If this is cost-cutting, just be honest, please

Now here’s an odd bit of news. Britain’s Royal College of Gynecologists (RCOG)—in one of those partnerships that make you go “Huh?”—has teamed up with the National Childbirth Trust (NCT) and the Royal College of Midwives (RCM) to issue "Making sense of commissioning Maternity Services in England – some issues for Clinical Commissioning Groups to consider," a set of guidelines on maternity services to British general practitioners.

British GPs (who are rather like family doctors) are often the first point of contact for pregnant British women and have considerable impact on their choices, so this is important stuff. The guidelines give GPs pointers on how to assist pregnant women, on which sort of birth units they should advise patients to go to, and what sort of questions they should ask of their local hospitals/birth units to make sure they are fit to be recommended.

Much of the guidelines covers matters such as ensuring pregnant women receive medical care early on, looking out for socially vulnerable women etc.—all great stuff and very welcome. But then things get surprising. Credit goes to Pauline Hull of Cesarean Debate who spotted the oddities in the guidelines and posted her own very thorough riposte which can be read in full here. Although the guidelines spend a lot of time talking about “choices,” they do nevertheless seem to be awfully keen that women make the choices that the NCT and RCM consider correct. They encourage GPs to push women towards midwife-led birth units, saying (for example) “There is now a good argument to be made for multiparous women being advised to choose a non-obstetric birth unit” (my emphasis). Most curiously of all, the guidelines also advise GPs that “a 20% rate [of cesarean section] is achievable and sustainable. Every provider unit should have a clear action plan for increasing its normal birth rate…”

I don't want to just repeat everything Hull has already said, so I'd like to focus on the bit about "increasing [the] normal birth rate." On the face of it, that doesn’t sound too scary—after all, nobody would want a woman to have an abnormal birth, surely… who could possibly object to increasing normal birth rates? Well, quite a lot of people, actually. The guidelines define “normal birth” as “without induction, without the use of instruments, not be caesarean section and without general spinal or epidural anesthetic before or during delivery.” The guidelines also advocate raising the vaginal delivery rate, which includes forceps and vacuum. Put this another way—“Every provider unit should have a clear action plan for decreasing its epidural rate, and—if necessary—resorting to more forceps and vacuum deliveries in order to get the cesarean rate down” —and suddenly it all sounds a bit less cozy.

The problem with targets (or, what if you like being abnormal?)
The problem with these kinds of targets is that in practice, they always end up reducing choice and harrying at least some women into birth experiences that they don’t want, simply because of the way target-driven healthcare tends to work—as pointed out by numerous posters on the popular online discussion forum, Mumsnet, where there has been for the most part a pretty angry reaction to these guidelines. In hospitals where VBAC/“normal” birth rates are below target and cesarean sections make up more than 20% of births (i.e. more-or-less all hospitals) medical practitioners are sure to start feeling the hot breath of their organizational managers down the backs of their collars, urging them to “see if they can’t get those rates down a bit,” which in turn will inevitably lead to women who prefer cesarean section being pressured, nagged or tricked into birth styles they don’t want—unwanted VBACs and forceps/vacuum deliveries especially. I’m a strong supporter of the continued availability of VBACs and forceps on delivery wards, as I discussed here—but I wouldn’t want either myself, and I don’t think women should be pressured into them or not given full and unbiased information on their risks, as well as on those of cesarean section. I’m particularly concerned about epidural coverage, because there is convincing evidence that British women are already being subjected to the Great Epidural Bait-And-Switch.

The problem is—and the guidelines themselves sort of admit this, funnily enough, if you read them through—British women are waiting until later and later in life to have their first child; they are heavier than ever at conception; they are gaining more weight during pregnancy and having bigger babies. My concern is that if this reality collides with political pressure to "get those cesarean rates down," we will inevitably see more and more “bad vaginal births”—more long and traumatically painful labors, deep instrumental deliveries, injuries to babies and serious pelvic floor trauma. No wonder Maureen Treadwell of the Birth Trauma Association has expressed her concern about these guidelines.

