Since this month's publication of my paper "The Burden of Suboptimal Breastfeeding in the United States" in Pediatrics with Arnold Reinhold, I'm often asked by reporters what the US can do better to improve our breastfeeding rates. I've also gotten quite a few comments asking if this research just makes moms feel guilty if they couldn't breastfeed.
The answers to both these queries are intimately related, and are best illustrated by the following Tale of Two Births. As you will see, if you compare what should happen when a woman gives birth, versus what actually happens, you can appreciate how tough it can be for US women to breastfeed, but how much easier it could be if only things were a little different around here.
Birth number 1: Having a baby in the ideal, family-friendly United States:
You give birth with the help of a birth doula. She helps you avoid a c-section or vacuum assisted birth, which is why your hospital hired her. Your baby is wiped off, then put directly onto your chest, skin to skin, with his head between your breasts. The nurse puts a blanket around you both, and then your partner cuts the cord. The nurse evaluates his initial transition to life outside the womb as he rests on your chest. As you lay semi-reclining, happy and exhausted, your baby uses his arms and legs to crawl over to your breast and he starts nursing. You and your partner are left undisturbed for an hour to enjoy your new baby, who has now imprinted the proper breastfeeding behaviors thanks to this initial breastfeeding. You are then transported to your post-partum room with your baby on your chest.
The nurse returns and weighs, measures, and examines your baby right there in your room. You are with him as she gives him his vitamin K shot and antibiotic eye ointment. Your baby is handed back to you, and again placed on your chest skin to skin. He stays in your room with you until you go home. From your prenatal class, you knew in advance to ask most of your visitors wait until you go home, so that you can get some rest, and you turn the ringer off your phone, so that no phone calls will wake you. Before you leave the hospital, your baby's routine heel-stick blood test is done while he is nursing, and you are amazed to see he doesn't cry at all. You are discharged with clear instructions around breastfeeding, and phone numbers to call if you need help. You are not given samples and "gifts" from a formula company.
Two days later, you see your pediatrician, who is a little concerned about the baby's weight, but your baby otherwise looks healthy. He quickly refers you to a licensed International Board Certified Lactation Consultant, and all you pay is your standard co-pay. She does a careful assessment and advises increasing the frequency of nursing for a few days, and that does the trick.
You enjoy three months paid maternity leave, at 80% of your usual pay. Your baby sleeps within arm's reach of you, and because you taught yourself how to breastfeed lying down in the dark, you awake fairly refreshed every morning.
When you return to work, your employer allows you flex time. Your employer has a policy that allows new parents to bring their infants to work, so often you bring your baby with you. As in other companies with such policies, your coworkers enjoy having a baby around, and you feel happy, calm, and productive.
When your baby gets more active, you put him in the daycare near your worksite so you can nurse him during lunch, and you can pump milk in the lactation room at work. You bought a nice pump with your insurance's Durable Medical Equipment allowance. After 6 months, you introduce solids. A few months later, you really don't need to pump any more and you and your baby enjoy breastfeeding for another year. Your baby is so healthy that you've never had to miss a full day of work.
Does that sound like your birth experience, or does this?
Birth number 2: Having a baby in the real United States:
Your give birth to a healthy baby, and you've never heard of a birth doula. The umbilical cord is clamped and cut before anyone can say, "It's a boy!" Immediately, your baby is whisked across the room to the warmer where Apgar scores are assigned, he's given a shot of Vitamin K, and antibiotic eye ointment is slathered in his eyes, clouding his vision. He's placed on a cold scale and weighed and measured. He is examined by his nurse, who takes him to a different room to do her evaluation. He is bathed, washing off his mother's scent. At last, he's professionally swaddled into a nice tight parcel and handed to you to hold, cradled sideways in your arms.
He's not skin to skin, and he can't move his arms and legs to crawl to the breast. Before you know it, an hour has passed since his birth, and since he's missed the window of "alert time" after birth, he slips into a deep sleep without having spontaneously breastfeed. You attempt to interest him in the breast, but he is really too tired to try very hard. Because he's wrapped up and has been given a bath, he can't use his sense of touch and smell to crawl his way over to find your breast. You don't know enough to unwrap him and feed him immediately after birth, because your prenatal class didn't stress the importance of skin to skin contact during the first 3 days of life. That was all discussed in a separate breastfeeding class and you didn't really have time or money to take two classes.
