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

Breastfeeding women seldom make history.

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

“Well-behaved women seldom make history.”

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

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

Why?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

No, no, no!

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

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

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

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

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

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

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

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

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

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

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

I read it so you don’t have to.

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

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

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

About 4000 words in, she first quotes me:

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

Then responds:

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

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

She then goes on to say:

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

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

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

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

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

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

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

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

Here’s my response:

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

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

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

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

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

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

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

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

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

How about breastfeeding?

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

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

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

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

What do the questions mean?

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

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

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

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

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

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

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

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

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

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

What do the questions mean in the context of breastfeeding?

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

What won’t answer the questions?

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

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

What would answer the questions?

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

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

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

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

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

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

Divide and conquer!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shame is integral to natural mothering.

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

Furthermore:

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

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

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

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

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

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

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

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

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

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

By that measure, it has been a stunning success.

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

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

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

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

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

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

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

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

I am willing to do that.

That’s why I responded with this:

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

Her answer is no.

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

This process has been independently designed …

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

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

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

Maureen feels sorry for herself:

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

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

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

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

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

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

And on … and on … and on.

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

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

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

They will recognize that Maureen has forfeited the debate.

I knew she would.

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

Who is Minchin?

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

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

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

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

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

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

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

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

She also posted to her Facebook page:

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

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

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

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

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

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

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

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

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

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

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

According to The Intelligencer:

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

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

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

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

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

What is a third degree laceration?

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

Here is an illustration of a third degree tear.

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

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

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

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

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

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

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

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

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

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

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

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

Vision is arguably the most important of our 5 senses.

It allows us to see a grain of salt, a mountain in the distance and everything in between. It is the key to game hunting, to precision manufacturing, to hitting a home run. It is 100% natural. All human beings are “designed” to see.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]C-sections and formula are like glasses and contacts: widely necessary and lifesaving despite the biological “norm.”[/pullquote]

Curiously, despite the centrality of vision to our existence and despite the fact that it is natural, the incidence of poor vision is extraordinarily high. Approximately 30% of Americans are nearsighted; approximately 30% of Americans are farsighted; an equal proportion of Americans suffer from astigmatism. These impairments of vision can occur alone and in combination. Indeed, there are many people over age 40 who are both nearsighted, farsighted and have astigmatism.

What does that tell us?

It tells us that even critical natural functions don’t work properly a large proportion of the time and that high failure rates are completely compatible with the survival of the species.

Now consider vision correction. Over 60% of Americans use glasses/contacts for vision correction.

Are people who need vision correction abnormal or unnatural? Of course not.

Are people who use glasses or contact lenses “giving in” to the inconvenience of not being able to see? That’s absurd.

Does a book written by someone wearing reading glasses have less merit than one written by someone with 20/20 vision? No.

Is a touchdown pass drilled to the receiver by a quarterback wearing contact lenses not really a touchdown? No.

If a nearsighted climber summits Mount Everest wearing glasses, is it a lesser achievement than if she had done the same thing without glasses? Absolutely not.

Why not? Because we judge achievements by the outcome, not the process. It makes no difference if someone needs vision correction to complete their activities or daily living or to fulfill their wildest dreams. The achievement is not marred by the need for vision correct.

And, importantly, 20/20 vision without glasses is not, in and of itself, an achievement.

Now consider childbirth.

It is critical to our existence, and women are “designed” to give birth. Curiously, despite the centrality of childbirth to our existence, and despite the fact that it is natural, the natural incidence of perinatal and maternal death is relatively high. It’s only a fraction as high as the incidence of faulty vision, but the death rates are far from trivial.

What does that tell us?

It tells us that even critical natural functions don’t work properly a large proportion of the time, and the obstetricians who point that out are not “pathologizing” birth, they’re simply stating a fact. Many women will need interventions (childbirth “correction,” if you will) to survive childbirth and for the baby to survive birth alive and healthy.

Are the births of women who need childbirth interventions abnormal or unnatural? Of course not.

Are women who choose pain relief in childbirth “giving in” to the pain? That’s absurd.

Is a baby born by C-section less intelligent, talented or valuable than a baby born by unmedicated vaginal delivery? No.

If a woman gives birth with every intervention known to man, is the result an “unnatural” or abnormal baby? No.

Is the birth of that baby any less joyous or worthy of celebration than the birth of a baby born by unmedicated vaginal birth? No.

Is the birth of that baby any less an achievement than the birth of a baby by unmedicated childbirth? Absolutely not.

