is breastfeeding ‘normal’? using the right language for

Accepted Manuscript

Is breastfeeding ‘normal’? Using the right language for breastfeeding

Virginia Thorley OAM, PhD, IBCLC, FILCA

PII: S0266-6138(18)30312-7DOI: https://doi.org/10.1016/j.midw.2018.10.015Reference: YMIDW 2366

To appear in: Midwifery

Received date: 9 May 2018Revised date: 22 October 2018Accepted date: 26 October 2018

Please cite this article as: Virginia Thorley OAM, PhD, IBCLC, FILCA , Is breastfeed-ing ‘normal’? Using the right language for breastfeeding, Midwifery (2018), doi:https://doi.org/10.1016/j.midw.2018.10.015

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https://doi.org/10.1016/j.midw.2018.10.015

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IS BREASTFEEDING ‘NORMAL’?

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Highlights

Precise language aids clear thinking and prevents ambiguity.

Breastfeeding is not viewed as the normal way to feed an infant in some settings, now or

historically

It is biologically normal, but not culturally normal.

Culture can be changed.

Interventions to increase breastfeeding are not equally effective.

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Is breastfeeding ‘normal’? Using the right language for

breastfeeding

Virginia Thorley, OAM, PhD, IBCLC, FILCA

Honorary Research Fellow

School of Historical and Philosophical Inquiry

The University of Queensland, QLD 4072

Australia

Email: [email protected]

Telephone (mobile): +61 – 0409 876 848

Funding: No funding was received for this work.

Conflict of Interest statement: These are no conflicts of interest

Wordage:

Abstract: 270 words

Text: 4,482

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ABSTRACT

Background: Accurate terms aid clarity in thinking and prevent confusion. In the infant

feeding field ‘normal’ can be ambiguous as biologically normal may not equate with

culturally normal in a given time or place. Similarly, the use of the term ‘intervention’ is

appropriate if a recommended practice is not perceived as ‘normal’ to that culture.

Objective: This article explores the meaning of ‘normal’ in the context of infant feeding,

since mothers may not perceive breastfeeding as ‘normal’ when this differs from the

experience in communities in which it is considered unusual.

Methods: Historical and recent sources were used to explore the effect of culture and

established practice on perceptions of what is ‘normal’.

Discussion: Iceland and several regions of Europe are used as examples of long-term

abandonment of breastfeeding during the late Medieval and Early Modern periods and the

19th

century. Ireland, the United Kingdom and the United States are discussed in relation to

fluctuations and declines in breastfeeding prevalence in the 20th

and 21st centuries. The rôle

of science and the rise of mother-support groups for breastfeeding, interventions to promote

breastfeeding, and the possibility of cultural change, are also discussed.

Implications for Practice: Culture influences the perception of what is ‘normal’ and where a

culture has abandoned breastfeeding, or where it is in decline, women are unlikely to view it

as the normal way to feed an infant. A more appropriate use of language is recommended,

describing breastfeeding as ‘biologically normal’ or ‘physiologically normal’, as it is not

always, and has not always been, culturally normal. In this context initiatives to improve

breastfeeding rates can correctly be termed ‘interventions’.

Keywords: breastfeeding; correct language; biologically normal; culture; interventions

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BACKGROUND

‘Normality’

Underpinning recommendations to use particular terms to support efforts to promote,

protect and support breastfeeding is the concept that the use of precise language promotes

correct thinking (Thorley, 2018). The theoretical basis is not usually well defined, and to what

extent use of new terms, or use of old terms in a different sense, can change attitudes and

behavior is still open to debate. However, Wiessinger has discussed the influence of word

choice specifically on infant-feeding decisions (Wiessinger, 1996), while Martin explored the

use of semantics and style to maintain the status quo in a society or, conversely, to effect

social change (Martin, 1985). At a practical level, agreement on and use of the same terms,

consistently defined, prevents ambiguity and disagreement. Recently, individuals and

organisations involved in breastfeeding advocacy have increasingly described breastfeeding

as the ‘normal’ mode of infant feeding. On these grounds, some advocates reject the idea that

breastfeeding advocacy, promotion and support can be an ‘intervention’ while others describe

initiatives to support breastfeeding as interventions (Kramer, Chalmers, Hodnett, & al, 2001).

