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Breastfeeding – Right or Privilege? How American Society Causes Inequalities in Breastfeeding…And How We Can Do Better

The fabulous Best for Babes recently released their 2011 State of Breastfeeding in the US report.  Best for Babes focuses on breastfeeding education and support, particularly in helping women to recognize and overcome “booby traps” that often impede successful breastfeeding relationships.  According to their statistics (taken I believe from the Center for Disease Control’s Breastfeeding Report Card), 75% of US mothers initiate breastfeeding, but only 13% are exclusively breastfeeding at the 6 month mark (the CDC reports that 44% of mamas are still nursing at least some at the 6 month mark).

6 months of exclusive breastfeeding is not an arbitrary number.  The American Academy of Pediatrics recommends 6 months of exclusive breastfeeding with nursing continuing until at least the one year mark in conjunction with solids.  The World Health Organization also recommends breastmilk only for the first 6 months with nursing continuing in conjunction with solids until the age of 2.  Despite these recommendations, the CDC reports that only 24% of mamas are nursing at all by the time their babies turn 1.  24%.

How is it that in the United States, a country that prides itself on being a leader on the world stage, fewer than 50% of mothers are providing any breastmilk at 6 months and not even one fourth of mamas will meet the recommendation to provide breastmilk to their babies for the first year of life??

Before I go any further I want to make very clear that this is NOT a failure on the part of mamas who do not meet breastfeeding recommendations.  This is a failure of American society, a society which continues to offer inadequate education and support for breastfeeding mothers.  An American society that continues to throw booby traps in the way of mamas who want to nurse.  An American society that has turned the ability to breastfed into a privilege – when it should in fact be the right of every mother and baby.

There have been many debates around breastfeeding which point out that mothers should have the right to choose how to feed their babies, that maybe all mothers don’t want to meet the breastfeeding goals of breastmilk only for 6 months and breastfeeding for at least the first year.  I don’t disagree with that.  But the reality is that for many women, breastfeeding (or feeding baby donor breastmilk) isn’t a realistic choice.   Until we provide every mother with quality education about and support for breastfeeding, we cannot claim that women are making a truly informed choice.  Until we remove societal barriers to successful nursing, we cannot claim that all women have a choice to make.    In other words, there are many mamas who – if all things were equal – would end up on the “plus” side of the above statistics.  We can do better.

It should be the right of all mamas to nurse their babies or otherwise provide them with breastmilk for the first year of life.  But it’s not.  In many ways, breastfeeding is a privilege in our society, an activity that cannot be participated in equally by all women due to social inequalities.   Let me explain …

 

Access to information about breastfeeding is not equally accessible to all women.  The first step to helping mothers become successful in meeting breastfeeding goals is to make sure that they have access to information about how breastfeeding works.  It’s not as simple as putting baby to the breast after all!   Many women read breastfeeding books, check out excellent web resources (like Kelly Mom or La Leche League), or attend a breastfeeding class while pregnant.  But what about the mama who doesn’t have access to the internet or even time to go to the library?  What about the mama who has to work long hours to stockpile money to provide for baby and doesn’t have time to research and read?   What about the mama who doesn’t even know there’s stuff she should know about breastfeeding before baby is born?   What about the mama who isn’t offered a breastfeeding class, attends one “taught” by a poorly informed person, or is unable to attend due to time or financial constraints?

We Can Do Better!  At minimum, all prenatal care providers should spend time AT EVERY PRENATAL VISIT discussing breastfeeding.  And I mean more than just the “it’s really great and you should do it” spiel accompanied by a pamphlet.  Expectant mamas need to hear about how breastfeeding works, what to expect in the early weeks, how to get off to a successful start, and so on.    They need to know that many mamas experience difficulties in the first few weeks of nursing and that the vast majority of those can be overcome with support.  They need to know where they can get that support.  They need to hear misinformation about breastfeeding (like “baby may need formula until your milk comes in” or “you should pump to bring in your milk” or “a big baby will need to be supplemented” or “little boobs won’t make enough milk” and so on) set straight.   And they need to hear these things early and often in their pregnancies.   Which brings us to our next area of inequality…

 

