A Recap of the USA Launch of the Lancet Series on Breastfeeding

by Lisa Mandell, MBA, IBCLC and Tova Ovits, BA, IBCLC

The USA launch of the Lancet Series on Breastfeeding took place 18 April 2023 in New York, New York, USA, and was attended by representatives of the International Lactation Consultant Association® (ILCA®), including Tova Ovits, BA, IBCLC, secretary of the ILCA Board of Directors, and Lisa Mandell, MBA, IBCLC, ILCA’s Global Advocacy Adviser. ILCA Executive Director Jenn Kasowicz, MA, attended the launch virtually. Ellen Chetwynd, PhD, MPH, BSN, IBCLC, the Editor-in-Chief of the Journal of Human Lactation, was also in attendance.

The purpose of ILCA’s representation at the launch was to gain insight into how the important information within the papers was being presented in the United States, and to have the opportunity to speak with other breastfeeding supporters and to advocate for skilled lactation care.

Introductory speakers Victor Aguayo, PhD, Director of Nutrition and Child Development at UNICEF, Fatmata Fatima Sesay, Nutrition Specialist in Infant Feeding at UNICEF, and moderator Nina Martin, editor and reporter for Reveal/Center for Investigative Reporting, opened the launch, collectively stating that the enablement of breastfeeding is a collective societal responsibility, not the responsibility of individual families, and set the stage for what the findings of the Lancet series mean for breastfeeding in the United States.

While 83% of birthing parents in the US initiate breastfeeding, only 24.9% of babies are being exclusively breastfed at six months of age, supporting the recurring theme that there is greater need for systems of support, including paid family leave and skilled breastfeeding support.

From the Series Authors’ Perspective

Rafael Pérez-Escamilla, PhD, professor at the Yale School of Public Health, explained that the phrase “commercial milk formula” (CMF) was used in the series rather than “breastmilk substitute” to highlight the artificial, processed nature of formula. The word “substitute” implies that formula is equivalent to human milk despite it being so different.

He discussed how commercial milk formula companies and marketers influence beliefs, values, and practices, especially by reframing normal baby behaviors (fussing, crying, spitting up) and creating opportunities that position formula as the solution. He also highlighted case studies from four countries which illustrated how investments in breastfeeding over the past decade has improved exclusive breastfeeding rates in those countries.

Cecília Tomori, PhD, Associate Professor and Director of Global Public Health and Community Health at the Johns Hopkins School of Nursing, identified that marketing of commercial milk formula has a powerful system of influence that is multifaceted, sophisticated, and well-resourced, especially with digital marketing that sells peace-of-mind while undermining parental self-efficacy. This type of product marketing differs from others as it has lifelong effects on the health, development, and rights of children.

She also shared that the WHO International Code of Marketing of Breast-milk Substitutes is oftentimes blocked, reinterpreted, circumvented, and ignored, and that the Codex Alimentarius is manipulated to establish weak standards that become a ceiling for CMF marketing regulation, instead of the minimum. Tomori emphasized that criticism of the industry’s marketing practices is not a criticism of parents’ decisions on how to feed their babies, further stating that the system targets individuals, families, society, businesses, government, and politicians to shape decisions that increase shareholder profits but at great cost. 

Katheryn Russ, PhD, Professor and Chair of Economics at the University of California – Davis, explained how the commercial milk formula industry is highly concentrated, with six highly profitable companies representing the majority of worldwide sales and provided examples of how the industry has worked to impact public policy and trade policy in the US. Inadequate paid leave makes it harder to breastfeed, and other policies make it difficult to pump milk at places of employment.

The authors also identified how racism in the US has resulted in inequities in Black and Brown communities, including breastfeeding support. 

Key Messages from the Series

• Breastfeeding success is a collective responsibility that depends on multifaceted policy and societal responses and is not the sole responsibility of individuals.
• Infant behaviors, such as sleep and crying, have normal trajectories like learning to walk or speak and can be misinterpreted as hunger or reframed as ‘abnormal’ to promote artificial solutions.
• Commercial milk formula marketing influences our beliefs, values, and practices. It has changed the infant-feeding ecosystem and its extent and power has not been fully appreciated by most in health, civil society, and government.
• There are many constraints for individuals who want to breastfeed. It is the responsibility of governments to implement structural interventions and policies to support breastfeeding and mitigate negative, undermining influences.

Additionally, the series speakers spoke about specific implications of the global Lancet series in the United States, and the many challenges facing implementation of the recommendations. Among the many important points they made, the following were most notable.  

