0:33 Intro. [Recording date: February 20, 2019.] Russ Roberts: My guest is obstetrician and gynecologist, author and blogger, Amy Tuteur.... Her book, which is the subject of today's conversation, is Push Back: Guilt in the Age of Natural Parenting.... So, tell us about your background, as an observer of all these issues related to childbirth and parenting. Amy Tuteur: So, I'm an obstetrician-gynecologist, as you mentioned. I'm also the mother of four children, now all adults. So, I had my children back in the 1980s and 1990s. But even then, the pressure on women to have a natural childbirth, to breastfeed, and to parent in certain ways was getting started. But, now, it is much worse. And I really feel very badly for a lot of young women who are struggling with the pressure--mostly because it's unnecessary. So many of the things that people are upset about--for example, when I used to be practicing, I used to visit a woman the day after her baby was born; and she would be very, very upset about the fact that she had an epidural--which she hadn't planned on. Or had a C-section [Caesarian Section] that she hadn't planned on. And no matter how much I tried to point out that the reason we were doing this was because she should have a healthy baby and she should be healthy herself, she would be inconsolable. And, I began to wonder why it is that new mothers feel that way; and who is making them feel that way; and what can we do to help them. Russ Roberts: I want to talk about a different--we are going to go through the different aspects of what you call natural parenting--the pressure to not have a C-section, to have a vaginal birth; the pressure to breastfeed; the--and then the issue of what you write about as attachment parenting and how close the child, the infant, should be to the parent at all times versus independence. Amy Tuteur: Right. Russ Roberts: So, I want to go through those one by one. Let's start with the C-section. There is a large--there has been an increase in C-sections in the United States. And the rate--I think in your book you quote a number of, roughly a third of all births or C-section births. And, as a--we had four children. That's not the right pronoun. My wife gave birth to four children. But I was a participant. In, of course, many ways. And one of the ways was that we, neither of us wanted a C-section. And felt there was pressure from parents that we had talked to, from their doctors; sometimes from the nurses--that a C-section was often just an easy way to deal with it. And that mothers who wanted to try longer and to go through labor were often not listened to, at least we were in at the time. So, give us your thoughts on that. Talk about the rate of caesarian section, and why you think that we should be more open to C-sections than we are culturally. Amy Tuteur: So, before we get into the attitude toward C-section, I feel like I need to say that when I was practicing, I had a 16% C-section rate. Which is really quite low. Although I acknowledge that where I am practicing now, it would probably be higher, because the changes in the rules about vaginal birth after C-section. Russ Roberts: When you say "rules," do you mean legal restrictions? Or hospital-imposed rules? Or what? Amy Tuteur: Well, there are legal and insurance restrictions. But they come about because we knew, right from the very beginning that vaginal birth after C-section had a increased risk, compared to vaginal birth in women who hadn't had a previous C-section. And that risk includes the rupture of the uterus and the potential death of the baby. And even the death of the mother. And although women signed consent forms saying that they understood that that could happen, when it began to happen, these women sued. And they won. They sued claiming that they--although they had been told that it could happen, they didn't really understand that it could happen. And, insurance companies paid out a lot of money. And as a result, they directed the doctors and the hospitals that they, um, that they covered, to have certain restrictions on vaginal birth after caesarian. And the American College of Obstetrician-Gynecologists codified some of these restrictions. And they included the ability to perform a C-section within 30 minutes. Which meant that the doctors involved--like, the obstetrician and the anesthesiologist--had to be in the hospital at the time that the woman was in labor. And a lot of community and rural hospitals don't have an anesthesiologist in the hospital 24 hours a day. And so, those hospitals stopped doing vaginal birth attempts after C-section, because they couldn't meet the standards.