All pre- and post-natal care providers and pediatricians are not equally knowledgeable about breastfeeding.  If I had a dime for every story about bad breastfeeding advice from a pediatrician or other medical person I’d heard, I’d have quite a pile of money.    As an example of the difference knowledgeable providers can make… Eleanor lost 10% of her birth weight, a full pound, and was slow to gain it back; she also spent 3 days in the NICU due to minor breathing issues.  We were fortunate to be in a breastfeeding friendly hospital which not only encouraged me to nurse Eleanor, but never offered any artificial nipples during our stay.   Eleanor was able to nurse normally, but if she hadn’t been, it was suggested that we syringe or spoon feed either my pumped milk or donor milk.  The word formula was never mentioned.   Both my midwife and Eleanor’s pediatrician are on top of their breastfeeding knowledge; both knew that her weight loss was not extraordinary given her birth weight and that some babies just take a little longer to hit birth weight (no one in the NICU was worried about her loss either).   I’ve talked to other mothers who found themselves with a similarly slow to gain baby; their pediatricians frequently recommended supplementing.  In fact, many supplemented with formula before they even left the hospital!

And this isn’t just anecdotal.  According to the CDC, nearly 25% of breastfed babies receive formula in the first 2 days of life – that’s 25% of babies whose mothers want to breastfeed.  Why is this happening?  Knowledgeable providers know that the early days of breastfeeding are huge in terms of getting mother’s milk to come in, establishing a supply, and laying the groundwork for successful nursing.  Supplementing with formula can really throw a wrench in the best laid breastfeeding plans – and for those mothers who haven’t received the best breastfeeding education, it can do even worse.  The fact is many medical professionals are laying booby traps left and right for mamas struggling with breastfeeding because they themselves lack a strong foundation in the basics of breastfeeding.

We Can Do Better!  Those that provide health care to mothers and babies should be well informed about breastfeeding and ready to connect nursing mothers to board certified lactation consultants when problems do arise.   There is overwhelming scientific evidence that breastmilk is the perfect food for babies.  It should be the priority of all medical professionals working with mothers and babies to make sure they are prepared to help all babies get that breastmilk.  This doesn’t mean that providers must become the “breastfeeding police” or be pushy or judgmental in promoting breastfeeding.  Rather it means that should know how milk production works, how to provide mothers with options aside from supplementing when breastfeeding hits a bump.   They should also know how to help mamas overcome common issues like nursing strikes, biting, growth spurts, sleep regressions – all things that can hamper breastfeeding as babies get older.    They do not have to be lactation experts (remember, we do have professional IBCLCs for that!); they do have to stop sabotaging nursing mamas.  Speaking of sabotage…

 

Formula marketing preys on those most likely to struggle with breastfeeding.  This topic has been addressed in depth by other breastfeeding advocates so I will simply say that the US should enforce the WHO code for the marketing of breastmilk substitutes.  Period.  It’s a violation of the WHO code for any health care provider to distribute formula samples.  And yet how many mamas do you know who received such samples from the hospital or pediatrician even when they expressed intent to breastfeed?  It may seem harmless to take home that “just in case formula,” but when it’s 3am and you are struggling to get baby to nurse, baby is crying and you are exhausted…who would blame mama for turning to the formula.  And yet we know that’s a slippery slope to supply issue and even the cessation of nursing.  All those formula ads with pictures of happy babies and mamas – violation of the WHO code.  Of course formula isn’t poison.  But when you see it all around you, it becomes the “normal” way to feed.  Bottles are still ubiquitous symbols for babies (and we still have a weird hang up about breasts being used for nursing…but that’s another post altogether) even when we are throwing around the “breast is best” phrase.   If you’ve always been surrounded by images of bottle fed babies and rarely ones of nursing babies, it’s no surprise that turning to formula seems the natural thing to do.   Again, I’m not claiming that formula is evil, but rather that if we truly want all babies to be breastfed, we should show babies being breastfed.  Images are powerful.

We can do better!   First, the WHO code should be enforced.  No more advertisements for formula, no more formula checks/samples/promotions, and so on.  Of course should still be available, but if we really want women to breastfeed, we can’t fill the airways with images of formula feeding.   Instead we fill it with images of breastfeeding and make breastfeeding support readily available.   Hospitals should all pledge to Ban the Bags and to follow the 10 simple steps outlined by the Baby Friendly Hospital Initiative to end formula marketing in hospitals and to promote breastfeeding success.   And just because I think it’s so darn important, I’ll say it again…enforce the WHO code.  We should be ashamed that we are not.  As for other things to be ashamed of…

 

The United States has a pitiful maternal leave policy that exacerbates existing inequalities.   I realize that many mother return to work by choice (more on that in a minute).  But the reality is that many mothers DO NOT have a choice when it comes to how much leave time they will take after having a baby.   The United States mandates no paid maternity leave (of course employers can choose to offer leave above and beyond the federal mandate).  This sets us apart from nearly every other developed economy and puts us behind many developing nations.  Only US mothers working at firms with 50+ employees are guaranteed any maternity leave (12 weeks) under federal law – and that leave is unpaid.   We rank right along side countries like Ghana and Swaziland.  Our fellow developed economies offer mothers either a much longer protected leave or a leave with some pay – or both.   For example, Swedish mothers get 480 days of leave at 80% of their salary and British mamas enjoy 90% of their salaries during their year at home with baby.

