One of the most depressing things about the philosophy of natural childbirth is that it treats women like children who can be chivvied into believing sugar coated nonsense. Perhaps the premier example of this tendency toward infantilizing grown women is the bizarre claim that birth represents woman at her most powerful. Milli Hill purveys this ridiculous drivel in her recent piece in The Guardian while whining that Facebook removed images that violate their policies:

You could argue that this is simply about nudity, but I think there’s more to it. Social media reflects our wider culture’s issue, not with naked women, but with naked women who look real and active as opposed to air-brushed and passive. It also reflects millennia of attempts to suppress women’s power, of which childbirth is perhaps the ultimate expression.

Oh, please, Milli; grow up! Women have been giving birth vaginally without pain medication (or dying in the attempt) since the beginning of human existence, and until relatively recently, women have had ZERO power. Indeed, in countries that lack access to modern obstetrics, where every woman is forced to endure natural childbirth, women still have ZERO power. In such societies women are viewed as the property of their husbands, have no political or economic rights, are married off while still children, die in droves due to hideous maternal mortality rates, have their genitals mutilated, and are raped with impunity in war and often in peace as well. Does that sound like power to you, Milli?

The idea that childbirth reflects women’s power would be ludicrous if it weren’t so offensive. Obviously Hill isn’t talking about poor women, women of color, women living a subsistence existence in developing countries. She’s not talking about THOSE women, who are the majority of women in the world. Hill is apparently talking about privileged, Western, white women like herself who are apparently the only ones who count.

But, you know what, Milli, you’re wrong about those women, too. In industrialized countries that accord women legal and economic rights, birth does NOT represent women at their most powerful. It represents women at their LEAST powerful.

There is no power in being in agonizing pain, incapable of doing anything other than screaming or moaning, barely rational, and totally bereft of the capacity to control anything. A woman in labor surrenders all her power to others. A woman in labor is extraordinarily vulnerable and is at the mercy of anyone who walks by. She can’t defend herself, she can’t assert herself, she can’t express herself, she can’t care for others and she can’t care for herself if the need arises.

Yes, the process of labor is powerful. Once it has a woman in its grip, it does not let go until the baby is born or the woman is dead. It’s powerful in the same way that a tornado or an earthquake is powerful. Claiming that labor represents woman at her most powerful, is like claiming that a woman sucked out of her tornado ravaged house is powerful. In both cases she is subjected to powerful natural forces, but she herself is completely powerless.

Birth doesn’t merely render women physically powerless, the storm of hormones that surround and follow birth can also render them emotionally powerless. Many women have trouble controlling their emotions, may experience unexpected sadness, depression and in severe cases, major mental illness. In addition, many women are uniquely vulnerable to psychological manipulation in the days and weeks following birth because they are overwhelmed with love for the new baby and desperate to do their best in caring for him or her. They can be helpless to defend themselves against the depredations of natural childbirth advocates and lactivists who gleefully shame them with false accusations that a baby won’t bond to a mother who had medication during labor or who chooses not to breastfeed.

No, Milli, birth does not represent woman at her most powerful, it represents woman at her most vulnerable, and anyone who claims to care for pregnant women and new mothers should recognize and acknowledge that. To the extent that some women are powerful, their power resides in their intellect, their talents, their money, their political power (if they wield any), their military power (if they wield any), their degrees, their qualifications, and their work experience. Powerful women do not derive their power from having a baby transit their vagina, and it is pure nonsense to pretend that they do.

Natural childbirth advocates need to stop treating women like preschoolers. It is fine to tell a toddler that using the potty means she is a “big girl,” but it is demeaning to tell a grown woman that pushing a baby out through her vagina means that she is “powerful.” Expecting women to accept sugar coated lies in place of real power simply emphasizes their powerlessness.

Oh, the horror!

Milli Hill of The Positive Birth Movement is outraged.

Over the weekend, Facebook removed two images from our page and subjected myself and my organisation to a 24-hour ban. This was because, in its words, the images “violated community standards”. Neither image fits the stereotypical picture that most of us have of birth. In the first, a woman kneels: she looks composed, vital and beautiful. The second shows a baby emerging underwater into her mother’s own hands.

You could argue that this is simply about nudity, but I think there’s more to it. Social media reflects our wider culture’s issue, not with naked women, but with naked women who look real and active as opposed to air-brushed and passive. It also reflects millennia of attempts to suppress women’s power, of which childbirth is perhaps the ultimate expression.

Hill needs to get a grip. Are we supposed to imagine that Mark Zuckerberg, Sheryl Sandberg, and their minions at Facebook spent even a microsecond imagining that images of naked natural childbirth advocates reflect “women’s power,” let alone plotted to suppress them? Hill’s presumption is breathtaking in its narcissism. We all know that the photos were likely flagged by an algorithm (or by disgruntled readers) and removed because they violate the policy of a private corporation. No one at Facebook cares about Milli Hill, about natural childbirth, or whether or not images of naked natural childbirth advocates are reflections of their power.

Hill demonstrates, yet again, that natural childbirth, far from being a feminist issue is an issue of privileged, Western, white, relatively well off women who think that the worst thing that can happen to them is that Facebook is interfering with their freedom of expression.

Make no mistake, childbirth is, indeed, a feminist issue, and we should all be working to end maternal mortality, prematurity, neonatal death, obstetric fistula, lack of access to birth control, and the shackling of women prisoners in labor, among other issues that violate the rights of women and limit their ability to pursue their own happiness. But those are issues that disproportionally affect poor women, women of color and women of underdeveloped countries. Who cares about them? Certainly not natural childbirth advocates.

