As the subject of a popular web reality series, Suzanne Barston and her husband Steve became a romantic, ethereal model for new parenthood. Called “A Parent is Born,” the program’s tagline was “The journey to parenthood . . . from pregnancy to delivery and beyond.” Barston valiantly surmounted the problems of pregnancy and delivery. It was the “beyond” that threw her for a loop when she found that, despite every effort, she couldn’t breastfeed her son, Leo. This difficult encounter with nursing—combined with the overwhelming public attitude that breast is not only best, it is the yardstick by which parenting prowess is measured—drove Barston to explore the silenced, minority position that breastfeeding is not always the right choice for every mother and every child.
Part memoir, part popular science, and part social commentary, Bottled Up probes breastfeeding politics through the lens of Barston’s own experiences as well as those of the women she has met through her popular blog, The Fearless Formula Feeder. Incorporating expert opinions, medical literature, and popular media into a pithy, often wry narrative, Barston offers a corrective to our infatuation with the breast. Impassioned, well-reasoned, and thoroughly researched, Bottled Up asks us to think with more nuance and compassion about whether breastfeeding should remain the holy grail of good parenthood.
Bottled Up How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn’t
After years of hitting the bottle, America has fallen in love with lactation. Breastfeeding rates are the highest they've been in two decades: by the most recent Centers for Disease Control and Prevention (CDC) estimates, a whopping 75 percent of new mothers in the United States are nursing their babies when they leave the maternity ward. The credit goes partly to the researchers whose studies have shown a myriad of benefits to human milk, and partly to activists who have fought admirably for better pumping rights and hospital policies, doggedly working to make breastfeeding the norm. But the real heroics of the breast-is-best revolution happen not in government buildings or laboratories but rather in online chat rooms, playgroups, and prenatal classes, in the pages of parenting magazines, and in the headlines of daily news feeds. Fear of being less-than is a forceful motivator, and these days, women who do not breastfeed are portrayed as lacking-lacking in education and support; lacking in drive; and, in the harshest light, lacking in the most fundamental maternal instinct. From social media to public service messages and an overwhelming societal bias in favor of breastfeeding, mothers hear the message loud and clear: breastfeed or bust.
More than a decade ago, writer Tracey Thompson coined the term mommy wars, a "shorthand for the cultural and emotional battle zone we land in the minute we become mothers." Thompson's war was between working and stay-at-home moms, and I certainly witnessed this struggle within my own family-my mom stayed at home, my aunt was a successful professional, and there was a constant stream of subtle barbs about who'd made the superior choice. But although I can vaguely remember some discussion of work versus motherhood in my young adult social circles, it was only on the periphery. The whole mommy war phenomenon seemed dated, something left over from the early 1990s. Like grunge music, or flannel.
Flannel has recently come back in style, though, and so have the mommy wars. But while the fight looks the same, this war is fought on a very different front. A literal front, actually: those two structures protruding from our female bodies, otherwise known as our mammary glands. This battle is over our breasts, and it is causing significant carnage.
While pregnant with my first child, I was aware of the breast-versus-bottle controversy on a peripheral level, as if it were a war waged in some far-off country. I looked at formula from an unemotional place because I didn't foresee it having any real impact on my life. I'd read study after study extolling the many virtues of breastmilk, and I was entirely convinced that it was the only choice for my son. He'd had such a rough start-my body hadn't done such a bang-up job of nurturing him internally, and he was born with the ominous label of "growth restricted"-so it was the least I could do to feed him liquid gold, as the books called it, from my breast once he was on the outside.
I knew there could be problems. I'd read about latching issues, insufficient milk supply, fussy eaters ... but nobody I knew in real life had actually complained about these things. Also-and I'm not proud of this-I had a theory that many breastfeeding "problems" were a result of women waiting too long to have kids; that we were a selfish generation and that my peers would just give up too easily, at the first sign of trouble; that we couldn't be bothered in the first place.
My husband, Steve, had a family friend who was due around the same time I was, putting us in the awkward spot of being constantly compared to each other in every way, shape, and form (especially shape and form-this woman had gained only twenty pounds during her entire pregnancy and had taught aerobics up until her due date; I had packed on more than thirty-five pounds and sat on my couch writing and napping for most of the nine months). But she had made it clear that she wasn't planning to nurse, that she might pump for a few months, but no more than three, and certainly no actual "breast"-feeding. She may have won at being the better pregnant person, I silently scoffed, but I was already beating her at being the better mother.
This wasn't just naivetÈ. It was judgmental, holier-than-thou ignorance. I was an unknowing foot soldier in a new mommy war, one with a strong and ever-growing army. To be part of the breastfeeding infantry, it doesn't matter if you're planning to work full-time or be a stay-at-home-mom, if you're gay or straight, if you're a card-carrying left-wing feminist or a Mormon with a penchant for traditional values. Instead, the battle lines are drawn mostly by class, and often by race, but perhaps most painfully between those who succeed and those who "fail."
