Why My Maternity Ward Locks Up Infant Formula

Much ink has been spilled about NYC Mayor Bloomberg’s support of breastfeeding.

In today’s guest post, nurse and lactation consultant Noa Hirsch Choritz explains how keeping formula with medications serves the needs of both breast-fed and bottle-fed babies.


New York City Mayor Michael Bloomberg recently announced that he will be supporting breastfeeding by encouraging hospitals to join the voluntary Latch On NYC program. Among other steps, the hospitals must agree to keep infant formula with medications instead of in mothers’ rooms.

The announcement has been met with outrage and hyperbole, with columnists warning about “forcing women to breastfeed.”

In the maternity ward where I work as a lactation consultant and nurse, we’ve been keeping the formula in the drug room for years. I’d like to share what really happens when formula is kept out of sight and locked up. Hint: No one is forced to do anything and no one starves.

My ward offers exclusive “rooming-in.” This means there is no nursery—all  babies are next to their mothers 24 hours a day. Generally speaking, mothers who choose rooming-in are more inclined to breastfeed. Not all the mothers wish to breastfeed exclusively, but our breastfeeding initiation rates are certainly higher. Baby nurseries exist elsewhere in the hospital.

Initially, formula was kept in the patient rooms alongside the diapers, wipes, and clothing. But I often noticed a half-full bottle of formula an hour after my last visit, even though the mother had told me she would be exclusively breastfeeding.

Why did these babies get formula? Sometimes the mother assumed she didn’t have enough milk because the baby was crying. Or Mom would be in the shower, so a well-meaning relative would feed the baby without asking. Other times, I would spend two hours helping a new mom learn to breastfeed and left in the evening when Mom was well on her way to successful breastfeeding. But in the morning I would see that the baby had been given formula all night long by a nurse who either didn’t have the time to help the mother latch baby on, or just didn’t care. It was frustrating.

We also found that many babies were fed enormous quantities of formula. The bottles, distributed free of charge by the manufacturer, contain 90 ml. (3 ounces) of formula – about 6 times more than any newborn could or should eat in one go. The nipples, also provided free of charge by the manufacturer, are designed to have very fast flow rates – much faster than a typical newborn nipple size 0 (and way faster than the human nipple!). Mothers would pump 60 ml (2 ounces) of formula into their 8-hour-old baby’s tummy (which can hold roughly 5 ml at that point). The babies would cry and forcefully vomit out the food.

There is also a hygiene issue: Formula bottles are meant to be used only once, because leftover formula harbors bacteria. But mothers would open the bottle at 20:00 and keep offering from it all night long!

I came up with the idea of removing the formula from the patient rooms as a solution to all of these issues. Eventually we moved the formula to the room where we keep medications, since formula should be viewed as medication: Essential and life-saving when necessary, but potentially harmful in other circumstances. By removing the formula from the patient rooms, we could increase patient-nurse communication, give better care to mothers, ensure that babies who received formula would be fed correctly, and encourage nurses to do what was best for the baby. Nurses are notoriously overworked/understaffed and sometimes (particularly at night, when there are only 2 nurses on the shift) it was easier for a nurse to hand the mother a bottle of formula rather than spend the few minutes helping her. If the nurse had to go down the hall to get the formula, she might decide to spend the same amount of time helping the mother latch her baby correctly.

Our ward has been functioning this way for at least 3 years now. All of our initial goals were met, and we had  some surprises along the way.

If a mother comes to our ward and says that she has no interest in breastfeeding (or cannot, for whatever medical reason) she will receive a few bottles of formula, along with a few nipples and instructions on how to use the formula correctly (correct amounts, to dispose of the formula after each feed, etc.). If we think the mother is receptive to hearing about the health benefits of breastfeeding for her and her baby, we may discuss them with her. Again, we use professional judgment. A mother who has birthed and formula-fed many children has clearly heard about breastfeeding before. A first-time mother on the fence may not have.

If a mother has started breastfeeding and is experiencing difficulty, she may ask us for formula. We will try and help her to the best of our ability and if she cannot manage, or is in pain, or exhausted and asks for formula, she will get it. Depending on her situation, we may explain (and not in a judgmental way) how formula-feeding may affect the baby and breastfeeding. Again, we use professional judgment: A mother who asks for formula because she wants to head over to the mall may get a different answer than a mother who hasn’t slept in two days, appears to be one diaper away from post-partum depression, and is not making enough milk (for whatever rare reason). Usually what happens is that we guide the mother on how to best give the formula to preserve breastfeeding, assuming breastfeeding is the goal. This includes feeding the formula from a syringe or spoon, giving the formula slowly (so baby doesn’t get used to a impossible-to-keep-up-with rate of feeding), and giving minimal amounts.

I don’t do the ordering, and we’ve never kept track ( I am now kicking myself for this) of whether our babies consume less formula, or more importantly, whether we increased breastfeeding rates in the long-term. But I still meet mothers who tell me that they never would have continued breastfeeding without the help they got in our ward. A woman recently came up to me in the pharmacy and told me that she managed to breastfeed only the last of her five children, because of me (!). I remembered her: she had come to the nurse’s station asking for formula – she said it was her 5th child and she had never made enough breastmilk so she wasn’t going to try this time. Knowing that there could be a reason for this, I went with her to her room, formula bottle in hand, to chat. The first thing I noticed was the allergy medication on her dresser, one known for drying up breastmilk. Turns out she’d been taking that medicine for 15 years! We asked the doctor for an alternative medicine and magic! – she had enough milk. But I would never have discovered that if she’d been helping herself to formula in her room.

