No sooner did I finish writing a post reviewing the large and growing body of evidence that the benefits of breastfeeding have been exaggerated out of all proportion to the data, another researcher comes along making another unsupportable and absurd claim.

I’m glad because it can serve as an object lesson and in how and why breastfeeding has been promoted beyond reason, sometimes to the detriment of the physical health of babies and the mental health of mothers.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Nearly all babies born in industrialized countries between 1955-1975 when formula use peaked were left-handed! Wait, what? They weren’t?[/pullquote]

The paper is Breastfeeding and handedness: a systematic review and meta-analysis of individual participant data published in the journal Laterality: Asymmetries of Body, Brain and Cognition.

Publicized by the author’s institution, it has received widespread public notice.

Want a right-handed baby? Breastfeeding may play a role, study finds is typical.

New parents might not be able to control a baby’s sleep habits or crying, but new research suggests mothers could play a role in determining if an infant becomes right-handed or left-handed.

Babies who are breastfed are less likely to be left-handed compared to infants who were raised on baby formula, University of Washington researchers found. Their study analyzed more than 60,000 mother-child pairings, and took into account other factors linked to handedness, making sure the research zeroed in on the link with breastfeeding in particular.

What did the actual study show? According to the author:

In summary, the findings of this study offer an independent line of evidence that breastfeeding may enhance brain lateralization. This finding provides additional evidence to counter the arguments of those whom dismiss breastfeeding despite its evolutionary normality, and despite the precautionary principle…

Now we understand why nearly all babies born in industrialized countries between 1955-1975 when formula use peaked were left-handed!

Wait, what! They weren’t left-handed? The incidence of left-handedness didn’t change at all?

What’s going on here?

The author gives us an important clue. He reveals that white hat bias — bias in the service of perceived righteous ends — drove him to respond to those who dismiss breastfeeding has having limited benefits by “finding” a new benefit. It seems never to have occurred to him that there is no reason to conduct a systematic analysis and meta-analysis when we already have the population data on what actually happened. And he was so fixated on finding a benefit that he ignored reality: large scale use of formula has had no impact on handedness.

Handedness seems to have a strong genetic component.

Two right-handed parents produce fewer left-handed offspring than parents with any other handedness combination and two left-handed parents produce the highest proportion of left-handed children, i.e. approximately 30–40%…

Handedness is observable is archeological evidence:

Handedness in ancient humans has been inferred by analysis of archaeological samples from skeletons, stone tools and various other artefacts (see Steele & Uomini (2005) for a review). By studying arm bone length, Trinkaus et al. (1994) observed a prevalence of right hand dominance in Neanderthal skeleton samples (dating from approx. 35 000 BP)…

With the advent of ultrasound, handedness can be detected before birth:

At 9–10 weeks, the foetus begins to exhibit single arm movements: a majority (75%, n=72) exhibited a greater number of right arm movements, 12.5 per cent a greater number of left arm movements, and 12.5 per cent an equal number of left and right arm movements… From 15 weeks of gestation, the foetus exhibits a preference for sucking its right thumb and the sucking behaviour at foetal state is related to hand preference at a later age…

Handedness, or rather expression of handedness, is culturally mediated. According to the author of Laterality: Exploring the enigma of left-handedness:

The highest rates of left-handedness, 10%, occur in North America, Australia, New Zealand and western Europe. The lowest rates, 4 to 6%, are in Asia, Africa and South America…

… Countries with higher rates of left-handedness are societies that tolerate left-handedness, do not punish left-hand use and do not pressure left-handers to convert to right-handedness…

How has handedness in the US changed over time?

Left-handedness fell in the late 1800’s to a nadir around 1910 and then rose steadily until 1960. Formula feeding rates were rising during part of that time, but then they began to fall precipitously and there has been no drop off in the incidence of left-handedness suggesting that formula feeding has no impact on handedness.

The disconnect between the data that the author analyzed and what has actually happened with handedness over the same period of time is similar to that found in much of the literature purporting to show benefits of breastfeeding. For example, various authors have claimed that by increasing breastfeeding rates we could save thousands of infants lives. But population data involving tens of millions of babies gathered over decades during which breastfeeding rates fell precipitously and then rose precipitously show that the predicted saving of lives did not occur. The theory has been utterly disproven by reality, yet breastfeeding researchers (and lactation professionals) still cling to the theory and ignore reality.

That’s why when you read about various claimed benefits for breastfeeding you should ask what has actually happened over time. We don’t have to rely on mathematical models of what was supposed to happen when we have the data on what actually happened.

That the author of this paper on handedness made no attempt to test his conclusion against reality is typical of breastfeeding research. All claims of breastfeeding’s benefits should be viewed with a great deal of skepticism unless and until they comport with what actually happens in the real world. Otherwise we risks being duped by researchers whose primary goal is to “counter the arguments of those whom dismiss breastfeeding despite its evolutionary normality.”

I have been arguing for years that the benefits of breastfeeding have been exaggerated far beyond what the scientific evidence could justify. In large part that exaggeration has occurred because of a massive marketing effort on the part of lactivists who repeated “breast is best” so often that it became conventional wisdom even though it wasn’t true.

It’s been 5 years since the publication, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons by Colen and Ramey that found the purported benefits of breastfeeding nearly all disappeared with corrected for confounding variables like socio-economic status and ethnicity. Multiple papers by other authors debunking various claimed benefits of breastfeeding have since been published.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]“…[E]xclusive breastfeeding at discharge from the hospital is likely the single greatest risk factor for hospital readmission in newborns.”[/perfectpullquote]

A recent paper tactfully titled Is the “breast is best” mantra an oversimplification? summarizes the evidence that the benefits have been overstated and the risks ignored.

The authors note:

Recommendations about breastfeeding — absent critical analysis and removed from context — may overvalue its benefit…

The benefits of breastfeeding for infants have long been touted as numerous and supported by overwhelming evidence…

Massive public health campaigns citing data for the many benefits of breastfeeding have been launched with the goal of increasing the breastfeeding rate…

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…

The authors review the existing scientific evidence in order to bring clarity to the discussion. They start by confirming the well known but small decrease in upper respiratory infections and episodes of diarrheal illness, but they find little support for most other claimed benefits, especially long term benefits.

IQ:

Several studies conducted in developed countries have linked breastfeeding to positive cognitive outcomes in children, including higher intelligence quotient (IQ).

These effects are conflicting, however, in studies that include sibling analysis and ones that control for maternal IQ. In the 2013 WHO meta-analysis, breastfeeding was associated with an increase of 2.2 points on normalized testing when only high-quality studies were included. A 2015 meta-analysis identified 4 high-quality studies with a large sample size and recall time

Obesity:

The relationship between breastfeeding and obesity later in life is debatable. A large, systematic 2014 review of 15 cohort and 10 cross-sectional studies found a significantly reduced risk of childhood obesity among children who were breastfed (adjusted OR=0.78; 95% CI, 0.74- 0.81). However, the review included studies that controlled for different confounders, and smaller effects were found in studies in which more confounders were taken into account.

