Support for breastfeeding is an environmental imperative

In counterpoint to responses criticising this editorial:

The editorial is valid in concentrating on infant formula’s environmental impact, over rehashing related health matters. Scientific consensus has authoritative bodies firmly positioning breastfeeding as important for public health, globally.

This is a medical journal editorial, labelled “intended for healthcare professionals” and titled “SUPPORT FOR breastfeeding is an environmental imperative (emphasis mine). Mothers are not targeted.

The editorial is valid in chiefly calling for investment in health professional education and breastmilk banks, in order to make breastfeeding a realisable option for more mothers who intend to breastfeed. This call works for, not against, health outcomes and women’s bodily autonomy. Unnecessary formula use is challenged, not necessary use.

Respondent Dr Tuteur presents a flawed notion that cows’ milk – in needing only grass for its production, compared to what breastfeeding mothers eat – is the most environmentally friendly food for human babies.

Firstly, lactating cows are only the starting point regarding producing breastmilk substitutes. Also needed are cow-milking machines, farm-to-factory transportation, processing machinery, fortification with many (usually imported) additives, packaging, distribution (usually international), and preparation with equipment and water that requires energy-using sterilisation.

Secondly, grass alone will not make cows lactate. They need to give birth. Dairy cows are inseminated yearly. This sees increased fodder consumption during gestation. Disposing of male newborn dairy calves (nearing two million annually in New Zealand alone), (1) involves fuel-burning transportation, and slaughterhouse machinery to process what little meat is on their bodies. Female newborn calves kept for future milking are fed reconstituted cows’ milk powder, which needs collecting, processing and transporting.

Thirdly, the world’s dairy herds largely consume stored forage and purchased concentrate and grains. (2) This involves mono-cropping and fossil-fuelled harvesting and transport systems. Grass-fed dairying systems also are monocrops that hurt native ecosystems. Identified detrimental environmental impacts from New Zealand’s pasture-based dairying include “nitrate leaching to streams and rivers, methane gas emissions, demands for surface and groundwater for irrigation, and reduced variety in pastoral landscapes”. (3)

As Poore et al, (2018) noted: “meat, aquaculture, eggs, and dairy use ~83% of the world’s farmland and contribute 56 to 58% of food’s different emissions, despite providing only 37% of our protein and 18% of our calories”. (4) Animal milk is the predominant base for generic infant formula production, but animal-based foods are not necessary for breastmilk production. The World Health Organisation Factsheet on Healthy Diet (2018) for beyond early-life does not position either meat or dairy consumption as necessary; it actually cautions about their saturated and trans fats. (5)

Neither direct breastfeeding nor expressed-breastmilk feeding require special foods. (6) Neither modern-day Western bras, special pillows nor special clothes are necessities; breastfeeding evolved without them, and they can impede infant positioning and/or latch. Hand expressing appears equal or superior to manufactured breast-pumps. (7, 8) Environmentally friendly cup-feeding with existing vessels (over baby bottles) is gaining traction due to breastfeeding-protective initiatives. Brazil’s world-leading donor breastmilk banking system sees breastmilk frozen in reusable glass mason jars, and collected, pasteurised and used locally. (9)

References:

(1). Ministry for Primary Industries. 2018. Mortality rate in young calves in the 2017 spring calving season: Ministry for Primary Industries Information Paper No: 2018/01. Wellington: Ministry for Primary Industries. P9
(2) FAO, IDF and IFCN. 2014. World mapping of animal feeding systems in the dairy sector. Rome. P1
(3) R. Baskaran, R. Cullen & S. Colombo. 2009. Estimating values of environmental impacts of dairy farming in New Zealand. New Zealand Journal of Agricultural Research, 52:4, 377-389. DOI: 10.1080/00288230909510520
(4) J. Poore, T. Nemecek. 2018. Reducing food’s environmental impacts through producers and consumers. Science, Vol. 360, Issue 6392, pp. 987-992. DOI: 10.1126/science.aaq0216
(5) World Health Organisation. October 23, 2018. Healthy diet Fact Sheet. Accessed October 10 2019,
(6) Ministry of Health. 2006. Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding Women: A background paper. Wellington: Ministry of Health. P2
(7) V. Flaherman, B. Gay, C. Scott, A. Avins, K. Lee, and T. Newman. 2012. Randomised trial comparing hand expression with breast pumping for mothers of term newborns feeding poorly. Arch Dis Child Fetal Neonatal Ed. 2012 Jan; 97(1): F18–F23. DOI: 10.1136/adc.2010.209213.
(8) G. Becker, H. Smith, F Cooney. 2016. Methods of Milk Expression for Lactating women. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CD006170.pub5
(9) NBC News, September 4, 2014. Brazil's Maternal Milk Banks A Global Model. Accessed October 10 2019,

We refer to the recent editorial by Joffe et al, ’Support for breastfeeding is an environmental imperative’ in which the authors presented the environmental impact of infant formula production and consumption as a reason for increasing investment in breastfeeding support.

