This paper, ‘Perceived pressure to breastfeed negatively impacts postpartum mental health outcomes over time’, was sent to me by someone I love and respect. They thought that as a clinical psychologist, I would be impressed by it. Having discussed with them why I see this as yet another another example of psychology gaslighting women, I thought I’d share my thoughts here too.
The paper begins with a list of benefits of breastfeeding. It cites, as ever, poor quality studies on which firm conclusions cannot be drawn. Not a good start! One benefit listed is that ‘successful breastfeeding journeys also provide mothers with feelings of accomplishment and connection’. The paper states that ‘even’ women from disadvantaged backgrounds ‘know’ breastfeeding to be best for their baby and assumes that there are many ‘complex’ ‘barriers to breastfeeding’.
What do they mean by ‘barriers to breastfeeding’? They say that over 70% of women experience breastfeeding difficulties, including pain, supply issues, fatigue and excessive crying [aside: might this be hunger?], which can lead to stopping breastfeeding and to ‘negative maternal mental health symptoms’.
Someone not ideologically captured to believe that breastfeeding is all benefit and no risk might say these ‘barriers’ are simply adverse effects associated with breastfeeding – risks of breastfeeding that outweigh any so-called ‘benefits’ for a great many families. The researchers do say that ‘positive mental health outcomes’ associated with breastfeeding are often interpreted as breastfeeding improving mental health, when they may in fact reflect mothers’ reactions to meeting societal expectations. But don’t hold your breath – it’s downhill from here.
Various ways in which breastfeeding has been ‘promoted’ are outlined: restrictions on formula marketing (including messaging on packaging that breastfeeding is superior); campaigns with tag-lines like ‘breast is best’ and ‘babies were born to be breastfed’; making hospitals more ‘breastfeeding friendly’ (removing the option of a newborn nursery for mothers who want to rest, locking up formula, or insisting parents who want to formula feed bring their own, and keeping information about formula from public view).
The researchers then hypothesise that all of this may result in ‘perceived’ pressure to breastfeed! Perceived?! They suggest that this ‘perceived’ pressure might lead to guilt and self blame. They argue that this is important because maternal mental health is a predictor of healthy child development and that increased stress can reduce breastfeeding capacities. Yes, you read that correctly: women’s emotions must be managed for the sake of their children and to maintain their breastfeeding capacity! And, by the way, most of what they describe are not symptoms of mental illness but perfectly ordinary human emotions.
So, they carried out a series of questionnaires about infant feeding and mental health outcomes. The participants were New Zealand based mothers of new babies, recruited by social media and a poster campaign. They also did some qualitative interviews and an analysis (which doesn’t seem to be especially hypothesis driven, nor based on a coherent psychological theory of anything, but there we go).
Surprise, surprise, they found that women did indeed experience ‘perceived’ pressure to breastfeed. They found that ‘perceived’ pressure to breastfeed was associated with anxiety symptoms, birth trauma symptoms and stress, but not depression or suicidal feelings.
Personally, I don’ t think it sensible to suggest that pressure to breastfeed (perceived or otherwise) causes stress, anxiety or birth trauma, but it might. It may also be that heightened stress, anxiety or traumatic experiences may increase focus on breastfeeding. Or, it may be that those struggling most with breastfeeding feel the most under pressure to continue, and consequently are the most stressed and anxious. Breastfeeding difficulties, such as pain, exhaustion, underfeeding and a screaming baby are, after all, horrible to endure.
They analysed the commentary they got from mothers thematically, developing four themes. Here is their interpretation of what women said to them:
Theme 1: ‘narrative of breast is best means that other options are bad and harmful’. Examples include a woman being told by a lactation consultant that baby formula is ‘equivalent to KFC’ (even though it had been recommended by a doctor) and another being told by a midwife that if you don’t breastfeed you won’t bond with baby and that your baby will be sick more often. So, can we talk about this word ‘perceived’?
Theme 2: ‘“I felt like it was my only choice.” Breastfeeding trumps mothers’ right to respect, informed consent and personal choice’. Women reported not getting information about all options and being pressured to breastfeed after a traumatic birth. Examples included healthcare professionals arguing with women to let their babies latch when they had decided they only wanted to express, midwives bringing up breastfeeding at every visit, even when it had been made clear that a woman didn’t want to do it, and denying access to formula when requested in hospital.
