This post originally appears on RH Reality Check, an award-winning, progressive publication covering global reproductive and sexual health news and information.
The results of a study released this month in the journal Pediatrics suggest the U.S. could save $13 billion dollars and over 900 newborn lives every year if the majority of American mothers (90 percent) breastfed for more than 6 months. This study has unleashed a wave of opinion and commentary from women around the web.
From mothers who blog to feminist birth activists to professional providers and advocates, people are passionately discussing the findings, imploring Americans to not only take notice of how important breastfeeding is to newborn and children's health and the relationship between mother and child, but also to fight for better woman-centered policies from hospitals to the federal government to improve women's chances of breastfeeding for longer periods of time successfully. The findings of the study are clear: there are tremendous benefits both financially and in actual human lives, when more women breastfeed their babies for longer than six months. Some comments about the study, however, take issue with the way this and other studies' findings are presented and used, making moms feel guilty if they choose not to or can't breastfeed. What the study does not address is that increasing rates of breastfeeding relies upon real women, with real lives, to make the decisions they are able to make given a range of societal, cultural and institutional factors. That is, while the study's findings present the information as a simple equation, the reality is more complex: if we can address the myriad reasons why women don't breastfeed, we'll undoubtedly provide more support and positive encouragement for successful breastfeeding relationships.
There has been a resurgence of interest in breastfeeding as both a public health and political issue, over the last several years. From Facebook groups protesting policies on breastfeeding photos on the site and rallies around the country supporting mothers' rights to breastfeed openly, in public, to public health initiatives like Healthy People 2010 (and, now, Healthy People 2020) in the United States which includes clear objectives for increasing breastfeeding rates, this is an issue which keeps gaining momentum. The Healthy People 2010 Initiative created in 1998 by the Department of Health and Human Services set a goal to increase the proportion of women who breastfeed their babies: ever, for six months, for one year, exclusively for three months and exclusively for six months, in order to bring us closer to the World Health Organizations' recommendations that mothers breastfeed their babies for at least six months but optimally for two years. Healthy People 2010 cites breastfeeding as a "cross-cutting" issue. It is not only the means by which an excellent nutritional source for newborns and babies is provided, helping to prevent death and disease, it can bring "positive health effects" for the mother; and act as a guard "against the effects of poverty" says the Healthy People 2010 objectives, since breastfeeding costs are relatively few.
So, if breastfeeding is as golden as we all know it is, why aren't more women breastfeeding for the recommended period of at least six months or more?
There are many issues at play. Among these: cultural stigma which makes women feel as if breastfeeding is not respectable or sometimes downright disgusting; the lack of "baby-friendly" hospitals in the U.S. which offer breastfeeding information and support as the first choice for new mothers; the lack of postpartum support (such as access to a lactation consultant) for women who want to breastfeed; societal stigma preventing women from being able to breastfeed freely and comfortably in public spaces; and workplace inflexibility including lack of paid family leave, and time and space to pump when women return to work.
Dr. Paige Hall Smith, Director of the University of North Carolina Greensboro's Center for Women's Health and Wellness and Founder/Co-Director of the annual Breastfeeding & Feminism Symposia (a partnership between UNC Greensboro and UNC Chapel Hill) says that although breastfeeding is seen as a "lifestyle choice" oftentimes, making some women out to be the "better mothers" and others made to feel guilty for their choices, in truth, "these choices are made within a constrained environment." Smith says, instead, that we need to look not just "at the decisions made but the constraints and structures in society that shape women's decisions" in order to understand more about why women do or don't breastfeed for extended periods of time.
From the Healthy People 2010 web site:
The social and physical environment--including family, community, health care system, workplaces, businesses, schools, transportation, and the media--exerts an enormous influence on breastfeeding success, often putting up barriers to improving duration and exclusive breastfeeding rates.
As Gina Crosley-Corcoran, blogging as The Feminist Breeder puts it,
"...I don't believe that most women are making this "choice." The CDC shows that 3/4 of women are initiating breastfeeding in the hospital, but only 13.6% of women are still exclusively breastfeeding at 6 months...Get mad that we have no paid leave to help support the breastfeeding relationship. Get mad that moms aren't being given free breastpumps, lactation consultants, and healthier food. Get mad at a system that puts Girls Gone Wild tits on the cover of every magazine, but bans breastfeeding pictures on Facebook. These are the issues that need our attention as mothers, or as feminists, or simply as women with brains... I believe women are capable. Give them the tools. Give them the time. Give them the respect they need."
