A reader shared her childbirth experiences in France with me and I was fascinated. I thought my other readers would be interested, too, and she gave her permission for me to share this, though she prefers to remain anonymous.

I live in France, and after having given birth twice here, I thought you may be interested in hearing about my experiences with what I consider to be a true baby (and mommy) friendly hospital. Granted, I gave birth twice in the same hospital, so my sample size is limited but I can say my experiences were consistent both times, and with those I’ve heard of friends who’ve birthed at other hospitals as well as friends who work in maternal care in other areas of the country.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]With my son, I knew we were going to formula feeding immediately, but I wanted to give him colostrum early on, a common practice here; they call it a “tetine d’accueil” – welcome nipple.[/pullquote]

First of all, I was required to give birth at a real hospital, neither a home birth nor even a clinic were options for me. With my first pregnancy, my daughter, I stated that I didn’t want an epidural upon arrival at the hospital, and no one tried to change my mind otherwise. The midwives who admitted us and got us settled in were completely understanding, the only caveat was that I wasn’t eligible for the “natural birthing” suite, I had to stay in one of the “medical” birthing rooms. The hospital is equipped with 14 private birthing rooms (plus the natural birthing suite, which apparently sits empty most of the time), each with a private bathroom and shower, and about half have bathtubs as well.

I finally gave in to the epidural with my daughter, after over 24 hours of back labor, and with my son, I asked for the epidural as soon as we arrived at the hospital as things seemed to be progressing more quickly with him. Again, in neither situation did I feel coerced into one choice or another, and I truly felt the choice was up to me. In both cases, as we were waiting for me to dilate enough to start pushing, we were taken through a questionnaire asking about any special requests during the delivery – extended cord clamping, skin to skin (and whether it would be me or my husband to go first, what would happen if I was unable to interact with the baby immediately after delivery), who would pull the baby out (my husband or me – totally left that one up to him!), whether we wanted any special music or mirror so I could see what was happening, feeding choices, etc.. In each case, our answers were listened to and clarified, with it being made clear that our requests would be honored as much as possible, as long as neither I nor the baby were in any danger. Luckily, I had relatively problem free deliveries in both cases, with both babies arriving after minimal pushing.

Both of my births were attended by 3 members of hospital staff: a midwife (which here is a nurse who does additional training in midwifery), a nurse specializing in babies and a student midwife. I did not see a single “real” medical doctor either time as there was no need for one, although I was reassured knowing that there were several doctors on site for emergencies and the operating suite was just down the hall. Our daughter had to be taken away to the NICU for some breathing problems (having swallowed some amniotic fluid), so she was seen by a pediatrician within her first few hours and her father was allowed to stay with her the whole time. Our son had no problems, and we were left alone in the birthing room, lights dimmed, for at least his first 2 hours to begin to bond with the baby, perform skin-to-skin contact and try his first feeding (more on that in a moment) with the midwives and nurses only entering when we called them.

With my daughter I had planned to breastfeed; however, after several days she was screaming non-stop, I was miserable as I HATED the feeling of breast-feeding, wasn’t getting any sleep and was actually dreading taking my baby in my arms. The midwives checked her latch, and even tried to feed her with a little tube running from a formula bottle to my nipple so that she would be getting milk while thinking she was breast feeding. I realize now that she probably wasn’t getting enough to eat and the poor thing was hungry. In the end, it was actually one of the midwives who was honest enough with me to say just to give her formula, explained that it’s just as good and pointed out that if I’m this miserable now, continuing breastfeeding and trying to pump would only make me more miserable and that I’d regret it later if I didn’t enjoy this early time with my baby.

After talking it over with my husband (who was 100% supportive of formula feeding if that was what I felt was best), I said I would have him bring some formula in the morning. Imagine my surprise when she said no, that wasn’t allowed. The hospital actually provides ALL of the formula while the baby is there, so that they know exactly what the baby is eating and that it’s prepared properly. Throughout both of our hospital stays, all the formula both of my babies ate was provided, in 70ml pre-mixed, disposable bottles, with sealed sterilized disposable nipples. When giving birth to my son, I found out that the various formula companies rotate in providing samples to the hospital and the hospital isn’t allowed to recommend any one brand over another, they instruct new mothers to just buy any formula from the grocery store or pharmacy for “premiere age” – birth to 6 months, or of course to consult with a pediatrician or family doctor.

Luckily, we made the decision to switch my daughter to formula when she was not even 3 days old, so I don’t have a lot of guilt from thinking I starved my baby for very long; and I was struck by the concern that was shown for my psychological well-being, not just the health of the baby. This was also true with the other nurses and midwives who rotated throughout the shifts and later noticed we had switched to formula – no judgment or lecturing, mostly just comments that each mother needs to do what works for her, and even a few congratulations for being willing to make the decision so early for both mine and the baby’s benefit (yes, MY benefit was included in those comments).

With my son, I knew we were going to formula feeding immediately, but I wanted to give him the colostrum early on (yes, I realize the research on this is inconclusive but I figured it can’t hurt; this is actually a common practice here in France for mothers who don’t want to breastfeed, they call it a “tetine d’accueil” – welcome nipple J). The midwife who was going through our requests with us was completely supportive, helped us to get set up to do his colostrum feeding and then brought in the formula samples in case he was still hungry.

I stayed in the same maternity ward with both babies, which is comprised of private rooms with bathrooms, and space for the baby’s cradle as well as an extra pull out recliner for dad to sleep on if he so wishes. The maternity ward is staffed 24 hrs/day with midwifes and nurses specializing in infant care, with a pediatrician and OB-GYN on call. This was a university hospital, so there were several students of these varying specialties as well. Babies can stay with the mom in her room, or there is an optional nursery next to the nursing/midwife stations where babies can be left in their cradles for however long mom needs. With my daughter, the midwives were concerned that I wasn’t sleeping the first night or two and encouraged me to leave her in the nursery for a few hours. I refused, however I did leave the babies there when they were sleeping and I wanted to take a shower, and the nurses and midwives were completely non-judgmental and simply told me how beautiful the babies were J

With my daughter we were in the maternity ward for a week, as they were concerned that she may have an infection from the amniotic fluid she swallowed and they wanted to monitor her. Anytime a baby under a certain age is admitted to the hospital, one parent has the right to stay with them 24/7 so we spent 7 days in what I call “baby boot-camp” – I learned to change diapers, give her a bath, measure her temperature, burp her, you name it. There was always someone on call to answer silly questions and to help as much or as little as I wanted. With my son, we were only in the maternity ward for 4 days, which is the minimum for someone with my health issues as they wanted to monitor me afterwards. In fact, the shortest maternity ward stay possible here is 48 hours, and that’s only authorized in cases of non-first birth where everything has gone exceptionally well with a vaginal delivery and mom has no pre-existing medical conditions, but there is a mandatory follow-up home visit with a midwife within the first week of the baby’s life.

