Childbirth is a reproductive rights issue.

Every woman deserves access to high quality obstetric care, and every woman deserves access to state of the art pain relief. That’s because medicalizing birth is a feminist triumph and all women should be able to share in its benefits.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”A possible death sentence came with every pregnancy.”[/pullquote]

Childbirth, in every time, place and culture, is a leading cause of death of young women and the leading cause of death of babies. As historian Judith Walzer Leavitt has noted in Under the Shadow of Maternity: American Women’s Responses to Death and Debility Fears in Nineteenth-Century Childbirth, until the last 100 years:

A possible death sentence came with every pregnancy.

Visit any cemetery, from any century, in any country, and you will find the gravestones of the countless young women who died in childbirth, many after days of horrific agony.

Maternity, the creation of new life, carried with it the ever-present possibility of death. The shadow that followed women through life was the fear of the ultimate physical risk of bearing children. Young women perceived that their bodies, even when healthy and vigorous, could yield up a dead infant or could carry the seeds of their own destruction… Nine months’ gestation could mean nine months to prepare for death.

The very real possibility of death during childbirth shaped women’s lives and relationships:

Perhaps more valuable to our understanding of the reality of maternal death is the observation that most women seemed to know or know of other women who had died in childbirth. One woman, for example, wrote that her friend “died as she has expected to” as a result of childbirth as had six other of their childhood friends. Early in the twentieth century approximately 1 mother died for each 154 live births. If women delivered, let us estimate, an average of five live babies, these statistics can mean that over their reproductive years, one of every thirty women might be expected to die in childbirth. In another early-twentieth century calculation, one of every seventeen men claimed they had a mother or sister who had died as the immediate results of childbirth.

Medicalizing childbirth changed that. Now no woman with access to medicalized birth expects to die during pregnancy.

But living through the birth was only the first hurdle for many women. Some sustained injuries that affected them for the rest of their lives:

In the past, the shadow of maternity extended beyond the possibility and fear of death. Women knew that if procreation did not kill them or their babies, it could maim them for life. Postpartum gynecological problems – some great enough to force women to bed for the rest of their lives, others causing milder disabilities – hounded the women who did not succumb to their labor and delivery. For some women, the fears of future debility were more disturbing than fears of death. Vesicovaginal and rectovaginal fistulas .., which brought incontinence and constant irritation to sufferers; unsutured perineal tears of lesser degree, which may have caused significant daily discomforts; major infections; and general weakness and failure to return to prepregnant physical vigor threatened young women in the prime of life.

Medicalizing childbirth changed that. Now no woman with access to medicalized birth expects to become permanently incontinent of urine and feces as a result of childbirth.

Women viewed childbirth not as the empowering fantasy so beloved of midwives and natural childbirth advocates, but as a specter of unremitting agony:

Apart from their concern about resulting death and physical debility, women feared pain and suffering during the confinement itself. They worried about how they would bear up under the pain and stress, how long the confinement might last, and whether trusted people would accompany them through the ordeal. The short hours between being a pregnant woman and becoming a mother seemed, in anticipation, to be interminably long, and they occupied the thoughts and defined the worries of multitudes of women. Women’s descriptions of their confinement experiences foretold the horrors of the ordeal.

The voices of these women have the power to move us profoundly more than one hundred years later:

Josephine Preston Peabody wrote in her diary of the “most terrible day of [her] life,” when she delivered her firstborn, the “almost inconceivable agony” she lived through during her “day-long battle with a thousand tortures and thunders and ruins.” Her second confinement brought “great bodily suffering,” and her third, “the nethermost hell of bodily pain and mental blankness. . . . The will to live had been massacred out of me, and I couldn’t see why I had to. Another woman remembered “stark terror was what I felt most.”

“Between oceans of pain,” wrote one woman of her third birth in 1885, “there stretched continents of fear; fear of death and dread of suffering beyond bearing.” Surviving a childbirth did not allow women to forget its horrors. Lillie M. Jackson, recalling her 1905 confinement, wrote: “While carrying my baby, I was so miserable… I went down to death’s door to bring my son into the world, and I’ve never forgotten. Some folks say one forgets, and can have them right over again, but today I’ve not forgotten, and that baby is 36 years old.” Too many women shared with Hallie Nelson her feelings upon her first birth: “I began to look forward to the event with dread-if not actual horror.” Even after Nelson’s successful birth, she “did not forget those awful hours spent in labor…”

Medicalizing childbirth changed that. Now no woman with access to medicalized birth expects to suffer severe, unremitting pain from the beginning of labor to the end. She can request and receive an epidural and simply rest and sleep through hours of contractions.

Indeed, so confident of excellent pain relief are women who have access to medicalized childbirth that some women actually think they’ve “achieved” something by refusing it.

One of the great deceptions of contemporary midwifery involves midwives fooling themselves and others that the philosophy of natural childbirth reverts back to unmedicalized birth. Nothing could be further from the truth. Natural childbirth is a philosophy of privilege, specifically the privilege of having easy access to medicalized childbirth. An “unmedicalized” birth can only be safe when embedded firmly within a society that provides unlimited access to obstetricians to rescue women from their own folly.

A midwife without an obstetrician is better than nothing at preventing death in certain limited circumstances, but virtually useless when it comes to saving lives in most emergencies. Without the ability to perform a C-section, midwives, like their ancient counterparts, are helpless in the face of everything from life threatening crises to simple failures of the baby to fit through the maternal pelvis. Without the ability to end a protracted labor by means of forceps or C-section, midwives are helpless to prevent obstetric fistula. Without the ability to offer epidurals, midwives are reduced to pretending that ineffective measures are effective, or, bizarrely, that labor pain is beneficial.

Childbirth is a reproductive rights issue.

Every woman deserves access to high quality obstetric care, and every woman deserves access to state of the art pain relief. They are only available in a system that medicalizes birth.

It used to be that sex was tightly culturally regulated and mothering had no oversight. In 2019, in industrialized countries mothering is tightly culturally regulated and sex has no oversight.

What happened?

For most of recorded history, there were regulations about who could have sex with whom, who pursued and who was expected to resist. From the Bible to the Puritans, the regulations were particularly rigid for women.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural mothering is the missionary position of contemporary motherhood.[/pullquote]

Men could have sex with any woman (but no men); men could have more than one wife; and men could — indeed were expected — to have sex outside of marriage. None of these practices were thought to have any effect on a man’s virtue. In contrast, a woman’s virtue was situated firmly in her vagina. She was allowed to have sex only after marriage and only with her husband at his whim; she had no right to refuse. Rape was routinely blamed on women and even if they were not blamed, they were “ruined,” condemned to live outside the circle of polite society.

