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.

How to have a bottle-refusing baby (and a life)

Before I had my baby 16 months ago, I was quite clear on one thing: if I breastfed her (and I wasn't yet sure which way I would swing), she was going to take a bottle. Oh yes, she would. I had no desire to join the dreaded ranks of the Mothers Whose Babies Will Not Take A Bottle. I'd read all the stories, you see--about how a bottle-refusing baby irrevocably ruined your entire life, chaining you to your infant night and day and ensuring that you never had a evening-out or date night ever again. I was horrified by such stories, but not terribly sympathetic. Really, these sad excuses for mothers had only themselves to blame for not introducing a bottle properly at the right time. Or maybe they did introduce a bottle in time, but then failed to follow up on it. Tut tut. Apart from anything else, how utterly irresponsible, I sniffed--what if they suddenly had to be hospitalized and the poor husband had no means of getting milk into the baby? I, by contrast, was going to do things properly.

And so I carefully introduced bottles--beautiful, carefully selected glass bottles--at five weeks, as per The Sleep Lady. Baby Seal took them like a dream and I congratulated myself on my superior mothering skills. I now had the ideal breastfeeding-yet-bottle-accepting baby who would allow me to leave her, when desired, with Dad or Grandma--though, if pressed, I would have been forced to admit that keeping my baby primed and ready for such occasions was actually a heck of a lot of work.

You see, the Sleep Lady stipulated a rule of "one bottle a day" to make sure that baby did not lose her bottle-latching skills. This meant that in addition to breastfeeding and babycare, I had to find time to sterilize the pump (carefully gripping each piece with tongs while pouring boiling water though it), set the pump up, mechanically wheeze the milk out drop by drop, store it, sterilize the bottle parts with more boiling water, screw the bottle together, fill it with milk and warm it. Then there was the business of trying to find a time-slot for fitting the bottle-feeding into the daily routine. As Baby Seal's bedtime became earlier, my husband was no longer home in time to give her an evening bottle, so I began to give it myself.

Perhaps that's where the trouble began. At any rate, at three months old, Baby Seal began to refuse her carefully prepared bottles. In horror, I posted on Facebook "She's stopped taking the bottle!!! HELP." Everyone weighed in with suggestions (from giving the bottle out of doors, to rolling the teat in icing sugar) all of which I duly followed--to no avail. My pliant little bottle-accepter was gone, and she never took one again... well, not until she was nine months old and bottles were no longer necessary anyway. Bit of a climbdown for me, as you can imagine.

And... it was okay. We managed--just about--without bottles. Not always very conveniently or efficiently, it's true (I moaned about the problems of my little bottle-refuser here). And yet, somehow, we got through it and came out the other side.

Needs
As it turns out, bottles are not absolutely indispensable for getting milk into a baby without a breast. Over the millennia, a variety of things from spoons to droppers to cups have been used for the purpose. So why the ubiquity of bottles? Well, the big advantage of bottles over other feeding methods is that they are a way of getting a lot of milk into a baby with relative speed and without wastage. If you are looking to get large quantities of milk into a baby sans breast, then a bottle is what you need. If speed/efficiency/quantity are less important--because you are, say, a stay-at-home/work-at-home mother or on mat leave and you only need to leave your baby for the odd evening out, the hairdresser's, doctor's appointments and so on, a bottle may not be essential and could even be more trouble than it's worth.
When it became clear that bottles were simply not going to work, I girded my loins and went to internet to learn about alternative feeding methods. Over the next few months our family ended up doing a mixture of dropperfeeding, cupfeeding and spoonfeeding (milk and cereal); no method was perfect, each method had its own advantages. On preparing to leave the house without the baby, I would basically defrost a container of breastmilk, sterilize a spoon, dropper, and cup, and say to Dad/Grandma, "Erm, your guess is as good as mine. Try lots of stuff and see what works." Here's my rundown.

• Dropperfeeding

This method suggested itself from the dropper I'd used to give Baby Seal her Infacol. I know, I know--feeding milk in a dropper sounds like it is going to really, really, really slow. In fact, for this particular purpose, droppers should really be named "squirters" because you put the milk in one squirt at a time, not literally drop by drop. Slowish, but not nearly as bad as it sounds, and less messy than some other methods.

