Public, positive messages to support a woman's right to breastfeed

I've been delighted to observe and be part of a movement for improvements in birth and maternity services that is gaining momentum (see this article by Toni Harman in the Huffington Post.) In the UK the Positive Birth Movement, with its network of positive discussion groups, and the establishment of Birthrights, has done much to foster genuine, productive debate about women's experiences of birth in today's society. Writer Milli Hill has been commissioned to write a positive birth column after her piece Is Kate being bullied about her birth? was a runaway success for bestdaily; home birth advocate and journalist Beverley Turner, of Radio 5s Bump Club, has also had a number of positive articles published in recent weeks. There's a real buzz about positive birth at the moment and it's great to see.

Conversely, National Breastfeeding Week 2013 has left me feeling a little flat. Not because there weren't some great things going on - both on and off-line - but because, as the figures revealed in the papers during the week showed breastfeeding rates taking a small dip for the first time in years (and Rebecca Schiller so clearly articulated in her piece in the Guardian), without government-level strategic support for breastfeeding, all the efforts of everyone who is passionate about supporting women to breastfeed are just scratching the surface. As Schiller summed it up: 'if policymakers aren't funding enough midwives or a centralised system of breastfeeding support we simply set women up to fail.' (In my own area, with no funding for National Breastfeeding Week, the NHS, through which we work as peer supporters, couldn't support the events we ran in any way.) She also pointed out that the constant breast v bottle debates in the media (which I've critiqued in other posts, like this one) are falsely polarised and damaging to both sides, with women suffering guilt, fear of judgement and lack of support, regardless of feeding method.

I can't help wondering whether the key to improving our dialogue about breastfeeding lies in learning some lessons from the movement for improving birth. If we alter the fundamental question at the heart of all the arguments, what happens? In the introduction to his forthcoming book A Gift for Life (Pinter and Martin, pub date Sept 2013) Dr Carlos Gonzalez, author of My Child Won't Eat and Kiss Me! How to raise your children with love, Spain's answer to Dr Jack Newman, writes:

"...lactation isn’t a tool for achieving health, but rather an integral part of health itself. Not a means, but an end. Telling people to ‘avoid artificial lactation because it causes diarrhoea’ now seems to me as absurd as exhorting them to ‘avoid blindness because blind people are more likely to get run over’. Lactation is no more a way of avoiding infection than being able to see is a way of avoiding accidents. They are both normal parts of a healthy life. I know now that lactation is not an effort, much less a sacrifice, that a woman makes for the good of her child, but rather that it is part of her life, of her own sexual and reproductive cycle. It is a right that no one can take away from her.

I am aware that some women don’t want to breastfeed. This is fine. A right isn’t the same as a duty. Many people don’t go on marches or vote in elections, but they still have that right." (my emphasis)

There's a parallel here with the idea (enshrined in law thanks to Ternovsky vs Hungary) that it is a woman's right to choose the circumstances of her birth. If we see breastfeeding as a woman's right then that frames the whole question of our duty, as a society, to ensure that her rights are respected and supported, in a completely different way. Viewed in these terms, breastfeeding is no longer a 'public health issue', or a 'women's issue'; the right to breastfeed, if she wants to, becomes a completely integral part of the care a woman can expect from maternity and child health services - it cannot be seen as an optional extra, or a 'nice to have', the cherry on the cake once mum and baby have navigated the birth itself. It demands commitment to breastfeeding, and supporting breastfeeding, at a strategic level.

(For the few women who cannot breastfeed, the logical extension of the idea that breastfeeding is a woman's right would be to have robust systems in place to provide those women with acceptable alternatives; provision of donor milk and supplementary feeding systems, wet-nursing or milk-sharing, for example.)

So seeing breastfeeding as a woman's basic right, which she is free to exercise or not, is one way of reframing discussion of it. We move on then from divisive breast v bottle polemics, and instead focus on how our society and culture is, or is not, doing what it needs to do to ensure that a woman's right to breastfeed is not infringed. We're part of the way there with laws that protect breastfeeding in public, but we must also look at our failure, in the UK, to fully implement the WHO Code on the marketing of breastmilk substitutes, and confront what the recent figures showed so clearly - that breastfeeding in Britain is effectively a postcode lottery (despite what we know about its potential to reduce health inequalities). As Rebecca Schiller, in her role as co-chair of Birthrights, says:

"Women have a fundamental right to autonomy when deciding how and where to give birth and how to feed their babies. Birth choices are often made with feeding goals in mind. However, women in the UK do not universally have equal provision of these birth settings and often tell us that they are refused entry to them. Birthrights is working hard to raise awareness of this issue and work with women and health professionals to ensure that the choices women make around birth  - for whatever reason - are respected, supported and made realistic.

