Wednesday, April 7, 2010

Is it wrong to talk about the public health importance of breastfeeding?

So there was this article in Pediatrics that estimated there are 911 preventable deaths a year in the U.S. due to lack of breastfeeding.

Should we not say that? The comments sections of a lot of the media coverage of this article, and several bloggers, think so. Apparently, saying that lack of breastfeeding has real public health consequences is making women feel bad. Because there are a hundred ways in which women in this country get poor support and/or have their breastfeeding attempts outright sabotaged, a lot of women don't manage to breastfeed successfully. So we should stop saying that breastfeeding has important public health effects, because then some women will feel guilty that breastfeeding didn't work out for them. Do you follow? I don't. I really, really don't.

I see an implication in those comments that no one is grappling with the structural issues that affect breastfeeding success, that breastfeeding advocates are not interested in those issues. I beg to differ. At the Breastfeeding & Feminism conference (which was awesome, and I only wish I had the time and brainpower right now to talk about the many facets of awesomeness) you could meet dozens and dozens of people who grapple with these issues in a vital part of their academic, professional, and/or personal capacity. If you feel like all breastfeeding advocates are doing is trying to guilt or shame women into breastfeeding, you aren't looking very hard at breastfeeding advocacy in this country.*

Just at my university and the associated hospital, I can think of the following breastfeeding advocacy projects happening right now: improving child care centers' breastfeeding-friendliness, working for the hospital to go Baby-Friendly, getting funding for free pumps for NICU moms, providing breastfeeding support training for physicians and medical residents, improving lactation room information and access on campus, encouraging businesses to identify as breastfeeding-friendly, training lactation consultants, teaching prenatal breastfeeding classes, referring to local WIC peer counselors, providing discounted pumps to university students & employees, offering a local breastfeeding support group for African-American moms, and studying the impact of each Baby-Friendly step on hospital breastfeeding rates.

With all of that work to facilitate people reaching their breastfeeding goals on a structural and community level, you can understand why I'm so frustrated when articles like the one in Pediatrics get the reception they do. Which of those activities is targeted at making women feel guilty? Which is just about trying to control women's bodies and tell them what to do?

In fact, let's take a look at the conclusions section of the article itself which reads, in its entirety:

"By being incredibly selfish and not trying hard enough, 911 American mothers kill their babies every year by not breastfeeding. Clearly, public health and medical authorities have failed to make women feel guilty enough for not breastfeeding. Further efforts are required to make all mothers feel shame for any amount of formula that they offer their babies, regardless of their individual circumstances."

Oh, whoops! That wasn't the actual conclusions section. I got confused there for a moment. Here's the real one:

"By allowing breastfeeding rates to continue at their current levels, rather than implementing supports to help more families follow medically recommended guidelines, the United States incurs billions of dollars in excess costs and hundreds of preventable infant deaths. Action to improve breastfeeding rates, duration, and exclusivity, including creation of a national infrastructure to support breastfeeding, could be cost-effective."

I don't see a single mention in there even of education targeted at consumers. I don't even see individuals mentioned. I hear talk about "implementing supports" and "creation of a national infrastructure". I see an admonishment to our country to facilitate breastfeeding success. When people talk about "articles like this making women feel guilty because a lot of women can't breastfeed" and "don't they know that breastfeeding is hard", my jaw just drops. The whole point of articles like this is to point out that we need to do better at making breastfeeding less hard, at enabling more women to overcome breastfeeding difficulties, to illustrate to policymakers and public health authorities that those efforts are worth it for very concrete human and financial reasons. To make them feel guilty for the piss-poor job we do of supporting breastfeeding specifically, and mothers in general. If we don't talk about the reasons breastfeeding is important, how can we advocate for system change?

There are hundreds if not thousands of public health professionals out there trying to make the system changes that people responding to these articles often point out. How can we support breastfeeding if we're not supposed to say WHY?


*Let's note that "looking hard" does not mean "reading blogs and comment sections". Can I bait a flame-war about breast vs. formula with people getting obnoxiously self-righteous on both sides? Yes; I can also start one about Pepsi vs. Coke, but that doesn't mean Pepsi is actually putting out ads calling Coke drinkers elitist jerk-offs.

