Alison Stuebe MD MSc presented on this topic at the recent Breastfeeding Advocacy Collective (BAC) meeting in Toronto on May 9th. Dr. Steube is a maternal-fetal medicine physician and president-elect of the Academy of Breastfeeding Medicine. Dr. Stuebe's following blog post is adapted from her presentation at the recent BAC meeting.
In June 2015, I heard a fantastic talk by Keith Hansen, Vice President for Human Development at the World BankGroup, at the Academy of Breastfeeding Medicine summit. Hansen spoke eloquently about the importance of breastfeeding for both global health and economic development; he said, “If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics.”
I’d brought my teenage son with me to Washington, and when we met up for lunch, I shared Hansen’s quote. He responded, “If breastfeeding were invented today, there would be an outrage, because of feminism.”
It took me a few seconds to fully process this response, as I began to consider the implications of a newly-discovered practice that would require one half of the population to engage in thousands of hours of unpaid work, at all hours of the day and night, for the greater good. There would, indeed, be an outrage. This disconnect between praise of breastfeeding and practicality of women’s lives is pervasive, and it is reflected in health promotion strategies. Posters list the ingredients of human milk vs. formula, celebrating the product of breast milk without acknowledging the process of breastfeeding.
Breastmilk is described as nature’s “most specific personalized medicine,” rather than celebrating breastfeeding as personalized nurturing. Even our public health goals aim to “increase the proportion of infants who are breastfed,” absenting the mother doing the breastfeeding from consideration. As a physician scientist, I know how easy it is to become fascinated by the science of human milk and the intricacies of oligosaccharides and the gut microbiome – but speaking of “milk as medicine” suggests a resource to be extracted from a passive mother, without regard to her bodily integrity or autonomy. As Benoit, Goldberg and Campbell-Yeo have written:
By placing breastfeeding focus on the biomedical and nutritional benefits of breastmilk, as opposed to maternal experience associated with nursing her infant, health care providers are perpetuating the patriarchal conceptualization of the ‘good mother’ as one who is defined as selflessly giving by nursing her child while asking for nothing in return.
Our excitement over the constituents of human milk reflects the reductionism of modern scientific research, in which the whole can best be understood by breaking it into its parts. And yet, doing so undermines the fundamental nurturing relationship between parent and child; as Van Esterik and O’Connor write in their critically important book, The Dance of Nurture, “Nurture is a relationship not a thing, and relationships cannot be reduced to their parts.”
Our focus on human milk constituents further fails to consider a growing body of evidence linking breastfeeding duration with maternal health. In reproductive physiology, lactation follows pregnancy, and when breastfeeding is disrupted, chronic disease burden for women increases. In observational studies that adjust for multiple confounders, shorter breastfeeding durations are associated with higher maternal risk of breast cancer, ovarian cancer, diabetes, hypertension and cardiovascular disease. Indeed, a recent cost analysis found that the health burden of suboptimal breastfeeding is far greater for mothers than for children. Policies that disrupt breastfeeding impair a woman’s lifelong health.
Given its importance in reproductive physiology and women’s health, breastfeeding is a woman’s reproductive right. However, Judith Galtry notes that the Convention on the Elimination of Discrimination against Women (CEDAW) barely mentions breastfeeding. The absence of breastfeeding from the human rights discourse when CEDAW was written in the 1970s may reflect the influence of Western feminists who were focused on liberating women from responsibility for child-rearing. In this context, breastfeeding was a chain to be broken, rather than a right to be protected. As Galtry writes, “It did not always occur to policymakers and legislators that many women did not actually have the right to breastfeed.” This focus on “my right to not breastfeed” continues to dominate discussions among professional women in high-income countries, at the expense of recognizing that economic constraints prevent many marginalized women from breastfeeding, regardless of their personal preferences.
Framing breastfeeding as a woman’s right encourages us to address the relative costs and benefits of breastfeeding for each mother and baby. Tully and Ball note that a woman’s investment in sustained breastfeeding reflects tradeoffs, and lowering the personal cost of breastfeeding would support longer durations:
Van Esterik summarizes the need to address the costs to mothers in a 1981 essay on breastfeeding and women’s work:
Breastfeeding may be viewed by some feminists as the epitome of nurturant behavior – restrictive and unappealing, constraining an emancipated woman from employment possibilities. For these women, biologically determined functions may be devalued and, whenever possible, replaced by technological innovations such as bottlefeeding. A more radical feminist might argue instead for a restructuring of society to support women in their productive and reproductive lives.
