The reaction to the Trump administration’s decision to oppose the World Health Organization’s formula advertising restrictions has highlighted how conventional wisdom shapes thinking on a topic. The conventional wisdom about breastfeeding is that it is lifesaving, but the conventional wisdom is dead wrong.

Here is one of the best descriptions of conventional wisdom I’ve seen.

In most cases, CW is a lumbering beast: slow to move, but difficult to alter course once its big bullish head is set on moving in a certain direction… It’s loud, pervasive, and impossible to ignore – and avoid. Oftentimes, entire careers are staked on maintaining its veracity. When that veracity is challenged, either by critics or by experiment, the challenger is often silenced… [A] conforming chorus of assent can be mobilized to drown out even the most rigorously defended thesis, just as long as Conventional Wisdom is at stake.

For decades the conventional wisdom on stomach ulcers was wrong.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If breastfeeding saves lives why can’t the WHO find any term babies whose lives have been saved?[/pullquote]

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.

At about the time I graduated from medical school researchers Robin Warren and Barry Marshall discovered H. pylori, the bacteria that actually causes ulcers.

The backlash was brutal. Dr. Larry Altman, medical correspondent for The New York Times, who reported these results, later wrote, “I have never seen the medical community more defensive or critical of a story.” I spoke with Dr. Altman about these events, and to this day, he recalls that “this was the review that got me the most heat for misleading the public” …

Warren and Marshall eventually broke through the conventional wisdom, and ultimately won the Nobel Prize in Medicine. But someone else had actually made the exact same discovery more than 40 years before they did.

As a young researcher at the Harvard-affiliated Beth Israel Hospital in Boston in 1940, Dr. [A. Stone] Freedberg became curious about stomach ulcers while studying the effects of fever on the heart and circulatory system when infections caused it to collapse. Scientific reports taught him that many such patients developed tiny bleeding ulcers in the stomach and small bowel…

He published his findings but was ignored. His superiors were convinced that he had made a mistake and counseled him to give up his claim and move on.

The conventional wisdom that ulcers were caused by acid was so strong that it suppressed the true cause for decades and people with ulcers, denied effective treatment, died as a result.

Today the conventional wisdom is that breastfeeding saves lives, that breastmilk is the “perfect” food and that women must be pressured into breastfeeding for the good of their infants. Whole careers (including careers at the World Health Organization) have been staked on maintaining the veracity of these claims. When that veracity is challenged, arbiters of the conventional wisdom attempt to silence the challengers.

The conventional wisdom on breastfeeding is DEAD wrong.

The evidence has been around for centuries. There once was a time when all babies were breastfed and 20-30% or more died in infancy. Indigenous cultures on nearly every continent practice pre-lacteal supplementation, giving babies teas, water or honey, in recognition that breastfeeding is often not enough to fully nourish a baby. Formula was invented in 1860’s specifically because some mothers could not produce enough breastmilk or because they died in childbirth. Indeed, as far as I can determine, there was NEVER a time or place where exclusive, extended breastfeeding was practiced in the way the World Health Organization now recommends.

The WHO insists that breastfeeding is lifesaving, quoting a variety of mathematical models that predict that when more women breastfeed fewer babies die. Yet the WHO can’t manage to find any term babies whose lives have been saved or any countries where increasing the breastfeeding rate has resulted in a decrease in infant mortality.

Nonetheless, everyone “knows” that breastfeeding saves lives.

The countries in the world with the lowest breastfeeding rates have the BEST infant mortality rates and the countries with the highest breastfeeding rates (approaching 100%) have some of the WORST infant mortality rates.

Nonetheless, everyone “knows” that breastfeeding saves lives.

In June 2017, NPR published Secrets Of Breast-Feeding From Global Moms In The Know:

It’s almost like in the U.S. we’ve lost the breast-feeding instinct. That Western society has somehow messed it up. [Evolutionary biologist Brooke] Scelza wanted to figure out why: What are we doing wrong?

So a few years ago, she traveled to a place with some of the best breast-feeders in the world.

In the desert of northern Namibia, there’s an ethnic group that lives largely isolated from modern cities. They’re called Himba, and they live in mud huts and survive off the land…

Moms still give birth in the home. And all moms breast-feed.

“I have yet to encounter a woman who could not breastfeed at all,” Scelza says. “There are women who have supply issues, who wind up supplementing with goat’s milk, which is not uncommon. But there’s basically no use of formula or bottles or anything like that.”

NPR neglected to mention that the infant mortality rate among the Himba is astronomical. According to USAID, the infant mortality rate in Namibia is 32.8/1000 (compared to 5.82/1000 in the US).

Nonetheless, everyone “knows” that breastfeeding saves lives.

During World Breastfeeding Week, Melinda Gates posted this on Twitter:

Between 2009 and 2014 breastfeeding rates tripled to 57% in Vietnam, soared to more than 80% in Bangladesh and increased to more than 80% in Ethiopia. But what happened to infant mortality rates in response? As far as I can determine, the change in breastfeeding rates had no impact on the trajectory of infant mortality rates.

Everyone “knows” that breastfeeding saves lives despite the fact that no one can find any term babies whose lives have been saved.

Meanwhile, as a result of aggressive breastfeeding promotion, we are literally breastfeeding babies to death.

The Baby Friendly Hospital Initiative was implemented around the globe without any evidence that it increases breastfeeding rates. The Ten Steps of the initiative directly violate both scientific evidence and medical ethics. There is no evidence that locking up formula improves breastfeeding rates; there is no evidence that banning supplementation improves breastfeeding rates (and there is evidence that supplementation increases breastfeeding rates); there’s no evidence to justify banning pacifiers and considerable evidence that pacifiers reduce the risk of sudden infant death syndrome (SIDS); and it is deeply unethical to restrict what providers can say when counseling patients about infant feeding.

Worst of all, there’s a growing body of evidence that aggressive breastfeeding promotion is leading to brain injuries and deaths of infants from hypoglycemia, jaundice, dehydration, starvation and infants falling from or being smothered in their mothers’ hospital beds because well baby nurseries have been closed.

But everyone “knows” that breastfeeding saves lives. That’s what the conventional wisdom about breastfeeding tells us but the conventional wisdom is wrong.

Don’t believe me? Ask those, including those at the WHO whose entire careers have been staked on the claim that breastfeeding save lives, to show you the term babies whose lives have been saved. Don’t allow yourself to be fobbed off by mathematical models; insist on real population data.

But don’t hold your breath while waiting for that data; because while everyone “knows” that breastfeeding saves lives, no one knows any term babies whose lives have been saved.

Yesterday I wrote about the Trump administration’s typically ham handed effort to oppose a World Health Organization breastfeeding resolution.

