Is bottle-feeding a mark of bad motherhood?

‘If formula milk wasn’t there you’d have mothers hanging themselves. It would just make motherhood so much harder. But what about mothers that just have to go back to work? What if you’re self-employed, what if you’ve got a small company? No, the day that they stop making formula milk is the day I stop having babies.’

‘I felt like a failure, I felt embarrassed, I felt miserable. I thought everyone was looking at me, and like I constantly had to justify myself. I just went on and on about it. I was swamped by it. Looking back I think I was depressed. I feel that I lost the first couple of months of the baby’s life really. I didn’t enjoy it, and I was very unhappy. I think it was taken away from me.’

‘You get the posters saying, you know, breast milk gives this and that, gives the anti-bodies and with their sight and their bowel movements as well and all of that, and so any time he was constipated or something it was like “oh my God it’s my milk”. And I think, especially when you’re a first time mother that’s what you think’.

These comments are taken from a piece of research I carried out recently with Professor Frank Furedi of the University of Kent, about women’s experiences of feeding their babies with formula milk (1).

We conducted the study to begin to fill a research gap. Women who use formula have been the subjects of much research, but the purpose of this has been to identify reasons why they do not breastfeed at all or stop breastfeeding when their baby is very young, with the aim of elaborating interventions that might increase breastfeeding rates. In contrast, there is relatively little research that investigates the effects for women of a cultural and social context where the message that ‘breast is best’ is strongly promoted.

In this context, how do mothers experience not breastfeeding? How do women who use formula milk in the early weeks (in fact, the majority of mothers), engage with the cultural expectation to breastfeed?

To answer these questions, the key objectives for research were:

• To understand how mothers who use formula milk exclusively or partly during the first six months following childbirth (and the first three in particular) come to this feeding option, and to find out about different pathways into formula use.
  
• To find out how mothers gain information about this way of feeding infants.
  
• To explore how mothers experience and respond to the content and delivery of information.
  
• To study the experience of mothers who use formula milk in regard to their interactions with health professionals, peer-group, partners, and other influences.
  

Some key findings are as follows.

Formula feeding as a source of anxiety

The key problem pointed to by this research is that formula use has come to be a source of tension and conflict for mothers. While feeding babies may inevitably be a source of anxiety, this seems to have been considerably more intense for women than it needs to be.

One group of women – about one in 10 mothers who intended to breastfeed – seem to have an especially difficult time. They feel a sense of failure together with guilt and uncertainty when they use formula milk. Perhaps unsurprisingly, such women very much want to breastfeed their babies, and can feel desolate when, for a variety of reasons, they are unable to do so.

Other women also emphasise feeling guilty when they formula feed, feelings mostly connected to perceptions of the health effects of formula use.

Those who experience the least anxiety about formula feeding, breastfeed and then introduce formula milk later. They explain their decision through reference to what is best for them and sometimes their family, as well as what is best for their baby. Some such women defend their feeding decisions in a defiant manner, however, as ‘nobody else’s business’. They claim that ‘mother knows best’ and may self-consciously reject the message ‘breast is best’. This suggests even those who do not report negative feelings, nonetheless feel defensive and that they have to justify their decision to use formula milk.

In practice, women in the end tend to be largely pragmatic about how they feed their babies, and most take a pragmatic attitude towards it. This aspect of baby care, in real life situations, has to be organised around other demands and pressures women experience, including in relation to work and day-to-day aspects of family life.

However, being pragmatic is experienced as difficult, because of a context that does not value or legitimise women doing so.

This problem seems to pertain because use of formula milk has become a measure of motherhood. How good a mother a woman is has come to be assessed on the basis of whether she breastfeeds. Therefore, departing from what is ‘best’ – breastfeeding – is not perceived or experienced as uncontroversial or acceptable, but as questionable and symptomatic of a woman’s failure as a mother.

The problem of support

That how a baby is fed has become moralised, as a measure of motherhood, has important implications. It is particularly worrying that two key areas of interaction that should provide support for new mothers – other mums and health professionals – have become often tense and difficult as a result.

Health professionals have the responsibility of communicating to pregnant women and new mothers factual information about how best to feed their babies. Some women discuss their experience of health professionals in a very positive way, emphasising how they felt supported and given sound practical help. But the need to communicate sound advice sometimes coexists with a moralising ethos regarding formula milk, and sometimes it is the latter that prevails.

