An academic critique of contemporary breastfeeding promotion

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A new paper succinctly lays out the academic critique of contemporary breastfeeding promotion, and basically recapitulates most of the arguments I have been making for years.

The paper is Discourses and critiques of breastfeeding and their implications for midwives and health professionals by midwives Smyth and Hyde.

Current policies must change to reflect the truth — not the wishful thinking — about breastfeeding.

While the slogan ‘breast is best’ has historically been a truism in health promotion discourses internationally, in recent decades, criticisms have emerged that challenge the campaign for breastfeeding. In this article, we consider a number of strands in the debate, starting with discourses of breastmilk and breastfeeding used to promote breastfeeding and then move on to explore charges that the em- pirical support for breastfeeding is not as strong as breastfeeding advocates often suggest.

1. The benefits of breastfeeding have been overstated.

While official organisations collectively promote breastfeeding on the grounds of scientific evidence, the science behind the consensus of breastfeeding has been challenged. Wolf asserted that many research studies linking breastfeeding to improved health are weakly significant and often fail to control confounding variables that could affect the outcomes…

Indeed, the benefits predicted by breastfeeding researchers — that increased breastfeeding rates would lead to decreased infant mortality, severe morbidity and healthcare expenditures — have failed to materialize.

2. Bias in promoting breastfeeding

Parallel to the increase in research on the health outcomes of breastfeeding in biomedical literature, including less than strong evidence of its superiority, social science literature (predominantly) has criticised the pro-breastfeeding discourse as problematic and biased. A growing concern is that educational and promotional breastfeeding literature has become one-sided and more a tool for persuasion than education and replete with hyperbole (Wolf, 2011). Knaak raises the question ‘Are we educating or advertising?’ Foss noted how the media have been criticised for perpetuating the ‘myth’ of breastfeeding as a choice. Indeed, breastmilk has been so highly regarded in media discourse that it has been suggested that the result is an implied assumption that ‘breastfeeding is the only ethically acceptable option in infant feeding’.

3. Ignoring the harmful impact on many women

For the woman who experiences great difficulties in breastfeeding and for whom breastfeeding is a less than joyous experience, feelings of guilt and failure may provoke a crisis in her sense of self. Williamson [et al.] noted that women were often surprised by the difficulties faced when breastfeeding and experience anxiety, upset and damage to their self-worth when breastfeeding fails. Foss … [noted] that [“breast is best”] is ‘dripping with insinuation on a mother’s inferiority and attributions of blame for not breastfeeding’. In Símonardóttir and Gíslason’s study, women experienced difficulties and pain (often severe) when breastfeeding with negative consequences for their emotional well-being. The pressure to breastfeed was linked to postnatal depression by several women in the study and one described her experience of feeling constantly guilty and ‘like a terrible failure’ for ‘not being able to perform this simple task’.

4. Ignoring the impact on women’s economic and professional status

Law argues that breastfeeding serves to consolidate the maternal role in the home, exacerbates the gendered division of labour and negatively impacts on women’s participation in the workforce. This limits women’s choices and impedes their progress in paid employment, sustaining their economic dependency on men. Law (correctly) asserts that promotional material about breastfeeding fails to mention the negative outcomes of breastfeeding, including its impact on women’s economic position in society in the long run. While breastfeeding may be free at the point of delivery … the cost to women’s lifetime earnings because of their lost years in the workforce does not get toted up, and thus, they trail behind men in terms of power and privilege.

So the benefits of breastfeeding have been exaggerated, breastfeeding promotion is biased, and the harmful impact of breastfeeding on women’s mental health and economic status has been entirely ignored.

How are midwives supposed to counsel women when the Baby Friendly Hospital Initiative makes claims aren’t supported by the scientific evidence?

The fact that midwives and other health professionals may work in hospitals that are signatories to the Baby Friendly Hospital Initiative potentially places them in a difficult position, where their own critical assessment of the practice of breastfeeding may be silenced by the need to convey an official pro-breastfeeding position.

Current policies must change to reflect the truth — not the wishful thinking — about breastfeeding. It’s the mother’s baby, the mother’s body, and it ought to be the mother’s choice how to feed her infant, free from manipulation by healthcare professionals.

