AmyTuteurMD

AmyTuteurMD
Bio
Dr. Amy Tuteur is an obstetrician-gynecologist. She received her undergraduate degree from Harvard College and her medical degree from Boston University School of Medicine. Dr. Tuteur is a former clinical instructor at Harvard Medical School.

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OCTOBER 20, 2009 7:56AM

Is breastfeeding a moral imperative?

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breastfeeding

Feminist scholar Michele Crossley's recent paper in the journal Feminism Psychology raises important questions about breastfeeding, and by extension, about unmedicated childbirth. Breastfeeding as a Moral Imperative: An Autoethnographic Study makes a controversial claim:

...[F]ar from being an 'empowering' act, breastfeeding may have become more of a 'normalized' moral imperative that many women experience as anything but liberational. Accordingly, an uncritical appropriation of the idea that 'breast is best' may not only be disempowering for women, but also problematic for babies.
Crossley begins by exploring the place of breastfeeding within our culture:
Many contemporary social movements ... highlight the risks associated with modern technology with the consequence that the rhetoric of the 'natural' has proliferated... This whole idiom of the 'natural' has surrounded childbirth and child-rearing and has been a key theme in the 'alternative birth movement.' As Oakley argued, 'like natural childbirth, natural infant feeding has become fashionable in a society that is technological "by nature"'.

...[B]reastfeeding has been associated with women's personal agency and empowerment. The promotion of breastfeeding has constituted part of an attempt to 'demedicalize' life events (such as pregnancy) and to return such processes to the 'rightful moral domain under the control of women themselves.'
Crossley's paper isn't really a study. It's just a description of her personal experience, which has led her to re-evaluate the rhetoric she previously accepted. Like many white, Western, well off women, Crossley uncritically embraced the bizarre notion that there is a "right way" to give birth and to "bond" with a newborn:
Related to my desire to establish a strong 'bond' was my desire for a 'natural' childbirth. I had read that if a delivery entails a lot of intervention, then the baby emerges into the world potentially traumatized by the effects of drugs and bright lights, all of which make the bonding process more difficult...

In preparing for labour, I totally discarded any notion of interventions such as a caesarean ... After over fourteen hours of labour, when the baby was eventually delivered by emergency caesarean section ... the first thing I remember was that I 'had to get that baby to the breast'. Because I had not had the opportunity to bond at the moment of birth as I had been anticipating, it made me all the more determined to ensure that breastfeeding happened in the way I wanted.
But the actual experience of breastfeeding was nothing like she had been led to believe. From the very beginning, the baby did not appear to be getting enough milk. Despite growing evidence that the baby was failing to thrive (his weight had fallen from the 75th percentile at birth to the 5th percentile at 10 weeks), and desperate entreaties by the baby’s father, Crossley refused to relinquish the fantasies promoted by breastfeeding advocates.
...The message that had been 'drilled into' my head at the antenatal classes and from the books I had been reading was that 'you always produce enough breastmilk', 'breastfeeding is a perfect system'. In fact, I had even asked the health visitor at the time if the baby’s constant screaming could be explained by the fact that he wasn’t getting enough milk. Her response was that 'you always produce enough breastmilk, always, there’s always enough ...'
The baby's father became frantic:
...I had to confront you about the breastfeeding. I felt at that point that we were gonna kill him or do him some serious damage ... and I just thought he is not gonna survive this. I felt as if I was, I suppose, I was the only person who could see this ...
They began bottle feeding the baby and he began to thrive. Crossley, however, was torn by feelings of guilt and shame:
I felt like a failure because ... I had 'taken on board' the message that breastfeeding was really difficult, it was hard work and 'many people didn't manage to do it'. One had to be 'really determined' to succeed, but if 'you tried really hard, you could manage it'... [M]y experience was entirely consistent with a woman in Lee and Furedi's study who commented that women who 'succeed at breastfeeding are made to feel like it's such an achievement, they have done so well, they deserve a medal…' As Lee and Furedi argue, some women have come to view breastfeeding as a 'measure of motherhood and consciously or unconsciously judge other mothers accordingly'...
Crossley's personal experience has led to an epiphany:
...[A]s with other health-related behaviours, the act of breastfeeding can become inextricably interrelated with the construction of identity and the creation of a sense of morality, values and orientation to 'the good.'

[T]he act of breastfeeding came to symbolize all that was important about being a 'good' mother. It meant 'bonding' and forming emotional connections, 'being there' for the infant, learning to 'go with the flow', 'letting go of the instinct to control' and 'learning to trust in one's own body'. Dykes has previously characterized this understanding of breastfeeding as deriving from the 'natural' discourse that has been popularized in recent years.

Crossley concludes:

Breastfeeding, far from being the 'resistant' body-project that advocates of demedicalization and 'women-centred' alternatives originally promoted, may have become more of a 'normalized' moral imperative that some women experience as anything but liberational ...

Lactivism is part of a distressing trend of grading motherhood as if it were  an exam and high scores obtained by appropriate "performances" at purportedly critical moments. Unfortunately, both the "grading" and the choice of "performance" have been chosen a select group of women, wealthy, white women from first world countries. The have managed to elevate their personal preferences to some sort of "ideal" to which other women should aspire.

Uncritically accepting what are nothing more than the cultural norms of a small group of self-appointed arbiters is dangerous to the well being of other mothers, but that, of course, is the point.  Just as in any cultural setting, the social arbiters enhance their own self-esteem by defining themselves as superior and excluding others who disagree.

In Crossley's case, her baby was literally starving for months while she attempted to meet the arbitrary performance standard. Fortunately the baby's father could stand apart from the cultural tyrrany and recognize that the most important part of parenting an infant is feeding it, not the method used to accomplish that task.

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Ah, well, I suspect that society has turned breastfeeding into a moral imperative in much the same way some have attempted to turn other behaviors into moral imperatives: Mainly by attempting to marginalize and even mock those who choose differently.
It's not society in the aggregate because large swaths of society are completely comfortable with bottle feeding. It a small group of white, Western, relatively well off women who have attempted to promote their personal preferences as an ideal to which other women should aspire.
I had my two boys in 1994 and 1996. I did not wish to breast feed either one and did not (for a litany of reasons that are away from this post). The pressure and criticisim I endured from physicians, friends, colleagues and family (even to this day), nearly drove me to anti depressants. Thankfully my husband was the one exception and did not pin either my womanhood nor my parenting "success" to my decision to feed our children one way or another. When women really feel comfortable defining "natural" to what is right for them, and not soley as a product of what our bodies can or can't do, or medical interventions, we will all be the better for it.
Is this a common problem, where babies do not get enough milk from their mother's breast?

Also, I have been told (I haven't read any scientific studies) that the first few days of breast feeding give the baby resistance to certain allergies, etc. Is that true?

I was born in 1953 when breast feeding was not in vogue. My mother didn't breast feed me and I ended up with hay fever, allergies, asthma, etc. Is their any POSSIBLE connection between the two?

Interesting post. A perspective that isn't usually put forward because it does seem like breast feeding is universally praised.
Elisa Minecci:

"Thankfully my husband was the one exception and did not pin either my womanhood nor my parenting "success" to my decision to feed our children one way or another."

The insistence on breastfeeding as the only right way to feed a baby is part of an fiercely held belief among certain mothers that process is more important than outcome.

The true success of parenting is in raising a healthy, happy, well adjusted child. That's hard to do, and there's no way to know in advance how it will turn out. It is so much easier and more comforting to pretend that breastfeeding or a vaginal birth means that you are automatically a good parent.
Roger:

"Is this a common problem, where babies do not get enough milk from their mother's breast?"

During my training I was taught that it almost never happens, but that's simply not true.

