Whose “fault” is it when a woman doesn’t breastfeed?

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Lactation professionals don’t think much of women and their ability to make decisions; they are sure that women who choose to formula feed are ignorant dupes.

In Reproductive Health and Maternal Sacrifice, sociologist Pam Lowe offers an excellent description of lactivism in general and the Baby Friendly Hospital Initiative in particular.

And:

The underlying assumption behind BFI, and many other breastfeeding campaigns, is that women who decline breastfeeding only do so through ignorance or as the dupes of formula marketing campaigns. Palmer is typical of this position. She suggests that infant feeding companies as well as ill-informed experts have contributed to a loss of faith in breastfeeding… “[W]hilst women should have a choice, they should all be informed that formula milk is signicantly detrimental to their baby’s health.” This is hardly a neutral position and is not necessarily based on the evidence…

But is that really why some women don’t breastfeed?

Lactation professionals resolutely ignore factors beyond women’s control, preferring to blame mothers or society.

The answer makes a big difference in assessing the ethics of breastfeeding promotion so it’s worth giving serious thought to the way we attribute causes to behavior, known in psychology (not suprisingly) as attribution theory.

Consider Weiner’s attribution theory of controllability. It sounds complicated, but it’s not hard to understand:

Weiner’s achievement attribution has three categories:

stable theory (stable and unstable)
locus of control (internal and external)
controllability (controllable or uncontrollable)

Stability influences individuals’ expectancy about their future; control is related with individuals’ persistence on mission; causality influences emotional responses to the outcome of task.

The theory is often represented graphically like this:

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Each factor is vital to the outcome, whether that outcome is a grade on a test or a winner of a race. The key to success for a paticular individual will depend on the mix of controllable vs. uncontrollable factors, but only the controllable factors can be improved by effort or undermined by lack of support.

So, for example, a student’s grade on a particular test can be attributed to intellectual ability, effort at studying, difficulty of the test and luck (not feeling ill on the day of the test, for example).

If a student gets a bad grade on a test and wants to do better next time, he can study harder and get tutoring support, but he cannot change his innate intellectual ability and he cannot control external factors like illness that can impact his performance.

It is perfectly reasonable for a teacher to chide this student for not trying hard enough, or to blame herself for not making the lesson clear enough, but she should not berate the student for inherent lack of intelligence or other factors over which he has no control.

What does this have to do with breastfeeding?

I’ve modified the chart to encompass the factors involved in successful breastfeeding:

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A mother who breastfeeds successfully will have adequate milk supply, and extend the effort (and endure the sleeplessness and possible discomfort) to teach the baby how to breastfeed and ensure that he or she is getting enough. She will also have the support she needs and not be swayed by the marketing efforts of formula companies. Finally, she will have a baby that is able to breastfeed and she herself will be healthy enough to breastfeed (no serious childbirth complications, etc).

Each of these factors is essential to ensuring successful breastfeeding and that has important implications for how we attribute “fault” when a woman cannot breastfeed or chooses not to do so.

In my view, the critical (and dangerous) problem with contemporary lactivist efforts, especially the Baby Friendly Hospital Initiative, is that they fail to take into account ALL factors and ascribe outsize influence to only two.

Consider the ability to produce adequate milk supply, the sine qua non of successful breastfeeding. There is a biological limit to what many women can produce. Some women will have inadequate supply in the first few days; some women will always have inadequate supply; some women will develop inadequate supply as the baby’s growth outstrips their ability to produce more milk.

How do lactation professionals deal with this critical factor?

They lie about it to each other and to their patients. Although it is a biological FACT that up to 15% of first time mothers will be UNABLE to produce enough breastmilk, particularly in the early days after birth, lactation professionals insist that insufficient breastmilk is vanishingly rare.

This is the central difference between “Breast Is Best” advocates and “Fed Is Best” advocates. Because they lie to themselves and each other about the non-modifiable factors that are necessary for successful breastfeeding, lactation professionals are left only with blaming mothers and the wider society.

We would consider it both ignorant and insensitive for a teacher to demand that an intellectually challenged student perform as well on a test as a student with an extraordinarily high IQ. We would consider it cruel in the extreme for the teacher to berate the intellectually challenged student by declaring that if he just studied harder, he could have done as well as the genius.

