UNICEF today announced research showing that increasing breastfeeding rates in the UK could save the NHS tens of millions of pounds. The report notes that investing more money in encouraging more mothers to breastfeed, and for longer, will pay dividends.
Is this likely to get more mothers breastfeeding? Well, I don’t think we’re off to a very good start. Take a look at some of the headlines used to report this story:
Boosting breastfeeding rates saves lives and money: Unicef (Telegraph)
Increase in breastfeeding could save NHS £40m a year, according to report (Guardian)
More breastfeeding will save NHS millions (Public Service)
A common theme in all these headlines is that they represent the breastfeeding-induced reduction in illness and NHS spend in terms of money and lives saved. This is not the only way to represent the data: rather than viewing breastfeeding as saving money and lives, we could view formula-feeding as costing money and lives. Increasing breastfeeding rates would, then, be a way to recoup some of the losses brought about by the prevalence of formula-feeding.
This alternative way of seeing things is not common, however. I ran a Google news search for reports of today’s UNICEF research, and of the 16 ‘most relevant results’, 9 mentioned in their headlines the reduction in illness and/or NHS spend that increased breastfeeding would bring about, and 8 of these represented this reduction in terms of savings rather than costs. (The result whose headline did not view the reduction in terms of savings also did not view it in terms of costs, but merely in neutral terms.)
Why is this important? Well, because of the way our views about gains and losses shape our behaviour. ‘Breastfeeding saves money and lives’ takes the current situation–in which breastfeeding rates are low–to be normal, and tells us us that breastfeeding would help improve it. ‘Not breastfeeding costs money and lives’, on the other hand, takes as normal some situation in which breastfeeding rates are higher than they are currently, and tells us that the reason the current situation is worse than normal is because we don’t breastfeed enough. In other words, ‘Breastfeeding saves money and lives’ tells us that our balance sheet is zero, whereas ‘Not breastfeeding costs money and lives’ tells us that we are running at a loss. And it is a fact about human psychology that people are much more highly motivated to try to recoup losses than they are to secure gains. This need to ‘break even’ and recover losses helps explain why gambling can be so addictive: those who see themselves as running at a loss continue to risk what little money they have left on gambles that the rest of us wouldn’t entertain. Therefore, we should expect policy-makers, healthcare professionals, and parents to be more strongly motivated to increase breastfeeding rates by the message ‘Not breastfeeding costs money and lives’ than by the (far more widespread) message ‘Breastfeeding saves money and lives’.
The dangers of viewing the benefits of breastfeeding as better-compared-to-the-norm have been recognised by the Breastfeeding Network, who in 2010 urged the government to scrap its ‘Breast is Best’ slogan on the ground that it does not motivate mothers to breastfeed. The chair of the Breastfeeding Network, Lesley Backhouse, complained that the slogan ‘implies something special, whereas breastfeeding is the physiological norm, and suggests that formula is the standard way to feed babies’. The importance of viewing breastfeeding as the norm also seems to be recognised by UNICEF, which refers many times in its report to the risks and costs associated with not breastfeeding. It is also recognised by the American breastfeeding advocate Diane Wiessinger in her famous article ‘Watch your language’, and by manufacturers of infant formula, who promote the ‘breast is best’ message without appearing to view it as a threat to their sales (see, for example, here, here and here). Presenting breastfeeding as better-than-normal conveys the message that breastfeeding is best, but not breastfeeding is okay. And it’s okay to be okay.
Of course, the danger of presenting formula-feeding as worse-than-normal is that it makes non-breastfeeding mothers feel bad. There is an appealing and pervasive view that we should support the feeding choices of all mothers, whether or not they breastfeed. However, this does not entail that non-breastfeeding mothers are best supported by shying away from strongly motivating mothers to breastfeed. Anita Tiessen, Deputy Executive Director of UNICEF reports that ‘90 per cent of women who stop breastfeeding in the first six weeks discontinued before they had wanted to’. Such women know that formula-feeding is an inferior choice. To encourage them to believe otherwise may be well-intentioned, but it is disrespectful and patronising: it fails to recognise what they already know about the relative merits of breastfeeding and formula-feeding, and it fails to acknowledge the disappointment and guilt that they may feel as a result of stopping breastfeeding.
