Shame, guilt and the search for common ground

In the fallout from the breastfeeding sibling study, I’ve been struck by the intensity of conversations about shame and guilt. A colleague and friend posted on Facebook:

This study is for my patients who have taken every tea, herb and drug to raise their milk supply, and are afraid to be seen in public giving their babies formula. They shun the social support they need from other mothers because bottle feeding has become so stigmatized. I see such relief on their faces when I tell them that they are outstanding mothers raising healthy babies, and am glad to have some evidence behind that.

A father commented on the ABM Blog:

I sat in pre-natal class with my wife as a bunch of women were given the implicit message that they were not real women or good mothers if they did anything but breast feed. And a lot of these women; young women, bought into that message wholeheartedly. I was appalled.

Others attacked the paper — and the conversations around it — for sugar coating the truth for mothers who formula feed:

Breast is best no matter what, now I understand there are mothers who have tried and fail. For medical reasons or another.But the truth is there is not that many. A lot of mommies make the choice to do formula over breastfeeding. But why should the breastfeeding community sugar coat the truth to spare a formula feeding mothers feelings by not saying the whole truth breastmilk benefits and nutrients far out way formula hands down. Except it firmuka mommies and companies we need to support mothers who can’t keep doing it find other options like donor milk from a fellow friend or a breast sister to keep this poison out of our babies bellies. I mean do you see cigarette companies saying smoking doesn’t really kill it just makes you sick. No they have to say smoking is harmful and we as adults have to make an informed choice. Which is what the breastfeeding community wants women to do. Do not just give formula because you hear it is the same as breastmilk because it is not even on the same playing field. It us like comparing apples to oranges IMO.

The study in question doesn’t actually speak to any of these concerns— Bimla Schwarz and I have blogged about the limitations of the analysis and its implications. Yet these issues of shame, guilt, autonomy and informed consent are crucial to understand and address if we want to improve health and wellbeing for mothers and infants.  There is tremendous anger and angst that poisons conversations about breastfeeding and prevents us from finding common ground.

This is bad for mothers, and it’s bad for babies.  In a compelling essay, Feminist Breastfeeding Promotion and the Problem of Guilt, in the book, Beyond Health, Beyond Choice: Breastfeeding Constraints and Realities, Erin Taylor and Lora Ebert Wallace note that conversations around breastfeeding inevitably involve discussions of guilt, but guilt may not be the correct term:

Our analysis of the feelings that women describe about feeding formula suggests that the dominant emotion may be more accurately described as shame. Much more damaging than guilt, shame involves the failure to live up to an ideal and the understanding of oneself as a lesser creature. Thus, it is the induction of shame, not guilt, that feminist breastfeeding promoters must resist.

The authors go on to distinguish between feeling of guilt and shame:

Guilt, then, is response to what one does, while shame is response to who one is. While Manion clarifies that “feeling guilty and feeling ashamed are not mutually exclusive,” we want to focus on the shame that these mothers’ experiences and comments suggest. They hold themselves up to a certain standard of motherhood and judge themselves as falling short, as failing.

In the last half century, breastfeeding has moved from an “alternative lifestyle” behavior to a centerpiece of health policy. That’s a huge win for mother and babies.  The breast-feeding world used to have to scream to be heard, and that required some rhetorical flourishes to get the rest of the world to pay attention.  Today, the First Lady’s signature initiative includes breastfeeding as a core strategy, and the CDC has funded a massive initiative to increase the number of Baby Friendly Hospitals.  To be sure, there are plenty of chasms yet to be bridged, but we are part of the conversation. And if we want to move forward, we must not poison that conversation with tactics that shame women who cannot — or decide not to — breastfeed.

I believe there is far more common ground than controversy — and that it is from this common ground that we will build a society that truly supports families.  I’ve been mulling, these past few days, whether we might be able to agree on some core assertions. Here are some thoughts on where we might start:

• Breast milk is different from formula, and breastfeeding is different from bottle-feeding.
• The preponderance of the evidence suggests that, on a population level, infant feeding is associated with differences in health outcomes for mothers and for their infants.
• Infant feeding is one of many determinants of health and well-being for mothers and infants. Mothers and babies who formula-feed are not doomed, and mothers and babies who breastfeed are not magically inoculated against all diseases for all time.
• Many of us have been parents, and all of us have been babies. Our personal experiences with infant feeding inform our opinions, actions and counseling.
• Every time a baby goes to breast, the formula industry loses a sale. The formula industry therefore spends billions of dollars marketing formula to breastfeeding families. These marketing efforts deliberately and systematically undermine a woman’s confidence in her ability to breastfeed.
• Mothers should have access to complete, objective, noncommercial information about what we know (and don’t know) about the risks and benefits of different feeding methods.
• All mothers should be encouraged to breastfeed, unless it is medically contraindicated.
• Maternity care providers should assess each mother’s knowledge of infant feeding, elicit her concerns, and provide individualized counseling so that she can make an informed decision.
• A mother’s decision about how to feed her baby should not be constrained by her life circumstances.
• Breastfeeding is not “free” — it requires a mother’s sustained time and effort over months to years of her life, whether she is nursing at the breast or expressing milk.  Calling it “free” implies that her time does not have value. Acknowledging the economic costs of breastfeeding to mothers and mitigating these costs can enable more women to breastfeed.
• Some women love breastfeeding. Some women do not. A mother’s personal experience of breastfeeding is important.
• The individual mother is the most qualified person to weigh these tradeoffs and decide what feeding method is “best” for her and her child.
• Shaming a mother for feeding her baby — in public or in private, whether at the breast or with a bottle — is unacceptable, and it should not be tolerated.
• Not all women are physically capable of breastfeeding. This has been true throughout human history. The statement, “All women can breastfeed,” is false. It is also harmful, because it implies that women who are not able to breastfeed are not women.
• Breastfeeding is a part of motherhood — it’s not the point of motherhood. If initiating or sustaining breastfeeding interferes with motherhood, it may not be “best.”
• A culture that protects the right of families to care for their children — with evidence-based maternity care, comprehensive support for new families, universal health care, paid maternity leave, high-quality childcare and a living wage — is also a culture that protects the right to breastfeed.
• Rather than squabble about the extent to which breastfeeding impacts biomedical outcomes, we should fight for the rights of mothers to decide how care for their children and enable them to do so, thereby improving health and well-being across two generations.

Let’s get started. What do you think defines the common ground?

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. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.