Whose Guilt is it Anyway?

Roll up, roll up! This evening we review another paper looking at guilt and shame in infant feeding by researchers at Liverpool University.

The paper starts, as most papers in this field do, with a recitation of the WHO creed that breastfeeding has, like, a million health benefits, and six months of exclusive breastfeeding is recommended and then breastfeeding for two years alongside other foods… Fear not: this paper will commit no heresy!

But alas, alack, very few families follow the recommendation, so it is important, say the researchers, to explore barriers. Hang on, guys! Are you framing guilt and shame as barriers to breastfeeding?! They claim that widespread understanding of the benefits of breastfeeding (or as we call it, ‘widespread misunderstanding of the current evidence regarding the health effects of infant feeding methods leading to grossly inflated perceived benefits of breastfeeding’) leads to guilt and shame for those who do not breastfeed. They cite a previous systematic review of the so-called ‘Baby Friendly’ Initiative in the UK, which suggested that current practice fails to prepare parents for ‘breastfeeding challenges’ and may contribute to guilt for those who do not overcome them.

But the authors don’t clarify what they mean by ‘breastfeeding’ challenges. Are they talking minor inconveniences? Or do they mean major pain, severe sleep deprivation and insufficient milk intake leading to clinical complications for newborn babies? They also do not note that there are currently no evidence-based solutions for common breastfeeding problems. (Well, not quite none. Several clinical trials have found supplementation of breastfeeding with infant formula reduces neonatal jaundice and newborn hospitalisations.)

They look at how the literature defines guilt and shame. They point out that most studies don’t define either emotion, often referring to feelings as ‘guilt’ that would more accurately be defined as ‘shame’ (e.g. seeing oneself as a bad mother). They set out to clarify the concepts of guilt and shame in relation to infant feeding by identifying the ‘Antecedents, Attributes and Consequences’ (AACs) of guilt and shame, with the aim of developing more ‘workable academic definitions’.

Then the researchers jump the gun. They suggest that if there were better definitions of guilt and shame, healthcare providers could identify ‘antecedents and attributes’ of guilt and shame and offer help to women who are experiencing them to prevent the consequences (they don’t define what they mean).

They identify not being able to breastfeed as leading to guilt and subsequent evaluations of self as failing to do the best for one’s baby. (We contest that this is shame, not guilt, because it involves the evaluation of the self as a failure). They argue that previous research has identified that guilt leads to reparative action – if you do something bad, then guilt motivates you to rectify and repair. Say, you eat your kids’ chocolate buttons, you feel guilty and buy them more (not that we would know). So how do mothers make reparation for our guilt about not breastfeeding, according to infant feeding researchers? Apparently, we defend ourselves and get angry with healthcare professionals.

Yes, really. They, along with other researchers in the field argue this. There is no evidence for it. The author of this blog is an experienced clinical psychologist and thinks this is waaay over-interpreting and simplistic. It tells only one story that women are defensive and angry. And we don’t hear defence. We hear women not allowing ours and our babies’ experiences of harm as result of breastfeeding attempts and breastfeeding promotion claims to be hidden. We hear women demanding that we, our babies and those who will share our experiences in the future are not ignored. And yes, we hear anger.

Of course we are angry. We are angry that current healthcare policy failed to meet our needs, that it failed to ensure our babies were fully nourished, that it failed to even acknowledge our physical and emotional needs. This anger is not driven by guilt. It is fierce compassion for ourselves, our babies and our families finding a voice. Such interpretations cannot be proven empirically, but we can and do speak from our own experiences and ask that researchers try to be more interested in understanding us than in interpreting us. But we digress…

The authors then go on to give examples of shame, including negative evaluations of self in reaction to breastfeeding challenges and as a reaction to breastfeeding in public. They suggest that shame arises from the perception that breastfeeding has benefits to health and attachment (i.e. the mother-baby relationship), personal goals and breastfeeding promotion. They identify fears about the health impact of formula and fear of judgement as contributing to guilt and shame. Although it should be noted that the research they draw on in does not well define guilt and shame and it is not sufficient to say what causes what.

