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By Melissa Bartick, M.D.
Judging from the hype around Courtney Jung’s new book "Lactivism," breastfeeding backlash is alive and kicking. In fact, if Donald Trump suddenly jumped into the breastfeeding fray, he might sound a bit like Jung: In her world, breastfeeding advocates are nearly always "lactivists," self-righteous extremists preying on innocent mothers in the name of science and good parenting.
Jung, a professor in the Department of Political Science at University of Toronto, conjures a villain (or villains) everyone can rally against, as evidenced in the book's subtitle: "How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy."
If only some of the glowing book reviews mentioned Jung’s sloppy reading of the scientific literature, her absurd claims about the breastfeeding industrial complex and her misplaced theories of breastfeeding class warfare.
Let’s be clear: There is no place for shaming any mother about how she feeds her infant. There are indeed people out there who deserve our ire, who shame and pressure women instead of listening and educating. But Jung lumps nearly all breastfeeding advocates into this camp, stoking hatred of an entire group where only some are guilty.
Perhaps the book is popular for the same reason Trump is popular. It taps into mothers’ collective anxiety, anger and fears over a highly emotional topic, and then hold up twin "culprits": breastfeeding zealots and bad science. The only problem is, the actual zealots are few (though offensive), and the science is not as Jung states.
Here are some facts: Breastfeeding mothers still get harassed in public and at work, and formula feeding mothers are subject to shame as well. For decades, formula feeding has been the norm in this country, and for much of our society it’s still the norm. CDC data show low-income women and African-American women have lower breastfeeding rates than middle class white women.
Not everyone can breastfeed and not everyone wants to breastfeed, but data show 68 percent of women who want to exclusively breastfeed do not meet their own goals.
To be fair, Jung does a few things right. For instance, a 2007 report from the Agency for Health Research and Quality (AHRQ) found that exclusively breastfeeding for three months cuts the risk of ear infections in half. To her credit, Jung highlights the same data from a different perspective, illustrating that six babies would need to be exclusively breastfed for three months to prevent one ear infection. And, also to her credit, she highlights fairly recent data showing little if any link between breastfeeding and lower risk of asthma, eczema and type 1 diabetes.
But overall, Jung’s grasp on the medical research is poor. Scientific papers are peer reviewed by other researchers who are experts in the same field and must pass rigorous standards before publication. Jung is not a medical researcher. While I don’t know if Jung’s book was reviewed by any medical authority, as a reviewer myself I can say it never would have made it past the first stage of the peer review process. It was reviewed by editors whose goal is to sell books.
She misstates so much of the medical literature, one wonders if she did more than just skim through these papers. Here are a few examples of inaccuracies:
• The rate of HIV transmission from mothers to their 6-month-old infants via breast milk is 4 percent among those exclusively breastfed, according to a study in The Lancet; Jung wrongly puts that number at 22 percent.
• Jung cites my 2010 paper showing that suboptimal breastfeeding rates in the U.S. cost our economy $13 billion and cause 911 excess deaths, but she claims it was based on data only on countries “without access to clean water.” In fact, our data was based on an AHRQ report of only developed countries, including the U.S and European countries.
• Infant diarrhea is actually cut by more than half by exclusive breastfeeding in developed countries such as the Netherlands, not just in “Afghanistan,” as Jung claims.
• The milk of mothers of preterm infants is different from that of term infants, contrary to what Jung writes.
• Jung cherry-picks the evidence on SIDS, omitting the seminal 2011 meta-analysis showing marked reduction of SIDS associated with breastfeeding, and fails to mention that numerous countries, including Canada and the U.K., include breastfeeding in their national SIDS prevention strategies.
• Jung does not discuss the significant effects that breastfeeding has on the health of the mother. Women who don’t breastfeed or who wean early, have higher risks of high blood pressure, <a href="http://www.ncbi.nlm.nih.gov/pubmed/19110223">heart attacks, type 2 diabetes, breast cancer and pre-menopausal ovarian cancer.
