In which I rabbit on about informed choice...

Informed choice requires two things – information and choice!

Seems a bit self-evident really. So why, when it comes to infant feeding, is giving people information – and pointing out inaccurate information (a quick thank you and link to the wonderful Dispelling Breastfeeding Myths here – whose mission is to do just that!) – so often seen as an attempt to curtail women's choices? And why do people seem to think that because some people don't have a choice, the information should be suppressed or downplayed? Or perhaps that it must be incorrect or exaggerated?

If a woman chooses to formula feed, that is her right. She should not be bullied into breastfeeding.

If a woman chooses to breastfeed, that is her right too. She should not be bullied into formula feeding (regardless of whether or not she is experiencing difficulties establishing breastfeeding).

Nevertheless, it is only fair that both of these women are made aware of the genuine risks vs benefits of her choice – and how it may affect her health or that of her baby. They should also be made aware of the other alternatives to breastfeeding or formula – donated milk or her own pumped milk. There are also options that are so far from ideal that they aren't even considered options, such as skimmed milk, coconut milk, fruit juices... Technically, these are all choices that could be made – it's OBVIOUS that any health care professional would criticise a mother's choice to feed any of these to her newborn infant. But, hey, would they rather the baby starved? 

 

It is impossible to make an informed choice if you do not know all the options, or you do not have sufficient information about the options, or you cannot realistically make a different choice.

If you have a choice between spending £1 or £2 on the same item, spending £1 is a good idea, the WISE choice. If someone then tells you that you could've spent 50p instead if you'd been in a different shop, that doesn't negate the fact that you WEREN'T in a different shop (and had no way of knowing about the price in that shop, and possibly couldn't have made it to that shop even if you HAD known). Nevertheless, responding to this information with 'I couldn't buy it for 50p, so I suppose you'd rather I'd spent £2?' or 'I know 50p is cheaper, but £1 isn't any more expensive', or telling others considering making a similar purchase 'I spent £1 and I didn't go bankrupt, so it doesn't matter if you pay £1 instead of 50p' is just nonsensical.

Or a more detailed metaphor:  

The local café has 3 sandwiches on the menu: ham, cheese and rabbit.

Andy and Belinda have never eaten rabbit in their lives. Andy elects to try it, while Belinda plays it safe with cheese. These are choices, but not truly informed choices.

Chris is not told that there is rabbit on the menu. He chooses cheese over ham – it's a choice, but it was made without all the information. Not informed.

Dave is a vegetarian. While he is technically choosing the cheese sandwich (after all, it is his choice to be a vegetarian, and if he doesn't want cheese he could go elsewhere for his lunch), it is hardly a fair choice. It's informed, but his choices were hugely limited.

Ellie is told they have run out of rabbit. She wanted to try the rabbit, but settles for cheese. It's her choice, but between cheese and ham – her choice was informed, but still limited.

Now – suppose that the café is visited by a food critic, who says that, while the cheese and ham sandwiches are passable, the rabbit sandwich is the greatest thing ever. Does this criticise the CHOICES that Chris, Dave and Ellie have made? Surely it can't, since none of them really had the option of a rabbit sandwich! The only people who had that option – Andy and Belinda – had no idea at the time that it was recommended, so it doesn't even criticise Belinda's choice (or for that matter congratulate Andy's), all it criticises is...the food! So, how can the solution possibly be to not give this information to others?

It is indeed rude, insensitive and pointless for Andy to tell all his friends how great the rabbit sandwich was if they won't be visiting the café again. It would be fairly unpleasant of Andy to specifically tell Dave about how great the rabbit is. (Rather like deliberately savouring a cake in front of someone on a diet!*) But Dave being a vegetarian is not a good enough reason for Andy to avoid mentioning that the rabbit is excellent to people who ARE planning to visit the café, even if it happens to be in Dave's hearing.

The fact that a vegetarian can only have the cheese is irrelevant to how good the rabbit is. It doesn't help vegetarians if omnivores decide to eat cheese instead of rabbit. In fact, if you want to help vegetarians get the best possible sandwich, surely advocating for higher quality cheese, or even better - rabbit-flavoured tofu – would be a far more useful solution than bitching about the rabbit-eaters trying to persuade other omnivores to eat the rabbit! In short - giving people reasons to try the rabbit does not remove cheese from the menu.

(* Have I just put a simile inside the metaphor? Blimey...I should wrap this one up)

A is for apple, B is for bottle, Pink is for girls...