And how much did all of this cost, you may ask? My husband and I paid a total of about 15 euro when leaving to take my daughter home, and that was for 2 meals that my husband ordered at the hospital to eat with me. We also had to pay out of pocket for a follow-up test during her first month, and I was mentally planning to take money out of savings to cover it until she would be registered with the health care system which would reimburse us – imagine my surprise when the bill arrived for 11 euros!. I’ve been closely watching the health-care debate in the US, and I have a friend who gave birth this past December at a clinic that apparently sends mothers home within 6 hours of giving birth, even with a first baby. When my daughter was born I had no idea how to care for an infant, and I am eternally grateful for that week in the maternity ward where I was able to learn how to care for my baby without any pressure or financial stress from worrying about the cost. By the time we took her home, I was confident in what I was doing. I’m also grateful for the support in giving up breast-feeding so early as it allowed me to really enjoy my daughter in those precious first days and weeks rather than dreading every feeding.

This is all on top of the fact that I was put on medical leave with both of my pregnancies for the last 3-4 months. Medical leave is paid 50% by the state here in France, with my private employer health insurance topping off the rest until maternity leave benefits kick in 6 weeks before the due date (paid at 100% until 10 weeks after the due date – 16 weeks total). This meant that I was able to truly rest during the last few months, without worrying about finances or job loss. Medical and maternity leaves are very strongly protected by the labor law here, and the overall culture is such that an employee giving birth is something to be celebrated, not dreaded.

I was raised in Canada, so for me a public health care system just seems like the obvious way to go; I also spent several years working in the US, and although I had good health insurance through my employer, it was odd and unnerving to always have the spectre of being uninsured (if I were unemployed) hanging over me. I realize that we pay much higher taxes here in France and that the idea of “being taken care of” by the state is antethema to the US mindset. But I don’t mind the higher taxes so much, as I see what I get for paying them.

My kids are now 16 months and 3.5 months old (the close age difference was on purpose, however termination of the second pregnancy was presented as an option in case it was an accident) and thankfully in perfect health. They’re both fully covered by the social medical system here, meaning that all doctor and specialist visits, and part of all their prescriptions, blood tests and vaccines are covered by the state; the remainder is picked up by my health insurance through work. I honestly can’t imagine how families can survive and thrive living under a cloud of fear that any medical problem can send them into financial distress or even bankruptcy (and now, even leave them with a pre-existing condition that may put their health insurance further at risk).

Earlier in the week I criticized the ProPublica/NPR piece on maternal mortality (What ProPublica didn’t explain and possibly didn’t even know about maternal mortality).

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We must create regional centers for maternal intensive care just as we have done for newborn intensive care.[/pullquote]

Because ProPublica failed to explain changes in reporting of maternal mortality, failed to explain the changing causes , failed to explain the outsize contribution of race and failed to explain the inherent deadliness of childbirth, they presented a fundamentally misleading picture of the issue. But there is disturbing fact that they got absolutely right: 60% of maternal deaths are potentially preventable.

In order to understand how these deaths could be prevented, we need to understand what causes them.

The chart above shows the leading causes of pregnancy related deaths. These causes can be roughly divided into three groups, pre-existing medical issues, complications of pregnancy, complications of hospitalization.

Let’s start with the easiest group first, complications of hospitalization. Deaths due to infection and thrombotic pulmonary embolism make up the bulk of these deaths. They aren’t strictly due to hospitalization; they have always been leading causes of death because childbirth puts women at risk of infection and pregnancy puts women at increased risk of blood clots. But there are easy to implement methods that can dramatically reduce both, including checklists and proper aseptic technique to reduce infection and low dose heparin and compression boots to reduce blood clot formation. A lower C-section rate could contribute to a reducing both complications as well. This is the low hanging fruit of the maternal mortality problem, easy to grasp and easy to correct. We will never be able to abolish all infection and blood clots in pregnancy, but we can do a lot better.

The second group is complications of pregnancy like hemorrhage and hypertensive disease (pre-eclampsia and eclampsia) as well as strokes resulting from high blood pressure. Both hemorrhage and hypertensive disease are endemic to pregnancy. Neither can be entirely or even mostly prevented (at least not yet); they must be treated. And before they can be treated, they must be diagnosed.

We know that a certain percentage of women will hemorrhage after childbirth just like we know that a certain percentage of women will developed hypertensive diseases of pregnancy. Diagnosing those problems as early as possible requires an high index of suspicion, careful monitoring, and the immediate application of technology. This is where algorithms, drills and tool kits come into play. No one should assume that a woman won’t develop childbirth complications; everyone should be alert to the a fact that they are both common and inevitable. Algorithms can help providers make an early diagnosis.

Hemorrhage and pre-eclampsia are often full blown emergencies where minutes count. Tool kits allow providers to have all relevant diagnostic and treatment technology at hand. Drills help providers utilize that technology expeditiously. They are often the difference between life and death.

Cardiomyopathy is also a complication of pregnancy but not nearly so common as hemorrhage and pre-eclampsia. It is relatively rare and therefore most providers may have never seen it. Nonetheless it is one of the fastest growing causes of maternal death. Unfortunately:

Early, rapid diagnosis of peripartum cardiomyopathy is not the norm. It took 7 or more days to establish the diagnosis in 48% of women, and half of those had major adverse events before the diagnosis was made…

In this situation the most important elements are high index of suspicion when women complain of shortness of breath or chest pain and rapid consultation with cardiologists and other specialists.

The final group is pre-existing medical conditions. Childbirth is now more common than ever in women who are older, heavier and suffering from a greater number and range of pre-existing medical conditions. In many cases, such as heart disease and kidney disease, pregnancy and childbirth can put tremendous strain on already weakened organs. Specialized intensive care is the key to preventing maternal deaths.

We long ago recognized the value of specialized intensive care in saving the lives of critically ill newborns. That’s what led to the creation of neonatal intensive care units (labeled Level I, II or III based on the type of technology available), neonatologists, and routine regional transfer of newborns to higher level NICUs. A premature or critically ill newborn will be transferred to a Level III nursery if born at a hospital that only has a Level I or II nursery.

It’s hardly surprising that we addressed the intensive care issue in newborns first. Death rates for newborns are approximately 100X higher than for new mothers. It is surprising that we have never addressed the issue of maternal intensive care units, maternal intensivists and routine regional transfer of critically ill mothers at all. Mothers are dying as a result.

