On Breastfeeding

A few blogs ago I said I would share some of the essays I write as part of my post graduate study in Child Health.

I failed my first essay, in the main for not writing it in an academic style (which requires writing in third person; using evidence from the literature; NOT using personal experience, anecdotes or opinions unless you can reference them from the literature).  Nevertheless, the issue is close to my heart so I have edited the referencing system to make it more readable, and I think it passes in blog form for anyone interested in the subject of breastfeeding, which is surprisingly fraught with political and economic agendas.

A couple of points before sharing the essay:

Firstly

I shared the following story about my friend’s experience in a maternity clinic in Cambodia 3 years ago, with another Cambodian friend recently.  He stated that the public health system in Cambodia do promote breastfeeding and do not supply milk substitutes near their maternity wards or services.  Nevertheless my observation at a private maternity clinic is worth sharing, with attention to the fact that it is not necessarily “the norm”.

When I visited <friend’s> wife in the maternity hospital (private) I was shocked to see baby formula and bottled water for sale inside the hospital.  You cannot do that here because the health system want to encourage breastfeeding and will not support formula company marketing as a matter of professional ethics.  When I tried to find out the name of the formula company owner, it seemed that it is a French company, with a very high profit margin.

At the time of the baby’s birth my friend rang me.  He was holding a very distressed baby and I suggested the baby was hungry.  He agreed but the hospital staff shut the baby outside with Dad and Grandmother, to “check Mum”. The baby cried for an excessive period of time and they were denied access to Mum.  Eventually Grandmother surrendered and bought formula and bottled water at the shop downstairs. It appeared to my outsider eyes, as a deliberate tactic.

Secondly

While exclusive breastfeeding for the first six months of a baby’s life is the optimal practice for multiple health reasons, mothers who do not or cannot sustain this should not be judged and their babies can still lead healthy lives.  I am aware that many mothers have felt unreasonable pressure to exclusively breastfeed, and then guilty when they have been unable or chosen not to.  It is not my intent to make anyone feel guilty because of their choices or individual circumstances.

Critical Analysis of a National Health Promotion Program
Baby Friendly Health Initiative

More recently named the Baby Friendly Health Initiative (BFHI), I first learned about the Baby Friendly Hospital Initiative during my Public Health studies over 17 years ago.  In 1991, World Health Organisation and UNICEF introduced the BFHI, “to protect, promote and support breastfeeding in all birth settings”1.  The initiative was introduced in Australia in 1993 and has been governed by the Australian College of Midwives since 19952.  The Australian Breastfeeding Association3 state that the BFHI project “aims to give every baby the best start in life by creating health care environments where breastfeeding is the norm and practices known to promote the health and wellbeing of all women and babies are followed”.

As outlined by the Australian College of Midwives2, BFHI accreditation is awarded to hospitals which meet certain standards relating to consistent and accurate information and support to mothers as they establish feeding.  A critical component of these standards is the WHO International Code of Marketing of Breast-milk Substitutes (“The Code”).  The Code comprises ten main points requiring that facilities in no way display, advertise, promote, provide products or otherwise engage with companies who sell infant milk substitutes, bottles and teats.  In Australia The Code is applied in part by the Marketing in Australia of Infant Formula (MAIF) Agreement, in which manufacturers and importers have voluntarily signed a self-regulatory code of conduct4.

Aware of The Code as a global initiative 17 years ago, I assumed effective global implementation was in place.  However in recent years I have spent time in Cambodia, where I learned that in those countries without strong health systems, who are in most need of protective policies such as Baby Friendly Health Initiatives, practices violate recommended guidelines.  Through many friends and colleagues in Cambodia, I have observed that the marketing of infant milk substitutes is blatantly immersed in maternal and child health care provision.  Milk substitutes, bottled water, bottles, teats and other related paraphernalia are stocked and sold inside private maternity clinics.  Established practices appear to discourage exclusive breastfeeding in favour of either adding or replacing with milk substitutes, generating a profit to providers.  It seems the milk substitute scandal that rocked the world in the early 1970s5, when it was disclosed that milk substitute companies were marketing their products aggressively and unethically in poor countries, leading to untold infant disease and mortality, continues today in many vulnerable places.  My personal observations are supported by Ellis-Petersen H6 who confirms that health providers from some of the world’s poorest countries are given financial and other incentives by milk substitute manufacturers, to promote their products at the expense of breastfeeding.