The 2013 WHO meta-analysis found a small (approximately 10%) reduction in the prevalence of overweight or obese children, but cautioned that residual confounding and publication bias were likely. At 6.5 and 11.5 years of follow-up, PROBIT failed to demonstrate a protective effect for exclusively or “ever” breastfed infants. Sibling analysis similarly fails to demonstrate a statistically significant relationship.

A 2015 meta-analysis of 23 high-quality studies with a sample size >1500 children and controlled for important confounders showed a pooled reduction in the prevalence of overweight or obesity of 13% (95% CI, 6-19).57 The protection in this meta-analysis showed a dilution of the effect as the participants aged and an inverse relationship of the effect with sample size.

Breastfeeding is, therefore, unlikely to play a significant, if any, role in combating the obesity epidemic.

NEC (necrotizing enterocolitis)

In preterm infants, breastfeeding has been associated with a lower rate of necrotizing en- terocolitis. In the 2007 Agency for Healthcare Research and Quality report, the association was found to be only marginally statistically sig- nificant, and the authors warned that, first, evidence is old and heterogeneous and, second, present preterm formula is much different than the formula used in earlier studies of preterm infant nutrition and necrotizing enterocolitis. A 2012 Cochrane review included newer stud- ies in its analysis but reached the same conclusion on the quality and heterogeneity of available evidence, with a NNT of 25.

SIDS (Sudden Infant Death Syndrome)

There is a statistically significant association between sudden infant death syndrome (SIDS) and feeding method. Infants whose cause of death is SIDS are approximately one half as likely to have been breastfed as matched controls…

The protective effect exists for any amount of breastfeeding and is stronger for exclusive breastfeeding, suggesting a protective role — not simply an association. Caution should be employed with this conclusion, however, because the studies included in the meta-analysis used univariate analysis primarily and did not control sufficiently for known confounders. In addition, the authors warn that publication bias might overestimate the association…

Assuming a protective role, available data suggest that more than 3500 infants need to be breastfed to prevent one case of SIDS.

Does breastfeeding save lives?

No clear association has been found between mortality and breastfeeding status in developed countries, except for the association with SIDS.

And breastfeeding has risks including dehydration, failure to thrive, weight loss, and hyper- bilirubinemia.

…[E]xclusive breastfeeding at discharge from the hospital is likely the single greatest risk factor for hospital readmission in newborns. Term infants who are exclusively breastfed are more likely to be hospitalized compared to formula-fed or mixed-fed infants, due to hyperbilirubinemia, dehydration, hyper- natremia, and weight loss (number needed to harm (NNH)=71). For weight loss >10% of birth weight with or without hospitalization, the NNH for breastfed infants is 13.

Many of these hospitalizations and events could be avoided with appropriate monitoring and medically indicated supplementation; the likelihood of long-term harm is low. Formula supplementation is often avoided if possible in hospitals to promote exclusive breastfeeding; however, several small randomized clinical trials have demonstrated that limited formula supplementation in breastfed infants does not affect the breastfeeding continuation rate at 3 and 6 months, and, therefore, might be a way to decrease in- fant rehospitalization.

The bottom line?

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.

Is breastfeeding advocacy harmful?

The “Ten Steps to Successful Breastfeeding” program of the Baby-friendly Hospital Initiative (BFHI; launched by UNICEF and WHO) has come under scrutiny because of an increasing number of reports of sudden unexpected postnatal collapse; fall injuries; modeling and encouragement of unsafe sleep practices; an overly rigid resistance to the use of formula supplementation; and the ban on pacifier use…

Some of the “Ten Steps,” such as the call for skin-to-skin care and 24-hour rooming-in, have well-established benefit yet, when performed without supervision, can have the rare but serious unintended consequences of sudden unexpected postnatal collapse (the incidence of which may be higher than that of SIDS) and unsafe sleeping practices.

Furthermore, despite evidence that early formula supplementation, when medically necessary, does not adversely impact the breastfeeding rate, the “Ten Steps” program advises that giving formula before breast milk comes in might “lead to failure to breastfeed.”

Similarly, the ban on pacifiers is contrary to available evidence. The use of pacifiers before last sleep is more protective against SIDS than breastfeeding (NNT=2733) …

What about the harms to mothers?

The literature that does investigate harm consistently finds that women who have difficulty breastfeeding or choose formula feeding report feelings of inadequacy, guilt, loss of agency, anxiety, and physical pain during breastfeeding that interferes with 1) their ability to bond or otherwise care for their infant and 2) competing work obligations…

What do mothers need to know? The authors offer compelling statistics about both short and long term benefits including:

Greater than 99% will not realize benefit from either the prevention of SIDS … or from improvement in long-term health measures …

Balancing the abundant, but often limited-quality, data on the benefits of breastfeeding and the sheer lack of data regarding the risks of advocacy represents a clinical and an ethical challenge for physicians. It is a challenge that can only be resolved through individualization of care and shared decision-making, in which the physician is expert on the benefits of breastfeeding, and the mother is expert on the personal circumstances to be weighed against those benefits.

Her baby, her body, her breasts, her choice!

Last month I wrote a piece condemning Harvard breastfeeding safety researcher Dr. Ronald Kleinman for failure to disclose financial conflicts of interest. My piece was based on an expose featured in WomensENews.

This morning I received an email from Harry Orf, PhD, Senior Vice President for Research, and Research Integrity Officer Massachusetts General Hospital informing me that I disseminated incorrect information. Much to my regret I repeated false claims and mischaracterized the situation. For that I am deeply sorry and want to correct the record as soon as I can.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Was this character assassination of a respected breastfeeding safety researcher by the breastfeeding industry?[/perfectpullquote]

Orf shared with me the letter he sent to the reporter and her editor detailing the falsehoods:

• The premise in your headline and lead paragraph that Dr. Kleinman has come under scrutiny is flawed. He has not come under scrutiny. Harvard received one complaint, which was reviewed, as we are obligated to do. Our assessment identified no problems or concerns – nothing.
• In response to your question about whether industry-funded research influences outcomes, Dr. Kleinman said, “There certainly have been some high-profile examples of industry-initiated studies that have not had the appropriate firewalls between the funder and the investigators, and the influence of the funder is obvious.” Your article, however, twisted his comment around, saying, “Kleinman believes ‘appropriate firewalls’ exist, even in the face of other high-profile examples where industry influence is present.” This is a total mischaracterization of his response.
• You wrote that Dr. Kleinman has financial connections to juice manufacturers. This is not true, yet you included it even though Dr. Kleinman told you he has never received compensation nor had a relationship with the Fruit Juice Association. Perhaps you should have checked with the association directly if you didn’t accept Dr. Kleinman’s response.
• You wrote, “Harvard’s review did not find any official fault, but due to recent investigative reporting by the New York Times and ProPublica, light has been shed on the conflict of interest for scientists in all fields.” Dr. Kleinman was not part of the NYT/ProPublica piece, and attempting to draw such a connection is grossly misrepresentative.
• You repeatedly suggested that Dr. Kleinman has published articles critical of breastfeeding. Dr. Kleinman has been a consistent and strong supporter of breastfeeding for 40 years and made this clear in his responses to you.
• The story alleged Dr. Kleinman has had an ongoing relationship with Nestle. Dr. Kleinman explained in his response that the relationship with Nestle involved him co-chairing two international symposia – one more than 20 years ago, the other more than 10 years ago. These were two discrete interactions with no relationship between Dr. Kleinman and Nestle since.
• Similarly, your story said Dr. Kleinman is a consultant for Burger King. As he noted in his response, Dr. Kleinman attended a one-day advisory meeting more than 10 years ago aimed at improving the nutritional profile of the meals Burger King serves. This advisory group included a future surgeon general and other prominent scientists and nutritionists from across the country. He has had no further interaction with Burger King since that single meeting.
• Your story suggested that Dr. Kleinman’s engagement as a member of the Alliance for Potato Research and Education led to a paper promoting potato consumption among children. In fact, nothing in the cited review paper, which was about vegetable consumption and young children, promoted potatoes or concluded that children should eat more potatoes. In addition, Dr. Kleinman had explained that his role as an advisory committee member involved evaluating research proposals seeking funding from the APRE. He himself never received research funding from the organization.
• You said Dr. Kleinman was on the board for US Dietary Guidelines 2010. He was not and never has been.(my emphases)

