No-BS breastfeeding resources (an ongoing project)

Suppose you're a normal mother-to-be who is planning to breastfeed... or, maybe thinking about it but not committed either way. You're looking forward to doing the sort of things the ordinary, everyday mothers around you do--you're planning a hospital birth with lots of nice drugs, you want to get your baby onto some vague sort of routine so you can plan the day, you'd certainly like baby to start "sleeping through" sooner rather than later, and you'll want to be able to leave your baby with your husband/mother-in-law/babysitter regularly so you can go out. You might go back to work while your child is still young.

Or maybe you're a second-time mother. You tried to breastfeed the first time round--oh, so very, very hard. And it didn't work out. Trouble is, by then you'd already spent months reading all the books and blogs--the ones that told you in no uncertain terms that your formula-fed child was going to be stupid, asthmatic and fat, that you wouldn't "bond" properly, and that anyway this was all your fault because you didn't have an all-natural birth bouncing up and down on a yoga ball, and because you caved and let the nurses take baby to the nursery for a couple of hours because you were too exhausted to see straight. A spiral into gloom, anxiety and hystronic post-partum depression was more or less guaranteed. Now you're girding your loins to try breastfeeding again. But the thought of reading those books again... the ones that were whispering in your ears at 3AM every morning while the tears rolled down your face...

I think you can see why most breastfeeding resources--the books, the blogs, the forums--are problematic for either one of these women. Such resources are heavily oriented towards natural birth, "natural" parenting, and natural just-about-everything-else, and waste no time in telling you about the horrors that await you and your child should you weaken and allow even a single bottle of that ghastly white stuff. And they are full of sloppy science, urban legends and pet theories.

Other books (usually not "breastfeeding books" but rather general how-to-look-after-your baby books) talk about routines and sleeping-through-the-night (almost fanatically, sometimes) yet fail to get the basics right regarding breastfeeding. For example, Gina Ford tells exhausted new mothers to start pumping pretty much from Day 1 in order to stretch out the gaps between feeds. Claire Byam-Cook and Tracy Hogg (the Baby Whisperer) tell women to measure how much milk they are producing by doing a "yield," i.e., pumping and measuring their output, apparently unaware that there are many women--including Yours Truly--who have a good supply but are mediocre at pumping. If I had followed these writers' advice, I would have been convinced that I was starving Little Seal with every feed.

For these reasons, I've decided to start compiling a comprehensive list of breastfeeding resources which I reckon are credible, science-based and reasonably representative of how most of us actually mother. I'll keep updating this as I come across more sources, but this is a start. There's some practical stuff here; there are also discussions of breastfeeding research and politics to muse on, or to wheel in as counter-evidence when someone online is talking bollocks.


Books

Actual breastfeeding books

As I moaned here, it is very hard to find breastfeeding books that don't seem to be written by someone with the shining light of the fanatic in her eyes. Marianne Neifert (in Dr. Mom's Guide to Breastfeeding and Great Expectations: Essential Guide to Breastfeeding advocates for breastfeeding but manages to do so without the harshly judgmental tone of other lactivists. She is almost alone in the breastfeeding book annals in her outspokenness about the difficulties and barriers many breastfeeders experience, and in stating frankly that low supply really exists and is not a myth. Most importantly, her books get all the nuts and bolts right; they are full of great, practical information about how the breasts work, the mechanics of breastfeeding, latching, troubleshooting, pumping and much, much more--everything you'll get in the Womanly Art of Breastfeeding, in short, but without the scaremongering and condescension. By the way, it was Estherar at Mainstream Parenting who first put me onto this book.; check out her review here. 

Solids ("weaning")

Weaning Made Easy is a fun yet evidence-based approach to weaning (=solids introduction, not breastfeeding cessation) which avoids the tedium of the gourmet-icecube tray approach (making overelaborate purees and then spending mealtimes trying to get it all inside the baby) and the pitfalls of the Gill Rapley baby-led weaning method (potential iron/zinc shortages, babies going for months on end without eating anything, neverending mess). It encourages parents to offer different foods in a variety of ways, including soft finger foods and purees of nutritious-yet-hard-to-eat things, based on sound nutritional principles--always with a stress on the individuality of each child and the need for you to feel comfortable with what you are doing. Which, I suspect, is how most people would wean anyway if we didn't have babycare writers telling us how to do it...

Sleep

I have half a dozen infant sleep books on my shelf (ordered by my husband in a fit of Amazon-inspired shopping mania). There they sit, their spines almost uncracked. When it comes to sleep there's only one book I use--Good Night, Sleep Tight by Kim West--and it's never failed me yet. This book (by a sleep specialist who's helped countless families) is moderate, eminently sensible, and flexible enough to work with a whole range of parenting "styles"--while she emphasizes sensible routines and self-soothing, she is also extremely sensitive to the needs and feelings of babies and young kids... and she has a gentler alternative to cry-it-out for those who can't quite face Ferberizing. She also breastfed both her daughters, and that's important because breastfeeding and formula feeding have subtly different dynamics that affect sleeping patterns. A lot of "sleep books".... well, they may give lip service to "bottles/breastfeeds" in their routines, but you can tell it's really formula feeders they have in mind. When a sleep book is written from the point of view of a breastfeeder, it makes the breastfeeding mother feel "This is advice that's realistic for my baby. I feel we have a chance of succeeding with this." With sleep advice it's vital to feel confident that it's achievable and practical for your situation, or you'll never be able to put it into practice. West is not super "into" bedsharing, but discusses it in a sensitive and nuanced manner--the various reasons people bedshare, how to do it safely, how to combine it with learning good sleep habits, and how to transition away from it when the time comes--unlike some other writers who just scold and shame parents who take their babies into bed with them. She is even not-rude about mothers who nurse longer than 12 months (not common in parenting books).

Colic/fussiness
The Happiest Baby on the Block is a mildly attachment parent-y book with some good and practical advice for getting through the colicky weeks months. Generally I'm all for keeping babies on a loose routine, but when colic is wreaking its merry hell, sometimes you just have to grit your teeth and do what's necessary to get through the day. I recommend going straight to the second half of the book and ignoring the first section, which goes on a bit too much about how primitive tribespeople's babies don't have colic because they are carried round all day long (or something).

Other possibilities (recommended by others--I haven't read them)
Milk Memos (nursing and working) sounds like a good and non-judgey read, looking at the Amazon reviews. Child of Mine: Feeding with Love and Good Sense (feeding in general) was recommended by a blog reader. Baby Love (baby's first year) by Robin Barker got a good write-up from several people: "No nonsense; and she calls a poo a poo."


Blogs and websites

Kellymom
Ah yes, Kellymom. I've moaned about Kellymom a few times on this blog (and will be writing a longer post on them in the future). And yet I've sent struggling new mothers off to Kellymom for information several times, and there is presumably a reason for that. Kellymom can be really useful as long as you confine yourself to the “How many wet/dirty diapers should my newborn be producing?” kind of stuff, and bear in mind that this is an attachment parenting promotion site more than anything else. I've compiled a list of pages that I think give decent advice, but with everything that comes from Kellymom keep your skepticism close at hand. If it smells like bullshit, it may well be.  Confirm with other sources if you are not sure!

Low supply
Milk supply worries
Breastfeeding and medications
Weight gain (but see the FFF also here and here for your pinch of skepticism)
Pumping  
Milk supply and the older baby
Newborn basics
 
Much of the other stuff on the site is dodgy, especially the stuff on weaning age, solids/iron and the exaggerated benefits claimed for nursing, especially extended nursing. The forums have some pretty crazy ladies.
PS: Stay away from the sleep advice on that site if you value your sanity.

Science of Mom

A blogger I have a girl-crush on. The post on why breastmilk is so low in iron shreds some myths and misunderstandings about iron and breastmilk. It's refreshing to see a mother who can describe the joys of nursing past a year while questioning some of the dodgy data being used to push this choice onto all mothers. Meanwhile, can breastmilk clear up an eye infection? Possibly yes (admittedly, most of the breastfeeding sites have similar information, but it's nice to see Science of Mom actually confirming this with some data). Other posts cover breastmilk and prematurity, maternal diet and colic, improving milk production in the NICU and more.

