Breastfeeding issues are something that I commonly treat as a paediatric osteopath. The more I learn about breastfeeding, the more complex I realise it is - there are so many factors to consider. Yet with the right conditions, it doesn't have to be so challenging. Breastfeeding is not just a physical act. It's also deeply emotional, a feminist issue and one that affects society through the generations.

I was delighted to interview Amy Brown, an academic and mother and author of "Breastfeeding Uncensored".

Hi Amy- Thanks for agreeing to be interviewed. You’re an Associate Professor in the Department of Public Health at Swansea University and your PhD was in the topic of baby-led breastfeeding. What led you to breastfeeding as an area of interest and expertise?

I’m a psychologist by background and have always had an interest in the factors that influence our decisions particularly around health and nutrition. I was actually meant to be doing my PhD on something else to do with nutrition and older children, but realised I was pregnant a few weeks after starting! I hadn’t really thought much about how babies were fed at that point – I saw it as pretty much an equal choice and you just picked one or the other. It was simple wasn’t it?

I soon realised that was perhaps the underestimation of the century and the more I spoke to new mums and experienced being a mum myself, the more I realised that in fact, how babies was fed was really complex. Reading around the area I was confused as to how the literature stated that the majority of women should be able to breastfeed, but almost the majority seemed to have issues. What I noticed, from my own experiences, was that although health promotion messages clearly promoted the ‘breast is best’ message, women’s experiences often didn’t fit with that. They struggled to get the right support, had others telling them to do things differently and formula adverts were everywhere. Mainly, there just seemed to be so little support for them actually mothering their baby, and lots of pressure to get their baby into a routine and get their own old life ‘back’.

In the end my PhD explored this idea of needing to get baby into a routine, what drove that decision and the impact it had on breastfeeding. Overall, trying to feed a baby in a strict routine meant that mums often stopped breastfeeding before they were ready, often with physical issues. Those who fed their baby whenever they wanted feeding were more likely to carry on. Notably, the decision to try to feed to a routine was either driven by anxiety that the baby should not feed so often or a desire to ‘get back to normal’ and be able to predict when the baby fed.

What does baby-led breastfeeding mean?

Baby-led breastfeeding is often called a number of things. We used to refer to it as ‘feeding on demand’ when your baby wanted to be fed. But that made things feel like babies were being unreasonable ‘demanding’ to be fed all the time. It also risked some sleepier babies not being fed enough.

Responsive feeding is the term that is used a lot in practice and in policy documents. Responsive feeding means following your baby’s cues and feeding them whenever they want rather than to a set routine. In other words, feeding them when they’re hungry not when a clock of book says – just like we as adults tend to eat and drink when we are hungry or thirsty.

Responsive feeding is really important because breast milk works on a demand and supply basis – the more milk that is removed from the breast, the more milk the body produces and vice versa. So feeding lots stimulates milk supply (and this is often why babies feed lots just before a growth spurt) but stretching out feeds or giving a bottle can reduce it. This is often how new mums end up with supply problems, because they are worried about feeding a baby too often, or in public, and try to stretch out, skip feeds or feed to a strict routine, which can mean less milk is produced. This can lead to feeding problems and an unsettled baby… and ultimately stopping breastfeeding before she is ready.

Responsive feeding is helped by keeping your baby close to you, so that you can recognise early cues to a baby wanting to be fed, rather than needing to wait until they cry. With breastfed babies this can be a lot! Most guides say every two hours or so, but it can be more than this, and often not to a set plan e.g. they might feed at 1pm, 4pm, 4.45pm and 6pm. A lot of babies tend to cluster feed, often in the late afternoon where they seem to be on and off the breast lots. This is perfectly normal. In indigenous cultures where baby wearing and feeding whenever the baby wants is normal, babies often feed several times an hour for a few short bursts!

Formula feeding can be responsive and baby-led too. Rather than following a set timed routine with set bottle sizes, you can watch your baby’s cues to want to feed and follow these. You don’t need to worry about giving a set amount, once your baby wants to stop feeding, just stop rather than worrying about what is left in the bottle.

Responsive feeding is really important, however you feed your baby, in developing positive eating behaviour and weight in later childhood and even life. When we are born we are good at self-regulating our intake of milk – babies fed responsively tend to just take enough of what they need and then stop. However our experiences in life (clear your plate, think of the starving children, eat at a set time) slowly break this down. Feeding to a strict routine might be part of the beginning of this and research shows that if you try and persuade a baby to take more milk from a bottle, even when they’re showing signs of being full, they will take more than they need. This can add up over time, increasing risk of overweight but also teaching babies to eat according to a set time and amount, rather than when they’re hungry.

