Friday, August 3, 2012

Latch On NYC: Less spin, more details please

"Mayor Bloomberg pushing NYC hospitals to hide baby formula so more new moms will breast-feed" screamed the headline a few days ago. In Mayor Bloomberg's Latch On NTC initiative, we were all told, not only were formula samples to be banned, but formula was now to be hidden away "in out-of-the-way secure storerooms or in locked boxes like those used to dispense and track medications," in order to discourage bottlefeeding, while those wicked mothers who requested bottles anyway were to be subjected to a "talking-to" for each and every bottle they received, by staff who will explain "why they should offer the breast instead." Now, two thoughts ran through my head upon seeing this. The first was, "Wow. This is going to cause a bit of controversy in the mommy blogosphere. I wonder if The Fearless Formula Feeder and Kellymom are onto this yet?" The second was, "Hmm. I notice that article doesn't actually link to an original source. I wonder how much of what's written here is true and how much is spin...?"

Well, the blogosphere got wind of Mayor Bloomberg's little wheeze, and commentary rapidly split down two predictable lines. The "Anti-lactivist camp" (many of the commentators on The Skeptical OB, The Fearless Formula Feeder, Bottle Babies and others) fumed about the proposals. "This is outrageous! It's a woman's right to choose formula--how dare hospitals lecture them about it? Or treat formula as though it was something akin to cigarettes?" The "Lactivist camp" (Kellymom, Best For Babes and all the rest of the crunchosphere--which, by the way, hugely dominate online discourse about motherhood in spite of the beleaguered-minority identity) immediately shot back, "No, this is a great initiative. And the media hasn't reported this properly. Go to the Latch On NYC website--they're not going to lecture women about using formula. And by the way, it's normal hospital practice to lock up items used in the hospital, including food."

Well... with some trepidation, I went to the Latch On NYC website, grimly saying to myself over and over again, "I will not, NOT form an opinion until I have read what the actual initiative itself says...minus the media spin." And even before opening up the Initiative Description and FAQs, it was pretty apparent that there was some serious spin going on. I mean, before long there were news articles appearing which were proclaiming "NYC plans to ban baby formula in hospitals"--absurd.

Well, according to the Initiative Description, the initiative consists of the following:

A call to all NYC maternity hospitals to make a voluntary commitment to support mothers who choose to breastfeed by:
- Enforcing the NYS hospital regulation to not supplement breastfeeding infants with formula
feedings unless medically indicated
- Limiting access to infant formula by hospital staff
- Discontinuing the distribution of promotional or free infant formula
- Prohibiting the display and distribution of infant formula promotional materials in any
hospital location
- A public awareness campaign to promote the health benefits of breast milk, and to inform women of their right to receive education, encouragement and support to breastfeed their babies if they choose to do so.
 So, it looks like the lactivist camp was right to claim that there is some media misreporting--or at least, overextrapolation--going on.
I'll be honest--I think much of what is written here falls into the categories of "Good" or "Neutral." I'm agnostic on ban-the-bags--I don't particularly feel that one's human rights are infringed on by not receiving a freebie; I didn't get free formula from my Japanese hospital, either, and didn't feel deprived. I also feel that ethically speaking, it is questionable for hospitals to receive gifts from commercial organizations because it can create conflicts of interest--although I think that if we are going to ban the bags then to be fair we should be banning all gifts and samples to the hospitals. The "unless medically indicated" bit did make me raise my eyebrows for a second... are they proposing that formula feeding should only be permitted for medical reasons, meaning women should not be permitted to formula feed by choice? But a second glance indicates that this is for breastfed infants only (i.e., you don't give formula to babies whose mothers have chosen breastfeeding, unless there is a medical reason to override her wishes). That's a positive thing.
What about the locking-up of formula? Let's take a look at the FAQ page.
 What does it mean to restrict access to formula?

Restricting access to formula means storing formula away from where it is easily visible and accessible to staff and mothers. Access to formula is restricted by both:

Storing formula in a locked location, such as a storage room, cabinet or an automated medication system or, storing formula in a location outside, but reasonably near, the maternity unit...
  "Locking up" does sound alarming, but I think it's only fair to point out that hospital supplies including sanitary pads, food and just about everything else are usually locked up, recorded and tracked--in part because patients are usually charged for them. Again I think we are seeing a little bit of the phenomenon of journalism that epidemiologist Elizabeth Pisani calls "beating it up." "Making it up" means inventing things up out of thin air. "Beating it up" means presenting true facts in a way which makes them sound as alarming as possible, in order to whip up a bit of hysteria and controversy (which in turn will generate sales and page clicks).

What does concern me a little, is the following sentence:
...Limiting the number of hospital staff with access to formula by implementing a system to identify which hospital member accessed the formula supply; some examples are a log book, a code or a key system.

