On Saturday I came across this tweet by one of the authors of the award winning ProPublica series on maternal mortality, Lost Mothers.

Very excited to be speaking today at DONA International 2018 Summit to a group of women who have done so much to protect other women from becoming Lost Mothers: doulas.

What have doulas done to prevent maternal mortality? I could find no peer reviewed scientific evidence that doulas have done ANYTHING to reduce maternal mortality.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How can doulas, who have fewer hours of training than some labors, prevent maternal deaths?[/pullquote]

But that hasn’t stopped the ugly effort of doulas to claim they can. And people are listening (although not applying any critical thinking). According to The New York Times:

Gov. Andrew M. Cuomo announced on Sunday a series of initiatives aimed at addressing a disturbingly high rate of maternal mortality among black women, who are four times more likely to die in childbirth than white women in New York State, according to a study released last year.

The plan includes a pilot program that will expand Medicaid coverage for doulas, birth coaches who provide women with physical and emotional support during pregnancy and childbirth.

Studies show the calming presence and supportive reinforcement of doulas can help increase birth outcomes and reduce birth complications for the mother and the baby…

We’re supposed to believe that doulas, who have fewer hours of training than some labors, can prevent maternal deaths?

I’m not exaggerating. Doula training involves only 16 hours of workshops. It is not unusual for the average first labor to last hours longer than that.

The leading causes of maternal mortality are cardiac disease, other chronic pre-existing disease and serious medical complications of pregnancy; how could doulas possibly prevent those? They can’t. It’s an especially puzzling claim when you consider that, as detailed in the Lost Mothers series, many women who die initially received false reassurance that the symptoms of their impending demise were merely variations of normal. Doctors’ chief complaint about doulas is that they offer women false reassurance in the face of high risk status and complications. So how are doulas, who are more likely to offer false reassurance, going to prevent doctors from offering false reassurance? They aren’t.

What’s this really about? Follow the money!

It’s yet another effort by “birth workers” to exploit tragedies to promote themselves. Doulas are desperate to have their high fees covered by insurance and Medicaid; they are expensive and most women can’t afford them. Insurance companies and Medicaid are unlikely to pay doulas to improve women’s birth experiences but they might be willing to pay to reduce deaths, so doulas pretend they can reduce deaths.

This cynical campaign comes from the Ina May Gaskin playbook. Gaskin is the grandmother of America’s homebirth midwives — a second class of midwife different from certified nurse midwives, who fail to meet international midwifery standards and are found no where else in the industrialized world. Gaskin came up with the “Safe Motherhood Quilt” as part of her campaign to receive insurance and Medicaid coverage for this second, inferior class of midwives.

Gaskin represented herself as shocked at the rate of maternal mortality. Yet as far as far as I can tell, homebirth midwives in general and Gaskin in particular have done NOTHING (no research, no education, no fund raising) to reduce the incidence of maternal mortality. They merely exploited the deaths to promote themselves.

Doulas are now doing the same.

But aren’t there studies that show doulas improve outcomes?

I couldn’t find a single peer review scientific study that shows that doulas reduced maternal mortality. There are studies that show that doulas can decrease intervention rates, but that’s a process, not an outcome. Moreover, most studies of doulas are riddled with confounding variables; even when doulas are offered for free, the women who choose doulas differ in important ways from women who don’t choose them and those differences are likely to impact outcomes.

What about the work of midwife Jennie Joseph showing that support improves outcomes?

Jennie Joseph is a British-trained midwife, a women’s health advocate, the founder and executive director of Commonsense Childbirth Inc. and the creator of The JJ Way®. She moved to the United States in 1989 and began a journey that has culminated in the formation of an innovative maternal child healthcare system, markedly improving birth outcomes for women in Central Florida.

What’s the JJ Way?

The key components in our health care delivery are: prenatal bonding through respect, support, education, encouragement and empowerment.

But there’s no evidence that the JJ Way has improved health outcomes for anyone. It’s never been the subject of peer reviewed scientific research. So why does anyone think it works? Because a paid “report” claims it does.

The “report” concludes:

Women who received maternal care The JJ Way® had lower preterm birth rates than women in Orange County and the State of Florida…

Women who received maternal care the JJ Way® had significantly better low birth weight rate percentages than women in Orange County and the State of Florida…

This evaluation of The JJ Way® model of prenatal care showed elimination of health disparities in preterm birth outcomes and reductions in low birth weight babies in at-risk populations.

The report, produced by a sociologist and a mental health counselor, shows nothing of the kind. Why not? Because the authors failed to correct for confounding variables other than race. The women who participated in the program were a self-selected group. As such, they are likely to differ from the average women in the county and the state on demographics like income, pre-existing health conditions, substance abuse, smoking status and a variety of other characteristics.

Unless and until Joseph corrects for those confounding variables, she isn’t entitled to make any claims about her program.

The bottom line is that there is very little evidence that support improves outcomes as opposed to merely reducing interventions. And there’s no evidence that support prevents maternal deaths.

Of course, there’s nothing wrong with doulas; they can be very helpful to women. But there’s something very wrong with them exploiting maternal deaths to promote themselves.

There’s a tremendous overlap between natural childbirth advocates and lactivists. That leads to the central conundrum of natural parenting: IS a healthy baby all that matters or ISN’T it?

Natural childbirth advocates believe they know the answer. According to Milli Hill, writing in 2014, a healthy baby is NOT all that matters:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Why is the woman who chooses high risk homebirth lauded while the woman who chooses formula feeding denigrated?[/pullquote]

Women matter too. When we tell women that a healthy baby is all that matters we often silence them. We say, or at least we very strongly imply, that their feelings do not matter, and that even though the birth may have left them feeling hurt, shocked or even violated, they should not complain because their baby is healthy and this is the only important thing…

In other words, women’s experience of birth is critical to their health.

Too often women who say they care about the details of their baby’s birth day are accused of wanting an ‘experience’, as if it is selfish to care about how their baby is born, how they feel or how they are treated.

Notably Hill doesn’t question the validity of women’s desires. It is enough for a woman to want a birth experience that differs from the hospital routine in order for her to be entitled to it.

Hill, like most natural childbirth advocates, is passionately committed to the principle that a healthy baby ISN’t all that matters … right up to the moment of birth. After that, Hill is equally passionately committed to principle that when it comes to infant feeding, a healthy baby IS the only thing that matters.

Wait, what?

Shouldn’t Hill’s claims about birth apply equally to breastfeeding? Doesn’t she believe that when we tell women that when it comes to infant feeding a healthy baby is all that matters we often silence them? How can we justify saying, or at least very strongly implying, that their feelings do not matter, and that even though breastfeeding may have them feeling hurt, shocked or even violated, they should not complain because breastfeeding will guarantee their baby is healthy and that is the only important thing?

How does Hill rationalize this hypocrisy? By questioning the validity of women’s desires:

But surely, breast or bottle, it’s all down to personal choice.

Every parent should have the freedom to decide how they feed their baby, and nobody should be judged for the path they take.

