Breastfeeding incentives in the media spotlight

It all began last night - our breastfeeding peer support line had a call from a Radio 5 Live researcher. As the only BEAR with any previous radio experience (one interview on local radio when my book came out!) I was chosen to return the call. They wanted to talk about this press release from the University of Sheffield, which describes ongoing research into whether a scheme offering voucher incentives to new mothers might work to increase rates of breastfeeding initiation and continuation in areas where 6-8 week breastfeeding rates are very low. Derbyshire is one of the areas the researchers are looking at.

Where BEARS is active, in Amber Valley in Derbyshire, we have areas where breastfeeding rates are very high, and areas where they are very low. Derbyshire as a whole is very committed to breastfeeding: we are aiming to achieve UNICEF Baby-Friendly full accreditation in the community next year. This means that a lot of groundwork in supporting breastfeeding has already been done. We have networks of peer supporters, like BEARS, who run breastfeeding support groups, attend antenatal sessions, go to baby clinics and answer calls on a helpline. We can make home visits to new mums too. We work alongside paid peer supporters, who in the target areas I mentioned above see all new breastfeeding mums on day 3 or 4 after the baby is born. Good statistics are collected and analysed at a county level. All those involved in supporting new mums have had up-to-date training, and we recently had a breastfeeding conference to celebrate our achievements so far and lay out the plan for future improvements. It's important to remember this context when considering whether the incentive scheme might work: here, it would be running alongside all this other support that's already in place. (This point has been overlooked in discussion in the media!)

I hadn't come across the story, so did some digging beforehand to try to prepare for my radio appearance. My first port of call was the University of Sheffield Public Health page on Breast Milk Policy, which explains the idea in more detail. The project, currently in its second phase, looking at the feasibility of the intervention, is a study by researchers - it is not policy, or something that 'will be brought in' as has been widely reported. The page states:

"The results of this study will be used to inform commissioners and other public health decision makers as to the acceptability, feasibility and cost-effectiveness of behaviour change support in the form of vouchers to mothers to breastfeed in neighbourhoods with low breastfeeding rates. If effective, the intervention could have a major impact on the long-term health of the population, reducing the risk of disease in infancy, childhood, and adulthood."

I wanted to get a sense of the rationale for assessing the idea of an incentive scheme. Earlier this week I'd seen the news that toothbrushing in Scottish nurseries, a simple, low-cost public health measure, had shown good outcomes and saved money in dental costs. The University of Sheffield cites other schemes, such as one successful project in Scotland in which pregnant women were given financial incentives to stop smoking during pregnancy, as convincing evidence that it is worth considering whether the approach might be applied to breastfeeding. In my late-night research session I also came across this study by the King's Fund that supported the idea that payment schemes could be used to modify behaviour in a public health context, even if only to a limited extent.

Next I talked to other breastfeeding supporters, both from BEARS and, on Twitter, across the country to see what they thought of the idea, hoping to be able to represent them better on the radio. It was a fascinating discussion; it led me to this interesting scheme that's already underway in Medway, in Kent. Emma Pickett, IBCLC and co-chair of the ABM, pointed out that it demonstrates our understanding of how breastfeeding benefits entire communities, and that spending relatively small amounts of money on public health interventions can reap great rewards, both financially and in terms of improved health for mothers and babies. I was reminded of the UNICEF report I blogged about last year, which showed that even small increases in breastfeeding rates could lead to large savings for the NHS - the headline figure was £40 million and was a conservative estimate. As local peer supporters we had concerns about the details of the scheme on the ground, and we were certain that any scheme would have to be tied in with the existing support, but we agreed that if it encouraged more mothers to at least consider the possibility of breastfeeding then that would be a good thing.

So I approached my radio interviews this morning (you can catch them here at 1:07:53, here at 2:24 and here at 1:25:23) cautiously positive about the scheme, and tried to talk about how such a measure could never replace the kind of peer support we offer, but might work alongside it to encourage a few mums who feel breastfeeding isn't for them to give it a try. I'm not sure how well the interviews went - let me know what you thought in the comments! - but I was interested to see, when I got home from the studio, how the debate continued to unfold across the various media channels; on TV, radio and on Mumsnet. Somehow the way in which the story has been reported has provoked many of the same old comments about breast and bottle feeding that we've come to expect, and the Jeremy Vine show trotting out Katie Hopkins to talk all over one of the actual researchers didn't make for particularly illuminating discussion. One Mumsnetter, TarkaTheOtter, hit the nail on the head:

"I expect the reporting on this is being a bit disengenous. Sounds like an academic study on the role of incentives in public health rather than a proposed govt initiative."

The way in which this story has been reported, as if it were an actual, real-life policy that's about to be implemented, rather than a small feasibility study making up part of a research study that might one day inform policy-making, forces people to form opinions, comment and potentially get angry or emotional in a way that is at odds with the reality of the situation. Nicky Campbell covered the story on Your Call with painful stories from women who'd had a tough time breastfeeding and hadn't had access to the support they needed and wanted; I feel for those women and I give my time as a volunteer peer supporter because of them, but I don't think their experiences should prevent us from truly examining all the potential ways in which we might work to raise breastfeeding rates in this country.

Reflecting on all the talking, Tweeting and interviews that have gone on today some unintended consequences have made me smile. First was the surprise of the 5 Live researcher when I explained that research shows that it's pregnancy, rather than breastfeeding, that causes saggy boobs (strike one for evidence-based education!), second was explaining twice on live radio that breastfeeding isn't best, it should just be normal, to people unfamiliar with that idea (strike two!) and third was meeting the leader of Derby City Council in the lobby at Radio Derby, who told me that the council chamber has a breastfeeding welcome sign on it. Nice.

Breastfeeding in swimming pools - Virginia Howes takes up the cause

Earlier in the year this post about breastfeeding in swimming pools became one of my most read ever - and I'm disappointed, after all the debate about those cases, to be revisiting the subject again so soon.

Virginia and Sophie Howes

On 26 October, Sophie Howes, a midwife and mother of two, was feeding her baby at the edge of the pool, partially submerged in the water, at the Stour Centre in Ashford when she was approached by the manager and asked to move to somewhere where she couldn't be seen. Apparently one of the lifeguards, a woman, was so 'offended' by the sight of a baby breastfeeding that she was 'unable to do her job properly'. Sophie, who left the pool and continued to feed her baby during the conversation (apart from one moment when the baby let go to look up at the manager - a mental image that has really made me smile) refused to move and pointed out that the manager was breaking the law (you can read what the law says here). The manager, however, insisted she move, citing 'company policy' (which she said she would email to Sophie later). Upset by the incident Sophie and her party left the centre.

And that might have been the end of it - another day, another breastfeeding mother discriminated against and belittled for responding to the needs of her baby, while going about her normal daily business - but Sophie is the daughter of Virginia Howes, independent midwife and star of ITV's Home Delivery, campaigner and author, who, as an outspoken advocate of the rights of women and their babies has both encouraged Sophie to complain about her treatment and taken up the cause: as she sees it, not only was the way that this individual case was handled indefensible, but it is also evidence of a widespread lack of awareness of the law that applies to breastfeeding mothers in our society. The law, as I said in my previous post, is there to protect women and their babies from being harrassed or victimised. As I wrote then:

"Regardless of how other individuals might have acted, or chosen to feed, or cover, or not, the law protects us all, whatever we decide to do. A mum who fed out of the pool, or in the changing room, or in the lobby, or under a towel, or at home before bringing the baby in, has just the same right to be respected by staff as the mum who, for whatever reason, fed in the pool itself."

