Guilt

In all the discussions about the breastfeeding ad campaign and the NYT article, guilt figures prominently.  Mothers feel guilty, and guilt is bad.  Guilt, I think, is part and parcel of being a mother: motherhood is a rocky road, with a remorse-mallow ribbon running all through it.  (Wait! Come back! I promise to be done with terrible puns now.)   Do mothers really feel more guilt, or more inappropriate guilt, about breastfeeding than about other choices they make?  And who is "making them" feel it?

Standard disclaimer for breastfeeding posts:  I understand that breastfeeding is about both individuals and populations.  To recognize the need for increased breastfeeding is not to disparage individual decisions about weaning.  Sometimes breastfeeding sucks in more ways than one.  Sometimes you take a cue from that fine philosopher Don Schlitz:  you gotta know when to hold 'em, know when to fold 'em.

That said:  why is the guilt card a conversation stopper?  If I were into conspiracy theories, I would think there was a formula-company-sponsored social marketing program afoot.  Can we talk about guilt today?

HCPs regularly use guilt to encourage patients to change their behavior.  It's all over the culture, actually.  There's trans-fat guilt -- can you eat an extra-large order of fries with an easy conscience?  There's SUV guilt -- for my money (and I dislike SUVs), these bumper stickers are a whole lot more obnoxious than the breastfeeding ad campaign posters.  Why is it worse to feel guilty about breastfeeding?

I have wondered if women don't want to be told to breastfeed because it's a decision involving their own bodies.  But we tell pregnant women what to do with their bodies all the time.  You haven't been taking prenatals?  Guilt!  If your baby has a neural tube defect it will be YOUR FAULT!  (What's that you say about the narrow window in which supplementation can make a difference, and the decrease in NTDs since folate fortification of grain products?  Never mind!  Hush up and take your vitamins.)  You had a glass of wine?  Guilt!  Fetal alcohol syndrome, coming your way!  (Why are some of the same people who say there is NO SAFE LEVEL for alcohol consumption in pregnancy so cavalier about formula supplementation?  Which one is really more likely to have long-lasting sequelae, a five-ounce glass of wine during pregnancy or a five-ounce bottle of formula in the nursery?)  You ate some Brie? Guilt!  (Needless guilt, since the Brie available in this country is made from pasteurized milk and therefore is not a listeria vector, but guilt nonetheless.)

In the uproar about telling mothers what to do with their children, we seem to have forgotten that we tell mothers what to do with their children all the time.  Is there a mother alive who hasn't heard someone say, "You need to [fill in the blank] with that kid"?  We think, and sometimes say, that the mother whose kids are rambunctious in the line at the post office ought to try something different; we are aghast when kids don't ride in carseats.

Occasionally, I have taken a hysterical child out of his carseat to quiet him while my husband was driving.  In those moments, I decided that the benefit of a baby who was no longer screaming would offset the risk of a fatal crash in the minutes it took to get him calmed down.  This was not a great choice; it was not even a legal choice.  I made it anyway, based on what I had to work with at the time.  Sometimes motherhood is like that.

On the subject of carseats, I just saw one of the most thought-provoking comparisons I can remember:  Margaret, a breastfeeding advocate and an occasional commenter here, looked at some of the National Highway Traffic Safety Administration figures on childhood deaths in car crashes and compared them to the Chen and Rogan study of deaths in the post-neonatal period.  NHTSA data show that in the five-year period 1998-2002, 1996 children under age 4 died in US car crashes, or approximately 399/year.  Of those, 766 (or ~153 per year) were unrestrained.  In the Chen and Rogan study, the authors concluded that breastfeeding could prevent roughly 720 deaths each year in this country for children in the post-neonatal period (28 days-1 year) alone.

Let me recap that.  Car crashes:  ~399 deaths each year for all kids under four years old, including ~153 among unrestrained kids in that age group. Lack of breastfeeding:  ~720  deaths each year for kids between four weeks and one year old.  In other words:  in this country at this time, more infants die of not breastfeeding than of car crashes.

Who knew?

