My first experience with a baby friendly hospital was far from pleasant….because no one had really showed me how to attach, just pushed and shoved my breast, my nipples became blistered and bloody…As day 3 approached it was clear my son was having a few issues.  He was becoming jaundiced, he still hadn’t passed any sort of wee.  This was when the contradictory advice began.  One told me he was a lazy sucker and that I had to watch for Nutritive sucking, where his whole jaw was moving, all the dummy sucking was not getting him any milk.  Another midwife told me that was nonsense and any sucking was getting him milk.  One told me my latch was good, another told me it was rubbish.  It seemed with every shift change I got another piece of different advice.  I was more confused than I had ever been in my life and I had absolutely no idea what I was doing.  They had me constantly hooked up to the breast pump, hoping to encourage my milk in but I never got even a drop out…he had lost nearly 30% of his body weight in 3 days, they aim for 10% at the most.  I felt angry,  I had told them my baby was starving.  Any time I had asked for formula I was told it would affect my milk supply and refused…I had to sign a form allowing him to have the bottle.  He gulped it down and went straight to sleep.  The first time really since he had been born.  The next morning when with a new midwife when I asked for another formula top up I was given a spiel on how ridiculous it was to have given it too him in the first place and I would destroy any chance of ever having any milk.  When my husband asked which formula they recommended if we decided to go that way because he could see how thoroughly overwhelmed I was he was told they don’t recommend formula.  Those two bottles allowed his weight to go up enough however to allow us home after another night so we finally got out of there.  I left exhausted, nipples absolutely shredded, confused, overwhelmed and violated….Baby friendly maybe, mother friendly most definitely not. - Courtney

“My local hospital is “baby-friendly”…  My own opinion of this implementation is that it was distinctly “mother unfriendly” - to the point I’m still traumatized by what went on now and regularly cry myself to sleep over it all. My daughter came prematurely, was sent to NICU, while I was sent to the post-natal ward… I had a leaflet on breastfeeding slung at me, and when I pointed out it was a tad insensitive- I had a premature baby in an incubator not even on the same floor in the hospital as me, and I couldn’t do anything since she wasn’t even WITH me (none of the staff had broached expressing or pumping at this point) – I got snarled at that “breastfeeding is really important you know” and the nurse flounced off…After about a week and a half, when I was truly at the point of crumbling, when we’d made no progress at all with breastfeeding and latching, one wonderful nurse put her neck on the line and broached the taboo (bottles, formula and teats were very much the elephant in the room everyone was too scared to mention) and told me that basically I would be looking at extending our time in hospital by another 2-3 weeks in order to be able to go home breastfeeding… I asked to try her with some of this expressed milk in a bottle to see what she would take… From there she really turned the corner. However because of being “baby friendly” – the bottles, teats and formula were hidden away behind the nurses’ station (very similar to the NYC proposals) – you had to do the walk of shame, akin to being on the Weakest Link, to go and collect them… it was literally a matter of a few days from that first bottle feed to her being able to take her full feed requirements and maintain/gain weight and have her feeding tube removed – the hospital would have let me plod on in ignorance that this was possible to sacrifice my mental health on the altar of their baby friendly status quite happily. The prolonged stressful nature of our hospital stay has left me with an anxiety disorder requiring medication, sleep problems and I cry myself to sleep on many many nights over the trauma we went through – this is after counselling as well. I switched to formula feeding as my supply dwindled and my breast pump motor died in the end.” -F.T.

A colleague said something to me last week that really knocked me on my ass. She asked if I had lost my passion for this blog, and for the cause in general; she told me that FFF “wasn’t what it was” a year ago. I’ve reflected on this for the past 5 days, and I started wondering if maybe I was the Internet equivalent of an aging beauty queen, hanging out at the local cougar bar and wearing pants that were more appropriate for my 14-year-old daughter. It was a scary thought. (And a little too close to home, as I still shop in the Juniors department, on occasion.)

On further reflection though, I don’t think I’m old, or tired, or lacking passion – I’m just a little jaded. I’m jaded because I realize that blogs can only go so far; that the time has come to take FFF to the next level and begin forming concrete advocacy efforts and fighting for real, practical change that can lead to flesh-and-bones support, rather than just the virtual kind.

