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Breastfeeding: Why is it such a battle ground?

Emma McGahan and her daughter, Amelia.

All new mothers want the best possible start for their babies, and they’re told again and again that breast is best. But what if breastfeeding is too great a struggle? Should women be bullied online, pressured by health professionals, even watch their babies suffer? Sarah Lang investigates the toll on mothers – and asks what’s happened to commonsense and kindness.

In November 2015, Emma McGahan from Lower Hutt gave birth to her first child, a daughter, in hospital. Because she had pre-eclampsia – a pregnancy complication that can potentially endanger mother and baby – she was induced three weeks early, and endured a long labour. “I was beyond exhausted,” she says.

McGahan suffers from a hormonal disorder, polycystic ovary syndrome, and was concerned it might affect her milk supply. “I thought breastfeeding might be hard, but I intended to do my best.”

Her lead maternity carer – a community (self-employed) midwife – visited McGahan in the postnatal ward on both days following the birth, then left on a pre-arranged holiday. So McGahan was attended by the hospital’s staff midwives. “They kept telling me my baby was feeding fine, and wasn’t hungry because she wasn’t screaming,” says McGahan. “But I could see her shaking.

“They were about to discharge us when I said, ‘Please weigh her and test her blood sugars first.’”

Read more: How this article brought out the bullies

Amelia had lost 11% of her birth-weight, and her glucose levels were very low. McGahan’s transitional milk (with its higher fat and calorie content) hadn’t yet followed the first milky substance called colostrum. “My baby was starving. That was devastating.”

Finally, a nurse decided an infant formula top-up was necessary under the following World Health Organisation (WHO) directive: “Give newborn infants of breastfeeding mothers no food or drink other than breast milk, unless medically indicated.” Still, one midwife didn’t agree with McGahan using any formula. “She said, ‘You should really try breastfeeding, for your baby’s sake.’”

She was trying. In hospital for another three days, she breastfed for hours at a time, expressed milk via breast pump, and gave formula top-ups as needed. The midwives seemed uneasy with formula, with one giving the baby too much, which she vomited up.

When McGahan went home after five days, she followed instructions to pump after every feed (including overnight), and do formula top-ups only if needed. “I got my milk supply up for a while.”

At four weeks, her daughter had regained her birth weight, and McGahan started exclusively breastfeeding.

However, a wakeful breastfeeding baby – coupled with McGahan’s on-and-off insomnia – was “torture”. Her midwife and a private lactation consultant asked if breastfeeding was affecting her mental health, but didn’t press her on it. “I felt pressure to continue breastfeeding from family members, online mums’ groups and the whole ‘breast-is-best’ noise.”

The sensation of her milk letting down started triggering intrusive, distressing thoughts. About four months in, she developed late-onset postnatal psychosis, characterised by mood disturbances and losing touch with reality. At one point, she believed an intruder was coming to take her daughter. “I was worried I was going to kill my baby and, once, I thought, ‘Well, then, I wouldn’t have to do this anymore.’” It was disturbing, but only ever an intrusive thought, nothing more.

At that point, McGahan started mixed-feeding (part-breast milk, part-formula). It helped, but by then she’d developed postnatal depression and severe anxiety. When her daughter was six months, McGahan began taking medication, and started formula-feeding only. “Looking back, I wish I’d stopped breastfeeding earlier. The pressure to breastfeed and initially starving my baby definitely contributed to me developing anxiety and depression. I believe things could have been different if there’d been education and support about breastfeeding difficulties and formula use.”

A mother breastfeeding her newborn baby with a midwife in the obstetrics and gynaecology department of a French hospital. “In my experience,” said a French mother, “the choice to breastfeed was left up to me. No medical professional ever pushed me to breastfeed or to bottle-feed. Both options were supported.” France has one of the lowest breastfeeding rates in Europe, and one of the highest fulltime workforce participation rates for women and mothers in the world.
Yes, breast is best. But when even the Ministry of Health says infant formula is safe and nutritionally adequate when prepared correctly, why is it so demonised? Childbirth educator Brenda Hinton recently said formula should be treated “more like a prescription drug”.