And in this case, respect was the last thing Sophie got. When Virginia Howes called the centre manager to discuss the incident, the manager claimed that if a lifeguard, or a member of the public, was offended by seeing a woman breastfeed, in the pool or in the cafe, then it was the manager's duty to speak to the mother and ask her to move, because it is a public place! This is totally backwards, since the breastfeeding mother is the party protected by the law. If nothing else it highlights a serious lack of training at the Stour Centre, and I suggest that it's unacceptable for the manager of a public leisure facility to have such a lack of understanding of her responsibilities in this area. (I refer her to my previous post about what should have happened!) And as for customer service...

You might expect, in the face of the high-profile coverage of the other swimming pool stories, and given the widespread response to this latest discrimination, that the pool, the council and everyone concerned might swiftly issue an apology and attempt to make amends. Unfortunately, that hasn't happened. You can read the correspondence on Virginia Howes' Facebook page here: the pool's representative has attempted to justify the position taken by the manager. Many of her 'health and safety' points were robustly debunked by the Analytical Armadillo, IBCLC here the last time the issue was debated; and indeed, many of those commenting on the campaign have pointed out that baby swimming instructors often recommend that babies are fed in the water to stop them getting cold! It also seems telling that the promised 'centre breastfeeding policy' has not materialised, despite repeated requests.

When I first heard Sophie's story I was saddened - as I always am when breastfeeding mothers and their babies are targeted - and I've been appalled at the response to the many complaints that have been lodged. But this time I think the issue will not be swept under the carpet - Sophie and Virginia have so many supporters that the campaign that ensues might succeed where others haven't. If they can raise awareness, and break down some of the barriers to breastfeeding that currently exist in our society, then that will be a great thing. And I can't help feeling just a little bit excited about that.

Epidural and breastfeeding: a call for better information

Image by ammateo - Creative Commons

Earlier this year a single line in Michel Odent's recently published book Childbirth and the Future of Homo Sapiens (Pinter and Martin, 2013) jumped out at me: 'The most common technique of epidural anaesthesia (with an opioid analgesic) has documented negative effects on the quality and the duration of breastfeeding.' It piqued my interest because I couldn't recall ever having come across a discussion of the effects of epidural on breastfeeding: intravenous pethidine, yes, but epidural? I started by looking up Odent's reference and reading the original research paper; Pubmed then led me to this study, and this one, and this one. While all the studies call for further research, they also all show demonstrable effects of epidural on breastfeeding behaviour in mothers and babies.

I was surprised not to have come across this information before, having had three babies in the last few years and having trained as a breastfeeding supporter. I did antenatal classes with the NCT, and while I clearly remember the discussion about pethidine making infants drowsy, and the impact this could have on breastfeeding, I don't remember breastfeeding problems being talked about as a possible side-effect of epidural, although the increased risk of instrumental delivery was certainly made clear. Indeed the NCTs page on pain relief in labour states clearly that pethidine may make the baby drowsy and thus make breastfeeding harder to establish, but does not make the same explicit link for epidural. When I was pregnant I was given this leaflet on pain relief in labour - which claims that with epidural 'Breast-feeding is not impaired, in fact it is often helped.'! (I'd be interested to know whether mothers are still being given this leaflet - let me know in the comments! - as I have numerous problems with it that might provoke a whole new blog post...) The NHS Choices page about the side-effects of epidural is brief, does not mention breastfeeding, and gives no indication of absolute risk (using figures such as 1 in 100) to enable women to make an informed choice. It seemed that accessible, up-to-date information about the potential side-effects of epidural, including on breastfeeding, was hard to come by.

I've never had an epidural - through luck, preparation, or most likely a combination of the two, I had three unmedicated home births. But I have had a spinal headache caused by a dural tap during a lumbar puncture (a complication that occurs in 1% of epidurals) - which was so awful that when faced with having the same procedure again years later, I collapsed in tears in front of the doctor, to his surprise and my own. A side-effect of that dural tap was a three-day separation from my older breastfeeding baby! So I was interested to find out more about the effects of epidural, particularly on breastfeeding. And when I started talking about it I found that women were quick to share their own experiences: from a very limited sample of just a few mothers I heard stories of a newborn whose sucking reflex was inhibited because of a reaction to the epidural, and of a mother who experienced such uncontrollable shaking as a result of the epidural that she could not hold or feed her baby for several hours after birth. Another mother described how the effects of the epidural (the need for a catheter, and the tingling in her legs) affected her movement for 12 hours after birth, leading to problems getting her baby out of the crib and into a good position for breastfeeding. A search of the Alpha Parent's Triumphant Tuesdays series of posts shows that many of the women, who have overcome considerable difficulties to breastfeed, gave birth with an epidural. But these were anecdotes, and I needed more data.

An internet search for articles led me to the La Leche League International page; their article is interesting, but dates from 1999. One of the best resources I found is Sarah Buckley's well-referenced article Epidurals: risks and concerns for mother and baby (2005), which specifically discusses breastfeeding. In addition to these I've also looked at The Impact of Birthing Practices on Breastfeeding by Mary Kroeger with Linda J. Smith, The Hormone of Closeness by Kerstin Uvnas Moberg, Birth Matters by Ina May Gaskin and Childbirth in the Age of Plastics by Michel Odent in terms of what they say about epidural and breastfeeding.

So what did I learn from all this research? There is now a growing body of work focussing on the critical importance of a woman's natural oxytocin (synthetic oxytocin, used in induction and to augment labour, acts differently) in promoting behaviours in mother and infant that help to establish breastfeeding and attachment, with a woman's oxytocin levels reaching a lifetime peak just after she gives birth - unless she has an epidural. As Uvnas Moberg explains:

"An epidural anaesthetic not only blocks the activity in the nerves in the spinal cord that transmit pain, but also in the nerves that lead to the release of oxytocin normally triggered when the baby's head is pushing against the cervix. Consequently, mothers who receive an epidural also have lower levels of oxytocin during labour." (p.64)

A potential side-effect of epidural is a drop in blood pressure (natural oxytocin acts to increase a woman's blood pressure slightly during labour); this may mean that the mother is given fluids via a drip (IV). A baby born to a mother given additional IV fluids may lose more weight than expected in the first few days, leading to concerns about breastfeeding, but this weight loss is is due to the infant excreting the excess fluids. (See this article by Nancy Mohrbacher for more.) If a new mother's confidence in breastfeeding is dented, it can be hard to repair.

Kroeger and Smith's chapter on pain relief concludes:

"Strong evidence exists from randomized controlled clinical trials that epidural anesthesia can lead to poor progress of labor...need for oxytocin augmentation, a longer second stage, a lower rate of spontaneous vaginal delivery, increased maternal fever, and increased evaluation and treatment of newborns for suspected sepsis...Observational evidence shows that epidural and narcotic analgesia affects inborn feeding behaviours and adversely affects breastfeeding." (p.114)

A Cochrane Intervention Review was carried out in 2011:

"The review identified 38 randomised controlled studies involving 9658 women. All but five studies compared epidural analgesia with opiates. Epidurals relieved labour pain better than other types of pain medication but led to more use of instruments to assist with the birth. Caesarean delivery rates did not differ overall and nor were there effects of the epidural on the baby soon after birth; fewer babies needed a drug (naloxone) to counter opiate use by the mother for pain relief. The risk of caesarean section for fetal distress was increased. Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever. Long-term backache was no different. Further research on reducing the adverse outcomes with epidurals would be helpful."

