Breastfeeding makes us stupid

How's that for a title? I do not mean, of course, that breastfeeding makes babies stupid; breastfeeding is important for growing brains. What I mean is that talking about breastfeeding seems to make the grownups stupid. Something about breastfeeding hits the media and the lactivists all say, "Look! Breastfeeding is important!" and the moms who had trouble breastfeeding say, "Don't make me feel guilty!" and perhaps Rebecca Goldin says "I'm a professor of statistics [with an axe to grind] so let me tell you that breastfeeding isn't very important"* and the lactivists say "Yes it is too!" and then somebody says "You only think that because you're a nazi who's planning to demand the right to defecate in public."

And then my head explodes. Again.

Here are two things you might like to know about the study published Monday in Pediatrics. 

1. The authors do not say anywhere that mothers are not trying hard enough. No one needs to read about this study and then run through the reasons why she stopped breastfeeding to make sure they're good enough. You in the pink shirt over there, relax. It's not about whether you suffered enough, not at all.
2. It's all about the fact that modest differences add up to big numbers in large populations. Because of the magnitude of the potential savings, the authors call for improved support and infrastructure for breastfeeding mothers.

Most of the blogosphere buzz about this article has focused on its calculation that six months of exclusive breastfeeding by 90% of mothers would save more than 900 children's lives as well as $13 billion annually. We can't have those kind of breastfeeding rates without paid maternity leave, people are saying, so what's your point, Dr. Bartick?

But they're not just talking about Breastopia in this article. The authors present a range of numbers, and the 90% values have gotten all the press because big numbers make big headlines. No one seems to be talking about the more attainable outcomes: if we could just hit the Healthy People 2010 targets, we would save still save billions annually (billions as in 2.2, but still, billions, plural) and 142 children's lives. Those are reachable goals: they specify that 75% of babies will begin breastfeeding -- a single attempt counts -- and 50% of babies will still be receiving some human milk -- even a tiny fraction of their intake -- at six months old.

We don't need to reform the whole maternity leave system to save lives and dollars. (Not that I'd complain if anyone wanted to tackle the vexed issue of maternity leave in the US.) Here are some things we do need:

1. Increased access to midwifery care. It's not just about birth, though see #2 below. Midwives expect to spend more time with women than OBs do; many midwives (depending on their credentials and their state regulations) can provide care to newborns as well as their mothers. Differential diagnosis of breastfeeding problems takes time, and some problems (thrush, tongue-tie) require coordinated treatment of mother and baby. A woman who calls her OB with a torturous case of thrush may have to work harder at getting what she needs.
2. Increased access to out-of-hospital birth. For a variety of reasons, complicated birth is often followed by complicated breastfeeding, and complicated birth is widespread in the current hospital birth culture. Out-of-hospital birth is not for everyone, but it is a safe option for low-risk women and their singleton vertex babies. (Also, I have never heard of a homebirth midwife shilling for a formula company.)
3. Michael Kramer has shown in a randomized controlled trial that Baby Friendly training for health care providers makes a massive difference for women who want to breastfeed. Remember that .5 SD difference in verbal IQ at school age? We have more than 5800 hospitals in the US.** Guess how many are BFHI-certified. Did you guess 88? Because that's how many. Crazyville, am I right?
4. What if Joint Commission standards addressed lactation consultant staffing? Women need access to board-certified LCs in the immediate postpartum period. RN licensure alone does not equip a person to provide skilled breastfeeding assistance. (Hospital staffing issues are an area in which I have almost zero experience; that's why this one is presented as a question.)
5. We need mandated, hassle-free insurance coverage for outpatient LC services. The cost of an LC visit is roughly equivalent to the cost of one bout of otitis media. Insurance companies should be tripping over themselves to reimburse LCs, because early breastfeeding success will save insurers money both in that first year of life and for a long time afterward.
6. More education. I'm not thinking so much about education for mothers here; I'm thinking about LCs who can go into junior high and high school health classes and talk to kids years before they become those parents facing down an irate baby with a latch problem. LCs who are interested in outreach can talk to college students, RD students, OT students, SLP students, nursing students, medical students. Clearly there's a need for some education among Twin Cities police. Imagine the power of a concise presentation that is rigorously accurate without taking itself too seriously, a presentation that makes students think and makes them laugh and also makes sure they know that most breastfeeding problems are solvable.
7. Last: I think it's important to avoid the echo chamber effect. We do a lot of preaching to the choir in the breastfeeding community, and we don't always notice the women slipping out of the pews even as we crescendo. Sometimes what's billed as a breastfeeding support meeting can become the lactator's equivalent of a pissing contest: I'll see your Birkenstocks and raise you one HBAC and three tandem nurslings. Do we really need to scrutinize each other's choices and second-guess each other's motives? I have come to think that one of the best gifts we mothers can give to each other is the benefit of the doubt.

I put that one last because I want to emphasize it: when a woman who thinks breastfeeding is icky is talking to a woman who waxes rhapsodic about her 4yo's weaning party, it's unlikely that any minds will be changed by the conversation. Each of those women is going to carry on thinking that the other is kind of a wacko. I think what matters here is smaller changes-- when the woman who thought breastfeeding was gross decides to let her second baby try to latch on once or twice. When the woman who was going to wean entirely because her maternity leave was ending decides instead to keep nursing at bedtime. When the woman who thought she'd never breastfeed in public decides to leave the formula at home this time. These incremental changes matter. Breastfeeding duration has been creeping upward, and not because women in America have decided en masse to go granola.

The coolest part of the Bartick and Reinhold article, I thought, was a little table on page 1049. In 1998 when I was first training as a breastfeeding counselor, I remember learning that 6% of US one-year-olds were still nursing. In the early 00s when I first heard about the Healthy People 2010 goals, I remember thinking, "Yeah, good luck with that." But do you know, things are really changing. These days more than 21% of one-year-olds are nursing. Seventy-four percent of mothers initiate breastfeeding; 42% of them are still nursing at least a little bit six months later. That's fabulous news: it means healthier babies, healthier mothers, lower healthcare costs for that segment of the population at a time when cost containment is a pressing issue.

So I think it's important not to let breastfeeding make us stupid. It's easy to lapse into fatalism (it's too hard and it doesn't matter anyway, à la Amy Tuteur) or extremism (lactivists who say "If you weren't willing to work at motherhood, maybe you should have bought a goldfish instead"). Let's not. Let's keep nudging it forward, remembering that there are real dollars and real lives at stake as we do.

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*What's up with that social workers comment? Social workers??

**Sorry, I don't know how many of those hospitals have maternity units.