It never has been.
Currently, in the United States it's not for most.
Stats & Facts
Of the 79% of newborn infants who begin nursing, a little over a quarter are still nursing by their first birthday. Most all children in the United States are formula fed. That's an important point to consider as you read on, because formula is the norm.
20% of babies born in the United States are given formula within two days of birth. A third are given formula within 3 months. By 6 months, close to 40% of breastfed infants are also given formula.
The American Academy of Pediatrics and World Health Organization recommend exclusive breastfeeding the first 6 months and continued nursing through at least 12 (WHO recommends 24). However, less than 19% of infants in the United States are exclusively breastfed by 6 months. Globally, that figure is closer to 38%. Only half of women worldwide are still breastfeeding at two years.
Of the 10,000+ hospitals and birthing centers in the United States, less than 300 are designated Breastfeed or Baby Friendly. 194 are designated Breastfeed or Baby Friendly. A little more than 14% of births occur in these facilities. Close to 65% of birthing facilities in the United States distribute infant formula to new mothers upon discharge from the hospital.
In 2012, the United States infant formula market generated 70% of the total $5.7 billion baby food industry. Abbot Laboratories, the makers of Similac, with a 43% share of the formula market, reported earnings of 1.73 billion. (That's quarterly earnings and includes all products and medical devices manufactured, distributed and sold worldwide). Mead Johnson, maker of Enfamil and holder of 40% of the market share, reported quarterly earnings of $1,111.1 million. Nestlé, with 15% of the market reported annual earnings of 92.2 billion for 2013 (This includes all products and services offered by the company).
The major purchaser of infant formula in the United States is The Special Supplemental Nutrition Program for Women, Infants, and Children, otherwise known as WIC. Because WIC is not an entitlement program, formula manufactures bid to be the WIC provider, sometimes rebating the product to 15% wholesale cost. Because whoever wins the bid, wins the market. 92% of grocery market sales and over half of other retailers. As of 2012, close to 8 million participate in this program, 76% are children, with close to half being a year or younger. The median duration of breastfeeding was 12 weeks.
Remember: Most all children in the United States are or have been formula fed. Formula is the norm.
If you are a mother who chose formula for your children, you are doing what is completely normal. Most all women in the United States chose formula as well. Either exclusively or as a supplement (which increases odds of using formula exclusively), the majority of children start their first year of life on formula.
If you choose not to breastfeed or are unable to, choosing formula is completely normal. If you continue lactation, that's normal too. It all depends on the definition you're used to.
It's important at this point to clarify the decisions we are making as mothers. It's important to understand that very rarely do we really choose to breastfeed. We choose not to. Or we can't. For birth mothers, lactating is the natural progression in pregnancy. Barring any medical complications, pregnancy will include development of colostrum and delivery of a child (either vaginal or cesarean) will trigger the production of milk in the mother. Human mammals produce human milk for their offspring as a part of the process of reproduction. But while lactation may be an innate characteristic of reproducing, nursing our offspring is not. Evolutionary study has shown us that unlike other mammals, primates require observation and experience for successful continued lactation*. Our advancements in technology and product development have not changed these evolutionary facts.
In rare cases, our bodies fail us. Or we think they do. In most cases, society does. In some cases, we're simply making our own choice to end lactation and substitute with other types of milk, sometimes human, sometimes not. For many, limited observation or exposure to breastfeeding and different cultural norms of anatomy has simply altered our understanding and expectations of infant feeding. For others, deeper struggles are a part of the story.
Whatever decision we make, it needs to be an informed and educated one. Any disruption to the evolutionary reproductive process in birthing carries with it the burden of proof that the mother and infant necessitate straying from the biological norm and that both mother and child will be at as little risk as possible if they do. Our efforts should strive to reach the healthiest possible outcomes for mother and child. Let me say again: The burden is not to prove breastfeeding or human milk is best or beneficial, the onus is on the artificial substitute to carry as little risk to mother and child as possible and prove itself a necessary viable alternative to the biological norm.
