The more research we do, the LESS support there is for the claim that C-sections impact the neonatal microbiome in ways that are ultimately harmful to health.

Research on the impact of C-section on the neonatal microbiome has been plagued with major problems, the most important of which is the naturalistic fallacy: the belief that if something is a certain way in nature, that must be the best possible way. Since passage through the vagina was the only way to give birth for most of human history, there are many people who believe it must be the best way to give birth.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The claim that C-sections alter the neonatal microbiome in ways that are harmful has never been proven and is likely to be nothing more than wishful thinking.[/pullquote]

Vaginal birth is obviously not the best way to maximize maternal and infant survival. C-sections save literally hundreds of thousands of mothers and babies each and every year. Research has shown that a minimal C-section rate of 19% is necessary to achieve low maternal and perinatal mortality. Those clinging to the naturalistic fallacy continue to search for something, anything, with which to demonize C-sections. The latest object of their affections is the neonatal microbiome. Many within the natural childbirth industry, and some within the medical profession, are claiming that C-section alters the neonatal microbiome in ways that are ultimately harmful to longterm health.

Last year I reported on the largest study to that date that looked at the impact of mode of delivery on the neonatal microbiome. Maturation of the infant microbiome community structure and function across multiple body sites and in relation to mode of delivery was published in Nature Medicine.

The authors 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) …

Now comes a new literature review that further undermines the claim that C-sections alter the neonatal microbiome. A Critical Review of the Bacterial Baptism Hypothesis and the Impact of Cesarean Delivery on the Infant Microbiome was published just this week.

The authors take aim at the bacterial baptism hypothesis.

…[E]pidemiological studies have linked Cesarean delivery with increased rates of asthma, allergies, autoimmune disorders, and obesity. Mode of delivery has also been associated with differences in the infant microbiome. It has been suggested that these differences are attributable to the “bacterial baptism” of vaginal birth, which is bypassed in cesarean deliveries, and that the abnormal establishment of the early-life microbiome is the mediator of later-life adverse outcomes observed in cesarean delivered infants. This has led to the increasingly popular practice of “vaginal seeding”: the iatrogenic transfer of vaginal microbiota to the neonate to promote establishment of a “normal” infant microbiome.

The investigators who first proposed the bacterial baptism hypothesis noted differences in the microbiota of the nose and mouth between infants delivered by C-section vs vaginal birth.

Given that neonates were swabbed within seconds of delivery, and thus it would be coated with vaginal fluids, this result is hardly surprising. This does not necessarily demonstrate colonization, however.

What about the initial neonatal gut microbiome?

Numerous studies describing the bacterial microbiota of first pass meconium (the first fecal material, passed shortly after birth) support the notion that CSD and VD neonates do not differ in their bacterial microbiomes in the first few days following birth.

How about thereafter?

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.

And the differences almost entirely disappear when infants start eating solid food.

Do the temporary differences reflect mode of delivery or confounding factors? It is very likely they are the result of confounding factors such as:

1. Antibiotics:

All mothers delivering by CS are administered intrapartum antibiotic prophylaxis (IAP), as is routine for any type of surgery. In some countries, IAP is administered after the cord is clamped, minimizing direct antibiotic exposure of the neonate. In others, antibiotics are given prior to commencement of surgery… Mothers delivering vaginally are not routinely administered antibiotics, with the notable exception of those who are vaginally colonized with Group B Streptococcus (GBS). Overall, rates of intrapartum antibiotic use are low in vaginally delivering mothers.

2. Labor:

…[L]abor causes changes in levels of endocrine, inflammatory, and contractile factors. These changes might influence the maternal microbiome or the establishment of the neonatal microbiome. Additionally, labor is often accompanied by rupture of the fetal membranes, exposing the fetus to maternal vaginal bacteria…

3. Breastfeeding:

Source tracking studies have shown that 27% of an infant’s gut microbiota is vertically derived from its mother’s breast milk, while an additional 10% is sourced from the skin around the areola.

4. Maternal obesity:

Obesity and high-fat diets have repeatedly been correlated with aberrations to the gut microbiome in humans. Maternal obesity alters the maternal gut microbiome during pregnancy, and the milk microbiome during lactation …

The microbiome of obese mothers may have a harmful effect on weight gain in toddlers:

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. In particular, children born to obese mothers had differences in abundances of Faecalibacterium spp., Eubacterium spp., Oscillibacter spp., and Blautia spp., all of which have been correlated to diet and body weight in previous studies.

5. Gestational age and NICU exposure:

Rates of CS delivery increase with decreasing gestational age at delivery. Preterm infants differ from their full-term counterparts in terms of their gut microbiota, immune development, and health outcome…

The NICU environment is likely to influence the microbiome, so duration of residence and the environmental microbiome of the unit are likely to have a significant impact…

6. Inter-individual variation:

Studies that compare the microbiomes of infants born by CS or vaginal delivery must have sufficient power to account for variation in the maternal microbiome, as this is likely to exert a large influence on an infant’s microbiome through breastfeeding and physical contact. Large cohorts are thus required with the ability to control variables, such as home environment, presence of pets, and exposures to other microbiome-altering factors including hygiene and maternal/infant diet.

To date there have been no studies involving large cohorts.

In summary:

…[G]iven the numerous and significant confounding factors present in studies comparing the microbiota after CS and vaginal delivery, it is impossible to say with any certainty that it is the act of delivering vaginally itself which confers this optimal microbiota, or what species/genera of bacteria might be responsible. Differences in antibiotic administration, labor onset, maternal body weight and diet, gestational age, and breastfeeding frequency and duration undoubtedly contribute to differences observed between CSD and VD infants. Further, it is likely that differences between CSD and VD infants do not develop until several days after birth. Given recent evidence that infant microbiome colonization begins in utero, it may be that the importance of “bacterial baptism” of vaginal birth has been significantly over-estimated.