Comments like this in the media have left some women very anxious. In December, a woman who has milk-supply problems posted in an online mothers’ group that she was so worried about primarily formula-feeding her three-month-old – and giving her 17-month-old some formula – that she keeps getting up in the night to check on them. She wasn’t sleeping at all. “I feel so horrible for being such a crap mum.”

The hard-line evangelism of breastfeeding advocates has alienated some women and harmed others who struggled with breastfeeding. Of six mothers we spoke to, five asked not to be named for fear of blowback from healthcare providers or their own communities, online or otherwise. They said even when their babies had gone hungry – and their own physical or mental health had crumbled – they had faced pressure to continue breastfeeding that was way out of proportion to the benefit.

Breast milk is undoubtedly the best food for babies, especially in countries with poor water quality and high infant mortality. Some breast-milk components can’t be replicated in formula (most commonly made using purified cow’s milk whey), including immune proteins such as antibodies. Breastfeeding can establish a healthy gut microbiome, and reduce babies’ risk of gastrointestinal infections, asthma and eczema.

Even so, a study published in JAMA: The Journal of the American Medical Association doesn’t support claims that breastfeeding reduces the risk of respiratory infections, ear infections, food allergies, croup, wheezing, or (in Western countries) infant mortality.

The largest high-quality, randomised and controlled study that’s been done on breastfeeding, the PROBIT (“Promotion of Breastfeeding Intervention”) trial involved 17,000-plus mother-infant pairs. This type of randomised trial – the most useful type – is rare because of the understandable unpopularity of randomly assigning mothers to different groups. Studies comparing the health of a breastfed baby with a formula-fed sibling can remove the confounding factors that muddle other studies. Research published in the journal Social Science & Medicine in 2014 compared 1773 pairs of siblings (one breastfed, one formula-fed) and showed no statistically significant differences in measures including weight, obesity, parental attachment, behavioural compliance or academic achievements.

Still, official breastfeeding policy leaves no question that breast is best. WHO recommends beginning breastfeeding within an hour of birth, and exclusive breastfeeding (no other liquid or solid) for six months, then continued breastfeeding with complementary foods up to two years or beyond. New Zealand’s Ministry of Health recommends exclusive breastfeeding until six months, continued with complementary foods for at least a year or beyond, though it says any breastfeeding is beneficial.

You’d look long and hard to find a woman who doesn’t plan to breastfeed. Unfortunately, most antenatal classes cover breastfeeding only briefly and, under WHO guidelines, facilitators can’t discuss formula in a group setting. Many expectant parents don’t attend antenatal classes, let alone specific breastfeeding classes. Many pregnant women assume it will just come naturally. But talk to new mums and it’s clear breastfeeding difficulties are more the norm than the exception. Issues include the baby “latching on” incorrectly (and not getting much, if any, milk); transitional milk not replacing colostrum for up to five days; a milk supply that dips; sore, cracked nipples; and mastitis, a painful breast inflammation.

A US study published recently in the journal Pediatrics found 92% of women reported problems with breastfeeding in those first three days. Dianne Powley, learning and development facilitator at the Government-funded New Zealand Breastfeeding Alliance (NZBA), isn’t convinced. “Struggle is a relative thing,” she says. Powley thinks it often boils down to a misconception “that breastfeeding is easy”, when it’s a learned skill. Like other breastfeeding advocates, she says at least 90% of women can physically breastfeed.

Powley also leads the Baby Friendly Hospital Initiative (BFHI) in New Zealand (see How Did We Get Here? at the bottom of this article). Through this organisation, WHO’s “Ten Steps to Successful Breastfeeding” are embedded within maternity facility policies. Staff – and community midwives with access agreements to maternity facilities as lead maternity carers – must abide by BFHI criteria. The initiative has seen national-average rates of babies exclusively breastfed on discharge from “baby-friendly” services rise from 55.6% in 2001 to 81.3% in 2016.