Every so often another baby t-shirt appears in the shops with a slogan that annoys the breastfeeding community. Something along the lines of 'Party in my crib. 2am. Bring a bottle' or the Old Navy 'formula powered' onesie that caused a fuss a couple of years ago, or the latest one I've seen (which inspired this post), linked on Facebook, on the wonderful Analytical Armadillo's page, which was just odd: an equation showing a picture of a cow + picture of a milk bottle = feed me.

Lots of people say 'Chillax, it's only a t-shirt – Jeez, way to overreact!” when this sort of thing gets flagged as less than ideal. What they are failing to realise that this t-shirt is not the problem; it's a symptom. It's as if you've described a blemish on your body to your doctor, and they tell you, 'Hey, it's one tiny zit, don't freak out' – not understanding that the significance is not that one spot, but that there are hundreds of them forming a rash all over your body!

This culture has a pervasive attitude of bottle = baby. These t-shirts feed into that assumption, making it harder to challenge, and making it harder for people to choose to breastfeed. Everyone THINKS they know breast is best, but the message they actually get is breast is the ideal, a special extra, for those privileged few who can manage it, while formula is normal, and just as good. (Which is not logically possible, people. But that's a topic for another day.)

This prevailing attitude and assumption is very comparable to the reasoning behind 'Pink stinks' http://www.pinkstinks.org.uk/ Everywhere we look, the idea that 'pink is for girls' is reinforced. It's as well known as 'a is for apple'! There is nothing wrong with pink as an option. There is EVERYTHING wrong with giving boys a choice between blue and green and red and yellow (but not pink), while girls have the choice between coral and fuchsia and rose and cerise! Surely such cultural bias is even more problematic when the preferred, expected option (bottles) is intrinsically inferior to the far less visible option – breastfeeding.

Personal anecdote time - my son is growing his hair out. It's not quite long enough to tie back in a pony tail yet, but he needs to be able to wear a head band of some sort to keep the hair off his face. So I started looking for hair bands for him. It took weeks before I found what I was looking for – something cheap and practical that was neither pink nor covered with flowers. In the interests of full disclosure, I did find purple – but it was a lilac shade, and very 'girly' looking. And how depressing is that? Even I, who am proud of my boy's occasional tom-girl tendencies, who am fully aware that 'pink is for girls' is a limiting nonsense – feel obliged to buy into the societal norm of NOT putting pink accessories on my son. (He is at an age where his peers are likely to tease him for it, and adults have occasionally mistaken him for a girl, purely because of his longish hair. I don't want him to be teased, and I certainly don't want to risk him ending up utterly rejecting all things feminine in reaction to it!)

This culture 'knows' that long hair = girl = pink. Just like this culture 'knows' that baby = bottle. Which isn't a noticeable problem if you fit that norm. But it makes it harder, much harder, if you don't. And adds extra pressure to conform. Especially if you are at a vulnerable time in your life – say you're a child, or a tired, nervous, struggling new parent.

Of course no one chooses to formula feed on the basis of one t-shirt. Of course they don't. And no one decides their favourite colour on the basis of one t-shirt either. But when almost every t-shirt, toy and accessory you've ever owned is pink, or has some pink on it, you start to associate pink with nice things, and you learn to love pink. What do you think is the most commonly stated favourite colour among girls? Is there any doubt in your mind? Now, it is true that some people claim that the cause and effect goes in the opposite direction: i.e. there's a biological difference between men and women – and girls get pink stuff marketed to them because they are naturally drawn to it, rather than being drawn to pink because it is advertised to them. But I can't think of a single logical reason for such a preference to have evolved (at least not only in females), and it seems even less plausible in light of the fact that in the past pink was considered a masculine shade (being similar to red - a strong colour, while pastel shades – such as pale blue – were considered more suitable for girls!) It seems much more reasonable to accept that the pervasive message of girl = pink is affecting the choices and preferences of the last few generations of women. And even if one were to accept the premise of a biological preference - there can be no real doubt that marketing pressure exaggerates that preference to a ridiculous degree. Similarly, the existence of the 2-5% of mothers who have a physical need to supplement their own milk does not account for the fact that well over 90% of mothers in the UK do so before their baby reaches 6 months!

Marketing works. It's not insulting, or suggesting people are too stupid to make up their own minds to say so. If you think you are not affected by adverts, I suspect you are either lying to yourself or have a brain that does not make synaptic connections in the usual manner. Could you sing a jingle from an advert you haven't seen recently? Do you occasionally realise you're hungry when you see an advert for food? Do you know what I mean by 'the Dulux dog' or 'the Andrex puppy'? Then you have been affected by ads. I have never – as far as I recollect – brought Andrex or Dulux in my life. But I would be more likely to refer to those dogs by the brand name than the breed name! I know the names of the products, and if I needed paint or loo roll, and had a choice between the famous brand and an unknown one (assuming they were at the same price etc.), I'd probably go for the famous brand. I've been conditioned to believe it's a good choice – through advertising.