Although numerous studies have demonstrated an association between CS delivery and altered microbiome establishment, no studies have confirmed causality.

The authors recommend abandoning the practice of vaginal seeding:

Health practitioners should not bow to popular pressure to perform vaginal seeding in the absence of data on need, effectiveness, and appropriate protocols for ensuring safety.

The natural childbirth industry is not going to give up on demonizing C-sections any time soon, but women need to know that the claim that C-sections alter the neonatal microbiome in ways that are harmful has never been proven and is likely to be nothing more than wishful thinking.

Have you no shame, La Leche League?

Once again you cruelly posted this “badge.”

I breastfed my baby through postpartum depression!

Never mind that women are literally killing themselves and their babies because of postpartum depression, and breastfeeding has been implicated in the suffering of these women:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Do you make a stick-on version of the badge that undertakers can affix to the coffins of new mothers who commit suicide?[/pullquote]

Florence Leung killed herself in despair over breastfeeding difficulties.

Charlotte Bevan discontinued her anti-psychotic medication while still in the hospital because it was not compatible with breastfeeding. With her baby she went directly from the hospital to a gorge and jumped; both she and the baby died.

Mary Jo Trokey used a gun to kill her baby, her husband and herself. According to her mother:

A combination of stressful factors, especially breastfeeding and returning to work, “all compounded” and led up to the killings.

Inquiring minds want to know, La Leche League: do you make a stick-on version that the undertakers could have affixed to the coffins of these women?

But what’s more important than LLL continuing to profit from the business of breastfeeding? Certainly not women’s mental health, right?

It’s instructive to juxtapose LLL’s ugly indifference to the suffering of those struggling with postpartum depression to the response to a new movie depiction of postpartum depression:

“Tully,” a movie about motherhood starring Charlize Theron that doesn’t open until Friday, is already generating a heated conversation about its portrayal of postpartum depression, a subject rarely depicted onscreen.

Some women are upset by the film:

Ann Smith, the president of Postpartum Support International, a nonprofit group, said her organization has been fielding complaints about the film since March, when spoilers began to circulate…

“The mommy world is up in arms,” she said, referring to survivors of perinatal mood disorders, which are diagnosed in one out of every seven women during pregnancy or postpartum. “I can see why there’s a lot of anger out there, and I think they have a right to it.”

What bothered many survivors of postpartum depression is that the suffering mother never gets mental health treatment.

According to midwife Diana Spaulding writing for Mother.ly:

The reason that people are so excited about Tully is because they feel like it is the first time that true motherhood is being portrayed on the big screen—but this is not true motherhood. Motherhood is hard, yes, but it is not this. This is mental illness. Brushing aside her mental illness again refuses to give it the attention it deserves.

Marlo needs immediate mental health treatment, and there is no direct acknowledgment in the film that she is getting it. Yes, a doctor tells her husband that she has PPD. Perhaps we can assume that means she’s getting help?

Here’s the thing though—all too often in mental health we assume that someone is fine and getting the care they need. So we don’t do anything or say anything.

We need to create a culture that is done assuming and starts ensuring.

I don’t know about the movie because I haven’t seen it, but this incisive criticism makes a perfect rebuke to La Leche League.

Breastfeeding through mental illness is not something to celebrate with a badge. Postpartum depression is a form of mental illness and its sufferers need immediate treatment. Yes, the badge acknowledges the existence of PPD but it says nothing about appropriate care and treatment; indeed it sends the message that treatment is unimportant compared to continued breastfeeding.

LLL utterly ignores the fact that sometimes the best treatment for an individual woman involves stopping breastfeeding in order to get more rest or to be able to take antidepressant medications incompatible with breastfeeding. To those women the badge conveys the repugnant message that they are bad mothers at the exact moment they are struggling desperately to feel like good mothers.

It implies that the good mother is nothing more than a milk dispenser, not a valued person whose mental health takes priority over the trivial benefits that breastfeeding provides.

That message isn’t merely reprehensible; it could be deadly.

It made intuitive sense that it would improve outcomes for babies. In fact, it made so much sense that it was implemented before large scale testing was conducted. Now, years later, it turns out that the benefits were dramatically overstated and the risks were ignored.

I could be talking about electronic fetal monitoring (EFM) that both monitors and records the fetal heart rate during labor. It made intuitive sense that it would improve outcomes for babies because the all too common phenomenon of stillbirth was preceded by abnormal fetal heart rate patterns. Once the equipment became available it was rushed into clinical practice rather than wait for large scale studies to prove its benefits. Now, decades later, we find that the impact on neonatal health is far less that we predicted and the side effects — particularly a dramatically increased rate of C-section for fetal distress — are far greater than we ever imagined.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Professional lactivists should learn from the mistakes of obstetricians. Just because something has intuitive appeal for improving outcomes doesn’t mean that it will.[/pullquote]

But I’m not talking about EFM; I’m talking about breastfeeding.

It made intuitive sense that breastfeeding would improve outcomes for babies because it had evolved to become the natural food for babies. In the wake of the Nestle debacle of the 1970’s, when African mothers were convinced to switch from breastfeeding to formula and their babies died as a result of the contaminated water used to prepare it, aggressive promotion of breastfeeding was rushed into clinical practice rather than wait for large scale studies to prove its benefits. Now, decades later, we find that the impact on neonatal health of term babies is nearly non-existent (though it is beneficial for preemies) and the side effects — including a doubling of neonatal hospital readmissions, an increase in neonatal hypernatremic dehydration and jaundice induced brain damage, and an epidemic of newborns dying in the hospital after being smothered in mothers’ beds or injured falling out of them — are far greater than we ever imagined.

The benefits of breastfeeding keep shrinking.

