There is a growing body of evidence that childbirth and breastfeeding professionals, ostensibly dedicated to helping women and babies, are harming them instead.

Over the years I’ve explored a variety of reasons for this — unthinking, ahistorical veneration for “nature”; desperation for professional autonomy; desire for profit — but there’s one that might be more important than all of the others. Childbirth and breastfeeding professionals are smug.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Smug is the moral equivalent of the Dunning Kruger effect.[/pullquote]

According to Dictionary.com, smug means:

contentedly confident of one’s ability, superiority, or correctness

If there’s one thing that unites childbirth and breastfeeding professionals, from UK midwives to homebirth midwives, from doulas to lactation consultants, from Lamaze International to the Baby Friendly Hospital Initiative, it’s the fact that they are contentedly confident of their ability, superiority and correctness compared to other health professionals and compared to women themselves.

The thesaurus is rich with synonyms: complacent, egotistical, pompous, self-righteous, self-satisfied, conceited, holier than thou.

All can be applied to many childbirth and breastfeeding professionals, rendering them impervious not merely to criticism, but to reality.

Babies dying at the hands of homebirth midwives who are more concerned with promoting “normal birth” than live babies?

No problem. From Ina May Gaskin to Henci Goer to Melissa Cheyney, they are smug:complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

Women traumatized by UK midwives who are more concerned with promoting “normal birth” than promoting women’s autonomy, being denied epidurals, needed C-sections, and compassionate care?

No problem. From Soo Downe to Sheena Byrom to Cathy Warwick, they are smug: complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

Babies sustaining brain injuries and even dying because lactation professionals are more concerned with promoting breastfeeding that healthy babies?

No problem. From the Baby Friendly Hospital Inititative, to lactation consultants, to researchers who produce endless numbers of crappy papers hailing the “benefits” of breastfeeding, they are smug: complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

Smug is the moral equivalent of the Dunning Kruger effect.

According to Dr. Dunning:

What’s curious is that, in many cases, incompetence does not leave people disoriented, perplexed, or cautious. Instead, the incompetent are often blessed with an inappropriate confidence, buoyed by something that feels to them like knowledge.

What’s equally curious is that, in many cases, injured and dead babies do not leave childbirth and breastfeeding professionals disoriented, perplexed or cautious. Instead, impervious to the harm they cause, the smug are — say it with me now — complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

They “know” unmedicated, vaginal birth is best for every woman; they “know” that breastfeeding is best for every baby. The injured, traumatized and dead do not dent their overweening self regard and unwavering certainty that they are correct.

Those in the grip of the Dunning Kruger effect lack knowledge; they literally don’t know what they don’t know. Those in the grip of “smug” lack humility; they literally cannot imagine being wrong despite the injured, dead and traumatized who are screaming into their faces that they are hurting, not helping.

Doctors aren’t immune to smug. Indeed the history of medicine is a history of doctors feeling smug while injuring and killing patients by bleeding them, balancing their “humors” or feeding them arsenic and mercury to “cure” them. Those doctors “knew” the process was correct even though the outcome was dreadful. The operation was a success but the patient died; it must have been the patient’s fault because smug doctors would not admit it could be their fault.

Childbirth and breastfeeding professionals should learn from that embarrassing history. The birth can NEVER be a success if baby or mother are injured or die. Breastfeeding can NEVER be a success if a baby is brain injured or dies or if a mother suffers depression and guilt. Childbirth and breastfeeding professionals need to stop smugly asserting that it must be the patient’s fault — she was lazy, weak, didn’t trust birth and breastfeeding enough — because they cannot admit it is their fault.

When babies and mothers die in the pursuit of normal birth, midwives need to own it, investigate it and change their practices. When babies and mothers are harmed in the pursuit of exclusive breastfeeding, lactation professionals need to own it, investigate it and change their practices.

The last thing they should be doing is being complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

They shouldn’t be smug; they should be horrified.

Another day, another poorly done study that claims to show that C-sections are harmful.

According to The Sydney Morning Herald, Caesareans linked to slower start at school: research.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The authors fail to control for the most important confounding variable, the risk that the infant sustained brain damage before birth.[/pullquote]

Children born via caesarean appear to lag behind their peers – who were delivered naturally – in school tests, new research has found.

While the gap in test scores is small, University of Melbourne researchers say it’s equivalent to a grade 3 student missing up to 35 days of school.

And they suspect different bacteria in the guts of babies delivered by caesarean could be behind the delay.

In fact, the study showed nothing of the kind. Indeed, it showed nothing at all for three important reasons:

• The authors didn’t correct for the single most critical confounding variable, oxygen deprivation.
• The effect size was tiny.
• The claim that the microbiome of C-section babies differs from that of vaginally born babies has been debunked.

As a result, the paper does not support the claims that the authors made.

The paper is The relation between cesarean birth and child cognitive development published in the journal Scientific Reports. It was written by two economists and a basic scientist who investigates neurophysiology.

Across several measures, we find that cesarean-born children perform significantly below vaginally-born children, by up to a tenth of a standard deviation in national numeracy test scores at age 8–9. Estimates from a low-risk sub-sample and lower-bound analysis suggest that the relation is not spuriously related to unobserved confounding. Lower rates of breastfeeding and adverse child and maternal health outcomes that are associated with cesarean birth are found to explain less than a third of the cognitive gap, which points to the importance of other mechanisms such as disturbed gut microbiota. The findings underline the need for a precautionary approach in responding to requests for a planned cesarean when there are no apparent elevated risks from vaginal birth.