To give Baby Seal a dropper feed, we would put her in her bouncy chair facing us. It's a funny thing, but when breastfed babies are being fed milk from anything other than a breast--a dropper, spoon, cup or bottle--they tend to prefer the whole experience to be as different from nursing as possible; different posture, different part of the room, and often from someone who's not the mother. It's as if anything that reminds them of breastfeeding makes them furious--"Look, I know this isn't real breastfeeding... do you take me for a fool??" Anyway, we started off with a few drops at a time, then increased to half a dropperfull, then a full dropperfull. I found a video here, but honestly, there is no special technique to dropperfeeding--it's just insert and squirt. Any medicine dropper will do.

• Cupfeeding

Baby Seal came to cupfeeding rather late--at four months, she grabbed the rice cooker measuring cup and put it to her mouth with a cheeky grin... and I had an "Aha!" moment. The best way to learn how to cupfeed is to see it in action--thank you, Youtube.
Shot glasses are the most popular cupfeeding option, but I used either the aforementioned rice cooker cup (which had a little "give" in it), or a tiny Japanese teacup. The trick with cupfeeding (and this flummoxed me for ages until I worked it out) is to get the baby's tongue inside the cup. You're not actually pouring the milk into her mouth, because if you do this, she will splutter and gag; you need the baby to use her tongue to sip or lap the milk from the cup.
I found cupfeeding faster than dropperfeeding, but at the expense of more wasted milk. When this is breastmilk you've spent forever carefully expressing and storing, that's hard (could this be the true origin of the old saying about crying over spilt milk?). After five months old when Baby Seal was having solids anyway, I made sure there was some ready-made formula knocking about in the house, which made it a bit psychologically easier to experiment with different ways of giving milk.

• Spoonfeeding

Spoonfeeding breastmilk struck me as being the slowest and messiest method of the three mentioned thus far--Baby Seal always seemed to have a lot coming out of her mouth, perhaps due to the tongue-thrust reflex--yet my mother-in-law and mother seemed to prefer it to other methods. I guess it comes down to familiarity--grandmas are usually accustomed to spoonfeeding babies. Which leads me to....

• Cereals

If a baby is at least four months old and you've been spoonfeeding breastmilk anyway, adding a little baby cereal like baby rice or oatmeal can be a nice, not-overthinking-it start to solid foods. It stabilizes the breastmilk and makes it less messy to feed, while also giving your baby a little extra iron... and there has recently been a swing back towards emphasising supplementary iron for breastfed babies. Now... I know I mentioned this in another post, but the funny thing about a lot of lactivists is that they think spoonfeeding breastmilk is great--like a kind of superior alternative to the evil bottle--but that spoonfeeding solid foods is a Bad Thing (forcefeeding, doesn't allow your child to control their food intake, blah blah). So according to this logic, the moment you add a little powdered rice to a spoonfull of breastmilk, your baby suddenly becomes incapable of controlling their intake of what's on the spoon, and you are essentially just waterboarding them with the contents. No, I'm not buying that bit of logic either. We did the cereal thing, and offered a couple of teaspoons of water as well, to counterbalance the solids that had been added.

• Sippies

I had high hopes that Baby Seal might take to a sippy cup super-early; alas, she hated every sippy I tried on her for the longest time. She even hated the soft-spout type which are recommended for young babies. Still, it's worth giving them a try; I've heard of bottle-refusers taking a sippy as early as four months.

It doesn't last forever
So in the end, it was okay. I got out without the baby; somehow, with a bit of this and a bit of that, Baby Seal got enough milk inside her.
Now, I should stress, however, that I'm speaking from the privileged position of someone who was able to take six months' mat leave and then work from home while using in-house childcare. If a mother is going to work outside the home in the usual way, a bottle-refusing baby is far more of an issue, which is why (as discussed in a previous post) it drives me nuts when I see lactivists disingenuously advising planning-to-return-to-work mothers to wait for two or three months before introducing a bottle, or even not bother at all. With the best will in the word, babies are not going to get huge amounts of milk inside them with these methods, so if we are talking about a baby who is at a daycare nursery much of the day, suggesting to mothers that they don't bother with the bottle and instead just have their baby fed with an open cup or spoon is basically tantamount to telling mothers to encourage their babies to reverse cycle--a phenomenon which sometimes occurs with breastfed babies of working mothers, whereby the baby eats next-to-nothing all day and then makes up for it by clusterf*ck-feeding all night long. Which some mothers may be okay with, and others most definitely are not. That's even assuming you can get a daycare nursery to handle cupfeeding with a baby in the first place.

