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9 Sociological and Cultural Influences upon Breastfeeding

Published onJul 01, 2018
9 Sociological and Cultural Influences upon Breastfeeding

9 Sociological and Cultural Influences upon Breastfeeding

Amy Brown, Prof, PhD, MSc

Expected Key Learning Outcomes

  • The social and cultural factors affecting maternal attitude towards breastfeeding and its success

  • The different influences in high-income and low/middle income countries

  • A key factor to empower mothers to make an informed choice in relation to socio-cultural issues

  • Other influencers in enabling a positive socio-cultural environment for breastfeeding

At first glance, breastfeeding could be perceived to be principally a biological issue. Indeed, earlier research in this area often focused primarily on understanding factors, such as milk production, latch, and pain. Much of this initial research was conducted in or around hospital settings by those with a background in medicine or nursing. Such research is paramount, but it neither provides the full picture nor on its own enables addressing the significant issues of breastfeeding rates or sub-optimal practices in many countries.

Breastfeeding is a biological act and breast milk production is hormonally driven. Milk starts to be produced in small amounts from mid-term pregnancy, with production of greater volumes once the placenta is removed after birth. A rise in prolactin and oxytocin post birth trigger this rapid increase in milk volume, and these hormones continue to play an important role in ensuring sufficient breast milk is produced throughout the breastfeeding period. Each time the infant sucks, a rise in prolactin is seen [1]. Meanwhile, breast milk supply is generally matched to the needs of the perceived infant; the more milk that is removed from the breast, the more milk is made and vice versa [2].

Research suggests that the majority of mothers should be able to produce breast milk for their infant, although some will experience impediments or have contraindications for breastfeeding [3]. For example, infants with galactosaemia (where infants lack the enzymes needed to digest lactose and galactose in milk) need specialist formulas. Mothers with active tuberculosis should be separated from their infant, although transmission in milk is low, and mothers with active herpes lesions around the nipple should not breastfeed. Some medications such as lithium, atropine, and iodides are contraindicated, but usually a safe alternative can be found [4].

The most common but relatively rare condition, affecting around one in 1,000 mothers, is insufficient glandular development [5]. This typically presents as little change to the breast during pregnancy or after birth. Breasts lack fullness vertically and horizontally, and are widely spaced with enlarged areola. Women often have low milk production despite frequent feeds after birth. In one study, 85% of mothers with the condition produced less than half of the milk needed for their baby during the first week, although it did improve. By one month, 55% produced less than half the milk needed and 39% produced the full milk requirement for their baby [6]. Other disorders, such as gestational diabetes [7] and polycystic ovary syndrome [8] may require more support in helping mothers achieve a full milk supply.

These data suggest that from a physiological perspective, the majority of women should be able to breastfeed their baby. In her reflections of time spent as a lactation consultant in Zimbabwe, Morrison found that less than 0.1% of the thousands of mothers she met could not produce sufficient breast milk [9]. This reflects the expected occurrence of insufficient glandular development. In many regions of Africa and Asia, it mirrors the high numbers of women who initiate breastfeeding at birth, which is similar to the numbers breastfeeding at six and 12 months.

However, these figures do not reflect the breastfeeding experiences of many women in Western cultures. In many Western countries, rates of both initiation and continuation are far lower. For example, while breastfeeding initiation is almost universal in African, Asian and some South American regions, only 81% of mothers in the UK and 77% in the USA initiate breastfeeding. Disparities also occur in duration of breastfeeding. At six months postpartum, virtually all women in African and Asian regions are breastfeeding while only half of mothers are breastfeeding in the USA and Australia, and one-third of mothers are breastfeeding in the UK [10]. There is no plausible, physiological reason why this variation should happen. This is not to say that women in these regions do not have physiological issues. In fact, the majority cite reasons of insufficient milk supply, pain, and difficulties with latch as reasons for stopping [11].

Conversely, issues such as pain, difficulty, and breast milk insufficiency are rarely given for breastfeeding cessation in cultures where breastfeeding knowledge, acceptance, and support is high. Anthropological research exploring influences on breastfeeding in a rural tribe in East Africa found that all infants were breastfed for at least six months, 90% for at least a year, and 75% until two years. Reasons for stopping breastfeeding before two years included maternal illness, pregnancy or the child being able to eat the diet of the tribe. Insufficiency or insurmountable difficulties were simply not a concept [12].

Firstly, it might be suggested that breastfeeding difficulties are a Western phenomenon — that Western women have lost the ability to breastfeed their babies. However, this shift is relatively recent in terms of history. Only 150 years ago, breastfeeding was still very much the norm. Infants were breastfed by their mother or a wet nurse, or neither. However, with the advent of the formula industry and the first formulas made at the end of the 19th century, behaviours started to change [13]. Physiological evolution does of course happen but slowly, while social evolution can progress at a much faster pace. Attitudes, norms and knowledge can change and be lost very quickly.

Secondly, this pattern of low rates of breastfeeding does not exist across the entire West. In Nordic regions, breastfeeding initiation remains almost universal, with around three-quarters of mothers continuing to breastfeed until six months postpartum. Differences in breastfeeding rates also occur within regions, in a pattern that cannot be explained by any geographical phenomena. In the UK, variation is seen in initiation and duration between the four countries: in England 83% of mothers breastfeed at birth compared to 74% in Scotland, 71% in Wales, and 64% in Northern Ireland [14].

Finally, rates of breastfeeding also differ between groups even within a country. Mothers who are older are more likely to breastfeed and for longer. In the UK, 87% of mothers aged over 30 years breastfeed at birth whereas only 20% of those under the age of 20 years do so [11]. This pattern repeats itself around the globe. Even when breastfeeding rates in a country are almost universal, those who are more likely to stop at a comparably earlier time point are more likely to be younger mothers [14]. From a biological perspective, the ideal time for a woman to have a baby is when she is younger, whereas you might expect older mothers to struggle more with breastfeeding as their fertility declines and other complications arise. Biology is therefore not responsible for this difference.

Breastfeeding rates also differ strongly by maternal education. The longer a mother spends in education, the more likely she is to initiate and continue breastfeeding. In the UK, 91% of mothers who leave full time education over the age of 18 years start breastfeeding compared to 63% of those who left at 16 years or younger. A similar pattern is also seen for occupation; 90% of women in managerial and professional jobs begin breastfeeding compared with 74% of those in routine and manual occupations, and 71% of those who have never worked [11]. These are global patterns. Education is also predictive of early initiation and exclusive breastfeeding in developing countries [14]. Education does not affect a woman’s physiology.

Patterns of breastfeeding go deeper than that, however, with significant differences seen in ethnic groups, even within countries. In the UK, women from non-white British backgrounds are significantly more likely to breastfeed than those from white backgrounds [11]. Conversely, in the USA, women from white backgrounds are significantly more likely to breastfeed than women from black backgrounds [15]. This is further affected by degree of acculturation and we will consider this later in the chapter.

What these statistics show is that breastfeeding cannot simply be a physiological issue if such extensive variation is seen between and within countries. Consensus is growing to the importance of taking a systems level, public health approach to breastfeeding, recognising the importance of the society, culture, and environment in which breastfeeding occurs. Breastfeeding is not simply a physiological process — the psychological, social, and cultural aspects can directly affect ability to breastfeed through influencing maternal behaviour and opportunity. As Victora et al. 2016 [10] state:

‘The reasons why women avoid or stop breastfeeding range from the medical, cultural, and psychological, to physical discomfort and inconvenience. These matters are not trivial, and many mothers without support turn to a bottle of formula. Multiplied across populations and involving multinational commercial interests, this situation has catastrophic consequences on breastfeeding rates and the health of subsequent generations.’

These social and cultural issues are numerous and complex but can broadly be split into two themes: 1) direct negative attitudes about breastfeeding and its impact and 2) more subtle factors that despite intention and desire to breastfeed, erode maternal ability to do so. Some of these influences are overt; negative attitudes to breastfeeding in public, beliefs that formula fed babies are more content, and pressure from family members to take part in the feeding. More covertly, a lack of understanding of how breast milk production works, a desire to manipulate infant feeding patterns, or religious and cultural influences can all lead to a low milk supply through practices that discourage either exclusive and/or responsive breastfeeding.

