[Content warning: This article references maternal suicide.]
Before she gave birth to her daughter, Dr. Stephanie Liu, a Clinical Lecturer with the Department of Family Medicine at the University of Alberta, expected she would breastfeed, but after extolling the benefits of breastfeeding to her patients for years, nursing did not come easily for Liu—but the guilt did.
"I struggled to get her to latch and when she did latch it was very painful. As a result, my milk supply was insufficient. For the first two weeks, I supplemented with formula and was racked with guilt that I was not doing the best for Madi," she writes for The Conversation
She is hardly alone in this. A recent commentary in the journal Nursing for Women's Health explains that "[p]sychological pressure to exclusively breastfeed has the potential to contribute to postpartum depression symptoms in new mothers who are unable to achieve their breastfeeding intentions."
Liu points out that a large 2011 study found mothers who had negative breastfeeding experiences were more likely to have symptoms of depression. On a personal level, she understands why.
"Breastfeeding was one of the things I looked forward to most when I was pregnant. In medical school I learned about the bond between mothers and babies when they are breastfeeding. I could not wait to experience this," Liu explains, adding that breastfeeding her daughter Madi turned out to be way more challenging than she had anticipated.
For Liu, this experience changed the way she practices medicine, and she hopes that in sharing it she may change the way other medical professionals counsel their patients.
"As a family doctor, I know that breast milk is the optimal feeding choice for health benefits, but as a mom, I know the extreme pressures that we are placed under as women to produce milk every time our baby needs it," she says.
The extreme pressure to breastfeed
The American College of Obstetricians and Gynecologists recommends mothers exclusively breastfeed their babies for the first six months of life, but ACOG also officially recognizes that a baby's mother "is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding or formula feeding is optimal for her and her infant."
Unfortunately, many moms don't feel that they have a choice. They just want to do what is "best" for their baby, and when they can't they feel like failures.
Mom Jen Harper was convinced that breastfeeding was the way to go, and felt devastated (and exhausted) when no matter what she tried, it just didn't work for her and her son. "I'd been conditioned to think that since I was a woman, breastfeeding would be the most natural thing I've ever done," Harper writes.
She finally found relief when an ear, nose and throat specialist told her that not every baby is a fit for every breast.
"I had to give up the notion that this was, in fact, a failure, because it wasn't. I had to let go of my notion that everyone around me was judging me for pulling out a bottle and powder instead of delicately unclipping my cute nursing bra," she explains.
Harper came to terms with the fact that supplementing with formula was better for her son than having "a sobbing mommy."
But research shows a lot of moms are sobbing over this issue and don't get the advice Harper did.
"Breast is best" was a super successful public health campaign, but it has created a maternal mental health crisis. A growing number of new moms are dying by suicide, and some of the fathers left to raise babies as single dads are speaking out about the role the extreme pressure to breastfeed can play in fatal cases of postpartum depression.
Vancouver father Kim Chen lost his wife Florence Leung in 2016 shortly after they became parents. Their dreams were coming true, but Leung was under so much pressure and died by suicide.
"I still remember reading a handout upon Flo's discharge from hospital with the line 'Breast Milk Should Be the Exclusive Food For the Baby for the First Six Months.' I also remember posters on the maternity unit 'Breast is Best.' While agreeing to the benefits of breast milk, there NEED[s] to be an understanding that it is okay to supplement with formula, and that formula is a completely viable option," Chen wrote in a Facebook post after his wife's death.
Their son thrived on formula after his mother died. He was in the 90th percentile.
Support is best
According to Suzanne Barston, the author of Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn't, it's time for those who support mothers—physicians like Liu, but also midwives, doulas, and those leading mom and baby support groups—to offer "solid, sensitive, personalized advice" to all mothers.
It's been over a decade since Barston launched her blog, The Fearless Formula Feeder and witnessed the evolution of online discussion of infant feeding go from "breast is breast" to "fed is best", but she says the conversation really needs to be a lot more nuanced than three word catch-phrases.
In 2018 she spoke to Motherly about why moms who use formula often feel unsupported in our society, and noted that while there has been a big shift in the last decade in terms of how people speak to and about moms who choose to supplement with formula, the choice to not breastfeed altogether is still not seen as a legitimate choice.
Moms feel like society doesn't support them overall, but when it comes to infant feeding, moms feel very unsupported. Moms are told they must do everything possible to succeed at breastfeeding, but that's extremely difficult in a society where many parents must go back to work when their infants are mere weeks old.
Yes, breastfeeding rates in America are lower than the World Health Organization would like, but this isn't because moms aren't educated about the benefits of breastfeeding. There are few among us who don't know the benefits of breastfeeding. In many cases, moms would like to breastfeed but can't because they don't have the support system to actually make it work.
"Whether you're feeling physically uncomfortable from your birth or you have to make dinner for your two other kids or you have to go back to work in three weeks, those are all very real issues that women have to deal with and no amount of awareness or education about breastfeeding changes," Barston told Motherly.
How to help mothers
Like Barston, Liu harnessed the power of the internet after her own infant feeding journey, and now supports other mothers in theirs through her blog, her blog Life of Dr. Mom.
It took having her own postpartum experience for Liu to learn that breast isn't always best, and she's changed the way she supports new mothers as a medical practitioner. There's just so much more nuance to this than "breast is best." You can't fit her thoughts as neatly on a poster, but her words are worthy of maternity ward walls and pamphlets and could save the lives.
"I always support the idea to breastfeed if you can, to reach out for support, and if you are struggling, there are other safe and healthy options to ensure your baby is well fed," she explains.
If you are struggling with postpartum depression, here are the resources you need.
If you are feeding your baby formula, breast milk or both, know that we support you and that you are a good mother.