In the past few weeks we have seen a lot of press about the decision by the Royal College of Midwives to drop their ‘campaign for normal birth’. Some have hailed this as a huge leap forward for patient safety where promotion of the ‘natural’ and emphasis on the process of giving birth has become more important than the outcome; healthy mothers and babies. Others believe that it is simply a change in terminology because using the word ‘normal’ has had the unfortunate consequence of leaving mothers feeling unsupported or ashamed of their births. What cannot be ignored is the outpouring of parents who responded to the news and articles, such as Hadley Freeman’s comment piece for The Guardian, with their own stories of how this rhetoric has hurt them at one of the most vulnerable times in their lives, and as they navigated the confusing world of infant feeding.
Whether you think this is just semantics or something more fundamental about how we care for families, it’s momentous. It’s an acknowledgement of the voices of many of those parents who have felt bitterly disappointed by maternity and infant care in the UK. A moment to reflect on the unimaginable pain of parents who have lost their babies or who are learning to live with life-altering brain injuries, that may have resulted from well-intentioned but overzealous application of the campaign’s tenets. It’s an opportunity to collectively step back and take a long hard look at the potential problems that could come with adopting language and approaches that prioritise process – the type of birth/method of feeding – at the expense of the outcome – a healthy and happy family.
We believe that this a bold and important warning for breastfeeding advocacy.
One of the things that concerned us the most during World Breastfeeding Week 2017 was the way in which breastfeeding advocates doubled down on some of the same worrying and divisive language around breastfeeding and breastfeeding promotion. Breastfeeding advocates including Alison Thewliss MP signed a letter asking breastfeeding to be taught as ‘normal’ and ‘natural’ to children in school. While it’s brilliant to teach lactation biology, anatomy and physiology at any age, we must take great care remain neutral. Biology sometimes doesn’t read the text book, sometimes science gives us the opportunity to override our biology, not all women are born with breasts and not all families have breasts. ‘Normal’ and ‘natural’ come in all forms and we must be sensitive to this. With increasing frequency I see memes and comments that hold breastfeeding up as the ‘biological norm’, this is not neutral and it is highly problematic.
As far back as 1996, Dianne Weissenger’s hugely influential essay ‘Watch Your Language’ advocated for a sharp move away from the slogan ‘breast is best’ to frame breastfeeding as ‘normal’1. Why? Because she felt that it would be more efficient to raise breastfeeding rates by capitalising on the shame that comes with being ‘abnormal’ and ‘inadequate’:
Let’s rephrase. Is your parenting inadequate? Is your home life subnormal? Do you provide deficient meals? Now it hurts. You may not expect to be far above normal, but you certainly don’t want to be below normal.
I don’t think even the strongest proponents could claim, hand on heart, that such campaigns are neutral and this last few weeks has shown us, without a doubt, that this is not OK. Alison Steubbe MD has recognised that this language is not neutral and that speaking about infant formula as though it is an abnormal or risky choice that threatens our children we could ‘actually INCREASE the undesired behavior, because people shut-out messages that they cannot act upon’.
Elevating the ‘normal’ and ‘natural’ to the gold standard, promoting these values above all else and focusing on the process of infant feeding over the outcome – happy and healthy families – hurts, in exactly the same way as ‘campaign for normal birth’ has been implicated. Those who can’t meet these lofty goals, or who do not want to, are left ‘abnormal’, ‘unnatural’ and report feelings of failure and guilt. Let us not forget that suicide is the leading cause of maternal death in the UK. In recent years I can recall at least two maternal suicides where those closest cited pressure to breastfeed as a contributing factor. The Fed Is Best Foundation is doing an incredible and difficult job communicating the risks of adverse outcomes of breastfeeding advocacy such as preventable malnutrition2 and maternal stigma3, based years of scientific research. Our own readers submit their experiences of feeling overwhelmed by the pressure to breastfeed frequently.
Perhaps some would argue that collateral damage is worth it in pursuit of increased breastfeeding rates. We feel otherwise and want to find a way forward that supports parents who wish to breastfeed and ensures that all parents feel confident in their infant feeding journey. We have got to acknowledge that in 2017 there is no normal, not all women are born with breasts and vaginas, and families are breaking free of the mould. Our children deserve to know that there is far more to parenting than biology and that our biology does not dictate the parent you can become.
Some proponents may argue that if we can talk about ‘normal breathing’ and ‘normal digestion’ we should also be able to talk about ‘normal’ in the field of birth’. But breathing and digesting, along with many other bodily processes, are things that the vast majority of us do without even consciously thinking about it; birth and infant feeding are intensely personal and formative events which only some of us have the huge privilege of doing a handful of times in our whole lives. There are no decisions to be made where most bodily functions are concerned, they just happen. With birth and infant feeding decisions we have choices to make every step of the way and have to do so with the overwhelming responsibility of another person’s life. When we talk about breathing and digestion we value the outcome; if there is a time where we’re not breathing or digesting ‘normally’ science and medicine intervene to make it normal, just as when birth and feeding goes awry, science and medicine intervene to make the outcome better. Interventions into other bodily processes are not morally charged, we would never shame someone because they need to use an inhaler sometimes.
It is not for infant feeding advocates to prescribe or promote a ‘norm’ or to value the natural over the will or circumstances of the individual. As much as there is no room for ideology in birth, there is no room for ideology in infant feeding. There are some small chinks of hope emerging with both the Australian Medical Association and Royal College of Paediatrics and Child Health cautioning that:
Parents who are unable or choose not to breastfeed should be provided with appropriate care and assistance to formula feed their child4.
Some mothers cannot, or choose not to, breastfeed and this also needs to be respected. What society must get better at is removing the multiple barriers which can stand in the way of breastfeeding5.
There is so much more that could be done to create a far more positive and supportive environment for all new parents.
We have got to start to present all feeding methods accurately and neutrally; informed only works if we eliminate bias. We have got to allow each individual family to be the centre of their own feeding decisions and support them in their goals. For some breastfeeding will be a beautiful and fulfilling experience, for others not, and there are many shades in between. Nobody in any group is ‘abnormal’.
We need to be there, in those precious first few months, cheering from the side-lines, instilling confidence and sharing in the pride and joy that come in those early months.
Let’s stop this before it starts. The new normal is that there is no normal.
1. Weissinger D (1996). Watch Your Language: Guest Editorial. Journal of Human Lactation, 12(1).
2. Neifert MR (2001). Prevention of Breastfeeding Tragedies. Pediatric Clinics of North America, 48(2):273-97.
3. Fallon V, Komninou S, Bennett KM, Halford JC and Harold JA (2016). The emotional and practical experiences of formula-feeding mothers. Maternal and Child Nutrition, doi: 10.1111/mcn.12392. [Epub ahead of print].
4. Australian Medical Association (2017) Position Statement on Infant Feeding and Parental Health.
5. Royal College of Paediatrics and Child Health (2017). Position Statement: breastfeeding in the UK.