Michael C. Latham*
July 21, 1998

Breastfeeding is acknowledged to be the optimal way both of feeding and caring for young infants (Baumslag, 1995). Human breastmilk provides the ideal food for the human infant. "Cow’s milk is best for baby cows, human milk is best for babies" is an oft quoted axiom.

There is no alternative. That it should be necessary to argue about the advantages of breastfeeding over other methods of infant feeding is wrong or even ludicrous. Do we argue in favor of breathing fresh air rather than oxygen from a respirator? In fact, to state that breastfeeding is "best" is to suggest that there are good alternatives. There are not. So rather we should state that other methods of feeding should be rare, and used only in extreme circumstances. We should not be lauding the advantage of breastfeeding any more than we praise the practice of breathing air. Rather we should be articulating clearly the harm and disadvantages of any alternative. We should not be stating that breastfed babies are healthier and have better psychological development than bottle fed babies. Rather we should be saying that formula fed babies have more disease and lower intelligence than normal babies. And also that mothers who do not breastfeed their infants have higher risks of certain cancers.

Breastmilk contains the right mixture of protein, carbohydrate, fat, vitamins, and minerals to provide ideal nutrition for the baby (Jelliffe and Jelliffe, 1989), and alone, without any supplementation (not even water), provides the ideal complete diet for the first six months of life. Then, after other foods are introduced, it will continue for another year, or more, to supply important nutrients. But besides its value as a nutritious food, it is also a "living fluid" with live cells, and it provides anti-infectious constituents such as antibodies, lysozyme, lactoferrin, macrophages, leukocytes and lymphocytes, and also others not normally considered of dietary importance but of great importance to the health of the infant (Lawrence, 1994). It may also contain nutrients yet to be discovered or chemically isolated.

Breastfeeding, which is the art of feeding a baby from the breast, is a unique form of infant care which has been shown to be very important for infant development, including mental development (Latham, 1995). Breastfeeding also provides benefits to the mother. These include clearly established health and psychological benefits, and also often social and economic benefits. Most breastfeeding mothers also state that it is enjoyable, some claiming that it is highly pleasurable.

For these reasons, the right of mothers to breastfeed their infants deserves to be accepted as a human right. Article 12 of the International Covenant on Economic, Social, and Cultural Rights clearly describes "the right to health," which is defined as "the enjoyment of the highest attainable standard of physical and mental health." It continues by listing steps to be taken by the states parties to the covenant to realize this right to health. The 1978 WHO/UNICEF conference on primary health care held at Alma Ata resulted in the Declaration of Alma Ata which states that health is a human right, and it defines health as "complete physical, mental, and social well-being, and not mainly the absence of disease or infirmity."

A WHO/UNICEF meeting held at the Spedale Degli Innocenti in Florence in 1990 issued the Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding. It recognizes that maternal milk provides an ideal nourishment without equal for the infant that it contributes to the health of the mother and infant, and has many other social, health and psychological advantages. It calls for world action to protect, promote and support breastfeeding.

The World Declaration and Plan of Action for Nutrition unanimously adopted by some 159 nations attending the FAO/WHO International Conference on Nutrition in Rome in 1992 in its first paragraph states:

We, the Ministers and the Plenipotentiaries representing 159 states and the European Economic Community at the International Conference on Nutrition (Rome, December 1992), declare our determination to eliminate hunger and to reduce all forms of malnutrition. Hunger and malnutrition are unacceptable in a world that has both the knowledge and the resources to end this human catastrophe. We recognize that access to nutritionally adequate and safe food is a right of each individual. We recognize that globally there is enough food for all and that inequitable access is the main problem. Bearing in mind the right to an adequate standard of living, including food, contained in the Universal Declaration of Human Rights, we pledge to act in solidarity to ensure that freedom from hunger becomes a reality. We also declare our firm commitment to work together to ensure sustained nutritional well-being for all people in a peaceful, just, and environmentally safe world. Surely, then, because for infants there is no other perfectly suitable food except breastmilk, because there are other health advantages for the infant resulting from breastfeeding, then infants who are not breastfed because of obstacles to breastfeeding have suffered unnecessarily. Because there are health and other disadvantages to the mother resulting from not breastfeeding, then obstacles to breastfeeding are also obstacles to the mother’s and infant’s human rights. All infants should where possible enjoy the right to be exclusively breastfed for the first six months of life, and to be breastfed into the second or third year after other foods are introduced. All mothers deserve the right to breastfeed their babies for the length of time that they want, and this is considered desirable for both her, and her baby.
The right to food and a particular diet

The World Food Conference held in Rome in 1979 in its final document (FAO/WHO 1992) addresses many world food issues. Among others, it proclaimed that "no child will go to bed hungry, that no family will fear for its next day’s bread, and that no human being’s future and capacities will be stunted by malnutrition."