How could the reporter have gotten it so wrong? Where did she come up with these accusations if not from the Harvard investigation?

Let’s look at whom she quotes: all three earn their money from the billion dollar breastfeeding industry.

• Kimberly Seals Allers, author of The Big Letdown—How Medicine, Big Business and Feminism Undermine Breastfeeding
• Lucy Sullivan,executive director of 1,000 Days
• Trish MacEnroe, Executive Director of Baby-Friendly USA

Another leading avatar of the breastfeeding industry, Melissa Bartick, MD, apparently filed the original complaint.

I also filed a complaint about Kleinman’s conflicts of interest to the Harvard Medical School Office of Academic and Research Integrity in December 2017, which was never addressed.

She wrote that in November 2018 and it, too, appears to be a mischaracterization. The complaint WAS addressed and it was dismissed as unsubstantiated.

What happened here? The final paragraph in Orf’s letter to the reporter and editor suggests a possibility:

Finally, Ms. Gale, at the end of your article, Women’s eNews acknowledges that this investigative series has been funded by the W.K. Kellogg Foundation. It has come to my attention that the Kellogg Foundation also provides significant support for the Baby Friendly Hospital Initiative and funds research of some of the individuals who have led the campaign to discredit Dr. Kleinman. Given that the focus of your article is on appropriate disclosure of conflicts, particularly around the Baby Friendly Hospital Initiative, it is surprising to me that Women’s eNews would not require that these relationships be fully disclosed to its readers.

Was this character assassination of a respected breastfeeding safety researcher by the breastfeeding industry? Was this an attempt by breastfeeding professionals to preserve the Baby Friendly Hospital Initiative at the expense of the health of babies and the wellbeing of mothers? We need more information to know for sure but it certainly looks like it.

I want to offer a heartfelt apology to Dr. Kleinman for my original piece. I repeated misinformation and for that I am deeply sorry. I’ll be waiting for Bartick, Seals Allers, Sullivan and McEnroe to do the same.

The New York Times recently issued an extraordinary mea culpa for its role in fanning hysteria around the purported epidemic of crack babies.

Today, with some notable exceptions, the nation is reacting to the opioid epidemic by humanizing people with addictions … That depth of sympathy for a group of people who are overwhelmingly white was nowhere to be seen during the 1980s and 90s, when a cheap, smokable form of cocaine known as crack was ravaging black communities across the country.

News organizations shoulder much of the blame for the moral panic that cast mothers with crack addictions as irretrievably depraved and the worst enemies of their children. The New York Times, The Washington Post, Time, Newsweek and others further demonized black women “addicts” by wrongly reporting that they were giving birth to a generation of neurologically damaged children who were less than fully human and who would bankrupt the schools and social service agencies once they came of age.

In other words:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The idea that formula is uniquely harmful to babies has about as much science behind it as the idea that crack cocaine was uniquely harmful to babies.[/pullquote]

Bad science and a moral panic, fueled in part by the news media, demonized mothers and defamed a generation.

But no one seems to have learned anything from the experience. Instead, we are recapitulating it, but this time infant formula is the new crack cocaine. The idea that formula is uniquely harmful to babies has about as much science behind it as the idea that crack cocaine was uniquely harmful to babies.

The similarities are remarkable.

…[T]he scourge of crack was still new in 1985 when the New England Journal of Medicine published a research paper that changed how the news media — and by extension the public — viewed the epidemic.

The author, Dr. Ira Chasnoff, asserted, based on a handful of cases, that the children of mothers who had used crack remained smaller, sicker and less social than other infants. He noted the limitations of his study and cautioned that rigorous research would be needed.

The lactation profession was still new in the mid-1980’s and there was little scientific evidence to support the insistence that breastfeeding is “best,” but that didn’t stop lactation consultants from making all sorts of extravagant claims about the benefits of breastfeeding and the risks of formula feeding.

No sooner was the evidence for an epidemic of crack babies presented than it was rebutted by further evidence. In addition, the predicted harms never appeared.

The myth of the “crack baby” … was debunked by the turn of the 2000s. But by then, the discredited notion that cocaine was uniquely and permanently damaging to the unborn had been written into social policies and the legal code.

The evidence for harms from formula feeding has been repeatedly debunked in the 2000’s and 2010’s. In addition, the predicted benefits of raising breastfeeding have rates never appeared. But by then, the discredited notion that formula was uniquely and permanent damaging to babies had been written into social policy and the legal code.

Why did fear about crack babies take hold in the absence of solid scientific evidence? Because it resonated with prejudices about race, class and privilege.

The idea of a mentally impaired “crack baby” resonated with long-held racist views about black Americans. It captured the imaginations of reporters, politicians, school officials and others who were historically conditioned to believe just about anything about the African-American poor.

As the medical writer Harriet Washington wrote of this period in her book “Medical Apartheid,” Dr. Chasnoff’s provisional research “was swallowed whole, then regurgitated in a racialized form by newspaper, magazine and even medical accounts.”

Why did fear about the “harms” of formula take hold in the absence of solid scientific evidence. Because it resonated with prejudices about race, class and privilege.

As researcher Catherine Robinson has written:

Successfully establishing and maintaining breastfeeding has arguably become a woman’s ultimate maternal makeover … The growth of a specifically maternal instance of broader ‘makeover culture’ supports breastfeeding as important transformative work …

Further, the breastfeeding makeover is furnished by all manner of expensive consumer and fashion products special to the breastfeeding body. Women prepared for breastfeeding by buying expensive nursing bras and singlets designed to be seen, breastfeeding clothing (including gym-wear), comfort cushions, footrests and armchairs …

Most importantly, breastfeeding’s needed time and space as specific middle class affordances mean that it is middle class women who have the capacity to forego paid work, access both paid and unpaid maternity leave, and focus on developing this tricky bodily competency …

It is hardly a coincidence that breastfeeding rates are lowest among poor women and women of color. Therefore breastfeeding serves the critical functions of making middle class white motherhood normative and demeaning poor women and minority women.

Many of the purported harms of crack were actually the result of other substances or of poverty itself.

