FFF: Furious Formula Feeders?

“The community of women who choose to formula feed, and the moms who have so many challenges with nursing that they formula feed, tend to feel that the lactation professionals are insensitive, pushy and overstate the amazing-ness of nursing a baby. And they are ANGRY!! Check out the Fearless Formula Feeder page and you will get a massive dose of angry. They seem to take so much personally and cannot seem to see the broader cultural ramifications of the formula companies’ marketing campaigns. They also do not seem to understand that successful nursing is time sensitive. It has to be initiated early after birth or there is really no going back.”

 

After seven years of working in the infant feeding space, I’ve become rather immune to criticism. There are people who will never understand why a site like this is needed; people who think what I do “promotes” formula feeding; people who don’t think there should be any sort of choice in how babies are fed. Recently, my Facebook readers were threatened by someone claiming they would be reporting them to social services for child endangerment, due to their feeding method. It happens. People suck, and all that.

But last night, I saw the above comment on the page of someone who claimed to be all about female empowerment, empowered choice, and sisterhood. This was someone I collaborated with – or, rather, allowed to use my image and words in a way that resulted in no financial compensation, favorable publicity, or support for my own cause (the exact opposite, actually – it was a film which portrayed formula as the devil and romanticized mostly white, upper class, celebrity women and their breastmilk). Someone I welcomed on the FFF page. Someone, I assumed, who respected that our opinions were different, but whose goals were ultimately the same: ensuring that mothers were informed, autonomous, and supported in their choices.

Seeing her comment did, indeed, make me “ANGRY!!”

Then, I started thinking… maybe she’s right. Maybe we really are ANGRY!!. For a moment, I felt self-conscious and defensive, wondering if I should post something sweet and positive to counteract this negative portrayal.

But then I stopped myself, because damn straight, I’m angry.

I’m angry that despite sharing hundreds of stories of what the “breast at all costs’ mentality does to women, the people who are responsible for perpetuating this culture refuse to listen.

I’m angry that these same people spend so much time and energy hating the formula companies, when the formula companies are not the ones mishandling women in the hospital, leaving IGT and other potential breastfeeding complications undiagnosed, ignoring the mental health needs of new parents, or forcing women to go back to work after a few short weeks in order to support their families.

I’m angry that they can’t see the difference between “anti-breastfeeding” and “anti-breastfeeding-extremism’. These are not the same things. quotescover-JPG-32

I’m angry that they continue to gaslight the women who come to me for help, sometimes suicidal, over their perceived “failure” to breastfeed.

I’m angry that they are allowed to be angry at anyone and everyone who doesn’t think the way they do, but insist on absolute complacency and infinite patience from us.

I’m angry that they think we are uninformed about breastfeeding, when the most common reason parents come to my page is that they were blindsided by formula feeding; they had read books and taken classes on breastfeeding, but never even thought of using formula. These women know more breastfeeding than most. They know about jaundice protocols, Thomas Hale, SNS feeding, galactogogues, tongue ties, lip ties, skin-to-skin, the magic hour, the breast crawl, good latches and bad latches, exclusive pumping, power pumping, and more. They know how important it is to breastfeed immediately after birth. There’s a reason nearly every FFF Friday starts with a scene in the delivery room.

I’m angry that some of the “new voices” in this debate are doing more harm than good, making claims that can’t be supported, confusing the issues, and making it harder for the rest of us.

I’m angry that my community members are told that they are victims when they don’t feel like victims. I’m angry that when they do feel victimized, they are dismissed, brushed off as unfortunate casualties in the War Against Big Bad Formula.

I’m angry that the formula companies continue to make stupid marketing moves, adding fuel to a fire that should’ve been extinguished back in the early 1980s.

I’m angry that “celebrating moms” always means “celebrating breastfeeding”. Moms should not be celebrated for feeding their babies. They should be celebrated for doing a job that is often hard and thankless, for bringing home the bacon, frying it up, and cleaning all the dishes afterwards before putting the kids to sleep and working on tomorrow’s quarterly reports. I’m angry that this myopic focus, this fetishizing of what should be a perfectly normal act, marginalizes adoptive parents, primary caregiving fathers, and anyone without working mammary glands.

