You don’t need to know why I don’t breastfeed, because it shouldn’t matter.

This past week, Emily Wax-Thibodeux’s excellent essay, “Why I don’t breastfeed, if you must know”, went viral. As it should have. It’s a cutting, heartfelt expose of just how ridiculous the pressure to breastfeed has become, made all the more powerful by the author’s recounting of her double mastectomy.

Unfortunately, even breast cancer didn’t stop the haters from hating.

“95% of the time people don’t breastfeed for reasons other than terminal illness. This is a red herring argument. She shouldn’t feel bad for having a legitimate reason for not breastfeeding and if she does then its really a personal problem,” said one comment on a Today.com thread.

“We all understand should and can are different. A mother who cannot breast feed is different than a mother who can but chooses not to…Breast milk is better for an infant than formula, I don’t think there is a doctor, nurse or midwife who would say that formula is better…Shame people would criticize this mother who CANNOT breastfeed like it was her choice,” wrote another (who happened to be male).

And then there was the woman who insisted that “(t)here is absolutely zero systematic or general judgment against infant formula or bottle feeding. It is the absolute expected norm by the majority of adults and parents in our culture. No one cares if you feed your baby infant formula or use a bottle…Most children start on the breast. Most children are weaned. Most children are given formula and fed with bottles. There is no public backlash against infant formula or bottle feeding. But here’s an article that pretends “infant formula shaming” is some actual thing. No. It isn’t. Not in the real world of critical thought and evidence. The data doesn’t support this notion at all.”

In the FFF community, there was tremendous support for Wax-Gibodeux’s piece, but an underlying concern about the title – because why must we know why she isn’t breastfeeding? Is shaming more acceptable for some mothers than others? What is the litmus test that rewards us with a breastfeeding “pass”? If a double mastectomy doesn’t quite cut it, I don’t know what will.

So maybe we should stop giving reasons altogether.

For those who fear formula as a product, no reason in the world is sufficient for a baby to be given anything other human milk. It doesn’t matter if the baby has to be wet nursed by someone with an unknown medical history – that is still better than formula.

For those who like to shame mothers – because that’s what it really is about, enjoying the act of shaming, of making yourself feel superior, or feel better about your choices by questioning those of others – no reason in the world will make a mother above reproach. She could always have done more – after all, breastfeeding is 90% determination and only 10% milk production, as a recent meme proudly stated. Best case scenario, she might get pity – but pity carries its own heavy scent, similar to the sour stench of shame.

Giving a reason for why you didn’t breastfeed is pointless.

That doesn’t mean telling your story isn’t important, because our narratives matter; they help those floundering in their own messy journeys make sense of what’s happening and find community with those who’ve been there. But there’s a difference between telling your story and owning it, and telling it to defend yourself. One gives you power, the other takes it away. 

We are at a turning point, I hope. Jessica Martin-Weber of The Leaky Boob has taken a stand against romanticizing the reality of breastfeeding, and is helping those in the breastfeeding community feel comfortable with bottle (and formula) use. When one of the leading voices in breastfeeding advocacy speaks out against a culture of fear and rigidity, that means something. Wax-Thibodeux’s piece has brought many powerful voices out of the woodwork, allowing women who’ve swallowed their shame to regurgitate it, and make the uninitiated understand just how sour it tastes.

Now is the time to draw a line in the sand. This conversation has moved beyond breastfeeding and formula feeding and whether one party is more marginalized than the other, or how superior one product is nutritionally to the other. We’ve been there, done that, and nothing has really changed. We’re all still hurting. We’re all still feeling unsupported, unseen, and resentful, like a 3-year-old with a colicky new sibling. Now, we need to stand up, collectively, and say it doesn’t matter why I am feeding the way I am. It is not up to anyone else to deem my reason appropriate or “understandable”. I’m going to stand up for anyone who has felt shamed about how she’s feeding, instead of just people who’ve had identical experiences to me, or those who I feel tried hard enough. 

A breastfeeding advocate shouldn’t be afraid to admit she questions aspects of the WHO Code. A breast cancer survivor shouldn’t have to have awkward conversations about why she’s bottle feeding. A woman who chooses not to breastfeed for her own personal reasons should not have to lay those reasons out in front of a jury of her peers.

