Mothers' Costs of Suboptimal Breastfeeding: Implications of the Maternal Disease Cost Analysis

On June 6, my colleagues and I published a study in Obstetrics and Gynecology entitled ‘‘Cost Analysis of Maternal Disease Associated with Suboptimal Breastfeeding.’’ In our study, we found nearly 5,000 excess cases of breast cancer, over 50,000 excess cases of hypertension, and nearly 14,000 excess heart attacks in mothers attributed to not breastfeeding each of their children for at least a year. The costs of the premature deaths from these diseases, as well as from premenopausal ovarian cancer and type 2 diabetes, total $17.4 billion, with direct and indirect health costs just shy of $1 billion in 2011 dollars. Because we wanted to know the degree of uncertainty in our results, we created an elaborate computer model to simulate a cohort of women in the U.S. population, which would allow us to measure the uncertainty of our results with rigor. The previous two cost analyses on breastfeeding did not measure uncertainty. We ran the simulation 2,000 times using current breastfeeding rates and another 2,000 times assuming 90% of women breastfed each child for at least a year. We did not find a statistically significant number of excess cases of type 2 diabetes, probably because we assumed that the effect of lactation disappears 15 years after the last birth, which is what one well-done study in the literature found. We also did not find an excess number of cases of premenopausal ovarian cancer, likely because it is a fairly rare disease. Finally, we found over 4,000 excess deaths, although this number was not statistically significant. The cost of those deaths was significant because those deaths were more likely to be distributed in middle-aged women rather than older women, and deaths in that age range have a much higher monetary value, in econometric terms (the value of a statistical life). The uncertainty meant that our data were not as newsworthy as the pediatric data published 3 years earlier in Pediatrics. Like many economic analyses, we did not do an analysis that would generate confidence intervals or p values, numbers that would tell us whether our results were statistically significant or not. The pediatric results made big headlines around the world: $13 billion in excess costs and 911 excess deaths, nearly all of which were in children across the 10 conditions we studied. We plan to redo the analysis in a way that will tell us whether our results are significant. It is interesting to consider what is newsworthy and what is not. One newsworthy result of the pediatric study was the public commentary that mothers who don’t breastfeed are guilty of all kinds of things: costing our economy money and allegedly causing deaths and diseases in their children. In the many interviews that followed after that publication, I repeatedly pointed out that most mothers want to breastfeed but are not supported adequately in doing so, especially when most women give birth in hospitals that do not adequately use evidence-based practices that support breastfeeding. Despite this, the so-called ‘‘Mommy Wars’’ only heated up further, perhaps culminating in last year’s Time magazine cover of a woman defiantly nursing her 3 year old, with the headline, ‘‘Are You Mom Enough?’’ The blogosphere has rattled with accusations that being pro-breastfeeding means some mothers must be bad parents if they don’t breastfeed, that breastfeeding entails some necessary sacrifice one must make for the sake of one’s children. It is even unclear to me whether the ‘‘Mommy Wars’’ are real or just a creation of a media looking for controversy. There are all the complex levels of mommy-combat: working moms versus stay-at-home moms, educated and wealthier women versus poorer women, women who work in offices where they could express milk versus women who work in Walmart and McDonald’s, women who were naturally endowed with the ability to breastfeed versus women who couldn’t seem to make enough milk (or didn’t have it in them to persevere until they did), even white women versus women of color (who historically have lower rates of breastfeeding and greater health disparities). The new maternal health data will hopefully end the socalled ‘‘Mommy Wars.’’ Breastfeeding is a women’s health issue and a costly one at that, with thousands of women needlessly suffering because of suboptimal breastfeeding duration. Research has shown that 60% of women do not even meet their own personal breastfeeding goals. That tells us that the national conversation about breastfeeding is no longer about who is a more valiant and selfless mother. It’s about supporting women so that they can breastfeed as long as they want and live longer and healthier lives because of it. It’s about empowering women to do what’s best for them. There is no more mythical Supermom ideal that women are supposed to hold themselves up to, at least not