As a women's mental health advocate I frequently hear from women, researchers, providers and policy makers that for women with mood or anxiety disorders the choice to breastfeed is not easy. I began following Suzie Barston's blog, Fearless Formula Feeder several months ago, and have been impressed with her ability to (a) unpack the science, and (b) impact sensibility and respect for women who choose to formula feed. After reading her book and then interviewing Suzie, I know that this community will appreciate her academic rigor, and social insights. - Walker Karraa

WK: Tell us how childbirth educators might approach reading your newly published book, Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood and Why It Shouldn't?

SB: I wrote the book with a few goals in mind - first and foremost, I wanted to offer some support and perspective for women dealing with conflicted feelings about infant feeding. But I also wanted to provide a resource for childbirth educators, medical practitioners, and breastfeeding advocates which would explain how it feels - viscerally - to 'fail' at breastfeeding in today's world. I believe that most people are trying to help mothers; the problem is that they often unintentionally do the opposite. There is a right way and a wrong way to educate parents about breastfeeding, and I hope that even if childbirth educators don't agree with some of what I have to say, they can approach it as a Field Guide to the American Bottle Feeder.

I'm only half joking - there is so much misunderstanding and miscommunication between formula feeding mothers and breastfeeding advocates, and I think that if we could all just listen to each other without our defenses up, we could change the conversation for the better. There are certain books in the breastfeeding canon which were difficult for me to read when I was in the thick of my grief and anger over my breastfeeding experiences; I was researching Bottled Up at the time, and the notes I wrote in the margins of these texts are embarrassing proof of my evolving mindset. I was so angry. When I went back and read the same books again a year later, when it came time to actually write my manuscript, I had a markedly different take. There were arguments that I understood on an intellectual level, and portions that had previously infuriated me that now provoked me to nod in agreement. I think if you truly care about a cause, you should care about learning as much as you can about the different perspectives involved in that cause, even if you don't agree with them. That said, I hope that most childbirth educators will enjoy the book rather than feeling like it's a homework assignment!

WK: How do you address the misperceptions regarding your work as anti-breast feeding?

SB: Unfortunately, there are those who assume that anyone who acknowledges formula feeding as a viable option is either a pawn of the formula companies, misinformed, anti-breastfeeding, or a combination of all three. I don't think there is anything I can say to convince those individuals that I am 100% pro-breastfeeding. But it saddens me, because I never saw this fight as breast versus bottle. For me, it is about fighting the pressure to breastfeed and the concept that nursing your child is the be-all, end-all of motherhood. I am against misrepresented science, but I don't want to prove that breastfeeding isn't best, or that formula feeding is just as good - I want it not to matter. I want us to ensure that we provide healthy alternatives to breastfeeding for women who can't or don't want to nurse, and to simultaneously provide support and education for the women who do. Being critical of how society portrays breastfeeding is not at all the same thing as being critical of breastfeeding as an act. I believe that by de-politicizing breastfeeding, and putting less pressure on women to do it, it will help women approach it as a natural and fulfilling part of motherhood. The way we present it now, it sounds like going to the dentist - something we need to do to keep healthy, but not something we look forward to or expect to enjoy. Also, I don't think breastfeeding and bottle feeding need to be competitors. They are two separate ways of feeding an infant. There is no reason that they can't both be acceptable options, at least in a moral, social sense.

WK: We spoke about your advocacy work for healthy feeding initiatives, how do you see childbirth education as part of that?

SB: I think the time to educate and empower women to breastfeed is prenatally - not 5 minutes after giving birth, when hormones are crazy and emotions are high. Most childbirth classes discuss breastfeeding, but informal polls I've done with women around the country found that the overwhelming majority was dissatisfied with how infant feeding was approached in their classes. Women are told about the importance of breastfeeding, and warned about all the ways people will try to sabotage their efforts, and yet there is little attention paid to common roadblocks that are far more detrimental to breastfeeding success than a bit of formula supplementation for jaundice, for example. Things like tongue ties; how to recognize insufficient milk; how long it can take for your milk to come in and what to do if it doesn't; recognizes food intolerances and engaging in elimination diets; and even more importantly, a simple conversation about how hard and painful breastfeeding can be for some women in the beginning, with the reassurance that it will get better.

Scaring parents with out-of-context statistics and vague warnings about the inferiority of formula fed kids only puts them in a negative headspace. One of the things I loved about my Lamaze classes was how positive and honest the instructor was about childbirth - I came out of there thinking that yes, birth could be painful, but that I had ample tools to help me through it, and that it was possible to enter birth in a positive way, without fear. I wish we could approach breastfeeding the same way.

Additionally - education about formula feeding is imperative. The majority of the women in this country are using some formula by the time their babies are six months old. While breastfeeding advocates are trying to raise breastfeeding rates, they can't stick their heads in the sand until those goals are reached. We need to ensure that when women are supplementing or full-on formula feeding, they are doing so in a safe, healthy way. Formula preparation and bottle-feeding technique should be incorporated into prenatal education curriculum, and if this isn't possible, classes need to be available post-natally to address parental concerns and questions.

