Maternal Malnutrition According to a report of a symposium

held in 1979, the precise roles of nutrition and malnutrition in determining the out­come of human pregnancy for mother and baby remain "Unknown" in official govern­mental and academic institutions in the United States (1). Most people in the childbirth education movement in the United States have believed that birth prac­tices, i.e., the medical-surgical management of labor and delivery, are the major prob­lems that contribute to a relatively high inci­dence of maternal-fetal-neonatal complica­tions.

Numerous clinical works and epidemio­logical studies of maternal and child disease statistics in the United States over the last 4 decades have documented, however, that low birth weight and premature labor and delivery are major problems for American women and their babies (2). Prematurity and low birth weight rates in several other nations are about one-third the present rates in the United States. Childbirth educa­tion to address this problem from the nutri­tional point of view must begin early in pregnancy, and ideally before conception occurs, rather than beginning at or after mid-gestation. The nutritional status of American women must be improved con­cretely, and adequate nutrition throughout the entire course of gestation must become a high priority in the prenatal care of all women.

We have collected enough scientific data to insist that the primary prevention of pre­maturity, low birth weight, small-for-gesta­tional-age babies, and congenital malfor­mations can only be accomplished by means of a concrete program of clinical prenatal care throughout gestation that will:

1 Prevent prenatal malnutrition and maternal hypovolemia

2 Protect both mother and fetus from all harmful drugs, chemicals, and radia­tion

3 Abolish the use of weight control regimens and pregnancy diets that blindly restrict calories and/or sodium or other essential nutrients

4 Eliminate the traditional nutritional nonchalance and neglect which charac­terize existing prenatal management and teachings in our medical schools'

VOLUME 14 NUMBER 1 1982

departments of obstetrics-gynecology and internal medicine.

No such program has been developed in the United States except in a few clinics, private practices, and alternative birth centers because our medical and "health" authorities do not even recognize the prob­lem exists! As long as officially "nothing is known" in this field about the etiology of human reproductive pathology and patho­physiology, little can be done about its primary prevention. It is obvious that clinical nutritionists, nutrition educators, and dietitians have a central role to play in really improving the outcome of human pregnancy in the United States. The medical profession and drug industry up to now have denied them their proper functioning in prenatal counseling and education. The American people can begin to solve this problem only when they learn the basic sci­entific and political facts.

Tom Brewer, M.D., President of the So­ciety for the Protection of the Unborn through Nutrition (SPUN), 16 Sunset Drive, Bedford Hills, NY 10507.

LITERATURE CITED

1 Metcolf 1., E. R. Klein, and B. L. Nichols, eds. Workshop on nutrition of the child: Maternal nutritional status and fetal outcome American Journal of Clinical Nutrition 34:658-817, 1981.

2 Shanklin, D., and 1. Hodin. Maternal nutri­tion and child health. Springfield, Ill.: Charles C Thomas, 1979, 205 pp.

Women and the Infant Formula Code

In the excitement of the argument be­tween the multinational world health or­ganizations (WHO, UNICEF) and the multinational milk companies regarding the so-called breast or bottle controversy (see JNE 13:80, 1981), I want to comment about another concerned group who seem to have been slighted - women.

The recently approved WHO Interna­tional Code of Marketing of Breast-milk Substitutes (1) is an unprecendented at­tempt by an international agency to inter­vene in culture-specific practices of child rearing and to designate a global timetable for weaning. The code affirms the impor­tant part women play in food decisions, yet it assigns them no instrumental· role in de­termining what these feeding methods

should be. Unilaterally, it calls on govern­ments to limit the use, promotion, and marketing of breastmilk substitutes.

All societies have evolved unique prac­ticesand directives defining what roles men and women shall play in the reproductive process, which includes feeding. Each culture has a melange of customs and taboos for women which establishes a delicate equilibrium that serves to keep some babies alive. Unrealistic, this intimi­dating WHO document comes at a time when women's customary maternal re­sponsibilities, including breastfeeding, have been altered immeasurably by con­temporary social movements and rapid economic development.

With migration to the cities, many poor women have lost the supportive network of caring kin. They now have to manage child rearing alone. This predicament, in a culture of proverty, has forced them to adopt new cultural responses, including in­novative feeding practices, in order to max­imize their chances of survival. These are women who reject the role of only breeders and feeders. Clinging to the hope of pro­viding themselves and their children a better life, they have come to the towns and cities. They have stayed on despite the abrupt change in their social relationships and economic status, despite fear and loneliness. Daily they cope with their own fatigue, no electricity or running water, jammed buses to and from work, and hours in line at the local clinic where they seek help for a feverish baby.

Juxtaposed against this reality is a funda­mental misperception among many health professionals about the lives of the poor in the developing countries. What they con­jure up is long gone-a pastoral setting, loving kin, plentiful food, a chubby baby, and a healthy environment where breast­feeding exclusively culminates in a never­ending supply of milk. But breastfeeding does not work that way. In truth, lactation is a delicate, sensitive human function, easi­ly disrupted and quickly abandoned when changes in lifestyle no longer can accom­modate it. At such a time, women, especial­ly those living within the urban web, seek and need more, not less, options regarding infant feeding.

The anthropological evidence confirms that women in poverty already act sensibly and rationally in their decisions about breastfeeding. Caught in a no-win situa­tion, they breast feed as long as they can. When their breastmilk will no longer satisfy their infant, they find ways to orchestrate

JOURNAL OF NUTRITION EDUCATION 5