SINGAPORE: When Ms Nuraizani Ismail gave birth in 2018, she was sure she would be breastfeeding her son, the milk would flow effortlessly and that the process would feel completely natural. She was prepared, and she was eager.
The reality was more challenging. She only had “small tiny dots of colostrum coming, but nothing else”, the 33-year-old part-time administrative assistant told CNA. She was referring to the milk-like fluid released after birth that is chock-full of antibodies for the newborn.
She was determined to increase her supply, but the experience she had with a lactation consultant at the hospital left her stressed and discouraged.
“They were like ‘no, you can (breastfeed)', like almost scolding me, and I’m like ‘I can't, I just can’t. Why are you forcing it on me? I just can't. Can you (not) scold me?’ I was almost on the verge of crying,” she said.
“It was so overwhelming.”
She persevered on her own at home, joining a social media group for breastfeeding support. She did not consider seeking professional help because she was afraid to see another lactation consultant, she said.
The process turned out to be exhausting, she found, with her son waking up every hour.
“I couldn’t even sleep for two hours. Half an hour, finish latching put him down, then half an hour later, he would be awake again. When am I going to sleep like this?” she said, recounting her struggle.
“I was very sad. I kept comparing myself to the ex-colleague of mine. I was like why don’t I have the same amount she has. What did I do wrong? Am I not eating well? Is there something wrong with me?"
Turning to social media for answers to these questions and hoping to learn from the experience of other new mums didn't help.
"When reading all those posts on one breastfeeding group, I got very demoralised. It’s like why can’t I, why they can?" she said.
“It got worse when I read through (comments on) the breastfeeding group that I should continue. Some comments were super pro-breastfeeding and they were like 'No no no! Formula is not good. That is for cows, not for babies, babies are human',” she said.
Ms Nuraizani struggled with guilt that she would be doing her baby a disservice by stopping breastfeeding altogether, she said.
“Here I am struggling, I just wanted somebody to back me up and say that it’s okay you tried your best, you’ve done what you can, it’s ok if you don’t have (breast milk supply), not everybody can,'' she said.
To reach out to more mothers, she started a Facebook page of her own. She said that the page is designed to be a non-judgmental place where mothers can discuss their issues with breastfeeding and discuss all options.
“My aim is to tell mummies there is no need to feel guilty that they cannot breastfeed or latch or have no or low supply,” she said. This was not how she felt when she sought help on the breastfeeding group she was on as she saw that discussion on formula milk or saying that it is okay not to breastfeed was not allowed.
PRESSURE FROM SOCIAL MEDIA
A look at breastfeeding advice on social media pages and discussion groups shows many positive and supportive messages for mothers who are struggling for various reasons to breastfeed.
However, it is not uncommon to find judgmental posts and comments questioning a mother’s breastfeeding struggles or looking down on their feeding decisions.
Among such comments seen by CNA was: "A baby that’s fed formula is getting the proteins and hormones that drive cow growth, not human growth."
Another one: "It (breastfeeding) was challenging for the first week or two but actually was really easy and quick after that. I lost weight quickly, I had the benefits of BF (breastfeeding) as well as my babies. Not everyone has problems, sometimes it's easy!"
Ms Ashwinni Manasseh from Alliance Counselling, who sees new and expecting parents, said that some mothers may experience shame when they compare themselves to other mums on social media.
“On social media, sometimes you see women who post pictures of how much milk they've pumped. And some women can become quite obsessed with their output and so they start to become fixated on pumping and checking how much milk they're pumping, they focus so much on the quantity,” she said.
“It can lead to depression because they're feeling a lot of shame and guilt and regret.”
Mother of two Ms Elizabeth Soh, 33, said that what she saw on social media made her think that she was not producing enough milk.
She would see photos of the amount of milk pumped by other mothers, and see that hers paled in comparison, and how mothers were taking supplements to increase their supply, said the business owner.
“I don’t think I was under-producing, but I started buying into it. That really stressed me and caused my supply to dip,” she said.