The most amazing for me was the nurse  I considered to be the biggest formula-pusher now counsels women to breastfeed! I don’t know whether if it was the trip down the hall to get the formula or seeing everyone else try harder, but it’s wonderful progress.

No one is trying to force mothers to breastfeed against their will, and no one will let babies starve. We simply want to make sure that the mothers (and babies) know what they are receiving and how to use the formula correctly. We don’t want mothers who hope to breastfeed to turn to formula out of desperation or fear. If nurses know which mothers are having trouble, we can allocate our time to those mothers. For mothers who aren’t sure if they want to breastfeed, providing them with a bit of education about the health detriments of formula feeding (ideally well before birth) can make a difference.

In Israel, many babies continue to get formula despite their mother’s best intentions. Along with better policies, we need more licensed lactation consultants in each hospital, and more staff training in lactation for all nurses  who work with mothers and babies.

Bio: Noa Hirsch Choritz is a board certified lactation consultant and nurse at Jerusalem’s Hadassah Ein Kerem hospital. She made aliyah in 2002 and lives in Efrat with her husband and 3 small children, Akiva, Hadara (pictured above), and Yonah. 

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  1. Great post! And thanks for helping me latch my son when he was born two years ago, Noa! We went on to breastfeed for 15 months.

  2. “A mother who asks for formula because she wants to head over to the mall may get a different answer” She was totally my roommate for my last baby!

    Can you talk more about how you handle rooming in for everyone. When I did rooming in for one baby I was stuck changing diapers at 2 am about 5 hours after I gave birth. I found that I got very little support and thus very little rest. The attitude of the nurses was I was on my own since I “chose” rooming in (didn’t really have a choice as that was the only room available- the hallway was obviously worse.) How do you insure that mothers get the rest and support they need without a nursery?

  3. Love this post. I think that many women are under the false impression that breastfeeding is really easy and doesn’t require any work. For my son and I, breastfeeding was lots of work AT FIRST – we had to learn how to nurse together. We received support from the hospital nurses, LCs, our La Leche League group and our family. I think this support was instrumental in our being able to successfully start and continue breastfeeding for 10 months. (I wish it had been longer, but my son decided he was ready to stop).

    Once we really knew what we were doing as a nursing pair, then we made it look easy. 🙂

  4. Great post. I really appreciate what this system means, even though I myself did not have problems with breastfeeding and only used formula in exceptional situations.

    However, when my son was born I chose rooming-in at Ein Karem, and I would echo Abbi’s comment/question about the rooming-in issue. I was very lucky that I found breastfeeding easy, so that was a non-issue for me (although one nurse did convince me to give my son a tiny bit of formula while we were in the hospital because she said I’d get to sleep for a few hours).

    By nature I wanted to be with my son at all times, so I chose rooming in. I was also lucky that I had a relatively simple labour – only 9 hours of active labour, no interventions, no drugs etc. When my son was born I felt both powerful and exhilarated. By the time I went home 2 days later that had changed, for various reasons, I was totally exhausted and felt incompetent. Many of the nurses were lovely (and I think you were one of them – your picture looks familiar to me!) However, I too felt that a few of the nurses I encountered seemed to feel that since I’d chosen rooming in I should do everything myself. Trying to hold a screaming 6lb newborn over a sink to get sticky meconium off him at 4am when you’ve been up for 24 hours, have just got through labour and have no experience of newborns is just an unfair expectation, but the nurse expected it of me and made me feel like a failure for not getting it right. I was terrified of dropping or hurting a baby that tiny; I certainly couldn’t get the hang of holding him in one hand dangling there while cleaning him with the other. I’ve changed plenty of nappies before (my brother is 15 years younger than me) but meconium is like tar! It sapped my confidence totally.

    Sharing a room when you are rooming in was the other big problem. It is hard enough to be alert to your own baby’s every need when those needs occur every other hour. But sharing a room with another new mother and baby meant that whenever my son was asleep I was kept awake by the other baby in the room. I don’t think I slept at all for 72 hours (my waters broke at 1am and contractions started infrequently then so I was awake for 8 hours before active labour began). I lay there willing myself to survive until my husband arrived each morning at 8am and I could collapse on him in tears.

    I am pregnant again now, and I honestly don’t know whether I’ll choose rooming in again for this birth. Ideally I want to, but only if there is a single room available. Otherwise I think I’ll choose one night of more sleep with the baby in the tinokia and hope that someone else will deal with that first meconium nappy and that they’ll bring him/her to me whenever he/she needs to feed, and then I’ll discharge myself and go the Hadassah hotel over the way where I can pay to have a single room for the other night.

    • Deborah- totally with you on washing off the meconium at 2 am! It is completely exhausting and frankly unnatural to be completely on your own taking care of a baby just hours after birth. At home, you have your family to help! Husband, mom, siblings if they’re around. Being stuck in an institution, without family help, taking care of a helpless newborn is just the worst of both worlds.

