Since when does a guideline become a rigid rule?
More on breastfeeding, and how those silly naughty mothers are just wilfully doing the wrong thing. This time it’s an article in the NZ Herald, coming out of the “Growing up in New Zealand case study”: NZ mums ignoring breast feeding advice.
An official guideline that babies should be fed only breast milk for their first six months is being challenged after a study of almost 7000 babies found the vast majority of mothers ignore it.
The director of the study, Dr Susan Morton, runs through some of the reasons for many mothers not breast feeding exclusively for six months, including the pressures of work, and the reality that in our developed first world nation, the water supply is reliable. She points out that the directive for women to breast feed exclusively for six months sets many women up for failure.
That seems to me to be a useful way to reflect on the advice handed out so freely to new parents. Instead of always pushing the ideal, let’s think about the practical realities, and see if we can develop guidelines, and support to help parents to with achieving the goals of the guidelines.
But the Children’s Commissioner is having none of that.
But the Ministry of Health and Children’s Commissioner Dr Russell Wills are standing by the official guidelines. Dr Wills said Dr Morton’s comments reflected a classic “authority’s dilemma”.
“What should authorities advise when what good science says is best for baby is not what most parents do?” he asked.
“If you compromise and say that something is fine when it’s not, you are misrepresenting the science and selling parents short.”
Hmm… let’s focus on that word, “authorities”. Yes, people can be authorities, and experts in their field, and someone that other people turn to for advice. But the way that advice is translated into practice often turns into on-going policing of parents, and in particular, women, and instead of being a guideline, the advice becomes a rigid rule.
Let me tell you a story. When my younger daughters were tiny, my Plunket nurse kept up home visits for a long time. For people overseas, Plunket is a child-health service, designed to support new parents and babies and young children. In the first few weeks after your baby is born, a Plunket nurse will visit you in your home, and offer you advice and assistance.
My Plunket nurse was, for the most part, excellent. She was unintrusive, she quietly made some very helpful suggestions about how I could manage my infant twins, and she had her eye on my elder daughter too. Of course, I would find it all comparatively easy having a visiting nurse in my home, because I am white and middle-class, and any judgements she was making were likely to be positive. I felt assisted, not assessed.
But one thing puzzled me. By the time my little girls were about 18 months old, they were fully weaned, and drinking cows’ milk. Not a lot, because they weren’t big milk drinkers. One little girl was drinking about 400mls a day, and the other about 500mls. “You should really try to get them up to 600mls,” the Plunket nurse said. “That’s the official guideline.”
Then, “What about your elder daughter?” At that time she was aged about four, and she was drinking somewhere between 800mls and 1,000mls a day.
“Too much!” said the nurse. “She should only be drinking 600mls a day.”
So it turned out that in my Plunket nurse’s mind, what was supposed to be a guideline was in fact a rigid rule. Children should drink 600mls of milk a day, no more and no less.
This to me is a large part of the problem with the rules about breastfeeding. What is intended to be a guideline is interpreted as a rigid rule, with no flexibility for the needs of the individual baby, nor for women’s and families’ varying circumstances.
I think that the “authorities” need to engage a little more with the realities of women’s lives, instead of turning guidelines into hard and fast rules, and then wondering why women ignore them.
Some more thoughts on the Weepu bottle feeding stoush
Like Annanonymous, the latest breast vs bottle dust-up has touched a raw nerve for me, no doubt due to my own experiences with breast feeding. But also because I find the number of shoulds and shouldn’ts that are dished out endlessly to parents deeply wearying. All too often the edicts seem to be handed out with little thought as to how parents might achieve them, or what constraints there might be, or what other issues a parent may be facing.
I’ve found some of the language used disturbing. This sentence from Dita di Boni’s column in the Herald is a case in point.
[La Leche League / midwives / etc] can suggest, coerce and press the issue, but it is a mother’s choice in the end whether or not to take the advice proffered.