Right?

Except, that would discount the persuasive power of marketing.

In other words, the exact same women who wouldn’t and shouldn’t be pressured to knuckle under to the “obstetric industry” with its promotion of technological birth are supposedly dupes for the formula industry.

How ironic is this? Let me count the ways:

It’s a violation of women’s autonomy. A woman’s right to control her own body is not expelled with the placenta. If a woman has the right to refuse to let anyone put fingers in her vagina to measure cervical dilatation, she ought to have the exact same right to refuse to let a lactation consultant grab her breast and shove her nipple into an infant’s mouth.

It’s disrespectful of women. While Hill and her natural childbirth colleagues have no trouble believing that women who make alternate choices for childbirth are “educated” and empowered, Hill and her lactivist colleagues cannot imagine that women who make an alternate choice to breastfeeding are equally educated and empowered.

It is utterly inconsistent. Although a healthy baby is supposedly NOT the only thing that matters when it comes to childbirth, a healthy baby is purportedly the ONLY thing that matters when it comes to infant feeding.

It seems impossible to reconcile these diametrically opposed views of women’s autonomy, ability to make informed decisions, and importance given to a baby’s health.

But not if you look at it from a different angle, an angle that takes the views of natural parenting professionals as central. Their view is in that any conflict between what is good for women and what is good for them, their needs and desires ought to take precedence.

For Milli Hill and her colleagues who profit from promoting natural childbirth, encouraging women to buy their books, products and services is always an unalloyed good. That means that women who choose their experience over the health of the baby must be supported in every way.

For Milli Hill and her colleagues who profit from promoting breastfeeding, encouraging women to buy their books, products and services is always an unalloyed good. That requires that women who choose their experience over the purported health of the baby must be excoriated in every way.

The woman who chooses to ignore medical advice and have a high risk homebirth is to be lauded but the woman who chooses to ignore medical advice and formula-feed must be decried as gullible, uneducated and selfish.

What matters is not the health of the baby but the financial health of Milli Hill and her colleagues.

When you look at it that way, it all makes perfect sense.

I don’t know Dr. Joan Y. Meek, Chair of the Section on Breastfeeding of the American Academy of Pediatrics, but I do know ridiculous hyperbole when I see it. Sadly, Dr. Meek is aggressively promoting it.

Meek wrote a piece, Breastfeeding has been the best public health policy throughout history, which has been republished in a variety of places. Too bad it’s complete and utter nonsense.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Nonsense in the service of righteous ends is still nonsense.[/pullquote]

Dr. Meek claims:

As a pediatrician and a nutritionist, I have provided direct patient care to breastfeeding mothers and children and also advocated for breastfeeding policies and practices. The scientific research in support of breastfeeding is overwhelmingly clear, and most mothers in the U.S. have heard that message and learned from it. Marketing and sales of infant formula have surged in developing countries, however. That’s created a dilemma for the U.S., which has not wanted to restrict the US$70 billion infant formula business.

This comes at another price. Lack of breastfeeding worldwide is blamed for 800,000 childhood deaths a year.

No, breastfeeding does NOT save 800,000 lives a year. That’s based on a mathematical model that did not correct for confounding variables and assumed, but never proved, causation. Indeed, until recently, lactivists had been unable to find any supporting evidence for that claim. They could not show that breastfeeding rates are correlated in any way to infant mortality. In fact, countries with the lowest breastfeeding rates have the lowest mortality rates and countries with the highest mortality rates have nearly 100% breastfeeding rates.

The best evidence on lives saved by breastfeeding, published only recently, is Mortality from Nestlé’s Marketing of Infant Formula in Low and Middle-Income Countries by Gertler et al.

Contrary to the claims of lactivists like Dr. Meek:

The introduction of infant formula shows no statistically significant average impact on infant mortality for the population as a whole.

That’s because formula is not harmful to babies; contaminated water is harmful. How harmful?

[An analysis] yields an estimate of 65,676 infant deaths with a 95% confidence interval of [24,868, 106,485], lower than earlier estimates of one million or more, but unquestionably a substantial loss of human life.

That was 1981. How about now?

According to Gertler:

…[T]he annual death toll has dropped to about 25,000, driven by improved access to clean water in the Southern Hemisphere.

That’s just 3% of the figure claimed by Meek.

So breastfeeding is hardly the best public health policy in history; it doesn’t rate a place anywhere in the top public health achievements of all time.

Why?

Because a great public health policy saves millions or even hundreds of millions of lives. In contrast, with the exception of extremely premature infants*, breastfeeding hasn’t yet been shown to save many lives at all.

To understand what I mean, lets look at some of the real greatest public health achievements.

1. Clean water

2. Sewers and sanitation

3. Antisepsis

4. Blood transfusions

5. Antibiotics

6. Vaccination

7. Anesthesia

8. Tobacco control

9. Modern obstetrics

10. Neonatology

Each of these has saved and continues to save many millions of lives every year. Breastfeeding doesn’t come anywhere close. Moreover, the purported lifesaving effect of breastfeeding would be entirely abolished if all women had access to clean water with which to prepare formula.

Why did Dr. Meek make her ridiculous claim? Sadly, like most lactation professionals, she ignores the facts about breastfeeding in favor of the fantasy.

Meek writes:

The benefits of breastfeeding for children and mothers are irrefutable. Initiation of skin-to-skin contact immediately after delivery, with early onset of breastfeeding within the first hour of life, supports newborn stability and provides protective immunoglobulins, especially secretory IgA, and other immune protective factors. Human milk provides human milk oligosaccharides, facilitating the colonization of the intestinal tract with probiotics and establishing a microbiome that protects against pathogenic bacteria.

In contrast, formula-fed infants face higher rates of gastrointestinal diseases, respiratory infections and a higher likelihood of sudden infant death syndrome. Longer term, they have a higher risk of obesity, type 2 diabetes, asthma and certain childhood cancers when compared to breastfed cohorts.

Far from being irrefutable, most of these purported benefits have already been refuted.

• The protective immunoglobulins exist, but they only prevent colds and diarrheal illnesses.
• Claims about the microbiome are mere speculation.
• While breastfeeding reduces the risk of SIDS, pacifier use reduces it by a greater amount.
• Claims about obesity, diabetes, asthma and childhood cancers have been thoroughly debunked.

The idea that breastfeeding has been the greatest public health policy throughout history is sheer, unadulterated nonsense. I’ve no doubt that Dr. Meek is making that claim for what she perceives to be anticorporatist, righteous ends — counteracting the marketing efforts of formula companies. But nonsense in the service of righteous ends is still nonsense.

Who am I to criticize the claims of Dr. Meek? I’m a physician who is very familiar with the breastfeeding literature and I am more than willing to put my criticism to the test. I’d be happy to debate Dr. Meek, in print or in person, on these very issues.

I doubt my challenge will be accepted. Professional lactivists never put themselves in positions where those who disagree could challenge them. Though they choose fantasy over facts, they are aware that inconvenient facts about the limitations and risks of breastfeeding exist and they are afraid to face them.