Only the rare obstetrician is trained in intensive care. No obstetrician should be trying to manage pregnant women with pre-existing medical conditions on his or her own. The appropriate specialists should always be involved hopefully before complications develop and certainly after.

Most intensivists trained in the care of adults are typically unfamiliar with the specific issues that arise in conjunction with pregnancy. We should create regional centers for maternal intensive care just as we have done for newborn intensive care. We should rank them by available technology and we should routinely transfer women to higher level centers to deliver there preferentially or when they develop complications after birth.

We’ve all read countless articles in the mainstream press about efforts to reduce pregnancy interventions, but there is precious little effort being made to reduce maternal deaths. New mothers will continue to die until we develop the will and deploy the technology to prevent these eminently preventable maternal deaths. Let’s stop wringing our hands, and start working.

One of the most amazing things about writing for this blog is that no sooner do I mention something untoward or dangerous and someone rushes to demonstrate it.

Yesterday I wrote about the way that a low index of suspicion for pregnancy complications leads to maternal deaths. Today, Consumer Reports publishes a ham handed piece, Childbirth: What to Reject When You’re Expecting, by Tara Haelle that obsesses about process without giving any serious consideration to the only thing that really matters, outcome. It’s as if Consumer Reports rated cars by cup holders and interior upholstery instead of by crash worthiness.

Haelle starts with the usual framing:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s as if Consumer Reports rated cars by cup holders and interior upholstery instead of by crash worthiness.[/pullquote]

Despite the benefits of a healthcare system that outspends those in the rest of the world, infants and mothers fare worse in the U.S. than in many other industrialized nations…

Infants in this country are more than twice as likely to die before their first birthday as those in Japan and Finland, and America lags behind nearly every other industrialized nation in preventing mothers from dying due to pregnancy or childbirth…

Why? There are no doubt many causes. But one likely contributor may be that medical expediency often takes priority over the best outcomes and evidence-based treatments…

That’s a brutal assessment requiring copious evidence to support it. Haelle and Consumer Reports provide none.

And in this setting in particular, that is inexcusable.

What is most ugly about this is that it ignores the fact that black women and babies are disproportionally affected, with death rates FOUR TIMES HIGHER than everyone else, far exceeding that of every other minority group,

We will never improve outcomes for black babies and women if we pretend that mortality is primarily a problem for privileged white women looking to craft a “birth experience.”

We will never reduce perinatal and maternal mortality as far as possible if we lie to ourselves about the real causes.

To my knowledge, there is NO EVIDENCE, zip, zero, nada, that perinatal and maternal deaths are caused by medical expediency. But that doesn’t stop Haelle or Consumer Reports.

They trot out the usual hobby horses for condemnation: the C-section rate, the induction rate, continuous electronic fetal monitoring, episiotomies, epidurals and sending babies to newborn nurseries.

These are processes, NOT outcomes. They affect the birth experience far more than they affect whether babies and mothers live or die. No matter. Consumer Reports and Haelle only mention death rates to imply that interventions cause death, not in any serious effort to prevent deaths.

Look at the reasons why mothers die:

How is obsessing about process going to have an impact on the most common reasons for maternal death, cardiac and other chronic diseases? It isn’t.

What about infant mortality?

How is obsessing about process going to have an impact on the most common causes of infant death, congenital anomalies, prematurity (generally extreme prematurity), and complications of pregnancy. It isn’t.

Though there is no evidence that medical expediency kills babies and women, there is considerable evidence that medical complacency, assuming that pregnancy is inherently safe when it is actually inherently dangerous, does kill.

As noted in the ProPublica/NPR report about maternal mortality:

Earlier this year, an analysis by the CDC Foundation of maternal mortality data from four states identified more than 20 “critical factors” that contributed to pregnancy-related deaths. Among the ones involving providers: lack of standardized policies, inadequate clinical skills, failure to consult specialists and poor coordination of care. The average maternal death had 3.7 critical factors.

California set out to reduce maternal mortality and the California Maternal Quality Care Collaborative created “tool kits” for providers:

The first one, targeting obstetric bleeding, recommended things like “hemorrhage carts” for storing medications and supplies, crisis protocols for massive transfusions, and regular training and drills. Instead of the common practice of “eye-balling” blood loss, which often leads to underestimating the seriousness of a hemorrhage and delaying treatment, nurses learned to collect and weigh postpartum blood to get precise measurements.

In other words, the CMQCC set out to raise the index of suspicion and insistuted drills to deal with emergencies, not offer false reassurance pretending they aren’t happening. The results are very impressive:

Hospitals that adopted the toolkit saw a 21 percent decrease in near deaths from maternal bleeding in the first year; hospitals that didn’t use the protocol had a 1.2 percent reduction. By 2013, according to Main, maternal deaths in California fell to around 7 per 100,000 births, similar to the numbers in Canada, France and the Netherlands — a dramatic counter to the trends in other parts of the U.S.

Sadly, the focus on process ahead of outcome is not limited to childbirth; it has been extended to breastfeeding and the results there have been even more disastrous.

The Baby Friendly Hospital Initiative, designed to promote breastfeeding (a process), has led to a large and growing number of DEATHS (an outcome). Aggressive breastfeeding promotion, including policies against formula supplementation and mandatory rooming in of babies in their mothers’ hospital rooms have led to an epidemic of infant brain injuries and deaths from dehydration, hypoglycemia (low blood sugar), and babies smothering in or fracturing their skulls falling from mothers’ hospital beds. No matter, the BFHI cluelessly touts breastfeeding rates as if that, in an of itself, is a measure of quality, while studiously ignoring and sometimes aggressively denying the entirely preventable deaths that result.

Process, in both childbirth and breastfeeding, does matter, just like cup holders and interior upholstery matter in cars. But outcome is far more important than process. Consumer Reports should stop pretending that childbirth is safe and the only thing we need to do to improve it is to decrease interventions. That doesn’t mean that we shouldn’t try to reduce C-section rates and the rates of other interventions, just that those efforts should take a backseat to reducing deaths.

The mainstream press has been buzzing about a joint ProPublica/NPR piece about US maternal mortality. But in crafting the piece to create buzz, they’ve fundamentally misrepresented the problem.

It’s starts with the title, The Last Person You’d Expect to Die in Childbirth. Yes, Lauren Bloomstein was the LAST person you’d expect to die in childbirth and, arguably, she died of malpractice, not childbirth. Therefore, she is not representative in any way of the real issue.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]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. [/pullquote]

The truth is that black women bear the brunt of pregnancy related deaths and they die for different reasons than white women, including lack of access to the technology that many white women take for granted.

What else did they get wrong?

