The Guardian and Danone infant feeding roundtable - and why the politics of breastfeeding matter

A couple of weeks ago I Tweeted my disappointment that the Guardian had decided to run a roundtable discussion in association with Danone Nutricia; yesterday an article reporting on the debate appeared in the paper's society section; a full page, with the Danone Nutricia Early Life Nutrition logo clearly displayed, and an explanation that the content is editorially independent (which presumably means that the journalist, Joanna Moorhead, wrote her piece reporting on the discussion without having the text approved by Danone). As Helen Crichton, head of public affairs for Danone Early Life Nutrition took part in the discussion itself, and Danone was able to suggest topics to be included in the discussion, the term 'editorially independent' is at best only partially accurate.

Mike Brady, Baby Milk Action's campaigns coordinator, has already published an excellent response to the Guardian article; you can read it here. What follows is my personal response to the article, which attempts to explain some of the reasons it made me so uncomfortable/furious.

Participants
Paul Lindley, founder of Ella's Kitchen
Helen Crichton from Danone itself;
Judy More, freelance dietician. Her website reveals that she is on the editorial board of the Journal of Family Health Care, which runs training events sponsored by formula companies including Nestle, Danone and Hipp Organic, and that she has worked for the Infant and Toddler Forum:

"The Infant & Toddler Forum is supported by an educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests."

Professor Paul Gately from Leeds Metropolitan University. He has previously been a speaker at an event sponsored by the Infant and Toddler Forum.

Four of seven panel members have a clear conflict of interest in the discussion, because they are currently, or have been in the past, paid by companies that make profits marketing and selling products aimed at babies and young children. Judy More and Paul Gately's conflicts of interest were not made clear in the article; I found their earlier links to Danone with a simple search.

A major problem with this sort of 'invitation' roundtable discussion sponsored by a formula company is panel selection. Anyone who's had any sort of training on the International Code of Marketing of Breastmilk Substitutes, who works in breastfeeding, public health or in a Baby Friendly accredited NHS Trust should refuse to be involved. (For more about health worker conflicts of interest, see here).

Content/discussion
Reading the article I found myself occasionally incredulous. Paul Lindley (Ella's Kitchen) is quoted as saying, 'Food is what brings people together, but they're not eating together very often and very young children aren't learning the art of conversation or the joy of eating with others.' This from a man who founded a company that makes pouches of ready-made pureed baby food that babies can slurp alone in their pushchairs without making a mess! Is it just me?

Dr Lucy Cooke said 'There's a lot of confusion about breastfeeding. The Department of Health says breastfeed to six months, but baby foods say 4-6 months on the jar'. Both Lindley and More, who should both surely understand the Code, the Department of Health guidelines and how information is given to new mothers, given their work, instead perpetuated the confusion, with Lindley appearing to advocate early weaning by saying that the earlier you give children vegetables, the more likely they are to eat them later on. What he didn't say was that early feeding (before six months) with pureed foods like apples, carrots and parsnips, which his company supplies in pouches, displaces breastmilk in a baby's diet and may reduce their overall nutrition rather than improve it.

I was also deeply uneasy about the suggestion that 'one change that would make a huge difference was to encourage better collaboration between the government and the food industry'. The food industry already has extensive access to contacts in government, and will lobby hard for its own interests. There is plenty of evidence that if companies are not regulated, then they will not restrain their marketing practices voluntarily. If the industry is so keen to do good, surely it should first put its own house in order: in the case of Danone, with 39 pages of marketing Code violations worldwide in the IBFAN Breaking the Rules, Stretching the Rules 2014 report, it would seem that the company has plenty of work to do before embarking on seemingly generous public health campaigns. Ella's Kitchen too could look at its early weaning guidance and labelling so that it better reflects the information that mothers are actually given.

And mothers are often given good information; but we didn't hear anyone talking about it in this debate because of the inherent conflict of interest. Health visitors, midwives and breastfeeding supporters could have painted another picture; one where UNICEF Baby Friendly and the First Steps Nutrition Trust are sources of clear, independent information for parents. The LIFIB (Lancashire Infant Feeding Information Board) is a great example of how information from companies can be critically reviewed and challenged before being passed on to health professionals (see @The_LIFIB).

I could go on, and on. I won't, but I will leave you with this quote from my forthcoming book with Gabrielle Palmer for Pinter and Martin Why The Politics of Breastfeeding Matter, which sums up my thoughts.

