**I warn you that this is a LONG post – over 4000 words – but the piece to which I’m responding had so much to unpack, I didn’t want to leave things out.  In honesty, though, I still feel like I left a lot out of what I would like to say.  Furthermore, in a rush to try and get this up, I expect there are typos, so forgive me, and I may make some changes in the days to come.  In the meantime, happy (?) reading…***

The New York Times recently published an opinion piece on breastfeeding written by a University of Toronto Political Science professor.  In this article, she takes breastfeeding to task, or rather, the supposed societal push to breastfeed and the “pushy” lactivists who are righteous and out to force women to breastfeed.

Pardon me while I bang my head against the wall.

There is nothing new in Dr. Jung’s opinion that hasn’t been said over and over again recently.  Based on articles like these, one would think we have a society filled with breastfeeding moms out bashing the rare woman who dares to pull out a bottle to feed her baby.  That women with bottles frequently hide at home, afraid of the backlash of a vicious majority.  Yet nothing could be further from the truth.  You can’t even say you support breastfeeding anymore unless you add a million caveats about choice, societal problems, and so on.  To admit you might be one to fight for women’s rights to do what is biologically normal if she wants is somehow akin to hanging a sign around your neck claiming you’re a bully who doesn’t give a shit about women.

So here we are again with another opinion piece, one trying to dismiss the work done by many to create a cultural change in which breastfeeding is supported.  An opinion that is based on so many incorrect numbers or analyses that I lost count early on.  An opinion that gets to be given more weight because this mom breastfed and that should make her opinion worth more, or so she seems to think.

No.  Just no.

If we’re going to talk about these issues, let’s talk about them and clear up the insane misrepresentations that are rampant in this piece.  Let’s make sure we don’t gloss over some very important issues when it comes to how accessible and “safe” formula is in the United States (where the focus of the original opinion is).  Let’s make sure we accurately represent the people involved in this fight to normalize and support breastfeeding.

So here we go.

Breastfeeding Rates

Source: KellyMom

Source: KellyMom

The very first part of Dr. Jung’s argument seems to stem from the fact that the US actually has better breastfeeding rates than other places.  Rates that are meeting the goals set by the Center for Disease Prevention and Control.  Seventy-nine percent of women initiate breastfeeding and 49% are breastfeeding at six months.  Sounds okay, right?  Sure, these numbers aren’t bad, but when you consider the World Health Organization recommendation that infants be breastfed exclusively for six months (and then breastfed combined with solids for up to 2 years and beyond), something seems a little off.  First off, that 49% isn’t exclusive breastfeeding, it’s any breastfeeding.  When exclusive breastfeeding is examined, only 18.8% of babies meet this goal (and even fewer are breastfeeding at 12 months).

Is this better than other countries?  Absolutely.  Does this mean that there is nothing to work on?  Absolutely not.  Using comparisons to other countries as a means to say “Hey – don’t worry” is asinine.  If you compared rates of diabetes or heart disease to other countries and discovered some were worse, would you advocate to stop efforts at reducing rates in your own country?  Hopefully not, or if you would, hopefully you aren’t in a position to make that decision for the people of your country.

The “Moral Fervor”

Dr. Jung argues that because these rates are good enough, she fails to understand the “moral fervor” that has led to all sorts of changes like education campaigns, hospital initiatives, and so on.  I’m sorry, but these initiatives are part of why the USA is meeting the goals it set out for breastfeeding.  Not only that, but these initiatives still only affect a fraction of the population in the USA.

Source: CDC

Source: CDC

Baby-friendly hospitals?  Only 292 hospitals meet this criteria and only 14.1% of births take place in them.  Women who want proper breastfeeding support and assistance have to seek out hospitals that will support them and women in 3 states won’t even be able to find one.  In one survey, 70% of hospitals admitted to giving all families formula upon leaving the hospital.

Work regulations?  Well, the only Federally mandated one is the Affordable Care Act and it’s estimated that it affects less than 50% of working women.  That means as much as it allows for breaks for pumping and a place to pump, less than half of working women get to take advantage of it.

