Wellness has been in the news a lot in the past few weeks.

Taffy Brodesser-Akner, writing about Gwyneth Paltrow a high priestess of wellness, had this to say:

The minute the phrase “having it all” lost favor among women, wellness came in to pick up the pieces. It was a way to reorient ourselves — we were not in service to anyone else, and we were worthy subjects of our own care. It wasn’t about achieving; it was about putting ourselves at the top of a list that we hadn’t even previously been on…

Jen Gunter noted:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If people want to tithe to Gwyneth Paltrow, is it really our job to stop them?[/pullquote]

Medicine and religion have long been deeply intertwined, and it’s only relatively recently that they have separated. The wellness-industrial complex seeks to resurrect that connection. It’s like a medical throwback, as if the halcyon days of health were 5,000 years ago…

I would go farther than that. In my view, wellness IS a religion.

It seems to meet the definition of religion:

[A] set of beliefs concerning the cause, nature, and purpose of the universe, especially when considered as the creation of a superhuman agency or agencies, usually involving devotional and ritual observances, and often containing a moral code governing the conduct of human affairs.

Wellness is a set of beliefs concerning the cause, characteristics and purpose of the universe considered as the creation of “Nature,” involving devotional and ritual observances.

Indeed, in both style and substance, wellness mimics religious theology, right down to the financial outlay demanded to support it.

For example:

1. The Creation Myth

Every religion has a creation myth and wellness is no different. Indeed the wellness creation myth bears a startling resemblance to the creation myth of Judeo-Christian tradition with the difference that God is replaced by “Nature.”

Nature designed human beings to function perfectly in all respects (the state of grace known as wellness) and to live in a Paleo Garden of Eden where everyone ate organic, exercised regularly, used only natural remedies and lived to ripe old age and beyond. In contrast to many religions that view the Garden of Eden as metaphorical, wellness imagines that it actually existed.

So what happened?

2. The Fall

Human beings fell from the grace known as wellness. The serpent in the Garden was technology, which lured people farther and farther from the state of nature. As a result, people developed diseases like autism, cancer and obesity.

We got sick because we ate from the Tree of Knowledge.

3. Demons

We are now plagued by demons. We might not be able to see them, and we certainly can’t find them with our scientific technology despite its sophistication. Of course we don’t call them demons. We call them toxins.

Toxins function like demons. They are everywhere; they are insidious; and they lie in wait to prey on the weak.

4. Predestination

Just like the Calvinist belief in predestination allowed the spiritual elect to be identified by their wealth and success, wellness has its own version of predestination. In wellness, the spiritual elect can be identified by their good health.

Luck played no role in Calvinist predestination. You weren’t wealthy because you were lucky or even skillful. You were wealthy because you had been chosen by God. Luck plays no role in wellness, either. You aren’t healthy because you are lucky; you’re healthy because you are one of the health elect.

It goes without saying that people who get sick must have done something to deserve it or must have been damaged by demons.

5. The Devil

The Devil is a shape shifter. One day The Devil is technology; the next it is Big Pharma; or perhaps it’s Big Medicine. The Devil is responsible for illness and the only way to remain healthy is to thwart The Devil’s machinations. How? By refusing what the Devil is offering: CHEMICALS!

What are chemicals in wellness theology? In contrast to the scientific definition of chemicals that encompasses every single substance both inside and outside the human body, “chemicals” means something different in wellness. It is any substance that has a long, scary name.

6. Exorcism

Disease is caused by toxins, the demons of wellness, so it is hardly surprising that preventing and treating disease involves exorcism, forcing demons from your body by cleansing and detoxifying it.

7. Faith

Like all religions, wellness requires faith in the face of the inability to prove that it works or is true. Of course in wellness they call it “intuition.”

For example, it doesn’t matter to anti-vaccine advocates that there is no science to support the claim that vaccines cause autism, because their intuition tells them that it does. They explicitly reject rational explanations, and, like true believers everywhere, the persistence of faith in the face of ever greater evidence is treated as a sign of devotion, not gullibility.

8. Priests

Like any religion, wellness has its own priests and priestesses, the purveyors of wellness goods and services. Instead of offering rational prescriptions for health, wellness priests and priestess offer (for money) superstitions, affirmations, and support in rejecting rationality. They sell substances with no efficacy (herbs, homeopathy) and provide friendship and companionship as a substitute for knowledge.

9. Prayer

Affirmations are the wellness version of prayer. Visualizing the destruction of cancer cells and birth affirmations reflect the magical thinking that thoughts have the power to affect outcomes.

10. Salvation

The goal of wellness, like the goal of many religions, is to be saved and welcomed into paradise. In the case of wellness, paradise is a return the imagined state of perfect health “designed” by Nature for blissful life in The Garden.

Where does that leave health professionals who are struggling mightily to address the myths of wellness?

Viewing wellness as a religion has important implications for how we deal with it. It is often impossible to reason people out of beliefs that they didn’t reasons themselves into. Hence education in the sciences, or specific disciplines of immunology, oncology, etc. is doomed to be ineffective. That’s especially true when persistent faith in the face of evidence to the contrary is venerated as devotion.

It might be more effective to alert people to the fact that wellness is a religion and that their faith in it as akin to religious belief. Wellness is a form of magical thinking. It allows people an illusion of control over their fears around health and disease, imagining themselves as destined for return to the state of grace afforded by the original health Garden of Eden.

Or should we leave people to worship wellness as they wish? What’s the harm if people want to waste their money on wellness products that will never make them well?

The harm is two-fold. Some wellness products can actually make people sick, and people who are already sick may delay getting effective medical treatment while wasting time and money on wellness “treatment.” But the same risks apply to faith healing of all types.

If people want to tithe to Gwyneth Paltrow, is it really our job to stop them?

Serena Williams appears to be suffering from postpartum oppression.

No, that’s not a typo. It’s a wake up call.

We’ve all heard of postpartum depression, a form of clinical depression that occurs after childbirth. It is a serious medical issue and is probably precipitated by wide fluctations in hormones after childbirth, compounded by lack of sleep and other features of new motherhood. Postpartum depression is a medical condition that requires medical attention.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s not totally normal to feel like you’re not doing enough for your baby; it’s totally American.[/pullquote]

There’s another phenomenon, far more widespread, causing misery to many more women. Unlike postpartum depression, which is internal, postpartum oppression is caused by external pressures. Its cardinal symptom is a suffocating sense of guilt for failing to meet the arbitrary guidelines of the dominant mothering ideology of attachment parenting. Serena Williams appears to be suffering from a classic case.

