The Bartick Study and Breastfeeding Disclaimer Syndrome

I had a blast from the past the other day.  I logged into Typepad to find a new comment (an actual, genuine comment, I mean, not a spam comment, which I get all the time), on my post from back in 2006 debunking the Stats.org anti-breastfeeding article.  (Do please check that post out if you've time and haven't yet read it, by the way - it's one I'm proud of.)  The reason this was a blast from the past is not just because I haven't read that post in a while, but because the commentator is one who not only commented on here several times in the past but also inspired a couple of my previous posts before dropping off the blogging scene a few years ago, to be sorely missed by many of us.  At least I'm assuming it's the same one - she has a different blog, but the personal details, expressed views, and thoughtful and intelligent writing style all match the Jamie I remember (female, by the way, and no connection to my son of the same name). 

So, not only does Jamie seem to be back (yay!) but she also had a request for a post from me, which I am also pleased about because I love getting post requests.  Jamie would like to know my response to the Bartick study. 

The Bartick study, for those who haven't heard, is the one that apparently worked out that $13 billion could be saved in healthcare costs in the USA if enough babies were breastfed.  My reaction to that was pretty much "Wow, that sounds good (um, must get round to reading it some time)."  Since even someone as wordy as I am can't get much of a blog post out of that, I've decided instead to write about my reaction to other people's reactions to the study. Jamie linked to an article from ABC News discussing the study, and it raised several points that I think are worthy of comment.

Firstly, Goldin seemed to be damning breastfeeding with faint praise when she described the research as showing 'some suggestions' that breastfeeding had benefits.  The evidence is, in fact, considerably stronger than Goldin is making it sound.  I wrote quite a bit more about this, but this point was only really meant to be an aside and I ended up writing so much about it I felt it was distracting attention from what I meant to be the focus of this post, so I snipped all of that and saved it for a potential future post, if anyone's interested.  Meanwhile, see this old post of Annie's at PhD in Parenting for a good layperson's summary of the best paper on the topic.  (The paper she describes, by the way, is the one that was used as the source for the figures used in the study that's causing all the current upset; so Bartick et al were in fact using fairly sound figures as to the rates of benefits from breastfeeding, despite what's been elsewhere alleged.)

Secondly, the article criticised the Bartick study on the grounds of not taking into account the costs to society of providing the support that would be needed to get breastfeeding rates up and subtracting that from the $13 billion.  True enough, but it seems to me to be missing the point.  I think the point of the study was not meant to be "Whoopee!  We just found a way to make $13 billion out of thin air without lifting a finger!" but "We can afford to invest a hell of a lot of money in providing support for breastfeeding mothers and making the necessary changes in maternity leave laws, and still come out ahead of the game financially."  Surely the real lesson of the study's findings is that investing money in breastfeeding support is a win-win situation?

Thirdly, the commenters' views seemed to carry a strong hint of what I once dubbed Science Myth 2 - the idea that it's well out of order for a researcher to (gasp! the nerve of them!) come up with findings you don't like.  Maybe I'm misinterpreting what was said there, because I'm only too aware of the risks of reading too much into quotes that may have been taken out of context, but Goldin's and Beard's comments did seem to be coming across as anger, not with any actual example of an interpretation of the study that they'd heard and disagreed with, but with the study itself.  (McKenna's attitude came across as rather more sensible.)  If the ABC article misrepresented Goldin and Beard in that regard, my apologies.  A much stronger example of this attitude came from Lenore Skenazy's 'Quit Picking On Moms Who Don't Breastfeed'.  Uh, Lenore?  Examining a legitimate research question is not the same as 'picking on' anyone, and - stop me if I'm wrong about this - I'm pretty sure no-one's used "Irresponsible Parents Continue To Formula Feed" as a headline either, outside your imagination.

(You know - now that I think about it, this whole phenomenon of taking research you don't like as a personal attack does seem to be something I cannot remember ever coming across before joining the mommyblogging world.  I used to spend a lot of time on an abortion rights debate group, and the members of that group would merrily ignore or misrepresent any research that didn't suit whatever their particular views happened to be, and occasionally a researcher who'd found something that other people didn't like would be accused of bias.  But I simply can't remember anyone on the group, or in other debates I've come across, displaying that same sense of being personally affronted by research they didn't like.  Am I wrong?)