Even within marriage, women’s sexuality was tightly regulated. Certain behaviors were considered the province of courtesans and prostitutes and proscribed for wives. The “good” wife settled for the missionary position when and only when her husband wished to meet his sexual needs; her needs were irrelevant.

In contrast, how she mothered her children was not regulated at all. There were no choices to be made in childbirth, but when it came to infant feeding women could breastfeed, supplemented by or replaced with a wide variety of (generally unsuitable) alternatives like animal milks, or — if wealthy — could hire a wet nurse. For those with means, day to day childrearing was outsourced to hired help or slaves; for those without means, children were often put to work on the farm and, later, in the factories. Your children were your husband’s property. He might care how you treated them; certainly no one else would. No one would have even looked askance if you beat your children regularly. Some even thought regular beating improved their character.

Today, in contrast, sexual license prevails. Have sex with anyone and everyone, inside marriage and outside it; most people don’t care. Sexuality is ascribed to women as well as men; everyone is believed to be entitled to sexual satisfaction as a matter of health and wellbeing. We have utterly rejected the rules that guided sexual relationships for most of recorded history. Instead — at almost precisely the same time — we have created elaborate rules for mothering.

There are rules for what constitutes the “best” birth; there is only one acceptable way to feed a baby; and we have become deeply censorious of mothers spending time apart from their children. So-called “natural mothering” is the missionary position of contemporary motherhood. The “good” mother embraces it. She has no higher purpose than to meet her children’s needs; certainly her own needs are irrelevant.

We have constricted motherhood as tightly as we used to constrict women’s sexuality and for the same reason — to control women.

You don’t have to have a sociology degree to understand that the myriad historical regulations around women and sex were created to protect men’s prerogatives. Every respectable woman was owned by a man and was forced to stay home to meet his needs, raise his children and preserve her virtue. While there were always women who rebelled at such strictures, by and large most women didn’t merely support this view of women, they defended it by shunning women who wouldn’t comply. For a woman, being excluded from polite society meant being excluded from and by other women.

It’s harder to see that the modern prescriptions around mothering — in particular the ideology of natural mothering, also known as attachment parenting or intensive mothering — have been promoted primarily to protect men’s prerogatives. A “good” mother has unmedicated vaginal births, breastfeeds exclusively and for an extended period of time, and literally wears her babies. With the advent of women’s legal and economic emancipation, women have thrown off traditional strictures so they must be forced back into the home. The primary enforcers, as in the case with sexual restrictions, is other women.

But in contrast to sexual restrictions, enforcing mothering restrictions has been professionalized: midwives, doulas, lactation consultants and attachment parenting “experts” profit only when they force women to comply with their priorities. Not surprisingly, they spend a great deal of time pressuring women. In addition to the shaming and shunning that were formerly applied to sex, they have hit upon an even more powerful motivator. They have claimed — with no evidence of any kind — that if women don’t knuckle under to natural childbirth, breastfeeding and attachment parenting, their will children won’t bond; in other words, their children won’t love them. That fate is far crueler than being shunned by one’s peers.

Make no mistake, I am not referring to women who make affirmative choices:

Some women are affirmatively heterosexual and monogamous. They have husbands and they are faithful to them. They might prefer the missionary position, feel uncomfortable initiating sex, or might not enjoy sex but submit because they love their husbands. I applaud them for living the lives they choose.

That’s very different from women who are forced to appear heterosexual and monogamous on pain of condemnation and shunning. They might want more from a sexual relationship than merely meeting a spouse’s needs and they should not be pressured into believing they are “bad” wives when they won’t submit to their husbands.

Similarly, there are some women who are affirmatively domestic. There is no place they would rather be than home with their children; there is nothing they would rather do than breastfeed a child; they glory in unmedicated vaginal birth. I don’t merely applaud them for living the lives they choose; in many respects I have emulated them.

But that’s very different from women who are pressured into unmedicated vaginal births they don’t want, breastfeeding they don’t enjoy, and enforced isolation with small children instead of a job or career they prefer.

Our society has gone from sexually puritanical and unrestrictive about motherhood, to sexually licentious and rigidly restrictive about motherhood. That’s not an advance. It’s just a different way to do the same thing: domesticating women by convincing them that they exist for the benefit of others, while their needs and desires are ignored.

Babies die.

The most critical difference between obstetricians and homebirth midwives is their response to these tragic deaths:

When faced with a dead baby obstetricians ask, “How can we prevent this from ever happening again?”

In contrast, homebirth midwives ask, “How can we avoid responsibility?”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]“I want a bumper sticker that says, ‘Babies Die’.”[/pullquote]

Don’t believe me? Consider the irresponsible, self-serving blather from Jan Tritten, Editor of Midwifery Today.

Remember Jan? She’s the one who presided over the hideous spectacle of homebirth midwife Christy Collins crowdsourcing advice as baby Gavin Michael died.

In the wake of the baby’s death, there was no soul searching about the entirely preventable death of a baby. There was no reflection on what was done wrong and how future tragedies could have been prevented. There was nothing; Tritten simply deleted the multiple posts and comments concerning the tragedy from her Facebook page. She and the presiding midwife tried to bury Gavin Michael twice: first in a small coffin in the ground, then from the memory of anyone who had followed the story.

Her current column gives insight into her ugly fatalism and repulsive lack of concern for anyone but herself and sister midwives.

I remember Marsden Wagner once saying, “I want a bumper sticker that says, ‘Babies Die’.”

Ha, ha, ha. Are you laughing yet?

Although that sounds awful, he was reflecting his experience of frequently appearing as a witness in cases where midwives were being prosecuted for the death of a baby at a homebirth.

Why did Wagner have to appear frequently? Homebirth deaths ought to be vanishingly uncommon — as they are in Canada, where homebirth midwifery is tightly regulated.

He knew full well that many more babies die in hospital birth than homebirth, but these were not the cases that got the attention. The authorities—opposed to homebirth—would bide their time and wait for a baby to die under the care of a homebirth midwife. Then they would pounce on that midwife. It was another great way to deal with “the midwife problem.”

