Who gets to decide what’s “best” for babies?


Pregnancy and paternalism go together like peanut butter and jelly, like milk and cookies, like salt and pepper. Where you find one, you almost always find the other.

What is paternalism? It’s the practice of people in positions of authority determining the freedom and responsibilities of others in the others’ supposed best interest. It’s the belief that those in authority know better than mothers themselves what’s best for babies.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Mothers — not doctors, not professional organizations, not activists — get to decide what’s best for their babies.[/pullquote]

Consider the ACOG policy toward alcohol that I wrote about yesterday. According to ACOG president Dr. Howard Brown, since we don’t know the safest upper level for alcohol consumption in pregnancy:

Why tempt harm when all risk can be avoided?

Dr. Brown is clearly incredulous than anyone could even think about accepting a risk in pregnancy, even a theoretical risk. He apparently subscribes to the contemporary view that constant sacrifice is the definitive feature of good mothering.

As sociologist Pam Lowe explains in Reproductive Health and Maternal Sacrifice:

…At its heart, maternal sacrifice is the notion that ‘proper’ women put the welfare of children, whether born, in utero, or not yet conceived, over and above any choices and/or desires of their own. The idea of maternal sacrifice acts as a powerful signifier in judging women’s behaviour. It is valorized in cases such as when women with cancer forgo treatment to save a risk to their developing foetus, and it is believed absent in female substance users whose ‘selfish’ desire for children means they are born in problematic circumstances…

I suspect that Dr. Brown might bristle at the notion that his paternalistic beliefs reflect an assumption that maternal sacrifice is the heart of motherhood. I imagine that he would claim, as he tried to do in his Letter to the Editor, that his admonition is not his personal opinion; it is merely what the science shows. Scientific consensus (therefore doctors) is purportedly the arbiter of what is best for babies. Mothers cannot be trusted to decide what’s best for their babies and themselves when it comes to the risks of alcohol in pregnancy. That’s paternalism.

That’s certainly the justification of The Baby Friendly Hospital Initiative and other lactivists organizations. Lactivists might not even balk at the idea that sacrifice is essential to good mothering. That’s why they turn a deaf ear to mothers’ claims of pain, frustration and inconvenience at breastfeeding.

As Michelle, a commentor on the Skeptical OB Facebook page, eloquently put it:


I care enough to give my kid something that IS natural, than be a selfish heifer and give them something that is meant for a calf. Breastfeeding takes time and you have to sacrifice.

The BFHI and other lactivist organizations are more temperate in their language, but the sentiment behind their mantra “Breast Is Best” is exactly the same. The assumption is that every mother can and should sacrifice to give her child the “best” regardless of the trivial nature of the benefits and regardless of the personal cost to mothers. When confronted they respond, like Dr. Brown implied, that it isn’t personal opinion, it’s what the science shows. In other words, scientific consensus (therefore lactation consultants) is the arbiter of what is best for babies. Mothers can’t be trusted to decide what is best for their babies and themselves when it comes to infant feeding. That’s paternalism, too.

Curiously, natural childbirth, breastfeeding and attachment parenting advocates, who thrill to invoking science as the arbiter in the case of alcohol consumption in pregnancy and breastfeeding are thereafter, are generally horrified when anyone dares suggest that science (therefore doctors) ought to be the arbiter on what is best for babies when it comes to vaccination and homebirth.

The science on the benefits of vaccination is far stronger than the science on the risks of alcohol consumption in pregnancy and the theoretical risks of formula feeding. No matter. Vaccination has become an issue of personal freedom. Forget the scientific consensus! Every mother has to “educate” herself and do her own “research.” Indeed, for anti-vaxxers, explicitly rejecting the scientific consensus is viewed as empowering and a mark of intellectual independence. Only mothers can be trusted to decide what is best for their babies when it comes to vaccination. That’s a rejection of paternalism.

Similarly, homebirth in the US increases the risk of perinatal death. The best statistics we have thusfar, from the state of Oregon, show that homebirth with a non-nurse midwife increases the risk of death by 800%! Over the years, the Midwives Alliance of North America (MANA), the organization that represents homebirth midwives (CPMs, LMs), has been forced to ado it that their own statistic show that homebirth markedly increases the risk of perinatal death. Yet, they, too advocate rejecting the scientific consensus and focus instead on women’s autonomy and personal values.

Homebirth is an expression of a woman’s autonomy … A woman has the right and responsibility to choose the place and care provider for pregnancy, birth, and postpartum and to make decisions based on her knowledge, intuition, experiences, values, and beliefs.

Only mothers can be trusted to decide what’s best for their babies when it comes to place of birth. That, too, is a rejection of paternalism.

Ironically, most anti-vaxxers and homebirth advocates are hypocrites, invoking science when it suits them and ignoring it when it does not. Nevertheless, the issue they raise is crucial: who gets to decide what’s best for babies?

In my view, medical ethics with its emphasis on patient autonomy, requires that mothers — not doctors, not professional organizations, not activists — get to decide what’s best for their babies. Hopefully those mothers will have accurate medical information at hand, but we cannot and should not force people to make decisions that those with accurate medical information prefer. That’s paternalism. The only exception is vaccination since that affects the health of others. The government may therefore choose to make vaccination a prerequisite for attendance at schools and childcare facilities.

That means that women can and should be free to make bad decisions; it is their right. Why? First, science is not always correct in its conclusions. Second, individuals have different values from each other and it is those values that they call upon to determine which risks are acceptable and which are not. As a general matter, people deciding for themselves (autonomy) make better decisions than authorities deciding for them (paternalism).

Women may elect to drink alcohol during pregnancy or they may elect to have a homebirth. That doesn’t mean that either is a good idea; it might be a very bad idea but as long as they are apprised of the risks, it is their choice. Of course they are also responsible for the consequences. The right to make a bad choice doesn’t mean that the rest of us have to approve of it. Very few people are going to applaud a woman’s decision to handicap her child with fetal alcohol syndrome just because she has the right to drink during pregnancy. Similarly very few people are going to applaud a woman’s decision to have a homebirth if it kills her baby.

To the extent that authorities choose to insert themselves in the promotion of one health choice over another, it is entirely appropriate for government to mandate vaccination in order to protect everyone. It is not appropriate for health authorities to mandate breastfeeding through programs like the BFHI since a woman’s decision to breastfeed or formula feed her baby affects no one outside of her family.

Women are people — not incubators, not breastmilk dispensers, not individuals whose only purpose in life is to sacrifice their needs for the theoretical needs of their children. Although “why tempt harm when all risk can be avoided?” might be my personal philosophy when it comes to pregnancy and birth, we cannot and should not mandate that it be everyone’s philosophy. That would be paternalism and that would be wrong.