Breastfeeding initiation rates in the US are the highest they have been in nearly 50 years.

As this chart from the Surgeon General’s Call to Action on Breastfeeding demonstrates, the rise has been dramatic, tripling from 1970 to 2007:

But you’ll also notice that breastfeeding rates fell off dramatically by 6 months both in 1970 and all the way through 2007. The number of women breastfeeding exclusively at 6 months is only a tiny fraction of those who had been breastfeeding at birth. The proportion of women breastfeeding at 12 months was only half the rate of women breastfeeding at 6 months.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Facing intense pressure, women who have no particular commitment to breastfeeding as well as those who have no intention to breastfeed, are forced to lie.[/pullquote]

The most recent data I could find shows that from 2011 to 2015 79.2% of mothers initiated breastfeeding, 20% were exclusively breastfeeding at 6 months, and 27.8% of mothers were still offering some breastfeeding at one year. The dramatic drop off is common at all maternal ages, all ethnicities, and every education and economic level. College graduates have the highest breastfeeding rates across the board: 91.1% at birth, 27.7% exclusively at 6 months, and 40.3 offering some breastmilk at a year.

Lactation professionals look at these numbers and insist (without any evidence of any kind) that the dramatic drop off in breastfeeding rates is due to “lack of support” for breastfeeding.

I look at these rates and reach a very different conclusion: there’s a whole lot of lying going on.

The foundational lie is the insistence that nearly every woman (once she is properly “educated”) wants to breastfeed.

The truth is that aggressive breastfeeding promotion efforts have become the norm in industrialized countries led by poorly named Baby Friendly Hospital Initiative that isn’t remotely friendly to babies and ignores mothers altogether. Ugly tactics — locking up formula, making women sign consent forms for formula, forcing lactation consultants on everyone — have become standard practice. There is tremendous pressure on hospital staff to increase breastfeeding rates at discharge and that pressure is transferred unabated to mothers. In the face of that pressure, women who have no particular commitment to breastfeeding as well as those who have no intention to breastfeed, are forced to lie.

A piece in yesterday’s Nursing Times, Changing the conversation around breastfeeding, notes:

In the UK, 81% of women initiate breastfeeding at birth but within the first day, exclusive breastfeeding has dropped to 69% – and down again to less than 50% by the end of the first week.

…[W]hy are so many women who want to breastfeed stopping before they would choose?

I suspect that they didn’t want to breastfeed at all; they merely said they did in order to stop the endless harangues from midwives, nurses and lactation consultants. No one who truly intends to breastfeed drops it after only one day. They obviously were not committed to it in any meaningful way. They just said they wanted to breastfeed to get the staff off their backs.

Moreover, there’s no guarantee that the breastfeeding rates at 6 months and one year are accurate. They are the results of reports by women, women who know that it is more socially desirable to claim to be breastfeeding, therefore they are likely to be inflated. If that’s the case, the drop off in breastfeeding rates is even more stark than advocates claim.

The other lie beloved of lactivists is that the difference between breastfeeding success and failure is support for breastfeeding.

There has arguably never been more support for breastfeeding in the past 100 years yet breastfeeding rates still drop off dramatically over time. Judging by the graph I posted above, breastfeeding support makes no difference to breastfeeding rates. While breastfeeding rates at 6 months and 12 months have risen over time, that reflects the fact that more women initially decided to try breastfeeding. The proportion of women who stop between birth and 6 months remains nearly unchanged. That suggests that factors other than support are responsible for the dramatic drop off.

These factors include the intrinsic failure rate of breastfeeding (up to 15% of first time mothers will not produce enough breastmilk in the early days), pain, frustration and inconvenience. Moreover, nearly every woman knows many people who were formula fed and they turned out just fine. No matter how often and how loud lactivists blare the purported benefits of breastfeeding, it is pretty obvious that most of those benefits are illusory.

What explains the dramatic difference in extended breastfeeding between college graduates and everyone else? Of women without college degrees only approximately 20% are breastfeeding at one year while 40% of college graduates are still doing so. I suspect that both structural factors and priorities are responsible for the difference. The structural factors include access to maternity leave and jobs compatible with pumping. In addition, many women with college degrees have made reaching the one year mark of breastfeeding a priority; they are achievement oriented to begin with and breastfeeding to one year has been promoted to them as an achievement.

What do breastfeeding rates tell us about breastfeeding promotion efforts? They have been successful in increasing initial breastfeeding rates though a significant proportion of the increase is illusory since it represents women lying about their intentions. They indicate that ongoing breastfeeding support has little to nothing to do with breastfeeding rates. Though the absolute number of women breastfeeding at 6 and 12 months has risen, the proportion of those who initiate breastfeeding who are still breastfeeding at 6 and 12 months has not changed; the majority of women still quit.

We’ve spent millions of dollars promoting breastfeeding, but what do we have to show for it? Not much. Yes, breastfeeding rates have risen, though far less than it appears. There’s no evidence that it has saved lives (with the exception of extremely premature infants) and no evidence that it has saved money, let alone returned the investment.

We’ve conducted a massive social experiment and virtually none of the promised results have occurred. And we’ve turned new mothers into liars. That doesn’t sound like success to me.

I just came across a post on Reddit that perfectly captures the negativity about Fed Is Best (the Foundation and the philosophy). It’s entitled Sick of the negativity about breastfeeding.

The writer whines:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mothers should make feeding decisions based on infants’ need for food, not lactivists’ wish to be admired.[/pullquote]

This is a throwaway rant about how people who don’t breastfeed feel the need to constantly talk down about it, try to argue and minimize the health benefits …

I’m just sick of it. I worked HARD to EBF my 15 week old who wouldn’t latch. I pumped and tried a nipple shield in between. Met with LCs, had engorgement, nipple pain, etc…

I pushed through because BFing was something that was personally important to me…

I’m proud to say he’s been EBF for his entire life – a little over 15 weeks and I see no slowing down in sight. BFing is not for everyone and that’s totally fine but this is a personal achievement that mattered to me.

To understand just how obnoxious this is, consider a parent whining about other parents who send their children to community colleges:

This is a throwaway rant about how people whose children don’t attend prestigious colleges feel the need to constantly talk down about it, try to argue and minimize the benefits.

I’m just sick of it. I worked HARD so my children could get the best educations possible and sacrificed spending on myself to save for college.

I pushed through because my children getting prestigious degrees was something that was personally important to me.

I’m proud to say all of my children attended highly ranked colleges. The Ivy League is not for everyone and that’s totally fine for those who think community college is acceptable but this is a personal achievement that mattered to me.

Why is that so unattractive?

It reduces something that is supposedly a gift to your children to a personal triumph.
It negates the possibility that an Ivy League education is not right for every child.
It demeans the accomplishment of graduating from community college.
It is poorly disguised self-aggrandizement

The writer continues in the same peevish, small minded fashion:

Every time I go on /beyondthebump there’s post after post about the misery of BFing and god forbid you defend it. Same thing in real life with my friends who FF.

I am 100% in the camp of fed is best, IDGAF how you feed your baby but could you imagine if we crapped all over FFing like they do to BFing? We’d be accused of being sanctimommies who think they’re better than everyone else.

In short – yes I BF my baby, no I don’t care or judge how you feed yours but please don’t tell me I’m wasting my time and energy and share illegitimate blog articles trying to downplay BFing benefits.

