Monday, August 19, 2013

A formula for ignorance

We all arrive in this world more or less the same way and in the same condition – naked, wet and ready for the breast. After that, nearly all bets are off as culture kicks in and we begin the long differentiating journey to becoming who and what we are based on the rules of the group into which we’re born.

Not surprisingly then, our approach to the only example of a universally common food and feeding system – breast milk and breastfeeding – is conditioned by culture’s stamp. Our identical biological birthright continues to be transformed – even deformed – in multiple ways in society today.

A not so rhetorical question

The world’s second biggest-selling English language daily, The Daily Mail, put it this way: “We know that breast is best for baby – so why do women in the UK continuously ignore the important health benefits of breastfeeding?”

Good question, particularly if you take a look at surveys undertaken to coincide with Breastfeeding Awareness Week. When the Department of Health published results of its 2004 survey of one thousand women, it noted that the UK had one of the lowest breastfeeding rates in Europe. Almost a third of women in England and Wales never even try to breastfeed, and the rate in Wales among those who do falls to 36% by one month. Younger women in particular are less likely to breastfeed with over 40% of mothers under 24 never trying. The survey also showed that:

  • Over a third of women believe that infant formula is very similar to, or the same as, breast milk. 
  • A fifth of young women aged 16–24 years believe that breastfeeding will ruin the shape of their breasts or body (obviously including Gwyneth Paltrow). 
  • Over two-thirds of women believe that people find breastfeeding in public unacceptable. 
  • Nearly all women believe that breastfeeding comes naturally to some and not to others. 
  • Nearly all women believe that some women don’t produce enough milk to be able to breastfeed. 

Unfortunately, according to the National Childbirth Trust results of a survey undertaken for Breastfeeding Awareness Week 2005 were hardly more encouraging:

  • More than 91% of Britons do not know that breastfeeding for just one month has a lasting impact on the first 14 years of life. 
  • Two thirds are unaware that breastfeeding early in life, even if it is not exclusive, provides protection against infections. 
  • Only just over half know that the current recommendation is that babies receive breast milk alone for the first six months. 
  • Almost half do not know that breastfeeding cuts the risk of osteoporosis and ovarian cancer in mothers.

How is it that our common nurturing and nutritional heritage is self-evident in some environments but routinely called into question – or simply ignored – in others? And why is it so obvious for some, yet so poorly understood by others, that initially feeding babies anything but breast milk is a dangerous deviation from the biological norm?

I’ve been considering attitudes toward breastfeeding from various angles for four decades, and my single overriding conclusion is this: Where it remains undervalued and under-practiced, the primary barrier to more and longer breastfeeding is society-wide ignorance both of human milk’s unique, species-specific properties and of the inescapable implications for health throughout the life course. Moreover, this ignorance is as much a sign as it is a source of the disrespect for the biological norm that contributes so effectively to low rates of breastfeeding prevalence and duration.

Every other barrier to breastfeeding – from attitudes and how they are formed, to non-supportive health services, to the multiple unhelpful ways society is structured – can be traced directly to this cross-cutting core ignorance. And thus, to return breastfeeding to the realm of the ho-hum ordinary (which is how I define my goal) we also need a society-wide shift in awareness, attitude and action.

Choice based on ignorance is illusionary

We cherish the role choice plays in our lives, which is understandable given how fond we are of describing our behavior in terms of rational decision-making. But where breastfeeding is concerned my sense is that the impact of choice is roughly equivalent to deciding whether to hold a small child’s hand as we cross a busy street together, which is to say none at all.

“I think I’ll hold my three-year-old granddaughter’s hand as we cross the street today, although frankly I’m getting a little tired of all this responsibility, so perhaps next time I’ll just not bother.”

Of course not. We hold a small child’s hand when crossing the street because we know – as do the vast majority of adults everywhere – that doing otherwise is irredeemably irresponsible, dangerous, culpable, and downright stupid.

So, do we “choose” whether to breastfeed based on carefully worked out criteria? In the main, I think not; we respond the way we have learned to respond. This is why I insist that, where artificial feeding has the upper hand, reverting to breastfeeding means transforming society in its structural complexity. It also requires seeing indisputably related factors in context and not in isolation, notably food manufacturers who tirelessly tout the virtues of routine use of infant formula, which is what I describe as synthetic dream merchants pushing an inert pediatric fast-food based on the milk of an alien species.