The fourth point is the main one I wanted to write about, and is in fact something I've hoped for some time I'd eventually be able to get round to writing a post about; a phenomenon I've come to think of as 'Breastfeeding Disclaimer Syndrome'.

Breastfeeding Disclaimer Syndrome (I'm not wedded to the name, by the way - if you have a better idea, I'm quite open to suggestions) is my term for the way in which people seem to feel the need to follow up any positive statement about breastfeeding with immediate disclaimers about the importance of recognising that of course many women can't do it and they should not be made to feel guilty.  Sometimes this reaction comes from others; a surprising amount of the time, it comes from the person who made the initial positive statement, as though we can't say anything about the benefits of breastfeeding without immediately qualifying it with the disclaimers about it not being univerally possible.

What interests me about this is that I don't remember ever seeing this happen with any other public health issue.  I don't, for example, see reports of studies on the benefits of exercise being responded to with hasty defensiveness about the importance of remembering that some people are quadriplegic and can't exercise and some people have such long working hours it's just impossible for them to find time to exercise and some people just find it really really difficult and painful and that amount of stress can't be good for anyone either so we shouldn't blame people who find a sedentary lifestyle works better for them and it's important not to make anyone feel guilty about it.  People can accept both that exercise can be good for you and that there are various reasons why someone may not actually follow that advice, without the conflict between those two facts ever being any sort of particularly big deal.  So why the difference?

I can think of several reasons.  One, of course, is the whole "But think of the chiiiiiiiiildreeeeeeen!" factor that makes any debate about parenting decisions so particularly heated - nothing hits people's hot buttons quite as hard as any suggestion that you may have been doing less than the best for your children.  One is the all-or-nothing attitude of breastfeeding activists, which I really do think often shoots them in the foot; the overwhelming emphasis on six-months-of-exclusive-breastfeeding that so often obscures recognition of all the benefits you can get from any amount of breastfeeding from any length of time.  If you feel guilty about your lack of exercise, you can appease the guilt with relatively simple measures like walking to the shops instead of taking the car; if public health announcements about the importance of exercise were all focusing on the importance of going to the gym for a complete workout every day for six months, I suspect we'd get a lot more of the same sort of overt defensiveness about exercising as we do about breastfeeding.

A third, major, reason is that breastfeeding is unique among healthy lifestyle measures in another way; it's a one-shot deal.  With any other healthy lifestyle measure you care to think of - exercising more, drinking less, eating better, stopping smoking - we can appease our guilt over not doing as well as we know we should by picturing the hypothetical but will-definitely-happen-someday future in which we clean up our act and do things a lot better.  This may not get us very far in terms of here-and-now improvement, but it does at least ease any guilt we feel to the point where we don't feel the need to get freaked-out defensive over it.  But, in the case of breastfeeding - with the little-known and time-limited exception of relactation - we don't get do-overs.  Any child we didn't breastfeed when we had the chance is going to stay non-breastfed. And it is very, very difficult to accept the idea of having done things in a way that you not only wish you hadn't, but that you will never have the chance to go back and do right.  Of course, that's something every human living has to deal with at multiple points in their life for all kinds of reasons, but add in the think-of-the-chiiiiiiiiildreeeeeeen emotiveness factor and the guilt can become overpowering.  And I think that's why we get so much emphasis on the need to remember all the reasons why women may end up not breastfeeding despite really wanting to.  It's our way of wanting to ease that pain by (rightly) giving women credit for their good intentions and best efforts.

The trouble with that particular temporary ease-off of the painful emotions involved in not managing to breastfeed is that it doesn't look at how the whole thing could be made better for women struggling with the same problems in the future.  Sure, it's important to recognise that many women can't breastfeed.  You know what's even more important?  Recognising that a much larger number of women could breastfeed if they had proper support and help when they needed it and a more breastfeeding-friendly culture.  Instead of putting all that energy into disclaimers, why not put it into clamouring for the importance of making the changes that would help more women breastfeed?

