One of the best things about being an academic is the stuff that people send you in the – usually entirely correct – belief that you’ll find it interesting. I’ve had emails about pink slime (for the blog) and on programmes about children’s literature (for my research). Recently, my friend Elizabeth, who’s a lawyer, forwarded me this from Legalbrief:
New draft baby feeding regulations will forbid formula manufacturers from ‘aggressively marketing’ their products to mothers and from sponsoring meals and professional development courses for healthcare practitioners, says a Weekend Argus report. It adds the standards set in the draft regulations, which the Department of Health has released for public comment, intend to promote safe nutrition for babies and young children and restrict inappropriate marketing practices. The department stressed that the regulations would not stop baby formula and complementary foods from being sold at retailers. ‘Although breastfeeding is best, government recognises that some women cannot breast-feed or decide not to breast-feed. These regulations do not in any way compel women to breast-feed against their will,’ the department is reported to have stated.
The proposed regulations, which fall under Section 15 (1) of the Foodstuffs, Cosmetics and Disinfectants Act, 1972, make for fascinating reading. Other than banning trans fats and artificial sweeteners in baby formula, their emphasis is on curtailing the advertising and promotion of artificial foods.
For instance, the packaging of baby formula may not have pictures of infants, young children, or any other ‘humanised figures,’ except for those included in instructions for preparing the product. Tins and containers may not ‘contain any information or make any negative claim relating to the nutritional content or other properties of human milk’, and they’re not allowed to include toys or gifts. Packaging must include in English, in bold letters at least 3mm tall, the message: ‘Breast milk is the best food for babies.’
The regulations will also radically limit the advertising of baby formula shops, in print and online, ban the distribution of gift packs and free samples, and prevent formula manufacturers from sponsoring or donating equipment bearing the logo of their products. These manufacturers may not
provide research grants or any other financial assistance relating to infant or young child nutrition to health care personnel working in a health establishment or health care personnel linked to a health establishment.
Nor may they give doctors, nurses, and health workers gifts, and ‘heads of health establishments, national, provincial and local health authorities shall take measures to promote, support and protect breastfeeding.’
It’s an ambitious piece of legislation, but one which is entirely in line with the World Health Organisation’s International Code on the Marketing of Breast Milk Substitutes. The Code was adapted in 1981, and places stringent regulations on how baby formula is advertised: it advises that baby milk formula should not be allowed to market products directly to pregnant women and mothers with young children, including handing out samples. Products should also state that breast milk is superior to formula.
Implementation of the Code has been slow, and there is evidence to suggest that it has been particularly poorly policed in developing nations where oversight of the activities of powerful multinationals is often lax. The South African regulations are far stricter than the Code, particularly as regards the relationship between the pharmaceuticals industry and academic research, but address a problem which campaigners have long identified: that there is a link between the way in which formula is advertised and how women feed their babies.
This isn’t to suggest that women should have their choices about how they feed their babies curtailed – or that it’s only advertising which causes women to choose to use baby formula. Far from it. The problem, though, is that, particularly in poor nations, advertising or other promotional methods encourage breastfeeding mothers to switch to baby formula when it’s unlikely that they’ll be able to afford to buy more formula, and where they may dilute formula with too much water to make it go further. This water may not be clean, and it’s difficult to keep bottles and teats sterile without electricity or plumbing.
The purpose of these regulations is to ensure that formula manufacturers don’t use the often less than ideal conditions in which mothers in developing nations raise their babies, to their own advantage.
We tend to associate the WHO’s Code with the Nestle Boycott, which was launched in 1977. The Boycott was based on a pamphlet published by War on Want in 1974, titled ‘The Baby Killer’ and, in Switzerland, ‘Nestle Kills Babies’. The charity alleged that Nestle’s advertising strategies were responsible for high rates of child mortality. After a legal tussle as well as an attempt to refute the Boycott’s allegations, Nestle agreed to implement the Code in 1984, although there remains some scepticism as to Nestle’s, and other companies’, commitment to this.
But concern about the advertising of baby formula predated the 1970s, and even the 1940s, when breastfeeding began to decline globally. As I’ve sat in the National Library over the past few months, reading Child Welfare and other child health magazines from the first half of the twentieth century, I’ve been struck by the number of advertisements for baby formula. They all feature fat, healthy babies and testimonials from relieved mothers who claim that the child was fed from birth on Lactogen or whichever other patent food.
Even Truby King, early twentieth-century breastfeeding evangelical and founder of the global mothercraft movement, developed artificial baby food which was produced in New Zealand and then shipped all over the world. Kariol, Karilac, and Karil were meant to be prescribed for babies who were not, for whatever reason, breastfed either as a supplement to cows’ milk, or to be taken on their own.