I’m angry that moms can’t nurse in public without it being a fucking federal case. Literally.

I’m angry that moms don’t get sufficient support in the hospital for breastfeeding – especially if they are young and/or non-white.

I’m angry that parents get no support whatsoever about formula feeding, and that parents in the UK need to preemptively bring their own supplies if they think there’s even a chance they might need or want to supplement. (Has anyone else thought about how this might be more self-sabotaging than having formula available in the hospital? Not that I think either is actually self-sabotaging, but for those constantly making that argument… let’s use basic logic for a minute.)

I’m angry that my use of formula is somehow threatening to your efforts to encourage other women to breastfeed.

 

I’m angry that women insist on battling each other in these snarky ways, like life is just one big junior high school. Grow up. Grow. The. Hell. Up. There are so many problems in the world – you really want to spend time arguing about whether we feed babies breastmilk or a perfectly viable substitute? Is live and let live really that hard a concept? Do you really have nothing better to do than tell random women on the internet how they are Doing It All Wrong? And formula-feeding moms who hang out on breastfeeding sites to cause trouble – I’m talking to you, too. You’re part of the problem. Making shitty comments about breastfeeding moms, who have just as much right to community and support as you do, is hypocritical and mean. Mean girl behavior is not “venting”.

I’m angry that comments like the ones above leave my community no choice but to stay silent. If they respond, and say what they want to say, they sound ANGRY!! If they don’t respond, they are silenced. Neither is an attractive or empowering choice.

I’m angry that I still feel the need to write posts like this, when my kids are in elementary school. I am angry that I care. I am angry because it doesn’t change anything, and I’d probably be a much happier person if I never said the word “lactivism” again.

So yes, I am angry. In fact, I am ANGRY!! And I’m sure much of it is self-imposed, because I could be focusing my own efforts on something more important, like the Syrian refugee crisis, the poverty and inequality in my own city. I could be focusing this energy on my children – sometimes I think that formula feeding made me a better mom, but Fearless Formula Feeder made me a pretty crappy one.

As for the FFF community? Sure, I suppose they are ANGRY!!, too. But no more than they should be. And if they are talking and venting and crying and supporting each other on my page, they are handling that anger appropriately. They have a safe space to work through that anger – but there are many people who want to take that away from them. “Concern Trolls” who repeatedly post inflammatory pieces (and if you’re going to argue that “information” isn’t ever inflammatory, ask yourself: would you post a piece on how easy it was for you to get pregnant on an infertility support page? Or an article about a plane crash on a Fear of Flying support group?), “experts” who try to school them, people who don’t believe they have any right t feel bad because formula feeding is so prevalent. (So is obesity. Doesn’t make the kid who gets relentlessly teased in school for their weight feel any better.)

Most of my readers work through their anger, and move on. Many go on to breastfeed future kids, armed with the knowledge they now have that there’s no such thing as failure. They understand relative risk. They know how to spot problems, and what can and can’t be done about them. They aren’t trapped in the sticky spider web of dogma. They know they have a soft place to land, should things not go as planned.

ANGRY!! isn’t a bad thing. ANGRY!! is what makes us act up, speak out, and create change. ANGRY!! is a healthy, justified emotion when you’ve been shamed, mistreated, embarrassed, ignored, and insulted. ANGRY!! is empowering, as opposed to sad, depressed, lonely, ashamed.

So yes, you’re right. We are ANGRY!! We don’t enjoy it. We don’t want it. We want to move on and be HAPPY!! CONFIDENT!! ACCEPTED!!

Maybe if you could just let us be, you could let us be.

_______

The following are some additional comments sent to me by FFF members, reacting to this piece.

