Hi Marianne
I love the way you're being so persistent in your attempts to
maintain ethical principles within your local organizations! And I
note your efforts lately to clarify whether we need to support
breastmilk, the product, or breastfeeding, the process, and how this
question fits in with the Code.
I've been having some thoughts about this too, in the last few
months. As background, first let me say that I'm a big fan of the
principles of the Code. I was involved in formulation of a national
Code in Zimbabwe and it was passed as law in parliament in 1998, and
fully implemented in 2000. It was fabulous to have such legislation
to fall back on when hospital practices might undermine breastfeeding
(rare) or when marketing of products falling under the scope of the
Code hit you in the eye in shops and supermarkets, doctors surgeries
etc (common).
However, the recent furore over marketing of certain breastpumps that
include bottles and teats in their advertising makes me distinctly
uncomfortable. I worked in an environment where breastfeeding was
aggressively protected and promoted, free formula was not available
in hospitals for healthy babies, and bottles and teats were
absolutely prohibited - if formula was medically indicated, it was
fed via nasogastric tube, or by cup. At the same time, in the early
Nineties breastpumps were simply not available either, and I worked
with many cases where lactation failed when engorgement had become so
severe that hand-expression simply did not work, or didn't work fast
enough. As time went on, pumps started to be imported, and mothers
who felt ambiguous about breastfeeding (without exception, all
non-African mothers) would start off breastfeeding or
breastmilk-feeding-by cup/spoon in the hospital because they had to,
and then often switch to breastmilk-feeding by bottle after a week or
so at home. Some could later be persuaded to give breastfeeding a
try, and I've worked with many babies who'd been almost exclusively
breastmilk-fed-by-bottle for several weeks, who subsequently simply
latched easily to the breast and went on to breastfeed without
incident as if they'd never been exposed to a bottle-teat. At first
I wouldn't have believed it if I hadn't seen it, but after a while I
realized that _bottles/teats are not the problem_!! However, I also
worked with many, many mothers who could never be persuaded to
breastfeed direct, and seen their faces light up to realize that they
could still give their babies the "best" milk, for as long as they
wanted, by breastmilk-feeding-by-bottle - in those cases they were
eager to know how it could be achieved, and many, many of them
proudly exclusively "breastfed" their babies in this way for weeks,
months and even years, and I helped them in the knowledge that the
method of delivery might not have been ideal, but the alternative
would have been formula.
Now that I live/work in UK where, clearly, bottle-feeding of formula
is the norm, I begin to understand the paranoia about bottles and
teats, even as I _can't_ reconcile myself to the easy-going
acceptance of handouts of free formula in hospitals and the community
to "poor" mothers who might otherwise (it is commonly believed) feed
their babies any inappropriate liquid rather than breastfeed. Where
I come from, the poverty has to be seen to be believed, and it's a
fact of life that mothers who can't afford to buy formula themselves
(and fuel, bottles, sterilizing equipment) have to breastfeed or risk
killing their babies, so a certain measure of responsibility is
placed on mothers, rather than on governments, for keeping their
babies alive and healthy - and this feels "right" to me. In fact, I
think that the necessity to actively support maternal choice about
breastfeeding or formula-feeding places LCs in the really poor
ethical position of having to endorse a baby-milk that is known to be
harmful in a situation where it is rarely medically necessary. We
usually refer to this as the breast/bottle question, but really it's
not - it's what goes _in_ the bottle that matters. Could it be that
it's the jargon used over the years, the so-called "breast/bottle
controversy" which is muddying the waters?
