Trust breasts?

It’s not the motto of the lactivist movement, but it could be. If breastfeeding advocates are sure of anything, they’re sure that breasts are the one organ system in the body that never, ever fails. In their view, if breastfeeding isn’t working for you and your baby, there are myriad possible reasons, but it is never the fault of your breasts.

Baby nursing for hours at a time yet still frantic with hunger and not gaining weight?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Don’t trust breasts. Trust women![/pullquote]

A reasonable person might conclude that you aren’t making enough breastmilk. But lactivists aren’t reasonable people. Since breasts are perfect, you surely have enough milk but:

• You are “misperceiving” the amount of breastmilk you are producing.
• You are ignorant of normal infant behavior. All babies cry like that.
• Babies don’t really need to gain steadily. You’re misled by the way that formula fed infants grow.

See, it’s all your head! Because you can trust breasts to work perfectly.

Except that it’s not all in your head. The scientific evidence shows that up to 15% of first time mothers don’t produce enough milk to fully nourish an infant in the early days.

So if you aren’t producing enough breastmilk, especially in the first few days before your milk comes in, a reasonable person might suggest small amounts of formula to tide your baby over, but lactivists aren’t reasonable people. Their “solution” it to flog your breasts and yourself more.

• You should just nurse more; breastfeeding depends on supply and demand.
• Pump in between nursing sessions; getting rest is not important.

See, you should just try harder! Because you can trust breasts to work perfectly.

Except that trying harder is not guaranteed to work. Breastfeeding may depend on supply and demand, but so does insulin production. In people with type I diabetes, the pancreas no longer responds to supply and demand as it should. Advising women whose babies are hungry and nursing constantly to just breastfeed or pump more is the equivalent of advising diabetics to just eat more sugar. If an organ is not producing optimally, stressing it more doesn’t work.

Experiencing excruciating pain while breastfeeding?

A reasonable person might conclude that having the force of a vacuum applied to the sensitive tissue of nipple and areola can be profoundly painful, especially early on, but breastfeeding advocates aren’t reasonable people. They’re sure that your pain is your fault!

• Adjust the baby’s latch. You must be putting him on the breast the wrong way.
• You aren’t getting enough proper support. If the previous generation had breastfed they would help you.
• Hire a lactation consultant. She will show you what you are doing wrong.

See, you must be doing it wrong! Because you can trust breasts to work perfectly.

Wait, what? The lactation consultant says that there is nothing wrong with the latch?

Well, then the baby must broken! Maybe he or she has a tongue tie.

While tongue tie can cause pain while breastfeeding, it is relatively uncommon and certainly never cut in nature. Though tongue tie surgery seems simple, it is quite painful for many babies, especially the repeated sweeping of the wound to prevent the tie from reforming during healing.

Think about how painful biting your tongue it; now imagine cutting it. A reasonable person might conclude pumping and bottle feeding, or formula feeding from a bottle were excellent alternatives to subjecting a baby to searing surgical pain, but lactivists aren’t reasonable people.

• He must have an anterior tongue tie. Cut it.
• She must have a posterior tongue tie. Cut that, too.
• Maybe it’s a lip tie. Just keep cutting.

See, it’s the baby’s fault, never the fault of your breasts!

Ready to give up on the painful, frustrating, exhausting process of breastfeeding because your child is starving? A reasonable person might sympathize with your suffering and recommend formula to alleviate it, but breastfeeding advocates aren’t reasonable people:

• You don’t care about your baby.
• Where did you get the idea that your pain, exhaustion and mental health matter? They don’t.
• Who says you need to return to work?
• You’re obviously a dupe of the formula industry.

Blame formula manufacturers! Blame capitalism! Blame society!

But whatever you do, don’t blame breasts because they’re perfect.

Ridiculous, right? But many women fall for it and end up feeling guilty, anguished and blaming themselves.

I have a better solution:

Don’t trust breasts; trust women.

You know whether breastfeeding is right for your baby and yourself. Don’t let breastfeeding advocates convince you otherwise.

Tobacco executives tried to convince people to ignore horror stories about lung cancer.

Car company executives tried to convince people to ignore the horror stories about exploding Pintos.

Pharmaceutical executives tried to convince people to ignore the horror stories about Vioxx.

Now lactation professionals are trying to convince people to ignore breastfeeding horror stories.

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

What Brown really means is: ignore breastfeeding horror stories. People share them without thinking of the consequences for ME!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When Brown tells you to ignore breastfeeding horror stories, she’s really telling you to ignore breastfeeding brain injuries and deaths. Don’t![/pullquote]

The tobacco executives, car company executives and pharmaceutical executives feared they would lose money, market share and status if people learned about the risks of their product, so they hid them. What’s a few dead people compared to their profitability? Brown and other lactation professionals fear they will lose money, market share and status if people learn the risks about their product — breastfeeding — so they hide them. What’s a few dead and brain damaged babies compared to their profits and prestige?

Make no mistake, when Brown tells you to ignore breastfeeding horror stories, she’s really telling you to ignore breastfeeding deaths, brain injuries, neonatal and maternal suffering.

She wants you to ignore Christie del Castillo-Hegyi’s horror story of her son who sustained permanent brain injuries from dehydration due to insufficient breastmilk.

She wants you to ignore Monica Thompson’s horror story of suffocating her daughter to death in her hospital bed trying to breastfeed.

She wants you to ignore Jillian Johnson’s horror story of losing her son to profound dehydration 12 hours after leaving the hospital which had assured her that her baby was receiving enough breastmilk.

She wants you to ignore the fact that the scientific literature is burgeoning with papers* detailing the high rate of insufficient breastmilk especially in the early days after birth (up to 15% of first time mothers) and the brain-threatening, life-threatening consequences. We are experiencing a dramatic increase in neonatal hypernatremic dehydration, hypoglycemia and kernicterus (severe jaundice). Exclusive breastfeeding is associated with tens of thousands of newborn hospital readmissions per year at a cost of hundreds of millions of dollars.