Strange bedfellows
As Hull says, the Royal College of Gynecologists teaming up with the NCT and RCM is…well… surprising. The NCT is a rather crunchy mothers’ association; and while the RCM is generally respected for its role turning out the National Health Service (NHS)’s own highly-trained midwives it is still heavily biased towards natural—sorry, “normal”— birth. In addition to its Campaign for Normal Birth—see, that word again—the RCM back in 2006 also (as Hull mentions) floated the idea of charging women 500 pounds for “unnecessary epidurals,” but backed down when faced with popular outrage.

But if I thought the RCM and NCT were strange bedfellows for the RCOG, my jaw dropped when I saw page 2 of the 2006 Making Normal Birth A Reality produced the Maternity Care Working Party and included on the RCOG website; “Members supporting the consensus statement” alongside the RCOG include the Independent Midwives Association and the Association of Radical Midwives (do check out the latter’s Facebook page; it makes interesting reading, especially the approving links to Birth Without Fear posts like the one on a "Home Birth of Twins Born Past 41 Weeks, One Footling Breech"?). You do have to ask, what the hell is the RCOG playing at?

Cost-cutting with added crunch
Now, there’s little doubt why the NCT and RCM like the idea of pushing women away from epidurals and c-sections—but it would appear that they’ve thought carefully about how to sell this idea to the NHS:

“Between 2001 and 2010 the national birth rate has increased by 22%... The cost… is set to rise… Commissioners… will need to work in close collaboration with their local maternity providers to ensure that services are both clinically and cost effective.”

The guidelines helpfully remind us that “Every potential cesarean section that is enabled to be a normal birth saves 1,200 pounds in tariff price alone.” Okay, now we're getting down to brass tacks.

In recent years we have seen a lot of initiatives springing up all over the world which dovetail  with earthy-birthy views of how we “should” mother, and which—by a delightful coincidence!—just happen to be marvelous little money-savers as well. There’s the Kick women out of hospital as soon as possible early discharge system which has become popular in places like Australia, and which is great for freeing up beds ensuring mothers and babies can enjoy special bonding time away from the dehumanizing atmosphere of the hospital  (see here and here... ah, and I see the phrase "normalise childbirth" yet again in that last link...). There’s the Baby Friendly Hospital Initiative (BFHI), which has resulted in the compulsory rooming-in policies now found in most Irish hospitals, for example—nice for the hospitals who no longer have to pay for well-baby nurseries or the staff needed for them… let mum do all the work, day and night (if you want to know how the Irish mothers themselves feel about the system, see here).

When I first heard about the BFHI, I remember thinking “So… where’s this going to end? Is the next thing going to be targets for reducing epidural take-up too?” Turns out that wasn’t such a far-fetched idea.

Just be honest, please
If you want to cut costs without howls of protest, there is no better way to do it than to do it in the name of “baby-friendliness,” “normal birth” and so on. It’s clever, really. Anxiety about being a “good” mother and a “real” woman is the 21st century woman’s Achilles’ heel. A woman can’t criticize initiatives which purport to be based on “baby-friendliness” and “normal birth” without leaving herself vulnerable to accusations that she is an abnormal mother who believes in being unfriendly to babies and probably punches kittens and puppies as a hobby in her spare time.

In an age of austerity and rising healthcare costs, governments of nationalized healthcare systems everywhere are looking for ways to limit or ration healthcare services. And you know what? That’s okay. No, honestly, it really is. No healthcare system—especially one funded by taxpayers—can pay for everything for everybody all the time, and sometimes tough choices have to be made. It’s fine to have discussions about whether free formula or cesarean delivery by maternal request (CDMR) or homebirth or whatever is something which taxpayers can’t afford to fund any more when there are other pressing demands on NHS money.

But if we are going to debate cost-cutting, can we please make the debate about cost-cutting, dammit, and not cloak it in sweetly-honeyed words like “natural,” “baby-friendly” and (for the love of God) “normal.” If someone thinks the NHS can’t pay for well-baby nurseries or epidurals, fine—they’re entitled to their opinion; but please just say so frankly. Because then we can all sit down and have an honest debate about where cuts should be made. When a plan to reduce epidural availability or kick women out of hospital early is put in terms of “Oh, but we’re doing this for the babies’ good!” this effectively silences women and shuts down open debate. And that’s just not good for babies, for mothers or for the NHS.