Although ultimately breast milk supply is determined by hormonal levels, the frequency of feeding is critical to a good milk supply with infant sucking triggering a rise in prolactin [1]. Responsive feeding, e.g., when the infant signals to be fed, is associated with the best outcomes. The volume of breast milk produced is predominantly affected by how much and how frequently breast milk is removed from the breast, either through a baby feeding directly or through milk expression. The more milk removed from the breast, the more breast milk produced by the body. Less milk is produced if demand declines, e.g., through bottle feeding with formula or lengthening the time between feeds [16]. The body is therefore adept at adapting milk production to meet the perceived needs of the infant. Infants who are breastfed responsively, e.g., whenever they signal hunger, are more likely to continue to be breastfed [17].

Although this mechanism between frequency of feeding and milk supply is physiological, societal and cultural norms play a significant role in determining whether this is successful. This is because responsive feeding is heavily embedded in the knowledge, attitudes, and norms of a society. In Western culture, many new parents and those supporting them either do not understand the importance of responsive feeding or are dissuaded from doing so by the environment in which they live. This dissuasion can be deliberate and direct or more subtle, with individuals not recognising the damage that is occurring. It is this environment that affects how responsively an infant is fed and consequently, how much breast milk is produced.

Breastfeeding is therefore the end point of a physiological issue, but many social and cultural issues determine the success of that physiology. Over time, societies and cultures build the breastfeeding environment that new mothers will adopt, and the resulting attitudes and norms can be very influential on new mothers. However, they are not fixed, and can and have been changed as we will see. Identifying and understanding these issues is crucial to being able to support new mothers to breastfeed to the very best of their ability. As Rollins (2016) [18] states:

‘The success or failure of breastfeeding should not be seen solely as the responsibility of the woman. 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.’

9.1 Societal Attitudes Towards Breastfeeding

A significant indicator of any health behaviour is the attitude that both an individual and their society hold towards the value and significance of that behaviour. The same is very much true for infant feeding. Individuals may hold beliefs that are different to the norm in their society, but they still formed that belief while being part of that society. They are very likely aware of how their attitude and decision compliments or contrasts with the opinion of the many.

The dominant attitude towards breastfeeding matters in a multitude of ways; whether it is through information sharing, reactions or ability to support. Breastfeeding in a community of peers with positive attitudes to breastfeeding is easier than when their attitudes differ, even if they do not overtly share their differing beliefs. Mothers who feel they are part of a supportive community where their peers breastfeed and honour their decision, are more likely to breastfeed, even if they are younger [26]. Conversely, many mothers, especially those living in areas of deprivation, talk about communities where formula feeding is the norm [19].

In Western culture, a number of attitudes towards breastfeeding are often known to, if not widely held, by communities. These are based around attitudes to breast milk itself, the breast, and to the act of breastfeeding. In addition, attitudes about formula milk directly affect attitudes towards breastfeeding, as they are often considered two opposing choices. These attitudes affect women’s decisions about breastfeeding directly or her decisions about when to breastfeed, potentially impacting upon formula milk feeding. Unsurprisingly, negative views towards breastfeeding are associated with formula use [20].

9.1.1 Perceptions of the Breast

As soon as the words ‘breast milk’ are uttered, many are drawn immediately to the word ‘breast’ and its connotations. For some, breastfeeding and the sexual nature of the breast are deeply intertwined and inseparable. The breast has become so highly sexualised by the media (and accepted as such) that it automatically triggers sexual connotations for many. There is nothing wrong with this; breasts are a sexual part of the body and many women take pride in their appearance.

However, it is the singular connotation of acceptable use of the breast that damages the image of breastfeeding. This is partly due to exposure. Whereas images of breasts in their sexual form are in every magazine and on every corner, the breast in its nurturing sense is rarely seen. This seeks to strengthen the automatic connotation of the breast as sexual, while reducing its connection with feeding [21]. Those who hold the highest attitudes about the breast as sexual, are those who are most intolerant to breastfeeding [22] and those who feel generally uncomfortable around sexual stimuli, feel significantly more uncomfortable around breastfeeding [23].

The sexual connotation of the breast is in part due to the lack of visibility of breastfeeding in society. In one study, only a quarter of adolescents had ever seen anyone breastfeed [24], yet it could be assumed that they had been exposed to many, many images of breasts in a sexual form. Representations of breastfeeding in the media are scarce, and mainly focused around newborn infants of white, educated, older women. Extended breastfeeding is not visible; it is seen as socially unacceptable and made others feel uncomfortable [25]. Additionally, of the references to breastfeeding, many make a play on the sexual nature of breastfeeding, using inappropriate humour [26].

Focus on the sexual nature of breast increases issues with maternal body image, affecting breastfeeding decisions. A common concern, especially for younger mothers is that breastfeeding will ruin the appearance of the breast, or that clothes needed for breastfeeding are unattractive [27]. Research shows that those women who are pregnant and worried about the potential impact of breastfeeding on their breast shape and volume, are unlikely to even plan to breastfeed [28]. However, despite research showing that it is pregnancy and not breastfeeding that affects breast shape [29], such myths perpetuate.

9.1.2 Perceptions of Breast Milk

Often intertwined with the view of the breast as sexual, the negative connotations of breast milk are associated with negative attitudes towards breastfeeding. A view that breast milk is a bodily substance and must therefore be dirty or contaminated is common, and held subconsciously by some. Many claim that breast milk is normal and healthy, but squirm if offered some to drink. Others are more overt in their disgust, comparing breastfeeding in public places to urinating, as if the two were somehow equal in their intent.

Breast milk is a unique substance in terms of bodily secretions. Other secretions may carry disease, signify ill health, or have the potential to cause harm, whereas breast milk does not. However, some to group all bodily fluids together, thus viewing breast milk as a contaminant. Generally, people hold the view that bodily fluids should be controlled and contained, but breastfeeding is a visible sharing of those fluids [30]. An interesting statistic emerged from YouGov polled research in response to a news story that a woman had breastfed her baby in a swimming pool. They survey found that while 65% of responders thought it appropriate to breastfeed when sitting beside a pool, only 36% believed it appropriate to breastfeed in the pool. This suggests a fear that breast milk would in some way contaminate the individual [31].

These attitudes contribute to the negative societal connotations of breastfeeding and thus upon breastfeeding itself. Women can feel that they should be hiding their milk; they are taught to feel ashamed of and hide other bodily fluids, such as menstrual blood [30]. Others feel uneasy that such a potential contaminant (e.g., to their eyes) should be present in food settings, creating unease for mothers trying to breastfeed their baby. Education is key; after all, many of those who hold negative views about breast milk are more than happy to have the milk of another species in their tea.

9.1.3 Attitudes to Breastfeeding in Public

The previous sections explore the concept of the breast as sexual and breast milk as a contaminant, factors that contribute directly to the issue of negative societal attitudes to breastfeeding in public. In the UK, under the 2010 Equality Act for England and Wales, a woman must not be treated unfavourably because she is breastfeeding. More specifically, in Scotland, a person must not be prevented from breastfeeding her child (if under two years of age) in a public place. Similar laws occur globally, including some regions of the USA, Canada, Australia, and Europe. However, individuals often consider public areas to be “their” space and feel that they can directly or indirectly dictate what happens in them [32].

However, protection by law does not prevent many from holding the negative attitude that women should not breastfeed in public. A global survey found that most members of the public agreed that babies should ideally be breastfed but simultaneously, between one-third and half believe women should not breastfeed in public, with the USA having the most negative views, followed by France. Others are more supportive of breastfeeding, but thought that bottle-feeding was more acceptable in public [33].