Where did the authors go wrong?

In any study, it is critically important to ensure that the two groups under study do not differ in any meaningful way from each other. For example, many breastfeeding studies produce spurious results because children who are breastfed differ economically from those who are not. The purported health benefits of breastfeeding are therefore likely to be benefits of being wealthy (which we know has a significant impact on health), not of being breastfed.

In this study, the single most important confounding factor that must be taken into account is brain health at birth. That’s why most studies that compare C-section babies to those born vaginally take care to limit the C-section group to non-emergencies. Emergency C-sections are typically performed for fetal distress presumed to be caused by oxygen deprivation. Therefore, the C-section group is almost guaranteed to contain some babies who have been harmed by lack of oxygen. Restricting the C-section group to elective surgeries limits that possibility.

The authors in this study corrected for nearly two dozen variables:

The analysis includes over 20 confounders grouped into two main categories (Table 1): those related to perinatal risk factors and those related to the socio-economic advantage associated with cesarean-born children in Australia. Perinatal risk factors include the taking of medication during pregnancy for blood pressure or diabetes (proxies for pre-eclampsia and gestational diabetes respectively), the taking of antibiotic medication (a proxy for bacterial infection, which may also affect the development of the infant’s gut microbiome); a dummy variable for low birth weight (coded 1 if less than 2.5 kg; 0 otherwise); weeks of gestation; maternal age at birth; dummy variable for multiple infant pregnancy; length and head circumference of baby (z-scores); dummy variable for whether the baby was conceived using IVF treatment and a gender dummy. We include taking antibiotic medication as a control because it has been associated with changes to the infant’s gut microbiome and possibly the risk of cesarean birth, which means failure to control for it will lead to bias due to unobserved confounding.

Yet they fail to control for the most important confounding variable of all, the risk that the infant sustained brain damage before birth. Since the authors can’t be sure that the babies in each group were cognitively equivalent at the outset, they can’t conclude that observed cognitive differences were due to C-sections.

A second factor undermining the authors’ claims is that the difference in cognitive ability was extremely small. The effect size was less than 0.1 standard deviation.

What is effect size?

The article It’s the Effect Size, Stupid; What effect size is and why it is important explains the difference between statistical significance and effect size:

‘Effect size’ is simply a way of quantifying the size of the difference between two groups. It is easy to calculate, readily understood and can be applied to any measured outcome in Education or Social Science. It is particularly valuable for quantifying the effectiveness of a particular intervention, relative to some comparison. It allows us to move beyond the simplistic, ‘Does it work or not?’ to the far more sophisticated, ‘How well does it work in a range of contexts?’ Moreover, by placing the emphasis on the most important aspect of an intervention – the size of the effect – rather than its statistical significance (which conflates effect size and sample size), it promotes a more scientific approach to the accumulation of knowledge. For these reasons, effect size is an important tool in reporting and interpreting effectiveness.

In this study, the effect size was less than 0.1. How do we interpret that?

Another way to interpret effect sizes is to compare them to the effect sizes of differences that are familiar. For example, describes an effect size of 0.2 as ‘small’ and gives to illustrate it the example that the difference between the heights of 15 year old and 16 year old girls in the US corresponds to an effect of this size. An effect size of 0.5 is described as ‘medium’ and is ‘large enough to be visible to the naked eye’. A 0.5 effect size corresponds to the difference between the heights of 14 year old and 18 year old girls. Cohen describes an effect size of 0.8 as ‘grossly perceptible and therefore large’ and equates it to the difference between the heights of 13 year old and 18 year old girls. As a further example he states that the difference in IQ between holders of the Ph.D. degree and ‘typical college freshmen’ is comparable to an effect size of 0.8.

So an effect size of less than 0.1 is tiny and therefore, not particularly meaningful.

Finally, the authors offer an explanation for the purported difference between C-section babies and vaginally born babies that has already been debunked.

According to the authors:

The direct association may occur through alterations to the infant’s gut microbiota. Unlike vaginally-born children whose gut is seeded by passing through the birth canal, the gut of cesarean-born children is seeded through contact with the mother’s skin and hospital surfaces. The result is long-term compositional differences in gut microbiota by mode of birth with differences observed up until age seven…

There is absolutely nothing in this study that gives credence to this explanation, and the authors acknowledge that this theory has yet to be proven in any context:

Although causal impacts on child development are yet to be proven, altered signaling from disturbed gut microbiota is thought to be a possible driver of higher rates of cognitive disorders, especially autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), among cesarean-born children …

In addition, a larger, more recent study has debunked the theory that the infant microbiome differs appreciably between C-section and vaginally born babies. The newer study concluded:

[T]here was no discernable effect of the cesarean mode of delivery on the early microbiota beyond the immediate neonatal period (and never inclusive of that in the meconium or stool) …

The bottom line then is that there is NO EVIDENCE that C-sections lead to cognitive delays.

Any study that claims to show that C-section babies have cognitive delays must correct for hypoxic birth injuries, have a moderate to large effect size and be based on a plausible biological mechanism.

This study strikes out on all three counts.