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  • Amazed

    I’m coming from Dr Amy’s Facebook page. Someone please tell me that this Heather chick of the mama trust who donates her unscreened milk and unchecked stupidity isn’t real. Please guys. She’s kidding. Right? RIGHT?

    • rational thinker

      I just read her posts….WTF is she that stupid. I would say she thinks being young and white and privileged along with wishful thinking and “mama trust” will protect her from anything bad. Seriously what a dip shit. I loved the last one where she says she is currently having the life sucked out of her (as a pun about breastfeeding) then posts a brelfie pic where you can see more boob than baby. She looks like shes 19 or very early 20’s so maybe she is just ignorant due to lack of life experience or has no other talent or skills other than producing breast milk. Maybe she just misses the lunch table in high school and has joined a new group of mean girls. Girls that blindly trust like that do get cheated on or fucked over but no that wont happen to her! Life and reality are gonna slap that girl right in the face one day and its not gonna be pretty.

      I dont have a facebook (and dont really want one) so I cant post a response to her myself but if anyone wants to cut and paste this and post it to her under your own facebook name/account you have my full encouragement to do so.

      • Amazed

        She claims to be in her 30s and working in the field of early child studies. It gave me the creeps.

        • rational thinker

          Yeah I dont believe any of it for a second. The whole face has a different appearance to it past 30, you kind of get a thicker look and she doesn’t have it. She is most likely under 25. As for the early child development degree im gonna call bullshit on that too. Remember jenny hitch who we fought with in the comments months ago, and how she awarded herself a PHD in motherhood and some other bogus crap. I think she is doing the exact same thing so ask for another picture one of her holding said “degree”.

          Early childhood development — Translation = Works in a day care for minimum wage or just had a baby so I know everything about children.

          • Amazed

            I thought the same. I can’t grasp what striving for breastmilk does to people and how. I know two women – both intelligent, well-off and whatnot – who casually mentioned that one of them used to pump for the baby of the other years ago. Dear God. At the time, the woman donoring the milk was a single mother, her partner having left her in late pregnancy after an AFFAIR WITH ANOTHER WOMAN! No need to say, it was all about mama trust. They had been friends for years, so the thought that perhaps there MIGHT be, just possibly, a problem with giving your child milk from an untested donor with a partner who had undoubtedly cheated never crossed the recipient mother’s mind.

          • rational thinker

            I dont know how its possible to be that naive and stupid. They think good thoughts and wishful thinking will protect them from anything. Hell HIV takes six months to even show up on a test.

          • Amazed

            It boggles my mind as well. I was stunned that for the mother, the most important thing was for the donating mother to pump. Heaven forbid that another woman might nurse her own precious child. No, this untested milk should only come through the pump. THAT was the important thing.

  • rational thinker
  • NewMom

    Hello, I haven’t been here for quite a while. I am 15wks pregnant and my husband might be offered a job in Germany(Berlin). I’ve had 2 previous c-sections. my 1st c-section was an emergency because baby’s heart rate was dropping but it was already scheduled for a c-section for sexual abuse/trigger issues. I feel like I need to have another c-section. I’ve tried searching how this is dealt with in Germany, but I’m finding lots of conflicting information. Does anyone have insight on birth in Germany? Thank you.

    • rational thinker

      I dont know about germany but if you have already had 2 c-sections any OB should consider your case an automatic c-section.

      • NewMom

        Okay, thank you.

    • AnnaPDE

      Yes you can have a scheduled CS. There is a bit of a “but don’t you want to do natural” faffing around especially with first time mums, but many doctors go out of their way to find a “medical” reason to make sure that you get a CS if you simply want one. And previous CS definitely counts as a reason anyway.

    • Griffin

      Yes, for sure you will be able to get a third c-section because VBAC comes with its own risks.

      Twenty years ago, I wanted an elective CS because it was safer for the baby and I wanted to preserve my pelvic floor. Because the country I was living in at the time (The Netherlands) wouldn’t allow elective CSs (the Ob-Gyns wouldn’t even talk to me about it), I went across the border into Germany (Frankfurt) to get one (my husband is German). At the time, we did have to be a bit hush hush about it but my links with Germany suggest that they’ve definitely loosened up on this since then. And anyway, as I said, NO ONE will force you into a VBAC once you already have a CS scar, largely because of the deadly risk of the scar rupturing during labor.

