SINGAPORE, Sept 23 — Ethel Yap, 36, who has a four-year-old child, remembers "feeling like a failure” when she resorted to feeding her son formula milk within the first week of his birth.

Surrounded by positive breastfeeding experiences from the other mothers in her family, the singer-songwriter thought that nursing her son would be easy when the time came.

However, without a supply of breast milk by the time her newborn was discharged from the hospital, she had to turn to feeding her son formula milk for a while.

"It was a massive, massive hit to me, because within the first two days of his birth, already my supply was just not coming in fast enough, and he was getting jaundice, his urine was crystallising, and all these horrible things.”

Later, even as her breast milk supply started flowing, Yap found that she had trouble getting her baby to latch for feeds.

"I was very, very depressed that we couldn’t exclusively latch,” Yap said, referring to the practice of feeding one’s child directly from the breast, as opposed to feeding expressed breast milk through a bottle.

"So even though it was sort of a half-latching-half-pumping routine, I just felt like a failure every time I had to pump, every time I had to bottle-feed him.

"My mind kept drifting to thoughts such as, ‘The only reason why my son is still alive is because we live in modern times, when formula has been invented and breast pumps have been invented. But if we were living in an earlier time... my son would have died because the latching was unsuccessful.’

"And I really tortured myself with these thoughts.”

The pressure she felt to breastfeed was compounded in part by reading and watching social media content of other mothers showing how much they had pumped, how big their stash of extra breast milk was, or pictures of their child latching in what was portrayed as a "beautiful bond” between mother and baby.

"Breastfeeding and struggling to latch my baby was quite a big contributor to the initial stages of my postnatal depression and my postnatal anxiety, which I had for 18 months,” recalled Yap, who is also a theatre actress and art educator.

The third National Breastfeeding and Child Feeding Survey — done by the Health Promotion Board (HPB) between October 2021 and February 2022 — found that 97 per cent of mothers here breastfed their babies at some point.

A decade before that in 2011, the national survey found that 96 per cent of mothers breastfed their babies at some point, similar to the 95 per cent in 2001.

Despite the high prevalence of mothers attempting to breastfeed in Singapore, the surveys found that the proportions of mothers who exclusively breastfed, or who were still breastfeeding their child six months after birth, were significantly lower.

The 2021 survey found that 46 per cent of respondents exclusively breastfed their infants aged zero to three months. The proportion fell to 35 per cent of respondents for those who were breastfeeding their infants aged four to five months.

And six months after giving birth, 3 per cent of mothers were exclusively breastfeeding their child.

Several mothers interviewed by TODAY said that while they were aware of the benefits of breastfeeding, it was not always easy in practice.

Some women said they struggled to produce enough breast milk for their child while other working mothers told TODAY that continuing to express milk when they returned to work was cumbersome.

Across the board, however, the women said that they could not help but felt a twinge of guilt when they chose to stop breastfeeding or were unable to breastfeed their child.

Tsuraiya Zakaria said that she felt pressured when she struggled to breastfeed her newborn.

The 33-year-old entrepreneur and mother of two recalled how when breastfeeding her firstborn, who is now five years old, she had blocked milk ducts and a low initial breast milk supply.

"I truly felt the pressure as a first-time mum, with the nurse emphasising that my son’s diaper was dry, which meant that the milk was not enough.

"It did take a mental toll on me and I was still healing from childbirth.”

Prevalence of breastfeeding in Singapore

Breastfeeding prevalence rates are high in Singapore now, but this was not always the case.

In 1951, more than 80 per cent of infants here were breastfed for four weeks or more.

By 1978, this figure had dwindled to about 20 per cent, based on a 1986 article published in the Journal of Tropical Pediatrics on Oxford University Press’ academic research platform.

From the 1990s, however, this figure began to climb again.

By the time the first National Breastfeeding and Child Feeding Survey was done here in 2001, 95 per cent of mothers reported trying to breastfeed their child at some point.

Experts attributed the initial decline in breastfeeding between the 1950s and 1980s to two overarching reasons: The rise in the number of working mothers and aggressive marketing by businesses selling infant formula milk.

The subsequent rise in breastfeeding prevalence into the 1990s was a likely result of the participating countries at a World Health Organization (WHO) meeting in 1990 accepting the Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding.

The declaration recommended that breastfeeding be initiated within the first hour of birth and babies be exclusively breastfed for the first six months of life.