Indeed, natural childbirth advocacy has a long and sordid history of exploiting poor women of color. It started with Grantly Dick-Read, the father of natural childbirth, who based its philosophy on the racist claim that “primitive women” (read “women of color”) are fundamentally different from white women, simultaneously simple (longing only to reproduce) and unafraid of dying in childbirth, rendering them immune to the pain and dangers of birth.

That racist trope is alive and well among contemporary natural childbirth advocates who pretend to themselves that they are re-enacting childbirth among indigenous peoples. Their fantasy bears as much resemblance to childbirth in nature as a 3rd grade Thanksgiving play bears to the real relationship between the Pilgrims and the “uncivilized” Native Americans they came to displace.

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

The philosophy of natural childbirth is a rejection of privilege that simultaneously confirms it. Simply put, you have to be privileged enough to have easy access to safe pain relief in labor in order to give meaning to refusing it. You have to be privileged enough to have immediate access to high quality emergency obstetric services in order to give meaning and assure safety to refusing the testing and procedures (“interventions”) designed to prevent those emergencies in the first place.

Milli Hill has helpfully demonstrated, yet again, the incredible privilege of the Western, white, relatively well off women who imagine that by refusing pain medication they are demonstrating their “power” and who in their egotism pretend that when Facebook applies the same standards to them as to everyone else, they are somehow singling them out for special treatment.

Sorry to disappoint you, Milli Hill; while childbirth is a feminist issue, natural childbirth is not. Feminists everywhere should be working to put an end to the scourges of maternal mortality, prematurity, neonatal death, obstetric fistula, lack of access to birth control, and the shackling of women prisoners in labor, among other issues. In a list of the top 10 feminist childbirth issues, however, the removal from Facebook of photos depicting naked natural childbirth advocates giving birth ranks approximately 29th.

We are all anti-bullying now.

We recognize that bullying based on race is wrong; bullying based on religion is wrong; bullying based on gender is wrong; bullying based on sexual orientation is wrong. In fact, there’s only one group that it is still acceptable to bully: new mothers.

And who are the bullies? Lactivists, natural childbirth activists, and the natural parenting industry.

How do these activists and industries bully new mothers? Let me count the ways.

1. Through the perversion of science

From individual lactivists to the so-called Baby Friendly Hospital Initiative, from individual birth bloggers to large organizations like Lamaze International and the Childbirth Connection, natural parenting advocates pervert the scientific evidence on breastfeeding and childbirth.

Yes, breastfeeding has real benefits, but those benefits are trivial in industrialized countries. That’s not surprising when you consider that the benefits of breastfeeding evolved in nature, where unsafe water supplies, scarce sources of food, and a myriad of untreatable pathogens pose a constant and massive threat to babies’ lives. In that setting, a safe source of water and nutrients, always available, generally present in adequate amounts, usually pathogen free and tailored to the specific needs of infants is the difference between life and death.

In first world countries, however, where we have safe water supplies, adequate sources of food and treatments for most pathogens, those threats to babies have largely disappeared. Infant formula is an excellent source of infant nutrition, safe, plentiful and convenient. Lactivists have chosen to ignore those changes and instead grossly exaggerate the benefits of breastfeeding, grossly exaggerate the “risks” of formula feeding, and use weak, poorly controlled and conflicting studies to do so. When all else fails, lying about breastfeeding and bonding is employed.

The perversion of science is, if anything, even worse in natural childbirth advocacy. Childbirth with modern obstetrics is actually dramatically safer than natural childbirth. That hasn’t stopped activists from lying about it. There is no lie that is too ridiculous for natural childbirth advocates to swallow: Michel Odent says pain is necessary for bonding; midwives promote “normal” birth as if the process is more important than the outcome; and there is no limit to the nonsense that issues forth from the mouths and pens of natural childbirth advocates (C-sections change DNA??!! C-sections destroy the infant microbiome??!!)

Lactivists and natural childbirth advocates repeatedly pervert science in order to use it as a cudgel with which to beat women who don’t conform to their values.

2. Emotional abuse

Among middle school girls there is probably no insult more devastating than “no one likes you.” That’s why it is wielded so promiscuously among middle school bullies. Among new mothers there is probably no insult more devastating than “your baby hasn’t bonded to you.” That’s why lactivist and natural childbirth bullies wield it so promiscuously among new mothers. There is NO EVIDENCE that bottle fed babies are less bonded to their mothers than breastfed babies; there is NO EVIDENCE that C-section babies are less bonded to their mothers than babies born by vaginal delivery. That hasn’t stopped activists from repeately invoking bonding to force new mothers into compliance with the ethos of the group.

3. Petty humiliations

“You only think you didn’t produce enough milk for your baby.”

“Your C-section was unnecessary.”

“Bottle feeding is so much easier; not suprising that you gave up breastfeeding and used formula instead.”

Or the humble brag version: “I breastfeed because I’m lazy. Who wants to sterilize all those bottles?”

“What a shame that your baby was born drugged because you gave in and got an epidural.”

4. Veneration of the biggest bullies

Many breastfeeding and birth bloggers are queen bees. They have arranged their little kingdoms to seek adulation from the minions. They practice shunning and silencing of those who disagree (through deleting and banning). They constantly emphasize their specialness and the specialness of their followers. They routinely shame those who will not go along.

