Doublethink in health care

A four-month-old exclusively breastfed baby in the 99th percentile for its weight and height was refused health insurance because it has “obesity” as a preexisting condition.

*Shakes head in disbelief*

This story in the Denver Post is a perfect example of the sort of Orwellian doublethink that must exist for people to oppose health care reform because it will add a layer of evil government bureaucracy into medical decision making.

Here’s a great quote from the article:

Health insurance reform measures are trying to do away with such denials that come from a process called “underwriting.”

“If health care reform occurs, underwriting will go away. We do it because everybody else in the industry does it,” said Dr. Doug Speedie, medical director at Rocky Mountain Health Plans, the company that turned down Alex.

This kind of um, logic, for lack of a better term, is what these newly enraged self styled radical libertarians are advocating as a superior framework for guiding medical coverage than the government?

(A tip o’ the chapeau to Hoyden About Town)

Edited to add:

Here is a picture of Z when he was about that age:

I am sure he was in the 99th percentile, if I cared to measure it. Oh, yeah, and he has always been accident prone, like his mommy.

Reply turned post, guilt and pain style

This is a reply to a post on the post Builds Character at A Little Pregnant. Hers is one of many responses to an article by a male midwife about the benefits of unmedicated labor.

OK, birth researcher here. Please excuse the scientific language to follow.

I think this is a difficult topic, but there are some tools to measure bonding or attachment. It is not impossible to discuss parental bonding as an advantage to an intervention (or lack of an intervention). It is actually a subject I am interested in possibly researching. We could argue the merits or accuracy of such measurements, but that is a different topic. Such tools exist. So do tools on other “mushy” sociological and behavioral outcomes.

Is there a possible negative group impact to the discussion of parental bonding due to method of delivery,or presence of a doula, or breastfeeding (or going back to work or having a TV on etc. and ad nauseum)?

Absolutely. Saying that one method of delivery or related variable influence something with social desirability, like parental bonding, can make people who did not receive that intervention or have that method of delivery feel a sense of guilt or even a sense of societal shame.

(Can you tell I have been reading the Belmont Report?)

Keep in mind we are talking about risk here, not causality. If I do research, hypothetically, following mothers who participated in a recent program that provided doulas for women of low socioeconomic status and tracking parental attachment, am I acting unethically? First of all, if I identify women of low socioeconomic status as being less attached i.e. “worse parents” (not my judgment, but the implied judgment there), and then if my research shows a significant difference between the attachment between the women who had the doulas and some peer comparison, I could be doing harm to groups of women by association just by doing the research. Imagine if I racially stratify the results.

This would also apply to breastfeeding initiation and/or continuation, mode of delivery, use of anesthesia, etc. I did read the original article. I would have preferred a source when he discusses “emerging evidence” about bonding centers of the brain and pain medications in labor. It is very typical of mainstream media discussion of medical issues to lack sources.

To me, the bigger picture is yes, it is a valid point to say that groups of women may suffer by association by possible research outcomes. But, is the benefits of the research to future practitioners, researchers and parents worth it? I think it can be, depending on how it is performed and presented.

Reply turned post, breastfeeding nazis and formula is poison style

PhD in Parenting has a hopping post about the term “breastfeeding nazi”. I also have a problem with that term, which I have written about.

After we dispensed with some devil’s advocate apologist nonsense in the comments, the conversation devolved into familiar territory. People telling horror stories about the two extremes: the most judgmental breastfeeding supporters (you know, certain message boards *roll eyes* have people tell people formula is poison), and the other alternative, (women who don’t want to breastfeed shouldn’t have children), and that breastfeeding should never be discussed in public. See Mommy Wars Bingo if you want to fill in some squares.

Anyway, this is my reply turned post. If you want to read more than a hundred comments, you can get all the nuance of this particular comment thread, but this is my most recent reply:

Wow, none of my breastfeeding posts got this many replies!

Breastfeeding, like every other health issue, must be discussed with nuance. It does not have to be avoided in the public sphere, and treated like a secret between the mother and her pediatrician.

