The enemies list in the subtitle of Courtney Jung’s new book, Lactivism, is remarkably diverse: feminists, fundamentalists, hippies, yuppies, physicians, and politicians. Collectively they are indicted for demanding that all mothers breastfeed and stigmatizing those who turn to formula. The federal Centers for Disease Control and Prevention and the American Academy of Pediatrics also get dinged for elevating breastfeeding to a public-health issue with policies that are imposed “stealthily” and whose effect can be “pernicious.” Meanwhile the multibillion-dollar business of breastfeeding — with its special pillows and whirring pumps — suckles at the teat, so to speak, of the federal government’s generous subsidies. The book paints a portrait of collusion and delusion, of a medical establishment and a thriving industry aligned against the basic right of a new mother to make the best choice for herself and her baby.
And that’s not the worst part: Their propaganda and profit-taking is based on the supposed benefits of breastfeeding, which fall apart under closer examination, according to Jung, a professor of political science at the University of Toronto. In an essay she wrote for The New York Times, published in advance of the book’s release this month by Basic Books, she contends that the advantages “just don’t seem to warrant the scrutiny and interventions surrounding American infant feeding practices.” In the book, she delves into the scientific literature and emerges unpersuaded: “Many recent studies suggest that breastfeeding has no effect on many of the outcomes it has been associated with, like obesity and allergies, and that, even where it has an effect, as it does with infection, in a developed country with routine access to clean drinking water, the effect is not nearly as powerful as many of us have believed. Sigh.”
But don’t take her sigh for it. The author visits Michael Kramer, a professor of pediatrics, epidemiology, biostatistics, and occupational health at McGill University, who is the lead researcher for the Promotion of Breastfeeding Intervention Trial, the largest study of its kind on the topic. Jung writes that he is a “giant in the field” and “probably the most prominent breastfeeding researcher in the world today.” After interviewing him, she concludes that Kramer “doesn’t believe that breastfeeding is important enough to justify the zealotry of ardent activists.”
That surprised me enough that I called Kramer, who co-wrote a World Health Organization report recommending that infants be exclusively breastfed for the first six months. Had Kramer, of all people, soured on mother’s milk?
In short, no. Kramer said that Jung sent him the science-related chapter of her book, and he didn’t like what he read. “I think she chose to ignore some of the science,” he said. “I don’t think it’s a balanced summary of the evidence, and I do think it sends the wrong message.” Like most researchers sensitive to sample sizes and confounding variables, Kramer tends to be circumspect in his assertions. “I would never recommend breastfeeding in order to protect a kid from getting heart disease or obesity or type 2 diabetes or asthma, but there are enough benefits that are solid that it’s a no-brainer for the mother’s health and the baby’s health,” he said. He points to research indicating that, for example, breastfeeding significantly lowers the risk of infection and of sudden infant death syndrome, calling those findings “very well established.”
Jung concedes in her book that recent meta-analyses have found an association between SIDS and breastfeeding. For instance, a 2011 meta-analysis of 288 studies concluded that breastfeeding is “protective against SIDS, and this effect is stronger when breastfeeding is exclusive.” Jung also acknowledges that breastfeeding reduces the risk of ear and respiratory infections among infants, but rolls her eyes at the effort expended for the protection granted. “Of course ear infections are no fun. They make babies cranky and miserable, and nobody gets much sleep. But they’re not life-threatening, either.” (Not normally, anyway. Untreated ear infections can be fatal.)
So what about breastfeeding’s touted effect on cognitive development? Again, Jung acknowledges that there’s evidence, including from Kramer’s study of 17,000 mother-infant pairs, that breastfed children score higher on measures of overall IQ. Right now Kramer is working on a follow-up to that study, which should be published early next year. But even if studies continue to show a genuine effect on IQ, Jung isn’t sold. “Those three or four IQ points probably aren’t worth going to the mat over,” she writes.
