Irony is dead.

In the wake of the most deadly mass shooting in American history, Republicans in Congress are preparing to introduce the Pain-Capable Unborn Child Protection Act, a ban on abortions after 20 weeks of pregnancy.

CNN reports:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Choose life — support health insurance & gun restrictions and oppose capital punishment & police brutality.[/pullquote]

The House of Representatives will vote Tuesday on legislation that would criminalize abortions after 20 weeks of pregnancy, with exceptions for instances where the life of the mother is at risk and in cases involving rape or incest.

The Pain-Capable Unborn Child Protection Act, which is similar to legislation that failed in 2013 and 2015, has support from the White House this time around.

The divisive issue of abortion has once again been brought to the forefront of national conversations since President Donald Trump assumed office. Trump issued support for the bill even before he won the election.

The same group of people who can’t be bothered to restrict guns, which kill more than 30,000 people per year, are rabid to restrict late term abortions, of which there are less than 10,000 per year. It’s hard to imagine how they could be bigger hypocrites.

Perusing their favorite slogans merely highlights their hypocrisy.

Choose life.

That’s an argument for universal healthcare, not an argument for banning abortions. Curiously, many of those who staunchly oppose pregnancy termination have no problem denying life saving healthcare for others, including children.

The same Congressmen who are enthusiastically promoting anti-abortion legislation had no trouble opposing Obamacare and had no trouble letting CHIP expire last week. CHIP is the program that provides low cost health insurance to 9 million children across the US.

The program, created under a 1997 law passed with bipartisan support during the administration of President Bill Clinton, provided coverage for children in families with low and moderate incomes as well as to pregnant women. It was instrumental in lowering the percentage of children who were uninsured from nearly 14 percent when it started to 4.5 percent in 2015. It was last reauthorized in 2015 and was due to be renewed by Sept. 30, 2017.

Amid unsuccessful efforts to repeal and replace the Affordable Care Act, the Republican-led Congress allowed the CHIP deadline to pass without action.

Providing health insurance for poor children is choosing life, but apparently for the anti-choice crowd all life is not equal. They are keen to protect life from conception up to, but not including, birth. Once you’re born, your life is worthless if you are poor.

Abortion stops a beating heart.

You know what else stops a beating heart? Capital punishment. Despite that incontrovertible fact, many of those who profess “pro-life” beliefs have no problem letting government stop the beating hearts of those convicted of crimes. If your reason for opposing late term abortion is to preserve life, it is hypocritical to promote mandated death at the hands of government.

They feel pain.

We could argue about whether or not science supports the claim that a 20 week fetus feels pain, but there is absolutely no doubt that everyone born, regardless of age, race or economic class feels pain. So why do the same Republicans who feel they must protect the unborn from pain have no problem letting the people of Puerto Rico suffer in pain, literally and figuratively, in the wake of widespread destruction of Hurricane Maria?

Pro-life means every life has value.

If every life has value, why isn’t everyone supporting Colin Kapernick’s campaign to kneel when the national anthem is played in order to draw attention to the black lives lost to police violence? Those opposing Kapernick justify it by claiming he is disrespecting the flag. That’s a lie, but even if it were true, are we supposed to believe that a piece of cloth has greater value than the life of a young black man?

Abortion is murder.

We could argue whether abortion is murder, but there’s no argument that murder is murder. Guns facilitate murder. Indeed, hand guns and semi-automatic and automatic weapons have no purpose other than to murder or threaten to murder others. If we actually cared about murder, we would ban murder weapons, but you won’t see anyone in Congress stand up to the gun lobby.

These five slogans of the anti-choice movement put its hypocrisy into high relief. The so called “pro life” crowd has no problem being anti-life whenever it suits them. So if ending late term abortion isn’t about saving lives, what is it about?

It’s about punishing women — but never men — for sex.

Providing medical care for children is more pro-life than preventing late term abortion, yet many “pro-lifers” don’t want to do it.

Banning capital punishment is more pro-life than preventing late term abortion, yet many pro-lifers are pro government spondered death.

Relieving the suffering of Puerto Ricans is more pro-life than preventing late term abortion, yet many pro-lifers seem curiously unconcerned about it.

Stopping the wanton police violence toward black men is more pro-life than preventing late term abortion, yet many “pro-lifers” are more concerned about a piece of cloth than actual human lives.

Regulating guns is more pro-life than preventing late term abortions, but when the choice is between right to life and right to guns, guns win every time.

Anyone who wants to choose life should be campaigning aggressively for health insurance for all and gun restrictions and against capital punishment and police brutality.

Otherwise, they’re merely Making Hypocrisy Great Again.

Another day, another US gun massacre, the biggest yet:

In the deadliest mass shooting in modern U.S. history, a hail of gunfire rained down from the Mandalay Bay Resort and Casino on Sunday evening, police said. The gunman, identified as Stephen Paddock, 64, is believed to be a “lone wolf” and was found dead in his hotel room, police said. More than 400 people were taken to area hospitals after the shooting, police said.

The details are horrific:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Gun rights advocates are denialists just like anti-vaxxers are denialists, and they are every bit as dangerous to public health.[/pullquote]

Under the neon glow and glitz of the Vegas Strip, thousands of concertgoers who had gathered for a three-day music festival dove for cover or raced toward shelter when the gunfire began at about 10 p.m. Sunday. Police said more than 22,000 people were at the concert when Paddock, who had checked into the Mandalay Bay on Thursday, began firing round after round.