Lactation professionals (most of whom fall squarely in the “Breast Is Best” camp) sadly behave as ignorantly and insensitively as the worst teacher. Because they lie about the true incidence of insufficient breastmilk, they demand that women with insufficient supply provide the same amount of milk as women who have adequate supply. They cruelly insist that those with inadequate supply would have more if they just tried harder or if they were cognizant of the many (mostly debunked) benefits of breastfeeding or if they weren’t gullible dupes of formula companies.

They also ignore the role of other factors beyond women’s control like a baby who is a poor nurser, excruciating nipple pain, or other medical problems that can impact supply. Rather bizarrely, they imagine that all women and all babies face the exact same challenges, all of which they insist could be overcome.

Furthermore, it is almost impossible to overestimate the impact that lactation professionals attribute to maternal effort and social factors. They are obsessed beyond reason with the idea that women who don’t breastfeeding successfully or choose not to breastfeed at all are either personally lazy, lacking in crucial support or under the influence of formula companies.

Whose “fault” is it when a woman doesn’t breastfeed?

According to attribution theory, it can be no one’s fault. It can be the result of factors beyond a woman’s control including simple luck. But in the echo chamber that is lactivism, it MUST be someone’s fault, either the lazy mother or the lack of societal support or the marketing of formula.

As a result, lactation professionals spend most of their efforts on nonsense: “educating” women about breastfeeding, banning formula marketing, and (most importantly for them) promoting greater employment for more lactation professionals to offer more “support.” To my knowledge, not a single one is engaged in investigating the uncontrollable biological factors that have such a critical impact.

When you fail to correctly attribute the cause of a particular behavior, you can’t modify it and you can’t offer real support; you can only produce guilt, shame and self-hatred among new mothers.

In that, lactation professionals have no peer.

  • Ardent

    I read ethnographic accounts of 19th-early 20th century tribal cultures because I have a hobby collecting women’s costume from specific tribes and ethnic groups. These books usually have a female costume section with a few plates or drawings which is why I buy them, but they also typically have a family life section. These family life sections are littered with accounts of women unable to breastfeed because of low supply, and the resulting sickly or dead babies from being raised on animal milk or sketchy formulas. It is absurd to think that insufficient supply is a modern invention.

  • JayBeHere

    I had three kids and honestly tried to breastfeed. With my second, I tried everything. The poor child was hungry. We started bottle feeding and all was well. But I still had this nagging feeling that I was a failure—especially after reading that not making enough milk only happened with “extremely rare” hormonal conditions. Now I’m past the childbearing years and I’ve found out that I AM one of those “rare” people whose hormones are out of whack and that making copious amounts of breast milk was not in the cards for me. What the “breastapo” don’t seem to understand is that there are a lot of reasons some women don’t breastfeed. Maybe they have a hormonal imbalance. Maybe they are required to take a medication that can pass through the breast milk. Maybe they adopted. Maybe they just don’t want to. Maybe it’s none of your business. People really need to back off.

  • kilda

    my mom likes to tell the story of how I ended up being formula fed. She was breastfeeding me and I was a very fussy baby. One day she had to go out and left me with my dad for several hours and he gave me a bottle. I drank it all and then went blissfully to sleep. When she got home, he said “this kid’s hungry!” They started formula feeding me and no more fussy baby. No guilting, no drama. If only it could be that simple for moms and babies nowadays.

    • S L

      If only. I see it in the fb mom groups all the time – exhausted new mother is desperate to get baby to settle for an hour or two, says she’s worried baby isn’t getting enough milk from her, and everyone piles on with “your supply is fine” “it’s just cluster feeding, totally normal” “don’t top up you’ll ruin your supply” “breastmilk is all baby needs”. God help anyone who comments that baby may be hungry, perhaps give formula after a breast feed to see if baby wants more milk. The responses to that are vicious. And with not a shred of science to back up the hateful bile they spew. Shhh, mustn’t let new mothers know that topping up can actually help them establish their supply, and keep baby happy while they learn to latch. I don’t need the hassle from the deluded mob so I’ve stopped commenting on those posts and instead I inbox them some encouraging words and links to Dr Amy’s writing.