  • Heidi

    Not directly related, but a person on my Facebook page got to meet Dr. McKenna. She said his material was evidence-based and scientifically accurate. I have a hard time believing that, but I would never buy anything he wrote anyway. I got my feel for him when I clicked on a link at University of Tennessee Medical Center and promptly emailed them about my concerns that they promote bed sharing when breast feeding just isn’t that important. It would be one thing if he simply told parents how to do a dangerous thing more safely. Sometimes we have to compromise. I’ve been there. But from what I’ve read from him, he seems to think it’s optimal to bedshare, not a last resort. The truth is you don’t even have to roll over an infant to suffocate an infant. Just being too hot or getting too much carbon dioxide can overwhelm an infant.

    But this seems to be a trend. Same person posts attachment parenting propaganda too. Another FB friend does too. It’s infuriating to me..I think this has to be an anti-feminist agenda that attracts otherwise progressive women. I can’t imagine the misery if I thought ignoring the occasional cry was tantamount to abuse and neglect.

    • EmbraceYourInnerCrone

      I always wonder how these Attachment parents think children survived previously? My grandmother married at 16 and had given birth 4 times by the time she was 20. She lost her 3rd kid to stillbirth(Rh factor). As a 20 year old with 3 kids under 4 in rural Vermont, in the early 1930’s she had no time to drop everything anytime one of them cried. And yet all 7 of her surviving children grew up to be productive, mostly decent humans.

      • Sarah

        Some of them don’t think and some of them don’t care.

      • Heidi

        “I am so much smarter, informed and woke than them.” It’s funny they think attachment parenting is natural. Why would it be? It’s a new luxury to be able to have only one or two children, spaced apart by a few years so that you can hyperfocus on a child. And even if “breast sleeping” is natural, I don’t think babies have evolved to do it on a Beautyrest. And of course dead babies are super natural unfortunately.

    • rational thinker

      I have read a lot about McKenna he takes credit for the phrase “breast sleeping”. In my opinion he is a dangerous asshole who in no way follows evidence based science. I often wonder how many deaths/near misses his bullshit is responsible for.

      “The truth is you don’t even have to roll over an infant to suffocate an
      infant. Just being too hot or getting too much carbon dioxide can
      overwhelm an infant.” – Very true I knew a woman who was laying on her bed midday and had her one month old baby was laying on moms chest. She dozed off unexpectedly and when she woke up baby was not breathing. It was accidental and baby usually slept alone in crib.

  • HailieJade

    Not to sound like a Debbie Downer here, but I have a serious question: Are these academic studies actually making any difference out in the “real world”? While it’s great that the issue is being studied, how long does it generally take for academic studies to have any real impact on actual hospital policies, for example? I feel like this blog posts study after study showing that breastfeeding is at best irrelevant to a baby’s health and at worst actively harmful, and yet I don’t hear about anything actually being done to stop the harm being caused to mothers and babies by overly aggressive breastfeeding promotion. A friend of mine who happily and proudly formula fed her two older kids has recently begun spouting #breastfeedingwarriormama nonsense on social media, and talking about how finally being able to EBF makes her feel like a “real mother” (gag) Fed Is Best is a good start, but I feel like an internet hashtag can only do so much without being backed up by the medical community. I’d really like to hope it won’t take another 30-odd years (roughly the time it took for breastfeeding to become the norm in western society) for the pendulum to swing back…

    • EmbraceYourInnerCrone

      I really hate this crap: EBF makes her feel like a “real mother”
      It paints anyone who is not a birth mother as “not a Real parent” it erases adoptive parents, foster parents, fathers and non-traditional families. My mom and my grandma were foster parents and my mom was an adoptive parent. Conversely I know people who have birthed and breastfed children, but who are terrible parents.

      • The Bofa on the Sofa

        I really hate this crap: EBF makes her feel like a “real mother”

        I’ve pointed this out before, it’s like the “I don’t want to have my body fail and have a c-section.”

        Who is the one who considers a c-section to be a failure? Or if you don’t breastfeed you are not a “real mother”? Not the OBs and pediatricians I’ve met.