Likewise, in research that has compared attitudes across different countries, significant variation is seen in rates. In one study exploring rates in European countries, 56% of respondents in Italy and 42% in Spain thought breastfeeding in public was wrong, whereas only 8% in Sweden thought it inappropriate [34]. In the USA, only 43% of those surveyed believed that women had the right to breastfeed in public [35]. This reflects the breastfeeding rates of the country; Sweden has some of the highest rates in the West, whereas the USA has some of the lowest.

Others do not disprove of breastfeeding, but report that it makes them feel uncomfortable [36]. Some add provisos that breastfeeding in public is acceptable as long as the woman is discrete and respects the feelings of others [37]. Ultimately, many appear to view the situation as their wish versus the wish of mothers, when in reality it should be considered as their wish versus that of infants.

Finally, some feel breastfeeding in public is unavoidable and should be tolerated, but are unhappy with it being depicted ‘unnecessarily’. For example, only one-quarter of the public in the USA believe it is suitable to show a mother breastfeeding on television [35]. Another study found that only 48% of men felt it was appropriate to show a woman breastfeeding on a magazine cover, 37% felt it was appropriate on a billboard or poster, and 46% felt it was appropriate on a family television show [38]. Media representations of breastfeeding often play to these views. When breastfeeding is shown on television, it is often shown in the context of the home, with cues depicting that this was a private activity, e.g., mothers wearing a nightgown while feeding their infants, rather than being out in public [39].

Most studies find breastfeeding attitudes vary with age. The most open to breastfeeding in public are those who have young children themselves, and older people. However, adolescents and university age students typically have the most negative views. In a Canadian study, nearly 80% of college students believed breastfeeding was an intimate act that should be kept private [37], while in America only one-third of undergraduate students believed it was acceptable to breastfeed in public [40]. In Quebec, a quarter of adolescent girls believed that breastfeeding in public showed a lack of respect for others, and one-third believed that it was important not to see the breasts if a woman was breastfeeding in public [41]. Attitudes also differ by gender. In general, men are actually a little more supportive of breastfeeding in public than women [35], and men who are fathers are more likely to have supportive views compared to men without children. A study in the USA showed that only 16% of fathers expressed an issue against women breastfeeding in public [38].

Why do the public hold negative views about breastfeeding in public? The view of the breast as sexual and of breast milk being potentially contaminating is common, but views about the function of the female body also play a role.

In Western culture women are required to look attractive and be perceived to be available. Their bodies are frequently used in popular culture in a sexual way, surrounded by misogynistic messages around ownership and consent [42]. For some, the sight of a woman breastfeeding provokes anger; the woman is using a part of her body to nurture a baby that they expect to see for themselves only, suggesting her attention will not be directed towards them [43]. Others feel anger towards women who break away from the mould of a “good woman”, labelling them (especially those who draw attention to breastfeeding through protests and celebrations) as silly, irritating and obnoxious [44].

This may seem far-fetched, but close links are seen between sexism and dislike of breastfeeding in public. When male sexism is high, men are less likely to approve of a photograph of a woman breastfeeding in public [22]. Two broad types of male sexism occur. The first is hostile sexism, which is a direct dislike of women and belief in masculine ideologies. The second is benevolent sexism, where men like women but believe they must be protected and cannot achieve the same things as men. Men with high levels of hostile sexism hold negative views of childbirth and breastfeeding [45]. However, although men with high levels of benevolent sexism are supportive of breastfeeding, because it suggests that a woman is a good, traditional female [23], they dislike a woman to breastfeed in public, because this signifies that she is breaking away from her ‘good woman’ role [22].

Public attitudes to breastfeeding do affect maternal decisions. Countries where attitudes to breastfeeding in public are the most positive tend to have the highest breastfeeding rates. This has a cyclical impact. The more breastfeeding is seen in public, the more normal and accepted it becomes, and vice versa. Research shows that experiencing negative attitudes towards breastfeeding in public is common amongst new mothers. In the UK, a large survey by a parenting magazine found that 60% of mothers felt that the UK was not breastfeeding friendly, 65% found breastfeeding in public a stressful experience, and 54% had directly received negative comments or actions [46]. Additionally, the UK Infant Feeding Survey 2010 found that 85% of breastfeeding mothers felt that society frowns upon mothers who breastfeed, and 68% believed it was the cultural norm to bottle feed babies [11].

Understandably concerns around breastfeeding in public – whether these are based on embarrassment, shame or fear – are associated with a shorter breastfeeding duration. Fear of being approached is common amongst new mothers. Others fear the silent disapproval and stares of others. Findings from the UK Infant Feeding Survey 2010 showed that only 8% of breastfeeding mothers felt comfortable breastfeeding wherever they wanted, and the majority felt self-conscious. As such, only around half of women breastfeed in public by six weeks in the UK compared to 80% of mothers in Sweden. Feeling uncomfortable breastfeeding in public is a common reason for not doing so [11].

Other women feel that they must practice “socially sensitive lactation”, where despite protection under law, mothers feel hesitant breastfeeding in public and try to do so covertly or use a private room [47]. Some may express milk to avoid breastfeeding in public. However, expressing can be time consuming and difficult, with some women finding they can only express a small amount [48]. Moreover, infants may not accept a bottle as it is shaped differently to the breast [49]. Finally, others may try to extend the time in between feeds, which can negatively impact milk supply [16].

9.1.4 Attitudes Towards Formula Milk

Interlinked but separate to attitudes towards breast milk, are perceptions of formula, particularly around its perceived impact on infant sleep. A very common perception is that formula fed babies are more content and settled, need to feed less often, and will sleep better at night [50]. This ties strongly into Western cultural norms, that infants should be quiet, settled and “good”. These beliefs are reflected in media representations of formula feeding; whereas breastfeeding is often presented in television shows as being difficult, formula feeding is typically presented as normal, problem free and something that others, particularly the father, can join in with [26].

In general, breastfed babies will feed more frequently, irregularly, and for longer from the first week of life than formula fed infants [51]. Formula fed infants typically have more defined feeds rather than tending to cluster feed [52]. Breastfed infants tend to feed around 8–12 times per 24 hours, whereas formula fed infants may feed 6–8 times [53]. Breast milk is not a uniform product, changing in energy density during the course of a feed and at different times of the day [54]. Growth spurts can also lead to a change in feeding patterns, with more frequent feeding before and during a growth spurt [51]. Indeed, in cultures where carrying and sleeping with infants is the norm, infants will feed up to several times an hour and throughout the night [55].

These differences can in part be explained by the significantly faster rate of digestion of breast milk compared with formula milk [56]. However, formula fed infants consume a greater volume of milk per feed [57], feeding more quickly, consuming milk at a faster rate, and having fewer sucking pauses [58]. Differences in the feeding mechanism contribute to this. Formula feeding works by a simple sucking action whereas breastfed infants must latch onto the breast [59]. This makes persuading a bottle fed infant to take more milk easier than with a breastfed infant, with research showing that with encouragement, bottle fed infants will consume on average a further 10% more milk [60].

Notably, a major difference between breast and formula feeding is the need for breastfeeding to be responsive to these frequent needs, to ensure sufficient milk supply. Missing or replacing breastfeeds, or extending the time between feeds, can lead to a reduction in milk supply. This issue does not arise with formula milk. Responsive feeding is associated with a faster production of mature breast milk [61], less weight loss after birth [62], and greater breast milk supply [63]. Conversely, attempting to reduce feeds or feed to a set schedule can lead to a reduction in milk supply [64], breastfeeding difficulties [50], and breastfeeding cessation [65].

In terms of sleep, waking at night is normal throughout the first year and beyond, despite significant social beliefs that it is not. Between 30– 80% of babies continue to wake up at night throughout the first year, with an average frequency of 1–2 times per night [66], [67]. In most non-Western cultures, mother and baby sharing a sleeping surface is normal [68]. Sleeping alone is a Western concept and is rare from a global perspective. Waking at night may be protective against sudden infant death syndrome [69]. Sleeping close to their mother impacts on infant behaviour and physiology. Infants who sleep next to their mother in hospital are more relaxed in their sleep than those placed in a nursery [70]. Sleeping next to their mother regulates the infant’s temperature control [71], heart rate [72], and breathing [73].

