Breast intentions

The strength and ubiquity of the “breast is best” message means there is greater awareness than ever of the benefits of breastfeeding: a public health message seen increasingly in terms of the risks of formula feeding. However, women remain unsupported in their choice to breastfeed, from work policies and a lack of timely information and support, to family attitudes and perceptions of a “good baby” as one which sleeps through the night and therefore requires slowly digested formula to do so.

The conflict between the lactating and revered sexual breast in Western society means that while the media is awash with images of “boobs”, public breastfeeding is taboo. A 2009 study found that 36 per cent of Australians said breastfeeding was unacceptable in a cafe or at work. Jennifer James of RMIT University, which conducted the study, said “Part of the issue why young mothers wean their babies too early is societal pressure and isolation from other mothers experiencing the same difficulties”.

The result is that many women do not establish breastfeeding, the trauma of which is then compounded by the censure faced when bottle feeding.

In recognition of the experiences of these mothers, counsellor Karen Holmes, is launching a counselling service in Christchurch, New Zealand, specifically for “unvalidated grief” around women's breastfeeding experiences.

Holmes explains: “This is something which is just never talked about, but for many women giving up breastfeeding is a very real loss which impacts their lives. It may never be acknowledged as grief - not by others and not even by themselves.”

University of Albany evolutionary psychologist Gordon Gallup believes the grief a mother may experience also operates at the level of biology, commenting: “For most of human evolution the absence or early cessation of breastfeeding would have been occasioned by miscarriage, loss, or death of a child. We contend, therefore, that at the level of her basic biology a mother’s decision to bottle feed unknowingly simulates child loss.”

A study of 50 mothers conducted by Gallop showed that those who bottle fed scored significantly higher for postnatal depression than breastfeeders.

Breast v bottle polarisation

The polarisation of breast versus bottle undermines mothers and those at the frontline of breastfeeding promotion. Holmes comments: “I think we need to appreciate that all women go through the same ringer when making decisions about feeding their babies. A successfully breastfeeding mother could have had endless struggle and interference to get to that point, just like a formula feeding mother. But the breastfeeding mother's trauma may be alleviated by her eventual success.”

Holmes spent ten years as a La Leche League (LLL) leader and observed that much of the meetings were devoted to discussions about addressing challenges from others towards breastfeeding women. For example “are you sure you've got enough milk” and assumptions about the need for supplementation with formula.

The breast versus bottle debate has also lead to an emphasis on breast pumps, by equating breastfeeding with breastmilk. However the use of breast pumps are linked to a decrease in milk supply and negatively affect breastfeeding outcomes.

Carol Bartle, coordinator of the Canterbury Breastfeeding Advocacy Service (CBAS) in Christchurch, comments “Breast pump marketing implies that all women need a breast pump to breastfeed, however the reality of pumping is that of a complex and time consuming practice that is hard to maintain.”

Bartle, who has 30 years' experience working in neonatal intensive care, where women try and establish their milk supplies using breast pumps, continues: “Many pumps are inefficient and do not remove milk effectively enough to maintain milk supply. Women who give breastmilk to their babies in bottles, and do not put their baby to the breast at all, are at the highest risk."

This observation is confirmed by a 2009 study from Stanford University School of Medicine, California, which found that “pump suction alone often fails to remove a significant fraction of milk as more can be expressed using manual techniques”. So pumping needs to be done in combination with hand massage techniques - something few women are aware of.

Barriers to breastfeeding

New Zealand's National Breastfeeding Advisory Committee (NBAC) in its 2008-2012 national plan for breastfeeding detailed a list of 13 social and environmental barriers to breastfeeding. These included the perception that artificial feeding enhances the father’s opportunities to bond with the infant; attitudes that make breastfeeding embarrassing or uncomfortable for the woman; a culture that portrays bottle feeding as normal; and returning to work.

The World Health Organization (WHO) says that “virtually all mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large”.

These sentiments are reinforced by the pro-formula backlash, for example the book Bottle Babies by Adelia Ferguson (1998), which catalogues letters from bottle feeding mums - many of which are a testament to a fundamental lack of support around their breastfeeding experiences.

In 2008, the UK's Scientific Advisory Committee on Nutrition said of the latest Infant Feeding Survey in 2005 that “The reasons mothers gave for abandoning breastfeeding suggest that relatively few mothers truly chose not to breastfeed ... Most women ... stop because they encounter problems and find that skilled support is not readily available.”

In recognition of this, CBAS provides not just information about breastfeeding but practical support in the form of networks between health care professionals, local groups and mothers. Commenting on needs at a national level in New Zealand, outgoing LLLNZ Director Barbara Sturmfels, says: “Legislative changes to improve conditions for breastfeeding mothers in the paid workforce, a public advertising campaign to promote breastfeeding in public, and support for the implementation of UNICEF’s Baby Friendly Initiative in New Zealand are some of the ways that the government is seeking improvements in breastfeeding rates through institutional and societal change.”

