Gail

Thank you for re-posting about your medical student from Bangladesh who said
that mothers in the USA see breastfeeding as an "option".  You have
introduced a subject I have become deeply troubled about in the last few
months - the concept of "choice" in relation to infant feeding - and I'm
hoping that others will send in their opinions.  At the beginning of the
year I was privileged to accept the job of co-coordinator of the task force
on children's nutrition rights for the World Alliance for Breastfeeding
Action (WABA) and I realize that this is a huge issue.  I agree that there
is a lot of work to do!

Currently, I am leaning towards the suspicion that the concept of infant
feeding choice may be more influenced by the culture that we come from than
any other rational, practical consideration.  Choice or free will is an
abstract concept, whereas feeding an infant is a practical matter, and what
is fed will influence his/her health, and even survival, in the short and
long-term.

Being a product of my own culture and environment, just like anyone else, I
am biased. In the hospitals where I visit as a private practice LC, mothers
are not given choices, they are expected to breastfeed.  I like this.  It
seems "normal" to me, and it sends an excellent message about the most
healthful way to feed all the babies, but it does quickly expose the few
mothers and babies who have real difficulties in initiating breastfeeding
(usually resolvable) and those mothers who actively do not want to
breastfeed (usually un-resolvable) because neither group can hide behind the
concept of just choosing not to make the attempt.  Usually I am just used as
a facilitator/technician, very seldom as an advocate, and consequently, to
me, there are certain aspects about whether a mother has the right to choose
how to feed her baby, which seem to be irrational.

I do realize that since time began there have always been women, or groups
of women (certain social classes) who found a way not to breastfeed, but
these women were usually in the minority.  It has only been as a consequence
of the "invention" and marketing of commercially manufactured breastmilk
substitutes, ie only in the last 100 years or so, a microcosm of time, that
large numbers of women in the more developed countries (North America, parts
of Europe, perhaps Australia) have been able to *not* breastfeed and still
have their babies survive, and thus have the apparent ability to "choose"
not to breastfeed if they don't want to.  Yet I think we sometimes forget
that in numerical terms -  babies born in the world annually - these mothers
still comprise a very small minority.

It helps to stand back a bit, and look at what has happened. In spite of the
fact that maternal breastmilk production occurs after the birth of almost
every baby, regardless of what anyone *thinks*, marketing of formula, and
enthusiastic acceptance of this substitute by women, often as a result of
the advice of healthcare workers, has been so wildly successful that it has
now become the cultural norm in much of the industrialized world. So we have
arrived at the point where current international human rights doctrine,
which we have to remember was developed by the west and reflects western
views, placing a very high value on independence, free will, individual
freedom of expression, now enshrines each individual mother's absolute
"right" to "choose" how she will feed her infant.

The normality of the concept is pervasive and so insidious that we may not
even realize how far it has gone. If you read the fine print in much of the
documentation/research on infant feeding, when the words "choosing", or
"deciding" are used in the same sentence as the words, "infant feeding", the
wording never refers to "breastfeeding" or "formula" as you would expect.
On the contrary, these documents always talk about either "breastfeeding" or
"choosing".  So that "choosing" really means choosing *not* to breastfeed -
which in turn means that the whole concept of choice has in fact become a
politically correct euphemism for the use of formula.  These documents are
now being used to superimpose a western ideology, practised by the minority,
on the global majority, for whom it has up to now been unknown and
completely alien, and thus it is not even democratic, let alone rational.
I think we need to be very alert to the possibility that the human rights
agenda, now so popular, is being actively used by industry in a very
effective way to exploit a huge potential market.

Now we come to the nitty-gritty. The physiology is that the hormones
produced by the baby's placenta will have caused his mother to produce from
as early as the 16th week of pregnancy, the exact milk that he needs to
survive and thrive. After birth the breasts continue to function as an
extra-gestational placenta, regardless of his mother's thought processes, or
the intellectual "choice" that she has made. In the normal course of events
the baby breastfeeds.  But what happens if the mother has been persuaded, by
whatever outside influence, to believe that she has the right to withhold
her milk from her baby?   An immediate conflict arises between the right of
the mother *not* to breastfeed and the right of the baby to be breastfed.

Currently, buried within the mass of human rights documents, it is stated in
one place that the baby has the right to "adequate nutrition", and in
another place the right to "the highest atttainable standard of health" -
another contradiction.  But nowhere is the acknowledgement made of this very
special conflict between the mother's and baby's rights, nor of the baby's
extreme vulnerability and need, and his right to be protected at this very
critical time in his life from the effect of a western-lifestyle "choice".
Instead, we continue to place the mother's ideological right to choose
*ahead* of the baby's extreme need.  Does this marginalize the rights of the
most vulnerable member of the dyad, and why should the mother's rights be
given precedence?