This advocacy will begin with an endeavor I am calling the Family Friendly Hospital Initiative (FFHI). I originally planned to call it the “Mother-Friendly” initiative since the mothers are the ones physically engaged in breastfeeding, but ultimately chose the name “Family Friendly” to reflect the fact that families are made up of not only babies and mothers, but also biological fathers, adoptive parents, gay and lesbian spouses, and siblings with their own specific needs. We need to approach all types of famiIies in a holistic manner, recognizing that the health, happiness and economic stability of the entire family is vitally important to emotional and physical health of a growing infant and to our society as a whole.

I plan to approach hospitals, local media, and government officials to encourage adoption of the FFHI, a program that can work in conjunction with the BFHI Ten Steps, taking the best parts of that program and clarifying the aspects that could potentially infringe on a woman’s right to choose how to use her body. I am going to fight, tooth and nail, for hospitals to start offering bottle-feeding classes, or if this isn’t a possibility, perhaps giving access to a hotline to connect new moms with trained peer advisers who can walk them through safe formula preparation, outline the best pumping and milk storage practices, offer suggestions to common formula concerns and complaints, and hopefully provide peer support groups which can meet, much like breastfeeding support groups, but for formula-feeding, pumping, tube feeding and combo-feeding mothers.

There is no reason that supporting and promoting breastfeeding has to mean punishing the women who either choose to formula feed, or end up doing so for any number of valid reasons. The Family Friendly Hospital Initiative will promote breastfeeding as the healthiest choice, but will frame it as a truly informed choice, giving concrete, real-world statistics in contexts that any parent can understand, not just the ones with a degree in epidemiology. It will adhere to practices shown to improve breastfeeding rates, but make the ultimate goal a healthy, fed baby and a confident, emotionally healthy mother and/or father. The FFHI will reach out to postpartum mental health professionals and organizations and attempt to make maternal postpartum health a significant priority. It will encourage researchers to engage in studies which will learn from women who are not breastfeeding, rather than dismissing them; studies which will make bottle-feeding (whether it be formula, donated milk, or expressed maternal milk) safer; studies which will help us determine how our societal evolution has affected breastfeeding, and how to merge a woman’s innate desire to feed her child naturally with the reality of an incredibly unnatural world.

Take the good….

When I asked my Facebook followers to share their experiences of “baby friendly” hospitals, I was shocked – and not for the reasons you might think. I was expecting tales of shaming, mistreatment, and inferior assistance with the actual mechanics of breastfeeding. But instead, the majority of the stories posted on my Facebook wall were positive. “I went in planning to use formula. I was so nervous,” says Amy. “Every single person was supportive, did not say one single word about it, and several actually expressed relief for me! …They didn’t have much advice on stopping my milk but they tried. My pediatrician seemed thrilled too. I went in ready to defend and they were all SO fantastic.” Natalie reports that the “hospital staff were all very kind. Every time they asked if I was going to try breastfeeding, I would start with my big long explanation, and they’d stop me right away and say ‘it’s your choice, you don’t need to explain’”. A few readers had given birth in both baby-friendly establishments and hospitals that hadn’t adopted the initiative, and they gave much higher marks to the baby-friendly ones. Allowing babies to room in, experience skin-to-skin immediately after birth, and having more lactation consultants or breastfeeding-educated nurses on staff are changes most new mothers would applaud. Obviously, there are elements to the baby-friendly program that should be commended and implemented worldwide.

