Melissa Cheyney is the Donald Trump of homebirth midwifery. Both think they can trick their followers and get away with it.

Trump has nothing on Cheyney and the Midwives Alliance of North America (MANA) when it comes to treating their followers with contempt. They appear to think that their followers are both stupid and gullible.

The only thing that is more amazing than their contempt is the fact that it is justified. It doesn’t matter how often Cheyney and MANA (or Trump) obfuscate, their followers slurp it up and then lick the floor looking for more.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]In a more than 3000 word piece ostensibly explaining the relative risks of homebirth, Melissa Cheyney refuses to tell women the actual risks.[/pullquote]

Last week I wrote Cheyney and MANA have finally acknowledged the hideous homebirth death rates that they’ve been hiding for years. The paper is Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States published in Birth: Issues in Perinatal Care, the journal owned by Lamaze International.

How hideous are they?

As you can see, in every category — with risks or without — homebirth increases the risk of fetal/neonatal death substantially and often enormously.

Even uncomplicated births to women who have given birth before are 3X more deadly than hospital birth; first births are 8.8X more deadly. It only gets worse from there, culminating in breech homebirths that are 56X more deadly than a planned C-section.

The REAL risks are almost certainly higher because these risks are based on a small subset of MANA members who voluntarily reported their outcomes.

So Cheyney and MANA have publicly acknowledged their hideous death rates, but — and this is the truly astounding part — they have so little respect for the intelligence of homebirth advocates that they think they can hide these death rates from them.

MANA has published Understanding Relative Risks In The Community Birth Setting: An Interview With Researcher Melissa Cheyney. There is not a single number in the piece. In a more than 3000 word piece ostensibly about the relative risks of homebirth, Melissa Cheyney refuses to tell women the actual risks.

Instead, she attempts to baffle them with bullshit.

Following the tactics of Trump, the piece starts with a brazen effort at misdirection:

Community birth (planned home and birth center births) has been demonstrated to be a safe option for low-risk women.

Yes, but NEVER in the US.

There has never been a single study — not even one — that has showed American homebirth to be as safe as comparable risk hospital birth.

According to Cheyney:

We started with the premise that given the larger literature on planned home and birth center births with trained midwives in high-resource countries, home birth clearly can be safe and for some outcomes safer than hospital births for a certain segment of the population. The Dutch, UK, and Canadian studies have clearly shown us this.

That sounds so familiar. It’s almost exactly what I wrote in my New York Times Op-Ed on homebirth Why is American Home Birth So Dangerous.

…[T]here are places in the world where home birth is relatively safe, like the Netherlands, where it is popular at 16 percent of births. And in Canada, where it appears safest of all, several studies have demonstrated that in carefully selected populations, there is no difference between the number of babies who die at home or in the hospital.

In contrast, home birth in the United States is dangerous…

According to Cheyney:

This caused us to question whether we were asking the right questions. Instead of asking, is home birth safe?, we argued that we should be asking, safe for whom?, under what circumstances?, and using whose definition of safe? This study was born out of a commitment to maternal autonomy and informed, shared decision making.

A commitment to informed decision making? How can American women be informed if Cheyney refuses to tell them the actual risks?

Instead:

I would group findings into three categories.

For example:

…[T]here is a third category, which was associated with much higher than anticipated fetal and neonatal mortality and morbidity: women presenting with a breech infant, multiparous women with a history of cesarean but no vaginal birth, and preeclampsia. The breech and preeclampsia findings were not surprising to us, but one of the outcomes we are really grappling with is the risk associated with a labor after cesarean in the community setting when there has been no previous vaginal birth. That is higher risk than we anticipated going into the study.

How much higher? Cheyney won’t say and then offers this:

The practitioner will always need to nuance these findings in their discussions with an individual family. Practitioners can begin by giving families a broad sense of the risk landscape. But then the conversation will have to narrow back in, not only to the mother’s individual risk profile, but also to her value system. It is her body, and until the baby is born, she has full autonomy in decision making. She will need to make choices about her care that fit with her worldview and her value system, because she is the one who will live in that body and raise that baby afterwards.

But how can she make an informed decision if she doesn’t know the actual risks?

My favorite quote, though, is this one:

…[W]hat studies like this do is they offer us the opportunity to be self-critical and reflective. They enable us to turn the lens inward and look at our practice as midwives and say, “Where do we need to improve?”

That’s hilarious — or it would be if American homebirth midwives weren’t presiding over so many deaths.

Cheyney’s study shows beyond any doubt that American homebirth midwives are grossly undereducated, undertrained and deadly. American homebirth is not safe and can never be safe until we abolish the second, inferior class of midwives known certified professional midwives (CPMs). We must mandate that — as in The Netherlands, the UK and Canada — no one should be allowed to call herself a midwife unless she meets the international standards of midwifery.

Only the stupid and the gullible could draw any other conclusion. So the only question that remains is whether American homebirth advocates are that stupid and that gullible.

I’ve written many times that I consider lactivism in general and the Baby Friendly Hospital Initiative to be unscientific, harmful and often unethical. Why? Because insisting that “breast is best” is no different than insisting that “heterosexual is best.” Both reflect prejudice, not science.