This Tower of (breastfeeding) Babble has reached a fever pitch. It’s time for it to come down. Pick up your axe and start chopping. And next time someone asks, simply tell them, “You don’t need to know why I don’t breastfeed. Because it shouldn’t matter.”

 

A World Breastfeeding Week Plea: Stop celebrating, start collaborating

Usually, I’m all over the place this week. Getting quoted in the requisite “it may be breastfeeding week but gosh darnit some women still find exclusive breastfeeding super hard” articles. Posting my own stuff here on the blog, or over on HuffPo. Talking about #ISupportYou and pissing off hundreds of people in the process, because they see it as a veiled attempt to “steal the thunder” from World Breastfeeding Week.

But this year, I’m all but invisible.

Part of this was unintentional. I’ve been going through some stressful career-change mishigas, dealing with the inevitable gaps in childcare that occur between camp and school, entertaining a ridiculous number of visiting extended family members. I’ve been too exhausted to blog, or talk to media sources, or self-promote (because let’s be honest – that’s a part of what all of us parenting bloggers do. Even the most altruistic of us. Even those of us who don’t depend on hits or advertising or who never make a cent off their blogs. We write because we want to be heard; we pray for bigger audiences, book deals, evidence that we’ve made some sort of impact. I happen to be rather shitty at this, which is why I don’t blog much anymore. I don’t have the stomach for that part of the job).

Another part of my conspicuous silence has been intentional, however. Probably more than I care to admit. See, I’ve been focusing my efforts on the supportive stuff. Reaching across the aisle, trying to understand all facets of this debate, and hoping that by creating better resources for all moms, I can help stop all the guilt/anger/resentment/confusion/hurt. I know that breastfeeding is important to many, many women. I want those women to succeed, and feel happy and proud and supported. So this year, I wanted to try and stay out of World Breastfeeding Week drama like I try and stay out of my kids’ sibling squabbles.

Yeah. Because that works so well with my kids.

The problem is, I also want formula feeding mothers to feel happy and proud and supported. And for some reason, it’s not okay to want both of these things. It’s ok to pay lip service to it, to claim #ISupportYou and tell formula feeding moms that celebrating breastfeeding isn’t about them. But if you actually do the work you need to do to ensure that non-breastfeeding parents are supported, you are violating WHO Code. You are taking attention away from the women who “need it”. You are stealing…. what? Resources? Sympathy? One-up(wo)manship?

I tried to stay out of it. I really did. I held my newly-minted CLC certification close to my non-lactating chest and bit my tongue.

And then the articles came, and came, and came. And so many this year were not about the benefits of breastfeeding, but rather how hard it was. Or how hard it was NOT to breastfeed. How this mom felt like she was poisoning her baby, or this one felt like she’d be booted from the “mom club” because she didn’t wear the EBF badge.

So much guilt/anger/resentment/confusion/hurt. None of it is stopping. There’s more this year than ever before.

Then this happened.

https://www.yahoo.com/health/olivia-wildes-breastfeeding-photo-causes-a-stir-93893024387.html

https://www.yahoo.com/health/olivia-wildes-breastfeeding-photo-causes-a-stir-93893024387.html

And I heard my community inwardly wince. Not for the reasons you might think. Not because they didn’t think it was a beautiful image, and not because it glamorized something that had been messy and painful for most of them, although those certainly were thoughts that some of us had to squash down into that endless pit of mother-guilt. No, it was because it was yet another image of a breastfeeding celebrity, with headlines and stories that spoke of her bravery for normalizing nursing, and comments all over the place about how breastfeeding was finally being celebrated.

I think, for many of us, it was the “finally” that did it. For many of us, it would seem far braver for a celebrity to do a shoot with her bottle-feeding her kid with a can of formula in the background. We have only seen breastfeeding being celebrated. There’s so much partying going on, and we feel like the crotchety old neighbors calling the cops with a noise complaint. But you know, it’s late, the music is loud, and we’re tired.

