To improve breastfeeding rates we need to drop the "all or nothing" message

[beru]

These posts in the "Dangers of Formula" thread has touched upon a topic I think a lot about:

Lucy in the Sky
"As much as I am very pro breastfeeding and love sharing that special bond with my son, I absolutely hate the extremism that I feel a certain sub section of breastfeeding advocates attempt to shove down people's throats. Breastfeeding exclusively does not work for everyone for many legitimate reasons and touting a one size fits all message about feeding is in my opinion quite dangerous."

Songbh
""True" low milk supply (as opposed to the low milk supply that results from common BFing mismanagement like scheduling feeds, giving unnecessary supplemental feeds, etc.) is much more rare than most people in our culture believe it to be. Because of the widespread belief that any problem with breastfeeding must indicate "not enough milk," the first thing an IBCLC or LLL Leader may consider when a mother reports low milk supply problems is that this mother may be misinterpreting what is happening. That IBCLC or LLL Leader may then become more focused on educating or convincing the mother to persist with exclusive breastfeeding rather than focusing on an accurate diagnosis of the problem.

Breastfeeding support providers can often feel that they are doing battle with an entire culture of myths and misinformation. If they carry this attitude into a helping situation with a mother, they can all too easily forget to listen closely and to trust that the mother truly is the expert on her baby."

Songbh has pointed out that these specific lactation supporters were probably trying to be supportive. I think we all have to watch ourselves when we help others. Breastfeeding came easy to me and I felt skeptical of mothers who stated they were "unable to breastfeed". (I would say they "claimed" to be unable to breastfeed.) or had other problems.

When I went back to work, I had great difficulty producing enough milk for my child in daycare. When I asked for help from LLL members and other breastfeeding supporters, no one suggested formula. I took all the suggestions to increase my supply, add extra pump sessions, pump on one side while baby nursed on the other, etc. I even bought 2 different pumps thinking maybe a different pump would work better for me. I stressed myself out so much that I became very resentful of nursing and pumping. I hit some kind of critical mass and stopped pumping suddenly (resulting in my first and only case of mastitis) and nearly weaned.

Before my new baby was born 2 months ago, I asked a LLL leader how I can make pumping for work better for me this time. She then suggested extra pump sessions, etc. The same things I heard before. I had a eureka moment and realized why I didn't like her answer. I know she didn't mean it this way but I feel like she was saying "you have to do it the right way or don't do it at all". There were no choices given...the advice was either breastfeed and provide breastmilk exclusively or I can't help you. Granted I don't blame her. She doesn't have the experience of working away from her kids and she never supplemented. But she had no advice on alternatives for me that I have since been exploring (early introduction of solids, encouraging reverse cycling, and supplementing with formula).

There are more than a half a dozen new moms at my work place and they look to me for breastfeeding advice. I think the reason they trust me is this. I always try to think of three options. I look up the "real" answer through research: look at kellymom, ask my LLL, etc. Then I give them the real answer as one choice of three: all, nothing, or in-between. There are 2 other choices if that "Real" answer is too stressful or feels undoable for other reasons: give up breastfeeding or modify the advice with the understanding that you might not succeed. For instance, one coworker came to me hysterical that she wasn't pumping enough and thinking about stopping breasfteeding altogethher. I said you can keep pumping in order to give your breasts the message to produce milk and supplement with formula. Your milk supply may go down from this. It could lean to early weaning. But maybe it won't. Wouldn't it be better to make the choice that could possibly provide some breastmilk than the choice (weaning) that gives the baby none? Then I said if you are not ready to take that risk try all these tips for pumping more (extra pump sessions, etc). The final message is does the benefits of exclusive breastmilk outweigh the risks of a stressed out mom. Does the risk of the possibility of premature weaning due to supplementing outweigh the potential you have for feeling guilty about it?

