The ideal and the real of breast-feeding
Personal Health: Some dispute the message that "breast is best" and cite concerns for the pressure and guilt it heaps on working mothers.
The New York Times
Concern is mounting that the "breast is best" dogma is creating undeserved guilt and hardships for a growing number of new mothers, many of whom cannot afford, professionally or financially, the prolonged maternity leaves needed to breast-feed their infants for the time now recommended.
Forty-three years ago, when my twin sons were born, the pressure to breast-feed exclusively for six months was not as strong as it is today. I nonetheless felt I had let them — and myself — down when this proved impossible. I had looked forward to feeding only breast milk for the six months of maternity leave my job allowed. But nature had a different plan.
At seven months pregnant, I learned I was carrying twins, and my doctor ordered me to stop working to avert an early delivery. The boys, born at 6 pounds 12 ounces each, were delivered by emergency cesarean section, after which I developed a life-threatening infection. Sustained by an IV drip for eight days, I was isolated from the babies and pumped breast milk while they suckled formula.
When we finally left the hospital, each boy was downing four ounces of formula every four hours, and I was producing less than half that in breast milk. My doctors gave contradictory advice.
Obstetrician: Just nurse them and your milk will come in. If you give them bottles, they won't bother to nurse.
Pediatrician: Forget about nursing. Give them formula, or they will be hungry and crying every two hours. They'll lose weight, and you and they will be miserable.
After a good cry myself, I decided to meld the advice: Nurse the babies first, and top off each feeding with formula. The boys gradually reduced their dependence on formula. But when they were 4 months, my leave was up, and I had to return to work, an hour's commute from home, to an office without on-site day care or any place to express milk.
An insurmountable gap
Many more women now work full time, most in places that cannot accommodate a nursing mother. Few can afford an extended unpaid maternity leave. As Alissa Quart noted recently in a lively essay in The New York Times, "The Milk Wars," many new mothers are finding it difficult, if not impossible, to feed their babies nothing but breast milk for six months.
Health officials have likened the failure to breast-feed to the risk of smoking during pregnancy, adding to the distress and guilt suffered by these women.
But as a recent study in Scotland showed, the gap between what is ideal and what is real is insurmountable for many families. The authors, who conducted 220 face-to-face interviews, mostly with pregnant women, new mothers and their partners, concluded that more realistic, achievable goals should be set, particularly in countries like the United States and Britain, which have thus far failed to meet targets for breast-feeding.
Hanna Rosin, mother of three breast-fed babies, wrote in The Atlantic in 2009 that breast-feeding involves "a serious time commitment that pretty much guarantees that you will not work in any meaningful way. When people say that breast-feeding is 'free,' it's only free if a woman's time is worth nothing."
The Scottish researchers, whose study was published in March in the journal BMJ Open, concluded that there is "a clash between overt or covert infant feeding idealism and the reality experienced." Some families, they found, "perceive that the only solution that will restore family well-being is to stop breast-feeding or introduce solids."
Even mothers who planned to devote themselves to breast-feeding often struggled with the time it took away from getting back to their pre-pregnancy lives, including sleep, exercise, friendships, couple time, attention to other children, even housework.
There may be little net benefit to breast-feeding if it results in distressed mothers or marital or family discord. As one woman in the Scottish study said, "It all seems to be, 'Don't ever do anything that would interfere with breast-feeding,' but it just doesn't fit in with the rest of your life, and I think people just give up because it's too difficult."
In some cases of exclusive breast-feeding, the women's partners or other children felt left out of baby care and the bond that comes from feeding a baby. A woman in the study said of her partner, "I think he's really delighted that the baby will finally take a bottle from him; that's their time to sit and chill."
The authors concluded, "Six months exclusive breast-feeding is considered unrealistic and unachievable by many families, and promoting this is perceived as setting parents up to fail."
They recommended that rather than dictate how babies are fed, health professionals should have open-ended discussions with families to see how well a particular feeding regimen would fit into family life.
Some mothers in the Scottish study resented the "propaganda" promoting breast-feeding, calling the message that "breast is best" overdone and questioning the strength of evidence that exclusive breast-feeding for six months reduces a baby's risk of allergies, asthma, eczema, ear infections, obesity, diabetes, heart disease, sudden infant death and diminished intelligence, as well as protecting mothers from breast cancer.
There is some evidence supporting such claims, but no randomized, controlled trials — the gold standard of scientific research — have proved that breast-fed babies fare better, at least in industrialized countries.
Babies who are exclusively breast-fed for six months typically come from families that differ in a variety of ways from those weaned early or fed formula from the outset. (Of course, breast-fed babies do fare better in less developed areas, where formula may be prepared with contaminated water or poverty prompts mothers to skimp on its use.)
As for the antibodies that protect babies early in life, most are acquired via the placenta during pregnancy. The main exceptions are antibodies against gastrointestinal infections (vomiting and diarrhea); these antibodies are transferred to a baby's gut through breast milk but not formula.
Based on her review of the medical evidence, Rosin, in her Atlantic article, wrote, "It shows that breast-feeding is probably, maybe, a little better, but it is far from the stampede of evidence" that has been promoted in the popular literature.
"Overall," she concluded, "breast is probably best, but not so much better that formula deserves the label of 'public health menace,' alongside smoking."
Perhaps it is time for more realistic, less polarizing messages about breast-feeding.