If raising a baby takes a village, then we're screwed. These days, when a woman is expecting and wondering what to expect, she will seldom turn to a book, her doctor, her mother, or even a friend. The closest thing our Internet-driven society has to a town square is Facebook. Confused or concerned? Simply punch any question into an Internet search box and voila-thousands of answers at your fingertips. Who needs a physician when there's WebMD? Or friends when there are chat rooms?
The Internet hooks you from the start: women struggling to get pregnant find themselves lured by the siren song of TwoWeekWait.com, where they'll be aided and abetted by others equally obsessed with having two lines pop up on a urine-drenched stick. Later, if you're considering a home birth, you can hit up Mothering.com, where there are plenty of folks assuring you that this is indeed the safer, smarter option. On the message board I frequented while pregnant, women would post queries like "is this labor?" or "am I miscarrying?" prior to calling an actual MD. The danger in this, obviously, is that anyone with a keyboard can claim to be an expert; the World Wide Web has opened us up to a world of biased misinformation under the guise of "Web journalism." The Internet is a physician, therapist, and best friend but also your worst enemy, a bad boyfriend who treats you like trash but then shows up with flowers and candy.
Google breastfeeding and you'll find a minefield of information. In addition to articles supporting the vast superiority of breastmilk over formula, there is ample help for any nursing problem under the sun-breastfeeding after a reduction or implants; nursing your adopted child; even lactation for men (which, for the record, is indeed possible). But amidst the plethora of substantial, legitimate information, there is also a cacophony of foreboding, judgmental voices: "lactivist" blogs that compare formula feeding to child abuse; public message boards with calls to action-"I automatically feel sorry for the baby sitting in the cart in the formula aisle as their parent loads up on cans of the stuff. I feel like yelling 'HOW CAN YOU DO THAT TO THE POOR CHILD!?'" says one poster on a Facebook breastfeeding group forum; diatribes from medical professionals and lactation consultants, using their professional credentials to validate staunch personal beliefs. Even a board dedicated to planning Disney World dream vacations devolves into a formula-versus-breastfeeding argument when a woman brings up the lack of nursing rooms in Frontierland.
When I first performed my own prenatal Internet search on infant feeding, I was surprised by the vitriol expressed in these lactivist websites toward formula feeders, but since the breastfeeders were in my prospective camp, I chose to ignore my sneaking suspicion that something was amiss. Plus, I admit that I possessed an embarrassingly classist view regarding formula. Better bonding, improved immunity, less chance of childhood obesity, higher IQ, reduced cancer risk-all this could be yours, simply by nursing. Knowing all this information was out there, I couldn't believe there was anyone who didn't breastfeed these days, other than uneducated teenage moms, those with uncompromising work situations, or those unfortunate women who were physically unable to do so (and according to what I had read on the La Leche League website, there were very few of these women out there-far fewer than the formula lobby and misinformed doctors would have us believe).
It was one thing if a legitimate medical reason, insensitive employer, or lack of education stopped a mom from nursing; but all things being equal, it seemed selfish not to breastfeed. I certainly didn't think formula was poison; almost everyone I knew in my generation was formula fed, and we all survived. But as another poster on that Facebook forum lamented, if we had all been breastfed, "who knows how much better [we] could have been?"
In my former life, I was more than immune to peer pressure; rather, I would choose the "alternative" point of view just to differentiate myself. But when it came to motherhood, I was a simpering mess, just waiting for the cultural zeitgeist to sway me in a certain direction. Because when it came down to it, like Prissy in Gone with the Wind, I didn't know much about birthing babies, and even less about raising them. If the smart, progressive moms were breastfeeding, then I would be breastfeeding too.
A few months before I gave birth, a package arrived at my door. It included a sample can of Similac formula and a ton of literature on breastfeeding.
My husband watched me open the package and raised his eyebrows when he saw its contents.
"Why did they send you that?" he asked. "We're breastfeeding."
It was a good question, with a rather convoluted answer. The International Code of Marketing Breastmilk Substitutes (known in lactivist circles as the "WHO Code"), prohibits formula companies from advertising in any conspicuous way: "There should be no advertising or other form of promotion to the general public of products within the scope of this Code," proclaims article 5.1 of this policy, coauthored in 1981 by UNICEF and the World Health Organization (WHO).
The creation of the WHO Code was inspired by events that caused the NestlÈ company to begin to be associated with infant death rather than chocolaty goodness. The debacle began when NestlÈ deployed "Mothercraft" nurses, dressed in white uniforms evocative of medical professionals, to assist new moms in the maternity wards of developing nations. The trouble was that these "Mothercraft nurses" were not nurses by any stretch of the imagination, and they liberally doled out formula along with infant-rearing advice. Mothers were encouraged to use formula under these false pretenses and sent home with free samples; their milk soon dried up, as did the formula freebies. Faced with limited financial resources and, in many cases, a contaminated water supply, babies were soon being fed with diluted bottles of disease-laced formula. This caused dehydration, malnutrition, and fatal cases of bacterial infections and gastroenteritis from the compromised water used to mix the formula; breastfeeding advocates claimed that up to ten million infant deaths could be attributed to the proliferation of infant formula use in developing nations. Physicians, religious leaders, and activists banded together to demand a boycott of NestlÈ products worldwide and to encourage the promotion of breastfeeding as the safest and best form of infant feeding.
