February 2006


A government report out today shows that….

…women earn less than men!

Shock! Astonishment! Well, I never.

Reports showing much the same thing are a regular feature in the news. As usual, there is much throwing up of hands and much pontficating on the best cure for this “problem”.

The same themes are repeated over and over.

Improve opportunities for women. Encourage women to make the most of education and training opportunities. Value the “nurturing professions” more. Make it easier for women to balance home and family commitments with their work commitments. More childcare. Get rid of stereotypes about what jobs women should do, so that they can break into other, traditionally male-dominated occupations. Make it easier for small business to employ women of child-bearing age.

Oh, and who shall we blame for all these “problems” that women face?

There aren’t many people who suggest that, actually, women might have it just about right or that it might be men who have the problem. But think about it. Why on earth should the problem be that women are struggling to get into the rat race? Who wants to be there, anyway?

I’m not saying that there is nothing to be done to make the workplace fairer for women, but surely we could also be working towards equalising the pay gap by encouraging men to downshift, spend more time with their families and enjoy the benefits of a better work / life balance. Why should the men be expected to work long hours and earn big bucks when instead they could take a little pay cut, kick back and play football with their kids in the park?

I don’t think I’ve heard this view expressed by anyone… why not?

Here are some clues, taken from the Executive Summary of today’s report (I was too lazy to read the full 148-page version):

the UK economy is losing productivity and output… removing barriers to women working in occupations traditionally done by men, and increasing women’s participation in the labour market, could be worth between £15 billion and £23 billion or 1.3 to 2.0 per cent of GDP.”

So let’s not be too touchingly naive about the government’s motives, eh?

Meanwhile, scientists have come up with a great way to combat climate change: catch the plague! And a pox on anyone who invents an anti-plague vaccine…

In 1990, John Gummer made a big mistake. He made his daughter eat a beef burger to “prove”, at the height of the BSE crisis, that it was safe to eat. He lived to regret it.

Now Jacques Chirac has made a point of eating chicken to “prove”, as bird flu spreads to Europe, that chicken is still safe to eat. (See it here.) Will he too end up with, ahem, egg on his face?

It has struck me today what a powerfully emotional experience it must be to be a grandmother. In twenty or thirty years’ time, when (if!) I become a grandmother, what will it be like?

Will I trust my daughter to be a good enough mother to my grandchildren? Or will I nag and complain and say “in my day…” and generally do my thoughtless worst to undermine her?

Will I take it as an opportunity to re-evaluate my own mothering experience? How will my mothering stand up to hindsight? What will it be like to see my daughter’s mothering, and to feel regret at the things she knows and does that I never did or could?

There is a data-fest going on at Playing it by Ear! :-)

I’ve just ploughed through lots of it, including a fair bit of the Infant Feeding 2000 survey. Much of it confirms what you would expect, and it’s good to know that someone has done some proper anaysis of feeding statistics! – as against my pretty crude but nevertheless most interesting number-crunching over the last couple of days…

(An aside, before anyone gets completely the wrong impression of how much time I have on my hands: I did a lot of copy-pasting and got Excel to do all the actual crunching. Hooray for time-saving technology!)

In the context of public breastfeeding laws, the following points from the Infant Feeding 2000 survey struck me as relevant:

Table 5.7 (p103) – Mother’s reasons for planning to bottle feed

19% of bottle-feeding mothers did not like the “idea” of breastfeeding and 4% “would be embarrassed” to breastfeed. (There may be some overlap as mothers could give more than one reason)

To my mind, if the perception of breastfeeding is that it is icky and/or embarrassing, then part of the underlying thinking for some women has to be an embarassment about doing it in public. Although it may not be a common reason, some women do feel that way (and I’ve heard them say so!) A law giving them the undisputed right would not solve the problem but, on balance, my gut feel is that it would help. Nothing I’ve seen yet has dissuaded me from that view.

Section 5.4 (p106) – Factors associated with planned feeding method

The way women were themselves fed as babies and how their friends fed their babies were both strongly associated with their planned method of feeding. This suggests either that contact with other people who have breastfed may be influential or at least that other people may contribute to create an environment that supports and encourages breastfeeding.”

