Peaceful Revolution: Motherhood and the $13 Billion Guilt

Since this month's publication of my paper "The Burden of Suboptimal Breastfeeding in the United States" in Pediatrics with Arnold Reinhold, I'm often asked by reporters what the US can do better to improve our breastfeeding rates. I've also gotten quite a few comments asking if this research just makes moms feel guilty if they couldn't breastfeed.

The answers to both these queries are intimately related, and are best illustrated by the following Tale of Two Births. As you will see, if you compare what should happen when a woman gives birth, versus what actually happens, you can appreciate how tough it can be for US women to breastfeed, but how much easier it could be if only things were a little different around here.

Birth number 1: Having a baby in the ideal, family-friendly United States:

You give birth with the help of a birth doula. She helps you avoid a c-section or vacuum assisted birth, which is why your hospital hired her.

Your baby is wiped off, then put directly onto your chest, skin to skin, with his head between your breasts. The nurse puts a blanket around you both, and then your partner cuts the cord. The nurse evaluates his initial transition to life outside the womb as he rests on your chest. As you lay semi-reclining, happy and exhausted, your baby uses his arms and legs to crawl over to your breast and he starts nursing. You and your partner are left undisturbed for an hour to enjoy your new baby, who has now imprinted the proper breastfeeding behaviors thanks to this initial breastfeeding. You are then transported to your post-partum room with your baby on your chest.

The nurse returns and weighs, measures, and examines your baby right there in your room. You are with him as she gives him his vitamin K shot and antibiotic eye ointment. Your baby is handed back to you, and again placed on your chest skin to skin. He stays in your room with you until you go home.

From your prenatal class, you knew in advance to ask most of your visitors wait until you go home, so that you can get some rest, and you turn the ringer off your phone, so that no phone calls will wake you. Before you leave the hospital, your baby's routine heel-stick blood test is done while he is nursing, and you are amazed to see he doesn't cry at all.

You are discharged with clear instructions around breastfeeding, and phone numbers to call if you need help. You are not given samples and "gifts" from a formula company.

Two days later, you see your pediatrician, who is a little concerned about the baby's weight, but your baby otherwise looks healthy. He quickly refers you to a licensed International Board Certified Lactation Consultant, and all you pay is your standard co-pay. She does a careful assessment and advises increasing the frequency of nursing for a few days, and that does the trick.

You enjoy three months paid maternity leave, at 80% of your usual pay. Your baby sleeps within arm's reach of you, and because you taught yourself how to breastfeed lying down in the dark, you awake fairly refreshed every morning.

When you return to work, your employer allows you flex time. Your employer has a policy that allows new parents to bring their infants to work, so often you bring your baby with you. As in other companies with such policies, your coworkers enjoy having a baby around, and you feel happy, calm, and productive.

When your baby gets more active, you put him in the daycare near your worksite so you can nurse him during lunch, and you can pump milk in the lactation room at work. You bought a nice pump with your insurance's Durable Medical Equipment allowance. After 6 months, you introduce solids. A few months later, you really don't need to pump any more and you and your baby enjoy breastfeeding for another year. Your baby is so healthy that you've never had to miss a full day of work.

Does that sound like your birth experience, or does this?

Birth number 2: Having a baby in the real United States:

Your give birth to a healthy baby, and you've never heard of a birth doula.

The umbilical cord is clamped and cut before anyone can say, "It's a boy!"

Immediately, your baby is whisked across the room to the warmer where Apgar scores are assigned, he's given a shot of Vitamin K, and antibiotic eye ointment is slathered in his eyes, clouding his vision. He's placed on a cold scale and weighed and measured. He is examined by his nurse, who takes him to a different room to do her evaluation. He is bathed, washing off his mother's scent. At last, he's professionally swaddled into a nice tight parcel and handed to you to hold, cradled sideways in your arms.

He's not skin to skin, and he can't move his arms and legs to crawl to the breast. Before you know it, an hour has passed since his birth, and since he's missed the window of "alert time" after birth, he slips into a deep sleep without having spontaneously breastfeed. You attempt to interest him in the breast, but he is really too tired to try very hard. Because he's wrapped up and has been given a bath, he can't use his sense of touch and smell to crawl his way over to find your breast. You don't know enough to unwrap him and feed him immediately after birth, because your prenatal class didn't stress the importance of skin to skin contact during the first 3 days of life. That was all discussed in a separate breastfeeding class and you didn't really have time or money to take two classes.

Just as you're getting to know your new bundle of joy, the staff decides to check his temperature and his blood sugar. His glucose level is 45 -- normal for a newborn, but low for an adult. His temperature is a little low, too -- all that time in the bath, the cold scale, the swaddling, and the time away from his mom's body heat has led to hypothermia.

Hypothermia and hypoglycemia can be signs of a serious infection, so immediately he is taken from your arms down to the nursery, where he gets what's known as a sepsis evaluation. Lying under a warmer down the hall from you, he gets his blood drawn, and then is left in his bassinet in the nursery to be observed for a few hours so you can't spend time with him as you recover from giving birth. He gets a 2 ounce bottle of formula, most of which he vomits, since the stomach of a five-hour-old baby is no bigger than a teaspoon, the perfect size to digest the colostrum your breast secretes for him in the first few days.

Finally, your baby's brought back to you, swaddled in a nice package. He's more alert, but never imprinted breastfeeding very well, and he's very stressed from all the day's events. He might be full from the formula he's given, and doesn't breastfeed well. He tries later in the day. The nurses try to help you, but it feels like they all give you different advice, much of it conflicting. Little do you know, their advice is based on their personal experiences rather than any scientific evidence because they haven't had much training in breastfeeding. You don't know what to believe.