"When ‘knowledge’ comes from company promotion [which is what Danone-sponsored activities are] and poorly trained or corrupt health workers, parents and children suffer. Knowledgeable and supported families, who are aware that breastfeeding is normal, that artificial feeding carries risks, and that cheaper, safer baby foods can be made from locally available ingredients, end up healthier and less poor. The Code states that governments are responsible for ensuring that objective and consistent information on infant and young child feeding is provided. But it is hopeless to invest public money in providing such information if it is eclipsed by promotional untruths."

Why are we working hard to get mothers to breastfeed, then encouraging them to stop?

This week I've been thinking about the messages mothers get from their health professionals, peers and the older generation about breastfeeding past six months, and how this plays out in our culture of infant feeding in the UK. (This train of thought was sparked off by several conversations I've heard

Breastfeeding my poorly 23-month-old

recently between mothers - mostly first-time mothers - and health visitors, Children's Centre workers and doctors. It's not my intention to be particularly critical, more to explore what we are actually saying to mothers, and the effect it has).

There's a lot of focus (at least in my area of Derbyshire, where we've been working towards, and recently obtained, full Baby Friendly accreditation in the community (DCHS) and the county council (DCC)) on improving rates of breastfeeding initiation and continuation (measured at 6-8 weeks). All the hard work, by DCHS, DCC and volunteer organisations such as BEARS, the peer supporters I am involved with, is really paying off and we were delighted to get the UNICEF endorsement - part of which involves interviews with mothers themselves - that shows how far we've come in recent years and how much better we are doing in supporting women who want to breastfeed, at least initially.

But what happens to mothers after six to eight weeks? Peer supporters at breastfeeding groups often have experience of breastfeeding for much longer than six to eight weeks - so they are well placed to offer ongoing support to mothers who continue breastfeeding. But not all mothers attend the breastfeeding groups, and as their babies grow they have more contact with health visitors, practice nurses and Children's Centre workers at baby weighing clinics, developmental reviews and vaccination appointments, and their friends, relatives and casual acquaintances will all have something to say on the subject of continued breastfeeding too. As the weeks and months go by mothers are exposed to an awful lot of misinformation - hardly surprising when as a nation our breastfeeding rates at six months and beyond are so low, with fewer than 1% of mothers exclusively breastfeeding for six months, and only 34% breastfeeding at all at the six-month mark. Our society's collective knowledge about breastfeeding past six months is thus sadly lacking, something it is well worth bearing in mind when weighing up how much importance to attach to people's comments.

When I took my youngest daughter for her vaccinations at a year old I mentioned to the nurse that she was still breastfeeding (as there was a box to tick in her red book for 'still breastfeeding at all at first birthday'). She said, dismissively, 'oh, we don't need to collect that information'. She then went on to tell me how, if she ever had children of her own, she would definitely bottle-feed them, based on her experience with puppies! I was taken aback, but it was only later that I wondered whether, if I'd been a first-time mum rather than an old hand, I might have been more affected, even unconsciously, by the way she casually diminished the importance of breastfeeding.

I've recently heard a mother of a ten-month-old baby, still happily breastfeeding, advised to cut his daytime feeds in order to give him 'healthy' snacks, and to reduce and stop his night-time feeds as he 'doesn't need it nutritionally'. This mum didn't ask for help to stop breastfeeding; she was worried about her baby's wakefulness at night (for which she was advised controlled crying, despite saying that she didn't want to go that route - a whole different post...). The mother of a seven-month-old baby, who is mixed feeding - breastfeeding with one bottle of formula at night - was again advised to offer snacks in the daytime and encouraged to hurry her baby on to more solids rather than breastmilk so that he will 'cut down on his feeds' - she was told that the baby should ideally be moving to three meals a day plus two healthy snacks, and, somewhat confusingly, that he should still be getting a pint of milk a day, which would equate to '2 or 3 breastfeeds at the most', and she was told that her baby needed vitamin drops as part of the same conversation. The implication was that these mothers were now meant to be transitioning away from breastfeeding, when the reality is that for infants under a year, breastfeeding is still a hugely important part of their overall nutrition, and can continue alongside other foods for as long as mother and baby want. We are doing mothers and their babies a disservice if we are, even with good intentions and an eye on the nutrition guidelines, shepherding them down a path that leads to reduced feeds and an early end to breastfeeding.

