There was a recent article in the Guardian (UK) suggesting that the research on breastfeeding versus formula isn’t all that strong and that really formula is just as good.  I’m sure many formula feeding parents were thrilled to read such a thing and have wished to see such an article for a while.  But I would caution them to be very, very careful of what you wish for. 

The main argument in this piece is from a professor of gender studies, Joan B. Wolf, who states that breastfeeding studies are not randomized controlled trials and this is the problem.  What does this mean?  It means that you can’t take 100 women and randomly assign who will breastfeed and who won’t and then look at outcomes.  This is the ideal way to do research when possible so that you avoid other factors in their lives that may influence the outcomes.

However, it’s not always possible and generally that is accepted in the medical literature.  Researchers do similar research on risk factors for cancer, for health outcomes for smoking, bad diet, etc.  And we don’t see people claiming that these results aren’t valid, do we?  Well, in fact, the tobacco company tried to argue against the link between smoking and cancer using the same argument.  People chose what group they belong to and so how do we know that it wasn’t other lifestyle factors that led to their heightened risk of cancer?  That is the argument being used here.

First, let me say that there is reason to suspect that’s not the case, and that’s that even with research that uses self-selection, we have incredible statistical tools that help us control for variables we expect to be confounding.  The greater risk of negative health outcomes associated with not breastfeeding (which, contrary to Dr. Wolf arguing is “small”, costs the US over $13 billion a year[1]) might be confounded with SES, which we know to influence health outcomes and breastfeeding rates.   But the vast majority of studies (and definitely more recent studies) have included SES and many other possible confounds as measures and thus been able to statistically control for their influence on health outcomes.  Have they measured them all?  Probably not, but I personally think we’re darn close and as people discover more, they will start to include them as well, if necessary.  (Oh, then there are the benefits to mom, like reduced rates of various cancers[2][3][4][5], that are not even discussed here, despite this being about women, but I suppose that’s a topic for another day.)

But that’s not the real reason my back got up with this article.  Yes, she’s right that we can’t use randomized control trials, but she’s wrong that it means we have to throw the research out – that’s an easy argument to make.  It’s her implication of what the problem is that isn’t being controlled for that should make every mother angry…

“Women who choose to go through the labour of breastfeeding have made a commitment to go the extra mile for the sake of their baby’s health,” says Wolf. “They are likely to be doing all kinds of other things too. Their homes are clean. They wash their hands. They will be reading more, talking more, serving more fruit and vegetables …”

Translation: If you’re using formula, you’re just a worse mom.  You’re too lazy to clean your home, wash your hands, read, talk, serve good food, etc.  Only moms who care would do these things. 

Personally I think we need to be very, very careful about going down this road.  The hidden argument is that formula itself isn’t so bad at all, but it’s the moms who are screwing up.  Given this is all in a book that’s supposed to help mothers, I fail to see how this does so.  It works if you want to maintain the status quo where there are low wages, crap maternity leaves and many families have two working parents to make ends meet.  Blame mom and laud formula as an equally good alternative.  Any problems with it must stem from a deficient mother (note sarcasm here on my end).  But why not change the system?  Why not argue that US policies are the problem, not breastfeeding research?

Dr. Wolf also manages to imply she knows what is and is not worth the effort for mothers:

“We are in danger of ignoring the drawbacks of breastfeeding, says Wolf, such as the potential loss to women’s earnings… One of the greatest lies promoted by breastfeeding advocates is that breastfeeding is free. But it’s not free if you count mother’s labour. For many you could say it has an extraordinary cost and is probably not worth the effort of continuing to do it.”

Financially, she may be right.  But I don’t believe many mothers who switch to formula so they can return to work to make a salary just to pay bills and not spend time with their children in the first year of life appreciate this.  Yes, you have a choice to either pay your bills or care for your child.  When you look at the cost-benefit ratio like this, breastfeeding in and of itself probably isn’t worth the effort.

But let me throw this out there… what if you lived in a country where you were given a year’s maternity leave?  Paid too.  Nothing huge in payments, but enough to live.  And your job was guaranteed to be there for you when you returned.  What’s worth the effort?  What’s the loss?  You have the ability to focus on your child, on breastfeeding, on whatever it is that makes the early days with a parent so important.  You also have your job waiting if that is a part of what you want or need in your life.  Now some women will choose to stay home after that year, but many won’t and they will have benefited from the time at home with their child, all without sacrificing their careers.

Dr. Wolf’s argument also misses one of the key things that many of us hear time and again: Women want to breastfeed, but through a lack of support, institutional blocks, and work, they can’t or don’t.  This is very different than not being worth the effort, and this is what we need to work on.  There needs to be more support and policies in place that give women the chance to breastfeed.  Without that, we are doing all mothers a disservice.

This is why I will never stop saying the problem lies within the system. 

But I’ll take it a step further.  Even if you don’t want to support changing things so that you live in a more family-friendly (and woman-friendly) society and you like the status quo, why not push to make breastmilk more readily available for moms who can’t or don’t want to breastfeed?  We know that breastmilk was made for human babies, it what they expect to be eating, and no matter how good we make artificial alternatives, it will not be the same.  And as we seem to have learned with all our other processed and genetically modified foods, I doubt it’ll be better.  So why don’t we try and get them that?  Why must we have doctors and feminists so intent on supporting mass corporations making a profit at the expense of families?

The saddest part to me is that these comments are always made as if they are said with mothers in mind.  And yet that’s not true.  If they had mothers in mind, we would be talking about a whole new way of living, not blaming moms for the fact that research supports breastfeeding.

 If you are interested in writing to your US representative to request longer and paid maternity leave, we have a research-based letter you can download, print, and mail.  You just need to enter your information and your representative’s information.  You can download this letter here.

[Image credit: The Daily Mail]

[1] Bartick M, Reinhold A.  The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis.  Pediatrics 2009; 125: 1048-56.

[2] Rosenblatt KA, Thomas DB, and the WHO collaborative study of neoplasia and steroid contraceptives. Lactation and the risk of epithelial ovarian cancer. International Journal of Epidemiology (1993); 22: 192-7.

[3] Brock KE, Berry G, Brinton LA, Kerr C, MacLennan R, Mock PA, & Shearman RP. Sexual, reproductive and contraceptive risk factors for carcinoma-in-situ of the uterine cervix in Sydney. The Medical Journal of Australia (1989); 150: 125-30

[4] Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet (2002); 360: 187-95.

[5] Rosenblatt KA, Thomas DB, and the WHO collaborative study of neoplasia and steroid contraceptives. Prolonged Lactation and endometrial cancer. International Journal of Epidemiology (1995); 24: 499-503