City of Ottawa Public Health Unit’s “Informed Consent” webpage: A case study in (un)informed consent

An anonymous FFF reader has allowed me to publish the following letter, which she sent to her local Public Health unit in Ottawa. I visited the site that caused her so much consternation, and I was equally incensed. Please click here to see what she and I are talking about:

Make an informed decision about feeding your baby

My thoughts on the Ottawa website follow this letter. I’d also encourage you to check out the letter sent by the blogger at Awaiting Juno. And, if you’re feeling inspired to do so and happen to be a citizen of Ottawa (or even if you just feel like giving them your opinion), feel free to write your own letter and send it to healthsante@ottawa.ca.

***

Dear City of Ottawa Public Health Unit,

I discovered the following webpage on Informed Consent and was utterly dismayed at what I had read.

I had my daughter seven years ago and am hoping to have another child within the next two years. When I was pregnant with her I knew I was going to breastfeed her. I felt that formula was vastly inferior. Unfortunately having breast hypoplasia (something that none of the literature of had prepared me for), made exclusive breastfeeding an impossibility. My daughter went from losing weight on my breasts alone (I did have a postpartum nurse who was very concerned about my breasts due to their shape and spacing, but I dismissed it as an unsupportive nurse, not as her giving me relevant information on my situation), to thriving on formula.

That page isn’t giving informed consent, it is scaring women into breastfeeding by bringing up scary words like “obesity”, “SIDS” and “Cancer”, without mentioning any potential  drawbacks for breastfeeding (including not being able to take certain medication and that it can be a physically and emotionally draining experience for some) and without making any positives about formula. It also doesn’t mention that formula prepared properly is a valid feeding method and choosing it doesn’t mean that a child will end up toothless, obese, diagnosed with cancer, or dead. From what I have seen about the research the main risks are a higher rate of gastrointestinal viruses and ear infections (which my daughter did get, when she was 5 and a half years old). For a woman who might be already sad that breastfeeding isn’t working out with them, such phrasing of information without perspective or actual risk amounts could contribute to postpartum depression. I should know- seeing that kind of information online (it exists all over the internet) after switching to formula was a contributing factor to my own depression.

You mention on the first page that the Baby Friendly designation includes supporting women’s feeding choices, but I do not see how that supports a formula feeding woman at all and could increase the stigma and isolation about using a product that is in fact very safe to use in our city.

I encourage you to take that “Informed Consent” page down and rework it so that it does not demonize formula. The benefits of breastfeeding in all honestly should be able to stand on its own without resorting to demonizing formula. Furthermore, I am more than willing to help with any rewording to help formula feeding moms feel more supported in their choice.

As a taxpayer, mother and a woman who felt intense guilt for 2 years for using a product that nourished my daughter where I couldn’t (I also have the perspective that she is a very healthy, active 7 year old), I urge you to reconsider your approach.

Yours truly,

A.

 ***

Before I return to my Pad See-Ew, which is currently getting cold (yet another reason to be annoyed at the city of Ottawa – they are ruining my damn dinner), I want to add a few of my own thoughts to Anonymous’s letter.

The document on the Ottawa Dept. of Health website is coercive and factually inaccurate, starting with the first sentence. They state:

Deciding how you are going to feed your baby is one of the most important decisions you will make as a parent.

What the “most important decisions” you’ll make as a parent are is entirely subjective.

Next, they state:

Making an informed decision means you have all of the information you need to help you decide what is best for your family.

Yep. Exactly. You deserve accurate, dispassionate information so that YOU can decide what is best for YOUR family. This document does the polar opposite. It confuses correlation and causation (I only see two uses of the important qualifier “may” in the lists of benefits and risks – for example, they claim that breastfeeding “helps to protect against cancer of the breast and ovary.” It would be accurate to say that breastfeeding “may help to protect…” or “has been associated with a lower risk of…”, but the way they pronounce this benefit makes it sound proven without a doubt. This is simply not true); it does not mention any of the potential downsides of breastfeeding, nor the benefits of formula feeding (even if they’d just said “the ability to feed your child when breastfeeding isn’t working or there isn’t a mom in the picture”, it would have sufficed); and most importantly, it does not leave the reader with any choice other than to breastfeed, or feel like an inadequate, terrible human being. And before someone starts misquoting Eleanor Roosevelt to me, let me stop you: yes, people CAN make you feel guilty without your consent. Or if you can’t agree with me on that, let’s forget about guilt – how about embarrassed or judged? Can people make you feel that way without your consent? And what if you’re not in any emotional place to give that consent? Like when you are a hormonal pregnant or newly postpartum parent, and it’s your city government posting a bunch of fear-inducing drivel under the headline “the benefits or breastfeeding for the baby, mother, family and the community”? How about then?