To draw together a few threads: epidural is often associated with synthetic oxytocin (synthetic oxytocin induction provokes painful labour, epidural slows labour progress, synthetic oxytocin augments labour...); this hormonal disruption can interfere with feeding behaviour. An increased risk of instrumental delivery after epidural means pain, stitches and a higher incidence of birth trauma for mothers, and the risk of bruising, swelling and trauma for the infant, which can interfere with early establishment of breastfeeding. IV fluids can distort assessments of baby's weight and dent confidence in breastfeeding. There's an increased risk of post-partum haemorrhage (PPH) after an instrumental delivery; this can lead to breastfeeding problems too, as described in this paper.

There are obvious problems, in our birth culture in the UK, with raising the issue of epidural as a contributing factor in breastfeeding problems. Epidural is common and widely regarded as easy and safe; indeed, there's a cultural perception of it as the 'ultimate' in labour pain relief. (The Lindo Wing, where the Duchess of Cambridge gave birth, reportedly has an epidural rate of 100%). Its efficacy (at relieving pain, although more than 10% of recipients report inadequate pain relief) is seen to outweigh the potential side-effects, although, as this post aims to point out, the true scope of these potential side-effects may be poorly understood, even among health professionals. There's also the (I think) separate issue of women's access to epidural: to be clear, I believe women should have access to the pain relief they need, when they need it - although I want them (and their care providers) to be as armed with the facts as they possibly can. There was a fascinating and in-depth discussion on Mumsnet with consultant obstetric anaesthetist David Bogod about epidural that covers many important points (although I disagree with him about breastfeeding!).

Good information empowers everyone. If midwives, maternity support workers, peer supporters and health visitors were more informed about some of the issues I've raised above, it might mean that more women who want to breastfeed, but are considering epidural or through circumstances have ended up with one they didn't plan for, are well supported. All breastfeeding supporters know that women having breastfeeding problems often need to talk through their births, and that this often gives many clues that shed light on their current difficulties: better information about the effects of epidural on breastfeeding can improve how we support these mothers.

The other side of the coin, of course, is providing women with genuine alternatives to epidural if they want to avoid the risks discussed. Some suggestions:

- continuous support in labour - shown to reduce need for epidural and thus reduce likelihood of instrumental birth.

- consider a home birth - research shows that home birth is safe, particularly for second or subsequent babies, and there are no epidurals at home deliveries (although of course you can transfer in if you do decide you want one). Booking a home birth can keep all options open for low-risk mothers. Information from the Infant Feeding Survey 2010 showed the highest rates of successful breastfeeding initiation and continuation in mothers who birthed at home; at least part of this could be down to the fact that these mothers have neither synthetic oxytocin nor epidural.

- avoid induction if possible.

- hospitals should increase access to water for labour, if not birth itself, for a greater proportion of mothers, not just those at lowest risk. Continuous foetal monitoring (CFM) has been shown to have no benefit over the midwife listening to the baby's heart at intervals, so why can't more women labour in water? Michel Odent (in Childbirth in the Age of Plastics) describes how labour immersion provides pain relief and also an increase in oxytocin...

- Finally, I've just read a case-study, in Birthrights' new Projects and Perspectives, published to coincide with their Dignity Forum on 16 October, of an Ayrshire maternity unit that has begun offering free Hypnobirthing courses to, among others, women who can't have opiate medication or epidural. I'd love to see this programme extended.


What do you think of this post? Too long, too technical? Let me know in the comments - I'd love to hear from you.

Advertising infant formula - WHO cares?

Last month, online retailer Ocado distributed, in print and online, a magazine that carried a feature advertising first-stage infant formula. They've now (after an initial delay) amended the online version of the magazine, which you can see here. The article on p34 originally had an image of a box of six ready-to-feed SMA bottles in the 'S is for Sleep' section (see right) - in fact the whole section looked as though it spelt out S.M.A. The first problem? It's illegal in the UK to advertise first-stage infant formula: the relevant legislation is here.

So far, so simple. Ocado were pulled up on their mistake, and they responded with an apology:

The SMA First Infant Milk product was included in the feature by mistake. The mistake occurred purely through human error and we are satisfied this is an isolated incident. We are very sorry that this has happened and we have made some changes to the ocadolife production process to ensure this cannot happen again. We take compliance very seriously at Ocado and as a responsible retailer we have voluntarily approached the relevant authorities to discuss this matter with them. We can also confirm SMA did not provide any funding for the inclusion of their product in the feature and we also extend our apologies to them for our error.

An end to the matter? Not really. The whole incident brought some of the issues affecting infant feeding in the UK sharply into focus. So much is wrong with the picture. That this image of formula milk appeared in the 'sleep' section of the article reflects a common misconception that formula feeding aids infant sleep (when in fact it increases the risk of SIDS). That the image appeared at all demonstrates a worrying lack of awareness of the law among editors, copyeditors, proofreaders... And a storm of comments on Facebook (I saw them on the Association of Breastfeeding Mothers page, and on the Ocado page) demonstrated just how poorly the general public understand the law itself, and the reasons for it (which reminded me of the comments made about breastfeeding in swimming pools that I blogged about here.) A small selection:

I don't see what's wrong with this. Some people formula feed, so what!!!

In today's world of equality and freedom of choice its a disgrace that such a law even exists... it hits a bit of a raw nerve when I read so many people trying uphold a law that in my opinion should never have been passed.

...not allowing advertising of first milk is making some mothers' failure at breastfeeding even more apparent... don't we need to be looking at the nhs midwifery service and the support (or lack of) that new mothers receive rather than the advertising...?

If these infant formulas were actually bad for baby and caused harm... then they wouldn't be allowed to be produced never mind advertised.

Adverts are allowed for everything else under the sun claiming to be healthy such as high sugar cereals, breakfast bars and alcohol!!!... but adverts aren't allowed when it comes to offering choice or advice on formula milk!!!

So why is it illegal to advertise formula?

I just don't get why people are so up in arms about a very small picture in a publication.

The law exists because of pressure groups who don't feel that people should be allowed to make their own choices.

The problem with this law is that it prevents the balanced info that you claim you want parents to have. 

Let me make it clear. The law exists to protect mothers and young babies, whether breastfeeding or artificial feeding. We know (and by we, I mean that it is common knowledge) that breastfeeding is the normal way to feed human infants, and we know, thanks to an ever-expanding wealth of scientific research, that not doing so carries a host of increased health risks for both babies and their mothers. Yes, even in the UK. It seems logical then that the marketing of breastmilk substitutes for infants, which are artificially-fed babies' sole source of nutrition, should be subject to checks and controls.

It's also clear, from even the most cursory look at the advertising practices of the formula manufacturers, that they will go to great lengths to promote their products, often making pseudo-scientific claims that do not stand up to scrutiny (cases have been brought against them, and won), adding ingredients of unproven benefit and cynically targeting health care professionals when they are denied direct access to parents. Baby Milk Action, and the UK Baby Feeding Law Group, monitor the activities of the various formula companies: you can find a great deal of further reading on their websites (my most-read post ever is about this topic too, here.) It seems obvious that companies aiming to maximise their profits are not best placed to offer objective information about formula feeding.

