Public health initiatives, by definition, are meant to improve public health.

[pullquote align=”right” color=””]We waste millions on a public health campaign that produces no discernible return on investment.[/pullquote]

They are usually based on solid scientific evidence, their implementation saves thousands if not millions of lives, and they pay for themselves many times over in lives saved, earnings preserved and medical expenditures averted.

Consider the classic public health campaigns to promote vaccination and to reduce tobacco smoking.

This graph from E&K Health Consulting shows the dramatic drop in incidence of vaccine preventable disease after the introduction of the vaccine for the specific disease:

Notice that the y-axis is logarithmic, which means that the actual changes were far more dramatic than a glance at the graph would indicate. For example, there were approximately a one hundred thousand cases of smallpox per year prior to the introduction of the vaccine. In 2012 there were no cases at all. For each and every vaccine, the number of cases decreased by several orders of magnitude after the introduction of the vaccine.

The public health campaign to reduce tobacco smoking has had similarly spectacular results.

This graph originally published in the National Cancer Institute Bulletin shows that in the wake of the Surgeon General’s report of 1964 warning about the link between smoking and lung cancer, per capita cigarette consumption dropped dramatically. After a lag period, lung cancer deaths began to drop dramatically, too.

We have spent millions of dollars promoting vaccination and reducing smoking and it has paid off in both lives and money saved.

How about breastfeeding?

In the past 20 years we have spent millions of dollars promoting breastfeeding despite scientific evidence that is weak, conflicting and riddled with confounders.

An entire industry, the lactation industry, has arisen to promote and profit from efforts to increase breastfeeding rates. For example, lactation consultants did not exist prior to the mid 1980’s. Now they are everywhere, in hospitals, in doctors’ offices and in private practice. There have been multimillion dollar health campaigns and there is now a certification costing hospitals more than $10,000 each to be designated as breastfeeding friendly.

Breastfeeding initiation rates have risen in response. But the breastfeeding rate appears to have had no impact on the infant mortality rate. The graph below illustrates the steep drop in infant mortality over the course of the 2oth Century. I’ve added markers for the breastfeeding rate at various points. As you can see, the precipitous drop in breastfeeding rates did not have an impact on infant mortality and the rising rate of breastfeeding initiation does not seem to have an impact, either.

Breastfeeding initiation rates have tripled since 1970 rising from 25% to over 75% today.

So where is the return on investment?

Where is the evidence that thousands of lives have been saved? Where is the evidence that millions of cases of disease have been prevented? Where is the evidence of millions of dollars in healthcare expenditures averted? Where is the evidence that the dramatic rise in breastfeeding has had any impact at all on infant or child health?

The only evidence for the beneficial effects of breastfeeding on infant mortality come from premature infants, not term babies.

Sure there are papers making claims about theoretical health and spending benefits of breastfeeding for term babies, but I haven’t found any evidence of actual health and spending benefits. If it exists, I invite anyone who has seen such information to share it with the rest of us.

In fact, there is a growing body of evidence that the aggressive promotion of breastfeeding is harming babies through an increased incidence of dehydration and starvation due to insufficient breastmilk (affecting up to 15% of first time mothers) as well as smothering in mother’s hospital beds or falling from them because of mandated 24 hour rooming in policies in hospitals.

That doesn’t mean that breastfeeding is a bad thing. It’s a good thing, but the benefits for term babies in first world countries are trivial. If those benefits were anything other than trivial, we should have seen a dramatic impact on infant health and pediatric care expenditure in the past 45 years when breastfeeding initiation rates rose by 200%, but we haven’t seen anything of the kind.

No doubt the lactation industry has benefited. The number of lactation consultants in the US has increased from 0 in 1980 to 3.5/1000 live births in the 2013 (14,000 lactation consultants). Tens of millions of dollars have been spent on public health campaigns, and tens of millions of dollars are spent by mothers themselves.

What do we have to show for it?

Nothing.

Unless, of course, you count the soul searing guilt and feelings of inadequacy among women who can’t or choose not to breastfeed.

Going forward we should dramatically scale back spending on breastfeeding promotion. In an era of scarce healthcare dollars, we can’t afford to waste millions on public health campaigns that produce no discernible return on investment.

Breastfeeding should be a private choice. There is no reason, scientific or economic, to spend millions promoting it.

 

Adapted from a piece that first appeared in August 2015.

I’ve spent the last few days wrangling with anti-vaxxers on the Skeptical OB Facebook page. I wasn’t arguing with them since a doctor can no more argue immunology with anti-vaxxers than a mathematician can argue calculus with a four year old. Neither knows enough to come to grips with the actual subject.

Most four year olds would be quick to tell you that they don’t understand calculus, but most anti-vaxxers aren’t nearly so self aware. As victims of the Dunning Kruger effect, they actually think they know what they are talking about.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Tuteur Corollary: If they don’t understand it, it must be a plot to harm them.[/pullquote]

The Dunning Kruger effect explains why those who know the least about a particular topic — health, for example  —actually believe they know the most. They simply don’t know what they don’t know. 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.

But it seems to me that there is a corollary to Dunning Kruger — I’m going to call it the Tuteur Corollary — that applies to advocates of alternative health in general and anti-vaxxers in particular.

I’ve noticed that when bad things happen to people, they can be roughly sorted into two groups: those who look at the untoward event they don’t understand and ask, “How did this happen?” and those who look at the exact same event and ask, “Who did this to me?” In other words, those with a modicum of knowledge want to understand — and assume they will be able to understand — what happened; in contrast, those who lack basic relevant knowledge (and often basic logic as well) assume that if they don’t understand something bad, it must be because someone, generally a corporation or government entity, is trying to harm them.

Simply put, the Tuteur Corollary to Dunning Kruger as is this:

Those who lack relevant knowledge look at what they don’t understand and imagine nefarious deeds.

For example:

Those who don’t understand basic immunology obviously don’t understand how vaccines work. Dunning Kruger leads them to conclude that vaccines don’t work; the Tuteur Corollary impels them to explain the world-wide consensus of immunologists, pediatricians and epidemiologists on the efficacy of vaccines as a world-wide plot to boost the fortunes of Big Pharma.

Those who don’t understand basic statistics obviously don’t understand that the apparent increase in the incidence of autism can be attributed to better diagnosis and expanded classification. Dunning Kruger leads them to insist that autism is an epidemic; the Tuteur Corollary leads them to conclude that corporations, with the blessing of government, are deliberately causing autism.

Those who don’t understand basic chemistry obviously don’t understand that a chemical that is dangerous in its elemental form, like mercury, is not dangerous when a component of a chemical compound, thimerosal. Never mind that there are many examples in every day life: elemental sodium is exposive; sodium chloride (table salt) is beloved as a seasoning for food. That’s Dunning Kruger. The Tuteur Corollary is responsible for the nonsensical belief that Big Pharma once added an expensive chemical to its vaccine preparations for no therapeutic reason and intended to poison children.

