Every complex problem has a simple solution … and it is wrong.

According to lactation professionals, the “problem” of low breastfeeding rates has a simple solution. Just end formula advertising and societal pressure to bottlefeed and all women would breastfeed successfully, exclusively and for extended periods. They’re wrong. But even worse, they’ve leveraged their “simple solution” to disempower mothers.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactation professionals arrogate authority over breastfeeding to themselves by de-legitimizing doctors and mothers.[/pullquote]

That’s what sociologist Emma Head explains in Understanding Mothers’ Infant Feeding Decisions and Practices.

The first part of this paper discusses the development of social research that focuses on the promotion of breastfeeding in public health campaigns and by health professionals. I argue that this work tends to conceptualize the choices of women as constrained by overbearing public health messages which need to be ‘rolled back’ to enable women to make feeding decisions according to their own wishes.

But that’s wrong.

The broad exploration of infant feeding found in social research—one that recognizes its temporal, embodied, and emotional dimensions and that it takes place in the wider context of specific health and policy regimes—is thus a challenge for more simplistic accounts which focus on changing attitudes or behaviors in an individualist way.

I can hear lactivists now: “But, but the SCIENCE!”

Critiques of the way that ideas of risk and science have dominated debates around infant feeding are based around two main arguments. The first of these questions the validity of the scientific evidence that supports the promotion of breastfeeding. Following on from this, the second is concerned with the restrictions placed on women’s abilities to make meaningful choices around infant feeding that the current formulation of health promotion supports.

Specifically:

[T]he promotion of breastfeeding on scientific grounds can be understood “… as the outcome of a cultural process in which the authority of science and medicine is borrowed by lobbyists and campaigners”, resulting in the diminishing of other forms of authority and the “de-authorization” of the parent.

Lactation professionals de-legitimize doctors by claiming they “don’t understand” breastfeeding and de-legitimize mothers by claiming they cannot resist formula advertising and cultural messaging. It’s not a coincidence that lactation professionals imagine that ONLY they have a clear-eyed understanding of infant feeding choices.

Curiously, lactation professionals ignore the pressure that they bring to bear on women.

…[O]ver time the constraints on choice around infant feeding have increased so the presentation of breastfeeding has become more of a directive than a choice. Knaak identifies how the ‘choice’ to breastfeed has become increasingly pressured as it is not just physical health outcomes that are linked to breastfeeding but “increasingly strong interconnections” are made with mother-infant bonding. This adds an additional pressure for women negotiating infant feeding and means their choices are constrained because formula feeding is represented negatively.

Moreover, in contrast to lactation professionals’ simplistic representation of infant feeding decisions, there is far more involved than formula advertising and the presence or absence of cultural support.

The gap between public health promotion and women’s experiences adds weight to the recommendation that those promoting breastfeeding should try to roll back the moralization of infant feeding and, more broadly, that the politicization of parenting needs to be undone.

That such a gap exists is largely the result of lactation professionals’ efforts to de-legitimize women’s experiences of and feelings about breastfeeding. Because lactation professionals have chosen to pretend that breastfeeding is perfect, any less than perfect breastfeeding experience must be ascribed to the failure of women to try hard enough, their failure to resist formula advertising and their failure to reject cultural support for formula feeding. Perhaps the most egregious example of the disempowering and de-legitimization of mothers is the entity of “perceived insufficient milk supply” as if women can’t be trusted to tell that their beloved babies are starving.

Lactation professionals arrogate authority over breastfeeding to themselves by claiming that neither doctors nor mothers can be trusted to understand breastfeeding. The result has been a disaster for babies — exclusive breastfeeding is now the leading risk factor for newborn hospital readmission — and a source of soul searing guilt for mothers — who are evaluated by lactation professionals only on their willingness to knuckle under.

The bottom line is that public promotion of breastfeeding, particularly within hospitals and by government agencies, has NOT been shown to be beneficial to babies and mothers and has actually been shown to be harmful. But this has never been about babies and it certainly isn’t about mothers. Breastfeeding promotion is about building the authority of lactation professionals by de-legimitizing doctors and mothers. The babies who are harmed are just acceptable collateral damage.

That has to end. It’s time for mothers to take back their authority from lactation professionals. Only then will women be truly empowered to make the infant feeding decisions that are right for their babies and themselves.

On Monday I wrote about the pseudoscience of bonding.

It pseudoscience with a purpose. The purpose is to control mothers.

When the contemporary medicalization of attachment was proposed in the late 1970’s, there was no evidence we were experiencing an epidemic of “detached” children. Today, in the late 2010’s, it’s clear that the extensive implementation of bonding ideology hasn’t led to any improvement in children’s mental health. So why have so many parenting professionals embraced the nonsensical idea that mother-infant attachment requires ritualized behaviors at birth and in the following days and weeks?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The medicalization of attachment benefits the natural parenting industry. It harms mothers and babies, but who really cares about them?[/pullquote]

Sociology Professor Mary Ann Kanieski addressed this issue in her paper Securing attachment: The shifting medicalisation of attachment and attachment disorders.

She starts with an ironic observation:

Scholars have argued that mothers have been subject to intensifying regimes of medicalisation in our society. While many feminists have focused on the medicalisation of reproduction and childbirth, other theorists have observed the ways in which medical expertise has attempted to regulate women’s behaviour in their roles as mothers. These perspectives have shed great light on the ways in which motherhood has become an experience that is dictated and regulated by external authorities.

Natural parenting advocates, attempting to de-medicalize childbirth, have medicalized attachment as justification.

It fits into the trend of surveillance medicine:

Under surveillance medicine, the attempt to distinguish between health and illness has been transformed into a search for risk factors that are probabilistically associated with the development of illness… When risk factors are found to be present, individuals are impelled to reduce their risk factors, often through lifestyle changes, in the promise of reducing disease. Failure to take action can be viewed as a moral failing resulting in individuals being held responsible for their own health … Individuals must be constantly monitored for the presence of risk factors as health is viewed precariously. Owing to the difficulty of surveying a large population, surveillance medicine requires that individuals be taught to monitor themselves for the risk factors of disease.