This is the 2302nd post that I’ve written on this blog and if there’s been one consistent theme over the past years it has been this: Mothers Matter!

I’ve written about baby-friendly this and baby-centered that, but I’ve rarely come across anything that is explicitly mother-friendly or mother-centered. That’s not an accident. In the 30 plus years I’ve been a parent, mothering has changed from caring for children to curating them.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mothers aren’t incubators or milk dispensers; they’re people who matter.[/pullquote]

Children are viewed as objects to be acted upon, shaped and molded. The actual child takes second place to the future adult that is purportedly being created, an adult with specific middle to upper middle classes achievements: smart, talented, and ready to enter the economic competition of adulthood at a high level.

The conceit motivating this type of mothering is that women can only be successful mothers if they lose themselves. Their pain doesn’t count; their suffering doesn’t count; their time doesn’t count. Mothers and children have been suffering as a result.

But mothers DO matter.

That’s why I’ve created a new Facebook group, Mothers Matter, as a place for women to support other women in navigating mothering the way that works best for them. I hope it will provide an opportunity to share their hopes, fears, tips and experiences. I hope it will be a place of support, not judgment. What worked for you and what didn’t? Who helped you and who didn’t? How did you cope with childbirth, breastfeeding and parenting or how didn’t you cope? What kind of support do you need and how can we provide it?

Mothers aren’t merely incubators requiring strict supervision of every habit and every bite they eat; they are grown women capable of making health decisions for themselves and entitled to accurate information with which to do so.

How did you navigate pregnancy? How did you handle the judgment and the nosiness?

Mothers aren’t merely packaging to be torn apart in order to get to the child inside. How women give birth matters. Their pain matters and it should be abolished if they wish. Their sexual function and continence matter. They should not be subjected to traumatic forceps deliveries in order to reach some arbitrary C-section rate target. Their safety is paramount and they should not be pressured to risk their lives attempting vaginal birth after C-section or homebirth in order to avoid spurious risks to their babies’ microbiome and enact a romantic (and ahistoric) ideal of birth.

What did you expect from birth and what did you get? What do you wish you had known beforehand?

Mothers aren’t milk dispensers. The benefits of breastfeeding in industrialized countries are trivial and it is up to women to weigh them against the right to control their own bodies, not up to activists intent on creating the breastfeeding version of the Handmaiden’s Tale.

Do you breastfeed or bottlefeed? Are you happy with your choice? How did you handle the pressure that you felt?

Mothers aren’t blankies or binkies or lovies to be glued to a child’s body 24/7/365. They are separate people with independent lives and while they sacrifice much for their children, exactly what they sacrifice and how they do it is up to them, not parenting “experts.”

Do you sleep in a family bed or only with a partner? Do you “wear” your baby or is that something that doesn’t work for either of you? Did you return to work or decide to stay home? Are you happy with your decision?

The group will be open to the public, but only those who join will be able to post their stories. Anyone will be able to comment to offer support or suggestions.

Mothers matter. It’s time to put the mother back in mothering. Please join us!

It’s often easy to tell the difference between an expert and a quack.

• An expert has formal education in the topic at hand, while a quack has none.
• An expert understands both science and basic statistics and can reach an independent conclusion about the existing scientific evidence. A quack has to take the word of someone else.
• An expert recommends what’s good for YOU. A quack recommends what’s good for HER.
• Experts change their recommendations based on new scientific evidence. Quacks never change recommendations regardless of what the scientific evidence shows.
• Experts take responsibility for their recommendations. Quacks wash their hands of you, or even blame YOU when THEIR recommendations cause more harm than good.

It’s much harder to tell the difference between an expert and a quaxpert.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Quaxperts have professional qualifications and use them to peddle pseudoscience.[/pullquote]

What’s a quaxpert?

It’s a person who has professional qualifications in the relevant discipline, but nonetheless peddles pseudoscience. Since both experts and quaxperts have professional educations, degrees, titles and even scientific papers, how can the average person tell the difference?

Here’s are some handy tips to help you tell experts and quaxperts apart.

1. Quaxperts have “secret” knowledge: Beware when someone implies they are sharing secret medical knowledge with you. There is no such thing as secret medical knowledge. In an age where there are literally thousands of competing medical journals, tremendous pressure on researchers to publish papers, and instantaneous dissemination of results on the Internet, nothing about medicine could possibly be secret.

2. Quaxperts claim giant conspiracies: In the entire history of modern medicine, there has NEVER been a conspiracy to hide lifesaving information among professionals. Sure, an individual company may hide information in order to get a jump on competitors, or to deny harmful effects of their products, but there can never be a large conspiracy because every aspect of the healthcare industry is filled with competitors. Vast conspiracies, encompassing doctors, scientists and public health officials exist only in the minds of quaxperts.

3. Quaxperts often employ flattery: They try to flatter potential customers (quaxperts are always selling something, be it books, supplements or courses) by implying that those customers are uncommonly smart, insightful and wary. They portray non-believers as “sheeple” who are content to accept authority figures rather than think for themselves. A real medical professional does not need to flatter you. He or she knows what is true and what isn’t and shares that information whether it makes you happy or is the last thing you want to hear.

