It’s May; it must be…Breastfeeding Awareness Week 1. Time for the government to throw some extra money at breastfeeding; the theme this year is the “health benefits of breastfeeding.” Caroline Deacon wonders whether promoting health benefits to new mothers could be seen as bullying, and considers the role health professionals could play in getting the message across sensitively.

We all know that breast is best, and we also know that breastfeeding rates in Britain are low; only around 66% of women giving birth in the UK start breastfeeding, while in Scandinavian countries, rates are around 90% or higher. It was estimated as far back as 1995 that if breastfeeding rates in the UK were nearer this 90% at thirteen weeks postpartum, the NHS would save £35million per year on babies hospitalised with gastroenteritis alone. 2

Why promote breastfeeding?

Breastfeeding needs to be promoted, if only because its substitutes are heavily advertised. Baby Milk Action’s most recent (1994) estimates suggest formula companies still spend £12million per annum in the UK promoting their wares – equivalent to £17 per new baby. The government’s spending on breastfeeding promotion (mostly through Breastfeeding Awareness Week) works out at a measly £1.20 per baby.

If you don’t believe advertising works, consider that following Milupa’s sponsorship of a hearing room in Hillingdon hospital, local sales of Milupa milks increased by 560%. 4 If you carry any “freebies” with brand names, you are contributing to a highly effective marketing strategy, described as the “halo effect”, where brands become seen as beneficial because of their association with trusted health professionals. 5

Yet many health professionals feel a dilemma about promoting breastfeeding directly to mothers. Changing Childbirth emphasises the importance of informed choice, but is this a valid concept when talking about breastfeeding? Many mothers choose not to breastfeed; do we risk alienating them or making them feel guilty by stressing the health benefits of breastfeeding?

Can health professionals influence women’s decisions?

Before we consider whether it is ethical to promote breastfeeding to pregnant women, it is worth considering whether this is an effective strategy anyway. Although health professionals believe themselves to be the most important influence on mothers’ decisions to breastfeed, 6 friends, relatives and partners have the greatest influence.7  By the time women come into contact with their midwife, the decision has usually been made. Our current understanding is that women decide to breastfeed prior to or very early in pregnancy; and that furthermore once she has decided how she will feed, she is unlikely to change her mind, although as the RCM pointed out, no-one has yet investigated the effect of telling women that bottle-feeding is problematic 8.

Breastfeeding information given antenatally may however, positively influence how long a woman breastfeeds. 9  In addition, by the time babies reach six weeks of age, more than one third of women who started breastfeeding have stopped, despite the fact that when questioned, 90% of them say they would have liked to breastfeed for longer. 10  Why do they stop?

Hospital practices can either help or hinder women to successfully establish and maintain breastfeeding. 11

A successful first feed; preferably within two hours of birth, ideally within the first hour, is likely to make the mother feel that her baby “likes” her and will contribute to the continuation of breastfeeding. 12 So removing the baby to wash or weigh it, or to allow suturing could be considered bad practice.

• Rooming in is standard practice in most hospitals, although bed sharing is not, despite findings that women who share their beds with their infants are more likely to be exclusively breastfeeding at discharge. 13
• Unrestricted duration and frequency of feeds is also crucial, while early supplementary or complementary feeds are detrimental to breastfeeding. 14

Expectations and realities

Although the above factors, within our control, have been found to influence breastfeeding rates, it is also worth considering why mothers themselves believe they stopped. Two recent phenomenological studies shed light on this. 15 16 In the first study, women described a clash between their idealised expectations of breastfeeding as natural and therefore unproblematic, and the reality of early breastfeeding. This mismatch could be addressed by better antenatal education. The second study described the reasons mothers cited for giving up breastfeeding early as “perceived breastmilk inadequacy”. The authors highlighted the need for sensitive and skilled support from health professionals.