Those who don’t understand the scientific method obviously don’t understand that a single scientific citation (or even a dozen) that they’ve never read is not an argument against vaccination, especially when compared with the literally tens of thousands of papers that demonstrate the safety and efficacy of vaccines. Dunning Kruger leads them to assume that they are more educated about vaccines that those with PhDs in immunology. The Tuteur Corollary forces them to conclude that the entire scientific, medical and public health communities are deliberately ignoring all the fascinating data on whale.to and NaturalNews that seems so compelling to them.

Dunning Kruger explains why those who know the least are most likely to fall prey to alternative health charlatans. The Tuteur Corollary explains why they abandon common sense to conclude that quacktress Suzanne Somers is more dedicated to curing their cancer than their own oncologists, that people peddling worthless miracle diets and cures and less interested in profit than doctors, and that the vaccine conspiracy is so massive and so dastardly that doctors, pharma execs and public health officials are willing to inject their own children with vaccines in order to maintain the deception.

It’s bad enough that we live in Dunning Kruger nation where variety of very loud “confident idiots” actually think they know more than the experts in their respective fields. What’s worse it that we appear to be living in a nation where such ignorance is enshrined in our values.

As Dr. Dunning explained:

Some of our most stubborn misbeliefs arise … from the very values and philosophies that define who we are as individuals. Each of us possesses certain foundational beliefs — narratives about the self, ideas about the social order—that essentially cannot be violated: To contradict them would call into question our very self-worth.

When it comes to healthcare, large groups of Americans now rest their self worth on the twin delusions that stupidity is knowledge and if you don’t understand it, it must be a plot to harm you.

I’ve been writing for years about the fact that UK midwives are running amok promoting “normal birth” and babies are dying. For years, the British media and the British population seemed uninterested, but now the death toll has become so high that even they cannot look away.

The Guardian reports in Exclusive: Baby deaths linked to lack of basic midwife training:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How many babies have to die and how many billions of pounds have to be paid out before the morally repugnant, incompetently trained, self-dealing, deadly UK midwives are held to account?
[/pullquote]

The number of claims for brain damage and cerebral palsy has tripled in a decade, amid widespread monitoring failures…

… Since 2004/5, the value of claims against NHS maternity units for brain damage and cerebral palsy has risen from £354m to £990m, official figures show.

The cases – often linked with a failure to monitor babies’ heart rates, to detect risks of oxygen starvation – fuelled maternity negligence claims of more than £1.2bn in 2015/16 [$1.5 billion].

Why? Among other reasons, it appears that UK midwives don’t know how to diagnose fetal distress.

Babies are dying and being put at risk of major brain injury because it is “commonplace” for British midwives to qualify without training in use of basic equipment, a senior coroner has warned.

The regulator for midwives has been told to reform the sylllabus for all trainees after a string of deaths of newborns following monitoring failures.

Hospital trusts have been advised to stop recruiting newly qualified midwives until they can prove they can perform foetal heart monitoring.

For example:

Baby Delilah Hubbard died two days after her birth at Leicester General Infirmary in March 2015. Although her mother Clara Bassford was classed as a “high risk” pregnancy, having had two previous babies prematurely, midwives failed to monitor her properly. After Ms Bassford warned that the baby was not moving, midwives tried to carry out checks. But they positioned the monitor wrongly – so that the child’s heart rate was not properly recorded. The NHS trust last year admitted that Delilah would have survived if staff had acted more quickly.

Baby Rupert Sanders died on Christmas Eve in 2012 after midwife Carol Marston switched off a heart monitor alarm 16 times during his birth. The midwife admitted to making “catastrophic” mistakes, failing to realise how severe the abnormalities were. Fellow midwife Anne Mather also failed to detect the gravity of the situation during the labour of first-time mother Lauren Sanders, at Stafford Hospital, the Nursing and Midwifery Council heard.

An investigation into maternity care at Shrewsbury and Telford NHS trust is examining the deaths of 15 babies and three women, including at least five cases involving foetal heart monitoring failures. The cases involve twins Ella and Lola Greene, stillborn in 2014, Graham Scott Holmes-Smith, stillborn in December 2015, the death of Kye Hall, at four days, in August 2016, and that of Ivy Morris, who died in May 2016, four months after her birth.

And that’s just the tip of the iceberg.

What, you might wonder, do UK midwives have to say about this?

Absolutely nothing.

As I recently explained, social media, particularly Twitter, allows UK midwives to recuse themselves from reality and reward themselves with a never ending round of dopamine-releasing self-congratulation. That rewarding feedback loop is infinitely more gratifying than facing the injuries and deaths that occur because of UK midwives overweening self-regard. Twitter allows them to customize their surroundings by blocking anyone who might intrude (laypeople and professionals) with distressing stories of babies and mothers who were injured or died because of midwives’ unethical promotion of “normal birth.”

As far as I can determine, neither Cathy Warwick, head of the Royal College of Midwives, nor Sheena Byrom, a leader of UK midwives, nor any other midwifery leader has even bothered to mention the story thusfar. Instead their Twitter feeds are filled with self-congratulatory messages to each other on their promotion of “normal birth”.

What about their blogs?

Today’s RCM blog post is about the upcoming election and what the various political parties are promising to do for midwives and the NHS.

The post currently featured on Sheila Byrom’s blog is a guest post entitled — what else? — All this push for ‘normal birth’ – why I keep pushing:

As a consumer of the media, I see this – or some variation on this theme – so often. In a somewhat sinister twist, I occasionally see this one:

“Midwives endanger lives with their stubborn insistence on pushing for normal birth.”

I’m a third year student midwife, and a birth addict. In October last year, I attended the International Normal Labour and Birth Conference in Sydney, Australia. Seeing so many esteemed, brilliant and passionate people assemble to protect and promote normal birth was somewhat overwhelming, and possibly even more so was trying to keep up with it all on social media! Thousands upon thousands of tweets, Facebook posts and #normalbirth16 hashtags flooded the web, drawing many comments from people near and far…

Her response:

Because the move to protect normal birth is not, and has never been, about trying to conscript women into accepting less intervention, less Caesarian section, less pain relief in birth. The purpose of such advocacy is never about blaming women for their choices and experiences. The point of the exercise is NOT to make mothers feel like failures if their birth did not meet the ‘optimum’ recommendations. Birth is not, and should never be, a competitive sport.

Advocating for normal birth is NOT about holding women accountable.

Advocating for normal birth IS about holding birth workers accountable.