“I’ll never forget the pain I went through. I was screaming and being restrained..."

“I just remember being brought into a [operating] theatre... packed with people. I wasn’t told what was happening. I was given a local anaesthetic. Then, two nurses put my hands behind my head, and two doctors pulled my legs apart...I’ll never forget the pain I went through. I was screaming and being restrained. I couldn’t see much except for them sawing. It was excruciating pain...”

"...the last thing I remember was my feet being pulled up into the stirrups and I don't remember anything after that until I was being wheeled out of the labour ward... I was lying flat on a board for about 5 weeks. I couldn't move. They actually split my pelvis bone...

"They showed me the saw… they showed me where they were going to open the pelvic bone. They didn’t explain—they said: “You are going to have your baby now.” It was such agony, a terrible severe pain.”

Three elderly Irish women describe their babies' births several decades ago. Stuck in obstructed labor or with a history of difficult births behind them, they might have expected to be delivered by cesarean section. Instead, a different fate awaited them.

 
Some women recall screaming in agony as they were forcibly restrained, while others only remember having their legs put into the stirrups and waking up later unable to move. "Something" had clearly been done to these young mothers, but no name was ever given for the mysterious procedure by either the doctors or attending nurses; one woman remembers no information about her operation other than a cryptic remark from one of the nuns on the labor ward, that she would "pay for it in her old age." In most cases it was decades later that these women finally learned the truth; they had been subjected to an utterly obscure obstetric procedure called symphysiotomy—a procedure most obstetricians in developed countries have never even seen, let along performed, but which was performed on more than a thousand Irish women around the middle of the 20th century due to the influence of the Irish Catholic Church.

The anatomical problem
Symphysiotomy is an operation in which the obstetrician partially severs the symphysis pubis--the cartilage holding the pelvis together. This partially unhinges the pelvis, which not only allows a baby to pass through if labor is obstructed, but is believed by some authorities to permanently enlarge the size of the pelvic outlet, thus—it is hoped—allowing future babies to be born more easily.

Birth is inherently problematic among humans, because we have narrow pelvises (all the better for walking upright with) and large heads housing enormous brains (all the better for doing crossword puzzles with). We somehow have to get a large-brained offspring through a small pelvic outlet. It’s not the greatest arrangement, and sometimes the head just won’t fit.

Cesarean section was known from ancient times, but because it almost guaranteed death for the mother, doctors and midwives generally shunned it in favor of the crude yet lifesaving (for the mother) technique of craniotomy—crushing the head of a dead or dying baby and removing its body piecemeal. It wasn’t until the 18th century that someone decided to experiment with the idea of getting a head through a pelvis by sawing through and enlarging the pelvis rather than crushing the head. Having first been tried out on animals and human corpses, the operation was first tried on a living woman—who had dwarfism and rickets— in 1777, allowing her to give birth to a live child for the first time; unfortunately, it also caused her to have walking problems and leak urine from a fistula for the rest of her life.

Over the centuries, symphysiotomy had several temporary vogues in various parts of the world as obstetricians tried it out for size... but were discouraged by the injuries caused to mothers and the high death rates among babies. Moreover, by the early 20th century cesarean section had become reasonably safe; it appeared that the problem of obstructed labor had been solved.

But symphysiotomy was to have one last outbreak before shrinking back into its rightful place in the “obscure, rarely performed techniques” sections of obstetrics textbooks, and as something done in remote areas where safe cesareans are not possible. That outbreak centered on a small country in north-western Europe: Ireland.

An unholy alliance
The problem was that cesarean section limited family size. The rule “once a cesarean, always a cesarean” still held, and it was well known that with repeated surgeries the risks to mother and baby multiplied as quickly as the scar tissue; most obstetricians set an upper limit of three or four.

