Warning: long diary ahead.

Hanna Rosin makes "The Case Against Breastfeeding" in the April issue of the Atlantic Monthly. The provocative title is misleading, because as Rosin explained in an interview on NBC's Today show on March 16, she isn't against breastfeeding. In fact, she kind of likes breastfeeding. Her problem is with the people who promote breastfeeding. Here's the lead-in to her piece:

In certain overachieving circles, breast-feeding is no longer a choice--it's a no-exceptions requirement, the ultimate badge of responsible parenting. Yet the actual health benefits of breast-feeding are surprisingly thin, far thinner than most popular literature indicates. Is breast-feeding right for every family? Or is it this generation's vacuum cleaner--an instrument of misery that mostly just keeps women down?

Rosin packs a lot into the article, but I would summarize her main points as:

1. American women face intense social pressure to breastfeed exclusively.

2. Advocates exaggerate the benefits of breastfeeding, which the scientific research does not support.

3. Advocates downplay the negatives about breastfeeding and fail to acknowledge that formula-feeding can be the right choice for some mothers. On a related note, Rosin depicts breastfeeding as extremely inconvenient for mothers who work outside the home.

4. Advocates have medicalized the conversation about breastfeeding, and American women are wrongly led to believe they are harming their babies if they give formula instead.

I address those points and more after the jump. Rosin's conflicted feelings about breastfeeding are valid, but unfortunately, she draws too many broad conclusions based on her personal experiences.

For those who don't care to read the rest of this post, be assured that as a feminist and pro-choice woman, I respect the right of women to decide what and how to feed their own babies. I am also aware that some women are unable to breastfeed for physical or medical reasons, and many more women are unable to breastfeed because they lacked the information and support they needed in the critical early weeks.

My intention is not to judge any mother for her choices or add to the pain of any mother who did not have the breastfeeding experience she sought.

1. Do American women face intense social pressure to breastfeed exclusively?

Let's review some facts about breastfeeding in the U.S. The American Academy of Pediatrics recommends that babies be fed breast milk exclusively for the first six months of life, and that babies continue to receive some breast milk at least until they turn 1 year old. (The World Health Organization recommends two years of breastfeeding.)

Reading Rosin's article, you'd get the impression that women who don't conform to these norms are social outcasts. But a new study showed that only 50 percent of first-time mothers who gave birth in an American hospital were exclusively breastfeeding when their babies were a week old. By age six months, only about one-third of American babies are getting any breast milk, and only about half that percentage are exclusively breastfed. (That's a big improvement on 15 years ago, when only 19 percent of American babies were getting any breast milk at age six months.) By 12 months of age less than 20 percent of American babies are still partly breastfed.

So contrary to what Rosin suggests, formula-feeding mothers are not some ostracized minority in this country. On the contrary, formula-feeding mothers vastly outnumber those who follow the American Academy of Pediatrics' recommendations on breastfeeding.

Similarly, Rosin claims,

From the moment a new mother enters the obstetrician's waiting room, she is subjected to the upper-class parents' jingle: "Breast Is Best." Parenting magazines offer "23 Great Nursing Tips," warnings on "Nursing Roadblocks," and advice on how to find your local lactation consultant (note to the childless: yes, this is an actual profession, and it's thriving).

When I walked into an obstetrician's office, nine weeks pregnant with my first child, the nurse offered me a free formula sample. Ask any pregnant woman, whatever her education level--my experience was typical. And virtually all American parenting magazines carry formula advertisements claiming formula has the same nutrients found in breast milk. (Mothering is the only parenting magazine I know of that refuses to run formula ads, and you'll never find it in an obstetrician's office.)

In the hospital where my children were born, as in just about every hospital in the country (aside from Massachusetts), new mothers always are offered free formula samples and coupons. Nurses on hospital maternity wards commonly offer to supplement newborns with a bottle of formula or water, even when the mother has declared the intention to breastfeed. Nurses may try to supplement if the baby has gone more than a few hours without nursing, or in the guise of helping the mother get some rest. Researchers have repeatedly found, most recently here, that when babies are given bottles in the hospital, their mothers are less likely to breastfeed exclusively. Yet the practice continues.

Formula samples are also frequently offered when mothers bring new infants to a pediatrician's office for the first visit, usually around two to seven days after birth.

So contrary to the picture Rosin paints of a society hectoring expectant and new mothers to avoid formula at all costs, most American women receive formula samples directly from trusted medical professionals.