How, then, can we best ensure that non-breastfeeding mothers are not made to feel guilty? Sorry, but we can’t. Even setting aside the perils and pitfalls of trying to breastfeed a child, becoming a mother is a good way of ensuring that you will spend a large portion of every day feeling guilty about something or other. (Diane Wiessinger has a great discussion about guilt in her article.) It is not constructive to deal with feelings of failure by adopting the attitude of Aesop’s fox and concluding that one is no worse off for having failed to achieve what one wanted–particularly when doing so deprives others of support in trying to achieve the same valuable end. A better approach would be strongly to promote the valuable end whilst offering support to those who fail to achieve it. In the case of trying to increase breastfeeding rates, that entails presenting breastfeeding as normal, presenting formula-feeding as sub-normal, and being respectful and sympathetic to mothers who do not breastfeed.
I think media should go more indepth reguarding information on breastfeeding as many mothers are aware of what they and there newborn babies are missing out on!
Unaware#
Thank you for your well-spoken remarks. In this light, I recall an on-line comment I made in 2007 that looks as valid today as then.
James Akre, Geneva, Switzerland
http://adc.bmj.com/content/92/6/471.1/reply
Dear Editor,
The Perspective on the paper by Akobeng and Heller is appreciated, as indeed is the paper itself. Both contribute convincingly to our collective awareness of breastfeeding’s centrality to human development. However, I’m concerned about communicating the benefits of breastfeeding without also making parents, health professionals and policy-makers aware that artificial feeding is a harmful practice with serious consequences throughout the life course.
We don’t usually stress the benefits of immunising children against major diseases, ensuring they are transported using safe car-seats, and not subjecting them to cigarette smoke. On the contrary, we focus on the nature and degree of the risks incurred if we fail to engage in these health-promoting behaviours.
There is certainly more than adequate information to reaffirm energetically the multiple benefits of breast milk and breastfeeding, even if “everyone” supposedly already knows this. But it’s time we also emphasized the steadily expanding evidence about the short- and longer- term risks associated with routine non-emergency artificial feeding; they should surprise no one given how fundamental a deviation from the biological norm it is for the young of our species to be ingesting a paediatric fast food prepared from the milk of an alien species.
Most people are unaware just how damaging routine artificial feeding is both for today’s children and tomorrow’s adults and the soaring price we pay for our collective ignorance. Postpartum child development, for better or for worse, is nutritionally programmed at the base level of still-maturing tissues and organs (1). It should be clear that achieving our genetic potential – including in terms of brain development, visual acuity, even longevity – is not going to happen by forgoing human milk’s unique, species-specific properties.
The Perspective rightly recalls the importance of the Baby Friendly Initiative for increasing breastfeeding rates. Yet it makes no mention of the adoption of other key measures to protect, promote and support breastfeeding – for example broad-based community support for mothers and babies, health-professional training consistently imbued with suitable messages, maternity protection in the workplace, and appropriate marketing and distribution of breast-milk substitutes. Yet these steps are unlikely to be taken until society and its leaders first embrace the notion that routinely feeding a breast-milk substitute carries with it serious consequences.
We’re fond of describing our behaviour in terms of rational decision-making. But where child-feeding mode is concerned – to breastfeed or not – my sense is that it’s roughly equivalent to the role that choice plays in deciding whether to hold a small child’s hand as we cross a busy street together, which is to say not at all. We respond the way we have learned to respond; thus, if we want to change society’s predominant artificial-feeding mode we need to change society in all its structural complexity and not just focus on one or two contributing factors in isolation.
The highest remaining hurdles to more and longer breastfeeding are neither scientific nor epidemiological; they are primarily political, socio-cultural, economic and organizational. It’s time to move more aggressively and sure-footedly on all four fronts. And as we do, let’s not forget the singular advantage that we have over anyone who would still dare to promote a routine deviation from the hominid blueprint (2). Embracing breastfeeding automatically places us on the right side of history.
