First ever Global Congress on Implementation of the International Code of Marketing of Breast-milk Substitutes spurs multi-national project

Earlier this summer, the World Health Organization (WHO) hosted its first ever Global Congress on Implementation of the International Code of Marketing of Breast-milk Substitutes.

INFACT USA’s Cadwell and Mulpeter ready for the Congress

INFACT USA Convener Karin Cadwell PhD, RN, FAAN and INFACT USA Program Coordinator Ellie Mulpeter, MPH, CLC were of the roughly 400 Congress participants.

The conference aimed to to increase knowledge and skills of national actors on strategies to end the unethical marketing of breast-milk substitutes, bottles, and teats, develop national roadmaps/work plans to strengthen legislation, monitoring and enforcement of the International Code of Marketing of Breast-milk Substitutes, and build regional networks to share information and support of national action on the Code.

Mulpeter says the overall energy was upbeat and eager.

“It was inspiring to see so many people from around the globe all dedicated to the same mission, and all passionate about implementation and enforcement of the Code to protect families across the world,” she reports.

Congress participants proudly pose

The Congress was intended to be as interactive as possible with breakout sessions organized by region. The U.S., Canada and the Caribbean were grouped together.

“The work being done in all of the Caribbean Islands is very impressive,” Mulpeter explains.  “They are all unique islands with their own unique policies and legislative processes, so it was fascinating to hear their representatives brainstorm together and discuss ways to work regionally in the future.”

Congress conveners created an industry influence grassroots monitoring simulation where participants had the opportunity to spot and record Code violations using the KoboToolbox platform.

Congress leaders also shared the the International Special Dietary Foods Industries (ISDI) statement released in response to being excluded from the Congress.

“It really drove home the point about how integrated the industry is when it comes to Code monitoring and enforcement,” Mulpeter comments.  “It’s a wild marketing tactic to blatantly lie about their dedication to breastfeeding families.”

As laid out by INFACT USA: “Here in the United States, there is an incredible amount of work to be done to advance the Code and its subsequent resolutions. To date, the U.S. is one of three countries in the world that did not sign onto the Code back in 1981. While that step may never come for the U.S., there are other options and avenues to implement protections against predatory marketing practices of these commercial baby-food product companies.”

Mulpeter points out that the Federal Trade Commission (FTC) already has an avenue to monitor false advertising and hold companies accountable for making claims that are not evidence-based.

“Additionally, the fact that the US is hyper-focused on data sharing and digital privacy at the moment may allow an opportunity to explore how targeted advertisements of formula companies are directed towards pregnant individuals and new parents,” she goes on.

Participants engaging at the Congress

What’s more, last week INFACT USA started the recruitment phase for a multi-national research project on the Code. The U.S., Canada, the UK and Australia are all participating in a Code monitoring project that will collect real-world violations from the general public.

Research participants are asked to download the Goose Chase Adventures application on their mobile device and participate in the missions outlined within the app. Submissions will help monitor Code adherence in several countries.

Individuals interested in learning more about this research study can visit: https://surveyswesternsydney.au1.qualtrics.com/jfe/form/SV_cN14ryUEZriqHL8

Should you have any questions about the project prior to or after signing up to participate, please contact Ellie Mulpeter at: info@infactusa.org or Jeni Stevens at: Jeni.Stevens@westernsydney.edu.au

Mulpeter explains: “We hope that the results from this study will not only allow us to assess what types of violations are happening most frequently in these four countries, but also to assess the frequency with which people see and recognize them as problematic at all. Pending the outcomes of the study, we hope that INFACT USA will be able to use the evidence gathered in this project to persuade legislators in the U.S. to implement stricter monitoring of predatory marketing practices of infant and young child feeding products. Ideally, Australia, Canada and the UK can use the results from this study to enforce stricter implementation and monitoring of the Code in their respective countries.”

Mulpeter and Cadwell applaud the efforts of the hosts of the first Global Code Congress: “It was a huge success!”

Respectful maternity care: the problem and suggested solutions

Guest  post by Donna Walls, RN, BSN, CLC, ANLC with intro by jess fedenia, clc

 

Donna Walls’s, RN, BSN, ICCE, IBCLC, ANLC unmedicated births were sort of a fluke.

“I remember being horribly afraid of someone sticking a needle in my back,” she recalls.