Make no mistake; Trump was only thinking about the welfare of formula manufacturers. But WHO breastfeeding recommendations are actually injuring and killing babies and they should have been changed long ago. How do I know? I read the scientific research.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Babies are dying because lactivists are lying.[/pullquote]

I hope you will read it, too so I’m citing and explaining the most important papers of the past 4 years. Collectively they show that 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.

The 2014 study, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons by Colen and Ramey, was a breakthrough study that showed that almost all the claimed benefits of breastfeeding don’t actually exist.

We have always known that breastfeeding varies among ethnic, cultural and economic groups and indeed, previous studies that corrected for these factors show that breastfeeding has only small advantages. This study looks at breastfeeding vs. bottlefeeding WITHIN families by comparing siblings who were fed differently.

The authors found that there were differences between breastfed and bottle fed children in 10 of the 11 measured variables when looking at the overall group. Those differences persisted when comparing families in which all the children were breastfed to families where all the children were bottlefed. But when the authors looked within families, there was NO SIGNIFICANT DIFFERENCE between breastfed and bottle fed children.

Previous research, in particular the PROBIT studies conducted over the past two decades by Michael Kramer in Belarus suggest a variety of benefits that have subsequently found to be illusory. At this point, the only confirmed benefits of breastfeeding for term babies are a slightly decreased risk of colds and episodes of diarrheal illness across the entire population of infants in the first year. The vast majority of infants will experience no measurable benefit from breastfeeding. The one exception to this is premature infants; breastmilk reduces the risk of necrotizing enterocolitis, a serious complication of extreme prematurity.

Don’t believe me? Listen to Michael Kramer himself.

Kramer is emphatic that breastfeeding does NOT prevent obesity, does NOT prevent allergies, and does NOT prevent asthma. When asked why lactivist organizations continue to insist on benefits that have been shown not to exist, he explains that these organizations rely upon preliminary data and simply refuse to accept anything that contradicts it. He is quite blunt that about the fact that lactivist organizations won’t accept scientific evidence that doesn’t comport with what they believe and he worries that their insistence of exaggerating benefits will undermine women’s trust in healthcare providers.

So most of the claimed benefits for breastfeeding don’t exist. But the real problem with aggressive breastfeeding promotion is that it HARMS babies.

That’s why in 2016 US public health officials changed the United States Preventive Services Task Force (USPSTF) guidelines reduce the relentless pressure on women to breastfeeding.

An accompanying editorial Interventions Intended to Support Breastfeeding: Updated Assessment of Benefits and Harms noted that the vaunted Baby Friendly Hospital Iniative wasn’t merely a failure, it also exposed infants to danger.

The BFHI bans pacifiers in contradiction to the scientific evidence.

Counseling to avoid the use of pacifiers in the newborn period is an intervention commonly used to support breastfeeding. However, evidence has been building that infant use of a pacifier may be associated with a reduced risk of sudden infant death syndrome,7 the most common cause of postneonatal death in the United States. The evidence review showed that avoiding pacifiers was not associated with any breastfeeding outcomes assessed in the evidence review. A recent Cochrane systematic review reached the same conclusion. Thus, routine counseling to avoid pacifiers may very well be ethically problematic.

The BFHI bans formula supplementation in contradiction to the scientific evidence.

Counseling mothers to avoid giving infants any food or drink other than breast milk during the newborn period is step 6 of the BFHI and one of the primary care interventions most commonly used to support breastfeeding. Three randomized trials have specifically examined the effectiveness of counseling to avoid giving newborns any food or drink other than breast milk; none showed a beneficial effect of such counseling on breastfeeding duration.

Other harms were noted in the 2016 paper Unintended Consequences of Current Breastfeeding Initiatives:

Enforced prolonged skin to skin contact leads to deaths from Sudden Unexpected Postneonatal Collapse (SUPC).

Reports of SUPC include both severe apparent life-threatening events (recently referred to as brief resolved unexplained events) and sudden unexpected death in infancy occurring within the first postnatal week of life. A comprehensive review of this issue identified 400 case reports in the literature, mostly occurring during skin-to-skin care, with one-third of the events occurring in the first 2 hours after birth …

Infant injuries and deaths as a result of enforced 24 hours rooming in and closing well baby nurseries.

An overly rigid insistence on these steps in order to comply with Baby-Friendly Hospital Initiative criteria may inadvertently result in a potentially exhausted or sedated postpartum mother being persuaded to feed her infant while she is in bed overnight … This may result in prone positioning and co-sleeping on a soft warm surface in direct contradiction to the Safe Sleep Recommendations of the National Institutes of Health. In addition, co-sleeping also poses a risk for a newborn falling out of the mother’s bed in the hospital, which can have serious consequences.

The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature confirmed many of the risks noted above as well of the lack of effectiveness of the BFHI itself.

How many babies are being harmed?

According to the 2018 paper Health Care Utilization in the First Month After Birth and Its Relationship to Newborn Weight Loss and Method of Feeding by Flaherman et al.:

We had data on inpatient feeding for 105,003 (96.6%) vaginally delivered newborns and 34,082 (97.0%) delivered by Cesarean. Among vaginally delivered newborns, readmission after discharge from the birth hospitalization occurred for 4.3% of those exclusively breastfed during their birth hospitalization and 2.1% of those exclusively formula fed during their birth hospitalization (p<0.001)… For Cesarean births, readmission occurred for 2.4% of those exclusively breastfed during the birth hospitalization and 1.5% of those exclusively formula fed during the birth hospitalization (p=0.025)…

To put that in perspective, with 4 million births each year and more than 75% hospital breastfeeding rates, that means we should expect 60,000 excess newborn hospital admissions at a cost of more than $240,000,000 each and every year — nearly a quarter of a billion dollars. And that doesn’t even count the downstream impact of brain injuries, a consequence that was beyond the purview of this study.

Lactivists have developed a cult-like fixation on exclusive breastfeeding and consider formula supplementation to be anathema, but the scientific evidence shows the opposite.

The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial

Current public health initiatives emphasize the importance of exclusive breastfeeding during the birth hospitalization, but our randomized trial of 164 newborns did not demonstrate improved outcomes for infants receiving exclusive breastfeeding compared with limited formula supplementation using the ELF strategy…

[T]hese results suggest that using ELF in a carefully structured, temporary manner may not interfere with breastfeeding or maternal experience in the first month or have a negative impact on intestinal microbiota. At the same time, our results suggest that further studies are needed to assess whether ELF reduces the risk of neonatal readmission, especially in the first week after birth. Using small volumes of formula on a temporary basis for newborns with pronounced weight loss may have the potential to help clinicians and mothers provide the nutritional volume needed by babies without interfering with duration of breastfeeding or with the health benefits achieved from longer breastfeeding duration.

Why is there such a disconnect between what lactivists claim about breastfeeding and what the scientific evidence actually shows?