The NestlÈ controversy was integral to the resurgence of breastfeeding in Western societies, many of which had become primarily bottle-feeding cultures in recent decades. It not only revealed that formula companies were out for the bottom line and apparently had no concern for the infants they were claiming to nourish, but also led morally driven scientists and social activists to question the formula-accepting status quo. Within several years of the NestlÈ disaster, WHO came out with its famous Code, an outpouring of studies suggesting the superiority of breastmilk hit the medical journals, and an international conference was convened to create the Innocenti Declaration, which could be considered the cornerstone of lactivism. Developed during a WHO/UNICEF policymakers' meeting in the summer of 1990 (held at the appropriately named Spedale degli Innocenti in Florence, Italy), this declaration outlined the importance of global breastfeeding initiatives: "As a global goal for optimal maternal and child health and nutrition ... all infants should be fed exclusively on breastmilk from birth to 4-6 months of age.... [T]his goal requires, in many countries, the reinforcement of a 'breastfeeding culture' and its vigorous defence against incursions of a 'bottle-feeding culture' ... utilizing to the full the prestige and authority of acknowledged leaders of society in all walks of life."
The serious tone of the Innocenti conference reflected a belief-inspired by the NestlÈ debacle-that formula feeding was legitimately dangerous. It didn't really matter that what caused the deaths of so many third-world children was not the formula, specifically, but a slew of formula-handling-related problems (contaminated water, lack of resources); even in affluent Western cultures where these problems were practically nonexistent, people began viewing formula as a deadly substance. This mentality became more pervasive through the decades, gaining momentum through literature that frames risks in ways that the average person can easily misinterpret. For example, in her book The Politics of Breastfeeding, nutritionist and outspoken breastfeeding activist Gabrielle Palmer chastises the United States for its hypocrisy in claiming to defend the life and liberty of babies in a myriad of military conflicts, and then being unwilling to set "guidelines for the marketing of a product which could kill children." The Los Angeles Breastfeeding Task Force website somberly states that "the practice of feeding babies infant formula ... carries with it profound risks in modern, industrialized countries, as well as in developing countries.... [M]any are unaware of how the lack of breastmilk and the use of infant formula compromise the health and well being of children in the United States. These risks are well documented in the medical literature."
The United States has taken flak for being the only "major country" not to adopt the WHO Code. (Ronald Regan's administration held out on the grounds that it restricted free trade. Score one for capitalism.) However, years of lobbying from groups like the La Leche League, the United States Breastfeeding Committee, and the American Academy of Pediatrics' Breastfeeding Section resulted in the United States adopting much of the Code in 1994. All this really meant was that the government informed formula companies about the Code and "encouraged" them to abide by the rules. Breastfeeding advocates attempt to police these rules, but it has admittedly been an uphill battle; formula advertisements are still seen prominently in parenting magazines and on television. But there have been many victories, as well-a substantial (and steadily growing) number of "breastfeeding-friendly" hospitals have ceased to hand out free formula samples, and formula manufacturers are required to print an advisory statement on their products explaining that breast is always best (but the formula you've just bought is an excellent substitute!). In other countries where the WHO Code is uniformly followed, formula companies are far more restricted-for example, they are not allowed to advertise at all. Breastfeeding advocacy groups like the National Alliance for Breastfeeding Advocacy (NABA) are working to encourage the United States to adopt similar policies. If this happens, formula will become part of a shameful club-the only other consumer goods in America that have these types of restrictions and laws governing their advertising and packaging are tobacco products and alcoholic beverages.
For those of us having babies in the twenty-first century, breastfeeding advocacy is becoming more like antiformula advocacy. Suggestions on raising breastfeeding rates focus on eliminating formula from our lives: What if we made formula available by prescription only? If hospitals went formula-free, only allowing parents to use it if deemed "medically necessary"? And this isn't just from grassroots organizations. Even the CDC, on a webpage explaining its 2010 Breastfeeding Report Card project, emphasizes that in our country, "too few hospitals participate in the global program to recognize best practices in supporting breastfeeding mothers and babies, known as the Baby-Friendly Hospital Initiative," an initiative that puts heavy controls on the use of formula in institutional settings-even if the parents have expressed no intention to breastfeed. But perhaps the biggest game-changer in the way breastfeeding advocacy is handled has been the concept of educating women on the risks of formula feeding rather than the benefits of breastfeeding. This has provoked a recent movement to trade in the old "breast is best" slogan for the new "breast is normal," although the sentiment is nothing new. "The truth is, breastfeeding is nothing more than normal. Artificial feeding, which is neither the same, nor superior, is therefore deficient, incomplete, and inferior," Diane Wiessinger, an outspoken lactivist and international board-certified lactation consultant (IBCLC), wrote back in 1996 in an oft-cited article, "Watch Your Language."
In this context, the formula freebies I received take on a darker meaning. But even for those who don't fear formula, and simply feel strongly that breastfeeding should be the default, these samples are troublesome. The belief is that samples are simply too tempting for women, that breastfeeding is difficult at first, and having formula in the home undermines a woman's confidence in her own body. There have been studies bolstering the suggestion that outlawing the samples might increase breastfeeding rates; one small Canadian study found that women were 3.5 times more likely to be breastfeeding exclusively at two weeks postpartum if they hadn't received formula samples.
