Ann wrote on the subject of latching on and other mammals and asked about
before-and-after experiences from breastfeeding cultures before formula
companies arrived on the scene.  I hope others will contribute to this
discussion, but maybe I can add a small perspective to this too.  I think I
might have written in a similar vein before, and hope no-one minds if I'm
repeating myself.

I feel quite strongly about the need to explode a possible myth.  It might
be tempting to think that because mammals apparently nurse their young so
easily, that indigenous populations for whom breastfeeding is perfectly
normal - those who have not been exposed to Western norms of formula and
bottles which so sabotage the art and skill and age-old wisdom  - will
breastfeed easily and successfully too.  I'd like to correct this
assumption even though I held it myself for quite a while and many of the
caucasian mothers I work with believe it too.  I've also met other people
from overseas, even those who actively work to support breastfeeding, who
seem to believe that if you take away the trappings of civilization
breastfeeding will happen almost by magic, and that all we need to do is
get back to our roots and all mothers would breastfeed with no problem at
all.  Not only is this not true, but it means that international efforts to
support and protect breastfeeding will be trivialized, or even deliberately
undermined.

Having worked with breastfeeding women of all races and socioeconomic
groups in Zimbabwe for the past 16 years  I can assure you that ordinary
African women living in great poverty, for whom *not* to breastfeed is
completely unthinkable and who, until recently (read on ...) would never
have known of feeding by any other method, *do* suffer from sore nipples,
mastitis and abscess.  And they often have babies who fail to thrive on
breastfeeding.  In fact, the very *worst* cases I have ever worked with -
the dreadfully damaged nipples that go on and on, the worst abscesses, the
babies who have lost 30% of their birthweight by 11 days of age, or who
have been found emaciated and dehydrated at one month, or even two months,
have been African mothers and babies.  I suspect that because the cultural
expectation is that breastfeeding has to happen and always works, that
maybe small problems get left too long.  Also, to be sure, medical
treatment is no longer free and has often become completely unaffordable
for women living in great poverty.  I also wonder what proportion of infant
mortality in indigenous populations could be attributed to
breastfeeding/lactation difficulties, and suspect that these things are
under-reported.

But the main difference between indigenous mothers and others, is that in a
breastfeeding culture (over 99% of all mothers initiate breastfeeding, and
most babies are weaned at 18 - 21 months) the African mothers who have
initial difficulties are just very, very persistent about persevering
through them.  Almost nothing causes them to abandon
breastfeeding.  Because there is simply no alternative these mothers are
very patient and determined, and they persist where the others would give
up.  I wish you could see the mothers of the prem babies sitting on hard
wooden benches in the neonatal units, no privacy, no comfort, expressing
their milk by hand endlessly into bowls before every feed and how they
almost always manage to supply the baby's entire needs within 2 - 3 days of
birth.

As to whether breastfeeding normalcy changes over time, yes this has
changed over the years, firstly for the better, then for the worse, and
maybe for the better again.  Many of our senior healthcare staff were
trained overseas, or were trained by local people who had received their
training in European hospitals using European policies and protocols. For
instance, in 1977 my newborn was kept in a central nursery, received
formula during his first 24 hours, and was subsequently brought to me every
4 hours for feeding.  But in 1989 Helen Armstrong and Elizabeth Hormann
came to present at a workshop for senior health personnel to promote
breastfeeding and, as far as I know, this marked the beginning of an
extremly aggressive and successful national breastfeeding campaign.  In
1990 our Minister of Health was a signatory to the Innocenti Declaration,
and in the next few years a National BF Coordinator was appointed and a
multi-sectoral committee was formed, and by 1997 we had certified nearly
25% of hospitals as baby-friendly.  In addition, we dug our draft Code
legislation out of mothballs, and got it passed finally in February
1998.  Mothers not only breastfed, many more of them *exclusively*
breastfed and EBF rates rose from 11% to 39% in about five years.  Working
mothers get 14 weeks maternity leave and two half-hour nursing breaks for
the first six months.  So by the late Nineties we had an existing
breastfeeding culture which was being very successfully and energetically
supported and protected.  Formula was simply not available in any hospitals
for full-term healthy babies, all mothers were expected to breastfeed from
Day 1, and they continued to receive the message that breastfeeding was
good for all babies.   As a BFHI assessor I loved it when we questioned new
mothers about the use of bottles and teats and they would just look puzzled
because they didn't know what we were talking about.  We wondered if even
asking such a question would make them curious and inadvertently "promote"
their use.  The marketing of infant formula and weaning foods for all
babies under 6 months was prohibited in supermarkets, the media etc. so
mothers were never exposed to freebies, or even "specials", or glossy
pictures or misleading advertising.