It is difficult to overestimate the impact of this changing perception of illness. Previously illness was viewed as something that happened randomly. Now illness is viewed — incorrectly — as something that only happens to people at risk who do not take steps to reduce their risk. We have created a culture of “wellness” that falsely reassures people they can control their own health and therefore are responsible for their own illness. All they need to do is trust “wellness” experts, buy their books and supplements and use their nonsensical — chiropractic, homeopathic — services.

How has that played out in mothering?

We have created a culture of “naturalness” — parenting “experts,” midwives, doulas, lactation consultants —that falsely reassures mothers that they can control the health (and IQ!) of their children by trusting “naturalness” experts, buying their books and supplements and using their expensive services. Why? To convince mothers that their attachment to their babies is precarious and must be constantly monitored for “risk factors.” Because it is difficult to constantly survey a large population, surveillance of mothers requires that individuals be taught to monitor themselves, constantly seeking to reduce the “risk factors.” Any women who refuses to behave in concert with the surveillance regime is labeled as lazy, selfish and a bad mother.

Because attachment came to be a protective factor as well as a risk factor, the aim of achieving secure attachment in children encouraged mothers to engage in intensive mothering as a means of achieving the benefits of secure attachment and avoiding the risks of less secure attachment. To be a responsible mother meant that one needed to be a sensitive, responsive mother. Mothers were taught to monitor themselves in relation to their behaviour towards their children as advice regarding attachment and bonding …

The ironies abound. Women are taught by midwives and doulas that rejecting the medicalization of childbirth promotes bonding, but that only makes sense if you medicalize attachment as precarious, contingent on risk factors — medicalized birth is supposedly a risk factor — and requiring constant expert maternal surveillance and self-surveillance to implement.

Women are taught by lactation professionals that rejecting the medicalization of infant feeding (formula) promotes bonding, but that only makes sense if you medicalize attachment as precarious, contingent on risk factors — formula feeding is supposedly a risk factor — and requiring constant expert maternal surveillance and self-surveillance to implement.

Women are taught by attachment parenting experts that rejecting careers and work outside the home in favor of “wearing” babies promotes bonding, but that only makes sense if you medicalize attachment as precarious, contingent on risk factors — any maternal separation no matter how short is supposedly a risk factor — and requiring constant maternal surveillance and self-surveillance to implement.

But perhaps the biggest irony is this: attachment occurs naturally and there’s no evidence that it requires experts, rituals or self-surveillance.

In contrast to childbirth, which has a high natural death rate, and breastfeeding, which has a high natural failure rate, attachment has a very low natural failure rate. While complications of childbirth and breastfeeding are common, complications of attachment are rare.

But don’t tell women that critical truth. What would happen to the employment prospects of midwives and doulas if women understood that childbirth has little to nothing to do with mother-infant bonding (as any father or adoptive parent could tell you)? What would happen to the income of lactation consultants if women understood that infant feeding has nothing to do with mother-infant bonding? What would happen to the book sales of attachment parenting experts, if women understood that mother-infant bonding happens spontaneously and there’s no need to read any books or practice specific parenting rituals?

The medicalization of attachment — and the self-surveillance and self-doubts of mothers — benefits the natural parenting industry and that’s why they have promoted it aggressively and relentlessly.

It harms mothers and it harms babies, but let’s be serious: who really cares about them?

Philosophy professor Fiona Woollard has written a fascinating paper on the issue of breastfeeding and maternal duties entitled Is It Okay to Let My Child Be Stung by a Wasp?

New mothers report feeling shamed for not breastfeeding, and constantly having to defend their use of infant formula from strangers on social media or in public places like cafes. Coming at a time when new mothers are extremely vulnerable, such guilt and shame can have devastating consequences…

Something that might help would be if we recognised that the health benefits of breastfeeding give mothers a reason, but not a defeasible duty to breastfeed. Defeasible duties are associated with guilt, blame and requirements to justify our behaviour. If you have a duty to do something then you are required to do it; if you don’t, other things being equal, you should feel guilty and people with appropriate standing can blame you.

Defeasible duty is a technical philosophy term; colloquially we might call it a moral imperative. So the question becomes: do the purported health benefits of breastfeeding lead to a moral imperative for a mother to breastfeed? Woollard believes that the answer is “no” because not all reasons reach the threshold of moral imperatives.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Is there a moral duty to do what is safest for a baby?[/pullquote]

Woollard notes:

We treat mothers and pregnant women as if they have a defeasible duty to perform each action that might benefit their child. That’s why we tend to act as if it follows from the fact that breastfeeding has health benefits that the mother has a defeasible duty to breastfeed. I call this a maximal maternal duty to benefit.

Most lactation professionals claim to believe, and craft their language to promote, the idea of maximal maternal duty to benefit. For them, the fact that breastfeeding has any health benefits is not merely a reason to breastfeed but a moral imperative to breastfeed.

But most of us, including lactation professionals, do not believe in a moral imperative to do anything that benefits a child regardless of other factors. For example, I doubt lactation professionals would claim that there is a moral duty to buy a Volvo, the safest car on the road.

If you do the math, the risk of a child dying in a car accident is far greater than the risk of being “harmed” by formula feeding, regardless of what magical benefits you ascribe to breastfeeding. But wait, you say. Volvos are expensive, many people cannot afford them and they might destroy the family budgets of even those who could scrape together the money. In other words, the benefits to the child can be balanced or even outweighed by the harms to the family. Therefore, while the fact that it is safer might be a reason to buy a Volvo, it does not lead to a moral imperative to buy a Volvo.

In other words, there is not a maximal maternal duty to benefit. Yet if reducing the greater risk of dying in a car accident isn’t a moral imperative, why would breastfeeding be a moral imperative?

