A slightly curmudgeonly rant about the drama over Save the Children’s “Superfood for Babies” campaign

The problem with writing a post which criticizes an organization which strives to help starving kids is that it makes you feel like the Grinch. Or Gargamel. I feel like I should be stroking an acrimonious cat and arching a pair of overgrown eyebrows inward.

Save the Children does a lot of wonderful things for children in dire straits, and I don’t want to come down on them too hard. And in many respects, I applaud their recently announced “Superfood for Babies” initiative. I do believe that breastfeeding is a hugely important part of improving childhood mortality in resource-poor nations, and the report supporting the program offers some excellent perspective on the challenges of raising exclusive breastfeeding rates in these areas.

In public health circles, there’s a lot of discussion on messaging – how to make PSAs culturally appropriate, sensitive, and effective. The thing is, this doesn’t only hold true for at-risk groups – it also applies to the middle-class factions of western nations. It’s just as ineffective (and inappropriate) to try and graft a message addressed to people living in tribal societies with problematic water sources onto a secretary in suburban Iowa as it would be to do the opposite. Yet, this is what happens – repeatedly – in our international discussions of breastfeeding. (Incidentally, this is at the root of my beef with Unicef and WHO, and why I feel it’s necessary to amend the Baby Friendly Hospital Initiative set forth by those organizations to be more culturally appropriate to developed, Western societies.)

This brings us to my scroogey analysis of the “Superfood for Babies” campaign.  I would encourage everyone to read the literature – it offers some truly excellent insight into the specific issues at play in a variety of developing nations, and makes it clear (whether or not it intends to) that formula is not the only barrier to encouraging exclusive breastfeeding. In some cultures, there are beliefs that breastfeeding for the first few days of a babies life is detrimental; in others, women feel pressured to produce as many babies as possible, thus making the fertility-restricting nature of breastfeeding a downside; and in others, it’s not formula which is used as a supplement but raw animal milks or concoctions of grains.

Save the Children (STC) did a lot right with this report. They addressed the need for social change; advised that governments subsidize breastfeeding women so that those in unstructured agricultural jobs (which don’t exactly come with a 401k or paid maternity leave) don’t need to return to work immediately, and have to choose between making a living and feeding their babies; and they press for better education and involvement from medical workers and midwives. I think their motives were great, and they did their homework.

Unfortunately, in their excitement, they lost perspective in three key areas…

1. They were (intentionally or unintentionally) vague about the research

Look, I would never argue that breastfeeding isn’t the best choice – by far – for babies in places where food is scarce, infection and disease runs rampant, medical care and antibiotics are severely limited, and the water source is questionable. Formula feeding is dangerous in these settings. But since breastfeeding advocates and orgs like WHO have made breastfeeding a global issue, we have a responsibility to be honest about what our body of research actually says. There are numerous instances in the STC report where claims are simply not held up by their citations. For example, this quote, on page vii of the report’s introduction:

It is not only through the ‘power of the first hour’ that breastfeeding is beneficial. If an infant is fed only breast milk for the first six months they are protected against major childhood diseases. A child who is not breastfed is 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhoea[2]. Around one in eight of the young lives lost each year could be prevented through breastfeeding,[3] making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths[4].

Let’s take a closer look at the citations. The first one, #2, is from a UNICEF report on diarrhea and pneumonia- not a study, but a report. So it took a bit of digging to see exactly where they were getting their data from. I *think* this figure comes from a table attributed to a Lancet piece, which “estimated”  that “Suboptimum breastfeeding was… responsible for 1·4 million child deaths and 44 million disability-adjusted life years”. I couldn’t get the full study on this one, but again – it was an estimate, most likely based on other studies – not hard data.

