We’re spending millions to promote breastfeeding; where’s the return on investment?

compact electric breast pump to increase milk

Public health initiatives, by definition, are meant to improve public health.

We waste millions on public health campaigns that produce no discernible return on investment.

They are usually based on solid scientific evidence, their implementation saves thousands if not millions of lives, and they pay for themselves many times over in lives saved, earnings preserved and medical expenditures averted.

Consider the classic public health campaigns to promote vaccination and to reduce tobacco smoking.

This graph from E&K Health Consulting shows the dramatic drop in incidence of vaccine preventable disease after the introduction of the vaccine for the specific disease:

cases pre and post vaccine

Notice that the y-axis is logarithmic, which means that the actual changes were far more dramatic than a glance at the graph would indicate. For example, there were approximately a one hundred thousand cases of smallpox per year prior to the introduction of the vaccine. In 2012 there were no cases at all. For each and every vaccine, the number of cases decreased by several orders of magnitude after the introduction of the vaccine.

The public health campaign to reduce tobacco smoking has had similarly spectacular results.

smoking lung cancer deaths

This graph originally published in the National Cancer Institute Bulletin shows that in the wake of the Surgeon General’s report of 1964 warning about the link between smoking and lung cancer, per capita cigarette consumption dropped dramatically. After a lag period, lung cancer deaths began to drop dramatically, too.

We have spent millions of dollars promoting vaccination and reducing smoking and it has paid off in both lives and money saved.

How about breastfeeding?

In the past 20 years we have spent millions of dollars promoting breastfeeding despite scientific evidence that is weak, conflicting and riddled with confounders.

An entire industry, the lactation industry, has arisen to promote and profit from efforts to increase breastfeeding rates. For example, lactation consultants did not exist prior to the mid 1980’s. Now they are everywhere, in hospitals, in doctors’ offices and in private practice. There have been multimillion dollar health campaigns and there is now a certification costing hospitals more than $10,000 each to be designated as breastfeeding friendly.

Breastfeeding initiation rates have tripled since 1970 rising from 25% to 75%.

So where is the return on investment?

Where is the evidence that thousands of lives have been saved? Where is the evidence that millions of cases of disease have been prevented? Where is the evidence of millions of dollars in healthcare expenditures averted? Where is the evidence that the dramatic rise in breastfeeding has had any impact at all on infant or child health?

I haven’t been able to find any such evidence.

Sure there are papers making claims about theoretical health and spending benefits, but I haven’t found any evidence of actual health and spending benefits. If it exists, I invite anyone who has seen such information to share it with the rest of us.

That doesn’t mean that breastfeeding is a bad thing. It’s a good thing, but the benefits for children in first world countries are trivial. If those benefits were anything other than trivial, we should have seen a dramatic impact on infant health and pediatric care expenditure in the past 45 years when breastfeeding initiation rates rose by 200%, but we haven’t seen anything of the kind.

No doubt the lactation industry has benefited. The number of lactation consultants in the US has increased from 0 in 1980 to 3.5/1000 live births in the 2013 (14,000 lactation consultants). Tens of millions of dollars have been spent on public health campaigns, and tens of millions of dollars are spent by mothers themselves.

What do we have to show for it?

Nothing.

Unless, of course, you count the soul searing guilt and feelings of inadequacy among women who can’t or choose not to breastfeed.

Going forward we should dramatically scale back spending on breastfeeding promotion. In an era of scarce healthcare dollars, we can’t afford to waste millions on public health campaigns that produce no discernible return on investment.

Breastfeeding should be a private choice. There is no reason, scientific or economic, to spend millions promoting it.

  • Julia B

    The NHS estimated cost savings from breast feeding promotion in a 2012 report. This is due to reduced numbers of GP visits due to infant colds, gastroenteritis and necotising colitis. I guess it depends on who is paying for the promotion and where the cost savings are. In the US, perhaps the cost savings are lower due to poorer access to healthcare and an unclear link between the organisations promoting breastfeeding and where the greater costs are. See link: https://www.nct.org.uk/first-uk-study-showing-investment-breastfeeding-could-save-nhs-money and http://www.unicef.org.uk/BabyFriendly/News-and-Research/News/breastfeeding-report-nhs-savings/

  • Busbus

    Great points, Dr. Tuteur. I couldn’t agree more.

  • The Bofa on the Sofa

    Found this random blog:

    “I Was Brainwashed into Breastfeeding Much Longer Than I Should Have”
    http://rolereboot.org/family/details/2015-08-i-was-brainwashed-into-breastfeeding-much-longer-than-i-should-have/

    So brainwashed was I by the idea that formula was bad for my baby that I chose to incapacitate myself for the first seven months of her life rather than give her formula. I chose to breastfeed her milk that was tainted with the antibiotics I had to take to fight the infection in my breasts rather than give her formula. I chose to endure terrible pain and to subject my family to vast inconvenience as I crashed out of their lives again and again for days at a time. I chose to let my confidence as a mother and as a woman be eroded by a twisted belief that this hell was preferable to the failure of giving my daughter formula.

    It wasn’t until my friend shook me out of my delusion by giving me “permission” to wean that I saw the very real damage I was doing to my baby and myself. I gave my daughter formula that day and began to regain my health, my self confidence and my relationship with my little girl.

