If breastfeeding is so great,
why are the rates so low?

(1) Baby-Unfriendly Maternity Hospital Practices

Maternity hospital practices contribute to widespread breastfeeding failure. The routine use of drugs during labor and delivery often results in babies arriving in this world in a drugged state, unable to bond their mothers or latch onto the breast. The immediate separation of mother and baby so that the baby can undergo routine tests and procedures (all of which could be delayed without any harm to the baby), also interferes with the baby's ability to initiate breastfeeding during the crucial first hour after birth, when most babies are in a relaxed, alert and receptive state. Unnecessarily aggressive suctioning of the airway immediately after birth traumatizes some babies so much that they shy away from all oral stimuli -- including bottles -- for days after birth. Many babies are routinely given bottles of formula or glucose water in the hospital nursery, even when their mothers have requested that no bottles be given and that their babies be brought to them to nurse. Since formula is easier to get out of a bottle than human milk is from the breast, even one bottle feeding can cause some babies to form an irreversible preference (sometimes known as "nipple confusion") for the bottle nipple; those babies may never be able to breastfeed normally.

(2) Formula Company Marketing Practices

Formula marketing targets women. New mothers are given free samples of formula, babies are given bottles in hospitals, coupons or food samples arrive in the mail, or booklets and videotapes are distributed on breastfeeding and weaning. The World Health Organization's Code for the Marketing of Breastmilk Substitutes prohibits marketing of these products in these ways. It covers formula, other milk products, cereals, teas and juices, as well as bottles and nipples.

The Code has 10 important provisions.

• NO advertising of any of these products to the public
• NO free samples to mothers
• NO promotion of products in health care facilities, including the distribution of free or low- cost supplies
• NO company sales representatives to advise mothers
• NO gifts or personal samples to health workers
• NO words or pictures idealising artificial feeding, or pictures of infants on labels of infant milk containers
• Information to health workers should be scientific and factual
• ALL information on artificial infant feeding, including that on labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding
• Unsuitable products, such as sweetened condensed milk, should not be promoted for babies
• Manufacturers and distributors should comply with the Code's provisions even if countries have not adopted laws or other measures.

The Code was endorsed by the United States in May, 1994.  Nothing has been done so far to implement the Code in the United States.  Here are a few examples of the formula companies' continued use of the prohibited unethical means to market their products:

Many hospitals have arrangements with formula companies in which the hospital receives hundreds of thousands of dollars annually from the formula company. The hospital then promises to give every post-partum woman a discharge package designed by the formula company. Not surprisingly, these "gifts" are covered with the logo and advertising slogans of the formula company, and contain free formula samples, coupons for more formula, and pamphlets full of misinformation about the hazards of formula feeding. When the new parents get home with their baby and their "gift," the result is often the following scenario:

Three days after baby is born. 3 a.m.
The baby has been crying for the last two hours. Mother's breasts are engorged and sore; baby is not latching on and sucking effectively. Parents don't know what to do because their knowledge of breastfeeding comes entirely from formula company sources. They are worried about baby being hungry. They are exhausted and do not know whom to ask for help. The bottle of premixed formula from the hospital discharge pack is sitting on the table next to the crib. They feed the formula to the baby, and s/he quiets down and sleeps for several hours because formula is more sedating and takes longer to digest than human milk. Mother's milk supply is reduced because the milk in her breasts wasn't removed by her baby. In the following days, baby needs more and more formula. Mother's milk supply quickly dries up and baby is fomula-fed.

The result of this marketing strategy is to ensure that every new mother is given misleading information about infant feeding, as well as the means to undermine any efforts she may make to breastfeed her baby.

Doctors and nurses charged with the care of post-partum women and their newborns are showered with gifts, including a full year's supply of free formula to any nurse or doctor with a new baby. This is a particularly brilliant marketing gimmick, since this greatly increases the chances that the nurses' and doctors' children will be formula-fed and a health care professional who has formula-fed his or her own children is hardly going to be able educate his or her patients about the dangers of artificial feeding.

Another gimmick is a contest with valuable prizes -- run by a formula company -- to see which of the nurses in the post-partum ward can collect the most formula can tops. Obviously, this puts the nurses' interest (to win the contest, she must have more patients who feed formula and do not breastfeed) directly in conflict with the health interests of his or her patients.

