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NEXUS Seminar: What can we learn from a century of breast feeding promotion policy in Canada? Ostry, Aleck Jan 31, 2009

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The Changing Determinants of  Breast- Feeding and Promotion Policy in Canada Over 90 Years Aleck Ostry, MA, MSc, PhD ostry@uvic.ca AND Tasnim Nathoo, MSc, MSW. tasnim@interchange.ubc.ca Acknowledgements Dr. Ostry holds a Canada Research Chair in the Social Determinants of Health and a Senior Scholar Award from the Michael Smith Foundation for Health Research. He is an Associate Professor at the University of Victoria. Acknowledgements { Tasnim Nathoo has two Masters degrees, one in Public Health and the other in Social Work. She is currently working as a therapist in Vancouver. Acknowledgements This talk is based on our book entitled “The One Best Way”? Breastfeeding History, Politics, and Policy in Canada from the 19th-21st century by Tasnim Nathoo and Aleck Ostry. This book will be published by Laurier Press and is available in early 2009.  Table of Contents { The book has four parts and 11 chapters { Part 1: TRANSITIONS, 1850- 1920 { PART 2: DECLINE, 1920-60 { Part 3: RESURGENCE, 1960- 2000 { Part 4: AT EQUILIBRIUM: Into the Twenty-First Century Chapter One { CHAPTER ONE: Infant Mortality, Social Reform, and Milk, 1850-1910 { Beginnings: Breastfeeding in Colonial Canada { Three Cultures of Breastfeeding: Montreal at the End of the Nineteenth Century { Social Reform and Domesticity { Milk and Infant Mortality { “Pure” Milk and “Perfect” Foods Chapter Two { Theory and Formulas: Scientific Medicine and Breastfeeding, 1900- 1920 { Early Pediatrics in Canada { Humanizing Milk { Cosmopolitan Ideas { Theory Runs Riot: Controversies in Infant Feeding { Breast Is Best … Whenever Possible Chapter Three { Nation, Race, and Motherhood: The Political Ideology of Breastfeeding, 1910- 20 { The Future of the Nation { The Infant Mortality Reports { Selfish Mothers and Ignorant Mothers { Working Mothers and Rural Mothers { “Literature, Instruction, and Assistance” { Choices and Constraints Chapter Four { Professionals and Government, 1920-30 { The Canadian Mother’s Book { Feeding the “Infant Soldier” { “Mother’s Helpers” { Scientists and The Normal Child { Scales and Timetables: Scientific Breastfeeding { The Sunshine Vitamin { The New Motherhood: Professionalism, Regulation, and Efficiency Chapter Five { Marketing Infant Feeding, 1930-940 { The Well Baby Clinic { Bigger Babies Are Better Babies { Placing the Blame: “Fictitious Difficulties” and a Lack of Proper Teaching { Scientific Infant Food: Alternatives and Complements { Advice and Advertising: Chatelaine’s Baby Clinic { Milk Banks and Miracles Chapter Six { Old-Fashioned, Time-Consuming, and a Little Disgusting, 1940-60 { “Dr. Couture’s Book”: The Canadian Mother and Child (1940 and 1949) { Birth: From Home to Hospital { Accepted, Familiar, and Attractive: Bottle- Feeding in the 1940s and 1950s { “Ironing out the Difficulties”: Pediatrics Abandons Infant Feeding Chapter Seven { The Return to Breastfeeding, 1960-80 { “Fashions” in Infant Feeding: Breastfeeding in the 1960s { Reclaiming Breastfeeding { “Commerciogenic Malnutrition”: International Interest in Breastfeeding and the Nestle Boycott { “In Our Own Backyard”: Bottle-Feeding in Aboriginal Communities { The Revival of Breastfeeding { Nutrition in The Canadian Mother and Child (1979) { “What Is Left besides the Poetry?”: The Scientific Rediscovery of Breastfeeding Chapter Eight { Promoting Breastfeeding, 1980-90 { A National Promotion Campaign { Implementing the WHO Code – Or Not { New Trends: Culture, Place, and Formula { Tradition and Change: Breastfeeding Trends in the Aboriginal Population { Family-Centered Maternity and Newborn Care { The Campaign Closes Chapter Nine { Protecting, Promoting, and Supporting? 1990- 2000 { Breastfeeding Anytime, Anywhere { The Responsibility of the Health Care System { “Competing with Women’s Breasts”: New Industry Marketing Strategies { The Purpose of Breasts: Sex or Food? { National Surveys Reveal … Breastfeeding Practices at the End of the 1990s { The Breastfeeding Committee of Canada and the Baby Friendly Initiative { Making Informed Decisions Chapter Ten { Continuities and Change: Breastfeeding in Canada at the Turn of the Twenty-First Century { Breastfeeding Rates in Canada in 2003 { Alternatives to Mother’s Milk: From Cow’s Milk to Breast Milk Banking and Commercial Infant Formula { Breastfeeding Knowledge and Skills: Shifting Domains { The Value of Breastfeeding Outline { Trends and the Promotion of Breast feeding in Canada in the 1920s { Trends and the Promotion of Breast feeding in Canada in the 1930s and 40s { Why these Trends in the 1920s to 40s? { Trends and the Promotion of Breast feeding in Canada in the 1950s and early 1960s { The 1970s and the