On Saturday, I took Mike Woolridge, former director of Baby Friendly UK, to task over his inability to demonstrate the benefits of breastfeeding that he claims exist.

Mike has written a variety of highly offensive things. In response to the many women commenting whose babies have suffered from insufficient breastmilk, he obnoxiously declared:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]I will not stay silent so that Mike and other lactation professionals can stay comfortable.[/pullquote]

They’re NOT starving and screaming in hunger, that’s just what you have culturally been indoctrinated to believe…

Referring to the fact that I breastfed my own four children, Mike made this bizarre claim:

Can you not see the profound ‘colonialist’, white-supremacist basis to this view? You’ve gained the benefit, but f**k everyone else.

But Mike feels he has been misrepresented and he has responded in a series of comments on an old Facebook post.

(1) I am NOT responsible for “extrapolation from smaller studies” either in relation breastfeeding or any other branch of Medicine. For the past 20 years, my role/job/paid employment has only ever been to evaluate the methodology of research studies, determine they’re appropriateness to the Null hypothesis being tested; determine whether the published statistics confirm that it is appropriate to reject the Null hypothesis; and whether the authors have limited their conclusions to the findings of their own study, or whether they’ve gone too far in extrapolating. That is the basis of CASP – the Critical Appraisal Skills Programme (UK); personally, I do NOT depart from these maxims, so you are wrong to accuse me of “extrapolation from small studies” in such an underhand way.

In other words, Mike has been extrapolating from small studies or quoting others who extrapolate from small studies. There is nothing underhanded about my claim. In some situations, especially in the early days of researching a particular topic, that’s all that anyone can do. But while that might have been appropriate evidence 25 years ago, we now have 25 years of data on what has happened as breastfeeding rates have risen dramatically. Breastfeeding researchers made a variety of predictions based on their extrapolation from small studies and with the exception of a reduction in NEC in premature babies, those predictions have not come to pass.

It’s not underhanded to continue to rely on extrapolation of small studies when those conclusions are not confirmed by evidence from larger groups followed over longer periods of time; it’s unscientific. The continued insistence by Mike and other lactation professionals that breastfeeding has major benefits for term babies reflects the fact that they view their beliefs about breastfeeding as non-falsifiable; that’s also unscientific.

Mike writes:

(2) You seem obsessed with the notion of there being a ‘Breastfeeding industry’ out there (as opposed to a huge ‘Formula Industry’) – I dispute that assertion and would like to make clear I have never “earned a salary by promoting breastfeeding”.

He then goes on to detail his job and research history that reveals — surprise! — his income comes exclusively from researching and promoting breastfeeding.

Over a 2 year period, 1993-95, I earned half my salary by developing and implementing a strategic plan for introducing UNICEF’s BFHI scheme into UK maternity units, and UK culture (I can supply you with a copy of the multi-faceted strategy I drew up). My job was to implement the initiative, not sell or promote breastfeeding because I had a personal mission to do so.

Mike wasn’t promoting breastfeeding because he had a personal mission or was receiving money for it; it’s apparently a coincidence that he was promoting breastfeeding because he took a job and accepted income for promoting breastfeeding. Does anyone understand the difference between these two things?

The rest of my salary, both before and after, was derived from research grants which I personally competed for.

All of which were predicated on and strove to support the belief that breastfeeding has major benefits.

So far as I can determine 100% of Mike’s income over the past 25 years has come from promoting breastfeeding.

Mike considers that the fact that he has taken money from the formula industry to research and speak about the benefits of breastfeeding as mitigating.

I have been excluded in recent years from speaking at UNICEF BFI conferences and events because of these links to industry, although I have delivered plenary talks to ILCA and ALCA. Additionally, following a recent presentation I made to the Nestlé Nutrition Institute Workshop, my services are no longer required by four international organisations: LLLI, LLL-GB, the Association of Breatsfeeding Medicine, and ILCA (having previously acted as professional adviser to certain of these).

This doesn’t change the fact that 100% of Mike’s income over the past 25 years comes from promoting breastfeeding.

Mike goes on:

(3) I utterly reject your assertion that the “benefits of breastfeeding in industrialised countries are almost entirely theoretical”

Why? Mike offers the logical fallacy Argument from Authority.

I can count at least two dozen national and international agencies, institutions, professional bodies and organisations which agree with my view …

Arguing that something is true because authoritative figures and organizations claim it it true is a valid strategy in most situations EXCEPT when asking whether authority figures and organizations are wrong. For example, 30 years ago I could have argued that episiotomy prevented vaginal/perineal tears because every major obstetrical organization and textbook claimed that it did. They were wrong and they recognized it when they new data was published that questioned and ultimately debunked what had been a time honored principle of obstetrics.

The two dozen national and international bodies that Mike invokes are also wrong. The big difference is that they refuse to recognize their mistake despite the fact that looking at larger populations for longer periods of time reveals that their claims — made because of extrapolation from small studies — cannot be true.

Mike ends in a huff:

This rest of this paragraph amounts to online abuse. “You’ve basically acknowledged…” No I haven’t, neither covertly nor overtly, that “…it doesn’t matter to you what the population data shows…” – it DOES MATTER very much indeed, which is why I only accept the evidence when it has been statistically proven to apply to populations. “…your career and self-image rest firmly on pretending breastfeeding has major benefits and you won’t be moved by mere facts” – this is slanderous and amounts to defamation of character, on which you need to be extremely careful.

I’ll take my chances, Mike.

Right now literally tens of thousands of babies are being hospitalized each year for iatrogenic complications because lactation professionals like Mike routinely exaggerate the benefits of breastfeeding and ignore (and in Mike’s case, actually deny) the fact that insufficient breastmilk is common.

I will do whatever I can to reduce the suffering of babies and mothers. I will not stay silent so that Mike and other lactation professionals can stay comfortable with the harm they have done and continue to do.