Now, just to be clear – I’m talking about breastfeeding being “celebrated” That celebration doesn’t do us much good. It does not mean that it is easy for moms to nurse in public. Obviously, it isn’t. Or that lactation services are plentiful and accessible to all. Obviously, they aren’t. Breastfeeding is celebrated, but that doesn’t stop it from being difficult for the new mom in the hospital, whose birth didn’t go as planned. Or the one who has to go back to work 2 weeks postpartum. Or the one with a job not conducive to pumping. Breastfeeding is celebrated, but not when you’re overweight. Or when you’re nursing a toddler.

Idealized images in the media of what breastfeeding looks like do not normalize nursing. In fact, I’d argue it fetishizes it – not for men, so much, but for women. Now, we don’t just have to feel inadequate for not fitting into size 2 jeans a month after giving birth, but we need to feel inadequate if we don’t meet the feeding norm and make it look gorgeous and natural and easy.

Please do not misread what I’m saying here – talking about breastfeeding, supporting breastfeeding, and implementing changes to make breastfeeding easier for those who want to do it are important, admirable, and necessary goals, as far as I’m concerned. But the comments I saw coming from my community after this photo hit the news were not about any of these things. They were from women feeling totally drained, frustrated, and alienated after a nearly a week of hearing how inferior their feeding method was, who were sick of being told they were defensive or that they feel guilty if they tried to stand up for themselves. This story was the last straw. It’s weird, when you think about it – it wasn’t the piece on the risks of formula, or the memes about the superiority of breastfed babies – what broke the camel’s back was a seemingly innocuous spread of a gorgeous, confident actress proudly nursing her baby.

This is what perpetuates the cycle of guilt/anger/resentment/confusion/hurt: our lived experiences are so damn different, that it’s like we’re constantly talking at cross-purposes. The nursing mom who is the only one in her small town not using a bottle sees a photo spread like this as thrilling, victorious, self-affirming – as she should. The formula feeding mom living in Park Slope who carries her formula-filled diaper bag like a modern-day hairshirt sees the same spread as just another celebrity being held up as a pioneer, when she’s only doing what’s expected of a woman of her stature – as she should. Both are right. Because both are personal, emotionally-driven responses.

Earlier this week, I said that deciding how to feed your baby is just one of a myriad of important parenting decisions. But somehow, it’s become the most important one. We cannot expect formula feeding moms to support their breastfeeding sisters when they don’t receive the same support. We just can’t. It’s not fair, and it’s not realistic. I feel like that’s what I’ve been asking of all of you, and somehow I just woke up to that fact.

Why are there still articles talking about how shitty we feel for not breastfeeding, instead of articles talking about what’s being done to change this? Where is the news story about the doctors who are saying enough is enough (because I know they are out there – many of them contact me, and I appreciate these emails, but I wish they were able to say these things publicly without fear of career suicide)? Where’s the NPR program about ways we can improve breastmilk substitutes so those who cannot or choose not to nurse aren’t left hanging? Where’s the Today Show, The View, The Katie Show, doing segments on why women are REALLY not meeting breastfeeding recommendations, instead of segment after segment on how brave so-and-so is for posing nursing their newborn on Instagram, or talking to dumbasses on the street about the “appropriate” age for weaning?

When we stop “celebrating” and start normalizing and supporting and being realistic about how different life can be even just a street away, maybe World Breastfeeding Week can have it’s proper due. Maybe we can actually talk about ways to help women in the most dire straits feed their babies as safely as possible – clean water, free breast pumps, free refrigeration, access to donor milk.

I want to be able to be silent during World Breastfeeding Week. It shouldn’t have to be “overshadowed” by emotional, personal pieces about breastfeeding “failure”. It shouldn’t be a time for articles about not making formula feeding moms feel “guilty”. These words shouldn’t even be part of our infant feeding lexicon, for godsakes. Failure? Guilt? For what?

This year, I want us to stop celebrating, and start having some calm, productive conversations with people outside your social circle. For many of us, the celebration feels exactly like high school, when the popular kids had parties and we sat home watching Sixteen Candles for the thirty-fifth time. That’s not to say breastfeeding isn’t worth celebrating, but the end goal should not be one group feeling triumphant and the other feeling downtrodden. Formula feeding was celebrated for decades too – and that celebration made the current atmosphere of breastfeeding promotion necessary. Please, let’s learn from our mistakes. Let’s move on. Rip down the streamers, put away the keg, and open the doors to the outsiders looking in. You never know – they could end up being the best friends you’ve ever had.