Police believe the 64-year-old Paddock, a local resident, was a “lone wolf” attacker. Lombardo did not give further details, however, on Paddock’s background or possible motivation. “We have no idea what his belief system was,” Lombardo said during a briefing. “Right now, we believe he was the sole aggressor, and the scene is static.”

Recordings of the attack suggested that Paddock used an automatic weapon. He was found with more than 10 rifles, Lombardo said.

The proximate cause is obvious to everyone in the world but gun aficionados; the proximate cause is the easy access to guns brought to us by a corrupt legislative process orchestrated by the National Rifle Association and its mounds of cash.

Gun restriction is associated with decreased gun violence. Yet, the NRA opposes gun control and their cash contributions to legislators trump all including the victims of American gun violence, and common sense itself. The truth is that the NRA is a group of gun violence denialists who have an amazing amount in common with science denialists of all stripes from creationists, to climate change denialists, to anti-vaxxers, to purveyors of “alternative” remedies.

Don’t believe me? Consider this definition of denialism offered by Andrew Dart in an chapter from Building your Skeptical Toolkit:

Denialism … is driven by ideology rather than evidence. Now denialists may claim they care about the evidence and will happily display any that supports their point of view, but in most cases they reject far more evidence than they accept. Furthermore, denialists will cling to evidence no matter how many times they have been shown that it is flawed, incorrect or that it does not support their conclusions; the same old arguments just come up again and again. Denialism also tends to focus on trying to generate a controversy surrounding the subject at hand, often in the public rather than scientific arena, and does so more often than not by denying that a scientific consensus on the matter even exists.

Pretty much nails gun violence denialism, right?

1. Denialists start with a conclusion and work backwards.

It doesn’t matter how much evidence you show to climate change deniers, creationists or anti-vaxxers. They’ve embraced a conclusion and they’re sticking to it, regardless of what the evidence actually shows. Similarly, there’s no evidence that you could show gun violence denialists that would cause them to even question their beloved conclusions about guns, let alone change those conclusions.

2. Denialists love denial.

Who you gonna believe, the NRA or your lying eyes?

Like the climate change deniers who will still be in denial as the water rises above their heads, and the evolution deniers who insist that dinosaur bones were planted by God to test our faith, or the anti-vaxxers who can still claim with a straight face that vaccines don’t prevent disease, gun violence denialists are still denying the dangers of easy access to guns as the pile of dead bodies mounts beside them.

3. Denialists love conspiracy theories.

As Dart explains:

So the vast majority of the scientific community and an overwhelming mountain of evidence is aligned against you, what are you going to do? Well you could always claim that there is a conspiracy to suppress the truth …

The favorite conspiracy theory of gun violence denialists is that the government wants to take away people’s guns in order to stage a fascist takeover.

Conspiracy theories, whether blunt or subtle, are nothing more than evasions of the actual evidence that easy access to guns leads to massive numbers of gun deaths, as well as the absence of any evidence of any kind that gun control is the first step to a fascist take over the of the US.

4. Denialists love cherry-picking.

Cherry picking is the act of selecting papers and evidence that seem to support your point of view, whilst at the same time ignoring the far greater body of evidence that goes against your position.

Gun violence denialists claim that research shows that easy access to guns makes us “safer,” when the evidence is all around us that in countries with easy access to guns life is more dangerous for everyone, particularly innocent people.

5. Denialists love echo chambers.

They seek support and validation for their views at NRA conventions and on Fox News and refuse to directly address the concerns of victims of gun violence and public safety experts.

6. They vigorously defend their “rights” while ignoring the rights of those around them.

They extol the “right” to bear assault weapons with large capacity magazines and “cop-killer” bullets, but ignore the rights of citizens to be free from random death. Like anti-vaxxers, they refuse to recognize that as members of society, they have responsibilities to the rest of us.

The inevitable conclusion is one that anyone who cares about scientific integrity and intellectual honesty should keep in mind:

It is not the topic that makes someone a denialist, it is how they the handle evidence that contradicts their cherished, immutable beliefs, in this case, the rising tide of the blood of innocent people injured and killed in gun rampages. Do they deny the evidence that is right in front of their eyes. Do they invoke outlandish conspiracy theories? Do they cherry pick the data and only present those findings that agree with them? And do they congregate in echo chambers that always validate and never question their beliefs?

Gun rights advocates are denialists just like anti-vaxxers are denialists, and they are every bit as dangerous to public health.

Adapted from a piece that first appeared in July 2015.

NPR reports on a bizarre and unethical practice:

An epidural is a common type of regional anesthesia that eases the pain of labor. As she had done many times before, Sweeney followed hospital protocol and called the anesthesia department. But to her shock, they told her they could not help her young patient.

“They said that without parental consent, … she would not be able to sign for her own epidural,” Sweeney says.

In Ohio, people under 18 who are in labor cannot consent to their own health care. They can receive emergency services, but nothing considered to be elective. For the many Ohio minors who become pregnant, it’s a painful gap in coverage.

Who would deny pain relief to a teenager in excruciating pain?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]An epidural for childbirth is a human right and no one, least of all state officials, should be allowed to pretend otherwise.[/pullquote]

Dr. Michael Cackovic, an obstetrician at The Ohio State University Wexner Medical Center, says every couple of months he sees a teenage mom who, under Ohio law, is unable to receive elective treatment, like an epidural. He says it’s frustrating to see patients in unnecessary pain.

… Cackovic … report[s] that, just as frequently, [he’s] had cases where the mothers intentionally denied their teenage daughters an epidural – as a sort of punishment for getting pregnant.

This is both cruel and bizarre. The same teen who is unable to consent to pain relief for herself, is able to consent to pain relief for the baby after its birth. It ought to be illegal for a very simple reason: pain relief is not considered elective for any other person in pain.

Were the same teen to be brought to the emergency room suffering abdominal injuries and requiring emergency surgery after a car accident, no one would deny her anesthesia claiming is it “elective.” Were a teen male brought to the emergency room with a fracture of his leg, no one would deny him pain relief while setting it.

In the paper Pain Management: A Fundamental Human Right, Brennan et al review the ethics of pain relief:

The importance of pain relief as the core of the medical ethic is clear. The relief of pain is a classic example of the bioethical principle of beneficence. Central to the good actions of doctors is the relief of pain and suffering. As Post et al. state, “the ethical duty of beneficence is sufficient justification for providers to relieve the pain of those in their care …” The principle of nonmaleficence prohibits the infliction of harm. Clearly, failing to reasonably treat a patient in pain causes harm; persistent inadequately treated pain has both physical and psychologic effects on the patient. Failing to act is a form of abandonment…

Childbirth is the only setting in which pain relief is wrongly viewed as elective and the reasons are religious, not medical.

In the case of analgesia for childbirth, there was bitter resistance on religious grounds. Fundamentalists cited the Bible as ordaining that childbirth was a necessarily painful process. Opposing both the church and powerful obstetricians, Queen Victoria requested that James Simpson administer chloroform analgesia for the delivery of her son, thus overcoming powerful negative attitudes that discouraged relief of the pain associated with childbirth…

In other words, many religious leaders believed, and some continue to believe, that women should be punished for having sex, and sex outside of marriage should be punished all the more. Abrogating that “punishment” with pain relief is therefore “elective.”

Lest you think that the idea that women deserve pain in childbirth is merely a relic of stodgy religious views, the belief has been secularized by the natural childbirth movement that deems epidurals in labor an “intervention,” but wouldn’t dream of labeling any other form of pain relief elective. Midwives and doulas are the only providers I am aware of that refuse to consult with anesthesiologists and condemn pain relief for ideological reasons.

What about the fact that epidurals have side effects? ALL methods of pain relief have side effects. Opioids administered into vein, muscle or by mouth have far more side effects — respiratory depression, addiction, death — than epidurals, yet no one claims that opioids for relief of severe pain are elective.

The relief of pain is NEVER elective, it is always emergent and ethically mandated. The only time that pain relief can be ethically withheld is if the patient refuses it.

What about the right of parents to determine appropriate medical care for children? If a parent brought a child to the emergency room with a severe burn from playing with matches, absolutely no one would honor that parent’s request to deny the child pain relief to “teach him a lesson.” They’d ignore the parent altogether and possibly petition the court on the grounds of child abuse. There is nothing elective about treating a painful burn regardless of whether the child brought it on himself.

There is also nothing elective about treating the pain of labor no matter how much or how brutally a parent or society wishes to punish women who have sex out of wedlock.

An epidural for childbirth is a human right and no one, least of all state officials, should be allowed to pretend otherwise.

It’s ironic when you think about it. Many of the same people who refuse infant eye ointment because the baby might be distressed by blurry vision, who refuse neonatal vitamin K because the injection will hurt the baby for a brief moment, think nothing of letting a baby (yours or theirs) scream for hours in hunger in the face of inadequate breast milk supply.

The promotion of breastfeeding invariably involves discussion of the benefits to babies of breastmilk but no one seems to care about the babies who suffer in an attempt to force them to breastfeed even when the breastfeeding relationship is not working.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Babies experience hunger as suffering.[/pullquote]

Hunger is probably the most elemental of infant drives and, as anyone who has seen an infant scream from hunger would probably agree, is experienced by the baby as suffering. For most mothers, myself included, the sound of their own infant crying is piercing in its intensity and distress. I remember being surprised by this when my first child was born. I had spent my entire professional life surrounded by crying babies and it had never bothered me, yet I found my son’s crying unbearable and always rushed to determine what was wrong and fix it in any way possible. I cannot imagine letting any of my infants cry in hunger for any length of time without feeding them. Indeed I recoil when I read about the infant care manuals of the early 20th Century that advised mothers to feed the baby on a schedule designed for maternal convenience instead of infant needs.

So why do lactivists think it okay to let babies scream for hours at a time because of desperate, all consuming hunger? Why do they advise women whose babies aren’t getting enough milk in the first few days to ignore that crying in an effort to promote breastfeeding? Why do they view supplementation in the first view days as an evil so great that it is preferable to force babies to endure distress?

Why do lactivists think it is okay to ignore an infant who is not gaining weight because of a maternal milk supply that does not match that infants needs? Why do they denigrate women who find their baby soothed and content after a bottle of formula, and chastise them that they should have let the baby scream instead?

Why do lactivists who have children who try to wean before their mothers have planned to stop breastfeeding counsel each other to starve the baby into submission? Why do they tell each other to offer no other source of nourishment until the baby is forced to give up his or her drive for independence and bow to the mother’s will to continue breastfeeding in order to survive?

Why do people who promote attachment parenting, which is supposed to be about meeting infant needs, to ignore their most elemental need, the need for adequate nutrition?

What’s the difference between the pediatricians of the early 20th Century who promoted feeding on schedule because of its supposed long term benefits and contemporary lactivists who ignore infant hunger because of the very small long term benefits that may or may not really exist?

It seems to me that one of the biggest ironies of all is lactivists who promote forced breastfeeding as “baby-friendly.” We already know that “baby friendly” hospital policies are definitely not mother friendly, but I suspect that such policies aren’t even baby friendly.

How could anything that ignores infant suffering be considered baby friendly?

Hallelujah! A national Baby Friendly Hospital Initiative is being shut down.

Without consultation or notice, in early 2016 the HSE Health Promotion & Improvement, Health & Wellbeing Division reduced the grant-aid it had been providing to the BFHI (which ranged over recent years from slightly under €50,000 to zero). The HSE then directed maternity units not to participate in BFHI activities, ceased all funding, and would not engage in any discussion of these precipitous HSE actions…

Why? Because it doesn’t work.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”There was no difference in breastfeeding rates in hospitals that had achieved baby friendly designation and those that had not achieved this designation. “[/pullquote]

As a member of the Irish governing party explained:

The initiative is funded by the Health Service Executive, which in 2016 commissioned a research team at Trinity College Dublin to undertake a review of the initiative… A key finding of the Trinity review was that there was no difference in breastfeeding rates in hospitals that had achieved baby friendly designation and those that had not achieved this designation. Following completion of the Trinity review, the HSE initiated engagement with the baby friendly hospital initiative and other stakeholders on developing a revised model.

What about all the healthcare dollars/euros that lactivists insist would be saved by increasing breastfeeding rates? No one — not the government nor the BFHI — can point to any real world savings.

I’ve made no secret of my contempt for the breastfeeding promotion campaign known as the Baby Friendly Hospital Initiatve (BFHI). Nearly a year ago, I contended that the BFHI has been a deadly failure. I cited three papers:

• 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

Together these US papers show that the BFHI doesn’t work, ignores the science on pacifiers, formula supplementation, and Sudden Infant Death Syndrome (SIDS) and leads to preventable infant injuries and deaths when babies fall from or get smothered in their mothers’ hospital beds.

And that doesn’t even take into account the babies who have sustained brain injuries or died due to dehydration, hypoglycemia and severe jaundice because the BFHI refuses to acknowledge that up to 15% of first time mothers cannot produce enough milk to fully sustain a baby.

The BFHI is the epitome of paternalism in medicine. Lactation professionals have decided what is “best” for mothers and babies without consulting mothers themselves. They insist that “science” shows that breast is best and therefore, they are justified in forcing breastfeeding on every woman regardless of her experiences and values, and regardless of whether it is a safe or realistic goal.

Yet informed consent requires presenting the risks of breastfeeding — insufficient breastmilk, dehydration, failure to thrive — as well as the benefits. Informed consent means that it is up to MOTHERS to determine whether to offer supplemental formula or pacifiers, NOT up to providers.

BFHI Ireland does not deny this; it does not even mention it. Instead of addressing the failure of the BFHI to increase breastfeeding rates, and the injuries and deaths that have resulted, BFHI Ireland defends itself thus:

An independently evaluated and published survey in March 2017 found that directors of midwifery and clinical midwife specialists in lactation were overall happy with the Initiative as currently run, valued the Initiative, and thought there would be negative effects if it was discontinued.

But the fact that those who were employed by the program were happy with the program has nothing to do with safety or effectiveness. Indeed, it supports my view that the program isn’t “baby friendly”: it’s “lactivist friendly” and baby-harmful.

What now?

If the BFHI were based on science, its members would ask themselves why it doesn’t work and investigate how it could be made more effective and safer. But the BFHI is based on personal conviction, not science, so there will be no attempt made to understand why it is ineffective.

A news story in The Times laments:

Only 15 per cent of children in Ireland are exclusively breastfed for the first six months, as advised by the WHO, compared with a global average of 38 per cent.

Yet Ireland has one of the lowest infant mortality rates in the world (3.3/1000), far lower than many countries with much higher breastfeeding rates. That’s not surprising since there is no real world evidence from any country that breastfeeding rates have any correlation with infant mortality.

The sad truth is that the BFHI is a boondoggle for lactation professionals, no more and no less. It was started with the best of intentions, but it is based on personal belief, not science and, indeed, is contradicted by the best scientific evidence. Hopefully Ireland will be merely the first of countries that recognize that money spent on funding the BFHI is money wasted. The end of the BFHI will be both baby friendly and mother friendly; it can’t come soon enough.

Breastfeeding is not a matter of will; it is a matter of biology.

That’s the take home message from the paper Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology by Lee and Kelleher, graduate student and professor of cellular physiology respectively.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]To pretend that breastfeeding is just a matter of will and support is both empirically wrong and gratuitously cruel.[/pullquote]

The most pernicious of the many pernicious lies promoted by lactation consultants is that any woman who wants to breastfeed can do so successfully. That’s why when breastfeeding fails, lactivists insist that it is because the mother didn’t try hard enough or didn’t get enough support. But lactation is a biological process and like any biological process it has a significant failure rate. Those failures of biologically based.

As the authors of the paper explain:

It has long been assumed that once lactation is successfully initiated, the primary factor regulating milk production is infant demand. Thus, most interventions have focused on improving breastfeeding education and early lactation support. However, in addition to infant demand, increasing evidence from studies conducted in experimental animal models, production animals, and breastfeeding women suggests that a diverse array of maternal factors may also affect milk production and composition.

Indeed:

…[I]t has been estimated that the prevalence of women who overtly fail to produce enough milk may be as high as ∼10–15% and can quickly lead to hypernatremia, nutritional deficiencies, or failure to thrive. Moreover, the prevalence of lactation “insufficiency” may be much higher, as ∼40–50% of women in the US and 60–90% of women internationally cite “not producing enough milk” or “baby not satisfied with breast milk” as the primary reasons for weaning prior to 6 mo.

Why does this happen?