And we should remember that those who "claim" they were "unable to breastfeed" really were unable to breastfeed. Even if it wasn't necessarily due to physiological causes, that doesn't negate the reality of the situation: the individual did not succeed breastfeeding. If someone was "unable to breastfeed" due to mismanagement and lack of support, that experience should be validated and we should work on correcting the mismanagement. I understand this is very tricky to do. I don't think we should ever say, "You probably weren't unable to breastfeed, you probably..." If we want to help, we have to find more respectful and creative language to see if the person needs education or not. I like to say, "Those who were unable to breastfeed previously can often succeed at breastfeeding a subsequent child. Sometimes all it takes is a more knowledgable health care provider."

I think this post didn't come out as coherently as I had hoped but I got to go cause I have to go get my two kids out of bed...

Ella

[mommajb]

I'm sorry your LLL leader didn't talk about the reverse cycling or mention breastfeeding when you are together. Any breastfeeding is good. More is even better. All women should be commended for trying and succeeding at all levels. You are right. We want mothers to see opportunities to give their children breastmilk where in the past the barriers may have been more visible.

[songbh]

Originally Posted by beru

The final message is does the benefits of exclusive breastmilk outweigh the risks of a stressed out mom. Does the risk of the possibility of premature weaning due to supplementing outweigh the potential you have for feeling guilty about it?

And here we are back again to the micro/individual level of analysis. Do you see how this framing (it's all on mom's shoulders, it's all about how hard she is willing to work and what her personal priorities are) again and again erases society from the picture?

The final message, IMHO, is that mothers don't breastfeed babies ALONE.

[BiscuitBaby]

At LLL meetings when people say they are going back to work and have questions about pumping, I often ask about the child care provider that they are going to use. If the provider is close enough to their job, they can nurse at lunch and again when they pick up the child. I understand that not everyone will have success pumping, but my first suggestion is not to supplement.

My personal issue with people saying they were not able to breastfeed [aside from medical issues] is that it makes it seem like breastfeeding is not worth trying. Why go through all that trouble if your Mom, Grandma, etc. said that they could not breastfeed?

I saw an ad in a magazine for an Avent pump that said "everyone needs a breast pump" or some lame slogan. So now we have new mothers thinking that to brastfeed they need an expensive pump, nurisng shirts, bras, pillows, etc. Those things are nice if you want them, but they are not necessary like having bottles and nipples when formula feeding.

There are many factors that go into a breastfeeding realtionship and whether or not someone is successful. Support from family, friends, health care providers and taking the time to educate yourself. How many people are ready to wearn when their child goes through a growth spurt? They think they are not making enough milk. It is so frustrating to me when I see the answer as nurse more and they automatically think, give the baby a bottle.

I really like this quote that I saw on the LLL website. I do not remember the author, but it is exactly how I feel about breastfeeding.

""Breastfeeding is an instinctual and natural act, but it is also an art that is learned day by day. The reality is that almost all women can breastfeed, have enough milk for their babies and learn how to overcome problems both large and small. It is almost always simply a matter of practical knowledge and not a question of good luck."

[amandaleigh37]

I had a eureka moment and realized why I didn't like her answer. I know she didn't mean it this way but I feel like she was saying "you have to do it the right way or don't do it at all". There were no choices given...the advice was either breastfeed and provide breastmilk exclusively or I can't help you.

You make a lot of good points. This part though... maybe I'm misunderstanding, but are you saying you would have preferred the LLL leader to present you with the option of supplementing? I think the reason she didn't is obvious - every mother knows they have that choice. That's the choice that is everywhere you look - bottles and formula. The leader probably assumed (as I think most would?) that by asking for her help, your goal was to continue exclusively BFing. So to suggest anything else, IMO, would be inappropriate.

There are 2 other choices if that "Real" answer is too stressful or feels undoable for other reasons: give up breastfeeding or modify the advice with the understanding that you might not succeed.

Isn't that pretty much where we are now? Women know they have "choices", and many see breastfeeding as an unattainable gold standard they can't reach, so don't even bother. Or like you said, it becomes "too stressful". At that point, I can almost guarantee that these mothers are getting the message to supplement or go entirely to formula - from posts I've read here it seems to come from everyone - family, friends, pediatricians, and as we know - magazine and TV ads. Why should it come from us too?

