How often does breastfeeding just not work?

Jessica Isles posted a great question today on my blog, “When Lactation Doesn’t Work:”

I was wondering if any comparative studies have been done on the statistics of lactation failure in various cultures both developed and less developed. Please post if you are aware of any – or any statistics on how many women’s milk never comes in (in the US), with a healthy full term new born, in an environment supportive of breastfeeding. We need to help mothers who struggle with this.

That’s a great question – and a difficult one to answer. Marianne Neifert estimates that “as many as 5% of women may have primary insufficient lactation because of anatomic breast variations or medical illness that make them unable to produce a full milk supply despite heroic efforts.”   [Neifert MR (2001). “Prevention of breastfeeding tragedies.” Pediatr Clin North Am 48(2): 273-97.]

We are working on a research project to try to estimate the proportion of women in the Infant Feeding Practices Survey II who experienced unplanned, undesired weaning due to physiologic problems with breastfeeding. One challenge is what to call this condition. I’ve written a draft of the paper using the term “failed lactation,” but I don’t like it.  I have problems using the word “failed” to describe mothers who have gone to heroic lengths to sustain breastfeeding. We’ve also tossed around “lactation dysfunction” or “unwanted weaning,” but those don’t quite cut it either. I want a phrase that health care providers will take seriously and moms will perceive as a lifeboat in a storm, not as insult added to injury. My personal favorite is “Lactastrophe,” but I suspect that would not make its way into the medical lexicon. What do you think we should call it when lactation doesn’t work?

We’re also finding that it’s quite difficult to tease out the issue of “a supportive environment” vs biological problems with lactation. It’s a bit like trying to tease out how much of the type 2 diabetes epidemic is caused by “biology” vs “the environment.”  Over the past two decades, the proportion of our population that is obese has sky-rocketed, in the setting of decreasing physical activity, ballooning portion sizes, neighborhoods without sidewalks, and worsening economic inequality and job insecurity. Some people who live in this country have developed diabetes, and some have not.  It’s likely that some individuals have a biological predisposition that makes them vulnerable, whereas others do not. Regardless of the precipitating factor, however, these patients need help to control their blood sugars.

Similarly, for lactation, there are some mothers who are blessed with ample milk supplies and with babies who are born with a championship suck-swallow pattern, and they would be likely to breastfeed successfully in just about any environment. And there are other dyads for whom one piece of bad advice or a nasty encounter with a stranger while breastfeeding in public is enough to throw lactation completely off track.  Furthermore, it’s likely that women who have been socialized to mistrust their bodies are more vulnerable to interpreting early feeding challenges as evidence that their bodies can’t sustain breastfeeding– and they are thus more likely to wean and attribute their decision to a physiological problem.

From a health and wellbeing perspective, however, I’m not sure that it matters whether we “count” both “biological” and “perceived” insufficient lactation together. The total burden of this problem is enormous, and mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support.  We need mothers for whom lactation doesn’t work to know that they are not alone.  And we need to demand research to develop the tools that will identify the underlying problems and allow us to implement the appropriate treatment.

We also need to step back from assertions that every mother can breastfeed, if she just tries hard enough. As Neifert has written, “The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.’ The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes.”

Lactation is part of normal human physiology, and like all other human physiology, it can fail. It’s time to stop bickering about whether this mom tried as hard as that mom to breastfeed. We have too much work to do.

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. She is a member of the board of the Academy of Breastfeeding Medicine. Posts on the ABM blog reflect the opinions of individual authors, not the organization a whole.