In this review, we provide a broad overview on our current understanding of the molecular etiology behind these factors that play a critical role in lactation physiology and the ability to optimally nourish the nursing infant.

Let’s pause here to address the inevitable lactivist claim that we “wouldn’t be here” if breastfeeding had a high failure rate.

To understand why the claim is false, it helps to analogize to miscarriages. Although the survival of the human race depends on successful pregnancies, it is entirely compatible with a natural miscarriage rate of 20%. There is a biological basis for those miscarriages; most are due to serious genetic defects present at conceptions, some are due to hormonal imbalances, and some are the result of factors we have not yet indentified. Furthermore, no amount of maternal effort or outside support can prevent miscarriages. A few can be prevented with medical interventions but most can’t be prevented at all. The same thing applies to insufficient breastmilk production.

Breastmilk production is a complex process:

During early pregnancy, primary hormones, including estrogen, progesterone, prolactin, and placental lactogen, induce the physiological transition of the mammary gland from a nonsecreting branched tissue into a highly active secreting organ comprised of a vast network of ducts and alveoli that are grouped into seven to 10 lobes in humans… In response to progesterone and estrogen withdrawal, concomitant with prolactin release following parturition, the differentiated epithelium gains a remarkable capacity to finely coordinate the synthesis and transport of various milk constituents for the onset of milk secretion, … which usually occurs after full-term birth in humans.

There are many ways that things can go wrong.

Breast hypoplasia or other abnormal breast conditions and previous breast surgeries are certainly factors that contribute to lactation insufficiency… What is much less appreciated and poorly understood is the role that maternal genetics and modifiable factors such as energy balance, diet, and environmental exposures may have on reproductive endocrinology, lactation physiology, and the ability to successfully breastfeed.

Genetics

…[R]ecent advancements have identified numerous genetic variants associated with milk production traits in production animals. A recent study using GWAS data collected from 16,812 Holstein and Jersey dairy cattle identified SNPs in key pathways that are critical for mammary gland development, prolactin signaling, and involution that explained variation in milk production and milk composition. For example, ∼50% of SNPs found in genes critical for prolactin signaling, including SOCS2, STAT3, STAT5A, STAT5B, PRLR, and β-casein, were associated with three or more milk production traits. Additionally, a large number of SNPs in genes that are critical for mammary gland involution, including ATF4, IGFBP4, IRF1, LIFR, OSMR, PTK2, and STAT3, were also associated with milk production traits…

We propose that similar variation may govern lactation physiology, milk production, and composition in breastfeeding women…

Hormones

In addition to prolactin, a complex combination of hormones works together to maintain the differentiated epithelium and milk secretion during lactation, including insulin, glucocorticoids, growth hormone, oxytocin, and thyroid hormone. Secretory activation and milk ejection require insulin and glucocorticoids to synergistically regulate the formation of tight junctions in the mammary gland, stimulate mammary differentiation, and induce milk protein expression. Insulin levels rapidly decrease during early lactation and steadily increase over time.

Obesity

Growing evidence suggests that in addition to systemic inflammation, obesity is also associated with an inflammatory microenvironment in the mammary gland, which has recently been associated with premature involution in murine models… Fundamentally, the altered mammary gland microenvironment that occurs in obesity can lead to failed secretory activation or suboptimal lactation, whereby the mammary gland is incapable of secreting copious milk to nourish the newborn.

Nutrition

In recent years, increasing evidence shows not only that adequate nutrient intake and appropriate nutrient homeostasis are important for maintaining maternal energy balance but that suboptimal nutrition has significant effects on breast physiology and milk production, secretion, and composition. Nutrient deficiencies can result in failed secretory activation from several perspectives, such as inefficient hormone responsiveness, and defects in cellular processes involved in morphogenesis and secretory pathways. Moreover, energy/nutrient imbalance may cause more perverse effects on immune response and increased risk of mastitis…

Environmental factors

Thus far, only a few studies in women have shown an association between toxins like PCBs and dichlorodiphenyl dichloroethene and lactation defects such that exposure to these toxins is associated with shorter breastfeeding duration…

…[N]atural components such as heavy metals exposure can affect the mammary gland during lactation. Some heavy metals (copper, zinc, and manganese) are biologically essential; however, the most pollutant heavy metals are lead, cadmium, and mercury that bioaccumulate following absorption, causing adverse health effects.

The bottom line is that lactation insufficiency is common; it can be caused by non-modifiable factors like structural breast abnormalities, genetics, hormonal imbalances and environmental exposures. No amount of maternal effort and no amount of lactation support has any impact on those factors.

To pretend that breastfeeding is just a matter of will and support is both empirically wrong and gratuitously cruel.

I’m been watching Ken Burn’s monumental documentary on the Vietnam War. It is a deeply sobering experience.

Both those who served in the war and those who protested the war were united in a curious way. Both never considered the possibility that the government would lie to them and both felt profoundly betrayed when they found out that many in the government had been lying all along.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Instead of feeling betrayed by lies, the American public demands them.[/pullquote]

The Vietnam War began a period of profound cynicism toward government, further bolstered by Richard Nixon’s behavior in orchestrating the Watergate break-in and systematically lying about it for years. Even those whose eyes had been opened by government sponsored lying during the war were nonetheless shocked that a president would break the law and attempt to get away with it.

The more things change, the more they stay the same.

Fifty years later, the government it still lying to us, with one important difference. Instead of feeling betrayed by lies, the American public demands lies.

Lie to me, they beg the President and the Republican Party.

Lie to me! Tell us that by demanding equality — which, afterall, merely means being treated equally — black Americans are insisting on special privileges.

