Monday, October 28, 2013

"Las Dos" and breastfeeding diversity



"Las Dos" 
"Las dos" (meaning "both") is a phrase used among many Hispanic women to describe the common practice of using formula supplementation alongside breastfeeding--not necessarily out of dire need but more as a matter of preference or culture. Many Hispanic women feel that "las dos" offers them and their babies the best of both worlds--they feel that their milk may not be enough, that formula will offer extra vitamins or that breastfeeding is just more convenient this way.

"Las dos" was recently discussed by the breastfeeding advocacy site Best for Babes, picking up from a 2010 poster campaign run by the Massachusetts Breastfeeding Coalition (scroll down to see). The posters urged Hispanic women to breastfeed exclusively, with the legends "Both Breast and Bottle? No!" and "If you give me formula, you won't produce enough milk for me/Your milk is full of important vitamins" in Spanish or English, accompanied by either a worried-looking baby or a picture of smiling breasts versus a bottle with a frowny face. Not a lot of room for ambiguity there, then.

The Best for Babes write-up covers the familiar territory: "But the problem with doing 'las dos' is that it deprives the baby of the benefits of exclusive breastfeeding, and it creates problems with the mother’s milk supply." ("It creates problems," mind you; not "It's possible it could create problems" or "It can create problems for certain women" or "Excessive supplementation creates problems.") We all know roughly what the argument is here: because breastfeeding is supply and demand, giving any formula at all is apt to lead the mother down the "slippery slope" of ever-increasing formula usage. Best for Babes suggested that women who practice "las dos" do so because they don't know better--a suggestion echoed by the study linked to on the same page, "Las Dos Cosas: An Analysis of Attitudes of Latina Women on Non-Exclusive Breastfeeding." (But don't worry; the study noted that "Women consistently demonstrated a willingness to learn from health professionals" about the need to avoid supplementation. So that's alright then.)

How true are the claims?
Now, the whole debate about the benefits of exclusive breastfeeding and how much greater these are compared to supplementing is a complicated one and I won't go into it in full here. I'll just say this: Exclusive breastfeeding to six months matters a lot in developing countries where a single serving of porridge/formula etc. made with contaminated water can kill a vulnerable baby. In developed countries, the benefits are likely to be "modest" and much harder to quantify.

I want to focus on the claim that adding-in formula causes supply issues (the "slippery slope" argument). The  trouble is, the evidence that combo-feeding causes supply problems in Hispanic women is actually kind of weak. For one thing, there's the awkward fact that in spite of frequently preferring to add in some formula, Hispanic women consistently show the highest rates of breastfeeding of any racial group in the United States, as long as the criteria used is "any breastfeeding" rather than exclusive breastfeeding.

What about if you compare Hispanic women who do supplement with those who don't? Linda Geddes looked at this area in her excellent book Bumpology. There's a dearth of evidence on the subject, but there is a 2005 analysis of 6,788 mother/child pairs of various races which found that "65% of the infants who were exclusively breastfed were still receiving any breastfeeding at 4 months compared with only 40% of the children who were fed a combination of breast milk and infant formula during the first week of life" but that "CBFF [combination breast milk and formula-feeding] is associated with shorter overall breast-feeding duration in white but not Hispanic or black mother-baby dyads." So for the babies overall, supplementing with formula early on significantly increases the chance that the mother stops nursing altogether--but for the non-white babies, this seems not to be the case, with those who get formula supplements being just as likely to go on breastfeeding as those that do not.

It tends to be the same story across many ethnic minorities in majority-white countries (African-American women being an important exception (Note 1)). In the United Kingdom, white women have the lowest breastfeeding rates of all racial groups (Note 2), while any-breastfeeding rates and predominant-breastfeeding rates are highest of all for African immigrant women (Zimbabwean, Somali etc.) followed by a tie between Asian (Note 3) and Afro-Caribbean women. But the exclusive-breastfeeding-to-six-months rate is low for all these groups because so many women do things like give formula till their milk comes in, add-in some formula even after that, or start solids before six months. Among Somali women in particular, comparing breastfeeding cessation rates for combo vs exclusive feeders would be tricky because supplementing is so normal that it's hard to find a control group. And exceptionally high numbers of Somali women breastfeed--around 90-95%. In Japan too we have high rates of predominant breastfeeding yet low rates of exclusive breastfeeding--most women add in some formula.

I once talked to a maternity ward nurse who worked in a London hospital where there were a lot of Somali mums, and I asked her if there was any conflict between the NHS's focus on exclusive breastfeeding versus the Somali mums' preference for supplementation. She laughed and said "The new nurses try and talk the mums out of supplementing at first. And then after a while they shut up, because they start to realize that the mums are a) taking no notice, and b) doing a good job of breastfeeding anyway, even though they're technically breaking all the 'rules.'"

Why might white women have more difficulties combo-feeding?
If combo-feeding is indeed more difficult  for white women than for other races, why would that be? There could be some kind of biological mechanism going on, but there could also be cultural explanations.

One possibility is that among white women, adding-in formula is not a cause of breastfeeding issues, but rather is a "marker" for women who tend to have breastfeeding/supply issues anyway. The theory goes something like this: "White" breastfeeding culture (which tends to be dominated by books, lactation consultants and the LLL) places a strong emphasis on exclusive breastfeeding and this is presented to white women as the ideal. So women avoid adding-in formula unless things are going wrong, like supply issues, a baby who isn't latching well or the presence of formula-feeding families/friends who pressure the mother to add some bottles to "fill him up." So when you look at the two groups, the "exclusive breastfeeding" group contains mostly women who find breastfeeding easy anyway, and the "combo-feeding group" has lots of ladies who have supply issues and other problems or are surrounded by unsupportive formula feeders... and maybe it's these issues that are causing them to give up, not the "slippery slope" of the formula itself. Among Hispanic, Zimbabwean etc. women (so the theory goes), combo-feeding is not seen as second-best and so the decision to combo-feed tends not to be strongly correlated with the existence of breastfeeding "problems."

