Of all the known approaches to saving infant lives, human milk has the greatest potential impact on child survival. (PATH) When direct breastfeeding or mother’s expressed milk is not available, donor human milk is the next best option.
Photo by Samer Daboul
As such, the 2018 WHO/UNICEF implementation guidance on the Baby-friendly Hospital Initiative stated that “Infants who cannot be fed their mother’s own milk, or who need to be supplemented, especially low-birthweight infants, including those with very low birth weight and other vulnerable infants, should be fed donor human milk.” The American Academy of Pediatrics, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition, and other national and global policy groups also call for use of donor human milk as the feeding of choice, if mother’s own milk is insufficient, unavailable or contraindicated. (WHO)
The ISRHML Trainee Interest Group recently presented A Global View of Human Milk Banking with Kimberly Mansen (PATH), Dr. Victoria Nakibuuka (Nsambya Hospital), Debbie Stone (Rogers Hixon Ontario Human Milk Bank), and Dr. Maryanne Perrin (The University of North Carolina Greensboro) which brought to light several, wonderful resources and is the inspiration for this week’s post.
Let’s take a look at some human milk banks around the world.
This tableau map depicts publicly known human milk banks. If you know of a milk bank that is not shown on the map, you can fill out this form and/or email kamundson@path.org or humanmilkbankmap@gmail.com.
Brazil
Donor milk banking thrives in countries such as Brazil, where there has been a concerted effort at the Health Ministry level to incorporate milk banks into health policy. (Arnold, 2006)
The Rogers Hixon Ontario Human Milk Bank in Ontario has dispensed over 1 million ounces of human milk. The Rogers Hixon Ontario Human Milk Bank is a non-profit organization and a joint initiative of Mount Sinai Hospital, The Hospital for Sick Children (SickKids) and Sunnybrook Health Sciences Centre. It is a member of the Human Milk Banking Association of North America.
Ukraine
The first and currently only Ukrainian Human Milk Bank was established in Kiev at the Perinatal Centre where approximately 80 percent of all premature babies in the city are born.
South Africa
The South African Breastmilk Reserve (SABR) has set up a total of 44 in-hospital human milk banks in public and private hospitals across South Africa.
Vietnam
The first human milk bank in Vietnam was officially opened on February 17, 2017, at the Danang Hospital for Women and Children. This facility is supported by the Vietnam Ministry of Health and the Danang Provincial Department of Health, and is the first human milk bank in Vietnam to be operated within the public health system and to international standards. (PATH)
The commercial milk formula (CMF) industry uses marketing tactics similar to those of the tobacco, alcohol, and ultra-processed food industries.
Photo Credit: Boston Public Library Date: ca. 1870–1900 https://ark.digitalcommonwealth.org/ark:/50959/3b591d51p Please visit Digital Commonwealth to view more images: https://www.digitalcommonwealth.org.
Earlier this winter, the Lancet published a three-paper series outlining the multifaceted and highly effective strategies used by commercial formula manufacturers to target parents, health-care professionals, and policy-makers.
“The industry’s dubious marketing practices—in breach of the breastfeeding Code—are compounded by lobbying of governments, often covertly via trade associations and front groups, against strengthening breastfeeding protection laws and challenging food standard regulations,” the Lancet summarizes.
In another recent publication, Pediatricians’ Reports of Interaction with Infant Formula Companies, the authors found that: “Of 200 participants, the majority reported a formula company representative visit to their clinic (85.5%) and receiving free formula samples (90%). Representatives were more likely to visit areas with higher-income patients (median = $100K versus $60K, p < 0.001). They tended to visit and sponsor meals for pediatricians at private practices and in suburban areas. Most of the reported conferences attended (64%) were formula company-sponsored.”
The authors write that “Seventy percent of countries follow the World Health Organization International Code of Marketing Breast Milk Substitutes that prohibits infant formula companies (IFC) from providing free products to health care facilities, providing gifts to health care staff, or sponsoring meetings. The United States rejects this code, which may impact breastfeeding rates in certain areas.”
The Lancet series authors provide recommendations to restrict the marketing of CMF to protect the health and wellness of mothers and babies, and ultimately society and the planet.