“Well yes I am angry. I am angry for being bullied into breastfeeding even though it was clearly not the right path for me. I’m angry my sons were left to go hungry and get sick because nobody would believe I wasn’t producing breast milk. I’m angry my midwives believed in breastfeeding at all costs. I’m angry there were entries in my post natal notes essentially calling me lazy and not trying hard enough to breastfeed. I’m angry that “normalise breastfeeding” has caused the vilification of formula feeding. I’m angry that I have been made to feel like a second rate mother who is poisoning her children and condemning them to a life time of low intelligence and obesity. That is, of course, if they survive child hood at all. I’m angry that I am supposed to laud and bend over backwards to accommodate breastfeeders but the courtesy is never returned. I’m angry that twaddle like “only 2% of women can’t actually breastfeed” is bandied around and taken as gospel, despite there being no respectable scientific research into such a claim. So yeah, I am angry. But as I usually say, if you kick the dog long and hard enough, sooner or later it will bite back.” – Emma

“What it comes down to is that unless you agree with the lactivist mentality that breastfeeding is a child’s “birthright” and that it’s the “end-all, be-all” of infant nutrition, then you wrong, misguided and angry. In reality, we are standing up for what we believe in just as much as they are standing up for their beliefs. However we believe in a women’s right to choose, to keep her bodily autonomy while still nurturing her children. And above all we lift one another up as mothers. I’m proud to be a part of the latter side.” – Deanna

“Being angry about having your body policed and having your parenting choices judged and shamed is a completely legitimate feeling/thing. Or are we as women only allowed to ever be happy or sad and anger is never ever appropriate?” – Nikki

“I wonder what the end game is if they actively alienate women who chose to, or had to, formula feed. I wonder, do they really care if we breastfeed? If so, do they think this kind of hurtful rhetoric will be a useful tool in convincing women to try breastfeeding again with the next child? Or are they just turning women off to their agenda through causing them pain? I for one have found the most support and kindness in caring for my child in the ff community, so I’d stick with what worked to keep myself and my family healthy and safe. It just seems so disingenuous that they are trying to “help” through hurting people. I don’t think they give a fig in the long run what I or any of you do, or for the health of our children. They just want to stare into their own reflections in solipsistic fantasy.” – Jessie

“I’m not angry that I couldn’t breastfeed. Not anymore, at least. You know what DOES make me angry though? A bunch of sanctimonious women (and men too, I guess) telling me how wrong I am for feeding my children formula. You know what? Formula saved BOTH of my kids’ lives. And it saved my sanity! My kids are happy, healthy, and thriving.” – Tasha

“I’m not angry or disappointed that BFing didn’t work out for us. I really don’t care anymore. Shit happens. I’m angry about the way moms are treated and babies put at risk for something that doesn’t really matter.” – Amy

“It’s funny because I’m not angry at all. Formula helped my son’s life from the beginning and formula helped me through PPD and other issues with my two girls. Not angry, grateful.” – Shannon

” I honestly think we are entitled to stand up for ourselves. All of us have at least one, if not many more, stories of being shamed for feeding our healthy and beautiful babies. The whole reason we’re here is to receive support from each other, that we are amazing mothers and parents, regardless of how we feed. We aren’t here to just bash breastfeeding, we are here for each other when everyone else is bashing us. were an amazing group of women who need support. We may come off as angry, but if these individuals who bash were in our shoes, they would see just how wrong their opinions of us are.” – Alexis

“They don’t even get *why* I’m angry. It’s not about me, I don’t give two shits I’m angry for two reasons. 1-All of the lovely ladies and GOOD MOMS who come here with broken hearts because of how the lactivist community has treated them and 2- Because their judgement doesn’t end with their side eye and snarky comments, they are changing public policy (think BFHI and all the horror stories from WIC offices) and that affects all of us. I don’t care if you sit there and comment about my bottles til the cows come home, but when you’re changing policies based on bad info that’s dangerous.” – Maria

“As someone who had no desire to BF whatsoever I have never gotten used to the opinion that we’re not allowed to decide what we want to do with their bodies and we’re not allowed to get angry when people tell us we’re not allowed to decide– or act as if we are stupid or misled when I KNOW we are some of the most informed women when it comes to this issue.” – Nicole

