For years, formula has been an easy option for new mothers, but institutional attitudes are changing to encourage breastfeeding among low-income and minority families
Despite being one of the wealthiest nations in the world, the United States is one of the sickest. Obesity is one of the fastest growing chronic conditions both globally and nationally, affecting 15 percent of American adults and 18 percent of American children, according to the Centers for Disease Control. It’s a contributing cause to other serious diseases such as diabetes, cardiovascular disease and some types of cancer. And these diseases are killing people at an ever escalating rate. The World Health Organization predicts that diabetes will be the seventh leading cause of death worldwide by 2030.
Chronic disease has become more than a public health crisis in the U.S. It’s not just that we are getting sicker, it’s also who is getting sick more often and who is dying at disproportionate rates from diseases that we now understand to be preventable. Looked at through this lens, chronic disease is as much about inequality as it is about public health.
One culprit comes in an innocuous — and usually subsidized package: baby formula.
Doria Thiele is a clinical assistant professor at Oregon Health & Science University. Thiele is also a certified nurse midwife studying lactation, the breastfeeding relationship and the role of breast milk.
“Human milk is ideal for human babies and when we introduce other things like formula or foods too early, we can disrupt the metabolic pathways. We have such a crisis with obesity and diabetes and cardiovascular disease in our country. And we know that some of the aspects of formula that babies can be exposed to, increase their likelihood of developing those diseases,” says Thiele.
A 2009 meta-analysis published in Advances of Experimental Medicine and Biology indicate that formula feeding does in fact increase a person’s likelihood of becoming obese by 20 percent. That isn’t surprising, considering that corn syrup is one of the main ingredients in most popular brands of formula.
Public health officials are trying to encourage more women to breastfeed, but convincing some women to ditch formula presents a huge hurdle.
“We need to be really careful because there’s a lot of people who can’t even meet their own basic needs,” says Thiele. Although 90.2 percent of Oregon mothers initiate breastfeeding, only 24 percent manage to continue breastfeeding their babies through 6 months of age. Rates are lower in low-income communities of color, especially for African American women, Latinas and Native American women. Consequently, illness, disease, and infant mortality rates are higher for these groups than the general population. In the U.S., a woman’s ability to nourish and bond with her baby has become an economic privilege denied to a growing number of women who lack the resources of time and money.
Surgeon General Regina Benjamin issued a call to action to support breastfeeding in 2011 and the American Academy of Pediatrics asserts that breastfeeding is a matter of public health, but the United States is one of the only countries in the world where infant formula companies are free to aggressively market their products.
In 1981, the World Health Organization adopted the International Code of Marketing of Breastmilk Substitutes. As of 2011, 103 countries have enacted some kind of legislation prohibiting the marketing of infant formula to the general public but the U.S. has taken no legislative action on the code.
Formula companies inundate hospital maternity wards with free formula, free branded supplies like diaper bags and even pamphlets on how to properly breastfeed, complete with instructions on how to switch to formula — just in case breastfeeding doesn’t work out.
For low-income women, the temptation to formula feed doesn’t end at the hospital. The federal Special Supplemental Nutrition Program for Women, Infants and Children, or WIC, is a recognized champion of breastfeeding in Oregon. They offer free lactation support and breastfeeding peer counseling to low-income moms. In addition to those services, federal requirements mandate access to free formula once the baby reaches 1 month of age.
In 2011 the U.S. Department of Agriculture released a study on how WIC’s contracts with formula companies impacted the infant formula market. They found that whatever company holds a sole-source contract with WIC also dominates formula sales by an average of 84 percent.
Three of the four formula brands offered by Oregon WIC without medical documentation are made by Similac, which is owned by Abbott Laboratories. Abbott is a global pharmaceutical company with an entire division devoted to diabetes care products.
“The pharmaceutical companies that produce formula are incredibly smart,” says Helen Bellanca, Maternal Child Program Manager at Health Share. “They know how to get their product out there and they know that if a baby starts drinking formula while they are still in the hospital after being born, then it’s likely the mom is going to continue to choose that same brand when they go home.”