    And this

    Formula is not the enemy. The enemy is when you’re so overwhelmed by the expectations of others who don’t know your story that you make decisions based on guilt. The act of being a good mother and taking care of your baby is made up of many moving parts. And sometimes, formula is actually one of them.

  • Seattle Mom

    Slightly OT, but now this woman has to factor a traffic ticket into her ROI: http://www.seattletimes.com/seattle-news/woman-pulled-over-on-i-5-for-breastfeeding-while-driving/

    • Young CC Prof

      On the Interstate, excellent. How does one even begin to explain the safety problems with that?

    • Megan

      Seriously? Pull over to feed your kid. Wow. Just wow.

    • Roadstergal

      Breastfeeding a 1-year-old while driving on I-5. It would only be a more WA story if she were driving under the speed limit in the fast lane.

  • Megan

    I have been trying to find the answer to this question but have been unable. As I was looking back on my experience in the hospital delivering DD I recalled that I was never told her weight and the nurses even sidestepped answering when I asked directly. Is this part of the BFHI? I told my husband that I want to know this baby’s weight every single day to prevent readmission like with DD and so it would help me to know when to supplement if needed. But then I recalled that no one would tell me DD’s weight (and they weigh the babies in the middle of the night) last time so it got me wondering if this is something I’ll have to fight about.

    • Young CC Prof

      You know, the same thing happened to me with my son, and his hospital was not at all baby-friendly, they were happy to use pacifiers and take him to the nursery. I asked a nurse about weight loss once, when he was either one or two days old, and was told “Point-zero-four.” She then left the room without explaining what the units were or what that meant. I was NOT told his discharge weight, and I learned only after he’d been readmitted that he was already down 11% at discharge.

      He weighed five pounds at birth, and four pounds four ounces when he was readmitted a day after discharge. His sodium level was 159 and his bili was over 19.

      You might want to talk to the staff about this beforehand, maybe during a hospital tour. Ask to see the specific numbers, every 12 hours. The pediatrician is more likely to be straight about this sort of thing than a nurse, so go ahead and ask the ped. Ask for specific bili numbers also if your daughter had jaundice. And have you heard about NEWT? Newborn Weight Tool? It’s a calculator for identifying excessive weight loss before it causes illness, and it’s new. You can start giving the baby small quantities of formula after every nursing session as soon as he drops below the curve.

      I think the bottom line on this problem is that the Joint Commission and other certifying groups have decided that breastfeeding is a priority, and preventable readmissions of basically healthy newborns isn’t. There are a few people working to change that.

      • NoLongerCrunching

        If you are going to be giving small amounts of formula after breastfeeding, you can actually use the formula as a tool to help the baby breastfeed more effectively. For example if you put the baby to breast and he is too sleepy to latch on, use a few sucks from the formula bottle to encourage him to wake up and get interested in eating. Latch him on and do your best to keep him sucking on the breast using massage and breast compressions. When he gets sleepy again give him a few more sucks from the formula bottle. Keep doing this “bait and switch” until he is satisfied. As the milk supply increases and his energy levels go up from getting enough to eat, he will do a better and better job of nursing. When possible, also pump so your breasts get good, non-sleepy stimulation. (Note: this is cookie-cutter info; if things are really going poorly, get some good hands on help from a professional or experienced mom).

      • Megan

        I’m glad I’m not the oh one who has experienced this! This time around I will make sure I get that info every day even if I have to be bitchy. I have heard of NEWT but I’m glad you reminded me because I had forgotten about it and it will be a good thing to follow in the hospital. I have no problem with formula supplementation and plan to use it if needed and I have told my doc as much. You know, I sometimes wonder if I don’t need a birth plan now more than before, since I don’t want so much of the crap that BFHI pushes. It would say things along the lines of, “I want to use the nursery so I can rest before going home to two children. I am ok with formula supplementation if needed. A paci is NBD to me either way. Don’t ask me to pump breastmilk; I won’t do it again. I want to know my baby’s weight and bili level at every check and want it written down for me so I can keep tabs on weight loss and prevent readmission for jaundice (which I really can’t have happen this time since I have another child at home). Etc “

    • Mattie

      AFAIK no, the criteria are listed here http://www.ncbi.nlm.nih.gov/books/NBK153487/ In my opinion weighing the baby is a procedure and should therefore be done with the consent of the parents, and the parents should know the outcome. Also, in the UK women have hand-held notes with them as well as their hospital notes and baby weight is recorded in those.

    • Amy M

      Huh. I knew my babies’ birth weight and what they weighed when we went home. I don’t remember learning any other numbers. But….my babies were pre-term twins, and small to start, and I was told on Day 2 that they wanted to keep them one extra day to make sure their weight loss had stabilized. They were being supplemented the whole time we were there, I had no milk yet and as soon as we got home, we switched straight to formula bottles. It appears that in (some?) BFHI places they want to push parents out asap before 1)baby loses too much weight and 2)parents start supplementing, so they can get their “went home breastfeeding” cred. That’s really obnoxious. Are there any studies looking at readmission of infants in BFHI v. Not?