The Universal Declaration of Human Rights of 1948 is generally regarded as the basic contemporary outline of human rights. That Declaration and the International Covenant on Economic, Social, and Cultural Rights, which came into force in 1976, are the basis for establishing the human "right to food." The Declaration states that "everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food." The Covenant recognizes "the fundamental right of everyone to be free from hunger."

These two documents, affirming that all humans everywhere have the right to adequate food, have been accepted by most nations. We know that inadequate intakes of food lead to malnutrition, a form of disease or ill health, and therefore infringes humans "rights to health." Added to these earlier international instruments, the Convention on the Elimination of all Forms of Discrimination Against Women, which came into force in 1979, and the Convention on the Rights of the Child, which came into force in 1990, also have relevance to food rights, and therefore to breastfeeding.

The newly established World Alliance for Nutrition and Human Rights (WANAHR) at its first meeting held in the Norwegian Institute of Human Rights in 1993 addressed the broader rights, not only to food but to good nutrition. It included among its terms of reference one which deals with breastfeeding. It states:

Believing that obstacles to breastfeeding often serve as a human being’s first hindrance to adequate nutrition, food , and care, the alliance pledges itself to further the principles of Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding (WHO/UNICEF 1990). That Declaration, described earlier, is an important milestone, because it indicates the total support of both WHO and UNICEF for breastfeeding.

Because as stated above, there is no other perfectly suitable food except breastmilk, and there are serious disadvantages of not breastfeeding for the infant and the mother, then it follows that mothers not breastfeeding because of obstacles have suffered the loss of a right. The Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights state that humans have a right to food, or adequate food, but do not describe what food. Other documents mention rights to good nutrition and rights to health.

There is one group of human beings, infants (over 250 million in the world in 1996), who are at risk of malnutrition or ill health if they do not consume one particular food. No other food except breastmilk ensures their good nutritional and health status. That food can only come from female human breasts. Even its storage diminishes some of its anti-infective properties. It is widely agreed that this food is best fed directly to the infant from the breast. It surely follows that the right to food, the right to health, and the right to good nutrition should be interpreted for infants as a right where possible to breastmilk, or even to being breastfed.

In their first few months of life, infants cannot satisfactorily be fed rice, wheat or maize, balanced with legumes, fruits and vegetables, as can adults. So, if infants are to enjoy the right to adequate food and nutrition, they have a right to food different from adults or older children.

The strange challenge to the right to breastfeeding

That the right to breastfeed is even being discussed or challenged, is strange, and even aberrant. It is a challenge to nature, to natural law and natural practice, and to our ecology and environment. Breastfeeding is a natural or God-given (however we may regard nature or god) act. All mammals nearly always feed their young in this way, unless humans prevent them from doing so. All mammalian mothers enjoy this natural practice. All mammals, humans and animals, have the organs and the hormones, the anatomy and physiology, to allow them to nurture their young in this way.

That huge numbers of human infants do not get breastfed, and that mothers are influenced not to breastfeed their newborn babies is a distortion of nature. Do not human beings have a right to walk and to run; to laugh and to cry; to breathe the fresh air; and to do a thousand other things using the organs, and body parts, the anatomy and physiology that nature bestowed on them?

Females are endowed with breasts, organs designed to produce colostrum and then milk after the birth of a baby, and in a form to allow the infant to feed directly from the mother. Breastfeeding in the United States in the 1970s declined so far that fewer than 20 percent of babies were being breastfed, even if only for a few days following birth, and fewer than 10 per cent were being breastfed at 3 months of age (Lawrence, 1994). In many northern, industrialized countries, very similar declines occurred.

That breastfeeding in some countries became a minority, not a majority way of infant feeding, is aberrant. It is perhaps as strange as if in the year 2020 the majority of Americans ate no food, but were fed a nutritious diet parenterally (through tubes). Adults then could attend day long meetings without interruptions for feeding. Is this more ridiculous, or aberrant, than the fact that the majority of babies are never breastfed in many communities and some countries? Would we not be outraged if it became well known that a relatively cheap, widely available medicine was being withheld from millions of human beings who could benefit from this? Would we not seek early, urgent action if we understood that not using this product greatly increased premature deaths (probably at least a million preventable deaths annually); resulted in much higher incidence of infections, other illnesses and malnutrition; caused more allergies; added substantially to the risk of certain common cancers; contributed substantially to unwanted pregnancies; was a factor in impoverishing many poor families; and had an adverse impact on the environment in most countries? Increasing the prevalence and duration of breastfeeding would provide all these benefits. Breastmilk is not a medicine, but breastfeeding can prevent all these problems. Yet breastfeeding is being withheld from millions of infants. It surely is a moral imperative that the world community take action. A general acceptance of breastfeeding as a human right could spur such action.