4. Quaxperts invoke toxins: I’ve written before that toxins are the new evil humors. Toxins serve the same explanatory purpose as evil humours did in the Middle Ages. They are invisible, but all around us. They constantly threaten people, often people who unaware of their very existence. They are no longer viewed as evil in themselves, but it is axiomatic that they have been released into our environment by “evil” corporations. There’s just one problem. “Toxins” are a figment of the imagination, in the exact same way that evil humours and miasmas were figments of the imagination.

5. Quaxperts often claim to be “brilliant heretics,” comparing themselves to Galileo or Darwin: They argue that science is transformed by brilliant heretics whose fabulous theories are initially rejected, but ultimately accepted as the new orthodoxy. The conceit rests on the notion that revolutionary scientific ideas are dreamed up by mavericks, but nothing could be further from the truth. Revolutionary scientific ideas are not dreamed up; they are the inevitable result of massive data collection. Galileo did not dream up the idea of a sun-centered solar system. He collected data with his new telescope, data never before available, and the sun-centered solar system was the only theory consistent with the data he had collected. Darwin also collected new data, which formed the basis of his theories about evolution.

6. Quaxperts love to baffle followers with scientific sounding bullshit: Quantum mechanics and chaos theory are two incredibly abstruse scientific disciplines, heavy on advanced math. If you don’t have a degree in either one, you aren’t qualified to pontificate on them. The same thing applies to new, imperfectly understood areas of science like epigenetics or the microbiome. Both are genuine scientific concepts, but we are in the earliest stages of elucidating them. Quaxperts like to invoke abstruse or poorly understood areas of science to justify quack theories.

There is a saying in science that “extraordinary claims require extraordinary evidence.” Quaxpert claims are typically extraordinary, but quaxperts don’t offer evidence, they offer “secret” knowledge, conspiracy theories, flattery and pseudoscientific nonsense. It’s designed to trick you into buying what they are selling, and quaxperts are invariably selling something. When you see one of these techniques, you can be virtually certain that you are in the presence of a quaxpert not an expert.

Run in the opposite direction.

Pediatrician Daniel Flanders doesn’t like the phenomenally successful Fed Is Best campaign. He made his feelings clear in a series of tweets.

After declaring:

#Fedisbest is an entirely unhelpful statement of the obvious. Beating heart is best. Functional brain is best. Breathing is best.”

He went on to claim:

it has evolved in a less helpful and more divisive direction. Lots of anti- breastfeeding rhetoric, “us vs. them” narratives, fear mongering.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When you’re accustomed to privilege, leveling the playing field feels “divisive.”[/pullquote]

At first I didn’t understand what he meant but then I realized what he was getting at. Fed Is Best is divisive in the exact same way that feminism is divisive. When you’re accustomed to privilege, leveling the playing field feels “divisive.”

For example, members of the misogynistic men’s rights movement are constantly whining that feminism discriminates against them.

Men’s rights activists have rejected feminist principles and focused on areas in which they believe men are disadvantaged, oppressed, or discriminated against. In the 1980s and 90s, men’s rights activists opposed societal changes sought by feminists and defended the traditional gender order in the family, schools and the workplace. Some men’s rights activists see men as an oppressed group.

I have no doubt that MRAs really believe that they are victims but that doesn’t make it so. Their self pity doesn’t erase eons of brutal discrimination against women and it doesn’t change the fact that women are still disadvantaged in most parts of the developing world and even in some spheres in the industrialized world. Pretending you are being discrimated against may be a satisfying rhetorical tactic, but it is has nothing to do with reality.

Similarly, lactivists like Dr. Flanders are now whining that Fed Is Best is “divisive” and — irony of ironies — is responsible for an “us vs. them” outlook and fear mongering about breastfeeding. Never mind that a central, deliberate tactic of lactivism has been to promote guilt and shame by claiming ever more fanciful “benefits” of breastfeeding and dividing women into “good” mothers who breastfeed and “bad” mothers who don’t

No doubt Dr. Flanders, like many other professional lactivists, is sincere. When you have been given free rein to bully new mothers into breastfeeding, being forced to stop feels divisive, but, as in the case of the MRAs, the claims are a way to mask anger over loss of privilege not a reflection of the facts.

Indeed, when I asked Dr. Flanders to explain how and to whom is Fed Is Best unhelpful, he responded with his Donald Trump impersonation:

tooooooter!!! Are you looking for more blog fodder” you don’t need me to push your agenda. Go on without me.

How articulate — NOT!

I guess he was hoping a childish insult would hide the fact that he couldn’t answer the question; it doesn’t.

Fed Is Best has been a game changer because it is both empirically true — fully fed with formula is undoubtedly better than underfed with breastmilk — and because it addresses the oppressive lactivist tactics that have been deployed over the past two decades. In an effort to bully women into breastfeeding, lactivists have grossly exaggerated its benefits, ignored its life threatening risks, taken agency over their own bodies away from women by banning formula supplementation and pacifiers in hospitals and closing well baby nurseries.

There could not possibly be anything more divisive than breast is best rhetoric, yet lactivists, rather than acknowledging their mistakes, and apologizing for their tactics insist that forcing them to stop practicing divisiveness is somehow divisive.

Lactivists have behaved badly; women and babies suffered as a result. It’s not divisive to point that out; it’s simply a matter of compassion and common sense.

I’ve been writing for years that anti-vaccine advocacy has nothing to do with vaccines or even children. At its heart, anti-vax is a form of social identity; it’s all about parents and how they wish to view themselves.

