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FEATURES
International Breastfeeding Initiatives and theirRelevance to the Current State of Breastfeeding in theUnited StatesMarsha Walker, RN, IBCLC
Exclusive breastfeeding is becoming an endangered practice. Breastfeeding has fallen from the foundation ofpublic health to something that is nice but not necessary in the minds of many consumers and health careprofessionals. Numerous international initiatives have been created to improve the initiation, duration, andexclusivity of breastfeeding throughout the world. These include the International Code of MarketingBreast-milk Substitutes, the Innocenti Declaration, and the Baby-Friendly Hospital Initiative. In the UnitedStates, the National Alliance for Breastfeeding Advocacy (NABA), the US Breastfeeding Committee(USBC), and Baby-Friendly USA have played important roles in improving breastfeeding. We begin with abrief history of these initiatives and organizations and move on to discuss some of the progress and programsthat can help return breastfeeding to its rightful place as the initial and most basic act of healthprotection. J Midwifery Womens Health 2007;52:549–555 © 2007 by the American College of Nurse-Midwives.
keywords: advocacy, Baby-Friendly, breastfeeding, the Code, Innocenti Declarationfpceptsicpdefcbhfdafiptfim
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NTRODUCTION
actation is an ancient process that predates placentalestation. It represents the normal and expected way toeed infants and young children, yet continues to sufferrom cultural and commercial barriers that make itifficult for mothers to adhere to the medical recommen-ation to breastfeed exclusively for 6 months, and toontinue breastfeeding with appropriate complementaryoods for 1 year and beyond.1 Infant feeding through theges has been subject to shifting attitudes toward theother/child relationship, the understanding (or misun-
erstanding) of the process of lactation and the compo-ition of human milk, and the escalating acceptance ofhe use of human milk substitutes.2 More than 1700 yearsf published Western medical advice, both ancient andurrent, often implies that the mother is inadequate toreastfeed her own infant or that her milk is not sufficiento sustain normal growth without being supplemented.3
his is a persistent and unfortunate belief that still lingersn many hospital maternity units, where the supplemen-ation rate of breastfed infants approaches 50%.4
Until the mid-1800s, almost all babies in the Unitedtates were breastfed. By the 1890s and early 1900s,owever, a shift occurred from breastfeeding to bottle-eeding. A confluence of factors caused breastfeeding toose its place as the foundation of preventive health care.he shift to artificial feeding redefined what constitutednormal” infant feeding. European manufacturing of infant
Mddress correspondence to Marsha Walker, RN, IBCLC, 254 Conantoad, Weston, MA 02493. E-mail: [email protected]
ournal of Midwifery & Women’s Health • www.jmwh.org
2007 by the American College of Nurse-Midwivesssued by Elsevier Inc.
ormulas began in the 1840s, and by the 1890s, theseroducts were available worldwide. Advertisements forommercial human milk substitutes appeared in US wom-n’s magazines, formula manufacturers offered free sam-les through the mail, and mothers and physicians adoptedhe belief that artificial feeding was efficient, modern, andcientific.5 The pasteurization of cow’s milk and the drop innfant mortality seemed to cancel out the difference betweenow’s milk and human milk, facilitating cow’s milk sup-lementation of breastfed infants.6 Mothers continued tooubt their ability to produce sufficient amounts of milk,specially as women’s magazines popularized mothers’aulty ability to breastfeed. Childbirth itself became medi-alized and moved into hospitals. The practice of givingreastfed newborns supplemental bottles was routine inospital maternity units by the 1930s.7 The more infanteeding became supervised by physicians, the more mothersecided they were incapable of producing sufficientmounts of milk without help from physicians and artificialeeding products.8 Breastfeeding also became medical-zed.9,10 While breastfeeding was promoted in medicalublications, it was often mishandled in practice, a problemhat persists today.11 To help stem the slide into a bottle-eeding culture, numerous international strategies have beennitiated over the last 3 decades that are designed to addressany of the challenges to breastfeeding.
