Medical advice through history and the decline of breastfeeding

I’ve been thinking a lot about Similac’s recent recall of 5 million cans of formula thought to contain beetle parts, and what it means for breastfeeding advocacy. At first blush, it looks like a slam dunk argument to encourage more moms to breastfeed. Faced with a decision between bug-part-tainted powder and mom’s milk, surely more moms will want to breastfeed.

Chicago public health poster urges mothers to breastfeed rather than feed babies tainted cow’s milk.

But history teaches us that tainted breastmilk substitutes are a losing argument for breastfeeding. In her fascinating book, “Don’t Kill Your Baby: Public Health and the Decline of Breastfeeding in the Nineteenth and Twentieth Centuries,” historian Jackie Wolf chronicles the breast vs. bottle debate a century ago in Chicago. Child health advocates of this era faced a double crisis: more and more mothers couldn’t make enough milk, and were turning to cow’s milk that, in the early 1900s, was unpasteurized and often contaminated with visible chunks of animal feces.Thousands of babies were dying, and advocates went to work to both encourage breastfeeding and clean up the milk supply. Within a decade and a half, milk was pasteurized, and, with the poop out of the cow’s milk, mothers figured that they didn’t need to breastfeed any more – and we began a decades-long decline in breastfeeding rates.

The problem was the apparent “epidemic” of failed lactation. Wolf quotes multiple pediatricians who decried the modern woman’s loss of milk producing capacity, attributed to the stresses of modern life. In fact, that epidemic was caused, in large part, by bad advice from pediatricians. In an era where industry and schedules was replacing productive work inside the home, mothers were advised that infants needed to be placed on a schedule, from their earliest days, so they would grow up to be responsible workers. Advised to feed every 3 to 4 hours, mothers’ milk supplies spiraled downward, forcing them to supplement. Clean cow’s milk become a public health imperative – and no one thought to consider how the medical profession and cultural norms had derailed breastfeeding physiology.

So what does this have to do with Similac and beetle parts? Much has been made of Senator Tom Harkin’s letter to Abbott about the recall and the need to clean up the formula supply chain. Clearly, we need to make sure than formula is free of contamination. But where are the calls to investigate the breastfeeding supply chain?

In the US, 75% of mothers start out breastfeeding, but a dismal 13% are able to meet AAP recommendations for 6 months of exclusive breastfeeding, and less than ¼ are still breastfeeding at one year. This is not a problem with maternal motivation: in a recent study of more than 2000 mothers, 60% of those who quit in the first year wanted to breastfeed longer than they did.

Many of the reasons that mothers quit could have been solved with adequate lactation support, skilled healthcare providers, and a culture that values mothers and babies. Yet every day, we fail women, whether through routine hospital practices that undermine moms or through workplace policies that force women to choose between nourishing their babies and supporting their families. We need to shine the spotlight to these “booby traps,” with the same urgency that politicians are investigating formula factory supply lines.

Tom Harkin might start in his home state of Iowa, where the CDC Breastfeeding Report Card for 2010 reports that maternity centers received a score of 61 out of 100 on the mPINC survey — a gentleman’s C — and none of the state’s live births occur in a Baby Friendly facility. Iowa has 2.2 board-certified lactation consulatants per 1,000 live births — below the national average — and has only one half of one FTE state employee dedicated to breastfeeding support. Along with 34 other states, Iowa has no legislation mandating employer lactation support. The issues here have nothing to do with how mothers want to feed their babies — these are systems problems that, like beetles on the assembly line, demand systems-level solutions.

The core public health problem with our epidemic of formula feeding is not that there are occasional recalls of tainted formula. The problem is that we are setting mothers up to fail, and then shrugging our shoulders and saying, “Once the beetles are out of the formula, what’s the big deal?”

Senator Harkin, you are chair of the Senate Committee on Health, Education, Labor and Pensions. Clean up the formula, please, but then, let’s tackle the breastfeeding supply chain. America’s moms are counting on you.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the Academy of Breastfeeding Medicine.