Resurgence of Breast feeding { 1980s Breast feeding Promotion { Inertia over the Past 20 Years { Breast Feeding Policy for the 21st Century: What does History have to Offer? Purpose The purpose of this overview is to describe the evolution of breast- feeding policy in relation to the changing socio-determinants of breast feeding in Canada over approximately 100 years. Introduction { The first national policies promoting breast feeding among Canadian women were promulgated and widely disseminated through the Children’s Division of the Federal Department of Health in the early 1920s. { Since then the federal government’s involvement in developing national policies promoting breast feeding has waxed and waned although throughout this period, policy makers have consistently promoted the view that breast feeding is the best way to feed an infant. { While the rhetoric of government health experts has always supported breast feeding as the only correct way to feed babies, the guidelines issued by government experts (e.g., guidelines advising on the duration of breast feeding) have varied enormously over this period. { For example, in the 1920s the recommended duration of exclusive breastfeeding was 9 months. This fell to a low of 3 months in the early 1950s and has recently climbed back to 6 months. Similar major variations can be found in the guidelines for timing the introduction of solid foods and recommendations about the types of solid foods and breast milk alternatives to feed infants. { Between the 1920s and the 1960s, the majority of Canadian women abandoned breastfeeding. However, beginning in the late 1960s and early 1970s a new generation of Canadian women reclaimed it. Yet, while there has been a sea change in breast feeding behaviours over this long time span,  there have been two consistent features to these efforts at promotion by government. { First, the focus of promotion efforts has been almost exclusively on the education of mothers through dissemination of guidelines and the Canadian Mother’s Books. { Second, except for a short period in the 1980s, breast feeding promotion has rarely been about breast feeding. It has almost always been viewed as a strategy to achieve other national or health goals. { We have reviewed both the changing social determinants and demography of breast feeding initiation and duration in Canada and the changing federal policies to promote the practice over an approximately 90 year period from the 1920s to the present. { The purpose of this presentation is to broadly present the results of this review and offer a way forward to the promotion of breast feeding in the 21st century. { As such this approach uses history to build a foundational understanding that should be of use to present day policy makers { We first review the trends in breast feeding initiation and federal health promotion efforts to the 1960s a period also when federal breast feeding promotion efforts were relatively intense. { In the second section of the paper we continue this review for the period between the early 1970s and the present. { In the last section of the paper we offer our recommendations, based on this review of trends in behaviour and promotion for the development of a breast feeding promotion policy for the 21st century. Trends and the Promotion of Breast feeding in Canada in the 1920s { In the 1920s, breastfeeding was presented, by government policy makers in terms of a moral crusade against the then high rates of infant mortality. { Infant mortality rates were persistently high until commencing a rapid decline in the late 1920s 50 60 70 80 90 100 110 192 1 192 2 192 3 192 4 192 5 192 6 192 7 192 8 192 9 193 0 193 1 193 2 193 3 193 4 193 5 193 6 193 7 193 8 193 9 194 0 194 1 194 2 194 3 194 4 194 5 I n f a n t  m o r t a l i t y  r a t e 35 55 75 95 115 135 1921 1923 1925 1927 1929 1931 1933 1935 1937 1939 1941 1943 1945 I n f a n t  m o r t a l i t y  r a t e  p e r  1 , 0 0 0  l i v e  b i r t h s Maritimes Quebec Ontario Prairies BC { The promotion of mother-centered breastfeeding in the first Canadian Mother’s Book, with its insistence on exclusive breastfeeding for nine months reflected the militancy of the federal health policy experts in the context of the post- World War One national crisis over the slowing birth rate and high infant mortality. { It also reflected a view of women as primarily caretakers of the family and a parallel role as nurturers of the next generation of Canadians. { The tone of this early breastfeeding campaign was catastrophic and patronizing. { The breast feeding promotion efforts of the 1920s were targeted almost exclusively at poor and less educated Canadian women even though they were, in general, much more likely than women of higher social and economic classes to breastfeed. { These promotion efforts were also based on an idealized conception of mothering and