The article linked to in that last sentence, by the way, is a piece by none other than Melissa Bartick, the lead author of the much-maligned study in question.  While she does have the occasional unfortunate tendency to meander off the point into unrelated thoughts of her own fantasy birthing experience (look, by all means get your partner to cut the cord if that's what you both want and by all means don't do that if it isn't what you want, but, either way, it's not going to make a blind bit of difference to your chances of breastfeeding successfully, so let's leave that decision in the realm of personal preference where it belongs and get back to the topic under question, please), she also raises a heck of a lot of good points.

So.  Work with me here, guys.  I'm throwing out these ideas as to why people react as defensively as they do to any kind of breastfeeding promotion, but I'd love further thoughts on where to go with this in terms of getting away from that attitude and, instead, seeing research like this as something we can use as a positive force for change.  Any thoughts?

Comments

[Leah Goodman]

You hit on something really important here too. The all-or-nothing is also a breastfeeding killer, imo.

My second child was not gaining weight and was constantly hungry and screaming despite nursing every 1.5-2 hours around the clock and having an excellent latch. I added domperidone AND fenugreek and still, no dice. At around 7-8 weeks, I started alternating formula with breastmilk. He packed on weight and started sleeping better and just acted less hungry and less upset and just overall healthier and "better." I kept going with both until 8 months, and then he stopped accepting the breast.

People kept telling me that I was crazy and it must be such a pain and I should just give up and use formula, because why bother if I wasn't exclusively nursing? - and these were people who *did* nurse their kids.

There were other people who gave me the "some breastmilk is better than none, so keep going for it," but there were a lot of people in the first camp.

The people who would have criticized me for not nursing got shot down very quickly because I would say things like "yeah, well I didn't want my son to die of starvation" so I didn't experience that at all. (With my first child, I had no milk due to placental retention/post partum hemorrhage, so I'd already been through it)

[Karen]

I have to say that although the aspect of who cuts the cord during the "fantasy birthing experience" is not necessarily important, many aspects of birth can and will impact breastfeeding. And a hospital's willingness to allow a partner to cut the cord- and after it has stopped pulsing- may indicate a willingness to provide better support for new mothers and babies. So it may be "fantasy" but isn't necessarily less important.

I really appreciated this: "We can afford to invest a hell of a lot of money in providing support for breastfeeding mothers and making the necessary changes in maternity leave laws, and still come out ahead of the game financially." Surely the real lesson of the study's findings is that investing money in breastfeeding support is a win-win situation?

All I can say to that is Yes, Yes, Yes!

[Erin]

Interesting. I think that if we lived in more "tribal" type communities, where we had so much support and examples around us, then we wouldn't have this problem. It would just be normal, and everybody would do it, pretty much... and because of the vast support and expertise around new mothers, they would be able to trouble-shoot any breastfeeding issues and nearly everyone would be able to breastfeed.

I don't understand the defensiveness when presented with studies and facts, either... although, as I was reading your post, a new thought suddenly popped into my mind: because, biologically speaking, women were basically programmed to nurse their young (as all mammals are), then perhaps the reality of not having done it triggers some deep, primitive reaction that comes across as anger and feeling "attacked?" Or does that sound bizarre? I haven't had a chance to flesh that out any in my mind, since I just thought of it...

Just found your blog via PhD in Parenting... I like your writing style. It reminds me a bit of my own. Thanks for covering this topic!! :)

[amoment2think]

I could probably write an entire post on this in response, but I will try instead limit myself to making a few points.

I can't speak for other formula feeders, but I will admit that I can be overly defensive about the issue. But here are a couple reasons why I am bothered by, not so much the studies, but the conversation the studies generate in the breastfeeding activist community.

No one implies that it is a quadriplegics fault that they can't exercise. They aren't called lazy, selfish and uneducated. Every time these studies come out, we formula feeders get a new round of "you are a horrible mother" attacks. It is for this reason I think that many breastfeeding advocates have your "Breastfeeding disclaimer syndrome," because unfortunately there are enough bf advocates out there that don't recognize/respect that not every women can breastfeed. Unfortunately, there are a lot of judgmental and unkind statements which are made about formula feeding moms.