Most papers cited in support of the benefits of breastfeeding are mathematical models based on extrapolation of small studies that are often riddled with confounders.

To my knowledge — please correct me if you have other data — there is NO CORRELATION (let alone evidence of causation) between breastfeeding rates and infant mortality rates. The countries with the lowest breastfeeding rates have the lowest rates of infant mortality and the countries with the highest infant mortality have breastfeeding rates approaching 100%. There is NO EVIDENCE that increasing breastfeeding rates within a country has any impact on the mortality rates of term babies.

Why have lactivists grossly exaggerated the benefits of breastfeeding and hidden the significant risks? That’s a philosophical problem; lactivists have claimed that breastfeeding — in contrast to all other natural processes — is perfect. But there is no biological process that is perfect. Just as 12% of women experience infertility, and 20% of pregnancies naturally end in miscarriage, breastfeeding has a failure rate, too, up to 15%.

Imagine what would happen if we told women struggling to get pregnant that infertility is rare and probably their fault. The result would be failure to have desired children and tremendous anguish. Imagine what would happen if we told women that miscarriage was rare and probably their fault. The result would be that millions of women would have their grief compounded by the sense that they were alone and could have prevented the miscarriage if they’d tried harder or had more support.

We don’t need to imagine what would happen if we told women that insufficient breastmilk was rare (though it is common) and that they could have breastfed successfully if only they’d tried harder or received more support. We know what happens: tens of thousands of newborn hospital readmissions; brain injuries and deaths from dehydration and other complications of insufficient breastmilk; injuries and deaths from babies smothering in or falling from their mothers hospital beds; an increase in SIDS from cosleeping and from depriving babies of pacifiers.

The sad truth is this: babies are dying because lactivists are lying.

Don’t take my word for it; read the scientific literature!

To my shock I find myself agreeing with something done by the Trump administration.

According to today’s New York Times:

A resolution to encourage breast-feeding was expected to be approved quickly and easily by the hundreds of government delegates who gathered this spring in Geneva for the United Nations-affiliated World Health Assembly…

Then the United States delegation, embracing the interests of infant formula manufacturers, upended the deliberations.

American officials sought to water down the resolution by removing language that called on governments to “protect, promote and support breast-feeding” and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children.

The lactivist community is outraged, but the new US policy — nakedly designed to benefit the formula industry — will almost certainly save the brain function and lives of newborns. Why? Three reasons:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Even had the purported benefits of breastfeeding appeared, they would not have justified the pressure on women; but those benefits never appeared. [/pullquote]

1. Most claims of lactation professionals have been thoroughly DEBUNKED by scientific evidence.
2. There is NO EVIDENCE that breastfeeding is correlated with infant health outcomes.
3. There is a significant and growing body of evidence that the pressure to exclusively breastfeed HARMS babies. It doubles the risk of newborn hospital readmission and increases the risk of neonatal brain injury and death from dehydration, severe jaundice, hypoglycemia, and smothering in or falling from maternal hospital beds.

Sadly, it is lactation professionals themselves who are responsible for this dismal state of affairs. By grossly over promising on the benefits of breastfeeding, by utterly ignoring the substantial risks, and by disingenuously and irresponsibly extrapolating from the impact of contaminated water used to make formula in underdeveloped countries to demonizing formula instead of contaminated water.

Lactation professionals have given the Trump administration moral cover for what is undoubtedly a business decision.

According to the spokesman for the US Department of Health and Human Services:

The resolution as originally drafted placed unnecessary hurdles for mothers seeking to provide nutrition to their children,” an H.H.S. spokesman said in an email. “We recognize not all women are able to breast-feed for a variety of reasons. These women should have the choice and access to alternatives for the health of their babies, and not be stigmatized for the ways in which they are able to do so.”

That’s 100% correct because WHO breastfeeding resolutions since 1981 have been designed to benefit the lactation industry, not babies. The point of these resolutions has been to place unnecessary — and increasingly ugly — hurdles in front of women who wish to use formula: banning formula supplementation, locking up formula in hospitals, forcing women to sign formula “contracts,” banning formula advertising and banning the use of discount coupons to purchase formula.

These ugly hurdles violate mothers’ autonomy; women have the absolute right to decide whether or not they wish to use their breasts to feed their infants. Even had the purported benefits appeared, they would never have justified the inappropriate pressure on women. But those benefits never appeared:

There is no connection between country-wide breastfeeding rates and infant outcome. The countries with the lowest breastfeeding rates (like the UK which is the absolute lowest) have some of the best infant health outcomes and the countries with the worst rates of infant mortality and morbidity have the highest rates of breastfeeding.

To my knowledge — please correct me if you have other information — there is no evidence that increasing breastfeeding rates within a country has EVER had any impact in term babies or overall morbidity and mortality rates.

That’s hardly surprising since the campaign to promote breastfeeding is based on an empirical lie. In truth: Breast is NOT best for every mother and every baby since breastfeeding has a significant failure rate.

Up to 15% of first time mothers will be unable to produce enough breastmilk especially in the early days after birth. Breastfeeding — like fertility and pregnancy — is imperfect.

This was well known to our ancient foremothers. Contrary to the current pressure to breastfeed exclusively, indigenous people on nearly every continent practice prelacteal feeding and supplementation. The high rate of death from insufficient breastmilk led to the supplementation of breastfeeding with teas, water and honey. Sadly, those had their own drawbacks because of microbial contamination but the practice has been widespread for probably tens of thousands of years or more. The risk of death from insufficient breastmilk was greater than the risk of death from microbial contamination of supplements.

Lactation professionals have also promoted the empirical lie that formula is harmful. More than 40 years after the fact they continue to point to the moral horror perpetrated in Africa by Nestle. In order to increase profits, Nestle deliberately and knowingly encouraged African women who lacked access to clean water to replace breastmilk with powdered formula. Babies died needless, preventable deaths as a result. Lactational professionals use the moral debacle to demonize formula even though it was the water that was unsafe, not the formula. There is NO EVIDENCE that formula — properly prepared with clean water — is harmful in any way.

No matter. Try having a conversation with lactivists and you will immediately run into (the newly named by me) Tuteur’s Law of Breastfeeding Discussion. The well known Godwin’s Law asserts:

As an online discussion grows longer, the probability of a comparison involving Hitler approaches 1.

In other words, if any online discussion goes on long enough, someone will inevitably be compared to Hilter.

Tuteur’s Law of Breastfeeding Discussion asserts:

In any online (or print) lactivist discussion of formula, the probability of the invocation of Nestle’s abhorrent behavior approaches 1.

In other words, in any discussion of formula, those noting the inherent risks and limitations of breastfeeding will inevitably be compared to Nestle.