[Sustainer]

Originally Posted by amandaleigh37

That's the choice that is everywhere you look - bottles and formula. The leader probably assumed (as I think most would?) that by asking for her help, your goal was to continue exclusively BFing. So to suggest anything else, IMO, would be inappropriate.

I can almost guarantee that these mothers are getting the message to supplement or go entirely to formula - from posts I've read here it seems to come from everyone - family, friends, pediatricians, and as we know - magazine and TV ads. Why should it come from us too?

:

[Da WIC Lady]

Originally Posted by songbh

And here we are back again to the micro/individual level of analysis. Do you see how this framing (it's all on mom's shoulders, it's all about how hard she is willing to work and what her personal priorities are) again and again erases society from the picture?

The final message, IMHO, is that mothers don't breastfeed babies ALONE.

Thank you! This is the thing that has been continually left out of the discussion or glossed over by those banging the "don't make them feel guilty" drum. Every time support being the key to breastfeeding success, it gets buried under a ton of excuses and what ifs and ignored. Everyone seems quick on the excuses and slow on the what to do about it except to criticize those actually doing anything. You know, I've realized I have even less patience for these arguments now that I've had the baby and am nursing two. Here I thought it was just me being pregnant. If you truly have not other choice but to exclusively FF or you at least to try to BF, you have nothing to feel bad about. Any breastmilk is better than none for however long you give it.


Anna

[turtlewomyn]

I agree. I am a working mom. I had problems with breastfeeding my DD at first and ended up supplementing. We got those problems fixed and went back on to exclusively nurse (or use expressed milk at daycare) until six months, I then went on to introduce solids and continued to give her no formula, just nursing and expressed milk, until a year when I quit pumping and gave her cows milk at daycare. She is over two now, and still nursing evenings, mornings, and weekends, and sometimes at night. I love to give advice to working mothers who wish to breastfeed. I always give tips on how to pump more (stimulation of the breasts before a pump, trying to relax, extra pumping sessions at night or before work) but I always try to tell them that if they have to supplement, it isn't the end of the world. I had a friend who nursed her DD for over a year, but she had to quit pumping at work around nine months. When her freezer stash ended she gave formula during the day, but continued to nurse at night, and that worked for her. It doesn't have to be all or nothing. I would much rather see more women giving some breastmilk than none at all.

[beru]

Originally Posted by songbh

And here we are back again to the micro/individual level of analysis. Do you see how this framing (it's all on mom's shoulders, it's all about how hard she is willing to work and what her personal priorities are) again and again erases society from the picture?

The final message, IMHO, is that mothers don't breastfeed babies ALONE.

I actually agree with you. I quoted you because I loved what you had to say. I agree that the way we have to change things is to change society. I think each mother deserves individualized support within the context of current society, within the context of the challenges that exist now. I think we shouldn't lose sight of that because we are fighting a bigger war. We shouldn't be fighting the war in this micro level. There are women who want to succeed at breastfeeding their own child and frankly aren't interested in others' success. They don't want to hear how most medical professionals are ignorant about breastfeeding and how the working mothers culture in this country sets us up for problems, etc. They just want individual support. I am addressing that.

I personally want to support breastfeeding, on the micro level, by supporting individual women nonjudgementally and, on the macro level, by addressing society. We need more educated health professionals who value breastfeeding enough to stop advising weaning at any sign of trouble. I think the thing that would help the most would be 6 months maternity leave. That would make a huge difference but since it isn't likely to happen anytime soon, we should have policies and laws that make it easier to pump at work. I do agree that OB/Gyns should be explaining to their patients the risks of non-emergency formula feeding (perhaps songbh thought I disagreed with that). They aren't being paid to be liked. They shouldn't be withholding facts because the think the patient might not want to hear it. I am unsure how I feel about the advertizing campaign that was scrapped (with the bull-riding and log-rolling commercials). It's a powerful message but will it just piss moms off? Maybe but I wonder if it would also be sort of a subliminal message for young people who aren't even thinking about those decisions yet.

Back to the point of this thread, I think when we help individual women, we should be taking a different approach than when we are trying to change breastfeeding culture overall.

[songbh]

Originally Posted by beru

I actually agree with you. I quoted you because I loved what you had to say.

