Supporting Breastfeeding: Let's Be Realistic in Our Expectations!

Conspiracy theory is a dangerous belief, as it potentially distorts one's capacity to rationally evaluate explanations of phenomena and precludes, all too often, any realistic approach to prevent or mitigate a given problem. On the other hand, the old adage that “just because you are paranoid doesn't mean that someone is not running after you” accentuates the dilemma of how to sort out what may be perceived as an organized attack on one's basic principles from what may be a realistic challenge to the implementation of beloved programs. Thus, in plain and simple words, shouldn't we possibly take the some of the issues raised by Jane Brody ¹ in The New York Times, and others, more seriously, rather than categorically dismissing them as part of an anti-breastfeeding crusade? No less so, shouldn't we begin to address their pronouncements as they may well be highlighting a combination of valid public health concerns, cultural clashes, and individual management dilemmas of the maternal–infant dyad, rather than simply writing them off as the purple prose of foot soldiers in the Mommy wars. I, for one, am willing to acknowledge the legitimacy of some of the issues raised by the more balanced critics without being concerned that I will be perceived by some as selling out.

Let me first dismiss what to me is the most egregious fault of these critics. Their claim that there is inadequate scientific evidence to substantiate the health advantages of breastfeeding for both the infant and mother is just plain bunk. One need not catalog again the reviews of the U.S. Agency for Healthcare Research and Quality, the monographs of the World Health Organization, or the 2012 Policy Statement on Breastfeeding from the American Academy of Pediatrics to realize the inappropriateness of quoting contrary opinions from individuals whose only qualification is the quality of their prose. Citing as evidence pronouncements from non-health professionals who are totally unequipped to dispute the validity of the evidence-based data not only doesn't hold water but is downright embarrassing for the science writers who presumably should know what is evidence, what is cultural bias, and what is just personal hang-ups. One must ask whatever happened to their journalistic standards.

On the other hand, if we can distance ourselves for a moment from the barricades of the Mommy wars, it behooves us to listen a bit to what the other side is saying. But before we attempt to analyze what is the gist of their complaints, let me state clearly what I perceive as the major challenge to us who are advocates of the dictum that breastfeeding is the normative and thus preferred way of infant feeding. Let us remember that while breastfeeding initiation rates in the United States have reached a relative satisfactory rate of over 75%, the disturbing statistics is the “any breastfeeding” rate at the recommended 6 months of only 44%. Similarly, the dramatic drop of the “exclusive breastfeeding” rates at 3 months to 33% and at 6 months to less than 14% is further testimony to the seriousness of the problem. Most upsetting is the fact that for minority infants, particularly those of color, breastfeeding rates are even lower by a magnitude of tens of a percent. Clearly our message is getting lost somewhere.

The point that I get from the Jane Brodys is that there is a chasm between our expectations based on our medical knowledge and evidenced public health recommendations and the cold realities of the actual world. When this is combined with the co-opting of our valid breastfeeding goals by individuals who have other agendas, it is not surprising that our message is, at best, being diluted, if not actually lost. For example, fighting the battle for the rights of a mother to nurse on an airplane (i.e., in the public forum) and not limiting the mother's nursing to her home is appropriate! Fighting for her right to nurse publicly in a non-discreet, flaunting manner is just plain stupid and frankly insensitive to realities of the cultural norms of our society. Requesting a mother to cover her breast (not her head) while breastfeeding is not analogous to asking an adult to have a meal under a blanket. Anyone with the most elementary knowledge of the maternal–infant attachment process and sensitive mothering would, in fact, encourage just such an act to minimize environmental stimuli from impinging on the infant at this intimate moment. I know of no infant who has complained of having to nurse from a breast that is not fully exposed to the world. Exposing one's self to make a point that is not in the interest of supporting breastfeeding and smacks of a defiant, provocative gesture to prove a point that has nothing to do with breastfeeding per se. The recently published Time magazine cover (May 21, 2012) is similarly a case in point. This provocative public display of a 3 year old nipping (not latching) onto his standing mother's fully exposed breast was frankly counterproductive as a case for prolonged breastfeeding and attachment parenting. In reality, it was nothing more than an advertising gimmick using the mother's svelte athletic and sexy figure to sell more magazines. Such friends we surely don't need!

