Volume 2, Issue 2 -- April 1999

Formula Purchasing: Moral Obligations of Health Institutions

There are two ways to nourish newborns: by using formulas manufactured to simulate breast milk or by breast-feeding. There is much evidence that breast-feeding results in better health for both mother and child. If the values underpinning the health system are such that the system's objective is to advance the health and well being of those in its care, then based on this evidence we ought to be promoting breast-feeding because it is the best way to achieve the goal of good health for both mother and baby. However, some Canadian health care institutions are taking actions that undermine breast feeding. These actions go against the basic values of benefiting those in the institution's care.

The health benefits of breast feeding to the infant are related to the species-specific composition of human milk, its high nutrient quality, its ease of digestion and absorption, and its immunological properties which provide protection that extends well beyond the first year of life. These benefits translate into reduced risk of infant mortality and morbidity with enhanced immunity and cognitive development. A few of many examples of these benefits include: formula-fed infants were twice as likely to have middle ear infections in the first six months of life compared to exclusively formula-fed infants (Duffy); an increase of invasive influenza infections was observed when breast-feeding was limited to less than 13 weeks - the association was stronger at 12 months, and persisted for months and years beyond the period of breast-feeding (Silfverdal); and epidemiological studies report increased morbidity from diabetes in children who were formula fed (Pettitt).

Breast-feeding protects a mother's health as well. There are data to indicate less anemia, reduced risk of breast and ovarian cancer, and potentially decreased incidence of osteoporosis in mothers who breast-feed (Lawrence).

That breast-feeding is beneficial is supported by international initiatives endorsed by Canada. In 1981 as a member of the United Nations, Canada supported an International Code of Marketing of Breast Milk Substitutes (the Code). Following the 1991 World Summit for Children, Health Canada established the Breast Feeding Committee for Canada (BCC). In 1996, the BCC identified the WHO/UNICEF Baby-Friendly Hospital Initiative as the primary strategy for promotion, protection and support for breast feeding in Canada.

In spite of these accomplishments, in Canada our progress is limited.

A survey of Canadian hospitals providing maternity care in 1995 reported that "while 58.4% (296/507) had a breast-feeding policy, only 4.6% (21/454) reported having one that complied with all of the WHO/UNICEF steps surveyed." When compliance with the Code was added, the number dropped to 6 hospitals (1.3%) (Levitt et al.).

While accurate and comparable data across the country are limited, it is reported that in 1995, 73% of mothers initiated breast feeding, but only 31-33% were still breast feeding two months after their baby's birth. While 73% appears to be a respectable level, one has to realize that this rate drops by one third within 24 hours of birth and by 6 weeks it is less than 50%; by 4-6 months post partum only 10-25% of mothers are partially breast-feeding. Yet, the majority of benefits to both baby and mother are directly related to the duration of breast feeding (Breastfeeding Committee for Canada).

Several factors contribute to a short duration of breast-feeding. First, learning to breast-feed takes time and proper support for both mother and baby. This is a challenge when hospital postpartum stays are reduced and women are much less likely to have a mother, sister or friend who has breast-fed and who can provide the required assistance (in Canada two generations of women have generally not breast-fed). Secondly, health care professionals tend to have limited knowledge of the importance of breast-feeding, of how to support it and of the techniques mothers need to know to be successful. Furthermore staff (like first-time mothers) are unlikely to have personal experience with breast feeding.

Inadequate support for the management of problems in the first few days is seen to be a major reason for cessation of breast-feeding. While infant formula, which is so easy to access, is a simple solution to these problems, it does not have the benefits associated with breast-feeding. Finally, the perception of breast-feeding as merely a lifestyle decision, rather than a significant health issue has been the prevailing public and health professional position. Consequently people mistakenly believe the choice to breast-feed is not an important one.

Underlying our health system is the moral value of beneficence. Accordingly, the goal of all health care activity is to protect/advance the well-being of those in our care. Above all, the maxim goes, one should "do no harm" in providing care. Breast feeding has been demonstrated to benefit immensely both moms and babies. Discouraging breast feeding could have relatively harmful effects on moms and babies. Therefore, there exists a strong moral obligation on health care providers and facilities in Canada to support breast-feeding.

The problem is that we continue to engage in practices that do just the opposite. On the one hand Canadian hospitals do not seem to be responding to the systemic concerns raised above that discourage breast-feeding. This is made worse by the fact that Canadian hospitals continue to accept large sums of money in return for exclusive contracts for infant formula.

This results in parents perceiving that: 1) formula is an appropriate and acceptable breast milk substitute, and 2) that the formula available in hospital is the "preferred" formula. Thus, the institution is seen as endorsing its use. This marketing advantage has been the target of formula companies for decades and is so significant, infant formula is usually provided free to hospitals. Again, this is ethically problematic because it violates the fundamental objective of the health system-advancing well being.

