Formula v breastfeeding: Should the state step in?
New York City has put forth an initiative to end free formula milk samples and make it more difficult to access formula in hospital. Will the measures promote breastfeeding or add to a culture of shame for those who use formula?
When New York City Mayor Michael Bloomberg announced the specifics of a new initiative called Latch On NYC, it seemed at first glance like another aggressive move by the health-focused mayor.
Bloomberg, who already made international headlines for banning the sale of giant-sized soft drinks in the city, said that as of September, the 11 city hospitals and 16 participating private hospitals would restrict access to formula milk. For mothers who choose to breastfeed, this means treating formula similarly to medication, requiring that it be doled out only for specific reasons, and signed out and noted on the baby's chart when administered. Mothers who chose to formula feed can still do so.
Participating hospitals would also eliminate discharge bags, full of formula samples and paid for by the formula companies. Recently, Massachusetts and Rhode Island banned this practice as well.
The Latch On program is designed to promote breastfeeding. But some mothers worry that it contributes to a culture that pressures and shames women who want or need to use formula. It's part of an ongoing battle over who really has women's best interests at heart.
Deborah Kaplan, assistant commissioner of New York City's bureau of maternal, infant and reproductive health, says that setting up good nursing habits in the hospital is crucial when breastfeeding, since the first few days after birth help set the pace of milk production.
"In the body it's a supply and demand system. Nursing and pumping stimulates to make more milk," she says, noting that 73% of women in New York City hospitals reported that their babies were fed with formula during their stay. "If the baby gets some their tummy is full, they don't nurse, mother's body doesn't make enough milk and it starts a vicious cycle."
Compared to formula-fed babies, babies who breastfeed:
- Score 5.2 points higher on IQ tests (American Journal of Clinical Nutrition)
- Are 40% less likely to develop diabetes before 40 in some communities (The Lancet)
- Have more immune-boosting flora in their digestive systems (Genome Biology)
- Are half as likely to suffer from asthma symptoms (European Respiratory Journal)
Limiting access, she says, will help prevent this from happening.
Diane Spatz, a professor perinatal nursing at the University of Pennsylvania school of nursing, says the free formula bags also send the wrong message.
"If you're giving them the company bag, you're endorsing that you think those companies are a good thing," she says. "At three in the morning when mom is alone and exhausted and doesn't have anyone around to help her, she will open it up and say 'well, the hospital gave it to me'."
But Jessica Valenti, author of the upcoming book Why Have Kids, worries that these initiatives will only further stigmatise mothers who can't - or don't wish - to nurse.
"I don't care about the gift bags," she says. "But if you're talking about keeping formula under lock and key, treating it as a medicine, making women explain why they want formula and giving them a lecture is so condescending.
"It comes from an assumption that women who don't want to breastfeed don't know better."
For their part, the formula companies say that women deserve to be presented with all their options. In a statement provided to the BBC, Mardi Mountford, executive vice president of the International Formula Council, said:
"Restricting access to samples and information from formula manufacturers is not the answer to increasing breastfeeding rates. A way to help mothers is to be supportive of the feeding choice they make for their infants regardless if they choose breastfeeding, formula feeding or a combination of both."
Breast is best, but by how much?
Some women have questioned how much more beneficial breastfeeding is than formula feeding. In her 2009 Atlantic article "The Case Against Breastfeeding" Hanna Rosin found that "the medical literature looks nothing like the popular literature. It shows that breast-feeding is probably, maybe, a little better ... A couple of studies will show fewer allergies, and then the next one will turn up no difference. Same with mother-infant bonding, IQ, leukaemia, cholesterol, diabetes. Even where consensus is mounting, the meta studies—reviews of existing studies—consistently complain about biases, missing evidence, and other major flaws in study design."
In researching her upcoming book, Madeleine Morris found that it's difficult to prove causation in breastfeeding studies. "What you can't account for is that a woman has chose to breastfeed for a reason, and that reason is she's more concerned about health outcomes," she says. "She might have better health practices elsewhere in her life. She might wash her hands more, she may talk to her baby more." Those factors are difficult to control for in scientific studies, and may contribute to the beneficial findings.
Though breastfeeding activists are quick to assert that no woman should be made to feel ashamed of their choices, mothers who have turned to formula feeding report feeling judged and criticised.
Valenti always planned to breastfeed, but her daughter was born prematurely and she wasn't able to produce enough milk. After struggling to make breast feeding work, she switched to formula feeding - and instantly felt more bonded to her baby. However, she said stigma endured. "I had people tell me I should have never had children," she said. Other women stopped her in public to lecture about the virtues of breast milk.
The persistent messages that breast milk is better has lead to a counter-narrative: that formula is poison. And when breastfeeding is unilaterally presented as far preferable to formula, it's easy to feel like a failure for not providing what's best for your baby.
"There's a dichotomy of 'good mothers breast feed, bad mothers formula feed'," says journalist Madeleine Morris, who is writing a book about the topic.
In fact, she says, in the UK many mothers utilise formula. Her research shows that only about a third of women in the UK breastfeed exclusively, while half use formula at least some of the time. In the US, she says, the numbers are slightly higher - but still point to a culture of women who turn to formula while at the same time believing it's substandard parenting.
"Because breast feeding is pushed so hard, even though most women formula feed, there is a taboo, a social stigma attached with it, and women self-judge and judge other women."
In the end, she says, a well-fed baby is more important than where that food comes from. "If you feed formula to your child, and a healthy loving home, and your baby was full term and healthy weight, then there are going to be minimal differences in the outcome of child," she says.
But Anne Merewood, director of the breastfeeding centre at Boston Medical Center, says that women deserve to be given every opportunity to breastfeed if they want to, and hospitals should be proactive in helping women get started.
"There are infinite things that need to be done, but many of us in the field would be happy if the hospitals would educate staff well and educate women well. So many hospitals don't even do that.
"It's a patient's right to have a supportive environment."
This article has been updated to clarify details of the Latch On program.