This created a dilemma, since in Catholic Ireland, all contraception, abortion and sterilization were illegal. Religious-minded obstetricians of the time thus had a very strong incentive to pursue alternatives to cesareans; women who realized the peril they faced from repeated cesareans might be led into “temptation”—that is, seeking birth control. Developing an alternative to cesareans would also enhance the reputation of Irish obstetricians—always sensitive to criticism from outsiders that they were held back by their Catholic faith.

Symphysiotomy—along with a sister operation, “pubiotomy” in which the pubic bone itself (rather than the cartilage joint) was sawn through using a wire saw—was revived in 1944 by Dr. Alex Spain at the National Maternity Hospital (NHM) Hospital in Dublin, in an unholy alliance between obstetrics and conservative religious forces. Dr. Spain and fellow symphysiotomy proponent Dr. Arthur Barry published writings in both the medical literature and the ecclesiastical press of Ireland, expounding the virtues of a procedure that prevented cesarean section with its attendant problem of “encouraging the laity in the improper prevention of pregnancy or in seeking its termination.”

The operation “spread like a plague in Ireland” in the words of Marie O’Connor, author of a book on the subject. Between 1944 and the 1980s, symphysiotomies and pubiotomies were performed on an estimated 1,500 women in hospitals from Cork to Kilkenny, and were particularly widespread at the notorious Our Lady of Lourdes Hospital in Drogheda. The atmosphere surrounding the operations was clandestine; women were typically not informed of what was going to be done to them, let alone asked for their consent.

“A midwifery of darker times”

"I wasn't in labour but I thought it was for my [cesarean] section... I was physically restrained…  they had this circular saw. I was screaming, asking what they were doing. They said 'new procedure'… They told me they broke the pelvis bone and my hips were dislocated… only God and myself know the excruciating pain, violation and intimidation I felt."

Because the whole point was to avoid a cesarean, women were left to push “through the agony of an unhinged pelvis” for as long as it took—often hours and hours. About 10% of babies died—far more than with cesareans—while many more were brain-damaged. This was well known by Dr. Barry and Dr. Spain, by the way—but the “benefits” in terms of avoiding "contraception, the mutilating operation of sterilisation and marital difficulty" were thought to justify this. British obstetricians, meanwhile, had other views on their Irish counterparts’ experiments, with one being moved to say “This is a midwifery of darker times. This is the murder of infants,” while another asked “Is it then your policy to sacrifice the first-born baby to use its dead or dying body as nothing more than a battering ram to stretch its mother's pelvis in the hope that subsequent brothers and sisters may thereby (possibly) enjoy an easier entrance into the world?”

Women, meanwhile, were left with serious damage—incontinence, pelvic instability (leading to great difficulties with walking) and chronic pain—rendered more serious because the secrecy surrounding the procedures meant that women did not receive proper nursing care and were dispatched from hospitals without medical advice. Most had no idea what had been done to them until the symphysiotomy scandal started to come out in the 1990s, leading ultimately to the creation of Survivors of Symphysiotomy (SOS), a support and advocacy group which is currently campaigning for compensation for the surviving victims. Many survivors speak of marriages blighted by sexual dysfunction and chronic pain, of isolation and loneliness caused by disability, and of the psychological trauma caused by the operations—including, in many cases, the death or injury of their babies.

One particularly grotesque twist in the symphysiotomy story concerns the calculated use of the procedure on many women either before labor or when already delivered of their babies, for training purposes. The Lourdes Hospital was run by the Medical Missionaries of Mary which operated missionary hospitals in Africa, India and other places. In environments lacking electricity or proper facilities, the attractions of a low-cost procedure that could replace cesareans were obvious. Symphysiotomies performed on Irish women—without their knowledge or consent—were thus an invaluable teaching aid for Catholic missions.

“The obstetrician, like God, must look to the future…”
Symphysiotomy and pubiotomy in Ireland began to decline in the 1970s due to changes in Irish society and other factors. In developed counties, it is now performed only in extremely rare life-threatening cases where labor is too advanced for a cesarean. Yet some of the issues surrounding these procedures have resonance for our times, in particular, women’s right to control over their fertility, and the question of how to balance the safety of the baby being born now—in this birth—against the safety of future pregnancies—a dilemma that we have faced ever since safe cesarean section become a possibility.