Although lactivists like to invoke “science” to support their claim that breast is best, their reasoning has much more in common with religion than science.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Both imply that a choice was made when there was never any choice at all.[/pullquote]

Consider:

1. Lactivists claim that women are “designed” to breastfeed. Science tells us that women aren’t “designed” at all; they are products of evolution. It is religion that insists on a designer and a design.

2. Lactivists claim that breastfeeding is nearly always perfect because it is natural. If science teaches us anything, it is that ‘natural’ is not a synonym for perfection. Hurricanes and earthquakes are entirely natural and generally quite harmful.

3. Lactivists claim that the fact that “we are still here” means that breastfeeding always works. That’s just a riff on the claim that breastfeeding is perfect, implying that our survival depends on perfection. Science teaches us that only the fittest survive, not everyone; and that survival is perfectly compatible with failure, imperfection and variation.

It’s easier to see the religious nature of these arguments when you realize that they are the exact same arguments that are often made to justify discrimation against gay people.

1. Homophobes insist that people are “designed” to have sexual relations with the opposite sex.

2. Homophobes insist that heterosexuality is best because it is natural.

3. Homophobes insist that heterosexuality is perfect because “we are still here,” implying that we wouldn’t be here if homosexuality were also natural. Science teaches us that population growth does not require that every individual have offspring.

Homophobia is rooted in a religious belief that homosexuality violates God’s “design.” Lactivism is rooted in the near religious belief that formula feeding violates nature’s “design.”

For many homophobes, their antipathy to gay people is rooted in the religious belief that sexuality is a choice. For many lactivists, their antipathy to women who don’t breastfeed is rooted in their belief that there are no women who are unable to breastfeed, only those who are unwilling. In other words, it’s a choice.

Many homophobes are advocates of gay conversion therapy, based on the idea that with enough “support,” gay people would become heterosexual. It is axiomatic for lactivists that women who can’t or don’t breastfeed are suffering from lack of support. According to their reasoning, if only women were only supported more, they would always be able to breastfeed.

Many homophobes blame contemporary culture for promoting homosexuality. Loose sexual morals, acceptance of difference, and the injunction against discriminating against gay people combine to make homosexuality an acceptable and therefore attractive choice. In the absence of a permissive culture, homosexuality would be non-existent. Nearly all lactivists blame contemporary culture for promoting formula feeding. In their view, acknowledging that insufficient breastmilk is common, pain is common, inconvenience is common combine to make formula feeding an attractive choice. In the absence of formula industry marketing, formula feeding would be non-existent.

It is easy to recognize the self-serving moralism of homophobes. It is harder to recognize the self-serving moralism of lactivists, but it is no less serious and harmful. The difference is that, through education, we have become sensitized to the ugly reasoning behind homophobia. Homophobia is inevitably about some people feeling superior to others.

Unfortunately, because of relentless efforts to promote breastfeeding as an unmitigated — and always perfect — good, we can’t always appreciate the ugly reasoning behind lactivism. It is inevitably about some mothers feeling superior to others.

Claiming that “breast is best” is like insisting that “heterosexual is best.” It implies that what is common must therefore be superior; it refuses to acknowledge individual variation; and most egregiously it invokes choice where there is often no choice.

Hopefully most of us recognize that claiming that “heterosexual is best” is nothing more than prejudice. It is love that makes a relationship, not corresponding sexual organs.

It’s time to recognize that “breast is best” also reflects prejudice. Motherhood is powered by love, not breastmilk.

After more than a decade blogging about natural childbirth, breastfeeding and anti-vaccine advocacy, I’ve become pretty inured to the vitriol directed my way.

I understand threatening the livelihoods of the birth industry and the breastfeeding industry isn’t going to win friends, and I appreciate that cognitive dissonance is hard for women who have staked their self-esteem on imagining that their adherence to the ideology of natural parenting marks them as superior mothers. I’m not blogging to make friends; I’m blogging to reassure women that mothering is about much more than the function of a woman’s reproductive organs.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Had I wanted to publicly make a fool of her, I couldn’t have done a better job than she just did herself.[/pullquote]

Every now and then, though, I am surprised by the vociferous response of a critic. That’s the case with Tara Haelle’s tantrum.

This is what Haelle posted on a Facebook page in response to my recent piece about MANA’s acknowledgement of their hideous death rates:

Oooh boy. Tuteur is not a credible source. She is a nasty woman whose tone actually DOES represent some aspect of her beliefs, even if it’s not as overstated as the tone comes across. Yes, she had a LOT of editing to get rid of the tone in her book, as she did in a NYT editorial. She’s a hateful, nasty woman with one of the worst cases of confirmation bias I’ve ever seen.

In short, she *is* against all home birth in the U.S., period. She looks askance at home birth in other countries, though she’ll deny that. She exploits women’s stories without permission and has illegally run an online medical advice service. The circumstances concerning her not having a license to practice anymore are uncertain and not necessarily nefarious, but she hasn’t had a license to practice in over 15 years and hasn’t practiced at all in over 25. She likely practiced for under 5 years and definitely under 10, and her belief in the evidence stalled when her practice did. She intentionally misreads certain studies and refuses to accept new data that comes out.

