This article in the World Journal of Pediatrics is based on a masters thesis that Dr. Jiang Jing Xiang did with me as her supervisor at Uppsala University. It uses data from the first national vitamin A deficiency survey done several years earlier throughout China.

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IMAGE: from http://www.thailine.com/

 

Photo from Erika Andresen’s (formerly Bergström) thesis. 

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This is another paper Jiang Jing Xiang wrote for her PhD at Uppsala Medical School in Sweden.

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Prepared for the Australian Breastfeeding
Association HOTMILK meeting

I work with nutrition in developing countries, and breastfeeding has always been a major component of my work.

I lived in Sweden for 20 years. My sons were exclusively breastfed for close to 6 months and continued breastfeeding until they were 3.5 years old. When the boys got old enough to understand language, their mother asked them to wait until they were in private-to avoid provoking people, for her and the children’s sake. We practiced attachment parenting, including a family bed for many years.

While many mothers in Sweden may start breastfeeding because they know it is better for the baby’s health, sustained breastfeeding is not promoted in Sweden as particularly important for infant health. About 40% breastfeed for longer than 9 months and about 20% for longer than one year. Some women ARE breastfeeding for a longer period of time; it is now accepted as something that is all right to do if you want to. Probably most women who do it simply do not want to force the infant to stop when they see how important it is for the child.

I don’t think we ought to need research for this kind of thing to obtain status and importance. For those interested in research, I can report that in my family research project with a sample size of two, the children have always been healthy, their teeth remained strong and free of caries, they were, if anything very independent young children and now young men, and they have had relationships with girls and women that fit well within the Swedish norm. As to the impact of the family bed approach we followed, this sample of 2 were never afraid of the dark, never were interested in teddy bears and never sucked their thumbs much. But they did breast feed a lot!

When breastfeeding is exclusive, it is quite a challenge, both for the mother and for us who try to support and promote it. It is something new, at least in the minds of most scientists, health workers, and social engineers–if there is such a thing. It’s strange that it did not occur to hardly anyone before the 1970s-as far as I know-since it would seem to be the “natural” thing that presumably was done by our most ancient ancestors. Exclusive breastfeeding does not seem to have been understood or respected in recorded history, however–which goes back only for a few hundred years in most cases and for a few thousand years in a few. Thus people have come to assume it was not possible or desirable, since it did not seem to be traditional.

Since we did not know exclusive breastfeeding was possible, let alone desirable, we have not created a society which provides women the support they need to practice it. Thus the challenge is broad, far beyond the usual approach of educating health workers, however important that may be.

I imagine that the Australian Breastfeeding Association asked me to give this talk because they share my concern about promoting breastfeeding as breastfeeding, not as the provision of breast milk. Swedish people might have trouble understanding what that meant, but I imagine all of you do. About 14 years ago I gave a talk in New York on the concepts of “protecting, supporting and promoting” breastfeeding. An old friend was in the audience and we discussed my talk afterwards. I gradually realized we were not communicating. Finally we realized that this was because to her “exclusive breastfeeding” meant basically providing breast milk exclusively to the child, which in turn nearly always meant doing a lot of pumping. So the idea that the mother and child had to be together during this period had never occurred to her–while the idea that they could be apart regularly had never occurred to me. It had simply never occurred to me that in countries without the long paid maternity leaves common in Europe, pumping is the norm for those who want their babies to get a lot of breast milk—let alone to exclusively breast milk. In Sweden women do pump in rare circumstances, but most do so for a short time if at all. Why and what are the implications?

For Swedish women I would say that breastfeeding is now seen as part of the experience of having a family. Nearly all women work before and after each baby they have, but they breastfeed exclusively during the first 4-6 months. (In Norway the pediatric community is more strongly behind exclusive breastfeeding until 6 months, so it is more common there. In Sweden confusion abounds, especially regarding the need to introduce gluten early to prevent celiac disease, but for the past 13 years 60-70% of babies have been exclusively breastfed through at least 4 months.) As is similar in most European countries, Swedish women have about a year of maternity and parental leave at about 75% pay, and the right to gradually go back to work, starting at even an hour a day if they want.

All of this I see as an expression by women that they and their children enjoy the breastfeeding experience, not that women are doing it out of a sense of duty or a sense that they provide certain biochemically-mediated advantages to their babies.

I recognize that pumping is for many the best solution. But I wonder if many mothers assume that pumping will be a relatively painless way to “have your cake and eat it too,” only to find out that it is more difficult than they expected. Or that it is fraught with unexpected risks, even leading at times to premature cessation of breastfeeding. The more time a mother spends away from her infant, the higher the risk. Thus perhaps one should counsel pregnant primiperas or those with newborns to if at all possible plan their lives in such a way as to delay or even avoid getting into pumping or expression. This is the same thing I would say regarding mixed feeding in general. It may at times be the best solution, but should not be viewed as “almost as good” or as a relatively unimportant decision.

