Rethinking the delivery of breastfeeding advice (TEDMED 2014)

Kirsten_headshotKirsten Patrick is deputy editor at CMAJ

Breastfeeding? Really? At TEDMED? C’mon breastfeeding is as old as humanity and we know everything there is to know about its benefits (just not how to make moms stick to it), right? How did breastfeeding end up as a topic of a TEDMED talk in a session called ‘TURN IT UPSIDE DOWN’ that I live-streamed this morning?

Well, as the speaker, Eleanor 'Bimla' Schwarz, pointed out we’ve been missing a trick in our thinking and communicating about the benefits of breastfeeding. We’ve been talking all about the benefits for the baby but we've failed to move beyond "it helps you lose the baby weight" when it comes to talking up the benefits for mom.

I’ve been an editor on a medical journal for a while now. I have seen my fair share of research submissions dedicated to exploring the differences between breastfed infants and non-breastfed infants in terms of long term outcomes. At one time it seemed that the question  receiving the most research interest was "Does breastfeeding your kids make them cleverer?" So many things confound the ‘is breast really better’ question – parents’ education level and socioeconomic status being the most important. Since we can’t do a randomised trial to see exactly how big the advantage of breastfeeding is for any given outcome, it is hard to know the size of its effect....which has led to guessing. Many, even physicians, say, "Yes in the developing world breastfeeding matters, but the benefits to baby of breastfeeding are so marginal for first world infants that we shouldn’t make moms feel bad about it."

But if we do turn the question upside down and look at the benefits of breastfeeding for the mom, in her lifetime, perhaps we can see a more compelling reason to make an effort to support moms to avoid formula feeding. And these benefits are many, apparently. Schwarz has collaborated on many research studies looking at long term health outcomes for women who breastfeed vs. those who don’t or breastfeed for only a short while. Population based studies have shown that women who breastfeed exclusively have lower risk of developing type 2 diabetes, and other risk factors for cardiovascular disease, particularly hypertension, than women who do not breastfeed or those who breastfeed non-exclusively. That’s after adjusting for all the traditional risk factors common to cardiovascular disease and breast feeding practice.

In her talk, Schwarz pointed out that ischaemic heart disease is the top killer in developed countries. We could probably save a lot of lives and health care dollars by making a real effort to get 90% of women to breastfeed exclusively for a reasonable length of time. Because a month isn’t long enough. She says that currently only 20% of women breastfeed exclusively for long enough and that just 8% of U.S. hospitals provide an environment that entirely and adequately supports mothers to breastfeed exclusively. We are much too quick – even as health professionals – to hand out bottles and formula.

Okay but what IS the innoculum?’ I have breastfed two sons and I can tell you what many mothers will tell you. Breastfeeding is TOUGH. It takes a long time for it to feel comfortable. It’s tiring and not as easy and fuss-free as the breastfeeding enthusiasts say it is. It can be excruciating. There’s mastitis. Babies grow teeth and bite nipples. How long MUST we stick to it to avoid having to feel guilty? The WHO says breastfeed exclusively for 6 months, but the days from four or five months can be very hard because baby gets hungry. Many other guidelines say keep breastfeeding for at least nine months to a year. I managed 8 months for son 1 and 10 months for son 2 but there was certainly the odd bottle of formula thrown in. I had to go back to work…..if you have to return to work expressing is a drag. I did it the first time around but the facilities at my place of work were less than optimal. I found the personal costs of trying to maintain almost-exclusive breastfeeding to be high even though it is cheaper. I'm sure I did it just as much because breastfeeding was free and formula not as for more laudable reasons. And I am deeply sympathetic to women who feel they just can't do it.

But there are bigger costs to not breastfeeding than just the price of formula, bottles and a sterilizer. Schwarz says that 14000 American women could avoid having a heart attack each year if 90% of women breastfed their infants for 9 months. She and colleagues undertook an economic analysis that assumed not nursing your infant was a causal factor for ischaemic heart disease. Published last year, it estimated that in the United States, suboptimal breastfeeding ‘incurs a total of $17.4 billion in cost to society resulting from premature death (95% confidence interval [CI] $4.38–24.68 billion), $733.7 million in direct costs (95% CI $612.9–859.7 million), and $126.1 million indirect morbidity costs (95% CI $99.00–153.22 million)’.

How’s Canada doing? Stats Canada’s most recent highlights on breastfeeding rates in Canada are as follows:

• The majority of mothers, 89%, breastfed their baby in 2011–2012, a slight increase from 85% in 2003.
• More mothers were breastfeeding exclusively for six months (or more): 26% in 2011–2012, compared with 17% in 2003.
• In 2011–2012, mothers who breastfed exclusively for six months (or more) tended to be in their thirties or older, and to have postsecondary qualifications.
• The most common reasons cited for stopping breastfeeding before six months were “not enough breast milk” and “difficulty with breastfeeding technique” in 2011–2012.

So we are doing better than we were but, arguably, still not well enough.

Breast feeding needs to be promoted not only as a child health issue but as a women’s health issue, says Schwarz. Supporting the majority of women to breastfeed for six months and more is a relatively cheap and potentially highly effective intervention that could save money and lives, a solution that is ‘hiding in plain sight’. Even Schwarz admitted that breastfeeding is hard. So how does she think we should support more mothers to breastfeed? Lobby for civilized maternity leave for working mothers, she said. Important in the United States…..Canada and most of Europe already have relatively civilized mat leave. It takes a village to breastfeed a child, she said. Rally around breastfeeding women. Partners, friends, grandparents should support mothers to breastfeed; employers should make facilities available for expressing milk or provide childcare on site; health care services must provide good lactation support services for every woman, particularly those from disadvantaged backgrounds; educate women about the personal health effects of breastfeeding that no diet or exercise routine can replace.

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