We also need to remember that our battle is to encourage, facilitate, and support mothers so they will breastfeed for at least 3 months and ideally for about 6 months. Thus, investing our energy and resources in promulgating breastfeeding beyond a year for a small elite minority should not be our priority. Getting the large percentage of poorly educated mothers from the lower socioeconomic levels of our society to get past the psychosocial and economic impediments of the first few months is the real challenge. We also need to acknowledge that the breast in our American culture is perceived as a sex object and that is used both by individuals in their interpersonal relationships and by the media as a tool to influence and seduce. As such, advocating the breast as an organ for the benefit of the infant may be at odds with its cultural image and actual use. Thus, to say the least, it is a hard sell to define the new and more mundane nurturing role of the breast. Similarly, expecting that the rates of breastfeeding following hospital discharge for the African American mother will increase without acknowledging that the expectation that she will have the necessary critical support of a partner is totally unrealistic, given the extremely high rate of single motherhood and the high percentage of African American male young adults who are incarcerated in prison.

Hoddinott et al. ² recently published the results of a study infant feeding practices. Utilizing the technique of qualitative serial intensive interviews they concluded that there is “a clash between overt or covert infant feeding idealism and the reality experienced.” In particular, they ascertained that immediate family well-being is the overriding goal of most mothers rather than what is perceived as theoretical health benefits in the long term. Thus, when faced with difficulties in infant feeding or logistical problems in arranging for nursing or family tensions, the solution is to formula feed or introduction of solids. The authors conclude that focusing on the technical aspects of feeding does not address the family dynamics and that the emphasis should be one of focusing on incremental and realistic goals rather simply advocating unrealistic goals of 6 months exclusivity. This study only reinforces the observation of Wenzel et al. ³ (cited by Jane Heinig ⁴ ), who pointed out that individuals who are in a stressful situation because of their inability to meet what they perceive as unrealistic idealized goals will minimize further stress by avoiding any contact with the ‘health providers” who they perceive as the source of the stress and in turn dismiss the supposed risk of feeding formula either as not truly based on “truths” or as surely not relevant to their reality. These studies and the comments of the Jane Brodys emphasize that what is lacking is not the initial motivation of mothers to breastfeed or the lack of knowledge of the risk of formula feeding. What is needed is a combination of practical, family-centered guidance that not only focuses on the technical aspects of nursing but also on the emotional, behavioral, and cultural setting wherein the mother has to function. This guidance has to supply practical and concrete advice and address the specific barriers to successful breastfeeding in that particular mother. Mothers in stress or in non-supportive environments or who have cultural expectations of their role as mothers and sexual partners will continue to reject idealized feeding goals as a solution to their own needs, and hanging guilt will just reinforce their conclusion that it is best to dismiss and ignore those who are putting them into these unrealistic and uncomfortable positions.

From my perspective the advocacy of the technical aspects of breastfeeding can only go so far. What is need is more emphasis on the combination of the emotional, behavioral, and cultural barriers in those individual and population groups for whom the barriers are perceived as insurmountable. Mothers are not evil when they feed formula to their infants, and such mothers should not be treated as pariahs or subjected to what some have called the tyranny of breastfeeding. For those of us (and surely that includes me) who are convinced that breastfeeding and the feeding of human breastmilk has vital advantages over formula feeding (including providing better nutrition, increasing disease prevention, and maximizing infant neurodevelopment), the challenge is not simply a matter of maternal education or improved lactation counseling. What is needed is a focus of assisting each mother in defining and overcoming the behavioral and psychosocial impediments in her particular situation in a realistic fashion, while continuing to focus on the unique cultural barriers to breastfeeding in that particular mother's environment. This is the universal message for all of us, irrespective of where we are practicing breastfeeding medicine.