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.

_________

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

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

Comments

[JeCaThRe]

I get so tired of the people who want to make war between those who breastfeed for years and those who never offer anything but formula. Once again you are a voice of reason. Thank you.

[Gina Gerboth]

So. Very. Excellent.

[Jody]

Well said. Written. You know what I mean.

[Jody]

Oh, this reminds me. You may remember when you and Moxie kindly got on the phone with me in the spring of 2006 after my sister had her first baby and ran into real trouble nursing. Thanks in part to your wise counsel, and her willingness to keep looking until she found the right LC, she managed to sustain breastfeeding.

For four years.

Through two more pregnancies.

(Not that I'm a big advocate for nursing-through-pregnancy. OUCH.)

She just delivered her third baby a few weeks ago, and is now tandem nursing a 2-year old and a newborn for the second time.

Everyone has different goals, and those goals shift over time (my sister ended up nursing a LOT MORE than she expected or wanted when she started), so this comment isn't meant to be prescriptive for anyone.

I just wanted to say, on her behalf, THANK YOU. Your assistance, from a distance and through a third party, has made a big difference in my sister's entire mothering life.

(Just to be clear: if breastfeeding hadn't worked out, that would have been OK, too. But my sister really wanted it to work, and it was not easy, and having helpful, trained people in her life made the difference.)

[Freyja]

I've been a volunteer lactation support layperson for many years and recently started coursework toward a bachelor's degree in social work. A lot of the training social workers get would benefit anyone in a "people" field, and also reminds me quite a bit of the communication skills training offered by La Leche League.

Social work also focuses on building an eclectic skill base as well as seeing a person in her environment (what's going on around mom to support her ... or not) and building on strengths (like you've said above about incremental changes).

I could see a social worker with lactation training of the what's normal/what's not sort being an excellent front-line "triage" person. So much of lactation support is listening to a mother's concerns and reassuring her that what she's experiencing is normal.

My own fantasy is an army of postpartum doulas who are experienced breastfeeding mothers who have had breastfeeding peer counselor training.

[Maia]

Thanks for this. I am comforted, although I don't know why. It doesn't change the fact that I'm suffering through a (self-diagnosed) "tortuous case of thrush" and dreading going to a doctor I have never met on our out-of-the-States military clinic. It does mean, though, that there are more of "me" who are staying in the pews instead of slipping out. Which, theoretically, means more help for me the next time I have trouble-at-the-breast, right?

[Tall Kate]

As usual, Jamie, this is just wonderful. You're a voice of reason. Thanks for taking the time to put this together!

[Lilian]

BRAVO, my friend!! It feels like the old blog all over again. Thanks for this very thoughtful post, yes, we have to make an effort so breastfeeding doesn't make us stupid -- either when supporting it or not.

I try to be an "informal" breastfeeding support people as often as I can to friends and family members. I almost became an LLL leader, but the timing wasn't right (I began the process when Linton was over 12 months old and by the time I was getting ready to get to the more intense part, he was almost weaned two years later, so I lost my mojo). And I wish I could become an LC, but I'm just not in the health care field or any related areas and I'm not willing to pay to go back to school for a totally unrelated area after getting that phd of mine. So, yeah... I'll try to help anyone I come across.

I LOVED to hear Jody sharing her sister's story. And I'll probably email her to talk more about it. I nursed through my pregnancy too, and it was FINE! (except that it did hurt -- the nipple and the strong cramps/contractions -- but it never started labor or anything).

Thanks again!!

[Celeste]

Outstanding post. I'm 8 years removed from having an infant but you completely held my interest.

[bearing]

Jamie, I recommend you add explanations of your acronyms to this post...

[rachel]

Jamie for President! or Emperor of the world. You pick.
And - can I add one thing to the list? Nice people make a world of difference, here more than elsewhere. I had perfectly efficient and knowledgeable LCs who made me feel awful, inadequate and stupid, even when it wasn't my first baby. I did everything in my power to avoid their useful advice and turn to the more patient, kinder, friendlier nurses. Postpartum women aren't stupid - but they do need some kindness, not just good advice.

[SE]

I was that person who was lucky enough to have a midwife to prescribe an oral medication for thrush (intraductal yeast causing horrible stabbing pain far worse than unmedicated labor). I tried twice to get a supposedly very breastfeeding-friendly family practice physician to prescribe it for me, and twice he refused, saying he didn't believe in thrush in the milk ducts and I should have a beer and relax. Seriously--a beer for someone who had been calm through unmedicated labor and was reduced to sob-shouting the Hail Mary by latching, even while taking loads of ibuprofen. The fluconazole got rid of the extreme pain within 24 hours, after I'd been enduring it for two weeks. If it was a placebo, it was a darn good one. Thank God for CNMs!

[Jamie]

Thanks for all the encouraging comments!

Jody, so glad to hear about your sister.

Freyja, I absolutely agree that social workers can bring valuable skills to breastfeeding support. Social workers without specialized training don't have a big role to play in supporting breastfeeding mothers, and Goldin's comment suggests to me that she is not well acquainted with the needs of mothers attempting to establish a breastfeeding relationship.

Maia, thrush is SO demoralizing. Email me if you need some encouragement. (My husband is out of town and I am running a little behind on email, but I'll keep an eye out.)

Lilian, I have a fun surprise for you. Maybe tonight!

Bearing-Erin, I'll do that.

Rachel, you are right about the kindness factor. Sorry to hear about your experience with LCs. :-(

Everybody else, thanks for reading and responding!

[Karen]

Jamie, I don't know what your PhD subject was exactly, and I don't know your specific career goals, but seriously. Please include advocacy in your thinking - I'm not sure academia would give you the soapbox you'd need to influence the policy decision makers, but you have such a great way of analyzing and summarizing the various positions on this topic (and others, I'm sure).