At least in my case, an unsolicited package from a formula company couldn't undo all the subtle, subliminal pronursing messages I'd endured since joining the profitable ranks of expectant mothers. Every time I walked into a maternity store, I saw huge sections full of Medela nursing products; rows of nursing bras and fashions; special rooms for "nursing moms"; breastmilk "test kits" in case a modern, socially active mom had one too many cocktails and still wanted to give her baby the best nutrition; baby and pregnancy magazines that consistently had cover stories on how breast is even better than we thought before, and so on. Nursing was the norm, at least in my socioeconomic and cultural stratum.
Even for mothers immune to social pressure, the fact that respected medical authorities have come down so dramatically on the side of breastfeeding makes a strong statement. The American Academy of Pediatrics (AAP), American Medical Association (AMA), and American Dietetic Association (ADA) all recommend exclusive breastfeeding for at least the first six months of life, followed by at least another six months of partial breastfeeding. WHO takes it a step further, commanding us to nurse for two full years. Although the Office on Women's Health, U.S. Department of Health and Human Services, argues that "the marketing of infant formula negatively affects breastfeeding ... [and being] given [an] infant formula kit [is] strongly discouraging" to breastfeeding efforts, a stereotypically anxious mother would have a hard time ignoring these research-backed mandates in favor of Similac's prettily packaged presentation of bottle-feeding bliss.
The same day the formula package arrived, I also got a coupon for a free six-piece chicken McNuggets from McDonalds. I don't eat fast food; I didn't run out to the drive-thru just because I could get something for free. I couldn't really understand why the formula package was any different. I did see one problem inherent in the free gift I was sent, however, and that was the enclosed reading material. I was media-savvy enough to understand that the pro-breastfeeding pamphlet included in my Similac-sponsored gift was just lip service, but obviously they were sending mothers a mixed message by offering free formula samples along with a small booklet of advice to help with all the potential problems we might face if choosing to breastfeed: Breastfeeding is hard. Choose formula. Message received.
There are other messages, though, received indirectly but just as powerfully. Shortly after I received that Similac sample, I found myself wandering the hallowed halls of Babies 'R' Us in a daze, agonizing over whether or not to register for bottles in case I wanted to pump somewhere down the line. I was afraid of what friends would think if they saw bottle paraphernalia on my registry; that I might be setting myself up psychologically for failure, or giving my baby "nipple confusion" (an inability to go from artificial nipple to actual nipple) as some of the breastfeeding books had suggested. I already felt a deep sense of anxiety and insecurity about motherhood; two miscarriages and a problematic pregnancy had rendered me unsure about my body's innate maternal abilities, and I was determined to at least get the retail aspect of the job done right.
There was a woman next to me, shoving several packages of disposable bottle liners (both environmentally and maternally irresponsible, I thought) into her shopping cart. She had two older children who were shoving each other, fighting over a push pop; her infant daughter was sitting unrestrained in the cart.
Next to her, a glowing, tall, blonde pregnant woman was conversing with her husband. "Grab those ones-the ones that say breastmilk storage bags?" she instructed him, as he reached for something on the top shelf of the display. "I've heard those are the best for pumped milk- no BPA!"
I smiled at the blonde woman, my kindred spirit, as the bottle-feeding mom's baby started wailing.
My old college roommate is Catholic, and we have a longstanding debate on who owns the monopoly on guilt-her team or mine. I'm the product of a long line of Jewish mothers; she has original sin hanging over her head. There has never been a clear-cut winner in this battle, until now. Now I am a mother. Game over.
The guilt starts early. You get five minutes of unadulterated, blissful excitement when the pee stick turns positive, but then it begins. What about those five glasses of Sangria you had a few nights back? Is your baby going to have fetal alcohol syndrome? Maybe you haven't been taking your prenatal vitamins as religiously as you should have been. Plus you opted for the generic brand over the fancy Whole Foods ones your sister-in-law recommended. Bad, bad mommy. We'll know who's to blame when your kid comes out with scurvy.
For the past decade, no conversation about breastfeeding promotion can escape the legend of the 2003 U.S. Department of Health and Human Services/Office on Women's Health Advertising Council breastfeeding campaign. The campaign most famously featured a thirty-second public service announcement showing a massively pregnant, attractive African-American woman in her thirties riding a mechanical bull. She falls off; the bar patrons watching are appropriately horrified. And the words flash on the screen, ominously: "You wouldn't take risks before your baby is born. Why start after? Breastfeed exclusively for 6 months." Another similar spot relayed the same message with an expectant mother engaging in a log-rolling contest.