Despite a year of tremendous achievements — a new baby, recovery from an emergency C-section, recovery from a pulmonary embolus, return to professional tennis, and a tournament win — Williams was brought low by fear that she is not a good mother.

Writing on her Instragram account in the wake of a defeat in the Wimbledon finals, Williams reported that she is dealing with “postpartum emotions.”

Last week was not easy for me. Not only was I accepting some tough personal stuff, but I just was in a funk. Mostly, I felt like I was not a good mom. I read several articles that said postpartum emotions can last up to 3 years …

What kind of emotions? Guilt appears to be chief among them.

It’s totally normal to feel like I’m not doing enough for my baby. We have all been there. I work a lot, I train, and I’m trying to be the best athlete I can be. However, that means although I have been with her every day of her life, I’m not around as much as I would like to be. Most of you moms deal with the same thing…

Actually, it’s not totally normal to feel like you’re not doing enough for your baby. It’s totally American. Indeed, women from English speaking countries promote an approach, attachment parenting, that can best be described as hyper-maternalism.

Attachment parenting is really a marketing term designed to romanticize maternal suffering and hide the true purpose: manipulating women. Although often presented as a recapitulation of mothering in nature, it bears little resemblance to the way our foremothers cared for children. It is meant to evoke attachment theory, but actually has nothing to do with it. It problematizes mothering by presenting the mother-infant bond not as spontaneous, as has been understood throughout history, but as fragile and contingent on specific maternal behaviors.

For most of human history, mothering was an interstitial task, taking place in the gaps while performing other tasks that required attention and energy. Hyper-maternalism, in contrast, imagines mothering as something you do to the exclusion of everything else. Women must erase themselves and embrace their own pain, exhaustion and battered mental health. Women must have an unmedicated vaginal birth, breastfeed for two years (at least!) and spend every waking moment with the baby (and every sleeping moment, too, by bedsharing). Women must submerge their identities in mothering, ignoring their own intellect, talents, needs and ambitions. The alternative is children profoundly damaged by their mothers’ selfishness.

Not surprisingly then, Williams felt tremendous guilt when she stopped breastfeeding in order to return her competitive best.

Williams said she made the decision to stop breastfeeding once she was emotionally ready.

I literally sat Olympia in my arms, I talked to her, we prayed about it,” she said. “I told her, ‘Look, I’m going to stop. Mommy has to do this.’ I cried a little bit, not as much as I thought I was. She was fine.

French women view mothering very differently as exemplified by their philosophy of breastfeeding.

According to Pamela Drukerman in Bringing Up Bebe:

French mothers know that breast is best. But they don’t view breastfeeding as a measure of the mom, or keep nursing through Dantesque trials of pain and inconvenience. Many pragmatically point out that they themselves are healthy, despite having drunk a lot of powdered formula—the old, worse formula … Frenchwomen still tend to think it’s unhealthy and unpleasant to breastfeed under moral duress. They believe that whether and how long to nurse should be your private decision, not your play group’s…

In contrast to English speaking mothers who are encouraged to feel guilty about any time spent apart from their children, French mothers believe that time apart is good for both mothers AND babies.

It’s not enough for French mothers to have pleasures and interests apart from their children. They also want their kids to know about these things. They believe it’s burdensome for a child to feel that she’s the sole source of her mother’s happiness and satisfaction. (A Parisian mother I know told me she was going back to work partly for her daughter’s sake.)

That need for separation applies to sleep as well. Instead of promoting the “family bed” on the theory that children in nature slept with their parents so that must be best:

Your Bedroom Is Your Castle

Guard it carefully. Your child doesn’t have the right to barge in whenever he wants…

It’s also important for him to understand—through tender gestures and closed doors—that there’s a part of his parents’ lives that doesn’t involve him…

French mothers are not oppressed by guilt the way that American mothers are because they haven’t been socialized to believe that children’s physical, emotional and intellectual health are dependent on a mother who ignores her own. They don’t feel bad for stopping breastfeeding, spending time away from their children, or insisting on private time and space with their partners. Contrary to the dire predictions of attachment parenting experts, French children are every bit as smart and healthy, physically and emotionally, as American children.

Serena Williams has accomplished more in the past year than most of us will accomplish in a lifetime. Yet she still feels oppressed by the fear that in trying to meet her own needs, she is short changing her child. If Serena Williams can be brought low by postpartum oppression, what chance to the rest of us have against it?

How do academic feminists feel about breastfeeding?

According to social scientist Suzana Ignjatović’s paper Breastfeeding Divisions in Ethics and Politics of Feminism, academic feminists are divided:

In general, all feminist positions on infant feeding can be placed in two strongly opposed views: pro-breastfeeding and pro-choice feminists, including the option called “beyond choice” perspective, which is basically a pro-breastfeeding position.

How do they differ?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The issue is biological essentialism.[/pullquote]

The pro-breastfeeding group of scholars refers to breastfeeding as a liberating practice or at least as an issue of women’s rights. It focuses on a woman’s right to breastfeed, which is a feminist response to the established right of the child to be breastfed. Within this framework, breastfeeding is empowering against the medicalization of a woman’s body.

But the pro-breastfeeding scholars have become strange bedfellows with conservative gender traditionalists.

During the 1970s, there was a convergence of the feminist movement and lactivism promoted by La Leche League as a reaction to medicalization of pregnancy, child care and mothering: “they were fed up with being lectured at and dictated to by male physicians”. La Leche League (LLL) is a conservative movement that promotes breastfeeding as a primary task of motherhood in early child development, stating that “good mothering was a full-time occupation” or “good mothering through breastfeeding.”

Other academic feminists have adopted a pro-choice position.

It seems that the “pro-choice” position has gained substantial support among feminists. Many feminist papers uphold the ongoing critical debate about biased or unconfirmed scientific facts about breastfeeding. Negative aspects of breastfeeding are significant …

It is the gender conservativism that has led these academic feminists to view breastfeeding as oppressive.

