When Michelle Delbaere gave birth to her son Henry seven months ago, she had planned to exclusively breastfeed him because she'd been told that a mother's milk is considered best for baby's health.
Despite her intentions, she agreed to initially bottle-feed her newborn with formula because it was taking time for her milk to come in.
"Once in the hospital. Actually, it was twice in the hospital," the first-time mother says, almost sheepishly, about consenting to formula at Ottawa General Hospital, where Henry was delivered. "I was very hesitant to use it."
"He was so hungry. And the nursing staff finally suggested we just give him a little bit of formula to make him a little more comfortable."
But with a push to have hospitals and other health-care centres promote exclusive breastfeeding, that scenario of opting for formula may be increasingly less likely to happen.
Indeed, a recent report by Ontario's Healthy Kids Panel recommends that hospitals across the province that deliver maternity and pediatric care should be encouraged to be certified as Baby Friendly Initiatives, a program launched by the World Health Organization and UNICEF in 1991.
Under the designation in Canada, hospitals must not accept free or low-cost breast milk substitutes, feeding bottles or soothers; they must strictly fulfil 10 criteria, including placing babies skin-to-skin with their mothers right after birth and encouraging mothers to breastfeed for a minimum of six months, unless supplements are medically indicated.
So far, just three hospitals in Ontario have earned their BFI accreditation – St. Joseph's Health Care in Hamilton, Grand River in Kitchener, Ont., and Toronto East General. Across Canada, there are roughly a half-dozen others already certified or in the process of becoming baby-friendly centres.
Experts say there are lots of health benefits linked to breastfeeding: breast milk contains disease-fighting antibodies that may also reduce a baby's risk of developing allergies, and research suggests breastfeeding offers some protection to women against breast and ovarian cancer as well as osteoporosis later in life.
"Babies who are breastfed exclusively have fewer hospitalizations, fewer trips to the doctor, fewer ear infections and respiratory illnesses," says Alex Munter, co-chair of the Healthy Kids Panel.
Recommendations by the panel are aimed at reducing the rate of childhood obesity – almost a third of Canadian kids and teens are overweight or obese – by 20 per cent in the next five years.
Promoting breastfeeding is one part of a multi-pronged attack on obesity.
"As it relates to obesity, we know that the longer a baby is breastfed, the more significant the impact," says Munter, CEO of the Children's Hospital of Eastern Ontario (CHEO) in Ottawa. "So it's estimated that for every month up to eight months, the risk of overweight and obesity is reduced by four per cent."
Statistics show that 87 per cent of Canadian moms start off breastfeeding their newborns, but by the six-month mark, only about 25 per cent are continuing the practice.
"Making the decision to breastfeed is a very personal matter," acknowledges Munter. "But seeing the data around the link between breastfeeding and reducing obesity, we want to make the environment as supportive as possible for women who make that choice."
Yet there's huge variability among the 100-plus Ontario hospitals that provide delivery services or pediatric health care: some have lactation consultants, others don't, he says. "Even at CHEO, there are varying degrees of expertise and knowledge amongst staff and physicians.
"What the Baby Friendly Initiative does is it helps hospitals up our game so that we can support women as they make a choice around breastfeeding to be able to maintain it and continue."
In response to the report, the Ontario government says it plans to look for ways to enhance breastfeeding supports, including more BFI-certified hospitals. Since 2011, the ministry of health has required all 36 public health units in the province to work towards BFI designation, a spokesman says.
But the process isn't easy, health providers say.
"It's pretty comprehensive," says Linda Young, director of Maternal Newborn and Child at Toronto East General, which recently went through its five-year recertification.
This country's accrediting body, the Breast Feeding Committee for Canada, conducts on-site interviews with doctors, nurses and other staff in obstetrics, pediatrics and the special-care nursery.
The process also includes an audit of obstetrical patients' charts, covering all three nursing shifts going back several days.
"And when they talk to nurses, they don't just say: 'How's it going?' They literally grill them on the 10 steps to see if they can answer questions," says Young. "They ask what they do with moms having difficulty breastfeeding, how they respond to someone who asks for formula, when did they initiate breastfeeding and what are they teaching mothers."
It took several years for the hospital to put all the BFI pieces in place, including a requirement that all staff take a 20-hour course on breastfeeding. Services for moms include free breastfeeding classes, a drop-in breastfeeding clinic and lactation consultants.
Formula – or rather, its restriction – is a key component.
"We have to buy formula," explains Young. "Hospitals who are not baby-friendly are getting their formula free (from producers). So we have to pay for all of our formula and we do not have it readily available. If a mom asks for it, we have to make sure it's an informed choice, so she knows what the consequences are potentially.
"If she still wants to use it, then we try to get her to cup-feed rather than bottle-feed. Also, we don't give a mom a full bottle of formula ... because babies do not need four ounces (120 millilitres) of formula when they're first born.
"We only give them what they need as they need it."
It's not just formula that's in deliberate short supply under BFI rules: product samples and promotional materials are also forbidden.
"Part of it is making sure your magazines and materials in your corridors are not promoting formulas or alternatives," says Simone Thibault, executive director of the Centretown Community Health Centre in downtown Ottawa, which was BFI-certified in early 2012. "I mean, you open any parenting magazine, there's a lot of it."
That also includes eschewing free baby bags or gift baskets chock a block with samples of creams, diapers and formula often offered by companies for new moms.
"It's not usually done, but sometimes a mother will go home and will be given a few samples of formula," says Centretown's lactation specialist Joan Bueckert, adding that because the mom was given a certain brand in hospital, she is more likely to use that product after she gets home.
"But it's more than that. If you're at home with your new baby and you do a search (online) about some breastfeeding issue, often you're going to come across a site that's sponsored by (formula makers) Nestle or Mead Johnson," she says.
"It's big business and they want to make money ... And it's baby's health that's at stake."
Predictably, that increasingly widely held attitude doesn't sit well with formula makers.
A spokesman for Mead Johnson says that given the acknowledged benefits of breastfeeding, the company is focused on making infant formulas as close to breast milk as possible.
But Christopher Perille says parents have a right to receive complete, balanced information about all feeding options for their babies – "and one of the best ways for mothers to receive accurate, helpful information about feeding options is through their health-care provider."
"Prohibiting or restricting health-care professionals from providing formula samples and information limits their communication with parents and interferes with their responsibility to help ensure the health and well-being of their patients."
Though Bueckert insists formula cannot match breast milk for its health benefits, she acknowledges that some new mothers prefer to bottle-feed: "You know, we've had a number of moms who have said 'I'm not going to breastfeed,' and that's fine. We support them and we're going to help them to have their baby as healthy as possible."
Still, she believes the choice to breastfeed and the ability to stick with that decision often depends on how much support a new mom has.
"I think some of that is different messages that people are getting, so although they're in the hospital and they're really determined to breastfeed, once somebody offers them some formula and they're given the formula, then they start second-guessing themselves."
Delbaere agrees that as a new mother, she often questions herself. But getting support from Bueckert and others at the Centretown clinic following Henry's birth gave her the confidence to carry on breastfeeding.
"There so many things that you could be doing different ways," she says. "And just to have someone there who could tell you: 'Yes, you're doing it the right way' or 'This is maybe an easier way for you' was very helpful."