Joan B. Wolf is an assistant professor of women’s studies at Texas A&M University and the author of the controversial new book Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood.
Q: The Canadian Paediatric Society recommends that babies be exclusively breastfed for the first six months of life. In your book, you argue that human breast milk is being falsely touted as a magical elixir.
A: The discourse surrounding breastfeeding is extraordinary. We’re told it can protect against everything from ear infections and diabetes to leukemia and heart disease, and can even improve social skills.
Q: Various studies have concluded that babies fed “non-human milk” have a higher incidence of respiratory disease, including pneumonia and bronchitis, diarrhea and other digestive illnesses, ear infections (up to four times more), urinary tract infections, meningitis and sudden death syndrome. One study says that during a baby’s first three months, exclusive formula feeding increases infant mortality by 61 per cent. Can all these studies be wrong?
A: They are all misleading because they are based on associational or observational research. You look at two variables and realize there is a connection and make the case that the connection is causal. But the leap to causal inference is in most cases not justified by the evidence.
The primary problem with breastfeeding research is this: these studies compare babies who have been breastfed with babies who were formula-fed. But they can’t control for critical confounding variables—something associated with breastfeeding that is itself also associated with better health outcomes. For example, one thing we know is that women who are middle class or more highly educated are more likely to breastfeed. So more recent studies say, let’s control for class and education and see if they make a difference, and in some cases they do. But none of the studies have been able to control for the decision to breastfeed. This is to say that mothers who choose to breastfeed usually do so because they have been persuaded that it has health benefits. These are the kinds of mothers who are willing and able to go the extra mile to provide the healthiest environment for their child.
Q: So you don’t believe breastfed babies are healthier?
A: I’m willing to go on record saying that on average breastfed babies are healthier. But that doesn’t mean breast milk causes better health. Women who breastfeed are more likely to do other things that will make their babies healthier. In the developed world, the differences in health outcomes are small enough that it’s reasonable to believe that differences in maternal or caretaker behaviour can cause them.
For example, if babies who are breastfed are less likely to have ear infections, is it the benefit from breast milk or the behaviour of the caretakers? If I make sure that anyone who comes to my house is not sick, that they wash their hands before they handle the baby, and if I don’t take my kids to the grocery store when it’s packed full of people on their way home from work and I sanitize the grocery cart, I am doing all sorts of things that could prevent my child from contracting a virus. Ear infections usually come after a virus that causes fluid to build up in the ear. So the question is: what is beneficial, that I am undertaking healthy behaviours or that I am breastfeeding? If I adopted all those behaviours and fed my baby formula, would you see any difference? We don’t have the answer to that question.
Q: Are there any medical benefits to breast milk itself?
A: We do have very good evidence that breast milk reduces gastrointestinal infections. The milk is ingested, goes into baby’s gut, and antibodies from the mother’s milk fight the bacteria in the gut. What we don’t have is any evidence that those antibodies have any effect anywhere else in the body. And whether reducing GI infections in itself justifies the discourse about breastfeeding—that if you don’t breastfeed all these terrible things will happen to your baby—is a question we need to ask.
Q: You write that the modern pressure on women to breastfeed “literally embodies social anxieties about risk, health and motherhood”—many of which have little to do with infant feeding per se. What do you mean?
A: I think we are a society that is consumed with risk. There is a degree of scientific sophistication in our lives that we don’t understand. That breeds, paradoxically, anxiety and a sense that we can control anything if we can just have the right information. The idea that we can prevent terrible things from happening to our children is very appealing. Science tells us how to behave, how to be the healthiest, and the information we get on breastfeeding is in keeping with that. What we don’t seem to realize in the case of breastfeeding is the science does not provide evidence for the claims that are made.
Q: Nothing I’ve ever written has received so much emotional response from readers as the time I wrote about my struggles breastfeeding my first son. My point was to say, this can be hard; take the breastfeeding class before the baby comes. But I was accused of discouraging people from nursing. There was a lot of anger in the letters. Why is this topic so emotional?
A: There is a certain defensiveness about the “natural” element of it. If you have to explain that it isn’t natural, there is work involved, then part of the force of the argument for why you should breastfeed disappears.
Q: You write that in recent decades we’ve replaced “good enough” mothering with “total motherhood”—a moral code in which mothers are exhorted to “optimize” every aspect of their children’s lives, beginning with the womb. Part of this is the “all-encompassing physical and emotional commitment” that it takes to breastfeed an infant every few hours, night and day. Are we putting too much pressure on mothers?
A: Yes, we are holding mothers accountable for outcomes that are completely beyond their ability to control. We expect mothers to work to prevent any risk to their children, regardless of how marginal the risk or what the cost or trade-off is to the mothers themselves. Every mother is out there trying to demonstrate that there is virtually nothing she wouldn’t do for her child.
Q: It’s interesting that you use the word “demonstrate.” One difference I’ve found between having a baby this past year and having my first five years ago is that now all my mommy friends are Facebooking while nursing. Not many status updates about bottle-feeding, though. Who are we demonstrating to?
A: We are demonstrating it to other mothers and also to ourselves. The more we sacrifice, the better the evidence that we are doing the best for our child.
Q: Are you against breastfeeding?
