Breast is best; it’s widely known. But just 29 percent of B.C. moms breast-feed their babies exclusively for the first six months of their lives as recommended by Health Canada and the World Health Organization.
Why so few? One key reason, say breast-feeding advocates, is the solid grip that infant-formula makers have on doctors and nurses. Case in point: the controversy over Nestlé that erupted last month in the maternity ward at Burnaby Hospital.
When Nestlé Nutrition, a leading formula company, invited health professionals in Burnaby for cocktails and dinner at the city’s Hilton Vancouver Metrotown hotel in June—oh, yes, and a little talk on infant nutrition and formula titled “The Infant Feeding Maze”—a staff member at Burnaby Hospital e-mailed the invitation to employees via an internal mail list.
When word got out to breast-feeding advocates, they mobilized and bombarded Nestlé and health authorities with angry e-mails. They said the event violated the World Health Organization’s 1981 International Code of Marketing of Breastmilk Substitutes. The code, which Canada and the B.C. Health Ministry have signed, says formula makers shouldn’t offer “financial or material inducements” to health-care providers to promote their products.
Even B.C. Health Minister George Abbott waded in with a letter in which an official writing on his behalf said “it is clear that Nestlé is violating the [WHO] code.”
Nestlé bowed to the pressure and cancelled the event after getting “over 100” protest e-mails, said Catherine O’Brien, a spokeswoman at the company’s office in Toronto. Yet she rejected Abbott’s letter (“He had no knowledge at all of what the event was all about”) and insisted the meeting wouldn’t have violated the WHO code because “refreshments” and a meal are not a “material inducement”.
In fact, the event was the second in B.C. that Nestlé has had to cancel. Last September, staff at Burnaby Hospital invited the company to put on a similar information session, which was to have been held in the hospital itself, O’Brien said. That event was also cancelled after community protests. (The WHO code prohibits any promotion of formula products within hospitals.)
Michael Bernard, a spokesman for the Fraser Health Authority, which oversees Burnaby Hospital, said he would call back with a comment, but he had not done so by press time.
Although breast-feeding advocates were rejoicing at the latest cancellation, the dispute left maternity-care professionals at the hospital divided and prompted the resignations of lactation consultants Linda Good and Renee Hefti-Graham. “Women in Canada are paying the price for these free meals,” Good said in reference to Nestlé’s wine-and-dine. Hefti-Graham said many of their coworkers at the hospital were ambivalent about supporting breast-feeding, while one manager dismissed WHO literature on the subject—as well as documented international information on Nestlé WHO code violations—as “propaganda”.
The conflict sheds light on the persistent obstacles to breast-feeding in B.C. and Canada nearly three decades after the adoption of the WHO code. Despite Abbott’s support in the Burnaby dispute, many experts fault his government and the broader medical community for not doing enough to promote breast-feeding or reduce the sway that formula companies have over infant feeding.
The stakes in the battle over the bottle are huge. Research shows that breast-fed babies have fewer ear and respiratory infections, fewer allergies, less diarrhea, a stronger immune system, higher IQ, less risk of diabetes later in life, better oral development, and more bonding with Mom. Mothers also benefit by losing weight quicker, experiencing a faster contraction of the uterus, and having a lower risk of osteoporosis and ovarian and breast cancers.
In fact, research shows breast-feeding is literally a life-and-death issue in some cases. A May 2004 U.S. study of 9,000 infants published in the journal Pediatrics found a 27-percent higher chance of death among kids who had never been breast-fed compared to those who had, including a 19-percent greater risk of sudden infant death syndrome and 69 percent more chance of death by injury.
“Breast-feeding is associated with a reduction in risk for post-neonatal death,” the study said. “Promoting breast-feeding has the potential to save or delay approximately 720 post-neonatal deaths in the United States each year.”
In B.C., officials like to tout the fact that 95 percent of women breast-feed at birth, the highest rate in the country. “We play that up and pat ourselves on the back,” said Karyn-grace Clark, a lactation consultant in Nanaimo. “Though we get them breast-feeding, we can’t keep them breast-feeding.”
Less known is the fact that hospital staff give many of those women infant formula even when their babies are healthy and breast-feeding. The practice is a violation of guidelines established by the WHO and UNICEF in 1991 as part of a program called the Baby Friendly Initiative. The initiative, which the B.C. Health Ministry and Health Canada have endorsed, is intended to reform hospital practices worldwide in order to promote breast-feeding and reduce reliance on formula.
The Baby Friendly guidelines say there are only a few exceptional situations in which formula truly is a medical necessity for newborns, such as when they or their mothers are severely ill.
Yet as many as 60 percent of healthy, breast-feeding newborns are being given supplementary formula in B.C. hospitals, estimated Sandra Yates, a doyenne of the province’s lactation consultants who teaches courses on breast-feeding to health-care providers at Douglas College.
“Nurses are overworked; formula is used as a quick-fix solution,” Yates said. “Often the problems are shovelled off to the next level because there isn’t time to do it. It takes time to sit with a mom through an entire feed.”
Sharon Prindle-Collins, chair of the Fraser Health Authority’s Breast-feeding Practice Council, estimated that about 40 percent of healthy babies get formula in the eight maternity hospitals in her region. She agreed that many of the cases aren’t motivated by any medical necessity.
“There is a bed crunch,” she explained; in order to make way for new arrivals, formula is sometimes given in order to promote a baby’s weight gain so she can be discharged. “If weight [of the baby] is not up by the time they go home, sometimes the health-care provider would recommend formula to get the weight up,” she said. The recommendation typically happens in the event of weight loss of 10 percent or more, she said.
