Just in the interests of fairness I thought it would be a good idea to post this up.
Mothers are constantly urged to breastfeed yet there is little evidence to suggest that it is better than formula milk
In 1792, Mary Wollstonecraft said that women who did not suckle their babies “scarcely deserve the name of a wife, and have not the right to that of citizen”. Two hundred years on, the public health message on breastfeeding is no less heavy-handed.
Formula-fed babies are fatter, more stupid, more diabetic, they have more asthma, eczema, and chest and ear infections, to name but a few of their misfortunes listed in the NHS leaflets I was given repeatedly when pregnant last year.
The picture of these poor mites could not be more wretched. Under the weight of this advice from the Department of Health, doctors, midwives, and breastfeeding activists, millions of Western women bow their heads and unclip their Elle Macpherson Maternelle bras. After all, the medical establishment can’t be wrong, can it?
Dark thought at 3am, when one’s nipples feel like shards of glass . . . or can it?
Joan Wolf is an American academic who says just that. Her forthcoming book on breastfeeding in the West examines the medical studies in painstaking detail. Her conclusion?
“The evidence to date suggests it probably doesn’t make much difference if you breastfeed.”
She delivers this verdict like a cool statistician, but the impact of what she says is explosive. An article in an American magazine earlier this year that merely referenced her work caused an internet firestorm. The feeding of newborns provokes powerful feelings, and almost any discussion of the topic — as most mothers will realise — sets off emotional arguments in which many cannot agree to disagree. So I did not want to question the instinctive urge to nurse your own baby, but I did want to get to the bottom of the medical evidence.
That was why, after speaking to Wolf, I put her conclusions to one of the world’s leading clinical experts on breastfeeding. He shared most of her concerns. For someone who prolonged my breastfeeding more out of duty than desire, this made me feel slightly nauseous. Yet it also raises a bigger question as to how truthful the medical establishment is being with women. According to the experts to whom I talked, the information on my NHS leaflet was outdated, if not utterly misleading. Many women — the ones who feel that they jeopardised their jobs, marriages, or sanity for the boob — have a right to feel angry about that. First, Wolf. When she became pregnant with her first child in 2001 she was “subjected, as we all are, to all the advice about how much better breastfeeding is”. While already writing a book on feminism at Texas A&M University, she intended to spend “maybe a week” looking at the medical literature and to find out what all the fuss was about. “I was not sceptical when I went in,” she says. “I never questioned that breast is best.”
What she found left her profoundly shocked and led to her devoting a year and a half to “nothing but reading medical studies”, and analysing why breastfeeding is so uniquely contentious that even medical science becomes emotive. “The conclusion is that the evidence we have now is not compelling. It certainly does not justify the rhetoric,” Wolf says The problem with the studies is that it is very hard to separate the benefits of the mother’s milk from the benefits of the kind of mother who chooses to breastfeed. In the UK, for example, the highest class of women are 60 per cent more likely to breastfeed than the lowest, so it is not surprising that research shows that breastfed infants display all the health and educational benefits they were born into. But even if education, class and wealth is taken into account, there is known to be a big difference between the type of mother who follows the advice of her doctor and breastfeeds, and the one that ignores it to give the bottle. In other words, breastfeeding studies could simply be showing what it’s like to grow up in a family that makes an effort to be healthy and responsible, as opposed to anything positive in breast milk.
This effect is called “confounding”. The studies that show small advantages to breastfeeding generally have not adequately adjusted for it, and those that have tried their best to take it into account give far more equivocal results.
For Wolf, there is only one condition that is clearly reduced by breastfeeding: gastrointestinal infections. In the developing world, breastfeeding is of course life-saving for this very reason. But I am concerned solely with the West, where diarrhoea and vomiting are usually mild complaints of the nursery.
For all the other claims, there have been studies that show an association between breastfeeding and better health, which are championed, and studies which show no link, which are largely ignored. Some studies show an increase of a few percentage points in IQ, then more rigorous studies come along and comprehensively disprove that link. And so on. Even the studies that show small associations between, say, bottle-feeding and respiratory illness, do not, Wolf says, fully take into account other reasons why such a family may be more prone to infection.
In 2007, the Agency for Healthcare Research and Quality (AHRQ), the highly respected American government organisation, did the first large-scale review of breastfeeding research in the West. Its scientists were exasperated with the quality of the evidence, giving a strong warning that, because the breastfeeding mothers were self-selecting, “one should not infer causality based on these findings”.
So why do doctors and governments persist in telling us so stridently that breastfeeding is so medicinal? “We have ended up with a huge body of literature, all of it problematic,” Wolf says. “But the degree of repetition in the results persuades people that there is something there. So many studies start ‘the benefits of breastfeeding have been well-proven’ when they haven’t. It has become like a mantra. Doctors will say to me: ‘We have lots of evidence that breastfeeding is better.’ And my response to that is: ‘We have lots of evidence to show that it isn’t’.”
I looked back at my NHS leaflet, entitled Breastfeeding: the Best Start for your Baby. It was starting to look like a blatant piece of propaganda. The NHS told me that “women who breastfeed get their figures back faster”. The AHRQ review said that this effect was “negligible”. The NHS told me that breastfeeding protected against “weak bones in later life”. The AHRQ said that “there was no relationship”. The NHS told me that breast milk would “help your baby develop”. The AHRQ said that “there was no relationship between breastfeeding and cognitive performance”.
Confused, I decided I needed to talk to the person acknowledged as one of the world’s most authoritative sources of breastfeeding research: Michael Kramer, professor of paediatrics at McGill University, Montreal. He has advised the World Health Organisation, Unicef and the esteemed scientific body, the Cochrane Library, and been conducting research into the health effects of breastfeeding since 1978. I expected him to toe the establishment line. He did not.
“The public health breastfeeding promotion information is way out of date,” Kramer says. The trouble is, he said, that the breastfeeding lobby is at war with the formula milk industry, and “neither side is being very scientific … when it becomes a crusade, people are not very rational.”
But shouldn’t our doctors be the neutral arbiters in this situation? “They’ve been brainwashed by the breastfeeding lobby. Most of them don’t have time to go through the evidence, so they would rather side with the good guys.”
So, with my NHS leaflet in hand, I put its list of health benefits to Kramer. Does breastfeeding reduce a child’s risk of obesity? “The evidence is weak”, he says. Allergies? “Weak.” Asthma? “Weak.”
“There is very little evidence that it reduces the risk of leukaemia, lymphoma, bowel disease, type 1 diabetes, heart disease, blood pressure . . .”
That was nearly everything crossed off. What about maternal benefits? The NHS told me that it would protect me against breast and ovarian cancer, and osteoporosis. “The breast cancer data is pretty solid, but on ovarian cancer and osteoporosis it is far iffier.”
Kramer is, however, less radical than Wolf. He thinks that the evidence is pretty encouraging not just for stomach bugs but respiratory problems too. He is also in the camp that believes that breastfeeding will turn out to have a slight effect on brain development, maybe by three or four percentage points of IQ, although studies that factor out the mother’s intelligence now tend to show no link.Is he hopeful that the public health message will become a little more realistic about the supposed elixir that is breast milk? “No. Because people don’t like complexity.”
Kramer has established his own significant and continuing study in Belarus, one of the few to tackle the problem of confounding. The results are, as I have now come to expect, mostly equivocal. So much so that it has made Sydney Spiesel, clinical professor of paediatrics at Yale University’s School of Medicine, question his “instinctive” belief in the power of human milk.
In a news interview on the latest results from Belarus, Spiesel says: “For all the benefits that are touted around breastfeeding, when you do a really good study, it’s very hard to find the tremendously powerful benefits that people have been claiming.”
Back in Britain, I tried to find out who was propagating the unqualified claims about breastfeeding. The Royal College of Midwives told me that its evidence comes from the Department of Health. When I asked the Department of Health to justify the list of (what I now know to be highly questionable) “facts” in NHS leaflets, it said that they came from the World Health Organisation. The WHO pointed me to a review of the research it conducted in 2007. When I looked at this, it concluded that the long-term gains of breastfeeding were mostly “relatively modest”, and also warned that because none of the studies it looked at dealt with the problem of confounding, the results could be explained by the “self-selection of breastfeeding mothers”.
What does it really matter, though, if “breast is best” is a catchier slogan than “breast is probably only a bit better”? If claims are exaggerated, if women aren’t trusted with the truth, what’s the harm? I put this to Wolf.
“People never say ‘don’t take your baby on a car journey’, even though the risk of a car accident is far greater than not breastfeeding. But when it comes to a mother’s time, nothing we can ask is too much.
“Let’s think about what would happen if we asked fathers to do this, if there were somehow evidence that babies who are looked after by their fathers at home for six months do better. We would see a lot more critiquing of the science, a lot more people saying the benefit is marginal, a greater reluctance to offer the advice.”
And that is probably a truth about breastfeeding we can all agree on.