The wrong prescription?

A suggestion from Dr. Jennifer James, a midwifery lecturer at RMIT University, has been inflaming parenting message boards and blogs all over today. Dr. James has been quoted in the main stream media about her proposal to remove infant formula from supermarket shelves and make it a prescription-only product.

I’m at least sympathetic to the idea: I can certainly see potential benefits to breastfeeding rates. Perhaps, in principle it seems similar to proposals to put cigarettes in plain packaging as a way to stop companies from marketing their products to consumers.

Except, infant formula is not tobacco.

Parents choose to use formula for a myriad of reasons (some of which feel little like actual choices) and the overwhelming feeling amongst commenters on the article and parents on Twitter seems to be that this is a push to make formula use taboo. Some parents who formula feed already feel they are shamed for it, and this feeling can result in a backlash against organisations who promote breastfeeding, like the Australian Breastfeeding Association. This proposal would likely only make the guilt-shame-anger cycle worse.

On the other hand, parents who have clear medical reasons for not breastfeeding might well feel vindicated by a prescription – they are less likely to be shamed or questioned, perhaps, if others readily assume that there is a ‘good reason’ for them not to choose breastfeeding. But I don’t think that’s a sound argument for supporting James’ idea; in fact, I think it just raises more questions.

What constitutes a ‘good reason’ to stop breastfeeding or supplement with formula? Who decides that? Why should it be any one’s but the breastfeeding parent’s right to decide what kind of reasons are ‘good enough’? What happens if an individual parent’s reasons are not good enough for a given health professional? Does that amount to forcing someone to breastfeed, or forcing them to find other (potentially less safe) ways to feed their baby? What happens if someone who is wanting help to persist with breastfeeding is issued a formula prescription by a health professional? Would that appear to amount to a directive to use formula? Would formula companies respond by marketing even more aggressively to health professionals, many of whom already know little about breastfeeding and how to support it? What would removing supermarket competition do to the cost of formula and how would that impact on low-income families, who are disproportionately dependent on commercial baby milk? How would it affect the availability of alternative feeding methods for parents who face literacy or language barriers or who have economic or other reasons for not seeing health professionals? How many babies would be fed cows’ milk as a stop-gap measure? I think that constitutes too many unanswered questions for this proposal to be something I could get behind.

I agree that the marketing of formula, including (especially) toddler milk, is not nearly well enough controlled and I believe that is to the detriment of breastfeeding rates. I think that the ready availability of formula and easy brand recognition combined with poor support for, and education about, breastfeeding contribute to lowering breastfeeding rates. The WHO code, which should be the minimum standard for regulating formula marketing, isn’t enforced in Australia, nor in much of the world. (Both links PDFs) And as a feminist I have a problem with that: women are being marketed to in the name of ‘choice’ to the potential detriment of our health and that of our children. As a lactivist I obviously have a problem with the marketing of infant formula and any implication that it is as good as, or better than, breast milk. But as a human being I also know that people are hurt, seriously hurt, when they feel judged and shamed and when they are exhaustedly holding a hungry, crying, baby at 2:30 am and it feels like no one can help them.

Removing systemic barriers to breastfeeding certainly may require improved measures to reduce the popularity of formula – popularity which can be attributed to decades of marketing not only to the public but to health professionals. A big part of that marketing is about convenience: huge displays in chemist shops and regular sales at the supermarket of products in familiar-looking tins add to the impression of ease of use and the normalisation of artificial feeding. But whether we like it or not, formula and its ready availability is important to many families. Removing that now feels like a stick where a carrot should be.

Give parents the tools to make sound decisions that benefit them and their babies. Give parents not only choices, but supported, realistic choices. Don’t tell a woman who has to go out of the home to work, or who has other children to look after and little support, that the choice to dedicate perhaps days to increasing her milk supply through frequent feeding and skin-skin contact to avoid supplementing with formula is an easy one: it clearly is not. Education and information are hugely important but they are only part of the picture when practical barriers still so often interfere with breastfeeding relationships.