27 comments:

Cherylyn said...

Thank you so much for this post! I'm a huge breastfeeding advocate, and it seems I'm always butting heads with the women who feel I'm trying to give them a guilt trip for not breastfeeding their babies. I like this quote from the article:

"There are a lot of factors contributing to low breastfeeding rates in the United States, and Bartick says moms shouldn't be blamed, because they receive mixed messages and often lack support from the moment their babies are born."

No one is pointing fingers at mothers, but we are definitely pointing fingers at the current maternity system. It goes on to say that we need improvements in maternity care. Well, isn't that the understatement of the century?!

Thank you for standing up for what's important and right.

Dou-la-la said...

Excellent, excellent, excellent.

Tania said...

Unfortunately, it's not just about "support". And, frankly, I'm not sure why "support" is such a huge thing in breastfeeding. Do people sit around formula feeding mothers and "support" them? I had no support while breastfeeding and did so for nearly 3 years. If you want to breastfeed - do it. I realize some women do have actual issues and need help and support, however those are few and far between. I think the fact of the matter is, not enough women actually *want* to breastfeed enough to succeed and give up easily. In addition, there are many women who just don't want to breastfeed period and never initiate it.

"There are a lot of factors contributing to low breastfeeding rates in the United States, and Bartick says moms shouldn't be blamed, because they receive mixed messages and often lack support from the moment their babies are born."

Mixed messages about breastfeeding? Even formula companies put "Breast is Best" on their packaging. I'm not pointing fingers at these mother, but if we are to think women are strong, intellegent beings, I think we are giving them far too little credit here. To say so many (nearly 50%?!) are confused about breastfeeding is an insult to that intelligence. They can research the best car seats and strollers, but are clueless about breastfeeding??

Kathryn Lane Berkwowitz said...

The same kind of arguments can be made for avoiding elective inductions and cesareans and it just makes me crazy. Wake up people ! Bad births = harder breastfeeding + illness and injuries to mothers and babies.
And am going to keep talking about it.
Thanks for your great post !

La Mama Loca said...

I don't understand why encouraging breastfeeding is singled out among public health issues as being "guilt inducing." We don't hesitate to tell moms to stop smoking, avoid drinking while pregnant, and to put their infants down on their backs for sleep, even though some amount of mothers continue smoking, drink while pregnant, and utilize tummy sleeping. I think the guilt issue may actually just be made up, honestly.

More than a mom said...

Having been part of the system as a WIC peer counselor, even in a position where I was supposed to help educate and empower women in breastfeeding I was not able to speak plainly to the people I was to help. I was not allowed to talk about the dangers of formula, but rather had to frame the risks around the benefits of breastfeeding. Instead of saying formula puts your child at greater risk for ear infections, diarrhea, and pneumonia, I had to say that breastfeeding decreased the risk of their children experiencing these conditions. By having to talk about breastfeeding in terms of formula being the norm and acceptable, it was absurd that I was expected to do anything to improve breastfeeding outcomes. I was not allowed to say or post anything that might make a mother feel bad about using formula even if it was not intended to cause guilt or grief. Basically, we were handing out free formula, a medical food, without informed consent. I think if you had to have a prescription for formula and sign a consent form that more people might think about the seriousness of their "choice". I think by not treating formula as the serious medical procedure that it is, that we do a great disservice to families.

Maureen said...

Love the article! I am constantly appalled at the number of people I hear who think it's okay to supplement, not pump because it's too inconvenient, are grossed out by the thought, or think it's weird or obscene! I shared this to my fb wall.

TempestBeauty said...

This was beautifully written! You are VERY right... the goal is not to shame mothers into breastfeeding, NOR to make them feel guilty if they couldn't or didn't.

I don't understand why breastfeeding advocacy has become such a negative thing, but I hope blogs like this one and people like you can reverse the trend.

Well done.

MomTFH said...

Excellent, excellent post!

*clap clap clap*

I went to a local ob/gyn society meeting last night, and listened to a fantastic speaker. He has worked in two administrations as a health care advisor, and was offered to be surgeon general under Clinton.

