Ask women who formula-fed what led them to that decision, and you'll get a sheaf of answers. Some tried to breastfeed but didn't get the support they needed; some couldn't get breastfeeding to work even with support; some never really thought about it, just opting for what all their friends and family had done; some had medical or practical issues that made breastfeeding a no-go; some hated the whole thought of breastfeeding from the start; some believed myths about breastfeeding; some researched the facts carefully before making their decision. No doubt you can think of a few I've missed off that list. But there's one reason I've never yet seen and really don't expect to see showing up significantly often, and that's "Because I knew the formula in the hospital would be free".
However, it seems an increasing number of policymakers in British maternity units do believe this to be a significant factor. At the beginning of June, a news article reported that the Hull and East Yorkshire NHS Trust would, except in emergencies, no longer be providing formula milk to new mothers. Women who plan to formula-feed have to bring supplies with them; women who plan to breastfeed but find things going badly and want to change their minds/give some supplementation while they get breastfeeding started, have to find a friend or family member that they can send to get one. Several other hospitals have followed suit, assuring us that it is not a cost-cutting exercise but simply a way of encouraging breastfeeding.
It took me a while to articulate the reasons behind my automatic feeling of dislike of this policy. My first thought was that this sounded like some sort of regression to a Third World country in which the hospital would expect the family to bring in a patient's food, rather than supplying it on site. If we treated any inpatients apart from newborns this way there would be an uproar; why was it considered acceptable to single out formula-fed babies in this way? Well, because it was all in the interests of encouraging breastfeeding, of course. So I did give some careful Devil's Advocate-style thought to whether that was a good reason. After all, it is fair to say that newborn babies are a unique case in that their mothers do normally produce their food supplies. Besides, hospitals are meant to be promoting healthy behaviour – is it worth treating newborn babies as a special case if this encourages breastfeeding?
Then it hit me that I was actually focusing on completely the wrong question. The most important question here was actually "How in the blue bleedin' heck is this supposed to be encouraging breastfeeding??"
I repeat: patients will make the choice to formula feed for a variety of reasons, but "Because I can get free formula while I'm still in hospital" just isn't one of them. So, conversely, who is going to decide to breastfeed just because the hospital will otherwise make them pay for their own formula? Women giving formula to their newborns while still in hospital fall, as far as I can see, into two categories: women who've decided to formula-feed from the start, and women who've decided to breastfeed but are struggling so much they turn to formula (either for good, or as a supplement to tide them over as they continue trying to get breastfeeding going). How is the decision to ban hospital-supplied formula going to play any part in encouraging breastfeeding in either of those two groups?
Women who've decided to formula-feed have, presumably, already weighed up the fact that one of various disadvantages of this choice is going to be the necessity of paying for 360+ days' worth of formula for their infant and have decided to go ahead anyway. Is the news that they'll have to add an extra few days' worth of formula costs to that bill really going to be the tipping point that makes them decide, oh, well, better breastfeed, then? If you think women might not have already thought about the costs of formula, discuss that with them beforehand in antenatal consultations and leave them to weigh it up and make up their own minds. If they've decided the bill is worth it to them, is a marginal increase in the total really going to make a difference to their decision?
Women who've decided to breastfeed, by definition, want to breastfeed. They're likely to be extremely happy to get support and help in the matter. If they're struggling so much they want to give formula then either all the support and advice you can give them will solve the problems effectively enough that they'll no longer feel that way (in which case, the decision over whether or not to let them have some formula will be a moot point anyway), or it won't (in which case, denying them free formula is not going to alter their decision).
So, either way, it's very hard to see just how the buy-your-own-formula rule is going to do anything whatsoever to encourage breastfeeding. Of course, what it might end up doing is putting the latter group of women through an extremely frustrating and distressing time. Imagine struggling mightily with feeding, feeling absolutely at the end of your tether, hearing your baby screaming with hunger, desperately wanting to be able to give even a bit of formula to ease the burden on both of you to the point where you could bear to carry on. Imagine, further, that it is the early hours of the morning, there is no-one that you can reasonably call up at that time to go get formula, your only chance of getting some is the midwife who is supposed to be your mainstay and support at this time… and she tells you that, no, dear, you can't have any formula because it's all for your own good and your baby's that you don't. Anyone think that scenario couldn't possibly happen, on a maternity unit with that sort of anti-formula attitude?