She believes that all doulas are suspect and that doula care does nothing to improve outcomes among women. She trusts very few midwives, regardless of where they work. She also believes that the C section rate is not too high (despite ALL evidence and expertise to contrary). She has personally attacked me and MANY MANY others, including my coauthor (in a particularly vicious way where she went after my coauthor’s kid) and Dr. Neel Shah, a Harvard OBGYN who teaches there and has been working assiduously to reduce C section rates safely.

Tuteur offers pretty much NOTHING to the discussion of home birth or birthing in general, she’s a nasty woman whose death I will not grieve, I have zero respect for her, and I have reduced respect for anyone who spreads her work after they learn who she really is and what she really does. And all of that is me with restraint.”

“And I’m almost certain all of that will get back to her because she has plenty of minions and flying monkey spies who look specifically for this kind of thing from me and others so they can screenshot it and send it to her, and I know this post is public. So this will be one more thing she gets to bitch about with me to her audience of sycophants. I don’t waste any more oxygen on her, which is why she’s blocked on all social media channels, as are several of her minions.

What precipitated this outburst of immaturity? As far as I can tell, it’s because I have publicly disagreed with Haelle on several issues and Haelle simply cannot abide that. She has a problem, and it’s one that afflicts all too many health journalists: she doesn’t have enough science knowledge to argue with me, so she’s reduced to ad hominem attacks.

Haelle is hardly alone in practicing health journalism by calling upon experts to interpret the scientific research for her. Most of the time that works quite well since often the science is settled. It doesn’t work at all for the subjects of childbirth and breastfeeding because there is a wide gulf between the science and the “conventional wisdom” espoused by the birth and breastfeeding industries.

Haelle offers the conventional wisdom in her writing and in the area of vaccines, for example, that is good enough. It’s basically useless, however, in addressing what I write about since the thrust of my writing is a paradigm shift: childbirth and breastfeeding, far from being perfect because they are natural, are inherently flawed precisely because they are natural.

Childbirth is inherently dangerous and any philosophical argument or public health campaign that doesn’t take that into account is likely to be deadly. Breastfeeding has a significant failure rate and any philosophical argument or public health campaign that doesn’t take that into account is likely to be deadly.

I also offer a philosophical argument of my own: most of what passes for natural childbirth and breastfeeding advocacy is deeply retrograde and fundamentally sexist. It’s a not so subtle way of reducing women to their reproductive organs and relegating them back to the home. It’s not a coincidence that natural parenting always represents more work for mothers.

Haelle is miffed because I have publicly disagreed with her and rebutted some of her empirical claims. She’s frustrated because she doesn’t know enough science to argue with me and is reduced to name dropping (e.g. Neel Shah who is apparently still smarting because he wrote an opinion piece about homebirth in the New England Journal of Medicine and I pointed out that he had no idea that there were two different types of midwives in the US).

It’s ironic that Haelle produced this wall of text in response to my piece about the latest MANA data. It makes her criticism look particularly foolish because it lacks substance of any kind. Haelle doesn’t bother to address the data in the my piece. I doubt she even read the piece before she commented.

In the few public arguments I’ve had with her, she hasn’t rebutted a single statistic that I’ve presented. Generally, she has stalked off when I rebutted her claims with empirical evidence.

She thoroughly misrepresents my positions such as my views on the C-section rate. I have repeatedly stated that the C-section rate is almost certainly too high, with the important caveat that while we know that many C-sections are unnecessary, we don’t know which specific C-sections are unnecessary in advance.

She wouldn’t grieve my death? That’s the statement of a petulant child, not an adult, and certainly not an adult who claims to be practicing journalism.

Grow up, Tara. Stop obsessing about your feelings and start addressing facts. If you can’t stand when it is pointed out that you are wrong, do more research and make sure you’re right. And thanks — had I wanted to publicly make a fool of you, I couldn’t have done a better job than you just did yourself.

This is a guest post from Cath Janes, the author of Birth Muthas, published in Standard Issue Magazine in response to Milli Hill’s gaslighting extravaganza The myth of the painful birth – and why it’s not nearly so bad as women believe.

Janes was shocked when Hill demanded that Standard Issue Magazine offer her the right of reply and even more shocked when the magazine gave in. Here is her response.

I’d been in blissful ignorance of Milli Hill until ten days ago, when I saw that she had written in The Telegraph about how “In an average eight hour labour, a woman can expect to be ‘in pain’ for only around 23 per cent of the time”. So when I was asked, by online mag Standard Issue, to respond in my usual truthful voice, I happily did. That was when Milli Hill made sure I would never be unaware of her again.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]”In all of my years as a journalist and editor for national magazines and broadsheets I had never heard of this happening before.”[/pullquote]

Well, Hill certainly wasn’t thinking positively on the day my piece was published. Very publicly, on Twitter, she began calling me unprofessional, claiming I had misrepresented her, demanding the piece be pulled and asking why I hadn’t given her the right of reply when I wrote it. It was stunning, not least because in all of my years as a journalist and editor for national magazines and broadsheets I had never heard of this happening before. An inherent right of reply to an opinion piece? The only upside was the dozens of messages I received from editors and journalists, all equally as stunned as I.

