Becoming a Breatfeeding Culture Peggy Omara

In 1956, when Marian Tompson and Mary White sat around at a church picnic talking about breastfeeding, they didn't intend to change the culture. They only wanted to help each other to breastfeed. In 1957, when they and five other friends founded La Leche League only 20% of US women were breastfeeding.

Sixteen years later in 1973, when I became pregnant with my first child in Alamogordo, the breastfeeding initiation rate in the US was still 20%. I could see immediately that breastfeeding was nature's way of ensuring intimacy, attachment and human survival and I got into it with great enthusiasm.

I was hungry for reliable information to help me be the kind of mother I knew I wanted to be intellectually but was ill equipped to be emotionally. I needed reams of information and gobs of studies. LLL learned early on that this combination of information and support was potent, that these two components are just what a mother needs to ensure breastfeeding success.

I became a LLL Leader in 1975 and was Newsletter Editor, Leaders' Letter Editor, Assistant Coordinator of Leader Applicants (ACLA) and CLA all in quick succession. Before you call me crazy, and believe me I am, there just were not that many of us back then. New Mexico did not have its own LLL but was part of Arizona's LLL. There were only 11 LLL Leaders in New Mexico and most of us had not met each other. As an over-eager Newbie, I was quickly set to work.

By 1978 when I moved from Alamogordo to Albuquerque, LLL of NM had established itself as an independent organization. Licensed midwifery became legal in the state and breastfeeding awareness was on the rise.

In the 1970s, Marian Tompson, then President of LLL, was a Breastfeeding Rock Star. Often interviewed in the media, she appeared on many national television shows. Breastfeeding was finally "discovered" and after two decades of active struggle, it was all good. In the ten years from 1970 to 1980, the breastfeeding initiation rate more than doubled and was at 55.3% in 1980.

Breastfeeding Initiation Rates continued to climb into the eighties and reached a high of 61.9% two years later in 1982. In just 12 years, the breastfeeding initiation rate had increased by 210%.

Those of us who were breastfeeding advocates at the time thought that we had won the war. We thought we could put aside our Womanly Art of Breastfeeding and only have to dust it off occasionally. We thought everyone in society would soon know about breastfeeding. Then the impossible happened. Things started to go backwards. The Breastfeeding Initiation Rates started to drop and continued to drop for 14 years. By 1990, the breastfeeding initiation rate was down to 51.5%, a 10% drop from the high of 1982. What happened?

It is no coincidence that Nestle began direct advertising of formula to consumers on television and in magazine display ads in 1989. This was in violation of a long-held agreement between the formula manufacturers and several national health organizations. Bristol-Myers, in partnership with Gerber, quickly followed suit with a television and magazine ad campaign.

These campaigns were a big success. Both Nestle and Gerber increased market share by nearly 3% each in one year and the infant formula industry grew to $2.1 billion in 1992. By 2000, the annual revenue from formula sales was $6 billion. In the last two years, the natural companies have entered the marketplace. Horizon Organic Milk now has an organic powdered formula. Nature's One and Toddler Health make toddler formulas.

Imagine with me the market share that Nestle, Gerber and the other formula manufacturers lost when the Breastfeeding Initiation Rate increased 210% in the 12 years between 1970 and 1982. In 12 years, they lost 42% of their market. They fought back. It came as a surprise to us naīve breastfeeding advocates of the 70s that corporate profit could trump good health. We had a lot of learn.

It was not only aggressive formula promotion that undermined breastfeeding in the 80s, but it was also a perhaps inevitable backlash against breastfeeding. More women were entering the workplace in the 80s and La Leche League, which at that time provided nearly all of the breastfeeding support, became perceived as anti-working mother. In truth, the organization has always navigated the delicate balance between the needs of the baby and the rights of the mother very well, but Leaders were not yet skilled at helping moms who were going back to work and many breastfeeding advocates were still ambivalent about breastfeeding and working.

In addition, breastfeeding began to be framed as a lifestyle issue rather than a health issue. Some argued that a baby was a happier if his or her mother made a free choice. Those of us involved in breastfeeding support know that the notion of free choice is severely compromised in a society where healthcare is a business. And, of course, breastfeeding is no more a lifestyle issue than is cigarette smoking.