After reading Lactivism, it’s hard not to wonder if Jung is simply difficult to impress. Ear infections are the most common reason for pediatrician visits in the United States, and even a modest decrease could mean a million or two fewer trips to the doctor. SIDS, while less common now that babies are put to sleep on their backs, still kills more than 2,000 infants in the United States each year, and a 2010 study found that breastfeeding might cut the risk in half. And while it’s certainly true that a few IQ points won’t transform a dullard into a prodigy, should we scoff at the prospect of IQ increases, even if they’re not dramatic?
The societal tension around breastfeeding remained, as the practice moved from underground to orthodox.
Science, particularly science related to human health, rarely serves up unequivocal findings, so the results on nearly any topic can be deemed “mixed” even when the best evidence leans heavily in one direction. And when that science gets thrown into a charged topic like breastfeeding, with its cultural baggage about who is or isn’t a “good mother” — whatever that might mean — then the argument over evidence collides with debates about gender equality and class.
The class angle is particularly fraught. In Jung’s book, the same breastfeeding science she deems “very disappointing” provides the justification for “punitive” and “invasive” public policy directed at poor women. She notes that the Special Supplemental Nutrition Program for Women, Infants and Children, commonly known as WIC, allows women who breastfeed to receive a wider selection of food and remain in the program longer. That’s accurate, though somewhat misleading: WIC spends far more every year on women who give their babies formula; in fact, most of the formula sold in the United States is purchased by women enrolled in WIC, reports the Department of Agriculture. During the first six months of a baby’s life, the dollar value of free formula exceeds that of the extra food for breastfeeding mothers.
For Jung, policies intended to support breastfeeding go too far and not far enough. The Affordable Care Act requires employers to provide space for women who breastfeed and requires insurance companies to cover the cost of breast pumps. One way to view this is as an attempt to make it easier for low-income women to breastfeed if they choose. That’s not how Jung sees it. “Obama’s pumping policies compel mothers to square the circle between the absence of maternity leave and the injunction to breastfeed exclusively for six months by pumping breast milk at work,” she writes.
In the era of the behavioral nudge — an idea that’s been eagerly embraced by the White House — it’s worth asking: When does encouragement become an injunction? And is offering incentives for mothers who breastfeed the same as punishing mothers who don’t?
Jessica Martucci provides a less polemical take on the modern history of breastfeeding in Back to the Breast: Natural Motherhood and Breastfeeding in America (University of Chicago Press). She tells the tale of how, for a few curious decades, the evolutionary method of feeding offspring not only fell into disfavor but was demonized by medical professionals who took it upon themselves to give women drugs, sometimes without their consent, that would dry up their milk supply and force them to use formula.
The logic for this strange shift was partly philosophical and partly pragmatic. During the 1920s, John B. Watson, a prominent psychologist and author, conducted a successful campaign against the evils of “mother love” — that is, the sort of cuddling and closeness between mother and child that Watson, best known for his Little Albert fear experiments, believed could stunt emotional growth and turn ambitious go-getters into feckless neurotics. Because it’s tough to both breastfeed and keep your baby at a proper, snuggle-free distance, Watson’s prescription for well-adjusted children helped make formula the norm. Breastfeeding also just felt less scientific, harder to quantify, at odds with the progressive ethos of the early 20th century. Martucci, a fellow in medical ethics and health policy at the University of Pennsylvania, writes:
Unlike formula feeding, which changed only in concentration as the baby grew, breastfeeding was a dynamic and largely invisible process, an emotional and physiological experience in constant flux as the infant grew and the mother’s body responded. Physicians who encountered breastfeeding mothers throughout this period struggled to find ways to fit the practice into a controlled scientific regimen, and generally failed in doing so.
Women who chose to breastfeed were derided as “frivolous, overly demanding, and even fanatical.” Those who expressed interest in breastfeeding were often told that they wouldn’t produce sufficient milk, or that their nipples were the wrong shape, or that they were otherwise unsuited for the biological task. By the early 1970s, most American women did not breastfeed, and the practice was regarded as a relic of a bygone century, like oil lamps or the horse and buggy — which, in a sense, it had almost become.