The above has been known for some time, and is recognised worldwide. Hence WHO (the World Health Organisation) created the International Code of Marketing of Breast-milk Substitutes, adopted in 1981, the aim of which is to:

...contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Can anyone find anything there to disagree with? It sounds perfectly sensible. In 2003, WHO and UNICEF, as part of a global strategy for infant and young child feeding, called for governments to 'review progress in national implementation of the Code, and consider new legislation or additional measures as needed to protect families from adverse commercial influences.' Unfortunately, in the UK we have still only partially implemented the WHO Code, which, as Emma Pickett IBCLC, co-chair of the ABM, explains:

...could be argued to have done more harm than good. It has led directly to the 'invention' of follow-on formula, which is not subject to the same advertising controls as first-stage formula. In countries that have fully implemented the Code, there is no follow-on formula at all - if it really were a distinct and medically necessary product, as the manufacturers would have UK parents believe, surely it would be available worldwide? Here in the UK we have evidence from the Diet and Nutrition Survey that 32% of parents have given follow-on formula before six months: proof, if any more were needed, that advertising really works.

She also describes a situation that breastfeeding supporters everywhere will recognise:

You meet mothers every day who use formula alongside breastfeeding and end exclusive breastfeeding because the messages they receive from advertising are far more powerful than the information they are drily given about the benefits of exclusive breastfeeding. The TV adverts stick in the mind long after someone mumbling something about gut flora and allergy prevention.

It's grimly ironic that those parents complaining about the law against advertising first-stage formula are the very same parents that are being ripped off, both financially and through misinformation, by the formula manufacturers. Rough calculations (companies won't reveal their figures) suggest that of an annual spend by parents of £436.54 on Aptamil powdered formula, for example, between £231 and £349 goes on marketing and profit. Still think the companies are acting in the best interests of consumers?

As for where parents should go for better information, UNICEF, First Steps Nutrition, Which? and others all have guides to artificial feeding for those who need them, freely available on the internet.

But there's even more to it than this. Want to see how deep the rabbit-hole goes? In this post on the Alpha Parent James Akre describes our culture of acceptance of formula feeding thus (my italics):

Given the mass of compelling scientific and epidemiological evidence about the harm caused by routine artificial feeding, it’s hardly farfetched to qualify as collective delusion the unquestioned faith that the general public and health professionals alike in many settings continue to place in infant formula...

...Infant formula will sustain life in a pinch, and thank goodness this is so. But as I describe elsewhere, from a nutritional and developmental standpoint, most people do not understand just how hugely inferior it is to breast milk...The idealized view of normalized infant formula feeding that manufacturers are so adept at portraying – and, regrettably, so many consumers, health professionals and politicians are inclined to accept – doesn’t allow for even a hint of this disenchanting reality.

Given all the evidence, why do you think we haven't fully implemented the Code in the UK? And why don't we make more use of the laws we have? Don't be fooled into thinking that the reasons have anything to do with any doubts about the benefits, in terms of public health, of doing so. It's an uncomfortable truth that we cannot rely on governments to act as they should, even in the face of overwhelming evidence and firm guidance from WHO (which has no power to compel countries to implement the Code). The pressure, on governments and other organisations, from vested interests within the baby food industry and elsewhere, is immense: the power of corporations, at the highest levels of politics and policy-making, cannot be dismissed as conspiracy theory. When so much profit is at stake, the interested parties will do all they can to exert an influence. This month a letter appeared in the Journal of the World Public Health Nutrition Association about conflicts of interest in the area of infant nutrition:

...concerned with the equally deep penetration of the transnationals and their associated or supportive organisations, into the scientific community, into nutrition policy-making at the highest level, and into public health programmes that affect the health and lives of hundreds of millions of people.
We see this largely as a consequence of the failure of elected governments to fulfil their first duty, which is to govern. We also feel that some policy-makers and many scientists, including those working at the highest level, underestimate or overlook the consequences of their own actions.
The influence of Big Food can be subtle, and may, in the opinion of reasonable people, be seen to affect the judgement of public policy agenda-setters who act in good faith and whose personal integrity is not at issue. We are not questioning the motives of any of the people mentioned in this letter. We are though, deeply concerned about the possible effects of their activities.

Our specific situation in the UK is part of a global issue that has far-reaching implications for mothers and babies. Just today Baby Milk Action posted this press release on their website about formula companies bribing hospitals in China - yes, those same formula companies that advertise and sell products in the UK.

I've covered a lot of ground: from a tiny image of first-stage formula in an Ocado magazine, to global politics, nutrition policy and economics, in one helter-skelter ride. And really, this is still only scratching the surface. I just hope I have gone some way towards showing how that one little article is part of a much bigger picture that should concern us all.

Breastfeeding in swimming pools - what do our reactions say about us?

There have been two reports in recent months of mothers breastfeeding at public swimming pools and being told off for it by staff: you can read them here and here. Both stories provoked a storm of comments, both on the newspaper report pages themselves and across the internet, including on Mumsnet, several breastfeeding pages I follow on Facebook and on the Jeremy Vine show. Most of those commenting on the story seem to have missed the point completely, which is that whatever your personal feelings about the appropriateness or not of breastfeeding in a public swimming pool, women's rights not to be harassed or victimised for doing so are enshrined in law. It is ironic then that the venom of the commentators is almost entirely directed at the women involved, and not the staff who approached them or the management of the respective pools, who may (investigations ongoing) have been acting illegally.

The comments about both incidents have deeply saddened me, as a breastfeeding mother, a breastfeeding supporter and as a human being. Even given what we all know about the accuracy of newspaper stories (the Cambridge story was reported with claims that the mother in question was in a jacuzzi at the time - it transpires that there is no jacuzzi at the pool, and in fact she was seated on the poolside with only her feet in a toddler pool area), nevertheless other women (and men) have been quick to weigh in with the full force of their opinions about what they would have done in the circumstances, what they think about the pool's policy, all sorts of very revealing nonsense about the 'ickiness' of breastmilk, and so on. This deeply unpleasant tendency to attack the actions of others when they act in ways that we ourselves would not does not reflect well on us as human beings - it is closed-minded, divisive and makes our society look downright hostile to some of its more vulnerable groups, including breastfeeding mothers. Regardless of how other individuals might have acted, or chosen to feed, or cover, or not, the law protects us all, whatever we decide to do. A mum who fed out of the pool, or in the changing room, or in the lobby, or under a towel, or at home before bringing the baby in, has just the same right to be respected by staff as the mum who, for whatever reason, fed in the pool itself.

The law on breastfeeding in public in England says that you cannot be 'harassed or victimised' for breastfeeding in a public place, and this specifically includes parks and leisure facilities. (There are no health and safety issues in a public swimming pool to qualify as an exception under the legislation - for a detailed examination of the 'hygiene worries' of Joe Public, see the Analytical Armadillo's excellent post here). So it is the actions of the staff that are important: in both cases, in the newspaper reports of the incidents and in the mothers' further comments online, it seems clear that the staff were rude, uneducated about breastfeeding and the law and upset mothers attending to the needs of their small children, who were paying customers of the leisure centre. The involvement of management (also uninformed about breastfeeding) compounded the problem rather than fixed it. This shows how little understanding there is of breastfeeding within organisations and is symptomatic of how, as a society, we consistently fail to take it seriously enough. Apart from anything else the mothers' treatment is appalling customer service that no one deserves. It seems to me to be part of the same kind of casual disrespect that is shown by those who are racist or sexist in public - it's ill-informed nonsense, which is why as a society we have legislation to protect people from it.