Among the signs that mothers may need to seek help for their mental health are struggling to bond with their babies, feelings of guilt, shame and hopelessness, constantly worrying that something bad is going to happen, not enjoying things that they used to enjoy and “obsessing” over things like infant sleep and milk supply, Ms Ashwinni said.
She urged mothers to monitor their social media usage because it can be “quite triggering” for mothers, adding that many of them tend to follow many pages on Instagram and Facebook.
“If you're struggling with anything in motherhood and you're constantly seeing images that are upsetting to you, it's really important to just ask yourself how is this serving you and if it's not, to unfollow any of those pages and really just set boundaries when it comes to social media,” she said.
She added that what they see, while often not an accurate depiction, can cause mothers to feel inadequate.
ADVICE FROM LAYPERSONS
Dr Kamini Rajaratnam, a psychiatrist with an interest in perinatal psychiatry, said that in her experience with patients, mothers get many opinions which are not from professionals when they seek help on social media platforms.
“They may be getting layman opinions, and because it’s a community of mums supposedly in the same situation (as her patients), they feel like ‘What is wrong with me? How come all of them can breastfeed and I can’t?'" she said.
She added that well-intended comments from these laypersons can sometimes be problematic.
“Sometimes, they try to be positive, but it can be quite toxic actually, when they say things like ‘Don’t give up, you can do it,'” she said.
“But this poor mum has been trying for six months and she can’t do it. If they say don’t give up, then she is going to feel like ‘Maybe I’m not trying hard enough.’.”
She said that mothers may also receive unsolicited advice. For example, a mother asking for recommendations on formula milk may get responses saying that using it should be avoided, she said.
“Not everybody is very sensitive on social media. If you don’t walk (in) the shoes of a mum who’s having a lot of difficulty breastfeeding, it’s really difficult to empathise.”
Dr Kamini suggested that mothers could make contact with a lactation consultant they find themselves comfortable with before giving birth, adding that those who have just given birth are “not in a place” to look for one. A trained lactation consultant will be able to give proper advice, she added.
“It’s very important to have someone you can reach out to if you’re struggling with breastfeeding,” she said.
“You need someone who is non-judgmental, someone who doesn’t scare you and someone who is willing to work with your goals. If you can find someone like that before delivery, that will be such an important person who can be an ally when you’re facing troubles, and then you know you can reach out and you can get proper advice and not get judgment and not get all this layman advice.”
Dr Mohana Rajakulendran, paediatrician at Parkway East Paediatric Clinic in Parkway East Hospital, said that when she encounters mothers struggling with their breastfeeding journey, she reassures them that they are doing well and doing their best and that any amount of breast milk they can give their baby is providing the benefits that baby needs.
She pointed out that they also need to take care of their own needs like rest, hydration and good nutrition as these are important to achieve good breast milk supply and maintain a healthy mental state as well, she said.
“A happy mother is a happy baby. And if formula supplementation takes away that stress and allows you to spend good time bonding with your baby then that is precious enough and your baby will definitely reap the benefits of love and attention from his mother,” she said.
Despite its potentially negative impact on some, the experts stressed that social media can help mothers, offering appropriate encouragement and providing worthwhile advice.
Dr Kamini said that when women ask questions on social media platforms, they sometimes get good responses from other mothers who are honest about their struggles.
"Social media can help in that it makes support for mums more accessible. You don’t have to go out and meet someone. That’s the good of it - support is very accessible and helps with this village that mums need," she said.
Ms Uma Thambidurai, director of Mother and Child, which provides prenatal and postnatal services, said that its such mother-to-mother support that helps these women through their tough times.
"Social media in this day provides a lot of support for all mothers when they are isolated at home, more than ever with COVID-19," she said.
FEELINGS OF INADEQUACY, SHAME AND GUILT
Mothers who do not breastfeed or exclusively breastfeed for reasons such as low milk supply and oversupply face feelings of inadequacy, shame and guilt, mental health experts said.
Breastfeeding, which is recommended to be initiated within the first hour of birth and done exclusively for six months by the World Health Organization, has well-documented benefits for mother and baby, including protection for babies from diseases like diabetes, heart disease, and eczema.
On the other hand, formula feeding has been associated with a higher risk of health conditions like obesity and Type 2 diabetes.