A recent paper on the breastfeeding practices of African Maasai women is filled with startling statistics.

According to Maternal perceptions of breastfeeding and infant nutrition among a select group of Maasai women in BMC Pregnancy and Childbirth:

• 100% of the women breastfed
• Nearly 100% began breastfeeding within an hour of birth.
• 100% breastfed for a year or more.
• 100% received breastfeeding guidance and support from older female relative.

It’s just the type of indigenous practice that breastfeeding researchers like to invoke when encouraging women in the industrialized world … except for the most starting statistic of all:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Supplementing breastfed babies is a universal practice.[/pullquote]

0% of the Maasai women breastfed exclusively; 100% of the women practice supplementary feeding!

How could the Maasai women get it so wrong?

It’s not for any of the reasons that lactation professionals invoke when disparaging women in industrialized countries: It’s not because of formula because they don’t use it. It’s not because of formula advertising. It’s not because of lack of support.

Why do 100% of Maasai women supplement their babies?

The majority of mothers reported they were not aware of the EBF recommendation. While a few stated the recommendation was a good idea, many felt this was not realistic in their circumstances and expressed the belief that mother’s milk alone was never adequate to provide for an infant’s needs… (my emphasis)

They offered a variety of liquids:

Mothers were asked if their baby was receiving anything other than mother’s milk. None of the twenty infants under six months of age were EBF since all were receiving a liquid (including semi-solids) in addition to breastmilk. Butter (semi-solid) and goat/cow’s milk were the most common supplements provided to the infants at the time of the interview. Honey, juice, and water were also given with most infants receiving more than one supplemental liquid.

They aren’t the only indigenous women who hold that belief. Supplementing breastfed babies, especially before the mother’s milk comes in, is practiced on nearly every continent.

Nonetheless, the researchers are sure that the Maasai women are doing it wrong. And they believe that Maasai infants are dying as a result.

The overall infant mortality rate in the Tanzania northern zone encompassing Arusha and NCA was 38 per 1000 for the ten years preceding the 2015–2016 national survey. Research assessing child health among the Maasai in the nearby Arusha and Manyara areas of Tanzania found Maasai children were substantially more vulnerable and reportedly experience diarrhea, pneumonia, and fever more frequently when compared to other co-located ethnic groups. Maasai children were also two to three times more likely to exhibit stunted growth and wasting compared to the other ethnicities, with 80% of Maasai households classified as severely food insecure. The Maasai children also had higher rates of stunting (57% versus 45%) and wasting (10% versus 5%) compared to the national average during the same time period. In 2008, the leading causes of death for children under-five at a rural hospital serving primarily Maasai people in the Ngorongoro District were pneumonia, malaria, diarrheal diseases, neonatal conditions, and malnourishment

The obvious cause of these problems is starvation and semi-starvation, yet the researchers believe — without evidence — that ending the practice of supplementing would save lives.

But women who are starving can’t produce enough milk. As the authors acknowledge:

Maternal nutritional status, in turn, affects the composition and volume of human milk. While some nutrient content, such as calcium, is independent of maternal diet, others such as vitamins A and B6 are highly dependent on maternal nutritional status. Research with lactating women in pastoral communities in Kenya found the volume of mother’s milk consumed by infants was related to the mothers’ body composition, and concluded “there is a possibility that lactating mothers practicing EBF living under harsh conditions may experience periods of low breastmilk volume”…

In other words, the Maasai women are supplementing their babies because the babies will die without additional fluids, calories and nutrients.

And that may be why so many indigenous women in a variety of cultures on every continent continue to supplement babies. Since most humans throughout history have lived a subsistence existence, insufficient breastmilk is likely quite common, not rare. And supplementing babies has become a near universal practice.

But wait. Aren’t women — like all other mammals — designed to breastfeed. Other mammals don’t provide supplements … and they have high rates of infant death as a result. The difference between humans and other mammals is probably NOT that we are unique in having a high rate of insufficient breastmilk; the difference is that we are smart enough to be able to understand the problem and try to fix it with supplements!

The authors of the paper seem to tie the high rate of supplementation to the high rate of death.

Increased EBF among the Maasai of NCA could have a positive impact since more intensive breastfeeding is associated with reduced incidence of respiratory and diarrheal infections, leading causes of infant mortality in this region. EBF could also reduce the risks of bacterial and viral infections acquired by infant consumption of raw goat/cow milk, reportedly a normal practice among this group of women.

You know what else could reduce the risk of infant death and reduce it more reliably and effectively?

Food for mothers to encourage the production of more breastmilk and formula to provide better nutrition to infants than the supplements traditionally used by the Maasai.

The authors conclude:

… While breastfeeding is universal, there are cultural and socioeconomic barriers adversely impacting the provision of optimal infant nutrition as recommended by the WHO.

And there may be biological barriers as well. Breastfeeding may not be as perfect as lactation professionals pretend.

I find it baffling that, to my knowledge, no one has investigated why the practice of supplementing has gained such wide global currency. Obviously we cannot know the original reasoning behind the practice, but odds are high that it reflects the fact that up to 15% of well nourished women have insufficient or delayed production of breastmilk. The rate is almost certainly higher among women living a subsistence existence, which is the majority of women who have ever lived.

Supplemental feeding is common worldwide, but lactation professionals cling to the fantasy that breastfeeding is always perfect for every baby. As a result, exclusive breastfeeding — the holy grail of lactation — is now the LEADING risk factor for newborn hospital readmission, affecting TENS OF THOUSANDS of newborns each year.

How ironic that lactivists invoke indigenous women as justification for banning supplementation while ignoring one of their central insights: many babies need and benefit from them.

Mike Woolridge PhD (Zoology), former director of Baby Friendly UK, appeared on my Facebook pages to defend Maureen Minchin and mansplain’ breastfeeding to us poor benighted womenfolk.

It has not gone well for Mike.