1. It’s not clear that the US maternal mortality rate has even risen, let alone risen dramatically.

The ProPublica has a very impressive graph that shows US maternal mortality rising gradually from 1990 to 2000, and then rising steeply between 2000 to 2010, an overall increase of more than 56%. What the piece fails to mention is that US death certificates were changed twice over those years (in 1999 and again in 2003) in an effort to capture a greater proportion of maternal deaths and to capture deaths far longer after birth (one year, not 42 days) than previously. Other countries did not institute the same changes.

How much of the purported increase is due to changes in reporting? According to this 2017 paper, Factors Underlying the Temporal Increase in Maternal Mortality in the United States: all of it.

Recent increases in maternal mortality ratios in the United States are likely an artifact of improvements in surveillance and highlight past underestimation of maternal death.

A 2016 paper, Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues, reaches a slightly different conclusion.

most of the reported increase in maternal mortality rates from 2000–2014 was due to improved ascertainment of maternal deaths. However, combined data for 48 states and DC showed an increase in the estimated maternal mortality rate from 18.8 in 2000 to 23.8 in 2014 – a 26.6% increase.

2. What are the leading causes of maternal mortality?

The ProPublica piece presented a bar graph from Report from Maternal Mortality Review Committees. That report looked at data from only 4 states. The data for the entire US is available from the CDC:

Hypertensive disorders of pregnancy, which is what killed Lauren Bloomstein, used to be a leading cause of maternal death, but has dropped down to seventh. The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. And that reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before. This is yet another way that Lauren Bloomstein’s story is not representative of the issue of maternal mortality.

3. The dirty little secret about pregnancy: it’s dangerous.

If you have been reading the mainstream media over the last few years, you might have come away with the impression that pregnancy is safe and technology is being overused. Millions of gallons of ink have been spilled over the C-section rate (which is a process) and relatively little has been written about maternal mortality (which, as an outcome, is far more important).

ProPublica notes that 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. In other words, you have to use technology. 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 of the fact that pregnancy, in every time, place and culture (including our own) has ALWAYS been one 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. As ProPublica notes:

Earlier this year, an analysis by the CDC Foundation of maternal mortality data from four states identified more than 20 “critical factors” that contributed to pregnancy-related deaths. Among the ones involving providers: lack of standardized policies, inadequate clinical skills, failure to consult specialists and poor coordination of care. The average maternal death had 3.7 critical factors.

Lauren’s death involved a myriad of these factors, but the most important is the one that isn’t mentioned: the low index of suspicion. In other words, no matter what happened, the doctor and nurses kept insisting that everything was fine while she was dying before their eyes. Instead of investigating her symptoms, everyone kept assuring her that she was fine. There’s a word for that kind of complacency: the word is malpractice.

The state of California has set out to eliminate complacency and their results have been impressive, particularly in cases like Lauren’s. 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).”

The California researchers created a series of “tool kits” for doctors, nurses and hospitals and achieved impressive result. Yet the limiting factor in rolling out these programs to other hospitals is complacency.

“It’s very hard to get a hospital to provide resources to change something that they don’t see as a problem,” ACOG’s Barbara Levy said. “If they haven’t had a maternal death because they only deliver 500 babies a year, how many years is it going to be before they see a severe problem? It may be 10 years.”

4. The central role that race plays in maternal mortality.

ProPublica didn’t ignore the role of race, but by framing the piece with a story of a white woman who died as a result of malpractice, they fundamentally misrepresented the issue.

Black women bear the brunt of maternal mortality. When it comes to conveying the remarkable disparity, a picture is worth a thousand words:

And it’s not just a matter of socio-economic status. According to Predictors of maternal mortality and near-miss maternal morbidity:

…In multiple regression analysis, this difference could not be explained by other risk factors… These included age, obesity, history of a chronic medical condition, prior cesarean delivery and gravidity. Education level, marital status and public medical insurance status, factors traditionally associated with socioeconomic status, could not explain the disparity…

Considerable controversy exists about the biological reality of race. Nevertheless, in our study, as in others, race or ethnicity, as defined in ordinary social terms, is identified as a substantial risk factor for adverse maternal outcome. Since race and ethnicity rather consistently emerge as important factors in both obstetric and other medical situations, investigation of the causation is strongly indicated…

This finding has been reported in women of African descent living in other countries as well. It has considerable importance when comparing maternal mortality among countries. Though ProPublica implied that countries that have lower maternal mortality rates than the US provide better care, that is not necessarily the case. It’s hardly a coincidence that the countries with the lowest maternal mortality ar the “whitest” countries. The US has the highest proportion of women of African descent. Maternal mortality may just be a proxy for race not a measure of quality of care.

The take home message about maternal mortality in the US is a lot more nuanced than the ProPublica/NPR piece implied. It’s not a problem of privileged white women who are victims of malpractice. It is a problem with profound racial disparities and changing causes of death. And it’s also a story about what happens when people forget that pregnancy is inherently dangerous and demonize technology instead of using it to save lives.

No one seems to learn anything from the endless parade of preventable homebirth deaths.

There’s been another:

My beautiful son R Was born on May 9th. He only lived 31 hours…

It happened “suddenly.”

I was in labor for about 35 hours and pushed for about 6… My midwife checked the heartbeat after every time I pushed and the baby sounded happy and healthy. Until he didn’t. All of a sudden the heartbeat sounded off so she called the paramedics… I ended up giving birth in the ambulance … R. was not breathing and he didn’t have a heartbeat. They started to resuscitate him in the trauma room. He needed to be put on machines to breathe … But his condition got worse and worse. They told u s that he had no chance of survival and there was no brain function. So we let him go …

R’s mother is reeling:

…This was my first pregnancy and I had so many high hopes for a home birth. I had no fear. No doubt in my mind that everything was going to be perfect… I felt him moving until the very end. What happened? Also, apparently my placenta had a huge blood clot … could that have something to do with him passing.

Why does it sound so familiar, practically a routine homebirth outcome?

Maybe it’s because it sounds exactly like this homebirth disaster, But the baby’s heartrate was fine right before it dropped nearly dead into the homebirth midwife’s hands.

Or these: So many homebirth deaths I can barely keep track.

Or these: Homebirth death watch.

Maybe these: Homebirth hell, 5, no 6 dead babies in one WEEK!

Perhaps these: The cult of homebirth kills babies; 5 deaths in the last few weeks.

Why did this happen? It happened because R’s mother chose homebirth with undereducated, undertrained, ideologically brainwashed midwives.

It happened because magical thinking — positive affirmations, having no fear — has NO impact on the incidence of complications and death.

It happened because intermittent Doppler monitoring is not as accurate as electronic fetal monitoring.