he International Code of Marketing of Breast-Milk Substituteshe decline in breastfeeding was not confined to thenited States. In 1939, Dr. Cicely Williams gave a
peech to the Singapore Rotary entitled “Milk and
urder” which linked artificial or commercial feeding to549
1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2007.06.013
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nfant death, raising the alarm regarding the dramaticrop in breastfeeding rates worldwide and the accompa-ying rise in infant mortality. In 1977, the US-basednfant Formula Action Coalition (INFACT) launched aonsumer boycott of Nestlé products to protest harmfulormula marketing practices in developing countries thatncluded Nestlé employees dressed up as nurses passingut formula samples in maternity units. In response,enator Edward Kennedy convened a Senate hearing in978 and referred the issue to the World Health Organi-ation (WHO). WHO and the United Nations Children’sund (UNICEF) convened an international meeting in979 on infant and young child feeding. The majorutcome of the meeting was the recommendation todopt the International Code of Marketing of Breast-milkubstitutes (“the Code”).12 The Code is a set of market-
ng recommendations, not a ban on the manufacture andale of infant formula. The Code was adopted for thentire world with no distinction between developing andeveloped countries. It recognized that breastfeeding is aealth issue, not a commercial one, and that it needsrotection. The Code functions as a tool to curb unethicalarketing practices, false and misleading advertising,
nd the complicity of the health care system in persuad-ng a mother to partially or completely replace her milkith a commercial substitute. In 1981, the United Statesas the only country to vote against the adoption of theode, but in 1994 it joined in the consensus in endorsing
he Code and subsequent resolutions to that point. Noart of the Code is legislated in the United States. Thecope of the Code covers products that are marketed in aay that encourages bottle-feeding or hinders breastfeed-
ng. Products include infant formula, follow-on formulas,nfant cereals, complementary foods, and other breastilk substitutes when marketed for use as partial or total
arsha Walker, RN, IBCLC, is the executive director of the National Allianceor Breastfeeding Advocacy: Research, Education, and Legal Branch (NABA
Table 1. Selected Provisions of the International Code of Marketing of B
o advertising to the public of any product within the scope of the Codeo free samples to motherso promotion of products in health care facilities, including the distributio company sales representatives to advise motherso gifts or personal samples to health workerso words or pictures idealizing artificial feeding, or pictures of infants on
nformation to health workers should be scientific and factualnformation to mothers should include the benefits and superiority of brea
formula bottles will cause reduced breastfeeding, and how difficult it mf materials discuss the use of infant formula, they must include: the cos
risks to the baby’s healthnsuitable products, such as sweetened condensed milk, should not be panufacturers should comply with the Code’s provisions even if the count
aEAL) in Weston, MA. She serves on the board of directors of theassachusetts Breastfeeding Coalition and Baby-Friendly USA.
50
eplacement of breast milk. Feeding bottles and artificialipples are also included, but pacifiers and breast pumpsre excluded. Selected provisions of the Code can beound in Table 1.
o Advertising to the Public of Any Product Within the Scope ofhe Code
regnant women are inundated with cases of formula,oupons, booklets, and formula company gifts through-ut their pregnancy. Misleading text in ads and on labelsork to convince mothers that infant formula is equiva-
ent to human milk. Companies promise smarter andealthier babies with better vision, claiming formula isjust like breast milk,” because of the addition of twoong-chain polyunsaturated fatty acids. However, re-earch has shown that there is little evidence to supportny beneficial effects in cognitive, motor, or visualunctioning from the addition of these fatty acids.13–15
o Free Samples to Mothers
amples are a marketing tool given to create brandecognition and brand loyalty. Hospital distribution oformula company discharge bags is such an effectivearketing tool that it is used as an example in marketing
extbooks. This hospital endorsement of formula feedingesults in mothers starting to use formula earlier andreastfeeding for shorter durations.16 In the presence ofhese bags, exclusive breastfeeding is reduced at alloints measured between 0 and 6 months.17
o Promotion of Products in Health Care Facilities, Including theistribution of Free or Low-Cost Supplies
ealth care facilities, including hospitals, physician of-ces, and clinics continue to be used as a primaryistribution channel for the promotion of infant for-ula.18,19 Obstetric offices introduce pregnant mothers
o formula20 through such gifts as a changing pad rolledround a can of powdered formula. These gifts result in
ilk Substitutes
ee or low-cost supplies
of formula cans or other foods for infants
g, how to prepare for and continue breastfeeding, that the addition ofto return to breastfeeding once bottle-feeding is establishedng artificial feeding products, the social implications, and the possible
for babiesnot adopted laws or other measures to implement the Code
reast-m
on of fr
labels
stfeedinay be
t of usi
romoted
substantial negative effect on the exclusivity and
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uration of breastfeeding, especially with mothers whoave uncertain or short breastfeeding goals.21
o Gifts or Personal Samples to Health Workers
ifts form the basis of building relationships betweenlinicians and formula companies. Even small gifts worko promote friendly and cooperative relationships withhe manufacturer, whose primary duty is to its sharehold-rs. This conflicts with the primary obligation of clini-ians, which is to act in the best interests of theiratients.22 Formula salespeople often appear on mater-ity units with food. Eating together promotes a cozy andnug working relationship that removes professionalarriers between vendors and health care professionals.hen salespeople combine food with flattery, recipients
end to like them more, regardless of what it is they haveo say.23 Many professional societies rely on industryponsorship from companies that violate the Code, cre-ting the potential for a conflict of interest.
