Breast is best? Try telling the midwife

Hospitals give up too easily when mothers run into problems

"The tears were running down my face and falling on to my baby's tiny nose and into his mouth because he was screaming. The milk was dripping from my breast. Even when he managed to get the nipple in, it hurt like hell. The midwife sat on the bed, and said very firmly, 'What you both need, dear, is a bottle.' "

Patricia Wilson's memories of her first week as a mother are marred by the distress she felt every time she tried to breastfeed. "What made it worse was that most people around me - midwives, the woman in the next bed who was bottlefeeding, even my own mother - made it clear they thought there was no point in struggling on. 'Just put him on the bottle.' Well I didn't and I'm glad. But I needed all my strength and determination to get through that first week."

It seems that we British aren't good at breastfeeding. It's not that we don't try. Patricia Wilson, whose baby was born in a major London hospital, is in the majority - 63 per cent of UK mothers start off breastfeeding. But by two weeks, a fifth have switched to the bottle - regretfully, yes, but often mightily relieved as well to wave goodbye to an unrewarding and sometimes painful experience. Four weeks later, only 39 per cent of babies are receiving any breast milk at all, according to government statistics.

Health education agencies and birth gurus alike never tire of stressing the benefits of breastfeeding. Mothers who have done it enjoyably for some time testify to the sense of self worth and satisfaction that it brings. But many mothers never reach that stage. They never get beyond the first days, beset by problems that leave them, and their babies, in tears of desperation.

The fastest fall-off in the British breastfeeding rates occurs when mothers are still in hospital. Because, for all the emphasis on its benefits, both hospital practices and staff attitudes often discourage breastfeeding, making it more difficult for women to succeed at a skill that everyone acknowledges has to be learnt and encouraged. Research shows, for example, that early bottles and breastfed babies don't mix. The bottle undermines a mother's confidence, hinders milk production and takes the edge off the baby's interest in the breast. A breastfed baby who has any formula while still in hospital is three times more likely to be fully bottlefed by two weeks than the baby who has had no formula at all. Yet in hospital, 45 per cent of breastfed babies are given bottles in those crucial first days.

"Health professionals like quiet babies, and they'll suggest a bottle to deal with crying," says Dr Tony Waterson, a consultant community paediatrician in Newcastle who has made a study of breastfeeding in hospital. "They have the suspicion that breast milk can't be enough." Institutional routines are difficult to change, he adds. "We know keeping mothers and babies together is good for breastfeeding - yet some units still insist on putting the baby in the nursery."

Getting a baby correctly attached and positioned at the breast - called latching on - is essential for effective breastfeeding, and for avoiding soreness. Breastfeeding is no longer learnt through a lifetime of watching other females do it, so skilled professional help is critical. Yet poor, often conflicting advice means almost a third of breastfeeding women suffer sore or cracked nipples while in hospital. In fact, 30 per cent of women who quit in the first week give soreness as their main reason.

Dr Waterson says that formula milk manufacturers have so heavily promoted their products to hospital staff that they now feel more knowledgeable about formula than they do about breastfeeding. Pati Rundall of Baby Milk Action agrees. "In the past decade and a half, healthcare facilities have allowed themselves to be inundated with materials, money and sponsorship from the milk companies. The result has been complete confusion about the benefits of breastfeeding."

The lack of confidence among health professionals when it comes to supporting breastfeeding is caused by poor training. "All we had on breastfeeding was one or two lectures plus whatever we could gather when we were with the qualified midwives," recalls Geraldine Dowling, a former midwifery student who is now a breastfeeding counsellor for the National Childbirth Trust. And learning by "sitting next to Nelly" can perpetuate bad practice rather than passing on wisdom. "When I was a student I heard experienced midwives give mothers very poor advice and saw them position babies on the breast in ways which were certain to cause problems."

The Royal College of Midwives and the Health Visitors Association are beginning to tackle the training issue: a new course, Invest in Breast Together, offers in-depth, post-qualification training and looks at staff attitudes as well as techniques and skills. Meanwhile, hospitals themselves are being challenged to adopt pro-breastfeeding policies by the World Health Organisation and Unicef, through their worldwide Baby Friendly Hospital Initiative (BFHI). The Jessop Hospital for Women in Sheffield is only the second British maternity unit to win BFHI status, after detailed appraisal by a team of assessors earlier this year.

The midwife Sue Ashmore is infant feeding adviser at the Jessop. "Our main problems were the same as everywhere else - women were getting conflicting advice from different professionals, and not getting enough support."

A new pro-breastfeeding policy has been implemented at the Jessop, using the WHO/Unicef programme's "10 steps" plan. It includes compulsory training in breastfeeding support for all staff, including doctors, and the outlawing of certain practices - breastfed babies are never given a bottle unless it is medically indicated.

Formula milk promotion is also outlawed on hospital premises. "We don't object to factual information, but we refuse logo-ed pens, diaries, sponsored events and leaflets," says Sue Ashmore.

Can all this go too far? After all, women can feel failures when they hit problems with breastfeeding, and guilty for months or even years if they quit. There is an argument that professionals should be neutral about feeding, to minimise upset and to protect the feelings of women who don't want to breastfeed.

Sue Ashmore is unrepentant. "We live in a bottlefeeding culture, and mothers may not get breastfeeding information from anyone but us. All women need to know that breast milk is the healthiest option. Then we'll support them whatever choice they make, and help them feed happily."

For more information on NCT breastfeeding counsellors call 0181-992 8637. A directory of more than 5,000 breastfeeding-friendly stores is published this week by the NCT. They include Asda, Boots, Debenhams, Principles, Safeway and Sainsbury's. Available from the NCT, price pounds 2.

'I felt a failure. No wonder so many women give up'

Four years after giving birth to Tabitha, Anabel Hands (left) still remembers every detail of her struggle to breastfeed while in hospital.

"I couldn't get Tabitha latched on. Some of the midwives were kind, but short of time; others didn't seem interested. Just hours after the birth I was told to give a bottle, as breastfeeding wasn't working. A nursing auxiliary said I had such small nipples I couldn't hope to feed properly, and suggested nipple shields. Someone else advised offering water. Everyone said something different."

To Anabel's distress, Tabitha was eventually given a bottle. "I felt devastated - a failure. Eventually. a midwife came and got Tabitha on the nipple, but she sort of did it for me. I felt like an idiot.

"There was no real support for breastfeeding in the hospital. I never had the impression that anyone there was really bothered about it. No wonder so many women give up."