To the national departments of health and treasury

Republic of South Africa

Embrace is national movement for connected, supported and celebrated motherhood. We want to see every new mother embraced and flourishing from the start of her motherhood journey, understanding that an empowered and embraced mother raises a thriving child. We work to achieve this goal by facilitating the inspiration, mobilisation and connection between the mothers of South Africa. If the first 1 000 days of life are when the foundations of healthy brain development are built, then mothers are the sacred soil in which these foundations are laid. You cannot step over a mother to invest in her baby. Embrace believes the best interventions are the ones that understand the richness of the soil. As such, we noted, with concern, the removal of infant formula from the list of items under consideration for zero-rating.

We asked members of our movement to share their stories during World Breastfeeding Week 2018.  We asked them to tell us their breastfeeding stories: whether or not they breastfed, no matter how difficult or easy they found the process, or how long they were able to breastfeed for. We would like to share with you what those stories reveal about the debate between breast and formula, and what they suggest about the zero-rating of infant formula.

‘Breast is best’ is a myth

It was clear from the comments we received that mothers are well aware that breastmilk is the best source of nutrition for infants. There is no need to emphasize the superiority of breastmilk in comparison to formula or other alternative sources of nutrition, as Sarah Cosentino puts it: “Breast isn’t best. It’s what every baby should eat. Anything else, sadly, is inferior. Formula is for when what babies should eat (breastmilk), cannot be provided”.  In other words, formula is not on par with breastmilk and the statement ‘breast is best’ perpetuates the myth that the two are comparable.

It’s about more than the milk

Additionally, mothers pointed out that breastfeeding is not just about the nutritional benefits to the infant: it also provides significant and critical bonding opportunities during the early stages of a child’s life.  Leanne Johansson wrote:

What I often find missing in this debate is the fact that feeding choices are about MORE than just nutrition/health – both for the child and the mom. Suckling, for babies who are not developmentally able to self-sooth, is an important resource in emotional regulation. There are many babies who need the sucking motion to calm down, fall asleep, feel secure etc. How you feed a child often shapes the comfort mechanisms they become attached to […] Babies introduced to formula feeding often develop a preference for artificial nipples and so bottles and pacifiers are useful for calming them down when upset/putting to sleep etc. Breastfed babies often refuse those resources and rely on the mother’s breast. This is wonderful and natural and all sorts of [amazing]. BUT it is also a huge amount of pressure to be SOLELY responsible for both nutrition/health AND emotional well-being of your infant! I remember how guilty I felt whenever I left my daughter (for work, or for any other reason) because I knew that if she was upset NOBODY and nothing else would be able to provide her with comfort, even if they could manage to get some food in her. So I would return to a red-faced, sobbing infant (instantly soothed by my breast). Ask any mother who has done exclusive breastfeeding and they’ll tell you the same woes. Would I do it again? Absolutely! BUT I would have liked someone to have told me how much MORE is involved than just nutrients/health. I would have liked someone to tell me that this decision will impact your lifestyle, your independence, the equality structure of your marriage (since he can’t do the feeding/comforting as well), your sleep patterns, when your child weans etc. so that I would have been better prepared. And I fully support mothers who choose to formula feed precisely BECAUSE nutrients aren’t everything that’s affected in this dynamic.

 In addition to this, mothers pointed out how the public conversation about breastfeeding forgets that women’s bodies are intimately involved in breastfeeding:

Also, the fact that we talk about which is best (breast or formula) in terms of health/nutrition/biology alone is really part of the whole medicalizing of women’s bodies etc. We should really be talking about it far more holistically as part of lifestyle.

Structural Support is Critical

The effects of this is a stilted and incomplete conversation, that completely ignores the fact that breastfeeding is deserving of adequate support and resources.  In the face of a lack of such resources and support, many mothers face structural barriers that make it almost impossible for them to continue to exclusively breastfeed (or, in some cases, breastfeed at all).  Hays O’Dell wrote:

[…] there is nothing problematic with encouraging breastfeeding, however there is a huge lack of knowledge and support for mothers, mothers need accurate and realistic information about normal infant feeding, behavior and sleep, health care professionals lack basic knowledge on breastfeeding and society in general are not supportive in hands on and meaningful ways. Mothers deserve the truth, breastfeeding can be hard, babies don’t sleep and formula carries risks. We need more support!

