Lactation non-profits and the ethical lactation medicine of the future
Lactation non-profits and purity of mission
The lactation non-profits around the English-speaking world, which aim to help a woman breastfeed her baby, remain in the thrall of deeply rooted traditional beliefs about the purity and rightness of breastfeeding. These beliefs are entangled with damaging ideas of maternal naturalness and buried in structural orientations of lactation non-profits, most particularly in their regulations about the WHO International Code of Marketing of Breast-milk Substitutions and its rigid and over-extended interpretations. (This ideological orientation remains the case, I argue, despite the lactation non-profits use of progressive and inclusive terms such as breast/chestfeeding and breastfeeding person.)
Belief in maternal naturalness fuelled the sentimentalisation of Motherhood in the emergent 19th century Western Europe middle class – a naturalness which served the patriarchal social order and which our social scientist and feminist sisters have spent decades deconstructing. It’s a naturalness that never really existed from an evolutionary perspective, given the highly social nature of infant care in pre-industrial societies, the diversity of infant care practices world wide, and the profound entanglement of biology and culture which uniquely characterises our most extraordinary of species, Homo sapiens.
My early research focussed on unsettled infants. By the 2000s, I was still reeling from the infant gastro-oesophageal reflux epidemic which had started in my home city in the early 1990s then spread down south and around the world, right before my youthful GP-IBCLC eyes. I had formed the view that we would only improve breastfeeding rates if we integrated management of breastfeeding problems with management of unsettled infant behaviour, since so many breastfeeding problems were misdiagnosed as signs of infant GORD or allergy. At the International Infant Cry Research Workshops I attended in those years, I was viewed as an oddity, an anomaly. One of the most senior infant cry researchers in the world at the time told me this over a glass of wine at the table with his wife late one evening after one of the workshops: don't come any more, he said to my face, you really don't belong. He meant it kindly. Mine were the first publications which drew on the research to propose a multi-domain approach to clinical management of unsettled infants and breastfeeding problems, at both a local and international level, but an unfunded independent clinical primary care researcher can't hold her ground against big university research teams (mostly at that time made up of psychologists, who had taken over the field of unsettled infant behaviour).
Instantly, on writing that, I hear the old voices in my own head which warn against boasting, which shout out 'imposter'! Maybe I have been excluded from belonging to BMNANZ, too, because my lactation medicine colleagues think me guilty of hubris, or worse, narcissism? I stopped submitting to Australian journals and only published internationally when an anonymous Australian lactation medicine doctor reviewer – a gatekeeper for years on what can get through concerning education of GPs in breastfeeding management in Australia - labelled the gestalt method ‘divisive’. Divisive? There is the permissible, and the impermissible, in science-based considerations of fit and hold? To introduce something new is divisive?
The inclusion of unsettled infant behaviour as part of lactation medicine, or the inclusion of lactation medicine in considerations of unsettled infant behaviour, was a radical reframe, and seemed to be a reason for my exclusion, I felt, from acceptance by my breastfeeding medicine colleagues back then, in the 2000s and 2010s, of whom there were only two or three publishing, since it seemed clear that they didn’t agree my work on unsettled infant behaviour was before all else about breastfeeding. I remember how upsetting attempts to discuss this with one of these medical colleagues was for me, back then: her incomprehension and lack of interest, sitting there in a foyer at a conference, me trying to explain. Breastfeeding was about breastfeeding and lactation, in her mind, not about the unsettled baby. Her mind just didn’t work like mine when it came to interdisciplinarity and complexity.
Lactation non-profits and authoritative knowledge or rightness
Lactation non-profits and their leaders remain structurally embedded in a historical purity, a certain righteousness, despite superficial accommodations to our times. For example, a tone of authoritative knowledge or rightness or definiteness widely characterises lactation medicine and clinical breastfeeding and lactation education and support. Those who stand outside the world of lactation medicine often comment to me on this when they hear this is my special interest. Those inside just think this is how you educate, or how you evoke confidence in your colleagues and in women. As lactation medicine doctor Professor Alison Stuebe once commented in an email to me: perhaps we’ve spent so long defending breastfeeding from detractors so that we’ve normalised a strident tone. I'm not convinced. That strident tone mirrors the tone of the medical patriarchs in my training and early days of medical practice, and is a tone that Australian general practice is increasingly abandoning. I watch the next generations of GPs stand with humility before the great unknowns in the way they educate, before the complexities of our patients’ stories.
This old-fashioned, authoritative, medicalised tone is adopted in lactation medicine even as theoretical models are being (wrongly) taught as scientific or clinical facts, since clinical breastfeeding and lactation support remains a research frontier. Someone like me, who might ask questions and dissent from a position of knowledge of the research, risks judgement and exclusion. The world of lactation medicine is frightened of dissent, or at least wants to control who can and can't dissent.
Lactation medicine is still emerging out of the industrial mindset that has characterised medical practice in general in industrialised societies: a mechanistic perspective that fails to take into account embodiment, that intimate mind-body connection fundamental to the human condition. For this reason, although you’d think it was fundamental, mechanosensing (the way mechanical forces act upon living cells and tissues) is still ignored in lactation medicine, and yet is radically foundational to my own work across multiple areas of breastfeeding management.
