Ellen stated that "Here in Israel, we have been trying for the past year (at least) to get a law passed banning any type of advertising for formulas, bottles and pacifiers within the walls of hospitals, baby clinics, drs. officeswhich are located within a government or public institution. (this would include pharmacys and shops located inside the hospitals or clinics). " it reads today,(the law) includes Day Care Centers. Now, funny as it may seem,both La Leche League and myself want to strike this from the proposed law.=20

Ellen and colleagues, I strongly disagree with you!  I implore you to look at the issue more carefully before you facilitate additional contact between nursing mothers and those who have only financial gain at heart.  Let's look at the issue as you have presented it here. 
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First you ask about research on daycare. I believe that there is research on your specific topic, but I can not recall anything off hand. I would check out the INFACT CANADA, http://infactcanada.ca/  web site for anything related to politics of breastfeeding. 
I would also review Avi Sagi's work on Israeli daycare (I believe 1999) in order to gain a sense of the emotional environment in Israeli daycare. I would apply this information to breastfeeding and daycare. However, this is for future reference not directly connected to the issue at hand. 

It seems that it might be helpful to define the issue that you are researching more clearly. May I suggest that we research the effects of advertising on breastfeeding in families whose children are in daycare. The variables that I might include in my investigation include breastfeeding behavioral patterns, factors that lead to early weaning and the advertising techniques utilized by companies to influence parents.  

You stated that the rationale for removing daycare from the list was that mothers "making the initial decision to bf, receive all the help and support at birth and the first 14 days,thereafter  enjoy a successful bf relationship for the first 3 months and hear from all her HCP's about the importance of exclusive bf for the first 6 months of life" It sounds like you are implying that once nursing is going well, mom will not be influenced by advertising at three months of age and will continue to nurse exclusively. Unfortunately, research and practice does not demonstrate  this pattern to be true.   

For example, in North America, the initiation rates of nursing have risen. For example, to the best of my knowledge in Ontario, Canada they are close to the 75%. However, the rate of exclusive breastfeeding drops rapidly after six weeks and thereafter. Subsequently, the rate of breastfeeding also drops. While there are many families who continue nursing in accordance with WHO recommendations ( I believe that Kathy Dettwyler is researching this issue) the percentage of these families is far below the high initiation rate.    

One of the precipitating factors that influences the addition of artificial baby milk and subsequent early weaning into the lifestyle of nursing family, is the brilliant advertising of the artificial baby milk and baby food companies. These companies take note of the behavioral patterns of nursing families. They apply marketing techniques that match the observed patterns as a means of eventually selling their product to the families who initiated nursing.  Where I live the companies have apparently responded to the high breastfeeding initiation rates by redirecting the focus of advertising to early supplementation and subsequently, the process of partial or full weaning from the breast. 

They seem to have recognized something that we should also bare in mind.  Their very subtle advertising methods reflect the idea that moms who are nursing well in the early post partum period are not necessarily moms who are going to continue for recommended periods of time. The development of the parenting role is a process and different events might be perceived as obstacles to age appropriate breastfeeding along the way. 

A well known perceived obstacle to nursing is working. Hence, the daycare center seems like a very logical and significant arena for advertising. For example, the companies might convey messages that speak to the anxiety sensed by moms overwhelmed by work and mothering.  

The possibility that the companies might gain access to daycare centers is very real as is indicated by Ellen's statement that "They, today, do not accept, nor do they need extra funding, but the spokesperson explained to me that ultimately, no one can tell what will happen with the economyand they would not want to be in a position where they would have to close, if it came to a time when they would need a sponsor."  Furthermore, when and if the companies loose their former strongholds (i.e. hospitals and clinics), they will likely look for other fertile territory such as, daycare centers bursting with  potential customers.   

The other part of your rationale for omitting the daycare centers from the list is that the women's organizations that run them are very powerful and you want to build a good relationship with them. I understand that you feel that by demanding that these organizations be on the list, you will isolate yourselves from the them and thus, impair support for working breastfeeding mothers. I believe that this thinking is flawed and that the short terms gains of apparent cooperation do not measure up to the long term effects inherent to genuine change. 

Genuine change is faciliated when the tutor or change agent conveys sincerity and strength in their convictions. As such the learning goals must be clearly defined and consistent.  Signs of actual change are evident when the learner, client or organization demonstrate ownership of the issue. 

According to the description in Ellen's letter, it seems that the womens' organizations do not sense any level of ownership of breastfeeding. On the contrary, they see themselves as disconnected from this issue and that the breastfeeding organizations are separate from them. It is important that we note that genuine change will not occur if we continue to release them from their responsiblity to take on breastfeeding as their own. We also will not evoke change when we convey to them that our goals are inconsistent and therefore, not important.  It seems very inconsistent to say that it is not OK to advertise and interfere with breastfeeding at the hospital level but it is ok when babies are older. Similarly, it sounds like you are demanding that health care professionals act responsibility in regards to infants but you are not demanding the same from the education, childcare and social services. This is hypocritical, demonstrates a lack of conviction and devalues the message. 

I would also like to point out that change occurs from the bottom up and not only vice versa. The families that use the daycare are the organization. By teaching families about the hazards of not breastfeeding and also about the methods of advertising that they will be exposed to as parents, we help them make the changes. 

So in the short term, you might not be on the best of terms with women's organizations. Let me reframe that. You will not be on the best terms with those who are presently in charge of the women's organizations. However, sometimes we have to look at the long term goals, and act accordingly, in order to enhance real change. By initially forcing the women's organizations to comply with family focused initiatives, we might trigger some important learning and eventual change.   

So to sum it up, the ministry's decision to promote this initiative at all levels sends the message that breastfeeding is important at all stages of development. As the true breastfeeding advocates that I know that you are, I hope that you will consider their position seriously! 

Bhazluchu (which means good luck)! 

Keren Epstein-Gilboa MEd BScN RN FACCE LCCE IBCLC
PhD (Candidate) 

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