Is Breast Best?

Alexandra Roumbas Goldstein reviews a book which challenges both the science behind the assertions and the value of breastfeeding campaigns in a "neoliberal risk culture"

, 18 May 2011


Of all the topics discussed by mothers online and off, one of the most controversial is the issue of breastfeeding. Debates and discussions rage over breast vs. bottle, with terms such as ‘Boob Nazi’ thrown around, and accusations of the dangers of formula feeding voiced in extremely passionate and emotional terms. But few people on either side of the debate seem to challenge the idea that breastfeeding is best, even confident formula feeders.

When I recently wrote about my experiences breastfeeding and the terrible guilt that can ensue when switching to formula, I too conceded that breastfeeding was the ultimate. This agreement was due to me accepting what I had been told by numerous reports and government programmes about the benefits of breast milk and breastfeeding. In Is Breast Best?, Joan B. Wolf challenges both the science behind the assertions and the value of breastfeeding campaigns, in the context of what she considers to be “neoliberal risk culture”. She does this not to defend formula feeding, but to examine the reasons behind, and effects of, the marked superiority that exists in pro-breastfeeding campaigns.

To accept Wolf’s conclusions about breastfeeding, you first have to engage with her idea of a risk culture. I find it hard to disagree with much of what she has to say on the topic, which essentially agrees with the Bad Science view of media reporting (and therefore public understanding) of scientific research. Reportage is rife with misunderstandings about statistical significance versus social significance and lacks any sort of contextual thinking. The risks of doing something are rarely balanced against the risks and trade-offs of not doing it, and vice versa. Think of all the things a certain publication says give you cancer; it’s media scaremongering at its best and the kind of environment that breeds an enormous pressure to be individually responsible for every single moment of ill-health you or your children might suffer.

One example Wolf gives is of a relatively reliable study, that shows that children breastfed for longer are 40% less likely to suffer at least one gastrointestinal upset (diarrhoea, basically) in the first year of life. Which sounds impressive, but that’s actually about 4% – or one in 25 – absolute risk (13.2% of one group vs. 9.1% of the other). Is that really what we’d consider a significant risk, socially speaking?

So assuming you accept Wolf’s definition of our risk culture, where does that leave mothers? Mothers, more than fathers, are often also placed below their children in the social hierarchy. Of course good parenting does require sacrifices and the placing of children’s needs before parents’ on many, even most, occasions. But breastfeeding, argues Wolf, is one area where women are routinely expected to completely ignore their own needs because not breastfeeding is presented as an active risk to their children. In addition, the impact of paternal influence on health and development is ignored almost entirely.

Slogans over images of heavily pregnant women log-rolling or similar, pressure those who wouldn’t take risks while pregnant not to start after the baby is born, which sends the message loud and clear: not only is breastfeeding best, but anything else is actively dangerous

Wolf discusses the concept of ‘total motherhood’, whereby women are held almost entirely responsible for raising perfect, healthy children; and breastfeeding is considered a key component of that. “As mothers,” she writes, “they seem to lose their status as women, or as individuals, and therefore they are not stakeholders in risk assessment.” The risks and trade-offs to women are secondary to the apparent risks to babies, without any consideration of how that in turn could impact on the parent-child relationship (or indeed any other relationships within the family).

As a UK-based reader, I found the discussion of the US National Breastfeeding Advocacy Campaign (NBAC) particularly interesting and I’m only surprised that such an overt presentation of the alleged risks of not breastfeeding wasn’t presented in this country. Slogans over images of heavily pregnant women log-rolling or similar, pressure those who wouldn’t take risks while pregnant not to start after the baby is born, which sends the message loud and clear: not only is breastfeeding best, but anything else is actively dangerous.

So of course the next logical step is to examine the science of breastfeeding. And it makes for fascinating reading.

Wolf’s full summary of her journey through the research is written so well as to be accessible to a layperson without being patronising. She carefully shows why few studies manage to assess the effects of breastfeeding in a reliable way, because they fail to separate the act from other confounding influences on the health of babies. And among those that are more reliable measures, only one area shows any sort of convincing advantage for breastfed babies: the study of gastrointestinal infections referred to earlier.

When so many women have physiological, emotional, cultural and socioeconomic issues with breastfeeding, are even the few apparently proven benefits enough to justify the frightening language of risk aversion that surrounds pro-breastfeeding campaigns?

Certainly there are political and other reasons to object to formula feeding, especially considering its history of development as something to further medicalise motherhood – but Wolf does not begin to defend formula feeding for its own sake, or even to argue about which is more appropriate. Her entire point is that this should be down to the parents who should be provided with clear, accurate and not overstated information to make their choice.

