It’s ironic when you think about it. Many of the same people who refuse infant eye ointment because the baby might be distressed by blurry vision, who refuse neonatal vitamin K because the injection will hurt the baby for a brief moment, think nothing of letting a baby (yours or theirs) scream for hours in hunger in the face of inadequate breast milk supply.

The promotion of breastfeeding invariably involves discussion of the benefits to babies of breastmilk but no one seems to care about the babies who suffer in an attempt to force them to breastfeed even when the breastfeeding relationship is not working.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Babies experience hunger as suffering.[/pullquote]

Hunger is probably the most elemental of infant drives and, as anyone who has seen an infant scream from hunger would probably agree, is experienced by the baby as suffering. For most mothers, myself included, the sound of their own infant crying is piercing in its intensity and distress. I remember being surprised by this when my first child was born. I had spent my entire professional life surrounded by crying babies and it had never bothered me, yet I found my son’s crying unbearable and always rushed to determine what was wrong and fix it in any way possible. I cannot imagine letting any of my infants cry in hunger for any length of time without feeding them. Indeed I recoil when I read about the infant care manuals of the early 20th Century that advised mothers to feed the baby on a schedule designed for maternal convenience instead of infant needs.

So why do lactivists think it okay to let babies scream for hours at a time because of desperate, all consuming hunger? Why do they advise women whose babies aren’t getting enough milk in the first few days to ignore that crying in an effort to promote breastfeeding? Why do they view supplementation in the first view days as an evil so great that it is preferable to force babies to endure distress?

Why do lactivists think it is okay to ignore an infant who is not gaining weight because of a maternal milk supply that does not match that infants needs? Why do they denigrate women who find their baby soothed and content after a bottle of formula, and chastise them that they should have let the baby scream instead?

Why do lactivists who have children who try to wean before their mothers have planned to stop breastfeeding counsel each other to starve the baby into submission? Why do they tell each other to offer no other source of nourishment until the baby is forced to give up his or her drive for independence and bow to the mother’s will to continue breastfeeding in order to survive?

Why do people who promote attachment parenting, which is supposed to be about meeting infant needs, to ignore their most elemental need, the need for adequate nutrition?

What’s the difference between the pediatricians of the early 20th Century who promoted feeding on schedule because of its supposed long term benefits and contemporary lactivists who ignore infant hunger because of the very small long term benefits that may or may not really exist?

It seems to me that one of the biggest ironies of all is lactivists who promote forced breastfeeding as “baby-friendly.” We already know that “baby friendly” hospital policies are definitely not mother friendly, but I suspect that such policies aren’t even baby friendly.

How could anything that ignores infant suffering be considered baby friendly?

Hallelujah! A national Baby Friendly Hospital Initiative is being shut down.

Without consultation or notice, in early 2016 the HSE Health Promotion & Improvement, Health & Wellbeing Division reduced the grant-aid it had been providing to the BFHI (which ranged over recent years from slightly under €50,000 to zero). The HSE then directed maternity units not to participate in BFHI activities, ceased all funding, and would not engage in any discussion of these precipitous HSE actions…

Why? Because it doesn’t work.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”There was no difference in breastfeeding rates in hospitals that had achieved baby friendly designation and those that had not achieved this designation. “[/pullquote]

As a member of the Irish governing party explained:

The initiative is funded by the Health Service Executive, which in 2016 commissioned a research team at Trinity College Dublin to undertake a review of the initiative… A key finding of the Trinity review was that there was no difference in breastfeeding rates in hospitals that had achieved baby friendly designation and those that had not achieved this designation. Following completion of the Trinity review, the HSE initiated engagement with the baby friendly hospital initiative and other stakeholders on developing a revised model.

What about all the healthcare dollars/euros that lactivists insist would be saved by increasing breastfeeding rates? No one — not the government nor the BFHI — can point to any real world savings.

I’ve made no secret of my contempt for the breastfeeding promotion campaign known as the Baby Friendly Hospital Initiatve (BFHI). Nearly a year ago, I contended that the BFHI has been a deadly failure. I cited three papers:

• The revised United States Preventive Services Task Force (USPSTF) guidelines
• Interventions Intended to Support Breastfeeding: Updated Assessment of Benefits and Harms
• Unintended Consequences of Current Breastfeeding Initiatives

Together these US papers show that the BFHI doesn’t work, ignores the science on pacifiers, formula supplementation, and Sudden Infant Death Syndrome (SIDS) and leads to preventable infant injuries and deaths when babies fall from or get smothered in their mothers’ hospital beds.

And that doesn’t even take into account the babies who have sustained brain injuries or died due to dehydration, hypoglycemia and severe jaundice because the BFHI refuses to acknowledge that up to 15% of first time mothers cannot produce enough milk to fully sustain a baby.

The BFHI is the epitome of paternalism in medicine. Lactation professionals have decided what is “best” for mothers and babies without consulting mothers themselves. They insist that “science” shows that breast is best and therefore, they are justified in forcing breastfeeding on every woman regardless of her experiences and values, and regardless of whether it is a safe or realistic goal.

Yet informed consent requires presenting the risks of breastfeeding — insufficient breastmilk, dehydration, failure to thrive — as well as the benefits. Informed consent means that it is up to MOTHERS to determine whether to offer supplemental formula or pacifiers, NOT up to providers.

BFHI Ireland does not deny this; it does not even mention it. Instead of addressing the failure of the BFHI to increase breastfeeding rates, and the injuries and deaths that have resulted, BFHI Ireland defends itself thus:

An independently evaluated and published survey in March 2017 found that directors of midwifery and clinical midwife specialists in lactation were overall happy with the Initiative as currently run, valued the Initiative, and thought there would be negative effects if it was discontinued.

