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.
Very interesting post. One additional point I just have to make is that the (currently allowed) adverts for follow-on milk do not contain any information about how to make it up, how to sterilise bottles etc. - they spend the entire 30 seconds portraying how beautiful and healthy your child will be if you use Brand X. So there's no reason to think that if adverts for formula were legalised they would be any different.
I do also want to ask why do you automatically equate bottles with non-breast-feeding even to the extent of vetoing baby cards that have bottles on them? My baby got a bottle of expressed breast milk at least once a day the whole time I breastfed.
Finally, in response to your question, about how health professionals can ask pregnant women "the question" in a sensitive manner, that is a hard one. For women who have already had their first baby, how about phrasing it as: "And how did the breastfeeding go the first time round? Do you think you'll need any help this time?"
Then again, maybe Emily is the best person to ask on this one...
Posted by: Clare Wilson | Wednesday, September 19, 2007 at 11:29
Well said and very well written.
Although not living in the UK and therefore not being submitted to exactly the same cultural environment about breastfeeding (much more common here in Switzerland), I completely agree with your take on formula advertising and the way it subtly shapes our minds, tricking us into thinking this is the "normal" way to go.
I was for instance quite disturbed to find samples of various formula brands in the "gift box" they give you at the hospital (here at any rate, don't know about in the UK). Of course the whole contents are only for marketing purposes, but what kind of message is being delivered here? I don't think it should be allowed either.
Being a breastfeeding mom myself, I was also amazed at how many comments I get to the effect of "when will you get her started on the bottle?" or, even better "Oh, that will sort itself out (insert here any small problem that may have arisen, specially if related to sleeping during night-time) when you get her on the bottle"... always "when", never "if"!
Last but not least, and I wish I had your talent to write about it: why is it that dolls, the ones that look like small babies, invariably come complete WITH a bottle? It may seem trivial, but it comes close to infuriating me. Talk about warping children's minds... Babies are NOT born with a bottle in hand. If you want or need one, buy it separately.
Posted by: V. | Thursday, September 20, 2007 at 13:27
Well V., one thing that does infuriate me about the pro-breastfeeding campaigners is their refusal to acknowledge that formula DOES generally help babies sleep through the night more.
As for the dolls, they could hardly come with an accompanying breast...
Best wishes
Clare
Posted by: Clare Wilson | Friday, September 21, 2007 at 21:29
Oh I could also rant on this subject, I've started so many blog posts but none of them worded as well as yours. I was also going to mention the dolls that all come with bottle and dummy (and yes, I have heaps to say on why I didn't use dummies!), and how I think this plants seeds in the heads of the very young, in fact, some brands of dolls even come with disposable nappies!!! (Yeah okay, so I used disposables but still think they shouldn't be promoted) No, obviously dolls couldn't come with an accompanying breast but is it so wrong that both my children (yes, including my son) went through a stage of lifting their t-shirts up to breastfeed dolls? I found it really difficult explaining to my dd why our friends baby drank bottles instead of from Mummy. Hopefully I've planted the breastfeeding seed in my children.
I've come across so many debates and spent lots of time in breastfeeding support forums and I can't believe there are still so many myths about breastfeeding and breastmilk. I was astonished while on the maternity ward with my newborn (who had a tongue-tie, btw) to hear the young girl in the next bed tell the midwife on duty that she had tried breastfeeding in the labour suite but the baby wouldn't take to it so in the end (the end? the baby was only a few hours old!) she had to give formula because the baby was hungry.
I think the option of mixed feeding needs alot more talking about. So many people believe that it has to be one or the other and once you've given a bottle then you can no longer breastfeed. I think that is such a shame, the odd bottle in the first few days (whether formula or breastmilk) could make all the difference to the continuation of breastfeeding. I was expressing for both of mine by day three just to give my nipples a few hours rest and for the chance to unplug them from me and pass them to someone else for a couple of hours. I think the advice not to express or introduce bottles before six weeks is very damaging.
