The White House surprised many observers by blocking a World Health Organization resolution on breastfeeding in the United Nations recently. For American mothers, this news can seem divorced from reality.
The pressure to breastfeed is palpable in the U.S., even outright aggressive, according to women who spoke with WikiTribune about their experiences.
American hospitals and public health agencies are instructed to promote breastfeeding over alternatives, as a matter of policy, helping lead to 81 percent of infants being breastfed with some regularity in 2016, the highest rate in recorded history (Centers for Disease Control).
Yet on the world stage, America has historically been reluctant to criticize the near $40 billion infant formula industry, despite scientific evidence that breast milk is the healthier choice (Global Citizen). The four biggest companies are Nestle, Danone, Mead Johnson Nutrition and Abbott.
This contrast between what the U.S. promotes domestically, compared to what it says abroad, is a relatively new phenomenon. Often compared to the tobacco industry, breastfeeding advocates see America’s elevated breastfeeding rates as the result of dedicated civil society.
America’s formula legacy
Infant formula used to be the norm in the United States. In 1971, breastfeeding rates hit 24 percent, according to the American Association of Pediatrics.
The marketing of formula forty years ago wasn’t demonstrably different in the developing world compared to the United States either. Americans saw ads for Carnation evaporated milk as a “healthy” alternative for infants, while mothers in Brazil were told Nestle was the “modern” choice for their babies (New York Times).
And despite the growing scientific evidence behind the benefits of breast milk, the United States government proved to be distinctly uninterested in regulating the infant formula industry. When the World Health Organization proposed rules on the marketing of formula in 1981, the United States was one of three countries to reject them (Washington Post).
Current National Security advisor John Bolton allegedly fired a United Nations delegate who refused to lobby against the resolution during his tenure with the Reagan administration. (USA Today).
The WHO resolution was mainly a protective measure for mothers in developing countries who often do not have access to clean drinking water. Since formula must be mixed with water newborns are often left with contaminated food, resulting in the deaths of tens of thousands every year.
But the general health benefits of breast milk were beginning to mount during this time as well, and the medical community was increasingly recommending breastfeeding. Yet breastfeeding rates hovered in the 40 percentile 1990s, according to the Center for Disease Control, dropping past regions of China, a country known for its unregulated formula market.
While the American medical system was moving towards breastmilk, the culture of formula-fed America was deeply rooted, according to Dr. Susan Vierczhalek, chair of the New York State Breastfeeding Council. Just having the science on their side wasn’t enough to fight the inertia towards the bottle. Targeted advocacy and educating healthcare workers was how the U.S. separated itself from its infant formula past.
“In the past, I think some of the perception has been this is something special, or extra.” Dr. Susan Vierczhalek told WikiTribune, chair of the New York State Breastfeeding Council. “People seem to understand now that this is important, and it’s not just a lifestyle choice.”
Reforming the U.S. healthcare system
The first step was getting healthcare workers to explicitly articulate breast milk as the superior choice. While the science behind the effects of breastfeeding and brain development are far from conclusive, there is strong evidence that breast milk helps develop a newborn’s immunities, especially its digestive system (Nutrients). The concept of nurseries, where to the baby is separated from the mother after birth, have been increasingly phased out in hospitals to ensure that breastfeeding beginnings immediately (Today).
The second step was going beyond advocacy, and tangibly assisting mothers to breastfeed. The “breast is best” slogan was used in American hospital rooms in the 1990s. But, similar to the “Just Say No” campaign against drugs in American classrooms, impact was limited. The particular challenge has been getting low-income mothers, with inflexible work schedules, “off to a good start.”
“For some who work in commercial industries and big, private corporations, a lot of them get paid leave as a benefit from their companies. Most of our moms who work in lower income jobs don’t.”
The Special Supplemental Nutrition Program for Women, Infants, and Children, known as “WIC” for short, provides half of the formula purchased in the United States (Wall Street Journal). Recipients can get baby formula, for no cost, typically for a year. In the past by the program essentially incentivized formula-feeding by offering more product if a mother did not breastfeed at all (International Breastfeeding Journal 2006).
However Kathleen Carpenter, a former nutritionist with WIC, says the program has come a long way in 40 years. “Since those early days, the program has steadily moved in the direction of being the ‘breastfeeding program’, not the ‘formula program'”
“All pregnant women are given information on breastfeeding and assigned a peer counselor who stays with them throughout their pregnancy and after delivery.” says Carpenter, who has continued her breastfeed advocacy since retiring from WIC.
While WIC remains the largest buyer of formula in the U.S., the program incentivizes breastfeeding by offering more generous WIC packages, if a mother commits to completely breastfeeding.
Civil society missing in the developing world
Government support for breastfeeding in the United States is only growing. After Idaho passed its legislation this year, breastfeeding in public is legal in every state in the union (USA TODAY). Several op-eds complain that the U.S. healthcare system bullies mothers to breastfeed, one from Slate defended Trump’s opposition to the UN resolution.
This system of grassroots advocacy, or public shaming, simply is absent in much of the developing world, despite it being more needed. Formula can become deadly for babies if mixed with unsanitary water, according to the World Health Organization. An article in the medical journal Lancet estimated that 800,000 child deaths could be avoided a year by breast-feeding.
Even with these inherent health risks, formula companies are increasingly marketing in developing economies (Guardian). These marketing efforts have been extremely effective in the Philippines where only 34 percent of mothers breastfeed for the full recommended six months, a staggering rate considered a month’s supply can eclipse many Filipino salaries. (Guardian).
Help improve this data: Salary Explorer, a user-generated data service, says the median salary in the Philippines is 29,000 pesos ($543). WikiTribune needs government data on salaries. Unicef says the average monthly supply of formula in 2003 was 4,000 pesos.WikiTribune needs a more current cost estimate.
The message in formula ads in developing countries is often the same as American formula TV commercials, including that the product is linked to intelligence and success – a tactic that studies show is particularly effective regardless of nationality despite their being no evidence for the claim (Science Direct).
Unlike the U.S.,there is little public momentum for breastfeeding initiatives in countries like Vietnam or the Philippines unless the federal government pursues such an agenda. Often these government led efforts are quelled before they begin. Associated Press reported that an attempt to regulate marketing practice in Vietnam was overwhelmed by a well-funded legal effort from the industry.
President Donald J. Trump, and the U.S. government in 1981, assert that they are not anti-breast milk, rather they simply want to preserve formula as option for mothers who are unable to breastfeed.
Patti Rundall, director of UK-based Baby Milk Action, is quick to agree that formula is sometimes necessary, especially in countries that lack the capacity to freeze and distribute donated breast milk. Her objection is in the specific marketing practices of formula companies, much of which are in violation of the 1981 UN code that the U.S. also opposes.
She says the most dubious forms of formula marketing has gone well beyond newborns, and towards what’s known as the “follow-up” market, meaning toddlers.
“These are unnecessary products that are aggressively and misleadingly promoted and are fuelling the obesity epidemic and undermining breastfeeding – undermining the health safeguards that exist in many countries.” Rundall told WikiTribune.
Advocates like Rundall have compared formula companies’ focus on the developing world to that of the tobacco industry. But at the same time, they are careful to not overstep in their campaigning (World Nutrition Journal).
She knows that educating women on the benefits of breastmilk doesn’t help them if without the time and resources to do so. Not every country guarantees mothers’ time off from work to bond with their child like the UK. “There are so many angry women out there who believe that we are trying to pressure them – when they have very few options. I take my hat off to women who manage to breastfeed with no state support.”