However, if you are, say, planning to leave your baby only for the odd evening out or whatever, having a bottle-refuser is a nuisance but not a disaster. Although I do generally rather hate the hoary platitude "This, too, shall pass," this is one of those instances where it does have the ring of truth. Most new mothers aren't doing much in the way of evenings-out for the first month or so after the birth anyway; and then at four to six months you start solids and the feeds start getting fewer and further apart; at seven or eight months baby may start taking a sippy cup, and so on, and the whole situation starts to look completely different. So in the great scheme of things, the time that having a bottle-refusing baby will inconvenience you is really, at most, only a few short months out of your entire life. And even during this period, honestly, you can go out without your baby when you want to--it's just a bit more fiddly and involves rather more spilt milk.

And there is a bright side to having a bottle refuser. At least you don't have to wean them off the wretched bottle if they never take to one in the first place (same with pacifiers). And to be honest, yes, going straight to an open cup probably is more hygienic, and better in terms of palate development and dental health.

In hindsight
Knowing what I do now... if I were to have another baby in similar circumstances, would I bother with the bottles this time? Well... I think would certainly introduce one like I did with Baby Seal--it's worth a try, at least. But I think that this time I wouldn't put myself through all that exhausting palaver of the daily bottle; it was just.so.much.work and I'm really not sure it was worth it. And if my hypothetical second child were to start refusing the bottle like Baby Seal, I 'm pretty sure that this time I wouldn't waste energy on fighting with her over the issue. I would just remind myself that the inconvenience of the bottle-refusing baby doesn't really last very long, and that in the meantime there is nothing more adorably precocious than the sight of a young baby drinking from a teeny little teacup.

Bullshitometer: Breastmilk has more calories than any solid food

Mmm....food!

One of those internet memes that is always cropping up on online forums is "Breastmilk contains more calories than any other food." Like all internet memes, it comes in various forms--"Breastmilk contains more calories than almost any other food," "Breastmilk contains more calories and nutrients than any other food," "Breastmilk contains more calories than any other food except avocado""Breastmilk contains as many calories as melted icecream" and so on. It's usually something you hear when some mother is debating whether to start her baby on solids (because her baby seems hungry on breastmilk alone) or whether to offer more solids to her older baby or toddler who is nursing almost exclusively and is gaining poorly. Sometimes, just to add to the general drama, there is a pediatrician involved in the background who is apparently telling the mother to stop/reduce nursing because this is "filling the baby up on breastmilk" and preventing them from wanting their solids.

This is the point where someone will inevitably advising the mother to sack the pediatrician, nursenursenurse, and not bother about introducing solids/offering increased amounts of solids--or even cut back on the things or stop them completely. Given the "breastmilk contains more calories than any other food" meme, it's easy to see why. If you actually believe that breastmilk contains more calories than any other food, then logically, why would you introduce/increase solids in response to hunger or poor weight gain? In fact, if you took the idea to its logical conclusion, you should actually decrease solids or better still, take them away altogether, because surely the only thing those rotten, puny solids are going to do is fill the kid up and reduce their appetite for your calorie-festa boobie milkshakes. Clearly you should introduce solids as late as possible, or better still, never.

Since my own impression of breastmilk's flavor--oh come on, like you've never tasted your own--is that it does not taste like melted icecream, I did some research into the calories counts of solid foods commonly offered to babies using USDA figures. Very easy to do. Here's what I found:

Food	Kcal per 100g
Acorn Winter Squash (without salt, mashed, cooked, boiled)	34
Cooked spinach	40
Orange	47
Apple	52
Boiled carrots	54
Pear	58
Yoghurt (whole milk)	61
Breastmilk	67
Cottage cheese	103
Baby cereal oatmeal cooked with milk	116
Baked or broiled haddock	128
Egg	154
Chicken breast	195
Brown bread	210
Lamb chop	314
Egg yolk	322
Baby rice cereal (NB: See below)	391

This is a pretty reasonable "range" of vegetables, cereals, fruits and animal foods, and in terms of calorie count, breastmilk comes slap in the middle of the list; not a low-calorie food by any means, but not "melted icecream" or "richer in calories than any solid food" either, not by a long shot.