Consider the new paper from Kramer et al. on the latest results from the PROBIT study, Breastfeeding during infancy and neurocognitive function in adolescence: 16-year follow-up of the PROBIT cluster-randomized trial:

A total of 13,557 participants (79.5% of the 17,046 randomized) of the Promotion of Breastfeeding Intervention Trial (PROBIT) were followed up at age 16 from September 2012 to July 2015. At the follow-up, neurocognitive function was assessed in 7 verbal and nonverbal cognitive domains using a computerized, self-administered test battery …

We observed no benefit of a breastfeeding promotion intervention on overall neurocognitive function…

This is big news because the PROBIT studies were among the first to claim neurocognitive benefits from breastfeeding. But it is not surprising news since the Colen study, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons, demonstrated that nearly every puported benefits of breastfeeding disappeared when researchers corrected for maternal socio-economic status.

What should we do when we find that our intuitive sense of benefit is not supported by the scientific evidence?

In the case of electronic fetal monitoring, we are stuck between a rock and a hard place. Research shows that EFM has a high false positive rate meaning that it suggests fetal distress in many cases where the baby is not distressed. On the other hand, when the baby is distressed, it will be accurately reflected in the heart rate tracing and should be acted upon; so it does have important clinical utility. Moreover, though we understand the limitations of EFM, we have nothing yet with which to replace it. We continue using it despite its limitations because it does have significant benefits that outweigh the risks. In the meantime, ongoing research is looking for more reliable ways of monitoring babies in labor.

In the case of breastfeeding, we are not stuck at all. We have infant formula, an excellent form of nutrition for babies that has been shown over multiple generations and tens of millions of babies to produce healthy offspring indistinguishable from those who were breastfed. In fact, despite mathematical models claiming that lives and money are saved when breastfeeding rates increase, professional lactivists are unable to point to any lives of term babies or money saved as the breastfeeding rate has triple over the past 40 years.

What do breastfeeding and electronic fetal monitoring have in common? Both have failed to produce the benefits predicted; both have serious risks, and both are in need of revision.

We’ve stopped overstating the benefits of EFM and we should stop overstating the benefits of breastfeeding.

We are working assiduously to reduce the risks of EFM and we should be working assiduously to reduce the risks of breastfeeding.

We’re looking for a substitute for EFM that has the same advantages without the unfortunate side effects. We already have a substitute for breastfeeding that has nearly all the same advantages without the unfortunate side effects. It’s called formula and instead of demonizing it, we should be promoting its use when needed or wanted.

Professional lactivists should learn from the mistakes of obstetricians. Just because something has intuitive appeal for improving outcomes doesn’t mean that it will. And when it doesn’t, we should reassess our claims instead of doubling down on them.

Privilege can be very ugly.

Witness the specter of a black obstetrician being upbraided primarily by white people for a speech about reducing racial disparities in maternal mortality.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Vilifying Dr. Brown for stating an incontrovertible medical fact — contraception saves women’s lives — reflects the privilege of well off, white women who have easy access to birth control and the money to pay for it.[/pullquote]

Dr. Brown made an incontrovertible claim: the single most effective way to prevent maternal mortality is birth control and now he’s being pilloried for it.

Comments, predominantly from white women, make three main accusations;

• Claiming that Dr. Brown wants women at risk of maternal death to stop reproducing.
• Implying that maternal death is due to an overuse of technology.
• Insisting that midwives could reduce the maternal death rate.

These commenters are blinded by pregnancy privilege.

As I wrote in a recent post, pregnancy privilege is a set of assets a woman can count in on cashing in, and to which she is by and large oblivious. By far and away the most important asset in pregnancy privilege is this: The pregnancy is planned and wanted.

That’s not the case for many women. While it is difficult to imagine anything more tragic than a woman dying to give birth to a baby she wanted, dying as a result of an unintended pregnancy is possibly worse. Since 45% of US pregnancies are unintended — and possibly an even higher percentage of pregnancies of women of low socio-economic status — that means that easy access to birth control, including insurance that covers the cost, is a simple, effective, relatively inexpensive way to prevent maternal deaths.

That was Dr. Brown’s point and it is hardly a trivial point in the current political atmosphere where reproductive rights are under sustained assault and “pro-life” means pro-fetus, not pro-mother. If all women had access to the means to control their fertility, maternal deaths would likely fall precipitously.

But apparently privileged women can’t grasp this basic point and are accusing Dr. Brown of blaming the victim. That’s the last thing he has in mind. Reproductive rights — specifically the right to avoid unplanned pregnancy — is the sine qua non of women’s health, both physical and economic.That disparities in access to contraception exacerbate disparities in maternal mortality is a preventable tragedy.

Pregnancy privilege blinds women to other realities about maternal death. The leading causes of maternal death are cardiac disease, chronic pre-existing health conditions and complications of pregnancy like pre-eclampsia. Many women die of these problems because they lack access to the high tech care that saves privileged women. They aren’t healthy to begin with; they don’t have health insurance; they receive care from clinics; they must deliver at hospitals with poor safety records.

Invoking the rhetoric of natural childbirth: that obstetricians don’t follow scientific evidence (false), that unmedicated vaginal birth is safest (false), that interventions cause more health problems than they prevent (false) is worse than useless. In nature, childbirth is inherently dangerous with a “natural” maternal mortality rate of 1000 per 100,000. That nearly 50X HIGHER than our current maternal mortality rate, which is unacceptably high. It is ludicrous to imagine that a return to nature — a beloved affectation of privileged white women — is going to save the lives of chronically ill black women when nature itself is deadly.

The same thing applies to calls for more midwifery care. How is a midwife going to save a woman dying during pregnancy or postpartum of cardiomyopathy or congenital heart disease or kidney disease or eclamptic seizures? She isn’t, but the privileged women who recommend midwifery care are thinking of themselves and what they want instead of poor women of color and what they need.