motherhood. { Helen MacMurchy and others policy makers in the 1920s believed that women should remain in the home and therefore provided no practical advice for the large number of poor Canadian women who had no choice but to seek employment outside the home. { Breastfeeding promotion efforts were mis- targeted as middle class and wealthy women were the ones moving most quickly away from breastfeeding during this time. { These breast feeding promotion efforts in the 1920s were mounted at the same time Canada and other western nations witnessed the most dramatic decline in breast feeding in history. { It is likely that secular changes based on the changing needs and roles of women, beginning with the middle and upper classes in the 1920s, drove the shifts in breastfeeding behaviour. Trends and the Promotion of Breast feeding in Canada in the 1930s and 40s { In the 1930s, federal breastfeeding promotion efforts waned as the Depression shut down many government initiatives. { By 1941, while the rhetoric of “the one best way” to feed infants continued, the advice promulgated in The Canadian Mother’s Book shifted away from an emphasis on exclusive breastfeeding. { During the Second World War, formula feeding with evaporated milk was recognized and supported by federal directives which gave new mothers priority access to canned milk a policy that de-facto undermined breast feeding. { By the late 1940s, advice on formula feeding began to appear in advice literature to mothers and the duration of exclusive breastfeeding in federal guidelines began a steady decline over the next 20 years from nine to three months. Why did Breastfeeding Decline so Markedly in the 1920s to 40s? { First, the increasing popularity of artificial feeding linked in turn to the scientific and modern image associated with the technological age ushered in after WW I. { Second, infant mortality rates, plummeted between 1920 and 1945 easing policy makers’ earlier concerns. { Third, notwithstanding the fact that Canada had just come through a second major war, the linkage between national survival, motherhood, and breastfeeding had been broken. { Fourth, the safety and availability of breast milk alternatives had increased and the cost of these mostly cow’s milk-based alternatives had dropped as clean water and milk became widely available by the 1940s. Trends and the Promotion of Breast feeding in Canada in the 1950s and early 1960s { Between 1940 and 1960 childbirth shifted entirely from the home into the hospitals: control over infant feeding advice became firmly entrenched in the hospitals and gave the medical and nursing professions heightened influence over infant feeding decisions. { In 1926, 17.8 percent of births in Canada occurred in hospitals but by 1940 this had increased to 45.3 percent. { The Second World War accelerated the shift of birthing from home to hospital.  By 1945,  63.2 percent of women gave birth in hospital. { This pace quickened (no pun intended) during the 1950s as by 1959, 93.1 percent of all births in Canada occurred in a hospital. Also, in 1954 the birth rate peaked (at 28.5 births per 1,000 women). { Women giving birth, particularly by the 1950s, represented the daughters of the first generation of mothers in Canadian history who had moved en-masse away from breastfeeding. { They were, therefore, the first generation who had little, and in some cases, no knowledge of the practical skills required for successful breastfeeding. { This loss of knowledge, in conjunction with the medicalization of infant feeding advice, and women’s own desires to use breast milk alternatives often meant that breastfeeding by the early 1960s was virtually a lost art. The 1970s and the Resurgence of Breast feeding { As shown in the next graph, from its nadir in the 1960s, breastfeeding made a spectacular comeback across Canada during the 1970s. { The rapid increase in breastfeeding in the 1970s was part of a secular movement of women returning to breastfeeding that preceded the rejuvenation of breastfeeding policy initiatives by the federal government in the 1980s.  { Percentage increase in initiation rates between 1965 and 1978 was 135 as rates went from 26 to 61 percent. { As shown in the next graph, this resurgence in breast feeding was not even as its pace differed by region. Breastfeeding initiation rates by region, 1965-71, 1978, 1982 0 10 20 30 40 50 60 70 80 BC Prairies Ontario Quebec Maritimes Canada 1965-71 1978 1982 { Increase was most profound in Quebec with rates going from 11 to 48 percent between 1965 and 1978. { Note the very low rates in Quebec and the Maritimes in the 1960s { By the 1980s these rates had narrowed in relation to national averages but still lagged { Income, was an important determinant of breast feeding behaviour too (See next slide) Percentage of Mothers Initiating Breastfeeding by Income Level, 1965-71 verus 1994-95 