KC, I am sorry about your grief about not being able to breastfeed. My closest friend, whose birth I was a doula for, had a similar situation. There are options, like the SNS (supplemental nursing system), available to provide nourishment (either in the form of pumped breastmilk, the mother’s or donated, or formula) while still supporting the breastfeeding relationship. For my friend, this worked for a while, but she ended up giving formula from a bottle after trying for months. With a hospital grade pump, and several consultations with lactation consultants.

What I am trying to say is that there are interventions that will nourish the baby if the baby is losing weight inappropriately when the breastfeeding relationship is not working adequately, for whatever reason. Supporting breastfeeding and lactation consultation are definitely not at odds with making sure babies survive optimally. If a baby is not getting enough nutrition, then obviously the health outcome is not ideal, and there should be a different health option, which would be to use an intervention like formula.

No responsible breastfeeding advocate would tell a mother that she is feeding her baby poison if her baby is not getting adequate nutrition over a physiologically significant period of time. (Or if there are any other medical reasons why she cannot or should not breastfeed).

This is the equivalent, but opposite, of the breastfeeding nazi remark. It is ridiculously out of proportion and meant to be hurtful. Do both extremes happen? Yes. Do they need to dominate every breastfeeding conversation? No.

But, remember, I have heard nurses, family members, doctors, and women in my own family say a baby is “starving” after one failed latch or during a crying spell on the first day, even if there has been other successful feedings. I have heard people say a baby is “starving” because the mother’s milk isn’t in yet, just the colostrum.

There is no reason why this can’t be handled with accurate information and sensitivity.

As for the sexual abuse and breastfeeding argument, this article in the journal Lactation says that women with a sexual abuse history report wanting to breastfeed more than those without. This article stresses the wise tenet from the article linked to above: never underestimate or overestimate a woman’s desire to breastfeed. Again, each situation must be dealt with with sensitivity, appropriate health treatment and accurate information. We cannot speak for other’s sexual abuse experiences, just as we cannot speak for other’s lactation experiences.

Call to action on breastfeeding

The HHS has a call to action on breastfeeding that is currently open for comments. (h/t to Our Bodies, Our Blog.)

I commented on Maternal and Infant Care Practices: Prenatal, Hospital, and Post-Delivery Care, and Paid Maternity Leave so far, but could easily comment on all of the topics. I hope they get lots of good feedback. Please comment!

I love Peggy O’Mara

My favorite thing about getting Mothering magazine was always reading her editorial column. She is a wonderful writer and a smart, compassionate woman.

I love her response to Hara Rosin’s Case Against Breastfeeding.

Reply turned post, breastfeeding bullies style

In my years of discussing breastfeeding promotion on the web, I have witnessed many conversations that started with the discussion of the health benefits of breastfeeding and ended with a lactation consultant bashing session. This is yet another permutation of the argument that lactation consultants are somehow bullies who, in this comment section on Stand and Deliver, commenters contend that women should not be “forced” to breastfeed, and that people (I am assuming they mean lactation consultants) do this by “yelling” and “nagging”.

I really have never met a lactation consultant who yelled or nagged at a new mother. I am not really sure where this stereotype comes from, or why discussions about breastfeeding often evolve to ignore the proven health benefits and turn into bashing sessions for these evil hypothetical people who force moms to breastfeed by yelling at them or guilting them.

I trained for two years at a birth center which treated breastfeeding as the norm and formula feeding feeding as a medical based intervention, which is sometimes necessary. We had a more than 90% success rate with breastfeeding initiation and continuation. Working moms, moms on public support, moms with mental problems, etc.

They were incredibly supportive, with home visits and moms having unlimited phone and in clinic support for breastfeeding problems. Women who were having problems would come and stay all day in clinic sometimes, and would have help with every nursing session.

