It’s no secret that I think the commentors on The Skeptical OB are the best, brightest, wittiest and most insightful on the internet.

That’s why I’d like to make you part of my forthcoming book Guilt Trap: New Motherhood and the Natural Parenting Industry to be published by the Dey Street imprint of Harper Collins in 2015. I’d be honored to have you share your experiences with natural parenting (natural childbirth, breastfeeding and attachment parenting) and guilt. The book is, after all, for you and others like you.

Do you feel badly about having had a C-section? Did friends trying to convince you that it was “unnecessarean”? Are you wondering if you or your baby missed out on something important because the baby did not exit your vagina? This book is for you.

Did you have pregnancy complications like pre-eclampsia that necessitated interventions? Did you have an induction? Did your baby experience fetal distress? This book is for you.

Were you planning on avoiding an epidural but ended up getting one anyway? Are you worried that you exposed your baby to harmful drugs by getting an epidural? Are you ashamed that you “gave in” when the pain became unbearable? This book is for you.

Were you committed to breastfeeding but found it very difficult? Did you struggle with pain and other issues? Was your milk supply not adequate to meet your baby’s needs? Did you have trouble combining breastfeeding and work? This book is for you.

Did you watch your wife or partner struggle with guilt and disappointment over not meeting the prescribed goals of the natural parenting industry? Were you concerned that she lost sight of the miracle of a healthy baby in favor of the arbitrary prescriptions of an industry that did not seem to care at all about her mental health and wellbeing? This book is for you.

Are you a midwife, obstetrician, neonatologist, pediatrician or anesthesiologist who has felt concern or fear when a mother rejects conventional obstetric or pediatric practice in favor of something she read on the internet? Have you felt frustration that your patients have been primed by the propaganda of the natural parenting to distrust you? Have you found yourself trying to save the life of a mother or baby because the mother rejected the preventive care that you and your colleagues offered? This book is for you.

Your voices should be heard!

If you are interested in sharing your perspective, you can submit it to guilttrap5@gmail.com.

I can’t guarantee that your story will appear in the book, but I can guarantee that it will be considered for inclusion by my editors and me. We want Guilt Trap to reflect the myriad ways that women have struggled against the guilt, shame and disappointment promoted by the natural parenting industry and the many ways that providers have struggled against the mistruths, half truths and outright lies of that industry.

Of course, Guilt Trap is also for anyone, male or female, concerned with women’s rights and freedoms and the effort to force women back into the home, not by a frontal assault on women’s equality in the political, economic, and intellectual spheres, but by way of a parenting Trojan horse concealing the age old desire to judge women by the function of their reproductive organs inside purported “concern” over the well being of their children. French philosopher Elizabeth Badinter argued that “the baby is the best ally of masculine domination.” I would amend that to reflect the fact that babies have no interest in promoting the control of one gender over another: Natural parenting proponents are the best allies of retrograde, sexist attitudes.

When you submit your perspective, please let me know if you would like to be named in the book or would prefer first name only, initials or being entirely anonymous.

Once again, the email address for submissions is guilttrap5@gmail.com. Submissions from everyone are welcome, whether or not they read or comment on The Skeptical OB. If you know of any friends who might like to contribute, please share the email address.

I will be deeply grateful for any and all participation.

Hi, folks! Ima Frawde here. Today I’m sharing the birth flight plan I use whenever I fly from my home at The Firm to various venues across the country where I share my wisdom with the masses.

Feel free to customize the plan to meet your specific flight needs.

Here it is:

I am looking forward to my flight on Joe’s Airline (conveniently located next to Joe’s Bar and Grill) from The Firm in Tennessee to visit my acolytes in Portland, Oregon next week. My previous plane flights have been uneventful, so I am not anticipating any problems. I ask that the following wishes be respected during this flight:

* I plan to bring my flight doula for support. I ask that ALL other passengers and unnecessary staff be turned away until I have had time to arrange the plane to my satisfaction.

* Once the flight has taken off, please address me through my doula so as to avoid breaking my concentration on the scenery.

* I refuse perineal shaving or an enema before take off.

* The flight environment is very important to me. For that reason I ask that the cabin lights be kept dim, noise be avoided and the cockpit door closed for privacy. I will bring my own music that should be streamed throughout the plane, and I plan to wear my own clothes during the flight, though I may strip them off and remain naked if I feel the need.

* I request the least invasive or restrictive versions of typical airline procedures. I deal best with the temporary discomforts of flight by moving freely throughout the cabin (including the cockpit). Please notify me if seatbelt use becomes necessary and I will return to my seat to let the flight attendant buckle my seatbelt no more than 45 seconds before an impending crash.

* A full first class meal is necessary for me to maintain my strength during the flight.

* I wish to fly via the Grand Canyon even thought it is not on the way to Oregon and respectfully request that the flight not be rushed to meet artificial deadlines like on time arrival. Birds do not worry about on time arrival during their flights, and neither should we.

* I will not consent to any delays caused by mechanical problems. I’ve done my research and it shows that many mechanical problems are just variations of normal and not a cause for diverting the scheduled take off of the flight.

* If serious mechanical problems develop, I wish to try non-technological methods (walking, breast stimulation, castor oil, sexual intercourse) for making the plane fly before resorting to technological methods.

* Please do not offer warnings of any kind. I am educated and I know that if the pilot says that there is not enough fuel to safely make it to Oregon if we detour over the Grand Canyon during the flight, he is just playing the “dead passenger card.” No doubt he has a tee time at a local golf course in Portland; I will not be rushed just so he can get there sooner.

* I refuse an episiotomy.

* No one is allowed to handle my checked suitcase except my doula or myself. We will retrieve it from the cargo bay ourselves and if the baggage handler feels that he must unload it, he should unload the doula or me from the cargo bay while one of us is holding it.

* The luggage tag should not be cut under any circumstances. I wish to practice delayed tag cutting to allow my suitcase the maximum benefit from continued tag association.