There are two conclusions one can draw from this. Firstly, look at the things in the upper part of the table with fewer calories than breastmilk: pear, carrot, squash and so on. Notice anything about them? Most of the the things which are offered to very young babies are actually pretty low in calories. So no, giving your five-month-old a few teaspoons of pureed carrot is not going to miraculously make her sleep through the night, as many disappointed parents have found out the hard way (seriously, is there anyone for whom this trick has ever actually worked?). Plus, let's face it, actually getting 100g of breastmilk into a young baby is usually easier than trying to get 100g of banana into them... as opposed to all over the floor, highchair, bib, baby's hair etc. etc.

How about rice cereal? Lest you are goggling at that last figure on the list, I should let you know that this appears to be the figure for dry baby rice; I can't seem to find a figure for rice cereal mixed with breastmilk, which is how it's usually served. Kellymom (which does things in ounces.... Americans, please get with the program and switch to metric like the rest of the planet!) gives 22kcal/ounce as the calorie count for breastmilk and 20kcal for a very watery-sounding "Baby rice cereal  (2 TBS dry cereal prepared in one oz water)," so I'm going to go right ahead and assume that 100g of regular-thickness breastmilk-mixed-with-rice-cereal probably contains somewhat more calories than 100g of breastmilk, though certainly not anywhere near as much as 391kcal. That said, The Sleep Lady is something of a goddess in my household, so when she says that of the countless parents she's worked with over the years who have dutifully given their babies rice cereal every night, she has never seen any cases where actual sleep improvements have resulted, I tend to believe her. Let's face it, there are a lot of reasons why young babies wake at night.

However. The second point one might take home from the chart is that it would appear to call into question the idea that introducing or increasing solids is unnecessary or harmful for on older baby/toddler who is eating very little food and is hungry or gaining poorly.

Three other points:

(1) Breastfeeding at the breast is quite hard work for the nursling, who has to suck hard for every mouthful, and the milk comes slowly. This of course is generally a good thing as it acts as a natural corrective to overfeeding, which is probably why excessive weight gain is less common with breastfed babies. On the other hand, if a mother has a hungry or failing-to-grow child and needs to "feed them up," I suspect that this feature of breastfeeding may become a hindrance, and easy-to-eat solid foods are probably more suited to her purpose.

(2) With breastmilk a mother limited to whatever her body can produce, and at times when it is available--i.e., she's probably going to have to feed throughout the night if she is to stand a chance of providing enough calories. With solids--assuming one is not living in the South Sudan famine belt or something--one can always just go to the fridge and get more.

Granted, some women no doubt can provide more than enough calories to sustain a baby up to a year or even beyond with little or no solid food, assuming they have a strong supply and are prepared to do plenty of night feedings. According to this USDA source, a 1-month-old baby boy requires about 472 calories a day, which means a mother of twin boys would need to produce 944 calories a day in breastmilk in order to exclusively breastfeed them. A single 12-month-old baby boy, on the other hand, requires just 844 calories a day (and bear in mind that breastmilk typically becomes more calorie-dense as your child grows older). Since there most certainly are mothers who manage to exclusively breastfeed twins to a month or well beyond, it would appear that some women, at least, are capable of producing more than enough calories to feed a child healthily to a year or so. There are other reasons why babies need solids by about six months or so (iron and zinc), but calorie-wise, a baby who takes to solids slowly is probably not a problem if they are gaining well and meeting milestones. But not everyone has a terrific supply. If a child is not growing well, they probably need more food.

(3) With the exception of infants in the Gerber puree stage, it's not like we human beings actually tend to sit down and eat Plain Boiled Carrot/Spinach With Nothing Else very often. You're more likely to eat, say, steamed veggies dressed with oil or butter, which boosts the calorie count quite a bit even for those low-cal foods at the top of the list. (And you'll notice that the super calorie-rich things like avocado and olive oil weren't even included on my chart.)