Researchers debunked the “damaged generation” theory numerous times, finding no indication that children exposed to crack in the womb faced long-term debilitation and that the effects once tied to exposure were attributable to other drugs like alcohol and tobacco, or to factors associated with poverty, including homelessness and domestic violence.

Many of the purported harms of formula are actually the result of other factors like maternal education, socio-economic status and racial discrimination. This has been demonstrated repeatedly over the past decade.

Activists deployed punitive tactics toward mothers supposedly to improve the wellbeing of babies.

…[L]egislators seized upon the twin fallacies of the “crack baby” epidemic — the notion that the drug was uniquely and permanently damaging and that pregnant women used it by choice instead of because of the disease of addiction — to promote the view that fetuses “needed to be protected from dangerous mothers who would kill them.”

Lactivists deploy draconian tactics toward mothers supposedly to improve the wellbeing of babies. They’ve seized upon the twin fallacies of breastfeeding advocacy — that formula is uniquely and permanent damaging and that new mothers use it by choice instead of by necessity — to support the claim that women must be forced to breastfeed through mandatory exposure to the education policies of the Baby Friendly Hospital Initiative.

Innocent women were profoundly harmed by efforts to control the behavior of women who used crack.

…[C]rack hysteria drove a draconian new welfare policy that “sacrificed poor women — especially black, crack smoking mothers — on the altar of ‘reform.’” In 1996, for example, Congress denied food stamps and welfare payments for life to people convicted of drug felonies — many of whom happened to be women with children in desperate need of medical or mental health care.

Innocent women (and babies) are being profoundly harmed by efforts to control the feeding choices of new mothers. Formula hysteria is driving the punitive tactics of the Baby Friendly Hospital Initiative such as locking up infant formula and forcing women to sign consent forms detailing its “dangers.”

The New York Times summarizes the debacle:

The story of the “crack baby” shows how weak science, poorly informed crusaders and racist attitudes can work together to shape public policy… [T]he science around pregnancy needs to be approached with humility and humanity. Because when that’s lost, even in a quest for social good, the results can be irreversible.

That applies equally well to the demonization of formula. Weak science, poorly informed but highly motivated crusaders and privileged attitudes can work together to shape public policy. The science around infant feeding needs to be approached with humility and humanity. Because when that’s lost in the quest for a social good — as it has been lost by contemporary lactation professionals — the results can be devastating.

Breastfeeding professionals have discovered a problem. After nearly a generation of aggressive breastfeeding promotion undertaken at their instigation a lot of women and babies have been harmed. Sadly, that’s not the problem. The problem for breastfeeding professionals is that the women are fighting back.

These women are uncompliant breastfeeders. Formula was not their initial choice. They fully embraced the mythology of breastfeeding as having major benefits (though its benefits are trivial), its inherent perfection (though like all biological functions it has a high failure rate) and were completely socialized to believe that breastfeeding is an integral part of good mothering (when it is irrelevant to the mother-child bond).

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Uncompliant breastfeeders are those who learned the hard way that breast is NOT best for many mothers and babies.[/pullquote]

But they were disillusioned by reality. They couldn’t breastfeed successfully; they sacrificed their mental health trying to breastfeed; they put their babies’ health at risk or actually harmed their babies trying to breastfeed. In other words, uncompliant breastfeeders are those who learned the hard way that breast is NOT best for many mothers and babies.

Professional lactivists tried their favorite tactic first: they ignored them. But in the last few years uncompliant breastfeeders have become impossible to ignore because there are so many of them and they have begun to organize. So now they must be disciplined and managed.

The first effort at disciplining uncompliant breastfeeders in still playing out. It involves characterizing them as ignorant, lazy and selfish, thereby exacerbating the trauma they already experience. This tactic has been gleefully deployed by both professional and lay lactivists to torment women who can’t or don’t wish to breastfeed.

The second effort has been institutional, in the form of the Baby Friendly Hospital Initiative that literally forces women to breastfeed or endure unpleasant consequences. The BFHI is truly dystopian in its tactics, ranging from mandatory education efforts, through muzzling of providers, to locking up infant formula and forcing women to sign consent forms detailing its “dangers.”

Not surprisingly, both these methods of disciplining uncompliant breastfeeders have brought a feminist backlash with academics and lay people arguing that the choice of whether and how a woman uses her breasts should be left to women themselves. So professional lactivists have turned from exacerbating the trauma of uncompliant breastfeeders to expropriating the trauma.

Psychology professor Amy Brown has been leading the way in attempting to manage uncompliant breastfeeders by mischaracterizing their trauma and prescribing more “support.” Brown is one of the contributors to a new book Social Experiences Of Breastfeeding; Building bridges between research, policy and practice.

Writing about the conference that serves as a source for the book its authors note:

We wanted to create a space where people could meet to consider how to further our understanding of women’s embodied, affective and day-to-day experiences of trying to breastfeed their babies, and to talk about how more UK women might be helped to breastfeed their babies for longer…

They should have talked to mothers but instead they talked to each other and thereby ignored the harmful impact they have on women. The chapter headings reveal lactation professionals insistence that uncompliant breastfeeders are traumatized a “lack of support”:

Changing cultures of night-time breastfeeding and sleep in the US
Breastfeeding and modern parenting culture: when worlds collide
Parenting ideologies, infant feeding and popular culture
Cultures of breastfeeding: reflections for policy and practice

No matter that there has never been more support for breastfeeding than exists today.

The contributors to the book should have read Misshapen motherhood: Placing breastfeeding distress by Catherine Robson, who found something very different when she did talk to mothers. Contemporary culture isn’t unsupportive of breastfeeding; it is obsessed with breastfeeding.

I became intrigued with the lived dynamics of breastfeeding struggle after being thoroughly immersed in the world of breastfeeding remedies and lactation support as a mother-patient … From the birth of my first child in 2008 to my third in 2014, the grief and frustration at failing to ever exclusively breastfeed slowly translated into a drive to shed narrative light on the maternal underworld of breastfeeding struggle…

As both a distressed mother and academic researcher it was difficult to find lived accounts of what exactly brought women into this zone of struggle and support, of what it was like, of how they and their babies survived, and of how they experienced and made sense of the clash between the unthinking expectation to breastfeed and the surprising corporeal and emotional mess this could end in. I developed a great hunger, as the women who took part in my eventual research likewise reported, to encounter alternative narratives of breastfeeding where anger, disappointment, fear, intense pain, struggle, failure, deep sadness and an enormous corporeal workload were vocalized, nutted out, engaged with front and centre…

She came to understand:

…[T]he breastfeeding distress I focus on here also emerges within a broader socio-spatial context of ‘total motherhood’ and within privileged, white, middle-class motherhood with which the principles of total motherhood most closely align. I will argue that it is the particular coalescence of these corporeal and sociospatial geographies which works to frame and maximize feelings of maternal distress – including grief, loss, shame and failure. As such, this research can be understood as a micro case study of how notions of the ideal proximate motherhood … are currently being socio-culturally amplified and with deep effect on maternal feelings, practices and identities…

Such an imperative to breastfeed … is framed by the emergence of a form of ‘total motherhood’ in which mothers are held responsible for the complete risk-management of their own and their infants’ bodies. This is a style of mothering which requires proximity, monitoring and information gathering, and which emphasizes the role of personal choice. In this context, breastfeeding becomes a widely relevant venue through which contemporary anxieties about general health risks and healthy choices play out, with extraordinary public pressure being brought to bear on mothers to mobilize scientifically evidenced best-practice in their feeding… Here personal morality powerfully melds with risk-management such that the breastfeeding mother is unquestionably the good mother who not only knows that breast is best and but who is prepared to make every sacrifice to ensure breastmilk is what her infant receives.