Now comes a scientific paper, Parenting as politics: social identity theory and vaccine hesitant communities, by Attwell and Smith, that expresses a very similar view.

This paper argues that the decision to vaccinate or not is an inherently social one, not a matter of pure individual rationality. This is a novel approach to engaging with what is often characterised and studied as an individual decision.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s ironic that while anti-vaxxers like to preen about their independence from authority, they are desperately dependent on in-group validation.[/pullquote]

In other words, vaccine refusal has nothing to do with understanding of science (although anti-vaxxers do have a deficient understanding of science) and is therefore not amenable to change by improving knowledge about vaccines. It’s about group-think, belonging and a sense of empowerment derived from opposing the majority. It’s ironic that while anti-vaxxers like to preen about their independence from authority, they are desperately dependent on in-group validation.

…[V]accine hesitant people are often found in tight-knit geographical communities, they take comfort and inspiration from people who share similar beliefs all around the world, connected via the internet, with whom they feel a sense of kinship as an enlightened but besieged minority… [T]he social context of vaccination puts choices beyond the realm of pure individual rationality. The decision to vaccinate or not is tied to how individuals view society and their place in it, the social groups they value, and the shared worldviews of social groups they belong to.

But don’t anti-vaxxers come from widely different economic, social and religious backgrounds? They do, but the authors argue that these are simply tribes within the larger group.

There are various worldviews among these tribes, some of which are affluent and some of which reject materialism; some of which follow traditional religion and some of which favour non-traditional forms of spirituality. However, we suggest that all are formed in opposition to what they perceive as the damaging practices of modern mass society.

The commonality between the distinctive tribes is a “natural” approach to parenting and lifestyle.

People who adhere to this worldview value their own expertise and that of alternative health practitioners over mainstream medical and scientific expertise. They distrust what they see as unthinking deference to industrialised, commodified and financially co-opted medicine, and do not believe that the vaccinating mainstream has any valid claim on them or their children… [They] appear to hold specific beliefs around the damage of mass society as it pertains to the realm of health, and the health of their children in particular. When it comes to this, they seemingly do not aspire to acceptance from mainstream society; rather, they define themselves in opposition to it.

The authors use the insights of social identity theory (SIT):

SIT posits that individuals see the social world in terms of in-groups and out-groups, develop favourable biases towards members of their own in-groups, and make judgments about others based on this in-group bias.

That’s a remarkably apt description of anti-vax groups.

Ultimately, it’s about parental self-esteem, not vaccines and not children:

The individual drive for self-esteem is central to SIT. Individuals enhance their own self-esteem by their association with highly valued groups. They are therefore motivated to regard their own in-group highly, and to favour other members of that group. Degradation of out-group members may be a further means of enhancing in-group, and thus individual, self-esteem.

How are these groups created?

While historically this has relied upon physical proximity or tangible relationships, the internet and social media have opened up avenues for geographically disaggregated individuals to connect around ideas and practices.

The groups cohere around a particular cultural “style.”

[W]e posit that there is a recognisable identity to a central VHR tribe, referencing wellness and the pre-eminence of nature… [We] explore how this identity is reliant on particular resources. These resources enable an emphasis on individualism, which can be recognised as further attributes of this identity.

This style is closely tied to belief in “alternative” health, natural childbirth, breastfeeding, the centrality of nutrition.

Reich explicitly teased out how her mostly white, educated subjects in California saw feeding as “key to both their mothering and health promotion practice”, breastmilk was seen as conferring immunity, and on this basis mothers quasi-rationalised refusing vaccines, even while implicitly recognising that vaccination might be appropriate for other children. “[E]fforts to manage nutrition generally” were seen as “protective of […] children’s health”, whether because the mother took supplements during pregnancy or fed her child organic food.

Anti-vaxxers reject the notion that they have any responsibility to others:

To “live naturally”, one needs the resources of money or time, as we noted above; only then can one act and reason individually. This “me-first” perspective provides a salient rationale for dismissing the impact on others, as highlighting the special and unique properties of one’s own child makes it hard to justify population-level interventions…

In summary:

Vaccine hesitancy and refusal is also about one’s own self-image in relation to groups to which one perceives oneself as either belonging or proudly oppositional. Vaccine refusers possess the social or economic capital to define themselves against the mainstream, and seek to act according to their own beliefs and desires. Whether following a natural lifestyle and questioning big pharma, or using wealth to insulate one’s family from child care, bad food and “the riff raff”, VHR parents are able to separate themselves conceptually and physically from the rest of us.

Anti-vaxxers cling so desperately to their failed ideology, not out of concern for children’s health, but as a critical source of personal validation.

During my internship, I cared for Mr. R who developed leukemia as a result of successful treatment for lymphoma. His values and his experience of previous cancer treatment led him to insist that if the odds of cure were low, he wanted to return to his native island to die on the beach surrounded by his family.

He never got the chance.

His oncologist’s values and experience led him to believe that every chance of cure, no matter how remote, should be pursued aggressively. Therefore, he deliberately told Mr. R that he had a high chance of cure though he knew the chance was low. Mr. R consented to the treatment.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]UNshared decision making has become the standard of care in midwifery and breastfeeding support.[/pullquote]

Mr. R spent the remainder of his life vomiting, shaking with chills, and writhing in pain. Because of his damaged immune system, he was unable to fight a serious infection and it spread further even though we were treating it as aggressively as we possibly could. Three weeks after he was admitted, Mr. R died without ever leaving the hospital and without ever saying goodbye to his family.