Who knows? Maybe Dr. Meek, unlike other professional breastfeeding advocates, has the courage of her convictions. I’ll be waiting to find out.

 

*Breastmilk reduces the risk of necrotizing enterocolitis, a potentially deadly complication of extreme prematurity.

Breastfeeding or formula feeding?

It’s a choice that provokes strong feelings, particularly among those who identify themselves as breastfeeding professionals. It often seems that there is a huge gulf between organizations like La Leche League, whose avowed goal is to promote breastfeeding and Fed Is Best, whose avowed goal is to promote safe infant feeding whether that it breastmilk or formula.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Our goal: a society where any woman COULD breastfeed; but no woman feels she SHOULD breastfeed and no lactivist insists she WOULD breastfeed if only she knew better.[/pullquote]

I believe that the gulf can be understood by considering just three small words: “could,” “should” and “would.”

COULD

We need to create a society in which all women COULD breastfeed if that is their choice.

Despite the myriad disagreements between lactivists and feeding safety advocates, there’s no disagreement on this point. Although lactivists often claim that anyone who disagrees with them “hates” breastfeeding, there’s no evidence that this is the case. In more than two decades of writing about mothering issues, I’ve never come across a single individual who feels that breastfeeding itself is undesirable or substandard.

When we say we want a society where all women COULD breastfeed if they wish, most of us mean:

• Women should receive any medical and social support they need to successfully breastfeed
• Hospitals should supply medical professionals for breastfeeding guidance
• Women should have access to sufficient paid maternity leave to establish breastfeeding
• Women who return to work should have access to private pumping spaces and time to pump
• Breastfeeding in public should be welcomed everywhere

Sadly, that’s where the agreement ends.

SHOULD

Breastfeeding advocates believe that we need to create a society in which all women SHOULD exclusively breastfeed, barring rare health issues.

In the view of most lactation professionals, the benefits of breastfeeding are so obvious, so strongly supported by science and so profound that women must be prevented from choosing anything other than breastfeeding.

They reject any empirical claims that the benefits of breastfeeding in industrialized countries are actually trivial, that exclusive breastfeeding has significant safety risks for babies because of the high incidence of insufficient breastmilk, and that it places significant burdens — physical and psychological — on mothers.

But rejecting those claims doesn’t change the fact that they are true. Indeed, the massive popularity of the Fed Is Best movement reflects the experiences of literally hundreds of thousands of women who support it. Those women know that the incidence of insufficient breastmilk is high because they’ve personally experienced it. They know that aggressive promotion of exclusive breastfeeding has significant safety risks for babies because their babies have been hospitalized, suffered brain injuries and even died because of dehydration, low blood sugar or severe jaundice. They know that breastfeeding places significant burdens on women because they’ve struggled with mastitis, pain, exhaustion, difficulty combining breastfeeding and work, as well as the profound shame and guilt of not being able to exclusively breastfeed.

Infant feeding safety advocates, myself included, reject the notion that all women should breastfeed because we recognize that breast is NOT always best for every mother and every baby. Furthermore, we are feminists who believe that women have the right to control their own bodies; to use them in ways that they wish and they must never be forced to use them in ways that ignore their own needs. We reject claims of biological essentialism — that the true fulfillment of women’s purposes lies in reproduction and nurturing of children. We reject the notion that biology is determinative. Just because women are “designed” for penetrative intercourse does not mean that it is wrong for women to be gay or celibate; just because women are “designed” to breastfeed doesn’t mean that it is wrong to formula feed or combination feed.

WOULD

When faced with feminist arguments about the right to formula feed, breastfeeding advocates respond that all women WOULD breastfeed if only they were properly educated and not subject to the marketing efforts of formula companies.

There’s no scientific evidence to support that claim. The message that breastmilk is best is everywhere, even on formula itself. It is deeply disingenuous, not to mention misogynistic, to claim that women are too stupid to understand it and are in desperate need of greater education about the benefits of breastfeeding. It also implies that women are so gullible that they fail to recognize and are incapable of resisting marketing messages about formula. It denigrates women who choose formula by implying that their choice isn’t free and they have have been manipulated into it.

The existing scientific evidence shows the opposite: that women are well aware that breastfeeding has benefits and is considered best, that women resent being hectored, that language on the “risks” of formula feeding makes them angry, and that they are shamed and traumatized by the intense pressure to breastfeed.

In summary then, the differences between breastfeeding advocates and Fed Is Best advocates is not about “could.” All of us support a society where every woman who wants to breastfeed COULD breastfeed.

The disagreement resides in the words “should” and “would.”

Where does that leave us?

Breastfeeding advocates ought to stop whining that anyone who disagrees with them “hates” breastfeeding or is uneducated or gullible. They ought to stop promoting public breastfeeding as an antidote to formula feeding and recognize that feeding safety advocates don’t oppose public breastfeeding; social conservatives do.

Our goal ought to be creating a society where any woman who wants to breastfeed COULD breastfeed; but no woman feels that she SHOULD breastfeed and no lactivist insists that she WOULD breastfeed if only she knew better.

Breastfeeding professionals are sure that breastfed infants are healthier than those who are formula fed.

There’s just one problem; they can’t find evidence to support that belief.

Countries with the lowest breastfeeding rates have the LOWEST infant mortality and countries with the highest infant mortality have the highest breastfeeding rates. Most of the claimed health benefits of breastfeeding have been debunked by studies that correct for the higher socio-economic status of women in industrialized countries who breastfeed. And although breastmilk can save the lives of extremely premature infants who face the deadly risk of necrotizing enterocolitis, breastfeeding professionals can’t point to the lives of any term babies who have been saved.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Calibrate infant growth charts to keep infants out of the hospital, well hydrated and not suffering brain injuries and deaths.[/pullquote]

To the horror of breastfeeding professionals, the scientific evidence shows that formula fed infants are equally healthy to breastfed infants.

What to do? Change the definition of healthy by altering infant growth charts!

That’s just what breastfeeding professionals have done and it’s working … sort of.

The headline from the BBC is typical, Too many babies overfed, experts fear.

It’s time to tackle over-eating from birth to make sure children get the best start in life, according to Public Health England.

It comes as government advisers publish new guidance – the first in more than 20 years – on feeding babies.

That report suggests three-quarters of UK babies and toddlers may be eating more calories than they should.
The same proportion weighed more than the ideal weight for their age, when plotted on growth charts.

The data comes from the Infant Feeding Survey and the Diet and Nutrition Survey of Infants and Young Children carried out in 2010 and 2011.

It’s long been known that breastfed babies and formula fed babies grow differently.

According to the CDC:

The WHO growth charts establish the growth of the breastfed infant as the norm for growth. Healthy breastfed infants typically put on weight more slowly than formula fed infants in the first year of life. Formula fed infants gain weight more rapidly after about 3 months of age. Differences in weight patterns continue even after complementary foods are introduced.

