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Breast milk is best for baby, so why are Hong Kong’s breastfeeding rates so low?

By Jeffrey Wong and Tracy Chan

At 3.00 a.m., a baby cries loudly for his mother’s milk. Although the mother wants to provide the best for her baby, she feels exhausted and weeps quietly on her bed. This is her 30th sleepless night.

“I expected it would be painful giving birth to a baby, but I never expected breastfeeding would also give me so much pain,” Maxie Lai, a mother of two says.

Lai experienced blocked mammary glands approximately three times a month while breastfeeding her first son. It gave her fevers and made her dizzy. “I wanted to give up every time it happened,” says Lai.

Worn down and sleep-deprived, Lai managed to persist in breastfeeding with support from her family, particularly from her mother-in-law.

Although Lai’s mother-in-law is not highly-educated, she had breastfed two children and has been extremely supportive. Lai thinks her mother-in-law’s advice is better than that given by professional nurses. “The problem is that they [nurses] only studied the academic theories but do not have hands-on experience,” Lai says.

Unfortunately, she did not receive same amount of support in her workplace. Breastfeeding mothers need to nurse regularly to maintain their supply, those who work need to make reserves for their babies. But Lai’s colleagues thought it was somehow shameful to pump milk at the office. The lack of space meant the only place mothers could express their milk was in the washroom. Lai finally resigned rather than explain to her colleagues that she needed to pump milk.

The unfriendly workplace environment for breastfeeding is one reason why only 14 per cent of Hong Kong mothers are breastfeeding after six months, despite the initial breastfeeding rate on discharge from hospital being as high as 83 per cent. According to the Department of Health, the overall breastfeeding rate in Hong Kong ranks nearly last among Asian countries and regions.

The city’s dependence on formula milk for infants was highlighted when the mass purchasing of formula by some mainland visitors and parallel traders led to a shortage of certain brands earlier this year. While parents of formula-fed babies panicked, those of babies who were breastfed were unaffected. Instead, they faced different challenges.

Wong Yee-mei, a working mother, had to reserve breast milk for her baby before leaving home for work. She had to pump milk every three hours at home, which seriously interrupted her sleep.

Wong also pumped milk at her workplace and stored it in the refrigerator. But her colleagues criticised her, saying it was disgusting. They said it was unnecessary to breastfeed as formula was more convenient and beneficial to babies.

Wong believes many people have been brainwashed by advertisements. “There are too many milk formula advertisements,” complains Wong. “Basically my friends, especially those of the older generation, truly believe that milk formula can make their babies know how to distinguish the size of bears and bees; know how to play the piano and be more outstanding,” says Wong of television adverts that promote the supposed health benefits of specific brands of formula milk.

To regulate the promotion of milk formula, the Department of Health proposed a set of voluntary guidelines, the Hong Kong Code of Marketing and Quality of Formula Milk and Related Products, and Food Products for Infants and Young Children (referred to as the Hong Kong Code), at the end of last year. It applies to milk formula products for infants and young children from birth to 36 months.

The code is currently undergoing public consultation and the Hong Kong Infant and Young Child Nutrition Association, formed by six leading milk formula manufacturing companies, argues it would limit the fundamental right of consumers to the free access of information.

Heidi Lam Yan-yee, an International Board Certified Lactation Consultant, thinks this argument is unreasonable.

Lam says the underlying aim of advertisements is not to provide information but to promote and increase the sales of products. “If consumers want to gain access to accurate information, they are not going to find it from advertisements,” she says.

Lam, who is also an active member of the La Leche League, says that even without the advertisements, Hong Kong lacks a breastfeeding culture. La Leche League is an international, nonprofit organisation that promotes breastfeeding.

“Breastfeeding is not something sacred or outstanding, it is just something natural and normal,” Lam says.

Christine Lam Chi-oi, breastfeeding nurse consultant in the Department of Obstetrics and Gynaecology at Queen Elizabeth Hospital, agrees. Lam points out the problem is deeply entrenched and goes back to at least to the 1970s when the breastfeeding rates were below 10 per cent. “Culturally, this generation lacks knowledge about breastfeeding,” says Lam. “This generation gap is very damaging since they cannot pass on the wisdom to future generations.”

As most mothers of this generation were raised on formula themselves, few of them see breastfeeding as an option. Lam says many mothers and grandmothers think that breastfeeding would starve the baby and disturb the mother’s rest. This means that mothers are sometimes resistant to breastfeeding, even when nurses want to help. As it is, Lam thinks nurses get insufficient training on breastfeeding. Today’s nursing undergraduates receive two hours of training over a four-year curriculum, unchanged from when Lam was at nursing school in the 1980s.

Mrs Lee, a nurse in Tuen Mun Hospital, and a mother of two, agrees most doctors and nurses in hospitals lack knowledge about breastfeeding.

“I can clearly tell you, as a nurse, we are not trained on this [breastfeeding],” Lee says. From her observation, many doctors and nurses not only fail to answer mothers’ questions on breastfeeding, some even give them incorrect information.

According to the UN World Breastfeeding Week Annual Survey Summary 2012, only 17 per cent of obstetrics and gynecology doctors, 28 per cent of paediatric doctors and 38 per cent of paediatric nurses had undergone the recommended 20 hours of breastfeeding training within six months of being employed.

Apart from training, the attitude of healthcare professionals is also very important. Lee recalls that when she fell sick while she was breastfeeding, her doctor asked her to stop breastfeeding in order to take an antibiotic when another baby-safe antibiotic was available. This was despite the fact that it is hard for a mother to resume breastfeeding once she stops. “They never think it is a problem to ask mothers to stop breastfeeding,” Lee says.