Inferiority and disadvantages of bottle-feeding

The many disadvantages of bottle feeding have been well researched and widely documented. In summary, they include:

    1. Unlike bottle-feeding, breastfeeding is convenient, the food is readily available for the infant, and no special preparations or equipment are needed.
    2. Breastmilk provides a proper balance and quantity of nutrients ideal for the human infant, whereas breastmilk substitutes do not.
    3. Both colostrum and breastmilk have anti-infective constituents that help limit infections; they are not present in substitutes.
    4. Bottle-feeding enhances the risk of infections from contamination with pathogenic organisms in the milk, the formula, the water used in preparation, and the bottles, teats, and other items used for infant feeding.
    5. Bottle-feeding has major economic disadvantages including the cost of purchasing infant formula or cows’ milk, the bottles and teats, and the fuel necessary for sterilization.
    6. Bottle-feeding may contribute to large family size whereas breastfeeding prolongs duration of postpartum anovulation, helping mothers to space their children;
    7. Artificial feeding results in poorer bonding between mother and infant when compared with breastfeeding.
    8. Formula fed babies have a higher risk of allergies, obesity, and other health problems compared with breastfed infants.
    9. Women who breastfeed their babies have reduced risks of breast and uterine cancer.
Obstacles to breastfeeding infringing infant’s rights

If women have a right to breastfeed their infants, then any obstacles or infringement to breastfeeding constitute an infringement of this right. Eliminating the many obstacles to breastfeeding or lessening their adverse impact on breastfeeding are all actions which enhance the enjoyment of the rights of mothers to breastfeed their babies.

In northern countries, in industrialized societies and among affluent families in most nations, the main alternative to breastfeeding is the use of what is termed infant formula, often made mainly from cow’s milk. In some societies cows’ or other animals’ milk is used directly or as other products such as condensed milk. The most commonly used method of "delivering" these fluids to infants is a feeding or other bottle. The manufactured formulas often called "breastmilk substitutes" often claim to be "humanized", but are not identical to human milk. Feeding using the bottle is very different from suckling from the breast.

In all countries, there are many babies who could be breastfed but are not. The reasons for this and the obstacles to breastfeeding are numerous. Some are common to all countries, others are more specific, and the relative importance of each obstacle varies from country to country, culture to culture, and from community to community.

Four obstacles are discussed in more detail below because they are important and because actions, albeit insufficient, to reduce the impact of these obstacles are underway. These four are:

    1. The medicalization of infant feeding, the negative impact of the medical profession on breastfeeding, and the lack of adequate support for breastfeeding in hospitals or other health facilities.
    2. The promotion and other marketing practices of manufacturers of breastmilk substitutes.
    3. Failure to assist mothers to breastfeed and to work.
    4. Lack of community support for mothers to initiate, sustain, and maintain breastfeeding.
There are of course many other obstacles to breastfeeding. In many developing countries, the decline has almost come to be regarded as part of modernization and industrialization. In fact it is a feature of "westernization" not unrelated to bad old "colonialism" and to more modern "neo colonialism." It comes to be regarded as modern or chic to bottle feed, and old-fashioned and "primitive" to breastfeed. Bottle feeding becomes a status symbol.

In the West we have developed a sort of breast culture, a mammary gland fixation. In our male-dominated society the female breast has become the dominant sex symbol accentuated in books, by the media, and in women’s clothes. Plastic surgeons earn large sums making small breasts large and large breasts small. Yet in many countries women still expose their breasts in public under quite normal circumstances, not in cocktail bars and on theater stages. Certainly it is accepted that infants be breastfed in public places. This practice is returning in some industrialized countries.

Western feminists have often opposed breastfeeding, on the false basis that it lessens women’s freedom and is "unliberating." More recently, van Esterik (1989) and the World Alliance for Breastfeeding Action (1992) have described breastfeeding as a feminist issue, and in fact empowering for women. The arguments are that breastfeeding:

    1. Requires changes in society to improve the position and condition of women.
    2. Confirms a woman’s power to control her own body and challenges both the male-dominated medical model and also business interests that promote formula feeding.
    3. Challenges the media model of women as consumers.
    4. Opposes the wide promulgation of breasts mainly as sex objects.
    5. Requires a greatly improved integration of women’s productive and reproductive activities.
    6. Encourages cooperation and solidarity among women at all levels—household, community, national, and international level.
In all this, breastfeeding becomes a part of women’s rights. Major improvements in women’s status—social, educational, economic,—are essential in order fully to support breastfeeding. It follows that any obstacles to a mother’s right to breastfeed is a violation of women’s human rights. Breastfeeding, and a woman’s right to breastfeed, then becomes a part of her reproductive rights and it is related to her sexuality. This then raises sensitive, often emotional issues, which although relevant to breastfeeding, are more in the arena of women’s rights and female liberation. Although not a declaration of rights, the 1995 Beijing World Conference on Women issued a consensus statement that women "have the right to determine the course of their reproductive lives and health."
The medicalization of infant feeding and hospitals
which are not supportive of breastfeeding.