  • rational thinker

    I think I got lucky when I had my kids 18 years ago. There was not as much pressure or contempt of formula feeding as there is now. My first baby was born in a BFHI hospital, and they were either trying to get or had just gotten the BFHI certification. So they weren’t that bad yet but then again I was 17 and very naïve about the BFHI thing in fact I had never even heard of it.
    My second 2 years later was born in a different hospital that was not BFHI. I remember being amazed when they said they had to take the baby to the nursery for the night. Also I wanted to take a shower cause I was not torn apart this time around. Again I was amazed when they said “sure, no problem we can take the baby if you want to shower or take a nap”. In the BFHI hospital they would not take the baby at all for any reason and if you wanted to take a shower you had to have a friend or relative come and watch the baby. They even came in my room every 5 min when they knew I was holding the baby in my bed just to make sure I did not fall asleep. In my opinion the NON BFHI hospital was much better. They only asked me once how I was going to be feeding baby and I said formula and that was it end of discussion.
    The BFHI hospital did attempt to get me to try it but I said no then at discharge they had me sign the paper and told me how unhealthy formula was but I did say to them kind of jokingly that “formula is probably a lot better than the crap coming out of my body” cause when I am not pregnant I don’t eat very well and I smoke a pack a day. The main reason I wanted to formula feed was cause it was important to me to know how much he was eating and when the pediatrician came to see my new son he seemed overjoyed to find out I was formula feeding and he was already eating well. It was a long time until I realized why the doctor was so happy about me formula feeding. My son had jaundice when he was born and by the time he was discharged he was quite yellow the nurses told me to just put him by the window to get some sun. A lot of people would say that doctor had something against breastfeeding but I think he was not worried too much about the jaundice because I was formula feeding so he knew he would be ok and in a couple days the jaundice did go away.
    When the nurses asked me I mostly told them “I just want my body back” which was true but another reason I chose not to was cause I wanted to know how much he was eating. The other reason was because of the gang rape and I had size 38 D chest with a petite figure in high school so when just walking down the halls random boys would walk by and just grab my breasts for a second and then run off quickly and this happened about 3 – 8 times a day and no the school did nothing about all these mini Donald Trumps. It has affected me enough that I always have sports bra on even overnight and I hate even having them uncovered even during a shower or during sex. So the thought of me personally breastfeeding makes me nauseous.
    If I ever have another baby I will formula feed again because it is my choice and that should be good enough without having to provide a reason.

    • seenthelight

      Yes. You should refuse to provide any reasons if you have another occasion to do so. It is none of their business why, and describing the sources of your pain to parties only interested in using you to up their breastfeeding-at-discharge rates… The things they may say to try to change your mind would be awful and probably triggering for you.

  • StephanieJR

    I always wonder, what about those women, whom can physically breastfeed successfully, but, for whatever reason – and I do mean whatever, as simple convenience is itself a valid reason – don’t, and choose to formula feed, a perfectly acceptable choice. What do lactivists do about them? Neither questionable ‘education’ nor shaming will work, so what tactics will they employ?

    • fiftyfifty1

      What do lactivists do about women who chose not to breastfeed? A lot of different things:
      1. Sometimes they harass them even months later when they are buying formula in the grocery store or feeding their babies bottles at the park.
      2. They criticize their other choices and link these to their feeding decision “so career driven she couldn’t be bothered to breastfeed her own baby, and she pays strangers to raise him (i.e.daycare.)”
      3. They link lack of breastfeeding to low-status populations (African American mothers, teen mothers)
      4. They keep repeating the same debunked health scare info, figuring that they can guilt mothers after the fact if their kid does happen to get sick.
      5. They keep up the pressure in the hospitals. Maybe she’ll breastfeed the next baby!

    • BeatriceC

      MrC and I were joking a few nights ago about having another baby (not a chance). I said I almost wanted to just to formula feed from birth, but then we decided revenge feeding a baby was a terrible reason to bring another human in the world.

      • seenthelight

        Same here! I don’t want any more, but reading this stuff makes me think it’d be so satisfying to have another just to refuse breastfeeding. But then I’d be making a baby a prop just like they do.

      • Kelly

        You can revenge feed my baby.

        • BeatriceC

          Ohhhhh! Can I? I’ll be right over. But just for a little bit. My teenagers, as much as they pretend otherwise, prefer things when I’m actually in town.

