Pamela Morrison, IBCLC, West Sussex, UK
Originally published February 2016, and republished with the express permission of the author.
Imagine that the world had invented a new ‘dream product’ to feed and immunize everyone born on Earth. Imagine also that it was available everywhere, required no storage or delivery—and helped mothers to plan their families and reduce the risk of cancer … Then imagine that the world refused to use it … This scenario is not, alas, a fiction. The ‘dream product’ is human breast milk, available to us all at birth, and yet we are not using it. UNICEF, 1991.
When friends and well-wishers asked me how I was going to feed my first baby, I always answered, “I’ll try to breastfeed.” Against all odds, my babies grew and thrived on exclusive breastfeeding, including the surprise twins who arrived five years to the day after the birth of our first son.
If I can…
Why did I believe that I might not be able to breastfeed?
Research suggests that mothers with less confidence are likely to give up breastfeeding early . “Not enough milk” is the most common reason that new mothers give for stopping breastfeeding  and the following kind of ego-sapping information is typical of the information new parents receive:
“ Although experts believe breast milk is the best nutritional choice for infants, breastfeeding may not be possible for all women. For many, the decision to breastfeed or formula feed is based on their comfort level, lifestyle, and specific medical situations. For mothers who are unable to breastfeed or who decide not to, infant formula is a healthy alternative. Formula provides babies with the nutrients they need to grow and thrive .”
The cost of not breastfeeding
With today’s research demonstrating the higher risks of mortality, allergy, illness, and later non-communicable diseases associated with the use of breast milk substitutes,  it is unacceptable that only 1% of British babies today are exclusively breastfed for the first six months as per global recommendations. There is an economic cost too to such a high rate of breastfeeding failure. If 90% of US families could comply with medical recommendations to breastfeed their babies exclusively for six months, the United States would save $13 billion per year and prevent an excess 911 deaths .
A US 2013 cost analysis of maternal disease associated with sub-optimal breastfeeding found that if 90% of mothers were able to breastfeed for at least one year after each birth, compared to current breastfeeding rates, this would result in savings of $17.4 billion resulting from premature death, and $733.7 million in direct and $126.1 million in indirect morbidity costs associated with breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction .
In the UK, UNICEF commissioned a report, published in 2012 , to examine how raising breastfeeding rates could save money through improving health outcomes. It was found that moderate increases in breastfeeding could save tens of thousands of hospital admissions and GP consultations for just five common childhood infections, and ultimately translate to a cost saving for the National Health Service of £40 million.
In January 2016 The Lancet Breastfeeding Series Global Launch reported on the most extensive piece of research into the effects of breastfeeding ever undertaken. Increasing breastfeeding worldwide could prevent over 800000 child deaths and 20000 deaths from breast cancer every year. Failing to breastfeed costs the global economy around US$302 billion every year [7a].
James Akre, in his book, The Problem with Breastfeeding: a personal reflection  maintains that all mothers love their babies and want the best for them, but it is whole communities who breastfeed, and the homily, “It takes a village to feed a child” remains true wherever we live. Akre postulates that if Irish women (who have the lowest breastfeeding initiation rates in the world , at 45%) lived in Sweden where breastfeeding rates are high, most of them would also breastfeed.
What is normal?
In global terms, breastfeeding is normal, whereas because only 8% of the world’s babies are born in countries where bottle-feeding is the cultural norm  some might describe bottle-feeding as a “traditional harmful practice of the minority,” as set out in the Innocenti Declaration . In resource-poor settings new mothers are not seen to have a choice about how to feed their babies, since not to breastfeed would place the infant’s health and survival in jeopardy. Certain cultural beliefs and taboos also ensure that breastfeeding will continue to be practised. Breastfeeding, often portrayed with reverence, is not only a duty and a privilege, but also a sign of sexual fidelity. By giving birth and having children, a woman’s status in society is elevated. By breastfeeding her babies, a woman demonstrates to her husband, family, and friends that she is a good wife and mother.
5% of all mothers?
So how often does breastfeeding really fail?