The Volvo example is a bit outlandish but there are several situations a lot closer to breastfeeding that pose the same moral conundrum.

Is there a moral imperative to avoid co-sleeping with infants?

There is simply no question that co-sleeping increases the risk of sudden infant death. True, not every breastfeeding pair has the same risk but the risk exists for everyone. In other words, there is a measurable benefit to a baby to sleep outside its mother’s bed. Any theory of a maximal maternal duty to benefit creates a moral imperative for mothers to reject the practice of co-sleeping.

Most lactivists and lactation professionals are appalled at the thought. Co-sleeping makes breastfeeding more convenient, and although they would be the first to lambaste a mother who chose formula because it is more convenient, they rate their own need for convenience in breastfeeding very highly.

Besides, they claim, breastfeeding itself reduces the risk of sudden infant death. So what? If there is a moral imperative to breastfeed because of the health benefits, then surely there is the SAME moral imperative to reject the practice of co-sleeping.

How about homebirth? If a maximal maternal duty to benefit leads to a moral imperative to breastfeed, then the same principle creates a moral imperative to give birth in the hospital.

Homebirth in the US dramatically increases the risk of perinatal death. The best analysis to date, conducted by Judith Rooks, CNM MPH shows that homebirth with a licensed homebirth midwife increases the risk of perinatal death by 800%.

But wait, homebirth advocates say, homebirth provides benefits for the mother. So what? If mothers are morally required to do what is best for babies, regardless of the impact on themselves, then it doesn’t matter how mothers might benefit from homebirth. They have a moral duty to deny themselves those benefits in order to maximize the health and survival benefits to the baby.

Is there a moral imperative to vaccinate?

Every pediatric health organization promotes vaccination even more aggressively than breastfeeding. If they were forced to choose between them, they would undoubtedly choose vaccination as far more beneficial to babies than breastfeeding. Even their absurd claim that higher breastfeeding rates could save more than 800,000 lives per year pales into insignificance compared to the hundreds of millions of lives saved by vaccination.

Anyone who insists that there is a moral imperative to breastfeed because the WHO says it saves lives must acknowledge that there is a greater moral imperative to vaccinate because it saves far more lives. Yet millions of parent insist that what they personally believe about the benefits and risks of vaccination should carry greater weight than WHO recommendations. If that’s the case, then how can there be a moral imperative to breastfeed when many women believe the risks to their babies, themselves and their families outweigh the benefits?

Where does that leave us?

At a minimum, we must acknowledge that we do NOT believe in a maximal maternal duty to benefit. We don’t believe that mothers are obligated to drive Volvos or nothing else. Moreover, many passionate advocates of natural mothering do NOT believe that the fact that co-sleeping, homebirth, and refusal to vaccinate increase the risk of death means that mothers are obligated to avoid co-sleeping, homebirth and vaccine refusal. They recognize and respect that fact that there are other factors (convenience, finances, parental beliefs) that are involved.

Now they just need to recognize and respect that there is more involved with breastfeeding than benefits to babies.

Nearly everything you think you know about mother-infant bonding is untrue … and that’s not an accident.

Where did the pseudoscientific beliefs about bonding come from and why did they appear when they did? It wasn’t because we were experiencing an epidemic of unbonded children. Why have pseudoscientific beliefs been maintained for the past generation? It isn’t because they have led to any improvement in the mental health of children. What’s really going on?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Bonding pseudoscience isn’t about what infants need; it is a way of controlling maternal behavior.[/pullquote]

It has been 25 years since Diane Eyer wrote the paper (and then the book) Mother-Infant Bonding: A Science Fiction:

A study of the research on postpartum mother-infant bonding shows that results from poorly constructed research programs were published in major journals and became a part of hospital policy because the bonding concept was politically useful in the struggle between advocates of natural childbirth and managers of the medical model of birth. The concept was also uncritically accepted because it was consistent with a longstanding ideology of motherhood that sees women as the prime architects of their children’s personalities.

Contemporary notions of bonding are less than 50 years old, but they were eagerly adopted by those who saw them as politically useful.

…[B]onding had become extremely popular in the mid 1970s primarily because of its usefulness in the political struggle between the natural childbirth movement and hospital obstetrics. The bonding imperative appeared to give women more control over their birth experience, appeared to be part of a more natural birth, and allowed them to have their infants and family with them in what had previously been a lonely and often demeaning experience.

Bonding pseudoscience serves the same purpose for natural childbirth and breastfeeding advocates as climate pseudoscience serves for big business and evolution pseudoscience serves for religious fundamentalists. It offers an opportunity for believers to force their beliefs on others.

Bonding is still widely believed to be an established rule for governing the mother’s behavior… [T]he concept has continued to flourish (in varying forms) as part of the ideology in which women’s constant proximity to their infants (whether they desire it or not) is seen as a formula for preventing later problems of the child.

The seminal research on bonding was conducted by Klaus and Kennel who analogized women to goats, cows and sheep. Their research methodology was deeply flawed:

… Kennell and Klaus studied the “bonding” of 28 low-income, predominantly black, unmarried primiparae (first-time mothers) of normal birth weight babies…

After one month, the mothers returned to the hospital for interviews and observations. One of the interview questions related to the assessment of their “caretaking” was: “When the baby cries and has been fed, and the diapers are dry, what do you do?” On a scale of 0 to 3, 0 was given for letting the baby cry it out and 3 for picking it up every time. Another interview question was: “Have you been out since the baby was born, and who sat?” A score of 0 was given if the mother had been out, felt good, and did not think about the infant while she was out and a score of 3 was given if she did not leave the baby or if she did go out but thought constantly about the baby. More of the extended-contact mothers reported picking up the baby when it cried and not wanting to leave the baby. The researchers evaluated this finding as evidence of stronger mother-infant bonding in the group that held their babies for 16 extra hours.