Don’t believe me? I have two words for you: Alpha Parent.

5. Institutional humiliations

The Baby Friendly Hospital Initiative has to be the biggest oxymoron in contemporary maternity care. This credentialing initiative isn’t baby friendly and it certainly isn’t mother friendly. It’s bully friendly. It is based on the premise that any woman who doesn’t wholeheartedly embrace breastfeeding must be forced to do so by constant hectoring, shaming, inconvenience (locking up formula), sleep deprivation (mandatory rooming in) and punishment (banning formula gifts).

To my knowledge, neither the component “steps” nor the program itself have ever been shown to increase long term breastfeeding rates. Their only “success” is increasing the number of women who claim they will be breastfeeding when they leave the hospital, not the number who actually do.

I could go on, but I think you get the idea. Most of what passes for lactivism and natural childbirth advocacy is poorly disguised bullying.

Although we have gone a long way toward reducing bullying based on race, religion, gender and sexual orientation, we have a long, long way to go. The tendency to bully appears to be innate to human beings; therefore, we must always be on guard against it.

Unfortunately, new motherhood appears to be the last bastion of acceptable bullying, where shaming, blaming and humiliating new mothers has been sugar coated as “science” and “education” when it is neither. It’s just old fashioned bullying, and the sooner we acknowledge that, the better.

Last Friday’s post on The Leaky Boob’s lie has generated a lot of discussion about Jessica Martin-Weber and her lie that she exclusively breastfed 6 children while the reality was that she often used bottles and sometimes used formula.

There are lots of problems with that lie, but one problem is bigger than all the others.

First the small problems:

1. It is wrong to lie

That pretty much goes without saying. Lying is not a good way to relate to others. It is a fundamental violation of their trust and has long term consequences. People will be much less likely to trust you going forward.

2. It is wrong to hold yourself out as a role model

Our heroes have feet of clay; that’s hardly news, but it is still disappointing. That’s why anyone who presumes to hold herself out as a lactivist hero as Martin-Weber did should be very sure that she is modeling the behavior that she extols. Martin-Weber knew the entire time that she was presenting herself as a hero, she was actually engaging in the very behavior she was ostentatiously condemning in print.

3. It is wrong to value process over outcome

Of course this is standard operating procedure for natural childbirth advocates and lactivists. Instead of judging their mothering skills by how their children turn out (which raises the possibility that they might not end up being declared perfect mothers), they evaluate their mothering skills by comparison with an arbitrary ideal. That way they can preen of their motherly perfection without the pesky need to wait until their children grow up and see how they turn out.

But most importantly:

4. The Leaky Boob’s Lie demonstrates that lactivism isn’t about breastfeeding, and it isn’t even about babies. It’s about mothers and their own self-image.

Why was Jessica Martin-Ellis writing about her breastfeeding experiences in the first place? It wasn’t to benefit her children since they couldn’t care less how random strangers view their mother. And it wasn’t to help other mothers with their breastfeeding difficulties since Martin-Weber refused to be honest about her own.

Martin-Weber was writing (dishonestly) about her breastfeeding experiences in order to bask in the adulation of strangers and boost her own self-esteem. That’s because lactivism isn’t about feeding and it isn’t about babies. It’s about some women trying to convince themselves that they are better than other women and grossly inflating the benefits and value of breastfeeding in order to do it. Breastfeeding isn’t that important to babies, but it’s desperately important to lactivists.

Lactivism is about image and new mothers would benefit greatly by realizing that. No mother should feel guilty about breastfeeding, because it is trivial in the overall scheme of child rearing. Those who wish to convince you differently have their OWN best interests at heart, not yours and not your children’s. In fact, they are so concerned about their own interests that they are willing to lie to maintain those interests.

Imagine if I made the following claim: Sexual intercourse is the perfect method of reproduction, formed by natural selection to result in a perfect baby every time. After you picked yourself up off the floor from laughing so hard, you’d probably point out a number of facts to me:

1. Every episode of sexual intercourse does not result in conception.

2. Every conception does not result in pregnancy.

3. Fully 20% of established pregnancies naturally end in miscarriage.

4. Many babies are born premature and die as a result.

5. Some babies are born with birth defects and die as a result.

So how have human beings taken over the planet, expanding from a population of perhaps 10,000 early in human history to 7 billion today?

First, population expansion does not require perfection in reproduction; it only requires more people in the next generation than in the one before. If a couple has 10 children and 7 of them die, the population still expands. Second, technology has dramatically improved our ability to survive and thrive in a myriad of environments, including those previous inhospitable to humans.

That’s because nature doesn’t do “perfect”; it only does “good enough.”

I would think that journalist Michael Pollan, often described as a “liberal foodie intellectual” would understand that, but apparently not. In a recent interview in the magazine Lucky Peach, Pollan makes the following absurd claim:

Breast milk is the perfect food, formed by natural selection to have everything the developing child—and its microbiota—needs. We’ve spent almost two hundred years trying to simulate it, because food companies can’t make money when people are nursing their babies.

Let me pick myself up off the floor from laughing so hard, and point out a number of facts to Michael Pollan:

1. Every pregnancy that results in a live baby does not result in a live mother. No mother = no breastmilk.

2. A mother’s ability to produce breastmilk exists on a continuum just like most other human characteristics. Most women will produce enough, but a lot of women will fall short and their babies would die if not for supplementation.