Surprise, normal birth is about midwives.

So don’t be fooled – advocating normal birth is not some crazy, midwife-led agenda to keep obstetricians out of work and see women suffer through difficult labour without pain relief (although that’s what some outspoken critics might have you believe). It’s true that many of the most articulate advocates for normal birth are midwives, but are midwives really that vicious?

But they ARE that vicious. At the same time the the NHS paid out £1.2bn in compensation for injuries and deaths, the Nursing and Midwifery Council (NMS) paid £240,000 to lawyers to keep the truth about baby Joshua Titcombe’s preventable death from his father James:

Now new documents reveal that the watchdog spent £240,000 on laywers – paid from subscriptions by nurses and midwives – on advice about how to respond to his attempts to uncover the truth.

The bereaved father sought information from the regulator, after the NMC refused to supply him with details of a review it had carried out, and correspondence to other regulators.

They also subjected James to a campaign of harrassment on social media.

For example:

Highlights include:

oh James-don’t let’s get on that roll again …

and:

getting out of bed in the morning has risks

Yes, James, how could you be so tiresome, always going on about the risks of childbirth and the babies who die as a result? Sheena is so over that.

Byrom ought to be ashamed of herself for the chilling way that she dismissed the father of a baby who died as a result of midwifery incompetence. But that would involve insight, compassion and a sense of responsibility, something in woefully short supply among UK midwives in general and Byrom in particular.

The latest revelations are hardly surprising given the appalling behavior of UK midwives in the past. All of which leads me to ask:

How many babies have to die and how many billions of pounds have to be paid out before the morally repugnant, incompetently trained, self-dealing, deadly UK midwives are held to account?

A reader shared her childbirth experiences in France with me and I was fascinated. I thought my other readers would be interested, too, and she gave her permission for me to share this, though she prefers to remain anonymous.

I live in France, and after having given birth twice here, I thought you may be interested in hearing about my experiences with what I consider to be a true baby (and mommy) friendly hospital. Granted, I gave birth twice in the same hospital, so my sample size is limited but I can say my experiences were consistent both times, and with those I’ve heard of friends who’ve birthed at other hospitals as well as friends who work in maternal care in other areas of the country.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]With my son, I knew we were going to formula feeding immediately, but I wanted to give him colostrum early on, a common practice here; they call it a “tetine d’accueil” – welcome nipple.[/pullquote]

First of all, I was required to give birth at a real hospital, neither a home birth nor even a clinic were options for me. With my first pregnancy, my daughter, I stated that I didn’t want an epidural upon arrival at the hospital, and no one tried to change my mind otherwise. The midwives who admitted us and got us settled in were completely understanding, the only caveat was that I wasn’t eligible for the “natural birthing” suite, I had to stay in one of the “medical” birthing rooms. The hospital is equipped with 14 private birthing rooms (plus the natural birthing suite, which apparently sits empty most of the time), each with a private bathroom and shower, and about half have bathtubs as well.

I finally gave in to the epidural with my daughter, after over 24 hours of back labor, and with my son, I asked for the epidural as soon as we arrived at the hospital as things seemed to be progressing more quickly with him. Again, in neither situation did I feel coerced into one choice or another, and I truly felt the choice was up to me. In both cases, as we were waiting for me to dilate enough to start pushing, we were taken through a questionnaire asking about any special requests during the delivery – extended cord clamping, skin to skin (and whether it would be me or my husband to go first, what would happen if I was unable to interact with the baby immediately after delivery), who would pull the baby out (my husband or me – totally left that one up to him!), whether we wanted any special music or mirror so I could see what was happening, feeding choices, etc.. In each case, our answers were listened to and clarified, with it being made clear that our requests would be honored as much as possible, as long as neither I nor the baby were in any danger. Luckily, I had relatively problem free deliveries in both cases, with both babies arriving after minimal pushing.

Both of my births were attended by 3 members of hospital staff: a midwife (which here is a nurse who does additional training in midwifery), a nurse specializing in babies and a student midwife. I did not see a single “real” medical doctor either time as there was no need for one, although I was reassured knowing that there were several doctors on site for emergencies and the operating suite was just down the hall. Our daughter had to be taken away to the NICU for some breathing problems (having swallowed some amniotic fluid), so she was seen by a pediatrician within her first few hours and her father was allowed to stay with her the whole time. Our son had no problems, and we were left alone in the birthing room, lights dimmed, for at least his first 2 hours to begin to bond with the baby, perform skin-to-skin contact and try his first feeding (more on that in a moment) with the midwives and nurses only entering when we called them.

With my daughter I had planned to breastfeed; however, after several days she was screaming non-stop, I was miserable as I HATED the feeling of breast-feeding, wasn’t getting any sleep and was actually dreading taking my baby in my arms. The midwives checked her latch, and even tried to feed her with a little tube running from a formula bottle to my nipple so that she would be getting milk while thinking she was breast feeding. I realize now that she probably wasn’t getting enough to eat and the poor thing was hungry. In the end, it was actually one of the midwives who was honest enough with me to say just to give her formula, explained that it’s just as good and pointed out that if I’m this miserable now, continuing breastfeeding and trying to pump would only make me more miserable and that I’d regret it later if I didn’t enjoy this early time with my baby.

After talking it over with my husband (who was 100% supportive of formula feeding if that was what I felt was best), I said I would have him bring some formula in the morning. Imagine my surprise when she said no, that wasn’t allowed. The hospital actually provides ALL of the formula while the baby is there, so that they know exactly what the baby is eating and that it’s prepared properly. Throughout both of our hospital stays, all the formula both of my babies ate was provided, in 70ml pre-mixed, disposable bottles, with sealed sterilized disposable nipples. When giving birth to my son, I found out that the various formula companies rotate in providing samples to the hospital and the hospital isn’t allowed to recommend any one brand over another, they instruct new mothers to just buy any formula from the grocery store or pharmacy for “premiere age” – birth to 6 months, or of course to consult with a pediatrician or family doctor.

Luckily, we made the decision to switch my daughter to formula when she was not even 3 days old, so I don’t have a lot of guilt from thinking I starved my baby for very long; and I was struck by the concern that was shown for my psychological well-being, not just the health of the baby. This was also true with the other nurses and midwives who rotated throughout the shifts and later noticed we had switched to formula – no judgment or lecturing, mostly just comments that each mother needs to do what works for her, and even a few congratulations for being willing to make the decision so early for both mine and the baby’s benefit (yes, MY benefit was included in those comments).

With my son, I knew we were going to formula feeding immediately, but I wanted to give him the colostrum early on (yes, I realize the research on this is inconclusive but I figured it can’t hurt; this is actually a common practice here in France for mothers who don’t want to breastfeed, they call it a “tetine d’accueil” – welcome nipple J). The midwife who was going through our requests with us was completely supportive, helped us to get set up to do his colostrum feeding and then brought in the formula samples in case he was still hungry.