To ask what the Code intended is a Very Good Question,
Marianne! Should the Code that was drafted to meet the marketing
strategies employed by industry in the 1970s still be endorsed nearly
forty years on, in a world that has changed beyond what was ever
envisaged at that time? For instance, breast pumps available in
1981 were so inefficient as to be virtually useless, and - presumably
not being seen as a threat to breastfeeding - were not included in
the provisions of the Code. Yet in 2009 pump manufacturers that
include bottles and teats in their literature have been tarred with
the same brush as formula manufacturers - to provoke an ethical
dilemma keenly felt by IBCLCs today. In 1981 the marketing of
"bottles and teats" was seen as harmful, since bottles and teats were
almost exclusively used to feed formula. But in 2009, IBCLCs use and
sell and breast pumps, and the bottles and teats which are often sold
with them, to aid breastmilk-feeding for babies who are compromised
(prem/sick babies) or whose mothers choose to or are forced to be
separated from them (eg millions of working mothers) - thus
protecting, promoting and preserving the use of breastmilk itself
over breastmilk substitutes. Supplementing with milk (either EBM or
ABM) is often temporarily medically necessary to protect the
nutrition of babies whose mothers have suffered partial or total
lactation failure (I agree that a miniscule percentage is inherently
necessary, but in the industrialized countries we work daily with a
damaged infant feeding culture). Importantly, cup-feeding is not
entirely benign, yet we have little research to support the WHO
recommendation that all supplements and replacements for
breastfeeding should be fed by cup, nor to show the consequences of
lack of sucking opportunities for exclusively cup-fed babies, which
are anecdotally reported to be profound.
So how is the existing Code being interpreted? Even as we're
enforcing adherence to the Code in the matter of bottles and teats to
the extent that we're actually harming the provision of mother's milk
as the normal food for infants, we're turning a blind eye to the
irrational wholesale use of breastmilk substitutes by hospitals,
governments, international aid agencies under the guise of fulfilment
of human rights, inadvertently contributing to the profits generated
by breastmilk substitute manufacturers. Would it not make sense to
look at the research undertaken since the Code was published, and to
include that evidence base in current recommendations for
breastfeeding promotion, protection and support in the new
millenium? Where is the evidence to show that the use bottles and
teats to feed babies breastmilk really undermines breastfeeding? Is
it the use of bottles and teats per se, or is it the contents of the
bottles that cause the major negative effects on the health and
well-being of babies and the adults they will become? I know we have
Brian Palmer's and others' research about the process itself, but is
cup-feeding of breastmilk ultimately "better" than bottle-feeding of
breastmilk where breastfeeding itself is not possible or not
chosen. Do we need to re-examine whether a mother who can't/wont
breastfeed should be helped to bottle-feed EBM without it being
condemned as a Code violation? Do we need to do more marketing of
breastmilk, as a way to celebrate the product and increase number of
mothers who might use it compared to those who currently opt for
formula? In order to do that, we'll need get over our current
attitudes towards bottles. We may need to re-visit the appropriate
use and feeding of expressed breastmilk and take a close look at all
the methods used to feed any milks to infants - what is rational,
what is appropriate, what is the difference between use and abuse?
So I'd like to thank you, Marianne, for being so persistent in your
quest for answers. I've felt increasingly over the last few months
that it might be time to revisit the ethical responsibility of IBCLCs
to uphold our interpretation of the provisions of a Code that was
conceived nearly 40 years ago for a world that was vastly different
at the time it was developed - to place the dilemmas for IBCLCs in
policy, practice, politics and research-based evidence (or lack of
it) under closer scrutiny? Let's all talk about this some more!
Pamela Morrison IBCLC
Rustington, England
------------------------------------------------
Date: Sat, 21 Nov 2009 15:44:34 +0100
From: Marianne Vanderveen-Kolkena <[log in to unmask]>
Subject: WHO-code, again...
Hi all,
Is there a way to conclude beyond reasonable doubt that the WHO-code
meant to protect either *breastfeeding* or *breastmilk feeding* (=
pumping and feeding otherwise)?
Or did the Code just not really think of breastmilk feeding, because
it was not as common then as it is now? Or put in a different way:
are bottles in the Code because they might cause suck confusion or
because they undermine the process (as opposed to undermining the
product) or for different reasons or for all reasons combined? Why
are the bottles justifiably in the Code? (Don't convince me... I'm
with you! ;-))
We are getting deeper and deeper into the discussion and I seem to be
more and more on my own and regarded a rebel, when I state the Code
first and foremost, even in 1981, meant to protect, promote and
support the process and that integrally respecting the Code also
means standing up for the process... Is there proof for that idea in
the Code itself?
Any thoughts?
Warmly,
Marianne Vanderveen IBCLC, Netherlands
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