The politics of exclusion and extraction: a call for change in the field of lactation medicine so that breastfeeding families receive the best possible science-based support

Our guiding star: the shared value of wanting the best possible care for breastfeeding women and their babies

"We have to invent new wisdom for a new age. And in the meantime we must, if we are to do any good, appear unorthodox, troublesome, dangerous, disobedient." John Maynard Keynes

Before all else, Neuroprotective Developmental Care or the Possums programs are values-based. That is, with respect to breastfeeding and lactation, everything in NDC aims to serve the best interests of women and their infants. From here on, this is referred to as our shared values as practitioners.

Some difficult questions we need to face in the fields clinical breastfeeding and lactation support

We face worsening health system crises globally, of

• Inequitable distribution of resources

• Failure to invest in primary care and prevention

• Worsening overdiagnosis, paramedicalisation, and overtreatment.

These global pressures impact significantly upon the training health professionals receive, and the quality of support offered to breastfeeding families. The wellbeing of families with infants can't be considered separately from an understanding of these global forces, which are fundamentally market driven in our era of late capitalism and its failure to protect the environment and secure equity and justice, including in health.

What is evidence-based, best possible clinical practice in the field of breastfeeding medicine?

PBL Advanced before all else aims to offer clinical interventions which are most likely to effectively address the problems breastfeeding women bring to their breastfeeding medicine practitioner or lactation consultant.

To do this, practitioners need

1. To understand the relevant research

2. To know how to think critically about the research

3. To be able to think critically about the theoretical models which derive from that research

4. To be aware of the difference between a theoretical model, which has been translated into a clinical intervention, and a clinical intervention which is proven to be effective.

Currently in breastfeeding medicine there is a great deal of blurring between theoretical models and what is claimed to be best practice interventions in clinical guidelines. Many of the researchers and clinical educator-researchers who could best address the research and also this problematic blurring between theory and clinical translation are excluded for ideological reasons from breastfeeding non-profit education platforms. This does not serve our shared values of promoting the best interests of mothers and babies.

How do we grow collective knowledge within health systems in order to best support breastfeeding families and their infants? Definitely not by practices of exclusion!

"All flourishing is mutual." Robin Wall Kimmerer

To answer the question of how best to grow collective knowledge in the field of breastfeeding and lactation according to our established shared values, we need to be willing to ask a particularly uncomfortable question. Are single issue breastfeeding and lactation non-profits the best vehicle for upskilling health professionals in breastfeeding medicine and lactation consultancy, and for creating health system change in the care offered to breastfeeding families?

This is an important question to ask because breastfeeding non-profits are foundationally built upon the principle of exclusion of others, in three ways.

1. Breastfeeding and lactation non-profits have titles that exclude

The title of breastfeeding non-profits exclude families who aren't using breast milk to feed their infants. This titular exclusion perpetuates women's distress when they are unable to breastfeed, through no fault of their own. This exclusion does not serve the best interests of breastfeeding women and their babies.

There's no doubt that since their inception from the 1980s, single issue breastfeeding non-profits have played a powerful role in promoting and supporting breastfeeding. However, does this remain the case?

Most recently, breastfeeding medicine non-profits claim expertise and leadership across the fields of perinatal mental health, unsettled infant behaviour (cry-fuss problems and sleep), sensory motor nourishment, and infant development. I note here that the NDC (or Possums) programs were the first internationally to make the case that these domains interact together and need to be considered together if we are to best help when breastfeeding problems emerge. Although breastfeeding and lactation are foundational to each NDC domain, I decided not to use program titles or organisational titles which exclude vital aspects of care, and exclude some families.

2. Breastfeeding and lactation non-profits practice ideologically-based exclusion of lactation researchers and educators

Breastfeeding non-profits globally actively exclude the contributions of many of the world's researchers who engage in breastfeeding, lactation, and human milk research.

They also exclude any clinician-educator who has engaged in collaborative research at any time with those researchers, even though the clinician-researcher and clinician-educator fills a particularly vital niche in the advancement of breastfeeding and lactation medicine. This does not serve the best interests of breastfeeding women and their babies, and arguably harms breastfeeding women and their babies by withholding research-based innovation.

Exclusion occurs because of ideological positions held within the leadership of breastfeeding non-profits. These ideologies are historically embedded in organisational constitutions and regulations of the world's dominant breastfeeding and lactation non-profits. Those who disagree are either not considered for, or feel unable to remain in, leadership positions. Challenging these ideological positions - which aren't scientific, nor deeply socioculturally informed, nor evidence-based - typically results in exclusion.

Currently, every professional who has a leadership role in breastfeeding non-profits nationally and internationally is aware of this exclusion of researchers and educator-researchers, and knowingly participates in its perpetuation.