Feeding at night is also normal from an anthropological perspective. Observational studies in rural cultures show that infants (who typically cosleep) breastfeed on average four times a night [12]. Infants can take up to half of their milk at night [74], with the amount increasing as they become toddlers, and more active and distracted during the day [75]. This is perceived as normal and not something that would be measured or considered an issue [55].

In Western culture, many do not understand that frequent feeding and waking at night is normal, thus worrying that something is wrong if breastfed infants feed in this normal pattern. Others perceive it to be inconvenient or incompatible with lifestyle, or believe that infants should be placed in a maternal-led schedule [55]. There is also the notion that formula milk and an early introduction to solid foods will promote deeper sleep. In early infancy, infants who are formula fed do start sleeping for longer periods and have fewer night feeds at an earlier age [76]. However, this pattern does not last. Research with slightly older infants shows that how babies are fed, both in terms of milk type and frequency of solid foods, does not impact on how often babies wake at night [66].

Infant waking is not the only predictor of maternal sleep. Research examining sleep duration in mothers who are breast or formula feeding shows that mothers who breastfeed get more sleep overall. Formula fed infants may wake less frequently, but the time taken for a mother to prepare a bottle and resettle the infant leads to greater sleep deprivation [77].

Breastfed infants are also less restless at night. Breastfed babies were less likely to snore, wheeze, cough or have breathing problems during their sleep, making maternal sleep easier [78]. Cosleeping and breastfeeding are closely linked. In one study, twice as many co-sleeping infants were breastfeeding at 3–4 months than those who slept alone [79]. This may be partly because infants who co-sleep feed twice as often at night than those who sleep separately [80]. However, this does not stop beliefs that infants should be encouraged to develop a stricter pattern for feeding and sleep. Unfortunately, attempting to encourage breastfed infants into a routine is associated with a shorter breastfeeding duration [65] and attempts to feed to a routine are associated with difficulties [50] and cessation [17].

We also known that responsive care for infants plays a crucial role in infant development [81]. When babies feel secure in the care of a primary caregiver, they go on to have better outcomes socially, educationally, and emotionally in childhood and later life than those who do not have such security [82]. Mothers who respond sensitively and promptly to their infants’ signals have more positive attachment bonds [83], with infants recovering more quickly from stressful events [84]. Conversely, allowing an infant to cry for an extended period of time can raise stress hormone levels [85], which may impact negatively on the developing brain [86]. These early experiences are critical. Increased and prolonged levels of stress in early infancy programme the nervous system to be over stimulated [87].

Attitudes that infants should be settled and that formula will remedy this are deeply embedded in the broader ideas of how babies should be fed, family traditions, and perceptions of the visibility of breastfeeding and breast milk. They are also tied into the wider notions about how we view, care for, and value our new mothers.

9.2 Societal Attitudes Towards Mothering

The decision to breast or formula feed is not made in isolation; it is made as part of a mother’s wider experience of how she cares for her infant. The attitudes towards breastfeeding, breast milk, and formula described above all affect her attitudes and choices, but so does her experience of being a mother.

Experience of mothering in modern Western culture is inherently different to that seen in previous generations or in other cultures. Typically, modern mothers are isolated without a support system in place. Many have moved away from their original family and, with the trend to have fewer children later in life, are not exposed to caring for newborn infants until they have their own. In one study exploring the experiences of young women without babies, three had never held a newborn and only one-fifth had ever babysat a very young baby, bottled fed or changed a nappy [88].

Becoming a mother can therefore be real culture shock. New parents often must move from a position of low-caring responsibility and independence to one of responsible 24/7 infant care. Older and more educated mothers feel this shift most harshly. Many report loving their children but not loving the loss of their former identity and lives [89]. Some stop working, and mourn the loss of their working identity and financial security; others attempt to juggle their former working lives with caring for an infant. Copious research articles and headlines talk about this issue, and the high levels of stress, anxiety, and exhaustion whatever the decision taken.

Unsurprisingly, many new mothers feel overwhelmed by this change in circumstance, reporting that they feel shocked, unprepared, and anxious about their new lifestyles [90]. Fathers feel this too, but typically not to the extent of mothers who shoulder most of the responsibility [91]. Maushart (2006) [92] describes this transition to motherhood as ‘the most powerful of all biological capacities and among the most disempowering of social experiences’. It should not be a shock that many do not feel happy with their change of circumstances, with some slipping into postnatal depression because of this.

9.2.1 Postnatal Depression

Postnatal depression is increasingly common in Western culture. Data suggest that around 15% of new mothers experience postnatal depression, but this is likely to be an underestimation. Many do not seek contact with health services because they are concerned about the implications or do not feel that they will be supported. Physiological explanations for postnatal depression are unclear and many models of the illness focus on psychological, social, and cultural factors. Lack of family support, relationship dissatisfaction, and isolation are key contributors to low maternal wellbeing, alongside the culture shock of the new responsibility and lifestyle change of becoming a new mother. Grief can play a central role, as the mother has to adapt to leaving her former life for a new intense responsibility for another. When mothers are isolated in doing this, risk of postnatal depression is higher [93].

The concept of postnatal depression is predominantly a Western infliction. Although episodes of postnatal illness do occur in many cultures across the world, their frequency is much lower. Societal and cultural reaction to these mothers is also different. In Western culture postnatal depression carries stigma, with mothers worrying that they will be perceived as “bad mothers”. Treatment often focuses on pharmacological treatment and counselling approaches, rather than addressing many of the social and cultural factors that increase postnatal depression risk. It could be argued that much of postnatal depression in Western cultures can be attributed to a normal reaction to the lack of emotional and practical support that new mothers need [94]. For example, sleep deprivation [95] and infant crying [96] is linked to an increased risk of postnatal depression, alongside feelings of loss of identity [97]. Mothers should be supported to care for their new infant rather than left to experience exhaustion.

The relationship between postnatal depression and breastfeeding is complex. Mothers who breastfeed for the longest duration have the lowest levels of postnatal depression. It is possible that being able to breastfeed for longer enhances maternal wellbeing. Conversely difficulty breastfeeding and feeling unable to do so may increase the risk of postnatal depression. Pain and difficulties with latch are associated with an increased risk of postnatal depression [98]. However, infant feeding is often blamed for these negative emotions. Numerous perceptions are held in Western culture about the impact of breastfeeding upon infant behaviour. Breastfeeding can often be perceived as the root of issues, as formula fed infants are perceived as more content [50]. Infant feeding in general, whatever the method, takes up considerable time in infancy and it is easy to place blame on this [99].

However, it could also be that wider circumstances increase the likelihood of both postnatal depression and a short breastfeeding duration. Infant temperament is one key area. Mothers with postnatal depression are more likely to have an infant with a difficult temperament; for some, this could be based on perception rather than actual infant behaviour [100]. Mothers with postnatal depression are more likely to perceive their infant as crying excessively and find it more difficult to regulate infant behaviour than those who do not have symptoms [101].

The symptoms of postnatal depression may also make breastfeeding more difficult. Mothers with postnatal depression interact with their baby differently, particularly with regard to responsivity. Mothers with depression have poorer interactions with their newborn compared with non-depressed mothers, with low rates of touching, less sensitivity to their needs, and reduced skin-to-skin contact [102]. They are also more likely to be less intuitive with holding their baby, and more likely to report latching issues and consequently a poor milk supply [103].

Chronic pain is more widely linked to a risk of depression via physiological pathways [104]. Other factors can further increase the risk of depression through an effect on the immune system. Cytokines rise in response to sleep deprivation, stress, and pain, which in turn increase the likelihood of depression from a stress hormone perspective [105]. Stress hormones can inhibit prolactin, which can interfere with milk letdown [106]. Experimental studies of breastfeeding women placed in stressful conditions (subjected to mental puzzles and noise) show that the oxytocin levels in these stressed women are half those of women without the stressful conditions [107]. However, supporting mothers with relaxation interventions leads to an increase in expressed milk output [108].