In the sophisticated, emancipated societies of the global west and north, it has been suggested that 5% of mothers are unable to produce enough breast milk to nourish their babies at the breast. Well-respected authors who have anecdotally referred to the 5% figure include Dana Rafael  in 1955 and Marianne Neifert  in 1983, but a search of the literature fails to reveal any primary research to document or validate it. Betty Crase, a La Leche League Leader and former director of the LLLI’s Center for Breastfeeding Information, exhaustively traced the 5% figure back to a remark in an opening presentation given by JC Spence, MD, FRCP, at the Annual Meeting of the British Medical Association in Plymouth, in 1938 . What Betty discovered was that since then everyone was just quoting everyone else who had used the figure. Researchers or authors in the 1980s or 1990s for example simply quoted Neifert. Betty concluded that whenever a specific number is quoted, it gives the impression that there is research behind the number. In this case, there was no research, just a remark in a speech by a physician at a prestigious medical meeting. The 5% had taken on a life of its own .
In reality, the physiology of lactogenesis (the production of breast milk) is much more reassuring. During early pregnancy, hormones including progesterone, produced by the placenta, which is fetal tissue, cause proliferation of the milk producing cells within a mother’s breasts. Thus the baby is responsible for generating his own future source of nutrition after birth, and the breasts are ready to produce milk any time after the 16th week of pregnancy.
Before birth, progesterone acts as a brake on milk production. Afterwards it is the abrupt withdrawal of progesterone following delivery of the placenta that causes the breasts to start producing copious quantities of milk.
Use it or lose it
Between day four and day nine postpartum, the breasts will produce 400–750ml of breast milk per day, regardless of whether the mother has decided to breastfeed or not. It is the frequent and thorough drainage of milk from the breasts that maintains continued breast milk synthesis. This is the most critical time in a mother’s lactation journey. If not removed, special milk proteins signal the cells to make less milk. Ongoing over-fullness (called engorgement) can dramatically reduce continued breast milk production within just four days. This is Nature’s way of ensuring that there is no waste. Use it or lose it is the principle new mothers need to be aware of.
If the baby is sleepy, or cannot latch and breastfeed effectively, or if the breasts become overfull for any reason whatever, mothers need prompt skilled assistance to express the excess milk enabling future milk production to be preserved. If a baby is too premature or too sick to breastfeed, then the mother can be taught how to provide her expressed milk to him until he matures.
In my practice as an International Board Certified Lactation Consultant, after ruling out known causes of delayed lactogenesis such as underactive thyroid, postpartum hemorrhage, or retained placental fragments, and after applying the very best lactation management techniques, I have documented that only one in a thousand (0.1%) of new mothers simply do not produce any breast milk at all. For the mother who wanted to breastfeed, this is a heart-breaking disappointment. Fortunately it is very, very rare.
Much more commonly the mother receives outdated information and inadequate help and ends up believing that—like so many of her friends who had similar negative experiences—she was unable to breastfeed.
The decision whether to breastfeed
In sophisticated societies where infant formula is both easily accessible and socially acceptable, where the value of mother’s milk is trivialized, and where there is clean water and expert medical care to treat the greater number of infections that a bottle-fed baby can be expected to suffer, mothers who are struggling to breastfeed may receive strong pressure from family, their peers, or even from less well-informed healthcare providers to switch to bottle-feeding. Often such mothers become very defensive as, rather than confront failure or accept that they themselves were failed by a poor support network, they attempt to rationalize a decision not to breastfeed.
An increasing number of articles, social support networking sites, blogs, books, and videos affirming mothers’ choice to formula-feed attest to the bitterness, disappointment, and strength of feeling generated by the failure to succeed at breastfeeding , , , , .
Anger is sometimes directed at breastfeeding advocates, who may be labeled “Fanatics,” “Lactivists,” “Nipple Nazis,” or “Breastapo.” Consequently there is often considerable stigma attached to breastfeeding promotion, coupled with a very real fear of engendering maternal guilt. Many breastfeeding counselors are at pains to rationalize formula-feeding by defending women’s right to bodily integrity.
A mother may absolutely believe that, when breastfeeding is difficult, her own emotional wellbeing is more important than her baby’s health:
“When the entire focus is on what’s ‘best for baby,’ we devalue mothers and their physical and emotional well-being. I was happier, more relaxed and less stressed when I switched to formula feeding my oldest son. That is important to acknowledge, even if I get flak for it. I was happier. And that was absolutely the best thing for my babies” .