3. Breastfeeding and lactation non-profits benefit financially from suppression of competition by other lactation educators

When breastfeeding non-profits actively exclude information about the contributions of primary care education organisations which are not formally structured as non-profits, they are advancing the commercial viability of their own conferences and workshops. This exclusion is not based upon credible assessments of quality of education, which would be a helpful service to their members. Instead, this exclusion of other educators secures the breastfeeding non-profit's own commercial dominance by exploiting

• The organisation's shared if unconscious belief in the moral superiority of the non-profit, even though colleagues operating in small business and social enterprise organisations may make substantially bigger personal financial sacrifices and operate from more carefully analysed and informed ethical considerations than those participating voluntarily in a non-profit context

• The public's limited understanding of the way non-profits operate commercially, including of the non-profit's existential need to pursue its own financial viability. It's in the commercial interest of a non-profit to not support efforts in the social enterprise or private sector, without regard to quality of education offered

• The public's limited understanding of the kinds of forces, including market forces, which increasingly and severely constrain possibilities within university contexts, and limit the kind of education which universities are willing to offer - or which make the cost of upskilling in a university context unaffordable for many. This drives breastfeeding education initiatives into the private sector. There has been little appetite and little funding available within university settings in Australia, for example, to establish high level breastfeeding and lactation education pathways, due to the current funding squeeze within the tertiary education sector.

The exclusion of high calibre social enterprise or private sector breastfeeding medicine education initiatives from paid or unpaid opportunities to promote their courses through breastfeeding medicine networks, without evaluation of calibre of education, has a commercially predatory flavour, given the non-profit's fundamental need to make their own competing courses financially viable. This exclusion of other educational initiatives from networking opportunities with colleagues in breastfeeding non-profits does not serve the best interests of breastfeeding women and their babies.

What is the difference between collective growth of knowledge and groupthink?

"Attributes that improve cohesion within groups, such as team orientation and mutual trust, may increase the risk of 'groupthink' and group conformity bias, which may lead to poorer decisions." Kaba et al 2016

The exclusion of dissenting voices, the exclusion of a wide range of researchers, and the failure to protect and celebrate those who are generating knowledge and innovation, are characteristics of the collective phenomenon known as groupthink, which operates unconsciously within organisations.

Groupthink not only causes harm to those who are excluded, but limits the growth and decision-making processes of the excluding organisation. The exclusion of others acts against stated shared values, that is, exclusion holds back the advancement of research and knowledge in the care of breastfeeding and lactating women and their families, usually quite unconsciously.

The practice of exclusion, operating in a groupthink, is characterised by

• A fundamentally unkind and unconscious projection onto another human being or subgroup

• Obfuscation and reluctance to be direct, including by using gaslighting, without transparent processes

• Self-censorship by members of the organisation who don't wish to jeopardise their standing and comfort within the organisation by speaking out or raising concerns

• Public denial of the exclusionary practices, which operate behind the scenes and mostly quite unconsciously

• Inaccurate representations of the excluded person's or group's work or life, again out of the public eye and to which the excluded person has no right of reply.

Exclusion of dissenting or questioning voices is a profound form of unkindness to colleagues, often towards other women in what remains a fundamentally gendered field. It does not serve the best interests of breastfeeding women and their babies.

Janis's groupthink theoretical framework

Psychologist Irving Janis was the first to introduce the concept of groupthink. He developed groupthink as a group decision making theory to show how groupthink resulted in impaired effectiveness of decision making. Janis identifies eight symptoms of groupthink, which are evident in the operations of breastfeeding non-profits globally.

Group cohesiveness is (quoting DePierro et al 2022) "the main determining antecedent of groupthink, that group members may avoid speaking out against decisions in order to maintain group harmony."

Extraction is an inevitable and unethical consequence of the practice of exclusion

Exclusion results in a range of unethical behaviours, including extraction.

The exclusion of researchers and educators for ideological reasons inevitably results in extractive practices, where the work of those researchers and educators influence or shape the knowledge-base of those within the single issue breastfeeding non-profit, but the voices of those whose professional lives have been dedicated to generating that knowledge remain excluded from professional groups or conferences.

Extractive practices do not regard the consequences (upon the planet or upon other human beings) of the extraction (whether of resources or knowledge) upon the one being extracted from. Extraction is a dominant characteristic of the times we live in, and is built upon shared (and inaccurate) assumptions about others' rights or lack of rights. When applied to knowledge extraction from other professionals

• Extraction is justified by shared illusions about the neutrality of knowledge or science

• Extraction, through unconscious processes within a group, refuses to consider the impact of extraction practices upon the other human being whose work is being relied upon

• Extraction promotes 'cancelling' of that person's work, supporting others to use the work and present it as their own or as neutral science, whilst the generator of the work remains cancelled.

Extraction harms colleagues and harms innovation in the field of breastfeeding medicine

Harming the one whose work is being used extractively without appropriate, ethical and collegiate acknowledgement and inclusion harms that person's capacity to continue their work, by 'cancelling' them in the channels which might otherwise raise the profile of their work or attract funding in a contemporary sociocultural context characterised by online networks and social media.

By harming colleagues who are working hard to make high calibre, research-based contributions, extractive practices fail to serve the best interests of breastfeeding women and their babies.