That’s like:
I constantly meet friends who wail about being unable to afford high cost of prestigious college degrees for their children.

I am 100% in the camp of doing what you can afford and what you think your child needs; IDGAF where you send your child, but could you imagine if we all crapped over community colleges the way they disparage the Ivy League? We’d be accused of being sanctimommies who think they’re better than everyone else.

In short – yes I sent my children to prestigious colleges; no – I don’t care or judge settling for community colleges but please don’t share illegitimate blog articles trying to downplay the benefits of the Ivy League.

Ugly, right?

The hypocrisy of claiming that you are not disparaging formula while simultaneously implying it is inferior is totally lost on the author. The insistence that she doesn’t care how other women feed their babies when she is completely obsessed with how other women feed their babies is bizarre. And the way she turns the choices of other women into a referendum on HER choices is incredibly self-absorbed.

The author has what we might call in other circumstances a conflict of interest. She cannot look dispassionately at the risks of breastfeeding or the benefits of formula because her ego is involved. She wants to believe that her decision to breastfeed is heroic, even though it is basically irrelevant to the health and well being of her child. She needs other women to admire her for her heroism when they have as little interest in how she feeds her baby as in what car she drives.

Women who choose to formula feed have different priorities than those who insist on breastfeeding despite the fact that their child is starving and they are suffering. The Fed Is Best Foundation created a meme that brilliantly lays out their priorities.

Top Priorities of Newborn Feeding
1. Protecting a newborn’s life
2. Protecting a newborn’s brain and vital organs
3. Protecting a newborn from disability and lower academic achievement
4. Protecting a newborn from hospitalization for feeding complications
5. Protecting a newborn from hunger, thirst and suffering
6. Protecting the newborn patient and human rights
7. Protecting a mother’s right to choose and to feed her hungry baby

Low Priority
Protecting the newborn from a single drop of formula
Protecting a newborn’s exclusive breastfeeding status at discharge.

Notice what’s not a priority at all:
Protecting a mother’s desire to feel superior to other mothers.

The negativity about Fed Is Best is clear evidence that breastfeeding advocates have failed to get their priorities straight. Infant feeding is not about them and their egos; it’s about babies and nourishment. Mothers should make their decisions based on infants’ need for food, not lactivists’ wish to be admired.

Whether breastfeeding advocates believe it or deny it, fed is truly best!

When one of my sons was four years old, he made a decision. He told me, “I’m never going to work as much as Daddy! He works too hard.”

My son did eventually become a lawyer like his father, but he avoided big firm law, choosing a job with lower pay but much better hours as well as the opportunity to serve the public. He’s quite willing to work hard, but he doesn’t want to be available to the office and to clients 24/7/365.

I thought of him when I read that the US birth rate has dropped to its lowest level in 30 years and may be heading down farther.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The pressure on mothers to parent “naturally” was supposed to force them back into the home; instead they’re rejecting mothering.[/pullquote]

I wonder if we have made motherhood look too hard.

According to NPR:

The birthrate fell for nearly every group of women of reproductive age in the U.S. in 2017, reflecting a sharp drop that saw the fewest newborns since 1987, according to a new report by the Centers for Disease Control and Prevention.

There were 3,853,472 births in the U.S. in 2017 — “down 2 percent from 2016 and the lowest number in 30 years,” the CDC said.

That reflects a drop in nearly every age group:

Broken out by age, the 2017 birthrate fell for teenagers by 7 percent, to 18.8 births per 1,000, a record low. That figure is for women from 15 to 19 years old. For that same group, the birthrate has fallen by 55 percent since 2007 and by 70 percent since the most recent peak in 1991, the CDC said.

Women in their 40s were the only group to see a higher birthrate last year. Between the ages of 40 and 44, there were 11.6 births per 1,000 women, up 2 percent from 2016, according to the CDC’s provisional data.

Birthrates fell by 4 percent both for women from 20 to 24 years old and for women of ages 25 to 29.

For women in their 30s — a group that had recently seen years of rising birthrates — the rate fell slightly in 2017. The drop included a 2 percent fall among women in their early 30s, a group that still maintained the highest birthrate of any age group, at 100.3 births per 1,000 women.

Why is this happening?

Some claim it reflects long term demographic shifts common to all industrialized countries.

Others claim that it is the fault of the patriarchy: the lack of maternity leave forces women to choose between being good mothers or good workers, sure that they can’t be both.

Still others insist that it represents a rebuke to the patriarchy. Women no longer buckle under the societal pressure to have children and are childless by choice.

I fear we may have “broken” motherhood.

I’ve written repeatedly about my belief that the political and legal emancipation of (some) women in the 20th Century was a watershed moment in history. For the first time women were able to assert the exact same rights as men. They went from being property to property owners. They went from being economic chattel to economic engines. They were finally able to express themselves in the political, technological and artistic realms.

And that made some people very, very unhappy.

No major social change occurs without backlash and we are currently living through the backlash. On the Right there has been a rise of religious fundamentalism that insists that God wants women to be subjected to men, immured in the home and occupied only in the raising of children, often many, many children. On the Left there has been a rise of secular “religion,” the worship of Nature. Women (though not men) are pressured to raise their children the way Nature intended. And Nature supposedly intended them to give birth with excruciating pain (epidurals are “bad”); breastfeed each child exclusively for years (formula is “bad”); and literally “wear” babies on their bodies (a mother who considers her own needs is very “bad”).

Being a mother was always hard, but now the pressure on new mothers is extraordinary. How extraordinary? Consider a tweet posted several days ago by Carole Dobrich.

Dobrich is a lactation professional:

Carole is the Senior Lactation Consultant and co-director at the Herzl Family Practice Centre – Goldfarb Breastfeeding Clinic where she works with a team of IBCLCs and family physicians trained in lactation… Carole is the past president of the association québécoise des consultantes en lactation diplômées de l’IBLCE (2004 – 2008) and is the current president of INFACT Quebec and is actively involved in breastfeeding advocacy work in Quebec, Canada and internationally.

She chose to share a slide from a recent conference:

The slide claims:

Children will never achieve their full genetic potential by starting post partum life with ingesting a pediatric fast-food prepared from the milk of an alien species.

That’s just gratuitous cruelty masquerading as breastfeeding promotion. It’s using guilt to force women back into a very constricted and constricting definition of motherhood.

As psychologist Susan Franzblau has written:

The idea that women are evolutionarily prepared to mother … is consistent with a long historical tradition of using essentialist discourse to predetermine and control women’s reproductive tasks and children’s rearing needs. Evolutionary and biological theories have been embedded in a history of misogynist discourse… Women’s “natural” function … is to reproduce and provide continual care for infants and young children. If the treatment of women differs from the treatment of men, such treatment could be justified in terms of its biological and evolutionary purposes…

It is not a coincidence that natural mothering neatly dovetails with religious fundamentalism:

Organizations such as the Christian Family Movement (established by the Catholic laity …) became the founders of the La Leche League in 1956… According to one natural childbirth advocate of the time, “childbirth is fundamentally a spiritual as well as a physical achievement …” Breastfeeding was heralded as an extension of this spiritual connection. Out of concern that recently instituted bottle-feeding and drug-assisted births would break family bonds, these religious advocates of breastfeeding prescribed a regimen that included suckling on demand day and night with no pacifier substitute … Any work that competed with the infant’s need for continuity of maternal care was out of the question. One La La Leche League International group leader said that she was “pretty negative to people who just want to dump their kids of and go to work eight hours a day.”