But there has been a resurgence. Encouraged by the surgeon general’s call to action and the supportive policies of the AAP, breastfeeding rates are slowly beginning to creep up. Oregon in particular has been a leader in the breastfeeding movement. And advocates say baby-friendly hospitals are one of the most exciting and promising developments for families in Oregon.
The Baby Friendly Hospital Initiative got its start in 1991 by the WHO and UNICEF. It’s a global initiative — any hospital in the world can become baby friendly as long as they submit to the International Code of Marketing of Breastmilk Substitutes and the Ten Steps to Successful Breastfeeding. It’s a long and often expensive transition for hospitals to make, but proven to dramatically increase breastfeeding rates and other birth-related health outcomes.
Oregon currently has five certified baby friendly hospitals, none of which are in Portland. However, five of the Legacy Health System hospitals in the Portland/Vancouver area are on their way to becoming baby-friendly. They have been implementing the steps over the past three years and hope to be certified by 2015.
So far, the hardest step to execute has been changing the hospital’s relationship with the formula companies. Going baby-friendly requires hospitals to ban the heavily branded goodie bag and pay fair-market value for their formula, whether their contacts at the formula companies like it or not.
Hester Carr is a Perinatal Clinical Nurse Specialist overseeing Legacy’s transition to baby friendly. She says that before Legacy started the transition, the more free formula they gave away, the more free stuff they would get, such as bottles for example. Formula companies even sponsored educational speaker events complete with catering. All of it makes nurses and other hospital workers more likely to hand out their products to patients. But not anymore.
“They are now jockeying for a new position,” says Carr. “They’re not trying to get more money out of us. They will say we’ll sell it to you for a penny a bottle. But baby-friendly won’t accept that as a fair market value.”
Legacy is currently in contract negotiations with the formula companies and is scheduled to begin paying for formula in January 2014.
Legacy doesn’t have any measurements yet to gauge how going baby friendly is affecting their breastfeeding rate at the time of discharge. But a 2001 study in Pediatrics measured breastfeeding rates at Boston Medical Center from 1995 to 1999, when the hospital became certified baby friendly. During that time, breastfeeding initiation rates increased from 58 percent in 1995 to 86.5 percent in 1999, while the percentage of infants exclusively breastfed at time of discharge increased from 5.5 percent to 33.5 percent. Carr expects Legacy to see similar improvements on their breastfeeding rates once all of the steps are in place.
Once mom and baby leave the hospital, Legacy will be required to make sure they have access to some kind of community support system that will help them continue breastfeeding. A number of culturally specific breastfeeding coalitions have emerged recently to address this need.
“People are disenfranchised because of systemic racism and economic barriers,” says Shafia Monroe, president and founder of the International Center for Traditional Childbearing. “It’s harder for them to breastfeed for a lot of reasons.”
In 2010, Monroe’s center conducted a survey about the birthing experiences of 245 black women in the Portland area. The results of the study revealed that two-thirds of women surveyed did not attend a birthing class, nearly one-third reported a lack of medical support, half the women surveyed were single and many of them gave birth alone. As a result, breastfeeding rates were lower than the national average.
Monroe is trying to nurture a more supportive environment within her community in an effort to raise breastfeeding rates. Education is vital. She wants all women to know that they have certain rights. They can tell their employer that they want to breastfeed and need more time. They can tell their doctor they want to see a lactation consultant before supplementing with formula. And she wants women to know that ICTC will advocate for women who need help asserting their rights.
“Breastfeeding is about empowering women,” says Monroe. “That they embrace who they are and that their bodies are perfect and that they are able to birth their child independently of a corporation, the medical system, and they are able to feed their baby on their own.”
Sometimes programs that are designed to help low-income women actually make breastfeeding more difficult. Welfare to work programs like the Job Opportunity and Basic Skills program (JOBS) through Temporary Assistance for Needy Families (TANF) require recipients to look for work in order to receive benefits. Monroe says this often creates a structural barrier that middle or upper-class women simply don’t face.
Today new moms are exempt from participating in the JOBS program for six months due to changes in government policy. In 2005 WIC partnered with TANF to educate women about their rights and resources for breastfeeding support.