The historical evidence suggests that the description of breastfeeding as ‘normal’, without

qualifiers, is imprecise and confusing, and so I propose better use of language. (In this article

‘normal’, rather than ‘usual’, will be the preferred term, in line with the Irish and United

Kingdom sources used.)

Breastfeeding is acknowledged as the superior food for human infants (Gertosio,

Meazza, Pagani, & al, 2016; Victora, Baht, Barros, & al, 2016), including in the development

of the infant gut biome and maintaining immune homeostasis beyond weaning (Turfkruyer &

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Verhasselt, 2015). Whether in developed or developing countries, on a population basis there

is a deficit in health outcomes when breastfeeding is replaced (Holla, Iellamo, Gupta, Smith,

& Dadhich, 2013). It is well accepted that breastfeeding is biologically and physiologically

normal, having evolved as the species-specific milk for young humans, but it has not always

been culturally normal. Humans cannot change the milk produced by the breast to that of

another species such as the goat or the cow – but they can, and frequently have historically,

fed their infants with the milk of other species (with or without modification) and with plant-

derived substitutes, using various implements as delivery systems. Sometimes babies have

not been breastfed because of the mother’s death or illness or a maternal or infant physical

anomaly. In these cases, alternative foods are imperative and life-saving, whether that

involves breastfeeding by another woman (wet-nursing) or using whatever mixture is

currently available for artificial feeding. At times in numerous cultures, substituting other

substances for breastmilk has been by choice, according to custom, not by necessity, these

practices becoming embedded in the culture.

Nevertheless, current global recommendations for Infant and Young Child Feeding

(WHO, 2002) are evolutionarily appropriate for the human infant’s optimal age for the

introduction of safe complementary feeding of around six months and continued

breastfeeding into the second year and beyond (Martin, 2018; Sellen, 2007). Sellen argues

that the human infant has not evolved to assimilate foods other than human milk efficiently

when younger than about six months (Sellen, 2007). Although human lactation has evolved

with a longer period of complementary feeding and allo-caregiver involvement, compared

with non-human primates, weaning earlier than the current recommendations is not supported

by evolutionary theory and has a cost (Martin, 2018; Sellen, 2007).

METHOD - HISTORICAL PERSPECTIVE

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This discussion draws on historical sources and recent publications to demonstrate

the influence of culture on infant-feeding practice and consequent perceptions of what is

‘normal’ when breastfeeding prevalence is low. Several well-documented examples will be

referred to here, rather than attempting the daunting task of providing an exhaustive coverage

of all non-breastfeeding regions and periods across time.

DISCUSSION

Iceland

Such a culture existed in Iceland for an estimated 10 generations through to the 1770s

at least, that is, through the 17th

and 18th

centuries. In farming districts breastfeeding had been

abandoned and in fishing villages the practice was of short duration, at best (Fildes, 1986;

Garðarsdóttir, 2002; Hastrup, 1992). If possible, cream was added, both the cow’s milk and

cream being undiluted and raw. Pre-chewed fish or meat was also offered very early

(Hastrup, 1992). In the 19th century, the exception to the almost universal practice of

artificial feeding was the very poorest women in fishing villages who, if they were unable to

procure cow’s milk, only breastfed as a last resort (Guttormsson & Garðarsdóttir, 2002). The

complexity of the thinking inherent in the choices made across the society, embedded in

Icelandic identity and the domestic sphere, have been discussed in detail by Hastrup

(Hastrup, 1992). Women believed that doing the best for their babies meant feeding them on

the more highly regarded and economically valued cow’s milk from their dairies in

preference to human milk that had no monetary value and was considered unhealthy

(Garðarsdóttir, 2002; Hastrup, 1992). So it is obvious that in this cultural milieu wet-nurses

were neither sought nor available.

Hastrup has described the cultural milieu in which women made their infant-feeding

decisions, as follows (Hastrup, 1992). Marriages were relatively late in Iceland and were

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necessary to legally establish a household. Although married Icelandic women had status and

agency in the domestic sphere, in the marginal economy houses were typically one-roomed

with earth floors and sleeping platforms for the married couple, single kinfolk, and unmarried

servants. Even though much of women’s work was done indoors, the infants were left on the

floor. These were not affluent women leading a trend away from breastfeeding, as happened

in Western countries in the 20th

century, but women in a marginal economy making a choice

to continue the established practice.