I can also think of a couple of ways in which this policy could backfire. Let's say a woman who hopes to breastfeed is planning to give birth at one of those units, she's aware that it might not all go smoothly, and she doesn't want to take the risk of ending up in the scenario outlined in the last paragraph. What's the obvious, sensible thing to do in that case? Take a carton of formula in just in case. If she doesn't need that formula while she's still in hospital, is she going to throw it away? Not likely – no point wasting it now she's got it, might as well put it in the cupboard just in case she needs it at a later date. What is the usual position of breastfeeding advisors on having formula sitting in the cupboard just in case it's needed? DON'T DO IT! DON'T DO IT!! On nights when breastfeeding is going badly, that formula will lure you with its siren song! And, if you yield to temptation and give it, it will interfere with the delicate balance of supply and demand and start you on an irreversible downward spiral of needing to give more and more formula until your supply fails completely! Don't have it in the house in the first place!! Just say no!
As you can possibly guess, I'm a wee bit sceptical over the whole 'just one bottle will inevitably cause the breastfeeding relationship to topple around your ears' theory – I suspect that, in fact, women who are going to be able to make breastfeeding work out are able to bounce back perfectly well from giving 'just one bottle', and, in cases when it doesn't work out, it's usually because of various other factors stacked against the woman rather than because of that One Bottle. However, it's possible that it might be the breaking of the camel's back for a woman who is having difficulties; and, regardless of what substance there may or may not be to the advice, having formula in the house is quite definitely a no-no in the book of most breastfeeding supporters. So, if buying some formula for emergencies is something that women are supposed to avoid, why set up a situation that positively encourages them to do so?
Another issue is the potential missed opportunity to talk to a woman who's reached the stage of feeling she needs to give some formula. Of course, most women who are struggling with breastfeeding while still on the maternity unit are going to come and ask the staff for help anyway; but some might not, and some might get so little help from the first midwife they ask that they conclude it isn't worth asking anyone else (probably not a hugely uncommon scenario, sadly). If a woman who wants formula has to go ask the midwife on duty for it, then that's a chance for that midwife to talk to her about whatever problems she's having and see if she can suggest anything. And while "No, we aren't going to give you any formula" doesn't do a darned thing to sort out whatever problems have led the woman to ask for it, a sensitive, sympathetic, non-authoritarian exploration of what's going on may identify something that can be helped and may give the woman the strength she needs to keep going a bit longer. If that woman is, instead, getting the formula out of her bag that she's brought in with her because she knows she'll have no joy asking for it and is worried she'll only get a lecture for her pains, then the midwife isn't going to hear about that problem and isn't going to have a chance to help.
So, there is a real chance this policy could do more harm than good to breastfeeding rates. Probably not a lot more: I'm guessing there aren't that many women for whom a carton of formula lurking in the cupboard, or a missed chance for an opportunistic chat with a midwife whom they wouldn't otherwise have thought to approach, was the one factor that led to them ultimately formula-feeding when they would otherwise have successfully continued breastfeeding. But I'm also guessing that that's still greater than the number of women who are unmoved by all the other practical, financial, and health drawbacks of using formula but decide that the need to pay for the amount of formula a newborn can drink in its first couple of days of life is the one factor that brings them round to breastfeeding. So, yes, overall I'm estimating more harm than good. (And, let's face it, if the best thing you can say about a policy is that it probably isn't going to do much more harm than good then that's a policy that shouldn't ever see the light of day.)
However, I also think that for the most part the practical effects of this are going to amount to nuisance value only; so, although that plus the occasional more serious impact is quite enough for me to oppose this policy, it doesn't quite account for the distaste I felt when I first heard about it. I thought more about that one, and finally managed to pin it down and put it into words. The problem is what it says about the attitude of the people who came up with it.
What we have here is a policy that is being sold as 'encouraging breastfeeding', when it clearly doesn't. It is in no way an attempt to look at how the obstacles in the way of breastfeeding can be removed, or how women can be helped to surmount them. Instead, it's an attempt to throw an extra obstacle in the way of formula feeding. This is not the sort of policy that gets thought up by people who see their goal as working together with women to help them make informed choices and achieve what they want to achieve in infant feeding. It's the sort of policy that gets thought up by people who see their goal as figuring out how to get women to do things the policymakers' way. The former lot of people want to work with us; the latter want to work on us. And, while it is not news to me that there are rather too many people with the latter goal in positions of power, it still isn't something I ever like to see examples of.