Some while back, as people may or may not remember, I wrote a blistering diatribe against the Mothering.com site's decision to ban the advertising of bottles on their site under the terms of the WHO code on formula advertising. I stand by every word of what I wrote; I still think this was an stupid, jobsworth, counter-productive application of a good set of guidelines. But, yes, I do also think that the WHO code is a good set of guidelines. I do think it's a good idea to ban professional formula companies from placing media adverts.
This, apparently, makes me an evil moronic formula Nazi with a one-size-fits-all approach who has lost sight of child and parent welfare.
(Damn. That's rather less effective than it was when I could link. That came from a post over at Emily's Doing It All Again, but her site has been first abandoned and then hacked, so I need to take out all links to it.)
This is a dilemma I struggle with. I don't mean the dilemma of being that person, because I don't believe I am, as I very much hope would be blindingly obvious to anyone who reads this blog on any sort of regular basis; I mean the dilemma of how to avoid coming across that way. How do I walk that thin line between making sure that mothers actually do have the information and help and support they need and deserve in order to make choices over feeding, and not making them feel pressured? If I ask a pregnant woman about whether she's planning on breastfeeding, will that be the last straw on top of everyone else nagging her about the subject? If I don't ask her, is she going to have any other source for learning the things I really want her to know - that support is available if you know where to look, that it's well worth trying breastfeeding for the first few weeks if at all possible because initial problems tend to improve with perseverance and the right advice, that just because she or her mother or grandmother had an awful time breastfeeding in the past doesn't mean it's going to be the same this time around, that just because the baby wants to nurse non-stop at first doesn't mean that she doesn't have enough milk or won't be able to feed or that it's necessarily always going to be that way, that if she's having pain then someone with the right know-how could almost certainly sort that problem out? How do I strike the best balance, in the context of a society where the personal decision over how to feed a baby has somehow become heavily politicised, fraught with emotion and defensiveness, and the very symbol, it seems, of what constitutes Good Motherhood?
Answers on a postcard. (I mean, that, actually - not the postcard bit, obviously, but I'd seriously like people's views on how best I can present the subject of breastfeeding as a doctor.) However, it is fair to say that all of that is a side rant. It isn't really all that relevant to the topic I first brought up here; that of whether it's unreasonable and wrong of me to hold an anti-formula-advertising stance.
So why am I against formula advertising? To correct a couple of misapprehensions expressed in Emily's post: it's not because I believe that mothers are so collectively ignorant of the world about them that if they don't see formula adverts on the telly they won't realise the stuff exists. (And if I did believe for a minute that this would be the case, I'd be all in favour of formula advertising; as Emily pointed out, it would be downright dangerous for mothers who don't breastfeed not to know about the best possible alternative.) Nor is it because I think mothers are gullible brainwashed simpletons who will take one look at a picture of a formula tin on the TV and cry "Of course! Forget the breast - that's what I should be giving my baby!"
It's because advertising works on a much more subtle level than that. Just because we don't consciously think it's having an effect on us doesn't mean that it isn't. Advertising helps create and contribute to particular cultures, particular images, particular ways of seeing the world. It encourages us to draw on one particular set of mental images rather than another when we form our thoughts.
We may know perfectly well on one level that messages about how we need to buy this or that are a load of baloney. Can we conclude from that that the bombardment with those messages - many of which are a lot more subtle and more delicately judged than "Buy this now!" - has no effect at all on anyone's actions? Is it possible that the reason big companies spend millions on these campaigns is because they actually do have at least something of an effect?
A few decades back, feminist groups were campaigning against the then-current practice of advertising cars by showing photos of attractive and scantily clad women draped over them. Was that really the most important issue facing women at that time? No (and nor have I ever heard of anyone trying to claim it was). Was anyone going to make a direct and conscious mental leap from seeing such a picture to believing that it was quite all right for women to have lower pay scales than men or to have their bottoms pinched wherever they went? No (ditto). Did that mean that these adverts were having no effect at all on the way anyone saw women? I believe that those adverts helped to contribute, just that bit, to a culture in which there was a tendency to think of women as brainless bimbos whose function in life was to look decorative and who weren't really to be taken that seriously. And the fact that I believe this doesn't mean that I believe that these types of adverts were the only issue facing women at that time. Or that they were the most important. Or that they were even particularly near the top of the priority list. It means that I think that those adverts probably had some overall effect on people's attitudes, and that I'm glad that they were changed.
I don't think that you have to be an utter simpleton who's instantly brainwashed to be affected by advertising. I think you just have to be an ordinary human being, no more or less gullible than the rest; because, to some degree, advertising affects almost all of us.