There is so much wrong with this study that it’s difficult to know where to begin:

First is the question of the degree to which many of these dependent variables, such as letting the baby “cry it out” or not going out without thinking about the baby, are actually valid measures of caretaking. The woman who can’t leave her baby might be anxious or might not have anyone to leave the baby with. The woman who is able to forget about the baby when she goes out might have a trusted baby- sitter or might be self-assured and highly competent. “Standing near the examining table” during the pediatric exam could be an indication of anxiety or attitudes toward medical authority, or it could result from the different treatment of the experimental group—mothers might be less shy with doctors and nurses who witnessed their holding the babies during the extra contact treatment…

No matter. The concept of bonding was seized upon as a tool in the ongoing effort of natural childbirth advocates to pressure obstetricians.

Lamaze instructors adopted the term, and the reform-minded obstetrician, who became aware of the bonding concept in 1976 with the publication of Klaus and Kennell’s book, claims that he was delighted to have a scientific reason to back up what he already wanted to do.

It is similarly used to this day and has been enthusiastically adopted by lactation professionals for the same reason. No one seems to care that there was no evidence that medicated birth or formula feeding had produced an epidemic of unbonded children; similarly, no one seems to care that increasing rates of unmedicated birth and breastfeeding have failed to improve any mental health parameters of children.

Perhaps even more important is the way that the pseudoscience of bonding confirms misogynistic beliefs about how women ought to behave:

Perhaps the most profound influence of all on the construction and acceptance of bonding was a deeply embedded ideology regarding the proper role of women and the political need to retain at least something of that ideology in the face of the feminist challenges of the 1970s and the continuing migration of women into the labor market…

Bonding pseudoscience isn’t about what infants need; it is a way of controlling maternal behavior.

The belief that infants and children are so profoundly shaped by their own mothers that a few hours of contact with them could inoculate them from harm, even enhance their lives for years to come, would seem to border on magical thinking. Yet the idea was readily embraced as a scientific truth because it fit so perfectly with presuppositions about women and infants that have been socially constructed over the course of a century and a half and were threatening to come undone.

None of that would matter except for the fact that bonding pseudoscience is actively harming women:

Bonding is an impossible standard to adhere to. Locking women into such standards and then blaming them for failing to conform is an emotional drain not only on women, but on the entire family…

[C]onceiving of women as unthinking automatons, the prime architects of their children’s fate, blinds us to the real causes of the problems of children, not to mention women, such as poverty and social isolation.

The bottom line is that most of what passes for conventional wisdom about mother-infant bonding is pseudoscience in the service of misogynistic cultural aims. It doesn’t benefit babies and it harms mothers.

It started with a sign.

Please let us know if you hire a doula during your pregnancy as Dr. Aguayo has decided not to collaborate with doulas or other lay support people… Please feel free to discuss any questions or concerns at your appointment.

It has escalated to a full fledged attack on a doctor orchestrated by Huntsville Alabama ICAN (International Cesarean Awareness Network). At this point, ICAN’s followers are jamming the phone lines and patients cannot get through to speak with the doctor or staff.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]ICAN Huntsville doesn’t understand that it might not have been Dr. Aguayo’s choice or they don’t care.[/pullquote]

When I first saw discussion of the sign on Facebook, I assumed (incorrectly) that the doctor was an older, man who got fed up with doulas acting outside their scope of practice by giving medical advice to patients.

But that’s not the case as a variety of testimonials on Facebook make clear:

Dr. Aguayo is wonderful and very pro patient choice. With both of my pregnancies she has been very kind to listen to my concerns and open to my choices, never once saying no to any of my requests. I chose to use a doula with my first birth and she was very encouraging and supportive of that. She even made recommendations when I brought the subject up. All I can say is something big must have happened to come to this point for her. Love her so much and I’m so glad she’s the one delivering my children!!

And from the page of Huntsville ICAN itself:

I love Dr Aguayo she is one of the kindest most patient providers Ive ever met…She has always been very welcoming to Doulas and has always encouraged natural child birth and wasn’t very invasive at all…I can’t imagine what would have happened to make her take this stand…There has to be more to this story…One of my best friends delivered with her just 2 months ago with a doula and it was a wonderful experience…‍♀️I think something had to have happened to make her take this stance.

It does not take a rocket scientist to figure out that Dr. Aguayo, apparently a staunch supporter of both natural childbirth and doulas, was probably forced into taking this action.

How might that have happened? It could have been precipitated by a dreadful outcome — a brain injured or dead baby — whose care was compromised by a doula operating outside her scope of practice. It may not have even involved Dr. Aguayo herself.

Nonetheless, Dr. Aguayo’s malpractice insurer might have told her that her insurance would be invalid if doulas were involved in patient care.

Dr. Aguayo’s hospital might have told her that doulas were not longer welcome in the wake of bad outcomes.

Dr. Aguayo herself might have come to the conclusion that certain doulas in her area were actively harming patients or interfering with the doctor patient relationship.

One thing seems certain, however; Dr. Aguayo is not personally opposed to doulas.

That didn’t stop ICAN of Huntsville from naming and shaming her. It resulted in a story on AL.com, Alabama OBGYN refuses to work with birth doulas, causing online uproar.

A local birth advocacy group, ICAN of Huntsville, posted the photo Tuesday morning. By Thursday afternoon it had been shared more than 1,500 times and had more than a thousand comments.

But for ICAN and many of the commenters, the online uproar over Aguayo’s policy isn’t just about the ability to use doulas with one doctor. It’s a natural outgrowth of changing cultural expectations for how childbirth is supposed to go. Doulas are often seen as patient advocates and witnesses in a setting that favors the needs of hospitals and doctors of those of laboring women.

“Birth culture is changing among consumers,” said Brianna Barker of ICAN of Huntsville. “We are realizing we do have the ability to take hold of our rights.”

They were especially angry that an ally had let them down:

The post also gained steam on Facebook because it was about Aguayo, said Barker.