He’s offered multiple comments to a variety of posts and has had the unmitigated gall to pontificate to the many women commenting whose babies have suffered from insufficient breastmilk.

They’re NOT starving and screaming in hunger, that’s just what you have culturally been indoctrinated to believe…

That’s unspeakably ugly and cruel.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mike’s ego is so tied up in believing that breastfeeding is perfect, he can’t see the terrible harm he has caused.[/pullquote]

But for me, the most interesting subthread has been his effort to insist that breastfeeding still has massive benefits despite the fact that he can’t demonstrate them.

After much hemming and hawing, Mike came up with this bizarre effort:

[L]et’s take just one benefit of breastfeeding in the first instance – the protective effect of pre-menopausal breast cancer; this is the form for which there is a familial tendency, so a woman could protect herself against this risk by breastfeeding. The evidence is that breastfeeding 3 or more babies, for 3 months or more provides maximum statistical benefit. That’s just the way population statistics work, its nothing biological – breastfeeding one baby for nine months would be equally protective, we just don’t do it commonly enough in the populations being studied.

My favorite part is this:

Can you not see the profound ‘colonialist’, white-supremacist basis to this view? You’ve gained the benefit, but f**k everyone else.

Of course, there’s a major problem with Mike’s claim. The incidence of premenopausal breast cancer been rising as the breastfeeding rate has risen.

Oops!

His response when I pointed that out.

Clearly because of other risk factors, which were controlled for as confounding factors in the study, but may be rising in population …

Sure, Mike!

I decided to take a different tack, asking Mike what evidence would convince him that the benefits of breastfeeding are mostly theoretical and therefore, nearly every prediction that breastfeeding researchers have made about benefits of raising rates has failed to occur.

I asked:

What evidence would I need to show you that breastfeeding does not have the benefits claimed by extrapolation from small studies? You tell me what it is and I’ll try to find it for you.

I suspect that there is NO evidence that would convince him and other professional lactivists. They are like creationists in this regard. Their foundational belief is literally non falsifiable.

Mike responded:

And I’m going to reply with a question. Please provide me with specific examples of small studies which have generated significant findings, but which have not generated real benefits when translated to ‘the real world’. I will then critique that study in the time honoured manner of Evidence-based medicine.

So I did.

All the studies prior to 2002 the that claimed that routine use of hormonal replacement therapy in postmenopausal women improved their health…

Why did the original studies show that HRT was beneficial when it really wasn’t? Why did those studies find no serious side effects when HRT actually raised the risk of breast cancer?

Oops!

Backpedaling furious, Mike attempted to reframe the question:

Sorry, I failed to specify breastfeeding and its health benefits, which this discussion was meant to be about!

Sure, Mike!

Deflect, deny, defy. It’s no longer working, Mike. Exclusive breastfeeding is now the LEADING risk factor for newborn hospital readmission in the US, responsible for literally tens of thousands of admissions each year at the cost of hundreds of millions of dollars. A new paper in the UK shows that neonatal hospital readmissions have been rising largely due to dehydration and jaundice, both consequences of insufficient breastmilk.

Indigenous cultures on nearly every continent practice prelacteal feeding. I guess they didn’t get the message that insufficient breastmilk is rare; they concluded that it is so common that babies should be routinely supplemented to improve their chances of survival.

The benefits of breastfeeding in industrialized countries are trivial and the risks of aggressive breastfeeding promotion are serious and rising. It’s unfortunate that your ego is so tied up in believing that breastfeeding is perfect that you can’t see the terrible harm you have done and continue to do.

Mike is offended:

Your response is crassly irresponsible. For example, any public health laboratory in the UK conducting an audit of admissions for g-i and respiratory infections, finds they are overwhelmingly biased towards formula-fed babies; like 98:2.

Mike hasn’t been keeping up with the literature. He seems to have missed the paper that found that exclusive breastfeeding is now the LEADING risk factor for newborn hospital readmissions. One in every 77 breastfed babies is readmitted to the hospital for consequences (like dehydration and jaundice) of insufficient breastmilk.

He hasn’t even been keeping up with the UK literature.

Hospitalisation after birth of infants: cross sectional analysis of potentially avoidable admissions across England using hospital episode statistics casts light on the harm that Mike and other lactation professionals have caused.

There were 1,387,677 admissions in the first year of life and 4,063,050 live births from 1st April 2008 to 31st March 2014. The overall rate of admission increased significantly over the period from 335·0 (95% CI 333·8–336·1) to 354·6 (95% CI 353·6–355·9) per 1000 live births.

The rate of admission for the potentially avoidable conditions increased by 39% from 39·79 to 55·33 per 1000 live births (Table 2). In the 0–6 day age category the increase in admissions to hospital for these three conditions from 12·36 to 18·23 per 1000 live births contributed 85% of the increase in admission rate…

The authors concluded:

Most of the increase in infant hospital admissions was in the early neonatal period, the great majority being accounted for by three potentially avoidable conditions ESPECIALLY JAUNDICE AND FEEDING DIFFICULTIES.” (my emphasis)

Oops!

This is the harm that lactation professionals like Mike have caused. Their aggressive efforts to promoted breastfeeding have literally made the rate of infant hospital readmissions rise, yet they are still unable to demonstrate the benefits they claim.

There are none so blind as those who will not see, Mike.

Stop quoting studies of small groups and open your eyes to what’s actually happening. The benefits of breastfeeding in industrialized countries are trivial and the harms are real.

Analyze a list of most influential women in history and you could reach a startling conclusion:

Breastfeeding women seldom make history.

Many of history’s most powerful women had no children. But even those who were mothers did not spend time breastfeeding; they hired wet nurses or they used formula. Otherwise they would not have been free to rule, or to create, or to compete.

“Well-behaved women seldom make history.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Is breastfeeding better for babies or better for the patriarchy?[/pullquote]

You’ve probably seen this quote on T-shirts or tote bags or bumper stickers and it was put there to highlight a truism: the women who make history are the ones who break the rules.