What if we leveraged the importance of breastfeeding to restructure our society around each woman’s human right to nurture her children as she desires?
As defined by the Officer of the High Commissioner on Human Rights, “Human rights entail both rights and obligations. States assume obligations and duties under international law to respect, to protect and to fulfil human rights.” If breastfeeding is a woman’s right, then it is not sufficient to urge women to breastfeed – we must enact policies that respect, protect and fulfill that right. A human rights framework recognizes that breastfeeding is not a one-woman job – multiple social structures are essential to enable a woman to exercise her human right to nurture her child as she desires. To that end, the Global Breastfeeding Collective has identified seven key strategies to enable mothers to achieve their infant feeding goals, including funding for breastfeeding support, implementing the WHO Code of Marketing, enacting paid family leave, implementing evidence-based maternity care, improving access to skilled support, strengthening links between health facilities and communities, and strengthening monitoring of processes and outcomes.
The collective has tracked country-level adherence to these recommendations with a Country Scorecard; to date, no country provides the minimum standard for support. Consider paid family leave: the standard for the Score Card is compliance with International Labor Organization conventions for at least 18 weeks of maternity leave and guarantees continuation of previous earnings paid out of compulsory social insurance or public funds. Slightly more than 10% of countries meet this standard; 90% of countries fail to address this fundamental barrier to a woman’s right to nurture her child.
Lack of paid leave is particularly egregious in the United States, where 23% of employed women return to paid work within 10 days of birth. Moreover, in 8 US states, single parent head-of-households with a newborn are not exempt from welfare work requirements. Women living in poverty are effectively punished for nurturing their children. As Burtle and Bezruchka have written:
The lack of policies substantially benefitting early life in the United States constitutes a grave social injustice: those who are already most disadvantaged in our society bear the greatest burden.
Given what we know about the importance of the first months of life for the health and wellbeing of mothers and infants, why haven’t we taken the necessary steps? In The Dance of Nurture, Van Esterik and O’Connor offer an explanation:
…we have not done the things that we need to do to support breastfeeding because these things conflict with deregulated capitalism and complacent consumerism.
Where to, then, from here? Do we conclude that modernity is inimical to breastfeeding, and rely on formula companies to provide “liberation in a can”? Or do we challenge societal structures that do not permit women to use their breasts and their brains at the same time? Feminist scholar Bernice Hausman writes:
Feminists …should be fighting for the right to breastfeed without social censure, loss of economic livelihood, or limitations on women’s freedom…Changing the bottle-feeding culture that we live in is a political enterprise than cannot be accomplished simply by advertising risks to replacement feeding or heralding the medicinal qualities of breast milk.
These are not new challenges, and these are not new ideas. In 1976, when I was 3 years old, Elisabet Helsing wrote:
In a world in which a female labour force is participating more and more, the peculiarities of this labour force have to be borne in mind. Until now, pregnancy and lactation have been strictly private enterprises, and society has not had to bother about how to cater to the newborn–that has always been regarded as the task of a woman… How can society adjust, so that she can remain useful to the society and simultaneously take the necessary care of her offspring?
Real liberation for women would not require us to choose between our professional and reproductive work. The current system incurs costs that reverberate across society by disrupting women’s participation in the paid work force. Indeed, a recent International Labor Organization / Gallup report found that balance between work and family is the number one challenge facing working women worldwide. Moreover, the report notes, “An ILO survey of 1,300 private-sector companies in 39 developing countries confirmed that family responsibilities borne by women was ranked as the No. 1 barrier to women’s leadership.” When societal constraints exclude women from participating in paid work, we all lose. As Gallup CEO Jim Clifton writes:
Our research also concludes that women have every bit as much game-changing talent as entrepreneurs and “builders” as do men. The problem is, millions of potential star women leaders are on the sidelines, and this isn’t good for organizations, societies or countries. Failing to maximize women’s talent to lead, manage and build stunts global economic growth and fails humankind.
It’s time for a feminist outrage that demands we restructure society to support women and men in their productive and reproductive lives. As Van Esterik wrote in 1994:
By enabling women to breastfeed we address women’s rights since the improvement of women’s social and economic status is necessary for supporting breastfeeding. Any violation of women’s right to breastfeed is a violation of women’s human rights.
Dr. Stuebe's entire blog post with graphics: https://bfmed.wordpress.com/2018/05/09/breastfeeding-advocacy-and-womens-rights/