Perhaps most important of all the reasons why breastfeeding rates dropped was the fact that as more women entered the workplace, they found it difficult if not impossible to continue to breastfeed. They simply did not know how to combine breastfeeding with working and the workplace did not accommodate it.

Enter the late 80s and the 90s. After getting the wind knocked out of us in the 80s, we advocates recovered and breastfeeding made a comeback. We got organized. We got sophisticated. We got ILCA. We got IBCLC. We got BFHI. We got WABA. We got NGOs. We got The Breastfeeding Answer Book (thank you, Nancy). We got the New Mexico Breastfeeding Task Force. We got busy. By 1997, we surpassed the past high of 1982 and the Breastfeeding Initiation Rate was 62.4%. The rate grew 3 percentage points from 1996 to 1997 alone. And, it's been steadily increasing ever since.

This growing increase has been facilitated by breastfeeding legislative efforts. Carolyn Maloney, US Representative from New York, has been a pioneer in introducing federal breastfeeding legislation. The first state to enact comprehensive breastfeeding legislation was Florida in 1993. It is no coincidence that the late lawyer, Liz Baldwin, lived in Florida. She served many of us for years by clarifying the confusing and rapidly developing face of breastfeeding legalities at the time. Liz always said that one inherently has the right to breastfeeding anywhere, anytime and, in fact, that is public policy today in Canada.

In the US, however, we still have to protect the rights of breastfeeding mothers - and infants - by continuing to pass legislation that not only protects the right to breastfeed in public, but also in the workplace. Just as in the 1980s, working continues today to be one of the biggest obstacles to breastfeeding success for too many women.

Just this week, our NM Governor, Bill Richardson, signed into law HB 1613, a law that safeguards a nursing mother's right to use a breast pump in the workplace and to have a flexible break time in which to use it. New Mexico State Representative Danice Picraux of Bernalillo County sponsored this bill. Danice is a retired LLL Leader whom I was proud to work with in Albuquerque in the late 70s and early 80s.

Increase in medical, governmental and social support, has also helped to fuel the continuing growth of breastfeeding. In 1997, the American Academy of Pediatrics (AAP) issued a statement on the benefits of breastfeeding and updated this statement in 2005. The AAP recommends exclusive breastfeeding for the first six months and continued breastfeeding until at least the child's first birthday. As you know this statement is the work of Larry Gartner, Ruth Lawrence, Audrey Naylor and the Breastfeeding Work Group of the AAP. Not all the AAP doctors support breastfeeding as the statement suggests. In fact, a 2001 study showed that only 37% of AAP Fellows actually recommend breastfeeding for one year.

Most other countries take breastfeeding support much more seriously. I looked at Breastfeeding Statistics compiled by Carol Huotari of the LLL Center for Breastfeeding Information. The stats were from September 15, 2003. With 86 countries reporting, the US was among only seven countries with breastfeeding initiation rates lower than 85%. 70 of the 86 countries have breastfeeding initiation rates of over 90%.

The World Health Organization (WHO) has been a world leader in protecting the rights of breatfeeding mothers and babies. The World Health Assembly of the WHO adopted the International Code of Marketing of Breastmilk Substitutes in 1981. The Code sets a "minimum requirement" to protect infant health. The US did not endorse the Code until 1994 and is among only eight other countries Central African Republic, Chad, Croatia, Estonia, Kazakhstan, Moldova, Republic of Romania and Somalia that have done absolutely nothing to implement the Code. Sixteen countries Brasil, Burkina Faso, Cameroon, Costa Rica, Dominican Republic, Guatemala, India, Iran, Lebanon, Madagascar, Nepal, Panama, Peru, Philippines, Sri Lanka and Tanzania have enacted legislation or other legally enforceable measures to implement the Code in its entirety.

At Mothering, we are proud to be the only US magazine that supports the code in our advertising policies. We do not take advertisements for formula, bottles, breastfeeding paraphernalia, or foods that compete with breastfeeding

The WHO established their Ten Steps to Successful Breastfeeding in 1989 and launched the Breastfeeding Friendly Hospital Initiative. As of 2002, there were 15,000 breastfeeding friendly hospitals worldwide, with 25 in the US. In 1990, the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding was signed. As you know, the WHO recommends breastfeeding for at least two years.