Just as the invocation of Hitler in Godwin’s law is designed to derail the discussion, the invocation of Nestle in Tuteur’s law is also designed to put an end to any discussion that might ultimately reveal the risks of exclusive breastfeeding.

In truth, Big Formula is no different from Big Pharma; both have behaved immorally in the past. But just as Big Pharma’s immoral behavior doesn’t invalidate the tremendous life saving powers of vaccines, statins, antihypertensives, anti-depressive and anti-psychotic medications, the immoral behavior of Big Formula doesn’t change the fact that formula has saved and continues to save the lives of more babies than breastfeeding ever could.

Once again the Trump administration is wrong, but this time they might save lives in spite of themselves. Even a broken clock is right twice a day.

I read your piece Dear Fed Is Best … and I am so sorry.

I am so sorry for your poor baby who suffered terribly as a result of your cult-like worship of breastfeeding.

My first few days with my baby were actually glorious in the moment…

Our bubble was violently burst on her fifth day of life. The midwife came to weigh my beautiful baby and she had lost 20% of her birth weight… I was asked to give my nipple a squeeze and when milk surfaced I was told ‘Oh. You’ve got loads’… Nevertheless, they thought it best to ring the hospital. Apparently, the paediatrician was not worried and decided that we should give her another 3 days to see what happened.

And so they left us. For another three days…

Why didn’t you just feed her formula??!!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]I am so sorry that being a breastfeeding apologist has robbed you and your fellow lactivists of simple human compassion.[/pullquote]

You were well aware that 20% weight loss is dangerous; that’s why you called the hospital, isn’t it? It’s as if you valued ideological purity above your daughter’s wellbeing as she was obviously failing to thrive.

Instead:

We ended up in hospital when she lost more weight. I watched the doctors tell me that they were deeply concerned about my baby, that they would need to transfer her to another unit for paediatric intensive care, that they would need to send a doctor and a nurse in the ambulance with her so we would need to make our own way as there wasn’t room for us. I watched the ambulance blaze past me on the motorway, blue lights flashing and siren blaring. Being separated from my precious girl was torturous.

There were moments of horrific trauma that week in intensive care. Like when they told us that they needed to re-hydrate her at a very specific speed and that if they got that wrong she could be left brain damaged. Or the time that her drip tissued and left blisters the size of her fist all along her arm, because somebody had given her a drip with potassium in. After that there were two hours of hell as the doctor tried desperately and repeatedly to replace her drip…

I am terribly sorry for her starvation and her traumatic hospitalization since you could have easily prevented it with formula but instead let her suffer until she was nearly dead.

But that’s not the only reason I am sorry.

You write:

I can only reason that for somebody to have launched a campaign such as yours they must have a story as harrowing as mine.

I am so sorry that you lack the insight to understand that the only reason your baby didn’t die or sustain permanent brain damage is LUCK; other mothers were not so lucky and now must live with empty arms.

There are stories that are MORE harrowing than yours and it baffles me that you don’t recognize the difference between a baby who recovers fully and one who never recovers or even dies.

You boast:

In a desperate attempt to ensure that this could never happen to us again, I learnt everything I could and sought support before having my next baby. And miraculously, this one thrived on breastfeeding alone from the very beginning. Nothing about my boobs changed between my first and second baby. My physiology remained exactly the same. And yet, I was able to feed my second baby totally and completely. The only thing that changed was the amount of knowledge and support that I had. Nothing more.

I am so sorry that you don’t understand that while your personal situation may have had a preventable cause, insufficient breastmilk is a very real biological phenomenon.

Breastfeeding, like fertility and pregnancy, has a significant failure rate as a result of known biological pathophysiology. No amount of support will reverse the effect of polycystic ovary disease or insufficient glandular tissue. It reflects remarkable ignorance or insensitivity or both to ignore that reality. It’s like claiming that because you had difficulty conceiving the first time and no difficulty the second, infertility doesn’t really exist.

You write:

Am I glad that in our time of crisis, there was substitute milk available to us that helped keep my baby alive . . . of course I am! But do I wish I’d formula fed her from the start and never put her to the breast? Absolutely not! …

I am so sorry that your daughter’s suffering turned you into an apologist for breastfeeding. Instead of recognizing that exclusive breastfeeding nearly killed your daughter, you continue to offer cult-like devotion.

I want to believe that your motivation in writing this piece is pure and that it is your desperatation to deny your own role in nearly killing your baby that makes you so insensitive to those who were not as lucky as you.

But then you write this:

I want to believe that your motivation is pure and that you are merely trying to spare other women from enduring what you have.

Advocates of Fed Is Best from the founders on down to individual women have given you NO REASON to question their motivation yet you do so anyway.

Why?

Because you can’t bear to acknowledge that breastfeeding isn’t perfect and that aggressive breastfeeding promotion doubles the rate of newborn hospital readmission, and leads to brain damage and death from dehydration, hypoglycemia, kernicterus and falling from or smothering in maternal hospital beds.

Ultimately, I am so sorry that being a breastfeeding apologist has robbed you and your fellow lactivists of simple human compassion.

Only someone who lack compassion could have written a piece like yours.

It’s almost as if lactivists can’t help themselves.

The mainstream media is suddenly full of mothers sharing the guilt of not being able to breastfeed and their anguish over nearly starving their babies. Over and over again new mothers have shared their stories about being wounded by the shaming language favored by lactation consultants: “artificial” baby milk, “risks” of formula feeding, comparisons of formula to tobacco.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Seals Allers and her colleagues appear to believe that everyone (millions of mothers, tens of thousands of doctors) is an ignorant dupe but themselves.[/pullquote]

I’ve learned that it is too much to expect lactation consultants to apologize as any healthcare professional would be ethically obligated to do, but is it really too much to expect them to stop using shaming language? Apparently it is.

Three days ago lactation consultant Kimberly Seals Allers posted this gem on Twitter:

No one would accept a nutritionist trained at a’McDonalds Health Institute’ but every day mamas face pediatricians only trained in breastfeeding by infant formula industry. The ones who financially benefit from failure of breastfeeding. We deserve better!

When called on it, Seals Allers resorted to that favorite lactivist tactic, gaslighting.

I speak facts. Shaming is your language not mine. My tweet is about where and how pediatricians receive training and who is best to do it. Commercial industry or non partisan medical authorities. All other assumptions about derision are made up and are your own.

So few words, so much lying and shaming.

1. The comparison of formula to McDonald’s is grossly irresponsible. Whereas certain McDonald’s products have lots of calories and little nutrition, infant formula is the PERFECT food for infants with the perfect amount of calories and the perfect amount of nutrients, indeed more nutrients than breastmilk.

2. It is meant to be vicious. The tweet not so subtly implies that women who choose to formula feed are knowingly and willfully choosing a nutritionally empty food for their babies.

