CNN: Stop fighting about breastfeeding and face this reality

July 11, 2018

Right now a whole lot of discussion is focused on the World Health Organization, US policy and the promotion of breastfeeding among new mothers around the world. After the New York Times reported that the US threatened other nations in an effort to water down a World Health Assembly resolution supporting breastfeeding this spring, intense responses from all sides galvanized the debate over whether the reported move by the United States stemmed from an alignment with infant formula manufacturers.

But this conversation about the United States pushing other countries on breastfeeding vs. formula misses a key point. How about putting the attention where it belongs, on what mothers need and want rather than what global institutions and international governments decide? Breastfeeding education is critically important, but if there is a silver lining to be found in the uproar regarding the WHO and America’s position concerning the push to promote breastfeeding, it is this: what better time could there be to look closely at the broader policies on breastfeeding education and what they mean for women’s lives on the ground in the toughest places and in the most difficult moments? And for folks who did not at all care about the issue of WHO policies on breastfeeding before it became ensnared in the headlines this week, I’d urge you to move beyond the domestic political question to the global policy matter: does international policy do enough to protect women and their babies even as it promotes the laudable goal of breastfeeding?

Women in conflict zones, as aid workers have taught me, may want to breastfeed, but they are also facing conflict, displacement, the need to feed multiple children of a variety of ages, a lack of nutrition for themselves and the imperative to be on the move to stay safe. Against that backdrop, some may not have the ability to breastfeed or may feel that at that very moment there are other options that will better allow them to take care of their families. This is not to argue against breastfeeding, but to say that there are other, pressing realities facing women that are also urgent. Certainly this is an argument that would be welcomed by the infant formula industry, but this is not about fattening an industry; this is about feeding little ones and alternatives women should have as they make choices about their own families.

As I wrote last summer, at a time when this was an obscure issue, at best, Doctors Without Borders (MSF) had sounded the alarm several times about the negative consequences of prioritizing breastfeeding promotion over saving lives. Just then the group was in Mosul in the wake of the war against ISIS and facing what it saw as the policy’s failure to reflect the reality of women’s lives — and that policy’s consequences: undernourished babies.

Indeed, it was through MSF that I first learned of the issue while reading a rather blunt post from the group’s leader in Iraq. In subsequent discussions I had with aid workers, none of whom would use their names due to lack of authorization, it was clear this was an issue causing anguish for folks on the front lines. The policy of promoting breastfeeding above all else left women’s choices — and realities — out.

“Over the past couple of weeks we’ve seen an increase in the number of malnourished children needing treatment,” Doctors Without Borders’ Iraq country director Manuel Lannaud said in an interview released on the group’s website last July. “It isn’t a problem of access to food. The malnutrition we see here is primarily due to the scarcity of infant formula.”

Wrote Lannaud, “International organizations like UNICEF and the World Health Organization (WHO) promote breastfeeding … provide infant formula, but only by prescription. We believe that distributing infant formula in a conflict situation like Iraq is the only way to avoid children having to be hospitalized for malnutrition.”

The aid organization was clear that it was indeed all for breastfeeding. But it was also about saving lives, not about sticking to policy.

“We also encourage mothers and tell them how important breastfeeding is, but if they need formula, we give it to them,” the group’s Iraq director wrote.

Shortly after I wrote about this issue, an aid worker who has spent a career focused on helping those facing conflict wrote to me to say that the issue had been one they had thought a lot about — with real anguish.

“I have recollections of staring blank in the face of local partners as we said no to baby formula with no good reason other than policy,” this aid worker wrote.

Doctors Without Borders went further in the Lancet earlier this year. The group defended itself against the idea that simply giving out formula was the problem.

“We encourage the adaptation of emergency interventions to reflect the feeding practices of the population, before trying to address the underlying behavioral practices,” the authors wrote in a letter the Lancet published. “Many of the women took the decision not to breastfeed before the war; others had a reduction in breast milk production because of the effects of the war. Their reasons are varied and are their own; hence, the utmost responsibility is to respect their choices in our interventions.”

Indeed, that is the critical point. Yes, it is important to educate and inform women about the benefits of breastfeeding and to help them understand its advantages. But when does the mother get a say? And when it comes to saving lives, how is it that those who are giving the care must treat formula as something requiring a prescription rather than as a means to saving lives?

As the Doctors Without Borders authors continued a few months back, “Timeliness of the response is a crucial factor, particularly when the prevalence of severe malnutrition reaches a quarter of the infant population younger than 6 months. Emergency responses should be adapted to population practices to ensure the accessibility and safety of adequate infant feeding and thereby avert avoidable deaths.”

Those on the ground, not in Geneva, should be able to best decide how to help those in need. And while breastfeeding is both important and praiseworthy, at some point women, too, get a say in how to feed their children. Aid workers have seen it firsthand and mothers know it.

And instead of getting caught up in the geopolitics of it all, the rest of us could — and should — use this moment to really consider how best to help women in some of the world’s most challenging places. On their terms, and reflecting their realities, not only ours.