Previous standards evaluated growth based predominantly on formula fed infants since most infants were formula fed at the time they were developed. Many breastfed infants were diagnosed as underweight using these charts. Breastfeeding advocates claimed that it was wrong to evaluate breastfed infants using formula fed infants as the standard.

They had a point, but it’s not clear that it was a valid one. It’s based on the assumption that every breastfed infant is fully fed when the reality is that breastfeeding has a significant failure rate and some breastfed babies are actually underfed. Far fewer babies receiving formula are underfed since they can eat until satiety instead of merely until the milk runs out.

The WHO charts purportedly show “how infants and children should grow rather than simply how they do grow.” But they don’t measure how infants “should” grow, they measure how breastfed infants, including underfed infants, grow. It’s a classic example of the naturalistic fallacy: if something is a certain way in nature, that’s how it ought to be.

This sleight of hand is only sort of working. Sure, it makes for great propaganda but it doesn’t change the fact that breastfed infants are suffering alarming rates of health problems due to insufficient breastmilk.

Breastfed infants are readmitted to the hospital at double the rate of formula fed infants. They are readmitted with hypernatremic dehydration, severe jaundice and hypoglycemia. In the US that translates to literally tens of thousands of hospital admissions each year at the cost of hundreds of millions of dollars. Brain injuries due to insufficient breastmilk are rising and infants are dying. Additional hundreds of millions of dollars of liability payments are being made.

In other words, redefining underfeeding as normal doesn’t change the fact that many breastfed babies are suffering gnawing hunger, dehydration, brain injuries and deaths.

I have a better idea:

Calibrate infant growth charts to keep infants out of the hospital, well hydrated and not suffering brain injuries and deaths.

If we don’t, we will continue to sacrifice the health of tens of thousands of infants each year to breastfeeding professionals’ increasingly desperate efforts to make breast SEEM best.

If gynecologists had a nickel for every time a teenage girl told them some version of the following, they’d be billionaires:

My boyfriend said I couldn’t get pregnant if we had sex standing up…
My boyfriend said I couldn’t get pregnant if I hadn’t had my first period…
My boyfriend said I couldn’t get pregnant if we did it during a full moon…

Most adult women recognizes such manipulation for what it is: lies told to convince women to cede control of ther bodies to young men. The young men may even believe what they say, but that doesn’t change the fact that their goal is to satisfying their own needs regardless of the harm that may come to the young women.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Teenage boys lie to young women so they’ll have sex with them. Natural childbirth and breastfeeding advocates lie to women so they’ll hire them and copy their choices.[/pullquote]

Such lies can be devastating, resulting in unintended pregnancy, sexually transmitted diseases and feelings of betrayal.

Sadly natural childbirth and breastfeeding advocates tell lies to women for similar reasons: to pressure them to cede control of their bodies. Natural childbirth and breastfeeding advocates may even believe what they say, but that doesn’t change the fact that their goal is to satisfy their own needs (for having their choices mirrored back to them or for increased employment as midwives, doulas or lactation consultants) regardless of the harm that may come to new mothers or their babies.

Such lies can also be devastating, resulting in extreme pain, traumatic births, incontinence, sexual dysfunction in the case of childbirth or in the case of breastfeeding maternal pain, exhaustion and shame in addition to newborn starvation, brain injury or death.

What follows is a list of the top ten lies used to manipulate expectant and new mothers:

1. Authentic women have no pain in labor. This is the foundational lie of natural childbirth advocacy, fabricated by Grantly Dick-Read, the father of natural childbirth. He claimed with no evidence whatsoever that primitive (i.e. black) women had painless childbirths because they recognized childbearing as their primary responsibility.

Dick-Read triggered a competition among privileged white women proving their authentic womanhood by denying the pain of labor and refusing pain relief. That competition continues to this day with women going so far as to claim they had not merely painless births, but orgasmic births. In falling for this lie, women have ceded control over their pain so that natural childbirth professionals can control their births.

2. C-sections are harmful. There was a time when C-sections WERE harmful and even deadly. Because of the dangers, just about any physical manipulation of babies and women — difficult mid-forceps rotations, massive vaginal and perineal tears — were justified in order to avoid the danger.

With the introduction of spinal/epidural anesthesia, C-sections have become remarkably safe. Nonetheless natural childbirth continue to rail against the dangers and completely ignore the risks of vaginal birth. Why? To satisfy their desperate need to have their own choices mirrored back to them, as well as to increase the employment opportunities for midwives and doulas.

3. Vaginal birth has an easier recovery than C-section. That depends entirely on what came before the birth. A vaginal delivery following 40 hours of labor including 5 hours of pushing is going to have a much longer recovery than an elective repeat C-section undertaken before labor begins.

4. There are no long term side effects to vaginal birth. To hear natural childbirth advocates tell it, the most important long term complication of birth is a future placenta accreta from a previous C-section. Placenta accreta is indeed dangerous, but the longterm complications of vaginal birth are far more common and debilitating. The risk of urinary incontinence from vaginal birth is 10,000% higher than the risk of subsequent accreta. No matter. Natural childbirth advocates routinely lie to women by omission, failing to disclose the risks of urinary incontinence, pelvic organ prolapse and sexual dysfunction.

5. Doulas are good for women. Doulas are undoubtedly good for doulas, but not necessarily good for mothers. Indeed, the metrics often used to evaluate doulas are epidural and C-section rates. Doulas are good at avoiding epidurals and C-sections, but epidurals relieve suffering and C-sections are often better for babies or mothers. A vaginal birth is not a victory when it results in a brain injured baby or decades of maternal urinary incontinence.

6. Insufficient breastmilk is rare. Breastfeeding advocacy is based in large measure on the Panglossian paradigm. The Panglossian paradigm asserts that everything that exists in nature today is the product of intense natural selection and represents the perfect solution to a particular evolutionary problem. Therefore, breastfeeding must be perfect.

But the scientific evidence shows that breastfeeding is not perfect. Lactation professionals routinely lie about the fact that up to 15% of first time mothers cannot produce enough breastmilk to fully nourish a baby especially in the early days. Instead of admitting this and offering formula supplementation, lactation consultants let babies suffer gnawing hunger and risk brain injury and death.

7. A newborn’s stomach is tiny. This is simply a bald-faced lie.

Lactation consultants tell new mothers that the average size of a newborn baby’s stomach is only a teaspoon (5 cc). That’s supposed to ease their minds when their newborns are screaming in hunger and they can tell that they are producing very little colostrum or milk. But the average size of the newborn stomach is NOT 5-7 cc but closer to 20 cc, rising dramatically over the first first days. If a baby seems hungry; she probably is hungry.

8. If breastfeeding hurts your baby needs surgery. Since breastfeeding is supposed to be perfect, problems must be ascribed to babies. The rate of diagnosis of tongue-tie and the surgery to sever it has exploded. Yet scientific studies show that the rate of tongue-tie is as low as it ever was and that surgery to “repair” it is largely ineffective in solving breastfeeding problems. Literally thousands of babies are undergoing painful, unnecessary surgery each year to maintain the illusion that breastfeeding is perfect.

