that bribing women to breastfeed is a spectacular waste of precious healthcare funds.

Offering shopping vouchers to new mothers can encourage them to breastfeed their babies, a study published in JAMA Pediatrics has found.

About 10,000 new mothers in Yorkshire, Derbyshire and Nottinghamshire were offered up to £200 in vouchers as an incentive.

Breastfeeding rates increased in these areas, which typically have low uptake.

The study is Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial by Claire Relton et al.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The authors spent more than $300,000 to get 300 women to partially breastfeed for 6-8 weeks, $1000 for each additional mother![/pullquote]

According to the authors:

In the intervention (5398 mother-infant dyads) and control(4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, −0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, −0.2 to 4.8; P = .07).

In their conclusion they acknowledge the weakness of their data:

Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.

But the weak data and limited effectiveness are not the biggest problem with the study. The biggest problem is that bribing women to breastfeeding is not remotely cost effective.

According to the authors’ own data, an addition 5.7% of women in the bribery group partially breastfed for 6-8 weeks compared to the control group. That’s approximately 300 women. How much did that increase cost?

This was the payment structure:

The incentive intervention was offered to women condi- tional on their infant receiving any breast milk. The scheme offered shopping vouchers worth £40 (US$50) 5 times based on infant age: 2 days, 10 days, 6 to 8 weeks, 3 months, and 6 months (ie, up to £200/US$250 in total). Vouchers were exchangeable at supermarkets and other retail shops with no restriction on allowable purchases. Receipt of vouchers was conditional on mothers signing a form stating that “my baby is receiving breast milk” and a countersignature from a clini- cian for the statement “I have discussed breastfeeding with mum today.”

Therefore all the woman who partially breastfed for 6-8 weeks received a total of $150. Since 37.9% of 5398 women (2159) partially breastfed for that long, the authors spent nearly $324,000 on those women. In other words, the authors spent more than $300,000 to get 300 women to partially breastfeed for 6-8 weeks, $1000 for each additional mother!

Even with all that money they didn’t increase the breastfeeding initiation rate, the rate of exclusive breastfeeding at 6-8 weeks and they didn’t increase breastfeeding rates at 3 months or 6 months.

Of the nearly $324,000 spent, only $45,000 went to the mothers who had been bribed to breastfeed. Nearly $280,000 was given to mothers who would have breastfed anyway.

The total cost of the program far exceeded the $324,000 because women who partially breastfed for 3 months received and additional $50 and women who partially breastfed for 6 months received an additional $100. All of those women would have breastfed for the same length of time even if they hadn’t received the money. Moreover, the program itself almost certainly cost additional money to administer.

Who could have predicted that such a large amount of money would be wasted? I not only could have predicted it, I did predict it!

In November 2014 I wrote Early results from the “bribe a woman to breastfeed” trial. I discussed the results of an earlier pilot study also written by Relton and colleagues. The pilot study involved only 108 women and a similar voucher scheme. When I did the math I found:

The government spent $1100 per woman to increase the breastfeeding rate and the bulk of that $1100 went to women who were planning to breastfeed anyway…

I predicted that the much larger study would just waste a much larger amount of money and that’s exactly what happened.

Shockingly, you would not know that to read the study because they authors either neglected to calculate or neglected to mention the simple arithmetic that is fundamental to determining whether the study was a success. Getting an additional 300 women to partially breastfeed for 6-8 weeks is likely to have a trivial impact on infant health. So the return on investment of $300,000 to get more women to breastfeed is essentially zero. A zero return on investment is an abject failure.

Just about any healthcare expenditure you can think of would have been a better use of scarce healthcare dollars. But that won’t matter to lactivists. They are so sure that breastfeeding is better for babies that they don’t dare to examine their own findings too closely; they fear that their own studies won’t confirm their prejudices.

Everyone knows that evolution works by survival of the fittest. Anti-vaxxers seem a bit confused on this point. One of the resident anti-vax trolls on this blog, ciaparker2, illustrates the problem.

