In her book Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood (New York University Press, 2010), Joan Wolf makes some points that resonate with me. I too find myself frustrated when we treat breastfeeding as a magic potion that confers magical properties to both the mother and baby. And I get angry when we tell new mothers “breast is best” and send them out in the world to solve breastfeeding issues on their own without much community support. (I’ll note here that we are making strides in this regard with the Affordable Care Act, the Business Case for Breastfeeding, the IRS decision to allow pre-tax dollars for breast pumps and other programs which, by their very creation and enactment, acknowledge that the community needs to help new mothers. But given book deadlines, the author may not have heard about all the good work that’s being done to remove these booby traps in time for publication.)
My concern is with how she addresses this pressure on the individual breastfeeding mother and lack of community support. And that’s because she heads in a direction we see all too often: the book devalues breastfeeding itself. Wolf concludes that the science supporting breastfeeding as being better than formula feeding is itself problematic and that in the “overwhelming majority of cases, either breastfeeding or formula feeding is a healthy option.”
The author argues that the consensus about the importance of breastfeeding is clear but hyperbolic and the science is sticky. Since randomized controlled studies can not be done to determine what effect breastfeeding may have (since randomizing a child to not breastfeed is unethical) we are left with observational studies. These observational studies can show correlation but not causation and therefore are inherently problematic.
In addition, observational studies showing the benefits of breastfeeding are marred by confounders, the most important of which, Wolf contends, is the inability to distinguish the benefits of breastfeeding itself from “a comprehensive commitment to healthy living that itself is likely to have a positive impact on children’s health.” So might it be, then, that the careful hygiene that a mother who chooses to breastfeed would practice that makes the difference and not the breastmilk itself?
She has no data to support that as a confounder: we do not know, as she suggests, that breastfeeding mothers wash their hands more or keep their children away from large crowds. But it is the theme to which she returns most frequently: the mothering technique of the breastfeeding mother is what counts, not the breastmilk. If mothers who fed formula to their babies just behaved as breastfeeding mothers do, we’d see the same benefits for those children. This can be so, since “science has not shown us how breastmilk works to protect a baby or promote health.” Therefore, without showing the causality between breastmilk and its purported benefits, we can ignore the observational evidence and conclude that breastfeeding has no real benefit to the developing world.
She also questions why feminists haven’t paid attention to the “all encompassing physical and emotional commitment from mothers” that choose to breastfeed, emphasizing the individual personal responsibility involved and the implied need to raise a child in a risk-free environment. She says the book is “an expose of motherhood and the collective fantasy that mothers can and should produce perfect children.” As to this last point, she shares many examples, but no data.
In order to evaluate Wolf’s premise that the science is problematic, we have to understand observational studies. Observational studies help generate or test a hypothesis. In these studies, groups with a certain risk factor are compared to those without the risk factor and then followed prospectively or retrospectively to find out whether or not the outcome of interest (disease, developmental outcome…) occurred.
And there’s the rub. Lactation is not a risk factor. It’s a physiologic process. And it’s hardly incumbent that those proposing to stick with physiology prove why we’d want to do such thing. Lactation is physiologic. It starts during pregnancy and continues after birth, on purpose. The risk factor is whatever is going to interfere with physiology. And if we choose to interfere with physiology, then the research question is not “does breastfeeding provide benefits?” but is “does the intervention cause harm?”
My hope is that the motivation for any book like this would be similar to the motivation we all share: to make sure that infant feeding decisions are informed; to support the mother in attaining her goals for her child; to engage the community to help her along that journey. A mother who has chosen to breastfeed needs our support. Devaluing the process of breastfeeding, attacking the science or the physiology, doesn’t make that decision less important to that mother.
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Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM is a general pediatrician and breastfeeding medicine specialist in Milwaukee, Wisconsin. She shares her thoughts on pediatrics and breastfeeding at www.drjen4kids.com, on Facebook (Dr Jen 4 Kids and Lakeshore Medical Breastfeeding Medicine Clinic) and on Twitter @LMCbreastfeed.