The document’s piece de resistance is this half-assed suggestion at the bottom of the page:

If you have made the informed decision to formula feed and need information on how to prepare it safely, please visit Ottawa Public Health’s Food safety page.

Ah, I see. So if you’ve made a decision to do something that causes nothing but inconvenience, pain, and suffering for you and your child (and your community- can’t forfet your community!) based on this “information”, you should just go to a different department, because we’re freaking OVER you. Notice that when the link for more information on breastfeeding follows this taxonomy:

Residents>>Public health>>Pregnancy and babies>>Healthy baby and parenting>>Feeding your baby>>Breastfeeding

There is NOTHING about formula in this “Feeding your baby” section. Instead, formula feeding monsters, er, mothers are directed to:

Residents>>Public health>>Food safety and inspections>>Baby Formula

Apparently, healthy babies and parenting only has to do with breastfeeding. Formula feeding is on par with selling hot dogs at softball games.

I don’t even know what to say, except to all the soon-to-be moms and currently formula-feeding or combo-feeding mothers in Ottawa, I am so, so sorry. Your city health department sucks donkey balls. And if I were you, I’d start the angry tweets and emails right. Freaking. NOW.

Twitter: @ottawacity

Email: healthsante@ottawa.ca

 

 

The ads on the bus go bad, bad, bad – a response to the Calgary Breastfeeding Matters Group campaign

“Children of parents who have diabetes have higher risk of diabetes themselves. Reproduce responsibly. Learn more.”

“Hispanic and Black children have higher risk of diabetes. Race matters. Learn more.”

“Children who are poor have higher risk of diabetes. Money matters. Learn more.”

 

If any of the above statements were posted on the walls of a bus, there would be an intense backlash, and rightfully so. Not only do these messages contribute to the shaming of people with diabetes – a condition that, according the American Diabetes Association, is primarily due to genetic predisposition – they are also offensive, misleading, and would fit quite well into a sci-fi thriller about eugenics. True, these factors are associated with higher rates of diabetes, but the story is far more complex than these slogans suggest, and to imply otherwise is nothing short of irresponsible.

Yet, a similar advertisement will be posted on public buses in Canada, suggesting that mothers of children who develop diabetes may be to blame for their children’s condition, due to their infant feeding choices (or lack thereof).

Ad from the Calgary Breastfeeding Matters Group (CBMG.ca)

Ad from the Calgary Breastfeeding Matters Group (CBMG.ca)

The slogan Babies who aren’t breastfed have higher risk of diabetes, is problematic. The omission of the word “may” (“Babies who aren’t breastfed may have higher risk…) implies that ALL babies whose mothers do not (or cannot) provide mother’s milk are doomed to a higher risk of diabetes.

Yet, the recent meta synthesis study by the World Health Organization (1) which examined 314 studies from 43 countries, reported that while breastfeeding may have protective effect for type -2 diabetes among adolescents, “Generalization from these findings is restricted by the small number of studies and the presence of significant heterogeneity among them” (p. 12). Moreover, there is no evidence to support that breastfeeding is protective against Type 1 diabetes, which is more common in the pediatric population (2).

To understand how this ad is misleading, it’s important to understand that diabetes is not one disease, but actually a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Saying blanket statements about diabetes is like saying “Brittany S sucks”. Who? Brittany Spears? Brittany Snow? Brittany S. Pears from Glee? Brittany spaniels? Same name, but very different entities. The causes of the various types of diabetes also vary. Although there are 3 main types of diabetes (Type 1, Type 2, and Gestational), people can get diabetes as a result of other conditions, like cystic fibrosis, organ transplantation, or having HIV/AIDS.

Type 2 diabetes, formerly known as non-insulin dependent diabetes or adult onset diabetes, is the most common form of diabetes across the general population. It is most often associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and certain ethnicities, and can typically be managed via weight control, dietary changes, and exercise. It has come to be viewed in society as a disease of “fault”; another spoke in the wheel of the obesogenic machine that is currently speeding through our society like a shiny, red Corvette, crushing all nuance and holistic scope in its path.

Type 1 diabetes is an autoimmune disease, unrelated to weight or lifestyle factors. This is important to distinguish because children with Type 1 and their parents often get unjustly blamed for the condition (imagine how it must feel, on top of worrying about your chid’s blood sugar levels getting deathly high or low, to contend with people asking if you fed him or her nothing but junk food?) While there is some data suggesting the existence of environmental, viral, or physiological “triggers” for Type 1 diabetes, current research has not shown that it can be prevented (3) by any means, including maternal feeding.