At the very least, pumping is taking away something pleasurable from both mother and baby. Being a man I cannot comment on this from personal experience, but I have certainly seen how breastfeeding (not the consumption of breast milk) seemed to transport my sons to realms of bliss, even when they were up to three years of age.

To increase the chances that we communicate well on this and that I am not so provocative that I turn some people off, let me begin by saying that in my nutrition work, I find it very useful to divide up plans for program and policy work into two categories-long term and short term. In the long term we may talk about more advanced types of nutrition programs, but in the short term we focus on what the country has the capacity to do now and is likely to be able to do in the near future with enough money. Capacity is the limiting factor often, more so than money.

But when I talk about breastfeeding outside of Europe, I like to focus on the long-term goals. I think that in focusing on short-term solutions like breast milk pumping, we all too often lose sight of the long-term goal. I’m here to remind you of what life for mothers and babies COULD be like. If we cared. And fought.

Why do we form civilized societies if not to meet the needs of the people? A large proportion of them are mothers and babies. Not meeting the psychological needs of babies is surely dangerous, even if they cannot report the effects to us. I wonder if this may be part of the explanation for the more serious social and psychological problems of various kinds the modern world seems to be saddled with.

No doubt in Australia, like America, there is less trust of government than in “old world” Europe where most believe that government has an obligation, to the extent it can be afforded, not only to respect but to fulfill its citizens’ economic, social and cultural rights. This may explain why Australia and the US are the only developed countries with no mandated period of paid maternity leave. (But some Australian states do mandate a short period of paid leave; and when it comes to unpaid, Australians have 46 weeks more than Americans!)

No doubt many of you in the audience who work do have access to paid leave, but certainly the lower socio-economic groups never will as long as access to such an entitlement is decided on by the employer rather than mandated by the government.

The best way to understand the implication of breastfeeding as a right is to think about the constraints to achieving more maternity leave. When Sweden was debating nearly a century ago whether women should get the vote, one argument against it was that elections would cost twice as much! We smile at that today only because human rights thinking has come a long way since then. Voting was not a right in Sweden or the US in 1910, it was a privilege that those who had the most power in society kept for themselves. Now we do not see personal power or wealth as being a criteria for who should get to vote–it is a right. That does not mean you HAVE to vote, just that no one has the right to stop you from doing it if you want to.

Two hundred years ago there was a debate about the economic consequences of doing away with slavery. Now, even though it still would benefit everyone who was not a slave, we do not entertain even the thought of it. Similarly for the worst forms of child labor. We only got an International Labor Organization Convention against it a few years ago. But already no one would argue that it is too expensive to implement. The money will simply have to be found to allow all children to attend school and not work under the slave-like conditions that many live under today. Carpets will have to cost more.

My friends, babies have not only a need but a right to be with their mothers during the first months of life. This is not just a breastfeeding issue. Babies get confused by having too many caregivers too soon before they have had a chance to bond with one person. The great expert on infant development, Uri Bronfenbrenner, once said that a child can do well without even having a mother, but EVERY child needs someone who is crazy about them-who delights and shows that delight at every little developmental step they take.

My first born was born in 1979 while I was a PhD student at what I do think was an enlightened department of nutrition at Cornell University. The same day a secretary there gave birth. Two weeks later, after taking her annual leave, she was back at work full time. That would not happen to the infant of a university employee in hardly any other country in the world, industrialized or developing. Even the poorest countries are not so stingy to their mothers and babies.

You’ve all seen bumper stickers about the meaning of life with texts like “the one who dies with the most toys wins.” Perhaps the best way to promote paid maternity leave is to print up ones that say “the one with the most toys and the most miserable children wins.”

We know the benefits of breast milk. What we desperately need is more research on the importance of the mother and infant being together during the early months—and widespread dissemination of the results. The giant multinational companies of the world are being completely honest when they tell us they are just giving us what we want. If all you want is the biochemical benefits of breast milk, the brave new future is already here. Infant formula continues to evolve and there are patents already for implanting genes for making human milk in mice. I have no doubt that the baby milk companies are patiently laying up long-term plans for how to get the mothers of the world to accept milk made in such mice–or other gene-manipulated animals. Then, unless we have a lot more research on mother-infant proximity, there will no longer be any need to breastfeed at all, especially in countries like the USA and Australia where working women do not tend to stay home for long periods after giving birth.

We had a movie star in Sweden a few years ago who openly bottle fed in public and said she wanted only the fun parts of having a baby. Six hundred people wrote in to the newspaper in response. One said, “Get a dog.” Yet I would not say Sweden is immune from cultural and especially commercial currents in the other direction. Here are a couple Swedish advertisements promoting the ideal that it’s possible to use the bottle to allow you have a baby but not be much bothered by it.