As women and feminists, it makes sense to support breastfeeding accessibility, if for no other reason than to allow women to make the choice to breastfeed if they want to. Middle class women breastfeed more than working class women because they have the luxury of choice: when you can afford a long maternity leave (or any leave), followed by a working environment in which you can request a place to pump and store milk, you’re much more likely to continue breastfeeding than if you have to return to a minimum wage job quickly.

Women in higher-paying jobs will, on the whole, have greater confidence in their job security, even in the current financial environment, to request these measures. Additionally those privileged women will spend more time looking after their children at home and are likely to have access to childcare that involves small groups of children, such as a nanny. Obviously when a child is not part of a larger group of children in a day care setting, they are less exposed to illness. The children of more affluent households are also likely to have other health and healthcare-related advantages.

So equally, as women and feminists, it makes sense to explore the reasons why women are encouraged so determinedly to breastfeed. If there is little compelling scientific evidence for its benefits, are we not just pandering to risk culture panic and heaping yet more stress on mothers, particularly working mothers? When so many women have physiological, emotional, cultural and socioeconomic issues with breastfeeding, are even the few apparently proven benefits enough to justify the frightening language of risk aversion that surrounds pro-breastfeeding campaigns? Wolf draws some timely comparisons between pro-breastfeeding claims and ‘obesity epidemic’ rhetoric that are very apt.

“Breastfeeding,” claims Wolf, “sits at the intersection of public discourse on science, health and personal responsibility.” Whatever your views on the subject of breastfeeding, that powerful and, I think, accurate statement alone is reason enough to explore the science of breastfeeding better.

The question, it turns out, isn’t “breast or bottle?” or even “is breast best?” but “are we giving parents the straight facts?”

Alexandra Roumbas Goldstein is a mum, blogger, editor and charity online community manager. In the best traditions of the internet she loves technology, cats, reading and baking.

Comments From You

Aparna // Posted 18 May 2011 at 12:48 pm

Thank you for this review – it made me think about the issue quite differently. However, I’d like to point out that “significance” is a very specific statistical concept. I’m not sure what you meant by “Is that really what we’d consider a significant risk, socially speaking?”, but statistically, relationships between two variables (such as breast-feeding and incidence of diarrhoea) can be adjudged as significant or not – though there are different views on the application.

Alexandra Goldstein // Posted 18 May 2011 at 4:06 pm

Hi Aparna, thanks for reading and for taking the time to comment! Yes, that’s exactly what I meant – that when studies are reported as ‘significant’ that’s read by the public as the commonly understood definition of significant, whereas in the study it’s meant mathematically.

As a general point not related to your comment, I should probably also have pointed out in the review that of course Wolf’s book is very much focussed on the developed world – what might not be a significant (and I mean that in the non-statistical way!) risk in the UK or the US could be very much so in parts of the world where access to clean water is not a given, etc.

Cycleboy // Posted 18 May 2011 at 4:51 pm

Although it is hard to argue against the idea that human milk ought to be best for human babies (given the millennia of evolution), it doesn’t take much thought to realise that not breastfeeding is so bad.

I may be mistaken, but I’m sure I’ve read that many western women were persuaded to bottle feed post-WW2. Though some of the babies might have fared better had they breast-fed, that generation didn’t do at all badly. So, bottle feeding can’t be THAT detrimental.

evieS // Posted 22 May 2011 at 1:46 pm

I was so disappointed to read your review. I was 22 when I had my first child – 22 yrs ago. An unmarried working class woman who had just managed to finish a degree. I wanted to breastfeed – for no other reason than it was cheaper and I had no money. The hurdles that were placed in my path were almost overwhelming: from midwives who complained if I breastfed in the ward without covering my breast, to the formula which was continually pushed upon new mothers – I was ‘told’ (without the words being said) that what was produced by my woman’s body was ‘dirty’ ‘inferior’ ‘subversive’. My child was hungry and demanding more – I was told I wasn’t producing enough; that I was failing to sustain my baby; that I was endangering her health (in the event she put on an average of 10 oz per week for the first 6 weeks). If we have travelled too far in our journey over the last 20 years to make the case for breastfeeding it is surely because of the exceptionally powerful opposing interests which stood in our way. From the formula companies which gave formula free to 3rd world mothers – thus almost ensuring the premature deaths of many babies whose mothers could not secure safe water supplies, nor afford the formula when they had to pay – to the anti-breastfeeding rhetoric and sexualisation of the breast which made so many women feel that they could not even consider breastfeeding. When I had my 5th child (as a professional f/t working mother) in 2003 the difference between birth in 1990 could not be more marked. The midwives were delighted to see me breastfeed – not only did I provided a massive boost to the breastfeeding stats for my area, I was also willing to demonstrate to younger mothers just how east and convenient breastfeeding was. Yes, formula has improved over the years – but the politics which underlie the debate haven’t. Breastfeeding uptake is still exceptionally low – particularly in working class or poorer areas. Women’s rights in the workplace (I am an employment law specialist) vis-a-vis breastfeeding/maternity etc are undermined continually by macho workplace tactics and women buckle under the obstacles which are placed in their way, preventing them from continuing to feed even when they want to. So, I am more concerned about the underlying reasons why women chose not to breastfeed (when – putting the health reasons to one side – it is so cheap and convenient). The messages to women are increasingly strident: the patriarchal body fascism which dictates pert breasts and necessitates implants and which portrays breasts as purely sexual is, to me, of massive concern. Until these issues are addressed and defeated – until women chose formula for positive pro-women reasons – then I really don’t have any sympathy with the contents of your review.

