One of the more crass responses to the ongoing formula shortage has been that mothers worried about empty shelves where their infant’s formula used to be should just breastfeed instead.

Breastfeeding alone would never be enough. The reality is there are families for whom breastfeeding is not an option, for medical or lifestyle reasons, and many more for whom it is not enough on its own.

But it’s also true that the US doesn’t do all that it could to support mothers who want to breastfeed their children. Instead, the patchwork of the US health system, the pernicious influence of special interests, and a failure especially to support marginalized families have put the country at a disadvantage compared to other wealthy nations, feeding a national dependence on formula that left the country more vulnerable in the most recent shortage and would make another factory failure equally damaging.

America has long been an outlier among its economic peers in breastfeeding rates: One 2005 OECD report placed the US 24th out of 28 countries in the percentage of its children who have ever breastfed. Breastfeeding rates in the United States and worldwide have been growing since then, part of a concerted global public health campaign, but the US still lags behind much of the rest of the industrialized world.

In particular, while the country has done a better job of getting new moms to attempt breastfeeding when their child is first born, some of those parents struggle to maintain the practice. About 80 percent of American children have breastfed at least once, but the percentages still doing so exclusively at three months (about 45 percent) and the American Academy of Pediatrics-recommended six months (less than 30 percent) are substantially lower.

The dramatic dropoff reflects the failures of the US health system to support women who are trying to breastfeed their children. It’s can be easy to get started. It’s harder to sustain.

“Breastfeeding is an extremely fragile relationship. So many things can happen that cause it to unravel,” Lois Feldman-Winter, professor of pediatrics at Cooper Medical School of Rowan University, said. Compared to other wealthy nations, with “very different health care systems,” she said overcoming those obstacles “is much more challenging in our country.”

Some of the problems that contribute to low breastfeeding rates are familiar American health care woes. Too many Americans don’t have health insurance or regular access to a doctor or lactation consultant who could help them work through rough patches. They might not have paid family leave, which the US does not guarantee. Their employer may not provide them time and space to pump breast milk once they go back to work; federal law mandating such time and space has plenty of loopholes. US women with lower incomes and Black women in general regardless of income have lower breastfeeding rates than women with higher incomes and white women.

The formula industry has stepped eagerly into those gaps in American health care. In the United States, there is often an in-kind relationship between hospitals and formula makers, who supply free samples and other perks upon which hospitals rely. Those samples serve as a marketing tool, introducing new moms to their product at a critical moment in the lives of their babies.

“Breastfeeding is not a panacea to the current crisis,” Brian Dittmeier, senior director of public policy at the National WIC Association, which advocates for low-income women and children, told me recently. “But the manufacturing sector has very aggressively pursued its customer base, with decades of questionable marketing practices that have undermined public health efforts to promote breastfeeding.”

Breastfed children have fewer childhood infections, lower rates of sudden infant death syndrome, and lower obesity rates. The women who breastfeed have lower rates of heart disease and are less likely to develop breast or ovarian cancer. The science is clear, and many women say they do want to breastfeed. They just fail to reach their goals.

The US could be doing more to help those parents. But it isn’t.

The many ways the US health system fails to support breastfeeding

Breastfeeding is not always easy. In one survey, mothers who said they wanted to nurse but failed to meet their breastfeeding goals (about 60 percent of all moms in the survey) name difficulties with milk supply as the most common reason they resort to using formula in addition to or instead of breast milk, known as supplementation. Concerns about the baby’s health, illness or the need to take medication, and the effort required to pump milk were also associated with the early termination of breastfeeding.

Jacquelyn Martin/AP

“Very often the knee-jerk response to things not happening perfectly is we jump to supplementation,” Winter said.

Women who don’t have a regular primary care doctor or pediatrician, more common among lower-income and non-white Americans, have more trouble getting the support they need when they run into problems breastfeeding. They might not have a doctor at all; one in four Americans don’t. Or their doctor may not have a skilled lactation consultant. The American College of Obstetricians and Gynecologists identified a lack of support from doctors — either due to the cost of care for the patient or the physician’s discomfort with providing breastfeeding advice — as one barrier to increasing breastfeeding rates in the US.

“In many other places in the world, mothers have access to skilled lactation support … to get women over that,” Winter explained. But in the US, “for many women, they don’t have access to skilled lactation support.”

For mothers who do not speak English as their first language, their doctor’s office also may not have a consultant who shares a language with them, said Natasha Sriraman, a pediatrician at the Children’s Hospitals of King’s Daughters in Norfolk, Virginia, who has studied breastfeeding practices in her academic work. She said in her practice she had seen women who had been breastfeeding for several months in their home country give up in a matter of weeks on average once they came to the United States.