    • Cristina

      They piss them off. I chose not to. I told off a nurse in the hospital while being induced. I had a different nurse basically throw formula prep instructions my way before storming off. The best way to get me to not do something is to tell me I have to do it, lol. I’m Canadian, so I have paid maternity leave and I was transitioning to a new job where I would work from home, so work wasn’t an incentive to never start. Honestly, I don’t understand why people get so worked up over it.

    • demodocus

      Fortunately, I just got a disgusted look or two

    • Sarah

      They get very irritated with us, especially if we’re familiar with PROBIT. Then we laugh.

  • fiftyfifty1

    So true. They always blame breastfeeding failure on a mother’s laziness or on a mother being “duped” by society or both . Which would be bad enough if breastfeeding were actually something important, but it’s not. Formula is a perfectly healthy substitute, no matter what the reason. This reminds me of dysgraphia. Some people get really caught up on calling the child “sloppy and lazy”, others insist that the problem is that society no longer provides “support for cursive.” I say, who gives a crap, we have keyboarding, a perfectly fine substitute.

    • guest

      “They always blame breastfeeding failure on a mother’s laziness or on a mother being “duped” by society or both.”

      OK, rant incoming:

      I desperately wanted to breastfeed. It was one of the few ways I felt I could bond with my baby while I was recovering from a car accident, and then a labor that almost killed both of us, and too injured/hurt to even walk or stand without assistance, for months. That quiet time I spent holding her and feeding her every day was really precious to me.

      But then my daughter almost starved. She was constantly fussy, and never stopped “cluster-feeding” – which the nurses and LCs told me was perfectly normal. Then she started dropping weight and having serious health problems. Turns out that I have mammary hypoplasia and almost no milk glands, producing, oh, maybe four ounces of milk in day? Yes, I was tested and this diagnosis was verified. And no, the pregnancy and nursing doesn’t magical grow you more/enough milk glands, in spite of what many LCs will tell you. The ones you get in adolescence are the ones you have for life.

      Even after I began supplementing, I still wanted to continue breastfeeding. It wouldn’t be her primary source of food, but I figured my daughter could still get some benefits from breastmilk ( I was believing what I was told at the time, that breastmilk had all these great benefits). But were LCs willing to help me combo feed? Hell no. They dropped me like a lead brick. I had so many questions about combo feeding – should I pump the milk and add it to bottles? Should I let my daughter continue to nurse? How do I maintain what little milk supply I have? Do I try breastfeeding her before, or after a bottle feed? How many times a day? And what’s the best way to transition the baby to bottles, anyway? Nobody ever taught me about bottle feeding!

      But nobody wanted to talk about it or answer my questions. The second they found out I was supplementing with formula (to save my child’s life and health) they gave some cold statement about how I must not really want to breastfeed, or how I had taken the easy/lazy way out, or how I didn’t need their help because “any idiot can read the back of a formula can”. Then they walked away.

      There I was, partially paralyzed, looking like death warmed over, begging for help with breastfeeding, with a stack of medical paperwork in front of me detailing the obstacles I was facing to breastfeeding, and my daughter’s hospitalization, and every LC I saw chocked my problems up to me being too shallow and lazy to try. Because even with a mountain of evidence in front of them, staring them in the face, they didn’t believe that low milk supply was real.

      I guess if I had really wanted to breastfeed enough, the magical lactation fairy would have flown in from La Leche League and gifted me new boobs. /s

      Oh well. I wanted a healthy, satiated child more, I guess.

      • guest

        Oh, and here’s my favorite bullsh*t line from the mountain of bullsh*t lines I heard from “lactation consultants” in out BFHI hospital –

        “Formula is not just inferior to breastmilk, it is actually dangerous. If mixed in the wrong proportions it could cause death! Too little and the baby won’t get enough calories or electrolytes, too much and the baby could die from an impaction. It is just not safe.”

        And then days later, from the same people “We don’t train on bottle-feeding. Any idiot can read the instructions on the back of a formula can”

        Hmmm. Shows how much they think of the new moms they work with.

        • Sarah

          Yeah, pick one and go with it.

          Although there is a need for better formula education, I think. I have seen people use bottles that have been left out for a long time, for example. For the small demonstrable advantages that breastfeeding does have over formula on a population level, I always wonder how much of that could be tackled by better formula feeding. Naturally, we’re not allowed any solutions that don’t involve breasts though.