Similarly, Shamim Allie wrote about the lack of breastfeeding support during the critical early postnatal stages:

I do think there is a gap in the health care system in that lactation care is not seen as a serious medical need. Hospitals, even private, do not always have accredited lactation consultants or a breast pump or know about cup feeding or kangaroo care, to name a few supportive measures for at risk infants.

One mom shared her experience:

I wanted to keep breastfeeding, but work made it impossible. Our office is open with zero facilities for me to use to pump and store my milk. After being on maternity leave, I didn’t feel I had the right to ask for any more accommodations from my boss or my team members. I had taken my 12 weeks’ maternity leave and it was clear people thought that was a luxury holiday. After two weeks of only being able to breastfeed in the nights and early mornings, my supply dropped and I felt defeated. The weekends were frustrating for my daughter and I. So we stopped. I feel a lot of guilt that I didn’t try harder to put my daughter before my boss.

(Exclusive) Breastfeeding is not always physically possible

In addition to structural barriers, some mothers report frustrating physical challenges they faced in trying to breastfeed.  Wardieya Mohammed writes:

I tried for one week after birth and my daughter was so unhappy, she always cried due to no / low milk supply. I started supplementing with formula and still enjoyed bonding during breast feeding whilst on maternity leave – best of both.

Marisa Calvert told us:

I too suffered from a low supply and the pressure on moms to breastfeed is so enormous, that you sort of get stage fright. Dealing with postpartum depression and the judgement from the mommy groups, I fell into a dark place. Until I met with other formula fairies who helped me overcome my own shortcoming. Now all I say is “Fed is Best”. Also, it’s been almost two years now and I am in a much better space.

Often, traumatic births in which mothers experienced a lack of support or appropriate care complicate the postnatal period and lead to significant challenges with breastfeeding. Philippa Webb writes:

After a very traumatic birth and ended in a general anesthetic for me, my daughter was born with a severe tongue tie. She had a beautiful latch but couldn’t get any milk out. After four dazed days of breastfeeding, she hadn’t had any dirty nappies and I realised something was wrong. Tongue ties are awful! Every doctor has an opinion and they all differ! It took 3 different doctors, a lactation consultant and a nurse before someone agreed to cut it for us. By then my milk supply had dwindled terribly and I couldn’t supply my daughter with any milk. I was devastated!

Formula for disaster: an information gap

In the absence of this affirmation of the decision to supplement breastfeeding with formula, or to stop breastfeeding altogether, there is often a dearth of information which can often prove deadly for infants. Tasmin Tiffany Johnson writes:

I love the saying breast is best however it is a very pressured statement. I’m all for breastfeeding and am always ready to give tips and advice to increase supply etc. But sometimes it’s just impossible to breastfeed. I have read many stories of babies dying because of dehydration because the mommy continued to breastfeed even though she had low supply. So I’m all for fed is best.

Even in cases were mothers were well-resourced and had easy access to good quality care for themselves and their infants, they found information was only made available to them at crisis points. Philippa Webb says:

I was very grateful to have a well-trained, level headed [lactation consultant] who advised on formula, feeding techniques etc. I found the lack of information on formula feeding very frustrating. Formula saved my daughter’s life. She’s a very happy, healthy toddler who has met all her developmental milestones. I was so surprised because I expected her to “suffer” on formula. I was able to breastfeed a little bit for a couple of months before and after work. It was more of a bonding experience for us than meeting her nutritional needs.