By appealing to mothers' propensity to guilt and fear, the PSA assumed a few things: first, that the target audience was committed to a healthy pregnancy and a healthy baby; second, that they were committed to the nutrition of their children; and third, that they were committed to being the best parents possible. So we're starting with a group of women who are already nervous, probably overloaded with information (my living room was a veritable obstacle course of pregnancy and parenting books), and the host of a ton of pesky hormones that make us cry at something as innocuous as a rerun of Saved by the Bell. The campaign's creators were well aware of the impact these ads would have; one member of the AAP's breastfeeding committee claimed the campaign signified "a change to promote breastfeeding as a public health issue rather than simply as a personal parenting choice." Even the slogan used in the campaign-"Babies are born to be breastfed," rather than the well-known adage "breast is best"-was significant. The Department of Health and Human Services (DHHS) intended the slogan to address its growing concern that breastfeeding should not be seen as the "ideal," but rather that formula should be framed as risky.
Even if one were to accept the general premise that babies were, indeed, sprung from the womb with a breastmilk birthright, where was the mother in the scenario presented by this slogan? Rebecca Kukla, professor of philosophy and internal medicine at the University of South Florida, voiced these concerns in a 2006 paper examining the campaign. Rather than addressing the real reasons women don't breastfeed-reasons that range from histories of sexual abuse and body image issues to economic and physical constraints-the campaign "portrays anything short of exclusive breastfeeding ... as a sign of moral corruption and bad character.... We can only conclude that DHHS believes that women can choose to breastfeed yet are failing to do so, not because there are any impediments to their voluntarily making this choice, but rather because they simply aren't willing to do the best thing for their babies unless more pressure is exerted."
There was a ton of controversy surrounding these ads, which were pulled shortly after their launch (but not before they scared millions of potential, current, and future moms, I'll bet). They even caused dissension within the American Academy of Pediatrics. On a 2003 episode of CBS's Early Show, Dr. Carden Johnston, the AAP's president at the time, claimed that he was absolutely in favor of a campaign to promote breastfeeding but worried about the tone of this particular campaign. "We want women to be able to choose to breastfeed and do that for positive reasons and not feel intimidated or scared," he said on air. "We are for the breastfeeding campaign and we want to encourage it and support it and we want it to be accurate and credible.... Pediatricians raise their children and support their families with positive nurturing experiences, not with scare tactics." A rational and considerate point of view, to be sure; unfortunately, Johnston and others who shared his concerns were accused of being in the pockets of the formula industry by some on the other side of the debate, and these cautious, balanced voices were silenced.
The DHHS/Ad Council campaign marked a significant change for the AAP. Although it had come out with statements supporting breastfeeding in the past, the organization had been cautious not to alienate the parents it served. At the time the bull-riding/log-rolling ads were released, the AAP was still relying on documents from the 1980s that, according to one breastfeeding activist, simply "encouraged breastfeeding and acknowledged the superiority of human milk." Then in 2005, "Breastfeeding and the Use of Human Milk," now used as the go-to for AAP breastfeeding policy, was released; it was profoundly different in tone, saying in no uncertain terms that "human milk is uniquely superior for infant feeding" and recommending that infants be breastfed for at least a year.
It seems likely that the new, unequivocal tone was at least partly inspired by the dissent in the AAP's ranks over the DHHS ads-especially when you consider that this statement was written by members of the 2003 AAP Section on Breastfeeding, the same group that cried foul when its parent organization, led by Dr. Johnston, pulled the plug on the DHHS campaign.
An older Southern gentleman with a slow drawl and kindly demeanor, Dr. Carden Johnston is like the poster child for a homey, warm, idealistic view of pediatrics; quite a contrast to how the defenders of the DHHS campaign had portrayed him in the press. In the kindest light they shone on him, he was a daft industry pawn; in the harshest, a slick political animal willing to throw the baby out with the formula water. "Dr. Johnston ... developed this sudden and seemingly urgent interest in this issue not via a last minute clinical review of the scientific literature, or even after consulting with the AAP's own recognized lactation science experts ... his concern came immediately after aggressive, personal lobbying by representatives of one of the AAP's biggest financial contributors, the $3 billion U.S. infant formula industry," wrote lactivist Katie Allison Granju in "The Milky Way of Doing Business," a rebuttal to the AAP's actions regarding the campaign. "Johnston hurled the considerable credibility and persuasive impact of the esteemed American Academy of Pediatrics into an explicit effort to stifle the most ambitious initiative ever undertaken to promote breastfeeding in the United States."
When I met with Johnston seven years later, his recollection of the events was less dramatic. "I found out that there was pressure to have an advertising campaign come out of the Office on Women's Health, which would use fear tactics to promote breastfeeding.... [S]ome of the things they were saying pushed the data to a level so that it was no longer credible ... 'If you don't breastfeed, your child is going to develop leukemia' ... those kinds of scare tactics were there," Johnston explained to me on the rare sunny day that we met in Seattle, where he and his wife live part-time. "Now, if the data that something in infant formula might cause leukemia was solid, the Academy would have to find out what in the formula was causing leukemia and eliminate that, and meanwhile, encourage everyone to breastfeed ... but the data was not that strong. And [the executive committee] needed to respond, because the Ad Council was working hard on this campaign and were likely to get something out pretty quickly. I signed a letter saying where the Academy was coming from; that the ads should be more positive than negative in promoting breastfeeding; and I think it's a very good letter.... What we didn't do, in retrospect, was to involve a lot of our breastfeeding advocates before we mailed it. We wouldn't have had to change the letter, but they should have been notified and consulted."