Well, that’s… revealing. “Coerce.” That has been exactly the problem for many mothers who have tried breastfeeding, but experienced tremendous difficulties, for whatever reason. There is an enormous amount of pressure on women to breastfeed their babies. And it is facile to say that women can just choose whether or not to take the advice. When that pressure to breastfeed is applied by an expert, it is very hard to resist it. All the more so in those early weeks and months with a new baby, especially a first baby. So many new parents know so very little about how to care for babies, so they are very dependent on midwives and health nurses and and La Leche League experts. To suggest that a new mother who is struggling with pain, and cracked nipples, and ever-feeding infants, has the emotional resources to withstand the pressure applied by those she is depending on is bizarre.
di Boni goes on to say that, “It is up to women to have confidence in their choices.”
And there it is again. Holding individual women responsible for the failings of a society that promotes breastfeeding, but doesn’t provide the resources to enable women to access help with it, and then berating them for lacking confidence if they try to withstand the pressure put on them by those who are experts. Experts in breastfeeding, that is, but not necessarily at all knowledgeable about the particular contexts within which individual women are living and rearing children.
On the other hand, I am baffled by the idea that being pro-breastfeeding is equivalent to being anti-fathers and fathers being involved in their children’s lives, and that bottle feeding is great because then men can be involved in caring for their children. That’s the view espoused by fathers’ rights activist Darrell Carlin.
But there are myriad ways for parents of any gender to care for their children: talking, playing, reading books, cuddling, settling to sleep, dressing, changing nappies, taking to doctors’ appointments, toting them around the house in a sling while you get the housework done, going for walks, singing. And that’s all just in the first few weeks, and just the things that you can do with the baby (c/f say, earning an income to support the baby, or doing housework while the baby is asleep). There is precisely one task that the great majority of fathers can’t do: breastfeeding. And really, if they really, really, really do want to do it, then they could always try a Lact-Aid.
The remainder of Carlin’s column is taken up with wailing about how the nasty feminists have taken over the world and men are oppressed. And put upon. And really, women should be fighting for men’s rights because after all, men gave women the vote. Also, the nasty feminists again. Whatever.
And the last thing that has surprised me: La Leche League’s complete inability to use social media. LLL has tried to say that all it did was ask the Health Council to remove a few seconds from an anti-smoking/pro-smokefree public service ad showing Piri Weepu feeding his baby. In doing this, the only thing they were trying to achieve was to ensure that one public service message – smoke-free – wasnt’ contradicting another – pro-breastfeeding.
But actually, that’s not all they did. As it turns out, what they also did was alert their membership to the issue.
The irony is the damage to the league was done by its own hand. When the Health Sponsorship Council asked their opinion on the Weepu advertisement, La Leche supporters responded intemperately by launching a mass email campaign. The language in the emails was, by the admission of one supporter, “passionate”.
“Passionate” was one word that was used to describe the e-mails. I also heard, “virulently intemperate”. I haven’t seen any of the e-mails, but I’m guessing that they were not polite. And that’s what created the story. Not the request made by LLL, but the allegedly vicious language used in the e-mails sent by supporters. I’m guessing that if LLL had simply given some advice on the ad, without initiating the e-mail campaign, then the story would never have hit the headlines in the first place.
Oh goody! Another breast vs bottle stoush.
Piri Weepu, All Black and devoted father, filmed an ad promoting non-smoking. As part of that ad, there was a few seconds of him feeding his younger daughter, using a bottle. Before the ad was finalised, the makers consulted the La Leche League and the New Zealand College of Midwives, who asked for the clip to be excluded from the final version of the ad, because it sent the wrong message.
The “wrong message” being the bit about bottle feeding babies, instead of breastfeeding.
Right…. let’s just overlook the minor detail that the great majority of men are unable to breastfeed at all, so if Piri Weepu is going to feed his baby girl, then he must use a bottle. We’ll also need to overlook the idea that our feeble lady branes are so feeble that the mere sight of a man using a bottle to feed his baby will result in mass abandonment of breastfeeding. To be fair, Piri Weepu is an All Black, which for non-NZ readers, means that he is a Hero, and to be even more fair, he is even more respected than many All Blacks, because not only is he a great rugby player, but he seems to be an admirable person off the field too (c/f say, what’s his name who spent large parts of last year getting drunk and falling over). Even so, is it really the case that a few seconds of a man bottle feeding his baby in a public service ad about the benefits of non-smoking is going to change someone’s decisions about breastfeeding?