        • Christine O’Hare

          Exactly. My C-section wasn’t because my “body failed.” My C-section was because the x-large peg (baby’s head) was never going to fit through the small hole (my pelvis). My C-section is a success of modern medicine, in times past myself and/or my baby would have ended up dead or severely injured/disabled because of the situation. Instead we both got to walk away alive and healthy – that’s success in my book.

          • The Bofa on the Sofa

            A c-section is a “variation of normal” right?

            Hell, it’s not even a variation. For an ob, a c-section is a perfectly normal outcome.

          • StephanieJR

            There’s no wrong way to have a body.

          • HailieJade

            C-sections are up there with germ theory and vaccinations as one of the greatest medical inventions in human history. God knows how many lives have been saved as a result!

      • HailieJade

        I hate it too. What’s extra frustrating is that this woman used to be quite outspoken about her struggle to breastfeed her older kids and how formula feeding is not something to be ashamed of; Now, it’s like she’s just done a complete 180. I have no idea who got inside her head but it made me angry that the cult of breastfeeding still apparently has so much power over women’s sense of self-worth.

        • rational thinker

          Sometimes women come and comment here that they formula fed but breast is so much better. These are people that are desperate for approval. They may have formula fed themselves but usually it is because they had to not due to personal choice.Actually they dont even acknowledge that there is a choice. Most will say formula feeding is fine but only if you tried to breastfeed first. Basically they are looking for a “good girl you tried” back pat from other lactivist sanctimommies. Now that she can breastfeed the newest child she is probably going to get worse with her comments or become a bully to other moms.

          • HailieJade

            You make a good point. Now that I come to think of it, she has always been a bit of an attention seeker on social media. She used to post a bunch of “fat acceptance” and “body positivity” stuff as well, but when you read between the lines it was very obvious she was actually quite insecure about her weight and simply using those hashtags to put on a brave face and act like she doesn’t care. It’s all very sad and I genuinely hope she eventually finds peace and genuine self acceptance. Unfortunately, the online lactivist cult is not where she’s going to find it!

          • mabelcruet

            I’m all for body positivity and confidence, being a chubster myself, but it annoys me when someone says something like ‘Real women have curves’, implying that anyone flat chested or slender isn’t a real woman. It’s possible to build yourself up without putting others down.

          • StephanieJR

            Imaginary women, as opposed to real women, are actually all two dimensional rectangles. Maybe a rhombus.

          • HailieJade

            Yeah exactly. I’ve struggled with my weight my whole adult life too, so I do get it, but I’ve honestly never seen the appeal of those so-called “body confidence” movements, which seem to be all about tearing other women down in order to build yourself up. I have several very close friends who are tall and skinny and they’re every bit as much “real women” as I am!

          • Cristina B

            The Fearless Formula Feeder page turned into that. Some were also super judgmental about the age you weaned to a cup and whether you used whole milk or toddler formula. It was ridiculous. The vast majority didn’t want to formula feed, it was their last resort, and usually said they were able to successfully breastfeed subsequent kids or they dry nursed or whatnot. I had to leave.

          • rational thinker

            Yeah, it always seems to be the ones who were breastfeeding or really wanted to but had problems and had to use formula. Imagine what they would have been like if the had been able to EBF.

            “Some were also super judgmental about the age you weaned to a cup” – Wow…I didnt know they were bitching about that too! With my first child who is developmentally normal I took the bottle and formula away on his first birthday and went to whole milk and juice in a sippy cup and he was fine with it. My second child is severely autistic so she had to stay on infant formula and a bottle until 2 and a half years old. She refused to eat any solids so she stayed on formula and got perfect nutrition from it.

            Those sanctimommy idiots need to realize that with babies there is no such thing as one size fits all. Different babies need different things. Then again what matters most to a sanctimommy is her image and social standing not necessarily the baby.

          • Cristina B

            Yeah, it was like using a bottle because you *had* to was fine, but as soon as they turned 1, you were supposed to throw them out. Ironically, I remember thinking that they wouldn’t have pressured a breastfeeding woman to wean a 1 year old.

          • rational thinker

            yeah bottle past 1 =BAD breastfeeding past one = GOOD They are such hypocritical assholes.

