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

 

 

Of nanny states and nonsense

This is why I hate politics.

Earlier today, Jennifer Doverspike’s scathing indictment of Latch On NYC popped up on the Federalist website. By this evening, Amanda Marcotte had written a similarly scathing indictment of Jennifer’s piece on Slate. Both talked about hospital policies, formula feeder paranoia, and boobs. But in the end, what should have been a smart point-counterpoint between two passionate, intelligent women turned into a steaming pile of another bodily substance.

Yep, I’m talking about shit. 

Look, guys, I’m sorry for the language, but I’m done being classy, at least for tonight. Tonight, my Boston-bred, townie self is coming out, because I. Have. Flipping. HAD IT.

 

Doverspike’s piece does veer into political territory, mostly from the use of the term “nanny state”, a phrase that is undoubtably evocative (and apparently intoxicating) in today’s partisan climate. There were portions of her article that made me (a self-proclaimed, sole member of the Turtle party – our platform is that we just hide our heads in our shells whenever political issues arise. Anyone’s welcome to join!) a little uncomfortable, mostly because I worried that her important message would get lost by those on the Left. But I naively thought (us Turtles are naive about such things, considering we start singing “Mary Had a Little Lamb” whenever someone brings up Congress and prefer to our news from the Colbert Report) that she’d covered these bases with her final paragraph:

 

There are, of course, many laws the government issues for our protection and those of our children. Seatbelt laws, child car seat booster requirements, bans on drop side cribs and helmet laws. Regardless of whether or not these encompass valid risks (many do, some don’t), they do not encroach on personal freedom the way laws regarding parenting methods do. And don’t get me wrong; this goes in all directions. Infant feeding, and the personal freedoms associated with it, is not a liberal or conservative issue.

 

Apparently, it is a liberal or conservative issue, at least according to Marcotte, whose response to Doverspike felt far nastier than necessary. Marcotte accuses Doverspike of not doing her homework regarding the implementation of the WHO Code, for example:

 

What Doverspike fails to mention is why the WHO wrote out these regulations in the first place, something a quick Google search reveals. As reported at the time by theNew York Times, researchers had discovered that poor parents were stretching out formula by watering it down, which was leading to malnutrition in infants. In addition, places that lack clean drinking water are places where formula feeding is downright dangerous. There are substantial benefits, particularly worldwide, to creating a culture where breast-feeding is the go-to way to feed children, and formula is only viewed as a supplement for cases where breast-feeding isn’t working. Of course, that does cut into formula company profits, so if that’s your priority, by all means, bash the WHO’s efforts to keep babies healthy some more.

 

Huh. See, that’s odd, because I clearly remember reading something in Doverspike’s piece about this very issue… let’s see… ah, right:

 

Unlike the city of New York, the WHO  has valid reasons to be concerned with breastfeeding rates worldwide. After all, in less developed countries not breastfeeding may mean instead using cow’s milk for infants. When formula is used, the risks of it being prepared incorrectly and using contaminated water is rather high…The WHO should focus being on how to educate and support women in developing countries regarding the dangers of cow’s milk, the benefits of breastfeeding, and the importance of correctly mixing formula. Unfortunately, the WHO Code saves most of its energy in marginalizing formula companies, requiring hospitals to under no circumstances allow formula advertising and requiring that product samples only be given for research at the institutional level — “In no case,” it stipulates, “should these samples be passed on to mothers.” The WHO is also requiring labels stating the superiority of breastfeeding and warning to not use the product until consulting with a health professional.

True, she didn’t delve into the issues surrounding formula use in developing nations as deeply as she could have, but Marcotte’s take on the subject wasn’t exactly accurate, either. The Nestle controversy which she alludes to involved corporate subterfuge (women dressed as nurses convincing new mothers to use formula; these “health workers” then packed up and left, abandoning the moms with no established milk supply, no resources to procure more formula, and dirty water to use for what formula they did have), and this was what drove well-meaning individuals to create the WHO Code… but the problems that exist which lead women in these same countries away from breastfeeding are so much more complex than our Western understanding of “unethical marketing”. And to compare the risks of not breastfeeding in these countries to the risks in countries which are debating baby-friendly initiatives isn’t fair nor useful. These are two entirely separate issues.