Why not? Because we judge achievements by the outcome, not the process. It makes no difference whether a woman needs childbirth interventions. It is the baby that is the achievement, not the presence of absence of interventions.

The same arguments can be made about breastfeeding. Yes, it’s natural. Yes, women are “designed” to breastfeed. Nonetheless a substantial proportion of women and babies will have difficulty with breastfeeding.

Are women who don’t breastfeed abnormal or unnatural? No.

Are woman who choose to formula feed “giving in” to the difficulties. No.

Are babies nourished with formula any less intelligent, talented or valuable than babies nourished with breastmilk? Of course not.

Is raising that baby into a healthy happy child with formula any less of an achievement than doing the same with breastmilk? That’s absurd. The achievement is the healthy, happy baby, not the breastfeeding.

The bottom line is that a home run with vision correction is better than a strikeout without it. A healthy baby born with the assistance of a myriad of interventions is better than a sick or dead baby born without them. A healthy formula fed toddler is better than a stunted toddler who is breastfed.

Some women want to view unmedicated vaginal birth and breastfeeding as achievements, but that says more about them and their fragile self-esteem (or the source of their income as midwives and lactation consultants) than it says about childbirth or breastfeeding.

C-sections and formula are like glasses and contacts: widely necessary and lifesaving despite the biological “norm.”

Financial conflicts of interest loom large in our evaluation of research and they should. But financial conflicts of interest are not limited to the impact of big corporations.

It is easy to understand how formula companies might represent a major conflict of interest in research about the benefits of breastfeeding; no one has any trouble recognizing that researchers who receive financial payments from formula companies might be tempted, possibly only subconsciously, to tilt research findings in favor of their financial sponsors. That’s why it is so important to for researchers to disclose any industry association. It doesn’t mean that the research is wrong or biased, but it helps readers evaluate the legitimacy of the claims within scientific papers.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation professionals are no different from surgeons when it comes to conflicts of interest in promoting their skill set.[/pullquote]

But money is money whether it comes from a large formula corporation or from elsewhere. Arguably, those whose entire income depends on promoting breastfeeding are even more vulnerable to financial conflicts of interest in breastfeeding research than those who receive payments or sponsorships from formula companies.

If payments from formula companies disappeared, the researchers who received them could still conduct research and would still receive salaries from their institutions. But if your entire job depended on finding benefits to breastfeeding — for example if you were employed by the breastfeeding industry — you’d have a very powerful financial conflict of interest to exaggerate the benefits of breastfeeding, as powerful as that stimulated by any formula company payments.

Such conflicts of interest occur all the time in medicine. For example, many types of cancer can be treated by surgery or radiation or chemotherapy or some combination of two or all three. We recognize that surgeons have a vested interest in promoting surgery, radiation oncologists in promoting radiation oncology and medical oncologists in promoting chemotherapy. That’s why many physicians, myself included, routinely recommend second and even third opinions before embarking on cancer treatment. It is only by learning the perspective of different professionals that patients can gain the best understanding of their treatment options.

Lactation professionals are no different from surgeons when it comes to conflicts of interest in promoting their skill set. Their recommendations about the benefits of breastfeeding, therefore, should be treated no differently than a surgeons’ recommendations about the benefits of surgery. It doesn’t mean they are venal and it doesn’t mean that they are wrong. It just means that their financial conflict of interest should never be forgotten.

Financial conflicts of interest are not the only conflicts of interest that can affect research results and professional recommendations.

That’s the point that Richard Saver seeks to make in Is It Really All About The Money? Reconsidering Non-Financial Interests In Medical Research:

Concern about financial ties crowds out consideration of other influences that may bias research conduct. But why? This article argues that we under-prioritize non-financial interests at our peril…

Making Sense of Non-Financial Competing Interests, written by the editors of PLoS Medicine offers examples:

Imagine you’re a peer reviewer who’s received a request to referee a paper. The paper reports the results of a study using cell lines derived from an aborted fetus as a diagnostic tool in identifying certain viral infections. You are also a member of a religious organization morally opposed to fetal cell research. In your review, you raise questions about the study’s validity and methodology that might undermine the paper’s chance of publication.

Imagine you’re an editor and you receive a paper from the scientist who supervised your postdoctoral fellowship. It’s been a couple of years since you left his lab, but he has supported your career and you have warm feelings toward him; plus you still join your former lab mates occasionally at their monthly pub night. You select sympathetic reviewers and you fight hard for the paper at the editorial meeting.