The pressure on mothers to parent “naturally” was supposed to force them back into the home; and for many women the artificially imposed guilt about “what children need” left women competing with each other about who suffered more for her children instead competing with men for economic equality in the workplace.

But now a new generation of women face this false choice and they are choosing differently. Having seen how their mothers and older sisters suffered to meet the ever more elaborate “requirements” for contemporary mothers they are choosing to forgo childbearing altogether. They don’t want to work as long and as hard on mothering as parenting experts prescribe. They don’t want to endure the guilt of failing to meet the arbitrary standards of good mothering. They like children but they don’t want the apparently crushing responsibility that comes with bearing them. Mothering is broken and as a result, they want no part of it.

Who broke mothering?

Advocates of natural childbirth, exclusive and extended breastfeeding, and attachment parenting broke it. Our country is going to pay a terrible price as a result. If the birth rate remains below replacement level our society will age dramatically, our social welfare programs like Social Security will fall apart and there will be no one to take care of us when we grow old.

But, hey, even though there will be far fewer children, at least they’ll be breastfed, right?

I read a terrific new book this weekend, Bad Blood: Secrets and Lies in a Silicon Valley Startup.

John Carreyrou of the Wall Street Journal tells the story of Theranos, a company with a brilliant idea that promised a revolution in healthcare but ended up as a billion dollar scam that delivered nothing.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When will we accept that the claims of breastfeeding advocates were always too good to be true?[/pullquote]

It reminded me of breastfeeding.

Theranos was the brain child of Elizabeth Holmes, who dropped out of Stanford at 19 to create it, a needle-phobe who envisioned running hundreds of blood tests using a single drop of blood drawn from a finger stick.

It was an idea that was too good to be true — literally. But Holmes would not, could not admit the truth even though it became clear early on that her vision was a physical impossibility. Despite what her engineers were telling her, Holmes doubled down again and again: 200 test results from a single drop of blood became 800; the number of companies supposedly using her test successfully multiplied while in reality no one was using it; most egregiously, she faked test results and offered those results as real. Along the way, naysayers were fired and silenced with iron clad non-disclosure and non-disparagement agreements.

Theranos was the healthcare version of “vaporware”: software announced with great fanfare, promising the moon to secure massive outside investment, but ultimately delivering nothing but misery and bankruptcy. Breastfeeding is another healthcare version of vaporware, promising extraordinary savings in lives and healthcare dollars, endlessly touted to secure ever larger outside investment, but ultimately delivering more than its share of misery and medical illness.

The claims about breastfeeding have always been too good to be true. It has been promoted as the “perfect” food for newborns when we know that nothing in nature is perfect. It has been promoted as lifesaving when we know that for most of human existence all infants were breastfed and they died in droves and though contemporary countries with the highest breastfeeding rates have the highest infant mortality rates. It was promoted to solve a problem that was fundamentally misrepresented. Babies died in Africa as a result of Nestle’s greed in encouraging African women to formula feed. But the problem was never the formula; it was the contaminated water used to prepare it.

The similarities don’t end there. Elizabeth Holmes had a wonderful vision of hundreds of tests from a single drop of blood and she was determined to “fake it until you make it.” She really believed that if she could dream it, she could make it happen. She would not compromise her vision merely because reality got in the way.

For the past 40 years or so professional lactivists have had a wonderful vision of every baby being breastfed and surviving until old age because of it. They really believed that if they could dream it, they could make it happen. They refuse to compromise their vision merely because reality gets in the way. The benefits don’t materialize and the risks keep mounting, yet they’re still trying to fake it until they make it.

Elizabeth Holmes sold many otherwise hard headed people on her vision to the tune of billions of dollars in investment. They believed in the dream; they wanted it to be true; and they were taken in by her lobbying efforts. Once a few prominent investors were on board, it was easy to recruit others. If former Secretaries of State Henry Kissinger and George Schultz were investing, it must be true! Others rushed to copy them.

Professional lactivists sold many healthcare professionals on their vision to the tune of millions of dollars. Lactivist lobbying initially swayed the World Health Organization and ultimately recruited the CDC, the American Academy of Pediatrics and the American College of OB-GYNs. If those eminent organizations were supporting breastfeeding, the claimed benefits must be true. Others rush to copy them. The Baby Friendly Hospital Initiative was created and welcomed into hospitals; it promised to increase breastfeeding rates and save money at the same time!

Elizabeth Holmes ran into problems early on; the product failed to perform. In response she began to fake results; testing blood on conventional machines back in company headquarters and wirelessly transmitting the results to her machines to make it look as though they were working. She continued to ignore the evidence brought to her by her staff that the product not only didn’t work but couldn’t work.

Breastfeeding advocates ran into problems early on; some women didn’t have enough breastmilk. In response, they began to lie, claiming insufficient breastmilk was rare when it is actually common. Then the touted benefits failed to appear. In response, they began promoting mathematical models which extrapolated weak, conflicting data riddled with confounders to make it look like the claims were true. Whenever new evidence appears that contradicts early claims, and it appears often, it is simply ignored.

When Holmes deployed her devices, they began to harm people by delivering faulty results. Holmes did not back down. She and her lawyers harassed and threatened the doctors and patients who complained.

Aggressive breastfeeding efforts are harming babies, increasing injuries and deaths from dehydration, jaundice and babies smothered in their mothers’ hospital beds. Professional lactivists have not backed down, dead babies be damned. Their organizations harass and demean founders and members of the Fed Is Best Foundation, accusing them of being in the pay of formula companies without even a shred of evidence to support those claims.

To this day Elizabeth Holmes maintains that her dream of hundreds of tests performed on a single drop of blood is possible and will happen. This despite the fact that she has been sanctioned by various government organizations, has seen her net worth drop from billions to zero, and may face criminal charges for fraud. She cannot be shaken from her conviction that merely imagining something is possible makes it possible.

To this day professional breastfeeding advocates repeat the claims of lifesaving benefits of breastfeeding without any risks. This despite the fact that babies have literally died from insufficient breastmilk and the closing of well baby nurseries, despite the scientific papers showing that most of the claimed benefits don’t really exist, and despite the utter failure to appear of touted improvements in lives and money saved. They cannot be shaken from the conviction that merely insisting breastfeeding is lifesaving makes it so.

One of the saddest incidents in Bad Blood occurs when Tyler Schultz, grandson of major Theranos investor George Schultz goes to work for the company. He quickly realizes Theranos is a scam that is harming patients. He quits, tells his grandfather what he’s learned and cooperates with the Wall Street Journal investigation. It destroys his relationship with his grandfather who refuses to believe that Holmes’ claims weren’t and couldn’t be true. Tyler Schultz is excluded from his grandfather’s 95th birthday party; Elizabeth Holmes is invited.

It remains to be seen how organizations and providers scammed by the breastfeeding industry react to the rising tide of data showing that breastfeeding saves neither lives nor healthcare dollars and may actually put both at risk. Will they reject the scientific evidence and the growing clamor from mothers of babies who have been harmed or will they accept reality that the claims of breastfeeding advocates were always too good to be true? Only time will tell.

It’s no surprise that a privileged, white natural childbirth advocate would deny my claim that white privilege plays a large role in natural childbirth advocacy. I am surprised, however, by the weakness of her denial.