Citation #4 is the one that’s bothersome, however (#3 is just a footnote with the definition of “exclusive breastfeeding”). The sentence “making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths” is most likely read as “breastfeeding is the most effective way to prevent child death”. That’s quite emotive. The citation leads you to a Lancet paper on child survival, which does have some dramatic data and charts regarding the interventions which would most reduce infant mortality in the developing world. Breastfeeding is shown to offer the most dramatic reduction in risk- but there’s one important point to consider: while this report focuses on death in children ages 0-5, the majority of these deaths occur in the first few months of life. Exclusive breastfeeding, as opposed to mixed feeding or exclusive feeding of substitutes including goat or buffalo milk, paps, or formula (important to note that in many of the countries STC is concerned about, traditions include feeding neonates animal milks or solids within hours of birth – so I think it’s arguable that the issue here is the risk of giving a baby anything but breastmilk via the breast, rather than breastfeeding being the “magic bullet” the report dubs it to be. Otherwise, we probably wouldn’t see consistently poor outcomes in mixed-fed kids, as a “magical” substance would compensate) is going to reduce the risk of infections that cause death in very young babies. In other words – if the most deaths are in newborns, and breastfeeding saves newborns more than any other interventions like vaccines, clean water, etc – then there will be a disproportionate representation of “babies saved by breastmilk” in the results. This is not to say that breastfeeding isn’t an incredibly worthwhile and effective solution to reduce infant mortality, but it’s a bit of a stretch to suggest that breastfeeding alone will be the most effective intervention for ALL childhood deaths, which is exactly what the STC report does.

2. They didn’t consider the societal implications of their recommendations, beyond the scope of infant health

I was taking notes as I read the STC report, and my heading for the section which included this quote was “OMGOMGOMG”:

Many women are not free to make their own decisions about whether they will breastfeed, or for how long. In Pakistan, a Save the Children survey revealed that only 44% of mothers considered themselves the prime decision-maker over how their children were fed. Instead it is often husbands or mothers-in-law who decide….

 

….To overcome harmful practices and tackle breastfeeding taboos, developing country governments must fund projects that focus on changing the power and gender dynamics in the community to empower young women to make their own decisions.

Changing the power and gender dynamics sounds like a fantastic idea, and I would support any program that attempted to do this. But STC has to realize that “empower(ing) young women (in developing countries) to make their own decisions is a complex and uphill battle that extends far beyond infant feeding. I fear that by placing an emphasis on UNICEF-lauded solutions like warning labels on formula cans/making formula prescription-only, and on educating fathers/elders on the importance of breastfeeding using the current overzealous and often misleading messages, in these countries – places where, all too often, females are already considered “property” and subjected to any manner of injustices – it will create an atmosphere where women who are physically unable to breastfeed will be ostracized, shamed, or penalized. I agree that we need to empower women, but I think that we also need to be verrrry careful about presenting “suboptimal breastfeeding” as a risky behavior in certain cultures.

In another section, the authors report that breastfeeding rates have gone up in Malawai despite poor legislation on maternity leave, breastfeeding rights, etc. – that these improvements are based solely on strict implementation of WHO Code. I’d like to be reassured that as women are being given no option other than breastfeeding without any of the protections which would make EBF feasible while working, this isn’t having a deleterious effect on their lives. It’s wonderful that breastfeeding rates are up, but what about correlating rates of employment, poverty, and maternal health?

3. They failed to differentiate between resource poor and resource rich countries

I’ve seen a wide range of opinions on the STC program online in the past few days. Most of the drama is over British media reports which mention putting large warning labels on all formula tins – not just the ones going to resource-poor countries. Some feel that these labels will cause unnecessary upset in the West; others argue that when it comes to saving starving/sick third-world babies, privileged mommy pundits should STFU. And others keep insisting that the STC report was misrepresented, and that the labeling stuff was a minor part of the larger plan and shouldn’t be harped on.

All of these arguments are valid, and yet all are missing the nuance necessary to have a productive conversation. We need to realize that not breastfeeding has quite different implications in certain parts of the world. We also need to acknowledge that a woman’s rights are important no matter how much money she has or where she lives, and that we all have a right to stand up for what we believe – it’s rather useless to play the “eat your dinner because children are starving in Africa” game, and rather un-PC as well.