Finally, your baby goes to the nursery for the night "so you can sleep," and he is brought in for you to feed him. He doesn't like it in the nursery, so he cries, and you don't get much sleep either.

You have some pain when he latches on, and you're told that's normal. You're so excited about his birth that you talk to everyone by phone, and lots of people come to visit. They pass him around. Maybe someone wants to give him a bottle, and you figure, ok, why not. He's chewing on his fist, but no one ever told you that means he's hungry, so you give him a hospital-issued pacifier to suck on instead of his hand. You don't know that giving formula and pacifiers in the hospital will undermine your efforts to breastfeed.

It's surprising the nursing staff doesn't inform you of this, and you didn't learn it in your prenatal class. You're too embarrassed to feed him with everyone there. Finally, your guests leave, but by this time, your baby's frantic, and nursing doesn't go well as a result.

Overnight, as he stays in the nursery, he gets weighed, and he's lost more weight than he should have. The doctor says it's because your milk isn't in yet, and recommends more bottles. He still sucks happily on a pacifier and sleeps in the nursery despite his alarming weight loss, and no one suggests that you nurse him more often, room in with him, get rid of the pacifier, or see a lactation consultant, all of which would help put him back on track with breastfeeding.

An hour before you're due to go home, the lactation consultant comes in briefly to check on you, but because her department is so understaffed, she couldn't see you earlier when you needed it most, and she has little time to spend addressing your problems. On your way out, a nurse hands you a marketing bag from a brand-name formula company, complete with free samples of formula and information on breastfeeding that makes it sound a little hard and scary. She tells you if you have any questions, to just call your pediatrician.

The first night at home, things don't go well. It's the middle of the night, and your baby won't stop crying when you try to breastfeed. You wonder if you should just give up. You reach for that ready-made bottle and his crying mercifully stops. The problem is solved, at least for now.

You are really motivated to breastfeed, so in the morning, you try to find a lactation consultant. You talk to someone you find in the yellow pages called a "lactation counselor" who is willing to help, but your insurance won't pay. You find someone else called a "lactation consultant." You have no idea what the difference is between a "lactation counselor" and a "lactation consultant." Since these professionals aren't licensed in any state, you have no way of knowing if they know what they are doing.

You meet with the lactation consultant, but have to pay out of pocket. She helps you. Afterwards, you have to file a claim with your insurance company and hope they reimburse you, all while caring for your newborn. The lactation consultant recommends pumping with a double electric pump to help you build up your milk supply, which is now threatened because of all the formula the baby got, and because his breastfeeding technique is not really good enough yet to extract milk well, since he didn't learn properly right from the beginning. Your insurance won't allow the breast pump to come out of your Durable Medical Equipment allowance, and you try to pay for it with your Flexible Spending benefit card, but it's denied. You pay $250 out of pocket. Good thing you had a gift card to pay for all that!

You go to your pediatrician for follow up. Since your pediatrician got very little training on breastfeeding, he doesn't know how to help you, but is concerned that your baby has lost too much weight, and advises giving some formula. You don't know what to do because the lactation consultant's advice was different.

Ugh!!! This is really hard, you think. Eventually, things miraculously end up working out, just because you persevere through thick and thin, and your partner and family and friends are very supportive. By about 4 weeks, your baby is now exclusively breastfeeding, and gaining well. And you are enjoying what time is left of your unpaid leave under the Family Medical Leave Act. But, you have only two more weeks before you go back to work. You can't afford any more time off.

You start pumping to build up a stash of frozen milk for your return to work. You arrange with your employer a place to pump -- how lucky you are that it won't be a bathroom! You go back to work, and before long you discover your milk supply is dwindling and now your baby wants to nurse all night long. You are exhausted.

You call the lactation consultant who tells you that it's common to see a drop in milk supply when moms go back to work. She explains that pumps aren't as efficient at removing milk as your own baby is, so your milk supply may drop, and your baby makes up for it by nursing more when you are with him -- it just so happens that that's at night. "It's called reverse cycle feeding," she tells you. You wonder why you never heard about this before, in any of your follow-up visits with your pediatrician or OB.

You want to see the lactation consultant again, but your insurance will only reimburse you for visits during the newborn period. Well, you think, at least my insurance paid for something -- my friend's insurance doesn't reimburse anything for lactation help.

You nearly fall asleep at the wheel driving to work. "This is crazy," you think. "My baby needs me to be alive, more than he needs me to be breastfeeding." Finally, you give up. You just can't do this anymore. You are very sad and disappointed.

You become a statistic: one of the 41% of US mothers who wean before 3 months. You feel guilty as hell, especially when all you ever hear is how great breastfeeding is, and now how that new study shows it could save the US economy $13 billion/year, and how everyone says it saves lives and how it will make you healthier too. You just wish all these people would just shut the heck up.

So, now that you've heard the difference between what your experience could have been like, and what it was actually like, you tell me:

Do you feel guilty for not breastfeeding? Or do you feel angry because it didn't have to be this way?

And if you answered "angry," then take that anger, and write to your hospital -- tell them you want them to become a Baby-Friendly hospital, so that no one else will have to go through what you did just to feed your child. Write to your state and federal legislators -- tell them to support laws that make breastfeeding easier, like licensing of lactation consultants, and the requirement that insurance companies reimburse for lactation care and services. And write to your US representatives and senators, and tell them you want tax-credits for onsite childcare, and that you don't want the US to continue being the world's only developed country without paid maternity leave.

Yes, I'm a researcher and a physician, but I'm also a mother. Since I live in the United States, you can probably guess what my birth experience was like. Maybe you've heard me on the news saying that moms shouldn't feel guilty. I've been there. So take that guilt and turn it inside out, and do something positive so that other moms don't have to go through what you did.

We all deserve better.

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