As the title of her piece, The Obstetrician Who Cried “White Privilege”, indicates, history Prof. Lara Freidenfelds considers my claim irresponsible.

In December of 2016, I wrote an essay for Nursing Clio called Nurse-Midwives are With Women, Walking a Middle Path to a Safe and Rewarding Birth. In the piece, I advocated that all women be given the option of delivering with hospital-based nurse-midwives … I only recently, quite belatedly, realized that OB-GYN Amy Tuteur had responded on her blog to my essay. She offered a belittling (and inaccurate) representation of my position on hospital-based nurse-midwifery, specifically invoking the specter of “white privilege.” Why? As far as I can see, it was an attempt to shut me down with highly-charged language that was intended to shame me and alienate those likely to be my allies.

Well, yes, natural childbirth advocates ought to be ashamed that in their privilege they imagine that what all women need is what privileged white women want. For better of for worse, Prof. Freidenfelds is a perfect example of white, pregnancy privilege.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Who wants to be accused of being a privileged white person? Certainly not a privileged white person![/pullquote]

As I’ve written before, pregnancy privilege is defined by 25 attributes:

1. My pregnancy is planned and wanted.
2. I am healthy.
3. I have health insurance.
4. I have a choice of healthcare providers and do not have to rely on a clinic.
5. I can access a hospital that has excellent statistics for neonatal and maternal outcomes.
6. I can be sure that the majority of my caregivers belong to my racial and demographic group.
7. I speak English.
8. I am married or have a reliable long term partner who is available to care for me when needed.
9. I have easy access to and can afford healthy food.
10. I can afford books on pregnancy.
11. I can afford to take childbirth classes.
12. I may have to sacrifice, but if I wish I can afford a doula or midwife.
13. I can hire a birth photographer.
14. I can afford weeks or months of maternity leave from my job.
15. I have easy, reliable access to the internet so I can share information with other pregnant women.
16. I can write well enough to create a birth plan.
17. I am not a victim of domestic violence.
18. I am not addicted to alcohol or drugs.
19. If I have older children, I have family or friends to care for them when needed.
20. I can create a baby registry on the assumption that I and my friends can afford to purchase new baby items.
21. I can afford a breast pump.
22. I have a job that offers both privacy and time to pump without loss of income.
23. I have a spouse or partner who is supportive of breastfeeding.
24. I don’t face a dramatically increased risk of premature birth.
25. I don’t face a dramatically increased risk of maternal death

Freidenfelds can correct me if I’m wrong, but suspect she scores close to if not exactly 25 out of 25 on the pregnancy privilege scale. And, like many beneficiaries of privilege, she’s in denial about her own privileged status.

Why? Acknowledging privilege is embarrassing, especially when you view yourself as speaking from a position of moral superiority.

My primary claim is that privileged, white women imagine that the childbirth experience that they want is what less privileged women need. I’ve analogized this in the past to sending sterling silver flatware to people dying of starvation.

To the extent that Prof. Freidenfelds engages with this claim, she deliberately misrepresents it (or, perhaps, misunderstands it).

Tuteur claims that nurse-midwifery could only possibly be appealing to middle-class white women such as myself, who she believes are inordinately attached to the idea that women might value a low-intervention birth experience, and therefore, when I advocate that nurse-midwives be available to all pregnant and birthing women who want them, I am cluelessly advocating from a position of white privilege. (my emphasis)

But that’s not my argument at all. I’m not talking about what is or is not appealing. I claim that nurse-midwifery is only appropriate for low risk women.

To use my sterling silver analogy, I would never say that fine flatware could only possibly be appealing to privileged, white women. Who wouldn’t want sterling silver flatware if they had plenty of everything else in their lives? But it is worse than meaningless for people who don’t have enough food to eat. Recommending midwives (specialists in low risk pregnancy and birth) to women who suffer inordinately from high risk conditions and complications is also worse than meaningless.

Freidenfelds also misrepresents my position on the safety of nurse midwives:

Tuteur will never accept evidence that any form of midwifery is safe. She is completely committed, at least publicly, to advocating for OB-GYNs at every birth, and no evidence of nurse-midwifery’s safety will ever be enough for her. That means that, at least as long as the evidence available to me supports the safety of nurse-midwife care for low-risk women, we will have to agree to disagree about the role of nurse-midwives.

That’s a bald faced lie. I’ve written more times than I can count that I always worked with certified nurse midwives, found them to be excellent practitioners and that the scientific evidence shows that they have a great safety record for low risk women. But by definition they can’t care for the most high risk women who are disproportionately African American, suffering from pre-existing medical problems and severe pregnancy complications. For example, the leading cause of maternal death in this country is cardiac disease. What, exactly, can midwives do to prevent cardiac deaths? Absolutely nothing.

That’s not the only thing that Freidenfelds refused to address.

Specifically:

The racist, sexist origins of natural childbirth advocacy.
The biological essentialism at the heart of natural childbirth advocacy.
The remarkable elitism of the movement that has only token representation of women of color and poor women.

Freidenfelds has nothing to say. She doesn’t deny any of that since it is all true; she simply ignores it.

How about the questions I ask in my piece?

What distinguishes midwifery from obstetrics? Is it truly a difference in outlook or merely midwives clawing for market share?
Should women be reduced to their reproductive organs and does reproduction mean the same thing to every woman?
Are midwives with all women or just privileged white women?

Freidenfelds doesn’t bother to answer these questions. As I noted in my original essay:

Natural childbirth advocates are overwhelmingly Western, white, and well off. Certified nurse midwives are overwhelmingly Western, white and well off. I find it quite shocking that in a country that struggles with high black perinatal mortality and high black maternal mortality, Freidenfelds doesn’t even bother to give lip service to the many women of color, women of other nationalities, and women with pre-existing medical conditions and pregnancy complications whose have no interest in and cannot be helped in any way by the philosophy of natural childbirth.

It’s almost as if these non-privileged women do not exist.

Freidenfelds writes:

As I explained in the essay, nurse-midwifery was originally developed to serve lower-income women who could not afford physicians’ fees. Midwives continue to disproportionately serve low-income rural and inner-city women, many of whom have difficulty accessing care otherwise.

And as I explained, that’s not true. While some nurse midwives prior to 1970 cared for poor women, they represented only a few hundred providers. Since then the number of nurse midwives has grown exponentially (now approximately 12,000) and there is no evidence they disproportionately serve poor women.

According to CDC Wonder, in 2016 African American women represented 16% of births attended by doctors and 13.5% of midwife attended births. CDC Wonder does not collect income statistics but it does collected statistics on maternal education. Women with a high school degree or less represent 40% of births attended by doctors and 37% of midwife attended births. In other words, midwives are LESS likely than doctors to attend births of African American women or poor rural/inner city women.

Freidenfelds concludes:

I do not accept Tuteur’s mis-use of the critical terminology of “white privilege.” Specious arguments based on claims about white privilege are pernicious because they weaken and discredit the concept.

I understand; who wants to be accused of being a privileged white person? Certainly not a privileged white person like Freidenfelds. She ought to present actual arguments debunking my claims instead of misrepresenting them or ignoring them. The fact that Freidenfelds cannot suggests she ought to check her privilege.

Writing on The Conversation, three UK scientists make an elementary error.