Seattle Mama Doc combines evidence-based advice (sleep, breastfeeding, nutrition and more) with a kind and non-judgmental tone that makes for reassuring reading. She's worth a read!

Good Enough Mum

A terrific set of posts from a terrific blogger. She writes about nightweaning for a breastfeeding mother, and breastfeeding the second time around, gives her view on the "Watch your language" thing, and on why brutally unpleasant lactivism is everyone's business, while giving her vision for what positive breastfeeding promotion could look like. She also shreds some of bad science surrounding extended nursing--it's not as beneficial as you think (which doesn't mean you shouldn't do it if you want to)--and takes issue with the idea that a single bottle of formula will ruin your child's "gut" forever.

Fearless Formula Feeder
The majority of breastfeeders will use formula at some point, yet most breastfeeding resources say little about formula other than "Don't" followed by a list of terrifying reasons why--or descriptions of "correct formula preparation" which one suspects have been presented with the deliberate intention of making formula use look as intimidating as possible. That's why the Fearless Formula Feeder site (and upcoming book) can be the breastfeeding mother's friend. Learn the real deal about combo feeding and supplementing, jaundice, the mechanics of formula feeding, spotting formula allergy/intolerance, why you can't use goat's/cow's milk as a formula replacement, growth charts for formula-fed and breastfed babies and much, much more. Suzanne's site is extremely respectful of all safe feeding choices for babies... and what's more, it manages to be scientifically rigorous, well-written and nice--three things that are very hard to combine in online writing.    

Mainstream Parenting, while now defunct, is still a great source of skeptical commentary and mythbusting, some of which covers breastfeeding.


Miscellaneous

Skeptically Speaking's 15-minute podcast on breastfeeding is well worth a listen for an interesting scientific slant on lactation.

Trolls With Wooden Spoons

Trolls (you have to join; oh, and despite the name, the group has nothing to do with the internet phenomenon of "trolling") was created by a bunch of Mothering.com escapees who had become disillusioned with the craziness and horrible moderation on that site. So it's crunchier than I am, yet is also one of the few places where you will seldom get extremist natural-parenting stuff pushed at you; people started this site to get away from all that. And it's full of experienced breastfeeding mothers. There is a refreshing absence of pretension and bullshit on the site. The Woo-Busters page is a good place to get a second opinion on anything which sounds like woo but you are not quite sure!

NB: Avoid Trolls threads on carseat safety or Thanksgiving.

Mammals Suck... Milk! looks at the science of lactation across the animal kingdom, including human beings. Not a "how to breastfeed" blog, certainly, but fascination stuff and great background information.

Bullshitometer: Food before one is just for fun

Poster A: I’ve been doing baby led weaning for the past few months, but I’m starting to get discouraged. DD is 10mo and eats basically nothing. She plays with pieces of food, gums them and drops them on the floor. Occasionally a bit of food will actually make it into her. She has plenty of breastmilk and seems okay, but my health visitor is starting to get on my case about it, saying she’s going to become anemic because my milk isn’t enough! I don’t know who to believe any more. 

Poster B: Just keep repeating to yourself: Food before one is just for fun. Your LO is doing fine—playing with food is all they actually NEED to be doing at this stage. 

Poster C: Your HV doesn’t know what she’s talking about. Breastmilk is a good source of iron, because it’s so bioavailable (see Kellymom). Anyway, it doesn't make any evolutionary sense that babies would need anything other than BM before they are able to feed themselves--what did tribal babies do before pureed babyfood and iron supplements? Keep on doing what you are doing, mama! 

Poster D: Babies eat when they are ready. If she isn’t willing and able to self-feed, that means her gut isn’t mature enough. Trust your instincts and remember that food is just for fun until they’re one. 

"Food before one is just for fun" has become a common phrase heard on the ‘net in recent years, probably due to the popularity of lactivism and baby led weaning (BLW). Lactivism tends to assert that breastmilk is the perfect food—the more breastfeeding the better, pretty much. BLW (in its true form, I mean, not as a newfangled term for finger foods alongside mashed food) is a philosophy asserting that babies should self-feed all foods right from the start, and that the development of the motor skills needed for self-feeding—sitting unassisted, picking things up, chewing and so forth—are actually signs that your child needs food for the first time. In parts of the parenting universe where BLW and “natural” childrearing methods are popular, therefore, it’s not uncommon to hear of babies who are seven, nine, 12, 15 months or even older and still virtually exclusively breastfed, while their relationships with solids amount to little more than playing with food before chucking it on the floor.

When mothers express anxiety at this state of affairs, the responses given tend to be more or less as given in the above exchange, and “Food before one is just for fun” is much heard. But how true is this? Breastmilk is a wonderful food, but do babies really have no need at all for solids in their first year?

A metallic problem
As I discussed in a previous post, in terms of calories, most mothers—assuming their supply is decent and they are prepared to do some night feeds—are probably capable of meeting the calorific needs of a baby through breastmilk alone until at least the age of 12 months. Breastmilk is a highly nutritious, digestible and well-absorbed food that really does contain most of the things a body needs—there is certainly nothing to be gained from crowding it out of the diet too quickly. And yet there are a couple of exceptions which keep coming up again and again in the literature; basically, iron and zinc. Because breastmilk isn't a very good source of either of these. And both iron and zinc are very important for a child’s developing brain.

What the World Health Organization says
The WHO's views on the role of solids for 6-12mo babies are set out comprehensively in its Guiding Principles for Complementary Feeding of the Breastfeed Child (2004, most recent edition). I don't know where the "food before one..." meme came from, but it's not from the WHO. After reiterating its support for delaying solid foods for six months, the WHO goes on to stress (repeatedly and explicitly) the importance of complementary solids from the middle of the first year onwards:

"Breast milk can make a substantial contribution to the total nutrient intake of chil- dren between 6 and 24 months of age, particularly for protein and many of the vitamins. However, breast milk is relatively low in several minerals such as iron and zinc, even after accounting for bioavailability. At 9-11 months of age, for example, the proportion of the Recommended Nutrient Intake that needs to be supplied by complementary foods is 97% for iron, 86% for zinc, 81% for phosphorus, 76% for magnesium, 73% for sodium and 72% for calcium (Dewey, 2001)." 

"...the Expert Consultation concluded that the potential health benefits of waiting until six months to introduce other foods outweigh any potential risks. After six months of age, however, it becomes increasingly difficult for breastfed infants to meet their nutrient needs from human milk alone (WHO/UNICEF, 1998)." 

"Average iron intakes of breastfed infants in industrialized countries would fall well short of the recommended intake if iron-fortified products were not available (WHO/UNICEF, 1998)" 

Iron- and zinc-fortified foods are encouraged on the grounds that without fortified foods or meat, it is difficult to meet babies' micronutrient needs. (Yikes, "solids are important" AND the dreaded rice cereal... no wonder none of the crunchy sites post links to the Complementary Feeding guidelines.) Incidentally, I quoted the WHO not because I think they are the top authority on everything (their recommendations do often tilt towards the developing world), but because the WHO is really, really, really pro-breastfeeding. If even they are stating explicitly that breastmilk is generally not enough to meet babies' micronutrient needs for much beyond six months, I think we should probably sit up and listen.

That Kellymom page
The evidence most often cited in support of the "babies-under-12-months-don’t-need-solids-or-additional-iron" idea is the Kellymom page on iron. The message that is often taken home from this page is that (a) Breastmilk is an awesome source of iron because it is so bioavailable to the infant; and (b) In any case, babies are born with enough iron to last them for their first year of life.

Now, breastmilk iron is unusually bioavailable (which means, roughly, that a high proportion of its iron is actually usable by the baby); but the amount of iron found in breastmilk in the first place is so low that even with a high absorption rate, the absolute amount available to the infant is still not very high--as Science of Mom discusses here in her excellent post, even with breastmilk's unusually bioavailability a baby aged 6-12 months would need to drink 4-13 liters of breastmilk a day to get enough iron. Most babies don't drink much more than a liter a day.

