Best, yes, but for whom?

BREASTFEEDING: what could be more simple? Best for mother, best for baby, the obvious and necessary feeding choice for all mums, and the only one ethical health professionals can support. Most women reading this would find such “facts’’ familiar.

The gut-wrenching feelings of guilt and inadequacy that accompany such pronouncements might also feel familiar. Because when it comes to breastfeeding, most of us feel like failures: either because we didn’t try to or didn’t succeed at breast-feeding our babies, or we fear we didn’t feed for long enough.

Women are consistently told that the nutritional superiority of breast milk makes breastfeeding the only ``choice‘’ for any mother who really cares about her baby. To ensure the maximum number of women ``choose’’ breastfeeding, public health officials, health professionals and breastfeeding advocates see themselves as justified in doing whatever it takes to ``support‘’ breastfeeding and to ``actively discourage’’ formula feeding.

Women may decide not to initiate or to continue breastfeeding for a range of reasons. They may not feel comfortable exposing their breast in public, they may ``fail’’ because of supply problems or mastitis, or they may have had enough after three or four months and want to hand over primary care to Dad.

The bar that today’s ``successful‘’ breastfeeders must leap is considerably higher than that needing to be vaulted by previous generations. Twenty years ago, breastfeeding was recommended for three months. Soon after target was set at six months. Now the World Health Organisation says all women (regardless of where they live and the adequacy of alternative food supplies) should breastfeed ``into the second year and beyond’’. Accordingly, many Australian researchers have begun pushing the government to adopt one-year targets.

The benefits claimed for breastfeeding are also on the rise, although advocates consistently fail to disclose the significant controversies among researchers about whether such benefits exist and whether they are caused (or just correlated) with breastfeeding. Selective reporting of research findings is also rife.

My favorite is a recent study that showed that while breastfeeding lowered breast cancer rates in pre-menopausal women, it appeared to raise the incidence of breast cancer in post-menopausal women. You’ll find the former finding in the fact sheets distributed by the La Leche League; the latter is strangely absent.

But the biggest problem is that breastfeeding advocates confuse decisions about breast milk with decisions about breastfeeding. Even women who have no doubts that breast milk is nutritionally superior to formula may make an informed and caring decision that, in their situation, breastfeeding is not the best choice.

This is because women don’t base infant-feeding decisions only on the respective qualities of the milk, but also on the costs and benefits of each feeding method to their infant, their other children, themselves, their partners and their family as a whole. For example, a woman may weigh up the ``risk’’ to her infant of giving some formula at three months so she can return to her full-time job, against that of losing her job altogether or falling out of the loop because of the extensive amount of time needed during the work day to express milk. Not only might the woman value her job as an important source of self-esteem and financial independence, her income may be essential to the family’s meeting its commitments to a mortgage or private school.

When a woman makes a decision according to her own values about how she is going to feed her infant, this decision merits support and respect regardless of what it is. For this to happen, a number of policies, practices and attitudes are going to need to change.

The first is the accuracy of the information disseminated to women about breast and formula feeding. Such information needs to distinguish between infant milk (breast and formula) and infant-feeding decisions. It must also either reveal all the confusing and contradictory findings and debates about the relative merits of breast milk and formula, or report only those findings about which there is little disagreement.

There also needs to be changes in workplace structure and attitudes to enable women who want to breastfeed to do so for as long as they wish without fear of losing their job. Extended paid parental leave is the most critical of these, but proper workplace facilities in which women can take adequate nursing breaks during the day are also important.

But such changes do not mean all women will choose to initiate breastfeeding or to feed for extended periods of time. Health officials and professionals who believe it would be unethical to support anything but breastfeeding must seriously rethink the meaning of ethical and professional behavior when it comes to caring for new mothers. It is unethical for health professionals to use their considerable power and authority to coerce (subtly or otherwise) competent and informed women to make decisions that accord with the health professional’s view of what is right.

It is even more unethical for such professionals to refuse to respect, to withdraw support from, or seek to undermine women’s decisions they deem ``wrong’’. Their moral and professional responsibility is to help women understand the information women see as relevant to their decision, and then to respect women’s capacity as competent informed adults to make the best decision for them.

Ah, respect for female autonomy and moral agency. What could be more simple?