Just as you're getting to know your new bundle of joy, the staff decides to check his temperature and his blood sugar. His glucose level is 45 -- normal for a newborn, but low for an adult. His temperature is a little low, too -- all that time in the bath, the cold scale, the swaddling, and the time away from his mom's body heat has led to hypothermia.
Hypothermia and hypoglycemia can be signs of a serious infection, so immediately he is taken from your arms down to the nursery, where he gets what's known as a sepsis evaluation. Lying under a warmer down the hall from you, he gets his blood drawn, and then is left in his bassinet in the nursery to be observed for a few hours so you can't spend time with him as you recover from giving birth. He gets a 2 ounce bottle of formula, most of which he vomits, since the stomach of a five-hour-old baby is no bigger than a teaspoon, the perfect size to digest the colostrum your breast secretes for him in the first few days.
Finally, your baby's brought back to you, swaddled in a nice package. He's more alert, but never imprinted breastfeeding very well, and he's very stressed from all the day's events. He might be full from the formula he's given, and doesn't breastfeed well. He tries later in the day. The nurses try to help you, but it feels like they all give you different advice, much of it conflicting. Little do you know, their advice is based on their personal experiences rather than any scientific evidence because they haven't had much training in breastfeeding. You don't know what to believe. Finally, your baby goes to the nursery for the night "so you can sleep," and he is brought in for you to feed him. He doesn't like it in the nursery, so he cries, and you don't get much sleep either.
You have some pain when he latches on, and you're told that's normal. You're so excited about his birth that you talk to everyone by phone, and lots of people come to visit. They pass him around. Maybe someone wants to give him a bottle, and you figure, ok, why not. He's chewing on his fist, but no one ever told you that means he's hungry, so you give him a hospital-issued pacifier to suck on instead of his hand. You don't know that giving formula and pacifiers in the hospital will undermine your efforts to breastfeed. It's surprising the nursing staff doesn't inform you of this, and you didn't learn it in your prenatal class. You're too embarrassed to feed him with everyone there. Finally, your guests leave, but by this time, your baby's frantic, and nursing doesn't go well as a result.
Overnight, as he stays in the nursery, he gets weighed, and he's lost more weight than he should have. The doctor says it's because your milk isn't in yet, and recommends more bottles. He still sucks happily on a pacifier and sleeps in the nursery despite his alarming weight loss, and no one suggests that you nurse him more often, room in with him, get rid of the pacifier, or see a lactation consultant, all of which would help put him back on track with breastfeeding.
An hour before you're due to go home, the lactation consultant comes in briefly to check on you, but because her department is so understaffed, she couldn't see you earlier when you needed it most, and she has little time to spend addressing your problems. On your way out, a nurse hands you a marketing bag from a brand-name formula company, complete with free samples of formula and information on breastfeeding that makes it sound a little hard and scary. She tells you if you have any questions, to just call your pediatrician.
The first night at home, things don't go well. It's the middle of the night, and your baby won't stop crying when you try to breastfeed. You wonder if you should just give up. You reach for that ready-made bottle and his crying mercifully stops. The problem is solved, at least for now.
You are really motivated to breastfeed, so in the morning, you try to find a lactation consultant. You talk to someone you find in the yellow pages called a "lactation counselor" who is willing to help, but your insurance won't pay. You find someone else called a "lactation consultant." You have no idea what the difference is between a "lactation counselor" and a "lactation consultant." Since these professionals aren't licensed in any state, you have no way of knowing if they know what they are doing.
You meet with the lactation consultant, but have to pay out of pocket. She helps you. Afterwards, you have to file a claim with your insurance company and hope they reimburse you, all while caring for your newborn. The lactation consultant recommends pumping with a double electric pump to help you build up your milk supply, which is now threatened because of all the formula the baby got, and because his breastfeeding technique is not really good enough yet to extract milk well, since he didn't learn properly right from the beginning. Your insurance won't allow the breast pump to come out of your Durable Medical Equipment allowance, and you try to pay for it with your Flexible Spending benefit card, but it's denied. You pay $250 out of pocket. Good thing you had a gift card to pay for all that!