According to the Department of Health’s Australian National Breastfeeding Strategy : 2017 and Beyond7, who recommend exclusive breastfeeding to around 6 months of age, “Evidence shows that breastfed babies are less likely to suffer from necrotising enterocolitis, diarrhoea, respiratory illness, middle ear infection, type 1 diabetes and childhood leukaemia.  Available evidence also shows that breastfed babies have enhanced cognitive development.  Breastfeeding also benefits mothers by promoting faster recovery from childbirth, reducing the risks of breast and ovarian cancers in later life, and reduced maternal depression”.  Referring to this page on the DOH website, it is possible to locate information on the Baby Friendly Health Initiative, but it is mentioned only briefly and near the bottom of the page.  The Department of Health also state that in Australia, 90% of children are initiated on exclusive breastfeeding, but only 15.4% of babies are exclusively breastfed to 5 months of age7.

The gap between what we know (exclusive breastfeeding to 6 months of age is optimal) and what happens in Australia (only 15.4% of children come near this target), suggests that improvements are needed in our breastfeeding health promotion strategies.  The fact that 90% of Australian mothers initiate exclusive breastfeeding suggests that sufficient information is available and intent exists in the baby’s first hours, days or weeks.  Something changes beyond that which needs to be addressed.

Holowko N et al8 found that breastfeeding rates in Australia have not increased substantially since 2001, although more infants are now breastfed for the minimum recommended six months.  They also found a correlation between women who have a low education or a low-educated parent, and lower rates of initiating breastfeeding, or maintaining breastfeeding to the recommended six months.  This evidence suggests a socio-economic link, identifying a possible target population for whom health promotion activities should focus.

With only 15.4% of Australian infants exclusively breastfed to the recommended six months of age, Hauck YL et al9 investigated the categories women listed as supporting their breastfeeding capacity, in an international study including women from Australia, Sweden and Ireland.  The categories are listed here in ranking of importance as outlined by the 449 Australian women in the study: breastfeeding was going well; maternal knowledge of health benefits; health professional support; informal face to face support; maternal self-determination; partner support; maternal knowledge of psychological benefits; cultural norm; work environment; informal online support.  This study outlines some possibilities for health promotion in encouraging breastfeeding in the Australian population.  It could be possible that the most important category for Australian women (breastfeeding was going well) is in fact influenced by other categories given less importance, such as partner support, cultural norm and work environment.  Some influences may even be unidentified, for example the comparison between Australia where The Code prevents marketing of infant milk substitutes in or near maternal and child health facilities and Cambodia where such marketing is highly visible.

Given the (often negative) attention that breastfeeding receives in the Australian media, it is probably necessary for health promotion to target not just young, antenatal or breastfeeding women, but also the general population.  Anecdotal evidence suggests some stigma attached to what is and is not appropriate in relation to breastfeeding infants in public places.  The Australian Breastfeeding Project, started in 2015, aims to reduce stigma and keep mothers breastfeeding for longer, with a group of breastfeeding women giving mixed reports around the issue of stigma attached to breastfeeding in Australia10.