Feminist critics also point to the implications of breastfeeding’s emergence as a mandatory norm. Breastfeeding constrains women by placing them in a contradictory position. On one hand, the “maternalist” position is based on a gender stereotype that breastfeeding is a part of a woman’s nature, thus implying that literally every mother can breastfeed. On the other hand, the medicalization of childcare has decreased a woman’s autonomy, imposing a constant need for expert advice. Similar ambiguity is found in Wolf’s concept of total motherhood, stating that a mother is completely responsible for a child’s wellbeing, yet she is constantly exposed to expert advice about proper child- care practice. A mother is “naturally” competent and ignorant at the same time.

The academic feminists who insists breastfeeding is liberating are aware that of the irony of promoting traditionalist gender imperatives. They have tried to elide that contradiction by pretending to themselves and others that they are offering a third way.

A self-named third option in feminist theory dealing with breastfeeding claims to be “beyond choice”, that is, beyond the debate “formula vs. breastfeeding”… The “beyond formula vs breastfeeding debate” position focuses on constraints to successful breastfeeding, addressing breastfeeding and women’s economic, social, and political status. It is assumed that women are constrained by structural factors and that these factors should be addressed instead. According to Hausman, the constraints include lack of paid maternity leave, lack of support, the sexualization of women’s body…

But these academics are not “beyond choice,” since they have no doubt that there is only one correct choice.

…[T]he obstacles-based approach is usually implicitly pro-breastfeeding. Shifting focus to obstacles and support means that women would choose to breastfeed (“all woman will ‘naturally’ adore breastfeeding”), if they get proper support.

What do these academic debates have to do with the rest of us? Quite a bit as it turns out. The contemporary debate about breastfeeding promotion among laypeople echoes these academic discussions in nearly all details though many of the lactivists advancing them appear to have no idea they are parroting academic claims.

Those who make their money or derive their self-esteem from breastfeeding adopt the position that best promotes their livelihood and self-esteem. They argue that breastfeeding must be promoted aggressively for its health benefits despite the fact that most or the purported benefits have been thoroughly debunked as the results of extrapolation of poor research and failure to consider that the decision to breastfeeding in industrialized countries is determined in large part by educational and economic status. They insist that breastfeeding is liberating and empowering despite the fact that it is quite obvious that women throughout recorded history have found it to be neither.

The pro-choice feminists (I consider myself to be part of this group) are deeply concerned about the way that women have become invisible within lactivist culture. Women’s pain, frustrations and difficulties are viewed as meaningless when compared to the supposed massive benefits conferred on babies. We are equally concerned about the biological essentialism that is such as visible feature of contemporary lactivism. Lactivists appear to think that the fact that women are born with breasts means that they are morally obligated to use them. They conveniently ignore the fact that those same women are born with brains and are quite capable of using them to make the choice that is best for their children and themselves.

Many prominent lactivists writing for laypeople today, like Prof. Amy Brown or Kimberly Seals Allers, have metamorphosed (at least publicly) from pro-breastfeeding/anti-choice to “beyond choice.” They promote practices that “normalize” breastfeeding and remove structural barriers such as lack of maternity leave under the assumption that women all women would breastfeed and would enjoy breastfeeding if only they received more “support.” These prominent lactivists are trying to square the circle, acknowledging that many women can’t or don’t wish to breastfeed, but insisting that they could or would if only “constraints” were removed.

The divisive issue for both academic feminists and lay lactivists is biological essentialism. Those who consider breastfeeding to be liberating insist the existence of breasts produces both a moral imperative to use them and a sense of empowerment in using them. Pro-choice feminists view breasts as no different from uteri. Just because a woman has a uterus does not mean that she is morally required to use it for pregnancy. They trust women to make the choice of how to use her body that is best for her. And they recognize that any situation that replaces two possible choices with one obligatory choice is always oppressive.

Hundreds of women are venting their fury on my Facebook page. Why? It isn’t merely because I have spent World Breastfeeding Week 2018 challenging their cherished belief in the perfection of breastfeeding. It’s because I’m raising doubt about their conviction in their own minds.

Nearly all of the touted benefits of breastfeeding are based on predictions made by extrapolating from small studies. The predictions often take the form of how many lives would be preserved, how many cases of serious illness would be averted and how many healthcare dollars would be saved if only the breastfeeding rate were higher. I’ve had the temerity to point out that breastfeeding rates in the US have risen dramatically since their nadir of 24% in 1973, yet NONE of the predicted benefits have occurred. Many have searched for data to rebut this claim but to their shock and horror have found that the predicted benefits of breastfeeding have indeed failed to appear.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Breastfeeding policy has been determined by biases that have nothing to do with actual science — bias toward the natural, anti-corporatist bias and anti-feminist bias. [/pullquote]

In their fury, they’ve accused me of being biased. I must be anti-breastfeeding, though I breastfed my four children. I must hate breastfeeding although it’s hardly hateful to point out that breastfeeding has failed to live up to the claims made on its behalf. Most egregiously, I must be in the pay of formula companies. No one has any evidence for that libel; I don’t receive any industry money from anyone.

In response they keep citing the same faulty studies whose predictions have failed to occur. Or they advance the logical fallacy of arguing from authority, insisting that if the WHO, UNICEF, the American Academy of Pediatrics, and various other health organizations claim that breastfeeding is superior, then it must be superior.

What they fail to realize is that contemporary breastfeeding policy is tainted by three specific kinds of bias: cognitive bias, anti-corporate bias and anti-feminist bias.

Cognitive bias

The belief in the innate superiority of breastfeeding has its intellectual root in the naturalistic fallacy, the belief that anything natural must be superior. This bias toward the natural is specific to Western cultures of the late 20th and early 21st Centuries. Prior to that, the same cultures exhibited a pronounced technological bias. That’s part of the reason why infant formula became so popular in the first place; in the early 20th Century all technology was viewed as inherently superior simply because it was an innovation. But neither is inherently superior. The relative value of the natural vs. the technological varies with the circumstances.