But STC also needs to take responsibility, here. The fact is that the report does not really differentiate between resource-poor and resource-rich countries when it is discussing WHO Code and formula marketing.  For example, this passage on p. 45 describes laws which STC wants implemented worldwide:

Breast-milk substitute companies should adopt and implement a business code of conduct regarding their engagement with governments in relation to breast-milk substitutes legislation. Companies should include a public register on their website that outlines their membership of national or regional industry bodies or associations, any meetings where the WHO Code or breastfeeding is discussed, and details of any public affairs or public relations companies they have hired, alongside the nature of this work… Any associations (such as nutrition associations or working mothers’ associations) that receive funding from infant formula companies should be required to declare it publicly. In addition to this information being made publicly available on the websites of individual companies, the International Association of Infant Food Manufacturers should publish a consolidated record of this information, updated on a quarterly basis.

Personally, I think the money spent on a “governing association” in order to police this policy would be better spent on funding literacy programs to help parents read the labels we’re arguing about. Some of these countries have literacy rates of like 30% – which makes me wonder exactly who the labels are geared to, if not the Westerners for whom formula feeding is far, far less of a risky endeavor.

Don’t mistake me – the evidence given in this report about the shady practices of formula co’s is alarming. There needs to be something done about unethical marketing practices in parts of the world where information is limited, education is a true privilege, and options are a joke. Yet, in the STC report, there is ample (and quite good) evidence that the unethical efforts of formula companies are only one slice of a thick-crust, Chicago-style pizza. There’s a lot of gooey, barely distinguishable elements which all combine to make a rather heavy problem, and focusing so much on one of them will leave you with the policy equivalent of Domino’s.

Further, the situation with breastfeeding in the developing world is markedly different from what’s going on in Great Britain, the US, Canada, and so forth. The online arguments are proof of this. I’ve seen the same people who argue that breastfeeding is a global issue turn around and tell concerned Americans and Brits that they have no idea what’s appropriate in Peru or Ghana. This may be true, but so is the reverse. International groups like STC have to remember that when they release papers making global recommendations about infant feeding, that they are inviting commentary from a global audience. That’s why we can’t make blanket statements about infant feeding and child health, or try and implement the same rules in order to get the same results. We wouldn’t go into a rural village where families share a 300-square foot hut and start lecturing them about the dangers of co-sleeping, and yet we assume that the same one-size-fits-all public health messaging is fair game when it comes to infant feeding. Breastfeeding might indeed be a global issue, but the type of issue it is varies greatly depending on what part of the globe you’re on.

 

About the Author:

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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23 thoughts on “A slightly curmudgeonly rant about the drama over Save the Children’s “Superfood for Babies” campaign

  1. I strongly encourage those who insist that STC works in developing countries ergo should be read as relevant only to them, and whining about “first world media” misunderstanding the scope of the report, to read the actual report, even just the first 6-7 pages. There is only one very vague mention of the fact that survival rates for babies BFing vs otherwise are different for developed vs LDCs, and up until page 5 they speak of a global population, not differentiating at all based on countries. Then there’s one sentence on dirty water, followed by two paragraphs insisting that even babies in rich countries and rich contexts are five times more likely to be hospitalized and at a higher risk of dying due to FFing (citing two crappy studies, read them and judge).

    There’s a damned good reason why this is problematic – it consciously elides or actively fudges the line between health outcomes in places with clean water and places without when it comes to infant feeding choices. The actual initiative they propose has a lot that is sound, but they’re risking their credibility with me and a lot of others by their disingenuous framing of the problem. This report will also be used by health workers and activists in the West to beat up on FFers, and if you believe everything the report says, they’d be right to. Again, read the report.

  2. Thank-you FFF — the same broad brush is also inappropriately applied to childbirth choices and feeds the judgmental sancti-mommies who would rather serve an ideology of biological essentialism than serve the best interests of children and their mothers (a mom is more than the sum of her girly bits FFS!)….

  3. I think breastfeeding is a very, very important thing for reducing infant and child mortality in poor parts of the world, but I think the majority of the protection comes from the method more than the milk itself. Breastfeeding from the breast means a food-and-drink on tap where there is no reliance on dodgy water supplies, no containers, bottles or cups to become contaminated, and it can’t be watered down or given to the men in the family (which is what often happens to the most nutritious foods in underprivileged parts of the world). If breasts made formula rather than breastmilk, I think the benefits in terms of lower mortality would not be that much lower, if you see what I mean.

