“Breast is Best.” In places where clean water access is a problem, it is well-established that feeding an infant with human milk rather than formula-feeding saves lives. Yet even in countries that don’t struggle with clean water access, like Switzerland, where I live, the creed of “Breast is Best” holds strong. Online parenting forums, midwives, and even infant formula websites and product labels emphasize and reemphasize the message that exclusive breastfeeding at the beginning of a child’s life provides the best form of nutrition—a “healthy start to life,” as per the slogan of a widely-distributed booklet issued by Breastfeeding Promotion Switzerland. There is something distinctively moralizing about the “Breast is Best” message. The implication is that a parent who feeds their young baby formula is not giving them a healthy start to life … [please read below the rest of the article].

Image credit: Evilspoon7 via Flickr / Creative Commons

It’s important to point out at the outset that the modern “Breast is Best” movement arose as a deliberate corrective to unethical infant formula marketing practices. For example, ads would identify formula products as “doctor approved” or “doctor recommended,” thus casting them as healthier than human milk. The guiltiest culprit was Nestlé: Drawing on questionable scientific research, its ads in Global South countries declared that extended lactation harmed maternal health and that formula produced better infant health outcomes.[1]

The World Health Organization’s “International Code of Marketing of Breast-milk Substitutes” was adopted by the World Health Assembly in 1981. This code is the reason why you don’t see advertisements for infant formula in trams or on television, why you don’t see photos of happy babies drinking from bottles in their caregivers’ arms or “other pictures or text which may idealize the use of infant formula” on formula containers. It’s why, if you go to the products page of infant formula websites, there’s a pop-up window with a lengthy notice that the World Health Organization recommends exclusive breastfeeding. (You have to then click a button that says that you understand and wish to view the webpage anyway.)

But there are some who have asked whether the ubiquitous message of “Breast is Best” goes too far. It may contribute to guilt on the part of those who cannot or do not wish to breastfeed—or chestfeed, as it’s often called in the trans community.[2] Worse, it may push new parents to carry on with breast/chestfeeding in the face of obstacles such as lactation issues or cracked nipples, sometimes with a negative impact on one’s postpartum mental and physical well-being.

Woollard on Breast/Chestfeeding and Defeasible Duties

Such worries are at the heart of recent philosophical work by Fiona Woollard, which challenges the idea that one would ever owe an explanation for not feeding a child with human milk, and demonstrates why human milk feeding is not a moral requirement.[3] Woollard’s argument goes something like this. When our moral duties are “defeasible,” we are answerable for our conduct to others. It is not necessarily wrong to not act on a defeasible duty—thus the language of “defeasibility”—but if you don’t, you have to have good reasons, and you may be called upon by others to say what these reasons are.[4] As Woollard argues, feeding babies with human milk is often treated as a defeasible duty. After giving birth, one hears the message time and again that breastfeeding is the right thing to do. It’s easy to feel compelled to explain oneself—to one’s health care providers, friends, and family—if one ends up feeding their child with formula.

According to Woollard, however, feeding one’s child human milk isn’t a defeasible duty, and shouldn’t be treated by society as such. There are moral reasons to breast/chestfeed due to the health benefits for the child, but it isn’t the case that defeasible duties arise in every situation where there is a moral reason to do something. She uses the analogy of running a race to raise money for charity. There are moral reasons for doing this, but someone who doesn’t participate isn’t required to offer a justification to others. Running for charity and human milk feeding are morally elective—or supererogatory, in the language of moral philosophy—morally good, but also morally optional.

Woollard’s vision of a world where no one feels like they have to explain their decision to not to feed their baby human milk is clearly compelling. I know this firsthand. After giving birth to my baby, I tried to breastfeed, but stopped after developing a rare condition known as postpartum facial palsy. A high-dosage steroid regime offered the best prospects for a full recovery, and my medical team recommended formula-feeding. I hadn’t produced any milk at that point anyway, and it was a relief, given how awful I felt, to have the excuse to focus on cuddling with my baby and on my recovery.

