The Social Medicine Portal

The ACLU, the Madonna & Breastfeeding in New York

Legal in New York State since 1984

Several years ago, a young mother of our acquaintance was visiting the Cloisters, the gorgeous annex of the Metropolitan Museum of Art dedicated to the Medieval period and located at the northern tip of Manhattan.  She sat down in the garden (shown at this link) to breastfeed her son.  She was soon approached by a very serious-appearing guard wearing a blue blazer who informed her that breastfeeding was not allowed in public.  She protested that they were surrounded by images of Madonnas feeding Christ.  She offered to cover over the baby’s head.  But to no avail.  The guard told her that rules were rules.

Well, the guard was wrong.

In 2006, the American Civil Liberties Union (ACLU) threatened  to sue Toys ‘R Us (mentioned in an earlier breastfeeding posting) for prohibiting a mother from breastfeeding in a store. Donna Lieberman, the ACLU executive director noted:“It’s ironic that a store that caters to children would prohibit a mother from doing what is best for her child.  One would think that Toys “R” Us would have moved past the puritanical notions that this incident reflects.” Toys ‘R Us responded that it simply asked the mother to go into one of the approved breastfeeding rooms of the store.

However, the ACLU had lobbied successfully for a 1984 New York State law that - in the words of La Leche League - “exempted the breastfeeding of infants from their criminal statutes.” (Think of it!)  The New York State law states that mothers have the right to breastfeed in any public place they have a right to be and need not go into special breast-feeding rooms.  [The specifics of this law and a review of US breastfeeding legislation can be found on the La Leche League website. ]

The ACLU has now produced materials for women outlining their rights with respect to breastfeeding. These rights cover being in the hospital,  in pubic and at work.  Here is their summary:

AT THE HOSPITAL
YOU HAVE THE RIGHT:

• To be with your baby at any time after you give birth.
• To start breastfeeding, so long as it’s safe for you and your baby.
• To get information about breastfeeding so that you can decide what you want to do.
• To have someone show you how to feed your baby.
• To get advice about the health benefits of breast milk for your baby, how to eat and stay healthy while you are breastfeeding, common problems nursing moms face, and how to collect and store your breast milk.
• To get information about how to feed your baby with formula if you can’t breastfeed or decide not to.

IN PUBLIC
YOU HAVE THE RIGHT:

• To breastfeed your baby in any public or private place where you have a right to be.
• This includes stores, day care centers, doctors’ offices, restaurants, parks, movie theaters and many other places.
• No one can tell you to leave any of these places because you are breastfeeding, and no one can tell you to breastfeed in a bathroom, a basement or a private room.

AT WORK
YOU HAVE THE RIGHT:

• To pump breast milk for three years after you give birth.
• To use your paid break or meal time, or take reasonable unpaid break times, to pump breast milk.
• To ask for a private place to pump breast milk close to where you work. Your employer must try to find you one.
• Your employer cannot discriminate against you for choosing to breastfeed your baby or for pumping milk at work.

Interested women can order a breast-feeding rights card at this link.

Commentary

This is an wonderful example of health activism on the part of lawyers.  It grows out of the ACLU Women’s Rights Project which was co-founded in 1972 by Ruth Bader Ginsberg. But clearly we have a long way to go before breastfeeding is seen as the norm and bottle feeding the exception.  What would Mary have said!

Posted by Matt Anderson, MD

The International Code of Marketing of Breast-milk Substitutes & Its Violators

In August of this year, we reported on an American Academy of Pediatrics endorsement of a Babys ‘R Us pamphlet in which advertisements for baby formula were featured.  One of our readers sent us links to several documents discussing the International Code of Marketing of Breast-milk Substitutes.

In 1981 WHO published an International Code of Marketing of Breast-milk Substitutes.  The Code was developed starting in late 1979 under joint WHO and UNICEF auspices and involved multiple stakeholders. After several revisions, the code was adopted by the Executive Committee of the WHO in January 1981 and by the World Health Assembly in May of 1981.

The Code runs some 10 pages long and is quite technical in parts.  Yet in its preamble it reflects the bold, social vision that animated WHO at the time:

“Recognizing that infant malnutrition is part of the wider problems of lack of education, poverty, and social injustice;

Recognizing that the health of infants and young children cannot be isolated from the health and nutrition of women, their socioeconomic status and their roles as mothers…”

And similarly the strictures put on marketing of breast-milk substitutes are also bold:

5.1 There should be no advertising or other form of promotion to the general public of products within the scope of this Code.

5.2 Manufacturers and distributors should not provide, directly or indirectly, to pregnant women, mothers or members of their families, samples of products within the scope of this Code.

5.3 In conformity with paragraphs 1 and 2 of this Article, there should be no point-of-sale advertising, giving of samples, or any other promotion device to induce sales directly to the consumer at the retail level, such as special displays, discount coupons, premiums, special sales, loss-leaders and tie-in sales, for products within the scope of this Code. This provision should not restrict the establishment of pricing policies and practices intended to provide products at lower prices on a long-term basis.