Marcotte also dismisses Doverspike’s concerns that under Latch On, formula ”must be guarded and distributed with roughly the same precautions as addictive and harmful narcotics” by citing a “sober-minded assessment” that she claims “shows that no such things are happening”. This “sober-minded assessment” is a CNN option piece from writer Taylor Newman, who repeatedly brings up her own breastfeeding experience in a hospital with piss-poor support. Newman engages in some of the most immature name-calling I’ve seen in a respected news source – those who disagree with her opinion of Latch On are “obnoxious”, “unhinged” they write “badly-written” posts that are just ‘kicking up dust”. (If this is sober-minded, hand over the vodka. This is mean-girl, bitchy, completely anti-feminist bullshit, is what it is. If a man called a fellow woman writer “unhinged” or accused her of being hysterical, I bet we’d see plenty of backlash from Slate. ) She also makes the fatal mistake so many reporters, pundits and advocates have made in this tiresome debate: she’s only seeing it through the lens of her own experience. It may not seem like a huge deal to someone who wanted to breastfeed (and ultimately did, successfully) that new moms will have to ask for formula each time a baby needs to eat, or that they will have to endure a lecture on the risks and intense questioning of their decision. But try living through that experience as, say, a single mom who was molested as a child. Imagine you don’t have anyone around to defend you, to demand that the nurses treat your decision not to use your body in a particular manner with respect. Imagine that you don’t feel like reliving your abuse and telling a total stranger – repeatedly – why the idea of letting a baby suck on your breasts makes you want to throw up.

I know I’m digressing here, and again, I’m sorry to be throwing my usual I-Support-You, let’s all hold hands and braid each other’s hair Pollyanna-esque, evolved FFF persona out the window. This is old school FFF, the angry one, the one whose claws come out when I see that women are being told their voices don’t matter, their concerns don’t matter, their choices don’t matter. The one who refuses to allow an important discussion – a women’s rights discussion, not a political one – get bogged down in right vs. left rhetoric.

Marquette’s choice of image to go along with her article is a baby holding a bottle with the caption “Freedom Fighters”. Again, I have to ask – really? Fine, be mad that the Libertarian Federalist invoked the Nanny State and beat up on poor old Bloomberg. Rage against that. But to belittle those of us who care about this issue is petty and cruel. And to ignore – once again – that what Latch On’s PR machine told the press was quite different from what was written in the actual materials used to implement the program; to ignore that no one has actually done a follow-up story since the initiative was announced which reports actual accounts from actual women who actually delivered in actual Latch On hospitals and used actual formula – this is just poor journalism.

Feminists, journalists, bloggers – I belong to all of your clubs, and I’m sure you’re about to revoke my membership, but I have to ask: Why are we rehashing the same arguments over and over, instead of discussing how we could come to a more beneficial, neutral ground? For example – couldn’t women be counseled on the benefits of breastfeeding before they enter the emotional sauna of the postpartum ward? Yes, I realize that not all women have access to prenatal care, but for those who do, this seems like a practical and  beneficial adjustment. If these issues are discussed beforehand, at least a mom who knows from the start that she doesn’t want to nurse can sign whatever documentation is necessary to tell the state s has been fully informed of the “risks” and “still insists” (Latch On’s term, not mine) on formula feeding. For those who change their minds while in the maternity ward – well, couldn’t we just agree that she gets one lecture on why it’s a bad decision, and then receives the education, support and materials she needs to feed her baby safely, rather than having to go through the whole rigamarole every time her infant begins rooting?

Or here’s another idea – take the hyperbole out of the initiative. Stop saying these things are “baby-friendly” or “progressive” or “empowering” because they aren’t necessarily so. And by saying that they are, you get people all riled up, politically. You start hearing terms like “nanny state” because some of us don’t want to be told how we should feel (or how our babies should feel, for that matter. If my mom couldn’t feed me and some nurses weren’t letting me access the next best thing, I’d be hella pissed, and that environment would become decidedly baby unfriendly. Especially when I punched the person refusing my mom the formula in the nose with my tiny baby fist). You start getting feminists shouting about second waves and third waves and whether women should feel empowered by their ladyparts or held down by them. It’s one big mess, is what I’m saying. So can we stop it, now? Can we start writing articles that are balanced reports rather than press releases for a particular administration or cause? Can we stop hurling insults at each other just because we don’t agree on what being a mother should mean?

Can we please, for the love of all things holy, just flipping stop?

Breastfeeding pressure doesn’t care about privilege

I am privileged.