WHO recommends that infants be exclusively breastfed for the first six months and for breastfeeding to continue “up to two years of age or beyond”.

New Zealand's breastfeeding rates compare favourably with other developed nations. Different countries measure the rates in different ways and for different years, but for a broad comparison, rates for exclusive breastfeeding are: New Zealand 2008 16 per cent at eight months; Canada 2008 14.4 per cent at six months, Australia 2007 14 per cent at six months, USA 2006 13.6 per cent at six months, UK 2005 less than 1 per cent at six months.

However seen globally it is clear the impact Western values may have on breastfeeding. The top five countries for exclusive breastfeeding at six months (Unicef 2008) are Rwanda 88 per cent, Kiribati 80 per cent, Sri Lanka 76 per cent, Solomon Islands 74 per cent, and Peru 69 per cent. At aged 20-23 months, Sri Lanka, Burkina Faso, Ethiopia, Bangladesh and Nepal all had breastfeeding rates of over 80 per cent, with Nepal at 95 per cent.

In New Zealand, rates for Māori and young mothers are much lower than average. As Glover et al explain in Māori Women and Breasfeeding (2008) “Beliefs and practices introduced to Māori by European immigrants to New Zealand have supplanted Māori infant feeding practices”.

Christchurch is fortunate in having the Young Parents' Breastfeeding Group Whāngai U “Mātua Puhōu”. Headed by public health advocate and breastfeeding peer counselling administrator Susan Procter, the group has more than 20 regular members and meets regularly to support breastfeeding families where the mother is aged under 25.

Breastfeeding as patriarchy

A further irony of the breastfeeding debate is that when a mother does successfully breastfeed, she is likely to be censured if she continues past an arbitrary cut off point of a few weeks or months.

Part of the problem is that motherhood is accused of becoming a patriarchy with male values overlaid upon it. For example the reverence of science over instinct, of experts over the mother's voice, and of consumer products over the mother's body. This is particularly relevant with the medicalisation of birth, with the rising number of caesarean sections impacting negatively on the establishment of breastfeeding.

Dr Truby King is a controversial example of the mothers' expert, having founded New Zealand's Plunket Society in 1907 and the Karitane Product Society (KPS) in 1927, which consolidated King's production of infant formula.

Linda Bryder says of King in A Voice for Mothers (2003) “The diagnosis of the problem and the solutions put forward were the same everywhere: mothers were ignorant of the correct methods of child-rearing and needed to be educated”. Meanwhile Sheila Kitzinger claims that King “Destroyed women's confidence in breastfeeding and made loving mothers feel inadequate and guilty”.

One hundred years later, that charge was still being leveled at Plunket for the promotion of scheduled feeding, based on the digestion time required for formula, rather than for quickly digested breastmilk. The emphasis has shifted recently with Plunket advising that “your baby may wake wanting frequent feeds. For breastfed babies these feeds are important to help establish and maintain breastfeeding.” However the organisation remains out of step with international WHO guidelines by recommending breastfeeding only “until they are at least 1 year or older”.

Plunket's controversial partnering of breastfeeding promotion with corporate interest through King's formula production, continues today with Wattie's sponsorship of Plunket. Wattie's promotes Nurturebaby formula and markets “Stage 1” baby foods for “4-6 months onwards”, in conflict with WHO's recommendation of “exclusive breastfeeding for 6 months” and Plunket's recommendation of “breastfeeding exclusively until around 6 months”. The Plunket logo appears on the packaging of Wattie's Stage 1 foods, giving the perception that Plunket endorses feeding solids at four months, despite the clear conflict with Plunket's own policy. The presence of the Plunket logo also gives the impression that Plunket is endorsing that particular brand of baby food above both competitive brands and baby food prepared at home.

The patriarchal legacy remains a tangible presence for women, their partners and families today. Holmes comments: “Progressively, women were told that their instincts, their feelings and everything else they may have previously believed were wrong and they needed to listen only to the experts if they wanted their babies to live. This creates internal conflicts which may become problematic, especially the thought that something must be wrong with a woman as mother.”

Holmes stresses that the understanding and support of fathers is a crucial part of this process. Holmes comments: “Breastfeeding is a human issue, not a women's issue. Men have a valuable and active role in supporting women to breastfeed and in protecting it.” This is reinforced by Sturmfels who says “Informed and skilful mother-to-mother support can really make a difference. A new mum needs the love and support of her partner and family.”

Holmes concludes: “What is most important is that all mothers are honoured in their experiences around infant feeding. That mothers feel supported, valued and confident in their own ability as a mother.”