Robinson is eloquent in explaining the source of distress for women who want to breastfeed but find they can’t:

…[T]he contemporary call to make motherhood so specifically through exclusive, direct breastfeeding remains dangerously structured by a ‘dichotomous spatial logic of proximity and distance’. The fetishising of breastfeeding as the key or even only venue of authentic infant-maternal connectedness positions all other infant-maternal contact as a form of separated and artificial interaction. This stigmatizing spatial logic and the broader embeddedness of breastfeeding as ‘trope’ of ‘risk culture’ combine to produce a paralyzing maternal landscape in which the effects of not breastfeeding creates social and emotional risks for women.

In contrast, the contributors to Social Experiences of Breastfeeding, rather than acknowledging and unpacking this source of maternal distress — the relentless pressure to breastfeed in a world that equates breastfeeding with good mothering — gaslight women by denying their experiences.

Women are telling breastfeeding professionals that they are reeling from too much pressure to breastfeed and breastfeeding professionals are trying to discipline them by misappropriating and mischaracterizing their trauma.

Natural mothering advocates have a problem. They live in terrible fear that their babies and children will be exposed to “toxins” and go to great lengths to prevent exposure.

But toxins — real, not imaginary — can be transmitted through breastmilk the purported elixir of life. What to do? Ignore the toxins, of course!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivists value breastfeeding more highly than a baby’s exposure to toxins, no matter how dangerous those toxins may be.[/pullquote]

Meg Nagle of The Milk Meg offered this message on New Year’s Eve:

Breastmilk with a small amount of alcohol is a better option than formula.

Today she explained further:

This statement is take directly from the Australian Breastfeeding Association’s PDF, Alcohol and Breastfeeding: A Guide for Mothers.

Indeed it does … without any attribution or citations. In other words, the lactivists at the ABA appear to have simply made it up.

The hypocrisy of lactivists is truly remarkable given the critical role that “toxins” play in natural mothering ideology and exhortations.

In The Polluted Child and Maternal Responsibility in the US Environmental Health Movement, a new paper in the Journal of Women in Culture and Society, Norah MacKendrick and Kate Cairnes explain that the idea of women’s bodies as the appropriate target of medical and moral anxiety has a long history.

The result is a culture that holds women responsible for protecting their children from toxins:

As disease risk is located in the maternal body, medical surveillance has extended in both temporal directions to include not only the pregnant body but also the pre-conception body, the breastfeeding body, and the feeding of young children. As women’s bodies come under greater scrutiny, so too do their actions and choices that might affect the fetus, infant, and child. This scrutiny corresponds to a culture of mother-blame that holds mothers accountable for their child’s health or behavioral problems…

Women’s desires are framed as dangerous:

Women are implored to eschew self-interest for the sake of the future child, whether by forgoing butter, skipping nail polish, or making homemade personal care products. These directives add to the long list of “rules” for controlling indulgences during pregnancy, where cigarettes, alcohol, unpasteurized milk, and raw fish are entirely forbidden, and balanced diets are a must, along with regular exercise (but not too much).

In Healthy Child Healthy World, women are warned against laziness:

The language of the “lab experiment” implies that mothers who fail to practice necessary vigilance are “experimenting” with the health of their baby. The guide presents fatigue as no excuse for lax control over the pregnant appetite:

“You’re tired and the last thing you want to do is cook. We get it. But consider this: When you dine out, order in, or consume processed packaged foods, you can never be entirely sure what you’re eating. Pre- paring your own meals at home using fresh, whole ingredients, on the other hand, gives you maximum control over what ends up on your plate. It’s the best way to ensure an optimally safe and healthy diet for both you and your baby. Besides, cooking tired is a necessary parenting skill…

Sound familiar? It should because it’s the language of the natural mothering movement, depicting women who choose epidurals, C-sections and formula feeding as weak and selfish.

… By taming cravings and “bad” habits during pregnancy, a woman begins her socialization into “good” motherhood, as she has perfected the careful, toxic-free habits of caregiving. The postpartum period puts this hard work to the test, as women are exhausted by breastfeeding and sleepless nights…

I found this statement particularly striking:

…[I]t is the pregnant woman’s desire to treat herself that puts her baby at risk.

The same goes for new mothers … unless the toxins are in breastmilk.

In the overwrought literature of lactivism, breastmilk is portrayed as perfect in every way: always available, always the right temperature, always the right amount and imbued with the power to improve health, prevent obesity and maximize intelligence. But breastmilk, like the pregnant mother’s blood, can transmit toxins and even concentrate them into higher amounts than in the maternal bloodstream.

Lactivists face a terrible quandary. They could eschew toxins altogether as they do in pregnancy. They could employ the same attitude to maternal indulgence in pregnancy and make it forbidden altogether. No smoking, no alcohol, no drugs and no medications (including pain relief for labor) can be countenanced during pregnancy. But whereas women cannot discontinue pregnancy in order to indulge their desires and still end up with a healthy baby, women can easily discontinue breastfeeding in order to indulge their desires and still end up with a health, formula fed baby. So lactivists have decided to take a laissez-faire attitude to substances in breastfeeding bodies that they would never countenance in pregnant bodies.

Professional lactivist Dr. Jack Newman helpfully lists the many toxins that would otherwise be verboten but are perfectly okay when found in breastmilk:

Tobacco smoking

A mother who cannot stop smoking should breastfeed. Breastfeeding has been shown to decrease the negative effects of cigarette smoke on the baby’s lungs …

Alcohol

…The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for breastfeeding mothers.

Recreational drugs

These drugs, for example, marijuana and cocaine, have the same negative associations as does alcohol … But what I said about alcohol is true of these drugs as well…

Medications

Almost no medication taken by the mother requires her to stop or interrupt breastfeeding.

Anesthesia

Mothers are usually told that they will have to interrupt breastfeeding for 24 to 48 hours after surgery under general anesthetic… This is completely unnecessary. After all, we frequently give babies having surgery the very same medication.

What about the fact that these toxins can be easily avoided by using formula instead? Here Newman comes to the heart of the matter:

…[W]hy do so many physicians assume that any and every drug is contraindicated during breastfeeding? Basically, because they don’t believe that it matters if the mother breastfeeds or not. Formula=breastmilk, bottle feeding=breastfeeding, it’s all the same. But it’s not all the same.

In other words, Newman and other lactivists value breastfeeding more highly than a baby’s exposure to toxins, no matter how dangerous those toxins may be.

Why do good mothers feel so bad?

Because in the guise of doing what’s “best” for them, we are harming women and their babies with the dominant parenting ideology of natural mothering.