Why?

Because the rules in most societies are designed to constrain women, to prevent or erase their accomplishments, and most importantly, to keep them in the home where they cannot compete with men. Being “womanly” is hedged around with so many prescriptions that those who aspire to womanliness will remove themselves from the world of political and economic power.

Fortunately, there were women who recognized that both law and society conspired to deprive women of power and they fought back.

A major transformation occurred within my lifetime. Like most women of my age, I was taught how to be “ladylike” during my childhood and being ladylike inevitably meant removing myself from academic and economic competition with men. Ending up at an legal, economic and political disadvantage to men was not a side effect of the pressure to be ladylike; it was a critical feature in a patriarchal culture.

In 2019 women can no longer be controlled by pressure to be “ladylike.” So now we are trying to control them by pressure to be “motherly.” Motherhood is hemmed around by more rules than ever, rules that not coincidentally end up rendering women at a legal, economic and political disadvantage to men. That’s not a side effect of the contemporary ethos of intensive mothering; it’s a critical feature in our patriarchal culture.

Consider the message that society sends women about breastfeeding. “Breast is best” — it could not possibly be more stark. But breastfeeding places significant physical, psychological and economic burdens on women. And that’s the point. It certainly isn’t because breastfeeding is particularly beneficial.

Ever since the 2007 publication of Joan Wolf’s Is breast really best? Risk and total motherhood in the National Breastfeeding Awareness Campaign there has been slowly rising awareness that nearly all of the benefits claimed for breastfeeding are based on scientific evidence that is weak, conflicting and riddled with confounding variables.

…The NBAC [National Breastfeeding Awareness Campaign] and particularly its message of fear, neglected fundamental ethical principles regarding evidence quality, message framing, and cultural sensitivity in public health campaigns. The campaign was based on research that is inconsistent, lacks strong associations, and does not account for plausible confounding variables, such as the role of parental behavior, in various health outcomes. It capitalized on public misunderstanding of risk and risk assessment by portraying infant nutrition as a matter of safety versus danger …

As the scientific paper, Is the “breast is best” mantra an oversimplification? noted:

In recent years, an increasing number of researchers, physicians, and authors have begun to question whether, in the United States, the benefits of breastfeeding children are exaggerated and the emphasis on breastfeeding might be leading to feelings of inadequacy, guilt, and anxiety among mothers …

After detailing an extensive scientific review of the literature, the authors concluded:

The evidence for infant breastfeeding status and its association with health outcomes faces significant limitations; the great majority of those limitations tend to overestimate the benefits of breastfeeding. Nearly all evidence is based on observational studies, in which causality cannot be determined and self-selection bias, recall bias, and residual confounding limit the value or strength of the findings.

Indeed, as I have repeatedly noted, the predictions of breastfeeding researchers — that increased breastfeeding rates would lead to lower mortality of term babies and reduced incidence of various diseases and conditions — have utterly failed to materialize.

But that hasn’t stopped breastfeeding researchers from doubling down by finding ever more arcane “benefits” (the microbiome! epigenetics!) and by creating ever more restrictions for women.

Consider this recent piece in The New York Times, Breast Milk Is Teeming With Bacteria — That’s Good for the Baby. In case you didn’t get the message, the subtitle pounds you on the head with it: Breast-fed milk may nourish a baby’s microbiome in ways that bottled breast milk can’t.

Obviously, if you want to be a good mother, you must feed your baby breastmilk.

But you can still work, right? You can just pump your milk.

No, no, no!

Moreover, breast milk seems to be rich in beneficial bacteria only when it comes directly from the mother’s breast — not even when the same milk is pumped and delivered later by bottle.

Good mothers must stay home and breastfeed! Who could have seen that coming?

You would never know from the irresponsible NYTimes piece that the research is so preliminary that it is unclear its findings are either real or clinically relevant. The studies involve only tiny numbers of subjects. Moreover, it is entirely dependent on two unsubstantiated beliefs of breastfeeding researchers that 1. differences in the gut microbiome of breastfed and bottle fed babies are meaningful and 2. we can assume that the differences mean that breastfed babies are getting a benefit and bottle fed babies are not. To date, there is no evidence for either of those assumptions.

But that’s not the point. Breastfeeding has received so much cultural support NOT because it is particularly beneficial for babies. The pressure to breastfeed is like the pressure to be ladylike. It’s not about what’s good for babies or mothers. It’s about keeping women immured in the home.

The next time someone tells you something is best for babies, consider whether that claim is just another way to keep women from seeking the same legal, economic and political power as men. In other words, it is really better for babies, or better for the patriarchy?

Breastfeeding women seldom make history. That’s not a coincidence.

Those who are following the debate between Maureen Minchin and myself may recall that in my response to her opening statement I noted:

• The widely touted benefits of breastfeeding are based on extrapolations of small studies riddled with confounders.
• The impact of increased breastfeeding rates predicted by lactation researchers have failed to occur.
• There has been no measurable impact on mortality of term babies or anything else.
• That’s in direct contrast to the benefits for extremely premature babies where increased use of breastmilk has led to a decreased risk of necrotizing enterocolitis and death.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Does Maureen even realize she has conceded?[/pullquote]

I pointed out that Maureen, despite putting a lot of words on paper, had not demonstrated that breastfeeding had saved any term babies’ lives, prevented any diseases or saved any money. I asked once again if Maureen could find any real world, population based evidence that breastfeeding has the benefits claimed.

You can find her bizarre, meandering response on her website.

I read it so you don’t have to.

Maureen Minchin uses 6000 words (??!!) to say “no,” she can’t show that the benefits of breastfeeding are real or clinically relevant.

She couldn’t show evidence of lives saved. She couldn’t show evidence of disease incidence reduced. She couldn’t show evidence of money saved, either.

Moreover, she admitted why there is such a massive disjunction between benefits claimed and benefits realized.