Although King’s patent foods seemed to contradict his enthusiasm for breastfeeding – and he came under enormous criticism in New Zealand and Australia for his promotion of Kariol and Karilac – there was a certain logic to his decision to manufacture wholesome baby formula. During the early decades of the twentieth century, doctors in Britain and the United States noticed that bottle-fed babies were considerably more likely to die during early infancy than those who were breastfed. Artificial foods – which ranged from thin porridges and condensed milk to baby formulas – were often nutritionally inadequate, particularly in poor families who could not afford better and more expensive substitutes.
But they also identified a link between bottle feeding and diarrhoea, then, as now, one of the main causes of death in infancy. William J. Howarth, the Medical Officer of Health for Derby
arranged in 1900 to receive weekly lists of the births registered during the past seven days from the local registrar. From November of that year until November 1093 women inspectors enquired into the feeding method of each registered child by personally visiting the mother and infant at home.
The results of the study, published in 1905, were telling. Of the infants surveyed, 63% were breastfeed, 17% were partly bottle-fed, and 19% entirely bottle-fed:
The mortality rates from ‘diarrhoea and epidemic enteritis’ in addition to those from ‘gastritis and gastro-enteritis’ were as expected: 52, or 10 per 1,000 of the breastfed, 36 or 25.1 per 1,000 of the mixed-fed, and 94 or 57.9 per 1,000 of the bottle-fed babies died. In other words the mortality rate of the bottle-fed infants was nearly six times greater than that of the breast-fed babies.
Howarth concluded: ‘In not one single instance does the death-rate in any class of disease among hand-fed children even approximate that recorded among children who are breastfed; the rate is invariably higher.’
The problem, in terms of the link between bottle feeding and diarrhoea, was not so much the nutritional content of artificial foods, but the difficulties in keeping them free from contamination, and particularly during summer when infant mortality rates soared.
Indeed, South African advertisements for Lactogen emphasised that the product did not spoil in warm weather. As criticism of artificial foods grew louder, so advertising became more subtle, and better adept at appealing to mothers aware of the potential problems of bottle feeding. Doctors were, though, also aware of the effects of advertising on mothers’ choices, as a medical officer based in Johannesburg wrote in 1925:
No one can deny the fact that the proprietary foods of today are a vast improvement upon those of twenty years ago. They all contain very sound instructions as to the preparation of the food and the amount to be given. The advertising of such foods is carried out on a most extensive scale and in a clever and attractive manner. No hoarding today is without a picture of a flabby and over-fat infant alleged to have been reared solely on the proprietary food advertised thereon. Many a mother who for one reason or another, is not satisfied with the progress of her baby, sees this advertisement, and immediately rushes off to secure this particular food for non-thriving infant.
But not only mothers were influenced by this advertising. He admitted that it was ‘only too true that many medical men and trained nurses are also gulled by such advertisements and circulars’. Dr Cicely Williams, best known for her identification of the condition kwashiorkor in the 1930s, worked in the Colonial Medical Service in West Africa and southeast Asia before World War II and became particularly interested in the treatment of the diseases of early infancy.
She was critical of the introduction of baby formula to Singapore and Malaya, where white-coated sales reps distributed samples of artificial foods to poor mothers. In 1939 she published a pamphlet, ‘Milk and Murder,’ in which she pointed out the benefits to both mothers and babies of breastfeeding.
Nevertheless, Nestle and other companies were still using the same strategies to convince mothers in developing nations to use baby formula in the 1970s, and there are still concerns that they are not fully compliant with the Code on breast milk substitutes. The new South African regulations, if passed, are aimed at remedying this.
The cause for these new regulations and other measures introduced internationally to encourage mothers to breastfeed for the first six months of life, is a concern that rates of breastfeeding remain low in comparison to what they were during the early twentieth century. For all the good that the Code and other laws have done, it remains the exception, rather than the rule, for women to breastfeed for such an extended period of time.
However true it may be that advertising does have an impact on women’s choices, it’s certainly not the only factor which influences how women feed their babies. What’s missing from these measures is any attempt to communicate with mothers themselves. As doctors in the early twentieth century believed that mothers, whom they characterised as emotional and irrational, simply followed any and all advice which they read or heard, so campaigners and governments today seem to be too quick to seek only one reason for women’s decision to breast- or bottle-feed.
In fact, we need to make it easier for women to choose to breastfeed: to eliminate the ridiculous prejudice against breastfeeding in public spaces; for work and childcare not to be mutually exclusive; and for sympathetic advice and information to be made available for all new mothers.
Texts cited here:
Linda Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare, 1907-2000 (Auckland: University of Auckland Press, 2003).
Deborah Dwork, War is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England, 1898-1918 (London and New York: Tavistock Publications, 1987).
Philippa Mein Smith, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia, 1880-1950 (Basingstoke: Macmillan, 1997).
Rima D. Apple, Mothers and Medicine: A Social History of Infant Feeding (Madison: University of Wisconsin Press, 1987).
Linda M. Blum, At the Brast: Ideologies of Breastfeeding and Motherhood in the Contemporary United States (Boston: Beacon Press, 1999).
