Why we still need to “Watch our language”

One of the family medicine physicians here at UNC wants to make sure doctors-in-training know the facts. “There are no benefits of breastfeeding,” he tells his students. “There are risks of formula feeding.”

Logically, these two statements are identical, but they feel completely different. In 1996, Diane Wiessinger spelled out the issues beautifully in her classic essay, ‘Watch your language.” Cathy Theys posted it on ABM’s Facebook page Friday. It’s a must-read for anyone who cares about mothers, babies and breastfeeding. Wiessinger writes:

Best possible, ideal, optimal, perfect. Are you the best possible parent? Is your home life ideal? Do you provide optimal meals? Of course not. Those are admirable goals, not minimum standards. Let’s rephrase. Is your parenting inadequate? Is your home life subnormal? Do you provide deficient meals? Now it hurts. You may not expect to be far above normal, but you certainly don’t want to be below normal….

When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a “special bonus;” but she may clamor for help if she knows how much she and her baby stand to lose. She is less likely to use artificial milk just “to get him used to a bottle” if she knows that the contents of that bottle cause harm.

A decade and a half later, we’re still talking about the “benefits of breastfeeding,” as though breastfeeding were an optional extra credit assignment for over-achievers, rather than the biologic norm. And yet, I find my voice straining when I use my colleague’s rhetoric, “There are no benefits of breastfeeding.” It’s harder to get the words out than you might think. When I lecture to medical students and residents, my first slide presents the risks of not breastfeeding, but I still feel like I’m apologizing. What if one of the women in my audience couldn’t breast-feed? Will I make her feel guilty?

Wiessinger’s essay takes on the widely-accepted dogma that counseling on the ‘risks of formula feeding’ will make mothers feel guilty:

Most of us have seen well-informed mothers struggle unsuccessfully to establish breastfeeding, and turn to bottlefeeding with a sense of acceptance because they know they did their best. And we have seen less well-informed mothers later rage against a system that did not give them the resources they later discovered they needed. Help a mother who says she feels guilty to analyze her feelings, and you may uncover a very different emotion. Someone long ago handed these mothers the word “guilt.” It is the wrong word….

Let’s rephrase, using the words women themselves gave me: “We don’t want to make bottle-feeding mothers feel angry. We don’t want to make them feel betrayed. We don’t want to make them feel cheated.” Peel back the layered implications of “we don’t want to make them feel guilty,” and you will find a system trying to cover its own tracks. It is not trying to protect her. It is trying to protect itself. Let’s level with mothers, support them when breastfeeding doesn’t work, and help them move beyond this inaccurate and ineffective word.

In fact, I’ve come to realize that physicians and policy makers cover all manner of sins with the “don’t make her feel guilty” mantra. If we accept that breast is best, but formula is fine, then we’re off the hook when we don’t know how to advise a breastfeeding mother, when we send her home with a duffle bag filled with formula samples, or when we maintain pitiful maternity leave policies that undermine her efforts to sustain breastfeeding. If breastfeeding is extra credit, then it’s up to mom to over-achieve. The rest of us are off the hook.

We need to talk about the “risks of formula feeding” so that we hold policy-makers and health care providers accountable. The “Booby traps” are more than a clever pun: they are a public health problem that’s undermining the health of women and their children.

What about moms who don’t want to breastfeed? When I meet a mom for the first time, I start the conversation by asking, “What have you heard about breastfeeding?” At a recent prenatal visit, my patient scrunched up her face and said, “I’ve heard you’re supposed to do it because it’s good for the baby.” I asked her why she was wincing, and she told me that she has really sensitive breasts, and she’s afraid that nursing will be painful, but she knows she’s “supposed to breastfeed.” We talked for a bit about early feeding and strategies for getting a comfortable latch. I shared with her the data on the risks of not breastfeeding, from more ear infections, diarrhea and pneumonia for baby to more diabetes, hypertension, heart disease and breast cancer for mom.

And then I reminded her that this is her decision. She can breastfeed in the early days, see how it goes, and then decide whether, for her, the pain that she’s anticipating outweighs the risks of formula feeding. If she cringes every time she feeds her baby, breastfeeding may be considerably worse for her and her child than formula feeding. She is the only one who can make a trully informed decision about how she should feed her baby. My goal is for each of my patients to be able to state, in a concise and clear fashion, “I decided to feed my baby this way because… ” It’s uninformed decisions, not well-informed decisions, that lead to guilt and regret.

And when lactation doesn’t work? That’s another blog post, but we still need to watch our language. If we talk about breastfeeding benefits, then breastfeeding is an add-on, not a fundamental part of female reproductive health and wellbeing. Loss of normal function implies a disease that requires treatment. Loss of “optimal” physiology does not.

So read Diane’s essay, and then practice — in front of the mirror, if it helps. “There are no benefits of breastfeeding. There are risks of formula feeding.”

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine.