Giving women ‘constrained choice’, not real choice

Joan Wolf's new book is a brilliant broadside against the pseudo-scientific dogmatism of today's pro-breastfeeding lobby.

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In her book Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood, the American academic Joan Wolf challenges the widely accepted opinion that breastfeeding is medically superior to bottle-feeding.

Wolf argues that there is no reliable evidence that breastmilk provides babies with unique health benefits, or that formula milk is a risky substitute. Nevertheless, breastfeeding has become the ultimate expression of maternal dedication, with government bodies and the scientific and medical communities – not to mention many mothers – remaining heavily invested in the idea.

A public obsession with health, and with what Wolf calls ‘total motherhood’, have turned breastfeeding into a cause célèbre. But Wolf, writing about the American context, asserts that this has more to do with the infatuation with personal responsibility and perfect mothering than with any concrete benefits of breastfeeding.

In the US, as in Britain, there is a growing number of government-supported initiatives to increase breastfeeding rates. Programmes that promote ‘breast is best’ thinking have been set up in maternity wards and in health and social-service centres. To choose any other form of feeding your baby is presented as wilfully risky. For instance, Wolf gives the example of the National Breastfeeding Awareness Campaign in the US, which included posters of pregnant women log-rolling and riding bucking broncos, with the tag-line: ‘You’d never take risks before your baby is born. Why start after?’

This unequivocal official line on the importance of breastfeeding, and on changing maternal behaviour in order to increase its prevalence, is based on the claim that all the available scientific evidence points to the need for this approach. Policymakers strongly associate breastfeeding with strategies to address health issues as well as social problems. Breastfeeding is promoted as a route to better physical health in mothers and in future generations. Policymakers have also claimed that there is a strong association between social inequality and differential breastfeeding rates across social classes and so, the logic goes, social inequality will decrease if more women breastfeed.

In recent years, however, several scholars, including Wolf, have published research that tells an important story about how women are affected by the promotion of breastfeeding and the demonisation of formula milk. This research paints a less cut-and-dried picture of what the evidence suggests, especially when it comes to tensions between policy presumptions and mothers’ lived experiences. There are three main points that emerge from this research, and that provide the context for Wolf’s book.

The politicisation of infant feeding

Numerous analyses have detected a long-standing tendency to represent individual mothers’ behaviour in relation to infant feeding as an important cause of major health and social problems. And so intervening in mothers’ feeding choices is justified as serving a wider social good. In fact, infant feeding is a prime example of the tendency today to individualise social problems and to redress them through interventions in people’s personal lives, by correcting our habits, feelings and lifestyles.

As Wolf argues, this tendency needs to be seen as part of a larger conception of families as being ‘at risk’ or ‘in crisis’. The health and safety of children, for example, are increasingly seen to be compromised by a ‘toxic’ social environment. Where the family is ever more located as the source of, and solution to, a whole host of social ills – from poor educational outcomes to recidivism – parenting has acquired a particular place in contemporary society. The burden of managing risks is increasingly devolved to families, most notably mothers (1). Infant feeding is right at the apex of these trends.

The moralisation of infant feeding and mothers’ behaviour

There is great effort among policymakers today to avoid labels that might stigmatise mothers. Women who do not breastfeed are usually represented as ‘insufficiently supported’ rather than as selfish or ignorant, as they were in the past (2). Nonetheless, infant feeding has been turned into a moral enterprise. The idea that there is a ‘moral context’ for infant feeding is upheld by virtually all studies about maternal experience.

So, one study from 2007 suggests that a dominant theme in the qualitative literature on the subject is that infant feeding is often experienced by mothers as a moral issue, as a measure of motherhood (3). In a ‘breast is best’ culture it is perhaps not surprising that women who formula-feed struggle the most to defend themselves as ‘good mothers’ (4, 5).

The misuse of science and the restriction of women’s choice

Wolf’s book is a major contribution to the understanding of the use of science in breastfeeding policies and how they have changed the meaning of choice. Wolf refutes the persistent claim that breastfeeding improves health – a claim that has circumscribed women’s choice.

Policymakers say they empower mothers to make ‘informed choices’, yet that ought to involve providing women with fair and honest information about feeding alternatives in order to help them decide on a course of action. However, according to Stephanie Knaak, who has written on this issue in Canada, ‘choice’ in infant feeding-methods is no longer defined as something that is ‘actual’ – mothers are not really being presented with the option of deciding between two alternatives that each have their own benefits (6). There is, rather, a context of ‘constrained choice’, because the alternative to breastfeeding is predominantly represented in very negative ways.

What about feminism?

There are two major opposing trends in feminist scholarship on infant feeding. The first is to ‘refute scientific claims to the health benefits of breastfeeding, at least in the developed world, so as to argue that breastfeeding promotion is largely political, having most to do with certain kinds of mothering’ (7). The second is to attempt to find ways of speaking about the benefits of breastfeeding without laying blame on individual mothers. The American writer and breastfeeding advocate Bernice Hausman, for example, has said that she became frustrated with ‘the feminist collusion with the idea that in order not to induce guilt in mothers who don’t or can’t breastfeed, we shouldn’t argue for its benefits, or even acknowledge that breastfeeding has a biological benefit at all’ (8).

By contrast, Wolf moves out of this ‘informed choice’ cul-de-sac. She shows that in many areas (for example when it comes to the relation between breastfeeding and obesity, IQ and psychological development) the scientific evidence is varied and inconclusive. She does show that breastfeeding protects infants against gastro-intestinal upsets, but overall, she writes, the benefits are hugely overplayed. The literature on the subject also tends to conflate correlation with causation, leading to distortion and over-claiming.

In Wolf’s view we need an account of why breastfeeding promotion is so forceful and so widely accepted, given that the science is in fact far less clear than is usually suggested.

The Science

As Wolf’s book shows, science, however dubious, is the primary form of authoritative knowledge in the US and UK today. So, claims that the ‘science shows’ something is good for infants have the effect of shutting down debate and dictating parents’ behaviour. Maria Jansson has noted that medical evidence in infant feeding research does this by serving ‘to articulate an issue in a mode where disagreement and/or (political) conflict becomes impossible’ (9).

Wolf shows how the consensus around the benefits of breastfeeding, and the desire to find science to back it up, affects the kind of scientific research that gets carried out in this area. Wolf gives the example of a paper that set out to find a correlation between breastfeeding and asthma and which stated that ‘breastfeeding does not appear to prevent asthma, or delay its onset, or reduce its severity. However, breastfeeding is still recommended for its many other benefits.’ This paper was reported as ‘supporting breastfeeding’.

It would have been useful if Wolf had looked further into the knowledge-claims that science appears to offer. Undoubtedly it is perceived as the most robust form of knowledge in the risk society that Wolf describes, but the idea that science should dictate behaviour or policy is not self-evident. In short, (good) science can tell us much about the world, but the meaning we ascribe to these facts (that is, how we should act on them) is not straightforward.

As Professor Frank Furedi has remarked: ‘Today, it frequently seems as if scientific authority is replacing religious and moral authority, and in the process being transformed into a dogma… Scientific studies are frequently used to instruct people on how to conduct their relationships and family life, and on what food they should eat, how much alcohol they should drink, how frequently they can expose their skin to the sun, and even how they should have sex.’

This modern-day version of David Hume’s is-ought distinction remains pertinent today because parenting is not only an exercise in creating scientifically optimal children. As Furedi puts it, ‘turning science into an arbiter of policy and behaviour only serves to confuse matters… Yes, the search for truth requires scientific experimentation and the discovery of new facts; but it also demands answers about the meaning of those facts, and those answers can only be clarified through moral, philosophical investigation and debate.’

Professor Rima Apple, author of Perfect Motherhood: Science and Childrearing in America, has described the ideology of scientific motherhood as one which designates good mothers as those who are guided by scientific information, subjugating their own perspectives to authoritative experts (10). Similarly, the ideology of intensive, or ‘total’, motherhood celebrates scientifically informed care. But this reliance on science is problematic because it means science becomes a yardstick by which we outline appropriate human interactions. Science has the capacity to flatten out the affective, joyous qualities of the parenting relationship. As Hausman says of the use of science in breastfeeding advocacy more widely: ‘Breastfeeding advocacy, while resting partially on the idea of maternal nursing as natural mothering, most often looks to science to verify its value and promote its interests. Such advocacy is problematic, I think, when it relies increasingly on the scientific case in its favour because that reliance simply knits a complex biosocial practice ever more firmly into science as the final arbiter of what we, as humans, should eat, how we should sleep, what kind of relationship we should develop with our children, and so on.’ (11)

Although Wolf disagrees on what ‘the science’ shows, one question that is less explicitly addressed than others in her book is whether science should be the final arbiter of what women do with their children. Because the benefits of breastfeeding are not as conclusive as suggested, is this a reason for women not to do it? Or should policymakers simply lay off the hardline tactics that conflate evidence, risk and individual responsibility? What other reasons might women have for breastfeeding, beyond a health agenda?

For mothers, feeding a baby is one part of a relationship that is surrounded by a complex set of influences and demands. Mothers inevitably respond pragmatically and in ways they have not anticipated to the experience of feeding a baby. Certainly, as Wolf’s analysis shows, a policy discourse that almost exclusively attaches benefits to breastfeeding and risks to formula feeding demeans the importance of truly informed choice. As other research in this field has shown, one-sided accounts of the benefits of breastfeeding create unnecessary anxiety in mothers. Finally, and perhaps most crucially, informal solidarity between mothers as well as relations between mothers and healthcare professionals appear to be negatively influenced by the dominant approach to infant feeding.

Wolf’s book is an important intervention into the debate and policymaking around infant feeding. It is, indeed, a great challenge to the ‘breastfeeding experts’.

Dr Charlotte Faircloth is a Mildred Blaxter post-doctoral research fellow at the University of Kent. Her book Militant Lactivism? Infant Care and Maternal Identity will be published by Berghahn Books later this year. Ellie Lee is senior lecturer in social policy at Kent University. She is the director of Parenting Culture Studies and author of Abortion, Motherhood and Mental Health, Medicalizing Reproduction in the United States and Great Britain. (Buy this book from Amazon(UK).)

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