6:22 Russ Roberts: Russ Roberts: So, that's one of the reasons that C-section rates are higher for second, third births, that--etc.--that after an original C-section, now those were increasingly C-section also, is what you are saying. Amy Tuteur: Correct. That's right. But I think it's important to go back a little to the history of the natural childbirth movement, to really situate the whole C-section issue within the movement itself. Now, most people don't realize that the natural childbirth movement was created in the 1930s and 1940s by Grantly Dick Read, who was a British obstetrician. He was also a eugenicist. And he was preoccupied--as were many eugenicists in the 1930s--with the problem of what he called 'white race suicide.' He bemoaned the fact that white women of the so-called 'better classes' were having fewer children, while women of color, of the lower classes, were having more children. And he felt that upper class white people would be drowned in a sea of their--what he felt--were their inferiors. And he-- Russ Roberts: He was a racist. He was a terrible racist. Got it. Amy Tuteur: Yeah. He was a racist. He was a misogynist-- Russ Roberts: How does that tie into the Natural Birth, thing, though? The natural parenting? Amy Tuteur: Well, so, he thought that the reason that women were not--women of the better classes--were not having enough children was that they were, first of all, too educated. They were what he referred to as overcivilized. And also that they were afraid of the pain. And, to fix that fear of the pain, it told them it was all in their head. He said that primitive women gave birth easily; had no complications; and had no pain. So, to the extent that women had pain or complications, it was because they were over-educated and over-civilized. Russ Roberts: This is something you call in the book, which I phrase--I like quite a bit--paleo-fantasy. That romanticization of pre-history and our primitive ancestry. Amy Tuteur: Right. But, he did it with a purpose. It wasn't that he didn't understand what childbirth had been like in nature. He wanted women to feel bad if they didn't give birth to children--a lot of them. And easily. And, that--the movement in the United Kingdom crossed to the United States in the 1950s where it got a somewhat different spin. And that was because medicine had become very paternalistic, both toward women and toward men. But women rebelled first. And, one of the things that they were unhappy about was that the only anaesthesia available was anaesthesia that put you to sleep. And, they wanted to be awake for the birth; and they were willing to accept the pain. And that's fine. You know--if that's what women wanted. And, the natural childbirth movement, as it crossed to the United States, it was responsible for a lot of important and valuable changes. Natural childbirth advocates asked, 'Why can't husbands and partners be in the delivery room?' And, doctors at first responded, 'Well, they can't.' And women said, 'Well, why not?' And doctors said, 'Well, actually we don't know. We always did it that way; but we don't know why we did it that way. We'll change.' And so, a lot of things changed, in the 1960s, 1970s, and 1980s. Also, what changed is the development of epidural anesthesia. And the improvement of safety of Caesarian sections. It is important for people to understand that up until the 1930s, C-sections were extremely dangerous. They were considered a bad thing. So, a lot of women would have vaginal births and their babies would die. After anaesthesia became better, and then definitely after introduction of spinal and epidural anaesthesia, C-sections became safe. And anesthesia became safe. So, there was no longer a medical reason to avoid c-sections. And, not surprisingly, the c-section rate grows. Because all the doctors wanted to save all the babies they possibility could. Russ Roberts: But it does pose--impose a much different post partum, after-birth experience for the women involved, in terms of recovery and ability to be with the child. So, talk about that. Amy Tuteur: Well, again, it all depends on how you frame it. It's certainly a much better recovery than if your baby dies. And that was the choice. Now, what also happened during that time period was the reemergence of midwifery as a profession. And, there have always been midwives; and they have always struggled to make birth safer. But, the reemergence of midwives had more to do with differentiating themselves from obstetricians. And so midwives began to promote what they could do as good and natural, and demonize what doctors could do as bad and harmful. And vaginal birth is a great thing, but it's not the right thing for everyone. There's actually a high rate of infant mortality and maternal mortality; and C-sections--in fact, Atul Gawande actually wrote about this--C-sections have saved more lives than almost any other surgical procedure. They've been an amazing success. Are there too many? Yes, there are potentially too many. But, of course, the problems with having too few are much bigger than the problems with having too many. And, you know, you don't want to have a C-section--it's surgery--that's fine, you don't want to have a C-section. But, you shouldn't feel bad if you do have a C-section. That's what's really changed. Not so much that women are disappointed, but they feel they've done something wrong. And they haven't done anything wrong. And they are told that they have missed out on a certain kind of experience. And they haven't really missed out. In the entire history of human existence, no woman said, 'What I really want is to have an agonizing, painful, near-death experience when I have a baby.' Russ Roberts: And it puts my child at risk, on top of it. Amy Tuteur: It definitely puts my child at risk. But what's happened, and it's kind of like what's happened with vaccines, is that neo-natal mortality and maternal mortality are now, fortunately, very rare. And so people have gotten the wrong idea--that childbirth is relatively safe. It's not inherently safe. Obstetrics has made it safe. C-sections have made it safe. Anaesthesia has made it safe. So, you can't really say what we want to do is go back to unhindered childbirth because it was awesome when it was unhindered childbirth. No: It was horrific when there was unhindered childbirth. And what we're looking for now is a balance: Are we at the right place? I don't think we're at the right place. But, we need practical solutions, not demonizing c-sections, and definitely not demonizing women who have c-sections.

