Lots of people have weighed in on “Latch on NYC,” the new New York City initiative to promote breastfeeding in hospital (for instance, here and here). While many breastfeeding advocates are thrilled, some are less so. They argue that the initiative has the potential to restrict choice and to judge women who choose either to supplement with formula or to not breastfeed at all, and is an attack on women’s right to choose.
However, I think the initiative, if implemented correctly and as documented on the NYC Department of Health Website (available here, with a more recently posted and helpful FAQ that clarifies some common misconceptions about the initiative). Here is why I think these changes are important, based on what I have seen as a doctor working in New York City hospitals. (Please keep in mind that examples I provide are based on my personal experiences; there is likely significant variation among hospitals in New York, and even more variation around the country.)
Why keep formula in a separate area so that women are required to ask for it if they need it?
The fact is that it is common practice to put dozens of bottles of formula on the baby’s bassinet regardless of what the mother’s intentions are for feeding. What’s worse, the hospitals strike deals with formula companies; in exchange for free advertising to a captive audience, the formula is free to the hospital. Hospitals that sign up to be part of this initiative can no longer stock bassinets with formula or accept free formula. Formula will be kept with other medical supplies.
For some perspective, in the hospitals I have worked in, while it’s easy to get formula, getting supplies to help moms who wanted to breastfeed can be next to impossible. Nursing pads, nipple shields, and other supplies that women may need are kept locked in a machine with the medications, and I actually am often unable to get those supplies when they are needed; for instance, women with inverted nipples often require nipple shields when they are first starting out with breastfeeding.
What about women with medical reasons preventing them from breastfeeding?
Many women cannot breastfeed due to their own medical conditions or medical conditions of their child, and according to the document they (and women who choose not to breastfeed for other reasons) are provided formula at no cost to them.
What about women who choose not to breastfeed for reasons that are not medical?
The documentation on the website clearly states that women should have full information about their choices, support if they choose to breastfeed, and should be given formula at no cost to them if they choose not to breastfeed. Additionally, staff are directed to refer women who choose to formula feed and cannot afford formula to the WIC program for after they leave the hospital. I will talk about this more below, but I completely recognize a woman’s right to choose not to breastfeed. Women have to do what’s best for them and their infants, and they clearly can be trusted to make this choice. However, it is crucial that they have access to information about breastfeeding and support for whichever choice they make.
Why will medical staff have to document every formula feeding and tell women about the benefits of breastfeeding?
Documentation is a very important part of medical care, to ensure that patients are getting high quality care and all the information to which they’re entitled. Nurses are supposed to document every formula feeding and the medical reason for it, and document that they informed women about the benefits of breastfeeding if there is no medical reason for formula feeding. Although this sounds excessive if you don’t have a medical background, documentation of everything is routine in the medical world. Nurses already document what the baby eats (breastfeeding or formula), and how much, and when, during every shift. This is standard medical care. The nurses also have to document if the mother wants to breastfeed or not. If she wants to breastfeed, nurses need to document if she needs help or not and if that help has been provided, and if not, when it will be. If the mother doesn’t want to breastfeed, the nurse has to document that she has been informed about the benefits of breastfeeding. It doesn’t say anywhere that this has to happen every time, so I imagine it only has to happen once. It really is important to ensure women are given full information, and the only way to be sure of that is to require that it be documented.
Don’t women already know about the benefits of breastfeeding? Isn’t this just lecturing?
To give some perspective on this, although women who spend a lot of time reading (and writing on) the internet about everything to do with pregnancy and motherhood mostly are well aware of the benefits of breastfeeding for themselves and their baby, the fact is that many of my patients truly would not have this information if they didn’t get it from me or from other health care providers. Some of my patients certainly do read the internet or books and get information there, but most of them get their information about pregnancy and child care from their sisters, mothers, aunts, and grandmothers. In the end, they trust that information more than the internet, books, or even me. Many of my patients are immigrants or the children of immigrants, coming from countries where the above-mentioned formula companies aggressively marketed (and in some cases continue to market) their products as superior to breast milk. The companies work around the world to mislead women and make them think that the best thing for their children is formula, and who doesn’t want the best for her baby? This gets transmitted from generation to generation. So although many people claim that of course women know “breast is best,” women in New York City (and surely many other areas with a high level of immigration) are particularly likely either not to know about the benefits of breastfeeding, or to benefit from hearing it again (especially since many are not hearing about it from their prenatal care providers).
The context here is critical. The fact is that New York City has among the lowest breastfeeding continuation rates in the country. Although 90% of women start breastfeeding, only 31% are breastfeeding exclusively two months later (source). In the hospitals I have worked at, babies are routinely given formula by nursing staff without ever asking the mother about their plans regarding breastfeeding. Even babies whose mothers have specifically requested that their infants be given no formula or pacifiers are routinely given bottles and pacifiers when the babies are not with the mother. Women who need breastfeeding support do not get it quickly enough. The result of this is that women who want to breastfeed can’t. Women who discontinue breastfeeding generally don’t do so because they made a conscious decision to stop, but rather because they were either having trouble with breastfeeding or were concerned that their baby wasn’t getting enough, and they didn’t get the support they needed to continue. Beginning at birth, we have created a system which routinely fails to help women achieve their breastfeeding goals.
This initiative seeks to turn the tide in a system that is not working for the women of New York City. It is not about punishing women or shaming them for their choices. As I’ve noted above, many women and children have medical reasons that breastfeeding is not a good option for them. Some women try to breastfeed and it doesn’t work for them physically, either because it’s too painful, their infant can’t latch on correctly, or they don’t produce enough milk. Still others find that breastfeeding exclusively on-demand is not possible in light of other responsibilities they have, and others don’t like the idea of breastfeeding at all and don’t want to breastfeed. All of these situations and choices are valid and women should choose what’s best for them, their baby, and their life.
Some bloggers have pointed out correctly that this initiative is pointless without also working on the other barriers and facilitators to breastfeeding. A new mother who has to go back to work two weeks after giving birth because we have such lousy maternity benefits in this country will probably have a lot of trouble continuing to breastfeed for 6 months. Even if she gets more than two weeks of maternity leave, breastfeeding won’t work for her if she doesn’t have a clean, private place to pump and enough break time in which to do it. And if she doesn’t have access to high quality, affordable day care she may not trust her provider to correctly store and reheat her breast milk even if she can pump.
However, we have to start somewhere. I applaud the New York City Department of Health, its Commissioner, Mayor Bloomberg, and those hospitals that have volunteered to follow these new standards. The concerns some have raised about not giving women full choices are valid, but upon inspection most of the claims are simply not true. As the devil is always in the details, those who are concerned about preserving access to all choices for all women should use their energy to ensure that the new requirements that hospitals report on how much formula they’re using do not lead to restrictions in choice for new mothers, and that women who choose not to breastfeed are treated with respect and referred to WIC for help paying for formula if they can’t afford it. The need to carefully monitor an initiative does not mean its implementation should be prevented. This is a step forward for breastfeeding choice for New York City mothers, and should be welcomed as such.