“All ‘fearless’ formula feeding means to me is that you feel you have made the best choice for your family, for your baby, for you. Fearless doesn’t necessarily mean regret-less, guilt-less, anger-less, resentful-less. It just means you’re not scared of your choice, because you know it is safe, and you know it was right” .
The World Health Organization maintains that “The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant —in the majority of health conditions affecting either the mother or the baby, breastfeeding should continue. The acceptable medical reasons why a baby should not receive breast milk, are very few, as follows :
Acceptable medical conditions in infants:
- Maple Syrup Urine disease
Acceptable medical conditions in mothers:
- HIV infection where the mother has not received antiretroviral treatment and where formula-feeding is deemed to be safe
- Severe illness, e.g. sepsis
- Herpes simplex virus type-1 on the breasts pending treatment
- Medication with sedating psychotherapeutic drugs, anti-epileptic drugs & opioids, radioactive iodine-131, topical iodine, cytotoxic chemotherapy.”
- As someone who works to resolve breastfeeding difficulties, I know better than most that when breastfeeding has been mismanaged, supplements to mother’s milk can be lifesaving in protecting a baby’s nutritional status. If donor or banked breast milk cannot be obtained, formula may be necessary in the short term while the mother works to increase her breast milk supply. Rarely, the baby may need supplementation for many months. But most of the time it is possible to pinpoint the cause, and identify the cascade of events that led to breastfeeding failure and to employ strategies and techniques which will increase breast milk production to slowly resolve the problem. Sometimes even though nursing directly is not possible breast milk-feeding using another method of delivery can be successfully achieved for weeks, months, or even years.
Choice and capacity
It is important to distinguish the difference between choice and capacity: to be clear that, given enough up-to-date information and skilled assistance when they need it, 99.9% of new mothers will provide enough milk for their babies. At the same time it is vital to afford sensitive care to the tiny number of individual mothers who are physically unable to breastfeed. When there is secondary breast milk insufficiency due to poor breastfeeding management, mothers who partially breastfeed can provide:
- ALL of the emotional benefits by encouraging comfort sucking whenever the infant wants, and by feeding breast milk and supplements at the breast, through the use of a supplemental nursing system.
- ALL of the immunological protection. When the volume of breast milk is low, as in colostrum or weaning milk, the antibodies are concentrated in colostrum or weaning milk , .
- PARTIAL nutrition. When the breast milk supply is low, supplements may be required to make up the nutritional deficit, but the partially breastfed baby still receives human milk enzymes, hormones, fatty acids, proteins, and sugars which cannot be obtained from any other source, and even 50 ml of breast milk each day is of huge benefit to the baby.
It is difficult to find a woman’s right to formula-feed set out in any of the Human Rights literature. On the contrary, the United Nations Convention on the Rights of the Child, the most comprehensive statement of children’s rights ever produced, ,  recognizes that every child has the right to enjoyment of the highest attainable standard of health, with the best interests of the child at the forefront of all actions and policies affecting their development, health, and survival. In particular, all segments of society are to be informed of the advantages of breastfeeding.
I conclude that breastfeeding is a learned behavior.
Young girls and new mothers need to receive:
- the clear message that breastfeeding is worthwhile because the value of their milk to their babies is irreplaceable,
- sufficient help and information to ensure that breastfeeding is successful, meaning that the baby thrives, and
- national policies that support working mothers’ rights to breastfeed.
It should be seen as a national scandal that a health care system can fail to equip its health care providers with the skills and expertise to motivate and assist mothers to initiate and maintain breastfeeding.
There is also a responsibility for mothers themselves to seek help when they run into difficulties. A Google search of “Breastfeeding Help” reveals 55 million hits in less than half a second. Expert assistance is available at the touch of a button including, in England, the number for a breastfeeding helpline with links to four breastfeeding support organizations, e.g. La Leche League, and over 400 International Board Certified Lactation Consultants.
Ultimately, being able to keep your baby well fed, happy, and healthy at the breast is one of life’s greatest gifts. I am so lucky that I had the help I needed to breastfeed my singleton, and then my twins. I cannot imagine the loss if I had not enjoyed this wonderful experience.
 Blyth, R., Creedy, D., Dennis, C., Moyle, W., Pratt, J., and De Vries, S. Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory. Birth 2002;29(4):278-84.