14:31 Russ Roberts: Let me ask a question of you as a practitioner; and it's not an easy question to answer; but, certainly there are births you attended where a C-section was called for unequivocally to save the life of the child or the mother. There certainly were times when a C-section was a risk that was being endured to gain something that was very remote, that safety. And then there's the gray areas, the in-between cases where it's hard to know whether a C-section is the definitive response to the risk that the mother and child are facing. As a practitioner, how many times, or how often, or how agonizing was that middle situation where it wasn't clear what the right thing to do is? I ask this because, our first--'our,' again the wrong pronoun--my wife's first delivery of our daughter, our doctor was--it was in the middle of the night; he hadn't arrived yet. There was a monitor of the baby's heart rate, my daughter's heart rate. It was going to very low levels when contractions were occurring. And the attending nurse--it was either an attending nurse or an attending, very young, inexperienced doctor--said, 'I think we need a C-section. Sign these forms.' And, we, like you point out, we were emotionally, culturally against a C-section. Whether that was right or wrong. But there was a lot of pressure on us, and we were not sure what to do. And very shortly thereafter the doctor came, and said, 'Oh, that's just the contraction. Don't worry about that.' And my wife had a very painful, but a vaginal birth; and mother and daughter were fine. That kind of moment, where it's not clear what the right thing to do is: Is that common? Or, in other words: How much leeway is there in trying to decide? I mean, I assume, as an economist, it's not usually--it's usually not open and shut. To use a bad metaphor. It's hard to know what the right thing to do is at any one time. And I think the legal system encourages doctors toward--I worry that the legal system encourages doctors toward c-section. So, what are your thoughts? Amy Tuteur: Well, the real issue is that we have a technical problem. We know that childbirth can be dangerous for babies, because every time the uterus contracts, the baby has to, figuratively, hold its breath. It cuts off the blood flow to the baby. That's not really a problem if the placenta is functioning well. But, you might imagine that, in a baby that isn't getting enough oxygen through the placenta between contractions, each contraction, it causes the baby to hold its breath and it doesn't have enough, for lack of a better term, enough breath to hold. It begins to suffer oxygen deprivation. We could eliminate a significant proportion of unnecessary C-sections if we could measure the baby's oxygen content. But, the baby is inaccessible to us. We really can't measure the baby's oxygen content. All we can do is listen to the baby's heartbeat. Now, imagine if you had a problem, a medical problem, and you went to your doctor; and the only thing your doctor could do was listen to your heartbeat. Obviously, if your heartbeat was really, really slow, your doctor would know that you were in terrible trouble. And if your heartbeat was normal, your doctor would be relatively safe in assuming that you were okay. But if it were somewhere in the middle, and there was nothing else the doctor could do to figure it out, both you and the doctor would be in a very difficult situation. Russ Roberts: Yup. Amy Tuteur: And that's the situation that we're in now, where we know some babies will be harmed by labor; we know what some of the signs are. But we don't know the thing we really want to know, which is: Is the baby getting enough oxygen? So, we have this very imperfect test, to measure the baby's heart rate. And the thing about that test is that it has a really high false-positive rate. In other words, it will show distress even when the baby is not in distress. But it also has a really low false-negative rate. So, if it shows that the baby is fine, the baby is definitely fine. So, then the question becomes: If it suggests that the baby is in trouble, what should you do if you can't actually figure it out? And, that is really a value judgment. And it depends on the patient's values and the doctor's experience. An experienced physician might be willing to wait and see what happens, reasoning that if things are going badly, they'll get worse; and they can intervene then. But, a lot of parents don't want to wait and see. They don't want to risk their baby's health or their baby's brain function. And they're--when they are told that the baby might be at risk, they say, 'You know what? I'd rather help[?] the baby. I'd rather have a baby who is completely intellectually intact.' And therefore, the number of c-sections has risen. Because, when you can't be sure, a lot of people feel it's better to over-treat, because the consequences of undertreating are so devastating.

20:48 Russ Roberts: So, your point, which I think is easily missed--you just sort of alluded to it briefly a few minutes ago, which I think is worth emphasizing, is that until, maybe, certainly it started at the beginning of the 20th century but certainly before the 20th century--childbirth was a terrible cause of death--of not just infant mortality of children that didn't survive or died before delivery, but of maternal mortality. And that transformation is one of the great achievements of human history. Amy Tuteur: Absolutely. Russ Roberts: It's just under-appreciated. Give us some feel for what the magnitudes used to be. Again, in semi-modern times. Not ancient times. Amy Tuteur: Well, in terms of maternal mortality, which is still higher than we would like it, but much, much lower than it was: If maternal mortality were now at the same rate now that it was, say, in 1900, approximately 45,000 women would die each year in childbirth. And that's equivalent to the number of women who die each year of breast cancer. And we all recognize breast cancer as a terrible scourge. So-- Russ Roberts: How many women die now of, in maternal, in childbirth? Amy Tuteur: In the United States, between 700 and 800 women a year. Which is more than we would like-- Russ Roberts: wish it were lower. Yeah. Amy Tuteur: But that's a far cry from 45,000. Russ Roberts: Now, I should just mention that: There's been a recent uptick--not small. The word, 'uptick,' is not the right word. A spike in maternal mortality in the United States. And, that, we could spend the whole rest of the time on that. Because it's complicated--to me, looking at it from the outside. It seems to me a change in how it's been measured-- Amy Tuteur: Absolutely-- Russ Roberts: and the way that states [nations?