Marulyn Yalom, A History of the Breast (New York: Ballantine Books, 1997).
Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.
Breast is Best?
On a cold morning in early December last year, I found myself sitting in the Highgate Literary and Scientific Institution in London, looking at pages and pages of breasts.
Pausing occasionally to wonder at the collection of life choices which had led to this moment, I scanned these black and white photographs of lactating women from the 1920s and 1930s, attempting to understand the set of criteria according to which they were categorised into ‘good’ and ‘bad’ breasts.
The pictures were taken and kept by the Mothercraft Training Centre in London, and were intended for nurses and other healthcare practitioners working with mothers and young babies. Informed by the programme of scientific childrearing developed by the New Zealand doctor Truby King during the first decade of the twentieth century, the Centre’s staff promoted breastfeeding as the best way of providing babies with adequate nutrition.
In King’s view, breastfeeding needed to be approached scientifically. Mothers should not feed on demand but, rather, according to a strict schedule, depending on the age of the infant. This feeding by the clock was a technique aimed as much at mothers as it was at shaping obedient and self-reliant babies and young children.
Like other specialists in the relatively new field of paediatrics, King believed that mothers were irrational and emotional, and inclined to follow what he characterised as the unscientific and unsanitary advice provided by their female relatives. By breastfeeding in King’s ‘scientific’ manner, mothers could learn to be rational creatures.
In King’s view, not only were there right and wrong ways of breastfeeding, but also good and bad breasts. The photographs in the Mothercraft Training Centre’s collection were meant to help nurses identify the link between the shape of women’s breasts and the ways they would feed their babies.
I was reminded of these photographs this week by the most recent cover of Time magazine, which features 26 year-old Jamie Lynn Grumet breastfeeding her son. She is young, slim, and wears a skimpy top, and her child is a sturdy three year-old.
The debate which erupted around the cover focussed on the age of the boy: wasn’t it weird, asked some, for a mother to be feeding so old a child? The picture – deliberately, I think – provoked this controversy by upsetting contemporary notions of what nurturing motherhood should look like.
But what interested me is that Time chose this particular photograph for its cover. The edition’s focus is not, in fact, on breastfeeding. It’s about a popular childrearing guide The Baby Book (1992) written by William Sears, which advocates that mothers and babies remain as close together as possible for as long as possible. Kate Pickert explains:
Hilariously lampooned by Maggie Gyllenhaal in Away We Go, attachment parenting has been the subject of extensive and frequently ferocious debate. Breastfeeding, though, is only one feature of this particular mode of parenting. So why the cover on Time? It’s partly because photographs of breastfeeding women still – depressingly – provoke argument. As Jill Lepore writes, there’s a long history of banning magazines which print pictures of breastfeeding women:
‘Respectable’ news magazines often print photographs of women with semi-covered breasts. If these usually sexualised images of women are tolerated, why do pictures of breastfeeding women provoke such disgust? Given that the World Health Organisation and many governments advise mothers to breastfeed their babies exclusively for the first six months of life, it seems strange that breastfeeding women should be regarded as a kind of social embarrassment.
Indeed, Facebook’s decision to treat photographs of women breastfeeding as pornography, and women’s experiences of being forced out of public spaces when breastfeeding, seem to suggest that the issue is connected to how women’s bodies are understood socially.
Our bodies are socially and culturally constructed. As South Africa has seen over the past fortnight, the portrayal of the President’s penis in Brett Murray’s painting ‘The Spear’ has provoked outrage partly because it defies taboos around nudity in some South African communities and is seen as being part of a long history of white exploitation of black bodies.
Depictions of breastfeeding women are relatively common in art before the early twentieth century. These were meant to celebrate women as mothers – in a role which most believed celebrated women’s God-given and ‘natural’ role on earth. The photographs of lactating breasts in the Mothercraft Training Centre collection were intended for medical purposes – as were the pictures of breastfeeding mothers in mothercraft publications. I wonder if it’s possible to link the worldwide decline in breastfeeding during the 1940s and 1950s to the decreasing tolerance for the portrayal of breastfeeding women in popular publications? As breasts have become increasingly sexualised in advertising and the media, has this accompanied a discomfort with the idea that they can also be used to nourish and to nurture?
Although decades apart, there are similarities between the attitudes which informed mothercraft and those behind the Time cover: that women’s bodies are not their own to control. The Time cover suggests, firstly, that breastfeeding in public is not only worthy of comment, but also freakish – that it should be done within the secluded confines of the home. And, secondly, it implies that when women are in charge of raising their children, they behave irrationally: that they embrace ‘gurus’ and are ‘driven to extremes’. There is nothing on this cover to suggest that this mother chose – calmly and carefully – to feed and to care for her child in this way.
Marilyn Yalom, A History of the Breast (New York: Ballantine Books, 1997).
Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.