I've never heard of a bottle-feeding mother being asked to leave a public place or retreat to a restroom to feed her baby. Nor are formula-feeding mothers ever asked to throw a blanket over an infant on a hot day. Yet these experiences are so common for nursing mothers that advocates have pressed for state laws affirming a woman's right to breastfeed in public.

As I read Rosin's depiction of breastfeeding as "a no-exceptions requirement," and her insistence that formula should not be considered a "public health menace," I wondered what planet she was living on. She occasionally qualifies her argument (alluding to "upper-class" environs or "certain overachieving circles"), but elsewhere in the piece she wrongly implies that American mainstream opinion is now hostile to women who don't breastfeed exclusively. She wonders, "how is it that every mother I know has become a breast-feeding fascist?"

I would encourage Rosin to get out more. I've attended at least 200 different meetings of various mothers' groups in central Iowa during the past six years. For every anecdote in Rosin's article about snooty breastfeeding moms looking down on their bottle-feeding peers, I could tell 20 stories about women whose friends and family continually make belittling comments about their nursing.

Ironically, I would not have seen Rosin's interview on the Today show if a woman I know (the only breastfeeder in her extended family) had not posted this query on a parenting board:

My mom dropped [baby's name] off to me yesterday and stated that my father had seen something on a morning show yesterday that said you shouldn't breastfeed past 6 months, that it was better to give formula. Did anyone see this or know what he's talking about? I'm curious what it said and the reasons given. My parents are the "if it's on TV it MUST be true" types so I need to have my position ready for when it gets brought up again.

If you watch Rosin's interview, you'll see she says no such thing. In the same segment, NBC's chief medical expert emphasizes that the American Academy of Pediatrics recommends exclusive breastfeeding for six months, followed by continued breastfeed until at least 12 months of age. Yet my acquaintance's father, who views breastfeeding from a hostile perspective, watched the segment and absorbed that someone on tv said it's bad to breastfeed past six months.

I regret that any women are made to feel bad for choosing not to breastfeed, or for admitting to mixed feelings about breastfeeding. At the same time, we must acknowledge that nursing mothers are also judged and criticized for their choices, especially once you get outside the "overachieving circles" most familiar to Rosin.

2. Do advocates exaggerate the benefits of breastfeeding?

Research has connected breastfeeding with an enormous list of benefits for child and mother. This page on the website of La Leche League International, an organization created to promote breastfeeding, includes many relevant links.

Rosin examines some of the scientific literature and concludes that the benefits of breastfeeding are minimal or illusory. Sure, breastfeeding may prevent a bout with a stomach bug here and there, but too much of the research on other benefits is plagued by confounding variables. Are babies who were breastfed smarter, healthier, or less likely to be obese because they were breastfed? Or did they benefit from other features of their household or upbringing that happen to be correlated with a tendency of their mothers to breastfeed?

I am sympathetic to this line of analysis. A statistician in my family has indoctrinated me to be wary of confounding variables.

At the same time, I think there is more consensus than Rosin lets on about some issues, like the role of exclusive breastfeeding in reducing the risk of food allergies and intolerances.

Also, I couldn't help noticing that Rosin focuses on the most difficult advantages to prove while ignoring other benefits that are indisputable, such as:

-You never have to worry about breast milk being recalled, whereas contamination prompts recalls of infant formula periodically (see also here).
-Breastfeeding develops the jaw and facial muscles differently, reducing the incidence of certain dental problems.
-The manufacture and distribution of infant formula incurs many environmental costs that can be avoided or dramatically reduced by breastfeeding.

But like I said, I am sympathetic to arguments about confounding variables, and Rosin is correct that experts disagree about the role breastfeeding plays in making babies smarter, healthier, and less likely to become obese.

I don't want to spend much time on the debate over breastfeeding and intelligence, because in my opinion the whole concept of IQ is flawed. Whether breastfeeding adds zero or five or eight points to a baby's IQ is of little concern to me. I'd be happy to ditch the whole "edutainment industry" with its Baby Einstein this and its Brainy Baby that.

I do think Rosin ignores one important part of the picture, though. She quotes a researcher who has found a connection between breastfeeding and cognitive abilities as saying the causal factor may not be the breast milk, but the fact that breastfeeding mothers interact more with their babies. That hypothesis makes perfect sense to me. The neurologist Lise Eliot shows in What's Going On In There? that frequent, simple connections (talk to your baby, play with your baby, sing to your baby, hold your baby, carry your baby) are extremely important for a baby's brain development.