Chimpanzees successfully suckle their infants without medical advice, they "room in" with their babies, and "bonding" appears to be important in the young chimpanzees’ development (Goodall, 1996). Kung Bushwomen in the Kalahari of Botswana breastfeed their babies for three or more years, and they sleep with the child without having had hospital instructions regarding infant feeding.

Gradually, over many years, the medical profession has increasingly taken upon itself the role of arbiters on infant feeding. This happened first in the western industrialized countries, and then increasingly in the developing nations. Doctors, nurses, and other health workers now play an important role in influencing mothers about their child feeding choices and also setting national and international policy and "norms" on infant feeding. These professionals stake a claim to this role only because they know what is best for human health. van Esterik (1989) has defined the medicalization of infant feeding as the "expropriation by health professionals of the power of mothers and other caretakers to determine the best feeding pattern of infants for maintaining maximum health." So what was previously and naturally, largely the concern of mothers, has increasingly become "part of the medical domain." As Illich (1976), and others, view these issues the medical community creates a market for its services by expropriating certain practices, behaviors, or events as "diseases." So overweight, homosexuality, anxiety, poor attention span, addiction, even pregnancy, and others have become prevalent "diseases" which require medical solutions. The market is established, and "treatment" of the new disease becomes very lucrative for the profession.

"Infant feeding" has not received the "disease" label, but any minor problems with it have, and some have become syndromes. The health profession (mainly men) has moved in to control, and direct, actions in an area of life previously controlled and directed by women—mothers, grandmothers, traditional midwives, and others. Medicalization of infant feeding, also results in actions that are "curative" rather than "preventive." Doctors, and some other health professionals entering the arena prefer to deal with each individual mother or baby on a one on one consultative basis, rather than have these issues dealt with in a community setting and in groups, taking account of social, cultural, and economic issues. Medical and nursing schools do not teach much about normal breastfeeding, but concentrate on formula feeding and on breastfeeding problems that then become diseases to treat.

The natural normal act of breastfeeding becomes part of the biomedical model and words like lactation are used for breastfeeding; mammary glands for breasts; insufficient milk syndrome for breastfeeding difficulties; and so on.

This medicalization of infant feeding played a major role in the decline in breastfeeding in the USA; in other western countries; and to a varying degree in non-industrialized countries. By 1969 in the USA the percentage of infants breastfeeding on leaving hospital had fallen to about 18 percent. So 82 percent of U.S. babies were never breastfed, not even for one day. In the 1960s practically no U.S. hospitals had rooming in, and babies spent the days following delivery in nurseries, separate from their mothers. Standard hospital practice was to give water, glucose water, or other fluids to newborn babies even though this is not needed and is contraindicated.

Many maternity units routinely formula fed all infants whether or not the mother wished to breastfeed. Many of these baby unfriendly practices, all known to be obstacles to breastfeeding, are still common in hospitals in North America, some European countries, and also in parts of Asia, Africa, and Latin America. Yet for many years WHO, UNICEF, and almost all national pediatric associations have agreed that "exclusive breastfeeding for the first 4-6 months is ideal, that babies should be put to the breast immediately after birth and room-in with their mothers in hospital, and that no water or other fluids need to be fed to infants for the first 4-6 months of life." More recently UNICEF and others have begun to recommend that infants should be exclusively breastfed if possible for 6 months. Yet hospitals all over the world have agreements with infant formula manufacturers. In exchange for free supplies, they give formula packs and corporation literature to all women delivering in hospital. All of these practices are obstacles to breastfeeding.

There is very clear evidence that health professionals and hospitals have had a major negative impact on breastfeeding worldwide (Latham 1991). So doctors and medical facilities have been responsible for placing serious obstacles in the way of optimum infant feeding and thus have prevented many babies from enjoying their right to breastfeed. Too often the medical profession has been, and still is, more formula industry friendly than baby friendly. The harmful partnership of physicians with industry has resulted in a synergism, which has been extremely harmful to the health, the nutritional status, and even the survival of infants all over the world. This is a serious violation of human rights which for years was largely ignored, and has always gone unpunished.

Happily, there have been some changes. More babies in some countries are enjoying their rights, while elsewhere the decline in infants being breastfed, or optimally breastfed, continues. A study in 1989 showed that 34 percent of WIC (Women's, Infants, and Children Program in the U.S.) and 63 percent of non-WIC infants were breastfed in the days immediately following delivery, but by 5-6 months of age fewer than 10 percent of WIC babies were still breastfed (Lawrence 1994). Better progress has been made in Western Europe, particularly in Scandinavian countries.

The attitude and practices of health professionals with regard to breastfeeding has improved over the last two decades. However, there is still much ignorance, and as a result the medical and health profession often has a negative impact on breastfeeding. The first need then is to educate all future health workers about breastfeeding and to re-educate existing professionals. In some countries, major efforts are underway, using seminars and refresher courses to educate existing health workers about sound infant feeding practices.