9. Breastfeeding saves lives. There’s no evidence that breastfeeding saves lives in countries with easy access to clean water. The one exception is the case of extremely premature babies, where breastmilk reduces the deadly risk of necrotizing enterocolitis. While lactation professionals tout mathematical models showing that breastfeeding saves lives in theory, they are unable to identify ANY term babies whose lives have been saved in practice.

10. Breastfeeding promotes bonding. This is the cruelest lie of them all, intimating that babies who breastfeed are more bonded to their mothers than those who formula feed. There is not and there has never been any evidence to support this vicious falsehood. It is merely a particularly ugly attempt at pressuring women.

The bottom line is this: many people lie to women in order to control their bodies. Teenage boys lie to young women so they’ll have sex with them. Natural childbirth and breastfeeding advocates lie to women so they’ll hire them and copy them. But lying to women to control them — regardless of motivation — is always wrong.

Last week I wrote about conventional wisdom and used the example of stomach ulcers.

When I started medical school, the conventional wisdom was that stomach ulcers were caused by excess acid. The conventional wisdom was loud, pervasive and impossible to ignore. Whole careers in gastroenterology had been staked on maintaining its veracity. When that veracity was challenged, the challengers were silenced.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]You can almost hear their eyes roll when a woman tells of her anguish at being unable to produce enough breastmilk.[/pullquote]

At about the time I graduated from medical school researchers Robin Warren and Barry Marshall discovered H. pylori, the bacteria that actually causes gastric ulcers. Because of cognitive bias and the logical fallacy of argument from authority (all the prominent medical associations were in agreement that acid caused ulcers!), he was ignored.

But then:

To defend his thesis, in 1984 Marshall intentionally drank cultured H pylori and developed gastric symptoms, which were relieved with antibiotics. Another health professional who was similarly frustrated by the rejection of the theory of an association between H pylori and gastritis leading to peptic ulcer disease also consumed the putative agent. Multiple gastric biopsies before and after ingestion nicely demonstrated the resulting disease; however, Marshall’s colleague was less fortunate because antibiotics were unsuccessful in eradicating his disease, and he had debilitating symptoms for 3 years.

To my knowlege, although there was fierce professional disagreement during those years, those favoring the original acid theory never accused the researchers who claimed that bacteria caused ulcers of nefarious motives, shilling on behalf of a corporate entity, welcoming patients’ deaths or hatred of stomach acid.

Sadly, the same cannot be said about breastfeeding. Professional breastfeeding advocates have created a culture of contempt for anyone who dares challenge the conventional wisdom.

For example, on Saturday The New York Times published yet another piece about breastfeeding, Breast-Feeding or Formula? For Americans, It’s Complicated. Author Christina Caron noted:

But now a new movement called Fed is Best has arisen because of the pressure placed on women to exclusively breast-feed, sometimes to the detriment of their infants. The movement seeks to educate families about all of the safe feeding options available to them, and the complications that can arise when exclusively breast-fed newborns don’t receive enough breast milk.

In response, Lucy Martinez Sullivan, a lobbyist for the lactivist organization 1000 Days, reached out to the author with this Tweet:

Ask who is behind the “Fed is Best” movement. Investigate. Do your homework @cdcaron. Ask who stands to benefit claiming women are harmed by the “pressure to breastfeed”

Followed by this one:

@cdcaron The @nytimes should ask if Fed is Best is a fake grassroots movement / industry front group – pushing disinformation about the supposed dangers of #breastfeeding.

Does Martinez Sullivan have any evidence that Fed Is Best Founders Christie del Castillo-Hegyi, MD and Jody Seagrave-Daly, RN IBCLC are anything other than concerned health professionals who make no money from teaching others to recognize the signs of insufficient breastmilk? Of course not.

It’s easy to obtain tax records from non-profit foundations. The tax records from Fed Is Best reveal that both Christie and Jody receive $0 compensation. In contrast, Martinez Sullivan makes $168,968/yr to promote breastfeeding.

So why did Martinez Sullivan feel free to make such outrageous, unsubstantiated claims? I suspect it is because breastfeeding advocacy has created a culture of contempt for anyone who challenges their beliefs and claims. Under the influence of cognitive bias, which allows them to ignore the scientific evidence that breastfeeding has significant risks, the fallacy of argument from authority (the WHO, the AAP and every other medical organization promote breastfeeding as lifesaving!) and white hat bias (Nestlé!), they freely express their contempt for Fed Is Best.

That culture of contempt begins with the way that lactation professionals (and lay lactivists) view women who don’t breastfeed. They portray them as running the gamut from lazy (too selfish and self-absorbed!) through stupid (they are duped by formula companies!) up to the supposed moral high ground of helpless (they didn’t get enough support!). Lactation professionals view women who don’t breastfeed with such contempt that it never even occurs to them that women may have personal reasons for not breastfeeding or may have made an informed decision not to do so.

The result of their contempt is that babies become breastfeeding casualties. The single biggest risk of breastfeeding is dehydration and related complications from insufficient breastmilk. Up to 15% of first time mothers will not produce enough breastmilk to fully nourish a baby, especially in the early days after birth. Professional lactivists deliberately lie, insisting that insufficient breastmilk is vanishingly rare, despite the fact that the latest scientific evidence indicates that there are literally tens of thousands of newborn hospital readmissions each year for this complication. You can almost hear their eyes roll when a woman tells of her anguish at being unable to produce enough breastmilk. They hold women who don’t breastfeed in such profound contempt that they laugh at their distress and accuse them of faking it to selfishly avoid breastfeeding.

To say that lactation professionals lack insight into their own behavior is a profound understatement. Backpedaling frantically after being called out for her vicious accusations, Martinez Sullivan responded:

No mother should ever be shamed or stigmatized for how she feeds her child. Aside from being hurtful, this is “mommy war” nonsense that plays into the hands of the formula company giants, who pretty much invented the infant feeding mommy wars.

But implying that women who can’t or don’t want to breastfeed are dupes “in the hands of formula company giants” IS shaming. It’s yet another expression of contempt.

Breastfeeding professionals’ contempt toward other professionals who point out the risks of breastfeeding knows no bounds. Whether referring to Christie and Jody, myself, Courtney Jung or Joan Wolf, they don’t hesitate to imply that we are on the payroll of some nefarious organization or simply unconcerned with the health and wellbeing of babies. Those who earn their money promoting breastfeeding can’t imagine that feeding safety advocates might love babies more than they love money.

As I noted above, doctors favoring the original acid theory of stomach ulcers never accused researchers who claimed that bacteria caused ulcers of nefarious motives, shilling on behalf of a corporate entity, welcoming patients deaths or a hatred of stomach acid. In contrast, those who insist that breastfeeding is both lifesaving and almost perfect routinely accuse anyone who challenges them of shilling on behalf of formula companies, welcoming infant deaths and (my personal favorite!) hating breastfeeding.