The oncologist had engaged in UNshared decision making. Believing that he knew what was good for Mr. R, he tricked and pressured him into a treatment course that he did not want.

I suspect that we could all agree that UNshared decision making is unethical. So it’s rather surprising then that UNshared decision making has become the standard of care in midwifery and breastfeeding support. UK midwives enshrined UNshared decision making in the Campaign for Normal Birth and breastfeeding professionals have enshrined UNshared decision making in the Baby Friendly Hospital Initiative. Both represent violations of fundamental ethical principles.

Shared decision making is considered the pinnacle of ethical patient centered care.

As Michael J. Barry, M.D., and Susan Edgman-Levitan, P.A. explained in The New England Journal of Medicine in 2012:

The process by which the optimal decision may be reached for a patient at a fateful health crossroads is called shared decision making and involves, at minimum, a clinician and the patient, although other members of the health care team or friends and family members may be invited to participate. In shared decision making, both parties share information: the clinician offers options and describes their risks and benefits, and the patient expresses his or her preferences and values…

Critically, the patient is free to make a decision that is different than the one the provider might have made for her. Yes, it is true that the provider knows more about the medical implications of certain decisions, but only the patient herself knows her preferences and values and respecting those preferences and values are integral to providing ethical medical care.

They summarize shared decision making with a quote from a patient:

Nothing about me without me.

The Campaign for Normal Birth was until recently promoted by the Royal College of Midwives. Although the name has been changed to Better Births Initiative, the RCM has not changed its focus. Indeed, the primary goal featured on its website is:

Facilitating normal births for the majority and normality for all women.

In other words, the primary goal of the Better Births Initiative like the Campaign for Normal Birth before it is UNSHARED decision making. Like Mr. R’s oncologist, UK midwives have decided what is “best” for women without consulting women themselves. They insist that “science” shows that unmedicated vaginal birth is safest and therefore, they are justified in forcing it on every woman regardless of her experiences and values, and regardless of whether it is a realistic goal.

As Natasha Pearlman explained in Nightmare on the Maternity Ward a brilliant piece in the Times of London:

…[L]ooking back I would have expected to have been talked through some options: to be given a room, offered an induction, even just some simple advice on how to turn the baby.

The midwives did nothing. It seemed as if they had made the decision, without consulting me, to push me to the absolute limit to deliver the baby naturally. There was no option for me to change my mind. I was in a system out of my control…

Similarly, the Baby Friendly Hospital Initiative is based on UNshared decision making. 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 realistic goal.

Included among the Ten Steps of the BFHI are these:

Inform all pregnant women about the benefits and management of breastfeeding…

Give infants no food or drink other than breast-milk, unless medically indicated…

Give no pacifiers or artificial nipples to breastfeeding infants…

But shared decision making involves presenting the risks of breastfeeding — insufficient breastmilk, dehydration, failure to thrive — as well as the benefits. Shared decision making means that it is up to MOTHERS to determine whether to offer supplemental formula or pacifiers, NOT up to the provider.

Whether it is cancer treatment, childbirth care or breastfeeding support, decisions should be, as far as possible, based on SHARED decision making. The provider offers his or her assessment on options and outcomes and the patient chooses based on his or her values and experiences. By design, the patient should always be free to make a decision that is different from the one the provider recommended.

The Campaign for Normal Birth and the BFHI violate the imperative, “Nothing about me without me.” Both are deliberately based on UNshared decision making and that is wrong.

It was unethical when Mr. R’s oncologist deprived him of the opportunity to make a treatment decision based on his values and experiences. There is no possible justification for the suffering that Mr. R experienced as a result.

It is unethical when midwives and lactation professionals deprive women of the opportunity to make childbirth and infant feeding decisions based on their values and experiences. There is no possible justification for the suffering that mothers and babies experience as a result.

Pardon my language, but what the fuck is wrong with these people?

Millions in Texas have lost everything; they are crammed into shelters, wet, dirty, hungry. They are desperately trying to comfort and care for small children ripped from their routine with no idea when anyone can go back to their homes or if there is anything to go back to. Lactivists, observing this tragedy, have decided that this is the perfect time to … GLOAT.

Consider this abomination from La Leche League International:

Flooding? Power Outage?

Breastfeeding is perfect for all kinds of weather and can save you from having to go to the store during a flood or dangerous wind conditions. When power and water supplies are impacted in an emergency, breastfeeding can be a lifesaver.

Or how about this lie packed gem from a Facebook page set up specifically to “protect” breastfeeding during Harvey?

Actually stress CAN cause milk supply to drop precipitously. So can limited access to food and water.

Moreover, women running for their lives don’t have time to breastfeed continuously and may — shocking I know — have other children as well as disabled or elderly relatives they need to provide for as well.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]In the midst of tragedy, lactivists have decided that this is the perfect time to gloat.[/pullquote]

The motto of the Facebook page is S.A.F.E.: Support, Assess, Feed, Empower.

Pardon my language again, but have they lost their fucking minds? In the midst of a natural disaster, the priorities should be Rescue, Feed, Shelter. It doesn’t matter how babies are fed in a natural disaster, only that they ARE fed.

What are lactivists trying to accomplish?