      I completely agree about the roomate’s baby as well. It just sucked all around with me. That was my second baby when I had rooming in. Never again. 3rd and 4th I happily handed over my babies to the tinokia and told them not to wake me for the first night for feedings so I could sleep after the birth. 3rd didn’t need a bottle at night but 4th did. I nursed all day the next day with each of them (pretty much hourly) and my milk came in by the time I left the next day for each of them (4th also got a bottle the second night after it was clear my colostrum was just not satisfying her and she could not settle down. I asked the nurses to give her a bottle, I drank liters of water, had a sandwich, got a good night’s sleep and woke up to floods of milk).

      • Well, than you know Abbi it is not for you. I on the other hand fought to get my baby #6 in my room (this was in NY) after a very long and difficult labor and was very happy to be “left on my own”. What is the big deal about changing a diaper?! Especially if you are expected to get up and go get your food anyway here in Israel. Comparing to that a diaper is nothing, yet people who have babies here consider it normal. At home I would have lots more people to worry about. This is why when I head my last baby at home I headed out to the maternity rest home 24 hours after. This was easier for me and my DH.
        Main thing is you should get a choice. Sounds like you got it.

        • Well, it sounds like there’s a new law or initiative that would make rooming in default for all in all hospitals. How would that be giving women a choice.

          Changing a regular diaper- not a big deal. Changing a meconium diaper in hospital hours after birth when you’re unfamiliar with the sink, tired, sore, probably hungry, alone, possibly with stitches in a bunch of places you’d rather they not be- big deal. It’s much stickier and messier then a regular one, usually requiring a bath, which requires a full change of clothes. The hospital baby clothes, which are sans snaps, are very difficult to figure out how to wrap up on your baby so she’s snug and warm, rather than flailing all over the place in a tangle of cloth.

          For women who prefer rooming in- it should be an option. It shouldn’t be forced on all.

          • In America, where I had my first son, rooming in didn’t mean being stuck doing everything yourself. First of all, private room meant husband sleeps over, so he does the diapers. Second, you are allowed to have the baby with you 24 hours a day, but there also is a nursery available that you can choose to send him to (I never did, but I liked that the choice wasn’t all or nothing). I understand why in Israel they don’t have the resources to give everyone private rooms, but I don’t understand why they can’t have the American model where you are allowed to have the baby with you all the time, or you may choose at any time to use the nursery.
            I overall really appreciated my time in the rooming in ward at Ein Karem, but I checked out of the hospital less than 24 hours after giving birth so that I could get home, where my husband and mother would take care of my baby and me.

          • I guess when Israeli nurses heard “rooming in” they looked at it as a way to ease the burden on nurses, not as a great way for moms and babies to bond and encourage breastfeeding. Regardless, this is the system as it stands now, and I don’t think it benefits mothers at all. If the choice is between 24/day and no help vs. 17 hours a day + being awoken at night for feedings if the mother chooses+ night nursery, I think the latter is much better for mothers who need the help.

            Hannah, I have to say I’m really surprised at your question and the seemingly low value you seem to place on a new mother’s need to be supported especially in the first 24 hours after birth. Going for meals, during the day, is nothing at all like changing a diaper and dressing a baby in the middle of the night. Especially for a new mom who probably has next to no experience just changing a normal diaper, this is a daunting task.

        • Whoops, apologies. I misread Henya as Hannah. Sorry about that. But my comment still stands as a reply to Henya.

  5. This is in reply to the comment above about it not being natural for a women to take care of a newborn alone. TOTALLY CORRECT!!!! From an anthropological (and evolutionary) perspective, human beings are meant to live in tribes. A new mother is helped and taken care of by the other women in her tribe. I recently heard a talk given by a woman who was raised in Ethiopia. She says a new mother does not lift a finger for a month. She rests and nurses and that is it.

    I suggested to MIL to do an interview of this Ethiopian woman and still think it might interest other readers.

  6. Abbi and Deborah –
    Addressing your issues with rooming-in. I am sorry you didn’t have the experience you’d hoped for in rooming in. In theory our plan is to teach you how to care for your own baby, and that is what our staff allotment is as well. Our goal is to spend time with you teaching you how to change diapers, identify a hungry baby, learn to care for your newborn. Unfortunately, mostly due to a staff shortage, sometimes a nurse has to make priority calls about what to do first – and sometimes diaper-changing (particularly if we know the mother knows how) comes second. I don’t think the nurses think “you chose rooming in, you’re on your own” but rather, “I have to do this more critical thing first” and by then you’ve changed your own baby’s diaper. It is in no way easier on the nurses – believe me, it is far easier for me to change your baby’s diaper than tot each you how to do it yourself. Just as its easier for me to give your baby formula than to teach you how to breastfeed…but we are doing the best we can with limited resources. In a night shift there are only 2 nurses on – for 12 mother-baby dyads and up to 10/12 high-risk pregnant women. Its not always possible to get to the diapers, so we do rely on the mothers to care for their own babies as best they can – but of course, if asked for help, we come. Likewise, if I hear a baby crying fro more than about 20-30 seconds I go to the room, even before being called.

    In terms of the roomate issue: I agree completely., I have suggested to management that even a simple drywall between the 2 beds (essentially making 2 tiny cubicles) would be preferable to 2 in a room. They are working on the idea. I know when I had my most recent baby (6 months ago) I had a roomate who was having serious breastfeeding issues (her baby had tongue-tie but she refused to clip the toungue, she refused to give formula, she wouldn’t breastfeed because it hurt and the baby was crying all night long), and it was awful for me – my baby was sleeping and eating quietly, but I couldn’t sleep because of her baby. The nurses did try to help her but she only wanted to keep putting a pacifier in the poor baby’s mouth. I eventually helped her express breastmilk and give that to the poor baby. But it was hellish on me…I went to the hotel the next night.