As for babies’ iron stores… the Kellymom page doesn’t actually say that babies are born with a year’s worth of iron inside them. It actually says that babies are born with enough iron for “at least the first six months” provided that they are (1) born at term; (2) at least 3000g/6.5lb at birth; and (c) born to mothers without gestational diabetes. It goes on to say that babies will certainly need to have additional iron from somewhere-or-other “toward the end of the first year”; so even Kellymom is not actually saying that babies need no food whatsoever for the first year.  Also, check the dates on the sources given towards the end of the page. There is a 1999 American Association of Pediatrics report, but not the Association's well-publicized 2010 Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age), which emphasizes iron for breastfed infants much more strongly (Seattle Mama Doc has an excellent summary of the report--see Further Reading below). Basically, the conclusions of the AAP committee regarding breastfed infants are that breastfeeding exclusively past four months—not six—creates an increased risk of iron deficiency, and that therefore babies older than this should ideally be either supplemented with iron or given iron-rich complementary foods. It also states explicitly that “Exclusive breastfeeding for more than 6 months has been associated with increased risk of IDA [iron deficiency anemia] at 9 months of age.”

By the way, I think the Kellymom people could do with updating their entire list of sources—it has at least one broken link and a lot of old/tiny studies which in many cases appear to be cherry-picked or misunderstood. For example, the Kellymom page states rather vaguely that babies “have been shown” to maintain normal iron stores and hemoglobin levels up to nine months… but the only evidence it gives in support of this turns out to be a single very small (30 infants) study that took place in Honduras back in 1995. (I am, of course, being flippant: of course Kellymom is not going to update their source page, because the people at Kellymom have already decided that iron supplementation and encouraging baby to eat enough solids are generally Bad Things, so they are not going to link to any paper which seems to contradict these ideas—even though the AAP's conclusions are up-to-date and based on a review of 77 studies.)

It’s difficult to find actual studies of babies in whom solids have been delayed for long periods of time simply because we are talking about a non-conventional parenting style. However, the fact that a significant minority of exclusively breastfed babies are already iron deficient at the six-month mark makes it hard to believe that there are not potential issues with waiting much longer for solids/supplementation (Even the World Health Organization admits that exclusive breastfeeding to six months can lead to iron deficiency in susceptible infants, but asserts that nevertheless, this disadvantage is outweighed by the fact that exclusive nursing for six months in developing countries is associated with lower rates of diarrheal disease and later return of fertility in mothers—both facts which are a lot less relevant for those of us in the developed world).

What does “natural” mean, anyway?
Now I'll be honest; whenever I hear someone talk about "readiness" for anything in a child-development context, I tend to reach for my skepticism; has anyone ever actually proven that the ability to sit up unassisted or reach out and grab things has any particular relationship with babies' ability to digest food or their nutritional requirements for it? And if we accept the "babies need additional iron and zinc" thing already discussed, the idea that babies only start to need solids once they reach certain development stages becomes a bit problematic. Like... okay, are we all supposed to believe that children who are slower than average to sit up are the ones who are handily born with larger-than-average iron stores in their bodies, while the ones born with less iron conveniently start sitting up earlier, or something? It doesn't really make a lot of sense to me, and as it happens the only evidence that I’m aware of on this topic seems to suggest the exact opposite—we know that in fact, iron stores tend to be lower in babies who were born small and/or premature, and these babies are also slower to reach milestones, on average.

Why would human babies and human mothers have evolved in such a way that significant numbers of babies need either iron supplementation or foods from six months at the latest (when many babies are incapable of self-feeding significant amounts of food) to avoid iron deficiency? The Science of Mom article discusses this very point.

It’s possible that breastmilk’s iron levels are low because of a good old evolutionary trade-off. Lower iron levels in the baby's GI tract reduce the risk of infections. Those cave-babies living eons ago were at high risk of gastro infections which were frequently lethal--better to risk developing a slight iron deficiency than to wind up dead from diarrhea. For those of us living in cleaner environments today, breastmilk's iron level may not be optimal and perhaps supplementation may have its merits. Furthermore, the environments where human beings evolved were also places where where (a) babies may have acquired extra iron from eating dirt off the cave floor, and (b) cord clamping was probably delayed.

Another possibility raised by a commenter on the above post is that both mothers’ and babies’ bodies evolved based on the “assumption” that babies would in fact be supplemented with easy-to-eat iron-rich food sources by the middle of the first year if not earlier. Pre-chewing of foods—especially meat—and feeding them to infants from about the middle of the first year is the norm among hunter-gatherer societies, as suggested by this intriguing paper here which floats the possibility that pre-mastication may have developed in humans as a way of providing babies with iron and other micronutrients. As I suggested in my previous post on BLW, this reality is another reason why I would question the “naturalness” of a strictly baby-led, self-feeding-only approach to solids; I think a more “natural” approach to solids might, rather, involve feeding different foods in a variety of ways, including—when necessary—mashing certain foods and helping the baby get them into his/her mouth. After all, if it’s good enough for orangutans….?

Oh the iron-y
Iron deficiency is popularly associated with pallor and general languidity; the truth is a bit more worrying than that. You can’t generally see moderate iron deficiency and it doesn’t necessarily result in your child showing any obvious signs of anemia. But that doesn’t stop it having negative and permanent effects on your child’s growing brain. Iron deficiency really does matter.

There has for a long time been a well-established body of robust evidence (see here, here and here) showing that iron deficiency in infants is associated with delayed milestones, in terms of both motor skills (walking, sitting and so on) and speech/social development. Worryingly, problems appear to persist even after the iron deficiency is caught early and corrected, suggesting that there are “window periods” when sufficient iron is needed for the normal development of particular cognitive functions: when infants who have previously been diagnosed as iron deficient are followed-up years later, they show higher rates of learning-related problems such as inattention, clumsiness and shyness, are more likely to repeat a grade and score lower on IQ tests, even after controlling for other factors such as maternal IQ and lead levels. These correlations are both robust across numerous studies and statistically significant.

Can you imagine the reaction we would see in the parenting blogosphere if a study were to come out which found comparable neurological/behavioral differences between—say—children who had been formula fed and those who had been breastfed? I just don't understand why so many breastfeeding advocates are so cavalier about iron and zinc. These things are important. Of course, an older baby eating very little is a lot less concerning if supplementary iron is given; however, a lot of the crunchy mothers tend to resist the idea of giving supplements, perhaps because they have bought so strongly into the idea that breastmilk is always a complete diet right into toddlerhood etc.; giving a supplement would be tantamount to admitting that that may not always be the case.

Bullshitometer verdict
I think the phrase “Food before one is just for fun” needs to go die a merciful death, to be honest. In all likelihood, the phrase itself was invented by some well-meaning person who wanted to encourage a more relaxed approach to solids among anxious mothers who were engaging in weird little mompetitions with other mothers about who could cram the most “jars” inside their child--and in the process, harmfully crowding breastmilk/formula out of the baby's diet.

But it’s looking increasingly as though this phrase has begun to be interpreted as meaning that solid foods play no nutritional role at all before one year of age—and that therefore, it’s completely fine and not an issue if months and months go by while your older baby eats basically no foods at all and does not receive any micronutrient supplementation either. And the evidence suggests strongly that this is just not true.

Obviously, you can hardly force-feed a child who doesn't want solids, but there is such a thing as being flexible--trying different things (purees, finger foods, spoon feeding, whatever) and seeing what the baby takes to, rather than insisting that a baby who won't self-feed is "not ready" for solid foods and therefore should not have them. And if a baby or toddler is refusing solids in any shape or form, an iron and zinc supplement is a wise idea. Rice-cereal-phobes can take heart, by the way—it’s looking increasingly as though iron is actually absorbed better from natural sources such as ground meat (which also provides much-needed zinc to babies).