Crossley's experience is more common than previously though and can have potentially fatal consequences. The paper Life-threatening hypernatraemic dehydration in breastfed babies (Archives of Disease in Childhood 2006;91:1025-1026) reports:

"We describe five babies, who were exclusively breast fed, with life-threatening complications of hypernatraemic dehydration secondary to inadequate breast feeding. An increased awareness among health professionals is required so that this potentially devastating condition can be prevented.

Five babies presented with hypernatraemic dehydration secondary to inadequate breastfeeding. In all five neonates, the presentation and early clinical course were similar: they were the first children of healthy non-consanguineous parents, born after uncomplicated pregnancies and deliveries, and were exclusively breast fed. They were regularly assessed by their midwives and in neonates 1, 3 and 5 by their general practitioners, and all the mothers were reassured that their babies were feeding adequately and did not need to be weighed. When subsequently seen at their local hospitals, all the babies were profoundly dehydrated with cold peripheries, scaphoid abdomens and doughy skin, but normal fullness of the anterior fontanelle...

All the babies had severe hypernatraemic dehydration and acute renal failure . Neonates 3–5 required paediatric intensive care management, with ventilation for a median of 7 (range 3–12) days. Neonates 3 and 5 required haemofiltration . A detailed renal ultrasound scan with Doppler imaging of the renal vessels and the aorta and its main divisions was carried out in all the babies. Neonates 1, 3 and 5 had extensive vascular thrombosis at the time of referral, and received systemic thrombolysis with tissue plasminogen activator followed by continuous heparin infusion. In neonate 3, as there was no resolution of the aortic thrombus, local thrombolysis via a femoral arterial catheter was given."

I don't mean to suggest that breastfeeding isn't beneficial. It certainly is. During the early weeks it provides immune protection against certain illnesses, for example. The data on other possible benefits, like preventing allergies, is far less definitive.
I enjoy your vaguely incendiary posts.
Breast feeding is another attempt to add more chores to "liberated" women.
Well put, Dr. Amy. I'm fed up with the breast feeding Nazis forcing this on women when they should have a choice. As you say, the important thing is that the baby receives nutrition whichever way.
triestina:

"Breast feeding is another attempt to add more chores to "liberated" women."

I agree. It's just another way for people to label women as "failures."

There's also another aspect, though, that's below the surface. Many lactivists believe, consciously or unconsciously, that a woman's place is in the home. The problems that many women face, single parenthood or the need to work, are dismissed out of hand. The subtext is that "good" mothers are mothers who stay home.
madcelt:

"the important thing is that the baby receives nutrition whichever way."

You would think that everyone would recognize that, but there is an irresistible urge among some women to obsess about process instead of outcome.
I think part of the problem is that society has, until recently, insisted that bottle-feeding is best because it doesn't involve boobies. The fact that breast-feeding is still regarded as something vaguely shameful that can't be done in public makes breastfeeding activists overreact in the opposite direction-turning breastfeeding into a "moral imperative" makes it easier to argue for the right to do so in public, the right to have accommodations made at work, etc. If it's just not that big of a deal, then why should we worry about making it easier for mothers to choose to breastfeed?

Every woman (not just rich white women with cushy corporate jobs or stay-at-home mothers) should have a right to breastfeed if she chooses, but it should be a free choice, not something she is pressured into.
I really don't see how an exhausted, in-pain, depressed, desperate, worried mother is bonding more with her hungry baby because she's attempting to nurse it than one who is happy, healthy, and bottle-feeding it formula.

It's a general rule that most women can produce enough milk for their babies and that most babies can come out without having to be surgically removed. But only a fool would insist there are no exceptions.
I would have bet that this post would have stirred up a lot more controversy, but it is only 8:45am.

Upon further reflection I can't help but wonder how selfish women are that put process ahead of outcome. After all, don't we all want healthy babies?
Ali512:

"Every woman (not just rich white women with cushy corporate jobs or stay-at-home mothers) should have a right to breastfeed if she chooses, but it should be a free choice, not something she is pressured into."

Amen!
Leeandra Nolting:

"But only a fool would insist there are no exceptions."

Even worse is the insistence that "failure" to breastfeed of have a vaginal birth is a failure to try hard enough.
Roger:

"I can't help but wonder how selfish women are that put process ahead of outcome. After all, don't we all want healthy babies?"

It's astounding to me. On MotheringdotCommune, a center of lactivism and "natural" childbirth advocacy I have read some truly mind boggling declarations.

One mother wrote in to describe how "proud" she was of herself and her daughter for successfully having a vaginal birth at home after two previous C-sections. Her daughter was unexpectedly dead at the time of birth, but she was still "proud" of herself.

On another occasion a member reported the unexpected death of her baby during a planned unassisted homebirth. Another member hastened to point out that she shouldn't feel like a failure merely because her baby was dead.
Donna,

Thanks for the link to your post.
Framing is wrong here. Of course breast feeding is a moral imperative for a society. It is wrong to think of breast feeding only as something that one woman does for her baby. Breast feeding is a socially constructed and supported activity, that occurs when a wide range of social supports and conditions are in place to make it possible for as many women as is possible. It is something that women do for their baby's and that societies facilitate for their children and future adults.

The superiority of breast milk in nutritional terms is not disputable (in the vast majority of cases) and the case for the bonding value of breast feeding is strong. But the imperative does not rest on the woman exclusively and any assertion that it does misunderstands the social nature of the human animal.

Breastfeeding should not be "liberational" and to imagine it as such is high foolishness. Nothing makes us more dependent on one another than the birth of a baby... fathers know this as well as mothers.

Pro-breastfeeding culture substitutes one set of interdependencies (a social support network and value system that surrounds and supports the nursing mother) for another ( a corporate formula production system and commercial values). We should rightly view the first as superior to the second, but neither represents a victory of the individual over the community or group.

63% of Oregon women breastfeed at 6 months, 69% or Utah women breastfeed at 6 months (http://www.statehealthfacts.org/comparebar.jsp?ind=501&cat=10), and those look to be among the better 6 month rates. In other states, Illinois, we're looking at disastrous 15% rates at 6 months.

It's not strictly speaking about you (it never is.) The choices we make are influenced by the choices that those around us enable us to make. We have to think about social choice, not individual choice. Are we going to be a breastfeeding society or not?

Whether an individual woman makes that choice will always depend partly on her circumstances and medical issues, but conceptualizing it strictly as a choice made between a woman and her baby is an mistake. Employers, spouses, extended family, cultural values, media, breastfeeding physical infrastructure all make the difficult possible... or less possible.

Liberation indeed. Life is a web of dependency, within which we exercise choices, but which also makes good choices possible, and limits us too. Breastfeeding is about creating a culture of health.... not a glorification of the individual's power.
I wanted to breastfeed, hearing all about how "breast is best," how the baby's immunity will be stronger, how the mother-child bond will be closer, etc. Breastfeeding was a nightmare, especially with the lactation counselors the hospital provided. The positions they wanted me to feed in were painful and uncomfortable, and when I wasn't producing enough milk, they acted as if they had never heard of such a predicament before. The day before I checked out, one told me, "I am so worried for this baby. You just need to try so much harder."

Luckily, I had lots of friends who had been down the same path and let me know it was okay to supplement my breast milk with formula, and a husband who was extremely supportive and understanding. I managed to make milk for about three months before stopping.

I am glad I was able to provide some of my son's nutrition, but I don't think I'll be breastfeeding if we have a second--it's time-consuming, uncomfortable to painful, stressful--and I am not sure its benefits outweigh its deficits, at least for me.