3. It is a lie. Pediaticians are not trained by formula manufacturers. Indeed, I challenge Ms. Seals Allers to name 5 pediatrics residency programs where formula manufacturers are in charge of breastfeeding education.

4. It implies that pediatricians who value infant health over ideological purity are dupes of the formula industry. A growing body of research shows that the aggressive breastfeeding promotion campaigns favored by lactation consultants are injuring and even killing babies. Exclusive breastfeeding doubles the rate of neonatal hospital readmission, leading to tens of thousands of babies who are readmitted to the hospital and hundreds of millions of dollars of healthcare spending each year. Babies are being brain injured and are dying from dehydration, hypoglycemia, kernicterus and smothering in or falling from their mothers hospital beds because well baby nurseries have been closed.

5. It implies that women who don’t breastfeed are selfish idiots. This is not merely an insult to women who choose formula, but it is a denial of their moral agency. This is how lactivists justify ignoring the reasons women give for choosing formula since those women “didn’t choose” to use formula, they were tricked into it.

This is not the first time that Seals Allers has struck out aggressively and viciously against women who use formula to feed their babies and the health professionals who support them.

Why?

I suspect it reflects extreme frustration with the ongoing failure of lactivist efforts. While breastfeeding initiation rates have gone up dramatically, rates of extended breastfeeding have not followed suit. Lactation professionals could look at the situation and ask, “What are we doing wrong?,” but that involves introspection and taking responsibility, both apparently too uncomfortable to contemplate. Instead lactation professionals ask, “Who is doing this to us?,” and embrace the conspiracy theory that formula manufacturers are behind lactivist failures.

What are lactation professionals doing wrong?

• They value ideological purity (exclusive breastfeeding) over combination feeding.
• They demonize formula to a ridiculous extent, making themselves look foolish.
• They lie about the fact that insufficient breastmilk is common.
• They recommend barbaric regimens of feed/pump/supplement without any evidence of efficacy.
• They ignore the harms (sometimes deadly harms) to both babies and mothers.

Instead of acknowledging their own mistakes they prefer to blame the formula industry:

They claimed easy access to formula in hospitals the prevented breastfeeding so they banned formula; breastfeeding rates didn’t change appreciably.

They claimed formula gifts given to new mothers prevented breastfeeding so they banned gifts; breastfeeding rates didn’t change appreciably.

They decried lack of hospital based lactation support so they created the Baby Friendly Hospital Initiative; breastfeeding rates didn’t change appreciably but readmissions and injuries rose.

Now, as neonatologists and pediatricians scramble to save the brains and lives of babies harmed by aggressive breastfeeding promotion, Seals Allers has the unmitigated gall to float a monstrous lie, that pediatricians are trained by formula companies.

It’s almost as if Seals Allers and her colleagues believe that everyone (millions of mothers, tens of thousands of doctors) is an ignorant dupe but themselves.

Of course there’s an alternate possibility: mothers and doctors are caring individuals who have discovered through experience or scientific evidence that breast isn’t best for every baby or every mother and a few thousand lactation consultants are the ones who are dupes. They’ve been duped by a philosophy that values ideological purity over infant and maternal health.

But lactation professionals never, ever consider the possibility that THEY are the ones who are wrong. Far easier to lie and shame others than to take responsibility for their own misconceptions, misinterpretations and mistakes in promoting breastfeeding above all else.

In our obsession with lowering C-section rates, there has been much handwringing over the lost art of forceps deliveries. The dramatic rise in C-section rates has been caused in part by the fact that many deliveries that would have been accomplished by forceps have become C-sections because of our reluctance to use forceps. But there’s a good reason why forceps have gone out of fashion: they are much more likely to harm a baby than C-sections.

This hideous case is just one example: Mom blames newborns’ death on doctor’s use of forceps.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We shouldn’t lament the passage of forceps into history  [/pullquote]

A Long Island obstetrician allegedly used forceps so aggressively during a delivery that he severed the infant’s head internally from his spine, according to court papers.

A devastated Megan Stirnweiss, 23, says her nightmare began when she went to Southampton Hospital in labor Dec. 30, in a last-minute decision after her home delivery became too painful.

What happened?

The doctor put forceps around the baby’s head and yanked, dragging Stirnweiss — who was holding onto the bars of her hospital bed — all the way down to the edge, court papers say.

Then “he pulled the forceps that he had around the fetus’s head, lifting [Stirnweiss] off the bed by the forceps around the fetus’s head, and shook her vigorously until the baby was delivered at 2:56 a.m.,’’ according to the lawsuit…

The baby — who “was internally decapitated” — was whisked away, the papers state.

As for Stirnweiss, she “suffered disruption, dislocation, tearing and lacerations of her internal organs and structures,’’ her suit says. She now “is in constant pain’’ and will “require reconstructive surgery,’’ the papers state.

The accompanying picture of the baby adds more detail for those who know where to look. While the doctor may or may not have used excessive traction, one thing appears indisputable; the doctor did not put the forceps on properly. Forceps are designed to rest over the baby’s cheeks. This baby has an obvious imprint of a forceps blade over his forehead, extending to his eye. The forceps application wasn’t even close.

This highlights a fundamental difference between forceps and C-sections. Forceps use requires far more skill than performing surgery.

As Atul Gawande wrote in a fabulous piece entitle The Score:

“Forceps deliveries are very difficult to teach—much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’ With the forceps, though, there is a feel that is very hard to teach.” Just putting the forceps on a baby’s head is tricky. You have to choose the right one for the shape of the mother’s pelvis and the size of the child’s head—and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, travelling exactly in the space between the ears and the eyes and over the cheekbones. “For most residents, it took two or three years of training to get this consistently right,” he said. Then a doctor must apply forces of both traction and compression—pulling, his chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. “When you put tension on the forceps, you should have some sense that there is movement.” Too much force, and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”

Back when C-sections were considerably more dangerous than they are today, fetal injuries caused by forceps seemed like a reasonable trade-off for avoiding a procedure that might kill the mother. Once the C-section became as safe as it is today, harming a baby’s health and neurological function no longer seems like a reasonable risk.

It is important to note that there are different types of forceps deliveries. Outlet forceps, as the name implies, are used only when the head is extremely close to delivery. These forceps shorten the time to a birth that was going to happen anyway. They are often used to shorten labor when fetal distress is diagnosed and they rarely cause injuries.

Mid-forceps, in contrast, are used to deliver a baby that is stuck despite what appears to be a large enough maternal pelvis. They involve far more skill, far more traction, and far higher risk of injury. The most dangerous mid-forceps procedures are mid-forceps rotations. These are used to turn a baby in the unfavorable occiput posterior (OP or “sunny side up”) to the more favorable occiput anterior position and then traction is applied to deliver the baby. Not surprisingly, these procedures require the most skill of all and pose the most danger to both baby and mother.

