Thursday, August 30, 2012

Brewing a Breastfeeding Controversy

From the moment I knew I was pregnant, I knew that I was going to breastfeed. I knew that it was the best choice for my son. However, despite my research, I did not anticipate the problems or challenges that I faced. I was not alone, as so many mothers out there had even worse barriers to overcome than me. I kept reading books and tried to find answers online. I went to lactation consultants. I spoke with other moms. Breastfeeding got easier, but I think that it was due to time and my persistence. Unfortunately, some moms do not have the support or access to resources that I did. Bonnie Modugno, MS, RD, CLE, is a registered dietitian in private practice in Santa Monica. She brings up important points about the disparity in support for nursing moms and why some don't succeed. Bonnie works extensively with individuals and families addressing nutrition concerns throughout the lifecycle, with a special focus on maternal, infant and child nutrition. She is a certified lactation educator. Bonnie recently contributed to Smart Bites for Baby by Mika Shino. She can be reached through her website

BREWING A BREASTFEEDING CONTROVERSY:  Why is there a gap between the numbers of women who intend to breastfeed and those who are actually breastfeeding?
There is no question more women understand that breastfeeding is best for baby. The intention to breastfeed is steadily increasing.  But as we all know, good intentions only go so far and knowledge is not the same thing as behavior.
The Center for Disease Control (CDC) follows trends that relate to health and disease. All indicators show that breastfeeding is incrementally increasing. Women in the US who attempt to breastfeed increased from 74.6% in 2008 to 76.9% in 2009 births.
While these numbers seem small, data shows that this is improvement and represents the largest annual increase over the previous decade. Breastfeeding at 6 months increased from 44.3% to 47.2%; breastfeeding at 12 months increased from 23.8% to 25.5%. But that is not the whole story. 
As more and more women intend to breastfeed, CDC data show the realities of modern life. At six months of age, only 21.7% of women—a bit more than one out of five-- are still exclusively breastfeeding. What makes it so hard for women who intend to breastfeed to continue to totally breastfeed until their infant is ready to take in solid foods?
Over thirty years ago I started working at WIC, a federally funded program for women, infants and children that promotes breastfeeding. During the 1970’s Breastfeeding enjoyed a nascent renaissance, fueled by a back-to-nature push, primarily from people eating granola and wearing Birkenstocks.  But these were college educated back-to- nature types.
Despite more and more women wanting to breastfeed, the world seems seduced, if not bedazzled with the convenience of formula. The medical world especially seems ambivalent. While lip service is given to breastfeeding, women regularly leave the hospital with their newborn and a couple of cans of infant formula courtesy of the hospital and one of the top infant formula corporations. Today, 24.6% of babies have been offered formula before two days of age. In California, the number is 26.3%.
There has always been push back to these not so subtle messages that formula is a good as breast milk. Today, the pushback is more visible, more political, and more polarizing than ever.
Earlier this year NYC Mayor Bloomberg propelled the debate to the front and center of national attention. In an effort to conform to the World Health Organization guidelines, he announced an initiative to minimize the impact of marketing by formula companies in hospitals. The “baby friendly hospital initiative” endeavors to limit access to formula on the hospital ward, as well as to ban freebie samples to the discharged moms.
In a Huffington Post article dated April 20, 2012, the intensity of the debate is evident, especially in the comments section. One comment posted August 2, 2012, especially caught my attention, mostly because it may be one that begins to explain why so many women intend to breastfeed, but aren’t breastfeeding even a few weeks after they give birth.
I would venture to guess she did really want to breast feed and her lactation experience was mismanaged from the get-go. This is a common scenario and a real tragedy”
I heartily agree. Lack of preparation, lack of support, and lactation mismanagement are core realities for many women who intend to breastfeed but at some truncated point and time decide to stop.
I am mostly concerned with women who think the breastfeeding discussion in childbirth classes is all they need to know. It is usually inadequate on its own. Pregnant women should be evaluated before the third trimester to see if there is anything that will preclude them from successfully breastfeeding.
Women who are intent on breastfeeding often do this research on their own. A woman who isn’t motivated on her own--and doesn’t receive care from pro-breastfeeding obstetricians or other health providers—is often left to herself until just before or after birth. Then she is asked, will you be breastfeeding or bottle feeding? What a set up.
Even with research, many women don’t have a support network to be successful over time. Too many clinicians don’t have the knowledge or time to adequately support women who want to breastfeed. Most women benefit from hands on support.
We have long lost the wisdom of the tribe where women readily supported each other by actually being involved with hands on care of the new mom and new baby. Today the internet provides virtual support, but that is not the same. There is nothing like watching a mother with her newborn and gently guiding her hands, her body position, the baby’s mouth and all the other visual and tactile adjustments that can help make the breastfeeding experience successful.
There is nothing like actually evaluating the breasts and counseling a woman long before the moment of a first feeding. There is nothing like day to day contact and support during the early weeks when everything is new and can easily be overwhelming. Most other cultures don’t pretend that a new mom is supposed to be able to do all of this without help.
In other countries, women are supported day in and day out after the birth of their baby. My sister home delivered her three children in Holland.  A nurse was at her side for a week after each birth. Can you imagine the success if we offered women in the US the same support?
Today we mostly rely on trained specialists to provide support to women who would like to breastfeed. The trouble is that they are in short supply—even in California-- and we fare much better than many other states. See complete data from Breastfeeding Report Card 2012, United States.
Number of La Leche League Leaders per 1,000 live births
Number of IBCLCs* per 1,000 live births
Number of state health department FTEs** dedicated to breastfeeding
State child care center regulation supports lactation***
U.S. National

* IBCLC - International Board Certified Lactation Consultant. **FTE - Full-Time Equivalent. ***Based on the PCO/CFOC IA1 standard I am concerned for all women, those who are invested in breastfeeding as well as the majority of women who are somewhat ambivalent or aren’t seriously considering breastfeeding. I find that too many women are not adequately prepared or informed before they are handed their baby.
Most women never have their nipples assessed during their pregnancy. I am shocked when inverted nipples are only assessed after a birth and latching on is challenging. I’ve watch this happen twice with my own extended family!
Inadequate preparation and personal attention leads to significant anxiety. When women are not personally motivated, they don’t seek out the information independently.
Even when women are motivated, the barrage of expectations surrounding birth and infant feeding is often overwhelming. It seems that any one challenge can be the tipping point, enough to change course and lead to the bottle. A screaming baby is hungry now. Waiting a few hours or days to get help is often just too long to wait.
The bottle represents the path of least resistance when you are sleep deprived, frustrated, exhausted, or just need a break---especially if the decision to breastfeed is full of ambivalence in the first place. Formula is predictable, and predictable is easy to manage. In addition, the first few cans are pretty cheap when they are free.
I’m not sure if the NYC initiative is the answer; I do know women need more, better and more available support if the number of women who are actually breastfeeding is ever going to match the number of women who intend to breastfeed.

Disclaimer: This article was written by a guest author. I did not receive financial compensation to publish this post on my blog. All information and opinions presented by the guest authors are solely theirs.