A Parent’s View – Emma Veitch
Breastfeeding is in the news AGAIN. A new statement from the Royal College of Midwives (RCM) has made the not-very-radical announcement that women must be supported if they choose to feed their babies formula, rather than breastfeed exclusively. A flurry of media articles focused on the difficult experiences that families go through when breastfeeding is promoted at the expense of individual needs. Huge numbers of families responded on social media to say how they were affected by failure to support them with formula feeding, leading to guilt, shame, postnatal depression, and even rehospitalisation of babies with complications linked with underfeeding. These reactions are uncannily similar to the response after a UK hospital was recently criticized for referring to formula feeding as “artificial feeding” in antenatal letters to parents. There seems to be growing acknowledgement that use of loaded language around infant feeding may be problematic: one researcher, who has highlighted the adverse mental health outcomes associated with feeding difficulties, acknowledged that…
“current breastfeeding promotional strategies are not “mum-friendly” enough and can foster negative emotional experiences”
However, the use of loaded language in infant feeding isn’t by any means accidental. While training as a breastfeeding peer-supporter, I was specifically told it was not correct to speak of the “benefits” of breastfeeding but rather the “risks” of formula. Negative framing to refer to formula feeding has been actively promoted by some breastfeeding advocates, and goes back to a 1996 editorial in the Journal of Human Lactation which argues that the stats from epidemiological studies should be flipped, to inform parents of the harms of formula feeding, rather than the benefits of breastfeeding:
“Artificial feeding, which is neither the same nor superior, is therefore deficient, incomplete, and inferior”.
“If breastfeeding is made to sound optimal than parents might settle for normal, but if breastfeeding is presented as normal then formula feeding becomes deficient and inferior”.
This editorial has been hailed as “seminal” and “highly influential”, and it’s been said that uptake of this approach would help to increase breastfeeding rates.
I’ve seen this idea put into practice in many discussions around infant feeding, for example:
Mass media articles: “breastfeeding doesn’t reduce the chances of a baby becoming obese; it’s formula feeding that increases the chances of childhood obesity…. we should be talking about the risk of formula feeding and not the benefits of breastfeeding”
Resources used by parents: “formula… comes with its own set of risks… comes with increased health risks for baby and mother”
Guidance for healthcare commissioners; “NOT breastfeeding is linked to an increased risk of..”, and elsewhere.
To begin with I was skeptical about the idea of negative framing, but didn’t know much about the evidence of its effects. In the UK, the vast majority of babies receive at least some formula during the first year of life, with 73% receiving milk other than their mother’s by six weeks – even if they are also breastfed. Mums who do introduce formula early seem to be at higher risk of stopping breastfeeding entirely, so surely it makes sense to do the most possible to help these mothers access support. So, is there any evidence on the effects of different framing approaches on mothers’ motivations, and their engagement with support services or promotion policies?
Does the “FORMULA = RISK” approach help promote breastfeeding?
Currently in the UK, many breastfeeding support services aim to provide non-judgemental support to help women meet their own breastfeeding goals. So ideally, services should motivate women who already want to breastfeed to seek the support they need to continue, without alienating women who are also formula feeding as well, or who don’t want to breastfeed in the first place.
Thankfully, behavioural science studies have been done on the effects of different information framing strategies for breastfeeding. I’ve found two studies, one involving expectant mothers, and the other undergraduate students, both male and female. These studies were done by researchers in the US; participants for the student study came from a midwestern university, and the mothers’ study recruited from a national online community for expectant parents. In both studies, the participants were randomized to either positively or negatively framed expressions of the same information about how infant health outcomes may be affected by breastfeeding or formula feeding. The two studies had completely consistent results: negatively framed presentations alienated participants from breastfeeding promotion strategies! In the “expectant mothers” study, women shown the “negative” framing were no more likely to say they wanted to breastfeed, but “were significantly more likely to say they found the text untrustworthy, inaccurate, and unhelpful”.
The researchers did a follow-on analysis of the expectant mothers study, with mothers quoted as saying, for example:
- “I will breastfeed but that was very biased”
- “Absolute bullsh*t”
- “It makes me angry because it uses very divisive language to make a mother believe that formula feeding is absolutely the worst thing they can do for their baby.”
