Why do breastfeeding researchers ignore the obvious?

It's time once again for a periodic festival of official hand-wringing over breastfeeding rates. Researchers are shocked, shocked that women quit breastfeeding at very high rates. And they are shocked, shocked that all their efforts to date to encourage breastfeeding have been essentially useless.

For me, the only thing that is surprisingly is that breastfeeding researchers are so incredibly clueless about why women stop breastfeeding. Or perhaps they are not clueless, they simply refuse to accept the obvious:

The dirty little secret about breastfeeding is that starting is hard, painful, frustrating and inconvenient. And continuing breastfeeding is hard, sometimes painful, and incredibly inconvenient especially for women who work, which in 2012 is most women.

The paper that has precipitated the latest round of hand-wringing is Baby-Friendly Hospital Practices and Meeting Exclusive Breastfeeding Intention by Perrine et al., posted this morning on the website of the journal Pediatrics. According to the study:

Among women who prenatally intended to exclusively breastfeed (n = 1457), more than 85% intended to do so for 3 months or more; however, only 32.4% of mothers achieved their intended exclusive breastfeeding duration. Mothers who were married and multiparous were more likely to achieve their exclusive breastfeeding intention, whereas mothers who were obese, smoked, or had longer intended exclusive breastfeeding duration were less likely to meet their intention. Beginning breastfeeding within 1 hour of birth and not being given supplemental feedings or pacifiers were associated with achieving exclusive breastfeeding intention. After adjustment for all other hospital practices, only not receiving supplemental feedings remained significant (adjusted odds ratio = 2.3, 95% confidence interval = 1.8, 3.1).

That is absolutely, positively, 100% consistent with the fact that breastfeeding is a lot harder in practice than advocates make it sound. Indeed, it is no different that what we would find if we surveyed a group embarking on an effort to run 5 miles a day for 3 months or more. People don't live up to their intentions because they find it too hard to do so.

But as I said above, no one wants to talk about the difficulties of breastfeeding. Indeed, most advocates, like the authors, don't even want to mention the truth. Instead they seek convoluted explanations that are not even justified by the evidence. The authors insist, with absolutely no empirical evidence, that women quit because hospitals are not supportive enough.

The authors' interpretation rest on several critical unexamined assumptions.

1. The authors assume that women who claim they will breastfeed exclusively actually intend to do so.

In 2012, there is so much pressure to breastfeed that it is socially unacceptable to tell researchers that you don't plan to do so. It never occurs to the authors that patients tell them what they think the researchers want to hear rather than telling them the truth.

This is a well known phenomenon among those who take surveys. According to market research firm Synovate in regard to survey questions:

Safe issues are those that elicit an honest response from most respondents most of the time. Surveys about daily activities such as television viewing and shopping can be considered safe...

Careful issues are topics that moderately elicit an honest response. For example, when it comes to personal finances (except for discussions about charitable contributions) an equal number of people would provide honest answers as not.

In surveys about the consumption of stimulants, alcohol and illegal drugs, the honesty of answers depends on the social acceptability of the substance under discussion. So 58% of Americans would be honest about cigarettes, 37% about alcohol and just 14% about illegal drugs...

N0-go issues are the unmentionables of survey topics.

Synovate learned that at least 60% of all our respondents would lie about sexual relationships, especially when it comes to taboo subjects like marital infidelity and sexual dysfunction.

2. The authors assume that women can make accurate predictions.

It is easy to claim that you are going to breastfeed for a specific duration when you have absolutely no idea what breastfeeding entails. When reality intrudes, mothers change their minds.

3. The authors make the elementary mistake of assuming that correlation equals causation. Just because more babies who received supplemental formula in the hospital were not ultimately exclusively breastfed does not mean that the formula itself contributed in any way to the duration of exclusive breastfeeding.

4. The authors assume that the supplemental feedings a baby received was due to hospital policy, not maternal request. It is highly unlikely that a baby will receive supplemental feedings if the mother insists she does not want them. Therefore, whether or not the baby received supplemental formula has much more to do with the mother's beliefs than the hospital's beliefs.

5. The authors assume that patients randomly are assigned to hospitals and that they have no role in choosing which hospital they attend. While that may be the case for some women, those who are particularly motivated about breastfeeding may be more likely to choose baby-friendly hospitals.

6. The authors assume that breastfeeding is easy and problem free. It seems never to have occurred to the authors that women gave up breastfeeding because it was painful, difficult or inconvenient. Amazingly, the authors never bother ask women why they stopped breastfeeding. It is an inexcusable omission.

The authors conclude:

Two-thirds of mothers who intend to exclusively breastfeed are not meeting their intended duration. Increased Baby-Friendly hospital practices, particularly giving only breast milk in the hospital, may help more mothers achieve their exclusive breastfeeding intentions.

The 6 unwarranted assumptions render the authors' conclusions essentially worthless. Indeed, it is ludicrous that the authors thought they could determine why women stop breastfeeding without even bothering to ask them why they stopped breastfeeding.

Women stop breastfeeding because for many it is painful, difficult and inconvenient. Breastfeeding advocates may not like that answer, but that's reality. I've written about this extensively in the past:

I don't really understand why breastfeeding activists refuse to acknowledge the reality of breastfeeding. They prefer to sugarcoat it with little maxims like "breast milk is always available," breast milk is always the perfect temperature," and "breast feeding saves money." Those statements are true, but they ignore the very real challenges in initiating and maintaining breastfeeding....

Breastfeeding is a learned behavior. It is not instinctual on the part of the mother and although a baby has the instinct to suckle, latching on properly and actually getting milk requires practice. A new mother and a new baby may get frustrated very quickly when things do not proceed smoothly.

New mothers are often emotionally labile, due to the effect of hormones. A baby screaming desperately in hunger (and all babies begin to screaming desperately within seconds of realizing they are hungry) can upset even an experienced mother. It's much worse for a new and inexperienced mother who can easily become frantic to satisfy the baby, fearing that the baby is starving...

Initiating breastfeeding is often painful. Cracked and bleeding nipples are every bit as unpleasant as they sound. Countless new mothers tell stories of bursting into tears whenever the baby starts to cry, in anticipation of the pain of nursing...

Maintaining breastfeeding while working is incredibly difficult. During the typical work day, a woman may need to pump twice or more, each session taking 20-30 minutes and requiring a clean and private place to pump, a breast pump, and a refrigerator to store the milk. Professional women may be able to assemble these resources, but the average working woman has neither the facilities, nor the time to pump at work.

The bottom line is that as long as breastfeeding advocates and researchers ignore the reality of breastfeeding, they are wasting everyone's time and money trying to blame low breastfeeding rates on everything but breastfeeding itself.