Standard Issue pulled my piece off its website upon Hill’s request, giving her 24 hours to write a right of reply which would be published alongside mine when it went back up. Except there was one difference; what was very obviously an analogy about injured troops had been removed at Hill’s demand and THAT is what you can read in my full piece here. I stand by that analogy with every fibre of my childbirth-broken soul. That’s because it was, I repeat, analogous and in no way descriptive. I don’t think I could state that any more clearly than I did in the piece and I do here now.

That Standard Issue decided to accede to Hill after the requested piece was published is one thing. As furious as I am about it, and as much as I have never heard of this happening before, I understand that Standard Issue has to operate in the way it feels is best for itself. We have parted ways because I no longer want to write for it and I now know of several other women who don’t want to write for it any more too.

What is quite another thing are Hill’s actions. For all of her claims that I had misrepresented her, her reply to my Standard Issue piece was hardly worth the wait. In fact it caused substantial hilarity amongst the many women who were following this debacle and I know that because they contacted me in support.
I’ve always been searingly honest about my experience of childbirth and the resulting PND, PTSD and career-ending breakdown. You can read in my piece about how the lack of honesty about what really happens during birth contributed significantly to this. I too believed I would get through my otherwise average labour with brilliant support and positivity and, more to the point, so did the hundreds of women who have since contacted me via social media and parenting forums. For balance, though, two women have told me that they feel there may be something in Hill’s theory even though they believe it to be flawed.

I’m a feminist who believes that women should always be empowered but only if that is underpinned with honesty. That is why I disagree so vehemently with Hill. I believe that to tell women that they are not feeling any pain at all for 77% of an average birth is to mislead them. Yes, the maths may be correct (for Hill has done the maths) but in terms of the emotions of panic, exhaustion, worry, fear and shock and the physical reactions of vomiting, breathlessness, tearing, cutting, bleeding and defecating it is not. Maths should never explain away the deeply personal process of giving birth and it should never be used to lull women into a false sense of security.

I’m not alone in feeling Hill’s ire or seeing her attempt to explain herself. She asked the Telegraph to change the headline that accompanied her original piece and has now told me that she didn’t expect Standard Issue to publish what she had written for them either. It’s good to know that I’m not alone. What isn’t good is that through her misguided, repeated and defamatory insistence that I have been unprofessional I have had to block her from my social media and private email accounts and am now considering legal action. The fact is that Hill and I will never agree on this issue and, in the belief that debate is good, I am fine with that. Whether she is good with her critics’ opinions being expressed is another thing. I’ll let you know after this too has been published.

I told you so!

I’ve been writing about homebirth for more than a decade. For most of that time, the Midwives Alliance of North America (MANA) and Melissa Cheyney, the Director of Research for MANA have insisted that their data show that homebirth is safe.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]In every category — with risks or without — homebirth increases the risk of fetal/neonatal death substantially and often enormously.[/pullquote]

In the meantime, the publicly available data on CDC Wonder has made it possible for me to demonstrate that homebirth deaths rates have been 3-7X higher than comparable risk hospital birth. Amos Grunebaum, MD and colleagues have published several papers using the same data and confirming my analysis. The most comprehensive analysis of homebirth death rates was performed by Judith Rooks, CNM MPH for the state of Oregon. Rooks found that homebirth midwives had a perinatal death rate 800% higher than comparable risk hospital birth!

Now, MANA and Cheyney have finally relented and published their own data that shows that PLANNED birth at home or in a birth center (generally just a rented home without special equipment) in the US has death rates EVEN WORSE than we imagined.

The new paper is Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States to be published in Birth: Issues in Perinatal Care, the journal owned by Lamaze International.

The authors used the data generated by their own members:

Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gesta- tional diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, his- tory of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education.

Ostensibly, the authors were attempting to determine appropriate criteria for allowing or risking out homebirths and birth center births.

They found:

The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6).

The author’s definition of “modest” are quite different than mine. They found that for almost all outcomes, homebirth had a nearly 100% increase in fetal/neonatal death. Breech babies had a death rate 700% higher and attempted VBAC had a death rate more than 900% higher than that baseline death rate at homebirth (which is already higher than the hospital death rate).

Two charts provide the most important information.

The first shows absolute death rates:

The death rate for first babies was 3.43/1000 and the death rate for second or subsequent babies was 1.03/1000. Compare that to CDC data that shows a hospital death rate of 0.36/1000 overall and 0.44 for first babies. In other words, homebirth had a neonatal death rate more than triple (200% increase) that of hospital birth for women having second or subsequent babies and 780% higher for first time mothers.

The second chart shows the increased risks of various pregnancy complications compared to the already elevated risk of homebirth demonstrated above:

For example, attempted VBAC increases the risk by more than 10 fold. Twins increases the risk more than 3 fold. Breech increases the risk more than 8 fold. Postdates nearly triples the risk. Pre-eclampsia increases the risk more than 10 fold.