The topic of feeding always seemed to come up in those first few months. Whether it was my gynecologist, my child’s pediatrician, or friends, I would always explain that I tried breastfeeding, but had to stop because I needed steroids for, well, you know, my partially paralyzed face. The explanation always seemed to spill out, and I would wonder, why did I feel the need to get into the whole saga? What if I had chosen to formula-feed my child just because? And the answer was pretty obvious. I wanted the people I interacted with to know that I cared about being a good mother. A good mother understands, even while using formula, that “Breast is Best.”

But the thing is, in countries with safe drinking water and high-quality formula options, the only well-established health benefits for babies fed with human milk are modest and short-term.[5] A reduced risk of gastrointestinal issues and eczema are the two main benefits.[6] Myriad myths circulate about long-term health benefits of a human milk diet in infancy, such as a reduced risk of obesity or higher IQ scores, but these are based on scientific research that is hardly conclusive.[7] Since there are ethical issues with running a randomized controlled trial where participants are assigned to human milk feeding or formula-feeding groups, most studies finding that human milk feeding produces life-long health benefits for children suffer from selection bias—parents who are affluent and healthier are less likely to use formula.

But correlation is not causation. That babies who grow up in more affluent households tend to have better outcomes later in life and are fed human milk at higher-than-average rates does not show that an early diet of human milk caused these better outcomes. (Unfortunately, findings from such studies are often uncritically presented as scientific fact in pro-breastfeeding reference materials.) As for the non-health-related benefits, many breastfeeding advocates talk about the distinctive powerful and intimate bond between mother and child that results. This, quite frankly, carries a suggestion insulting to those of us who use formula—that our bond with our child is deficient.[8]

As my husband and I discovered, feeding our child with formula has had benefits that often go undiscussed.[9] Human milk-fed babies drink smaller amounts of milk more frequently, every 2-3 hours for a total of 8-12 feeding sessions per day, something that optimizes milk supply. Formula-fed babies drink larger amounts of milk and thus need to drink less often—for us, it was every 3-4 hours in the beginning and every 4-5 hours soon thereafter, for a total of 5-6 feeding sessions per day. Fewer night feedings translated into more sleep for my husband and me. We heard many stories from friends of nights filled with cycles of short interlude of sleep—feeding session—repeat, repeat, repeat, and feeling like zombies all day long. This wasn’t our experience.

Also, by using formula, my husband and I found it easy to share feeding-related tasks equally. Pumping also makes it possible to split up feeding sessions, and I don’t want to suggest that couples that feed their baby human milk are less successful at equal parenting than formula-feeders, any more than I want someone who breast/chestfeeds to judge my bond with my child to be lesser-than. But I’ve heard complaints that when only one person is producing milk, the logistics of equal parenting are a challenge, especially when a baby is young. For us in those early months, we naturally fell into a rhythm of taking turns being on feeding duty every other night while the other one slept. This felt cool and very second wave feminist to me—a reassuring feeling that helped counterbalance my underlying dissatisfaction with my non-milk-producing breasts.[10]

One purpose of Woollard’s philosophical work on breast/chestfeeding is to engage in recent bioethics debates about a person’s duty to benefit their child upon procreating. This is why she spends so much time discussing defeasible duties versus moral reasons for actions that are supererogatory: She wants to conclusively demonstrate why there is only a moral reason to feed one’s baby human milk, not a defeasible duty. As she argues, defeasible duties to benefit one’s child are only general in nature, not particular. If you make your child’s life so bad that she’d have been better off not being born, you violate a defeasible duty. However, you don’t have particular defeasible duties to do certain things to benefit your child, only moral reasons to do them. One thus doesn’t have a defeasible duty to feed their child human milk, only a moral reason.

Though Woollard’s reasoning is sound, her argument can easily mislead one into thinking that breast/chestfeeding is somehow unique. In fact, there are all sorts of benefits one could potentially provide as a parent that generate moral reasons. There are moral reasons to put a child in daycare. (Daycare is beneficial for a child’s social development and communication skills.) There are moral reasons to keep a child at home. (Spending all day in a daycare group with other children can be long and tiring for a child.) If the short-term health benefits for a child give rise to a moral reason to breast/chestfeed, a child also benefits from the above-described aspects of formula-feeding. Thus there are also moral reasons not to breast/chestfeed. That there are moral reasons both for alternatives I and II alike is not an issue for moral philosophers—moral philosophers know that there are moral reasons to do all sorts of things. But Woollard does not spend time on the moral reasons not to breast/chestfeed.

