PE R S PE C T IV E the dobbs decision —exacerbating health inequity

The views and opinions expressed in this
1. Harvey SM, Gibbs SE, Oakley LP. Asso-
article are those of the authors and do not
necessarily reflect the views of their employers.
Disclosure forms provided by the authors
are available at NEJM.org.
From the College of Public Health and Hu­
man Sciences, Oregon State University,
Corvallis (S.M.H., J.T.W.), and OCHIN,
Portland (A.E.L.) — both in Oregon.
This article was published on April 15, 2023,
-­medicaid​-­e xpansion​-­decisions​-­i nteractive​
ciation of Medicaid expansion with access to
abortion services for women with low in-
comes in Oregon. Womens Health Issues
2021;​31:​107-13.
2. Guttmacher Institute. Interactive map:
US abortion policies and access after Roe.
February 20, 2023 (https://states​.­g uttmacher​
.­org/​­policies/​­).
3. Kaiser Family Foundation. Status of
state Medicaid expansion decisions: inter-
active map. February 16, 2023 (https://www​
-­map/​­).
4. Foster DG. The Turnaway Study: ten
years, a thousand women, and the conse-
quences of having — or being denied — an
abortion. New York:​Scribner, 2020.
5. All Above All. Action plan for abortion
justice. 2022 (https://allaboveall​.­org/​
­campaign/​­abortion​-­justice​-­action​-­plan/​­).
DOI: 10.1056/NEJMp2216698
Copyright © 2023 Massachusetts Medical Society.
The Dobbs Decision — Exacerbating Health Inequity

at NEJM.org. .­k ff​.­org/​­medicaid/​­issue​-­brief/​­status​-­of​-­state​

Breast or Bottle — The Illusion of Choice

Breast or Bottle — The Illusion of Choice

Amy J. Kennedy, M.D.​​

T he question was always

posed to me in a hurried
manner, an item on a long
checklist that the obstetrician,
labor and delivery nurse, and
pediatrician all needed to get
through: “Will you breast or bot-
tle feed?”
As a first-time mother, I was
anxious about the uncertainties
that lay ahead and uncomfort-
able with the never-ending
strings of questions about my
upcoming delivery. As a physi-
cian, I was relieved when we got
to the breast-feeding question. It
was a simple answer, a yes–no
question. I confidently answered
“breast-feed!” each time I was
asked, assured by the science I
had learned in medical school
and by the American Academy
of Pediatrics (AAP) recommen-
dations to exclusively breast-feed
for at least 6 months, followed
by continued breast-feeding for
2 years or beyond.1 Who would
ever choose otherwise, I won-
dered. It wasn’t until later that I
realized breast-feeding was not
the clear decision I thought it
would be.
As a new mom, I had no idea
what I was getting into. After my
son was born, I asked for a lacta-
enough milk, in order to increase
their supply, while also helping
the baby continue to learn to
tion consultant immediately, but latch on and gain appropriate
since it was a Saturday, no one weight. It’s ironic to me now that
came to see me until Monday the primary advice given to me,
evening, two full days later. The as someone who was obviously
consultant’s main recommenda- struggling with breast-feeding,
tion was to start using nipple was to triple my efforts (try ex-
guards (tiny plastic top hats for tra, extra hard) and expect better
one’s nipples that fall off in a results to magically occur.
millisecond), which theoretically After that visit, I became ob-
help with the pain of breast-feed- sessed with keeping detailed logs
ing. Once we’d been discharged of every feed and wake cycle. I
and saw a new lactation consul- spent hours scrolling through
tant at our pediatrician’s office, physician “mommy blogs,” will-
she quickly dismissed the recom- ing myself to find some magical
mendations from the inpatient cure to my failure to produce
provider, which only exacerbated enough milk. I felt most ashamed
my confusion. of the pain I had with latching
At the first pediatrician visit, (if all women go through this,
we found out that my son was why can’t I?) and would often
underweight, the first sign that sob through breast-feeding ses-
breast-feeding was not going as sions. I looked for answers every-
expected. I was told to start do- where. Everything available on-
ing what is called “triple-feeding,” line discussed the “benefits” of
a cycle of breast-feeding, pump- breast-feeding, including bond-
ing, and formula feeding that ing and weight loss, and remind-
takes at least 60 minutes to com- ed new mothers about how much
plete, repeated every 3 hours. easier breast-feeding was than
This technique is recommended bottle feeding, given that you
for people who are not producing “didn’t have to get out of bed in

