The importance of supporting women who haven’t been able to meet their breastfeeding goals

by Amy Brown, ABM Breastfeeding Counsellor

We don’t really need research to tell us that a positive breastfeeding experience can be an amazing boost for maternal mental health. Anyone who has met their breastfeeding goals knows that although it can be tough, the rewards are usually worth it. Even when everything else feels like its falling apart, breastfeeding can be a life raft. A common message emerging from my research is often ‘Breastfeeding felt like the one thing I got right’.

Likewise, from a scientific perspective, we can see the physiological protection throughout the body. Breastfeeding helps maintain the hormone levels the body would expect after birth, keeps levels of oxytocin raised and can help the body combat inflammation caused by a lack of sleep or pain after the birth (1). All these factors – psychological and physiological – help explain the lower levels of postnatal depression in women who breastfeed 2.

But although breastfeeding can be beautiful, sadly, we know that far too many women struggle to have that fabulous experience. Although most women say that they want to breastfeed, in the UK, more women have given a bottle of formula by the end of the first week than are exclusively breastfeeding (3). And we know why. Too many barriers are being placed in too many women’s way that lead them down a path where they will eventually stop breastfeeding. A traumatic birth, lack of professional support, inaccurate beliefs about how breastfeeding works, pressure from others, insane public attitudes, the lure of false advertising and more can all contribute to pain, perceived or real low milk supply or a belief that formula is needed (4).

Of course, the standard public health approach we seem to have in the UK is to tell women that ‘breast is best’ before their baby is born but once the baby is here to solve any problem with a bottle of formula. Difficulties, slow weight gain, lack of milk transfer, sleep issues… all solved with ‘have you tried a top up’ or ‘one bottle won’t hurt’. Of course, we know this is a slippery slope to stopping breastfeeding altogether, and has been shown to increase risk of postnatal depression. Small issues that could have been solved with the right expertise and guidance become insurmountable issues leading to 90% of women who stop in the first few weeks saying they weren’t ready to do so (3).

But where does that leave women?

Other than literally holding the baby (and a bottle)? It leaves them with lasting scars that’s where. Time and time again I meet women, with babies who are grown up and even with their own children, who once they hear what I do tell me their stories. They’re usually the same. A longing to breastfeed which turned into just a few days or weeks. Pain and difficulty that made everything feel worse (5). And a deep regret that they couldn’t breastfeed for longer. Of course, when you dig a little deeper, there is always a trail of sadly predictable experiences that led to them being let down by a system that should have protected and nurtured them.

So what are we going to do about it?

Two things. Firstly, demand better support and investment in breastfeeding (6). And secondly care for those who have been let down by the system.

We’re all up to speed with the demanding better support and investment thing, which of course is integral to reducing the need for the second bit. But an absolute key way of moving forward, and gaining allies for the first part, is to ensure we are doing everything we can for those who haven’t been able to breastfeed. Primarily this is essential in preventing more women from spiralling down a black hole of regret, loss and anger. But secondly, supporting women to work through their grief at not being able to breastfeed can help us prevent the next generation of women from being let down by enabling us to have better conversations about breastfeeding (6).

Too much anger and vitriol abound, particularly online and in the media about ‘pressure to breastfeed’ and ‘evil lactivists’ forcing women to breastfeed when they can’t or don’t want to. Again, when you dig down, what you really find is that trail of women being let down and not being properly supported when they wanted to breastfeed. And they’re angry. Anger is certainly often righteous anger. They have not had the care and support they deserve. But who does that anger really need to be directed to?

Of course, anger is often not anger, but rather a transference of guilt, hurt and fear. Supporting women to unpick those emotions and to redirect their anger towards the system that let them down is vital. If we could just package up all the negativity online and direct it into a campaign to ensure that women and families got the support they needed…

What might support for those who haven’t been able to meet their goals look like?

Recently I conducted research exploring how women feel when they haven’t been able to meet their breastfeeding goals. Over three thousand women replied in a couple of weeks, their stories of grief, devastation and anger flooding in. As sadly expected, their stories often contained significant barriers, poor advice and a lack of support along the way, leading them to stop before they were ready and left overwhelmed with negative emotions.

