Yesterday, coinciding with the beginning of World Breastfeeding Week 2019, Baby Friendly USA published a piece by Chief Executive Officer Trish MacEnroe, Let’s Talk About Clinical Standards and Clinical Judgment.

Let’s!! I have questions!

MacEnroe writes:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Exclusive breastfeeding has become the LEADING risk factor for newborn hospital readmission, Ms. MacEnroe. What do you and BFUSA plan to do about that, besides blaming others instead of yourselves?[/pullquote]

As I write this, there are 576 Baby-Friendly designated facilities in this country. This seemed unattainable when I joined Baby-Friendly USA (BFUSA) almost ten years ago. In a few short years, we have seen massive change in an industry that is typically slow to shift its deeply-embedded and commercially-influenced practices.

We have achieved a significant and important cultural shift because, as a global public health initiative, the Baby-Friendly Hospital Initiative (BFHI) promotes evidence-based best practice standards that increase breastfeeding rates and advance the wellbeing of mothers and babies across the population.

1. Ms. MacEnroe, where is the evidence that this “significant” shift has had a significant (or any!) impact on the wellbeing of mothers and babies across the population?

I also wish to remind everyone that Baby-Friendly protocols are not the only way to practice under all circumstances. It is imperative that clinical judgment also be exercised…

2. If that’s the case, Ms. MacEnroe, why do the Ten Step FAIL to mention the important role of clinical judgment?

Baby-Friendly guidelines are just that – guidelines – and should be followed in most circumstances. However, there are times when rigid adherence to these protocols is not the best thing. We depend on the wonderful, talented, compassionate caregivers at Baby-Friendly designated facilities to know when to individualize care for the mother or infant based on the circumstances that present themselves in each unique situation.

3. Ms. MacEnroe, why is the care and feeding of babies individualized based on CAREGIVERS’ beliefs and training and not MOTHERS’ needs and preferences?

…[M]others describe being unable to care for their infants shortly after birth due to some combination of extreme exhaustion, pain and medications and not having a family member or friend with them for support. Their experience was one of feeling unduly pressured to keep the baby in the room and shamed by their healthcare providers when they asked to have the infant removed from the room for a while…

Clearly, this should not happen.

4. If mothers are not supposed to feel pressured to keep the baby in the room, Ms. MacEnroe, why do the Ten Steps fail to include this critical point?

Rooming-in is one of the Ten Steps to Successful Breastfeeding, and therefore part of the BFHI, because strong scientific evidence has shown it facilitates mother-baby bonding and breastfeeding initiation.

5. Then why does the latest scientific evidence show the OPPOSITE, Ms. MacEnroe?

Mother-infant bonding is not associated with feeding type: a community study sample was published in April 2019. The authors found that breastfeeding had NO positive effective on bonding and some negative effect.

Rooming-in is the standard of care and the right policy for the vast majority of cases – and most mothers love it and feel it enhances their postnatal experience.

6. Ms MacEnroe, why isn’t maternal preference the standard of care?

Baby-Friendly protocols are designed to support appropriate clinical decision-making, not inflexibility or rigid adherence at all cost.

7. Then why, Ms. MacEnroe are tens of thousands of babies readmitted to the hospital each year as the result of inflexibility and rigid adherence to protocols at all cost?

And my final question:

8. Exclusive breastfeeding has become the LEADING risk factor for newborn hospital readmission, Ms. MacEnroe. What do you and BFUSA plan to do about that, besides blaming others instead of yourselves?

Let the backpedaling begin!!

As a society, we invest in public health campaigns because they provide two main benefits: improved health of populations and cost savings.

But what if a public health campaign provided neither?

It’s World Breastfeeding Week 2019 and it’s time to ask: where is the return on investment in breastfeeding promotion?

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s time to end the fiction that breastfeeding has a public health benefit.[/perfectpullquote]

For 25 years, we’ve been told that it was worth spending millions on breastfeeding campaigns because the result would be improved health for infants, children and adults. Where are the improvements? For 25 years, we’ve been told to spend ever more because we would glean massive healthcare savings. Where are the savings?

What does it look like when a public health campaign leads to improved health?

Vaccination has provided spectacular gains. There have been dramatic reductions in both cases of disease and deaths from disease.

Vaccination didn’t merely reduce the incidence of vaccine preventable diseases, it often resulted in NO CASES at all. Vaccination didn’t merely reduce the number of deaths from vaccine preventable diseases, in some cases it ELIMINATED them entirely.

It is important to note that these are not theoretical benefits. This is what actually happened when vaccination programs were implemented.

Let’s look at another public health campaign, the effort to reduce lung cancer from tobacco smoking. The results have not been as spectacular, but are impressive nonetheless.

In the wake of the Surgeon General’s 1964 report 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. This is not a theoretical benefit. This is what actually happened.

In the past 25 years we have spent millions of dollars promoting breastfeeding even though the scientific evidence on the benefits is weak, conflicting and riddled with confounding variables.

An entire industry, the breastfeeding industry, has arisen to promote and profit from efforts to increase breastfeeding rates. Lactation consultants did not exist prior to the mid 1980’s. Now they are everywhere, in hospitals, in doctors’ offices and in independent practice.

A private company, Baby Friendly USA, is allowed into hospitals to promote their philosophy. For a fee of more than $10,000, a hospital can to be designated as breastfeeding friendly — but only if it is in lockstep with the practices recommended by the breastfeeding industry.

Breastfeeding initiation rates have risen in response. But the breastfeeding rate appears to have had no impact on the infant mortality rate. The graph below illustrates the steep drop in infant mortality over the course of the 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.

The only measurable impact has been the reduced incidence of necrotizing enterocolitis among very premature infants, a benefit that was not predicted but was found as breastfeeding rates rose.