What should have happened
Day 1 of lifeguard induction: 'This is a family pool and we encourage all members of the public to access our facilities. Our policies reflect the welcoming environment we try to create: we run family sessions, women-only sessions, and baby swim classes alongside our programme of school lessons and public swimming sessions. One relevant point of law that you need to be aware of is that breastfeeding mothers have the right to feed their children in any part of our facilities and you should not ask them to move or stop breastfeeding as this is against the law. If another patron raises the issue with you, take that person aside, explain the law and our policy, and refer them to management if they are not satisfied. You can, if you wish, inform mothers that we have a dedicated infant feeding room for their convenience, but they are under no obligation to use it. This is entirely separate from our policy on no food and drink in the pool area, which is there simply to maintain our high standards of cleanliness around the pool.'

Another day: mum is breastfeeding in the pool, lifeguard notices. 'Mum feeding her baby. Oh right. Wonder if she knows about the room? I'll just nip down and tell her.'
Lifeguard: 'Excuse me, madam, [smiling] I'm sorry to interrupt - I just wanted to check that you know we have an infant feeding room next to the changing rooms, which you're welcome to use if you want to.'
Mum: 'Thanks, but I need to stay here because I'm watching my toddler over there.'
Lifeguard: [smiling again] 'No problem at all madam, enjoy your swim.' Walks off.

In my example the general public, observing (if they even notice) sees the interaction as an endorsement of breastfeeding rather than an attack on it. Smiling mum, unconcerned lifeguard - subliminal message: BREASTFEEDING IS NORMAL. No news story.

Full disclosure: I have breastfed in the changing rooms, on the poolside, and actually in the water at public swimming pools. At the time I didn't give it a second thought - I was just responding to the needs of my baby. Never had a comment from anyone, either member of public or member of staff.

Public, positive messages to support a woman's right to breastfeed

I've been delighted to observe and be part of a movement for improvements in birth and maternity services that is gaining momentum (see this article by Toni Harman in the Huffington Post.) In the UK the Positive Birth Movement, with its network of positive discussion groups, and the establishment of Birthrights, has done much to foster genuine, productive debate about women's experiences of birth in today's society. Writer Milli Hill has been commissioned to write a positive birth column after her piece Is Kate being bullied about her birth? was a runaway success for bestdaily; home birth advocate and journalist Beverley Turner, of Radio 5s Bump Club, has also had a number of positive articles published in recent weeks. There's a real buzz about positive birth at the moment and it's great to see.

Conversely, National Breastfeeding Week 2013 has left me feeling a little flat. Not because there weren't some great things going on - both on and off-line - but because, as the figures revealed in the papers during the week showed breastfeeding rates taking a small dip for the first time in years (and Rebecca Schiller so clearly articulated in her piece in the Guardian), without government-level strategic support for breastfeeding, all the efforts of everyone who is passionate about supporting women to breastfeed are just scratching the surface. As Schiller summed it up: 'if policymakers aren't funding enough midwives or a centralised system of breastfeeding support we simply set women up to fail.' (In my own area, with no funding for National Breastfeeding Week, the NHS, through which we work as peer supporters, couldn't support the events we ran in any way.) She also pointed out that the constant breast v bottle debates in the media (which I've critiqued in other posts, like this one) are falsely polarised and damaging to both sides, with women suffering guilt, fear of judgement and lack of support, regardless of feeding method.

I can't help wondering whether the key to improving our dialogue about breastfeeding lies in learning some lessons from the movement for improving birth. If we alter the fundamental question at the heart of all the arguments, what happens? In the introduction to his forthcoming book A Gift for Life (Pinter and Martin, pub date Sept 2013) Dr Carlos Gonzalez, author of My Child Won't Eat and Kiss Me! How to raise your children with love, Spain's answer to Dr Jack Newman, writes:

"...lactation isn’t a tool for achieving health, but rather an integral part of health itself. Not a means, but an end. Telling people to ‘avoid artificial lactation because it causes diarrhoea’ now seems to me as absurd as exhorting them to ‘avoid blindness because blind people are more likely to get run over’. Lactation is no more a way of avoiding infection than being able to see is a way of avoiding accidents. They are both normal parts of a healthy life. I know now that lactation is not an effort, much less a sacrifice, that a woman makes for the good of her child, but rather that it is part of her life, of her own sexual and reproductive cycle. It is a right that no one can take away from her.

I am aware that some women don’t want to breastfeed. This is fine. A right isn’t the same as a duty. Many people don’t go on marches or vote in elections, but they still have that right." (my emphasis)

There's a parallel here with the idea (enshrined in law thanks to Ternovsky vs Hungary) that it is a woman's right to choose the circumstances of her birth. If we see breastfeeding as a woman's right then that frames the whole question of our duty, as a society, to ensure that her rights are respected and supported, in a completely different way. Viewed in these terms, breastfeeding is no longer a 'public health issue', or a 'women's issue'; the right to breastfeed, if she wants to, becomes a completely integral part of the care a woman can expect from maternity and child health services - it cannot be seen as an optional extra, or a 'nice to have', the cherry on the cake once mum and baby have navigated the birth itself. It demands commitment to breastfeeding, and supporting breastfeeding, at a strategic level.

(For the few women who cannot breastfeed, the logical extension of the idea that breastfeeding is a woman's right would be to have robust systems in place to provide those women with acceptable alternatives; provision of donor milk and supplementary feeding systems, wet-nursing or milk-sharing, for example.)

So seeing breastfeeding as a woman's basic right, which she is free to exercise or not, is one way of reframing discussion of it. We move on then from divisive breast v bottle polemics, and instead focus on how our society and culture is, or is not, doing what it needs to do to ensure that a woman's right to breastfeed is not infringed. We're part of the way there with laws that protect breastfeeding in public, but we must also look at our failure, in the UK, to fully implement the WHO Code on the marketing of breastmilk substitutes, and confront what the recent figures showed so clearly - that breastfeeding in Britain is effectively a postcode lottery (despite what we know about its potential to reduce health inequalities). As Rebecca Schiller, in her role as co-chair of Birthrights, says:

"Women have a fundamental right to autonomy when deciding how and where to give birth and how to feed their babies. Birth choices are often made with feeding goals in mind. However, women in the UK do not universally have equal provision of these birth settings and often tell us that they are refused entry to them. Birthrights is working hard to raise awareness of this issue and work with women and health professionals to ensure that the choices women make around birth  - for whatever reason - are respected, supported and made realistic.

Women most certainly have the right to adequate levels of postnatal support and the right to make fully informed choices about how they give birth and feed their babies. If our maternity service doesn't offer all women the chance to make and realise those choices through appropriate provision of a range of birthplace settings and experienced, adequately staffed postnatal services, it certainly raises the question as to whether, through lack of resources and lack of evidence-based policy, we are effectively giving an illusion of choice where often none exists." 

Another way of reframing the discussion of breastfeeding takes a different tack - focussing on public, positive messages about breastfeeding (again, following in the footsteps of the Positive Birth Movement and Tellmeagoodbirthstory). My book Breastfeeding: stories to inspire and inform and its accompanying Facebook page attempt to promote positive breastfeeding stories - a recent favourite is this one from a mum who never thought she'd breastfeed, but changed her mind. Other groups and individuals are doing their bit to normalise breastfeeding and breastfeeding in public. Christina Conboys and a group of mums in Harrow have put together a book of fabulous, inspiring photographs called Breastfeeding is Beautiful; spoken-word poet Hollie McNish's heartfelt poem 'Embarrassed' is being shared all over the web - it sums up brilliantly some of the cultural issues affecting how we see breastfeeding in Britain. I also love the work of We Do It In Public, a photographic library of normal mothers breastfeeding in all sorts of everyday situations - for (paid) use by organisations, companies, websites and anyone who needs images of infant feeding to accompany their content. And it's a great resource for mothers to browse too.

