When ideology not medical reasoning guides infant feeding policy, nobody wins.
World Breastfeeding Week is upon us which means it is that time of year for the release of the World Health Organization (WHO) and UNICEF-led Global Breastfeeding Collective’s report and scorecard. Unfortunately, this missed opportunity merely shows how nothing has changed. Just like last year, no country in the world has met their idealized metrics for universal breastfeeding and the lack of implementation of their at all costs breastfeeding campaigns speaks to the fact they do not work. They have failed. And yet these groups continue to demand more resources be spent toward the prospect, in every country no matter how different the nation or unique the nature of its problems. Given the political climate, it is no surprise that last month’s correct effort by the U.S. delegation at the World Health Assembly to soften the language of a global breastfeeding pledge was met with media and public outrage that implied the Trump Administration by even suggesting women should know all of their options and the pledge should be revised must be anti-woman, anti-baby, and anti-decency. When ideology guides infant feeding policy, nobody wins.
If we can’t have an honest, complete discussion about infant nutrition, then we shouldn’t be making any commitments. As a physician, giving only part of the story would be undermining my obligation to provide fully informed consent. It would violate a patient’s autonomy. Policymakers should not be framing stories, rather they should be identifying issues in their entirety, enacting solutions that work in the real not just theoretical world and course-correcting to minimize the damage caused by unintended, adverse effects.
No doubt well-intentioned, the Global Breastfeeding Collective has done none of that self-reflection. Instead, they are doubling down on insisting breastfeeding within moments after birth is a matter of life and death, should be done so exclusively, and with significant restrictions placed on the awareness of formula.
What also needs to be said
Breastfeeding can be wonderful, but isn’t all of the time or for everyone. Formula, too, has saved lives. You can accept both of these statements and be a supporter of women, babies, families and breastfeeding.
There are a number of medical scenarios where breastfeeding moments after birth is not a priority - and shouldn’t be. For example, an infant born via C-section routinely experiences delaying transitioning, so can be breathing too fast and in need of respiratory support. Oxygen is way more important than risking aspiration by prematurely feeding the baby. The reason why the surgery was performed can also influence this reality, as can an unstable condition of the mother. Suggesting to women that their baby has a higher rate of dying as a result of not feeding that soon is not based on medical reasoning.
If a mother is profoundly malnourished, then the baby will not thrive. Declaring breastfeeding should be exclusively done under any and all circumstances has led to infant malnutrition, dehydration, hospital readmission and worse. Lumping formula into the category of “breast milk substitutes” does not recognize that it is a major medical advance as an alternative source of nutrition. The existence of this sole source of sustenance for an infant who cannot breastfeed is invaluable as is its use as a supplement when necessary. It needs to be differentiated from the other liquid and food sources (e.g. sugar-water, honey) that certain cultures or parents are using that pose real risks to an infant.
Putting the entire world into one pot ignores the regional disparities that contribute to the maternal and infant mortality rates. A lack of enduring public health infrastructures, access to clean water and proper sanitation are the major culprits in spread of disease. These issues are significant in areas of natural disasters and developing nations. Because breast milk is ready-made, it is understandable the global collective wants women to breastfeed. Formula can be ready-made, but that version tends to be more expensive and less available. As a result, many families in the U.S. and developing nations prefer powdered formulations since those are cheaper, easier to ship and have a longer shelf life. But, they need to be reconstituted with water. Contaminated water can make the process problematic. These WHO-UNICEF mandates to governments don’t address the fact that there are biological reasons a mother cannot breastfeed (in all parts of the world) or that she can be so poorly nourished herself because of the lack of refrigeration and clean water in the first place. Forcing a woman to breastfeed exclusively under these conditions can be harmful for the baby.
Women in countries with reliably clean water also face a lot of shaming with regard to how they feed their infant. The so-called Baby Friendly Hospital Initiative the Global Breastfeeding Collective endorses has contributed to stigma around bottle feeding. It also encourages infants to room-in with mothers 24 hours a day. This has created perverse incentives by hospitals to truncate staff and nurseries. With some mothers recovering from major surgery and on pain medications, the practice can put a baby at risk. One Oregon woman accidentally smothered her own infant to death. She is suing the hospital claiming the Ambien and Vicodin she was on for the C-section made her groggy and unaware when a nurse came in the middle of the night and left the baby beside her unattended to breastfeed. And, she just might have a case.
The list goes on with respect to the women who are on medications incompatible with breastfeeding (e.g. chemotherapy for cancer) or are under substantial stress (e.g. sudden death of a spouse). Others just don’t want to breastfeed - and that is okay too.
The policy the world actually needs
It is time for governments to shift their focus to implementing water purification systems, infection control measures and building public health infrastructures. Giving women a choice, knowledge and access to the best options available for feeding her baby should be center stage. So should education about signs of distress in an infant. Making all of these parameters accessible to all women throughout the world should be the goal - and sometimes steps to attain that won’t include exclusive breastfeeding. And, that’s okay.