Encouraging breastfeeding: A relational perspective

Abstract

Despite the WHO recommendations that babies should be breastfed exclusively for six months and thereafter for up to two years and beyond this pattern of feeding is far from the global norm. Although breastfeeding is triggered through biological mechanisms which have not changed with time, the perception of breastfeeding as a phenomenon is variable, as it not only reflects cultural values of motherhood but is also negotiable from the perspective of the individual. This paper argues that relationships are central to encouraging breastfeeding at an organisational, family and staff–parent level. This shifts our conceptualisations away from the primary focus of breastfeeding as nutrition which, in turn, removes the notion of breastfeeding as a productive process, prone to problems and failure.

Introduction

Breastfeeding is universally acknowledged as providing health benefits to both mothers and infants [1]. The Global Strategy for Infant and Young Child Feeding [2], provides an international, evidence-based guide to protecting, promoting and supporting breastfeeding and to optimising practices in relation to infant and young child feeding. The Global Strategy aims to ‘improve – through optimal feeding – the nutritional status, growth and development, health, and thus the survival of infants and young children’ [2, p 6]. Central to this is the recommendation that infants should be exclusively breastfed for the first 6 months of life and thereafter receive nutritionally adequate and safe complementary foods with breastfeeding continuing for up to 2 years of age or beyond. The Global Strategy refocuses, internationally, attention towards policy and practice on the feeding and well-being of infants and young children, by calling for a renewed commitment to the WHO International Code of Marketing of Breastmilk Substitutes [3], the Innocenti Declaration on Protection, Promotion and Support of Breastfeeding [4] and the Baby Friendly Hospital Initiative (BFHI) [5].

The BFHI was developed by WHO and UNICEF to reverse the medicalisation of infant feeding that occurred during the twentieth century to include rigid determination of the frequency and duration of feeds, separation of mothers and babies and unnecessary supplementation of breastfeeding with infant formula [6], [7], [8]. It aimed to restore the relational aspects between mother and baby, staff members and parents and to provide additional support for women once they left hospital. Key aspects include provision of health professional education, providing appropriate antenatal information, encouraging skin-to-skin contact between mother and baby, providing health professional support with lactation to include those mothers separated from their babies, avoidance of giving unnecessary breast milk substitutes, keeping mothers and babies together, encouraging flexible, baby-led breastfeeding and offering mothers peer support once discharged from hospital. Research has identified that implementation of the BFI has a positive impact on breastfeeding rates [9], [10], [11], [12], [13], [14], [15], [16], [17] though there are continuing challenges in achieving successful implementation [18].

Whilst initiatives like the BFHI are crucial, when we ask ourselves the question, ‘how can we encourage women to breastfeed and to do so exclusively and for longer? Our starting point needs to centre on, why, given the overwhelming evidence of the value of breastfeeding for mother and child, do so few women initiate and continue to breastfeed in many communities across the globe? This can only be answered by focusing upon the cultural issues related to breastfeeding. There is a growing body of research that illuminates the ways in which maternal dietary and infant feeding practices relate substantially to local cultural norms and constraints [19], [20], [21], [22]. Therefore, we cannot simply recommend interventions without thoroughly exploring the socio-cultural context and constraints that operate within a given community. Without this socio-cultural knowledge any intervention may ‘fall at the first hurdle’ due to contradictory cultural beliefs and/or constraints upon families in taking up or implementing designated changes. This cultural assessment needs to take place with regard to the general norms within the community setting. Some of the barriers to breastfeeding in the community include: cultural taboos and beliefs about colostrum and breastfeeding, negative attitudes towards the body and breastfeeding, sexualisation of women's bodies in the media and; loss of community based knowledge about breastfeeding [22]. This sets the context for women's decisions related to infant feeding. However, when a woman gives birth in a maternity unit or when her baby needs neonatal care she is subject to an organisational culture that influences the attitudes and actions of the staff and, in turn, the information, support and care that they provide for the woman. This organisational culture also needs to be understood. Relationships are central to all human experience and when considering breastfeeding consideration of human interactions must be our first priority. To structure this discussion we look at three levels of relationship that influence women, babies and families with regard to their experiences: relationships within an organisational context, mother – baby and staff – mother with a particular focus on maternity and neonatal units.