* Please be advised that I am a paying customer and the customer is always right. The pilots, the flight attendants, the mechanics and the baggage handlers are here to serve me.

* If for any reason the pilots feel that they cannot comply with my demands, my doula will fly the plane.She doesn’t have a pilot’s license, but neither do birds and they seem to fly without any problems

Thank you for taking the time to help us achieve our birth flight plan. Our lawyer will be meeting us at the arrival gate ready to sue you if anything goes wrong.

On Friday I wrote about the breathtaking, unrelenting viciousness of Alpha Parent Allison Dixley’s new book Breast Intentions. True to form, Dixley doubles down on her own blog with today’s post, The Formula Feeder Doth Protest Too Much.

She starts off with the conceit of narcissists everywhere: if you aren’t cheering what she likes, you are treating it with contempt.

If you’re been alive for the fast five or so years, you may have noticed something peculiar: the emergence of a new zeitgeist of contempt for breastfeeding. Even a cursory look at the lifestyle section of many online newspapers reveals a contemporary back-catalogue now groaning under the weight of the collective bitching of a vocal minority of failed breastfeeders.

In this post I question the motives of these failed breastfeeders, let’s call them ‘formula apologists’ – the folk who make it their raison d’etre to criticise breastfeeding – that is, to criticise its promotion and its significance.

No, instead of questioning them, let’s take a look at the science. Although everything that Dixley writes rests on the premise that formula feeding harms babies, the evidence shows something very different.

I shared these graphs last year, and they make the case quite powerfully.

Over the past 100+ years US breastfeeding initiation rates have dropped precipitously and begun to rise again, but there appears to have been no impact on infant mortality, life expectancy or IQ. Sure breastfeeding provides benefits in industrialized countries, but those benefits are trivial.

So Dixley’s unrelenting viciousness toward women who can’t or don’t want to breastfeed rests on precisely NOTHING. It’s as though her entire blog were devoted to demonizing women who don’t buy the same type of car that she drives. She’s vicious because she is desperate to have her own choice mirrored back to her, not because her choice actually matters. And she utterly misrepresents that nature of the choice, the science behind breastfeeding, and the reasons why people oppose her.

It’s easy for her to go after women who chose to formula feed as trying to excuse their “failure” to breastfeed, but she can’t seem to account for the fact that someone like me, who easily and successfully breastfed four children would vociferously reject both her claims about breastfeeding and her vicious way of making them.

It’s hardly surprising that I don’t support Dixley, given my claims that lactivism, like most of natural parenting is not based on scientific evidence and that the emphasis on time intensive parenting that requires the presence of the mother 24/7/365 is retrograde and sexist. But then I got to thinking about who does support Dixley, and besides her followers who are equally desperate to have their own choices mirrored back to them, she is supported by … NO ONE.

With her message of the vital importance of breastfeeding to the health and well being of children, you might expect that she would garner the support of professional lactivists. I could find no evidence that Dixley’s stance is supported by any professional breastfeeding organizations, any lactivism programs, or, any major authors in the field whether they write for lay people or for other professionals.

Dixley’s new book, Breast Intentions, has no blurbs from other lactivists, pediatricians or public health experts. Thus far, a week after it has been published in the UK, the book has received no professional reviews. As of this morning, there hasn’t been a single positive comment on Amazon UK or Amazon.com.

It’s as if (to appropriate the crude language of Dixley herself) the book is like “a fart trapped in an the elevator,” a repulsive eruption of which everyone is doing their best to ignore, in the hope that it will simply fade away.

When considering Dixley’s writing, both on her blog and in her book, readers would do well to keep in mind that her opinions are her own and are not supported by any breastfeeding organizations, lactivism programs or healthcare professionals. If professional lactivists shun Dixley and her viciousness, and they do, everyone else should, too.

You don’t have to be Freud to recognize that someone who dubs herself The Alpha Parent, and doesn’t have her tongue firmly implanted in her cheek, has self-esteem issues. And we’re all quite familiar with the sanctimoniousness of lactivists. But even I have to admit to surprise at the brutal, toxic and abusive nature of Allison Dixley’s new book Breast Intentions; How women sabotage breastfeeding for themselves and others.

I can’t say I wasn’t warned. On her Facebook page, Dixley heralded the publication of the book with this:

Forget pussy-footing around “feelings.” Get some of this in your eyeballs. My new book Breast Intentions, available worldwide on Tuesday!”

I bought it, laid my eyeballs on it, and quite honestly was filled with … glee. As so often happens, no one does a better job at destroying the credibility of lactivists and exposing their true agenda than lactivists themselves. Dixley has staked her breasts as the two hills she’s willing to die on and no one could be happier than me.

The publisher, Pinter and Martin, has helpfully posted the full introduction to the book on line, so everyone can understand that Breast Intentions is a cri de coeur, trumpeting Dixley’s conviction that women who don’t breastfeed their infants should be consigned to a living hell of soul sucking guilt. Every page of the book, including the introduction oozes with contempt.

It starts on the very first page, in only the second paragraph:

Many women having babies today were formula-fed as infants. And the world around them is dominated by perceptions of infant feeding that can only be described as regressive: as a species, we have moved from the uncostly, self-regulating and environmentally friendly breast to the unquenchable industrial teat – a capitalist’s dream.

And Dixley knows just whom to blame: mothers!

The argument that individual women aren’t responsible for their failure to breastfeed appears plausible, comprehensible and consistent with the timeless and persistent world-view of women as the weaker sex…

Yet this response to a normal bodily function is needlessly reactive and awkwardly paternal. A blame-free breastfeeding culture infantilises women, framing them not as active agents capable of controlling their destiny and achieving their goals, but as passive wallflowers at the mercy of forces they are powerless to defy.