How do I know? Because for decades, I have served as a witness. First as a practicing obstetrician and then as blogger, I have been present literally and figuratively as women cried their hearts out over the many ways they are supposedly failing the infants and children they love so desperately.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mothers should trust themselves … and be kinder to themselves.[/pullquote]

Our views on mothering have changed dramatically in the past 70 years. It’s easy to see when you compare the advice of the legendary Dr. Benjamin Spock, author of Dr. Spock’s Baby and Childcare, to the advice natural parenting experts offer today.

Dr. Spock told new mothers:

Trust yourself, you know more than you think you do.

Natural parenting experts tell new mothers, ‘Don’t trust yourselves, you know nothing until you’ve read my book.’

Dr. Spock said:

The more people have studied different methods of bringing up children the more they have come to the conclusion that what good mothers and fathers instinctively feel like doing for their babies is usually best after all.

Natural parenting experts say, ‘If you love your baby you’d do exactly what we tell you because that’s what mothers did in nature; otherwise you are a lazy, selfish cow.’

He was remarkably perceptive and forgiving:

All parents do their best job when they have a natural, easy confidence in themselves. Better to make a few mistakes from being natural than to try to do everything letter-perfect out of a feeling of worry.

Natural parenting experts are notably unforgiving. They tell women, If you don’t have an unmedicated vaginal birth, breastfeed for more than a year, and practice attachment parenting, your child will end up obese, illiterate and unhappy and it will be YOUR fault.’

Dr. Spock counseled:

Don’t take too seriously all that the neighbors say. Don’t be overawed by what the experts say. Don’t be afraid to trust your own common sense.

Natural parenting experts say, ‘All your friends on Facebook expect you to follow my advice. But ignore what doctors say; they’re all in the pockets of Big Pharma.‘

The result?

While women stake their self-esteem on having an unmedicated vaginal birth and obstetricians obsess endlessly about the C-section rate, poor women of color die in ever increasing numbers for LACK of obstetric interventions.

While new mothers torment themselves in making sure not even a drop of formula is allowed to touch their precious baby’s lips, breastfed babies are being re-admitted to the hospital at double the rate of formula fed babies and brain injures and deaths from dehydration and jaundice are making a shocking comeback.

While women imagine themselves as educated for refusing newborn vitamin K injections, their babies suffer ghastly injuries and deaths from bleeding into the brains.

While women preen over refusing vaccines, their babies die of pertussis as measles and other nearly eradicated infectious diseases return.

While new mothers tell themselves they are responsive and exhaust themselves catering to a child’s every whim, those same children show no evidence that their mental health is improved and considerable evidence that they are less resiliant, less capable of handling disappointment and less able to cope with the demands of adulthood.

So who has benefited?

Natural parenting experts and no one else.

The lactation profession is the paradigmatic example. Prior to the 1990’s if you needed help with breastfeeding, you could consult a La Leche League volunteer. But that was a matter of your discretion; you sought help and support only if you felt you needed it and wanted it. No one was getting paid for providing breastfeeding advice.

Now breastfeeding is a multibillion dollar business with lactation professionals providing breastfeeding advice for money whether you want it or not. The Baby Friendly Hospital Initiative, to my knowledge the only private group that is allowed to operate within hospitals, has forced hospitals to promote breastfeeding and demonize formula feeding, pacifiers and well baby nurseries. They have whipped up hysteria about breastfeeding rates as if breastfeeding rates had anything to do with infant health. Thus far NONE of the claimed benefits of increasing breastfeeding rates has been realized and the only obvious health impact has been making some babies suffer starvation related brain injuries and deaths … and making mothers suffer guilt if they can’t or don’t want to breastfeed.

The ultimate irony is that there is nothing natural about natural mothering.

Can you imagine an indigenous woman refusing pain relief in labor if it were available? That would be unnatural.

Can you imagine a prehistoric foremother refusing a C-section that might save her baby’s life? That would be unnatural.

Can you imagine a woman in a developing country letting her baby die of dehydration just so she could brag to her friends that nothing but breastmilk was allowed to touch her baby’s lips? That would be unnatural.

Can you imagine any mother from any age up to the present one refusing possible protection of her child from hemorrhage or infectious disease? That would be unnatural.

In truth mothers in nature, including many animal mothers, fight fiercely to give their offspring EVERY chance of survival. They also fight fiercely to protect themselves, recognizing that their ability to mother is critical to their baby’s survival.

My hope for 2019 is that we recognize that natural mothering is a cultural construct that has nothing to do with mothering in nature. May both mothers and obstetricians focus on maximizing maternal and child survival. I want to see the demise of the Baby Friendly Hospital Initiative; it’s only a matter of time before we stop sacrificing newborn brains and lives on the altar of breastfeeding. May anti-vaxxers recognize that they are victims of a massive effort on the part of charlatans to sell worthless services and products.

But most of all my hope for 2019 is a return to the philosophy of Dr. Spock, encouraging mothers to trust themselves and be kinder to themselves. May they stop trying to be letter-perfect in recapitulating an image of mothering in nature that never actually existed and concentrate on simply doing the best they can.

A tremendous amount of ink has been spilled by doctors, scientists and public health officials pondering the bizarre beliefs of anti-vaccine parents. How can they promote such obvious nonsense? Why don’t they respond to efforts to improve their knowledge base? Why can’t we get them to understand the risks they pose to society in general and their own children in particular?

Sadly, we’ve been asking the wrong questions because we have assumed that anti-vax beliefs are the result of scientific ignorance. While ignorance of immunology, science and statistics are necessary concomitants of anti-vax beliefs, they are not sufficient. The missing piece we have failed to consider is the rise of performative mothering.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Anti-vax advocacy is perhaps the acme of performative mothering. It only acquires meaning by being performed under the gaze of other mothers.[/pullquote]

What is performative mothering? As I explained over the past two days, a mother used to be something you were; now it’s something you do, hence the term “mothering.” And you do it under the gaze of other mothers, micro-branding yourself by your choices, and disseminating a carefully curated portrayal through social media, artlessly seeking validation through the “likes” of strangers.

Anti-vax advocacy is perhaps the acme of performative mothering. It only acquires meaning by being performed under the gaze of other mothers, especially those on social media. Indeed, in a country where vaccination rates are high, it has almost no meaning unless it is observed. Until recently herd immunity meant that most unvaccinated children would never be exposed to most childhood infectious diseases. Therefore, there was no obvious difference between vaccinated and unvaccinated children. The only observable difference was the preening of anti-vax mothers.

Anti-vax advocacy acquires further meaning by being performed under the gaze of pediatricians and other healthcare providers. Behavior is not transgressive unless it is demonstrated to authority figures, eliciting the delicious disgust that gives meaning to the act.