The potential danger to the baby is obvious: fractured skull, neurological injury, and internal decapition (fracturing the top of the spine). The potential danger to mothers is also significant: far higher rates of anal sphincter injuries and subsequent problems with continence and sexual function.

Mid-forceps, and in particular mid-forceps rotations, are used to deliver babies that probably will not come out or will not come out alive if nature is left to take its course. If the baby cannot be delivered, the mother will die, too. So allowing a woman to push more than 3 or 4 hours in this situation won’t result in a vaginal delivery. The only choice is between forceps and Cesarean.

Most mothers and many obstetricians think it’s no choice at all. A C-section, which involves slightly more risk for the mother and virtually no risk to the baby, makes more sense than forceps, which involves very significant risks to the baby and risks to the pelvic floor of the mother.

Had this doctor opted for a C-section instead of forceps, both the baby and mother probably would have done fine.

Instead:

Stirnweiss, a cook for the US Coast Guard, said she and her husband kept their baby alive on machines for seven days so that his organs could be donated. A baby from Toronto, Canada, received Matthew’s lungs.

“He gave the ultimate gift of life,” she told The Post of her son.

Is this an indictment of all forceps?

Dr. Steven Goldstein, a professor of obstetrics and gynecology at NYU Langone Medical Center who is not involved in the suit, told The Post, “This is a terrible case.

“This is very sad, but this is not necessarily indicative of the way that forceps can and should be used,’’ he said. “Some forceps are still very safe.”

That’s true. Outlet forceps are very safe because the baby would have eventually come out vaginally in any case. But mid-forceps, the forceps procedures that have been replaced by C-sections, have major risks to both babies and mothers. No one should lament their passing into history or the higher C-sections rates that result.

Yesterday I wrote about the fact that midwifery philosophy has been notoriously unsuccessful. Despite tremendous rhetorical efforts to demonize inductions, epidurals and C-sections, the rate of all three has only increased. Breastfeeding professionals have been similarly unsuccessful. Despite aggressive promotion of exclusive, extended breastfeeding — involving both hospital and government backing — exclusive, extended breastfeeding rates are still quite low in many industrialized countries. More women try breastfeeding, it’s true, but most stop when they find it’s painful, inconvenient and, most importantly, doesn’t satisfying their babies’ hunger.

What’s going on? Despite relentless pressure on women to avoid childbirth interventions and infant formula, the vast majority of women have pushed back.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Campaigns to promote unmedicated vaginal birth and breastfeeding have largely failed except in one area: peer pressure exerted through social media. But those women are not your peers.[/pullquote]

Why?

Many women don’t believe the claimed “science” behind natural childbirth and lactivism since their own experience as well as that of their mothers, sisters and friends, contradicts it. Although epidurals, C-sections and formula are claimed to have “risks,” those purported risks are so rare that most people have never met anyone who experienced them.

Most women reject the sexist notion that their pain does not matter as much as the pain of men. If men aren’t empowered by the agony of passing a kidney stone, they reason, women aren’t empowered by the agony of childbirth.

Many women reject the traditional view, beloved of both religious fundamentalists and advocates of a “natural” lifestyle, that women are obligated to use their bodies to serve children regardless of the physical and psychic cost to themselves.

So the aggressive campaigns to promote unmedicated vaginal birth and exclusive, extended breastfeeding have largely failed except in one area: peer pressure, particularly pressure exerted through social media.

Many midwives and natural childbirth advocates routinely pathologize women who refuse to conform to their dictates. In Pushing Ecstasy: Neoliberalism, Childbirth, and the Making of Mama Economicus published in the journal Women’s Studies, Kate Rossiter explains:

…[W]hat on the surface may appear to be an ethic of care that empowers women in their choice-making ability is in fact a tactic that individuates and ultimately disempowers women …

Rossiter notes:

…[T]his discourse juxtaposes two images of the birthing mother: one wild, and one under technocratic gaze; one pure and authentic, and one living uncritically and irresponsibly within contemporary culture. Paradoxically, in order to access this wild self, the mother must work very hard to regulate herself and her surroundings in order to ensure that her ecstatic potential is realized… This is a mother who, through her diligent preparedness has optimized her natural capacity to birth … This is the mother who forgets herself in the face of her baby’s needs, and, crucially, enjoys this erasure of her non-maternal self…

It pathologizes women who refuse to go along, attempting to shame them into conforming:

This model holds no place for alternate reactions, such as ambivalence, grief, or anger. Rather, the implicit correlation is that deviation from the ideal of the ecstatic mother marks some kind of failure or pathology—suggesting that the birth circumstances were not optimal, or the mother’s hormonal system is somehow faulty, or that she herself is not a natural mother.

Women who can’t or don’t want to breastfeed are similarly pathologized.

Sunna Simmonardottir notes in Getting the Green Light: Experiences of Icelandic Mothers Struggling with Breastfeeding:

This idea that women have a ‘natural ability’ to breastfeed is culturally very strong but at the same time is counteracted with messages about the possible ‘faults’ that the women possess. They are discursively situated as both ‘natural’ and ‘unnatural’ at the same time, and in order to successfully breastfeed they have to rectify those unnatural faults often by going through quite technical processes, involving a range of breastfeeding aids such as breast pumps, artificial breasts and finger- or syringe feeding systems.

There is tremendous effort expended in shaming these women to force them to conform:

Should a mother exercise her own agency and decide for herself that the best thing for her would be to give up on trying to breastfeed, she runs the risk of being constructed as the villain, the selfish mother who didn’t want to inconvenience herself for the sake of her child. The biggest sin according to this cultural script of good mothering is not trying hard enough and giving up without a fight…

Social media like Facebook and Twitter can and do provide support for women who wish to pursue natural childbirth and/or exclusive, extended breastfeeding. But it often seems that they devote nearly as much effort to vicious criticism of women who don’t share their views. The tremendous number of likes, share, and approving comments may give these women the impression that they are part of the majority and may result in shame and guilt in those whom they attack.

But social media is not the real world. In the real world most women choose and enjoy epidurals, follow the advice of their obstetricians, and welcome any interventions that might assure the safety of their babies. In the real world most women use formula at least some of the time. In the real world, women who consider themselves more than the sum total of their reproductive performance are too busy working or caring for their families to waste time avidly liking and sharing posts that disparage women who make different choices.

People are swayed by what they think their peers are doing. Women who chose epidurals in labor, who requested C-sections, who couldn’t or wouldn’t breastfeed their babies often feel shame because they are the “only ones” who didn’t fulfill the script. But they aren’t the “only ones,” they are the majority and can find comfort in numbers.