This seems to confirm the commonsense view that mothers care about what people around them think and do, and that breastfeeding is more likely to happen if breastfeeding is seen as “normal” and “ordinary”.

I can personally vouch for that, because I know that feeling “normal” has been very important for me. My own breastfeeding story might have been very different if I had not surrounded myself with breastfeeders and breastfeeding supporters who gave me the confidence and self-belief that is so essential to breastfeed successfully in our bottle-feeding culture.

As such, I personally believe that breastfeeding in public is vital – a mother should be and feel able to do it both because that helps her to feel normal and (secondarily, of course) because it helps others around to her to see breastfeeding as normal. If a legal right helps even a small number of women to feel confident enough to take the plunge – and, again, on balance I think that it could – then it would delight me to know I was part of the campaign…

That said, I do believe wholeheartedly that there are many more and better measures that should also be taken. I would support those too – and with much more passion and far fewer reservations, I suspect.

For example, numerous studies, and common sense, all show that measures such as the control of formula marketing and the promotion of the baby friendly initiative make a clear and significant difference far in excess of the difference that a mere public breastfeeding law could be expected to make. If I had to choose between this public breastfeeding measure and, say, a ban on the marketing of formula and other breastmilk substitutes – well, there would be no contest, would there?

But I don’t think we have to choose which idea to support. We can ask for both / all of them! And, who knows, passing this law might even dispose the government to look more favourably on other breastfeeding measures. Wouldn’t that be nice?

In recent posts I have asserted that a change in the law to explicitly permit public breastfeeding would help to support women in a choice to breastfeed, by removing or reducing an existing barrier to breastfeeding.

I asserted that nervousness about public breastfeeding was an existing barrier to breastfeeding in that it plays a role in women’s thinking about whether to breastfeed. I suggested that explicitly legalising public breastfeeding would give at least some of these women the extra confidence they might otherwise lack in order to support a choice for breastfeeding.

My assertions were based on my own experiences and impressions of talking to women about breastfeeding choices, and particularly from listening to women who chose not to do it. However, I did not have any objective evidence to back up my assertions.

Today I spent some time looking for any surveys, reports or other data online that might show whether my assertions had any real factual basis. I did not find any. (At least, not yet!) I have, however, done a very crude study of my own, and would like to share the results.

What I did

I used the United States Center for Disease Control’s Geographic-specific Breastfeeding Rates data for 2003 and 2004. This data is based on information gathered from the CDC’s National Immunization Survey. It breaks down breastfeeding rates by US state. Each state has from around 330 up to over 1,000 respondents included in the survey (for 2004, figures for 2003 were not given). Using this data, I took for each state in each of 2003 and 2004 the percentage of babies who had ever been breastfed. This seemed the most relevant statistic given that I was mainly interested in the choice to breastfeed in the first place rather than success, duration or exclusivity of breastfeeding.

I then assessed each state using information taken from La Leche League’s summary of US current breastfeeding law. I looked at (1) whether the state had law explicitly supporting the right to breastfeed in public and (2) whether the state had other law in place to support or encourage breastfeeding.

35 states had laws supporting public breastfeeding, usually either by explicilty stating that a woman was entitled to feed her child in public places or by exempting breastfeeding mothers from indecency or related legislation.

25 states had other laws, typically: exempting breastfeeding women from jury duty; relating to breastfeeding mothers in the workplace; providing for breastfeeding to be taken into account in family proceedings; prohibiting discrimination against breastfeeding women or breastfed babies; or promoting breastfeeding in other ways using hospital or other health-related regulations.

I then carried out a rudimentary analysis to see whether the states that had laws promoting or supporting breastfeeding in some way ended up with higher breastfeeding rates.

