Breast is best … except when it’s not!

806BB1CC-21AC-4A62-92B3-0D6438917989

Kudos to the Journal of Human Lactation for publishing a paper that challenges a central lactivist assumption.

The paper is Breast Is Best . . . Except When It’s Not by Lynne M. McIntyre, MSW, Adrienne Marks Griffen, MPP, Karlynn BrintzenhofeSzoc, PhD. Each woman suffered postpartum depression:

We come to the intersection of PMADs [perinatal mood and anxiety disorders] and breastfeeding not only as perinatal mental health professionals but also as mothers who suffered from postpartum depression and anxiety and who breastfed our five children for a combined total of more than 6 years. Our individual experiences with PMADs affected us so profoundly that we each changed our careers. We each have served as coordinators with Postpartum Support International for more than a decade, providing direct support to women experiencing PMADs and researching, educating, and advocating about these illnesses…

The authors learned from both personal and professional experience how breastfeeding can be harmful to women’s mental health. In other words, for many women breastfeeding is not best and the pressure to breastfeed is injurious.

Lactivists have aggressively shamed women into breastfeeding. It’s inevitable that such cruel, cynical efforts would harm women’s mental health.

We estimate that far more than half of the new mothers who seek our assistance struggle with breastfeeding emotionally, physically, or both. Some want to breastfeed but are not able; others do not want to breastfeed but feel enormous pressure to do so. Some wean earlier than planned; others breastfeed, pump, and/or bottle feed around the clock for many months. The vast majority indicate that their breastfeeding experience and their mental health are inextricably intertwined.

The authors demonstrate how the message that “breast is best” is harmful for many women.

1. Sense of failure

Lactation failure includes (a) failure of the breasts to produce adequate milk, (b) failure to thrive in the infant, and (c) failure of the mother to achieve her preset goal for duration of lactation. This sense of failure can be compounded if a new mother finds that breastfeeding, which she believed would be easy, natural, and enjoyable, instead is difficult, painful, or unpleasant.

The sense of failure is exacerbated by lactation professionals’ unwillingness to counsel women about the difficulties and risks of breastfeeding as well as the benefits.

2. Fear of medication

Too many parents and providers believe that women suffering PMADS face an either/or decision: either treat their PMADs with psychotropic medication or continue breastfeeding. Fortunately, this is not true for most postpartum mental health conditions. Although there is no completely risk-free approach, there are many medications to treat anxiety and depression that are widely considered safe for lactating women and their infants. Professionals who work with lactating women should understand the risks of not treating PMADs as well as the risk of the specific medication being considered and should be able to discuss the risks and benefits with their patients so that no woman feels that she must choose between breastfeeding her infant and her own mental health.

In a curious omission, the authors fail to address the issue of women with pre-existing mental health disorders for which they already take medication and took medication before pregnancy. Many of these women are at heightened risk for the development of PMADs unless they continue their medication. They, too, must be counseled about appropriate medication choices and should never be encouraged to avoid medication in order to breastfeed.

3. Sleep deprivation

Sleep interruption prevents deep restorative REM sleep, which can exacerbate symptoms of anxiety or depression. Severe sleep deprivation and poor sleep quality are widely considered risk factors for PMADs. As a result, reproductive psychiatrists often encourage their patients to try to obtain 5 to 6 hr of uninterrupted sleep before progressing to treatment with medication.

In other words, sleep is preventive treatment for PMADs, yet lactation professionals counsel women to adopt practices that further exacerbate sleep deprivation. These include allowing newborns to nurse for comfort, discouraging pacifiers and the utterly barbaric practice of recommending that women who have low supply should nurse, pump and feed expressed breastmilk. Such practices drive up the physical and psychic costs of breastfeeding substantially.

4. Shame

For mothers suffering PMADs or breastfeeding challenges, the postpartum period in general and breastfeeding in particular can be very challenging. Acknowledging these struggles is often accompanied by shame and stigma, which can lead a new mother to deny and/or hide her symptoms from the friends, family, and providers who could help. Sleep deprivation, anxiety, and depression distort thinking; in this context, a new mother may equate her lack of enjoyment of motherhood or breastfeeding with the belief that she is a “bad” mother. Perinatal professionals who honestly and nonjudgmentally assist women in making decisions concerning breastfeeding and PMADs can greatly help to reduce shame and stigma.

Sadly, this is a feature of contemporary lactivism, not a bug. For the past 20+ years lactation professionals have aggressively attempted to shame women into breastfeeding by exaggerating its benefits and refusing to acknowledge its risks. It was inevitable that such cruel and cynical efforts would harm women’s mental health.

The real problem is that contemporary lactivist philosophy considers mothers’ needs irrelevant. It’s hardly surprising that the same people who ignore women’s pain, ignore their frustration, ignore their perceptions of inadequate breastmilk, ignore their right control their own bodies and ignore their need to care for other children and/or to work have no trouble ignoring the impact of breastfeeding on women’s mental health.

