The Backlash to Breast is Best

Originally published on, April 21st, 2009

The worldwide “Baby Friendly Hospital Initiative” is a great campaign – get the baby skin-to-skin with mom first thing after birth, leave them be for an hour to start nursing, and basically phase out the nursery. A centerpiece of the initiative is to ban formula companies from giving out free samples in maternity wards. But perhaps calling it “baby friendly” was a bad idea. Perhaps it sends the message that breastfeeding is somehow not “mother friendly.”

That’s essentially what Hanna Rosin argues in an article in this month’s Atlantic, “The Case Against Breastfeeding.” (Babble ran a similarly critical piece by Marjorie Ingall a few years back; it’s still one of the “most viewed” articles). Rosin is a contributing editor and mother of three children, all of whom she breastfed, and the youngest of whom she is still breastfeeding, she has said – the several thousand words denouncing its health benefits notwithstanding – “because it’s nice.”

Rosin’s case against breastfeeding isn’t so much that it’s a pain, like housework. It’s that it is holding women back, “stuck at home,” like housework. She actually compares breastfeeding for the full year recommended by the American Academy of Pediatrics to the vacuum cleaner of Betty Friedan’s day, a symbol of domestic imprisonment. “It was not the vacuum that was keeping me and my twenty-first-century sisters down,” Rosin writes of her epiphany, “but another sucking sound.”

Of course, breastfeeding is both luxury and burden for Rosin, because she works from home. One can sympathize with this “middle-class mother’s prison,” but in her effort to break the chains, she starts questioning the “breast is best” pronouncements and public health rhetoric that equates exclusive breastfeeding with rearing baby Einstein. And here the article takes an unfortunate and irresponsible turn.

Rosin stays up late one night reading “dozens” of journal articles and concludes that it’s all a big lie – “magical thinking.” The recommendations of the World Health Organization, the American Academy of Pediatrics, and just about every health ministry across the globe; the claims that breastfeeding will make your kid smarter, happier, healthier; the idea that breastmilk is “liquid vaccine,” you hear all these things, “and then you read the scientific literature,” Rosin said on the Today show, “and frankly, there isn’t the solid evidence you’d expect to support it.”

That’s not my understanding of the evidence, so I called Miriam Labbok, MD, a professor of public health at the University of North Carolina, whom I was surprised wasn’t quoted in the article. Labbok has thirty-plus years in the field of maternal and child health, was recently senior advisor to UNICEF on infant feeding, and lately she’s been organizing conferences on feminism and breastfeeding. Labbok called in NPR to rebut Rosin (she’s has been on quite the media tour) and cosigned a letter to the Atlantic along with two dozen other researchers and advocates: “The online review of the medical literature described in the article misrepresents the evidence . . . ” it reads. The American Academy of Pediatrics also responded: “The evidence for the value of breastfeeding is scientific, it is strong, and it is continually being reaffirmed by new research work.”

“Epidemiological research always has confidence limits,” Labbok explains to me. Sure, if you scan a handful of studies, you’ll notice that one might show a strong association, one might show no association; that maybe three out of twenty achieve statistical significance. “But those who understand epidemiology go in and sort out the predominant evidence, and that’s accepted science.”

Rosin quotes a review article from 1984 but doesn’t cite the most recent and comprehensive epidemiological review of the literature, published in 2007, which surveyed 9,000 studies. This report is upfront about the limitations of studying breastfeeding (namely that it is impossible to conduct a randomized controlled trial – you can’t tell women how to feed their babies – and thus it is nearly impossible to prove causation) but nevertheless concludes, “A history of breastfeeding is associated with a reduced risk of many diseases in infants and mothers,” and goes on to name a dozen. There are some relationships that remain unclear, such as whether breastfeeding makes babies smarter or moms shed pregnancy pounds more quickly. But the thrust of the evidence is clear: breastfeeding is optimal. The full review, commissioned by the famously cautious U.S. Agency for Healthcare Research and Quality, is 186 pages long. Labbok tells me that based on this, AHRQ put out a clinical guidance, which they only do when they are “fully convinced” by the scientific data.

Rosin is right that the individual risk of formula-feeding her children may be relatively small, but public health is about the collective, and among a population the risks of not breastfeeding are significant. For example, formula fed babies will have more severe diarrhea and respiratory infections. One could argue that such consequences aren’t a huge deal if they are born into families with good access to health care (like Rosin and her friends). But however treatable these ailments, they become more serious among poor families in the U.S., and it’s clear that in non-industrialized countries they cause babies to die. That’s why the group Save the Children calls breastfeeding “one of the most effective interventions for newborn survival.”

That said, public health initiatives have been known to overstate risk and play on fear in an effort to affect behavioral change. And breastfeeding PSAs have shamelessly sunk to playing the bad mother card (see ad that likens formula-feeding to riding a mechanical bull while pregnant). No, formula is not poison. It is a life-saving intervention when needed, much like the C-section. A satisfactory substitute. The problem is that it should never have come to be seen as equivalent to normal physiology, the superiority of which is really quite breathtaking when you think about it.