You go to your pediatrician for follow up. Since your pediatrician got very little training on breastfeeding, he doesn't know how to help you, but is concerned that your baby has lost too much weight, and advises giving some formula. You don't know what to do because the lactation consultant's advice was different.
Ugh!!! This is really hard, you think. Eventually, things miraculously end up working out, just because you persevere through thick and thin, and your partner and family and friends are very supportive. By about 4 weeks, your baby is now exclusively breastfeeding, and gaining well. And you are enjoying what time is left of your unpaid leave under the Family Medical Leave Act. But, you have only two more weeks before you go back to work. You can't afford any more time off.
You start pumping to build up a stash of frozen milk for your return to work. You arrange with your employer a place to pump -- how lucky you are that it won't be a bathroom! You go back to work, and before long you discover your milk supply is dwindling and now your baby wants to nurse all night long. You are exhausted.
You call the lactation consultant who tells you that it's common to see a drop in milk supply when moms go back to work. She explains that pumps aren't as efficient at removing milk as your own baby is, so your milk supply may drop, and your baby makes up for it by nursing more when you are with him -- it just so happens that that's at night. "It's called reverse cycle feeding," she tells you. You wonder why you never heard about this before, in any of your follow-up visits with your pediatrician or OB.
You want to see the lactation consultant again, but your insurance will only reimburse you for visits during the newborn period. Well, you think, at least my insurance paid for something -- my friend's insurance doesn't reimburse anything for lactation help.
You nearly fall asleep at the wheel driving to work. "This is crazy," you think. "My baby needs me to be alive, more than he needs me to be breastfeeding." Finally, you give up. You just can't do this anymore. You are very sad and disappointed.
You become a statistic: one of the 41% of US mothers who wean before 3 months. You feel guilty as hell, especially when all you ever hear is how great breastfeeding is, and now how that new study shows it could save the US economy $13 billion/year, and how everyone says it saves lives and how it will make you healthier too. You just wish all these people would just shut the heck up.
So, now that you've heard the difference between what your experience could have been like, and what it was actually like, you tell me:
Do you feel guilty for not breastfeeding? Or do you feel angry because it didn't have to be this way?
And if you answered "angry," then take that anger, and write to your hospital -- tell them you want them to become a Baby-Friendly hospital, so that no one else will have to go through what you did just to feed your child. Write to your state and federal legislators -- tell them to support laws that make breastfeeding easier, like licensing of lactation consultants, and the requirement that insurance companies reimburse for lactation care and services. And write to your US representatives and senators, and tell them you want tax-credits for onsite childcare, and that you don't want the US to continue being the world's only developed country without paid maternity leave.
Yes, I'm a researcher and a physician, but I'm also a mother. Since I live in the United States, you can probably guess what my birth experience was like. Maybe you've heard me on the news saying that moms shouldn't feel guilty. I've been there. So take that guilt and turn it inside out, and do something positive so that other moms don't have to go through what you did. We all deserve better.
A Peaceful Revolution is a blog about innovative ideas to strengthen America's families through public policies, business practices, and cultural change. Done in collaboration with MomsRising.org, read a new post here each week. Submission inquiries to Nanette@MomsRising.org.
My daughter breast fed right away, and for 2 years after, and was never out of my care or my husbands the whole time we were in the hospital. I had a regular OBGYN, not a doula or a mid-wife.
I am not sure when people have to jump to a either or scenario, the extremes on both ends are not right.
Unfortunately for economic reasons that hospital (St. Clare's in Schenectady NY) has now closed its OB/GYN services and people have to give birth at other local hospitals. I know the staff at those other hospitals is good (because the staff from the closed hospital have moved to other places) but I don't know about overall hospital policies.
I was lucky, and tenacious enough, to research and read a lot before I decided what kind of birth experience I wanted. There is so much information out there -- if you are willing to look for it. I am not superwoman, but with a lot of preparation during my pregnancy and some believe in my own strength and some luck I was able to birth my son without any drugs. But I also made sure the hospital couldn't intervene and bother what was naturally happening -- I didn't go to the hospital until 20 minutes before the birth. I wasn't stuck in bed on a monitor, I was free to move how I needed to to deal with the contractions. I wasn't scared into taking drugs or a C-section.
