BACKGROUND
Few people today would argue formula feeding is superior to breastfeeding, with the nutritional, immunological, and emotional benefits of breastfeeding being well documented.1 The World Health Organization (WHO) recommends women should breastfeed their infants exclusively for at least the first 6 months. Yet despite recent efforts to increase maternal education as to why ‘breast is best’, UK breastfeeding rates still fall short. Within the UK only 35% of mothers breastfeed at 1 week, decreasing to as little as 3% at 5 months.2 These low rates have called for a change in our breastfeeding culture. Incentive schemes that pay mothers to breastfeed are being trialled in South Yorkshire and Derbyshire, in which mothers exclusively breastfeeding at 6 months receive £200 in high-street vouchers.3 However do we need financial incentives to look after our children? Some would argue ‘yes’ in accordance with our exceptionally low breastfeeding rates. However others would argue that we need to tackle the ‘bigger picture’ and spend this money on improving support, advice, and providing continuity of care.
The Baby Friendly Initiative was started up by WHO and UNICEF in 1991 to encourage a standard best care and practice in hospitals and the community.3 It was successful in increasing the number of breastfed babies at birth by 10% by improving support and education. However, breastfeeding rates still remained low with a large majority of mothers resorting to bottle feeding within the first few days and weeks after birth. Of these mothers 90% reported they would have liked to have continued breastfeeding.4
So where is the missing link? To what extent do factors other than education, support, medical care and health, such as the cultural values and social forces, shape women’s breastfeeding attitudes and decisions?
HOW CULTURE CAN INFLUENCE PRACTICE
Breastfeeding is a heavily culturalised behaviour, with rates varying between countries, societies, and cultures, with a vast array of influencing factors: embarrassment, body impact,5 sexuality,6 views of partners and family, education, time restraints, inconvenience, and insufficient public facilities.7 The list is vast, even discounting the medical reasons and considering the health of mother and baby.
By looking at two contrasting cultural beliefs, we can see how influential the biocultural perspectives of a community can be on the decision to breastfeed.
In Mali, breasts have retained their primary biological function and hold no sexual connotations or stimulus. The public hold strong beliefs that breastfeeding is essential to create a bond of kinship, and render the child biologically related to the mother. Needless to say this belief has a positive effect on the rates of breastfeeding with 98% of mothers breastfeeding their babies up to an average age of 22 months.8
In contrast, within the Mende culture of Sierra Leone, women choose to use tinned milk to feed their children based on the cultural belief that if a woman were to be disloyal to her husband, the semen of a man other than the child’s father can lead to the production of ‘bad milk’ causing sickness within the child. With disease rates being high due to malnutrition and poor sanitation, childhood illness is common. They therefore prevent accusations of being unfaithful by feeding their children tinned milk.8
Although these may be seen as quite extreme views, they are strong examples of how external cultural influences affect a mothers decision to breastfeed.
Within more Westernised societies, what are the cultural and social beliefs affecting a mother’s decision to breastfeed? It has been postulated that as many as 69% of women worry people would judge them for breastfeeding in public, 80% are too embarrassed to breastfeed in public, and 77% are embarrassed by a friend or family member breastfeeding in front of them.5 Despite a social movement where bikinis, low-cut tops, and skin-revealing attire are no longer classed as ‘indecent exposure’, even less exposure, such as a mother discreetly breastfeeding in public, can be perceived as awkward, disrespectful, and uncomfortable. The public perception still remains that bottle feeding in public is more acceptable than breastfeeding, despite the known health benefits.
So why do the public have this view? Why is exposure of the breast, in the context of breastfeeding, still seen by many as being inappropriate in a public place?
THE SEXUALISATION OF BREASTS
It has been argued that if you say the word ‘breast’ to a group of heterosexual men, they think of sex first, not breastfeeding.6 How often are breasts portrayed in the media in a maternal and natural role, rather than a sexually provocative role? In a study looking at traditional and non-traditional magazines, 73% of women were portrayed in a ‘decorative and alluring way’, 5% in an employment role, and 10% in family roles.9 Visual examples of the sexual objectification of women are especially prominent in the world of advertising. However a study has shown that only 27% of mothers thought it was appropriate to portray breastfeeding women on television.5 Our cultures seem to struggle with the transference of ideas from breasts that you dress up to look attractive, by push-up bras, low-cut tops, and implants, rather than a maternal mammalian necessity for feeding our young. Our culture is comfortable with portraying breasts in a sexual connotation without too much thought of indecency, yet the portrayal of breasts in one of the most maternal, and natural of settings, can be perceived as uncomfortable.
FOLLOWING BY EXAMPLE
So what can be done to increase the breastfeeding rates in the long term? In the 1970s, breastfeeding rates in Scandinavia were as low as those currently seen in Britain. To increase their rates, they adopted a policy with a number of strategies to increase maternal breastfeeding support. This included the banning of all advertising of artificial formula milk, a years maternity leave with 80% pay, and on the mother’s return to work, an hour’s breastfeeding break daily. Today 98% of Scandinavian women initiate breastfeeding, with 42% at 6 months. These rates are the highest in the world.10
CONCLUSION
In conclusion, education programmes on why breast is best have been successful in raising awareness on the importance of breastfeeding. However, despite the encouragement by the medical community, many women do not breastfeed because of perceived social sanctions and factors beyond a simple lack of awareness. Cultural and social ideals have a vast and deep underlying effect on a mothers’ decision to breastfeed, to include social perception, embarrassment, the sexualisation of breasts, views of partners, and public facilities.
But why is this important? We know that breastfeeding decreases incidences of childhood disease and illness. In the UK, raising breastfeeding rates has been identified as a key step in reducing health inequalities with a 10% rate increase translating into an estimated cost saving of £5.6 million annually in money now spent on the treatment of ear infections, asthma, and other maladies.11
Perhaps the root of the problem is how breastfeeding in public is such an unusual behaviour to see. Only 26% of adolescents have ever seen a mother breastfeeding, publicly or privately.12 Maybe it is not solely maternal education that needs improving to change the expectation and views on breastfeeding, but the education of a culture. The iconic image of a baby feeding is with a bottle. Maybe if there were more images of breastfeeding women in the media, and increased openness and support for breastfeeding mothers in public places, mothers may be able to break the taboo by doing the taboo thing,11 and seeing a woman breastfeed in public would elicit a more positive response, or even no response at all? Not having been a mother myself, I would like to breastfeed my children in the future. However this desire is mainly influenced by the fact that I understand the benefits and believe I would have the support from my family, not because it is culturally expected to do so.
Notes
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2014
