Mom's Tinfoil Hat did a post a while ago, talking about the recent study (and accompanying press release) that "obese" women breastfeed less. She had a number of criticisms of it, as do I.
The medical community and their media lackeys love to do these "fat women breastfeed less" studies, but it really bothers me that they don't go beyond the sensationalist headlines when doing them.
I believe it is probably true that, when looking at women of size as a demographic group, they probably do breastfeed somewhat less than women of average size, and that documenting this is not necessarily a bad thing if it leads to meaningful research into the cause and more outreach to increase breastfeeding in women of size.
But when do they examine WHY fat women breastfeed less, other than to simply blame obesity? Where's the meaningful information that helps with the problem instead of merely reporting one?
Instead, they always go for the simplistic angle (Fat is bad! Fat inhibits breastfeeding!) instead of trying to draw more meaningful information out of the issue. And frankly, I loathe the way they market these studies to the media, exploiting them to fan the obesity hysteridemic and to be as sensationalistic as possible.
Do they really think that story is going to be helpful to most fat women? Do you think most fat women who read that story come away thinking, "Yeah, I'd better get to La Leche League or a lactation consultant so I have the support I need for breastfeeding"?
Or do some fat moms read that story and think, "Oh well, I don't have a very good chance of breastfeeding, so what's the point?"
And what about healthcare professionals? Do researchers really think most are going to read this and think about all the ways they can encourage women of size to breastfeed? Some will, but many will not. Some are just going to conclude that it's probably hopeless anyhow, that this is yet another way in which fat women's bodies "don't work right" so why bother referring them to a lactation consultant or to La Leche League?
Although the researchers tell themselves that they are helping, I think the overall effect of such stories is to discourage breastfeeding among many women of size, not to encourage them to ask for help. And while the article authors may sincerely feel they are "just trying to help," I think the end result is that publicity such as this makes the problem worse.
It certainly encourages the perception that most fat women "can't" or "won't" breastfeed, when in fact most can and do breastfeed. The rates are lower than women of average size, yes, but there are significant numbers of fat women who do breastfeed successfully. Where are the stories featuring these women?
And where is the thoughtful analysis of why the breastfeeding rates in women of size might be lower? Why not study why fat women initiate breastfeeding less, and why they stop sooner? Why not investigate more closely possible physiological reasons for milk supply issues? And why not study the differences between the fat women who do manage to breastfeed successfully and those who do not?
I think the reason is because most researchers aren't willing to ask the hard questions. They want a quick and easy publishing score in a publish-or-perish academic world, they want simplistic answers ("See, fat interferes with lactation! Therefore lose weight to fix the problem!"), and they are in denial about how their own practices lower the breastfeeding rate in women of size.
Many Factors Affect Breastfeeding in Women of Size
Many factors affect breastfeeding rates in women of size; the culprit may not simply be "obesity" itself, yet researchers always assume that it is. In fact, as with so many issues, the association between "obesity" and lower breastfeeding rates may simply be due to correlation, not causation.
Here are some possible other factors that could explain why women of size have lower rates of breastfeeding.
Management of Labor and Birth
As we recently discussed and Mom's Tinfoil Hat pointed out, many of these studies don't control for cesarean delivery, which research shows can impact breastfeeding initiation rates in particular, and to a lesser extent, breastfeeding duration rates too. It can lessen the amount of milk a newborn receives, which may lead some women to give up breastfeeding or supplement excessively.
Since the rate of cesareans in women of size is so high, this is likely a significant factor in why many fat women do not initiate breastfeeding or give up within the first few weeks. Not the only factor, but a significant one.
And labor management can torpedo breastfeeding as well. There's a terrific book called Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum (by Mary Kroeger with Linda J. Smith) that documents how labor management affects breastfeeding.
Many of the pharmacological drugs used in labor (artificial oxytocin, epidurals, IV narcotics) tend to lower the levels of hormones (like prolactin and endogenous oxytocin), inhibit milk secretion or suckling behaviors, or have lower breastfeeding rates associated with them.
The high rate of interventions commonly used in the births of "obese" women often leads to a "perfect storm" of conditions that interfere with breastfeeding. [See my experience below.]
Yet even otherwise comprehensive reviews of breastfeeding and obesity often fail to mention how high-intervention labor management may affect breastfeeding initiation and duration in women of size.
This is part of the determined blinders that obstetric caregivers put on about how rates of undesirable outcomes (high cesarean rates, low breastfeeding rates) can be iatrogenic.....that is, influenced by caregiver management practices.