Surely some women are too unwell to breastfeed? Powley admits medical difficulties exist and says mothers are assessed case by case, but it’s “increasingly rare for a mother to be told to stop feeding permanently”. Only maternal HIV is listed under the criteria as a reason to halt breastfeeding permanently.

Maternal conditions that “may justify” temporary avoidance include severe illness like sepsis, sedating psychotherapeutic drugs, taking anti-epileptic drugs and opioids, and cytotoxic chemotherapy. “Breastfeeding can still continue, although health problems may be of concern” with hepatitis B, hepatitis C, tuberculosis and some substance abuse. Mental health isn’t mentioned.

In 2014, a Whangarei woman had what you’d think would be a compelling case for not breastfeeding. “That pregnancy almost killed me,” says Kate*, a former nurse and mother-of-three.

Already dealing with a chronic condition that requires prescription painkillers, Kate suffered hyperemesis gravidarum (severe nausea, vomiting and dehydration) during pregnancy. She was hospitalised every other day, and sometimes for weeks at a time, with a permanent intravenous line in her chest providing fluids.

When Kate was six months pregnant, her IV line became infected, and a blood clot caused a life-threatening pulmonary embolism (lung-artery blockage). Her intensive-care doctor said breastfeeding might not be possible. “But ‘breast is best’ so I felt I should try,” Kate says. Heavily pregnant, Kate asked the hospital lactation consultant about formula as a back-up. “She physically squeezed colostrum out of my nipple, saying ‘There’s proof you can breastfeed.’” Kate continued squeezing out colostrum to save for the baby.

After the required caesarean section, Kate’s wound burst and got infected. Still, for 10 days in hospital, she exclusively breastfed her daughter, who screamed a lot, slept little and lost weight, despite two-hour feeding sessions. “I just wanted someone to tell me formula was okay and how to use it, but no one did because of the WHO guidelines. I left hospital with an antibiotic pump, a double breast pump, and no information on supplementation.”

At home, the baby still seemed hungry after two hours’ breastfeeding. Kate’s midwife never mentioned formula. Two weeks in, Kate saw a hospital lactation consultant at an off-site clinic. “She said, ‘There are no latching problems. Put more effort in, up the feedings, eat and drink more yourself.’

“I explained I was reliant on food-
replacement drinks and antiemetics [anti-
nausea medication], and I was struggling with my pain condition and postnatal depression. I told her we’d tried formula just one evening. She said, ‘The baby can’t digest nasty, artificial formula.’ As a mother, hearing you’re harming your baby is horrible. As a nurse, I knew she was talking rubbish.”

Kate’s Plunket nurse suggested her breast milk might contain too little fat; a doctor confirmed this. “At six weeks, my daughter was 50/50 breast and formula; formula-only by four months. She was suddenly a happy baby.”

Kate’s still angry. “As someone with complex health issues, to have ‘breast is best’ rammed down your throat past the point of reason is crazy, as is not discussing formula. This cookie-cutter stance doesn’t take people with health issues into account.”

And there’s a trickle-down effect. Kate, who visits an Auckland hospital six-weekly for her pain condition, once pulled out a bottle in the Westfield St Lukes parents’ room. “One of two mums there said, pointedly, ‘These chairs should only be for breastfeeding mothers.’ I left, then started bawling.”

Hostility in online mothers’ groups is worse, Kate says. “A lactivist posted a photo of a starving African woman breastfeeding and commented, ‘There’s no excuse not to breastfeed.’” Kate posted that sometimes formula was necessary, and later discovered her comments had been reposted and picked apart in a lactivist group. “One person said I was sickening. But you get this on run-of-the-mill mothers’ groups, too. One bipolar woman posted explaining she had to take anti-psychotic medication, and asked for advice on formula because her midwife wouldn’t talk about it. Someone posted, ‘If you loved your child, you’d come off the medication.’”