Pro-tip: when comparing the safety of two groups of providers, we look at death RATES, not absolute numbers. The death RATES at homebirth in the US are up to 800% HIGHER than comparable risk hospital birth. The death RATES at homebirth in the US are up to 800% HIGHER than homebirth in Canada.

Are midwives in Canada smarter, better educated, more extensively trained than homebirth midwives in the US? Yes on all counts.

That’s relevant if you care about protecting babies and mothers. Jan is only interested in protecting providers.

Life is a circle. Some babies live only a few months and may pass in utero… Some babies live 10 years, some live 80 years, but all will pass into the next world.

Ho, hum, babies die. How dare anyone try to hold homebirth midwives accountable?

Tritten’s lackadaisical attitude toward dead babies isn’t merely a betrayal of homebirth clients, it’s a betrayal of the long, proud tradition of midwifery.

There have always been midwives. Ever since our ancestors acquired the ability to walk upright, human childbirth has been fraught with extreme risk to both mother and baby. The first midwives were those who recognized that assistance in childbirth can minimize those risks.

Above all, ancient midwives were empiricists. Their very existence was predicated on the inherent dangers of childbirth and everything they did was devoted to preventing death and injury. They abjured magic incantations in favor of empirical observation. They noted what worked and what did not and faithfully strove to incorporate those scientific observations into practice. They didn’t simply throw up their hands and declare, “Babies die.”

Why would Tritten and other homebirth midwives betray the ideals of midwifery? Because they aren’t really midwives; they are women who can’t be bothered or lack the intellectual ability to complete real midwifery training. They are birth hobbyists who want to be paid as if they were real midwives, who want to be respected as if they were real midwives, but absolutely refuse to be held accountable as if they were real midwives.

It’s no different than if your neighbor decided she was qualified to declare herself a surgeon because she watched multiple seasons of the TV show Grey’s Anatomy. It’s no different from that neighbor insisting — each and every time someone died from botched surgery — that patients died from surgery in the hospital, too.

Which would you prefer, a real surgeon who cared whether or not her patients died and tried to prevent future deaths, or a self-proclaimed surgeon whose chief concern in the wake of a preventable death was to avoid blame for it?

Thinking about homebirth? Which do you prefer, a real midwife who cares whether or not her patients die and tries to prevent deaths, or a self-proclaimed midwife who cares only about avoiding responsibility?

Yes, sadly, babies die, but the critical difference between obstetricians and homebirth midwives is that obstetricians are desperately trying to reduce infant deaths while homebirth midwives prefer to pretend they’re inevitable.

Whom do you trust with your baby’s life?

Can women be empowered by a philosophy designed to re-domesticate them?

Yesterday I asked whether women can be empowered by the philosophy of natural mothering, a philosophy created for the express purpose of oppressing them. Thinking further, it occurs to me that there is a better way to frame the issue. Natural mothering advocates seek to oppress women in a specific way — by re-domesticating them.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Can women be empowered by philosophies created with the express intent of re-domesticating them? Only if you think “empowered” actually means powerless.[/pullquote]

Re-domesticating best captures the goals of natural childbirth, breastfeeding and attachment parenting advocates because of the multiple meanings of the word.

According to Google, these multiple meanings include:

1. To tame.
2. To cultivate.
3. To make fond of home life and housework.

It comes from the Latin word domus, meaning home.

It’s no coincidence that natural mothering advocates are obsessed with returning everything to the home from homebirth to homeschooling. Because the ugly truth is that while advocates of natural mothering market it as empowering women by taking control over birth and schooling back, the real purpose is to take control of women by forcing them back to the home.

Achieving the goal of re-domestication of women requires collective amnesia over why women outsourced these traditional practices and why they wanted to leave the home.

Women were glad to outsource childbirth to hospitals because childbirth is inherently dangerous and excruciatingly painful. Moreover, the rapid rise in popularity of hospital birth owes much to the fact that for many women, hospitalization represented the only vacation from the endless drudgery of childcare and household tasks.

The process of re-domesticating women through natural childbirth (preferably homebirth) involves convincing them that childbirth is inherently safe and that pain is “good” for women. Midwives have taken to the task with gusto, recognizing that their income depends on not merely convincing women that they don’t need doctors, but going much further by claiming that doctors “ruin” childbirth with their pesky interventions; the interventions “interfere” with maternal-infant bonding for no better purpose than to save the lives of mothers and babies.

It only remains for lactation professionals to ruin the hospital as a place of rest by mandating rooming in and the closing of well baby nurseries so women will never be able to rest from their many domestic tasks and might as well return home early.

The process of re-domesticating women through breastfeeding is designed to keep them out of the workforce and immure them back into the home. Breastfeeding professionals and researchers have fully embraced the task, creating new “benefits” of breastfeeding as fast as the old “benefits” are debunked. They’ve demonized formula, deliberately eliding the fact that infant feeding was outsourced for many valid reasons: insufficient breastmilk is common and many women want to utilize their minds in fulfilling work instead of being tied to the home by the need to breastfeed. And, of course, advocates claim that anything other than exclusive breastfeeding “interferes” with maternal-infant bonding.

Though natural mothering advocates decry medicalization of childbirth, they adore medicalization of breastfeeding — from pumps, to breastmilk banks, to the off-label use of powerful medications with the goal of boosting milk supply. While they initially sought to make breastfeeding compatible with work outside the home, the latest research is directed toward demonizing pumping by claiming that pumping — like formula — harms the infant gut microbiome. Never mind that the evidence is remarkably weak and preliminary.

But when it comes to re-domesticating women, the philosophy of attachment parenting is by far the most transparent in its goals. Mothers are encouraged to literally wear their infants so they will never enjoy a moment’s solitude, a moment that might — heaven forbid — be used by a mother to meet her own needs.

But at least she can rest when her children are asleep, right? Wrong! Attachment parenting teaches that babies need to sleep in the same bed as their mothers. Never mind that bed-sharing literally kills babies. Mothers should not have any time at all when they are not in constant physical proximity to their children. Why? You guessed it: anything else will “interfere” with mother-infant bonding.

But even those years eventually come to an end, that’s why mothers must be loaded up with additional tasks like homeschooling and home medical care: “researching” vaccines and creating customized schedules, stocking up on tinctures and essential oils to create home remedies, growing organic food with which to laboriously hand grind baby food, shopping for all natural products, etc. etc. etc.

The “good” mother won’t merely avoid temptation to leave the home, she will be so busy that she will be unable to leave the home.

