Bottlefeeding mothers around New Zealand have spoken out during the past week, saying they have been badly treated by health professionals and the community. Features editor Claire Allison asks what's happening in South Canterbury.
Breast is best. It's the mantra for all new mothers.
But it doesn't always work out like that, and some will turn to the bottle to feed their babies.
And that's when, according to media reports and online comments this week, some have been made to feel bad about that; by health professionals and even complete strangers.
Christchurch mother Jess Schulz said she was made to feel like a bad mother after using formula when her baby failed to gain weight, with one stranger telling her, "if you can't breastfeed, don't breed".
A Wellington mother said she was furious no-one told her about formula during pregnancy, and when her milk never came in, there was no support.
Online comments have resulted in the coining of the word "breastapo", and referred to baby formula being locked away and bottle-talk banned.
It seems that sometimes mums just can't win; abused for bottlefeeding their baby in public, or abused for breastfeeding their baby in public.
The Timaru Herald opened up the issue on our Facebook page, and received some mixed reports.
Some felt they had received support when they were unable to breastfeed, others said they had received little information about formula feeding, or were made to feel bad about their decision to bottlefeed.
The Health Ministry has said it will discuss the issues raised with district health boards.
But the policies in place; infant nutrition guidelines, the Baby-Friendly Hospital Initiative - while all emphasising the benefits of breastfeeding - already make provision for bottlefeeding, and health professionals spoken to this week all maintain that women are supported if they choose to bottlefeed their babies.
Plunket referred us to the Health Ministry's infant nutrition guidelines, saying all its policy came from those guidelines.
A 174-page document, those guidelines state: "While stressing the superior benefits of breastfeeding for both infants and mothers, health practitioners must give mothers and families who decide to feed their infants infant formula objective, consistent and accurate advice on the proper use of formula (Ministry of Health 2007). Such information should include the appropriate type of formula, how to prepare the formula and the equipment, and how to feed the infant."
Antenatal classes are offered in Timaru by both Timaru Hospital and the Timaru Parents Centre. Both are funded by the South Canterbury District Health Board, and both are covered by the World Health Organisation (WHO) code of practice around baby milk substitutes. That means that while breastfeeding is covered in the classes offered, bottlefeeding isn't.
However, if prospective parents want to discuss bottlefeeding, that can be done on a one-on-one basis.
Parents Centre president Kim Sugrue says the centre's childbirth educators will advise their classes about how the code relates to their practice.
"Unfortunately, a lot of people are not aware of the provisions of the WHO code and the fact that it's worldwide. They might feel that they aren't given enough information, but our childbirth educators will say at the start of the breastfeeding section what the WHO code is and how it governs their practice, and they will tell the class that if anyone wants more information about bottlefeeding, this can be covered on a one-to-one basis."
Kim points out that information on safe bottlefeeding is equally relevant to breastfeeding mothers if they need to express and store breastmilk.
Timaru Hospital's Jean Todd maternity unit puts out a brochure for pregnant women planning to give birth at the hospital. It states that: "Most new mums choose to breastfeed their babies, but if you plan to formula feed you will need to bring your formula and equipment with you. The staff will show you how to prepare feeds."
DHB staff Syd Horgan (primary and community services), Jean Todd unit manager Julie Dockrill, lactation consultant Pauline Hole and maternity services manager Donna McCann responded to questions about the hospital's policies and practices around bottlefeeding.
They say if a mother wants to bottlefeed, and has made an informed choice to do so, she is given as much help as a breastfeeding mother to achieve that result, and ensure the baby is safely formula-fed.
"A mother who is bottlefeeding should feel just as confident going home with her baby to do that."
Timaru Hospital has been accredited Baby-Friendly for 11 years; Donna says she believes that over time, people's understanding of that BFHI has changed.
"Not just from health professionals, but also from the general public. When we first went down this track, people thought women were going to be shunned if they wished to bottlefeed."
They say being baby-friendly is about the care of the mum as well, and that includes bottlefeeding mums.
Bottlefeeding will go in cycles; they might have no mothers for a month who bottlefeed, and then there might be four. In 2011, 6 per cent of well babies went home being bottlefed.
Pauline says she would expect that the minute a mother says she no longer wishes to breastfeed, she is supported in her decision to switch to bottlefeeding.