Steps should be taken to ensure that in all health institutions the infant is put to the breast as soon as possible after birth, preferably within the first half hour. The advantages include beneficial effects on the mother’s uterus, promotion of mother-infant bonding, supply of immune substances to the newborn, and a positive influence on subsequent successful breastfeeding. In many communities in Africa, Asia, and Latin American very early breastfeeding is discouraged, and in many cultures the colostrum is discarded because it is not considered to be good for the baby. This is one of the few instances where traditional practices related to breastfeeding are not ideal. Efforts should be made to influence mothers about the benefits of early feeding and of colostrum fed to their infants.

The importance of rooming-in, which allows women after delivery in hospital to remain with their infants, is now accepted but not practiced everywhere. No hospitals should remain where rooming-in is not the norm. Health professionals need to guard against influence on them by formula manufacturers, and should avoid becoming obligated to the corporations by accepting favors, donations, or even research grants from them. If the multinational corporations wish to support research or projects dealing with infant feeding they should not provide grants directly to scientists, involved in research on infant or young child health or nutrition. All of those practices which even in a small way reduce the incidence, prevalence, and duration of breastfeeding are obstacles which then can be viewed as an infringement on the right of mothers to breastfeed their infants.

The baby-friendly hospital initiative (BFHI)

In March 1992, UNICEF and WHO launched a new initiative to help protect, support, and promote breastfeeding by addressing problems in hospitals. These included hospital practices that were not supportive of breastfeeding, for example separation of the mother from her infant, and others that directly influenced mothers to formula-feed; for example, free formula packs given to mothers. This new activity has been termed the Baby-Friendly Hospital Initiative (BFHI). It is designed to make hospitals help mothers and babies achieve their rights to breastfeeding and it recognizes that hospitals and health professionals have often not fostered breastfeeding. It addresses the prevalent problems of hospitals being a major source of misinformation about breastfeeding, and practices in hospitals and approved by physicians and others which undermine breastfeeding (UNICEF 1992).

The two major objectives of the BFHI as enunciated in 1992 were then (a) to end the distribution of free or low-cost supplies of breastmilk substitutes, and (b) to ensure hospital practices supportive of breastfeeding. The first goal should have been relatively easy to achieve. UNICEF believed that the major infant formula manufacturers had agreed to end free distribution of their formula in all hospitals. As in the past, agreements apparently reached with those corporations are not adhered to, or exceptions are sought. Profits are paramount, and the health of babies takes second place. So, in fact, the second goal of improving hospital practices has made more progress in many countries than has the first goal.

The practices that hospitals are expected to undertake in order to be considered baby-friendly have been termed the "ten steps to successful breastfeeding." The relevance of the BFHI for countries and communities where most babies are born outside the hospital setting has been questioned. Certainly it may be less important there. But the BFHI if successful removes misinformation about infant feeding from one of its most important sources, namely the hospitals, which are also the trend-setters and the places where health professionals are trained. If hospitals become places which promote rather than deter breastfeeding, this can have an influence beyond the hospital.

The BFHI is a very encouraging and positive development. It is hoped that as it spreads, more and more hospitals all over the world will indeed be baby friendly and mother friendly as well. But in some ways if BFHI becomes the major national or international activity in favor of breastfeeding, this will in fact be legitimizing the medicalization of infant feeding. The initiative can be seen as "fixing" a system, rather than protecting or returning to a situation where societies and communities, family members, and friends, and various local support groups are the main players supporting and protecting breastfeeding. This is a preferable situation, rather than having the medical profession being the major player on the scene either in terms of advising individual mothers or in determining national or community policy. Some would claim that the BFHI is empowering mothers and babies to be the major players, and should have a community emphasis.

Others have a fundamental misunderstanding of the baby-friendly hospital initiative (BFHI). It is a rights approach. It should give the mother control over her child through rooming in from birth, through making all infant feeding decisions, and through ensuring that she will have a free choice of what to feed her baby. This implies that there will be no free supplies of a single brand of formula. It gives her complete, unbiased, and useful information which frees her from dependence on commercial advice.

The promotion and other marketing practices of
manufactured breastmilk substitutes

A major contributing cause of the decline in breastfeeding worldwide has been and remains the promotion and marketing of manufactured breastmilk substitutes. This is a very profitable business, but profits have been put ahead of human well-being including the health and even survival of babies. The promotion of formula and its adverse results are similar to the promotion and marketing of cigarettes.

In the 1950s and 1960s a small group of physicians, pediatricians, and nutritionists working in developing countries were drawing attention to the dangers of bottle feeding and decrying the role of industry in the decline of breastfeeding (Latham, 1964). During that time, advertising of breastmilk substitutes was widely used in newspapers and magazines, and on radio and later on television. The corporations were using "milk nurses" to push their products in health facilities; free samples and glossy literature on their products were provided to mothers soon after delivery; and a number of other hard-sell tactics were being used. The success of these unethical marketing practices can be measured in the many millions of babies worldwide not being breastfed and in huge corporate profits. Unfortunately it can also be measured in hundreds of thousands of infant deaths attributable to bottle feeding.