The “glorious” feelings of confidence and joy were unexpected consequences, but thinking back, Donna says, “Boy, I am sure glad I [gave birth that way.]”

In all other aspects of parenting, Walls credits growing up in the 1960s for becoming a self-described Granola Mom.

“When everything went ‘back to nature’, that was a big influencer for me,” she says.

As a nurse, Walls was always drawn to maternity care and supporting breastfeeding as the natural progression after giving birth.

It felt thorny to her when babies were taken to the transition nursery immediately after birth and later given back to their mothers.

This ritual sent the message that “We (as in the staff) can take better care of your baby than you (as in the mother) can.” That never sat right with Walls.

Then, one pivotal moment in particular, Walls on duty in the transition nursery, walked by a baby only a couple of hours old.

“He was frightened,” Walls begins. “His lip was quivering and he was splayed out underneath the warmer. He was so frightened. It just affected me.”

After that, Walls galvanized to change the culture in this hospital. She worked very hard alongside a physician colleague to open a birth center within the hospital. In 1995, Family Beginnings at Miami Valley Hospital in Dayton, Ohio was unveiled, offering families an option where birth wasn’t pathologized and where mothers and babies were honored as dyads. (Birthing at Family Beginnings remains an option for those in the Dayton area today.)

The center was designed to look like a home. There was no nursery for babies to be separated from their parents. When mothers came in to labor, the staff would pop in bread to bake, a special touch of aromatherapy.

Freshly baked bread, though enticing, wasn’t the number one reason families signed up to birth here. Instead, they chose Family Beginnings because they didn’t want their babies taken away from them, Walls reports.

Walls has since retired from her work in the hospital, but respectful maternity care remains forward in her mind and in her advocacy.

She graces us with reflections on respectful maternity care in her guest post this week on Our Milky Way. Read on!

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As a nurse in maternity for over 40 years, I have too often witnessed what I refer to as the “empty vessel theory”. Women are regarded as merely a container for the fetus and care providers merely the technician to remove it, usually as quickly as possible. I have often been saddened when the emotions and spirituality of birthing are disregarded or even mocked. This miraculous process is a rite of passage with all the inherent pain, joy, lessons and connections needed to begin the journey into parenting. My hope is that through discussions and activism, we can reach a point where the birthing family is honored and all newborns are brought into the world with love and respect.

Photo by João Paulo de Souza Oliveira: https://www.pexels.com/photo/gray-scale-photo-of-a-pregnant-woman-3737150/

Respect is “showing regard for the feelings, wishes, rights or traditions of others”. Concerningly, there is an abundance of anecdotes from patients and caregivers that demonstrate how maternity care practices are often disrespectful, sometimes even abusive.

Disrespectful care encompasses racial inequity, lack of confidentiality, physical and/or emotional abuse, denial of care or provision of substandard care, lack of informed consent or coercion or condescending communications. This type of care occurs in all countries around the world, to all demographics of women and their families. Fortunately, disrespectful care has drawn the attention of many health organizations, including the World Health Organization, and steps are being taken to stop disrespectful, abusive care practices.

Examining the intersection of maternity care and human rights has been a recent topic in many maternal and infant care advocacy groups as well. We cannot assume that hospital admission for an appendectomy is equal to admission for the birth of a baby. This is because  the scope of the process of birthing impacts a person, a family, a community and a nation which is not so of a surgical procedure.

Most women and families expect they will receive safe, inclusive, compassionate care and trust their caregivers to provide prenatal, intrapartum and postnatal care with honest communication and respect for their needs and choices. Provision of safe care should look beyond the basics of preventing maternal, fetal or neonatal morbidity or mortality and consider how to support the family’s human rights– rights inherent to all people, without discrimination, regardless of age, nationality, place of residence, sex, national or ethnic origin, color, religion, language or any other status. (White Ribbon Alliance, 2020)

Photo by Dipu Shahin DS: https://www.pexels.com/photo/baby-in-pink-and-white-blanket-4050647/

The first stated right is to be free from harm and mistreatment, yet we find continuing cases of physically and emotionally abusive treatment of pregnant and birthing women. Secondly is the right to competent, culturally sensitive care for both mother and newborn.  Next is  the right to companionship and support, and lastly the right to meet the basic life-sustaining needs of the dyad, including breastfeeding support for the newborn.