Breastfeeding helps women themselves, and it's another reason why I believe society should be supporting women to breastfeed longer. It's really not about moral righteousness or good or bad parenting.
Jung paints breastfeeding as the stylish choice of the middle class, and assumes middle class women and lactivists scoff at the feeding “choices” of lower-income and African-American women.
In fact, Jung seems to be unaware that there is much work going on in this country to close what breastfeeding advocates see as a tragic injustice and inequity. Large government-sponsored initiatives are targeting predominantly African-American and low-income areas to improve hospital and community support contributing to low breastfeeding rates. WIC initiatives have markedly improved breastfeeding rates among low-income women and women of color, and non-profits such as the WK Kellogg Foundation and the U.S. Breastfeeding Committee, on whose Board I served for the past six years, has been committed to raising breastfeeding rates in communities of color. And it’s been working.
We deeply understand that breastfeeding is not a viable “choice” at all for so many women. The low breastfeeding rates among these populations represents a complex, multifaceted social problem, much bigger than any individual mother.
Jung describes a working mother who gets harassed for pumping at the factory. What mothers like this need is support from bosses and coworkers. This is what breastfeeding advocates mean when we talk about “civic obligation,” a term Jung misunderstands as depriving women of feeding choice. “Civic obligation” does not mean forcing women to breastfeed. And that is the fundamental flaw of Jung’s book.
The vast majority of breastfeeding advocates want to support women, and empower them, not force them to breastfeed. They educate, not pressure. Sadly, an unfortunate encounter with a true zealot can color one’s perceptions of the rest of the field of compassionate advocates.
About those breastfeeding extremists, I offer myself as Exhibit A in Jung’s book. She spends pages tearing apart a 2007 essay I wrote on combating formula proponents’ use of the word “choice.” Taking my essay out of context, she implies to readers that breastfeeding advocates do not think mothers should be given a choice in how they feed their infants. Here she describes me as an “ardent lactivist,” although in that very essay, I caution against “lactivism.” Jung couldn’t have gotten me more wrong: I have never engaged in any of the judgmental pressuring tactics to women I meet typical of the lactivists Jung describes.
In fact, I recently wrote a blog post asking breastfeeding advocates to stop using the word “lactivist” and all it stands for. I work with scores of breastfeeding advocates in numerous organizations, and the overwhelming majority of them understand that mothers are just doing the best they can for their circumstances. As with me, Jung misjudges most breastfeeding advocates, mistaking fair-minded people for zealots, stoking hatred where none is warranted.
Repeatedly, Jung tells us how she endured those thousands of hours of breastfeeding, all for little health benefit to her kids, telling us breastfeeding comes at “considerable personal (financial) cost.” Never mind that formula feeding costs thousands of dollars a year, and preparing and washing bottles also takes time, and may not provide as much emotional satisfaction to mother or infant. That is not in Jung’s calculus.
Also noticeably absent in Jung’s calculus are the continuing exploitative marketing practices in the United States and abroad of the multibillion-dollar formula industry, whose products have enormous profit margins, and who make false and confusing marketing claims.
Instead Jung “exposes” the breastfeeding industry, especially pumps, which is tiny by comparison. In 2013, U.S. formula sales totaled $4.8 billion and $14.8 billion globally, whereas Medela, the world’s leading breast pump manufacturer, had 2014 global revenue of $630 million.
In the U.S., lactation consultants cannot even get reliably reimbursed by insurance companies and low-income women have no reliable access to professional breastfeeding help.
A book on the "bad" policies of breastfeeding is bound to resonate for some. But Jung’s review of the science is sloppy and irresponsible, and her few good arguments are subsumed by more absurd points. And to top it all off, Jung writes from Canada, where she benefits from paid maternity leave and national health care. From this vantage point, Jung's writing has the potential to set our American struggle back further.
Melissa Bartick, M.D, MSc, is an assistant professor of medicine at Cambridge Health Alliance and Harvard Medical School.
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