If children raised on perfect food without their mother’s presence is not your idea of a utopia, I suggest we all stop focusing so much on the wonders of breast milk and look more closely at the issues involved in exclusive breastfeeding and in mother-infant proximity. Breast milk is not magic. It’s as normal and ordinary as sex and pregnancy; like masturbation and cesarean section, artificial feeding has its place, but is inherently inferior and should only be used when the natural alternative is not available. Similarly, the expression and pumping of breast milk should be recognized as something inherently inferior, and used only when required. Pumping should be seen as a short-term approach to cope with a situation where mothers’ and infants’ rights are not being respected. A society where pumping is the norm has serious problems, and breastfeeding advocates should seek allies in making broader social change. Short-term measures to deal with this situation include: crèches at the work place, time and space for pumping at the work place, etc. But such short-term approaches should not take resources away from the long-term work needed to create a society which recognizes and facilitates the mother being with her infant for at least the first six months of life.

I am sometimes confronted by women who find this provocative. They point out that many women have to pump and many want and need to be away from their babies. Let me deal with this kind of statement now:

* I am not saying pumping is bad. Unlike many in the breastfeeding community, I also do not think infant formula is bad. It can be life-saving, just like caesarean section can. Hurray for us human beings who can in that sense play god and save babies who otherwise might die! All I’m saying is that these things are for emergency use and where they become the norm something is awry in society as a whole. In saying they are inferior to nature, I am stating a fact, not trying to hurt anyone’s feelings.
* Women do not have to go back to work soon after giving birth in a society that respects their and their babies’ rights.
* Some, but only a few women will want to go back to work when their baby is less than six months of age if they are receiving something close to the same pay to be at home with the baby and ensured of returning to the same or an equivalent job without losing seniority. In Sweden, your pension is not even reduced much if you take off work for less than four years to be with each child.

Breastfeeding provides a convenient “excuse” for the men, so we do need to deal with the gender inequality inherent in women having to do more of the child care. Some countries are moving in the same direction as Sweden, where parents receive 14 weeks of maternity leave and 10 days of paternity leave at about 80-90% pay. Then the couple is offered another year or so of paid parental leave and another several months with only token payment. Each parent must take two months of parental leave or those months are lost. Sweden is considering increasing that. Thus the ideal might be for the mother to take the first six months full-time, then the father to take over ¼ time and the mother ¾ for another six months, then equal for six months, and so on until the careers of both are equally affected by the birth of each child. Even in Sweden this is a long-term ideal-now men take only about 20% of the parental leave (but this has doubled in the past 7 years or so). Spending equal time with the baby should be optional of course, since not all mothers or infants would want it this way, even if the father did. But it illustrates how there need not be inherent gender unfairness in creating societies in which six months of exclusive breastfeeding was enabled and eventually taken for granted.

About 25 years ago, the “breastfeeding promotion community” decided that health worker training was the most important intervention. I agree that reducing the harm untrained health workers tend to do is useful; that trained lactation management experts can play one important role; and that lay counselors can play an even larger one. But as its foundation, breastfeeding promotion does not need doctors. It needs empowered women. When they need it, such women will get help from health professionals, and where possible reject or educate those they encounter that say and do breastfeeding unfriendly things. Even if basic research DID convince all the health professionals about breastfeeding, they are going to need a complete sea change in their mentality before they are the right people to depend on to empower anyone about anything. More importantly, it’s only parents who can create a society that fosters mothers and babies being together—getting back to breastfeeding as an experience!

Australian babies are worth as much as babies everywhere else: don’t give up the fight!

Image from www.voanews.com

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This was a comment I was requested to write by The Lancet medical journal.

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At PATH I now direct the Ultra Rice project. The goal is the develop models for increasing the supply of and demand for fortified rice in China, India, Brazil and Colombia. You can read about this ingenious technology at http://www.path.org/projects/ultra_rice.php

At the Micronutrient Forum international meeting in Istanbul, Turkey in April 2007, an abstract was presented of a clinical trial showing that consuming iron-fortified Ultra Rice greatly reduced anemia in women factory workers in Mexico.

Click here to download the abstract.

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While exclusive replacement feeding reduces the risk of transmission between HIV-positive mothers and their infants, it does not adequately address the specters of infection and undernutrition that accompany avoidance of breast-feeding. We are convinced by data from regions that are similar to Rwanda and even from African countries with higher standards of living that replacement feeding from birth is a dangerous and inappropriate approach for HIV-affected families in countries like Rwanda.