There are papers predicting health and spending benefits of breastfeeding, but I haven’t found any evidence of actual benefits, with one exception: the reduced incidence of necrotizing enterocolitis among very premature infants, a benefit that was not predicted but was found as breastfeeding rates rose. If other benefits actually occur, I invite anyone who has seen the evidence to share it with the rest of us. Otherwise, we must conclude that — unlike vaccination efforts and efforts to reduce smoking — the benefits are purely theoretical and therefore probably not real.

Moreover, there is a growing body of evidence that the aggressive promotion of breastfeeding is harming babies through dehydration and starvation due to insufficient breastmilk (affecting up to 15% of first time mothers). Exclusive breastfeeding is now the LEADING risk factor for newborn hospital readmission. It is nothing short of appalling that 1 in 71 breastfeeding newborns will be readmitted to the hospital. That’s tens of thousands of hospitalizations per year at a cost of hundreds of millions of dollars.

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

No doubt the lactation industry has benefited. The number of lactation consultants in the US has increased from 0 in 1980 to approximately 14,000 lactation consultants in 2013.

What do the rest of us have to show for it?

Nothing.

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

It’s World Breastfeeding Week 2019 and it’s time to admit that breastfeeding promotion has been an expensive failure.

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

It’s time to end the fiction that breastfeeding has a public health benefit. It’s a personal choice, no more, no less. There is no reason — scientific or economic — to spend millions promoting it.

If I offer support to the victims of an earthquake in South America does that mean I can’t offer support the victims of a typhoon in South East Asia, too?

If I express support for those who lost their homes in a hurricane does that mean I can’t express support for those who lost their homes in a wildfire, too?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Support is not a zero sum game.[/pullquote]

If I support women who have breast cancer, does that mean I can’t support women who have ovarian cancer, too?

Sounds ridiculous, right?

So why can’t I support formula feeding mothers AND support breastfeeding mothers?

Because lactivism embraces victimhood as central to its understanding of breastfeeding and the women who choose it.

This Facebook comment is a perfect example:

“Don’t shame me for formula feeding by saying breast is best but I’ll downplay your accomplishment of breastfeeding by saying fed is best” That’s all I’m hearing from you.

In the world of lactivism, support is a zero sum game and any support offered to women who choose formula feeding is viewed as support that is stolen from breastfeeding mothers.

The celebration of their victimization serves several important roles in the lactivist cosmology. First, and foremost, it guarantees moral superiority. As Sommer and Baumeister explained in the book The human quest for meaning:

…[C]laiming the victim status provides a sort of moral immunity. The victim role carries with it the advantage of receiving sympathy from others and thereby prevents [one’s own behavior] from impugning one’s character…

Never mind that women who try breastfeeding represent the overwhelming majority of women, lactivists insist breastfeeders are a tiny minority, oppressed by the formula industry, and ceaselessly harassed by formula feeders. They’re victims dammit and that means that nothing they do to promote breastfeeding is ever wrong.

Second, the insistence on victimization serves to simplify the world by creating a false dichotomy. For lactivists, the world is divided into diametrically opposed camps of breastfeeders and formula feeders. It seems never to have occurred to them that combining breastfeeding and formula feeding is not merely possible, but common. Since the world is divided into diametrically opposed camps, in the lactivist cosmology everyone is either with them or against them.

When you are a breastfeeding victim, the fact that others don’t agree with you, or at least validate your feelings of victimization, is viewed as a form of re-victimization.

Other women choose formula? They are victimizing you by refusing to mirror your choice back to you.

Formula feeders want to choose formula without being harassed by hospital lactation consultants, vilified by breastfeeders, or told that they aren’t “baby friendly”? They’re victimizing you.

What if I (or anyone else) point out that the benefits of breastfeeding in the industrialized world have been massively exaggerated and are, in reality, limited to a few less infant colds and episodes of diarrheal illness in the first year? I am supposedly victimizing you. Lactivists insist I hate breastfeeding, and imagine I bathe daily in Similac, drying off using hundred dollar bills sent by Nestle as payment for services rendered.

Third, their status as self-proclaimed victims has been instrumental in allowing lactivists (particularly professional lactivists like La Leche League) to take control of public health messages and discussion in the public sphere. Breastfeeding rates were low purportedly because of the victimization of breastfeeders. That was the justification behind massive public and private initiatives to support breastfeeders and thereby promote breastfeeding. How has it worked out?

As a society, we have spent tens of millions of dollars promoting breastfeeding in order to improve child health and save on medical costs. Where’s our return on investment? Where is the evidence that overall infant health has improved as a result of breastfeeding rates nearly quadrupling in the past 50 years? There isn’t any. Where are the billions of dollars in healthcare savings we were promised as a result of increasing breastfeeding rates? No one can find them.

Yet lactivists continue promoting these programs and initiatives on the grounds that breastfeeding mothers are being victimized.

Interestingly, the goalposts of lactivist victimization are always moving. Fifty years ago the evidence of breastfeeders’ victimization was that hospitals did not support their efforts. In 2019, when hospitals do everything humanly (and inhumanely) possible to increase breastfeeding rates and when even cans of formula proclaim “breast is best,” failure to wholeheartedly embrace and praise public breastfeeding is viewed as … you guessed it … victimization.

Indeed, the goalposts have moved so far, basic civility to women who choose formula feeding as best for their babies is routinely cited —as in the Facebook comment above — as victimization of women who breastfeed.

It’s time for lactivists to grow up and stop bleating endlessly about their victimization. Breastfeeding is just one of two excellent ways to nourish an infant, nothing more and nothing less. Breastfeeders aren’t morally superior, aren’t better mothers, and certainly aren’t being victimized. They’re no different from formula feeding mothers, both trying to do what is best for their babies, their families and themselves.

Support is not a zero sum game.

We can support women who breastfeed AND women who formula feed. We don’t have to choose between them … no matter how much lactivists insist that we do.