In traditional societies, high infant mortality rates create a more philosophical attitude to child death, while also necessitating multiple pregnancies if a couple want to make sure they leave any living descendants behind them. And cesarean sections are highly risky. In such environments, techniques like symphysiotomy make a grisly sort of sense—sure, this baby might have a 10% risk of dying, but avoiding primary cesarean means the mother can give birth to many more babies. As discussed here, symphysiotomy remains part of the obstetrician’s box of tricks in parts of sub-Saharan Africa—not because symphysiotomy is good, but because it's better than letting the mother die or sectioning her in an insanitary environment where there is no guarantee she could make it to the hospital next time, and where large families are still considered essential.

As infant mortality rates have fallen, the average number of children a woman will give birth to has declined sharply; meanwhile, we have higher expectations of safety and are no longer content to regard dead babies as disposable or do-overs… and cesareans are safer than ever. Present-day trends in obstetrics reflect these patterns, with cesarean section replacing not only symphysiotomy but also vaginal breech delivery and (increasingly) forceps deliveries and vaginal birth after cesarean (VBAC).

But respecting women’s control over their bodies goes both ways, and there is a case for saying that when obstetric practice is based only on the desire to reduce all risk to the fetus to zero, it can become decidedly unfriendly to many women who actually choose to have larger families. VBAC, for example, involves a small but real risk to the unborn baby because of the possibility of the uterus rupturing, as was discussed recently on The Skeptical OB; but what about the risks (to futuer babies) of multiple surgical births? I am going to quote in full one particular poster (who had a prior cesarean) because I think what she said was so moving and so important:

“I have always wanted a large family, but stories like these scare the crap out of me. It's been extremely difficult for me to decide whether I should have a VBAC or 4-6 c-sections…. If there were some way to know that I'd end up being one of the women with 4-5 c-sections and minimal scar tissue I'd be all over it, but I know I could just as easily end up being like someone I know of who had so much scarring after two that her third birth was a classical c-section followed by a hysterectomy.

“I think I could ultimately accept just 3 kids, but I would always feel like someone was missing and long to love and hold them. It kind of bugs me that there are so many in VBAC threads that berate moms for even considering a VBAC over a RCS [repeat cesarean section] in order to protect the lives of future babies who might end up stillborn, etc., but if you want additional children you love and long for them every bit as much as you do your first… It's like people who tell infertile couples to just adopt and then are bewildered and even mad when they say it's just not the same even though logically it should be because they'll still end up with kids. I just don't think wanting to do what's safest for your family as a whole is a choice that deserves such much criticism and so little understanding.”

Childbirth politics generally takes the form of as a conflict between those who see birth as inherently hazardous and regard it as a medical matter, and those who see it as a basically functional process where interventions are seldom necessary. Symphysiotomy in Ireland is difficult because it doesn’t fit neatly into either “side.” You can read Ireland’s symphysiotomy scandal as “Obstetrics has a history of violating women’s bodies with interventions that are not evidence-based” or as “Thank God we have cesareans now! See, this is what happens when you prioritize vaginal delivery above all else.” I prefer to see it as a story of what happens when religious doctrine takes precedence over women’s rights to informed consent and control over their bodies. This is something we should bear in mind as we face the possibility of a US vice-president—a Catholic—who is completely opposed to abortion even in cases of rape and incest, and who has sponsored a bill that would outlaw some forms of birth control.

In many countries, it has become increasingly common for women who prefer cesarean and plan to have a small family to be permitted a prophylactic cesarean section without medical indication. I think this represents an extremely important moment in terms of respecting maternal choice. I also hope that there will be room on maternity wards for VBAC, forceps deliveries and even (carefully screened) vaginal breech deliveries, and that in the future, obstetricians will give women unbiased information on the risks of cesarean and vaginal deliveries, discuss women’s desired family size with them and take this into consideration when presenting information and options.

As the surviving symphysiotomy victims wait for justice, what a wonderful tribute it would be to see their struggle not as a victory for a certain “type” of birth, but as a moment for reflection on the importance of women being able to make informed decisions about their bodies and fertility—an issue which is as relevant in our times as it was all those years ago in Ireland.