Additionally, other provisions of the Code restrictisleading claims and pictures of infants from being
hown on formula can labels. All information provided toealth workers should be scientific and factual. Mosttudies funded by a manufacturer report outcomes favor-ble to the sponsoring company.24 The Code also con-ains 14 subsequent resolutions that close loopholes torevent exploitation by the baby food industry.Once the Code was set in motion, WHO’s World
ealth Assembly continued with efforts to improvelobal breastfeeding rates. Recognizing that the qualityf breastfeeding support in the hospital is crucial forothers to meet their breastfeeding goals,25 WHO andNICEF issued a joint statement in 1989 entitled Pro-
ection, Promotion and Support of Breastfeeding: Theen Steps to Successful Breastfeeding. This documentalls on hospitals and healthcare facilities to adoptractices that encourage and protect breastfeeding bymplementing ten interventions. The Ten Steps (Table 2)re a series of best practice standards describing a patternf care where commonly found practices harmful toreastfeeding are replaced with evidence-based practices
Table 2. The Ten Steps to Successful Breastfeeding
1. Maintain and routinely communicate a written breastfeeding policy to2. Train all health care staff in skills necessary to implement this policy3. Inform all pregnant women about the benefits and management of br4. Help mothers initiate breastfeeding within 1 hour of birth.5. Show mothers how to breastfeed and how to maintain lactation, even6. Give infants no food or drink other than breast milk, unless medically7. Practice “rooming in”—allow mothers and infants to remain together8. Encourage unrestricted breastfeeding.9. Give no pacifiers or artificial nipples to breastfeeding infants.0. Foster the establishment of breastfeeding support groups and refer m
ource: WHO and UNISEF.26
roven to improve breastfeeding outcomes.26 h
ournal of Midwifery & Women’s Health • www.jmwh.org
HE INNOCENTI DECLARATION
he Innocenti Declaration was created by participants athe WHO/UNICEF policymakers’ meeting on “Breast-eeding in the 1990s: A Global Initiative,” which waso-sponsored by the United States Agency for Interna-ional Development (USAID) and the Swedish Interna-ional Development Authority (SIDA) and held at thepedale degli Innocenti, Florence, Italy, in 1990. Theocument was signed by the United States and set annternational agenda, specifying targets that governmentsere to attain by 1995. These goals included establishingational breastfeeding coordinators and committees, en-uring appropriate maternity services (inspiring develop-ent of the Baby-Friendly Hospital Initiative), renewing
fforts to implement the International Code of Marketingf Breast-milk Substitutes, and enacting imaginativeegislation protecting the breastfeeding rights of workingomen. The World Alliance for Breastfeeding Action
WABA) was formed in 1991 to act on the Innocentiargets, specifically through large-scale social mobiliza-ion projects such as the annual World Breastfeeding
eek.While the US government has established breastfeed-
ng objectives for the nation (Table 3), it has notmplemented any of the Innocenti goals.27 Breastfeedingdvocates have worked to partially fulfill the ambitiousargets. The National Alliance for Breastfeeding Advo-acy (NABA) was formed in 1995, as the US member ofhe International Baby Food Action Network (IBFAN).ABA monitors violations to the Code within the US,
eports them to relevant agencies, and provides sugges-ions for reducing the commercial barriers to breastfeed-ng that non-adherence to the Code creates.18,19 NABAorks on advocacy issues at the federal level and
acilitated the formation of the US Breastfeeding Com-ittee (USBC) in 1998. The USBC is a collaborative
artnership of more than 40 organizations working torotect, promote, and support breastfeeding in the Unitedtates by focusing on national policy issues. It fulfills thennocenti goal for establishing a national breastfeedingommittee. The American College of Nurse-Midwives
lth care staff.