This is, and has been, a source of contention for many women throughout history. Reproduction disrupts the bodily autonomy of a woman throughout pregnancy and lactation. The evolutionary wean for a human mammal of milk ranges somewhere between 2.5-7 years, thus childbearing carries with it a maximum maternal parental investment anywhere from 3-8 years. The personal desire to stimulate the wean in addition to the economic need to has shaped our views on alternative feeding throughout centuries. Necessary becomes both an objective and subjective term. With good reason.
The necessity or decision not to breastfeed is an ancient one. Wet nurses can be traced as far back as 2000BC. Issues with lactation can be found in medical encyclopedias dating 1550BC. By 950BC, social status drove the wet nurse industry. Aristocrats would purchase slaves for the specific purpose of nursing trafficked infants. By 400AD, laws had been established and contracts were drawn and medical journals covered qualifications for any woman who became a wet nurse.
This societal trend pushed breastfeeding by an infant's own mother further and further away from the mainstream. By the Renaissance period, bodily autonomy was desired by the upper class. Fashion refused to conform to the nursing breast. The needs and attachment of nursing a child interfered with social status. And the demands for income drove women to make the more economical decision to hire an inexpensive laborer to wet nurse as they headed to work.
By the industrial revolution, wet nurses were common in all classes, but peasants.
Animal milk had been used long before Similac came on the scene. For as long as there were wet nurses, milk from other species were competing for the mother's breast. Sometimes delivered directly from the animal, other times through crude vessels fashioned for delivery, artificial feeding was used through the centuries.
By the late 19th century, societal norms and economic hardships had solidified the custom of supplementing and weaning a child completely from the mother's breast. Increased public disapproval of wet nursing along with advancements in feeding bottles made artificial feeding the new norm. Infants at three weeks were being fed boiled or raw unpasteurized cow's milk. With deadly results.
Various public service campaigns would spring up in efforts to move mothers back towards the breast. Door to door visits from nurses to help educate women and encourage breastfeeding lowered infant mortality rates almost immediately. At the same time, aggressive efforts to perfect the manufacturing and distribution of cow's milk dominated the culture. Campaigns to promote nursing were dwarfed by the push to perfect artificial feeding.
The introduction of baby formula in the late 19th century immediately impacted breastfeeding. Wet nursing declined and commercial production of formula climbed. With advertisements to and recommendations from pediatricians, even amidst infant illness and deaths, formula sales sky rocketed. The ingredients were a little more than cow's milk, whey and carbohydrates.
It wasn't until 1929, formula manufacturers were required to seek AMA approval and not until 1932 that solicitations to medical personnel were barred. By then, formula had already become a substitute for breast milk and in 1965, hospitals were purchasing commercial formula in bulk for distribution to new mothers. Breastfeeding rates by the 1970s were abysmal with less than 25% of infants being breastfed in week one and less than 14% by three months.
If you were born prior to 1975, the odds are that you never fed from your mother's chest.
For thirty years, breastfeeding rates began a slow but steady climb. Technological advancements in our understanding of lactation along with increased infant illness and exposure of unethical marketing practices by formula companies created a public backlash back to the breast. In 2008, breastfeeding rates were at a twenty year high with 75% of newborns nursing their first week. Still, the majority of infants were given formula within 3 months. Most all received formula prior to 6 months.
National and global initiatives began to increase awareness and education and improve the health of mothers and infants. Efforts to pressure legislation for protection of nursing mothers in public and in the workplace began. Public support of breastfeeding was on the rise worldwide.
Formula manufactures fought back.
Through 1980-1986, The Infant Formula Act was passed defining infant formula by law as "suitable as a complete or partial substitute for human milk." By 1988, commercial formula companies had begun advertising directly to the mother. State of the art consumer data collection in addition to strong financial ties to hospitals across the nation allowed the industry immediate access to women during pregnancy and after delivery. Formula marketing continued in hospitals, birthing centers, pediatric offices, and prenatal appointments and clinics. Yet insufficient education about infant feeding or the inherent differences between human milk and artificial feeding was permeate. As of 2013, only half of adults surveyed disagreed with the statement that infant formula was "as good as breast milk" for a child. For mothers, the majority were unclear as to whether the statement was correct or not.
For the last twenty five years, artificial feeding marketing has saturated the market in the United States and across the globe. Artificial feeding of infants remains the cultural norm.