Social pressure?  This one always confuses me.  You can’t go a day without seeing discrimination against women for breastfeeding in public – it’s so bad that women need laws to protect their right to feed their babies from the breast.  Less than half of women are breastfeeding at all at six months, less than 1 in 5 are exclusively breastfeeding.  If the social pressure were so great, wouldn’t we expect to see different numbers?  Most women I know who are breastfeeding at six months have done so despite societal pressure to switch to formula, even just to supplement.

The only “moral fervor” I have seen regularly applied is from those who are offended that anyone would actually continue to fight for women’s and baby’s rights to breastfeed and be breastfed.  Yet articles like this place their outrage on those who fight for paid maternity leave (something lacking in the USA that Dr. Jung alludes to when referencing pumping) instead of using it as reason to not fight for breastfeeding.  They are the ones who help women find ways to make breastfeeding work for them if they want it.  They are the ones who look at a broken system and try to find ways to make it work, because for all the upset over these initiatives, the system before was not working.  It was failing far more women.

(See here for a letter to send to your representative to get Paid Maternity Leave in the USA.)

The Research

Source: Nurtured Child

Source: Nurtured Child

This one drives me nuts, I must admit.  Clearly Dr. Jung’s Political Science degree did not include much in the way of understanding quantitative research or statistics.  Let’s first discuss the issue of how the “benefits” of breastfeeding may be “modest”.  Breastfeeding is biological norm for human beings.  There are no benefits.  I realize this is a hugely contentious issue, but it’s very important we understand what our baseline for research needs to be.

Human beings, as mammals, expect certain biological behaviours.  In terms of feeding, this includes exclusive breastfeeding for approximately six months and continued nursing with solid foods until a child reaches age 2-3, minimum.  When we move away from this biological norm, it is up to us to research the effects of this, and this puts the onus on formula to show there is no risk associated with its use (or the risk falls within an acceptable range).  Just as we examine the risks of other changes to our biology, like the use of the birth control pill (we never speak of the “benefits” of not being on the pill) or a diet filled with fast food (again, we don’t speak of the “benefits” of avoiding McDonalds), the same holds for breastfeeding.  Or rather, should hold.  The fact that it doesn’t speaks to the power of the formula industry and the societal push for formula to be seen as the norm.

With that out of the way, what does research tell us?  Well, Dr. Jung first focuses on telling us the research says the “benefits” of breastfeeding are only “modest”.  Given how the research has been done, it’s shocking anything is found at all.  The vast majority of breastfeeding research has treated breastfeeding as something that can be done outside this biological norm and still confer “benefits”.  It assumes that breastfeeding is something magical where one or two feeds can provide your baby with everything it needs to have a successful life.

Holding anything up to that standard will fail.

Yet we still see “modest benefits”.  Hmmm.

Really what we do have, though, is evidence that as soon as biologically normal breastfeeding is included in analyses, we see the risks associated with not breastfeeding in this manner.  We’ve seen effects on risk for certain subtypes of childhood cancer, obesity, SIDS, respiratory tract infections, and more in infants as well as risk for certain subtypes of cancer in women as well.  Interestingly, she fails to mention the well-established findings pertaining to gastrointestinal diseases, respiratory tract infections, and sudden infant death syndrome.  Even the PROBIT trials, in which Dr. Jung focuses on areas where effects were not found, found many benefits that she seems to gloss over.  The only “benefit” she mentions is cognitive development, one she likely feels comfortable mentioning as she then tries to use recent problematic research that says there is no link between breastfeeding and IQ, a study so problematic that the only possible conclusion is that a single breastfeeding session will not affect IQ.  If you needed a study to tell you that then we need to talk about your grasp on reality.

Is breastfeeding/formula-feeding research great?  No, though that is starting to change.  Our understanding of confounding factors in breastfeeding research means these are being controlled for.  Even the understanding that we need to be making comparisons to biologically normal breastfeeding means some (though not all, as was the case for the breastfeeding-IQ research mentioned above) researchers are ensuring they assess exclusivity and duration of breastfeeding instead of just “ever breastfed”.

Dr. Jung then moves on to tackle the issue of the “benefits” of breastfeeding during the period babies are breastfed, claiming that we shouldn’t put too much stock in them either.  Here I can only assume she doesn’t quite understand the number needed to treat for an intervention given how quickly she dismisses the data she herself presents.