They also talk about dissociation from one’s maternal identity as a consequence of shame (they don’t define ‘dissociation from maternal identity’) and suggest this manifests as low self-confidence in response to negative comments about breastfeeding in response to unanticipated breastfeeding challenges. They identify depressive symptoms in response to shame in mothers who formula feed, thinking they have not done ‘best’ by their baby. They also identify avoidance of parenting classes and hiding formula bottles from healthcare professionals as shame responses. They identify humilation as a consequence of manipulation and objectification of breasts by healthcare professionals attempting to facilitate breastfeeding (i.e. when we are touched inappropriately and manhandled by healthcare providers.) They conclude the following definitions of guilt and shame (but bear in mind, this is based on researcher interpretations of data where the concepts are ill-defined):

We don’t think there is sufficient data to build an overarching model of what factors contribute to guilt and shame in response to infant feeding experiences. We also don’t think there is data to say what would be helpful to women experiencing difficult emotions in response to their infant feeding experiences. We think they are probably right that not providing information about formula exacerbates guilt and shame. However, let’s not forget, current policy does not allow information about formula on public display or formula feeding education in front of women who are breastfeeding, lest it ‘undermine breastfeeding’! Who knew that treating something like it is a dirty secret not to be mentioned in polite company might generate a stigmatising context, which leaves people feeling a lot of shame about themselves?

And they are probably right that failing to inform women about breastfeeding challenges is a disservice, but let’s be clear that breastfeeding challenges can be clinical complications that put women and babies’ health at risk. Our friend and ally, Dr Vera Wilde draws attention to these complications here.

They suggest open communication to work through breastfeeding challenges. We say: no! Let’s not assume challenges can be ‘worked through’. Remember, there is no evidence that anything prevents or alleviates common breastfeeding challenges. The goal should be feeding babies in ways that take care of the entire family’s needs, with no pre-judgement as to what method that will be: compassion, autonomy and safety.

Then they hand-wring about formula advertising leading to inconsistent feeding advice and misleading marketing claims (it should be noted that advertising first infant milk is not allowed in the UK). You guys, the so-called Baby Friendly policy is to not have information about formula on public display or demonstrated in antenatal classes! Current policy also misleads parents about breastfeeding challenges:

You cannot point the finger at formula companies for the failure of healthcare policy to provide sensible information to patients! And when it comes to misleading health claims, shall we look at what everyone says are the health benefits of breastfeeding? Shall we look at the total refusal to acknowledge breastfeeding complications, including insufficient milk intake leading to low blood sugar, jaundice and dehydration? Shall we look at adverse effects on mothers who experience significant pain, mastitis (in some cases leading to sepsis), stress and sleep deprivation as a result of breastfeeding? You can’t discuss balance without acknowledging these things!

Finally, on the basis of their data, they draw implications for clinical practice. Now, you have to remember that previous research has found that healthcare providers are not even managing to ensure parents know how to make up a bottle. Nevertheless, they propose these same professionals should be having discussions about ‘attributes and antecedents’ of guilt and shame to prevent negative maternal wellbeing outcomes:

In our opinion, this risks pathologising women’s emotional reactions to an infant feeding context that presents breast and formula feeding as being in opposition to each other, that generates stigma and shame and creates a heavily moralised context. Maybe it isn’t us you should be looking at…

Turn around. What is creating stigma, guilt and shame? Why don’t parents feel at ease to feed their babies in ways that meet their babies’ nutritional needs and foster a relaxed and sustainable family life? We don’t need to work through guilt and shame because they are barriers to breastfeeding! We need to be able to feed our babies confidently and to have assuredness in our decisions. For some of us, maybe even most of us, that won’t involve breastfeeding in accordance with WHO recommendations!

So, let’s talk guilt: guilt as a reaction to when we cross a moral boundary and do wrong; guilt as a driver to stop what we are doing, offer apology, offer reparation and restore connection; guilt, as a healthy and necessary human emotion. It shouldn’t be mothers feeling guilty. Let’s look at how healthcare providers, among others, have caused harm to us and to our babies. Let’s look at their guilt. Is there the courage to acknowledge it?

Is there the courage to acknowledge what thousands of us already know: that policies promoting exclusive breastfeeding landed our babies in hospital as a result of insufficient milk intake and that this is perfectly evident in the clinical and research literature? Is there the courage to not try to fix us and our messy emotions, including our anger, even when that anger is directed at you? Can you look at yourselves and acknowledge the role you have played in causing harm? Is there the courage to embrace guilt and allow it to move in the direction of compassion, to create a new healthcare policy and construct a new social context in which the needs of babies and families are put before breastfeeding rates? Is there the courage to make safe, comfortable and sustainable feeding the goal and to trust that loving parents are best placed to make good decisions for their families? Do you have the courage to trust us and let go of the need to tell us what you think would be best for us?

As angry as we might be, if the harm and the hurt is acknowledged without defence, you will find us very willing to build a better world of infant feeding for families.

This blog was adapted from a thread on Twitter.

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