Yet another paper on the benefits of breastfeeding (real and purported) was released today (Bartick and Reinhold, The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis) in the ongoing, well meaning but basically futile effort to "educate" (i.e. bully) women into higher rates of exclusive breastfeeding. Using highly fanciful methods, Bartick and Reinhold "estimate" that the US could save 900 infant lives and $13 billion if 90% of US women breastfed. These numbers are grossly misleading since not even a single US infant death (let alone 900 per year) has ever been attributed to not breastfeeding and since the purported savings are primarily the "lost wages" of the 900 dead infants.
But let's leave aside for the moment, the fact that the figures on which Bartick and Reinhold based their claims are profoundly suspect. Let's look at their potential motivation.
Breastfeeding advocates like to pretend that women stop breastfeeding because of lack of education, because hospitals give out formula, because of lack of professional support, because of lack of peer support, etc. etc. etc. All this pretending reflects the profound unwillingness of breastfeeding advocates to avoid addressing the real reasons that women stop breastfeeding or fail to start in the first place. The dirty little secret about breastfeeding is that starting is hard, painful, frustrating and inconvenient. And continuing breastfeeding is hard, sometimes painful, and incredibly inconvenient especially for women who work, which in 2010 is most women.
Any article such as this virtually requires the author to demonstrate her bona fides, so let me get that out of the way. I have four children, I breastfed them all nearly exclusively until they weaned themselves. I breastfed even when I was working up to 70 hours a week and was on call every 3rd night. I always had access to an office that could be locked, a state of the art breast pump, and a fair degree of control over my own schedule. I never contemplated doing anything else, but that doesn't change the fact that it was hard, painful in the early stages and incredibly inconvenient. I did it despite the difficulties.
Breastfeeding advocates insist on eliding or ignoring these difficulties. And because they insist on ignoring the experiences of women, their well meaning attempts at encouraging breastfeeding are almost complete failures. Education efforts, counseling efforts and banning of formula gift bags have made little or no difference in breastfeeding rates. Bartick and Reinhold's latest paper on the purported economic benefits of breastfeeding, even if true (and there is a great deal of extrapolation that is probably not true) is destined to have an equally negligible effect.
I don't really understand why breastfeeding activists refuse to acknowledge the reality of breastfeeding. They prefer to sugarcoat it with little maxims like "breast milk is always available," breast milk is always the perfect temperature," and "breast feeding saves money." Those statements are true, but they ignore the very real challenges in initiating and maintaining breastfeeding.
Perhaps breastfeeding activists fear that women will not attempt breastfeeding if they are informed honestly about the difficulties. Yet it appears that the opposite is true. By not acknowledging these difficulties up front, breast feeding activists set women up for failure, when those women encounter pain, frustration and inconvenience.
Breastfeeding is a learned behavior. It is not instinctual on the part of the mother and although a baby has the instinct to suckle, latching on properly and actually getting milk requires practice. A new mother and a new baby may get frustrated very quickly when things do not proceed smoothly.
New mothers are often emotionally labile, due to the effect of hormones. A baby screaming desperately in hunger (and all babies begin to screaming desperately within seconds of realizing they are hungry) can upset even an experienced mother. It's much worse for a new and inexperienced mother who can easily become frantic to satisfy the baby, fearing that the baby is starving. Prior to the advent of formula, there was no choice but to stick with the first inexperienced attempts. Now, with formula at hand and able to satisfy an infant in seconds, it may seem pointless or even cruel (not to mention harrowing to the mother) to force a baby to figure out breastfeeding.
Initiating breastfeeding is often painful. Cracked and bleeding nipples are every bit as unpleasant as it sounds. Countless new mothers tell stories of bursting into tears whenever the baby starts to cry, in anticipation of the pain of nursing. For most women, the pain disappears over time, but it can take days or even weeks. Breastfeeding advocates like to blame women themselves for their pain, insisting that they are positioning the baby in the wrong way. The truth is that women can do everything right, and still have pain. It simply has to be ignored until it goes away and it is hardly surprising that some women do not want to wait that long.
Maintaining breastfeeding while working is incredibly difficult. During the typical work day, a woman may need to pump twice or more, each session taking 20-30 minutes and requiring a clean and private place to pump, a breast pump, and a refrigerator to store the milk. Professional women may be able to assemble these resources, but the average working woman has neither the facilities, nor the time to pump at work.
The demographics of breastfeeding reflect the fact that it is difficult. Breastfeeding is associated with higher levels of maternal education and higher income levels. Successful and long term breastfeeding require a willingness to delay personal gratification, and a willingness to shoulder burdens in exchange for long term benefits. Those traits are closely associated with higher levels of education and professional success. Economic success also makes it easier to continue breastfeeding because women don't have to work, enjoy extended maternity leaves, have private space at the workplace in which to pump and can afford high quality equipment.
Should we encourage breastfeeding? Of course, we should, but we should not forget that the health benefits are relatively small and the difficulties can be large. We should stop spending money on trying to convince women to breastfeed, since most efforts are ineffective. Instead, we should devote smaller sums to providing counseling to women who truly want to breastfeed and leave everyone else alone.