Ideally, families should be given honest information to make the decisions that suit them--not pressured or bullied into what others think is best.
BenAdam:

Thank you for your thoughtful comment. I was with you until this:

"Breastfeeding is about creating a culture of health"

No, it's not. It's a way of feeding a baby. It is the desire to freight it with all sorts of cultural baggage that is causing the problem.
zandermama:

"Ideally, families should be given honest information to make the decisions that suit them"

I agree, and honest information includes telling women about things that can go wrong, and counseling them that the method of feeding the baby is not an indication of the mother's love for the baby.
There are so many intelligent, caring women who have only the best of intentions when it comes to caring for their infant, and yet they are blindsided by the messaging "breast is best." Part of the problem is that a portion of those who do manage to exclusively breastfeed feel as though it warrants a lifetime of bragging and preaching rights, which only increases the peer pressure . I delivered all three of my children by c-section, and wasn't able to exclusively breast feed any of them (even though that was my desire.) Does this make me any less of a mother? I think not. If you're looking to hear more about the realities of breastfeeding, I co-authored a book called "UNBUTTONED: Women Open Up About the Pleasures, Pains, and Politics of Breastfeeding." Twenty-five amazingly talented writers share their stories about the good, the bad, and in-between b-feeding experiences.
Maureen Connolly:

"Does this make me any less of a mother? I think not."

I agree.

My children are young adults and teens now, and the issue of how they were fed as infants is entirely irrelevant. I think back to the playground squabbles among the mothers and I can see how their children turned out. The success (or lack) in raising happy and productive adults had no correlation with the method of infant feeding.

That's hardly surprising since parenting is a lifelong process of identifying and trying to meet the needs of each individual child, not a series of performances that can be graded by others.
"Cultural tyranny"?!! No, not every woman can breastfeed, but such women are few, and the benefits of breastfeeding are still overwhelmingly favorable in comparison to formula. Human breast milk is one of nature's "super foods" and actually changes its nutritional content for the infant's benefit, especially in the case of premature infants. It protects against ear infections through at least the first two years after birth, not to mention all the mother's antibodies being passed to the infant. You didn't mention any of this.

As for medicated childbirth, the leading culprit behind ADHD, learning disablities, and other problems, I can't imagine hoping and praying for a normal, healthy infant, and then drugging it before it takes its first breath. Natural childbirth can be painful at times, but it's one day of a woman's life, for God's sake!

I went through natural, drug-free, Certified Nurse-Midwife assisted childbirth twice at ages 32 and 34 after two miscarriages with no problems whatsoever. I also breastfed for four years straight, one baby into the next, keeping in mind that most of the world's infants are assisted into the world by midwives and also, most mothers breastfeed throughout the world.

This seems a silly topic, unless the medical establishment views natural childbirth and breastfeeding as a threat to profit. Instead, why not address the fact that the medical establishment performs far too many (profitable) Casearean sections in this nation? How about the fact that our "high tech" system ranks 17th in the world for infant mortality? What about all the problems associated with medicated, drugged childbirth for both mother and baby that the medical establishment rarely admits, just as its control of the media is reflected in its failure to admit the hundreds of thousands of deaths it causes every year!

Why don't you address some real issues concerning childbirth in this nation!!?
Ramesh:

"WHY NATURE GIVEN BEREAST TO WOMAN?"

That's what's known as the naturalistic fallacy, the claim that because something has always been a certain way, that is the best way.

Do you brush your teeth?

Nature certainly didn't intend that you brush your teeth. Both the brush and the toothpaste are unnatural. Yet brushing your teeth is better than not brushing them, right?

There are a lot of bad things in nature: hurricanes, earthquakes, plagues. That doesn't make them good or necessary.
Amy, the "culture of health" line does sound too much like "culture of life", and I certainly did not mean to imply that whole set of political arguments. But I'm glad you agreed with what I said, and I intended "culture of health" to sum up those arguments, so perhaps a different moniker would be appropriate.

Yes breastfeeding is about feeding... but the whole point is that no mother feeds her baby on an island.... everything around her makes it possible, or difficult... that's the culture. And we as a society choose whether to create that culture... call it what we will.
From a purely sociological pov - The part of society that wishes to remain in the control of men (for example, everyone at Fox News) has a vested interest in keeping women shackled to notions /abitrary standardsof being perfect mothers - these notions serve to control mothers and predict what products and services they will buy (how valuable to the arbiters of these standards!), and keep women so busy turning this way and that trying to meet the performance standards, they don't have time to worry about real empowerment as they raise their children - their job becomes solely to raise their kids 'right' , and they are bamboozled into thinking this is empowering. It's fine if a woman chooses to focus entirely on her kids and raising them well - parenthood (not just motherhood) is a job to be taken seriously. But creating fear in women that if they don't do x and y they are not doing it right is an excellent recipe for disempowerment...and it handily keeps them niched into an area where they are more easily controlled.
Soap Box Amy:

"No, not every woman can breastfeed, but such women are few, and the benefits of breastfeeding are still overwhelmingly favorable in comparison to formula"

They are not remotely close to the benefits of vaccination yet you oppose vaccination. If it's all about the benefits, then shouldn't you do what is MOST beneficial.

"As for medicated childbirth, the leading culprit behind ADHD, learning disablities, and other problems, "

Hmm, in earlier decades women were drugged into a stupor by medications that crossed the placenta, and virtually all women in the US received those medications. Current medications are much milder, have fewer side effects and are far less likely to reach the fetus. In addition, the proportion of women receiving pain medication in labor has actually dropped.

Are you suggesting that dropping the uniform insistence that all women receive scopolamine and morphine in labor increased the risk of ADHD, learning disablities, and other problems? That's a novel theory.
BenAdam:

"Yes breastfeeding is about feeding... but the whole point is that no mother feeds her baby on an island.... everything around her makes it possible, or difficult... that's the culture. And we as a society choose whether to create that culture... call it what we will."

I passionately favor increased support for breastfeeding mothers within the workplace and elsewhere. Nonetheless, it is important to realize that the benefits of breastfeeding, while real, are quite small. When viewed in that light, making women feel guilty for not breastfeeding seems pointlessly cruel.
Sandra Stephens:

"But creating fear in women that if they don't do x and y they are not doing it right is an excellent recipe for disempowerment...and it handily keeps them niched into an area where they are more easily controlled."

That's the dark side to lactivism, homebirth, attachment parenting, etc. It is predicated on the notion that women are supposed to be at home meeting their children's every need in preference to any needs of their own.
I do think discussions such as this one set up a false dichotomy, in which one side must be wrong in order for the other to be right. It's possible to say that breastfeeding is best — which I firmly believe — without declaring that formula is worst. There are several worse possibilities. Out here they range from stretching a nipple over a can of diluted evaporated milk to death from malnutrition or dehydration.

Likewise, it's possible to say that breastfeeding is not always possible or even desirable without declaring that any attempt to promote it is evil, and without casting all efforts to support it as manipulative.

Nearly all parents want what is best for their children, even when it involves sacrifice on their parts. The world often does not allow for easy choices between competing interests. But women don't need to fan the flames licking at the feet of their sisters.

Disclaimer: I nursed my biological children exclusively, on demand, until they weaned on their own. None of the dire results that were predicted have befallen them, and they're now well into their 20s.
High Lonesome:

"it's possible to say that breastfeeding is not always possible or even desirable without declaring that any attempt to promote it is evil, and without casting all efforts to support it as manipulative."

Of course. Unfortunately, we've gotten to the point where women who should know better are literally allowing their babies to starve in an attempt to maintain membership in the group of women who breastfeed their babies exclusively. That suggests that the messages being sent to women are not benefit those who receive them, but only those who send them.
When we were starting our family, we were self-employed w/o medical insurance. We liked the "natural", non-surgical aspects of home birth, but a large part of our choice when I became pregnant the first time was financial as well. A homebirth with a midwife would cost about 1/3 of a hospital delivery. When you're paying cash, that's a big deal. Our first attempt, we used a mid-wife. She lived down the street, was well-known, had excellent references (including some docs) and I don't blame her for my miscarriage.