 Li, R., Fein S., Chen, J., Grummer-Strawn, L. Why Mothers Stop Breastfeeding: Mothers’ Self-reported Reasons for Stopping During the First Year, Pediatrics 2008;122;S69, DOI: 10.1542/peds.2008-1315i.
 Kids Health, accessed November 22, 2015.
 Grummer-Strawn, L. & Rollins, N. World Health Organization, Summarising the health effects of breastfeeding. Acta Paed 2015;104:1-2, November 2015 and subsequent special issue.
 Bartick, M. & Reinhold, A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010;125(5):e1048-56 doi: 10.1542/peds.2009-1616. Epub 2010 Apr 5.
 Bartick, M., Stuebe, A., Schwarz E., Luongo, C., Reinhold, A,, Foster, E. Cost analysis of maternal disease associated with suboptimal breastfeeding, Obstetrics & Gynecology 2013;122(1):111-119, doi:10.1097/AOG.0b013e318297a047.
 Renfrew, M. et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK UNICEF UK October 2012.
[7a] Victora, C. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect The Lancet 30 January 2016; 387 (10017): 475-490.
 Akre, J. The Problem with Breastfeeding: a personal reflection, Hale Publishing 2006.
And see: WHO , Akre J, editor: Infant Feeding, the Physiological Basis, Bulletin of the World Health Organization, 1989 Supplement to Vol 67.
 The Journal.ie National Breastfeeding Week: Irish breastfeeding rates below European neighbours, Oct 1, 2012.
 UNICEF 2003. Statistical Tables: Economic and Social Statistics on the Countries and Territories of the World with Particular Reference to Children’s Wellbeing, calculated births in industrialised nations as percentage of world births, figures for 2003.
 UNICEF 1990, Innocenti Declaration.
 Rafael, D. The Tender Gift: Breastfeeding, Knopf Doubleday Publishing Group, September 12, 1955.
 Neville, M. & Niefert, M. Lactation: Physiology, Nutrition and Breast-Feeding, Plenum Press 1983.
 Spence, J. The Decline of Breastfeeding, (a discussion in the Section of Diseases of Children at the Annual Meeting of the British Medical Association, Plymouth) British Medical Journal, Oct 8, 1938:729-733 (accessed October 5, 2015).
 Marian Tompson, LLLI Founder, Personal Communication with Betty Crase shared with the author on October 29, 2012.
 Jung, C. Overselling Breastfeeding, Op-ed piece in New York Times, October 16, 2015.
 Barston, S. Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn’t, University of California Press, October 2012.
 Stoller, D. A father’s perspective on the Similac ad, The Badass Breastfeeder, (accessed November 23, 2015).
 Wallace, K. Similac commercial is a hit. Judgy moms and dads face off in hit ad. January 28, 2015, CNN.
 Fearless Formula Feeder Facebook page.
 Kristina Wright. 8 Reasons to Formula Feed Your Baby, July 10, 2015.
 Fearless Formula Feeder Facebook page meme, accessed November 23, 2015.
 WHO 2003 Global Strategy for Infant and Young Child Feeding, clause 18, page 10.
 WHO 2009, Acceptable medical reasons for use of breast milk substitutes.
 Goldman, A., Garza, C. et al. Immunologic factors in human milk during the second year of lactation. Act Paediatr. Scand. 1983, 72, 461-2.
 Pietersen, B. et al. Quantitative determination of immunoglobulins, lysozyme and certain electrolytes in breastmilk during the entire period of lactation during a 24-hour period and in milk from the individual mammary gland. Act Paediatr. Scand. 1975, 64, 709-717.
 UN (1989) Convention of the Rights of the Child. Adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989; entry into force 2 September 1990, in accordance with article 49.
 UN Convention on the Rights of the Child, General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24)* April 2013.
Pamela Morrison is the mother of three adult sons, including twins, who were all breastfed. She became a La Leche League Leader in Zimbabwe and then certified as the first IBCLC in the country where she practiced until 2003. Now living in England, Pamela enjoys working to assist mothers who wish to maximize their milk supply in challenging circumstances, for example those wishing to induce lactation or to relactate for adopted, surrogate, sick babies, or those whose babies experience inadequate weight gain or failure to thrive.