Cia says:

On the one hand, weak babies and children stand a much greater chance of surviving to reproduce now than was formerly the case, which may or may not be good for them. On the other hand, the survival of the weak damages the vitality of the species, while the survival of the fittest, natural law, enhances it.

What Cia and other anti-vaxxers fail to understand is that on the cusp of 2018, vaccinated children ARE the fittest.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Fitness is measured by surviving offspring, not surviving genes.[/pullquote]

Cia and her anti-vax friends are confused about genes, fitness and natural selection.

Genes are the units of inheritance. Many genes correspond to specific traits like hair color or height. Genes can change over time because of mutations. Each time the DNA of a gene is duplicated, there is a small possibility of error, a mutation. Most errors have no impact on the animal that inherits them. Some mutations are harmful, leading to the early death of the animal. A very few mutations are beneficial; they give the animal a greater chance of surviving to reproduce.

Evolution works by natural selection, also known as “survival of the fittest.” The animals that have the greatest number of surviving offspring are the “fittest” for that environment.

Based on her comment, Cia seems to think that children who survive when they haven’t been vaccinated are fitter than those who survive because of vaccination. Therefore, vaccination decreases the overall fitness of the population.

Let’s try a thought experiment to show Cia and other anti-vaxxers the error of their “reasoning”:

Imagine a lion and a man meet on the savannah and the lion outruns the man, brings him down with his superior strength, kills the man, and eats him.

Who is fitter for the environment of the savannah? The lion, right? The lion has survived with the ability to have more offspring and the man is dead and can reproduce no more.

If a lion is fitter than the average man, how much fitter will it be compared to a man who is below average?

Imagine the same lion meets a different man who is weak, slow and nearsighted, but this man has a gun. The man aims the gun, shoots the lion and eats it.

Who is fitter in the scenario? The man, right? He survived and can go on to reproduce and the lion can’t.

What’s the difference between the two disparate outcomes? It’s the gun, right?

Possessing guns increased the fitness of the man and since his descendants have guns, too, their fitness will also be increased. That’s why there are a lot more people today than lions.

Although it looks like technology is more important than genetics, that’s not really the case. Strictly speaking, it isn’t the gun that increased the man’s fitness, it is the genes for intelligence that allowed people to invent guns. Despite the fact that lions are still bigger, faster and stronger, people are smarter and that makes them fitter. Have guns “weakened” the human genome? Have they deprived the human species of vitality? Hardly.

Vaccines are like guns.

Those who are smart enough to get them are fitter. The “vitality” of their descendants is increased. Technology doesn’t weaken the human genome; it makes those who possess technology and utilize it fitter than those who don’t. Therefore, vaccinated children are fitter than unvaccinated children.

Remember, fitness is measured by surviving offspring, not surviving genes. The lion’s genes may “stronger,” but it is just as dead when shot by the gun as it would be if humans had doubled in size, speed and strength and overpowered the lion that way.

It’s pretty obvious that children who die of disease are unfit by virtue of the fact that they can never reproduce. Back when vaccine preventable illnesses routinely carried off millions of a children each year, the children who survived were fitter than those who died. But now that vaccines can prevent death, the children who survive without vaccines are no fitter than those who survive because of vaccines. And the children who die of vaccine preventable disease because their ignorant parents withheld those vaccines are the least fit of all.

Human beings have become the most numerous large animals on the planet. We have spread to and mastered nearly every place and climate. We didn’t outcompete other animals with size, strength or speed; we outcompeted them because of intelligence. Vaccines, like all technology, doesn’t “weaken” the underlying genome; it’s the manifestation of our superior intellect. In other words, it’s a product of better genes.

One of the most fascinating aspects of the ongoing ProPublica/NPR series on US maternal mortality is watching the reporters learn from their research.

To their credit, the reporters abandoned their original understanding of maternal mortality and crafted a new one. That process is still ongoing and their latest piece, Nothing Protects Black Women From Dying in Pregnancy and Childbirth, is an example of both how far they’ve come and how far they have to go.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Both Shalon Irving and Lauren Bloomstein died because medical professionals dismissed their symptoms as variations of normal when they were signs of impending death; they died of malpractice.[/pullquote]

They’ve come far enough to recognize that maternal mortality is disproportionately a problem of black women and they are correct that racism is part of the problem, but not necessarily in the way that they think. Moreover, they keep confusing malpractice with other issues.