    • Thanks for the explanation, Noa. Although teaching new moms the basics of baby care is a worthy goal, I don’t think that should be done at the expense of the mother’s recovery. (With the nursery system, hadracha was given on a daily basis between rounds, so I doubt anyone left the hospital not knowing how to change a diaper, bathe and dress the baby). There’s also the issue that many mothers are not on the ward for the first time. Their main priority is recovery and rest before going to home to care for the baby and 1,2, 3 or maybe even 10 other kids.

      • Again, Abbi – this is your choice. No one is forcing you to choose rooming-in, and no one forces any woman! Even the new intiative will only require each hospital to offer it as an option (as is done at Hadassah and Meir). Your main priority may be recovery, but for other mothers it may be spending time taking care of their baby. Judging by the fact that our ward is almost always full to the gills, and as soon as there are discharges we have women waiting in the non-rooming-in wards for their turn, I think many women do choose the latter.

        • Actually it was forced on me- when I was stuck in the hallway after being wheeled up from the delivery room, the only option was rooming in. I certainly wasn’t going to stay any longer in the hallway to get a regular room. I realize this is the reality of Israeli maternity wards and it’s no one’s fault but the health ministry’s, maybe (this was before the expansion at HEK).

          • But you did have a choice – you could have waited in the hallway for a non rooming-in room to open up. You* chose* to take the option that wasn’t really cut out for you, and then you’ve spent the past day trying to convince all of us that what you didn’t enjoy isn’t really the best thing for mothers and babies – despite overwhelming scientific evidence to the contrary. I think I understand your point of view better now.

  7. Also, although this isn’t ideal, new mothers are welcome to have female relatives spend the night with them in rooming in to help out. Because of the 2 to a room situation we can’t allow husbands to sleep over, as it may be uncomfortable for the other mother in the room, but female friends and relatives often spend the night helping out. If husbands wish to sleep over, they can sleep in the dining room (which isn’t ideal, we know) to try and help the mother. I agree with you about the evolutionary need for a “tribe of women” helping a new mother out – in other cultures and our own history, that is how young girls learned how to eb mothers – how to breastfeed, how to care for a baby. Also, mothers would cross-nurse and breastfeed other babies if the need arose. We do our best in the hospital given the resources we have, and we do fight to try and make things better for mothers and babies.

    • This works if you have close female relatives at hand who are willing to sleep in a chair to help you. They do exist, but I wouldn’t say that’s the norm. And for olim who give birth here without close family- they’re out of luck too.

    • I DIDN’T KNOW THAT!!! Totally doing that next time, God willing.

  8. I gave birth at HEK nearly four years ago and chose rooming-in. I was in so much pain from a terrible latch and just as terrible type 1 tongue tie and so I turned to the nurse on duty for some help. [There was no LC as it was chol hamoed and they were working fewer hours.] I was rather shocked and hurt when she casually replied, “Well, there’s always Materna”, waved her arm toward the fully stocked drawer of ready-to-feed formula bottles, and walked out of the room. What a great initiative on your part to remove the formula from the rooms!

    There was one nurse who was incredible, and to this day when I tell people about my wonderful experience at HEK I refer to her as a malach. She had the overnight shift and came to help me with whatever I needed whenever I called her. In particular, she sat with me for a half hour helping me latch my baby on and helped me out with some basic baby care.

  9. Rena,

    I am glad you had such a positive experience. One slight addition: You mnetioned there was no LC on since it was chag. All of the LC’s at Hadassah Ein Karem are also nurses, and for the most part work as regular nurses doing regular shifts. As an IBCLC I do not get specific “hours” where I am just an LC, I (and most other) LC’s do our lactation care as part of our general nursing shifts. This is difficult because it is frustrating for both the mothers and for us – we know there is a mother who needs our help, she knows we exist, but because I have other duties as a nurse I cannot give her the help she deserves. It could be seen as a positive, because it means I am always out amongst the mothers and don’t ahve to wait to be “called”. It also means that sometimes I am there at night or on the weekend, unlike traditional LC’s in hospitals. The Israeli Ministry of Health (which as yet doesn’t really recognice lactation consulting as a vital part of a maternity ward) is moving towards the trend of certifying nurses who already work with mothers and babies with an advanced nursing degree in lactation. The goal is that by January 2013 (coming up!) on every shift in the wards where mothers and babies stay, there will always be at least one nurse who is certified with the advanced degree in lactation.

    • Noa,

      I’m happy to hear that’s how things are. When I was there they announced that the LC was stationed in the cheder hanaka from time x to time y (roughly two hours in total) the day I gave birth, and that otherwise there wouldn’t be an LC on staff until after the chag. Looks like things have improved further!

    • Ideally, shouldn’t LC training just be part of getting a nursing degree, especially for those who want to work on a maternity ward?

      • Nice idea but LC training involves 500 to 1000 hours of ‘internship” plus numerous advanced courses. Basic help and such is included in most nursing curriculum, but it isn’t even a fraction of LC training.

      • Shmuel Yonah says

        LC is a minor fraction of the women’s health course during the basic 4-year nursing degree. (I had the best teacher 😉 ) Nurses that choose to specialize in certain fields (e.g. operating room, intensive care, trauma, midwifery, etc) are required to take certain advance courses to be able to work in those fields. In other fields (maternity, ER, internal medicine, pediatrics, etc), taking advanced courses is not required, but highly recommended. While it would certainly be advantageous to have all maternity ward nurses take the LC specialty course, it’s not required as the way things currently stand there is almost never a shift without an LC nurse.