Dixley comes across like a nightmare version of a mother-in-law. Sure she’s blaming you for your failure as a mother, but it’s for your own good! She’s not going to “infantalize” you by demonstrating any of those sissy virtues like compassion and understanding.

Sociological theories would have us believe the answer lies in factors beyond the mother’s control – fetishism of the breast, formula-company advertising, vague notions of ‘lack of support’ and ‘a disabling social environment’ – in other words, we are led to believe that individual mothers are not responsible for the outcome of their attempts at breastfeeding. This assumption is defeatist and disempowering.

At times, Dixley’s prose reads like parody:

‘Social support’ is the buzzword of this apologetic era and dominates breastfeeding discourse. Yet social support is a broad umbrella term that can be conceptualised in so many different ways that it becomes redundant as a definition. Even so the term persists, hanging around like a fart trapped in an elevator. And, like a fart, the ‘support’ rhetoric functions as a comforting if elusive scapegoat, nifty at deflecting attention from other salient issues …

Dixley makes it clear that she is not one of those wishy-washy lactivists who euphemize their condemnation of women who can’t or won’t breastfeed as “support.” Their support reeks like a fart in an elevator. Dixley believes that what is needed is exhortations laced with casual cruelty, because the goal ought not to be to understand women who can’t or don’t wish to breastfeed, but rather to condemn them in the most vicious possible terms.

Dixley does use humor, though inadvertent:

The philosopher Nietzsche warned that we are most clueless about what is closest to us… Emotions drive our behaviour, yet we have a relatively ignorant understanding of them. If we want more women to choose breastfeeding in the ‘real world’, then we need to understand more about ‘real women’ – that is, women influenced by emotion.

You don’t say, Allison!

Neitzche also said:

You have your way. I have my way. As for the right way, the correct way, and the only way, it does not exist.

But introspection is the last thing on Dixley’s mind (obviously!).

In Breast Intentions you may read things you would prefer not to. Indeed, there is a darker, more malignant side to the breast vs formula debate, particularly concerning women’s relationships with each other. This book exposes the unforgiving and angry constituents of the maternal character, revealing a mother’s capacity to deprave as well as to nurture. In exploring the mechanics involved in deception, guilt, envy, contempt, defensiveness and sabotage, the book penetrates emotions that often feel too ugly or too unacceptable to talk about, particularly in such a feminine domain. Yet this dark and opaque side of motherhood is one we leave untreated at our peril.

I agree, Allison.

Your deception, envy, contempt and defensiveness positively “reek” from every sentence that you write. And believe me when I say that I don’t view YOUR feelings as too ugly or unacceptable to talk about in a feminine domain. Indeed, I believe that the ugly emotions that you display, and the casual cruelty that hides your fundamental insecurity, are precisely what we SHOULD be talking about when we talk about contemporary breastfeeding advocacy.

Let me emphasize that I speak about your viciousness from the perspective of someone who breastfed four children until they weaned themselves, and I enjoyed it. But just because I did it doesn’t make me a better mother than anyone else who loves her children with her whole heart, indeed her entire being, as most women do. And that means it doesn’t make you a better mother, either, no matter how desperately you cling to that fiction.

Breast Intentions is breathtakingly, relentlessly vicious because Allison Dixley is breathtakingly, relentlessly vicious. She is the poster girl for everything that is wrong with professional lactivism, and I couldn’t be more delighted.

This year the holidays came early to The Skeptical OB; I suspect that Breast Intentions is the gift that will keep on giving.

Lactivism, like all natural parenting, suffers from three serious flaws:

1. It perverts the scientific evidence to support pre-approved conclusions
2. It is an industry that relentlessly markets its own services
3. It is deeply sexist and retrograde

Don’t believe me? Consider this latest attempt by lactivists to move the goal posts, appearing in the Pacific Standard, The Unseen Consequences of Pumping Breast Milk. Sounds ominous, doesn’t it … and it’s meant to.

Exclusive pumping is becoming more popular among American moms, often seen as a way moms can “have it all.” Meanwhile, the effects on maternal and infant health—and workplace policies—are rarely discussed.

You thought that breastfeeding made you a good mother? Fool! The only good mother is one who sacrifices her career and her income to stay home 24/7/365 with her baby.

Problematically, the rise of pumping also implies that moms don’t need as much time at home to spend with their babies—they can simply pump, store, and go back to work. What most moms may not know is that beneath the perceived convenience of pumping, there are potential consequences both for workplace norms and for the health of themselves and their infants. There’s an assumption that bottle-feeding breast milk to a child is equivalent to breastfeeding, but that may not be the case.

Oh, the horror! Women don’t have to be with their babies 24/7/365 in order to provide them with the benefits of breastmilk. That can’t be right; there must be some way we can make women who work feel that they are not giving their children the very best, and not so incidentally, proclaim the overweening sense of superiority of lactivists. Hence the claim that feeding a baby pumped breast might MAY not be the same as breastfeeding.

It’s a trifecta! Lactivists have managed to pervert the scientific evidence, market their own services and advance their antediluvian sexism all in a single claim.

Let’s take a look at the scientific evidence, but before we do, let’s examine what we would need to see in order to conclude that pumped breastmilk is inferior to the breastmilk of women who love their babies enough to stay home instead of putting their own trivial, selfish need for income and/or career on hold.

That’s going to be hard to do since in industrialized countries the benefits of breastfeeding are trivial, amount to nothing more than a fewer episodes of colds and diarrheal illness among infants in the first year. You’d have to show that the babies whose mother fed them breastmilk exclusively and never pumped were appreciably healthier than those who received pumped breast milk.

Are there any studies that demonstrate this? Of course not, since it isn’t true.

What evidence does the author of this piece marshal to support her assertion?

There’s a commentary in a public health journal that makes the bizarre claim that:

Milk expression may also be problematic for mothers, and it may be particularly problematic for infants if they are fed too much, fed milk of an inappropriate composition, or fed milk that is contaminated. (my emphasis)

The authors then proceed to offer NO EVIDENCE that this is happening.