Understandably, no care provider wants to believe that they are negatively affecting outcomes in their patients, but any worthwhile study of medical interventions must take account the possibility of unexpected negative side effects from these interventions.
While labor interventions are clearly needed sometimes, their routine use often presents more risks than benefits and can have unexpected side effects. And nowhere are birth interventions used more routinely than in the births of "obese" women.
If they truly want to improve outcomes in women of size, caregivers MUST start examining how their own attitudes and interventive practices influence outcomes both positively and negatively.
Poly Cystic Ovarian Syndrome (PCOS)
I keep waiting for mainstream researchers to have anything meaningful to say about PCOS (a metabolic disorder found in many "obese" women) and breastfeeding as well.
Some research (and a lot of anecdotal evidence) shows that severe PCOS often affects breastfeeding supply. So how much of this reduced breastfeeding rate in "obese" women is due to PCOS supply issues, and how much isn't?
How come very few of these breastfeeding and obesity studies even mention the possibility of PCOS affecting milk supply?
Most of the "lower breastfeeding in obese women" studies only mention a study done in 2004 that showed a lower prolactin response in "obese" women in response to nursing.
So now all these studies blame obesity for lower prolactin response to suckling.......when actually it could be PCOS causing disturbances in the mother's metabolism and hormones, which in turn causes problems with lactogenesis and obesity. From the article on PCOS and low milk supply at MOBI:
According to Lisa Marasco, the IBCLC whose breakthrough research revealed the connection between PCOS and low milk supply, there are several different ways that PCOS could potentially interfere with breastfeeding.[In addition, more than one study also shows that prolactin response was lower in women delivered by cesarean, so that may be a synergistic factor as well.]
- Due to the hormonal imbalances which occur, there is the potential for poor breast tissue development during puberty and pregnancy. Fewer menstrual cycles in early puberty can translate into less estrogen to develop mammary tissue.
- Prolactin and oxytocin are two of the main hormones involved in the onset of lactation. Women with PCOS have higher levels of androgen hormones that can interfere with prolactin reaching its receptors.
- In addition, if too few prolactin receptors were formed during pregnancy, milk production will be limited.
- Estrogen is known to inhibit lactation, particularly in the early days after delivery. Women with PCOS typically have an imbalance called “estrogen dominance.” If estrogen levels are not down-regulated after birth, circulating estrogen may interfere with lactation. This is why the contraceptive pill is not recommended for breastfeeding mothers.
- Insulin resistance may affect breast growth and milk synthesis. Insulin is known to be an important factor in lactation in conjunction with prolactin and cortisol.
Where are the studies looking at these possibilities? Lisa Marasco made research on PCOS and low supply the topic of her Master's thesis, but she is one of the lone voices in the wilderness. She first published about this in 2000.....it's been 10 years since her initial work was published, yet only minimal new work on this has been published since then.
There have been a few studies here and there, and one comprehensive review of obesity and breastfeeding does mention PCOS as a possibility in passing, but really, after all these years, why isn't more being done on the PCOS/breastfeeding connection, and why isn't there more acknolwedgement of the connection in the research reviews?
Many "obese" people have higher levels of TSH...not always enough to get formally diagnosed with hypothyroidism, but generally higher than in people of average size.
This may indicate that many fat people actually have a form of subclinical hypothyroidism......not quite severe enough to be diagnosed or treated with current diagnostic guidelines, but severe enough to cause symptoms and difficulties with metabolism.
There is currently a strong debate whether or not people with subclinical hypothyroidism and symptoms of the Metabolic Syndrome should be diagnosed and treated with thyroid meds. [I believe they should.]
We know that more severe hypothyroidism can affect milk supply; might borderline cases also have higher rates of supply difficulties? I strongly suspect it has a role as well for many women. And since a higher number of women with PCOS have hypothyroidism, there may be a combination of factors at work here.
Anemia is another possibility. It can affect milk supply too.
Obesity itself has been associated with higher rates of postpartum anemia, although whether this is secondary to increased interventions is unclear.
Postpartum hemorrhage can be associated with insufficient milk supply. Cesareans can increase the rates of anemia due to increased blood loss during surgical delivery. Yet many doctors fail to routinely check for anemia after a cesarean, even when the woman is symptomatic.
If a high rate of "obese" women are undergoing cesareans, might undiscovered or undertreated anemia be playing a role in delayed lactogenesis?
