Beyond the Breastfeeding Mothers' Bill of Rights

In 2009, New York passed its Breastfeeding Mothers' Bill of Rights, affirming mothers' rights to breastfeed any place, public or private. The focus of many provisions was on increasing mothers' access to information. Subsequently, hospitals had to share breastfeeding rates and other statistics.

A study to be published this fall in the American Journal of Law and Medicine finds that the law may have had larger effects, as hospitals and their staff responded to new disclosure rules by changing their practices. In a blog post today, Timothy Lytton writes:

The DOH regulation requiring hospitals to disclose breastfeeding rates among their maternity patients also influenced management within hospitals. Maternity unit managers used the breastfeeding data required by the regulation to train clinical staff, set performance goals, and monitor outcomes. The regulation has also encouraged frequent collection and use of breastfeeding data for quality improvement. A perinatal clinical nurse specialist in one New York hospital told us that she generates daily reports on breastfeeding rates in her unit and has been able to document a steady increase in the rate of breastfeeding among mothers in the unit. Data have also helped maternity unit managers advocate more effectively within their hospitals for changes in clinical policies.

Repeated reviews of compliance with DOH’s model breastfeeding policy and periodic data reporting have maintained a prominent place for breastfeeding promotion on the agenda of maternity care units and hospital management. Policies must be reviewed for compliance. Data must be disclosed to patients. These requirements continuously demand the attention of administrators, unit managers, and staff.

Our findings suggest that transparency policies can significantly influence government regulators and hospital administrators independently of their effects on patients. DOH officials and maternity unit managers appear to have used the pressure and information generated by New York State’s breastfeeding transparency laws to reform hospital policies and practices proactively, not merely in response to signals from patients.

Lytton and coauthors Barbara Dennison, Trang Nguyen, and Janine Jurkowski suggest that the study may have implications beyond just breastfeeding policy, providing an example of the ways that disclosure rules may have a downstream impact on actual services.

Oh, really? Hanna Rosin in the Atlantic makes the case against breastfeeding

Hanna Rosin's new article in the Atlantic follows a script that one commonly sees in reporting about nutrition science.

We have the headline boldly claiming that everything you thought you knew is overturned ...

The Case Against Breast-Feeding

... and the mild claim, buried in the middle, that defeats only a straw dummy (formula is not as menacing as smoking).

So overall, yes, breast is probably best. But not so much better that formula deserves the label of “public health menace,” alongside smoking.

We have the belittling of important results, whose main defect seems to be disagreement with the author's story line.

Kramer followed 17,000 infants born in Belarus throughout their childhoods. He came up with a clever way to randomize his study, at least somewhat, without doing anything unethical. He took mothers who had already started nursing, and then subjected half of them to an intervention strongly encouraging them to nurse exclusively for several months. The intervention worked: many women nursed longer as a result. And extended breast-feeding did reduce the risk of a gastrointestinal infection by 40 percent. This result seems to be consistent with the protection that sIgA [an element of breastmilk] provides; in real life, it adds up to about four out of 100 babies having one less incident of diarrhea or vomiting.

And I think we may have an instructive misunderstanding or misquoting of some statistical results.

Rosin quotes one fascinating study by Evenhouse and Reilly that compares cross-sectional analysis (showing how different breastfeeding practices for children in different families are related to different outcomes) to a within-family fixed effects analysis (showing how different breastfeeding practices for children in the same family are related to different outcomes). The fixed effects analysis has an important advantage, by controlling for confounding characteristics of the family. The fixed effects analysis also has an important disadvantage, lower precision (much bigger standard errors) because there are fewer mothers who change breastfeeding practices for different siblings.

Because of the lower precision (bigger standard errors), the same estimate of the effect of breastfeeding -- such as the finding that breastfed children are lighter or brighter -- could be "statistically significant" in the cross-sectional analysis and "statistically insignificant" in the fixed effects analysis. The important thing to do, in such cases, is to look at the actual estimates to see if they are much different in the two analyses.

If I am understanding Evenhouse and Reilly's analysis correctly, the cross-sectional estimates showed the usual benefits of breastfeeding for many outcomes. The fixed effects estimates agreed fairly closely on most of these outcomes, but were statistically insignificant because of larger standard errors.

For one key cognitive function score (PVT score), even the fixed effects analysis found a benefit of breastfeeding. So, Evenhouse and Reilly, in their summary, have good things to say about breastfeeding.

The significant correlation between breastfeeding and PVT score in our within-family model provides more credible evidence of a causal link between breastfeeding and cognitive ability than do existing nonexperimental studies. The effect is large enough to matter, and it is lasting, persisting into adolescence. Stronger evidence of causality may argue for intensifying breastfeeding promotion, particularly among groups that suffer from high rates of academic failure and other problems that some researchers have correlated with lower IQ (e.g., incarceration, poverty, or welfare recipiency). Some of the same social problems that justify additional expenditures on education and Head Start, for example, may also warrant additional efforts to raise breastfeeding rates.