3. Breast milk is not a perfect food. For example, it does not contain enough Vitamin K to prevent hemorrhagic disease of the newborn in a significant number of babies. Those babies “naturally” die by bleeding to death.

4. Babies are not perfect, either. While most will be able to breastfeed successfully, not all will and if they can’t figure it out in time, they will simply die of starvation.

5. Breastmilk substitutes have existed long before the advent of record history. Babies whose mothers died were nursed by other women (wet nurses). Babies whose mothers couldn’t produce enough milk received milk from goats and cows. Throughout recorded history, women supplemented breastmilk with a wide variety of substances.

6. Formula was not created by corporations. It was created by doctors who were tired of seeing so many babies die for lack of breastmilk and because previous supplements were contaminated with bacteria or lacking in adequate nutrition.

That’s because nature does not do “perfect”; it only does “good enough.” Breastmilk isn’t perfect and neither is breastfeeding. It is only good enough, and Pollan ought to know that.

According to Pollan:

It’s human arrogance to think we can outwit nature.

To which I would say:

It is the human tendency to romanticism to pretend that we do anything other than outwit nature every moment of every day of every year. Nature is not that nice lady wearing a flower crown in the Chiffon Margarine commercial. That was an advertising campaign that thoroughly misrepresented nature in order to sell a product. Nature is heartless. Starvation is natural. Drought is natural. Disease is natural. Earthquakes, tornados and hurricanes are natural. War is natural. Infanticide is natural.

Everyone who lives in a house outwits nature. Everyone who wears clothes outwits nature. Everyone who cooks their meat instead of eating it raw outwits nature. Everyone who ever took an antibiotic to cure an infection, a vaccine to prevent smallpox, or had surgery to removed an inflamed appendix has outwitted nature. Every one of the many, many millions of babies who survived because of formula has successfully outwitted nature.

Breastmilk is good. It has advantage over formula, although in industrialized societies those advantages are trivial. It is not perfect because nothing in nature is perfect. I would venture to guess that the human tendency to romanticize nature, as Pollan has done with breastmilk, is entirely natural. That doesn’t change the fact that it is nothing more than a touching fantasy beloved of intellectuals, most of whom who wouldn’t last 5 minutes if they actually had to live in nature.

She’s hardly the first prominent person to lie in order to maintain her place in the natural parenting pantheon.

Actress Kate Winslet lied about the birth of her first baby Mia because she was ashamed of her C-section.

Attachment parenting guru Katie Granju (MamaPundit) lied by omission about her late son’s drug use, painting a picture of an idyllic family life that was anything but.

Now comes word that Jessica Martin-Weber of The Leaky Boob has lied about breastfeeding, and she is ashamed (The Romanticized Myth of What Constitutes Successful Breastfeeding- An Apology.)

… My shame is that I upheld an artificial picture of what it looked like to successfully breastfeed and called it supporting the WHO Code.

My shame is that my actions supported the WHO Code more than they supported women, babies, and families….

Screw shame. I’m done. And I’m sorry. I’m deeply sorry that it has taken 3 years for me to find my courage to take the stand I live but never shared here. I’m sorry that I’ve not been honest…

For every single one of my 6 beautiful children, bottles and breast have been a part of me reaching my goals. And not just because I had to go back to work. I choose to go back to work, I love working and am a better parent when I work, but even when I didn’t work outside the home, I elected to partially bottle feed my milk to my baby. This was a positive thing for me as I get physically stimulated very easily and as an introvert found the need to create some space for myself. I did better mentally and emotionally, which meant I was in a healthier place mentally and emotionally to parent my children. It was the best healthy choice for us. I have never, not once, regretted it. Today, with a breastfeeding 2.5 year old, I also don’t believe it ever interfered with our breastfeeding nor did bottles have a negative impact on me reaching my breastfeeding goals.

In fact, I firmly believe that without bottles, I would have quit breastfeeding early on.

That’s particularly ironic in light of what Martin-Weber wrote early this year in a guest post on The Fearless Formula Feeder’s Blog:

… Sometimes tough love really isn’t tough love, it’s a power trip down false-sense-of-superiority lane.

Even those purporting to support families. Birth, breastfeeding, and, ironically, gentle parenting advocates, far too often resort to shaming other parents. Because that makes sense, something negative is going to have a lasting, positive impact. Undermining parents’ confidence surely is going to result in change for the better, right?

Wrong.

It may get your website page views, it may increase your “talking about” numbers on Facebook, it may even get people pinning your content on Pinterest. But helping people? … Shaming is intentionally trying to make someone not only feel guilt but to internalize it as believing that somehow they are bad/lazy/stupid/unloving/pathetic/unloveable/worthless as a result. Ultimately, shaming comes from a desire to see someone feel bad about themselves…

The Leaky Boob isn’t about that kind of passion. The information, images, stories, and interactions we share are meant to inspire and encourage people. While we can’t control nor are we responsible for the emotions of others, we don’t intentionally try to manipulate others’ feelings.

Yet at the same moment that Martin-Weber was declaring that she doesn’t intentionally try to manipulate others’ feelings, she was busily manipulating others’ feelings.