          • HailieJade

            It’s because bottles are always Bad and Evil and therefore the less time a child spends in the presence of one, the better. Breasts are the opposite. They are always Good and Holy and beyond reproach, and therefore the longer any child stays attached to the Almighty Breast, the better. Breasts/breastmilk = God. Bottle/formula = Satan. It really is a religion for these people.

          • HailieJade

            The more I read about the online sanctimommy universe, the more I’m convinced that this is a bunch of women who are used to being in control (be that in their career/relationship/family life) and simply can’t handle the fact that there is suddenly something in their life they have literally no control over (birth/breastfeeding/weaning) It’s very sad but at the same time makes me glad I decided never to have biological kids myself.

          • Cristina B

            The online stuff is why I stay away from mommy blogs and honestly, it’s lovely not to know what new crap they’re fussing over. Plus, kids are so different and I’ve learned my kids milestones don’t reflect on me as a parent or as a person.

          • The Bofa on the Sofa

            The problem with milestones is that there are such large ranges that can work. Some kids can be walking before 8 mos. Others might not be at 15 mos. That’s a huge range for a baby. But it’s all basically normal.

          • HailieJade

            And a child not meeting milestones within the expected time can often have a very simple explanation, e.g. kids who grow up in bilingual households often take longer to begin talking than those who grow up amongst monolingual speakers. Comparing the two is literally pointless!

          • Cristina B

            Exactly. Milestones are individual to the child, but some parents take it personally if their child doesn’t have a massive vocabulary at 3 (for example) because they did everything “right” to encourage it.

          • HailieJade

            As I said I’ve never had kids nor do I intend to, however I am the oldest kid on both sides of my family so I grew up looking after plenty of babies and toddlers. If there’s one thing I learned from that experience it’s exactly as you say – every child is different, and the more you try to control the situation, the more disappointed you will be. When it comes to child-rearing, Common Sense is what rules (if only it were more common!)

          • rational thinker

            If you want to read some real crazy sanctimommy shit look up the alpha parent / allison dixley you will have a good laugh at that site.

          • Anna

            I always thought Alpha Parent was a satire! I also thought for a while that bauhauswife was a satire. Like a Borat kinda thing. Sadly they’re both serious.

          • HailieJade

            I’m kind of afraid to look tbh. I can’t afford a new phone right now and from your description I’d say there’s a high chance that site may make me throw my current one forcefully at a wall… lol!

          • HailieJade

            Unreal the lengths some people will go to feel superior to others. The lack of self awareness among those judgy sanctimommies is incredible!

    • DaisyGrrl

      I don’t have an answer for how long it generally takes for information from studies to become practice, but I think a few issues are at play that will impact how long it will take to get over “breast is always best.” As you mentioned, it took roughly 30 years for the breast is best to really become entrenched in western society to the degree we see it today. The available studies still demonstrate that there can be some (minor) benefits to breastfeeding, and the evidence that breastfeeding/BFHI can be damaging is generally limited to academic circles.

      To get the level of change we’d need to see to reverse this, there would need to be: 1) substantive changes in the recommendations/clinical practice guidelines from major medical societies, 2) change in the public discourse surrounding breastfeeding (critical mass of social support for reversing BFHI and other initiatives), 3) government and public health officials changing their reimbursement structures and promotional material, and 4) possibly the WHO releasing guidance that recognizes the differential impacts of breastfeeding in developing and developed countries.

      Government can be susceptible to public pressure and advocacy, however it is otherwise remarkably slow to change course unless faced with overwhelming evidence that change is needed. If all of the national-level guidance is pro-breastfeeding, and funding for programming/reimbursement is linked to endorsement of BFHI and rates of breastfeeding, then there is little chance that change will happen quickly. Sub-national authorities will often align with national standards, for simplicity and resource management considerations. Everyone will point to the WHO as the one true authority, and thus there is a perfect vicious cycle of self-reinforcing policy.

      Individual providers in these settings have fallen victim to performance measurement initiatives, where they are expected to contribute to an institution’s ability to meet “quality” metrics. So if exclusive breastfeeding at discharge from hospital is a quality metric, then professionals are incentivized to overlook signs that baby needs supplementation and dismiss maternal concerns that their baby is not receiving adequate nutrition. To change a quality metric, there would need to be change in official policy stance from multiple medical associations, national-level guidelines, etc.