“I think that awareness of the right to breastfeed [is important],” says Xochitl Esparza, Program Manager for TANF. “Awareness that it’s a law in the state of Oregon and that they can advocate for themselves when they are in a job, either looking for a job or after they’ve been hired, that there are resources available.”
Roberta Eaglehorse Ortiz, community health worker and founder of the Oregon Inter-tribal Breastfeeding Coalition, knows the value of both from personal experience.
Seventeen years ago she journeyed from Baker City to Portland, a pregnant, 19-year-old Oglala Souix/Yomba Shashone woman, with her 3-year-old son in tow. She has been rallying for Native American rights ever since.
“It felt like me, one native woman, talking about all of these things. There wasn’t anybody else providing services, or even cultural support,” she says.
She works out of her home office that’s strewn with childrens toys, a closet full of baby clothes and donated office supplies. She has been a doula for eight years, a Peer Counselor and Community Health Worker.
She says that more than anything, Native American women don’t know what questions to ask their doctors when receiving medical services. They are often intimidated by a medical institution that has historically stripped them of their reproductive freedom.
“It was taken from us so long ago, so women forgot and they are afraid of their bodies, they are insecure, they have no knowledge,” she says.
What’s lost is a pride of having families. Through the breastfeeding coalition she hopes to restore some of that pride within her community and other disenfranchised communities as well.
Ortiz is currently working with Multnomah County homeless shelters to make sure that homeless women are able to access breastfeeding support, and Monroe works with Right 2 Dream Too. They both emphasize the empowering nature of being self-sufficient.
“If you’re not in a stable situation and you’re transient right now for whatever reasons, no judgment, the best thing you can do to make your life easier economically is to breastfeed your child,” says Monroe. “It’s always going to be clean, it’s always going to be the right temperature, it’s the ideal food.”
Ortiz says that even though the medical establishment might make assumptions that homeless moms are not able to breastfeed, many services are available. ICTC offers free doula service, Nursing Mother’s Council offers free breastfeeding support over the phone, and women who give birth in a hospital can go back to re-visit a lactation consultant.
In the future she would like to see all CHWs working with homeless populations trained in breastfeeding basics with at least three resources in their community that they can point families to.
With the recent passing of House Bill 3407, it may soon be easier for Ortiz to help make that goal a reality. The bill prompted the Oregon Health Authority to create a traditional health worker commission that will outline the roles, training and certification processes for different types of community health work.
The bill includes doulas. Doulas have been shown to improve birth outcomes, according to a 2012 study in the Cochrane Database of Systematic Reviews. Shafia Monroe with the International Center for Traditional Childbearing helped spearhead the bill with the goal of providing free doula services to low-income women.
“People who have means have doulas. Poor people don’t have doulas, unless it’s a volunteer program,” says Monroe. “We know doulas help women to breastfeed, then we need to find a way that every woman can have a doula regardless of her economic ability to pay.” She also believes the bill will provide a career path for low-income women committed to working in childbirth.
Oregon has seen a groundswell of breastfeeding advocacy in the last 15 years. The result has been a number of legislative victories for breastfeeding mom’s and babies. In 1999 Governor Kitzhaber signed a statute exempting breastfeeding mothers from jury duty. That same year another statute was passed to assure women the right to breastfeed in public. Then in 2007 the state legislature passed the Worksite Rest Breaks for Milk Expression law, which mandates that employers with more than 25 employees provide breastfeeding women a clean, private space to pump and a 30 minute break every four hours.
In 2007 and 2009 Oregonians came close to passing legislation for paid family leave. For most breastfeeding advocates, it is the Holy Grail of breastfeeding public policy. In most of the country, including Oregon, new moms and dads can take six weeks of unpaid leave after the birth or adoption of a child. But taking six weeks without pay is simply not an option for many families.
“If we really want to support family to be as healthy as possible on a number of fronts, not just breastfeeding, we’ve got to allow families to take paid time off when they have a newborn or adopted child so that everybody can bond and optimize their health without having the pressure to go to work,” says Bellanca.