About 4000 words in, she first quotes me:

What won’t answer the questions? The statements of authority figures or organizations, scientific citations of studies that found effects in small groups, the naturalistic fallacy (“if it’s natural it must be good”), personal beliefs and personal anecdotes, mathematical models based on extrapolation of small studies.

Then responds:

…Out goes all infant formula research, which often consists of groups of 40-100 children at most. There goes our beliefs about how food works in bodies, which are based heavily on animal studies -as I said, pigs and rats for formula.

Thank you for admitting that, Maureen. The widely touted benefits of breastfeeding are based on small studies with tiny sample sizes and animal studies. I’m not sure she even realizes that she has conceded my point.

She then goes on to say:

How did scientists and society find out about smoking causing cancer? individual case histories, small studies, animal experiments, mathematical models, basic biology which suggested that lungs clear of tar might work better (but that’s the naturalistic fallacy) – all played a role.

But scientists were spurred to investigate the link between cigarettes and smoking because of clinical evidence — real world, population based data; the incidence of lung cancer was rising and people who smoked had a much higher risk of lung cancer than those who didn’t. In the intervening 55 years since the publication of the Surgeon General’s Report on smoking and lung cancer, the predictions made have come true. Physicians and scientists predicted that the rate of lung cancer would drop if fewer people smoked. That’s exactly what happened.

That’s a stark contrast with breastfeeding. Nearly all of the predictions made by smoking researchers have come to pass, nearly none of the predictions made by breastfeeding researchers have come true.

The bottom line is that Maureen has acknowledged that she can’t show that the benefits of breastfeeding aren’t real or clinically relevant. That’s not surprising. Over the years I’ve asked real breastfeeding researchers from Melissa Bartick to Amy Brown to Jack Newman to demonstrate that the benefits of breastfeeding are real. They haven’t been able to do it, either.

The only remaining question is whether anyone should continue to believe that the benefits of breastfeeding are real when its strongest proponents CAN’T show that increased breastfeeding rates have had a meaningful impact on the health of term babies.

Maureen Minchin has refused to abide by impartial debate rules so she has forfeited. She’s still forging ahead any way, posting what amounts to an opening statement.

At no point does she provide any evidence that breastfeeding has been shown to actually have the benefits claimed; she simply repeats the claims. On her Facebook page she reports that writing the piece was “a lot of work and great fun, too.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Maureen Minchin’s piece — verbose and self-promoting — is non-responsive. She has yet to show that breastfeeding has the benefits claimed; she simply repeats the claims. [/pullquote]

Here’s my response:

Are the benefits of breastfeeding real and clinically relevant or merely theoretical and not reproducible in large populations?

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

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

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

This graph shows the dramatic drop in incidence of vaccine preventable disease after the introduction of the vaccine for the specific disease:

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

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

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

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

How about breastfeeding?

An entire industry, the lactation industry, has arisen to promote and profit from efforts to increase breastfeeding rates. They’ve claimed a myriad of benefits for breastfeeding and predicted that an increase in breastfeeding rates would produce a decrease in infant mortality as well as reductions in a variety of diseases and conditions.

Breastfeeding initiation rates have risen in response. They have nearly quadrupled since 1970 rising from 22% to over 83% today. But the breastfeeding rate appears to have had no impact on the infant mortality rate. The graph below illustrates the steep drop in infant mortality over the course of the 20th Century. I’ve added markers for the breastfeeding rate at various points. As you can see, the precipitous drop in breastfeeding rates did not have an impact on infant mortality and the rising rate of breastfeeding initiation does not seem to have an impact, either.

Breastfeeding was supposed to prevent obesity, but obesity rates continue to rise. It was supposed to prevents asthma but rates have continued to rise. In fact, nearly all the predictions that flow from claims about the benefits of breastfeeding have failed to come to pass.

That raises the question: Are the benefits of breastfeeding real? It also raises a follow up question. If the benefits of breastfeeding are shown to be real, are they clinically relevant?

What do the questions mean?

Before we can answer those questions, we need to understand what they mean. I’m going to use a simple, silly example to explain.

Imagine a study that looked at the average body temperature of children in different grades. The investigator went to a local elementary school and took the temperatures of all 189 first graders in multiple different classes and all 193 second graders in multiple different classes.

He found that the average temperature of first graders was 98.7 and the average temperature of second graders was 98.9; he concluded that getting promoted from first to second grade raises body temperature.

What do we mean if we ask if that is a real result? We aren’t questioning whether the investigator took temperatures properly or whether he accurately wrote them down and accurately averaged them. When we ask if a result is real, we’re asking (among other things) whether it is reproducible. Would the results be the same if the investigator repeated the investigation a month later? Would the results be the same if the investigator repeated the investigation in a different school? Would the results be the same if the investigator repeated the results using 1000 first graders and 1000 second graders?

We can’t consider the results real unless the same results occur repeatedly.

In reaching his conclusion that promotion to second grade raises body temperature, the investigator assumed that first graders and second graders were otherwise the same in all respects except for body temperature. But what if he had measured the temperature of the first graders before recess and the second graders after recess? The extra physical activity of the second graders have been responsible for their higher average body temperature.

Recess in this example is what is known as a confounding variable. It isn’t the promotion that caused the second graders’ average temperature to be higher, it’s the physical activity that occurred before their temperatures were measured.

We can’t consider results real unless they have been corrected for confounding variables.

What do we mean when we ask if a result is clinically relevant?

In the example of the first and second graders, the second graders had an average temperature of 0.2 degrees higher than the first graders. Even if it were a real result (reproducible and corrected for confounding variables), it isn’t a clinically relevant result. Both groups of children had average body temperatures well within the normal range. It makes no difference that the average temperature is higher in second graders; both groups are healthy.

What do the questions mean in the context of breastfeeding?

When I ask whether the benefits of breastfeeding are real and clinically relevant, I’m asking whether they have been reproduced, whether they have been corrected for all confounding variables and whether they make a meaningful difference to the health of babies and mothers.