The ugly truth is that vilifying Dr. Brown for stating an incontrovertible medical fact — contraception saves women’s lives — is a reflection of the privilege of women who have easy access to birth control and the money to pay for it. Recommending natural childbirth and midwifery care to reduce racial disparities in maternal mortality is the obstetric equivalent of “let them eat cake”: repugnant, clueless and entirely ignorant of the reality of life for anyone other than the privileged.

Yesterday I wrote about the new ACOG recommendations for postpartum care and the fact that they are cheap, low tech window dressing for expensive, high tech problems. The most obvious example is the recommendation to screen for postpartum depression.

Screening for postpartum depression is literally the first mandate in the long list of recommendations.

Screen for postpartum depression and anxiety with a validated instrument.

Postpartum depression and anxiety are serious, and in some cases life threatening, mental health conditions. Screening for it is easy and cheap. But what’s the point of screening for it if the majority of women who have it can’t access treatment because it is expensive and not covered by most insurance?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The stark reality is that mental health care after pregnancy is available only to the privileged: well off and well insured.[/pullquote]

Just last month California radio station WQED asked: To Screen or Not to Screen? Doctors Debate Post Partum Depression Testing.

Lawmakers will begin debate next month on a bill that would require doctors to screen new moms for mental health problems – once while they’re pregnant and again, after giving birth.

But a lot of doctors don’t like the idea. Many obstetricians and pediatricians are afraid to screen new moms for depression and anxiety.

“What are you going to do with those people who screen positive?” said Laura Sirott, an OB/GYN who practices in Pasadena. “Some providers have nowhere to send them.”

It’s a serious problem:

Of women who screen positive for postpartum depression, 78 percent don’t get mental health treatment, according to a 2015 study review published in the journal Obstetrics & Gynecology.

There are three primary reasons why women don’t get treatment for postpartum depression.

1. They can’t access it because there is no provider in their area trained in reproductive psychiatry, the mental health care of pregnant and breastfeeding women.

2. They can’t access it because insurance doesn’t cover it and out of pocket costs are exhorbitant.

3. They can’t access it because they can’t get the childcare, transportation and/or time off from work to see a mental health professional.

The stark reality is that mental health care after pregnancy is available only to the privileged: well off and well insured. Mandating postpartum depression and anxiety screening will likely help them and no one else, further exacerbating the gulf in health outcomes between the privileged and the less privileged. The new ACOG recommendations ignores this reality.

ACOG also ignores ways that we could prevent or mitigate postpartum depression. The most important of these would be to back off on aggressive breastfeeding promotion.

As I noted yesterday, the lead author of the new recommendations made this odious comment:

The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

She was slandering obstetricians but the reality is that lactation professionals, of which Dr. Stuebe is one, are the guilty parties. They treat babies like kings and mothers like cows.

Despite the fact that the benefits of breastfeeding for term babies in industrialized countries are trivial (limited to 8% fewer colds and 8% fewer episodes of diarrheal illness across all infants in their first year), lactation professionals evince complete disregard for maternal well being.

Maternal autonomy is ignored in the effort to pressure every woman to breastfeed regardless of her own health, needs and priorities. Maternal exhaustion is not merely ignored, it is promoted by closing well baby nurseries, recommending the barbaric practice of triple feeding (nursing, pumping and supplementing) and insisting, despite scientific evidence to the contrary, that anything that makes life easier for new mothers — i.e. formula, pacifiers — must not be allowed.

Worst of all, women’s mental health is viewed as irrelevant. Lactation professionals are much more concerned with whether treatments for postpartum depression are compatible with breastfeeding than with whether they are the best possible treatment for the mother’s psychological condition. Women are encouraged to continue dispensing breastmilk even when they are inexorably approaching complete psychological collapse.

Postpartum depression and anxiety are very serious problems and they require very serious — and expensive — treatment. ACOG can congratulate themselves on recommending screening but until they tackle the problems of prevention and access to treatment, it’s nothing more than window dressing.

I am going to look a gift horse in the mouth.

ACOG has just released new guidelines for postpartum care. They were long overdue but sadly they are more window dressing than substantive improvement. Moreover, the way they are being promoted is odious.

The American College of Obstetricians and Gynecologists (ACOG) have published the guidelines as Optimizing Postpartum Care.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How can the recommendations for postpartum care prevent  maternal deaths when the majority (65.5%) occur during pregnancy, on the day of birth or the first 6 days postpartum?[/pullquote]

The weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being. During this period, a woman is adapting to multiple physical, social, and psychological changes. She is recovering from childbirth, adjusting to changing hormones, and learning to feed and care for her newborn. In addition to being a time of joy and excitement, this “fourth trimester” can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence. Women also may need to navigate preexisting health and social issues, such as substance dependence, intimate partner violence, and other concerns… [M]ost women in the United States must independently navigate the postpartum transition until the traditional postpartum visit (4–6 weeks after delivery). This lack of attention to maternal health needs is of particular concern given that more than one half of pregnancy-related deaths occur after the birth of the infant. Given the urgent need to reduce severe maternal morbidity and mortality, this Committee Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm for postpartum care.

Sounds great, huh? But right off the bat it is completely misleading.

Let’s start with the implication that this is going to reduce maternal mortality. How could that possibly be when the majority of maternal deaths (65.5%) occur during pregnancy, on the day of birth or the first 6 days postpartum?

According to Pregnancy-Related Mortality in the United States, 2011–2013:

532 (30.5%) died before delivery, 293 (16.8%) on the day of delivery or pregnancy termination, 317 (18.2%) between 1 and 6 days postpartum, and 372 (21.3%) between 7 and 41 days postpartum; only 229 (13.2%) died on or after 42 days postpartum.

Why do they die?