There’s just one problem: it’s normal for breast-fed newborns to lose up to 10 percent of their birth weight due to fluid loss, according to the WHO/UNICEF guidelines. Weight gain usually doesn’t start until day four or five after birth—after the baby goes home. (The usual postnatal hospital stay is one to three days.) In other words, a lack of weight gain in hospital is pretty much the norm.
In fact, the Baby Friendly Initiative says the only weight-related situations in which formula is a medical necessity are when a baby has “very low” birth weight—less than 1.5 kilograms—or hasn’t regained his birth weight after two to three weeks. “For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements,” the guidelines state.
Aren’t some women just unable to breast-feed? Linda Good, one of the lactation consultants who resigned from Burnaby Hospital, said just three percent of moms can’t produce enough milk to breast-feed their babies exclusively, usually due to damage to breast ducts or nerves from cancer, burns, or surgery. But even these women can still usually breast-feed to some extent. Fewer than one percent of women can’t breast-feed at all; even women who adopt can produce breast milk, Good said.
Yet formula use in B.C. hospitals actually appears to be on the rise. Between 2005 and 2007, the percentage of all breast-feeding new moms (including those with pre-term babies and cesareans) who got some formula while in hospital went up from 24.2 to 25.3 percent, according to the B.C. Health Ministry’s Perinatal Health Program. The rate rose in four of the province’s six health authorities. (Barbara Selwood, a perinatal nurse consultant with the program, speculated that the higher numbers may just be due to more accurate data collection.)
As well, none of the province’s six health authorities managed to hit the WHO/UNICEF standard of 80 percent of all babies getting nothing but breast milk while in hospital (including those born by cesarean section). Overall, 69.2 percent of B.C. moms exclusively breast-fed their babies while in hospital last year, down from 69.5 percent in 2005.
It’s really no big surprise that health care in B.C. falls short of the WHO/UNICEF standards. Just one hospital in the province has thus far been certified as a Baby Friendly facility—Quesnel’s G. R. Baker Memorial Hospital, which got the designation last January.
To be sure, the situation isn’t much better elsewhere in Canada. Seventeen years after Health Canada endorsed the Baby Friendly Initiative, only 18 of Canada’s some 500 hospitals and health facilities offering maternity care have gotten the certification. (Thirteen are in Quebec, the only province to mandate all its maternity facilities to achieve the designation.) About 20,000 hospitals have been certified worldwide, but only 500 are in industrial countries.
In B.C., authorities have talked a good talk about Baby Friendly. Back in 2003, the province’s deputy health minister, Dr. Penny Ballem, wrote a letter to the CEOs of the six regional health authorities urging them to get certified. But no funds were attached to the recommendation, and it remains up to each authority to decide whether or not to go for it.
The B.C. Women’s Hospital and Health Centre has been working toward accreditation since 2004 and hopes to get it this month. That process, which typically takes five to 10 years, is just beginning for the Vancouver Coastal Health Authority, whose senior executive team will decide whether or not to pursue the designation in coming weeks, according to spokesperson Viviana Zanocco.
Baby Friendly would usher in a sea change in hospital routines in B.C. Getting certified means changing practices like taking babies from mothers right after birth in order to do a physical exam, administer a shot and eye ointment, and swaddle them. That process, which can last five minutes, has been shown to interfere with the establishment of breast-feeding, Yates said. Instead, Baby Friendly rules say newborns should be immediately placed on Mom’s chest so they can start trying to suckle; nurses can examine the baby there.
The WHO/UNICEF guidelines would also mean education for all maternity-care providers and moms on breast-feeding techniques. It used to be that a new mother’s aunts or mother would show her what to do, but after doctors and nurses started touting infant formula as being as good as breast milk in the 1950s—a belief that numerous studies have since discredited—several generations of women lost that knowledge.
Today, the 40 percent of mothers who encounter problems with breast-feeding—like sore nipples, infections, failure of the baby to latch, or poor milk supply—usually turn for help to public-health nurses and family doctors, but few of those professionals have undergone the breast-feeding training that the WHO/UNICEF guidelines recommend.
In early 2007, the B.C. Health Ministry brought 90 nurses from across the province to Vancouver to take a 20-hour course on breast-feeding, with the idea that they’d return to their facilities and teach the course to their coworkers. That second phase has stalled, however, amid squabbling between the ministry and health authorities over who will pay for staff to take time off work for the training.
Lactation consultants say change is also needed at the federal level and in the broader culture. Ottawa has yet to adopt the 1981 WHO code on formula marketing as law, which means formula companies are free to flout the code’s admonishments against formula ads in the media and giveaways of product samples to parents at Vancouver’s frequent baby fairs.
“Formula is so ubiquitous and integrated into our thinking that when we think of a baby, we think bottle. When there are breast-feeding challenges, the first thing women try is the bottle,” Yates said.
Good, who worked as a midwife in South Africa before she emigrated here 25 years ago, agreed. “I was shocked when I came to Canada. It felt like it was almost a different species. Mothers [here] live in a culture where we never see a baby on a breast. The whole society doesn’t know what breast-feeding should look like.”
On the other hand, many breast-feeding experts are heartened to see new generations of women challenge the medical community and formula companies like Nestlé. “As a culture, women have to take their power in breast-feeding,” Yates said. “They should do the research beforehand and know the potential problems [with breast-feeding], much as they plan out the birth. Then women won’t be as easily misled by health professionals.”
For more on this subject, check out Pieta Woolley's blog posting on the trials and tribulations of being a breast-feeding mother in Vancouver.