--Econlib Ed.] report maternal mortality. I don't think the United States has become more dangerous place for women to give birth. And one of the challenges of measuring maternal mortality is that a woman who dies 6 months after childbirth can be classified as an example of maternal mortality. Because of a coroner's decision and the way that was kept track as changed over time-- Amy Tuteur: Right-- Russ Roberts: So it's quite complicated. I just want to mention that for listeners. This is the kind of issue that we like to talk about here: how data can be, quite, a lot more complicated than it appears. The other issue is that, the United States has a very high rate of deliveries of women, 40 and 45 and older, which are more dangerous. Amy Tuteur: Yeah. So, that seems to be less of an issue. It's certainly a problem. But, I think the important thing is to look at what women are dying of. So, the--the shape of the problem has changed dramatically. In 1900, women were dying primarily of hemorrhage. Of infection. And of pre-eclampsia. In 2019, women are dying primarily of cardio-vascular disease, including congenital heart disease. And, pre-existing chronic conditions, like kidney disease, diabetes, other things. And so, what you find is that women are dying of high-tech problems that require high-tech solutions. And, you think about how we lowered infant mortality: One of the things that we did is we developed a triage system: different levels of nurseries. We have Level 1, 2, and 3. And, we transfer babies to Level 3 Nurseries if they are very sick, because those nurseries have specialized care. And that's dramatically improved neo-natal mortality. We have nothing like that for mothers. And we should be putting together something like that for mothers. We should have more peri-natologists, more maternity ICUs [Intensive Care Units]. Because, those are the women who are dying. And they are dying from lack of technology. So, one of the things that I find very upsetting is that, although we can argue whether, um, childbirth has been medicalized too much, when it comes to the issue of maternal mortality, the women who are dying are dying because they lack access to that technology. And it's bizarre--and very unfortunate--to claim that we could reduce maternal mortality if we lowered the C-section rate. Or lowered the intervention rate. Because, those things have--are exactly the opposite of what is going on. And, that's a phenomenon that I have referred to, and others have referred to as 'Medical Colonialism,' in that we have been expropriating, or activists have been expropriating the tragedies of underserved women to advocate for what privileged women want. So, you find something like, New York State, promoting doulas, in response to the maternal mortality situation. Russ Roberts: Explain what a doula is. Amy Tuteur: A doula is--it comes from the Greek word for slave. And it's basically a woman who helps other women cope with childbirth. Who supports them through childbirth. Both by giving encouragement and also by, you know, cold washcloth for their brow, cheerleading when they are pushing. Things like that. Russ Roberts: Counting, for their Lamaze breath. Amy Tuteur: Right. Right. But the, the sad thing, the tragic thing, is that, while doulas are very good, and they can definitely improve the experience of childbirth, the women who are dying are not dying from bad experiences. They are dying from heart disease. They are dying from kidney disease. And, it seems perverse to offer these women who are suffering a amenity that privileged women would really enjoy. Russ Roberts: Yeah. Um. Let's--I agree.

27:25 Russ Roberts: Let's move to the epidural issue. A lot of people believe--and I know you do not, so I want to hear your take--a lot of people believe that an epidural puts the baby at some risk. And therefore it's better to have a "natural childbirth." And that that pain relief is just unnecessary. Amy Tuteur: Well, unnecessary for whom? You know, I happen to think, as a physician and as a human being, that treating pain is the cornerstone of what any person should do for any other person. If somebody wants to be in pain, that's okay. But, um, you know, all pain relief has risks. Why is this the only form of pain relief where anybody talks about the risks? And why is it that those risks are magnified? So, for example, the risk of--the risk of a baby being harmed by an epidural is purely theoretical. The risk of a baby being harmed by attempted vaginal birth after a Caesarian is both very real and orders of magnitude greater than any theoretical risk of epidurals. So, why are natural childbirth advocates promoting VBACs [Vaginal Birth After Cesareans], but demonizing epidurals? It doesn't make sense, if what they are really talking about is the risk. Russ Roberts: A VBAC is a Vaginal Birth After a Cesarean. Amy Tuteur: Correct. Russ Roberts: So, what are your thoughts on the risk? You said it was theoretical? Or hypothetical? Amy Tuteur: There's really no risk. I mean, you know, one of the things that I always find very interesting is that women obstetricians don't believe any of this stuff. Because it's nonsense. Women obstetricians have epidurals in droves. They have C-sections at much higher rate than average. They don't believe,and their experience tells them, that these things are not bad things. They are just choices. And, one of the reasons that they've been portrayed as bad things is, sadly, because of the reemergence of midwifery. Midwives can't give epidurals. Midwives can't do C-sections. And so they've demonized them. In the United Kingdom, where midwives can administer Nitrous Oxide--laughing gas--for pain relief in labor, they consider that perfectly compatible with a natural childbirth, even though that's a drug. Russ Roberts: That's interesting.