Contrary to the assumption today that breastfeeding (whether by the mother or a wet-

nurse) must have been universal for the human race to survive, Thorley has postulated that

the human species is preserved by two evolutionary mechanisms relevant here: breastfeeding,

and a back-up mechanism in the absence of breastfeeding (Thorley, 2018). This second

mechanism is the increased fertility of women who either never initiate breastfeeding or

cease breastfeeding early, which occurs in the absence of lactational amenorrhoea (i.e.

lactation-related delay of menstruation and ovulation) (Fildes, 1986; Thorley, 2018). So,

while many of their infants succumbed to infection or inappropriate nutrition and died early,

mothers in these circumstances and without recourse to contraception had very close birth

intervals and consequently often had large numbers of births (if the mothers survived). The

Icelandic population declined but, inevitably, enough of these more numerous infants

survived (Hastrup, 1992). It seems that women were unable to see the connection between the

method of feeding and infant health and survival. Indeed, Fildes cited reports that the children

in non-breastfeeding villages in the southern German-speaking regions of Europe were in fact

considered to be particularly hardy as it was the fittest who survived (Fildes, 1986).

Regions of Europe, late Middle Ages to Early Modern period

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Knodel and van de Walle described areas of Europe where breastfeeding was largely

absent from the culture in the late Middle Ages and Early Modern Period, specifically

Bavaria, Württemberg, Swabia, Baden, Saxony, Bohemia, and the Italian Tyrol (Knodel &

van de Walle, 1967). The custom from at least the 15th

century was to feed infants artificially

from birth, often on cow or sheep milk mixed with barley flour. Mothers in southern

German-speaking regions of Europe were actively deterred from breastfeeding (Pruhlen,

2007) and Fildes cited reports that in the district around Moscow, as well as in Iceland,

breastfeeding was ‘unknown’ (Fildes, 1986). The influential 15th

-century German physician,

Bartholomäus Metlinger (1440-1491) published the first book in the German language

offering advice to mothers, which ran to many editions as it was more accessible than the

Latin texts. He advised against using the mother’s milk for 14 days postpartum, using

another woman to breastfeed the newborn child, and applying young puppies to suck to

relieve the new mother’s breasts (Prühlen, 2007). A delay in initiating breastfeeding to

prevent the infant from ingesting colostrum was not new. Metlinger also recommended

feeding infants on ‘mush’ (a cereal-based concoction) in addition to wet-nurse’s milk and

subsequently using ‘mush’ to replace the milk of the mother or wet-nurse for many

indications (Prühlen, 2007). Although Metlinger has been credited with the decline and

abandonment of breastfeeding in his region, Prühlen suggests that it is not clear whether he

led the decline or merely reflected current practice.

Knodel and van de Walle analysed statistics from Bavaria and parts of the Tyrol

where breastfeeding was discouraged during this period as being contrary to the culture, even

‘swinish’ (Knodel & van de Walle, 1967). Icelandic breastfeeding rates have progressively

improved, with regional variations, although, as Guttormsson and Garðarsdóttir pointed out,

it took many generations (Guttormsson & Garðarsdóttir, 2002). By 1985, the Icelandic

exclusive breastfeeding rate at 3 months was 57%, while the combined exclusive and partial

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breastfeeding rate was 67% at 3 months and 43% at 6 months (Freysteinsson & Sigurdsson,

1996). Five years later, in 1990, the exclusive breastfeeding rate was 70% at 3 months, with

the combined exclusive and partial rate reaching 83% at the same age (Freysteinsson &

Sigurdsson, 1996). In contrast, a very low breastfeeding prevalence persisted in Bavaria and

the Tyrol in the late-19th

century and into the early-20th

century (Knodel & van de Walle,

1967).

In other regions that differed from neighbouring districts by having particularly high

rates of artificial feeding, the underlying reason was apparently economic necessity, rather

than a distrust of human milk. For instance, Moring describes how, in the Osthrobothnian

region in Finland in the 18th

and early-19th

centuries, women’s long hours of heavy

agricultural labour outdoors led them to resort to using implements fixed to the infant’s cradle

to provide soured cow’s milk during the mother’s absence (Moring, 1998).

