Submitted on 2009/10/05 at 11:23pm
In response to: New Study Hypothesizes Bottle-Feeding Simulates Child Loss Increasing a Mother’s Risk for PP Depression
Dear NursingBirth,
As so often happens with interpretation of breastfeeding studies, you are ignoring the fact that this study was observational. Yes, certain factors were controlled for; however, since it wasn’t a case where they took 100 women with postpartum depression (PPD) and forced half to breastfeed and half to formula feed, you have to look at the results with some perspective. One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD. It certainly did for me, and for many women I have interviewed for a book I am working on.
I am certainly not anti-breastfeeding; I think it is a wonderful thing. But there are cases where formula feeding is the best – or only – choice, and implying that formula feeding can cause PPD is just plain irresponsible, in my opinion. The LAST thing women struggling with PPD need is pressure to do anything. If they want to breastfeed, then great; however, it is often far more useful to get on antidepressant medications, which are not universally recommended for lactating women. There have been studies saying that the long-term effects on babies who’ve been exposed to antidepressants in breast milk are negligible, but as my own pediatrician said, “none have proven this without a doubt.” If nursing is going to keep a woman from taking needed medication, then I do not think it is a healthy thing for baby or mother.
Just another opinion….
~Suzanne
fearlessformulafeeder.blogspot.com
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Dear Suzanne,
Thank you for commenting. I appreciate all comments left on my blog, both assenting and dissenting, as long as they are not ad hominem attacks. I also see that you are a new blogger and would like to welcome you to the world of blogging! If you are anything like me, you will both love it and hate it! I don’t know how long you have been following my blog but I invite you to take a look at one of my past blog entries entitled My Philosophy: Birth, Breastfeeding, and Advocacy. Here is an excerpt:
“I believe that pregnancy, birth, and the postpartum period are milestone events in the continuum of life that profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.
I believe that breastfeeding provides the optimum nourishment for newborns and infants which does NOT mean that I am not grateful for the advancements in artificial milk for those mothers and infants who truly require it.”
Now that you know a little more about me, I’d like to respond to your comment. I will number the points for ease in reading:
#1 You write, “As so often happens with interpretation of breastfeeding studies, you are ignoring the fact that this study was observational.” I fail to see how I am ignoring the fact that this study was observational. For one, I posted a direct link to the original study in which the authors discuss the method of their study. The authors write:
“We recently completed a study of over 50 mothers recruited through local pediatric offices at 4–6 weeks postpartum. Consistent with previous reports, we found that those who [formula] fed their babies scored significantly higher on the Edinburgh Postnatal Depression Scale than those engaged in breastfeeding. The increased risk of depression among mothers who relied on [formula] feeding held true even after we controlled for such things as age, education, income, and the mother’s relationship with her current partner.”
No where in there do they claim that the study is a randomized controlled trial, often regarded as the gold standard for research as it is considered to obtain the highest level of evidence. However not all research questions can ETHICALLY be answered with a randomized controlled trial. You wrote:
“Yes, certain factors were controlled for; however, since it wasn’t a case where they took 100 women with postpartum depression (PPD) and forced half to breastfeed and half to formula feed, you have to look at the results with some perspective.”
The fact of the matter is Suzanne that that type of study is completely unethical in this situation and therefore completely implausible and therefore it is unfair to suggest that this is a flaw in the author’s study. It is certainly a limitation but not a flaw. This is a problem that is realized the by research community, that is, that you can’t always randomly assign patients/subjects/participants to a certain cohort because you, for example, cannot force someone to breastfeed or someone else to bottle feed. Or force some to have a vaginal delivery and someone else a cesarean section. Or force someone to have a hospital birth and someone else a home birth Or force someone to smoke cigarettes and someone else not to smoke cigarettes. For this reason observational studies may address these problems to some degree and might therefore be the best way to answer research questions that cannot ethically be answered with a randomized controlled trial. The bottom line: It is careless of you to dismiss the implications of this study just because it is not a randomly controlled trial.
I also wrote about how this study was observational in nature in my post:
“The paper’s authors (who work in the Department of Psychology at the University of Albany/ State University of New York, Albany) recently completed a study of over 50 mothers recruited through local pediatric offices at their 4-6 weeks postpartum visit and evaluated them using the Edinburgh Postnatal Depression scale.”
Seems like transparent writing to me! I fail to see how I was “ignoring” anything.
[Side note: I am truly interested in learning more about your educational and professional background as I feel that you may lack experience in reading healthcare research if simply for the fact that you continue to misuse words like “cause.” Being that this study is a Level II observational study without randomization the authors by definition and design cannot (and DO NOT) claim or imply that formula feeding CAUSES anything! They can only imply that formula feeding might be a risk factor for PPD, which is exactly what they do. Being a “risk factor” for something and “causing” something are not one in the same. For example Human Immunodeficiency Virus (HIV) causes AIDS. Having unprotected sex with multiple partners and sharing dirty needles are both risk factors for acquiring HIV and hence developing AIDS. Having unprotected sex with multiple partners and sharing dirty needles do not cause AIDS. See the difference?