Aw shucks ... thanks, beru!

Back to the point of this thread, I think when we help individual women, we should be taking a different approach than when we are trying to change breastfeeding culture overall.

You know, it's funny -- I was thinking about your post and the other recent threads here while I was out battling holiday shopping crowds all day (ugh!) and I ended up precisely at this idea before I got back to see your reply.

I keep writing here that we can walk and chew gum at the same time -- that there is no quick/simple fix that will turn the U.S. into a breastfeeding society, and so lactivism has to have room for multiple and simultaneous approaches to the problem.

This distinction between breastfeeding support (individual, one-at-a-time, problem-solving and educating work) and breastfeeding advocacy (big-picture, structure-focused, public-health-style work) is emerging as a very important distinction in how we think and talk about lactivism.

Because you're absolutely right: the individual mother who is struggling to meet her own breastfeeding goals doesn't have the time or energy to think about societal structures or cultural norms, and she shouldn't have to. The messages that may convince politicians and bureaucrats to invest real capital in breastfeeding are quite different from the messages that will help individual mothers to feel empowered and supported in their immediate breastfeeding challenges.

[beru]

Originally Posted by amandaleigh37

You make a lot of good points. This part though... maybe I'm misunderstanding, but are you saying you would have preferred the LLL leader to present you with the option of supplementing? I think the reason she didn't is obvious - every mother knows they have that choice. That's the choice that is everywhere you look - bottles and formula. The leader probably assumed (as I think most would?) that by asking for her help, your goal was to continue exclusively BFing. So to suggest anything else, IMO, would be inappropriate.

Isn't that pretty much where we are now? Women know they have "choices", and many see breastfeeding as an unattainable gold standard they can't reach, so don't even bother. Or like you said, it becomes "too stressful". At that point, I can almost guarantee that these mothers are getting the message to supplement or go entirely to formula - from posts I've read here it seems to come from everyone - family, friends, pediatricians, and as we know - magazine and TV ads. Why should it come from us too?

I absolutely do think she should have mentioned that supplementing may be necessary if we can't solve the problem in other ways. I believe women have 3 choices, providing breastmilk exclusively, forumla feeding exclusively or they can attempt to combine both (which may or may not work). I didn't understand this before when my biggest supporters were breastfeeding advocates. I thought I had to breastfeed exclusively and if I didn't do everything the optimal way, I would fail to breastfeed and I would end up on formula totally. So I don't agree that mothers know about the choices that are available to them.

Where else am I supposed to go for advice? The "family, friends, pediatricians, and as we know - magazine and TV ads" that you are speaking of encourage supplementing and formula feeding without clarifying the consequences. As someone who wants to succeed in providing as much breastmilk as possible for me, I want to be advised by those who successfully breastfeed not those who are ignorant about it. The part that is missing is the education on the consequences. When those who are ignorant about breastfeeding suggest supplementing they may be causing problems and not knowing it. I think breastfeeding advocates should be in the habit of talking about supplementation because we are knowledgable about what the impact is on breastfeeding. When the mom gets this info, an informed decision is possible. Otherwise she hears "It won't hurt to supplement" from one side and "Do everything you can to avoid supplementing" on the other. Where is the support if you want to be able to both supplement and succeed at breastfeeding?

Finally, you ask "Why should it come from us too?" Because, otherwise, you are withdrawing your support. I have provided both breastmilk and formula to my kids and I want support too.

Ella

[wasabi]

Originally Posted by amandaleigh37

You make a lot of good points. This part though... maybe I'm misunderstanding, but are you saying you would have preferred the LLL leader to present you with the option of supplementing? I think the reason she didn't is obvious - every mother knows they have that choice. That's the choice that is everywhere you look - bottles and formula. The leader probably assumed (as I think most would?) that by asking for her help, your goal was to continue exclusively BFing. So to suggest anything else, IMO, would be inappropriate.

I thought the same. You asked her how to improve the pumping experience. She gave you all the suggestions she had. Saying "oh don't worry about pumping, just supplement and nurse when you're home" would not be telling you how to improve the pumping experience so I can't imagine why she would have ever told you that. If you wanted her to give you that answer then you should have asked if it was ok if you didn't pump or some such.