Contracts with companies making infant formula are entered into by hospitals in exchange for funding that benefits patients - a laudable objective at first glance. However, there is reason to think that not only are these practices ethically questionable, but also fiscally inefficient! Contracting with formula providers also results in immense costs to the health care system as a whole. For example, a 1995 study from New Brunswick reported breast-fed babies were 47% less likely to have gastrointestinal illness, 34% less likely to have respiratory illness, and 56% less likely to have middle ear infection (Beaudry et al.). Data from a five-year follow-up of infants at high risk for allergies support the recommendation that exclusive breast-feeding is an extremely cost-effective strategy for prevention of allergic disease in high risk children (Chandra). It is clear that the potential cost savings associated with breast feeding are significant.

Breast-feeding is important to the health of mothers and babies and results in reduced financial costs to the health system as a whole. Hospitals have a moral obligation to do what they can to endorse and support this method of nourishment. Hospitals accepting money and/or free formula run the risk of: 1) violating basic values of the health system by not providing the best care available - indeed of possibly causing relative harm, and 2) being "penny wise and pound foolish" looking after short term financial interests instead of long term fiscal responsibility. The potential to realize lost health and financial benefits represented by the current lack of breast-feeding rests in the hands of public policy makers, health care professionals and the public at large.

• Beaudry M., et al. 1995. "Relation Between Infant Feeding and Infections During the First Six Months of Life." Journal of Pediatrics 26(2):191-197.

• Chandra R.K., 1997. "Five Year Follow-Up of High Risk Infants." Journal Pediatric Gastroenterology Nutrition 24(4): 380-88.

• Duffy L.C. et al., 1997. "Exclusive Breast-Feeding Protects Against Bacterial Colonization and Day Care Exposure to Otitis Media." Pediatrics 100(4):e7.

• Lawrence R.A., 1997. "A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States" Maternal and Child Health Technical Information Bulletin. Arlington, VA: National Center for Education in Maternal and Child Health.

• Levitt C.A. et al., 1996. "Breast-Feeding Policies and Practices in Canadian Hospitals Providing Maternity Care." Canadian Medical Association Journal 155(2):181-188.

• Pettit D.J. et al., 1997. "Breast-Feeding and Incidence of Non-Insulin Dependent Diabetes Mellitus in Pima Indians." Lancet 350(9072):166-168.

• Silfverdal S.A. et al., 1997. "Protective Effect of Breast-Feeding on Invasive Haemophilus Influenzae Infection: A Case-Control Study." International Journal of Edpidemiology 26(2):443-50.

Announcements

• St. Stephen's College in Edmonton is hosting a workshop entitled "Understanding Our Tough Choices: Introducing the Ethical Preferences Inventory" on May 11, 1999. For more information please contact the College at (780) 439-7311.
  
• The Network office is in the process of updating its list of Ethics Committees and Chairs in the province. If you are a member, and particularly a chairperson, of an ethics committee in Alberta, please visit the listing of ethics committees posted at http://www.phen.ab.ca/ethics committees , and send a message to the PHEN Webmaster, indicating whether the information listed is up-to-date.
  
• PHEN hosted a meeting of RHA representatives to discuss the state of regional and institutional ethics committees across the province on March 29, 1999 in Edmonton. All 17 Regional Health Authorities, as well as the Alberta Cancer Board, Provincial Mental Health Advisory Board, and the Catholic Hospitals Corporation, were represented. Donna Towers, a surveyor for the Canadian Council on Health Services Accreditation, reported on the criteria for evaluating processes to resolve ethical issues within a region, and on the new draft accreditation requirements being considered for introduction in 2001/02. A number of regions reported having operational regional committees, with a few others in the process of, or considering, establishing one. Challenges cited included: difficulty accessing ethics resources, particularly for rural RHAs; limitations of volunteer time and resources; misperception of the role of ethics committees; and growing pains in establishing committee credibility and awareness. It was felt that holding similar meetings on a regular basis, perhaps annually, would be helpful.
  
• In response to a request from Alberta Health, PHEN coordinators and member representatives met with representatives of Alberta Health's Information Division to discuss the ethical implications of Health Information Protection legislation. Michael Yeo, a Bioethicist in Ottawa who has done extensive work on Ontario's parallel legislation, also attended. For information on this meeting please contact either of the Network Coordinators.
  
• Michael Stingl, Associate Professor, Department of Philosophy, University of Lethbridge, has been appointed to the Steering Committee for the Alberta Project to Enhance Organ and Tissue Donation and Transplantation in Alberta.
  
• PHEN Coordinators met with representatives of Population Health, Calgary Regional Health Authority on April 19, 1999 to identify possible areas of collaboration in working on a framework for public consultation. For more information, please contact Bashir at the Northern Alberta office.
  
• A reminder that April 30 will be the last day for early registration for PHEN's May 21 Annual General Meeting & Conference, "When Values Collide Between Health Care Providers and Recipients". Visit PHEN's website for details.
  
• The next application deadline for PHEN's User Fund, offering financial assistance to those interested in pursuing education in health ethics by attending conferences and other courses, is May 1, 1999.
  
• The PHEN Board is pleased to confirm the appointment of Al-Noor Nathoo as Executive Director for the Network. Based in Calgary, Al-Noor will also continue to serve as PHEN's Southern Alberta Coordinator.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.