For example, this tracing shows a baby in serious trouble:

Surprised? You might be if you thought that a fetal heart rate tracing supplied the same information as intermittent auscultation (listening) with a doppler. But electronic fetal monitoring provides a wealth of information that cannot be obtained by listening, and that allows for a more comprehensive view of fetal well being.

This is a tracing with limited beat to beat variability and subtle late decelerations.

Notice what you don’t see:

You don’t see a bradycardia, a sustained period of abnormally low heart rate. That’s because bradycardia is often a terminal event. Most babies can tolerate long periods of significant oxygen deprivation before they die, and they may not have any bradycardias until immediately before death. On this tracing, there is never a single moment when the heart rate is outside of the normal range, but the baby is nonetheless suffering from serious oxygen deprivation.

This is almost certainly what is happening in hours before a dead or nearly dead baby drops into a homebirth midwife’s hands. The midwife may be intermittently listening to the baby’s heart rate, but unless she is listening for long enough AND frequently enough AND exactly at the right times AND can distinguish subtle changes in heart rate, she will be blissfully unaware that a baby is dying right in front of her.

Homebirth advocates and their midwives who insist that the baby’s heart rate was “fine” until just before delivery are almost always completely wrong. The baby’s heart rate was not fine; they just couldn’t tell what was happening because they only listened intermittently.

And because they couldn’t tell, the baby died.

Most of all, these entirely preventable homebirth deaths keep happening because homebirth advocates construct a wall of denial around every death, insisting that even though their family, friends, and doctors warned them that EXACTLY THIS TRAGEDY was more likely to happen at homebirth, the fact that it happened is just an amazing coincidence!

Like this one:

…My story is similar to your. We heard a healthy heartbeat shortly before birth and baby was making strong movements an hour before. My sweet E was born sleeping at home with no warning that anything was wrong.

Or this one:

I attended a birth where the baby passed in labour, (their first baby), it was terrible and shocking! … Life has some really tough lessons. We can grow and learn and use these experiences for positive change.

Apparently not.

No one seems to learn anything from the endless parade of preventable homebirth deaths.

I’ve long thought that lactivists were being deliberately obtuse about the assertion that Fed Is Best. They repeatedly claim, with no plausible justification, that Fed Is Best means routine supplementation with formula for all infants.

I’ve recently revised my assessment. Maybe lactivists aren’t being obtuse; maybe they just don’t get it. There’s a critical difference between ‘fed is best’ and ‘breast is best’ and lactivists imagine the difference is formula. They’re wrong:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Fed Is Best is about safety; Breast Is Best is about process. The difference between the two is the difference between life and death.[/pullquote]

Fed Is Best is about safety; Breast Is Best is about process. The difference between the two is the difference between life and death. Seems simple, but it’s a difference that lactivists seem incapable of understanding.

For example, I’ve been participating discussion about insufficient breastmilk in a private group.

Someone asked me:

Truthfully Dr Amy, is it your professional opinion all neonates should be supplemented in order to prevent dehydration, brain injury and/or death?

I answered:

I view breastfeeding like vision; both have a natural failure rate. It would be malpractice for me to tell a mother who reports that her child doesn’t seem to able to see that she should ignore it since most children see just fine. Similarly, it is malpractice to tell a mother who reports that her child seems desperately hungry that she should ignore it since most babies don’t need supplementation.

I am no more in favor of universal formula supplementation than I am in favor of giving every new baby a pair of glasses. (emphasis added)

And:

When I did my pediatrics rotation in medical school, the preceptor told me something I never forgot: when a mother tells you her baby is suffering, believe her!

So when a mother tells me that her baby is screaming from hunger, no one, regardless of any policy, should ignore her. It is up to the professional to make sure that the baby is fine, not simply insist that the baby must be fine since most babies are fine.

I thought I couldn’t possibly be clearer, yet this was the response:

To be honest, that doesn’t clarify it for me. I’m still not sure where you stand as I feel you contradict yourself. I don’t say that in an antagonistic way. I’m genuinely confused.

Confused? What could she possibly be confused about? It certainly can’t be the meaning of my words since I was very plain. I guess she’s confused because since she’s obsessed with breastmilk, she imagines that I must be obsessed with formula.

No, I am obsessed with safety. That’s why lactivists’ claims that “fed is best” means you can feed your infant McDonald’s are wrong. Fed Is Best advocates don’t believe that McDonald’s is safe for infants anymore than they believe that goat’s milk or homemade formula is safe for infants.

Meg Nagle IBCLC doesn’t get it either.

To say “nothing happens” with supplementing is incredibly hard for me to read because I’ve seen first hand the incredibly challenging situations women and babies find themselves in when their child has a reaction to formula. My friend’s baby was seriously ill in hospital for 3 months. She was routinely pushed to “fortify” (put formula) into her expressed milk. When she finally fell to this pressure he had a severe reaction and immediately threw it all up. She refused to allow this again. I’ve seen so many women in my office telling me the challenges they have faced trying to find a supplement that doesn’t make their baby have a serious reaction. So no. For many families supplement is a big deal and does cause further complications…

Situations? ONE baby who simply threw up? That was the “incredibly challenging situation?” A seriously ill baby wasn’t getting enough nutrition and Meg thinks the problem in that situation is that the baby threw up formula? Sure, formula might not have agreed with that baby, but it was worth trying since the only other alternatives might be malnutrition or an IV to administer TPN (total parenteral nutrition).

Does a baby who is not getting enough need to be fed? YES. Does a baby who is getting enough need to be supplemented? NO.

Duh!

Fed Is Best advocates do NOT recommend routine supplementation with formula for every infant. Why would we when our concern is safety? Babies growing and thriving on breastmilk are safe. But babies who aren’t growing, who aren’t thriving, who are screaming from hunger even after being offered the breast repeatedly AREN’T safe. Those babies should be supplemented to assure they are adequately fed.

Meg, a baby vomiting up a bottle of formula is “an incredibly challenging situation”? Really? I’ve got news for you: a baby struggling with permanent brain damage from dehydration or hypoglycemia is more challenging. Most challenging of all is a baby who dies a preventable death because lactation consultants like you demonize supplementation.

Breast Isn’t Best. Fed is Best because Safety Is Best. It’s just that simple.