I saw moms who were having problems who cried. I have personally wiped tears off of a mom’s bare breast while helping her tape a Supplemental Nursing System tube to her skin. She was not sad because I yelled at her or that she felt guilt. She was sad because she was facing health obstacles in the success of her breastfeeding, and she was very grateful for our support.

I have seen moms (just this week!) furious because nurses disregarded their wishes to breastfeed and fed their babies formula, even though there was no medical indication. I have seen many more health care practitioners pushy about feeding and recommending formula than the other way around. I have seen lactation consultants bend over backwards to support moms emotionally. I am sick of these roles being flipped in the discussion.

OK, off my soapbox.

Another reply-turned-post, breastfeeding style

I have added yet another blog to my reader. I liked this post at Hugo Schwyzer’s blog. He discussed the Rosin breastfeeding article and mommy wars in general. The comments had some mommy wars type arguments in them, so I figured I would reply:

*****

Great post.

I write about the subjects of mommy wars and breastfeeding a lot. In fact, I have a Mommy Wars Bingo Card since so many of the same kinds of comments come up over and over again.

I wrote about Rosin’s article, too. The problem with her (and some of the comments on here, and many of the discussions about breastfeeding vs. formula) treatment of the discussion of breastfeeding is the assumption that breastfeeding is the intervention and formula feeding is the norm, and the greater problem of not treating this as a health decision (with obvious social and feminist and classist issues, but primarily a health decision).

Breastfeeding is and should be the normal and recommended feeding of all newborns. If an intervention is sought (formula feeding), there should be ample health indications for doing so. Just like any other health treatment, other issues do come into play (such as compliance – if the mother can’t comply due to work obligations or unwillingness) then that is of course an issue. If the infant is losing weight despite lactation consulting, that is a health issue. However, those must be weighed against the absolutely undeniable health benefits of breastfeeding.

Interventions due to complications (such as formula feeding, induction of labor, cesarean section) should not become the “normal” treatment options for women and newborns who do not warrant interventions. The evidence does not support improved health outcomes with such interventions, it actually shows more harm than benefit.

I am all for discussing the social, economic, and other considerations that come into play with delivery, access and compliance when it comes to these and other health decisions, but let’s keep the ideal treatment options in perspective when we have these discussions.

A premature reply-turned-post, breastfeeding style

I haven’t read the original article, “The Case Against Breastfeeding” in the Atlantic. I am not sure if my stress levels can handle it. I am started with a link to it on Alas, a blog. I am planning on thoroughly enjoying a critique of the Rosin article and her manipulation and misquoting of statistics on the U.S. Food Policy blog. From what I have read (I would have to look this stat up again) there are hundreds of studies a year published that confirm the advantages of breastfeeding. It is easy to hand pick a few with the weakest results and say the evidence is “thin”.

But, that didn’t stop me from posting a reply on the post I did read on Alas, a blog:

One of the main problems I have with a lot of the discussion about breastfeeding is that it is a health care decision. It is not a lifestyle decision or a social decision. Of course, as in any other health decision, there are many cultural and social aspects involved. But, whether one is a stay at home mom or works is not in the Healthy People 2010 goals. Increasing breastfeeding rates is, for a good reason.

There are absolute, irrefutable health benefits to breastfeeding for the mother and infant(s) (congrats on the twins!) that are not on the same level as “talking about the advantages of breastfeeding makes me, a formula feeding mom, feel guilty”. (See Mommy Wars Bingo). Breastfeeding is and should be the way that one is supposed to feed infants, barring any health issues that are contraindications. Just like a vaginal delivery is the healthiest way to deliver a baby, barring any health reasons that are contraindications. Of course there are complications and exceptions, but that is true for every health decision, from aspirin to knee replacement surgery.

It is of course relevant to discuss the greater social aspects of breastfeeding, but it seems like the conversation is always dominated by this topic, and whenever it is brought up as a health discussion, people want to negate that aspect of the discussion by saying the social aspects are more important.

******

I found an even better reply! This is from the US Food Policy post:

Hanna Rosin did not quote from the wide body of literature on the risks of formula feeding. Breastfeeding is the normal state of feeding an infant. It confers no benefits — it is the norm. The risks and costs of alternatives are what need to be assessed.