Because pregnancy and childbirth are inherently dangerous, because some women lack access to the high tech childbirth care that could save their lives and because women’s complaints are ignored. One of the most notable things about the recent prize winning ProPublica/NPR series on maternal mortality is the high proportion of deaths due to malpractice. A consistent thread runs from Lauren Bloomstein whose preventable death framed the initial piece in the series to Shalon Irving, the black CDC epidemiologist whose preventable death was featured in the piece about black women dying in pregnancy and childbirth, and many of the women in between: medical professionals dismissed their symptoms as variations of normal when they were signs of impending death. These women died of malpractice and no amount of optimizing of postpartum care would have saved them.

60% of maternal deaths are (potentially) preventable. But in order to prevent a death you have to suspect that something is going wrong, diagnose it and correct it. Unfortunately, there has been a relentless trend in the US and other developed countries to promote “normal birth.” Hospitals emphasize their decor and the availability of waterbirth, women bring their doulas and their birth plans, and doctors are cautioned repeatedly to reduce the routine application of technology like fetal monitoring and C-sections. It’s as if everyone has developed collective amnesia for the fact that pregnancy, in every time, place and culture (including our own) has ALWAYS been one of the leading causes of death of young women.

Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion. All providers should drill for deadly complications like hemorrhage and eclamptic seizures. Labor and delivery suites should be set up to provide easy access to life saving technologies like blood, uterotonic agents, anti-seizure treatments, etc.

California has been leading the way. In their initial assessment of maternal deaths in their state they found that the most preventable deaths were from “hemorrhage (70 percent) and preeclampsia (60 percent).” California researchers created a series of “tool kits” for doctors, nurses and hospitals and have achieved impressive result. The limiting factor in rolling out these programs to other hospitals is complacency.

I find Dr. Alison Stuebe’s misrepresentation of the problem particularly ugly.

“The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

Perhaps that is Dr. Stuebe’s attitude as a perinatologist. Her patients are referrals for pregnancy problems and she doesn’t care for them for very long after birth. If she wants to smear herself and her perinatology colleagues, she can have at it.

But she does a tremendous disservice to OB-GYN’s who traditionally have life long relationships with their patients. They’ve known these women before pregnancy, providing care for contraception, sexually transmitted diseases and GYN health; they will care for the same women after pregnancy, providing contraception, treatment for menstrual disorders, incontinence and menopause. For most OB-GYNs the mother — far from being the “wrapper” — is the primary patient and the one with whom they have an ongoing relationship; the baby is a temporary patient and out of mind once delivered.

Dr. Stuebe’s claim is particularly ironic considering that it is the natural mothering industry that treats the mother as the “wrapper” and ignores the long term risks of vaginal birth on future continence and sexual function, ignores the risks of aggressive breastfeeding promotion on maternal mental health, and shames women for choosing pain relief, C-sections or formula.

That’s not to say that postpartum care can’t be improved. There’s plenty of room for improvement but even there the new ACOG recommendations fall short of what is needed. In particular, they fail to prevent many serious problems that are intrinsic to childbirth (like perineal tears, prolapse and subsequent incontinence) or problems that we make worse with our aggressive promotion of breastfeeding (like maternal exhaustion as a result of closing well baby nurseries and mental health problems exacerbated by pressure to breastfeed).

The recommendations are cheap, low tech window dressing for expensive, high tech problems. We’ll explore their limitations in a future post.

New York Times movie critic Amanda Hess has written one of the best takedowns of contemporary patriarchal ideology I have ever read. She explains how women are pressured not merely to meet male needs and desires but duped into believing they are empowered by the very ideology that is designed to constrain them.

But part of the conditioning of the “patriarchal ideal” is to make women feel empowered by it on their “own terms.” That way, every time you critique an unspoken requirement of women, you’re also forced to frown upon something women have chosen for themselves. And who wants to criticize a woman’s choice?

Hess is writing about beauty standards, but should could just as easily have written about motheng standards. Both have never been stricter.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mothering-standard denialism, like beauty-standard denialism, allows women to pretend that they are empowered by knuckling under to patriarchal ideals.[/pullquote]

Hess is reviewing Amy Schumer’s new movie ‘I Feel Pretty.”

In the film, the down-on-herself Renee (played by Amy Schumer) conks her head in a SoulCycle accident and awakens believing that she has miraculously become supermodel-hot. She revels in it — charging into a bikini contest, snagging a promotion and basking in the affections of a beefy corporate scion — only to discover that her looks never changed a bit. The benefits she thought she accrued through beauty were won instead through her newfound self-confidence.

The movie suggests that the only thing holding back regular-looking women is their belief that looking regular holds them back at all. That attitude puts the onus on individual women to improve their self-esteem instead of criticizing societal beauty standards writ large…

But:

The reality is that expectations for female appearances have never been higher. It’s just become taboo to admit that.

This new beauty-standard denialism is all around us. It courses through cosmetics ads, fitness instructor monologues, Instagram captions and, increasingly, pop feminist principles. In the forthcoming book “Perfect Me,” Heather Widdows, a philosophy professor at the University of Birmingham, England, convincingly argues that the pressures on women to appear thinner, younger and firmer are stronger than ever. Keeping up appearances is no longer simply a superficial pursuit; it’s an ethical one, too. A woman who fails to conform to the ideal is regarded as a failure as a person.

Entire industries — the weight loss industry, the cosmetic industry, the fashion industry — exist to market the male ideal of the female body to women and to pressure them into denying that reality by calling it “empowerment.”

We see it, for example, in the health moralism around weight: Every woman is still expected to torture her body into the male ideal of thin, lithe and cellulite free, but now it is presented as “healthier” instead of the ugly truth that it is what appeals to men.

[T]he beauty ideal is so pervasive that it is internalized in many women, who are haunted by idealized visions of their own bodies — fantasies of how they might look after undergoing extreme diets or cosmetic procedures. But because nobody can ever achieve perfection, we instead begin to fetishize the striving for it — spinning on bikes and slathering on lotions. So even after Renee experiences her awakening to self-acceptance, she ends up right back at SoulCycle, this time having completely swallowed the “I’m doing this for me” line.

