We are going to look at a recent study of women’s perceptions of breastfeeding pain using online forums. It starts, as almost all papers about infant feeding do, with a recitation and affirmation of the creed that breastfeeding has many benefits. Oh boy…
The authors highlight that pain is detrimental to breastfeeding experiences. While we are sure this wasn’t intentional, they seem to be more focused on the impact of pain on continued breastfeeding than on the individual in pain. They note that pain associated with stopping breastfeeding correlates with guilt, dissatisfaction, upset and risk of postnatal depression. However, we don’t think the literature can tease out whether it is painful breastfeeding or stopping breastfeeding that leads to adverse psychological outcomes. They highlight that women feel guilty because their baby isn’t getting the benefits of breastfeeding. However, they do not consider that most claims about the myriad of health benefits conferred by breastfeeding are a long way from being strongly supported in the scientific literature.
The authors note: breastfeeding-related pain is common; the reasons for pain are varied and not well understood; the literature is contradictory about whether positioning of the baby causes nipple pain; it is possible that other physical and psychological factors contribute. This is a good summation, in our opinion. They decide to look at how women seek support for breastfeeding pain online, by taking personal stories shared on public forums, including Mumsnet and What to Expect. While web forums are in the public domain, these are deeply personal stories, often shared at a time of significant distress. This may be acceptable to ethics committees, but it does not sit well with us. Is collaborative engagement, including full informed consent, too much to ask?
The authors identify four themes in their data:
1. Variation in the type of pain. (Note, these researchers are gleaning descriptions from online posts, not clinical assessments of breastfeeding pain, so how much meaningful data can really be gleaned from this?)
2. Variation in perceptions of the cause of pain, including identified clinical conditions that cause pain (e.g. mastitis, Raynaud’s, thrush) and women advising each other of ways to manage their pain and attach their baby.
3. Cessation of breastfeeding due to pain, including the psychological impact (e.g. feeling guilty and sad, perhaps due to knowing that breastfeeding is beneficial for the baby).
4. Shared experiences and support, including mothers sharing their experiences, recommending medications, creams and latching advice and sharing varying experiences of professional support.
They argue that by using the internet, they can get more information about different experiences of pain from a wider range of women. They suggest their study will be less impacted by selection bias (although it selects only women who post on public internet forums about their experiences…). We question whether web posts are a good way to get the information needed to understand breastfeeding pain and ways it may be resolved. Structured, comprehensive clinical assessments would likely yield far more insight into the causes of and potential interventions to help breastfeeding pain.
The authors suggest there is a need to raise awareness of when to seek help for pain experiences (but how? There’s little evidence about how to assess or treat pain) and suggest women are given coping mechanisms (e.g. cognitive restructuring) to cope.
This seems a rather naive perspective on psychological approaches to pain management. They don’t identify common cognitions or beliefs that might contribute to psychological distress for women. They seem to assume that unrealistic expectations, rather than pain itself, are the key problem. Perhaps one way to reduce distress would be a realistic and scientifically literate account of the health effects of infant feeding methods, rather than the gross exaggerations of the benefits of breastfeeding that are almost always taken at face value by researchers in this field?
Then they conclude that their findings provide promising evidence that online peer support could provide normalising support for women who are struggling to keep breastfeeding. Interesting phrasing! Maybe it can also provide normalising support for women who are struggling to stop? Perhaps online forums increase anxiety, guilt and shame? Endless and contradictory advice from strangers doesn’t seem like a wise pain management strategy to us. The authors didn’t look at Facebook breastfeeding groups, but we can tell you that the mere mention of ceasing breastfeeding often results in one reaction: being booted out!
Why are these researchers seemingly not concerned about the quality of advice being given by and to strangers on the internet about matters such as pain management and medications? Have they considered potential adverse effects of internet peer support? Why not highlight the dearth of evidence to inform clinical care for women with breastfeeding-related pain? They conclude that there is a need for realistic information. We agree! It looks like this:
– The supposed health benefits of breastfeeding are gross exaggerations of the actual evidence.
– Breastfeeding is not risk-free. Pain is one of the risks and it is common.
– Formula is not without benefit, including being a comfortable way to feed a baby that can be shared with other people.
– Painful breastfeeding experiences are a significant risk to the physical and emotional health of women and lactating parents and potentially also their relationships with their babies. (Does anyone really imagine that breastfeeding through pain is ‘bonding’?)
– The reasons for breastfeeding-related pain are poorly understood.
– Bringing an end to painful breastfeeding experiences by using bottles, whether to feed pumped milk, to mixed feed or to switch entirely to formula, are all sensible options that may be essential for physical and emotional health.
We appreciate these authors’ intentions and do not wish to be critical. I’m sure we all agree that achieving comfortable feeding experiences is in everyone’s best interests. However, we need evidence-based and responsible clinical care and a focus on helping families, not breastfeeding rates.
This blog was adapted from a thread on Twitter.