Governmental and social support for breastfeeding has increased since 2000. That year, the US Health and Human Services published its Blueprint for Action on Breastfeeding. This blueprint reiterated the goals of Healthy People 2010, which call for 75% breastfeeding initiation, 50% at six months and 25% at one year. In 2005, the Office of Women's Health was funded to carry out the recommendations of the blueprint. Anne Merewood spoke to you yesterday about the politics of this initiative. The Healthy People targets were first set in 1979, but breastfeeding targets were not added until later.

In just the last five years, there has been a dramatic increase in political activism related to breastfeeding. This has been fueled by the growing political consciousness of mothers in this country and by the growth of online communities. There's a Mother's Movement brewing in this country and many new organizations have emerged to support this nascent political awareness: The Mother's Support Network, The National Association of Mothers' Centers, International Moms Clubs, Mothers of Color at Home, the Motherhood Project, the Centre for Research on Mothering at York University in Toronto, Holistic Moms Network, Mothers Ought to Have Equal Rights (MOTHERS), Mothers Acting Up, Mothers and More, and Moms Rising.

Our website mothering.com has more traffic than any other parenting site on the web, save Baby Center. We have 11 million hits a month, 1 million unique visits a month and nearly 78,000 members of our discussion boards, Mothering Dot Commune. Many of these members are second generation. They are the daughters of LLL Leaders, birth activists, and natural living pioneers.

96% of the readers of Mothering breastfeed their babies. 41% breastfeed for one to two years; 32% breastfeed for three to four years and 8% breastfeed past four years. A couple of years ago, we ran an article on discreet breastfeeding with a sidebar on indiscreet breastfeeding. The overwhelming response to the article was that we got it wrong. The indiscreet should have been the main article. The readers liked it better. This generation of mothers is not prepared to apologize for breastfeeding.

In addition to the second-generation breastfeeders, there is a second generation of breatfeeding fashions. In my day, we didn't have breastfeeding fashions. We just pulled up our shirts. Now, there are nursing tops that pull down and expose more of the breast, possibly bringing more attention to breastfeeding mothers.

Perhaps it is inevitable that these newly confident breastfeeding mothers would eventually meet resistance. In the last two years there has been an increasing number of public incidents and subsequent public demonstrations related to breastfeeding in public. At first I thought that this meant breastfeeding was in trouble. Now, I see it as further evidence of the assimilation of breastfeeding into our society. At first, a new idea is ignored, then ridiculed, and finally attacked. Attack is the last step before assimilation.

In June 2005 mothering.com reported on a demonstration by 300 breastfeeding moms outside ABC in NYC. The lactivists were protesting comments by Barbara Walters on "The View' that she and others felt "very uncomfortable" when they saw a mother breastfeeding her baby next to them on the airplane.

Later that month, Seattle's ABC news commentator Ken Schram defended Walters when he compared public breastfeeding to public urinating. In response to his outrageous comments, 150 Mothering readers and other breastfeeding supporters gathered at the Seattle Center to demand his apology on June 27th. Schram failed to apologize and implied that brazen breastfeeders were the problem.

This same question of discreet vs. indiscreet breastfeeding is at the heart of the debate. In the summer of 2006, Emily Gillette from Santa Fe was asked to cover up on a plane where she was breastfeeding her 23-month old daughter. When she declined, she and her family were asked to leave the plane. In response, 800 lactivists staged demonstrations at 40 Delta Airline counters all over the country in November and December of 2006. See Nurse-Ins Across America at U Tube:
http://www.youtube.com/watch?v=kmgLgIUB2T4

The demonstrators were also asking for an apology and a clear corporate policy on breastfeeding.

We've experienced several incidents at Mothering in which the covers of our magazines were covered up or removed because there was the image of a breastfeeding mother on the cover. I have come to realize that you can be practically naked on the cover of a US magazine, but you cannot show any suggestion of a NIPPPLE. In all cases the companies apologized and clarified their policies regarding pornographic covers so that they exclude breastfeeding images.