“Anybody else in town would have been less shocking,” she said. Aguayo is well-known in the Huntsville area for her welcoming attitude toward birth plans, natural birth, and her willingness to work with doulas.

“That’s why I chose her,” said Lowder. “I have very natural views on childbirth and wanted to have a doctor that supported that. And she did.”

Without bothering to consider that Dr. Aguayo might have been forced to stop working with doulas, they crucified her.

The online anger was swift. Negative reviews popped up on Google. Barker said she and Justen Alexander, also of ICAN, spent hours deleting inappropriate comments on the post and banning commenters who stepped out of bounds, including those who shared links to Aguayo’s personal information.

At All Women’s OBGYN, the phone lines have been so backed up that patients have had a hard time getting through, Janah Baker, the office manager, told AL.com.

“It’s been disheartening and frustrating,” said Baker.

Huntsville ICAN and its followers were so drunk on self-righteous rage that they never stopped to analyze the situation or consider the impact of their actions. They’ve been backpedaling ever since.

If you feel strongly about this policy, writing a letter may be the best way to share your concerns without disrupting the patient care. Do not post links to Dr. Aguayo’s personal profile – these comments will be deleted. Please do not leave reviews on her page unless you have been her patient. This is about her policy, not about her as a person. Please do not call her office unless you are a patient.

But they still don’t get it.

ICAN does not support maternity care providers dictating who a patient can privately contract for services. The abuse of power dynamic is outlined in ACOG’s Committee Opinion of refusal of medical recommendations.

They either don’t understand that it might not have been Dr. Aguayo’s choice or they don’t care; they crucified her anyway.

With friends like Huntsville ICAN, who needs enemies.

I’ve written repeatedly about the toll of illness, injury and death that the relentless promotion of breastfeeding takes on babies. That’s because it is easy to see the damage: tens of thousands of babies readmitted to the hospital each year, as well as babies who suffer permanent brain injuries or even die due to dehydration, hyperbilirubinemia and hypoglycemia.

But as bad as that is — and it is inexcusable — the toll on women may be worse. It’s just less visible because it involves their mental health.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women who choose to stop breastfeeding often do so for the BENEFIT of the baby.[/pullquote]

A reader shared a fascinating scientific paper that attempts to outline and explain those harms. The paper is Existential security is a necessary condition for continued breastfeeding despite severe initial difficulties: a lifeworld hermeneutical study.

There’s a lot of jargon in the paper, but it’s not hard to wade through to reach valuable insights.

The authors start by attempting to understand what happens to a mother when her baby fails to thrive on breastmilk. Of note, the study takes place in Sweden, a country with one of highest breastfeeding rates in the world, with extensive support for breastfeeding and with maternity policies designed to promote breastfeeding.

Nonetheless:

Almost 30% of mothers initiating breastfeeding experience some kind of difficulty and is a major reason for breastfeeding cessation. Breastfeeding success is often taken for granted during pregnancy and difficulties are thus largely unexpected by mothers. Such idealistic expectations evoke emotional distress when difficulties occur. Severe initial breastfeeding difficulties can lead the mother to feel lost in her role as a mother, leading to a constant struggle both emotionally and practically.

In other words, even when women have substantial breastfeeding support, almost a third of all mother-baby dyads will have difficulty.

Moreover, in contrast to the lactivist insistence that women who stop breastfeeding are lazy and selfish, many do so for the benefit of the baby.

The mother’s perceptions of the infant guide her breastfeeding decisions and her experience of herself in the breastfeeding relationship. Her own understanding of the infant’s response will determine whether she feels confirmed as a breastfeeding mother or not. When the mother … does not feel confirmed [because the infant is not thriving], she loses faith in herself as a breastfeeding mother. She concludes that the infant is mistreated by breastfeeding and her motivation to continue breastfeeding is lost.

In such situations, breastfeeding can become psychologically unbearable:

When the body gives positive responses, such as a good milk supply or less painful breasts, it provides hope and confidence in the body’s ability, which becomes a positive sign. A lack of positive signals from the body contributes to a sense of being trapped in the body, making the mother mistrust its function. The feeling that the body desires to be released from suffering arises and the situation is so painful that breastfeeding becomes unbearable.

But doesn’t she just need more support? It depends of what’s being supported, the act of breastfeeding or the wellbeing of the baby and mother.

…[C]are can be experienced as non-caring as, for example, intrusive hands-on breastfeeding help, or care that focuses solely on the infant or the body. Such care is degrading in that it objectifies the woman and reduces her to solely an instrumental functionality…

Such “care” is the opposite of support:

An instrumental way of giving care undermining mothers’ breastfeeding and seems to be based on the idea that a woman who has just given birth does not have the same need for extra care as for patients who, for example, are being treated for some medical condition. A new mother can nevertheless be exhausted, in healing from surgical procedures, and under the influence of the hormonal transition that occurs when the milk comes in… Being allowed to have the same care needs as for a “real” patient appears to be significant for the mother’s possibility to overcome breastfeeding difficulties … [I]n the absence of such acceptance, suffering becomes overwhelming, leading to her feeling forced to cease breastfeeding. (my emphasis)

The result?

Mothers who initiate breastfeeding with severe difficulties may feel overtaken and violated by the needs and demands from her infant, the extensive pain and/or changes in her body, and her own as well as others’ expectations for her to succeed. Contact with professional carers whom she experiences as too demanding or her own feelings of anger and loneliness may further enhance these feelings of being overtaken and violated…

Continuing breastfeeding in this situation can harm the mother-infant relationship.

When feelings of being overtaken and violated make her consider her body primarily as a biological tool, separated from the mother-infant relationship, feelings of alienation easily emerge. The intended reciprocal and intimate relationship with the infant becomes the opposite wherein it is difficult to feel closeness…

It’s hardly surprising then that stopping breastfeeding in such situations is an act of love.