In every category — with risks or without — homebirth increases the risk of fetal/neonatal death substantially and often enormously.

What conclusions do Cheyney and colleagues reach?

The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

In other words, they attempt to minimize their own findings, despite the fact that they are uniformly terrible and often hideous. And these findings almost certainly UNDERESTIMATE the true death rate at homebirth in two critical ways: first, they compare complicated homebirths with uncomplicated homebirths, undercutting the impact of the fact that even uncomplicated homebirths have higher death rates than comparable risk hospital birth; second, this data is only a subset homebirths attended by members, voluntarily submitted by those members. The real death rates at homebirth are almost certainly even higher.

The bottom line is this: after years of denying that homebirth has a dramatically increased risk of fetal/neonatal death, Melissa Cheyney and MANA have finally admitted the truth. There is not a single category in which homebirth is a safe as hospital birth and in many cases, homebirth increases the risk of fetal/neonatal death by nearly 1000%!

Every American woman has a right to have a homebirth because she has the right to control her own body. But homebirth advocates should stop pretending that homebirth is safe. It is never as safe as hospital birth and generally far more deadly.

I’ve written before about the tribalism of natural parenting advocates.

According to sociologist Jan Macvarish:

The idea of ‘parental tribalism’ … [is] descriptive of a tendency among individuals to form their identities through the way they parent, or perhaps more precisely, through differentiating themselves from the way some parents parent and identifying with others …

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]For lactivists and natural childbirth advocates the only thing that matters is whether a scientific paper supports their “side.”[/pullquote]

And I’ve written about the parallels between Trumpworld and the world of lactivism and natural childbirth. Both rest on a foundation of ignorance and lies.

But rarely have I read such an apt description of the “tribal epistemology” of lactivism and natural childbirth:

Information is evaluated based not on conformity to common standards of evidence or correspondence to a common understanding of the world, but on whether it supports the tribe’s values and goals and is vouchsafed by tribal leaders. “Good for our side” and “true” begin to blur into one.

The author, David Roberts of Vox, is referring to right wing talk radio aficionados but it applies equally to the world of natural parenting.

Most lactivists and natural childbirth advocates have no idea how to read a scientific paper, what constitutes scientific evidence or how to analyze statistics. As a result, they are forced to rely on leaders to spoon feed them the information that supports the tribe’s values and goals. Lactivists have no idea what the scientific evidence shows about breastfeeding; they only know what people like Melissa Bartick tell them. They have no idea what the scientific evidence shows about childbirth until Henci Goer or someone similar “interprets” it for them.

Sadly for both the thought leaders and acolytes the only thing that matters is whether a scientific paper supports their “side.” Everything else is ignored.

Listen to Rush Limbaugh’s assessment of the worldview of conservatives and liberals:

We live in two universes. One universe is a lie. One universe is an entire lie. Everything run, dominated, and controlled by the left here and around the world is a lie. The other universe is where we are, and that’s where reality reigns supreme and we deal with it. And seldom do these two universes ever overlap.

As Roberts explains:

In Limbaugh’s view, the core institutions and norms of American democracy have been irredeemably corrupted by an alien enemy. Their claims to transpartisan authority — authority that applies equally to all political factions and parties — are fraudulent. There are no transpartisan authorities; there is only zero-sum competition between tribes, the left and right. Two universes.

In the view of lactivists, the core institutions of medicine and science have been irredeemably corrupted by the formula industry. Their claims to authority — through rational thought and scientific evidence — are deemed fraudulent. There is no unbiased scientific evidence, there is only a zero-sum competition between breastfeeding supporters and the formula industry.

In the view of natural childbirth advocates, the core institutions of obstetrics and medicine have been irredeemably corrupted by the institutions and practices of “technocratic” birth. Their claims to authority — through rational thought and scientific evidence are deemed fraudulent. There is no unbiased scientific evidence, only a zero-sum competition between midwives and doulas on the one hand and obstetricians on the other.

Extrapolating from Robert’s views of tribal epistemology in politics, we can assert that on one side is what we might call the classic theory of science as a search for knowledge. In this view, science is a kind of structured contest. Factions and parties battle over scientific evidence, implications and policies, but the field of play on which they battle is ring-fenced by a set of common institutions and norms like journals and conferences, both open to all.

In contrast, lactivists and natural childbirth advocates insist that science itself, its rules and referees, are captured by the other side (the formula industry, the hospital birth industry), operating for the other side’s benefit. Any claim of scientific authority is viewed with skepticism, as a kind of ruse or tool through which industry and medicine seek to dominate lactivists and natural childbirth advocates.

As a result, both the lactivist world and the natural childbirth world operate as the equivalent of right wing talk radio. They are filled with ignorance, misrepresentation of both scientific evidence and physicians, and bitterness. Rather than trying to compete with physicians, scientists and industries through journals and conferences, lactivists and natural childbirth advocates have withdrawn into a world of their own, complete with their own conferences and journals from which mainstream scientists and physicians are excluded.