Dr Kamini said that the ability to breastfeed centres heavily in her clients’ issues.
“A 100 per cent of my mums with postpartum depression have had very traumatic experiences with breastfeeding or with judgment around how they feed their baby,” she said.
“There is a lot of guilt and shame involved when they can’t successfully breastfeed or exclusively breastfeed.”
She said that the issues with breastfeeding are usually shared by clients in recounting their birth stories. “They are bruised and in a lot of pain, but nobody is focused on the mum,” she said.
When they are unable to provide for their babies immediately after birth, they think they have done irreversible damage to their babies, she said.
“It leads to a lot of feelings of inadequacy as a mum because you feel like ‘Oh, why don’t I have enough milk?’ but the truth is that you did just give birth, and you are still in a bit of shock, emotionally and physically and it can be very hard to put all that aside and successfully breastfeed,” she said.
As a medical doctor, Dr Kamini said she is aware of the benefits of breastfeeding but she said that the judgment mothers get is “unnecessary”.
She said that while trying to make breastfeeding more accessible and trying to undo the marketing efforts of formula milk companies that touted their products as being superior to breast milk, society has created the pressure for mothers to exclusively breastfeed.
“Many mums were thinking that formula is the best, but they (breastfeeding advocates) tried to turn the tide by saying that breastfeeding is easy, and you can do it. That’s how it started. It’s a fantastic movement,” she said.
“But it is just about giving mums the choices and empowering them with the options. If you do have problems breastfeeding, what can you do? There has to be a middle ground, it’s not all black and white, you can always re-establish it later. It’s about being a bit more kind with mums, and just giving them the option.”
When mothers seek help online, they are asking how they can continue to breastfeed while keeping their sanity, she added.
“They are not asking for judgment, or the easy way out. It is not an easy choice to formula feed an infant,” she said, adding that formula feeding has its own challenges, such as a baby refusing to take a bottle.
ONLINE SUPPORT FOR MOTHERS
Ms Khatim Hamidon, president of Breastfeeding Mothers’ Support Group (Singapore), said that the group, which has 25,000 members on its Facebook page and is a popular resource, recognises that there may be situations where a mother eventually decides to give her baby formula milk in the early days or many months after.
However, the group does not give technical advice on formula milk or suggest particular brands as it is not the group's mandate, she said.
"Having said that, any mother who seeks advice on how she can make breastfeeding work despite having to use formula is welcome to gain support from us and we have provided support to many," she said.
There are instances when mothers wish to wean their babies off formula milk and relactate and also mothers who give their babies breast milk and supplement with formula milk because of perceived low supply, she said.
“We will then provide resources that they can tap on to increase their supply and transit baby to full breastfeeding,” she said. She said that counsellors on the page, who go through an “intensive” 12-week training programme licensed by the Australian Breastfeeding Association, are trained to counsel every mother with “unconditional positive regard”.
Each day, about 15 counsellors log in to help mothers through the group’s helpline, WhatsApp service and Facebook, she said.
In their training, the emphasis is on the importance of providing empathy, commiseration and care in interactions with mothers, she said.
“We will support the mother’s decision even if she chooses to supplement with formula and continue to provide her with breastfeeding support and knowledge if she requires it,” she said.
She added that they are “very insistent that our mothers fully abide by the group rules - such as limiting coarse language and snarky comments”.
LOW SUPPLY ISSUES
Social media pages are rife with questions from mothers worried that their supply is low.
Ms Khatim said that it is common for new mothers to perceive that they have low supply, especially in the early days after giving birth.
“There are two reasons why this happens - misinformation about what is considered normal about breastfeeding in a formula-feeding society, and the lack of trained or skilled support from her environment,” she said.
For example, colostrum, the sticky, yellow “liquid gold” that a mother produces during the first few days, is counted in milliliters which is often mistakenly thought to be insufficient, she said.
“Though small in quantity, it is highly concentrated with what a newborn needs - antibodies - and is just in the right amount because newborn tummies are very small. Colostrum is usually best extracted through a baby’s latch or by hand expressing if the mother is unable to latch her baby,” she said.