It may sound frustratingly circular, but recent history shows this: We are unlikely to see adequate measures widely adopted to protect, promote and support breastfeeding – for example broad-based community support for mothers and babies, health professionals who are knowledgeable about breastfeeding and motivated to promote it energetically, baby-friendly maternity services, maternity protection in the workplace, and appropriate marketing and distribution of breast-milk substitutes – until society and its leaders first embrace the proposition that routinely feeding a breast-milk substitute represents a major deviation from the biological norm with serious life-long consequences for mothers and children alike.

Reframing the breast vs. formula debate

There is a lot of confusion about this defining feature of our shared humanity, whether in the general population or among health professionals and politicians. And it is essential that we take this confusion into account in promoting the shift – in society-wide awareness and attitude – that’s required to return breastfeeding to its place of primacy in human development and health.

Resolving the situation is a complex challenge that depends on considerably more than accumulating and communicating yet more scientific and epidemiological evidence. Education is essential, of course; but education is insufficient, by itself, to turn things around.

It is a serious fallacy to think that, if we just tell people the facts, because they are basically rational beings, they will reach the right conclusions and do the right things. In fact, it is often easier to change ideas than it is to change beliefs and behavior.

We need to do something more. We need to go on the offensive in the ideas marketplace. We need to seize the initiative by establishing a new frame that will permit us to communicate effectively what is really at stake for the health and well-being of all our mothers and children, and thus society as a whole; and what, by working together, we can do to improve the situation.

Let’s begin by turning two tired truisms on their head. No, breast is not best. Instead, breastfeeding is normal, routine, commonplace, even ho-hum ordinary. By adopting this attitude we avoid implying that artificial feeding is the norm and that breastfeeding is somehow better than the norm. On the contrary, anything else is a deviation from the norm.

And no, infant formula is not second-best. Obviously the second-best option after breastfeeding is other human milk, whether expressed by a baby’s own mother, or from a healthy wet-nurse, or a human-milk bank. And only as a last resort, when breast milk is unavailable, does formula assume its rightful role as an emergency nutrition intervention and the least-bad nutritional alternative.

Fortunately, in an emergency formula can sustain babies who do not have access to human milk. But no matter how appropriate it is under such circumstances, feeding an inert pediatric fast-food based on the milk of an alien species is no less a deviation from the norm for the young of our species.

In this connection, I invite you to reflect on the following not-so-rhetorical question: At what point should we begin to regard a routine deviation from the biological norm as deviant behavior?

Please bear in mind that infant formula was originally developed for emergency use. Thus, pitching formula as somehow suitable for a routine non-emergency purpose means two things. The product is instantaneously denatured, and it thereby forfeits its only claim to legitimacy as a life-sustaining crisis commodity.

To put this alimentary aberration into perspective, consider routine non-emergency formula use as the feeding equivalent of emergency devices on airplanes – overhead-bin oxygen masks and under-the-sat life jackets – suddenly being transformed into everyday must-have fashion accessories (see here).

It’s not women who breastfeed after all

To conclude, I invite you to focus on a single notion. With only rare exceptions, all mothers love their children and thus, by definition, want what is best for them. However, translating a mother’s love into suitable feeding behavior is invariably a culturally determined act. Therefore, our best hope of seeing more mothers and children breastfeeding longer lies in transforming the society in which they are born, reared, come of age, beget, birth and nurture.

It is indisputable that the processed-food industry is actively engaged in fostering a market that is favorable to its products, for that is what commercial interests do the world over. But let us also recall that the industry does not operate in a vacuum. The purchasing public shares responsibility for creating and sustaining a non-emergency supply of breast-milk substitutes at the expense of Mother Nature’s market share. Don’t forget – it still takes two to tango!

Taking on the synthetic dream merchants implies considerably more than a regulatory frontal assault on supply. We also need to decrease demand for the synthetic dream. The most efficient and effective way to reduce the supply of infant formula is to reduce demand for infant formula; and the most efficient and effective way to reduce demand for infant formula is to increase demand for breast milk.

Please take careful note: None of this is either easy or fast!

James Akre prepared this post for The Alpha Parent. It is adapted from his book "The problem with breastfeeding. A personal reflection" (Hale Publishing, 2006). As founder, chairman and CEO of the International Breastfeeding Support Collective, James focuses on the sociocultural dimension of the universal biological norm for feeding infants and young children, and on pathways for returning breastfeeding to the realm of the ho-hum ordinary everywhere. He is a member of the editorial board of the International Breastfeeding Journal and of the Scientific Advisory Committee of La Leche League France, and past member of the board of directors of the International Board of Lactation Consultant Examiners (IBLCE).

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