The U.S. CDC’s Health People 2020 Objectives include targets to increase breastfeeding (CDC 2016). Unsurprisingly, the first item on this agenda [1] outlines specific goals for the proportion of infants breastfed at birth through six months. The remaining items address changes to workplaces and hospitals, intended to facilitate the first, overarching goal of increasing breastfeeding rates [2]. On their face, these goals are unremarkable but they presage a radical redefinition of breastfeeding: The first of these proposed institutional changes does not directly facilitate breastfeeding in a traditional sense—it facilitates pumping breast milk (Jung 2015). Consistent with this emphasis on supporting breastfeeding indirectly, by promoting breast milk pumping, Obamacare mandates that insurance companies provide new mothers with a free breast pump and that employers enable women to pump at work (HealthCare.gov; Spiggle 2014)

Pumping is a uniquely American phenomenon (Jung 2015). The U.S. is also unique among similar nations in not providing paid parental leave (Livingston 2016). Thus, other nations can promote breastfeeding without relying on breast milk pumping, at least for a moderate duration (leave times vary from 14 weeks in New Zealand to 87 weeks in Estonia, for example). In contrast, American policymakers attempt to reconcile breastfeeding targets with non-existent paid maternity leave by redefining “breastfeeding” to include feeding babies pumped breast milk.

This redefinition of breastfeeding has consequences. Although I was unable to find survey data on women’s subjective experiences, it is reasonable to assume that few women enjoy pumping and many loathe it (see, for example, Jung 2015). Women often find pumping at work difficult or impossible, even when employers are overtly supportive (Brown et al 2014; Jung 2015). Still, pumping, however inconvenient and unpleasant, is increasingly becoming an integral aspect of the American breastfeeding experience. In fact, in one survey of breastfeeding mothers, roughly half of mothers pumped breast milk (exclusively or in combination with traditional breastfeeding) at three months postpartum (Brown et al 2014). Other surveys find that 80 to 90 percent of breastfeeding mothers pump (Jung 2015).

Certainly, many women (myself included) pump at work so that they can continue to breastfeed when they are with their baby. Other mothers pump because they or their babies were unable to breastfeed directly—there is even a website devoted to “exclusive pumpers” (http://exclusivepumping.com/). Clearly, breast pumps are valuable in that they enable breastfeeding, or the feeding of breast milk, for mothers who would otherwise be unable to achieve their breastfeeding goals. In this sense, breast pumps may empower women, even as they extend the breastfeeding imperative to working mothers who may face enormous difficulties pumping at work. But we need to acknowledge and debate the subtle redefinition of “breastfeeding” to include bottle feeding pumped breast milk and the concurrent demands on working mothers.

We also need studies that differentiate between breastfeeding and feeding breast milk. The benefits of breastfeeding may be overstated (Rosin 2009; Jung 2015), but insofar as there are benefits, extant research has largely conflated the effects of breast milk and breastfeeding (Jung 2015). To my knowledge, the only large-scale, randomized trial comparing the outcomes of breastfed and formula fed babies was conducted in Belarus and Belarusian mothers rarely pump milk (Jung 2015; Kramer 2001). Some of the touted benefits of breastfeeding, such as increased resistance to certain infections, are linked to the composition of the milk—breast milk includes antibodies and immune cells. But other proclaimed benefits, particularly regarding socio-cognitive outcomes [3], may result from the mother-infant interaction and bonding constituent with the act of breastfeeding (Jung 2015).

Many aspects of the breastfeeding promotion movements are troubling, including the overstatement of benefits and the villainization of parents who chose to feed formula (Artis 2009; Jung 2015; Rosin 2009). Although it receives less attention, the implicit assumption that pumping and breastfeeding are substitutable is also ethically problematic. I have nothing against pumping or against mothers who pump (I am one myself). However, by promoting pumping rather than providing paid leave, U.S. policy emphasizes milk over mothering. Viewed in this light, breast milk pumping is arguably an objectifying experience, transforming the mother into a vehicle for milk production.

The choice to breastfeed, pump breast milk, and/or feed formula is fundamentally a personal choice, dependent on individual preferences, circumstances, and capacities. In this sense, policies that allow women to achieve their feeding preferences are laudable, including policies that facilitate pumping. Still, I find it problematic that U.S. policymakers have promoted pumping as the primary means of reconciling the CDC directive to breastfeed for at least six months with the absence of paid parental leave. Although pumped breast milk has benefits, breastfeeding is about more than milk. I breastfed because my baby and I wanted to breastfeed and because breastfeeding came naturally to us. My choice was not motivated by the evidence in favor of breast milk over formula, but by my baby’s innate desire to breastfeed. The act of breastfeeding is not interchangeable with the feeding of pumped breast milk and policies intended to enable “breastfeeding” should not treat them as such.

Notes:

[1] MICH-21: Increase the proportion of infants who are breastfed.

[2] MICH-22: Increase the proportion of employers that have worksite lactation support programs. MICH-23: Reduce the proportion of breastfed newborns who receive formula supplementation within the first two days of life. MICH-24: Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies.

[3] Evidence that breastfeeding significantly improves socio-cognitive outcomes, including increased intelligence and decreased behavioral disorders, is at best inconclusive (see Jung 2015 for a review).

References

References:

Artis, Julie E. 2009 “Breastfeed at Your Own Risk.” Contexts 8(4):28‐34.

Brown, N.,  L. Geller, C. Kazbour & Members of the BABES Advisory Committee. 2014. “Breastfeeding Experience Survey Outcomes.” Palo Alto Medical Foundation. http://www.pamf.org/babes/outcomes.html#pumping

CDC. 2016. “Healthy People 2020 Breastfeeding Objectives” https://www.cdc.gov/breastfeeding/policy/hp2020.htm

HealthCare.gov. “Breastfeeding benefits” https://www.healthcare.gov/coverage/breast-feeding-benefits/

Jung, Courtney. 2015. Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians made Breastfeeding Big Business and Bad Policy. New York: Basic Books.

Livingston, Gretchen. 2016. “Among 41 nations, U.S. is the outlier when it comes to paid parental leave.” Pew Research. http://www.pewresearch.org/fact-tank/2016/09/26/u-s-lacks-mandated-paid-parental-leave/

Kramer, Michael S., et al. 2001. “Promotion of Breastfeeding Intervention Trial (PROBIT): A Randomized Trial in the Republic of Belarus.” JAMA: Journal of the American Medical Association. 285(4):413-420. https://www.ncbi.nlm.nih.gov/pubmed/11242425

Rosin, Hanna. 2009. “The Case Against Breast-Feeding” The Atlantic. https://www.theatlantic.com/magazine/archive/2009/04/the-case-against-breast-feeding/307311/

Spiggle, Tom. 2014. “What the Law Says About Pumping Breast Milk at Work” Huffington Post. https://www.huffingtonpost.com/tom-spiggle/what-the-law-says-about-p_b_5679487.html

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