In August, Kate noticed an outraged member of an online mothers’ group had posted a photo of a resource included in her Plunket welcome pack for new mothers. It was a double-sided card created by Change for our Children, a social innovation company, for its 2008 “6+1” infant-survival pilot project, which trained six young parents to share information about protecting babies’ lives. Six images on the front depict six “key principles”, including breastfeeding, which match six “fact prompts” on the back. One “fact” prompt includes these words: “Formula-fed babies… get sick more often and more frequently and are more likely to die.”

Kate posted the image in another mothers’ group, commenting, “As a mum who had postnatal depression twice and had to use formula with my youngest, it would have put me over the edge 100%.” She’s still angry. “Because how is this helpful? What right do they have to say our babies are more likely to die? What impact might that have on mothers who can’t breastfeed?”

Cass Gray, Plunket’s Waikato clinical-
services manager, won’t comment on how the card got into the welcome pack received on August 21. However, she says Plunket immediately contacted the woman to apologise and explain it doesn’t represent the organisation’s views. Plunket has also investigated to prevent it happening again.

Change for our Children director Stephanie Cowan is surprised the card turned up in a Plunket pack. “While appropriate in its original training context, in our view, it isn’t appropriate to present blunt facts to new parents in an unsupported context.”

While she regrets upsetting the mother, she believes the statement to be true. Cowan stresses the postnatal mortality rate of New Zealand babies aged between one and 12 months has dropped 38.5% since 2009 (when the national Safe Sleep programme began) and 2016. However, this programme addresses many factors other than breastfeeding, including preventing accidental suffocation, targeted provision of portable Safe Sleep devices (such as pēpi-pods), and DHBs adopting safe-sleep practices. The programme’s “Talk Cards” for health professionals – and take-home pamphlet for parents – don’t say formula-fed babies are more likely to die.                       

One bonus of formula is the chance for dads to handle some bottle feeds, including overnight. Breastfed babies tend to wake more often and feed for longer than formula-fed babies, meaning less sleep for mums..
It's obvious why breastfeeding is promoted militantly in developing countries with poor water quality and over-zealous formula marketing. But this isn’t the case here. New Zealand is a signatory of the International Code of Marketing of Breast-milk Substitutes, and so, in consultation with the Ministry of Health, the Infant Nutrition Council (representing manufacturers and marketers of infant formula in Australia and New Zealand) developed the Infant Nutrition Code of Practice for the Marketing of Infant Formula in New Zealand. This prohibits the promotion of formula suitable for babies under six months.

Meanwhile, the ministry’s Code of Practice for Health Workers asks them to “meet their obligation to give detailed information” to families of “breastfed and formula-fed infants” on infant-feeding. Both codes are voluntary and self-regulated but the ministry administers a complaints process for breaches.

For BFHI accreditation, maternity services must meet standards of care for “non-breastfeeding mothers”, including guidance on formula feeding. However, the NZ Breastfeeding Alliance’s website expects “the facility manages the usage of infant formula to keep it to a minimum”. Some midwives and nurses are too scared of falling foul of the BFHI to even whisper the word formula. Jackie*, a nurse, witnessed this while struggling herself with breastfeeding in hospital. She says some staff are so obsessed with breastfeeding that they’ll watch a baby lose weight beyond the initial drop expected in those first days and still not suggest formula. “Breastfeeding pressure is diabolical and can affect mum and bub’s health.”

One Wellington mum spent a week in hospital with a baby who suckled almost continuously and rarely slept. “The midwives said they couldn’t take the baby to let me nap or give a top-up due to WHO regulations about formula, ‘rooming-in’ [keeping baby and mother together 24/7 ] and breastfeeding on demand. A few times, I fell asleep sitting up and almost dropped my newborn onto the hard lino.” Sleep deprivation led to several days of postpartum psychosis, including hallucinations, which shook her deeply.