Another mother I know of, who had a rough start to breastfeeding and was worried she might have to stop despite having fed her first child for a year, was told not to worry as the 'target' was six to eight weeks! The problem here is not the sentiment - I'm sure this person was trying to say something reassuring to a mum who was struggling - but that actually, her comment misrepresented the situation entirely. The immediate target for increasing breastfeeding rates may be the six to eight week measure in terms of the breastfeeding strategy in the county, but for that individual mother the NHS and WHO guidelines, which recommend breastfeeding to two years and beyond, are much more important for her own health and that of her baby.

What's missing, in all of the above, is an understanding and appreciation of the flexibility of breastfeeding an older baby, toddler or child: the way it continues to provide valuable, tailored nutrition, how it can fit in around solid food, going back to work and changing night-time routines, and the way in which it can continue to be hugely important to mothers and their babies for years to come, both in terms of nutrition, and in terms of their relationship (I wish more people could experience breastfeeding an older child who is poorly and miserable and can't stomach anything else, for example). Children grow up so quickly - why hurry the weaning process if there's no need? Why can't we support and encourage women to breastfeed in the longer term, and then support and encourage them when, for whatever reason, they or their children want to stop?

It's been heartening to see Sharon Spink in the news in recent months talking about breastfeeding her five-year-old, after Michelle Atkin did so earlier in the year. And I loved this story about a mother breastfeeding her toddler on Australian TV. I hope that stories like these, and the debates they provoke, will help us as a society to improve our collective knowledge of longer-term breastfeeding so that we can offer better support to mothers, who in many cases have struggled to establish breastfeeding, only to have it suggested, after a few short months, that they should be 'moving on'.

There's a point to be made here, too, about how that 'moving on' message is one that's frequently heard and seen in advertising for follow-on formula and 'growing-up milk'; if we think babies and toddlers need milk, what better milk for them than that of their own species, delivered by their own mothers, rather than an unnecessary product developed to circumvent the regulations governing the advertising and composition of infant formula, which exists to line the pockets of the big baby food companies? Those companies work hard to target health professionals and mothers to get their messages across - so it is not just that our collective knowledge is lacking, it is also being undermined by those with vested interests. (For much more on this see the Baby Milk Action website; good information about formula milk is available from First Steps Nutrition.)

I'm sorry the blog has been so quiet in recent months; I've been busy working on all sorts of exciting projects, of which more news in future posts...

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.

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.

Good news for breastfeeding supporters: it can save the NHS £millions and improve public health

Supporters of breastfeeding have long thought that increased rates of breastfeeding would both save the health services money, and improve public health. Given all that we know about the risks of not breastfeeding it seemed obvious, and indeed it has been the underlying policy assumption behind much of the work to support breastfeeding in recent years. But until now, there was no UK-specific study to quantify how much money might be saved, and the scale of the improvement in public health. That has changed today with the publication of UNICEF's new report: Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. You can find the report, and a summary of the findings, on the UNICEF website.

As a passionate supporter of breastfeeding - I'm the mother of three breastfed children, a volunteer peer supporter in the NHS in Derbyshire and the editor of Breastfeeding: stories to inspire and inform, a collection of real-life accounts of breastfeeding designed to encourage and support mothers - the report made fascinating reading: although it aims to answer the question of how much money could be saved by increasing breastfeeding rates in the UK, in doing so it touches on many other aspects of the reality of breastfeeding in today's society.

What the report shows, in a nutshell, is that not breastfeeding is costing the NHS a lot of money. Or, to look at it the other way round, breastfeeding could save the NHS a fortune every year if it could only invest in the programmes, of training, information and support, that would enable women to breastfeed and to keep going for longer. The good news is that these programmes are relatively cheap (under £500,000 in the first year for an area the size of Lancashire, less year-on-year) and show a rapid return on investment, maybe even within one year. The NHS has precious few opportunities for such cost-effective health interventions - let us hope that the health planners and commissioners seize on the findings of this report and act on them immediately.