Bottle-feeding mothers can be just as attentive as any nursing mother, but if breastfeeding tends to promote this kind of regular interaction between mother and baby, that looks to me like a collateral benefit of breastfeeding, not simply a confounding variable.  

The same goes for mother/child bonding. Clearly mothers do not have to breastfeed in order to form a secure attachment with their babies. Attachment Parenting International offers suggestions on bottle-feeding techniques that promote attachment. It's notable that these mimic breastfeeding behavior: have one parent be the primary feeder, always hold the baby while the baby is eating or sucking on a pacifier for comfort, switch sides and make eye contact while your baby is eating, and so on. A nursing mother cannot avoid doing these things. If you're formula-feeding, it takes more effort and commitment not to prop a bottle in your baby's mouth so you can get an early start on dinner.

Consider the research on obesity. Breastfeeding is no guarantee that your child will not become obese. But overfeeding an infant has been shown to raise the risk of obesity, and it is much easier to overfeed if you are bottle-feeding. Whether a baby is guzzling or just nibbling on a bottle, food will continue to drip into the baby's mouth. Parents also have a tendency to keep trying to finish off the bottle so as not to waste any formula. In contrast, you cannot force a nursing infant who is not hungry to keep eating. A baby may continue "comfort-sucking" for a long time, but will not ingest a significant amount of milk without making real effort to suck and swallow.

Again, I would view this as a collateral benefit of breastfeeding; it naturally leads you to respect a baby's cues on hunger and satiety.

So much for what breastfeeding does for babies. Rosin also examines the other side of the coin:

3. Is breastfeeding much more unpleasant for mothers than its advocates are willing to admit?

Rosin was juggling a lot while writing this article, parenting three children and launching a new web site. She sometimes resented being tied down while nursing and was impatient for her son to finish his meal. When people say breastfeeding is free, Rosin writes,

I want to hit them with a two-by-four. It's only free if a woman's time is worth nothing.

Even staunch breastfeeding advocates can relate to these feelings. I've been to a lot of La Leche League meetings where women lament how little they get done and complain about their babies' nursing habits--marathon nursing at night, biting, climbing, or popping on and off the breast frequently.

I think Rosin generalizes too much about her experience, though. She frequently refers to breastfeeding as inconvenient for mothers, but my friends who have raised both breastfed and bottle-fed children will swear on a Bible that breastfeeding was 100 times more convenient. They didn't have to worry about forgetting a bottle or not having access to clean water when they needed to mix a bottle. They could feed their baby at a moment's notice without taking the time to assemble and warm a bottle. They didn't go to the trouble of making a bottle only to find that their baby wasn't really hungry and just wanted a few seconds of comfort sucking. The list goes on.

I've never worked outside the home while nursing, but I have traveled with babies and toddlers and found breastfeeding to be much less hassle than having to bring along the right kind of food and clean containers. I haven't felt trapped at home either; my babies accompanied me to who knows how many meetings, receptions and political events.

Rosin goes too far to suggest that choosing to breastfeed "pretty much guarantees that you will not work in any meaningful way." Taking care of a baby is time-consuming no matter how you are feeding. Furthermore, I have many friends who have worked outside the home while continuing to breastfeed. They enjoyed maintaining the breastfeeding relationship and connecting with their baby in a way that no substitute caregiver could match.

Some women are able to work from home or take their nurslings to work with them in the early months. Iowa State Representative Janet Petersen and State Senator Staci Appel come to mind. Taking your baby to work is obviously easier if you work for yourself or for an unusually enlightened employer. The successful Des Moines attorney Roxanne Conlin told me a few years ago that she lets her employees bring babies to work until the babies can walk.

If the "mommy track" does tend to derail women in certain high-status professions, I think it's wrong to pin the blame on breastfeeding. Workplaces are often inflexible, and the demands of parenting small children are unrelenting.

For reasons I do not understand, Rosin ignores many proven benefits of breastfeeding for mothers, especially those who nurse for longer than a few months: regular release of the hormones oxytocin and prolactin, reduced risk of several types of cancer as well as rheumatoid arthritis, reduced risk of postpartum bleeding, stronger bone density, and delayed resumption of menstruation and fertility. Many nursing mothers also find it easier to lose weight, although that is not true for everyone.