  • OT: I posted a while ago about getting ready for my C section with accreta. We came through it great! Baby was born at 35 weeks and is nursing like an old pro. The accreta was only in one area so they were able to cut out the attached portion of the uterus instead of doing the hysterectomy. So far it’s the best outcome I could have hoped for. I’m grateful to my cautious and skilled MFM, who saw the problem on the ultrasound and came up with the plan to deal with it.

    • Who?

      Congratulations. Enjoy your new addition and take care of yourself so you can recover well.

    • Inmara

      Congratulations!

    • Cobalt

      Congratulations and thank goodness.

    • Sue

      Great! Congrats!

    • Megan

      That’s great! Congrats and enjoy your new baby!

    • Montserrat Blanco

      Congratulations! I am really glad it all turned out well. I wish you can take your baby home soon and also best wishes for your recovery.

    • KeeperOfTheBooks

      I’m so glad you both came through so beautifully! Congrats on the new little squish, and hurrah for awesome docs!

    • moto_librarian

      Oh, I am so happy to hear this! Glad that everyone is well!

    • Roadstergal

      Hooray for heads-up doctors and happy families!

    • Amazed

      Congrats! So happy for both of you!

    • So glad it has worked out well.

    • Conga-rats!

  • Bugsy

    All-natural and GMO-free! 🙂 Lol…that does make it seem a bit better, hehehe!

  • Kq

    My cousin’s partner is laboring (in the hospital) right now! Impatient to welcome the new cousin, and to finally find out her name (they’ve been calling her Oprah Tender Roni)

  • DaisyGrrl

    Reading this post, I started thinking about what would have an impact on infant health in terms of public health spending (aside from vaccines, that’s a biggie). A major determinant of health is income, even in countries with universal healthcare. Since many new mothers in the US have to return to work relatively soon after giving birth (especially poor women who lack social supports), it seems that providing women with some sort of paid leave during the first year of their child’s life – a maternity leave, if you will – could prove a positive influence on infant health.

    Off I went to PubMed and entered “maternity leave infant health”. Most of the hits seem to be looking for correlations between breastfeeding and maternity leave policies (because breast is best! and therefore more breastfeeding = better health). But I found this article that had some interesting observations: http://www.biomedcentral.com/1471-2458/13/1049 it discusses redistributive policies and how they impact child health.

    While some of their data points are a bit wonky (they also fall for the breastfeeding/mat leave trap), their conclusions aren’t too crazy. “Generous redistributive policies are associated with a higher maternal leave allowance and pay and more preventive child healthcare visits. A decreasing trend in infant mortality, low birth weight rate, and under five mortality rate were observed with an increase in redistributive policies. No clear influence of redistributive policies was observed on breastfeeding and immunization rates.”

    So, lower death rates, no impact on breastfeeding rates. One major omission from the analysis was availability of universal health care and the impact on maternal and child health. I suspect this might also explain some of the discrepancies between the US and other countries. Definitely food for thought on where public funds could be directed to maximize health outcomes.

    • Mattie

      Sort of laughable that in the US standard paid parental leave is a radical idea. Personally I also quite like the ‘baby box’ idea from Finland, which goes a long way to helping the poorest families and I believe has had a huge (positive) impact on infant health and mortality rates. http://www.bbc.co.uk/news/magazine-22751415

      • Roadstergal

        A friend of mine on Twitter shared that link about the ‘baby box,’ and while the article was overall awesome, this quote:

        “At a certain point, baby bottles and dummies were removed to promote breastfeeding.

        “One of the main goals of the whole system was to get women to breastfeed more,” Pulma says. And, he adds, “It’s happened.””

        Sigh.

      • sdsures

        I love the idea of the “baby box”, too!!

    • SuperGDZ

      The surest way to raise the level of income available to a child is to raise the level of income available to its mother, which means that the most significant way to raise the health and welfare of children is either a socialised system which keeps all citizens out of poverty (not coming to the US in our lifetimes) or an environment in which mothers can go back to work and stay at work. A period of paid maternity leave is great, but isn’t going to have any lasting impact on the financial situation of the family. Job protection, affordable high quality childcare and flexible working hours are the kinds of initiatives that will help mothers and children.

      • Sarah

        True. I’m a strong advocate of paid maternity leave myself, believe the US should implement it, and have taken/am taking the majority of the leave available to me. But it’s also true that time out of the workplace potentially has a detrimental effect on mother’s income, unfortunately. With that said, better that it exists than doesn’t.

        • SuperGDZ

          I agree that there should be paid maternity leave and took 6 months of paid maternity leave myself (negotiated with my employer). I just don’t think that a long period of paid maternity leave on its own will improve the financial situation of mothers. Unless part of a strong framework protecting the rights of working women, mandatory paid maternity leave for extended periods is likely to work against women in general as employers may be less inclined to hire or promote women or invest in their training and education. On the other hand, without adequate paid maternity leave, women who might otherwise have stayed employed give up work altogether.

          • Inmara

            In my country, as in most other European countries, maternity leave is paid from social insurance which is mandatory for all employees. So from financial standpoint there is no difference between genders, except for the hassle of arranging replacement worker.

          • Young CC Prof

            One thing that can help there is to make sure that it’s offered to both men and women. Here in NJ, we now have 6 weeks of paid leave for each parent, which can be taken consecutively. Many families now do that.