5.4 Manufacturers and distributors should not distribute to pregnant women or mothers or infants and young children any gifts of articles or utensils which may promote the use of breast-milk substitutes or bottle-feeding.

5.5 Marketing personnel, in their business capacity, should not seek direct or indirect contact of any kind with pregnant women or with mothers of infants and young children.

A brief pamphlet from the International Baby Food Action Network discusses the main points of the code and its subsequent revisions.  IBFAN produces a regular report called Breaking the Rules which documents violations of the Code.  Various pages of this report are available online and contain pictures of advertisements violating the code.  For the page about Abbott, click here.

The Nestle Boycott

Based on their studies IBFAN considers Nestle Corporation to be the biggest violator of the Code and has organized an ongoing international boycott of Nestle Products.  Baby Food Action, the British affiliate of IBFAN has an excellent page on the Nestle boycott which might serve a resource for other activists interested in boycotts.  Nestle had pledged in 1984 to observe the Code in exchange for a seven year suspension of the boycott; this agreement broke down in 1988.  The IBFAN website has a history of the boycott. Nestle has published its own version of the story.

In 2007 the Guardian published an expose written by Joanna Moorhead entitled “Milking It” about how Nestle violates the Code in Bangladesh.  To quote from the article:

“Here’s how: on [Hospital Pediatrician Dr Khaliq] Zaman’s desk, lots of small pads lie scattered: each contains sheets with information about formula milk, plus pictures of the relevant tin. The idea, he says, is that when a mother comes to him to ask for help with feeding, he will tear a page out of the pad and give it to her. The mother - who may be illiterate - will then take the piece of paper (which seems to all intents and purposes a flyer for the product concerned) to her local shop or pharmacy, and ask for that particular product either by pointing the picture out to the pharmacist or shopkeeper, or by simply searching the shelves for a tin identical to the one in the picture on their piece of paper. “I’d never give these pieces of paper out - when I’ve got a big enough bundle, I take them home and burn them,” says Zaman. But that does not mean every other health worker would do the same.

At least three types of Nestlé formula are among the brands whose tear-off pads are on Zaman’s desk.”

The WTO & the Code

According to the SpeakEasy.org website, a 1983 Guatemalan law implementing the Code was cited by the US as a violation of Gerber’s patent law.  The complaint was filed in 1993 and after several years of discussion “in 1995, under threat of a WTO challenge by the U.S. State Department, Guatemala changed its law to allow labelling of imported baby food products that violates WHO/UNICEF guidelines.”

Posted by Matt Anderson

World Breastfeeding Week 2008

World Breastfeeding Week (August 1-7, 2008) is currently underway. This is an initiative of the World Breastfeeding Alliance, a global network of individuals & organizations concerned with the protection, promotion & support of breastfeeding worldwide. The WBW website has a map of the world covering with flaming Olympic torches linking to activities supporting the week. You can download a beautiful WBW poster from this link

Here is their description of WBW 2008:

Breastfeeding results from a reproductive health continuum for the mother to the child with no beginning or end, from generation to generation. When a practice is disrupted, it must be restored. However, restoration of the breastfeeding culture demands more resources and mobilization.

In conjunction with the Olympics next August, WBW 2008 calls for greater support for mothers in achieving the gold standard of infant feeding: breastfeeding exclusively for six months, and providing appropriate complementary foods with continued breastfeeding for up to two years or beyond.

As every country sends its best athletes to compete at these global games, it is important to remind ourselves that, in a similar fashion, a healthy young athlete can only emerge from a healthy start on life. There is no question that optimal infant and young child feeding is essential for optimal growth and development.

Supporting Mother = Supporting Her to Provide the Golden Start For Every Child !

In New York City we are working on promoting the Baby Friendly Hospital initiative, developed by the World Health Organization and UNICEF. Happily, in July of 2008 Harlem Hospital became the first baby friendly hospital in New York City.

Here are the Ten steps to a Baby Friendly Hospital.

1. Maintain a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give infants no food or drink other than breast milk, unless medically indicated.
7. Practice “rooming in”– allow mothers and infants to remain together 24 hours a day.
8. Encourage unrestricted breastfeeding.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

posted by Matt Anderson, MD

With thanks to Rebecca Williams, MD and Natalie Davis, MD

Is the American Academy of Pediatrics Helping Babys R Us Promote Formula?

It was the attractive young couple sitting on the brownstone that drew my eye. It looked like a patient education brochure for expectant parents. After all, it was sitting in the clinic hallway outside the office of our busiest obstetrics provider, advertising itself as a “comprehensive resource guide for getting ready for baby.” But there was something wrong here.