 

“How can they read the stories of what the mothers and babies went through to establish breastfeeding, and still blame women and claim everyone can Bf!!. DARN RIGHT I am angry!!!!!. I bought the “everyone can breastfeed” BS. None of those brilliant nurses (who were also licenses LCs) managed to help my baby latch. My baby had hypoglycemia, jaundice and lost 10% of her birth weight within two days, under their ‘watchful eye’.” -Bahan

“The justification for why why “should not be angry” is both condescending and misdirecting. Also, I’m pretty sure a lot of us are way more educated on formula and breastfeeding, and have given far more thought about the rhetoric surrounding it and it’s implications than most people.” – Bethanny

“They’re silencing us, undermining our autonomy. ‘They make X choice because they’re angry and stupid so X isn’t valid'” – Stephanie

Vital Signs: Ignoring postpartum depression and psychosis won’t make them go away

Another horror story. Another mom. Three beautiful girls who will never have another birthday, whose last memory will be terror at the hands of the person they trusted the most.

I don’t know the details. I don’t really want to know the details. I do know that this mother reached out, told her own mom she was “feeling crazy”. I do know that she had three babies in a row, and that the youngest was 2 months. I do know that there’s a strong chance that this was the result of postpartum psychosis.

And I know that this has got to stop.

Can we protect every family, prevent every case? Of course not. But postpartum mental health is taking a backseat when it should be sitting shotgun to every maternal and child health program. That’s a start, at least. We spend so much time worrying about a woman’s breasts, while we dismiss her mind. We worry about how hormones and birth practices affect lactation, while we disregard how they affect our emotions.

After we give birth, we are whisked off to the maternity ward. Our vital signs are monitored, but other vital signs are ignored. A mom who can’t seem to connect with her baby. Who is scared, and asking for help. Who is alone and voiceless. Her pulse may be steady, but her hands shake. Her breasts may leak colostrum, but her eyes may leak silent tears. And we ignore this.

GE-Healthcare-Dash-2500-v4-Vital-Signs-Monitor

OB/GYNs don’t see mothers until 4-6 weeks postpartum. In some cases, that will be too late.

Pediatricians see moms with their newborns several days postpartum, but they are focused on the infant. As they should be. We don’t expect a heart surgeon to be concerned with the diabetic foot of his cardiac patient’s wife.

When I see the role of lactation consultants and breastfeeding counselors growing, gaining more attention, more insurance coverage, I also see an opportunity. What if these professionals could be trained to screen for postpartum mental health issues, if they could recognize red flags and know how to refer families to the proper resources? What if they were trained to support families in their feeding journeys, with the goal being a happy, healthy family and not just a breastfeeding statistic?

With the state of our health care system, I don’t expect that an entirely new support staff can be instilled at every hospital, for the sole purpose of protecting maternal mental health. But when 1 in 7 mothers suffer from postpartum depression or anxiety, I think that constitutes just as much of a public health concern as the supposed risks of “sub-optimal breastfeeding practices” in developed countries. If we are going to focus so heavily on breastfeeding, could we at least give a little simultaneous attention to a mom’s mood while we inspect her breasts?

What happened to the Coronado family is sub-optimal. What passes as “support” for postpartum women is sub-optimal. There is no reason we can’t support breastfeeding while prioritizing maternal mental health. Both are important, but one has been systematically ignored, shoved under piles of paperwork, given lip service. We only seem to worry about postpartum depression in terms of how it affects breastfeeding “success”. There are so many things wrong with that sentence, with that mentality. It’s like worrying about prostate cancer only in terms of how it will affect sex and procreation. Biological norms are important, but support also means protecting those whose biology turns on them.

If we can only speak of maternal needs under the umbrella of lactation support, I can live with that. As long as those needs are met, I can live with that. As long as those needs are being met, maybe we can all live with that.

Survive with that.

Thrive with that.