He said the key to lowering health care costs is to change the societal issues underlying the poor outcomes and disparities. He said we as physicians (well, I am a medical student, but I was a guest of a physician!) are only trained to handle people when they are sick, and we can't wait until they are sick.

I am not implying that formula feeding is a sickness. It is a significant health intervention, however, that effects the entire first year of an infants life acutely, and the rest of its life in associated ways, and the same goes its effects the postpartum mother's body. It is not the default of physiological health that breastfeeding is. It alters the nutrition, physiology, and literal anatomical structure of both the mother and child, and is not the same thing as lifestyle decisions like cloth diapers vs. disposable.

In other words, there needs to be a societal shift in how we look at breastfeeding. It should be kind, and fair, and sensitive to women who can't, and supportive to women who want to. And, support of breastfeeding should include very real, very common research methods to confirm the public health implications, which should be reported to the public with accurate medical information, without a knee jerk reaction.

MomTFH said...

Oh, and one more thing. I love this:

"Let's note that "looking hard" [at breastfeeding advocacy] does not mean "reading blogs and comment sections"."

May I please add message boards to that list?

I think many people have a hard time knowing the difference between reality and individuals bloviating on the internet, when it comes to public health issues.

-L said...

For those interested in reading the actual article in Pediatrics, here's the citation with the PubMed ID.

Bartick M, Reinhold A. The Burden of Suboptimal Breastfeeding in the United
States: A Pediatric Cost Analysis. Pediatrics. 2010 Apr 5. [Epub ahead of print]
PubMed PMID: 20368314.

Thanks for sharing this CNN report in your blog.

Arual said...

This is an excellent summation of how many people misread pro-breastfeeding research and assume we want to torment formula-feeding mothers. I wish I could have said it so well myself.

Aphra said...

Right on---great response!

rachel mosley said...

i just wanted to say thanks for this post! i am a breastfeeding mother, and i recently read an artical about "breastfeeding bullies" and started to wonder if i was one of those ladies?! why am i made to feel embarassed about doing what is best for my baby, and advocating it?

Ilanna said...

Thanks. I've been very torn about a lot of this that's been going on. I couldn't BF my first child (most likely due to lack of support/education etc needed) - pumped 3 weeks, and then switched to formula. This time forewarned/forearmed - i'm hiring a private LC.

That is neither here nor there. I think the problem is not so much the article etc, but the way some folks have presented the information.

Yes, BF is better, yes it has potential to save billions of $$ and lives of children. I think the problem is - the article is being interpreted and presented by some as "if you use formula you are killing your child." Which - is ridiculous. While not optimal, and with disadvantages, formula is not UNHEALTHY (good quality formula etc etc...) - it's not as healthy or as beneficial as BM. Problem is, you have parents who aren't given any choice at all (adoptive parents, foster parents, widowers, medical necessities etc) who then get this sensation of "i'm killing/harming my child b/c I don't have the BM available." The article itself is benign. Scientific information should NEVER be taken guilty or otherwise - it's facts/figures. Period. I think it really just falls under how others are interpreting and presenting... (just my opinion of course)

Diana said...

This is so important, and it does get tough, sometimes, when discussing with women who have not breastfed for whatever reason. Thank you for pointing out the importance of the issue and the underlying problem that women are not getting the support they need, or possibly are getting to much support of the alternatives (formula).

JMT said...

Rebecca, I kind of love your indignation. Thanks for the post.

This is something I have been thinking about in my current PH course (Social and Behavioral Sciences in Public Health). Sometimes professionals and health organizations fall into the trap/habit of thinking about health issues at the level of the individual and sometimes not. A focus on the individual and her power to change her own situation is in some ways the quintessential American POV, though.

I think that public health consumers are themselves often resistant to the idea that they are not responsible for their own decisions, actions, and outcomes. To some people, telling them that these things are embedded in and influenced by larger structural/institutional/social issues sounds like "you aren't responsible for your own actions," not "you aren't to blame for your own outcomes". It can feel like a lessening of personal power, or an unwanted excuse made by someone else on your behalf.