More information:

Mutilating mothers in the name of God (video)

Latch On NYC: Less spin, more details please

"Mayor Bloomberg pushing NYC hospitals to hide baby formula so more new moms will breast-feed" screamed the headline a few days ago. In Mayor Bloomberg's Latch On NTC initiative, we were all told, not only were formula samples to be banned, but formula was now to be hidden away "in out-of-the-way secure storerooms or in locked boxes like those used to dispense and track medications," in order to discourage bottlefeeding, while those wicked mothers who requested bottles anyway were to be subjected to a "talking-to" for each and every bottle they received, by staff who will explain "why they should offer the breast instead." Now, two thoughts ran through my head upon seeing this. The first was, "Wow. This is going to cause a bit of controversy in the mommy blogosphere. I wonder if The Fearless Formula Feeder and Kellymom are onto this yet?" The second was, "Hmm. I notice that article doesn't actually link to an original source. I wonder how much of what's written here is true and how much is spin...?"

Well, the blogosphere got wind of Mayor Bloomberg's little wheeze, and commentary rapidly split down two predictable lines. The "Anti-lactivist camp" (many of the commentators on The Skeptical OB, The Fearless Formula Feeder, Bottle Babies and others) fumed about the proposals. "This is outrageous! It's a woman's right to choose formula--how dare hospitals lecture them about it? Or treat formula as though it was something akin to cigarettes?" The "Lactivist camp" (Kellymom, Best For Babes and all the rest of the crunchosphere--which, by the way, hugely dominate online discourse about motherhood in spite of the beleaguered-minority identity) immediately shot back, "No, this is a great initiative. And the media hasn't reported this properly. Go to the Latch On NYC website--they're not going to lecture women about using formula. And by the way, it's normal hospital practice to lock up items used in the hospital, including food."

Well... with some trepidation, I went to the Latch On NYC website, grimly saying to myself over and over again, "I will not, NOT form an opinion until I have read what the actual initiative itself says...minus the media spin." And even before opening up the Initiative Description and FAQs, it was pretty apparent that there was some serious spin going on. I mean, before long there were news articles appearing which were proclaiming "NYC plans to ban baby formula in hospitals"--absurd.

Well, according to the Initiative Description, the initiative consists of the following:

A call to all NYC maternity hospitals to make a voluntary commitment to support mothers who choose to breastfeed by:
- Enforcing the NYS hospital regulation to not supplement breastfeeding infants with formula
feedings unless medically indicated
- Limiting access to infant formula by hospital staff
- Discontinuing the distribution of promotional or free infant formula
- Prohibiting the display and distribution of infant formula promotional materials in any
hospital location
- A public awareness campaign to promote the health benefits of breast milk, and to inform women of their right to receive education, encouragement and support to breastfeed their babies if they choose to do so.

 So, it looks like the lactivist camp was right to claim that there is some media misreporting--or at least, overextrapolation--going on.
I'll be honest--I think much of what is written here falls into the categories of "Good" or "Neutral." I'm agnostic on ban-the-bags--I don't particularly feel that one's human rights are infringed on by not receiving a freebie; I didn't get free formula from my Japanese hospital, either, and didn't feel deprived. I also feel that ethically speaking, it is questionable for hospitals to receive gifts from commercial organizations because it can create conflicts of interest--although I think that if we are going to ban the bags then to be fair we should be banning all gifts and samples to the hospitals. The "unless medically indicated" bit did make me raise my eyebrows for a second... are they proposing that formula feeding should only be permitted for medical reasons, meaning women should not be permitted to formula feed by choice? But a second glance indicates that this is for breastfed infants only (i.e., you don't give formula to babies whose mothers have chosen breastfeeding, unless there is a medical reason to override her wishes). That's a positive thing.
What about the locking-up of formula? Let's take a look at the FAQ page.

 What does it mean to restrict access to formula?