Curtail the power and political activities of the CMF industry
End state practices that do not uphold, or that violate, the rights of women and children
Recognise, resource, and redistribute women’s care work burdens in support of breastfeeding
Address structural deficiencies and commercial conflicts of interest in health systems
Increase public finance and correct the misalignment between private and public interests
Mobilise and resource advocacy coalitions to generate political commitment for breastfeeding
In Mexico, UNICEF and Instituto Nacional de Salud Pública have designed infographics for policymakers as well as parents and caregivers to educate on the impact of digital marketing.
The partners are also working on proposed modifications to current Mexican regulations that involve commercial formula milk and ultra processed food marketing to infants and young children. Further, development is underway for a mobile app tool for monitoring the Code in Mexico.
In other efforts to protect parents and babies, Breastfeeding Advocacy Australia released a video on how the organization monitors predatory marketing. Find it here. You can find their Facebook group here.
It has been hypothesized that starting around nine weeks of fetal development, the pattern and sequence of intrauterine movements of the fetus seem to be a survival mechanism, which is implemented by the newborn’s patterns of movement during the first hour after birth (described as the 9 stages) when skin-to-skin with the mother to facilitate breastfeeding.
Photo credit United States Breastfeeding Committee
Not only are human babies hardwired to progress through 9 stages and self attach to the breast, mammalian bodies are hardwired to produce milk too.
Around 16 weeks of pregnancy, the body starts to prepare for breastfeeding. This phase, called Lactogenesis I is when colostrum begins to be created. During Lactogenesis II, the secretion of copious milk follows the hormonal shift triggered by birth and the placenta delivery. After this phase, milk production must be maintained through a supply-and-demand-like system. [Neville 2001]
Even before a pregnancy is achieved, individuals are being influenced by the infant feeding culture that surrounds them, consciously or subconsciously laying a foundation for how they feel about feeding their own babies.
Pat Hoddinott’s, et al study found that women who had seen successful breastfeeding regularly and perceived this as a positive experience were more likely to initiate breastfeeding.
Exposure to prenatal breastfeeding education also affects breastfeeding outcomes. Irene M. Rosen and colleagues found that women who attended prenatal breastfeeding classes had significantly increased breastfeeding at 6 months when compared to controls.
Photo by Luiza Brain
Mode of birth and birth experiences influence infant feeding too, for both members of the dyad.
A growing body of evidence shows that birth by cesarean section is associated with early breastfeeding cessation.
Intrapartum exposure to the drugs fentanyl and synOT is associated with altered newborn infant behavior, including suckling, while in skin-to-skin contact with mother during the first hour after birth. [Brimdyr, et al 2019]
What’s more, the authors of Intrapartum Administration of Synthetic Oxytocin andDownstream Effects on Breastfeeding: ElucidatingPhysiologic Pathways found “No positive relationships between the administration of synthetic oxytocin and breastfeeding.” They comment, “Practices that could diminish the nearly ubiquitous practice of inducing and accelerating labor with the use of synthetic oxytocin should be considered when evaluating interventions that affect breastfeeding outcomes.”
Labbok points out that a paradigm shift on the issues in the reproductive continuum – family planning, pregnancy and birthing and breastfeeding– is needed.
“These are issues that are intimately, biologically, gender linked in women’s lives, and yet ones that are generally divided up to be addressed by a variety of different professional disciplines,” Labbok begins. “Despite the impact of child spacing on birthing success, of birthing practices on breastfeeding success, and of breastfeeding on child spacing, we are offered family planning services by a gynecologist, birth attendance by an obstetrician or midwife, and baby care by a pediatrician. Having these ‘silos’ of care, each with its own paradigm and priorities, may lead to conflicting messages, and hence, may undermine the search for mutuality in goals, and collaboration.”
One such initiative looking to deconstruct siloed care is the Baby-Friendly Hospital Initiative which includes standards and goals for birthing practices, for breastfeeding-friendly communities, and guidance for birth spacing, in addition to reconfirming the original Ten Steps to Successful Breastfeeding, in recognition that breastfeeding occurs along a continuum.
In the U.S. context, the 1,000 Days initiative recognizes comprehensive health coverage, comprehensive guidelines on nutrition during pregnancy, lactation, and early childhood for women in the first 1,000 days, paid family and medical leave policy for all workers, and investments to ensure parents and caregivers can access good nutrition as solutions to a well nation and a well world.