Brown, like other breastfeeding professionals, fears that mothers will learn the single most important fact about breastfeeding: like pregnancy, it has risks as well as benefits.

She and they are terrified of the impact of the Fed Is Best Foundation:

The Fed Is Best Foundation is a non-profit, volunteer organization of health professionals and parents who study the scientific literature on infant feeding and real-life infant feeding experiences of mothers through clinical practice and social media connections. We work to identify dangerous gaps in current breastfeeding protocols, guidelines, and education programs, and provide families and health professionals the most up-to-date scientific research, education and resources to practice safe infant feeding with breast milk, formula, or a combination of both. We provide safe, brain-protective infant feeding education for breastfeeding, mixed-feeding, formula-feeding, pumped-milk-feeding and tube-feeding mothers and families to prevent feeding complications to babies that have become too common in today’s “Breast is Best” world.

Breastfeeding professionals treat Fed Is Best like Voldemort: it’s the organization that must not be named!

They strive to diminish it by labeling it a social media campaign, refusing to acknowledge its 501(c)3 charitable status, its physician advisers and its tremendous resonance with ordinary mothers (its Facebook membership exceeds La Leche League).

That lactivist terror is expressed in the most recent issue of Clinical Lactation devoted to breastfeeding’s “bad press”:

Over the past few years, we have seen a distinct risk in social media campaigns that have claimed that breastfeeding harms babies. The gist of these campaigns is that we should focus on the fact that babies are fed, not on how they are fed …

In this special issue, we want to equip you to address the challenges presented by these negative social media campaigns …

It is replete with articles like these:

Debunking the Misunderstandings of the Baby-Friendly Hospital Initiative and Designation Requirements

Sensational headlines and messages surrounding breastfeeding in the media are leaving the public confused. There are also myths being circulated about the Baby-Friendly Hospital Initiative (BFHI) that are causing some to question the value and safety of its practices.

The False and the Furious by Kimberly Seals-Allers

…Negative social media campaigns have highlighted the “dangers” of breastfeeding and used extremist language to brand breastfeeding supporters. This article suggests some specific strategies for addressing gaps in our current system and countering the negative information…

Is Exclusive Breastfeeding Dangerous? By Marsha Walker

Social media has been alight with descriptions of exclusive breastfeeding being dangerous, resulting in significant and severe negative outcomes in infants whose mothers wished to breastfeed. This backlash has been led by a campaign that uses inflammatory anecdotes and misleading and inaccurate interpretation of research to bolster its assault on breastfeeding…

What Do Women Lose if They Are Prevented From Meeting Their Breastfeeding Goals? by Amy Brown:

Many women stop breastfeeding before they are ready, often leading to feelings of anxiety, guilt, and anger. Critics of breastfeeding promotion blame breastfeeding advocates for this impact, claiming that if the focus were merely on feeding the baby, with all methods equally valued and supported, maternal mental health would be protected. Established health impacts of infant feeding aside, this argument fails to account for the importance of maternal breastfeeding goals, or the physical and emotional rewards breastfeeding can bring…

Amy Brown bemoaning breastfeeding disappointment is like the fashion industry bemoaning negative body image.

Pious concern for women’s feelings is difficult to take seriously when it comes from the very people who make women feel anxious, guilty and anguished for failure to breastfeed. In the case of the fashion industry, idealized representations of the female body lead to self hatred when women’s bodies don’t meet the fashion industry norm. In the case of the breastfeeding industry, idealized representations of breastfeeding lead to self hatred when women’s bodies don’t meet the breastfeeding norm.

Professional lactivists are right about one thing, though. The Fed Is Best campaign is making tremendous headway against the breastfeeding industry refusal to acknowledge the risks of breastfeeding.

Unfortunately, as the special issue of Clinical Lactation illustrates, lactivists are still missing the point. Instead of publishing a special issue about publicity around breastfeeding injuries and deaths, they could have published a special issue about preventing breastfeeding injuries and deaths. But that would involve caring about babies more than profits, something that appears beyond them.

Instead, like the tobacco executives, car company executives and pharmaceutical executives before them, they will just tell people to ignore the horror stories while they ignore them, too.

 

* Recent publications:

• United States Preventive Services Task Force (USPSTF) guidelines
• Interventions Intended to Support Breastfeeding: Updated Assessment of Benefits and Harms
• Unintended Consequences of Current Breastfeeding Initiatives
• The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature
• Health Care Utilization in the First Month After Birth and Its Relationship to Newborn Weight Loss and Method of Feeding
• The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial

Yesterday I wrote about the new JAMA review of the World Health Organization’s Baby Friendly Hospital Initiative.

I reported that although the review is couched in careful language, the conclusions are devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.

I noted that the review suggest that the BFHI has changed its definition of “exclusive breastfeeding.”

[The Institutional Guidance] national monitoring definition of exclusive breastfeeding is now receiving “only breastmilk during the previous day.”

I was startled by this claim since the breastfeeding professionals at the WHO had already gone on record that babies who are injured and die because of insufficient breastmilk are not a priority:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s still business as usual at the BFHI where the babies who suffer, are brain-injured and die from insufficient breastmilk are not a top priority.[/pullquote]

When asked whether WHO plans to inform mothers of the risks of brain injury from insufficient breast milk, and that temporary supplementation can prevent complications, Dr. Rollins responded that this recommendation was not identified as a “top priority.”

Therefore, I was especially heartened by this purported change since it would be both brain- and life- saving. It would be an acknowledgement that early judicious formula supplementation not only saves lives, but it doesn’t harm breastfeeding, and it would make it possible for women who supplemented babies before their milk came in to still claim they were exclusively breastfeeding.