To her credit, Martin-Weber is eloquent in her understanding of what she has done:

Through The Leaky Boob I have contributed to a beautiful yet often unattainable depiction of what it looks like to breastfeed. In my attempt to normalize breastfeeding and provide support up what breastfeeding looks like, I have held up at the breast breastfeeding as being more beautiful, more important, more viable, more worthy of sharing and discussing and promoting than any other infant feeding methodology…

… [F]or the last 4 years as The Leaky Boob I have not been entirely honest with you. As a public voice in breastfeeding support, I have contributed to a mythical image of breastfeeding. I wish I could say it wasn’t intentional but it was and of the 4 years I’ve been doing The Leaky Boob, I have wrestled with this for three years. Motivated by fear, I allowed myself to present a picture of my breastfeeding journey and an idealized image of “successful” breastfeeding that simply wasn’t true. Well, not true for me anyway and likely not true for many of you. And I know holding that ideal up was damaging for some and a sort of betrayal for others. It wasn’t that I overtly lied, it was more of an omission of truth. I was wrong to do so and I am sorry.

She is deeply insightful about her motivation:

Leakies I am sorry I never shared images of my babies and other babies receiving bottles. I was wrong to only ever present a side of my infant feeding journey that was safe for me as a public breastfeeding supporter. Anxious that I would be inviting drama and attacks from other breastfeeding supporters, educators, blogs, organizations, and my own readers, I didn’t want to risk being accused of being a WHO Code violator by posting pictures of my babies with their bottles. Specially since I do make some income from The Leaky Boob, I was concerned that if I ever even showed bottle feeding some would think it was sending the wrong message.

But message or not, this is the truth: my babies, all 6 of them, got bottles. One got mostly formula in her bottles. Back when I was attending women as they had their babies, often I was helping a new mother and baby pair with their first few feedings while my baby was at home getting a bottle of my milk…

She ends with a heartfelt apology:

By intentionally keeping that part of my breastfeeding journey quiet, by not sharing images of my baby receiving a bottle, by just sharing images of my babies feeding only at my breasts, and by neglecting the real life bottled-up aspects of the breastfeeding journeys of others, I perpetuated a romanticized myth of what constitutes successful breastfeeding.

I am sorry. Please forgive me.

With all my love, sincerely,

~Jessica

What can we learn from this episode?

First, many natural parenting advocates are not honest about what they really do. They hold up an ideal of birth, or breastfeeding, or attachment parenting that is unachievable even by them.

Second, a great deal of natural parenting is not about what is good for babies. The natural parenting advocates who lie about what they’ve been doing are good parents; the fact that they’ve done what is best for their children demonstrates that they care above all for the wellbeing of their children, and that their commitment to ideology comes in second.

Third, natural childbirth, lactivism and attachment parenting is about women boosting their own self esteem by projecting an image of themselves as “better” mothers than other women. It’s about competition among sanctimommies, and the many women who are hurt by it are collateral damage.

Fourth, and perhaps most important, natural parenting advocacy has created a world where women feel compelled to lie in order to preserve their status among their peers. Instead of sharing true images of birth. breastfeeding and parenting, they present a carefully curated image designed to impress.

The take home message, in my view, is this:

Every mother needs to do what she thinks is best for her child and herself, without regard to what other women insist is correct. That’s what Jessica Martin-Weber did even if she didn’t have the courage to admit it.

The next step is creating a world in which is doesn’t take courage to admit that you put your children ahead of your ideology.

Natural childbirth advocates are obsessed with unmedicated vaginal birth with no interventions of any kind. That’s because they value process over outcome. How a baby is born is apparently more important than whether it is born dead or alive, healthy or brain injured.

Unfortunately, the natural childbirth obsession with process at the expense of outcome has infiltrated conventional medicine. Just as natural childbirth advocates judge hospitals and providers by C-section rates and induction rates, cost cutters and self-appointed avatars of quality like Consumer Reports have fallen prey to woo. Hence the bizarre invocation of C-section rates and induction rates and measures of “quality.”

There’s just one problem. The process of birth has NOTHING to do with the outcome. A new paper in the Journal of the American Medical Association (JAMA) makes that crystal clear. The paper is Association Between Hospital-Level Obstetric Quality Indicators and Maternal and Neonatal Morbidity by Howell et al. A more accurate title would be Oops! There is No Association Between Hospital-Level Obstetric Quality Indicators and Maternal and Neonatal Outcome.

As part of its core measure set, The Joint Commission now recommends 2 perinatal quality measures that address important aspects of obstetric care during childbirth: elective deliveries performed prior to 39 weeks of gestation and cesarean deliveries performed in low-risk nulliparous women. The elective delivery measure, which includes nonmedically indicated deliveries associated with medical induction or cesarean delivery at more than 37 weeks and prior to 39 weeks of gestation, is also mandated by the Centers for Medicare & Medicaid Services.11 The elective delivery before 39 weeks of gestation indicator is intended to reduce neonatal complications among term infants. Assessing rates of cesarean delivery performed in low-risk patients is intended to reduce unnecessary variation in rates of cesarean delivery. Both of these measures may be associated with maternal outcomes. However, how well hospital performance on these quality indicators correlates with maternal or neonatal morbidity is not known.(my emphasis)

In other words, C-section rates and inductions rates became indicators of “quality” without anyone bothering to determine if they had anything to do with quality. Why? I suspect that it is because of the unholy alliance between natural childbirth advocates and cost cutters. Natural childbirth advocates have managed to convince cost cutters that “unhindered” vaginal birth is “better” because it saves money. The truth is that rather different on both counts.