The mother’s overwhelming feelings of suffering, anger and loneliness lead to a feeling of alienation from the breastfeeding relationship that can encourage her to see the decision to stop breastfeeding as an act of caring responsibility.

How should healthcare providers respond?

It is therefore important that health care professionals have the ability to extend their care beyond the biological body and the instrumental way of caring …

With this in mind, new mothers, especially those with severe initial breastfeeding difficulties, need to be met in a sensitive way that allows them to reconcile themselves to their feelings of alienation and come close to their infant, regardless of continued or stopped breastfeeding.

In other words, lactation professionals should be focused on WOMEN, not just on their breasts. Most importantly, they should understand that many women who stop breastfeeding do so not out of selfishness but out of love.

It is the LEADING risk factor for newborn hospital readmission. It is responsible for the hospitalization of TENS OF THOUSANDS of newborn babies each year, not to mention an untold number of brain injuries and deaths from dehydration, hyperbilirubinemia and hypoglycemia.

And yet, the American Academy of Pediatrics continues to promote it.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The current situation is an abomination. The harms — the tens of thousands of neonatal hospitalizations, the brain injuries, the deaths — are almost entirely caused by the mindless insistence on exclusivity. [/pullquote]

Yesterday the AAP posted this on its Twitter feed:

Breastfeeding matters! It’s important for the health of children – and mothers.

It’s not true. In the US, breastfeeding DOESN’T matter. With the exception of premature babies, there is no evidence that breastfeeding reduces mortality rates, severe morbidity rates, disease incidence rates or healthcare spending. This despite the fact that breastfeeding rates have nearly quadrupled in the past 40 years. If we haven’t seen the purported benefits yet, they don’t exist regardless of how many mathematical models predicted them.

The accompanying video is filled with bald faced lies.

Breastfeeding is the best start for your baby? Then why is it the leading risk factor for newborn hospital readmission?

Breastmilk contains all the nutrients your baby needs? Then why do breastfed babies need vitamin and iron supplements?

Breastfeeding promotes a “special bond” to your baby? In addition to the fact the claim is a lie that has been thoroughly debunked, it is an unspeakably cruel insult to adoptive parents, fathers and non-birthing partners in lesbian marriages.

Breastfeeding is great when it works. I know; I breastfed four babies. But it is hardly necessary for infant health and wellbeing. Two generations of Americans — the so-called “Greatest Generation” and their children — were raised nearly entirely on formula and mortality rates and morbidity rates continued to drop at a brisk pace. There is no evidence that those generations suffered from bonding difficulties with their parents. They grew up to be taller, healthier, and with higher IQs that the generations before.

The AAP can’t point to any benefits of breastfeeding that have come to pass, while I and others can point to literally tens of thousands of babies harmed each year by breastfeeding promotion. That raises the question: is the AAP morally culpable for the harm they cause by promoting breastfeeding?

In my view, the AAP does bear moral responsibility for the tens of thousands of hospitalizations each year, the permanent brain injuries and deaths, not to mention the soul searing guilt carried by many of the nearly 15% of women who can’t exclusively breastfeed, particularly in the early days after birth.

The AAP bears moral responsibility for these egregious harms because, as exemplified by their Tweet, they continue to promote falsehoods.

I’m not suggesting that the AAP wanted babies to be harmed by aggressive breastfeeding promotion; they never expected it. But they bear morally responsibility for the harms because they have ignored them. The AAP seems to have decided that those hospitalized and injured babies (and their mothers) are acceptable collateral damage.

Why? Because they’ve been co-opted by the breastfeeding industry encompassing, the tens of thousands of lactation consultants, lactation leaders and companies that profit by promoting breastfeeding.

The AAP bears moral responsibility for the harms because they’ve allowed and supported the industry — in the form of BabyFriendly USA — to operate freely in hospitals, replacing scientific evidence with lactivist ideology.

The AAP bears moral responsibility for the harms because they’ve allowed BFUSA to force doctors and nurses to abide by an ideology that many consider untrue at best and harmful at worst.

The AAP bears moral responsibility for the harms because they’ve allowed themselves to be blinded by white hat bias. They are still so angry at the formula industry for its behavior in Africa in the 1970’s that they demonize formula itself.

But most of all the AAP bears moral responsibility for the harms because they have made no effort to stop them. It wouldn’t be difficult. All they would have to do is point out that while breastmilk is good, there is precious little evidence that the purported benefits require exclusive breastfeeding.

The current situation is an abomination. The harms — the tens of thousands of hospitalizations, the brain injuries, the deaths — are almost entirely caused by the mindless insistence on exclusivity.

It’s the equivalent of telling parents that the benefit of a healthy diet for a child is entirely negated by an occasional piece of candy. It’s the equivalent of claiming that the occasional piece of candy would destroy their children’s gut microbiome and result in epigenetic changes. It’s the equivalent of insisting that parents who let their children eat candy occasionally don’t bond to them or love them as much as those who ban candy entirely. It would be ugly, unscientific and cruel to children and parents.

But that’s what the AAP is doing when it promotes breastfeeding exclusivity at the expense of the physical health of babies and the mental health of mothers. And so they bear moral responsibility for the tremendous harm caused by their complicity in a breastfeeding promotion campaign that has produced very few measurable benefits and a large amount of harm.

Breastfeeding is the biological norm.

So right-handedness.

So is heterosexuality.

So is continuing unwanted pregnancy.

Why do lactivists give moral authority to nature when it comes to breastfeeding but deny that same moral authority when handedness, sexuality and unwanted pregnancy are involved?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Why do lactivists pathologize women who don’t breastfeed, but not women who are left-handed, gay, or those who have had abortions?[/pullquote]

Why do they pathologize women who don’t breastfeed, encouraging moral condemnation, but would never pathologize women who are left-handed, gay, or those who have had or seek abortions?