There seems to be the assumption among some bf advocates that formula feeders 'made the choice' to formula feed, and many of us feel like it wasn't a choice. At least not a choice we wanted to make. So all the talk about the risks of formula do us no good, we get it. We wanted to breastfeed, we just couldn't. Maybe Erin is right. I certainly believe I experienced some significant mourning over the realization that my body could not do what nature intended- to feed my child. But I don't think I would feel attacked if there weren't people there ready to add insult to injury by telling me on a regular basis that I am harming my child with formula.

Every time there is a new study there is more pressure. I don't think the pressure is good for any new Mom, we are already stressed enough. By framing breastfeeding versus formula feeding as the difference between a healthy, smart kid and a sick, stupid one, we up the pressure and the stress. I feel the stress to succeed negatively impacted my ability to produce enough milk. Sure, it didn't cause my problems, but it sure didn't help.

So I think both sides of the debate need to take responsibility for turning this conversation around from an "us against them" to something we can all get behind. We need to focus on how to get Mom's better support. Better maternity leaves, better hospital experiences, more flexible work options, ect. Let those things guide the conversation and get all Mom's on board, breastfeeding or not.

[Dr Sarah]

Leah: Thanks for sharing your story and good for you for breastfeeding your baby in the face of so much difficulty! What you did isn't just 'better than none', it's an excellent start in life for your baby, and I so wish more people knew that mixed feeding can be a perfectly good option.

Karen: I agree that it can be really helpful for a hospital to be willing to go along with the choices that will help a woman feel comfortable in her birth, but assuming that everybody ought to have a super-crunchy-style birth isn't doing that any more than assuming that everybody ought to have a super-medicalised birth. Bartick didn't say “Your hospital providers work with you and your partner to ensure that you get to do things such as choosing who cuts the cord in a way that makes you feel comfortable and relaxed.” She said “your partner cuts the cord.” Which left me thinking, lady, don't put your idea of the ideal birth experience onto other people. (By the way, a birth in which my husband cut the cord would decidedly not be a 'family-friendly' experience as far as our family is concerned, because he would hate it.) I actually felt that detracted somewhat from the breastfeeding advocacy, because there's already something of a perception that breastfeeding is for crunchy moms only and I think details like that from Bartick just played into that.

Erin: Hmmm. You may have something there. While I really dislike the 'biology is destiny' argument, it's not totally without a grain of truth, and I do have to agree that there is something quite primal in the way people react to this issue. Then again, as amoment2think said, don't underestimate the power of constant social pressure in driving people so utterly nuts that a topic just becomes a complete hot button.

Amoment2think: I'm so glad you came and took the time to comment, because yours is exactly the sort of perspective I'm hoping for. That's a very good point about nobody implying it's a quadriplegic's fault – I might post further about that. But what I'd really like to know is *how* we can turn this around, *how* we can get from this adversarial atmosphere to one in which mothers work together to fight the problems in the system, and *how* we can be effective breastfeeding advocates without alienating people while working in a society where formula-feeders have to experience this kind of pressure and judgement. (So, in other words, I'm not really asking very much at all. ;-) )

[Fearless Formula Feeder]

Sarah, I'm really glad you linked to this post on my blog - I hope that some of my readers (who I honestly believe are some of the smartest, most educated and sensitive women out there who also happen to be formula feeders)will respond as well.

I think you make some good points here, even though I fundamentally disagree with a few things you said. First and foremost - we HAVE to stop immediately slamming anyone who questions a breastfeeding study as "anti-breastfeeding." I am very familiar with Goldin and STATS and there is NOTHING on that site that could be fairly construed as "anti-breastfeeding". It may be "anti-breastfeeding PRESSURE" or "anti-breastfeeding OVERSTATING FACTS" but anti-breastfeeding? Goldin nursed all of her (numerous) kids while holding down a professorship and working for STATS. She's committed to breastfeeding. She believes that women should, if they can. I know this. I've spoken with her.