Many mothers said formula wasn’t mentioned until their baby had lost a worrying amount of weight, if it was raised at all. NZBA executive officer Jane Cartwright says decisions around formula aren’t just about weight loss, but assess the welfare of both mother and baby. Cartwright compares establishing a good milk supply to charging a cellphone, and warns that introducing formula can trigger a low-supply spiral. “Staff often get attacked for a ‘no-formula’ stance, but it’s not ‘no formula’ – it’s about identifying the right time to use it.”

Unfortunately, doctors, nurses and midwives who can organise formula top-ups may interpret the term “medically indicated” differently. Often one says formula is needed, mothers note, while another says it isn’t. Cartwright believes the BFHI’s mandatory “educational component” should prevent mixed messages, but staff “come with their own history”. If a mother requests formula? “That’s where she needs support from staff. Health professionals need to make sure people make an informed choice, and are supported in that choice.”

Dianne Powley adds that staff are a counter-balance when women consult the internet, or grandmothers and fathers suggest formula. If mothers insist on formula, 18 of 20 district health boards require they sign an “informed consent” form. Powley says this is so babies aren’t given formula without the mother’s knowledge, and so she’s aware of the risks.

What about the risks of inadequate breast milk? A peer-reviewed scientific paper published in the American Journal of Physiology – Endocrinology and Metabolism estimates 10-15% of women clearly don’t produce enough milk, which can lead to babies experiencing hypernatremia (high sodium levels), nutritional deficiencies and weight loss/inadequate weight gain.

In the US, concerns have also been raised by the Fed is Best Foundation, a non-profit organisation of health professionals and parents providing education on safe methods for breastfeeding, mixed-feeding and formula-feeding. It says the WHO guidelines put newborns at risk of starvation, and complications can include dehydration, jaundice and hypoglycaemia: all established causes of brain injury and permanent disability.

In September, Fed Is Best leaders, including emergency physician Dr Christie del Castillo-Hegyi, presented data to the WHO Breastfeeding Programme on the high incidence of complications resulting from BFHI practices. When she asked if WHO planned to inform mothers that temporary supplementation can prevent complications from insufficient breast-milk, the response was it wasn’t a “top priority” because health providers already had guidelines on the danger signs.

In late 2017, WHO released for public submissions a draft document that proposes some revisions to the Ten Steps, following an evidence review (see How Did We Get Here?, page 36).

The proposed revision to Step 6 slightly rewords but doesn’t materially change it: “Mothers should be discouraged from giving any food or fluids other than breast milk, unless medically indicated.” However, WHO has admitted that “medical requirements for and effects of additional feeds on infants and mothers need further research”.

WHO wants more than half of infants worldwide breastfed exclusively for at least six months by 2025. That’s unlikely here. National-average rates for exclusive or full (“almost exclusive”) breastfeeding drop from 81.3% on discharge from “baby-friendly” hospitals to 49% six weeks after birth, then 16.7% after six months. The Ministry of Health clearly minds the gap between these rates and its targets of 90% at six weeks, 70% at three months and 27% at six months.

The University of Auckland’s longitudinal study, Growing Up in New Zealand, published research in the New Zealand Medical Journal in December highlighting the drop-off in breastfeeding rates. Tracking 6000-plus children from birth to two years, it found 97% were breastfed initially, with just over half exclusively breastfed to four months. One in six was exclusively breastfed to six months, and one in eight received some breast milk up to two years. Mothers were likelier to breastfeed exclusively for longer if they were 20-plus, European, tertiary-educated, had planned the pregnancy, or had other children.

Anecdotally, women stop breastfeeding “early” for many reasons, including pain, sleep deprivation, returning to work, waning milk supply, and the baby losing interest. Also, practical breastfeeding support fluctuates in quality and, later, accessibility. Midwife lead maternity carers (LMCs) are usually the primary source of breastfeeding information and help, but their practical skills and referral knowledge vary. It’s now up to community midwives to update their own breastfeeding knowledge through wider continuing education.

