A Breastfeeding Q and A

Missy Berggren

Have questions about breastfeeding, from how to up your milk supply to knowing when to wean? Breastfeeding expert Sally Wendkos Olds provides the answers.

This article is reprinted with permission from Missy Berggren at The Marketing Mama.  The questions and answers provided in this article are geared primarily toward women in the United States and are not intended to provide complete answers for women in low-resource settings. 

Sally Wendkos Olds literally wrote the book on breastfeeding — The Complete Book of Breastfeeding that is. It’s newly revised and full of solid info for breastfeeding moms. Today Sally is joined by Laura Marks, MD, a pediatrician who co-wrote the book, to serve as our experts for the Expert Q&A series. Thanks Sally and Laura!

Here are the questions submitted by readers here on the blog, via facebook and e-mail, followed by Sally and Laura’s answers:

Why am I hearing it’s bad to use a used breast pump? Is it really bad if you get new tubes, filters and everything else? Hospitals and rental places let multiple people do it all the time, as long as each person has new tubes and holders.

The only type of pump that can be used by more than one woman is the kind designed with special barriers to prevent contamination from one user to another. Hospital-grade electric pumps have this, as do a few commercial pumps. Hygeia II states that its piston-driven personal-use electric pump has been FDA-cleared for use by more than one mother, each of whom needs to have her own accessory kit, the only part of the pump that touches her body or breast milk.

Is there anything I can do/use to prep myself for breastfeeding before birth?

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You don’t have to do anything during pregnancy to prepare your breasts for nursing, unless you have inverted nipples, in which case you may want to wear special plastic breast shells. These shells, also known as shields or milk cups, exert a constant gentle and painless pressure that gradually draws out a flat or inverted nipple. You can find them through your childbirth or breastfeeding education organization, through a catalog, or online. They are different from the rubbery nipple shields that are sometimes advised for sore nipples, but which should not be used. Women with inverted nipples used to be advised to do exercises during pregnancy, but this is no longer recommended.

Do supplements/teas/vitamins work to increase breastfeeding supply? If so, which ones? Any other ways to up supply besides actually nursing more often?

There’s no hard evidence that supplements, teas, or vitamins help to increase a mom’s milk supply, but many women swear by specific preparations. Most of them can’t hurt, but if you’re thinking of using herbal tea, stick to reliable brands and drink in moderation. Just because something is natural doesn’t mean that it’s safe. Always check with your doctor before using anything. Meanwhile, remember that the best way to increase your milk supply is to keep removing milk from your breasts, primarily from frequent breastfeeding, and also from pumping.

When do you quit trying to breastfeed? I was told to stop at 2 weeks and go to pumping only so that we knew how much my daughter was really getting due to failure to thrive. I think now that if I had stayed with direct versus pumping I may have had success and that my milk was just late to come in, but the inefficiencies of a pump over an actual baby stalled it. But obviously, at some point you have to admit that it really isn’t going to work for some reason. How do you know where that point is, and when to keep pushing?

Even if you have to give your baby supplements of formula to help her gain weight, you should continue nursing as often as you can for the first couple of months. Even the best breast pump is not as efficient as a vigorously suckling baby in stimulating the breasts and thus increasing milk supply. Current recommendations include giving the supplement first so the baby is not so wildly hungry and will be more likely to nurse.

How is it possible that I can breastfeed my 15-month-old only once a day, when before I would get too engorged to go that long between feedings?

Breastfeeding is the ultimate example of supply meeting demand. As your breastfeeding schedule changes with your baby’s development, your breasts adapt. Your 15-month-old is now eating solid foods and not needing as large a supply of milk, so your breasts respond by producing less milk.

What changes will happen to my body when I completely wean my baby? Will my weight be affected? Will my hormone levels shift? Also–how might my weight be affected when I stop nursing? I know I won’t be using as many calories, but are there also hormonal changes that may affect my weight when I stop nursing?

