Before she gave birth to her first baby in June 2018, Amanda Renner was certain she would breastfeed. She loaded up on supplies ― a breast pump, nursing covers and bras. She was set to deliver at a Baby-Friendly designated hospital, which follows strict protocols meant to promote breastfeeding. Immediately after her daughter was born, Renner had skin-to-skin contact with her and saw a hospital lactation consultant who spent time fiddling with her daughter’s latch.

But late at night ― alone with her new and hungry baby in a hospital room ― things began to unravel. The baby furiously tried to latch, screaming inconsolably. Renner paged a nurse asking for a bit of formula to tide them over until they could get a better handle on breastfeeding but was told it required a doctor’s order. Renner waited for the doctor to come ... and then waited some more. Finally, she asked her husband who was home with her stepson to drive to the hospital, in the middle of the night, to sneak in some formula. In the hallway, he ran into a nurse who made her displeasure known.

“He was told that breastmilk was a ‘medical necessity,’” recalled Renner, now 36, explaining that her daughter had jaundice, which only amplified the pressure she felt to get something ― anything ― into her tiny stomach.

“To be talked to that way, and to be brushed off and ignored, especially when I asked for the ‘doctor’s orders’ for formula, you just feel totally insufficient,” Renner said. “You feel like a failure.”

Improving breastfeeding rates has, in the past few decades, become an entrenched public health goal. The American Academy of Pediatrics recommends women breastfeed exclusively for the first six months of a baby’s life, and continue while supplementing for a full year ― or beyond. But the reality is that relatively few women actually hit that goal. In the United States, less than half of babies are still exclusively breastfed at three months postpartum. By six months, it’s down to just 25%, which means the vast majority of American moms actually “fail” to hit breastfeeding recommendations.

Despite that fact ― and as many new moms can attest ― the pressure to hit those marks can feel relentless. It comes from all directions, from health care providers to would-be lactation experts (some who are fellow moms) who insist that milk supply issues are incredibly rare and that women’s struggles boil down to a simple lack of perseverance.

But increasingly, experts are joining moms in calling out the very real toll that kind of pressure can take on women’s mental health ― and arguing for a more nuanced approach to a complex issue, no matter how “natural” breastfeeding may be. A recent commentary in the journal Nursing for Women’s Health is advocating for more research into maternal stress related not just to breastfeeding but to the often intense pressure put on moms to nurse their babies.

“We need more research on what happens to a person who wants to breastfeed and who can’t. What do they feel? Is this a risk factor for postpartum depression?” said Ana Diez-Sampedro, an author of the article and a clinical associate professor at the Florida International University Nicole Wertheim College of Nursing & Health Sciences.

“We think that for mothers, breastfeeding is the best option,” Diez-Sampedro continued. “But that’s not the case for some mothers.”

The breastfeeding and postpartum depression connection

Diez-Sampedro and one of her co-authors ― Maria Olenick, who is chair of undergraduate nursing at FIU ― were inspired to write their paper not necessarily because of their clinical experience but because of their experience as moms. Diez-Sampedro has twins whom she hoped to breastfeed, but was unable to. Olenick gave birth to her second baby in 2011, 20 years after her first. And the shift she noticed in the rhetoric around breastfeeding was profound.

“Personally I noticed a tremendous difference in the way they approach it with women,” Olenick said. “When I had my first daughter, it was more or less just a question ― which would you prefer? With my second child, who was born in 2011, it was really clear what they preferred.”

The researchers’ new commentary points to some existing findings suggesting there is a connection between breastfeeding challenges and depression and anxiety, although that connection is not necessarily linear.

“Women who breastfeed for shorter periods of time tend to have more depression, but whether the depression causes the weaning or the weaning contributes to the depression ― or something causes both ― is really hard to disentangle,” said Dr. Alison Stuebe, a maternal-fetal medicine physician and medical director of lactation services at University of North Carolina Health Care. She did not work on the new commentary but has been studying the connection between breastfeeding and perinatal mental health for more than a decade. She echoed the call for more research into this topic across the board.

“We have a tendency to talk in terms of ‘should’ and ‘must’ and telling women what to do, instead of saying, ‘This is complicated, and there are tradeoffs every minute of every day in parenting.’” - Dr. Alison Stuebe

What is clear is the profound toll that postpartum mental health problems can have on women and babies. Children whose mothers grapple with postpartum depression are at greater risk for behavioral problems and language delays, for example. And untreated depression can lead to everything from physical pain to increased suicide risk.