Nonetheless, they offer the truly obnoxious suggestion that:

To characterize women’s behavior related to milk expression, it may be necessary to develop a new vocabulary for breastfeeding so as to distinguish milk extracted from the breast by the baby from that extracted by a pump for feeding to the baby at a later time.

Wouldn’t want those selfish, self-absorbed, career- women who are pumping to imagine that they are providing “real” breastmilk, would we?

Then there is a commentary in The Journal of Human Lactation entitled New Insights into the Risk of Feeding Infants by Bottle discussing a study published elsewhere.

[T]hose who received human milk by bottle only gained 89 g (P = .02) more than their breastfed only counterparts, respectively.

So babies fed breastmilk from a bottle reportedly gained of 3 ounces/month more than babies who received breastmilk directly from the breast. That’s not very impressive when you consider that the babies’ weights were based on maternal recall and may not be accurate.

That’s it. No other data was presented to support the claim that there is any difference between breastmilk from a bottle and breastmilk from a breast. That doesn’t stop lactivists:

“Promotion of breast-milk feeding as identical to breastfeeding is misleading,” says Virginia Thorley, a lactation consultant and honorary research fellow at the University of Queensland in Australia. “The new challenge is to use language accurately, and tell mothers the truth that feeding their milk to their babies by bottle is less than equivalent to breastfeeding.”

Thorley has written extensively on the potential perils of “normalizing” the separation of breast milk from breasts. She says that bottle-feeding of breast milk has a place in specific circumstances, such as when a baby is unable to adequately stimulate the mother’s milk supply, or in cases like Boss’, where a baby is unable to nurse directly. And while she agrees bottled breast milk is better than infant formula, “breastfeeding is about more than the milk.” Babies don’t just breastfeed for nutrition; they nurse for comfort, closeness, soothing, and security.

And what “perils” might those be. Thorley doesn’t mention any, but we can guess. One peril is that women who pump instead of breastfeed might not need the services of a lactation consultant. Lactation consultants have a habit of making claims that result in profit for themselves. They grossly exaggerate the benefits of breastfeeding; they grossly exaggerate the “risks” of formula feeding. They attempt to punish women who will never be their clients by banning formula gift bags, locking up formula in hospitals, and denigrate women who can’t or won’t breastfeed.

The chief peril, of course, is that “normalizing” the separation of breast milk from breasts actually normalizes working while mothering. And we all know that “good” mothers never work. “Good” mothers give up income, career and self-actualization in favor of staying home, having babies (vaginally, without pain medication, of course!), breastfeeding (no pumping allowed), baby wearing, and welcoming them to the family bed. “Good” mothers judge themselves and others by the functions of their breasts, vaginas and uteri. Their intellect and their character are irrelevant.

The piece concludes with a flourish of the viciousness for which lactivism has become known:

The three infant-feeding options available—formula, pumped breast milk, and breastfeeding—likely fall on a continuum of good, better, best… For parents who have the luxury of truly choosing any feeding method, it’s fine to choose exclusive pumping in the same way that it’s fine to choose formula, as long as they understand the differences in health outcomes. The problem is that for exclusively pumped milk, moms need to understand there’s still a lot we don’t know.

“I feel like I both succeeded and failed. Many moms can’t or won’t exclusively pump for as long as I did, but I still feel like I failed at breastfeeding,” Boss says. “I realize I did the best that I could. And that’s all our kids can ask from us.”

There is NO EVIDENCE that feeding babies pumped breast milk is in any way inferior to breast milk directly from the breast, but the dirty little secret of lactivism is that it has nothing to do with babies or even with breastfeeding. Lactivism is all about lactivists and their desperate need to feel better than other mothers, about hating and hurting women who make choices different than theirs, and it rests on an antediluvian, sexist conviction that a woman’s place is in the home, bearing (vaginally! without pain medication!) and nourishing babies, and ignoring their own wishes and needs.

The fact that such shaming aligns with their never ending attempts to market their services is purely coincidental.

I first wrote about the “bribe a woman to breastfeed” trial a year ago.

Bribing women will create a culture where breastfeeding will be seen as the norm?

Earth to lactivists: if you have to bribe someone to do it, you are sending the exact OPPOSITE message. You are sending the message that it is difficult, expensive and distasteful. Otherwise you wouldn’t be offering bribes.

The early results are in and lactivists are calling them promising, but if this is what “promising” looks like, I’d hate to see failure.

According to the BBC:

Initial results of a controversial scheme offering shopping vouchers to persuade mothers to breastfeed have shown promise, researchers say.

Mothers in three areas of Derbyshire and South Yorkshire where breastfeeding rates were low – between 21% and 29% – were offered vouchers of up to £200…

Of the 108 eligible for the trial scheme, 37 (34%) earned vouchers for breastfeeding at six-to-eight weeks…

Of the mothers eligible for the scheme, 58 signed up.

So let’s see if I get this straight. They raised the breastfeeding rate from approximately 25% to 34%. If 108 women were eligible, that means they raised the number of women breastfeeding from 27 to 37; 10 additional women breastfed for 6-8 weeks who might not have done so.

How much did it cost? At £200 ($300) per participant, it cost $11,100.

In other words, the government spent $1100 PER WOMAN to increase the breastfeeding rate and the bulk of that $1100 went to women who were planning to breastfeed anyway.

Dr Clare Relton, from Sheffield University’s School of Health And Related Research public health section, is running the scheme, part of a four-year research project.

She said: “The UK has one of the worst breastfeeding rates in the world – yet it gives better health outcomes to mums and babies, and saves the NHS money.

“We think this idea has the potential to increase breastfeeding rates in the UK, but we don’t have enough information yet.

“So we are conducting a large-scale trial [4000 women] to help us find out how acceptable and effective the scheme is – and whether it would a good use of public money in the future.”