Not coincidentally, all economic power will be in the hands of men, and women will be rendered vulnerable to the whims of their husbands, permanently tied by their desire to protect their children from want.

Voila, re-domestication!

Of course there are women who are domestic by desire. There is no place they would rather be than home with their children performing domestic tasks. There’s nothing oppressive about women making choices to suit themselves. But that’s very different from women making choices because they’ve been socialized to believe that their children will not bond to them unless they stay home to give birth, breastfeed for years, and never have their children farther than a 12 inches from their bodies.

Can women be empowered by philosophies created with the express intent of re-domesticating them? Only if you think “empowered” actually means powerless.

In the good old days, women knew their place: in the home, repeatedly pregnant, breastfeeding, and in continual proximity to their children. They wouldn’t dare compete with men since they didn’t have the time or energy to do so.

In the past century, for the first time in history women in some countries achieved a measure of legal and economic equality. Even that tiny bit is too much for some; a backlash ensued. On the Right, that backlash took the form of religious fundamentalism. If you believe in God, when He supposedly wants “good” mothers to stay home, repeatedly pregnant, breastfeeding, and in continual proximity to their children, it’s hard to refuse.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Being “empowered” by a philosophy designed to oppress women represents the ultimate in submission to misogyny.[/pullquote]

That was never going to work on the Left, where belief in religion has been waning; so opponents of women’s equality created their own form of fundamentalism — belief in the perfection of the natural order. When Nature supposedly wants “good” mothers to stay home, repeatedly pregnant, breastfeeding, and in continual proximity to their children, it might be difficult to refuse.

Natural mothering — natural childbirth, breastfeeding and attachment parenting — were created explicitly to control women. Grantly Dick-Read (a fundamentalist and eugenicist) made it abundantly clear that his philosophy of natural childbirth was designed to pressure women into having more children. La Leche League was explicit in its purpose on founding (by religious traditionalists); the philosophy of “mothering through breastfeeding” was created to keep mothers of small children from working. William Sears (a religious fundamentalist), the man who created the philosophy of attachment parenting, initially made no secret of the fact that he believed his philosophy was vouchsafed by God as His preferred method for organizing the family.

Which raises the question: can women be empowered by parenting philosophies explicitly designed to oppress them?

Can women be empowered by refusing pain relief in labor on the say-so of a racist, misogynist?

Can women be empowered by exclusive, extended breastfeeding, because a group of women who wanted to force them out of the workforce told them it was the best way to mother?

Can women be empowered by a philosophy of parenting that goes so far as to tell women to “wear” their babies so they can never enjoy a moment’s solitude?

But wait! I hear natural parenting advocates invoking Margaret Sanger and Planned Parenthood.

Sanger was also a eugenicist and was explicit in her belief that birth control could be used in “the process of weeding out the unfit [and] of preventing the birth of defectives.”

Her views were every bit as vile as those of Dick-Read:

In reading her papers, it is clear Sanger had bought into the movement. She once wrote that “consequences of breeding from stock lacking human vitality always will give us social problems and perpetuate institutions of charity and crime.”

As appalling as are Sanger’s ugly views, there is a crucial difference. Sanger never viewed birth control as a method of controlling women’s behavior; Dick-Read always viewed natural childbirth as a method of controlling women’s behavior so as to keep them immured in the home.

Of course, women are free to refuse belief in the necessity of natural childbirth, breastfeeding and attachment parenting, aren’t they?

Not exactly. In order to ensure compliance, advocates of natural mothering have taken children hostage. They’ve declared, usually in the absence of scientific evidence, that children benefit from being mothered in the same way our ancient foremothers cared for their children.

Nature “designed” women to give birth vaginally without pain medication; ergo pain relief, interventions and C-sections must be “bad” for babies, at a minimum interfering with their ability to “bond” to mothers.

Nature “designed” women to breastfeed exclusively for extend periods; ergo formula, even “just one bottle,” must be “bad” for babies, at a minimum interfering with their ability to “bond” to mothers.

Nature “designed” women to maintain constant physical proximity to their children; ergo putting a baby down, using a stroller, letting a baby sleep in a crib must be “bad” for babies, at a minimum interfering with their ability to “bond” to mothers.

Are you sensing a theme here?

I am and it amazes me that many otherwise thoughtful women are not.

Don’t midwives like Sheena Byrom and Hannah Dahlen understand that natural childbirth is a method created to oppress women, forcing them to endure excruciating pain for the “benefit” of their babies?

Don’t lactation professionals like Amy Brown and Melissa Bartick understand that “mothering through breastfeeding” is a philosophy dreamt up to oppress women by forcing them out of the workforce?

Don’t attachment parenting advocates understand that it is a worldview promoted by a religious fundamentalist in order to force women to live dependent upon and subservient to men, “as nature intended”?

That doesn’t mean that women can’t make the choice to have unmedicated childbirth, to breastfeed, and to practice attachment parenting if that is what they feel is the best choice for their families. Similarly women are free to choose to wear a burqa or be subservient to their husbands.

Natural mothering is as empowering as wearing a burqa or creating a marriage where the husband rules the wife. Being “empowered” by a philosophy designed to oppress women represents the ultimate in submission to misogyny.

OMG! OMG! OMG!

Growing ‘brexting’ habit of texting on phones while breastfeeding newborns is damaging relationships between mums and their babies.

The horror!!!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Breastfeeding promotion is, and has always been, about pressuring women to ignore their own needs and desires.[/pullquote]

Health authorities are warning new mothers that scrolling on their phones while breastfeeding may be damaging bonding with their babies.

The modern day habit, which even earned the hashtag worthy name of ‘brexting,’ may be affecting children’s development and their relationships, experts say.

‘When a breastfeeding mum focuses on the phone… it can disrupt an important developmental process that relies on baby seeing and responding to mum’s face,’ Royal Australian College of General Practitioners president Harry Nespolon told The Courier Mail.

That, Dr. Nespolon, is baloney! It’s yet another product of romanticizing mothering.

Wait, don’t all mammals gaze lovingly into their offspring’s eyes while nursing?

How about dogs?

I guess not! They nurse multiple pups at once and given the location of their teats, can easily nurse without even seeing their offspring, let alone looking them in the eye.

How about animals that give birth to only one at a time, like cows?

The cow is looking into something of the calf’s, but it certainly isn’t its eyes.

Primates, our closest relatives must gaze lovingly into their infants’ eyes, right?

Not exactly.