Obvious limitations / likely distortions

  • A state that encourages breastfeeding through its laws may well be more likely to encourage it through other means. There is no evidence whether improvements in breastfeeding rates in states with breastfeeding laws were brought about by the laws or by the other means (or, more likely perhaps, a combination of the two).
  • Conversely, poor rates may have been the reason for imposing legislation in the first place – if so, then a comparison between breastfeeding rates and the existence of legislation will not be fair or meaningful.
  • I came at this expecting to see that laws can improve breastfeeding rates. I mention this because it is possible that such bias affected my objectivity, although I am not aware of any respect in which it did so.
  • I have not taken account of any factors such as how long the laws had been in force (in at least one state – Ohio – the law was not brought in until 2005, after the date when the statistucs were gathered!)
  • My figure work is rudimentary and was done swiftly. I may have committed errors or distorted the results by my approach. If so, the distortion / mistake could go either way. If anyone wants to check my analysis then I would be glad to hear from them!

The results

So, bearing in mind all the limitations mentioned above, the results are as follows (the first figure given is for 2003, the second is for 2004):

Average across all states: 70.22% / 69.70%

With / without public breastfeeding law

States with a public breastfeeding law:

  • whether or not there are other breastfeeding laws: 72.15% / 72.17%
  • with other breastfeeding laws: 72.06% / 72.98%
  • without other breastfeeding laws: 72.28% / 70.97%

States with no public breastfeeding law:

  • whether or not there are other breastfeeding laws: 65.72% / 63.93%
  • and there are no other breastfeeding laws either: 63.63% / 61.36%

With / without other breastfeeding laws

States with other breastfeeding laws:

  • whether or not there are public breastfeeding laws: 71.97% / 72.66%
  • with public breastfeeding laws: 72.06% / 72.98%
  • without public breastfeeding laws: 71.48% /70.98%

States with no other breastfeeding laws:

  • whether or not there are public breastfeeding laws: 68.47% / 66.74%
  • and there are no public breastfeeding laws either: 63.63% / 61.36%

Other interesting points

In the 2003 “Top Ten” breastfeeding states, only Arizona in tenth place (80.4%) had no breastfeeding laws. Louisiana came last (46.4%) despite having strong breastfeeding laws – albeit relatively recent laws. Apart from Louisiana, every state in the bottom six lacked a breastfeeding law.

In 2004, Arizona had risen to 8th place (with 80.9%). Arizona aside, you need to go down to 14th place (Wyoming, 75.5%) and then 26th place (North Dakota, 69.1%) to find the next states without breastfeeding laws. At the other end of the table, Louisiana had risen to third from bottom (48.8%) but all other states in the bottom seven lacked breastfeeding laws.

In both 2003 and 2004, four of the top five states had both public breastfeeding laws and other laws supporting breastfeeding.

Conclusions

On average, breastfeeding rates are significantly higher in states that have breastfeeding laws than in states that do not. In states with only one kind of law, it does not seem to make any significant difference whether the law is about public breastfeeding or supports breastfeeding in some other way, however the best rates are found in states with both kinds of law.

From 2003 to 2004, breastfeeding rates generally improved or stayed about the same in states having laws (notably Louisiana, which enacted laws in 2001-03, improved rates by nearly 2.5% from a very poor starting point). States with both kinds of laws generally had the best improvements. Meanwhile, rates generally worsened in states without laws.

Despite the crudity and limitations of this analysis, it does tend to support the view that breastfeeding legislation is at least worth exploring as a means to improve breastfeeding rates.

Edited with additional analysis: Wednesday 22 February 2006

This post has been prompted by a discussion today on Playing It By Ear.

Having commented ad nauseam on there (sorry C!) I am now feeling the urgent need to blog my thoughts at length over here…!

So why a breastfeeding bill?

It is a waste of time, money and effort, because it will make very little difference to people.

It’s true that negative public breast-feeding experiences are rare. Occasionally somebody will be told to feed their baby in the toilet, or told off for nursing on a park bench or the like and such an incident will (because it is unusual) create a stir. But in the scheme of things, it just doesn’t happen much.

However, I believe that a law would still make a difference, albeit that it would perhaps be more to people’s perceptions than anything else. By “people” here I mean both mothers / expectant mothers considering breastfeeding and people generally who might have opinions on the subject of public breastfeeding.

Mothers or expectant mothers are often fearful or nervous about breastfeeding in public, and consequently they are more likely to choose bottle feeding.