A woman’s body goes through profound physical and hormonal changes to grow and birth a baby, but also to continue growing that baby after it is born. Some even call breastfeeding the “fourth trimester.” Physiology ensures that the baby will eat. And not just that she will eat, but that she will eat what she needs to eat, when she needs to eat, how she needs to eat. “Your body is capable of producing this amazing, perfect food,” writes author and cartoonist Kate Evans in a delightful new book, The Food of Love: Your Formula for Successful Breastfeeding (Soft Skull Press).

That kind of talk may sound frothy, but it is true. And what’s truly amazing is how the milk actually shapeshifts to meet the baby’s needs. Fresh out of the womb the baby gets antibody- and nutrient-rich colostrum, which primes the gut and immune system for life on the outside. Women who give birth prematurely actually produce more colostrum for a longer period of time – the body knows; mother and newborn may be separate but they are still very much in sync. The immunoglobulins within the milk actually change depending on the pathogens the mother is exposed to. A feed itself is dynamic, with the foremilk more hydrating than the creamy hind milk. “There simply isn’t any question that something is lost if you don’t breastfeed,” says Labbok.

Physiology – if we respect it, if we support it – keeps mother and baby physically linked in the immediate postpartum so that breastfeeding can be established. The umbilical cord, left intact, ensures this proximity (modern obstetrics routinely cuts it, but science continues to refute this standard practice). In fact, if born under optimal conditions, babies instinctively reach for their mother’s breast and start sucking away.

But the majority of U.S. maternity wards are not “baby friendly,” let alone mother friendly. Physiological childbirth itself isn’t supported, and thus part of the reason women find breastfeeding so difficult is because they are recovering from C-sections, or their babies’ esophageal tracts have been preemptively suctioned, and irritated, or they’ve been induced too early and can’t breathe on their own; and the cord was cut and the baby has been whisked away rather than getting the recommended immediate skin-to-skin contact, and many hospitals still routinely give formula rather than facilitating a breastfeed within the recommended first half hour; and most obstetricians don’t get involved, and most pediatricians don’t either, and nurses are busy, and lactation consultants are disparaged and cut out from insurance reimbursement, and here’s where the dissonance begins.

We tell women that breast is best, we tell them to breastfeed exclusively for the first six months, we even tell them it will raise their kid’s IQ (and we should give that a rest), and then we send them home with formula samples, or with a baby whose throat is too sore to suckle, or a mom whose milk is delayed because of surgery, and we don’t teach technique, and we are offended when a woman breastfeeds in public, so we make her feel housebound, and we don’t give a mother and her partner paid leave, and we send her to go back to a workplace without on-site childcare, and so her only alternative to formula is to plug her nipples into a machine, and if she’s lucky she gets periodic breaks and a “non-bathroom lactation room” in which to pump, and if she’s not she gets a toilet, and so on and so forth.

It’s no wonder women are ready to burn their nursing bras.

But it’s not that these public health recommendations are grounded in some return-to-the-1950s conspiracy, as Rosin suggests; they’re grounded in physiology. And science is validating the physiology of the mother-baby dyad – that is, both are healthier when they remain close to each other during the first several months postpartum. It’s not simply the milk that’s inimitable; it’s the mothering. (Indeed, “We actually don’t know if feeding infants human milk has the same benefits as breastfeeding,” says Labbok.) And mothering is something that our culture does not value enough to support. It is this dissonance between physiology and culture that has women so frustrated, and feminists like Rosin grasping at the bottle as a proxy for equality.

But is that really what we want? Powder rather than real power? In a brilliant New Yorker piece about the rise of the breast pump, Jill Lepore questions the direction of breastfeeding advocacy, which seems to be settling on the pump as a compromise to this conflict, with tax incentives for businesses with “Mother’s Rooms” in which babies are explicitly not welcome (“pump stations,” Lepore calls them) and Baby-Friendly hospitals sending women home with manual plastic pumps, and the president of the National Organization for Women calling for more “corporate lactation” programs. “It appears no longer within the realm of the imaginable that . . . ‘breastfeeding-friendly’ could mean making it possible for women and their babies to be together,” writes Lepore. “When did ‘women’s rights’ turn into ‘the right to work’?”

What a great question. Why did American feminism evolve in such a way that we think of biology as destiny, and that destiny as a prison? Why are we so willing to surrender the parts and processes that makes us female rather than demanding that society support them? We’ve broken down doors and cracked glass ceilings, when what we need to do is redesign the building.

Labbok, who’s worked in some fifty countries, tells me the feminists in northern Europe have done this. “In northern Europe, women fight for the right to breastfeed,” she says. There, feminism isn’t just about “making women act more like men,” the right of women to be full citizens and the right of babies to be given best possible care are not at odds. “There’s an understanding of human rights outside the U.S. that includes the right of women to breastfeed. And that means women shouldn’t be expected to do it unless everyone is fully supporting it – her family, her society, her workplace, everybody all the way down the line to her government.” And where there is paid leave, it should be noted, there are no “mommy wars.”

In the podcast accompanying the Atlantic story, Rosin reveals her pessimism: “We are never going to be Norway,” she says, rolling her eyes. “There will never be a situation in America where women . . . will have six months time to exclusively breastfeed their children.” Really? Did we ever envision an organic garden being planted at the White House by the nation’s black first family? This is the real tragedy of the mommy wars: they drag us down where expectations are so low, where we don’t value mothers enough to fight for them. We’re making a case against ourselves.

Originally published in Babble, April 21st, 2009