Breast is Best

Issue 144 – May/June 2009
By Peggy O’Mara, Editor & Publisher of Mothering Magazine

Yesterday I received an e-mail, signed “Wavering Somewhat,” from the nursing mom of a 26-month-old daughter. The mom had read Hanna Rosin’s “The Case Against Breast-Feeding,” an article published in the April 2009 issue of The Atlantic Monthly, and was now questioning the benefits of breastfeeding over formula. Rosin’s article, and an interview with her on The Today Show (March 16, 2009)—in which NBC News chief medical editor Nancy Snyderman, MD, said, “Formula is wonderful”—divide women by mocking our national health goals and defaming breastfeeding.

In her article, Rosin describes her cursory review of the medical literature on breastfeeding to shore up her personal decision to possibly forgo it, and concludes that all the talk about the benefits of breastfeeding is just “magical thinking.” But it’s irresponsible to imply that such a brief and biased analysis of the medical literature could somehow trump the conclusions of the world’s leading health organizations and medical authorities. By now, the superiority of breastmilk to formula is axiomatic.

While we don’t really need studies to tell us that the milk of our own species is superior to any other infant food, such studies abound. One of them, “Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries,” published in 2007, reviewed the evidence on the effects of breastfeeding on short- and long-term infant and maternal health outcomes. This study looked at systematic reviews and meta-analyses, randomized and non-randomized comparative trials, and prospective cohort and case-control studies, and rated them for methodological quality. Nine thousand abstracts were reviewed. Forty-three primary studies on infant health outcomes, 43 primary studies on maternal health outcomes, and 29 systematic reviews or meta-analyses representing approximately 400 individual studies were included. (Only reviews published in English were considered.)

This review of the medical literature showed that “a history of breastfeeding was associated with a reduction of the risk for children of contracting acute otitis media, nonspecific gastroenteritis, severe infections of the lower respiratory tract, atopic dermatitis, asthma (young children), obesity, type 1 and type 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis.” For mothers, a history of breastfeeding was associated with reduced risk of type 2 diabetes, and cancers of the breast and ovaries. Ceasing breastfeeding early or not breastfeeding at all was associated with an increased risk of postpartum depression.

What Rosin calls our “national obsession with breast milk as liquid vaccine” turns out to be an international obsession. In Global Strategy for Infant and Young Child Feeding, the World Health Organization (WHO) and UNICEF define optimal infant feeding as six months of exclusive breastfeeding, with continued breastfeeding (along with age-appropriate complementary foods) for up to two years or longer. A description of optimal infant feeding as exclusive breastfeeding for six months has also been adopted by the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the Blueprint for Action on Breastfeeding in Europe, the International Federation of Gynecology and Obstetrics, and the International Pediatric Association, among other important organizations.

Encouraging breastfeeding is also a key strategy of the US Centers for Disease Control and Prevention (CDC) in meeting their goal of improving the health of mothers and their children. To follow the progress of breastfeeding, the CDC has created the Breastfeeding Report Card, which tracks the Healthy People 2010 breastfeeding objectives by state.

The breastfeeding goals of Healthy People 2010, a national initiative of promoting health and preventing disease managed by the US Department of Health and Human Services (HHS), build on health initiatives pursued for several decades. The breastfeeding goals for both 2000 and 2010 call for 75 percent breastfeeding initiation, 50 percent breastfeeding at six months, and 25 percent at one year. However, the US did not meet these goals in 2000, and we will not meet them in 2010.

It is this slow growth in the rate of breastfeeding that explains the zealousness of advocates Rosin portrays as “breastfeeding fascists.” As of 2005, less than half of the states had met the Healthy People 2010 goal of 75 percent initiation rate, according to the CDC. Only ten states had met the goal of 50 percent breastfeeding at six months, and 25 percent of infants were breastfeeding at one year in only 12 states. Eight states, however—Alaska, California, Hawaii, Idaho, Oregon, Utah, Vermont, and Washington—did achieve all three of the Healthy People 2010 goals for breastfeeding initiation and duration.

Our initiation rates lag far behind the norm in the rest of the world. Data from 86 countries indicate that the US is among only ten countries with breastfeeding initiation rates lower than 85 percent; 70 of the 86 countries have breastfeeding initiation rates at or over 90 percent.

These rates, however, are only for breastfeeding initiation, not the exclusive breastfeeding recommended by the WHO, the AAP, and other health organizations. According to provisional numbers from the CDC, while 74.2 percent of US mothers initiated breastfeeding in 2005, only 11.9 percent were exclusively breastfeeding at six months. This means that most women who breastfeed in the US also use formula; contrary to Hanna Rosin’s perceptions, it is still bottle-feeding, not breastfeeding, that is the norm in the US.