Just about the only area in which natural childbirth and lactivism have been successful is in promoting peer pressure, particularly on social media. But the truth is that natural childbirth advocates and lactivists are not the peers of most women. Their peers are the majority of women who made the exact same choices they did.

Midwives are so busy congratulating themselves and each other that they’ve failed to notice that their philosophy of birth is being rejected.

The latest example comes from a Stanford study. Despite decades of midwifery demonization of pain relief in labor, the US epidural rate has … risen.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Midwifery philosophy has had essentially no impact on childbirth metrics.[/pullquote]

“We were blown away,” said Alexander Butwick, MD, an associate professor of anesthesiology. “We were really surprised the rates were so high.”

Seventy-one percent of pregnant women get epidurals or other spinal anesthesia, according to the study, which appears online in Anesthesiology. That’s an increase of 10 percent from 2008, according to the researchers…

“There’s a lot of misinformation available online that is more likely to suggest epidurals may not be great,” Butwick told me. “And yet, here we are. The rates have gone up, for whatever reason.”

The sine qua non of contemporary midwifery philosophy is cult like obsession with unmedicated vaginal childbirth. There are two main reasons for this: the naturalistic fallacy and the promotion of midwifery itself.

The naturalistic fallacy is based on the erroneous belief that if something was a certain way in nature, that’s the way it ought to be. Couple that with basic ignorance of the inherent dangers of childbirth — astronomical rates of perinatal and maternal mortality — and you end up with the bizarre injunction to “trust” birth.

The promotion of midwifery has led to the demonization of anything that takes childbirth out of control of a midwife.

There is nothing natural about checking blood pressure, listening to the fetal heart with a Doppler or recommending chiropractic. Some midwives recommend herbs or over the counter medications like castor oil to stimulate labor and prevent a term pregnancy from extending into a higher risk postdates pregnancy. But as anthropologist Margaret MacDonald explained The cultural evolution of natural birth:

[If an intervention] can bring back the clinical normalcy of the labour pattern and keep it within the midwifery scope of practice, it is generally regarded as a good thing by midwives …

Toward these dual ends — glorifying nature and discouraging anything midwives cannot do — midwives have routinely demonized childbirth “interventions,” reserving particular opprobrium for epidurals and C-sections.

How’s that working out?

In addition to the epidural rate rising by 10% since 2008, there has been no change in the C-section rate, the induction rate reached an all time high in 2010 (23.8%) and has declined only slightly since then. Furthermore, mounting data indicates that labor induction at 39 weeks offers the best outcomes for babies and mothers and actually reduces the C-section rate.

Childbirth care in the US is a doctor led system, but the trend is similar in countries with midwife led care.

The Canadian C-section rate rose from 26.7% in 2007-2008 to 28.2% in 2016-2017.

In the United Kingdom induction rates increased from 20.3 per cent in 2006-07 to 29.4 per cent in 2016-17 and the cesarean rate rose to 27.8%. In addition, the Royal College of Midwives was forced to shutter its Campaign for Normal Birth as a result of multiple midwifery scandals involving high rates of death among babies and mothers and massive increases in maternity liability payments.

The Australian C-section rate at 33% is higher even than the US rate and has increased from 30.9% in 2007.

The one exception is the Netherlands. The low Dutch C-section rate decreased from 16.7% in 2010 to 15.9% in 2015.

Arguably the issue nearest and dearest to the hearts of midwives is homebirth since that is the setting that affords them the greatest autonomy. But despite efforts to promote homebirth, sometimes backed by the government, the results have been dismal.

In the US, the rate of planned homebirth has been rising but still represents less than 1% of planned births.

In the UK the homebirth rate dropped from 2.3% in 2012- 2015 to 2.1 in 2016.

Australia’s rate of planned homebirth is only 0.4%.

The homebirth rate in the Netherlands has continued to plummet falling from nearly 30% in 2006 to only 13% in 2015. The dramatic decline was attributed to more women wanting access to pain relief and to greater publicity of the relatively high Dutch perinatal death rates.

There appears to be only one area in which midwifery philosophy has been relatively successful and that’s its penetration into mainstream media and social media. There is a plethora of mainstream media articles bemoaning high C-section and intervention rates; there are countless books extolling midwifery philosophy, and the Twitterverse in particular is filled with midwifery advocates routinely exchanging tweets involving dozens of midwives congratulating themselves.

Midwifery conferences reinforce this sense of professional success. Midwifery has become an echo chamber; midwives rarely venture outside of it to engage with their colleagues in obstetrics or any childbearing women who don’t already share their high opinion of themselves.

But the numbers don’t lie. Midwifery philosophy has had essentially no impact on anything beyond paying lip service to it. Intervention rates continue to rise; scientific data and rising liability payments continue to demonstrate the deadly outcomes of trusting birth; and women ignore the injunctions closest to midwives’ hearts — continuing to choose epidurals in rising numbers and rejecting planned homebirth.

While it can be infuriating to watch midwives on social media congratulating each other for propounding a philosophy that harms mothers and babies the reality is that they are so busy patting themselves on the back that they’ve failed to notice that most people have stopped paying attention to them.

It is an article of faith within the breastfeeding industry that lactation consultants are good at what they do and are caring and considerate in how they do it. Many women beg to differ.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation consultants are failing not merely at their chosen metric, exclusive breastfeeding rates, but at their fundamental task, providing breastfeeding support.[/pullquote]

I undertook a survey to determine just how effective lactation consultants are and whether they are indeed as caring as they believe. The results ought to be deeply concerning to lactation consultants.

Over 400 women participated in the survey, which was open to anyone who had initially wanted to breastfeed.

The first question was “Did you find the lactation consultants at your hospital helpful to your efforts to breastfeed?” and these were the results:

The good news for lactation consultants is that many women found them helpful in their efforts to breastfeeding. The bad news is that the majority did not. Over 46% of respondents rated their hospital based lactation consultants as somewhat helpful or very helpful. That’s far lower than I expected since lactation consultants have one and only one job, to promote breastfeeding. I would have thought that they would at least be effective in doing so.

The reality was that more than half of the respondents found lactation consultants to be ineffective or even harmful. That group was almost evenly divided between those who thought their lactation consultants made no difference, made them feel pressured or even made them feel inadequate. Considering the strenuous effort and millions of dollars expended to promote breastfeeding this is a disturbing finding.

Why are hospital based lactation consultants so ineffective? The survey cannot tell us but several possibilities come to mind.

I doubt that this reflects the competence of lactation consultants themselves. I suspect the overwhelming majority are well educated, well trained and deeply committed.

Is the training itself flawed? That’s certainly a possibility since a lot of what passes for “knowledge” among lactation consultants is actually false. Lactation consultants are taught that breastfeeding is nearly perfect, that insufficient breastmilk is rare, and that with proper “support” nearly any woman can exclusively breastfeed. But breastfeeding, like any other natural process, has a significant failure rate, insufficient breastmilk is common and that women stop breastfeeding for a host of reasons, not typically for lack of support.

