Breast is best … except when it’s not!


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.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivists have aggressively shamed women into breastfeeding. It’s inevitable that such cruel, cynical efforts would harm women’s mental health.[/pullquote]

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.