Wednesday, August 20, 2014

Bad Evidence Drives Bad Decisions and Bad Policy

There is a saying: “Bad evidence drives bad decisions.” Unfortunately there appears to be growing mountains of bad evidence (or misinterpreted evidence) when it comes to maternity care, and that bad evidence is being fed into bad policy that then results in bad practice and ultimately moms and babies who suffer. Sadly, some of the bad evidence is likely a result of a backwards cycle of evidence and policy where by a policy is developed based on ideology or theory, and then evidence is sought out to support the policy or practice after the fact.

It’s a logic (and arguably ethics) fail of elephantine proportions.

A failure that has yet again been demonstrated in yet another study, widely reported by the BBC: http://www.bbc.com/news/health-28851441 – this time finding that breastfeeding cuts depression risk.

The first big red flag – the thing that should cause policy makers and their brethren pause for thought is the real finding of this study (as opposed to the trumpeted headline) – which is the following: There is a large increase in the risk of depression in women planning to breastfeed who are then unable to do so.

Think about that for a moment, women who successfully breastfeed, who manage to fulfill their objective are seen to have a lower risk of depression (50 percent decrease in risk), while those who plan on, but ultimately find that they cannot, for whatever reason – suffer a large increase in risk of post-natal depression. It is remarkably similar to a recent study that found that women who had births that were unlike the births that they had ‘planned’ were at increased risk for post-natal depression.

So what are the policy implications of this study?

In the news article, the conclusion is drawn that mothers should be encouraged to breastfeed and that there are so many benefits, and that more support to breastfeed is needed, but those who “fail” should be identified as being at risk and health visitors should keep an “eye” on those women.

So in short, the policy response to this study is to keep doing what is likely causing the observed relationship between breastfeeding and depression. Applaud and support the “good mothers” who breastfeed, and further stigmatize those who either choose not to or find that they are unable to breastfeed.

I am dumb founded at the sheer lack of insight as to what ought to be done in response to this study. It seems incredibly clear to me that the right policy response, is to build resilience among all expectant mothers as many might find that for whatever reason they are either not wanting to or not able to breastfeed and by supporting them in the choices that best meet their needs and those of their babies. That would mean toning down the incredible amount of pro-breastfeeding/anti-formula propaganda that mothers are exposed to. That means sending different messages about the meaning of being a “good mother” – messages that focus on outcomes, not process and contribute to a feeling of confidence in what is to many a challenging and difficult new role.

11 comments:

  1. I don't see stating the importance of breastfeeding as "propaganda". It is simply stating the obvious. Breastfeeding is the way humans have adapted over millenia to be fed. Departing from that imparts some risk. Mothers are failed badly in our societies so that it is made harder to achieve their breastfeeding goals. This is a feminist issue. Lack of breastfeeding knowledge by health professionals,especially doctors, is an absolute scandal. For many years women were patronizingly told that formula feeding was the only solution to breastfeeding problems. Only in the last few years is real research happening so that women can go on to breastfeed exclusively or partially if they wish. The lack of skilled follow up care and lack of parenting leave makes it very difficult for mothers who want to breastfeed their babies to be able to do so. Of course it goes with out saying that women who are unable or wish to not breastfeed should be treated well. It is a human right to be able to breastfeed but it should not imply that a breastfeeding mother is the only good mother.

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    1. WIt t I want to know, and I've asked time and time again and never received a real answer to this, is what exactly is the solution to breastfeeding problems if not for formula? Because all I ever heard from lactation consultants, and many women have shared similar stories with me, was 'Keep trying! Just keep on trying!" Well exactly how long are women supposed to 'just keep trying' when both mom and baby are suffering and nothing is working. Now even the fathers are being encouraged to chime in on this harassment, but yet still no real answers other than 'keep at it' and a bunch of scary stats thrown at mom about what a horrible life baby will have if they don't receive breastmilk. I'm sorry, but in what delusional world does someone consider that 'support?!' We've all heard the same crap.....it must be a lip tie! Maybe you should change your diet! Try changing positions!

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    2. My phone is messing up....let me continue. .basically what I'm saying is, if breastfeeding is making mom and baby miserable it is highly unlikely that repeating the same junk advice that we've heard a thousand times is NOT going to help. It also doesn't help to lie to women and tell them breastfeeding won't hurt (it does at first) or that it will be easier (it wasn't). Also, the myth that women are just now being told that nursing is good is a bunch of crap. My own mother knew this in the seventies so bullshit to anyone that says this is new news.

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  2. Anonymous - you've never walked a mile in the shoes of a mother who either did not want to or could not breastfeed in the context of constantly being told that "Breast is Best." You've never known anybody who snuck away to prepare formula because of the judgement of the mommy group they were in. You've never had the feeling of seeing all the support lavished on a breastfeeding mother - and then contrasted it with the void for the formula feeding mother. Women who wish to breastfeed should absolutely be supported - but that does not mean that women who can not or do not want to should be neglected in their needs or chastised for their choices.

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  3. No I personally haven't been made to feel unwelcome and shamed for formula feeding but I have for breastfeeding. Some people are thoughtless, tactless and unkind.
    The problem as I see it is that women are being informed about the importance of breastfeeding without the societal scaffolding in place to help it happen. We all need to work to improve that scaffolding which should also include support for mothers who are unable to or choose not to breastfeed.
    As for the " just try harder" lactation support. Yes, a degree of perseverance is necessary to make breastfeeding work. When it is particularly challenging, ideally the lactation professional can work with the mother to find a path that is doable for the her. For some mothers this may mean weaning to donor milk or formula. In my experience lBCLCs and breastfeeding counselors already do this.

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    1. What do you mean by "find a path that is doable for her?" This is more of the vague jibber jabber that I'm talking about. Not any real advice or help, just vague responses....

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    2. Hi, by that I meant working with the mother to formulate a plan that the mother feel she can do.eg how much breastfeeding, expressing she is able to do without too much stress for herself or her family.

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  4. The obvious policy change is to provide more breastfeeding support. With increased support, including sufficient maternity leave, mothers who intend to breastfeed will be more successful. For mothers who are unable to breastfeed fully, lactation supporters can help resolve the differences between the expectations and the realities of the breastfeeding experience.

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    1. We all know that this isn't really what happens. The VAST majority of lactation consultants are die-hard lactivists who will not accept anything other than EBF. Sure, there are exceptions..but they are rare.

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    2. I am sorry that was your experience. IME IBCLCs help mothers ensure the baby is fed. That may mean complementing with ebm, donor milk or formula.
      The education of CLCs in the US is not very comprehensive....far less than volunteer breastfeeding counselors in my country. Perhas this affects the quality of breastfeeding support in the US.

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  5. Anna - no. Yes breastfeeding should be supported, but so should formula feeding and a woman's right to freely decide what to do with her body should not be taken away or unduly influenced.

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