Kathy and Heather,

Thank you for taking the time to say, (Kathy) in such a poetic way, 
why you believe that the mother's mental and emotional well-being is 
more important to you than the baby's health.  And thank you Heather 
for sending in your thoughts and especially for asking in what 
context and to whom we would ever say 'the
baby's health (ie the contination of breastfeeding) is of such 
over-riding importance that it should continue even at the expense 
of  the mother's emotional well-being'

At one time I was the co-coordinator of the WABA Task Force on infant 
nutrition rights and I've explored the maternal breast-bottle 
decision with a lot of people.  So I do realize that you express very 
commonly held attitudes.  It's always very seductive to think that 
the mother's interests come first, and the human rights people can 
become quite exercised at any suggestion that a mother might be 
_forced_ to allow her baby once born, unlimited access to her body. 
But the perspective that breastfeeding could be harmful to the mother 
is interesting. I think most of us would agree that in fact 
breastfeeding is a lovely way to nourish and nurture a baby. The work 
of Nils Bergman and James McKenna suggest that it's essential to the 
future well-being of the individual.  It's likely that most of us on 
Lactnet have ourselves known how fulfilling it can be.  So when we 
advocate for breastfeeding, it's not as if we're suggesting that the 
mother should make any heroic or painful self-sacrifice. Yet, 
maternal discomfort/distress seems to be one of the prime reasons for 
advocating for the mother's choice to be paramount.  In fact, the 
argument for the mother's right to formula-feed often hinges on the 
apparent belief that breastfeeding can cause serious (negative?) 
emotional issues for the mother.  I'd put it to you that this may 
well be the case in western cultures, but that it's a _cultural_ 
construct.  Conversely, in the six African countries that I lived in, 
breastfeeding is seen not only as a necessary duty of a mother 
towards her baby, regardless of her circumstances, but also as a 
privilege.  Not only is she proud to breastfeed; she wants everyone 
to _see_ her breastfeeding.  I had a client once whose prem baby was 
too small/young to actually feed at the breast, and her in-laws were 
horrified and her husband eventually divorced her.  So an African 
mother's status in her society is elevated because she now has a 
child and she breastfeeds. The child - as UNICEF so often exhorts - 
is placed at the centre of the decision.  And, as a result, the 
African baby's chances of survival are greatly enhanced because his 
mother breastfeeds and because not to breastfeed is unthinkable.

In a similar vein, it's suggested that a mom with desperate 
post-partum depression might also need to wean.  Yet we now have 
research to show that weaning may aggravate postpartum depression by 
causing prolactin levels to plummet (the body thinks the baby 
died).  So while the mother may feel that she cannot cope with the 
physical demands of the baby to be breastfed and this adds to her 
existing distress, again it's a cultural attitude often peculiar to 
western societies that says a mother has a duty (usually not framed 
as a choice) to keep a home running, look after a husband, go to 
work, shop, cook, clean etc. but that when breastfeeding a baby is 
too much for her she can, and indeed should, jettison that 
duty.  What does it say when we - who know more than anyone else, 
about how to breastfeed, and the health consequences of not 
breastfeeding - agree with this mindset??

I'm sorry, but this way of looking at the "rightness" of the maternal 
infant feeding choice doesn't make sense to me.  It certainly 
reflects the attitudes and cultural norms of those of us living and 
practising in western societies, and our friends in industry promote 
and indeed exploit the notion of the appropriateness of the choice 
not to breastfeed.   But infant survival rates would plummet if we 
accepted that this was a universal human right.  In fact the first 
principle of the IBLCE Code of Professional Conduct reads, "Provide 
services that protect, promote and support breastfeeding."   It's 
simply not possible for us to know what we know including the ability 
to distinguish between maternal lactational incapacity vs maternal 
idealogical choice, to provide sufficient information to mothers to 
enable them to make that choice, and still wholeheartedly publicly 
condone a choice not to breastfeed. We know when a mother is 
flanneling us, she might fool her friends when she says she can't 
breastfeed because she kept getting mastitis, but we know when the 
cart goes before the horse... and when mastitis is more likely...

For bottle-feeding to take hold it must be easily accessible and 
socially acceptable.  And both conditions are alive and well in our 
affluent western societies.  Several years ago, a very learned and 
respected lady at UNICEF told me that only 7.5% of babies were born 
into countries where formula-feeding was seen as normal.  So we could 
conclude that, in global terms, bottle-feeding is a "traditional 
harmful practice" of the minority (as described in the Innocenti 
Declaration) and while we need to respond respectfully to every 
mother's cultural beliefs, we also have a duty to do our best to 
modify practices that actually have the potential to cause real harm.

I believe that we need to be respectful and gentle with our 
individual western-world mother-clients.  When I work with a mom who 
clearly cannot stand to have her baby near her breast (for whatever 
reason), I'll start talking about the possibility of providing 
exclusive expressed-breastmilk-feeding and explain exactly how she 
can feed her baby her own tailor-made milk without breastfeeding 
direct.  I may have had African clients who were also sexually 
abused, but the stigma of _not_ breastfeeding overrides everything 
for them - once again, this is a cultural consequence to a universal 
phenomenon.  When I have a mother who says to me "I know breast is 
best, but....." and then explains that she has some other pressing 
commitment which she herself sees as more important than her baby's 
health, and even after exploring all the options she still wants to 
wean, then I'll help her to do it as safely and as slowly as 
possible, and praise her for the 2 days or the 2 weeks or the 2 
months that she did actually breastfeed.  But if I'm dealing with 
this controversy in the abstract (on Lactnet or elsewhere) or 
reviewing a policy, or writing an article, I'll make it clear that 
breastmilk and breastfeeding are crucial for the health of babies 
everywhere.  And actually that's not difficult because we have whole 
libraries full of research to show that that's a fact.