I’m not rich, but I have never gone hungry; never been without a roof over my head; never wanted for anything (well, nothing more pressing than a better body and maybe a date with Ewan MacGregor circa Trainspotting). I don’t know how it feels to be judged by the color of my skin. I’ve been discriminated against, as a Jew and a woman; called names like kyke and jewbeggar and bitch, but I’ve never been racially profiled or held back by a language barrier, or assumed to be suspicious or uneducated because of the way I look.  I have a great husband and amazing friends and ridiculously supportive parents and in laws.

I realize that in the United States, this means I am incredibly lucky. I also realize that this means I have no business assuming things about anyone else’s lived experience. It doesn’t matter how many academic texts I read or people I speak with in a clinical setting – I can’t know how it feels to be dependent on welfare, or in an abusive relationship, or at a dead-end job with a sexually harassing boss.

I often hear that the pressure to breastfeed is a problem plaguing a specific socioeconomic and geographical subset of women; that my assumption that women are being harmed by overzealous breastfeeding promotion is dripping with “privilege-laden assumptions”. The people making these claims insist that poor, minority women think formula is superior (because they’ve all been victims of unscrupulous marketing and social pressure), and do not know the benefits of breastfeeding, and that if anything they feel ostracized if they breastfeed. Formula feeding, they say, is the unfortunate norm – my concerns have no place in these communities.

I don’t deny that I am coming from a certain perspective, and I always acknowledge that things are different depending on where you live, and what your social circles are doing. I also don’t deny that these social and marketing influences are real. But I think it’s just as privileged to assume that all women in lower socioeconomic areas need to be “educated”, and to ignore the fact that the lower a woman’s status in society, the easier it is for her bodily autonomy or emotional well-being to be violated. Ensuring that the rights of these women are protected is more important than raising breastfeeding rates – and the same policies which are worrisome for a privileged white woman are even more deleterious for someone whose voice is already struggling to be heard.

Yesterday morning, I met with two women who work at an organization serving a lower income neighborhood of Manhattan, helping teenage mothers from a variety of cultural backgrounds. These women told me that in some of the ethnic groups they serve, breastfeeding is very much the norm; in others, it is not as culturally accepted. Their organization is extremely pro-breastfeeding – there is no formula available at their office to give to girls in need, and they encourage breastfeeding throughout the prenatal period and beyond. But when I brought up the idea that the girls these women work with are not being affected by the “breastfeeding makes good mothers” philosophy, I was met with disbelief. “The ivory tower ideal is even more of an ideal for someone who is already struggling to fit the definition of a good mother,” one of them explained. They expressed a need for better messaging – encouraging at-risk women to focus on mothering rather than just feeding. Things like promoting skin-to-skin, reading to your baby, eye contact… not putting the emphasis on breastfeeding as the be-all end-all of parenting.

I also learned that the breastfeeding education these girls are given mostly consists of comparisons between formula and breastmilk, and information on how breastfeeding leads to better bonding and healthier kids. There is little instruction on the actual mechanics of breastfeeding, or how to manage the lifestyle barriers that could make exclusive nursing difficult. So while these young women may go into labor wanting very badly to give their babies the best (and they are well aware its the best, as their prenatal education features lectures on the differences between formula fed and breastfed babies), once they leave the maternity ward and have to return to work or school within a few weeks, without successfully establishing breastfeeding, or knowing how to pump, or how to advocate for their right to express in the workplace (if their workplace even falls under the parameters of the latest breastfeeding laws, many end up on formula- without any advice on how to do so safely.

After that meeting, I had lunch with an FFF who lives in Brooklyn. Her story was all too familiar – wanting to breastfeed, finding herself faced with low supply, getting conflicting advice from healthcare providers, balancing her own health and sanity with her (incredibly nuanced) understanding of breastfeeding’s benefits. The same sort of story we often see on this blog, from an educated mom with a supportive partner who had the ability to hire lactation consultants, and knew how to read scientific literature well enough to suss out her own risk/benefit analysis.

Obviously, this woman came from a very different situation than the women represented in the day’s earlier conversation.  But there was a remarkable similarity in what was expressed by everyone I spoke to. There was consensus on what we need: a more balanced, less hysterical, more individualized approach to infant feeding. All agreed that an honest discussion of the challenges of breastfeeding would be helpful, and that education on formula feeding safely and knowledgeably would go a long way in protecting the physical health of babies and the emotional health of mothers, regardless of their socioeconomic or ethnic background.