She says six women would need to breastfeed exclusively for 6 months to prevent one ear infection, a number so amazingly high it would receive a green light in any research on interventions.  She mentions that 1 in 26 babies can avoid hospitalization for a respiratory tract infection if mom breastfeeds exclusively.  To put this in perspective, bypass surgery has been found to have a NNT of 1 in 25 to prevent death over 10 years from another heart attack yet also includes risks of harm from the surgery itself (e.g., 1 in 14 required extended life support and 1 in 83 died from surgery) and we consider it a huge success.  Steroid use for croup gets a green light for an NNT of 11 for avoiding a return visit to the doctor and 5 for improving symptoms.  And these are numbers for cases in which children and adults already have the disease.  The breastfeeding numbers are preventative.

If you consider that there are approximately 4 million babies born each year, that’s 666,666 ear infections and 153,846 hospitalizations for RTIs avoided.  All this for an act that is biologically normal and expected by human babies.  If one thinks about the cost to the health care system and how biologically normal breastfeeding is what results in the most noticeable changes, is it any wonder there’s a “moral fervor” to try and increase rates even more?  Furthermore, it doesn’t even mean that women need to breastfeed themselves, but rather we need to focus on providing breast milk and ending the stigma of donor milk.

(Of note, the accusation that some of these findings are from research funded by companies that have a stake in breastfeeding without mention that some of the studies that do not find results are funded by formula companies is just beyond unethical here.  It’s okay to call out one, but mention the proportion of research and that it goes both ways.  Exactly why we need to look at the research itself to see how good it is.)

The Big Business of Breastfeeding

Forget the formula industry, we need to consider how much money there is in breastfeeding!  By 2020, the breast-pump market might hit $1 billion a year in the USA!  And with all the other things like pillows and covers, it could get close to $3 billion a year for it all!  It seems we just need to follow the money to see where this “moral fervor” is coming from, right?

Um… WTF?

Source: Quartz

Source: Quartz

So in 5 years, we’re expecting the entire breast-pump market to approximate what the top-selling formula brand in the USA makes at this moment.  Yes, Similac Advance (just Similac Advance, not all Similac brands), who holds the #1 spot in the USA, has a market share of $791 million.  When you consider the top 10 formula brands (as there are even more than that), we’re talking about $3.16 billion, less than what we’re expecting the entire breastfeeding market to provide.  And this doesn’t include bottles or the “follow-up formula” that formula companies are producing and selling to formula and breastfeeding families alike.

And this doesn’t even consider the unethical marketing practices of these very same companies in developing countries.  But yes, by all means let’s focus on the evil, money-grubbing breastfeeding companies!

The Shaming Debate

Yes, breastfeeding has become all about what kind of parent we are.  Good mothers breastfeed, shit mothers use formula.  Yada, yada.  Oddly, the people that push this the most are the formula companies.  Wonder who came up with “Breast is Best”?  Formula companies.  Ads that tell us we’re fighting amongst ourselves?  Formula companies.  As I (and many others) have written on over and over, there are individual assholes out there that mothers should look out for no matter how they feed their babies, but lactivists and lactation consultants are hardly the enemy.  They are people who fight to support women in ways that actually support their choices instead of balking when hard times hit and saying, “It doesn’t matter if you use formula”.  That’s not support.

Source: Lansinoh

Source: Lansinoh

Let’s not forget the little detail that when it comes to “shaming”, breastfeeding women – a minority – require legal statutes to be able to breastfeed outside their homes.  They face discrimination on a regular basis while out eating or shopping because of their choice to breastfeed.  They are told they are child abusers if they breastfeed too long.  They are told they are immoral or disgusting if they nurse without a cover in public.  They are shamed over and over and over again.  Every day I read multiple comments from people about how “disgusting” breastfeeding is.  Recently I was faced with a tweet by a man who said if his “girl” ever breastfed in public, he’d whip her across her tits.

The USA is a society that is so unsupportive of breastfeeding and has so normalized formula-feeding that to try and suggest the shaming is a one-way street is so biased and incorrect that it would be comical if it wasn’t so sad.

Racial and Economic Disparities

Are there racial and economic disparities in breastfeeding rates?  Yes.

Is this the fault of breastfeeding advocates?  No.