Furthermore, to date, no studies have shown direct correlation between maternal feeding and the development of either form of diabetes, as this campaign would suggest. There is some evidence that children who were breastfed have a lower incidence of developing Type 1 diabetes [4] but the data are merely associative, as there are multiple confounding factors known to develop conditions for the disease. For example, the data coming from the burgeoning field of epigenetics have demonstrated a fairly robust association between allostatic load, or stress, in pregnancy, and higher risk for diabetes, coronary and ischemic disease. [5]

The Babies who aren’t breastfed have higher risk of diabetes advert, sponsored by the Calgary Breastfeeding Matters Group (CBMG), is the fifth in a series of pro-breastfeeding posters. The first four successfully inform and empower public awareness regarding breastfeeding; promoting the message that breastfeeding in public is normal with witty slogans and amusing imagery. This makes the current diabetes-themed poster all the more troubling–with its image of a bottle marked with the word “insulin” next to a foreboding hypodermic needle. To promote the scientifically inaccurate message with hyperbolic imagery misleads the general public, and burdens the parents and children affected by both Type 1 and Type 2 diabetes with unnecessary doubt and concern.

The CBMG may have expected backlash as its website offers a “Resource Sheet” to accompany the advertisement. They link to three different sources of data to back up their claim, with the introductory proclamation that “Recent 2013 research states that breastfeeding as a preventative measure against Type I and Type II diabetes is Level III Evidence”. The first link, to a Nordic systematic literature review, does confirm that the evidence supporting longer-term breastfeeding as a preventative measure (as opposed to “any” breastfeeding) is “Level III evidence”, indeed. What the CBMG fails to mention is that “Level III evidence” is defined as “limited-suggestive”. [6] (To be fair, the study does qualify the evidence for “any” breastfeeding being potentially protective as Level 2 – “probable” – based on studies of varying quality and methodologies.)The other two citations – another review and a seminar about epigenetics [7] [8] – both contain numerous caveats about their findings; neither offers anything close to conclusive evidence that breastfeeding is protective against diabetes – evidence that is hardly worth screaming from the rooftops. Or posting on the wall of a bus.

Without going into a lengthy discussion on the limitations of using two reviews and a lecture as the basis of an emotive advertising campaign, It should suffice to say that infant feeding has not been adopted as a significant reductive factor worthy of promoting to the general public by the American Diabetes Association, nor the Canadian Diabetes Association, expert authorities on this condition (although both of these sources do discuss the research into the breastfeeding-diabetes connection on their websites). In fact, diabetes expert Dr. David Lau  has already spoken against about the campaign, telling the Calgary Herald that the studies used to support the campaign “were essentially surveys…(and) he called any ad based on current, formal research to be an ‘extrapolation’.”

The CBMG “Resource Sheet” also contains a “Q and A”:

So, I breastfed my baby but she still got diabetes!  Is that my fault?

  • There are many risk factors which influence chronic diseases, not breastfeeding is only one of these risk factors.
  • When you have not realized your breastfeeding goals, you may inappropriately blame yourself, when it is the lack of information and support which is the real culprit
  • Let go of guilt. Use that energy to enjoy and celebrate your child and the accomplishments you have made.

This ad is cruel! It makes women who did not breastfeed feel guilty.

 

  • This argument by the public and health professionals takes the responsibility away from those supporting mothers who have not provided the information and support to help her reach her breastfeeding goals. 

  • Information about the health risks of formula do not come from formula companies, but it is very important for moms-to-be to realize there are risks. This needs to be delivered along with breastfeeding support resources.

(Source: CBMG.ca)

In other words, if your baby was breastfed and still got diabetes, there’s a potential that other factors may be at play- but more likely, you didn’t meet your breastfeeding goals. Don’t feel guilty, though – you were probably booby trapped! It’s not your fault you gave your baby diabetes. Although it kind of is.

This ad, well intention as it may be, will quite possibly inflict unnecessary shame and guilt on the parents of children with diabetes; perpetuate the confusion between Type 1 and Type 2 diabetes; and stigmatize women into breastfeeding rather than encouraging them to do so in a positive, constructive way. It would serve CBMG to remove this ad from their otherwise positive breastfeeding promotion campaign. Otherwise, they risk ruining an empowering, powerful campaign with the usual polarizing, negative, and historically ineffective tactics that have perpetuated the “bottle/breast” wars and kept parents from the important work of keeping themselves, and their babies, happy and healthy.

This post was a collaborative effort between Suzanne Barston (the FFF) and Walker Karraa, MFA, MA, with assistance from Polly Palumbo, PhD,  Sarah Lawrence, PharmD, MA,  Teri Noto, and Kristin Cornish, and several others who wish to remain anonymous for professional reasons. 

Citations

[1] Word Health Organization. 2013. Long-term effects of breastfeeding: A systematic review.

[2] University of Rochester Health Encyclopedia, date unknown. Type 1 Diabetes in Children.

[3] American Academy of Pediatrics, 2013.  Healthy Children.org – Diabetes Mellitus.

[4] American Diabetes Association, date unknown. Genetics of Diabetes.

[5] Barker DJ, Winter PD, Osmond C, Margetts B, Simmonds SJ (1989) Weight in infancy and death from ischaemic heart disease. Lancet 2:577-580.

Barker DJP, Bull AR, Osmond C, Simmonds SJ (1990) Fetal and placental size and risk of hypertension in adult life. BMJ 301:259-262

Barker DJP (1995) Fetal origins of coronary heart disease. BMJ 311:171-174.

Barker DJP, Osmond C, Forsén T, Kajantie E, Eriksson JG (2005) Trajectories of growth among children who later have coronary events. N Engl J Med 353:1802-1809.

[6] Hörnell A,et al. Breastfeeding, introduction of other foods and effects on health: a systematic literature review for the 5th Nordic Nutrition Recommendations. Food Nutr Res. 2013; 57: 10.3402

[7] Nolan CJ, Damm P, Prenkiki M.Type 2 diabetes across generations:from pathophysiology to prevention and management. Lancet. 2011 Jul 9;378(9786):169-81.

[8] Patelarou E, et al. Current evidence on the associations of breastfeeding, infant formula, and cow’s milk introduction with type 1 diabetes mellitus: a systematic review. Nutr Rev. 2012 Sep;70(9):509-19]


 

 

 

Getting a grip on the Strong Mom Empowerment Pledge Controversy

The latest outrage in the breastfeeding advocacy world doesn’t have to do with dying children in resource poor nations, or bogus “breastfeeding advice” hotlines run with the nefarious goal of undermining a mother’s goals. It’s not even about someone questioning the benefits of breastfeeding, or urging the government to rethink some of its public health messaging.

No, this week’s rage-fest is over a campaign asking women to pledge not to bully one another based on their parenting choices.

Sound silly? Well, according to a handful of well-respected bloggers, it’s about as silly as a car wreck. This is because the campaign is sponsored by Similac, a formula company, which has everything to gain by women feeling “empowered” to use their second-best (or fourth best, if we’re going by the WHO hierarchy) product in a world made less judgmental by a pledge such as this.

On a purely anti-capitalist, anti-marketing level , I understand why some may feel a little queasy about this campaign. I’ve seen some backlash against the Dove Real Beauty ads for the same reason – the message is great, but the fact that it was created by a group of advertising executives rather than a non-profit, purely altruistic group, sullies it. There’s an ad term for what Dove and Similac are doing – the “halo effect” – meaning that when you use the product, you’ll have positive, do-gooder type feelings about it. Coke’s done it, too. (Remember that catchy “I’d like to teach the world to sing” jingle? Halo effect, right there.)

I assume this is what was behind tweets I came across today suggesting that formula companies have no place talking about parenting issues. My counter argument to this is that many of us formula feeders feel abandoned by the parenting gurus (paging Dr. Sears) and in some cases, even our own pediatricians – the message we receive is that if we’re formula feeding, we’re pretty much a lost cause. So while I can’t say I’m thrilled that a formula company stepped up to fill this gap, I think we need to think a little more critically about why the gap was there in the first place.

For the record, with this particular campaign, Similac isn’t giving parenting advice, but rather advocating for an end to mother-to-mother judgment. More of an anti-bullying campaign than anything about parenting issues. Which is probably why they have Michele Borba as one of the spokespeople – she’s a well-known expert on bullying as well as parenting issues, but she barely deals with the infant/toddler set. For that matter, I don’t think babies are mentioned at all in the campaign literature –most of it has to do with embracing your parenting choices and not allowing other people to make you feel less-than.

But I’m not even all that interested in discussing the campaign itself – I’m more concerned with the response to it. Comments I’ve seen; articles I’ve read from some folks I have utmost respect for, but whom I feel really missed the mark on this one. Some of these arguments include: Similac has no right to talk about mommy judgment because formula feeding shouldn’t be a lifestyle choice; the bloggers who came on board to support the campaign are sell-outs or shills for Big Forma; and that the campaign is one big booby trap.

In a thought-provoking and controversial NY Times Motherlode column, KJ Dell’Antonia quotes Kimberly Sears Allers, who maintains that the Strong Moms Empowerment campaign is faulty because formula feeding is a public health issue, not a personal choice:

One centimeter beneath the surface of Similac’s “Strong Moms” Summit and online campaign you will find that framing of infant formula use as a “lifestyle choice” that is not to be judged has been its primary marketing strategy for decades. … And since choices are individual, they have no social consequences; women are therefore relieved of responsibility of considering the broader implications of their decisions. And once I make my choice, no one is to challenge me. We can’t talk about it. And if you do, you are judging me.

Admittedly, I’m taking major poetic license here, but my take-away from Allers’ post was that we can’t not judge other moms for doing something which puts babies at risk. KJ’s own argument is more nuanced and balanced; she suggests that this whole conversation has become too personal, and the “judgment” rhetoric just dilutes the real issues.