Advertising works. And it works on everyone. And its effect is cumulative. And any t-shirt/greeting card/wrapping paper design/icon that plays into the baby = bottle assumption is adding another layer to the advertising of formula, and therefore undermining breastfeeding. Every time we see the image of a bottle associated with a baby, that association is reinforced in our subconscious, and the idea that actually babies (and their parents!) can manage perfectly well without bottles seems less likely, even to the point of being ludicrous.

When these sorts of t-shirts appear, and get challenged, we aren't really saying that this particular t-shirt is a terrible threat. It is a symptom of the problem, not the problem itself. And people ARE working to fix the problem, but the symptoms need to be acknowledged and treated too. All we want is to challenge the insidious idea that formula is the normal way to feed babies. It's not ok that this culture treats the breastmilk as special and formula as normal. FORMULA is special – it's a lifesaving medication for those in need. Breastmilk is normal. And it's a shame that the assumption is that baby = bottle.

And that is why people get irritated. Not because they are judging formula feeders, or even the companies that make these t-shirts – they are just doing their job, and probably have no idea of the ramifications of their product. Not because they think this one t-shirt alone will inspire someone to formula feed instead of breastfeeding. Leaving the tap dripping into a bucket for one minute won't flood your house. Leaving it on for one week would. And one of those minutes is going to be the one when the bucket starts to overflow...

Comments confession

I admit it, I have a problem. I keep on reading the comments. I know I shouldn't, but I do it anyway. Every single time. It's just so hard to resist, even though it almost invariably makes me sad. In general, I believe in people – I think, on the whole, people are smart, and capable of great kindness and tolerance. The comments section of almost any article seems to indicate I'm wrong on that one.

But then again, on the whole, smart, kind and tolerant people don't often comment on articles. So the people who do comment are those who feel particularly strongly about the subject matter (which doesn't always lead to the most tactful phrasing), or those who are too self-obsessed to realise that other people have valid feelings and opinions too. And trolls, of course. And naive people like me, who want to make the world a better place, and think they can help others to see the point that has been so spectacularly missed. But the comments section of almost any article seems to indicate I'm wrong on that one, too.

It seems like every time an article appears mentioning how breastfeeding is actually better than the alternatives, at least one person has to comment that that's all very well if you can do it, but some people can't, and some people choose not to, and how dare anyone suggest they should be shamed for this? Plus formula has never done THEM any harm, and they know a breastfed infant who's always sick....and so on and so forth.

Doesn't all this seem a bit, well, irrelevant, to anyone? I mean, imagine this...

Dear Water Fascist

I was appalled to read your judgemental article in 'Sporting Today' entitled “Swimming – it could be the sport for you!” There are so many things wrong with it, I hardly know where to start!

Most of us – shock horror – live on dry land. And if we want to cross a stretch of water, well, that's what aeroplanes and bridges are for! So your point about how 'it could save your life' is totally irrelevant in this country, and is really meant for people who send all their time on boats.

You completely ignore the fact that a lot of people find swimming really hard, and just can't do it. My lifeguard friend informs me that many people are not naturally buoyant, and are simply physically incapable of remaining afloat. Did you stop and think for even one minute how they might feel to read 'it's one of the best forms of cardiovascular exercise out there, and it's fun too”? How insensitive! Way to make them feel guilty!

And then there are those who, like me, simply decided that swimming wasn't for them. That is MY CHOICE, and you have no right to force me into the water! I prefer not to show my body off in public pools, with their communal changing rooms and showers. Maybe I just have more modesty than these swimming crazies who love to flaunt their bodies and rub the noses of decent people in the stench of chlorine. How dare you shame me for making a different choice to you? I'll have you know that I am super fit, unlike my obese, diabetic cousin, who goes to the pool every weekend, and even went surfing in the sea last summer, where she nearly DIED, and had to be rescued by the lifeguard. And yet SOMEHOW I survived paddling in rock pools, despite my inability to do the breaststroke. It must be a miracle!

If someone actually wants to swim, more power to them. As long as they cover up properly – after all, if you wouldn't be comfortable wearing a bikini to go shopping, why would you think it's OK to dress like that just because you are going swimming? But, provided no one is forcing me to watch their prune-like, wrinkled behinds as they skinny dip, I'm happy to live and let live. Why oh why can't you people do the same?

Lucy - Landlocked, and Loving it!

