Features

Challenging views on breastfeeding

07 June 2017

Why isn’t UK culture conducive to breastfeeding? And can it ever change? Helen Bird explores some of the reasons behind our low breastfeeding rates and looks at what could reverse the trend.

The practice of a mother feeding her child in the most natural way now makes regular headlines – and often for the wrong reasons. Just last month, a senator breastfeeding her child in Australian parliament was deemed shocking enough for the world’s media to report on it (see page 12-13), with images flooding social networks to predictably polarising reactions. ‘It’s frankly ridiculous, really, that feeding one’s baby is international news,’ said the senator at the time.

Back home, Northern Ireland has ‘among the world’s worst’ breastfeeding rates, the media fairly reported in May (Northern Ireland Assembly, 2017). Also reported was data showing almost half of mothers who gave birth after 2012 left hospital ‘without attempting to breastfeed’ (Detail Data, 2017). These findings together with the senator hitting the headlines, help to reveal where western culture stands on breastfeeding.

Nationwide issues

Headlines aside, Northern Ireland’s low uptake is causing concern, as is the rest of the UK as a whole: it has recently been shown to have among the lowest breastfeeding rates in Europe (WBTi, 2016).

And last November, the World Breastfeeding Trends Initiative (WBTi) published a report with worrying results for the UK: on national policy for instance, the UK scored just one out of 10 for having ‘no established UK-wide infant-feeding group for sharing good practice’ (WBTi, 2016).

The problem appears not to be with initiation – aside from the recent findings from Northern Ireland, the UK as a whole scores highly on breastfeeding babies within an hour of birth (WBTi, 2016) – but with continuation. In England, for example, less than half of women are still breastfeeding two months after giving birth, according to a recent Public Health England (PHE) (2017) poll. And this is in spite of the WHO’s widely publicised and accepted recommendation of exclusive breastfeeding for the first six months of life (WHO, 2016).

A lack of support

So what’s going wrong? The WHO’s Dr Nigel Rollins blames a fundamental lack of support. Nigel co-authored the significant breastfeeding series in The Lancet last year, claiming that more than 800,000 child deaths per year could be prevented by breastfeeding (Rollins et al, 2016). ‘The success or failure of breastfeeding should not be seen solely as the responsibility of the woman,’ he says. ‘Her ability to breastfeed is very much shaped by the support and the environment in which she lives. There is a broader responsibility of governments and society to support women through policies and programmes in the community.’

There’s already a wealth of research highlighting the health benefits of breastfeeding to mother and baby, and clear public health and long-term economical motivations for driving up the UK’s rates. We also know that financial investment is required from the next government so that healthcare professionals can support all women who want to breastfeed beyond that crucial two-month point.

But it’s the societal and cultural factors influencing the nation’s perceptions of breastfeeding that need deeper investigation. It’s vital to look beneath the surface at why women are reluctant to breastfeed, why those who start are abandoning it, and what can be done to better support them.

Public shaming

A recent news story shows the kind of reactions women may face when breastfeeding in public: it was reported that a young mother was asked to stop publicly nursing her son in the Royal Liverpool Hospital by a nurse who implied it was ‘sexual’ and would make others ‘uncomfortable’. Little wonder women feel wary of breastfeeding in public.

‘Something is wrong if you can’t figure out that parts of the body can have more than one role and adapt your thoughts accordingly,’ says Dr Amy Brown, programme director for child public health at Swansea University and author of Breastfeeding Uncovered. ‘Mouths can be used in a sexual way, yet we don’t criticise people for eating in front of others, do we?’ It is perhaps for this reason that bottle, not breast imagery is used for baby clothes, changing room doors and children’s dolls, says Amy. ‘Bottles are so symbolic of motherhood and that is blindly accepted,’ she adds.

Bernadette Wood, a health visitor and infant-feeding trainer based in Suffolk, agrees. ‘Children’s playthings continue to present formula feeding as the norm,’ she says. ‘And I think the idea of babies as parasites, along with the sexualisation of the female body, has led to girls thinking of breastfeeding as disgusting or just plain wrong.’

 

Mixed messages?

Dr Tim Kurz, senior lecturer in psychology at the University of Bath, has carried out research analysing how various public health materials deal with the topic of infant feeding, as well as how mothers engage with and feel about the messages. ‘We have identified a paradoxical situation in which mothers are given a clear directive that breastfeeding is the optimal way to feed their infant, but at the same time are told that they shouldn’t “feel guilty” or “let anyone make them feel guilty” if, for whatever reason, they use formula,’ he says.

‘Furthermore, it is often suggested in advice materials that mothers who formula feed must not let themselves feel guilty, because this will have negative effects on the child.

