Breastfeeding Medicine

Physicians blogging about breastfeeding

Running a road race without shoes

with 17 comments

Imagine you are running your first marathon. You’ve been training for months, and you’re looking forward to the sweet satisfaction of crossing that finish line.  When you arrive at the start, you are dismayed to discover that you didn’t register for a “runner-friendly” race.

An official confiscates your shoes and your water bottle. “We recommend that you run 26.2 miles today,” you are told. “Good luck.”

It’s an absurd way to start a marathon. And if you’re a mom who planned to breastfeed and birthed in an American hospital, it also sounds familiar.  Breastfeeding after an American birth is disturbingly similar to running a road race without shoes.

Consider that the CDC’s mPINC survey found that one quarter of US hospitals routinely formula-feed healthy term infants and 45% routinely provide pacifiers, despite strong evidence that such practices undermines breastfeeding.  Seventy percent of hospitals hand out formula company marketing packs to breastfeeding mothers, despite evidence from multiple studies that this practice directly undermines a mother’s ability to adhere to recommendations to exclusively breastfeed for the first 6 months of life. On a scale of 1 to 100, the mean hospital score for breastfeeding-supportive hospital policies was a 63.

This is the starting line for the American mom’s breastfeeding marathon. “We recommend you breastfeed your baby for six months, but we’re taking him to the nursery tonight for more formula that his tiny stomach can hold in 24 hours, and then we’re sticking a pacifier in his mouth. And because we don’t think you’ll be able to cut it breastfeeding, we’re sending you home with a tote bag filled with formula. Good luck.”

Fortunately, there’s a metric to sort out whether your hospital is going to allow you a fair start: The Ten Steps to Successful Breastfeeding. This internationally-developed standard guides hospitals and birth centers in how to get mothers and babies started breastfeeding successfully. Those that implement all Ten Steps are eligible for designation as Baby Friendly.  As of July 2, 94 US Hospitals and Birth Centers met the standard.

The science backing the Ten Steps is strong: These policies directly impact a mothers’ likelihood of reaching her own breastfeeding goals. Ann DiGirolamo studied the number of steps a mom experienced and her chances of meeting her own breastfeeding goals, and found that 97% of moms who experienced all steps met their own goal to breastfeed for at least 6 weeks, whereas only 70% of moms who experienced none of the steps met their own goals.

Think about this. Three out of ten moms delivering at a “no steps” facility will fail to meet their own infant feeding goals. And because “Baby-Hostile” hospital care is more subtle than an official saying,  “I’m sorry, we don’t allow shoes in this marathon,” three out of ten moms will most likely blame themselves for a painful, disappointing breastfeeding experience.

This World Breastfeeding Week, mothers around the world are celebrating the Ten Steps. If your maternity care set you up for success, take a moment to write a thank you note. And if you endured Baby Hostile care, transform some of your frustration into constructive criticism. Hospital administrators are stunningly responsive to letters from patients — far more responsive than to published articles in peer-reviewed medical journals. Write a letter – here’s a rough draft to get you started.

Dear Maternity Center Director:

I gave birth at your facility in XXX of this year, and I intended to breastfeed my baby. I had looked forward to receiving high-quality care for myself and my baby. The Ten Steps to Successful Breastfeeding are internationally-developed, evidence-based practices that support initiation of breastfeeding. At your facility, I did not receive breastfeeding-supportive care. Specifically, my caregivers did not:

–       Allow me to hold my baby skin-to-skin and initiate breastfeeding in the first hour after birth (Step 4)

–       Provide my baby nothing but breastmilk, unless medically indicated (Step 6)

–       Support my desire to have my baby to room in with me (Step 7)

–       Allow me to breastfeeding on demand, rather than on a schedule (Step 8 )

–       Avoid routine use of pacifiers (Step 9)

–       Provide me with information on breastfeeding support before I was discharged (Step 10)

As a consequence of the poor quality care I received during my maternity stay, I encountered tremendous difficulties with breastfeeding.

I was deeply disappointed in the quality of care I received at your hospital, and I look forward to learning what steps you are taking to improve the care that you deliver to breastfeeding mothers and babies.

Thank you for your attention to this matter.


Cc: Hospital CEO

Director of Obstetrics

Director of Pediatrics

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by astuebe

August 1, 2010 at 9:44 pm

Posted in policy, The Ten Steps

17 Responses

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  1. “Breastfeeding-hostile!” great term!

    Linda Smith

    August 1, 2010 at 10:01 pm

  2. Love the marathon without shoes analogy, Alison. As if a marathon isn’t already hard enough and beyond the reach of most. I use a similar analogy (with a check-list of features to score) to assess how breastfeeding-friendly or breastfeeding-hostile a society (or individual or family or healthcare system or…) is….. Is breastfeeding a Walk in the Park (Breastfeeding Culture) or a Marathon (Artificial Feeding Culture). I’ll have to add Marathon-without-Shoes to describe a culture that has taken breastfeeding-hostility to even greater depths than I had previously imagined. Oh dear, if only it weren’t so.

    Barbara Sturmfels

    August 1, 2010 at 10:17 pm

  3. I love the analogy as well! I am now even more thankful that I was lucky enough to give birth at one of the 94 Baby Friendly hospitals. My daughter will be 2 this month and we are still breast feeding thanks in part to the great start we got at the hospital.