0 20 40 60 80 100 1965-1971 1994-95 Year P e r c e n t a g e  o f  M o t h e r s Low Income Medium Income High Income { In the 1960s income mattered as poor women were less likely to initiate breastfeed than rich women. { By the early 1990s income appears to be a less important determinant of initiation of breast feeding than 30 years prior. { The revolution in breast feeding behaviour among educated women was closely linked to re-emergence of feminism in the 1960s and 1970s and associated efforts by women to reclaim control over their bodies in relation to technology, particularly medical technology. { In the 1920s middle class birthing women wanted medical technology including artificial feeding. { In the 1920s working birthing women needed artificial feeding. { In the 1970 birthing women wanted natural child birth and breast feeding. 1980s Breast feeding Promotion { A national campaign to promote breast feeding was launched by Health Canada in 1979. { According to Myres, “It was believed that if first the medical profession could be influenced to be more supportive in motivating women to breastfeed and secondly, that if this was followed up with practical and helpful advice, a significant step forward would be made which would have a cascading effect throughout the health care system” (Myres 1988, 101). { Breastfeeding promotion efforts of the 1980s were the broadest, best-funded, best-designed, best-programmed, and least dependent on mother’s education, ever developed by any Canadian federal government, they were promulgated after a decade of dramatic increases in breastfeeding rates. { As well, during the heyday of these promotion programs in the mid-1980s, breastfeeding rates remained relatively flat in Canada. While these promotion efforts may have consolidated and helped sustain these increases in breastfeeding practices, they clearly did not cause them. { The breastfeeding promotion efforts in Canada in the 1980s were unique because they involved government promotion of much broader initiatives rather than a focus solely the education of mothers. { The federal government became involved in complex efforts to promote linkages and alliances with women’s groups, La Leche League, industry, hospitals and hospital associations, various health professional organizations, and consumers. { These efforts occurred within the context of a strong, popular, broadly-based, international and national movement against the marketing of infant formula launched by the Nestle Boycott beginning in 1977. { A 1982 survey was implemented on breast feeding initiation and revealed that 71 percent of all mothers received a free sample of commercial infant formula in hospital. { These sorts of results in the context of the Nestles boycott created pressure on hospitals throughout the country to dispense with free provision of formula. { Education efforts were, for the first time directed at changing the practices of health professionals and, probably most importantly, encouraging hospital practices which valued and supported breastfeeding. { Finally, these efforts were universal, that is they were not targeted at particular “high risk” groups of mothers and lacked the moral and patronizing tone of the 1920s. Inertia Over the Past 20 Years { Federal breastfeeding promotion efforts shifted once again in the mid- 1990s, and these coincided with an approximate 10 percent increase to the 2000s, in breastfeeding initiation rates. But, the efforts of the 1990s were in some ways a retreat from the 1980s. Many initiatives have been partially or inadequately implemented. { While the federal government has been a signatory to international agreements such as the WHO Code, the Innocenti Declaration, and the Convention on the Rights of the Child, these agreements have never been translated into legislation or backed with substantial financial or material resources. { Surveys and anecdotal evidence suggest that most health professionals remain woefully ignorant of the benefits of breastfeeding and lack the practical skills to support mothers. { Since the mid-1990s, the formula industry has developed more aggressive and direct marketing campaigns. { While Canada has signed on to important international accords promoting breastfeeding, it is not clear that the federal government has followed through on these agreements within Canada. { Finally, it appears that the money allocated for breastfeeding promotion over the past decade is significantly less than in the 1980s and that the alliances, activism, and political context of this promotion has drastically shifted. { In the absence of federal leadership, several provincial governments have begun to develop and introduce breastfeeding policies, including Quebec (2001), Nova Scotia (2005), and New Brunswick (2006). { While several provinces do not have explicit breastfeeding policies, several have provided