Amity Reed // Posted 22 May 2011 at 9:21 pm

evieS, you said what I wanted to say so well that I simply cannot improve or add to it. Brava!

Jess // Posted 24 May 2011 at 2:06 pm

I also loved your post, EvieS.

And I wanted to pick up on this; “I was ‘told’ (without the words being said) that what was produced by my woman’s body was ‘dirty’ ‘inferior’ ‘subversive’.” When I read the class analysis it the original article I did wonder if working class women breast feed less because they are more likely to think of their bodies as ‘dirty’, ‘inferior’ and ‘subversive’ than their middle-class counter-parts.

However as a counter-point, since we are talking capitalism and a neoliberal risk culture this might be of interest; Liquid Gold: The Booming Market for Human Breast Milk

Seemingly a situation where some working-class women because of the un-replicable benefits of human breast milk for human infants exploit their capacity for breast milk production to pay the bills…

evieS // Posted 24 May 2011 at 2:52 pm

Thanks Jess – and Amity…

Jess – Your comment prompted me to go read the article you linked to. I certainly believe that many women produce a huge quantity of excess milk – I did and donated for a wee while to my local special care baby unit. So I found it a fascinating read. Then it made me think…

Should we be concerned by the sale of breast milk? I wonder… Financial and power inequalities do tend to pervert even the most natural of processes. Wet nurses of yore would often require to ignore their own children in order to feed the children of the rich masters.

We live in a world where the bodies of the poor are cheap and for sale; womb space is for rent; babies can be sold; kidneys and other organs are marketed…

I’m afraid I am cynical enough to imagine a world where enslavement of the breast milk producer (whether for the supply of other babies or the pervy-dudes referred to in The Wire article) is a reality.

Regular ray of sunshine, me!

James E Lyon // Posted 25 May 2011 at 10:29 pm

It’s a few years since this matter was topmost in my mind, but I recall my conclusion at the time. It seemed quite simple to me in the end, sort of.

The “breast is best” message came out through the W.H.O., I thought, and it occurred to me that for babies growing up in a developing country where clean water to make formula milk was often a challenge and the longer-term nuances of health and socio-psychological benefits were marginalised, then perhaps the strong message had its place. But the “World” Health Organisation delivered one message for all societies, and so — as you mention in your comments about risk assessment — where a large proportion of the population can take clean running water for granted and more readily afford formula, with far more relevance of the emotional, socio-psychological and long term development effects of a happy, guilt-free, confident, respected feeding regime, all suddenly turns the WHO message on its head.

In short, for those who find breast-feeding readily goes well, and choose to do so for however long, then lovely . . All well and good. But for those who choose, regardless of the reasons or motivations, to use formula, then that’s just fine and dandy too. The negative impact of forcing or guilt-tripping those who don’t breast-feed, I am quite sure, must far outweigh any slight advantages to the breast-feeding.

Oh, and not enough good things can be said about highlighting the all-too-common statistical reporting that something is “40% worse or better”, when that 40% means a change from 0.1% chances to 0.06% chances. Faced with “6 in 10,000” vs. “10 in 10,000”, the 40% doesn’t look so headline-worthy any more.

Jess // Posted 26 May 2011 at 5:03 pm

^ we already live in a world where the enslavement of breast milk producers is the norm and until we start paying women for their unpaid work (and breast feeding is just the start of the intensive care that babies and young children need to thrive) then that will always be the case. imo

evieS // Posted 26 May 2011 at 8:26 pm

Thanks Jess. Mmmm. Maybe that’s a whole other debate… Not sure that I’m comfortable thinking of my breastfeeding days as unpaid work – or, in fact, the care of my children as unpaid ‘work’. Mostly because ‘work’ is not a person I love but rather something I feel compelled to do in order to earn money to feed and clothe and house those people I love… I acknowledge that I’m probably now both privileged and ‘odd’ – but I found myself a bit possessive of my children – and silently very glad that I didn’t have to ‘share’ them when they were feeding too…their poor father had to put up with the stuff I didn’t want to do (housework mainly!)…

Yes, childcare in this male-dominated world tends to be ‘female’. Jobs associated with young children tends to be female-dominated and lower paid as a consequence. But care of my own children is something that I ‘fought’ (said with tongue in cheek) their father for – eventually (as I was the slightly higher wage earner) I returned to work and he did the caring.

