Lactivists and the distortion of risk

This piece originally appeared on Homebirth Debate in April of 2008. Since then Joan Wolf has expanded the cited paper into a book, entitled “Is Breast Best?: Taking on the Breastfeeding Experts and the New High Stakes of Motherhood,” published in December 2010.

Joan Wolf, of Texas A&M University, provides a spot-on description of breastfeeding activism. Writing in the Journal of Health Politics, Policy and Law, August 2007, in an article entitled Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign, she describes the lactivist as moral scold:

In Chicago, a counselor at a federal Women, Infants, and Children clinic laments the tragedy of teenage mothers choosing to go to school instead of breast-feeding their babies. The director of the neonatal intensive care unit at District of Columbia General Hospital tells mothers of infants with runny noses that the babies would not be sick if they breast-fed. And an anthropology professor argues that formula producers, “just like tobacco companies, produce a product that is harmful to people’s short and long-term health”. Such rhetoric is commonplace in the world of breast-feeding advocacy, and it is staked on an overwhelming consensus that breast-feeding is the optimal form of nutrition for babies.

Yet while breastfeeding has indisputable advantages, the medical advantages are quite small. In light of the known scientific evidence, Wolf questions the ethical obligations of those who wish to promote breastfeeding. Is their moralizing justified by the scientific evidence? Is the scientific evidence being presented accurately? Do public health officials have ethical obligations to be truthful?

… Debates among scientists and scholars engaged in public health research provide good reason to question government-sponsored breast-feeding promotion and even stronger grounds to challenge a risk-based campaign. Perhaps the most problematic dimension of the National Breastfeeding Awareness Campaign (NBAC) was the science on which it was based. Medical journals are replete with contradictory conclusions about the impact of breast-feeding: for every study linking it to better health, another finds it to be irrelevant, weakly significant, or inextricably tied to other unmeasured or unmeasurable factors. While many of these investigations describe a correlation between breast-feeding and more desirable outcomes, the notion that breast-feeding itself contributes to better health is far less certain, and this is a crucial distinction that breast-feeding proponents have consistently elided. If current research is a weak justification for public health recommendations, it is all the more so for a risk-based message that generates and then profits from the anxieties of soon-to-be and new mothers. Yet in its emphasis on the dangers of not breast-feeding, the NBAC consciously attempted to manufacture fear in order to increase breast-feeding rates. It did so, moreover, in ways that exploited widespread popular misunderstanding of “risk” and deep seated normative assumptions about the responsibility that mothers have to protect babies and children from harm…

Wolf begins the article with a 9 page comprehensive analysis of the existing scientific literature. The analysis reveals that the purported medical benefits of breastfeeding are actually quite small, and that the studies themselves suffer from serious methodological problems. Wolf believes that the incremental nature of the benefits and the lack of a firm scientific foundation mandate caution in creating public health initiatives to promote breastfeeding.

… [T]he first tenet of the APHA Code of Ethics states that “public health should address principally the fundamental causes of disease and requirements for health” and explains that “this Principle gives priority not only to prevention of disease or promotion of health, but also at the most fundamental levels”. Drunk driving and smoking are underlying causes of traffic fatalities and lung cancer, and public health campaigns to reduce them would seem in keeping with the standard set by the APHA. But the evidence for breastfeeding is not nearly as powerful. Even if breast-feeding research were unassailable — if the studies were meticulously designed and carried out, confounding convincingly eliminated, and plausibility established — the associations would still not be strong enough to make the case that not breast-feeding is a fundamental cause of the health problems cited by the NBAC. By most measures, in fact, the campaign did not meet the evidentiary standards for ethical public health practice set by multiple institutions.

Wolf argues that despite the limited medical benefits, and despite the inconclusive scientific evidence on which it is based, breastfeeding activists have embarked upon a campaign to encourage breastfeeding by deliberately misrepresenting the “risks” of bottle feeding and by deliberately playing on the public’s known inability to understand risk.

Risk, however, is grossly misunderstood. Research suggests that cognitive limitations, skewed media coverage, and misconstrued personal experience distort the process of risk calculation, even among the well informed, and that “people systematically violate the principles of rational decision-making when judging probabilities, making predictions or otherwise attempting to cope with probabilistic tasks”…

Directed at pregnant women, for whom “risk” is weighted with particular emotional freight, the NBAC capitalized on public misapprehension of risk. Even if infant-feeding studies were more compelling, for example, the campaign drew dubious risk analogies. In the television spots, logrolling or riding a mechanical bull pregnant and not breast-feeding were portrayed as comparably dangerous acts or threats to a baby’s safety. Many of the campaign’s most outspoken proponents, including USBC chair Amy Spangler, likened bottle-feeding to tobacco use: “[W]e don’t hesitate to tell parents what smoking does to themselves and their children,” she said. “Why should we not tell people the consequences of not breast-feeding?”. Commenting on the NBAC, a pediatrician on ABC’s 20/20 also contended that not breast-feeding and smoking carried similar risks. Yet this kind of reasoning is specious. All risk is not the same, and even if breast-feeding research were methodologically sound, the risks of formula-feeding would be infinitesimal compared to those for smoking…

The tactics of breastfeeding activists are in direct conflict with codes of ethics for public health:

Conversations among practitioners and ethical codes established by epidemiologists virtually always stipulate that great care should be taken to present research results honestly and without distortion. This is part of the “implicit contract between epidemiologists and the members of society”. According to the Ethics Guidelines of the American College of Epidemiology (ACE), for example, “epidemiologists should strive to ensure that, at a minimum, research findings are interpreted and reported on accurately and appropriately . . . The significance of the findings should neither be understated nor overstated. Epidemiologists should put the strengths and limitations of their research methods into proper perspective”. For researchers, this might mean foregrounding caveats that are normally found in the last paragraphs of published studies. For public health practitioners, it might require that campaign messages be carefully balanced and that those designed to scare people be limited to interventions for which the evidence is strong and the negative outcome serious and likely, conditions that do not obtain in not breast-feeding. Once the NBAC framed infant feeding as a matter of sickness versus health or danger versus safety, it was practically impossible to portray not breast-feeding as risky and to present the nuances of research findings. Whereas in ethical public health practice a campaign is designed to represent the research, the message subordinated the science in the NBAC.

The bottom line is that breastfeeding activists, in an effort to promote breastfeeding, have engaged in unethical practices designed to scare and trick women into breastfeeding. Rather than providing women with all the scientific evidence to make their own decisions, breastfeeding activists have determined that THEY are the appropriate arbiters of what women should do and now concentrate on browbeating women or deceiving them to do it.