But certainly our indigenous ancestors spent their days gazing into the eyes of their babies, didn’t they?

Surely not.

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

Consider cradleboards:

Cradleboards were used during periods when the infant’s mother had to travel or otherwise be mobile for work … The cradleboard could be carried on the mother’s back … The cradleboard can also be stood up against a large tree or rock if the infant is small, or hung from a pole (as inside an Iroquois longhouse), or even hung from a sturdy tree branch…

Mothers literally immobilized their babies and propped them against a tree so they could get things done. Who knows what tasks they were performing while breastfeeding — sewing, grinding grain, etc.?

And that doesn’t even take into account their role in supervising older children.

What’s really going on here?

In the world of natural mothering, if you aren’t suffering, you aren’t doing it right. And that means constantly moving the goal posts.

You feed your baby formula? How can you live with yourself?

You breastfeed but supplement? Don’t you know even one bottle destroys the gut microbiome.

You breastfeed exclusively but pump? Milk from the pump may have different bacteria!

You breastfeed, never use formula, never pump, but look at your phone while breastfeeding? How could you?

Because the ugly thing about breastfeeding promotion is this:

From the inception of La Leche League, promoting breastfeeding has focused on restricting women, not what’s good for babies.

La Leche League was started with the express (religious) intent of promoting 1950’s style nuclear families with the father as breadwinner and head and the mother relegated to caregiver in second place. Breastfeeding was promoted explicitly as a way to keep women immured in the home and to discourage them from working.

It is not a coincidence that one of the earliest speakers at a major LLL gathering was Grantly Dick-Read, who fabricated the benefits of natural childbirth in order to force women back into the home. It’s not a coincidence that one of the early Medical Directors of LLL was William Sears, a religious fundamentalist who has claimed that his philosophy of attachment parenting was vouchsafed to him by God as His preferred method for family organization.

Breastfeeding promotion is, and has always been, about pressuring women to ignore their own needs and desires.

LLL was created a quarter century BEFORE anyone imagined that formula feeding had risks, and that realization reflected experience in Africa preparing formula with contaminated water. In the wake of the Nestle debacle in Africa, LLL partnered with the United Nations to create the International Code of Marketing of Breastmilk Substitutes and the Baby Friendly Hospital Initiative, both referencing benefits of breastfeeding even though there was no scientific evidence to support them. The past 30 years have been spent with breastfeeding researchers desperately searching for evidence of those benefits.

Initial research seemed promising, uncovering one benefit of breastfeeding after another. Yet larger studies that corrected for confounding variables like maternal education and socio-economic class debunked nearly all of them.

No matter, breastfeeding professionals are engaged in finding ever more arcane “benefits” (epigenetics! the microbiome!) and risks (texting!) with which they can pressure women.

But there’s no reason why women should succumb to the pressure. If you want to text while breastfeeding, go right ahead; it won’t harm your baby. For that matter, if you want to avoid breastfeeding altogether, go right ahead and use formula. It won’t harm your baby, either.

Good mothering means taking into account the needs of everyone in the family and mothers are part of the family.

Maternal suffering is not required.

Add this new study to the long list of papers that claim to show the benefits of breastfeeding through mathematical modeling.

According to The cost of not breastfeeding: global results from a new tool:

The results of the analysis using the tool show that 595 379 childhood deaths (6 to 59 months) from diarrhoea and pneumonia each year can be attributed to not breastfeeding according to global recommendations from WHO and UNICEF. It also estimates that 974 956 cases of childhood obesity can be attributed to not breastfeeding according to recommendations each year. For women, breastfeeding is estimated to have the potential to prevent 98 243 deaths from breast and ovarian cancers as well as type II diabetes each year. This level of avoidable morbidity and mortality translates into global health system treatment costs of US$1.1 billion annually. The economic losses of premature child and women’s mortality are estimated to equal US$53.7 billion in future lost earnings each year. The largest component of economic losses, however, is the cognitive losses, which are estimated to equal US$285.4 billion annually. Aggregating these costs, the total global economic losses are estimated to be US$341.3 billion, or 0.70% of global gross national income.

There’s just one problem. These claims are nonsense for two simple reasons:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]In the language of computer modeling, the model was never verified or validated.[/pullquote]

• The authors inexplicably failed to include the costs of breastfeeding itself
• The authors never compared the model to the real world

In the language of computer modeling, the model was never verified or validated. Both problems afflict all current mathematical models of breastfeeding benefits, so they’re worth exploring in detail.

Wikipedia has an excellent, relatively simple explanation of verification and validation:

…The developers and users of these models, the decision makers using information obtained from the results of these models, and the individuals affected by decisions based on such models are all rightly concerned with whether a model and its results are “correct”. This concern is addressed through verification and validation of the simulation model.

Verification is essentially checking the math.

As far as I can determine, the authors did not verify their model, but for the sake of this discussion we will assume that errors of implementation of the model are small.

Validation is concerned with whether or not the model reflects the real world.

Validation checks the accuracy of the model’s representation of the real system…

There are many approaches that can be used to validate a computer model. The approaches range from subjective reviews to objective statistical tests. One approach that is commonly used is to have the model builders determine validity of the model through a series of tests.

One of the key components of validation is determining whether the predictions of the model match what actually happens in the real world:

Naylor and Finger formulated a three-step approach to model validation that has been widely followed:

Step 1. Build a model that has high face validity.

Step 2. Validate model assumptions.

Step 3. Compare the model input-output transformations to corresponding input-output transformations for the real system.

Existing modeling of the benefits of breastfeeding do have face validity. Lactation professionals and organizations have great faith in these models because, the models confirm their pre-existing beliefs that breastfeeding has major benefits and that increasing breastfeeding rates will save massive numbers of lives and money.

The problems start with the model assumptions.

Assumptions made about a model generally fall into two categories: structural assumptions about how system works and data assumptions.

Models of breastfeeding benefits fail on both these counts.

First, these models assume causation whenever correlation exists. But many studies that claim to show that breastfeeding has a specific benefit are riddled with confounding variables. Although the initial data seems to show that increased breastfeeding rates lead to increase in that benefit, correcting for confounding variables makes it clear that it was maternal education, socio-economic status or IQ that was responsible for the observed benefit. A model that rests almost entirely on correlations is bound to be inaccurate. That’s because, as everyone knows, correlation is NOT causation.

Second, the authors also made poor data assumptions.