Our results also suggest, however, that many of the other long-term effects of breastfeeding have been overstated.

How does Rosin describe what these authors say?

Almost all the differences turned out to be statistically insignificant. For the most part, the “long-term effects of breast feeding have been overstated,” they wrote.

Notice how Rosin quotes selectively from just part of Evenhouse and Reilly's last sentence. The rest would disagree with her story line.

WIC messages: "Touching Hearts, Touching Minds"

Instead of lecturing low-income mothers about nutrition science, the Touching Hearts, Touching Minds site from the Massachusetts WIC program takes an emotion-based approach towards healthy living education for pregnant women and mothers of infants and young children.

In addition to providing nice posters and teaching materials for free, the WIC site offers much to think about on topics frequently covered on U.S. Food Policy. If you have been weighing the money and time costs of home cooking for a low-income single parent, you may be interested in some of the site's recipe materials as examples that show the possibilities and limits. If you have been contemplating food industry marketing that implicitly encourages early weaning from breastfeeding, you may like the site's materials for mothers of infants. This poster about "pester power" and food advertising is also interesting.

How safe and effective are DHA and ARA additives in infant formula?

Infant formula companies say oils that have been added to infant formula in recent years make the products "closer than ever to breastmilk." But these additives -- DHA (an omega-3 fatty acid) and ARA (an omega-6 fatty acid) -- may be ineffective or even unsafe, according to a report released today (.pdf) by the Cornucopia Institute, a Wisconsin-based food policy advocacy group.

What is troublesome, however, is that some infant formulas contain DHA- and ARA-containing oils that are novel foods—extracted from laboratory-grown fermented algae and fungus and processed utilizing a toxic chemical, hexane. These algal and fungal oils provide DHA and ARA in forms that are structurally different from those naturally found in human milk. These manufactured oils are known as DHASCO and ARASCO, which stand for docosahexaenoic acid single cell oil and arachidonic acid single cell oil.

These oils are produced by Martek Biosciences Corporation and appear to be added to infant formula primarily as a marketing tool designed to convince parents that formula is now “as close as ever to breast milk.” Substantiating this thesis is a Martek investment promotion from 1996, which reads as follows: “Even if [the DHA/ARA blend] has no benefit, we think it would be widely incorporated into formulas, as a marketing tool and to allow companies to promote their formula as ‘closest to human milk.'”

Scientists have conducted numerous studies that show little or no benefit to an infant’s development from adding DHASCO and ARASCO to infant formula. Overall, research results are inconsistent and inconclusive. Meanwhile, the formula companies have advertised aggressively in an attempt to convince parents that their DHA/ARA formula provides the same nutrients, and therefore the same benefits, as breast milk.

A former employee for the Program for Women, Infants, and Children (WIC) in Texas explains: “Since they added these oils to formula, many new mothers seem to believe that formula is just as good for their babies as breast milk. It became much harder for us at WIC to convince mothers to breastfeed when formula ads claim that formula is as close as ever to breast milk.”

Mainstream web sources on DHA and ARA offer little reassurance. The Food and Drug Administration's FAQ page about infant formula says there is mixed evidence of short term benefit and no evidence of long term benefit. FDA says systematic monitoring is not in place to assess risks and benefits in countries where these addititives have been used, and the agency has asked formula makers to do postmarket surveillance of infants who consume these additives.

Breastfeeding promotion and formula marketing

Formula companies sometimes attempt to use the past tense to describe their heavy-handed marketing campaigns at the expense of breastfeeding. "Sure, we used to do wrong," they might say, "but now we promote breastfeeding."

A breastfeeding advocacy website has an interesting series of reports about industry-sponsored websites that promote formula under the guise of simply offering motherly advice. I read at PR Watch, for example, that Mothering Magazine reports that the Moms Feeding Freedom blog is linked to the International Formula Council. The advocacy website banthebags.org reports that the Moms Feeding Freedom blog has started deleting comments critical of formula industry marketing. Fortunately, archived copies of the original comments are available here.

The site reminds me to link to the Washington Post's excellent coverage last month of a formula industry coup, convincing a federal breastfeeding promotion campaign to tone down its most potent print ads.

The original proposed ad graphically emphasized the association between formula feeding and risk of respiratory disease (click for larger image).


The final ad offered a pointlessly bland graphic, and required close reading to understand the same message.


I imagine some readers may find the original proposed ad too blunt. Addressing that question puts me in a bind as a writer. I can write truthfully: "Some women cannot breastfeed, for medical or employment reasons. Formula is a satisfactory replacement, at least in the United States." But my fingers cringe hovering over my keyboard, because those same true sentences are also industry talking points that are used to exaggerate the hardships of breastfeeding and the quality of formula. You have to read those sentences in the same context with this one: "Almost all women can breastfeed, and breastfeeding is best."

Regardless of which ad you prefer, at least two things are clear as day: the formula industry should not have been given the opportunity to sway the choice of ad, and hospitals should stop routinely giving out bags of formula to new mothers.