I agree with KJ, actually – it’s a point I’ve made myself, in my own somewhat pissy rants about how the only anti-breastfeeding-promotion opinions we hear come in the form of personal stories (which are important in their own right – don’t get me wrong – but hardly a match against scientific studies and “fact”-driven articles). But making things “less personal” doesn’t just mean that every blog post discussing breastfeeding must stop devolving into a who-had-it-harder string of comments. The onus can’t purely be on those whose choices are being questioned to buck up and be “strong”. If we’re going to make it less personal, than breastfeeding advocates cannot be in charge of conducting research on infant feeding. We need to ensure that voices from both sides are heard, so that formula feeding mothers don’t need to sit in awkward, shameful silence while the food that so beautifully nourishes their infants is compared to tobacco, lest they be accused of “taking things so personally”.  And outlets like the New York Times need to post intellectually-driven or research-based pieces from the “other” perspective, rather than just personal stories of breastfeeding failure, so that the conversation isn’t so one-sided.

But I think, in some ways, KJ’s point gets convoluted by Allers’ quote. It can’t not be personal, when a woman’s decision to formula feed is being equated to a public health issue. This is where the misinterpretation of risk within the breastfeeding canon is problematic; it is where people like Joan Wolf are so vitally important. And yet, Joan Wolf can’t participate in the conversation because it has become so personal: her assessment of the literature is brushed off as anti-breastfeeding, lost in the fervor of those who fear that discussing breastmilk as anything less than a miraculous and perfect substance, and breastfeeding as anything less than a moral imperative, will negate their admirable efforts to normalize what should be a human right.

The other common refrain in the past few days is that formula feeding mothers should be offended by this campaign. I’m crying foul. First of all, I take issue with breastfeeding advocates speaking for me – someone who felt completely ousted, chastised, and disenfranchised from their community, and their ideal of good mothering. Just like I will never know the hot rage felt by a nursing mom who is asked to leave a restaurant, someone who has a fundamental belief that breast is best will never know what it feels like to be told that your maternal instinct is faulty, due to susceptibility to marketing, stupidity, selfishness, or some combination of the three.  To hear a company which created a product that nurtured my babies echoing the same sentiments I’ve been preaching for years – that the judgment must stop; that moms need to stop fighting each other and work together for better parenting rights; that women need to stop engaging in sorority-level hazing in order to wear the label of “Good Mommy/Good Radical Feminist/Strong Woman – makes me happy. I don’t feel preyed upon; I am well aware that they are hoping to sell more formula, and you know what? If I had to decide between a brand that is marketing to breastfeeding moms and one that is finally trying to appeal to its actual audience, I’d probably choose the latter.

Someone commented on the NYT article that it would’ve been nice if this campaign came from an individual or group without profit-driven motives. Spoiler alert: that would be me. That would be Bottle Babies. We’re out there, doing this. But most people aren’t aware of us – we each top out at about 3k Facebook followers, opposed to the popular breastfeeding blogger-activists, who are all in the 200k range or higher (some of whom, incidentally, could benefit from a pledge not to bully other moms. Just sayin’.)  We have nothing behind us – no advertising, no sponsors. No money. It’s slow going, trying to make a dent, attempting to create change in a positive and real and measured way. We waste a lot of time defending ourselves against accusations of working for the formula companies; of being anti-breastfeeding; of being uninformed and defensive.  And trying to run our ad-free websites and blogs and attend conference on our own dime and BE HEARD when there are so many more powerful, louder people out there. I realize this sounds like a whiny me-me-me rant, but I’m trying to paint a picture here – because it helps explains why I’m okay with the Similac campaign. Until the indie, unsponsored voices are able to reach the masses, I’m just happy that someone can. I’m happy that women who are feeling judged and guilty and embarrassed about their choices, who are forced to read “Breast is Best” every time they see a formula ad, or open a can of food for their baby, can finally have an opportunity to feel good about the product they are using. That for once, we can feel like part of the sorority – part of the “empowered” group – even if it’s all manufactured and for profit, even if it’s bullshit.  It’s not even about the cheesy “empowerment” pledge – it’s about seeing a formula company treat formula feeding as something matter-a-fact, rather than constantly comparing itself to breastmilk, and in a more subtle and unintentional way, comparing formula feeding mothers to breastfeeding mothers. It’s about being able to feel okay about the way a formula company is operating, rather than cringing at how they are sending free samples to moms intending on breastfeeding (rather than those of us who’ve filled out the damn internet form 300 times and never received a single coupon, but I digress) or marketing some asinine product (like the company in question, with its new “formula for supplementation”. Jesus, Similac. I’m wasting time defending you and then you pull something like this? For real?)