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As part of our celebration, we are giving away an online learning module with contact hours each week. Here’s how to enter into the drawings:
Email info@ourmilkyway.org with your name and “OMW is 10” in the subject line.
This week, in the body of the email, please share with us some or all of your birth stor(ies).
Subsequent weeks will have a different prompt in the blog post.
We will conduct a new drawing each week over the 10-week period. Please email separately each week to be entered in the drawing. You may only win once. If your name is drawn, we will email a link with access to the learning module. The winner of the final week will score a grand finale swag bag.
“More doctors smoke camels than any other cigarette,” claims the ad from 1950. Today, it’s preposterous to imagine that any physician would align themselves with the tobacco industry. Starting in the 1920s and continuing well into the 1950s though, tobacco companies used doctors to help them sell their products. Stanford’s Research into the Impact of Tobacco Advertising has a collection of over 1,000 advertisements that feature doctors endorsing tobacco products.
In an eerie parallel, WHO’s February 2022 report, How the marketing of formula milk influences our decisions on infant feeding, states that “Recommendations from health professionals are a key channel of formula milk marketing. Health professionals spoke of receiving commissions from sales, funding for research, promotional gifts, samples of infant and specialized formula milk products, or invitations to seminars, conferences and events.” (p. 7)
Last week, Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500 and I shared our reflection on the forces that shape physicians’ personal infant feeding experiences. In this second installment, we explore how physicians as professionals can support breastfeeding despite being targeted by the breastmilk substitute (BMS) industry and despite generally being woefully equipped with proper lactation education, training and counseling skills. These predicaments can lead physicians to “explicitly or inadvertently, introduce doubts around the ability of women to breastfeed and the value and quality of their breast milk.” (WHO, p. 12)
Pervasive industry influence for generations
Because “health professionals are among the most respected and trusted members of society…[their] advice…is highly influential for pregnant women and parents of infants and young children, including around infant feeding decisions.” Formula milk companies exploit this relationship of trust. (WHO, p. 12)
Source: United States Breastfeeding Committee
BMS representatives target physicians “with a range of incentives, including funding for research, commissions from sales, ambassadorial roles, merchandise, gifts and all expenses paid promotional trips.” (WHO, p.13)
The psychology behind gift-giving, both big and small is that “ it imposes…a sense of indebtedness…. The…rule of reciprocity imposes…an obligation to repay for favors, gifts and invitations…” (Katz 2003) Instead of supporting infant feeding purely through a health and wellness lens, physicians feel obliged to a company muddying their relationships with their patients.
Interestingly, most physicians feel immune to marketing’s influence, despite clear evidence to the contrary, Frederick S. Sierles, MD lays out in The Gift-Giving Influence.
Our culture fails to acknowledge the mother baby unit as a dyad, and this influences the way physicians can support breastfeeding too.
Source: United States Breastfeeding Committee (USBC)
“We are never taught, in our fragmented system, that the mother and baby are a unit,” Lee reiterates. “OB/GYN/midwife sees mama; peds sees babies. There are even different places for them in the hospital: nursery, postpartum unit. What a struggle we had with the BFHI to keep mother and baby together.”
The Alliance for Innovation on Maternal Health’s (AIM) Patient Safety Bundles offer models for how health professionals can use task force approaches that break down silos of care and open channels of communication. The strategies used in these bundles aim to ultimately shift from fractured care to continuity of care where the dyad is protected.
We must also consider how physicians are compensated for their work. In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans, as we mentioned in our first installment. In short, the more RVUs a physician racks up, the more they’re paid. Breastfeeding counseling takes time.
Inadequate education
How are physicians to spend time with their patients, educating and supporting breastfeeding when they’ve had little to no breastfeeding education invested in them? Dr. Nigel Campbell Rollinspointed out in WHO’s How the marketing of formula milk influences our decisions on infant feeding webinar that faculty in medical schools themselves sometimes believe that formula products are inevitable or necessary.
A cross-sectional study in the UK suggests that UK medical schools are not adequately preparing students to support breastfeeding patients.
Often, it is a physician’s own struggle to breastfeed that seems to spur advocacy and change. Our Milky Way’s repository includes a breadth of physicians’ stories of personal struggles that have inspired them to become breastfeeding champions for their patients and communities.