It isn’t feeding babies. Babies that are aren’t being breastfed and currently starving for lack of formula can’t get breastmilk since breastfeeding isn’t a faucet you can turn on and off at will. It isn’t protecting breastfed babies whose mothers have experienced a decrease in supply because of the extraordinary stress of life threatening events since they don’t have access to anything that could help them increase their supply. And it isn’t protecting breastfed babies who are doing well with exclusive breastfeeding since they don’t need any help.

The folks at LLL and Safely Fed USA are gloating, imagining that their babies would be protected from hunger during a natural disaster. It’s the equivalent — in heartlessness and self-absorption — of boat manufacturers chiding those who are drowning for lack of a boat: Boats are perfect for hurricanes and can save you from having to be rescued by others. In the midst of this hurricane don’t you wish you had a boat?

And pardon my language one more time, but what the fuck is wrong with the folks at the American Academy of Pediatrics?

They’ve given us this piece of garbage.

Pro tip: The middle of a natural disaster is not the time to wax poetic about the virtues of breastfeeding. Pediatricians should not be supporting breastfeeding; they should be supporting babies.

Advocate for optimal feeding options for orphaned infants, including HIV- donor milk.

Have the folks at AAP lost their collective minds? When people are drowning in the streets, there is no way they can access donor milk. It’s the equivalent of insisting that starving older children an adults should restrict themselves to organic food or not eat all while homeless.

… Powered formula is a last resort.

Bullshit! Powdered formula prepared with clean water is equally effective as breastmilk in keeping babies in disaster areas alive.

Lactivists, LLL and the AAP should be ashamed of themselves!

Here’s a thought: if lactivists are so concerned about babies being deprived of breastmilk during Harvey, why don’t they head down to Houston area shelters and breastfeed as many babies as you can.

Male or not currently lactating female? Learn to lactate. No doubt you could do it if you try hard enough.

Oh, right. You’re not interested in sacrificing to help others, just gloating in the face of those experiencing tragedy.

One of the most pernicious of the many pernicious aspects of breastfeeding promotion is the insistence by lactation consultants that all women can make enough breastmilk to fully nourish an infant.

Not only is it factually false, but it has given impetus to two additional erroneous beliefs:

1. Insistence that low supply is a misperception on the part of the mother

2. Belief that documented low breastmilk supply, and the relentless infant hunger that results, is the mother’s fault.

The assumption (sometimes stated, often implied) is that women who have low supply aren’t trying hard enough, aren’t breastfeeding often enough and long enough, aren’t pumping enough, shouldn’t have had an epidural or C-section, never should have let the baby have a pacifier, etc.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Low breastmilk supply is as real as diabetes. [/pullquote]

These are incredibly harmful beliefs. First, they hurt new mothers who are desperately trying to breastfeed without success. The only thing more devastating than hearing your baby scream incessantly from hunger is being told that it is only your imagination or worse, the result of your selfishness. It’s the equivalent to insisting that those with type I diabetes lack insulin because they are too lazy to produce it.

Fortunately, within the past year or so, increasing attention has been paid to the harmful impact of such claims on maternal mental health. Women have been sharing their stories of guilt, shame and depression and pushing back against the overwhelming pressure to breastfeed exclusively.

The second harmful aspect of such beliefs often goes overlooked. By insisting that low breastmilk supply is imaginary or simply a matter of maternal effort, lactivists have systematically failed to investigate biological causes of low supply. That’s the equivalent to refusing to look for a cause of type I diabetes and blaming diabetics instead.

The truth is that low breastmilk supply (like diabetes) is real, is no one’s “fault” and has a biomarker to prove it.

Earlier this year I wrote about the discovery of a biomarker for low breastmilk supply: high sodium concentration within breastmilk.

High levels of sodium in breast milk are closely associated with lactation failure. One study showed that those who failed lactation had higher initial breast milk sodium concentrations, and the longer they stayed elevated, the lower the success rate. This association has subsequently been confirmed.Several possibilities have been suggested as to the cause of increased sodium levels in breast milk… It has been shown that sodium values are not affected by the mother’s diet or by the method of milk expression …

Subsequent research demonstrated that women who expressed concerns about breastmilk supply were more likely to have the biomarker than women who did not.

If concerns about milk supply among exclusively breastfeeding women were primarily owing to a lack of knowledge about the signs of abundant milk production, then the expected outcome would be no difference in breast milk Na:K as compared with exclusively breastfeeding women without milk supply concerns… Instead, the observed prevalence of elevated Na:K was 2-fold greater in the mothers with milk supply concerns (42% vs 21%)… This result challenges the belief that milk supply concern in the context of exclusive breastfeeding is primarily maternal misperception.

These findings also challenge the belief that all women make enough breastmilk to fully nourish an infant and it is their fault if they don’t.

Now comes evidence of a genetic basis for low milk supply. Milk cell gene expression of mothers with low breast milk production is a basic science paper with important clinical implications. It was funded by a grant from Medela AG, a maker of breast pumps.

Initial analysis found cells isolated from women with low milk production showed significantly lower expression of the genes estrogen related receptor beta (ESRRB, p=0.027) and neurotrophin receptors sortilin (SORT, p=0.010) and tyrosine receptor kinase 2 splice variant 1 (TRKB1, p=0.007) and higher expression of a progenitor marker (REX1, p=0.025) compared with cells isolated from women with normal production.