What effect does formula advertising have on our images of how babies are fed? It's one of many things contributing to our images of bottles as the normal way to feed babies. Emily says that formula feeding is marginalised, but I'm not sure that's true; there is no doubt that it's frowned upon, but I don't think that disapproval is necessarily the same as marginalisation. According to the statistics Emily quoted from the article, 24% of women never try breastfeeding, more than 50% are fully formula-feeding by the time their babies are six weeks old, and 75% are fully formula-feeding by six months. Which means that, among mothers of babies less than a year old at any one time, breastfeeding mothers are going to be quite noticeably in the minority. (And that's even before we get to society's marked disapproval of mothers who breastfeed into toddlerhood or beyond.) This is made even more noticeable by the fact that public breastfeeding is still so frowned upon - it's only within the past year that it's even been made illegal to stop a woman from breastfeeding in public, and newspaper stories of women being asked to leave venues for breastfeeding invariably seem to be followed up with flurries of comments in support of the decision. All of which means that nearly all the babies we see being fed are being fed from bottles. It's one of the strongest mental images we associate with babies.
(Some months back, I tried to find a 'Congratulations' card for a new mum. Knowing that she also was strongly pro-breastfeeding, I deliberately looked for cards without pictures of bottles on them. They exist, all right - it wasn't even desperately difficult to find one. But it was quite noticeable how it limited my choice.)
Emily pointed out that if 76% of new mothers start out breastfeeding, then that means that more than three quarters of new mothers have got the message that breastmilk is the best option. There's another side to that statistic, of course - almost one in four new mums, whether or not they realise breastmilk is better, don't even give it a try. Why? For many and complex reasons, of course. A few women have medical reasons why breastfeeding really isn't best in their case. Others have been advised by medical professionals that breastfeeding wouldn't be best in their case (which, unfortunately, is not necessarily the same thing as the statement I made in my last sentence). Many women just had such awful experiences with breastfeeding a previous baby that they can't face trying again (Emily was almost in this group), or have an exaggerated mental picture of how difficult it's likely to be, or don't want to try something that seems to them to be likely to be too much of a challenge on top of the inevitable other challenges thrown up by new motherhood. And... I would say, anecdotally, that one further reason on top of all that is that formula-feeding is so much the norm that quite a few new mothers don't even picture themselves breastfeeding. They take it for granted that they're going to formula-feed because that's what mothers do. All the mothers they know or can picture themselves being like, anyway. Breastfeeding seems like something strange and exotic, something done only by a different and exclusive breed of women.
So what effect does it have if, to the pervasive images of bottle-feeding that already permeate our society, are added further images carefully designed for maximum impact and persuasiveness by professional advertising teams deliberately setting out to promote those images?
Maybe none, for all we know. It is entirely possible that we've reached saturation point as far as normalisation of formula goes, and that an advertising campaign just wouldn't have any further effect over and above the images that already surround us. But we don't know, and can't assume, that this is the case. It could well be that formula advertising does exactly what the formula companies are willing to spend large amounts of money to try to get it to do; reinforces the formula-as-norm message and, thus, add that extra bit of influence to the decisions women make on the subject.
And let's also not discount the indirect effect. We live in a society where even women who try to breastfeed are often destined to fail because simple, straightforward sources of support and help aren't made available. Medical professionals are often taught little or nothing about breastfeeding and how to support it. Many hospitals with maternity wards or baby units don't have breastfeeding counsellors available. You mentioned tongue tie in your post, Emily? Tongue tie should never have to prevent any baby from breastfeeding - it's curable with a simple snip that takes only basic training to provide. But there are large areas of the UK where nobody gets that training and where mothers with tongue-tied babies have the choice between setting off on a long road trip with a newborn to reach someone who can solve the problem or being unable to breastfeed. (Yes, I'm bitter. You noticed?) And, of course, it's only very recently that the law has been changed to specify that women can legally nurse in public. So why in the hell has it been this way for so long, in spite of so much increasing evidence as to the benefits of breastfeeding for babies and mothers? Given the number of people out there who could have been putting these measures into place and who haven't done so, it really does seem that that, to a lot of people, it just isn't seen as terribly important to support breastfeeding or to work actively to ensure that women have every possible chance to make it work. So... how might those priorities have been reinforced by a culture in which formula was not only the norm but actively promoted? Again, I have to wonder how formula advertising may have contributed to these attitudes on the part of policy-makers, health care professionals and those who educate them, and all the other people who've let the ball slip so badly and for so long on this one.