How much will it cost the government to reproduce these “promising” results on a large scale?

Out of 4000 women, we would expect 2148 women to sign up and 1,360 women to successfully breastfeed for 6-8 weeks, compared to 1000 women who would have breastfed anyway. At £200 ($300) per participant, it would cost the government $408,000! Of that amount, fully $300,000 would go to women who were planning to breastfeed anyway.

There is no possible way that an investment of more than $400,000 can be justified by getting 360 additional women to breastfeed for 6-8 weeks. The pediatric health savings from such short term breastfeeding are likely to be negligible, if they exist at all.

This scheme is all the more odious when you consider that the government is struggling to pay for obstetric care. According to SkyNews:

Between April and September 2012, more than a quarter (28%) of maternity units were forced to close their doors to patients for at least half a day because of a lack of space or a shortage of midwives.

Of these units, 11% closed for the equivalent of a fortnight or more, the report found.

The result?

A fifth of maternity services funding is spent on insurance against malpractice, according to a review by the National Audit Office (NAO).

The report found the NHS in England spent £482m on clinical negligence cover in the last year – the equivalent of £700 per birth.

The most common reasons for maternity claims are mistakes during labour or caesarean sections and errors resulting in cerebral palsy, the review said.

For $408,000 you could hire a few more midwives. Which is likely to have a greater impact on perinatal health? Hiring the midwives, of course.

So why are lactivists pushing a program that costs a fortune and has few, if any demonstrable health benefits? It’s because it is yet another way for them to get women to validate lactivists by having their own choices mirrored back to them. In addition, it is a fabulous way for them to demonstrate their contempt for women who bottle feed.

I’m not the only person who has questioned the wisdom of bribing low income women to breastfeed.

As Eliane Glaser points out in The Guardian, It’s class, not whether a baby is breastfed, that determines life chances:

The scheme’s supporters cite the power of financial reward to trump social conditioning, but that undermines the claim that the women are acting as free agents. If the women are regarded as entirely self-determining, then the conclusion must be that their reason for not breastfeeding is a negligent lack of inclination.
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Thus what appears to be a straightforward transaction sends a set of troubling messages to the women in the study and beyond. It begs the question of why middle-class mothers are so in tune with what’s best for baby that they don’t need incentivising. And it reinforces the guilt felt by mothers who have problems breastfeeding, or for whatever reason choose not to do it. The implication for them is that the controversy generated by the voucher scheme must be worth it. Not only is breast best; formula must be actually harmful.

Her critical points:

But the scientific evidence is not what it seems. The only really consistent finding is that breastfeeding reduces a baby’s chance of getting a stomach bug. The protection only lasts for as long as you breastfeed. And it’s not clear whether the protection comes from something in the breast milk or from not using dirty bottles. The other supposed benefits are derived from contradictory and disputed evidence, suggesting that what is at stake in a country such as the UK with access to clean water, is not so much medical outcomes as an idealised version of motherhood that serves to stigmatise working-class women…

The more that social and educational background is taken into account, the smaller the differences between breast and bottle become. Crudely speaking, researchers see that children who were breastfed turn out better and regard breast milk as the determining factor, when it might well be because they’ve been given organic kale and flute lessons. When Clare Relton, who led the voucher scheme, defends it by saying that “not breastfeeding is a cause of inequality”, she is putting the cart before the horse. Class determines whether or not you breastfeed, but being breastfed doesn’t make you middle-class. (my emphasis)

The bottom line is that bribing women to breastfeed is extraordinarily expensive, offers no demonstrable health savings, ignores the real reasons for difference in health among social classes, and reinforces the stigmatization of women who don’t validate lactivists by mirroring their own choices back to them.

If that’s success, I’d hate to see failure.

Dear Ms. Lake,

According to The New York Times:

One of the most talked about and provocative documentaries about childbirth is having its own rebirth.

“The Business of Being Born,” the 2008 film by the former talk show host Ricki Lake questioning the American medical system’s approach to childbirth and presenting the benefits of home birth, will be rereleased digitally in late January, becoming available globally for the first time. The updated version of the documentary, which also spawned a DVD series and a book, will include interviews with celebrities like the actress and model Stacy Keibler who were swayed by the film and, like Ms. Lake, gave birth at home.

I’ve noticed that you have been quick to claim credit for a rising number of homebirths:

The impact of the documentary was monumental. The blogosphere blew up (I can handle a few people yelling at me if it means my message is being heard!) Every day women stop me on the street to share stories of their safe, successful, meaningful births. Many say they felt “in the dark” about their options until seeing The Business of Being Born …

I wonder if you’re also willing to accept blame … for the babies and mothers who have died because they believed your nonsense.

What do you say when women stop you to share stories of their dead babies, babies who died because their mothers saw your movie and believe that homebirth was safe and empowering? What do you say when they share their stories of a ruptured uterus, a breech baby with a trapped head, a severe shoulder dystocia? What do you say when they tell you how their “midwife” encouraged them to labor for days and push for hours, all the while unaware that the baby had died from the stress of labor?

What do you tell them, Ms. Lake? How do you explain why you ignore the large and growing amount of data and statistics that show that homebirth leads to the preventable deaths of babies who didn’t have to die?

I know, and perhaps you know, too, that in January 2014 the Midwives Alliance of North America (MANA), the organization that represents homebirth midwives, published their landmark “study” (actually a non-representative survey of less than 30% of their members completed 5 years ago) claiming that homebirth is safe but ACTUALLY showing that homebirth increases the risk of perinatal death by 450%.

In March 2013, Oregon released an analysis of homebirth deaths prepared by Judith Rooks, CNM, MPH that showed that PLANNED homebirth with a LICENSED Oregon homebirth midwife had a death rate 800% higher than comparable risk hospital birth.

In June 2013, Grunebaum et al. demonstrated that homebirth increases the risk of a 5 minute Apgar score of zero by nearly 1000%.