WK: One of the interesting aspects you discuss in your chapter 'Of Human Bonding' is the impact of sensory disorders on breastfeeding experience for women. Can you tell us about the sensory disorders piece?

SB: Every Friday, I feature a guest post from a parent about his or her infant feeding experiences. In addition, I receive numerous emails a day from women who are struggling with a variety of issues that make breastfeeding an extreme challenge. I started noticing that a lot of these women were mentioning sensory disorders, and others were using language that reflected some sort of sensory issue. Yet I haven't come across any research which addresses how sensory disorders might affect breastfeeding. One woman explained how every time her baby would latch, she had to fight the urge to shove him off of her chest. Interestingly, she was fine holding him any other time - but something about the act of suckling at the breast was a tremendous trigger for her. Dysphoric Milk Ejection Reflex (D-MER) is just starting to be explored; it makes me wonder how many other physiological/psychological conditions might be affecting women in similar ways. And I think it just proves a point I try and make quite often about Baby Friendly initiatives: I want to ensure that when women request formula, they are not asked why. It is not a nurse or lactation consultant or pediatrician's right to ask this question, because the answer might be highly personal, or something the mother herself can't even articulate. A better way to handle it would be to a say, 'I'm happy to honor that request - but I want to make sure there's nothing I can do to help you breastfeed if that is something you want to do. Is there anything you need from me, or want to ask me?' And then leave it at that.

WK: As a woman who experienced postpartum depression and breastfed and now examined the literature in this area, where do you see the gaps between research and practice?

SB: I am well aware that the research suggests that breastfeeding has a protective effect against postpartum depression. But the majority of this research does not ask the right questions: Why did the women in the sample stop breastfeeding? Did they stop because they were experiencing feelings of depression? Did whatever caused them to stop trigger the depression? I hear from so many women who claim that their PPD was exacerbated by breastfeeding issues - feeling of failure, desperation, inadequacy... coupled with physical stress and a lack of sleep (as anyone who has struggled to breastfeed or has had low supply can attest, you need to wake up every 2 hours to nurse until your supply gets established, and when your baby takes an hour to latch each time - that can take a toll after awhile). A study recently came out correlating breastfeeding problems with postpartum depression, and I think this is the first step in figuring out exactly how the two interrelate. But regardless of the research, we are talking about depressed women here, who are having trouble adjusting to motherhood. The last thing we should be doing is telling them that if they mother in a certain way, they won't be depressed. That isn't going to be true for every woman. I think PPD needs to be treated in a very individual way, and it always worries me when blanket statements are made about how 'breastfeeding prevents PPD'. Touting an associative, incremental advantage is not worth the potentially detrimental affect that sort of meme can have on a woman. The physical act of breastfeeding may help trigger oxytocin, but who is to say that oxytocin is going to affect every woman's brain the same way? Who knows if the PPD is complicated by something like an eating disorder or past sexual trauma, things which can make breastfeeding an emotional powder keg?

WK: How could childbirth educators address this gap?

SB: I see breastfeeding advocates engaging in online debates with mothers who swear that breastfeeding launched them into PPD, telling them that their experiences either don't matter or were just plain misinterpreted. This is not okay. When a woman has postpartum depression, the focus needs to be on getting her well. If breastfeeding is helping her, by all means we need to support it and not tell her to quit just because she needs Selective Serotonin Reuptake Inhibitors (SSRIs). But on the flip side, we need to tell her that it's okay to formula feed. Not 'it's okay if there is not other option', but rather 'it's okay' full stop. And it is. Even if breastfeeding does offer incomparable health benefits, the studies so far have shown those benefits to be relatively small on an individual level for those of us blessed to live with money, resources, and healthcare. The risk of having a mother who is incapacitated by a severe postpartum mood disorder is not so easy to counteract. Childbirth educators and doulas could do wonders in this area ' they could make it understood to all women, both prenatally and postnatally, that whether or not you breastfeed has no bearing on your worth as a mother.

WK: One of the things you shared in our conversation was your desire to engage with WIC. What would that look like?

SB: I know that WIC has a vested interest in getting lower income women to breastfeed, but I think they are going about it the wrong way. They are using the same approach that most breastfeeding advocacy uses - telling women that breastfeeding will give them healthier kids; making a subliminal suggestion that a 'good' mother will breastfeed. I don't think this approach is good for anyone, but at least women with resources can hire lactation consultants, take maternity leave, and buy expensive pumps, herbs and off-label medications to make breastfeeding work when it doesn't come easily. Many women who use WIC are single mothers, working mothers in low, hourly-wage jobs... if middle class women are finding it hard, women without ample resources and supportive partners are going to have it a lot worse. I think it's great to support breastfeeding in WIC, but I think the campaigns should focus on the positives and offer as much free support as possible. Perhaps getting together a volunteer force of peer supporters who could make house calls in the early days and help new moms get the swing of things? Instead, I see WIC programs doing things like offering incentive packages for new mothers who are breastfeeding. What sort of message does that send? Sure, it might entice women to breastfeed, but at what cost to our sense of humanity?