Furthermore, hypothyroidism is often associated with iron-deficiency anemia and low ferritin (stored iron) levels, so it's possible that if fat women have a higher rate of borderline hypothyroidism, they might also have a higher rate of anemia. Could the two factors be synergistic? Especially if combined with a stressor like a cesarean? And PCOS issues?
Perhaps it is not so much one physiologic factor as it is several combining factors.
Other factors may be psychosocial in nature, not physiological, and a few reviews of breastfeeding and obesity do take time to discuss these possible factors.
The 2007 review focused a lot of attention on "intention to breastfeed." In other words, obese women planned to breastfeed far less often than women of average size. In smokers (another group with lower breastfeeding rates), intention to breastfeed is very tied to actual breastfeeding rates, so the authors speculate that this is a significant (and overcome-able) factor for fat women too. This is a valid point.
Now, why obese women would intend to breastfeed less than other women, it's hard to say. If there are more obese women in lower socioeconomic groups, and if women in lower socioeconomic groups tend to breastfeed less, the association may merely be coincidental. Or it may also be a subtle reflection of years of internalized fat-phobia.
After years of being told their body was "defective" or didn't "work right," fat women may simply be all too ready to believe that they "can't" breastfeed and give up easily....or decide not to bother trying in the first place.
This sounds simplistic but I believe it is a powerful force behind women of size not breastfeeding as much or as long as other women. Never underestimate the toll that years of negativity have on a woman's self-confidence in her own body and willingness to trust in its ability to work "right."
Some fat women face outright discouragement from medical professionals, who may tell them that they'd never make enough milk for a big baby or that their breasts are "too large" to breastfeed successfully, or that they'll "suffocate" the baby.
Or they may receive more subtle discouragement ("that little baby will have problems latching onto that large nipple") or not receive the same level of support and encouragement as women of average-size because the healthcare professional believes that they are a lost cause.
A difference in breast size and feeding mechanics may also play a role. Really well-endowed women may need to adapt the hold they use for nursing (for some like me, the football hold is the only hold that works). Of course, not all fat women have large breasts, but enough do that not providing adequate instruction about nursing with large breasts means that many fat women will find it difficult and frustrating to figure out how to manage their differences and may give up quickly.
In addition, breastfeeding books and videos rarely feature pictures of women with large breasts breastfeeding, so there are few pictures to inspire women with larger breasts to try. Some breastfeeding books don't address how to adapt for these differences. Others do, but the hints they give may be suitable for the "D" cup woman but not the J, I, or O cup woman. (Propping your breast with a rolled-up washcloth doesn't usually work for the O cup woman!) Many lactation specialists really don't "get" the special needs of women who are extremely well-endowed and don't have much useful advice for them.
Furthermore, there is a real lack of breastfeeding-friendly gear in larger sizes. Although some companies now carry nursing bras in larger band sizes and larger cup sizes, they can be hard to find if you don't know where to look. Most fat women certainly can't go in to a maternity store in the local mall and buy a nursing bra or a nursing top, so that can act as yet another subtle discouragement from long-term breastfeeding.
And almost never is there a picture in breastfeeding books of a woman of size (regardless of cup size) breastfeeding at all. While I'm sure the authors never mean to imply that fat women can't breastfeed, it's the underlying message that comes across when there are no pictures of women of size breastfeeding.
Just as we desperately need more images of women of color breastfeeding, we very much need pictures of women of size breastfeeding too. And how about some breastfeeding pictures of women of color who are also women of size?
The lack of pictures showing fat women breastfeeding, the lack of breastfeeding gear for women of size, the subtle and not-so-subtle negative feedback about breastfeeding when well-endowed, and the sometimes blatant discouragement away from breastfeeding combine with the negative self-image some fat women have to strongly discourage fat women away from even considering breastfeeding.
Add in the extremely high rate of interventions around labor and birth in women of size, then any issues with hypothyroidism, anemia, or PCOS, and is it any wonder that "obese" women have lower breastfeeding rates?
The above are only a few possible factors; there may certainly be others at play as well. If it's that easy for me as a non-healthcare professional to come up with possible reasons, why can't the professionals do so? Why won't they investigate these other possibilities seriously? Why don't they even mention these as possibilities in their studies?
Answer:....because they like simplistic answers, and because it suits the anti-obesity agenda of some researchers to blame every problem on obesity. If the problem is obesity, then the "fix" is to lose weight, right? Simple problem, simple solution, no messy complicating details.
Furthermore, what financial reason do they have to study breastfeeding in women of size in more detail? It's far easier to make a quick publishing hit by noting a lower rate of breastfeeding in women of size, tsk-tsking over it in the media, and promoting it as another reason to lose weight --- without having to inconveniently prove that losing weight improves breastfeeding outcomes.