ding.
are separated from their infants.ted.rs a day.
to them on discharge from the hospital or clinic
all hea.eastfee
if theyindica24 hou
others
as been a valued member from the beginning. Recent
551
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SBC projects include the convening of a nationalummit of state breastfeeding coalitions to advance statend local breastfeeding activities, and the provision ofnput into a model benefits plan that the National Busi-ess Group on Health has constructed for businesses as aecommendation of what health benefits should be cov-red or provided by employers. Breastfeeding recom-endations include a $2500 per child per year durableedical equipment credit for banked breast milk within
he bounds of industry standard medical necessity crite-ia, and up to 5 lactation consultant visits per pregnancyall women/all infants) provided by a primary carerovider or international board certified lactation consul-ant (IBCLC).
No part of the Code is legislated in the Unitedtates; however, New York and Massachusetts includeestrictions in their perinatal regulations regardingospital distribution of commercial discharge bags.here is no federal legislation protecting the rights ofreastfeeding women in the workforce, but a fewtates have versions of worksite protection laws.
HE BABY-FRIENDLY HOSPITAL INITIATIVE
he Baby-Friendly Hospital Initiative (BFHI), launchedn 1991 by WHO and UNICEF, is a call to action for allaternity services, whether freestanding or in a hospital,
o become centers of excellence in breastfeeding support.aternity centers become accredited when they demon-
trate that they meet the WHO/UNICEF criteria as aaby-Friendly Hospital. In 1997, Healthy Childrenroject, Inc. formed Baby-Friendly USA as the non-rofit organization that implements the Baby-Friendlyospital Initiative in the United States. There are 56ospitals and birthing centers in the US holding theaby-Friendly certificate.A maternity facility can be designated Baby-Friendly
hen it does not accept free or low-cost breast milkubstitutes, does not provide feeding bottles or artificialipples, and has implemented 10 specific steps to supportuccessful breastfeeding. The Ten Steps address a majoractor in the erosion of breastfeeding: maternity careractices that interfere with or are ineffective in sup-orting breastfeeding. Baby-Friendly hospitals support
Table 3. Healthy People 2010 Revised Breastfeeding Objective
Objective No.Increase in Percentage ofMothers Who Breastfeed
6-19a. In early postpartum period6-19b. At 6 months6-19c. At 1 year6-19d. Exclusively through 3 months6-19e. Exclusively through 6 months
ource: Office of Disease Prevention and Health Promotion.27
reastfeeding through education of health care providers b
52
n maternity and neonatal services. Institutional changesn hospital practices are effective in increasing bothnitiation and duration of breastfeeding.28 During themplementation of the BFHI in one inner city hospital,reastfeeding rates rose from 58% to 87%. Of interestas the increase among US-born African Americanothers, whose breastfeeding rates rose from 34% to
4%.29 A study conducted by researchers from severalederal agencies surveyed 1085 new mothers about theirospital experience regarding the presence or absence ofof the Ten Steps (initiation of breastfeeding within 1
our of birth, 24-hour rooming-in, no supplements,eeding on cue, and non-use of pacifiers). Only 7% of theothers experienced all 5 steps. Those who experienced
one of the steps were 8 times more likely to haveiscontinued breastfeeding before 6 weeks’ postpartum.he more steps a mother experienced, the more likely sheas to continue breastfeeding to 6 weeks and beyond.he major risk factors for early termination of breast-
eeding were late initiation of breastfeeding and supple-enting the baby.30
The evidence-based breastfeeding management thathe BFHI promotes is designed to improve exclusivereastfeeding rates at discharge, with exclusive breast-eeding during the first month being linked with areastfeeding duration of longer than 6 months.31 Exclu-ive breastfeeding is an important concept, as babies whore mixed-fed or formula-fed tend to have increased ratesf acute and chronic diseases and conditions, such asespiratory tract infections and otitis media.32 For eachonth of breastfeeding, there is a 4% decrease in the risk