‘While well intentioned, these mixed messages place an unfair psychological burden on mothers,’ Tim adds. The result, he suggests, is a sense of guilt that could cause women to feel inadequate as mothers. We need to be careful about language when communicating with them, he says.

‘Either women genuinely have the “right to choose”, in which case they should be told that they are not guilty, rather than that they should not feel guilty.’ Or public health materials should accept their advice makes women who don’t breastfeed feel guilty, rather than blame women for feeling that way, he says.

It could well be that breastfeeding promotion would benefit from a slightly different approach. Charlotte Faircloth, senior lecturer in social sciences at the University of Roehampton, observes that the public health perspective ‘fails to take into account that breastfeeding is an embodied practice, and that mothers and babies are part of a social network’.

‘A focus on the mother-child dyad can often screen out the other pulls on a woman’s time that might make breastfeeding difficult or unrealistic, such as other children and work commitments,’ she says, adding that a sense of responsibility could extend far beyond infant feeding.

‘I worry that one of the effects of this culture of instructing women as to how best feed their babies plays into the idea that it is mothers who are responsible for wider health inequalities or similar. In fact, the broader structural systems in society – class, for example – are more of a determinant of how babies turn out, not the practices of individual mothers.’


The Unicef Baby Friendly call to action

Unicef’s Baby Friendly Initiative is calling on UK and devolved governments to implement four key actions to create a supportive, enabling environment for women who want to breastfeed:

1. Develop a national infant-feeding strategy board in each of the four nations, including members from all relevant government departments and tasked with developing a comprehensive national infant-feeding strategy and implementation plan

2. Include actions to promote, protect and support breastfeeding in all policy areas where breastfeeding has an impact

3. Implement evidence-based initiatives that support breastfeeding, including the Unicef UK Baby Friendly Initiative, across all maternity, health visiting, neonatal and children’s centre services

4. Adopt, in full, the International Code of Marketing Breastmilk Substitutes.

For more on the UK’s engagement with the initiative, see Last word (page 48-49), and to view the call to action in full, go to bit.ly/Unicef_BFI_call


Social standing

Like it or not, there is an association between breastfeeding and social class. While women in poorer countries tend to breastfeed for longer than those in higher-income countries, in the highly developed UK, the better health and social outcomes linked to breastfeeding have in some ways caused it to be perceived as a middle-class practice.

Yet this is more likely based on correlation than causation, says Charlotte. ‘Breastfed children tend to be healthier, but middle-class women tend to breastfeed,’ she observes. ‘Is it the breastfeeding? Breastmilk? A general middle-class orientation to parenting? We don’t really know, because even in those studies that say they control for it, the “choice” to breastfeed or formula feed isn’t always a choice.’

What is surely needed is better education for everyone about breastfeeding, starting from childhood. ‘As a society we have lost knowledge around what breastfeeding is really like,’ explains Amy. ‘The fewer women who breastfeed, the fewer people will see it, and the fewer will understand how to support it. ‘Children should be taught about breastfeeding, the breast and how breastmilk works, as young as possible, so that the next generations of mothers feel more prepared. This would also enable them to learn about it in a context that is separate from being parents themselves: they can think about it without feeling pressured or overwhelmed,’ Amy adds.

This ties in with the recommendation from the WBTi 2016 report that all professionals who could affect women’s decision to breastfeed and continue breastfeeding, including childcare workers and GPs, should receive high-quality training (WBTi, 2016).

A new way forward

Ultimately, does UK culture need to undergo a shift in order to better accommodate breastfeeding and better equip women to adhere to the six- month exclusive recommendation? The response seems to be a resounding ‘yes’.

‘There is a lot of pressure on new mothers to get their lives back – whether that means losing weight, regaining their social life or going back to work as quickly as possible,’ says Amy. ‘But [life] before [your baby] has gone: you have a brand new person to care for and we should have systems in place that make that easier: better maternity leave, better support for new mothers and simply better value for the mothering role.’

Amy adds that much can be learned from the countries that score highly in breastfeeding uptake and duration. ‘[These countries] tend to view breastfeeding as normal, but more widely they support their new parents better,’ she says. ‘Longer, better paid maternity leave and extended paternity leave for fathers is common in Scandinavia, where breastfeeding rates are high. This would help in instilling the value of what mothers and families do.’

Charlotte suggests that a shift in conversation could be needed from health benefits to ‘reproductive rights and women’s autonomy’.

‘The regulation of women’s behaviours in the reproductive years is getting tighter and tighter,’ she observes. ‘We are now meant to regulate our diets before we even think about having a baby. I see this as an extension backwards of a broader parenting culture, in which fierce debate about women’s reproductive choice reigns.’