How did your experience as a mother influence you in your profession and how did your professional role influence you as a mother? 

I think this has worked both ways. I started teaching in this area before I had children myself, but more widely in terms of infant development and child diet. Like many, I didn’t realise just how complex and important this area was until I had my own babies and gradually my research and teaching moved over to focusing on pregnancy, birth and early motherhood, particularly around how babies are fed.

I think my own experiences have given me huge insight into the issues in the area. This is not to say I base everything around my own issues, but certainly it opens my eyes to the gaps in the evidence base and the challenges new mothers face. A number of my projects have been started after I have experienced something, gone to look up the evidence for it and found none! It also makes me very aware of the deep emotion in this field and the importance of being sensitive to the fact you are talking about something that is of great relevance to people. I think sometimes researchers come to this area with little knowledge of these factors and can unknowingly cause harm.

Also, being very much part of the parenting community myself, and having breastfed my own three children, it enables me to understand the issues that are currently relevant and need exploring. Parents have come to me and asked whether I would consider researching X or have I thought about Y. It also allows me to react and explore topics as they occur. For example at the moment I am exploring the issue of ‘breastfeeding trauma’ (where mums have wanted to breastfeed but had to stop before they were ready and feel angry and upset about it) and how we can move forward with promoting breastfeeding whilst being sensitive to this. Being part of the community also means that my research requests are trusted and widely shared and I am very grateful to being able to collect such rich data because of this.

In terms of how my profession affects me as a mother, I was just saying the other day that I wish I could stop being a social scientist sometimes, ha! I find myself analysing gender stereotypes in the children’s pantomime performances for example and writing angry emails when I see the baby Jesus doll being formula fed. On a serious note though, it does mean that I tend to read quite widely around the literature before making decisions with my own children, and am very grateful that my ability to access and understand these papers helps me in making decisions. I wouldn’t say I made every decision based on the literature though - a certain amount of real life comes in! I often joke that I was interested in the literature around how you should not bribe your children with chocolate and then, well… I had my own children!

It has also meant that I have probably been quite a challenging mum to care for at times when I had my own babies. I’ve had a few conversations with health professionals who have suggested that there is no evidence for X … and I’ve pulled out a paper I wrote earlier! Although I must say it has often led to a lot of interesting discussions about the evidence base behind things … although I did wonder if I had finally gone crazy when discussing the evidence behind natural versus an injection for third stage delivery whilst actually being asked to make the decision myself during labour!

In your book you talk about the Western culture struggle with breastfeeding. Why do you think this exists? 

I think it’s really complicated. One issue is that we have lost understanding of what breastfeeding is really like because although some will say there is too much pressure to breastfeed, actually most people have more experience of formula feeding than they do breastfeeding. More than half of mums have given formula by the end of the first week compared to just 1% exclusively breastfeeding for six months and only one in two hundred giving any breast milk at all by twelve months. This means we don’t see breastfeeding much – a mum breastfeeding in public is something different. Extended breastfeeding is seen as unusual. Most people use formula so some can’t understand why everyone can’t just give a bottle in public.

Meanwhile, our society over sexualises breasts and the female body. It’s fine to see a half naked woman in a newspaper but a mother breastfeeding receives criticism even though you can see far less. Some people don’t seem to be able to distinguish the sexual breast from the nurturing breast and realise parts of the body can do different things in different contexts. Mouths for example – can be very sexual, but no one suggests people don’t eat in public! We’re really messed up as a culture.

The other issue is that we don’t value mothering more widely. We put too much pressure on new mums to ‘get their lives back’ and somehow return back to their pre baby life despite having created a whole new human being. We don’t value the ‘work’ they put in to caring for a baby and instead prioritise things that make money e.g. work and formula. We also don’t care for our new mothers very well whilst they’re doing this. In other cultures, the community comes around the mother to support her … whilst here our new mothers are often isolated and doing it all alone. We weren’t meant to do things this way – it really does take a village to raise a child. But our villages are now dispersed and relying on formula milk as the solution. And you can see why – if you’re feeling isolated and devalued and no one is caring for you whilst you try to responsively feed a small person, formula might sound like the ideal solution. You can have a rest! They’ll sleep! They’ll be more settled! …. Apart from the fact that there is no evidence this will happen and often you’re still the one who ends up getting up in the night and doing most of the feeds.

What do you think of the suggestion that the more developed a person becomes intellectually or analytically, the more they lose their body connection and the harder it is to conceive, or birth or breastfeed? 