The impact of these positive, public messages about breastfeeding cannot be underestimated. They are the antidote to all the little comments that undermine breastfeeding that we all come across every day: about four-hourly feeds, about a bottle before bed to get them to 'go a bit longer', about 'needing your body back', about no nutritional benefit after six months, about formula being 'just as good these days', about how 'he's using you as a dummy'. It works in the same way that positive birth stories counter negative messages about birth. It's well-known that supportive breastfeeding groups (again the parallel with the Positive Birth Movement is obvious), where mothers meet other women with similar experiences to their own, are of immense value in supporting women to meet their breastfeeding goals; that's why the major breastfeeding charities, such as La Leche League and the ABM, put mother-to-mother support at the core of their activities. I recently read this interesting blog about how negative experiences of breastfeeding in public affect mothers and influence their decisions about how long to breastfeed for; if we exchange those negatives for positives we both support breastfeeding and support women.

It seems to me that raising the profile of breastfeeding in the UK requires (at least!) a two-pronged approach. If we started by accepting that it is a woman's right to breastfeed if she wants to, then that would give us a clear way forward: breastfeeding needs to be at the heart of what we do, in government, in law, and in public life. It's not rocket science. It's just something else that HR departments, TV programme commissioners, editors and policy-makers would need to at least consider, in the way that they already consider diversity, gender, accessibility. And if, at the same time, we could increase the visibility of breastfeeding as it's done, everyday, by thousands of women, then it wouldn't be long before everyone stopped paying so much attention to it. It would just be normal.

(I'm reminded, in writing this, of feeding my daughter on a trip to the Westfield centre in Derby, a huge shopping mall with multiple, well thought-out parents' rooms. I often suggest to new mums I support that it's a good place for an early trip out with the baby because of these facilities. However, last time I was there and my daughter needed a feed I was close to benches in a large, airy seating area, with all sorts of people sitting on them - older Asian men, Derbyshire grannies and giggly teens. I consciously chose to join them all and feed my daughter there rather than going to the parents' room. I felt, as a confident third-time mum, that I was doing my bit to normalise breastfeeding. It may have backfired, however, as the Derbyshire grannies that cooed over the baby had leaned right over, stroked her head and tried to talk to her before they even realised she was feeding...)

What do you think of the idea of breastfeeding as a woman's right as a normal part of her sexual and reproductive life? I'd love to hear from you in the comments.

National Breastfeeding Week 2013: some thoughts on breastfeeding support

I've been a breastfeeding peer supporter for two and a half years, since shortly after my third child, who only recently stopped breastfeeding, was born. In that time I've been constantly reminded of the incredible value in what we do. When I hear women's stories (such as this one) of how they've been supported to overcome problems and achieve their feeding goals, I have a great feeling of pride and good fortune to have been able to be part of their support network. 

Breastfeeding support doesn't begin and end with a new mother and her baby, although they are at the heart of it. It ripples outward and affects others too - the partner who desperately wants to be supportive but doesn't have all the information he needs; the mother-in-law worried about why mum isn't giving the baby water between feeds; the GP who isn't up to date with treating thrush; the pregnant woman wondering how she will feed her baby; the young girls walking past mothers breastfeeding in coffee shops.

Whatever the ins-and-outs of the latest 'breast v bottle' debates in the papers, on TV or on the radio, peer support, which is truly mother-focussed, exists outside that arena. No one, surely, could have a problem with the idea of women supporting other women, who want to breastfeed, to achieve their goals. In the introduction to my book Breastfeeding: stories to inspire and inform, published a year ago by Lonely Scribe during National Breastfeeding Week, I wrote:

"Peer support is not about judging mothers' choices, or breastfeeding evangelism - it's about positive ways of helping those who want to breastfeed, for whom it matters, to continue as long as they want to, and supporting them to make informed choices for themselves and their families."

With its focus on listening (see this lovely post), taking time to understand mothers' concerns and making appropriate, supportive suggestions, peer support fills a need that maternity services and health visiting teams can struggle to provide. (Which is not to say that peer support alone is sufficient to properly underpin breastfeeding in the community; for that you need good systems of upward referral for more complex problems, often sadly lacking). Peer support comes in different guises; we are trained by and supervised by the NHS, but in other areas support may be offered through other organisations, such as the Association of Breastfeeding Mothers, La Leche League and the Breastfeeding Network, or through community interest companies like realbabymilk.org or Little Angels.

The feedback we get from mothers who attend our groups and see us at clinics, have home visits from us or call our helpline, is that the service we offer, voluntarily and free of charge, is highly valued and hugely important. Women remember kind words, a listening ear and calm suggestions, whatever course their breastfeeding journey takes, and this in itself is important - they may try breastfeeding again with subsequent children, or be more encouraging of their friends, or challenge misinformation when they hear it, based on their interaction with us. That's a responsibility, but one that I welcome; it feels like an incredibly gentle way of changing the world.

---

I'm a peer supporter with BEARS in Amber Valley, Derbyshire. Follow us on Twitter @feedingsupport, and check us out on Facebook for details of groups and clinics, and our National Breastfeeding Week events. We're running our popular 'Breastfeeding Millionaire' quiz, with a host of fantastic prizes, all week, as well as a Positive Postcard Project (send a positive breastfeeding message to someone, and receive one yourself). And there's a Big Feed picnic in Belper River Gardens on Wednesday 26th June 2013 at 1pm.

Other Keep Britain Breastfeeding bloggers are involved in breastfeeding peer support: look up Mummyisagadgetgeek, lifeloveandlivingwithboys, Circus Queen, Hex Mum and Twinkle Mummy.


a Rafflecopter giveaway

Bedsharing and breastfeeding in the media - an analysis

This morning on Facebook the first thing I read was on one of the breastfeeding support pages I contribute to, from a mum who'd heard reports of the latest bedsharing research, published in the BMJ Open online, on the radio, worried about what she'd heard. I read the paper itself and the various articles about it, as well as a host of responses to it. A thread about the research on Mumsnet had over 300 posts last time I looked, and many of the articles have attracted numerous comments.

There's no question that reports of research in the mainstream media can have a massive impact on audiences. How could they not, with headlines and subheads like these: 'Bed-sharing newborns five times more likely to die suddenly than those who sleep in a cot, study shows' (Guardian), "Sudden infant death risk 'is five times higher if the baby sleeps in its parents' bed'" (Daily Mail), 'Parents should never allow babies to sleep in bed alongside them due to the risk of cot death, according to research which has prompted the Government to order an “urgent” review into official guidance.' (Telegraph), 'Bed-sharing "raises cot death risk fivefold" (BBC). The Mumsnet thread is full of people questioning their own behaviour in the light of the new research. The Facebook mum is not alone; all over the web there have been concerned parents, who've heard snippets on the radio or seen TV news items, wondering whether this new research can be believed.

There's a marked tendency in us to feel as though any 'new' report somehow trumps any previous research and this is certainly apparent in many of the comments on media reports - people believe that scientific research is a progression, and that each new finding is more reliable than the last, because it must build on what has gone before. That couldn't be further from the truth. The reality of scientific research is that it is much more complex a web than we might think. The research that is done depends on the interests of researchers, the availability of research funding grants, the whims of senior academics with preferred pet topics, the commercial aspirations of companies with cash, the declared aims of charitable organisations and many more variables. There are endless dead-ends, blind alleys and studies that contradict one another. And once the research is done there's the issue of making something of it, getting it noticed. Academic careers, the standing of institutions and future funding applications depend upon research reputations. Even when, as in this case, there is no suggestion of a conflict of interest among the authors, or of the funding for the study having come from a commercial interested party, there is still a need to publicise research, which is why editors and interested parties got a press release about this paper, which highlighted the most striking aspects of the research (as identified by the authors, or the press office?).