Women most certainly have the right to adequate levels of postnatal support and the right to make fully informed choices about how they give birth and feed their babies. If our maternity service doesn't offer all women the chance to make and realise those choices through appropriate provision of a range of birthplace settings and experienced, adequately staffed postnatal services, it certainly raises the question as to whether, through lack of resources and lack of evidence-based policy, we are effectively giving an illusion of choice where often none exists." 

Another way of reframing the discussion of breastfeeding takes a different tack - focussing on public, positive messages about breastfeeding (again, following in the footsteps of the Positive Birth Movement and Tellmeagoodbirthstory). My book Breastfeeding: stories to inspire and inform and its accompanying Facebook page attempt to promote positive breastfeeding stories - a recent favourite is this one from a mum who never thought she'd breastfeed, but changed her mind. Other groups and individuals are doing their bit to normalise breastfeeding and breastfeeding in public. Christina Conboys and a group of mums in Harrow have put together a book of fabulous, inspiring photographs called Breastfeeding is Beautiful; spoken-word poet Hollie McNish's heartfelt poem 'Embarrassed' is being shared all over the web - it sums up brilliantly some of the cultural issues affecting how we see breastfeeding in Britain. I also love the work of We Do It In Public, a photographic library of normal mothers breastfeeding in all sorts of everyday situations - for (paid) use by organisations, companies, websites and anyone who needs images of infant feeding to accompany their content. And it's a great resource for mothers to browse too.

The impact of these positive, public messages about breastfeeding cannot be underestimated. They are the antidote to all the little comments that undermine breastfeeding that we all come across every day: about four-hourly feeds, about a bottle before bed to get them to 'go a bit longer', about 'needing your body back', about no nutritional benefit after six months, about formula being 'just as good these days', about how 'he's using you as a dummy'. It works in the same way that positive birth stories counter negative messages about birth. It's well-known that supportive breastfeeding groups (again the parallel with the Positive Birth Movement is obvious), where mothers meet other women with similar experiences to their own, are of immense value in supporting women to meet their breastfeeding goals; that's why the major breastfeeding charities, such as La Leche League and the ABM, put mother-to-mother support at the core of their activities. I recently read this interesting blog about how negative experiences of breastfeeding in public affect mothers and influence their decisions about how long to breastfeed for; if we exchange those negatives for positives we both support breastfeeding and support women.

It seems to me that raising the profile of breastfeeding in the UK requires (at least!) a two-pronged approach. If we started by accepting that it is a woman's right to breastfeed if she wants to, then that would give us a clear way forward: breastfeeding needs to be at the heart of what we do, in government, in law, and in public life. It's not rocket science. It's just something else that HR departments, TV programme commissioners, editors and policy-makers would need to at least consider, in the way that they already consider diversity, gender, accessibility. And if, at the same time, we could increase the visibility of breastfeeding as it's done, everyday, by thousands of women, then it wouldn't be long before everyone stopped paying so much attention to it. It would just be normal.

(I'm reminded, in writing this, of feeding my daughter on a trip to the Westfield centre in Derby, a huge shopping mall with multiple, well thought-out parents' rooms. I often suggest to new mums I support that it's a good place for an early trip out with the baby because of these facilities. However, last time I was there and my daughter needed a feed I was close to benches in a large, airy seating area, with all sorts of people sitting on them - older Asian men, Derbyshire grannies and giggly teens. I consciously chose to join them all and feed my daughter there rather than going to the parents' room. I felt, as a confident third-time mum, that I was doing my bit to normalise breastfeeding. It may have backfired, however, as the Derbyshire grannies that cooed over the baby had leaned right over, stroked her head and tried to talk to her before they even realised she was feeding...)

What do you think of the idea of breastfeeding as a woman's right as a normal part of her sexual and reproductive life? I'd love to hear from you in the comments.

National Breastfeeding Week 2013: some thoughts on breastfeeding support

I've been a breastfeeding peer supporter for two and a half years, since shortly after my third child, who only recently stopped breastfeeding, was born. In that time I've been constantly reminded of the incredible value in what we do. When I hear women's stories (such as this one) of how they've been supported to overcome problems and achieve their feeding goals, I have a great feeling of pride and good fortune to have been able to be part of their support network. 

Breastfeeding support doesn't begin and end with a new mother and her baby, although they are at the heart of it. It ripples outward and affects others too - the partner who desperately wants to be supportive but doesn't have all the information he needs; the mother-in-law worried about why mum isn't giving the baby water between feeds; the GP who isn't up to date with treating thrush; the pregnant woman wondering how she will feed her baby; the young girls walking past mothers breastfeeding in coffee shops.

