Laurie, I can identify with your feelings of exasperation and your wish to
help prolong duration of breastfeeding when it *has* been initiated.  I
think the basic reasons why mothers give up so soon are 1) social
acceptance of formula within their community, and 2) easy availability.   I
have learned to suspect that some mothers are not going to persist with
breastfeeding even in hospitals where there is no formula at all.  In
addition to the risk factors you mention, I find that if a mother actually
cries (real tears) then this rings red alarm bells about her underlying
intention to "give up" asap.  And body language - pulling away at the
crucial moment, just as the baby is about to latch, and then telling me the
baby "can't".  Sometimes I have nurses accosting me in the corridor after
the consult hissing "that baby can *suck*" because they know it too.  And
of course the overt and covert verbal messages that we receive.

What to do?  I don't know the answer.  In our hospitals mothers simply
don't have access to formula for healthy, full-term babies, and the
paediatricians are reluctant to discharge the mother and baby home unless
the baby is breastfeeding competently.  So some of these marginally
motivated moms have to stay in the hospital for an extra day or so, and I
find that some will actually starve the baby rather than
breastfeed.  Sounds judgemental, but it happens.  That's usually when
someone calls me to do a hospital consult - in the hope that I might
persuade a reluctant mom.  Sometimes I can, but sometimes I
can't.  Occasionally, this kind of mother may be really interested in
breastmilk-feeding - giving EBM by spoon in the hospital, and changing to
delivery by bottle as soon as she goes home - and carrying on for many
months.  Others just make a reason to start the formula.  I've actually
wished that these mothers could be confined to the hospital for two full
weeks, so that they could see how necessary their milk is to their babies'
survival - often wondering how long it would take.  The other alternative
would be to discharge them home to the kind of environment into which over
90% of the world's babies are born - a little one-roomed shack, with no
running water, no electricity, insufficient cash to buy breastmilk
substitutes and no-one there to hand out any freebies.  Eventually such a
mother might see that there would be a point at which her  wish not to
breastfeed will place her baby's health and survival in jeopardy.  I
suspect I've worked with several failure-to-thrive babies whose mothers
might fall into this category.   Ultimately, the ability *not* to
breastfeed and still have your baby survive is dependent on community
acceptance and approval of formula feeding, and easy availability.  Until
we can change those factors, we will continue to encounter mothers who just
don't want to do it, and we feel somehow ethically obliged to support
them.  But is this really ethical, when we know the difference in health
outcomes for the baby, the future adult, and the mother?

This may sound a little harsh.  In recent months I've needed to modify the
information I give to mothers who let me know they are thinking of adding
formula supplements, or abandoning breastfeeding altogether.  Formula is
becoming increasingly difficult to find, no matter how rich you are.  So
the excuses we have grown to accept as rationalizations for *not*
breastfeeding (choice, history of sexual abuse, going back to work,
overload of other responsibilities) become less and less justified when the
chips are *really* down.  So I'm talking about food security, and making
sure that the mother understands that her feelings needs to be placed lower
on the scale of needs than the fact that her baby can continue to receive
milk - any milk - since, effectively, it's looking as if breastmilk may be
the *only* sure, on-going source of milk in Zimbabwe today and in the
immediate future.  It's quite scary.  It places an enormous weight of
responsibility on the mother who is suddenly confronted with the fact that
her baby could literally starve unless she breastfeeds him, and that there
is no social net on which to unload this task.  This has made me re-examine
whose well-being we put first - the mother's, or the baby's.

It's all relative.  In a situation of plenty, where society picks up the
slack and either condones the use of breastmilk substitutes, or even
provides them for free, we can afford to give mothers choices, knowing that
society also picks up the responsibility for the collateral damage to a
formula-fed baby's health and keeps him alive through the infections we
know he'll suffer. But the more hostile the environment the more
responsibility the mother herself has for the survival of her
children.  What I'm re-examining is the responsibility *I* have (and all of
us have) for giving the mother enough information.  It makes me acutely
uncomfortable to have to look a reluctant mother in the eye and tell her
that although I can see she doesn't really *like* the thought of
breastfeeding, and although she might have a can or two of formula tucked
away at home, she runs the risk of her baby starving in the future if she
doesn't make every effort now to generate a full breastmilk supply.   I'm
running the risk of her being angry, and of myself being labelled a
fanatic. I'm used to placing the mother's feelings ahead of the  baby's
survival by suddenly changing tack and talking about  the *most* important
thing not being the type of milk used, but the mother-baby relationship,
and how my role is to support *her* goals. But to give this spiel now would
be bordering on negligence.  So, in many ways for me it's easier now than
it was to sort out the ethical issues.  What I'm wondering about, as a
result of Laurie's post, is how much we, as professional advisors of
mothers about infant feeding, prefer to accept the politically correct (for
whom?) route of appearing to support a non-breastfeeding mother's decision
to withhold her milk from her baby, *knowing* that there will be health
consequences for the *baby*.  We also often feel that we have to support
less than baby-friendly hospital policies or the direct orders of less than
baby-friendly OBs and paediatricians, so as not to rock the boat.  I've
done it myself.  My changed situation here now (dwindling breastmilk
substitutes) only differs in degree from those of us working in privileged
environments with many social nets (easy access to formula, hospitals,
doctors, antibiotics).  But the global political mind-set (mothers don't
have to breastfeed) is a one-size-fits-all, designed for the latter, where
only 7.5% of the world's babies live - do we need to have a closer look at it?

Pamela Morrison IBCLC
Harare, Zimbabwe
-------------
Date: Mon, 5 May 2003 03:57:31 +0000
From: laurie wheeler <[log in to unmask]>
Subject: risk factors for early weaning
Barbara is right. Increasing Initiation rates is only half the battle. We
need to work on bf duration, and of course, exclusive bf. I am pretty
accurate at predicting which moms will d/c bf early, some even before they
ever leave the hospital. I think most LCs who have been practicing awhile
can do this. This would be a hypothesis I guess. I think High risk moms are
"c/s moms" who rarely, if ever, bf in the delivery or recovery room, and
usually do not bf the first evening/nite. Also mothers who have (what to us
would be) minor bf challenges, but who have formula fed previous babies.
Mothers who ask me "what if I just don't like it, how do I dry up the milk?"
after the first feeding. Mothers who consistently give supplemental bottles
even after good feeds with info/support to exclusively bf. This sounds like
I'm being judgemental but most of these situations have a lot to do with
institutional barriers. My quandary is that even though I can identify that
these moms are high risk for weaning, how exactly do I intervene to prevent
this? Obviously I am constantly trying to change the hospital culture to be
baby friendly and to refer to LLL (the population of moms I work with and
the docs and nurses are resistant to this). But until that happens, what can
we do for the moms to keep them going?
Laurie Wheeler, IBCLC, MN, RN
New Orleans Louisiana, s.e. USA

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