Here’s a quote that breastfeeding professionals ought to keep in mind:

Science: If you don’t make mistakes, you’re doing it wrong. If you don’t correct those mistakes, you’re doing it really wrong. If can’t accept that you’re mistaken, you’re not doing it at all.

It is understandable that breastfeeding professionals have made mistakes in claiming that breastfeeding is perfect and complications are rare. But if they don’t correct those mistakes, they’re doing science wrong.

And if they can’t accept that they are mistaken — and treat everyone who disagrees with contempt — they aren’t doing science at all.

Everyone knew it was the gold standard for both health and sophistication.

Doctors recommended it and were sure to do it themselves. This despite the fact that for hundreds of years there had been obvious casualties.

It’s wasn’t until the Surgeon General’s Report of 1964, that the truth was finally presented for all to see. Tobacco wasn’t safe and had never been safe. It caused cancer, heart disease and lung disease. Thousands of people had been dying each year for decades, so why hadn’t anyone noticed?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Formula, not breastmilk, is the gold standard in infant nutrition.[/pullquote]

Marketing!

Breastfeeding is currently the gold standard for health and nutrition of infants.

Doctors recommend it and are sure to do it themselves. This despite the fact that for thousands of years there had been obvious casualties.

Aggressive breastfeeding promotion leads to tens of thousands of neonatal hospital readmissions each year in the US alone at a cost of hundreds of millions of dollars each year. Aggressive breastfeeding promotion causes neonatal brain injuries and deaths from dehydration, severe jaundice, low blood sugar and infants falling from or smothering in their mothers’ hospital beds. A single case of infant brain injury can cost millions in liability payments, not to mention the destruction of potential and the anguish of families.

So why hasn’t anyone noticed? Marketing!

As I explained yesterday, La Leche League, originally created by a group of traditionalist Catholic women in order to convince mothers of small children not to work, exploited the Nestle African tragedy to partner with the World Health Organization in promoting breastfeeding. Never mind that it was not infant formula that harmed babies, but the contaminated water used to make it. Never mind that children continued to die in their hundreds of thousands because they bathed in and ultimately drank that same contaminated water. This was the perfect opportunity to market breastfeeding and they took it.

They took it because it dovetailed neatly with their financial plans to profit from breastfeeding. At the same time that they partnered with the WHO to promote breastfeeding, they began to monetize it by creating the lactation consultant credential and lobbying heavily to install lactation consultants (themselves) in hospitals and doctors’ offices.

The heart of the marketing campaign was to convince everyone that “breast is best” and that breastmilk is “the perfect food.” Neither of those things were ever true (just as tobacco was never healthy) but after 30 years of marketing the average person “knows” that breastfeeding is the gold standard just like the average person in 1959 “knew” that smoking was healthy, or at a minimum, safe.

Don’t get me wrong: breastfeeding is not dangerous in the way that tobacco is dangerous. There is no safe way to use tobacco while millions of babies can be fully nourished with breastfeeding. But breastmilk is hardly the gold standard.

What would it take for something to be the perfect infant nutrition?

• It should contain all the nutrients and other factors that an infant needs.
• It must be available in sufficient quantity to promote vigorous growth of the infant.
• The infant must be able to access it easily.

Breastfeeding fails on all three counts. Breastmilk lacks sufficient iron and vitamin D; exclusively breastfed infants need vitamin supplements. As many as 15% of first time mothers cannot produce enough breastmilk to fully nourish an infant especially in the early days after birth. Moreover, a significant minority of infants cannot access milk from the breast. It has become fashionable to diagnose those babies as “broken” due to tongue tie and subject them to painful surgery though the scientific evidence provides no support for that treatment in the vast majority of cases.

You know what DOES meet the definition of the perfect infant nutrition? Formula!

It contains more nutrients than breastmilk. It is available in endless quantities. All infants can easily access it through bottles or feeding tubes.

In addition, it dramatically reduces the risk of neonatal hospital readmission, reduces the risk of dehydration, severe jaundice and low blood sugar, saving hundreds of millions of healthcare dollars and liability payments.

But, but, but breastfeeding is natural and formula is not. So what? Contaminated ground water is natural and filtered tap water is not. Living in caves is natural and central heating is not. Unvaccinated is natural and vaccines are not. In all three cases it is the “unnatural” that is far safer.

Wait, what? Formula doesn’t have maternal antibodies? That’s true, but the vast majority of antibodies a baby receives from its mother are transmitted across the placenta. Most antibodies in breastmilk can’t be absorbed through the infant gut; only the smallest antibodies, IgA, are biologically active within the infant. That accounts for the slight reduction in colds and diarrheal illnesses across the entire population of infants in the first year.

What about all those other benefits claimed for breastfeeding? Nearly all have been thoroughly debunked by careful studies that revealed that it is the higher maternal socio-economic status of breastfeeding mothers that accounts for benefits of breastfeeding, not breastfeeding itself.

I’m hardly the only person to point this out. Joan Wolf wrote in yesterday’s New York Daily News:

But, the WHO and myriad pro-breastfeeding groups will claim, the science on infant feeding is virtually unanimous. Breastfed babies are healthier, smarter and more socially successful than those who were formula fed throughout the life course, and formula feeding is dangerous. So they say.

The problem, as I have demonstrated in “Is Breast Best: Taking on the Breastfeeding Experts and the New High Stakes of Motherhood,” is that this research is poorly designed, executed and interpreted — and then grossly misrepresented among scientists and between researchers and the public.

Courtney Jung pointed the same thing out in her book Lactivism and an her op-ed in The NYTimes Overselling Breastfeeding:

Oddly, the fervor of breast-feeding advocacy has ramped up even as medical research — published in The Journal of the American Medical Association, BMJ in Britain and The American Journal of Clinical Nutrition — has begun to report that the effects of breast-feeding are probably “modest.”

Some sobering results have come from Dr. Michael Kramer’s Probit trial, which has studied a wide range of outcomes among about 14,000 mother-infant pairs for 16 years… While Probit found that breast-feeding had some benefits, including for cognitive development, it did not reduce the risk of obesity, asthma, allergies, dental cavities or attention-deficit hyperactivity disorder.

The benefits associated with breast-feeding just don’t seem to warrant the scrutiny and interventions surrounding American infant feeding practices… [A] meta-analysis of the research on breast-feeding done by the United States Agency for Healthcare Research and Quality in 2007 concludes that much of that research is weak: Some studies are too small, or they fail to control for confounding variables. The findings themselves are often inconclusive. One study will find evidence of an effect and another won’t — so we just don’t know which results to trust.

So why do we believe that breast is best? For the exact same reason we believed that tobacco was safe: marketing!

A new Surgeon General’s report might finally convince people that they’ve been duped by excellent marketing and that breast is NOT best for every mother and every baby.