First, she uses sleight of speech to disparage a wide body of doctors who contributed to the American Academy of Pediatrics Policy Statement on Breastfeeding and the Use of Human Milk. She provides no evidence whatsoever to support her statement about these doctors have an agenda. Conflict of interest in the medical arena usually involve payments of large sums of money from those who have commercial interests to those who are making statements. No one pays doctors to make positive statements about breastfeeding.

Second, if you look at the American Academy of Pediatrics statements, she avoids the conditions for which there is solid evidence that there is an increased risk from formula use including bacterial meningitis, bacteremia, diarrhea, late onset sepsis in preterm infants, necrotising enterocolitis, urinary tract infections, and postneonatal mortality. Solid — meaning lots of credible studies. Since I started an MHS at Hopkins in 1983 through completing a doctorate in Nutritional Sciences at Cornell in 1993, I literally read THOUSANDS of credible studies — and there are tens of thousands out there. I have stacks of meta-analyses under my desk and I reach very different conclusions

What she tackles in her article one condition among the many conditions of the “suggestive” research that is very hard to prove. This is the realm of SIDS, asthma, diabetes I and II, overweight and obesity, hypercholesterolemia, Hogkins, lymphoma and leukemia. These conditions are multicausal. It is very easy to design a study poorly and not see results and very hard to design a good study to find the causal links because the many of the effects are modified by other effects.

But even if all of this suggestive research turns out to not be so suggestive, what about the solid research? And she did not even site the risks to women when they don’t breastfeed.

Now, why is it that someone like Hanna Rosin with no science background at all can call into question what is a huge body of research by mentioning one little sideline of the many studies that show an increased risk of disease from use of formula? Does she have better qualifications than MDs that have no conflicts of interest that wrote the policy statement?

As for the economic analysis of a breastfeeding, the World Bank tried such an approach many years ago with their Disability Adjusted Life Years. I worked on the protein energy malnutrition section. This approach was deeply flawed in that there was no way to include the fact that some interventions provide multiple benefits. Those interventions that addressed a single disease showed up better than those that addressed many diseases and had multiple benefits because the economic models were inadequate to deal with multiple benefits.

In terms of the costs of breastfeeding, what we are really talking about is the costs of caregiving. Babies need contact and interaction. Breastfeeding is but one way to provide this while at the same time providing food. What unfortunately has happened during the years when women were discouraged from breastfeeding is that we adopted feeding modes that are unhealthy for infants. I would love to work with exclusively formula feeding mothers to assist them to do what I do with mothers that have had breastfeeding problems — that is “mimic normal infant feeding” and “mimize risk”. The culture has adopted unrealistic expectations for the frequency and length of infant feeding as well as the amount of interaction that is really needed. In the past, women were in communities where sharing of childrearing with close kin members was far more common. Woman also did their productive activities in close proximity to their children so the displacement to feed their infants while working was not as much of a problem. Now women are expected to do it all on their own and conduct their income generating activities in a separate environment from their infants. The segregation of mothers from their infants does come at a cost.

Finally, the real clincher that everyone forgets about is that we had a healthier alternative in the past. Wet nursing was acceptable and available. Your sister could feed your infant to give you a break and no one would bat an eyelash at the practice. Now, in our super sterile environment where we confuse an infant’s normal food with yucky body fluids — such an idea is usually met with shock and horror.

Yet, human donor milk has been shown in many studies to be less risky than formula.

As for her assumption that only formula feeders are given a hard time, I beg to differ. If you took a sample of 1000 women, I am dead certain that 100% of that sample would say that their infant feeding choice has been criticized, regardless of what choice they made. If you took a sample of 1000 women on any parenting issue, you would find the same results. BUT, there is a false equivalency in this statement. If you looked at the degree of negativity in the “criticism” you would find that the most negative, disgusting comments are reserved for women who nurse in public. There is a huge degree of Lactaphobia in the culture due to the sexualization of the breast. You would never get away with saying that African Americans, homosexuals, the elderly, Jews, Muslims or any other group would have to eat in the bathroom. Yet, routinely, women are told that the only place their infants can eat normally is in the bathroom.

