Formula labeling violations to the WHO Code: a quantitative and qualitative analysis

BACKGROUND: The WHO Code on Marketing of Breastmilk Substitutes is intended to be adopted as a minimum requirement by all governments and aims to protect infant health by preventing inappropriate marketing of breastmilk substitutes. Labels need to have correct and clear dispositions since they frequently are the only source of vital information for consumers regarding the content of the product and its uses. OBJECTIVE: The purpose of this study was to determine violations to the provisions of the International Code Article 9 regarding infant formula labeling existing in Puerto Rico. Methods: A quantitative and qualitative evaluation of 34 labels of infant formula was done. Instrument 4-A of the IBFAN Monitoring Project (IMPIII) and the Standard IBFAN Monitoring (SIM) was utilized. This instrument included 14 criteria that identified violations to the International Code of Breastmilk Substitutes on labeling. Descriptive analysis was used for all variables. The 34 labels evaluated represent 77.3% of infant formula labels of the four companies which market them in the island. RESULTS: All the labels (100%) that were evaluated were found to violate the Code in one or more of its dispositions. Most striking violations include: a statement that breastfeeding is best is lacking in 73.5%, as well as a statement that the product should be used only on the advice of a health worker. None of the labels are written in Spanish, the local language. Text which may idealize the use of infant formula or discourage breastfeeding is present in 97.1% of the samples, and the same percentage has a photo or picture idealizing the use of infant formula. CONCLUSIONS: It is vital to produce legislation that implants the WHO Code in Puerto Rico in order to regulate indiscriminate marketing practices and their subsequent ill effects on children's health and breastfeeding practices.

Exploratory study: breastfeeding knowledge, attitudes towards sexuality and breastfeeding, and disposition towards supporting breastfeeding in future Puerto Rican male parents

Identify the breastfeeding knowledge, the attitudes towards sexuality and breastfeeding and the disposition towards supporting breastfeeding in future fathers were the aims of this study. A non-probabilistic sample (n = 100) of future Puerto Rican male parents was used in this study. A self-administered questionnaire was used consisting of four sections. Descriptive statistics were used for data analysis and t-test to the inferential analysis. 88.8of the participants presented a low level of knowledge. However, 81.6had a positive attitude toward sexuality and breastfeeding. Also, 92.0of the participants indicated much/enough willingness to support their partners in exclusively breastfeeding. Disposition to support the breastfeeding was associated with knowledge towards breastfeeding (p = 0.04) and attitudes toward sexuality and breastfeeding (p = 0.00). The knowledge and the attitudes, in this study, are strongly related with the disposition of the father to supporting the breastfeeding in the future.

Effectiveness in the implantation of law 155 of 2002 ordering the designation of spaces for breastfeeding in government agencies

As part of an effort to promote and protect breastfeeding among working mothers in Puerto Rico, Public Law 427 was passed in December 2000. This law grants a paid breastfeeding daily break for milk extraction in the workplace. In support of this initiative Public Law 155 was passed in 2002 ordering Secretaries, Directors, Presidents and Public Administrators of the government of Puerto Rico to designate breastfeeding spaces in the workplaces. OBJECTIVE: Describe the level of compliance with the dispositions of Law 155 in government agencies. METHODOLOGY: A cross sectional descriptive study was carried out. A sample of 28 government agencies was randomly selected, representing 25of the total number of agencies, and a structured telephone interview was administered using an instrument made up of 6 premises. RSEULTS: All (100) of the agencies had knowledge about the existence of this law, but only 50had set up and equipped the spaces. Of these, all had a table, a chair, and an electric outlet, 43had available running water, and 71provided a refrigerator for milk storage. Fifty three percent of the agencies reported having received followup communications to verify whether they were complying with the law, and 61reported having a written public policy in support of breastfeeding for working mothers. Only 54of the agencies stated they had offered some type of orientation to their women employees regarding their breastfeeding rights. CONCLUSIONS: In spite of over two years since the passing of Law 155, the majority of government agencies in Puerto Rico have not complied with its legal dispositions. It is necessary that the responsible entities watch for the satisfactory compliance with this law since working mothers need a secure and accesible place for milk extraction during the working day.

Puerto Rican health teachers: attitudes towards breastfeeding.

OBJECTIVE: The purpose of the study was to identify attitudes towards breastfeeding and support for breastfeeding in public in a group of health teachers in the Department of Education. METHOD: The study design was correlational descriptive. A self-administered questionnaire was used (Cronbach's alpha = 0.83) for 125 health teachers. Descriptive and inferential statistics (chi square and t test) were used for data analysis. RESULTS: 89.6% were women, 47.1% had 39 years of age or less, 76.4% were married, the median of years in the profession was 12.5. Only 8.8% had breastfed exclusively, 46.1% used artificial feedings exclusively, and 45.1% combined artificial milk and breast milk. A moderate/negative attitude towards breastfeeding was shown by 53.1%. 60.3% stated they agreed or totally agreed that in order to breastfeed the mother must follow a specific diet, 36.0% agreed or totally agreed that breast milk should alternate with artificial milk, and 100% of participants do not support breastfeeding in public. No significant difference was found in the attitude scale towards breastfeeding and the gender, the age, years in the profession, and the type of milk given their children. CONCLUSIONS: We must train teachers in the Department of Education, on a priority basis, in the field of human lactation in view of their importance for health promotion.