Woollard’s analysis thus reinforces the operative societal assumption that breastfeeding is better. This prevents her philosophical demonstration that those who don’t feed their child human milk aren’t required to explain themselves from having a meaningful practical effect. If “Breast is Best,” and governments severely limit the dissemination of the information that formula-feeding is also good—more on this in a moment—there are many who will still feel the need to justify a deviation from the breastfeeding norm to others and themselves. Let us go back to Woollard’s charity race analogy. In a country like Switzerland or the UK (where Woollard is based), there is not the omnipresent message that people who run for charity are good people who are doing the right thing. Someone who has never run a charity race is unlikely to feel bad about it.[11] In fact, they are unlikely to ever think about it at all.

This is hardly analogous to the situation of a new parent, who is necessarily confronted with the decision of how to feed their child. Take my own birth experience: In the hours and days after my son was born, I was flooded with love hormones. Looking into my son’s eyes and holding him close, so naked and vulnerable, I felt a great sense of responsibility. I wanted to do right by him. Doing the right thing meant breastfeeding, as I saw it at the time. Though my husband and I worried about getting enough sleep, the parental division of labor, and things of that ilk, we’d make it all work with breastfeeding somehow. That’s what good, devoted parents do: They make it work. This is the mindset one easily has in the face of tremendous societal pressure to feed an infant one way and not another. While Woollard’s argument is technically accurate in saying that there is a moral reason to feed one’s baby human milk—again, there are moral reasons in favor of innumerable things human beings may or may not choose to do—it fails to challenge the moralized picture where breastfeeding is the “right” thing to do.

This moralized picture can make those of us who bottle-feed feel really bad about ourselves. Given rates of the “baby blues” and postpartum depression, this is no small matter. Moreover, I worry that there may be many families out there for whom bottle-feeding would be the right decision, but who have an exaggerated impression of how beneficial human milk is, and who are not fully informed about the benefits of formula. In a counterfactual world in which I didn’t have a serious health problem that prevented me from breastfeeding, I likely would have kept trying to make it work. This would not necessarily have been the best decision for our family.

In contrast to a vision of a world where those who formula-feed do not feel compelled to explain themselves, I’d like to see breastfeeding advocacy completely drop its moralizing language. There are many countries where breast/chestfeeding, formula-feeding, and “combination” feeding could all safely be presented as good options with their own pros and cons, with no single option considered the default.[12] New parents should not only be given brochures on how to breastfeed, but also brochures with information about formula and combination feeding and explanations about how to properly sterilize and make a bottle. Awareness campaigns aimed at destigmatizing public human milk feeding are quite obviously important, as is advocacy work aimed at making it easier and more comfortable for parents back at work to regularly pump milk. Breast/chestfeeding can be difficult, and those who wish to do it should be supported; in Switzerland, basic health insurance fully pays for consulting sessions with lactation specialists, and that’s a good thing. But campaigns and advocacy work geared at a lopsided promotion of human milk’s benefits should be scrutinized, and it seems far from justified that public funds are used for such campaigns in countries with clean and safe drinking water. Furthermore, the present ban on pictures of parents feeding their babies with a bottle on formula containers is far too extreme and should be lifted. In the first few months of my baby’s life, coming to terms with not breastfeeding was a veritable emotional challenge. As I was counting scoops of white powder, an image of a happy parent bottle-feeding their happy baby would have been a nice reminder that I was doing a good thing for my child.

Breast is Best in Historical Perspective

Let’s spend a bit more time on this last point. According to a common narrative, it was the aggressive ads peddling falsehoods about infant formula that produced a worldwide breastfeeding decline in the 20^th century—thus the need for the WHO’s “International Code of Marketing of Breast-milk Substitutes.” Despite the efforts of the WHO and other pro-breastfeeding organizations, mothers continue to be influenced by the formula companies’ unscrupulous profit-seeking tactics, and as a result, exclusive human milk feeding rates in OECD countries are lower than ideal—the ideal apparently being as close to one hundred percent as possible.[13] But why should universal exclusive human milk feeding be the target? This is based on a flawed assumption that this is the right choice for every family. And what does it say about our views of a woman’s exercise of decision-making autonomy to posit the influence of advertisers as the main reason why she wouldn’t breastfeed?