      The change needed is systemic, and systems change takes time. It needs overwhelming evidence, public pressure, and the backing of the medical community. Academic research is the first step, and as the evidence turns against the current practices we should see change come about eventually. Hopefully it won’t take 30 years, but realistically I expect it will take at least another 10 years before the tide turns.

  • Anna

    Also if you want to see a thing of beauty check out the poem Dr Dahlen has written about midwifery on her FB page. Its very humble, not at all overblown and dramatic. Its called “Warriors of the Night”. I can’t decide if my favourite line is the one about midwives as co-creators of the universe or the bit about “crouching in the dark corners like ancient mystics etched in candlelight”.

    • mabelcruet

      I really, really wish I hadn’t bothered looking for that. FFS, why are they so up themselves?? That is the most ridiculous, narcissistic pretentious shit I’ve ever read (although some of Sheena Byrom’s twittering and blogposts come close). It’s like an overwrought 13 year old Goth doing a creative writing assessment, and that’s probably an insult to 13 year olds.

  • Anna

    This echoes the literature review I did for an assignment on how breastfeeding promotion affects women’s wellbeing. I think its very tough for health professionals and I think they do often feel torn. My local hospital and health network isn’t BFI but I assumed it was because of their unwillingness to use the F word, even in the face of someone in clear distress and a baby not thriving. No-one ever even just said “hey, you know we support you either way but you don’t have to keep doing this”. Its going right up to department heads though I did have a paed’s regi give me a little reassurance after I asked her if it would harm my baby if I couldn’t keep up with pumping. Midwives over here are being trained by the likes of Dahlen and Reed and in the UK Wickham, Downe, Byrom. They do placement from first year here so they will very quickly see when they do postpartum visits what women are going through. Whether they can connect the dots when they have been told its all the system, formula companies and Drs know nothing about normal infant behaviour is harder.

  • fiftyfifty1

    Written by midwives?! Let’s hear more from these midwives who haven’t been cowed into submission!!

    • The Bofa on the Sofa

      Yeah, I was surprised by this:

      The fact that midwives and other health professionals may work in hospitals that are signatories to the Baby Friendly Hospital Initiative potentially places them in a difficult position, where their own critical assessment of the practice of breastfeeding may be silenced by the need to convey an official pro-breastfeeding position.

      Seriously? Midwives are “silenced” by the BFHI? As opposed to being the ones who promote it more than anyone?

      • Pevensie

        I realize this is anecdote, but my midwives have been far more open-minded about exclusive breastfeeding vs. combo/formula than the staff at the BFI hospital where they have privileges.

      • rational thinker

        Yeah, id have to agree. The midwives are a large part of the problem. If anything doctor’s are being silenced by the BFHI.

      • PeggySue

        I read this as saying that workers (doctors, nurses, midwives) in BFHI hospitals are silenced; I saw that in the system where I worked up until two years ago. The staff caring for mothers and infants were strictly constrained in what they could/could not say and do because BFHI. Not all implementations are that strict, but some are.

      • mabelcruet

        I get the impression that midwives are more likely to report other midwives for not following rules-they are very protocol driven so anyone deviating gets dobbed in. I used to be on the hospitals incident and error committee-each directorate had their own committee, but there was also an overarching hospital committee that was set up to look at trends. We had an incident a while back where a midwife accidentally dropped her security card coming into the ward (the doors are locked so no one can steal babies or whatever). The door closed behind her and it wasn’t til she got to the nurses station about 10 metres away that she realised it had fallen off her lanyard, so she immediately went to look for it. It had been lying on the floor for all of about 30 seconds, but one of the other midwives did a Datix (incident reporting) form saying that she had left the unit insecure and at risk. It was basically a petty squabble arising from interpersonal issues, but I suspect that the midwives have to be seen to be pushing the BFHI because that’s what the protocols say they have to do, and they do it so they don’t get in trouble. There’s no room for clinical opinions and clinical decision making when you’re following protocols.

      • Sarah

        I’m not sure it’s either/or, especially for the ones who’ve been around long enough to predate the current woo.