 

All new parents deserve a place at the consumer protection table, not just breastfeeding ones: A response to the “Day of Action: Keep Infant Formula Marketing Out of Healthcare Facilities”

Public Citizen is known for its advocacy for ordinary citizens who have been harmed by large entities–and rightly so.  Much good has been done by this organization in the name of everyday citizens who otherwise have little power to lobby our government for stronger laws and regulations to protect our society.  However, Public Citizen’s recent event, “Day of Action: Keep Infant Formula Marketing Out of Healthcare Facilities,” does not accomplish the goal of protecting consumers.  A consumer protection advocacy organization has an obligation to women to support their right to bodily autonomy, as well as support their and their children’s health care needs—issues that are sometimes incompatible with breastfeeding and do not currently receive sufficient support in our breastfeeding-centric post-partum health care model.

The Day of Action fails to address many of the true issues that affect women’s and children’s ability to breastfeed.  A complete lack of formula advertising is not going to enable women with insufficient glandular tissue (IGT) to make sufficient milk, or change the fact that many women have to take necessary medications that are incompatible with breastfeeding.  It is not going to prevent complicated births or medical conditions in babies that sometimes make it exceedingly difficult – or impossible –for moms to breastfeed.  It does not reduce adoptive or foster families’ need for formula.  And a lack of advertising is not going to change the fact that some women do not want to breastfeed, and have a right to their bodily autonomy.  While we agree that it would be best for parents to receive information about formula from a non-profit source, currently, there is no such source that provides accurate, unbiased formula information, even to families for whom breastfeeding is not an option at all.

The Day of Action implies that information about formula is plentiful and accurate.  Nothing could be further from the truth.  Information about formula is typically riddled with fear mongering about not breastfeeding and uses value-laden language that assumes women who use formula lack perseverance or are selfish, lazy, uneducated, immoral, or ambivalent about their children’s health, despite ample evidence to the contrary. Formula supplies in hospitals are hidden in drawers or even locked up.  Lactation consultants are held to the WHO Code and urged not to discuss formula unless under special circumstances (lest it send a message that formula is “just as good as breastfeeding,” even though it is a medically appropriate option, and sometimes the only option).  Doctors are not taught about formula preparation and are frequently scared off of even talking about formula for fear of being labeled anti-breastfeeding.  Where are formula-feeding families supposed to get the accurate, unbiased, judgment-free information they need?

Perhaps Public Citizen is unaware of the extent to which breastfeeding marketing relies on shaky claims.  Maternity wards are typically papered over with literature that claims breastfeeding improving babies’ IQ and helps new moms lose weight—claims that some assert are based on poorly-done research that frequently confuses correlation with causation, and that have not been borne out in more powerful, well-designed studies.  Recent research on breastfed and formula fed siblings (three well-regarded published studies[1]) showed little to no long-term effect of breastfeeding for a number of oft-mentioned issues.  These studies are powerful because, unlike many other studies on breastfeeding, variables such as parental IQ, educational status, and socio-economic status are much better controlled.  Several large metastudies (including those conducted by WHO[2] itself and the United States’ Agency for Healthcare Research and Quality[3]) have found that the evidence in favor of breastfeeding is marred by confounding factors.

A consumer protection advocacy organization has the responsibility to ensure that advertising claims are based on sound science, but the “absolutes” plastered on maternity ward walls, city buses, and doctor’s offices (“Breastfeeding prevents asthma[4]”, “breastfeeding makes babies smarter[5]”, “Breastfed babies grow up stronger, healthier and smarter[6]”) and liberally sprinkled in literature distributed to new parents do not fulfill this criteria. Public service messages cannot be immune to the regulations that restrict other advertising.

Further, perhaps Public Citizen is unaware of how much of the advertising for breastfeeding actually benefits corporate entities.  New moms in hospitals are given sample tubes of Lansinoh nipple cream, Medela breast pads, and coupons or ads for local boutiques that sell breastfeeding products such as Boppy nursing pillows and covers.  It is common for new mothers to receive sample magazines, which exist both to promote themselves as well as the advertisers within. It seems counter to Public Citizen’s goals to protest one form of advertising and not others.

