The more things change, the more they stay the same…

Baby W, a few days old.

In 2016 UNICEF heavily featured the phrase Change The Conversation in their much publicised Call to Action on breastfeeding.  We completely agree, and the tone of the conversation for the brand new 2017 Breastfeeding Month gives us the opportunity to reflect on whether that commitment to change was real or just a jingo.

The need for change is abundantly clear to anyone who casts a cursory eye over breastfeeding rates and the support available in the UK. A recent survey reported that 97% of UK infant feeding coordinators stated that a breastfeeding support service was available in their area, and 92% said that peer support specifically was available. Once multiple respondents from the same area were taken account of, this showed that 89% of areas actually had a breastfeeding support service (however, reported in the media widely as 56%). Other data show that support services are consistently failing to reach the women who need them; furthermore the quality of the provision available is patchy at best.

The Infant Feeding Survey of 2010 tells us that women are aware of and offered these services, 84% within the hospital setting and 82% after discharge as well as the 69% of women alerted to relevant voluntary organisations and 64% aware of the National Support Helpline which itself was accessed by only 4% of women. We can’t say that this is simply a case of Mothers not knowing what is available to them. When women are asked for their thoughts and experiences of infant feeding in the UK we consistently hear that they feel emotions such as guilt, failure, moral judgment, stigma and dissatisfaction around their infant feeding decisions.

One blog post, featured on the UNICEF website as rallying cry for change (and also featured, in a slightly edited form, across two articles for The Huffington Post back in 2016) was written by Sue Ashmore, director of the UK BFHI and the hook is:

In light of new research about the benefits of breastfeeding, Sue Ashmore discusses why we need change the way we talk about breastfeeding.

Ashmore mourns the loss of opportunity for an inclusive, factual and non-judgemental conversation about breastfeeding and informs us that the current ‘change the conversation’ tag line was prompted by a Lancet study in which it’s claimed that 823,000 children under five years old could be saved if we had a ‘near-universal’ breastfeeding rate.  But can this number be applied to women and babies in the UK and is it novel in any way to expect women to breastfeed for the good of the nation? Not much of a spoiler alert to hear the answers are no, and no.

The Lancet paper uses mathematical modelling to estimate the number of lives that could be saved per year in low and middle income countries. The data used to produce this this estimate of lives saved was taken from seventy-five low income countries which collectively contribute over 95% of the world’s infant deaths. In such countries, infant mortality rates are many times higher than in the UK, and a large proportion of such deaths are attributable to diarrhoea and upper respiratory tract infections, both of which can be prevented through breastfeeding. However, the much lower infant mortality rate in the UK and the fact that diarrhoea and respiratory tract infections would be very unlikely to contribute to UK infant mortality, make this 800,000 lives saved statistic not relevant to UK, or UK-like settings. This doesn’t prevent Ashmore from claiming that “breastfeeding saves lives […] in every country rich and poor”.

Not only is it difficult to argue that these mortality estimates are relevant to the UK, Ashmore goes as far as to state that:

Children who are breastfed for longer periods have higher intelligence, fewer infections, fewer dental problems, reduced morbidity and mortality, and are less likely to be overweight or diabetic in later life. For mothers, breastfeeding protects against breast and ovarian cancer and diabetes.

And in this associated Huff Po piece claims that:

On the one hand, there is more evidence than ever before that breastfeeding has long-lasting and profound benefits for both mother and baby. 

But the Lancet study being used to illustrate her point simply does not conclusively stretch to that impressive list of benefits, which you can see by reading through the tables that the authors produced assessing research into each health outcome.

In reality, when we look at the highest quality, randomised controlled studies on the benefits of breastfeeding in a developed context, we find that some benefits either disappear altogether or are actually quite small. The well-known PROBIT study (a cluster randomized study of breastfeeding support), found that the key benefits of increased breastfeeding were reductions in diarrhoeal disease, a small increase in IQ and a benefit for eczema in the first year. The Sibling study, which crucially managed to eliminate confounding by socio-economic status as siblings are brought up in the same homes with similar opportunities, found more mixed results for IQ and actually, an increased risk of asthma for breastfed babies. There is an excellent summary of all of this here.

Using the Lancet study as a stick with which to threaten UK women into breastfeeding for the good of the nation is not only factually flimsy, but it’s also nothing new. In fact, the whole ‘good of the nation’ rhetoric is age old.  This moral imperative to breastfeed is absolutely indicative of the same old same old that we’ve been hearing not only for years but for centuries. In his work Emile, Or On Education Rousseau writes:

Do you want to bring everyone back to his first duties? Begin with mothers […] But let Mothers deign to nurse their children, morals will reform themselves, nature’s sentiments will be awakened in every heart, the state will be repopulated. This first point, this alone will bring everyone back together. […] Let women once again become mothers, men will soon become husbands and Fathers again.