Says Dr. Smith, "The problem isn't breastfeeding. This has to do with increasing the status of women. If we do that, we will increase the rates of breastfeeding."
Dr. Smith points to recently released CDC data (referred to by Crosley-Corcoran above) which states that while 73 percent of American mothers initiate breastfeeding, only 14 percent of babies in this country are exclusively breastfed at six months of age.
"The problems we're experiencing have to do with the fact that women aren't able to continue breastfeeding more than ensuring that women start breastfeeding. We have a lot of work to do to make more hospitals baby-friendly...but we need to get into how breastfeeding reacts with the constraints on women's lives.If women really don't have enough control over their life, their body, their time and their space to be able to breastfeed for 6 months, if they want to, what does that say about the status of mothers and women in this country? Breastfeeding rates are low in this society because the status of women is low."
Given this lack of focus on radically improving many of the conditions that contribute to lower breastfeeding rates, we have not met the Healthy People 2010 targets. It's also why, in part, the Healthy People 2020 initiative includes new objectives aimed more at changing the ways in which our health care institutions operate than just solely aiming for increased rates of breastfeeding:
* Increase the percentage of employers who have worksite lactation programs
* Decrease the percentage of breast-fed newborns who receive formula supplementation within the first 2 days of life.
* Increase the percentage of live births that occur in facilities that provide recommended care for lactating mothers and their babies.
There are and will always be women who cannot or do not want to breastfeed (or exclusively breastfeed) either for medical reasons (they are HIV positive or they are taking medication contraindicated with breastfeeding, for example), because they do not produce enough milk, or have a history of sexual abuse or assault which makes the physical closeness of a breastfeeding relationship difficult.
No woman should feel that she is deficient in her care for her baby should conditions be present under which she cannot or does not want to nurse her baby. Writes one commenter on the Feminist Breeder's post,
I breastfed my daughter exclusively for the first four months. I had her in a UNICEF "baby-friendly" hospital where they insisted on exclusive breastfeeding. I wanted to breastfeed her...But I. JUST. DIDN'T. PRODUCE. ENOUGH. MILK...Turns out there was a reason she was hungry all the time -- I wasn't producing enough. She should have been eating twice as much as I was producing, and my body wasn't ramping up even though she'd been trying desperately to make it do so...So I supplemented with formula, and pumped, and pumped, and pumped so she'd have breastmilk too. But she likes to eat, and it became clear pretty soon that we were kidding ourselves saying we were "supplementing" with formula. We were supplementing with breastmilk; even though I was pumping constantly, I produced about enough for two feedings a day out of eight or so. I made it to five months, and stopped pumping; it was hard to pump every two hours when I was back to work full-time...Do we need better maternity leave, more societal support for breastfeeding, access to lactation consultants, etc.? Especially in the United States? Hell yes.But should EVERY mother breastfeed EXCLUSIVELY for the first six months? No. Sooner or later, you have to do what's best for your child. Sometimes that's not exclusive breastfeeding.
As a mother of two myself, I understand both sides of this coin. I deciced to discontinue breastfeeding my first child just days after he was born for a host of reasons, despite having tremendous support, access to information and resources. The guilt I experienced, at the time, was overwhelming. I felt like I was on the outside looking in as I struggled to connect with other new mothers whose first few weeks and months revolved around their stories and experiences of nursing their babies. It wasn't a false sense of separation, of course. I was, to a degree, experiencing something very different. And when I decided to breastfeed my daughter after she was born, I was both scared and excited. Would I fail? Was I just not the "type of mom" who enjoys breastfeeding? Did I have it in me (as if I was headed into battle or preparing to climb a mountain -- both of which, by the way, are apt metaphors at varying points in a woman's breastfeeding life)? Turns out, breastfeeding a baby is not some secret society to which only some women hold the password. I breastfed my daughter for three years, enjoying (almost) every moment of it in a way I have never and certainly will never experience again. It had as much to do with my frame of mind as anything else.