[songbh]

Originally Posted by amandaleigh37

are you saying you would have preferred the LLL leader to present you with the option of supplementing? I think the reason she didn't is obvious - every mother knows they have that choice. That's the choice that is everywhere you look - bottles and formula. The leader probably assumed (as I think most would?) that by asking for her help, your goal was to continue exclusively BFing. So to suggest anything else, IMO, would be inappropriate.

I wonder if every breastfeeding mother does in fact know that she might choose to supplement with formula but continue to breastfeed. I think what many mothers hear from both "sides" is that there is breastfeeding, and there is formula-feeding, and they get to "choose" between them, the way one chooses Coke or Pepsi.

And if the mother is strongly committed to breastfeeding, she may never have heard or considered that there would be any situation in which some formula use might be the appropriate solution.

I think it is quite common for people trained in lactation support (IBCLCs, LLL Leaders, etc.) to assume that if a mother has sought out their help, she is aiming to breastfeed exclusively. But properly done, LCs and LLLL's should NOT assume that they know what a mother's breastfeeding goals are.

It is often worth the time and effort to have a conversation aimed first at discerning what the mother's driving concern and ultimate goal is. This can be tricky if the mother herself isn't clear about this -- it may take some very high-level active listening and non-leading-questioning to get to the heart of the matter. But once you get there, just helping the mother to clarify and put into words what she really wants can be a valuable gift.

[beru]

Originally Posted by beru

The part that is missing is the education on the consequences. When those who are ignorant about breastfeeding suggest supplementing they may be causing problems and not knowing it. I think breastfeeding advocates should be in the habit of talking about supplementation because we are knowledgable about what the impact is on breastfeeding. When the mom gets this info, an informed decision is possible.

I need to add one thing. In this scenario, if I made an informed decision about supplementing that would potentially hurt my breastfeeding relationship and it did end up hurting it, I wouldn't go running around telling every woman I know that I was "unable to breastfeed".

[songbh]

Originally Posted by beru

I absolutely do think she should have mentioned that supplementing may be necessary if we can't solve the problem in other ways. I believe women have 3 choices, providing breastmilk exclusively, forumla feeding exclusively or they can attempt to combine both (which may or may not work). I didn't understand this before when my biggest supporters were breastfeeding advocates. I thought I had to breastfeed exclusively and if I didn't do everything the optimal way, I would fail to breastfeed and I would end up on formula totally. So I don't agree that mothers know about the choices that are available to them.

Where else am I supposed to go for advice? The "family, friends, pediatricians, and as we know - magazine and TV ads" that you are speaking of encourage supplementing and formula feeding without clarifying the consequences. As someone who wants to succeed in providing as much breastmilk as possible for me, I want to be advised by those who successfully breastfeed not those who are ignorant about it. The part that is missing is the education on the consequences. When those who are ignorant about breastfeeding suggest supplementing they may be causing problems and not knowing it. I think breastfeeding advocates should be in the habit of talking about supplementation because we are knowledgable about what the impact is on breastfeeding. When the mom gets this info, an informed decision is possible. Otherwise she hears "It won't hurt to supplement" from one side and "Do everything you can to avoid supplementing" on the other. Where is the support if you want to be able to both supplement and succeed at breastfeeding?

Finally, you ask "Why should it come from us too?" Because, otherwise, you are withdrawing your support. I have provided both breastmilk and formula to my kids and I want support too.

Ella

This post is a keeper. Well said.

I might quibble about your call to present mothers with "3 choices" -- all BF, some formula supplementing, and all FFing -- because if this isn't done with care to educate about risks and benefits of each option, I think it could very easily be heard as a kind of Goldilocks scenario, with partial BFing sounding like the most reasonable "just right" common-sense choice. But otherwise, as my previous post in reply to amandaleigh37 indicates, I quite agree with you.