Our experiences with the covers have taught me that the pubic generally supports breastfeeding and breastfeeding in public. Our hometown newspaper made it a front-page story when our first cover was covered up. According to a survey conducted by the National Breastfeeding Awareness Campaign, 69% of men are comfortable seeing a baby being breastfed in public. A poll on Dr. Phil's website, which we practically stacked, showed that 61% of respondents were good with breastfeeding, "anytime, anywhere."

It's important that breastfeeding mothers feel comfortable breastfeeding anywhere they are. In July, 2006 we published an article entitled "Taking Down the Almighty Bottle: Breastfeeding in a Bottle Feeding Culture." Just this week we received notification that the article is a finalist in the public service category for a Maggie Award from the Western Publications Association. Last year I won a Maggie Award for my editorial, "Breastfeeding in Whose Public?"

The Almighty Bottle article is inspired by Jack Newman's slide show in which he shows how much the imagery of bottles decorates everything for and about babies. We decided to hold a contest to come up with an international symbol for breastfeeding. We wanted the symbol to be used to promote breastfeeding and specifically to be used to designate private areas in public places like airports and universities where a woman could breastfeed or pump. We wanted an image that could be used instead of the image of a bottle.

We received over 500 entries from both the design and breastfeeding communities and selected one winner in the fall of 2006. The international breastfeeding symbol is a copyright-free image in the public domain and can be used by anyone who is interested. Already, it was used in the Delta demonstrations, and has been used in two airports and one university. We just got this news item yesterday: [READ AIRPORT PRESS RELEASE and show PIX] here are some copies of the international breastfeeding symbol. More are available on our website as well and guidelines for how to use the symbol to promote breastfeeding will be up there soon.

So, we've all been doing a lot to promote breastfeeding and we've come a long way. But, the perils are still great. As you know, even as our breastfeeding initiation rates are going up, our rates of exclusive breastfeeding are not. They have been at 46% for the last five years. And, we have more to do to get mothers breastfeeding past the first two months.

But what do these numbers mean? In both cases, they reflect the need for more education on the nature of breastfeeding and the integrity of breastmilk. While many in the US appreciate the benefits of breastfeeding, few actually understand how breastfeeding works. This is an issue in the breastfeeding in public debate where opponents think a mom can just wait until she gets home to nurse.

In addition, nowadays the working mother model of breatfeeding has become the norm. We're still modeling a bottle-feeding culture. Dad wants to feed the baby and mom doesn't see anything wrong with giving the baby a bottle once and awhile when she wants to get away. Few understand the realities of supply and demand or the significance of the sterile gut.

But, here in New Mexico we have something to be proud of. We have a success story. In a state where we score low in many other markers, in maternity care we are doing an exemplary job. At a time when the national average for cesarean deliveries is nearly 30%, New Mexico is one of two states with the lowest rate in the US, 19%. Thirty percent of our babies in New Mexico are delivered by midwives, nearly 4 times the national average. In fact, our maternity care in New Mexico more closely resembles the Netherlands than it does any other state in the country. In New Mexico we're doing a better job than the US as a whole.

And, New Mexico particularly excels in breastfeeding success. As a rural state with one person to every 17 miles, and a strong Hispanic heritage, we are already predisposed to breastfeeding. We have the good fortune of the outstanding New Mexico Breastfeeding Task Force, which has kept breastfeeding awareness in the forefront and worked hard for breastfeeding advocacy.

I've mentioned the Healthy People 2010 goals of HHS. New Mexico has already surpassed them in 2007.

2010 US NM

Initiation 75% 65% 82%

3 Months70%
6 Months50% 29%
1 Year 25% 16%

And, there's more good news. I know you have all heard the statistics that non-WIC participants out breastfeed their WIC counterparts. In fact, one study showed that non-WIC participants breastfeed at a rate 71% greater than WIC participants. In 2003, the national breastfeeding initiation rate for WIC participants was 54.9% up from 41.6% in 1993.

On Tuesday, Sharon Giles-Pullin told me that the NM Dept of Health PRAMS for 2005 show that the breastfeeding initiation rate for WIC participants at 73%. In clinics without peer counselors, it is 68% and in clinics with peer counselors it is 75%. This too exceeds the national average and already complies with the 2010 goals.