        Given the very basic instruction in my Women’s health course, I feel confident enough to try and help a new mother with lactation, but I certainly wouldn’t feel confident enough to answer questions and deal with more complicated cases (e.g. prior breast surgery). We’ll see how this actually pans out next year when I have my Women’s health rotation.

  10. I agree with Abbi, Ariela, et al.. that moms do need help after birth, and it’s distressing for them to be on their own.
    It’s also important to remember that the baby is even less equipped to be on his own in the nursery. He will not necessarily get fed or changed quickly, much less held or comforted. If the nurse doesn’t have time to help a mom with a diaper, she also won’t be able to come wake up the mother as soon as the baby is hungry.
    If a mom is not confident about changing a diaper she should wait until she can get help.

    • I’m not really sure I’d agree that a baby is “less equipped” to handle some crying. Babies are very adaptable, otherwise we wouldn’t have survived this long as a species. Twins cannot be attended to simultaneously, even by the mother at home. One of them will have to cry a bit while waiting their turn to be fed or changed- would you suggest that such crying will scar the babies for life?

      Whenever I’ve picked up my child in the nursery, I’ve never heard a chorus of screaming babies. It’s usually quite calm, and while night nursing I’ve spent up to a half hour at at a time in or right next to the nursery. I just don’t recall masses of crying, and this was both in HEK and Meir Hospital.

      Basically, hospital recovery is less than ideal for all involved. But I think the mother’s recovery should be balanced with the baby’s needs.

      • Abbi, its interesting that we could have such different experiences at the same hospitals. I also gave birth to my chidren at Meir and Hadassah. With my first chld, I took the tour at Meir very late in the evening as I did my birth-prep course there as well. I was horrified by the crying babies – and a quick head count – something like 3 nurses to 40 babies – plus the evidence in front of my own eyes, let me know that my baby’s needs were not going to be met immediately. I chose rooming-in then, and when I later became a maternity nurse I only was interested in working in the rooming-in ward. Babies are meant to have their needs met quickly – the reason crying sounds so sad and awful to us as parents is to arouse our sympathy and ensure that baby’s needs will be met. Its actually an evolutionary survival technique. Twins are a very rare naturally occuring phenomenon; with the wonderful advances in assisted reproductive techonolgy theya re far more common today, but they were a rarity. I would not say that crying scars a baby for life, but new researcg in the field of epigenetics shows that crying does effect the genetic makeup of a baby. Its actually quite fascinating.
        It does seem that rooming-in is just not your cup of tea, so I’m not sure that anything I say here can change that. But for the mothers who would like that opportunity (and we’ve had mothers of their 14th child choose rooming-in for the first time in our ward!) it is wonderful to have it available. I know that were there not rooming-in for me, I would check out after 6 hours in the hospital. That’s what is wonderful about both Meir and Hadassah – they have rooming-in as an option, not a requirement. Even if it was a requirement, there are plenty of other hospitals that don’t have rooming-in, so mothers can choose what best suits them.

        • Yes, that is funny that we had completely different experiences at the same hospitals. I’m sure there was some crying while I was sitting and nursing in those nurseries, but I don’t have a major memory of a cacophony of baby crying.

          I think my main concern is new mothers leaving the maternity ward exhausted and overwhelmed, as Deborah described her experience. I don’t think the few extra hours of bonding is worth an exhausted mother, which I would imagine could put her at more risk for PPD and other ills (speaking of which, did your former roommate get a psych eval or at least a visit from a social worker? That sounded like a dangerous situation!)

          I have a strong memory of lying in the hallway after my second birth at HEK, 7 years ago, paralyzed with anxiety that my baby was crying and I couldn’t hear her in the nursery. My hormones were obviously all over the place, and I felt very sad, alone and helpless (my husband had gone home already, maybe it was already evening? Maybe he had to run baby errands? Don’t remember.) Then I went into my rooming in room and spent the rest of the night up with the baby, because she couldn’t settle. I didn’t leave the ward very rested, needless to say. With the next two babies, I made the conscious decision to put myself first, and make sure I got the rest I needed at night (I still nursed all day and the second night, but the first night I gave to myself. ) It made a huge difference to my recovery and my mental state. I didn’t feel any of the depression with the other babies.

      • Shmuel Yonah says

        “Twins cannot be attended to simultaneously, even by the mother at home. One of them will have to cry a bit while waiting their turn to be fed or changed- would you suggest that such crying will scar the babies for life? ”
        As a father of twins, I can confidently say that it is entirely possible to feed two newborns at one time. Trust me, I spent more time doing this than I can remember. Which is probably more due to a complete lack of sleep for the first two months rather than poor memory. If the mother is breastfeeding, she has two breasts and there are multiple positions in which she and the babies can arrange themselves to conduct a double-barreled breastfeeding. If the mother is unable to breastfeed or chooses not to, then either parent simply sits loosely cross-legged, takes one kid in the crook of one knee, the other in the other knee, and using two hands each holding a bottle, feeding two kids.
        Triplets, on the other hand…

  11. I do still think that rooming-in would be ideal – but only with all the caveats I already mentioned. A lot depends on the condition of the mother, how hard her labour was, how tired she is, and her sensitivity to noise. I’ve read of some women having epidurals and napping during labour – I had no pain relief and by the time I was left alone at 10pm, my husband gone, I had been awake already for over 36 hours. Oh, and my waters broke the night after Yom Kippur; although I didn’t fast fully, I had eaten and drunk in shiurim, so was probably more tired and weak because of that, too. I am also extremely sensitive to noise – after I got home with my son I think we lasted only a few days having him in the same room as us – I was so alert to every little snuffle and snort he made that I didn’t sleep at all. I had to put him in the next room so that I could sleep through the snuffles and get up for the feeding. Other women co-sleep for months and it is wonderful for them, but I would have been dead from sleep deprivation within weeks!