We are shaped by our experiences, of course. I'm guessing that many 
of my colleagues are highly influenced by living somewhere where more 
babies are bottle-fed than are breastfed.  Now that I live somewhere 
like that too I can see how it could easily happen.  And the Similac 
people would really like us to believe that the choice of feeding 
method really is less important than that we respect each other's 
choices. My work on the controversial topic of HIV and breastfeeding 
has shown me that even those who write the policies use western 
language and western attitudes as the norm and are not immune to 
ethnocentrism.  But I'm grateful that I've lived and worked in a 
place where breastfeeding was recognized as a necessity and _not_ 
portrayed as a choice, and where mothers in the maternity units were 
absolutely _not_ given the option of formula-feeding their 
newborns.  Eventually due to political turmoil, there was simply no 
formula in the shops (which is extremely scary) and I had what I felt 
was the duty of literally _begging_ the mothers in my antenatal 
classes to exclusively breastfeed because if they didn't, then their 
babies would starve.  Then we spent the rest of the class talking 
about exactly how to make enough milk and how to most effectively 
deliver it to the baby. This time was an incredible eye-opener for 
me.  Not one mother in those few months called me due to 
"not-enough-milk", they were all happy to work through the sore 
nipples, and all the other little teething difficulties which 
apparently can become insurmountable when there's the choice to quit 
staring you in the face. I wouldn't have believed that it was so easy 
if I hadn't seen it.  The glaring difference - the factor that I wish 
I could bottle and sell - is "maternal motivation".  And maternal 
motivation is partly influenced by the culture and partly by the 
information that _we_ as IBCLCs or as breastfeeding counselors give them.

We live in an artificial situation, in such a privileged environment 
that we can afford to feed our babies a sub-standard food and still 
have them survive.  This provides mothers, and those of us who work 
with them, the illusion of empowerment.  The inherent risk to the 
babies in this situation is always exposed when we have a natural or 
a man-made disaster.  To me, the universal biological reality will 
always be that during gestation the baby grows his own means of 
continued survival after birth and that were it not for all our 
layers of civilization, to deliberately withhold breastmilk is 
somehow pathological. And why?  Because ultimately, to come full 
circle, breastfeeding is a lovely thing to do - why *wouldn't* you 
want to breastfeed?

When we didn't know the difference, it was perhaps excusable to tell 
mothers that they could choose between the real thing and a 
nutritionally/immunologically inadequate substitute.  But according 
to Ruth Nduati, the Nairobi researcher who oversaw the only 
randomised controllled trial ever conducted on breastfeeding vs 
formula-feeding in the context of HIV, the ethical promotion of 
infant feeding choice is only permissible in a balanced state of 
ignorance.  I believe that we know too much. We can't be accountable 
for mothers' decisions, but we _can_ consider whether playing nice by 
agreeing that they always make the right decisions is entirely 
appropriate. Or whether it's our own knowledge that places on us the 
duty to help mothers _breastfeed_ and to contest the ideology of the 
acceptability of maternal infant feeding choice wherever we find it.

Lastly, I'd like to also thank my colleagues who wrote privately :-)

Pamela Morrison IBCLC
England, formerly Zimbabwe.

At 05:00 06/02/2015, you wrote:
>Date:    Thu, 5 Feb 2015 17:02:30 -0500
>From:    Kathy Lilleskov <[log in to unmask]>
>Subject: Re: Feeding Babies and Green Hair
>
>I have to say that in my opinion nothing trumps the emotional 
>well-being of the mother. I consider it the most important thing 
>contributing to the future health of any child. If a mother is 
>troubled by breastfeeding to the point of it causing serious 
>emotional issues for her, then she may have to wean and it is our 
>job to support her through this decision and process. In my ten 
>years of private practice, I have had to help a few mothers wean for 
>their own mental health. It was intense work. It was sad work. And 
>it was important work. To help a mother do something which she knows 
>might have negative consequences for her child, so that she can 
>become healthy herself and mother her child, can actually be 
>ultimately more important than helping another mom through her 
>temporary sore nipples or supply issues.
>
>I completely disagree that I, as a private practice lactation 
>consultant, am there as an advocate for the baby. I have been 
>invited in by the mother, to help her achieve her goals. I am 
>walking through the door with her permission. I am there because she 
>is seeking someone to help her achieve her goals. If I were walking 
>through the door to advocate for the baby then I am there to achieve 
>my goals. That is not what she understands her relationship with me 
>to be, nor why she let me enter her home. It is my job to help her 
>figure out what she feels she needs and how I can assist her. Many 
>times when I walk through that door, I am informed by the mother 
>that I am her last shot before weaning. And more often then not, we 
>find a way to continue nursing that works for her. I just got a call 
>from such a mom this morning and she is still going strong at six 
>months after we sorted out her issues five months ago. She was 
>teetering on the brink of weaning, in emotional turmoil. We found a 
>path for her and she is passionately in love with breastfeeding at 
>this point. That call made me feel wonderful.
>
>It is different feeling that I get when I help a desperate mom with 
>a postpartum depression to wean. I don't think that I would describe 
>the feeling as wonderful but knowing that I am easing her crisis a 
>bit by forging a connection based on knowledge and  kindness and 
>empathy with this woman, is also a very special feeling. It is 
>indescribable. I know that I am doing something to help shine a 
>light into the darkness encompassing this mother and baby. Nothing 
>in the world is more important than the need a baby has for the 
>light that emanates from a mother's heart. Nothing.
>
>Kathy Lilleskov RN IBCLC
>Brooklyn NY


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