Rousseau believes that everything can be brought back to the role of the mother, her actions are the most vital signifier of the future character and behaviour of each baby born and that if she just fulfilled her moral duty to breastfeed, the morality and wealth of the entire nation could be transformed and improved through generations. For Rousseau breastfeeding was a literal and figurative symbol of an entire nation and such it was very much a public health imperative. This moved breastfeeding from private act and personal choice to moral imperative. Ring any bells?

Mary Wollstonecraft, a philosopher and early feminist who believed that women needed the same education of men and felt that confinement within households was harmful, author of A Vindication of the Rights of Women (1792), wrote:

Her parental affection, indeed, scarcely deserves the name, when it does not lead her to suckle her children, because the discharge of this duty is equally calculated to inspire maternal and filial affection.

Again, breastfeeding is seen as a duty for the woman. Her ideas about a woman’s rights and responsibilities may have differed wildly from Rousseau’s but the message when it comes to breastfeeding is the same. It’s a duty and responsibility and a woman cannot be considered a Mother without doing it.

We still see reflections of this when Ashmore says:

We can stop laying the blame for a major public health issue in the laps of individual women, and acknowledge the collective responsibility of us all to remove the barriers to breastfeeding which lead to eight out of 10 women reporting they had to stop breastfeeding before they had wanted to.

It is difficult to assess a writer’s intent, but each one of the quotes above is notable for the complete absence of any consideration of individual mothers’ experiences and the extent to which they may wish to flexibly adapt to their current situation. Each illustrates an attitude that highlights social and political management of the maternal body. Where you choose to apportion “blame” for such a major public health issue, if indeed it is, is irrelevant. Strip all of that rhetoric back and it’s clear that the major organisations involved in breastfeeding advocacy and support are still putting out a message centred on why mothers should breastfeed and not what it might be like for them.

What I feel we can all agree on is this:

First, we need to be upfront and admit that yes, sometimes, well-meaning efforts to promote breastfeeding have been insensitive and over-zealous. […]Second, we must also be upfront with the evidence around breastfeeding.”

Yes, evidence shows that on a population level, there are benefits to the infant of to being breastfed – specifically –reduced risk of diarrhoea, otitis media and upper respiratory tract infections and slightly lowered relative risk of some forms of breast cancer for the mother. In a developed country, as far as the infant is concerned, these are all short-term and limited outcomes. Women already know why breastfeeding might be a good idea, the UK 2010 Infant Feeding Survey tells us that, 83% of women are aware of the health benefits of breastfeeding and 83% of first time mothers cite health benefits for baby as their reason for wanting to breastfeed.

Beautiful submission from an anonymous reader.

A change will come when we begin to take a mother-friendly approach and place individual women and families at the centre of advocacy efforts.   That means acknowledging and accounting for mothers’ lived experiences and being honest and realistic about the health implications of infant feeding in the UK and the realities of different feeding methods. We can accept that while these benefits are real, they may not apply to the individual mothers and who need to be able to weigh up those benefits with their own priorities, values and pressures. Maybe breastfeeding is too painful, time consuming, physically demanding or just disliked or maybe it an absolute breeze, all of their experiences are important too and it’s their choice to make.

So, after all of this, where do we find advocacy efforts at the start of the 2017 breastfeeding week? Just about here:

Many people understand the importance of breastfeeding, yet too often the responsibility for it is placed entirely on the mother, without any consideration of the political, social, and environmental factors that shape breastfeeding.

Countries lose more than $300 billion annually because of low rates of breastfeeding

Longer breastfeeding durations are associated with higher scores on intelligence tests – that translates into stronger economic success through improved academic performance, higher earning potential and productivity

The ghost of Rousseau is haunting us, he could have written that himself. It is utterly disappointing to see that three hundred years can pass without progress.

If we want to see an improvement in breastfeeding rates in the UK, if we want to invest in sensitive, woman-centred support, and if we want to stop women suffering needlessly as a result of overzealous breastfeeding promotion then we have got to move forward with a real commitment to change.

Let’s recognise that breastfeeding your baby is a huge commitment and responsibility for individual women, no matter how you spin it.

Let’s make the case for infant feeding at the individual level. All women and families are different and we need infant feeding policy that reflects this and puts their needs first, way ahead of the responsibility of the economic success of the entire nation.

Let’s see sensible and supportive conversation detailing actual and not imagined risk/benefit analyses.

Let’s champion bodily autonomy and allow people the freedom to make decision over their own bodies, based on their own needs and the needs of their family.

We owe it to them to do that.