After 4-6 weeks, LMCs refer mums to a Well Child/Tamariki Ora provider, usually Plunket. Along with core checks, Plunket provides additional visits if requested, breastfeeding advice through its 24/7 PlunketLine, and some drop-in or “ring-first” breastfeeding-support sessions. Plunket’s clinical services general manager, Helen Connors, says staff promote breastfeeding but recognise each situation is unique.

Many women speak highly of midwives and Plunket, but other stories are worrying. One in five breastfeeding mothers experiences mastitis, where blocked milk ducts cause painful inflammation and often flu-like symptoms. Auckland mum Cassie* had three bouts. Told by her midwife and then her Plunket nurse to continue breastfeeding and push through the pain, she was eventually in such agony she saw her GP. She was hospitalised and given intravenous antibiotics.

Seeing a certified lactation consultant can help, but public-sector waiting lists are long. Plunket will this year introduce video-conferencing with lactation consultants, while La Leche League (a not-for-profit organisation providing “mum-to-mum” breastfeeding support) can make referrals.

Breastfeeding-support clinics (run by DHBs and other organisations) are helpful, but patchy nationally and underfunded – if funded at all. Wellington-based Well Child nurse Liora Noy, who is also a private certified lactation consultant, has run the non-profit Newtown Breastfeeding Support Centre for five years. For a koha, mums get a half-hour, Monday-morning appointment with her for non-judgmental breastfeeding (and emotional) support that prioritises the mother’s physical and mental health.

“With breastfeeding, there’s a lot of pressure and not enough support,” she says. “I’ve seen many mums get severely depressed, anxious or both because of breastfeeding challenges. They say things like, ‘Why didn’t anyone tell me it would be so hard? Why isn’t there more support?’ We need to be more realistic with mums, especially antenatally.”

Noy, who has a master’s degree in public health, teaches breastfeeding courses to prepare expectant parents for the challenges of breastfeeding newborns. She can’t discuss formula because of WHO guidelines, but will point to a website explaining how to prepare it.

Noy also volunteers for PND Wellington, offering peer support (non-professional counselling) for women suffering antenatal or postnatal distress. She recently started a course educating expectant parents about postnatal depression. “If a mum has breastfeeding challenges, she’s at higher risk – and a mum with postnatal depression might have a harder time breastfeeding.”

“We have to encourage mums to get help, and to try to breastfeed,” stresses Noy. If it’s still too tough? “Sometimes I suggest a few days’ mental and physical break, while expressing and keeping up supply. But sometimes, if it’s not working, we need to give permission to choose to stop. Those mums [feel they] need that permission, and once they get it, they feel huge relief.”

She’d like funded training for health professionals covering breastfeeding difficulties and referrals. Ideally? “Free support centres open daily, where mums can see lactation consultants and mental-health counsellors, while other mums cuddle their babies or nap. And let’s talk about why breastfeeding’s good, not why formula’s bad. The huge question is, how do we promote breastfeeding without promoting anxiety, depression and guilt among mums facing huge breastfeeding challenges? I think through consistent, supportive advice – and awareness of mothers’ mental health. Let’s support each mum to find her own way.”

Some mothers are so lost they’re paying for private help. “A lot of people are challenging the way babies are looked after,” says the NZBA’s Jane Cartwright. “A lot more 30-something mums can access any manner of person trying to give them advice. People are latching onto not necessarily the right information.”  

Rangiora-based postnatal practitioner Philippa Murphy.
Rangiora-based postnatal practitioner Philippa Murphy is considered dangerous by some breastfeeding advocates. Her philosophy? “Breast is best until it’s not, and then fed is best. We need more of a balanced, holistic approach that takes everything into consideration, including the mother’s mental health.”

A parenting author and clinical child development researcher, Murphy was a leading maternity nurse in England for decades, working with newborns (including Kate Winslet’s daughter). Now her primary work as a postnatal practitioner in her clinic BabyCues sees her helping mothers sometimes at breaking point over breastfeeding issues.