Sound familiar? It should because it’s also the tactic behind marketing natural mothering ideology. Expectations for mothering have never been higher but it’s taboo to admit it.

The natural mothering ideal is a traditional male ideal, tens of thousands of years old: women immured in the home restricted to fulfillment through their use of their vaginas, uteri and breasts and barred from fulfillment through their intellect, talents and character. All the while, the industries that profit from these sexist philosophies — natural childbirth, breastfeeding and attachment parenting — are promoting them as “empowering.”

This new mothering standard is all around us. It flows through natural childbirth and breastfeeding websites, parenting Facebook groups, Instagram photos and efforts to “normalize” unmedicated vaginal birth, exclusive breastfeeding, and baby wearing. The patriarchal ideal of women barefoot, pregnant and in servitude to her children has been refashioned. The denialism of the mothering standard involves insisting that women are empowered by it. That way, every time someone critiques an unspoken requirement of mothers — unmedicated vaginal birth, exclusive breastfeeding, attachment parenting — you’re forced to frown upon something women have ostensibly chosen for themselves.

Mothering-standard denialism is like beauty-standard denialism in yet another way.

[A]ll regular women need to succeed is a healthy dose of confidence. That new beauty mantra mirrors corporate messaging around “impostor syndrome” and “leaning in” — the idea that women’s lack of confidence is holding them back from professional success, not discrimination. In fact, our culture’s ideal woman is beautiful and modest.

According to midwives and lactation consultants, the only thing women need to “succeed” at childbirth and breastfeeding is more confidence, not the reality that childbirth is dangerous and excruciating or the reality that the natural failure rate of breastfeeding is high. And, inevitably, the best way to get that confidence is by purchasing the services of — you guessed it — midwives and lactation consultants.

Hess concludes:

The amount of brainpower I spend every day thinking about how I look is a monumental waste. The sheer accumulation of images of celebrity bodies in my browser history feels psychopathic…

The amount of brain power, energy, guilt, shame and suffering spent trying to attain the mothering standard is a monumental waste. The accumulation of images “celebrating” and “normalizing” natural childbirth and breastfeeding is nothing short of oppressive. It doesn’t make babies healthier, safer, smarter or better in any way.

Mothering-standard denialism serves the same purpose as beauty-standard denialism. It allows women to pretend that they are empowered by knuckling under to patriarchal ideals instead of recognizing that they are being manipulated.

One of my proudest moments as a physician occurred years after I stopped practicing.

At a holiday dinner table a cousin commented that had I faced infertility, I would have opted for adoption over complex medical treatment just as she had done. I was surprised since nothing could be further from the truth; I would have aggressively pursued every medical option.

It was her turn to be surprised since she remembered I was one of the very few doctors supported her decision to forgo infertility treatment without even trying. How, she asked, could I have kept my desires out of our discussion? Because, I answered, it is the job of a physician to support a patient’s choices, not to seek validation by having the patient make the physician’s preferred treatment choice.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is the provider’s ethical obligation to support the patient’s goals not to substitute their own values — midwives and lactation consultants included.[/pullquote]

I believe, as matter of both medical and personal ethics, that doctors should never look to patients for validation of their own ideals. It is the doctor’s legal and medical obligation to support the patient’s goals not to substitute his or her own values.

If a Jehovah’s Witness wants to decline blood transfusions, I have no right to insist that she accept them even though I would eagerly choose them if the need arose. If a patient wants to decline a life saving C-section for her baby, I have no right to insist that she undergo surgery even though I would accept immediately. If a patients wishes to treat her cancer with herbs and supplements instead of chemotherapy, I have no right to insist that she accept chemotherapy in favor of a course of action I know to be worthless.

I suspect most doctors would agree with my views; that’s what we are taught. In contrast, midwives and lactation consultants seem to think that is their job to pressure patients to mirror the choices that midwives and lactation consultants would make. They rationalize it by telling themselves that “normal birth” and breastfeeding are best; midwives and lactation consultants therefore imagine that they have the patient’s best interests at heart but not only is that deeply paternalistic; it is entirely untrue.

As Atul Gawande Tweeted yesterday in reference to new cancer treatments:

The seriously ill have goals for their care besides just survival. When we don’t ask what they are (what tradeoffs they’d make & not make; what quality of life is unacceptable) and tune care accordingly, incl new treatments, the result is suffering.

This also applies to pregnant women. Many have goals for their care that may not include vaginal birth, refusing pain relief and avoiding interventions. Yet many midwives ignore those goals. They “know” that unmedicated vaginal birth is “best” and they force women into accepting it, going as far as creating promotional campaigns for so called normal birth.

It’s not that they don’t understand the concept of separating the patient’s interest from the provider’s interest. They have no trouble counseling women to ignore doctors’ recommendations on C-section, interventions and the advisability of homebirth, claiming that “birth rights are human rights” and often insinuating that doctors’ push interventions for their own benefit. Nonetheless, they appear entirely blind to the concept that birth rights include the right to a timely epidural as soon as a woman asks, the right to request term induction even if there is no medical reason and the right to a C-section on maternal request.

Many midwives are simply incapable of separating the patient’s interest from their interests. Their treatments recommendations for others reflect what they would choose for themselves; they need patients to mirror their preference for unmedicated vaginal birth back to them and they force them to do so. They often insist that patients who don’t agree aren’t properly informed or adequately supported.

The same midwives who would react (appropriately) with horror at a doctor forcing a C-section on a woman who has declined have no trouble forcing an unmedicated vaginal birth on a woman who doesn’t want one. That’s unethical.

