The moral case against lactivism and breastfeeding promotion

49745688 - autonomy word cloud concept. vector illustration

Last week the Royal College of Midwives took the extraordinary step of reminding its members that every women has the right to bottle feed and that the choice should be suppported and respected. It was an implicit acknowledgement of just how harmful promotion efforts like the Baby Friendly Hospital Initiative have become. Babies’ physical health and women’s mental health are being compromised by the mantra that “breast is best” and, in particular, the risk based language (“artificial baby milk,” “risks of formula feeding”) and tactics (locking up formula, making women sign formula consents) often employed.

The Baby Friendly Hospital Initiatve, as well as the lactivists who promote it, are engaged in unethical violations of women’s autonomy.

Literally tens of thousands of babies and women are suffering each and every year from these pernicious tactics and it could have been avoided if lactation professionals had considered the ethical dimensions of their language and policies. Indeed, this exact situation — suffering as a result of unethical promotion efforts — was predicted back in 2006 by Rebecca Kukla. Kukla is Professor of Philosophy at Georgetown University and Senior Research Scholar at the Kennedy Institute of Ethics.

In 2006 Kukla published a paper in Hypatia, a journal of feminist philosophy, entitled Ethics and Ideology in Breastfeeding Advocacy Campaigns.

Writing about breastfeeding promotion in 2006, she makes the following claim:

I argue that the campaign is unlikely to substantially increase breastfeeding rates, unresponsive and even hostile to many women’s actual concerns about breastfeeding, and well positioned to produce shame and compromise agency among the women it targets.

And that’s precisely what has happened.

Kukla’s thesis was that breastfeeding promotion efforts violated women’s autonomy and sense of agency while simultaneously ignoring women’s stated reasons for being unable to or choosing not to breastfeed.

She starts with the often unexamined belief that by controlling women we can control children’s health:

Accordingly, many of our public health initiatives specifically target mothers’ choices, as though these were morally and causally self-contained units of influence; if only we could talk women into making the right choices, these initiatives presume, then children would turn out healthy. However, even if we grant that, given our social division of labor and the natural facts of reproduction, mothers really do have special duties as caretakers of their children’s health, this does not justify the conclusion that mothers’ agential, independent, responsible choices exert primary control over child health outcomes, nor that these choices are straightforward and self-contained sites of moral accountability. We need a more sophisticated ethical analysis in order to avoid an easy individualist politics of blame and a single-minded public health strategy.

By 2006 lactivists had spent more than a decade pressuring to breastfeed yet breastfeeding rates were still considered low:

First, why isn’t the information that “breast is best” — now disseminated in every form, from the bare slogan to detailed scientific information, through hospitals, community health centers, media campaigns, advice books, prenatal classes, Web sites, and parenting magazines, in every language, in Braille and in large font — enough to make women choose to breastfeed? … Second, given that breastfeeding advocates imagine and promote breastfeeding as a joyous natural bonding experience, how can they explain the behavior of the majority of American women, who initiate breastfeeding (presumably with the intention of continuing) but quit early?

They concluded that women needed ever more “education” as well as increased pressure produced by employing risk based language and tactics.

This view is patronizing at best:

We need to think hard about the condescension and even the strategic imprudence involved in throwing our social resources into finding yet more ways of giving women information they already have. Even more fundamentally, we need to question our assumption that improper education is the cause of low breastfeeding rates.

It pathologizes women who can’t or don’t want to breastfeeding:

Rather than looking to the social and symbolic context that might make her feelings explicable and reveal her needs, we pathologize her, casting her as deviant and unmotherly… The emphasis here on personality lays the responsibility for a less-than-joyous breastfeeding experience directly upon the individual character of the mother, while invoking a litany of stereotypical images of gendered virtue.

Hence lactation professionals feel justified in using tactics — like the Baby Friendly Hospital Initiative — that deprive women of autonomy and agency.

I want to end by arguing that the current strategies and imagery used by American breastfeeding advocates … are not only inappropriate, but also constitute unethical assaults on new mothers’ autonomy and agency…

How?