Expectations also play a major role. Mothers who believed that breastfeeding would be easy and straightforward were at an increased risk of postnatal depression compared to those who perceived it might be more challenging [109]. Indeed, it is intention to breastfeed that predicts postnatal depression more strongly than duration itself. Mothers who want to breastfeed but cannot are at an increased risk compared to mothers who did not want to breastfeed. Notably, antenatal education often significantly lacks the much needed information about what breastfeeding is like and how to overcome difficulties, leading many women feeling unprepared [110].

9.2.2 Work

Alongside caring for an infant, many new mothers also have the additional pressure of returning to work. Whether this is through choice or necessity, many face juggling competing responsibilities. In the UK, around 50% of women return to work when their baby is aged 6–9 months old [111] but in the USA, most women returning to work do so by the third month due to the absence of statutory maternity leave [112]. This is in contrast to the extended, well paid maternity and paternity leave allowances of Nordic countries where maternity leave paid at 8% extends into the second year.

Employment can impact on breastfeeding success in a number of ways. Firstly, it can stop women initiating breastfeeding at all, through the belief that their infant will not adapt to a bottle when they need to return to work. It is also a significant reason given for why women stop breastfeeding, particularly when infants are over the age of 3 months. In the UK, one-fifth of women who stop breastfeeding at 4 months cite a return to work as the main reason, with return to work rising to the predominant reason for stopping breastfeeding between 4 and 6 months postpartum [113]. This pattern is reflected around the Western world with similar findings in the USA, Europe, South America, and South East Asia [114].

Unsurprisingly, a sooner return to work is associated with a shorter breastfeeding duration. A return in the first 3 months is associated with an average one-month shorter breastfeeding duration than if return to work is after 3 months [115]. In the USA, women who received paid leave were more likely to start breastfeeding and still be breastfeeding at 6 months than those who were not [116].

Ability to continue breastfeeding on return to work is context dependent. Some mothers are able to visit their infant at an on-site nursery and breastfeed them directly. However, others will need to express milk and if they want to give it to their infant, they will need to store it. Not all mothers find expressing breast milk simple, and many find they cannot express a significant amount despite being able to produce a good supply when feeding their infant directly.

Employers do have some obligation to support breastfeeding, but guidance is unclear. In the UK, employers are not permitted to refuse to support breastfeeding, but there are no requirements around what that support entails. Mothers should have somewhere safe and appropriate to rest, including a space to lie down, and should be risk assessed. There is guidance that women should have access to a private room in which to express and a fridge in which to store milk. However, these are guidelines and not laws and many employers do not follow them.

Conversely, in the USA, many states have issued legislation making it mandatory for employers to provide breaks for women to express, and breastfeeding rooms in which they can do so. However, research has shown that many pregnant and new mothers are unaware of company policies around breastfeeding [114]. Providing good quality breastfeeding support has a positive impact for the organisation. In the USA, it can reduce the premiums that organisations pay for employee health care cover. Increased breastfeeding rates are associated with reduced rates of infant and maternal illness, and reduced rates of absenteeism. When support for breastfeeding is strong, maternal moral increases [117].

However, not all organisations understand the importance of supporting breastfeeding for both population health and for themselves. In a study exploring breastfeeding support and attitudes across 157 businesses, most had little understanding of how breastfeeding could benefit the business or why it might be important to support breastfeeding mothers [117]. Conversely, organisations may state that they support breastfeeding in principle, but few can explain why this is important [118]. Many women feel uncomfortable in telling their employer that they will be breastfeeding on return to work, or raising the need for specific facilities or breaks. Returning to work after maternity leave can be daunting for new mothers, and many feel that discussing breastfeeding will be an additional challenge. Others worry that they are vulnerable on their return and do not wish to ask for additional support [119].

Additionally, organisations may express embarrassment at discussing breastfeeding or in some cases feel offended by it [120]. In a world where business settings are predominantly male dominated, breastfeeding is seen as a bizarre request and at odds with how the typical employee acts in the workplace [121]. Perceptions of the breast as sexual – whether it be an explicit or implicit view – can increase these reactions, particularly when the context of breast milk as a bodily fluid is included. In general, many are uncomfortable with bodily fluids, including breast milk. This, combined with the perception of the breast as sexual, can lead some to view breast milk as a sexual fluid [122].

From looking at the experiences of women who do feel supported to continue breastfeeding when they have returned to the workplace, a number of common factors appear to enable this. Mothers value flexibility, particularly in terms of working hours or break times to express when they need to. Paid lactation breaks are appreciated, albeit fairly rated, and private rooms again are appreciated, but rare. More broadly women value support in their decision, both from their employers but also their partner and wider family [45].

Facilities on site to support breastfeeding can increase breastfeeding duration. When workplaces have breastfeeding rooms and breast pumps, employees breastfeed for longer [123]. Some organisations go as far as offering breastfeeding education classes during pregnancy, and access to a lactation consultant after the birth, which is associated with increased breastfeeding rates at 6 months [124].

9.3 Familial Influences

Significant predictors of many psychological models of behaviour are the attitudes and behaviours of those around an individual. Research has shown that the attitudes of a woman’s partner and her own mother predict her attitudes towards breastfeeding and whether she is likely to initiate or continue to breastfeed. In short, positive attitudes and support are protective of breastfeeding, while negative attitudes can be significantly anxiety provoking and damaging.

9.3.1 Fathers/Partner

Key influences on breastfeeding success are the attitudes and behaviours of a woman’s partner. When fathers are supportive of breastfeeding, a mother is far more likely to initiate and continue breastfeeding [26]. Moreover, the majority of fathers state that they want their baby to be breastfed or at least respect their partner’s decision to do so [125]. The most supportive fathers act in ways that boost maternal confidence, providing both practical support and emotional assistance [126]. Fathers who can act as an advocate for the mother are important to breastfeeding success [127]. However, attitude and behaviour are not necessarily linked, and not all fathers want or are supportive of their infant being breastfed.

Fathers who themselves were breastfed are significantly more likely to be supportive of breastfeeding, perceiving it to be normal, and more likely to have had experience of breastfeeding in their wider family. Those who were breastfed are more likely to hold positive attitudes of breastfeeding in public and do not feel embarrassed when their partner breastfeeds in front of others [128]. Some however, are disinterested or have no opinion, particularly if they are younger fathers [129].

However, although many fathers state that they want to support breastfeeding, many struggle with how to do this, feeling helpless and unprepared. Others fear doing the wrong thing or take control, wanting to fix the problem rather than supporting the mother emotionally [128]. Despite wanting their infant to be breastfed, many feel unsettled by the reality reporting that they feel excluded, voicing concerns over bonding. Some report feeling jealous of the mother and her perceived bond with the infant [130]. Others feel embarrassed or unsettled at the mother breastfeeding in public, particularly in front of friends and family [128].

Often fathers are excluded from breastfeeding antenatal education, fuelling feelings of being left out and resulting in them having a poor understanding of breastfeeding and its mechanisms. Many report wanting this additional information so that they can support their partner with issues that arise [131]. This lack of understanding about the wider role of breastfeeding support can increase the likelihood of fathers wanting to specifically fix issues rather than support the mother more broadly [132].

9.3.2 A Woman’s Own Mother

Infant feeding decisions are significantly affected by familial patterns and traditions. One of the biggest predictors of both breastfeeding initiation and continuation is whether a woman was herself breastfed. If a mother herself was not breastfed, the amount of contact she has with her mother predicts her breastfeeding duration; more contact and she is less likely to breastfeed [133]. This is in part due to the knowledge and experience the grandmother would have gained. Grandmothers who themselves have breastfed will be more able to offer support around feeding patterns and issues such as latch [134]. However, it is also linked to attitudes. Mothers value acceptance and encouragement from their mothers [135].