The authors explain what they included:

The cost of not breastfeeding tool incorporates three categories of indicators for human and economic costs attributed to not breastfeeding according to recommendations, including (1) women’s and child morbidity and mortality, (2)for health system and household formula costs and (3) the future economic costs due to mortality and cognitive losses.

But what they failed to mention (and probably never considered) is that breastfeeding has costs as well as benefits. This failure is catastrophic for the utility of the model.

The authors include savings accrued by assumed lower child morbidity and mortality, but failed to include the costs of tens of thousands of hospitalizations per year for dehydration, jaundice and starvation as a result of insufficient breastmilk at a price tag of hundreds of millions of dollar in the US alone. They failed to include the costs of infants who suffer permanent brain injuries and infants who die, smothered in maternal hospital beds or killed by falling from those same beds.

The authors include savings accrued due to household formula costs, but inexplicably, fail to include lost wages of mothers who can no longer work full time or work at all because they are breastfeeding.

They include savings due to assumed mortality and cognitive losses of formula fed babies, but, inexplicably, fail to include mortality and cognitive losses of babies harmed by breastfeeding, and cognitive losses to mothers who have to give up education and career at least temporarily and possibly permanently.

But the biggest failure in validation of the model is that the authors never compared it to the real world.

According to the Wikipedia article:

The validation test consists of comparing outputs from the system under consideration to model outputs for the same set of input conditions. The model output that is of primary interest should be used as the measure of performance. For example, if system under consideration is a fast food drive through where input to model is customer arrival time and the output measure of performance is average customer time in line, then the actual arrival time and time spent in line for customers at the drive through would be recorded. The model would be run with the actual arrival times and the model average time in line would be compared with the actual average time spent in line using one or more tests.

In the case of statistical models of the benefits of breastfeeding, the input is breastfeeding rate and the output is lives and money saved. The model should be run with actual breastfeeding rates and then predicted lives and dollars saved would be compared to actual lives and dollars saved.

For example, the new tool purports to be able to tell us how many lives and dollars would be saved if the breastfeeding rate increased by 20% by 2030. How do we know if those predictions are valid? By putting in data from the past:

What was the change in breastfeeding rates over the last 40 years? What was the predicted benefit in terms of lives and dollars saved? Is that what actually happened? No, not even close; that means that the model itself is invalid and that makes it useless for predicting future benefits.

This is why, if given the opportunity, I ask every lactation professional to show me the real world benefits of breastfeeding as opposed to extrapolations from small studies. Most recently, both Maureen Minchin, self-proclaimed breastfeeding “researcher” and Mike Woolridge, former head of Baby Friendly UK, were completely unable to do so.

Thus far, NO lactation professional has been able to do so. That’s not surprising when you consider their claims of benefits are based on mathematical models that assume causation, fail to take confounding factors into account, and fail to include the costs of breastfeeding.

This paper makes the same mistakes. In technical terms the authors are proposing a model that has never been validated.

In lay terms, their claims are nonsense.

You might think that Oregon homebirth midwives would be shocked into action by their hideous death rates.

You would be wrong.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Who cares about dead babies? Not Oregon homebirth midwives.[/pullquote]

In August 2010, Melissa Cheyney, then Director of Research for the Midwives Alliance of North America (MANA) and also the head of the Oregon Board of Direct Entry Midwifery, rejected a call by the state for access to the MANA homebirth death rates for Oregon. As a result, the State decided to collect the statistics themselves. They turned to Judith Rooks, a certified nurse midwife and midwifery researcher who was known to be a supporter of direct entry midwifery, to analyze the Oregon homebirth statistics for 2012.

In March 2013 presented the data using this chart:

Rooks regretfully acknowledged:

Note that the total mortality rate for births planned to be attended by direct-entry midwives is 6-8 times higher than the rate for births planned to be attended in hospitals. The data for hospitals does not exclude deaths caused by congenital abnormalities.

Many women have been told that OOH births are as safe or safer than births in hospitals …

Who cares about dead babies? Not Oregon homebirth midwives.

Since then, as far as I can determine, no similar analysis of homebirth safety has been undertaken and homebirth midwives have dragged their feat in implementing higher standards.

Finally, the Oregon Board of Direct Entry Midwifery has proposed new standards to enhance safety and Oregon homebirth midwives are incensed. They have directed their clients and supporters to bombard the Board with a form letter that summarizes their objections. Thus far 86 people have sent the form letter as originally written, and additional people have submitted it with modifications.

Here are the objections as stated in the letters:

The proposed rules that I do not agree with are:

• Requiring midwife to terminate midwifery care when an indication to transfer presents
• Requiring midwife to immediately transfer care to the hospita] when a transfer of care indication arises in labor.
• Transferring care in labor for two blood pressures over 140/90
• Transferring care in labor for inability to hear fetal heart tones
• Transferring care in labor for outbreak of genital herpes
• Transferring care in labor for thick meconium-stained amniotic fluid when birth is not imminent
• Transferring care postpartum for retained placenta
• Transferring care postpartum for a client with postpartum depression or mood disorders with suspicion or possible endangerment of self or others
• Transferring care postpartum for high blood pressure
• Transferring care for the newborn with high respirations
• Transferring care for the newborn with temperature below 97 degrees
• Having to consult in pregnancy for someone taking any medication
• Having to consult in pregnancy for all VBAC clients
• Having to consult in labor for someone who has one high blood pressure (140/90)
• Having to consult in labor for a surprise breech
• Having to consult in the postpartum period about any evident or suspected infection
• Requirement that each time fetal heart tones are taken they be assessed continuously during and after contractions
• Removing twin home births from LDMs scope of practice.

These higher standards are in no way unusual. Nearly all the proposed changes reflect compliance with standards in countries like the UK, Canada and the Netherlands, where homebirth is much more highly regulated and, in consequence, much safer than in Oregon.

Who cares about international standards? Not Oregon homebirth midwives.

Every single one of these situations is a risk factor for death of the baby, the mother or both. It is only reasonable that homebirth midwives should do everything in their power to prevent dead babies and dead mothers.

But there’s an additional risk; its a risk to the midwives themselves. It’s the risk of losing money. That risk to their wallets is apparently more important to Oregon homebirth midwives than the risk that babies or mothers might die preventable deaths.

Of course, there’s yet another possible reason for midwives to oppose these standards and it’s even more appalling than the financial conflict of interest. Homebirth midwives are so poorly educated and so poorly trained that many may not understand the significance of these risk factors. Indeed they might not recognize them as risk factors at all, euphemizing them as “variations of normal.”