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 PERS PE C T IV E
the middle of the night” to make
a bottle. I read this statement
several times, bleary-eyed at 2 a.m.,
before I understood it: “Oh,
some women can actually breast-
feed without getting out of bed
at night?”
At my son’s 1-month visit, I
was still triple-feeding, getting a
maximum of 2 hours of sleep at
a time. The grit and perseverance
I had mustered to get through
my medical training had helped
me get to this point. It had also,
maladaptively, led me to accept
this superhuman responsibility. I
remember the fear I felt when the
nurse told me my son’s weight —
still below the 1st percentile,
hardly any weight gain at all. I
was even more disheartened
when my pediatrician smiled at
me as she left the room, reassur-
ing me to “keep doing what I
was doing” and to follow up in a
month. How would I survive an-
other day of my current ritual, let
alone another month?
Apparently, most women who
“keep doing what they were do-
ing” are not able to continue
breast-feeding. Only about 25%
of women in the United States
exclusively breast-feed for the
recommended period.2 After my
struggles, these statistics seem
realistic to me, but before I went
through it myself, I had no con-
cept of how hard it could be. Af-
ter that 1-month visit, I felt mis-
erable. I had no idea how things
were going to get better. I was
asked to do more and more
to make breast-feeding work,
while I continued to slip deeper
and deeper into depression and
anxiety.
At around 3 months, I was
finally making enough milk to
“exclusively breast-feed.” I had
1448
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Copyright © 2023 Massachusetts Medical Society. All rights reserved.
Breast or Bottle — The Illusion of Choice
achieved my goal but continued
to feel miserable. Though much
has been done to help support
mothers with postpartum de-
pression, the connection between
the struggle with breast-feeding
and postpartum mental health is
less often discussed. Recent
studies have shown that women
who struggle with breast-feeding
have higher rates of postpartum
depression than those who are
able to breast-feed.3,4
I started a medication for
anxiety and depression around
the time my son turned 6 months
old. It took me that long to get
up the courage to talk to my pri-
mary care doctor about my
symptoms. He was the first sym-
pathetic clinician I had spoken to
about my struggles. He gave me
the courage to start taking medi-
cation and to stop breast-feeding
that very week. Though the guilt
about stopping has never fully
gone away, the joy and happiness
in my life quickly returned.
My son is now 3 years old,
solidly in the 90th percentiles for
weight and height. Though I have
many loving memories about
him, the first 6 months of his
life remain a blurry and often ex-
tremely painful time for me to
reflect on.
I am now living in a new city,
and my husband and I are ex-
pecting another child. The anxi-
ety about breast versus bottle
feeding has slowly crept into my
world again. I am comfortable
now talking to my physicians
about my postpartum struggle,
but time and again I am subtly
and not-so-subtly reminded about
the benefits of breast-feeding.
Even after I’ve told them that I
might not choose to breast-feed
this time around, multiple doc-
n engl j med 388;16  nejm.org  April 20, 2023
The New England Journal of Medicine
tors have “reminded” me that
breast milk has been shown to
carry Covid-19 antibodies — yet
another reason to feel ashamed
if I choose not to breast-feed. I
even had one physician recom-
mend that I stay on my anti­
depressant during pregnancy
because it “helps promote breast-
feeding.” I am hopeful that this
time around I can embrace for-
mula feeding more quickly if
that is the path that works best
for me and my baby, but I worry
I will waver when the time
comes.
Exclusive breast-feeding did
not work for me before, and it
might not work this time either.
I am not alone in this struggle. I
encourage the AAP and other
national health organizations to
consider how their statements on
exclusive breast-feeding are per-
ceived by the public. If 75% of
us are not meeting this goal, a
more patient-centered approach
and recommendation is needed.
Everyone’s journey is different,
and it’s time that health care
providers and organizations rec-
ognize this variability and work
with their patients on a more
compassionate and individualis-
tic approach to support the path
that works best for each parent
and child.
Disclosure forms provided by the author
are available at NEJM.org.
From the Division of General Internal Medi­
cine, University of Washington School of
Medicine, and the VA Puget Sound Health­
care System — both in Seattle.
This article was published on April 15, 2023,
at NEJM.org.
1. Meek JY, Noble L. Policy statement:
breastfeeding and the use of human milk.
Pediatrics 2022;​150(1):​e2022057988.
2. Centers for Disease Control and Preven-
tion. Breastfeeding report card. August 31,
 PE R S PE C T IV E Breast or Bottle — The Illusion of Choice

2022 (https://www​.­cdc​.­gov/​­breastfeeding/​
­data/​­reportcard​.­htm).
3. Borra C, Iacovou M, Sevilla A. New evi-
dence on breastfeeding and postpartum de-
pression: the importance of understanding
women’s intentions. Matern Child Health J
2015;​19:​897-907.
4. Brown A, Rance J, Bennett P. Under-
standing the relationship between breast-
feeding and postnatal depression: the role
of pain and physical difficulties. J Adv Nurs
2016;​72:​273-82.
DOI: 10.1056/NEJMp2300346
Copyright © 2023 Massachusetts Medical Society.
Breast or Bottle — The Illusion of Choice

In “Not Otherwise Specified,” Dr. Lisa

Rosenbaum, cardiologist and national cor­
respondent for the New England Journal of
Medicine, defies our sound-bite culture to go
deep with some of medicine’s most innova­
tive thinkers. Her guests’ stories and ideas
about health care’s toughest challenges and
greatest promise may change the way you
think about medicine, health, and society.
Listen to the latest episode, “The Pragmatism of Hope,”
at NEJM.org or wherever you get your podcasts.

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