Adding practical barriers to formula use, as I think this proposal would, isn’t a particularly kind way to help parents. Being caught between a rock and a hard place doesn’t make the rock seem any easier to budge: it just makes it hurt more to be stuck there.

***
Edit: The Herald Sun article I linked to (and some discussion I’ve seen elsewhere) implies that the Australian Breastfeeding Association is supportive of the proposal to make formula prescription-only. That’s misleading: the Association’s statement to the media on the comments by Dr James was:

The idea of obtaining formula on prescription is worth serious discussion although the Australian Breastfeeding Association is not currently advocating this. Research shows formula fed infants are more likely to become ill so being in contact with a health professional could be very beneficial. A health professional could counsel the mother, address any breastfeeding problems and help the mother make an informed decision. Many of the calls to the Australian Breastfeeding Association 24 hour helpline are about reassuring mothers about their milk supply, feed frequency and normal baby behaviour. For example mothers often think they have an inadequate milk supply when baby cluster feeds in the evening however this is normal baby behaviour. Sore nipples, mastitis and attaching the baby to the breast are also very common calls. Over 90% of mothers start out breastfeeding by 6 months only 50% are partially or fully breastfeeding, many more would continue with better support and information.
Australian Breastfeeding Association supports a ban on marketing of Infant formula in line with the WHO Code as this is proven to affect breastfeeding rates.
From ABA Facebook page

21 Comments

Filed under Breastfeeding, Lactivism and Doula-ing, Feminism, Motherhood and Parenting

21 responses to “The wrong prescription?

  1. T.A.

    This is exactly what I meant when I said that the pendulum is swinging too far the other way.

  2. This is an excellent post. I have both breastfed and bottlefed. The latter was not a choice, or if a “choice”, then it was one made under duress.

    Being caught between a rock and a hard place doesn’t make the rock seem any easier to budge: it just makes it hurt more to be stuck there.

    Sing it!

  3. goodgollymissholly

    Great post!

    I published a piece about this topic this morning, and I was horrified to hear that Herald Sun had manipulated ABA’s statement just to further fan the flames of an already controversial, highly emotive subject.

  4. I think, given the almost universal desire to breastfeed among Australian mothers at the birth of a child, and then the fast drop-off rate, the problem is with support. There is only so much a largely voluntary organisation like the ABA can do, improving the skills of midwives, maternal and child health nurses and general practitioners and providing incentives for them to acheive lactation consultant qualifications would be more effective without applying the stick to mothers.

    • “I think, given the almost universal desire to breastfeed among Australian mothers at the birth of a child, and then the fast drop-off rate, the problem is with support. ”

      Absolutely!

  5. lilacsigil

    Exactly – the WHO code is there *right now* to help. Removal of barriers to breastfeeding is far more important (and likely to succeed). Positive reinforcement, not negative enforcement.

    The cost of the prescription may not be a primary issue in this case – the NHS means that the specialist formulas that are currently on prescription are considerably cheaper than commercial products – but access to doctors (and pharmacies, in rural areas) certainly is. And it really seems like placing yet another gatekeeper in women’s way – “We will tell you what to do with your body AND your baby’s body by threatening you.”

    • We have the PBS here in Aus, not the NHS. Putting all formula on the PBS would probably make it cheap for families, true, but only if it were government-subsidized. That raises a whole lot of economic and ideological problems in my opinion. Should government health systems be paying for a product whose use puts a further drain on their own resources through increased incidences of illnesses such as gastroenteritis in babyhood? And if PBS will pay for formula, would they also subsidize breast pumps?

  6. I enjoy you on twitter and I’m so glad I found your blog…very informative well written, and thought provoking. I hope this blog reaches millions.