However, she, like the lactation consultants who spoke to CNA, said that there are cases where mothers could have a real supply issue.
“When mothers are stressed and anxious, we find that the milk letdown reflex may be hindered and the milk flow is reduced,” said Dr Mythili Pandi, who is an International Board Certified Lactation Consultant (IBCLC) and a doctor.
However, she said that skin-to-skin contact between mother and child can help in such situations as there is a surge of oxytocin - the so-called love hormone - which aids milk flow.
Other reasons behind low supply are ineffective latching by babies, the mothers’ health such as diabetes during pregnancy or insufficient glandular tissue or poor breastfeeding management like sleep training or infrequent milk removal from breasts, Dr Mythili said.
Health issues like hormonal or endocrine problems like thyroid problems and polycystic ovary syndrome (PCOS) could also impact breast milk supply, she said. She added that some medication, like long-term antihistamines and certain types of birth control pills can affect milk supply.
Having a caesarean birth may also affect milk supply both physiologically and psychologically, Dr Mythili added.
“It’s got to do with how the mother feels, that the birth process may have hindered on her capacity or feelings about mothering and feelings about being able to nurture her child,” she said.
“When mums and babies miss out on that precious hour, or that time right after birth, that actually does have an impact on the rest of the breastfeeding journey, the bonding and the ability to connect after birth,” she said.
She added that the scar from the surgery could be so painful that mothers may struggle to hold their child and breastfeed in certain positions. Pain itself may also hinder milk supply, she added.
Dr Mythili said that it is important to understand what exactly is affecting milk supply. “Once we have identified the issues, we can then work on possible solutions which suit the family,” she said.
The experts stressed the importance of seeking help early, and specifically from a certified professional.
“I would always suggest that mothers see an IBCLC prior to discharge from the maternity hospital so that the position and attachment at the breasts is checked and early issues can be identified and managed,” Dr Mythili said.
She added that there are many IBCLCs in the community who can do home visits as well, after the mother has been discharged from hospital.
She urged mothers to verify that the professional they are seeking help from is a trained IBCLC “to be assured that you are receiving evidence-based and well-studied knowledge and assistance”.
Ms Uma also said seeking help early is crucial.
“Not often are they coming early enough for help. if they come early enough, you can turn it around. As lactation consultants, we steer them and guide them and support them and give them the advice to get them through the early weeks,” said the IBCLC.
She acknowledged however that the services of private lactation consultants like herself may not be affordable to many.
“I would like to see all polyclinics having IBCLC to help. Then the help is available to everybody,” she said.
“That's where they should be looking at to provide every woman with the support because she's going to the polyclinic from day one to check the jaundice levels and weigh the baby, and if there was an IBCLC there guiding her, then she's getting that support from day one.”
Ms Uma, who said she sees many mothers with issues of low milk supply, said that she encourages mothers who see her to latch their babies instead of using a pump because “the baby is far more a stimulant than a pump”.
“While what they did wrong or did not do enough of in the first two weeks may have contributed to a low milk supply, “we can still work on it”, she said. Ms Uma said that in her more than 20 years of experience, she has dealt with mothers, who by the time they approach her, have tried “everything”.
“(It) may be at six weeks, it may be in three months, we can still do something to increase the milk supply,” she said, adding that it is common to see new mothers having problems with breastfeeding especially in the early weeks.
While many women may be able to increase their supply with help, the experts said that there are cases where that does not happen.
“In rare cases where very little else can be done to increase the milk supply, then we remind mothers that breastfeeding does not have to be an all-or-nothing method of feeding their baby,” Dr Mythili said.
Ms Uma said: “If we don't (increase milk supply), I tell mothers that they should be actually enjoying the acts of breastfeeding, bonding with their child, rather than worrying about how much the baby's actually getting from them.”
Ms Nuraizani said that she did find some tips and encouragement on social media, but that it did not comfort her.
"If they (people on social media) know someone is not going through a smooth (breastfeeding) journey, they could be more sensitive in their choice of words. If it not working them for some reason, tell them that it is okay, that they are not alone," she said.