A year later, WHO and Unicef, which works with the United Nations and its agencies on matters related to children, launched the Baby-friendly Hospital Initiative (BFHI) as a global effort to introduce pro-breastfeeding practices and to ensure that maternity units were equipped to provide breastfeeding support to new mothers.

On its website, WHO states that breast milk is the "ideal food” for infants because it is safe, clean and contains antibodies that help protect against several common childhood illnesses.

Breastfed children perform better on intelligence tests, are less likely to be overweight or obese, and are less prone to diabetes later in life, the organisation says.

Mothers also benefit from breastfeeding because it reduces their risk of breast and ovarian cancers, it adds.

WHO is now working to increase the global rate of exclusive breastfeeding for the first six months of an infant’s life from the current 48 per cent to at least 50 per cent by 2025.

In Singapore, all public and private maternity hospitals are either BFHI-certified or adhere to best practices, said the Health Promotion Board (HPB) in response to TODAY’s queries.

Some of the guidelines for BFHI-certified hospitals include facilitating the initiation of breastfeeding as soon as possible after birth, supporting mothers in maintaining breastfeeding, and managing common difficulties through to post-discharge, added HPB.

Linda Wee, 63, a retiree, said that in her time when she had her firstborn in 1987, her baby was fed formula milk immediately after delivery, so she just hunted for the same formula after she was discharged from hospital.

By the time her second child was born in 1990, there was some information circulating and people were starting to say that breastfeeding the baby was good, she recalled.

So she tried to breastfeed her daughter but stopped after a week or two because she had no or low breast milk. In between, she was supplementing the feeds with formula milk.

"The pressure was from myself. I just felt that I should breastfeed her. My daughter came out one week earlier so she was born rather small. I thought it would help boost her weight and immune system. So the pressure came from myself. My parents, my parents-in-law never said anything about breast milk.”

She discontinued breastfeeding after a while.

"Back then in my time, we didn’t have these lactation consultants or whatever. So for young mothers these days, without getting all this help, they will feel pressured wondering why they cannot breastfeed their babies,” Wee said.

Societal push that breast is best

The global push in favour of breastfeeding, beginning in the 1990s, has led to the widespread adoption of the belief that "breast is best”.

For some mothers, they started to feel an implicit pressure to breastfeed and a subsequent sense of having "failed” when their own breastfeeding journeys were not smooth and did not measure up to what they understood to be the standard journey of a new mother.

Gwendolyn Toh who has three children under five years old, including a three-month-old infant, said that breastfeeding was "challenging” for the first child, when her milk supply took longer than expected to start.

"I’ve heard that breast milk can take around four days to kick in, but for me, it was more like a week plus,” the 30-year-old graduate researcher said.

"It was very stressful hearing (my) baby cry and thinking that he was not getting enough."

"I ended up getting some breast milk from a friend who had given birth around the same time, but it was difficult to see my baby gulp down that milk hungrily,” she said, adding that it made her "feel like a failure”.

She eventually overcame such a mindset when she found peace with nursing her baby at her own pace.

"I think there is this societal push that as a mother, you need to breastfeed.

"I have come to terms with accepting that my journey with breastfeeding is my own and it is not important what others expect me to do. I have to follow my own pace and do what works for me.”

Breastfeeding a natural act but also a learned skill, say experts

Lactation consultants told TODAY that new mothers can be harsh on themselves when it comes to breastfeeding, especially when they forget that they are doing something new to them.

Eliza Koo, an international board certified lactation consultant and founder of her own lactation consultancy Tender Loving Milk, said: "The misconception that breastfeeding should come naturally and easily, when it may not, may shock many new mothers.

"Breastfeeding is a natural act (but) it is also a learned skill for mothers.

"In (our) society, we’re simply not exposed to breastfeeding as children, so we grew up not knowing what’s normal or abnormal with breastfeeding a baby.”

Although lactation support is offered in hospitals here to parents after their children are born, most families may not get the dedicated attention they need to learn fully from the lactation nurses due to time constraints, Koo explained.

"It is a huge challenge for families to learn about breastfeeding within a short period of time — usually 10 to 15 minutes (in the hospital environment), for example,” Koo added.

Generally, healthy full-term babies are born with the innate ability to breastfeed. For most mothers, producing breast milk is also a naturally occurring process after she delivers her baby and the placenta, or the temporary organ in the womb that feeds the baby.

However, some women — a small group — may have diagnosed health conditions that can increase their risk of low milk supply. These conditions may include hormonal imbalances, autoimmune diseases, consuming certain medications, or having had breast surgery, Koo said.