Proving true causation is very very difficult (and for some questions, theoretically impossible) and requires multiple studies at different levels of evidence that can be duplicated with different populations by different researchers at different times. One book that I found helpful to learn more about research was Nursing Research: Methods, Critical Appraisal, and Utilization by Geri LoBiondo-Wood and Judith Haber. I had to read it for a class I took in nursing school. Even if you are not a nurse I still think it can be a great learning tool for you, or anyone, who is interested.]
#2 You write:
“You have to look at the results with some perspective. One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD.”
First off, I do not deny that feelings of guilt regarding a variety of things can exacerbate PPD. Secondly I do believe that the authors are interpreting the results of their study with “perspective.” In fact their conclusion at the end of the article is written as follows:
“Bottle feeding practices and hospital procedures that simulate child loss may increase the risk of postpartum depression and fall within a growing number of medical issues that could benefit from an evolutionary perspective.” [Emphasis mine]
In addition, in my blog post on the study my conclusions are as follows:
“This is a fascinating article to me for a variety of reasons. First off, it is written by psychologists, not health care professionals and hence, takes a look at this very important topic from a completely different perspective. Second, it is a study/analysis that focuses “not on the advantages of breastfeeding per se, but rather on the negative psychological consequences of the decision not to breastfeed.” Thirdly, for mothers who cannot breastfeed (as related to the health of the baby or mother for example) or choose not to breastfeed, this article shows us how important it is as health care professionals to assess these mothers thoroughly for signs and symptoms of postpartum depression as well as to educate these mothers and their loved ones about their potentially increased risk for postpartum depression so that they can obtain help and/or counseling if their “baby blues” turn into something more serious.”
Sounds like a whole lot of “perspective” to me!! NO WHERE in either the study or my blog post did the authors or I ever make any claim that the results of this study are completely definitive or that formula feeding your child will most definitely cause you to suffer from postpartum depression. In fact the perspective the authors are taking is an evolutionary one. As any good study does this one raises more questions than it provides answers to and it opens the door to thinking about breastfeeding from the perspective of evolutionary medicine, or human history.
To deny the existence of the complex cocktail of hormones involved in labor, birth, and breastfeeding as well as their importance is something that mainstream medicine has been doing for decades. This study does not make judgment calls on women who either cannot or choose not to breastfeed and neither do I. But it is foolish to not at least take into consideration that we, as human beings, are indeed MAMMALS and by design are intended to nurse our young and if we do not or cannot, that we and our offspring as mammals might suffer some consequences.
Second, as far as your “One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD” comment, you are incorrect. In theory someone might be able to make the opposite interpretation but YOU cannot make such an interpretation (and neither can I) since YOU (nor I) have access to the study’s data and the authors did not elaborate on what else besides age, education, income, and the mother’s relationship with her current partner they controlled for. They could have controlled for other emotions the mothers were feeling…no one but the authors know… and perhaps not controlling for “guilt” is another limitation of their study. But neither YOU (nor I) can take such a leap without access to a more thorough description of the method (which was not provided by the authors) or the raw data itself. If you feel there might be another explanation other than the author’s explanation for the results, it would take another study to test your hypothesis. You cannot derive a conclusion from a study about a hypothesis that you didn’t test for. That’s research 101.
Thirdly, you comment that “studies like these” will exacerbate a formula feeding mother’s PPD reveals your lack of respect for research in general. The studies on depression that have been carried out over many decades have led to a better understanding about the disease and better care for people who suffer from the disease. Don’t mothers who suffer from PPD deserve the same?
#3 You write,
“I am certainly not anti-breastfeeding; I think it is a wonderful thing. But there are cases where formula feeding is the best – or only – choice, and implying that formula feeding can cause PPD is just plain irresponsible, in my opinion.”
I ask you Suzanne, why are you so afraid of the possible evolutionary and biological connection between the early cessation of lactation and neonatal loss? The authors of the study write,
“The present paper focuses on the decision people make to unwittingly depart from one of the defining features of mammalian evolution: to [formula] feed rather than breastfeed their infants. For 99.9% of human evolutionary history the decision not to breastfeed would have been tantamount to committing infanticide. The technology that lead to [formula] feeding as a substitute for the breast (e.g., bottles, rubber nipples, formula) has only become available within the last 100 years.