But the fact that those who were employed by the program were happy with the program has nothing to do with safety or effectiveness. Indeed, it supports my view that the program isn’t “baby friendly”: it’s “lactivist friendly” and baby-harmful.

What now?

If the BFHI were based on science, its members would ask themselves why it doesn’t work and investigate how it could be made more effective and safer. But the BFHI is based on personal conviction, not science, so there will be no attempt made to understand why it is ineffective.

A news story in The Times laments:

Only 15 per cent of children in Ireland are exclusively breastfed for the first six months, as advised by the WHO, compared with a global average of 38 per cent.

Yet Ireland has one of the lowest infant mortality rates in the world (3.3/1000), far lower than many countries with much higher breastfeeding rates. That’s not surprising since there is no real world evidence from any country that breastfeeding rates have any correlation with infant mortality.

The sad truth is that the BFHI is a boondoggle for lactation professionals, no more and no less. It was started with the best of intentions, but it is based on personal belief, not science and, indeed, is contradicted by the best scientific evidence. Hopefully Ireland will be merely the first of countries that recognize that money spent on funding the BFHI is money wasted. The end of the BFHI will be both baby friendly and mother friendly; it can’t come soon enough.

Breastfeeding is not a matter of will; it is a matter of biology.

That’s the take home message from the paper Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology by Lee and Kelleher, graduate student and professor of cellular physiology respectively.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]To pretend that breastfeeding is just a matter of will and support is both empirically wrong and gratuitously cruel.[/pullquote]

The most pernicious of the many pernicious lies promoted by lactation consultants is that any woman who wants to breastfeed can do so successfully. That’s why when breastfeeding fails, lactivists insist that it is because the mother didn’t try hard enough or didn’t get enough support. But lactation is a biological process and like any biological process it has a significant failure rate. Those failures of biologically based.

As the authors of the paper explain:

It has long been assumed that once lactation is successfully initiated, the primary factor regulating milk production is infant demand. Thus, most interventions have focused on improving breastfeeding education and early lactation support. However, in addition to infant demand, increasing evidence from studies conducted in experimental animal models, production animals, and breastfeeding women suggests that a diverse array of maternal factors may also affect milk production and composition.

Indeed:

…[I]t has been estimated that the prevalence of women who overtly fail to produce enough milk may be as high as ∼10–15% and can quickly lead to hypernatremia, nutritional deficiencies, or failure to thrive. Moreover, the prevalence of lactation “insufficiency” may be much higher, as ∼40–50% of women in the US and 60–90% of women internationally cite “not producing enough milk” or “baby not satisfied with breast milk” as the primary reasons for weaning prior to 6 mo.

Why does this happen?

In this review, we provide a broad overview on our current understanding of the molecular etiology behind these factors that play a critical role in lactation physiology and the ability to optimally nourish the nursing infant.

Let’s pause here to address the inevitable lactivist claim that we “wouldn’t be here” if breastfeeding had a high failure rate.

To understand why the claim is false, it helps to analogize to miscarriages. Although the survival of the human race depends on successful pregnancies, it is entirely compatible with a natural miscarriage rate of 20%. There is a biological basis for those miscarriages; most are due to serious genetic defects present at conceptions, some are due to hormonal imbalances, and some are the result of factors we have not yet indentified. Furthermore, no amount of maternal effort or outside support can prevent miscarriages. A few can be prevented with medical interventions but most can’t be prevented at all. The same thing applies to insufficient breastmilk production.

Breastmilk production is a complex process:

During early pregnancy, primary hormones, including estrogen, progesterone, prolactin, and placental lactogen, induce the physiological transition of the mammary gland from a nonsecreting branched tissue into a highly active secreting organ comprised of a vast network of ducts and alveoli that are grouped into seven to 10 lobes in humans… In response to progesterone and estrogen withdrawal, concomitant with prolactin release following parturition, the differentiated epithelium gains a remarkable capacity to finely coordinate the synthesis and transport of various milk constituents for the onset of milk secretion, … which usually occurs after full-term birth in humans.

There are many ways that things can go wrong.

Breast hypoplasia or other abnormal breast conditions and previous breast surgeries are certainly factors that contribute to lactation insufficiency… What is much less appreciated and poorly understood is the role that maternal genetics and modifiable factors such as energy balance, diet, and environmental exposures may have on reproductive endocrinology, lactation physiology, and the ability to successfully breastfeed.

Genetics

…[R]ecent advancements have identified numerous genetic variants associated with milk production traits in production animals. A recent study using GWAS data collected from 16,812 Holstein and Jersey dairy cattle identified SNPs in key pathways that are critical for mammary gland development, prolactin signaling, and involution that explained variation in milk production and milk composition. For example, ∼50% of SNPs found in genes critical for prolactin signaling, including SOCS2, STAT3, STAT5A, STAT5B, PRLR, and β-casein, were associated with three or more milk production traits. Additionally, a large number of SNPs in genes that are critical for mammary gland involution, including ATF4, IGFBP4, IRF1, LIFR, OSMR, PTK2, and STAT3, were also associated with milk production traits…

We propose that similar variation may govern lactation physiology, milk production, and composition in breastfeeding women…

Hormones

In addition to prolactin, a complex combination of hormones works together to maintain the differentiated epithelium and milk secretion during lactation, including insulin, glucocorticoids, growth hormone, oxytocin, and thyroid hormone. Secretory activation and milk ejection require insulin and glucocorticoids to synergistically regulate the formation of tight junctions in the mammary gland, stimulate mammary differentiation, and induce milk protein expression. Insulin levels rapidly decrease during early lactation and steadily increase over time.