Women deserve to know the full range of medically viable options for feeding their children, in an unbiased, accurate, and judgment-free manner, and we feel a consumer protection organization should be at the forefront of that fight.  Formula feeding parents need help, advice, and support just as much as breastfeeding parents. Unless Public Citizen is willing to help establish a non-profit center to train “infant feeding consultants”, not just “lactation consultants,” whose job is to support all medically viable methods of feeding a baby, this Day of Action seems just another way to deny formula-feeding families what little information they can still get about their health care options for their children.  It seems to contradict the stated goals of Public Citizen to protect consumers.

We encourage Public Citizen to speak with actual formula feeding parents, many of who feel marginalized in our healthcare system for the choice or necessity of formula.  Breastfeeding—and products and service providers who support it—is so heavily promoted in hospitals that formula feeding families are left without the kind of education or support that breastfeeding families receive. As there are no non-profit sources of education for formula, other than a few websites run by mothers who have taken up the charge, companies are the only remaining source. This is not ideal, but it is currently all we have. We encourage Public Citizen and all who support this Day of Action to read the stories of actual formula-feeding parents, the vast majority of whom report seeing no advertising prior to using formula, at FearlessFormulaFeeder.com, and consider how they may equitably represent the needs of pregnant, birthing, and post-partum mothers and their babies at the consumer protection advocacy table.

Signed,

Concerned Members of the FearlessFormulaFeeder.com Community

 

 


[1] Evenhouse, Eirick and Reilly, Siobhan. Improved Estimates of the Benefits of Breastfeeding Using Sibling Comparisons to Reduce Selection Bias. Health Serv Res. Dec 2005; 40(6 Pt 1): 1781–1802; Geoff Der, G David Batty and Ian J Deary. Effect of breast feeding on intelligence in children: Prospective study, sibling pairs analysis, and meta-analysis. BMJ 2006;333;945-; originally published online 4 Oct 2006; Colen, Cynthia G. and Ramey, David M. Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons. Social Science & Medicine, Volume 109, May 2014, Pages 55–65.

 

[2] Horta, BL and Victora, CG Long-term effects of breastfeeding: A systematic review. World Health Organization, 2013.

[3] NIH Agency for Healthcare Research and Quality (AHRQ). Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Reports/Technology Assessments, No. 153, April 2007.

 

 

Guest Post: I Am Not a Cow

I’m thrilled to share this post with you, from my friend Andrea Nord. Andrea is the chairperson for the non-profit organization “Bottle Feeding in Sweden” and is an admin for a Swedish Facebook group like the FFF private group, which can’t be an easy job, considering the infant feeding attitudes of that country. She’s one of the most astute, brave, and seriously awesome women I’ve had the pleasure of getting to know in this crazy sort of advocacy I’m in, and I’m glad I get to share her brilliance with you via this post (which she graciously translated into English for us). The post originally appeared on Petra Jankov Picha’s bottle feeding blog “Att Flaskmata”.

About twenty km east of Lund, in the southernmost part of Sweden, is a large natural area called Revingehed. The Swedish military uses this area for short periods for their exercises and sometimes you can hear the sounds of gunfire in the village of Veberöd where I live. But for the most part, the area is a quiet and peaceful place where hundreds of cows graze freely to keep the grass short and the grounds open. Sometimes we take a drive there for a near-cow-experience, as my kids call it. If you are lucky you may see cows on the road just when you are driving by. It’s a really lovely experience that I heartily recommend, especially now when the calves are small.

When you think of cows you might think of beautiful black and white Holsteins wandering back to the barn after a long day of grazing in the meadows. All the cows are the same, it’s just the patterns on their coats that are different. Otherwise, they all have the same needs, they all want the same things and they all do the same things all day long. There are no cows with any special needs or aspirations, except of course the famous fictional cow Mamma Moo from the Swedish children’s books with the same name, the cow who was not satisfied with just grazing and chewing. She wanted to do everything that people did, she wanted to swing and go down a slide, despite her good friend the crow’s desperate attempts to point out to her that she is in fact just a cow, and cows do not behave like humans. Period.