What won’t answer the questions?

There’s a long list of things that might at first sound impressive, but don’t really answer the questions.

The statements of authority figures or organizations don’t answer the questions.
Scientific citations of studies that found effects in small groups don’t answer the questions.
The naturalistic fallacy (“if it’s natural it must be good”) does not answer the questions.
Personal beliefs and personal anecdotes don’t answer the questions.
Mathematical models based on extrapolation of small studies don’t answers the questions.

What would answer the questions?

As with any public health measure, the proof of the pudding is in the eating. In other words, the benefits must be measurable.

Would we believe that a vaccine was worthwhile if we gave it to millions of children but we could not find a measurable impact on the incidence of the disease it was supposed to prevent? No.

Would we believe that stopping smoking reduces the risk of lung cancer if millions of people stopped smoking and the rate of lung cancer remained the same? No.

Should we believe that breastfeeding has a myriad health benefits for term babies including saving lives if no one can show that any lives have been saved? No. Should we believe that breastfeeding has a myriad of health benefits if incidence of the diseases that breastfeeding was supposed to prevent remained unchanged or even rose? No.

Maureen Minchin’s piece — verbose and self-promoting — is non-responsive. She has yet to show that breastfeeding has the benefits claimed; she simply repeats the claims.

Why? Because she couldn’t find any data that shows that the benefits claimed for breastfeeding term infants are real or clinically relevant.

Divide and conquer!

What better way to subjugate women than to have them fight with each other about who is the better mother? Not only will it keep them too preoccupied to challenge misogyny, it is self-perpetuating. Shame one woman and she might temporarily be unable to fight back; teach women to shame each other and you’ll never have to worry about controlling them again.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Shame one woman and she might temporarily be unable to fight back; teach women to shame each other and you’ll never have to worry about controlling them again.[/pullquote]

I’ve written extensively about problems with the ideology of natural mothering.

It is based on the naturalistic fallacy, a logical fallacy that claims because something was a certain way in nature, that must be the “best” way. It is based on a serious misunderstanding of natural selection, imagining that evolution produces perfection and survival of all when it actually leads to survival of few (the fittest). It is anti-feminist: natural childbirth, breastfeeding, attachment parenting were deliberately created to keep women at home, out of the workforce.

But perhaps its most pernicious impact is that natural mothering is combative mothering. It relies on constant competition, and the associated shaming and blaming, to force women to regulate their own behavior.

As Abetz and Moore explain in “Welcome to the Mommy Wars, Ladies”: Making Sense of the Ideology of Combative Mothering in Mommy Blogs, the mommy wars used to refer to conflict between working mothers and stay at home mothers, but that has changed:

The “mommy wars” metaphor has since evolved to refer to an expanded set of rivalries between mothering philosophies and practices, and is undergirded by the ideology of combative mothering, which mandates that mothers be in constant competition with one another to be the best mother. Now more than ever before, mothers appear to be fragmented into smaller and smaller camps, often defending their own parent- ing choices as best for their children…

Abetted by social media, we live in the age of combative mothering.

The mothering ideology that normalizes constant competition between mothers, especially in terms of parenting philosophies, practices, and choices, is termed combative mothering… The metaphor of the mommy wars problematically pits mother against mother, overshadowing social and structural issues of motherhood that negatively impact working families, such as paid parental leave and flexible scheduling. In the contemporary mommy wars, mothers become separated into competing factions based on their parenting philosophies, where they must justify and defend their own choices and practices against contradictory philosophies. The mommy wars metaphor … strip women of agency by constraining possibilities for maternal identities.

I would argue that stripping women of agency is the point of the competition. Moreover, when women are competing with each other over who is the better mother, they are not competing with men over jobs and power, economic as well as political.

Abetz and Moore examine mommy blogs, but they could just as easily be describing the many Facebook groups that slice and dice women based on ever more arcane parenting practices that provide ever more opportunities for women’s self-abnegation.

These new mommy wars are referred to by one blogger as “the ‘everyday’ mommy wars,” which “are about methods of baby feeding, sleep training, working mothers and sometimes even screen time.” This evolution beyond the stay-at-home versus working mother indicates that combative mothering relies on fragmentation and particularization as debates about new philosophies and practices proliferate …

…[M]othering choices are used to impose certain conditions … where good mothering relies on continued self-improvement and individual empowerment to make the best decisions for their families. This competition creates rivalries and sustains divisions between mothers, ultimately constraining opportunities for vulnerability and support across differences in parenting practices.

And that, too, is the point. Divide and conquer. It’s always about making mothering harder, not easier. If they were able to support each other, mothers might realize that they are being manipulated by ideologies that aren’t about what’s good for babies, but about constraining mothers.

Shame is integral to natural mothering.

One blogger observed that “moms can be shamed from anything these days”, through statements like, “Did you see how she’s feeding her baby? I can’t believe she thinks that’s ok?!” “He goes to bed where? What kind of parent would let their child sleep that way?”. Another stated that “Whether a mum works or stays home, breastfeeds or bottle feeds, co-sleeps or sleep trains. (…) there is still so much ‘mummy shaming’ out there”.

Furthermore:

…[T]he ideology of combative mothering is perpetuated and sustained through mothers’ anticipation and experience of judgment from others mothers. One blogger shared an experience of feeling shamed, where the other mothers were not trying to make her feel bad: “it’s a habit of we modern moms. We’re conditioned to feel the burn of judgment — or the defensive suspicion that we were being judged. It’s something we’ve come to expect”. This ideology operates within a broader neoliberal framework that recasts mothering as “a competitive exercise in highly personalized decision-making.”

Though some mothers regret the shaming and blaming, curiously they do not question the ideology of combative mothering that is making so many mothers miserable:

…Overwhelmingly, these solutions do not challenge the ideology of combative mothering, and instead shame and blame mothers for not keeping judgments to themselves … A few also assert that judgment is natural and essential, and therefore identify the problem as the expression of judgment, not the judgment itself.