f being overweight in childhood.33 Receiving no infantormula decreased overweight by 11%.34 Researchersave shown consistent evidence of a relationship be-ween breastfeeding and reduced risk of obesity, with aose–response relationship (i.e., the higher the dose ofreast milk the lower the incidence of overweight andbesity).35
isconceptions Regarding the BFHI
others Will Be Forced to Breastfeed
he BFHI is not a coercive approach to improving
1998 BaselineUnless Noted (%)
2010 Target(% of Mothers)
64 7529 5016 25
43 (2002) 6013 (2002) 25
reastfeeding rates, duration, and exclusivity. It is a
Volume 52, No. 6, November/December 2007
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echanism to remove barriers that occur in maternityacilities while educating staff in a series of best practicesor breastfeeding management.
abies Cannot Have Bottles
on-medical formula supplementation is associated witharly abandonment of breastfeeding. Two or more bottlesefore 20 hours of age can contribute to early weaning byto 10 days postpartum.36 Infants given non-medically
ndicated supplements in the first 48 hours of life orffered pacifiers are 2 to 3 times more likely to haveuboptimal breastfeeding behaviors on days 3 and 7.37
upplemental feedings should only be given when aedical indication exists.38 Mothers who exclusively
ottle-feed are provided with formula for their infantsnd instructions on how to prepare, use, and feed formulao their baby.
FHI Facilities Cannot Buy Formula
ormula can be purchased for about $0.20 to $0.50 perottle. The cost of providing food for infants is passed ono the patient in the room and board charges, just likeood on any other unit in the hospital. Formula manu-acturers may claim that the hospital would have to payxorbitant amounts of money based on a costing of otheroods and services the hospital receives from the com-any, but this is not the case.39
t Will Make Bottle-Feeding Mothers Feel Guilty
here are no data showing that bottle-feeding mothers inaby-Friendly hospitals are adversely affected by birth-
ng in such a setting. In a study of preterm mothers whosenitial intent was to formula feed but subsequentlynitiated lactation following encouragement of neonatalntensive care unit (NICU) care providers, mothers de-ied feeling forced or pressured into breastfeeding bytaff who presented an unequivocal message regardinghe importance of breastfeeding.40 Women who areubsequently made aware of the nutritional and immu-ological properties of human milk in relation to im-roved health outcomes often express anger and frustra-ion with the health care professionals who failed to sharehis knowledge with them.40 The health care provider hasn ethical responsibility to avoid withholding informa-ion related to the non–evidence-based concern that tonform mothers of research-based options may makehem feel guilty if they choose not to breastfeed.41
linicians Are Supposed to be Neutral on Infant Feeding
nadequate, insensitive, or apathetic approaches toreastfeeding by health care providers often culminate in
downward spiral of frustration and weaning by 2eeks. Mothers reporting that hospital staff expressed no
reference regarding infant feeding were more likely to tournal of Midwifery & Women’s Health • www.jmwh.org
e bottle-feeding at 6 weeks, especially if the mother’sriginal intent was to breastfeed for less than 2 months.42
others Will Not Come to a Hospital Where they Cannot Get Theirree Discharge Bag
ost Baby-Friendly hospitals distribute their own gift bag,arketing the hospital’s birthing services. The commercial
ischarge bag is not really free. It markets the most expen-ive brands of infant formula, resulting in a formula-feedingamily paying approximately $700 more to feed their babyhe hospital-endorsed brand compared with store brandormulas. The mothers who purchase formula pay for thefree” gift bags. If a mother really wants this bag, she canall the toll-free number of the manufacturer and order one.