It’s the best piece I ever read about natural childbirth. Published on the website Feminist Current, Eve’s punishment rebooted: The ideology of natural birth by C.K. Egbert is a powerful, thought provoking essay.

There’s something pornographic about the way we depict childbirth. A woman’s agony becomes either the brunt of a joke, or else it is discussed as an awesome spiritual experience… [W]e talk about the pain of childbirth — with few exceptions, the most excruciating, exhausting, and dangerous ordeal within human experience — as valuable in and of itself. Hurting women is sexy.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”Hurting women is sexy.”[/pullquote]

The euphemistically termed “natural childbirth” is often justified on the basis that it is a woman’s choice, that pregnancy and birth is a “natural process,” and that it is best for the woman and baby (both for medical reasons, and because a woman won’t feel attached to her child otherwise). Put into context, these arguments ultimately boil down to “women’s suffering is good.” …

When people tout “natural birth” as an “empowering choice” (sound familiar?), they conveniently ignore all the women who have been harmed by these practices and for whom giving birth was (completely understandably and legitimately) one of the worst experiences of their lives. Natural birth advocates, just like many in the pro-sex movement, don’t seem to be concerned about the harm that women suffer through this practice or finding ways of preventing this harm from occurring. Women can choose, as long as they choose to suffer and see themselves as liberated through suffering.

Egbert is brutally honest about the philosophy of natural childbirth. Responding to the claim that natural childbirth is “better,” she notes:

What about the argument for women’s health? We probably wouldn’t give much credit to an argument that we should strap patients to the operating table and refuse them anesthetic during surgery, even though general anesthetic is usually the most dangerous part of surgery. Rather than eliminating palliative care, we seek safer and more effective means of performing surgeries and administering anesthetic. Natural birth advocates are not concerned with women’s welfare, because they are not advocating for safer and more effective forms of pain management; they argue they should be eliminated, because women’s suffering is itself a good. And while feminists applaud efforts to give women support and comfort during the birth process (e.g., emotional support, more home-like birthing environments, etc.), this is compatible with providing women pain medication. Once again, the danger of anesthetic only becomes an issue — rather than a normalized part of medical treatment — only when and because it can be used to hurt women. (my emphasis)

Not surprisingly, there was tremendous denial from natural childbirth advocates, but Egbert skillfully defended her thesis in the comments section.

But this isn’t about the best way to give birth. It’s about what significance we give to women’s suffering and pain, and how that relates to women’s subordination in general.

Exactly, and in the world of natural childbirth advocacy, women’s pain and suffering is “sexy” and “empowering.”

That’s not surprising when you consider that the philosophy of natural childbirth was created by old, white men who tried to convince women that the pain of childbirth was in their heads, not their bodies. And the philosophy of natural childbirth has been perpetuated by white women (midwives, doulas and childbirth educators) who enjoy wielding power over other women and glory in humiliating them for failing to mirror their own choices back to them. The tragedy is that many women are complicit in their own subjugation and claim to be “empowered” by it, because they are so used to being judged and bullied that they believe it is for their own good.

Simply put, the philosophy of natural childbirth is deeply retrograde and profoundly anti-feminist.

I’ll even go a step further. The philosophy of natural childbirth is sadistic in that its promoters derive pleasure from convincing others to needlessly endure pain.

The originators of the philosophy of natural childbirth were sadists when it came to women’s pain. They felt that it was irrelevant, unworthy of treatment, and annoying to doctors. The philosophy of natural childbirth could best be encapsulated as, “Shut up and give birth without bothering us.”

The contemporary avatars of the philosophy of natural childbirth are often sadists when it comes to women’s pain. They consider it irrelevant, unworthy of treatment, and demonize effective pain relief as “weakness” and “unhealthy,” when it is neither.

The midwives and doulas who chivvy women into refusing pain relief, who delay calling the anesthesiologist when a woman requests an epidural, who promote inadequate forms of pain relief and praise women as warrior mamas (i.e. “good girls”) for enduring labor without pain relief are sadists. They believe that women’s pain and suffering aren’t worthy of their compassion and concern. They believe that women are improved by agonizing pain and diminished by relief.

The philosophy of natural childbirth is not based on science; it is based on fundamental beliefs about the unimportance of women’s suffering. It is based on beliefs about the ways that women “should” use their bodies. And not coincidentally, it is based on the value that midwives and doulas place on their own autonomy, in addition to the satisfaction they gain from having their personal choices mirrored back to them.

The philosophy of natural childbirth is about embracing and enjoying women’s agony and that, of course, is sadism.

I have been called a shill for the formula industry more times than I can count. Any medical professional who dares question the perfection of breastfeeding is typically subjected to the same treatment.

What’s it like to be called a formula shill?

Imagine Sue is allergic to strawberries. Joe insists that Sue is only saying that because she hates the taste of strawberries.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Accusing a medical professional who cares for babies of being a formula shill is like accusing an allergist of being an EpiPen shill.[/pullquote]

When Joe is asked whether Sue might actually be allergic to strawberries, he denies the possibility since he loves strawberries and eats them all the time without any side effects. In his view, since strawberries are harmless for him, they must be harmless for everyone.

Joe believes claiming a strawberry allergy is therefore proof of hating strawberries.

Now imagine that Joe is confronted by Sue’s doctor. With Sue’s permission he confirms her allergy, offers details and explains the physiology. How does Joe react? He accuses the doctor of being a shill for the EpiPen industry.

Now not only can he ignore Sue’s lived experience of allergy, he can ignore the doctor’s lived experience of treating that allergy.

That’s what it’s like to be called a formula shill.

Those familiar with the fundamentals of logical argument will recognize the shill gambit as a fallacious argument. But I believe it is also a variation on the pernicious practice of testimonial silencing, denying the lived experience of medical professionals who confirm the harms of aggressive breastfeeding promotion.