I find the whole breast vs bottle discussion enormously difficult. I breastfed one baby for just under a year, and then after about ten days or so, bottle fed my twins. It has taken me years to shake off the guilt I felt about not being able to breastfeed my younger babies.
And that’s where the La Leche League and the NZ College of Midwives get it wrong. There are enormous structural failings in our society that make it difficult to breastfeed, and for many women, there are physiological problems that make it difficult to breastfeed, yet women who are unable to do so are made to feel that they are inadequate at best, and at worst, people who are deliberately setting out to do something terrible to their children by feeding them with formula.
Things that militate against breastfeeding in our society? How about the underfunding of maternity hospitals and wards which leads to new mothers being kicked out just three or four days after birth, whether or not breastfeeding has been successfully established. If a woman wants to leave within hours or days of birth, then of course she should, but just because some women can do so doesn’t mean that all women should. What about the fact that many women go home to with a new baby to a house full of other children who need to be cared for, but with little home help? Our social structures used to be such that a sister, an aunty, a cousin, a grandmother, could come and stay for weeks to enable the new mother and her baby time to recover from birth and establish breastfeeding before having to take on the full load of running a household, but it is a rare woman these days who can call on such help. Ignoring the changes in our social structures means that individual women are made to carry the blame for not being able to devote all their time and attention to their new baby.
As for the physiological problems… these are unavoidable, and perhaps can be mitigated in some cases, if a woman is given sufficient support. I was not, despite asking for it, and despite having my babies in what was allegedly a baby-friendly hospital. Because I have had some benign breast lumps removed, I have only one breast that can produce milk. It turns out that perhaps the other breast could have produced milk, if I had been given advice and support about tandem feeding right from day one. But that advice and support was not forthcoming, even though I had explicitly asked to talk to a lactation consultant both before, and immediately after the birth. There was no support to help me to overcome the particular physiological difficulty I faced. And some women simply don’t produce enough milk to feed their babies. Or they could, if all they had to do was lie on a couch all day, but the great majority of women in our society don’t have that option. Dairy farmers are fully cognisant of the fact that some cows produce more milk than other cows, even when they are in exactly the same paddocks and being fed exactly the same food. Cows differ from each other in their capacity to produce milk, and so do women. That’s why some women simply must supplement their breastmilk with formula. Otherwise, in the absence of donated breastmilk, their babies will starve. Some women have tremendous difficulties with latching their baby on, and with pain, and with cracked nipples. These are not trivial problems, but they are brushed aside as though they do not matter by many of the pro-at-any-costs breastfeeding promoters.
There are some medical benefits to breastfeeding, but in a developed Western nation with an excellent water supply, they are not large. Meta-analyses of the advantages of breastfeeding show that that there is some reduction in diarrhea, and some inconsistent evidence about other factors which may or may not be associated with breastfeeding (source). All other things being equal, breastfeeding is better for your baby. Even just most other things being equal, breastfeeding is better for your baby. But formula is not poison, and a baby in New Zealand who is fed with formula will do just fine.
Let me be clear. I am in favour of breastfeeding, and all going well, I would have liked to have been able to breastfeed all my babies. Not just “liked”. I desperately wanted to breastfeed all my babies, and I was shocked and distressed by my inability to breastfeed my twins. I was even more distressed because of the huge load of guilt that was heaped on me for bottle feeding.
The answer is not to stop promoting breastfeeding. It is to get serious about offering support for it, instead of just guilting individual women out for being unable to breastfeed. And it is to normalise breastfeeding, to make it part of everyday life. When Facebook can ban pictures of breastfeeding, but ignore pleas for it to remove pro-rape pages and groups, we know which activity is acceptable.
As for Piri Weepu and the La Leche League… I find it bizarre that a small section of the ad showing him caring tenderly for his infant daughter has been removed. Annanonymous puts it well:
Talk about looking at the hole instead of the doughnut. Here was Weepu – national icon and male role model – proudly taking part in childcare, and lending his voice on a key health issue affecting kids. La Leche shot him down for taking part in the feeding of his own baby – a baby who, at six months old, can now be bottle-fed even by World Health Organisation guidelines.