When you stop breastfeeding, your body will undergo a number of physiological changes as your hormonal balance reverts to what it was before you became pregnant. As soon as you added foods other than breast milk to your child’s diet, it became easier for you to become pregnant again. If you have not already adopted a method of birth control and if you don’t want to conceive right away, you’ll now need to use some means of contraception.

The most obvious change will be in your breasts. It may take several months for you to lose the bulk of your milk, even though none may be apparent within days after the last nursing session. Some women are able to express a drop or two of milk from their breasts up to several years after weaning. Nipple stimulation promotes milk production, so if you’re always checking for milk, you’re likely to find some. Also, consistent nipple stimulation during sexual activity can result in slight milk secretion for some time.

It may take several months for your breasts to return to their former size. They’ll most likely be less firm than they were before you became pregnant, but this is the result of childbearing, not breastfeeding. They’ll probably seem to be the same size they were before your pregnancy, although some women feel that their breasts become larger or smaller after nursing. This may have something to do with the amount of weight gained or lost or with their having become accustomed to having larger breasts.

Breastfeeding can help a mom return more quickly to her pre-pregnancy size. There’s some evidence that nursing helps women to regain their figures, since the fat stores developed during pregnancy are laid down specifically for lactation. Women who don’t nurse may have a harder time working off this fat. Just think of it—you’re burning about 500 calories a day through lactation, as many calories as you’d burn on a five-mile run. Some women do retain a few pounds of extra weight while they’re nursing, which they often lose after weaning without doing anything special. Other women find that after weaning they need to cut back on calories and embark on an exercise program to lose this weight.

My daughter is starting to eat more at night and less during the day (reverse cycling), how do I get her to stop? I’m a stay-at-home-mom, so I would prefer she eats during the day when I’m awake rather than 2-3 times at night. Any hints?

She needs to learn the difference between night and day! You can help her by keeping lights on and noise present (maybe from a TV or radio) during the day. You can also wake her at intervals that correspond to her present night-schedule. Also, taking her out in the fresh air and sunlight should help.

Are there official recommendations for mothers who have cesareans or who have premature babies, including micro premies? I know the idea is that breast milk is best, but many moms are separated from their babies and/or they are told that formula is better for their babies. What suggestions do you have for these mothers, especially about feeding at the time of birth and during the hospital stay.

Mothers who have cesarean deliveries can start to nurse as soon as those who have vaginal deliveries. You’ll have to make special efforts not to put pressure on your incision, but otherwise the process is about the same. For moms who deliver prematurely the situation is different, depending on the size and health of the baby. If the baby cannot nurse right away, you can pump your milk and either supply it to the hospital or freeze it for later use. Prematurity is temporary, but breastfeeding can continue for many months.

Procedures for feeding a baby born before term vary, depending on the infant’s size, gestational age, strength, and special needs. Your baby may be technically classified as preterm, but be well formed and strong and lack only a few ounces to be considered of normal weight. In this case, you can probably start to nurse immediately.

Very tiny infants, however, are often not able to suck; they may have to be fed by gavage (via a tube that goes from the nose into the stomach) for several weeks until they become strong enough to nurse. Ideally, the doctor in your hospital’s preterm unit will graduate your baby directly from gavage to breast. In the United States this often happens when an infant reaches a weight between three and four pounds. Some hospitals, however, still require preterm babies to suck first from a bottle to demonstrate their ability to feed; only when they’re taking a bottle at every feeding are they permitted to nurse at the breast.

Because of the protective factors in breast milk, it is best for preterm babies too – if the mother can produce enough milk, either to nurse her baby directly or to pump milk that will be fed by bottle or gavage. Very small preterm infants, however, who are receiving pumped breast milk may need more nutrients than the mother’s milk can provide. These babies often receive a supplement added to breast milk called human milk fortifier (HMF), which is rich in calcium and protein. Your doctor may want your baby to continue to receive extra calcium and protein along with your breast milk for some months after discharge from the hospital. Since HMF is not available outside of hospitals, these nutrients may come from specially fortified formula given in addition to breast milk.

