When Carlene Allen, 24, became pregnant with her second baby, she planned to do everything the "right" way, as she put it. She did her research, listening to podcasts on unmedicated childbirth and breastfeeding. After her daughter was born, she seemed to latch well, and Allen told Romper she nursed "like a champ" at the hospital. But within the first week, she discovered that something wasn't quite right at the baby's first weight check.
“We found out she wasn’t gaining appropriately," Allen told Romper.
Since her baby appeared to be nursing well, Allen's pediatrician sent her to a lactation consultant, who diagnosed her with low milk supply. Following her lactation consultant’s advice, she began a rigorous feeding schedule in hopes of increasing her supply. Every two hours, she fed her daughter and then supplemented with breast milk or formula. She then followed that up with 20 minutes of pumping.
“I would get her all set, then pump, then clean up,” Allen said. “All I did was feed and pump. I only did this regimen for about two weeks before I fell in a deep depression. I just cried all day and all night.”
Allen had struggled with depression for years, and she was taking antidepressants while nursing. But it was clear that the medication wasn't helping. "I just felt like a prisoner to the bedroom. Which for me, was awful," she said. "I felt like all I did was sit and feed or pump. I just felt isolated."
After a few weeks, Allen's husband insisted she consult with her doctor about adjusting her dose. He also encouraged her to consider formula feeding as an acceptable alternative to breastfeeding. “He turned off my alarm, let me sleep and gave [my daughter] a formula bottle," she said.
It wasn't an immediate fix, but it did allow Allen to get more sleep and ward off the feeling of isolation that came with her rigorous feeding schedule. "From that point on, [we] decided it was best to just go ahead and stick with formula," she said. "It was so much better for my daughter, because she finally started gaining weight. And it was so much better for my mental health.”
Allen’s experience certainly isn’t uncommon. Following the publication of a number of studies highlighting the benefits of exclusive breastfeeding, as well as the popularization of the "breast is best" mantra, the number of mothers who exclusively breastfeed their babies is rapidly growing, from 79 percent of new moms in 2011 to 81.1 percent in 2016, according to the Centers for Disease Control. Yet as breastfeeding rates climb, new mothers are reporting facing increasing pressure to breastfeed — and for many women who try to breastfeed and fail, that pressure can be toxic, particularly for women who are already prone to anxiety or depression.
The conversation around the pressure to breastfeed went viral in late 2016, when Canadian mother Florence Leung took her own life shortly after the birth of her first child. In January 2017, Leung's husband spoke up on social media, saying that his wife had postpartum depression (PPD) that had been exacerbated by her failure to breastfeed. He argued that there needed to be clearer communication between patients, doctors, and lactation consultants that formula feeding is a perfectly healthy option for babies.
“I would hide in the shower so I could cry and my husband would literally beg me to stop breastfeeding. He said it wasn’t worth what it was doing to me.”
"For all the new moms experiencing low mood or anxiety, please seek help and talk about your feelings," he shared on Leung's memorial Facebook page. "Do not EVER feel bad or guilty about not being able to 'exclusively breastfeed', even though you may feel the pressure to do so based on posters in maternity wards, brochures in prenatal classes, and teachings at breastfeeding classes."
Jeanne Eschenberg Sager, mom of one, told Romper that she sympathized with Leung. She had been diagnosed with depression before becoming pregnant, but she experienced intensifying symptoms toward the end of her pregnancy. After her daughter was born, she struggled for two weeks to try to make breastfeeding work, even though her daughter screamed at the breast every time she tried to feed her. Sager admitted feeling like she had failed her daughter before she even left the hospital. Those feelings only intensified after she brought her daughter home.
“I would hide in the shower so I could cry and my husband would literally beg me to stop breastfeeding,” she said. “He said it wasn’t worth what it was doing to me.” Though she did eventually switch to formula, she said she felt so ashamed of her choice that she refused to leave the house for months.
Postpartum mood disorders like PPD and postpartum anxiety (PPA) are extremely common. For new moms, there is a one in seven chance of experiencing a postpartum mood disorder, according to the American Psychological Association (APA). That number goes up for women who have a history of anxiety or depression, as Allen and Eschenberg Sager did.
A wide range of factors can play a role in putting a mom at risk for PPD, according to Kimberly Hershenson, a New York City-based therapist specializing in maternal mental health. She cited loss of sleep, feelings of social isolation, and changes in the relationship with the other parent as potential stressors.
“Any of these factors or even hormone changes can lead to intense anxiety and/or postpartum depression," Hershenson told Romper.
“Feelings of inadequacy or not ‘properly caring for your baby’ are common thoughts that come up for moms who are having difficulty breastfeeding. Comparisons to other mothers who breastfeed may also make a new mom feel sad or anxious.”
Hershenson added that the cultural pressure to breastfeed can also contribute to feelings of depression after childbirth. “Feelings of inadequacy or not ‘properly caring for your baby’ are common thoughts that come up for moms that are having difficulty with breastfeeding," she said. "Comparisons to other mothers who breastfeed may also make a new mom feel sad or anxious.”
There isn't clear evidence that postpartum depression symptoms can be directly attributed to the cultural pressure to breastfeed. Yet some studies indicate that there might be a correlation between the two. For instance, a 2011 study in the journal of Obstetrics & Gynecology examined infant feeding practices of 2,586 women who reported to have breastfed. The researchers found that moms who disliked breastfeeding or experienced pain while breastfeeding during the first two weeks of their baby's life were at a higher risk for experiencing postpartum depression by the time their baby was two months old.
"Women with breastfeeding difficulties should be screened for depressive symptoms," the authors of the study concluded.
There is a near-unanimous consensus in the medical community that breast is best, with the World Health Organization (WHO) recommending that mothers exclusively breastfeed infants for a minimum of 6 months. Yet doctors and lactation consultants also admit that for some women, the cultural pressure to breastfeed has gotten out of hand.