Abandonment of breastfeeding and sending the infant to a hired wet-nurse was the

common practice among the aristocracy in England and France in the 16th

and 17th

centuries,

and the result was frequent pregnancies. No matter how high born, aristocratic grand

multiparas often paid a high price for their fecundity though deaths in childbirth (Fildes,

1986). Those few high-born women who did breastfeed were remarked upon (Fildes, 1986).

Best-known is the Countess of Lincoln because of her treatise written in 1622 to implore

other women to breastfeed, dedicated to her daughter-in-law whose ‘rare example’ of

breastfeeding her own infant the old countess admired (McClaren, 1979).

The United Kingdom, Ireland, and the United States

While other European and some Asian countries had low breastfeeding prevalence in

the late-20th

century, Ireland and the United Kingdom are used as examples here because

their breastfeeding rates remain the lowest of comparable countries in the second decade of

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the 21st century. The United States is used as an example of a substantial increase in

breastfeeding acceptability in recent years, from a low base.

Trends in the last few generations have made breastfeeding beyond the early post-

partum period unusual in parts of the British Isles. For the last half century there have been

low breastfeeding rates in all four countries of the United Kingdom, and in the Irish Republic.

In the 1960s, breastfeeding was rare in maternity hospitals in several areas, with infant

formula assumed to be how mothers would feed their newborns (Scott & Mostyn, 2003;

Thorley, 2018).

In Ireland today, breastfeeding initiation rates remain low. In 1982 rates of

breastfeeding on discharge were 29% exclusive and 3% partial (i.e. 32% full or part

breastfeeding) and in 1991 it was still similar, with a breastfeeding on discharge prevalence

of 31.9% (full or part). Despite a subsequent improvement in initiation rates, few mothers

continued ‘any breastfeeding’ for long and exclusive breastfeeding at 6 months has been

extremely rare. Only one infant was exclusively breastfed to 6 months in a 2011 study of an

Irish hospital cohort by Tarrant and colleagues (Tarrant, Younger, Sheridan-Pereira, &

Kearney, 2011). Indeed, breastfeeding is regarded by many Irish-born mothers as socially

unacceptable and embarrassing (Tarrant, Younger, Sheridan-Pereira, White, & Kearney,

2009). Today, despite a slow increase, Ireland is believed to have one of the lowest

breastfeeding rate in Europe and possibly the world.

Table 1. Breastfeeding Initiation Rates (comparative). Courtesy of Elizabeth Quinn,

with permission.

By the middle of the second decade of the 21st century, despite a gradual rise,

Ireland’s breastfeeding prevalence on hospital discharge remained low relative to comparable

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countries, which had had greater increases. The October 2017 report of the Institute of Public

Health in Ireland, Breastfeeding on the Island of Ireland, gave the 2015/2016 rates for any

breastfeeding at discharge from hospital in the Republic of Ireland as 58% (48% exclusively

breastfed) (Purdy, McAvoy, & Cotter, 2017). Breastfeeding initiation rates were not

available. The same document reported Northern Ireland statistics at discharge as 46% for

‘any breastfeeding’ (38% exclusive breastfeeding) (Purdy, McAvoy, & Cotter, 2017). The

increase in the Republic was attributed to immigrant mothers, as Irish mothers were least

likely to breastfeed.

Irish mothers’ perceptions of breastfeeding are still anything but positive. In a survey

in the Irish Times of 6 Feb 2015, a typical response to the question, ‘Why don’t Irish women

breastfeed?’, was: ‘If you never see other mothers doing it, you’re never going to think it’s

normal.’ The paper reported that the negative influences encountered by women come from

the hospital, the woman’s partner, her family and friends, with influences of the older

generation important. Media interviews in 2018 indicated that little has changed in relation to

Irish women’s perceptions of breastfeeding (Anderson, 2012).