WK: Tell us about your experience with the supportive Lactavist community?

SB: I've met some truly amazing women who are able to support and promote breastfeeding in a positive way, while being sensitive to the experiences and opinions of others. And these women do so much good. What saddens me is that in the online world - which is the 'real' world for many new mothers - the people who have the most power, the most followers, are the most intolerant, the most extreme. This just widens the divide between mothers, and divided we truly do fall. I don't see how making formula feeding moms the enemy helps anyone's cause. The women who are out there being kind and non-judgmental and simply want to help others enjoy something that they themselves enjoy... these are the women who are going to raise breastfeeding rates. The others are just causing a backlash.

'The refusal to acknowledge the legitimacy of personal reasons for not breastfeeding could be written off as a misunderstanding; the experience of motherhood is a tough thing to measure and varies depending on socioeconomic, ethnic, and geographical factors' (p. 89).

WK: In our conversation, we discussed the need to understand and address these factors for all women. How do you see culture and class as important considerations for childbirth community at large with regards to breastfeeding? And how could childbirth educators integrate these considerations into curriculum?

SB: Breastfeeding advocacy tends to come from one specific socioeconomic subset - upper-middle class, highly educated women and men. They tend to base their ideas about other cultures and socioeconomic groups on self-reported data culled from problematic surveys - problematic, because the questions are phrased in ways that immediately set us up for classist mistakes. We cannot assume to know the intricate decision-making process that any particular woman goes through. I think the advantage that childbirth educators have, however, is that they are teaching within certain geographical areas. You can at least understand the basics of the group you're talking to. If you are teaching a group in Santa Monica, CA, or Portland, OR, you can safely assume that these women are well-aware of the importance of breastfeeding. It is their cultural norm. If anything, these women probably need guidance in understanding that things can go wrong, and arming them with the information that might help them survive a challenging breastfeeding experience. On the other hand, a group in small-town Iowa might have a bias in favor of bottle-feeding, so normalizing breastfeeding might be a beneficial goal. But even this isn't always going to work, because of the Internet. The rising popularity of sites like The Bump, Babycenter, and the proliferation of parenting blogs have made the global culture of motherhood more standardized. Many women form deep friendships on these message boards and trust certain bloggers more than their pediatricians. The online world is not a reflection of our nation's breastfeeding rates - because online, exclusive breastfeeding and attachment parenting are the 'norm'. So we can't assume that just because someone lives in an area where bottle-feeding is prevalent that they won't be feeling internal pressure to breastfeed- and when you mix that internal pressure with the external lack of support, you get a tough situation for a new mom.

WK: This is a heated, much debated topic. You clearly dove right in to both the science and the sensibility of the issue of breastfeeding choices. Your research has included interviews with some of the biggest names in science, pediatrics, social science and policy. What are some of the surprises you experienced?

SB: I was downright shocked at the lack of communication between all the people weighing in on infant feeding issues. Sociologists aren't communicating with biologists; pediatricians aren't communicating with obstetricians, and no one is communicating with the moms who are struggling to breastfeed. Yet, everybody is making assumptions and proclamations about things out of their area of expertise. There is no reason that a biologist should be making sociologically-based claims about women who don't breastfeed, without doing the field work necessary to form these opinions. Infant feeding science is the only field of study I've seen where it is perfectly acceptable to begin non-social-science study reports with sweeping generalizations about why women behave in certain ways. I see criticism of people like Joan Wolf or Jules Law (both critics of breastfeeding science who I interview in the book) saying that since they are not epidemiologists, they have no right weighing in on the validity of the scientific literature. But these folks are reading the literature like it should be - as a body of work - and realizing that there are giant gaps and misunderstandings and unwarranted leaps. Their separation from the science lets them escape the tunnel-vision so prevalent in the research and advocacy communities.

The most shocking thing I discovered, however, was the utter lack of long-term research that was informing recommendations concerning drugs and breastmilk. The danger in having this overzealous - and I believe unfounded - fear of formula is that the answer almost always is 'breastfeeding on x drug is safer than formula feeding.' But these claims are never backed up by legitimate science. There are newborns who have died because their mothers were on prescribed doses of postpartum painkillers- and yet we are told taking these drugs is perfectly safe. The discrepancy between the way we speak about formula-related risks and breastfeeding-related risks is astounding.

That said, I think that the most important thing I learned while researching this book is that there are no easy answers. If we are looking at infant feeding as a cold, risk-benefit type of thing, than it has to come down to a very individualized decision based on a lot of factors. But the fact that we are approaching it this way - instead of an enjoyable, rewarding experience, where parents can bond and nourish their children ' is just sad. I wish the conversation could move away from the science and move towards the sensibility- which is, of course, supporting women in their decisions and helping them ease into the often difficult transition to motherhood.

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