Restricting access to formula means storing formula away from where it is easily visible and accessible to staff and mothers. Access to formula is restricted by both:


Storing formula in a locked location, such as a storage room, cabinet or an automated medication system or, storing formula in a location outside, but reasonably near, the maternity unit...

  "Locking up" does sound alarming, but I think it's only fair to point out that hospital supplies including sanitary pads, food and just about everything else are usually locked up, recorded and tracked--in part because patients are usually charged for them. Again I think we are seeing a little bit of the phenomenon of journalism that epidemiologist Elizabeth Pisani calls "beating it up." "Making it up" means inventing things up out of thin air. "Beating it up" means presenting true facts in a way which makes them sound as alarming as possible, in order to whip up a bit of hysteria and controversy (which in turn will generate sales and page clicks).

What does concern me a little, is the following sentence:

...Limiting the number of hospital staff with access to formula by implementing a system to identify which hospital member accessed the formula supply; some examples are a log book, a code or a key system.


Restricting access decreases the likelihood that staff will distribute, and inadvertently market, formula.

 It may well do so. It also increases the likelihood that mothers are going to be kept waiting God knows how long while waiting for a bottle to appear (as their newborn screams with hunger) because the reality of hospitals is that there are never enough staff and there are constant complaints from new mothers about lack of support already anyway, and restricting. And then you get mothers inadvertently stretching out the periods between feeds  as long as possible... and pushing the baby to "finish the bottle" when the formula is finally available, in order to avoid the whole process of trying to actually get hold of a bottle of milk. This isn't promoting good feeding practices or responsive parenting. Rule No. 1 = Feed The Baby.

What about the "lecture with every bottle" bit that is allegedly going to form part of Latch On NYC? Here is the relevant section in the FAQ.

What do we tell our staff to do when mothers (families) request infant formula?


While breastfeeding is healthier for both mothers and babies, staff must respect a mother’s infant feeding choice. Educating mothers and families about breastfeeding and providing encouragement and support, both prenatally and after birth, is the best way to ensure breastfeeding success in your hospital.


While in the hospital your staff can:
Assess if breastfeeding is going well and encourage the mother to keep trying.
Provide education and support to mothers who are experiencing difficulties.
If the mother still insists on receiving formula, document it in the chart along with the  reason and distribute only the amount of formula needed for the feeding.
Train staff in breastfeeding support (CLC, IBCLC) who can be available to assist new mothers at all times regardless of day, night or weekends.

 Well, first of all, claims that formula feeding is going to be banned from New York hospitals do indeed appear to be a bit of media hype; Latch On NYC does give at least token support for mothers' choice to formula feed. The bit about training staff in breastfeeding support is great.

But what does "Assess if breastfeeding is going well and encourage the mother to keep trying" actually mean in practice? If the mother says clearly "I don't want to do this any more," is the nurse required to keep urging her to continue? Where do you draw the line between support and nagging? The initiative gives us no clear answers. Certainly, the use of the word "insist" here is deeply problematic. My understanding is that a person only "insists" on doing something when they continue to state their need after having experienced a considerable amount of pressure to do the opposite.

My guess is that what will actually happen is that these ideas will be interpreted in different ways depending on the hospital staff member in question: staff who are basically respectful of all feeding choices will continue to act accordingly, but staff who have the lactofanatic light in their eyes may well see this as a permission slip to harangue mothers more than they are already doing. I don't think it's much of a stretch to imagine this, given that women are already being harassed in "baby friendly hospitals" for choosing to give formula.

Details, details, details
There is a lot about this initiative that is concerning, but we need to make sure that we are focusing on the right things. The initiative doesn't say anything about giving mothers a "talking-to" about using formula, and it certainly doesn't seek to ban formula. But there are some real problems with some of the things it is outlining. What's more, a lot of the initiative is maddeningly vague, and that openness to different interpretations could result in it becoming a green light for bullies.

There has been a lot of negativity about Latch On NYC in the past few days; if its authors want to rescue its credibility, they need to rewrite the thing, spelling out carefully exactly what they are going to do to support breastfeeding and formula feeding mothers and make their lives easier. Otherwise, the only thing Latch On NYC will achieve will be to add an extra keg of dynamite to the mommy wars.