But cognitive bias toward breastfeeding is so strong that it led to publication bias. The aim of nearly all breastfeeding scientific literature is to validate the belief that breastfeeding must be better, not to test it. Most of the breastfeeding scientific literature is produced by partisans in journals that are edited by partisans. I am aware of researchers who cannot get their scientifically accurate papers published because calling the purported benefits of breastfeeding into question produces cognitive dissonance among those who have staked their scientific careers on the supposed superiority of breastfeeding.

Anti-corporatist bias

Breastfeeding policy is rooted in anti-corporatist bias toward Nestle and other formula companies. Don’t get me wrong, Nestle and other formula companies DID engage in unethical behavior in Africa by luring women away from breastfeeding even though they lacked access to clean water with which to prepare formula. The result was the death of tens of thousands of babies.

But what got lost in the righteous anger toward Nestle’s behavior is that there was NEVER anything wrong with formula itself; the problem was the water used to prepare it. All the African babies who died would have lived if Nestle had provided clean water along with powdered formula. No matter; formula itself was demonized and a series of draconian advertising restrictions instituted specifically to punish formula companies. Bias toward Nestle was transmuted to bias toward its completely safe, perfectly healthy product.

This anti-corporatist bias is a form of white hat bias:

‘White hat bias’ [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends… WHB bias may be conjectured to be fuelled by feelings of righteous zeal, indignation toward certain aspects of industry, or other factors…

But bias in the service of righteous ends is still bias and bias has no place in scientific research or policy.

Anti-feminist bias

La Leche League and its daughter organizations have been the prime movers in ALL breastfeeding policy in the past 35 years. They lobbied the WHO/UNICEF to punish Nestle and other corporations and to demonize formula in the process. But LLL always had another agenda entirely. It was created by religious traditionalists to promote breastfeeding as a means of forcing working mothers back into the home.

In the book La Leche League: At the Crossroads of Medicine, Feminism, and Religion, Jule DeJager Ward explains that LLL was founded as a backlash to the emancipation of women:

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

The original goal of LLL was to convince women that their primary purpose in life was to use their reproductive organs rather than their intellect or talents. It has succeeded beyond its wildest dreams. Now there are women who actually claim that the decision to breastfeed is feminist when it is nothing more than biological essentialism. And it has produced a cadre of lactivists — women who define both themselves and other women by how they use their breasts. Because breastfeeding has become part of lactivists’ self-image, any suggestion that it is less than immensely beneficial produces profoundly uncomfortable feelings of cognitive dissonance.

The bottom line is that breastfeeding policy has been determined by biases that have nothing to do with actual science — bias toward the natural, anti-corporatist bias and anti-feminist bias.

Pointing out that breastfeeding has failed to deliver its predicted benefits isn’t hating breastfeeding; it’s simply loving truth more than comforting biases.

How do we know if a public health campaign works?

That’s easy. We check to see whether the benefits predicted — lives preserved, disease averted, money saved — actually occur when the plan is put into practice. In other words, we don’t accept theory; we demand proof.

That’s how we know that vaccines are a spectacular public health success. Just as predicted, near universal vaccination saved lives, averted disease and saved money on a grand scale. As a bonus, a major infectious scourge, smallpox, was wiped from the face of the earth.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Insist that breastfeeding professionals provide proof that theoretical predictions came true as breastfeeding rates rose and watch them fail.[/pullquote]

That’s how we know that anti-smoking campaigns are successful. Just as predicted, lowering the rate of smoking dramatically lowered the incidence of lung cancer, thereby saving lives, preventing related disease and saving money.

That’s how we know that the campaign for universal postmenopausal hormone replacement therapy was NOT a success. Not only did the benefits fail to occur as predicted, it led to a rise in breast cancer, an entirely unpredicted result.

What about breastfeeding?

Breastfeeding professionals have been promoting breastfeeding ever more aggressively since 1981. They’ve carried out informational campaigns, restricted formula advertising and instituted the Baby Friendly Hospital Initiative. As predicted, the breastfeeding rate rose. For example, in the US, the breastfeeding initiation rate rose from 24% in 1973 to nearly 83% today. Unfortunately, the predicted benefits have failed to occur, and an increase in neonatal hospital readmissions, brain injuries and deaths have been an entirely unpredicted results.

That’s why the most important thing to do during World Breastfeeding Week 2018 is pretty simple: demand proof!

When breastfeeding professionals claim that increasing the breastfeeding rate could save over 800,000 lives per year, demand proof!

Ask them to demonstrate how many lives have been saved as the US breastfeeding rate has tripled. They’ll be able to show you that deaths of premature babies have decreased because breastmilk lowers the risk of necrotizing enterocolitis (NEC), a deadly complication of prematurity. But they won’t be able to demonstrate that the lives of term babies have been saved because they haven’t.

When breastfeeding professionals claim that increasing the breastfeeding rate could prevent serious illnesses, demand proof!

Ask them to show how the incidence of various serious illnesses dropped. They won’t be able to do it because their predictions were faulty.

When breastfeeding professionals claim that breastfeeding saves money, demand proof!

Ask them to show you how many healthcare dollars have been saved as breastfeeding rates in the US have tripled. They won’t be able to do so because no money has been saved. While you’re at it, ask them to explain why hundreds of millions of dollars are spent each year on the tens of thousands of babies readmitted to the hospital for breastfeeding complications like dehydration, low blood sugar and jaundice.

When breastfeeding professionals claim that closing well baby nurseries to promote breastfeeding improves infant health, demand proof!

They won’t be able to provide it because they can’t provide evidence that increasing breastfeeding rates reduce deaths, prevent serious disease or save healthcare dollars. While you’re at it, ask them to explain the increase in sudden unexpected infants deaths from babies who are smothered in their mothers’ hospital beds as well as the skull fractures and deaths that result from babies falling from their mothers’ hospital beds.

Why is there such a tremendous gap between what breastfeeding professionals predict and what actually happens? There are lots of reasons: their predictions are based on studies that are weak and conflicting; their predictions are based on studies that are riddled with confounding variables: their predictions are based on assuming causation for every beneficial outcome correlated with breastfeeding despite the fact that we know that correlation does not equal causation.

Ultimately, though, it doesn’t matter why they are wrong; it only matters that they are wrong and you can prove it for yourself. The most important thing to do during World Breastfeeding Week 2018 is very simple. When lactation professionals claim breastfeeding has major health benefits — lives preserved, serious illness averted, healthcare dollars saved — demand proof. Then watch as they scramble to provide it and ultimately fail because their predictions did NOT come true.