Opting not to breastfeed precludes and/or brings all of the processes involved in lactation to a halt. For most of human evolution the absence or early cessation of breastfeeding would have been occasioned by the miscarriage, loss, or death of a child. We contend, therefore, that at the level of her basic biology a mother’s decision to [formula] feed unknowingly simulates child loss. The death of a child is a well documented trigger for profound parental grief and depression, and evidence shows that mothers tend to be more affected than fathers. Suarez and Gallup theorize that depression as a response to the death of a child may be an adaptive mechanism that functions to (1) punish instances of inappropriate parenting or neglect, and (2) trigger social and psychological support from close friends and relatives during the particularly difficult period following the loss of an infant. Because [formula] feeding simulates child loss at a physiological level it may also play an important role in postpartum depression.” [Emphasis mine]
I ask you Suzanne, what do you find so objectionable about those paragraphs? What do you find so objectionable about my own conclusions? What do you find so objectionable about the possibility that formula feeding (and not using your breasts for breastfeeding) could be a risk factor for developing PPD simply for the fact that there are levels of HORMONES involved in breastfeeding that are not being released when you formula feed!!! For goodness sake it’s BIOLOGY!
Biology Fact #1: When an infant suckles at the breast as during breastfeeding, the pituitary gland releases both prolactin and oxytocin in the mother.
Biology Fact #2: Prolactin is a hormone also known as the “motherhood hormone” that stimulates development of the breast during pregnancy, controls the production of milk, is responsible for nest building in animals, and triggers aggressively defensive behavior in lactating females.
Biology Fact #3: Oxytocin is a lactogenic hormone also known as the “hormone of love,” is released during suckling, labor, birth, sexual intercourse, and while sharing a meal with others and is responsible for uterine contractions, male and female orgasm, the ejection of milk from the milk producing sacks in the breast, and feelings of calmness and bonding during childbirth and breastfeeding.
Biology Fact #4: If a mother does not breastfeed, prolactin levels usually reach non-pregnant levels by 7 days postpartum. Mothers who exclusively breastfeed have higher oxytocin levels over time than do women who supplement with formula or exclusively formula feed. When a mother supplements with formula or exclusively formula feeds her infant, prolactin levels decline markedly and fall even further over time, and oxytocin levels remain depressed and do not climb.
Biology Bottom Line: Mothers who exclusively breastfeed experience levels of hormones that mothers who supplement with formula or exclusively formula feed do not.
(References: Breastfeeding and Human Lactation by Jan Riordan & Birth and Breastfeeding by Michel Odent)
What is so objectionable about taking a further look into these hormones and their potential link to PPD?! What is so objectionable about educating gestating and new mothers about the benefits of breastfeeding the potential hazards of formula feeding so that they can make a truly INFORMED decision about whether to breast or bottle feed? And if in the end these mothers choose to bottle feed, as health care providers, what is wrong with being more aware of the potential increased risk these mothers have to developing PPD, just as we would be more aware of the increased risk of developing PPD with mothers who have experienced a loss or with mothers who have a history of depression. It’s called being a RESPONSIBLE HEALTH CARE PROVIDER and therefore I reject your claim that this study and by default my blog post are irresponsible!
#4 As far as your statements about the use of antidepressant medications during lactation, I believe that just as with the use of antidepressant medications during pregnancy, every mother should be counseled by her health care provider on a case-by-case basis where the risks are weighed against the benefits for both the mother and fetus/baby. I personally am not an expert in the use of antidepressant medications in pregnancy or lactation but I understand that there is an important debate regarding this issue that I have to learn more about.
In conclusion I am excited about all of the breastfeeding research that is out there, both past, present and future! And as far as your position as a “fearless formula feeder,” one point that I agree with you on is that mothers (and fathers) have to STOP the guilt trips and senseless competition. But unlike some other choices, I feel like the “to breastfeed or formula feed as a choice” question is not one that should be taken lightly (and I am not talking about the mothers or babies that cannot breastfeed for other reasons besides choice).
The more research that is done on breastfeeding the more we are learning that breastfeeding should no longer be considered “just nice” or “better” or “best” and formula feeding should no longer be considered “good enough”. The “choice” to breastfed should not be on par with the decision on what new car to buy [“Well the Lexus minivan is better but the Chrysler minivan is good enough]. Breastfeeding is NORMAL and more and more research is showing that formula feeding puts your baby AT RISK. If the benefits outweigh the risks when it comes to formula feeding for you or your baby then so be it. If not, but you still choose to formula feed, my only concern as a healthcare provider is that your choice is based on INFORED CONSENT and NOT misinformation, pressure from family or friends, untruths, or lack of support or resources. There are too may women out there who want to breastfeed but lack the support from family, friends, nurses and even doctors as well as lack the resources, and/or knowledge to do so. I am sorry but the cause of those women needs more attention which does not mean that I condone the “guilting” or judging of women who choose not to (and certainly not towards women or babies that cannot) breastfeed.
I dream of a world where ALL mothers who are willing and able to breastfeed get the support and encouragement and resources they need to do so! And I work everyday to make my dream a reality.
Sincerely,
NursingBirth
P.S. I encourage you to read a couple of my past blog posts:
My (Aggravated) Response to “Ban the Breast Pump” and Why The Today Show Hurts America (or, Battling The Case Against Breastfeeding)