The stories these women are telling are not about white or black, native or immigrant, poor or rich. This isn’t about politics. It’s about what will be the best choice for an individual woman in her individual circumstances. These are stories with one moral: that we can – we must – support a woman’s right to breastfeed as well as her right to choose not to breastfeed.  This isn’t about doing away with Baby Friendly, because we need to ensure that women are getting a good start to breastfeeding and every opportunity to make it work (and that means switching the focus from vilifying formula to actually helping women initiate and sustain breastfeeding in practical ways). But we need to speak up and insist that there is a way to do this without loading more pressure onto new mothers.

I have a feeling breastfeeding guilt is seen as a problem of the privileged, because we are the ones with the time, resources, and autonomy to speak up about it. That doesn’t mean women of other backgrounds aren’t feeling the same pressure, perhaps manifesting in even more damaging ways. Still, it’s not my place to pretend to understand them, or to put words in their mouths. There’s no way I could, because these women aren’t an aggregate. They are individuals. To speak for the “disenfranchised” or “minority communities” as a sole entity is asinine. My experience is extremely different from other moms in middle-class Los Angeles – that doesn’t make it any less real, or valid.

One-size-fits-all infant feeding policies do not work, because women are not one-size-fits-all. In fact, in both fashion and life, one size usually just fits a lucky few. To label breastfeeding guilt as solely an experience of one type of woman, and paternalistic “education” as necessary for another, is just plain wrong.  It would be nice, instead of arguing about who has the most altruistic motives to help certain groups of moms feel empowered, we just focused on empowering all women to make choices that feel right for them, and to decide how their bodies are utilized.  Because while I would never attempt to speak for anyone, I don’t think it’s a privileged assumption that most of us would appreciate the ability to speak for ourselves.

 

 

Public Citizen Jumps on the Ban–the-Bags Bandwagon: Advocacy group forms petition to rid hospitals of formula samples

One time, this potato bug terrorized our stairs for three days straight. Being the anti-violence-against-all-creatures vegetarian I am, I urged it to move on by gently prodding it with a stick. It wouldn’t budge. I finally gave up and decided it was it or me, so I ended up spraying it with all-purpose cleaner. It survived the assault. (All we had was organic cleaner in the house, so for all I know the stuff I used made the bug grow bigger and stronger.) Finally, I had to be all lame and stereotypically female and call my husband to take care of the situation – and he had to stomp on it seven times before it expired.

He was too ugly to live. Forgive me. 

I feel like a broken record, talking about the movement to outlaw formula goodie bags from hospitals, once again… but just like our friend the potato bug, the damn issue just won’t die.

The newest incarnation of the old debate comes from the advocacy group Public Citizen. They have put forth a petition on their website, and have submitted a letter to hospitals that continue to hand out formula samples. According to the letter,

There is overwhelming consensus among all major health professional organizations regarding the health benefits of breastfeeding for mothers and babies and the importance of exclusive breastfeeding for the first six months of life.[1]  Hospital promotion of infant formula through dissemination of these discharge bags contravenes this consensus, needlessly and inexcusably harming babies and families. Moreover, formula feeding imposes a significant burden on the nation’s economy. Breastfeeding saves families and the economy countless dollars….
 When hospitals distribute formula samples…they imply that these products are medically approved and recommended. Yet, there is ample evidence that formula samples reduce breastfeeding duration and exclusivity. Multiple studies have shown that women who receive commercial hospital discharge packs stop breastfeeding sooner than those who do not.[2] Hospitals expend resources to support mothers to breastfeed, but reduce the impact of these efforts by distributing formula samples.  Research shows that bag distribution sends a message more powerful than any verbal messages.[3] New mothers who at first experience difficulty breastfeeding are apt to choose to use free formula samples given to them in discharge bags instead of seeking out assistance with breastfeeding. Aware of these dangers, in 1981 the WHO established the International Code of Marketing of Breast-milk Substitutes.[4] The Code states that healthcare facilities are not to be used for the marketing of infant formula. Hospitals in the U.S. that continue to distribute formula samples are in violation of the WHO Code.