Next time, when we had our son, we went the traditional route. 9I write about it here: http://open.salon.com/blog/blue_in_tx/2009/08/11/personal_story_wimpy_white_boy_miracle ) Needless to say, I didn't get to breast feed normally. I did pump and fed him that way up to about 3 mos. I did feel "less than", and it was hurtful.

I've had friends for whom breastfeeding is effortless. Savings is a again a powerful motivator for some women. Through three kids, at $15 per can of formula and a can a week average, breastfeeding represents substantial savings. If a family is not poor enough for WIC, but right on the borderline, that could be crucial.

Doctors and hospitals push the formula, putting it in give away diaper bags etc. I'm not sure that's a good thing any more than coercing women to breast feed is a good thing. I agree with the commenter who said moms should get to choose and not be judged either way. To really choose, moms have to be informed about breast feeding as well as given formula samples.
Are people unfairly judgmental of those who make different parenting decisions? Absolutely. But that's the name of the game: parenting is one of the most personal things you do. Of course people feel passionately about the choices they make. Look at any parenting issue, particularly those that affect babies and young children: spanking, feeding (not just nursing, but introducing solids, what to feed, etc), sleeping. They all have rabid, opposing sides. Breastfeeding moms get a lot of mud slung at them too, "Oh, when are you going to wean that baby?" "Are you going to do that HERE?" "Ewwww, he's sucking on WHAT?"

This "study" as you said consists of one woman's experience. In your citation you don't mention her consulting her doctor or a lactation consultant. That was an unforgivable error, and shouldn't be blamed on breastfeeding advocates. Nowhere do lactivists say you have to do it on your own. She could have sought a La Leche League meeting, which likely would have recommended that she see a professional.

I breastfed both of my children, each for over a year. With both I went back to work full time when they were less than 3 months old. Neither got a drop of formula. My son has a chromosome abnormality that gave him low muscle tone, and his speech therapist credits his great eating and speaking skills with the fact that he nursed for 15 months, building and toning the muscles of his mouth.

I respect women who own their choices. I owned mine, and didn't care when people told me I should be weaning. Formula feed if you want, but own your choice, and don't blame others for your feelings on that choice.
I would also add that formula companies make a killing (literally) in developing countries by plying new mothers with samples just until their milk dries up, then forcing them to buy formula. Infants die because of formula mixed with contaminated water in these countries, and many lives would be saved if these women were given breastfeeding support.
Just thought I'd share this - my brother became quite enamored of the lactivism movement, and one evening was spouting off vehemently about good mothers 'should' do. My mom listened quietly until he was done and then informed him that none of her children were breast fed - not one. For whatever reason, none of us thrived on her milk though it was plentiful. When my birth weight of 4 lbs dropped to under 2 lbs she stopped killing herself with guilt that what was 'natural' was also, somehow, her fault (she was determined that she'd raise at least one of her kids 'right' after going through the same problems with my brother), and from that point on I thrived on formula and mom let go of her guilt - for which I'm glad.

Here's a particularly strange note: my sister breast fed supplemented heavily by formula; while in the hospital, they brought my mom a baby with a cleft palate - the mother refused to breast feed it. My mom said sure she'd give it a try, and the baby thrived - whatever elements in her milk that weren't working for us, worked for that baby. Happy endings all around, but nothing done as it 'should' be.
Ah, this again. . . Wouldn't it be great if women were just left alone to make their own choice? Both camps in this and the "birth debate" disgust me.

There are no cookie cutters in life, everyone has their own situations and must make their own choices accordingly.
First of all, if this is an attempt to empower women it falls severely short. To empower, we must all be free to choose and given both sides of the story. You have given us your side only, and in effect hurt your own argument.

I just assumed given your resume that you would be giving more objective information rather than,“the issue of how they were fed as infants is entirely irrelevant.”

Entirely? Did you really intend to use such strong language? How about “in my opinion….” And then provide us with some studies to support that.

One reason that my husband and I chose breastfeeding for our family was that the jury is still out on the long term benefits associated with breastfeeding. You must know that! Some studies indicate that long-term immunity to certain diseases, including diseases that the mother and father have had, and reduced rates of cancer MAY be possible. Some studies that have contrasted the U.S. with other cultures who almost exclusively breastfeed have supported this finding. Now, comparing cultures isn’t a controlled study, I understand that it is difficult to compare with so many other variables. But, other studies have linked reduced rates of allergies and autoimmune diseases decades down the road. And some rather important studies highlight increased I.Q.’s among breastfed babies.

Whether or not you agree with these findings, you must admit that many of your colleagues do. You are doing an irreparable disservice to your patients by exerting your opinions as fact. You also make folks doubt the validity of all medical advice. In the end you might fan the flames of the wild conspiracy theories of some folks because of your own unwillingness to face the gray areas. As a doctor, it is ok to admit “I don’t know for sure.” In fact, I would actually trust you more.


Breastfeeding was not as fun and easy as the proponents told me. I will absolutely agree with you on that point, and I am glad that it is over. But after reading the studies that I mentioned above, flawed as they might be, we made the choice partly because my husband and I both have allergies and his side of the family has cancer. Sure, I wanted to bond and feel natural too, but that’s not the only way to do that. My sisters and most of my friends chose to use formula and we all support, and never preach, to each other.
>Fortunately the baby's father could stand apart from the cultural tyrrany and recognize that the most important part of parenting an infant is feeding it, not the method used to accomplish that task.

Hear, hear! Thank you for this important post, Dr. Amy, and for reminding us that what's "best", especially where child-rearing is concerned, is often highly personal.
kathleendsm:

"I breastfed both of my children, each for over a year. With both I went back to work full time when they were less than 3 months old. Neither got a drop of formula."

So?

Does that make you a better mother? Does that mean you care about your children more than other mothers care about theirs?

I say this as someone who breastfed all four of my children. We have to get away from some women claiming superiority over other women simply because they chose to feed their children differently.
High Lonesome:

"But women don't need to fan the flames licking at the feet of their sisters."

That is the essence of this post. Thank you for articulating it so clearly.
Great points as usual, Amy. However, I found this (what I believe is one of your more important points) buried in a comment below:

"I don't mean to suggest that breastfeeding isn't beneficial. It certainly is."

The article above lacks any mention of the benefits of breastfeeding for mothers who are able to do so - and these benefits are a separate and distinct issue from the feelings of shame and peer-pressure felt by mothers unable or unwilling to breastfeed - that societal stigma is certainly misplaced, I agree with you.

Some other people's comments have alluded to this as well - there is a wealth of data to show that formula is not nearly as nutritious as breast milk, and breastfeeding as an act promotes bonding. Bottle feeding and/or formula are certainly important alternatives for mothers who can't breastfeed, for whatever reason.
If someone CAN breastfeed though, the data seem to show that milk is better for the baby than formula or a bottle. I think its important to strip the emotional responses from the issue and look at the facts.
Blue in TX:

"To really choose, moms have to be informed about breast feeding as well as given formula samples."

Agreed, but is it right to assume that women who choose bottlefeeding are uninformed?
Sandra Stephens:

"My mom listened quietly until he was done and then informed him that none of her children were breast fed - not one."

Great story. How did your brother respond to your mother's declaration?
Y Heron:

"One reason that my husband and I chose breastfeeding for our family was that the jury is still out on the long term benefits associated with breastfeeding."

No, not really. There are benefits to breastfeeding, but they appear to be quite limited.
Dr. Amy: as i read thru the comments, I was amazed at how frequently you responded, in detail, to all of us. I've never seen that in any other blogger. I admire your commitment to understand us, and educate us. And I wish my physician was more like you. It is my hope, wish, blessing upon you, that this rare drive you have to understand and educate is a joy to you--and not something that drives you. What a gift to your patients, and to us.
suzlipman:

"what's "best", especially where child-rearing is concerned, is often highly personal."