Philosophy professor Alison Suen confronts some of these issues in her new paper The Construction of a Consumable Body in Feminist Philosophy Quarterly.

She cautions against assuming that the biological norm is either desirable or necessary:

… [F]eminists should be especially wary of this sort of “nature” talk… [T]he idea that it is “natural” (and hence necessary) for a lactating woman to breastfeed may inadvertently promote the perception that the woman’s body is always at the service of others… [T]he way reproduction happens nowadays is highly regulated by technology—there is nothing “natural” about taking birth control pills or wearing a condom, and while miscarriage is part of nature, abortion is not. Given that many of the reproductive rights we want to safeguard for women are not “natural,” the appeal to nature in pregnancy narratives is problematic from a feminist point of view.

If contraception, abortion and other reproductive technologies (in vitro fertilization, freezing one’s eggs) are perfectly acceptable UNnatural choices for women who wish to control their own bodies, why isn’t formula use equally acceptable for the same reason?

And she gets to the heart of the matter when she discusses the dangers — for women in particular — of ceding moral authority to nature:

When nature becomes a “moral authority,” can it still make good on its initial promise to liberate women, allowing them to reclaim control over pregnancy and childbirth? Or does it liberate women from the tyranny of the medical establishment only to subject them to the new puissance of “nature”?

More to the point, does giving moral authority to nature liberate women from technology or subjugate them to misogynistic beliefs on how women ought to behave? Giving moral authority to nature would justify efforts to “support” left handed women into becoming (or pretending to become) right handed. It would justify efforts to “support” gay women into becoming (or pretending to become) straight. It would justify laws that limit access to safe, legal abortions.

But the greatest danger is this:

…[A]n appeal to nature that accords nature a moral authority does not necessarily promote diversity or tolerance, especially when such an appeal merely replaces one practice with another as the proper, normative practice. In other words, even if the language of nature may empower some, it is done at the expense of others…

When the biological norm becomes a moral standard, those who are biologically “abnormal” are almost invariably oppressed. For example, the most malignant expressions of homophobia are often justified by insisting, correctly, that heterosexuality is the biological norm.

Suen concludes:

It is time to jettison our reverence for “nature” and consider a new strategy to support breastfeeding mothers, a strategy that does not presuppose a good mom/bad mom dichotomy or deepen the perception that it is an ever-present responsibility for women to maintain a consumable body… [W]ithout the “authority” of nature to normalize … we can also begin to reconsider the question of what makes something or someone consumable, and whether we are justified to treat them as such.

In short: fuck the biological norm.

Just as the biological norm does not and cannot justify homophobia or restricting access to abortion, it does not and cannot justify pressuring women to breastfeed.

I’d like to propose a new term: breastsuffering.

Breastsuffering refers to the large and growing toll of aggressive breastfeeding promotion. Breastsuffering encompasses breastfeeding starvation, breastfeeding suffocation and breastfeeding skull fractures for babies and breastfeeding guilt, anxiety and depression for mothers.

Sadly, lactation professionals and lactivists have become apologists for breastsuffering.

More than three decades ago lactation professionals decided, absent any evidence, that breastfeeding is best for babies. In their defense, they were responding to the egregious, deadly corporate practices of large multi-nationals like Nestle; they had sought to replace breastfeeding in Africa with formula made using contaminated water. Although it was the water that harmed and killed the babies, breastfeeding advocates sought to elide that point in order to promote breastfeeding.

Moreover, at the time there was very little scientific evidence about the harms of breastfeeding.

Now we know that each year tens of thousands of breastfed babies starve to the extent that they need to be readmitted to the hospital at a cost of hundreds of millions of dollars. Why? Because lactation professionals — with no scientific evidence of any kind — have claimed that formula supplements interfere with breastfeeding.

Each year hundreds of babies suffocate to the point of brain injury or death in their mothers hospital beds in an effort to promote breastfeeding. Why? Because lactation professionals — with no evidence of any kind — insist that prolonged periods of skin to skin contact are required for breastfeeding.

Each year an unknown number of babies are injured or die after falling from their mothers hospital beds. Why? Because lactation professionals — with no evidence of any kind — have claimed that mandated rooming in of babies and mothers increases breastfeeding rates.

Each year tens of thousands of women suffer soul searing guilt, disabling anxiety and life threatening postpartum depression. Why? Because lactation professionals — with no evidence of any kind — have claimed that women who don’t breastfeed don’t care about their babies.

You might think that lactation professionals and lactivists would be horrified by what they have wrought. You would be wrong. Instead they have become breastsuffering apologists.

How does it work?

Breastsuffering apologists invoke the naturalistic fallacy.

Starvation apologists insist that starvation while breastfeeding is impossible because it would have ended our species. That’s nonsense. Approximately 20% of established pregnancies end in miscarriage and it has not prevented growth of our species. Even 15% of babies starved to death, it would not hardly have wiped out the species.

Suffocation apologists — like Prof. James McKenna who coined the term breastsleeping and Melissa Bartick, MD — insist that because babies in nature sleep on the hard, flat ground with their mothers, contemporary babies ought to sleep on soft, suffocating beds with their mothers. Skull fracture apologists invoke similar “reasoning.”

Breastsuffering apologists insist that the benefits of breastfeeding outweigh the permanent brain injuries and deaths.

There’s a major problem with that argument. Though I can show you tens of thousands of babies readmitted to hospitals, hundreds of babies brain injured and even babies who have died as a result of breastfeeding, they can’t show that any term babies’ lives have been saved, incidence of any serious disease being reduced, or that even a nickel has been saved by promoting breastfeeding in term babies.

Breastsuffering apologists insist it is “lack of support” that is leading to the hospitalizations, brain injuries and deaths.

It is not a coincidence that many of the very people who profit by providing support insist that more support — and therefore more money for themselves — is needed. They evince a startling lack of awareness that it is precisely their support for any amount of breastsuffering in the pursuit of higher breastfeeding rates that has led to the hospitalizations, brain injuries, maternal depression and death.