Whatever the ins-and-outs of the latest 'breast v bottle' debates in the papers, on TV or on the radio, peer support, which is truly mother-focussed, exists outside that arena. No one, surely, could have a problem with the idea of women supporting other women, who want to breastfeed, to achieve their goals. In the introduction to my book Breastfeeding: stories to inspire and inform, published a year ago by Lonely Scribe during National Breastfeeding Week, I wrote:

"Peer support is not about judging mothers' choices, or breastfeeding evangelism - it's about positive ways of helping those who want to breastfeed, for whom it matters, to continue as long as they want to, and supporting them to make informed choices for themselves and their families."

With its focus on listening (see this lovely post), taking time to understand mothers' concerns and making appropriate, supportive suggestions, peer support fills a need that maternity services and health visiting teams can struggle to provide. (Which is not to say that peer support alone is sufficient to properly underpin breastfeeding in the community; for that you need good systems of upward referral for more complex problems, often sadly lacking). Peer support comes in different guises; we are trained by and supervised by the NHS, but in other areas support may be offered through other organisations, such as the Association of Breastfeeding Mothers, La Leche League and the Breastfeeding Network, or through community interest companies like realbabymilk.org or Little Angels.

The feedback we get from mothers who attend our groups and see us at clinics, have home visits from us or call our helpline, is that the service we offer, voluntarily and free of charge, is highly valued and hugely important. Women remember kind words, a listening ear and calm suggestions, whatever course their breastfeeding journey takes, and this in itself is important - they may try breastfeeding again with subsequent children, or be more encouraging of their friends, or challenge misinformation when they hear it, based on their interaction with us. That's a responsibility, but one that I welcome; it feels like an incredibly gentle way of changing the world.

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I'm a peer supporter with BEARS in Amber Valley, Derbyshire. Follow us on Twitter @feedingsupport, and check us out on Facebook for details of groups and clinics, and our National Breastfeeding Week events. We're running our popular 'Breastfeeding Millionaire' quiz, with a host of fantastic prizes, all week, as well as a Positive Postcard Project (send a positive breastfeeding message to someone, and receive one yourself). And there's a Big Feed picnic in Belper River Gardens on Wednesday 26th June 2013 at 1pm.

Other Keep Britain Breastfeeding bloggers are involved in breastfeeding peer support: look up Mummyisagadgetgeek, lifeloveandlivingwithboys, Circus Queen, Hex Mum and Twinkle Mummy.


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Bedsharing and breastfeeding in the media - an analysis

This morning on Facebook the first thing I read was on one of the breastfeeding support pages I contribute to, from a mum who'd heard reports of the latest bedsharing research, published in the BMJ Open online, on the radio, worried about what she'd heard. I read the paper itself and the various articles about it, as well as a host of responses to it. A thread about the research on Mumsnet had over 300 posts last time I looked, and many of the articles have attracted numerous comments.

There's no question that reports of research in the mainstream media can have a massive impact on audiences. How could they not, with headlines and subheads like these: 'Bed-sharing newborns five times more likely to die suddenly than those who sleep in a cot, study shows' (Guardian), "Sudden infant death risk 'is five times higher if the baby sleeps in its parents' bed'" (Daily Mail), 'Parents should never allow babies to sleep in bed alongside them due to the risk of cot death, according to research which has prompted the Government to order an “urgent” review into official guidance.' (Telegraph), 'Bed-sharing "raises cot death risk fivefold" (BBC). The Mumsnet thread is full of people questioning their own behaviour in the light of the new research. The Facebook mum is not alone; all over the web there have been concerned parents, who've heard snippets on the radio or seen TV news items, wondering whether this new research can be believed.

There's a marked tendency in us to feel as though any 'new' report somehow trumps any previous research and this is certainly apparent in many of the comments on media reports - people believe that scientific research is a progression, and that each new finding is more reliable than the last, because it must build on what has gone before. That couldn't be further from the truth. The reality of scientific research is that it is much more complex a web than we might think. The research that is done depends on the interests of researchers, the availability of research funding grants, the whims of senior academics with preferred pet topics, the commercial aspirations of companies with cash, the declared aims of charitable organisations and many more variables. There are endless dead-ends, blind alleys and studies that contradict one another. And once the research is done there's the issue of making something of it, getting it noticed. Academic careers, the standing of institutions and future funding applications depend upon research reputations. Even when, as in this case, there is no suggestion of a conflict of interest among the authors, or of the funding for the study having come from a commercial interested party, there is still a need to publicise research, which is why editors and interested parties got a press release about this paper, which highlighted the most striking aspects of the research (as identified by the authors, or the press office?).