When I had my first child, in 1974, the breastfeeding initiation rate was 32.2 percent. By 1982, due to the information and support provided by La Leche League, the rate had nearly doubled, to 61.9 percent. But by 1990 the rate had fallen again, to 51.5 percent. It was no coincidence that in 1989, for the first time, Gerber, in cooperation with Bristol-Myers Squibb, began to directly advertise formula to mothers.

In her article, Rosin criticizes the Breastfeeding Awareness Campaign, another HHS initiative, for its ineffective ads. The ineffectiveness of these ads was deliberate—their content had been watered down by interference from the formula industry. According to an August 31, 2007 article in the Washington Post, the Committee on Oversight and Government Reform, then chaired by Rep. Henry Waxman (D-CA), investigated allegations that “those designing the ad campaign were overruled by superiors at the formula industry’s insistence.” The final approach used in the ads was one that HHS had been advised would be ineffective, and indeed it was. According to the Ross Mothers Survey, an ongoing mail survey that is sent to new moms, breastfeeding rates dropped after the campaign. It is no coincidence that the formula industry nearly doubled its advertising, to almost $50 million a year, as soon as the Breastfeeding Awareness Campaign was launched.

This aggressive advertising of formula is one of the chief obstacles to breastfeeding success, and the domination of health by profit is a classic feminist issue. Women will not have equal access to breastfeeding as long as well-funded commercial interests oppose it. Many of the countries with higher breastfeeding rates than the US comply with the WHO International Code of Marketing of Breastmilk Substitutes by legally limiting formula advertising.

It’s no coincidence that the countries with high breastfeeding rates also have strong social supports for women. Rosin is correct to rail against the bitter irony of being told to breastfeed in a country in which one’s right to do so is not always legally protected. But breastfeeding is not the problem. It is the lack of social support for the work of caregiving in the US—another classic feminist issue—that creates the oppression Rosin describes in her article.

The US offers 12 weeks of unpaid maternity leave. In a study conducted at Harvard University in 2004, 163 of the 168 nations included in the study had some kind of national paid maternity leave. Only the US, Australia, Lesotho, Papua New Guinea, and Swaziland had no paid maternity leave.

In most industrialized countries, working parents are entitled to paid maternity leave, paternity leave, parental leave, and childcare leave. Of 22 countries surveyed in 2006, 20 provide paid maternity leave, and of those 20, the period of maternity leave was mostly between 14 and 20 weeks, with payments of 70 to 100 percent of usual earnings. In addition, all EU member states must provide at least three months of leave per parent for childcare purposes. Four of the non-EU countries in the study also provide parental leave, the sole exception being the US.

Is it any wonder, then, that Hanna Rosin feels oppressed? She well articulates two of the top obstacles to breastfeeding: lack of support from family and lack of support from society. Bottle-feeding does not, however, automatically solve the “unequal dynamic” of couples that Rosin bemoans. In fact, when Betty Friedan first wrote about this unequal dynamic, in 1963 in The Feminine Mystique, 75 percent of women were bottle-feeding. One of the things that feminism teaches us is that we must value our own contribution if we expect it to be valued by others. However, when society attributes economic worth to formula but not to breastmilk, our confidence can be undermined.

For example, sales of formula are included in figuring our Gross Domestic Product, but breastmilk is not. A 2001 Food Assistance & Nutrition Research Report study calculated that a rise in breastfeeding rates could result in potential US cost savings of more than $3.6 billion.

Unsurprisingly, this lack of valuation of breastmilk translates to the workplace. According to Jake Aryeh Marcus, JD, in “Pumping Nine to Five,” in the May-June 2008 issue of Mothering, in 2007 only 26 percent of US employers reported having a “lactation program/designated area” for their employees. However, employers report that lactation programs are on the rise: that 26 percent in 2007 is up from 18 percent in 2003. No federal law establishes or protects a right to pump breastmilk in the workplace. Only 18 states (plus Puerto Rico) have statutes related to breastfeeding in the workplace; these statutes vary widely.

We’re doing better with legislation that protects breastfeeding in public. Twenty-nine states protect breastfeeding in public but have no enforcement provisions. Nine states (plus Puerto Rico) do have laws with enforcement, and seven have laws that exclude breastfeeding from certain criminal charges. Only four states—Idaho, Nebraska, North Dakota, and West Virginia—do not protect public breastfeeding at all.

Hanna Rosin’s article exposes the dichotomy between the high value we place on breastfeeding and the low value we place on mothering, but it is cowardly to blame breastfeeding. Slandering breastfeeding because our society makes it inconvenient is like vacillating on equal pay for women because it’s difficult to achieve.

This is no time to waver: Powerful economic and political forces are continually undermining breastfeeding progress. Surely, we need state and federal protections for breastfeeding—that’s a given. To achieve our national health goals, we—like our sisters around the world—also need guaranteed health care, paid family leaves, and caregiving credits. Bottle-feeding is an old-school feminist solution to inequality. The equal-rights arena of today is breastfeeding.