Lie to me! Tell us that immigrants, a criticial engine of both innovation and population growth, are stealing our jobs even though they have nothing to do with the decline of manufacturing in the US.

Lie to me! Tell us that rogue nations like North Korea will be intimidated by a flaccid, floundering buffoon of a president who thinks Twitter insults are a form of warfare.

Lie to me! Tell us destroying Obamacare, the best and most inclusive health insurance program that this country has ever known, will not deprive people of health insurance.

No one should think that the American taste for lies is restricted to government. Indeed the desperate desire for lies and the credulousness with which they are greeted was pioneered within the realm of healthcare.

Many people are begging for lies:

Lie to me! Tell us that autism is a government conspiracy, not a genetic defect.

Lie to me! Tell us that vaccines, one of the greatest public health achievements of all time, don’t work and actually cause harm.

Lie to me! Tell us that our foods are riddled with toxins and we can prevent cancer by eating right and wasting money on detoxes and crystals.

Lie to me! Tell us that childbirth is inherently safe and interventions are bad even though childbirth is inherently dangerous and interventions save lives.

Lie to me! Tell us that the secret to mothering resides in breastfeeding and that breasts never fail.

Lie to me! Tell us that disease is caused by improper alignment of the spine, and chiropractors can manipulate us back to health.

Lie to me! Tell us that medicines become more powerful by being diluted and homeopaths perform a valuable service by marketing water to the gullible.

What has happened to us? Why can’t we handle the truth in politics or in health?

Why? Because we are lazy and weak.

We prefer the comforting lie over the painful truth. In politics we prefer to pretend that we are victimized rather than acknowledge that we are more often victimizers. In healthcare, many delight in imagining that they are educated and bold, when the reality is that they are merely ignorant, defiant and very, very afraid.

Nearly 60,000 Americans died in Vietnam because we believed government lies, but in our defense, we didn’t realize that the government was lying. Now we know better, yet now we insist on lies. Many among us are happy to believe government lies and healthcare lies. Tragically, the death toll this time is bound to be much higher.

Yesterday I wrote about the single most important reason for the UK’s massive maternity payouts: the failure to properly investigate bad outcomes and the resulting failure to learn from them. That was the finding of a just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data.

The author of the report proceeded to investigate the poorly investigated claims and found recurring clinical reasons for massive liability payments:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Nearly every error was a failure of omission and all involved failure to inform women of the risks of vaginal birth.[/pullquote]

The 50 claims were clinically varied but by reviewing them all together to get a national picture it was possible to identify common themes:

1) Errors with fetal heart rate monitoring
2) Breech birth
3) Inadequate quality assurances around staff competency and training
4) Patient autonomy and informed decision making

Nearly every error was a failure of omission. Nearly every error was a failure to undertake clinically indicated interventions. It’s not hard to see the impact of the Royal College of Midwives’ Campaign for Normal Birth at work here; in an effort to “achieve” vaginal birth, important warning signs were ignored and babies were grievously harmed as a result. Moreover, mothers were unable to make informed choices because they were not informed of the very real risks of vaginal births.

The most glaring errors occurred with fetal heart rate monitoring including failure to monitor, failure to properly interpret monitoring and failure to act on abnormal results.

Who made the errors?

Twenty four claims involved a midwife but only one involved a consultant.

Why did midwives repeatedly make serious errors? I suspect it is because UK midwives fundamentally misunderstand the value of fetal heart rate monitoring.

The report notes:

The most recent Cochrane review demonstrates that, compared to intermittent auscultation, continuous fetal monitoring using a CTG, is associated with a 50% reduction in neonatal seizures (RR 0.50 95% CI 0.31-0.80). However, it does not reduce the risk of developing CP and is not associated with any other benefits in fetal wellbeing. These finnings were consistent in high and low risk pregnancies and in preterm births …

Many midwives have looked at this data and concluded that fetal monitoring is worthless and therefore should be avoided or ignored. But the scientific evidence doesn’t show that fetal monitoring is worthless; it shows that continuous electronic fetal monitoring is no better than rigorously performed intermittent auscultation. Monitoring itself can provide critical information.

The other caveat about fetal monitoring is that it has a high false positive rate. That means that fetal monitoring may show an abnormal result for a normal baby, but that is not a reason to ignore abnormal results.

To put it in terms that may be easier to understand, finding a breast lump also has a high false positive rate. Most breast lumps are not cancer but that doesn’t mean that doctors should ignore breast lumps because most of them are not cancer. Some of them are cancer and it is only by investigating further and intervening (breast biopsy) that the correct determination can be made. Yes, if we wait long enough, the cancer will eventually progress and become obvious but that’s not an argument for watchful waiting.

Similarly, only some of the abnormal fetal heart rate tracings are due to fetal oxygen deprivation. Yes, if we wait long enough, the lack of oxygen will eventually become obvious by leading to fetal collapse, but that’s not an argument for watchful waiting. It’s an argument for investigating further and intervening (childbirth interventions).

UK midwives are fundamentally wrong about the value of fetal monitoring and that’s part of an even larger error: they’re fundamentally wrong about the value of vaginal birth because they confuse cause and effect.

Sure, scientific evidence shows that those who have easy, uncomplicated vaginal births fare better than those who have complicated C-section births but the C-sections don’t cause the complications; the complications cause the C-sections. Scientific evidence also shows that people who were never admitted to the ICU during their hospitalizations fare better than those admitted to the ICU, but that’s not because the ICU causes complications; it’s because people with complications are admitted to the ICU. Refusing to use childbirth interventions for those who develop complications in pregnancy is like refusing ICU admission to who develop complications during hospitalization. It’s a deadly mistake.