Theme 3: ‘“I would be a failure if I did not breastfeed.” Breastfeeding as inherent to motherhood identity’. One woman told the story of not breastfeeding and being asked by her healthcare professional ‘What, not even the colostrum?’ Another talked about feeling guilty about her own food choices and impact on the baby when she was breastfeeding and another spoke of feeling disappointed at not being able to establish a full milk supply. Many reported feeling that breastfeeding difficulties reflected something about themselves as a mother.
Again, can we talk about that word ‘perceived’? May we remind you that it was midwives telling some of these women that if they did not breastfeed, they would not bond with their babies and would expose them to more risk of illness!
Theme 4: ‘“I’m the only one that can do it.” Environment of isolation and struggles’. Women reported finding breastfeeding difficult, exhausting and stressful and having to keep any formula feeding secret and be discrete when breastfeeding. Participants discussed the huge toll of breastfeeding on their mental health. Here is one example: ‘I was in tears every time I needed to feed them. And then I was supposed to go and pump afterwards to build my supply. I could barely eat food or sleep during the first few months, it felt like an impossible task to also breastfeed’.
This is what is often called ‘triple feeding’. When I first heard about ‘triple feeding’ from a dear friend who had done it, I felt the blood drain from my face. This is an obvious act of torture that no human being could or should endure. Unbelievably, though, it is a NICE recommended practice if a baby is struggling to gain weight.
The analysis leads the researchers to conclude that some healthcare professionals try to encourage breastfeeding in ways that are idealistic and contributing to an unhealthy mental perspective. They decide that these ideals might contribute to increased rates of mental health difficulties in those reporting ‘perceived’ pressure to breastfeed. They make three suggested recommendations:
1. ‘We need to provide balanced scientific information on all feeding practices’. Do we need to remind you that their own paper misrepresents scientific evidence, suggesting far greater benefit for breastfeeding than the literature suggests?
2. ‘Informed feeding choices should be respected and supported by all health professionals’. What a banal recommendation! A far more interesting question, in light of their own data, would be to ask: why are healthcare professionals acting in such bullying, coercive and cruel ways?
3. ‘Individualised breastfeeding support in particular should be the intervention of choice’. This sounds lovely, but here the researchers fail to contend with a reality: there are currently no evidence-based interventions for any breastfeeding problem! They exhort healthcare professionals to ask what women need to ‘reach their feeding goals’. The idea of ‘infant feeding goals’ is one of the most bizarre concepts that has arisen in recent years, always seeming to overlook the most important goal: feeding the baby!
These researchers are especially keen on what they call ‘counselling interventions with a support element’ in order to ‘increase breastfeeding rates, improve child development and improve maternal mental health’. What does this mean? Based on a systematic review that they reference, these ‘counselling interventions with a support element’ include telling women about the importance and benefits of exclusive breastfeeding and how to manage problems. So, wait, aren’t we back to where we started?
Is it surprising that bullying and coercing women to breastfeed and insisting they exhaust themselves with torturous feeding regimes is not good for mental health? Is it any more surprising than a nosebleed when someone punches you in the face? You don’t need to worry about punch-inducing nosebleeds if you don’t go round punching people in the face! Unfortunately, these psychologists have made the false assumption that healthcare providers are making ‘incorrect interpretations of the Baby-Friendly Hospital Initiative’. The problem is the reverse: the guidelines were accepted and followed with enthusiasm.
What we need to understand is how our healthcare professionals and public health systems around the world have come to act so cruelly towards new mothers and babies, all while genuinely believing they are doing the best thing for our babies. Psychologists should know this. We understand conformity, obedience, authoritarianism and how good people can find themselves doing terrible things. However, these researchers, like so many others before them, focus on women’s emotional reactions, not on bullying and coercive healthcare policy. But it is not women’s feelings that are the problem. It is the policy.
This blog was adapted from a Twitter thread. Follow us to join the discussion.
Ruth Ann Harpur