Is it reason to end breastfeeding advocacy?  What the hell?

Source: CDC

Source: CDC

Look – there are racial and economic disparities in a ton of areas in our society – take education for example.  People who are trying to reform education do so in part because of these disparities.  By a similar argument to Dr. Jung’s (and many, many others), this is akin to “shaming” those who have to attend poor quality schools and thus we should be angry with those who promote access to better education.  In short, it’s ridiculous.  The fact that racial and economic disparities exist is not a reason to censor discussion over the risks of formula feeding or non-biological breastfeeding.  Just as they are not a reason to censor discussion on education or later dietary and health choices.

Moreover, recent research that was presented at the annual meeting for the Academy of Breastfeeding Medicine found that breastfeeding may actually be something that evens the playing field based on socio-economic differences.  That is, exclusive breastfeeding was found to moderate differences in cognitive development based related to lower SES; those who were exclusively breastfeed did not show the same effect of SES on cognitive development than those who were not.  This research is preliminary, but if it holds up in long-term studies, this has huge public health implications and should provide our politicians with even more of a push to create policies that support women’s rights to breastfeed and breastfeed exclusively.

(To read up on the highlights of the recent research mentioned at the ABM 2015 conference, here is a great summary from an attendee.)

In fact, lactivists have attempted to end this disparity by pushing for better education and support for minority and lower SES groups, yet even these attempts are being called out by those against any form of breastfeeding advocacy.  It’s almost as if they want things to stay in this segregated manner and ignore the other issues facing lower SES families who formula feed.

Yes, that’s right, there’s inequality in formula feeding as well with lower SES families facing serious problems such as access to safe water (even in the United States), enough money to afford enough formula for the month, the proper preparation of formula and sterilization of bottles to avoid disease, and the early introduction of solids or even watering down formula.  These are all issues that face too many families in the USA, yet in the privileged discussion of “choice” this is all happily ignored.

Oh Those Policies!

Dr. Jung takes much offense to policies in the USA that she feels shame formula-feeding mothers.  Here is where I’d like to say that she raises some good points about the policies in place (some, not all), but where her anger is misdirected.  Instead of blaming inept politicians, she decides to go after lactivists, which is woefully ignorant and unfair.

Where I find Dr. Jung to be wrong in her assessment of policy is her idea that labeling breastfeeding as a public health issue portrays mothers who don’t as bad parents and irresponsible citizens as it blatantly ignores that it is a public health issue.  It has nothing to do with shaming individual mothers, but rather acknowledges that the societal effects – financially and health-wise – of breastfeeding are too important to ignore.  By labeling it as such, the American Academy of Pediatrics and surgeon general have brought the issue to the forefront of politics where it had previously been swept under the rug.  Only with this type of awareness can we make real progress in terms of policies that need to be implemented to help women.  (Though because of the ineptness of politicians, this is not actually happening in ways anyone appreciates.)

The discussion of WIC policies in her article has many people – rightfully – up in arms, but they are up in arms at the wrong people.  Yes, WIC wants to promote breastfeeding because, as previously mentioned, it is a public health issue, but Dr. Jung forgets that there are financial and practical realities of a public subsidy program that need to be mentioned as well.  People seem to forget that WIC pays for a large portion of the formula provided to moms who do not breastfeed, money that is used for the extended food package for moms who do. For example, in the first six months, an exclusive formula WIC package costs 25% more than an exclusive breastfeeding package.  (Interestingly, the cheapest option for WIC would be to have every mother-infant dyad on the partial breastfeeding package for the entire first year of a baby’s life.)

wic breastfeeding wic formula

Should all moms have access to good, healthy foods?  Abso-freaking-lutely, but when someone else is paying for it, you can bet they’re going to be pretty stringent with the money they spend and when it’s the government, that pesky issue of public health is also going to play into it (remember the numbers for infections and hospital visits?).

Is this right or fair?