In April and May 2017 the Australian Health Ministers’ Advisory Council held a series of stakeholder consultation workshops as part of the implementation of the Australian National Breastfeeding Strategy : 2017 and Beyond7.  As per Fact Sheet 2 in the reference, participants recommended a national campaign, identifying that mothers cannot be the only target population in any health promotion campaign, and that mothers, partners, families, the health system, governments and the community at large have a shared responsibility to make breastfeeding a biological and cultural norm.  I would argue that while the community at large have a shared interest in ensuring our future generations have the best start possible in life, without appropriate awareness campaigns their responsibility relating specifically to breastfeeding is limited.  Participants also recommended strengthened implementation of The Code on Marketing of Breastmilk Substitutes; increased support and funding for the BFHI, such as making BFHI a requirement of accreditation; research to understand the barriers and allow better targeting of priority groups; as well as other recommendations which can be found in the reference.

A 2012 opinion piece by Barker R11 states that very few women in Australia deliberately choose to abandon breastfeeding, and that it is the circumstances around breastfeeding that lead women to stop breastfeeding early.  These circumstances are listed as including the commercialization of readily available breastmilk substitutes with manufacturers exploiting a loophole in the MAIF Agreement ; unresolved breastfeeding problems met with conflicting advice; early return to paid work requiring some form of supplementation; and lack of family and community support.  Barker offers a number of solutions including one year of paid maternity leave; allocation of funding to research breastfeeding problems and how to manage them; defragmentation of perinatal care; end milk substitute manufacturers’ exploitation of a loophole in the MAIF agreement which allows for certain milk substitute advertising; plain packaging of infant milk substitutes; and all milk substitutes in the first six months to be available by prescription only.  This piece is written by a retired Midwife and Child and Family Health Nurse with 30+ years of experience, however it remains an opinion piece and further study is needed to provide objective information on the reasons and solutions for early breastfeeding abandonment.

The Baby Friendly Health Initiative is clearly successful at promoting breastfeeding initiation in Australian women but it falls short in promoting appropriate duration of breastfeeding.  The initiative is directly linked to the Australian College of Midwives, whose role starts in the antenatal period and normally ends with domiciliary care termination at around six weeks of age, when Child and Family Health Nurses assume responsibility.  Better integration of services between Midwifery care and Child and Family Health Nurse care could potentially be required, as mentioned in some of the literature about fragmented care and conflicting advice.  I suggest that the BFHI should be part of a more comprehensive program connecting to services beyond Midwifery and Child and Family Health, to capture the attention of a broad range of service providers, consumers and the general community.

Only targeting young women and mothers designates the issue of breastfeeding as a female / mother-specific concern, ignoring the investment needed from partners, families, the health system and the wider community.  BFHI is specific to maternal and child health care facilities, which may be too narrow a focus for a successful breastfeeding health promotion campaign?  However, aspects to maternal and child care obviously do need improvement, such as providing more specialized support via lactation consultants, research into the problems women experience with breastfeeding and a more consistent approach between health professionals regarding appropriate advice and support for solutions.  Establishing the BFHI as a requirement for hospital and health facility accreditation will also bring the issue to the forefront of all health services, not only those who already have a breastfeeding focus.  The Department of Health’s Breastfeeding website page only mentions BFHI briefly, with the Australian College of Midwives and Australian Breastfeeding Association – two non governmental agencies – being the initiative’s main representatives and advocates.  I suggest that the DoH need to give a more significant priority to BFHI, to highlight it as an important intervention embraced across government and non-government agencies.

As a privileged and developed nation geographically positioned so close to some of the world’s least privileged nations, Australia also has a more global role to play.  While various infant milk substitute companies are signatory to the MAIF Agreement here in Australia, those same companies are not only exploiting loopholes in the Australian agreement they have signed, but they are clearly exploiting vulnerable populations in our region and beyond, whose children most need the protection breastfeeding offers.  Australia are already building partnerships in places like Cambodia, for example the WHO Collaborating Centre at the University of Technology Sydney, who this year launched a Bachelor of Science in Midwifery Bridging Course at the University of Health Sciences in Phnom Penh in collaboration with UNFPA12.  The aim of this partnership is to reduce maternal and neonatal mortality in Cambodia.  Partnerships such as this are well positioned to advocate for the implementation of Baby Friendly Health Initiatives in some of the world’s most vulnerable places, making Australia a potential leader of the Baby Friendly Health Initiative on a global scale.

