When I got pregnant, I was surprised to find that what people wanted to talk about most was breastfeeding. To me the exciting questions were how big is the baby right now? (the size of a poppy seed? an avocado?) is it a boy or a girl? have you thought of names? I really wasn't primarily concerned with how I would feed the baby.
I was told, more than once, that breastfeeding was the most important thing I would ever do for my child. I discovered women who could talk about the joys and benefits of breastfeeding for an entire evening. I met men who said they couldn't respect a woman who did not breastfeed.
I did end up breastfeeding my children, and I assumed they would be better off for it. But I couldn't understand the moral fervor surrounding breastfeeding, or the smug superiority of many breastfeeding mothers. I'm a political science professor, so I decided to write an article, or maybe even just a pamphlet. I'd be the Thomas Paine of breastfeeding. After all, how much could there be to say? And who would care?
The truth is that breastfeeding research is not very good, and there's a lot we don't know
If only I had stopped with the pamphlet. As I waded in, I learned many things that defied pretty much everything I had taken for granted about breastfeeding. Just because I didn't buy into the moralizing zeal didn't mean I didn't think it was a pretty good thing.
At first I didn't believe it — or maybe I couldn't understand it. Was I really the only person reading this stuff? How could the conventional wisdom surrounding breastfeeding be so far removed from what scientists actually knew?
How could the public health initiatives promoting breastfeeding be so punitive, and so racist? How could someone who is probably the most well-known breastfeeding advocate in the world join forces with AIDS denialists to claim there is no evidence that breastfeeding transmits HIV? How could breastfeeding be big business? When did human milk become a commodity?
I'd gone down the rabbit hole, only to find that it was the perspective I had left behind that was distorted.
Here are a few examples of what I discovered. Almost all of them are things I wish weren't true.
1) In countries where women have access to clean water, the health benefits of breastfeeding are probably very small
The truth is that breastfeeding research is not very good, and there's a lot we don't know. But here is what we do know. Breastfeeding reduces the risk of ear, respiratory, and gastrointestinal infections, and of a rare condition called necrotizing enterocolitis that affects some premature infants.
But that reduction is tiny. According to the director of the Agency for Healthcare Research and Quality, six women have to breastfeed exclusively for six months in order to prevent a single ear infection. That's 5,400 hours of breastfeeding to prevent one ear infection. The numbers for respiratory infections are even less impressive.
2) There is strong evidence that breastfeeding has no impact on obesity
Or Type 1 diabetes, asthma, allergies, dental cavities, or the following types of cancer: acute non-lymphoblastic leukemia, non-Hodgkin lymphoma, central nervous system cancers, malignant germ cell tumors, juvenile bone tumors, and other solid cancers.
The evidence of other long-term health benefits, such as reducing the risk of cardiovascular disease, high blood pressure, or Type 2 diabetes, is either weak or inconclusive. The fact is that the benefits of breastfeeding have been vastly oversold.
3) The US is one of only four countries in the world without federally mandated paid maternity leave
The others are Swaziland, Papua New Guinea, and Liberia. On average, women in the United States take six weeks of maternity leave, cobbled together from a combination of vacation, sick, and personal days. But 30 percent of new mothers take no maternity leave at all. Women in higher-paid jobs often have better maternity leave benefits than women in lower-paying jobs.
The absence of maternity leave makes breastfeeding a lot harder in the US than it is in, say, Norway, where women have a choice between 49 weeks of maternity leave at full salary or 59 weeks at 80 percent of their salary.
Not surprisingly, the most important factor in predicting whether and how long an American mother will breastfeed is whether she plans to return to work.
4) Recent government initiatives to promote breastfeeding actually support breast pumping
Faced with the gap between the recommendation to breastfeed exclusively for six months and the absence of federally mandated paid maternity leave, most recent "breastfeeding" initiatives actually promote pumping, creating the expectation that a new mother should pump on the job so that someone else can feed her baby breast milk from a bottle.