Murphy breastfed her son (now three) for two weeks before her supply waned for reasons she later learned were hereditary and hormone-related. “I’m a strong advocate for breastfeeding when it works well. When mothers spend nearly all their time breastfeeding, pumping, then giving expressed top-ups – on little sleep – it can affect their mental health, which in turn can affect the baby.”

Murphy largely works with newborns who are unsettled, not sleeping well, and sometimes diagnosed as having colic (extended, unexplained crying) and reflux (spitting up milk). “Sometimes low supply that won’t increase is an issue, and formula needs to be considered.” But some health professionals are unlikely to discuss formula, she says, because they’re aligned to the Baby Friendly Hospital Initiative. “I support what the BFHI’s doing for breastfeeding rates. I just wish formula was discussed more readily so parents can make informed decisions.”

When breastfeeding starts adversely affecting mums, and they ask about formula, Murphy informs them about mixed-feeding and using formula. “Some look at me in disbelief that they’ve found a health practitioner who’ll talk about it.”

Murphy works with some mothers who have terrible trouble breastfeeding but feel awful contemplating formula. “We’re conditioned to think if we don’t breastfeed, we’re not good mums. But being a good mum is about supplying what your baby needs – and sometimes that isn’t the breast.”

Sometimes only colostrum and no transitional milk has come in by days four, five or six. “That’s when babies can be in danger from hunger. Perhaps having lactation consultants visit homes three or four days post-birth would help – as would educating parents about formulas available and making up correct amounts so they can give it, while working to get breast milk supply up.

“Surely, our bottom line is all about protecting the baby,” she says. “Education around formula does that, and doesn’t mean the mother necessarily stops breastfeeding.”

In 2016, Murphy founded a piloting non-profit organisation, The Pudding Club, which provides expectant parents in North Canterbury with practical, low-cost education about postnatal challenges; it’s looking to expand nationally. Murphy has a petition on change.org asking the government to fund dedicated postnatal education for parent. 

Wellington mother of five Sarah Christie is still breastfeeding five-year-old Paddy
While there’s immense pressure to breastfeed babies, there’s also immense pressure to stop breastfeeding toddlers. Wellington mother of five Sarah Christie – a former champion middle-distance runner – stopped breastfeeding her eldest, Boston, when he was one.

“Unfortunately, I felt you were meant to stop then. I wasn’t ready, physically or mentally, and got mastitis. I wish I’d had the okay to continue.”

Christie decided to follow her instincts and breastfed Baker, now 13, Anabelle, now 10 and Bridie, now eight, until the next baby came along. She’s still breastfeeding five-year-old Paddy.

“My husband jokes that, because there’s no new baby, I’ve forgotten to stop,” she says. “It’s whenever Paddy wants it; right now that’s once in the morning, once at night. I think it’s up to him to decide [when to stop]. It’s normal to breastfeed older children in other countries. Look at African mothers.”

According to anthropologist Jared Diamond, the average weaning age in hunter-gatherer societies is three. Experts estimate the median age of child-initiated weaning is between three and five.

Christie wants to show mothers that extended breastfeeding is “normal and natural. But we get mixed messages in the Western world. People are shocked when I say I still breastfeed Paddy. Some people think I’m joking. I get the impression people feel uncomfortable, which is the last thing I want, but this is what feels right to me.

“My GP, husband, parents and sister have always thought it’s great. When I was having cancer surgery, Paddy was seven months and my sister, who also had a breastfeeding baby, breastfed him at night. He didn’t even open his eyes, and stayed settled.”

Christie’s always felt comfortable breastfeeding in public. “I’ve had disapproving looks and comments like, ‘At some point it’s just for the mother,’ but they’re nearly all well-meaning, and don’t really worry me.

“Breastfeeding provides emotional and physical benefits to mother and child. Children get so much out of it: comfort, nutritional value. If there wasn’t something in it for them, they wouldn’t do it. My kids didn’t seem to pick up as many bugs, and it was easier to comfort and hydrate them when they were sick.”