Public outrage in the 1970s began to develop over these tactics, and an increased understanding developed over the very harmful effects of bottle feeding in developing countries. Most doctors and health workers both in the North and in countries of the South were at best unsupportive of the growing public pressure to rein in the promotional activities of the corporations, and at worst doctors sided with the manufacturers against the critics of the corporations.

In 1979, unable to resist the pressure, WHO and UNICEF organized a meeting in Geneva at which a handful of experts met with representatives of industry, of non-government organizations (NGOs), and of delegates from selected countries, to discuss possible regulations to control the promotion of breastmilk substitutes. This meeting probably would not have taken place had it not been for the tireless efforts of certain NGOs and their enthusiastic staffs. At the 1979 Geneva conference, despite rearguard actions by the major manufacturers, a decision was made to develop a Code of Conduct and some of the main principles of a Code were agreed upon. Several meetings followed to develop wording for the Code. On 21 May 1981, the World Health Assembly overwhelmingly adopted the International Code of Marketing of Breastmilk Substitutes (WHO, 1981). Only one country, the United States, voted against the Code. The Code applies to the marketing of breastmilk substitutes, and its most important article stated that "there should be no advertising or other form of promotion to the general public of breastmilk substitutes and other items mentioned in the Code." Other details dealt with provision of samples at sales points; contact between marketing personnel and mothers; the use of health facilities for the promotion of infant formula; and the labeling and quality of products.

Many formula manufacturers violate the Code. They interpret the different provisions to suit their marketing strategies so as to maximize sales and profits, and they have little conscience about ignoring the spirit of this Code that they participated in developing.

The Code is not binding on signatory states, but it suggests that governments should take action to give effect to the principles and aims of the Code. In practice, the Code (coupled with actions such as the Nestlé boycott) has resulted in almost complete cessation of blatant advertising of breastmilk substitutes to the public by large manufacturers. That is not to suggest that some more subtle advertising is not done. Manufacturers spend millions of dollars annually promoting infant formula. Many countries have introduced legislation based on the international Code. The use of samples has declined but has not been halted. Many Ministries of Health are now more supportive of breastfeeding than in the past. But it is often forgotten that the Code was a compromise agreement, that it was the very minimum needed to address a small part of a large problem, that all codes have loopholes, and that industry has worked hard to circumvent the Code. A few countries have introduced legislation which is more stringent than the Code. For example, Papua-New Guinea passed a law which made infant feeding bottles available only on prescription. It is believed that the major manufacturers are still spending very large sums to promote infant formula. Although aggressive advertising to the public has almost ceased, corporations are continuing to advertise to health professionals. The corporations have worked in many countries to weaken or prevent the Code from becoming law; and they are increasingly advertising to the public the use of their manufactured weaning foods for consumption by very young babies.

Free formula is still provided by many manufacturers to hospitals in many countries. In exchange, the hospitals hand out free formula together with company literature to mothers after delivery of the baby as they leave the hospital (Latham, 1996). This gives the mother the impression of medical endorsement of formula feeding. Corporations try to purchase support from pediatricians, senior health officials, and others by giving funds for travel, for society meetings, for research and for other purposes. All of this is promotion.

The World Health Assembly (WHA) adoption of the Code and subsequent WHA resolutions very supportive of breastfeeding have led to some complacency and to a false belief that the problem has been solved. Those who worked for the Code knew that it could at best solve only a part of the problem, yet support for actions to deal with other important causes of breastfeeding decline is now more difficult to obtain. There is currently a need to strengthen and broaden the Code by making it applicable to manufactured weaning foods as well as breastmilk substitutes, and to prevent advertising to health professionals as well as to the general public. More support is needed for NGOs involved in the monitoring the Code and for their work to protect, support, and promote breastfeeding. All such actions help mothers enjoy their rights to breastfeed.

Failure to assist mothers to breastfeed and work

In most countries north and south, mothers have to make difficult decisions in an attempt to fulfill their responsibilities both to provide proper childcare and to their work. Mothers have productive and reproductive responsibilities. All mothers work, and therefore their breastfeeding as part of optimal childcare impinges on their work. Often the challenge is greater for those who have paid employment away from home.

Some countries have made it easier for working women to breastfeed. Many employers facilitate breastfeeding by working women. But these are exceptions, and yet they should be the rule. The Declaration from the FAO/WHO International Conference on Nutrition held in 1992 acknowledges the "right of infants and mothers to exclusive breastfeeding" and the final report states that governments and others should:

Support and encourage mothers to breastfeed and adequately care for their children, whether formally or informally employed or doing unpaid work. ILO conventions and regulations covering this subject may be used as a starting point. The ILO Convention recognizes the rights of women to maternity leave and to breastfeed their infants.