 

 

Guest Post: On HIV, stigma, and the pressure to breastfeed

If people read one post on this blog, I hope to god it’s this one. I didn’t write it – it was submitted by Megan DePutter, who works as a Community Development Coordinator at a Canadian AIDS Service Organization – and therefore it tackles so much more than the usual mommy-war crap I tend to drone on about. 

Please read this, and talk about it, and share it as much as you can. As Megan says, as we advocate and empower women to breastfeed, we cannot simultaneously allow women who are already marginalized feel more shamed and judged. This doesn’t hold true only for women living with HIV, but those dealing with a whole slew of medical and emotional conditions that might make breastfeeding difficult or contraindicated. Sort of puts a new spin on the saying “the perfect is the enemy of the good”, doesn’t it?

– The FFF

***

On HIV, Stigma, and the Pressure to Breastfeed

By Megan DePutter

I work in a small-ish community (about 130,000 people) in a town about an hour outside of Toronto, in Ontario, Canada.  Locally, provincially and nation-wide, “baby-friendly initiatives” in health care and social service institutions aim to encourage and exclusive breastfeeding for 6 months. Bypassing for now the unfortunate name of the initiative (which seems to insinuate that any other approaches to feeding are “baby un-friendly”), I understand that these initiatives are evidence-based and well-intended. The problem is that, for the women I aim to support, these initiatives can create further isolation and shame to people who are already marginalized. The women I am referring to are women living with HIV.

See, while the complexity of the HIV virus is still stumping scientists who are working towards the distant prospect of a vaccine or cure, HIV has become primarily a social and a political problem, rather than a biological one.  Canada is one of the best places in the world to be living with HIV – although it’s far from perfect. But here in Canada we have readily available treatment – treatment that is more effective and easier to manage than ever before.  HIV can still pose health risks even with treatment, and the side effects can be unpleasant to say the least, but someone who is diagnosed today with HIV, takes their medication regularly, doesn’t smoke and takes care of their health can expect  a near normal lifespan.   This means if someone living with HIV today has access to treatment, health care and other necessities of good health, such as good food and stable housing (and these are big ifs for a lot of people), they can enjoy a full and productive life. They can work, they can love, they can even have children.  That’s right – they can have children! HIV positive women can – and do – give birth to HIV negative babies. In Canada, with proper treatment, the risk of giving birth to an HIV positive baby is reduced to less than 1%! This is great news for women who are HIV positive and want to have a family. However, because HIV can be transmitted through breastmilk, it is important that they do not breastfeed.

Let me back up for a minute. HIV – which stands for Human Immunodeficiency Virus – is the virus that attacks the immune system and, left untreated, causes AIDS (Acquired Immune Deficiency Syndrome). The distinction between HIV and AIDS is important because today, with proper treatment, the virus can be successfully suppressed.  Without treatment, the immune system breaks down, leaving the individual vulnerable to life-threatening opportunistic infections, at which point an individual is said to have acquired AIDS, and without medical intervention, will likely die.  With treatment though, someone can live with HIV for decades and never develop AIDS. So, if AIDS isn’t the biggest threat to people living with HIV, what is?

The answer is unequivocally stigma.  Contrary to a lot of myths, HIV is not spread through casual contact such as sharing sheets, linens, clothing, food, dishes or cutlery, bathwater, swimming pools, or toilet seats. HIV is not spread through touching, hugging, or kissing. HIV is not spread through coughing, sneezing, urine or feces, sweat, tears or saliva.   Moreover, the effective use of condoms are a successful way of preventing HIV transmission during sex, and viral load suppression through medication further reduces the risk of transmission to a near impossibility.  Methods of getting pregnant for couples who are sero-discordant (mixed HIV status) are plentiful. In other words, there is no reason to be afraid of living with, loving, or building a future with someone who has HIV.  Yet HIV positive people continue to face rejection upon disclosure of their HIV status – from potential partners, from family members, from friends, from their church and from entire communities.  People face discrimination in accessing housing and in the workplace and even from health care workers.  Whether out of fear, lack of knowledge, or judgments around how someone may have acquired HIV (which often stems from racism, homophobia, sexism and/or stigma around sex or drug use,) social exclusion can be an everyday part of the life of someone living with HIV. It is impossible for me to overstate the impact that stigma has on the health and wellbeing of people who are positive, even at a time when people with HIV are at their healthiest.