As a health promotion program the BFHI has an imperative role in promoting breastfeeding as a culturally normal, biologically desirable start to life for all Australian children.  There are successes worth celebrating since the BFHI was introduced to Australia 25 years ago, but there are also gaps in the program which need to be strengthened to improve our national breastfeeding outcomes.  Australia’s strong and functional health system also has a role to play beyond our national borders for the good of the world’s most vulnerable populations.

References

  1. World Health Organisation (n.d.), Baby-friendly Hospital Initiative, http://www.who.int/nutrition/topics/bfhi/en/
  2. Australian College of Midwives (undated), What is the WHO Code?, https://www.midwives.org.au/what-who-code
  3. Australian Breastfeeding Association (undated), Is Your Hospital Baby Friendly?, https://www.breastfeeding.asn.au/bf-info/your-baby-arrives/your-hospital-baby-friendly
  4. Department of Health (March 2005), Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement – the MAIF Agreement, http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-publicat-document-brfeed-maif_agreement.htm
  5. Muller, M (1974), ‘The Baby Killer’, War on Want, https://waronwant.org/sites/default/files/THE%20BABY%20KILLER%201974.pdf
  6. Ellis-Petersen Hannah (27 February 2018), ‘How formula milk firms target mothers who can least afford it’, The Guardian https://www.theguardian.com/lifeandstyle/2018/feb/27/formula-milk-companies-target-poor-mothers-breastfeeding?CMP=share_btn_fb
  7. Department of Health (November 2017) Australian National Breastfeeding Strategy : 2017 and Beyond, http://www.health.gov.au/breastfeeding
  8. Holowko N, Jones M, Koupil I, Tooth L, Mishra G (2015), ‘High education and increased parity are associated with breastfeeding initiation and duration among Australian women’, Public Health Nutrition Vol 19(14), pp 2551-2561
  9. Hauck YL, Blixt I, Hildingsson I, Gallagher L, Rubertsson C, Thomson B, Lewis L (2016) ‘Australian, Irish and Swedish women’s perceptions of what assisted them to breastfeed for six months: exploratory design using critical incident technique’, BMC Public Health Vol 16:1067 https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3740-3
  10. Tovey A 2015 ‘Breastfeeding photo project helps reduce stigma and keeps mothers feeding for longer’, ABC News online 15 March 2018, http://www.abc.net.au/news/2018-03-15/photo-project-to-reduce-stigma-around-breastfeeding-in-public/9544616
  11. Barker R 2012 ‘Duration not initiation is the real breastfeeding battle’, ABC News online 5 November 2012, http://www.abc.net.au/news/2012-11-05/barker-breastfeeding-battle/4352172
  12. University of Technology Sydney (3 April 2018), ‘New partnership to boost midwifery education in Cambodia’, https://www.uts.edu.au/about/faculty-health/news/new-partnership-boost-midwifery-education-cambodia

 

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Baby Business

Herman Melville Quote

The other day here in Australia, I was with a friend in town when her daughter called her, panic-stricken after being bitten by a snake at their home 10km from town.  As I sat on the phone with Emergency Services, who answered on the first ring, replying to their orderly and systematised questions, my surprisingly calm friend drove us home.  We followed organised traffic past well posted speed signs on sealed roads.  Within minutes of our arrival a distinctly marked emergency car with one paramedic led a fitted-out ambulance with two more paramedics into the driveway, sirens blazing.  They calmly entered the home wheeling a shining stainless steel, adjustable stretcher with a fitted mattress and carrying custom-made bags organised with various first aid equipment.  Their assessments and treatment were methodical, calm and professional.  Moments later the local snake handler arrived, photographed the bite site to help identify the species of snake he should look for, and took his snake hook outside hoping to capture the culprit (alas, to no avail).