For the past two days I’ve been engaged in a discussion in a private Facebook group about the injuries and deaths caused by lactation consultants who lie. As anticipated, I was met with a wall of denial from lactation professionals. During the course of the discussion I presented more than a dozen scientific citations and those disagreeing with me presented zero, yet that didn’t move the lactation professionals even a tiny bit. Neither did the reports of infant injuries and deaths including the heartbreaking and entirely preventable death of Baby Landon Johnson.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Making breastfeeding readmissions never events will reduce the epidemic of babies injured by relentless promotion of exclusive breastfeeding. It will save babies and it will save money — the ultimate win-win.[/pullquote]

As I noted earlier this week — lactivists lie first and foremost to themselves and each other — claiming that insufficient breastmilk is rare when it is common. The purported justification is that women are “designed” to breastfeed. It’s like insisting that nearsightedness is rare because eyes are designed to see.

The wall of denial illustrates the primary problem with lactation consultants; they aren’t real medical professionals. When a patient dies from a hospital error — and, make no mistake, infant injuries and deaths from exclusive breastfeeding are hospital errors — real medical professionals ask, “how can we avoid this happening to anyone else?” Lactation consultants, in contrast, ask, “how can we avoid blame?”

Therefore, the best way to protect babies from lactation consultants who lie is to force hospitals to monitor them. The best way to do that is to designate breastfeeding readmissions as “never events.”

What are “never events”?

According to the Agency for Healthcare Research and Quality (AHRQ):

The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable…

For example, the “death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy” is a never event.

Hospitals should do everything in their power to prevent never events, since the whole point is that they should never happen. As a result:

Because Never Events are devastating and preventable, health care organizations are under increasing pressure to eliminate them completely. The Centers for Medicare and Medicaid Services (CMS) announced in August 2007 that Medicare would no longer pay for additional costs associated with many preventable errors, including those considered Never Events. Since then, many states and private insurers have adopted similar policies…

In other words, when a hospital presides over a never event, they will not be reimbursed for the treatment required as a result. That’s a tremendous impetus for hospitals to do everything in their power to prevent never events. Most importantly, it an unbiased, independent method of holding hospital employees to account even when hospitals themselves would prefer not to do so.

There are currently 29 designated never events. We should add a thirtieth: death or serious injury of a neonate associated with exclusive breastfeeding in a low-risk pregnancy that occurs within the first two weeks after birth.

If hospitals had to bear the cost of readmissions for dehydration, hypoglycemia and starvation, it wouldn’t merely break a hole in lactation consultants’ wall of denial about the high incidence of insufficient breastmilk; it would obliterate it.

How common are such readmissions?

According to this 2013 paper in the journal Pediatric Emergency Care:

In the neonatal period, dehydration … is one of the most common causes of re- hospitalization. According to the serum osmolality, dehydration is classified into 3 forms as hypernatremic, normonatremic, and hyponatremic dehydration. Hypernatremic type is a potentially lethal form because it adversely affects central nervous system, leading to devastating consequences such as intracranial hemor- rhage, thrombosis, and even death. Recently, along with many other etiologies, early discharge and failure of breast-feeding are increasingly documented as major causes of hypernatremic dehydration.

High serum sodium (Na) concentration, which is associated with diminished fluid or excessive Na intake, or excessive fluid loss, is usually caused by inadequate breast-milk feeding in otherwise healthy newborns…

How common is readmission for neonatal dehydration?

During the study period, 4280 neonates were admitted to NICU. Among them, 97 had HD. Sixteen patients were ex- cluded from the study. Prevalence of HD was 1.8% (81/4280). All the patients were fed with breast milk. Fifty-nine patients were born in our hospital; 51 patients were discharged from the hospital within the first 48 hours of life.

And that’s just readmissions for dehydration. When you add hypoglycemia and injuries that result from infants falling from or smothering in mothers’ hospital beds the numbers would be considerably higher.

The cost to the hospital if insurance companies refused to pay for these readmissions would be enormous. As a result, we could expect to see hospitals’ risk management departments undertake thorough education on monitoring of its lactation consultants.

At the moment, lactation consultants have no accountability when babies are injured or die as a result of their lies and their relentless promotion of exclusive breastfeeding and near pathological resistance to the benefits of formula supplementation. That would change quite dramatically and it would no longer be possible for them to continue lying to themselves, each other and vulnerable new mothers.

If we take lactation consultants at their word, they should be delighted to accept accountability. According to them, neonatal injuries and deaths as a result of exclusive breastfeeding are vanishingly rare and are prevented when lactation consultants assiduously weigh and monitor newborns and offer timely formula supplementation.

If they’re wrong, it’s going to cost hospitals a fortune. As a result lactation consultants will no longer be free to ignore scientific evidence in favor of ideology. Moreover, they will start telling mothers the truth about the fact that insufficient breastmilk is common, particularly during the first few days after birth. They will teach mothers to look for and respond to the signs of dehydration instead of falsely reassuring them that these warning signs are no reason to be concerned.

Most importantly, making breastfeeding readmissions never events will reduce the epidemic of babies injured and even killed by overzealous encouragement of breastfeeding.

It will save babies and it will save money — the ultimate win-win.

It’s hard to predict when a tipping point will occur but once it happens, everything changes.

For example, peremptory airline behavior toward passengers — over booking flights, bumping passengers — has been going on for decades, but everything changed when a United Airlines dragged a passenger down the aisle, bloodying him along the way, in an effort to get back to business as usual. The issue rose to public consciousness in a way that it never had before, prompting wholesale review of airline procedures, not to mention a large payout to the injured passenger.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation consultants didn’t intend to lie to Landon’s mother; they just told her the same lies they tell themselves.[/pullquote]

Similarly, peremptory treatment of mothers by lactation consultants — ignoring their concerns about starving babies, in particular — has been going on for decades, but everything changed when Jillian Johnson shared the story of her son Landon’s death from dehydration due to insufficient breastmilk (If I Had Given Him Just One Bottle, He Would Still Be Alive). The issue rose to public consciousness in a way that it never had before, prompting new attention and hopefully a wholesale review of relentless effort to promote breastfeeding.

Landon cried. And cried. All the time. He cried unless he was on the breast and I began to nurse him continuously. The nurses would come in and swaddle him in warm blankets to help get him to sleep. And when I asked them why he was always on my breast, I was told it was because he was “cluster feeding.” I recalled learning all about that in the classes I had taken, and being a first time mom, I trusted my doctors and nurses to help me through this – even more so since I was pretty heavily medicated from my emergency c-section and this was my first baby…

So we took him home … not knowing that after less than 12 hours home with us, he would have gone into cardiac arrest caused by dehydration…

Landon died years ago and his story remained a private tragedy. Then the Fed Is Best Foundation was created by Christie Castillo-Hegyi, MD and Jody Seagrave-Daly, RN, IBCLC precisely to prevent such tragedies. Jillian felt that she could finally tell Landon’s story to medical professionals who understood, as opposed to lactation consultants who proverbially dragged her down the aisle, bloodying her along the way, in an effort to get back to business as usual.