Obesity

Growing evidence suggests that in addition to systemic inflammation, obesity is also associated with an inflammatory microenvironment in the mammary gland, which has recently been associated with premature involution in murine models… Fundamentally, the altered mammary gland microenvironment that occurs in obesity can lead to failed secretory activation or suboptimal lactation, whereby the mammary gland is incapable of secreting copious milk to nourish the newborn.

Nutrition

In recent years, increasing evidence shows not only that adequate nutrient intake and appropriate nutrient homeostasis are important for maintaining maternal energy balance but that suboptimal nutrition has significant effects on breast physiology and milk production, secretion, and composition. Nutrient deficiencies can result in failed secretory activation from several perspectives, such as inefficient hormone responsiveness, and defects in cellular processes involved in morphogenesis and secretory pathways. Moreover, energy/nutrient imbalance may cause more perverse effects on immune response and increased risk of mastitis…

Environmental factors

Thus far, only a few studies in women have shown an association between toxins like PCBs and dichlorodiphenyl dichloroethene and lactation defects such that exposure to these toxins is associated with shorter breastfeeding duration…

…[N]atural components such as heavy metals exposure can affect the mammary gland during lactation. Some heavy metals (copper, zinc, and manganese) are biologically essential; however, the most pollutant heavy metals are lead, cadmium, and mercury that bioaccumulate following absorption, causing adverse health effects.

The bottom line is that lactation insufficiency is common; it can be caused by non-modifiable factors like structural breast abnormalities, genetics, hormonal imbalances and environmental exposures. No amount of maternal effort and no amount of lactation support has any impact on those factors.

To pretend that breastfeeding is just a matter of will and support is both empirically wrong and gratuitously cruel.

I’m been watching Ken Burn’s monumental documentary on the Vietnam War. It is a deeply sobering experience.

Both those who served in the war and those who protested the war were united in a curious way. Both never considered the possibility that the government would lie to them and both felt profoundly betrayed when they found out that many in the government had been lying all along.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Instead of feeling betrayed by lies, the American public demands them.[/pullquote]

The Vietnam War began a period of profound cynicism toward government, further bolstered by Richard Nixon’s behavior in orchestrating the Watergate break-in and systematically lying about it for years. Even those whose eyes had been opened by government sponsored lying during the war were nonetheless shocked that a president would break the law and attempt to get away with it.

The more things change, the more they stay the same.

Fifty years later, the government it still lying to us, with one important difference. Instead of feeling betrayed by lies, the American public demands lies.

Lie to me, they beg the President and the Republican Party.

Lie to me! Tell us that by demanding equality — which, afterall, merely means being treated equally — black Americans are insisting on special privileges.

Lie to me! Tell us that immigrants, a criticial engine of both innovation and population growth, are stealing our jobs even though they have nothing to do with the decline of manufacturing in the US.

Lie to me! Tell us that rogue nations like North Korea will be intimidated by a flaccid, floundering buffoon of a president who thinks Twitter insults are a form of warfare.

Lie to me! Tell us destroying Obamacare, the best and most inclusive health insurance program that this country has ever known, will not deprive people of health insurance.

No one should think that the American taste for lies is restricted to government. Indeed the desperate desire for lies and the credulousness with which they are greeted was pioneered within the realm of healthcare.

Many people are begging for lies:

Lie to me! Tell us that autism is a government conspiracy, not a genetic defect.

Lie to me! Tell us that vaccines, one of the greatest public health achievements of all time, don’t work and actually cause harm.

Lie to me! Tell us that our foods are riddled with toxins and we can prevent cancer by eating right and wasting money on detoxes and crystals.

Lie to me! Tell us that childbirth is inherently safe and interventions are bad even though childbirth is inherently dangerous and interventions save lives.

Lie to me! Tell us that the secret to mothering resides in breastfeeding and that breasts never fail.

Lie to me! Tell us that disease is caused by improper alignment of the spine, and chiropractors can manipulate us back to health.

Lie to me! Tell us that medicines become more powerful by being diluted and homeopaths perform a valuable service by marketing water to the gullible.

What has happened to us? Why can’t we handle the truth in politics or in health?

Why? Because we are lazy and weak.

We prefer the comforting lie over the painful truth. In politics we prefer to pretend that we are victimized rather than acknowledge that we are more often victimizers. In healthcare, many delight in imagining that they are educated and bold, when the reality is that they are merely ignorant, defiant and very, very afraid.

Nearly 60,000 Americans died in Vietnam because we believed government lies, but in our defense, we didn’t realize that the government was lying. Now we know better, yet now we insist on lies. Many among us are happy to believe government lies and healthcare lies. Tragically, the death toll this time is bound to be much higher.

Yesterday I wrote about the single most important reason for the UK’s massive maternity payouts: the failure to properly investigate bad outcomes and the resulting failure to learn from them. That was the finding of a just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data.

The author of the report proceeded to investigate the poorly investigated claims and found recurring clinical reasons for massive liability payments:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Nearly every error was a failure of omission and all involved failure to inform women of the risks of vaginal birth.[/pullquote]

The 50 claims were clinically varied but by reviewing them all together to get a national picture it was possible to identify common themes:

1) Errors with fetal heart rate monitoring
2) Breech birth
3) Inadequate quality assurances around staff competency and training
4) Patient autonomy and informed decision making

Nearly every error was a failure of omission. Nearly every error was a failure to undertake clinically indicated interventions. It’s not hard to see the impact of the Royal College of Midwives’ Campaign for Normal Birth at work here; in an effort to “achieve” vaginal birth, important warning signs were ignored and babies were grievously harmed as a result. Moreover, mothers were unable to make informed choices because they were not informed of the very real risks of vaginal births.