The shill gambit has been described as an ad hominem attack, a form of poisoning the well. It is designed to undermine a claim by discrediting the person making the claim instead of addressing the claim itself:

[It]occurs when one party dismisses another party’s arguments by proclaiming them to be on the payroll of some agency…

Of course, it is possible for medical professionals to be on the payroll of formula companies. But it’s a gambit when there is no evidence that such a relationship exists.

[W]hen a shill gambit is used fallaciously the only “evidence” given of such a connection to a big company or government is that someone endorses a particular position—and therefore they must hold that position only because they’re being paid or receiving some other deal-sweetener.

The shill gambit is typically invoked when someone cannot address the claim under discussion: I point out that exclusive breastfeeding is currently responsible for tens of thousands of preventable newborn hospital admissions each year. Any lactivist who tries to deny it will lose the argument because there is copious evidence. Therefore, lactivists derail the discussion by insisting that the fact that I made the claim is “proof” I am on the payroll of formula manufacturers; anything I say can be ignored. The claim itself is never addressed, let alone rebutted.

But the formula shill gambit is more for lactivists than merely a way to forestall losing an argument. It is an opportunity to deny the lived experience of professionals who address the harms of aggressive breastfeeding promotion. It is a form of testimonial silencing.

Last week I wrote about how lactation professionals use testimonial silencing to deny the lived experience of women with breastfeeding complications.

I noted:

[T]estimonial injustice occurs when someone’s knowledge is ignored or not believed because that person is the member of a particular social group …

Tactics of testimonial silencing include: erasure from breastfeeding literature, refusal to believe, pathologizing, claiming “lack of support,” disparaging women’s stories and banning from social media feeds.

We have a word for that type of behavior and the word is “cruelty.” Sue is a victim of Joe’s cruelty in denying her lived experience of strawberry allergy. Similarly, women who struggle with breastfeeding complications are victims of lactation professionals’ cruelty. Nothing can convince lactation professionals of the reality of breastfeeding complications since they have already justified their decision to ignore the sufferers.

It’s one thing to ignore the experience of sufferers, but it is another thing entirely to ignore the medical professionals who treat the sufferers. There’s a growing body of scientific literature attesting to the harms of aggressive breastfeeding promotion. An increasing number of physicians and nurses are writing about the harms of breastfeeding promotion, harms that they have witnessed professionally and can explain physiologically.

The tactics used by lactation professionals in response mirror those used against women who suffer breastfeeding complications — erasure from the professional literature by refusing to publish their papers, refusing to believe them, claiming they “hate” breastfeeding (even though many of them actually breastfed) and banning them from social media feeds. But nothing beats accusing them of shilling for formula companies.

Could doctors be formula shills? Of course they could, but serious accusations ought to require actual proof. To my knowledge, no medical professional accused of shilling for the formula industry has ever been shown to be receiving payments from them.

It doesn’t matter, though, since the point of the accusation is not to establish the truth, but to smear anyone who questions the perfection of breastfeeding. The tactic has been working, but as ever more professionals are coming forward to detail the growing harms of aggressive breastfeeding promotion — the hospitalizations, the permanent brain injuries and the deaths — it is a tactic that won’t work for much longer.

Childbirth in the UK—it’s time to be honest about what the NHS can deliver is the title of a powerful piece in the BMJ. It’s written by Dr. Laura Downey. In her day job, she “provides assistance to governments … for health system strengthening and improving the value for money of healthcare investments…”

She writes:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Maternity care should be patient-centered, not midwife-centered.[/pullquote]

I gave birth to my daughter at an NHS hospital in London three weeks ago. As a public health professional … I consider myself fairly well informed about how the system should work. I understood the information and advocacy tools available to me and knew I could use them to inform my decisions throughout pregnancy and childbirth.

It turned out, however, that like so many other women who give birth in NHS care across the country, I was misinformed.

How?

The publicly available national clinical guidelines and myriad information leaflets handed to me throughout my pregnancy led me to believe that I had some agency in my own “birth experience,” such as choice of pain relief or mode of delivery. I did not.

What happened instead?

Antenatal care clinics run by midwives actively shepherd women towards giving birth “naturally” in their local birthing centre, where there is no access to epidural pain relief or obstetric care. This push for a “natural” or “normal” birth also precludes women from undergoing a caesarean section delivery under any circumstances other than a medical necessity. While such practice is not in line with NICE guidance, it is common across the NHS for hospitals to put in place local procedures that do not allow maternal requests for caesarean sections, even where a woman has asked for one because of a previous traumatic birth, an underlying medical condition, or because they’ve experienced past sexual trauma. Furthermore, in circumstances where women choose to leave the birth centre in favour of an epidural, many are denied their request for this mode of pain relief.

Midwives substitute their personal beliefs for patients’ needs and requests, even when that conflicts with official policy.

Moreover:

The language around birth and persistent use of the words “natural” and “normal” in the UK belittles the birth experience of many women and is both socially harmful and offensive. There is no shame in pain relief and mode of delivery bares no reflection on a woman’s worth… It is crucial for women to be supported by the health system to feel that they have agency over their own body and what happens to it during birth, especially if the alarming statistics about birth trauma and PTSD in the UK are to be addressed.

The only thing that surprises me about Dr. Downey’s observations is that it took so long for someone in a position of authority to recognize what thousands of women have been suffering for decades. I’m not sure why anyone expected anything different from the longstanding Royal College of Midwives “Campaign for Normal Birth.”

Promoting normal birth is about promoting midwives at the expense of patients.

You won’t find any real medical professional who insists that he or she “promotes” one treatment over another. Ethical medical professionals promote health and safety, not the opportunity to line one’s pockets or increase professional autonomy.