I just resent that whenever a breastfeeding advocate says something offensive, people are so quick to say that they were "misquoted" or "taken out of context". As a journalist, I can vouch for the fact that quotes are selectively distributed throughout an article for the greatest effect...

Another theory is that people like Goldin (and myself, on a much smaller, insignificant scale) who study these issues constantly can get tired and cynical after awhile of defending our point (which usually comes down to 2 main elements: confounding factors and relative risk) and I'm sure that exhaustion can come through in our written/quoted tone.

Okay- so that is what I disagree with. On to more positive things.

One of my readers made a comment the other day that she wished the powers that be would spend less time shoving the "need" to breastfeed down our throats, and more on discovering why so many women have trouble doing so. I'm not saying societal factors aren't real - I am aware that I live in a privileged area, breastfeeding-wise, where it is absolutely the norm and formula feeding is practically unheard of - but if the women who visit my blog are any indication, society has little to do with severe mastitis, low supply, milk allergies, latching issues, severe recurrent mastitis...

I suppose you could argue that with proper support, these issues could be overcome. Perhaps. But time and time again, I heard stories of visits with a variety of LCs, LLL leaders, etc, none of whom were able to help.

I honestly feel that when breastfeeding advocates stop insisting that the majority of women can breastfeed and start realizing that evolution - and actually, I take what I said before back, society - has created constructs (older motherhood, ferility issues, toxins, stressful lifestyle, lack of family support, nonexistent maternity leave) which are, at least in the short term, unfixable, and which make breastfeeding a real challenge for some - actual inroads will be made. I would love it if we could raise breastfeeding rates. But only in a way that is gentle, kind and possible for all women.

And for the record, there was a headline all over twitter yesterday to the effect of "Women who do not adhere to breastfeeding recommendations cost our country millions". So yeah. These studies CAN be dangerous to women's rights, even if that wasn't the authors' intent.

[Best for Babes]

This is a great post and we couldn't agree more that ABC News missed the boat. In fact, I wrote about it a couple of weeks ago, http://www.bestforbabes.org/2010/04/abc-news-get-your-facts-straight-on-costs-of-low-breastfeeding-rates/ . By the way, I think it was very gracious of you to give Goldin & Beard the benefit of the doubt . . . it's possible, but at least Beard's clear formula industry ties make it hard to not be skeptical.

I LOVE what you wrote about the guilt issue. It is so tricky and complicated and you hit a number of points on the head: the limited window of opportunity to breastfeed, how the breastfeeding advocates are shooting themselves in the foot, and how important it is that we shift the pressure OFF moms and put it on the "boobytraps" that are keeping moms from making informed decisions and carrying them out, whether that it is to breastfeed for 2 years, 2 months, 2 days or not at all.

Thank you for linking to our booby traps and for a thoughtful commentary on this issue!

[Dr Sarah]

FFF – Great to see you, and thanks so much for taking the time to come over and comment on this and my other post and to spread the word about the 'opinion poll' post.

The reason I refer to the Stats.org article (not the authors) as 'anti-breastfeeding' is not because it questioned breastfeeding studies, but because it did a hatchet job while pretending to be a fair and impartial look. I don't know whether or not you read the post of mine that I linked to, but I go into a lot more detail there. Fair enough – maybe 'anti-breastfeeding' is still too strong a term, but they did seem to be going out of their way to tear it down to an extent that was not actually warranted.

I quite agree with wanting to see people look harder at the reasons why women end up not breastfeeding, and doing what they can to remove barriers. (Written about this before, BTW, at http://goodenoughmummy.typepad.com/good_enough_mum/2006/06/would_you_like_.html.)

[Fearless Formula Feeder]

I did read your post - and thought it was a really great breakdown of the issues you had with the article. I can't speak to accuracy of what STATS wrote - you are far better equipped than I to do so. My only issue was that tearing down breastfeeding studies - if that is, indeed, what they were doing - is not by definition "anti-breastfeeding", in my opinion. I know some very dedicated breastfeeders who love breastfeeding and believe it is a wonderful, natural thing to do for your child, but who still resent the constant barrage of studies trying to prove its superiority. In the words of one of these friends, "the fact that they are justifying it so much makes me feel like it NEEDS to be justified". I thought that was interesting.

