Breastfeeding: A Medical Release Form

In accord with the intent of World Breastfeeding Week (Aug. 1-7, 2007) to draw attention to the importance and values of breastfeeding, I submit the following:

“The natural law obliges mothers to nurse their babies with their own milk…This obligation is serious, but admits of parvity of matter if there is a serious reason to excuse and a sufficient alternative is provided.” W. D. Virtue, Mother and Infant, p. 278.

A Form Indicating the Risks of Ignoring Advice to Breastfeed
Prior to having eye surgery, my husband had to sign a release form. On this form, in bullets and in bold face, were 24 serious side effects, many leading to blindness. Because of this list of side effects, my husband went back to his primary eye doctor and discussed these serious side effects and what would happen if he chose not to have the surgery. After these consultations, he chose surgery.

Afterwards, my husband conceived of the idea of translating his medical release form into a form for mothers who choose not to breastfeed. So I took his form and followed the format.

Before I provide the form, it should be said that in a few countries mothers who choose not to breastfeed already have to sign a medical release form stating that they are ignoring the medical advice given to them. Someone recently told us this is happening in Australia. As far as I know, this is not happening in the United States.

Some mothers could take offense at such a form, especially those mothers who tried to breastfeed and were unsuccessful. I have the greatest sympathy for them, and they should not feel bad because they gave it their best try. You do what you can within your abilities or situation.

The release form has been a big hit at breastfeeding conferences. This form could be used for educational purposes, such as teaching a high school or college class. If the form is given to the students, the form needs to be explained but I would not read from it The current research is so fascinating that one only has to point to several diseases on the form and give the research. For example, take diabetes protection for the mother. This would be of interest to a class of girls. Tell them that if they breastfeed their baby for one year, they receive a 15% risk reduction for acquiring type-2 diabetes. Nurse two babies, each for a year, and receive a 30% reduction for acquiring this disease. And this protection lasts for 15 years after the birth of your last baby! That is simply astounding. At least it is interesting research.

The form can be modified. Maybe a teacher would prefer to list the benefits of not using formula or give the risks when formula is used. You have to gear it to your audience. Maybe it would provide a shock value at a medical seminar to motivate doctors and nurses to promote breastfeeding via their own words and via posters around the office.
Somehow we have to get the word out to our communities that breastfeeding is the first choice of feeding our babies and that breastfeeding is normal and good.

The tragedy of not breastfeeding is observed especially in other countries. This June it was reported that 160,000 children die each year in the Asia-Pacific region due to the decline in breastfeeding. According to a recent Save the Children report, it is believed that globally 114,000 lives could be saved monthly if breastfeeding rates were improved. In the Philippines the World Health Organization is seeking the help of the Catholic Church to promote breastfeeding because 16,000 babies die in that country every year due to inappropriate feeding.

What are the monetary savings here in the States if 75% of the mothers breastfed after birth and 50% were still breastfeeding at six months? The savings were estimated for the state of Wisconsin and here are the health care savings for that state if the breastfeeding rates attained those goals:
$4,645,250/year Acute Otitis Media
$437,120/year Bronchitis
$6,699,600/year Gastroenteritis
$262,440/year Allergies
$758,934/year Asthma
$578,500/year Type 1 Diabetes
$17,070,000/year Maternal Breast Cancer

The United States Federal Government has told mothers that their babies are at risk if they do not breastfeed. During these blogs, I have tried to show readers why this is so. Leaving you with that, here is the medical release form. I hope the form does not offend anyone, especially at this time during World Breastfeeding Week.

When Choosing Not to Breastfeed

NAME OF THE BABY:_______________________________________________________

SITUATION: I have chosen not to breastfeed my baby for personal and/or for medical reasons. I understand that not-breastfeeding entails health risks to my baby and to myself. While my formula-fed baby may be healthy, I understand that research shows that breastfed children are overall healthier as babies and also in their later years compared to their formula-fed peers. While I may be healthy now and in later years, I understand that research shows that I may suffer some adverse consequences from not breastfeeding.

RECOMMENDATIONS:* Mothers should do exclusive breastfeeding for six months and nurse for at least one year. Anything less is second best.

ALTERNATIVE: I may choose to use donated breastmilk.

I understand that medicine, breastfeeding, and formula-feeding are not exact sciences. I understand, however, scientific research shows that not-breastfeeding exposes my baby to increased risks of the following diseases:
• leukemia • lymphoma
• type 1 diabetes • obesity
• diarrhea • type 2 diabetes
• allergies • ear infections
• asthma • respiratory tract infections
• eczema • urinary tract infections
• bacterial meningitis • multiple sclerosis
• botulism • inflammatory bowel disease
• gastroenteritis • necrotizing enterocolitis
• Crohn’s disease • ulcerative colitis
• autoimmune thyroid disease • sudden infant death syndrome

I realize my child may have a poorer school performance with lower cognitive scores during grade school and high school. Likewise there might be more doctors’ visits and hospital visits because I did not breastfeed.

By not breastfeeding I understand that I, as the biological mother, may have an increased risk for the following diseases:
• breast cancer • ovarian cancer • lupus
• thyroid cancer • anemia • osteoporosis (increased chance of a hip fracture) • endometrial cancer • rheumatoid arthritis

I hereby certify that I have read (or have had read to me) and understand the possible risks of not breastfeeding my baby, whether by choice or for medical reasons. All of my questions regarding the risks have been answered to my satisfaction.
Mother’s Signature:_____________________________Date:____________________
Witness/Professional Signature:__________________________Date:______________

*The above recommendations and risks are found at the following websites: American Academy of Pediatrics:, American Academy of Family Physicians:, and the U. S. Breastfeeding Committee: See USBC’s “The Benefits of Breastfeeding” and “The Economics of Breastfeeding.”

© 2006 Sheila Kippley. Reproduction permission is given for purposes of breastfeeding education. This release was adapted from the release form her husband had to sign for eye surgery. This one-page form is available upon request.

Message: Please breastfeeding your baby exclusively for six months and continue to nurse for at least one year and hopefully at least two years.

PS: Sorry. It was impossible for me to line up the “side effects” columns properly.

Sheila Kippley
NFP International
Author: Breastfeeding and Catholic Motherhood (Sophia, 2005)
Natural Family Planning: The Question-Answer Book (e-book
at this website, 2005)

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