The milk of women who bear preterm babies differs from the milk produced by women who deliver at term. Mothers of preterm babies produce milk specifically designed for their own babies at the infants’ stage of development.

Compared to the milk of a mother of a full-term baby, the milk of a mother of a preterm baby is easier to digest and better constituted for developing the preterm baby’s brain and nervous system. Milk from mothers of preemies has higher levels of nitrogen, protein, sodium, and chloride than full-term milk, and lower lactose content than full-term milk. It provides more energy for the preterm infant’s growth needs than mature milk. It also has a high level of lipase, an enzyme that aids in fat digestion.

Can a mother switch to exclusive breastfeeding (if she wants to) if a premie was given formula or bottles in the early days?

Yes. If she has kept up her milk supply by pumping, she should be able to provide whatever her baby needs once the baby is strong enough to nurse.

I heard recently that formula is now as good as breast milk, is this true? Can it ever really be done?

Formula will never be as good as breast milk for human babies. The milk of every species of mammal is different in composition from every other milk, and formula is typically based on milk from cows. Furthermore, each mother’s milk is custom-designed for her own baby: Women develop specific antibodies against bacteria and viruses in their own lungs and intestines, which also appear in their milk. Breast milk changes in composition from feeding to feeding, from day to day, and from month to month, whereas formula remains the same at every feeding.
Human milk contains at least one hundred ingredients that are not in cow’s milk, and while artificial formulas try to imitate mother’s milk, they can never duplicate it exactly. No manufacturer has ever officially claimed that a formula product is just as good as or better than breast milk, and none is likely to make such an audacious claim. In fact, the Food Standards Agency in Great Britain plans to bar infant formula makers from making claims that their products are close to breast milk. As one team of researchers wrote, “Formula milk is just a food, whereas breast milk is a complex living nutritional fluid that contains antibodies, enzymes, and hormones, all of which have health benefits.”

We’re constantly discovering new ingredients in mother’s milk. With breast milk, the whole is greater than the sum of its parts. We don’t know all the constituents in breast milk and how they work together.

My first baby refused to take a bottle. I was a stay at home mom and was happy to breastfeed, but felt completely confined because I could not leave my husband home with a bottle of breast milk. Do you have any tips on how to get a baby to drink from a bottle when they are primarily breast fed?

The solution is to start offering a bottle early – after the course of breastfeeding is well established, but before the baby makes up her mind that the bottle is not for her. This window of opportunity generally comes up between 6 and 8 weeks of age. If a baby is older than this when you want to introduce the bottle, there are a few ways to overcome the baby’s refusal of the bottle: warm the nipple and milk to body temperature, ask someone else to pick up the baby when he’s sleeping but almost ready to wake so that his instinctual urge to suck takes hold, and experiment with different feeding positions.

If I drink a glass of wine, how long before it gets into the breast milk? Is it best to “pump and dump” when I plan on having a drink? What about four drinks?

What the mom takes in usually reaches the breast milk in a few hours. The best scheduling involves having your glass of wine soon after a feeding. Having four drinks within a short period of time can be considered “binge drinking,” and not only would it be dangerous for a baby to nurse after the mother’s having drunk that amount, it’s not healthy for the mom either. As with so much in life, moderation is the key. While you’re nursing it’s best to be extra-moderate.

Is there a best age for weaning?

The American Academy of Pediatrics recommends nursing for at least a year and as long thereafter as mother and child want to continue. Both the World Health Organization and UNICEF recommend breastfeeding for at least two years. However, even if you cannot or do not want to nurse for many months, whatever breastfeeding you do offer your baby will go far to provide a good start in life.

During the first couple of days after birth, infants get the immunological advantages of colostrum, and they continue to receive immunological benefits from breast milk at least through the toddler years. During about the first six months, babies can usually satisfy all their nutritional needs from breast milk; at some time after this the combination of breast milk and various other foods will provide their essential nutrients. By nine months they usually have enough teeth and the intestinal maturity to handle a wide variety of foods. They are still, of course, dependent on their parents for many of the essentials of life, but from a nutritional aspect, they need no longer be dependent solely on their mothers’ milk.