Normal birth has nothing to do with normal and nothing to do with birth. The definition of normal birth is simple and straightforward: If a midwife can do it, she calls it normal. If she lacks the skill to provide the needed care, she insists that the birth is not normal even if it results in a healthy mother and a healthy baby. “Normal birth” is nothing more than a marketing term for promoting midwives.

Most women don’t fall for it. British women resent the fact that access to obstetricians is severely curtailed. They despise the fact that such practices have led to the needs and desires of mothers being ignored. They are not alone. Dutch women go to other countries to give birth rather than settle for midwife led care; there has been a precipitous drop in homebirth, now down to only 13%. And the majority of American women, regardless of the availability of midwives, choose obstetricians. Indeed, there are not enough practicing obstetricians to accommodate all the patients who want them.

Here’s what Downey recommends:

A logical starting point towards improving women’s experience of childbirth in the UK would be to redress the imbalance in patient information and clinical reality to close the gap between what is promised and what is delivered. Transparency is key to empowering women to make their own evidence based choices about childbirth and what is right for them and their unborn child. However, information is meaningless unless women are kept fully informed about what they can reasonably expect. If the level of clinical care promised to expectant mothers deviates in any way from publicly accessible national or local guidance, women need to be made aware of this from the outset so that they are informed and prepared, and care providers can be held accountable.

I have a better idea:

Make maternity care patient-centered, not midwife-centered. Re-integrate midwives into the healthcare system: have obstetricians supervise midwives instead of letting midwives run their own private fiefdom for their own benefit. Midwives have been allowed to run patient care and patients have suffered as a result.

In other words, put obstetricians — not midwives — in charge of maternity care.

If the mind of the mother be withdrawn from her child to other pleasures, her milk will be less nutritious and less in quantity. — Dr. Richard Kissam, The Nurse’s Manual and Young Mother’s Guide(1834)

…[P]umping … is not equivalent to direct nursing … The microbiome of expressed breast milk is different, for one. — Annie Lowrey, The Atlantic (2019)

A new piece in the Atlantic, Pumping Milk and Nursing Are Not the Same, by Annie Lowrey inadvertently gets to the heart of contemporary efforts at breastfeeding promotion. It has never been about what’s good for babies; the purpose has always been to re-domesticate women.

Central to that task is convincing mothers that having a job, a career or even interests apart from caring from children is harmful to their babies.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]“Good mothers” provide breastmilk straight from the tap.
[/pullquote]

Although La Leche League has carefully scrubbed their website of the fact, it was a religion inflected organization originally founded in 1956 by seven traditionalist Catholic women. The goal was keeping mothers out of the workforce by convincing them to breastfeed.

In the book La Leche League: At the Crossroads of Medicine, Feminism, and Religion, Jule DeJager Ward explains:

[A] central characteristic of La Leche League’s ideology is that it was born of Catholic moral discourse on family life … The League has very strong convictions about the needs of families. These convictions are the normative heart of its narrative… The League’s presentations and literature carry a strong suggestion that breast feeding is obligatory. Their message is simple: Nature intended mothers to nurse their babies; therefore, mothers ought to nurse …

Breastfeeding professionals and researchers have fully embraced the task of re-domesticating women, creating new “benefits” of breastfeeding as fast as the old “benefits” are debunked. They’ve demonized formula, ignoring the fact that it was created for a variety of important reasons: insufficient breastmilk is common and many women want to utilize their minds in fulfilling work instead of being tied to the home by the need to breastfeed. And, of course, advocates claim that anything other than exclusive breastfeeding “interferes” with maternal-infant bonding.

Though natural mothering advocates decry medicalization of childbirth, they adore medicalization of breastfeeding — from pumps, to breastmilk banks, to the off-label use of powerful medications with the goal of boosting milk supply. While they initially sought to make breastfeeding compatible with work outside the home, the Atlantic article about pumping represents the newest front in re-domesticating women: convincing them that they must stay home because “good mothers” provide breastmilk straight from the tap.

Lowrey writes:

The number seems small, but gets larger and larger as you contemplate it: 6 percent. That is the estimated share of breastfeeding mothers who exclusively pump and bottle their milk for their infants, never directly nursing. It is a number that was functionally zero less than a generation ago. And it is a subset of a much larger figure, the 85 percent of breastfeeding mothers who use a pump at least some of the time…

Maybe this is a good thing, if pumping helps babies receive more breast milk, or if it enables mother and child to sustain a desired, direct breastfeeding relationship for longer. Maybe pumping helps women have it all—a full-time career and a breastfed baby.

But breastfeeding promotion is NOT about women having it all; it’s about convincing mothers that babies need breastmilk breastfeeding more than women need … anything.

The “research” such as it is, is surprisingly weak. No one knows what the normal infant gut microbiome is supposed to contain. No one knows whether deviations represent problems or merely individual variations. No one knows whether the infant gut microbiome has any impact on infant health or anything else. No one cares. It is a convenient cudgel with which to discipline women who dare to work.

If that were your goal, could you possibly do better than scaring women with this?

But while pumping might support direct nursing, it is not equivalent to direct nursing, researchers have found. The microbiome of expressed breast milk is different, for one. “Indirect breastfeeding” is associated with a greater prevalence of pathogens, which “could pose a risk of respiratory infection in the infant, potentially explaining why infants fed pumped milk are at increased risk for pediatric asthma,” according to Shirin Moossavi of the University of Manitoba. Plus, breast milk degrades when it is cooled, as it often is when stored for bottle-feeding. There is also the risk of contamination, given that dangerous bacteria flourish on pump parts.

“is associated,” “could,” “potentially” — weasel words all, but perfect for manipulating women.

And why stop there? Just tell women that their babies won’t love them as much if they bottlefeed, even when breastmilk is in the bottle.

Researchers also sense that the experience of breastfeeding—the eye-gazing, the cuddling—is a big part of the benefit of breastfeeding for the baby, and a big part of the joy of breastfeeding for the mother. How does bottle-feeding change the equation?