Dr. Bridget Young, Doctor or Perinatal Nutrition and Lactation Counselor and researcher in the department of Pediatric Nutrition at the University of Colorado Anschutz Medical Campus, assists families who had intended to breastfeed exclusively, but have decided to stop or to supplement with infant formula. Although some of her clients do continue to breastfeed along with supplementation, she fills a unique need by offering nutrition consultation only to families who are no longer exclusively breastfeeding.
“I fully believe in the power of breastfeeding and we’ve done a really awesome job getting that message out culturally," she told Romper. "But sometimes I see a disconnect... we’ve lost sight of the fact that maternal mental and emotional health and mom’s overall well-being also have a direct impact on baby’s health."
“Women place so much shame and guilt upon themselves when they don’t meet these breastfeeding goals. Some women internalize it so deeply that it can contribute to increased postpartum anxiety and depression.”
Most often, Young said, mothers who experience breastfeeding difficulties, such as low supply, will follow standard advice from their lactation consultant to breastfeed every two hours, followed by pumping for 15 minutes to encourage milk production. The rigorous schedule will start to take a toll on mothers' mental health.
"By the time the whole feeding routine (including washing pump parts) is over, she has (at-most) 1.5 hours before the next feed," Young explained. "She has not slept longer than a 50-minute stretch for over 10 days. Obviously, this is not sustainable long-term, and it can result in a significant compromise to her physical and emotional health."
While Young admits that the roots of PPD are complex, she said she personally witnesses the pressure to breastfeed contributing to mothers' mental health struggles on an almost-daily basis. “Women place so much shame and guilt upon themselves when they don’t meet these breastfeeding goals," Young said. "Some women internalize it so deeply that it can contribute to increased postpartum anxiety and depression.”
Part of the problem, Young added, is that some mothers who have depression in their history will stop taking antidepressants, out of concerns that medication will have a negative impact on their nursing child. This concern might be putting new mothers at unnecessary risk, particularly considering the fact that research from Clinical Obstetrics and Gynecology shows the risks associated with breastfeeding on antidepressants are relatively low.
As for where the pressure to exclusively breastfeed comes from, there's no one source that is culpable. Many moms, however, report that extreme efforts to promote the benefits of breastfeeding, such as a lower risk of SIDS or chronic disease later on in life, has contributed to a culture that shames mothers who cannot exclusively breastfeed, as does judgment from finger-wagging family members and friends.
Sager told Romper that breastfeeding was a part of her family culture, as both her and her husband had been breastfed as babies. She also said that criticism from her pediatrician made her feel ashamed of her choice to switch to formula-feeding.
“He saw me feeding my baby a bottle and said something along the lines of ‘You've stopped breastfeeding already?’, with emphasis on the ‘already.’” Sager recalled. “By this point she was probably at least five or six months old.”
"I specifically remember a lady on a podcast saying, ‘It is what your body was made to do. Why not just be natural and allow it to do its job?’ That was painful to me. I felt like I was such a failure.”
For Allen, the pressure was more indirect, stemming from the natural-minded online parenting resources she found before pregnancy.
“I think the pressure came from social media and podcasts,” she said. “I had been listening to a podcast for pregnant and new moms and...I specifically remember a lady on a podcast saying, ‘It is what your body was made to do. Why not just be natural and allow it to do its job?’ That was painful to me. I felt like I was such a failure.”
Allen also said she was shamed by the nurses at the hospital where she gave birth, which had adopted the baby friendly hospital initiative (BFHI) developed by WHO and UNICEF. In order to be deemed a baby friendly hospital, care providers must adhere to a list of guidelines, include immediate skin-to-skin contact until the completion of the first feeding, requiring the baby to “room-in” with the mother during their hospital stay, and banning supplementation unless medically indicated (such as a maternal illness that separates mom and baby).
There is some debate among health care providers whether the Baby-Friendly Hospital Initiative friendly guidelines actually increases breastfeeding rates in new moms, or if it creates a culture of pressure and shame for mothers who struggle with breastfeeding. In fact, a 2016 paper from JAMA Pediatrics concluded that the initiative might be less safe for babies and mothers than initially believed. Potential issues include unsafe sleeping practices, dangerous exhaustion for mothers, and the demonization of supplementation among hospital staff.
The controversy over baby-friendly hospitals was drawn into sharp relief in early 2017, when Fed Is Best, a non-profit that supports formula supplementation, published a story by Jillian Johnson, a mother whose baby Landon died in a BFHI. According to Johnson, Landon starved to death after lactation consultants discouraged her from giving the baby formula. (In response, Baby-Friendly USA, the organization that promotes baby-friendly policies, published a statement saying "the lesson of this story is not that exclusive breastfeeding is dangerous...The real lesson of this story is that there are certain conditions that require further assessment and close follow up with the mother, infant, or both.")
"Your ability as a mother doesn’t have anything to do with how much breastmilk you’re able to produce.”
Ultimately, mothers should remember the role their own mental health plays in raising a healthy child, said Young. Left untreated, postpartum depression or feelings of resentfulness towards a baby because of the struggle to breastfeed can prohibit bonding, which can negatively affect a child’s neurological development.
“Remember, you can always provide a lot of the benefits of breastfeeding to your baby while supplementing,” said Young. “Even if you’re not nursing, being able to have skin-to-skin, providing cuddle time with them, having them at your chest, even on your breast, while you’re giving them a bottle, that closeness with the baby and your body heat regulating their temperature allows the baby to relax. All of these things help with bonding and are very healthy for the baby and none of that has to do with actual transfer of milk. Because your ability as a mother doesn’t have anything to do with how much breast milk you’re able to produce.”