Most breastfeeding mothers will tell you that breastfeeding starts to get comfortable around six weeks in.  And guess when many mamas are returning to work?  It’s no wonder then that many choose to switch to formula feeding after only a short go at nursing – why stick with something if you never get to be around to enjoy it once it gets good?  To further un-level the playing field, not all mamas can afford to take a full 12 weeks of leave, even if it is offered to them – they simply can’t afford not to work.  Or they risk losing their status at work, their shifts, or even their job.  Mamas who work for hourly wages are most likely to find themselves unable to take an extended leave from work, either because they can’t afford to do so or because they risk losing their position.

We can do better!!  At the very least every working mother, regardless of the size of the firm she works for, should be guaranteed a year of leave from her job without fear of losing anything.  If we want mamas to breastfed for a year, we need to give them an opportunity to be with their babies for a year.  And at least some (preferably all!) of that leave should be paid.  I could get into a big cost savings argument here but I won’t.  Suffice it to say that if we add up the savings in childcare alone, paid leave makes perfect sense.  Even providing every mother with 3 months of paid leave would do wonders for breastfeeding rates as it would give time for mamas to establish a strong nursing relationship before returning to the workplace.  And for those that do return to work…

 

Not all women who do return to work have equal abilities to maintain a nursing relationship.  I realize that some mamas return to work because they have to.  And some return to work because they want to.  And I fully support mamas who make the choice to work.  Even if we did have a fabulous maternal leave policy, I bet some mamas would still go back before their leave is up.  We need to make sure, then, that all mamas who work outside the home are supported in their breastfeeding efforts.   Right now they aren’t.

A provision of the recent health care act, requires firms (again those with fewer than 50 employees may be exempt) to provide a private space (that is not a bathroom) and as many breaks as needed for mothers to pump.  This is a step in the right direction.  But despite this law, many mamas still find it difficult if not impossible to pump during the work day.   If I’m working an 8 hour shift waiting tables at Applebee’s, it’s going to be tough to pump.  If I’m an elementary school teacher with breaks too close together or too far apart, I may find it difficult to keep up with milk production.  If I’m a corporate lawyer who sets my own schedule and has a private office…now things are a bit easier.

We can do better!!  The current law is a big step towards workplace pumping equality, but it should apply to all employers regardless of size.  If breastfeeding becomes the cultural norm, then pump breaks will become a given – and not fodder for water cooler jokes.  Larger employers should work to provide on site daycare so that mamas can have mid-day nursing sessions (some already do of course).  Pumping is great but many women struggle to keep up their supplies when pumping during the work day; being able to nurse at least once during the workday or even being guaranteed a private space and adequate time without fear of repercussions would take some of the stress off pumping – and make the milk flow faster.  And when the milk doesn’t flow…


Donor milk is not a viable option for most mothers unable to breastfeed or who struggle with supply.  There are mamas who can’t nurse for various reasons or who are unable to produce enough breastmilk.  For most of those mamas, the only viable option currently is formula.  Donor breast milk is available from two sources:  milk banks (like those of the Human Milk Banking Association of North America) or informal milk sharing networks like Eats on Feets.  Most milk banks are prohibitively expensive for long term use.  And as the milk is generally in short supply; milk bank milk (which has been screened and pasteurized) is reserved for premature and sick babies.  Informal milk shares provide an alternative and the milk is generally free.  The downside of course is making connections with trusted donors and the logistics of acquiring milk on a regular basis.  I have two mama friends who have used donor milk from informal milk sharing networks; both had the knowledge, connections, and time to spend tracking down and picking up milk.  Not all mamas have the time and connections (or even transportation to pick milk up) that my friends have meaning donor milk is not equally available to all mamas and babies who may wish to use it.