Finally, it’s good to see that delayed cord clamping seems to be becoming mainstream, as routine DCC could prevent a fair bit of iron deficiency. When all's said and done, though, DCC appears to improve infants' iron store levels up to six months of age; even if this became standard practice from tomorrow onwards, babies wouldn't be getting a years' worth of iron pumped into them.

I do understand that there is a lot of resistance to the idea that most breastfed babies probably need some solids (or supplements) by six months or so, because so many people are powerfully attached to the idea of breastmilk as being the perfect food. But perhaps, as Science of Mom suggests, “This should not be taken as a deficiency of breast milk but rather as an indicator that it is important and natural for babies to start consuming solid foods around 6 months.” Breastfeeding is best; but we should also be focusing on the nutritional quality of the complementary foods that we offer babies, and in doing what we can to help them eat enough of them.


Further reading
Guiding Principles for Complementary Feeding of the Breastfeed Child: Good background reading, but like all WHO stuff should probably be taken as a very rough guide--trying to make sure your child gets XXX number of solid-food calories a day sounds like a guide for how to give yourself a nervous breakdown
 Guiding Principles for Feeding Non-Breastfed Children 6-24 Months: For you bottle feeders; I haven't had a chance to look through it, though!
Why is breastmilk so low in iron: A great post from a real nutritionist (and extended breastfeeding mother!)
Baby Led Weaning (or starting solids) book review and nutritionist weighs in (with her 7 month old daughter!) Another blog post by someone who knows about nutrition
Iron for babies & toddlers: I love Seattle Mama Doc; she is always so reassuring and kind.

If this is cost-cutting, just be honest, please

Now here’s an odd bit of news. Britain’s Royal College of Gynecologists (RCOG)—in one of those partnerships that make you go “Huh?”—has teamed up with the National Childbirth Trust (NCT) and the Royal College of Midwives (RCM) to issue "Making sense of commissioning Maternity Services in England – some issues for Clinical Commissioning Groups to consider," a set of guidelines on maternity services to British general practitioners.

British GPs (who are rather like family doctors) are often the first point of contact for pregnant British women and have considerable impact on their choices, so this is important stuff. The guidelines give GPs pointers on how to assist pregnant women, on which sort of birth units they should advise patients to go to, and what sort of questions they should ask of their local hospitals/birth units to make sure they are fit to be recommended.

Much of the guidelines covers matters such as ensuring pregnant women receive medical care early on, looking out for socially vulnerable women etc.—all great stuff and very welcome. But then things get surprising. Credit goes to Pauline Hull of Cesarean Debate who spotted the oddities in the guidelines and posted her own very thorough riposte which can be read in full here. Although the guidelines spend a lot of time talking about “choices,” they do nevertheless seem to be awfully keen that women make the choices that the NCT and RCM consider correct. They encourage GPs to push women towards midwife-led birth units, saying (for example) “There is now a good argument to be made for multiparous women being advised to choose a non-obstetric birth unit” (my emphasis). Most curiously of all, the guidelines also advise GPs that “a 20% rate [of cesarean section] is achievable and sustainable. Every provider unit should have a clear action plan for increasing its normal birth rate…”

I don't want to just repeat everything Hull has already said, so I'd like to focus on the bit about "increasing [the] normal birth rate." On the face of it, that doesn’t sound too scary—after all, nobody would want a woman to have an abnormal birth, surely… who could possibly object to increasing normal birth rates? Well, quite a lot of people, actually. The guidelines define “normal birth” as “without induction, without the use of instruments, not be caesarean section and without general spinal or epidural anesthetic before or during delivery.” The guidelines also advocate raising the vaginal delivery rate, which includes forceps and vacuum. Put this another way—“Every provider unit should have a clear action plan for decreasing its epidural rate, and—if necessary—resorting to more forceps and vacuum deliveries in order to get the cesarean rate down” —and suddenly it all sounds a bit less cozy.

The problem with targets (or, what if you like being abnormal?)
The problem with these kinds of targets is that in practice, they always end up reducing choice and harrying at least some women into birth experiences that they don’t want, simply because of the way target-driven healthcare tends to work—as pointed out by numerous posters on the popular online discussion forum, Mumsnet, where there has been for the most part a pretty angry reaction to these guidelines. In hospitals where VBAC/“normal” birth rates are below target and cesarean sections make up more than 20% of births (i.e. more-or-less all hospitals) medical practitioners are sure to start feeling the hot breath of their organizational managers down the backs of their collars, urging them to “see if they can’t get those rates down a bit,” which in turn will inevitably lead to women who prefer cesarean section being pressured, nagged or tricked into birth styles they don’t want—unwanted VBACs and forceps/vacuum deliveries especially. I’m a strong supporter of the continued availability of VBACs and forceps on delivery wards, as I discussed here—but I wouldn’t want either myself, and I don’t think women should be pressured into them or not given full and unbiased information on their risks, as well as on those of cesarean section. I’m particularly concerned about epidural coverage, because there is convincing evidence that British women are already being subjected to the Great Epidural Bait-And-Switch.

The problem is—and the guidelines themselves sort of admit this, funnily enough, if you read them through—British women are waiting until later and later in life to have their first child; they are heavier than ever at conception; they are gaining more weight during pregnancy and having bigger babies. My concern is that if this reality collides with political pressure to "get those cesarean rates down," we will inevitably see more and more “bad vaginal births”—more long and traumatically painful labors, deep instrumental deliveries, injuries to babies and serious pelvic floor trauma. No wonder Maureen Treadwell of the Birth Trauma Association has expressed her concern about these guidelines.

Strange bedfellows
As Hull says, the Royal College of Gynecologists teaming up with the NCT and RCM is…well… surprising. The NCT is a rather crunchy mothers’ association; and while the RCM is generally respected for its role turning out the National Health Service (NHS)’s own highly-trained midwives it is still heavily biased towards natural—sorry, “normal”— birth. In addition to its Campaign for Normal Birth—see, that word again—the RCM back in 2006 also (as Hull mentions) floated the idea of charging women 500 pounds for “unnecessary epidurals,” but backed down when faced with popular outrage.

But if I thought the RCM and NCT were strange bedfellows for the RCOG, my jaw dropped when I saw page 2 of the 2006 Making Normal Birth A Reality produced the Maternity Care Working Party and included on the RCOG website; “Members supporting the consensus statement” alongside the RCOG include the Independent Midwives Association and the Association of Radical Midwives (do check out the latter’s Facebook page; it makes interesting reading, especially the approving links to Birth Without Fear posts like the one on a "Home Birth of Twins Born Past 41 Weeks, One Footling Breech"?). You do have to ask, what the hell is the RCOG playing at?

Cost-cutting with added crunch
Now, there’s little doubt why the NCT and RCM like the idea of pushing women away from epidurals and c-sections—but it would appear that they’ve thought carefully about how to sell this idea to the NHS:

“Between 2001 and 2010 the national birth rate has increased by 22%... The cost… is set to rise… Commissioners… will need to work in close collaboration with their local maternity providers to ensure that services are both clinically and cost effective.”

The guidelines helpfully remind us that “Every potential cesarean section that is enabled to be a normal birth saves 1,200 pounds in tariff price alone.” Okay, now we're getting down to brass tacks.

In recent years we have seen a lot of initiatives springing up all over the world which dovetail  with earthy-birthy views of how we “should” mother, and which—by a delightful coincidence!—just happen to be marvelous little money-savers as well. There’s the Kick women out of hospital as soon as possible early discharge system which has become popular in places like Australia, and which is great for freeing up beds ensuring mothers and babies can enjoy special bonding time away from the dehumanizing atmosphere of the hospital  (see here and here... ah, and I see the phrase "normalise childbirth" yet again in that last link...). There’s the Baby Friendly Hospital Initiative (BFHI), which has resulted in the compulsory rooming-in policies now found in most Irish hospitals, for example—nice for the hospitals who no longer have to pay for well-baby nurseries or the staff needed for them… let mum do all the work, day and night (if you want to know how the Irish mothers themselves feel about the system, see here).