enefits of the Baby-Friendly Status
ospitals can experience numerous benefits by becomingaby-Friendly. Many of the Ten Steps are easily adapt-ble as quality improvement projects. The Joint Com-ission, which accredits US health care organizations,
ooks favorably upon voluntary efforts to improve patientare and services. Hospitals may benefit from costontainment because increased breastfeeding rates canave impact on many health care costs, such as reducingmergency department visits. Insurers may engage inreferential referral to Baby-Friendly hospitals and in-rease their reimbursement to these hospitals because iteduces the costs of insuring babies who use less healthare services. One study looked at the excess costs offfice visits, hospitalizations, and prescriptions for threeommon childhood illness (otitis media, gastrointestinalllness, and lower respiratory illness) in formula-fednfants compared with infants exclusively breastfed for 3onths. These additional services cost the insurers an
xtra $331 to $475 per never breastfed baby during therst year of life.43 Insurers may therefore be more willing
o increase reimbursement for in-hospital lactation ser-ices. Some insurers may institute pay for performanceeasures where BFHI status or adoption of specific steps
r practices that result in longer duration and exclusivityf breastfeeding are reimbursed at higher levels. BFHIlso presents an opportunity for favorable public rela-ions and marketing. Families who feel adequately sup-orted during the vulnerable postpartum days will returnor other health care needs and serve as a communityource for recommending the facility to others. Last butertainly not least, the BFHI award is very prestigious.he receipt of this international award engenders pride inoth staff and administration.
ONCLUSION
reastfeeding serves as the foundation of health, yet itsxclusive practice is diminishing. Numerous interna-
ional initiatives have been created to improve the initi-553
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tion, duration, and exclusivity of breastfeeding through-ut the world, and several US organizations are workingowards these goals. There are a number of actions thatlinicians can take to build on the foundation of thesenternational initiatives and national organizations (Table). A renewed commitment in advocacy to remove breast-eeding barriers will have outcomes that last a lifetime.
EFERENCES
1. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D,chanler RJ, et al. Breastfeeding and the use of human milk.ediatr 2005;115:496–506.
2. Fildes V. Breasts, bottles, and babies: A history of infanteeding. Edinburgh, Scotland: Edinburgh University Press, 1986.
3. Gartner LM, Stone C. Two thousand years of medical advicen breastfeeding: Comparison of Chinese and western texts. Seminerinatol 1994;18:532–6.
4. Gagnon AJ, Leduc G, Waghorn K, Yang H, Platt RW.n-hospital formula supplementation of healthy breastfeeding new-orns. J Hum Lact 2005;21:397–405.
5. Levenstein H. Revolution at the table: The transforming of themerican diet. Berkeley, CA: University of California Press, 2003.
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Table 4. Clinician Actions
ospital ActionsContact the Quality Improvement Department, perinatal practice commi
hospital.Start to implement the Ten Steps, one at a time.Work to eliminate commercial influences within the maternity unit.Ask all formula company salespeople to adhere to the hospital’s vendoAbandon the practice of distributing commercial discharge bags to newAsk colleagues to remove formula company materials and gifts from th
ommunity ActionsJoin a state or local breastfeeding coalition as an individual, and askWork on state legislation for worksite protection of breastfeeding.Meet with state health insurers to improve coverage for lactation care
in the community.Review the state perinatal regulations. Ask the Department of Public H
practices for hospitals and a prohibition on the hospital distributionmanagement training for hospital staff and require that each hospitLactation Consultant on staff.
006;1:172–7.
54
11. Hausman BL. Mother’s milk: Breastfeeding controversies inmerican culture. New York: Routledge, 2003.
12. Breastfeeding Committee for Canada Web site. The interna-ional code of marketing of breastmilk substitutes and subsequentesolutions. Available from: www.breastfeedingcanada.ca/html/ebdoc12.html [Accessed June 10, 2007].
13. Simmer K. Longchain polyunsaturated fatty acid supple-entation in infants born at term. Cochrane Database Syst Rev
001;4:CD000376.
14. Singhal A, Morley R, Cole TJ, Kennedy K, Sonksen P,saacs E, et al. Infant nutrition and stereoacuity at age 4-6 y. Am Jlin Nutr 2007;85:152–9.