I’m not going to rehash my feelings about formula samples (if you’re interested in what I think – and trust me, it’s not all that interesting or revolutionary – you can check out this previous post or this one on the same topic) or drone on about WHO Code (like I did here). I simply want to address some of the inaccuracies and (what I feel are) harmful statements in this letter, which is making the rounds in the media and blogosphere.
1. The authors do not give a citation for the statement that “formula feeding imposes a significant burden on the nation’s economy”, but I’ll give them the benefit of the doubt that they meant to cite the Bartick/Reinhold study which claimed that “suboptimal” breastfeeding costs the United States 911 lives and 13 billion dollars per year. Please look to Momma Data’s Polly Palumbo for an astute analysis of this study and form your own opinions about the truth of this statement. I’d also submit that even if you believe Bartick and Reinhold were 100% correct, these results were basically a hypothesis; the study did not give sufficient information to start making such dramatic claims as if it were fact. 

2.  They state that “when hospitals distribute formula samples…they imply that these products are medically approved and recommended.” Well, um…that’s because they are. They are not recommended over breastfeeding (except in some cases) but they are indeed medically approved and recommended as breastmilk substitutes. Like it or not, formula has been deemed a safe alternative to breastmilk by medical authorities. A more accurate statement would have been “when hospitals distribute formula samples, they imply that they are advocating the use of formula over breastmilk.” Now that’s a train upon which I could climb on board. Hell, I’d even be the conductor. I agree that handing parents a bag of formula without asking if they are planning on formula feeding is utter and complete crap. It’s contradictory to the “breast is best/breast is normal” message and very confusing, especially coupled with the typically sub-par, hospital-grade breastfeeding support. (Don’t get excited – I’m not advocating that they do away with these sample bags. I think they should offer two versions – a breastfeeding one and a formula feeding one. Breastfeeding one could be provided by the state, since they are pushing so hard for the citizens to nurse their young. Formula one could be provided by the formula companies, because no one else is going to do it. And while we’re at it, it’s pretty depressing that the literature which comes in these bags is often the only education most parents get on how to safely bottle feed.)

3. Invoking WHO Code is pointless. The United States is notorious for being the only “major” country that doesn’t enforce the WHO Code; in this country, it is not a “law”, but rather a moral code which formula companies are “asked” to respect. It doesn’t matter that distributing these bags is violating the Code; until the government makes it illegal to pass out formula samples, hospitals have a right to do so.

Speaking of making formula bags illegal, the Ban the Bags movement was in the news for a different reason this week, as well.

(Ahem. Before I “go there”, I’m going to ask that we pretty please with a ginormous cherry on top do not let this veer off course into a political argument. This is not about the candidate in question or his political party, but merely some statements made by his camp many years back.)

One of the skeleton’s dragged out of Republican presidential contender Mitt Romney’s closet was his clash with breastfeeding advocates back in 2006. As Governor of my former home state, Massachusetts, he fought against an initiative to legally ban formula sample bags in hospitals.  According to BuzzFeed.com,


Romney’s spokesmen at the time and current campaign advisor Eric Fehrnstrom said the decision was about freedom of choice. “We’re not disputing the health benefits of breast-feeding, but we think that new mothers should make that choice,” Eric Fehrnstrom said. “If they choose to bottle-feed, they should be supported in that decision.”… Romney attacked the decision by the Department of Public Health as an intrusion of big government saying “I’m not enthusiastic about the heavy arm of government coming in and saying, ‘We think we know better than the mothers and we are going to decide that they can’t get free formula when it comes as a welcome home kit from the suppliers of formula with Q-tips, baby lotion and so forth. Let’s let the moms decide.”

Regardless of your political views, I do think it’s interesting that this story came out in the exact same week that Public Citizen released its letter and petition. If I were prone to conspiracy theories, I might say that Big Formula isn’t the only group that can orchestrate clever marketing campaigns. But I’m not prone to conspiracy theories, so I’ll just say this: Romney may or may not have been in cahoots with the formula companies (as was the accusation at the time, obviously), but that doesn’t make what he or his spokesperson said any less true. Let the moms decide.

So: if you really believe that receiving a sample bag hurt your breastfeeding efforts, let your voices be heard. Sign the petition. But please, don’t let this ridiculous battle overshadow the realities of the infant feeding discourse. Fighting for better support, longer paid maternity and paternity leaves, etc., would do far more for actually helping women to meet breastfeeding goals.

Lastly, using coercive tactics to convince the public about the superiority of your product is never okay.
And I’m not just talking to the formula companies.

WTF, AAP? The problem with the American Academy of Pediatrics’ newest statement on breastfeeding

“Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice.”