When I first heard about the BFHI, I remember thinking “So… where’s this going to end? Is the next thing going to be targets for reducing epidural take-up too?” Turns out that wasn’t such a far-fetched idea.

Just be honest, please
If you want to cut costs without howls of protest, there is no better way to do it than to do it in the name of “baby-friendliness,” “normal birth” and so on. It’s clever, really. Anxiety about being a “good” mother and a “real” woman is the 21st century woman’s Achilles’ heel. A woman can’t criticize initiatives which purport to be based on “baby-friendliness” and “normal birth” without leaving herself vulnerable to accusations that she is an abnormal mother who believes in being unfriendly to babies and probably punches kittens and puppies as a hobby in her spare time.

In an age of austerity and rising healthcare costs, governments of nationalized healthcare systems everywhere are looking for ways to limit or ration healthcare services. And you know what? That’s okay. No, honestly, it really is. No healthcare system—especially one funded by taxpayers—can pay for everything for everybody all the time, and sometimes tough choices have to be made. It’s fine to have discussions about whether free formula or cesarean delivery by maternal request (CDMR) or homebirth or whatever is something which taxpayers can’t afford to fund any more when there are other pressing demands on NHS money.

But if we are going to debate cost-cutting, can we please make the debate about cost-cutting, dammit, and not cloak it in sweetly-honeyed words like “natural,” “baby-friendly” and (for the love of God) “normal.” If someone thinks the NHS can’t pay for well-baby nurseries or epidurals, fine—they’re entitled to their opinion; but please just say so frankly. Because then we can all sit down and have an honest debate about where cuts should be made. When a plan to reduce epidural availability or kick women out of hospital early is put in terms of “Oh, but we’re doing this for the babies’ good!” this effectively silences women and shuts down open debate. And that’s just not good for babies, for mothers or for the NHS.

“I’ll never forget the pain I went through. I was screaming and being restrained..."

“I just remember being brought into a [operating] theatre... packed with people. I wasn’t told what was happening. I was given a local anaesthetic. Then, two nurses put my hands behind my head, and two doctors pulled my legs apart...I’ll never forget the pain I went through. I was screaming and being restrained. I couldn’t see much except for them sawing. It was excruciating pain...”

"...the last thing I remember was my feet being pulled up into the stirrups and I don't remember anything after that until I was being wheeled out of the labour ward... I was lying flat on a board for about 5 weeks. I couldn't move. They actually split my pelvis bone...

"They showed me the saw… they showed me where they were going to open the pelvic bone. They didn’t explain—they said: “You are going to have your baby now.” It was such agony, a terrible severe pain.”

Three elderly Irish women describe their babies' births several decades ago. Stuck in obstructed labor or with a history of difficult births behind them, they might have expected to be delivered by cesarean section. Instead, a different fate awaited them.

 
Some women recall screaming in agony as they were forcibly restrained, while others only remember having their legs put into the stirrups and waking up later unable to move. "Something" had clearly been done to these young mothers, but no name was ever given for the mysterious procedure by either the doctors or attending nurses; one woman remembers no information about her operation other than a cryptic remark from one of the nuns on the labor ward, that she would "pay for it in her old age." In most cases it was decades later that these women finally learned the truth; they had been subjected to an utterly obscure obstetric procedure called symphysiotomy—a procedure most obstetricians in developed countries have never even seen, let along performed, but which was performed on more than a thousand Irish women around the middle of the 20th century due to the influence of the Irish Catholic Church.

The anatomical problem
Symphysiotomy is an operation in which the obstetrician partially severs the symphysis pubis--the cartilage holding the pelvis together. This partially unhinges the pelvis, which not only allows a baby to pass through if labor is obstructed, but is believed by some authorities to permanently enlarge the size of the pelvic outlet, thus—it is hoped—allowing future babies to be born more easily.

Birth is inherently problematic among humans, because we have narrow pelvises (all the better for walking upright with) and large heads housing enormous brains (all the better for doing crossword puzzles with). We somehow have to get a large-brained offspring through a small pelvic outlet. It’s not the greatest arrangement, and sometimes the head just won’t fit.

Cesarean section was known from ancient times, but because it almost guaranteed death for the mother, doctors and midwives generally shunned it in favor of the crude yet lifesaving (for the mother) technique of craniotomy—crushing the head of a dead or dying baby and removing its body piecemeal. It wasn’t until the 18th century that someone decided to experiment with the idea of getting a head through a pelvis by sawing through and enlarging the pelvis rather than crushing the head. Having first been tried out on animals and human corpses, the operation was first tried on a living woman—who had dwarfism and rickets— in 1777, allowing her to give birth to a live child for the first time; unfortunately, it also caused her to have walking problems and leak urine from a fistula for the rest of her life.

Over the centuries, symphysiotomy had several temporary vogues in various parts of the world as obstetricians tried it out for size... but were discouraged by the injuries caused to mothers and the high death rates among babies. Moreover, by the early 20th century cesarean section had become reasonably safe; it appeared that the problem of obstructed labor had been solved.

But symphysiotomy was to have one last outbreak before shrinking back into its rightful place in the “obscure, rarely performed techniques” sections of obstetrics textbooks, and as something done in remote areas where safe cesareans are not possible. That outbreak centered on a small country in north-western Europe: Ireland.

An unholy alliance
The problem was that cesarean section limited family size. The rule “once a cesarean, always a cesarean” still held, and it was well known that with repeated surgeries the risks to mother and baby multiplied as quickly as the scar tissue; most obstetricians set an upper limit of three or four.

This created a dilemma, since in Catholic Ireland, all contraception, abortion and sterilization were illegal. Religious-minded obstetricians of the time thus had a very strong incentive to pursue alternatives to cesareans; women who realized the peril they faced from repeated cesareans might be led into “temptation”—that is, seeking birth control. Developing an alternative to cesareans would also enhance the reputation of Irish obstetricians—always sensitive to criticism from outsiders that they were held back by their Catholic faith.

Symphysiotomy—along with a sister operation, “pubiotomy” in which the pubic bone itself (rather than the cartilage joint) was sawn through using a wire saw—was revived in 1944 by Dr. Alex Spain at the National Maternity Hospital (NHM) Hospital in Dublin, in an unholy alliance between obstetrics and conservative religious forces. Dr. Spain and fellow symphysiotomy proponent Dr. Arthur Barry published writings in both the medical literature and the ecclesiastical press of Ireland, expounding the virtues of a procedure that prevented cesarean section with its attendant problem of “encouraging the laity in the improper prevention of pregnancy or in seeking its termination.”

The operation “spread like a plague in Ireland” in the words of Marie O’Connor, author of a book on the subject. Between 1944 and the 1980s, symphysiotomies and pubiotomies were performed on an estimated 1,500 women in hospitals from Cork to Kilkenny, and were particularly widespread at the notorious Our Lady of Lourdes Hospital in Drogheda. The atmosphere surrounding the operations was clandestine; women were typically not informed of what was going to be done to them, let alone asked for their consent.

“A midwifery of darker times”

"I wasn't in labour but I thought it was for my [cesarean] section... I was physically restrained…  they had this circular saw. I was screaming, asking what they were doing. They said 'new procedure'… They told me they broke the pelvis bone and my hips were dislocated… only God and myself know the excruciating pain, violation and intimidation I felt."

Because the whole point was to avoid a cesarean, women were left to push “through the agony of an unhinged pelvis” for as long as it took—often hours and hours. About 10% of babies died—far more than with cesareans—while many more were brain-damaged. This was well known by Dr. Barry and Dr. Spain, by the way—but the “benefits” in terms of avoiding "contraception, the mutilating operation of sterilisation and marital difficulty" were thought to justify this. British obstetricians, meanwhile, had other views on their Irish counterparts’ experiments, with one being moved to say “This is a midwifery of darker times. This is the murder of infants,” while another asked “Is it then your policy to sacrifice the first-born baby to use its dead or dying body as nothing more than a battering ram to stretch its mother's pelvis in the hope that subsequent brothers and sisters may thereby (possibly) enjoy an easier entrance into the world?”