          • Sarah

            On the one hand, time out of the workplace tends to make you earn less in the long run. On the other hand, paid maternity leave gives you more time to physically recover, and sick leave obviously can be detrimental too. I suspect women who have to go back after a couple of months are less likely to be physically recovered.

            We do have an issue in the UK with unofficial discrimination against women of childbearing age. I recently was successful in a job interview and I wonder if it was significant that they knew I had two children already, which is sort of professional woman code for ‘probably not having any more’. The new provisions to allow men to take nearly all the leave if the parents prefer may well be helpful.

    • lawyer jane

      I have read that the primary driver of infant mortality disparity in my city (DC) is due to prematurity. At least one person who follows the issue thinks that this is due to the greater overall stress faced by mothers living in poverty: http://www.washingtonpost.com/local/dc-politics/poor-dc-babies-are-more-than-10-times-as-likely-to-die-as-rich-ones/2015/05/04/27200040-f268-11e4-b2f3-af5479e6bbdd_story.html

      But although I agree that better economic conditions would solve the problem, I don’t think we can wait for that. I want to see specific interventions that reduce the mortality rate now …

      • Young CC Prof

        Prematurity is the primary driver of infant mortality, period. In the USA, two-thirds of infant deaths occur in premature babies, and half of them occur among the 2% of babies born before 32 weeks, that is, very premature.

        Yes, unfortunately there are major racial gaps in the rate of premature birth. Some of it is due to specific socioeconomic factors, like lack of access to care, teen pregnancy, etc, other parts can’t be directly explained and may indeed be due to stresses of poverty.

        There are people working on it, trying to make sure all women get cervical length screening during their anatomy scans and interventions for short cervix.

      • DaisyGrrl

        I remember reading in the comments here that one of the biggest barriers to prenatal care among low income Americans was that the clinics weren’t adequately accessible (location, time open, requiring appointments, insurance issues). A “quick hit” could be to have drop-in prenatal clinics in under-served areas where social workers help women sign up for services like medicaid, etc. They could rotate times/locations, have childcare available, and provide money for transportation if needed. No idea if this is feasible in the US, but could really help improve access to services for high-risk women.

    • Sarah

      I would imagine you’re probably right! Hence US going from a pretty decent perinatal mortality rate to an appalling infant mortality rate.

  • Anne Catherine

    Best Fed Bed Beginnings, a government program to increase breastfeeding rates and the number of Baby Friendly Hospitals just put out a study on the impacts of this program.

    There is no mention in the study of whether there were any improvements in health outcomes for babies or in hospital readmissions for babies born in baby friendly hospitals. I actually wrote Best Fed Beginnings and Baby Friendly and asked if their programs had ever done any research on this.

    The Response from Best Fed Beginnings was that “that was not the scope” of their program. It has been over a week, and I have not heard from anyone at Baby Friendly.

    There is a link to the study at the bottom of this page

    http://www.nichq.org/sitecore/content/breastfeeding/breastfeeding/solutions/best-fed-beginnings

    Honestly—it’s just so annoying that so much money and time is spent on this without a whole lot in results.

    If they told the truth about the sucess rates and benefits of breastfeeding, it wouldn’t bother me too much, but the way breastfeeding is promoted now with the scare tactics and all, I think, ends up doing a lot more harm that good.

    I guess I am speaking to the choir, here…Thank you Dr. Amy for pointing this out!!

    • Young CC Prof

      Exclusive breastfeeding during initial hospital stay is such a stupid measure! I mean, think about it. Even if there’s no colostrum at all or the baby’s latch is completely ineffective, a healthy newborn baby can usually fake it for 2-3 days before insufficient intake becomes an emergency, which will get you out the hospital door and down as a success in their book.

      I’ve said this before, if you measure that and don’t measure readmission, you are incentivizing your staff to ignore breastfeeding problems and kick the can down the road. Not only is it not a key health outcome, it’s not even necessarily a good measure of breastfeeding success.

      • KeeperOfTheBooks

        As seen with my best friend and her baby in a BFH, where despite a pediatrician ordering the kid get a bottle due to jaundice until mom’s milk came in (and mom being perfectly on board with this), the nurse said that formula “wasn’t allowed” and wouldn’t give them one or let them go get one to feed to the kid. By the time they jumped through the hoops for early discharge and got to the pediatrician’s office for a bili check, the baby was sufficiently jaundiced that she had to be readmitted.
        But hey, baby had been exclusively breastfed prior to discharge, so win, right? /sarcasm

        • EmbraceYourInnerCrone

          I am completely aghast at the formula is “Not Allowed” bull. People are Not Allowed to feed their own babies? WTF What to they do to people who go to the hospital intending to formula feed from the begining? Take away your formula if you bring it with you?

          • Roadstergal

            All of this BFHI stuff, and the quote from the Finnish ‘baby box’ man (of course), above – it’s all so effing belittling to women. “Poor little dears, they can’t be trusted to do the Right Thing, we’ll just have to make sure all of the bottles and pacifiers and formula is kept away from them.” Treating them like _toddlers_, for god’s sake.

            Even not considering the harm to babies, it’s galling.

  • demodocus

    So, basically, they’re spending millions on promoting the Mediterranean diet over other sensible, healthy diets, but pretending the competition is the exclusively junk food diet.