From her personal experience, Lee thinks peer support is vital in sustaining breastfeeding. Lee says every mother experiences her own difficulties, for example, blocked mammary glands and infected mammary ducts; baby’s failure to latch on; unsupportive families or workplaces.

“We share our experience and give each other advice,” smiles Lee. “You also know that you are not the only one who is suffering, which makes you feel better and helps you to carry on.”

Marie Tarrant, an associate professor in the School of Nursing at Hong Kong University agrees that Hong Kong is lagging behind in breastfeeding.

For instance, not a single Hong Kong hospital has gained Baby-friendly Hospital status. The award is given by UNICEF and the World Health Organisation to hospitals for promoting breastfeeding and dissuading mothers from using formula. There are over 6,000 baby-friendly hospitals in mainland China.

Most public hospitals lack dedicated lactation consultants to assist mothers with breastfeeding and the nurses are overworked. “They do want to provide the support for breastfeeding. They just don’t have the time, they are too busy,” she says.

To remedy the situation, Tarrant suggests there should be a lactation consultant on every shift who could help initiate breastfeeding and help mothers to nurse. However, she does acknowledge the Hong Kong Hospital Authority is making improvements to make their hospitals more baby-friendly. Starting from April 2010, public hospitals and some private hospitals have banned all milk supplement promotions. They no longer give out free milk formula samples to mothers.

Many Hospital Authority hospitals are also promoting skin-to-skin-contact between mother and baby immediately after birth. Medical research shows that breastfeeding babies immediately after giving birth can increase the level of antibodies in the babies and increase the success rate for breastfeeding.

However, milk formula companies still give free samples and other gifts to private clinics and sponsor many continuing education activities for doctors. Given the financial relationship between these clinics and milk formula companies, Tarrant worries mothers might get misleading and confusing advice from private doctors.

Besides infant formulas, Tarrant suggests the promotion of so-called follow-up or follow-on formulas should also be regulated. She says that with a global increase in breastfeeding, formula producers have sought to create another, highly lucrative market for follow-on formulas. These are aimed at babies aged from six months, who are ready to start supplementing milk with simple solid food, to toddlers who can get all the nutrients they need from solid foods. Tarrant says most of these children do not need follow-on formula.

“The claim they made about these formula is absolutely false,” says Tarrant. “There is no nutritional benefit in these follow-on formulas.” She adds that some nutrients that come naturally from breast milk which are beneficial to babies do not have the same effect when added to milk formulas.

Follow-up formula and “picky-eating” formula are not covered under the proposed Hong Kong Code on Marketing of Breastmilk Substitutes.

Professor Tony Nelson, who chairs the Department of Paediatrics at the Chinese University of Hong Kong, suggests there is a strong commercial reason why breastfeeding is undermined. “It [milk formula] is a US$11.5 billion industry, it’s big, big money,” says Nelson. “Promoting milk formula makes shareholders really wealthy.”

The price of a can of milk formula ranges from around HK$100 to a few hundred dollars. Normally, a baby finishes one tin of infant formula a week, and parents can spend between around HK$600 to HK$2,000 a month.

Given that mother’s milk is the best nutrition a baby can have and costs nothing, Nelson says formula producers have to launch aggressive advertisements to persuade mothers to buy the inferior milk formulas.

“Breastfeeding has advantages no matter if it’s intelligence, protection for infection, protection from obesity and protection from long-term illnesses,” says Nelson. “The medical evidence is so strong that there should be no debate.”

Nelson says it is a shame that even though the evidence-based benefits of breast milk are so clear, Hong Kong people do not seem to recognise them. “They [parents] will spend a vast amount of money on extra piano lessons, mathematics lessons, anything else to give the baby the best chance in life,” sighs Nelson. “And yet, surprisingly, one of the very best things that they could do, they don’t see it as important.”

Nelson says many mothers give up nursing because of the misconception that they do not have enough milk, but research shows that this is not true for more than 90 per cent of cases. In fact, insufficient supply is caused by supplementing breast milk with formula.

He explains that breastfeeding is a self-fulfilling process. The supply of breast milk depends on the baby’s demand, which creates a biological feedback. “Milk companies know that, so they just persuade mothers to take a little bit of formula, even a bottle in the ward or one bottle at night,” says Nelson. “In many cases, the supply [of breast milk] will really come down.”

“We have the duty to let mothers know that they have been misled by the companies to buy and waste their money on what they don’t need when there is a much cheaper better alternative,” says Nelson

 Edited by Kris Lee


  1. Congratulations, Jeff and Tracy, on your careful and thoughtful exploration of an important topic! As the medical experts you quoted said, breast really is best – but like most biologically-based behaviour, breastfeeding involves some learning and a supportive community. Since a lot of the traditional networks are no longer present in Hong Kong (as you explained) maybe the internet and online social networks could be used to “show and tell”, share experience, and help build support for breastfeeding – and university students, like yourselves, can lead the way in campaigning for effective breastfeeding education – not just “how to” for new mums but public education on the value of breastfeeding, workplace support for lactating mothers, and a public health code with strong backing for breast-milk over formula. I breastfed my children (now grown up) for a year each, and weaned them on to cow’s milk and solid food bit by bit – I’m so glad I did, and would be happy to think that the young women I teach in Hong Kong can have the same experience – and yes, without putting their careers on hold. Go, go, Jeff and Tracy – hope your article starts a debate, and a movement for change!

  2. In this information explosion era, for the same strong commercial reason, I hope the baby formula company will shift their business in breast feeding equipment and accessaries. Similar to the cloth diaper business which might be more sustainable and profitable in a long run. It is a freedom of choice which is important to all the parents. New parents should have the right to understand the pros and cons for both choices. (Mother of two, breastfeed til 1 year / 7 months)

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