Ironically, lactivists and natural childbirth advocates love to assert that they have educated themselves about breastfeeding and childbirth, but they are no more educated about either than Fox News viewers are educated about politics. Neither has anything to do with increasing knowledge; both are concerned above all with promoting tribalism.

Where does that leave us? It leaves us with a medical system that could benefit from the interests and concerns of lactivists and natural childbirth advocates at precisely the moment when, sadly, lactivists and natural childbirth advocates have become divorced from both scientific evidence and reality.

Sometimes I wonder if lactivists think what they say before they say it.

Consider this tweet from Dr. Alison Stuebe of the Academy of Breastfeeding Medicine.

Parallels between big tobacco tactics and big formula tactics – look how doubt it being peddled to mother

That tweet is offensive on so many levels that it is difficult to know where to begin.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]I hereby invite Dr. Stuebe to debate me.[/pullquote]

1. The comparison of formula to tobacco is grossly irresponsible. Whereas tobacco is always dangerous and never saves lives, formula is almost never dangerous and saves tens of thousands of babies’ lives each and every year.

2. It is meant to be vicious. The tweet not so subtly implies that women who choose to formula feed are knowingly and willfully harming their babies.

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

4. It is an attempt to libel the Fed Is Best Foundation. The implication is the Foundation — which is drawing attention to the very real and deadly risks of relentless breastfeeding promotion — is in the pocket of the formula industry. If Dr. Stuebe has evidence of this, she ought to present it. Otherwise, she ought to stop libeling the Foundation.

5. It is, ironically, projection. Perhaps Dr. Stuebe is not aware that in the wake of the Surgeon General’s report declaring that tobacco smoking causes lung cancer, the tobacco industry tried to deny and induce doubt about the scientific evidence. Now, in the wake of mounting scientific evidence that relentless promotion of breastfeeding is leading to infant injury and death, it is the breastfeeding industry that is trying to deny and induce doubt about the scientific evidence.

How can we address the attempts of the breastfeeding industry to demean women who can’t or don’t wish to formula feed?

I have a suggestion:

I hereby invite Dr. Stuebe to debate me on the issue of the risks of breastfeeding.

We can conduct an debate in print simultaneously on my blog and the Academy of Breastfeeding Medicine blog so that everyone can be sure that both sides are accurately transmitting the views of the other.

I propose that we address three issues:

• The risks of breastfeeding, complete with actual incidence figures.
• The moral agency of women who can’t or don’t breastfeed and their right to be respected.
• Accusations of collusion between those highlighting the dangers of breastfeeding and the formula industry.

How about it, Dr. Stuebe? Surely you can step outside the lactivist echo chamber to engage briefly with those you criticize.

Is it ethical to lie to patients when you are doing it in their best interests?

I suspect most of us would answer ‘no.’ Lying to patients deprives them of moral agency, impairs their ability to give informed consent and is shockingly paternalistic. The liar imagines that he or she knows better than the patient herself. The liar may even be correct in this assumption, but lying to patients is unethical nonetheless.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivist dishonesty is deadly not just because lactation professionals lie to patients, but because they lie to each other.[/pullquote]

Curiously, both natural childbirth advocates and lactivists, who would be rightly appalled if a doctor lied to them about the risks of childbirth interventions or the benefits of breastfeeding, have no problem lying to women to promote their own ends. Indeed, efforts to promote both natural childbirth and breastfeeding rest on the assumption that telling women the truth will scare women away from doing what is best for them.

Of course activists don’t call it lying. They drape their falsehoods in finery, calling their efforts ‘The Positive Birth Movement’ and ‘Trust Birth’ or the ‘Baby Friendly Hospital Initiative’ and ‘Breast Is Best.’ These sound lovely, but they are lies and paternalism nonetheless.

Consider Milli Hill’s justification for lying to women about the excruciating pain of childbirth.

Most pregnant women are very scared of labour. But by putting all the focus on how painful it is, are we failing to give them the full picture? And in doing so, could we actually be making labour worse – in some sense, setting them up to fail?

Fail? If the baby that’s inside her uterus ends up in her arms alive and healthy, she’s succeeded. When Milli Hill talks about failing at labor she means failing at the conceit of a specific performance of labor — vaginal birth without pain relief or other interventions.

The full picture? What does that even mean in the context of pain? When we tell women that cosmetic surgery involves pain are we depriving them of the ‘full picture’ of face lifts? Or are we giving them what we are ethically required to give them: the truth without which they cannot give informed consent.

The lying and paternalism in lactivism are even worse. Under the guise of promoting what is best for babies, lactation consultants and their organizations aren’t merely lying to women, they are letting babies die. Their motto appears to be ‘Better Dead than Formula Fed.’

Many of the tenets of the Baby Friendly Hospital Initiative are lies. Pacifiers not only don’t interfere with breastfeeding, they prevent SIDS. Judicious formula supplementation not only doesn’t reduce the likelihood of breastfeeding success, it actually increases it. Locking up formula in hospitals doesn’t improve breastfeeding rates, but it does increase the psychological distress of women who can’t or don’t wish to breastfeed.