I don’t see that on the horizon since most doctors of the early 21st Century are as enthralled by breastfeeding as the doctors of the early 20th Century were by smoking. I suspect that it will be insurance companies that will lead the way on this issue. Health insurers will realize how much they are spending on infant hospital readmission and will stop paying for it; as a result hospitals will revert to common sense in formula supplementation instead of aiming for lactivist ideological purity. Furthermore, malpractice insurers will look at the millions they are spending on babies falling from and smothering in their mothers’ hospital beds and pressure hospitals to bring back well baby nurseries instead of knuckling under to lactivist insistence on mandatory rooming in.

No matter how desperately lactation professionals continue to exaggerate the benefits of breastfeeding (the microbiome! epigenetics!) it simply costs too much in infant illness and death, maternal anguish and money to maintain the fiction — breast is best — that has been created through marketing.

 

Don’t believe me? I’d be happy to publicly debate (in print or in person) any well known lactation professional on this issue. Don’t hold your breath waiting for that to happen, though. No lactation professionals would dare subject their claims to a public debate; they know they would lose.

Welcome to the thousands of new readers who have visited the blog over the past few days. You’ve been drawn by the posts on breastfeeding in which I’ve attempted to correct the massive amount of misinformation that passes for “education” on the topic.

On Sunday (New US breastfeeding policy, adopted for the wrong reasons, will almost certainly save lives) I wrote about the fact that Trump, though generally wrong about everything, is right to oppose the draconian WHO regulations around infant formula.

On Monday (What the breastfeeding literature REALLY shows) I provided a summary of major papers published in the breastfeeding literature in the past 2 years. Collectively they show that insufficient breastmilk is common (up to 15% of first time mothers), formula supplementation makes successful breastfeeding more likely, pacifiers prevent SIDS and extended skin to skin contact leads to babies falling from their mothers’ hospital beds or suffocating while in them. Most importantly, the myriad purported benefits of breastfeeding actually come from the higher socio-economic status of breastfeeding mothers, not breastfeeding itself.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivism, like anti-choice activism, isn’t about babies; it’s about controlling women’s bodies.[/pullquote]

On Tuesday (The conventional wisdom about breastfeeding is DEAD wrong!) I wrote about the ways in which the benefits of breastfeeding have become conventional wisdom and how conventional wisdom is often wrong.

Yesterday (Finally, data on lives saved each year by breastfeeding: only 8% of WHO claim!) I showed that the WHO’s central claim about breastfeeding, that it could save more than 800,000 lives each year is based on a faulty mathematical model and is thoroughly undercut by the actual evidence. At its peak, formula use in developing countries resulted in 65,000 deaths per year, ENTIRELY due to contaminated water, not formula itself. That peak occurred in 1981. Since then according to Paul Gertler whose research established the 65,000 peak death toll:

…[T]he annual death toll has dropped to about 25,000, driven by improved access to clean water in the Southern Hemisphere.

That’s only 3% of the total claimed by the WHO.

So why have professional lactivists, including those at the WHO, grossly exaggerated the benefits of breastfeeding, ignored the risks, massively inflated the number of lives that could be saved and clung to the conventional wisdom long after it had been disproven? Their tactics have a lot in common with those of anti-choice activists because neither breastfeeding nor abortion is about babies. This is about controlling women’s bodies.

Although La Leche League, the original and premier lactivist organization has carefully scrubbed their website of the fact, it was a religion inflected organization originally founded by seven traditionalist Catholic women designed to keep other women out of the workforce by convincing them to breastfeed.

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

…founded in 1956 by a group of Catholic mothers who sought to mediate in a comprehensive way between the family and the world of modern technological medicine…

[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 idealization of motherhood reflects the place of Mary in Catholic popular devotion…

The League’s answer to the question “What should mothers do” is grounded in … the original faith community of its founders.

For those women, the contents of their Catholic faith and the existential question of motherhood are interdependent…

From its very inception lactivism has been about policing women through control of their bodies. The medical justifications were embroidered on later to conceal the religious goal.

From its founding in the late 1950’s through the 1970’s, LLL was an organization that depended entirely on volunteers for peer to peer teaching of breastfeeding. Two things happened in the early 1980’s to propel LLL to its current status as arbiter of and nexus for all things breastfeeding.

First, breastfeeding was monetized. LLL spun off a variety of organizations to create, educate and monitor an entirely new profession: lactation consultant. Though LLL continued to give away breastfeeding information for free, its daughter organizations worked aggressively to install lactation consultants in hospitals, doctors offices and public health organizations. The monetization of breastfeeding led inexorably to the moralization of breastfeeding. In an effort to create ever more employment opportunities for lactation consultants, ever more “benefits” were conjured for breastfeeding and ever more pressure was applied to women culminating in the Baby Friendly Hospital Initiative, a program to aggressively promote breastfeeding to new mothers while they were hospitalized after birth.

Second, these efforts dovetailed with moral outrage over Nestle’s behavior in Africa. In an effort to improve market share Nestle convinced women to abandon breastfeeding for the convenience of formula, deliberately ignoring the fact that many did not have access to clean water. LLL became an advisor to the WHO in creating a response which involved aggressive promotion of breastfeeding. It was at this point that lactivism devolved into a campaign against formula even though there was no evidence that it was formula itself that had caused the problem.

Nestle’s corporate malfeasance is so central to breastfeeding promotion that to this day, more than 30 years after the fact, outrage against Nestle remains front and center in every lactivist effort centered on demonizing formula, which is just about every lactivist effort.

But make no mistake, lactivist organizations have never dropped their original commitment to controlling women by policing their bodies.

Lactivism is not about babies since the benefits of breastfeeding are trivial in countries with access to clean water.

In truth, nearly all the claimed benefits of breastfeeding are based on studies that are weak, conflicting and riddled with confounding variables. When corrected for confounders like maternal education and socio-economic status, the only benefits that remain are an 8% decrease in the risk of colds and an 8% decrease in episodes of diarrheal illness across the entire population of infants in the first year. In other words, the vast majority of infants will experience no demonstrable benefit from breastfeeding.

Lactivism is not about saving babies lives since, with the small exception of extremely premature infants, breastfeeding DOESN’T save lives in industrialized countries.

Lactivism isn’t about following the scientific evidence since most efforts, like the Baby Friendly Hospital Initiative, IGNORE the scientific evidence about the benefits of formula supplementation and pacifiers and ignore the rising number of breastfeeding casualties: the tens of thousands of babies readmitted to the hospital each year for dehydration and other breastfeeding complications.

Lactivism isn’t about saving money since any potential healthcare savings are dwarfed by the hundreds of millions of dollars spent each year to hospitalize babies suffering breastfeeding complications and the hundreds of millions of dollars spent in liability payments for babies’ brain injuries and deaths as a result of those complications.

Lactivism is about controlling women through policing their bodies, imposing a restrictive view of motherhood on women in order force them back into the home. It’s about dictating to women how they should use their bodies, pressuring them to use their bodies in approved ways, and lying to them to convince them to knuckle under.

Is breastfeeding a good thing?