One thing which seem very hard to verify is whether overconsumption of breastmilk really can "fill a child up" and stop them eating enough solid foods. My own hunch would be that if you've a child who just plays with solids, restricting nursing for a bit might be worth a try, to see if it can kickstart a child's developing a bit more of an appetite for solids... some kids are just very reluctant to try anything new and may need an initial kick up the butt to get them going. If that doesn't work, an assessment for texture/aversion issues might be an idea. I very much doubt whether stopping nursing altogether is necessary; some pediatricians are genuinely biased against extended nursing and tend to see it automatically as being the cause of any problem that a child's parents complain of.

Bullshitometer verdict

Breastmilk appears to have plenty of calories--more than a few teaspoons of pear puree or whatever, anyway. That said, it's not true that it has more calories than any other food. If you have an mostly-breastfed older baby who's not growing too well, they probably need more solids. I think it's worth banging on about this a bit because while there is no real evidence that solids-introduction methods have any long-term effects on children, and the differences between breastmilk and formula are probably a lot smaller than many people believe, there is a ton of robust evidence suggesting that chronic shortages of calories (and iron) in the first couple of years can have long-term negative effects, especially on cognitive development.

It might seem like a no-brainer that a child not getting enough calories is bad for them, but it seems a few people really do need telling--and that people who have drunk deep of certain kinds of woo can start looking at their children through a kind of distorted lens. On Trolls With Wooden Spoons (an interesting forum created by former Mothering.com posters who had become disillusioned with the site), I remember an occasionally disturbing thread titled something along the lines of "What was the stupidest thing you ever did under the influence of Mothering.com?" (quoting from memory). One poster wrote something particularly sad. It was, roughly, "The stupidest thing I ever did because of MDC was exclusively breastfeeding my toddler, and telling myself again and again that he was a perfectly healthy toddler who just happened to be really tiny for his age." Yikes. As they say, "Rule No. 1: Feed the baby"!

Attachment parenting isn't about checklists (or is it?)

Happy_Hippie: People are so obsessed with the idea that attachment parenting is about a laundry list of parenting "rules"--that it's about babywearing or baby led weaning or natural birth or whatever. Well, it's not actually about those things at all. It's about following your heart and your child. It's about doing what works for you as a family.


AttachedAndLovingIt: Exactly! What gets me is that they're painting attachment parenting as something for martyr mommies. Well, guess what? I only do attachment parenting because it's actually easier for me--cosleeping and breastfeeding are totally the lazy way! My 18-month-old is still up four or five times a night--can you imagine if I had to go downstairs and sterilize and prepare bottles of formula for him each time?


K8lynne's_mommeee: And recovering from a natural birth is way easier than from a c-section!


GranolaGirl: I have hard time with these sorts of discussions, to be honest. I tried really hard to birth my son, but after 56 hours of back labor, things just weren't progressing and we had to have a cesarean section. And I wanted desperately to do babywearing but he hated the sling. I kind of feel like I was lied to by the books and websites that told me that there is only one correct way to parent...


AttachedAndLovingIt: But GranolaGirl, you CAN be a great attachment momma even if you did have a c-section! I had a c-section and I challenge anyone to say that I'm not an attachment parenting mother--I wore my daughter for hours on end when she was a baby and we did baby led weaning and we co-slept and nursed and used rear-facing carseats till she was almost three, in spite of the fact that I didn't have a natural birth. Attachment parenting is not about checklists, people!


Happy_Hippie: The other thing that really bugs me is the way Time magazine kept talking about attachment parenting as The New Latest Thing To Do--like some sort of a 21st century fad. But the reality is, attachment parenting is just going back to basics--it's the way human beings have parenting since the beginning of time. Hello, co-sleeping and breastfeeding into toddlerhood--all this was considered completely normal and mainstream until very recently in human history!


I'm didn't blog about the Time magazine cover and I'm certainly not going to do so now, because frankly I think we're all a bit sick of this rather stale bit of news that was never particularly interesting in the first place. (My own reaction to hearing about that Time had put an extended nursing picture on its cover was rather like my reaction the first time I heard that scientists had succeeded in cloning animals for the first time: basically, "I'm a bit embarrassed to admit this when everyone else seems so terribly excited about this news, but to be honest I actually had this vague idea in the back of my head that they'd already done this years ago.")