• The US voted against adoption of the International Code of Marketing of Breastmilk Substitutes in 1981 and has continued to undermine the Code and subsequent World Health Assembly (WHA) resolutions.
• Lax privacy laws in the US allow for targeted digital marketing of CMFs and the lack of Code legislation results in rampant formula marketing of all kinds.
• US trade policy positions undermine attempts of other countries to regulate inappropriate marketing of CMFs.
• According to the Organization for Economic Cooperation and Development, the US is the only country out of 41 that lacks mandated paid parental leave.
• Systemic inequities in the US result in Black and Hispanic parents being significantly less likely than white parents to meet their breastfeeding goals. These same inequities influence Native and Indigenous families, but data is lacking. Racism is a key driver of these inequities.
• Many factors, including climate change, emergencies, water safety issues, formula contamination, racism, and more, result in a vulnerable first-food system in the US and contribute to an infant feeding crisis.
• There is extensive influence on health professionals in the US through sponsorship of conferences, associations, and research by CMF manufacturers (in violation of WHA 69.9).
• Health professionals in the US receive insufficient lactation training.
• The Baby Friendly Hospital Initiative (BFHI) has been a huge success in the US, with over a million births (almost 28% of all births) taking place in 590 BFHI-designated facilities.
• BFHI in the US still needs more investment, especially in facilities that serve communities that have not been reached, including many that serve Black and Brown communities.
• The 2022 White House National Strategy on Hunger, Nutrition, and Health recommends expanding breastfeeding support and counseling for mothers (p. 26) and recognizes some of the societal problems that need to be addressed.

Panelist Perspectives of US-Specific Issues

Sekeita Lewis-Johnson, DNP, FNP-BC, IBCLC, from the US Breastfeeding Committee’s Board of Directors, spoke about the need for greater breastfeeding support due to the coercion to give formula, lack of access to care, and lack of informed choice. She identified the important work needed to correct policy failures and to prevent them from happening again, the need for infrastructure to deal with emergencies, and the importance of centering policy decisions on the lived experience of Black and Brown families.

Ruth Petersen, MD, MPH, Director of CDC’s Division of Nutrition, Physical Activity, and Obesity, identified that although there have been improvements in breastfeeding initiation, racial disparities remain and that 60% of breastfeeding parents don’t meet their breastfeeding goals. The CDC now has county-level data that can help evaluate disparities and help local advocates focus on areas that need more support.

Stacy Davis, MPH, IBCLC, the Health Equity and Community Partnerships Manager for the National Women, Infant and Children (WIC) Association, spoke about the lack of societal support and the different needs in rural areas in accessing support. She identified that WIC is working to train staff as registered dieticians (RDs) and International Board Certified Lactation Consultants (IBCLCs) so they are more reflective of the communities they serve.

Lori Feldman-Winter, MD, MPH, Professor of Pediatrics at Cooper Medical School of Rowan University, identified the huge gap in physician education on breastfeeding as an important issue, with 55% of recent graduates reporting no training. She also discussed the lack of accountability and collaboration with other healthcare providers as well as short visits in clinical settings as contributing factors. Prenatal opportunities to discuss how to breastfeed, not just why, help increase breastfeeding initiation rates.

Camie Goldhammer, MSW, LICSW, IBCLC (Sisseton-Wahpeton Oyaté), clinical social worker and lactation consultant, founder of several organizations, and a devoted leader for Indigenous families, discussed the significant lack of diversity of IBCLCs and how breastfeeding is a traditional cultural practice. She emphasized the importance of increasing access to high-quality lactation support, especially with more peer counselors.

Tina Sherman, Senior Campaign Director for Maternal Justice at MomsRising, highlighted several achievements: the passage of the PUMP Act, Pregnant Workers Fairness Act, and the postpartum Medicaid extension. She shared that she would like to see more accomplishments in the areas of paid leave, affordable childcare, and having every parent go home with their baby.

ILCA’s Participation

As the only international association representing skilled lactation consultants, ILCA continues to support and actively participate in important advocacy-related efforts such as the Lancet Series on Breastfeeding. At the conclusion of the presentation, ILCA’s Advocacy Adviser Lisa Mandell thanked the Lancet authors and panelists, recognized the number of IBCLCs on the panel and in the audience, and asked how lactation professionals can help improve coordination of lactation care after hospital discharge.

Lori Feldman-Winter suggested that lactation consultants collaborate with and participate in dialogue with pediatricians about such cases. Sekeita Lewis-Johnson emphasized the importance of respect for the different roles of care providers, as well as the importance of dismantling the hierarchies prevalent in the healthcare field. 

What You Can Do

ILCA invites and encourages you to read the important information presented in the 2023 Lancet Series on Breastfeeding, and consider how you can use this information to advocate for improved policies and support in your community. You can also watch a recording of the USA Lancet Series on Breastfeeding launch, available in English and Spanish, here.