Lactivism has begun to seem like an endless parade of lies:

Breastfeeding saves lives of term babies — a lie!

Breastfeeding within the first hour of birth saves lives — a lie!

Insufficient breastmilk is rare — a lie!

Every baby needs nothing more than colostrum for several days — a lie!

But in my view, there’s no lie more cruel or more ugly than the one peddled by Kimberly Seals Allers on the Huffington Post — Presenting Breastfeeding As A Choice Is Contributing To Black Infant Deaths — the lie that black women are responsible for their deaths of their own children.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Breastfeeding would do NOTHING to prevent most of the deadly risks that black infants face.[/perfectpullquote]

Seals Allers writes:

Studies show that even college-educated black women disproportionately give birth to babies who die during infancy from complications related to birth size and weight. Nationally, black babies die at more than twice the rate of white babies. And some areas of the country have it worse than others; in prosperous San Francisco, black infants die at a rate of 9.6 percent compared to a rate of 2.1 percent for white infants.

It’s true. Black women are more likely to end pregnancy with heartache and empty arms than any other ethnic group. Whose fault is that? Seals Allers choose to blame the victims:

For more than 40 years, stark racial disparities have existed between white and black breastfeeding rates, particularly when you look at women who exclusively breastfeed for six months and who exclusively breastfeed for 12 months (the gold standard of infant nutrition as recommended by the American Academy of Pediatrics). According to recent CDC data, only 17 percent of black infants were still breastfeeding at 12 months, whereas nearly double the rate of white infants met that standard.

If it weren’t ugly enough to blame black mothers for their own losses, the reasoning is uglier still. Seals Allers appears to believe that black women are uniquely ignorant and gullible.

National discourse often frames breastfeeding as a lifestyle choice instead of a public health matter ― more akin to choosing a cloth diaper as opposed to the preventative medicine it provides…

How dare anyone treat women like adults and let them choose how they wish to use their own bodies? How dare anyone imagine that black women are as capable of making responsible choices as white women?

Don’t get me wrong: Kimberly Seals Allers is neither anti-feminist or racist.

She — like nearly everyone who seeks to restrict women’s autonomy — believes she is on the side of the angels. She — like those who seek to restrict reproductive freedom — believes that “choice” is anathema because there is only one right choice. She — like those who propose arduous hurdles for termination of pregnancy or who refuse to fill prescriptions for birth control because it offends their religious values — are convinced there is no limit to the rights that can be trampled because the ends justify the means.

That doesn’t change the fact that blaming black women for killing their own babies by not breastfeeding is both anti-feminist and racist — and factually false.

Why do black babies die? According to the Office of Minority Health:

The leading cause of black infant death are prematurity, congenital anomalies, maternal complications of pregnancy and sudden infant death syndrome (SIDS).

How would breastfeeding reduce black infant death? It’s easier to list what it WOULDN’T do than what it would.

Breastfeeding would NOT reduce the incidence of prematurity.
Breastfeeding has NO impact on congenital anomalies.
Breastfeeding has NO impact on maternal complications of pregnancy

So breastfeeding would do NOTHING to prevent most of the deadly risks that black infants face.

How could breastfeeding reduce black infant mortality? Breastfeeding reduces the risk of necrotizing enterocolitis (NEC), a deadly complication of extreme prematurity, and breastfeeding is associated with a reduction in the risk of SIDS.

But there are important caveats to these benefits:

1. Deaths from NEC represent only a small fraction of deaths from prematurity. Most premature babies die from respiratory complications and brain hemorrhages. There’s no evidence that breastfeeding has any impact on those causes.

2. Breastfeeding does not prevent NEC; it merely reduces the incidence.

3. The leading risk factor for SIDS deaths is bed sharing, not failure to breastfeed. Moreover, reduction of SIDS deaths that could be accomplished by increasing breastfeeding rates could equally be accomplished by promoting pacifier use.

What could save the lives of MORE black babies than breastfeeding?

Reducing prematurity.
Reducing maternal complications of pregnancy.
Promoting early prenatal care.
Making sure black women and their babies have access to high risk care.
Reducing bed sharing.

The bottom line is that breastfeeding could potentially prevent only a small fraction of black infant deaths. Even if all black women breastfed, their babies would still continue to die at a much higher rate than white babies.

That makes Seals Allers implication that black mothers who formula feed are responsible for their own bereavement about as ugly an insinuation as one could make.

World Breastfeeding Week has sadly devolved into a festival of lactivist lies and WBW 2018 is no exception. Up first is the lie that breastfeeding in the first hour after birth saves lives.

According to a press release from the World Health Organization:

An estimated 78 million babies – or three in five – are not breastfed within the first hour of life, putting them at higher risk of death …

The report notes that newborns who breastfeed in the first hour of life are significantly more likely to survive. Even a delay of a few hours after birth could pose life-threatening consequences. Skin-to-skin contact along with suckling at the breast stimulate the mother’s production of breastmilk, including colostrum, also called the baby’s ‘first vaccine’, which is extremely rich in nutrients and antibodies.

“When it comes to the start of breastfeeding, timing is everything. In many countries, it can even be a matter of life or death,” says Henrietta H. Fore, UNICEF Executive Director…

It’s worth looking at the lie in detail to understand just how entities like the World Health Organization play fast and loose with the truth in an effort to manipulate women. Like all the best lies, it contains a grain of truth — babies who breastfeed in the first hour are more likely to survive. The problem is the imputation of causation.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Babies who breastfeed in the first hour are more likely to survive because only a healthy baby can breastfeed in the first hour.[/pullquote]

Consider this claim: Patients discharged to home on the day of surgery have a lower death rate than those discharged 2-23 days after surgery. Therefore if we discharge every patient on the day of surgery, we will improve surgical outcomes.

That’s ridiculous, right? People who are discharged home on the day of surgery differ in important ways from those discharged later. They are probably healthy to begin with; their surgery was probably simple; they did not experience complications during the surgery.

