José J. Gorrín, MD, MPH, FACOG Professor and Director Maternal and Child Health Program

1. Commentary to: Office Prenatal Formula Advertising and Its Effect on Breastfeeding Patterns (Howard C et al) José J. Gorrín, MD, MPH, FACOG Professor and Director Maternal and Child Health Program Graduate School of Public Health University of Puerto Rico

2. Variables studied: • Breastfeeding (BF) initiation • BF cessation prior to discharge • BF cessation < 2 weeks • BF > 2 weeks • Subgroup analyses • Mothers with uncertain goals • Mothers with goals 12 weeks or <

3. Results: • Not affected: • BF initiation and BF > 2 weeks • Negatively affected: • BF cessation prior to discharge (RR 5.80) • BF cessation < 2 weeks (OR 1.91) • Mothers with uncertain goals or goals < 12 weeks (Exclusive, full and overall)

4. Population studied: • White - not Hispanic - 92-95% • Private insurance - 97-99% • Cesarean - 17-24% • Married - 82-86% • Education - 13.9 - 14.1 years • Infant’s gestational age - 39.6 wks (SD 1.3 - 1.4 weeks) • Infant’s birth weight - 3510 - 3519 gms. (SD 487 - 545 gms)

5. Acknowledged limitations of the study • Lack of socioeconomic and racial diversity • Widely available BF education and support • Baby-friendly hospital environment • Results in more vulnerable populations may differ • Generalizability of results is limited

6. The artificial formula industry • Scientific evidence of the benefits of human milk and breastfeeding Raisler et al 1999; Lawrence, 1997; Anderson et al, 1999.

7. The artificial formula industry • The hazards of artificial feeding Walker, 1993; 1998

9. The artificial formula industry • Position of the medical profession with regards to breastfeeding vs artificial feeding Periodic Survey of Fellows, AAP; Howard et al, 1993, Howard et al, 1997

10. The artificial formula industry • Promotional efforts Bird, 1996; Valaitis et al, 1997; Howard et al 1997; Howard et al, 2000

13. Profit versus Public Health • The profit motive of the formula makers is in contradiction with public health

14. Profit versus Public Health • The net effect of the marketing practices of artificial formula manufacturers

15. Profit versus Public Health • Bribery efforts to health professionals Baumslag & Michaels, “ Milk, money and madness - the culture and politics of breastfeeding”, 1995; Margolis, 1991

16. The artificial formula industry • The utilization of health professionals Valaitis et al 1997; Greer & Apple, 1991; Baumslag , 1989

17. Health policy efforts for the protection of breastfeeding • WHO Code • IBFAN • WABA • BFHI • Public Policy for the Promotion of Breastfeeding - (PR)

18. International Code of Marketing of Breastmilk Substitutes

19. Objectives of the WHO Code “To provide breastfeeding infants with sufficient and secure nutrition by protecting and promoting breastfeeding and assuring the correct use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution methods.”

20. The WHO Code covers: • All breastmilk substitutes (formulas, including those for toddlers) • Baby-foods • Other milk-based products • Teas and juices • Bottles • Nipples and related equipment

21. WHO Code dispositions: • Prohibits publicity and promotion of these products to the general public • Prohibits the promotion of these products in health services installations • Prohibits the distribution of free samples to pregnant or breastfeeding mothers which could promote the use of breastmilk substitutes or bottle feeding

22. WHO Code dispositions: • Does not allow personnel provided or paid by formula manufacturers or distributors to offer orientation to mothers on infant feeding • Prohibits gifts or free samples of these products to health professionals • Prohibits the use of images or texts which could idealize the use of breastmilk substitutes, including baby pictures

23. WHO Code dispositions: • Information provided to health professionals on these products should be scientific and objective and will not imply or lead to believe that formula feeding is equivalent or superior to breastfeeding • Information on artificial feeding, including labels, should explain the advantages and superiority of breastmilk and the cost and hazards associated to artificial feeding

24. WHO Code dispositions: • Inappropriate products, such as condensed milk, should not be promoted for use in feeding of infants • All products should be of high quality and should take in consideration climate and storage conditions in each country

25. International Baby Food Action Network

26. The 7 principles guiding IBFAN: • The rightof boys and girls all overthe world to reach the highest possible level of health • The right of families, especially women and children, to sufficient and adequate nutrition

27. The 7 principles guiding IBFAN: • The rightof women to breastfeed and make informed decisionsregarding the feeding of their children • The right of women to receive total support in achieving successful breastfeedingand adequate infant nutrition

28. The 7 principles guiding IBFAN: • The universal right of access to health services capable of fulfilling basic necessities • The rightof health services personnel and consumers to access health services systems freeof commercial pressures

29. The 7 principles guiding IBFAN: • The rightof persons to organize in international solidarityin order to achieve the necessary changes to protect and promote basic health

30. World Alliance for Breastfeeding Action WABA 1991

31. Baby-Friendly Hospital Initiative (BFHI) 1991

32. 1. Breastfeeding policy 2. Capacitation of personnel 3. Education of women on benefits of breastfeeding 4. Initiate breastfeeding within 30 minutes after delivery 5. Assist mothers in initiating breastfeeding even if separated from their babies 6. Provide no other oral intake 7. 24 hour rooming-in 8. Encourage breastfeeding on demand 9. No artificial nipples or pacifiers 10.Encourage the creation of support groups The 10 steps for successful breastfeeding

33. Public Policy for the Promotion of Breastfeeding in Puerto Rico 1995

34. The industry of breastfeeding equipment Amin, 1996; Parrilla, 1999; Wilson-Clay, 1994; Van Esterik, 1996; Nommsen-Rivers, 1999

35. Guilt vs informed decisions • Fear of health professionals of informing about the risks of artificial feeding • Instruments to undermine self-esteem among mothers • Fear of not being able to offer effective assistance

36. Guilt vs informed decisions • Decisions based on complete and correct information should not produce guilt feelings

37. Recommendations • Health professionals should refuse to accept any and all monetary support from formula companies

38. Recommendations • Health professionals must develop a clear understanding of the ethical aspects of the work we do, of our image in society and, above all, of the implications for public health

39. Recommendations • Health professionals must fully understand the enormous importance for society of returning to breastfeeding as the cultural norm for child nutrition and rearing

40. Parrilla Rodríguez, A.M. & Gorrín Peralta, J.J. (2000). Aspectos Éticos en la Promoción de la Lactancia Humana y el Amamantamiento. Puerto Rico Health Sciences Journal, 19, 145-51.