Another possibility is that it's to do with confidence and normalization. If a Hispanic, Somali etc. woman thinks of breastfeeding as normal, when faced with issues she may take the pragmatic attitude of "Let's see if I can mix things up a little." A white Anglo woman may be surrounded by stronger external pressures to formula-feed--if she experiences difficulties she may be more likely to see breastfeeding itself as the cause of her worries, and feel that the best thing to do for her sanity is to cease nursing altogether. She may not have successful combo-feeders among her peers; if she is getting her breastfeeding knowledge and support primarily from online fora and lactation consultants, attempts to discuss combo-feeding may just result in lectures rather than practical advice. Perhaps white breastfeeding culture's emphasis on the "slippery slope"makes a struggling breastfeeder feel that attempts at combo-feeding are doomed to fail anyway and will just add to her stress.

A final possibility is that certain childrearing practices make combo-feeding easier, or are so supportive of breastfeeding that they "make up for" any issues that combo-feeding might create. In my thoughts on breastfeeding in Japan, I mused that the widespread practice of bedsharing (and frequent night-nursing) might be why widespread formula supplementation, low nursing-in-public levels and rigid, old-fashioned hospital routines don't seem to send Japanese women's breastfeeding into a tailspin. Bedsharing is commoner among Hispanic America, African immigrant, British Asian and Afro-Caribbean women than among white women, so perhaps this is worth looking into. Other practices like extended periods of post-partum rest following childbirth, common in several cultures, also merit investigation.

So much to talk about
We have a situation where the highest breastfeeding rates in both the UK and the US are found among non-white ethnic minorities, and in the UK in particular white women are less likely than any other racial group to breastfeed...and yet mainstream breastfeeding advocacy remains very white. In general, breastfeeding advocates' response to the non-white minorities where breastfeeding rates are high has been either to a) Ignore them; or b) Complain that the minorities in question aren't breastfeeding "properly" (because they give solid foods too early or add in formula), and then advise the minorities in question on how to breastfeed in the "approved" way. The Best for Babes article does have some really interesting discussion on how American hospitals and ways in which hospitals have tried to cater to Cambodian-, Chinese- and Mexican-American women's needs, and mentions that Hispanic women initiate breastfeeding more often than white women, yet skirts over the fact that they are also much more likely to still be breastfeeding at six or 12 months. Black Breastfeeding Week in the United States a few months ago provoked some great discussion about the barriers faced by African-American women hoping to breastfeed, but there was surprisingly little discussion of the fact that other groups of black women in America already have very high breastfeeding rates and are highly confident in their breastfeeding abilities.

Wouldn't it be good if these women's voices were reflected more in conversations about infant feeding? I'm curious to know how women from Laos or Nigeria or Somalia feel about the breastfeeding advice they are getting in English-speaking countries. Is it helpful? Is it annoying? Does it allow for individual and cultural preferences? If breastfeeding rates are high among certain groups, wouldn't it be great to start analyzing why they are high? And combo-feeding can be a Godsend to women working outside the home; if we want to develop good guidelines on how to combo-feed, perhaps breastfeeding advocacy needs to be getting more input from groups of women who are already combo-feeding successfully...?

What diversity really means
So many ways to breastfeed---including, apparently, 
with breasts made out of multicolored fun-fur
Although the question of "how much better is exclusive breastfeeding than combo feeding" is complex, in developed countries the differences are unlikely to be large enough to justify the Massachusetts Breastfeeding Coalition's approach of basically ordering everyone to exclusively breastfeed, without pausing to consider cultural
differences and individual preferences, as though the feelings of mothers counted for absolutely nothing. And while the question of whether combo-feeding increases the risk of giving up breastfeeding is not 100% clear, there is enough uncertainty surrounding the issue that the blanket statements of the Massachusetts' advocacy materials--"Breast and Bottle? No!""If you give me formula, you won't produce enough milk for me"--sound pretty bossy and over-the-top.

What we really need is more research on what's going on with combo-feeding and breastfeeding styles among women of various ethnic backgrounds. In the meantime, if some Hispanic women prefer to supplement, I suggest that the Powers That Be in hospitals and elsewhere respect their choice and give them the best advice we have at the moment--like making sure women have the basic facts straight (if a woman is combo-feeding purely because she thinks her baby won't get enough vitamins from breastmilk alone, it's surely reasonable to inform her that that's unlikely to be the case), teaching women how to keep an eye on their supply so that formula use does not keep creeping up and up, and making sure that women understand how to prep and feed bottles in an optimal manner--an area the National Association of Hispanic Nurses is now focusing on. True diversity is not about putting a few token non-white faces on display in breastfeeding books and blogs; it's about opening one's mind to the possibility that there could be many ways to breastfeed successfully.

(Note 1) I use "African-American" to refer to black people in the United States who trace their origins to African slaves in that country, while "Afro-Caribbean" refers to black people in the US and UK whose immediate origins are in the Caribbean rather Africa--i.e. they or their parents etc. migrated from there. I use "African immigrant" to refer to black people who migrated from Africa or whose parents or grandparents did so. I'm not thrilled with the term as I don't think someone who has lived in the UK/US all their life can be described to as an "immigrant," but I don't know of any other term that can be used to include all the people in this group.

(Note 2) Except for Romani Gypsies and Irish Travellers

(Note 3) In the UK, most Asian people are of South Asian origin--i.e. their ethnic origins lie in places like Pakistan, India and Bangladesh--rather than East Asian as tends to be commoner in the US.







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