On the other hand, I always felt stupid somehow when I was breastfeeding. I'm talking estrogen deprivation stupid. Not behaviorally out-of-touch. Still miss those days tho!

[Brigitte Glowa Levy]

Fabulous post. As a 3rd time mom who has been pregnant and/or nursing for 5 straight years now, I fully agree that better support straightaway from birth is so important to establishing and maintaining the breast-feeding relationship. And I plan to quote you: "incremental changes do matter", when I attend my local breast-feeding support group tomorrow morning! Keep up the great posts.

[TheFeministBreeder]

"These incremental changes matter." Ab-so-lutely! Incremental change is just about the only kind that CAN be made. My transition from a "oh my god I will NEVER breastfeed that is disgusting yuck yuck yuck" type of woman, into the Lactivist-still-nursing-a-2-year-old that I am today, was slow, slow transition. It didn't happen overnight. It all came from a spark - a seed - an idea. One mother said "hey, what about this" and then another and then another, and here I am today.

I'm so tired of people trying to silence lactivists though. If there were none of us, I think breastfeeding would soon be going the way of the do-do bird.

[Lauralee]

Great. Thanks so much for a well thought out post.

[Cathy]

Thank you thank you thank you for saying what I've been longing to hear--support of breastfeeding that includes giving other women the benefit of the doubt. I especially loved point 7, as I often get the feeling we're comparing AP practices like Boy Scout badges, and a mom doesn't deserve children if they don't have enough of them. I have heard loving women say, almost word for word, what you said about goldfish in the last paragraph, and it blows me away. Really? Seriously? You feel your friend doesn't deserve to have a child if she uses formula when she raises her child in love with wisdom? I may not be slipping out of the pews when the crescendo hits its apex (I've nursed three kids into toddlerhood and am working on four now), but I lose a lot of respect for the preacher at that point. Thank you for saying so eloquently what I've felt for a long time!

[Lisa Keyser]

Fabulous post. Thank you!!

[Erika]

Thank you for writing something I have been feeling, and couldn't explain!
I am a breastfeeding mom and absolutely pro educating new moms and supporting all.But I have witnessed a LLL leader being so pushy with a mother I know from playgroups, I almost wanted to cry! My friend decided to wean her 22 months old because she's pregnant and maybe there are other reasons she did not want to tell. The LLL leader was pushing so hard to convince my friend that she did the wrong thing, that she herself still nurses her 4 year old, that the OB didn't know what he was talking about, that she should try to revert... I didn't want to be rude, but it made me really sad. I'm not talking about a mom who nursed for 22 days, she did it for 22 months! so I wish more people would read your blog and think about your points, so everybody could be more comfortable!

[Pearline Foo]

Totally agree with you. I am no breastfeeding counselor (only had breastfeeding experience continuously for more than 5 years including tandem nursing) , but try to provide assistance to new breastfeeding mothers who are at our shop, as well as friends. If I am unsure of the advice to give, I refer them to LCs. Some have successfully breastfed and this gives me strength to give out my number to people whom I come across and may need that little bit of encouragement and support. Often, I find that this is what matters and what helps. Granted, some give up along the way for various reasons, but it was good for them to know that they tried. :) Wonderful post! I'm gonna share this.

[Babs]

I was just linked over to this post this afternoon. Beautifully written: I love the way you've put this together. Thank you.

[Dr Sarah]

Good lord, but it's good to have you back on the blogging scene, Jamie.

You asked about my reaction. Sorry it's taken so long - finally got it posted at http://goodenoughmummy.typepad.com/good_enough_mum/2010/04/the-bartick-study-and-breastfeeding-disclaimer-syndrome.html

[Erin]

That really is good news! I love breastfeeding, but it is not always easy. I'm glad you can be so reasonable about such a sensitive subject. I once wrote a post on my old blog equating breastfeeding with justice, about how I felt that women and babies were being robbed of something so fundamentally human by AIDS, by corporations, by negative attitudes. Boy, was I made to pay for that! Of course the woman who had difficulty breastfeeding and so went to the bottle thought I was talking about her, and it just got ugly from there.

[Vacationland Mom]

I had my son at the 1st Baby Friendly Hospital in Maine and they were FANTASTIC. I love(d) my CNMs. I loved the LC's, some were a little wacky, some were hip, all over the map. The single best thing the hospital did for me was that they were available, 24 hours a day, 7 days a week, at the Nurses Station. One night about 2 weeks postpartum, I called at around 2am crying, a wreck, my son wouldn't sleep, wanted to nurse around the clock, etc. (all normal stuff... but I didn't know that then), and she told me to try lying down nursing and see if it helped me get some rest. If I hadn't done that, I think I would have... I don't know what. She gave me implicit permission to try cosleeping, even though many had made it seem BAD. Another time right before my 3 month postpartum appt I was afraid my supply was gone. I was having trouble finding time to make food/eat/etc. This fantastic LC came to my house within a half hour, and showed me that my breasts had plenty of milk, she helped me relax, helped me feel like I was doing a great job, not to give up. She also said if I remember correctly that she could get milk "out of anything." haha. But seriously though, what you're saying about support is PARAMOUNT. I didn't go into my BFing relationship with my son expecting to be going this long, but I'm super proud of myself. I have been following my son's lead since his birth, and he is healthy, intelligent, and wonderful.

What I'm trying to say is that the biggest thing is not just having information, it's having SUPPORT around that information, hands-on help, and also feedback about trusting your instincts. That's what I was given and it has made all the difference.

P.S. I just found your blog and I love it. Thank you!