This change would reduce the number babies who suffered brain injuries and died because of the breastfeeding profession’s reflexive demonization of early formula supplementation. It would alleviate the suffering of hundreds of thousands of babies who endure desperate hunger in their early days because the BFHI has substituted lactivists’ personal beliefs and wishful thinking for scientific evidence.

Alas, in carefully examining the multiple documents that were cited in the review, I can find no evidence that the BFHI has changed its definition at all.

Indeed, the current World Health Organization definition of exclusive breastfeeding is:

Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or solids are given – not even water – with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines.

As far as I can determine, in the hundreds of pages of both evidence and guidance documentation, there is only one instance of exclusive breastfeeding being defined as only breastmilk in the previous day. That occurs in a chart in Protecting, promoting and supporting BREASTFEEDING IN FACILITIES providing maternity and newborn services:

This chart illustrates the impact of additional foods or fluids at 3 months of age on breastfeeding. Exclusive breastfeeding is mentioned more than 100 times through the document but this is the only use of the purportedly revised definition that I could find.

Like many of the charts and analyses in the document, it tracks the impact of various interventions on breastfeeding, NOT on babies. It’s almost as if the BFHI cares more about promoting breastfeeding than whether babies live or die!

As far as I can determine (feel free to correct me if you find evidence otherwise), there has been NO change in the definition of exclusive breastfeeding, NO recognition of the widespread prevalence of insufficient breastmilk (up to 15% of first time mothers in the early days of breastfeeding), NO acknowledgement of the suffering, brain injuries and deaths due to insufficient breastmilk, not to mention the literally tens of thousands of newborn hospital readmissions that result.

It’s still business as usual at the BFHI where the babies who suffer, are brain-injured and die from insufficient breastmilk are not a top priority.

Last week I noted that the editor of premier breastfeeding journal declared that it is time for a critical review of the Baby Friendly Hospital Initiative and its Ten Steps.

The editor’s key point:

What is needed in my opinion is not a rigid categorical defense of a magic (holy?) 10 but an intellectually rigid evaluation of the individual steps and their possible various combinations (not necessarily of all 10) that are both safe and efficacious.

Perhaps he was thinking about a new evaluation of the BFHI guidelines that was just published in the Journal of the American Medical Association. The JAMA Network has produced a Clinical Guideline Synopsis of World Health Organization Baby-Friendly Hospital Initiative Guideline and 2018 Implementation Guidance.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The review is couched in careful language, the conclusions devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.[/pullquote]

The review notes three major revisions in the evidence guidelines [EG]:

1. Recommendations around skin to skin care

The benefit of early skin-to-skin care (SSC) for glucose homeostasis (blood glucose level at 75-100 minutes after birth: meaningful difference, 10.49 mg/dL … 95% CI, 8.39-12.59), thermoregulation (a slight increase in axillary temperature at 90-150 minutes after birth: meaningful difference, 0.30°C; 95% CI, 0.13-0.47), and any breastfeeding at age 1 to 4 months (relative risk [RR], 1.24; 95% CI, 1.07-1.43) was cited. The EG recognizes the potential for sudden infant collapse during unobserved SSC in the first 2 hours of life, citing rates of 1.6 to 5 cases per 100 000 live births with mortality rates of 0 to 1.1 per 100000 livebirths. This is addressed by a recommendation for close observation for at least the first 2 hours after delivery coupled with vigilance to assess and manage signs of distress and prevent the infant from being hurt unintentionally.

Previous BFHI guidelines recommended continuing the practice of SSC throughout the hospital stay while rooming-in. As there are no studies that specifically demonstrate that SSC confers benefits beyond the early hours of life in term newborns, this practice, when coupled with rigid compliance with breastfeeding exclusivity, has raised safety concerns about unmonitored SSC, particularly overnight by an exhausted or sedated mother. The new guideline focuses on immediate (within 10 minutes of birth) and early SSC (10 minutes-23 hours) without explicitly advocating for ongoing SSC beyond that time. It notes the need for safety vigilance during SSC and that hospital resources may be inadequate to safely perform the task beyond the immediate period. The EG also notes that while there are many benefits to rooming-in, many mothers prefer not to and rooming-in “probably makes little to no difference to any breastfeeding at 6 months”.

Take home messages:

• There is no evidence of benefit of skin-to-skin in term babies beyond the early hours.
• Even those benefits are trivial.
• Unmonitored SSC increases the risk of neonatal death.
• Rooming in makes essentially no difference to breastfeeding at 6 months.

2. Formula supplementation

While supportive of breastfeeding exclusivity, the IG [Implementation Guidance] recognizes that supplementation may be necessary for some infants because of inadequate milk supply and maternal choice. The IG mentions the need for vigilance for the risk for late preterm newborns of jaundice, hypoglycemia, and feeding problems. The EG also cites a Cochrane review of randomized controlled trials demonstrating that “addition of artificial milk in the first few days after birth probably makes little or no difference to the success and duration of breastfeeding at discharge” (RR, 1.02; 95% CI, 0.97-1.08) and the IG national monitoring definition of exclusive breastfeeding is now receiving “only breastmilk during the previous day.” A recommendation was also added to provide donor milk to healthy full-term newborns who required supplementation without providing cost-benefit evidence to support this practice in term infants.

Take home messages:

• Formula use may be necessary because of inadequate milk supply.
• There is no evidence that judicious formula use in the first few days has any impact on breastfeeding.
• There is no evidence to support a recommendation of donor breast milk for term infants.

3. Pacifier use

Consistent with evidence that pacifiers reduce the risk of sudden infant death syndrome (SIDS) and high-QOE that pacifiers do not interfere with breastfeeding outcomes, the draft IG had pro- posed eliminating pacifier restrictions. Despite evidence that mothers value using pacifiers, this change was not included in the final IG. Instead, advice to counsel mothers about hygiene risks was added without mentioning the reduced risk of SIDS associated with pacifier use.