The first step toward respectful care is choosing  healthcare providers who value open, honest communication and who will discuss options and listen to the family’s needs and concerns. WHO defines respectful communication as communication which  “aims to put women at the centre of care, enhancing their experience of pregnancy and ensuring that babies have the best possible start in life.” (WHO, 2018)

Other components of respectful communication include the use of positive body language, active listening, the use of non-judgmental language, assuring patient privacy and honoring physical and emotional needs.  Respectful communication can begin with simply referring to the person by the name they prefer. If it is not documented, ask.

Another important step is selecting the birthing place. (Niles, 2023) Most care providers practice at one to two hospitals or birth centers. Choosing the birthing environment is an important decision in creating a birth experience which is in line with the family’s expectations and goals. Research and discussions with childbirth educators, lactation care providers and other families can give insights into common or routine practices at that institution. Will the family’s requests be honored? Will questions be answered with open and honest informed consent? Will the birthing and breastfeeding practices support their goals? These are all questions that need to be answered before a birthing place decision is made.

Creating an environment of respectful care in the birthing place is foundational. It is care that assures women and their families will be regarded as capable of making decisions. Making decisions which respect the values and unique needs of the birthing woman can only be made when patient autonomy– the right of patients to make decisions about their medical care without their health care provider trying to influence the decision–  is recognized.

Photo by Rebekah Vos on Unsplash

Individuals often comment on birthing in the hospital as a time when you lose all modesty; however, it is possible to follow protocols that set a standard for assuring privacy and modesty which can positively impact the birth experience. Simple steps like not discussing patient history or current conditions in front of others (without the patient’s permission), being mindful of covering intimate body parts (or culturally sensitive covering) whenever possible, asking permission before touching or knocking (and waiting for a response) before entering the room are a huge part of maintaining patient dignity. It cannot be overstated that any cultural requirements for modesty must be respected at all times.

More on respect in health care on Our Milky Way here, here and here.

Other recommended resources 

The International MotherBaby Childbirth Initiative (IMBCI) A Human Rights Approach to Optimal Maternity Care

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.

Exploring Evidence for Disrespect and Abuse in Facility‐based Childbirth: Report of a Landscape Analysis

 

Gestational carrier provides milk for babies born via surrogacy

Erin Graham suffered six bouts of mastitis and a subsequent antibiotic allergy while breastfeeding her firstborn. Moreover, when her daughter was just five weeks old, Graham required emergency surgery for gallstones she’d developed. The care team reported that she would need to pump and dump her milk on account of the anesthesia, but Graham made a point to connect with a lactation care provider who dispelled this misinformation.

Photo courtesy of Erin Graham

Despite it all, Graham persevered and went on to breastfeed her daughter for a year.

When her son came along, breastfeeding proved much easier.

“Breastfeeding my son was a piece of cake,” she recalls.

Becoming a mother was the most transformative and defining experience of her life, Graham goes on to say. So, when she witnessed friends and family members struggling to create and grow their own families, she felt especially touched and inspired. That’s when she applied to become a gestational carrier (surrogate). Graham has given birth to three babies as a gestational carrier since then and has pumped milk after each pregnancy.

The decision to pump milk for her surrogate babies started with a simple conversation early on in the surrogacy process, during match meetings where prospective surrogates and intended parents connect. Graham says there was never any pressure from any parties.

“It was all just gratitude and positivity,” she remembers. The first intended mother she worked with would even make her snacks to help keep her energy up while pumping around the clock.

During her first two experiences, the families were local, so they would coordinate meet ups to drop off the milk. She and her family became quite close to both of the families, so she found herself sometimes pumping at their houses during get togethers.

After her final surrogacy, Graham and the family coordinated shipping through FedEx, and while Graham says she’s  heard horror stories of lost and thawed milk upon arrival, she never experienced any of these misfortunes.

When one of the families decided that they no longer needed Graham’s milk, she was connected to another family whose surrogate was unable to provide milk. Graham wasn’t ready to wean, so she provided milk for this infant instead. It’s one of her favorite infant feeding stories.

Graham shares how her experiences breastfeeding and pumping were so different. While breastfeeding, Graham says she never thought about how many ounces of milk she produced; instead, she focused on her babies’ cues. While pumping, she didn’t have the babies’ cues to prompt her, so she’d rely on an alarm and found that she became quite focused on her output. Pumping also required her to hone in on her organizational skills, making sure the freezer bags laid just right so that she could store and package them most efficiently.

