I spoke with Ginny Kotzias- a public health researcher and a PhD candidate at the Norwegian University of Science and Technology. She focuses on the intersection of economic shocks, social protection policies, and maternal/child health outcomes.
Ginny’s current project, Milk Shock, looks at how Covid caused changes to women’s living and working environments that impacted how they feed their babies. You can find more information on her project website or by signing up for free research updates through her newsletter
What does your work show about how easy breastfeeding is?
For a small minority of women, about 10%, breastfeeding is easy. This is not the usual story though. We don’t have perfect data but we think about 9% of women are physically unable to breastfeed at all, for instance due to a glandular insufficiency.
For the remaining 80% or so, breastfeeding is possible but challenging.
Even when expectant mothers report feeling aware that breastfeeding could be tough, they don’t really know the challenges until they are in the midst of facing them. There are supply issues, latching, infections, nipple damage, mastitis. It’s very stressful to navigate.
Beyond the physical impact there are women who suffer feelings of deep dread or depression that seem to be triggered by the hormones which ‘let down’ their milk. That’s very rare but there are plenty of more common concerns. How do you know if the baby is getting enough? How do you know if they're gaining enough weight? And then what is the proper way to use a pump? It seems like nobody is actually taught how to use them.
So in general what my work finds is that for women who want to breastfeed and know it might be hard, they don't know how hard it really is until there's a very tiny human they're trying to feed every two to three hours, 24 hours a day, while they're also struggling with pain and supply a bunch of these other issues.
Why do you think that the myth about breastfeeding being easy is so entrenched?
To answer this I think a brief history of breastfeeding is helpful.
For all recorded history there has been an acknowledgement that breastfeeding is not always easy or possible.
There are records of wet nurses being used in China a few millennia BC and in ancient Rome. In the Middle Ages we know that babies who weren’t getting enough breastmilk were fed a mix of animal milk and breads. In the 19th century we get the introduction of the glass bottle and the rubber teat and then in the early 20th century breastmilk substitutes- formula- start to become available.
The coinciding availability of bottles, teats and formula leads to a huge boom in formula feeding. Obviously mothers would have welcomed the flexibility- other caregivers could now feed their baby. The formula industry also pushed a hygiene narrative, saying that animals breastfeed and “civilized, sophisticated” people should be using formula. By the time we get to the mid 40s- early 50s breastfeeding rates have plummeted and around the same period the family has become more atomised. We’re no longer living in large multigenerational homes so there’s less exposure to breastfeeding and less sharing of wisdom and experience.
The knowledge got lost and by the late 60s less than 30% of US firstborns were breastfed.
Then there was a cultural swing. In the 70s feminist and hippie movements both contributed to a narrative that women’s bodies are powerful and breastfeeding is an amazing and natural thing to do.
The rhetoric around feeding choices went from being aggressively pro formula to aggressively ‘breast is best’. I think the echoes of that are still felt today.
There is a lot of cultural pressure that you absolutely should breastfeed, you don’t want to feed your baby commercialised, processed, ‘artificial’ products etc etc. So modern mothers are in a difficult spot because the pressure to breastfeed is very strong but we also have less exposure, less knowledge, less support to enable breastfeeding.
What impact did the pandemic have on mothers' ability to start and continue breastfeeding?
Fascinatingly, Covid had a mixed effect on breastfeeding. We're still trying to figure out if it had a net positive or net negative effect. We know from prior breastfeeding literature that women's experiences in the hospital and leading up to the birth can very much affect how successfully they will breastfeed.
During Covid women were operating in a place of complete uncertainty leading up to giving birth. What would the hospital policies be? Would they have to wear a mask in labour? Would they have to be alone?
This created an environment of fear and uncertainty that we know affected women’s mental and physical health, and therefore breastfeeding success.
Covid also put additional huge strain on medical professionals. Understandably, staff had to be allocated to where they were most needed and new mothers in hospital had fewer experts on hand to help them. On top of that, external professionals like lactation consultations might not have even been allowed in the hospital.
We know those early days are so crucial for establishing breastfeeding but some countries suspended many of their Baby-Friendly Hospital initiatives in order to implement more infection control measures and we know that this had a detrimental effect on women’s ability to initiate breastfeeding.
When new mothers got home, appointments with peer supporters or lactation consultants were run online which of course is better than nothing but not as good as when someone can really see what’s going on.
There was also less informal support from friends or family who could either help troubleshoot breastfeeding problems or just help around the house so mom could spend more time bonding with baby.
Once women got back to work, Covid restrictions also made breastfeeding more difficult. Lactation/ pumping rooms might have been closed or in restricted parts of the building. Kitchens were often closed, so there was nowhere to store pumped milk. The economic shock of Covid also made more women’s jobs precarious, or made their shifts unpredictable which makes having a breastfeeding and pumping routine even harder to maintain.
There were positives though. Lots of women reported that they had more time and space to dedicate to breastfeeding. There were women who said that having fewer visitors was nice because they weren't distracted by all these other people they had to entertain.
There were some extra motivations to breastfeed too. Some women were more determined to breastfeed because of the immune system benefits and the chance to pass on some of their Covid vaccine antibodies. In the US there was also a major infant formula shortage which of course was a very strong incentive to breastfeed.
In terms of the impact on work and employment some women had access to increased unemployment benefits and they used this income security to quit jobs that were hostile to breastfeeding or provided no support to new mums, returning to a different role once their baby was a bit older.
Online working also greatly increased during Covid, which gave a lot of moms more flexibility to take care of their babies. Remote working highlighted that people have lives outside of work. People’s kids and pets were on screen. Some women report seeing a chance in workplace culture which they attribute to Covid: more flexibility with scheduling, more reasonable expectations about when work gets done.
All of these factors were at play during or in the aftermath of the pandemic. For different individuals different positives and negatives were felt more or less strongly depending on their location, circumstances, socioeconomic status, and the expectations of their cultural group.
Which policies seem to help mothers who want to breastfeed?
Lots of the factors that influence breastfeeding initiation and duration are cultural so there is no quick or perfect policy solution but there are things that do help:
Maternity leave. This can sound obvious in a European context but having time off work to focus on your baby, learn how to breastfeed and get comfortable with feeding before returning to work is a huge factor in breastfeeding success.
Accommodations at work. Once mothers return to work if they can pump privately without being pressured to ‘get back to work’ and if they can have some flexibility in their hours to facilitate feeding then this helps too.
Availability of resources to learn about breastfeeding. For instance, cheap or free and readily available classes which go into sufficient detail about how to initiate, continue and troubleshoot breastfeeding.
Formula marketing regulations. In the 1980s the World Health Organisation and Unicef released the International Code of Marketing of Breast Milk Substitutes. It's essentially a list of criteria that tries to limit how formula is marketed to try and reduce some of the bad practices of formula manufacturers in the 1970s. The 84 countries that have adopted this Code tend to have higher breastfeeding rates.
The Baby-Friendly Hospital Initiative- another joint WHO and Unicef initiative introduced in the 1990s. To be accredited as baby-friendly a hospital has to meet a set of criteria like supporting skin-to-skin and having mothers and newborns ‘rooming in’ together in the first 24 hours. Areas with Baby-Friendly Hospitals tend to have higher breastfeeding rates than areas where the hospitals have not implemented these practices.
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