But I think the main issue that really needs to be dealt with is the whole guilt thing. If you genuinely believe that you do not have enough milk, or that your baby wasn't thriving or even if you just couldn't cope with the idea of breastfeeding and you formula feed because it is the absolute best thing you feel you can do for your child then why would you feel guilty? Guilt is reserved for people who have made a choice they feel is wrong. If the majority of Mums are bottle feeding their babies then why do they all feel guilty? Mums shouldn't be feeling guilt for doing what they believe is best for them, their families and their babies.
I think it is great that there are doctors who are pro-breastfeeding. My ds was very useless at feeding and at 20 days was diagnosed with pyloric stenosis. This involved two nights in our local hospital with medical staff continually questioning me on how many ounces and bottles he usually had a day and what type of milk he was on and I felt like I was being really awkward by breastfeeding. After we were transferred to another hospital so that he could be operated on he was nil by mouth and after alot of asking and several hours wait I was finally provided with a breastpump. I wanted to keep the expressed milk in case he needed to be tube fed afterwards but was told that nowadays bottles and breastpumps didn't need to be sterilised and was assured that warm water alone would be sufficient. And then somebody suggested that as we hadn't breastfed for nearly a week it would be a good time to switch to bottles (I really need an eye-rolling icon).
I don't know how you could bring up the subject of breastfeeding with pregnant ladies or new Mums but I know that I was inspired by every doctor, midwife, health visitor etc who told me they had breastfed. I think the most subtle way I was asked was "Have you thought about how you want to feed this baby?"
Posted by: Lucy | Saturday, September 22, 2007 at 22:19
OMG! I'm so sorry about the length of that comment.
Posted by: Lucy | Saturday, September 22, 2007 at 22:22
Babies don't need "help" to sleep through the night. It is the parents who want them to sleep because it is more comfortable (and yes, I agree, it is more comfortable - we could now open a debate on the pros and cons of co-sleeping, but let's not change subjects).
Yes, they sleep longer with formula - and that's because it is harder to digest, so their little tummies are hard at work all that "extra time". To the extent that, from what I've read, the liver of a formula-fed baby is 1/3 larger than that of a breastfed baby. Now I'd love to hear from another (reliable) source if that is truly the case.
As for dolls coming with breasts... well, I've never heard of a mum having to buy herself a set, so why should little girls need to? And Lucy, I loved the story about your son lifting his t-shirt!
Posted by: V. | Sunday, September 23, 2007 at 21:03
Hi V. Yes, I totally acknowledge that it is my comfort I am thinking of and not the baby's. That is allowed, isn't it, to consider the mother's needs too?
I'm not saying that would influence me to switch to formula before 6 months, as I believe the baby's health is more important than my sleep. But I do wish the "lactivists" out there would be a bit more honest and realistic about parents' needs sometimes. It is comments like that, suggesting that it is terribly self-centred to want the "comfort" of them sleeping through the night that put people off the whole lactivism thing...
Anyway, best wishes
Clare
Posted by: Clare Wilson | Tuesday, September 25, 2007 at 19:48
I'm a bit late to this conversation, but I do want to pipe up that when I was planning for my first (adopted) baby, I scanned adoptive breast-feeding info and decided it really wasn't for me (many good reasons). But when it came to choosing a formula, I KNEW I wanted organic (no hormones, no antibiotics, no pesticide traces) and I had a HELL of a time finding it.
The market seems to have caught up a bit (though at exhorbitant prices) now that I have my second baby. But I was kind of annoyed that there was a silence around which formula might be BETTER than another one, because people concerned with babies' health were so busy chanting "breast is best!" And they all say formula is all the same because it's regulated so tightly by the government. But it isn't the same because organic is really different and if my kids weren't getting breast milk I wanted the BEST formula.
Don't know if that translates to advice. Maybe just to say that if you are to talk about it with a woman, you might say something about there being choices in formula for better or worse. (Some of those choices might be ethical/political too--like avoiding companies that advertise or send free samples to Africa or something. My formula company doesn't do that either.)
Posted by: Shannon | Wednesday, October 03, 2007 at 04:48