In many countries serious obstacles are placed in the way of mothers’ rights to breastfeed. The world should move to adopt the view that hindering a woman’s right to breastfeed is intolerable. Among the common obstacles are very short maternity leaves, or no maternity leaves for casual employees; loss of jobs for those who do take maternity leave; a lack of child care facilities which should be available in places where large numbers of women are employed; a failure to provide breastfeeding breaks for women who could breastfeed during long work shifts; and open targeting of working women by formula companies to persuade them to formula-feed rather than breastfeed their infants.

What can be done? In the first place, governments and the general public should ensure that at a very minimum the terms of the ILO Convention are adhered to, and never infringed. Those include 12 weeks of maternity leave with cash benefits of at least 66 percent of previous earnings; two 30-minute breastfeeding breaks during each working day; and prohibition of dismissal during maternity leave. Other actions that can be taken include:

For the individual mother who in the weeks after delivery needs to return to a work place away from home, it is important to maintain breastfeeding, and if possible for the infant to receive only breastmilk for the first 4 to 6 months of life. Many mothers in the days before returning to work learn how to express breastmilk, to store it, and to teach the caregiver how to feed it to the baby from a cup while the mother is away. The mother then breastfeeds her baby normally during the 16 hours in the day when she is not away at the workplace. She may breastfeed more at night and in the early morning than do other mothers. In some societies, support groups are formed for child care, cooperative strategies are developed for working women, and occasionally women agree to breastfeed babies other than their own, while the infant’s mother is away.

For many working women in many countries, however, there are obstacles to breastfeeding, especially when they have paid employment away from home. These obstacles are infringements of mothers’ rights to breastfeed. So in the same way that actions are being taken to make hospitals baby friendly and supportive of breastfeeding, it is also important for all societies to make their workplaces more baby friendly and more supportive of breastfeeding. Any successful actions in this direction are assisting women in their right to breastfeed and babies likelihood of being breastfed.

Lack of community support for breastfeeding

Each mother should be allowed to exercise her own choice about how to feed her infant. Few people live in isolation, and the community in which a mother lives is likely to influence choices and the practices of infant feeding. The community usually includes the family, others living in the household and neighborhood, people at the mother’s place of work, friends in town or living nearby, and so on.

Community support can help mothers to initiate, to sustain and to maintain breastfeeding, and lack of community support can be an obstacle to satisfactory breastfeeding. Mothers who get much support from those in their community to initiate and sustain breastfeeding are overall more likely to be more successful in breastfeeding.

Some communities which themselves are not very supportive of breastfeeding may have a breastfeeding support group which can be helpful. In the U.S., there are thousands of local La Leche League groups which play this role in a whole society that in general for decades has not been very supportive of breastfeeding, and that in the 1960s seemed to oppose it.

A community which becomes supportive of breastfeeding can change a non-breastfeeding culture into a breastfeeding culture. As more mothers exclusively breastfeed for 6 months, and plan to continue breastfeeding into and beyond the second year, and have positive attitudes, and experiences with breastfeeding, the community itself changes and becomes increasingly baby friendly.

But all too often there are community obstacles to breastfeeding - for example many community women may question the decision of the new mother to breastfeed (and may even be prejudiced against it); many may talk to each other about the disadvantages and potential problems; the community may not approve of breastfeeding in public; the local hospitals and clinics and health facilities may not be supportive, and may not adopt ethical practices related to the promotion of infant formula in their institutions; the work place may make breastfeeding difficult; and there may be no support groups. These and other obstacles to breastfeeding are infringements on the right of mothers to breastfeed.

To promote breastfeeding worldwide, the World Alliance for Breastfeeding Action (WABA) organizes a World Breastfeeding Week for the first week of each August. In 1996 the theme was "Breastfeeding: A Community Responsibility". In 1997 the theme is "Breastfeeding: Nature’s Way", emphasizing the natural, environmentally safe character of breastfeeding. In 1998 the theme for World Breastfeeding Week will be "Breastfeeding and Economics".

The brochure used for World Breastfeeding Week suggests many actions that can be taken by different groups to help communities become more baby friendly and more supportive of breastfeeding. For example . . .