Did I miss anything? (I couldn't manage to fit comparisons to sex/urinating in there, and besides, that little chestnut has it's own post brewing....)

Latch on NYC (Needs Your Comprehension)

Over the last few days, I've read several articles about 'Latch on NYC' – which is about regulating the use of formula in New York hospitals. A lot of people are up in arms about this, claiming it's about bullying mothers, undermining their choices, will lead to hungry, screaming babies, etc, etc.

As a starting point, here are two of the numerous articles I've seen on the subject: the most negative and the most positive ones I have come across. 

nypost

phdoula

In addition, there was a comment on another article (this one, IIRC: http://www.askmoxie.org/2012/07/the-illusion-of-choice-the-free-market-and-your-boobs/comments/page/2/#comments) suggesting that the restriction of formula in this way was equivalent to refusing women epidurals until they were at a certain threshold of pain.

This analogy is completely flawed. The equivalent would actually be hospitals not offering epidurals to women who don't ask for them. And explaining, to women who do, that it is medically healthier not to have one. And then, if they say they want one anyway, giving it to them! What currently happens (not every time, nor in every hospital, but it's not rare by any means) is the equivalent of women being offered epidurals as soon as they arrive at the hospital, no matter how well they are tolerating labour and what their birth plan says, and if the woman declines, saying “Well, I'll get everything ready for it anyway, for when you change your mind.” Sadly, this often does happen with epidurals (and c-sections) too, actually. 

And with that....the first metaphorical story of this blog was born:

Imagine you have to go into hospital for minor surgery. There are 2 types of medication you could use – Formex and Boobimel. You are aware you'll need to take the medication once a day for a week. Boobimel is universally acknowledged to be medically the safer, better option: the list of potential side effects from Formex is long and varied (ranging from mild constipation to complications that can prove fatal), but there are no known side effects from Boobimel. Still, no one you know ever had a problem, and most of your friends took Formex because Boobimel was simply not offered at the time they needed it. They are all fine. (Well, some of them have medical issues that are listed as potential side effects of Formex, but LOTS of people have similar medical issues who never took Formex - and no one can know for sure that Formex caused/exacerbated these issues in your friends.) Sure, there's a risk, but it seems to be relatively small.

Boobimel is injected (you hear it's a REALLY BIG needle and hurts like hell), Formex is taken orally and apparently it tastes yummy. You also see adverts for Formex on TV and billboards. Not that they influence you, of course, but you are vaguely aware that if it was that much worse than Boobimel they would be in trouble with trading standards, surely...

You haven't made up your mind as you enter the hospital, but you think you'll probably give the needle a shot (no pun intended). If you don't like it, you can always take Formex for the next 6 days, after all.

Scenario A:

The doctor tells you that you will need to find your own way to the other side of the hospital to be injected with Boobimel, and there is no guarantee that it will actually be ready for you when you get there. There is a Formex packet on the table next to you, and you can take one RIGHT NOW. The doctor looks at their expensive watch, which bears a Formex logo, impatiently, and hands you a glass of water...

Scenario B:

The doctor tells you that Boobimel is the recommended medication for this procedure, and shows you where to go to find it in the hospital. They explain that there might be a bit of a wait, but there is tea and coffee in the waiting room. They answer any questions you have and reassure you that the needle is not as big as you've heard. You ask about Formex, and are told that it is certainly an option, and, so long as you are fully aware of the potential risks involved, they will go and fetch you a Formex, though they are ethically obliged to suggest you at least attempt Boobimel for the first day.

Scenario C:

There is no Boobimel in the hospital, and your surgery has to happen today – you are in a lot of pain! In addition, you are utterly needle-phobic. You have to endure an hour long lecture on why Boobimel is better and are told that the Formex will probably kill you, before the third doctor you speak to reluctantly allows you to have a packet of Formex pills, and walks out in disgust, without telling you how many to take.

No one, absolutely NO ONE, is advocating option C. The current initiative is about replacing option A with option B. (In the circumstances described in Scenario C, the doctors should be apologetic, and sympathetic, and recommend, in your case, going with the Formex, although if you really want to wait til the next day in the hope some Boobimel will arrive in hospital, that's your choice, they will keep monitoring your condition and inform you if anything changes.)

Sure, post-natally, you are often scared, in pain, suffering, and don't WANT to be reminded that it isn't a good idea to supplement when that seems so attractive when your newborn is struggling to latch. But when I was in labour, scared, in pain, and told my baby was not coping very well, I signed the c-section consent form. I would have let them cut me open if they believed it was MEDICALLY a good idea. Heck, I'd have let them cut off my arms and legs at that point if they had told me it would help! I didn't have a c-section, because I didn't need one in the end. I don't think it would have been appropriate for them to accept my hasty signature (while in pain and panicking) as my 'choice', despite the lack of medical necessity, since my birth plan, into which I'd put a lot of thought, clearly stated that I wanted to avoid interventions if possible.