Similarly, in the United Kingdom in the 21st century, a country which rivals Ireland

for the lowest breastfeeding rate in the world (Relton, Umney, Strong, Thomas & Renfrew,

2017b), mothers continue to lack role models for breastfeeding. Even though they are well

aware of promotional messages about breastfeeding and why it is recommended, early-21st-

century studies confirmed that breastfeeding away from home is considered embarrassing and

socially unacceptable. (Condon, Rhodes, Warren, & Withall, 2012; McFadden & Toole,

2006; Scott & Mostyn, 2003). This is despite legal protection of breastfeeding in public

places, in Scotland since 2005, in Northern Ireland under a 2008 amendment to the Sex

Discrimination (Northern Ireland) Order 1976, and throughout the United Kingdom under the

Equality Act of 2010 (IFF Research, 2012). With low breastfeeding initiation and a cultural

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taboo on breastfeeding in public, especially in socially disadvantaged areas, mothers and

future mothers may never have seen another mother breastfeeding in their communities and

are sometimes the first in their families to breastfeed (McFadden & Toole, 2006; Scott &

Mostyn, 2003). For example, in a small sample of teenage mothers in Bristol, whose

breastfeeding initiation and duration rates were above the national average, the participants

stated they never saw other young mothers breastfeeding when out, and saw bottles used

everywhere (Condon, Rhodes, Warren, & Withall, 2012). Thus they experienced social

norms and cultural pressures as barriers to breastfeeding.

Women interviewed before a recent intervention trial in a region of England with low

breastfeeding rates knew no one who breastfed and stated they themselves had fed their

infants on ‘normal’ milk (formula) (Relton, Umney, Strong, Thomas & Renfrew, 2017a). In

these circumstances, new mothers are unlikely to perceive breastfeeding as the normal way to

feed a baby. This is despite the success of concerted efforts to increase breastfeeding rates.

There are limitations to the 20016-2017 breastfeeding prevalence figures for England as the

data consists of aggregate totals for only those areas of the north-east and east of the country

for which the information was validated (Public Health England, 2017). Released as

‘experimental statistics’, the aggregate breastfeeding prevalence at 6-8 weeks after birth was

44.5% (range 19.3% - 75.6%) (Public Health England, 2017).

At this writing, the most recent United Kingdom figures available are for Scotland

(Scottish Maternal and Infant Nutrition Survey, 2017). There the breastfeeding initiation rate

was similar in 2010 and 2017 (74 % vs 75%). At hospital discharge, prevalence of any

breastfeeding was 69% (53% exclusive breastfeeding), but there was a high drop-out rate at 4

to 7 days postpartum and in subsequent weeks. Encouragingly, the breastfeeding prevalence

(any breastfeeding) at 6 months rose from 32% to 43% between 2010 and 2017 (Scottish

Maternal and Infant Nutrition Survey, 2017). This may be partly due to support, as 89% of

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women who reported experiencing breastfeeding difficulties confirmed having received

assistance.

In the United States in 1971, only 24% of infants had ever been breastfed, even once,

followed by a rise and then a fall in the 1980s, and a surge to 60% in 1995; however, over

half of infants received formula feeds by the age of 1 week in the early-1990s (Wolf, 2003).

All through this period the prevalence of exclusive breastfeeding and duration of any

breastfeeding were low and breastfeeding was not the normal practice. In the most recent

figures available, of US infants born in 2015, 83.2% initiated breastfeeding, though in the

first 2 days, 1 in 6 newborns were supplemented with formula. .At 6 months, 57% were

receiving some breastmilk (25% exclusively breastfed) (CDC. 2018).

In both the United Kingdom and the United States, while breastfeeding (or not) is

attributed to a mother’s own agency, structural and cultural barriers remain a major influence

(Carter & Reyes-Foster, 2016; Tomori, Palmquist, & Dowling, 2016; Reyes-Foster & Carter,

2018). The American mother whose goal is to give her child breastmilk has to balance ideals

of good motherhood and neoliberal personhood as a good worker; which is difficult given

that achieving this balance is predicated on skills most often associated with white, middle-

class privilege (Reyes-Foster & Carter, 2018). Lack of paid maternity leave and pressure for

an early return to the workplace are structural obstacles for the American mother yet, despite

this, breastfeeding prevalence at most infant ages has increased more rapidly than in Britain.

The greater increase in overall breastfeeding rates in the United States may be due to multiple

determined efforts in that country to implement initiatives supportive of breastfeeding at

community level (Barrera, et al., 2018; CDC, 2016; Friesen, Hormuth, & Curtis, 2015;

Rutledge, et al., 2015), in contrast to funding cuts for such services in the United Kingdom

(Axcell, C. 2017).