I stayed in the same maternity ward with both babies, which is comprised of private rooms with bathrooms, and space for the baby’s cradle as well as an extra pull out recliner for dad to sleep on if he so wishes. The maternity ward is staffed 24 hrs/day with midwifes and nurses specializing in infant care, with a pediatrician and OB-GYN on call. This was a university hospital, so there were several students of these varying specialties as well. Babies can stay with the mom in her room, or there is an optional nursery next to the nursing/midwife stations where babies can be left in their cradles for however long mom needs. With my daughter, the midwives were concerned that I wasn’t sleeping the first night or two and encouraged me to leave her in the nursery for a few hours. I refused, however I did leave the babies there when they were sleeping and I wanted to take a shower, and the nurses and midwives were completely non-judgmental and simply told me how beautiful the babies were J

With my daughter we were in the maternity ward for a week, as they were concerned that she may have an infection from the amniotic fluid she swallowed and they wanted to monitor her. Anytime a baby under a certain age is admitted to the hospital, one parent has the right to stay with them 24/7 so we spent 7 days in what I call “baby boot-camp” – I learned to change diapers, give her a bath, measure her temperature, burp her, you name it. There was always someone on call to answer silly questions and to help as much or as little as I wanted. With my son, we were only in the maternity ward for 4 days, which is the minimum for someone with my health issues as they wanted to monitor me afterwards. In fact, the shortest maternity ward stay possible here is 48 hours, and that’s only authorized in cases of non-first birth where everything has gone exceptionally well with a vaginal delivery and mom has no pre-existing medical conditions, but there is a mandatory follow-up home visit with a midwife within the first week of the baby’s life.

And how much did all of this cost, you may ask? My husband and I paid a total of about 15 euro when leaving to take my daughter home, and that was for 2 meals that my husband ordered at the hospital to eat with me. We also had to pay out of pocket for a follow-up test during her first month, and I was mentally planning to take money out of savings to cover it until she would be registered with the health care system which would reimburse us – imagine my surprise when the bill arrived for 11 euros!. I’ve been closely watching the health-care debate in the US, and I have a friend who gave birth this past December at a clinic that apparently sends mothers home within 6 hours of giving birth, even with a first baby. When my daughter was born I had no idea how to care for an infant, and I am eternally grateful for that week in the maternity ward where I was able to learn how to care for my baby without any pressure or financial stress from worrying about the cost. By the time we took her home, I was confident in what I was doing. I’m also grateful for the support in giving up breast-feeding so early as it allowed me to really enjoy my daughter in those precious first days and weeks rather than dreading every feeding.

This is all on top of the fact that I was put on medical leave with both of my pregnancies for the last 3-4 months. Medical leave is paid 50% by the state here in France, with my private employer health insurance topping off the rest until maternity leave benefits kick in 6 weeks before the due date (paid at 100% until 10 weeks after the due date – 16 weeks total). This meant that I was able to truly rest during the last few months, without worrying about finances or job loss. Medical and maternity leaves are very strongly protected by the labor law here, and the overall culture is such that an employee giving birth is something to be celebrated, not dreaded.

I was raised in Canada, so for me a public health care system just seems like the obvious way to go; I also spent several years working in the US, and although I had good health insurance through my employer, it was odd and unnerving to always have the spectre of being uninsured (if I were unemployed) hanging over me. I realize that we pay much higher taxes here in France and that the idea of “being taken care of” by the state is antethema to the US mindset. But I don’t mind the higher taxes so much, as I see what I get for paying them.

My kids are now 16 months and 3.5 months old (the close age difference was on purpose, however termination of the second pregnancy was presented as an option in case it was an accident) and thankfully in perfect health. They’re both fully covered by the social medical system here, meaning that all doctor and specialist visits, and part of all their prescriptions, blood tests and vaccines are covered by the state; the remainder is picked up by my health insurance through work. I honestly can’t imagine how families can survive and thrive living under a cloud of fear that any medical problem can send them into financial distress or even bankruptcy (and now, even leave them with a pre-existing condition that may put their health insurance further at risk).

Earlier in the week I criticized the ProPublica/NPR piece on maternal mortality (What ProPublica didn’t explain and possibly didn’t even know about maternal mortality).

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We must create regional centers for maternal intensive care just as we have done for newborn intensive care.[/pullquote]

Because ProPublica failed to explain changes in reporting of maternal mortality, failed to explain the changing causes , failed to explain the outsize contribution of race and failed to explain the inherent deadliness of childbirth, they presented a fundamentally misleading picture of the issue. But there is disturbing fact that they got absolutely right: 60% of maternal deaths are potentially preventable.

In order to understand how these deaths could be prevented, we need to understand what causes them.

The chart above shows the leading causes of pregnancy related deaths. These causes can be roughly divided into three groups, pre-existing medical issues, complications of pregnancy, complications of hospitalization.

Let’s start with the easiest group first, complications of hospitalization. Deaths due to infection and thrombotic pulmonary embolism make up the bulk of these deaths. They aren’t strictly due to hospitalization; they have always been leading causes of death because childbirth puts women at risk of infection and pregnancy puts women at increased risk of blood clots. But there are easy to implement methods that can dramatically reduce both, including checklists and proper aseptic technique to reduce infection and low dose heparin and compression boots to reduce blood clot formation. A lower C-section rate could contribute to a reducing both complications as well. This is the low hanging fruit of the maternal mortality problem, easy to grasp and easy to correct. We will never be able to abolish all infection and blood clots in pregnancy, but we can do a lot better.

The second group is complications of pregnancy like hemorrhage and hypertensive disease (pre-eclampsia and eclampsia) as well as strokes resulting from high blood pressure. Both hemorrhage and hypertensive disease are endemic to pregnancy. Neither can be entirely or even mostly prevented (at least not yet); they must be treated. And before they can be treated, they must be diagnosed.

We know that a certain percentage of women will hemorrhage after childbirth just like we know that a certain percentage of women will developed hypertensive diseases of pregnancy. Diagnosing those problems as early as possible requires an high index of suspicion, careful monitoring, and the immediate application of technology. This is where algorithms, drills and tool kits come into play. No one should assume that a woman won’t develop childbirth complications; everyone should be alert to the a fact that they are both common and inevitable. Algorithms can help providers make an early diagnosis.

Hemorrhage and pre-eclampsia are often full blown emergencies where minutes count. Tool kits allow providers to have all relevant diagnostic and treatment technology at hand. Drills help providers utilize that technology expeditiously. They are often the difference between life and death.

