I live in British Columbia, Canada (BC for short) and lately one of our health regions has been making news with the accusation that they are forcing mothers to sign a “breastfeeding contract”. There are articles out there declaring that women are being “shamed” for formula feeding and raising anxiety for women who have problems breastfeeding because of this sheet. The very first thing to be clear on is that it’s already been reported that this is an older document that hasn’t been used for a bit and that a new one is in the works with “better wording” (i.e., they heard that people were feeling bad and are aiming to fix the problem). I don’t know what they’ll change but I’ll reserve judgment on whether it’s an improvement or not when the new one is released (not to say I don’t think it could be improved, but you never know how these things go).
Onto the document itself… The document isn’t a “breastfeeding” contract, it’s a “Mother-Baby FEEDING Plan” (emphasis mine) and a “Parenting Decision-Making Tool” (you can see the full document in PDF by clicking here). [Big note: It is supposed to be given to parents BEFORE birth, hence the “plan” part of it (if it’s not being used in this manner we have a different discussion on our hands).] Yes, it talks science, specifically the risks associated with using formula, because it’s a medical form, much like the one you read when you agree to an epidural or a homebirth. It also states that if you can’t feed your baby breastmilk (yours or banked) that commercial infant formula is next best. It also says that although doctors recommend breastfeeding, you may have a valid reason for using formula. Parents then check off what type of feeding they plan on (exclusive breastfeeding, mixed feeding, and exclusive formula feeding) where some much-needed information about each is mentioned (including, for example, in the formula section that parents will need to learn to sterilize bottles and not to use powdered formula for premature or ill babies unless recommended by a doctor). It is INFORMATION. (On this note, the one big improvement I can think of would be to add in absolute risks as well as relative risks because it helps contextualize the risks, though of course we also need to then add the absolute and relative risks by subgroups if we want to be complete. But hey – why the heck not? Isn’t information what we’re trying to share?)
The bone of contention is that parents who select mixed or exclusive formula feeding have to acknowledge that they understand the risks stated on the first page of the document. This sharing of information is what is “shaming” and “anxiety producing”. I gotta say: I don’t get it. Isn’t it our job as parents to make our decisions with the available information? I understand how putting blinders on may be more reassuring, but if the risks mentioned outweigh the benefits of formula for you, then plan on breastfeeding. (Remember this is given to women before birth, not two months in.) If the risks don’t outweigh the benefits of formula for your family then check off the right box (mixed or exclusive formula) and move on. (Note: I could understand this being an issue if this were given to moms 2-3 weeks postpartum, but pre-birth?)
In fact, I’m going to take it one step further and say a form like this is actually a brilliant idea. When I read the page moms sign I think it’s great (although I don’t know it’s necessary to actually sign). There are families who use formula and don’t realize the risk of powdered formula for their premature babies. There are families who do not sterilize properly, putting their infant at an even higher risk. What this contract does, if used properly (and yes, I’ll talk about that), is allow nurses and health educators to focus on what each group of moms needs to learn. Moms who sign the exclusive breastfeeding contract can have support tailored to their needs including issues with supply, latch, etc.. Mixed feeding moms can be given information about how mixed feeding can be problematic for breastfeeding and how to overcome it (especially if the goal is long-term mixed feeding). And, as mentioned, formula feeding moms are given information on cost (because formula is free in the hospitals in this region), sterilization, and how it can influence the decision to breastfeed if mom changes her mind. If used right, people get the kind of support they need.
The main issue, as I see it, is how this is being used. Now, so far no reports are saying that nurses or lactation consultants or doctors are “shaming” mothers with it. Indeed, the mothers that have spoken out have been clear it’s the document itself that’s the problem. As one mother told CBC, “I received great care from all of the professionals I visited.” Another woman, whose doctor recommended formula because her baby was premature, said, “I found the form to be insulting and upsetting. It gave the impression I was putting my son at risk if I followed the doctor’s direction. It implied he would have a higher risk of getting cancer, even.” I hate to say it, but yes. Although very premature babies require a special formula, premature babies whose mothers are lactating and are large enough (typically 1500 grams) do not need supplementation unless mothers want it. There is no medical need outside of any individual circumstance. (To read up on this, you can check out this great piece from Dr. Jack Newman on the topic.) So by listening to this particular doctor, you are putting your child at higher risk. Is it a risk worth taking? Only you can answer that and once you do, your choice should be respected, just as you should respect the balance of risks and benefits you are taking.
This respect bit is where I want to end. One of the things I like about this form is that it should increase the likelihood that a woman’s choice is actually respected. You know mom has read the information and is making her choice. You may disagree with it, but now comes the issue of making sure she has the right information and support for that particular choice. Perhaps having women sign is one thing (unless it’s being used in hospital for nurses to know who can and cannot get formula in which case another form could easily be given), but education and respect are not antithetical nor should we assume they are.
Knowledge is power. We cannot decide that knowledge should not be shared because we don’t happen to like that knowledge or it makes decisions more difficult than we’d like them to be. I understand this may be very hard to read for women who wanted to breastfeed and couldn’t and have to face risks they didn’t intend on taking, but hiding from the information doesn’t change this for you or anyone else. For you, allow yourself to feel everything you do (grief, anger, frustration) and accept that all of those feelings are completely acceptable. Hopefully when you’ve allowed yourself your own emotions, you can see that you still did the best with what you were given which is all we can ask of parents. (If not, and you are feeling overwhelming guilt or sadness, please seek help so you can feel confident as a parent.)
[Addendum: I would like to add that in no way do I think this document usurps the need for very real support for women who have planned on breastfeeding and cannot for whatever reason. These women are at some of the the highest risks for post-partum depression and any and all resources should be available to them to process this, accept the feelings associated with it, and find support (emotional, practical, etc.) moving forward. The discussion of prenatal information and postnatal support do not run counter to each other and in fact can complement each other if done properly.]