The most glaring errors occurred with fetal heart rate monitoring including failure to monitor, failure to properly interpret monitoring and failure to act on abnormal results.

Who made the errors?

Twenty four claims involved a midwife but only one involved a consultant.

Why did midwives repeatedly make serious errors? I suspect it is because UK midwives fundamentally misunderstand the value of fetal heart rate monitoring.

The report notes:

The most recent Cochrane review demonstrates that, compared to intermittent auscultation, continuous fetal monitoring using a CTG, is associated with a 50% reduction in neonatal seizures (RR 0.50 95% CI 0.31-0.80). However, it does not reduce the risk of developing CP and is not associated with any other benefits in fetal wellbeing. These finnings were consistent in high and low risk pregnancies and in preterm births …

Many midwives have looked at this data and concluded that fetal monitoring is worthless and therefore should be avoided or ignored. But the scientific evidence doesn’t show that fetal monitoring is worthless; it shows that continuous electronic fetal monitoring is no better than rigorously performed intermittent auscultation. Monitoring itself can provide critical information.

The other caveat about fetal monitoring is that it has a high false positive rate. That means that fetal monitoring may show an abnormal result for a normal baby, but that is not a reason to ignore abnormal results.

To put it in terms that may be easier to understand, finding a breast lump also has a high false positive rate. Most breast lumps are not cancer but that doesn’t mean that doctors should ignore breast lumps because most of them are not cancer. Some of them are cancer and it is only by investigating further and intervening (breast biopsy) that the correct determination can be made. Yes, if we wait long enough, the cancer will eventually progress and become obvious but that’s not an argument for watchful waiting.

Similarly, only some of the abnormal fetal heart rate tracings are due to fetal oxygen deprivation. Yes, if we wait long enough, the lack of oxygen will eventually become obvious by leading to fetal collapse, but that’s not an argument for watchful waiting. It’s an argument for investigating further and intervening (childbirth interventions).

UK midwives are fundamentally wrong about the value of fetal monitoring and that’s part of an even larger error: they’re fundamentally wrong about the value of vaginal birth because they confuse cause and effect.

Sure, scientific evidence shows that those who have easy, uncomplicated vaginal births fare better than those who have complicated C-section births but the C-sections don’t cause the complications; the complications cause the C-sections. Scientific evidence also shows that people who were never admitted to the ICU during their hospitalizations fare better than those admitted to the ICU, but that’s not because the ICU causes complications; it’s because people with complications are admitted to the ICU. Refusing to use childbirth interventions for those who develop complications in pregnancy is like refusing ICU admission to who develop complications during hospitalization. It’s a deadly mistake.

And that mistake is compounded by the most unforgivable clinical error identified by the report, the failure to obtain informed consent.

Evidence of a lack of informed consent was evident throughout the 50 claims reviewed.

That’s pretty damning.

An example was a woman who opted to have a vaginal birth after caesarean section (VBAC) but her initial caesarean was complicated by a difficult delivery that involved making a J-shaped incision on the uterus. This is not an absolute contraindication to VBAC but there is “insufficient evidence to support the safety for VBAC in women with previous T or J incisions” and there should have been a documented discussion by a consultant which made an individualised assessment around the suitability for VBAC and the possible increased risk of uterine rupture. The issue here is not that the woman was offered a VBAC but that she was not adequately given the information on which to make an informed decision.

In other words, the mother was not offered accurate information about the risks of vaginal birth. The same thing happened with breech births, history of shoulder dystocia and twins. There is a word for that type of behavior; the word is “paternalistic.” This paternalism is a direct violation of medical ethics.

… The practice of autonomy and patient consent revolves around the key feature of informed decision making, whereby the healthcare professional and the patient engage in dialogue about treatment options, their benefits, risks, consequences and alternatives… [T]his information must be clear, accurate, balanced without bias, take into consideration the individual patient, the nature of their condition and in a language that they understand.

Promotion of normal birth is bias pure and simple. It isn’t merely unethical; it’s a critical clinical factor behind the soaring UK maternity liability payments.

The promotion of normal birth doesn’t merely hurt babies and families. It is an extroardinarily expensive mistake.

Last month I wrote a series of posts about the decision by the Royal College of Midwives to shutter its Campaign for Normal Birth. Although the RCM leadership denied it, some going so far as to claim dead and injured babies are “fake news,” the campaign was stopped because of skyrocketing rates of maternity liability claims. Indeed nearly £2bn was paid out in compensation in the past year alone.

A just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data, investigates those claims. The report is detailed, comprehensive, and contains multiple valuable recommendations. It also identifies the single most important reason why UK maternity liability claims have been skyrocketing: perinatal deaths and injuries aren’t being properly investigated.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Perinatal deaths and injuries aren’t being properly investigated.[/pullquote]

As the Executive Summary of the report notes:

The quality of root cause analysis was generally poor and focused too heavily on individuals.

Due to the poor report quality, the recommendations were unlikely to reduce the incidence of future harm.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The gold standard for investigating errors is Root Cause Analysis (RCA).

It seeks to identify the origin of a problem using a specific set of steps, with associated tools, to find the primary cause of the problem, so that you can:

Determine what happened.
Determine why it happened.
Figure out what to do to reduce the likelihood that it will happen again.