Their piece is entitled Jaundice in newborns could be an evolutionary safeguard against death from sepsis.

In newborn babies, jaundice is so common as to be termed physiological. It affects around 60% of term babies and around 80% of preterm babies in the first week of their lives. Clinicians need to monitor it carefully and sometimes treat it, since it can lead to conditions like acute bilirubin encephalopathy and kernicterus that can damage the infant’s brain and cause developmental problems.

But it now looks as though this jaundice is not merely one of the pitfalls of entering the world. New research just published in Scientific Reports, in which we have been involved, suggests that it is one of the gifts of evolution. Humans may develop jaundice as newborns to protect from something even more serious: sepsis.

The elementary mistake is invoking the the naturalistic fallacy, a logical fallacy that presumes that anything that exists in nature must be good.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How would we determine if jaundice prevents sepsis? We would look at the relatively risk of sepsis in jaundiced babies vs. non-jaundiced babies.[/pullquote]

…[W]hy have humans not evolved to overcome this temporary bilirubin problem?

Why? Because evolution through natural selection does not produce perfection. A variety of often conflicting evolutionary pressures may result in a relatively high wastage rate.

For example, in nature many babies and mothers die because the baby is too big to pass through the maternal pelvis. The evolutionary pressure on maternal pelvis size is entirely independent of the evolutionary pressure on fetal head size. If natural selection produced perfection, human beings would have evolved some way for the mother’s body to communicate with the fetus’ body to constrain its size. That has not happened because natural selection is limited in what it can accomplish; it can only produce limited results with existing genetic material.

Moreover, evolution through natural selection leads to the survival of the fittest, NOT the survival of all. The fact that a given natural process has a relatively high death rate is entirely in keeping with that principle.

There is no evidence I’m aware of that shows that neonatal jaundice is beneficial in any way to a baby, but that hasn’t stopped these investigators from fantasizing otherwise.

One night he was looking after a baby boy who had sepsis, which is where the immune system goes into overdrive to protect against infection, potentially leading to severe inflammation, organ failure and death. This baby was profoundly unwell in intensive care, suffering from inflammation and a strikingly high bilirubin count that was only just being controlled with three phototherapy lamps. Usually this kind of difficult jaundice is caused by an immune reaction between mum’s and baby’s blood groups, but not in this case.

Richard began wondering if the bilirubin was directly linked to the infection, and if it was part of the baby’s body’s attempt to clear the sepsis (in this case the baby survived). He started thinking about the problem in evolutionary terms – if jaundice can harm the baby, what benefit does it offer to balance this?

The odds are high that the bilirubin is linked to the infection but not in the way that the investigators imagine. Sepsis can injure the liver, decreasing its ability to metabolize bilirubin. Sepsis induced jaundice occurs at all ages.

According to Clinical review: The liver in sepsis:

During sepsis, the liver plays a key role. It is implicated in the host response, participating in the clearance of the infectious agents/products. Sepsis also induces liver damage through hemodynamic alterations or through direct or indirect assault on the hepatocytes or through both. Accordingly, liver dysfunction induced by sepsis is recognized as one of the components that contribute to the severity of the disease.

In other words, there is no reason to believe that neonatal jaundice is protective against sepsis and no data that shows that neonatal jaundice prevents sepsis. No matter.

The results of this project have just been published. Our team have shown that even modest concentrations of bilirubin reduced by one third the growth of Gram-positive Streptococcus agalactiae. We also showed that bilirubin may alter substrate metabolism in the bacteria.

In short, it looks like the hypothesis is bearing out. We now need to do more work, probably in animal experiments of sepsis. This will enable us to think about whether clinicians should raise the accepted bilirubin threshold for babies at risk of sepsis – those born prematurely, for example.

No, it does NOT look like the hypothesis is bearing out.

That bilirubin kills some common bacteria is not unexpected. The whole problem with jaundice in the newborn is that bilirubin is cytotoxic; if it could kill newborn brain cells, it’s hardly surprising that it can kill bacteria, too. That doesn’t mean that excess bilirubin occurs to prevent bacterial sepsis.

Sadly, this is a “just so story.”

What’s a just so story? The term comes from a Rudyard Kipling book of the same name, filled with stories like “How the leopard got its spots.” It is:

an unverifiable narrative explanation for … a biological trait … The pejorative nature of the expression is an implicit criticism that reminds the hearer of the essentially fictional and unprovable nature of such an explanation.

This story could be titled “how the infant got its jaundice.”

Kipling’s just so stories were fairytales and most contemporary efforts to use just so stories to explain evolutionary phenomena are also fairytales.

As Steven J. Gould wrote:

…unfortunately a very large part of evolutionary theory and practice, natural selection has operated like the fundamentalist’s God–he who maketh all things… When evolutionists try to explain form and behavior, they also tell just-so stories–and the agent is natural selection.

But natural selection is not the only engine of evolution.

…[W]e now reject this rigid version of natural selection and grant a major role to other evolutionary agents (genetic drift, fixation of neutral mutations, for example). We must also recognise that many features arise indirectly as developmental consequences of other features direct subject to natural selection. Moreover, and perhaps most importantly, there are a multiple of potential selective explanations for each feature. There is no such thing in nature as a self-evident and unambiguous story.

How would we determine if jaundice prevents sepsis? We would look at the relatively risk of sepsis in jaundiced babies vs. non-jaundiced babies. Unless and until we can show that jaundice is protective, we have no business asserting that it is protective. We also have no business extrapolating from test tubes to human beings. No doubt bleach also kills the bacteria that cause neonatal sepsis, but that’s not a reason to start giving sick babies bleach.

The authors conclude:

It feels like we’re discovering something new about the physiology of newborn babies. It’s the excitement of being a clinician scientist: taking an idea from a real patient into the laboratory and testing then developing it to hopefully help future patients. When newborn babies develop jaundice in future, we’ll still need to treat it carefully. But quite possibly we will also be thankful that it’s protecting them from something potentially life-threatening.

No one has discovered anything about the physiology of newborn babies because no one looked at the physiology of newborn babies. They made up a just so story.

Just so stories are remarkably attractive; that’s why scientists must be very careful not to invoke them. They should be even more cautious about advancing therapeutic recommendations based on what at the moment is little more than wishful thinking.

Bed sharing has always been dangerous. The first reported bed sharing death occurred nearly 3,000 years ago.

Two women came to King Solomon and stood before him. One woman said: “My Lord, this woman and I dwell in the same house, and I gave birth to a child while with her in the house. On the third day after I gave birth, she also gave birth. We live together; there is no outsider with us in the house; only the two of us were there. The son of this woman died during the night because she lay upon him. She arose during the night and took my son from my side while I was asleep, and lay him in her bosom, and her dead son she laid in my bosom. when I got up in the morning to nurse my son, behold, he was dead! But when I observed him (later on) in the morning, I realized that he was not my son to whom I had given birth!”

You may recognize this as the background to a story of King Solomon’s wisdom in suggesting that the two women split the baby.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Those who promote bed sharing “have never heard the guttural scream from a mother who was just told her baby was dead.”[/pullquote]

Bed sharing was a deadly problem in 950 BC and it’s a deadly problem in 2018. That’s why pediatricians and public health officials are in agreement that bed sharing with young infant should be avoided. Lactivists, however, who believe that bed sharing is critical to promoting breastfeeding, have been working very hard to conceal or minimize its risks.

