April 5, 2010 -- A new study calculates the cost in the United States of not breastfeeding infants in their first six months of life at $13 billion each year, but others say it fails to take into account the costs women must pay to breastfeed in the first place.
The study, appearing in the most recent issue of Pediatrics, bases the $13 billion estimate on the increased medical costs of diseases caused by a lack of breastfeeding.
But besides saying the study fails to consider the costs of what would be needed to make breastfeeding easier for mothers, outside researchers say it may further stigmatize mothers who can't breastfeed.
"The biggest barrier to mothers continuing to breastfeed seems to be the fact that more mothers are in the workplace," said Dr. Lillian Beard, an associate clinical professor of pediatrics at the George Washington University School of Medicine and Health Sciences and an assistant professor at the Howard University College of Medicine.
"It's a very impressive number," she said of the $13 billion estimate, "but I want to know: Did the study take into account the cost for breastfeeding mothers?
"I think this report puts an unfair slant on it," Beard said. "It's not taking into account that for almost two thirds of U.S. families, women are either the co-breadwinner or the breadwinner. Returning to work is germane for the survival of the family."
Beard said that while a majority of women may want to breastfeed, outside constraints make it difficult and there is a drop-off in breastfeeding once they have to return to work.
"I think we have to continue to make efforts and create opportunities to increase breastfeeding rates, but we have to address the major barrier, which is the lack of workplace support," Beard said.
The study's lead author said that while people may question the cost estimates, the conclusions still stand.
"Breastfeeding is a very important economic and public health issue," said Dr. Melissa Bartick, an instructor in medicine with the Cambridge Health Alliance and Harvard Medical School. "We need to support families more if we hope to achieve higher breastfeeding rates."
The study itself spelled out the high cost estimates for current breastfeeding rates.
"The United States incurs $13 billion in excess costs annually and suffers 911 preventable deaths per year because our breastfeeding rates fall far below medical recommendations," the researchers write in the study. "Substantial gains could be made with exclusive breastfeeding for 4 months and any breastfeeding at 6 months."
While Bartick acknowledged that the study did not address costs of improving breastfeeding rates, she said some steps could be taken that did not have significant costs.
For example, she said, after a baby is born it should not be taken away and weighed and bathed, but should be placed in the mother's arms and against her bare chest so it can try and nurse within the first hour of life.
"We shouldn't be blaming mothers that our rates were so low," said Bartick, "because mothers are not supported well and their efforts to breastfeed are undermined by such things as poor hospital practices."
James McKenna, director of the mother-baby behavioral sleep lab at Notre Dame, said the current study likely would help mothers gain support in breastfeeding.
"You can't control the effects of any new insight," he said, allowing that some might use it to pass judgment on mothers who do not breastfeed.
At the same time, he credits the large amount of breastfeeding research going on with positive policy changes.
"Already across the country, we find that states are passing laws to protect mothers who are breastfeeding," said McKenna. "These things are making it possible for mothers to adapt these practices."
Breastfeeding typically has been a difficult area to research.
"There is some research that suggests a benefit [to breastfeeding]," said Rebecca Goldin, an associate professor of mathematical sciences and director of research for the Statistical Assessment Service at George Mason University.
At the same time, she said, it becomes difficult to draw wide conclusions because the studies typically are not randomized -- where women wouldn't be able to decide for themselves whether to breastfeed or not. As a result, researchers have to take into account any factors that might affect a woman's decision to breastfeed.
That may be why, for example, Goldin said, women who breastfeed tend to have fewer accidental deaths among their children -- simply because women who choose to breastfeed may be more attentive mothers.
But as to the Pediatrics study, Goldin said the $13 billion cost savings it estimates is not useful.
"It would take a lot of social and medical support to make that happen," she said, including support from nurses and possibly keeping women in the hospital longer.
But other costs would be higher.
"Probably, many of the costs to get breastfeeding that high would be social, not medical expenses," she said, including compensating employers for giving women time to breastfeed and having social workers visit homes to help new mothers with nursing.
"Those are very real costs," said Goldin. "When you do an economic comparison, it's unfair to only look at one aspect of the cost for any one particular decision. It's not clear that this is a fair savings to the nation."
But, Goldin said, studies like the current one present a problem for women who can't afford or otherwise choose not to pay those costs of breastfeeding, because often they are looked upon poorly.
"One of the risks of these kinds of studies is that they perpetuate that," she said. "I think it's perfectly within the realm of risks we take every day to decide not to nurse."
She asserted that driving could be made to look equally bad, given the medical costs in the form of car accidents.
"Is it fair to look at the medical costs of driving and talk about the morality of driving?" she said.
However, she agreed with other researchers that women who want to breastfeed should be able to.
"I think that women should get support for breastfeeding. I think that it shouldn't be so difficult to do it for women," said Goldin.
While she emphasized the benefits of breastfeeding, Beard agreed that when women can't breastfeed, there are acceptable substitutes.
"Without question, breastfeeding has some specific maternal and infant benefits," she said. "Although breastfeeding is absolutely ideal, for the mothers who cannot and choose not to breastfeed, infant formula is what's recommended. I don't want to beat her over the head with guilt. I let her know that infant formula is the safest, most nutritious and only recommended alternative to her milk."