Breastfeeding Wars: When Baby-Friendly is Mom-Unfriendly
The emotional toll on mothers from misguided breast-feeding initiatives.
Posted Nov 09, 2019
There is good news for stressed out parents: the pressure to breastfeed exclusively may let up soon. Breastfeeding is known to be beneficial to babies, but the way we approach helping mothers is not working. For years now, hospitals have been urged to adopt the public policy initiative known as Baby-Friendly, a set of workflows in the newborn period meant to encourage breastfeeding. Though it’s called Baby-Friendly, most parents experience it as parent unfriendly. Now, new research in Pediatrics concludes that Baby-Friendly doesn’t work.
What is Baby-Friendly?
The pressure to breastfeed is so pervasive that every mother I know shudders at the mention of it. It starts in the prenatal period with an avalanche of advice and slogans. And then mothers are given threats: that their baby won’t thrive or might not be as smart if they don’t breastfeed. But once the reality of childbirth comes and exhausted mothers face the shock that their milk won’t come in for five days or so, the discouragement sets it. Pediatricians and nurses in the hospitals know this, and in the past we had ways to support mothers through a vulnerable time. Nurses would comfort them and take the baby to the nursery so they could sleep for a few hours. Small amounts of formula were given to support the baby and decrease the mother’s stress.
Then along came “Baby Friendly,” a designation given to hospitals who meet certain criteria around breastfeeding. Meant to increase rates of breastfeeding and hopefully decrease later rates of childhood obesity, it seemed like a good idea at the time. Responding to the 2011 call by the Surgeon General of the U.S., the CDC put a lot of effort behind rolling out the initiative to every hospital in America.
That's when some pediatricians started questioning the initiative that seemed more based in assertions than science. The goal of better maternity care and support for breastfeeding is a worthy one, but the practical implementation has been a different story. For new parents, Baby-Friendly has meant a withdrawal of support. To improve bonding, babies are to be kept in the room with parents, no matter how much pain the mother is in or how fussy the baby. Formula is not to be offered easily, and breastfeeding mothers are no longer sent home with formula samples in case the baby needs supplementation when breast milk has not yet come in.
Stressed Out Parents and Hungry Babies
But the cultural messages around breastfeeding have a much more powerful impact on new parents than simply the stress of not being given a break by nurses in the hospital. These messages feed right into the culture of criticism that pushes perfectionistic parenting. This is the ShouldStorm that tells parents they should breastfeed or their child will miss out for life. Parents are told they should breastfeed exclusively and that it should work smoothly right from the beginning. The flip side of that message is that if breastfeeding doesn’t work exclusively, it’s because a mother didn’t try hard enough.
The push for “exclusive” breastfeeding takes a profound emotional toll because it sets the bar too high. Mothers cry in my office almost daily under the pressure. In my clinical observation, this pressure contributes to postpartum depression. After all, it’s black or white thinking, and that’s a cognitive distortion of the kind that drives anxiety and depression. This is the opposite of the self-compassion which is now understood to be the basis of good mental health.
As more and more hospitals have obtained the Baby-Friendly designation, the hoped for outcomes in breastfeeding rates have not materialized. Recently, monitoring of neonatal sentinel events (preventable problems in newborns) have been shown to be “associated with some of the prescribed compliance requirements of Baby-Friendly designation.” Upon analysis of the CDC Breastfeeding Report Card, the study authors found something crucial. Initiation of breastfeeding, i.e. getting the baby to the mother’s breast as quickly as possible after birth, “is positively associated with targeted breastfeeding outcomes.” However, Baby-Friendly is not. (1)
Furthermore, pediatricians increasingly believe that supporting babies and their parents with small amounts of formula actually helps them succeed in breastfeeding. Last year, a study showed that small amounts of formula supplementation in babies did not interfere with breastfeeding at 1 month old, and may reduce rates of hospital readmission. (2)
In practice, we see that parents are more able to embrace a “good enough” approach to parenting, when we are not rigid with rules about breastfeeding.
Bass, Joel, MD. et. al. Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: Public Policy Implications. J Pediatr 2019. Oct.
Flaherman et al. The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial. J Pediatr 2018. May;196.