The climb

The climb
Climbing together

Wednesday, December 2, 2015

The False Equivalence of Pumping and Breastfeeding

Me, reading that LA Times Blog post about Pumping today

Someone (who recently wrote a book about Lactavism and obviously doesn't need any more press from the likes of little old me) has written yet another blog post, among a string of recent doozies, most of which have elicited similar reactions as pictured above. I understand, you wrote a book, and these blog posts are part of the necessary media blitz to generate buzz about your book so that you can at the very least break even, if not make a big splash in the small pond that comprises "books about lactavism".

False Equivalence

The term false equivalence describes a situation that is superficially logical and apparently equivalent, when in reality the situation is neither logical nor equivalent. This is a type of informal fallacy, among the long string of logical fallacies that are often implemented, either consciously or unconsciously, by people who are mired in a debate. Politicians use them a lot.

Breastfeeding isn't pumping; in fact, these two skill sets are related only in that they involve the lactating breast. Comparing them is like comparing apples and oranges, as the saying goes. Maybe apples to applesauce, in this instance. It's all fruit, and both apples and applesauce offer nutrition - but in different ways.

Native mothering has a cool post about this topic, and references the World Health Organization's Global Strategy for Infant and Young Child Feeding when mentioning that expressed milk using an alternative feeding method (bottle, SNS, cup, syringe, etc) when babies are unable to feed directly at the breast is considered the next best option.

This is not me. 
The suggestion that breastfeeding advocates support pumping for some materialistic reasons vaguely related to the profit margins of breast pump manufacturers, which can only be considered razor thin in comparison to the profit margins of multi-billion dollar formula companies, is a bit disingenuous. First of all, as a breastfeeding advocate I can tell you that I am not aware of a single, solitary breastfeeding advocate that is profiting due to their support of breastfeeding mothers and babies. In fact, most of us are operating at a loss, and we supplement our activism (as most activists do) by having day jobs, which also usually yield a meager sum.

And of course companies are capitalizing on the increased interest in offering human milk, in whatever way possible, to infants. OF COURSE. This is the way our socioeconomic system goes, am I the only one who is not surprised that this has happened, and also not appalled? We operate under the constraints of current policy. Humans are instinctively inclined to figure out how to adapt tools to more effectively achieve what needs to be done. Thus, the breast pump industry. And thank goodness it exists, and innovation is happening, because breast pumps that were available in the old days were exorbitantly expensive and most mothers who worked and breastfed in the 1970s had one option: hand expression.

Doing the best that we can with the tools we have

The indomitable Gini Baker, director and instructor for the UC-San Diego Lactation Educator Program, repeated this phrase frequently throughout the course when I took it this past summer: we do the best that we can with the tools that we have.

Pumping is a necessity for most mothers in the US. 

I think we all know that realistically, the legislative gears that shape the landscape of US policy turn very slowly, especially in an election year. We have no mandated, paid parental leave, so mothers go back to work weeks, sometimes days after they give birth, and only specific classes of protected workers have federal protections when it comes to lactation accommodation, or even access to 12 weeks of unpaid leave with no health insurance coverage .

Pumping is hard work. I won't extend to the realms of hyperbole to say that there isn't a mother on the face of the earth who likes pumping, because the researcher in me says "that's statistically impossible," there is at least one data point that contradicts that conclusion. You can't reliably conclude that this is true unless you sample every available data point, and that's not going to be happening any time soon. It's a skill all of it's own and I can't express my level of appreciation and awe of mothers who work full time, pump milk, and maneuver through the minefield of child care and well-meaning relatives. It's a super-stressful lifestyle and I sincerely believe that as we move forward, and continue with the process of advocacy to bring more light and awareness to the situation, the landscape will shift.

Many studies of the composition of human milk have been conducted, you can read a nice recently published and publicly accessible synopsis here: Human Milk Composition: Nutrients and Bioactive Factors.

A few issues related to research on breastfeeding and expressed breast milk.

First of all, it's not like there's a lot of money floating around to do breastfeeding research (yet... please Lord let this be in the process of changing somehow. Magically.) Unless you can yolk breastfeeding onto some other, sexier research topic that is currently being favored by the NIH in its various guises - something like obesity, or diabetes, or something related to the internet, for example - you probably won't get very far.

There are ethical issues related to doing breastfeeding research that prevent the use of the "gold standard" for research - the controlled clinical trial. You can't take randomly assign a group of mothers to breastfeed, another group to exclusively pump, and another to formula feed. That would directly oppose some of the fundamental human protections that have been built into the ethical practice of research in the last 50 years or so. As a result, you'll frequently see self-report data, samples are skewed to include mostly babies that are already affected by the other, underlying reasons that mothers may choose to exclusively breastfeed (which are numerous and layered), and use the appropriate statistical methods to address potential confounding issues.

The confounds that are related to the natural experiments assessing effects on breastfed vs. formula fed babies will follow the babies fed expressed milk vs. those fed at the breast - there are underlying reasons why mothers pump exclusively. Identification of those issues can inform the use of statistical methods to control confounds, but at the end of the day, in order to measure the substance itself, breast milk must be expressed.