For example, a person who is discharged to home on the day of laparoscopic knee repair has a higher survival rate than a person discharged on day 10 after a heart transplant, but early discharge is NOT the cause. It would be both misleading and irresponsible to claim that early discharge causes improved survival. It would be a lie.

Similarly though babies breastfed in the first hour after birth do have a higher survival rate, breastfeeding is NOT the cause.

What is?

Babies who breastfeed in the first hour after birth differ in important ways from babies who don’t. For example, a baby has to be relatively healthy in order to breastfeed. Babies who have suffered traumatic birth injuries or oxygen deprivation during birth are much less likely to be able to breastfeed within an hour of birth than healthy babies. They are also much less likely to survive than other babies. It’s not because they didn’t breastfeed; it’s because they couldn’t. It’s a perfect example of the axiom that correlation does not equal causation.

The sicker the baby, the longer it will be until the first effort at breastfeeding. Hence it is no surprise that the longer it takes before babies breastfeed for the first time, the less likely they are to survive. It’s not because they didn’t breastfeed earlier; it’s because they couldn’t.

Mothers who breastfeed in the first hour after birth also have to be relatively healthy. Those suffering from major hemorrhage or pre-eclampsia/eclampsia are much less likely to be able to breastfeed immediately. They are also much less likely to survive and babies whose mothers die are also much less likely to survive. It’s not because those babies didn’t breastfeed earlier; it’s because they couldn’t breastfeed earlier. It’s yet another example of the axiom that correlation does not equal causation.

The authors of the largest study cited by the WHO acknowledge this:

It is important to note that there are many reasons for delayed breastfeeding initiation that may confound the relationship between breastfeeding initiation and mortality.

They then ignored that acknowledgement and proceeded inappropriately to draw a conclusion WITHOUT correcting for these confounding variables!

There’s another critical reason makes the WHO claim completely misleading. Most of the supporting studies were done in developing countries where mothers often offer traditional prelacteal feeds of water, sweetened water or teas. These prelacteal feeds may consist solely or in part of contaminated water.
Those babies are more likely to die not because they didn’t breastfeed earlier, but because they received contaminated water that made them sick. It, too, is an example of the axiom that correlation does not equal causation.

But if correlation does not equal causation, what does? The nine facets of the Hill’s Criteria, developed and used to show that tobacco causes lung cancer, can help us determine the difference between correlation and causation. There are two criteria that are particularly important in this case. One is “consideration of alternative explanations.” The papers cited by the WHO did not consider alternative explanations; they selected a preferred explanation and ignored everything else.

The other important criterion is “plausible mechanism.” The lactivists at the WHO offer no plausible mechanism by which putting a baby to the breast in the hour after birth could be lifesaving. They make vague allusions to antibodies and skin to skin contact but fail to show that a sip of colostrum or brief contact with a mother’s skin could save a baby’s life. That’s because there’s no such evidence.

Obviously the folks at the WHO know the difference between correlation and causation and between reasonable conclusions and unreasonable ones; so why do they make a claim that is both implausible and unsupported by the existing evidence? Because of white hat bias:

‘White hat bias’ (WHB) [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends …

The lactivists at the WHO view the promotion of breastfeeding as so righteous that they feel justified in deliberately misleading women in order to convince them to breastfeed. They’re wrong. In the first place, the benefits of breastfeeding are trivial. There’s no evidence that formula is dangerous, merely that formula made with contaminated water is dangerous. Second, women are not children to be manipulated with fables. Women are entitled to scientifically accurate information with which to make healthcare decisions. The WHO’s efforts to manipulate women are fundamentally unethical and no possible benefit of breastfeeding justifies unethical behavior on the part of providers.

The claim that breastfeeding within the first hour after birth saves lives is nothing more than a lie. It is a deliberate and fundamentally dishonest attempt to manipulate women. Sadly, it is just one of many lactivist lies told by the WHO and other healthcare organizations — involving weak data riddled with confounding variables, imputing causation to correlation and making absurd claims without any plausible mechanism. The truth, a truth that the WHO is loath to admit, is that the benefits of breastfeeding are trivial and that the millions of dollars spent to promote it are a terrible waste of money.

On the eve of World Breastfeeding Week 2018, I’m reminded of the tale of The Emperor’s New Clothes:

…about two weavers who promise an emperor a new suit of clothes that they say is invisible to those who are unfit for their positions, stupid, or incompetent – while in reality, they make no clothes at all, making everyone believe the clothes are invisible to them. When the emperor parades before his subjects in his new “clothes”, no one dares to say that they do not see any suit of clothes on him for fear that they will be seen as stupid. Finally, a child cries out, “But he isn’t wearing anything at all!”

Sadly, the story of lactivism is similar: professionals promise women that breastfeeding is a better way to feed their babies, provides massive benefits, and has no risks. They tell women that anyone who questions those benefits is stupid or incompetent, while in reality, the benefits of breastfeeding are trivial and the risks — of dehydration, hypoglycemia and jaundice — are significant. This has been going on for nearly three decades and there’s no evidence that increased breastfeeding rates have any impact on mortality, morbidity or healthcare savings for term infants. Breastmilk does reduce the risk of death from necrotizing enterocolitis in extremely premature infants, an exception that serves to prove the rule.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Everyone knows that breastfeeding has massive benefits, just as everyone knew that the sun revolved around the earth.[/pullquote]

It’s time to cry out the obvious: breastfeeding DOESN’T matter!

Why do we keep pretending it does? For the same reason that the emperor’s subjects were afraid to tell him he was naked: peer pressure. No one dares accept the evidence of their own eyes for fear of a powerful backlash.

In the case of the emperor, his subjects feared that he would punish them for insulting his dignity. In the case of breastfeeding, everyone is afraid they will be demonized by lactation consultants and their medical allies. Why? Because lactation professionals, whose dignity is apparently insulted by the truth that the promised benefits of breastfeeding have never appeared, react by vilifing, slandering and shunning.

Everyone “knows” that breastfeeding has massive benefits, just as everyone once “knew” that the sun revolved around the Earth. That wasn’t true, either, but there were religious leaders with a vested interest in promoting the biblical view of the solar system; because they had access to the levers of power, they were able to suppress the truth for generations. It was more important to religious leaders to maintain their belief system regardless of what the evidence showed. Anyone who opposed them faced draconian penalties.