Cardiomyopathy is also a complication of pregnancy but not nearly so common as hemorrhage and pre-eclampsia. It is relatively rare and therefore most providers may have never seen it. Nonetheless it is one of the fastest growing causes of maternal death. Unfortunately:

Early, rapid diagnosis of peripartum cardiomyopathy is not the norm. It took 7 or more days to establish the diagnosis in 48% of women, and half of those had major adverse events before the diagnosis was made…

In this situation the most important elements are high index of suspicion when women complain of shortness of breath or chest pain and rapid consultation with cardiologists and other specialists.

The final group is pre-existing medical conditions. Childbirth is now more common than ever in women who are older, heavier and suffering from a greater number and range of pre-existing medical conditions. In many cases, such as heart disease and kidney disease, pregnancy and childbirth can put tremendous strain on already weakened organs. Specialized intensive care is the key to preventing maternal deaths.

We long ago recognized the value of specialized intensive care in saving the lives of critically ill newborns. That’s what led to the creation of neonatal intensive care units (labeled Level I, II or III based on the type of technology available), neonatologists, and routine regional transfer of newborns to higher level NICUs. A premature or critically ill newborn will be transferred to a Level III nursery if born at a hospital that only has a Level I or II nursery.

It’s hardly surprising that we addressed the intensive care issue in newborns first. Death rates for newborns are approximately 100X higher than for new mothers. It is surprising that we have never addressed the issue of maternal intensive care units, maternal intensivists and routine regional transfer of critically ill mothers at all. Mothers are dying as a result.

Only the rare obstetrician is trained in intensive care. No obstetrician should be trying to manage pregnant women with pre-existing medical conditions on his or her own. The appropriate specialists should always be involved hopefully before complications develop and certainly after.

Most intensivists trained in the care of adults are typically unfamiliar with the specific issues that arise in conjunction with pregnancy. We should create regional centers for maternal intensive care just as we have done for newborn intensive care. We should rank them by available technology and we should routinely transfer women to higher level centers to deliver there preferentially or when they develop complications after birth.

We’ve all read countless articles in the mainstream press about efforts to reduce pregnancy interventions, but there is precious little effort being made to reduce maternal deaths. New mothers will continue to die until we develop the will and deploy the technology to prevent these eminently preventable maternal deaths. Let’s stop wringing our hands, and start working.

One of the most amazing things about writing for this blog is that no sooner do I mention something untoward or dangerous and someone rushes to demonstrate it.

Yesterday I wrote about the way that a low index of suspicion for pregnancy complications leads to maternal deaths. Today, Consumer Reports publishes a ham handed piece, Childbirth: What to Reject When You’re Expecting, by Tara Haelle that obsesses about process without giving any serious consideration to the only thing that really matters, outcome. It’s as if Consumer Reports rated cars by cup holders and interior upholstery instead of by crash worthiness.

Haelle starts with the usual framing:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s as if Consumer Reports rated cars by cup holders and interior upholstery instead of by crash worthiness.[/pullquote]

Despite the benefits of a healthcare system that outspends those in the rest of the world, infants and mothers fare worse in the U.S. than in many other industrialized nations…

Infants in this country are more than twice as likely to die before their first birthday as those in Japan and Finland, and America lags behind nearly every other industrialized nation in preventing mothers from dying due to pregnancy or childbirth…

Why? There are no doubt many causes. But one likely contributor may be that medical expediency often takes priority over the best outcomes and evidence-based treatments…

That’s a brutal assessment requiring copious evidence to support it. Haelle and Consumer Reports provide none.

And in this setting in particular, that is inexcusable.

What is most ugly about this is that it ignores the fact that black women and babies are disproportionally affected, with death rates FOUR TIMES HIGHER than everyone else, far exceeding that of every other minority group,

We will never improve outcomes for black babies and women if we pretend that mortality is primarily a problem for privileged white women looking to craft a “birth experience.”

We will never reduce perinatal and maternal mortality as far as possible if we lie to ourselves about the real causes.

To my knowledge, there is NO EVIDENCE, zip, zero, nada, that perinatal and maternal deaths are caused by medical expediency. But that doesn’t stop Haelle or Consumer Reports.

They trot out the usual hobby horses for condemnation: the C-section rate, the induction rate, continuous electronic fetal monitoring, episiotomies, epidurals and sending babies to newborn nurseries.

These are processes, NOT outcomes. They affect the birth experience far more than they affect whether babies and mothers live or die. No matter. Consumer Reports and Haelle only mention death rates to imply that interventions cause death, not in any serious effort to prevent deaths.

Look at the reasons why mothers die:

How is obsessing about process going to have an impact on the most common reasons for maternal death, cardiac and other chronic diseases? It isn’t.

What about infant mortality?

How is obsessing about process going to have an impact on the most common causes of infant death, congenital anomalies, prematurity (generally extreme prematurity), and complications of pregnancy. It isn’t.

Though there is no evidence that medical expediency kills babies and women, there is considerable evidence that medical complacency, assuming that pregnancy is inherently safe when it is actually inherently dangerous, does kill.

As noted in the ProPublica/NPR report about maternal mortality:

Earlier this year, an analysis by the CDC Foundation of maternal mortality data from four states identified more than 20 “critical factors” that contributed to pregnancy-related deaths. Among the ones involving providers: lack of standardized policies, inadequate clinical skills, failure to consult specialists and poor coordination of care. The average maternal death had 3.7 critical factors.

California set out to reduce maternal mortality and the California Maternal Quality Care Collaborative created “tool kits” for providers:

The first one, targeting obstetric bleeding, recommended things like “hemorrhage carts” for storing medications and supplies, crisis protocols for massive transfusions, and regular training and drills. Instead of the common practice of “eye-balling” blood loss, which often leads to underestimating the seriousness of a hemorrhage and delaying treatment, nurses learned to collect and weigh postpartum blood to get precise measurements.

In other words, the CMQCC set out to raise the index of suspicion and insistuted drills to deal with emergencies, not offer false reassurance pretending they aren’t happening. The results are very impressive:

Hospitals that adopted the toolkit saw a 21 percent decrease in near deaths from maternal bleeding in the first year; hospitals that didn’t use the protocol had a 1.2 percent reduction. By 2013, according to Main, maternal deaths in California fell to around 7 per 100,000 births, similar to the numbers in Canada, France and the Netherlands — a dramatic counter to the trends in other parts of the U.S.

Sadly, the focus on process ahead of outcome is not limited to childbirth; it has been extended to breastfeeding and the results there have been even more disastrous.