Source: United States Breastfeeding Committee (Photo by Sara D. Davis)
“There was no training about [breastfeeding] technique, no discussion about common problems before discharge, no training about clinical problems as far as in the first few months postpartum…when to introduce complementary food,” she continues.
We are honored to have been able to feature the work of the late Audrey Naylor in Commendable contributions to the field of lactation. With a lifetime interest in illness prevention, Naylor said she was quickly convinced of the power of breastfeeding after only attending a few hours of a breastfeeding seminar in 1976.
“Neither medical school nor pediatric residency taught me anything about breastfeeding,” Naylor said.
“It is easy to become frustrated with nurses and physicians who – often inadvertently sabotage breastfeeding mothers and babies, but I also sympathize,” she explains. “We are in a position where we are supposed to have answers, but no one has taught us the skills necessary to provide those answers.”
Other stories and models for care
Lori Feldman-Winter’s, et al Residency curriculum improves breastfeeding care showed that “a targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.
As part of their work to build a cohort of breastfeeding-friendly pediatricians, the Georgia Chapter of the American Academy of Pediatrics and the Georgia Breastfeeding Coalition launched a “Breastfeeding-Friendly Pediatrician Interest Form.” Georgia pediatricians who are interested in becoming certified as a “Breastfeeding-Friendly Pediatrician” are invited to fill out the form.
“Even in the harshest of trade regimes, there is space for public interest laws to meet legitimate health objectives when they are founded on internationally adopted standards and recommendations such as the Code and subsequent relevant WHA resolutions.”– WHO, 2016
All three of my kids sport a similar look when they lie. As soon as the fabrication tumbles out, their cheeks suck in ever so slightly toward pursed lips. Once they’ve heard themselves, their eyes widen a smidge and their bottom jaw drops just a few degrees.
Most of us don’t like to be lied to, but usually the dishonesty we encounter can be considered trivial. “I didn’t do it!” when there’s crayon art on the kitchen walls. “Your hair looks great!” when you know it doesn’t. “Of course I remember you!” when you haven’t the slightest clue.
Just as humans tend to react physiologically when we lie, we have an ability to detect when someone is lying to us. Inundated by the lies told by marketing companies on behalf of major industries though, detecting truth and falsehoods can be majorly challenging. There’s no lip biting, no shifting eyes, no perspiring to give it away. Instead the tactics industries use are cunning, targeted, sometimes irresistible and truly brilliant in many ways. The lies they tell are perpetual, and their claims have completely saturated our culture, influencing just about every facet of our lives, all for commercial gain.
There’s a promotional video featured by a cooking show that showcases a chef professing his allegiance to gas stoves. The video was created by a utilities provider though, and having worked aggressively with state legislatures “to block legislation that would provide cleaner, electric-based building codes,” their marketing got us to believe that cooking on a gas stove is somehow the best while simultaneously waging “war on local electrification initiatives all over the country.” [https://www.thresholdpodcast.org/season-4-episode-6-transcript]
Here’s another example. Most of the seafood that we purchase and consume in the U.S. is mislabeled as something completely different. This “Seafood Fraud” is detailed in (Mis)labeled Fish.
Fossil fuel companies are greenwashing their efforts, helping to sow doubt about the fossil fuel industry’s role in the climate crisis.
As explained on How to Save a Planet: “They’ve… done it indirectly, by funding organizations who lobby congress, launching fake grassroots campaigns, and perhaps most importantly, through advertising. These ads, according to Martin Watters at the nonprofit firm ClientEarth, are greenwashing.”
Now consider the baby milk substitute (BMS) industry. A recent WHO report examines the scope, techniques and impact of digital marketing strategies for the promotion of breast-milk substitutes which reveals how the $ 55 billion baby formula industry “insidiously and persistently” targets parents online through “tools like apps, virtual support groups or ‘baby-clubs’, paid social media influencers, promotions and competitions and advice forums or services, formula milk companies can buy or collect personal information and send personalized promotions to new pregnant women and mothers.” [https://www.who.int/news/item/28-04-2022-who-reveals-shocking-extent-of-exploitative-formula-milk-marketing]
Their efforts have further adapted to target older children with their toddler milks and formulas. Lurie again calls out false claims like “Brain & eye development” and “Plant-based protein for toddlers.”