We can do better!!  The work of national organizations like Eats on Feets and smaller local networks (I’ll give a shout out to the Diapering Doula if any of you are in central NC!) have made informal milk sharing a more viable option for mamas who need to supplement and wish to use donor milk.  Social networking sites like Facebook have facilitated mothers connecting.  But we need more education about milk sharing and how to do it safely (and we’ve got to enforce the WHO code so that donor milk is seen as the normal option instead of something done under the table).  And we need more mamas to donate milk.  Many women who pump part time or exclusively find themselves with excess milk in the freezer; if all of those mamas donated their milk, the availability of donor milk would increase.  And if every mama who pumped pumped just a little extra every week, think how much more donor milk could go to those seeking it.  In the days before formula, babies needing breastmilk were wet-nursed by another lactating mama in their community.  Consider milk donation and milk sharing the modern day equivalent.  Of course milk sharing brings me to my final point, the importance of community…

 

All mothers do not have equal access to support networks and connections to others who breastfeed.  Breastfeeding is a learned skill, a skill best learned by talking to and watching other mamas nurse.  Some time ago I wrote about a chimpanzee born at my local zoo whose mother was unable to nurse her, in large part because she’d never seen another chimp breastfeed.  I am completely convinced that one of the primary reasons so many mamas struggle is because they haven’t had exposure to other breastfeeding women and/or they have no women in their circle who are breastfeeding or who have breastfed.  Like many of my nursing friends, I have attended La Leche League meetings – one easy way to meet other nursing mothers.  But not every mama who wants to nurse has the time do so, least of all those who must work long hours and return to work shortly after birth.  I have talked to a number of mothers who are the only ones they know locally who breastfeed, making it more difficult for them to seek help or reassurance when they need it.   Part of the reason I knew that it was totally normal for my newborn to want to nurse all the time was because other mamas I knew and trusted told me that’s exactly what their newborns did.  That sort of personal guidance goes a long way towards making mamas confident about their abilities to nurse their babies.

We can do better!!  The more nursing mamas are visible about their breastfeeding, the more normal it becomes and the more connections new nursing mamas can make.  By visible, I don’t mean that women have to run around bare breasted in public as some opponents of public nursing seem to think!  Rather, mamas should feel free to nurse their babies wherever they feel comfortable, covered or not.  And a simple encouraging smile and knowing nod can go a long way – if you see a mama, especially one with a new baby, nursing, acknowledge it!  If you have nursed, remember what it felt like to be uncertain and struggling and pass on your wisdom.  Consider joining groups like La Leche League that support and promote breastfeeding.  Basically, just talk about breastfeeding!!

 

Let me leave you with one final illustration of how these inequalities very much impact whether or not a mother will be successful in meeting the goal of nursing for one year.   I am a white, middle class mama with an advanced degree; I was 30 when my first child was born – facts I mention because statistics show that women of color, women in poverty, less-educated women, and younger women are all less likely to breastfeed (not surprising as they are most affected by the above inequalities).

While pregnant with my first baby, I had the time and resources to research breastfeeding and was aware of how to handle many common problems (or where to seek help) that new mamas face in breastfeeding.  I had providers who talked to me about breastfeeding and delivered in a hospital that sent me home with a manual pump and nursing supplies instead of a bag of formula.  I nursed my first born within the first hour of his birth; he was never given anything other than my milk and never left my side at the hospital.  My second child had a 3 day NICU stay; still I was able to nurse her within hours of birth, had unlimited access to do so, and was offered the use of donor milk in the event she was unable to nurse and I was unable to pump for her.  I had a pediatrician who never mentioned the word formula to me nor offered me samples.

As a full-time PhD student, I had the leisure to choose to stay at home with my children or to return to work (or rather I was able to chose to maintain my student status while still being virtually a stay at home mama).  Had I chosen to return to work outside the home full or part-time, I would have had access to a private space to pump and unlimited time to pump.  I would not have risked my job or pay in order to pump.   I could afford to pay for any support services such as a lactation consultant that I might have needed while nursing.

Had I been physically unable to nurse, I would have had access to information about donor milk and the social/financial/time resources to make donor milk a possibility.  I know many women who nurse and have a support network available to me.

I fell on the side of the privilege line that says I have a pretty good shot at meeting any nursing goal I set.  Had any of the above things not been true, my breastfeeding story might have been very different.  There should be no privilege line, no inequalities in access to breastfeeding, no inequalities in the ability to make a choice about how to feed one’s child.  Nourishing a baby with breast milk is a fundamental right – and we would do well to treat it as such.

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Published in Breastfeeding Popular