30:09 Russ Roberts: Let's talk about breastfeeding, because that's another area where there's been a lot of emotional, cultural issues that interface with actual science to the best of our knowledge, which is, of course, imperfect. There's a lot of pressure on women, you suggest in your book, to breastfeed rather than to administer formula. Why is that a mistake? Amy Tuteur: Well, I often say that the key thing to know about breastfeeding is that the moralization of breastfeeding parallels the monetization of breastfeeding. Sometimes it's an advantage to be old--like I am. I'm 60 years old. And I remember a time before formula--before breastfeeding was magical. When it was just a way that you could feed your baby. A good way, but it didn't have all these supposed benefits. And then came the profession of lactation consultants. Which are good things. They are very helpful to women who are trying to breastfeed. But, instead of concentrating on helping women who want to breastfeed to do so, they are constantly seeking to increase market share. They want every woman to breastfeed. And that's, honestly, none of their business, how another woman uses her body. If a woman wants to breastfeed--great. I mean, I breastfed my four children. I enjoyed it. They thrived. It was a great experience. But that doesn't me the ideal that other women should aspire to. Other women have different preferences, different life histories that may make them feel differently about breastfeeding. But we've crushed that under the notion that breastfeeding has such massive benefits that no good mother should avoid doing it. And, theoretically, it's possible that breastfeeding has all sorts of massive benefits. Certainly there were small studies that suggested it might. But we've already done the big study that shows that it doesn't have big benefits. You know, two entire, nearly entire generations of Americans were raised on formula. Nothing happened that was bad. And, if you look at, um, breastfeeding rates, they've gone up dramatically since the 1970s. In 1973 I think we bottomed out with a breastfeeding initiation rate of 24%. Now, over 80% of women are leaving the hospital claiming that they are going to exclusively breastfeed. And in that time, there's been absolutely no impact on the infant mortality of term babies, and no impact on major parameters of infant illness and hospitalization for term babies. The only proven benefit has been for premature babies who have immature digestive systems. So, at this point, honestly, we are just lying to women. In order to get them to breastfeed, we tell them it has benefits that it doesn't have. Russ Roberts: And the benefits, we're told, are better immunity against disease, better nutrition, healthier--whatever. Amy Tuteur: Right, but then you should be able to see it. It's not that it couldn't have those benefits. But if it did have those benefits then the breastfeeding rates should at least be related in some way to infant mortality and infant morbidity--which is sickness. And, look around the world: the countries with the highest breastfeeding rates have the highest infant mortality rates. And the countries with the lowest infant mortality rates have the lowest breastfeeding rates. Russ Roberts: But as you would point out--and you do in the book--there are lots of other factors. And so, those kind of crude comparisons are not definitive. They are provocative-- Amy Tuteur: It's not that they are not definitive. It just shows that people have been deceiving women. Don't tell women--if you look at the Lancet papers on breastfeeding or the World Health Organization, they say 823,000 lives could be saved each year if more women breastfed. Well, in the first place, those are not in industrialized countries, so why that should matter to American women is an issue. And in the second place, it isn't even true. Because, babies don't die of lack of breastfeeding. They die of prematurity; they die of congenital anomalies; they die of dirty water. But, breastfeeding is not going to save that many lives. And it's wrong to keep insisting that it will. Russ Roberts: Well, in the poorer countries that don't have access to clean water, breastfeeding--a crude switch, just simply nothing else changes but formula is used less and breastfeeding is used more--that could save lives because that water issue. But it wouldn't be the breastfeeding per se. It's that the water is the problem. Amy Tuteur: Well, and not only that: It's all well and good to breastfeed your baby till two; and then the baby has to still drink the dirty water. And then the baby will die. So, if we really want to save lives in those countries, we should help them with water purification. Russ Roberts: I agree with that.