Raakhi Gadodia says:

When I had the nipple bleed and the one breast was slow, my [paediatrician] who is a close friend said, still breast feed but top up with a formula feed too. I was [hesitant]. She looked me straight in the eye and said “Fed is best!” And that was where my guilt was left. On the hospital floor, to be mopped away! Breastfeeding is an amazing privilege, but for a lot of us, when our bodies don’t perform we bring on the Mom guilt! FED IS BEST is my motto and it worked for my son and I. He got both breast milk and formula and is a healthy happy baby.

No information = bad information

Bongi Hill, a mother who is also a paediatric medical officer, says that the absence of information on formula in all spaces, but especially in less- and under-resourced spaces, gives the impression that formula is the preserve of the rich and well-resourced. As a result, mothers whose children are under her care often assume that formula is the best option for their babies.  She writes:

There’s this growing feeling or view that breastfeeding is for poor people with no resources/ access to amenities. This is actually making people in lower socio-economics reject breastfeeding and see it as uncool. I’ve seen the huge impact it makes to my patient’s moms when I tell them that I breastfed.

Rather than indulge in a meaningless comparison or debate, Dr Hill feels our focus should be on ensuring adequate information and sustained is available to all mothers:

I’m not at all interested in the silly good moms vs bad moms battle over feeding which is a usually a battle between (white) privileged people to be completely honest. I’m interested in helping women and children to survive and thrive. Every woman has a right to be fully informed and supported regardless of their feeding journey.

Conclusion

What does this mean for the matter of whether or not infant formula should be included on the list of zero-rated items? What these stories tell us is that formula feeding is not merely the result of a lack of knowledge about the nutritional and emotional benefits of breastfeeding. Rather, breastfeeding is often impeded by the following factors:

  • A lack of structural support in workplaces
  • A dearth of adequate and appropriate postnatal care and support for mothers
  • Significant physical challenges in the postnatal phase, for which mothers are not provided with appropriate care and advice

While breastfeeding is negatively affected by the above factors, it is critical to note that the availability and accessibility of formula is not given as one of these. Instead, the lack of information about formula feeding is identified as further complicating the feeding journeys of mothers who find themselves unable to breastfeed because of one or more of the factors identified above. This lack of information means mothers will continue to attempt exclusive breastfeeding, even when structural barriers or physical impediments make it extremely stressful.

Similarly, the secrecy in which formula feeding is shrouded gives the impression that it is an exclusive and, by implication, superior way in which to feed infants. This introduces a false dichotomy in working class and poorer communities, and the choice to formula feed is often made on the basis of this false impression.

Merely restricting the information about formula and the presence of formula companies in healthcare facilities, as per the World Health Organisation’s (WHO) International Code of Marketing Breast-milk Substitutes, is not doing enough to address dismal breastfeeding rates. If anything, our work with mothers suggests that restricting and regulating messaging and marketing alone contributes to declining breastfeeding rates. Instead, efforts to encourage breastfeeding must focus on the following:

Finally, we would ask the national treasury and the department of health to consider:

  • Making information to formula available in public documentation such as the ‘Road to Health’ booklet and in postnatal health briefings; and
  • Easing the (financial, emotional and physical) burden on those mothers who have tried to breastfeed and have, because of any of the impediments listed above, been unable to ensure their own and their child’s global health and well-being through breastfeeding.

While zero-rating formula may not prove to have much of an impact on the (relatively high) market cost of infant formula, zero-rating will prove an acknowledgement of mothers’ expertise and autonomy when it comes to their bodies and their children’s well-being as well as recognition of the fact that breastfeeding is not always possible. As it stands, the current high costs of formula, with the added sales tax, punish consumers and do not necessarily regulate the market which is dominated by a handful of multinational corporations.

The bulk of governmental efforts should therefore focus on those reasons why breastfeeding is not always possible, taking note that the accessibility of (and information on) formula is not such a reason.

We hope you will reconsider the decision to remove infant formula from the list of zero-rated items in join us by making this small step for the mothers of South Africa, and affirming the WHO’s assertion that “educational systems and other social services should be involved in the protection and promotion of breastfeeding, and in the appropriate use of complementary foods”.

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