Such conflicts of interest may be even more important than financial conflicts of interest:

Non-financial competing interests (sometimes called “private interests”) can be personal, political, academic, ideological, or religious. Like financial interests, they can influence professional judgment… Indeed, because professional affinities and rivalries, nepotism, scientific or technological competition, religious beliefs, and political or ideological views are often the fuels for our passions and for our careers, private competing interests are perhaps even more potent than financial ones.

It’s not hard to imagine the private interests of breastfeeding researchers. Most have staked their entire research careers on the belief that breastfeeding is the “best” way to feed babies because it has substantial medical benefits. They have a vested psychological interest in promoting breastfeeding and even when their findings don’t support the foundational belief that breastfeeding is best, they are generally spun to ignore that reality or are dismissed with the claim that the failure to find benefits reflects a cultural “lack of support” for breastfeeding. Moreover, there are reports that suggest that over the past decades it has been nearly impossible to get acceptance for publication of papers that dispute the benefits of breastfeeding.

How can we address these non-financial conflicts of interest? With disclosure, policy and research.

Disclosure:

It’s necessary to establish a standard by which authors, reviewers, and editors are required to disclose whether they have non-financial interests that (1) might influence their reporting or review of the paper and/or (2) would negatively or positively be influenced by the publication of the paper… For example, authors should declare if they serve on the editorial board of the journal to which they are submitting or if they have acted as an expert witness in relevant legal proceedings. Reviewers should be expected to declare if they have held grants, co-authored papers, or worked in the same institution with the authors of the study they are reviewing.

Moreover, journal editors should be explicit in acknowledging their biases. If breastfeeding journals won’t accept papers that question the benefits of breastfeeding or papers that reveal risks of breastfeeding, they should publicly state that fact.

Policy:

Journals … they can develop clear and explicit policies that outline definitions of non-financial conflicts of interests and expectations for author, reviewer, and editorial behavior… Our policy states that no decision on papers submitted to PLoS journals will be made until the competing interests—financial, personal, and professional—of all authors are declared, and that we will publish all relevant positive and negative statements of competing interests. Reviewers are required to declare any interests that might interfere with their objective assessment of a manuscript, and these are considered by the editors in determining the suitability of the reviewer.

Research:

…The development and implementation of explicit policies on non-financial competing interests will clearly benefit from being based upon strong evidence of the extent, nature, and impact of private interests.

…Any assumption that non-financial competing interests are less common or influential than financial incentives is probably misguided.

The key point about non-financial conflicts of interest in breastfeeding research is this: Unless and until researchers, editors and reviewers acknowledge (to themselves and especially to the public) that their income, careers and even self-esteem may depend on confirming their personal belief that breastfeeding has major benefits, all research by breastfeeding professionals will be suspect.

Natural mothering advocates employ affirmations as a form of magical thinking. They appear to believe that if they just wish hard enough, they can affect the likelihood of the unmedicated vaginal birth that they are supposed to want or the success of the breastfeeding relationship they’re supposed to desire.

That’s nonsense, of course. But such affirmations are also anti-feminist. They are anti-feminist because they assume that a woman’s worth resides in her vagina and breasts, because they ignore women’s needs and desires, and because they arise from philosophies that seek to immure women back into the home.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]A mother’s worth does not reside in her vagina or breasts. [/perfectpullquote]

My feminist mothering affirmations rest on the opposite premises:

• A woman’s virtue resides in her mind, talents and character. Whether or not a baby transits her vagina is no more important than whether or not she wears glasses.
• Women’s needs — for pain relief in labor, for control of whether their breasts are used to feed their babies, for participation in the world beyond mothering — are more important than any purported benefits from natural childbirth, breastfeeding or attachment parenting. Whether or not a woman chooses to adhere to these philosophies is her decision, based on what she thinks is best for her children, not what other people, ignoring scientific evidence, think is best for her children.
• Women — and society — benefit when they are encouraged to use the full range of their talents in the wider world, and women — and society — are harmed when women are immured in the home, forced to restrict themselves to childcare.

Here are my top ten feminist mothering affirmations:

1. It makes no difference how my baby is born.

Over the course of your son or daughter’s childhood, you will have many occasions to ponder how your actions impact your child’s life and you will second guess yourself many times, wondering if you had handled a specific situation differently might your child have been happier or more successful. Whether your baby was born vaginally or by C-section should never be one of them. It will make absolutely, no difference to your child how he or she emerged from your womb (or, in the case of an adopted child, even if he or she emerged from your womb). There is no reason for you to worry or obsess about how your baby is born.