References:
1. Koletzko B, Akerblom H, Dodds PF, Ashwell M. Early nutrition and its later consequences: new opportunities. Perinatal programming of adult health. New York, Springer, 2005 http://www.danoneinstitute.org/publications/book/pdf/Book_Koletzko_ISBN_1402035349.pdf.
Thanks for your comments, Stephanie and James.
James, I agree with every word! It’s interesting to consider why we don’t promote breastfeeding the way we promote car seats and immunisations. Perhaps it has something to do with the fact that it’s the mother’s (but not the father’s) fault if her child is not breastfed, whereas it’s the fault of either or both parents if a child is not constrained in a car seat, inhales cigarette smoke, or is not immunised: this doesn’t sit well with our ideas about fairness and equality. If that’s the case, it seems to presuppose an absurd belief that we can use social and political factors to iron out or deny biological differences. Better to start from the recognition that there exist biological differences, and work our ideas about fairness and equality around them–e.g. by recognising that only women can be responsible for breastfeeding, and building a system of support for them (us).
Thanks, Rebecca. I think you raise a number of key points where individual parents and couples are concerned. However, having considered the topic from a number of angles for better than four decades, my single overriding conclusion is this.
Where breastfeeding remains undervalue and under-practised, the primary barrier to more and longer breastfeeding is society-wide ignorance of both human milk’s unique, species-specific properties and the inescapable implications for the health of all people throughout the life course. Moreover, this ignorance is as much a sign as it is a source of disrespect for the biological norm for feeding the young of our species that contributes so effectively to ensuring a continuation of already low rates of breastfeeding prevalence and duration.
Every other barrier to breastfeeding – from individual attitudes and how they are formed, to non-supportive health services, to the multiple unhelpful ways society is often structure – can be traced directly to this cross-cutting core ignorance. And thus, to return breastfeeding to the realm of the ho-hum ordinary – which is how I define my goal for society – we also need a society-wide shift in awareness and attitude.
What I am saying can also be described this way. Contrary to the traditional view, I have concluded that it is not women who breastfeeding after all. Rather it is entire cultures and societies that do – or variously don’t. In other words, cultures and societies, as a whole, are responsible for producing and sustaining the complex value system that results in more – or variously less – breastfeeding by the mothers and children in their midst.
I base this observation on a single universal constant across time and geography: With only the rarest of exceptions all mothers love their children and want what is best for them. And in terms of feeding behaviour, “best” is invariably a culturally determined value.
In many environments, including those under the Anglo-Saxon arc, we don’t see breastfeeding promoted the way we see car seats and immunisations promoted for lack of the same global shift first in attitudes and then in behaviour. As this week’s UNICEF/UK report – and, for that matter, the negative reaction to it – make clear, we still have a way to travel before the society-wide shift in awareness has been adequately achieved.
James, thank you for these truly fascinating insights. Breastfeeding was not an issue I had ever really thought about before I had my first child three years ago, and my attitude to it was: I’ll have a go, but if I encounter pain or problems, I’ll switch to formula. The message I’d passively absorbed over the years was that formula feeding was good enough, and breastfeeding was not something worth suffering for. So, your comments about it being entire cultures who breastfeed makes absolute sense to me.
I love your analogy with holding a child’s hand to cross a street, and I’ve been thinking of ways that the analogy could be made even stronger. For example, sometimes breastfeeding can be very difficult and inconvenient, and this is often cited as a reason for stopping. But sometimes holding a child’s hand to cross a street can be difficult and inconvenient too: the child might be having a tantrum and refusing to cooperate, the adult accompanying the child may also be carrying a much younger child who is wriggling and getting difficult to control, and may also be carrying shopping bags, trying to locate car keys, and feeling tired and fed up. All fairly standard parenting stuff. But even in such a case, there would be absolutely no question of allowing the small child to cross the road alone. For that even to figure as an option, something dramatically awful would have to happen: for example, there might be a murderous maniac on the loose who has just stabbed and immobilised the parent and is about to turn on the child,so the parent might then urge the child to run for it and take their chances with the road.
Thinking in these terms really highlights how far UK society has to go before breastfeeding is seen as comparably important.
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