Thus begins the newest statement from the American Academy of Pediatrics regarding infant feeding. And consequently, thus begins the newest battle for FFFs anyone who cares about the freedom of women to choose how they feed their babies, and how they use their bodies.

The ghosts of statements past

It may seem like an overreaction, but the choice of words in this “official statement” from the preeminent child health organization of the United States, is deeply disturbing to me. To explain why, I think it may be helpful to look at the AAP’s past statements regarding breastfeeding, over the last 15 years.

Back in 1997,the AAP concluded its position paper on breastfeeding by stating that “Although economic, cultural, and political pressures often confound decisions about infant feeding, the AAP firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant. Enthusiastic support and involvement of pediatricians in the promotion and practice of breastfeeding is essential to the achievement of optimal infant and child health, growth, and development.” This reads like a strong suggestion to breastfeed; a plea for pediatricians to support breastfeeding but at the same time acknowledging that sometimes there are complications which make the “preferred” choice a difficult one to carry out.

By 2005, an updated statement was released. This statement was relatively similar to the 1997 one, but contained some updated information (including an advisory statement about Vitamin D supplements in breastfed infants). The concluding statement was the same as that in the 1997 document.

Now, in 2012, we are presented with a document that’s opening paragraph puts the kibosh on personal autonomy for mothers. There is no longer any acknowledgment – however cursory – of external factors which might complicate the decision to breastfeed; the section on contraindications is worded in a way which suggests that even meth-addicted women are better off breastfeeding; and pediatricians are encouraged that their “role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.” The concluding paragraph is in stark contrast to that of prior statements:

Research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as
a lifestyle choice but rather as a basic health issue. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.

I am woman, hear me roar (unless it keeps me from breastfeeding, in which case I should shut up)


In this statement, pediatricians are called upon to visit an AAP website which will “provides a wealth of breastfeeding-related material and resources to assist and support pediatricians in their critical role as advocates of infant well-being.”

Labeling the intended audience of this paper as “advocates of infant well-being” is exactly right: pediatricians are advocates of infant well-being, not maternal well-being. Within a section on “maternal benefits” to breastfeeding, the authors claim that “a large prospective study on child abuse and neglect perpetuated by mothers found, after correcting for potential confounders, that the rate of abuse/neglect was significantly increased for mothers who did not breastfeed as opposed to those who did.” This study was the one we discussed here; if you go back and read that post, you’ll realize that this study did NOT control for the most important (and in my opinion, most obvious) confounder, which was that women who are most likely to be neglectful or abusive will not choose to breastfeed in the first place. This study was one of the weakest, most ridiculous pieces of drivel that I’ve read in the entire body of breastfeeding science, and that’s saying a lot. The fact that the AAP would stoop so low to add this to their official breastfeeding statement speaks volumes, in my opinion. (Although considering they later allude to the infamous Bartick study as an “evidence-based stud(y)” which has “confirmed and quantitated the risks of not breastfeeding”, I guess I shouldn’t be too surprised.) Insult is added to injury by their brief discussion of postpartum depression (“Prospective cohort studies have noted an increase in postpartum depression in mothers who do not breastfeed or who wean early…”).

It is one thing for pediatricians to write a strongly worded statement about the benefits of human milk to babies. If we’re going to talk about maternal benefits, I’d like to hear about that from a cancer specialist, a psychiatrist or clinical psychologist who specializes in maternal mental health, and maybe an OBGYN. Not my child’s pediatrician, who hasn’t focused on adult vaginas or brains since they graduated from medical school. “But FFF”, you’re probably saying, “it’s for the children! The children!!” Yes, it may well be. But if we’re going to discuss subjugating the needs of the mother for the needs of the child, then we are getting ourselves into a very controversial area, and one which I don’t think the AAP has the right – or the depth of knowledge – to tackle. And regardless of where you may personally stand on that issue, I fear that if we go down this path, it’s a short trek over to another road where they start sterilizing women over 40 because they have a higher risk of birth defects, or making certain reproductive technologies illegal because they aren’t the “normative standard” of how we are supposed to reproduce. Melodramatic? I sure hope so, but I don’t think it’s that far a stretch.

