Want U.S. families to choose breastfeeding? Stop pretending it’s easy

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By: Bethany Kotlar, MPH, Associate Directer of the Maternal Health Task Force

In 2018, breastfeeding rates in the United States increased, according to the annually released CDC Breastfeeding Report Card. The percentage of babies still breastfeeding at 6 and 12 months increased from 2017, yet despite these gains, few babies are being fed according to recommendations. The American Academy of Pediatrics recommends that infants be fed only breastmilk until 6 months of age, and then a combination of solid foods and breastmilk until at least 12 months of age. The World Health Organization (WHO) goes further, recommending breast milk up to the age of two.

These recommendations are far from baseless; despite methodological challenges in studying breastfeeding, studies have uncovered a laundry list of benefits for babies (reduced risk of leukemia, obesity, irritable bowel syndrome, and ear infections to name a few), and even for mothers. After years of effort, public health practitioners and clinicians have successfully relayed the message that “breast is best” to U.S. parents, over 80% initiate breastfeeding, yet 3 months later less than half are exclusively breastfeeding. This steep decline in breastfeeding prevalence speaks to the crux of the matter—parents want to breastfeed, but something is making it hard for them to succeed.

Of course, anyone who’s tried to lactate, whether by breastfeeding or pumping, for a small human knows it’s incredibly hard. My own 19-month breastfeeding journey with my son taught me quickly how difficult the mechanics are (especially in early infancy), akin to shoving your nipple into a wet vacuum cleaner, and a very impatient one at that. Nipples leak, hurt, sometimes bleed, and if you have anything resembling the typical newborn, that sucker is going to want to breastfeed near constantly. While the physical slog of breastfeeding, a newborn can cause some to throw in the towel, breastfeeding rates decline quickly once mothers return to work, around the 3-month mark, and continue to decline afterwards.  At three months, less than 50% are exclusively breastfeeding, at 6 months less than 25% are exclusively breastfeeding and only approximately 36% of mothers are still providing any breastmilk to their infants at 12 months, thus the vast majority of children in the U.S. are not being fed according to current recommendations.

Although research into barriers to breastfeeding success has expanded, public health campaigns to increase breastfeeding rates have largely focused on early initiation, like the Baby-Friendly Hospital Initiative, or educating parents on the benefits of breastfeeding. While education is key, few interventions have focused on the real and significant structural challenges to meeting current recommendations on breastfeeding duration.

The first and most glaring is that the U.S. is one of only two countries in the world with no statutory national policy of paid maternity leave (the other is Papua New Guinea). This is despite the fact that 71.5% of women with children under the age of 18 work outside of the home. The Family Medical Leave Act (FMLA), the only national statute on leave, guarantees 12 weeks of unpaid leave, and only to employees who work for companies with more than 50 employees, and only if that employee has been employed longer than 12 months and worked more than 1,250 hours. In 2016, only 14% of U.S. workers had any access to paid family leave.

Lack of access to paid family leave means mothers are all too often forced to return to work just a few weeks after giving birth. The first 2-3 months are crucial for establishing a breastfeeding relationship, as it’s critical that a newborn baby be close to its mother in order to feed frequently. This both ensures the baby’s growth and also serves to establish a mother’s milk supply (breastfeeding works on a supply and demand loop, the more a mother breastfeeds or pumps, the more she will produce, and vice-versa). Separating a mother from her child before this relationship is established will force a mother to pump on schedule instead of her baby’s cues, putting her milk supply out of sync with what baby needs, often eventually leading to early weaning.

Under the Affordable Care Act (ACA), employers of 50 or more people are required to provide time and a clean space that is not a bathroom for lactating women to pump. This time does not have to be paid, there’s no stipulation on how much time should be provided, and enforcement of employers that do not provide these protections is almost non-existent. Recently, the Supreme Court refused to hear the case of Angela Ames, a woman who alleged she was forced to resign in the words of her supervisor to “go home and be with [her] babies” after attempting to access a room to pump. The lower court that dismissed her case claimed her supervisor’s comment was not sex-based discrimination as both sexes can be parents and that even if she had been fired for lactating, that would not be sex discrimination as “Ames has not presented sufficient evidence that lactation is a medical condition related to pregnancy.” By refusing to hear the case, the Supreme Court has upheld the lower court’s burden of proof, making it that much harder to ensure workplace protections for lactating women.

These policies (or lack thereof) harm all families. However, wealthier families are able to overcome these systemic barriers more often, as they are more likely to have the financial ability to take unpaid leave (and to work for employers who offer paid leave), the job freedom to pump, and the ability to weather and to fight unfair discrimination. Unlike Ames, who had the means to bring her case to court, women working in low-wage jobs are often afraid to speak up – even if they are covered under ACA protections.  These women are forced to either leave their jobs, or more likely, turn to formula, which, although quite expensive, at least allows them to also bring home a paycheck.

Our capitalist society produces a tiered system in which companies compete for highly skilled workers by offering family friendly policies-like onsite childcare, or extended paid family leave, while low-wage workers are left to fend for themselves. For example, currently, my own employer, Harvard T.H. Chan School of Public Health, has a two-tiered system of paid family leave. Faculty receive 13 weeks at full pay, while staff must patch together short-term disability, sick and vacation time, and up to 4 weeks paid by the department, and many will receive pay at 75% of their typical salary. While this is not atypical of employers (in most workplaces, hourly workers often receive many fewer benefits than salaried workers), and is actually generous for abysmal U.S. standards, it speaks to the fact that even in seemingly benign institutions (a school of public health!), this two-tiered system is upheld. Effective in January 2021, all employees will be entitled to at least 12 weeks of paid family leave, but this change only occurred when Massachusetts passed legislation that mandated 12 weeks of paid leave to all employees. While employers certainly should do the right thing by ensuring the existence of family and breastfeeding-friendly workplace policies, the fact is that without legislative pressure or strong labor market pressures, most will not.

The lack of policies that support breastfeeding has created an awkward message for families, that they should choose breastmilk for their children, but must shoulder the complete financial and logistical cost of doing so. It’s no wonder that breastfeeding initiation is high, but rates at 3, 6, and 12 months are worryingly low. For many families, it’s either breast milk or a paycheck. By focusing public health programming on communicating the health benefits of breastfeeding rather than championing widespread policies to support breastfeeding, we are reinforcing disparities in breastfeeding rates and ignoring the fact that our society is structured in a way that makes breastfeeding an unattainable luxury for the majority of parents, rather than a right. Worse, we are echoing the message that the onus of breastfeeding should be placed solely on the parent’s shoulders, when in fact, it should be on the shoulders of the society as a whole. This message is frankly insulting. It’s no wonder there has been a public backlash against the “Breast is Best” slogan, the Baby Friendly Hospital Initiative, and pressure on parents to  breastfeed in general, one article going so far as to posit that breastfeeding is “this generation’s vacuum cleaner—an instrument of misery that mostly just keeps women down.”

If we don’t reconsider the way we promote breastfeeding, we will lose our audience. If public health practitioners, clinicians, and breastfeeding advocates want U.S. parents to follow current feeding recommendations, we need to shift our focus away from education and towards advocating for national labor policies that enable families to choose to breastfeed. We must concern ourselves with national and state-level policies that hinder breastfeeding success, and we must move beyond hospital-based initiatives. Our fight must be to mandate paid parental leave, establish and enforce policies protecting breastfeeding and pumping at work, and push for universal access to healthcare that focuses on the postpartum period and early childhood. Only then can we ethically and equitably be able to spread the word that “breast is best.”