Howell et al. looked at births in New York State in 2010:

… The final sample included 115 742 deliveries, of which 2732 (2.4%) were associated with severe maternal morbidity. Of the 119 793 newborns identified, we excluded 4672 multiple births, 4447 with congenital anomalies, and 7258 with gestational age less than 37 weeks. The final sample included 103 416 newborns; of these, 8057 (7.8%) were associated with neonatal morbidity.

What did they find?

Hospital rankings on both quality measures were not associated with hospital rankings for maternal or neonatal morbidity as demonstrated in the Figure. In fact, among the 10 hospitals with the best performance (lowest rates) on elective deliveries, only 3 were in the lowest quartile of risk-standardized severe maternal morbidity. Among the 10 hospitals with the best performance (lowest rates) on the low-risk cesarean delivery measure, only 3 were in the lowest quartile of risk-standardized severe maternal morbidity. The rankings were similarly discordant for neonatal morbidity.

As the scatter plots show, there is no relationship between C-section rates and outcomes or between induction rates and outcome.

The authors conclude:

… Severe maternal morbidity rates varied 4- to 5-fold between hospitals, and there was a 7-fold variation in neonatal morbidity at term between hospitals. Although there was substantial variation in morbidity rates, they were not correlated with the performance measures designed to assess hospital-level obstetric quality of care.

Our results are consistent with findings from the Maternal Fetal Medicine Network and studies in NICUs demonstrating that performance assessment based on isolated measures do not accurately characterize the overall quality of care in a hospital…

… Our findings highlight the need for an expanded array of obstetric quality measures.

I personally think that the findings highlight the fact that process measures are NOT quality measures.

Contrary to the claims of natural childbirth advocates, C-sections and inductions do NOT lead to an increase in poor outcomes. The key to good outcomes is ensuring the correct match between what a patient needs to have an optimal outcome for both mother and baby and what she gets. Interventions themselves as not measures of quality. Only outcomes can tell us whether we are providing high quality care.

The increased risk of death and serious injury at American homebirth is well established and a remarkably robust finding across multiple studies, including:

Grünebaum A, McCullough LB, Sapra KJ, et al. Early and Total Neonatal Mortality in Relation to Birth Setting in the United States, 2006-2009. Am J Obstet Gynecol. 2014 Mar 21. pii: S0002-9378(14)00275-0. doi: 10.1016/j.ajog.2014.03.047.

Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013; 209: 325.e1-8.

Grünebaum A, McCullough LB, Sapra KJ, et al. Apgar Score of Zero at Five Minutes and Neonatal Seizures or Serious Neurologic Dysfunction in Relation to Birth Setting. Am J Obstet Gynecol. 2013; 209: e1-323. e6

Wasden, S., Perlman, J., Chasen, S., and Lipkind, H. 506: Home birth and risk of neonatal hypoxic ischemic encephalopathy. Am J Obstet Gynecol. 2014; 210: S25

The most remarkable finding is the analysis of Oregon data from 2012 by Judith Rooks, CNM, MPH demonstrating the planned homebirth with a licensed (CPM, LM, DEM) midwife has a perinatal death rate 800% higher than comparable risk hospital birth.

Even the data from the Midwives Alliance of North America survey of their members (Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health. 2014; 59: 17-27) shows that homebirth increases the risk of perinatal death by 450%.

Why do so many babies die at homebirth? A new paper Perinatal Risks of Planned Home Births in the United States by Grunebaum et al. provides answers.

Data from the United States (US) Centers for Disease Control’s National Center for Health Statistics birth certificate data files from 2010-2012 were utilized to analyze the frequency of certain perinatal risk factors which were associated with planned midwife-attended home births in the United States and compare them with deliveries performed in the hospital by certified nurse midwives (CNM). Home birth deliveries attended by “others” were excluded; only planned home births attended by midwives were included. Hospital deliveries attended by certified nurse midwives served as the reference. Perinatal risk factors were those established by ACOG and AAP.

What did the authors find?

Twins:

… 1 in 156 (0.64%) of midwife-attended planned home births were twin pregnancies, even though ACOG considers twins a contraindication for home births, as there is no adequate fetal monitoring, no experienced team, and no ultrasound available in home births. Studies on safety of home births from Canada, England, and the Netherlands excluded twins as candidates for home birth because of increased risks..

Breech:

… 1 in 135 (0.74%) of planned home births attended by midwives were vaginal breech deliveries. Breech vaginal birth is associated with significantly increased risks… Azria et al. recommended that a trial for vaginal births in breech presentations should be attempted only with continuous electronic fetal heart rate monitoring (EFM) and presence of ultrasound during labor and delivery. Neither EFM nor ultrasound is available in home births. Janssen from Canada and the Home birth in England Study excluded breech presentations from their home birth eligibility requirements. Therefore it is not surprising that the Midwives Alliance of North America (MANA) study of planned home births, reported an intrapartum death rate of 13.51/1,000 and a 9.16/1,000 neonatal mortality rate in breech presentations.19 When compared to the neonatal death rates from hospital deliveries these adverse neonatal outcomes are significantly increased

Postterm:

ACOG and AAP criteria for home births specifically exclude pregnancies ≥41 weeks from their home birth eligibility. In this study, 28.19% of home births were ≥41 weeks. Postterm pregnancies are associated with multiple, well-known complications, such as labor dystocia, increased perinatal mortality rate, low umbilical artery pH levels at delivery, low 5-minute Apgar scores, postmaturity syndrome, fetal distress, cephalo-pelvic disproportion, postpartum hemorrhage, and increased risk of neonatal death within the first year of life.

