Everyone agrees breastfeeding is best for babies – but vulnerable new mothers are being bullied into it. Anne Wollenberg finds some disturbing evidence

After writer Jai Fagan, 31, gave birth to her son, Isaac, she decided not to try breastfeeding. "After a relatively traumatic birth and lots of invasive treatment and painkillers, the last thing I wanted to do was try it," she says. But the hospital staff had other ideas. "The midwife said if I didn't do it now, I probably wouldn't be able to. I went from thinking I could potentially do it to feeling that if I didn't, I wasn't going to be a good mother."

Jai says she received excellent medical care from St Michael's University Hospital, Bristol, "but I wasn't listened to about breastfeeding. I was desperate to go home, but I was told I wouldn't be allowed until I'd had one good feed," she says. "I asked what would happen if I bottle fed and was told they couldn't help with that." Breastfeeding Isaac continued to be a struggle. "It started to affect the way I was bonding with him. One day my health visitor asked if I was enjoying my baby and I burst into tears. I felt like so much had gone wrong."

Are new mothers really being pressurised to stay in hospital until they can breastfeed? Yes, says Dr Ellie Lee, a senior lecturer in social policy at the University of Kent, who says she heard a number of similar stories while researching infant feeding. She says there is a gap between policy and women's actual experiences.

"You can't say there's anything wrong with the way policies work at the moment – they're in denial that there's any problem at all."

Ask a midwife and they'll say it's unlikely any new mother would be kept in hospital under duress. But Amy (not her real name) says that's what happened after she gave birth at the Royal Devon & Exeter (RD&E) Hospital in September 2009. "I was told that under no circumstances would I be able to leave until I successfully breastfed," she says. "They said when my baby got hungry I should ring the buzzer so they could watch me try. I felt really pressurised. They were writing things down every day – they kept writing: 'still can't breastfeed'."

For Amy, who had experienced a long, traumatic labour, breastfeeding stopped seeming like a choice. "I hated feeling I couldn't go home until they were satisfied. I felt they were saying I couldn't look after my baby properly unless I did. But I thought if I discharged myself I'd be seen as a troublemaker." Instead, she transferred to another hospital.

Everyone agrees that breastfeeding is good for babies, and the drive to increase breastfeeding rates is undoubtedly well intentioned. But Jai and Amy are not the only women who feel they have fallen victim to hospitals' targets for breastfeeding, some of which are extremely high – a hugely ambitious 90 per cent in some cases – and the pursuit of which seems to be causing distress to new mothers at a very vulnerable time. Targets for the number of mothers breastfeeding were previously included in local area agreements (which set out local priorities agreed with central government), although these are now being abolished. The Department of Health says it does not set targets nationally, although it collects data from PCTs.

University Hospitals Bristol NHS Foundation Trust says it can not comment on individual cases. Sarah Windfeld, head of midwifery, says: "We encourage breastfeeding, but we would never pressurise women to breastfeed. We do respect women's choice, but we also have to follow best practice and public health guidance. Research does show that breastfeeding gives babies the best start."

Tracey Reeves, head of midwifery at the Royal Devon and Exeter NHS Foundation Trust, says: "Mothers who have their babies in our care are encouraged to make informed choices about how they feed their babies. Mothers often plan to breastfeed, but some may find establishing breastfeeding challenging, as this is a new skill to be learned by mum and baby, at a time when the mother may be tired and emotional from the physical demands of her delivery and adjusting to the life-changing event of becoming a parent. It is understandable that when tired, uncomfortable and emotional, some mothers may regard advice and offers of support as a pressure to continue breastfeeding. This is never the intention of our midwives, who have only their patient's best interests at heart and seek to provide mothers with accurate information, enabling them to make choices and then to support them in those decisions. Our midwives do not have targets to meet – their motivation and professional responsibility is to promote and support breastfeeding because of the universal evidence about the benefits of breastfeeding for mum and baby.

"We need to ensure that a baby is feeding adequately prior to mum and baby being discharged. We would recommend that mum and baby remain in hospital to provide the right support and care to ensure that the baby is feeding adequately and to avoid further stress and possible return trips to the hospital later on down the line. It would be irresponsible of the Trust to allow someone to go home without ensuring that they are able to successfully feed their baby and our intention is always to provide the best possible care for the baby."