36:05 Russ Roberts: You mentioned a study, and you talk about it in the book, of siblings. Obviously, as you point out, many studies that purported to show that the benefits of breastfeeding were flawed because the sample of people who chose to breastfeed in the past was not a perfect match--control--with the people who weren't breastfeeding-- Amy Tuteur: Correct-- Russ Roberts: Classic problem in economics and epidemiology and elsewhere. But, there was a study that was somewhat more controlled, which is of siblings. Can you talk about that? Amy Tuteur: Yeah. The Colen study was published in 2014. And it was a very elegant study. And it looked at 10 years of data in New York State. And it looked at the difference between, within families, between children who were bottle fed and breast fed. And there was no difference. All the parameters that seemed to be different for, if you looked as a group, of all children who were breastfed compared to all children who were bottle fed, on 11 different measures, like asthma and IQ [Intelligence Quotient] and you name it--every single one of the advantages that supposedly accrued from breast feeding disappeared. Russ Roberts: And not surprisingly, breast feeding advocates have suggested that study is flawed. Amy Tuteur: Right. But, you know, I think that the important thing here--we can get into the weeds with the scientific evidence, but the important thing is: This is an issue of choice for women. This is not just about what is good for babies. And, the fact of the matter is that the benefits of breastfeeding are so trivial that you can't even measure them. I mean, we can't find them in any large population. And, if that's the case, why are we pressuring women to use their bodies in an approved way? Shouldn't it be up to women to weigh the risks and benefits? I mean, why do we have something like the Baby-friendly Hospital Initiative, which goes into hospitals and pressures women to breastfeed? That, to me, is completely unethical. Russ Roberts: Well, you talk about the self-interest of lactation consultants--you mentioned a minute ago. The irony, of course, is the original claim, was that formula has been foisted on women by the profiteering of multinational corporations. And now, you are suggesting that that's being overwhelmed by the self-interest of licensed and trained lactation experts. Amy Tuteur: Well, the fact of the matter is, formula was not foisted on people by formula companies. Formula companies met the need for--women were already not breastfeeding. They were feeding their children cow's milk and various other concoctions instead of breastfeeding. And those babies died at a massive rate. We found infant feeding bottles from ancient Egypt. There have always been women who can't or don't wish to breastfeed. Formula fills the need. Did formula companies do a terrible thing in Africa in the 1970s? Absolutely. They did. And formula companies should be demonized for that. But that doesn't mean we should demonize formula. And that doesn't mean that we should pressure women in 2019 to breastfeed to punish formula companies for what they did in 1970. Every woman should be able to make her own decision. You know, people--lactation consultants talk a lot about the benefits of breastfeeding. Well, what about the benefits of trusting mothers to do what they think is best for their babies? What about the benefits of not pressuring them? I don't understand why that doesn't end up on our radar somewhere. Russ Roberts: Well, I just want to mention: At one point I think you talk about the claim that 'a single bottle of formula is harmful to a baby's health.' This just seems to go against common sense. It reminds me of--I may have mentioned this before, but I think it's a tragic story; I think it's informative of human nature. Adelle Davis, the nutrition advocate and expert, died of cancer. And when she got cancer, she attributed it to a bag of potato chips she had eaten as a child, or in her youth. Amy Tuteur: Right. Right. Russ Roberts: And, that just--I mean, that's human nature to find things that allow us to keep our narratives intact. But the idea that one bottle of formula is going to lead to a disaster--but that is the claim. Is that correct? Amy Tuteur: Well, yes. And it's part of a larger effort. Lactation professionals are well aware that the benefits that they predicted for breastfeeding have not come to pass. So, now they are predicting ever-more arcane benefits. And the latest thing is that formula ruins the micro biome of the infant gut. And that formula somehow changes the genetics of babies--the epigenetics of babies. Those things are both unproven, but also they are acknowledgement that the other benefits that they've been touting all this time have not come to pass. Russ Roberts: Yeah, and of course it's possible that, as you say, the rise in breastfeeding in the 1970s and 1980s and 1990s and into today will lead to children who will live much longer: 'All the problems of formula and breastfeeding are going to show up in old age.' It's conceivable. I think it's unlikely. And with you: I think you want to focus more on the infant morbidity and mortality. But, it's conceivable that these kind of benefits could be there. But, as you point out, finding evidence--there's no real reason to think it's the case. Amy Tuteur: Right. And, in the meantime, we're just flattening women. We're just telling them, 'This is what you have to do, and if you don't do it, you're a bad mother.' And women are literally committing suicide over this, over these, essentially non-existent benefits. Because they are being pressured. And, you know, one of the things that I've come to wonder about, and animates all that I do now, is: Why do good mothers feel so badly about themselves? And the reason is because there is a whole bunch of people whose profession is to make them feel badly about themselves. You know, make them feel badly if they don't breastfeed. Make them feel bad if they had a C-section. Make them feel bad if they had an epidural. How on earth is this helpful to babies, let alone to mothers? I don't see it.