Attempted vaginal birth after C-section (VBAC):

A trial of labor after prior cesarean delivery (TOLAC) is associated with a greater perinatal risk than is elective repeat cesarean delivery without labor. TOLACs have an overall small but significantly increased risk of uterine rupture with often catastrophic consequences to mother and/or fetus.22,23 This study showed that nearly 1 in 23 (4.4%) of midwife-attended home births (n=2,463, 4.4%) had a home VBAC in spite of the fact that ACOG considers prior cesarean section an absolute contraindication to planned home birth… The recent MANA study showed a very high 2.85/1,000 intrapartum fetal death rate with VBACs.

In other words, babies die because American homebirth midwives ignore the risk guidelines accepted by ACOG, the American Academy of Pediatrics, Dutch midwives, British midwives and Canadian midwives. What’s the difference between American homebirth midwives and every other provider who accepts the risk guidelines? American homebirth midwives aren’t real midwives. They lack the education and training of ALL other midwives in the industrialized world and they are ineligible for licensure in ALL other first world countries. American homebirth midwives are lay “birth junkies” who made up their own credential and awarded it to themselves in order to trick American women into thinking they are healthcare providers.

American homebirth midwives are frauds and ignore the safety guidelines accepted by midwives and obstetricians around the world. It is hardly surprising then that so many babies die at American homebirth.

I have a dear friend who is a breast cancer oncologist. It is hardly unusual for women to cry in her office, but one incident that she shared truly shocked me.

When my friend opened the exam room door, her patient was already crying. No, she wasn’t feeling ill. No, her disease was not progressing. In fact, she had come to the appointment eager to celebrate her progress. Why, then, was she crying?

When she checked in at the front desk of the office, the secretary had looked at her and blurted out, “You’re bald! What happened to your beautiful hair?”

How could the secretary be so unthinkingly cruel? Obviously her hair had fallen out from chemotherapy.

That topped my list for clueless cruelty until yesterday. That’s when I read Why I don’t breastfeed, if you must know, by Emily Wax-Thibodeau.

Wax-Thibodeau has also battled breast cancer. She was subjected to unfathomable cruelty, not from a medical secretary, but from people who ought to know better, lactation consultants.

The truth is, I’m a breast cancer survivor, and after a double mastectomy with reconstruction, which probably saved my life, I simply wasn’t able to breast-feed…

Five years after the operation that saved her life:

… We were cleared to try getting pregnant. But because chemotherapy ravages fertility and I was now 37, we found ourselves saving money and signing up for in vitro fertilization.

It took two rounds of IVF to get pregnant.

On Jan. 29, 2014, I gave birth to a 7¹ / ₂-pound baby boy who had a head full of light brown hair and whose ravenous appetite and old-man snore we instantly found mesmerizing, maybe in a way only parents could.

“You never gave up,” my husband said, laughing as he watched Lincoln gulp down his first two-ounce serving of formula, which my husband fed to him.

As the two of them cuddled afterward, I was in a mood that I can describe only as postpartum elation.

That is, until those I jokingly call the “breast-feeding nazis” came marching in to my room.

Despite her medical history:

“You really should breast-feed,” the hospital’s lactation consultants, a.k.a. “lactivists,” said.

When I simply said, “I’m going to do formula,” they didn’t want to leave it at that.

So holding my day-old newborn on what was one of the most blissful days of my life, I had to tell the aggressive band of well-intentioned strangers my whole cancer saga.

You might think that would have shut them up. You would be wrong.

“Just try,” they advised. “Let’s hope you get some milk.”

“It may come out anyway, or through your armpits,” another advised later …

These are supposed health professionals. Their ignorance is astounding — mastectomy removes all breast tissue, even the tail of the breast that extends into the armpit — but their cruelty is truly mind-boggling. What’s next, chiding a paraplegic to get out of that wheelchair and exercise?

But as I’ve written many times in the past, many lactation consultants aren’t healthcare professionals. They are laypeople who had an easy time breastfeeding and enjoy feeling morally superior to other mothers. Shaming is integral to lactivism because shaming others is integral to the self-image of lactivists. All their so-called “baby friendly” initiatives — locking up formula in hospitals, mandating lectures on the benefits of breastfeeding to exhausted new mothers, abolishing well baby nurseries — aren’t friendly to babies, and they certainly aren’t friendly to mothers; they are friendly ONLY to lactivists.

Wax-Thibodeau almost feels relieved at having an “acceptable” reason for not breastfeeding.

As Jezebel’s Tracie Egan Morrissey wrote: “What those lactivist [expletive] conveniently forget to tell people — in their ongoing campaign of castigating bottle-feeding mothers as unnatural and ignorant, masking their concern-trolling as “support” — is that breastfeeding, for many women, is an incredibly painful, almost traumatizing endeavor. It was all so miserable and I associated that misery with my new baby, whom I secretly resented.”

Others literally lowered their voices to a whisper, confessing as if they had committed a crime that they supplemented breast-feeding with formula.

Why did they feel they had to whisper? In many ways, it reminded me of the stigma that comes with having a C-section.

The comparison is telling. Lactivists are often natural childbirth advocates, too. And in the same way that they grossly inflate the benefits of breastfeeding, they grossly exaggerate the “risks” of C-sections.

