Breastfeeding Evidence
This month's Atlantic Monthly has a controversial article about breastfeeding, specifically making arguments against breastfeeding. The arguments are of two types. One is social and normative, and the other is on the evidence. My thoughts, naturally, are on the evidence. The journalist makes a classic error in understanding and interpreting "treatment effects." Here is a clip:
"Both the Kramer study and the sibling study did turn up one interesting finding: a bump in “cognitive ability” among breast-fed children. But intelligence is tricky to measure, because it’s subjective and affected by so many factors."
The Kramer study was a randomized control trial (a clustered encouragement design). The sibling study is an econometric study which tries to control for parental fixed effects by comparing siblings (but can't control for a series of stories one could dream up about ordering effects). Both find positive effects on IQ. The RCT finds a 5 point increase.
But Hanna Rosin dismisses the evidence that breastfeeding causes a "bump in cognitive ability" by five points because it is "affected by so many factors." This is akin to saying that even though we know that eating better as a child leads to higher height, it should be dismissed because, well, aging has so much more to do with height than eating a bit more protein! The fact is, five points is significant, and the fact that IQ tests bounce around day to day is simply a matter of having sufficiently large sample sizes in the study, something Kramer has done and thoroughly addresses.
Rosin also makes reference to Kramer's valid point that he cannot separate the milk from the cuddling, and that is fine... we may lack clear knowledge on the mechanism, but we still know the end result: breastfeeding leads to a five point increase in IQ, on average.
The irony of course that Rosin did not address is that the real "cost" of breastfeeding is actually imposed by society... the embarrassment factor. If more women openly breastfed while sitting in the park, at the bank, in the office, or on the bus, we probably would be having a completely different conversation. In developing countries, breastfeeding in many places is the norm. I'd guess in a typical village bank microfinance meetings, one out of 10 women breastfeed while making their loan payments, or answering all our questions we ask when conducting a survey.
But it is the case that in many parts of the world, women still lack important information about breastfeeding. Freedom from Hunger, one of our favorite NGO's because of their dedication to the poorest, and their dedication to evidence-based development work, works diligently to integrate breastfeeding education modules into microfinance programs around the world. We are working with them in Benin and Peru in fact to evaluate the impact of their health education modules.
So back to Rosin, she poses another question which I find much more interesting: why is there a growing social norm that if you do not breastfeed, you should be shunned. There are countless things we do not do as parents that would be good for our kids, but we just deem them too costly (the safest possible car, e.g., or even the simple choice of how much time to spend with them). Why do some "costs-benefit" analysis become subject to social pressure and norms, and others do not? An easy answer would be externalities, but that doesn't seem to be the case. So what is it about breastfeeding that generates this type of rhetoric?
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Dean, of course we appreciate
Dean, of course we appreciate any “marketing” of FFH that you give us, but I think you’ve posed some interesting questions---not only related to our work, but how it relates to women in the United States in general. Sorry that my post will be long, but having recently had a child, the topic feels a bit relevant.
Mothering Magazine (I’ll admit, this magazine reaches a certain target audience because of its approach to “natural parenting”) has put out many issues about research conducted on benefits of breastfeeding—both for mothers and babies. Not all RCTS of course, but fairly large studies that end up being fairly influential. They try to back up their “rhetoric” as best as they can. As a researcher, I appreciate being provided some of the more technical studies in a parenting magazine. Interestingly, I’ve probably been more influenced by working at FFH in regards to breastfeeding (you know, trying to walk the talk) than some of the literature, but the literature of course is compelling (but, our education is based on the literature as well, so I guess I am influenced by both). As you questioned, why is the tide turning?
I think hospitals have changed their policies and/or been “strongly encouraged” by breastfeeding advocates so that there is a lot more support for new mothers post-partum to help with breastfeeding. Frankly, breastfeeding is not an instinctual thing to do and it’s much harder than it looks...getting a woman past the first month is a challenge and I know the Leche League data (I think this is the reference) shows that breastfeeding is high for the first month, but that it drops off drastically after 1 month and much more drastically after 2-3 months (likely related to women going back to work and not having an environment supportive of breastfeeding—or providing time to use a breast-pump). I think because breastfeeding does present its own set of challenges (allotting the time for it, being primarily responsible for child’s nutrition, etc.),you find women that have breastfed or are breastfeeding their children are really supportive of other women trying to do the same…because you recognize the challenges and want to help others overcome them.
So, if you acknowledge “embarrassment” as a cost and reason for NOT breastfeeding, “guilt” is a cost or reason why women work so hard to breastfeed. That guilt of NOT breastfeeding is likely to fuel—at least on a woman’s part—why they might want to see some data support reasons why they are not actually feeding their child a sub-par food or nutrient, if no other obstacles exist besides personal choice and freedom (for example, a mother wanting the father to get up at 2 and 4 a.m. for a feeding, simply not wanting to commit the time—breastfeeding takes a lot longer than bottle feeding, etc.). Or even in the case where there are significant obstacles to breastfeeding (premature babies not getting enough nutrients who need an “extra push” of calories, infection, illness, drugs excreted through breast milk, etc.)—you still don’t want to think that you’re reducing your child’s chances of becoming the next Einstein or having great health. To me the debate about breastfeeding is similar to other parenting debates: organic vs. non-organic foods, vaccines or no vaccines, stay-at-home mom versus working mom, spanking versus time-outs, etc. We’re all trying to do our best for our children and when we can’t, we want to justify certain behaviors (and for some, want to be able to back it up).
My sister had a baby at 24 weeks and the child was in the NICU for 3.5 months. The NICU was begging for any breast milk that my sister could provide, whereas the nurses in the maternal ward of the hospital threw away the milk because they didn’t think it was enough to warrant carrying it down to the NICU for the baby. Also, the NICU eventually convinced my sister that the baby wasn’t getting enough calories and decided to give the baby formula—even though my sister was pumping enough milk. So, even at the medical level, you get mixed messages and I’m disappointed they didn’t work harder to keep the baby on breast milk.
I’d venture to say that there are adamant and passionate people who support breastfeeding...and then there are people simply lukewarm about it. Not particularly opposed to it, but not fully convinced or bought into the benefits and how those compare to the costs. One point that she doesn’t raise that I think should be promoted more often (beyond health benefits) are the financial benefits of it. Formula costs anywhere between 20 and 30 dollars a can. For women in the developing world and frankly, people anywhere on a budget, this is a huge expense. Breastfeeding is free, you can practically do it anywhere and you don’t have to be worried you forgot the bottle, the formula, or have a good source of water. And one added benefit I found is that it gives the mother a wonderful excuse to tell the pesky in-laws or other family members to hand back the baby and to sneak away for some peace and quiet during family visits. Oh, the power!
breastfeeding
Ms. Rosin's article offends me both as a former journalist and as a nurse-midwife. Seems to me that her argument is entirely based upon her opinion and that she is interpreting the literature in a way that supports her belief and current attitude about breastfeeding. I am curious how this woman's emotional baggage got elevated to the level of respected journalism.
More importantly, in a country where exclusive breastfeeding rates at 6 months are still in the teens, do we really need somebody to make a case against it?
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