Lactation consultant Jessica Wong from Oriental Jamu, said that having tuberous breasts — a congenital condition that results in an irregular breast shape — may also affect a mother’s ability to produce an adequate milk supply.

Can't run away from social media, guilt

Experts said that the mounting anxiety and internalised pressure to breastfeed that some women experience may be a result of certain online depictions of motherhood, and they were possibly comparing themselves to other positive breastfeeding experiences that they see on social media channels.

Ong Hui Tze, a lactation consultant and founder of postnatal services firm My Milkie Way, sees an average of about 20 clients a month.

"Among the breastfeeding mums I support, most are overwhelmed because breastfeeding has not been what they visualised, as social media shows relaxed mums feeding babies, or mums displaying the many bags of expressed breast milk in their freezers.

"As with everything else, people tend to always compare themselves with others, which inevitably causes unnecessary stress,” she said.

If not addressed, a build-up of such pressure may eventually lead to adverse ripple effects on the mothers’ mental and emotional health.

Last December, a 33-year-old Singaporean woman was found dead at the foot of a public housing block, about a metre away from her three-week-old son.

An Aug 6 report by news channel CNA on the coroner’s inquiry into the incident revealed that those around the woman had suspected that she was suffering from postpartum depression.

The mother had reportedly felt overwhelmed about being unable to take care of her newborn son and was worried about his persistent jaundice and her own struggles with pumping enough breast milk.

Medical experts told TODAY that anxieties around breastfeeding — including worries about establishing or maintaining breastfeeding — can contribute to a woman’s mood disorders after giving birth, such as postnatal depression and postnatal anxiety.

Qi Zhai-McCartney, a psychotherapist and counsellor at psychological services firm Alliance Counselling, said that at least 20 to 30 per cent of new mothers among her own clients do raise some kind of breastfeeding issue or concern.

After all, breastfeeding is time-consuming and not always convenient, and exclusive breastfeeding for the first six months of the baby’s life can mean interrupted sleep for the mother.

Head of NUH’s department of psychological medicine, Dr Cornelia Chee, said that some women may have mental health conditions that deteriorate rapidly with sleep deprivation, for example.

Dr Chee, who set up the Women’s Emotional Health Service at NUH in 2008, said that hospital staff work with each mother to assess her situation, and may propose a workable arrangement such as partial breastfeeding during the day, if the impact of night feeding is likely to affect her mental health negatively.

"In such cases, ‘something is better than nothing’ and presents a compromise that allows the mother to still feel she is able to breastfeed, thus avoiding too much guilt, and she may get the sleep recovery she needs,” Dr Chee added.

Dr Chua Tze-Ern, senior consultant and head of the women’s mental wellness service at KK Women’s and Children’s Hospital, added that though wonderful, breastfeeding is often a "labour of love” and comes at a "cost” to each and every mother.

"It costs a mother time, energy, effort and sometimes, even pain. The pain could be physical from engorged breasts and cracked nipples, or emotional from anxiety, self-doubt, and in some cases, past trauma,” she said.

HPB: Infant formula a "viable alternative" if breastfeeding not possible

Gone are the days of aggressive direct-to-consumer marketing by infant formula milk companies. On the contrary, e-commerce sites selling infant formula milk in Singapore today display pop-ups that require buyers to acknowledge that "breast milk is best for babies”.

In response to queries by TODAY, the Health Promotion Board (HPB) said that all stakeholders, including online retailers, are obligated to adhere to the Code of Ethics on the Sale of Infant Foods in Singapore. Retail products within the Code’s scope should display advisory statements on the importance of breastfeeding.

HPB added that asking consumers to acknowledge such pop-ups are not a requirement under the Code.

This Code is aligned with the WHO’s International Code of Marketing of Breast Milk Substitutes and covers the "proper and safe use of breastmilk substitutes when necessary” and its appropriate distribution practices in Singapore.

Similar statements on the benefits of breastfeeding are likewise displayed on the packaging of stage 1 and stage 2 infant formula products meant for children up to 12 months.

On how the nutritional benefits of infant formula milk compare to that of breast milk, HPB said that "optimal breastfeeding practices are recommended in the first instance, in line with WHO’s recommendation”.

Nevertheless, where exclusive breastfeeding is not possible, infant formula is a "viable alternative”, said HPB adding that all formula sold here, regardless of price, meets the safety and nutrition requirements to provide sufficient nutrition for infants to grow up healthy.

HPB said that while breastfeeding guilt is a common feeling among mothers who face challenges with nursing, every mother’s journey is unique.