People's reactions to the news were actually a lot more interesting than the news itself. There have been a lot of conversations about attachment parenting taking place on blogs, boards and Facebook pages in the wake of Timegate. Online conversations about attachment parenting are basically really, really weird. They go round and round and round in circles, and are full of contradictions that never really get properly discussed.

Take the whole little speech about "Attachment parenting isn't actually about babywearing or baby led weaning or natural birth--it's not a checklist of parenting rules, it's about relating to your child in a way which works for you" etc. etc., some version of which can be found hundreds of times over on any attachment parenting-oriented attachment parenting-/natural family living-related website or blog, Google group, discussion board or what-have-you.

Now: I would like to propose a little experiment (no, seriously; you can actually try this one out). Go to one of these online fora, and ask people one of the following questions: "How popular is attachment parenting where you live?" "Do other members of your family do attachment parenting?" or "Can you recommend any children's books which have images of attachment parenting in them?" Check the responses.

Now here's the thing: I can guarantee that pretty close to 100% of the responses will basically talk about breastfeeding and bed-sharing, homebirth and baby led weaning, rear-facing car-seats, midwives and slings. "This is a very attachment-parenting friendly area--you just step outside the door and babies in Ergos are at least as popular as babies in strollers." "I'm the only one in my family who does attachment parenting; my sister-in-law [BFWOBS: why is it always sisters-in-law?] formula-fed from day one and had an epidural at 2cm so she wouldn't 'feel any contractions' LOL" "Well, Mommy Had A Baby is pretty attachment-parenting-friendly--the mom gave birth at home and it definitely shows a baby that appears to be in the parent's bed asleep, although I was rather disappointed to see a picture of a baby being spoonfed at one point..." (I remember stumbling across a group of online mothers who were picking over every last detail of a Dora The Explorer episode--yes, really--in terms of whether the newborn mom was parenting her twins according to a laundry list of attachment parenting "rules," and thinking to myself, "I'll definitely be remembering this one next time I hear someone insist that 'attachment parenting isn't about checklists, you know.'")

To be honest, though, you probably don't have to go so far as to start a whole new thread in this manner. See the little imaginary discussion thread above. It's weird, really. Someone will do the whole speech about "attachment parenting isn't about checklists," and someone else--or sometimes the same person--will then go on to say things like "Attachment parenting is the historical norm for human societies, because look at all those ancient tribal people doing bed sharing and carrying their kids in slings" or "I attachment parent because breastfeeding and co-sleeping and babywearing so on are so much easier." And everyone then agrees with everything that everyone else has said, and nobody really points out that some of those statements directly contradict each other. Like, you kind of feel like saying, "Erm, hang on. I thought we'd all just agreed that attachment parenting actually isn't about breastfeeding and co-sleeping and babywearing, right? So... now you're saying it is basically about these things after all? Which do you mean?"

The other comment you might be tempted to make is along the lines of "Sooo.... you're saying that if your circumstances had dictated that formula feeding [for example] had proved to be more convenient than breastfeeding, then you would have done that instead?" Seriously, go to an attachment parenting/natural family living forum and try telling them that "I sleep train because I'm lazy, and sleeping eight hours in a row is easier than being woken up all long by a 12-month-old," or "I prefer cesarean section because it saves me the effort of laboring" or "I'm too lazy to do this babywearing thing. For me it's more convenient to put the baby in an exersaucer and use a pram." You won't get very positive responses (understatement of the century there). This is not an attempt to start a conversation about (for example) whether vaginal delivery or ceserean section is actually the easier way to give birth, because that's actually a very complicated question. Rather, the point is that with the "I am an attachment parent because it's soooo much easier" people, the "easier" solution is only embraced when it happens to be one of the items on the checklist. So yeah... checklists again.