When the European Academy of Breastfeeding Medicine invited me to talk in 2023 about my reframes of mastitis and its management (which is linked with my work on nipple pain, too) using mechanosensing as a foundational theoretical model, the panel was explicitly set up so that there could not possibly be direct discussion or argument amongst the panellists. I’m grateful that the EABM invited me since at the time IBLCE was communicating to conference organisers in various countries who’d reached out to me that I was in violation of the WHO Code, so that invitations were withdrawn. The EABM did not seem to be intimidated by this, confident their conference would succeed even if some presenters like myself, an outsider, or the esteemed Professor Thomas Hale, highly respected within lactation medicine circules, weren’t able to be attributed CERPs. This demonstrated to me how narrowly my Asia Pacific colleagues choose to interpret alleged violations of the WHO Code, how selectively the sanctions are applied.
Dissent, respectful disagreement, debate, is utterly fundamental to the evolution of science. Dissent and debate is at the very creative edge of scientific and clinical advance. The flattening or silencing of dissent and disagreement explains why so much of the clinical support breastfeeding women receive doesn’t help, at a time when collective knowledge is otherwise stunning global acceleration. It explains the rapid rise in overmedicalisation, paramedicalisation, and overtreatments of breastfeeding women and their babies, with all the attendant risks of other unintended outcomes (documented in the research and which I see, over and over, in the clinic).
Lactation non-profits arise historically out of a pure or righteous belief that breast is best, which segues into a belief in the justness and necessity of breastfeeding advocacy as the primary and dominant concern in infant care. In this model of purity, persisting with breastfeeding is more important clinically than maternal mental health or family wellbeing. For example, the US-based global leaders in lactation medicine, to whom BMNANZ looks, regularly recommend anti-depressants for women with persistent nipple pain.
This explains why lactation non-profits operate structurally from the pure or righteous belief (which lacks any evidence base) that the predatory marketing practices of formula companies is the main cause of breastfeeding problems, both historically and currently, in high income countries. I have even heard Australian doctors claim recently that the allergy diagnosis was driven by formula companies – again, a historical distortion which uses the familiar scapegoat of the formula companies to compensate for the failure to invest in lactation research and to engage in discussion with those awkwardly disruptive voices of dissent.
The lactation non-profits themselves drove allergy and reflux diagnoses as explanations for fussy infant behaviour at the breast or between feeds for a couple of decades, and my programs contested this from 2011, an unpopular position. When I wrote about the misdiagnosis of gastro-ooesophageal reflux disease in infants in the first 16 weeks of life, a little article in ABA’s Essence magazine, there was (apparently, according to the Essence editor) a furore. To my disappointment, ABA declined to publish a clarifying statement which supported my research-based statement that reflux was not a cause of unsettled infant behaviour which would respond to medications in the first few months of life. I was reported to AHPRA for causing harm to babies (by promoting the withholding of treatment). I was also reported to the Head of School of Medicine at The University of Queensland for harming babies. That venerable doctor firmly interrogated me, and chided me for the way I described paediatric gastroenterologists. (I'd writteen that the paediatric gastroenterologist - the discipline which had started this overmedicalisation - tended to see the infant from the perspective of a tube between mouth and anus, a joke about how this was the focus rather than the whole child. I thought I’d written it as a funny line, but apparently not.) “I’ll let it go this time,” the Head of School said.
I mentioned this story last year to a midwife and leader in ABA, who was defending ABA’s decision not to allow Possums to pay for ads in their parent or health professional newsletters alongside ads for baby expos and other items, on the grounds that promoting the Possums programs didn't further ABA's goals. I was attempting to explain a long history of being excluded on grounds of differing perspectives, even though my work has been vindicated as time has passed. But the manager was offended. (I hadn’t intended offence but was trying to explain that ABA is often on the wrong side of the gap between evidence and practice, because this is the nature of consensus clinical or educational guidelines: necessarily very conservative.) The conversation floundered in her negative feelings towards me and quickly ended. Since then, ABA has taken on a China-based breast pump company as a platinum partner, having conducted market research for this business amongst ABA's membership. But our country’s cherished parent-facing lactation non-profit won’t allow a small Australian social enterprise to pay for ads in its newsletters letting parents and health professionals know about the breastfeeding and lactation education opportunities we offer?
Non-profits are not necessarily operationally pure and can resort to predatory or exploitative business practices to ensure their own financial survival
Lactation non-profits leverage goodwill from the belief, which I would say now from intimate personal experience is quite naïve, that the lactation non-profit is a pure or superior form of governance structure for supporting breastfeeding women, compared to a business or social enterprise structure. This belief in the governance purity of the lactation non-profit fails to take into account growing critiques of charity and non-profit operations. Because they too need to survive commercially, non-profits can quite easily take on the worst of predatory business practices. Others may be tightly controlled by families or founders, in order to secure founders’ incomes, with this being transparently declared as a conflict of interest. Others act like predators (for instance, using various levers to exclude or silence perceived competitors) under the guise of non-profit purity of intent. This naivity concerning the governance structure of lactation non-profits does not serve the best interests of lactating women and their babies.