Exactly!
aliquot:

"breastfeeding as an act promotes bonding"

The nutritional benefits of breastfeeding exist, but the reality is that they are really quite small. As far as bonding is concerned, there is no evidence that breastfeeding improves bonding. The most important problem with studies of bonding is that there is no objective way to measure bonding.
ame i:

"I had an emergency C with my first daughter but didn't feel I had missed out on any bonding moments."

The argument that C-sections or bottle feeding interfere with bonding strikes me as similar to insisting that if you didn't love your husband at first sight, or if you didn't date according to a prescribed ritual, your love for your husband is somehow compromised.

The mother child bond is deeply complex, evolving, and dependent on the personality characteristics of both members of the pair. To suggest that the initial meeting or the method of feeding would have an impact on that strikes me as absurd.
KennewickMan,

Thanks for your kind words.
Amy, no, it doesn't make me a better mother. My point was in response to your comment later on:
"There's also another aspect, though, that's below the surface. Many lactivists believe, consciously or unconsciously, that a woman's place is in the home. The problems that many women face, single parenthood or the need to work, are dismissed out of hand. The subtext is that "good" mothers are mothers who stay home."

My point was that I managed to breastfeed and work a demanding job outside the home full time.
Ok, Amy, I agree with you here and you're quite correct:

"The most important problem with studies of bonding is that there is no objective way to measure bonding."

So, then how does this comment below follow from the one above?

"The mother child bond is deeply complex, evolving, and dependent on the personality characteristics of both members of the pair. To suggest that the initial meeting or the method of feeding would have an impact on that strikes me as absurd."

If we can't objectively measure bonding, then how do we yet know WHAT could affect it? It is conjecture and unscientific to claim that a potential effect is absurd without any data to support it or discount it.
I also have to laugh a little bit at the idea of society pounding breastfeeding into people's heads. Doctors offices are full of formula samples. The hospitals often send people home with BAGS of formula samples, perfect for those first rough nights when it just seems easier. Parenting magazines are filled with formula ads. Breastfeeding gets one or two articles every so often, typically filled with information on how to wean.

The scorn cuts two ways here. Have you ever tried breastfeeding in a restaurant, even with a blanket draped over you? Compare that to bottle feeding.
kathleendsm:

"My point was that I managed to breastfeed and work a demanding job outside the home full time."

I did, too, but I'm very cognizant of the fact that just because I did does not mean that it would be easy for everyone else to do it. Working outside the home or having an unsupportive partner or no partner make many aspects of parenting much harder. I think it is very important to acknowledge that.
kathleendsm:

"Doctors offices are full of formula samples. The hospitals often send people home with BAGS of formula samples, perfect for those first rough nights when it just seems easier. Parenting magazines are filled with formula ads. Breastfeeding gets one or two articles every so often, typically filled with information on how to wean."

But that's not some sort of conspiracy to interfere with breastfeeding. It reflects the fact that many women WANT to bottlefeed and feel it is the right choice for their families.
aliquot:

"If we can't objectively measure bonding, then how do we yet know WHAT could affect it? It is conjecture and unscientific to claim that a potential effect is absurd without any data to support it or discount it."

It's the null hypothesis. Without any evidence to substantiate a claim that breastfeeding improves bonding we have to assume it makes no difference.

I'm all in favor of breastfeeding. I breastfed all four of my kids. However, in the absence of scientific evidence, I think it would be beyond presumptuous and self servingof me to declare that I bonded better with my children than a bottlefeeding mother did with hers.
Great, thanks for the clarification. I do read your blog because its one of the best here for science/medicine. Looking forward to more.
I couldn't agree more that we need to question the rhetoric around breastfeeding and "natural" mothering, "attachment" childrearing, etc. I live in Canada where breastfeeding is even more the norm and where it is encouraged much more -- so much so that I sort of feel bad for mothers who end up bottle feeding as they certainly must feel they are "failures" or "bad mothers"; I had problems breastfeeding and though I stuck with it, I used to refer to the nurses who were my official "lactation counselors" as the "nursing nazis." The problem may be with the fusion of a rhetoric of "natural" with a medical approach that is still strongly interventionist and clinical by its very nature. I definitely feel that the efforts to take back our bodies that began in the '70s has been to some degree co-opted and become a pressure to be an earth mother -- all the while managing to work, clean the house, and do everything else. There was a reason our mothers uses playpens.
"Breastfeeding moms get a lot of mud slung at them too, "Oh, when are you going to wean that baby?" "Are you going to do that HERE?" "Ewwww, he's sucking on WHAT?" Kathleendsm.

That, I think, is the crux of the breastfeeding movement: they were made to feel uncomfortable as breastfeeding mothers, so in turn, they must make mothers who formula feed feel uncomfortable.

Personally, I don't care whether babies are breast or formula fed: anything that makes the baby healthy and happy, whether it's one method alone or a mix of the two, is what parents should be aiming for.

Disclosure: The eldest had a mix of breast and formula, the youngest was breast fed for two years. Anytime I've had a pregnant friend ask my opinion on breast versus bottle, my response has been "Give the breast a try if you want, but bottle feeding is as good. Breastfeeding doesn't always work out... and you're *not* a failure if it doesn't"

As for breastfeeding allowing you to bond with the baby: wet-nurse.
Bonding comes with time and more shared experiences than nursing, and passing baby out to be fed was an old, old social construction that people seem to have conveniently forgotten about in their quest for"pure parenting" or whatever.
alice maurice:

"I definitely feel that the efforts to take back our bodies that began in the '70s has been to some degree co-opted and become a pressure to be an earth mother -- all the while managing to work, clean the house, and do everything else."

Somehow the ante has been upped for women in both the workplace and the home. Not only are women supposed to be perfect mothers; perfect has been redefined to be harder to attain than it ever was.
hourglass figure:

"passing baby out to be fed was an old, old social construction that people seem to have conveniently forgotten about in their quest for"pure parenting" or whatever."

Right you are. It's ironic that advocates of "natural" parenting never hark back to what really happened in nature. It's the same thing with childbirth. "Natural" childbirth advocates like to tell themselves that they are doing things the way nature "intended," but nature intended women to get pregnant shortly after menarche, have as many children as humanely possible, and then die at age 35.
I don't mind seeing a babe breast feeding in public. They don't even have to cover up, as far as I'm concerned.

And I don't think of it as a "power" thing when I see it happening.
Some friends of mine could not have biological children and adopted a little girl. The mother has never given birth or breastfed a child in her life, yet somehow she's perfectly well bonded to her daughter and loving every minute of being a mother.
Leeandra Nolting:

"Some friends of mine could not have biological children and adopted a little girl. The mother has never given birth or breastfed a child in her life, yet somehow she's perfectly well bonded to her daughter and loving every minute of being a mother."

The whole notion that birth and breastfeeding are necessary to bonding is particularly cruel to adoptive mothers. As you point out, they don't love their children any less than biological mothers.
@AmyTuteurMD: "But that's not some sort of conspiracy to interfere with breastfeeding. It reflects the fact that many women WANT to bottlefeed and feel it is the right choice for their families."

Well, I somewhat agree. I actually think it mostly goes back to corporate interests (the formula manufacturers), it's THEIR interest to discourage breastfeeding, not the doctor or the hospital or the parenting magazine. But I think formula is far more in the culture overall than breastfeeding.

Honestly, I think the absolute most important piece of the equation here is that the parents and the baby are all happy with their choice. A miserable mother (I say mother because she, in particular, is given to taking the pressure on herself) is doing nobody any good, whether breast or bottle feeding.

My sister in law was mocked by a natural birthing advocate for choosing a second C-section rather than a VBAC after her first was born via emergency-C. There is no end to what people will chastise each other over.