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In both countries breastfeeding is acknowledged as nutritionally desirable, but both

lay and professional people regard practices that support a longer breastfeeding duration with

suspicion. Tomori, Palmquist, and Dowling (2016) identified these stigmatising practices as

breastmilk sharing, nighttime breastfeeding, and breastfeeding infants beyond the early

months. Breastfeeding in public remains contentious in both countries (Boyer. 2011, 2012).

Despite an increased overall prevalence and acceptability of breastfeeding in the US,

low breastfeeding rates have persisted into the 21st century in some regions and population

groups, particularly in the south-east (CDC, 2008). Kim and colleagues identified a number

of cultural barriers in their survey of African-American mothers in a Women, Infants, and

Children (WIC) program, and recommended interventions that provide realistic social

support to breastfeed to mothers and their support networks (Kim, Fiese, & Donovan, 2017).

Breastfeeding, women’s milk, and science

In the early- and mid-20th

century, the emphasis on ‘scientific motherhood’ had a

dampening effect on breastfeeding prevalence in industrialised Western settings, with

physician-directed or nurse-directed artificial feeding becoming the norm (Apple, 1994;

1995). In the 1950s and 1960s, when breastfeeding rates at any age were low, it was mother-

support groups – first the Nursing Mothers’ Council, and soon after, La Leche League

(1956), soon to become international – which supported the rise in interest in breastfeeding

among middle-class women and their physicians (Cowan, 2011). The 1960s saw the

establishment of other organisations to provide peer support to breastfeeding mothers, for

example, the Nursing Mothers’ Association of Australia (now the Australian Breastfeeding

Association) in 1964 and Ammehjelpen in Norway in 1968 (Barnard & Twigg, 2014;

Helsing, 2012). From the 1970s, there was a marked increase in journal articles on

breastfeeding, though some of these articles were marred by poorly defined terms and study

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design. Since the 1980s, new journals specifically on breastfeeding have flourished. Early in

the 21st century, the World Health Organization (WHO) and UNICEF released evidence-

based guidelines supporting exclusive breastfeeding for about six months and continued

breastfeeding with complementary food (‘solids’) thereafter (WHO, 2003), in contrast with

earlier practices, based on custom. Despite these advances, the diverse cultures in which

individuals live often prove a barrier to putting evidence-based practice into effect.

Breastfeeding promotion as an intervention

Culture can be changed; for example, the cessation of foot binding of infant girls in

China after 1911 as a top-down intervention, and public health interventions to encourage

smokers to quit the habit. Promoting breastfeeding can be considered an intervention in

times, places or cultures with strong traditions of little or no breastfeeding across generations,

or very short durations. Without interventions, the status quo continues.

It is sometimes difficult to categorise interventions as ‘positive’ or ‘less helpful’,

because effects can be interpreted differently, especially where objectives, scale, culture and

timelines differ. However, the most recent report from ongoing intensive peer counselling

interventions in two poor communities in Bangladesh), in which mothers were appropriately

supported, with continuity of care, has impressive outcomes for early initiation of

breastfeeding and exclusive breastfeeding (Haider & Saha, 2016). Of infants born at normal

weights, 94% were exclusively breastfeeding at 6 months, while 92% of Low Birth Weight

infants (6% of the total) were exclusively breastfed for 6 months. To be effective,

interventions need to provide ongoing support (Haider & Saha, 2016) and in Western

cultures, they also need to recognise that women have agency, that is, they receive and test a

number of influences within their own personal, family and community environments and

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test new advice against competing information (Heinig et al., 2006). Social Marketing Theory

informs some of the better programs today (Bartholemew, Adedze, & Solo, 2017).

The US Surgeon General’s Call to Action on Breastfeeding (United States

Department of Health & Human Services, 2011) was based on market research and provided

very specific recommendations for implementation. Its objectives for giving mothers the

necessary support to breastfeed their infants, include developing programs to educate partners

and grandmothers about breastfeeding and community programs. Further, it urged a national

approach to the promotion of breastfeeding, evidence-based breastfeeding education for

health professionals, access to skilled support for breastfeeding women, and fostering

workplace change. The Call for Action has made skilled lactation support available to more

women who were previously not supported.