In February 2014, he presented data showing that homebirth has a 4X higher risk of neonatal death than comparable risk hospital birth:

In January of 2014, Wasden et al. demonstrated that the risk of anoxic brain injury is more than 18 times higher at homebirth than comparable risk hospital birth.

And those are just the highlights. Other papers and datasets were also published and all, without fail, showed that homebirth has a death rate 3-9 X higher than low risk hospital birth.

Let’s be honest, Ms. Lake, the homebirth industry ignores safety in order to make money and you are the leading example, as you mentioned in explaining why you made BOBB in the first place:

She said that she made the film because she was contemplating her legacy after the September 11th attacks, and that her only goal was not to lose money.

Indeed, you turned homebirth into an industry, both for yourself and others. There’s an entire industry of homebirth midwives [unlike real American midwives (CNMs), homebirth midwives (CPMs, LMs, DEMs, lay midwives lack the education and training of all other midwives in the first world], doulas, childbirth educators, birth pool rental services, etc. profiting by risking babies lives, and just like you, Ms. Lake, they take no responsibility for the death and destruction they leave in their wake.

Ms. Lake, you ought to set some of your profits from YOUR business of being born (books, DVDs, etc) into a no-fault compensation fund for those parents who have lost babies at a homebirth. I’m not sure how much money would be available for each family, since, unfortunately, there is a large and growing number of such families, and I don’t know if would be enough to cover the millions of taxpayer dollars that are going to be spent caring for the babies who were left brain damaged by homebirth. Nonetheless, it seems to me that it is the least you could do.

But if you don’t plan to take responsibility, and I’m not holding my breath because I would turn awfully blue, the very least you could do is amend your film, books and website to reflect the increased death rate of homebirth. I don’t doubt that you were unaware of the dangers of homebirth when you started, but you can’t be unaware now. It doesn’t take any specialized knowledge to count the growing number of dead babies, babies who died preventable deaths because their mother listened to you. But if you don’t correct the mistruths, half truths and outright lies in the original issue of BOBB, any money you make now is just blood money.

Sincerely (and with a great deal of sadness and anger),

Amy Tuteur, MD

I’ve often remarked that no sooner do I write a post about some aspect of the natural childbirth industry than advocates leap to validate my concerns and demonstrate the truth of my warnings.

Today Rebecca Dekker demonstrates the seductive marketing tactics of the natural childbirth industry.

Her latest piece is What is the Evidence for Inducing Labor if Your Water Breaks at Term?, which, as it typical in the natural childbirth industry, an alternate world of internal legitimacy, was immediately trumpeted by another industry outlet, Lamaze International’s Science and Sensibility.

In a piece nearly 10,000 words long, Dekker and associates break no new ground, come up with no new recommendations, but act as if they’ve reinvented the wheel.

For perspective, let me tell you how prolonged rupture of membranes was managed 30 years ago when I started my training:

If a woman at term presented with ruptured membranes but not in labor, she was assessed for fetal well being (using the fetal monitor), maternal well being (including fever) and risk factors. No vaginal exams were done; occasionally a sterile speculum exam was performed. In the absence risk factors, the woman was advised to wait 24 hours and then return for possible induction of labor since the risk of an neonatal sepsis (severe infection of the newborn) begins to rise after membranes have been ruptured for more than 24 hours.

What did Dekker and associates recommend after their 10,000 word review? EXACTLY THE SAME THING!

Specifically:

Evidence shows that in women who meet certain criteria (single baby, head-first position, clear fluid, no fever or signs of infection in mother or baby, negative Group B Strep test), waiting for labor to start on its own for up to 2-3 days is as safe for the baby as inducing labor right away, although the mother is more likely to get an infection herself.

So what’s the big deal? Why the hoopla, the avalanche of words, the charts and lists?

That’s all part of the seductive marketing tactics of the natural childbirth industry that Dekker is so helpfully illustrating for us.

To wit:

1. Never forget that natural childbirth is an industry

Dekker is constantly branding and constantly selling. And she doesn’t let you forget it.

Through December 1 only, you can download a printer-friendly PDF of this entire article, plus a 52-page annotated bibliography PDF, for FREE!! Included with your download is copyright permission to print and share the blog article PDF with anyone you like– friends, health care providers, coworkers, clients! The cost of these two PDFs is “pay what you want,” meaning that you can download them for free, or you can pay what you feel is the value of these materials (suggested value = $5-10).

All flyers preview

Those who give $25 will receive a high-resolution of these 8.5 by 11 inch PROM flyers to print and share with anyone you like!

If you want to purchase the PDFs, I have a special “thank you” for those of you who pay $15 or more. In addition to the printer-friendly PDF and the annotated bibliography, you will get access to an online quiz about PROM that you can take to earn a continuing education certificate for one nursing contact hour!! Nursing contact hours are accepted by most doula, childbirth educator, and some midwifery organizations (check with your certifying organization to see if they accept nursing contact hours.)

Finally, for those of you who pay $25 or more for the materials, you will get everything listed above– the printer-friendly PDF, annotated bibliography, quiz plus contact hour, PLUS four colorful 8.5 x 11 inch handouts about PROM that you can print and share with anyone you like! These beautiful flyers are perfect for placing in client folders, hanging at the nurse’s station, or giving out at maternity fairs.

To download the printer-friendly PDF and annotated bibliography for $0+ (suggested value $5), click HERE. (PayPal users, click here!) …

I’ve helpfully bolded the standard sales pitches. Hey, if it works for the Ginsu knife, why shouldn’t it work for the nonsense that Dekker is selling?

The key point: Dekker tries to monetize everything, no matter how trivial (“Those who give $25 will receive a high-resolution of these 8.5 by 11 inch PROM flyers”).

Dekker, a cardiology nurse, is trying to monetize a blog post about obstetrics, when the information is available anywhere for free.

Does anyone really pay for this crap?