Landon’s story has appeared in countless newspapers and blogs, in People Magazine and today it has reached television on the show The Doctors. Here is a deeply moving clip:

How could this have happened?

It happened because lactation consultants lie — first and foremost to themselves and each other, but most importantly to parents — insisting that breastfeeding is perfect and problems are rare. Regardless of the age, size and temperament of the baby, many lactation consultants claim that his mothers breasts ALWAYS make enough milk to fully nourish him and that ANY supplementation of breastmilk with formula destroys the breastfeeding relationship. Why? Because women were “designed” to breastfeed. But the truth is that breastfeeding, like any natural process, has a natural failure rate and complications are common.

It’s like insisting that nearsightedness is impossible because eyes are “designed” to see or claiming miscarriage is rare because women’s bodies are “designed” to produce babies. The truth is that 30% of Americans are nearsighted and the natural rate of miscarriage is 20%. Therefore, it should not be surprising that up to 15% of first time mothers (as Jillian was) won’t produce enough breastmilk to fully support a baby in the first few days.

This should not be news to anyone since across large swathes of the world, women offer pre-lacteal feeds in the first few days after birth, such as sugar water, teas and even honey, to their babies. Prelacteal feeding is practiced from Africa to Southeast Asia, to Central and South America, suggesting that a variety of peoples independently believed it to be necessary.

Not surprisingly, pre-lacteal feeds led to illness since they were often made with contaminated water. Lactation consultants looked at the phenomenon and drew the wrong conclusion. They decided that it was the process of supplementing in the first few days that was harmful, rather than the reality that it was the specific supplements that were harmful. It apparently never occurred to them to wonder why millions of women around the world and across the generations had come to the conclusion that colostrum was simply not enough.

Lactation consultants promulgated a variety of rules, embodied in the Baby Friendly Hospital Initiative, that are based on their belief, unsupported by scientific evidence, that every woman can make enough breastmilk and that offering anything other than the breast (formula, a pacifier) will destroy the breastfeeding relationship.

The scientific evidence actually shows the opposite: judicious formula supplementation actually increases the odds of extended breastfeeding and pacifiers not only don’t interfere with breastfeeding, they actually prevent SIDS.

Many lactation consultants lie to themselves and each other about the high rate of insufficient breastmilk and the high and rising rate of breastfeeding complications like dehydration, low blood sugar, permanent brain injury and even death. Their answer to any and all breastfeeding problems is “breastfeed harder.”

How can they ignore that harm that they are causing? They have conjured an all purpose excuse for breastfeeding difficulties, “lack of support.” Since they insist that breastfeeding is perfect, it must be mothers who are lazy or who aren’t being supported that are at fault.

It’s as if “vision consultants” suddenly started telling women that they couldn’t be nearsighted because their eyes were “designed” to see and therefore nearsightedness is rare. It’s as if they withheld glasses and contact lenses on the theory that if women just “looked harder” or got more “vision support,” all but an unfortunate few would have 20/20 vision.

No doubt the lactation consultants who told Landon’s mother he was doing fine while he was actually dying before their eyes believed what they were saying. That is what they were taught and that is what they continually tell each other. They didn’t intend to lie to Landon’s mother; they just told her the same lies they told themselves. Landon died as a result.

Worst of all, when presented with the evidence of Landon’s death, they are fabricating new lies. Some of the lies — such as the lie that Landon’s mother accidentally suffocated him — are extraordinarily ugly. The new lies speak to the desperation of lactational consultants and lactivists to continue believing their old lies that breastfeeding complications are rare.

Nothing will bring Landon back. Nothing will assuage his parents’ heartbreak. But we can hope that the story of his easily preventable death will serve as a tipping point so lactation consultants can’t go back to business as usual.

There he goes again.

Dr. Jack Newman has a disturbing tendency to rationalize or ignore the iatrogenic injuries and deaths causes by relentless promotion of breastfeeding.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Worst case scenario if you give a baby an unnecessary bottle of formula is — nothing! Worst case scenario if you fail to give a baby a needed bottle of formula is brain damage and death.[/pullquote]

Sadly, he resembles many physicians who refuse to take responsilbity for the preventable errors that are so prevalent in today’s medical system. Like the classic paternalistic doctor, he is sure that he knows best. Hence he refuses to acknowledge harmful errors, tries to blame others for the injuries and deaths, and justifies it all by implying that individual harms are acceptable in light of the overall good.

In a May 5th Facebook post, Dr. Newman wrote:

In many hospitals, 10% weight loss is used as an accurate measure of how the breastfeeding is going in the first few days after birth. In fact, it is nothing of the sort. All too often it results in babies getting unnecessary supplementation, often by bottle, and the mother and baby do not get the help they need to succeed in breastfeeding…

He presents NO data and NO scientific citations to support his claims (not surprisingly since there aren’t any). Instead he offers bizarre attempts to deny reality: the scales are wrong, people don’t use the scales properly, babies start out over-hydrated, babies can’t latch because women’s nipples and areolas are swollen from IV fluid.

He refuses to acknowledge the obvious: that breastfeeding, being a natural process, has an entirely natural failure rate.

Everything we know about human and animal reproduction teaches us that there’s an incredible amount of wastage and death associated with creating the next generation — from miscarriages, to pregnancy complications, to prematurity and infant anomalies. The historical reality of cemeteries filled with the bodies of babies and mothers who died in childbirth or shortly thereafter is testament to the fact that pregnancy, childbirth and breastfeeding are not perfect and that high rates of death are entirely compatible with robust population growth.

There is simply no question that babies are being injured and killed by overzealous breastfeeding promotion.

The evidence for iatrogenic injuries and death from breastfeeding promotion include:

• 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 papers showed that the premier effort to promote breastfeeding, the Baby Friendly Hospital Initiative doesn’t work, ignores the science on pacifiers, formula supplementation, and Sudden Infant Death Syndrome (SIDS) and leads to preventable infant injuries deaths when babies fall from or get smothered in their mothers’ hospital beds. These injuries and deaths did not happen until hospitals and providers began aggressively promoting exclusive breastfeeding.

We are also seeing babies injured or dying as a result of dehydration and starvation as a result of insufficient breastmilk (which occurs in up to 15% of first time mothers) and profound hypoglycemia (low blood sugar).

In the face of this scientifically documented reality, Dr. Newman offers a wall of denial.

What the baby needs [who has lost 10% body weight or more] is not automatic supplementation, but rather, first and foremost, the baby needs help getting a good latch. This requires good help from hospital staff and midwives, which may include reverse pressure softening of the nipples and areolas so that the baby does get a deep asymmetric latch and gets milk from the breast.