Public health ethics often focuses on analyzing the extent to which restrictions of autonomy that curtail free choice (such as helmet laws, smoking bans, and, to a lesser extent, campaigns designed to change behavior) are justified by their welfare benefits. But I want to suggest that such limitations on negative liberty usually do not cut as deep into people’s intact agency as do violations that undercut our ability to make responsible, agential choices at all. If we have no morally livable options open to us, or if our moral judgments and risk judgments have been seriously distorted by the messages we receive from our culture, then our ability to exercise autonomous agency has been crippled … Autonomy, on any full-bodied account, involves the positive capacity for responsible action, and this capacity is compromised when we are offered only morally distorted representations of reality and self-damaging choices. Contemporary breastfeeding advocacy chips away at the autonomous agency of American mothers …

She concludes:

The breast vs. bottle debate is sometimes framed in terms of the competing interests of mothers and infants … but, overwhelmingly, these interests do not in fact compete. It is in a baby’s interest to have a competent, comfortable mother, and in a mother’s interest for her baby to be healthy and well nourished. Most mothers care deeply about their role as caretakers of their children’s health. Once we begin from this premise, rather than from the assumption that mothers are selfish or stupid until proven otherwise, we need to conclude that since most mothers also already know about the important health benefits of breastfeeding, they would do it if they realistically could.

With respect to breastfeeding, our public health goal should be to make breastfeeding a livable, comfortable, well-informed option for women, and not to cripple women’s ability to find a way of making caring choices for their children.

The Baby Friendly Hospital Initiatve, as well as the lactivists who promote it, are engaged in unethical violations of women’s autonomy in an explicit effort to deprive them of agency in choosing how to feed their children. The result has been injuries and deaths for babies and anguish for mothers. The Royal College of Midwives has acknowledged the harm; sadly, many lactation professionals still can’t bring themselves to do so and continue to write articles and make Facebook and Twitter comments that are both condescending and cruel.

  • Allie

    “…since most mothers also already know about the important health benefits of breastfeeding, they would do it if they realistically could.”

    And… mic drop.

  • lawyer jane

    I’d like Prof Kukla to update her paper, now that the risks and (lack of) benefits of breastfeeding are much better known!

  • Sarah W

    I wish I could have read this back before my son was born. I am still grateful to read it now. It’s validation for my feelings of anguish at being unable to breastfeed and of resentment toward all the pressure I received, direct and indirect, insisting that I had to keep trying harder anyways.

  • Jessica

    This — the idea that the only moral choice is breastfeeding — is what hurts so many people. I breastfed my daughter for 6 months and my son for 4 months. I hated it both times. The first month was terribly painful despite good latch, and with my son I also experienced dysphoric milk ejection reflex (which confused the hell out of me because I wasn’t depressed but wanted to weep every time I nursed). Both kids nursed every 90 minutes to 2 hours so I was trapped at home with no ability even to run to the store, for fear of returning to a starving, hysterically crying baby.

    Things improved in both cases but then when I went back to work (to a supporting environment where pumping was private, I had a fridge, etc.), I struggled both with supply and with finding time to pump in a demanding job. I found myself hoping my children would eat less so I wouldn’t have to try to pump more out of dry breasts through pain. I worried when the milk looked thinner. I cried when we had to throw out 3 weeks’ worth of pumped milk because my daughter had a cow’s milk protein allergy. I spent most of my time worried that my kids were not eating enough, worried that I should be pumping more, worried that my supply was going to keep dropping. Worried in my daughter’s case that I would accidentally poison her by failing to read a label (she screamed hysterically for 2 hours from pain when I drank 3 sips of coffee with regular cream).

    I tried combo feeding but it was still a struggle because my supply completely tanked without regular day pumping. It became clear that my choices were full time breastfeeding or stopping altogether. I chose to stop. Not because I was uneducated, or unsupported. But because the costs didn’t make sense for our family. Both my kids are thriving (my son is now 5 months, my daughter 3) and I no longer have to devote hours of my day to ensuring that they are simply fed — I can interact with them, love them, enjoy long play sessions, send them to school, send myself to work, take a day off — all of those things that were not possible with our breastfeeding schedule. No amount of education and support would change that reality.

  • demodocus

    I was “elderly” when I had my babies 4 and 2 years ago. I’m a natural skeptic and have a strong logical streak and yet, i still find myself giving people reasons why my 2nd was eff. I don’t feel a need to give reasons for bf’ing my 1st, even though that was probably something I should’ve quit much, much earlier.

  • OttawaAlison – In Seattle

    I wish I had read that when my daughter was born in 2006. I took the condensed hospital birthing class one Saturday back in May 2006, we spent a quarter of the class on breastfeeding and had a breakout session where we had to basically list why breastfeeding was better than formula – looking back on it now it was very infantilizing (we all knew the bullet points and I was probably the youngest in the room at 28), it was just to convince us that breast milk was better which the room at that point was convinced and knew the rhetoric. There was zero acknowledgement that breastfeeding doesn’t always work out.

  • Roadstergal

    “but, overwhelmingly, these interests do not in fact compete. It is in a baby’s interest to have a competent, comfortable mother, and in a mother’s interest for her baby to be healthy and well nourished.”

    This needs to be emblazoned on billboards.

    • Sarah

      Outside hospitals and birth centres.