The authors concluded:

Preliminary findings suggest variations in cell signalling and function, examined through gene expression that might contribute to low milk production. Further investigations will potentially determine significant roles of key genes enabling successful human lactation.

This shouldn’t be surprising. Genes control everything from height to eye color to susceptibility to disease. Why wouldn’t they also control breastmilk supply?

By investigating the biological basis for low milk supply we can find the cause and, hopefully, a cure. Alternatively, we may find that as with type I diabetes, no cure is currently possible, and supplementing (with insulin in diabetes, with formula in low breastmilk supply) is the only course of action. In either case, it should relieve the stigma on new mothers with low supply.

Low breastmilk supply is as real as diabetes and it poses a substantial health threat to infants. It’s not a mistaken maternal perception; it’s not mothers’ fault; and it can’t be fixed with greater maternal effort.

It’s almost certainly genetic.

Psychological defense mechanisms are strategies that protect people from emotional distress:

[They are] brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses and to maintain one’s self [image].

Denial is one of the most primitive and most powerful defense mechanisms:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Homebirth advocates insist they are taking responsibility for their baby’s health … right up until the baby is harmed by their choice.[/pullquote]

Refusal to accept external reality because it is too threatening; … resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality.

Denial is one way that women whose children have been harmed at homebirth try to avoid responsibility for the harm that resulted from their decision. For example:

I want everyone to realize something…because I was asked again today if I still agree with home birth. Let me make this clear…what happened with M would have happened in the hospital too!! Group B strep can go undetected and then when baby tries to breathe, they just can’t. It had NOTHING to do with birthing her at home! And arguing with me that she would have had better and quicker care in the hospital is bogus too. My midwife immediately began exactly what doctors would have done (minus cutting the cord as that is what was literally keeping M alive!). Doctors would have done neonatal resuscitation and oxygen first as well. Then moved on to ventilator. THIS WAS DONE!! Homebirth does not mean we birth in a cave with no emergency supplies. So stop asking me if I still agree with homebirth!
I AM 100% STILL IN SUPPORT OF HOMEBIRTHS AND I WILL ALWAYS RECOMMEND THEM TO WOMEN.
Again, homebirth did NOT cause M’s struggles…a horrible horrible infection did that.

I wrote about this mother and baby a few weeks ago, Another baby grievously harmed by homebirth; another mother desperately pretending it’s not her fault.

She was in denial then and she’s still in denial now.

This would likely not have happened in the hospital for a variety of reasons, but the most important one is this: we now test women for group B strep bacteria at the end of pregnancy and elaminate it before it can infect a baby by giving antibiotics in labor. The results have been remarkable:

The incidence of invasive early-onset GBS disease decreased by more than 80% from 1.8 cases/1000 live births in the early 1990s to 0.26 cases/1000 live births in 2010; from 1994 to 2010 we estimate that over 70,000 cases of EOGBS invasive disease were prevented in the United States.

Why didn’t M’s mother know she was colonized by group B strep and her baby was a risk of a brain threatening, life threatening infection? Because she declined the group B strep test at the end of pregnancy and therefore was not treated with antibiotics during labor.

But that’s not the only serious complication that Baby M suffered as a result of her mother’s choice to put her life at risk at homebirth.

She was deprived of oxygen during labor.
She inhaled meconium.
She needed an expert resuscitation with intubation.
She was unexpectedly breech.

Each factor ratcheted up the risk. Each factor was unknown or ignored at home and would have been treated very differently in the hospital.

The breech position would almost certainly have been diagnosed before labor and the mother offered an elective C-section; had she taken it, the baby would not have suffered a severe insult to her brain.

The oxygen deprivation during labor would almost certainly been diagnosed during labor by the use of electronic fetal monitoring. EFM has a very low false negative rate; it almost never misses actual fetal distress. Doctors would have recommended an emergency C-section and the baby would not have suffered a brain injury.

The meconium would have been taken into account in a diagnosis of fetal distress. Had the mother consented to an emergency C-section, the baby might not have inhaled meconium or would not have inhaled as much.

The baby would have received an expert resuscitation, intubation and immediate treatement with antibiotics to minimize any injury in progress.

What about the mother’s claim that it was delayed cord cutting that kept baby M alive? That’s nonsense. The problem was that baby M was not getting enough oxygen in utero. That’s why there was meconium; that’s why the baby inhaled it; that’s why the baby was born not breathing; the brain injury was already in progress. The idea that delayed cord clamping was lifesaving is foolish; it wasn’t providing enough brain preserving oxygen before the baby was born, it certainly wasn’t providing any more after the baby was born.

Homebirth advocates often insist that by choosing homebirth they are taking responsibility for their baby’s health … right up until the baby is harmed by their choice. Women who choose homebirth do so because they believe that routine hospital interventions are almost never needed. Yet when a baby is born injured because she did need those routine interventions but was deliberately deprived of them, many homebirth mothers retreat into denial. All of a sudden nothing is their responsibility; everything supposedly would have happened exactly the same way in the hospital.

Denial, as powerful as it is, rarely lasts forever. There will almost certainly come a time when the mother will have to reckon with what she did: she made a choice that profoundly harmed her baby and both she and her baby will wake up to that horrible reality every day for the rest of their lives.

Think homebirth is safe? Think again.