According to UNICEF, worldwide, 95% of babies are fed with human milk at some point. The rates of exclusive human milk feeding are high in low- and middle-income countries—the message about formula being unsafe when there is not clean water access has been successfully disseminated—but vary considerably in high-income countries.[14] Some give up human milk feeding after doing it initially; others combine human milk and formula-feeding. Self-reported reasons for introducing formula typically include factors like a concern that one’s baby isn’t getting enough to eat and lactation issues.[15] In spite of this, news organizations often treat current human milk feeding rates in OECD countries as indices of a public health crisis—“The countries where 1 in 5 children are never breastfed,” announces a CNN headline[16]—and there is a continual focus on the marketing practices of formula, er, “breast-milk substitute” companies. A 2020 WHO report analyzes which WHO member states have set laws complying with its infant formula marketing code. 70% of WHO member countries—a total of 136—have laws in place aligned with parts of the code, with 112 countries banning pictures idealizing the use of formula, 114 banning infant formula advertising, 24 banning the distribution of information/education materials distributed by formula companies, and so on.[17] As the report concludes:

The Code remains as relevant and important as when it was adopted in 1981, if not more so. The Code is an essential part of creating an overall environment that enables mothers to make the best possible decisions about infant feeding, based on impartial information and free of commercial influences, and to be fully supported in doing so. Protecting the health of children and their mothers from continued misleading marketing practices should be seen as a public health priority and human rights obligation by countries.[18]

No mention, of course, of the potential of “an overall environment that enables mothers to make the best possible decisions about infant feeding”—i.e., that pushes breastfeeding as the best possible decision about infant feeding—to make individuals feel ashamed for stopping breast/chestfeeding, or not starting in the first place, because of medical reasons or because of having other priorities.

Pro-breastfeeding campaigns didn’t start with the WHO. They have an extremely long history. In some parts of the late 19^th and early 20^th century United States, there was a 13% infant mortality rate, and it was common for doctors to link this to diarrhea and feeding infants cow’s milk instead of human milk. Public health workers hung posters with messages like “Don’t Kill Your Baby: Mother’s Milk is Best of All.”[19] There is the sexist image of women as mindless consumers—buying this or that because some nice lady tells them to—that breastfeeding advocacy efforts often feed into. However, the rise of infant formula in the 20^th century coincided with a broader general trend that included the rise of washing machines, dishwashers, and other household appliances, not to mention forms of contraception, that made it increasingly more feasible for women to have careers outside the home. Why isn’t the potential freedom-giving capacity of formula part of the official narrative of the 20^th century breastfeeding decline?

The WHO’s infant formula marketing code had its roots in a 1979 meeting on Infant and Child Feeding. While parts of the official statement that came out of the meeting address important progressive issues like women’s health as a human rights issue, one cannot but notice the conservative and somewhat paternalistic language about how societies should guard against changes that threaten to unsettle the traditional, biologically-rooted role of women as mothers. “Breastfeeding is an integral part of the reproductive process, the natural and ideal way of feeding the infant and a unique biological and emotional basis for child development,” the official meeting statement declares. “It is therefore a responsibility of society to promote breastfeeding and to protect pregnant and lactating mothers from any influences that could disrupt it.”[20]

An annex on Maternal and Child Health appended to the proceedings of the 1979 World Health Assembly is more explicit about the importance of preserving breastfeeding in a society with changing ideas about gender roles. “While changes in traditional family life-styles are inevitable, every community must make an effort to see that valuable practices such as breast-feeding are not allowed to disappear.”[21] Of those who attended the 1979 World Health Assembly or the 150 participants involved in the Infant and Child Feeding meeting, it is impossible to know the gender break-down, since many of the participant names are listed only with the title of “Dr.,” a first initial, and a surname, and aren’t easily searchable on the internet. However, while it is nice to think that the WHO would have wanted its official breastfeeding stance to be female physician-led, given the time, this is doubtful. It is far likelier that these words reflected the consensus view of a cadre of majority-male medical professionals who were not weighing the tradeoffs that a person who feeds a baby self-produced milk necessarily faces.