Which is why solely focusing on public policy or solely focusing on the health benefits of breastfeeding or solely focusing on just trying to convince moms of how wonderful breastfeeding can be are not panaceas. There will always be women like myself, or women who have commented on other blog posts around the web who say, "Hey, I tried. I wanted to make it work. I decided to stop for this reason or that reason." And that must be okay. If we continue to say, "No, we expect more of you than you can or are able to give at the moment" then we set up an impossible standard for women to meet. These feelings of inadequacy can contribute to lingering problems for a woman who wants to enjoy parenting, far beyond when a breastfeeding relationship ends. If we say to a woman right off the bat that she somehow failed to positively establish the first relationship she'll have with her child, what does she carry forward as a parent?
But, says Dr. Smith, with almost 75 percent of women who birth in this country initiating breastfeeding, and only a small percentage actually breastfeeding for extended periods of time, it seems likely that most women want to breastfeed but come up against barriers that prevent them from doing so.
So, what's the answer?
Dr. Smith says, "We need to give women control...That's the bottom line. We must create structures in society that give women more control over their bodies. Women who have control over their lives, body, time and space [and I'm talking about private, public and work space] are more likely to breastfeed than those who don't have that same kind of control."
It's the feminist answer -- work towards equality and justice and we'll allow women to make decisions they feel are right for themselves.
Some of that control will arise from public policy changes.
Kristin Rowe Finkbeiner of the grassroots parenting rights organization, Momsrising.org, points to workplace flexibility and parent-friendly policies as it relates to the care of newborns and breastfeeding:
"It is absolutely imperative for women to have time to care for their infants and next to impossible for them to do that without any form of paid family and medical leave.We have members [of Momsrising] who have babies on a Thursday and end up back at a desk on a Tuesday...Some women don't even have enough of a break to even get the infant started breastfeeding."
The U.S. "stands out like a sore thumb with our lack of paid family leave", says Rowe Finkbeiner. "Of over 170 countries, only four don't have some form of paid family leave for new mothers: Papua New Guinea, Swaziland, Liberia and the U.S."
These statistics relate directly to the breastfeeding study. If more mothers' breastfed says the report, fewer newborns would die each year. But more mothers simply cannot and will not breastfeed, without support in the form of policies like paid family leave.
Even though we spend more, per capita, every year on health care, we rank 37th in infant mortality in the world. According to Momsrising.org, when paid family leave is instituted we see a 25 percent drop in infant mortality rates. One of the reasons? It allows mothers the time to establish a breastfeeding relationship with their new baby.
Breastfeeding saw a boost from public policy recently with the "right to pump" provision that mandates that employers with 50 more employees must establish reasonable spaces (other than the bathroom, thank you very much) for women to be able to express breast milk, for up to one year.
In addition to public policy, we must see shifts in hospital policies, where the majority of women in the U.S. give birth, as well. This means increasing the number of Baby-friendly designated hospitals throughout the country, especially hospitals that serve African-American women who are the least likely to breastfeed in the nation, according to Womens eNews.
Increasing the number of women who breastfeed for extended periods of time, then, requires much more than studies and statistics. It requires a coordinated, feminist response that acknowledges the full range of women's needs, wants and rights, according to Smith and her co-organizers of the annual Breastfeeding & Feminism Symposia.
As Dr. Smith eludes to, feminism doesn't end with what's between women's legs. Smith's symposium each year addresses almost every and any topic related to feminism and breastfeeding and brings together advocates and scholars from around the world in order to establish a rights-based foundation for breastfeeding in the U.S. Topics over the last five years have included: work-life integration, making the business case for improved breastfeeding policies, the cultural contexts of guilt, popular media representations of breastfeeding, the implications of breastfeeding in public when women's bodies have been publicly sexualized, racism and health disparities in breastfeeding, infant formula companies use of the "choice" frame in regards to infant and baby feeding, the "medicalization" of infant feeding in hospitals and more.
A study that finds that breastfeeding saves money and lives is not earth-shattering. But what we do with this information has the potential to be. From public spaces to workplaces, hospital rooms to women's living rooms, society must expand its notion of what women need to feed their babies from birth and beyond.
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The study itself is ridiculous. It is based on nothing more than fanciful "estimates" of theoretical costs. It is utterly reliant on pretending that correlation in breastfeeding rates with disease rates means that breastfeeding causes or prevents diseases.