…But Leave the Bad

I delivered at a baby-friendly hospital. I had intended on giving breastfeeding a try but was not sure I wanted to do it long term…When I delivered, a nurse helped me initiate breastfeeding…He was not latching well, which I assumed the LC would have told me. I now found out that it is against their policy to use prosthetics (shield), which would most likely have saved our nursing relationship and helped my sleepy baby latch… They checked his bili levels and they were sky high. I told the night nurse she could feed him formula and I was fine with that. She fed him 25ml through a syringe. The next morning I was told the machine used to check the levels was malfunctioning and he was actually fine. The LC berated me for allowing my baby formula. After our release he became too tired to latch and would scream. The pediatrician told me I should supplement. I gave him a bottle, and he refused to nurse. By the next day, he had gained 4oz and changed color. I stopped after that for my own sanity and recovery. My experience wasn’t horrible at the hospital, but when I was looked down upon for allowing him formula I felt as though it wasn’t so much about me making a decision I thought was best, but them not being able to check off that ‘exclusively BF’ checkbox.” -Sara

“Because of my problems with (my first child) I was leaning towards formula but still wanted to attempt the breast or at least get the colostrom benefits.  When the lactation consultant came in, she was rude.  So rude.  I explained my troubles with my first son- where she informed me that the problems I experienced were impossible, she isn’t there to convince me to breastfeed, and I am sabotaging my efforts with son 2.  By the time she left the room, I was crying. Literally crying.  I told the nurse to get my son a bottle of formula so I would never need to see that woman again.  Turns out son 2 tongue sat back in his mouth a little too far and needed a preemie bottle nipple.  LC might have caught that and offered me a shield or something if she hadn’t been there to just berate the hell out of me. - Betsy 

Despite the numerous positive experiences voiced in this small sample, adopting procedures which focus on an end goal (having most babies exclusively breastfed upon discharge from the hospital) can lead some care providers to fall prey to human tendencies of fear, selfishness, and bias. It is evident that so much depends on the individual care providers and administrators of each hospital; the Baby Friendly Hospital Initiative (BFHI) is based on the organization’s Ten Steps to Successful Breastfeeding, which are meant to “promote, protect, and support breastfeeding”. Yet, the program is often simultaneously promoted as a way to improve maternity care in the United States, to bring hospital birthing to a more personalized, less sterile level. And while these two goals might seem to work in tandem, there’s too much left to interpretation in the Ten Steps to ensure that they really do. In fact, in some cases, it seems that the emphasis on exclusive breastfeeding for the good of the babies is subjugating the needs, autonomy, responsibility, rights and desires of the mothers.

Still, I do believe that things must change in our hospital system so that women will be supported in their efforts to breastfeed. New mothers shouldn’t be sabotaged or bullied, no matter if the substance in question is formula or breastmilk. And the early days of breastfeeding are incredibly vital – both physically and emotionally. I simply want to make sure that women are supported in both the former and the latter respects.

Engage the professionals

“My son was born in a “baby-friendly” hospital. In theory, it’s all very good and helpful, but I feel the nurses need to be given a reminder about personal boundaries and coherent advice. I was pretty upset that they wouldn’t let my husband hold him after the birth and that they manhandled my breasts (without asking first) to try to painfully extract some colostrum (which I didn’t have at all) because my son apparently needed to have some *right now*. I was exhausted and just wanted to be left alone. I wanted my husband to take the baby so I could sleep. There was a lot of manhandling and nipple-pinching during the next feeding attempts, which was very painful and disturbing…Also, my son slept for most of his 48-hours hospital stay. I went to the nurses station to ask them if I should wake him to feed him and I was told “no”, but when I was discharged, a nurse scolded me for not attempting to nurse every 3 hours. I felt confused and misdirected. I was happy to leave!”  -Roxane

I believe that most people go into the medical field – a care profession – to help others. We cannot ask nurses and physicians – professionals who carry the credo do no harm close to their hearts – to subjugate the needs of one patient for that of another. We should be asking these professionals to work with us to improve infant feeding practices, rather than demanding they behave in certain ways (ways that may be in direct conflict to their instincts as caregivers) in order to meet government goals. Therefore, I hope that medical professionals – especially maternity care specialists – will join me in urging the adoption of this initiative. Perhaps it will also be more palatable to hospitals who have shied away from becoming baby-friendly; if the goal is to end practices which sabotage breastfeeding, it shouldn’t matter whether we do it via WHO/UNICEF-endorsed methods or our own modified American version.