    August 2, 2010 at 7:54 am

  4. I did exactly this after I had my son at my local hospital. I had called their lactation “warm line” about 10 times, left numerous messages and no one ever called me back. My son was perfectly healthy and was given formula EVERY DAY without my knowledge (only realized it when I looked at our discharge papers…who knew they would give him formula when they took him for his hearing test?) Sigh. So I wrote the hospital CEO and she wrote me back and seemed to take all of my concerns very seriously. A few months later I got a letter in the mail stating that all of the nurses who worked in maternity had received additional training on supporting breastfeeding and that they had made changes to their care policy because of my letter. I can only hope that it really made a difference.

    Elita @ Blacktating

    August 2, 2010 at 8:06 am

  5. I’m such a fan of KellyMom and am glad to have found this wonderful resource! All the info helped me to continue nursing my babies into their toddler years and I’m still nursing my 3 and 2 year old

    I did have a good chuckle at thr analogy howver as I am a barefoot marathoner as well! I know the intent was to show how the right tools are essential for success but I just wanted to comment that the analogy didn’t quite fit for me as I have done thousands of hours of research on shoes, running injuries and how the two correlate. Our feet were born perfectly fine and I would take a gander as to say that many issues with knees, hips etc were born the moment we shoved our feet into the little coffins we call shoes. Other than the analogy I love all the info and support from Kellymom!! :)

    Mari Freeman

    August 2, 2010 at 8:47 am

  6. Thank you, Alison, for the great analogy. Thank you, also, for the excellent template letter. I often urge my clients to let the hospital administrators know about their concerns, and now I will have your example to share with them.

  7. Good analogy! Though it was years ago, I wil always be grateful to the La Leche League for their support. Despite a hurdle at the beginning, I was able to breastfeed both my babies till they decided to quit. Why is our society so perverse on this issue?

    Margaret Hasselman

    August 2, 2010 at 12:53 pm

  8. […] Running a road race without shoes Imagine you are running your first marathon. You’ve been training for months, and you’re looking forward to […] […]

  9. Thank you for publishing this and especially for the template of a letter. I gave birth four years ago at a Baby Friendly Hospital, but it only took one poorly-qualified nurse to mess me up for months! Despite being a trained doula I was too exhausted to demand a lactation consultant and thus was sent home with formula and an SNS due to my son losing more than 7% bodyweight in his first two days. I was sooooooooo determined, though and I pumped and sought help in my home with a postpartum doula as well as going to the local lactation clinic. Then, when I had sufficiently recovered I wrote a letter similar to yours to the director of nursing and received a phone reply stating that nurses’ training had been changed/updated due to my letter. It was a small relief that other moms wouldn’t go through the same thing, but I was so disappointed that I had to endure so much due to one person’s bad judgment.

    Shari Exo

    August 2, 2010 at 7:14 pm

  10. Perfect Analogy. As a runner I can’t imagine coming up to a much anticipated Marathon, only to be told I wasn’t ready! I still remember w/ my 1st birth at a Hospital, the lack of actual support compared to constant concern and correction of how and how much I was nursing. I was told that I had to write down every feeding, questioned and even made to feel as if I wasn’t doing things right. I was actually relieved when I was finally alone to nurse my son.


    August 3, 2010 at 10:21 am

  11. I’ve never birthed in a hospital (thank God!!!) but I watched a relative have her breastfeeding efforts completely sabotaged by hospital staff. I wondered if they were getting some sort of kickback from the formula industry. She kept requesting to see a lactation consultant, who never came. I heard she was having trouble nursing, so I visited and explained how to get the baby to latch on. While I was there, they brought her baby, with a bottle of formula of course. I left, and she experienced successful breastfeeding due to my tips. The staff then instructed her to “top the baby off” with formula after nursing!!! Prior to my visit, the staff had been threatening force feeding the baby via a tube down her throat if the parents could not get her to drink a certain amount of formula!!! The baby, born via c-section (unnecessary induced labor prior to due date!), was still drugged from the labor/birth drugs, so was not very interested in eating yet.


    August 3, 2010 at 12:44 pm

  12. This is a wonderful analogy and sadly what you said is so very true. I have seen it happen with my doula clients and I try to protect that space, but as a birth doula I typically leave 2 hours after the baby is born and then it is out of my hands.

    So many hospitals and nurses throw down so many road blocks to nursing and it is sad.


    August 5, 2010 at 10:52 pm

  13. Love this post!

    I’d add a cc to Risk Management to the list. That seems to get hospitals’ attention.


    August 15, 2010 at 12:58 pm

  14. This is very helpful for mothers who are struggling with breast feeding their new borns.

    Health Centre Toronto

    September 18, 2010 at 8:49 pm

  15. […] and a culture that values mothers and babies. Yet every day, we fail women, whether through routine hospital practices that undermine moms or through workplace policies that force women to choose between nourishing their babies and […]

  16. Nice Info. Thanks
    please visit RSUD Cengkareng

    teddy risnayadi

    November 9, 2010 at 5:39 am

  17. Well said! My only other suggestions would be to also CC the hospital CNO (Chief Nursing Officer – may be called CNE [Chief Nurse Executive]) – and to include a copy of/link to The Ten Steps to Successful Breastfeeding. Don’t assume administrators knew of the 10 Steps or have time to track down a copy. Make it easy. When a hospital does it right, it helps to let them know that too so they keep doing it right!

    Thanks for a great article!

    Karen Gromada

    January 11, 2011 at 7:13 pm

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