Breastfeeding rates rise in concert with income and education. So does infant health. It is irresponsible to claim that breastfeeding itself, as opposed to the confounding factors associated with increased maternal education and income, is wholly responsible for differences in death and disease.
The "costs" are in large part absurd. Not a single infant death has been definitively linked to failure to breastfeed, yet the authors insist that 911 deaths each year can be attributed to failure to breastfeed. The putative "lost wages" of these unfortunate infants do not represent any type of cost saving at all. Society does not lose money when an infant dies, so claiming that we would save more than $9 billion dollars (out of a total savings of $13 billion) is ridiculous, and renders the authors' entire argument suspect.
Which scientific findings would those be?
I'm not claiming that breastfeeding isn't beneficial, merely that the authors estimate of the "costs" of not breastfeeding is rather fanciful. There is NO evidence that breastfeeding prevents any illnesses, only correlation between breastfeeding and rates of certain illnesses. Statistics teaches us that correlation is not causation, yet the authors ignore this important caveat.
The methodology of the study is highly suspect. To get to the $13 billion figure of purported savings, the authors claim that the lost wages any infants who die amount to $10 million per infant (adding up to fully $9 billion of the $13 billion figure). What living person has lost those expected wages. Not a single one. And if no one has lost those wages, we can't count them as "savings."
Leaving aside the serious methodological problems with the study, I also object to the underlying philosophy. Lactivists have chosen to frame the low level of exclusive breastfeeding by using scare tactics ("your baby will die if you don't breastfeed"). Not only is that factually false, it is a complete failure in motivating women to breastfeed.
Women deserve HONEST information, not scare tactics fabricated by lactivists to promote their own choices as some sort of ideal.
Correlation is definitely not causation but we are not going to get to causation in the present climate of "evidence-based medicine" when the answer to the question may not be "testable" in a randomised controlled trial.
1. Recent studies confirm that islets of Langerhans in diabetic pancreas do not contain autonomic nerves. So the question arises "How does the "autoimmune" process attack both the islets and the nerves ?"
2. Another view might be that the injury to the nerves is the primary injury in T1DM. We know that in adults physical efforts during labor and during defecation cause major injuries to pelvic autonomic nerves.
3. How do you prove that persistent physical efforts during defecation in infants, or, during toilet training, accounts for the loss of nerves in T1DM ? And different sites of injury in different sizes and shapes of baby account for other autonomic injuries ?
4. It is "autoimmunity" that is wrong. It has been a dustbin for all kinds of disease aetiologies because of the (positive) finding of CD4 and CD8 lymphocytes rather than the (negative) finding of loss of autonomic nerves.
5. If physical efforts during defecation across the lifespan cause injuries to autonomic nerves then how do you test that question in "randomised controlled trials" and the present - dysfunctional - "EBM paradigm" ?
We hope you will adopt the Best for Babes Credo: All moms deserve to make an informed feeding decision without pressure, judgment or guilt, and all moms who decide to breastfeed deserve to achieve their personal breastfeeding goals without being undermined by the "Booby Traps".
Please join us in shifting the pressure OFF moms and ON to the "Booby Traps"--the barriers that are keeping them from achieving their personal breastfeeding goals, whether that is 2 days, 2 months or 2 years, many of which the author of this piece mentioned. As long as there is judgment against formula or formula feeding our cause is lost. Please join our cause instead of pouring fuel on the fire.
But before that I was also one of those mothers who really, really wanted to breast feed but wasn't producing enough milk. I had lots of support, did everything I could think of to get the milk flowing--tired the weirdest contraptions that seemed to counteract the whole point of breast feeding, but I did it any way. I had a baby or a pump on my body almost every hour for almost 48 hours straight, and my daughter was still starving. I was spiraling into a scary, deep depression about it.
Formula was not soda or evil or wrong. It nourished her, it pulled me out of a scary funk, and it allowed us to bond. If I have another child will I attempt to breast feed again? Absolutely. Every pregnancy/baby is different--it might work out next time and I know breast milk is what a baby needs more than anything. But I'm still grateful for formula.
I'm glad breast feeding worked out well for your family, but please don't attack people who don't have that ability.