Reasons women give for choosing alternative feeding are varied. We know that the majority of women state a desire to breastfeed prior to delivery and that a majority of infants do start on the breast. Decisions to introduce alternatives are made sometimes with wise council and sometimes under duress. The psychological burden of breastfeeding can be overwhelming for many mothers.
Research shows 92% of new mothers are worried about their efforts in nursing. More than half of nursing mothers feared their infants were not feeding well on the breast and as many as 40% of mothers perceived they had inadequate milk supply to feed their children. This is within the first three days of delivery. A notable concern was the fear of pain or actual pain experienced by the mother's when nursing, close to half of the women surveyed reported nipple pain or general physical discomfort as a top worry in breastfeeding.
The findings aren't surprising in the scope and history of infant feeding. Other surveys have shown similar concerns regarding milk supply, in addition to necessity to return to work or school as major influences on decisions to supplement or wean entirely.
While most all mothers acknowledge that breastfeeding is optimal, the anxieties and confusion expressed regarding nursing continue to be a contributing factor to a switch to artificial feeding. The greater concerns a mother has, the more likely she is to supplement or wean completely. Alleviating these concerns is a more difficult challenge without adequate education and support, in addition to realistic expectations surrounding lactating. That is not to say that a mother's concerns are not valued or valid, only that the decision to supplement is sometimes made based on myths and not facts.
For many women, the stress of these concerns, premature or not, outweigh the initial desire to nurse. Their expectations of breastfeeding are different than the personal reality they are experiencing. The accessibility of alternative feeding options is a preferred choice for these women. Sometimes through grief and other times with relief and contentment, not breastfeeding is a difficult decision. In a recent online poll, of the 78% of women who nursed a minimum of 4 months, over three quarters felt some level of guilt when weaning.
Marketing, Support & Informed Choice
Since 1974 increased efforts to sway women towards continued lactation have been implemented around the world. The marketing of artificial feeding came under tight scrutiny and efforts to remove the advertising in medical facilities began. The International Code of Marketing of Breast-milk Substitutes was ratified in 1981. Ten years later, in 1991, The Baby Friendly Hospital Initiative began to educate physicians, parents and law makers on the health outcomes associated with infant feeding. In 2012, Latch On NYC joined cities across the globe in banning the default distribution of infant formula to new mothers.
The influence of medical personnel in a mother's decision on infant feeding cannot be denied. The distribution of infant formula by hospital staff outweighs verbal council or education on lactation. Commercial product samples are included in patient "Goodie Bags" upon discharge in approximately 65% of hospitals nationwide. Consistent research shows that infant formula samples directly impact breastfeeding rates. Mothers that receive free formula are more likely to wean early and more likely to purchase the brand they received after delivery at significant mark up in cost. Physicians and healthcare professionals are named the primary source for information on infant feeding, yet most mothers are still unclear as to the difference between formula and breast milk.
Because infant formula is categorized as a food and not a drug, the FDA puts no restrictions on the commercial advertising or distribution of the product in medical facilities. However, the Council of Medical Specialty Societies' Code for Interactions with Companies outlines ethics and best practices for medical personnel and their relationship with for profit companies. The American Academy of Pediatrics, American Public Health Association, American Congress of Obstetricians and Gynecologists and the United States Surgeon General all recommend against the practice.
Opposition to the regulations regarding default infant formula distribution and the marketing of alternative feeding methods has come from manufacturers and citizens. Abbot, Meade and Nestle/Gerber have all violated the ICMBS Code. Efforts to regulate formula marketing receive push back from mothers who could not nurse or chose to wean. The International Formula Council participates as well*.
Marketing efforts to promote breastfeeding are dwarfed by the dollars spent advertising alternative infant feeding. The CDC's Infant Feeding Practices Study II showed only a small fraction of mothers were able to recall seeing or hearing national campaigns that supported breastfeeding, either prior to or after delivery. In 2012, the majority of adults surveyed stated they were not exposed stories about breastfeeding in the media. (This was the same year a Time Magazine Cover went viral that pictured a toddler nursing). Infant formula information dominates mass media and has equal representation online. The annual budget of the most well known international breastfeeding advocacy group, La Leche League, is well under 4 million. In contrast, Abbot Labs, the makers of Similac reported $930 million (a $90 million dip due to a recall) in earnings from infant formula in one quarter.