That — to use a technical term — is bullshit!

No matter. In the effort to re-domesticate women through breastfeeding, no tactic is too cruel. It is imperative to convince women that any time they spend away from their babies will harm those babies.

Lowrey concludes:

But however they pump, for whatever reason, they do it in a vacuum: with a thin body of knowledge and little social support. Alas, it sucks.

There is precisely ZERO clinical evidence (as opposed to laboratory experiments) that formula feeding harms term babies. There is even LESS evidence that feeding expressed breastmilk harms babies. But the truth doesn’t matter when you are trying to re-immure women back into the home.

That’s what sucks!

When I was a third year medical student, a surgery resident on my team hit on me.

It was exceedingly unpleasant and rather surprising since I made it clear that I was happily married. That didn’t deter him from making a suggestive phone call at 2 AM waking me from sleep in the on call room adjacent to his.

The next morning I reported his behavior to the Director of Surgery who immediately declared: “That didn’t happen!”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Imagine if the scientific literature were filled with papers referring to sexual harassment as “perceived sexual harassment”.[/pullquote]

When I insisted that yes, indeed, it had happened, he announced that he was sending me to a psychiatrist to find out what was wrong with me; henceforward I would be viewed as a trouble maker.

The Director was engaged in a form of epistemic injustice known as testimonial silencing.

Every day breastfeeding professionals do the same thing to women who experience breastfeeding complications.

According to the Wikipedia article about epistemic injustice:

The term was coined by Miranda Fricker in 2007 …

In Fricker’s 2007 book Epistemic injustice: power and the ethics of knowing, she defines two kinds of epistemic injustice: testimonial injustice and hermeneutical injustice… [T]estimonial injustice occurs when someone’s knowledge is ignored or not believed because that person is the member of a particular social group … A hermeneutical injustice occurs when someone’s experience is not understood (by them or by others) because there are no concepts available that can adequately identify or explain that experience.

My report of sexual harassment was not believed because I was a woman. I was immediately pathologized as a liar and labeled a troublemaker.

Breastfeeding professionals routinely treat women with breastfeeding complications exactly the same way. They aren’t believed; they are pathologized and they are viewed as trouble makers.

Tactics of testimonial silencing include: erasure from breastfeeding literature, refusal to believe, pathologizing, claiming “lack of support,” disparaging women’s stories and banning from social media feeds.

1. Breastfeeding professionals erase women who experience physiological complications from the breastfeeding cannon.

Although breastfeeding complications are common — insufficient breastmilk alone is experienced by up to 15% of women in the days after birth — the breastfeeding literature routinely ignores reality in favor of fantasy, claiming falsely that breastfeeding complications are rare.

It’s the equivalent of insisting that sexual harassment in the workplace is rare. If you’ve been taught that sexual harassment uncommon, you are unlikely to look for it, recognize it or know how to deal with it. Your first response may be: “That didn’t happen.”

The same thing applies to breastfeeding professionals and complications. When you are taught they are rare, you are unlikely to look for them, recognize them or know how to deal with them when they occur. The first response when faced with breastfeeding complications is often: “That’s not what’s happening.”

It would be difficult to overemphasize the impact of the erasure of breastfeeding complications from the breastfeeding literature. It serves as the proximate cause as well as the justification for the testimonial silencing that follows.

2. Women aren’t believed.

Imagine if the scientific literature were filled with papers referring to sexual harassment as “perceived sexual harassment”. The implication would be that women who report sexual harassment at work cannot be believed; they must have “misperceived” the interaction. Only others can judge what “really” happened because a woman’s judgment is not reliable.

The breastfeeding literature is filled with papers referring to insufficient breastmilk as “perceived insufficient milk.” The implication is that women who report insufficient breastmilk cannot be believed; they must be “misperceiving” their babies cries of hunger. Since women’s judgment can be dismissed out of hand as unreliable, only breastfeeding professionals can judge what “really” happened.

3. Women are pathologized.

The first response of breastfeeding professionals to women who report complications is to pathologize the reporters. At best, reporters are pathologized as incorrect in their assessment and not trying hard enough to make breastfeeding work. At worst, they are pathologized as lazy, selfish women who are looking for an excuse not to breastfeed.

Since breastfeeding complications are supposedly so rare as to have been nearly erased from the professional literature, those who report them must have sinister motivations in making claims that can’t be true.

4. “Head patting”

There are many ways to ignore and undermine women’s claims while pretending to take them seriously. In the case of breastfeeding complications, head patting takes the form of claiming “lack of support.” Breastfeeding complications are routinely dismissed by insisting that women just need more breastfeeding support.

Tell lactation professionals that breastfeeding is painful and they’ll insist that it wouldn’t be painful if you had received support.

Tell lactation professionals that your nipples are cracked and bleeding and they’ll claim that wouldn’t have happened if you had received more support.

Tell lactation professionals that you don’t produce enough breastmilk and they’ll tell you that you would be producing enough if only you had the correct support.

5. Disparaging women’s stories of complications.

You can’t make this tactic any clearer than Prof. Amy Brown did in her horrible piece Here’s Why You Should Ignore Those Breastfeeding Horror Stories:

Try not to pay too much attention to breastfeeding horror stories. People like to share stories – it makes them feel better – without thinking about the consequences for you.

Women claim they experienced breastfeeding complications? Just ignore them!

6 Banning from social media feeds.

Amy Brown is a master of another tactic of testimonial silencing, banning those who report breastfeeding complications from her social media feeds. She is hardly alone in making her social media “complication free.” No doubt she and her colleagues would justify it as deleting and banning trolls. But what does it say about them that they view women who have suffered and whose babies have suffered as nothing more than trolls? It’s no different from labeling women who report sexual harassment as trolls.

Social media banning completes the practice of testimonial silencing begun by the erasure of women with breastfeeding complications from the scientific literature.