The picture painted in the report of the current state of breastfeeding in the UK is bleak. Across the country some 81% of mothers begin breastfeeding (although this varies from 42.5% to 92.5% by locality), but the number exclusively breastfeeding at one week drops to 45%. At 6-8 weeks the rate of any breastfeeding varies from 19.4% to 83.2% by locality. By five months 75% of babies get no breastmilk at all. Just 1% of mothers are exclusively breastfeeding at six months (see WHO guidelines). Women are clearly encountering problems or social barriers to breastfeeding and stopping early, often before they want to, and this is certainly my experience of working with breastfeeding mothers, even though I live in an area with high rates of breastfeeding initiation.

The costs of not breastfeeding, for the purposes of this report, are the costs to health services. (The costs to families of artificial feeding are not included). And the savings, even at modest increases in breastfeeding rates, are not to be sniffed at: for the five illnesses where the best quality evidence exists (gastroenteritis, necrotising enterocolitis (NEC), acute otitis media (ear infection), lower respiratory tract infections and breast cancer in mothers) the annual savings amount to over £40 million per year. Then there’s another set of outcomes (SIDS, cognitive outcomes, obesity) for which the authors couldn’t carry out the same statistical analysis as for the ‘top five’, but where cost savings are still suggested, and a further list of outcomes where breastfeeding is likely to have an effect (diabetes, ovarian cancer, cardiovascular disease, among others) but where more research is needed. That £40 million, it seems, might be just the start.

In terms of achieving the suggested increases in breastfeeding rates, the report acknowledges that breastfeeding promotion and support have not yet been consistently implemented, even in the areas where breastfeeding rates are lowest. The social, economic and political barriers to breastfeeding are clearly explained:

‘…an unsympathetic public attitude to breastfeeding outside of the home, an acceptance of formula feeding as a normal and safe way to feed babies, a lack of expertise and experience of breastfeeding among health service staff and, in many communities, a dearth of practical experience of breastfeeding among grandparents… Breastfeeding is... commonly associated with images of sexuality, or of feeding difficulties, rather than being seen as a normal, unremarkable, and fundamental aspect of parenting… As a result, when women encounter serious but preventable problems with breastfeeding (such as embarrassment and isolation when breastfeeding in public, painful breasts and nipples as a result of not understanding how to effectively attach the baby to the breast, and anxiety about their milk supply), they may struggle to find appropriate care and support. This may lead to their families, friends, and health professionals advocating that they solve the problem by using formula instead... Women’s choice to start or to continue to breastfeed is therefore constrained by the culture and community in which they live.’

Exactly.

One of the great strengths of the report is that it shows how putting programmes of breastfeeding promotion and support in place will show a rapid return on investment, as well as improving health outcomes for mothers and babies and addressing health inequalities (babies who are not breastfed are at increased risk of ill-health, and the babies most likely not to be breastfed are in the lowest socio-economic groups). The case studies in the report show how this can be achieved in practice.

There is more good news. The report takes what the authors call ‘a robust, systematic, conservative, UK-specific approach’ - it’s likely that, if anything, the cost savings to the NHS (and, by extension, the other positive outcomes) have been underestimated by the methodology used. It is clear from the findings that the more common breastfeeding becomes, particularly exclusive and continued breastfeeding, the higher the cost savings to the health service will be. This is great news for those of us already working in supporting breastfeeding: it confirms that our aim to encourage mothers to breastfeed and to keep going for as long they want to is not only the right thing for individual mothers and babies, but also for society as a whole. It also busts the old myth about breastfeeding only being best for developing countries where they don't have clean water or enough money for formula - this report, which uses only evidence from the UK or comparable industrial societies, couldn't be clearer about the impact of not breastfeeding on British babies.

The report both calls for a wider debate on infant feeding and contributes to that debate. The findings have implications that reach beyond the health service; we all have a role to play in normalising breastfeeding and every individual can make a difference. Breastfeeding your baby in public, smiling at another mother doing the same, or becoming a peer supporter - all these can help, in a small way, to change how breastfeeding is viewed in our society. Ultimately, we'll all be better off.

NB: It's important to be clear, in talking about improving breastfeeding rates and the risks of not breastfeeding, that we are referring to changing behaviour across the whole population of the UK. People's individual circumstances will vary, and what mothers need to know is that any breastfeeding will provide some protection against illness, and more breastfeeding will provide a greater protective effect. It's not the intention - of the report or this post about it - to put pressure on individual women to breastfeed (see here for a great post about pressure). But wouldn't it be great if, in the course of the discussion of the report, we could open a few people's minds to the idea of breastfeeding, or breastfeeding for longer?