Take home messages:

• Pacifiers prevent SIDS.
• Pacifiers do not interfere with breastfeeding.
• The new guidance ignores this scientific evidence.

The authors note that the BFHI is not the only way or even the best way to support breastfeeding:

Institutional and public health clinicians should consider using the EG to develop their own policies whenever a specific recommendation in the IG is inconsistent with evidence or does not seem applicable to local circumstances.

A notable shift of emphasis that will foster local innovation is the IG conclusion that BFHI designation is not the only worthy public policy option for breast feeding support. Consistent with the US Preventative Services Task Force evidence report, the draft for public comment stated “While the designation of baby-friendly is one way to recognize facilities that provide appropriate care, designation is not the most effective strategy to achieve sustainable improvement in the quality of maternity care.”

Though the review is couched in careful language, the conclusions are devastating: the BFHI ignores the scientific evidence, risks babies’ lives and isn’t even particularly effective.

Earlier this week I wrote about the new GateHouse Media expose of homebirth midwifery, Failure to Deliver. It features many tragic stories about preventable infant death including the tale of homebirth midwife Christy Collins. After repeatedly ignoring Danielle Yeager’s serious pregnancy complications — more than 2 weeks past her due date and no amniotic fluid:

Collins took the Doppler wand and placed it on Yeager’s belly, moving it around until they could hear the whoosh-whoosh-whoosh of the heart.

It sounded different this time. Slow. Dangerously slow. A number appeared on the monitor: 90 beats per minute. Not the normal, healthy fetal heart rate of 120-160 bpm.

“At that point, I said, ‘We need to go,’” Brooks [the baby’s father] recalled.

Although they were in a clinic connected to Spring Valley Hospital near the heart of Las Vegas, Collins instructed them to meet her at Centennial Hills Hospital, more than 16 miles north. It’s about a half-hour trek.

By the time Yeager arrived at the other hospital, it was too late. Despite an emergency C-section and extensive neonatal resuscitation efforts, baby Gavin Michael was dead.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Even among homebirth midwives who routinely lie about their role in preventable deaths, Christy Collins stands out.[/pullquote]

There are two things that make the story of Christy Collins particularly damning: 1. She had been prohibited from practicing midwifery in California so she simply moved to another state. 2. Nearly every claim she made to Gatehouse Media was shown — through texts, recollections of the parents, and recollections of the medical professionals — to be a lie.

Now her husband Chuck is publicly lying on her behalf.

I remember the anguish, the confusion as to why her client, someone that Christy had grown close to, had refused to be seen by specialists after an abdominal assault incident. Or the car accident, or bleeding that followed. It was obvious that the client did not trust the medical community, but Christy did, and gave every chance short of force to make that happen. Multiple ultrasounds, a cancelled perinatologist appointment by the client who accused my wife of trying to subject her to ‘the dead baby flag,’ refusals of hospital induction, refusal to stay at the hospital, and blaming my wife’s urgency for putting stress and pressure on her, as she believed it was preventing her from going into labor. Many other parts of her care were above and beyond a typical client of Christy’s, not just because it was needed, but because the client declined a higher level of monitoring. There were no statutes in that state protecting a midwife from abandonment charges after 36 weeks if the care of a noncompliant client was dropped or transferred. I remember Christy staying in the hospital room after the passing for many many hours, making sure those parents knew their son, helping them cope in the days that followed. In the week that followed (something else missing in your reporting), the client had told my wife that the reason she kept saying she wanted more time was because she KNEW. She knew something was wrong and she wanted more time with her baby while he was still alive. It seems nearly impossible that ANY mother wouldn’t immediately jump into action if their midwife told them that their baby needed to come out. It doesn’t make sense. When the client’s mother found out about California in the weeks that followed, she even went as far to try and have Christy arraigned again for practicing in Nevada. Christy again, had to appear in court only to be told by the judge what she had already been legally advised, that her practice in Nevada was NOT in violation of any part of her legal issue in California.

I suppose if you are committed to lying, it hardly makes sense to worry about how monstrous the lies are, but it does make sense to worry about the existence of documentary evidence proving that it is a monstrous lie. And I have that documentary evidence. I was the one who originally reported the tragedy of Gavin Michael’s preventable death and identified Christy Collins as the midwife responsible.

It wasn’t that hard after Collins crowd sourced Yeager’s complications on Facebook, asking Jan Tritten, the editor of Midwifery Today to solicit advice from other homebirth midwives:

…[W]hat do we truly feel are the risks compared to a woman whose water has been broken and so baby/cord has no cushion there either. Cord compression only? True possibility of placenta being done although it looks good? Can anyone share stories/opinions? …

Do you see any evidence that Collins was trying to convince Yeager to go to the hospital immediately? Me, neither.

In the wake of Gavin Michael’s death, Collins immediately took to social media to share the midwife’s story without acknowledging that SHE was the midwife:

The midwife was ON TOP OF THIS SITUATION

I asked Christy on her own Facebook page whether she was the primary midwife in the case. She lied:

No, I’m not, but enough details had been passed around to select midwives to realize it was not what got created on Jan’s page, and it was NOT Jan. Someone needed to say something …

I asked for the identity of the midwife and Christy lied again.

I’m sorry, you know I can’t do that. Coming to the defense of others is something I will do if I feel that their actions were defensible. With what I have heard, and with what others posted, they were. It was presented by the midwife poorly, but the actions taken up to that point and past appear to have been within OB protocol …

Chuck is now lying when he says that Christy repeatedly urged Danielle to go to the hospital. How do I know? Back in 2014 I quoted the text that Christy sent to Danielle on the day after the baby’s death. In it she acknowledges that she actually advised Danielle to ignore the perinatologist who warned that the baby might die.