The emotional benefits that a mother and child derive from breastfeeding are just as valid, however, at two months, six months, nine months, one year, or later. If you want to continue nursing for emotional reasons rather than nutritional ones, there’s no need to stop at any specified time.

But what if you decide, for one reason or another, to stop nursing before six months? Even if you have nursed only a few weeks and you have to, or want to, stop breastfeeding, you are still a successful nursing mother. You have given your baby a good start in life and you yourself have known the special joy of the nursing relationship. Any breastfeeding is better than none at all.

Sally Wendkos Olds has written extensively about breastfeeding in the Complete Book of Breastfeeding (Become a fan on facebook!), relationships, health and personal growth. She also wrote The Working Parent’s Survival Guide, Super Granny: Great Stuff to Do with Your Grandkids, among others, and writes a fun blog called Super Granny: How today’s grandmothers have fun with, relate to, and communicate with our grandchildren.

Analysis Economic Justice

New Pennsylvania Bill Is Just One Step Toward Helping Survivors of Economic Abuse

Annamarya Scaccia

The legislation would allow victims of domestic violence, sexual assault, and stalking to terminate their lease early or request locks be changed if they have "a reasonable fear" that they will continue to be harmed while living in their unit.

Domestic violence survivors often face a number of barriers that prevent them from leaving abusive situations. But a new bill awaiting action in the Pennsylvania legislature would let survivors in the state break their rental lease without financial repercussions—potentially allowing them to avoid penalties to their credit and rental history that could make getting back on their feet more challenging. Still, the bill is just one of several policy improvements necessary to help survivors escape abusive situations.

Right now in Pennsylvania, landlords can take action against survivors who break their lease as a means of escape. That could mean a lien against the survivor or an eviction on their credit report. The legislation, HB 1051, introduced by Rep. Madeleine Dean (D-Montgomery County), would allow victims of domestic violence, sexual assault, and stalking to terminate their lease early or request locks be changed if they have “a reasonable fear” that they will continue to be harmed while living in their unit. The bipartisan bill, which would amend the state’s Landlord and Tenant Act, requires survivors to give at least 30 days’ notice of their intent to be released from the lease.

Research shows survivors often return to or delay leaving abusive relationships because they either can’t afford to live independently or have little to no access to financial resources. In fact, a significant portion of homeless women have cited domestic violence as the leading cause of homelessness.

“As a society, we get mad at survivors when they don’t leave,” Kim Pentico, economic justice program director of the National Network to End Domestic Violence (NNEDV), told Rewire. “You know what, her name’s on this lease … That’s going to impact her ability to get and stay safe elsewhere.”

“This is one less thing that’s going to follow her in a negative way,” she added.

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Pennsylvania landlords have raised concerns about the law over liability and rights of other tenants, said Ellen Kramer, deputy director of program services at the Pennsylvania Coalition Against Domestic Violence, which submitted a letter in support of the bill to the state House of Representatives. Lawmakers have considered amendments to the bill—like requiring “proof of abuse” from the courts or a victim’s advocate—that would heed landlord demands while still attempting to protect survivors.

But when you ask a survivor to go to the police or hospital to obtain proof of abuse, “it may put her in a more dangerous position,” Kramer told Rewire, noting that concessions that benefit landlords shift the bill from being victim-centered.

“It’s a delicate balancing act,” she said.

The Urban Affairs Committee voted HB 1051 out of committee on May 17. The legislation was laid on the table on June 23, but has yet to come up for a floor vote. Whether the bill will move forward is uncertain, but proponents say that they have support at the highest levels of government in Pennsylvania.

“We have a strong advocate in Governor Wolf,” Kramer told Rewire.