Some might see my argument for breast/chestfeeding, formula-feeding, and combination feeding to all be framed as good options in countries like the UK and Switzerland as threatening to the fight for enhanced workplace accommodations and protections around human milk feeding. If formula were to be seen as a good infant feeding option, wouldn’t employers see such accommodations as needless, since parents have the choice to formula-feed their babies? Such a concern, though valid, should not be dispositive. If we are exaggerating the risks of feeding a child with formula and making a public health-based argument in order to try to convince parent-unfriendly employers to do something that they should be doing anyway, we cede way too much to these employers. My argument for de-moralizing breastfeeding isn’t based on a claim that feeding a child with human milk isn’t good. It’s a diagnosis of how societal norms would need to change so that formula-feeders like me would really not feel the need to explain themselves. It’s a plea for “an overall environment that enables mothers to make the best possible decisions about infant feeding, based on impartial information”—including information about the benefits of formula.

Acknowledgments

This essay has benefited greatly from comments and suggestions from a number of colleagues and friends. You know who you are. I am grateful!

[1] Cueto, Marcos, Theodore M. Brown, and Elizabeth Fee. 2019. The World Health Organization: A History Cambridge: Cambridge University Press, 186.

[2] In this essay, when speaking generally about human milk versus formula, I use terms like “breast/chestfeeding” and “human milk feeding” because this language is more inclusive of trans and nonbinary people than traditional language (see articles like Diana Spalding, August 24, 2021, “What Is Chestfeeding?” Motherly. https://www.mother.ly/life/what-is-chestfeeding). When speaking about my own experience, I use the terms like breastfeeding, mother, etc. because it fits my identity as a cisgender woman. I also use cisgender terminology if I am channeling the point of view of the World Health Organization and other breastfeeding advocacy organizations, because that’s the language they use.

[3] Woollard, Fiona. 2018. “Motherhood and Mistakes about Defeasible Duties to Benefit,” Philosophy and Phenomenological Research 97 (1): 126–49.

[4] Woollard, “Motherhood,” defines “defeasible” duties in the following way: “An agent who has a defeasible moral duty to perform an action is liable to moral censure if she fails to perform the action without being able to provide sufficient countervailing considerations” (127).

[5] I draw on: Oster, Emily. May 20, 2015. “Everybody Calm Down About Breastfeeding.” FiveThirtyEight. https://fivethirtyeight.com/features/everybody-calm-down-about-breastfeeding/; Der, Geoff, G. David Batty, and Ian J. Deary. 2006. “Effect of Breast Feeding on Intelligence in Children: Prospective Study, Sibling Pairs Analysis, and Meta-Analysis.” BMJ (Clinical Research Ed.) 333 (7575): 945–951; Colen, Cynthia G. and David M. Ramey. 2004. “Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-Term Child Health and Wellbeing in the United States Using Sibling Comparisons.” Social Science & Medicine 109: 55–65. doi: 10.1016/j.socscimed.2014.01.027; Brenøe, Anne Ardila, Jenna Stearns, and Richard M. Martin. “Causal Effects of Breastfeeding Promotion on Child Health and Development: Understanding the Role of Nutrition.” Manuscript on file with authors; Brenøe, Anne Ardila and Claudio Schilter. “Causal Effects of Breastfeeding on Child Development: An Economist’s View.” Manuscript on file with authors.

[6] Improved weight gain is also causally linked to a human milk diet, but this is based on an older study where the alternative to human milk was typically water or juice rather than high quality formula. See Brenøe, Stearns, and Martin, “Causal Effects of Breastfeeding Promotion.”

[7] One study discussed by Brenøe and Schilter, “Causal Effects,” shows a positive causal effect of human milk on a child’s cognitive development compared to formula, but they caution that the study uses 20-year-old UK data, before formula supplemented with DHA and ARA (the fatty acids that aid brain development) was available in the UK.