    Noa – it is interesting that there are less nurses on a maternity ward at night. If anything, I’d think it would be better to have more nurses on at night than during the day. They’re dealing with a population that is exhausted and in pain from labour, with a major new responsibility to deal with, the responsibility doesn’t end at night if you are rooming in – and that’s something that is much harder at night when they are even more tired and need to sleep. Also, I personally am a very obliging, people-pleasing kind of person and if a nurse tells me I should do something myself, it’s not easy for me to turn around and say “no, you do it, i’m not capable right now.” The nurse that came to me was not telling me to change the meconium nappy because she had to go and do something else, she was seeing it as a teaching moment – but a teaching moment at 3am when I haven’t slept for over 36 hours and have just been through labour and it’s the middle of the night -isn’t really a teaching moment. Plus, the necessity of teaching any mother how to change a meconium nappy is debatable – it’s vastly different from a regular nappy and is not going to happen again.

    I think your suggestion of building a drywall between the two sections of each ward is a great idea. Sharing a room when your baby is not in there all the time is one thing but sharing when you’re rooming-in seems a recipe for disaster to me. Are there any single rooms at Ein Karem? I ask because at one point when I was at the hospital but not yet in active labour they sent me and my husband up to a room on the maternity ward and it had only one bed in it, so that seemed to be a single room. I’d pay a lot to get that room next time!

  12. Sadly, there really aren’t single rooms. While we were under construction there were a few tiny cubicles that were used as rooms temporarily, but not anymore. We probably put you in the breastfeeding room or something to give you privacy instead of making you labor in the hallway. The matter of how many nurses are assigned to each shift is decided by no less than the Ministry oh Health – even the hospital doesn’t get to choose, let alone each indovidual ward.

  13. Noa, this is a really interesting post, and I think you did some really good things. However, I have two issues. One is that formula is NOT like medication, and telling mothers that it is, is at best not useful and at worst extremely harmful.

    That is not the biggest problem, though. What you describe is not what is going on, and is being pushed, in NYC. The idea here is not just to make it as easy for the nurse to help the mother as to get formula. *That* is an excellent idea. The idea is to make it *difficult* for the nurses and mothers to access formula. This is being explicitly stated by advocates of the program. They saying “We are going to respect the choice of the mother.” But then they say things like “The key to getting mothers to nurse is to make formula hard to get.” We are not just talking about having the nurse spend a couple of extra minutes / walk down the hall. We are talking about applying the same procedures to FOOD (yes, formula happens to be FOOD), as to medications. It’s bad enough when you have to wait 20- 30 minutes to get an aspirin that the doctor has already prescribed(and that really does happen!) Having that happen with a hungry baby is NOT a good thing. And, it’s going to happen if you handle the formula in the same way as medication – after all, the key to the medicine closet is not suddenly going to be distributed to more nurses, and the overhead of making a full notation on the patient’s chart (which is part of the requirement) is not going to get less.

    And, that is assuming that the hospitals implement the “education” piece with some sense. That’s not a given in any hospital that I’ve ever had to deal with, and I’ve dealt with more than one.

    Yes, I agree that hospitals should NOT be pushing formula and should not be promoting formula advertising. Also, hospitals should actively help mothers nurse – by helping them with other tasks, by having patience with the “fumbles” of a new mother especially with nursing, by having GOOD lactation consultants available, and by not “over medicalizing” nursing. Helping new mothers nurse is a GREAT idea. But, trying to force the issue by breathing down women’s backs, and making it hard to get at formula is not the way to do it.

    In fact, in my opinion, if a key really is making it hard for the mother and nurse to get formula (and making the nurse justify giving formula on “medical grounds”) you are doing a TERRIBLE job of training your staff and giving women what they REALLY need. (You may artificially drive nursing rates up, but odds are that within two weeks, you won’t see any difference.)

    (I’m using the generic “you”, not “you, Noa from Israel”)

  14. Observer, if you read you will see that for mothers who are exclusively formula feeding for whatever reason, we will give them a few bottles and artificial nipples at a time, to ensure that they don’t have to go looking for a nurse at each mealtime. The mother will notice when the bottle supPly is low and receive more, much as she’d need to do at home, notice that her formula supply is low in advance. Secondly, all nurses have the key to the medication room, it’s encoded onto our ID cards magnetic strip. No baby will have to wait 20-30minutes for food. Sorry, that is just more hyperbole. We have made the formula less accessible, much as they are doing in NYC . And I haven’t seen a baby starve yet, or heard from a mother who feels she was forced to breast feed. And we’ve been at this for three years now. I think it’s a matter of reframing your expectations – the new and unknown seems scary, which is the point of this blogpost. To give you a real-life example of what happens when this scary unknown actually occurs successfully.