As for the claim that the formula companies were influencing the AAP, Johnston says that "the formula company was monitoring the website [so they] were able to show me what was on the website before the Office of Women's Health pulled it down. So, is that influence or not?"
Certain members of Johnston's own organization clearly believed that it was. Dr. Lawrence Gartner, head of the Breastfeeding Section of the AAP, spoke harshly about Johnston when interviewed for Granju's article. "Some of us within the AAP have long suspected that the infant formula companies had this sort of direct access to AAP leadership.... Dr. Johnston's actions have revealed the extent of this influence more clearly than anything else I've seen. Many doctors within the AAP are very disturbed by this."
Whether there really had been "many doctors" offended by the executive committee's actions, or if it had merely been the vocal few that comprised the Breastfeeding Section, is likely a matter of interpretation. It's tough to know where the majority of the AAP really stands, since you'd be hard pressed to find anything on the AAP website having to do with breastfeeding that hasn't been written by the Breastfeeding Section. Johnston spent about twenty minutes trying to explain the role of a section to me; basically, it is "a group of individuals [within the AAP] who are enthusiastic about an issue." The executive committee will then turn to the section when it needs to construct a policy on that specific issue; for example, the majority of information on infant feeding that gets filtered through to the public via the AAP website is written by the Section on Breastfeeding.
I asked Johnston if those in the Breastfeeding Section were single-minded, and if this posed a problem for the rest of the organization; he told me I had it backward. "Those are who you want to have in there. If it's child abuse, sexual abuse, if it's immunizations, if it's breastfeeding, if it's safety, child passenger safety, ATV's-you want the enthusiasts in there, leading. But I think that passion sometimes will distort interpretation of studies the same as it does for me when I'm doing child passenger safety studies"-child safety is Johnston's field of interest, as a former emergency room doctor-"and I read a study, and I completely believe it. There may be some holes in it that I'm not seeing.... You know, you've got all this science, and then you have your personal biases and beliefs. Now, which one do you go with? I mean, this is emotionally correct. This is scientifically correct. Which one is stronger? When the science is hard, it's not an issue. But we're making statements before the science is that hard. So you're using experts interpreting the best data that's available." (Which makes me wonder: The statements of the AAP are considered the word of God by most American parents. If the enthusiasts are the ones writing the policy, and being enthusiastic may alter one's perception of the facts, are the rules we've been following based on little more than bias and zealotry?)
Johnston feels that it's a pediatrician's job to lay out the facts and encourage breastfeeding. But he also warns that when dealing with a mom "who's had emotional problems before, or guilt or insecurity," doctors should tread more carefully. "I think you would handle that a bit differently and let her ventilate some about how important she feels breastfeeding is, and about her family support system.... How much does she want to breastfeed? And then, support her decision. I think a pediatrician still can approach each parent, each situation differently."
In practice, most pediatricians (at least the good ones) are probably taking this type of approach. I've heard rumors of a few rogue doctors in the Los Angeles area who won't accept patients who aren't breastfed, but on average, physicians seem to share Johnston's moderate modus operandi. Several studies have been conducted examining pediatricians' attitudes toward breastfeeding advocacy, and most conclude that pediatricians aren't pushing breastfeeding as much as the AAP official policy suggests they should. In a 1999 survey of more than fifteen hundred fellows of the AAP, "only 37% recommended breastfeeding for 1 year ... [and a] majority of pediatricians agreed with or had a neutral opinion about the statement that breastfeeding and formula-feeding are equally acceptable methods for feeding infants." (Interestingly, the same study also found that physicians-presumably the female ones-who had themselves breastfed were "more informed and confident in their [breastfeeding] management abilities" and suggested that "educational programs also be targeted to professionals to effect changes in their personal behavior." I wonder how female physicians would react to being told that what they do with their breasts is integral to the well-being of their patients. Or if the same type of approach were taken with the obesity epidemic, and the AAP sponsored weekly weigh-ins to ensure that its members were leading by example.) And while government and media support for breastfeeding has increased since 1999, and the AAP has issued stronger and stronger statements supporting the process in recent years, a study conducted in 2004 found that pediatrician support for breastfeeding had actually declined. Compared to a comparable study in 1995, pediatricians were "less likely to believe that the benefits of breast-feeding outweigh the difficulties or inconvenience ... fewer believed that almost all mothers are able to breastfeed successfully ... [and] more pediatricians reported reasons to recommend against breast-feeding." Since the DHHS campaign fiasco occurred in 2003, I wonder if these changes reflected an underlying backlash against the extreme sentiments voiced in the campaign and throughout the resulting debates within the AAP.
Unfortunately, when doctors publicly speak out against the pressure to breastfeed, they risk their professional and personal reputations. After the birth of his first child, Dr. Barry Dworkin's wife was having trouble breastfeeding. The Canadian family practitioner came home one evening and found his wife in tears because a lactation consultant she had called for advice had "essentially told her that she was endangering our child's life because she was not breastfeeding properly, or breastfeeding enough, [that] supplementing was harmful to our baby."