It can be. I breastfed four children (all adults now). They were fat, happy babies and I enjoyed it and was able to combine it with an extremely demanding job. But I have no illusions that it improved the health or intelligence of my children or my relationship to them.

In my view, given the facts about breastfeeding, our approach to breastfeeding ought to be the same as our approach to abortion:

HER baby, HER body, HER choice …

Anything else is an attempt to control women by controlling their bodies.

In 2016 The Lancet published a paper that made an extraordinary claim. According to Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect:

The scaling up of breastfeeding to a near universal level could prevent 823,000 annual deaths in children younger than 5 years …

It’s an extraordinary claim because it is belied by all existing real world data on the impact of formula around the world. Indeed countries with the lowest breastfeeding rates have the LOWEST infant mortality rates and countries with the highest infant mortality rates have the HIGHEST breastfeeding rates. And after 30 years of breastfeeding promotion that resulted in increased breastfeeding rates in a variety of countries, there’s no evidence that increasing the breastfeeding rate has any impact on infant mortality.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Breastfeeding doesn’t save lives; clean water saves lives.[/pullquote]

Since that claim was published I’ve searched incessantly for real world data to support that claim and was unable to find any. Neither could anyone else; I’ve challenged just about every major breastfeeding professional from every major breastfeeding organization to show me how many terms babies’ lives* are actually saved by breastfeeding. Thus far, no one could identify even a single one.

Now finally — finally! — a paper shows just how many lives are saved each year by breastfeeding: 65,000, a tiny fraction of the 800,000 claimed by The Lancet and the World Health Organization.

The paper is Mortality from Nestlé’s Marketing of Infant Formula in Low and Middle-Income Countries.

It’s an economics paper not a peer reviewed scientific paper. I wasn’t able to find it before because it was published only a few months ago in March 2018.

In contrast to The Lancet paper that relies on mathematical modeling, it it an attempt to find out exactly how many babies die when women who otherwise could breastfeed are pressured by companies to choose formula feeding instead.

The authors note what I have repeatedly emphasized: the WHO has staked out the claim that increasing breastfeeding rates could save more than 800,000 lives per year without ANY data to support it.

Intensive and controversial marketing of infant formula is believed to be responsible for millions of infant deaths in low and middle-income countries (LMICs), yet to date there have been no rigorous analyses that quantify these effects…

The authors attempt to rectify that problem. They start by explaining the “original sin” of Nestle:

The beginning of the public controversy over infant formula marketing practices in the developing world began in August 1973 when an article, The Baby Killer, was published in the New Industrialist. The article stressed the nutritional inadequacy of infant formula relative to breast milk, and provided examples of specific marketing abuses by Nestlé, the first major formula manufacturer to enter LMICs and the largest supplier worldwide. At the same time, public health researchers documented a large decline in breastfeeding contemporaneous with the introduction of infant formula, and published estimates of infant deaths resulting from the introduction of infant formula into LMICs ranging from annual figures of 1 million to 10 million …

The World Health Organization reacted:

In response, the World Health Organization and UNICEF organized a meeting of stakeholders out of which the International Code of Marketing of Breast-milk Substitutes (ICMBS) was created and later enacted in 1981.

The authors attempted to determine the impact of Nestle’s behavior on infant mortality over the past decades:

Nestlé’s phased entry over time into national infant formula markets provides plausibly exogenous variation in the market availability of formula conditional on location fixed effects. We exploit this variation to identify the causal effect of formula availability by estimating difference-in-differences models with location and year fixed effects. We interpret the results as Intent-to-Treat (ITT) estimates that capture the average mortality response to the availability of infant formula for purchase proxied by whether Nestlé is actively selling formula in the country. Our estimated treatment effects represent the intersection of adoption of infant formula by mothers within the exposed population and the impacts on infants from consuming the formula. The impact on infant mortality will also vary depending on whether formula is combined with clean water and whether it substitutes for breast milk or for some inferior nutritional supplementation such as water, diluted condensed milk, juice, rice water, or other low-quality substitute.

Looking at the data as a whole they found NO IMPACT of formula feeding on infant mortality:

The introduction of infant formula shows no statistically significant average impact on infant mortality for the population as a whole.

That’s why I and others have been unable to find any real world population data that shows that breastfeeding saves the lives of term babies.

The authors then drilled down into their data to find the impact of formula feeding among populations that lack access to clean water.

…[O]ur results show large and significant infant mortality deaths from formula introduction concentrated in vulnerable sub-populations. Specifically, infant formula availability had a significantly negative effect on mortality of infants born in households that used surface water. The availability of formula increased infant mortality by 12.9 per 1000 for households that used surface water relative to higher-quality water using households. The net effect of formula availability is an increase of 9.4 infant deaths per 1000 among mothers with poor-quality water.

What’s the magnitude of that effect? The authors looked at what happened in 1981, the year where Nestle’s market penetration was the highest:

We estimate the number of deaths for 1981, arguably the peak year of the controversy when media attention was the highest. We do this by multiplying the 47.8 million 1981 live births that occurred in Nestlé formula sales countries by the fraction of those households with surface water in those countries and by our estimate of the impact of formula on infants from households with only unclean surface water access, i.e. This yields an estimate of 65,676 infant deaths with a 95% confidence interval of [24,868, 106,485], lower than earlier estimates of one million or more, but unquestionably a substantial loss of human life.

It’s a substantial loss of life, but only a tiny fraction of the one to ten million lives claimed by lactation professionals and the WHO.

Since then the impact of formula on infant mortality has dropped both because of reductions in use of formula and increases in the availability of clean water. The claim that breastfeeding could save more than 800,000 lives per year is absolute nonsense. Indeed the real number is fewer than 65,000 lives per year, only 8% of the claimed impact.

Formula itself does NOT harm babies. Only contaminated water harms them. If we really wanted to save lives we would improve water quality since even breastfed babies have to bathe in that contaminated water and eventually drink it as they grow older. But it’s so much easier and cheap to hector mothers and pontificate about breastfeeding than it is to provide the very poor with clean water.

That doesn’t mean we should stop promoting breastfeeding; it’s still a valuable goal even if it only saves tens of thousands of lives each year instead of hundreds of thousands as claimed by the WHO. But it does mean that aggressive breastfeeding promotion through programs like the Baby Friendly Hospital Initiative has no place in societies with easy access to clean water. It means that draconian restrictions on formula advertising in industrialized countries are totally unwarranted. Most importantly, it means that the documented harms of aggressive breastfeeding promotion: brain injuries and deaths from dehydration, hypoglycemia, kernicterus, and babies falling from or being smothered in their mothers’ hospital beds, are inexcusable.

It also means that we cannot trust the WHO’s claims about breastfeeding being lifesaving. The claims were supported by real world data; now that we finally have that data, it appears that increasing breastfeeding rates can save less than 65,000 lives per year, a far cry from the 800,000 claimed by the WHO.

 

*There is real world data to show that breastmilk reduces the risk of necrotizing enterocolitis, a serious complication of extreme prematurity.