And that mistake is compounded by the most unforgivable clinical error identified by the report, the failure to obtain informed consent.

Evidence of a lack of informed consent was evident throughout the 50 claims reviewed.

That’s pretty damning.

An example was a woman who opted to have a vaginal birth after caesarean section (VBAC) but her initial caesarean was complicated by a difficult delivery that involved making a J-shaped incision on the uterus. This is not an absolute contraindication to VBAC but there is “insufficient evidence to support the safety for VBAC in women with previous T or J incisions” and there should have been a documented discussion by a consultant which made an individualised assessment around the suitability for VBAC and the possible increased risk of uterine rupture. The issue here is not that the woman was offered a VBAC but that she was not adequately given the information on which to make an informed decision.

In other words, the mother was not offered accurate information about the risks of vaginal birth. The same thing happened with breech births, history of shoulder dystocia and twins. There is a word for that type of behavior; the word is “paternalistic.” This paternalism is a direct violation of medical ethics.

… The practice of autonomy and patient consent revolves around the key feature of informed decision making, whereby the healthcare professional and the patient engage in dialogue about treatment options, their benefits, risks, consequences and alternatives… [T]his information must be clear, accurate, balanced without bias, take into consideration the individual patient, the nature of their condition and in a language that they understand.

Promotion of normal birth is bias pure and simple. It isn’t merely unethical; it’s a critical clinical factor behind the soaring UK maternity liability payments.

The promotion of normal birth doesn’t merely hurt babies and families. It is an extroardinarily expensive mistake.

Last month I wrote a series of posts about the decision by the Royal College of Midwives to shutter its Campaign for Normal Birth. Although the RCM leadership denied it, some going so far as to claim dead and injured babies are “fake news,” the campaign was stopped because of skyrocketing rates of maternity liability claims. Indeed nearly £2bn was paid out in compensation in the past year alone.

A just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data, investigates those claims. The report is detailed, comprehensive, and contains multiple valuable recommendations. It also identifies the single most important reason why UK maternity liability claims have been skyrocketing: perinatal deaths and injuries aren’t being properly investigated.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Perinatal deaths and injuries aren’t being properly investigated.[/pullquote]

As the Executive Summary of the report notes:

The quality of root cause analysis was generally poor and focused too heavily on individuals.

Due to the poor report quality, the recommendations were unlikely to reduce the incidence of future harm.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The gold standard for investigating errors is Root Cause Analysis (RCA).

It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

Determine what happened.
Determine why it happened.
Figure out what to do to reduce the likelihood that it will happen again.

Although RCA can provide information and closure for families, it’s primary purpose is to identify modifiable factors that can be improved in order to prevent future bad outcome.

As the NHS Report notes:

A RCA should be logical, fair, open and adopt a just, or fair blame, culture, as it is often a system failure rather than an error by an individual that is at fault. It is therefore vital that a RCA looks at the wider environmental and organisational factors, often referred to as latent conditions, that allowed the error to occur.

In other words, rather than seek to blame individual bad actors, an RCA looks for systemic failures. In contrast, internal investigations of NHS maternal liability claims focused on assigning blame, not the root causes.

Looking at the root causes within the reports, it appeared that the question of why the incident happened, or was allowed to happen, is often missing…

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The root causes identified in the reviewed cases included:

The most common contributing factors were poor individual skill level and failure to communicate with others.

Why was the pathological CTG managed incorrectly? What went wrong with the undiagnosed breech and why did that result in CP? Why was the scan incorrect? Was it inadequate training, a faulty machine, that the operator was distracted? Why did a woman with a concealed abruption have a baby born with CP, remembering that these 50 claims are due to admitted clinical negligence, so what went wrong with her care?

No attempt was made to address these critical questions.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

This is not new information:

The Kirkup report identified significant systematic and organisational failures which the Morecambe Bay hospitals own SI investigations and RCA process missed, as they were “rudimentary, over protective of staff and failed to identify underlying problems…”

The RCOG EBC project identified that 25% of local reviews did not contain sufficient information to allow the care to be classified. Of those reviews that were of sufficient quality, just over 60% of investigations used a RCA methodology, while 21% contained no actions or recommendations and 23% recommended actions focusing solely on individuals.

The CQC report demonstrated a worse picture within acute trusts. Only 8% of reports demonstrated evidence that a clearly structured methodology was used, which would identify the key issues, contributing factors, system issues and causal factors that led to the incident…

As the parent of an injured baby explained:

It feels like the priority of the serious incident process is damage limitation rather than learning from mistakes. What makes this even worse is the lack of learning both by the trust and the wider NHS from what happened. The problem with the quality of the report… is that its purpose was not to blame individuals and was to nd a root cause [but] it stopped at individual mistakes and not once did it ask why people made these mistakes.

“The frustration from our case is that if a proper root cause had been found, such as training not being given or procedures not being known then it would not just stop similar cases to ours but could reduce serious incidents across the trust.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

If there is no serious attempt to identify modifiable systemic failures, the same failures will occur over and over again. And that is precisely what has occurred.

It appears that the individuals involved were expected to follow guidelines that were in place the next time a similar incident occurred, without identifying why they were not followed in this instance. Identifying an issue with the guidelines that could be changed may result in better care for someone else.

This is not new information, either.

The findings of this review are very similar to those identified within the RCOG EBC programme, that only 56% of the investigations they analysed had actions or recommendations that took a systemic approach, 23% focused solely on individuals, often to attend training, and 21% contained no actions or recommendations.