Profile of calls to a breastfeeding clinic information and help telephone line.

Breastfeeding mothers need orientation and help in order to succeed with breastfeeding. Lack of support from health professionals and societal barriers result in a median duration of breastfeeding in Puerto Rico of only 3 weeks. A telephone warm line at our breastfeeding clinic tries to provide some much-needed support and orientation. The purpose of this study was to determine the principal reasons for calls to the warm line and the action taken by the counselor. Five hundred and thirty three calls were received in a 4-month period. They were handled by certified lactation educators who gathered demographic and feeding information from the mother and registered the action taken. Descriptive analysis was used with crosstabs tables and multi-response analysis; chi-square test was used to establish the association between variables. 78.7% of callers were breastfeeding fully, while 21.3% were breastfeeding partially or formula feeding, 62.8% of the babies were 2 months old or less. 68.8% of the calls originated in the metropolitan San Juan area. The source of the referral was family/friend in 64.2% of calls, while only 9.8% of the callers were referred by a physician, 3.0% by hospital personnel and 2.0% by other health care providers. Significant differences between full breastfeeders and partial or artificial feeders were found in calls related to position (p = 0.01), engorgement (p = 0.04), breast refusal (p = 0.001), product information (p = 0.02), medications (p = 0.009), breastmilk management and storage (p = 0.001), and relactation (p = 0.02). Actions taken by the counselor included orientation, referral to breastfeeding specialist physician and referral to breastfeeding support groups or classes. Results indicate that more active promotion of referral to breastfeeding support groups or classes is warranted since this action was taken in only 14.5% of fully breastfeeding mothers and 12.6% of partial breastfeeding or formula users. Promotion of the warm line among physicians, hospitals and other health care professionals is also needed.

[Public policy for the promotion of maternal lactation in hospitals]. / Política pública para la promoción de la lactancia materna en las instituciones hospitalarias.

The policy for Breastfeeding Promotion in Puerto Rico includes as one of its goals, that all hospital in the island become Baby Friendly Hospitals. The authors present a hospital policy model which can be adopted and recommendations for the implementation of this policy are given.

[Ethical aspects of human lactation and breastfeeding]. / Aspectos éticos en la promoción de la lactancia humana y el amamantamiento.

Breastfeeding has experienced a surge in Puerto Rico thanks to the efforts of many women, as well as governmental, non-governmental and private organizations. Among the aspects which can affect the initiation, establishment and maintenance of successful breastfeeding one finds potential ethical conflicts among health professionals as well as the financial interests of the companies which produce and market artificial milks. These companies dedicate great marketing efforts and enormous sums of money in the sale of their products, in detriment of breastfeeding. The profit motive of these companies is in open contradiction to public health and to breastfeeding promotion. The international community has carried out efforts for more than two decades in the creation of structures which protect the rights of women and their children to ideal nutrition practices, free from commercial pressures, through breastfeeding. Possible ethical conflicts related to the new industry of breastfeeding paraphernalia are discussed, especially when these are marketed exclusively for profit. Recommendations are presented for health professionals in order for them to be able to face and respond to the unethical strategies practiced by the manufacturers of artificial milks in utilizing these professionals for legitimating and marketing their products.

The management of labor and delivery and its implications for breastfeeding.

The main professional organizations of obstetrical and pediatric care providers in the United States and Puerto Rico have issued official position papers in favor of breastfeeding. Routine labor and delivery practices, however, constitute frequent barriers for the initiation, type and duration of breastfeeding. Many of these practices, moreover, lack the scientific basis to justify their routine use. We analyze in this article some of the most common obstetrical practices and their impact on breastfeeding.

[Breast feeding in Puerto Rico: traditional patterns, national trends and future strategies]. / La lactancia materna en Puerto Rico: patrones tradicionales, tendencias nacionales y estrategias para el futuro.

The Puerto Rican society has gone through profound transformations during the past 50 years. Industrialization and the incorporation of women into the labor force have been accompanied by medicalization of the reproductive process and a progressive reduction in the prevalence of breastfeeding as the cultural norm for nutrition of infants. The data base for 1990 places Puerto Rico significantly below Latin America and the United States in the percentage of breastfed infants. The authors report their experience in the promotion of breastfeeding during the last 5 years. The principal negative factors which hinder the beginning and maintenance of successful breastfeeding are of a social nature. The orientation of physicians towards technology underrates the benefits of breastfeeding. The marketing strategies of the corporations which manufacture artificial milk continuously violate the International Code for Marketing of Breast Milk Substitutes and disfigure the community's perception on the benefits of breastfeeding. The lack of social and legal support for the breastfeeding working mother frequently prevents her from carrying out successful breastfeeding for the recommended period of time. Strategies are presented for the overturn of the existent barriers which have reduced breastfeeding in Puerto Rico to the present precarious levels.