I think sometimes we overthink things and worry too much, although given we’ve just been made responsible for a whole new person that’s understandable! More widely around birth, I know that over thinking it too much means that the body is often unable to relax into the primal state that helps the body to give birth. Thinking often leads to anxiety which leads to the stress hormone cortisol being produced … which can lead to less oxytocin in the body, which slows things down.

In terms of feeding, my own research shows that the more anxious mothers become around how much their baby is feeding and when, the more likely they are to try and monitor and control it, with the unfortunate consequence that this then all goes wrong and they often end up stopping breastfeeding before they are ready. There is also a hormonal role – some studies show that stress can interfere with the milk ejection reflex or sometimes less milk being produced. Being able to go with the flow (pun not intended) and feed responsively often means a better milk supply which means baby is happier!

Certainly, books that advise strict routines for feeding and sleeping should be thrown in the bin as far as I’m concerned. They promote anxiety and reduce confidence in just following what your baby wants. They are often unrealistic and research we have done shows they may increase risk of postnatal depression as mums feel that they have failed if they cannot follow the advice. On top of all of that they typically promote feeding routines that are the opposite to responsive feeding and following such routines often lead to mums stopping breastfeeding.

How can dads be involved to support their partners with breastfeeding? 

A supportive partner is really important when it comes to breastfeeding. My own research with dads shows that they really want to be involved but often feel a bit helpless. It is really important that they are included in antenatal education on breastfeeding and given lots of good tips and advice as they are the ones there at 2am, not the midwife! One issue is that dads in particular often want to fix things with a solution but actually mums value the emotional support the most – just knowing your partner is supportive and protective of you breastfeeding can be really helpful.

If partners, or indeed anyone wants to help, then the best thing they can do is care for the mother whilst she breastfeeds the baby. So feed her, and you will feed the baby! There are also lots of ways to care and bond with the baby outside of feeding it, so once the baby has been fed you can wrap them up in a sling and carry them around yourself, take them for a walk, massage or sing to them or perhaps give them a bath. I’ve made an animation here, based on research asking breastfeeding mums what they found helpful.

I’ve noticed that if a client chooses not to breastfeed or stops breastfeeding after challenges, she might be made to feel guilty.  How can society support women to feel more comfortable breastfeeding, but ok if they choose not to?

I think this is one of the biggest challenges we face at the moment – how to we encourage breastfeeding when so many mums have felt unable to breastfeed and feel terrible about it. This often leads to a lot of bad feeling between perceived ‘camps’ of mothers and a lot of arguing, which we could turn into fighting for a better future for tomorrow’s new mothers. We need to prevent more mums from feeling this way.

The first step is that we need to recognize that those mums who were unable to breastfeed have been hugely let down by a society that does not support it. Most mums should be able to breastfeed but many struggle in the UK because they cannot get the support they need as services have been cut by the government or when they try to breastfeed so many barriers are put in their way. This starts right at the beginning – a difficult birth can increase the risk of breastfeeding complications and midwives are so overworked that they might not have the time to really sit and support new mothers. But more widely, as I said above, we put so many barriers in the way to stop mums breastfeeding – pressure to get their lives back, get their baby into a routine, formula promotion, how we view the female body, negative comments about breastfeeding in public … it all adds up and its little wonder mums stop breastfeeding. A lot of these issues actually discourage responsive feeding e.g. feed your baby less often, don’t feed them in public, give them a bottle whilst you go to the gym. So society can actually damage milk supply meaning mums stop feeding before they are ready.

The answer to all of this? I don’t know yet. But we need to recognize the importance of how new mums have been let down and how strong their emotions around this loss can be. We need to find sensitive ways or trying to raise our low breastfeeding rates whilst also helping others come to terms with having to stop. I would say that if possible we need to encourage mums to repackage this guilt, turn it into anger and direct it at our government! They have been let down and it’s not fair.

How can people find you to find out more about your work and get your book Breastfeeding Uncovered?

The best way to buy a copy of Breastfeeding Uncovered is direct from the publishers Pinter and Martin at

http://www.pinterandmartin.com/breastfeeding-uncovered.html

Outside of the UK Wordery do free worldwide delivery

https://wordery.com/breastfeeding-uncovered-dr-amy-brown-9781780662756#oid=1072_1

You can follow ‘breastfeeding uncovered’ on Facebook and shortly the website will be fully functional at www.breastfeedinguncovered.co.uk

Thanks Amy for such an insightful interview. I am particularly interested to see what comes of research into breastfeeding trauma- it's certainly something that comes up in my work and I think more support is needed.