He writes: “The multibillion-dollar infant-formula industry is trying to convince parents that children older than 12 months need formula. They don’t. The beverages—made largely of fortified powdered soy or dairy milk, oil, and corn syrup solids or maltodextrin—typically supply added sugars. They certainly don’t beat a diet of healthy foods.”
The WHO report confirms these concerns: “Science is a dominant theme in the marketing of formula milk across all eight countries, including scientific imagery, language and pseudo-scientific claims. Formula milks are positioned as close to, equivalent and sometimes superior to breast milk, presenting incomplete scientific evidence and inferring unsupported health outcomes. Ingredients, such as human milk oligosaccharides (HMOs) and docosahexaenoic acid (DHA), are advertised as ‘informed’ or ‘derived’ from breast milk and linked to child developmental outcomes. Examination of the scientific evidence cited does not support the validity of these claims.” (p. 9)
In response to the absurdity of BMS industry claims during Protecting Breastfeeding in the United States: Time for Action on The Code, David Clark, International Public Health and Human Rights Lawyer and Legal Advisor for the UNICEF Nutrition Programme (1995 to 2020), laughed “I don’t think I’ve seen anything so outrageous in my life.”
The marketing of formula products is different from other commodities because it impacts the survival, health and development of children and mothers; disrupts truthful information– an essential human right as noted by the Convention on the Rights of the Child; disregards the International Code of Marketing of Breast-milk Substitutes; and exploits the aspirations, vulnerabilities and fears at the birth and early years of our children solely for commercial gain. (WHO/UNICEF, 2022, p. x)
Considering the current state of affairs– the industry’s guileful tactics, the permeation of their influence in every sphere of life, our nation’s lack of adoption of the International Code of Marketing of Breast-milk Substitutes/ subsequent WHA resolutions and any monitoring or enforcement systems– it’s easy to feel crushed as a maternal child health advocate, like the way forward is straight into the Apocalypse.
Fear not. Researcher Britt Wray has suggestions on how to keep ourselves within our windows of tolerance in order to continue to mobilize. While Wray’s work focuses on the climate crisis, her findings are easily applied to maternal child health advocacy. Learn about these techniques here.
There are also simple actions (and some bigger ones too) that we can employ to continue to move the needle.
Françoise Coudray of ADJ+ Allaitement Des Jumeaux et Plus offered this to health advocates attending the launch of WHO’s latest report : “The mosquito: small, small, but have one in your bedroom and you will have a very bad night; so do the mosquito, let us all do the mosquito.”
On Facebook, find the three little dots in the upper right hand corner of the ad to locate the “Report ad” prompt.
When marketed formula products on social media platforms, report them directly to the platform.
Make a presence at the Codex Committee on Contaminants in Foods Public Meetings. In April, individuals like Consumer Reports Senior Staff Scientist Mike Hansen, Ph.D, Environmental Defense Fund’s chemicals policy director Tom Neltner and Center for Science in the Public Interest’s Thomas Galligan, PhD made clear in brief comments that we need to rethink how toxin levels are approached at CCCF. Hansen pointed out that the current permitted levels are not sufficient to protect infants and young children. Echo these demands for safer products. [While we wait for more stringent requirements, consumers can check out the Clean Label Project to find information about food and products not available on their labels.]
Join forces with other advocacy groups to put pressure on the enforcement agencies responsible for food safety.
Get people fired up. Increase public interest participation using NACCHO’s flyer on advocacy and lobbying to drum up attention about how the Code benefits all babies, no matter their feeding method. This has been grossly overlooked and cannot be overstated as formula companies often attempt to pit breastfeeding advocates against those who do not breastfeed.
Support the Baby-Friendly Hospital Initiative (BFHI). In the U.S., this is the only “federal” program that is enforcing the Code, albeit voluntary participation.
Encourage divestment. Check out Norwegian Secretary-General of Save the Children Tove Wang’s push for the Norwegian Government Petroleum Fund’s withdrawal from investments in companies aggressively pushing infant formula in developing countries. According to Save the Children’s Don’t Push It, “The largest global fund management firms have more than $110 billion invested in companies that market milk formula. As we have documented in this report, the profits these companies generate are fuelled in part by marketing practices that directly – and profoundly – harm children….Active investment funds have the power to wield huge influence over the boards of the companies they have a stake in.” (p44-45)
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