Cultural influences

We live, it is claimed, in a bottle-feeding culture, aided and abetted by the media. Research recently confirmed what many of us had long suspected; the British media portray breastfeeding as problematic, funny and embarrassing, associated with middle class or celebrity women, while bottle-feeding is seen as normal. 17  In such a culture, breastfeeding in public can be labelled “aggressive.”18

Breastfeeding does not happen in a cultural vacuum, for British women it takes place in a society where a women’s sexuality is defined by her breasts; interestingly, also a culture where we continue to drink milk after weaning. Both of these cultural practices are, historically and anthropologically speaking, unusual. Women who breastfeed are warned to make sure their partner does not feel left out, 19 while fathers’ attitudes to breastfeeding are crucial to success or failure.20

Pam Carter describes women as “engaged in a complex negotiation about the control and autonomy of their bodies”, where “their bodies as the site of adult heterosexual pleasure are divorced from that body as a source of infant pleasure and gratification.” 21   It has been suggested that because feeding a baby crosses the boundary between private and public behaviour, it is culturally problematic. 22

Women who reject breastfeeding could also be refusing the endless responsibility for feeding others which culture assigns to them. 23  Pam Carter did an interesting historical survey and found that women receive more help with bottle-feeding than with any other household duties 24 , so perhaps it’s true that bottle-feeding “gives mother a rest”. Despite the WHO code, Nestle are currently offering a month’s free supply of formula as a prize to mothers who feel like they haven’t had much time for themselves recently. “Here’s our chance to take care of you!” 25

Our culture believes that bottle-feeding is easier, it gets you into a routine, gives you time off, and is there if you “can’t” breastfeed. 26   The recent phenomenal sales of books which emphasise routine above all 27 are, it could be argued, fulfilling a deep-seated need in new mothers to feel in control, working to a time-table – which bottle-feeding rather than breastfeeding fulfils.

It is fascinating to consider that the main benefits of breastfeeding are bio-medical, but when we look at the reasons women choose not to breastfeed, these could be classified as personal or social. A biomedical model of breastfeeding has disadvantages too; if frequent weighing of babies is a way of measuring “success”, we can create unrealistic expectations in mothers, and we ignore the most important factors in the equation.  Perhaps this is why Breastfeeding Awareness Week 1999 was the most successful - it tried to create positive social and personal influences by focusing on icons such as The Spice Girls as positive role models.

Is promoting breastfeeding political?

Maureen Minchin has pointed out that there seems to be a taboo about talking about the risks of formula feeding. 28 Talking instead about the “health benefits” of breastfeeding suggests that breastfeeding is an additional option, as the National Childbirth Trust is stressing this week. What we need to do is to change the public perception so that breastfeeding is normal, formula feeding is seen as a fourth-rate substitute (behind breastfeeding, expressed breastmilk and donor breastmilk - World Health Organisation priorities). 29

Health professionals are prepared to point out in no uncertain terms the risks smoking, alcohol or drugs pose to unborn babies. Is formula feeding really any different, when we consider the accumulated evidence of real health risks? The disadvantages of formula feeding may seem harder to perceive in a developed country; after all the babies who become ill from formula have access to good health care, and many healthy adults seem to “prove” that “formula feeding doesn’t do much harm. However, we all know 90 year olds who smoke 60 per day and seem healthy, but it doesn’t stop us promoting abstinence. It is also interesting that the recent paper which suggested 30 that breastfeeding for more than four months could cause raised blood pressure was widely reported, without anyone worrying whether breastfeeding mothers might be made to “feel guilty”.

It would seem that society certainly could do with some breastfeeding promotion – but let’s lay off the mothers. It’s no good promoting the benefits of breastfeeding to them if we cannot offer skilled back up – this puts the onus for success or failure on the mother, and makes guilt inevitable.  We need to ensure that our practical skills are up to date, and most importantly, we need to focus on the individual mother and her situation, finding out what for her, is appropriate and relevant advice and support. To illustrate this, a small survey recently asked mothers what they saw as good or bad advice. In general, if a mother had decided she really wanted to breastfeed, she rated as ‘worst’ advice that suggesting she give up, whereas if she had decided that she had had enough of breastfeeding and wanted to stop, she rated as ‘worst’ advice that which told her to persevere.31   This shows just how important it is to listen to the mother, find out what she wants to do, and provide the support she needs to help her to do it.
 
© Caroline Deacon.

Article first appeared in Nursing Times May 2001