In addition, avoiding breast-feeding from birth can be exceedingly risky, particularly in the same regions where the risk of mother-to-child transmission of HIV is highest. While Partners in Health (PIH) offers high-quality healthcare support and financial assistance to reduce the risks associated with breast-feeding avoidance in two districts in Rwanda, it is impossible to eliminate those risks. Researchers have found that children in Ghana, Peru, and India who are not breast-fed between the ages of six weeks and six months have a ten-fold higher risk of death [2]. A multi-country analysis by the World Health Organization (WHO) showed that infants who were born to mothers with little education and were not breast-fed had a five-fold increased risk of death from six to 11 months of age. Since about 5% of breast-fed Rwandan babies already die in the first six months of life and another 3.5% from six to12 months [3], it is essential that PIH substantiate the mortality, nutrition, and morbidity outcomes resulting from their approach before promoting it more widely.

Given that breast-feeding avoidance increases the risk of death from other causes, even as it decreases the risk of HIV transmission, is there a net gain? The concept of “HIV-free survival” combines the likelihood of surviving with the likelihood of not becoming HIV infected, allowing a more comprehensive assessment of the risks and benefits of infant feeding. In Botswana [4] and the Ivory Coast [5], rates of HIV-free survival were no better among formula-fed infants than among infants breast-fed for three to six months. At this year’s WHO Consultation on HIV and Infant Feeding in Geneva, reports showed high death rates in ongoing trials in Kenya, Uganda, and Malawi associated with breast-feeding cessation at three to six months. These results were despite earlier assumptions that breast-feeding cessation at this age might be safe, while avoiding most of the HIV transmission associated with prolonged breast-feeding [6]. Since these carefully controlled studies represent best-case scenarios for replacement feeding, most actual program settings will favor breast-feeding (actually, disfavor replacement feeding).

The risk of mother-to-child HIV transmission in the first six months in a country like Rwanda, where 81% of women are still exclusively breast-feeding at four to six months [3], is relatively low, probably approximately 0.3% per month [7]. It may be even lower in districts like those in which PIH works, where eligible HIV-positive mothers begin receiving highly active antiretroviral therapy during pregnancy, because the majority of postnatal HIV transmission is from mothers with low CD4+ cell counts [8].

Scientific evidence amply demonstrates the significant risks that accompany replacement feeding and the safety and effectiveness of exclusive breast-feeding for the first six months, and continued breast-feeding thereafter as appropriate and safe. Around the world, researchers, programmers, and policy makers are becoming increasingly convinced that the infant feeding counseling component of prevention of mother-to-child transmission of HIV programs must focus on optimizing HIV-free survival rates, not simply on HIV transmission. Accomplishing this means taking full account of all factors, both social and molecular, that are at work in a particular context, and tailoring responses to meet them.

Ted Greiner (tgreiner@path.org)
Katherine Krasovec

Program for Appropriate Technology in Health
Seattle, Washington, United States of America

Christophe Grundmann
Christian Pitter
Catherine Wilfert

Elizabeth Glaser Pediatric AIDS Foundation
Chapel Hill, North Carolina, United States of America

References

1. Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) Structural Violence and Clinical Medicine. PLoS Med 3(10): e449 doi:10.1371/journal. pmed.0030449

2. Bahl R, Frost C, Kirkwood BR, Edmond K, Martines J, et al. (2005) Infant feeding patterns and risks of death and hospitalization in the first half of infancy: Multicentre cohort study. Bull World Health Organ 83: 418-426.

3. ORC Macro (2006) Rwanda Demographic and Health Survey 2005. Available: http: www.measuredhs.com/pubs/pub_details.cfm?ID=594&srchTp=ctry. Accessed 26 January 2007.

4. Thior I, Lockman S, Smeaton LM, Shapiro RL, Wester C, et al. (2006) Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: A randomized trial: The Mashi Study. JAMA 296:794-805.

5. Leroy V (2006) Presentation at WHO Consultation on HIV and Infant Feeding; 25 October 2006; Geneva, Switzerland. World Health Organization.

6. Piwoz EG, Ross JS (2005) Use of population-specifi c infant mortality rates to inform policy decisions regarding HIV and infant feeding. J Nutr 135:1113-1119.

7. Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, et al. (2005) Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 19: 699-708.

8. Coutsoudis A, Dabis F, Fawzi W, Gaillard P, Haverkamp G, et al. (2004) Late postnatal transmission of HIV-1 in breast-fed children: An individual patient data meta-analysis. J Infect Dis 189: 2154-2166.

Citation: Greiner T, Grundmann C, Krasovec K, Pitter C, Wilfert C (2007) Structural violence and clinical medicine: Free infant formula for HIV-exposed infants. PLoS

Med 4(2): e87. doi:10.1371/journal.pmed.0040087

Copyright: © 2007 Greiner et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors received no specifi c funding for this article.

Competing Interests: The authors have declared that no competing interests exist.

February 2007 | Volume 4 | Issue 2 | e88 | e87

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