Although RCA can provide information and closure for families, it’s primary purpose is to identify modifiable factors that can be improved in order to prevent future bad outcome.

As the NHS Report notes:

A RCA should be logical, fair, open and adopt a just, or fair blame, culture, as it is often a system failure rather than an error by an individual that is at fault. It is therefore vital that a RCA looks at the wider environmental and organisational factors, often referred to as latent conditions, that allowed the error to occur.

In other words, rather than seek to blame individual bad actors, an RCA looks for systemic failures. In contrast, internal investigations of NHS maternal liability claims focused on assigning blame, not the root causes.

Looking at the root causes within the reports, it appeared that the question of why the incident happened, or was allowed to happen, is often missing…

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The root causes identified in the reviewed cases included:

The most common contributing factors were poor individual skill level and failure to communicate with others.

Why was the pathological CTG managed incorrectly? What went wrong with the undiagnosed breech and why did that result in CP? Why was the scan incorrect? Was it inadequate training, a faulty machine, that the operator was distracted? Why did a woman with a concealed abruption have a baby born with CP, remembering that these 50 claims are due to admitted clinical negligence, so what went wrong with her care?

No attempt was made to address these critical questions.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

This is not new information:

The Kirkup report identified significant systematic and organisational failures which the Morecambe Bay hospitals own SI investigations and RCA process missed, as they were “rudimentary, over protective of staff and failed to identify underlying problems…”

The RCOG EBC project identified that 25% of local reviews did not contain sufficient information to allow the care to be classified. Of those reviews that were of sufficient quality, just over 60% of investigations used a RCA methodology, while 21% contained no actions or recommendations and 23% recommended actions focusing solely on individuals.

The CQC report demonstrated a worse picture within acute trusts. Only 8% of reports demonstrated evidence that a clearly structured methodology was used, which would identify the key issues, contributing factors, system issues and causal factors that led to the incident…

As the parent of an injured baby explained:

It feels like the priority of the serious incident process is damage limitation rather than learning from mistakes. What makes this even worse is the lack of learning both by the trust and the wider NHS from what happened. The problem with the quality of the report… is that its purpose was not to blame individuals and was to nd a root cause [but] it stopped at individual mistakes and not once did it ask why people made these mistakes.

“The frustration from our case is that if a proper root cause had been found, such as training not being given or procedures not being known then it would not just stop similar cases to ours but could reduce serious incidents across the trust.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

If there is no serious attempt to identify modifiable systemic failures, the same failures will occur over and over again. And that is precisely what has occurred.

It appears that the individuals involved were expected to follow guidelines that were in place the next time a similar incident occurred, without identifying why they were not followed in this instance. Identifying an issue with the guidelines that could be changed may result in better care for someone else.

This is not new information, either.

The findings of this review are very similar to those identified within the RCOG EBC programme, that only 56% of the investigations they analysed had actions or recommendations that took a systemic approach, 23% focused solely on individuals, often to attend training, and 21% contained no actions or recommendations.

The CQC report on SI investigations also highlighted the same problem. They found that “too many reports concluded that the actions of staff were the key causes of the incident” and many investigations focused their recommendations on staff failing to “follow trust policy and procedures.” Only 35% of investigations had recommendations that could reduce the risk of recurrence and many focused on reminding staff be more vigilant or to follow guidelines.

It’s almost as if the people responsible for deadly errors don’t want to know why they happened.

The Report makes a critical recommendation:

In line with the Kirkup and RCOG Each Baby Counts reports, all cases of potential severe brain injury, intrapartum stillbirth and early neonatal death should be subject to an external or independent peer review.

If those responsible for understanding why deadly errors occur either can’t or won’t identify systemic causes, review should be undertaken by external, independent panels.

Unless and until that happens, babies will continue to be injured and will die and the NHS will continue to bleed money on liability claims for preventable errors.

You have to give Drs. Melissa Bartick and Alison Stuebe credit for brazenness. Not only do they still insist that increasing breastfeeding rates saves money, despite a complete lack of evidence, they have created a “calculator” to estimate the fallacious savings.

Using current literature on the associations between breastfeeding and maternal and pediatric health, we modeled the costs of health outcomes for a US cohort of mothers and their infants born in 2002 and followed to age 70 years… The 9 pediatric conditions considered in this model were: acute lymphoblastic leukemia (ALL), acute otitis media (AOM), Crohn’s disease, ulcerative colitis, gastrointestinal infection (GII), hospitalization for lower respiratory tract infection (LRTI), obesity in non-Hispanic whites to age 4, necrotizing enterocolitis (NEC), and Sudden Infant Death Syndrome (SIDS). The 5 maternal conditions modeled were breast cancer, pre-menopausal ovarian cancer, type 2 diabetes mellitus, hypertension, and myocardial infarction…

Only lactivists would dare to “calculate” future savings from increasing the breastfeeding rate when they can’t manage to demonstrate past savings although the breastfeeding rate has tripled in the last 40 years. Barticle and Stuebe did not use “current literature,” they used only papers published by themselves. Moreover, they neglected to include the costs of breastfeeding such as hospitalizations for dehydration, jaundice, long term therapy for brain injury and deaths as a result of insufficient breast milk.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Rates of lymphoma, inflammatory bowel disease and breast cancer have been rising NOT falling as breastfeeding rates have climbed.[/pullquote]

To put the problem in context, we know that vaccines save money because we have seen dramatic decreases in the rate of vaccine preventable diseases and their associated costs. We know that ending cigarette smoking saves money because we have seen dramatic decreases in lung cancer rates and their associated costs. In contrast, we have seen almost NO decreases in the rates of diseases supposedly prevented by breastfeeding despite the fact that breastfeeding rates have increased from 24% in the early 1970’s to over 76% in the past few years.