The answers to the second question “Did you breastfeed?” bear that out:

Less than 28% of respondents were able to breastfeed exclusively for as long as they wanted. Slightly more than 16% of respondents found breastfeeding too painful, inconvenient or distressing. Over 26% felt that their babies were not getting enough to eat and more than 24% found that combo feeding (combining breastfeeding and formula) worked best. That amounts to a remarkably dismal failure rate for lactation consultants. Their goal is nearly 100% exclusive breastfeeding and their failure rate exceeds 66%.

This is similar to overall US breastfeeding rates. Over 79% of women try breastfeeding but only 20% are exclusively breastfeeding at 6 months.

Were lactation consultants willing to use a different, more realistic metric, they’d find themselves far more successful. Fully half of women were giving their babies some breastmilk for as long as they wanted. Sadly lactation consultants do not bother to consider women’s desires in their assessments.

That may explain why the majority of women found lactation consultants to be useless or harmful. Lactation consultants are obsessed with rates of exclusive breastfeeding. Women are concerned with happy babies, happy mothers and happy families. Breastfeeding might be a part of that but only to extent that it is satisfying for babies. Therefore, there is a tremendous mismatch between the support women want and the “support” that lactation consultants have been taught to give.

Lactation consultants would do well to keep these informal definitions in mind:

Support: Helping a women achieve HER goal.
Pressure: Helping a woman achieve YOUR goal.
Cruelty: Telling a mother that if she CARES about her baby, she’d replace HER goal with YOUR goal.

Nearly 18% of survey respondents felt pressured by the hospital based lactation consultants and nearly 17% reported that the lactation consultants were cruel enough to make them feel inadequate. In other words, more than 1/3 of respondents found hospital based lactation consultants to be harmful instead of helpful.

Obviously this is not a scientific survey, but it should give lactation consultants pause. Do the majority of women find their services unhelpful at best? Do a third of women experience them as harmful? I’d be interested to see the results of similar surveys undertaken by lactation consultants or the hospitals that employ them but I have been unable to find any such surveys or studies. It’s almost as if lactation consultants don’t wish to know how women experience their “support.”

Any way you want to look at it, lactation consultants are failing not merely at their chosen metric, exclusive breastfeeding rates, but at their fundamental task, providing breastfeeding support. They need to change what they are doing and how they are doing it because at the moment, the only task they are succeeding at is satisfying themselves.

In the ongoing effort to demonize C-sections, the association between C-sections and childhood obesity has received a lot of press. There have been numerous efforts to show that C-sections cause future obesity and a complex mechanism involving the gut microbiome has been proposed.

But there’s always been a serious problem with such research; the failure to adequately correct for confounding variables. We know that maternal obesity is a risk factor for C-section and we also know that maternal obesity is a risk factor for childhood obesity. Does the purported association between C-section and obesity mean that C-sections cause of obesity or that maternal obesity causes child obesity?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The risks of C-section have been overstated because of failure to fully correct for confounding variables.[/pullquote]

A new study in JAMA Pediatrics attempts to address that issue by looking at the impact of C-sections within families. Association of Cesarean Delivery With Body Mass Index z Score at Age 5 Years is an analysis conducted by researchers from Harvard and the NIH.

The authors explain the current state of research:

Two meta-analyses, summarizing data from 24 studies, have reported an increased risk of obesity for individuals with cesarean birth (pooled odds ratio [OR], 1.22 [95% CI, 1.05-1.42] and 1.33 [1.19-1.48]).1,2 Limitations of earlier studies include small sample size in several studies and lack of adjustment for maternal body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) and sociocultural factors. Even after adjusting for these measured maternal characteristics, residual confounding is likely.

And propose a solution:

Within-family analysis is one way of controlling for such confounding. Because siblings grow up in similar social, economic, and cultural environments and share the same genetic predisposition to obesity, sibling studies minimize the variation in several of the noncausal factors that could explain why cesarean delivery could appear to be associated with a higher risk of obesity.

What did they find when they conducted within-family analysis?

Mean BMI z score was 0.45 among siblings who both had vaginal delivery, 0.51 among siblings with 1 cesarean and 1 vaginal delivery, and 0.63 among siblings who both had cesarean delivery.

What does that mean?

We found that, within families, cesarean delivery was not associated with higher BMI z score at 5 years of age. This null finding suggests that confounding by unmeasured variables, such as maternal BMI and sociocultural factors, accounts for observed associations between cesarean delivery and BMI z score in some earlier studies…

C-section does not increase the risk childhood obesity, but rather the maternal characteristics that lead to the need for C-section are responsible for the observed increased risk of childhood obesity.

That’s consistent with a variety of recent studies.

Maturation of the infant microbiome community structure and function across multiple body sites and in relation to mode of delivery found:

…[T]here was no discernable effect of the cesarean mode of delivery on the early microbiota beyond the immediate neonatal period (and never inclusive of that in the meconium or stool) …

A Critical Review of the Bacterial Baptism Hypothesis and the Impact of Cesarean Delivery on the Infant Microbiome showed:

Although most studies report no differences in the microbiome of VD and CSD neonates in the first days of life, evidence is compelling that differences begin to develop shortly thereafter and persist for weeks or months.

That suggests that it is not the mode of delivery that contributes to the difference.

Mother-to-child transmission of obesogenic microbes continues to disrupt microbiome patterns into early childhood. Galley et al. found that the gut microbiomes of toddlers born to obese mothers of high socioeconomic status (SES) clustered away from those of toddlers born from lean high SES mothers…

It’s not the C-section but rather the mother’s microbiome itself.

Sharp eyed readers will recall that it was a within-family study that put to rest the notion that breastfeeding has massive health benefits.

Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons by Colen and Ramey, showed:

When we more fully account for unobserved heterogeneity between children who are breastfed and those who are not, we are forced to reconsider the notion that breastfeeding unequivocally results in improved childhood health and wellbeing. In fact, our findings provide preliminary evidence to the contrary. When comparing results from between- to within-family estimates, coefficients for 10 of the 11 outcomes are substantially attenuated toward zero and none reach statistical significance (p < 0.05). Moreover, the signs of some of the regression coefficients actually change direction suggesting that, for some outcomes, breastfed children may actually be worse off than children who were not breastfed.

In other words, the benefits of breastfeeding had been dramatically overstated because of failure to fully correct for confounding variables.

Similarly this new within-family analysis suggests that the benefits of vaginal birth have also been dramatically overstated because of failure to fully correct for confounding variables. C-section does not increase the risk of childhood obesity. The risk is increased because of the factors that led to the C-section, not the C-section itself.