What struck me though was the breadth and strength of those emotions. Sadness, grief, anger, guilt all emerged. But words like trauma, inadequate, and failure also held top positions. As one woman explained, and she was not alone, ‘I hate myself and think I am not a good mother. Nothing anyone says or do can change the fact that I failed’. Note the strength of those emotions. The self-blame. The perspective that it was her fault. How do we support women like her? How can we stop this happening again?

Some would say we should simply stop talking about breastfeeding. If we stopped promoting it and talking about how great it is then women wouldn’t feel like this.

Would they? Really?

I don’t believe that for a second. Women don’t want to breastfeed because a health promotion poster has told them their baby will get fewer ear infections. They want to breastfeed because it is normal and instinctual. Breastfeeding isn’t just about the health benefits. It’s about love, bonding, hormones … and not having to get up in the middle of the night or forgetting to take your baby’s food out the front door.

Think back to those women in their 60s, 70s, 80s and older still. They had their babies in a time where breastfeeding was at an all-time low. Formula was everywhere. Promoted as science milk that was the choice for mothers who cared about their baby’s health. No one was telling them that ‘breast is best’. There was no perceived pressure that ‘good mothers breastfeed’. Quite the opposite in fact (7). Yet those who wanted to breastfeed and couldn’t still hold these same emotions decades later. So don’t try to tell me that.

This aside, in no other area of health would we simply stop promoting it because people were finding it tough. Imagine the smoking cessation support programmes being slashed because it was tricky. Or Jamie Oliver saying ‘oh forget it, turkey twizzlers are great’. Not going to happen. We owe is to future generations to keep shouting loudly that breastfeeding needs greater investment.

But we also owe it to women who have been let down by our current system to support them through how they are feeling. Critically in the research I mentioned above, when I asked how we should change breastfeeding promotion to feel less damaging to those who were struggling, just 5 out of 3000+ women said we should stop promoting breastfeeding. Five. Or in other words 99.9% of women who were hurting at not being able to breastfeed still thought we should carry on. Adjust some messages perhaps. But still very much carry on.

And in fact the top way in which women felt we could reduce how breastfeeding messages negatively affected women was to invest more in breastfeeding. How the majority of women feel is not the vitriol of particular voices online. As in previous research I have conducted, again women called for better identification of difficulties, more time to be supported, enhanced training for all professionals (including GPs) and clearer messages in antenatal education and public health about how breastfeeding worked and what it was really like (8).

What else did women say would have helped them?

One of the strongest messages that came out of my research was the finding that it wasn’t just the disappointment of not being able to breastfeed that led to women feeling so awful but the way in which they then felt they were treated once they were no longer breastfeeding. They felt that their emotions, needs and experience had been pushed aside and presumptions were made that they didn’t want to breastfeed. They believed that if they had been cared for, supported and guided through this period, their mental health would have been protected.

So what did they suggest needed to happen?:

1. More knowledge and expertise around reasons why some women might need to supplement or not be able to breastfeed

We still do not have a clear picture of how many women truly cannot breastfeed or will not make a full milk supply no matter what they do. We still don’t understand from a research perspective what all the underlying factors are. This would be inconceivable if men breastfed. There would be tests. Diagnoses. Treatments that helped. Not simply a suggestion that breastfeeding didn’t matter.

2. Practical support when they needed to bottle feed

There are many good reasons for not promoting bottle feeding. But when women do need to bottle feed they need good, clear advice on how to safely prepare bottles. And how to bottle feed responsively. They also need support in stopping breastfeeding gradually if they need to stop altogether. Women talked about how they felt abandoned when they moved to bottle feeding. Some raised the idea of having mixed feeding support groups. This isn’t straightforward and of course, resources are limited. But women talked about feeling excluded from groups they once visited once they stopped breastfeeding. Or needing the support of others and having no clear place to go. They also suggested that perhaps for those who have little experience of successful breastfeeding, seeing other mums feeding might help them next time.