Many years ago I read Harold Kushner’s outstanding book When Bad Things Happen to Good People. Kushner offered an important insight into why people saying unspeakably cruel things to those who suffer misfortune. When confronted with someone who has suffered a tragedy, people often say “It could have been worse” but they mean “it could have been me.” In other words, many cruel remarks directed toward others are actually self-referential.

That is precisely what is going on with the shaming and blaming so beloved of lactivists and lactation consultants. Their comments, and even many of their “scientific” claims are self-referential. They reflect the need for lactivists and lactation consultants to boost their own self-esteem by criticizing others, often under the guise of “support.”

I have bad news for lactivists. In industrialized countries, the benefits of breastfeeding, while real, are trivial. Lactivists are not superior to other mothers; they are just women who chose one excellent form of infant nutrition over another excellent form of nutrition. They wield guilt, not for the benefit of babies, and certainly not for the benefit of mothers. They wield guilt for the benefit of themselves. Their cruelty comes from their self-absorption and those who are victims of that cruelty should not despair.

How you feed your baby is irrelevant. How you love your baby is what counts!

Another day, another homebirth narcissist!

Johanna Parker at Mommyish treats us to yet another boring, self-absorbed “Look at ME! Look at ME! grab for attention” that homebirth advocates love so dearly. The title is I Know You’re Judging Me For Having A Home Birth. Parker is both right and wrong. She’s right that I’m judging her, but she’s wrong about the reasons why.

Parker writes:

When my husband and I made the decision to have a planned home birth, I knew we would be met with some opinions and concerns, both from our loved ones and from any random stranger within an earshot of us talking about it. So after doing a ton of homework and arming myself with every fact and statistic I could find on the subject, I felt ready to take on the haters. I did a ton of research on midwives and bookmarked several websites on my phone that I would always have at the ready in case I needed some backup explaining why someone would choose this method of delivery. The problem is, many people just don’t know much about home births, nor do they want to. They’re happy picturing you burning sage while a woman in Birkenstocks chants over you and your naked family floating together in a giant inflatable tub in your living room (which, by the way, is totally cool if that’s your thing). One major thing I’ve realized is that most people who were upset with or concerned about our decision didn’t even know what a midwife was. Trying to argue the virtues of a home birth with them is like trying to talk politics with your parents – you just can’t.

Excuse me as I pick myself up off the floor for laughing so hard at the napalm grade stupidity and hubris that leads women like Parker to risk killing their own babies for bragging rights. How ignorant and how arrogant is Parker? Let me count the ways:

1. Parker is so ignorant that she actually thinks that she has done “research” by reading a bunch of websites. Research involves reading scientific papers and textbooks, not websites for laypeople.

2. Parker fails to understand that homebirth is a business and that the websites that promote it make their money by selling it. These websites are just extended advertisements. “Researching” the relative merits of homebirth and hospital birth using homebirth websites is the equivalent of researching the relative merits of Ford cars and GM cars by using the Ford website. Only a fool would think she had done research by reading the material from one side.

3. Parker is a walking, talking embodiment of the Dunning-Kruger effect. According to Wikipedia:

The Dunning–Kruger effect is a cognitive bias manifesting in unskilled individuals suffering from illusory superiority, mistakenly rating their own ability much higher than is accurate. This bias is attributed to a metacognitive inability of the unskilled to recognize their ineptitude…

Dunning and Kruger proposed that, for a given skill, incompetent people will:

• fail to recognize their own lack of skill;
• fail to recognize genuine skill in others;
• fail to recognize the extremity of their inadequacy …

4. In her overweening confidence in her own “research” abilities, Parker appears to think that she has armed herself with every fact and statistic she could fine. Really? She seems to have missed quite a few crucial statistics:

• According to MANA’s (Midwives Alliance of North America) own data, homebirth increases the risk of death by 450%.
• According to Judith Rooks, CNM MPH’s comprehensive analysis of Oregon’s homebirth data, PLANNED homebirth with a LICENSED homebirth midwife increases the risk of death by 800%.
• In the Netherlands, the country with the higest rate of homebirth, midwives caring for low risk patients have a HIGHER perinatal mortality rate than obstetricians caring for high risk patients.
• The risk of a 10 minute Apgar score of zero (stillbirth) is 1000% (yes, 3 zeros) higher at homebirth.

5. Parker believes that others do not know the truth about midwives, but it is likely Parker herself who is misinformed. American homebirth midwives are not really midwives. They are simply lay people who couldn’t be bothered getting real midwifery training and proclaimed themselves “midwives” anyway. The credential of American homebirth midwives is not recognized or accepted by any other country in the industrialized world. Women who hire a homebirth midwife are simply paying a lay birth junkie to amuse herself by ogling someone else’s labor. In the event of an emergency, American homebirth midwives are useless. That’s why the death rate at homebirth is so much higher than comparable risk hospital birth.

The arrogance of people like Parker never ceases to amaze me. Obstetricians, pediatrician, and neonatologists are all on record as noting that homebirth is NOT as safe as hospital birth, but Parker, with no medical education of any kind thinks she knows better and is willing to risk killing her own baby to prove it.

You’re right, Ms. Parker, I’m judging you. I’m judging you as a fool who, in the words of Wikipedia, is suffering from illusory superiority, mistakenly rating your own ability much higher than is accurate. This bias is attributed to your metacognitive inability to recognize your own ineptitude.

As Dame Edith Sitwell said:

I am patient with stupidity, but not those who are proud of it.