Restricting access decreases the likelihood that staff will distribute, and inadvertently market, formula.
 It may well do so. It also increases the likelihood that mothers are going to be kept waiting God knows how long while waiting for a bottle to appear (as their newborn screams with hunger) because the reality of hospitals is that there are never enough staff and there are constant complaints from new mothers about lack of support already anyway, and restricting. And then you get mothers inadvertently stretching out the periods between feeds  as long as possible... and pushing the baby to "finish the bottle" when the formula is finally available, in order to avoid the whole process of trying to actually get hold of a bottle of milk. This isn't promoting good feeding practices or responsive parenting. Rule No. 1 = Feed The Baby.

What about the "lecture with every bottle" bit that is allegedly going to form part of Latch On NYC? Here is the relevant section in the FAQ.
What do we tell our staff to do when mothers (families) request infant formula?

While breastfeeding is healthier for both mothers and babies, staff must respect a mother’s infant feeding choice. Educating mothers and families about breastfeeding and providing encouragement and support, both prenatally and after birth, is the best way to ensure breastfeeding success in your hospital.

While in the hospital your staff can:
Assess if breastfeeding is going well and encourage the mother to keep trying.
Provide education and support to mothers who are experiencing difficulties.
If the mother still insists on receiving formula, document it in the chart along with the  reason and distribute only the amount of formula needed for the feeding.
Train staff in breastfeeding support (CLC, IBCLC) who can be available to assist new mothers at all times regardless of day, night or weekends.
 Well, first of all, claims that formula feeding is going to be banned from New York hospitals do indeed appear to be a bit of media hype; Latch On NYC does give at least token support for mothers' choice to formula feed. The bit about training staff in breastfeeding support is great.

But what does "Assess if breastfeeding is going well and encourage the mother to keep trying" actually mean in practice? If the mother says clearly "I don't want to do this any more," is the nurse required to keep urging her to continue? Where do you draw the line between support and nagging? The initiative gives us no clear answers. Certainly, the use of the word "insist" here is deeply problematic. My understanding is that a person only "insists" on doing something when they continue to state their need after having experienced a considerable amount of pressure to do the opposite.

My guess is that what will actually happen is that these ideas will be interpreted in different ways depending on the hospital staff member in question: staff who are basically respectful of all feeding choices will continue to act accordingly, but staff who have the lactofanatic light in their eyes may well see this as a permission slip to harangue mothers more than they are already doing. I don't think it's much of a stretch to imagine this, given that women are already being harassed in "baby friendly hospitals" for choosing to give formula.

Details, details, details
There is a lot about this initiative that is concerning, but we need to make sure that we are focusing on the right things. The initiative doesn't say anything about giving mothers a "talking-to" about using formula, and it certainly doesn't seek to ban formula. But there are some real problems with some of the things it is outlining. What's more, a lot of the initiative is maddeningly vague, and that openness to different interpretations could result in it becoming a green light for bullies.

There has been a lot of negativity about Latch On NYC in the past few days; if its authors want to rescue its credibility, they need to rewrite the thing, spelling out carefully exactly what they are going to do to support breastfeeding and formula feeding mothers and make their lives easier. Otherwise, the only thing Latch On NYC will achieve will be to add an extra keg of dynamite to the mommy wars.


  1. My concern over the initiative comes from comments made by Bloomberg and his camp in the press. That colored my reading of the actual literature (which I did actually READ, unlike most of the folks commenting about this online). I think you're quite right that the vague nature of the language her leaves a lot to interpretation, and that is why I worry.

    I saw one commentator make an analogy between what's recommended in this initiative and showing a woman an u/s of her fetus prior to allowing an abortion. I actually think this is a good analogy. In both cases, the folks upholding these policies can calmly say, "see? We're not BANNING you from anything; we're not FORCING you to use your bodies in ways which we deem 'correct.' We're simply providing you with more information, so that you can be REALLY sure about your choice." And they are right. But there's a reason why people are up in arms about the ultrasound-before-abortion thing, and it has nothing to do with "banning" or "forbiding" a woman to terminate a pregnancy. It's because doing this is cruel, and while it may serve to change some minds, it will do a lot of damage in the process, and also really infringes on personal liberties and, well, common decency.

    I understand where you are coming from, and I think you offer a very rational POV on this. But I also stand by my outrage at this act.

  2. My biggest problem is that this initiative is SO focused on the formula. It doesn't set women up for breastfeeding success by educating health care professionals on BF and BF troubleshooting; by informing women of the benefits and what to expect prenatally (when they have time to weigh the arguments before post-partum stresses and a new baby arrive); or by providing the support, both immediate and extended, needed for many women to successfully breastfeed. IMO, not setting a woman up for breastfeeding success and then making her jump through (unnecessary, punitive feeling) hoops if she does is just cruel.