Women are no longer willing to go along with the testimonial silencing of sexual harassment. In my case, the dean of my medical school believed me, although he told me that the best he could do was to get the resident transferred to another surgical team without any acknowledgement of what had happened.

It was hardly a good result, but I never forgot that when institutional forces were trying to silence me, someone in authority believed me and fought for me.

Women who experience breastfeeding complications are no longer willing to go along with the testimonial silencing — erasure, refusal to believe, pathologizing, claiming “lack of support” disparaging women’s stories and banning from social media feeds — at the hands of breastfeeding professionals.

I hope they know that I believe them and will continue to fight for them.

BFUSA presents breastfeeding as natural yet requiring medical and administrative oversight, mothers as empowered but uniquely vulnerable, and medical staff as responsive to mothers but driven by objective goals and unquestioned medical evidence. BFUSA policies frame mothers as capable of, and entitled to, individual choice but then undermine this “choice” by repeatedly pointing to the ways in which a mother’s infant-feeding practice impacts not just her, but her baby and society as a whole.

I’ve written a great deal about the ways in which the Baby Friendly Hospital Initiative is coercive and violates women’s fundamental right to bodily autonomy. Cornerstones include forced lectures on benefits, prohibitions on formula supplementation and pacifiers, and mandated 24/7 rooming in of babies. It rests on power differentials, duress and false claims about the benefits and risks of breastfeeding.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation professionals treat women who can’t or don’t want to breastfeed, not as individuals with valid concerns, but as deviants who jeopardize lactivist goals.[/perfectpullquote]

But I had never fully appreciated the way in which rhetoric has been mobilized with the specific aim of silencing and oppressing women until I read Reframing Efficiency through Usability: The Code and Baby-Friendly USA by Oriana Gilson. It appears in the forthcoming book Women’s Health Advocacy: Rhetorical Ingenuity for the 21st Century.

The chapter is larded with jargon (I’ve tried to excise as much as I can in the following quotes), but it is worth the effort to read it and explore the themes.

In this chapter, I consider rhetorics of efficiency … to analyze how the policies and guidelines of BFUSA [Baby Friendly USA] rhetorically situate certain bodies as bearing responsibility for the public health…

Gilson is challenging the insistence by BFUSA that their claims are morally neutral, arguing that they ignore the reality of breastfeeding by blaming women.

Engaging issues of silencing … [feminist scholars] address how “medical evidence” can silence patients … I argue that … power-diffused rhetoric is needed within breastfeeding policies. Such a move would not only support … opening space for … communities previously unacknowledged – but would also provide space for diverging medical evidence to be incorporated and understood … This approach moves beyond a singular objective truth that negates the possibility for diverse user voices to weigh in and be recognized. With the aim of … making apparent the benefits and constraints of “choice” in breastfeeding policies, I draw on feminist rhetorics and disability studies scholars as they situate the rhetorical construction of binaries as both false and materially oppressive;

Lactation professionals in general and BFUSA in particular use the rhetoric of “medical evidence” to silence and coerce women who can’t or don’t want to breastfeed. “Medical evidence” is used to justify ignoring women’s voices and women’s experiences, creating the false binaries of educated and loving breastfeeding mother vs. uneducated and lazy formula feeding mother. The very name of the Initiative, “Baby Friendly,” is a rhetorical strategy designed as a blatant false binary; if breastfeeding is “baby friendly” then women who don’t breastfeed can’t possibly be good mothers.

What are the rhetorics of efficiency to which Gilson refers?

Concepts of efficiency are rhetorically and culturally situated … and ultimately privilege particular bodies, evidence, and practices over others. I suggest that the rhetorical construction of efficiency (both explicitly and implicitly) in BFUSA policies fail to adequately acknowledge that what is framed as most efficient – for baby, family, and society – relies on a disproportionate investment of time, energy, and self on the part of certain bodies.

In this case, the privileged bodies are those of white, well educated, well off, married women. The cost to women in lost income, lost career opportunities and lost time are viewed as irrelevant.

Hence breastfeeding advocates relentlessly promote economic models of how much money could be saved if more women breastfed. These models, besides being unvalidated and therefore false, never include the costs — economic and personal — to women, because they are predicated on the notion that women’s time is worthless and women’s bodies exist to serve others.

BFUSA policies aim to bring bodies into alignment through traditional, patriarchal rhetorics designed to persuade – to intentionally and consciously convert or change another. In doing so, the policies engage traditional rhetorics of efficiency – promoting a single practice performed by a normative body as objective and good – and explicitly or implicitly ignore or undermine varied embodiments and alternative approaches which are instead framed as jeopardizing the success of policy goals…

BFUSA treats women who can’t or don’t want to breastfeed, not as individuals with valid concerns, but as deviants who jeopardize BFUSA’s goals. Instead of invoking best practices in medical communication — listening, sympathizing and respecting differing viewpoints — BFUSA seeks to “educate” women, pressure them and force them to breastfeed.

These would be unacceptable tactics even if there were substantial benefits to breastfeeding. The truth is that the benefits of breastfeeding term babies in industrialized countries are contested:

This … ignores the considerable body of work that calls into question the extent and scope of beneficial health outcomes directly linked to the practice of breastfeeding versus other indicators (for instance, socioeconomic status or family dietary habits), and reflects what some argue is breastfeeding advocates’ tendency to conflate correlation with causation.

Therefore we have policies that:

•ignore or undermine competing and/or nuanced views in order to further an image of the policies and guidelines as grounded in objective fact;
• stress measurable outcomes (for instance, target numbers or set goals) over responsiveness to individual users;
• rely on reductive rhetorics of “choice” that downplay inequities and situational constraints, and instead point to individual motivation or ignorance as the barriers to successful outcomes; and
• hold mothers responsible for individual, infant, and public health.