Source: http://9teen87spostcards.blogspot.com/2011/07/mamma-moo-cow-riding-bicycle.html

Source: http://9teen87spostcards.blogspot.com/2011/07/mamma-moo-cow-riding-bicycle.html

 

Part of what makes Mamma Moo so funny is her inability to comply with expected and “natural” cow behaviour. Mamma Moo is a.. feminist! Imagine that! And then the idea hit me – why does the WHO and our Swedish National Board of Health and Welfare assume that all women in the world are the same, that we all do the same things and want the same things? Why do people think that women don’t have different needs, wants or conditions? Why this astonishment whenever we want to do something different from the expected and “natural”?

Does the world see us women as.. cows? Because if you do not see women as unique individuals but as cows, then it is close at hand to recommend that we should all do things exactly the same way. What is “best” is then best for everyone. The word recommend is perhaps the wrong word, require is probably closer to reality. And there are many “truths” that we women are expected abide by and now we come to The Mommy Wars, which I see as the social pressure to get all women to comply to a perceived truth. You see, all of us women are supposed to do things exactly the same way!

If there was tolerance for women doing things in different ways, then there would be no reason to get all upset about it. But women do in fact want different things – some want to work, others want to be at home. Some breastfeed, others bottle feed. The nerve of them!

It’s interesting that I find it hard to find similar examples where one would try to get all men to do the exact same things or get upset if they didn’t. The mere idea is completely ridiculous, for men are seen as individuals, they are all different and they are allowed to do what they think is best. The only example I can think of, when trying to get all men to do the same thing, is when you recruit them into the army and send them out to war. Then and only then are men oppressed to all do the same thing. But in peacetime, they are all free to do whatever they want and however they wish to do it. Now I would like to end this rant with an appeal to the WHO, the National Board of Health and Welfare and all the health authorities: stop seeing us women as cows! See us instead as unique individuals capable of thinking and making decisions about what is best for ourselves and our families!

Let us be free to decide how we want to feed our babies and stop trying to round us up and herd us all into a corral. We are women, not cows.

A slightly curmudgeonly rant about the drama over Save the Children’s “Superfood for Babies” campaign

The problem with writing a post which criticizes an organization which strives to help starving kids is that it makes you feel like the Grinch. Or Gargamel. I feel like I should be stroking an acrimonious cat and arching a pair of overgrown eyebrows inward.

Save the Children does a lot of wonderful things for children in dire straits, and I don’t want to come down on them too hard. And in many respects, I applaud their recently announced “Superfood for Babies” initiative. I do believe that breastfeeding is a hugely important part of improving childhood mortality in resource-poor nations, and the report supporting the program offers some excellent perspective on the challenges of raising exclusive breastfeeding rates in these areas.

In public health circles, there’s a lot of discussion on messaging – how to make PSAs culturally appropriate, sensitive, and effective. The thing is, this doesn’t only hold true for at-risk groups – it also applies to the middle-class factions of western nations. It’s just as ineffective (and inappropriate) to try and graft a message addressed to people living in tribal societies with problematic water sources onto a secretary in suburban Iowa as it would be to do the opposite. Yet, this is what happens – repeatedly – in our international discussions of breastfeeding. (Incidentally, this is at the root of my beef with Unicef and WHO, and why I feel it’s necessary to amend the Baby Friendly Hospital Initiative set forth by those organizations to be more culturally appropriate to developed, Western societies.)

This brings us to my scroogey analysis of the “Superfood for Babies” campaign.  I would encourage everyone to read the literature – it offers some truly excellent insight into the specific issues at play in a variety of developing nations, and makes it clear (whether or not it intends to) that formula is not the only barrier to encouraging exclusive breastfeeding. In some cultures, there are beliefs that breastfeeding for the first few days of a babies life is detrimental; in others, women feel pressured to produce as many babies as possible, thus making the fertility-restricting nature of breastfeeding a downside; and in others, it’s not formula which is used as a supplement but raw animal milks or concoctions of grains.

Save the Children (STC) did a lot right with this report. They addressed the need for social change; advised that governments subsidize breastfeeding women so that those in unstructured agricultural jobs (which don’t exactly come with a 401k or paid maternity leave) don’t need to return to work immediately, and have to choose between making a living and feeding their babies; and they press for better education and involvement from medical workers and midwives. I think their motives were great, and they did their homework.