Here's another reason why I think it's okay to stress the costs of formula:  as a general rule, breastfeeding gets easier with practice. No one can tell you what the learning curve will look like for you, but you can be pretty certain that nursing a four-month-old will be easier than nursing a four-day-old.  It can be hard to keep that in in mind during the painful haze of the newborn period.  Moreover, some of the effects of breastfeeding are dose-related, and if you hang in there, it can make a difference to your baby.  Families deserve complete information about infant-feeding choices.  Some will choose to keep working at breastfeeding; some will not.  But let's make sure they have good information about the consequences of their decisions.

Yet another consideration:  public service announcements have never been about the nuanced approach; they've never gone down the "consider that this might make a difference and then choose responsibly based on your individual situation" road.  Probably, your brain will not fry if you try illegal drugs.  Probably, you will not be in a fatal car accident.  Realistically, the chances that you will prevent a forest fire are remote.  And yet I don't think I've ever heard anyone up in arms about those campaigns.  Why the furor about the breastfeeding PSAs?

Is guilt bad?  Yes and no.  In a post-Christian culture, guilt gets a bad rap.  Mothers do carry around unnecessary guilt -- every time I see the recipe for "I Ought To Feel Guilty Cheesecake" in Whole Foods for the Whole Family I want to say, "No! No, you should not feel guilty about cheesecake!" I know that sometimes I get stuck in counterproductive guilt -- if I feel bad enough about a mistake, I can focus on feeling bad instead of problem-solving.  Sometimes if I stress how awful I feel, the person I have wronged will say, "Don't worry about it," even when worrying about it is appropriate.  That's bad guilt.

But sometimes guilt serves a purpose:  sometimes I feel bad because I ought to, because it's a cue for me to own my mistakes and to figure out what I can do better next time.  I don't think we should attempt to eliminate that sort of guilt.

My neighbor the LLL Leader talks about mothers who seem almost as if they're seeking absolution once they find out she's part of LLL.  "I wanted to breastfeed," they say, "but...."  My friend is quite uncomfortable with this.  She has no desire to be a HURDLE (autHority on Unarguable Reasons for Discontinuining Lactation Efforts) to the women in this community.  She knows most mothers are doing the best they can with what they've got.

The funny thing about childrearing is that it's intensely individual and yet at the same time it's a community undertaking.  If I don't teach my kids that it's wrong to hit (I'm trying; believe me, I'm trying), what will they do to your kids on the playground?  If my kid hits your kid, you have every right to approach me about it even though I will probably feel guilty after our interaction.  I don't think you have a right to be a jerk about it, but I need accurate information from you to do the right thing by my child (and yours). 

If I don't breastfeed my kids there are repercussions for the health of my community, not just for my family.  My kids will have a weaker immune response to their vaccinations.  My kids' health care costs will be higher, and the community will absorb them in the form of higher insurance premiums.   It's not just about this baby in this year; it's about this generation of babies, and their health for years to come.  Is it really so bad to be emphatic about formula-feeding's cost to communities -- while acknowledging, always, the rights of individuals?

I have found that part of the psychological work of motherhood has been separating others' opinions of me from my opinion of myself.  I have learned not to give much weight to feedback, good or bad, from random strangers.  During our April trip to Tennessee, my 6yo had a total freakout meltdown, a fling-himself-in-the-floor-and-wail meltdown, in Walgreen's.  The looks we got!  The silent censure!  I know of five reasons why he fell apart, and there are probably others I haven't considered.  I didn't feel the lingering embarrassment I would have felt five years ago about the disapproval of strangers.  In fact, I laughed at the irony:  ten minutes earlier, a stranger had said, "I've been watching your boys all through lunch and they're the best-behaved kids I've ever seen."

The weird thing about that particular juxtaposition:  I was working much harder to be a good mother to Marty in Walgreen's than I was in the restaurant.  I was trying to set a calm example, to be clear that the behavior was unacceptable while being understanding about his intense frustration.  The situations in which I look like a good mother may or may not be situations in which I'm practicing good mothering.  I have learned that snapshot glimpses of mothering choices don't say a lot about the big picture.  I will never look at a bottle-feeding mother and assume she made a lousy decision.

When it comes down to it, here's what I think about guilt:  it's reasonable for me to feel guilty when I don't do my best for my children.  Most of the time, nobody but me knows what my best looks like.