The authors conclude that combative mothering is the dominant contemporary mothering ideology:

…[W]e contend that due to the sustained cultural relevance of the mommy wars, combative mothering should be acknowledged as a dominant mothering ideology in the United States that is distinct from intensive mothering and new momism. Mothers are not only compelled to devote themselves completely to their children, through time, energy, resources, and knowledge, but are also obliged to compete to be the best mother, superior to all other mothers, in a zero-sum battle where some mothers are winners and other mother are losers.

But is combative mothering really distinct from intensive mothering? I don’t think so. Indeed, intensive mothering is not supported by scientific evidence and, indeed, has been largely debunked by science. It persists because the pressure to compete persists.

I strongly agree, though, with the authors’ articulation of the rationale for combative mothering:

The pitting of mother against mother can also be contextualized as part of a much broader patriarchal ideology that undermines female solidarity and positions women as their own worst enemies who could never unite across difference. This “divide and conquer” strategy weakens women’s potential to resist existing patriarchal structures…

Resentment between women is an integral part of this systemic misogyny that relentlessly pushes the message that women are not one another’s allies. Thus, combative mothering presents a contemporary articulation of multiple historical ideals that, when couched within the mommy wars metaphor, obscures its ideological legacies…

Natural mothering isn’t about what’s good for babies. If it were, it would be judged a failure. Natural mothering is, and has always been, about controlling women by diverting them into fighting with each other.

By that measure, it has been a stunning success.

On Friday I wrote about breastfeeding advocate Maureen Minchin’s increasing desperation to have her cake and eat it, too.

On the one hand, she is trying to get out of a debate with me that agreed to months ago; on the other hands she doesn’t want her followers to know that she is running scared.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]She tries to drown her refusal of impartial debate in a tsunami of irrelevant verbiage.[/pullquote]

Her “solution”? To claim I have not responded to her entreaties and delete and block anyone who informs her followers otherwise.

That was not working, so in response to Friday’s post, Maureen offered this long screed, which began (ironically) by bemoaning long screeds:

Communicating via Facebook has limitations. Long posts are tedious, hard to read and hard to retrieve later.. To keep a record of multiple threads going on any topic takes work. I prefer to put longer posts on my website. So bookmark www.infantfeedingmatters.com.

Maureen’s priorities, as best I can determine, are to control what appears in print, have opportunity to censor her words or mine, protect her fragile ego from any outside comments … and, as always for Maureen, to promote her website and her self-published book.

But debates are not about shielding yourself from criticism; they’re about the opposite. A debate like this means having enough faith in your own arguments, and your ability to present them compellingly to others who have no vested interest that you are willing to expose yourself to questions and even criticism.

I am willing to do that.

That’s why I responded with this:

Maureen Minchin, yes or no? Oxford rules of debate. No censorship of any kind.

Her answer is no.

It’s also ridiculously verbose — complete with supplement — and inadvertently hilarious.

This process has been independently designed …

Pro-tip, Maureen, when YOU design it, it’s NOT independent.

But I am not interested in any (even my alma mater Oxford Uni) debating society rules. She would surely know, as I do, that these are geared around VERBAL debate as persuasive performance and emotive entertainment, not as rational discussion aimed at establishing fact.

Is there a relevant difference between oral and written debate that would render Oxford rules unusable? Maureen doesn’t offer one.

Maureen feels sorry for herself:

Nor will I commit to anything beyond my capacity to manage as a woman living on a small income after decades of helping families free of charge. This debate is meant to be my knowledge and ideas contesting AT’s and trying to (a) find common ground; (b) identify points of disagreement; and (c) compare our knowledge and ideas on those contested topics in light of the scientific evidence.

And she can’t resist promoting her book and herself in what she imagines is a persuasive argument.

A new edition of Milk Matters: infant feeding and Immune disorder will be where any recent detailed referencing and scientific discussion will emerge in due course.

That book is my massive argument for the importance of breastfeeding in every country,. It has been warmly greeted by eminent men and women knowledgeable in various medical fields and public health; my work has led to involvement in their research, membership in scientific societies, and much more. To have a leading immunologist write in an email that I’m their “breastfeeding encyclopedia” suggests that ex-obstetrician Tuteur should be a little more respectful of the many mothers like me, who, because of harms to their children, spend a lifetime learning about a field in which they have no formal qualifications.

She tries to drown her refusal of impartial debate without censorship in a tsunami of irrelevant verbiage.

That said, I have already wasted considerable time in a busy life on this rhetorical melodrama, and my patience isn’t infinite, even if my obstinacy can be, if I say I will do something…

And on … and on … and on.

Feel free to read the rest, including the supplement: ridiculously and unnecessarily convoluted “rules” for posting.

I proposed a debate, not because I have any hope of changing Maureen’s mind or the mind of her followers. They will undoubtedly pretend that even her refusal to debate by impartial rules is some sort of magnanimous offer on her part.

I proposed a debate to offer information to the vast majority of women who aren’t ideologically committed to one side or the other.

They will recognize that Maureen has forfeited the debate.

I knew she would.

Maureen Minchin agreed to debate me and now she’s trying to get out of it. Of course, I expected that she would back out; I just didn’t expect that she would lie to her followers about it.

Who is Minchin?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Minchin tries to dodge our debate while concealing that fact from her followers[/pullquote]

She’s a lactation professional (with no training in science or medicine) who has a self-published book on — I’m not kidding — breastfeeding and immunology.

Several months ago, in response to a complaint about her lack of sympathy and concern for women who cannot breastfeed, Minchin produced this contemptuous screed:

… I am sorry that you had such a hard time with your first, and understand your rage, and your decision to go with formula for your second, and I am glad that worked out so well for you. It doesn’t for some other people, and that’s the point: we can’t know ahead of time which children will be badly affected, but some will, in every country, some will die in every country, and all will develop differently from what they would have done if breastfed. That’s just biological fact…

At the time, I challenged Minchin to debate the issue of whether breastfeeding has real, not merely theoretical benefits and she agreed.