I wish I could go back in time, and have said stronger words – enough to make you hate me, and fell you had no choice but to go into the hospital the day before. I could’ve lived with you hating me, over this feeling of devastation.

I know we say that we don’t know if it would’ve been any different; maybe he would’ve been very sick, but alive. I don’t know. But I wish I wouldn’t pushed much hard and said the things that we never want to hear the ‘experts’ say…

Instead of … telling you to “be prepared that the perinatologist doing the NST is likely to tell you that your baby could die if he doesn’t come out;” those should have been MY words. You might have been really pissed at me for pushing you into a corner where you felt you didn’t have a choice, but … I wouldn’t care… I am angry at myself for being the midwife who tried to be as firm but gentle as possible when advising to go in when I could’ve waved the dead baby flag…

I wanted so badly to see a change in fluid … while you just wanted time/space to think … If I hadn’t agreed, and used the words “your baby could die because of this …”, maybe he would still be here…

Back in 2014 Christy told Danielle that she blamed herself for the baby’s death:

I blame me. I would rather have you hate me for pushing you harder into a bad birth experience … so you could hold a live baby instead.

Midwifery implies choices. Informed consent. Informed refusal. No woman would refuse an induction if she knew what having a dead baby felt like. In the future, I’ll pressure until my client hates me. I won’t care.

She promised she would learn from her role in Gavin Michael’s preventable death, but, of course, she lied about that, too.

I’ve argued repeatedly in the past that aggressive breastfeeding promotion in general and the Baby Friendly Hospital Initiative in particular are scientific failures. They ignore the scientific evidence in favor of the personal beliefs of lactation professionals — exaggerating the benefits of breastfeeding, hiding the risks (dehydration, jaundice, brain injures and deaths) and demonizing pacifiers and judicious formula supplementation as harmful when in fact they are lifesaving.

But aggressive breastfeeding promotion, particularly the Baby Friendly Hospital Initiative is also a moral failure. A new paper in Current Sociology, Social roles and alienation: Breastfeeding promotion and early motherhood, explains:

…The article argues that the effort to rigidly impose a moral code as the role [of mothering] is taken on has potentially alienating effects, as it limits the scope for the agent to appropriate and identify with it. An approach to health promotion which instead trusts women to exercise situated moral judgement about infant care, rather than subjecting them to an externally imposed moral code, would reduce the emotional strain and potential for alienation in early motherhood.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Baby Friendly Hospital Initiative treats women not as ethically valuable in themselves but instead as the means for achieving breastfeeding targets.[/pullquote]

Our views about motherhood have recently undergone substantial change:

Motherhood has undergone significant transformation in recent decades, as the expectation of individual autonomy has reshaped gender and family life. Women now expect to become mothers not because of biological destiny, coercion, or social duty, but instead as an aspect of a self-directed life. Motherhood is expected to be taken on only when it is understood as integral to the agent’s realization of her intentions and values.

At the same time, the practices of mothering, particularly in the early stages, have become the focus of intense public interest. Cultural ambiguity about the value of full-time mothering has shifted public debates away from the question of whether mothers should engage in paid employment at all, to a focus on the quality of maternal caregiving.

As a result:

Time-intensive mothering practices, especially breastfeeding, have become an important focus of status claims for both stay-at-home and employed mothers.

Ironically, at the same moment that women have been freed from the expectation to have children for no better reason than because it is their biological destiny and therefore must be best, women who choose to have children are still prisoners of the expectation they will breastfeed because it is their biological destiny and therefore must be best.

It’s hardly surprising then that so many good mothers feel so bad about breastfeeding:

Breastfeeding tends to be experienced as emotionally intense, in positive and negative ways. Sustained breastfeeding is generally understood to depend on self-control, in the form of maternal self-sacrifice and concentrated effort, if it is to be ‘successful’. Most women are fully aware of the message that ‘breast is best’, but tend to act in ways which take account of various other considerations.

Then they are shamed for daring to take other considerations into account.

The expectation that good mothers will breastfeed is a feature of the Baby Friendly Initiative. This is a programme for promoting breastfeeding as ‘the golden standard of care’ in maternity centres and amongst health professionals caring for mothers and infants following birth…

Women have not been imagined as decision-makers in this initiative, but instead as passive recipients of information, training and support.

That is a serious moral defect:

Health promotion strategies like this tend to assume that target populations are likely to comply with moral pressure. Such behaviourist expectations take little account of human agency, autonomy, or the indeterminacy of the social world… Such utilitarianism treats agents not as ethically valuable in themselves but instead as the means for achieving public health targets.

In other words, women are treated as objects to be acted upon, not as individuals capable of making their own decisions.

What’s the harm?

When pressure is brought to bear on women to breastfeed in the first hours, days and weeks after giving birth, the role becomes rigidly defined. This undermines agency, the ability to ‘take and make’ motherhood, developing some command over the role through interpretation and improvisation.

That accounts for the plethora of recent articles in which women detail how they and their babies suffered under pressure to breastfeed. It also accounts for the popularity of the Fed Is Best movement; not only is being fully fed with formula better for babies than starving on breastmilk, using formula to ease the stress of new motherhood is better for mothers than struggling to breastfeed.

Even breastfeeding professionals have been forced to address women’s suffering, but sadly they interpret it through the lens of breastfeeding promotion. They’ve defined breastfeeding “trauma” as the disappointment of being unable to breastfeed when the reality is that breastfeeding trauma is a result of treating women as merely the means to reach breastfeeding targets, instead of compassionately as individuals with their own needs, desires and moral agency.

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

It took 40 years from the time that Heliobacter pylori was identified as the cause of stomach ulcers for doctors to acknowledge it. That’s because the conventional wisdom was that acid caused stomach ulcers and the conventional wisdom was so deeply entrenched (entire careers had been staked upon it) and people with ulcers, denied effective treatment, died as a result.