    • Why the vitriol? Observer is not talking about you, she’s not talking about your hospital. There’s no way on Earth she could have made it clearer that she’s talking about NYC.

      I think an apology is in order. Your agenda has apparently messed with your reading comprehension.

      I’ve waited two hours for prescribed fentanyl that was 12 feet away in a lock box. Food’s almost certainly not going to take precedence over the level of pain that requires fentanyl, and the extreme physiological stress that withdrawal brings.

      I’ve seen women told “He’ll latch when he’s hungry enough”, I saw an 18 year old sobbing in agony for 48 hours, nipples cracked and bleeding from baby’s odd latch, being told she was a “Silly little girl”, and “a lazy mother” because she wanted to rest her breasts by using formula for one night.

      Judgement, shaming, and scare stories don’t make women breastfeed, it makes them feel bullied and overwhelmed. If the attitude of some LCs, that one drop of formula will taint and sicken the baby, means mama has nothing left to lose (in her eyes) by switching to formula.

      • Baraska – I don’t see where my response contained hatred and vitriol. I simply corrected two inaccuracies in her comment – as far as I understand mothers who choose to formula feed in new York will also be given access to batches of formula instead of looking for the nurse each time, and the fact that all licensed nurses are allowed access to the medicine room. I stand by my statement of reframing your expectations: If until now we (and I mean all mothers/nurses in hospitals) have been abke to get formula without thinking about it, now we will have to think about it in advance. That extra step of thinking about it is designed to make the intelligent nurses (and I agree, not all are) think about whether the formula is the right step for this mother-baby dyad. If its a mother who has already stated she definitely wants to formula feed, then the answer to “Is this the right step” should be “Yes”.

        • It would be nice if you would stop repeating incorrect information about the original proposal, the reality in NYC hospitals and what my position is.

          To repeat, as others have stated women ARE already sometimes being bullied into nursing. This is a fact not a “conjecture” or something we are afraid “might” happen. It DOES happen.

          As others have noted, it routinely takes at least half an hour to get SIMPLE medications, and sometimes even more. The reason for this is not important. This is a FACT. And, as others have noted, there is no reason to believe that nurses are going to behave any differently with formula than any other item in the locked medicine cabinet.

          As was also noted, this not just about women who decide in advance that they are going to bottle feed, but women who want to try nursing. These women will absolutely NOT be getting batches of formula in advance. They are going to have to ask for formula as they need it, and if the formula is going to be in a locked box, there is no reason to believe that it’s going to show up any faster than any medication.

  15. As I said, whet you are doing in your Hospital may be working – I’ll take your word for it. But that is VERY different from what is happening in NYC. Yes, there ARE women who felt bullied into nursing. And, I can tell you from first hand experience that it DOES regularly take 20-30 minutes (and sometimes more) for things as simple as Tylenol. This is such a widespread problem that one OB advised women in a public forum to bring their own Tylenol or Advil so that they are not stuck waiting for pain relief.

    I’ll also repeat that proponents of the plan originally explicitly stated that one of the reasons for the new initiative (locking away the formula) was to make to difficult for the nurses to get the formula. They specifically stated that they do not want the nurse to be able to walk down the hall and get a bottle of formula (most hospitals have removed the formula from the bassinets a while ago.)

    They’ve been forced to back away from the locked box, mostly for the simple reason that in NYC, anything that needs to come from a locked box is going to take a while to show up. If a mother needs that extra bottle, then this is a VERY bad thing. I have no intention to “reframe my expectations” to find this acceptable. Nor do I have any intention of ignoring reality in the name of “nursing friendliness.” There are better ways to do this.

  16. i don’t have a strong position on this either way. but i think that bloomberg’s initiative is being misrepresented. i was listening to one morning radio show and woman after woman called in to complain that (for various reason) it is wrong to take away formula from new mothers. they don’t seem to understand that it is till an available option.

    “There is also a hygiene issue: Formula bottles are meant to be used only once, because leftover formula harbors bacteria. But mothers would open the bottle at 20:00 and keep offering from it all night long!”

    i’m skeptical about this.

    • You’re skeptical about the bacteria. or that the mothers are doing it? Here are the WHO guidelines for safe preparation and consumption of formula. It says to throw out all leftover formula after offering to baby. Babies are of course much more vulnerable to infection. http://www.who.int/foodsafety/publications/micro/PIF_Care_en.pdf

    • There are a number of solutions to the problem of bottles being kept too long once they are opened. This initiative, though, is likely to make things worse, because many parents will want to save themselves the inconvenience of having to call the nurse, possibly having to wait for the nurse to show up and then have to wait for the nurse to get the formula. Better to provide a smaller bottle, with an explanation of why this is being done.

  17. Observer,
    I don’t know what is being done in NYC, but in my hospital if a mother has stated that she will be formula feeding we give her a bunch of bottles in one go (like 5 or 6) so that she doesn’t have to find us for each feed. In terms of the size of the bottles – they are provided free of charge by the manufacturers who know full well that 90 ml is too much for a newborn meal. They are banking on breastfeeding mothers giving their babies huge amounts of formula in order to undermine the breastfeeding. If they wanted to provide more appropriately sized bottles they could. I have heard of other companies offering slightly smaller ones (60 ml) which is still too much for a 1-2 day old baby

    • It’s good that mothers who know that they are going to bottle feed get batches of formula. (I’m not sure that it would be considered acceptable under the new guidelines, but that’s a different issues.) However, this does not hold true for women who have stated a preference for nursing. Those women ARE going to have to ask for each bottle. That’s a very real issue.