  7. I worry that if formula was prescription-only, it would put some women who have very valid but extremely personal reasons not to breastfeed in the unfortunate position of having to explain themselves to a pediatrician. A mom shouldn’t have to explain that she was molested or taught to feel shame about her body as a child. And for anyone who chooses to formula feed regardless of the reason–I already feel there are enough things to trot the babies off to the doctor’s office for. Doctors already have so much influence that I really don’t feel good about setting them up as formula permission-granters, too.

    • Great point about women who have personal reasons for not breastfeeding.

      “Doctors already have so much influence that I really don’t feel good about setting them up as formula permission-granters, too.”

      To be frank, that’s my biggest concern about this idea. As a midwifery and lactation expert, Jennifer James is surely aware that many GPs and also peadiatricians lack basic skills in supporting breastfeeding. I’ve had some pretty shocking misinformation about breastfeeding given to me by GPs – luckily I knew enough to ask elsewhere! Without a huge education programme for health professionals, I don’t see how a prescription programme would really work. And the likelihood is that the ‘education’ that would be happening would come from formula companies themselves, and the research shows that pharmaceutical companies have a huge influence over who prescribes their product through the way they woo health professionals. Formula would be no different. So that really raises questions for me about whether this would actually do much for breastfeeding rates when there may well be doctors who think ‘oh, I’ll just give this fussy baby a formula prescription and problem solved!’ Of course, the other side to that is that even when a doctor or pead is well-versed in breastfeeding support, it should still be up to the parent to decide how to feed. Proposing to take that decision out of women’s hands seems anti-choice to me. My body, my breasts, my choice, y’know?

  8. Sarah

    Thanks for your article, and to the other commenters for their insights also. I’m not a mother but this debate has really bothered me. Personally I think parents should be allowed to parent in their own way, and if they need or want to try using formula then they shouldn’t have to ask anyone’s permission to do so. I have a similar view as commenter Jenny – I have many personal reasons that make the choice about whether to become a parent difficult enough, without feeling like, if it does happen, I’ll have to deal with these kinds of added (and unnecessary) hurdles too.

  9. JMT

    Thanks for the thoughtful post. I always wonder how things would be different if formula had been prescription-only from the get-go, although it’s clearly not a viable option now.
    The medicalization of eating in general is a bad road to go down, I think.

    • I know this isn’t quite what you meant, but I do see some value in formula being prescription-only in hospital for babies of parents who wish to breastfeed. The WHO Baby-Friendly hospital initiative asks that no supplementary feeds be given to babies unless medically indicated, and I think that’s a really important element. The old practice of topping up babies with formula so mum could sleep longer, sometimes without even telling her, was not only detrimental to breastfeeding but also, I think, a trust violation. I wish I had asked to see a peadiatrician before agreeing to give Bean formula in hospital, but that’s another story! Anyway, I think perhaps one way that a programme like this could be helpful would be in alerting parents to the need to think carefully about introducing any formula, and to ensure that nurses and midwives don’t overstep by giving formula when there is no real medical need for it. But again, parents who don’t want to breastfeed at all shouldn’t be forced to, so there would have to be a way to manage such a system to accommodate those for whom breastfeeding was not a goal.

    • Katherine

      At least it’s formula now and not cow’s milk that they sneak into babies at the hospital to let you sleep longer. My family history has heaps of allergies in it, so my mum was pretty appalled when she found out the hospital gave me cow’s milk as a newborn.

      Still, they shouldn’t be doing either without mum’s permission.

  10. I agree with pretty much all that you’ve said.

    I can’t help but wonder why she’s not pushing for something practical like medicare subsidies for lactation help? By the time we were in trouble and I was able to travel (by public transport after a cesarean) we were outside of the 28 days of free care by a lactation consultant at our hospital and there’s no way we could have afforded to see a private LC.

    • Yeah, lactation clinics are a big help to many. The government should fund more of them.

      To be fair, Jennifer James isn’t the first person to make this suggestion, and she does also advocate for other forms of breastfeeding support. I wouldn’t want to suggest that this comprises her whole breastfeeding promotion strategy!

