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.