    I'm also a bit of a cynic, since I see this as a hospital PR move. By "voluntarily" signing on to Latch on NYC, the hospital can get the PR boost from a breastfeeding-friendly façade without actually having to invest in the staff infrastructure to really help more women breastfeed. Consider my breastfeeding example: Mother's baby has early onset jaundice. Baby miserable under bili lights so falls asleep any time nursing. Baby's jaundice worsens because he's not getting enough fluids. LC around for about 10 minutes and says there's nothing wrong with mother's technique. Still worsening, pediatrician says to supplement with formula and nurse gives it to baby in a bottle. There you go, formula medically indicated per the Latch on NYC guidelines. Did that help me succeed at breastfeeding? Hell no!!! The ONLY thing that saved my ability to breastfeed was that I knew that breastfeeding wasn't going well and I needed more help than the hospital was able to provide. I hired a private lactation consultant, was able to tell the staff I needed a pump and syringes for finger feeding (something NEVER even mentioned before the private LC), and pushed myself through the extra pumping-induced sleep deprivation (whilst recovering from a c-section with a deployed husband no less). And I was only motivated to push through the difficulties because I had it explained long prior to the birth how important breastfeeding was and why it was worth it. I desperately wanted to breastfeed and was almost pushed into formula feeding by a hospital that for all intents and purposes with me followed Latch on NYC because they didn't have the staff infrastructure of educated healthcare professionals to keep me from failing!

    1. And I say that because the only parts about educating and training staff are exceptionally vague, unlike the formula-controlling formula. No guidance on how many LCs the hospitals should hire, what percentage of their time would be taken up by actual consulting vs. other nursing work, when/if there should be prenatal breastfeeding classes and how to run it, or WHAT is needed to train staff, but by golly, you know what you should do with that formula!

  3. No kidding. I never saw a LC in the 3 days I was in hospital. I saw one with my first baby-- on the last day. I got a pump, but I had to wash my own pump parts (thanks!) and was never given a firm answer on what I should do with my pumped breast milk. The staff delays between getting pain meds and formula were bad-- if I hadn't known what I needed (because I'd done it before) I would have been in a pretty pickle.

  4. Breastfeeding Without BSAugust 5, 2012 at 2:39 AM

    "By "voluntarily" signing on to Latch on NYC, the hospital can get the PR boost from a breastfeeding-friendly façade without actually having to invest in the staff infrastructure to really help more women breastfeed. "

    This is a really, really good point! The initiative is remarkably vague on what kind of support (as opposed to bottle-blocking) they are going to do... figures, targets, nowhere to be found.

    "But there's a reason why people are up in arms about the ultrasound-before-abortion thing, and it has nothing to do with "banning" or "forbiding" a woman to terminate a pregnancy. It's because doing this is cruel, and while it may serve to change some minds, it will do a lot of damage in the process, and also really infringes on personal liberties and, well, common decency."

    Yup, this is the other worry. I wonder how high a price (in terms of PPD) we are all going to pay for all of these initiatives...

  5. I have to say, in addition to the excellent, thoughtful points you make, I am actually worried about the language about "medically indicated". You correctly point out that this clause is limited to breastfeeding infants, but the interpretation of this as "if the mother chooses to provide formula we do not need a medical reason to give formula" is pretty sophisticated reading - and not necessarily obvious to a staff member trained in things that are not interpreting legal language. They may read the language - as I think many of the lay people who read the initiative read it - to mean "only allow moms to give formula if there's a medical reason". I would also add that even a mom who initially wanted breastfeeding - and wants to continue breastfeeding - might want, at times of exhaustion, to supplement with formula - lots of moms do at home - and I don't accept that it's okay to limit that supplementation to when there's a medical reason (though I think your point about staffing applies here too: If a mom initially committed to breastfeeding, finding a staff member to provide formula on demand will not be as easy as it may seem). I think this language is problematic.
    I also think that for most moms, going home after 24-48 hours, at most a few days, it's not as big a deal - but I'm wondering how this would work for moms with kids with problems who need to stay in the hospital a long time. Many of these kids will require formula for medical reasons; but again, this sounds, as I think you said (correct me if I'm misrepresenting your words) as if it will make access to formula harder, period - and over a few months, that sounds problematic.

    1. Yes, this was my main concern too, that "medically indicated" means a parent who says they want to bottle feed out of choice will be in a limbo. If the default option is to treat all mothers as breastfeeders and give them the support they need but then tell those who don't BF that they'd better try harder or are off the wagon and essentially on their own is problematic. There should be protocols for those who say they want to BF, separate protocols for those who say they want to FF, and perhaps a third set of protocols for those who want to BF but run into difficulties. I suspect the latter category is the one that the initiative is targeted at, because so many women fall into this category and feel they were undermined or, conversely, bullied, against or for BFing. I think the hospitals would do better to have a strict "respect the parents' choice" protocol first. Then, hire and train better lactation support staff. You aren't going to increase BFing rates by simply restricting formula-pushing.

  6. Hey- just wanted to let you know I quoted (and linked back to) this post today:

  7. You did indeed--thanks!

    The annoying thing is, I had the original documents from the Latch On initiative actually printed out in full (I was reading them over the bath). If I hadn't thrown them away, I could have scanned the whole thing and added them to the blog post so that we would have had the whole thing in full. Too late now... oh well!