Yes, it’s not perfect. But it’s a start. And if you think it’s sad that we are so desperate for acceptance and celebration that we are willing to get into bed with a formula company that thinks of us like an easy booty call, I’d recommend taking a long, hard look at yourself: at the comments you make; the Facebook posts you share; the policies you write; the initiatives you implement; the articles you publish.

Because yes, it is sad. It is sad that Similac has been able to capitalize on this need. It is sad that there is the need to capitalize on. And it’s sad that those who have created that need are refusing to see how implicit they are in the development of such a sad situation.

It’s just sad.

 

“Where is the mother in the discussion?” An interview with Walker Karraa on maternal mental health and infant feeding

Some of you may know Walker Karraa from her comments on our Facebook community page, or from her fantastic posts on Science & Sensibility. But I doubt you’re aware of the full magnitude of her bravery and dedication to issues surrounding maternal mental health. I recently interviewed Walker for a short piece on formula feeding and postpartum adjustment, and was so blown away by her answers – I was only able to use a few of her wise words due to word count constraints, so I’m thrilled she’s agreed to let me post the interview in full here on FFF.

Walker is a doctoral candidate at Sofia University, where she is conducting a study on the transformational dimensions of postpartum depression. She was also the founding President of PATTCh, an organization founded by Penny Simkin dedicated to the prevention and treatment of traumatic childbirth, and is a perinatal mental health contributor for Lamaze International’s Science and Sensibility, Giving Birth With Confidence, and the American College of Nurse-Midwives (ACNM) Midwives Connection. Like that wasn’t enough on her plate, Walker also served as social media manager for the Integral Leadership Review, and has her own social media consulting business, On My High Horse, and is currently working toward co-authoring a book regarding PTSD following childbirth with Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA. 

I’m exhausted just reporting all of that. And did I mention she has two kids and is a breast cancer survivor? Yeah, she’s all that and a bag of reduced fat potato chips.

I hope you guys will appreciate the revolutionary nature of Walker’s discussion here – her opinions, while brilliant, probably seem uncontroversial to those who follow this blog, but they are quite “rogue” in the birth/maternal-child health community. I can’t thank her enough for being a dissenting voice and speaking up for the benefit of all women. 

FFF: Here on FFF, we see stories almost weekly which discuss how a perceived “failure” to breastfeed can lead to depression, anxiety, and self-esteem issues. Do you think the maternal mental health community has recognized how breastfeeding (or lack thereof) can affect the emotional state of new moms?

Walker Karraa

WK: I think that overall breastfeeding is very well addressed in the health psychology, and developmental psychology fields. What’s lacking is the reframe of the research to integrate more qualitative data, and methods, into the consideration of the full range of implications of breastfeeding from multiple perspectives—including the woman’s perspective.

In a 1985 Lancet article on maternal mortality, Allen Rosenfield asked the famous question, “Where is the ‘M’ in MCH (Maternal Child Health)? In the discussions of MCH, it is commonly assumed that what is good for the child is good for the mother.” (Rosenfield & Maine, 1985, p. 83). In many ways this is relevant in the discussion of breastfeeding and maternal mental health. Where is the mother in the discussion? And in what ways do we still assume what is good for the child is good for the mother? For me, this is all about reproductive rights and a deeper issue about our discomfort with women’s sovereignty over their reproductive, physical, and mental health.

The mental health community has responded to the growth in published data regarding infant health and breastfeeding. This has also been the funding stream for a large part of the last 20 years. But maternal mental health has yet to directly address a woman’s infant feeding choice as a part of her reproductive choice, rather than discrete periods of time that occur with as a continuum of events that are inextricably woven through reproductive events—none of which, taken by themselves, gives either the best data on mental health.

FFF: What do you feel needs to change in order for new mothers to be better supported in terms of mental health in general?

WK: I think one of the first calls to action must be for maternal care providers to get support in knowing that perinatal mood and anxiety disorders are common and create the conditions for morbidity and mortality for mother and children. This is starting to happen, but still very slow. I think new models of medical care such as Dr. Michael C Lu’s life course model, which places the woman at the center of care, not the doctor. And, she is treated across the lifespan, not merely when she is pregnant. This facilitates better reproductive health in preconception and interconception, and uses a reproductive life plan for women and families from an early age. At puberty, to have a conversation with medical, nutritional, mental health providers as to planning one’s reproduction (girls and boys) would be ideal.

FFF: Many women struggle with the decision of whether to treat postpartum or prenatal depression/anxiety with psycho-pharmaceuticals, especially when they are breastfeeding. Why is there such mixed information and messaging about what drugs are safe, and what the relative risks are (ie, breastfeeding without meds vs breastfeeding on meds vs formula feeding and taking the meds)?

