Pam,
What a great way to start my morning by reading your interesting and
informative post.  It was an eye opener and I confess to sort of having the
idea about there not being issues if the culture were breastfeeding
friendly, you know rose colored glasses.  It just strenghthens the need for
all of us to keep working hard doing the work we do every day, wherever we
are and supporting each other every step of the way!  One of the great
things about email is that we can be so closely connected.  Learning about
what our colleagues are doing and going through in different parts of the
world is an awesome learning experience.  It gets us out of the bubble we
are in in our own part of the world. Thank you Pam!

Laura Walker RNC, IBCLC, RLC
Johnson City, NY


----- Original Message -----
From: Pamela Morrison <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, March 19, 2003 12:03 AM
Subject: Breastfeeding cultures, difficulties and choice (long)


> 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
> [log in to unmask]
>
>
>
>
> 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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