15. Wright K, Coverston C, Tiedeman M, Abegglen JA. For-ula supplemented with docosahexaenoic acid (DHA) and arachi-
onic acid (ARA): A critical review of the research. J Spec Pediatrurs 2006;11:100–12.
16. Guise JM, Palda V, Westhoff C, Chan BK, Helfand M, LieuA, et al. Effectiveness of primary care-based interventions toromote breastfeeding: Evidence and meta-analysis. Ann Famed 2003;1:70–8.
17. Donnelly A, Snowden HM, Renfrew MJ, Woolridge MW.ommercial hospital discharge packs for breastfeeding women.ochrane Database Syst Rev 2000;2:CD002075.
18. Walker M. Selling out mothers and babies: Marketing ofreast milk substitutes in the USA. Weston, MA: National Alli-nce for Breastfeeding Advocacy, 2001.
19. Walker M. Still selling out mothers and babies: Marketing ofreast milk substitutes in the USA. Weston, MA: National Alli-nce for Breastfeeding Advocacy, 2007 (in press).
20. Howard CR, Howard FM, Weitzman ML. Infant formulaistribution and advertising in pregnancy: A hospital survey. Birth994;21:14–9.
21. Howard C, Howard F, Lawrence R, Andresen E, DeBlieck, Weitzman M. Office prenatal formula advertising and its effectn breast-feeding patterns. Obstet Gynecol 2000;95:296–303.
similar group and begin the process of becoming a Baby-Friendly
rs.es.
onal organizations (e.g., ACNM state chapter) to join also.
vices in hospitals, in the outpatient setting, in offices and clinics, and
amend the regulations to include best breastfeeding managementmercial discharge bags. Ask that these regulations require lactationmaternity and newborn services have an International Board Certified
ttee, or
r policy.mothe
eir offic
professi
and ser
ealth toof comal with
22. Moynihan R. Who pays for the pizza? Redefining the rela-
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26. Philipp BL, Radford A. Baby-friendly: Snappy slogan ortandard of care? Arch Dis Child Fetal Neonatal Ed 2006;91:145–9.
27. Office of Disease Prevention and Health Promotion, USepartment of Health and Human Services. Healthy People 2010idcourse review: Maternal, infant, and child health. Available
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28. Fairbank L, O’Meara S, Renfrew MJ, Woolridge M, SowdenJ, Lister-Sharp D. A systematic review to evaluate the effective-ess of interventions to promote the initiation of breastfeeding.ealth Technol Assess 2000;4:1–171.
29. Philipp BL, Merewood A, Miller LW, Chawla N, Murphy-mith MM, Gomes JS, et al. Baby-Friendly Hospital Initiative
mproves breastfeeding initiation rates in a US hospital setting.ediatrics 2001;108:677–81.
30. DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternityare practices: Implications for breastfeeding. Birth 2001;28:94–00.
31. Piper S, Parks PL. Predicting the duration of lactation:vidence from a national survey. Birth 1996;23:7–12.
32. Chantry CJ, Howard CR, Auinger P. Full breastfeedinguration and associated decrease in respiratory tract infection inS children. Pediatrics 2006;117:425–32.
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43. Ball TM, Wright AL. Health care costs of formula-feeding in
he first year of life. Pediatrics 1999;103:870–6.The Breastfeeding Rights: With Apologies to Miranda1. You have the right to remain breastfeeding.2. Any breast milk you pump may be used if put in the refrigerator.3. If you are under the age of 18, any time you breastfeed as a juvenile, your juvenile offspring can
mature you and make you an adult, so that soon you will be breastfeeding as an adult.4. You have the right to talk to a lactation consultant before giving up breastfeeding, for
answering any questions.5. You have the right to breastfeed your baby immediately after birth, during your La Leche
League meetings and while meeting your lactation consultant during the questioning.6. If you cannot afford a lactation consultant, one will be appointed for you without cost,
before or during breastfeeding, if you desire.7. Do you understand these rights?
eprinted with permission from The Friends of Breastfeeding Society, Compleat Mother Magazine.
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