    • Yes, good points. I realise no report can get into all nuances but what did you think of how the STC report presented the nature of the risk? To me it was pretty strikingly overstated – and I agree with and support the goal of promoting BFing for better health outcomes FFS.

      • Still working my way through the report (damn work! too busy this week). I think most of the measures the report are talking about are fine/great, but the CEO of STC IS on record as saying that he supported the strongly-worded labels on formula even when it is sold in developed countries “in case it gets exported.” That is going too far.

  4. FF something you said above on the report’s focus on empowering women and taking an individual-focused approach to education made me think about context: along with ensuring women have better healthcare and supportive family members, which the report suggests as part of its initiative, there isn’t all that much consideration of how to make exclusive BFing (which is the focus of public health efforts – it doesn’t matter that 95% of women in rural Egypt breastfeed, for them, but the fact that they all supplement pretty much from the get-go is what is seen to cause disease) work with women’s other responsibilities. There are cash payments that have worked in some countries, which may be the way to go when maternity leave isn’t relevant – yet when women have a zillion other household and childcare responsibilities without the option of snapping their fingers for more help, will pushing them to BF add to their burden? Is it possible to ensure the protective effects of breastfeeding/avoid the risks of contaminated supplements within the limits of what women in poor areas can realistically do? I think we all probably have a specific context in mind when we’re thinking of women who don’t BF but could: for some activists, it’s women of the not-poorest urban classes bullied by doctors and ads into using formula when they could BF; when I think of women in this situation, I think of an overworked village woman who may not be in a position to ALWAYS be on call when their babies need to be fed. This is another reason why I think cheap water purification machines may be a good idea too.

    • I am wondering about the “overworked village woman” you imagine, who can’t always be on call for her breastfeeding baby. Who would be on call for that baby? I am assuming you aren’t suggesting that the baby be left all on his or her own!!! So if the mother doesn’t feed the baby her breast milk, someone else will have to feed the baby something else, right? It’s not like the job of feeding the baby goes away just because the mother isn’t doing that feeding. Do you envision that the fathers will feed the babies then? Or do you envision this task will fall on other overworked village women?

      • It is not a question of what I “envision” – it’s a question of knowing what women’s responsibilities are in this situation. Yes, other women from the family, often older women, will feed the child; if the woman has a daughter over the age of ten, she is often left to care for the baby. If the baby is female and has a toddler brother that the parents are more interested in keeping alive, she may breastfeed him. If she has to work on the fields and fetch water and milk the cows and cook for the family, there will be times in the day when her baby is left in the care of her mother in law. Some women carry their babies on their backs and care for them while working, some don’t (e.g. you see women doing road construction with their babies sitting on the roadside, in most parts of N. India). Therefore this idea that somehow all you need to do is to tell rural women to BF misses part of the picture, in my view. Their social and economic roles, some of which can be changed by counselling and some of which may be more difficult to change, are also at play here. You can moralize about how this *should not* happen but it does. Poor, patriarchal farming communities don’t always work that way. It is of course important for public health messages to emphasize the importance of letting a new mother rest and recover and how crucial early BFing can be in making the baby healthier overall. Whether this will suffice to change gender roles, I don’t know. And these are not communities where formula is affordable, and watered down milk is being fed to babies anyway, so focusing on formula advertising isn;t going to change much.

  5. “We also need to acknowledge that a woman’s rights are important no matter how much money she has or where she lives”

    What about the rights of children to the healthiest start in life? If formula has such a negative impact on babies in developing nations, regardless of water sanitation etc, what makes Western babies so super-human that they can withstand the harmful effects of consuming exorbitant amounts of sugar, industrial contaminants and GMO’s (to name a few)?

    It disturbs me on a *neurotic* scale that you are so concerned with the ‘rights of women’ but fail to mention the rights of the BABIES. Your blog, your page, your book all focus on how it’s a mother’s ‘right’ to ‘choose’ how she feeds her baby. What about the baby’s rights? What about the baby’s rights to the consumption of biologically appropriate and protective nutrition? There are *billions* of women on this planet, more than enough for us to feed each others babies without succumbing to the pretty pictures on the box in the main room of the house or in the glossy fancy book in every single freaking outlet. The human race did not expand to it’s current size because of formula. It flourished because of breastmilk and breastfeeding. It flourished because, on the rare occasion that a woman TRULY could not breastfeed, there were others to feed her baby for her. Now we are seeing higher infant mortality rates GLOBALLY and that’s because of the interventions of modern ‘medicine’ and its proponents such as yourself.