[8] In saying this, I do not wish to discredit the experience of anyone who sees their loving bond with their child as linked to their experience of breast/chestfeeding. See Woollard, Fiona. 2019. “Requirements to Justify Breastfeeding in Public: A Philosophical Analysis.” International Breastfeeding Journal 14 (1): 1–8, page 6, for breastfeeding as a form of a loving parent-child interaction. Thanks to Fiona Woollard for bringing up this point.

[9] This is not to suggest that formula has no downsides. It’s more expensive than breast/chestfeeding; you need to organize bringing bottles, water, and powder if you take your baby somewhere; and it feels wasteful to throw non-recyclable formula containers in the trash.

[10] Laura Frances Callahan. 2019. “Moral Reasons Not to Breastfeed: A Response to Woollard and Porter,” Journal of Medical Ethics 45 (3): 213–14, goes further than my claim here, worrying that breastfeeding “may inculcate patterns of behaviour in which mothers assume parental responsibilities by default.” But as a recent article points out, in heterosexual couples, formula-feeding doesn’t guarantee gender equality in a society where it is assumed that mothers are the caregivers. One woman recounts: “Right now, I’m at peace with my decision [to formula-feed], but I sometimes doubt how helpful it really was in breaking down traditional gender role images. There are many other factors that make you a mother: internalized images and those of your partner, ideas about what I or he can do better. But also from the outside: The daycare always turns to me first when something is wrong.” Noëmi Landolt. June 17, 2021. “Muttermilch Für Die Weltwirtschaft.” Die Wochenzeitung. https://www.woz.ch/-ba1f (my translation.)

[11] Of course, one may reasonably disagree with this assessment. (Thanks to Fiona Woollard for making this point to me.) Perhaps I am universalizing my own experience of never having felt bad about not running charity races.

[12] Note that Woollard also advocates that information about all infant feeding options should be made available, with no single option pushed as the best one. See Woollard, Fiona, Heather Trickey, Phyll Buchanan, Marta Glowacka, and Laura Dennison. 2019. “Feeling Good About Feeding Babies.” https://feelingsaboutfeedingbabies.co.uk/but-if-we-just-see-the-benefits-of-breastfeeding-as-one-reason-to-breastfeed/. In a personal correspondence, Woollard characterized her overall view as being “That judgments about what feeding method is ‘best’ are summative judgments that involve weighing up personal factors that no one outside that individual family is in a position to make.”

[13] See, e.g., “Breastfeeding: A Mother’s Gift, for Every Child.” 2018. New York: UNICEF.

[14] “Breastfeeding: A Mother’s Gift, for Every Child.” 2018. New York: UNICEF.

[15] Li, Ruowei,  Sara B Fein, Jian Chen, and Laurence M. Grummer-Strawn. 2008. “Why Mothers Stop Breastfeeding: Mothers’ Self-Reported Reasons for Stopping during the First Year.” Pediatrics 122: S69-76.

[16] https://edition.cnn.com/2018/05/09/health/breastfeeding-unicef-study-parenting-without-borders-intl/index.html.

[17] World Health Organization. 2020. “Marketing of Breast‑milk Substitutes: National Implementation of the International Code.” https://www.who.int/publications/i/item/9789240006010, page 15.

[18] “Marketing of Breast‑Milk Substitutes,” page 26.

[19] Wolf, Jacqueline H. 2001. Don’t Kill Your Baby: Public Health and the Decline of Breastfeeding in the Nineteenth and Twentieth Centuries. Columbus: Ohio State University.

[20] “Joint WHO/UNICEF Meeting on Infant and Young Child Feeding: Statement, Recommendations, List of Participants.” 1981. Geneva, Switzerland: World Health Organization, 1981. https://apps.who.int/iris/handle/
10665/62980, page 7.

[21] World Health Assembly. 1979.  “Thirty-Second World Health Assembly: Resolutions and Decisions, Annexes.” Geneva, Switzerland: World Health Organization. https://apps.who.int/iris/handle/10665/153658, page 85.

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Tags: “Breast is Best”, baby formula, baby human milk, breast/chestfeeding, breastfeeding, Fiona Woollard, Jennifer Page, pediatric care