They often cite Notre Dame anthropologist James McKenna who wrote the 2015 paper There is no such thing as infant sleep, there is no such thing as breastfeeding, there is only breastsleeping.

McKenna coined the term “breastsleeping” in an effort to:

help both resolve the bedsharing debate and to distinguish the significant differences (and associated advantages) of the breastfeeding–bedsharing dyad when compared with the nonbreastfeeding–bedsharing situations, when the combination of breastfeeding–bedsharing is practiced in the absence of all known hazardous factors. Breastfeeding is so physiologically and behaviourally entwined and func- tionally interdependent with forms of cosleeping that we propose the use of the term breastsleeping to acknowledge the following: (i) the critical role that immediate and sustained maternal contact plays in helping to establish optimal breastfeeding; (ii) the fact that normal, human (species wide) infant sleep can only be derived from studies of breastsleeping dyads … and (iii) that breastsleeping by mother–infant pairs comprises such vastly different behavioural and physiological characteristics compared with nonbreastfeeding mothers and infants …

That’s a fancy and long winded (and unverifiable) way of implying that promoting breastfeeding is more important than whether babies lie or die.

Is it?

I belong to a private Facebook group of medical professionals who were discussing this issue. The stories that nurses told were chilling. If you think bed sharing death is something that only happens to other people, people who smoke and drink and use drugs, think again.

Consider:

Whenever I think about cosleeping it reminds me of a former patient of one of my coworkers. My friend and coworker had cared for a baby in NICU for 4 months. The first night the parents had the baby home, they decided to sleep with the baby in their bed. The baby ended up suffocating and dying that night, first night home after 4 months in NICU.

Or this:

This issue really hits home with me. For the last 2 years I have been living in xxxx, where they are proud of the fact that every maternity hospital is designated Baby Friendly. I know I have personally cared for 3 infants who died from SIDS after discharge due to co-sleeping. I have also helped futilely code a 2 month old brought into the ER in cardiac arrest. Mom admitted to co-sleeping and was EBF.

The baby was not considered high risk.

This infant would have been considered “low risk,” .., thus it would have been an acceptable risk to co-sleep. They obviously have never heard the guttural scream from a mother who was just told her baby was dead. There are not words to comfort her when she keeps asking how she is going to tell her husband who is deployed overseas.

The nurse goes on to say:

Mind you I am currently a nurse in a small 15 bed level II NICU. Formerly, I worked in a xxxx 90 bed high acuity level III NICU, which unofficially practiced Fed is Best. We would occasionally hear of some of our former graduates dying of SIDS, but nothing like the frequency I hear about in my current NICU. If one of the stated benefits of exclusive breastfeeding and a promoted benefit of Baby Friendly hospital designation is reduced SIDS rates, then why does there seem to be a real issue in a state where the only option is to deliver at a baby-friendly facility?

A third nurse writes:

I too have been involved with multiple SIDs cases. One was IN our BFHI hospital, suffocation while BF during the night–fresh section mom.

That’s not the only harm from breastfeeding promotion. As the second nurse comments:

Believe me, it has been an eye opening experience going from a feeding friendly hospital to a baby-friendly hospital. The amount of preventable infant harm I have seen is sickening. From severe dehydration to SIDS, there are so many things wrong with baby friendly practices.

The idea that co-sleeping must be closest too perfection because it’s natural is a perversion of evolutionary theory. Evolution does not lead to perfection. Many natural practices have high failure/death rates. Only the fittest survive and fitness changes as the environment changes.

Even if it were the case that women and babies co-slept in the past, they did so on bare ground in the cold. Humans haven’t slept on the bare ground in the cold since fire was mastered. The way we sleep has changed over time and now we sleep in ways that are harmful to babies: on soft surfaces and with soft bedding.

Moreover, there is nothing inherent in sleeping separately that prevents a mother from breastfeeding exclusively. Bed sharing just makes breastfeeding more convenient and therefore supposedly more likely. The underlying assumption is that breastfeeding is so critically important to infant health and that risking an infant’s death is a reasonable choice in order to promote breastfeeding. Except breastfeeding is not critically important and dead babies can’t breastfeed.

An individual mother may consider the small risk of death from bed sharing an acceptable choice. But she can’t make an informed choice if lactivists lie about the risks. Bed sharing is deadly in low risk situations as well as high risk situations. Mothers deserve to know.

Another study has found exclusive breastfeeding dramatically increases the risk of newborn hospital readmission.

We’ve known for sometime that aggressive breastfeeding promotion has significant risks including hypernatremic neonatal dehydration and jaundice induced brain damage (kernicterus); indeed 90% of cases of kernicterus are associated with breastfeeding. Closing well baby nurseries in order to force infants to room in with mothers has additional harms: babies being smothered in or falling from mothers’ hospital beds.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Infants treated with phototherapy had a 72% reduction in risk of readmission. Infants allowed unrestricted access to formula had a 76% reduction in risk of readmission.[/pullquote]

In January I reported on Health Care Utilization in the First Month After Birth and Its Relationship to Newborn Weight Loss and Method of Feeding by Flaherman et al., which appears to be the first study to quantify the harms of aggressive breastfeeding promotion.

Exclusively breastfed newborns had higher readmission rates than those exclusively formula fed for both vaginal (4.3% compared to 2.1%) (p<0.001) and Cesarean deliveries (2.1% compared to 1.5%) (p=0.025). Those exclusively breastfed also had more neonatal outpatient visits compared to those exclusively formula fed for both vaginal (means of 3.0 and 2.3, p<0.001) and Cesarean deliveries (means of 2.8 and 2.2, p<0.001)

In addition to the pain and suffering of the newborns and anguish of the parents, a tremendous amount of money was spent.

…[S]ince the cost of a neonatal readmission has been estimated at $4548.27 a potential savings of $7.8 million might be realized for a cohort similar to ours if the readmission rate of exclusively breastfed newborns approximated that of newborns exclusively formula fed.

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. And that doesn’t even count the downstream impact of brain injuries, a consequence that was beyond the purview of this study.

A new study Efficacy of Subthreshold Newborn Phototherapy During the Birth Hospitalization in Preventing Readmission for Phototherapy was undertaken to determine whether prophylactive phototherapy could reduce the risk of hospital readmission for severe neonatal jaundice.

As the authors explain:

To estimate the efficacy of subthreshold phototherapy for newborns with total serum bilirubin (TSB) levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold during the birth hospitalization in preventing readmissions for phototherapy, and to identify predictors of readmission for phototherapy.

Phototherapy works! But the authors serendipitously found a far simpler intervention that also dramatically reduces the risk of readmission: formula!

Among 25 895 newborns with qualifying TSB [total serum bilirubin] levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold, 4956 (19.1%) received subthreshold phototherapy and 241 of these (4.9%) were readmitted for phototherapy compared with 2690 of 20 939 untreated newborns (12.8%) (unadjusted odds ratio [OR], 0.35; 95% CI, 0.30-0.40). In a logistic regression model, adjustment for confounding variables, including gestational age, race/ethnicity, formula feedings per day, and the difference between the TSB level and the phototherapy threshold, strengthened the association (OR, 0.28; 95% CI, 0.19-0.40)… Subthreshold phototherapy was associated with a 22-hour longer length of stay (95% CI, 16-28 hours).