Once stable the patient was rolled onto a sheet, the stretcher was lowered smoothly to floor level and she was lifted onto it.  A clip of a switch lifted it to normal height and she was wheeled out to the ambulance, where the stretcher clicked onto a hydraulic system and manoeuvred into the ambulance cab with minimal manual effort.  The vehicle was equipped wall-to-wall with state-of-the-art emergency apparatus and appropriate seatbelts to ensure the comfort and safety of the patient and other passengers.  In the Emergency Department she had her own private, shining clean, spacious cubicle with two doctors and two nurses hooking her up to monitors and inserting intravenous lines, all following well-established and evidence-based protocols.  After a few unsuccessful attempts at intravenous cannulation the doctor disappeared briefly, returning with a mobile ultrasound machine to help him locate a vein.  Mum and daughter were well informed about every procedure and every discussion between the team included them.

Not only are all of the bells and whistles available in our health services, but our health professionals have received first world, advanced training, with regular professional development to ensure practices remain up to date.  They work in teams so that no single person “owns” all of the information, nor all of the power in decisions made about patient care.  This does not mean that mistakes are not made, but all of these very first world aspects to health care reduce the chances of error significantly.  Every health professional we encounter earns a salary allowing them to feed their families, pay off mortgages or afford rent, furnish homes, take out loans on motor vehicles, go on regular holidays and various other first world “needs”.  Not one requires, nor works in a system which allows them to ask for or expect, cash payments from the patients in their care.

In comparison to this experience, images of the “Emergency” ward in Cambodia flashed in and out of my mind like waves crashing to shore.  Memories of a nurse at either end of a canvas fitted through two rusty poles, bearing half-shares of the patient’s weight as they ran their stretcher hurriedly across uneven gravel, past leaking sewerage pipes and stained, dirty concrete walls.  Passengers sitting unrestrained on the bare floor of a mini van with an almost comical siren squealing from it’s roof, a single red strip across the vehicle’s centre identifying it as some sort of ambulance.  Patients lying in rows of steel beds without mattresses, surrounded by others lying on hard concrete floors, with dust and dirt and grime in every nook.  An immobile elderly patient clambering out of bed onto a floor-level toilet pan in plain sight, sound and smell of at least 30 other people.  Stepping over crowds of sick bodies mingled with newborn babies.  The complete lack of anything remotely resembling a monitor.  Bags of fluid hooked onto the ends of bamboo sticks.  A malnourished elderly man, ribs sucking in and out with each breath, in desperate need of unavailable oxygen, his only relief a wet cloth patted on his forehead by a doting daughter.  Nurses dressed in white from the caps on their heads to the shoes on their feet, reminiscent of 1920s Australia.

Photographing my friend sitting in the ambulance with her daughter, she shouted out to me “You’re not in Cambodia now!”, explaining to the paramedics that I had “just come back from living in Cambodia”.  The snake handler turned to me and said “you have to try quite hard to die from snake bite in Australia but the opposite can be said for places like Cambodia”.  No truer words were spoken, and snake bite is only the tip of the deathly iceberg!

Mos Dangerous DAy

Financial Times reporters on three continents follow the fates of three women and their babies in this report on childbirth in poor nations at Three Births

Last year when Chom’s wife was having their second child, and again this year as Samantha approached the birth of her second child, I found myself increasingly exasperated by both couples’ apparent ill-informed and irrational medicalised approach to childbirth.  Chom’s wife had miscarried previously and Samantha’s first child is her now-2.5yo son who continues to exist with a severely debilitating, ultimately terminal, genetic condition for which the only care he receives is from his impoverished family.  Even so, the apparent obsession both couples expressed about medical interventions seemed bewildering to my first world brain, which knows that excessive medical interventions are more likely to be harmful than helpful in normal pregnancies.  The talk from both couples included innumerable ultrasound scans for no apparent reason and excessive talk about caesarean sections, all of which are costly and unnecessary interventions.  Given my descriptions herein of the public hospital experience it was no real surprise that both sought obstetric care in a private clinic, but the lead up to both births left me flummoxed at how medical it all seemed, for no credible reason.