Portraying breastfeeding in the media as a normal part of life has been advocated

(Henderson, 2000). When locally appropriate, positive role models are used in health

education material and the media, with believable community women breastfeeding matter-

of-factly in daily situations, the mother can identify with them. Yet today. images of

breastfeeding still fail to reflect ordinary mothers and their lived reality. Ziniel (2012) found

that breastfeeding images in American media and on the covers of breastfeeding-related

books portrayed women who were Caucasian, dark-haired, relatively slim and married

(indicated by a wedding ring). The children portrayed were predominantly 0-3 months in age,

seldom over 6 months, and racially similar to their mothers (Ziniel, 2012). The pictures were

usually posed, instead of depicting real-life situations. The recent proliferation of online

sharing of breastfeeding images – many of them everyday images of ordinary women and

babies in a variety of poses – is intentionally providing women with online communities that

normalise breastfeeding (Marcon et al., 2018). They can be found on open social media sites

such as Instagram, Twitter, and Facebook by using the hashtag #normalizebreastfeeding.

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Sometimes seemingly positive interventions are marred by mixed messages, which

may foster some gains, but preserve the status quo. At the turn of the 20th

century, the British

Government promoted breastfeeding because of poor infant growth in the lower socio-

economic classes, the future foot soldiers and workers for the Empire. Dvork (1987) has

described the national concern that three-fifths (60%) of recruits were rejected as physically

unfit for service in the South African (Boer) War of 1899-1902. An association was made

between survival from diarrhoeal disease and respiratory infections from inadequate artificial

feeding in infancy, and subsequent morbidity and stunting (Dvork, 1987). Breastfeeding was

promoted, but much of the resultant action involved efforts to improve the quality of the

cow’s milk fed to infants - though this was only one of a plethora of infant foods commonly

substituted for breastfeeding (Davenport-Hines & Slinn, 1992).

In the United States the Loving Support program, begun in 1997 to improve

breastfeeding support and staff training of the US Special Supplemental Program for Women,

Infants, and Children (WIC), has over time been developed and improved. However, despite

positive breastfeeding initiatives in WIC, Kent has identified WIC’s continued provision of

free infant formula on a large scale as a conflict of interest and source of mixed messages that

still needs to be addressed (Kent, 2017).

Less helpful breastfeeding promotions have included the ’breast is best’ message and

emphasising the fact that breastfeeding is free. ‘Breast is best’ is aspirational, rather than

acknowledging and addressing community barriers to a mother’s achievement of her

breastfeeding goals. Emphasising that breastfeeding is free or low-cost may actually be

counter-productive. Mothers ill able to afford commercial substitutes for breast milk may

misinterpret this message as meaning that breastfeeding is only for when they cannot afford

the commercial products, and they will struggle to buy infant formula lest their neighbours

think they are too poor to afford it (Thorley, 2018).

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Implications for practice

I would postulate that it is more realistic to promote breastfeeding, especially

exclusive breastfeeding, as feasible for mothers. While breastfeeding is undeniably

biologically normal, it has not always been normal to a culture. For mothers with no

community exposure to breastfeeding, promoting it simply as ‘normal’ makes it likely that

they will stop listening. So it makes sense to look for alternative terms, more precise terms. I

argue that it is more accurate to describe breastfeeding as ‘biologically normal’ or

‘physiologically normal’, acknowledging that it is not necessarily normal to a culture. Above

all, effective breastfeeding promotion entails listening to the mother’s concerns and directing

her to ongoing support, including online support, to make it feasible.

In conclusion, there is no single means of changing breastfeeding culture. While in

some circumstances policies and edicts (top down strategies) can work, it is when the

messages are supported at every level that they can be reinforced and made applicable to the

individual mother. This means listening to mothers and working with them to identify

barriers and to find what is possible for them. Recent experience in the United Kingdom.

Ireland and the United States reveals that a lack of breastfeeding role models is an important

barrier for pregnant women and mothers of babies. Locally appropriate images of mothers

and infants in information material provided to mothers and in the media should include

‘ordinary’ women breastfeeding in real-life situations. This is beginning to be addressed

through images posted on social media sites to create online communities where

breastfeeding is normalised.

ACKNOWLEDGMENTS

No funding was received for this research.

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Table 1. Breastfeeding Initiation Rates (comparative). Courtesy of Elizabeth Quinn,

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June 19, 2016

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