This personal experience, and hearing similar horror stories from his patients, led Dworkin to write a column for his local paper titled "The Hazards of Breastfeeding." "In my practice, I observe many mothers equating breastfeeding to their competency to be good mothers. This narrowed perspective-the dependency upon one aspect of newborn care-can be damaging to the mother's well-being," he explains in the column, which appeared in a 2002 issue of the Ottawa Citizen. "Despite the best of intentions, women are bombarded with messages that lead them to believe if they stray from breastfeeding they are potentially harming their newborn child.... There must be a balanced approach to newborn feeding. If a mother is unable to breastfeed, and yes this does happen, she should not be made to feel that she is a failure.... Every woman should be encouraged to breastfeed but should not be subjected to judgment of her maternal skills in a punitive fashion."
Within days of the column's publication, Dworkin received piles of irate letters, which called him "uneducated, unethical, and unprofessional.... I had people who felt that anything that forestalled breastfeeding was a criminal offense writing me, telling me how irresponsible I was, and how terrible it was that I'm an assistant professor at a university, that I must be poisoning medical students' minds with this kind of information." It didn't matter that Dworkin praised breastfeeding as a practice, or that his criticism was centered on the pressure women feel to nurse and the dangers inherent in inflexibility, moral coercion, and misinformation. We've gotten to a place where you can't utter the word breastfeeding in a negative context without serious backlash.
Before I left our interview, I asked Dr. Johnston about his own family's experiences with breastfeeding. He told me that his wife had nursed their two daughters, but that her milk had never come in with their first child. "Our first kid didn't get any milk, so at the end of a week he was underweight. We gave him formula, and the kid caught up," he said casually as I gathered my things together.
"Oh, and that son now is a breastfeeding advocate. He works for UNICEF in Africa and does emergency nutrition. He got interviewed for Voice of America the other day about Breastfeeding Week."
A champion of breastfeeding, sprung from the loins of the man whom Mothering Magazine accused of "dismissing breastfeeding advocates"? I can only imagine how Thanksgiving dinner went down at the Johnston household in 2003.
The ad industry certainly didn't give birth to the concept of mother guilt. Advertising just capitalizes on feelings that are a natural part of motherhood. Mainstream breastfeeding advocacy has acknowledged the power of these emotions as a valuable tool for increasing breastfeeding rates-albeit in a quiet, underlying sort of way. Sociologist Elizabeth Murphy has argued that government breastfeeding policy in the United Kingdom has relied on a sort of "quiet coercion," a phenomenon quite similar to what is happening here, on the other side of the pond. "Forcing women to breast feed would be unthinkable as an illegitimate incursion into the privacy of family life and an assault on mothers' autonomy and self-determination," Murphy suggests. Instead, by promoting breastfeeding as a way to better the health of the nation, the government encourages us to think and behave in certain ways, and to judge others accordingly; in effect, we are policing ourselves. "While experts are not, in the end, able to control how mothers feed their babies, they do set the standards by which women may be judged by others and, perhaps most importantly, judge themselves." (The late Frank Oski, M.D., perhaps the most prominent physician breastfeeding advocate of the twentieth century, once alluded to this same useful tactic, stating that "if the truth makes mothers feel guilty and they develop some anxiety, perhaps the discomfort will tip the scales in favor of breastfeeding.")
Murphy's theory might explain why being pregnant is tantamount to wearing a "kick me" sign on your back-or, rather, a "give me your unsolicited opinion" sign. That big belly gives strangers the license to weigh in on a number of things that seem entirely irrelevant to anyone other than you and your gestating fetus, and breastfeeding tops that list. One of my clients asked me in the midst of an eight-person meeting if I had started "toughening up my nipples" in preparation for Leo's arrival. At the time, I was just uncomfortable with her talking about my nipple activities in front of professional colleagues, but she also made the assumption that I was planning on nursing. As if it was unthinkable that I would be doing anything but.
There was also subtle pressure-the random older woman in a restaurant who asked me if I would be breastfeeding; the infant care classes where formula feeding wasn't even mentioned; the nurse on my maternity ward tour who warned us that we'd be woken up every two hours to nurse, and asked for a show of hands: how many in the group were going to be breastfeeding? (Needless to say, all hands shot up.)
These experiences weren't particularly unique, or even that bad in the scheme of things. Jennifer, who teaches at a prestigious Los Angeles private school, was told by a student's dad that he "wouldn't respect her as a woman" if she didn't breastfeed. (He delivered this gem during a parent-teacher conference, no less. Bet that didn't help his kid's grade.) Nurse practitioner Shannon endured months of chastising from her peers when she confessed she was planning on formula feeding. "I did not expect to get the flak I did from other medical professionals-none of which are my personal physicians-about my decision not to breastfeed," she lamented. "I was told multiple times, 'Oh, why don't you just pump for a month?' 'Why won't you breastfeed, it's the BEST thing you can do for your baby,' 'It's such a great bonding experience,' 'You will regret not doing this.'"