Financial Abuse in Its Many Forms

Economic violence is a significant characteristic of domestic violence, advocates say. An abuser will often control finances in the home, forcing their victim to hand over their paycheck and not allow them access to bank accounts, credit cards, and other pecuniary resources. Many abusers will also forbid their partner from going to school or having a job. If the victim does work or is a student, the abuser may then harass them on campus or at their place of employment until they withdraw or quit—if they’re not fired.

Abusers may also rack up debt, ruin their partner’s credit score, and cancel lines of credit and insurance policies in order to exact power and control over their victim. Most offenders will also take money or property away from their partner without permission.

“Financial abuse is so multifaceted,” Pentico told Rewire.

Pentico relayed the story of one survivor whose abuser smashed her cell phone because it would put her in financial dire straits. As Pentico told it, the abuser stole her mobile phone, which was under a two-year contract, and broke it knowing that the victim could not afford a new handset. The survivor was then left with a choice of paying for a bill on a phone she could no longer use or not paying the bill at all and being turned into collections, which would jeopardize her ability to rent her own apartment or switch to a new carrier. “Things she can’t do because he smashed her smartphone,” Pentico said.

“Now the general public [could] see that as, ‘It’s a phone, get over it,'” she told Rewire. “Smashing that phone in a two-year contract has such ripple effects on her financial world and on her ability to get and stay safe.”

In fact, members of the public who have not experienced domestic abuse may overlook financial abuse or minimize it. A 2009 national poll from the Allstate Foundation—the philanthropic arm of the Illinois-based insurance company—revealed that nearly 70 percent of Americans do not associate financial abuse with domestic violence, even though it’s an all-too-common tactic among abusers: Economic violence happens in 98 percent of abusive relationships, according to the NNEDV.

Why people fail to make this connection can be attributed, in part, to the lack of legal remedy for financial abuse, said Carol Tracy, executive director of the Women’s Law Project, a public interest law center in Pennsylvania. A survivor can press criminal charges or seek a civil protection order when there’s physical abuse, but the country’s legal justice system has no equivalent for economic or emotional violence, whether the victim is married to their abuser or not, she said.

Some advocates, in lieu of recourse through the courts, have teamed up with foundations to give survivors individual tools to use in economically abusive situations. In 2005, the NNEDV partnered with the Allstate Foundation to develop a curriculum that would teach survivors about financial abuse and financial safety. Through the program, survivors are taught about financial safety planning including individual development accounts, IRA, microlending credit repair, and credit building services.

State coalitions can receive grant funding to develop or improve economic justice programs for survivors, as well as conduct economic empowerment and curriculum trainings with local domestic violence groups. In 2013—the most recent year for which data is available—the foundation awarded $1 million to state domestic violence coalitions in grants that ranged from $50,000 to $100,000 to help support their economic justice work.

So far, according to Pentico, the curriculum has performed “really great” among domestic violence coalitions and its clients. Survivors say they are better informed about economic justice and feel more empowered about their own skills and abilities, which has allowed them to make sounder financial decisions.

This, in turn, has allowed them to escape abuse and stay safe, she said.

“We for a long time chose to see money and finances as sort of this frivolous piece of the safety puzzle,” Pentico told Rewire. “It really is, for many, the piece of the puzzle.”

Public Policy as a Means of Economic Justice

Still, advocates say that public policy, particularly disparate workplace conditions, plays an enormous role in furthering financial abuse. The populations who are more likely to be victims of domestic violence—women, especially trans women and those of color—are also the groups more likely to be underemployed or unemployed. A 2015 LGBT Health & Human Services Network survey, for example, found that 28 percent of working-age transgender women were unemployed and out of school.

“That’s where [economic abuse] gets complicated,” Tracy told Rewire. “Some of it is the fault of the abuser, and some of it is the public policy failures that just don’t value women’s participation in the workforce.”

Victims working low-wage jobs often cannot save enough to leave an abusive situation, advocates say. What they do make goes toward paying bills, basic living needs, and their share of housing expenses—plus child-care costs if they have kids. In the end, they’re not left with much to live on—that is, if their abuser hasn’t taken away access to their own earnings.