      As for putting the blame on the manufacturers, I think that’s a total cop-out. The hospitals can either stop accepting free gifts from the formula companies (a good idea, in any case) or only accept formula in smaller bottles. Lets face it. If this were ANY other item, no one would find it acceptable to use something inappropriate to patients, just because someone wanted to advertise by giving “free gifts” to the patients. Why should we accept it for formula?

      • Michal Levy says

        Observer, that is because formula isn’t seen as medication. I agree that it should be treated as such. In my ideal world, formula would be available by prescription only and it would be free.

  18. Difficulties for women who choose to formula feed under such a system must be weighed against the fact that free and easily accessible formula leads to unnecessarily supplementation and the harm that this causes to public health. It’s the constant question–we don’t want mothers who decide to feed formula to feel like they are bad mothers. They face real challenges. On the other hand we want a public health policy that supports optimal health for newborns, and formula feeding in the early days increases the risk of illness in the short and long term. It’s not only because it might affect breastfeeding in the long term.

    • Michal Levy says

      Was that a response to me?
      I think a prescription will make the treshold to formula feed higher.
      I think formula should be free for 2 reasons:
      1. IMO it’s unfair that a woman who can’t breastfeed has to pay so much money to feed her baby
      2. Making formula free, would hopefully stop the horrble formula marketing.

  19. “This is from an e-mail I received from the mayor’s office:”

    The email from the mayor totally did not address the issue of locking formula away, nor explicit statements about the need to make formula inaccessible. The phrase “we will support the mother’s decision” is meaningless.

  20. Here is a link to a fact and myth document put out by Latch On NYC


    No one is locking up the formula. All you need to do is ask for it. The big deal really is that you will no longer be given free samples when you go home and I think that is amazing. I nursed my first child for only 3 month and part of my problem was the very can of formula that I had been given as a “gift”.

    Everyone seems so obsessed about not making mothers feeling guilty about formula feeding as opposed to those who want to breastfeed but are undermined by free formula. I personally believe (and yes it may seem to be a radical idea by some) that before a mother makes a decision to formula feed that she should receive full disclosure about the disadvantages of formula feeding for both mother and child. A good place to start would be the AAP’s statement on Breastfeeding and the Use of Human Milk:


    • What that release fails to note is that it was released AFTER some changes were made, the most important one being to the change to the lock-box policy. That information is no longer on the NYC site, of course, but that was absolutely part of the plan.

      I agree that parents should not be given “gift packs” with formula- and most hospitals have had a policy for a long while, of not giving them to parents who have expressed an interest in nursing. This new policy had nothing to do with it.

      In my opinion, if we want to encourage parents to nurse we need to rethink our approach. Most mothers are quite aware of the benefits to nursing, and very few that I know stopped because they thought that it REALLY made no difference. Lecturing them is not going to change much. What will help are some practical changes.

      Nurses are still woefully ignorant about nursing. Some of the other posters have mentioned examples. One that I just witnessed a few weeks ago. My daughter just had a baby, and the infant was eating quite nicely. She latched on minutes after birth (and both I and my daughter know what a proper latch looks and feels like) and was sucking actively, and it was clear that she was swallowing. She was also having the appropriate number of diapers in the 24 hour period. However, one of the nurses was badgering my daughter to feed the baby more often, because she had not had a diaper during HER (the nurse’s) 3 hour shift. This kind of stupidity is not going to help new mothers, and could easily make it harder for new mothers to develop a successful nursing relationship. Training the nurses, and making pain relief easily available are probably the two most important things hospitals can do to help new mothers, at least in NYC, where formula has not been put in bassinets or given to mothers who want to nurse (at least officially) for quite some time. (Of course, making sure that the nurses follow policy is important here…)

      Post hospital, the main policy issue is making it easier for women who work out of the home (more often than not, not by choice) to nurse and pump. I was fortunate that my working conditions made it relatively easy for me to fully nurse my older ones, and pump enough for the younger ones not to need formula. But, I know many women who are not so fortunate. And, it’s quite clear that my experience is not an anomaly.

      Of course public eduction to help create an over-all more supportive environment would be good, too, but I think that concrete changes in the workplace are of more direct benefit, and could also help reshape the conversation in a healthy way.

  21. In looking for something else, I came across this app that is supposed to help parents track their nursing, called “iBaby Feed Timer”. It’s no big deal but the reason the parents looked for the app in the first place does concern me. ” at which point I took over scribbling each feed in a paper log provided by the hospital. Stuff like: when feeding began, at which breast, how long the feed lasted, what was in the diaper afterward and more. Twenty-four hours of logs scrawled by a guy with atrocious penmanship prompted me to poke around the App Store, which turned up iBaby Feed Timer, an elegant $1.99 app that makes tracking breastfeeding a cinch, with perks.”

    Of course, if this kind of thing makes a mother feel more comfortable, or if there is really reason to suspect a problem, this kind of thing is great. But to make this a norm? Please! It’s a huge amount of pressure, and it’s generally not necessary. And it can be quite misleading: The normal range for most aspects of nursing is huge, and diaper output doesn’t always track that closely with feedings; its what happens over a 24 hour cycle that matters, not after any given feeding.