Not really, for a few reasons.  First, although formula is supplemented with vitamins and minerals, hopefully no one actually believes that this replaces high-quality whole food in terms of the health benefits.  Second, it ignores the varied reasons women make the choices they do with respect to infant feeding; until other policies are in place that support women’s right to make an actual choice (*cough* paid leave *cough*), it does come across as punishment for some women.  Third, given the racial and economic disparity that already exists in infant feeding practices, it does, as Dr. Jung states, serve to create greater health disparities between the haves and have nots (for even within those who use WIC, there are differences).  But none of this was instituted by breastfeeding advocates.  These were instituted by inept politicians.  Let’s be clear that breastfeeding advocates aren’t out celebrating these disparities.  More often than not, they are equally disparaging of policies that put the best interests of moms and babies behind the dollar bill.

I agree completely with Dr. Jung that the USA needs better policies in place such as paid maternity leave, flexible work schedules, on-site daycare, and so on.  These are things breastfeeding advocates have been pushing for far longer than the anti-breastfeeding brigade.  The entire basis of this past year’s World Breastfeeding Week was on working mothers and pushing for changes that enabled working moms to reach their breastfeeding goals.  Yet even that week, we were all treated to an endless barrage of how horrible lactivists are and how we just need to say “formula is just as good”.  Yet in no world does that attitude help foster change for anyone.

Choice

Source: MomJunction

Source: MomJunction

Here we get to the crux of the entire argument and perhaps the hardest part to rationally discuss.  Choice.  Or rather a woman’s choice to breastfeed or not.  (Of course there is also the often-overlooked issue of whether or not a baby should get any say in this as breast milk is often preferred by babies and is their biological norm.  All I will say on this is that we need, need, need more of a push to normalize donor milk for women who can’t or don’t want to breastfeed but also don’t want to use formula.)

There are a ton of considerations here and no lactivist I know believes women should be denied the choice to breastfeed or use an alternative.  None.  So all this mythical movement of people who are out trying to stamp out choice really seems to be a fear tactic used by those who really seem hell-bent on keeping things the same.  And by “same” I mean a society where “choice” is still an illusion.

According to a recent CDC report on breastfeeding and the experiences of American women, some startling data emerged, such as:

  • 60% of American women who want to breastfeed don’t reach their goals;
  • 74% of American hospitals routinely fed formula to breastfed babies with no medical indication, just because it’s what they do;
  • 55% of American hospitals do not have rooming-in for the entire stay of a newborn and mom despite that being one of the biggest predictors of breastfeeding success (and no, this isn’t about choice either, it’s hospital policy).

Where is the choice in any of this?  How are women actually given a choice to breastfeed when everything is stacked against them?  And when changes, like baby-friendly hospitals, come into play to try and enable choice, backlash like what we see here in Dr. Jung’s piece (and many others) comes flooding to the surface and try to make it seem like the majority are being persecuted.  (Yes, even in baby-friendly hospitals you can use formula by choice.  You just have to get it yourself, not exactly impossible, is it?)

No policy change and no group is out trying to stop women from using formula.  None.  La Leche League is a volunteer organization of women who help and support one another in their breastfeeding journey.  You don’t want to breastfeed?  LLL isn’t a place you’re going to be going.  Lactation Consultants are professionals who are trying to help women reach their goals of breastfeeding and yet even they will often recommend formula for short periods or even ongoing when the need or want arises.  Again, you choose to go to one, they don’t come knocking at your door.  The rest of us “lactivists” are out there pushing for proper information so women can make informed choices, or changes to policies that can help women reach their goals, no matter what they are, because of the immense importance to women’s mental health when they are able to complete these goals.  We share this information on a public stage that everyone is welcome to ignore if they want.  So again, if you want to formula feed, go ahead.  You’re in the majority.

I hear of more women reporting being told they should be switching to formula or supplementing than anything else, yet we don’t seem to have a problem with that, do we?  The myth of the “anti-choice” people taking over is based solely on the idea that there may be a few people out there who take an extreme view (though no one ever provides concrete examples of this on a large scale).  It doesn’t exist on any significant scale, though any personal attack sucks, but they exist on all sides of, well, everything.  Women trying to breastfeed have faced personal attacks for years, with doctors and family and friends telling them everything from “You’re starving your child” to “You’re sexually abusing your child” for their nursing habits.

All those of us who care about breastfeeding are fighting for is a change to the status quo.

Changing the status quo is not taking away your choice.  It’s actually providing choices to those who haven’t had them before.  So, on that note I will end with this: A woman should formula-feed if she wants to, not because a broken system forced her to.