I just still don't see the value of a "study" written as an opinion piece based on the one, rather extreme experience of one person.
I liked these excerpts. There's a bit of Caesarean stigma as well, & a failure to realize that for generations helped by technology, there might be no 'choice' in the matter.
I must say though, Dr. Amy, I am greatly enjoying your blog and am very pleased that this post led me here! I agree with much of what you have to say, even though I appear antagonistic on this topic.
Amy, are there any studies vis. a vis the nutritional value of breast milk vs. formula (and pre-mixed vs. powdered formula)? This is an anecdote, so some data would be helpful.

As for how to bond with an infant, I don't understand why you term the idea that there is a "best" way "bizarre." Some ways to bond are not better than others?

N.B.--I have nothing against bottle feeding. My daughter was able to breast-feed with no trouble, so we did. My niece and nephew couldn't, so they didn't.
Cocoalfresco:

"There's a bit of Caesarean stigma as well, & a failure to realize that for generations helped by technology, there might be no 'choice' in the matter."

More than a bit in some circles, unfortunately. One of the most pernicious implications of "natural" childbirth advocates is that virtually all women could have a vaginal birth if they tried hard enough. They don't seem to realize that neonatal mortality has dropped 90% and maternal mortality has dropped 99% in the past 100 years because childbirth complications are actually common, not rare.
kathleendsm,

I'm glad you're enjoying the blog and the back and forth of the comments section.
Douglas:

"are there any studies vis. a vis the nutritional value of breast milk vs. formula"

According to Prof. Joan Wolff in the paper "Is Breast Really Best" (http://jhppl.dukejournals.org/cgi/reprint/32/4/595) the science is contradictory at best. It's worth looking at the article itself because it comprehensively addresses some of the issues we have been discussing.
Thanks.

I admit that my personal preference is for breast-feeding; one would hope that evolution would have provided a good newborn infant nutritional solution. But I'm happy to have the data; I'll give it a read.
Douglas:

"my personal preference is for breast-feeding"

My personal preference is also for breastfeeding and I always recommend it strongly to patients and friends alike. However, I recognize that it is not right for everyone, and it certainly is not an indication of being a "good" mother.
Anyone who has spent any time on or near a farm knows that not all mother animals produce enough milk to feed their young. They usually do, but Mother Nature can be a capricious bitch sometimes. (And unlike with formula-fed human infants who in the vast, overwhelming majority of cases do just as fine as their breast-fed peers, it's not at all uncommon for a bottle-fed calf or lamb or piglet to up and die or be runty all its life because it didn't get the nutrients it needs from formula.)

Why some people think that human beings are somehow different in this regard from other mammals is beyond me.
Hey Dr. Amy,

We bottle-fed our two children born in 02 and 06. It was such a no brainer of a decision. My husband and I born in the late 60's and early 70's were both bottle fed. We are of great health and both possess graduate degrees. Our children are also healthy, well-adjusted, precocious young children.

I felt the breast-feeding pressure a bit more with my first, but felt very resolved in my decision to make experience with a newborn as least stressful as possible. My husband tells the tale of having to practically beat back the roving Le Leche Leaguer's trying to force themselves into my hospital room right after my c section. It's crazy!

Anyway, we split the night shifts and had each kid sleeping through the night (6 hours all at late night!) by 4 and 6 weeks of age respectively. When other moth's would ask about my babies sleep habits, they always said "You're SO LUCKY!"...

"No, it's called formula. It's regulated like how Tylenol is sold. It meets ALL of the babies nutritional needs and he/she sleeps like a champ."

The most important thing of all is providing boundless love and affection while meeting all of a baby's physical needs. I think people lose sight of that sometimes by focusing on one very specific thing.

Great post! Thank you!

Sara
Amy: "However, I recognize that it is not right for everyone, and it certainly is not an indication of being a "good" mother."

You may faint from shock, but I agree completely. I had to help my sister overcome the scorn of family members who felt otherwise, and assure her that her genuine, physical issues did not in any way make her a "bad mother."
I breastfed my daughter for 10 months, basically because it was very easy for me. I made lots of milk and I was lazy. I did not want to measure, sterilize and look after bottles. (This was '79, things may have changed since then), I could pop out a breast and dinner was ready, (I was truly lazy). Now my daughter just had her first. She has been breastfeeding but I did not comment on her choice, because it was hers to make. She make quit soon or she may go on for months. Her choice. However, she is fortunate like me in that her daughter took to it right away and she has good milk production.
I also have friends who could not nurse for medical reasons, the kids are thriving and not deprived because of the lack of "boob juice".
Feed your kid what will make her grow.
I hate that feeding one's child has become so politicized. I breast fed. I have many friends who breast fed. I have many who bottle fed. Who cares? As long as the child is being fed.
Leeandra Nolting:

"Why some people think that human beings are somehow different in this regard from other mammals is beyond me."

Part of the problem is that people have a very romanticized view of "nature" that bears little if any resemblance to what really goes on in nature.
Sara:

"The most important thing of all is providing boundless love and affection while meeting all of a baby's physical needs."

I strongly agree.
Fred the Cat:

"Feed your kid what will make her grow."

Words to live by!
What's really needed is a market for human milk. That way those well off white western women can feed their babies real breast milk without the hassle of having to breastfeed or pump themselves.
I'm with you, Amy, for all sorts of feminist reasons. I'm an adoptive mom, so probably don't have any cred in the "natural woman" debate, but I will say that, yes, you feed your kid what he or she needs to grow--period. What's interesting to me is how gender roles still hold in many adoptive families, even when a baby isn't literally breastfeeding. In our house, my husband fed our baby son as often as I did. I have to say I think that was a wonderful thing for us all.

Hanna Rosin wrote a great feminist piece about this in the Atlantic earlier this year (I apologize if this has come up in an earlier comment, and I missed it). Here's the link: http://www.theatlantic.com/doc/200904/case-against-breastfeeding

She got a lot of lactivists pissed off at her, too.
Sorry, SoapBox Amy, but I don't buy "It protects against ear infections through at least the first two years after birth."

My daughter was exclusively breast-fed and began having chronic ear infections at 4 months of age, not to mention being hospitalized for pneumonia at that age because she had already developed asthma. I'm not denying that there is some evidence for health benefits, but it's just that kind of blanket statement that makes women feel like crap if they can't (or choose not to) breastfeed. What woman, when told that, would think, "Eh. I'll use formula, because I don't really care whether or not my kid gets sick." (And I breastfed my second child, too, but by that time, I didn't expect miraculous wellness.)
I'd like to add a couple of other thoughts here. For one, my son was delivered by an emergency c-section after 9 hours of labor. His heart rate was dropping and when they got him out, he literally had to be jump started. I am so thankful for the medical team and their competency in delivering my child and myself through that harrowing, wildly painful, and crazy-scary experience; and we are both are alive today! -Modern Medicine: Woo-hoo!!! :)

I happen to also have a few sisters-in-law who each breast-fed exclusively all their children for at least a year each, ad spoke to me on the subject rather forcefully. The youngest of these 8 kids in total is now 18. They have sadly all struggled in life, several have either dropped out of high school or college or both and have generally floundered in adulthood. Several of them are also afflicted with asthma, hay fever, peanut allergies/combination of all three and two with ADHD, you name it, they have it, including a couple of unplanned teenage pregnancies of their own.

A friend of mine also lost her daughter (born in 2000) to cancer at the age of 8 who was also "Exclusively breast-fed" for the first year of her life.

This is all anecdotal evidence of life's difficulties and tragedies, and to say that breast feeding has any impact on a person's future medically, intellectually, or otherwise is complete nonsense in my book.

Love and nourish your children by whatever means possible is all that matter at the end of the day!

My goal is to see my children through so that they are healthy, well adjusted, thriving individuals who will successfully graduate college and have as many options as possible for their own futures.