some funding to support breastfeeding initiatives (e.g., British Columbia, Alberta, Manitoba, and Saskatchewan). While these initiatives are encouraging, they have resulted in a patchwork approach to promoting breastfeeding. { It appears that, in the 2000s, the pendulum has swung back towards earlier promotion strategies based on educating mothers { Rather, as in the 1980s, than emphasizing the importance of industry, the health care system, networks of women, and employers, government policy tends to view mothers as being most responsible for infant health. Breast Feeding Policy for the 21st Century: The Role of Historical Insights { There are five principles, garnered from a consideration of the changing history of breastfeeding practices and policy, that we think are important for policy makers seeking to increase breastfeeding rates in Canada. { First, definitions of breastfeeding success (which become the goals of promotion policy) must be made with the full participation of breast feeding women and, most importantly, with much better knowledge and understanding of their diverse needs. { Second, the very real tension between women’s productive and reproductive roles and the state’s interest and function in supporting these distinct but related roles must be made explicit in the development of breastfeeding policy. { The issue of women’s work has been implicit in past policymaking and the inability of policy-makers to accurately analyze and understand these issues has constrained the design of labour force policies which improve the lives of breastfeeding women and their children. { Third, sole reliance on classical health promotion education directed at mothers to change breastfeeding practices is a mistake. { Fourth, education efforts instead should be directed to hospital administrators, nurses, and physicians to ensure that they have the necessary education and tools to support the choice of mother’s to breast feed. { Fifth, the market place must be constrained as it has historically not been the best place to develop and promote ideas about infant feeding. References Almey, Maria, Josée Normand, Colin Lindsay, Jennifer Chard, Sandra Besserer, Valerie Pottie Bunge, Heather Tait, Marcia Almey, and Nancy Zukewich. 2000. Women in Canada 2000 A Gender- Based Statistical Report. Ottawa Ontario: Statistics Canada Ayre-Jaschke, Leslie Elaine. 2004. Preparing for Breastfeeding: Mothers' Perspectives on learning from Unsuccessful and Successful Experiences, Faculty of Graduate Studies and Research, University of Alberta, Edmonton Breastfeeding Committee for Canada. 2006. Breastfeeding Canada, Issue 1. Toronto: Breastfeeding Committee for Canada. Greiner, Ted. 1990. Breastfeeding and Working Women: Thinking Strategically. Paper read at Work, Women, and Breastfeeding, at Brasilia. Harrison, M.J., J.M. Morse, and M. Prowse. 1985. Successful breastfeeding: the mother's dilemma. Journal of Advanced Nursing 19:261-269. Hauck, Y., and J Reinbold. 1996. Criteria for successful breastfeeding: mother's perceptions. Australian College of Midwives Incorportated Journal 9:21-27. Leff, Ellen W., Margaret P. Gagne, and Sandra C. Jefferis. 1994. Maternal Perceptions of Successful Breastfeeding. Journal of Human Lactation 10 (2):99-104. Leff, Ellen W., Sandra C. Jefferis, and Margaret P. Gagne. 1994. The Development of the Maternal Breastfeeding Evaluation Scale. Journal of Human Lactation 10 (2):105-111. McKinley, Nita Mary, and Janet Shibley Hyde. 2004. Personal Attitudes or Structural Factors? A Contextual Analysis of Breastfeeding Duration. Psychology of Women Quarterly 28:388-399. Millar, Wayne J., and Heather Maclean. 2005. Breastfeeding Practices. Health Reports 16 (2):23-31. Palda, Valerie A., Jeanne-Marie Guise, C. Nadine Wathen, and Canadian Task Force on Preventive Care. 2004. Interventions to Promote breast-feeding: applying the evidence in clinical practice. Canadian Medical Association Journal 170 (6):976-978. Province of British Columbia Ministry of Health. 2005. Baby's Best Chance: Parents' Handbook of Pregnancy and BabyCare. Sixth ed. British Columbia, Canada: Open School BC. Schmeid, Virginia, Athena Sheehan, and Lesley Barclay. 2001. Contemporary breast-feeding policy and practice: implications for midwives. Midwifery 17:44-54. Schmied, V., and L. Barclay. 1999. Connection and pleasure, disruption and distress: Women's experiences of breastfeeding. Journal of Human Lactation 15 (4):325- Sokoloff, Heather. 2004. 40% get nothing for maternity leave Series: The Myth of Maternity Leave. National Post, Mar 15, A.1.Fro. Van Esterik, P, and T Greiner. 1981. Breastfeeding and Women's Work: Constraints and Opportunities. Studies in Family Planning 12 (4):184-197. Van Esterik, Penny. 1989. Beyond the breast-bottle controversy. New Brunswick, N.J.: Rutgers University Press.


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