Today’s conventional wisdom is that breastfeeding has major health benefits and that promoting it aggressively through the Ten Steps of The Baby Friendly Hospital Initiative (BFHI) is the key to improving infant health. It has been the conventional wisdom for nearly 30 years despite the fact that there is little evidence that breastfeeding has major health benefits for term babies, copious evidence that aggressive breastfeeding promotion has major risks and no evidence that the BFHI even works in improving breastfeeding rates.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”[T]he 10 steps should not be treated as the equivalent of the Ten Commandments …”[/pullquote]

No matter. Entire careers, indeed an entire profession (lactation consultant) have been staked upon promoting the Ten Steps of the BFHI.

That’s why it is remarkable to see Arthur I Eidelman, the editor of the premier breastfeeding journal Breastfeeding Medicine, highlight the need for review of the BFHI in general and the Ten Steps in particular.

I find the author’s use of scare quotes particularly telling:

One cannot argue with the recent “success” of the Baby-Friendly Hospital Initiative (BFHI) that was established in 1992 in response to a call to action for support of breastfeeding by the 45th World Health Assembly…

In 2011, in only two states was there >20% BFHI penetration. In 20 states there were no Baby-Friendly facilities. Seven years later, in 2018, 40% of the birthing facilities in 12 states were certified as Baby-Friendly. Most striking, >1 million births (roughly 25%) of the annual US birth cohort were taking place in such facilities…

But recent studies do not support claims of either safety or effectiveness of the BFHI.

Eidelman does not necessarily agree, but:

Careful reading of the two recent reviews confirms that the authors are demanding the same standards of evidence thatare required for any other care plan, procedure, or medication. What they are more than implying is that the 10 steps should not be treated as the equivalent of the Ten Com-
mandments that were chiseled in stone at Mount Sinai and that each of the steps be evaluated separately for evidence-based conclusions.

He notes:

In fact the WHO itself has acknowledged this and recently published a revised set of guidelines for the 10 steps, modifying among other things its previous restrictive policy as to the use of pacifiers, bottles, and teats.

Although he neglects to mention that these restrictions were put in place without any evidence to back them and have resulted in significant suffering for babies and mothers.

His conclusion is powerful nonetheless:

What is needed in my opinion is not a rigid categorical defense of a magic (holy?) 10 but an intellectually rigid evaluation of the individual steps and their possible various combinations (not necessarily of all 10) that are both safe and efficacious.

There is one issue, though, on which I strongly disagree. Eidelman insists:

The measure of success of any initiative should not be the number of certified institutions per se but the actual breastfeeding rates that will meet our healthy people objectives.

Actually it should be neither since both are measure of process, not outcome. The measure of success of any public health initiative is improvement in health OUTCOMES such as reduction of deaths, reduction of illness and reduction of healthcare spending.

The BFHI and the Ten Steps have been around for nearly 30 years, and with the exception of premature infants, they’ve been unable to demonstrate any improvement in health outcomes at all.

That should be a glaring signal that the conventional wisdom about breastfeeding is wrong.

Is there medical professional more devoid of ethics, morality and simple human compassion than a midwife who ignores dead babies?

I doubt it, but Ginger Breedlove, CNM, former president of the American College of Nurse Midwives, appears willing to ignore all three when her profits and those of other birth workers are at stake.

Breedlove has produced what she imagines is a riposte to Gatehouse Media’s incredible expose of American homebirth midwives (CPMs, LMs), Failure to Deliver. Instead she confirms what seems to me to be its central contention: babies are dying as a result of substandard midwifery care and the midwifery leadership can’t be bothered to give a damn.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Breedlove tries to bury dead babies twice, first in tiny coffins and then by refusing to acknowledge that they lived and died.[/pullquote]

The central characters in Failure to Deliver are the babies who died. Their lives and preventable deaths are engraved on the hearts of their bereaved parents. In a 600 word rant, Breedlove doesn’t mention the babies even once! Instead, like many homebirth advocates and midwifery leaders Breedlove attempts to bury dead babies twice, first in tiny coffins and then by trying to expunge their existence from public consciousness.

Yesterday, in writing about Failure to Deliver, I identified some of the tactics homebirth midwives use to mislead consumers. Today, Breedlove demonstrates them.

She starts with the bait and switch:

I submit we would NOT see this type of clear attack on midwives and birth centers in ANY other high-income country where midwives have worked for decades, in all settings, with far better outcomes while delivering far more babies than their OB counterparts.

Duh! The most important revelation in Failure to Deliver is that homebirth midwives (CPMs, LMs) don’t meet the standards of midwives in ANY other high income country, but try to trade on the achievements of those other midwives. Homebirth midwives seek to confuse consumers about this second, substandard class of midwives, and Breedlove continues the deliberate deception.

She includes the classic midwifery red herrings:

WHY NOW? When we are battling the highest rate of maternal mortality in over 20 years, untenable inequities for black and brown communities in receipt of comprehensive maternity care, the battle over respectful maternity care and realities of consumer choice?

Maternal mortality has risen because women are dying for LACK of high tech interventions, the very interventions that midwives don’t provide. Untenable inequities for black and brown communities? Indeed, the number of black and brown midwives is tiny. Perhaps midwives ought to look to their own glass house before throwing stones.

Breedlove rails against fear:

ANY news that begins with emergency 911 recordings is intentionally designed to evoke fear in the readership. For me, it leads with an intentional set up as a page turner that keeps you on the edge of your seat, and ends with provoking the same reader emotions – FEAR.

But why shouldn’t we fear the preventable deaths of babies? Oh, right, because it would hurt the incomes of midwives and what’s a few dead babies compared to midwife profit?

Again and again Breedlove ignores the dead babies to focus on midwives:

As we work at #GrowMidwives to advance the Midwifery profession among many stakeholders including hospitals, physicians, midwives and consumers, it is quite frustrating to have to sort out fact from fiction, misuse of titles, and a void of comparison to hospital birth with similar populations including relative risk data.