3. Emotional support to help them deal with the loss of their breastfeeding relationship

Women talked about mourning the loss of their breastfeeding relationship and the future they had planned. They may have a strong identity as a ‘breastfeeding mother’, particularly if they have breastfed previously. This can be further exacerbated by the increased inconvenience of formula feeding, such as needing to get up in the night to make a bottle. They may feel they have lost an important ‘mothering tool’ of being able to soothe their baby quickly with their breast.

Some women described how they had specifically sought counselling to help them work through not being able to breastfeed and felt that they had benefitted from support to reattribute blame they were placing on themselves. For some this counselling may need to be more formal. For others it might mean talking through their emotions with a breastfeeding counsellor who understands. But women need an outlet to talk about their stories, plans, and what happened to them, and to help them work through (and redirect) any feelings of guilt or self-blame.

4. Watch the language that is used to promote breastfeeding

The vast majority of women believed we should continue to promote breastfeeding but did identify that the language sometimes used should change. In particular three key phrases that caused further grief to women were highlighted. The first of these is the dreaded ‘breast is best’ message that we hope is being stamped out. We know breast isn’t best anyway – it’s normal – and anyway, knowing something is best doesn’t help anyone. Other triggers however included anything that mentioned ‘choice’ to breastfeed. For many, many women they felt that the choice had been taken away from them. ‘Failure’ was another flashpoint. The scientific literature is terrible for using this word in the context of ‘breastfeeding failure’ and it can have devastating effects on how women subsequently blame themselves. System failure yes. Mother failure no.

5. Recognise that breastfeeding matters to women

Of course, this is one we know. Breastfeeding matters because women matter. Although not a direct question in my research, several brought up the concept of the phrase ‘fed is best’. We know that some women find comfort in this phrase (although my thoughts on the further damage this enables to investment in breastfeeding are well known 9). But others described how being told ‘fed is best’ made them feel that their experience and desires were being diminished. Women need their voices to be recognised and acknowledged, not be told it doesn’t matter. Would men be told this if a part of their body wasn’t working? As one mother said: ‘I think a big part of my pain is from people trying hard to comfort me with comments like fed is best. That didn’t help and it made me feel like my feelings were invalid. All I wanted was for people to listen and acknowledge my struggle without outside opinions or advice – unless explicitly asked’

And this sums up the reason why we must keep talking about breastfeeding, for the sake of women who have been let down and the generation that will soon be feeding our new babies.. We must let them tell their stories and recognise the grief that has been caused and help them in finding peace – or indeed revolution to make change. We owe it to all of us to ensure that breastfeeding is recognised as a public health and societal responsibility and when it doesn’t work as planned, for these to receive the blame not the individual mother herself 10.

References

One day, in between roaming the world and arguing with people on the internet, Amy will finally finish writing this up for publication. I’m sure she’ll mention it. But keep a look out for it soon.

1. Kendall-Tackett, K. (2007). A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. International Breastfeeding Journal, 2 (1), 6.

2. Dennis, C. L., & McQueen, K. (2009). The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics, 123 (4), e736-e751.

3. McAndrew, F., Thompson, J., Fellows, L., Large, A., Speed, M., & Renfrew, M. J. (2012). Infant feeding survey 2010. Leeds: Health and Social Care Information Centre.

4. Brown, A. (2016) Breastfeeding Uncovered: Who really decides how we feed our babies? Pinter & Martin ltd.

5. Brown A, Rance J, Bennett P. (2016) Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of advanced nursing, 72(2):273-82.

6. Palmer, G. (2009) The politics of breastfeeding: when breasts are bad for business. Pinter and Martin Ltd.

7. Trickey, H. (2017). Can we have better conversations about breastfeeding? The Unicef Baby Friendly Initiative Blog https:// www.unicef.org.uk/babyfriendly/betterconversations-about-feeding/

8. Brown, A. (2016) What do women really want? Lessons for breastfeeding promotion and education. Breastfeeding medicine, 11 (3), 102-110.

9. Brown, A. (2016) Why fed will never be best. The FIB letting our new mothers down. Huffington Post https://www.huffingtonpost.co.uk/amy-brown/whyfed-will-never-be-bes_b_12311894.html?guccounter=1

10. Brown, A. (2017). Breastfeeding as a public health responsibility: a review of the evidence. Journal of Human Nutrition and Dietetics, 30(6), 759-770.

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