    • Ah the gross misuse of capital letters. The first sign of a complete ideologue.

      Modern medicines have done wonders to keep people healthy and live longer lives in many parts of the world. It’s not perfect, but research continues every day to improve medications. My degree is not in science, it is in history. History is full of plagues, outbreaks, women and babies dying in childbirth, starvation, unsanitary conditions, etc. Many of these types of deaths are prevented today and we don’t even realize it.

      Modern inventions such as medications, vaccinations, sanitizers, water purifiers, safer surgeries, even the almight GMO help improve the quality of life. You have a choice whether or not to accept those inventions in your life, but don’t berate someone else who does choose them. You don’t have any idea how they live from your high horse in the sky.

      It never ceases to amuse me those who lash out against modern medicine and obstetrics all the while typing their rant on a smartphone.

      • “It never ceases to amuse me those who lash out against modern medicine and obstetrics all the while typing their rant on a smartphone.” => spewing water from mouth.

  6. The full body of research is very clear that breastfeeding is better for all babies, whether in poor countries or not, than formula. Be careful that you’re not falling into the trap that you’re trying to avoid.

  7. Perhaps it is worth considering that, although I agree with you that making sweeping statements across the globe tends to diminish accuracy, the importance of breastfeeding in third world countries– and the importance of getting that word out– is far more of a crucial goal here than understating the risks of formula feeding in those countries. After all, women and children in developed countries, where there are not the same risks involved in FF, are also far more likely to receive that information and to have choices in the matter than the women for whom this study, and others like it, are targeting to help. So, the fact that the wording is stated a bit strongly for some who are obviously invested in defending their right to not breastfeed (from the safety of their sanitized, safe, clean water filled perch), seems a bit like semantics to me. These studies aren’t meant to take away your right to do what’s best for your children, but, rather for women without the luxury of debating their choices- nor the education to back them up.
    As to being vague about the research, again, the people who this study is most likely to help may not have the resources to research and understand a long and complex series of studies. You do, but, then, again– you are already clear on the issue. As to focusing on infant health as the only social implication taken into consideration, well… it is a “Superfood for BABIES” campaign, and, lastly, if they are not focusing equally on resource rich and resource poor countries, oh, well. If a mother in a research rich country is misled into feeding her baby breast milk (gasp!), the consequences are not at all on par with a mother in a research poor country putting her child at risk with poor water because she didn’t understand the comparative risk of bottle feeding.
    That being said, I don’t begrudge any mother the right to chose what is right for her and her own children. I don’t even begrudge their right to blog about it– I enjoy reading it, in fact– and I understand that it is frustrating to feel criticized for making those choices. But to lash out (even semi-apologetically) at organizations that are doing far more good, where it is needed, than harm, seems a bit over the bend to me.

      • Also, these reports never seem to take into account the malnourishment of the mother in parts of the 3rd World – dirty water and watered down formula might endanger babies lives, but demanding that women exclusively breastfeed for at least 6 months when they are often severely malnourished and overworked, leads to “suboptimal” outcomes for the mother and child in any case. I’m an middle class and highly educated Indian woman (born and raised in Mumbai, still living and working there). I had to formula feed my daughter because of very low milk supply and ongoing latching on issues. (I had a lot of help from my family and lactation consultants in hospital, BTW, but nothing worked). As the child of an environmental lawyer and an academic, my daughter goes to one of Mumbai’s best schools and has every other advantage you could think of. She is being raised to be compassionate and to not be an entitled brat, however, the reality is that she is among the privileged in my country (as are my husband and I). Are the sickly babies I see being fed by starving beggars at traffic lights, really going to be better off than her only because they are breast fed?

  8. coming from a single mom in a third world country without any given support from the father of my child, i can’t see anything wrong with formula feeding as long as it feeds my child well. It is much better for us single moms to work 8 hours a day and leave our child at home with formula milks on their mouth than staying at home and breastfeeding our babies and starving ourselves to death.

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