Law & Public Opinion
As of 2014, not all states in the U.S. offer protection under the law to nursing mothers in public or in the workplace. Discrimination, harassment and public scorn for open nursing is a reality women face. Breastfeeding in public was identified as the top concern of nursing mothers, with even a third of breastfeeding mothers stating that public nursing was attention seeking, embarrassing or wrong. Additional surveys have shown that 70% of adults felt restaurants, malls and other public places should have privacy rooms for nursing moms. The general consensus in the public is that breastfeeding doesn't belong in public. Many state laws disagree, but offer little enforcement, if any. Not surprisingly, most nursing mothers are not comfortable nursing in public.
Only half of adults surveyed believe nursing mothers should have legal protection to pump or express milk in the workplace. It's important to remember what lactation is at this point. The feeding relationship between mother and child is one of supply/demand. Any decrease in breastfeeding will slow production in the mother's body. Expressing milk from the breast is necessary to prevent reduced supply. In addition, milk that is not removed from the mammary gland can lead to engorgement, plugged ducts and mastitis. A nursing mother who is away from her child for an extended amount of time must express her milk in order to maintain supply and prevent health complications.
The history of artificial feeding shows us that economic realities of being in the workforce is a major contributing factor to an early wean. While advancements have certainly been made in providing family leave or time for pumping, the balance between breastfeeding and working outside the home is simply not a practical decision for many parents. According to the U.S. Department of Labor, the labor force participation rate of mothers with infants is 57.3%. With only three months protected leave and many companies not obligated under the law to provide for expressing, working mothers must find alternate solutions in breastfeeding or will switch to the convenience of supplementing or complete weans.
Dollars and Sense
When it comes to infant feeding, the economics can get confusing. Working outside the home pushed the demand for wet nurses and remains a top motivation to wean earlier than recommended. Individual cost/benefit will usually outweigh any long term benefits to society as families make these decisions.
Infant formula will set a parent back about $1500-$2000 a year per child. This breaks down to less than $1 per hour for a full time working parent or about $29 per week in a family's feeding budget. These figures do not account for coupons, brands or assistance programs. Purchased breast milk can cost $2-$4 an ounce. Donor milk and a mother's own breast milk are no cost. Cow's milk for children over the age of one year will cost a little under a quarter per cup for the recommended 2-3 cups per day. Pumps, bottles, sanitation costs and other product expenses aren't included.
For society, breastfeeding trumps artificial feeding in regards to overall healthcare costs in the U.S. While the economy is certainly stimulated through the competitive infant formula market and dairy farms, the United States savings in infant medical care through exclusively breastfeeding would be $2.2 billion a year. That's about $550 per child. However, in looking at maternal health, those numbers change drastically. Heart disease, cancer, hypertension and diabetes are all a part of the larger lens in evaluating health outcomes in infant feeding. In factoring in the potential maternal healthcare costs to society, the annual figure is closer to $18 billion.
In other words, the woman who continues to lactate offers significant financial benefit to society through lower healthcare costs. The parent who exclusively uses artificial feeding methods offers financial benefit to society through stimulating other aspects of the economy. In factoring in cost/benefit individually, the financial differences are relatively negligible, but for society as a whole, breastfeeding appears to benefit more.
Discussions about the risks in infant feeding can get hairy. There is no doubt, all things being ideal, that human milk is optimal for human offspring. There is also no doubt that artificial feeding is a necessity for many parents. Physiological, psychological and personal needs for bodily autonomy cannot be discounted in examining infant feeding. As with any aspect of reproduction, continued lactation comes with its own set of risks. As with any manufactured product, supplementing carries risk as well.
Weighing risk is an objective and subjective experience. Knowledge is imperfect. Continued efforts to learn more about our own anatomy (and our child's) in addition to scientific study and the history of infant feeding offer some, but not all, of the answers we need. Trial and error has been the pattern in our learning, sometimes marked by ignorance and other times measured by science.
All the current data we have shows that the use of artificial feeding is still a risk*. From infant illness to mortality, we cannot deny the evidence of contamination, cell death, and increased odds of health ailments. Milk banking concerns are valid and should be well understood. And for women, early weaning dramatically alters their risk factor for death and disease.