Thank you for listening. :)
Amy - my bottle fed genius IQ brother knew enough to shut up, and the subject was never raised again.
Martha Nichols:

"Hanna Rosin wrote a great feminist piece about this in the Atlantic earlier this year (I apologize if this has come up in an earlier comment, and I missed it). Here's the link: http://www.theatlantic.com/doc/200904/case-against-breastfeeding"

Yes, Rosin's piece is very thought provoking and she took a lot of grief for it. I enjoyed it.
findyourinnerrockstar:

"This is all anecdotal evidence of life's difficulties and tragedies, and to say that breast feeding has any impact on a person's future medically, intellectually, or otherwise is complete nonsense in my book."

Your stories are anecdotes, but when researchers have looked at large groups they have found only small benefits to breastfeeding, confirming your point.
Sandra Stephens:

"my bottle fed genius IQ brother knew enough to shut up, and the subject was never raised again."

Good move on his part!
Leeandra Notling... about your post...

"Anyone who has spent any time on or near a farm knows that not all mother animals produce enough milk to feed their young. They usually do, but Mother Nature can be a capricious bitch sometimes. (And unlike with formula-fed human infants who in the vast, overwhelming majority of cases do just as fine as their breast-fed peers, it's not at all uncommon for a bottle-fed calf or lamb or piglet to up and die or be runty all its life because it didn't get the nutrients it needs from formula.)

Why some people think that human beings are somehow different in this regard from other mammals is beyond me."

...it's called ego! People have this problem thinking they are superior, and therefore more privileged, to all other life... including being super-beings. I agree with you.
AmyTuteurMD:

"It's not society in the aggregate because large swaths of society are completely comfortable with bottle feeding. It a small group of white, Western, relatively well off women who have attempted to promote their personal preferences as an ideal to which other women should aspire."

Yes, "a small group of white, Western, relatively well off women" and the World Health Organization - for at least two years.

According to the World Health Organization, a "lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year."

There is a moral imperative to attempt to breastfeed if reasonably possible. There is also an undisputed moral imperative to ensure that an infant does not starve or become dehydrated. It is the responsibility of parents and caregivers to discern between allowing for the possibility of establishing breastfeeding and injuring and infant.

It did not occur to my mother-in-law the breastfeed. My own mother felt she was part of a counter-culture by breastfeeding. When she gave birth to my sister at home with the help of a midwife - it was illegal. Women are regaining territory in the areas of pregnancy, birth, and infant care. This is a cause for celebration, despite the challenges it poses for modern mothers.

I am a full-time Ph.D. student. I started using daycare when my son was three and a half months old. He is now 20 months and he is still breastfeeding. We both enjoy it. I am not super-human. I am supported by my multicultural and well-educated community, by the city of Guelph, and the government of Ontario. I appreciate that I and my son were born into a culture of home birth, midwifery, and breastfeeding. In another time and place, our story might be very different.

We should not downplay the importance of breastfeeding to save the feelings of those who are unable or unwilling to do it. Perhaps revisiting sharing nursing with other women, or allowing breast milk to be donated or marketed could provide alternative solutions, along with tube-feeding at the nipple. Breastfeeding is not simply a lifestyle choice of little consequence to the physical and mental health of mother and child.

10 Breastfeeding Facts from WHO:
http://www.who.int/features/factfiles/breastfeeding/facts/en/index.html
Olathe MacIntyre:

"According to the World Health Organization, a "lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year."

As you surely know, or should know, that is an extremely disingenuous claim. Why do those children die? It is because powered formula is mixed with contaminated water, the only water available in many third world countries.

In other words, that claim has precisely ZERO relevance in any discussion of breastfeeding in a first world country. Lactivists are so zealous to promote their personal preferences as "ideal" that they are willing to play fast and loose with the truth.

"I started using daycare when my son was three and a half months old. He is now 20 months and he is still breastfeeding."

Let's do a little thought experiment. Suppose I said to you:

"If you really loved your son, you wouldn't have put him in daycare. You would have stayed home with him. I stayed home with my children. In nature, women were rarely separated from their infants.

Why did you put your personal preferences ahead of raising your child in the most natural, best way?"

How would you feel about that? What would you think about anyone who chose to speak to you that way? Would you feel it appropriate to be required to justify your decision to return to work? Would you feel it appropriate to be called selfish for putting your work ahead of your son's well being?
David codelli:

"Were it not for the Lactivists, many women would trust the formula pushers"

Has it ever occurred to you that women choose formula deliberately because it meets THEIR needs?
I'm just weary of conspiracy theories that simultaneously "explain" and degrade the choices of some women. The concept that women bottlefeed because formula is "pushed" on them is one of those theories.
AmyTuteurMD:

"As you surely know, or should know, that is an extremely disingenuous claim. Why do those children die? It is because powered formula is mixed with contaminated water, the only water available in many third world countries.

In other words, that claim has precisely ZERO relevance in any discussion of breastfeeding in a first world country. Lactivists are so zealous to promote their personal preferences as "ideal" that they are willing to play fast and loose with the truth."

Do you mean to imply that I am a zealous lactivist who is playing fast and loose with the truth? Strong language. Why are you limiting the discussion to first world countries? Perhaps the quote was not well enough contextualized - maybe it could make first world women think they might be risking their babies lives by supplementing - that was not my intent. My point is that there are recognized universal moral imperatives and breastfeeding is one of them - within reason.

Do you mean to imply that the "strong recommendations" of the World Health Organization, for the world, which are based on many more factors than access to clean water and infant mortality (check out their webpages - http://www.who.int/topics/breastfeeding/en/ ), are not relevant to the "small group of white, Western, relatively well off women" for whom breastfeeding is merely a personal preference?

Do you think women in developing countries, who do not have access to clean water, or may not be able to afford an adequate supply of formula for six-months, and do not have access to pharmaceutical birth control, have a moral imperative to breastfeed if emotionally and physically possible?

These Cochrane Reviews are certainly relevant to the first world:

"Infants who are exclusively breastfed for six months experience less morbidity from gastrointestinal infection than those who are mixed breastfed as of three or four months, and no deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for six months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea. Although infants should still be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided, the available evidence demonstrates no apparent risks in recommending, as a general policy, exclusive breastfeeding for the first six months of life in both developing and developed-country settings. Large randomized trials are recommended in both types of setting to rule out small effects on growth and to confirm the reported health benefits of exclusive breastfeeding for six months or beyond." (http://www.cochrane.org/reviews/en/ab003517.html)

"This review showed that health education and peer support interventions can result in some improvements in the number of women beginning to breastfeed. Findings from these studies suggest that larger increases are likely to result from needs-based, informal repeat education sessions than more generic, formal antenatal sessions. These findings are based only on studies conducted in the USA, among women on low incomes with varied ethnicity and feeding intention, and this raises some questions regarding generalisability to other settings." (http://www.cochrane.org/reviews/en/ab001688.html).

These reviews do not have any ring of zealotry to them. However, a "general policy" sounds like the normalized moral imperative and "informal repeat education sessions" sound like women talking honestly to other women.

I agree, we should not make personal attacks on each other and the benefits of breastfeeding are situational. However, that is very different from dismissing the benefits and framing the decision in terms of personal preference and calling me a zealot - if that is what you meant to do. Zealots in any area are dangerous, good point, but that is not all you have said in the forum and your voice holds weight.

Regarding your thought experiment, any individual can say what they want about me using daycare - it is the support of my community and society that make the choice possible and help me to feel good enough about it, even though I recognize that it is not ideal. The same goes for supplementing, which I have done at times.

It is a slippery slope when we begin to make moral judgments about anything (especially what a woman does with her body) - but we do make them - they are the fabric of our society. A woman ultimately has sovereignty over her body, that does not mean she should have no moral guidance. I know you are trying to help women, but you do them a disservice by ignoring and downplaying truths.