WK: Not having good information is a barrier to care for everyone involved. The OB/GYN or midwife, the social worker, the woman, her partner and family—when we don’t have good information, we cannot make informed choices. And for women in poverty, the risk is twofold. Specifically regarding breastfeeding, but also education across the board regarding psychopharmacology, pregnancy, and lactation. With organizations such as OTIS (Organization of Teratology Information Specialists) and Motherisk, there really is no excuse for not having current evidence-based data regarding risk and benefit of untreated depression and anxiety, as well as risks and benefits of medications used to treat them.

Byatt et al. (2012) did a wonderful grounded theory study regarding community mental health provider reluctance to providing psycho-pharmacotherapy. 28 obstetric care providers (nurses, OB/Gyns, etc.) shared how they perceive community mental health practitioners as obstacles to psychopharmacology for perinatal women. The participants felt community mental health providers “99% of the time” discontinued a patients’ medication, and put women at risk of relapse. Secondly, Byatt et al., (2012) reported that participants perceived a lack of collaboration and communication between community mental health care providers and OB/Gyn providers, and that pharmacists also “further impede or delay depression treatment by not filling needed psychotropic prescriptions, often exacerbating women’s mental health symptoms” (p. 3).

FFF: Why do you think so many women express grief, guilt, and feelings of failure around the subject of infant feeding?

WK: Because that is their experience! And I attribute all of it to social constructs that are completely ingrained in medical, social, and mental health systems that have been made for and by men. The intentions of those men is not necessarily nefarious, and not really the point. It is that the constructs we have to measure ourselves (abilities and weaknesses) are made by men. We tell women from the get-go that they need us to be good mothers. They need our insight, knowledge, treatment, book, video, technique, services, product to be taught how to mother. This is so ironic, because so many of the birth movements have evolved from a call to empower women. But to empower, we have just made more systems of knowledge that mimic the ones we refute. That is not very popular to say, but it is true. The messages still given to women is that if they “know” something analytically, they are devoid of femininity, and if they “know” something inter-subjectively, they are devoid of ration.

Shame is a powerful force for women. And at no time in her life is a woman more susceptible to shame than early motherhood. If they are lucky enough to find a safe space to share their feelings without judgment, such as your blog, they are given the gift of voice. They can speak their truths.

FFF: Any tips for a mom who is having a tough time reconciling her use of formula?

WK: You know, when I was a doula, I had clients ask me to go buy formula for them so they wouldn’t be seen in public. When I was diagnosed with breast cancer shortly after the birth of my second, I underwent two mastectomies before she had turned one. I learned that my body parts have nothing to do with my inherent ability to love her. My breasts were gone—off of my body, one in one hospital and another at a hospital down the road. I fed, nurtured, attached with, loved, and parented without them…and still do! So my advice is to write down on a piece of paper: My breasts have nothing to do with my love for my child. And keep it where you can see it. Memorize it, know it.

Can formula feeding really be “fearless”?

The lovely KJ Dell’Antonia recently mentioned my book and blog in a Motherlode column she wrote about the recent onslaught of breastfeeding-pressure backlash. There was the refreshing -albeit unfortunately titled- piece by a father in the Atlantic, followed by another excellent Motherlode post by writer Marie C. Baca about “embracing” bottle feeding- these came on the heels of a number of other articles which cropped up over the summer and in the early fall, as a result of Latch On NYC and a few other initiatives that have passed in the United States and abroad. Dell’Antonia observed that in all of these writers’ submissions (including yours truly’s) to the infant feeding discourse, one thing remained consistent:

…What’s striking about Ms. Barston’s and Mr. Kornelis’s stories, and most stories of “fearless formula feeding” is still really how “fearless” they aren’t. In every narrative of not breastfeeding, there is the obligatory note of failure, as though justification were the first order of the day… for most women, not nursing, for whatever reason, remains a troubling topic. As long as women are occupied with the litany of excuses… then the conversation will stay on defending the bottle or breast, and off the more important question of how to ensure that the choice between them is dictated more by health and happiness and less by circumstance.

This struck a nerve with me. Scratch that – it pinched a nerve. Her theory was like a constant, nagging backache, reminding me that it needed attention every time I moved a bit too fast. It took me a few days to untangle what bothered me so much about these assertions; the ensuing discussion on the FFF Facebook page only served to deepen my desire for answers (or a good massage).

All of you made fantastic points about why we so often appear to be defensive about our choices. Some argued that while we may indeed give excuses, this is because we are conditioned to expect judgment. “I think our stories are tinged with defensiveness since before even sharing them we are already preparing to be attacked,” Tara mused. Lisa echoed that sentiment. “For me, it wasn’t inner guilt – it was everyone’s expectation that I SHOULD feel guilty and that I had done something wrong. Frankly, I was outright pissed off by the insinuations and outright accusations that by formula feeding my daughter, I was setting her up to be fat, stupid, and unhealthy. That’s where my defensiveness came from – the need to defend my choice.” And others thoughtfully mentioned that while we may indeed appear defensive, a lot of it may simply be our way of dealing with complex emotions over the inability to do something we wanted very badly to do:   “”I don’t believe that guilt is a simple emotion – I felt guilty because my boobs failed, I also felt guilty that I was happy that formula was working for us. I felt I was letting my daughter and others down. Guilt is often the result of being unable to change a moment in time – it’s not always about what is right or wrong,” wrote Allison.