The situation is not as bad for breastfeeding. A doctor like myself who dares point out the obvious does not face a trial and potential execution for heresy, just withering criticism. It is babies and mothers who suffer because those who hold the levers of power in the world of public health have a vested interest in suppressing the truth. It is more important to lactation professionals to maintain their belief system regardless of what the evidence shows and regardless of how many babies and mothers are hurt in the process.

It would be pathetically easy to prove me wrong if I were wrong:

Just show me how the infant mortality rate has dropped as breastfeeding rates have risen.

Just show me how the rate of serious medical illness has dropped as breastfeeding rates have rise.

Just show me how the rate of healthcare spending on infants has dropped as breastfeeding rates have risen.

Wait, what? No one can demonstrate even one of those things, let alone all three of them?

Of course not, because the emperor has no clothes.

No amount of pretending by his subjects could change the fact that the emperor was naked. Similarly no amount of pretending by lactation professionals changes the fact that breastfeeding doesn’t matter for term infants.

I will continue to point that out; vilification, slander and shunning won’t stop me. The only thing that will convince me otherwise is if someone demonstrates that breastfeeding has an impact on term infants in the real world, not just in the unvalidated theoretical models beloved of lactivists.

I’m not holding my breath.

The mainstream media is filled with stories claiming that the US maternal death rate has risen dramatically since 1990. The latest effort comes from USA Today, Hospitals know how to protect mothers. They just aren’t doing it.

The vast majority of women in America give birth without incident. But each year, more than 50,000 are severely injured. About 700 mothers die. The best estimates say that half of these deaths could be prevented and half the injuries reduced or eliminated with better care.

Instead, the U.S. continues to watch other countries improve as it falls behind. Today, this is the most dangerous place in the developed world to give birth.

They include a helpful chart:

There’s just one problem and it’s a big one: no one knows if those measurements of US maternal mortality are accurate. Indeed, there’s a growing body of evidence that the US is over-counting maternal deaths.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There’s a growing body of evidence that the US is over-counting maternal deaths.[/pullquote]

In the 1990’s it was recognized that the US was failing to capture all maternal deaths. As a result, the US death certificate was changed twice (1999 and 2003) to add specific questions to determine the pregnancy status of the deceased. But death certificates are prepared by individual states and each changed their deaths certificates at different times.

As MacDorman et al. explained in 2016 in Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues:

To improve ascertainment, a pregnancy question was added to the 2003 revision of the U.S. standard death certificate. The question has several checkboxes to ascertain whether female decedents were: Not pregnant within past year; pregnant at time of death; not pregnant, but pregnant within 42 days of death; not pregnant, but pregnant 43 days to 1 year before death; or unknown if pregnant within the past year…

However, there were delays in states’ adoption of the revised death certificate, and thus the new pregnancy question. In addition, some states had pregnancy questions that were inconsistent with the U.S. standard. This created a situation where, in any given data year, some states were using the U.S. standard question, others were using questions incompatible with the U.S. standard, and still others had no pregnancy question on their death certificates.

Due in part to the difficulties in disentangling these effects, the United States has not published an official maternal mortality rate since 2007 …

MacDorman et al. used statistical estimates to correct for the differences. While raw data suggested that US maternal mortality had more than doubled since 2000, they found that the real increase was only 26.4%, a much smaller increase, but an increase nonetheless.

But even this increase may not be real. Suspicion initially fell on the data from Texas that had shown a massive increase in maternal mortality:

Reproductive rights advocates seized on the data to argue that Texas’ efforts to roll back access to reproductive care had led to the increase, but a closer look revealed that the state had dramatically over-counted maternal deaths.

In Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012, Baeva et al. found:

Fifty-six maternal deaths were confirmed to have occurred during pregnancy or within 42 days postpartum. Using our enhanced method, the 2012 maternal mortality ratio for Texas was 14.6 maternal deaths per 100,000 live births, less than half that obtained using the standard method (n5147). Approximately half (50.3%) of obstetric-coded deaths showed no evidence of pregnancy within 42 days, and a large majority of these incorrectly indicated pregnancy at the time of death.

How did this happen?

In Texas, unintentional user error in reporting pregnancy status may be responsible. Texas’ current electronic death registration system displays pregnancy status options as a dropdown list. The “pregnant at the time of death” option is directly below the “not pregnant within the past year” option; this could have led to erroneous selection and could explain why pregnancy at the time of death was reported for nearly 76% (n556) of the 74 obstetric-coded deaths with no evidence of pregnancy on review.

The situation in Texas is not unique.

MacDorman and Declercq writing in the June 2018 issue of Birth: Issues in Perinatal Care (published on behalf of Lamaze International) note:

For example, a recent Centers for Disease Control and Prevention (CDC) report from maternal mortality review committees in four states found that 15% (97/650) of reported maternal deaths were not maternal deaths at all, since the women involved were confirmed to be not pregnant or postpartum within 1 year of death. The same study also found that the checkbox identified cases, particularly during pregnancy or late postpartum, that were identified only because of the checkbox, and with no other evidence that the case was a maternal death. Thus, the errors of overcounting were predominantly because of errors in the pregnancy checkbox.

This is a serious error:

The problems in reporting of pregnancy status are compounded by United States coding rules that code every death with the pregnancy or postpartum checkbox checked to maternal causes, regardless of what is written in the cause-of-death section. The only exception is for external causes of injury (ie, accident, suicide, or homicide) which are coded to non-maternal causes. This coding scheme makes the checkbox information essentially the sole factor in deciding whether a death is maternal or nonmaternal. For example, right now, if “sunburn” is written as the cause of death, and if the pregnancy or postpartum checkbox is checked, United States coding rules code this as a maternal death. This coding is clearly not in keeping with the spirit of the World Health Organization maternal mortality definition of maternal death …

They conclude:

Given concerns about overreporting with the pregnancy checkbox, it is illogical to continue to use it as the sole means of identifying maternal deaths. The National Center for Health Statistics (the agency responsible for collecting and disseminating NVSS data) should undertake a systematic evaluation of current coding methods for maternal deaths, and develop scientifically defensible alternative methods, which are compatible with international standards.