Unfortunately, due to low breastfeeding rates in the 60s, 70s, and 80s, many of today’s mothers were not breastfed themselves. When a grandmother only has experience of using a bottle, it is easy to suggest that as a solution to her daughter’s problems. A lack of understanding around how breastfeeding works and the damage non-responsive feeding can do, may lead to grandmothers suggesting a bottle if a baby feeds frequently, does not sleep, or simply as a means to give the daughter some time away from feeding. These additional bottles can however damage mothers’ milk supply [135].

Families are, however, not always supportive of breastfeeding. Many studies suggest that grandmothers will actively try and dissuade their daughter from breastfeeding if they don’t agree with her decision [136]. This impact is most strongly seen for younger mothers who are likely more reliant on their own mother, potentially financially as well as emotionally. Challenging negative attitudes towards breastfeeding can seem impossible to mothers who are not independent, and younger mothers do often listen to the advice of their own mother rather than to that of health professionals [137]. This can have a direct impact; a study which used a counselling intervention to support younger mothers to initiate and continue breastfeeding worked well as long as the mother was living independently. When she was still living with her own mother, the intervention failed [138]. Interventions that target the wider family are therefore critical.

9.4 Ethnicity, Acculturation, and Religion

Much of the above discussion has focused on the issue of low breastfeeding rates in Western countries in predominantly white communities. However, breastfeeding rates, practices, and attitudes are significantly intertwined with ethnicity, the degree of acculturation to a country, and religious practices. Breastfeeding rates might be optimal in terms of duration in many non-Western regions, but practices are not always so. Significant sociocultural barriers within these communities contribute to perceptions around breastfeeding and breast milk.

9.4.1 Ethnicity in Western Regions

An interesting pattern can be seen in breastfeeding rates between different ethnic groups, dependent on the country in which they live. In the UK, White British women have the lowest levels of breastfeeding, with women from European, Black, Asian and Chinese families initiating breastfeeding at higher rates and doing so for much longer durations. For example, in the UK, 97% of women from a Chinese background initiated breastfeeding, 96% from a black background, and 95% from an Asian background compared to 79% of White mothers [11]. Similarly, in Ireland 49% of mothers from White Irish backgrounds initiated breastfeeding at birth compared to 86% of those from other White backgrounds. African or black women had a 92.5% initiation rate while Chinese and Asian women a 91.5% rate. Irish born mothers were significantly less likely to initiate or continue breastfeeding compared to those who were born outside of Ireland. Only 50% of Irish born mothers initiated breastfeeding compared to 89% of those born outside of Ireland. Again, the longer a mother lived in the country, the less likely she was to breastfeed [139].

Why do these differences occur? One reason is a strong family history of breastfeeding, particularly if women were born in a country where breastfeeding is the norm. There are also ties with religious practice, which we will consider in the next section. In an earlier version of the infant feeding survey, mothers from Indian, Pakistani, and Bangladeshi felt that they would have breastfed for longer if they had given birth in their home country. Reasons given included cultural norms, greater knowledge, and increased exposure to breastfeeding for both mothers and fathers [140]. Moreover, mothers who move to another country but keep ties to their heritage, have stronger breastfeeding rates. In Australia, Arabic and Chinese speaking women were more likely to initiate and continue breastfeeding than English speaking women [141].

A woman does not have to belong to an ethnic group with high breastfeeding rates to be influenced by practices. In the UK, White women who have a partner from a different ethnic group are more likely to breastfeed than if their partner was also White. Breastfeeding rates were also higher among White single mothers, when they lived in high ethnic communities [142]. This suggests that community norms — whether that is an ethnic community or a physical one — impact on attitudes and support to breastfeed. Conversely, in the USA, women from Black American backgrounds are significantly less likely to initiate or continue breastfeeding than both White Americans and Hispanics [143]. This leads to significant health disparities between Black and Hispanic groups, despite having significant poverty levels. Health outcomes for Hispanics are significantly better than their income levels would predict. Known as the “Hispanic paradox”, this can at least in part be explained by long durations of breastfeeding in infancy [144]. Mothers born in the USA are also significantly less likely to initiate or continue breastfeeding compared to foreign-born mothers. In fact, the odds of an American-born mother initiating breastfeeding are reduced by 85% compared to those born outside the USA [145].

Why do women from Black American backgrounds have lower breastfeeding rates? In the US, women from African American groups report different levels of engagement with Women, Infant, and Children services compared to White women, with lower rates of breastfeeding advice received [146]. Other research with Black mothers reveals that they felt that unless they initiated a conversation with health professionals about breastfeeding, no one would talk to them about it under the presumption that they would not want to do it. Others felt that the image of the strong Black woman meant that African American women treasured their independence and did not want to ask for help with problems [15]. Racially biased healthcare, whereby Black Americans do not get access to the same support or quality of information compared to women from other ethnic groups, is an issue across the healthcare system particularly in America [147].

In an in-depth study of African American mothers, a common theme was that of not viewing other Black women breastfeeding. They were not exposed to positive photos or other images of Black women breastfeeding in the literature or on the Internet. Black women are also more likely to be in lower paid jobs with long hours, returning to work within 6 weeks after the birth. They were worried about raising legal rights because they feared losing their job. Historical issues with slavery play a major role, particularly for older generations. It was not so long ago that Black women were required to nurse White women’s babies, and the connotation between breastfeeding and slavery has remained. Grandmothers in particular, some of whom may have been wet nurses themselves, hate the idea of breastfeeding and see formula feeding as a freedom [15]. Black women are also more likely to experience a series of health problems that can make breastfeeding more difficult. These include an increased risk of poor perinatal health, chronic illness, depression and stress, all of which can make the experience of breastfeeding more difficult [148]. Poverty also plays a major role [149].

9.4.2 Acculturation

Acculturation occurs when immigrants to a country start to adopt the practices, attitudes, and beliefs of the country they have moved to. This can be positive or negative, but for many women moving to a Western country, the impact on breastfeeding rates is typically damaging. For example, although those born outside of the USA have higher breastfeeding rates than those mothers born in the USA, the odds of a foreign-born mother breastfeeding decrease by 4% for each year she lives in the USA. Notably, a similar pattern was seen for every year an immigrant father lived in the USA [145].

Why does living in another country affect breastfeeding rates? Firstly, acculturation can mean that the mother adopts the negative breastfeeding practices of the country or experiences the same barriers as those of women born in the country. Secondly, they can be exposed to new negative beliefs and start to become anxious that these are true. In a study of Somali women in Norway, one mother noted that the concept of not having enough milk was alien back in Somalia, but that this worried many of her new peers. Finally, the stress of being in a new environment can make breastfeeding challenging, particularly if a mother is taken from the support systems in her home country [150].

9.4.3 Religious and Cultural Beliefs

Cultural beliefs and normative behaviour have a very powerful impact on human behaviour, particularly in relation to nutrition [151]. References to breastfeeding are present in many historical and religious texts. For example, the UK and USA could very much be seen as a formula feeding cultures today, although historically, views around breastfeeding and breast milk have not always been this way in these countries. In England and America, in the 18th century, breast milk was seen as a medicine, having restorative powers for adults who were sick or older. Breast milk was believed to cure infections and references are often made to its power to cure eye infections, something still used today. Breast milk from another woman was thought to speed up childbirth. Writing in early texts romanticised breastfeeding as the ultimate expression of love [152].

References to breastfeeding as something to be treasured and protected also occur throughout the texts of the major religions. References to breastfeeding are made throughout Christian religious texts, and it is mentioned throughout the bible in reference to love, calmness, and security. Religious imagery often showed infants being nursed [152]. However, references to breastfeeding in Hindu and Muslim texts are of considerably greater depth.