Here’s a tip for them: if it substantially increases the risks of death, it’s not a variation of normal.

For example, the Oregon Health Evidence Review Commission informed the Board:

We have highlighted two key areas in which the proposed rules conflict with the updated evidence review related to recent evidence of infant harms…

• Vaginal Birth After Cesarean (VBAC) -up to 4 prior cesarean sections, or 3 without a previous successful vaginal delivery
• Breech presentation

… A 2014 study by Cheyney included in the 2015 Coverage Guidance found that breech position increased the intrapartum fetal death rate by 13.51/1000 v. 1.09/1000 vertex (p<0.01) – a 12-fold increase in death rate. This study included 16,924 planned home births with 222 breech presentations and 5 perinatal deaths…

VBAC updated evidence

The updated HERC evidence review found 2 new comparative U.S. studies that provide additional information about the harms to neonates in women with prior cesarean planning an out-of-hospital birth.

Who cares about scientific evidence? Not Oregon homebirth midwives.

Standards? Oregon homebirth midwives don’t need no stinking standards!

The history of foot binding is a history of women’s pain.

According to Amanda Foreman, writing for Smithsonian Magazine:

A small foot in China, no different from a tiny waist in Victorian England, represented the height of female refinement. For families with marriageable daughters, foot size translated into its own form of currency and a means of achieving upward mobility. The most desirable bride possessed a three-inch foot, known as a “golden lotus.” It was respectable to have four-inch feet—a silver lotus—but feet five inches or longer were dismissed as iron lotuses. The marriage prospects for such a girl were dim indeed.

Descriptions of the practice make for chilling reading.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Elite women in industrialized countries no longer believe that their value lie in the pain of foot binding. Instead they believe that their value lies in the pain of childbirth.[/pullquote]

Beginning when a girl was between 5 and 6 years old:

…[T]he feet were massaged and oiled before all the toes, except the big toes, were broken and bound flat against the sole, making a triangle shape. Next, her arch was strained as the foot was bent double. Finally, the feet were bound in place using a silk strip measuring ten feet long and two inches wide. These wrappings were briefly removed every two days to prevent blood and pus from infecting the foot. Sometimes “excess” flesh was cut away or encouraged to rot. The girls were forced to walk long distances in order to hasten the breaking of their arches. Over time the wrappings became tighter and the shoes smaller as the heel and sole were crushed together…

Despite the appalling pain, millions of Chinese women perpetuated the tradition for a thousand years. They believed a woman’s worth was in the pain she was willing to endure to achieve tiny feet. Or to put a modern spin on in, Chinese women were “empowered” by foot binding. Using today’s language, they might have claimed that the choice of foot binding, undertaken solely at the discretion of and under the control of women, was a feminist choice.

Consider the story of Wang Lifen.

Footbinding was first banned in 1912, but some continued binding their feet in secret…

Wang Lifen was just 7 years old when her mother started binding her feet: breaking her toes and binding them underneath the sole of the foot with bandages. After her mother died, Wang carried on, breaking the arch of her own foot to force her toes and heel ever closer…

“Because I bound my own feet, I could manipulate them more gently until the bones were broken. Young bones are soft, and break more easily,” she says.

At that time, bound feet were a status symbol, the only way for a woman to marry into money.

But we know better, right? We understand that the practice of foot binding was a way to subjugate women, forcing them to endure excruciating pain in the short term and appalling disability for the rest of their lives.

Fortunately, elite women in industrialized countries no longer believe that their value resides in the pain of foot binding. Instead they believe that their value resides in the pain of childbirth. Indeed, they claim to be “empowered” by the pain and some even insist that the choice to endure excruciating pain in labor is a feminist choice.

I imagine that any natural childbirth advocates who have read this far are incensed by the comparison, but what’s the difference?

The philosophy of natural childbirth, promulgated by obstetrician Grantly Dick-Read in the 1930s, was expressly created to subjugate women. He was trying to convince middle and upper class women that childbirth pain is in their minds, thereby encouraging them to have more children. Read’s central claim was that “primitive” women do not have pain in childbirth. In contrast, women of the upper classes were “overcivilized” and had been socialized to believe that childbirth is painful.

He famously said:

The mother is the factory, and by education and care she can be made more efficient in the art of motherhood.

Grantly Dick-Read’s theory of natural childbirth grew out of his belief in eugenics. He was concerned that “inferior” people were having more children than their “betters” portending “race suicide” of the white middle and upper classes. Read believed that women’s emancipation led them away from the natural profession of motherhood toward totally unsuitable activities. Since their fear of pain in childbirth might also be discouraging them, so they must be taught that the pain was due to their false cultural beliefs. In this way, women could be educated to have more children.

According to Read:

Woman fails when she ceases to desire the children for which she was primarily made. Her true emancipation lies in freedom to fulfil her biological purposes.

Dick-Read would be delighted that his philosophy — women are meant to suffer and are improved by suffering — has been embraced as empowering and a feminist choice.

But wait! Unmedicated childbirth is natural while foot binding is unnatural. That may be true, but the meaning ascribed to each is entirely cultural. There are many different types of natural pain that we do not consider empowering and many types of unnatural pain (think marathons and mountain climbing) that elicit admiration. The insistence that the pain of childbirth is empowering and the decision to refuse pain relief or standard medical care is a feminist choice are cultural beliefs.

But wait! Anything that woman chooses deliberately must be a feminist choice, right?

Wrong. Unfortunately women are often the most enthusiastic enforcers of patriarchal values. Consider female genital mutilation. It is a practice designed by men, for men, to preserve men’s privileges, but it is performed exclusively by older women on female children in order to make their bodies “respectable” for men.

But wait! Foot binding left women with permanent disabilities while natural childbirth does not. Really? The disabilities caused naturally by childbirth — incontinence, prolapse, sexual dysfunction — are less visible than the tottering walk of women whose feet were bound, but every bit as life limiting if not more so.

The bottom line is that foot binding, female genital mutilation and natural childbirth are forms of social currency. Within the societies that promote them, bound feet were considered “beautiful,” mutilated female genitals are considered “clean” and unmedicated vaginal birth is touted as empowering. That doesn’t change the fact that all reflect the belief that a woman’s value resides in her suffering.

Just as there is nothing feminist or empowering about foot binding or genital mutilation, there is nothing feminist or empowering about unmedicated vaginal birth — regardless of how many women insist there is, promote it or choose it for themselves.

