For Part 1 in this literature review, please see the post here.
Feeding Infants in Public Spaces
Breastfeeding in public is considered normal in many Third World countries (as well as several Western countries), but has been incredibly controversial in the United States; prior to the 1980s, breastfeeding was actually considered a form of indecent exposure. Though 49 of the 50 states currently have legislation in place to protect a mother’s right to feed her infant publicly (Idaho as the single exception), the anticipation of hostile reactions and fear of stigma still remain. To support women who encounter any hostility while breastfeeding in public, in the United States many women participate in “nurse-ins” to protest or boycott businesses that have harassed, blocked, or in other ways treated breastfeeding mothers badly.
Breastfeeding mothers engage in behaviors that align with a perception of a more hostile environment regarding public breastfeeding, such as practicing discreet feeding, avoiding specific locations to prevent the possibility of publicly breastfeeding there, monitoring the “male gaze,” and explicitly redefining the breasts as maternal to limit the discomfort with their dual role (Hurst, 2013). Many women will resort to strategies to avoid breastfeeding in public at all by expressing milk at home to take outside, pumping in a bathroom stall, or using formula (Scott, et al., 2015).
In Scotland, 74% of women initiate breastfeeding, but only 30% continue by 6 months of age; Sweden, on the other hand, has a nearly universal initiation rate (97%) and 63% of women continue breastfeeding at 6 months (Scott, et al., 2015). A comparative study between Scotland, Sweden, Spain, and Italy (Scott, et al., 2015) highlighted that negative cultural perceptions do impact breastfeeding initiation and duration, and that it isn’t a problem specific to the United States. Swedish mothers, with their near universal initiation rate, disagreed with the statement “women should not breastfeed in public places such as restaurants,” whereas Italian mothers, with a 36.3% initiation rate, more strongly agreed with this statement, and were significantly less likely to ever have breastfed in public. Additionally, having breastfed in public, after controlling for known sociodemographic factors to duration, reduced the likelihood of discontinuing breastfeeding before 12 months of age. Of those who do not breastfeed, or do so for a limited time, cite embarrassment as the dominating factor in the decision (Scott, et al., 2015, Johnston-Robledo & Fred, 2008).
Overall, women’s perception of negative social judgment is far harsher than any actual experience of that disapproval (Hurst, 2013), and though only 28% believed it was appropriate to show a breastfeeding woman on television, 43% of respondents in the same survey believed the woman had a right to feed her child in public (Acker, 2009). Some of the concerns regarding public breastfeeding involves whether or not the individual views breastfeeding as a sexual act, and their discomfort with those perceptions (Hurst, 2013). Some women have voiced concerns with “turning men on” (Hurst, 2013), doing so in front of “impressionable children,” and relate it to public displays of sexual behavior (Johnston-Robledo & Fred, 2008).
These concerns involving perception of negative reaction and the association with sexual behavior have a demonstrable impact on breastfeeding initiation and duration. In a study conducted by Johnston-Robles, Wares, Fricker, & Pasek (2007), women with higher scores on the Public Breastfeeding as Indecent scale had more negative attitudes towards public breastfeeding, as well as higher scores on the concern measures related to embarrassment, body impact, and sexuality impact. These women also planned to breastfeed for shorter periods of time. Unfortunately, in the United States, many of these barriers impact the same demographic groups that are susceptible to the economic barriers as cited previously. Non-white race, low income, and less education are associated with more negative perceptions of breastfeeding in public (Hurst, 2013), referring to it as “nasty” or being concerned with others viewing them as perverted (Johnston-Robledo & Fred, 2008). The negative perceptions of breastfeeding in public also impact the interest women express with pumping; for women with concerns regarding the psychosocial aspects of breastfeeding, pumping milk in private settings to be used in public later, despite the inherent discretion, was not an option in which they were interested. (Johnston-Robledo & Fred, 2008). Internalized perceptions of vulnerability related to breastfeeding in public are significant enough to impact a mother’s feeding choices, and an actual, observed public response need not occur (Hurst, 2013).
Although women are more knowledgable about breastfeeding than men, women are often concerned about a male’s perception in choosing to breastfeed, especially in public situations. And a man’s attitudes towards breastfeeding are predicted by sexism (Acker, 2009): those high in hostile sexism regarded breastfeeding women less positively, regardless if it was done in public or private. Men who were classified as benevolent sexists, that is, viewing women as an ideal – a person to protect and cherish – only expressed strong disapproval when the breastfeeding was done in public, likely because this act, in their view, violates the traditional gender role expectations involving modesty. As the prevalence of non-sexist males increases, since male attitudes significantly impact breastfeeding choices for women, it is possible that breastfeeding initiation and actual duration, by way of increased acceptance of breastfeeding in public spaces, could improve.
What are the Official Recommendations?
The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) both recommend exclusive breastfeeding through 6 months of age; this means the infant only consumes breastmilk – no formula, no solids, no water. Only 17% of American women follow this guideline; 53% of mothers introduce formula before the baby is a week old, and 81% of mothers have introduced formula by the time the babyahas turned 4 months old. Beyond 6 months, the two organizations differ in their recommendations. The AAP encourages continued breastfeeding through age 1, while the WHO recommends breastfeeding through age 2. Ultimately, the more meaningful predictor of health is not that a child was ever breastfed, but rather that they were exclusively breastfed, and that the mother continued for a period of time.
However, these goals are more difficult to meet with negativity, real or perceived, towards public breastfeeding. Breastfeeding that can be observed by others, thereby becoming more familiar and commonplace, could improve community attitudes and social norms towards breastfeeding, which in turn impact a mother’s attitude and action regarding breastfeeding initiation and duration (Vari, et al., 2013, Scott, et al., 2015, Johnston-Robledo & Fred, 2008).
Acker, M. (2009). Breast is Best…But Not Everywhere: Ambivalent Sexism and Attitudes Toward Private and Public Breastfeeding. Sex Roles, 476-490.
Burdette, A. M., & Pilkauskas, N. V. (2012). Maternal Religious Involvement and Breastfeeding Initiation and Duration. Research and Practice, 1865-1868.
Hurst, C. G. (2013). An Initial Validation of a Measure of Sexual Perceptions Regarding Breastfeeding. Social Work in Public Health, 21-31.
Johnston-Robeldo, I., Wares, S., Fricker, J., & Pasek, L. (2007). Indecent Exposure: Self-objectification and Young Women’s Attitudes Toward Breastfeeding. Sex Roles, 429-437.
Johnston-Robledo, I., & Fred, V. (2008). Self-Objectification and Lower Income Pregnant Women’s Breastfeeding Attitudes. Journal of Applied Social Psychology, 1-21.
Scott, J. A., Diet, G. D., Kwok, Y. Y., Synnott, K., Bogue, J., Amarri, S., . . . Edwards, C. A. (2015). A Comparison of Maternal Attitudes to Breastfeeding in Public and the Association with Breastfeeding Duration in Four European Countries: Results of a Cohort Study. Birth, 78-85.
Vari, P., Vogeltanz-Holm, N., Olsen, G., Anderson, C., Holm, J., Peterson, H., & Henly, S. (2013). Community Breastfeeding Attitudes and Beliefs. Health Care for Women International, 592-606.
Wolf, J. H. (2003). Low Breastfeeding Rates and Public Health in the United States. American Journal of Public Health, 2000-2010.