"And the relationship with her midwife throughout her pregnancy, she should feel confident to be able to tell her, or me, or anybody, that she wants to bottlefeed."
She says it's important if a mother plans to stop breastfeeding when she leaves Jean Todd that she has the information she needs to know how to wean and formula feed safely.
"We help them, we don't want them to stop breastfeeding without learning to take care of their breasts. We want the mother to be well and healthy, it's part of our role."
However, they all say that mothers are more informed of the normality of breastfeeding, and more mothers now are wanting to breastfeed.
"The information is out there, it's been out there for a long time, that breastfeeding is the normal way to feed a newborn baby."
Timaru Hospital's breastfeeding rates are high, and easily outstrip the requirement to have 75 per cent of mothers exclusively breastfeeding well babies when they leave Jean Todd. The past six months to June, the rate was 87.5 per cent, 2011, 86 per cent, and 85 per cent in the previous year.
Annual audits involve pregnant women, breastfeeding mothers and non-breastfeeding mothers contacted for their feedback, and those audits aren't showing problems.
Dianne Cox is a midwife with South Canterbury Independent Midwives. She says things have changed during the 30-odd years she's been a midwife in South Canterbury.
"When I first started work in Timaru in the early 1980s, it was quite a bottlefeeding culture. Over the years, it has changed, as midwives and women became more aware of the benefits of breastfeeding."
Dianne says about 3 per cent of women physically can't breastfeed, for reasons relating either to them - for example, previous breast surgery - or to their babies.
"And there are just some women, just for whatever reason, they might have been abused at some stage, or they just think that the idea of having a baby attached to the breast is totally abhorrent. There are women who just can't produce breastmilk, or they just feel they can't breastfeed, they have sore nipples, problems with baby feeding, or they have got such confusing advice from different people, they just feel that it's too much.
"They are few and far between, but we should be a baby-friendly society, so if that means we have to bottlefeed, it's better for mother and the baby. As midwives, we have to support that decision, knowing they have had information about the pros and cons of both."
Dianne says most women start out wanting to breastfeed, but says it can be a hard slog. "Some women don't realise how hard it is; it's not just going to take two to three days, it can take weeks."
Dianne says that as far as she is concerned, her job is to support that mother and baby.
"And if the only way to support that mother and baby is to support them bottlefeeding, I'm more than happy to do that."
Birth plans, care plans and feeding plans document what's happening, so if a woman decides to bottlefeed, she should not be approached about it over and over again.
Is it a fine line between encouraging breastfeeding and a woman feeling pressured?
"Yes, I think it comes down to the relationship between the midwife and the woman. I don't have that (breastfeeding) experience, so I will support women in whatever they decide, as long as they are making an informed decision."
As for public comments about how a mother is feeding her baby, Dianne says that's simple.
"I think people just have to mind their own business. They don't know what goes on behind the scenes. I don't think it's anybody's right to publicly criticise any woman who chooses to either breastfeed or bottlefeed."
The Baby-Friendly Hospital Initiative is an international programme launched in 1991, in an effort by Unicef and the World Health Organisation to ensure that all maternity services become centres of breastfeeding support. The WHO has stated that the "Baby Friendly Initiative is the primary intervention strategy for improvement in infant and young child health". BFHI aims to improve exclusive breastfeeding rates and ensure evidence-based best practice standards of care in maternity services. Baby Friendly facilitites work to see that all women receive appropriate advice and support. For the women who choose not to breastfeed, BFHI requires that they are provided with unbiased information and advice and are supported in their decision.
Ten Steps to Successful Breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within a half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants of breastfeeding mothers no food or drink other than breastmilk, unless medically indicated.
7. Practise rooming-in - allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no articial teats or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital.
The WHO code of marketing of breastmilk substitutes says:
No advertising of breast-milk substitutes to the public.
No free samples to mothers.
No promotion of products in health-care facilities
No company "mothercraft" nurses to advise mothers.
No gifts or personal samples to health workers.
No words or pictures idealizing artificial feeding, including
pictures of infants on the products.
Information to health workers should be scientific and factual.
All information on artificial feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding.
Unsuitable products, such as condensed milk, should not be promoted for babies.
All products should be of a high quality and take into account the climatic and storage conditions of the country where they are used.
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