Take at look at some gratuitous Piri Weepu photos, and especially this one, taken at training just before the big quarter final match in the Rugby World Cup.
I also recommend Spilt Milk’s excellent post about breastfeeding: Breastfeeding support: less is not more, which takes a different view of the support offered by the La Leche League.
Signal boost: Kaapua Smith’s blog
Blogging from Kaapua Smith, who is in the second place on the Maori Party list.
Her post, Welfare reform: what I learned as a single mum, is a must-read with respect to the National party’s welfare reform.
I wrote a few days ago about Dr Jackie Blue, and talked about the importance of having people who can tell it like it really is in our parliament. I hope that Kaapua Smith is elected: we need voices like hers.
H/T Morgan Godfrey
Is there a right to choose C-sections?
Women could be given right to choose Caesarean birth
The National Health Service in the UK is considering giving women the right to choose a c-section, even when there is no medical need. That seems appropriate to me.
My reasoning goes like this. Yes, caesarians are risky, as all abdominal surgery is risky. However, mere risk alone is not enough to disallow particular activities. If it was, then none of us would ever be allowed to get into a car. Even high degrees of risk are not enough to rule out activities, such as studying volcanoes (volcanologists, especially those who study erupting volcanoes, have a very high death rate).
You might argue that caesarians can cause harm to a woman, but again, choosing an activity that causes harm to yourself is permissible. As it turns out, delivering babies vaginally can cause harm to women too, as women who have spent years and years doing Kegel exercises will tell you.
Perhaps we might worry about harm to the baby, but that only comes into play if we ascribe moral standing to the baby, and treat women merely as receptacles of precious objects. It does seem to be the case that babies are at higher risk of complications if they are delivered through a c-section, but in order to use that as a reason for refusing c-sections, we would have to say that the woman’s role in pregnancy and childbirth must be to be the best possible bearer of babies. That is, she is not important, and only the baby is important. If a woman says that she wants the best outcome for the baby, then it would be appropriate to take the risks to the baby into account when determining whether or not to have a caesarian, but only in the sense that in order to achieve the outcome she wants, that is, factors militating against that outcome must be considered.
We might be concerned about whether a c-section is medically necessary, with the underlying assumption that no medical procedure should be undertaken unless it is medically necessary. But if that’s the case, then there goes the entire plastic surgery industry, including plastic surgery or reconstructive surgery. Of course, we can defend plastic and reconstructive surgery on the grounds of psychological need, but in that case, the psychological needs of women preparing for childbirth need to be considered too, and those psychological needs may well be met by planned c-sections.
Following on from that, perhaps women choose c-sections because they are concerned about the process of labouring and delivering a baby. If that’s the case, then the answer is to provide more support for women who are preparing for childbirth, perhaps in the form of counselling and education, not just to prohibit one option for giving birth.
On the financial side, if planned c-sections are more expensive than other forms of childbirth, then given that the National Health Service in the UK is funded by taxpayers, then we might have some concerns about cost, both for the caesarian itself, and for the on-going care of mothers babies. However, it seems that allowing women to choose a c-section would just formalise existing practice, whereby women who want a c-section can already arrange to have one. Formalising the practice might well be preferable, because it would at least reduce the capriciousness of the health system, whereby women in one hospital might be able to access c-sections, but women in another might not, just because of differences in attitude.
In general, we tend to think that if someone has considered all the relevant factors, and chosen to engage in a particular activity (such as going bushwalking by themselves in the middle of winter), then that is their business. We might deplore their choice, but we don’t stop them from doing it. And if they get into trouble, we pile in resources to help them. I think that the same approach must be taken with respect to childbirth. Setting aside the matter of cost, if a woman wants to have a c-section, and she has considered all the issues, then that is her business. In fact, even if she hasn’t considered every last detail, we should still not put barriers in the way. To do otherwise is to treat women as though they were children, dismissing their fears and concerns, and telling them that they just don’t understand and that really, they had better just let the grown-up doctors and nurses and midwives make the decisions for them.
Update: Art and my Life (in comments) linked to a 2006 article by University of Orgao bioethics lecturer Claire Gallop looking at exactly the same issue: Women’s right to choose Caesarean.