In 2010, the Fair Labor Standards Act was amended to require employers to "provide reasonable break time" and space for women to pump breast milk at work. To be clear, those breaks are unpaid, and the Department of Health and Human Services encourages employers to have mothers come in early or stay late to make up the time they spend pumping. Since 2013, the Affordable Care Act has required insurance companies to cover the cost of a breast pump for new mothers.
Such policies have quietly realigned our expectations of what new mothers should do to care for their newborns, making mothers work harder, for less pay, under conditions that risk compromising their dignity and professionalism.
They are also explicitly conceived as business-friendly strategies that enable women to comply with the injunction to breastfeed at no cost to employers. Who needs a lavish European-style maternity leave when we've got breast pumps?
5) There is no research comparing health outcomes among babies who are breastfed with outcomes among babies who are fed breast milk from a bottle
Policies that promote pumping as an alternative to breastfeeding depend on the fundamental premise that what matters about breastfeeding is the chemical composition of human milk, and not the mother-infant contact at the breast. In fact, three important sources of funding for research into breastfeeding — the US government, companies such as Medela that make breast pumps, and companies such as Prolacta Bioscience that make human-milk based nutritional supplements — have a direct interest in promoting this perspective.
But there are reasons to think breastfeeding and bottle-feeding with pumped milk may not be the same thing. If breastfeeding protects against infection, breast milk that has been pumped, stored, refrigerated or frozen, and thawed may not. The routine processes that go along with pumping and storing human milk also degrade some of the proteins, vitamins, and micronutrients in that milk. At any point in the process breast milk could pick up bacteria that might actually cause illness.
If breastfeeding improves cognitive development, some experts believe it is because of intense mother-child interaction at the breast, not because of the chemical composition of human milk.
But the bottom line is that we really have no idea if breastfeeding and feeding a baby human milk from a bottle are the same thing — and yet US health policy and public messages blithely proceed as if they are. That assumption is beneficial to employers, breast pump manufacturers, and the makers of breast milk–based nutritional supplements, but not necessarily to mothers and babies.
6) Breastfeeding has become big business
In the next few years, the world market in breast pumps is expected to reach $2.6 billion. Forty percent of that market is in the US. The market for breastfeeding accessories like clothes, pillows, and nutritional supplements is also booming, with stores dedicated to nursing products cropping up in expensive neighborhoods across the country.
And all that pumping is creating a surplus of human milk, which now routinely sells on the open market for $1 to $3 an ounce. Mothers sell their milk to other mothers who use it to feed their own babies, to athletes hoping to boost their performance, or to anyone who is just eager to try the latest superfood.
Mothers may also sell their milk to companies like Prolacta Bioscience that use human milk as a raw material in the production of nutritional supplements. Prolacta buys human milk for $1 an ounce and sells its supplements for $180 an ounce.
7) Breastfeeding rates are fairly high in the United States
Breastfeeding advocates and public health initiatives often create the impression, or just claim outright, that American breastfeeding rates fall woefully short of public health goals, or that we are far behind other countries. That is simply false.
The most recent Breastfeeding Report Card, which recorded infant feeding patterns among babies born in 2011, showed that 79 percent of American women initiated breastfeeding and 49 percent were still breastfeeding at six months. That means that American women have met or surpassed most of the 2010 Healthy People Goals for breastfeeding established by the Centers for Disease Control and Prevention.
The US is roughly in line with Canada, where 52 percent of women are still breastfeeding at six months. It's true that we fall below Norway, where 80 percent of women are breastfeeding at six months, but we are way ahead of France, where 62 percent of new mothers initiate breastfeeding and only 23 percent are still breastfeeding at six months.
And here's an interesting thing about Norway: Although almost 99 percent of women initiate breastfeeding, only 82 percent are still breastfeeding exclusively at four weeks, and at six months that number is only 9 percent. (In the US, 19 percent of mothers are breastfeeding exclusively at six months.)
The infant-feeding norm in Norway, the country that is most often touted as having the highest breastfeeding rates in the developed world, is a combination of breastfeeding and formula feeding. As far as exclusive breastfeeding goes, we're doing way better!
8) Not all women can breastfeed
The breastfeeding advocates' refrain that "all women can breastfeed" is simply false. The "proof" they offer — that human beings are mammals — is as ridiculous as it is irrelevant.
As Dr. Marianne Neifert, a pediatrician and leader in the field of breastfeeding medicine, has explained, the human body often fails to work "the way it's supposed to. A health care professional would never tell a diabetic that every pancreas can make insulin. The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes."
In fact, all kinds of things can interfere with a body's ability to produce milk. Doctors estimate that up to 15 percent of women do not produce enough milk to feed their babies — but the number could be much higher, because it so often goes undiagnosed. Some women have a condition called insufficient glandular tissue or hypoplasia, which impedes milk production.
I wish breastfeeding, or anything, actually, could protect babies from just about every illness they might encounter
Pituitary and thyroid conditions often affect lactation, as does a condition called polycystic ovarian syndrome. Complications during childbirth can also affect milk production. Women who have had mastectomies, thoracic surgery, breast reductions, and even, sometimes, augmentations or reconstructions may not produce breast milk. There is also research that shows women who have been victims of sexual abuse are often unable to tolerate breastfeeding.
Mothers who do not produce enough milk to feed their babies are often told they are doing something wrong, or that they aren't trying hard enough. More often than not, that is just not true. Insisting that all women can breastfeed is not only cruel to those mothers who can't, it endangers babies' lives.
Yes, it's true that women are mammals. It's also true that there have always been wet nurses.
9) Not all women should breastfeed
Mothers taking medication may be advised against breastfeeding because many medications, including many of the anti-depressants a mother might need to treat postpartum depression, have not been tested for safety with breastfeeding. The real danger is that mothers have been known to avoid treating their depression so they can breastfeed — with foreseeably tragic results.
Women whose diets are lacking in essential vitamins and minerals will produce breast milk lacking in some important micronutrients. In resource-poor settings where mothers are malnourished, breastfeeding may compromise the health of both the mother and the baby.
But the nutritional quality of breast milk is also a concern among mothers following a vegan or vegetarian diet, who may not be getting enough iron, protein, and calcium in their diets. Mothers who eat no animal products at all produce milk that is deficient in vitamin B12, which is important for infant brain development.
Although many breastfeeding advocates claim that mother's milk is "the perfect food" no matter what she eats, a mother's diet does in fact affect her milk. That doesn't mean women with vitamin deficiencies shouldn't breastfeed, but it does mean they will pass those deficiencies along to their babies if they don't take vitamin supplements.
A baby with galactosemia, a metabolic disorder that prevents the baby from metabolizing galactose, will die or suffer brain damage from breastfeeding.
Finally, the CDC advises women with certain health conditions, including HIV/AIDS, untreated tuberculosis, and human T-cell lymphotropic virus, and women who are undergoing chemotherapy or radiation treatment, against breastfeeding. HIV can be transmitted from mother to baby via breast milk and breastfeeding. If a mother is taking antiretrovirals, and sticking religiously to her regimen, the risk of HIV transmission is reduced, but it is still sufficiently high that the CDC recommends that mothers infected with HIV feed their babies formula.
Most of this is bad news. I wish breastfeeding, or anything, actually, could protect babies from just about every illness they might encounter. I wish American women didn't feel compelled to pump breast milk in a broom closet so someone else could feed their babies breast milk from a bottle. I wish that all women who wanted to breastfeed actually could.
Still, it's better to know, because it might help us reconsider the way we approach breastfeeding. Do we really want to embrace breastfeeding with the passion we have, given that it sets us up for wildly unequal parenting obligations and has little health benefit for our children? Do we really want to fall for this whole pumping thing? Shouldn't we give some thought to whether a market in human breast milk is a good idea?
I worry that there's a lot going on here that has sort of snuck up on us. Reasonable people will reasonably disagree about many of the strange new realities surrounding breastfeeding. But at least we should start talking about them.
Courtney Jung is a professor at University of Toronto and the author of Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, Physicians and Politicians Made Breastfeeding Big Business and Bad Policy. She lives in Toronto with her family, but she is from New York.