To get breastfeeding off to the best possible start, the new WIC food package strongly encourages exclusive breastfeeding. Since giving formula in the early weeks may prevent mothers from making enough breast milk, WIC helps protect a mother’s milk supply by not offering formula to breastfed babies in the first month of life.This news prompted some questions that I'd like to discuss:
In turn, fully breastfeeding mothers receive a greater variety and amount of foods than anyone else participating in the program. Fully breastfed infants receive more than twice the amount of baby foods than formula-fed babies from six months of age until their first birthday. Throughout an infant’s first year of life, the new WIC benefits are greater for women who choose to offer their babies more breastmilk than formula.
1) WIC is one of the largest purchasers of infant formula, distributing around half of the infant formula used in the United States. Is giving out formula for free (to the receipient at least, not to the taxpayer) inherently incompatible with its support of exclusive breastfeeding? In other words, can you really be promoting breastfeeding when you're still providing formula to any qualified WIC mother who wants it? I found that others have been asking the same question. In the International Breastfeeding Journal, George Kent discusses WIC's promotion of infant formula in the United States (full text is available--it's definitely worth the read!). A few excerpts from his article:
WIC has a breastfeeding promotion program, but its positive impact is diluted by WIC's infant formula program. It is difficult to see how offering free formula could fail to be an incentive to use formula. The inducement is not simply that something of value is being offered at no cost. Even if it is unspoken, there is the implicit message of endorsement: if a government agency is handing out this product, it must be good....2) Should WIC restrict formula distribution to mothers who have a medical contraindication to breastfeeding (adoption, certain medications or diseases, documented low supply from an IBCLC, etc)? One could argue that this would inhibit "freedom of choice"--a phrase that Americans love to throw around whenever they feel threatened in some way. Would women feed their infants something else besides formula (diluted juice, straight cow's milk, etc) if WIC did not provide it for free? Is it better to provide an inferior substitute for free, than to refuse to subsidize it "just in case" some women might (hypothetically) feed their infants something even worse?
WIC encourages breastfeeding as the best source of infant nutrition, and it earmarks funds for breastfeeding promotion and support activities. However, the budget for breastfeeding promotion [0.6% of the total WIC budget excluding rebates] is far less than the amount spent on obtaining formula.
On the other hand, would ending formula subsidies really inhibit freedom of choice? Women on WIC would still receive assistance with their own nutritional needs, and with food for their baby once it starts on solids. They could still choose to use formula--just at their own expense.
Is it right--from both public health and ethical perspectives--to not give free formula to women who choose not to breastfeed? There is a huge body of evidence about the health risks of infant formula. Is it right to supply it, for free, when breastfeeding would have greater health benefits and fewer health & medical costs? George Kent argued:
In 1993 the US government's General Accounting Office (now called the General Accountability Office) recommended that the government "develop written policies defining the conditions that would contraindicate breastfeeding and determining how and when to communicate this information to all pregnant and breastfeeding participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)" [p3]. The resulting study spells out the benefits of breastfeeding, and it provides a detailed analysis of the conditions under which breastfeeding might not be advisable, such as cases in which the mother has specific diseases or has taken certain kinds of drugs. The study concludes by reiterating the benefits of breastfeeding, and recognizing that there are rare situations when the mother should be counseled to not breastfeed. It ends by saying that "Breastfeeding should not be withheld from any infant unless absolutely necessary" [p32].The US Food Policy blog has a discussion about these very issues. Several commenters pointed out that there are other complex behind-the-scenes issues: lack of education about breastfeeding, breastfeeding difficulties, lack of maternity leave, lack of support for breastfeeding/pumping in the workplace. One commenter wrote:
What happened with these recommendations? Surely one must recognize the contradiction between acknowledging that mothers should only rarely be counseled to not breastfeed, and at the same time providing free infant formula to very large numbers of mothers.
Perhaps people should have the opportunity to choose to use infant formula, just as they are allowed to choose greasy hamburgers and cigarettes. The point here is that allowing a questionable product to be on the market is one thing. Having the government promote it is quite another. Having the government promote infant formula particularly among poor people raises enormous ethical questions. Does the balance of benefits and risks from the use of infant formula justify the government's providing infant formula to almost half the infants in the US?
Even if they ask, WIC will not provide alcoholic beverages to its clients. The fact that they might ask for beer, for example, is not a sufficient reason to provide it. Similarly, the fact that some WIC clients prefer to use infant formula is not a sufficient justification for WIC to provide it. The large-scale distribution of free infant formula by WIC to all clients who ask for it is a situation that needs to be fixed.
If infant formula could be demonstrated to produce better infant health, there might be a reason to distribute it without cost to those who could not otherwise afford it. However, there is no evidence to support the generalization that the use of infant formula results in better infant health than breastfeeding. On the contrary, the evidence clearly and consistently shows that the use of infant formula increases the risks of morbidity and mortality throughout the life cycle. The use of infant formula has been shown to be harmful to the health of mothers as well. The inescapable conclusion is that the government should not be distributing free infant formula.
It might be argued that if they were not supplied with infant formula, some WIC clients might instead use juice, cow's milk, evaporated milk, or over-diluted formula. There is that risk, but it is likely to be overcome with proper breastfeeding support, from WIC, employers, and others. Moreover, those who feel that they must use infant formula would remain free to purchase infant formula. It does not seem sensible to promote an inferior product simply because one can imagine something that is even worse.
The true killer of breastfeeding is the fact women in the US have to work to make ends meet- not the WIC office. Mothers are not milk cows and unless you have a sympathetic boss, pumping every two hours to maintain your milk supply disrupts work. Even then, some women find it impossible to pump because their bodies know the difference between pumping and nursing so then their milk supply drops or even dries up completely. Am I saying that women should not work?- No I am not. However I am pointing out how complex this problem is.Let's discuss!