I personally have rarely received research funding. The most I can attribute was $10,000 in 2009. The Chris Silagy award from the RACGP gave $20,000 – but stipulated none could go to the researcher herself. My own role in my 30 or so research publications has been self-funded. That is, most of the work I’ve done over the years has been ‘voluntary’, funded by seeing my patients in the clinic (and latterly, by drawing on my own now almost used up superannuation).
I feel an ache when BMNANZ’s automatic emails refer how the organisation is run by volunteers, asking the recipient to understand and forgive delays and so on. I feel an ache because I am confident I have invested many multiple times more of my personal finances and indeed my own future into the largely voluntary work that I have and still perform in this field relative to any other volunteer participant in BMNANZ. My willingness to expose myself to great financial risk, in the absence of spousal protection or generational wealth, is a kind of foolishness, a kind of crazy-brave bone-deep hope for the future of families who seek our help, for which I take complete responsibility. This foolish investment of my own security has been a clear-eyed choice. For me, it has been a matter of professional purpose, of professional meaning, and I’ve not known what else I can do to earn a living into the future (since I can’t afford to stop paid work). But my volunteer work is not considered by my colleagues BMNANZ as something to respect and honour and support, even celebrate.
This is among the many small unkindnesses of the in-group of prominent lactation medicine doctors towards outsider colleagues. Others have told me similar stories of painful smallness over the years. It’s why so many doctors in other fields shake their heads when you talk about lactation medicine. There’s a lack of generosity, a lack of intellectual adventurousness or big picture perspectives. How does this, then, impact upon that woman with the ulcerated, bleeding nipples who is still trying to breastfeed her baby? Lactation medicine needs to be embedded in a 21st understanding of complex systems Each of these beliefs – that the disruptive outsider who disrupts group purity requires punishment and dehumanising, that the lactation non-profit mission is pure, that there is a purity of knowledge and authority in lactation education, these beliefs are simplistic distillation of very complex realities. For instance, the disruptor does cause discomfort and inconvenience, even though she needs to be invited in to the group, for the sake of the health of the group.
21st century knowledge of complex systems teaches us that If we start to behave according to simplistic or reductionist paradigms, we risk causing unintended and sometimes very dangerous outcomes, in a world and in families which operate as complex systems. This is the tragedy of lactation medicine today, even as it begins to gain traction as a standalone special interest or field within medicine.
It’s why I’m calling for change. I lift my older woman’s voice to say that the lactation non-profits globally are driving dangerous levels of overmedialisation, paramedicalisation, and overdiagnosis, and this is because of a historical ‘purity’ of thinking, that fails to grasp either intellectually or viscerally the complexity of the times we are forced to inhabit. I lift my older woman’s voice to say to the younger leaders in our field that there isn’t time to mess around: leaders in every field of human endeavour, including in lactation medicine, need to get real about the extraordinary nature of our times, and quickly. We need to get real about complexity and abandon fantasies of purity.
There’s something cruel about the smallness of purity. There’s something cruel about excluding women who decide, in the face of shocking nipple pain or damage, in the face of the exhaustion of long-term triple feeding (that’s direct breastfeeding, pumping, then bottle feeding routines) and baby weight gain concerns, in the face of a little one who fusses on and on at the breast, that they need to use formula. There’s something cruel about excluding them from belonging by using the title 'lactation medicine'. This is particularly dangerous because in recent years I notice the field of lactation medicine is claiming more and more territory, claiming special expertise across multiple domains of infant care.
There’s also something cruel about excluding women (it is mostly women researchers and educators who are affected) from educating alongside colleagues in a field that they are passionate about, have devoted their life to, are courageously attempting to make a contribution in – at the same time as their work is extracted without appropriate acknowledgement, often without recognition of where the work even comes from since this has been going on for so many years.
There is a cruelty to the pure.
Related resources
Lactation non-profits, ideology, and real world harms
The ethical lactation medicine of the future refuses to accept lactation non-profit ideology
Groundbreaking research is 'cancelled' by single-issue breastfeeding non-profits
Selected references
Azad MB, C NN, Bode L. Breastfeeding and the origins of health: interdisciplinary perspectives and priorities. Maternal and Child Nutrition. 2020;17:e13109.
Chetwynd E. From censorship to conversation: agnotology, market influence, and the ethics of breastfeeding research. Journal of Human Lactation. 2025;4(3):303-305.
Chetwynd E. The 4-year question: optics, ethical clarity, and the future of lactation research in times of upheaval. Journal of Human Lactation. 2025;41(4):451-453 doi:410.1177/08903344251387116.
Frances, Nic & Cuskelly, Mary Rose. The end of charity: time for social enterprise. Allen & Unwin 2008.
Kendall-Tackett K. Have we returned to the Dark Ages: Excommunication and its chilling effect on science. Clinical Lactation. 2020;November:DOI: 10.1891/CLINLACT-D-1820-00024.