Redundant Redundancy

Here’s what I find interesting: the authors state that they are releasing this updated statement because “(r)ecently published research and systematic reviews have reinforced the conclusion that breastfeeding and human milk are the reference normative standards for infant feeding and nutrition. The current statement updates the evidence for this conclusion…” And yet, the main source of data is the AHRQ Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, which is also the basis for the recent Surgeon General statement on breastfeeding. This document is actually a really good read, as nearly every benefit they cite is capped with a strong warning not to get over-excited over the findings as they are bogged down by study limitations, confounding factors, etc. If you haven’t read it, I strongly suggest that you do – it will make you feel a hell of a lot better about the foreboding statements made by our government and the AAP.

If you look at the references at the bottom of the newest AAP breastfeeding statement, you’ll see that quite a few of the cited studies are indeed from after 2005, when the last AAP statement was released. In that sense, a new statement is justified. But what do these studies really tell us that the older ones haven’t? None of the “rules” have changed; it’s more of the same type of evidence, which suggests a slight benefit after adjusting for confounders (which are usually not appropriately comprehensive). As usual, I feel I must state for the record that I am in NO WAY suggesting that these findings are fundamentally incorrect – I’m only trying to remind everyone that the methods used to obtain this data are inherently flawed. Breastfeeding may indeed be so far superior to formula that it makes breastfeeding look like Lindsay Lohan circa-Parent Trap, and formula feeding resemble post-jail Lohan. But so far, the body of evidence looks more like a comparison between chubby Renee Zellwegger and skinny Renee Zellweger. The body might be a bit different, but the face is cute regardless. (And hell, she won an Oscar for the film she did when she was chubby.)

Now, there have been some studies published since 2005 that would have been interesting to include – like this one, which argues that breastfeeding problems are strongly linked to PPD, which may explain away the data that they are using to promote breastfeeding as a maternal mental health advantage. Or how about this one, which counters the claim that breastfed children are smarter than their peers. Or this one, this one, or  this one, which found that breastfeeding has no correlation with future obesity risk? But no. The AAP cherry-picks the studies which support its ideologies, and ignores the ones which might offer some truly new insight. Now, whether or not we like to admit it, here on the interwebz and in scholarly debates, we all cherry-pick to some degree. (In fact, one could argue that I just did it now, by purposely finding 5 studies which supported my argument.) This is because we take sides; we fall victim to confirmation bias; or sometimes, we just don’t do our homework. But a major medical organization should be bipartisan. A major medical organization should be honest about the evidence, especially when there are conflicting studies. A major medical organization should not be cherry-picking.

The really nasty elephant in the room (or better yet, elephantitis, maybe of the testicles. It’s that disturbing.)

And lastly…Let’s pretend, for the sake of argument, that formula is so risky that it is a true health threat to our nation, and meriting this dramatic sort of action on the part of the government and the AAP. Then why the heck doesn’t anyone try to improve formula? We live in a time where we can clone sheep and create human life in a test tube – we really can’t come up with an adequate substitute for human milk? Why shouldn’t women have the ability to overcome their biology if they so desire? Whatever science has to say about modern infant formula as a product, the fact remains that sociology may see it in a different light. Formula feeding does allow a woman to choose to return to work immediately and allow a partner or caregiver – god forbid, even a male one – to care for her infant. Whether we agree or disagree with her choice, it is, and should remain, her right. If we are going to argue that not breastfeeding is as risky as other health concerns like smoking or drinking and driving, then why aren’t we rioting in the streets demanding better?

I don’t believe that the situation with formula is that dire; not be a long shot. I happen to think that formula does a pretty bang-up job of nourishing kids, and that loving, nurturing formula feeding parents do amazingly well at providing the “nonnutritive” advantages despite their lack of lactation. But I’m starting to realize that there is a hideous punchline to this debate: if people think that formula is so awful, why is the only solution to breastfeed exclusively? I believe that for most, breastfeeding would end up being the preferred way to go if all things were equal. Social inequities aside, however – there are women out there who may just not want to breastfeed. Just like there are women out there who don’t want to have a hospital birth. Or women who want to be single mothers by choice. Or pick any other choice which falls outside the “norm” or may not be accepted as kosher by mainstream society.

So, AAP, here’s what I have to say about your “amended statement”: please realize that by “advocating for children” in this manner, you are putting mothers – and fathers, for that matter – in a really stressful situation. You are doing so based on research which is no in many ways no better than it was 5, 10, or even 20 years ago. And you are certainly not helping children by aiding a system which is trying to take away a choice from their parents, a choice which has the ability to solve medical, marital, employment, and financial problems, thus making them better parents in the long term.

FAIL. Try again, please.

 

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