Unfortunately, in too many hospitals, the automatic first reaction is to give the baby a bottle of formula. And that definitely does not help improve the baby’s latch.

Why not give a baby a bottle of formula? Isn’t it more important to preserve the baby’s brain function than to preserve breastfeeding? The worst thing that will happen if you give a baby an unnecessary bottle of formula is — nothing! The worst thing that will happen if you fail to give a baby a needed bottle of formula is brain damage and death.

There’s something very ugly about promoting a process instead of an outcome. It is indisputable that a baby needs adequate nutrition. He or she cannot grow or thrive without it, and even a short term failure to receive adequate fluid and nutrition can result in permanent brain damage and death. A baby does NOT need breastfeeding; he or she can easily grow and thrive without it.

Lactivists like Dr. Newman have propagated the lie that insufficient breastmilk is merely an excuse for not breastfeeding, since every woman can make adequate milk if she just breastfeeds harder. This ugly edifice of denial is beginning to crumble under a large and growing body of scientific evidence demonstrating that aggressive promotion of breastfeeding leads to iatrogenic injuries and deaths.

Preventable infant injuries and deaths are a terrible indictment of the current system. The truth is that breast is not best for all babies. Lactivists’ insistence on promoting a process (breastfeeding) over outcomes (healthy babies) has led us to this point and we need a serious adjustment in the way we treat and counsel new mothers.

Instead of measuring breastfeeding rates (process), we should be measuring jaundice rates, dehydration rates, readmission rates, injury rates and death rates (all outcomes). We should recognize and acknowledge that hospital readmissions for jaundice and dehydration, as well as brain injuries and deaths are iatrogenic injuries. We are CAUSING them and therefore, it is up to us to PREVENT them, not to deny that they are happening.

The job of health care providers is to nurture babies, NOT to promote breastfeeding. The sooner that Dr. Newman and other lactivists recognize this, the sooner we can put an end to preventable iatrogenic injuries and deaths.

I might have wondered what Andrew Wakefield feels about sparking a measles epidemic among a vulnerable population in Minnesota, but I should have known that he would feel exactly like executives of Big Tobacco felts about lung cancer deaths.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s hardly surprising that Wakefield apes the actions of Big Tobacco executives in denying responsibility. The fundamental strategy of anti-vax advocacy comes straight from the Big Tobacco playbook.[/pullquote]

The young mother started getting advice … Don’t let your children get the vaccine for measles, mumps and rubella — it causes autism, they said.

Suaado Salah listened. And this spring, her 3-year-old boy and 18-month-old girl contracted measles in Minnesota’s largest outbreak of the highly infectious and potentially deadly disease in nearly three decades. Her daughter, who had a rash, high fever and cough, was hospitalized for four nights and needed intravenous fluids and oxygen.

How could such a thing happen? Even though her sister died from the disease in Somalia, the mother believed that her children couldn’t get the measles in the US.

“I thought: ‘I’m in America. I thought I’m in a safe place and my kids will never get sick in that disease,’ ” said Salah, 26, who has lived in Minnesota for more than a decade.

Anti-vaccine activists repeatedly brought Andrew Wakefield to speak to the community. You may remember Wakefield, now stripped of his medical license, because he published a paper in which he lied about a connection between the measles, mumps, rubella vaccine and autism. Why did he lie? Because he was preparing to market a different vaccine that he was going to claim was safer. Despite the fact that he has been repeatedly and thoroughly discredited, anti-vaxxers still believe him. Not all that surprisingly when you consider anti-vaxxers have a perfect record in their 200 years of existence; they’ve never been right about anything!

So how does Wakefield feel about the harm he has caused:

“The Somalis had decided themselves that they were particularly concerned,” Wakefield said last week. “I was responding to that.”

He maintained that he bears no fault for what is happening within the community. “I don’t feel responsible at all,” he said.

Hmmm, why does that sound familiar? Oh, I remember; that’s the defense that Big Tobacco used for years to disclaim responsibility for lung cancer deaths from cigarettes.

The technique of blaming the victim is outlined in the paper Tobacco Industry Use of Personal Responsibility Rhetoric in Public Relations and Litigation: Disguising Freedom to Blame as Freedom of Choice:

The tobacco industry’s use of explicit personal responsibility rhetoric reached its height in the 1980s, during a wave of consumer litigation in which the tobacco defendants countered injured smokers’ lawsuits with claims that ultimately the responsibility for the consequences of smoking cigarettes belonged to the smoker who voluntarily consumed them.

As a Philip Morris executive wrote in 1985:

It all comes down to the individual’s right to make up his own mind and to take responsibility for his own actions.

It’s hardly surprising that Wakefield apes the actions of Big Tobacco executives in denying responsibility. The fundamental strategy of anti-vax advocacy comes straight from the Big Tobacco playbook.

We have access to tobacco company files that detail marketing strategy, including a memo from the late 1960s that provides an overview:

Doubt is our product since it is the best means of competing with the “body of fact” that exists in the mind of the general public. It is also the means of establishing a controversy. Within the business we recognize that a controversy exists. However, with the general public the consensus is that cigarettes are in some way harmful to the health. If we are successful in establishing a controversy at the public level, then there is an opportunity to put across the real facts about smoking and health. (my emphasis)

The memo is startling for its insight. Simply put, tobacco companies did not have to refute the scientific evidence about smoking and cancer; merely creating doubt in the mind of the American consumer was all that was necessary to maintain or increase demand for cigarettes.

It’s the same strategy employed to equally deadly effect by Wakefield and the anti-vax movement.

Doubt is their primary product. They don’t have to refute the scientific evidence about the safety and efficacy of vaccines (nor could they). Merely creating doubt in the mind of the American parent is all that is necessary to promote vaccine hesitancy and refusal. If it’s good enough for tobacco executives in promoting their product, it’s good enough for anti-vaxxers in promoting theirs.

Indeed, the overall strategy of anti-vaxxers maps that of Tobacco industry to a remarkable degree, including:

1. Denying the validity of the overwhelming majority of scientific evidence on the dangers of cigarettes/vaccine refusal.

2. Cherry picking and promoting the tiny fraction of studies that disagree

3. Insisting that science can never provide 100% certainty

4. Claiming the issue is a matter of individual freedom

Anti-vax advocacy has added its own little fillips: framing doubt, the most important product, as a sign of intellectual independence (“doing your own research”) and framing defiance of authority as a good in and of itself.

Andrew Wakefield is no different from tobacco executives — selling a deadly product, denying the scientific evidence, promoting dangerous choices as “freedom,” blaming the victims by invoking personal responsibility — and equally despicable.