  • hmm hmm

    OT, if anyone would like to comment on this development in Vancouver. http://www.vancouversun.com/health/Plans+conceived+birthing+centre+Paul+Hospital/11317660/story.html

    • JellyCat

      I’m from Vancouver BC, and I think building a new birthing centre when we cannot even accommodate medical patients admitted to the hospital and are forced to treat them in hallways is simply not ethical.
      By treating in the hallways I mean that. Patients are in the hallways instead of patient rooms. We try to do our best and limit this, but this is not always possible.
      Forget the hallways, we had treated patients in TimHortons.

      • Bugsy

        Yep. Here in Richmond, they ship mat patients across the Lion’s Gate to the hospitals on the North Shore when our mat ward is full. Granted, it’s due to very Richmond-specific reasons that our mat ward fills up, but it seems to be a cause for concern for exactly no one. My OB has assured me it hasn’t happened much recently…but I still dread the possibility.

        • JellyCat

          At least maternity patients are not required to give birth in the hallways just yet. I suppose it’s a definite plus.

          • Haelmoon

            No, but they occasionally have to deliver in triage or the PAR, not much better than the hallway.

          • Mattie

            According to some of the midwives I worked with they had babies born in the hospital car park, or reception, and I believe once in a lift…not planned, and 2 midwives were hastily despatched to assist lol

        • Bombshellrisa

          I would too! Hit bad traffic downtown and you face the possibility of giving birth in Stanley Park.

          • Bugsy

            Yep…that would be a total spectacle for all of the cruise ships passing by underneath!! 🙂

          • Bombshellrisa

            Oh wow. Didn’t even think about that.
            I wonder how long it’s going to take before someone and her doula decide that laboring while walking back and forth across the Capilano suspension bridge (or the smaller one in N Vancouver, can’t remember the name) will be good to move things along?
            The only good thing I could see about having to cross the Lion’s Gate to give birth is the possibility of having someone bring me something from Savory Island Pie Company when I was done.

          • Bugsy

            I’ll have to keep that pie company in mind if I get shipped off to North Van!

          • Bombshellrisa

            Savory island is worth visiting, it’s actually in West Van, across and just a little up from the Safeway. Kid friendly too.

          • Bugsy

            Thanks! We don’t get to the North Shore too often but are always looking for great new places to try.

    • Bugsy

      I’m from Vancouver, too, and read that article in the paper this morning. Two lines in particular jumped out at me: “‘”Birthing centres are a popular out-of-hospital option in the U.K. and New Zealand, so we are looking at that model of care,'” and “But for uncomplicated deliveries, and for women who want to give birth in a nonhospital environment, birthing centres are seen as a more desirable, cost-efficient model of care.”

      In other words, let’s follow the UK model for out-of-hospital births because they’re less of a financial burden to our medical system.

      (Sorry to be so cynical; I’m still a bit peeved that I had to fight tooth-and-nail to get my TDAP in pregnancy even though the federal government up here recommends it.)

      • fiftyfifty1

        You had to fight to get your Tdap?! That’s horrible. Who was denying you?

        • Mac Sherbert

          I know last time I was pregnant my OB was all about giving TDAP to me at xx weeks before I had the baby. That sounds so odd they wouldn’t give it.

          • Cobalt

            I had to get my most recent third trimester DTaP from my GP, and I couldn’t even get an appointment just for that. I had to get a physical, so I had to wait until it had been a year since my last physical for insurance to cover it.

            The big driver of hoop jumping in my case was my insurance. Everything has to be coded just so in order to get coverage. They could have saved a ton just letting the OB do it at one of my regular prenatal appointments.

            Nuckin futz, says I.

          • Bugsy

            Yep. My guess is that up here, it’s an expense the government isn’t willing to fund unless there’s an immediate outbreak. I just wish they’d admit to that, though, and not try to cover it up with “it’s not recommended due to long-term safety concerns.”

          • Haelmoon

            Most OB offices are not set up for giving vaccinations safely. Although most just require the shot, there is a requirement of being ready with epinephrine for an allergic reaction. At least in BC, we can send them to the health unit (not all GPs even give vaccines here)

          • Bugsy

            I agree…before this pregnancy, I never would have guessed this would be the policy given my previous experience in the United States. It seems so strange to me!

        • theadequatemother

          I had to go through a few hoops to get my Tdap in 2013 in Canada. The OB didn’t do them and seemed ignorant of the CDC recommendation, so I had to call my family doc and make a separate appointment. It wasn’t the end of the world but it was a pain. I don’t think its standard of care in Canada the way it is in the US yet.

        • Bugsy

          Both my OB and the pharmacy we use said that they don’t recommend Tdap in pregnancy because there aren’t any long-term studies done on it…the public health unit was only willing to give me one if I haven’t had a booster as an adult.

          Heck, I would have been willing to pay for it out of pocket if needed…but it really seems to be that we’re turned away unless we’ve never had an adult booster or there’s a pertussis outbreak (or you need the tetanus shot due to injury). Really frustrating, and completely the opposite of my OB’s office back in the U.S. the last time around.

        • Inmara

          I didn’t get Tdap during pregnancy because it’s just not done here, my OB didn’t see the need and I was not willing to jump through that many hoops. Fortunately vaccination rate is still high here and I haven’t heard of pertussis outbreaks.