Women, meanwhile, were left with serious damage—incontinence, pelvic instability (leading to great difficulties with walking) and chronic pain—rendered more serious because the secrecy surrounding the procedures meant that women did not receive proper nursing care and were dispatched from hospitals without medical advice. Most had no idea what had been done to them until the symphysiotomy scandal started to come out in the 1990s, leading ultimately to the creation of Survivors of Symphysiotomy (SOS), a support and advocacy group which is currently campaigning for compensation for the surviving victims. Many survivors speak of marriages blighted by sexual dysfunction and chronic pain, of isolation and loneliness caused by disability, and of the psychological trauma caused by the operations—including, in many cases, the death or injury of their babies.

One particularly grotesque twist in the symphysiotomy story concerns the calculated use of the procedure on many women either before labor or when already delivered of their babies, for training purposes. The Lourdes Hospital was run by the Medical Missionaries of Mary which operated missionary hospitals in Africa, India and other places. In environments lacking electricity or proper facilities, the attractions of a low-cost procedure that could replace cesareans were obvious. Symphysiotomies performed on Irish women—without their knowledge or consent—were thus an invaluable teaching aid for Catholic missions.

“The obstetrician, like God, must look to the future…”
Symphysiotomy and pubiotomy in Ireland began to decline in the 1970s due to changes in Irish society and other factors. In developed counties, it is now performed only in extremely rare life-threatening cases where labor is too advanced for a cesarean. Yet some of the issues surrounding these procedures have resonance for our times, in particular, women’s right to control over their fertility, and the question of how to balance the safety of the baby being born now—in this birth—against the safety of future pregnancies—a dilemma that we have faced ever since safe cesarean section become a possibility.

In traditional societies, high infant mortality rates create a more philosophical attitude to child death, while also necessitating multiple pregnancies if a couple want to make sure they leave any living descendants behind them. And cesarean sections are highly risky. In such environments, techniques like symphysiotomy make a grisly sort of sense—sure, this baby might have a 10% risk of dying, but avoiding primary cesarean means the mother can give birth to many more babies. As discussed here, symphysiotomy remains part of the obstetrician’s box of tricks in parts of sub-Saharan Africa—not because symphysiotomy is good, but because it's better than letting the mother die or sectioning her in an insanitary environment where there is no guarantee she could make it to the hospital next time, and where large families are still considered essential.

As infant mortality rates have fallen, the average number of children a woman will give birth to has declined sharply; meanwhile, we have higher expectations of safety and are no longer content to regard dead babies as disposable or do-overs… and cesareans are safer than ever. Present-day trends in obstetrics reflect these patterns, with cesarean section replacing not only symphysiotomy but also vaginal breech delivery and (increasingly) forceps deliveries and vaginal birth after cesarean (VBAC).

But respecting women’s control over their bodies goes both ways, and there is a case for saying that when obstetric practice is based only on the desire to reduce all risk to the fetus to zero, it can become decidedly unfriendly to many women who actually choose to have larger families. VBAC, for example, involves a small but real risk to the unborn baby because of the possibility of the uterus rupturing, as was discussed recently on The Skeptical OB; but what about the risks (to futuer babies) of multiple surgical births? I am going to quote in full one particular poster (who had a prior cesarean) because I think what she said was so moving and so important:

“I have always wanted a large family, but stories like these scare the crap out of me. It's been extremely difficult for me to decide whether I should have a VBAC or 4-6 c-sections…. If there were some way to know that I'd end up being one of the women with 4-5 c-sections and minimal scar tissue I'd be all over it, but I know I could just as easily end up being like someone I know of who had so much scarring after two that her third birth was a classical c-section followed by a hysterectomy.

“I think I could ultimately accept just 3 kids, but I would always feel like someone was missing and long to love and hold them. It kind of bugs me that there are so many in VBAC threads that berate moms for even considering a VBAC over a RCS [repeat cesarean section] in order to protect the lives of future babies who might end up stillborn, etc., but if you want additional children you love and long for them every bit as much as you do your first… It's like people who tell infertile couples to just adopt and then are bewildered and even mad when they say it's just not the same even though logically it should be because they'll still end up with kids. I just don't think wanting to do what's safest for your family as a whole is a choice that deserves such much criticism and so little understanding.”

Childbirth politics generally takes the form of as a conflict between those who see birth as inherently hazardous and regard it as a medical matter, and those who see it as a basically functional process where interventions are seldom necessary. Symphysiotomy in Ireland is difficult because it doesn’t fit neatly into either “side.” You can read Ireland’s symphysiotomy scandal as “Obstetrics has a history of violating women’s bodies with interventions that are not evidence-based” or as “Thank God we have cesareans now! See, this is what happens when you prioritize vaginal delivery above all else.” I prefer to see it as a story of what happens when religious doctrine takes precedence over women’s rights to informed consent and control over their bodies. This is something we should bear in mind as we face the possibility of a US vice-president—a Catholic—who is completely opposed to abortion even in cases of rape and incest, and who has sponsored a bill that would outlaw some forms of birth control.

In many countries, it has become increasingly common for women who prefer cesarean and plan to have a small family to be permitted a prophylactic cesarean section without medical indication. I think this represents an extremely important moment in terms of respecting maternal choice. I also hope that there will be room on maternity wards for VBAC, forceps deliveries and even (carefully screened) vaginal breech deliveries, and that in the future, obstetricians will give women unbiased information on the risks of cesarean and vaginal deliveries, discuss women’s desired family size with them and take this into consideration when presenting information and options.

As the surviving symphysiotomy victims wait for justice, what a wonderful tribute it would be to see their struggle not as a victory for a certain “type” of birth, but as a moment for reflection on the importance of women being able to make informed decisions about their bodies and fertility—an issue which is as relevant in our times as it was all those years ago in Ireland.

More information:

Mutilating mothers in the name of God (video)

Latch On NYC: Less spin, more details please

"Mayor Bloomberg pushing NYC hospitals to hide baby formula so more new moms will breast-feed" screamed the headline a few days ago. In Mayor Bloomberg's Latch On NTC initiative, we were all told, not only were formula samples to be banned, but formula was now to be hidden away "in out-of-the-way secure storerooms or in locked boxes like those used to dispense and track medications," in order to discourage bottlefeeding, while those wicked mothers who requested bottles anyway were to be subjected to a "talking-to" for each and every bottle they received, by staff who will explain "why they should offer the breast instead." Now, two thoughts ran through my head upon seeing this. The first was, "Wow. This is going to cause a bit of controversy in the mommy blogosphere. I wonder if The Fearless Formula Feeder and Kellymom are onto this yet?" The second was, "Hmm. I notice that article doesn't actually link to an original source. I wonder how much of what's written here is true and how much is spin...?"

Well, the blogosphere got wind of Mayor Bloomberg's little wheeze, and commentary rapidly split down two predictable lines. The "Anti-lactivist camp" (many of the commentators on The Skeptical OB, The Fearless Formula Feeder, Bottle Babies and others) fumed about the proposals. "This is outrageous! It's a woman's right to choose formula--how dare hospitals lecture them about it? Or treat formula as though it was something akin to cigarettes?" The "Lactivist camp" (Kellymom, Best For Babes and all the rest of the crunchosphere--which, by the way, hugely dominate online discourse about motherhood in spite of the beleaguered-minority identity) immediately shot back, "No, this is a great initiative. And the media hasn't reported this properly. Go to the Latch On NYC website--they're not going to lecture women about using formula. And by the way, it's normal hospital practice to lock up items used in the hospital, including food."

Well... with some trepidation, I went to the Latch On NYC website, grimly saying to myself over and over again, "I will not, NOT form an opinion until I have read what the actual initiative itself says...minus the media spin." And even before opening up the Initiative Description and FAQs, it was pretty apparent that there was some serious spin going on. I mean, before long there were news articles appearing which were proclaiming "NYC plans to ban baby formula in hospitals"--absurd.

