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Key points
- There is a lot of pressure on women to breastfeed.
- Formula has all the nutrition of breastmilk.
- The well-being of both the mother and the baby must be considered.
By Gail Erlick Robinson, MD
Mary, three weeks postpartum after a normal delivery and having a healthy baby, is struggling with low mood. She has insomnia and finds it difficult to fall asleep, even when her baby is sleeping. She has lost her appetite and is unintentionally losing weight. Most importantly, she is having problems bonding with her child.
Mary had planned to breastfeed her baby, but she was producing very little milk. The lactation consultant, with whom her obstetrician had referred her, advised Mary to feed, pump, and then feed again and to do this 12 times a day. However, Mary felt overwhelmed by this demand. Yet, having been told by her doctor and friends that breastmilk was the only healthy way to feed her baby, her difficulty providing it made her feel like she was a bad mother and a failure as a woman.
What went wrong?
The lactation consultant was not paying proper attention to Mary’s depression symptoms and the difficulty she was already having in coping with a new baby. The complexity of the instructions she received was unlikely to produce more milk, but very likely to leave her feeling exhausted and with no time for any breaks away from the baby.
Further, the evidence that breastfeeding is the only way to keep a baby healthy is not as certain as was presented to Mary, although there are many advantages to breastfeeding when it works. Ideally, if a new mother wants to breastfeed, it can be an easy, convenient, and satisfying way of nurturing her baby if the following conditions are met:
- Mom is not depressed or anxious and too overwhelmed to breastfeed
- Mom has sufficient milk
- Mom does not develop nipple infections
- Mom does not find breastfeeding too painful
The concern is what happens to the baby and mother if any of these requirements are not met.
Is breastfeeding really best?
There is great pressure on women to breastfeed. The World Health Organization, the U.S. Department of Health and Human Services,and other major associationspromote the idea that all women should breastfeed for at least six months. Some research suggests that breastfeeding also decreases the risks of gastric and upper and lower respiratory tract infections, otitis media, and while not being so clear on the benefits to cognitive development, or a decrease in allergies or asthma in the child. This research, however, has some major flaws.
Associations between breastfeeding behaviors and infant health outcomes are confounded by socioeconomic and psychosocial factors. For example, the only randomly assigned large-scale trial in a developing country, the promotion of breastfeeding intervention trial in Belarus, did not find strong associations between breastfeeding and improved infant health. The study was flawed because even some women in the control group were breastfeeding. Consequently, although there were some trends supporting the benefits of breastfeeding, they were not strong enough to be conclusive.
Further, the majority of the breastfeeding literature is limited to studying women who generally were well-educated and financially secure. The effect on the baby’s health and development stemming from the lifestyle, intelligence, environment, and knowledge of these mothers has generally not been considered.
For example, the greatest decrease in the occurrence of Sudden Infant Death Syndrome, SIDS, occurred when parents were told to stop putting their babies to sleep on their stomachs. The mothers in the studies of breastfeeding may be more aware of these recommendations and, therefore, may be more likely to be following them which might also explain the decreased occurrence of SIDS.
Another study that looked at siblings found there were no differences in infant outcomes between those who were breastfed versus those who were not. Confounding things further are studies showing the same benefits in health outcomes for the babies whose mothers intend to breastfeed whether or not they actually breastfeed. Again, this suggests that many of the benefits associated with breastfeeding may be attributable to demographic characteristics such as socioeconomic status.
Finally, there has been a natural experiment in North America. For decades until the 1990s, women were not pressured to breastfeed. Postpartum women came home with samples of formula and bottles. There is no evidence that these generations grew up sickly, unintelligent, or unsuccessful.
In summary, the purported advantages of breastfeeding may be more likely due to the demographics of the women and children being studied. Given the state of the research, it is appropriate to encourage but not pressure women to breastfeed. However, a woman’s mental state must also be part of the consideration.
If the conditions cited above are not met, North American women live in countries where formula and clean water are available. If and when a mother feels better using formula and is not made to feel guilty and inadequate, the baby will also do well.
Gail Erlick Robinson MD FRCPC, CM, OOnt, is a member of the Committee on Gender and Mental Health at the Group for the Advancement of Psychiatry.
References
Resources:
FED is BEST is a website that supports breast and bottle feeding.
References:
Dieterich CM, O’Sullivan E, Rasmussen KM. Breastfeeding and Health Outcomes for the Mother-Infant Dyad. Paediatr Clin N Am 60(2013) 31-48
Colen CG, Ramey DM. Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons. Social Science & Medicine 109 (2014) 55e65.
Raissian KM, Su JH. The best of intentions: Prenatal breastfeeding intentions and infant health. SSM Popul Health. 2018 Jun 18;5:86-100. doi: 10.1016/j.ssmph.2018.05.002. Erratum in: SSM Popul Health. 2020 Dec 10;12:100713. PMID: 30094314; PMCID: PMC6077263.