Graham has remained deeply connected to the infertility and surrogacy space and has worked for a surrogacy agency and fertility marketplace where she helped both intended parents and surrogates find the agencies and clinics that fit their particular needs and desires.

In order to best serve her clients, Graham recently completed the Lactation Counselor Training Course (LCTC).

Having had the vastly different experiences of directly breastfeeding her own babies and pumping milk for her surrogate babies, now coupled with the LCTC training, Graham offers a unique perspective to her clients.

Graham has been featured in a GoStork Q&A where she offers more of her experience as a surrogate and fertility care advisor. You can find that here.

Monumental ‘Skin-to-skin contact after birth: Developing a research and practice guideline’ calls for immediate, continuous, uninterrupted skin-to-skin contact for all mothers and all babies from 1000 grams, after all modes of birth

In Western culture, we tend to trust the process of pregnancy and the capability of a human body to grow and nourish a fetus, but there’s a moment between then and the approaching birth of the baby and beyond when that confidence is lost. Among other reasons, loss of trust in the female body forces mostly unnecessary and often harmful interventions on the process of labor and birth. Thereafter, though the safest place for most newborns immediately after birth is skin-to-skin with their birthing parent, common maternity practices often strip the dyad of this sacred, critical transition diminishing the capability of the mother and the infant.

As the authors of The nine stages of skin‐to‐skin: practical guidelines and insights from four countries put it, alarmingly, “despite the research and compelling directives from world authorities, the implementation of immediate, continuous and uninterrupted SSC for all healthy mothers and newborns, regardless of feeding choice, has not become standard practice.”

Last month, Kajsa Brimdyr, et al published the monumental Skin-to-skin contact after birth: Developing a research and practice guideline.

Authors not in order of appearance: Kajsa Brimdyr, Jeni Stevens, Kristin Svensson, Anna Blair, Cindy Turner-Maffei, Julie Grady, Louise Bastarache, Abla al Alfy, Jeannette T. Crenshaw, Elsa Regina Justo Giugliani, Uwe Ewald, Rukhsana Haider, Wibke Jonas, Mike Kagawa, Siri Lilliesköld, Ragnhild Maastrup, Ravae Sinclair, Emma Swift, Yuki Takahashi, Karin Cadwell

It’s an “excellent overview of the huge quantity of evidence supporting skin-to-skin contact after birth and give evidence-based guidelines, endorsing the recommendations of the World Health Organisation, that ‘immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 grams with experienced staff if assistance is needed), after all modes of birth,’” Andrew Whitelaw writes in this editorial.

Source: United States Breastfeeding Committee (USBC)

In the review, the expert panel– representing all continents but Antarctica– sifted through roughly 8,000 articles and ultimately pared down to only include those with a clear definition of immediate, continuous, uninterrupted skin-to-skin contact.

The panel concluded that “delaying non-essential routine care in favour of uninterrupted skin-to-skin contact after birth has been shown to be safe and allows for the progression of newborns through their instinctive behaviours.”

The guideline includes the Pragmatic Implementation Guide for Skin-to-Skin Contact after Birth which serves as a how-to for staff, preparing them to facilitate skin-to-skin contact before and during the birth. The document is downloadable here: Appendix S1.

Brimdyr points out that none of the information presented is new; instead it’s consolidated in a way that hasn’t been done before.

“It takes the expertise of so many people and puts it in one place,” she explains.

Brimdyr says she believes it will give practitioners the confidence to make this practice work for moms and their infants.

“All of these babies, all of our mothers really deserve this opportunity,” Brimdyr advocates. “They deserve to have the best start.  This research is so well established… the fact that we’re not doing it everywhere is absolutely upsetting.”

Also last month, Brimdyr released a new film, The 9 Stages of Premature Infants, which documents  the nine stages as demonstrated by premature infants. The film brings to life the implementation of facilitating skin-to-skin for this population of infants and their parents.

“There is something absolutely magical seeing how capable babies are that really transforms any words on a page into reality,” Brimdyr says. “The research has been there to say premature babies can do this, but it’s so much more powerful to see premature infants do this.”

You can find a collection of skin-to-skin research here.