Let’s get back to breastfeeding.  For women living with HIV, motherhood can raise a gaggle of other complex social and emotional challenges. I’ve already mentioned that stigma impacts people living with HIV, but what about women specifically? People might assume that she’s a drug user, that she’s been a prostitute, that she’s been promiscuous. Given the judgments and attitudes that are often formulated around women’s sexuality, you can imagine what a woman living with HIV might face. For mothers, this stigma is intensified. And, since women with HIV must not breastfeed (although the best-practice around this differs depending on what country you live in; the guidelines are different for women living in countries without access to clean drinking water or formula) women living with HIV often face added judgment around their inability to breastfeed.

Since most women will not want to disclose their HIV status to others, they cannot divulge the very good reason they have for not breastfeeding when facing scrutiny.  The questions they are inevitably asked by friends, family, and health practitioners cause anxieties for women who are attempting to keep their HIV status a secret. In some cases, people can be very pushy about it; I have even heard stories where family members or friends may get so involved as to physically attempt to place the baby on the breast and have the baby feed without consent.  If a woman does disclose her status, she would, unfortunately, very likely face further stigma and judgments about her HIV status.  And if word got around (which it often does), she could be virtually expelled from her community. For women who are newcomers, do not speak English fluently, or are living in poverty, community engagement is often an imperative component of physical, mental and emotional wellbeing. When it comes to keeping HIV a secret, there is a lot at stake.

Furthermore, pregnancy and motherhood can bring up feelings of guilt and shame about the illness; in addition to facing external stigma, many women experience internalized stigma, and may feel guilty for not being able breastfeed. Feeling guilty about not being able to breastfeed is problematic enough for any mother, but for women who are already marginalized, further feelings of guilt and shame add to an already pretty big burden.  Some women may be tempted to breastfeed despite the risks. Others may withdraw from social circles. Others may be reluctant to access social services or health care where they are made to feel guilty about formula-feeding or pressured to discuss their personal reasons for formula-feeding.  For women living with a disease that needs to be managed through access to treatment, good health care, food, housing and community supports, social isolation can be dangerous.

HIV is not something a lot of people think about today, but it still exists – it’s just hidden.  Unfortunately a lot of health care workers in our community are unaware of HIV, the scientific developments in prevention and treatment, and the social implications of the disease.  HIV workers aim to help support women through these challenges, but we need our communities to be aware of these issues and help create supportive environments. Just because women living with HIV do speak openly about their illness does not mean the problem has gone away.

Mothers who are living with HIV need proper information and support around formula-feeding, and they need this information offered in a non-judgmental space. When programs are designed they need to take in to consideration the multitude of needs that may be spoken or unspoken.  I believe it is important that health-promotion programs, including those that support breastfeeding, be designed in an inclusive way. Women already face extensive social and political control – particularly around our bodies, sexuality, and children. It is important that social and health care programs foster independence, support diversity, and create a safe atmosphere that is free of judgment and respects the privacy and confidentiality of all women.  This is about respecting the critical health priorities of women who may already have extensive trauma issues and already experience marginalization.  I know there has been a lot of important and empowering work done towards providing better support and education on breastfeeding that is free from the outside influences of companies who sell formula, but we need to prevent the pendulum from swinging towards exclusivity.  I hope to educate health care and social service providers in my community to share information and create spaces that are built on models of inclusivity and support, rather than stigma and shame.

Please feel free to contact me at communitydevelopment (at) aidsguelph.org for more information or if you have tips or suggestions to share on how service providers can create a supportive environment for all women!  For more information about HIV and AIDS, you can also contact your local AIDS Service Organization. Other great resources are thebody.com and CATIE.ca.

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.

 

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.

 

 

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