These sort of initiatives are about encouraging informed choice, not reducing people's choices, but expanding it.  If an infant is supplemented with formula, especially in the early days, that mother's milk supply is damaged, sometimes irreparably. This reduces her ability to choose.  If a mother is given accurate information - even if that information is unwelcome at the time - it has no impact on her ability to make a choice.

But I'm about to go off at a tangent, so I'll leave the matter of choice until next time...

 

Ok, here we go...

So, in honour of World Breastfeeding Week this year, I'm actually going to start my own blog.

I've been thinking about doing it for years, since the days when I actually HAD a breastfed child and first got involved with the whole online lactivist thing.  Every now and then, a response I'm writing to a comment or post gets out of hand and dissolves into a metaphorical story analogous to the situation. I've got several of these saved on my computer, that have never made it online (as I tend to go off at tangents.)

So, I'll pop  'em up here, as and when I get round to tidying them all up, alongside my thoughts on current relevant news and articles.


A couple of   A few  SEVERAL quick things about me:

1.  I am lazy and a talented procrastinator - so I will probably not update this as much as I should - or will update MORE than I should when I ought really to be getting on with real life stuff. I might get bored and not check comments for weeks or months. This is a hobby for me. Don't expect a professional standard of response. 
2. I'm English. I'll refer to nappies, dummies and trousers, rather than diapers, pacifiers and pants. If I use the word pants, I'll probably mean underpants. I will also spell colour and favourite with a u. (And, not that it's going to be relevant unless I write a poem, I pronounce 'grass' and 'castle' gr-ah-ss and car-sul. Which is EXTRA fun when I have a 5 year old son who is learning to spell, and most of the people around here say 'grass' and 'cassel'. And 'scone' has a magic e, dammit. Ahem.)
3. I use sarcasm a lot, and have little patience for hypocrisy. If you comment on here, and you can make a respectful, logical argument stating your case, I'll listen, whether you agree with my point of view or not. If you make illogical or hypocritical arguments, or are disrespectful, I will call you out on it, whether you agree with my point of view or not.  I'll probably be polite about it, at least as long as you are.
4. I don't care if you are male, have no kids, or have never breastfed, you still have every right to your opinion. The validity of an opinion is based on its own merits, not the experiences of the person who holds that opinion. (Although such experiences can lead to a more informed opinion, the lack of them does not mean it is ill-informed.)
5. Everything we do is based on a risk/benefit analysis - and only we can make our own judgements as to how these balance out.  ALL parents choose how to feed their children based on which method they believe to tip the scales more towards the benefits than risks.  ALL parents are doing the best they can in the circumstances they are in. It is rude, arrogant and, frankly, stupid to claim that because a parent made a different decision to the one you did/would make that they have deliberately chosen a more risky, less beneficial path. That's like assuming that because you found sports easier than music lessons at school, people who joined the choir instead of the football club were deliberately making things harder for themselves.
6. And finally - I am a true agnostic. I am talking here about my thoughts, feelings and beliefs. I have not done serious medical research, and am taking it on trust that the scientific research I have read (in summary - I'm pretty smart, but I'm no expert and find the actual research papers hard to digest) is genuine. However, to put this into perspective, I am also taking it on trust that Australia exists. I've never been there myself, after all.   I am such an agnostic that I am not absolutely convinced in the non-existence of the Flying Spaghetti Monster. It seems astronomically unlikely that such an entity exists, but it is not, I repeat, it is NOT impossible. Similarly, if you believe that formula is better than breastmilk, I will admit that there is a possibility you are right. You are extremely unlikely to be right, according to all the evidence I have ever seen - but the possibility exists. If you can make logical arguments to support your belief, I will listen to them. (See also point 3).
7. General disclaimer: I am not a medical professional. If I ever give any advice to anyone (I almost certainly won't, I'm not qualified, but if you ask, I might tell you what I think) - it's just that some random person, who did do a breastfeeding peer support course 5 years ago, and has kept up to date online on related stuff, but that's all, thinks. Nothing I say is to be taken as proof of anything. (See point 6.)

So - welcome to my blog. There will be stories, suggestions and similies; there will be discussions, debates and diatribes;  there will be rants, reasonings and randomness; there will be mammaries and metaphors, mostly on matters of motherhood. There may be an aspect of alliteration....