Lactivist dishonesty is particularly deadly not simply because lactation professionals lie to patients, but because they lie to each other. Lactation consultants are ostensibly medical providers and like all medical providers, they are responsible for preventing, diagnosing and managing medical problems.

There’s an aphorism about diagnosis that has relevance for all providers: ‘what is rare is rare and what is common is common.’

That’s what’s known as a heuristic:

…any approach to problem solving, learning, or discovery that employs a practical method not guaranteed to be optimal or perfect, but sufficient for the immediate goals.

Heuristics are short cuts to diagnoses. Brain tumors are rare; tension headaches are common. When a patient complains of a headache, it’s much more like to be a simple tension headache, not a brain tumor. Sure some people with headaches will have brain tumors, but that represents only a tiny percentage of people with headaches. That’s why most people who have headaches can be reassured and sent away.

In contrast when someone starts coughing up blood, odds are high that something is wrong with their lungs and they should not be simply reassured and dismissed. Doing so can easily result in missing a deadly pneumonia or a deadly lung cancer.

Imagine then if we erroneously taught providers that pneumonia and lung cancer are vanishingly rare and that patients who cough blood from their lungs should be sent home and told to call if they’re still coughing blood a few days later. Many cases of pneumonia and other serious lung ailments would undoubtedly be missed at the moment when they are easiest to treat. Providers would be falsely reassuring patients with deadly conditions because the providers themselves have no idea just how common those conditions are.

That’s precisely what is going on with lactation professionals at this moment. Because they are taught that insufficient breastmilk is rare when in fact it is quite common (affecting up to 15% of women or more), they are falsely reassuring the mothers of critically ill newborns that their babies are fine when, in truth, they are actually dying of jaundice, dehydration, starvation or all three.

Babies are dying because lactivists are lying. And lactivists are lying because they believe that telling women the truth about the risks of breastfeeding as well as the benefits may lead them to ‘fail’ at breastfeeding. But the goal of providers should never be promoting a specific process; that’s unethical. The goal should always be promoting the wellbeing of patients regardless of how that outcome is achieved.

Lying is never justified, whether it is lying about the pain of labor or the risks of breastfeeding.

Natural childbirth isn’t best. Breast isn’t best.

Honesty is best.

What natural childbirth advocates like Milli Hill don’t know about the neurophysiology of pain could fill a book — or several.

Hill recently wrote The myth of the painful birth – and why it’s not nearly so bad as women believe. It is a typical paean to ignorance and disrespect — implying that childbirth pain is culturally conditioned and due to lack of support.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Milli Hill and her natural childbirth colleagues don’t know much about history. They don’t know much biology, either.[/perfectpullquote]

At the moment, we simply do not know what birth would be like for women if they were given more positive messages and went into labour feeling strong, confident and capable. We simply don’t know what it would be like if all women were given one-to-one support from a midwife they really trusted, or if we created birth rooms, even in hospitals, that were dimly lit, homely and uninterrupted.

Since the beginning of time women have described childbirth as agonizing because they always gave birth in hospitals with bright lighting and unsympathetic male physicians. Oh, wait! Up until very recently all women gave birth in dimly lit, homely surroundings complete with one-to-one support from a midwife.

Obviously Milli Hill and her natural childbirth colleagues don’t know much about history. They don’t know much biology, either.

When it comes to sport, we all seem to understand just how much negative thoughts can affect your performance both physically and mentally. We know how powerful a confident attitude can be. Perhaps it’s time to consider that with birth, things are no different.

Wrong! The neurophysiology of sports pain is very different from the neurophysiology of childbirth pain.

Let’s start with the most basic difference. Most sports pain is somatic pain whereas labor pain is visceral pain. The distinction is critical.

According to Wikipedia, somatic pain can be deep or superficial:

Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Examples include sprains and broken bones. Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first degree) burns.

The pain of crowning, when the baby’s head stretches the vagina, is somatic pain, but the pain of uterine contractions is visceral pain:

Visceral structures are highly sensitive to stretch, ischemia and inflammation, but relatively insensitive to other stimuli that normally evoke pain in other structures, such as burning and cutting. Visceral pain is diffuse, difficult to locate and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull.

The neurophysiology of the visceral pain of uterine contractions is very different than that of somatic pain. Most importantly, visceral pain activates the autonomic nervous system, the nerves which control the automatic functions of the body like heart rate and blood pressure. In other words, visceral pain — unlike somatic pain — has a variety of effects that go beyond the conscious sensation of pain. These include elevated heart rate, elevated blood pressure, nausea and vomiting, and profuse sweating. Visceral pain — whether it originates in the heart, the gall bladder, or the uterus — is often perceived as “sickening.”

In her piece, Hill claims:

…[E]ven in ‘the nightmare labour from hell’ – 36 hours of contractions coming thick and fast – she can still expect to be without pain for around 60 per cent of the time.