2. The primary product being sold by the natural childbirth industry is distrust of obstetricians

Dekker disgorged a 10,000 word post on prelabor rupture of membranes that tells us nothing that we didn’t know decades ago, but you’d never know it by looking at the 24 point font, the exclamation points, and the charts and handouts.

Why? Because Dekker’s secondary purpose (after her primary purpose of enriching herself) is to encourage distrust of obstetricians.

There are many examples within the post, but the most egregious is probably the claim that obstetricians view prolonged rupture of membranes as an indication for C-section. Dekker trumpeted this claim several days ago on yet another outlet of the natural childbirth industry, ImprovingBirth.org.

When I questioned the provenance of this claim, I was offered a paper written back in 1966, not corroborated by any others and NEVER recommended by an obstetric organization. Shortly thereafter, my comments were deleted, I was banned from ImprovingBirth.org, and now I can’t find the post on their Facebook page.

Why? Presumably because I publicly pointed out the deliberately misleading attempt to portray obstetricians as incapable of following scientific evidence. Removing my comments and banning me is an indication that Dekker and ImprovingBirth.org are well aware that the claim is misleading. That didn’t stop Dekker from including it in her post:

Many doctors at this time said that women should give birth within 24 hours after their water broke, even if that requires a C-section.

In 1966, Shubeck et al wrote,

“With rupture of membranes, the clock of infection starts to tick; from this point on isolation and protection of the fetus from external microorganisms virtually ceases…Fetal mortality, largely due to infection, increases with the time from rupture of membranes to the onset of labor.” (Shubeck et al., 1966)

One doctor, Shubek, who no one listened to, back in 1966 said women should have a C-section if they hadn’t delivered within 24 hours is maliciously and misleadingly transformed into a policy that “many doctors” followed.

The entire point is gratuitous. No one really care what anyone said back in 1966, let alone someone that everyone else ignored, but Dekker couldn’t resist including it (and lying about it) because one of her primary purposes (after enriching herself) is to promote distrust of obstetricians.

3. Natural childbirth advocacy seeks to create personal conflict and hostility between women and their obstetricians

Dekker has learned nothing new. She has simply reiterated a policy that has been in place for at least 30 years, but you’d never know that. The implication of the piece is that Dekker has discovered something new, something ignored by obstetricians, and now is teaching women how to protect women from their ignorant doctors.

Dekker said everyone should feel free to use this image on their own blog, so I am doing so.

Dekker reiterates this in the Science and Sensibility piece:

Finally, probably the single most important thing that women need to know is to not let people put hands up your vagina after your water breaks! That is the single most important risk factor for infection, and hands need to be kept out as much as possible.

But who was recommending vaginal exams for prelabor rupture of membranes in the first place? No one.

What is the point of emphasizing to women that they should not let an obstetrician do what he or she wasn’t planning to do anyway? It’s like mentioning outdated procedures like shaves and enemas on a birth plan. It’s only purpose is to create conflict and mistrust between women and their providers.

Finally, Dekker’s piece, indeed her entire blog, is notable for one other feature characteristic of the natural childbirth industry. Dekker takes no responsibility for anything she writes. According to her disclaimer:

The Evidence Based Birth® website and blog content only provides general information that may or may not apply to your personal health condition or circumstances. The opinions expressed on this website and blog by Rebecca Dekker, PhD, RN, APRN or any other Evidence Based Birth® team members or volunteers on behalf of Evidence Based Birth® are strictly their own personal opinions and not the opinions or policies of any third party, including any health care provider, employer, educational or medical institution, professional association or charitable organization… (my emphasis)

If you rupture your membranes before labor begins, your obstetrician takes full responsibility for any advice, recommendations, examinations or procedures. Rebecca Dekker fills your head with misleading claims, implies that your obstetrician is not to be trusted and tells you what you should refuse and she takes no responsibility for any of that. Why? Because it’s just her personal opinion and if you are gullible enough to follow it, that’s your (and your baby’s) problem.

Thank you to Rebecca Dekker for publishing an plethora of words about nothing (and trying to make money from it) and for Science and Sensibility and Improving Birth.org for promoting it. All have helpfully illustrated the seductive marketing tactics of the natural childbirth industry.

They are in it for profit, not for your well being or your baby’s well being; natural childbirth advocacy is an industry and you should never forget it.

Lana Muniz, PhD has prepared a fabulous resource on state midwifery laws and their impact on homebirth mortality rates.

Muniz wanted to know whether stricter regulation of homebirth midwives leads to better outcomes.

Using the CDC Wonder website, U.S. neonatal mortality rates (NNM) are examined for term, singleton births attended by non-nurse midwives in out-of-hospital settings. States are grouped by regulatory status, and NNM of those groups are compared to assess whether state midwifery laws have an impact on out-of-hospital birth mortality.

Not surprisingly, more regulation of homebirth midwives and greater adherence to the regulations leads to lower risk of perinatal death at homebirth.

States which require midwives to be licensed have a 30% reduction in NNM below the national average. States which also require malpractice insurance (only Florida during the study period) have a 50% reduction in NNM, though this result does not quite reach statistical significance at the 5% level.

The impact of requiring collaboration or a low-risk scope is unclear due to small sample size. The RR for scope has a large confidence interval, and the collaboration study is highly correlated with the malpractice insurance study; Florida births comprise over half the collaboration study group. Thus, there is insufficient data to conclude whether collaboration and low-risk scope have an impact on NNM.

However, it is clear that mandatory malpractice insurance is the most important driver of safer outcomes at out-of-hospital births, for it cuts neonatal mortality in half. Requiring malpractice insurance and collaboration did not appear to restrict access to out-of-hospital births, since nearly 10% of out-of-hospital births under study were in Florida. However, even with these regulations, the mortality rate in Florida (RR: 1.83) is almost double that of births to hospital midwives.