"It is important to acknowledge that mothers should not need to feel guilty for choosing the most appropriate feeding option for her baby that best suits her circumstances,” said HPB.

Look at a mother's overall well-being

While the evidence on the benefits of breastfeeding is clear, this recommendation should be considered holistically within the broader context of a mother’s overall well-being, said experts.

Dr Chee said: "While we will always have the stance that breastfeeding can and should be the first-line for babies where possible, we also need to balance this against the individual mother’s unique circumstances and mental health constraints.”

Zhai-McCartney the counsellor agreed.

"My advice is that all things being equal, ‘breast is best’, but it’s most important to do what is ‘best for you’. A happier, better-rested, more physically comfortable mother can better meet the needs of her child. Striving to meet a certain ‘standard’, even if it’s set by reputable international organisations and suffering through it isn’t ‘best’. In a sense, it misses the point.

"No organisation has ever recommended ‘breast is best even if you’re physically or mentally suffering, if you’re exhausted, if you’re cranky and reactive toward your baby as a result of trying to slog through breastfeeding’,” she said.

Society at large should also help to promote a more nuanced view of the ‘breast is best’ approach, Zhai-McCartney added.

"A better message is one that values maternal emotional and mental well-being as being critical parts of what is ‘best’ for a child.

"This includes educating our family members and peers to avoid explicitly or implicitly pressuring mothers to breastfeeding.”

Beyond this, gender experts told TODAY that the culture around breastfeeding is also emblematic of the wider issue of "one-size-fits-all” standards being imposed on women and mothers.

Sugidha Nithiananthan, director of advocacy, research and communications at the Association of Women for Action and Research (Aware), said: "Women are often expected to live up to idealised, one-size-fits-all notions of motherhood, leading to judgement in many aspects of their lives, whether it’s how they give birth, how they feed their babies, or how they balance work and family.

"These societal expectations can be overwhelming and harmful, particularly when they ignore the diverse experiences and challenges that women face.

"The pressure that some mothers face to conform to a single ideal of motherhood, such as breastfeeding, adds unnecessary stress during an already challenging time of recovery and adjustment.”

To strike a better balance, it is crucial for society to reduce the pressure on mothers by being supportive and non-judgemental, regardless of a mother’s decision to breastfeed or not.

"What truly matters is that mothers feel empowered to make informed decisions, with full support from their communities, healthcare professionals and their workplaces,” Sugidha added.

And just as women should not feel pressured to breastfeed at the expense of their own emotional health and well-being, empowering them to make their choice also means ensuring that there are enough resources provided to support the mothers who do still wish to breastfeed.

Ultimately, breastfeeding is also a team endeavour and not a solo effort and mothers require a supportive ecosystem, Wong of Oriental Jamu said.

"Spouses and family members need to be supportive, since certain compromises are necessary to accommodate a breastfeeding schedule.

"This might include choosing to go to malls with nursing rooms, dining at restaurants that cater to breastfeeding mothers, and having understanding friends who are willing to meet when it aligns with the mother’s breastfeeding schedule.”

Beyond familial support, some mothers are turning to external support groups.

Toh remembers calling the Breastfeeding Mothers’ Support Group (BMSG) support group’s hotline between 3am and 4am when she first started breastfeeding.

"I was distraught and the counsellor on duty picked up my call groggily. I had woken her up. She was able to calm me down and offered me encouragement and tips. It really made a difference to hear someone calm and knowledgeable on the other end of the line.

"It wasn’t just about getting tips and advice on how to troubleshoot or improve breastfeeding, but also a lot of support and commiserating with other like-minded mothers,” she said of the charity focused on breastfeeding advocacy, support and awareness.

The BMSG told TODAY that it receives an average of 300 counselling queries each month.

All of the group’s counsellors must have had breastfed or are still breastfeeding.

They are trained to provide mother-to-mother support through its channels, which include its breastfeeding counselling phone and WhatsApp lines, a private Facebook group for women, in-person breastfeeding support meetings and workshops.

Its spokesperson said: "As much as possible, we handhold the mother to think about her goals and how realistic they can be in light of their unique conditions and circumstances.

"Ultimately, we want to empower mothers to become good problem solvers... It takes a village to raise a child, but it also takes a village to make a mother.”

Where Singapore mothers can get help

Samaritans of Singapore hotline: 1767

Institute of Mental Health’s helpline: 6389 2222

Singapore Association for Mental Health helpline: 1800 283 7019

NUH Women’s Emotional Health Service helpline: 6772 2037

Breastfeeding Mothers’ Support Group hotline: 6339 3558