Formula advertising directed to parents is rampant in hospitals and doctors' offices on prescription pads, pens, growth charts, pamphlets and posters. Doctors and hospitals routinely send personal information about pregnant women to the formula companies so that direct mail advertisements can be directed to them. This can have tragic results. as the mothers of stillborn babies continue to receive cases of formula in the mail for months after they have buried their children. Those formula companies that have been unable to penetrate the medical community as effectively, such as Nestle-Carnation and Gerber, advertise their products directly to the public on TV shows directed at new parents and in parenting magazines such as "Parents," "Child," "American Baby," and "Parenting," again, all in violation of the WHO Code.

Imagine what it would be like if breastfeeding were advertised competitively with formula!

(3) Medical Professionals' Ignorance of Breastfeeding

Another related reason for low breastfeeding rates is the almost complete absence of breastfeeding curricula in medical schools. A study published in the Journal of the American Medical Association shows that most doctors know little about breastfeeding. Freed GL et al. National assessment of physicians' breast-feeding knowledge, attitudes, training, and experience. JAMA 1995;273:472-476. The study looked at doctors' knowledge of the clinical aspects of breastfeeding. It revealed disturbingly high rates of ignorance about why breastfeeding is important and how to handle breastfeeding difficulties.  The authors of this study surveyed more than 3,000 residents and nearly 2,000 physicians practicing obstetrics, pediatrics and family medicine and found that few of them knew the basics of breastfeeding such as how to teach a new mother how to use a breast pump or what to do about low milk supply. Many doctors who are not educated about breastfeeding advise supplementing with formula when any problem arises with breastfeeding. The result: the baby is quickly weaned from the breast to the bottle because the mother's milk supply diminishes immediately in response to her baby's diminishing demand for her milk.

Interestingly, the study found that most important factor influencing whether a physician was knowledgeable about breastfeeding was whether the doctor herself, or the doctor's wife, had breastfed children.  This is apparently not news to the formula companies, who make sure that every physician who treats pregnant and post-partum women and is expecting a baby is offered a full years' supply of formula for free.

In addition, obstetricians generally decline to advocate breastfeeding to their pregnant patients on the grounds that "it might make the mothers who choose formula feel guilty." Of course, the doctors have no such qualms about advising pregnant patients to eat a healthy diet, or to quit smoking and drinking, because that might make the mothers who ignore their advice feel guilty. Formula appears to be the only health hazard that doctors fear to warn of because of fear of inducing guilt.

(4) The Bottle-Feeding Culture

Another big reason for the low breastfeeding rates is the bottle-feeding culture that has developed as a result of formula promotion and medical ignorance of breastfeeding. Babies are associated closely with bottles, not breasts. Go to any toy store. It is difficult to find a baby doll that doesn't come with a bottle. Look around you where mothers with babies can be found. Most of the babies are fed with bottles. The sight of a woman breastfeeding her child in public is so rare as to be remarkable.

The result is that the chain of cultural breastfeeding knowledge has been broken. Where breastfeeding is the norm, girls grow up seeing their mothers breastfeeding their younger siblings, their aunts breastfeeding their cousins, their older sisters breastfeeding their nieces and nephews, their neighbors breastfeeding their children, etc. Breastfeeding is a normal part of everyday life, and a girl inherits the accumulated knowledge of previous generations about such things as how to position the baby at the breast, how to tell if you have a let-down of the milk, and how to tell if the baby is properly latched on and is getting milk.

New mothers in a bottle-feeding culture need expert medical advice to take the place of the lost cultural knowledge of breastfeeding.  As the study cited above makes clear, such advice is unlikely to come from your doctor.  Someone with specific training in human lactation, such as a board certified lactation consultant. or a leader from a mother-to-mother support group, such as La Leche League International, is much more likely to be able to help you with breastfeeding problems than your doctor.

(5) Maternal employment

The belief that breastfeeding cannot continue when the mother works is an unfortunate misconception. Maternal employment is only a complete obstacle to breastfeeding if the mother must be separated from her baby for weeks. Otherwise, an employer need only make minor accomodations to allow employees to breastfeed their babies. With a clean, private place and about 20 minutes every 4 hours, a mother can express her milk for later use by her baby. With on-site or nearby daycare, a mother can breastfeed her baby directly during brief breaks. Even a mother who cannot pump or breastfeed during the workday can breastfeed her baby when they are together and supplement with formula at other times.

Formerly part of