(Actual example: I once came across a discussion on cloth diapering on a certain board I frequent, which was full of posters earnestly claiming that they did cloth diapering out of sheer laziness... Reasons given for this rather incredible claim were that (a) using disposables causes so many blow-outs that you end up doing more laundry than if you were using cloth, and (b) when you are using disposables you constantly run out of them and have to rush to the store to buy more. Now, firstly, disposables only cause lots of blow-outs if you are using the wrong size. And the second argument isn't really very logical, because if you really were trying to minimize effort, the rational thing to do would be to use mostly disposables and keep a few cloth diapers on hand for those times when you run out, not to use cloth the whole time. (Also, I am strangely touched to think that in 2012 there are people who apparently don't know of the existence of online ordering and bulk buying. Back when I used sposies exclusively, I never ran out) Don't misunderstand me--if you have decent laundry facilities and are prepared to mix 'n' match with sposies, cloth diapering is usually not an insurmountable amount of extra work, but honestly, it is extra work and it's just silly to claim otherwise. Well... on this particular discussion thread, an unrepentant disposable diaper-using mum turned up and pointed all this out--and almost instantly the whole tone of the discussion changed and suddenly everyone became very hostile towards the idea of doing diapering or anything else "the easy way." For an outsider, this is all highly amusing.)

 I think you get my point. Honestly, I think there really is a strong element of modern tribalism about attachment parenting and other parenting styles--that is to say, the practice of sorting other human beings into "Us" and "Them" based on differences of dialect/vocabulary, dress, appearance, taboos, food, body modification (or absence of same) and dining rules--whether people are prepared to admit this openly or not. Like... c'mon, let's get real, people. Nobody in the books or on the blogs or message boards actually says you can't be classified as an "attachment parenting" mother if you don't do [natural childbirth, babywearing, whatever]--that's a straw man argument. But these media do do a really good job of making it clear that some choices are definitely considered less equal than others, and of making mothers who are unable to succeed at these things feel permanently apologetic and "less-than" as a result... Like those c-section mothers who, every time the subject of their child's birth comes up, feel the need to go into this long, rambling apology about how much they wanted a vaginal delivery, and how hard they tried, and how much they hate having had a surgical birth, and... It's easy to dismiss these women as hooking for compliments or head-pats, but I think their anxieties are quite genuine. They really are insecure about the way they gave birth. It's all a bit sad, considering that for the most part we are talking about mothers who love their children heartily and whose children are surviving and thriving in their care.

Well, I suppose it might be possible to come up with a more thoughtful definition of attachment parenting that is based on being a truly connected and conscientous parent who does what works for their family etc. etc. rather than being based on checklists (although, if you were to do this, you would have to formally detach yourself from Sears, Granju and pretty much the whole AP canon); the trouble is, if you define any parenting style along these terms, it all ends up becoming so vague as to be completely meaningless. I mean, really, how many parents don't consider themselves to be connected and conscientious parents who do things that work for their families? Not too many.

So, if we recoil at the idea of parenting by checklist, wouldn't it make more sense to just do away with the whole idea of defining yourself by a label in the first place? After all,  at the end of the day the parent-child relationship is merely a human relationship, no more and no less--like being a spouse, a sister, a next-door neighbor or an employee. And most of us would think it kind of odd to actually describe ourselves as a [insert adjective] wife or [insert adjective] daughter-in-law or whatever. (I wonder what a self-defining "attachment wife" would be like? "Sorry, girls, can't have a drink after work, I'm an attachment wife. Have you read Jane Smith's book on Attachment Wiving?" For some reason, I'm envisaging a  kind of crunchified Stepford-Wife type with the secret soul of a bunny boiler, who you know is one day going to snap and drown her husband in the bath. But I digress)

And that's enough of that. I'm got that off my chest. And after four posts in a row that go on (and on) about parenting styles/attachment parenting, I think it's time to step away from the fly-blown horse carcass. Tomorrow I am having a day off from work, and I shall be off to Yoyogi Park with Baby Seal to roll around on the grass with her, laughing and having fun, because that's what you do with people with whom you have a loving human relationship.

And my next post will be on the role of solid food before the age of 12 months. Are they just for entertainment? To what extent do they fill an essential nutritional role? Can you nourish a child effectively for the first year on exclusive (or almost exclusive) breastfeeding? (So far, the answer seems to be "It Depends.") Stay tuned.