Is breastfeeding longer than two years significantly beneficial? WHO’s position is, “There is no evidence either way.” However, the American Academy of Pediatrics says there’s no upper limit to breastfeeding duration.

Dr Louise Brough from the Massey Institute of Food Science and Technology thinks disapproval of extended breastfeeding is odd. “It’s interesting some people think it’s okay for a toddler to drink milk from a bottle, but not from a breast. One reason could be that breasts are highly sexualised in our society. Another issue is breastfeeding in toddlerhood is perceived as delaying the child’s development, but it doesn’t.”

Christie’s not alone. Eighteen mothers posting in a New Zealand Facebook-group discussion were breastfeeding or had breastfed older children, one as old as six. They spoke of stigma, criticism and feeling the need to conceal it. “There’s so much pressure to breastfeed, then later to stop!” says Christie. “Let’s respect people’s choices around breastfeeding. If people can’t or choose not to breastfeed, let’s support them too. What matters is you’re okay and the baby’s okay.”

Two years on, Emma McGahan has just started to feel more like herself. It helped recently leaving a Facebook mothers’ group, where she’d commented on posts where she felt “lactivists” were being insensitive. “I wanted people to understand where non-breastfeeding mothers were coming from, and always pointed out I wasn’t anti-breastfeeding. But some people tried to demonise me.”

One woman, a social worker, posted that “people who cbf [can’t be fucked] breastfeeding are basically child abusers”. McGahan was appalled.

“If I’d read that while really ill, I might not be here today. These are people who should know better. When it comes to breastfeeding, people can forget or ignore science, ethics, common decency and common sense.”

How Did We Get Here?

Throughout human history, when mothers died or couldn’t breastfeed (and wet nurses weren’t available), babies were fed various nutritionally inadequate substances. After the rise and fall of over-hyped evaporated-milk formulas, the development of more nutritious commercial formulas (plus sterile bottles) in the 1950s and 1960s saw infant formula use increase. In the 1960s, marketing campaigns by formula companies saw the use of formula rise, along with infant mortality, in developing countries with poor sanitation. Breastfeeding advocates began speaking out.

In 1991, WHO and Unicef launched the Baby Friendly Hospital Initiative (BFHI) to promote breastfeeding. It’s since been implemented in about 20,000 hospitals in 156 countries. In 1998, breastfeeding advocates successfully petitioned the Ministry of Health to establish the New Zealand Breastfeeding Authority (now the New Zealand Breastfeeding Alliance, NZBA) to launch the initiative here. Since 2000, the ministry has contracted the NZBA to implement and facilitate the BFHI, and monitor and assess all maternity facilities against its criteria. Sixty-five are BFHI-accredited and seven others are in the process. Currently, 99.85% of babies born in New Zealand (other than home births) are delivered in these accredited facilities. The NZBA audits each facility every three or four years; more frequently if necessary.

Since 2007, the alliance has also run the Baby Friendly Community Initiative (BFCI). It’s under review, but still applies to 18 community organisations and educators who voluntarily signed up and were audited under the seven relevant steps of the BFHI’s Ten Steps (listed below). These include some community midwives, and some La Leche League regional branches. Plunket won’t confirm some of its regional branches are BFCI-accredited, saying only that it supports the concept.

Following an evidence review and public consultation, WHO will publish updated guidelines in early 2018. A draft document proposes changing or rewording some of the Ten Steps to ensure “care is delivered consistently and ethically”, and giving countries more discretion over how strictly certain steps are applied. The draft sees Step 9 (“Give no artificial teats or pacifiers”) removed, and Step 8 (“Encourage breastfeeding on demand”) replaced by a statement about helping mothers learn to breastfeed. New Zealand will likely adopt the revised guidelines, but it will probably be a year before changes take effect.

Ten Steps to Successful Breastfeeding
Source: Baby Friendly Hospital Initiative

  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. (This step is now interpreted as: Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognise when their babies are ready to breastfeed, offering help if needed.)

  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 breast milk, 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 artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital.



This was published in the February 2018 issue of North & South.