But then came HIV.  Later in 1998 UNICEF reversed their position on HIV and
infant feeding, to encourage all HIV+ mothers not to breastfeed if they
could possibly feed replacements instead. With an HIV prevalence rate of 25
- 40% amongst antenatal mothers, instead of industry marketing its products
we had the international healthcare agencies saying breastfeeding for over
a quarter of our infant population was dangerous.  And breastfeeding
promotion stopped dead in its tracks.  Now we have at least 30 sites
promoting this policy and nearly all healthcare staff are terribly worried
about promoting breastfeeding "just in case".  WBW was not celebrated at
all last year and I haven't been invited to a BFHI Task Force meeting for
ages.  So there has been a serious erosion of our lovely breastfeeding
culture, and a huge spillover effect.  It's such a shame.

The irony however is that the recent destruction of commercial farming, the
collapse of our economy and the fall-out for our healthcare system creates
the situation whereby the sabotage of breastfeeding is itself being
undermined as it becomes obvious that when resources are very low or
non-existent, breastfeeding is necessary to keep babies alive.  Milk of all
kinds is terribly terribly scarce (that's pasteurised, long-life, dried -
few dairy cattle left = little milk).  Sugar is almost impossible to
find.  There is only one local manufacturer of infant formula whose product
is now price-controlled.  Slapping price controls on any commodity
immediately causes severe shortages because a) the manufacturer is unable
to sell it for what it costs to produce, and b) clever entrepreneurs will
buy up all existing stocks for re-sale on the black market at outrageous
prices.  Consequently, sufficient locally produced formula to feed one baby
for one year would cost 50% of the annual minimum wage, even at the
controlled price (approx US 81 cents for 450g in real terms) and bearing in
mind that unemployment is over 60%.  But even more importantly, the stuff
is virtually unobtainable.  Imported formula, ranging from 2.5 to 3 times
the annual minimum wage is slightly more easily obtained - well, now,
anyway - though the acute shortage of foreign exchange means that imported
formula is likely to become more and more difficult to find as time goes on.

So we have reached the point now where in effect mothers have no choice but
to breastfeed.  Even my very "rich" privileged clients. This makes it very
fraught for those few babies whose mothers experience real difficulties,
but certainly the overwhelming majority of babies benefit from this
situation. I wrote to Lactnet a few days ago about mothers who were
encouraged to exercise choices, and about the obligations of LCs to
identify the rights of the baby.  This is becoming *much* easier for me now
with the mothers I would describe as "marginally motivated" to
breastfeed.  I simply point out that choosing not to breastfeed is becoming
very risky.  One baby needs 40 kg of formula for the first year of
life.  As they know, formula is becoming increasingly scarce/unobtainable
(as well as horribly expensive, inflation is expected to reach 500% this
year) and buying a tin or two, or even a case or two of formula now will
not be enough to guarantee their babies' food security for the next
year.  Whereas if they *breastfeed* their babies will be safe.  I keep the
focus on the baby and not on the mother.

It has been said that in order for formula feeding to take hold two
conditions need to exist: 1) it needs to be available and 2) it needs to be
socially acceptable.  The HIV and infant feeding debacle has made formula
feeding somewhat more acceptable, at least to healthcare staff, if not to
mothers.  But lately the first condition is not fulfilled.   I think that
mothers in resource-poor settings are much more prepared to work through
the difficulties associated with initiating and maintaining
breastfeeding.  And in any situation where there is flood, famine, civil
emergency, war, political withholding of food etc, it is life-saving if
there is a breastfeeding culture to fall back on.

Thank you to all who sent in such wonderful replies to my choice post.  I
hope I've made it clear that "choice" is the luxury of privilege.  I agree
with the point that Barbara made that women cannot be ordered to breastfeed
in conditions whereby breastfeeding will fail.  There is also a
responsibility to help them succeed.   One of the problems is that the
protocols and policies in areas of the world where the choice *not* to
breastfeed is seen as perfectly normal (where less than 10% of the world's
babies are born) are so very influential!  IF there was an underlying
universal acceptance that the baby had the right to breastmilk then we
could all work towards creating conditions whereby women's rights could be
strengthened, they *would* be helped to breastfeed, and they would *not* be
encouraged, or rarely need, not to.  And IF formula feeding was made less
easy, then more babies would be breastfed.

Pamela Morrison IBCLC
Harare, Zimbabwe
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Date: Mon, 17 Mar 2003 16:09:50 -0700
From: "Lown, Ann" <[log in to unmask]>
Subject: Latching on and other mammals
For the longest time, like so many people, I've wondered about the
relationship between bad latching, reduced maternal confidence and
formula-culture interference. Anybody out there, like Helen Armstrong or
Kathy Dettwyler, with experience of breastfeeding in places before Western
culture, formula-feeding culture and formula companies arrived? Then with
experience in the same place later to see how things changed? What is the
incidence of sore nipples in populations where breastfeeding really is
normal? The incidence of mastitis? Or, if this is already old news, anybody
got ideas for an archive search to pull out the answer: I'd need to look at
more than "sore nipple". Thanks.
Ann Lown RN RLC, Santa Fe, New Mexico

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