    1. Schools- where children should learn about breastfeeding, where children who are future mothers and fathers can become supportive of breastfeeding early in life, and where sound information on child health, child care , and child nutrition should be taught.
    2. Media- the media including the press, radio, TV, and computer networks should be avenues for support of breastfeeding and should not be used to promote breastmilk substitutes.
    3. Health facilities- as described earlier in this paper, hospitals need to be baby-friendly and health workers need to be supportive of breastfeeding.
    4. Public places including restaurants, business premises and others- these all need to make it easy for women to breastfeed; there must not be obstacles for mothers who wish to breastfeed in public, and there must be an atmosphere which makes mothers feel comfortable breastfeeding in places of work, and in shops, restaurants, and on public transport and elsewhere.
    5. Work places- mothers who work away from home, as described above, need to be facilitated to breastfeed. Work places need to be baby and mother friendly.
    6. Churches and other religious institutions- for many people, religion has important influences on the lives of families. It is helpful if breastfeeding is well understood and supported by religious leaders, is facilitated and encouraged for mothers attending services or other activities, and is approved of as a family planning measure.
    7. Government- national, provincial, district, and local government institutions and policies can either help or hinder breastfeeding in the community. It is important that there be a good national breastfeeding policy; that regulations similar to, or more stringent than, the WHO Code prevent any promotion of breastmilk substitutes; and that government institutions at all levels vigorously support the Innocenti Declaration.
In many developing countries, especially in rural areas where there is still a breastfeeding culture, there is a need in communities to protect mothers from forces which may influence them not to breastfeed or which in some way may undermine breastfeeding. In other communities, the prevalence and duration of breastfeeding has declined and obstacles to successful breastfeeding exist. In these communities, breastfeeding support groups can be very helpful, and now exist in many countries. There may also be a need for promotion of breastfeeding.

"Human rights" are sometimes termed entitlements. Internationally they include recognition of certain items or forms of treatment that all persons deserve or to which they are entitled. It is then expected that societies will take steps to ensure that their members enjoy these rights or entitlements. This may be achieved in part by national legislation and national actions. But in the end it takes people and communities to ensure compliance and to take actions to help all enjoy their rights. The assumption is that all members of a community deserve at least certain minimal rights.

Certain basic rights have been included in international declarations, have been promulgated by authoritative international bodies as codes or standards for all society or all nations, or have been incorporated in national constitutions. Some of these rights, ranging from the 1948 Universal Declaration of Human Rights to the 1989 Convention on the Rights of the Child have been outlined in the introduction to this paper. These and many other international documents establish human beings’ rights to health and to food, and even to good nutrition. If we accept these rights, then this paper argues that it is logical that mothers have rights to breastfeed. Breastmilk is the only ideal food to ensure the good health, proper development, and well-being of young infants. Breastfeeding also contributes to women’s health.

This logic then leads to acceptance that any obstacles to breastfeeding are infringements of human rights. Major negative influences on breastfeeding therefore contribute to loss of this human right, and any persons who place obstacles in the way of breastfeeding are parties to infringements of human rights.

Major negative influences on breastfeeding include (1) the health profession, hospital practices, and the medicalization of infant feeding; (2) the promotional and marketing practices of manufacturers of breastmilk substitutes; (3) failure of nations and communities to assist mothers both to breastfeed and work away from home; and (4) lack of community support for mothers to initiate, sustain, and maintain optimum breastfeeding.

The contention here is that mothers have a human right to breastfeed their infants, and that obstacles to this are infringements on this right. As with other rights, states have obligations to respect, protect, facilitate, and fulfill this right. The WHO/UNICEF Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (WHO/UNICEF, 1990) provides a useful framework for nations to honor these states obligations.

This paper does not discuss in detail the possible tensions between infants’ rights to be breastfed and mothers’ rights to choose not to breastfeed. The WABA Global Forum on Children’s Health, Children’s Rights held in Thailand in December 1996 wrestled with this issue. The Forum agreed to include the following wording in its recommendations:

Combined with the fact that breastfeeding is in the best interest of children and mothers, WABA interprets these general provisions of the Convention on the Rights of the Child as implying that children have a right to mother’s milk as the only fully adequate food, and that mothers and children have a right to enjoy conditions that facilitate breastfeeding. States Parties have an obligation to respect, protect, and facilitate or fulfill the right to enjoy such conditions by the removal of obstacles to breastfeeding and to appropriate complementary feeding and by the creation of supportive social and economic environments for parents and children.

This shall in no way be understood or perceived as the mother having a duty to breastfeed since it is the circumstances which lead to the choice not to breastfeed that must be altered."

It is certainly not proposed that mothers who choose not to breastfeed their infants should be penalized, ridiculed, or prosecuted. Mothers need to have the freedom to choose how to feed their babies. But it is argued here that almost all mothers living under optimally baby friendly conditions would make the choice to breastfeed. This is shown in countries as diverse as Norway and Tanzania. Therefore, what is needed is actions to remove those obstacles to breastfeeding, many of which are discussed in this paper. In some countries, such as the United States, a major obstacle is the lack of knowledge that there is no good alternative to breastfeeding.

The argument made is that mothers have a legal right to breastfeed their babies if they chose to do so. Infants’ interests in optimal health and nutrition may be jeopardized if not fed on human breastmilk, or even if not breastfed. This should be viewed in terms of ethical, moral or civic interests and duties, not as legal obligations on the mother deriving from legal rights of the infant.

We should help mothers understand the benefits of breastfeeding to themselves and their infants. We can then agree that states have responsibilities and obligations to respect, protect, support and promote the removal of all obstacles to breastfeeding. When this is achieved, it probably will be unusual for infants not to be breastfed.



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