Questioning the benefits of breastfeeding neglects where our burden rests. This is a reproductive issue and as such, the onus is on the reproductive alternative. And the risks to infant and mother are shown to be evident in ceasing lactation and using artificial feeding.
As with all reproductive choices, careful consideration of evidence weighted against realistic expectations, informed decision making and respect for bodily autonomy should result in the overall best outcomes for families. As with all decisions regarding nutrition and care for ourselves and our children, there are facets and factors that determine our decisions that can't be oversimplified or ignored. As with all discussions regarding the public health in society, individual and collective strive for balance together in the interpersonal nature of community. Reasoning encompasses many things.
So What's It All Mean?
Artificial feeding isn't going anywhere. It's a constant in our evolutionary story as a reproducing species. As long as women have birthed children, alternative feeding options have been attempted. Whether born of medical necessity, economic realities or personal preferences for bodily autonomy, history shows decisions not to breastfeed as part of the fabric of humanity. In looking back at the journey, our species has searched for a way to wean from the biological norm since the very beginning.
And yet, with all our advancements in technology and all our rigorous study, with all our efforts to replicate the composition and chemical reactions of the living food produced by our own bodies, we still have not come remotely close to something equal. It's possible we never will.
But if history is any indication of our future, it is quite probable the battle between the breast or the wean will continue long into centuries. Everything old is new.
Choose wisely mamas. Choose wisely.
Additional Resources & Recommended Reading:
- Breastfeeding Moms Around The World Infograph - 2014 Global Survey from Lansinoh
- Child Standard Growth Charts - CDC
- "Breastfeeding In Mongolia" - Ruth Kamnitzer on Dr. Momma
- "Two B's and the Big C" - Evolutionary Parenting
(EP's approach is rather direct and her stated priority is breastfeeding, milk banks, infant formula only when medically necessary. You might disagree with her position, but she is consistent in her drive for education and scientific examination for best biological outcomes for women and children).
- "Breastfeeding As A Rape Or Sexual Abuse Survivor" - Pandora's Project
- "Blaze A Trail Through Your Tears; When Breastfeeding Doesn't Go As Planned" - MOBI
- Postpartum Support International
- "A Mother's Guide to Weaning", Native Mothering
- "Breastfeeding, the ICU, Support and Facebook - Support That Keeps On Giving" - The Leaky Boob
- Toddler Nursing Myths & Stories - I Am Not The Babysitter
- Bottle Prep Safety Guidelines for Infant Formula - International Formula Council
(It is worth noting that IFC has incorrect information regarding the preparation and handling of breast milk included in their instructions for bottle preparation. Do not shake breast milk.)
- The Human Microbiome Project - National Institutes of Health
- "Using Science To Blame Mothers" - Tania Lombrozo, NPR
(While this article is not on infant feeding, it is worth the read to understand our relationship to scientific findings as women and the impact that reporting findings can have culturally. I strongly encourage a read of the full commentary linked).
*The "normalizing" of breastfeeding is vital from an evolutionary perspective. Nursing is a learned activity and data shows limited exposure and lack of support in societies correlate with lower breastfeeding rates. Nursing covers, privacy rooms and calls for modesty (don't get me started) are counterproductive to normalizing and foster inappropriate understandings of lactating and the female body. The choice for privacy should be one of personal preference and not based on others' expectations.
*The IFC states they are committed to all infant feeding choices while encouraging articles called "related material" that question or disparage breastfeeding in many cases (with incorrect statements of fact). In addition, as noted above, incorrect information regarding the handling of breast milk is also given. While infant formula is highly regulated (although not approved prior to market), this is a commercial industry, as such, conflicts of interest regarding infant feeding decisions are likely. Commitments to improve artificial feeding can be achieved through economic principles regarding innovation and competition within the industry itself and need not be positioned against the reproductive system of a woman.
*It is important to understand that correlation is not causation, however, causation cannot always be determined with every variable controlled, thus, researchers will look for consistent statistical evidence of links to assess whether patterns can be predictive and encourage additional research.
*Risk is a word that must always be framed in context. In the developed world, the use of artificial feeding will be lower risk than in developing nations. The use of artificial feeding with neonatal infants will be higher risk to their health than those full term.