It's been a long road to the 2010 goals. When we first get involved in breastfeeding advocacy, we believe that because of the virtue of the issue, it will soon be universal. But, social change doesn't happen that way. Social change takes a long time. They say that social movements take 100 years. It took 100 years to get universal schooling, 100 years to get jails instead of lynching. The women's suffrage movement and the civil rights movement took 100 years and are not over yet. We may be only 50 years into the universal breastfeeding movement. We still have a long way to go.

Working for social change has many benefits. We have the satisfaction of enriched personal lives. We have a sense of purpose, pride and service. Social activism shows us how to confront daunting obstacles, experience new worlds and offers us a sense of camaraderie. Through activism, many of us have built powerful friendships over the years. There is no greater antidote to powerless than joining with others for a common cause.

Social activism involves a certain tolerance for mixed feelings, for doubts and for contradictory outcomes. As Paul Loeb says in Soul of a Citizen, "others may view us as heroic knights riding in to save the day, but we're more like knights on rickety tricycles, clutching our fears and hesitations as we go. Gandhi called his efforts, "experiments in truth" because successful results could only be discovered through trial and error. We take action despite our fears and less-than-perfect preparation.

So, in New Mexico with "less than perfect preparation" we have succeeded. You have succeeded. I hope that New Mexico can be a model for other states and I congratulate all of you and each of us who have come so far and done so much for so many.

Let's get to 90%!

References:

http://www.lalecheleague.org/LLLIhistory.html?m=1,0,0

http://www.kellymom.com/writings/bf-numbers.html#usa

Ross Products Division of Abbott Laboratories. "Breastfeeding Trends 2003."

Huffman, Sandra. "Formula Marketing: A Primary Healthcare Issue." Mothering 1991. No. 60: 81-85.

Coburn, Jennifer. "Formula for Profit: How Marketing Breastmilk Substitutes Undermines the Health of Babies." Mothering 2000. No. 101: 58-68.

Weimer, Douglas Reid. CRS Report for Congress. Summary of State Breastfeeding Laws and Related Issues. January 12, 2005.

Picraux, Danice. New Mexico House Bill 613. February 2, 2007.

American Academy of Pediatrics. Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics. Vol. 115 No. 2 February 2005, pp. 496-506.

US Department of Health and Human Services. Healthy People 2010: Conference Edition. Volumes I and II. Washington, DC. US Department of Health and Human Services, Office of the Assistant Secretary of Health, January 2000.

Phillipp, Barbara et al. "Physicians and Breastfeeding Promotion in the Unites States: A Call for Action. Pediatrics. Vol. 107 No. 3 March 2001, 584-587.

Huotari, Carol. "Breastfeeding Statistics." LLLI Center for Breastfeeding Information. September 15, 2003.

Barrington-Ward, The Right Reverend Simon. "Putting Babies Before Business." Mothering. 1998 No. 88, 64-71.

www.babyfriendlyusa.org

Lewis and Clark Research. Mothering Magazine Readership Study. August 2006.

O'Mara, Peggy. "Breastfeeding in Whose Public." Mothering. 2005. No.132. 10-14.

O'Mara, Peggy. "Becoming Breastfeeding Friendly. Mothering. 2006. 140. 10-14.

www.youtube.com/watch?v=kmgLgIUB2T4

Haynes, Suzanne G. National Breastfeeding Awareness Campaign Results. Office of Women's Health. US Department of Health and Human Services. 2005.

"Minneapolis-St. Paul International Airport Caters to Nursing Mothers." Business Wire. March 15, 2007.

http://www.mothering.com/sections/action_alerts/iconcontest/icon-winner.html

New Mexico WIC Program Breastfeeding Initiation Data. Oct 2006 to Dec 2006.

"New Mexico Selected Health Statistics Annual Report for 2003." New Mexico Department of Health, Bureau of Vital Records and Health Statistics. 2005

Wagner, Marsden. "Midwifery in the Industrialized World," Journal of the Society of Obstetricians and Gynaecologists of Canada 20. No. 13. November, 1998: 1225-1234, note 28.