The entire social safety net isn’t conducive to breastfeeding. Mothers with less food security are more likely to miss their breastfeeding goals, according to one 2019 study published in Midwifery Women’s Health. Many women in the United States, particularly those with lower incomes and who are Black or Hispanic, do not have paid family leave. A 2016 study published in BMC Pregnancy Childbirth found that women who returned to work earlier were less likely to give up breastfeeding before six months.

“We don’t value mothering,” Winter said. “To a penny, mothering is clearly not valued in the way that it is in other countries.”

And perhaps most critically, what happens at American hospitals — for better and for worse — helps determine whether American mothers are able to breastfeed as much as they wanted to.

On the one hand, research has found that some things hospitals do, such as initiating breastfeeding within one hour of a baby’s birth and sticking to breast milk only with no formula supplementation, are associated with a higher percentage of mothers breastfeeding as long as they intended.

But when a newborn baby does receive formula supplementation in the hospital, they are more likely to prematurely wean off breastfeeding, according to a study published in 2020 by Pediatrics.

And many US infants do receive formula while they are still in the hospital — often due to medical necessity, but also because the sheer prevalence of formula in American hospitals contributes to more supplementation.

How the formula industry plugs into the health system to push its products

The formula didn’t end up in hospitals by accident. Its manufacturers have worked hard to place their products there, making it easily accessible to the new parents who are trying to figure out how to feed their newborn babies. Babies are sometimes fed formula either in the NICU or an overnight nursery. Hospital staff may send new parents home with free pre-made formula bottles, too. (As a parent of twins born a few months ago, I experienced all of these.)

They have good reason to do so: Brand loyalty is critical to baby formula. In any given state, one company tends to dominate the entire market. The companies want to get in early.

“You can’t underestimate that we’ve created a system where brand loyalty is important,” Winter said. “That begins at the hospital, with giving away free samples.”

Winter, who trained and worked as a nurse in hospital maternity care, said the giveaways to hospitals can be so generous that some facilities don’t even budget for purchasing formula on their own. Formula companies provide other benefits to hospitals besides free supplies of their product, like supporting residency and other medical education programs.

Gabe Souza/Portland Press Herald via Getty Images

Fewer US hospitals are handing out free samples these days, part of a concerted global health effort to encourage breastfeeding, but one-third still do. And only one in five US hospitals are currently considered baby-friendly by the standards set by the World Health Organization and Unicef, Winter said. The hospitals that aren’t considered baby-friendly either hand out free samples or they pay less-than-market value for the formula that they do purchase, deepening their ties to the formula industry.

Such in-kind relationships inevitably influence the medical staff’s attitudes. “I felt indebted for all of the educational support,” Winter said.

The formula industry has been sharply criticized in two recent World Health Organization reports that documented its marketing techniques. The reports found that the companies targeted both patients and medical workers around the world, often with misleading information about the health benefits of formula compared to breast milk.

The Infant Nutrition Council of America, which represents formula manufacturers, said through a spokesperson that its members “have always shared the goal of supporting and promoting the benefits of breastfeeding.”

“Mothers should be encouraged and supported to breastfeed,” the group said. “However — if breast milk is not available or not chosen — parents should have access to accurate, balanced information on all appropriate infant feeding options regardless of whether they breastfeed, formula-feed, or use a combination of both.”

The WHO reports pointed to the free samples offered in the hospital and digital marketing campaigns, which most of the women had been offered or had seen, as the most pervasive marketing techniques. The research also found recommendations to use formula from medical staff, who themselves are often targeted for marketing, were particularly persuasive.

Effectively all public health authorities say that most infants should be able to eat only breast milk for up to six months, with exceptions like infants who have a special allergy or mothers who can’t naturally produce enough breast milk.

More than once during my conversations with breastfeeding experts, comparisons were drawn to the tobacco industry and its history of nefarious advertising practices that in part relied on doctors. The WHO’s February 2022 report concluded that formula manufacturers “systematically” target health professionals in marketing campaigns. Practitioners will be approached by the industry’s representatives and sometimes offered funding for research, commissions from formula sales, and even all-expense-paid promotional trips.

The WHO reported that health professionals sometimes (wittingly or not) pass those marketing messages along to new parents and that the advice given by clinicians is very influential on parents’ feeding decisions.

“They have taken people who are otherwise able to produce breastmilk and undermined their confidence and abilities to do so,” Ann Kellams, a pediatrician with the University of Virginia and president of the Academy of Breastfeeding Medicine, told me. “Women are failing because we as a society, as a health system, are failing them.”

The ongoing formula shortage has prompted advocates to argue for fundamental reform to the baby formula industry, up to and including “hospitals’ relationship with formula manufacturers,” Dittmeier said.

“How much are we promoting breastfeeding in hospital settings?” he said. “We have to minimize free samples and giveaways, which are the lynchpin of building the consumer base for formula.”