Breastsuffering apologists accuse anyone who tries to increase awareness of breastsuffering of hating breastfeeding.

That’s just a way of diverting attention from the real problem. Many of those who oppose breastsuffering — like me — breastfed their own children. The difference between us and lactation professionals is that we would never have let our own babies suffer just so we could say we breastfed; we despise the fact that many lactation professionals are willing to let their own and other people’s babies suffer for bragging rights.

Breastsuffering apologists attempt to assuage their cognitive dissonance by tormenting women who chose or were forced to choose bottlefeeding.

The mantra of breastsuffering apologists is “fed is minimal” (or for the grammar challenged “fed ain’t best”). But the truth is that fully fed with formula is far better than underfed with breastmilk. This also speaks to the high premium lactation professionals and lactivists place on their own hunger for achievement and recognition. For breastsuffering apologists, the need to feel superior to other mothers outweighs any other considerations, including the suffering of their own children.

Breastsuffering apologists are everywhere. They run webpages and blogs that grossly exaggerate the benefits of breastfeeding and ignore the risks. They create Facebook groups to bully formula feeders and to wallow in their unmerited sense of superiority. They engage in testimonial silencing on the their social media feeds, trying to banish the evidence of breastsuffering. And should anyone draw their attention to breastsuffering, they act as apologists for it.

Breastsuffering is real, significant and growing. Breastsuffering apologists are legion. It’s time to recognize the harm and put an end to it.

One of the best things about having four children is that you quickly learn that each is an individual from the moment of birth. One infant loves to be snuggled; another hates it. One baby is soothed by a pacifier; another refuses it altogether. One child is constantly striving for new experiences and milestones; another hangs back for fear of the unknown.

That’s why I can’t understand the natural mothering penchant to portray each infant as the same as every other.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Natural mothering advocates assume babies are frightened by life outside the womb when actually they might be fascinated.[/pullquote]

Consider this from Lucy Ruddle, IBCLC. I’ve seen similar sentiments from other natural mothering advocates, but she expresses it most eloquently:

Let’s imagine the womb…

Dark, warm, lovely muffly sounds from outside, you’re naked, suspended in fluid. Nothing is scratchy, cold, or bright.

Let’s compare that to a cot in a hospital / nursery / living room…

Bright lights, cold air blowing through every time someone walks by. Loud, sharp noises – bells, alarms, the TV, a dog, children. You’re wearing a scratchy nappy and clothes. You’re laying in all this SPACE, you feel exposed, scared. Your brain is hardwired to keep you safe, and it doesn’t know a cot is safe. You cry for help because your brain thinks we live in 2000BC and a wolf will eat you if you’re left exposed.
There’s ONE place where your heart rate lowers. Your temperature stabilises. Your stress hormones drop.
That’s the chest of another human.

The soothing sound of a familiar heartbeat. A familiar smell. Warmth, darkness, arms enclosing you safe and close.

Skin to skin contact is home for newborns.

How does Lucy know that this is how infants feel? She doesn’t; she just made it up to suit her personal beliefs. She believes that infants feel “safe” in the womb, are “frightened” by life outside it and crave skin-to-skin and breastfeeding to recreate that feeling of safety.

It’s a “just-so story.”

Most people are familiar with just-so stories through the book Just So Stories for Little Children by Rudyard Kipling:

Kipling began working on the book by telling the first three chapters as bedtime stories to his daughter Josephine. These had to be told “just so” (exactly in the words she was used to) or she would complain. The stories describe how one animal or another acquired its most distinctive features, such as how the leopard got his spots.

But a just-so story is an appealing fiction:

In science and philosophy, a just-so story is an unverifiable narrative explanation for a cultural practice, a biological trait, or behavior of humans or other animals. The pejorative nature of the expression is an implicit criticism that reminds the hearer of the essentially fictional and unprovable nature of such an explanation.

It is the opposite of a scientific explanation:

…[T]he first widely acknowledged use of the phrase in the modern and pejorative sense seems to have originated in 1978 with Stephen Jay Gould, a prominent paleontologist and popular science writer. Gould expressed deep skepticism as to whether evolutionary psychology could ever provide objective explanations for human behavior, even in principle; additionally, even if it were possible to do so, Gould did not think that it could be proven in a properly scientific way.

What evidence does Lucy Ruddle provide for her assessment of infant psychology? Absolutely none. How could she prove her claims are true? It’s not clear that she could. How much does her culture — a culture that postulates that if it’s natural, it must be best for babies — influence her theory? She never considers how or even whether it does.

Like most natural mothering advocates, she imagine that infants feel safe in the womb, but they could just as easily feel bored. Natural mothering advocates assume babies are frightened by life outside the womb when they might be fascinated. They tell themselves and each other that infants crave a return to the old when they might actually be impelled toward the new. They claim that babies brains are “designed” for 2000 BC when, in truth, they are “designed” to make the best use of whatever environment they are born into.

Anyone who has ever spent an extended amount of time with babies knows that they love to acquire new skills. Consider the effort — and the bumps and bruises — required in learning to walk. Prior to walking, they are carried everywhere by parents. Why should they learn to walk if someone else is willing to do the work for them? But they try, and they try, and they try again until they master the skill and seem to be thrilled with themselves when they do so.

The problems with the theory do not end with the fact that it is unprovable and to a large extend literally unknowable. In my view as a mother of four, the theory founders on the belief that all babies are exactly the same and therefore need exactly the same things. Not all of my children liked to be held. Some tried harder to reach developmental milestones and reached them earlier. Two were adventurous and loved anything new while two were hesitant and had trouble with transitions. I initially tried to treat them exactly the same; they quickly made it clear that they each wanted and needed different things from me.

The ultimate irony, of course, is that natural mothering claims to be about meeting baby’s individual needs, yet its advocates imagine that babies are all the same, not individuals.