Formula supplementation was equally effective:

Newborns who received formula feedings had lower adjusted odds of readmission for phototherapy compared with exclusively breastfed newborns (OR, 0.58; 95% CI, 0.47-0.72 for >0 to to <2 formula feedings per day; OR, 0.24; 95% CI, 0.21-0.27 for 6 formula feedings per day).

Infants treated with phototherapy had a 72% reduction in risk of readmission. Infants allowed unrestricted access to formula had a 76% reduction in risk of readmission.

Contemporary pediatricians are rediscovering what our ancient foremothers learned long ago: supplementation in the days after birth improves outcomes.

Our ancient foremothers supplemented with prelacteal feeds. Prelacteal feeding — feeding babies supplements like water, tea and honey in the early days of breastfeeding — is common in indigenous and rural cultures around the world.

So why have lactivists, who promote breastfeeding as beneficial precisely because it was the practice of our foremothers, discarded this “ancient wisdom”? First, it doesn’t comport with their belief in the near magical properties breastfeeding. Second, studies have demonstrated that prelacteal feeding is associated with higher infant mortality.

That’s not surprising since the supplements are often contaminated with harmful bacteria, and therefore compare unfavorably with exclusive breastfeeding for women who produce enough breastmilk. But supplements probably compare favorably with death from insufficient breastmilk production. Since insufficient breastmilk in the early days after birth is relatively common, prelacteal feeding became a widespread practice the world over.

Are we actively and aggressively ignoring what indigenous mothers have known for centuries, that a significant proportion of babies cannot survive and thrive without initial supplementation?

Are we risking babies’ lives and brain function because lactivists and breastfeeding professionals have become obsessed with promoting the process of exclusive breastfeeding, privileging it over the outcome of healthy babies?

Sure, we could prophylactically treat large numbers of breastfed infants with phototherapy in order to reduce the risk of life threatening side effects of aggressive breastfeeding promotion: severe jaundice and hospital readmission. But as the authors note:

Phototherapy is generally considered a low-risk intervention. Still, it can cause physical separation of the mother and the newborn, potentially interfere with breastfeeding and bonding, increase inpatient hospitalization costs, and increase the hospital length of stay…

Or we could just allow babies unrestricted access to formula, an equally effective intervention that is far easier to employ, far less expensive, and would have the added bonus of treating newborn hunger, thus reducing suffering for both babies and mothers.

Breastfeeding is causing otherwise mentally healthy women to lose their minds.

Consider this piece from the Today Show.

Donna Freydkin writes:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Like mass hysteria, it appears to be contagious, directly transmitted by lactation professionals who suffer from their own version of Breastfeeding Derangement Syndrome.[/pullquote]

Then my glorious globes failed me. No milk came out. Not a trickle. Not a drip. Not a sprinkle. We got Alex’s tongue clipped and I’d attach him, but it was akin to walking a cat on a leash. Pretty much futile. The nurses gave him formula (to my disgust but whatever, the kid had to eat) and I wore a La Leche League hair shirt of guilt.

It sounds like she experienced primary lactation failure. It would never have harmed her child since she had easy access to formula and clean water with which to prepare it, but it definitely harmed her psychological health:

I made myself crazy. Actually, I owe an apology to the word crazy. I, in fact, became deranged with guilt.

She developed what I’ve begun to think of as Breastfeeding Derangement Syndrome. It happens when women who otherwise think clearly completely lose perspective about the limited benefits of breastfeeding.

It is a situational disorder; it depends on social milieu.

…We lived on the Upper West Side of Manhattan, the ground zero of mommy wars, where the women I met at playgroups competed for the Golden Globe in Parenting Decisions. One bragged about growing her own organic fruits so she could make her child’s food from scratch. Another schooled me on powering through nursing issues, telling me to drink lactation tea and just keep trying and trying and trying because I could do it!

All the moms I met — all of them — insisted that breast was best, that formula was second to arsenic when it came to baby nutrition, and that they would practice child-led weaning, even it if meant nursing until their kids were doing college tours. I nodded as I shamefacedly mixed Earth’s Best powder with warm water in my bottle and fed it to my kid, who guzzled it down like it was the world’s greatest sake.

It is characterized by deep feelings of guilt and shame. Its sufferers are nearly prostrate with intrusive thoughts that they are bad mothers, that their babies are being harmed. And like many psychological illnesses, it is impervious to reality. The truth is their babies aren’t suffering; their babies aren’t merely doing better than they were while breastfeeding; they’re thriving, chubby, happy and hitting developmental milestones on target or early.

Why are so many women developing Breastfeeding Derangement Syndrome? Like mass hysteria, it appears to be contagious, directly transmitted by lactation professionals who suffer from their own version of Breastfeeding Derangement Syndrome. Lactation professionals have acquired a monopoly — through La Leche League, the Baby Friendly Hospital Initiative, and a variety of health organizations captured by the lobbying efforts of LLL and the BFHI — over the dissemination of information about breastfeeding. That has allowed their delusions to go mainstream.

In reality, breastfeeding in industrialized countries has trivial benefits, but lactation professionals promote their delusion that the benefits of breastfeeding are massive.

In reality, breastfeeding, like all natural processes, has a significant failure rate (up to 15% of first time mothers in the early days after birth), but lactation professionals promote their delusion that breastfeeding failure is rare.

In reality, breastfeeding has no impact on mother-infant bonding because it is the fact of being fed that promotes bonding, not how the baby is fed. But lactation professionals promote their delusion that breastfeeding is necessary for bonding.

In reality, there are a myriad of possible breastfeeding problems, and not all are amenable to treatment. But lactation professionals promote their delusion that any difficulties with breastfeeding are due to lack of maternal will or lack of support.

Breastfeeding Derangement Syndrome causes lactation professionals — who are ostensibly medical providers subject to ethical guidelines — to behave in ways that are grossly unprofessional, bullying and shaming new mothers while simultaneously muzzling or drowning out other providers. Pediatricians, neonatologists and obstetricians are desperately trying to draw attention to the very real harms, including neonatal brain injures and death, from aggressive breastfeeding promotion not to mention maternal mental health issues.

Prevention is the key to relieving the suffering from Breastfeeding Derangement Syndrome. The Baby Friendly Hospital Initiative must be ended; no outside special interest group should be allowed to make hospital policy. Simultaneous efforts must be made to root out Breastfeeding Derangement Syndrome from the lactation profession. Lactation consultants’ training should involve neonatologists and pediatricians to educate them about the very real limitations and risks of breastfeeding, and mental health professionals to root out their tendency to bully and shame mothers who can’t or don’t wish to breastfeed.

Obstetricians and pediatricians have a special role to play: offering unbiased information about the limited benefits and real risks of breastfeeding, instead of the propaganda many are forced to offer now. Obstetricians and pediatricians should also offer reassurance.

Freydkin credits her obstetrician with helping her regain perspective:

This would have gone on indefinitely until I had a checkup with my OBGYN, Dr. Andrea M. Dobrenis, a doctor both witty and wise.

She commented on what a big, healthy baby Alex was, and asked how feedings were going. I immediately kicked into my prepared remarks, not even catching my breath as I ranted apologetically about why I was such a failure as a mother, despite the breasts that should be performing their milk-producing function. She told me to please take a breath and calm down. And here’s what she said: “Donna, do you have access to clean drinking water? Do you have access to quality formula? Is your son thriving? You’ll be fine. Stop beating yourself up and enjoy your time with your baby.”