Lactation professionals are, if anything, worse. La Leche League won’t even allow you to become a volunteer leader unless you have breastfed a baby for 9 months. Lactation consultants exist for the sole purpose of promoting breastfeeding; they promote a process independent of outcome even though the benefits of that process are trivial and side effects are common. It’s not for the good of babies. Breastfeeding doubles the risk of neonatal hospital readmission, increases the risk of neonatal hypernatremic dehydration and hypoglycemia and is the leading cause (90% of cases) of jaundice induced brain damage. Lactation consultants pressure women to mirror their own feeding choice back to them without regard to a mother’s personal needs, desires and priorities. That’s unethical

The bottom line is that patients don’t exist to support providers; providers exist to support patients whether or not providers approve of patients’ choices. It’s long past time for midwives and lactation consultants to recognize this.

The adulation must be truly head turning.

I can’t otherwise explain why Neel Shah, MD, who ought to be completely cognizant of both the scientific literature and the history of people he supports, is giving legitimacy to midwives with blood on their hands and self-serving nonsense in their heads.

Advocates of “normal” birth have been waiting for years for a respected obstetrician to legitimize their deadly ideology and Dr. Shah is making their dreams come true without a thought for the many mothers and babies who have suffered at their hands.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Dr. Shah is making their dreams come true without a thought for the many mothers and babies who have suffered at their hands.[/pullquote]

First we learn that Dr. Shah is taking part in the for profit venture Birthpedia a website that features advocates of pseudoscience and poor practice, including Ina May Gaskin, Michel Odent, Brad Bootstaylor, Barbara Harper and a chiropractor, among others.

Dr Gena Bofshever has an infectous personality to go along with her thorough chiropractic skills to help women who want to get pregnant by making the organs in their body easier to talk with their brain. (my emphasis)

Dr. Shah wasn’t merely one of the contributors; he featured prominently in their promotional materials:

“Imagine having a Harvard OBGYN answer your specific question/concern for only $8 a month. We are changing how providers and patients intake information about birth where any pregnant woman can get answers by qualified professionals” – Co-Founder Justine Tullier

After I wrote on my Facebook page about Dr. Shah’s association with quackery, the Birthpedia information on Dr. Shah and the other contributors disappeared from the internet. Hopefully Dr. Shah was unaware that he was associating with quacks and charlatans and reconsidered his involvement.

Several days ago, Dr. Shah tweeted his excitement at a forthcoming meeting of Sheena Byrom, a leader in UK midwifery.

Byrom is the poster child for moral depravity in the face of preventable infant deaths. She has the unmitigated gall to defend the unethical behavior of midwives in privileging process over outcome by arguing that it is more important to preserve “normal birth” than human life.

Despite dozens of preventable perinatal and maternal deaths at the hands of UK midwives, despite the fact that liability payments now account for fully 20% of UK midwifery spending, despite multiple investigations detailing poor midwifery practice and strenuous attempts to hide it by midwives lying to investigators and regulators bodies, Byrom insists on Normal birth – a moral and ethical imperative:

Yes, there needs to be learning from incidents, and development where needed. But blaming one professional group, or a particular type of birth, does little to improve any situation.

Actually, insisting that a professional group take responsibility for their own deadly mistakes does A LOT to improve any situation.

But that’s not the worst of Bryom’s behavior. She has become well known for publicly tormenting a father who lost his son in the Morecambe Bay midwifery scandal.

Now comes news that Dr. Shah is headlining Normal Birth 2018.

Of course Dr. Shah may have no idea what he’s getting into. It wouldn’t be the first time.

He certainly had no idea about homebirth when he wrote about it in the New England Journal of Medicine, A NICE Delivery — The Cross-Atlantic Divide over Treatment Intensity in Childbirth, and for a companion piece Are hospitals the safest place for healthy women to have babies? An obstetrician thinks twice on The Conversation.

Dr. Shah appeared entirely unaware of the two most important issues in American homebirth.

1. In contrast to the UK where there is only one type of midwife, highly educated and highly trained, in the US there are two types of midwives: certified nurse midwives (CNM), the best educated, best trained midwives in the world, and a second, inferior class of midwife, certified professional midwives (CPM), who lack the education and training of midwives in every other industrialized country.

2. There is a large and growing body of research that demonstrates that home birth with an American home birth midwife has a death rate 3-9 times higher than comparable risk hospital birth.

Dr. Shah is one of the plenary speakers at Normal Birth 2018. Others include Melissa Cheyney, anthropology professor and homebirth midwife and Soo Down, midwifery professor and promoter of goofy, quack midwifery theory.

Does Dr. Shah know that Melissa Cheyney has single-handedly done more to hide the growing toll of tiny bodies of babies who succumb to American homebirth than anyone else? She has lied, denied, decried and defied efforts to inform the public of the hideous death toll at homebirth.

Does he care that Cheyney, in her role as the Chair of the Oregon Board of Direct Entry Midwifery, steadfastly REFUSED to release the homebirth mortality rates in her possession for fear that regulatory authorities might wish to investigate the death rate and discipline the midwives involved in the deaths. In the face of that refusal state of Oregon subsequently hired Judith Rooks, CNM, MPH, a known supporter of homebirth, to calculate the Oregon homebirth death rate in 2012. Rooks found that the death rate at the hands of LICENSED homebirth midwives was 800% higher than comparable risk hospital birth.

Is Dr. Shah aware of Soo Downe’s midwifery “philosophy”? Downe, like many quacks, won’t accept the existing scientific evidence and invokes quantum mechanics, a concept she knows nothing about, to rationalize her refusal to accept copious evidence on the dangers of promoting “normal” birth.

The implication of the new subatomic physics was that certainty was replaced by probability, or the notion of tendencies rather than absolutes: ‘we can never predict an atomic event with certainty; we can only predict the likelihood of its happening’… This directly contradicts the mechanistic model we explored above, and it implies that a subject such as normal birth needs to be looked at as a whole rather than its parts…”

Prof. Downe has managed a stupidity trifecta: she used the wrong theory, from the wrong field, wrongly interpreted to reach the ideologically predetermined result.