That statement might be true if we were talking about the limited nature of somatic pain. If you poked someone with a pin for 20 seconds out of each minute they would feel fine for the 40 seconds that you aren’t poking them. But it’s definitely not true for visceral pain like uterine contractions. Even when the pain recedes the elevated heart rate and blood pressure as well as the nausea, vomiting, sweating and overall sickening sensation often do not recede completely before the next contraction begins. So women in labor do not spend most of the time feeling well except for intervals of pain. They spend most of the time feeling awful.

That has important implications for the philosophy of natural childbirth. The pain of uterine contractions is very different from the pain of athletic endeavor. The idea that the pain of labor is socially conditioned is nonsense; we can identify the receptors and trace the pain pathways. Most importantly, the pain of uterine contractions triggers a cascade of neurological responses that are not under conscious control.

No amount of support in labor is going to prevent women from having a profound physical response to uterine contractions that goes far beyond the sensation of pain itself. In contrast, an epidural, which blocks the neural pathway by which uterine pain reaches the brain does more than merely eliminate the pain. It also eliminates the autonomic nervous system response. When the pain goes away, the nausea, sweating and sickening feeling usually go with it.

The bottom line is that natural childbirth advocates promote a philosophy based on wholesale ignorance of neurophysiology. Childbirth pain doesn’t come from lack of support or lack of confidence. It comes from pain receptors, neural pathways, and the activation of the autonomic nervous system. Telling women about the excruciating pain doesn’t set them up to fail as Hill would have us believe. It’s simply telling them the truth.

The title of her piece is the first giveaway, The myth of the painful birth – and why it’s not nearly so bad as women believe.

You might have thought that the hours you spent in labor were agonizing, but Milli Hill knows better.

Most pregnant women are very scared of labour. But by putting all the focus on how painful it is, are we failing to give them the full picture? And in doing so, could we actually be making labour worse – in some sense, setting them up to fail?

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Denying the reality of women’s experience of agony and trauma in labor is a form of psychological abuse.[/perfectpullquote]

Milli’s done the math:

… In an average eight hour labour, a woman can expect to be ‘in pain’ for only around 23 per cent of the time. The other 77 per cent is ‘pain free’.

Is this woman an idiot? Would she tell a man that passing a kidney stone isn’t painful because only around 23% of the time is spent writhing in agony and vomiting. The rest of the time is “pain free!” I doubt it.

No, Milli is not an idiot. Like many people who make their money promoting the philosophy of natural childbirth, she’s a psychological abuser. Her abuse technique of choice is known as gaslighting.

According to Wikipedia:

Gaslighting … is a form of psychological abuse in which a victim is manipulated into doubting their own memory, perception, and sanity. Instances [include] the denial by an abuser that previous abusive incidents ever occurred …

The term comes from the play Gas Light:

…The plot concerns a husband who attempts to convince his wife and others that she is insane by manipulating small elements of their environment, and subsequently insisting that she is mistaken, remembering things incorrectly, or delusional when she points out these changes.

As practiced by Milli Hill and her colleagues, gaslighting means responding to stories of agony, desperation and trauma by denying the reality that most women experience.

Classic gaslighting phrases include:

That never happened!

You’re overreacting!

It’s all in your head!

You’re so sensitive!

Think your pain was excruciating? You’re overreacting!

And even in ‘the nightmare labour from hell’ – 36 hours of contractions coming thick and fast – she can still expect to be without pain for around 60 per cent of the time.

Still traumatized by 36 hours of agony? It’s all in your head!

When it comes to sport, we all seem to understand just how much negative thoughts can affect your performance both physically and mentally. We know how powerful a confident attitude can be. Perhaps it’s time to consider that with birth, things are no different.

Performance? Childbirth is not a performance anymore than passing a kidney stone is a performance. How powerful is a confident attitude in treating the pain of a kidney stone or a migraine or a broken leg? It has no effect at all. Why then would it have any effect on labor pain?

Look back on your labor as endless hours of intense suffering? That’s not what happened!

The importance of words is also emphasised by childbirth expert Penny Simkin, who stresses the vital distinction between ‘pain’ and ‘suffering’.

“Many women ‘suffer’ in childbirth, and it’s because they’re not respected, or kindly treated, they don’t have the tools to cope, or they feel unloved, or alone. If a woman crosses the line from ‘pain’ into ‘suffering’ in childbirth, we’ve failed her.”

Unloved? Unloved??!! These women are peddling pure bullshit.

At the moment, we simply do not know what birth would be like for women if they were given more positive messages and went into labour feeling strong, confident and capable. We simply don’t know what it would be like if all women were given one-to-one support from a midwife they really trusted, or if we created birth rooms, even in hospitals, that were dimly lit, homely and uninterrupted.

Does Milli Hill ever listen to herself? We simply don’t know? What about what millions upon millions of women have told us since oral tradition and written language came into being? What about the fact that the people who wrote the Bible were so impressed by the agony of childbirth that they concluded it could only be explained as a punishment from God? What about the childbirth prayers from the Middle Ages and women’s own accounts from colonial times to the present?

According to Milli Hill and her colleagues: They were overreacting. It was all in their heads. It never even happened.

Milli Hill makes her money by gaslighting women, denying the reality of their experiences of excruciating pain and trauma. And that’s psychological abuse.