[Knowledge about breast feeding and attitude to breast feeding in public of a group of high school students in the Caguas Educational Region]. / Creencias hacia la lactancia materna y la actitud hacia apoyar la lactancia en público de un grupo de estudiantes de salud de una escuela superior de la Región Educativa de Caguas.

The objective of this study was to identify the knowledge and attitudes towards breastfeeding and towards breastfeeding in public of a group of high school students in the Caguas Educational Region. The study design was a descriptive survey. The sample consisted of 101 students registered in the Health Course. A self administered questionnaire was used to gather the information. Descriptive and inferential statistics (chi square and t test) were used for data analysis. We found that the majority of the participants have the intention of breastfeeding or supporting breastfeeding for their children. We found, nevertheless, that there were misconceptions regarding breastfeeding which could develop into barriers for effective breastfeeding. It was also observed that support for breastfeeding varied depending on the location where it took place. Support was greater if it was done in non-public places. In conclusion, it became evident that there is a need for educational programs with correct information on breastfeeding and the importance of breastfeeding in public.

[Factors related to initiation, type and length of breast feeding among participants and non-participants in prenatal breast feeding education at a local hospital]. / Factores asociados al inicio, tipo y duración de la lactancia materna entre participantes y no participantes a charla prenatal de educación en lactancia materna de una institución hospitalaria.

The objective of this study was to determine the factors associated to initiation, type and duration of breastfeeding among participants and non-participants in prenatal breastfeeding classes at a local hospital (n = 153). Pre-experimental study design was used. The participants of the study were selected by simple systematic random sampling. Median age of participants was 28 years and 85% were married at the moment of the interview. 88.9% began to breast feed at some time and of these 32% breastfed for six months. Average number of school years completed by participants was 15.1 with a standard deviation of 1.9 years. The inferential results reflected statistical association between participation in prenatal breastfeeding classes and the initiation, type and duration of breastfeeding. Multiple regression results indicate a positive relationship between duration of breastfeeding and participation in breastfeeding support groups, after controlling for all factors of the conceptual model. The results of this study give support for hospital and community initiatives for increasing the incidence of breastfeeding and for extending the duration of breastfeeding. It is further recommended that continued education courses be offered to health professionals on breastfeeding techniques.

[Gynecologists-obstetricians and pediatricians: knowledge and experience concerning breast feeding]. / Ginecólogos-obstetras y pediatras: conocimientos y experiencia hacia la lactancia materna.

The objective of this study was to identify the level of knowledge and the experience towards breastfeeding of medical personnel (obstetricians and pediatricians) in two private hospitals in Metropolitan San Juan, Puerto Rico. An exploratory research design was used for the study. The studied population consisted of obstetricians and pediatricians practicing in those hospitals. The sample was non-probabilistic and was selected according to availability for participation among the physicians who visited those hospitals in June 1997. The sample was made up of 55 physicians (29 pediatricians and 26 obstetricians). Descriptive statistics, crosstab tables, chi square and Fisher Exact tests were used to establish association between the physician's specialty and his/her knowledge and experience on breastfeeding. It was found that both the pediatricians and the obstetricians studied had lack of knowledge in areas related to breastfeeding and little practical experience in the management of breastfeeding.

[Obstetricians and pediatricians: experience with breastfeeding in their residency programs]. / Obstetras y pediatras: experiencia con la lactancia materna en sus programas de residencia.

A prior study had the objective of identifying knowledge and experience on breastfeeding of obstetricians and pediatricians in two private hospitals of the Metropolitan Area of San Juan, Puerto Rico. This study presents the experience of those physicians regarding breastfeeding education during their residency training. An exploratory research design was used, the sample was non-probabilistic and was selected according to availability for participation among the physicians who visited those hospitals during June, 1997. The studied sample included 29 pediatricians and 26 obstetricians. Descriptive statistics and crosstab tables were used to describe the results. It was found that participating physicians had little or no exposition to breastfeeding related topics during their respective residency programs. They are aware of the importance of their role in the achievement of successful breastfeeding. They perceive themselves as effective in stimulating breastfeeding although they recognize that they should have received better training on the subject. This attitude is worrisome in face of the fact that this same group presented significant deficiencies in a previous study with regards to knowledge in the management of breastfeeding.

[Analysis of the role of caregivers in human lactation and breastfeeding]. / Análisis sobre las funciones de los proveedores de cuidado en lactancia humana y amamantamiento.

The provision of care and support in breastfeeding and human lactation is a function of health professionals as well as of the members of the community. These functions must be appropriately defined so that the importance and degree of responsibility of health professionals and of the community be understood. The legal aspects of the practice of Lactation Consultant are discussed. The training course for Lactation Educator offered by the Maternal and Child Health Program in the Graduate School of Public Health is presented as an alternative in basic training and service. The scope of the practice of the Lactation Educator should be determined by the basic role of the graduate within the system of care for the breastfeeding mother and her infant.