The CQC report on SI investigations also highlighted the same problem. They found that “too many reports concluded that the actions of staff were the key causes of the incident” and many investigations focused their recommendations on staff failing to “follow trust policy and procedures.” Only 35% of investigations had recommendations that could reduce the risk of recurrence and many focused on reminding staff be more vigilant or to follow guidelines.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The Report makes a critical recommendation:

In line with the Kirkup and RCOG Each Baby Counts reports, all cases of potential severe brain injury, intrapartum stillbirth and early neonatal death should be subject to an external or independent peer review.

If those responsible for understanding why deadly errors occur either can’t or won’t identify systemic causes, review should be undertaken by external, independent panels.

Unless and until that happens, babies will continue to be injured and will die and the NHS will continue to bleed money on liability claims for preventable errors.

You have to give Drs. Melissa Bartick and Alison Stuebe credit for brazenness. Not only do they still insist that increasing breastfeeding rates saves money, despite a complete lack of evidence, they have created a “calculator” to estimate the fallacious savings.

Using current literature on the associations between breastfeeding and maternal and pediatric health, we modeled the costs of health outcomes for a US cohort of mothers and their infants born in 2002 and followed to age 70 years… The 9 pediatric conditions considered in this model were: acute lymphoblastic leukemia (ALL), acute otitis media (AOM), Crohn’s disease, ulcerative colitis, gastrointestinal infection (GII), hospitalization for lower respiratory tract infection (LRTI), obesity in non-Hispanic whites to age 4, necrotizing enterocolitis (NEC), and Sudden Infant Death Syndrome (SIDS). The 5 maternal conditions modeled were breast cancer, pre-menopausal ovarian cancer, type 2 diabetes mellitus, hypertension, and myocardial infarction…

Only lactivists would dare to “calculate” future savings from increasing the breastfeeding rate when they can’t manage to demonstrate past savings although the breastfeeding rate has tripled in the last 40 years. Barticle and Stuebe did not use “current literature,” they used only papers published by themselves. Moreover, they neglected to include the costs of breastfeeding such as hospitalizations for dehydration, jaundice, long term therapy for brain injury and deaths as a result of insufficient breast milk.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Rates of lymphoma, inflammatory bowel disease and breast cancer have been rising NOT falling as breastfeeding rates have climbed.[/pullquote]

To put the problem in context, we know that vaccines save money because we have seen dramatic decreases in the rate of vaccine preventable diseases and their associated costs. We know that ending cigarette smoking saves money because we have seen dramatic decreases in lung cancer rates and their associated costs. In contrast, we have seen almost NO decreases in the rates of diseases supposedly prevented by breastfeeding despite the fact that breastfeeding rates have increased from 24% in the early 1970’s to over 76% in the past few years.

What has happened to the rate of diseases supposedly prevented by breastfeeding?

Pediatric acute lymphoblastic leukemia

According to the National Cancer Insitute: “Cancer in children and adolescents is rare, although the overall incidence of childhood cancer, including ALL, has been slowly increasing since 1975. (my emphasis).

Crohn’s disease and ulcerative colitis

According to the paper Epidemiology of Pediatric Inflammatory Bowel Disease: A Systematic Review of International Trends:

Globally rising rates of pediatric IBD (due primarily to the rising incidence of CD) was demonstrated in both developed and developing nations … (my emphasis)

Breast cancer

This graph comes from the United States Preventive Services Task Force:

New cases of both invasive and non-invasive breast cancer have risen since 1975.

I have confronted Dr. Bartick in print about the fact that she is unable to demonstrate past savings from rising breastfeeding rates; and she couldn’t rebut it. Over 2 years ago I wrote this comment on an Academy of Breastfeeding Medicine post:

Breastfeeding rates have tripled in the past 50 years. Where is the evidence that term babies lives has been saved? Where is the evidence that the diseases you insist are decreased by breastfeeding are actually decreasing as a result of breastfeeding? Where are the billions of healthcare dollars you claimed would be saved as the breastfeeding rates rose? Where is the return on investment of the millions of dollars spent to promote breastfeeding?

Here’s how Dr. Bartick responded:

I have given you the evidence on NEC and SIDS. You can dig up the evidence on the other diseases. To my knowledge, no one has actually dug it up yet. It’s not fair to say “it doesn’t exist.” It would be wonderful if you gather your team of statisticians and experts, and did the research yourself and published your own paper on it, Dr. Tuteur, instead of saying the evidence doesn’t exist…

My reply:

Sorry, Dr. Bartick, that’s a cop out. You’ve given no evidence that the decreases in SIDS and NEC are caused by breastfeeding. You’ve given no population evidence of any kind for any of your other contentions.

Don’t tell me that I can dig it up on my own. If it were available, you would have already posted it…

So Drs. Bartick and Stuebe have created a fanciful calculator that “models” future savings from increasing breastfeeding rates despite the fact that they are utterly unable to demonstrate the central assumptions of their model. They insist that breastfeeding saves lives in theory even though there is no evidence that it saves lives of term babies or mothers in practice.

I don’t doubt that Drs. Bartick and Stuebe believe deeply that breastfeeding saves money, but wishing doesn’t make it so. The existing population data shows that increasing breastfeeding rates does not save money or lives of term babies or mothers. That’s not surprising since breastmilk is just one of two excellent ways to nourish a baby. In first world countries, it’s benefits are trivial.

Dr. Bartick and Stuebe ought to immediately withdraw their fallacious breastfeeding “calculator.” It is based on easily disproven assumptions, provides erroneous data, and reflects ideology instead of science.