Another important point to make is that whatever the scientific ins and outs of the data presented in the paper, of which more below, researchers and academics are nonetheless able to draw their own subjective conclusions and have their own opinions about their research, based on their own experiences, culture and background, and this comes across strongly in the discussion/conclusions in the full paper. My feeling is that the paper's authors, while they may not have set out to provoke a media storm, nonetheless wanted to make a 'statement', and a recommendation that we reconsider the current UK guidelines is certainly that. (Several people I've talked to or seen comments from have thought, based on the reporting, that the guidelines are being or have already been changed to reflect this research - this is not true, although the BBC reports that the government have asked NICE to review their guidance in light of the findings.) I don't think the paper's authors have considered how their findings will be viewed by parents, or that they have much understanding or experience of our culture of parenting and infant feeding in the UK, although they do make some efforts to link their research to the UNICEF report on the cost savings associated with breastfeeding that I blogged about here.

Matters don't improve when the research is published. In the translation from the press release to finished articles, TV snippets, reports and local radio phone-ins much that is important is lost, and the discussions become less about what the research really shows, and more about the broad brushstrokes of an uninformed debate (much like the breastfeeding/bottle-feeding articles I regularly comment on).

Making sense of the crowded landscape of information requires time, an in-depth understanding of the subject in question and critical thinking, and the reality is that many of us rely on others to do this for us. (I am a non-fiction editor well used to reading and sifting large amounts of information, with a specialist interest in parenting and breastfeeding, and I still struggle at times to get to the heart of the matter.) Which is why I was delighted, having read the paper and some of the articles in the press, to find that UNICEF, Professor Helen Ball of ISIS online, and The Praeclarus Press, among others, had issued detailed statements that dig deeper into the research and expose some of its limitations. Professor Helen Ball also contributed to Radio 4s PM programme, where she discussed the findings with one of the paper's authors, Professor Bob Carpenter.

I've been interested in the whole media maelstrom from a breastfeeding perspective, because in peer support I'm often asked about sleep in the context of breastfeeding. Since studies suggest that co-sleeping and breastfeeding have an interdependent relationship, and we know that night feeds are important for maintaining mums' supply and on Radio 4 Professor Ball cited her own research that showed breastfeeding rates were twice as high among mothers who bedshared with their infants younger than three months, coupled with the fact that not breastfeeding increases the risk of SIDS, I've always believed, along with many others who work to support families, that black and white advice about bedsharing, as advocated by the authors of the paper, is inappropriate for breastfeeding mothers. I direct parents to UNICEFs leaflet Caring for Your Baby at Night and to Isis online for more information to help them make informed decisions. The NCT's page about bedsharing (cited by the authors of the BMJ study as evidence of 'a pro-bedsharing lobby', which I thought might be a clue as to their personal hang-ups on the subject) says that up to 50 per cent of parents admit to bedsharing on occasion. On the Mumsnet thread I mentioned above there were many contributions from mothers of infants who resorted to bedsharing as a practical solution to meet the needs of the whole family, and as the mother of three babies who breastfed frequently at night for many months I have been there myself.

So what of the relative risks for breastfeeding mothers who choose to co-sleep? Some interesting numbers can be extracted from the full paper. In the study, of 1,444 babies who died, 540 were breastfed (any breastfeeding - in this study even babies fed artificial milk at night in an attempt to get them to sleep longer would be in this group) and 940 were bottlefed. Of 1,405 babies who died (the exact numbers change slightly because of missing data), 1,091 had one or two parents that smoked. Of 1,422 babies who died, 607 had been put to sleep on their front (another criticism of the study is that it uses old data, including many babies who slept on their front). Overall, the rate of SIDS in the UK is approximately 3 in 10,000. Among breastfed babies, of parents who don't smoke and whose mothers have not had alcohol or illegal drugs, that is reduced to 1 in 10,000 for crib sleepers in parents' room and is 2 in 10,000 for co-sleepers. Breastfed babies thus have a lower than average risk of SIDS. In 2010 there were 254 unexplained deaths in England and Wales and 723,165 live births. (ONS). Given the above, it is easy to see why Professor Ball commented: '...both sleep locations for breastfed infants of non-smoking parents in the absence of alcohol experience very few SIDS deaths. It is curious, therefore, that the authors issued a press release to call attention only to this small difference in predicted SIDS rates for breastfed babies of non-smoking parents who bed-share compared to room-sharing – while ignoring the hugely inflated risks associated with hazardous bed-sharing environments. It appears as though the authors choose to target breastfeeding mothers in this way as they are a sub-group with strong opinions about the benefits of bed-sharing, even though the infants of these mothers contribute negligibly to UK SIDS rates.' Without wanting to overstate the case it seems that even in the conclusions of research papers there is an undercurrent that undermines breastfeeding and parenting behaviour that promotes it. Fascinatingly this chimes with something else I read today, the Alpha Parent's look at how societies can be 'gendered' - some of our problems with this research and the reporting of it may be able to be explained by 'masculine' traits in our culture.

Of milk and memories: how my breastfeeding story ends

I knew this time would come eventually. I can't remember when I last fed my baby. It might have been on Friday morning, or last Tuesday. It would have been first thing in the morning, and I would have gone into her room, having heard her calling brightly 'Mummy-Daddy! Mummy-Daddy!' from her cot. I would have gathered her up, warm and sleepy in her pyjamas, still clutching her comfort blanket, and carried her through to my bedroom. She might have said, 'My want my milks', and I would have propped up my pillow, and sat back in bed, and she would have dropped her blanket and draped herself across my lap. She might have said 'That one first, Mummy, then that one [pointing].' She might have paused mid-feed to look up at me and say 'Yummy, yummy, in my tummy rummy!' with a wide grin. Then she might have said, 'All done now, mummy. Can my have some weetabix?' And wriggled down from the bed, and run to the door, turning back to say, impatiently, 'Come ON, mummy!'

My daughter Ada, my third and very likely last baby, is thirty months old and just about weaned (I think). The morning feeds have been becoming less frequent as the months pass, and they've been short (though very sweet). And this week it feels as though the end is nigh; this morning she said 'Milks?' when I got her up and I said 'Ok', but she shook her head, and squirmed to get down, and spotted her brother through the banisters, and went off to play instead.

Ada's first feed, November 2010

I find myself with mixed emotions: pride when I see how my daughter is growing up and becoming her own person, more separate from me; wistfulness when I recall her babyhood and realise how quickly it has passed; and a gentle sadness that my own experience of breastfeeding, which has brought me so much, in all aspects of my life, is coming to an end. When I wrote up my breastfeeding experiences for my collection of positive breastfeeding stories, Breastfeeding: stories to inspire and inform (published when Ada was eighteen months old), I concluded: 'It seems strange to think that I might be approaching the end of breastfeeding when it has been so central to our family life over the last few years. There's no doubt I will look back on it as one of my most precious experiences of motherhood.' I feel very lucky to have had almost another year of breastfeeding since I wrote those words, and that Ada has had such a gradual, gentle weaning. It will be fascinating to see whether, as she gets older, she will remember breastfeeding. A few weeks ago, my older daughter, aged six, came into the bedroom in the early morning while I was feeding Ada. 'Mummy!' she exclaimed in shock as she looked at us, 'I'd completely forgotten that you breastfeed Ada! How could I have forgotten that?' We all laughed, but I was struck by how, when we don't have constant reminders, even things that were once a completely integral part of the family 'furniture' can slip into memory.