Unfortunately, in their excitement, they lost perspective in three key areas…

1. They were (intentionally or unintentionally) vague about the research

Look, I would never argue that breastfeeding isn’t the best choice – by far – for babies in places where food is scarce, infection and disease runs rampant, medical care and antibiotics are severely limited, and the water source is questionable. Formula feeding is dangerous in these settings. But since breastfeeding advocates and orgs like WHO have made breastfeeding a global issue, we have a responsibility to be honest about what our body of research actually says. There are numerous instances in the STC report where claims are simply not held up by their citations. For example, this quote, on page vii of the report’s introduction:

It is not only through the ‘power of the first hour’ that breastfeeding is beneficial. If an infant is fed only breast milk for the first six months they are protected against major childhood diseases. A child who is not breastfed is 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhoea[2]. Around one in eight of the young lives lost each year could be prevented through breastfeeding,[3] making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths[4].

Let’s take a closer look at the citations. The first one, #2, is from a UNICEF report on diarrhea and pneumonia- not a study, but a report. So it took a bit of digging to see exactly where they were getting their data from. I *think* this figure comes from a table attributed to a Lancet piece, which “estimated”  that “Suboptimum breastfeeding was… responsible for 1·4 million child deaths and 44 million disability-adjusted life years”. I couldn’t get the full study on this one, but again – it was an estimate, most likely based on other studies – not hard data.

Citation #4 is the one that’s bothersome, however (#3 is just a footnote with the definition of “exclusive breastfeeding”). The sentence “making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths” is most likely read as “breastfeeding is the most effective way to prevent child death”. That’s quite emotive. The citation leads you to a Lancet paper on child survival, which does have some dramatic data and charts regarding the interventions which would most reduce infant mortality in the developing world. Breastfeeding is shown to offer the most dramatic reduction in risk- but there’s one important point to consider: while this report focuses on death in children ages 0-5, the majority of these deaths occur in the first few months of life. Exclusive breastfeeding, as opposed to mixed feeding or exclusive feeding of substitutes including goat or buffalo milk, paps, or formula (important to note that in many of the countries STC is concerned about, traditions include feeding neonates animal milks or solids within hours of birth – so I think it’s arguable that the issue here is the risk of giving a baby anything but breastmilk via the breast, rather than breastfeeding being the “magic bullet” the report dubs it to be. Otherwise, we probably wouldn’t see consistently poor outcomes in mixed-fed kids, as a “magical” substance would compensate) is going to reduce the risk of infections that cause death in very young babies. In other words – if the most deaths are in newborns, and breastfeeding saves newborns more than any other interventions like vaccines, clean water, etc – then there will be a disproportionate representation of “babies saved by breastmilk” in the results. This is not to say that breastfeeding isn’t an incredibly worthwhile and effective solution to reduce infant mortality, but it’s a bit of a stretch to suggest that breastfeeding alone will be the most effective intervention for ALL childhood deaths, which is exactly what the STC report does.

2. They didn’t consider the societal implications of their recommendations, beyond the scope of infant health

I was taking notes as I read the STC report, and my heading for the section which included this quote was “OMGOMGOMG”:

Many women are not free to make their own decisions about whether they will breastfeed, or for how long. In Pakistan, a Save the Children survey revealed that only 44% of mothers considered themselves the prime decision-maker over how their children were fed. Instead it is often husbands or mothers-in-law who decide….

 

….To overcome harmful practices and tackle breastfeeding taboos, developing country governments must fund projects that focus on changing the power and gender dynamics in the community to empower young women to make their own decisions.

Changing the power and gender dynamics sounds like a fantastic idea, and I would support any program that attempted to do this. But STC has to realize that “empower(ing) young women (in developing countries) to make their own decisions is a complex and uphill battle that extends far beyond infant feeding. I fear that by placing an emphasis on UNICEF-lauded solutions like warning labels on formula cans/making formula prescription-only, and on educating fathers/elders on the importance of breastfeeding using the current overzealous and often misleading messages, in these countries – places where, all too often, females are already considered “property” and subjected to any manner of injustices – it will create an atmosphere where women who are physically unable to breastfeed will be ostracized, shamed, or penalized. I agree that we need to empower women, but I think that we also need to be verrrry careful about presenting “suboptimal breastfeeding” as a risky behavior in certain cultures.