I was initially struck by the title: “Becoming Us,” which seemed to imply that the advent of the baby was uniting the couple. Then I noticed that the brochure was sponsored by “Babies R Us” and suddenly the implication changed: Did having a baby somehow made one part of the “Babies R Us” family?

Although the pamphlet stated that it was a “comprehensive resource guide to getting ready for baby”, it seemed that getting ready for baby primarily involved buying products available at BRU. Some of these products appeared in ads. But others appeared in infomercials, sitting alongside apparently neutral advice. In short, like much of the so-called patient education materials, this guide was simply advertising.

There was, however, something particularly disturbing about this catalog. On the cover it stated “Editorial content reviewed by the American Academy of Pediatrics” giving a medical endorsement of the information in the catalog. This impression is, undoubtedly, reinforced by being distributed in a clinic where prenatal care is provided. In case a reader missed the point, the first page contains the stamp of the AAP along with a little disclaimer that the AAP is not endorsing “any product or service or the claims made for any product or service by any advertiser.” But in an infomercial, where does the advertising stop and the content start? (The Babys R Us webpage on Buying Guides and Advice also comes with a prominent AAP endorsement and again creates the same confusion.)

This endorsement is particularly troubling given the prominent role played by baby formula in the pamphlet. Before entering into the specifics, it is important to remember that the promotion of breast-feeding is one of the key maternal, infant, and child health goals of the Healthy People 2010. Current HP2010 goals call for 75% of mom’s to initiate breast-feeding, 50% to continue at 3 months (40% exclusively breastfeeding), 17% to exclusively breastfeed at 6 months and 25% to continue breastfeeding at 12 months. As we have posted previously, breast-feeding has multiple health benefits for mother and child. And regrettably we do not have a single baby-friendly hospital in New York City.

Back to our “comprehensive resource guide”: There is one overt ad for “Nestle’s Good Start Supreme” which can “support Baby’s Healthy Immune System.” This comes in the middle of the section on “Mealtime” which opens with a beautiful two-page spread of Dad bottle-feeding an infant. The mealtime section is divided into 3 parts. The first is about breast-feeding and two 1/4 page pictures of breast-feeding Mom’s compete with a 1/2 page of bottle paraphernalia. “Mealtime: Bottles” has our “editorial content” on bottles next to a picture containing two types of “Earth’s Best” powder, a can of Similac and a bottle of Similac “Organic.” Finally, the “Big Eaters” shows us a baby starting solids “between four and six months.” Not exclusively breast feeding. Finally, the “changing tables” section reminds us not to forget “bottle and formula.”

Companies are, of course, free to advertise what they will (although one often wishes that Congress would do the right thing by babies and just outlaw advertising of formula). A study published in Obstetrics and Gynecology in 2000 by Howard et. al. concluded that: “Although breast-feeding initiation and longterm duration were not affected, exposure to formula promotion materials increased significantly breast-feeding cessation in the first 2 weeks.” So why should the AAP endorse commercial advertising which not so subtly gives expectant mothers the message that formula feeding is a normal choice, just like breast feeding. And one wonders how these pamphlets made their way into our clinic which is, in theory, closed to advertising of this type?

The answer for us is that we deluged with such advertising. Sometimes in comes in boxes of magazines and pamphlets that look like legitimate publications coming from legitimate organizations, but are really vehicles for pharmaceutical advertising. (Some of this is even endorsed by professional associations!) It comes to the physicians and staff in envelopes with handouts or CME offers or “patient education” DVD’s or pamphlets. It comes in the form of pre-packaged television such as CNN’s Accent Health. Or patient education billboards such as those produced by EURO RSCG. It comes in the pads and pens that somehow manage to find their ways into our pockets and desks. Getting rid of this is a bit like exterminating cockroaches. It’s a never ending job.

Why does AAP endorse such infomercials? It violates the spirit of their own policy on breast feeding which states that pediatricians should:

• Promote, support, and protect breastfeeding enthusiastically. In consideration of the extensively published evidence for improved health and developmental outcomes in breastfed infants and their mothers, a strong position on behalf of breastfeeding is warranted.
• Promote breastfeeding as a cultural norm and encourage family and societal support for breastfeeding.

And this endorsement of Babys R Us seems to undermine the work of the the AAP Section on Breastfeeding, and specifically contradicts their advice to doctors that they:

• Provide noncommercial educational materials on breastfeeding.
• Remove commercial logos and other indirect formula endorsements (eg, note pads and pens with brand names, decorative logos, calendars), and store formula supplies out of view.

Unfortunately, AAP’s main Continuing Medical Education Publication, Pediatrics in Review, is sponsored by Abbott Nutrition, makers of Similac. And presumably the AAP does not endorse BRU “editorial content” for free. But there is a price to pay for dancing with the devil.

We hope the AAP will amend their policy and no longer endorse content for commercial publications which advertise and feature formula. This could be an important step in achieving their own objective of establishing breastfeeding as a cultural norm.

posted by Matt Anderson, MD