Well, according to the Initiative Description, the initiative consists of the following:

A call to all NYC maternity hospitals to make a voluntary commitment to support mothers who choose to breastfeed by:
- Enforcing the NYS hospital regulation to not supplement breastfeeding infants with formula
feedings unless medically indicated
- Limiting access to infant formula by hospital staff
- Discontinuing the distribution of promotional or free infant formula
- Prohibiting the display and distribution of infant formula promotional materials in any
hospital location
- A public awareness campaign to promote the health benefits of breast milk, and to inform women of their right to receive education, encouragement and support to breastfeed their babies if they choose to do so.

 So, it looks like the lactivist camp was right to claim that there is some media misreporting--or at least, overextrapolation--going on.
I'll be honest--I think much of what is written here falls into the categories of "Good" or "Neutral." I'm agnostic on ban-the-bags--I don't particularly feel that one's human rights are infringed on by not receiving a freebie; I didn't get free formula from my Japanese hospital, either, and didn't feel deprived. I also feel that ethically speaking, it is questionable for hospitals to receive gifts from commercial organizations because it can create conflicts of interest--although I think that if we are going to ban the bags then to be fair we should be banning all gifts and samples to the hospitals. The "unless medically indicated" bit did make me raise my eyebrows for a second... are they proposing that formula feeding should only be permitted for medical reasons, meaning women should not be permitted to formula feed by choice? But a second glance indicates that this is for breastfed infants only (i.e., you don't give formula to babies whose mothers have chosen breastfeeding, unless there is a medical reason to override her wishes). That's a positive thing.
What about the locking-up of formula? Let's take a look at the FAQ page.

 What does it mean to restrict access to formula?


Restricting access to formula means storing formula away from where it is easily visible and accessible to staff and mothers. Access to formula is restricted by both:


Storing formula in a locked location, such as a storage room, cabinet or an automated medication system or, storing formula in a location outside, but reasonably near, the maternity unit...

  "Locking up" does sound alarming, but I think it's only fair to point out that hospital supplies including sanitary pads, food and just about everything else are usually locked up, recorded and tracked--in part because patients are usually charged for them. Again I think we are seeing a little bit of the phenomenon of journalism that epidemiologist Elizabeth Pisani calls "beating it up." "Making it up" means inventing things up out of thin air. "Beating it up" means presenting true facts in a way which makes them sound as alarming as possible, in order to whip up a bit of hysteria and controversy (which in turn will generate sales and page clicks).

What does concern me a little, is the following sentence:

...Limiting the number of hospital staff with access to formula by implementing a system to identify which hospital member accessed the formula supply; some examples are a log book, a code or a key system.


Restricting access decreases the likelihood that staff will distribute, and inadvertently market, formula.

 It may well do so. It also increases the likelihood that mothers are going to be kept waiting God knows how long while waiting for a bottle to appear (as their newborn screams with hunger) because the reality of hospitals is that there are never enough staff and there are constant complaints from new mothers about lack of support already anyway, and restricting. And then you get mothers inadvertently stretching out the periods between feeds  as long as possible... and pushing the baby to "finish the bottle" when the formula is finally available, in order to avoid the whole process of trying to actually get hold of a bottle of milk. This isn't promoting good feeding practices or responsive parenting. Rule No. 1 = Feed The Baby.

What about the "lecture with every bottle" bit that is allegedly going to form part of Latch On NYC? Here is the relevant section in the FAQ.

What do we tell our staff to do when mothers (families) request infant formula?


While breastfeeding is healthier for both mothers and babies, staff must respect a mother’s infant feeding choice. Educating mothers and families about breastfeeding and providing encouragement and support, both prenatally and after birth, is the best way to ensure breastfeeding success in your hospital.


While in the hospital your staff can:
Assess if breastfeeding is going well and encourage the mother to keep trying.
Provide education and support to mothers who are experiencing difficulties.
If the mother still insists on receiving formula, document it in the chart along with the  reason and distribute only the amount of formula needed for the feeding.
Train staff in breastfeeding support (CLC, IBCLC) who can be available to assist new mothers at all times regardless of day, night or weekends.

 Well, first of all, claims that formula feeding is going to be banned from New York hospitals do indeed appear to be a bit of media hype; Latch On NYC does give at least token support for mothers' choice to formula feed. The bit about training staff in breastfeeding support is great.

But what does "Assess if breastfeeding is going well and encourage the mother to keep trying" actually mean in practice? If the mother says clearly "I don't want to do this any more," is the nurse required to keep urging her to continue? Where do you draw the line between support and nagging? The initiative gives us no clear answers. Certainly, the use of the word "insist" here is deeply problematic. My understanding is that a person only "insists" on doing something when they continue to state their need after having experienced a considerable amount of pressure to do the opposite.

My guess is that what will actually happen is that these ideas will be interpreted in different ways depending on the hospital staff member in question: staff who are basically respectful of all feeding choices will continue to act accordingly, but staff who have the lactofanatic light in their eyes may well see this as a permission slip to harangue mothers more than they are already doing. I don't think it's much of a stretch to imagine this, given that women are already being harassed in "baby friendly hospitals" for choosing to give formula.

Details, details, details
There is a lot about this initiative that is concerning, but we need to make sure that we are focusing on the right things. The initiative doesn't say anything about giving mothers a "talking-to" about using formula, and it certainly doesn't seek to ban formula. But there are some real problems with some of the things it is outlining. What's more, a lot of the initiative is maddeningly vague, and that openness to different interpretations could result in it becoming a green light for bullies.

There has been a lot of negativity about Latch On NYC in the past few days; if its authors want to rescue its credibility, they need to rewrite the thing, spelling out carefully exactly what they are going to do to support breastfeeding and formula feeding mothers and make their lives easier. Otherwise, the only thing Latch On NYC will achieve will be to add an extra keg of dynamite to the mommy wars.

How to have a bottle-refusing baby (and a life)

Before I had my baby 16 months ago, I was quite clear on one thing: if I breastfed her (and I wasn't yet sure which way I would swing), she was going to take a bottle. Oh yes, she would. I had no desire to join the dreaded ranks of the Mothers Whose Babies Will Not Take A Bottle. I'd read all the stories, you see--about how a bottle-refusing baby irrevocably ruined your entire life, chaining you to your infant night and day and ensuring that you never had a evening-out or date night ever again. I was horrified by such stories, but not terribly sympathetic. Really, these sad excuses for mothers had only themselves to blame for not introducing a bottle properly at the right time. Or maybe they did introduce a bottle in time, but then failed to follow up on it. Tut tut. Apart from anything else, how utterly irresponsible, I sniffed--what if they suddenly had to be hospitalized and the poor husband had no means of getting milk into the baby? I, by contrast, was going to do things properly.

And so I carefully introduced bottles--beautiful, carefully selected glass bottles--at five weeks, as per The Sleep Lady. Baby Seal took them like a dream and I congratulated myself on my superior mothering skills. I now had the ideal breastfeeding-yet-bottle-accepting baby who would allow me to leave her, when desired, with Dad or Grandma--though, if pressed, I would have been forced to admit that keeping my baby primed and ready for such occasions was actually a heck of a lot of work.

You see, the Sleep Lady stipulated a rule of "one bottle a day" to make sure that baby did not lose her bottle-latching skills. This meant that in addition to breastfeeding and babycare, I had to find time to sterilize the pump (carefully gripping each piece with tongs while pouring boiling water though it), set the pump up, mechanically wheeze the milk out drop by drop, store it, sterilize the bottle parts with more boiling water, screw the bottle together, fill it with milk and warm it. Then there was the business of trying to find a time-slot for fitting the bottle-feeding into the daily routine. As Baby Seal's bedtime became earlier, my husband was no longer home in time to give her an evening bottle, so I began to give it myself.

Perhaps that's where the trouble began. At any rate, at three months old, Baby Seal began to refuse her carefully prepared bottles. In horror, I posted on Facebook "She's stopped taking the bottle!!! HELP." Everyone weighed in with suggestions (from giving the bottle out of doors, to rolling the teat in icing sugar) all of which I duly followed--to no avail. My pliant little bottle-accepter was gone, and she never took one again... well, not until she was nine months old and bottles were no longer necessary anyway. Bit of a climbdown for me, as you can imagine.