[beru]

oops

[MaryJaneLouise]

Originally Posted by amandaleigh37

You make a lot of good points. This part though... maybe I'm misunderstanding, but are you saying you would have preferred the LLL leader to present you with the option of supplementing? I think the reason she didn't is obvious - every mother knows they have that choice. That's the choice that is everywhere you look - bottles and formula. The leader probably assumed (as I think most would?) that by asking for her help, your goal was to continue exclusively BFing. So to suggest anything else, IMO, would be inappropriate.

Not necessarily. Some really do think that bfing is all or nothing. If you don't go whole hog, it's not worth it at all. Of course, that is incorrect; by limiting the amount of formula you supplement with, you minimize its negative impact.

Originally Posted by amandaleigh37

Isn't that pretty much where we are now? Women know they have "choices", and many see breastfeeding as an unattainable gold standard they can't reach, so don't even bother. Or like you said, it becomes "too stressful". At that point, I can almost guarantee that these mothers are getting the message to supplement or go entirely to formula - from posts I've read here it seems to come from everyone - family, friends, pediatricians, and as we know - magazine and TV ads. Why should it come from us too?

I think the OP's point is that when there IS medical problems with supply (or severe social problems, like WOHMs not responding well to the pump) that BF advisors (health professionals, LLL leaders, etc.) should encourage partial bfing, as an alternative to complete weaning.

What I would REALLY like to see is a much wider acceptance (society wide : Song) of the use of donor human milk for those who must supplement. This would be much, much safer than the widespread use of cow's milk or soy milk formula.

[beru]

Originally Posted by songbh

I might quibble about your call to present mothers with "3 choices" -- all BF, some formula supplementing, and all FFing -- because if this isn't done with care to educate about risks and benefits of each option, I think it could very easily be heard as a kind of Goldilocks scenario, with partial BFing sounding like the most reasonable "just right" common-sense choice. But otherwise, as my previous post in reply to amandaleigh37 indicates, I quite agree with you.

You're right. It does have to be done with care. When I speak about combining supplementing with breastfeeding, I don't make it sound necessarily desirable. I stress the fact that it very possibly won't work. It could lead toward full weaning.

You said some great things about trying to learn about the moms motivation when you are advising her. That is so great. I think that is exactly my point. The LLL I referred to in my original post assumed I would be willing to pump 3 to 4 extra times at home in order to express enough milk. She thought I wanted it that bad. But I wish she would have presented it differently. She didn't really acknowledge how much work that is or how stressful it potentially could be. I know that we own our feelings and no one can make us feel guilty but I could have reacted by feeling guilty that I wasn't willing to work hard enough for my baby.

[Ruthla]

Originally Posted by amandaleigh37

You make a lot of good points. This part though... maybe I'm misunderstanding, but are you saying you would have preferred the LLL leader to present you with the option of supplementing? I think the reason she didn't is obvious - every mother knows they have that choice. That's the choice that is everywhere you look - bottles and formula. The leader probably assumed (as I think most would?) that by asking for her help, your goal was to continue exclusively BFing. So to suggest anything else, IMO, would be inappropriate.

But NOT everybody is aware of the option of long-term supplementing. Some women really do think that the choice is either to make breastfeeding and pumping work, or to switch entirely to formula.

[readytobedone]

Originally Posted by songbh

I wonder if every breastfeeding mother does in fact know that she might choose to supplement with formula but continue to breastfeed.

well, i can't speak for all mothers, but i can't tell you how many times in the first 2 months i was told about "combo feeding," ran into moms who were combo feeding, and the like. tons, tons, tons of BFing moms supplement.

i was actually pretty irked by being constantly reminded i could use the "occasional bottle of formula" when i didn't feel like nursing (literally, it would've been because i didn't feel like it, since i had plenty of supply and was not working outside the home). no one ever talked about the negative consequences that could come from supplementing, just told me i should do it because i seemed tired/frustrated/needed a drink/whatever.

so i don't really agree with your premise that moms feel like it's all or nothing. on the contrary i think so many feel like of course they will be giving formula at some point. i have even seen posts on mainstream message boards that are like, "when do i need to introduce formula?" or talking about how their pediatrician advised them to intro formula at like 3-4 months just to make sure the baby will take it. WTF? :