Currently, Unicef's Baby Friendly Initiative (BFI) is seen as the optimum standard for maternity services. To gain accreditation, hospitals must adopt the BFI's ten steps to successful breastfeeding, which say women who choose to formula feed must do so only in the context of informed choice, "by being fully informed of the benefits of exclusive breastfeeding and the risk of supplementary feed". As Dr Ellie Lee wrote in her 2007 paper on infant feeding, "this approach conveys, in a medicalised form, powerful messages to women about what 'good' mothering constitutes."

The BFI doesn't ban advice about formula feeding. Its guidance says: "If a mother chooses to bottle feed, then minimum standards for her care (such as ... ensuring that mothers know how to prepare a bottle feed) are ensured as part of the Baby Friendly standards." But midwives are often reluctant to discuss formula, adding to perceived pressure to breastfeed for some mothers.

Jai Fagan was refused information about bottle feeding, even when her husband called the ward in desperation at 3am. "They said they couldn't give advice on formula. We could phone a breastfeeding helpline – if we waited until the morning." Amy says she felt so guilty and worried when she finally stopped trying to breastfeed, she hid the bottles from her health visitor.

Rachel (not her real name) felt guilt-tripped into staying at the Royal United Hospital (RUH) Bath. "We wanted to go home but they weren't happy as my son wasn't feeding. They seemed very pessimistic of our chances to get him to feed at home. They also said when feeding wasn't established, they often saw babies being readmitted to hospital a few days later with jaundice."

Rachel struggled to relax, "which is why I found it strange they were so reluctant to let us leave. I couldn't understand why they thought I'd be more likely to get him feeding in a strange, clinical setting. After childbirth and the shock of him not feeding, I really wanted to be home with my husband."

Vicky Tinsley, assistant director of midwifery for Wiltshire Community Health Services, which employs RUH Bath's midwives, says: "We always prefer mothers to be able to breastfeed at the earliest opportunity after birth, which usually means they are still in hospital. But we do realise not all mums are able to breastfeed for all sorts of reasons, so they might start when they get home, or try and not be able to carry on. It's certainly not uncommon for mums to feel that they're letting themselves and their baby down if things don't happen in a straightforward way. Wherever they are and whatever the circumstances, we give ongoing support to new mothers through what is an extraordinarily emotional and sensitive time."

Lucy Jolin, a spokesperson for the Birth Trauma Association, says a lot of women come under huge pressure to breastfeed while exhausted and in pain. "I don't think I've ever had an email from a woman who's had a traumatic birth that doesn't contain an issue around breastfeeding." New mothers may find sitting painful if they've had stitches, or be unable to move or pick up their babies. "A woman who's just given birth is not in an ideal condition to learn a new skill, but you are told to just get on with it.

After what other major medical event are you forced to do that?" she asks. "What really matters is being given genuine help and understanding, tactful support. If a woman wants to go home after an exhausting, painful experience and quietly get to know her new baby, there is nothing wrong with that."



www.babyfriendly.org.uk

www.breastfeeding.nhs.uk

www.birthtraumaassociation.org.uk

Bottling it up: the facts



* Unicef's Baby Friendly Initiative requires maternity facilities to adopt its 10 steps to successful breastfeeding in order to be accredited as "baby-friendly". These include:

- Informing all pregnant women about the benefits and management of breastfeeding

- Helping mothers initiate breastfeeding within half an hour of birth

- Giving newborn infants no food or drink other than breast milk, unless medically indicated



* The last infant feeding survey in 2005 found that 76 per cent of mothers across the UK started out by breastfeeding, but more than a third stopped in the first six weeks. Some 90 per cent of women who stopped breastfeeding said they wanted to continue but experienced too many difficulties or didn't get the support or information they needed.

* A University of Connectcut study showed that women who have traumatic birth experiences tend to respond in one of two ways. "Failure to breastfeed made them extremely depressed, caused physical pain and encouraged flashbacks of the birth and symptoms of trauma or depression," says Lucy Jolin of the Birth Trauma Association . "Or, however much pain they were in, they kept trying to breastfeed as a way of proving they weren't 'bad mothers'."

* National Institute for Health and Clinical Excellence (Nice) guidelines issued in 2008 say mothers should have access to independent advice on the use of infant formula, including information on the potential risks of feeding with formula and on how to obtain ongoing advice once home.

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