In Hinduism, the primary sacred texts are the Vedas (1800 BC), which consists of four texts: Rig Veda, Sama Veda, Yajur Veda, and Atharva Veda. Alongside this, ancient Ayurvedic writings are followed, including writings from paediatricians, surgeons and Acharya Charak considered the Father of Medicine [153]. There are no references in these texts to bottle feeding, although wet nurses are often referred to. Throughout these writings breast milk and the breast are mentioned in terms of longevity and sweetness, describing the breast as a pitcher full of nectar. Breast milk is life giving; when the God Shiva creates the baby boy Parvarti out of her dress, he comes to life only when she puts him to her breast [154]. Reference is also made in Hinduism to the importance of caring for the mother after birth. In Hindu culture, a mother is protected to rest for 40 days after the birth. During this period, she is excluded from housework to recover from the birth and care for her newborn. She will be offered regular meals, but also special foods that are believed to increase the quantity and quality of her milk, including dried fish, dahl, and eggplant [154].

In Islam, the Koran states that mothers should breastfeed for two years. Breast milk is seen as God’s gift for the baby, so the mother has an obligation to God to breastfeed. Breastfeeding is seen as passing the mothers wealth onto the baby. Most Muslim women believe they will be punished if they do not breastfeed and fulfil this obligation [155]. Muslims are required to fast between the hours of sunrise to sunset during the month of Ramadan. Exceptions are made, including for breastfeeding women. However, many who are exempt still fast; one study found that around 50% of breastfeeding women still fast. Notably, one-third of those who said it was acceptable for breastfeeding mothers not to fast were still fasting [156].

Religious texts are therefore generally very positive about breastfeeding, seeing it as something to be protected and encouraged. This may in part explain the higher levels of breastfeeding among communities that have high adherence to Islam and Hindu beliefs and practices. However, breastfeeding practices are not optimal despite the fact that in many African, Asian, and South East Asian communities, breastfeeding rates are almost universal and long term, with little use of formula milk. The World Health Organization (WHO) recommends that babies are exclusively breastfeed, with breastfeeding starting within the first hour of life. Initiating breastfeeding after the first hour doubles the risk of mortality [157]. However, only 41% of babies in South Asia are breastfed within one hour of birth [14]. In Ethiopia, children who receive prelacteal feeds are nearly twice as likely to be stunted (low height-for-age) compared to those who do not receive them [158]. Non-optimal breastfeeding practices are often embedded in religious or cultural practices, or norms of the community in which a woman lives.

Firstly, delaying breastfeeding until after a certain event or number of days is common. Some Hindu medical literature suggests that breastfeeding should not be started until the third day, although others recommend feeding on the first day [154]. In rural Ghana, first time mothers must go through a cultural cleansing process before they can breastfeed. This involves pouring warm herbal water over the mother, for three days if the baby is male and for four days if the baby is female. The baby will either be wet nursed or fed herbal tea while this occurs [159]. In the Haryana tribe in India, a common practice is not to initiate breastfeeding until stars have been seen in the sky. If a baby is born in the morning, the mother should not breastfeed until that evening but if the birth is at night, breastfeeding can start sooner [160]. Muslim societies hold a call to prayer (“Adhan”) five times a day. It is believed that breastfeeding should be started after three Adhan calls. This means that babies will not be breastfed for 8–16 hours after the birth. Waiting until this time means that babies will be patient and more resistant to hunger [161].

Secondly, many cultures particularly in Africa and Asia, discard colostrum despite its immune properties, believing it is dirty or too thick based on its colour and consistency [162]. Others believe colostrum holds no nutritional value, may make babies sick or even bring bad luck [163]. Some cultures believe that colostrum has been stored in the breast for the entire pregnancy and is therefore unsafe or “dirty water”. In Turkey, older generations particularly recommend a mixture of butter and sugar water that is thought to prevent vomiting [161]. Some believe colostrum may kill the newborn because it has been stored for 9 months in the breast and is dirty [164]. Similarly, in Indonesia, around one-fifth of mothers’ discard colostrum, believing it to be indigestible, “cheesy” or dirty; children who drink it will suffer from stomach ache or be “stupid” [165].

A study in rural Northern Ghana highlighted a practice of expressing colostrum and putting black ants in it to test for bitterness. If the ants crawl out, the breast milk is considered acceptable; if the ants die, the breast milk is considered bitter, dirty and poisonous, and could make the baby ill or even die. Before she can feed her baby, the mother must go through a ritual to purify the milk. This involves using herbs or shea butter to wash her breasts. The ritual lasts three days if the mother has a boy, and four days if the mother has a girl [159]. A lighter version in Hindu literature suggests that the mother should express a few drops at the beginning of each feed to purify the tubules [154].

Thirdly, prelacteal feeds are common in many African, Indian, and South East Asian regions. Estimations range from around 60% in Nigeria [166] to 27% in Nepal [167]. Perceptions that infants are born hungry and need immediate feeding can lead to prelacteal feeding, with foods such as porridge, salt or sugar often given in many African and Indian communities. Prelacteal feeds may be given because of rituals that delay breastfeeding until a certain time or discard colostrum. They are closely tied to religious practices, and those who follow the religion of Islam are more likely to give prelacteal feeds than those who follow Christianity [166].

However, prelacteal feeds are often given for other reasons. Different prelacteal foods are perceived to have different benefits, such as honey and ghee that are believed to help the infant pass meconium [154]. Others believe that these feeds can cleanse the infants stomach [168]. In Pakistan, prelacteal feeds are often given via a finger of an elderly person and believed to clean the stomach and strengthen the newborn [169].

Prelacteal feeds are frequently part of religious ceremonies. In Hinduism, the child is welcomed into the family during a traditional ceremony called Jatakarma. Here, a family member who is seen to have “virtuous qualities” writes the word ‘Om’ onto the infant’s tongue using jaggery (unrefined brown sugar) dipped in ghee. This is believed to pass the person’s good qualities on to the baby. Additionally, the father uses his fourth finger and a gold rod to give the baby honey or ghee. If the baby is a boy, the father uses a golden spoon. This ritual is believed to give wisdom, longevity, and protection from the gods [154].

Cultural beliefs also exist as to when it is appropriate to breastfeed, and these can be very different to those in Western culture. In Kenya, some mothers fear breastfeeding in public, although this is not due to societal beliefs around its acceptance. Some believe that breastfeeding in public might lead to people with an ‘evil eye’ watching them. The evil eye represents a malevolent gaze, which passes on a witchcraft curse and leads to milk drying up or breast sores. Actions and emotions are also believed to affect breast milk. Research in two slums in Kenya found that women talked about how milk can become “unclean” if a woman has an extramarital affair. Such affairs lead to the curse “chira”, which may cause the infant’s death. Some perform cleansing rituals to clean the mother (and her milk), but a community stigma still exists that if a woman has sex with multiple men her baby will die. Mothers should not breastfeed if they have an argument with their spouse, family or other community members until they have performed a cleansing ritual. This often involves eating herbs in a special remedy known as “manyasi” [162].

Finally, beliefs around the impact of breast milk sharing can affect decisions about breast milk donation. In Islam, children who are breastfed by the same women are considered milk siblings. Under consanguinity laws this means that they are unable to marry. Mothers must therefore be known to each other to prevent such marriages. There has been considerable discussion over just how many feeds a baby must receive before they are considered milk siblings; some suggest just one, while others suggest at least five or up to ten times. Others suggest to consider feeds over a sustained period, such as for ten consecutive feeds or all feeds over a 24-hour period [170].

A further debate is how breast milk is given. Some suggest that if milk is expressed and given in a bottle or cup then this milk-sibling relationship does not occur. This has considerable implications for donated breast milk for premature and sick babies. Some suggest that sufficient milk must be given from one mother to ‘build flesh and bone’; donated breast milk from a breast milk bank is therefore acceptable, because the milk given is from a mixture of milks from different women, so no one woman’s milk would contribute sufficiently to the infant’s growth. However, others see this as unacceptable, because it is not possible to trace who the milk came from [171].

This concept is not constrained to religion. In many cultures, those who have fed from the same mother are believed to have a special bond [170]. Some hold the same view that marriage should be avoided between those who have received milk from the same mother, and have customs that wet nurses should therefore only nurse a child of the same gender to avoid this [172]. Others are more relaxed, seeing instead only a special bond. In Turkey, for example, those who have shared the milk of one woman are considered to be friends for life. Among older generations in Poland today, men who have been breastfed by the same woman consider themselves milk brothers [156].