As Pru Hobson-West explains in ‘Trusting blindly can be the biggest risk of all’: organised resistance to childhood vaccination in the UK:

Clear dichotomies are constructed between blind faith and active resistance and uncritical following and critical thinking. Non-vaccinators or those who question aspects of vaccination policy are not described in terms of class, gender, location or politics, but are ‘free thinkers’ who have escaped from the disempowerment that is seen to characterise vaccination…

…[Anti-vaxxers] construct trust in others as passive and the easy option. Rather than trust in experts, the alternative scenario is of a parent who becomes the expert themselves, through a difficult process of personal education and empowerment…

Ironically, despite the collective derision for experts, anti-vax advocates depend heavily on pseudo-experts like Dr. Bob Sears and similar anti-vax charlatans. What distinguishes Dr. Sears from other pediatricians? It isn’t merely his flexible ethics that allow him to pander to anti-vaxxers for profit. Bob Sears is fluent in the language of performative motherhood.

Consider how anthropologist and certified professional midwife Melissa Cheyney describes homebirth in Reinscribing the Birthing Body: Homebirth as Ritual Performance:

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

Bob Sears understands that as a socially performed act of differentiation, anti-vax advocacy is constructed in opposition to dominant ways of protecting children.

Homebirth practices, thus, are not simply evidence based care strategies. They are intentionally manipulated rituals of technocratic subversion designed to reinscribe pregnant bodies and to reterritorialize childbirth spaces and authorities. For many, choosing to deliver at home is a ritualized act of “thick” resistance where participants actively appropriate, modify, and cocreate new meanings in childbirth.

Anti-vax, thus, is not an evidence based strategy to protect children. Bob Sears understands it is a ritual of technocratic subversion performed for the admiration and gratification of other mothers.

Bob Sears is fluent in the language of performative motherhood. To paraphrase Gallo and Cruz’s description of midwives:

Sears provides emotional support by sharing beliefs about the experience and by affirming the woman’s right to assign her own unique beliefs to vaccines. This seemingly simple service of association and presence is a critical social need in the context of anti-vax advocacy that depends on a shared cultural consensus for its significance.

As he notes in the final chapter of his book The Vaccine Book: Making the Right Decision for Your Child:

I’m sure you are trying to answer the question that is on every parent’s mind: What should I now do? How do you make the right choice for your child? I have offered you all the information you need to make this decision, but I have held back from actually telling you what to do. I want you to formulate your own decision without letting my opinion sway you one way or the other.

Whereupon he proceeds to give his opinion on an alternate vaccine schedule that has no basis in science but creates maximum scope for performative mothering. And he repeatedly panders to the pretentions of performative mothers.

Alternative vaccine schedules aren’t for everybody. It takes a lot of extra time, effort, and planning to follow them. In addition, some doctors will fight you if you try to “change the system.” …

You can’t walk into your appointment unprepared and ask your doctor to come up with an alternative schedule for you. There is only one standard schedule that doctors are trained to follow; working outside this schedule is foreign to most doctors. You must understand the diseases, feel comfortable with your knowledge of vaccines, and establish your own vaccine plan prior to seeing your doctor. The suggestions I offer in this chapter are a good place to start. If the doctor sees that you’ve thoroughly thought this through, he or she is much more likely to work with you.

Performative mothering is toxic for a host of reasons: it places women under tremendous pressure to perform for other mothers; it ignores the needs of the individual child in favor of the social approbation of the group, and — as in the case of anti-vax advocacy — it is dangerous, even deadly, for children.

Yesterday I wrote about the way that mothering has changed between fictional grandmother Myrna and her fictional granddaughter Mira.

Myrna assumed that her child would turn out fine without any special effort. Mira assumes her child will be a fat, unhappy, failure unless she interposes herself between him and the myriad risks she imagines he faces.

The ultimate irony is that while Mira imagines her grandmother as oblivious to high stakes of childrearing, Myrna managed to raise the happy successful adult that Mira dreams of creating with a massive amount of effort.

This difference reflects a fundamental change in the way that we view both risk and our reaction to it. Myrna was not unaware of the risks her child faced, but she didn’t believe that she could control them. Mira, on the other hand, is hyper-aware of the risks her child might face and believes that her primary purpose is to identify and manage those risks.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mira is a stylist of motherhood, selecting from parenting identities and practices to present a meticulously crafted mothering persona designed for gaze of other mothers.[/pullquote]

For example, Myrna fed her son John canned vegetables while Mira prepares Jace’s food herself from organic produce that she sources at specialty markets. Myrna did not know or worry about toxins; Mira is obsessed with protecting her child from toxins, including toxins that are purely imaginary.

But there is another critical difference between Myrna’s experience and Mira’s. The intervening half century has witnessed the rise of performative mothering. A mother used to be something you were; now it’s something you do, hence the term “mothering.” And you do it under the gaze of other mothers, micro-branding yourself by your choices, and disseminating a carefully curated portrayal through social media, artlessly seeking validation through the “likes” of strangers.

When it came to raising John, Myrna might have feared the judgments of her mother and mother-in-law but she did not particularly fear the judgment of her peers since they were all doing the same thing. Everyone went to the hospital to have a baby; everyone was unconscious at the moment of birth; everyone bottle fed. For better or for worse, there was incredible uniformity in parenting practices.

Mira, in contrast, faces not merely the judgment of her peers, but she actively submits herself to the judgment of the larger world by engaging on Facebook. Mira is a stylist of motherhood, selecting from parenting identities and practices to present a meticulously crafted mothering persona designed for the gaze of other mothers.

In theory Mira carefully choreographed the experience of Jace’s birth because unmedicated vaginal birth is “better” for the baby; in truth she choreographed it to demonstrate to other mothers that she is a “natural” mother. That’s why she was so devastated when her birth did not go according to plan.

In theory Mira starved her baby because breastfeeding is “better” than formula feeding; in truth she let Jace suffer to preserve her natural mothering “cred” in the view of other mothers.

In theory Mira has created a alternative vaccine schedule because it is “better” for Jace; in truth she consulted other mothers extensively in order to “perform” natural mothering for the delectation of her peers.

Moreover, Mira hired other professionals, like a midwife and a doula, who understood — and therefore reinforced — the notion of mothering as a performance staged for the gaze of other mothers.

As Markella Rutherford and Selina Gallo-Cruz explain in Great Expectations: Emotion as Central to the Experiential Consumption of Birth:

… [T]he midwife’s role is critical … because she is fluent in the alternative symbolic orientations to and understandings of natural birth … [She] also provides her association and emotional support either by sharing beliefs about the experience or by affirming the woman’s right to assign her own unique beliefs to birthing. This seemingly simple service of association and presence is a critical social need in the context of extraordinary experiences and rites of passage that depend a shared cultural consensus for their significance.

While a midwife may have a medical function in addition to her role in confirming the performative nature of birth, a doula has no function beyond the permformative aspect of birth. Women hire doulas for the primary purpose of relentlessly reminding them of the image they wish to craft and bolstering the imperative to perform when pain or exhaustion threaten the mother’s commitment to the performance. Toward that end relieving pain with an epidural is framed as “giving in” and a C-section is framed as a failure.

While a lactation consultant has a medical function in addition to confirming the performative nature of exclusive breastfeeding, she also serves as a goad to ignoring the suffering of both baby and mother in an effort to continue the performance. Simply hiring her protects the mother from the judgment of her peers since a lactation consultant can give her “permission” to supplement with formula or stop breastfeeding altogether on medical grounds.

