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As a new mom in 2011, parenting unfolded before me like an obstacle course, an uphill battle of picking the right choices from an ocean of wrong ones. In the complex quest for credible parenting information, one choice seemed clear, backed by seemingly incontrovertible data: When it comes to feeding your baby, breast is best.
The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 based on this assumption, “to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding.” The initiative is built around the Ten Steps to Successful Breastfeeding, which aims to increase breastfeeding initiation and duration. According to Baby-Friendly USA, there are currently 453 BFHI hospitals in the U.S. and Puerto Rico.
In accordance with the Ten Steps, BFHI hospitals encourage "help[ing] mothers initiate breastfeeding within one hour of birth"; "[giving] infants no food or drink other than breast milk, unless medically indicated"; and "[giving] no pacifiers or artificial nipples to breastfeeding infants."
Moms who choose to supplement with formula at a BFHI facility may be asked to sign a consent form informing mothers of the “risks of supplementation.” Trish MacEnroe, executive director of Baby-Friendly USA, tells SELF that guidelines require health care staff to explore the reasons a mom requests supplementation, “and educate her about the possible consequences to the health of her infant and the success of breastfeeding. If the mother still requests a breast milk substitute, her request should be granted and the process and the informed decision should be documented.”
Though BFHI is a partnership between the World Health Organization and the United Nations Children's Fund, even the most highly regarded institutions can implement policies based on misinterpreted scientific literature. Data show that it’s questionable whether the initiative actually improves breastfeeding success, and—perhaps more importantly—that the “breast is best” mantra may overstate the benefits. Breastfed infants tend to have better outcomes, including lower rates of obesity and certain types of cancers, according to the Centers for Disease Control and Prevention, but is breastfeeding itself the cause of these improved outcomes?
In the developed world, women who breastfeed tend to also have higher levels of education, higher incomes, better access to health care, and are less likely to smoke, among other differences. Research on early childhood development and other health outcomes suggests that breast milk may only be negligibly better than formula when taking such confounding factors into account. Yet headlines continue to hype the breast is best adage, over-interpreting studies that say no such thing.
Take a recent study published in the Journal of Pediatrics, which suggests that black infants had over twice the deaths of white infants attributable to lack of optimal breastfeeding. The problem is, this study relied on computerized simulations of two hypothetical cohorts of women (rather than examining real world health disparities) and it was based on the assumption that poor health outcomes are caused by—rather than associated with—sub-optimal breastfeeding. With the exception of necrotizing enterocolitis, an intestinal disease that occurs in premature infants (there is strong evidence that breast milk can prevent it), the study fails to show a causal link between sub-optimal breastfeeding and negative health outcomes. Though experts criticized the study for poor methodology, many news outlets once again made the “breast is best” leap.
It’s no news flash that childbirth is the most physically and mentally grueling and painful experience most biological mothers have gone through. As a sadistic bonus, it’s also the most sleep-deprived time of our lives. Now, a growing number of BFHI hospitals are eliminating infant nurseries in line with number seven of its 10 steps—practicing “rooming in,” or keeping baby with mother 24/7 to encourage breastfeeding.
This is exhausting for new parents and, as described in the Journal of Perinatology, potentially dangerous due to the possibility of suffocation when a breastfeeding mom falls asleep with the baby in her bed. Rooming in seemed like torture after my painful yet skillfully executed forceps delivery at a BFHI hospital in 2011. When my son was born two years later, again at a BFHI facility, I requested use of the nursery overnight, and asked the nurse to bring him every few hours to breastfeed. She acquiesced, but I was told in no uncertain terms that I wouldn’t have been allowed to use the nursery for my first child, because new moms need to learn to care for their babies.
Though some BFHI facilities no longer have infant nurseries, there may be other options. “If a mother needs help, for any reason, during the hospital stay, she should ask for it,” says MacEnroe. “The hospital is expected to be responsive to her concerns and needs. However, they may be able to offer a variety of solutions, other than the specific request.”
Experiences with rooming in at BFHI facilities vary. Tiffany Blackmon, who gave birth in Portland, Oregon in 2015, tells SELF that a nurse offered to take her baby for three hours so she could sleep. “I was grateful she offered, and I recommend asking if you need the sleep,” she says.
“The only sleep that I got was about a half an hour when my epidural was put in during labor,” Amber Hunter, who gave birth at a BFHI hospital in San Diego in 2009, tells SELF. “If you need respite, keep asking for them to take your baby,” she says. Remember, nobody would hand a baby to a man following surgery and expect him to care for it 24/7.
For healthy, full-term infants whose families have access to clean water and supplies, what’s important is weighing what works for you and your family. While the BFHI promotes “breastfeeding as the normal and optimal way to care for a baby,” there is nothing abnormal or suboptimal about formula, which is heavily regulated to contain a precise balance of what babies need.
Popular parenting sites often present a false dichotomy about feeding costs—breast milk is easy and free compared to expensive formula—but that’s not always the case. Consider that breastfeeding or pumping breast milk can be as time consuming or more so than formula feeding, and often requires costly accessories. Giving up my bodily autonomy (read: having to pull out my breasts to feed or pump every couple hours for several months) was a significant cost for me.
Lactation consultants and leading breastfeeding advocacy organizations tell new mothers that newborns who nurse frequently will get enough milk, and that a newborn doesn’t need much milk in the first few days of life. But it's estimated that up to 15 percent of moms don't produce enough milk, due to complex factors including genetics, and newborns who aren’t fed sufficiently can develop dehydration, low blood pressure, and hypoglycemia (low blood sugar), which can cause irreversible brain injury and, in rare cases, death. Insufficient supply in the first days after birth, before milk “comes in,” is more common in first-time mothers.
According to the American Academy of Pediatrics, a baby who still seems hungry after most feedings may not be getting enough milk and should be evaluated immediately. The Fed is Best Foundation, a non-profit organization of health professionals and moms who seek to provide information on the safest, most brain-protective methods for breastfeeding, mixed-feeding, and formula-feeding mothers and families, offers extensive resources for parents, including advice on hand-expressing milk from the breast before feeding to make sure milk is present.
BFHI also espouses the popular “nipple confusion” theory, which suggests that since the mechanics of sucking on a bottle or pacifier differs from nursing at the breast, introducing an artificial nipple will hinder breastfeeding success. But there is little evidence to support it, according to a 2015 literature review in the Journal of Perinatology. In fact, research shows that early limited supplementation can be a temporary coping strategy for parents dealing with weight loss in newborns, and it may even reduce long-term formula use.
After my daughter lost too much weight in the days following birth, my doctor gently suggested supplementing with formula until my milk fully came in. After two days of nursing, pumping to increase supply, and supplementing with a bottle, we ditched the formula and I nursed her exclusively until we began solid foods. If you’re still worried about nipple confusion, a Supplemental Nursing System (SNS)—feeding pumped breast milk or formula through a thin tube attached to the breast—is also an option. My husband and I requested a hospital grade pump and SNS when my son was born in 2013.
All of this isn’t to say that breastfeeding doesn’t deserve support. It’s an injustice when parents who want to breastfeed don’t get the help they need. Knowing what I know now, after giving birth twice at a BFHI hospital, I would have more compassion for myself and encourage all new moms to do the same. Breastfeeding can be a great choice, but a well-fed baby and a mom's well-being should trump the goal of exclusive breastfeeding every time.
Related:
- Is Drinking While Breastfeeding Bad?
- Whitney Port Opens Up About 'Tongue Tie' and the Painful Side of Breastfeeding
- 10 Pregnancy Comments You Should Keep to Yourself
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