43:17 Russ Roberts: Well, there is another issue--it came up in our earlier episode with Emily Oster on how to deal with pregnancy and what's the evidence on the right behaviors during pregnancy. And I want to let listeners know: I expect to have Emily on in the next few months, on her new book, Cribsheet--good title-- Amy Tuteur: yeah-- Russ Roberts: which is what we know about the child-raising process, once the birth has happened. And one of the issues that came up with Emily before is that, there would be issues like, should women have a glass of wine while they are pregnant. Should they drink caffeine? One of the things that matters in the health of the baby is the mental wellbeing of the mother. And, driving perspective of moms, or moms after childbirth, is not the best thing. It comes with a cost. That's all I'll say. As an economist, it's-- Amy Tuteur: Well, it more than comes with a cost. It suggests that what's going on here is not what we see on the surface. I mean, most people don't realize that like natural childbirth, both breastfeeding and the attachment parenting movement, were started by people who were explicitly trying to force women back into the home. [?] began in the late 1950s and came out of a traditionalist Catholic mothers' group, where the women, in this suburb, were upset that some mothers of young children were going to work. And they reasoned that if they convinced women to breastfeed, they'd have to stay at home. And so, the history of lactivism has always been about getting women to stay home. And, over the years--what you told them had to change. Because our sensibilities had to change-- Russ Roberts: yeah-- Amy Tuteur: So, it used to be, well, breastfeeding is good. You should stay home and do it. Now it's: You better breastfeed, or your child will be mentally defective and [?] it may be penitentiary. But, again, it's an effort to manipulate women. And attachment parenting--which, in its most popular inception is, by Dr. Bob Sears--Bob Sears was the medical director--I mean, Bill Sears. Bob Sears is his son, the anti-vaccination person. Bill Sears was the Medical Director of LaLeche League. And he and his wife believed, and they wrote in their first book, which is something like The Christian Guide to Parenting and Childbirth--they said that attachment parenting was given to them by God. They prayed on it and they received it from God as the way that God wants the family to be ordered, with the husband as the head and wife solely occupied with caring for him and the children. And I don't think that you can really ignore that these things were created to control women, and that they still are attempting to control women. That's a bad thing, in my view. Russ Roberts: Well, I want to come to attachment parenting next. But, before we do, it's important to mention for people who have never fathered or mothered a child, that not every woman can breastfeed. On a physical basis, to produce enough milk to sustain the health of the child--I think most people just assume that this just a question of convenience. If you are working, it's hard to breastfeed. You have to pump milk and store it, or bring your baby to work, or get home for lunch; or whatever. But this is not what we're talking about. It's relevant; but, what we're talking about is the fact that-- Amy Tuteur: Well, right. But the reason they assume that--they don't assume it. They were told that by the lactation profession. If you read official lactation literature, it says that the incidence of insufficient breast milk is rare. But it's not rare. It's common. Just like miscarriages are common, because pregnancy isn't perfect, insufficient breast milk is common because breastfeeding isn't perfect. And yet, there's no acknowledgement of that. And so that the women who were told that breastfeeding is natural and there's not going to be any problem so long as they were committed to it and loved their baby enough, when they find themselves with insufficient breast milk, they blame themselves. They consider themselves freaks. I mean, imagine if we told women, when they had a miscarriage, that it was their fault? There's enough grief that comes from having a miscarriage without blaming women for it. And, what we've done with breastfeeding, we've said that women who are having problems, it's their fault. It's lack of, insufficient--it's lack of devotion, and lack of concern, and laziness. And, honestly, I can't think of anything more cruel than that. Because, it's not true.

48:28 Russ Roberts: So, let's talk about that. And I agree with you. Let's talk about attachment parenting. And I want to mention that--I want to set this up with--just let you react to this. We had Sebastian Junger on late last year. And there were many interesting things that came out of his book, Tribe. But, one of the themes of that book is that it's cruel to make small children sleep in their own room, because we evolved, of course, probably, in situations where parents and children slept close to one another, because there was a lot of physical danger through most of human history. So, you wouldn't go put your kid out on a--15, 20, 30 yards away. You'd keep 'im close. Because otherwise they'd get eaten by a sabretooth tiger. So, his claim is that--and I found this very poignant, and I know you're a skeptic on some of this, so I want you to react to it-- Amy Tuteur: Oh, yes-- Russ Roberts: Hang on. So, I'm just going to finish this example, though, because it's juicy. His claim is that the attachment that children have for their teddy bear, their stuffed animal, is this desperate attempt by a small human being to find the source of comfort in a world where they've been shoved out of the family bed. So, the idea that kids should sleep in their own room because it's good for them, they'll get better sleep habits, he suggests is actually not true; and in particular he suggests that in most cultures in the world, the idea of making your kids sleep in their own room would be seen as a sign of cruelty. So, talk about attachment parenting generally; and then tell us why-- Amy Tuteur: Well, I want to address that, because I think it's nonsense. It's nonsense on a number of different levels. First of all, the idea that there was one universal culture in pre-history and that all people did the same thing, and parented the same way is just completely bizarre. And, you know, if there was anything I learned from practicing medicine, it was that people in different parts of the world--because when you practice medicine in a city like Boston where I am, you meet people from all over the world--that there are a zillion different ways to raise children. Just like there are a zillion different ways to conduct marriages, and whole bunch of different ways to relate to your parents--you know, your