James – my reservations in relation to your analysis relate to the reasons why women continue to chose formula. If the choice has nothing to do with commercial pressure nor sexualisation of female bodies then fine… But it makes little sense to me to choose to pay for stuff that is produced en masse to make profit for multi-nationals when there’s a natural freely available alternative – and I’d say this regardless of the health arguments. It’s lack of support (social, family, workplace etc etc ) which makes women chose formula.

As for the statistical info – isn’t there an old saying: ‘there’s lies, damned lies and statistics’…

Billi-Jo Highdale // Posted 30 May 2011 at 4:21 pm

I thought of this article whilst I was in Boots today. There were signs all over infant milk saying that it was exempt from their Parenting Club promotion because of recent government legislation (or words to that effect) and I couldn’t help but jump to the conclusion that it’s so that women are “encouraged” to breastfeed. I looked it up and I literally can’t believe that it’s against the law to somehow encourage women to bottle feed and how all packaging and advertisements for formula HAVE to advertise that “breast is best”.

Aside from the fact that as an formula-fed baby with a mother who chose bottle-feeding so she and I could have independence, I find it pretty shocking that the government have that sort of power. Yes, put your leaflets in the GP and give information out to new mums, but to actually stop bottle-feeding mums from getting a discount on infant milk or guilting out a mother who may not have the capability to breastfeed every time she sees an Aptamil advert? Disgusting.

evieS // Posted 30 May 2011 at 5:36 pm

Billie-Jo – I disagree. Not disgusting. However, what IS a failure of the duty incumbent upon public health guardians is the failure to successfully convince our society of the value (both physical and emotional health and financial benefits) of breastfeeding. Without legislation, those same manufacturers of formula (who – let me remind you -are in it for the financial profit not for the health and well-being of babies) have previously used the most appalling tactics to ‘hook’ mothers (of the developed and the developing world) onto their products.

What I find disgusting is the attitude which encourages breastfeeding mothers to think of themselves as inadequate or dirty or odd or anti-social or perverted or unable to sustain or meet their baby’s needs…

Yes, some mothers will choose to formula feed. They are free to make that choice – as long as they can afford the financial cost, of course. I was formula fed and don’t guilt-trip my mother for making that choice (in her case childhood sexual abuse had a profound impact upon her body-image and how she felt about her breasts in particular). However she fully understands and accepts that breast milk is designed to meet a baby’s needs – and that manufacturers cannot replicate it.

I am curious – how did your baby indicate that he/she wished to be independent of you? Do you think that you may have made a different decision if you had been aware that expressing your own milk and storing it would have allowed you to spend time away from your baby (and he/she time away from you)?

Alexandra Goldstein // Posted 6 June 2011 at 10:08 pm

evieS – none of what you say is unfair, or untrue, and I thank you for sharing your story. I have a real issue with the very poor support for breastfeeding, because actually uptake is very good – but only at the very, very beginning, and then women begin to give up because they are not properly supported through what can be very tricky. I’ve heard countless stories like yours and they are extremely upsetting.

My review, and my praise for Wolf’s work, does not reflect a negativity about breastfeeding in the slightest. In fact, I think it’s highly important that books like this make the point that breastfeeding shouldn’t be about campaigns and making women who have to or want to formula feed feel like they’re poisoning their babies. They shouldn’t be about making breastfeeding the gold standard and then leaving women to their own devices thinking ‘breast is best, but I’m failing at it’. They should be about being honest about the science and putting money where it’s really needed – making sure that every single woman who intends to breastfeed (around 75% in the UK!) is given the support to do so.

My sister volunteers with her local NCT, and some pro-breastfeeding mothers who would agree with you on every point did NOT want to get involved with breastfeeding ‘awareness raising’. Because awareness is not the problem.

“what IS a failure of the duty incumbent upon public health guardians is the failure to successfully convince our society of the value (both physical and emotional health and financial benefits) of breastfeeding” – they HAVE convinced us of the value (sometimes beyond what is actually proven); what they’ve failed to do is help us DO it.

And yes, there are still many ethical reasons to reject formula feeding. I could only really mention this in passing or risk writing a six page review, but you won’t hear argument from me there.

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