I don't know what direction this line of thought points or what conclusions to draw - just thinking out loud!

mamapoekie said...

Thank you, wonderful post! I'll be linking to it on Sunday and I'm adding you to my blogroll

Bikes said...

We need a breastfeeding culture. Food is about culture. I believe we will see a change when women and babies can do their thing in public without anyone raising an eyebrow. In all the countries I know of where breast feeding rates are high, public nursing is the norm.

Glad I found your blog. It's good stuff.

Rebecca said...

@Tania: I think you're right (and research bears you out) that women do understand that "breast is best". We can argue about how well they understand the exact risks/benefits, but it's true that most women understand that breastfeeding is considered optimal. I'm glad that you were able to breastfeed so long without support, but I wonder if you are not noticing the amount of support you were given. If you had friends & family who did not openly criticize your decision to breastfeeding, then that is support. If the place where your child was born did not give unwanted formula, and hand you formula samples on the way out the door, that is support. If you had a way to stay home and breastfeed, or an employer who was flexible with pumping, that is support. I'm not talking about cheerleading (which is great too), I'm talking about support like the foundation your house sits on top of. Without it, things aren't going to stand for long. To say that women should "just do it" denies real barriers that exist.

Rebecca said...

@MomTFH and @Rachel: I do think those "breastfeeding bullies" exist, on blogs and comments sections and messageboards, and you know what? They're jerks. And inasmuch as this Pediatrics article might give dumb jerks their misinformed fodder for OMGZ U R KILLIN UR BABEE WIT FORMULA (apparently dumb jerks talk like LOLcats in my head) - that sucks. But it doesn't negate what the article says (which the bullies probably haven't read any more than the angry formula people have).

I think the real key is being sensitive and talking about this stuff at the right time and place, and in the right way. Talking about breastfeeding as something that saves lives and how glad you are that YOU are breastfeeding can come across as kind of self-congratulatory (and critical of others who aren't able/willing to make the same choices). Talking about it in that way to "educate" some woman who you perceive as insufficiently educated and want to influence: also uncool. This is actually an interesting topic and one that I think deserves more discussion.

Rebecca said...

@Ilanna: "Yes, BF is better, yes it has potential to save billions of $$ and lives of children. I think the problem is - the article is being interpreted and presented by some as "if you use formula you are killing your child." Which - is ridiculous."

Absolutely! And this goes with my comment about the breastfeeding bullies above. It's misinformed and unhelpful and you know, wrong.


"While not optimal, and with disadvantages, formula is not UNHEALTHY (good quality formula etc etc...) - it's not as healthy or as beneficial as BM."

Again agreed, with one difference. I think we need to understand that breastmilk is the norm for infant feeding. Formula rarely actively kills infants (although it does occasionally happen with cases of tainted formula) and it is more healthy than not feeding a baby at all, or feeding it straight cow's milk, or something like that. But it is unhealthy inasmuch as, because they are fed formula, 911 babies are estimated to die a year. It's like saying "Sure, it's not as good as babies sleeping their backs, and it's not optimal, but tummy sleep is not UNHEALTHY for babies." Its unlikely to kill them and most of us were put to sleep on our stomachs and we're fine! But there does seem to be a measurable difference in SIDS mortality. There IS something wrong with tummy sleeping, and there IS something wrong with formula. (Which of course does not mean that people who use formula are horrible people whom I plan to judge and guilt trip personally.)


"Problem is, you have parents who aren't given any choice at all (adoptive parents, foster parents, widowers, medical necessities etc) who then get this sensation of "i'm killing/harming my child b/c I don't have the BM available." The article itself is benign. Scientific information should NEVER be taken guilty or otherwise - it's facts/figures. Period. I think it really just falls under how others are interpreting and presenting... (just my opinion of course)"

Yes yes yes. I hate seeing this stuff used for guilt trips. Again, this should be used only to guilt trip policymakers into things like creating more mothers milk banks so more babies can get breastmilk even if their own mothers can't provide it.

Rebecca said...