Partly that is due to their own embarrassment at the idea. No law could change that – at least, only by acting as a catalyst for a wider, longer term change in our ideas about immodesty. However, in many cases, the fear is specifically related to what other people might think or do: am I allowed to do that here? The humiliating prospect of being asked to “put your bosoms away, please, Madam” is enough to put many people off the idea completely (almost regardless of how unlikely it is to happen in practice). This law would help to shift perceptions, and would help the mother to be confident that her choice to breastfeed in public will not be open to challenge.

Meanwhile, the perceptions of members of the public may also alter as they stop questioning whether a woman should be “allowed” to feed her baby in public and start accepting that breastfeeding is, as it should be, a normal part of everyday life.

Let’s dream a while. A change in public attitudes could produce a virtuous circle: the more women are able to confidently feed in public, the more commonplace and “normal” it becomes, and thus ever more mothers feel able to take the plunge and do it themselves. OK, I know, this is idealism and optimism at its peak, and I don’t say that the proposed law would achieve all this. I only say that it could help to achieve it, as part of a many-pronged effort to promote and encourage breastfeeding.

But there are so many other, better things we can do instead… why this?

There are a zillion things we must do to help promote breastfeeding and, more to the point, redress the current situation – where bottle feeding holds sway and many women who would like to breastfeed find themselves unsupported and unable to achieve this.

For example we could:

  • Ensure that health professionals, particularly midwives and health visitors, receive specialist training in supporting and promoting breastfeeding.
  • Set up breastfeeding support groups throughout the country.
  • Ban the unethical marketing practices used by formula companies.
  • Discourage other positive images of bottle feeding (for example, bottle feeding dolls or bottle feeding on TV) – or at least, promote greater prominence for positive images of breastfeeding.
  • Review the provision of a subsidy on formula milk via the milk vouchers scheme.

Some of these measures are the subject of existing work by the government or others, or are the subject of existing campaigns by interested groups. However, none are likely to happen any time soon and in the meantime here is something that could be done, very quickly at very little financial or other cost. If it helps (and I think it would), then the fact that it will not of itself solve all our problems is in my view no reason to oppose it.

Why do we need a law anyway? There is no sense in legislating for other people to respect a woman’s choice to breastfeed. Women should just get on with it if they want to breastfeed. It is up to them to stand up for their convictions.

Infant feeding isn’t just about a woman’s own personal choice or her own convictions.

Breastfeeding is a normal, natural and optimal way to feed infants and children which is being and has for many years been subverted by continuing pressure to use formula, including the negative portrayal of breastfeeding as difficult, immodest or unpleasant, and the normalisation of formula use. Bottle feeding is an artifical and sub-optimal way to feed infants, which few women would freely choose in the absence of this pressure. It certainly has its place and is a life-saver for babies who for whatever reason cannot have breast milk. But breastfeeding is and should be normal and should not be subverted by inappropriate cultural or commercial pressures.

To the extent that society creates these inappropriate pressures on women, it is up to society to change. No woman should have to feel that she will become a social pariah if she breastfeeds, or that in order to breastfeed she will have to screw up her courage and be ready to stand up for herself in case of challenge. Ideally, that would be brought about by cultural change and education. However, in the meantime, a little piece of legislation to help women deal with societal pressure is not a lot to ask.

OK, I agree in principle that women should be legally allowed to breastfeed in public… but there are enough crimes already! Should it really be a crime for a person to try and stop someone from breastfeeding in public?

This is the argument used by Caroline Flint’s office in a recent reply to my questions about this issue. In my view, it is wholly disingenuous, coming from a Labour minister in a government that has brought in so many brand new criminal offences.

However, much as I hate to admit it, it is the most convincing of the arguments I have heard so far. I am against criminalising people unless there is a very good reason to do so. If I could think of a way to legislate for a woman’s right to breastfeed in public places without creating a statutory offence at the same time, then I would support that instead. Sadly, I can’t.

I make only the point that, as already mentioned, very few people in practice would fall foul of this law. As such, it would be primarily symbolic and would not in fact criminalise any significant number of people. In reality, the likelihood of a prosecution taking place is tiny to non-existent.