Let's get together


The world does not need more "stunning indictment." We probably all have "stunning indictment fatigue."

In order the affect change, you have to work from within. You play the game, and make the small changes that that make the way for the watershed moment where a wave of big change shivers through our collective consciousness. Rarely, big policy changes happen from podium-level indictments by outsiders. We need more advocates for policy change that allows parents adequate protection to nurture their children. Full stop. It seems nonsensical to argue for choice when the structure of the social system limits the choices available to those with earning potential that falls below a certain threshold.

I am knee-deep in breastfeeding research on a daily basis, so maybe this is more obvious to me than others. The criticisms of the research that shows breast milk as the optimal form of human nutrition is a little silly, IMO, and I can't wrap my head around that argument. Of course breast milk is the optimal source of nutrition. A decades-long body of research cannot be refuted by a handful of secondary data analyses with seriously methodological flaws.  There is no way that a formulated, manufactured powder could replicate a substance that we still don't fully understand. The public health benefit has been clearly established. Read the Cochrane Review Special Collection on Breastfeeding. We know the health outcomes related to breastfeeding compared to formula feeding, here's a 67 page literature review you can peruse for specific health condition comparisons.

Low-income parents suffer from multiple obstacles when it comes to breastfeeding. Working parents have to overcome hurdles to maintain breastfeeding. Let's keep pushing for higher level structural shifts that involve inclusive and equitably policy making that endow citizens the right to equal access to primary prevention to establish a foundation of health, and put the supports in place to allow mothers to choose to breastfeed. We're in transition right now, you know how it is when you give birth. This is when you're like, ugh I can't do this - but that baby's head is about to crown and there's no turning back.

Most mothers have the intention to breastfeed; recent data suggests that the majority of mothers do not meet their own breastfeeding goals. At minimum, more than half of babies in the US are ever breastfed (a far cry from the dismal statistics of the 1950s and 60s), and in some parts of the country more than 85% of infants are ever breastfed. The ratio rapidly decreases  as babies age because we do not have a social system that enables the maintenance of this health behavior. Equity based policy making should be aimed at ensuring that parents can meet their goals, and if the majority of mothers aren't meeting their own goals, then it follows that advocacy needs to be focused on supporting that rather than supporting a choice, that is actually no choice at all. Using the term lactivism as a reductionist insult isn't going to get us anywhere. It's just another way to create a barrier and an "in" vs "out" group.

At this point, infant feeding choices are more of a reflection of necessity than a true reflection of the intention of parents. Any parent will tell you this: you do the best you can with the tools you have, and when you know better, you do better. Until we have access to better family leave policies, until we restructure our understanding of what work and productivity is and where it truly comes from, we will continue to pump our milk, and the "lactavists" or how about...advocates? maybe?....will continue to do the hard grass-roots work on the systems that are slow to change in response to the needs of the constituency. Maybe we could get together on that.


  1. I completely understand that pumping is the reality of so many mothers and it is a lot more work and probably most mothers wish that they did not have to do it. I truly believe that most breastfeeding experts are not trying to be divisive when they give information. I do think thought that it is very negligent to promote both practices as equal. That is the the same kind of bad thinking that made so many mothers choose to formula feed back in the day because doctors touted breastfeeding and formula feeding as equivalent. None of us are perfect and no matter what we do or choose, there will be mistakes and things to aspire to, regrets etc. Think of if this way. We live in a society where fast food is a reality for many people because they have to work and don't have time to eat better or some are just uneducated about what is healthy to eat and what is not. Just because it is the reality does not mean that you stop promoting fresh whole foods and denying the fact that it is healthier for our bodies. The same with breastfeeding and bottlefeeding breastmilk. Yes we need compassion for mothers who have no choice but to pump. But as breastfeeding advocates and experts, do we sell a lie to women that it is the same? I respectfully disagree with your opinion about promoting what is the optimum practice. I would prefer for us to come together being able to acknowledge the role that society plays in forcing us to have to make less than stellar choices and work towards making sure that women have the opportunities to provide the optimum situation for their babies and work together towards better.

    1. I don't think you and I disagree at all! The title of this blog post is "the false equivalency of breastfeeding and pumping" - they are not the same thing. As I said, we do the best we can with the tools we have. That being said, part of advocacy is acknowledging that things can be better and working towards that goal - that means changing the context for the next generation so they aren't forced into infant feeding circumstances and are actually in a place to make a real choice, rather than the lesser of two evils.

  2. Society is all of us agreeing. It or we should not force us to ignore new health information. We can agree that work is important Just not more important than the health of our nation. We can support our young families with infants have time and support to feed at breast for at least 6 months if "we the people" agree this is important.

  3. Your wrote as a stand-alone sentence/paragraph, "Pumping is a necessity for most mothers in the US." Most working mothers or most mothers?

    1. Valerie, I used the term "most mothers" because the majority of mothers in the US have to work full or part time jobs.