I can’t begin to imagine how Breedlove believes her “frustration” is more important than the preventable deaths of babies and the shattered lives of their parents, but apparently she does.

She has papers!

We have numerous studies to counter some of the cited associations made in the article about home birth and birth center birth.

So what! The tobacco companies had numerous studies to counter the association between tobacco and lung cancer. That didn’t make them true.

There is absolutely no question that CPMs and LMs have neonatal death rates triple (or more) death rates from comparable risk hospital birth. What does Breedlove plan to do about that? Absolutely nothing!

Ethical medical professionals put the wellbeing of their patients first. Not Breedlove:

And, #GrowMidwives will continue to help #GrowConsumers and others who see the value in full integration of Midwives in this country.

In the meantime, the rest of us will continue to work tirelessly to see the value in live, healthy babies and mothers. And we will continue to marvel and mourn the fact that enablers like Breedlove don’t give a damn and keep burying dead babies twice.

Breedlove should be ashamed of herself, but that would require both ethics and insight and apparently she has neither.

It’s hard to become a real midwife.

American certified nurse midwives (CNMs) are the best educated, best trained midwives in the world. They have an undergraduate degree in nursing, a master’s degree in midwifery, and extensive hospital training in diagnosing and managing birth complications. European, Canadian and Australian midwives are also well educated and well trained; they have an undergraduate degree in midwifery and extensive hospital training in diagnosing and managing birth complications. In addition, American, European, Canadian and Australian midwives meet the International Confederation of Midwifery (ICM) Global Standards.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]No one should be allowed to call herself a midwife unless she meets the International Confederation of Midwifery Global Standards.[/pullquote]

But what if you couldn’t be bothered (or couldn’t handle) the necessary preparation to meet the ICM Global Standards but wanted to masquerade as a midwife anyway? You could take a correspondence course, attend a few dozen deliveries outside the hospital, pay money for an exam and you are a “certified professional midwife” (CPM). Actually, you don’t even have to complete even those minimal requirements. You can simply submit a “portfolio” of births that you have attended, pay the money and take the exam, and voila, you too are a CPM.

What would happen in a system where consumers couldn’t tell the difference between real midwives and lay people who awarded themselves the bogus CPM credential?

You don’t have to imagine. In a stunning journalistic review, Failure to Deliver, reporters Emily Le Coz, Josh Salman and Lucille Sherman, have produced a comprehensive look at the deadly failure of American homebirth midwifery.

The review is deep, wide ranging and involved dozens of professionals as well as grieving families and I encourage everyone to read every word. But, in truth, the entire review can be summed up in one sentence:

When you allow lay people who can’t meet the Global Standards of Midwifery to masquerade as midwives, babies and mothers die of medical neglect.

The stories are gut wrenching:

Baby Aquila never took a breath.

Her limp body slipped from between her mother’s legs in a river of blood during a Texas home birth in December 2009. The certified professional midwife, who missed a cascade of earlier indications of the baby’s distress, tried to save the girl. But she had locked her medical kit in the car and had to improvise…

Liz Paparella buried her daughter two days before Christmas.

And:

The laboring mom didn’t know her son was breech when she checked into Gentle Birth Options, a freestanding birth center in the Florida Panhandle community of Niceville. Riley trusted the midwife to guide her through the process.

But Cynthia Denbow, a certified nurse midwife and birth center owner, didn’t check the baby for more than an hour. By the time she discovered its bottom-first position, Riley was fully dilated and ready to push, according to Florida Department of Health records D…

Denbow called no physician. She encouraged Riley to stay at the birth center and push.

Riley did so for 22 minutes, as her unborn son went into distress and Denbow finally called 911. Doctors at Fort Walton Beach Medical Center delivered Baby Franklin by emergency C-section and rushed him to the neonatal intensive care unit for resuscitation. They couldn’t save him.

And:

…[Florida midwife Deborah Jacobs] Marin promised she would transfer Pino in case of emergency, as state regulations require.

Instead, the midwife let Pino actively labor for hours while her baby was stuck inside the birth canal, her head turtling in and out. The little girl suffered irreversible brain damage from a lack of blood and oxygen, court records show.

When Maddie finally emerged, she was covered in thick, pea soup meconium — the baby’s first stool — which stained her fingernails yellow, Pino recalled. She didn’t cry. She was purple and not breathing. Only then did Marin yell for someone to call 911.

The little girl lived in a semi-vegetative state until she died in February 2013, three days before her third birthday.

There are many more tragic stories in the piece, but all are eerily similar in their basic facts:

1. Failure to inform parents that CPMs don’t meet the Global Midwifery Standards.

These tragedies almost always start with a bait and switch. CPMs boast about the excellent out of hospital outcomes of Dutch, Canadian and Australian midwives without telling parents that they themselves wouldn’t be allowed to practice in those countries because of lack of education and training.

2. CPMs converting the liability of not being allowed to practice in any place with rigorous professional standards into the virtue of a homelike environment.

CPMs promote out of hospital birth because it is the ONLY way they can make money. Unlike ALL other midwives in the industrialized world, CPMs are alone in their inability to practice in hospitals and are therefore alone in their inability to manage their patients in both places. Therefore they have an incentive to ignore risk factors and avoid medically indicated transfers.

3. CPMs routinely violate the law.

Many CPMs practice illegally by ignoring state laws about who can be a midwife. In states that license CPMs, they also practice illegally by failing to meet even the minimal requirements promulgated specifically for CPMs including having a obstetrician to back up their practice, having a designated hospital to which they can transfer women experiencing complications, and by ignoring laws that bar them from overseeing high risk pregnancies and births.