adult--when you are an adult to relate to your parents. There's all sorts of different ways. And, one is not better than the other. I saw people from other cultures parent their children in ways that I would never parent, who raised happy, healthy, well-adjusted people. And, it seemed to me that the key, in looking at all these different cultures, was that children need to be loved, and need to know that they are loved. And that, all the rest is just commentary. Russ Roberts: Yeah--so, sending them off to their own room is like saying, 'I don't love you.' Amy Tuteur: Well, that's ridiculous-- Russ Roberts: By the way: All my kids, most of my kids, slept in their own room. They did in the mornings, sometimes, crawl into bed with us. But we did put them in their own rooms. So, I'm just--just to get that on the record. Amy Tuteur: Well, I mean--my husband and I had basically what you would call a family bed, because we let anybody crawl in who wanted to. That worked well for some children. For other children, they were disgusted that we took up too much room. And went back to their own beds. But, you know, that's another thing about this, that: Not only the idea that all ancient culture was homogeneous across the entire world and across 50,000 years of human pre-history. It's that all children need the same thing: That, you know, what's good for one child will be good for all children. And, one of the great things about having more than one child--and I don't know if you and your wife also felt this way--is that you learn that everything is not your fault. That, children are born with their own personalities, and their own needs; and that the challenge of parenting is meeting the need of the child in front of you. Not some theoretical child, and not some pre-historic child, but the actual child standing there who needs something specific from you. And that might be something very different from what his brother or sister needs from you. Russ Roberts: So, you have four kids. We have four kids, also. All of ours, it turns out, are the same. Exactly the same personalities, needs. Actually, the only thing they have in common is that they don't listen to EconTalk with any regularity. So, I can actually talk about them as much as I want. But, our kids were--yeah. One of the blessings of having more than one child, and even more than two, is the variety of personality, [?] skills, gifts, shortcomings, challenges, handicaps. It's an incredible--and I think they all came from the same parents. I'm pretty sure. Not 100%; but of course, it can't be. But I'm pretty confident that they are still from the same urn of genes. But it just comes out differently. Amy Tuteur: Right. And so, you know, this idea that there's some Ur-child that we're all parenting is ridiculous. And, I also encourage people to consider: Why is there natural mothering, but no natural fathering? Why aren't people saying, 'You know, what children really need is for their fathers to go out and hunt big animals with spears?' And-- Russ Roberts: Well, we've had some guests who hinted[?] that as being a healthy thing. I'm just going to leave that alone. Amy Tuteur: Right. But, for example, you know, we--one of the things that we do nowadays is have fathers in the delivery room when children are born. No indigenous, or virtually no indigenous cultures have fathers involved in childbirth. They are--women are banished to some hut or room or something far away from the men so they won't contaminate the men with the blood. And, when they are healed, then they can come back. So, why is it that we're not seeking to re-emulate that and banish women to birthing huts, and yet we're supposed to be, you know, re-emulate the family bed? Russ Roberts: I have to say--I think my favorite moment in your book is when you talk about the husband who is there in the delivery room to support his wife, and she's in terrible pain; and she demands and epidural; and the husband says--it reminds me of the scene in Young Frankenstein. This is two, a couple of episodes in the last few months with this, where Gene Wilder says, 'No matter what I do, no matter how hard I beg: Don't open that door.' Well, similarly, this couple had decided, in advance, when they had their faculties fully about them, that they would not get an epidural. And they--*ahem* the wrong pronoun--would have a natural childbirth. And then, when confronted with the actual experience--and I should mention my wife had four natural childbirths; very pleased with that--she is; it was her choice--but, many women choose not to. And this woman, in the throes of labor, decided she wanted an epidural. And her husband said, 'Well, honey, you know we just decided--when you were calm--that this was not a good idea. So, I'm just--we shouldn't do this.' And at some point, as this conversation continued--I think the quote is, the mother turned to the doctor and, speaking of the husband, said, 'Kill him.' Amy Tuteur: Yes. Yes. Russ Roberts: Which, a number of women have confessed to me that they have said things in the middle of labor that they regret. That might be one of them; might not be. I don't know. But the idea of the husband being there is different, yes. Not common. Amy Tuteur: Well, and that kind of incident really encapsulates so much of what is wrong with these movements. I mean, where else in, you know, in higher breadth of human existence would somebody ask you to decide whether or not you needed pain medication before you experienced the pain? And yet, that's what we tell women to do. And, you know, you talk about your wife had four natural childbirths. Well, I had four children, two with epidurals, two without. And so I can speak to the difference. And the difference was, the pain. Russ Roberts: Yeah. Amy Tuteur: That was the difference. Russ Roberts: That reminds me of when we would go to classes before our children were born, and they would teach Lamaze to my wife and I. And I, of course, was a participant, because I was going to be her coach and help her with her breathing. And, you know, I--she found a place during her births and deliveries to get through it. I don't know if Lamaze had anything to do with those at all. But I expressed skepticism beforehand, because I said, 'If you could really control pain by breathing, they'd teach it to soldiers.' Or other people. The fact that it's only taught for childbirth suggests that it probably doesn't work. Amy Tuteur: Right. It doesn't work. It absolutely doesn't work. And, it's--frankly, I think it's encouraging women to torture themselves, and embracing them for doing it. I mean, if you need a fallback and you are afraid of an epidural--fine; don't have an epidural. But don't tell me that this is empowering women. Why is it that women are the only ones empowered by pain and not men?