As I’ve been researching the BFHI, another realization I’ve had is that despite all intentions, women are still being given atrocious advice in baby-friendly hospitals- advice that would make most experienced LC’s cringe. A friend recently gave birth at a Kaiser hospital here in California, one that prides itself on being Baby Friendly. She told me the most curious tale of how, when her newborn didn’t latch right away (and I’m talking like 3 minutes into the first skin-to-skin, right after the cord had been cut), a nurse dribbled formula all over my friend’s chest, apparently to encourage the baby to latch. Considering step 6 of the BFHI is “Give newborn infants no food or drink other than breastmilk, unless medically indicated” and my friend’s baby was born perfectly healthy, I have no flipping idea why this would have been done.

I suspect that when the focus is solely on having women leave the hospital breastfeeding exclusively, rather than on encouraging long-lasting, healthy, happy breastfeeding dyads, bizarre and contradictory actions will continue to occur. By talking with healthcare professionals rather than treating them as the enemy, or assuming they are all pawns for the formula industry, we can hopefully come up with better protocols that lead to better outcomes overall.

Encourage individualized patient care

“My baby latched perfectly and all was great. Except that I hated it. No matter what the hospital does, I believe women will quit breastfeeding for all kinds of reasons. I hate calling it “succeeding” at breastfeeding because I think success is determined by a happy healthy baby and mom, which isn’t always breastfeeding.” - Erin

“I have 2 sons, now 2 and 4.  I also have PCOS and hypoplastic breasts.  I tried to breastfeed my first, didn’t work.  Didn’t even try with the second (with the blessing of the same LC who was at the same hospital and remembered me!  Took one look at me and said, “nope, don’t bother.”).  By the time I had my 2nd child, the hospital had become “breast friendly”, in their words.  So they were not giving away the formula bags and samples any longer.  Nurses told me that they actually had to THROW THEM AWAY.  Since I had been expecting these items, I was shocked to hear this.  When the director of nursing stopped by to take a little survey on my stay, I really let her have it.  “But we’re BREAST FRIENDLY” she kept repeating.  My response?  ’Well guess what honey, my breasts aren’t very friendly, and they don’t make milk’”.-Rebecca

I actually believe that most of the 10 Steps outlined on the BFHI website are perfect for encouraging breastfeeding, and seem to reflect the research that has been published on this issue. But I think that there is a fundamental flaw in the program: it does not give sufficient attention to the needs of bottle-feeding parents. Mothers have different birth experiences, different socioeconomic backgrounds, different ethnicities, different emotional makeups, different physical impediments. Mothers are different. Treating all American mothers as one homogeneous, uniformly-lactating group is a recipe for disaster. There’s a movement afoot to change the face of maternity care in this country – homebirths, or hospital births assisted by doulas or performed by midwives are becoming more popular. We seem to be having two parallel conversations – one that says “treat me like an individual, not as a medical case to be managed” when it comes to birth, and one that begs for overly-monitored, medicalized, one-size-fits-all treatment when it comes to breastfeeding.

There is no reason we can’t follow most of the BFHI steps, and still provide resources, emotionally neutral education, and equal support for those who opt to combo feed or formula feed.

Education, Not Indoctrination

“No discussion of challenges in our BFing class, just all the joys and benefits. Frankly, I think it’s much better to discuss potential problems even if they affect only 10% or so of mother-baby pairs. Knowledge is power, and you aren’t blindsided by pressure or bullying or confusion either way in the days immediately after birth if you know what to expect. I seriously don’t understand why anyone would think it wasn’t important to discuss potential problems. It would be so much better for getting people to know when to get help.” -Sumita

“In fairness breast feeding wasn’t really covered either – it was more here are the benefits this is why you should – and this is briefly how it’s done- we will show you when you have your baby. Formula wasn’t even mentioned at all. - Kate 

I took a breast feeding class at the baby friendly hospital I have birth in. They never talked about any problems that could come up. Only the benefits and good things about breast feeding. I spoke to a nurse while I was in the hospital and asked her how come I wasn’t told about flat nipples, latching issues and such and she said that they don’t discuss negative things in the breast feeding class so that women aren’t discouraged. In my case it would have been very helpful to know about issues like that because it would have avoided me getting depressed about not being able to breast feed my premature baby.” -Rosella