Hanna Rosin doesn’t have the credibility to debunk the vast body of literature that I have read with her brief skimming of a few choice articles. She merely follows formulaic rules for justifying a billion dollar industry that took away choice from women for several generations and wants to perpetuate myths the risks of their product.

A better analogy than smoking is diabetes. Would you give insulin to someone without diabetes? No. Would you tell someone with diabetes that they are just as healthy as someone without it? No. Would you hesitate to give insulin to someone with type I diabetes? No. Would you tell them it was poison. No. Would you try to get someone with type II diabetes to eat better and excercise? Yes. If they still needed insulin, would you give it to them? Yes. Would you still work to help them overcome barriers to diet and exercise? Yes. Would you call health care practitioners that spoke frankly about diabetes “fanatics” or “nazis”? No.

Most of the discussion of infant feeding is highly irrational and overly emotional.

In the meantime, I will continue to assist women with pragmatic solutions to mimic normal and minimize risks of feeding their infants tailored to their own specific situations.

Susan E. Burger, MHS, PhD, IBCLC, RLC

Reply turned post, but what about the CHILDREN?? style

This is one of those three way mirrors kind of posts. I am reply -turned – posting to a reply – turned – post. PhD in Parenting has a post about a post on Blog it out, Bitch about how breastfeeding in public somehow forces disapproving parents to talk about breastfeeding with their children before they are ready and willing.

My response (with a few typo / grammar edits *twitch twitch*):

Great post!

I really have a problem with the idea that breastfeeding in public is forcing parents to discuss something with their children before they are willing. It is the same exact argument being used by parents protesting a host on a British children’s show who has a congenital deformity of one of her arms.

No one can force someone to have a discussion with her child before she is ready. I have an IUD pin on my white coat (I am a medical student who plans to practice Ob/gyn.) . When my son said “You have a pogo stick on your white coat!” I said “Yes I do!” because I didn’t think a discussion on birth control was age appropriate. I make these sorts of judgment calls every day. A parent who doesn’t want to discuss the TV host with the different arm can turn off the TV, say “I don’t want to talk about that” and stick her head in the sand all she wants.

Parents DO get to choose what they discuss and what they ignore. What they cannot control is the entire world around them, and the sooner they learn that, the better. And, the sooner they stop using “But what about the CHILDREN??” as an excuse to cover up their own biases and fears, the better we will all be.

Breastfeeding is in absolutely no way disgusting, sexual, inappropriate, or wrong, and I refuse to defend or accept the defense of someone who tries to pretend it is. Neither is seeing a biracial or homosexual couple together (I am not talking about sex here, but holding hands or in a book or something), a TV host with a differently abled body, or a myriad of other examples of biases people have.

I will judge women who go to restaurants with their breasts, midriffs, thongs or buttcheeks hanging out of their clothes in a sexual manner. (I live near South Beach in Miami. Not only have I seen all this at restaurants, I have seen mothers dropping off their children at school dressed like this. No kidding.) I do not pretend that there won’t be groups of parents who think my breastfeeding in restaurants was obscene, just like there are apparently people who think my judgment of women who walk around like they are auditioning for a porno is some sort of wrong attitude toward a sex positive ideal.

We don’t agree, and I can live with that. I don’t have to defned their point of view, however.

Antibreastfeeding Bingo

I want to be a Hoyden when I grow up!

Please go visit Lauredhel’s new Antibreastfeeding Bingo Card.

It is kind of sad how easy it probably was for her to come up with these. I have seen each of these comments repeatedly.

Breastfeeding disclaimer: Moms who can’t or choose not to breastfeed can obviously be wonderful, loving mothers, do have to deal with unfair judgment from some quarters, and this isn’t about that.