      • Sarah

        Freestanding birth centres, as opposed to midwife led units inside a hospital building and right next to the consultant led units, actually are not particularly popular in the UK at all. Well under 10% of births take place there. The FMLU in my city is relatively underused, for example. This can’t all be explained by the stringent entry criteria either.

        Not for the first time, people commentating on the UK system from elsewhere are confusing the popularity of midwife led birth inside a hospital with midwife led birth outside it. Either they’re doing it on purpose, which is unconscionable, or they’re doing it out of ignorance, which suggests they’re not someone who should be listened to on the matter.

        Sorry you had trouble getting your vaccine btw. That’s one thing the UK does do well.

    • DaisyGrrl

      At least that birthing centre will be on hospital grounds. Here in Ontario, birthing centers are run independently of hospitals. The one in my city is a 10 minute drive from the hospital (so good luck transferring in anything under 30 minutes).

    • theadequatemother

      1) we shouldn’t be spending money to create special units for a demographic class that is going to have amazing good outcomes no matter what you do. Also not likely to save money because each birth will need two midwives or a midwife and FP or a FP and a nurse and full backup by the main hospital (the cost of maintaining LDR capacity and emergency surgical services is never factored into this stupid birth center home birth cost analysis).
      2) 60-80% of normal first births occur with an intervention not avail in the birthing center – an epidural. (and in BC something like 40-50% of second or subsequent births)
      3) on the grounds of the hospital is still too far. A transfer from that building to the main building will still likely involve the ambulance service unless there is a tunnel or a skyway. Heck, we have a surgical site across the street that my anesthesia group staffs and if there is a code there we have to call 911. I once had to transport a patient in status from the ECT suite in the psych building to the recovery room which was across the parking lot and it took over 30 min. The birthing center on hospital grounds is no better than home…possibly worse because of a false perception of safety and expedient help.
      4) midwifery led care in the UK and NZ has outcomes worse than what we are achieving
      5) its makes OBs more effective and less likely to burn out to have some easy cases mixed in with their tough cases.
      6) the transfer rate will probably be around 40% for first time moms.
      7) other similar birth centers in Canada have been shut for problems in care quality or lack of interest amongst women (I’m thinking of Winnepeg here).

      • Ash

        I really hope there’s a skywalk/covered walkway between the two buildings. Otherwise it’d be great fun to transfer a patient on a gurney out in the winter…

        • Haelmoon

          The winter is not too bad in Vancouver 🙂 However, in all seriousness, I agree with the adequate mother – why are we spending more money on women who already have good outcomes, when those with poor outcomes, particularly associated with SES factors are left to fend for themselves. We have had some very pro-natural women who used up more resources before delivery because they wanted to have a natural birth – there was recently a planned homebirth of breech/breech twins in Vancouver – 4 midwives (real ones, not the Gloria Lemay type) attended. Some much time was spent ahead of time trying to get her into the hospital. I have mono/di twins with TTTS or sIUGR who have used less resources antenatally. Tell me that was cheaper or better than a hospital birth.

      • Monkey Professor for a Head

        3) makes me think of the time my old hospital was in the process of moving to a new building on the same site. The psych ward was moved before the rest of the hospital and in that time I attended an emergency call for a big GI bleed there. It basically a complete shambles, and once I realised that this was not the appropriate place for this patient I had to figure out the logistics of getting him to an acute area. As there were no ICU beds immediately available, we ended up getting an ambulance and taking him to the emergency department, where I had a fight with the ED consultants (as he was technically an inpatient) before being able to bring him in. This guy was fine in the end, but if it had been a bigger bleed (and postpartum haemorrhages can certainly be torrential) then that delay in treatment could have killed him.

      • demodocus

        Then there’s one of my local hospitals, which calls their L&D a “birthing center.” Sounds sparklier and they did have some odds and ends like birthing balls, but they also had the OR 10 ft away.

        • Ash

          Yes, the L&Ds in this city have been renamed “birth center” as well.

        • KeeperOfTheBooks

          Right. As I’ve said before and will say again, there is nothing wrong an quite a lot right with giving in on nonessentials. Mom wants a rocker/birthing ball/squat bar in a comfy, homey room? It makes her happy/more comfy, it does no harm, and as you say, the OR is a few feet down the hall. Perfect compromise.

        • Liz Leyden

          My local hospital recently renovated L&D, merged it with postpartum (which had been 3 floors down in a different building), and renamed it the Birthing Center. It still has a tub room and 2 ORs, and is very close to the NICU. The biggest improvement is single rooms for recovery.

      • Chi

        Can you expand a little about number 4? I’m from NZ and here, we don’t have a hell of a lot of choice when it comes to prenatal care. The government doesn’t fund OBGYNS unless you need specialist care, leaving laypeople with no choice but to go to midwives.

        However I’m finding it very hard to find data on homebirth in NZ. I went looking for it because my younger sister informed me that she was having one and I worried. She got lucky (in my opinion) because her baby was fine and she got off with a little bit of tearing (though, I’m not sure of her definition of ‘a little bit’ as it required something like 7 stitches).