But how can cultural change come about? Sociologists have previously claimed that new customs and practices are likely to be more readily adopted under two conditions: if they represent what is viewed as socially desirable and useful; and if they do not clash with existing and still-valued customs and practices.

‘Of course it is going to take time,’ concedes Amy. ‘We need to reverse a generation or more of formula being the norm. I think we need to take a wider approach to supporting new families better.’

Maybe we could start by listening to women. ‘Culture change happens from both the top down – for example, policy – and the bottom up, with people’s experiences,’ says Charlotte. ‘The top-down approach hasn’t worked so far on the infant-feeding front, and we have a huge gap between the two. Perhaps starting from women’s experiences and what they say they actually want might help build a more supportive culture.’ (See below for two women’s views).


Listening to mothers – Two women have their say…

‘The phrase “breast is best” is unhelpful’

Lyndsey from Barnsley says:

‘I think the UK has low breastfeeding rates for various reasons.

‘I was fortunate to live in a health authority that had invested money in providing breastfeeding information, education and support in the community. This isn’t universally available and I think if it were, more first-time mums might try it.

‘I also think there’s still a taboo about breastfeeding in public; either mums don’t feel comfortable breastfeeding their baby in public or they find other people’s reactions and attitudes to it unsettling or off-putting. It might be a generational thing – more people may choose to breastfeed if they themselves were breastfed.

‘I think the phrase “breast is best” is really unhelpful and negative. It puts pressure on mothers to breastfeed by inferring that if they use formula milk they clearly don’t want what is best for their children. Breastfeeding can easily work for some people and it can be a rewarding and positive experience, but it can equally be incredibly difficult, if not impossible for others, and be a stressful and negative experience.

‘To resolve the taboo around breastfeeding in public, there are simple things that could be done. Signs in shops and cafés supporting breastfeeding are helpful. And creating a separate, comfortable room with seating would provide privacy for any mums anxious about breastfeeding in public, and without them having to resort to feeding their child in a toilet cubicle.’

‘It’s about convenience’

Debbie from London says:

‘Breastfeeding never appealed to me, and I knew the second I fell pregnant that I would not be swayed. I wanted to share every second of my son with my husband as I had carried my son for nine months and wanted to make sure that once he was born, looking after him was equal.

‘Secondly, as I did not take maternity leave it meant I was able to have the help of other people feeding my son while I worked, without me having to ‘cluster feed’ and be tied to my baby. Thirdly, since I was born, formula milk has advanced and my son so far has an immune system on a par, if not better, than some breastfed babies.

‘I also think it’s [the culture in the UK] about convenience. Formula milk is available everywhere and means you can confidently feed your child in public without being shamed. I know you can express into a bottle but again this can be painful and not as convenient. It also means you can quickly return to your busy life of eating and drinking as normal, plus lots of new mums go back to work straight away so breastfeeding simply wouldn’t work for them.’


As we approach yet another general election at the time of going to press, the next government needs to recognise that well-supported healthcare professionals who are not exhausted or under pressure will be able to invest more time in promoting the healthiest choices to women.

Bernadette refers to an encouraging survey in her local press, which found most mothers try to breastfeed ‘because their midwife or health visitor recommends it’. The same survey suggested health benefits are lowest on the list of reasons, below cost and convenience.

Perhaps the smartest way forward, in addition to implementing better national policy and education around breastfeeding, is simply to listen and learn.

References

Betts J, Russell R. (2017) Breastfeeding: attitudes and policies. See: niassembly.gov.uk/globalassets/documents/raise/publications/2016-2021/2017/health/0917.pdf (accessed 25 May 2017).

Detail Data. (2017) Breastfeeding status of infants. See: data.nicva.org/dataset/breastfeeding-status-infants (accessed 25 May 2017).

PHE. (2017) New survey of mums reveals perceived barriers to breastfeeding. See: gov.uk/government/news/new-survey-of-mums-reveals-perceived-barriers-to-breastfeeding (accessed 25 May 2017).

PHE. (2015) New mothers are anxious about breastfeeding in public. See: gov.uk/government/news/new-mothers-are-anxious-about-breastfeeding-in-public (accessed 25 May 2017).

Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, The Lancet Breastfeeding Series Group. (2016 ) Why invest, and what it will take to improve breastfeeding practices? The Lancet 387: 491-504.

WBTi. (2016) WBTi UK report 2016. See: worldbreastfeedingtrends.org/GenerateReports/report/WBTi-UK-2016.pdf (accessed 25 May 2017).

WHO. (2016) Infant and young child feeding. See: who.int/mediacentre/factsheets/fs342/en (accessed 24 May 2017).

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