In another section, the authors report that breastfeeding rates have gone up in Malawai despite poor legislation on maternity leave, breastfeeding rights, etc. – that these improvements are based solely on strict implementation of WHO Code. I’d like to be reassured that as women are being given no option other than breastfeeding without any of the protections which would make EBF feasible while working, this isn’t having a deleterious effect on their lives. It’s wonderful that breastfeeding rates are up, but what about correlating rates of employment, poverty, and maternal health?

3. They failed to differentiate between resource poor and resource rich countries

I’ve seen a wide range of opinions on the STC program online in the past few days. Most of the drama is over British media reports which mention putting large warning labels on all formula tins – not just the ones going to resource-poor countries. Some feel that these labels will cause unnecessary upset in the West; others argue that when it comes to saving starving/sick third-world babies, privileged mommy pundits should STFU. And others keep insisting that the STC report was misrepresented, and that the labeling stuff was a minor part of the larger plan and shouldn’t be harped on.

All of these arguments are valid, and yet all are missing the nuance necessary to have a productive conversation. We need to realize that not breastfeeding has quite different implications in certain parts of the world. We also need to acknowledge that a woman’s rights are important no matter how much money she has or where she lives, and that we all have a right to stand up for what we believe – it’s rather useless to play the “eat your dinner because children are starving in Africa” game, and rather un-PC as well.

But STC also needs to take responsibility, here. The fact is that the report does not really differentiate between resource-poor and resource-rich countries when it is discussing WHO Code and formula marketing.  For example, this passage on p. 45 describes laws which STC wants implemented worldwide:

Breast-milk substitute companies should adopt and implement a business code of conduct regarding their engagement with governments in relation to breast-milk substitutes legislation. Companies should include a public register on their website that outlines their membership of national or regional industry bodies or associations, any meetings where the WHO Code or breastfeeding is discussed, and details of any public affairs or public relations companies they have hired, alongside the nature of this work… Any associations (such as nutrition associations or working mothers’ associations) that receive funding from infant formula companies should be required to declare it publicly. In addition to this information being made publicly available on the websites of individual companies, the International Association of Infant Food Manufacturers should publish a consolidated record of this information, updated on a quarterly basis.

Personally, I think the money spent on a “governing association” in order to police this policy would be better spent on funding literacy programs to help parents read the labels we’re arguing about. Some of these countries have literacy rates of like 30% – which makes me wonder exactly who the labels are geared to, if not the Westerners for whom formula feeding is far, far less of a risky endeavor.

Don’t mistake me – the evidence given in this report about the shady practices of formula co’s is alarming. There needs to be something done about unethical marketing practices in parts of the world where information is limited, education is a true privilege, and options are a joke. Yet, in the STC report, there is ample (and quite good) evidence that the unethical efforts of formula companies are only one slice of a thick-crust, Chicago-style pizza. There’s a lot of gooey, barely distinguishable elements which all combine to make a rather heavy problem, and focusing so much on one of them will leave you with the policy equivalent of Domino’s.

Further, the situation with breastfeeding in the developing world is markedly different from what’s going on in Great Britain, the US, Canada, and so forth. The online arguments are proof of this. I’ve seen the same people who argue that breastfeeding is a global issue turn around and tell concerned Americans and Brits that they have no idea what’s appropriate in Peru or Ghana. This may be true, but so is the reverse. International groups like STC have to remember that when they release papers making global recommendations about infant feeding, that they are inviting commentary from a global audience. That’s why we can’t make blanket statements about infant feeding and child health, or try and implement the same rules in order to get the same results. We wouldn’t go into a rural village where families share a 300-square foot hut and start lecturing them about the dangers of co-sleeping, and yet we assume that the same one-size-fits-all public health messaging is fair game when it comes to infant feeding. Breastfeeding might indeed be a global issue, but the type of issue it is varies greatly depending on what part of the globe you’re on.

 

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