On balance, I still support the proposal, because I want breastfeeding rights enshrined in law more than I want to avoid criminalising the handful of people who might fall foul of that law.

Q: So how do we know that vaccines are safe?

A: Because they are tested!

What happens first is that relatively small trials are conducted. The trials will not usually have more than a few hundred “guinea-pig” subjects, if that. Such trials can to some extent show us how effective the vaccine is, and whether there are common ill effects, but in a small trial, you cannot expect to show up an ill effect that is as rare as, say, one in a thousand. To spot the less common side effects, you need a much larger trial.

Unfortunately, it just isn’t considered practicable to do large trials. For one thing, you are injecting large numbers of people with “untested” substances. To do this ethically you would need to explain to the subjects the risks that they were taking, and if you did that then you might struggle to find the large numbers of volunteers that you would need…

So large scale vaccination safety trials are just not done. Vaccine products are normally licenced for widespread – and in some countries mandatory – use on the basis of small trials only.

But we would know about it if a vaccine was licensed but turned out to have dangerous side effects. Wouldn’t we?

Once a vaccine is put into general use, we are then reliant on doctors reporting safety data from the vaccines in actual use. But those doctors are not instructed to look out for side effects – so, for all we know, many may go undetected. Indeed, those doctors may be told “in clinical trials, no side effects were detected” (or the like) and thereby actively deflected away from seeing side effects even when they happen. Moreover, vaccines are not generally administered and vaccinated children are not generally monitored in any controlled scientific way. Nor do suspected reactions appear to be investigated with any particular or routine thoroughness. As such, it is rarely going to be possible to analyse suspected reactions adequately so as to identify whether the vaccine really was the cause. This is not a scientific way to conduct safety trials.

A third methodology used to try and prove safety is by means of population studies. Take two large populations – one vaccinated and one not. Compare rates of certain conditions or diseases in the two populations. If, say, autism is higher in the vaccinated population then vaccination may cause autism. If not, then vaccination cannot be a cause of autism.

That all sounds plausible, but it is a massive over-simplification.

In a scientific trial you would normally expect to see a “test” group (receiving vaccinations) and a “control” group (not receiving vaccinations). The groups would be identical in all other material respects so that a comparison between them could genuinely be considered true and fair. Each group would have to be large enough that any trends identified would be statistically significant.

However, these factors are not normally present in population studies. Many, many factors contribute to trends in the health of a large population, which can vary from country to country and even within a country. Diet and exercise habits, pollution levels and ethnic differences are just a few factors that spring immediately to mind as potentially relevant. For these reasons, it must be near impossible to find two large groups of people, one group vaccinated and one not, with no other significant differences between them. The real world is complex with infinite variations, but scientific trials need simplicity with only one variation (i.e. the one being tested).

(Here’s a rather absurd illustration: the number of obese people in 1940s Britain was very low. Since then, vaccinations have been on the increase and so has obesity. Could it then be argued that obesity is caused by vaccinations? No. There are so many factors at work, that it would be impossible to draw any conclusions about whether obesity and vaccinations are linked in any way.)

Even if population studies were to some extent workable, they would still have serious data quality problems. There is a difficulty even with a straightforward questions, such as “How many children who have been vaccinated with MMR subsequently contract rubella, compared with those who have not been vaccinated?” What if the child has had mild rubella without being taken to the doctor and so without being included in the data? Even if the child was taken to the doctor, what if the doctor did not rcognise rubella, or overlooked the possibility precisely because he knew that the child had been vaccinated? How can the study control for these sorts of difficulty?

Where does that leave us?

Useful clinical safety trials are rarely if ever conducted.

The alternatives are reaction reporting and population studies. Reaction reporting by doctors is likely to be patchy and will almost certainly be scientifically inadequate. Population studies are very difficult to do in that appropriate “control” groups are very hard to come by. These options are also retrospective – they can only test the safety of a vaccine after it has been administered to thousands or even millions of children. This is hardly ideal.

So how do we know that vaccines are safe? Because they are tested?

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