The Baby Friendly Hospital Initiative, designed to promote breastfeeding (a process), has led to a large and growing number of DEATHS (an outcome). Aggressive breastfeeding promotion, including policies against formula supplementation and mandatory rooming in of babies in their mothers’ hospital rooms have led to an epidemic of infant brain injuries and deaths from dehydration, hypoglycemia (low blood sugar), and babies smothering in or fracturing their skulls falling from mothers’ hospital beds. No matter, the BFHI cluelessly touts breastfeeding rates as if that, in an of itself, is a measure of quality, while studiously ignoring and sometimes aggressively denying the entirely preventable deaths that result.

Process, in both childbirth and breastfeeding, does matter, just like cup holders and interior upholstery matter in cars. But outcome is far more important than process. Consumer Reports should stop pretending that childbirth is safe and the only thing we need to do to improve it is to decrease interventions. That doesn’t mean that we shouldn’t try to reduce C-section rates and the rates of other interventions, just that those efforts should take a backseat to reducing deaths.

The mainstream press has been buzzing about a joint ProPublica/NPR piece about US maternal mortality. But in crafting the piece to create buzz, they’ve fundamentally misrepresented the problem.

It’s starts with the title, The Last Person You’d Expect to Die in Childbirth. Yes, Lauren Bloomstein was the LAST person you’d expect to die in childbirth and, arguably, she died of malpractice, not childbirth. Therefore, she is not representative in any way of the real issue.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion. [/pullquote]

The truth is that black women bear the brunt of pregnancy related deaths and they die for different reasons than white women, including lack of access to the technology that many white women take for granted.

What else did they get wrong?

1. It’s not clear that the US maternal mortality rate has even risen, let alone risen dramatically.

The ProPublica has a very impressive graph that shows US maternal mortality rising gradually from 1990 to 2000, and then rising steeply between 2000 to 2010, an overall increase of more than 56%. What the piece fails to mention is that US death certificates were changed twice over those years (in 1999 and again in 2003) in an effort to capture a greater proportion of maternal deaths and to capture deaths far longer after birth (one year, not 42 days) than previously. Other countries did not institute the same changes.

How much of the purported increase is due to changes in reporting? According to this 2017 paper, Factors Underlying the Temporal Increase in Maternal Mortality in the United States: all of it.

Recent increases in maternal mortality ratios in the United States are likely an artifact of improvements in surveillance and highlight past underestimation of maternal death.

A 2016 paper, Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues, reaches a slightly different conclusion.

most of the reported increase in maternal mortality rates from 2000–2014 was due to improved ascertainment of maternal deaths. However, combined data for 48 states and DC showed an increase in the estimated maternal mortality rate from 18.8 in 2000 to 23.8 in 2014 – a 26.6% increase.

2. What are the leading causes of maternal mortality?

The ProPublica piece presented a bar graph from Report from Maternal Mortality Review Committees. That report looked at data from only 4 states. The data for the entire US is available from the CDC:

Hypertensive disorders of pregnancy, which is what killed Lauren Bloomstein, used to be a leading cause of maternal death, but has dropped down to seventh. The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. And that reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before. This is yet another way that Lauren Bloomstein’s story is not representative of the issue of maternal mortality.

3. The dirty little secret about pregnancy: it’s dangerous.

If you have been reading the mainstream media over the last few years, you might have come away with the impression that pregnancy is safe and technology is being overused. Millions of gallons of ink have been spilled over the C-section rate (which is a process) and relatively little has been written about maternal mortality (which, as an outcome, is far more important).

ProPublica notes that 60% of maternal deaths are (potentially) preventable. But in order to prevent a death you have to suspect that something is going wrong, diagnose it and correct it. In other words, you have to use technology. There has been a relentless trend in the US and other developed countries to promote “normal birth.” Hospitals emphasize their decor and the availability of waterbirth, women bring their doulas and their birth plans, and doctors are cautioned repeatedly to reduce the routine application of technology like fetal monitoring and C-sections. It’s as if everyone has developed collective amnesia of the fact that pregnancy, in every time, place and culture (including our own) has ALWAYS been one the leading causes of death of young women.

Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion. As ProPublica notes:

Earlier this year, an analysis by the CDC Foundation of maternal mortality data from four states identified more than 20 “critical factors” that contributed to pregnancy-related deaths. Among the ones involving providers: lack of standardized policies, inadequate clinical skills, failure to consult specialists and poor coordination of care. The average maternal death had 3.7 critical factors.

Lauren’s death involved a myriad of these factors, but the most important is the one that isn’t mentioned: the low index of suspicion. In other words, no matter what happened, the doctor and nurses kept insisting that everything was fine while she was dying before their eyes. Instead of investigating her symptoms, everyone kept assuring her that she was fine. There’s a word for that kind of complacency: the word is malpractice.

The state of California has set out to eliminate complacency and their results have been impressive, particularly in cases like Lauren’s. In their initial assessment of maternal deaths in their state they found that the most preventable deaths were from “hemorrhage (70 percent) and preeclampsia (60 percent).”

The California researchers created a series of “tool kits” for doctors, nurses and hospitals and achieved impressive result. Yet the limiting factor in rolling out these programs to other hospitals is complacency.

“It’s very hard to get a hospital to provide resources to change something that they don’t see as a problem,” ACOG’s Barbara Levy said. “If they haven’t had a maternal death because they only deliver 500 babies a year, how many years is it going to be before they see a severe problem? It may be 10 years.”

4. The central role that race plays in maternal mortality.

ProPublica didn’t ignore the role of race, but by framing the piece with a story of a white woman who died as a result of malpractice, they fundamentally misrepresented the issue.

Black women bear the brunt of maternal mortality. When it comes to conveying the remarkable disparity, a picture is worth a thousand words:

And it’s not just a matter of socio-economic status. According to Predictors of maternal mortality and near-miss maternal morbidity:

…In multiple regression analysis, this difference could not be explained by other risk factors… These included age, obesity, history of a chronic medical condition, prior cesarean delivery and gravidity. Education level, marital status and public medical insurance status, factors traditionally associated with socioeconomic status, could not explain the disparity…

Considerable controversy exists about the biological reality of race. Nevertheless, in our study, as in others, race or ethnicity, as defined in ordinary social terms, is identified as a substantial risk factor for adverse maternal outcome. Since race and ethnicity rather consistently emerge as important factors in both obstetric and other medical situations, investigation of the causation is strongly indicated…

This finding has been reported in women of African descent living in other countries as well. It has considerable importance when comparing maternal mortality among countries. Though ProPublica implied that countries that have lower maternal mortality rates than the US provide better care, that is not necessarily the case. It’s hardly a coincidence that the countries with the lowest maternal mortality ar the “whitest” countries. The US has the highest proportion of women of African descent. Maternal mortality may just be a proxy for race not a measure of quality of care.