“The ability to plan your future, the ability to get away from [abuse], that takes financial resources,” Tracy told Rewire. “It’s just so much harder when you don’t have them and when you’re frightened, and you’re frightened for yourself and your kids.”

Public labor policy can also inhibit a survivor’s ability to escape. This year, five states, Washington, D.C., and 24 jurisdictions will have passed or enacted paid sick leave legislation, according to A Better Balance, a family and work legal center in New York City. As of April, only one of those states—California—also passed a state paid family leave insurance law, which guarantees employees receive pay while on leave due to pregnancy, disability, or serious health issues. (New Jersey, Rhode Island, Washington, and New York have passed similar laws.) Without access to paid leave, Tracy said, survivors often cannot “exercise one’s rights” to file a civil protection order, attend court hearings, or access housing services or any other resource needed to escape violence.

Furthermore, only a handful of state laws protect workers from discrimination based on sex, sexual orientation, gender identity, and pregnancy or familial status (North Carolina, on the other hand, recently passed a draconian state law that permits wide-sweeping bias in public and the workplace). There is no specific federal law that protects LGBTQ workers, but the U.S. Employment Opportunity Commission has clarified that the Civil Rights Act of 1964 does prohibit discrimination based on gender identity and sexual orientation.

Still, that doesn’t necessarily translate into practice. For example, the National Center for Transgender Equality found that 26 percent of transgender people were let go or fired because of anti-trans bias, while 50 percent of transgender workers reported on-the-job harassment. Research shows transgender people are at a higher risk of being fired because of their trans identity, which would make it harder for them to leave an abusive relationship.

“When issues like that intersect with domestic violence, it’s devastating,” Tracy told Rewire. “Frequently it makes it harder, if not impossible, for [victims] to leave battering situations.”

For many survivors, their freedom from abuse also depends on access to public benefits. Programs like Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), the child and dependent care credit, and earned income tax credit give low-income survivors access to the money and resources needed to be on stable economic ground. One example: According to the Center on Budget and Policy Priorities, where a family of three has one full-time nonsalary worker earning $10 an hour, SNAP can increase their take-home income by up to 20 percent.

These programs are “hugely important” in helping lift survivors and their families out of poverty and offset the financial inequality they face, Pentico said.

“When we can put cash in their pocket, then they may have the ability to then put a deposit someplace or to buy a bus ticket to get to family,” she told Rewire.

But these programs are under constant attack by conservative lawmakers. In March, the House Republicans approved a 2017 budget plan that would all but gut SNAP by more than $150 million over the next ten years. (Steep cuts already imposed on the food assistance program have led to as many as one million unemployed adults losing their benefits over the course of this year.) The House GOP budget would also strip nearly $500 billion from other social safety net programs including TANF, child-care assistance, and the earned income tax credit.

By slashing spending and imposing severe restrictions on public benefits, politicians are guaranteeing domestic violence survivors will remain stuck in a cycle of poverty, advocates say. They will stay tethered to their abuser because they will be unable to have enough money to live independently.

“When women leave in the middle of the night with the clothes on their back, kids tucked under their arms, come into shelter, and have no access to finances or resources, I can almost guarantee you she’s going to return,” Pentico told Rewire. “She has to return because she can’t afford not to.”

By contrast, advocates say that improving a survivor’s economic security largely depends on a state’s willingness to remedy what they see as public policy failures. Raising the minimum wage, mandating equal pay, enacting paid leave laws, and prohibiting employment discrimination—laws that benefit the entire working class—will make it much less likely that a survivor will have to choose between homelessness and abuse.

States can also pass proactive policies like the bill proposed in Pennsylvania, to make it easier for survivors to leave abusive situations in the first place. Last year, California enacted a law that similarly allows abuse survivors to terminate their lease without getting a restraining order or filing a police report permanent. Virginia also put in place an early lease-termination law for domestic violence survivors in 2013.