        I had a midwife also, but had a hospital birth, which was my choice as there was no way in hell I wouldn’t deliver in a hospital where immediate help was available if needed. I needed the reassurance of that (and the painkillers too).

        So yes, I’d be very interested in what you mean by outcomes worse than what we’re achieving 🙂

  • Mel

    There has to be a sensible middle ground.

    Women who want to breast feed may benefit from support from trained professionals who can help them problem-solve various breast-feeding problems. As a society, we should be willing to provide that support along with scheduling modification for pumping breaks.

    We should also provide support needed for mothers who choose to formula feed.

    It’s not rocket science, really.

  • Megan

    I just had a big pep talk with one of my friends who just had her first baby. Baby is 6 weeks old and still cannot latch. Mom has been doing the crazy feeding/pumping schedule since birth and supplementing with some formula since she can’t keep up with baby’s needs. Baby is growing well but has had issues with gas and colic since birth despite mom cutting out all dairy. Basically she’s sick of it and wants to switch to all formula so that she can use one better geared for her baby’s colic. Her family and of course, the LC’s at the hospital have been harping on her about her supplementing and now trying to make her feel guilt for wanting to switch. Our hospital is a BFH. It took an hour long pep talk with her for me to reassure her that her baby will be just fine on formula and that not wanting to pump so she could spend more time with baby was a great reason to quit. I told her to do what was best for her family and not listen to anyone else. I also told her that the next time someone criticized her that “breast is best” she should ask them what they though of the PROBIT and discordant sibling studies. I also told her to remind herself that she can’t tell the difference between her formula fed and breastfed friends and if it made that much difference she would be able to.

    Our public breastfeeding initiatives have done a world of harm to moms for whom breastfeeding just isnt working. Enough is enough. I wish my hospital would’ve spent money becoming a BFH on something else.

    • Mel

      Depending on your friend’s personality and her relationship with the LC’s, you could point out that the LC makes more money for the hospital promoting a miserable breast-feeding relationship for mom and baby than the LC does by saying “Yeah, formula’s a better choice this time.”

      Compare that with the kid’s pediatrician – who is going to be seeing the family for years and doesn’t need a miserable baby and mom taking up schedule time – and see which recommendation you would trust.

      • Megan

        Oh yeah. Her pediatrician already told her it was fine to quit. I think she just wanted to hear it from me since I’m not only a doc who sees a lot of kids but also a fellow mom and her friend. I just hate that her family hasn’t been supportive. The “breast is best” campaigns have made them think it’s ok to criticize her feeding choices rather than be supportive.

        • KeeperOfTheBooks

          Thank you for being so supportive of your friend! I still remember how helpful it was for me when I finally switched over, and neither of the pediatricians at DD’s practice–both of whom, incidentally, were breastfeeding moms themselves–said anything beyond, “That sounds like the right decision for you, and your daughter’s doing great. So, which formula are you using? Want some samples?” I’d felt horribly guilty, and having that affirmation really made a positive difference in my outlook.

      • swbarnes2

        For what it’s worth, two different LCs at the hospital had prepared spiels about how I SHOULD supplement my late pre-term newborn, at least until I could get anything out with the pump. So not all of them are Lacti-nazis.

        • Mel

          Oh, I agree. There are some awesome LCs out there who have done some great work for my teenage students who wanted to breast-feed but had no idea what to do.

          Then there is the local hospital that requires BF moms to sign a paper if they want a pacifier that the binkie might interfere with breastfeeding. *rolls eyes*

          • Sarah

            Is there a ‘so fucking what’ section of the form?

          • KeeperOfTheBooks

            If not, I suggest adding one, complete with appropriate box, and checking/initialing that box. 😉

    • Michele

      Not that a random internet person’s opinion should mean anything, but as someone who exclusively pumped for #1 for almost a year, tell her that I COMPLETELY support her doing what is best for her family. I’ve been there with the hell of the crazy feeding/pumping schedule. If I had to do it over again I would not, for my own mental health and the amount of time it took away from my family.

      • Megan

        Oh believe me, I get it. I exclusively pumped for my baby for seven months and it was the dumbest thing I did. I regret the time I wasted and wish I’d spent it with my daughter. I told my friend as much.

    • Montserrat Blanco

      From the mother of a preemie: switch to formula. The worst time of my life I spent it attached to a pump. And believe me, after you are cleared from necrotizing enterocolitis it makes no difference at all.

      • Daleth

        For real. I was SO jealous of my husband, mother-in-law etc. holding my babies while I pumped. I wanted to cuddle my twins and get to know them! SO GLAD I gave it up and switched to formula.

        • Kelly

          I remember being so jealous that people had a “good” reason to formula feed. I felt that since I could produce well, that I could not quit. We were also trying to “save” money.

          • Liz Leyden

            The deciding factor for me was finding out that my kids qualified for WIC, which pays for formula.

          • Kelly

            We barely did not qualify for WIC and so we were on a tight budget. I honestly think that all the money I put into pumping was just as much as if I had fed my child formula. I wish I knew then what I know now.

    • The Bofa on the Sofa

      I hope you also used the opportunity to reassure her that she should trust her pediatrician.

      • Megan

        Of course. But she wanted to talk to a supportive friend.