‘She was absolutely fantastic, brilliant. She was really good, she was more concerned with the concerns that you had and if you weren’t concerned about bottle-feeding then neither was she’.

‘I never ever at any point felt that any of the midwives were like “oh that’s fine, that’s your decision, great, how are you with it”. I mean I did have a midwife once ask me and when I said I just don’t like the idea of the breast she goes “well that’s not what they’re there for, sex, you know, it’s for breastfeeding a baby”‘.

‘I was sitting outside feeding the baby, with the other two playing and my husband there, like a nice family scene. And she said, “I don’t like what I’m seeing”. And we were, “what? What do you mean?” It was all about me not breastfeeding’.

An unfortunate outcome of the tendency to moralise health advice is that it becomes hard for a culture of empathy and trust between health professionals and women to develop. One outcome is that women come to distrust professionals, become distanced from their expertise, and sceptical about the value of professional knowledge and advice. This is indicated in accounts of women lying about their feeding practices, and of interactions with professionals where there is a sense of ‘us and them’.

‘When I went to the clinic to get him weighed I used to hide the bottle in my bag and if there was no-one there then I’d give him a quick sip before and then if someone came, if I could hear them coming up the stairs I’d put this bottle away. I think now why didn’t I just say “I’m bottle-feeding and I’m proud”, you know, but no.’

Empathy between women is also damaged by the way formula feeding has become moralised. Women constitute an important source of advice and support for each other. But women also, consciously or unconsciously, draw upon a framework that measures and assesses motherhood according to how mums feed their babies. How babies are fed has become connected with women’s self-identity as mothers, meaning they do not feel indifferent towards what other women do, but judge women by how they feed their babies. They perceive that others’ feeding practice touches them personally and reflects on them.

Women may therefore judge the actions of other women when they bottle-feed their baby and call them into question. The outcome, especially when babies are very young, can be tension and divisiveness when mothers who use formula milk interact with those who are breastfeeding.

‘I went to this class and one of the women there was bottle-feeding, for whatever reason, and she used to have to say “oh sorry” and disrupt the group and say “can I go and get my water now” and they’d heat this water up and you would see all the other mums look at her, like “why aren’t you breastfeeding then?”‘

‘I remember going to a party and I went to get a bottle out of the fridge and a woman said “oh, you’re bottle-feeding your child. Why aren’t you breastfeeding?” I had to explain why I was, you know, it’s odd that I had to explain to this woman who I didn’t even know why I was bottle-feeding my child’.

Take politics out of the maternity ward

These research findings suggest that a process of cultural transmission has turned provision of health information about the benefits of breastfeeding into a campaign against formula use. The effects of this upon women, babies, and health professionals, are very problematic.

The main recommendation that can be made on the basis of our research is that use of formula milk needs to be depoliticised and treated objectively as a routine aspect of baby care, rather than as a moral issue. Politics need to be taken out of communication with women regarding the health benefits of breastmilk. While women need to know the health benefits of breastmilk, informing them about this nutritional issue needs to be detached from negativity about formula use.

Mothers’ experience of, and attitudes to, using infant formula in the early months, by Dr Ellie Lee and Professor Frank Furedi, is published by the School of Social Policy, Sociology and Social Research, University of Kent, June 2005. The full report, further details regarding methodology, or any other aspect of this research, can be obtained from Dr Ellie Lee: E.J.Lee@kent.ac.uk

(1) There were two components to the research. One was an in-depth qualitative interview study, conducted by researchers from the University of Kent, with 33 women who used formula milk to feed their babies wholly or in part during months 0-3, who were recruited for interview for this reason, and whose babies were aged one year or less at time of interview. All quotations that appear above were taken verbatim from these interviews. As with any qualitative study using a sample of this size, findings should be taken as providing insights about women’s experience, but not as representative of the experience of all women.

The other component of the research was quantitative. Telephone interviews were conducted by NOP World with a quota sample of 503 women about feeding babies during months 0-6, whose babies were six months of age or less at time of interview. The interviewing took place in July 2004. All of the statistical information that appears above is based on the results provided by NOP World.

The research was funded by INFORM, an initiative of the Infant and Dietetic Foods Association.