Breastfeeding rhetoric is designed to silence and coerce women. Babies and mothers are suffering as a result.

Breastfeeding research is a flawed paradigm in which statistically illiterate methods, meaningless “benefits” and ideological censorship dominate the literature.

It’s the inevitable result of the fact that lactation professionals made extravagant claims about the benefits of breastfeeding more than a decade before they bothered to check if those claims were true. By now it’s become obvious even to them that their original predictions about lives and healthcare dollars saved and diseases and conditions prevented have utterly failed to materialize. We are constantly treated to ever more desperate efforts to find ever more arcane “benefits” of breastfeeding.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Breastfeeding did NOT prevent infant hospitalizations for respiratory or GI infections.[/pullquote]

A new paper, Breastfeeding Status and Duration and Infections, Hospitalizations for Infections, and Antibiotic Use in the First Two Years of Life in the ELFE Cohort, is a perfect example.

Spoiler alert: the authors found that breastfeeding didn’t have the anti-infective benefits claimed for it. But that’s not how they presented their findings. Because of ongoing pressure for ideological conformity in breastfeeding research, they concluded:

Predominant breastfeeding for <1 month was associated with higher risk of a single hospital admission while predominant breastfeeding for ≥3 months was associated with a lower risk of long duration (≥4 nights) of hospitalization.

Which is just another way to say breastfeeding does NOT reduce the risk of infant hospitalization.

Let’s see what the authors found and examine how they had to slice and dice the data to arrive at the misleading conclusion.

They start by rehearsing the claims made for breastfeeding benefits:

The World Health Organization (WHO) recommends exclusive breastfeeding for 6 months, or at least the first 4 months of life. These recommendations were mainly based on the protective effect of breastfeeding against infectious morbidity and mortality. In fact, breast milk components, such as immunoglobulin A (IgA) or maternal leukocytes, can both supplement and promote the newborn’s immature immune system and therefore lead to protective effect against infections.

More precisely, recent literature has shown that breastfeeding is related to a reduced rate of hospital admission for diarrhea and respiratory infections as well as a protective effect on otitis media in children up to 2 years old. Of note, otitis media studies were mostly from high-income countries, whereas results on diarrhea and respiratory infection studies were mostly found in settings from low- and middle-income countries. In high-income countries, the preventive effect of breastfeeding on respiratory tract infections is less consistent across studies. In the cluster-randomized trial on promotion of breastfeeding (PROBIT), which took place in Belarus in the 1990s, breastfeeding was related to a reduced risk of gastrointestinal infections in the first year of life.

This is an excellent summary. Contrary to the claims of lactation professionals, the existing research shows that breastfeeding reduces the risk of ear infections in high income countries and respiratory infections and diarrheal illnesses in low income countries.

The authors set out to investigate whether breastfeeding in a high income country (France) reduces the risk of serious respiratory and gastrointestinal infections by looking at the impact of breastfeeding on pediatric hospital admissions.

Here’s what they found:

There was NOT EVEN ONE statistically significant association between breastfeeding and hospitalization for fever, gastrointestinal infection or respiratory infection.

Oops!

It’s hardly surprising. No one has ever been able to show that breastfeeding reduces the risk of hospitalization in term infants.

But given the mandated ideological conformity in breastfeeding research, no one was going to publish that inconvenient fact. Therefore, the authors began data dredging, slicing and dicing the data to come up with any association, no matter how arcane.

They looked at parent reported “events” of respiratory infection, ear infection and antibiotic use.

Finally they found a few statistically significant results:

Compared to never-breastfed infants, infants who were predominantly breastfed for <1 month were at higher risk of being hospitalized …

Oops!

How did the authors deal with that finding? They excluded early hospitalizations.

Why? They provide no compelling reason.

Compared to never-breastfed infants, infants who were predominantly breastfed for at least 3 months were at lower risk of long duration (≥4 nights) of hospitalizations…

And:

Compared to never-breastfed infants … any breastfed for <1 month infants were at higher risk of hospitalization from gastrointestinal infections.

Oops!

So they sliced and diced the data even more and finally came up with something:

…[P]redominant breastfeeding for over 3 months was related to lower risk of at least 4 nights of hospitalization up to 2 years, while any breastfeeding for over 3 months was related to higher risk of 1 or 2 bronchiolitis events in the first 2 years of age. Finally, both any and predominant breastfeeding durations were negatively associated with frequency of antibiotic use.

What does this mean? Absolutely nothing because it is an example of data dredging (aka p-hacking).

According to Wikipedia:

Data dredging (also data fishing, data snooping, data butchery, and p-hacking) is the misuse of data analysis to find patterns in data that can be presented as statistically significant when in fact there is no real underlying effect. This is done by performing many statistical tests on the data and only paying attention to those that come back with significant results, instead of stating a single hypothesis about an underlying effect before the analysis and then conducting a single test for it.

Why are these results meaningless?

Conventional tests of statistical significance are based on the probability that a particular result would arise if chance alone were at work, and necessarily accept some risk of mistaken conclusions of a certain type … When enough hypotheses are tested, it is virtually certain that some will be statistically significant but misleading, since almost every data set with any degree of randomness is likely to contain (for example) some spurious correlations…

In other words if a significance level of 0.05 is used (as in this paper), there’s a 5% chance that statistically significant conclusions will be spurious. In a large dataset with only a few statistically significant associations, that virtually ensures that those associations are not valid. Hence data dredging is considered a misuse of data analysis.

The authors of the paper claim:

Even in the context of a high-income country with short breastfeeding duration, we highlighted a lower risk of infectious morbidity related to breastfeeding duration, especially for duration of hospitalization and antibiotic use.

But the truth is they found nothing of the kind.

This is just the latest example of statistically illiterate methods, meaningless “benefits” and ideological censorship that render invalid most of the scientific literature on the benefits of breastfeeding.