A “more equitable distribution of wealth is what we need, what we’re talking about,” Tracy told Rewire.

As Pentico put it, “When we can give [a survivor] access to finances that help her get and stay safe for longer, her ability to protect herself and her children significantly increases.”

Commentary Economic Justice

The Gender Wage Gap Is Not Women’s Fault, and Here’s the Report That Proves It

Kathleen Geier

The fact is, in every occupation and at every level, women earn less than men doing exactly the same work.

A new report confirms what millions of women already know: that women’s choices are not to blame for the gender wage gap. Instead, researchers at the Economic Policy Institute (EPI), the progressive think tank that issued the report, say that women’s unequal pay is driven by “discrimination, social norms, and other factors beyond women’s control.”

This finding—that the gender pay gap is caused by structural factors rather than women’s occupational choices—is surprisingly controversial. Indeed, in my years as a journalist covering women’s economic issues, the subject that has been most frustrating for me to write about has been the gender gap. (Full disclosure: I’ve worked as a consultant for EPI, though not on this particular report.) No other economic topic I’ve covered has been more widely misunderstood, or has been so outrageously distorted by misrepresentations, half-truths, and lies.

That’s because, for decades, conservatives have energetically promoted the myth that the gender pay gap does not exist. They’ve done such a bang-up job of it that denying the reality of the gap, like denying the reality of global warming, has become an article of faith on the right. Conservative think tanks like the Independent Women’s Forum and the American Enterprise Institute and right-wing writers at outlets like the Wall Street Journal, Breitbart, and the Daily Caller have denounced the gender pay gap as “a lie,” “not the real story,” “a fairy tale,” “a statistical delusion,” and “the myth that won’t die.” Sadly, it is not only right-wing propagandists who are gender wage gap denialists. Far more moderate types like Slate’s Hanna Rosin and the Atlantic’s Derek Thompson have also claimed that the gender wage gap statistic is misleading and exaggerates disparities in earnings.

According to the most recent figures available from the Census Bureau, for every dollar a man makes, a woman makes only 79 cents, a statistic that has barely budged in a decade. And that’s just the gap for women overall; for most women of color, it’s considerably larger. Black women earn only 61 percent of what non-Hispanic white men make, and Latinas earn only 55 percent as much. In a recent survey, U.S. women identified the pay gap as their biggest workplace concern. Yet gender wage gap denialists of a variety of political stripes contend that gender gap statistic—which measures the difference in median annual earnings between men and women who work full-time, year-round—is inaccurate because it does not compare the pay of men and women doing the same work. They argue that when researchers control for traits like experience, type of work, education, and the like, the gender gap evaporates like breath on a window. In short, the denialists frame the gender pay gap as the product not of sexist discrimination, but of women’s freely made choices.

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The EPI study’s co-author, economist Elise Gould, said in an interview with Rewire that she and her colleagues realized the need for the new report when an earlier paper generated controversy on social media. That study had uncovered an “unadjusted”—meaning that it did not control for differences in workplace and personal characteristics—$4 an hour gender wage gap among recent college graduates. Gould said she found this pay disparity “astounding”: “You’re looking at two groups of people, men and women, with virtually the same amount of experience, and yet their wages are so different.” But critics on Twitter, she said, claimed that the wage gap simply reflected the fact that women were choosing lower-paid jobs. “So we wanted to take out this one idea of occupational choice and look at that,” Gould said.

Gould and her co-author Jessica Schieder highlight two important findings in their EPI report. One is that, even within occupations, and even after controlling for observable factors such as education and work experience, the gender wage gap remains stubbornly persistent. As Gould told me, “If you take a man and a woman sitting side by side in a cubicle, doing the same exact job with the same amount of experience and the same amount of education, on average, the man is still going to be paid more than the woman.”