@JMT: "I think that public health consumers are themselves often resistant to the idea that they are not responsible for their own decisions, actions, and outcomes. To some people, telling them that these things are embedded in and influenced by larger structural/institutional/social issues sounds like "you aren't responsible for your own actions," not "you aren't to blame for your own outcomes". It can feel like a lessening of personal power, or an unwanted excuse made by someone else on your behalf."

And I think this is the fine line to cross - we don't want to get into "you poor thing, I guess if you'd just had better support you would have breastfed" (implied: you can't make your own decisions and you didn't get good support because you weren't smart enough to find it LIKE ME). So I think we need to consistently note that this is not about an individual - somebody may have had all the support she wanted and decided that breastfeeding sucked and she was out. But the truth is that we know that women in this country are not meeting their own goals for breastfeeding, and we know there are structural practices that are hindering them. I think we have to reiterate that.

Anonymous said...

As an American living in Germany, I still am amazed at the cultural resistance to breastfeeding in America. Here in Germany, I received not only lactation support while I spent a week (yes, you heard me, a WEEK) in the hospital post-delivery, as well as ten weeks of home visits from a mid-wife to ensure successful breastfeeding. The support I received in the beginning phases made it possible to breastfeed my child for well over a year.

My second point is that part of the problem in America has to do with cultural hang-ups we Americans have about The Body. We Americans have been raised to feel shame about our bodies, and this emotional factor simply may trumph all else.

TheMinimalistLife said...

As a mother who did everything that I knew how to do (contacted LLL for help, asked the nurses for help, asked the doctor, read a lot literature ahead of time, called everyone I knew who breastfed successfully to ask for help) and yet, I still wasn't able to breastfeed successfully because I couldn't get help.

This article and most breastfeeding advocates tell me that if I had tried harder then I would have been able too. Do you know how that feels as a mother to hear from a lot of advocates of something that you wanted to do that you have failed as a mother because you didn't try hard enough? I tried as hard as I could and then I didn't have any help so I stopped trying and gave my kid a bottle.

I understand your point that the system as a whole needs to change, and all of those things that you mentioned at your hospital didn't exist at mine. However, the fact of the matter is that although you sound like a great advocate--there are many advocates out there that look at a non-breastfeeding mother and say "well, you should have done more".

So yes, I think the news media has a right to be upset about the way in which this article is worded. To say that not breastfeeding killed 911 babies just sounds like its trying to stir up controversy.

Is there any reason the article could not have said, "Breastfeeding can save precious infant lives in the United States and we need to support mothers becasue by our national infrastructures lack of support we are contributing to infant fatalities."

There's nothing wrong with that. THe 911 number can still be used in explanation of the methodology. I understand your passion on this topic and admire it, but perhaps understand that this article was written poorly despite its noble intentions and that's why people are upset.

Dionna @Code Name: Mama said...

Love this post. It baffles me when women say that we don't need to normalize breastfeeding or focus on supporting nursing mamas. If we lived in a culture that respected and promoted breastfeeding, we wouldn't see the brouhaha that ensues every time someone touts the benefits of breastfeeding.

Rebecca said...

@MinimalistLife: I agree with you that the narrative some people use of "If you just tried hard enough, or did X and Y, you could have breastfed, so I guess you didn't try hard enough FAIL" really sucks, and no one should be using it. I don't think you're a failure as a mother, and I don't support people who would imply that you are.

Still, I'm not sure I understand your objection to the way the article is worded (I assume you're talking about the original article, not the CNN summary I linked to). The wording you prefer sounds like an excellent paraphrasing of exactly what the conclusions of the original article said.

Do you object to putting a number on deaths? I think that it's important to quantify. Putting a number on it is not controversy-stirring; it is good science. I just had a professor send a paper back for revisions because I was using vague terms like "more" and "greater" and "reduced" in a literature review. He reminded me that "more" can mean "1% more" or "500% more" and it was not good scientific writing. Similarly, if the researchers in this case say that "some" babies are dying they could mean 5 or 5,000. Obviously 1 death is too many, but when policymakers are struggling with limited resources and competing priorities, the magnitude of a problem is important information to have available.