Freydkin’s story is more poignant than most. At the same time she was struggling with breastfeeding guilt and shame her husband was dying of brain cancer.

…To overcompensate for being a working mom who excelled at interviews with Meryl Streep and Brad Pitt but who was a flop at feeding her son, I spent hours at farmers markets buying certified organic produce, which I would then meticulously steam and turn into baby food — saved only in glass containers, due to BPA fears. His sheets were fair-trade organic cotton. As were his clothes. I fixated on everything but what mattered — spending intimate time with my husband, who was undergoing chemotherapy for brain cancer, and our son.

Breastfeeding Derangement Syndrome blighted the Freydkin’s early days of motherhood, just as it does for many new mothers. That’s a tragedy, one that — fortunately — we have the power to prevent.

California is about to experiment on its mothers and babies.

Ordinarily we would look with horror on a state’s desire to experiment on its own people. Yet when the purported justification is preventive care, we suspend our distaste under the theory that preventive care is always a good thing; as a result people get hurt or even die. Sadly, we have not yet learned our lesson from other preventive care debacles like those with hormone replacement therapy (HRT) and the PSA test.

According to NPR:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Its proponents are sure that it will lead to improved outcomes and money saved; the proponents of routine HRT, routine PSA testing, and the 39 week rule were also sure. They were wrong.[/pullquote]

Many women who don’t need a C-section often get one anyway, according to the data — and it varies from hospital to hospital. Even for low-risk cases, Lang says, several California hospitals are delivering 40 percent of babies by C-section. At one hospital, it’s 78 percent…

… Performing it when it’s not needed exposes a woman to unnecessary risks: infection, hemorrhage, even death.

Studies also have found that babies delivered by C-section are more likely to have complications and spend more time in the neonatal intensive care unit.

That’s not quality health care, Lang says, and that’s why Covered California is telling hospitals they need to reduce their C-section rates to 23.9 percent or lower, for low-risk births.

What will happen if they don’t?

Starting in less than two years, if the hospitals haven’t met certain designated targets for safety and quality, they’ll risk being excluded from the “in-network” designation of health plans sold on the state’s insurance exchange…

… Covered California is telling hospitals that if don’t play by the rules, they’ll be benched

Surely a massive experiment like this is based on solid data that definitively shows two things: that lower C-section rates cause better outcomes and that blunt efforts to lower C-section rates don’t lead to increased deaths and injuries. Nope. It’s based entirely on studies that show a correlation of lower C-section rates with acceptable outcomes in some settings. To my knowledge, there are no large scale studies of what happens when insurers pressure hospitals to lower C-section rates.

We’ve been here before — many times.

When I finished my residency 30 years ago, it was standard of care to prescribe hormone replacement therapy for all post-menopausal women. Many physicians were well aware at the time that the data showed only a correlation between HRT and lower mortality from heart disease. We were equally aware that there was no data to tell us what the side effects of years of HRT might be.

No matter. We were told that HRT would lead to better fewer cardiac deaths and would surely save money. Sadly, the exact opposite happened. HRT did not cause fewer cardiac deaths (no money saved there) and actually increased the rate of breast cancer (a very expensive side effect).

A similar debacle occured with PSA (prostate specific antigen) testing. Since increased PSA is associated with prostate cancer, doctors began recommending routine PSA screening, despite the fact that there were no large scale, long term studies demonstrating benefit. It was preventive medicine; so surely it would cause better outcomes and save money. Wrong again.

According to the National Cancer Institute:

Until about 2008, some doctors and professional organizations encouraged yearly PSA screening for men beginning at age 50. Some organizations recommended that men who are at higher risk of prostate cancer, including African American men and men whose father or brother had prostate cancer, begin screening at age 40 or 45. However, as more was learned about both the benefits and harms of prostate cancer screening, a number of organizations began to caution against routine population screening…

It turned out that many prostate cancers did not grow fast enough to threaten a man’s life. Removing such cancers led to the dreaded side effects treatment: incontinence and erectile dysfunction without saving any lives. It didn’t save money, either.

In order to lower the induction rate we are currently engaged in an experiment on mothers and babies. The 39 weeks rule (no elective inductions before 39 weeks) has been enforced for several years. It was promised that it would lead to a lower neonatal mortality from late prematurity, though many obstetricians suspected that it would actually lead to higher stillbirth rates. The preliminary data was not encouraging.

Changes in the patterns and rates of term stillbirth in the USA following the adoption of the 39-week rule: a cause for concern? was presented at the 2016 annual meeting of the Society for Maternal-Fetal Medicine.

Between 2007 and 2013 in the USA, the implementation of the 39-week rule achieved its primary goal of reducing the proportion of term births occurring before the 39th week of gestation. During the same period the rate of USA term stillbirth increased significantly. Assuming 3.5 million term USA births per year, more than 300 more term stillbirths occurred in the USA in 2013 as compared to 2007…

A new, large study, Association of Temporal Changes in Gestational Age With Perinatal Mortality in the United States, 2007-2015, shows that the 39 week rule has changed the distribution of gestation age at birth — reducing births at 37-38 weeks and increasing births at 39 weeks — but has NOT had the promised impact on death rates.

I graphed the change in gestational age distribution:

What happened to infant deaths?

The overall perinatal mortality rate decreased from 9.0 per 1000 births in 2007 to 8.6 per 1000 births in 2015 (P < .001).

Perinatal mortality decreased at gestational ages of 20 to 27 and 39 to 40 weeks but showed annual adjusted relative increases of 1.0% (95% CI, 0.6%-1.4%) at 34 to 36 weeks, 2.3% (95% CI, 1.9%-2.8%) at 37 to 38 weeks, and 4.2% (95% CI, 1.5%-7.0%) at 42 to 44 weeks.

Stillbirth rates increased at gestational ages of 20 to 27, 28 to 31, 32 to 33, 34 to 36, 37 to 38, and 42 to 44 weeks and remained unchanged at 41 weeks. Neonatal mortality rates decreased at gestational ages of 20 to 27 and 28 to 31 weeks; increased at 34 to 36, 37 to 38, and 42 to 44 weeks; and remained unchanged at 41 weeks.

That’s almost exactly the opposite of what was predicted. Neonatal mortality at 34-36 weeks and 37-38 weeks did NOT drop; it actually INCREASED. Moreover, stillbirths INCREASED, too.

Why did the overall perinatal mortality rate drop? NOT because of the 39 week rule, but because of improvements in the care of extremely premature infants (21-27 weeks).

What went wrong? Once again correlation was confused for causation and a measure designed to save lives at 34-38 weeks actually led to increased deaths.

And now we’re about to embark on a similar experiment to lower C-section rates.

So far, the prospect of exclusion, plus the coaching for hospitals on how to reduce the rates, have functioned as an effective motivator.

By 2020, Covered California’s Lang believes all hospitals will either have met the target or be on their way.

“It’s a quality improvement project,” Lang says, “but with a deadline.”

Its proponents are sure that it will lead to improved outcomes and money saved … exactly the proponents of routine HRT, routine PSA testing, and implementation of the 39 week rules were sure that those were quality improvements. They were wrong.

California is embarking on a massive experiment on mothers and babies. Let’s hope they don’t inadvertently injure and kill them as a result.