4. Reckless disregard of the signs and symptoms of impending or ongoing life threatening complications.

If CPMs recognize complications (and many can’t), they have multiple incentives to ignore them. They lose control of patients they transfer. They are often practicing illegally and therefore need to hide their actions. They have represented themselves to their clients as knowledgeable but any transfer has the potential to reveal that they had no idea what they were doing.

Countries where homebirth is practiced routinely have strict criteria for transfer and high transfer rates. That’s why homebirth is relatively safe in those countries. Most CPMs have no transfer criteria and boast of low transfer rates. That’s why babies (and sometimes mothers) die.

5. Industry capture of regulatory bodies.

To the extent that CPMs are regulated, they are regulated by other CPMs, either those on state licensing boards or those who run CPM professional organizations. In other words, these regulatory bodies are captured by the industry they are designed to regulate. A medical equivalent might be if obstetricians served as the judge, lawyers and jury for obstetric malpractice cases AND believed that their primary purpose was to protect obstetricians, not patients.

Fortunately, the solution to these preventable tragedies is simple. All we have to do is what every other country in the industrialized world has already done: mandate that the ONLY people who can call themselves midwives are people who meet the Global Midwifery Standards. Contrary to the claims of homebirth advocates, this is NOT an issue of reproductive freedom or medical paternalism, it is an issue of truth in advertising.

We must abolish the CPM designation and make it illegal for these women to call themselves midwives. What should they call themselves instead? It doesn’t really matter so long as there is no possibility that mothers will confuse them will real midwives.

In 2018 there is reality and what certain segments of society prefer to believe.

Reality is that immigrants enrich our country, take jobs that no one else wants, and are no more likely to come to our border than they ever were. In the overheated imaginations of our president’s followers, immigrants steal from our country, take all the desirable jobs, and have begun coming to our border in massive numbers.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Brooks’ New York Times piece is inaccurate, disorganized and based on personal beliefs not supported by facts.[/pullquote]

Why the discrepancy? Because cognitive dissonance won’t allow blue collar white workers to blame the real authors of their misery: the Republicans who promote the interests of the rich over the needs of the working poor.

In 2018 there is the reality of maternal mortality and what certain segments of society prefer to believe. This includes Kim Brooks, the author of America Is Blaming Pregnant Women for Their Own Deaths, an opinion piece in the NYTimes.

Reality is that maternal mortality is disproportionately a problem of black women, that the leading causes of death are heart disease and pre-existing chronic medical considitions, and that women are dying from LACK of high tech interventions not too many interventions. In the overheated imagination of Kim Brooks, an individual with no professional education or training in obstetric issues, the problem is that doctors are mean to women.

Brooks’ piece is inaccurate, disorganized and based on personal beliefs that are not supported by the facts.

This appears to be the key sentence:

For experts studying the United States’ maternal mortality and injury rates — which are estimated to far surpass those in other developed countries — and for women in labor, the failure to treat mothers as people is neither antiquated nor dystopian, but absolutely pressing.

That’s is sheer, unadulterated bullshit, the intellectual equivalent of claiming that immigrants are ruining our country. Reality is very different.

Reality #1: Women of African descent die at much higher rates than women of other ethnicities.
Reality #2: Maternal mortality rates are a function of “whiteness” of the country.
Reality #3: The leading causes of maternal death are cardiac disease and pre-existing medical conditions
Reality #4: Women are dying in the days, weeks and months before and after childbirth, NOT in labor.
Reality #5: Women are dying because of lack of access to high tech interventions.
Reality #6: Maternal mortality is a social problem as much as it is a medical problem.

I could write reams about these issues but a few graphs and charts make reality quite clear.

1. This graph shows the stark difference between maternal mortality rates for black women and all other women:

2. This disaparity is true for all industrialized countries and in some it is even larger. As a result, the “whitest” countries have the lowest maternal mortality rates and international comparisons that don’t account for ethnic composition within nations are meaningless.

3. Why do women die in pregnancy, childbirth and the year afterward?

The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. And that reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before.

4. In her piece Brooks refers repeatedly to dying in childbirth, but as Neel Shah, MD notes, more than 80% of maternal deaths don’t occur on the day of delivery and more than 60% aren’t even within a week of delivery.

5. Brooks, like most people imagines that maternal mortality is a problem of too many interventions and unnecessary interventions (“too much, too soon”) when in reality it is a problem of LACK of interventions (“too little, too late”).

Brooks approvingly quotes an executive of the California Health Care Foundation:

“Women know what they want when it comes to labor and delivery, and it turns out the things they want (midwives, doulas, fewer unnecessary interventions and cesarean sections) are less expensive and produce better outcomes.” The problem is not that pregnant women are uneducated or uninformed; the problem is that those in charge aren’t listening to them.

There is precisely ZERO evidence that midwives, doulas, fewer interventions and fewer C-sections could reduce maternal mortality. Indeed, just this month the New England Journal of Medicine published What We Can Do about Maternal Mortality — And How to Do It Quickly recommends four strategies to reduce maternal deaths:

• Best practice bundles for common obstetrical emergencies
• Enhanced preparedness for complications
• Drilling for emergencies
• Timely transfer to high resource hospitals

6. Pointing out that maternal mortality is in large part a social, not a medical problem is not blaming pregnant women for their own deaths anymore than pointing out that drug abuse is primarily a social problem not a medical one.

The leading causes of maternal death are cardiac disease and pre-existing medical conditions; that’s because maternal age is increasing, obesity is increasing and therefore the prevalence of chronic medical conditions is increasing. No one is to blame for that and refusing to acknowledge it is a lazy attempt to protect women’s feelings at the expense of their lives.

The bottom line is that America is NOT blaming women for their own deaths. Claiming that midwives, doulas and fewer interventions will prevent maternal mortality is like claiming that a border wall will protect blue collar workers from economic harm. Some people may prefer to believe it, but it’s not reality.