I spoke with a young mother who finally decided to "swallow [her] pride" and enroll in WIC (the Women, Infants, and Children program, a government assistance plan the mission of which is to insure proper nutrition for low-income mothers and their children) when she was six months pregnant. "During intake I got asked if I was going to breastfeed. I said no, that as a sexual abuse survivor I was uncomfortable with it.... [M]y breasts had been used in my attack, and to do so was to feel like I was molesting my child, to feel like I had no control over my body as it was being used in service for others. The [licensed practical nurse] told me that if I really loved my baby, I would breastfeed." She recounts that several of her WIC counselors told her that "they 'knew' lots of women who had been raped who breastfed," and suggested that since she had obviously had sex to conceive a child since being attacked, she was sufficiently healed to nurse that child.
Most of the women I've interviewed cite their own previous judgment of formula feeders as an ironic reminder of how powerful the "good mothers breastfeed" meme really is. "I studied the breastfeeding failures of friends and family.... I assumed they were lazy. I assumed they didn't try hard enough. I believed everything I read in breastfeeding literature as though it were the gospel truth," says Kelli, whose son was ultimately unable to latch, causing jaundice and insufficient weight gain. A mom of twins had felt sure that "'good' mothers breastfed their children," and admits she "bask[ed] in the praise I received when someone asked if I was planning on breastfeeding and I answered 'of course.'"
"It's almost like with something like circumcision, or 'crying it out,' there's an understanding that multiple views are okay, but with breastfeeding we have reached a point where alternative viewpoints are considered uneducated or wrong," says Stephanie Knaak, a Canadian sociologist who has written several well-regarded papers on the infant feeding discourse. "There's a whole stream of thought that breastfeeding is natural and it's for bonding and it's this kind of wonderful mother-child relationship thing, and so it's good in that way. And there's the medical sciences aspect-we know that breastfeeding is very strong from a nutritional standpoint, and it protects your baby, it makes them healthy, and it makes mothers healthy. And then you've also got a public shifting of views about motherhood-that a good mother is the mother who does everything for her child.... [M]othering is supposed to be labor intensive, self sacrificing. Breastfeeding fits in very nicely with that idea. All of these different forces culminate into the same thing, and it makes it a particularly intense pressure. There aren't really any forces that speak against it."
On the many lactivist blogs and Twitter feeds I followed while researching this book, the words of Eleanor Roosevelt would be thrown around like paper airplanes in a fourth-grade classroom-inappropriately and haphazardly, and often hitting unintended targets. Although Eleanor's original verbiage involved inferiority, not guilt, the (mis)quote most often used when the subject of guilt and infant feeding arises is that "nobody can make you feel guilty without your consent."In context, this quote often coincided with the argument that women feel guilty only because they know they have something to feel guilty about. In other words, it's a good thing they feel guilty about how they are feeding their kids because they have royally mucked it up.
What the people who use this argument don't seem to understand is that the most powerful motivator for breastfeeding is not peer pressure, fear, obedience, or any other "quiet coercion." It's desire. The desire to be everything your coveted child needs; the desire to have that indelible bond with the human you created; the desire to provide sustenance from your very being. And when for whatever reason this desire goes unfulfilled, the resulting emotion is often guilt-not because we feel like we did something wrong but because we feel there must be something fundamentally, awfully wrong with us, to be unable to perform this most basic of human functions.
In one oddly worded article, Dr. Jack Newman, author of The Ultimate Breastfeeding Book of Answers, writes that the concept of mother guilt is just another ploy of breastfeeding detractors; that we should not stop promoting breastfeeding just because it makes women feel guilty. "Who does feel guilty about breastfeeding?" he asks. "Not the women who make an informed choice to bottle feed. It is the woman who wanted to breastfeed, who tried, but was unable to breastfeed who feels guilt."
Awkward phrasing and intention aside, those last two sentences are the truest things I've ever read about breastfeeding. I didn't find this article until I was six months postpartum, but I wish I had come across it during those rosy, innocent prenatal wanderings through the World Wide Web. Maybe it would've given me some warning about what was to come.
I had been writing for a popular health and wellness website prior to my son's birth, and the founder of the site had lent me a few books on the psychology of newborns. One had described how, if an infant is placed on the mother's belly immediately after birth, he will instinctively claw his way up to her breasts and latch right on. It seemed so primal, this preprogrammed knowledge, an instinct to both forage for food and seek comfort. I couldn't wait to see it in action.
To my obvious pleasure and relief, my first moments with my son Leo went exactly as the book described. His tiny movements up the outside of my stomach were like reverse echoes of what he had been doing on the inside for the past months. Familiar but hyperreal; I couldn't reconcile this small being on my skin as the same creature that had been cohabitating with my internal organs. It was disconcerting. His big eyes looked up at me as he pushed his damp head into my rib cage; the nurse shoved him roughly up toward my nipple and he found his target. It was exhilarating. The books hadn't lied. The nurse told me Leo was a nursing pro, that we were doing just great. I believed her.
Later, I was wheeled up to the maternity ward. There was a bassinet in our room with a baby in it. My long-awaited, desperately wanted, beautiful, healthy baby. He was a good baby-quiet, alert, an "old soul," according to my father.
He was perfect. For about three hours.
And then he got hungry.