Comparing their original article to the latest piece demonstrates progress. The original piece, The Last Person You’d Expect to Die in Childbirth used the death of a privileged white woman, Lauren Bloomstein, as the frame. The journalists didn’t explain and probably didn’t even know the most salient facts about maternal mortality.

They weren’t entirely to blame for their lack of knowledge. The natural childbirth industry — a group of Western, white, relatively wealthy women — has weaponized the tragedy of maternal mortality in order to attack modern obstetrics. I’ve written extensively about the cynical, racist misuse of the issue:

Natural childbirth advocates are positively eager to use the misfortunes of women of color to advance their own privileged agenda. They delight in pointing to relatively high rates of perinatal and maternal mortality in the US (as compared to other, “whiter” countries), yet ignore that they are the result of appalling death rates among African American women and their babies.Natural childbirth advocates and organizations have the unmitigated gall to imply that these women are dying of “too much” medical intervention when the reality is that they are dying of too little intervention for the serious complications they face.

Ina May Gaskin, a privileged white woman, has led the way in this exploitation. Gaskin never misses an opportunity to highlight mortality rates and even created a “Safe Motherhood” quilt project to draw attention to the problem. Gaskin represents herself as shocked at the current rate of maternal mortality. Yet as far as far as I can tell, homebirth midwives in general and Gaskin in particular have done nothing (no research, no education, no fund raising) to reduce the incidence of maternal mortality.

What are the salient facts about US maternal mortality?

• It is disproportionally a problem of black women.
• The leading causes of death are cardiac problems and other chronic diseases.
• Pregnancy is inherently dangerous.
• Women die from lack of high tech care, not too much of it.

Since then the ProPublica/NPR journalists seem to have come to grips with the true nature of the problem. Their latest piece is framed by the tragedy of the preventable death of a privileged black woman.

At 36, Shalon [Irving] had been part of their elite ranks — an epidemiologist at the Centers for Disease Control and Prevention, the preeminent public health institution in the U.S. There she had focused on trying to understand how structural inequality, trauma and violence made people sick. “She wanted to expose how peoples’ limited health options were leading to poor health outcomes. To kind of uncover and undo the victim blaming that sometimes happens where it’s like, ‘Poor people don’t care about their health,’” said Rashid Njai, her mentor at the agency. Her Twitter bio declared: “I see inequity wherever it exists, call it by name, and work to eliminate it.”

Much of Shalon’s research had focused on how childhood experiences affect health over a lifetime. Her discovery in mid-2016 that she was pregnant with her first child had been unexpected and thrilling.

Then the unthinkable had happened. Three weeks after giving birth, Shalon had collapsed and died.

The article goes on to discuss the role of racism in health disparities.

But it’s the discrimination that black women experience in the rest of their lives — the double-whammy of race and gender — that may ultimately be the most significant factor in poor maternal outcomes. An expanding field of research shows that the stress of being a black woman in American society can take a significant physical toll during pregnancy and childbirth.

It’s chronic stress that just happens all the time — there is never a period where there’s rest from it, it’s everywhere, it’s in the air, it’s just affecting everything,” said Fleda Mask Jackson, an Atlanta researcher and member of the Black Mamas Matter Alliance who studies disparities in birth outcomes…

Arline Geronimus, a professor at the University of Michigan School of Public Health, coined the term “weathering” for how this continuous stress wears away at the body…

That’s an appealing explanation but it’s almost certainly wrong. Racism in the US is not restricted to black people. Hispanics and Native Americans face their share of discrimination, chronic disease and poor socioeconomic status yet they don’t have the same problem with maternal mortality. The maternal mortality rate among Hispanic women is lower than that of white women.