Rosin seems to harbor a special loathing for breast pumps, judging from one cruel passage in her article. Writing about a friend who was exclusively pumping breast milk because her baby could not nurse, Rosin comments,

One of them sat on my couch the other day hooked up to tubes and suctions and a giant deconstructed bra, looking like some fetish ad, or a footnote from the Josef Mengele years. Looking as far as humanly possible from Eve in her natural, feminine state.

Words fail me here. My friends who have pumped for babies with special needs found it comforting to be able to feed their milk to their babies despite less than ideal circumstances. Portraying them as freaks or torture victims is so uncalled for. By the way, PumpingMoms.org is an excellent resource for women who are exclusively feeding their babies breast milk in bottles.

Pumping is probably not the favorite aspect of any working mother's day, and women who detest it should feel free not to do it. But many women have no regrets about pumping, and I've talked with older women who say they would have loved to nurse their babies longer if breast pumps had been available in their day.

Rosin's antagonistic view of pumping is related to one of her other beefs with the breastfeeding establishment:

4. Do breastfeeding advocates mislead women about the harm they will do if they choose not to breastfeed?

Rosin doesn't like the trend for breastfeeding advocates to talk about its benefits in medical terms, as if breast milk were an essential vaccine. She has a point, but let's face it--we Americans trust science and what our doctors tell us. If you come from a family where everyone formula feeds, a touchy-feely argument about bonding will carry less authority than telling your parents that you're breastfeeding because Dr. So-and-so said it's healthier for the baby. I've met many new mothers who came to support groups seeking talking points to use with hostile relatives, and they invariably latch on to the medical arguments in favor of breastfeeding.

Rosin is deeply offended by any suggestion that choosing not to breastfeed puts your baby at risk. I get where she is coming from. Mothers face so many competing demands in our society and tend to beat themselves up for every perceived failure. Parenting an infant is exhausting and can be overwhelming, whether or not you are nursing. The last thing a mother needs is one more reason to feel guilty.

If we're honest, we could all be doing more for our bodies, our families and our planet. But we don't ask nutritionists to stop talking about healthy eating because it could make less mindful eaters feed bad. We don't ask global warming activists to stop talking about carbon footprints because it could make energy hogs feel bad. By the same token, it is unfair to ask advocates to stop talking about the health, environmental or emotional benefits of breastfeeding because doing so could make formula-feeding mothers feel bad.

Along these lines, Dr. Jack Newman provides a good analysis of breastfeeding and guilt in his Ultimate Breastfeeding Book of Answers, which for my money is essential reading for every nursing mother.

One of my friends who happens to be an accredited La Leche League leader read Rosin's article and had this reaction:

I think what she was trying to accomplish with this article is to basically support mothers who choose not to breastfeed. [...]  There will always be mothers who choose to use formula for their own reasons and they need support, too.

So true. I would like to see more tolerance and acceptance for all loving mothers. In addition, mothers who work outside the home deserve better support, such as longer maternity leaves and more flexible schedules, no matter how they are feeding their babies.

Who cares what Hanna Rosin thinks about breastfeeding?

By now readers may be wondering why this political blogger has bothered to write so much about one magazine article. Besides the fact that I enjoy the Atlantic Monthly and Rosin's previous work (see here and here), this article touches a nerve with me for various reasons. The title is a cheap gimmick to sell magazines that will inevitably be misinterpreted by breastfeeding opponents.

I also was disturbed by the author's smirking reference to lactation consultants ("note to the childless: yes, this is an actual profession") and condescending description of La Leche League.

Not so many years ago, I was a new mother who wanted to breastfeed. I would have wanted to even if breast milk had zero nutritional or environmental benefits over formula. But I had no family or friends nearby who were experienced nursers, and breastfeeding did not come naturally to me or my child. Some of our early difficulties were commonplace, and a couple of issues were more unusual.

I didn't need someone to tell me sticking with it didn't matter, because breastfeeding is overrated for babies and a big hassle for mothers.

What I needed was practical advice and support from knowledgeable and compassionate women. I got that from an outstanding lactation consultant and a group of La Leche League leaders who spent many unpaid hours getting me--a stranger to them--past the early obstacles.

As a result, I cannot accept Rosin's portrayal of breastfeeding advocates as bullying scolds who do mothers and babies no favors.

I didn't need to breastfeed in order to love my children or be a good mother. But breastfeeding has enriched my life. For that I am grateful to the advocates who made our family's experience possible.