9.5 The Way Forward

The attitudes and beliefs of societies and cultures, both towards breastfeeding and wider connotations of motherhood, therefore have a significant impact on breastfeeding initiation and continuation. These show that breastfeeding is not simply a biological issue that can be fixed with practical support. Yes, good quality hospital and community support with breastfeeding are important, but at the same time, we must change the environment in which a woman breastfeeds. As UNICEF Baby Friendly UK note in their Call to Action:

‘It is time to stop laying the blame for a major public health issue on individual women, and instead work together to build a supportive, enabling environment for women who want to breastfeed.’

Specific interventions that might work should focus on educating the society around the mother, rather than the mother only. Further legislation is needed to support women to breastfeed on return to work. Ideally, maternity leave would be extended to the levels seen in Nordic regions, including paternity leave. Mothers should not need to return to work for financial reasons when they are predominantly breastfeeding their baby and sleep deprived. Particular focus should be given to the disparity between ethnic groups in the USA, protecting those women with very low incomes, especially those from Black backgrounds, enabling them to spend longer with their infants rather than returning to work in the early weeks after birth.

Public health campaigns should focus on promoting women’s legal protection to breastfeed making public spaces more breastfeeding friendly. Further imagery is needed of breastfeeding – in the media, literature, and public spaces. If we want the breast to be associated with breastfeeding as well as its sexual function, it must be shown this way. Moreover, showing breastfeeding is the only way to make it more acceptable and normal [110]. Seeing breastfeeding works. In one study, young mothers were encouraged to look through a photo album containing photographs of mothers breastfeeding and interacting with their babies. After viewing these, the mothers were more likely to state that they planned to continue breastfeeding [173].

Fathers and grandmothers should be included in breastfeeding education. In Australia, attending antenatal and postnatal breastfeeding classes increased breastfeeding at six weeks [174]; teaching fathers to identify and manage breastfeeding problems increased breastfeeding rates at six months [175]. Another study saw a rise in exclusive breastfeeding rates when fathers attended antenatal classes with their partner [133]. Educating grandmothers about breastfeeding has been shown to increase their knowledge of breastfeeding but not change their attitude [176]. However, caution is warranted as some research has suggested that paternal involvement in infant care can lead to lower breastfeeding rates [177] and that grandmother’s own preference dictates whether she will be supportive [176]. Criticism has also been raised in that men and women often have different preferences in learning style and approach, so messages can be interpreted differently. Additionally, some women may feel uncomfortable discussing breastfeeding when men are present, due to cultural and societal connotations of the breast [178].

In terms of religious and cultural beliefs, these are a sensitive issue. However, in terms of non-optimal feeding practices, education is key. Prelacteal feeds and discarding of colostrum are particularly related to the attitudes and presence of grandmothers and traditional birth attendants [179]. Fathers are also a major influence. In rural Ghana, attitudes of the father strongly predict breastfeeding; over 98% of babies are breastfed when the father approves, but only 27% when he does not [180]. Educating the wider community will help to support more optimal practices. Meanwhile, home deliveries make it particularly likely that these feeding practices will be adopted. Helping more women to access healthcare may reduce occurrence [181]. For example, a lack of understanding about the risks of prelacteal feeding significantly increases the likelihood that infants will receive these feeds. A study in Ethiopia found that mothers who had not heard of the risks of prelacteal feeding were 3.7 times more likely to give such feeds [168].

On a wider note, prelacteal feeds, delaying the first feed, and discarding colostrum are all reduced when mothers have a higher level of education [166]. Wider education for all in the community, alongside greater access to healthcare services may reduce these practices. Finally, exposure to formula advertising, which can have a devastating impact in developing countries, is also related to giving prelacteal feeds. Ensuring adherence to the WHO code may protect more families from this practice [182].

Brazil is an excellent example of how implementing such a society-wide approach significantly increases breastfeeding rates. In 1986, median duration of breastfeeding was 2.5 months, but by 2006 had risen to 14 months. Exclusive breastfeeding rates to four months also increased from 4% to 48%. To make this happen, the government invested heavily in promoting breastfeeding at the societal level, including multi-organisation working, media campaigns, training of health workers, and the development of mother-to-mother support groups. Policy wise, a strict enforcement of the International Code was introduced, maternity leave was extended to six months and more than 300 maternity hospitals gained Baby Friendly Hospital Initiative certification. Investment in over 200 human milk banks led to Brazil having the highest number of milk banks in the world. The combination of these interventions led to their success, along with the fact that they did not focus solely on maternal knowledge but focused on the mother’s wider environment and support system, enabling her to breastfeed her baby [183].

In summary, interventions to raise breastfeeding rates in Western cultures and improve breastfeeding practices in developing regions are desperately needed. These should however focus not only on practical support with physiological issues, but look to the wider societies, cultures, and communities in which breastfeeding occurs. Governments must invest in breastfeeding to support mothers, babies, and future population help. The return will be priceless.

9.6 Summary

Breastfeeding cannot be considered as simply a physiological issue; numerous social and cultural factors affect both maternal attitude towards breastfeeding and its success. Breastfeeding works on a demand and supply basis, and responsive feeding enables the best possible milk supply, infant weight gain and ease of experience. However, numerous socio-cultural factors affect knowledge, desire, and ability to breastfeed responsively, leading to its discontinuation.

In Western culture, attitudes towards breastfeeding are often adverse. Sexual connotations surrounding the breast, fears of breast milk as a bodily fluid, and poor acceptance of breastfeeding in public lead to formula use. Interventions must target public health promotional messages and create “safe” spaces for women. Wider pressures on mothers in modern society can make them feel that breastfeeding is impossible. A lack of care for new mothers and dispersed families can lead to maternal exhaustion and the cessation of breastfeeding. Similarly, a need or desire to return to work can result in the avoidance of breastfeeding, as it is perceived as being too difficult to juggle both. Greater investment in mothers is needed in terms of healthcare and extended leave.

Breastfeeding attitudes and norms are strongly tied to ethnicity. In the UK, white British mothers have the lowest breastfeeding rates; both initiation and continuation are far higher in women from Black, Asian, and Chinese backgrounds, predominantly due to cultural norms and support in their communities. Conversely, in the USA, women from Black American backgrounds breastfeed for significantly shorter durations, affected by historical norms around slavery, poorer healthcare and poverty.

Although breastfeeding duration is optimal in developing countries, many sub-optimal breastfeeding practices, such as delaying the initial feed, discarding colostrum, and giving prelacteal feeds, place the infant at risk. These practices are strongly tied to religious and cultural norms and must be treated sensitively. However, greater access to healthcare and education, particularly for older women in the community, help reduce their occurrence.

Overall, governments must recognise the importance of creating environments that are conducive to breastfeeding. Practical support is not enough. Investment works; countries that have adopted a systems approach to raising breastfeeding rates have seen increases in breastfeeding and thus in population health.

Key Points

  • There is indication that several socio-cultural themes influence a mother’s decision to breastfeed. Initial understanding shows that in high income societies, sexual connotations, fear of breast milk as a bodily fluid, and poor acceptance of breastfeeding in public seem to play a key role in choosing to use formula. Whereas in low/middle income countries cultural/religious beliefs seem to be more important. Family influence and work-related issues play a an important role irrespective of geography

  • Education needs to focus on all factors to assist mothers to make an informed choice

  • Governments must recognise the importance of creating breastfeeding-friendly environments by implementing practical support, investment, and a multilevel, multidisciplinary approach to increase breastfeeding rates

Professor Amy Brown, PhD, MSc is an Professor in Child Public Health at Swansea University, Wales. With a background in psychology, her research explores the multitude of socio-cultural, psychological and political factors that affect maternal decision and ability to breastfeed. She has published over 50 articles examining maternal experiences of breastfeeding and seeks to develop interventions to support families to breastfeed for longer.

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