The take home message about maternal mortality in the US is a lot more nuanced than the ProPublica/NPR piece implied. It’s not a problem of privileged white women who are victims of malpractice. It is a problem with profound racial disparities and changing causes of death. And it’s also a story about what happens when people forget that pregnancy is inherently dangerous and demonize technology instead of using it to save lives.

No one seems to learn anything from the endless parade of preventable homebirth deaths.

There’s been another:

My beautiful son R Was born on May 9th. He only lived 31 hours…

It happened “suddenly.”

I was in labor for about 35 hours and pushed for about 6… My midwife checked the heartbeat after every time I pushed and the baby sounded happy and healthy. Until he didn’t. All of a sudden the heartbeat sounded off so she called the paramedics… I ended up giving birth in the ambulance … R. was not breathing and he didn’t have a heartbeat. They started to resuscitate him in the trauma room. He needed to be put on machines to breathe … But his condition got worse and worse. They told u s that he had no chance of survival and there was no brain function. So we let him go …

R’s mother is reeling:

…This was my first pregnancy and I had so many high hopes for a home birth. I had no fear. No doubt in my mind that everything was going to be perfect… I felt him moving until the very end. What happened? Also, apparently my placenta had a huge blood clot … could that have something to do with him passing.

Why does it sound so familiar, practically a routine homebirth outcome?

Maybe it’s because it sounds exactly like this homebirth disaster, But the baby’s heartrate was fine right before it dropped nearly dead into the homebirth midwife’s hands.

Or these: So many homebirth deaths I can barely keep track.

Or these: Homebirth death watch.

Maybe these: Homebirth hell, 5, no 6 dead babies in one WEEK!

Perhaps these: The cult of homebirth kills babies; 5 deaths in the last few weeks.

Why did this happen? It happened because R’s mother chose homebirth with undereducated, undertrained, ideologically brainwashed midwives.

It happened because magical thinking — positive affirmations, having no fear — has NO impact on the incidence of complications and death.

It happened because intermittent Doppler monitoring is not as accurate as electronic fetal monitoring.

For example, this tracing shows a baby in serious trouble:

Surprised? You might be if you thought that a fetal heart rate tracing supplied the same information as intermittent auscultation (listening) with a doppler. But electronic fetal monitoring provides a wealth of information that cannot be obtained by listening, and that allows for a more comprehensive view of fetal well being.

This is a tracing with limited beat to beat variability and subtle late decelerations.

Notice what you don’t see:

You don’t see a bradycardia, a sustained period of abnormally low heart rate. That’s because bradycardia is often a terminal event. Most babies can tolerate long periods of significant oxygen deprivation before they die, and they may not have any bradycardias until immediately before death. On this tracing, there is never a single moment when the heart rate is outside of the normal range, but the baby is nonetheless suffering from serious oxygen deprivation.

This is almost certainly what is happening in hours before a dead or nearly dead baby drops into a homebirth midwife’s hands. The midwife may be intermittently listening to the baby’s heart rate, but unless she is listening for long enough AND frequently enough AND exactly at the right times AND can distinguish subtle changes in heart rate, she will be blissfully unaware that a baby is dying right in front of her.

Homebirth advocates and their midwives who insist that the baby’s heart rate was “fine” until just before delivery are almost always completely wrong. The baby’s heart rate was not fine; they just couldn’t tell what was happening because they only listened intermittently.

And because they couldn’t tell, the baby died.

Most of all, these entirely preventable homebirth deaths keep happening because homebirth advocates construct a wall of denial around every death, insisting that even though their family, friends, and doctors warned them that EXACTLY THIS TRAGEDY was more likely to happen at homebirth, the fact that it happened is just an amazing coincidence!

Like this one:

…My story is similar to your. We heard a healthy heartbeat shortly before birth and baby was making strong movements an hour before. My sweet E was born sleeping at home with no warning that anything was wrong.

Or this one:

I attended a birth where the baby passed in labour, (their first baby), it was terrible and shocking! … Life has some really tough lessons. We can grow and learn and use these experiences for positive change.

Apparently not.

No one seems to learn anything from the endless parade of preventable homebirth deaths.

I’ve long thought that lactivists were being deliberately obtuse about the assertion that Fed Is Best. They repeatedly claim, with no plausible justification, that Fed Is Best means routine supplementation with formula for all infants.

I’ve recently revised my assessment. Maybe lactivists aren’t being obtuse; maybe they just don’t get it. There’s a critical difference between ‘fed is best’ and ‘breast is best’ and lactivists imagine the difference is formula. They’re wrong:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Fed Is Best is about safety; Breast Is Best is about process. The difference between the two is the difference between life and death.[/pullquote]

Fed Is Best is about safety; Breast Is Best is about process. The difference between the two is the difference between life and death. Seems simple, but it’s a difference that lactivists seem incapable of understanding.

For example, I’ve been participating discussion about insufficient breastmilk in a private group.

Someone asked me:

Truthfully Dr Amy, is it your professional opinion all neonates should be supplemented in order to prevent dehydration, brain injury and/or death?

I answered:

I view breastfeeding like vision; both have a natural failure rate. It would be malpractice for me to tell a mother who reports that her child doesn’t seem to able to see that she should ignore it since most children see just fine. Similarly, it is malpractice to tell a mother who reports that her child seems desperately hungry that she should ignore it since most babies don’t need supplementation.

I am no more in favor of universal formula supplementation than I am in favor of giving every new baby a pair of glasses. (emphasis added)

And:

When I did my pediatrics rotation in medical school, the preceptor told me something I never forgot: when a mother tells you her baby is suffering, believe her!

So when a mother tells me that her baby is screaming from hunger, no one, regardless of any policy, should ignore her. It is up to the professional to make sure that the baby is fine, not simply insist that the baby must be fine since most babies are fine.

I thought I couldn’t possibly be clearer, yet this was the response:

To be honest, that doesn’t clarify it for me. I’m still not sure where you stand as I feel you contradict yourself. I don’t say that in an antagonistic way. I’m genuinely confused.

Confused? What could she possibly be confused about? It certainly can’t be the meaning of my words since I was very plain. I guess she’s confused because since she’s obsessed with breastmilk, she imagines that I must be obsessed with formula.

No, I am obsessed with safety. That’s why lactivists’ claims that “fed is best” means you can feed your infant McDonald’s are wrong. Fed Is Best advocates don’t believe that McDonald’s is safe for infants anymore than they believe that goat’s milk or homemade formula is safe for infants.

Meg Nagle IBCLC doesn’t get it either.