“We are set up for failure and every real life mom I know knows it. SO many women I talk to NOW commiserate with how hard it can be, but all the literature, all the websites give such an opposite impression. Like, why WOULDN’T you breastfeed if its beautiful, bonding and almost everyone can do it? If everything they said was true, everyone WOULD breastfeed. But its not true for everyone.“- Rachel 

“The number of mistakes I made formula feeding my first born because of the lack of info frightens the hell out of me to this day. I called a nurse hotline once to ask some questions and got a lecture about how I should try to re-induce lactation.” - Mina 

Regardless of what happens in the 48 hours after delivery, the education parents are receiving about infant feeding is downright embarrassing. Classes drill the importance of breastfeeding into our heads without giving us much practical information on how to actually nurse; this is somewhat understandable as it’s the kind of thing you can’t really learn without doing. However, a brief acknowledgment of some of the more common complications would be an easy thing to add to prenatal curricula - latching issues, flat or inverted nipples, tongue ties, commonly used drugs that may be contraindicated, health conditions such as diabetes or PCOS which could potentially complicate breastfeeding – and doing so would prevent many women from feeling like failures when breastfeeding doesn’t come easily. Considering the emphasis on avoiding nipple confusion and establishing milk supply in the first few weeks which permeates the canon of breastfeeding advocacy literature, it seems logical that we should do whatever we can to ensure that women are not blindsided by these issues – forewarned, they could come up with a solid plan with a lactation professional which could prevent actions made in moments of confusion and panic.

Additionally, the lack of education about formula feeding is a travesty. I have written about this many times before, but I will reiterate: if only 36% of American mothers are breastfeeding exclusively at 3 months, that means a majority of babies are being fed formula. It is IMPERATIVE that they are properly supported in doing so. Ignoring the fact that formula is a reality in the lives of many parents doesn’t just punish the parents- it affects the babies. True, formula feeding isn’t brain surgery – but it could be argued that breastfeeding is an instinctual act for humans. Formula feeding? There’s nothing instinctual about it. There is a huge margin for error. I personally suspect that many of the subtle health disparities we see in the aggregate between formula fed and breastfed babies are due to avoidable and common mistakes in formula preparation and selection. Most parents have no idea what the difference is between a “sensitive”, “hypoallergenic”, or “lactose-free” formula. They don’t know that the angle of the bottle, the flow of the nipple, and the type of formula (powdered, liquid, concentrated) could affect their baby’s digestive system. They don’t know what water to use, how often they really have to sterilize bottles, or what formula to choose. They must rely on friends and the internet for advice about something that should be – unlike breastfeeding – a regimented and meticulous process (sadly, it seems our society has this flipped. Breastfeeding is treated like brain surgery, and formula feeding is seen as something we should inherently know how to do…). Medical professionals may be used to the “formula feeding model” for things like weight gain and feeding schedules, but even this is more true of the “old guard” (those who have been practicing for a long while, before breastfeeding’s resurgence) and these same folks might not be aware that there’s been research and new thought on the bottle-feeding front since they got out of med school in 1963.

I propose that breastfeeding education be altered to reflect some of the realities of breastfeeding – common challenges, medications, diet, and pumping – the same things discussed on KellyMom, Mothering.com, and The Bump. I also want to see hospitals offering bottle-feeding classes and resources once a mother has voiced a desire to either supplement or completely formula feed.

The “Parent-Friendly” Manifesto

I am not sure what form this “initiative” will take just yet, but I am hoping that FFFs across the country will join me in advocating for positive change. It is healthy and necessary to mourn the loss of breastfeeding, or rage against the current atmosphere of shaming and belittling formula feeding moms – but we can turn that anger and grief into positive change. I know we can. Let’s work on this, together, so that no new moms have to go through what we have gone through. Let’s make it so  FFF Fridays become obsolete, because there will be so few people who feel bullied, abused, or let down by their experiences. Let’s make my friend’s comment a reality – make it so that I have lost my passion, because there will be nothing left to get fired up about.

Who’s with me?