The EPI report cites the work of Harvard economist Claudia Goldin, who looked at the relative weight in the overall wage gap of gender-based pay differences within occupations versus those between occupations. She found that while gender pay disparities between different occupations explain 32 percent of the gap, pay differences within the same occupation account for far more—68 percent, or more than twice as much. In other words, even if we saw equal numbers of men and women in every profession, two-thirds of the gender wage gap would still remain.

And yes, female-dominated professions pay less, but the reasons why are difficult to untangle. It’s a chicken-and-egg phenomenon, the EPI report explains, raising the question: Are women disproportionately nudged into low-status, low-wage occupations, or do these occupations pay low wages simply because it is women who are doing the work?

Historically, “women’s work” has always paid poorly. As scholars such as Paula England have shown, occupations that involve care work, for example, are associated with a wage penalty, even after controlling for other factors. But it’s not only care work that is systematically devalued. So, too, is work in other fields where women workers are a majority—even professions that were not initially dominated by women. The EPI study notes that when more women became park rangers, for example, overall pay in that occupation declined. Conversely, as computer programming became increasingly male-dominated, wages in that sector began to soar.

The second major point that Gould and Schieder emphasize is that a woman’s occupational choice does not occur in a vacuum. It is powerfully shaped by forces like discrimination and social norms. “By the time a woman earns her first dollar, her occupational choice is the culmination of years of education, guidance by mentors, parental expectations, hiring practices, and widespread norms and expectations about work/family balance,” Gould told Rewire. One study cited by Gould and Schieder found that in states where traditional attitudes about gender are more prevalent, girls tend to score higher in reading and lower in math, relative to boys. It’s one of many findings demonstrating that cultural attitudes wield a potent influence on women’s achievement. (Unfortunately, the EPI study does not address racism, xenophobia, or other types of bias that, like sexism, shape individuals’ work choices.)

Parental expectations also play a key role in shaping women’s occupational choices. Research reflected in the EPI study shows that parents are more likely to expect their sons to enter male-dominated science, technology, engineering, and math (often called STEM) fields, as opposed to their daughters. This expectation holds even when their daughters score just as well in math.

Another factor is the culture in male-dominated industries, which can be a huge turn-off to women, especially women of color. In one study of women working in science and technology, Latinas and Black women reported that they were often mistaken for janitors—something that none of the white women in the study had experienced. Another found that 52 percent of highly qualified women working in science and technology ended up leaving those fields, driven out by “hostile work environments and extreme job pressures.”

Among those pressures are excessively long hours, which make it difficult to balance careers with unpaid care work, for which women are disproportionately responsible. Goldin’s research, Gould said, shows that “in jobs that have more temporal flexibility instead of inflexibility and long hours, you do see a smaller gender wage gap.” Women pharmacists, for example, enjoy relatively high pay and a narrow wage gap, which Goldin has linked to flexible work schedules and a professional culture that enables work/life balance. By contrast, the gender pay gap is widest in highest-paying fields such as finance, which disproportionately reward those able to work brutally long hours and be on call 24/7.

Fortunately, remedies for the gender wage gap are at hand. Gould said that strong enforcement of anti-discrimination laws, greater wage transparency (which can be achieved through unions and collective bargaining), and more flexible workplace policies would all help to alleviate gender-based pay inequities. Additional solutions include raising the minimum wage, which would significantly boost the pay of the millions of women disproportionately concentrated in the low-wage sector, and enacting paid family leave, a policy that would be a boon for women struggling to combine work and family. All of these issues are looming increasingly large in our national politics.

But in order to advance these policies, it’s vital to debunk the right’s shameless, decades-long disinformation campaign about the gender gap. The fact is, in every occupation and at every level, women earn less than men doing exactly the same work. The right alleges that the official gender pay gap figure exaggerates the role of discrimination. But even statistics that adjust for occupation and other factors can, in the words of the EPI study, “radically understate the potential for gender discrimination to suppress women’s earnings.”

Contrary to conservatives’ claims, women did not choose to be paid consistently less than men for work that is every bit as valuable to society. But with the right set of policies, we can reverse the tide and bring about some measure of economic justice to the hard-working women of the United States.