To say “nothing happens” with supplementing is incredibly hard for me to read because I’ve seen first hand the incredibly challenging situations women and babies find themselves in when their child has a reaction to formula. My friend’s baby was seriously ill in hospital for 3 months. She was routinely pushed to “fortify” (put formula) into her expressed milk. When she finally fell to this pressure he had a severe reaction and immediately threw it all up. She refused to allow this again. I’ve seen so many women in my office telling me the challenges they have faced trying to find a supplement that doesn’t make their baby have a serious reaction. So no. For many families supplement is a big deal and does cause further complications…

Situations? ONE baby who simply threw up? That was the “incredibly challenging situation?” A seriously ill baby wasn’t getting enough nutrition and Meg thinks the problem in that situation is that the baby threw up formula? Sure, formula might not have agreed with that baby, but it was worth trying since the only other alternatives might be malnutrition or an IV to administer TPN (total parenteral nutrition).

Does a baby who is not getting enough need to be fed? YES. Does a baby who is getting enough need to be supplemented? NO.

Duh!

Fed Is Best advocates do NOT recommend routine supplementation with formula for every infant. Why would we when our concern is safety? Babies growing and thriving on breastmilk are safe. But babies who aren’t growing, who aren’t thriving, who are screaming from hunger even after being offered the breast repeatedly AREN’T safe. Those babies should be supplemented to assure they are adequately fed.

Meg, a baby vomiting up a bottle of formula is “an incredibly challenging situation”? Really? I’ve got news for you: a baby struggling with permanent brain damage from dehydration or hypoglycemia is more challenging. Most challenging of all is a baby who dies a preventable death because lactation consultants like you demonize supplementation.

Breast Isn’t Best. Fed is Best because Safety Is Best. It’s just that simple.

For the past two days I’ve been engaged in a discussion in a private Facebook group about the injuries and deaths caused by lactation consultants who lie. As anticipated, I was met with a wall of denial from lactation professionals. During the course of the discussion I presented more than a dozen scientific citations and those disagreeing with me presented zero, yet that didn’t move the lactation professionals even a tiny bit. Neither did the reports of infant injuries and deaths including the heartbreaking and entirely preventable death of Baby Landon Johnson.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Making breastfeeding readmissions never events will reduce the epidemic of babies injured by relentless promotion of exclusive breastfeeding. It will save babies and it will save money — the ultimate win-win.[/pullquote]

As I noted earlier this week — lactivists lie first and foremost to themselves and each other — claiming that insufficient breastmilk is rare when it is common. The purported justification is that women are “designed” to breastfeed. It’s like insisting that nearsightedness is rare because eyes are designed to see.

The wall of denial illustrates the primary problem with lactation consultants; they aren’t real medical professionals. When a patient dies from a hospital error — and, make no mistake, infant injuries and deaths from exclusive breastfeeding are hospital errors — real medical professionals ask, “how can we avoid this happening to anyone else?” Lactation consultants, in contrast, ask, “how can we avoid blame?”

Therefore, the best way to protect babies from lactation consultants who lie is to force hospitals to monitor them. The best way to do that is to designate breastfeeding readmissions as “never events.”

What are “never events”?

According to the Agency for Healthcare Research and Quality (AHRQ):

The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable…

For example, the “death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy” is a never event.

Hospitals should do everything in their power to prevent never events, since the whole point is that they should never happen. As a result:

Because Never Events are devastating and preventable, health care organizations are under increasing pressure to eliminate them completely. The Centers for Medicare and Medicaid Services (CMS) announced in August 2007 that Medicare would no longer pay for additional costs associated with many preventable errors, including those considered Never Events. Since then, many states and private insurers have adopted similar policies…

In other words, when a hospital presides over a never event, they will not be reimbursed for the treatment required as a result. That’s a tremendous impetus for hospitals to do everything in their power to prevent never events. Most importantly, it an unbiased, independent method of holding hospital employees to account even when hospitals themselves would prefer not to do so.

There are currently 29 designated never events. We should add a thirtieth: death or serious injury of a neonate associated with exclusive breastfeeding in a low-risk pregnancy that occurs within the first two weeks after birth.

If hospitals had to bear the cost of readmissions for dehydration, hypoglycemia and starvation, it wouldn’t merely break a hole in lactation consultants’ wall of denial about the high incidence of insufficient breastmilk; it would obliterate it.

How common are such readmissions?

According to this 2013 paper in the journal Pediatric Emergency Care:

In the neonatal period, dehydration … is one of the most common causes of re- hospitalization. According to the serum osmolality, dehydration is classified into 3 forms as hypernatremic, normonatremic, and hyponatremic dehydration. Hypernatremic type is a potentially lethal form because it adversely affects central nervous system, leading to devastating consequences such as intracranial hemor- rhage, thrombosis, and even death. Recently, along with many other etiologies, early discharge and failure of breast-feeding are increasingly documented as major causes of hypernatremic dehydration.

High serum sodium (Na) concentration, which is associated with diminished fluid or excessive Na intake, or excessive fluid loss, is usually caused by inadequate breast-milk feeding in otherwise healthy newborns…

How common is readmission for neonatal dehydration?

During the study period, 4280 neonates were admitted to NICU. Among them, 97 had HD. Sixteen patients were ex- cluded from the study. Prevalence of HD was 1.8% (81/4280). All the patients were fed with breast milk. Fifty-nine patients were born in our hospital; 51 patients were discharged from the hospital within the first 48 hours of life.

And that’s just readmissions for dehydration. When you add hypoglycemia and injuries that result from infants falling from or smothering in mothers’ hospital beds the numbers would be considerably higher.

The cost to the hospital if insurance companies refused to pay for these readmissions would be enormous. As a result, we could expect to see hospitals’ risk management departments undertake thorough education on monitoring of its lactation consultants.

At the moment, lactation consultants have no accountability when babies are injured or die as a result of their lies and their relentless promotion of exclusive breastfeeding and near pathological resistance to the benefits of formula supplementation. That would change quite dramatically and it would no longer be possible for them to continue lying to themselves, each other and vulnerable new mothers.

If we take lactation consultants at their word, they should be delighted to accept accountability. According to them, neonatal injuries and deaths as a result of exclusive breastfeeding are vanishingly rare and are prevented when lactation consultants assiduously weigh and monitor newborns and offer timely formula supplementation.

If they’re wrong, it’s going to cost hospitals a fortune. As a result lactation consultants will no longer be free to ignore scientific evidence in favor of ideology. Moreover, they will start telling mothers the truth about the fact that insufficient breastmilk is common, particularly during the first few days after birth. They will teach mothers to look for and respond to the signs of dehydration instead of falsely reassuring them that these warning signs are no reason to be concerned.

Most importantly, making breastfeeding readmissions never events will reduce the epidemic of babies injured and even killed by overzealous encouragement of breastfeeding.

It will save babies and it will save money — the ultimate win-win.