I think a lot of my anger on this subject (and why I keep harping on it) is exemplified by the comment above this one. When an organization as seemingly balanced and well-meaning as Best for Babes is going around accusing people of having ties to the formula industry just b/c they had a different opinion than they have, I feel like we are veering into dangerous territory.

I'm so glad, though, that there are people like you out there, who take the time to articulate your opinion rather than hurling unfounded accusations. The more I read of this blog, the more I respect and admire you.

[Esther]

You're probably not going to be too surprised about this, Sarah, but I think many of Goldin's points are very valid ones and

I don't see her as anti-breastfeeding or even damning breastmilk with faint praise. There's a real problem with the way these

results in particular, and breastfeeding promotion in general, are being relayed to the public.

The elephant in the room about breastfeeding promotion is the fact that even under the best of conditions, aggressively

promoting breastfeeding is, in effect, telling women what to do with their bodies for several months, as you said, utilizing

the "But think of the chiiiiiiiiildreeeeeeen!" argument. Personally, I would like to see more women blow a big raspberry at

that particular argument, but it is a powerful one and should be used judiciously.

The thing about most of the breastfeeding benefits (and I agree that both of us are somewhat more optimistic about them than

Goldin is) is that even with the most optimistic stats around, for most individual children, they are relatively slight. The

main benefit is seen at the population level, and because we are dealing with aggregates, what often gets lost in the

statistical shuffle is that there are subgroups of children (e.g., preemies or children with chronic diseases) who will

benefit from breastfeeding far more than others...which isn't PC to say, is it? For your individual average, healthy term

baby, the benefit is there, but makes an overall small contribution to a child's overall health (and mostly in infectious

disease prevention area).

There's a real problem with the way breastfeeding is promoted these days. The whole concept of an odds ratio, if you don't

know the a priori chance of X happening to your baby, it's hard to assess the actual benefit - hence I would rather see this

information relayed in terms of NNTs. This could help women to come to an informed decision (not a bullied-into one) about

whether the risk of not breastfeeding is 'worth it' for themselves and their babies (and also might help prevent the attitude

of those who like to pretend formula is poison, mind). I realize that some breastfeeding advocates are less interested in

having women come to an informed decision than swaying them to what they consider the 'right' decision, but that's what an

honest breastfeeding campaign should be doing IMO. Some women would look askance at a mother who chooses not to BF and thus

'allows' her child to have a 1/10,000 chance of leukemia instead of a 1/20,000 one, or who thinks that an (average) extra ear

infection or two isn't that big a deal, but at least it keeps thing in the proper proportion.

Goldin is right that you can't randomize well (though the PROBIT studies seem to be doing so WRT more BF vs. less BF) nor

control for every difference between the BF/FF groups, but when many studies with different designs are pointing to the same

conclusion, it's still a good bet that breastfeeding is having a salutary effect, though it may well be exaggrated. The

effect may be the other way, as well (to the detriment of breastmilk). So that point of hers is one I don't necessarily agree

with.

I also think that Bartick is very naive about those $$ saved by BF. Even if the calculations are correct and even if 90% of

mothers exclusively breastfed for 6 months (to remind you, a figure not achieved even in the BF heaven that is Scandinavia),

the ills of the American system (both in the workplace and the medical system, and they're not IMO necessarily the ones that

Bartick is fixating on) are such that it'll take far more than $13billion to fix and sustain. So I don't think that the US

economy will come out ahead, money-wise. I'm assuming that's what Goldin means when she discusses the social price of

breastfeeding in the ABC article. That's not to say that those changes shouldn't be made and the parts of the system that

work to undermine breastfeeding shouldn't be done away with, but those calculations are rally not helpful and are pretty pie

-in-the-sky to begin with.

Hope that wasn't too much of a tl;dr :) .

[Esther]

(The above wouldn't post initially so I copied it to a text file, and tried again with a copy-and-paste. Hence the weird formatting. Sorry.)