Dr. Shah, these women are not your friends. More importantly, they are not the friends of babies and mothers, too many of whom have died at their hands or as a result of their beliefs.

Do you really want to legimitize midwives with blood on their hands?

Are you a paleo-sucker?

Paleo-suckers believe in the central conceit of modern alternative health that human beings reached the acme of our existence during the Paleolithic Era. According to advocates of “natural living,” our bodies were designed for the demands of life in the Paleolithic and technology, whether modern diets, modern medicine or modern parenting, is making us sick; and returning to the Paleolithic lifestyle will make us healthy.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Paleo-suckers are longing for a past that literally never existed anywhere except in their dreams.[/pullquote]

Nothing could be further from the truth. The dirty little secret about our Paleolithic ancestors is that they were relatively poorly designed from an evolutionary perspective. Indeed, we came very close to extinction during that era and our closest hominid relatives, the Neanderthals, did become extinct. The fact that we are still here has nothing to do with our biology and everything to do with technology.

So where did some people get the idea that life in nature was wonderful?

William Buckner explains in Romanticizing the Hunter-Gatherer:

In 1966, at the ‘Man the Hunter’ symposium held at the University of Chicago, anthropologist Richard B. Lee presented a paper that would radically rewrite how academics and the public at large interpret life in hunter-gatherer societies. Questioning the notion that the hunter-gatherer way of life is a “precarious and arduous struggle for existence,” Lee instead described a society of relative comfort and abundance. Lee studied the !Kung of the Dobe area in the Kalahari Desert (also known variously as Bushmen, the San people, or the Ju/’hoansi) and noted that they required only 12 to 19 hours a week to collect all the food they needed. Lee further criticized the notion that hunter-gatherers have a low life expectancy, arguing that the proportion of individuals older than 60 among the !Kung, “compares favorably to the percentage of elderly in industrialized populations.” On the basis of Lee’s work, and other material presented at the symposium, anthropologist Marshall Sahlins coined the phrase “original affluent society” to describe the hunter-gatherer way of life.

It is difficult to overestimate the impact of this idea.

It’s not often that you see a 50-year-old paper repeatedly referenced in mainstream publications, but you can find mentions of Lee’s work pretty much everywhere today. In the Guardian, the New York Times, the London Review of Books, the Financial Times, and Salon, among others. Much of this attention has to do with two recently published books, Against the Grain by James C. Scott and Affluence without Abundance by James Suzman, both of which are informed by Lee and Sahlins’s conception of hunter-gatherer affluence. An article in the September 18 [2017] issue of the New Yorker by John Lanchester heavily cites each of these books in order to make “The Case Against Civilization.”

There is just one problem. The claims in the paper were not true.

As Lee himself would later mention in his 1984 book on the Dobe !Kung, his original estimate of 12-19 hours worked per week did not include food processing, tool making, or general housework, and when such activities were included he estimated that the !Kung worked about 40-44 hours per week.

That still sounds pretty good in exchange for a life of abundance.

But:

[I]t is important to note that this does not take into account the difficulty or danger involved in the types of tasks undertaken by hunter-gatherers. It is when you look into the data on mortality rates, and dig through diverse ethnographic accounts, that you realize how badly mistaken claims about an “original affluent society” really are.

Though hunter-gathers purportedly “work” less time to get their food, they are much more likely to die doing so.

Moreover, Lee’s claims are belied by actual mortality data:

In his later work, Lee would acknowledge that, “Historically, the Ju/’hoansi have had a high infant mortality rate…” In a study on the life histories of the !Kung Nancy Howell found that the number of infants who died before the age of 1 was roughly 20 percent. (As high as this number is, it compares favorably with estimates from some other hunter-gatherer societies, such as among the Casiguran Agta of the Phillipines, where the rate is 34 percent.)

In other words, the death rate from natural mothering — the holy grail for contemporary advocates of “normal” birth and breastfeeding — was astronomical.

And although there may be individuals over 60 in these populations:

Life expectancy for the !Kung is 36 years of age. Again, while this number is only about half the average life expectancy found among contemporary nation states, this number still compares favorably with several other hunter-gatherer populations, such as the Hiwi (27 years) and the Agta (21 years)…

Who would want to emulate that?

But aren’t hunter-gathers better protected against infectious diseases that occur when large numbers of people live close together?

Much is made of the increased risk of infectious disease in large, concentrated, sedentary populations, but comparatively little attention has been given to the risk of ‘traveler’s diarrhea’ common among hunter-gatherers. For mobile groups, infants, the elderly, and other vulnerable individuals have little opportunity to develop resistance to local pathogens. This may help explain why infant and child mortality among hunter-gatherers tends to be so high. Across hunter-gatherer societies, only about 57% of children born survive to the age of 15. Sedentary populations of forager-horticulturalists, and acculturated hunter-gatherers, have a greater number of children surviving into adulthood, with 64% and 67%, respectively, surviving to the age of 15.

Why have people clung to the original claim about the “abundance” of hunter-gatherer society despite the fact that they have been debunked again and again? Why do people allow themselves to become paleo-suckered?

In wealthy, industrialized populations oriented around consumerism and occupational status, the idea that there are people out there living free of greed, in natural equality and harmony, provides an attractive alternative way of life. To quote anthropologist David Kaplan, “The original affluent society thesis then may be as much a commentary on our own society as it is a depiction of the life of hunter-gatherers. And that may be its powerful draw and lasting appeal.”

Paleo-suckers from Gwyneth Paltrow to the Food Babe Army, from anti-vaxxers to lactivists and natural childbirth advocates are longing for a past that literally never existed anywhere except in their dreams.

There would be nothing wrong with that if the only thing injured as a result were people’s wallets. Sadly, attempting to recapitulate a natural Eden that never existed injures people, keeps them from getting appropriate healthcare and can even lead to death.