  11. This is a brilliant and thoughtful response to this issue.

    I used to think that making formula prescription would be a good thing, as someone who had a “medical” reason for stopping breastfeeding. It would allow me to feed my child without the scorn of the pro-breastfeeding community I live in. So I hear that argument, loud and clear.

    But since starting my blog and talking to women with all sorts of reasons for not breastfeeding, I now feel strongly that there are plenty of legitimate reasons for choosing formula. I think there are far better (and kinder, and more feminist) ways to boost breastfeeding rates. Better support would be a good start, at least here in the US. Our rates are far worse than Australia. And yet there is still a shadow of shame following formula feeders around…. it’s such a strange and complicated issue. I know there must be a way to improve BFing rates, but we need to also ensure that women are nursing b/c they WANT to, not because they are coerced into doing it.

    So again- thank you, as always, for being such a great voice in the lactivist community. I LOVE how you make the distinction between being a breastfeeding activist and being a human being. I think we all could stand to remember this, no matter what cause we support – that our political agendas are one thing, but sometimes our humanity will force us to see that things aren’t so black and white.

  12. Pingback: Of Tofu, Pop-Tarts, and Boobs « Kittywampus

  13. Deanna

    Well, I tend to fall down on the side of more freedom for individuals, not less, so the idea of there being a prescription required for formula feeding goes against my very nature. (And I am a huge breastfeeding advocate.) I believe it places the physician or other prescriber in a place of power that is inappropriate. Formula isn’t a drug, it’s food. It may not be the ideal food, but it may be the best choice that many parents can make for their own individual situations. (Isn’t it ironic that at a time when more and more formerly prescription drugs are now available over-the-counter–at least here in the U.S.– there is an effort to make food a prescription item?)

    Not to negate anyone’s perceptions of being shamed for formula-feeding, but from a sort-of historical perspective, it’s interesting how things have turned around, just in the last 30 years or so. In my obstetrics classes in nursing school 28 years ago, I vividly recall many of my fellow students scoffing at the idea that breastfeeding was, for most situations, a better option than formula. When my best friend had her first child in the 90s, her dear inlaws derisively told her that in their day, the only people who breastfed were n*****s and white trash. How lovely.

    So I do applaud the increased knowledge about and acceptance of breastfeeding. However, there will always be mothers who just can’t nurse, for whatever reasons, and they shouldn’t have to come grovelling to a health care professional for a prescription for formula. Hold manufacturers accountable for the quality of their formula, demand truthfulness in advertising, provide more education about the pros/cons, but let mothers make their own choices about what they feed their children.

  14. I’d have been happy to be able to talk to someone about what formula to use who actually knew what they were talking about. I used formula for 2 out of 3 kids (after breastfeeding for differing amounts of time) and I used the highly scientific method of buying the most expensive formula. I have no clue if that was sensible or not.

    Even more frustrating, my first kid lived on yoghurt from 7 months when I had to stop breastfeeding because he couldn’t tolerate formula. I didn’t have any idea where to go to sort it out. He’s fine now, the yoghurt seems to have done him no harm, and he’d been on solids as well for a while before I stopped bfing. Still, I feel some sort of unbiased consumer advice would be very valuable. However, I share your lack of faith in an average GP being able to provide that. I’d really like to see some kind of unsponsored advice both before choosing to change to formula (I felt pretty well supported in this step, both in terms of not stopping for no good reason, and in terms of not continuing after it had clearly become a Bad Idea), and in deciding which formula to choose. Somehow the brochures with drug company names on them I had at my disposal didn’t convince me.

    I think needing a script, especially for my 2nd kid, would have been devastating. I really think yoghurt alone would have been Bad for a 4 month old.

  15. Katherine

    It’s ridiculous that any life essentials that are not actively dangerous would ever be prescription-only. You don’t need a prescription for alcohol or nicoteine, and those are actively dangerous. What are they going to do next, make frozen veg prescription-only because it isn’t as good as fresh?

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