Racism is a hideous problem in this country and an insidious problem in medicine, but Shalon Irving didn’t die because of “weathering”; she died of malpractice, ironically the same thing that killed Lauren Bloomstein, the privileged white woman whose death frames the initial ProPublica/NPR piece.

If you have been reading the mainstream media over the last few years, you might have come away with the impression that pregnancy is safe and technology is being overused. Pregnancy has been portrayed as inherently safe when, in fact, it is quite deadly. Medical professionals now have a low index of suspicion for pregnancy complications when they should have a high index of suspicion. You can’t diagnose complications if you don’t think about them.

Both Shalon Irving and Lauren Bloomstein died because medical professionals dismissed their symptoms as variations of normal when they were in reality signs of impending collapse and death. In other words, they died of malpractice.

Shalon Irving repeatedly presented to her healthcare team with serious postpartum complications.

What troubled the nurse most, though, was Shalon’s blood pressure. On Jan. 16 it was 158/100, high enough to raise concerns about postpartum preeclampsia, which can lead to seizures and stroke. But Shalon didn’t have other symptoms, such as headache or blurred vision. She made an appointment to see the OB-GYN for the next day, then ended up being too overwhelmed to go, the visiting nurse noted on Jan. 18… Overall, Shalon told the nurse, “it just doesn’t feel right.” When the nurse measured her blood pressure on the cuff Shalon kept at home, the reading was 158/112. On the nurse’s equipment, the reading was 174/118…

Irving should have been admitted to the hospital immediately for treatment of her blood pressure and evaluation for postpartum pre-eclampsia. Instead she was reassured and sent home.

On the morning of Tuesday, Jan. 24, Shalon took a selfie with her father, who’d been visiting for a week, then sent him to the airport to catch a flight back to Portland. Towards noon, she and Wanda and the baby drove to the Emory Women’s Center one more time. This time, Shalon saw a nurse practitioner. “We said, ‘Look, there’s something wrong here, she’s not feeling well,’” Wanda recalled. “‘One leg is larger than the other, she’s still gaining weight’— nine pounds in 10 days — ‘the blood pressure is still up, there’s gotta be something wrong.”

The nurse’s records confirmed Shalon had swelling in both legs, with more swelling in the right one. She noted that Shalon had complained of “some mild headaches” and her blood pressure was back up to 163/99, but she didn’t have other preeclampsia signs, like blurred vision… She ordered an ultrasound to check the legs for blood clots, as well as preeclampsia screening.

Both tests came back negative. As Wanda remembers it, Shalon was insistent: “There is something wrong, I know my body. I don’t feel well, my legs are swollen, I’m gaining weight. I’m not voiding. I’m drinking a lot of water, but I’m retaining the water.” Before sending Shalon home, the nurse gave her a prescription for the blood pressure medication nifedipine, which is often used to treat pregnancy-related hypertension.

The provider made the worst possible error of malpractice; she refused to believe an obviously unwell patient sitting in front of her. It’s the same error made by Lauren Bloomstein’s providers with the same deadly result.

It only gets worse from there:

They got home and sat in Shalon’s bedroom for a while, laughing and playing with the baby. Around 8:30 p.m., Shalon suddenly declared, “I just don’t know, Mom, I just don’t feel well.” She took one of the blood pressure pills. An hour later, while she and Wanda were chatting, Shalon clutched her heart, gasped and passed out.

Paramedics arrived to find Shalon on the floor near the foot of her bed “pulseless and not breathing…” They tried to stabilize her, then rushed her to Atlanta’s Northside Hospital, just a couple of miles from her home. In the emergency room, doctors discovered that the breathing tube had been “incorrectly placed,” according to the ambulance service report — into her esophagus instead of her lungs. She never regained consciousness. Four days later, on Jan. 28, Wanda and Samuel withdrew life support and she died.

Was Shalon Irving a victim of racism in her life? Undoubtedly, but racism didn’t kill her, malpractice did, specifically the belief of her providers that they didn’t need to worry about childbirth complications even though Shalon and her serious complications were sitting right in front of them. Childbirth is dangerous; women die when we pretend otherwise.