The rise of performative mothering explains the distrust engendered between natural mothering advocates on the one hand and obstetricians and pediatricians on the other hand. Most obstetricians and pediatricians are not fluent in the requirements of performative motherhood and are therefore not supportive of sacrificing the baby’s health and wellbeing for the express purpose of crafting an image designed for consumption by other mothers.

In contrast, quacks and charlatans like Ina May Gaskin and Dr. Bob Sears are successful precisely because they are fluent in the language of performative motherhood and are willing to countenance and even bless anything, no matter how dangerous, in the pursuit of micro-branding and image curation.

Finally, the performative nature of contemporary motherhood requires fabricating an endless series of threats to children that can only be ameliorated by mothers.

Perinatal mortality, infant mortality, and child mortality are at historic lows. Vaccine preventable diseases have been nearly vanquished. Rates of sudden infant death syndrome are falling. Congenital defects like heart disease can be treated. Malnutrition and vitamin deficiencies are rare. Foods and medications are safer than ever because of government oversight.

In other words, while Mira worries far more about her child than Myrna did, the actual threats to Mira’s child are smaller than those that Myrna’s child faced. But you’d never know that if you are part of the natural parenting culture, where motherhood is performed as the management of a never ending series of risks.

The piece in yesterday’s New York Times, The Relentlessness of Modern Parenting, has generated 1000 comments and counting.

Parenthood in the United States has become much more demanding than it used to be.

Over just a couple of generations, parents have greatly increased the amount of time, attention and money they put into raising children. Mothers who juggle jobs outside the home spend just as much time tending their children as stay-at-home mothers did in the 1970s.

Why?

Parent” as a verb gained widespread use in the 1970s, which is also when parenting books exploded. The 1980s brought helicopter parenting, a movement to keep children safe from physical harm, spurred by high-profile child assaults and abductions (despite the fact that they were, and are, exceedingly rare). Intensive parenting was first described in the 1990s and 2000s by social scientists including Sharon Hays and Annette Lareau. It grew from a major shift in how people saw children. They began to be considered vulnerable and moldable — shaped by their early childhood experiences — an idea bolstered by advances in child development research.

I would argue that our major shift in outlook was not in how we see children, but in how we see mothers. For most of human history we have viewed mothers as nurturers who raise children. Today we see mothers as risk managers who raise future competitors in the marketplace. It’s the difference between fictional grandmother Myrna and her fictional granddaughter Mira.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We used to see mothers as nurturers; now we see them as risk managers.[/pullquote]

Myrna gave birth to her first child in the late 1950’s at the age of 22. Her granddaughter Mira gave birth to her first child in the late 2000’s at the age of 32.

Myrna had a baby because that is what one did within a year or so of marriage. She never thought to do otherwise and, in the absence of effective birth control, there wasn’t a great deal of choice about the matter. Mira worked hard at her career and delayed both marriage and childbearing to give priority to climbing the career ladder. Having used effective birth control for well over a decade, she deliberately chose to stop using it in order to conceive.

Myrna assumed that if she went to the doctor regularly throughout pregnancy and rigorously followed his advice, she could count on having a health baby. Her granddaughter Mira considers that attitude frighteningly blasé. Her grandmother had never worried about all the things that could go wrong and all the risks that must be managed. Mira controlled her food choices rigorously, avoided a myriad of foods that might harm her baby and possibly interfere with reaching his or her full intellectual potential. She had to be constantly on her guard.

When labor started, Myrna’s husband dropped her and her suitcase at the door of the maternity ward and reappeared after baby John had been born while Myrna was anesthetized and unaware of what was happening. Myrna may have worried about caring for a newborn, but she never worried for even a moment that her baby might not bond to her. Of course she was going to love her baby and her baby was going to love her.

Mira, in contrast, choreographed Jace’s birth with exquisite care with the help of her midwife and doula and then was devastated when it did not go according to plan. Had she harmed mother-child bonding by “giving in” to an epidural? Had she destroyed Jace’s microbiome by having a C-section thereby condemning him to be sickly? Only time would tell and Mira would have to be alert for the signs.

Myrna and baby John came home to a present from her in-laws: two weeks of a night nurse so she could rest and recover. She cracked open a can of formula powder, fed the baby as much as he wanted, and then put him to sleep in his crib. She didn’t do a single night feeding until the baby nurse left two weeks later by which point she was well on the road to recovering from the rigors of birth.

Mira, in contrast, could not sleep for more than 2 hours at a stretch until Jace was nearly 4 months old; even when she slept she didn’t sleep well since her baby was in her own bed beside her. At one point she was hallucinating from exhaustion, but what choice did she have? She had to breastfeed exclusively in order to protect Jace’s health and future intellectual potential. As a responsible mother she wasn’t going to let a drop of formula touch her infant’s lips.

Sadly she wasn’t producing enough milk to fully nourish her baby so she had to pump in between feedings to boost her supply. And because Jace remained hungry, he couldn’t settle and required hours of soothing each and every day.

Myrna never worried about any of that. Sure the relentless cycle of change diapers, feed, sleep was both boring and wearying, but she and her friends could commiserate. They were all doing exactly the same thing.

Every two months Myrna took her baby to the doctor so he could get his shots and his polio vaccine. She was so grateful to live in a time when infectious disease did not routinely kill babies. Mira, in contrast, spent countless hours researching vaccines by consulting with her mom friends on Facebook. There were so many decisions to be made about the choice and timing of vaccination. Obviously she wasn’t going to simply follow doctors’ recommendations. She presented her pediatrician with a modified vaccine schedule that the doctor was expected to follow.

Myrna’s doctor told her to start the baby on rice cereal at 4 months and that’s exactly what she did. Her son gradually progressed to eating little jars of Gerber puréed foods. Mira, in contrast, was determined to hold off on solid food until at least 6 months even though it became clear at 5 months that Jace was falling off his growth chart. When she did start him on solids she prepared everything herself from organic produce with no additives of any kind and served from bowls that were BPA free. There were so many toxins in the environment and she had to be on constant alert to protect her baby.

And so it went. John played outside in his backyard; Jace went to play groups. John watched television; Jace was only allowed screen time as a special treat. John had toy guns and cars; Jace started learning his alphabet and numbers at the age of 2.

John walked to and from elementary school and was allowed to play outside after school anywhere in the neighborhood; Jace’s mother drove him to school and then ferried him to various activities afterward. John built a model of the solar system by himself from styrofoam balls and coat hangers; Jace’s mom redid his first effort, deeming it unable to meet the high standards that might be required for future entry into a competitive private high school 5 years hence. John, Mira’s father, went to Harvard; it’s important to Mira that Jace go to Harvard, too and she will leave nothing to chance.

What’s the difference between Myrna and Mira?

Myrna assumed that her child would turn out fine without any special effort. Mira assumes her child will be a fat, unhappy, failure unless she interposes herself between him and the myriad risks she imagines he faces.

The ultimate irony is that while Mira imagines her grandmother as oblivious to high stakes of childrearing, Myrna managed to raise the happy successful adult that Mira dreams of creating with a massive amount of effort.

Children haven’t changed in the past 50 years, but mothers expectations of themselves have changed nearly beyond recognition.