And... it was okay. We managed--just about--without bottles. Not always very conveniently or efficiently, it's true (I moaned about the problems of my little bottle-refuser here). And yet, somehow, we got through it and came out the other side.

Needs
As it turns out, bottles are not absolutely indispensable for getting milk into a baby without a breast. Over the millennia, a variety of things from spoons to droppers to cups have been used for the purpose. So why the ubiquity of bottles? Well, the big advantage of bottles over other feeding methods is that they are a way of getting a lot of milk into a baby with relative speed and without wastage. If you are looking to get large quantities of milk into a baby sans breast, then a bottle is what you need. If speed/efficiency/quantity are less important--because you are, say, a stay-at-home/work-at-home mother or on mat leave and you only need to leave your baby for the odd evening out, the hairdresser's, doctor's appointments and so on, a bottle may not be essential and could even be more trouble than it's worth.
When it became clear that bottles were simply not going to work, I girded my loins and went to internet to learn about alternative feeding methods. Over the next few months our family ended up doing a mixture of dropperfeeding, cupfeeding and spoonfeeding (milk and cereal); no method was perfect, each method had its own advantages. On preparing to leave the house without the baby, I would basically defrost a container of breastmilk, sterilize a spoon, dropper, and cup, and say to Dad/Grandma, "Erm, your guess is as good as mine. Try lots of stuff and see what works." Here's my rundown.

• Dropperfeeding

This method suggested itself from the dropper I'd used to give Baby Seal her Infacol. I know, I know--feeding milk in a dropper sounds like it is going to really, really, really slow. In fact, for this particular purpose, droppers should really be named "squirters" because you put the milk in one squirt at a time, not literally drop by drop. Slowish, but not nearly as bad as it sounds, and less messy than some other methods.

To give Baby Seal a dropper feed, we would put her in her bouncy chair facing us. It's a funny thing, but when breastfed babies are being fed milk from anything other than a breast--a dropper, spoon, cup or bottle--they tend to prefer the whole experience to be as different from nursing as possible; different posture, different part of the room, and often from someone who's not the mother. It's as if anything that reminds them of breastfeeding makes them furious--"Look, I know this isn't real breastfeeding... do you take me for a fool??" Anyway, we started off with a few drops at a time, then increased to half a dropperfull, then a full dropperfull. I found a video here, but honestly, there is no special technique to dropperfeeding--it's just insert and squirt. Any medicine dropper will do.

• Cupfeeding

Baby Seal came to cupfeeding rather late--at four months, she grabbed the rice cooker measuring cup and put it to her mouth with a cheeky grin... and I had an "Aha!" moment. The best way to learn how to cupfeed is to see it in action--thank you, Youtube.
Shot glasses are the most popular cupfeeding option, but I used either the aforementioned rice cooker cup (which had a little "give" in it), or a tiny Japanese teacup. The trick with cupfeeding (and this flummoxed me for ages until I worked it out) is to get the baby's tongue inside the cup. You're not actually pouring the milk into her mouth, because if you do this, she will splutter and gag; you need the baby to use her tongue to sip or lap the milk from the cup.
I found cupfeeding faster than dropperfeeding, but at the expense of more wasted milk. When this is breastmilk you've spent forever carefully expressing and storing, that's hard (could this be the true origin of the old saying about crying over spilt milk?). After five months old when Baby Seal was having solids anyway, I made sure there was some ready-made formula knocking about in the house, which made it a bit psychologically easier to experiment with different ways of giving milk.

• Spoonfeeding

Spoonfeeding breastmilk struck me as being the slowest and messiest method of the three mentioned thus far--Baby Seal always seemed to have a lot coming out of her mouth, perhaps due to the tongue-thrust reflex--yet my mother-in-law and mother seemed to prefer it to other methods. I guess it comes down to familiarity--grandmas are usually accustomed to spoonfeeding babies. Which leads me to....

• Cereals

If a baby is at least four months old and you've been spoonfeeding breastmilk anyway, adding a little baby cereal like baby rice or oatmeal can be a nice, not-overthinking-it start to solid foods. It stabilizes the breastmilk and makes it less messy to feed, while also giving your baby a little extra iron... and there has recently been a swing back towards emphasising supplementary iron for breastfed babies. Now... I know I mentioned this in another post, but the funny thing about a lot of lactivists is that they think spoonfeeding breastmilk is great--like a kind of superior alternative to the evil bottle--but that spoonfeeding solid foods is a Bad Thing (forcefeeding, doesn't allow your child to control their food intake, blah blah). So according to this logic, the moment you add a little powdered rice to a spoonfull of breastmilk, your baby suddenly becomes incapable of controlling their intake of what's on the spoon, and you are essentially just waterboarding them with the contents. No, I'm not buying that bit of logic either. We did the cereal thing, and offered a couple of teaspoons of water as well, to counterbalance the solids that had been added.

• Sippies

I had high hopes that Baby Seal might take to a sippy cup super-early; alas, she hated every sippy I tried on her for the longest time. She even hated the soft-spout type which are recommended for young babies. Still, it's worth giving them a try; I've heard of bottle-refusers taking a sippy as early as four months.

It doesn't last forever
So in the end, it was okay. I got out without the baby; somehow, with a bit of this and a bit of that, Baby Seal got enough milk inside her.
Now, I should stress, however, that I'm speaking from the privileged position of someone who was able to take six months' mat leave and then work from home while using in-house childcare. If a mother is going to work outside the home in the usual way, a bottle-refusing baby is far more of an issue, which is why (as discussed in a previous post) it drives me nuts when I see lactivists disingenuously advising planning-to-return-to-work mothers to wait for two or three months before introducing a bottle, or even not bother at all. With the best will in the word, babies are not going to get huge amounts of milk inside them with these methods, so if we are talking about a baby who is at a daycare nursery much of the day, suggesting to mothers that they don't bother with the bottle and instead just have their baby fed with an open cup or spoon is basically tantamount to telling mothers to encourage their babies to reverse cycle--a phenomenon which sometimes occurs with breastfed babies of working mothers, whereby the baby eats next-to-nothing all day and then makes up for it by clusterf*ck-feeding all night long. Which some mothers may be okay with, and others most definitely are not. That's even assuming you can get a daycare nursery to handle cupfeeding with a baby in the first place.

However, if you are, say, planning to leave your baby only for the odd evening out or whatever, having a bottle-refuser is a nuisance but not a disaster. Although I do generally rather hate the hoary platitude "This, too, shall pass," this is one of those instances where it does have the ring of truth. Most new mothers aren't doing much in the way of evenings-out for the first month or so after the birth anyway; and then at four to six months you start solids and the feeds start getting fewer and further apart; at seven or eight months baby may start taking a sippy cup, and so on, and the whole situation starts to look completely different. So in the great scheme of things, the time that having a bottle-refusing baby will inconvenience you is really, at most, only a few short months out of your entire life. And even during this period, honestly, you can go out without your baby when you want to--it's just a bit more fiddly and involves rather more spilt milk.

And there is a bright side to having a bottle refuser. At least you don't have to wean them off the wretched bottle if they never take to one in the first place (same with pacifiers). And to be honest, yes, going straight to an open cup probably is more hygienic, and better in terms of palate development and dental health.

In hindsight
Knowing what I do now... if I were to have another baby in similar circumstances, would I bother with the bottles this time? Well... I think would certainly introduce one like I did with Baby Seal--it's worth a try, at least. But I think that this time I wouldn't put myself through all that exhausting palaver of the daily bottle; it was just.so.much.work and I'm really not sure it was worth it. And if my hypothetical second child were to start refusing the bottle like Baby Seal, I 'm pretty sure that this time I wouldn't waste energy on fighting with her over the issue. I would just remind myself that the inconvenience of the bottle-refusing baby doesn't really last very long, and that in the meantime there is nothing more adorably precocious than the sight of a young baby drinking from a teeny little teacup.