The story is almost surely more complex than that.
My Own Story
This is admittedly a hot-button subject for me.
Breastfeeding with my first baby was almost completely torpedoed because of classic cascade of interventions: long hard induction, cesarean, severe edema from pitocin and copious IV fluids, 8 hours of separation before I was allowed to start nursing, frequent formula and glucose water supplements given by the staff, a sleepy baby from jaundice and all the drugs, etc. Add to that a mother in severe pain, little information about how to adapt breastfeeding for larger breasts, and a lifetime of "your body is broken" messages, and you have a classic recipe for breastfeeding "failure."
It's actually a miracle we managed to preserve breastfeeding at all. It was three months before everything really worked out, and I really considered giving up many times. Frankly, the only reason I kept going was because my MIL and SIL had breastfed for 4 months each and I wanted to prove that I could too. Then suddenly, things turned around between month 2 and month 3, and things worked out. We ended up doing extended nursing....but it was a very close thing in the beginning.
I had no problems breastfeeding my later babies, but breastfeeding almost "failed" with my first. The only major difference was in labor management and neonatal interventions, so I'm convinced that interventions plays a very strong role in the lower breastfeeding rates in women of size.
My first labor was the only one where I had so many interventions during labor and where my baby had so many interventions after birth. I had another labor and c-section with #2 but there were no induction drugs, minimal IV fluids, no separation after the birth, frequent and early nursing, and NO formula, pacifiers, or bottles of any kind. Same mother, similar delivery (labor and c-section).......but a totally different outcome. Yes, I'd breastfed before, which helps.....but I think the difference was labor interventions and management.
And things were even easier with the next 2 babies, my VBAC babies. No c-section to separate us at all or to delay my milk coming in.
You CANNOT tell me labor management and neonatal interventions don't matter.
And why did I have all those labor interventions with my first child? Because of a high-intervention management style the OB used due to my weight.
Correlation is not causation. Sometimes factors other than obesity are at work when breastfeeding doesn't work out. Wouldn't it be nice if this were acknowledged in these studies?
And when there is a physiologic cause, such as PCOS, wouldn't it be nice if there was more acknowledgement of that fact, and more meaningful research into how to mitigate that issue?
There are so many of us fat moms who HAVE breastfed successfully, not just for a few months but long-term as well. Why is it rarely mentioned that many fat women DO breastfeed just fine? Where are the stories and pictures documenting successful lactation in women of size?
If fatness truly caused poor lactation, then no fat women would be able to breastfeed. The truth is that some do and some don't, so there are likely multiple factors at work here, not just "obesity."
Why aren't they studying the fat women who HAVE breastfed successfully long-term and comparing them to the ones who haven't and see what the differences are? I bet that'd show some interesting differences.
In my observation, those differences usually relate to severity of PCOS, hormone levels, and/or high-tech labor management, delivery mode and neonatal interventions....but no one wants to hear that. They'd rather just take the easy way out by blaming obesity and assume that losing weight is the best answer for fixing the problem.
There needs to be more MEANINGFUL research on this topic instead of just simplistic sensationalism that discourages and blames fat women instead of encouraging and empowering them. Ugh.
Are you listening, lactation consultants and maternity care providers?
*Special note to the moms of any size out there who had difficulty or were not able to breastfeed: I have a special empathy for this situation because of how close I came to "failing" at breastfeeding with my first. Please don't read into this article any criticisms of you. I know you did the best you could and in no way are you a "lesser" mother for not being able to breastfeed. I simply want to point out the need for the research on obesity and breastfeeding to be more complex and meaningful.
**If you would like compassionate support for breastfeeding difficulties, please check out the MOBI site (Mothers Overcoming Breastfeeding Issues). This is a great site for women who have had difficulty breastfeeding, and offers information and non-judgmental support whether you continue to breastfeed or decide you need to stop. It can help you you get to the root of low milk supply, learn more about improving breastfeeding, or grieve a difficult or lost breastfeeding relationship. I can't recommend the site highly enough.
***Breastfeeding picture by Stanisław Wyspiański (1905), found at Wikimedia.
****If you are a woman of size and you are willing to share a picture of you breastfeeding for this blog or for my general use as needed, please send me a note at kmom at plus-size-pregnancy dot org and be sure to give me permission to use the picture. As noted, I am particularly interested in having more images of fat women of color in pregnancy, birth, and breastfeeding.