Happy to do so 1. when you have read my book in full and 2. when it is convenient. It is absolutely not a priority for me, as your writing to date persuades me that it will be a pointless exercise, but who knows, after reading Milk Matters you may have a little more respect for those who think differently, have more clinical experience of breastfeeding, have spent more time researching the topic, and whose work is admired by many experts around the world.

I never expected her to do it and promptly forgot about it until reminded by my readers. Maureen claimed that the end of May was no longer convenient but she was setting aside June 19-21 for a moderated debate.

On June 11, Maureen sent me a private message informing me that she had drafted “rules” for the debate, and promptly blocked me before I could respond to it.

She also posted to her Facebook page:

I’ll let you read the “rules” for yourself. As you can see, they’re mostly concerned with Maureen protecting herself from criticism.

Since Maureen blocked me from sending private messages and blocked me from posting on her Facebook page, I responded within hours on my page:

Maureen Minchin, I’ve read your proposed rules for debate. You are appropriately concerned with impartiality and I share that concern. It can’t possibly be an impartial debate if you make the rules. We must use existing, impartial debate rules.

The type of debate we have been considering is basically an Oxford style debate with the motion being: The benefits of breastfeeding are real and clinically relevant. You are arguing in favor and I am arguing in opposition.

The rules for Oxford style debate already exist in a variety of forms. Those are the rules we should use. We can negotiate the details like time for response, etc.

If you won’t participate in a debate using impartial rules, please let me know.

Ignoring my response on June 11, Maureen declared to her followers:

And here’s the best part: it appears that Maureen closed the comments so that NO ONE could publicly share my reply! It’s been four days and Maureen is still insisting she hasn’t heard from me.

Of course I never expected that Maureen would actually debate; she fears she’d be humiliated.

But I didn’t expect her to set a new standard for immaturity in the process. I should learn to be more cynical.

Many juries have awarded large judgments for babies harmed by failure to perform a necessary C-section. This is the first case I’ve heard about where the large judgment was awarded for failure to perform a requested C-section and the mother suffered the injury.

According to The Intelligencer:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women have the right have to control their own bodies by opting for a C-section instead of a vaginal birth.[/pullquote]

A Bucks County jury has awarded a mother $11 million for ongoing health issues following the birth of her second child.

A Bucks County jury has awarded $11 million to a mother who suffered disfiguring and ongoing injuries during the birth of her second child. The lawsuit states that she had requested a cesarean delivery because of a difficult first birth.

She had suffered a shoulder dystocia and a third degree vaginal tear during her first birth:

The suit, first filed in August 2013, states that in Giberson’s first delivery, which occurred in 2008, her baby was born with shoulder dystocia which occurred when a baby’s shoulder gets wedged under the pelvic bone in the birth canal. Giberson suffered a third-degree laceration with the delivery. Those complications were detailed and known or should have been known by Stoneridge Obstetrics & Gynecology physicians, the suit states.

What is a third degree laceration?

All vaginal tears are not alike. The decision on whether they should be repaired, how they should be repaired and the consequences of not repairing them depend completely on the type of tear. Most tears occur downward into the area between the vagina and rectum known as the perineum. It is more accurate, therefore, to refer to them as perineal tears. The Mayo Clinic website has an excellent series of slides detailing the normal anatomy of the perineum and the 4 degrees of perineal tears. First degree tears are the least serious and 4th degree tears the most.

Here is an illustration of a third degree tear.

The perineal muscles identified in the illustration are the superficial perineal muscles. The anal sphincter is the ring of muscle that holds the anus closed. It is directly responsible for preventing bowel incontinence. If it will is torn completely apart and not properly repaired, the woman will be incontinent.

Her history put this mother at high risk for a second shoulder dystocia with possible injury to her baby, herself or both. Then she developed another risk factor for shoulder dystocia — gestational diabetes.

She communicated to the practice that a C-section “was requested and necessary” since her first child had been born at 9.9 pounds with shoulder dystocia.

On the day of birth she once again requested a C-section:

On July 21, 2011, the day she gave birth, she again requested a C-section because of the difficult first birth and the fear that something would happen to her or her baby. But, according to the suit, Hancock and the other defendants opted for a vaginal delivery.

The complaint states that ”(the baby) was stuck in the birth canal and not coming out.” The baby weighed 9 pounds, 8 ounces and was not breathing when delivered, the suit states. The baby recovered.

According to the suit, Hancock caused a laceration to Giberson but didn’t inform the plaintiff of the degree. The mother was discharged “in excruciating pain” and was incontinent…

We don’t know if the mother sustained another third degree tear or possibly a fourth degree tear.

A fourth degree tear extends into the rectum. The result is that the vaginal and rectum form one continuous space. The repair of a fourth degree tear starts with the repair of the rectum itself. Depending on the how far the tear extends up into the rectum, the repair can be technically challenging and can take an hour or more. Once the rectum is repaired, the rest of the tear is repaired like any other third degree tear. However, because the rectum itself has been torn, the possibility exists that the tear may heal improperly and leave a hole (fistula) between the vagina and rectum with continual leaking of feces from the vagina.

The article does not specify the type of tear that the mother sustained, whether it was properly identified and whether it was properly repaired. Something went wrong, however, to render the mother incontinent and surgery was recommended. According to a report in a legal publication, the mother will require additional future surgery.

The verdict sends an important message. A healthy baby is not enough. A woman’s wishes about her own body also count and the desire for a C-section is a woman’s reasonable attempt to prevent damage to her vagina and surrounding tissues as well as future incontinence.

It’s about time that we acknowledge the important right that women have to control their own bodies by opting for a C-section instead of a vaginal birth.