Why Swedish Midwives Say Unnecessary Baby Formula Is an Emotional and Professional Battle

Formula supplementation of breastfed newborns without a medical reason is officially discouraged in Swedish postnatal care, yet it happens on a striking scale. National figures show that between 20 and 40 percent of infants on postnatal wards receive formula, with an average rate of around 30 percent, even though early supplementation is consistently linked to reduced breastfeeding exclusivity and shorter breastfeeding duration. A new qualitative study from southern Sweden, published in Frontiers in Global Women’s Health, offers one of the first in-depth looks at how the midwives responsible for breastfeeding support actually experience these decisions, and the picture that emerges is one of moral strain, inconsistent ward cultures, and quiet negotiations at the bedside.

The research team, led by Pernilla Ny of Lund University together with colleagues at Kristianstad University and Skåne University Hospital, interviewed eleven licensed midwives working on three postnatal wards in a single Swedish region. The interviews, conducted between November 2024 and April 2025, lasted between 18 and 49 minutes and were audio-recorded and transcribed verbatim. Using an inductive qualitative content analysis, the researchers allowed categories to emerge from the data rather than testing predefined hypotheses. The participants ranged in experience from one to 35 years, with a median of three years, and about half had completed advanced-level breastfeeding education, while all had undergone workplace-based training and some held specialist lactation consultant credentials.

Three main categories crystallized from the analysis: workplace culture is crucial, negotiating infant feeding decisions, and moral and professional tensions. Together they suggest that non-medically indicated formula supplementation is not simply an individual clinical error or a matter of parental preference. Instead, the authors argue, it is produced at the intersection of organizational culture, professional competence, interprofessional communication, and the relational dynamics of encounters with new families. Where teams shared a common breastfeeding-supportive understanding, supplementation was perceived as less frequent and more clinically justified; where that consensus was absent, formula provision became normalized and drifted outside established guidelines.

The midwives described concrete mechanisms behind that drift. Supplementation sometimes occurred without the indication or even the intervention itself being documented in the infant’s medical record. One participant explained that when formula was used merely to encourage the baby during breastfeeding, it was not always written down. Infants perceived as unsettled, jittery, or breathing rapidly were occasionally supplemented without further evaluation or physician consultation, even when guidelines indicated that waiting was appropriate. Another participant described a kind of random giving of formula with no real structure and no specific reason, attributing it to stress, lack of time, or, at times, lack of interest in breastfeeding support.

Knowledge levels emerged as a decisive factor. Wards that regularly provided internal training on breastfeeding fostered a shared understanding among midwives and assistant nurses, leading to more reflective decision-making and greater caution before initiating supplementation. Participants said such training made them think more carefully rather than supplement automatically. In contrast, in settings without structured education, variability in practice was greater, and formula could sometimes be given by other staff without consulting the responsible midwife. Professional dialogue also mattered: when colleagues discussed supplementation decisions, the outcome was often more considered, and in some cases supplementation was avoided altogether. Midwives noted that it takes professional security to question a physician’s decision, something a newly graduated nurse might lack.

The second major theme concerned the delicate relational work of negotiating feeding decisions with parents. When parents requested formula, midwives tried to explain what introducing it could mean for breastfeeding outcomes, and they asked about the reasons behind the request to tailor their support. This was not always straightforward. Parents who lacked prior knowledge about breastfeeding or held unrealistic expectations of newborn behavior, such as expecting babies to sleep for long stretches, were harder to inform, and postpartum fatigue and emotional vulnerability could further limit how much information they could absorb. The midwives saw their ward-based actions as setting the tone for what parents would continue doing at home, and they observed that when formula appeared to calm an unsettled infant, parents often perceived it as an effective solution and became more likely to request it again, reinforcing a cycle that can erode breastfeeding confidence.

The third theme revealed the emotional cost. Midwives described frustration, sadness, and professional discomfort when supplementation occurred without medical indication, with one participant recalling that giving formula initially felt wrong, like the last thing she wanted to do. Because breastfeeding support is explicitly written into the Swedish midwifery scope of practice, supplementation without medical justification can feel like a departure from the core values of the profession. The participants actively resisted non-indicated supplementation, describing it as something they constantly had to work against, and instead mobilized the resources already present in the mother-infant dyad, for example by helping mothers hand-express colostrum or optimizing breastfeeding technique rather than reaching for a bottle.

The authors place these findings in a broader context. Breastfeeding carries substantial short- and long-term benefits for both mother and child, including reduced maternal risk of breast and ovarian cancer, cardiovascular disease, hypertension, and type 2 diabetes, and lower infant risk of respiratory and gastrointestinal infections, otitis media, obesity, type 1 diabetes, and sudden infant death syndrome. The World Health Organization recommends exclusive breastfeeding for the first six months of life. In Sweden, breastfeeding intention is remarkably high, with 95 to 99 percent of first-time mothers reporting that they intend to breastfeed, yet less than 72 percent of infants are exclusively breastfed during the first week. The gap between intention and early practice is precisely where postnatal ward routines exert their influence, and the study suggests that supplementation is sometimes used as a pragmatic response to clinical strain rather than infant need, a pattern the authors find concerning given the Baby-Friendly Hospital Initiative’s emphasis on organizational responsibility for breastfeeding-promoting care.

The study also situates infant feeding within a rights framework, connecting breastfeeding to the Right of the Child Act, Sustainable Development Goal 3 on healthy lives and well-being, and Swedish gender equality goals affirming women’s right to give and receive care on equal terms. The authors draw on the theory of professional midwifery articulated by Halldorsdottir and Karlsdottir, which holds that competence, judgment, caring, and interpersonal skill can only be integrated within a supportive practice environment. In other words, even where midwives possess the necessary expertise, organizational conditions may prevent them from practicing in accordance with evidence and professional standards. The researchers acknowledge limitations, including convenience and snowball sampling that may have attracted participants with a strong interest in breastfeeding, data collection limited to one region, and the fact that only midwives’ perspectives were captured, leaving the views of nurses, physicians, and assistant nurses unexplored.

The practical implications are clear. Reducing non-medically indicated supplementation, the authors conclude, requires not only individual professional commitment but organizational support for coherence, a clearly defined leading role for the midwife in breastfeeding support, regular interprofessional training, clear local protocols, and structured team dialogue. Organizations must ensure midwives have the authority, time, and backing to lead breastfeeding-promoting care and to challenge supplementation that lacks clinical justification. Timely, realistic information about newborn behavior, breastfeeding physiology, and the consequences of supplementation should ideally be offered during pregnancy, particularly given short postnatal hospital stays where early experiences can shape feeding practices long after discharge. Strengthening breastfeeding-promoting postnatal care, the study suggests, is ultimately a systems problem, not merely a matter of individual conviction at the crib side.

Subject of Research: Midwives' experiences of non-medically indicated formula supplementation in Swedish postnatal care

Article Title: Midwives’ experiences of formula supplementation for non-medical indications in the Swedish postnatal care context

Article References: Ny, P., Khalaf, A., Dowler, T., Karlsson, L., & Thies-Lagergren, L. (2026). Midwives’ experiences of formula supplementation for non-medical indications in the Swedish postnatal care context. Frontiers in Global Women's Health, 7, Article 1893484. https://doi.org/10.3389/fgwh.2026.1893484

Image Credits: AI Generated

DOI: 10.3389/fgwh.2026.1893484

Keywords: breastfeeding, formula supplementation, midwifery, postnatal care, infant feeding, qualitative research, Sweden, Baby-Friendly Hospital Initiative, moral distress, maternal health, lactation support, healthcare policy