How NDC aims to offer a different paradigm for the development of knowledge which supports breastfeeding women and their babies

"Medical professionals are responsible for being wary of latent groupthink." DiPierro et al 2022

A groupthink closes down and limits the rate of advancement in the field, by excluding dissent.

In contrast, NDC aims to

• Celebrate well-argued intellectual and scientific difference of perspective

• Invite in active intellectual engagement across disagreement

• Celebrate the work of all those (often other women) who are passionate about supporting and researching the wellbeing of mothers and babies, without exclusion, with the degree of foregrounding of the work based only upon the scientific calibre of the work

• Ethically acknowledge the knowledge, research, and contributions of others

• Maintain open and transparent processes and willingness to engage difficult conversations

• Encourage individual responsibility and leadership in speaking out in support of ethical practices

• Develop nuanced, socioculturally-attuned analyses of the role of non-profits, social enterprise and small business in delivery of services and education to both breastfeeding women and their families, and the health professionals who support them.

Our small NDC social enterprise is openly and transparently committed to trying to be true to the principles above, and does not carry the historical burden of breastfeeding non-profits' ideologies which are structured into their regulations and belief systems.

The importance of welcoming in disruptive thinking and dissent in the development of collective knowledge

Breastfeeding women and their families need an urgent response to the health system blindspots that characterise their care. We urgently require an accelerated development of collective intelligence, that is, scientific knowledge concerning the care of breastfeeding families. This growth in collective intelligence is different to groupthink. The growth of collective knowledge in the field of breastfeeding medicine is achieved by

• Welcoming in (not being afraid of and exclusing) the disruptive or dissenting thinker.

• Setting up forums which foreground debate and discussion across different perspectives, and which occurs with mutual care and respect. (This is different to setting up forums which aim to debate contentious issues yet actively exclude the voices of those who are excluded. This strategy obfuscates and misleads participants, perpetuating groupthink.)

• Transparent organisational processes

• Celebration of the achievements of women in the field of breastfeeding medicine - celebration of their leadership, successes, courageous initiatives, and also offering genuine support during their failures - even when those women or people hold views and scientific interpretations which are different to our own

• A mature understanding of conflict of interest, the role of declarations of conflict of interest, and the nature of small business in primary health care systems and primary health care innovations. An ideologically driven perspective on conflict of interest is inevitably a less professionally mature response, which fails to understand the sociocultural complexities of our time and of our health systems, and which weaponises conflicts of interest to meet ideological ends and the commercial needs of breastfeeding non-profits. This puts the brake on the advancement in collective knowledge and is not in the best interests of breastfeeding women and their babies.

From the NDC perspective, lactation medicine

1. Has a fundamental role to play in Neuroprotective Developmental Care of families with infants, but cannot be allowed to operate in a way that excludes others, either through organisational title or through ideological practices

2. Fundamentally serves the flourishing of families and infants across all domains of feeds, sensory motor needs, unsettled infant behaviour, and perinatal and infant mental health, without making the implicit and unscientific claim that breastfeeding is more important than, say, a woman's mental health, or an infant's sensory motor needs, to the flourishing of the nascent human being.

That is, lactation medicine is foundational to all aspects of NDC, and as a result, does not require a titular elevation which acts to exclude.

Recommended resources

Possums Breastfeeding & Lactation articles which address lactation non-profits, ideology, and harm

Selected references

Azad MB, Nickel NC, 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 infuence, 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.

DiPierro K, Lee H, Pain KJ. Groupthink among health professional teams in patient care. Medical Teacher. 2022;44(3):309-318. doi: 310.1080/0142159X.0142021.1987404.

Greenhalgh T, Russell J. Reframing evidence synthesis as rhetorical action in the policy making drama. Healthcare Policy. 2005;1:31-39.

Janis IL (1982). Groupthink: Psychological studies of policy decisions and fiascoes 2nd ed. Boston: Houghton Mifflin.

Kaba A, Wishart I, Fraser K, Coderre S, McLaughlin K. Are we at risk of groupthink in our approach to teamwork interventions in health care?. Med Educ. 2016;50(4):400-408. doi:10.1111/medu.12943

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.

Keynes, John Maynard. Am I a Liberal? The Nation and Athenaeum. 8 and 15 August 1925, quoted in Kernick D. Wanted - new methodologies for health service research. Is complexity theory the answer? Family Practice. 2006;23(3):385-390, p. 390

Kimmerer, Robin Wall. The serviceberry: abundance and reciprocity in the natural world. New York: Scribner 2024.

Levitt HM, Surace FI, Wu MB, et al. The meaning of scientific objectivity and subjectivity: From the perspective of methodologists. Psychol Methods. 2022;27(4):589-605. doi:10.1037/met0000363

Roper WL. Science, health, and truth. Science. 2022;377(6601):7. doi:10.1126/science.add6477

Winburn AP, Clemmons CMJ. Objectivity is a myth that harms the practice and diversity of forensic science. Forensic Science International: Synergy. 2021;3:100196 doi:100110.101016/j.fsisyn.102021.100196.