Though not quite. Martucci counters the caricature that breastfeeding ever actually vanished. It was kept alive all along, she writes, by a relatively small contingent of nurses, doctors, and, most important, mothers themselves, who “created a body of expert knowledge about motherhood.” That band of lactation rebels helped set the stage for a breastfeeding resurgence in the mid-to-late 1970s, a time when ideas about a return to nature and getting “back to the land” took hold among those who had come of age in the 1960s and were now starting families of their own. By 1984, about 60 percent of American women breastfed their babies, triple the proportion from the beginning of the previous decade.
The societal tension around breastfeeding remained, however, as it moved from underground to orthodox. Some visions of so-called natural motherhood, promoted most notably by La Leche League, could seem idealized and inflexible, unaccepting of working mothers who could not or did not want to stay home with their babies. One of the league’s core tenets had it that “the baby has a basic need for his mother’s love and presence which is as intense as his need for food.” That could be read as a paean to a mother’s value or a condemnation of women who didn’t subscribe to the gospel according to La Leche.
It’s that attitude that seems to needle Courtney Jung. She singles out attachment parents, with their “organic cotton” slings decorated in “ethnic-looking colors and prints and imported from places like the Amazon rain forest or rural Vietnam, places where we imagine attachment parenting is seamlessly integrated into everyday life.” Jung recounts how, while she was pregnant, a woman buttonholed her and, while “gesticulating dramatically with her cosmopolitan,” extolled the myriad virtues of breastfeeding your infant. “Even before my baby was born, encounters like the one I had at that cocktail party exposed a righteousness that made me uneasy.”
If Jung took aim only at vodka-swilling boors, her book might be read as trenchant social commentary. But she’s also trying to take the shine off the science, to assure readers that it’s much ado about not much. In 2009, The Atlantic published an article with a thesis nearly identical to Jung’s book, That essay, “The Case Against Breastfeeding,” by Hanna Rosin, argued that breastfeeding was a burden for many mothers and not nearly the health boon for babies that its strident proponents liked to claim.
When David Meyers read that article, he remembers feeling a knot in his stomach. Meyers, who is chief medical officer at the federal Agency for Healthcare Research and Quality, didn’t think Rosin’s case against breastfeeding was valid on scientific grounds. “There are very few interventions we have that show this many benefits,” he says. He worried that women would now be more resistant to information about breastfeeding. And, indeed, some expectant mothers told him, “Yeah, I read the article, I know what you’re going to say, but don’t waste your breath. I’ve made up my mind.”
Meyers gets mentioned — mocked, really — in Jung’s book for a presentation he gave in which he noted that, for every 26 infants who were breastfed for the first four months, one would be prevented from being hospitalized for pneumonia. He offered those numbers as yet more concrete evidence of breastfeeding’s upside, though the statistic elicits a shrug from Jung. “Dr. Meyers must do a different cost-benefit analysis than most mothers would do,” she writes. That sort of dismissal leaves Meyers feeling exasperated. “If we can decrease it,” he asks, “why wouldn’t we?”
I spoke with Jung about the criticism from Meyers and Kramer. She says she was “really surprised and bummed” by Kramer’s assessment, because she had made changes to the manuscript based on his feedback. (Kramer describes those changes as minor.) Since her Times essay was published, Jung says, she’s heard from women who felt shamed for not breastfeeding, and they’ve thanked her for speaking out. “I think Dr. Kramer and Dr. Meyers may have less appreciation of what the social impact of really zealous breastfeeding advocacy is,” she says. “I think turning it into a public-health issue and erasing the idea of choice is not helpful to the discourse.”
Both Kramer and Meyers said they don’t believe it’s necessary to breastfeed in order to raise a healthy child, and they acknowledge other factors that can be important, along with the many pressures and obstacles that mothers face. But they don’t think that the choice between formula and breast milk is a toss-up. What would the world’s most prominent breastfeeding researcher say to a mother on the fence about how to feed her child? “I wouldn’t hesitate for a second,” Kramer says. “You should breastfeed your baby. And you should do it exclusively.”
Tom Bartlett is a senior writer at The Chronicle.