Visiting Chom’s newborn at the private clinic, some of my puzzlement fell into place.  A beautiful building in comparison with any public clinic or hospital, although equally as crowded with newborn babies and their families squeezed into every space in foyers and along open corridors.  Chom paid extra for a private room which was furnished elaborately with a private bathroom, air conditioning and a television.  Superficially, everything looked superior to the alternative and I understood why private clinic was considered the best choice.  However, these clinics are run as profit making enterprises by the doctors who own them.  Medical interventions paid for by the client are highly profitable, including ultrasound scanning and caesarean section, so I came to understand why such interventions are promoted as “best care” when in fact, they are quite the opposite.

Cambodia’s health literacy is led by private-clinic-owning doctors, in a population crippled by poverty whose young adults of today are a single generation away from the complete destruction of the country’s education system.  The promotion of unnecessary and often risky interventions to paying clientele, in a country with no malpractice liability and low health literacy, is hardly surprising.  With a lack of access to alternative reliable information, it is also unsurprising that their clientele believe what they are told by wealthy and successful doctors working out of superior health facilities.  Even so, most Cambodians cannot afford to attend these clinics, and childbirth usually takes place either at home or in public facilities.  This is likely the only reason that the caesarean section birth rates are as low as they are, at just 3%.

Caesarean section is major surgery with many associated short and long term adverse effects, from wound infection and infertility in the mother, to feeding difficulties and lung problems in the baby.  The World Health Organisation recommends caesarean sections only be performed when medically necessary, and has stated that there is no justification for C-section rates to be any higher than 10 to 15% of all births in any given region.  The outcomes for both mother and baby are generally much better when childbirth occurs naturally, except for those rare cases where C-section is indicated for medical reasons.  Despite this, there has been a profound upward trend of caesarean births in wealthy nations.  When first measured in 1965, the national C-section rate in USA was 4.5%.  In 1991 Australia’s national C-section rate was 18%.  Today both countries record C-section birth rates of around 32%.  The rate in Australia’s private clinics rises to 43%.

It is difficult to pinpoint exactly what leads the upward trend towards caesarean sections and doctors appear to give different reasons than midwives, for the pattern.    Two medical reasons given, which are not relevant in poor nations such as Cambodia, include the increase in age of mothers and the increase in obesity, both of which are more likely to be associated with an indication for C-section.  Many doctors also claim that women are increasingly asking for C-section while midwives have claimed that women are subtly coerced by obstetricians, whose training is almost entirely related to abnormal pregnancy and surgical intervention, to consider C-section as a preferable alternative.  Midwives also argue that most women who deliver by C-section do so despite not wanting to.  While there are no direct financial incentives in Australia for performing C-section, scheduled elective surgery does allow doctors to take on more clients, so there is a definite indirect financial benefit to the doctor when women choose C-section.  Another determinant in a country like Cambodia, is likely the observation from afar, of the rising popularity of this intervention in wealthy countries.  We are, after all, shining examples of health care, to be emulated wherever possible!

In the lead-up to the birth of Samantha’s second child, she was given multiple reasons for the recommendation of caesarean section birth, none of which held up well to proper scrutiny.  She has always claimed that her first child was born after a difficult and lengthy labour.  However, upon questioning it appears that in fact, she had not progressed to labour yet, when an emergency C-section was determined necessary.  She blamed her son’s neurological condition on this “difficult labour” for many months.  When we were in Seattle together with Paula my very kind friend arranged a consultation with a paediatrician who determined that his condition is in fact genetic and nothing to do with anything that happened during pregnancy or childbirth.  Nevertheless, she was understandably anxious about the second birth, this time of a girl who will not be afflicted by the same genetic syndrome.