One truth you downplay is that formula manufacturing companies can influence a woman's choice. That is why WHO's international code to regulate the marketing of breast-milk substitutes was adopted in 1981. It calls for:

* all formula labels and information to state the benefits of breastfeeding and the health risks of substitutes;
* no promotion of breast-milk substitutes;
* no free samples of substitutes to be given to pregnant women, mothers or their families; and
* no distribution of free or subsidized substitutes to health workers or facilities.

Is that irrelevant too? Did you mean to imply in your last post that WHO is really just the Developing Country Health Organization?

A moral imperative does not force anyone to do anything - it is a cultural and social guideline for best practice. You know what the best practice is, you chose it for your children, but you are calling it a personal preference in this forum and downplaying the risks associated with not following it. Why are you yourself an advocate of breastfeeding if it does not matter at all?

You "passionately favor increased support for breastfeeding mothers within the workplace and elsewhere." Why the passion? You do not wish to be "pointlessly cruel" by making women who do not breastfeed feel "guilty". But you still "recommend it strongly to patients and friends alike". Could that be enough to make them feel guilty about not doing it? Is it therefore wrong? Why the "strong" recommendation if the benefits are so small as to be insignificant?
Dr. Amy didn't breastfeed and she feels the need to rationalize her decision.

Read about what goes into baby formula. Or,
Here is a nice video about sugar, a talk given by a doctor, and we know Dr. Amy only respects the opinions of medical professionals.

http://www.youtube.com/watch?v=dBnniua6-oM

Toward the end Dr. L- talks about the unhealthy ingredients in baby formula.
BenAdam articulates the point that first occurred to me when I read this post: It may be true that breastfeeding can feel tyrannical and therefore not liberating, but does individual liberation trump societal good? I don't place personal liberation above everything else, although I'm aware that some do.

Breastfeeding ultimately offered me convenience, and by the time I got to the third kid, I understood that the uncomfortable beginning was well worth it in terms of the ease with which I could live my life once we settled in. That having been said, I experienced something like what Crossley did when it came to my middle child. Whether it was an outcome of a traumatic birth experience for both mother and child or some other thing, I simply did not produce enough milk. Like Crossley, I had been indoctrinated to believe that such a thing could not happen, that giving in to a bottle was criminal. I was shocked into reality when a pediatric gastroenterologist pushed for emergency testing of my 4-month-old to check for organ failure due to starvation. I really can't look at pictures of my son from that time because they make me cry. I don't think everyone is as susceptible as I was to the kind of brainwashing that I fell for; perhaps it's a particular personality. At any rate, I immediately began feeding him formula and he not only plumped up but became a different person, much happier. I will die with that guilt. I embarked upon breastfeeding my third son a much more measured person, aware that I would do what I needed to do to ensure he thrive. Fortunately, thrive he did on breast milk alone.
Formula should be available only by prescription; it should not be an OTC consumer "choice." It's great that we have tube feeding, intravenous feeding, supplements, etc., for situations when a person (or other animal) cannot get adequate nutrition through normal eating. But no-one would try to claim that any of these feeding methods were suitable for use by "choice" in the absence of medical need -- with the exception of formula.

The people who get on their high horse about "choice" are forgetting that all choices are not equally valid. You have a choice whether to feed your kid junk food or healthy food but those are not equally defensible choices. You have a choice whether to provide your child with socialization and intellectual stimulation or plop them in front of the TV. Again, not equally valid choices. There is nothing wrong with condemning someone for making poor choices, unless they make them out of ignorance, in which case they deserve some slack because they didn't know better.

If push came to shove (pun intended), I would side with the process over outcome camp; however, that is largely a false dichotomy that pretends that there is no connection between process and outcome. Saying that someone chooses natural childbirth or breastfeeding because the process of doing it naturally is more important than the outcome of a healthy baby neatly overlooks the fact that natural childbirth and breastfeeding lead to better outcomes. The interventions used in medically-assisted childbirth are detrimental to both mother & baby. So, process is linked to outcome and it is disingenuous to claim that someone who wants a natural birth or to breastfeed is only concerned with process, not outcome.
What is your ongoing issue with breastfeeding? I hope as a Dr. you are not trying to question the benefits of breastfeeding. The comparrison to teethbrushing is funny and scary. Why do you keep asserting it is these uberpowerful white, rich women that are endangering the lives of underfed babies? I have never heard of sucha thing. None of my breastfeeding friends are rich, and none of them hate on women who choose the bottle. I agree that it is wrong to try to marginalize someone for not breastfeeding, but why attack the benefits? Breastfeeding is not widely accepted; people still judge you for doing it publically, even with a cover-up. I would never want you as my Dr. as you seem to have some issue with the breastfeeding culture. No breastfeeding advocate in their right mind would allow a baby to starve in favor of the breast. You speak of an isolated incident.
"No breastfeeding advocate in their right mind would allow a baby to starve in favor of the breast."

Actually that's not true. I hang around on mothering.com a lot these days and you'd be shocked at how many women tolerate egregious malnutrition (eg failure to regain birth weight by several MONTHS of age!!) in the name of exclusive breastfeeding.

I've seen a number of posts like this, and amazingly nobody on the boards calls these women out on the fact that they are actually starving their children. They just praise the mom for her perseverance.

I do think it is true that a lot of women who would have had plenty of milk end up with diminished supplies through injudicious supplementation, and I understand why the pro-lactation camp is so anti-formula. But there is also a willful refusal to acknowledge the fact that sometimes the mother really isn't making enough milk.
amyalternate:

"Dr. Amy didn't breastfeed and she feels the need to rationalize her decision"

But that's not true. I breastfed all four of my children and pumped at work.

Here's the big difference between me and many of the lactivists: I don't feel compelled to insist that my choices are the best choices for everyone else. Why is so difficult for lactivists to realize that they are not some sort of standard to which other women should aspire?
"I don't feel compelled to insist that my choices are the best choices for everyone else. Why is so difficult for lactivists to realize that they are not some sort of standard to which other women should aspire?"

Uh, perhaps because they are? Some choices are better than others, and the best choices should set a standard to which others should aspire. The fact that different choices exist does not make them all equal, and it's long past time we stopped pretending they are.
Greengoddess:

"Some choices are better than others"

Do you drive with your child in the car? It is indisputable that it is safer for a child to never be in a car than for a child to ride in a car regularly. Why do you casually risk your child's life simply for your own convenience? Wouldn't you have to admit that a mother who did not put her child in a car is a better mother than you are?
Sweet Tester, what a pointless debate! Humanity, or some version of it, has been around for over 30,000 years. In the vast majority of that time, we didn't have 'formula' or any other such nonsense. If it was good enough for Eve (the one in Africa, not Iraq), it's good enough for your kid. If you don't think so, take a walk over to the nearest reflective surface. See that face? That means humanity made it here on breast milk just fine.
For the inevidible "oh but we're modern now and we have choices, blah bu blah bu blah," I offer only this.
Babies don't care as long as they get the goods. Just ask them.
As for moral imperatives, it's a meaningless question. Survival of the species is the only imperative. All things contrary to that will be weeded out by natural selection.
Andy Heizeler:

"In the vast majority of that time, we didn't have 'formula' or any other such nonsense. "

And what was the infant mortality rate in those years?
"What was the infant mortality rate during that time?" That's the best you can come up with? Really?
Let's talk about correlation without causation. You remember learning about that don't you? I do.
If you wish to assert that infant mortality rates were higher at one point as a direct result of breastfeeding, rather than the myriad of other nutritional, genetic and enviornmental factors presented in the pre and early post industrial era, I would suggest you go forth and attempt in vain to collect a very large body of evidence to support such a unique and ignorant hypothesis.
On the other hand, if you were just trying to be 'cute' and make a quick, sound byte style comeback, I award you 'bravo' points for doing so. I'm sure it would look quite nice on a bumper sticker.