A: I am not against breastfeeding in principle. I want to stress that there are women who adore breastfeeding, for whom it does feel natural, and the baby is born, put to the breast, and there is nary a problem. There are others who have struggled and ultimately found a good place. But there are life circumstances that I think will make [either] breastfeeding or bottle-feeding a better choice. And the medical evidence in the developed world is certainly not strong enough to be telling mothers that breastfeeding is the greatest gift they can give to their babies.
Q: Under what circumstances do you think breastfeeding is a bad idea?
A: When a mother doesn’t like it. When breastfeeding is a very stressful situation for mothers and they know in their hearts that they’d rather feed with a bottle, I don’t think the medical evidence is strong enough to tell them that formula-feeding is risky. For women who are very invested in their work, the idea that everything else in the universe stops because only mother can feed her baby, regardless of when or how often that is—that can be very disorienting, and the scientific evidence simply doesn’t warrant it.
Q: You also write about social class. That it might be one thing for a woman with an office job to pump milk in a special lactation room—I once used a very nice one in a U.S. Senate office building—and quite a different matter for a woman who does shift work or is a waitress.
A: Imagine you’re a waitress on a shift and your breasts are engorged. You can’t tell people who’ve come in that you need to leave for 45 minutes to pump. Women who work in factories or retail face similar issues. If there is a great breastfeeding room in the Senate or on the campus where I work, I’m not opposed in principle. But I am concerned that these rooms reinforce the misperception that breastfeeding is much healthier. I also strongly believe that all kinds of changes could be made in the workplace to make life easier for people with families and I’m not convinced that scarce resources are best used on lactation rooms.
Q: What was your own experience breastfeeding?
A: I made a decision that I am going to leave my own kids and my own experience out of it. My concern is that when people have asked that question it’s almost always out of a desire to pathologize: “What on earth would compel someone to make this case? Shame on her! She’s condoning child abuse!”
Q: Has someone actually said that?
A: Yes! And I’ve been compared to a Holocaust denier and an advocate of cold fusion. The implication is that what I am arguing is shameful and should be dismissed in the same way we dismiss people who say there were no gas chambers in the Second World War.
Q: So what brought you to this topic?
A: Intellectually, in looking at feminist research on reproduction—and there are tomes—it is striking that there is relatively little on breastfeeding. And very few people have intimated that the science may not be as compelling as we are led to believe.
Q: I’ve always thought of breastfeeding to be a feminist act. It takes control away from doctors and formula manufacturers and empowers the mother and her female support network of other mothers or lactation consultants. Is breastfeeding feminist or anti-feminist?
A: It’s both. It really does depend on the context in which you are making the decision. For a long time, doctors told women they didn’t make enough milk or that it was of poor quality, so women turned to the bottle. And there is no question that breastfeeding advocates have done a tremendous service by demonstrating that this was bunk. So breastfeeding is very much a feminist act in that sense. But not when we latch on—no pun intended—to breastfeeding as the only way to feed. Telling a woman she must breastfeed when she doesn’t want to or when she wants her partner to be equally engaged with the baby, to tell her that the only feminist position is to breastfeed, is antithetical to feminism.
Q: When neither of my kids gained any weight for two weeks on exclusive breastfeeding, the pediatrician told me to supplement with formula. I felt like such a failure that I cried in the doctor’s office. You write that “infant feeding is a fateful moment, one fraught with consequences for self-identity and opportunities for shame.” How did the stakes get so high?
A: It has to do with the risk culture I talk about—the belief that if we micromanage our lives and make responsible choices, nothing bad will happen. But I also think the high stakes come from total motherhood, the belief that mothers are uniquely responsible for preventing risks to their babies.
Q: I didn’t eat tuna for 10 years before I got pregnant.
A: Exactly. You try to design the optimal womb. What soap do I use, is Diet Coke okay, can I still dye my hair? And the truth is that in most instances, there is no evidence that what you do has any impact on the fetus.
Q: What do you think about the movement of women donating breast milk to each other through Facebook groups or milk banks?
A: There are clear risks to feeding with unscreened milk. But there is no risk-free way to feed your baby, including breastfeeding. Breast milk is loaded with pollutants whose long-term effects for either mom or baby we don’t know. Mothers who breastfeed when they’d rather not are more likely to be depressed, which is bad for them, for babies, and for an economy that depends on productive workers. Mothers who are marginalized in the workforce because they care for babies and small children are at greater risk for economic hardship when they are older, particularly in the case of divorce. So when making the feeding decision, parents need to decide which risks they can live with.
Q: Throughout your book, there is a concern that mothers are treated as a means to an end (the healthy child). But haven’t parents always sacrificed? Where does motherhood end and subservience begin?
A: That is the big question. Of course parenting is about prioritizing the needs of children. But at what point is a mother allowed to say, enough! At what point is she allowed to say the benefit that might come to her baby is not worth the cost to her?
Think of it this way: cities are polluted and children who live in them are more likely to get asthma. Can you imagine a public health campaign to get everyone who is considering having a baby to move out of the city? It’s an absurd suggestion because it’s too big a sacrifice. The reason we find breastfeeding to be so obvious is because we expect mothers to sacrifice. It’s part of our understanding of what motherhood is.