In breast milk vs. formula, science is a red herring

http://groundedparents.com/2018/08/01/how-breast-became-best/ 

This “Robin reads the internet” comes courtesy of a colleague of mine whose MO is promoting science with a slavish religiosity, which in my opinion leads to making loud arguments about complex social issues at the expense of those who are actually affected by them. The “breast is best” debate is his latest shout into the void, and while this article he shared isn’t incorrect, to my mind it misses the point. 

For those unfamiliar with the debate: in the 1950s, baby formula became the standard for infant nutrition in the US and UK, but around the ’90s a major pushback gained momentum, touting the motto “breast is best” to encourage mothers to go back to breastfeeding their infants; now, this dichotomy has became one of the most active debates in child-rearing and there is a further pushback to the pushback. The linked article above argues that “breast is best” advocates have ignored the real medical needs of women who cannot produce sufficient or sufficiently-nutritious breastmilk and instead moralizes breastfeeding as a white upper-class behavior that punishes poor minority women. I agree with this point over all, but I think it misses a key element, which is that the very scientific studies used to establish these ideas of motherly insufficiency are themselves influenced by class and race. As with other issues surrounding women’s health, this debate isn’t about what each individual woman chooses, but about whether she has a choice in the first place.

First, I will say that I am extremely skeptical of studies that show 15% of women being unable to produce enough breastmilk. I’m just going with what my doctors, lactation consultants, and other childbirth professionals I’ve talked to have said, which is that insufficient supply is actually an extremely rare condition and that most issues with breastfeeding come from an improper latch. This, of course, is the current line in breastfeeding – everything comes down to latch. “Latch” is the term used to describe the baby’s attachment at the breast – if the nipple isn’t far enough into the baby’s mouth, the sucking motion doesn’t actually pump milk and it puts painful pressure on the nipple. Milk production is based on demand, so an insufficient latch can prevent the baby’s efforts to nurse from signaling demand to the mother’s body. I don’t know whether this is as much of an explanation for breastfeeding problems as childbirth professionals say it is – maybe there really is a major issue with insufficient production. But whether there is or not, at least the first line of support for new mothers should be access to informed healthcare professionals and other resources that can help them determine where their difficulty is coming from. And this is very much an issue of class and race in the US. If you give birth in a good, well-staffed, well-funded hospital, you will receive a visit from a lactation consultant soon after, who will sit with you and help you figure out positioning and latching, as well as talk to you about breastfeeding schedules, nutrition, and follow-up resources. If you have a well-paying job at a company with more than 15 people, you are entitled to maternity leave, during which time you can exclusively breastfeed if you choose and further establish breastfeeding habits, bond with your newborn, and troubleshoot any issues that arise. Furthermore, employers such as those are required to provide both the time and physical space for women to pump breastmilk at work and are more likely to have on-site childcare. Pumping at work allows women to keep up their supply and create a stash of stored milk, both of which extend the amount of time a baby can subsist on breastmilk, and a stash allows a caregiver other than the mother to feed the baby to the same degree of nutrition. All of these benefits are overwhelmingly more available to women who work in traditional office jobs, have stable healthcare, and can afford childcare. Poor women, on the other hand, are very much encouraged to feed their babies with formula, both because their work situations are less likely to allow for breaks, childcare, or time off, and because the policies around food stamps make it easier to buy formula than to buy more fresh food that a woman can use to feed herself and eventually her baby. But even more insidiously, US aid organizations and companies that make formula have spent decades encouraging women in other countries to feed their infants formula when they didn’t need to, and when those women couldn’t afford formula, they have turned to nutritionally inferior substitutes, like sweetened condensed milk (which is sugar syrup made out of milk).

The disparity in access to the choice to breastfeed or not reveals the real conflict in the breast vs. formula debate – how social systems force women into behaviors that not only remove their ability to choose but also determine the health of their children. Breastmilk is not necessarily more nutritious on a calorie level than good formula, but rather it offers developmental protections that encourage the immediate and lifetime health of the baby. Breastmilk transmits maternal antibodies to babies under 6 months, which allows the baby’s underdeveloped immune system to rely on the mother’s during that vulnerable stage of life. Furthermore, there is almost no risk of contamination or toxic chemicals in breastmilk, provided the mother is careful about drinking and drug use (but that’s another debate). Women who do not have the opportunity to breastfeed do not get to decide whether the benefits of formula – enhanced freedom to work the hours they need, more flexible childcare options, less stress on their own bodies – outweigh the risks of contamination, sub-par nutrition, and mounting health problems in the baby. Obamacare made a small inroad into granting more choice to new mothers by requiring all insurance providers to supply free breast pumps, but this is a benefit that women have to opt into, they have to be insured, they have to know it exists, and, most significantly, they still need the structure in their day to do the pumping (and the extra calories to the produce the milk, and the money to buy the milk storage bags, and the childcare support to actually feed that milk to their babies…).

It is offensive to all women that breastmilk vs. formula has become a moral issue about each woman’s choice when most women simply don’t have a choice. It has become such a part of our thinking about this issue that recently, on an academic listserv dedicated to the history of medicine, a scholar referred to “breastfed babies” of the Middle Ages, to which someone else responded “there was no alternative.” Premodern mothers largely didn’t have a choice – the closest they came was the use of a wet nurse, which introduced a further social complexity, in that children of the wealthiest classes were often raised until the age of 3 by their wet nurse as part of her family. Premodern peoples didn’t exclusively breastfeed simply because their circumstances didn’t allow for the alternative, but because without formula (which mimics the protein structure of human milk), babies would not have been able to eat anything. It’s not that babies lack the teeth to eat other foods, but that their stomachs are unable to break down the proteins and sugars in other foods at all before 6 months old, and can’t do so effectively enough to satisfy their nutritional needs until 2-3 years old. Women breastfed their children until 2 or so not because of oppressive social structures that kept them out of the workforce (because there was no industrialized workforce and women did in fact constitute a significant portion of it) but because if they didn’t their children would get sick and die.

Thinking about these structures of premodern life also made me think back to one of the few compendia of women’s medicine that survives from the Middle Ages, the Trotula, and how that text approaches breastfeeding. The Trotula is most accurately described as a book of women’s wellness, in the same sense as we talk about wellness in 2018 – a combination of medical concerns, holistic health, and cosmetics. It turns out that for a source that addresses issues ranging from skincare routines to childbirth methods, the Trotula completely fails to mention issues with lactation. For whatever reason, this simply wasn’t a concern for medieval women, even though preventing tearing during childbirth apparently was. I can’t say why medieval women were not afraid of an inability to supply their children with sufficient milk – whether because the higher infant mortality rate obfuscated issues like that or because social structures allowed women to deal with them more effectively – but the fact that they were not suggests to me that this whole debate is a lot more far-ranging than scientific studies are currently accounting for.

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