- “I felt the tone of the introduction was alarmist and that made me feel that the other information may have been cherry-picked or misrepresented to support the narrative. Therefore I do not trust the information to be unbiased”
Some prominent breastfeeding advocates have picked up on this and feel that negative rhetoric around formula feeding should be reconsidered.
Understanding how women feel about formula
When my second baby was around three months old, a close relative became terminally ill and had repeat hospital admissions for complications associated with his metastatic cancer. I needed to help get his partner to visit him on the acute care ward and stay there with them both, so she could provide emotional support for him, as he was delirious and distressed. I left my baby at home with another carer but there was no time to organise expressed milk; somebody else would have to feed the baby while I was gone. If someone had told me at that time that “formula has risks”, this probably would have led me to ignore their message and turn down any offer of help. I didn’t need help with breastfeeding, it was established and easy by then. I was doing everything “correctly” but my personal circumstances had changed and if someone told me that formula – the tool which allowed me to provide emotional support to my loved ones during an awful time – was risky would have been in no way helpful and would have added unnecessary distress, anxiety and self-scrutiny.
When I helped at breastfeeding support groups it was so common for women to come in severe emotional distress, linked with their feeding difficulties, and often describing real anxiety around the need to give the baby formula. One researcher investigating this describes the “highly pervasive nature of negative emotions occurring among formula‐feeding women”. She has said this may come from self-reproach, but also that external factors (eg, criticism from other mothers, or healthcare professionals) can be involved. If women are told that “formula has risks”, this could:
- accentuate feelings of guilt and shame, experienced by a mother who is after all, nourishing her baby in a safe and nutritionally adequate way
- deter a mother from supplementing when her milk is insufficient
- alienate mothers from health promotion policies and services, if they perceive the “formula = risk” message to be an “official” policy
Moving forwards: what’s the best way to present information to families?
These themes are backed up in research looking into family perceptions of infant feeding decisions. A study on families in disadvantaged areas of Scotland found that high-level “policy” goals, like 6 months of exclusive breastfeeding, were thought to be unrealistic. Families in that situation might have a dim view of messages saying “anything less than this is a risk or suboptimal”. These researchers say that support should be framed around the individual families’ reality and needs.
What does this all mean in the context of the RCM statement? Language needs to be respectful, and all information should be balanced and relevant. How that is implemented in reality is important. If I were starting my infant feeding journey again, I would want information communicated as neutrally and informatively as possible, avoiding emotionally charged language, and taking account of my family’s unique situation. Ideally, I’d want all information about risk to be given quantitatively, focusing on important health outcomes and using accepted guidance, like the NICE standard for communicating health information. For example, if a case of diarrhoea or upper respiratory tract infection is less likely in a breastfed baby, how large are those differences, in absolute terms? Then, I can weigh this up in a balanced way against the practical issues – breastfeeding difficulties, the need the baby has for supplementation because my milk is insufficient, and so on.
My hope would be that if breastfeeding advocacy groups can reject the “language of risk”, and other types of emotionally charged language around infant feeding, they will be able to achieve two goals simultaneously: to increase trust in this area of health policy overall, and to increase breastfeeding rates, through building engagement with support services. And that can all come from watching our language.
Emma Veitch, PhD
Competing interests: EV has never received any money or had any involvement or with any for-profit organization or company in the area of infant feeding (eg, formula companies, baby food manufacturers etc). She has previously spent a number of years training and volunteering for one of the UK’s breastfeeding support charities, however is not currently involved with them. As part of this volunteering, she helped contribute to a Cochrane systematic review of breastfeeding support, which had funding from Baby Friendly, but EV did not receive any funds or benefits for her contribution.
This article is a revised version of a blog that previously appeared on Infant Feeding Support UK, a group dedicated to promoting the communication of safe, unbiased and science-based infant feeding information to parents and carers. Many thanks to Steph Maia and Erin Williams for discussions on these and other ideas around issues in infant feeding, and for publishing the original blog