It is crucial that we take action to minimise the impact of production of all foodstuffs, and that includes infant formula. However, the authors do not call on industry to improve their practices in this regard, rather they place the burden of reducing the environmental impact of infant formula into the laps (or indeed onto the breasts) of individual mothers.

As the authors state, many women who express a desire to exclusively breastfeed their babies ultimately find themselves using infant formula, either exclusively or in part. While a lack of breastfeeding support is part of that, many other factors also contribute – including the desire to share feeding with their partner or family, meet the demands of their other young children, or the need to return to work.

We appreciate that the intent of the editorial may have been to use growing concerns about the climate to persuade government to increase investment in breastfeeding support and services, but we are concerned it may only fuel a culture in which women are ultimately held responsible for mitigating against all risks, real, imagined or predicted. Nowhere is this more true than in relation to pregnancy and childrearing.

There is absolutely no doubt that we should do more to improve infant feeding support to all women. It should be noted that the current provision of breastfeeding support in the UK urgently needs review as research suggests the present delivery of the Baby Friendly Initiative may promote unrealistic expectations of breastfeeding, fail to meet women’s individual needs, and foster negative emotional experiences (Fallon et al, 2019), and in its present form therefore offers an inadequate response to the issue of low breastfeeding rates the authors are concerned about. However, even with the best possible breastfeeding support, infant formula will remain a legitimate product needed and used by families across the UK.

By focusing on the suggested environmental benefits of breastfeeding over the use of infant formula the authors fail to hold the correct people to account for the issue - the producers - and instead place the onus on consumers, who are predominantly women. The responsibility for reducing whatever global climate burden is posed by infant formula should not come at the expense of women’s reproductive rights, which are inclusive of how women use their breasts.

We suggest engagement with all food manufacturers, including infant formula companies, to reduce the carbon footprint of production systems without undermining a woman’s ability to make the decision that is right for her and her family about how she feeds her baby.

REFERENCES

Fallon VM, Harrold JA and Chisholm A. (2019) The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed‐methods systematic review. Maternal & Child Nutrition 15:e12778. https://doi.org/10.1111/mcn.12778

Shenker et al. look only at the environmental benefits of breastfeeding, ignoring both costs and risks.

Consider that breastmilk supplies the same calories per ounce as formula and those calories have to come from food consumed by the mother. In contrast to cows, who need only to consume grass to make milk, women need meat (often produced by industrial farming), vegetables and fruits (often produced by industrial agriculture) and fish (often caught by practices that are harming oceans).

Moreover, how green is a plastic breast pump? How green is the electricity and batteries used to power them? How green are nursing bras made with synthetic fibers, special clothing, breastfeeding pillows and other breastfeeding accessories? Shenker et al. don’t tell us.

Several decades after predicting that increased breastfeeding rates would lead to decreases in infant mortality, severe morbidity and healthcare spending, none of those things has come to pass. To the extent that increased breastfeeding has caused any measurable change for term babies, it has only made things worse: exclusive breastfeeding is now the leading risk factor for newborn re-hospitalization in the US (1), leading to tens of thousands of readmissions per year at a cost of hundreds of millions of dollars (2).

What is the environmental impact of tens of thousands of newborn re-hospitalizations, including neonatal incubators (made largely of plastic), IV tubing, blood drawing needles, etc?

By refusing to consider the environmental impact of breastfeeding itself and the increased risk of hospitalization, Shenker et al. haven’t made the environmental case for breastfeeding. Unfortunately, they have shifted responsibility for addressing climate change from corporations (which could fix it) and instead blame mothers. Ultimately, Shenker et al. exert even more pressure on women.

Recent research has noted how pressure to breastfeed has harmed women’s mental health (3). Diez-Sampedro et al. recommend:

“Health care providers also need to be supportive of women who choose to supplement with formula or who eschew breastfeeding altogether. It is not possible for health care providers to be aware of all the factors that play a role in forming a woman’s infant feeding intentions, but so long as a woman is provided appropriate education to make informed decisions, clinicians must trust that a woman will choose to do what is best, even if the woman’s definition of best is different than that of the health care provider.”

In short, Shenker et al. fail to make the case that breastfeeding is an environmental imperative, implicate individual women in a problem that is largely due to corporate activity, and add more pressure to women already struggling with overwhelming pressure to breastfeed.

References:

1. Wilson, J. L., & Wilson, B. H. (2018). Is the" breast is best" mantra an oversimplification?. The Journal of family practice, 67(6), E1-E9.

2. Flaherman, V., Schaefer, E. W., Kuzniewicz, M. W., Li, S. X., Walsh, E. M., & Paul, I. M. (2018). Health care utilization in the first month after birth and its relationship to newborn weight loss and method of feeding. Academic pediatrics, 18(6), 677-684.

3. Diez-Sampedro, A., Flowers, M., Olenick, M., Maltseva, T., & Valdes, G. (2019). Women’s Choice Regarding Breastfeeding and Its Effect on Well-Being. Nursing for women's health.