Ada's favourite book at the moment is The Paper Dolls by Julia Donaldson, illustrated by Rebecca Cobb. We currently read it every single night. It's a beautiful book and the part that brings a lump to my throat, even on the umpteenth reading, is the part where, after the paper dolls have been snipped into pieces by a little boy with scissors, they continue to sing their song:..

'And the pieces all joined together,
and the paper dolls flew... 
...into the little girl's memory
where they found white mice and fireworks,
and a starfish soap,
and a kind granny,
and the butterfly hairslide,
and more and more lovely things
each year.'

I'm hoping that buried in the corners of my children's minds, along with all the other lovely things, there are some memories of breastfeeding that will be there all their lives. As for me, it's not so much a corner of my mind as an overflowing treasure chest.

And in some ways it's definitely not the end of the story: with publishing, writing, peer supporting and campaigning, I think I'll be busy with breastfeeding for a long while yet.

Baby milk shortages - formula manufacturers, the politics of infant feeding, breastfeeding

The news that Danone, which makes Aptamil and Cow & Gate formula milks, has imposed sales restrictions on parents in the UK has been all over the media this week. Shoppers are now limited to purchasing two packs of powdered infant formula per day. Supposedly this is to prevent bulk buying and informal export of formula to China - at least, that is the explanation that Danone have given on the brands' respective websites, in a letter from managing director John Sykes.

However, there can be no denying that the story has generated massive publicity for the brands involved. For example, in this segment on the BBC website the mother is filmed using Aptamil formula, and this article from the Daily Mail carries a prominent shot of both Danone brands on supermarket shelves, complete with shelf-edge explanation of the buying restrictions.

What better way to add cachet to the Danone brand than to let its UK market know how highly prized its products are in China? The fact that millions of Chinese consumers (in a country beset by formula milk scandals, where formula advertising is aggressive and unregulated, and breastfeeding rates are on the way down) trust the brand and will pay inflated sums for it is surely something worth (from Danone's perspective) instilling in the minds of UK consumers. In addition, products in short supply have 'rarity value' - it's like must-have toys at Christmas, or petrol, or limited-edition designer handbags - that 'value', in the minds of consumers, is great news for retailers and manufacturers. Crucially, 'news' stories are not seen as 'advertising', although in practice, as anyone involved in the media knows, they fulfil the same function - there is truth in the old maxim 'all publicity is good publicity'.

The knock-on effects of all this on our culture of infant feeding on the UK are more subtle. A slew of articles about formula feeding normalises it further - a shortage that affects millions of parents across the UK gives the message that 'everyone' is using formula as opposed to breastfeeding. Images of specific brands accompanying the articles make it more likely that parents, faced with a shelf full of products and with little access to accurate, unbiased information about infant formula, will reach for the product they recognise. As shown by the Daily Mail article mentioned above, a focus in the media on formula feeding can bring with it a wave of anti-breastfeeding feeling. The author of the article claims that "the breastapo are out in force, berating the formula feeding pariahs who feed our babies this manufactured 'poison'." I don't believe this or see any evidence of it; all this article shows is that, given a convenient peg to hang it on (news of a formula shortage), the same tired elements of a FF v BF argument that helps no one and only serves to divide women and line the pockets of the formula manufacturers, can be trotted out yet again.

(A separate, but I suspect related, article in the Mirror about vitamin D deficiency mentioned Cow & Gate Growing Up Milk by name, causing me to wonder whether the article had been 'inspired' by a Danone press release... the formula companies are very keen for parents to know that children consuming more than 450ml of first stage or follow-on formula per day do not need vitamin D supplements.)

Consider the context of all this. We already know from the Infant Feeding Survey 2010 that in the UK many parents are unaware of the differences between infant (first stage) formula and follow-on formula (suitable from six months) - the latter being an unnecessary product specifically designed to circumvent the restrictions on marketing infant formula imposed by the WHO code on the marketing of breastmilk substitutes, which is not even fully implemented in the UK. We also know that the formula companies will battle incessantly for market share with a huge array of marketing tactics (carelines, baby clubs, marketing to health professionals, roadshows... the list goes on). All this is funded by marketing budgets, paid for by formula consumers. Increased market share means increased profits. In this sort of climate a shortage of product makes perfect sense as an aggressive marketing ploy.

In case you think I'm overstating the case here, I'd like to highlight the work of Baby Milk Action, which has recently published a new report Look What They're Doing in the UK!. In the press release that accompanies the report Mike Brady, Campaigns and Networking Coordinator, says:

"Given the massive production capacity that Danone has in nearby Ireland there is something about this story that does not ring true: it is surely more likely Danone that is prioritising other markets than people exporting supermarket stocks. Danone is locked in fierce competition with Nestlé, particularly in Asia. Danone is gaining massive publicity for its products on the back of this shortage scare, but parents who use formula can heed Department of Health advice and switch to other brands. Claims made that one particular brand is better than another do not stand up to scrutiny. As our Look What They're Doing in the UK report demonstrates, companies are endlessly imaginative in how they push their products."

In the BBC report on the issue, Nestle, the second largest formula manufacturer in the UK market, said that it had not seen an increase in demand due to unofficial exports, and that there was no shortage of its products. (Nevertheless, some supermarkets are limiting sales of Nestle brands too.)

It seems to me that what's needed, as usual in reference to infant feeding, is wider access to clear, unbiased information that doesn't come from the formula manufacturers themselves, and this article in the Telegraph made the same point. UNICEFs Babyfriendly initiative publishes A guide to infant formula for parents who are bottle-feeding, which is a great place to start. Another good source (aimed at health professionals, but anyone can download the report) is Infant Milks in the UK.

It's also not unreasonable, as part of the ongoing discussion, to talk about breastfeeding. It's not shaming of those who use formula to point out that, on a population level, increased breastfeeding would mean both improved public health and less reliance on commercially-driven formula milk manufacturers. The 'shortage' story could be seen as demonstrating perfectly some of the most amazing qualities of breastfeeding: most mothers can produce hundreds of litres of breastmilk (incomparable to formula) for a zero carbon footprint - no food miles, no energy costs of manufacture or reconstitution, no supply-chain issues. 

I've been considering the implications of all this for breastfeeding support. I had a conversation with a formula-feeding mother while I was planning this article: she asked me what, as a breastfeeding peer supporter, I would do if someone asked me about formula feeding. I thought hard about what I could do in this situation, aside from talking to the mother about her reasons for switching to see if there was anything I could help her with before she stopped breastfeeding, and discussing the option of mixed feeding (on the grounds that any breastfeeding is better than none). I realised there's a lot of information I can give, although I would be upfront about my lack of personal experience of bottle or formula feeding. I do, however, know about the most recent guidelines for making up bottles and the reasons for them, and am happy to talk to mothers about them. I have also read the guides above and feel that I could tell a mother that since the composition of formula in the UK is regulated, and claims about differences between brands don't hold water, her decision can be based on price and what her child seems to prefer, and she needn't be restricted to one brand. I'd hope, in doing this, to leave the mother feeling better-informed about her options, and not let-down by a sudden lack of support when her circumstances change. I'd love to hear what other breastfeeding supporters think about this.