As a few of you rightly pointed out, so much comes down to perspective. Unless you have lived through this particular kind of hell, you just can’t understand it. As Misty explained. “I think they mistake bitterness with defensiveness. Unless you’ve suffered the same societal and personal condemnation and guilt tripping that comes with the breast v bottle war, you can’t imagine what kind of damage and pain it causes to a woman’s soul. Obviously, not every woman who tried to nurse but went to formula experiences anguish about it, but many of us do, especially those who had fully embraced the ‘breast is best’ mantra. I still struggle with resentment toward the BFing friends and professionals who, in my opinion, needlessly caused me to suffer terribly as a new mother. I still have sorrow that my first year as a mother was so joyless, because others chose to reinforce my flawed views about BFing (which I’d gotten from them) instead of guiding me compassionately to a more balanced and emotionally healthier way of feeding my child.”

Perspective also plays into the issue of defensiveness in another way: the further away from it you are, the easier it is to approach the “Why I Formula Fed” question dispassionately. I guarantee that for most new mothers, ten years from now- hell, even five – this debate will bore the hell out of them. Other issues will take its place – education, bullying, puberty, safety concerns, etc. However, there are those of us for whom this isn’t just a personal tragedy, but a social problem, a cause which deserves our anger and outrage and yes, defensiveness. I don’t think it’s entirely realistic to hope that we can move away from defensiveness completely, because we are typically reacting to offensiveness.

I think you can be fearless and simultaneously feel the need to defend yourself. All “fearless” formula feeding means to me is that you feel you have made the best choice for your family, for your baby, for you. Fearless doesn’t necessarily mean regret-less, guilt-less, anger-less, resentful-less. It just means you’re not scared of your choice, because you know it is safe, and you know it was right.

But as for what KJ refers to as the “litany of excuses”… I’ve always suspected these are a necessary tool, a ticket to participate in the conversation. By explaining how much you wanted to nurse, and talking about all the struggle you went through to do it, it might help the opposition understand that this is not a matter of lack of education or drive. That it would at least start us on a level playing field, and take down the barricades at the border – I wanted to nurse, you wanted to nurse, we both believe in breastfeeding, so let’s try and discuss this rationally. I have nothing but admiration for women gutsy enough to just come out and say nursing wasn’t for them – I loved Amy Sullivan’s essay in The New Republic, and it was, indeed, the most “fearless” argument for bottle feeding I’ve seen (interestingly, Dell’Antonia felt that Baca’s piece was free from the normal guilt-ridden excuses. I thought it was an excellent piece, on every level – I mean really, really excellent, and quite fearless in a number of important ways – but the fact remains that Baca still mentioned that that she was physically unable to nurse. That gives her a “pass”, in many people’s estimation; it’s still a preemptive strike against condemnation, unconscious as it may have been). But one look at the comment section of Sullivan’s editorial, and you’ll see that it immediately erupted into a hate-fest. Breastfeeding moms took her words as an affront to their method of feeding; breastfeeding advocates told her she was misinformed; judgmental sanctimommies hurled accusations of the usual flavors- Sullivan was selfish, shouldn’t have had kids, etc.

Still, in the past few months, I’ve noticed something: no matter what the writer says, in every online piece I’ve read about formula feeding, the response thread is Exactly. The. Same. The same arguments, the same people, the same facts and studies and name-calling. So while I think we have a right to our emotions – whether these emotions are guilt or regret or anger or pride- we shouldn’t feel the need to state our case in order to create a more peaceful discourse. No matter what you tell them, haters are gonna hate, or whatever that saying is.

Ultimately, I think KJ is right: I’m not sure we can move forward in creating positive change for anyone until we can stop the vicious cycle of guilt-defensiveness-bitterness. I would argue, though, that this is not the responsibility of the women (or men) sharing their stories, but rather that the conversation at large needs to change focus and tone. This might start with media outlets allowing for more nuanced, balanced features on why breastfeeding isn’t working for so many women, rather than coping out with opinion pieces. It might continue with physicians being able to speak out against some of the newest breastfeeding promotion endeavors without risking their careers to do so. It might end with us accepting that changing our society to be more breastfeeding-friendly is far less of a public health issue than it is a question of personal freedom, women’s rights, and trusting our own instincts over what the experts deem is best.

 

 

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