She underwent multiple ultrasound scans during pregnancy and from a very early time began speaking of caesarean section.  The reasons given at differing times included: previous C-section as an indication for future C-section (this is incorrect, and trial of labour is normally recommended for women who have had one previous C-section); breech presentation on scan at 34 weeks pregnant, when a large proportion of babies have not yet turned (and when scan is not indicated); nuchal cord (umbilicus around the neck) on another scan at about 38 weeks, which is an extremely common presentation and not considered to be associated with adverse events during normal vaginal birth.  Each of these reasons suggested that she was either looking for a reason to have caesarean section, or being coerced by her private doctor to believe it was the best option.  She said things to me such as “I must do the right thing for my baby, so I should have a C-section”.

Each time she returned from her (many) medical appointments, she presented a new reason for C-section birth.  When I and my midwife friends explained away each pseudo reason, she would present after her next appointment with a new medical “reason”.  Finally a midwifery lecturer friend and I met with her by video conference to speak at length about the reasons that normal vaginal birth would likely have better outcomes for both baby and mother.  In no small way did one of these reasons include a financial saving of many hundreds of dollars.  She appeared convinced and we felt we’d done a very good deed for a young family.

On the due date she presented to hospital with pre-labour pains and was informed that she had appendicitis and needed an appendicectomy!  As they must operate anyway, they would deliver the baby by C-section at the same time!  With so much persistent talk about C-section over so many months, and an absence of any symptoms of appendicitis except abdominal pains, this reeks to me of fabrication and her family will be paying their surgical debt for months if not years to come.  With the severe damage done to Paula’s gastro-intestinal system by over-zealous and obviously unqualified surgeons, the thought of agreeing to abdominal surgery in Cambodia fills me with horror and I was glad that I only learned of Samantha’s fate after the event.  She is now home and apparently recovering.

Associated with this topic, is the issue of breastfeeding versus artificial feeding.  In the 1970s the World Health Organisation introduced an international code of marketing for infant milk substitutes.  This followed the scandal of formula companies, most famously Nestle, unscrupulously promoting their products to impoverished mothers.  Hundreds of thousands of babies died unnecessarily in third world countries, and many more suffered malnutrition, disease and permanent stunting. because of this rampant corporate exploitation.  The scandal was first publicised in Mike Muller’s 1974 report, The Baby Killer.  It is one of the most infamous public health scandals of the 20th century and led to Australia’s very strict rules around baby formula and all baby products, which cannot be sold or advertised in the vicinity of facilities providing care to pregnant or post-partum women.  I studied this scandal in detail, understanding exactly why, as Nurse Manager of a Paediatric Ward some years ago, I had to be vigilant to the presence of anything that could appear to be marketing any kind of baby products whatsoever in our hospital, down to health promotion materials even mentioning the name of certain corporations.

Last September when I walked into the maternity clinic to visit Chom and his new baby, I was stopped dead in my tracks inside the main door, by the sight of baby formula and bottled water stockpiled from floor to ceiling!  Across the foyer was a second shop, stashing every imaginable baby product from powders and soaps to strollers and cots.  Chom’s new son had arrived by normal vaginal birth without complication.  Immediate skin-to-skin contact with Mum is recommended to promote breastfeeding and he explained that this had happened but after five minutes, baby was whisked out of the room and handed to Dad and grandma “because they had to make sure <mum> was okay”.  Mum was perfectly fine and there was no other reason given for her to be separated from her baby, making me wonder at why, in a maternity clinic blatantly promoting baby formula, this separation appeared to be normal practice?  The baby screamed incessantly for a prolonged period and because he was so hungry his grandmother finally sent Chom downstairs to purchase water and milk powder so that he could be fed.  How calculated and convenient it all seemed!  The scandal which was so widely publicised in the 1980s, appears to me, to be proceeding unabated in countries where people are ill-informed and powerless, and where practices are poorly monitored, if at all.