The popular current thinking seems to duck this issue by suggesting that we
should protect the *joint* right of the mother and baby to breastfeed. It is
assumed that the mother will be motivated to act in the the best interests
of her child, and that all we need to do is to protect the mother-baby unit
from any outside influences which might subvert their joint right.  But in
the case of a mother who is persuaded that she doesn't need to breastfeed,
it still leaves the baby out in the cold, and there seems to be a general
unwillingness to acknowledge the competing needs of the mother and the baby.
Concerns have also been voiced that it would be impossible to enforce a
baby's right to be breastfed because no mechanism exists to force an
unwilling mother, and it would be unthinkable to penalize her for making
what we would consider a poor choice since we're all allowed to make poor
choices - usually as long as they don't hurt anybody else.

When it comes to the competing needs of the mother and the baby in this sort
of situation, I find it illogical, and actually downright dangerous, that we
currently place the rights of the adult member of the pair, who is fully
grown, and mostly immuno-competent, ahead of the needs of the very
vulnerable infant. I do it myself, but I wonder just what it is that makes
us attach a higher order of importance to the imperative of avoiding making
a mother feel guilty if she chooses not to breastfeed, at the expense of
speaking out for her baby's need for her milk?

Certainly, the mother has the ability, because she's bigger and stronger, to
feed the baby mulligatawny soup if she wishes. Where there are rights, there
are usually corresponding obligations placed on people or governments to
find ways and means to uphold and enforce those rights. Consequently, in
some countries the State meets the obligation to protect its infants' rights
to "adequate nutrition" by providing breastmilk substitutes in case
low-income mothers who do not breastfeed should feel no personal
responsibility to feed their babies a "suitable" food.  It is interesting
that often the State is *not* obliged to foster an environment where the
infant could attain "the highest standard of health" by receiving the most
logical and economical food in the circumstances - breastmilk.

It becomes even more irrational if we take the accepted ideology of infant
feeding choice in the most civilized/developed countries to the
resource-poor settings into which the overwhelming majority of the world's
babies are born. 1.5 million of the world's babies die every year because
they have not been breastfed.  10 million children under the age of 5 die of
diseases where malnutrition is at least partly responsible and longer
breastfeeding would reduce this toll.  Then we realize that it is only in
areas where there is unlimited formula, and clean water, and where
mothers/families/governments can access doctors, medications, hospitals to
treat the deficiencies, allergies and infections that result when
breastfeeding is abandoned, that mothers *can* afford to choose *not* to
breastfeed.  Not to do so without these luxuries would be to place the
baby's health and survival in jeopardy.   So do mothers living in conditions
of poverty still have the right to choose?  No?  OK, so the right to
"choose" is *not* universal?  Could it be then that the right to choose is
limited in certain instances, or that it is a selective right?  Or could it
be that mothers living in so-called resource-full settings have the
*privilege*, rather than the "right", to withhold breastfeeding, or
alternatively that they can afford to *forfeit* their babies' right to be
breastfed?

The more I ponder, the more it seems that a gap exists in the current human
rights law on infant feeding.  The very words "infant feeding", rather than
"breastfeeding" alert me to this possibility!  Perhaps the UN meetings
coming up later this year could provide a forum for the nutritional rights
of babies and young children to be re-examined. I think most of us who love
this work are motivated by what we believe is "best" for babies. That is, we
work with mothers, to enable them, to assist them, to provide them with
techniques and tools, so that more of them can breastfeed their babies, and
for longer.  Now we have libraries full of evidence-based research to back
us up. If it was clearly stated somewhere that the baby had the right to be
breastfed and/or as far as possible to receive his own mother's milk, it
would give us a much stronger position to continue to work from - to remove
the many obstacles that mothers face as they attempt to give their babies
the best possible start in life.  One of the biggest obstacles is the
perception that breastfeeding is only an "option".

Pamela Morrison IBCLC, Zimbabwe
[log in to unmask]

Gail Hertz wrote, "I have a new medical student working with me this month.
She is a young woman with 3 children (all breastfed). She was from
Bangladesh, but had moved to the US as a school-aged child. We were
discussing breastfeeding (of
course), particularly why so many women don't breastfeed their babies. And she
said: "Women in this country see breastfeeding as an 'option'." ... We have
a lot of work to do...."

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