And it is also clear that forcing the message on women doesn’t work.

“I think this is part of a bigger problem, which is the way that we communicate with mothers about their health and well-being,” Stuebe said. “We have a tendency to talk in terms of ‘should’ and ‘must’ and telling women what to do, instead of saying, ‘This is complicated, and there are tradeoffs every minute of every day in parenting.’”

“To bludgeon people and say, ‘This is the right thing to do, and you must do this,’” she added, “does not solve the problem.”

Urging the “experts” to do better

Despite the ubiquity of the simplistic “breast is best” adage, there is actually a lot of subtlety baked into many public health recommendations around breastfeeding and maternal mental health. The American College of Obstetricians and Gynecologists says, for example, in its guidelines for supporting breastfeeding moms that women who can’t meet their breastfeeding goals often experience considerable distress and that those feelings should be validated by their health care providers. ACOG also calls for OB-GYNs to be aware of the connection between breastfeeding challenges and postpartum depression, and to be actively on the lookout for any mom who may be struggling.

Yet there is no shortage of women who’ve been made to feel guilty about their feeding choices, either by clinicians who have aggressively promoted breastfeeding, or by having their personal challenges subtly dismissed. Women like Amy Weinstein, 34, who was also dead-set on breastfeeding before she had her first baby in 2014, but who immediately struggled with production. She pumped around the clock to try to boost her milk, joined a lactation support group and drove weekly to meet with an expensive lactation consultant who assured her she would help her meet her goals.

About 10 weeks after her son was born, when she was still pumping every two hours but never getting more than 10 ounces of breast milk per day, her lactation consultant told her: “I don’t usually say this, but I think you should quit.”

It was a message Weinstein was grateful for, but one she wished she’d heard weeks or months before. Instead, all the messaging she’d received around breastfeeding ― both explicit and implicit ― made her feel like it was not OK to stop, like she’d be failing her baby.

“Clinicians must trust that a woman will choose to do what is best, even if the woman’s definition of best is different than that of the health care provider.” - From article in the journal Nursing for Women's Health

“It was so depressing and isolating ... I felt tied to my pump, and tied to my tracking,” Weinstein said. “There’s something about the way we treat breastfeeding that almost validates you. It’s like you get your ‘mom card’ for working correctly, and I felt like mine was going to be taken away.”

In their new commentary, Diez-Sampedro and Olenick argue for a few simple changes in how clinicians care for women that they feel could go a long way in mitigating undue breastfeeding pressure. Among them: Anyone who works with a new mom should at least be aware of the research on the link between breastfeeding challenges and postpartum depression, and should be prepared not just to refer women to lactation consultants as needed, but to offer them emotional support. Doctors should talk to women about safe formula feeding practices before they give birth, just so they know it is an option ― even if it’s one they never use.

“It is not possible for health care providers to be aware of all the factors that play a role in forming a woman’s infant feeding intentions,” the authors write, “but so long as a woman is provided appropriate education to make informed decisions, clinicians must trust that a woman will choose to do what is best, even if the woman’s definition of best is different than that of the health care provider.”

But that kind of emotional support takes experience, which is why some experts are calling for anyone who works with a woman on breastfeeding to be schooled in the basics of mental health.

“I have a bias here, and I will name it as a bias because it is important to say so,” said Kate Kripke, a clinical social worker and founder of the Postpartum Wellness Center of Boulder. “I would never refer a new mom to a lactation consultant that wasn’t trained in perinatal mental health. Ever.”

Kripke believes lactation consultants have good intentions, and that they want moms to be able to reach their breastfeeding goals. “But if they’re not trained to understand the nuances of how maternal mental health issues show up, they can participate in the unintentional shaming that comes to a mom, when actually what that mom may need to be healthy is to stop breastfeeding,” she said.

Ultimately all of this is, in a way, a call to rethink the ongoing clash between “breast is best” and “fed is best” that so often consumes mom forums and comments sections on breastfeeding articles. The idea is really more that “mom is best.” Not because a mother’s needs are more important than her baby’s, but because they too have a profound impact on her own well-being ― and that of her baby. Some degree of difficulty is expected with breastfeeding; it is hard to sustain another person with your own body. But misery is not. And that is where doctors, nurses, midwives, lactation consultants ― everyone ― must tread carefully, and be vigilant about taking women’s own mental health needs into account.

“I firmly believe my postpartum depression and postpartum anxiety was triggered from the whole breastfeeding experience,” Renner said.