    • Mac Sherbert

      It’s so hard to stop that BF cycle even when you really want to. Something about the sleep deprivation and hormones makes it an emotional not a rational thing.

      • Inmara

        Oh yes! I’m in that place right now, considering supplementation because just boob seems to be not enough and I haven’t figured out pumping yet, though it may work for me. Still feeling a bit like failure despite reading SOB so much.

        • Cobalt

          If you are feeding your baby nutritious food in good quantity, either breast milk or formula, you are not failing. You are winning against a natural cause of illness and death that has killed millions or even billions of babies throughout human history and into modern times.

          Don’t let anyone, or even your own all-natural hormones, tell you otherwise. Easier said than done, I know.

          On a side note, if you’re interested in continuing with the pump (totally personal choice), try different settings. Sometimes you can turn the pump pressure down and get better results. It might help, if that’s something you want to pursue.

          • Inmara

            I have some medical and psychological background with my breasts which makes breastfeeding tricky and causes these failure feelings as well. But rationally I agree with you 100% and will go on with supplementation if our pediatrician will advise so. Thank you for kind words and practical advice, now I need to somehow schedule pumping between soothing baby, having a walk, eating, sleeping , petting cats and other Very Important Things.

          • Cobalt

            My personal method, which you should throw straight out the window if it doesn’t suit your needs, is to think about what “me five years from now” might want to tell “me here in the moment being overwhelmed by (insert circumstance)”. The perspective of time helps put most decisions where they belong on a scale of importance. Of the choices you CAN make, which will give you the best “look back” and least regret, or will they all fade away into irrelevance over time?

            Again, if that isn’t helpful, please disregard it entirely. I’m unusually philosophical this morning, that’s what I get for running out of coffee and having to drink tea instead.

          • Mac Sherbert

            Yes. My parenting advise I give to myself goes something like this…when they go college will I look back and regret doing or not doing xyz? Perspective helps a lot!

      • Megan

        I really do think hormones make it harder to stop. That’s one of the reasons I am scared to even try when this baby gets here, because I’m afraid I will have a hard time stopping and will fall back “down the rabbit hole” of lactation. I think it I’d been more rational the first time I would’ve stopped around three months but I just couldn’t. I was a crying mess every time I thought about it.

        • Young CC Prof

          Would it help to set a deadline beforehand, and put it on the calendar? Like, if it’s not working well by X weeks, just quit?

          • Megan

            Yes I think I will do that. I’ve been toying around in my head what that deadline would be but ultimately I have refused to pump this time around. Period. So basically it becomes a question of whether my milk comes in adequately or not. Last time it took 1-2 weeks to fully come in and even then wasn’t much until I took Domperidone (which I also will not do again). I also had a traumatic delivery last time though with a severe PPH that required methergine (apparently associated with deceased prolactin levels) and transfusion so that probably didn’t help me. Basically i think my plan at this point is to BF in the hospital, supplementing if needed. I don’t mind hand expressing colostrum but I will not pump. If milk comes in, great. If not, oh well. If breastfeeding works out well and goes easily I’ll continue until I’m tired of it (or LO gets teeth!) but if it’s a pain or I’m supplementing more often than not I’ll stop by maybe 4-6 weeks depending on how much unpaid leave I can afford to take. I’ve told my husband and my best friend to remind me that I did not want to go to extremes this time and they’ve both agreed to try to remind me of I get overzealous! (My friend even took a screenshot of our text conversation to show me!) My plan may change but I have a while until LO is due in March.

  • Cobalt

    Breastfeeding requires protection (employment issues come immediately to mind, reasonable accommodation should be made to allow working mothers pump) but not promotion.

    As a private choice, neither the government, employers, or private industries should be making it for women.

    • Megan

      Agree with this. Breastfeeding doesn’t have to be promoted as “best” in order to be a valid chiice that is protected for those who choose it. I agree that pumping at work should be protected and also that all moms should get paid maternity leave regardless of their feeding choice. We don’t need to promote breastfeeding as magical in order to promote maternity leave. There are lots of other reasons for moms to have paid leave other than to be home to breastfeed, like healing from delivery, bonding with their newborn and taking care of said newborn.

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    • Young CC Prof

      Exactly. Reproducing is a human right, and breastfeeding ones children should be part of that. I am all in favor of promoting things that make breastfeeding possible, but I am not in favor of promoting breastfeeding above other feeding methods. The benefits are just way too small.

      • fiftyfifty1

        “Reproducing is a human right, and breastfeeding ones children should be part of that.”

        I agree….and yet I ask myself why. If I play devil’s advocate with myself I have to ask “If breastfeeding has only trivial benefits for a child, why should an employer have to make accommodations for something that really is just a lifestyle choice?”

        • Cobalt

          Because at some point you have to draw the line between employing cogs and employing humans, humans who have lives and deserve to live them. Reasonable accommodations are appropriate for both employers (clean, safe, private space, restructuring breaks to space them evenly through the day) and employees (making up extra breaks, being discreet, scheduling pump breaks as undispruptively as possible). Accommodating demands to spend half the paid workday pumping topless in the lobby or expecting women to pump on the toilet is not.

          Business exists to serve humanity, not the other way around.

        • KarenJJ

          Business already accommodate lifestyle choices of little/no benefit, eg smoking.