2. There is no reason for me to suffer.

Some lucky women have a manageable amount of pain in labor and don’t need any relief. Most, however, have an unmanageable amount of pain and desperately seek relief. There is NO REASON to forgo pain relief when you are in pain. It is not safer, healthier or better in any way for your baby or for you to withstand hours of excruciating pain.

3. I am not in competition with other women.

Admittedly this is hard to believe when your friends, acquaintances and casual strangers demand details of your birth so they can compare their “performance” to your “performance,” but it’s true. It’s nobody’s business how you choose to give birth to your child and they don’t deserve to comment upon or even to know those private details.

Childbirth is not a performance that ought to be rated or compared. Childbirth is a bodily function like vision. Sometimes it works well; sometimes it needs help. No one judges women who wear glasses or contacts for nearsightedness even though their eyes don’t work “as nature intended.” Nearsightedness just happens, is no one’s fault and implies nothing about the overall health or quality of a woman’s body. Similarly, childbirth complications just happen, are no one’s fault and imply nothing about the overall health or quality of a woman’s body.

4. I am not guaranteed a healthy baby, so I need to consult with the professionals who can help me ensure my baby’s health.

Human reproduction, like all reproduction, has a high degree of “wastage,” which is another way of saying that death is a common complication of pregnancy. For example, 1 in 5 established pregnancies will end in miscarriage. No amount of wishing and hoping will change that. Similarly, in nature, nearly 10% of pregnancies will end in the death of the baby, the mother or both. Fortunately, the interventions of modern obstetrics can prevent the vast majority of those deaths, but only if you avail yourself of those interventions and the expertise of the people trained to use them.

5. I will not trust birth, because birth is not trustworthy.

Trusting birth makes about as much sense as trusting vision. No amount of trusting will prevent nearsightedness, so refusing eye exams in favor of trusting vision is stupid in the extreme. That goes double for childbirth, which is far more deadly than nearsightedness.

6. I will carefully analyze the motives of those who declare that any particular way of giving birth is “better” than any other.

When you take the time to analyze the advice and recommendations of “birth workers” like midwives, doulas and childbirth educators, ask yourself if they profit when you follow their advice. That does not mean that their advice is necessarily wrong, but it can and too often does compromise their recommendations. Instead of recommending what is good for you and your baby, they may be recommending what is good for their wallet.

Similarly, you should analyze the advice and recommendations of friends and acquaintance looking at how they benefit if you do what they suggest. Are they anxious for you to validate their birth choices by making the same choices? If so, feel free to ignore them.

7. I will not take pregnancy advice or care from anyone who won’t take responsibility for that advice or care.

If a homebirth midwife doesn’t carry insurance, and makes you sign a document declaring that the responsibility for any and all outcomes in yours, she is signaling that even she doesn’t believe that she is educated enough or trained enough to take responsibility your baby’s life or for your life. Real professionals take legal and ethical responsibility for their work; amateurs and hobbyists never do.

8.My baby does not care whether he or she is breastfed or bottlefed.

It makes literally no difference to the baby how he or she gets fed, only that he or she gets fed. Yes, breastfeeding does have some advantages, but those advantages are small and in industrialized countries those benefits are trivial.

9. Both the baby’s needs and my needs matter when it comes to infant feeding.

Yes, breastfeeding can be difficult and stressful in the first few days and weeks, and it is great to persevere through those difficulties if breastfeeding is important to you. But the baby’s hunger and suffering count for a lot, and if you feel your baby is suffering from hunger, you should feel free to feed the baby formula. Your pain and suffering count, too. If your nipples are raw and bleeding, if you have horrible pain when nursing, if you start crying every time the baby cries with hunger, dreading nursing, it is perfectly healthy and acceptable to use formula instead, either for supplementing or exclusively.

10. I will not judge my mothering by the performance of my body.

You mother with your entire body. Your arms hold and embrace your children. Your hands guide. Your lips kiss. Your brain plans and worries, and your metaphorical heart loves your child. Your uterus, vagina and breasts are trivial when compared to the other body parts, so it makes no sense to judge your mothering by whether you had a vaginal birth or breastfed your children.

Mothering is hard. I know; I have four children and I have spent countless hours caring and worrying, wishing I could carry their burdens, smooth their paths, and absorb their hurts. My children are adults now, and no doubt there are many things that they think I could have done better, but they never, ever give any thought to their route of delivery or to whether or for how long they were breastfed.

Don’t judge yourself on these issues, and don’t let anyone judge you. It isn’t simply doesn’t matter … and it’s anti-feminist.