With my blog, Dagmar's momsense, I encourage and want to empower women to seek out the right choice for them, and to trust into their ability to birth a child without much interference. And I also provide them with resources and support for breastfeeding -- because there isn't enough of that out there.
Dagmar
Dagmar's momsense http://DagmarBleasdale.com
Yes, breastfeeding is the biological norm and is undeniably better than formula feeding. But the ability to walk is also a biological norm, and undeniably better than being confined to a wheelchair. Being free from cancer is a biological norm, and undeniably better than being riddled with it. A physical inability to breastfeed does not make you a bad mother, or a bad person, any more than does being in a wheelchair or having cancer.
Sure, I encourage you to do everything you can to breastfeed. I encourage you to seek a second opinion -- something I always recommend as my own personal experience is one of having had unnecessary surgery after being misdiagnosed with a rare condition based on ridiculous, trumped-up "symptoms." But if you truly cannot breastfeed, please don't beat yourself up. Be sad, be angry, be depressed, be whatever you need, but please do not think that this is your fault or that you should feel guilty. It's not your fault.
This all kind of ticks me off, now that I've read this. (But I'll know next time, if next time happens. Thank you for writing this.)
The expericne I had is available to everyone. I had it because I studied my options. I read about births in the US, I educated myself. And I trusted my own instincts.
It was tragic to me, how many conversations i had with women who would look sadly at me & say, "I'd love to do a homebirth but my dr. said no." Or the woman who was in the hospital so long with her baby, she talked about how they induced labor, how they gave her pitocen to speed delivery, how she ended up with a c-section. "Those drs saved my baby's life!" she ethused. But everything she said was a classic setup for surgery. She had no problems until they started hurrying things. We are so brainwashed. TV shows where the woman is pregnant. "Oh honey, the baby's coming"! Husband: "let's get you to the hospital right now!" It is sooooo sad that women are so pressured to give up all autonomy on such a personal experience.
However, the experiences we had are not available to everyone. Putting aside women with risk factors who need to deliver in hospitals, or those who live in states where homebirth is illegal or hb midwives are unavailable, there are many - perhaps most - women who can not have the birth you describe, no matter how much they study, because they simply can not afford the fees involved with homebirth. Although homebirth midwifery care costs a fraction of the same care provided in hospitals, for many it is still out of reach without insurance coverage - which is hard to come by here.
I can assure you that all the studying in the world will not get a mom a homebirth-like experience in a hospital if the care provider (doctor on call) is not on board, or if hospital policies don't allow it. Those lucky enough to have their choice of hospitals and care providers may be able to do some shopping around to get what they are looking for (I did to a certain extent for babies three and four), but all too often insurance companies dictate those "choices" to us. Sadly, health care reform as it stands now does little to address these very real economic and quality of care issues.
After giving birth, no one was whisking my baby in and out--he stayed with me pretty much the whole time. Yes, they weighed him and his dad cut the cord, but he was back on my chest to feed--unbathed--right as I finished delivering the placenta. The nurses were all trained to help new moms breastfeed, the lactation consultants were free, and no one tried to give him a bottle or a pacifier unless you specifically asked for it.
Just because a woman chooses to give birth at a hospital--or, heaven forbid, wants pain medication--doesn't mean she is somehow less of a mother / oppressed by "the medical establishment" or any such thing. Any woman who gives birth is amazing.
Having your new baby in your arms is a glorious moment and I hope all Moms are able to savor it and have a positive experience.
As a homebirth midwife, I see moms and babies 1 day after the birth, on the 3rd day, at 5-7 days, 2-3 weeks and 6 weeks. Those are the regularly scheduled visits. They get more if there are any breastfeeding or recovery issues.
I credit my success to her because she breastfed me when it was unpopular to do so. Because I saw her nurse my siblings, I always knew I would do the same with my own babies. It simply never occurred to me to feed my child in any other manner. So when things became incredibly difficult, my newborn daughter and I never gave up.
When we breastfeed our children, in addition to reducing health costs, we're also passing down our values to our children, who will be determined to do the same. That's how change happens.