There a scientific aphorism that suggests extraordinary claims require extraordinary evidence. In this case there are two extraordinary claims: since 1999 US maternal mortality has risen dramatically and the US now has the highest maternal mortality in the industrialized world.

The evidence, far from being extraordinary, is incredibly inaccurate because of over-counting.

That does NOT mean that our efforts to reduce maternal mortality should flag. No one is questioning the massive gap in maternal outcomes between black and white women and that must be reduced. But it does mean that the hand wringing over the rise in US maternal mortality might be both premature and overblown.

Aaron Carroll had a fabulous piece in yesterday’s New York Times entitled What if a Study Showed Opioids Weren’t Usually Needed?

Participants were randomly assigned to one of two arms. Both involved stepwise progression from less to more potent medications. One arm involved opioid medications (a progression from hydrocodone/acetaminophen to sustained release morphine to fentanyl patches, for example) and the other involved non-opioid medications (a progression from ibuprofen to nortriptyline to tramadol, for example).

The medications were adjusted based on patient preferences and responses. Providers could switch patients to different drugs at the same level; change the dose or frequency of doses; add other drugs to manage side effects; and move patients up or down levels of intensity. They were also allowed to use any nonpharmacological pain therapies they liked.

The results were unexpected:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It doesn’t matter what works better in theory; it only matters what works better in practice.[/pullquote]

The study followed 240 patients for 12 months. Pain-related function, or how much pain affected their activity, was no different between the two groups. Pain intensity was actually better in the non-opioid group, and adverse symptoms were lower in that group as well.

How can that be? We know that opioids are “stronger” than non-opioids in theory; shouldn’t they perform better is practice?

Not necessarily because there is a difference between explanatory trials and pragmatic trials.

…[M]ost studies, even the gold standard of randomized controlled trials, focus squarely on causality. They are set up to see if a treatment will work in optimal conditions, what scientists call efficacy. They’re “explanatory.”

Efficacy is important. But what we also need are studies that test if a treatment will work in the real world — if they have effectiveness.

These … are called pragmatic trials …

It’s the difference between theory and practice. In theory opioids provide superior pain relief; in practice other medications can actually be more effective and have the additional, major benefit of avoiding opioid addiction.

This does NOT mean that the explanatory studies that showed opioids aren’t stronger than non-opioids were wrong. In the perfect conditions of the explanatory studies, opioids are more effective. But in real world conditions, they have no additional benefit and dramatically increased harms.

The take away message is this: it doesn’t matter what works better in theory; it only matters what works better in practice.

What does this have to do with childbirth and breastfeeding? Quite a lot as it turns out.

There are many explanatory studies of childbirth that claim to show that unmedicated vaginal birth is superior to C-sections. Natural childbirth advocates, midwives in particular, have seized upon these studies to rationalize their preference for unmedicated vaginal birth as an ideal toward which providers and hospitals should aim. The Royal College of Midwives in the UK used such studies to justify their “Campaign for Normal Birth.” The RCM predicted that their campaign would reduce intervention rates, save lives and save money.

That’s not what has happened. Indeed, the results have been disastrous. Maternal and infant health has not improved; preventable infant and maternal deaths have climbed; maternity liability payments have exploded.

Why? Partly this reflects the fact that many of the explanatory studies don’t correct for confounding variables so their results don’t show what their authors claimed. But mostly it reflects the fact that although unmedicated vaginal birth — like opioids — may be better in theory; it’s NOT better in practice.

Similarly, there are quite a few explanatory studies of breastfeeding that claim to show that breastfeeding is superior to formula. Lactation professionals have seized on these studies to rationalize their preference for breastfeeding over formula feeding. The Baby Friendly Hospital Initiative (BFHI) is a campaign to promote breastfeeding. Lactation professionals predicted it would increase breastfeeding rates, save lives and save healthcare dollars.

That’s not what happened. While the BFHI has increased initial breastfeeding rates, the fall off after leaving the hospital is quite dramatic. With the exception of extremely premature infants, it hasn’t been shown to save ANY lives in industrialized countries and certainly hasn’t saved any healthcare dollars on term infants. In fact, literally tens of thousands of babies are readmitted to the hospital each year because of breastfeeding problems (primarily insufficient breastmilk) at a cost of hundreds of millions of dollars

Why? Partly this reflects the fact that many of the explanatory studies of breastfeeding don’t correct for confounding variables. But mostly it reflects the fact that while breastfeeding — like opioids — may be better in theory; it’s not better in practice. Indeed, for some babies exclusive breastfeeding leads to serious health problems, permanent brain injuries and even death.

Where do we go from here?

No doubt drug companies will try to discredit the results of pragmatic trials of opioids and continue to bombard doctors with explanatory trials that show that opioids are stronger. Hopefully, doctors will no longer be swayed by the explanatory trials alone and will demand data demonstrating how opioids perform against non-opioids in the real world.

Similarly, midwives and other natural childbirth advocates completely dismiss the fact that campaigns for normal birth have utterly failed to produce the predicted results. They haven’t met a midwifery scandal resulting in preventable infant and maternal deaths that they don’t lie about, deny, hide and ignore. They comfort themselves and each other with “research” by which they mean explanatory trials. The only question remaining for the rest of us is how many more babies and mothers have to be harmed and die before obstetricians, government officials and public health authorities insist that midwives prove their claims are true in practice, not just in theory.

Lactation professionals behave in exactly the same fashion as midwives and opioid manufacturers. They dismiss the fact that the BFHI and other efforts to promote breastfeeding have utterly failed to produce the predicted results. When confronted with data that the benefits of breastfeeding in industrialized countries are trivial, that no term babies lives have been saved and no healthcare dollars have been saved, they wave explanatory studies that demonstrate the theoretical benefits of breastfeeding. The only question remaining for the rest of us is how many more babies and mothers have to be harmed or even die before pediatricians, obstetricians, government officials and public health authorities insist that lactation professionals prove their claims are true in practice, not just in theory.

As Carroll notes:

Randomized controlled trials are great for certain things. They absolutely have their place in determining efficacy and causality. But sometimes pragmatic trials are better. If we want to see improvements in care in the real world, not just the lab, we may need to push for more of them.

That applies to opioids and it applies equally to efforts to promote unmedicated vaginal birth and breastfeeding.