I know all of this is speculation. I know I've just stated, a couple of paragraphs back, that I don't know that formula advertising does any harm or that legalising it would make any difference to the culture we already have. I do know that I can't see a good reason to take the chance. I want to promote a society where breastfeeding is what's seen as the normal thing to do with babies. Not the gold standard that mothers have to torture themselves with guilt over not reaching, not a huge big deal, but just something that, if you've never thought about it a lot either way, you automatically take it for granted you're going to try because that's what everybody else does. I'd like it to be seen in the same way as buying a cot or a pushchair for your baby. Mothers-to-be don't plan to buy pushchairs because anyone has hassled them over the decision or laid a huge guilt trip on them over the thought of not buying one; they buy pushchairs because it's generally taken for granted that that's the way things are done. That's the view I'd like people to have of breastfeeding. And formula advertising seems to me to be one way of taking a step away from that society. So why not ban it?
Emily gives two possible reasons why not. Firstly, she expresses concern over mothers who do formula-feed not knowing how to do so safely. I'm a bit surprised that this was even raised as an issue; formula tins (unlike women's breasts) do have fairly detailed instructions on the back. When Jamie needed formula to supplement what I was pumping for him at work, Barry bought a tin of the stuff, mixed a jug of it according to the instructions, and gave Jamie a bottle when he was hungry. I wasn't there, obviously, but I don't recall him mentioning that he found it to be any sort of problem or big deal to figure out. The baby books I've encountered have generally had a section on preparing and feeding formula (and this includes at least one well-known book on breastfeeding that I've read). Come to think of it, I found it rather easier to find information on formula-feeding than to find accurate information on pumping and milk storage (that same breastfeeding book gave me completely the wrong information on how long I could store pumped milk; if I hadn't had several other sources of information available, I'd have ended up wasting quite a bit of milk that was actually perfectly OK to use).
So, as I say, I'm not convinced that that one is really such a big issue. But, if it is, then it's not one that's going to be solved by legalising formula advertising. Adverts are thirty-second soundbites on why you should do something, not detailed lectures on how you should do it. I can't see what useful information Emily thinks we'd get from them. This issue seems to me to be a completely different one; that of how well healthcare professionals provide information and support about formula feeding where needed. I entirely agree that this is something that health visitors and midwives should be able to do, but that has nothing to do with the issue of whether formula advertising should be legal.
The other issue that Emily raises is that of the guilt laid on women who don't breastfeed, the ways in which they're made to feel second best (or worse) as mothers. And that is a big problem. A huge one. A problem I hate, hate, hate. But is legalised formula advertising really something that we need in order to be able to solve it?
I don't know that I can speak with authority on this one, because I did manage to continue breastfeeding, and so I doubt if I'm the best person to be commenting on how it feels not to be able to. I know that I would have been devastated had that been the case, and that, yes, I would have felt guilty. But would formula adverts really have made me feel better? As far as I can picture my reaction to a situation that I didn't have to live through - no, they wouldn't. They might well have made me feel worse, since I wouldn't have wanted to deal with anything that brought the whole issue of formula closer to the forefront of my mind than it already would have been. But I can't imagine that softly-lit pictures of formula tins or bottle-feeding babies, or glibly reassuring voice-overs about the quality of formula brand X from people paid to say that stuff, would have somehow made my hurt and guilt about the situation fade. Maybe I'm kidding myself, or just unusual; maybe people who really have been there feel differently. I don't know.
Nor do I know what the solution to the problem is. Just because I don't think formula advertising provides a route to a world in which we can all stop judging mothers, including ourselves, doesn't mean that I know what might provide that route. I wish I could wind this one up as simply as I wound up the last objection, with a nice neat paragraph about how of course formula advertising isn't the answer because, as should be self-evident, X is. I can't.
But one thing I do believe is that if we want to live in a less judgemental world, then one big step towards it - and I merely throw this out here as a suggestion - might possibly be for us all to be ready to be a bit less bloody judgemental. And that applies to more issues than the feeding decisions we make for our babies. It also applies - and here's the really difficult bit - to people who have the temerity to hold different viewpoints to ourselves.
The kind of epithets Emily was directing towards people who held anti-advertising viewpoints were not the kind of thing that gave me a warm fuzzy feeling of moving one step closer to that non-judgemental Utopia that we all think we want to see. Yes, I'm against formula advertising. Guess what? Holding that view did not require me to sign a binding contract stating that this would be my only contribution to the complex world of breastfeeding promotion or that I would nag, criticise and judge women who formula-feed while offering them no practical help. I don't judge a woman as a mother or a person based solely on the decisions she made about a single and relatively unimportant aspect of parenting. Similarly, I would appreciate it if people wouldn't judge me as a person based solely on the decisions I make about a single contentious issue.