A nurse I was discussing this with said something like the following:
"If you tell a mom that formula is not as good, and she decides to formula
feed anyway, then how has she started life with her baby?  By making 'the
wrong decision'.  What kind of a way to start out with her new baby is that?"

I was interested that she put it that way and it did help me see where she
was coming from.
I disagree *entirely* with her conclusion, which is that she really doubts
whether moms should even be informed that formula-fed babies are less
likely to be fully healthy than breastfed babies.  The same old "keep it
positive" spin.  In the same conversation I used the phrase "formula-fed
babies are less likely to live through their first year" and the other
nurse I was talking to had a fit -- mainly because she was afraid I'd say
this to a formula-feeding mom.  Now this is a key point.  Who was I going
to say this to, and in what settings?

It's not as clear-cut as we sometimes say it is.  It is patronizing and
wrong-headed to withhold information because one is afraid it will make
somebody feel bad.  But I actually do not agree that people's feelings
about what you say to them are their own business entirely.  Deliberately
wounding and hurtful comments will cause pain, and I think it's unfair to
put the whole burden of responsibility for those feelings on the
hearer.  When the remark is clearly unkind by pretty much any standards
that conclusion seems pretty straightforward to me (though I know that
people can & will argue the point).  What is more difficult is that "plain
straightforward pure objective facts" can also be presented in such a way
as to cause pain or resentment or resistance, and those feelings will be
justified and long-lasting.

People will say "all I did was tell her the truth".  But a recent post
brought up the question: when a smoking mother *has borne* a sickly small
baby, do you then tell her "see, this is what smoking does"?

Try this one: "folic acid prevents neural tube defects like spina
bifida".  You can write this on cereal boxes, say it in prenatal class,
teach it in nutrition classes, and even wear a placard or a t-shirt saying
it if you like.  But who on earth would walk into the hospital room of a
woman who'd just delivered a baby with spina bifida and say, "if you'd
taken your supplements this might not have happened"?

We all know breast is best.  Is there any earthly use in stressing that
point with a pregnant woman who has had a bilateral mastectomy?

Information has to be implicitly or explicitly requested or accepted
beforehand, like in a class, an office visit, a clinic or a La Leche League
meeting or call.  There has to be a good chance the recipient can make use
of it.  And the facts have to be presented respectfully and with a due
regard for the listener's situation.

Two more examples.  "Breastfeeding can prevent breast cancer both in the
mother and the baby daughter."  Would you *volunteer* this information to:
--a childbirth/breastfeeding class
--a woman with a family history of breast cancer debating whether or not to
breastfeed her baby girl
--a breast cancer survivors group
--a woman who bottle-fed her babies and has just learned that she has
advanced breast cancer
--her husband at her funeral
In some of those settings the statements is appropriate, empowering, and
may save lives.  In others it would be cruel.

How about "bearing children and having them before age 30 can help prevent
breast cancer".  I think we agree that it's a woman's own business to
decide whether to have babies or when to start her family, based on a lot
of considerations.  It's appropriate for her to know this fact while she's
young, but are you really going to make that point to a cancer patient who
never had children or whose babies were born after she was 35?  Thanks a
bunch, right?

A couple in childbirth class or contemplating a c-section had better be
told there's a fourfold increased risk of maternal death associated with
c-sections.  Again, it would be remarkably heartless to repeat the fact to
the widower if things went wrong.

This is why we try to make important information widespread and a part of
the fabric of daily life (like the folic acid) -- so that it reaches
everyone *before* they need it.  There can come a time when for a
particular person, it is too late.  Information disseminated generally is
not considered to hurtfully target these people.  A woman whose baby has
spina bifida may wince every time she reads her cereal box, but no one
argues that the information should be withheld from the general public to
protect her.

***This is why we have informed consent.***  So that no one needs to learn
for the first time after it's too late what they should have known
beforehand.  So that we can safely proceed on the assumption that a
person's decisions were made in the presence of all the relevant and
important facts.

So I believe there's a window of opportunity for presenting information in
a way that empowers people to affect their own and their babies' health,
but that once that window has closed, the very same facts if insensitively
presented will come across as reproachful and unkind.  If we ignore that
distinction, then people talking about guilt will feel we aren't hearing them.

Many people have noticed that in discussions of guilt, the guilt at issue
is often really that of HCPs.  How is anyone to come to grips with being
told something that means "you have given inadequate or misleading
information to patients and this has probably led to the illness and even
death of several children"?  What a horrible thought.  But if we can say
"helping mothers breastfeed will save health and lives" then the opposite
is certainly also true.
I think the only way to tackle that is to look ahead.  Again, after the
fact is too late.  Blame and reproach are dead ends.  How do we make it
clear that we are not dwelling on the past but trying to give doctors and
nurses and grandmothers and neighbors the facts that will enable them to
help young mothers *from now on*?

Elise
LLLL, IBCLC
New Hampshire

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