You can find the whole report below:

[gview file=”http://www.skepticalob.com/wp-content/uploads/2014/11/Do-State-Midwifery-Laws-Matter-v1.pdf”]

 

You can download the entire report here.

Kudos to Muniz for the massive amount of work that went into this and for the valuable information that resulted. This will help women make better decisions about the risks of homebirth.

A startling number of professional natural childbirth advocates are anthropologists or sociologists. They believe that they ground their advocacy of unmedicated vaginal birth in the ancient practices of indigenous cultures. One of the best known is anthropology professor Melissa Cheyney, who is also a homebirth midwife and an executive of the Midwives Alliance of North America (MANA) the trade organization of homebirth midwives.

In her paper Reinscribing the Birthing Body: Homebirth as Ritual Performance  Cheyney writes about the importance of “meaning-making” among homebirth midwives.

… As a socially performed act of differentiation, homebirths are constructed in opposition to dominant ways of giving birth, although just where the lines between consent and resistance lie are not always clear, shifting with each provider and each mother, over time and in the retellings.

You might have thought that prenatal and intrapartum care was about delivering healthy babies to healthy mothers. How tragically naive; it’s all about peeling away fictions:

Midwives describe the desire to peel away these fictions of medicalized prenatal care, exposing strong and capable women who “grow” and birth babies outside the regulatory and self-regulatory processes naturalized by modern, technocratic obstetrics…

And if that wasn’t enough jargon for you, how about this?

… Capitalizing on the semiotic potential, heightened emotion, and the liminality of the birth itself, midwives seek to overturn mechanistic views of the faulty female body in need of medical management, replacing them with the language of connection, celebration, power, transformation, and mothers and babies as inseparable units. Homebirth practices, thus, are not simply evidence based care strategies. They are intentionally manipulated rituals of technocratic subversion designed to reinscribe pregnant bodies and to reterritorialize childbirth spaces and authorities. For many, choosing to deliver at home is a ritualized act of “thick” resistance where participants actively appropriate, modify, and cocreate new meanings in childbirth.

There are others anthropologists and sociologists is whose work is not colored by the need to justify the beliefs of the natural childbirth/homebirth subcultures. They have investigated the anthropology of the natural childbirth movement itself. In the chapter The Dialectics of Disruption: Paradoxes of Nature and Professionalism in Contemporary American Childbearing, Caroline Bledsoe and Rachel Scherrer examine why meaning-making is so important within the culture of natural childbirth advocacy.

Their description of the current situation is spot on:

… Birthing is depicted culturally as an individual achievement, one in which a woman should be in control of her actions. For this, women attempt to present themselves as professionals, medical as well as legal: as close as they can come to being equals with their medical peer doctors, informed and trained to evaluate their qualifications (my emphasis).

Bledsoe and Scherrer recognize that meanings and meaning-making are luxuries of a society in which childbirth is so safe that women have forgotten that in reality it is inherently dangerous:

… As childbearing became safer and more benign visions of nature arose, undesired outcomes of birth for women came to consist of a bad experience and psychological damage from missed bonding opportunities. Today, with safety taken for granted, the new goal has become in some sense the process itself: the experience of childbirth… (my emphasis)

In other words, as I have written repeatedly since for NCB/homebirth advocates outcome is taken for granted, the focus has shifted entirely to process. And the most critical element in the process, the one to which the most significance is imputed, is control.

Their critical insight:

… But with *control* being such a crucial issue in cultural ideals of childbearing, the greater the expectations that a scripted birth plan creates, the greater the surety that the woman will fall short of her ideal. Some elements will go wrong, and with them the hope of remaining the equal of the professionals who deals with her birth. This relegates obstetricians, who have the power to disrupt a naturalism but also to save lives if something goes wrong, to being the inevitable targets of opposition. (my emphasis)

Specifically:

If nature is defined as whatever obstetricians do not do, then the degree to which a birth can be called natural is inversely proportional to the degree to which an obstetrician appears to play a role. The answer to why obstetricians are described with such antipathy thus lies not in the substance of what obstetricians do that is unnatural – whether the use of sharp incision. forceps, and medications that blunt sensation. or anything else- but in the fact that obstetricians represent a woman’s loss of control over the birth event. Obstetricians are thus perceived as the chief source of disruption in the birth event, backed by the licensing power of medicine and the law. And yet it is not what obstetricians do that women find problematic but the fact that they are the people who step in when the woman is seen to have failed. (my emphasis)

In other words, as I have written repeatedly, the “natural” in natural childbirth has nothing to do with nature. Natural is defined as anything a midwife can do. In contrast, if only an obstetrician knows how to do it, it is “unnatural” by definition in the NCB subculture.

The authors summarize:

… Today, because of medical and technological advances that have brought so many of the life-threatening complications of childbirth under control, the naturalism in childbirth that women now envision is not only benign but desirable. But to the extent that childbearing remains less about nature than control, animosity will likely continue to be directed at doctors because they represent failure to attain nature, and animosity will continue to be directed at obstetricians, regardless of what they actually do or what their gender is. (my emphasis)

Ultimately, there is nothing wrong with Cheyney’s attempt to describe the meanings and meaning-making of contemporary NCB/homebirth advocates. The problem is that she fails to question the fundamental assumptions that undergird these meanings. Just as human sacrifice only makes sense to those who believe that the gods are pleased by throwing virgins into volcanoes, natural childbirth only makes sense to those who believe that childbirth is inherently safe. And while we have no idea whether there are “gods” and whether they are pleased by human sacrifice, we do know that childbirth is not inherently safe.

Bledsoe and Scherrer understand:

… As we turn to the disruptions that preoccupy US middle-class women as they contemplate the birth of a child. it is vital to keep in mind both the dangers that reproduction can entail and the science that has allowed us to imagine as common sense a safe, uninterrupted, reproductive life trajectory.

Mothers need to understand this, too.

 

A version of this piece first appeared in December 2011.