What has happened to the rate of diseases supposedly prevented by breastfeeding?

Pediatric acute lymphoblastic leukemia

According to the National Cancer Insitute: “Cancer in children and adolescents is rare, although the overall incidence of childhood cancer, including ALL, has been slowly increasing since 1975. (my emphasis).

Crohn’s disease and ulcerative colitis

According to the paper Epidemiology of Pediatric Inflammatory Bowel Disease: A Systematic Review of International Trends:

Globally rising rates of pediatric IBD (due primarily to the rising incidence of CD) was demonstrated in both developed and developing nations … (my emphasis)

Breast cancer

This graph comes from the United States Preventive Services Task Force:

New cases of both invasive and non-invasive breast cancer have risen since 1975.

I have confronted Dr. Bartick in print about the fact that she is unable to demonstrate past savings from rising breastfeeding rates; and she couldn’t rebut it. Over 2 years ago I wrote this comment on an Academy of Breastfeeding Medicine post:

Breastfeeding rates have tripled in the past 50 years. Where is the evidence that term babies lives has been saved? Where is the evidence that the diseases you insist are decreased by breastfeeding are actually decreasing as a result of breastfeeding? Where are the billions of healthcare dollars you claimed would be saved as the breastfeeding rates rose? Where is the return on investment of the millions of dollars spent to promote breastfeeding?

Here’s how Dr. Bartick responded:

I have given you the evidence on NEC and SIDS. You can dig up the evidence on the other diseases. To my knowledge, no one has actually dug it up yet. It’s not fair to say “it doesn’t exist.” It would be wonderful if you gather your team of statisticians and experts, and did the research yourself and published your own paper on it, Dr. Tuteur, instead of saying the evidence doesn’t exist…

My reply:

Sorry, Dr. Bartick, that’s a cop out. You’ve given no evidence that the decreases in SIDS and NEC are caused by breastfeeding. You’ve given no population evidence of any kind for any of your other contentions.

Don’t tell me that I can dig it up on my own. If it were available, you would have already posted it…

So Drs. Bartick and Stuebe have created a fanciful calculator that “models” future savings from increasing breastfeeding rates despite the fact that they are utterly unable to demonstrate the central assumptions of their model. They insist that breastfeeding saves lives in theory even though there is no evidence that it saves lives of term babies or mothers in practice.

I don’t doubt that Drs. Bartick and Stuebe believe deeply that breastfeeding saves money, but wishing doesn’t make it so. The existing population data shows that increasing breastfeeding rates does not save money or lives of term babies or mothers. That’s not surprising since breastmilk is just one of two excellent ways to nourish a baby. In first world countries, it’s benefits are trivial.

Dr. Bartick and Stuebe ought to immediately withdraw their fallacious breastfeeding “calculator.” It is based on easily disproven assumptions, provides erroneous data, and reflects ideology instead of science.

There is a growing body of evidence that childbirth and breastfeeding professionals, ostensibly dedicated to helping women and babies, are harming them instead.

Over the years I’ve explored a variety of reasons for this — unthinking, ahistorical veneration for “nature”; desperation for professional autonomy; desire for profit — but there’s one that might be more important than all of the others. Childbirth and breastfeeding professionals are smug.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Smug is the moral equivalent of the Dunning Kruger effect.[/pullquote]

According to Dictionary.com, smug means:

contentedly confident of one’s ability, superiority, or correctness

If there’s one thing that unites childbirth and breastfeeding professionals, from UK midwives to homebirth midwives, from doulas to lactation consultants, from Lamaze International to the Baby Friendly Hospital Initiative, it’s the fact that they are contentedly confident of their ability, superiority and correctness compared to other health professionals and compared to women themselves.

The thesaurus is rich with synonyms: complacent, egotistical, pompous, self-righteous, self-satisfied, conceited, holier than thou.

All can be applied to many childbirth and breastfeeding professionals, rendering them impervious not merely to criticism, but to reality.

Babies dying at the hands of homebirth midwives who are more concerned with promoting “normal birth” than live babies?

No problem. From Ina May Gaskin to Henci Goer to Melissa Cheyney, they are smug:complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

Women traumatized by UK midwives who are more concerned with promoting “normal birth” than promoting women’s autonomy, being denied epidurals, needed C-sections, and compassionate care?

No problem. From Soo Downe to Sheena Byrom to Cathy Warwick, they are smug: complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

Babies sustaining brain injuries and even dying because lactation professionals are more concerned with promoting breastfeeding that healthy babies?

No problem. From the Baby Friendly Hospital Inititative, to lactation consultants, to researchers who produce endless numbers of crappy papers hailing the “benefits” of breastfeeding, they are smug: complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

Smug is the moral equivalent of the Dunning Kruger effect.

According to Dr. Dunning:

What’s curious is that, in many cases, incompetence does not leave people disoriented, perplexed, or cautious. Instead, the incompetent are often blessed with an inappropriate confidence, buoyed by something that feels to them like knowledge.

What’s equally curious is that, in many cases, injured and dead babies do not leave childbirth and breastfeeding professionals disoriented, perplexed or cautious. Instead, impervious to the harm they cause, the smug are — say it with me now — complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

They “know” unmedicated, vaginal birth is best for every woman; they “know” that breastfeeding is best for every baby. The injured, traumatized and dead do not dent their overweening self regard and unwavering certainty that they are correct.