On my arrival at the clinic I asked Chom’s wife if I could please photograph the bottled water and formula to send to my friends in Australia “because they would be so shocked”.  Chom said “this is normal in Cambodia, it is okay”, looking slightly dumbfounded at my reply which went something like “it is absolutely not okay, it is babies in poor countries who suffer because of formula feeding”.  That day he and his wife decided to discard the formula, despite having paid for it and planned not to let it go to waste.  As far as I know, his baby was then exclusively breastfed, although I know that they introduced solids much earlier than recommended, relying as so many do, on their own ideas about what to do, in the absence of any proper information.  WHO describe breastfeeding as “the normal way of providing young infants with the nutrients they need for healthy growth and development. Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large….  Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond“.

It disappointed me this week, after relaxing when I heard that her baby was breastfeeding well, to hear Samantha say “because I don’t have enough milk, I get formula for her too and she will have both”.  This is contrary to the well established evidence that breastfeeding stimulates milk production and adding formula feeds ensures the failure of breastfeeding for many known physiological and psychological reasons.  Again, my first world brain was horrified and I gave a strongly worded response, asking if the clinic sold formula.  Possibly afraid of giving the wrong answer, Samantha did not reply to this question.  The answer is surely yes!

It is astounding to see this promotion of artificial feeding for no reason other than what appears to be profiteering, in a population who can ill afford the extra unnecessary expense.  This is even more shocking when malnutrition, infectious diseases and ill health already dominate peoples’ lives, all of which can be prevented in the first months of life by exclusive breastfeeding.

The dangers associated with childbirth in developing countries appear to have opened up a market of unethical practices, such as promoting surgical intervention and artificial feeding as the best choice for mothers and babies, all because these have a much more profitable result for the facilities providing care.  The general population are in a vicious cycle, aware through close hand experience, of the perils of childbirth, therefore wanting the best.  “The best” appears to be available from private enterprises who prosper from implementing bad practices, ultimately resulting in worse long term outcomes for mothers and babies?  The debt of a mother who dies in childbirth will not be forgiven, and widowed fathers and extended families can spend years trying to repay money owed to clinics responsible for their loved one’s death or disability.  There was no better example of this, than Paula, whose repeated surgeries were not pregnancy-related.  Her intestines were quite literally hacked to pieces and she was sent home to die, her family left in severe debt to the people responsible.  Their search for a “cure” resulted in severe disability leading to a slow and painful death, and a debilitating family debt.

Some of the indicators in reports by UNICEF and WHO, for positive maternal and neonatal outcomes, include such things as the number of facilities offering peri-natal care, per head of population.  With what I have learned about the private facilities and their focus on profits, I wonder if this necessarily equates to positive outcomes?  As most pregnancies are normal and healthy physiological processes, could it be that poor villagers who have no choice but to give birth at home, might in fact be ultimately better off than people who have the capacity to take out loans for private health care?  The examples of Chom and Samantha alone, would suggest so.  When I told Win some days after my visit to Chom’s family at the maternity clinic, that I had stood on the stairs and photographed the clinic shops, he replied “that is why they do not like foreigners to go to their clinics, because you know too much and it can cause problems for them”.

When I feel exasperated by some of the behaviours of my friends, particularly around health care, I have to remind myself consciously of the comparison between our experiences and perspectives.  As someone from the rich and privileged world, I know what is best from my educated and unexploited place in the world.  That does not mean however, that I am in a position to judge the behaviours of those who only know adversity that I have never even had to imagine.  Figuratively speaking, it is all too easy to condemn the behaviour of those floundering in bare feet on jagged stones as we amble comfortably along soft terrain at lofty heights with an unlimited choice of footwear.  It is also, as Herman Melville said, preposterous of us to do so.