The authors offer several suggestions to minimize the harmful effects of breastfeeding promotion on women’s mental health. The most important is the acknowledgement that there’s nothing wrong with formula.

The current recommendation from virtually all parties concerned with maternal-child health, from the WHO to the American Academy of Pediatrics, is that infants should be provided only human milk for the first 6 months of life. Although this recommendation for exclusive breastfeeding is derived from solid research and is widely considered most beneficial for the infant, it does not necessarily take into account the well-being and mental health of the mother. Unfortunately, we have seen that adhering to this recommendation has sometimes exacerbated the depression or anxiety of mothers with whom we have worked. If we bear in mind that recommendations are guidelines, not rules, we can better support mothers as they incorporate these recommendations into their own, unique situations.

They conclude:

[W]e have worked with hundreds of women for whom breastfeeding was not working, was not possible, or simply was not desired. We have held them and counseled them as they not only grieved but also judged themselves failures as mothers. These women have taught us that it may be time for a new motto: “Breast is best . . . except when it’s not.”

I would go farther. In truth, breast is NOT best. It is only slightly better at the population level but that tells us NOTHING about whether it is good for an individual mother-baby dyad. It’s time to stop pretending otherwise.

  • I’m not a mum yet. We’re not going to be TTC until about this time next year if things go to plan, but my psych meds are a major part of why I have no intent to breastfeed, except maybe the first week or so if possible. I gotta get back on that stuff or I’ma be a neurotic mess. No baby needs that.

  • Mel

    In my area of West Michigan, PCPs (at least) have become a lot more relaxed about prescribing SSRIs during pregnancy and lactation. In 2013 or so, I discussed my plans to try and get pregnant while I was on Effexor. I was on a low-dose of Effexor ER and it controlled both my anxiety and depression quite well. My PCP wanted to try a different SSRI with a longer history of safety data so I weaned off Effexor and switched to Prozac.

    I’ve known plenty of people who did well on Prozac – but Prozac and I apparently do not get along. I became extremely agitated and rather paranoid (although I didn’t think I was paranoid, of course). Thankfully, my husband helped me that I was much more unhappy on Prozac than I had been before the Prozac and that I should talk to my doctor about switching back to the Effexor. I did.

    For a variety of reason we postponed having Spawn for a few years. When I brought up our breeding plans in 2016, my PCP was like, “Yeah, just stay on Effexor. The only side-effect is that the baby might be a bit sleepy and less responsive at birth than the average baby – but you deserve a break after delivering a baby anyways.” I did – and I suspect the fact that I was already on Effexor and seeing a therapist greatly mitigated the emotional fall-out of Spawn’s second trimester forced eviction.

  • demodocus

    Sadly, in myPPD group, there’s regularly someone worrying about taking their psych meds while pregnant and breastfeeding. Even Zoloft. Seems to me that a lot of PCPs and psychiatrists are leary of prescribing much of anything to pregnant women and transmen.

  • Cristina

    I had no desire, whatsoever, to breastfeed. In fact, the thought made my skin crawl. Nearly every single person I encountered assumed I would and when I said I wouldn’t, suggested I try it anyway because I might like it. Um, no thanks. Formula was definitely the best decision for me.

    • Griffin

      For me too, with all 3 of my kids. The thought of breastfeeding revolted me and in any case, there were so many pluses it seemed crazy not to formula feed. In particular, my husband could do all the night feeds. He doesn’t need as much sleep as I do and he loved doing it, and since I am not a nice person when sleep-deprived, it worked out perfectly for all of us.

      • Cristina

        My youngest was in the NICU and then pediatrics for 2 weeks after he was born. The nurses took over his night feeds because I was such a sleep-deprived bitch. I was a lot more pleasant after that. With my oldest, my husband did the midnight and 3 am feeds because he was up gaming until then anyway.

    • rational thinker

      Me too, the thought of me breastfeeding also made my skin crawl. I have been reading a lot of posts on different sites about this and I see a lot of women saying “It is perfectly ok to formula feed and you shouldnt be made to feel guilty about it” then they will say in the same sentence “but, you should at least try it as long as you tried its ok not to” To me that is just as bad as the others they claim not to be like, I find that kind of thinking equally as awful.

      • Cristina

        Yeah, no thanks, lol. I’m not putting myself through something I really don’t want to do, just to prove myself “worthy” of using formula. I just stayed off all baby websites to avoid that kind of talk.

  • The Bofa on the Sofa

    So they have basically discovered Bofa’s 2nd Law

  • Breast CAN be best, under a specific set of circumstances.

    You could say precisely the same thing for formula.

    New parents should be given the facts they need to make the best decision for their family. (I say “new parents,” because fathers should know this stuff, too.)