Those in the grip of the Dunning Kruger effect lack knowledge; they literally don’t know what they don’t know. Those in the grip of “smug” lack humility; they literally cannot imagine being wrong despite the injured, dead and traumatized who are screaming into their faces that they are hurting, not helping.

Doctors aren’t immune to smug. Indeed the history of medicine is a history of doctors feeling smug while injuring and killing patients by bleeding them, balancing their “humors” or feeding them arsenic and mercury to “cure” them. Those doctors “knew” the process was correct even though the outcome was dreadful. The operation was a success but the patient died; it must have been the patient’s fault because smug doctors would not admit it could be their fault.

Childbirth and breastfeeding professionals should learn from that embarrassing history. The birth can NEVER be a success if baby or mother are injured or die. Breastfeeding can NEVER be a success if a baby is brain injured or dies or if a mother suffers depression and guilt. Childbirth and breastfeeding professionals need to stop smugly asserting that it must be the patient’s fault — she was lazy, weak, didn’t trust birth and breastfeeding enough — because they cannot admit it is their fault.

When babies and mothers die in the pursuit of normal birth, midwives need to own it, investigate it and change their practices. When babies and mothers are harmed in the pursuit of exclusive breastfeeding, lactation professionals need to own it, investigate it and change their practices.

The last thing they should be doing is being complacent, egotistical, pompous, self-righteous, self-satisfied, conceited and holier than thou.

They shouldn’t be smug; they should be horrified.

Another day, another poorly done study that claims to show that C-sections are harmful.

According to The Sydney Morning Herald, Caesareans linked to slower start at school: research.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The authors fail to control for the most important confounding variable, the risk that the infant sustained brain damage before birth.[/pullquote]

Children born via caesarean appear to lag behind their peers – who were delivered naturally – in school tests, new research has found.

While the gap in test scores is small, University of Melbourne researchers say it’s equivalent to a grade 3 student missing up to 35 days of school.

And they suspect different bacteria in the guts of babies delivered by caesarean could be behind the delay.

In fact, the study showed nothing of the kind. Indeed, it showed nothing at all for three important reasons:

• The authors didn’t correct for the single most critical confounding variable, oxygen deprivation.
• The effect size was tiny.
• The claim that the microbiome of C-section babies differs from that of vaginally born babies has been debunked.

As a result, the paper does not support the claims that the authors made.

The paper is The relation between cesarean birth and child cognitive development published in the journal Scientific Reports. It was written by two economists and a basic scientist who investigates neurophysiology.

Across several measures, we find that cesarean-born children perform significantly below vaginally-born children, by up to a tenth of a standard deviation in national numeracy test scores at age 8–9. Estimates from a low-risk sub-sample and lower-bound analysis suggest that the relation is not spuriously related to unobserved confounding. Lower rates of breastfeeding and adverse child and maternal health outcomes that are associated with cesarean birth are found to explain less than a third of the cognitive gap, which points to the importance of other mechanisms such as disturbed gut microbiota. The findings underline the need for a precautionary approach in responding to requests for a planned cesarean when there are no apparent elevated risks from vaginal birth.

Where did the authors go wrong?

In any study, it is critically important to ensure that the two groups under study do not differ in any meaningful way from each other. For example, many breastfeeding studies produce spurious results because children who are breastfed differ economically from those who are not. The purported health benefits of breastfeeding are therefore likely to be benefits of being wealthy (which we know has a significant impact on health), not of being breastfed.

In this study, the single most important confounding factor that must be taken into account is brain health at birth. That’s why most studies that compare C-section babies to those born vaginally take care to limit the C-section group to non-emergencies. Emergency C-sections are typically performed for fetal distress presumed to be caused by oxygen deprivation. Therefore, the C-section group is almost guaranteed to contain some babies who have been harmed by lack of oxygen. Restricting the C-section group to elective surgeries limits that possibility.

The authors in this study corrected for nearly two dozen variables:

The analysis includes over 20 confounders grouped into two main categories (Table 1): those related to perinatal risk factors and those related to the socio-economic advantage associated with cesarean-born children in Australia. Perinatal risk factors include the taking of medication during pregnancy for blood pressure or diabetes (proxies for pre-eclampsia and gestational diabetes respectively), the taking of antibiotic medication (a proxy for bacterial infection, which may also affect the development of the infant’s gut microbiome); a dummy variable for low birth weight (coded 1 if less than 2.5 kg; 0 otherwise); weeks of gestation; maternal age at birth; dummy variable for multiple infant pregnancy; length and head circumference of baby (z-scores); dummy variable for whether the baby was conceived using IVF treatment and a gender dummy. We include taking antibiotic medication as a control because it has been associated with changes to the infant’s gut microbiome and possibly the risk of cesarean birth, which means failure to control for it will lead to bias due to unobserved confounding.

Yet they fail to control for the most important confounding variable of all, the risk that the infant sustained brain damage before birth. Since the authors can’t be sure that the babies in each group were cognitively equivalent at the outset, they can’t conclude that observed cognitive differences were due to C-sections.

A second factor undermining the authors’ claims is that the difference in cognitive ability was extremely small. The effect size was less than 0.1 standard deviation.

What is effect size?