Another important point to make is that whatever the scientific ins and outs of the data presented in the paper, of which more below, researchers and academics are nonetheless able to draw their own subjective conclusions and have their own opinions about their research, based on their own experiences, culture and background, and this comes across strongly in the discussion/conclusions in the full paper. My feeling is that the paper's authors, while they may not have set out to provoke a media storm, nonetheless wanted to make a 'statement', and a recommendation that we reconsider the current UK guidelines is certainly that. (Several people I've talked to or seen comments from have thought, based on the reporting, that the guidelines are being or have already been changed to reflect this research - this is not true, although the BBC reports that the government have asked NICE to review their guidance in light of the findings.) I don't think the paper's authors have considered how their findings will be viewed by parents, or that they have much understanding or experience of our culture of parenting and infant feeding in the UK, although they do make some efforts to link their research to the UNICEF report on the cost savings associated with breastfeeding that I blogged about here.

Matters don't improve when the research is published. In the translation from the press release to finished articles, TV snippets, reports and local radio phone-ins much that is important is lost, and the discussions become less about what the research really shows, and more about the broad brushstrokes of an uninformed debate (much like the breastfeeding/bottle-feeding articles I regularly comment on).

Making sense of the crowded landscape of information requires time, an in-depth understanding of the subject in question and critical thinking, and the reality is that many of us rely on others to do this for us. (I am a non-fiction editor well used to reading and sifting large amounts of information, with a specialist interest in parenting and breastfeeding, and I still struggle at times to get to the heart of the matter.) Which is why I was delighted, having read the paper and some of the articles in the press, to find that UNICEF, Professor Helen Ball of ISIS online, and The Praeclarus Press, among others, had issued detailed statements that dig deeper into the research and expose some of its limitations. Professor Helen Ball also contributed to Radio 4s PM programme, where she discussed the findings with one of the paper's authors, Professor Bob Carpenter.

I've been interested in the whole media maelstrom from a breastfeeding perspective, because in peer support I'm often asked about sleep in the context of breastfeeding. Since studies suggest that co-sleeping and breastfeeding have an interdependent relationship, and we know that night feeds are important for maintaining mums' supply and on Radio 4 Professor Ball cited her own research that showed breastfeeding rates were twice as high among mothers who bedshared with their infants younger than three months, coupled with the fact that not breastfeeding increases the risk of SIDS, I've always believed, along with many others who work to support families, that black and white advice about bedsharing, as advocated by the authors of the paper, is inappropriate for breastfeeding mothers. I direct parents to UNICEFs leaflet Caring for Your Baby at Night and to Isis online for more information to help them make informed decisions. The NCT's page about bedsharing (cited by the authors of the BMJ study as evidence of 'a pro-bedsharing lobby', which I thought might be a clue as to their personal hang-ups on the subject) says that up to 50 per cent of parents admit to bedsharing on occasion. On the Mumsnet thread I mentioned above there were many contributions from mothers of infants who resorted to bedsharing as a practical solution to meet the needs of the whole family, and as the mother of three babies who breastfed frequently at night for many months I have been there myself.

So what of the relative risks for breastfeeding mothers who choose to co-sleep? Some interesting numbers can be extracted from the full paper. In the study, of 1,444 babies who died, 540 were breastfed (any breastfeeding - in this study even babies fed artificial milk at night in an attempt to get them to sleep longer would be in this group) and 940 were bottlefed. Of 1,405 babies who died (the exact numbers change slightly because of missing data), 1,091 had one or two parents that smoked. Of 1,422 babies who died, 607 had been put to sleep on their front (another criticism of the study is that it uses old data, including many babies who slept on their front). Overall, the rate of SIDS in the UK is approximately 3 in 10,000. Among breastfed babies, of parents who don't smoke and whose mothers have not had alcohol or illegal drugs, that is reduced to 1 in 10,000 for crib sleepers in parents' room and is 2 in 10,000 for co-sleepers. Breastfed babies thus have a lower than average risk of SIDS. In 2010 there were 254 unexplained deaths in England and Wales and 723,165 live births. (ONS). Given the above, it is easy to see why Professor Ball commented: '...both sleep locations for breastfed infants of non-smoking parents in the absence of alcohol experience very few SIDS deaths. It is curious, therefore, that the authors issued a press release to call attention only to this small difference in predicted SIDS rates for breastfed babies of non-smoking parents who bed-share compared to room-sharing – while ignoring the hugely inflated risks associated with hazardous bed-sharing environments. It appears as though the authors choose to target breastfeeding mothers in this way as they are a sub-group with strong opinions about the benefits of bed-sharing, even though the infants of these mothers contribute negligibly to UK SIDS rates.' Without wanting to overstate the case it seems that even in the conclusions of research papers there is an undercurrent that undermines breastfeeding and parenting behaviour that promotes it. Fascinatingly this chimes with something else I read today, the Alpha Parent's look at how societies can be 'gendered' - some of our problems with this research and the reporting of it may be able to be explained by 'masculine' traits in our culture.