It’s just the kind of evidence I have been looking for.

I’ve relentlessly hammered the point that although small studies suggest that breastfeeding has benefits in industrialized countries, population data has failed to demonstrate the predicted benefits in real world experience. The decreases in infant mortality of term babies, reduced incidence of various conditions and savings in healthcare costs have never materialized.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The data suggest reverse causality: deathly ill newborns can’t breastfeed; that doesn’t mean newborns who don’t breastfeed become deathly ill.[/pullquote]

A new paper in Breastfeeding Medicine,Associations Between Breastfeeding Initiation and Infant Mortality in an Urban Population, analyzing data from a poor, urban area (Shelby County, Tennessee) purports to show that the benefits are real, not merely theoretical:

Initiation of breastfeeding was associated with a significant reduction in total infant mortality (OR=0.81, 95% CI=0.68–0.97, p=0.023). Neonatal mortality was also significantly reduced with any breastfeeding (OR=0.49, 95% CI=0.34–0.72, p=0.001). Postneonatal mortality was not significantly asso- ciated with breastfeeding initiation in the overall population (OR = 0.95, 95% CI = 0.78–1.17, p = 0.65), but was significant in the nonblack population (OR = 0.63, 95% CI = 0.41–0.98, p = 0.039). An association was observed between breastfeeding initiation and infant mortality from infectious disease (OR = 0.49, 95% CI = 0.32–0.77, p = 0.002).

The authors conclude:

In an urban area with high infant mortality and low breastfeeding rates, initiation of breastfeeding was significantly associated with reductions in overall infant mortality, neonatal mortality, and infection-related deaths. Breastfeeding promotion, protection, and support should be an integral strategy of infant mortality reduction initiatives.

But if you take a closer look, it’s just another example of breastfeeding researchers assuming causality without justification. And they leave out some critical information that threatens their conclusions.

The authors start with a very impressive set of graphs:

It shows that as breastfeeding rates rose in Shelby County, infant mortality declined. The decline among black women in particular is quite impressive.

How does that compare to the surrounding area?

Here’s a graph from another source, a report from the Shelby County Health Department:

Against the backdrop of an 18% decline in infant mortality in Tennessee, Shelby County experienced a remarkable 34% drop.

Was breastfeeding responsible? The authors of the new paper compared ever breastfed to never breastfed infants. In other words, if the baby was put to the breast at all, it was classified as ever breastfed, regardless of whether the baby was breastfed exclusively or breastfed for any length of time beyond the postpartum hospital stay.

They claim that breastfeeding is the cause of the reduction in infant mortality. Looking at their data suggests otherwise.

I added the red arrows to highlight the results that are statistically significant. They’re startling: breastfeeding appears to have its impact on neonatal deaths (deaths in the first 28 days), not postneonatal deaths; that’s the opposite of what you might expect since the purported benefits of breastfeeding are supposed to accrue over the long term, not immediately.

Indeed, when assessing the benefits of breastfeeding, many researchers have excluded the first month after birth entirely. As the influential 2004 paper Breastfeeding and the Risk of Postneonatal Death in the United States notes:

Because infants who are sick from birth may be unable to breastfeed and children who become ill later may stop, breastfeeding infants may seem healthier because illness, especially mortal illness, prevents breastfeeding rather than because breastfeeding prevents illness. The recommended methods for dealing with this problem are to exclude deaths that occur in the neonatal period and to assign feeding category by how the child was fed at some time before death occurred… These tactics do not exclude reverse causality completely, but they should minimize its effects.

Had the authors of the new paper followed these guidelines, they would not have much to write about, since the bulk of comparisons between never breastfed infants and ever breastfed infants showed no statistically significant difference. So although they reference these guidelines, they chose to add neonatal mortality back in though they excluded the first week post birth. Their statistically significant results occur during that period, the very time that reverse causality is most likely to affect results. The differences between ever breastfed and never breastfed infants who died before 28 days of life may simply reflect the fact that the babies who died were never well enough to breastfeed.

Looking at the causes of death raises further doubts.

Ever breastfed infants did NOT have a reduced risk of SIDS and there were so few deaths from NEC that the impact of breastfeeding could not be assessed. The main difference between ever breastfed and never breastfed infants was in deaths from infectious agents.

According to the authors:

Infectious etiologies coded on the death certificate identified the following organisms: Staphylococcus species; Streptococcus species; Klebsiella, Pseudomonas, and Escherichia coli species; cytomegalovirus; herpes; Candida; “viral”; Meningococcal species; “Whooping Cough”; and unspecified.

CMV is transmitted before birth and herpes during birth. Klebsiella, Pseudomonas, and systemic Candida are devastating infections that are often acquired by compromised infants in the NICU. It is likely, therefore, that in the case of these infectious agents, the babies were too sick to ever breastfeed. It wasn’t the lack of breastfeeding that led to the infections; it was the infections that led to the lack of breastfeeding.

So the data in this paper suggests that while breastfeeding was associated with fewer infant deaths, it did not cause fewer infant deaths.

Equally important, the authors failed to note that in 2006 Shelby County had embarked on a multi-pronged plan to reduce its high infant mortality rate.

This table appears across two pages in the presentation and I pasted them together:

As you can see, breastfeeding was one prong and indeed breastfeeding rates rose by 7.2% but there were other successes as well: the rate of early prenatal care rose; the rate of smoking in pregnancy dropped; and the teen pregnancy rate dropped by more than 21%. These factors almost certainly contributed to the drop in infant mortality in Shelby County but they aren’t even mentioned in new paper.

The bottom line is this:

1. The authors of the paper recognize that real world evidence (the same evidence I have been demanding from lactation professionals) is critical to demonstrating that the benefits of breastfeeding are real.

2. The authors claim that their data shows that increased breastfeeding caused decreased infant mortality. The evidence they provided shows the opposite: breastfeeding had almost no impact on postneonatal mortality and the effect on neonatal mortality almost certainly reflects that fact that deathly ill newborns can’t breastfeed, NOT that newborns who don’t breastfeed become deathly ill.

3. The authors disingenuously failed to mention a major multi-pronged effort to reduce infant mortality in Shelby County that produced critical changes — such as the steep drop in the teen birth rate — that almost certainly had as much or more to do with the decline in infant mortality than breastfeeding rates.

In other words, this paper did NOT show that breastfeeding provides real world benefits. We’re still waiting for that evidence.