The article It’s the Effect Size, Stupid; What effect size is and why it is important explains the difference between statistical significance and effect size:

‘Effect size’ is simply a way of quantifying the size of the difference between two groups. It is easy to calculate, readily understood and can be applied to any measured outcome in Education or Social Science. It is particularly valuable for quantifying the effectiveness of a particular intervention, relative to some comparison. It allows us to move beyond the simplistic, ‘Does it work or not?’ to the far more sophisticated, ‘How well does it work in a range of contexts?’ Moreover, by placing the emphasis on the most important aspect of an intervention – the size of the effect – rather than its statistical significance (which conflates effect size and sample size), it promotes a more scientific approach to the accumulation of knowledge. For these reasons, effect size is an important tool in reporting and interpreting effectiveness.

In this study, the effect size was less than 0.1. How do we interpret that?

Another way to interpret effect sizes is to compare them to the effect sizes of differences that are familiar. For example, describes an effect size of 0.2 as ‘small’ and gives to illustrate it the example that the difference between the heights of 15 year old and 16 year old girls in the US corresponds to an effect of this size. An effect size of 0.5 is described as ‘medium’ and is ‘large enough to be visible to the naked eye’. A 0.5 effect size corresponds to the difference between the heights of 14 year old and 18 year old girls. Cohen describes an effect size of 0.8 as ‘grossly perceptible and therefore large’ and equates it to the difference between the heights of 13 year old and 18 year old girls. As a further example he states that the difference in IQ between holders of the Ph.D. degree and ‘typical college freshmen’ is comparable to an effect size of 0.8.

So an effect size of less than 0.1 is tiny and therefore, not particularly meaningful.

Finally, the authors offer an explanation for the purported difference between C-section babies and vaginally born babies that has already been debunked.

According to the authors:

The direct association may occur through alterations to the infant’s gut microbiota. Unlike vaginally-born children whose gut is seeded by passing through the birth canal, the gut of cesarean-born children is seeded through contact with the mother’s skin and hospital surfaces. The result is long-term compositional differences in gut microbiota by mode of birth with differences observed up until age seven…

There is absolutely nothing in this study that gives credence to this explanation, and the authors acknowledge that this theory has yet to be proven in any context:

Although causal impacts on child development are yet to be proven, altered signaling from disturbed gut microbiota is thought to be a possible driver of higher rates of cognitive disorders, especially autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), among cesarean-born children …

In addition, a larger, more recent study has debunked the theory that the infant microbiome differs appreciably between C-section and vaginally born babies. The newer study concluded:

[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) …

The bottom line then is that there is NO EVIDENCE that C-sections lead to cognitive delays.

Any study that claims to show that C-section babies have cognitive delays must correct for hypoxic birth injuries, have a moderate to large effect size and be based on a plausible biological mechanism.

This study strikes out on all three counts.

This is the 2302nd post that I’ve written on this blog and if there’s been one consistent theme over the past years it has been this: Mothers Matter!

I’ve written about baby-friendly this and baby-centered that, but I’ve rarely come across anything that is explicitly mother-friendly or mother-centered. That’s not an accident. In the 30 plus years I’ve been a parent, mothering has changed from caring for children to curating them.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mothers aren’t incubators or milk dispensers; they’re people who matter.[/pullquote]

Children are viewed as objects to be acted upon, shaped and molded. The actual child takes second place to the future adult that is purportedly being created, an adult with specific middle to upper middle classes achievements: smart, talented, and ready to enter the economic competition of adulthood at a high level.

The conceit motivating this type of mothering is that women can only be successful mothers if they lose themselves. Their pain doesn’t count; their suffering doesn’t count; their time doesn’t count. Mothers and children have been suffering as a result.

But mothers DO matter.

That’s why I’ve created a new Facebook group, Mothers Matter, as a place for women to support other women in navigating mothering the way that works best for them. I hope it will provide an opportunity to share their hopes, fears, tips and experiences. I hope it will be a place of support, not judgment. What worked for you and what didn’t? Who helped you and who didn’t? How did you cope with childbirth, breastfeeding and parenting or how didn’t you cope? What kind of support do you need and how can we provide it?

Mothers aren’t merely incubators requiring strict supervision of every habit and every bite they eat; they are grown women capable of making health decisions for themselves and entitled to accurate information with which to do so.

How did you navigate pregnancy? How did you handle the judgment and the nosiness?

Mothers aren’t merely packaging to be torn apart in order to get to the child inside. How women give birth matters. Their pain matters and it should be abolished if they wish. Their sexual function and continence matter. They should not be subjected to traumatic forceps deliveries in order to reach some arbitrary C-section rate target. Their safety is paramount and they should not be pressured to risk their lives attempting vaginal birth after C-section or homebirth in order to avoid spurious risks to their babies’ microbiome and enact a romantic (and ahistoric) ideal of birth.

What did you expect from birth and what did you get? What do you wish you had known beforehand?

Mothers aren’t milk dispensers. The benefits of breastfeeding in industrialized countries are trivial and it is up to women to weigh them against the right to control their own bodies, not up to activists intent on creating the breastfeeding version of the Handmaiden’s Tale.

Do you breastfeed or bottlefeed? Are you happy with your choice? How did you handle the pressure that you felt?

Mothers aren’t blankies or binkies or lovies to be glued to a child’s body 24/7/365. They are separate people with independent lives and while they sacrifice much for their children, exactly what they sacrifice and how they do it is up to them, not parenting “experts.”

Do you sleep in a family bed or only with a partner? Do you “wear” your baby or is that something that doesn’t work for either of you? Did you return to work or decide to stay home? Are you happy with your decision?

The group will be open to the public, but only those who join will be able to post their stories. Anyone will be able to comment to offer support or suggestions.

Mothers matter. It’s time to put the mother back in mothering. Please join us!