One of the most sensitive debates in “mom circles” is what method of feeding to pursue with your newborn. Hospitals strongly advocate breastfeeding for a multitude of health reasons (nutritional, immunological, developmental, psychological [Acker, 2009]) for both the baby and mother, offering breastfeeding classes and providing lactation consultants that visit your room upon delivery (and at times thereafter, and are then available after hospital discharge to assist you further as you adjust to this new practice). Many women find breastfeeding difficult because of their baby’s preferences or difficulty in engaging in the process at all; others avoid breastfeeding because of their own personal discomfort or external barriers that hinder or explicitly prevent the capability to do so. Has breastfeeding always been considered the preferred means of providing nutrition to infants? If it is largely understood to be beneficial to both mother and child, why don’t more women do it, and why is there a negative reaction to seeing it in public places if breast truly is “best”?
Breastfeeding Practices in the United States
In the colonial days of the United States, women normally breastfed through their infants’ “second summer,” and it wasn’t until the mid-19th century that mothers moved to earlier weaning. Some argue the change in the expectations of marriage for middle-class women contributed to this shift: the desire for love and companionship in a marital union, as opposed to economic practicality and procreation, encouraged women to prioritize the connection with their husbands over any resulting infant (Wolf, 2003). For working class mothers, the primary driver for bottle-feeding was rooted in economic factors; if a woman worked outside of the home in the 19th century, she was simply unable to breastfeed her baby. There was no legislation of the workplace to allow for breastfeeding breaks, or the technology to efficiently express breast milk and pump a supply for the infant to be fed by a different caregiver.
As of 1897, 18% of Chicago infants died before their first birthday, 53% of which passed away due to diarrhea. Similarly, in Baltimore, there was a 59% higher than average mortality rate for infants whose mothers worked outside of the home; of mothers who worked in the home, the infant mortality rate was 5% lower than the average. Public health campaigns to lower infant mortality recognized and addressed, initially by means of displaying posters in urban neighborhoods, a significant contribution to the early death of infants: many were being fed, in lieu of breastmilk, spoiled, adulterated cows’ milk, as there were no industry regulations at the time regarding the safe production and consumption of dairy.
Along with the overall public health campaigns, some cities utilized public health nurses to work within the community in breastfeeding assistance – what was essentially a highly involved lactation consultant. In Chicago, the nurses were sent to immigrant neighborhoods as there was a false understanding of the barriers to breastfeeding. Human milk advocates in Chicago believed non-acculturation was the root of infant mortality, that it was an immigrant problem; as a result, native-born Black and White infants were ignored and infant mortality largely remained unchanged. After 4 years of home visits, only 39% of mothers exclusively breastfed newborns. Minneapolis, in comparison, assigned a public health worker to each new mother, regardless of ethnicity or national origin, immediately after birth and assisted as many times as necessary through the infant’s first nine months to help with any lactation-related problems. Their results were striking: after the first year of this resource, 96% of babies were breastfed exclusively through their second month, 72% continued through 9 months, and infant deaths had declined by 20%.
Following pasteurization and hygienic handling of cows’ milk legislation in the 1920s, the campaign encouraging breastfeeding had virtually disappeared. There continued to be public health problems, but the link between nutrition and infant mortality and illness became less obvious when cows’ milk was safe to drink. A single decade later, even pediatricians viewed human milk as “nothing sacred.” By 1971, breastfeeding hit an all-time low in the United States. Only 24% of mothers had tried breastfeeding a single time prior to hospital discharge following delivery. The low initiation rates of breastfeeding of that time, and that continue today, seem to be discriminating along race and education lines; that is, since the 1970s, only one group has embraced breastfeeding in large numbers – college-educated white women.
Factors that Impact Initiation and Duration
There are certainly a variety of barriers to initiation of breastfeeding and achieved duration of breastfeeding, most notably employment. Only 10% of full-time working mothers breastfeed their babies by 6 months; stay at home mothers, in comparison, are nearly 3 times more likely to breastfeed through 6 months. But the real kicker – this statistic holds true regardless of ethnic, education, and age groups. This indicates that the biggest, single barrier to breastfeeding duration is simply whether or not the mother works full-time. In fact, research has found that some low-income women wanted to breastfeed but did not, and viewed it as a privilege available to women who do not have to work (Johnston-Robledo & Fred, 2008).
In addition to employment status, a variety of sociodemographic characteristics are predictors of breastfeeding initiation, as are a number of psychosocial factors. Higher education level, higher family income, and race are associated with increased rates of breastfeeding initiation (Johnston-Robledo & Fred, 2008; Acker, 2009); these sociodemographic differences held true regardless of nationality in a comparative study between the United States, Canada, Europe, and Australia. Breastfeeding barriers for lower income women include – beyond the need to return to school or work – low levels of self-efficacy and negative attitudes toward breastfeeding, often facilitated by members of their communities.
Another strong predictor of breastfeeding initiation is the attitude of the partner (Acker, 2009). A partner with a positive attitude towards breastfeeding increases the likelihood that the mother will initiate and continue breastfeeding the infant. Attitudes and behaviors of members within the mother’s community also influence the woman’s intention and commitment to breastfeeding (Vari, et al., 2013) as do the attitudes of the mother’s parents (Scott, et al., 2015). Further, increased exposure to breastfeeding, that is the number of childhood observations of breastfeeding, predicted more positive attitudes towards breastfeeding (Vari, et al., 2013).
Religiosity is positively associated with breastfeeding initiation (Burdette & Pilkauskas, 2012); attending church once a week or more was associated with a 55% increase in the odds of initiating breastfeeding as compared to never attending services. This was true across religions – conservative Protestants, Muslims, and other religious faiths – regardless of marital status, as 3/4 of the dataset included births to unmarried parents. This finding is in line with previous research that has suggested church attendance to be inversely correlated with risky health behaviors among pregnant and postpartum women.
Somewhat counterintuitively then, egalitarianism is also strongly associated with breastfeeding intentions (Acker, 2009). The more egalitarian the woman, the greater her intention to breastfeed. However, less egalitarian women that did initiate breastfeeding continued doing so for longer than those that held the nontraditional gender role attitudes.
Breastfeeding and Sexual Perceptions
A pervasive theme throughout recent literature has focused on a particular psychosocial construct: self-objectification and the resulting concern with sexual perceptions during the act of breastfeeding and those held towards the mother’s body following breastfeeding practice.
In America, women are socialized to evaluate their bodies based on how they appear to others, placing a prioritization of physical attributes related to appearance over those related to health or competence (Johnston-Robledo & Fred, 2008; Johnston-Robledo, Wares, Fricker & Pasek, 2007). Of disadvantages discussed related to breastfeeding, sagging breasts, stretch marks, and impact to breast size are often cited; simultaneously, expressions in favor of breastfeeding over bottle-feeding cite more rapid postpartum weight loss (Johnston-Robledo & Fred, 2008). Additionally, some support for breastfeeding is centered on a partner’s positive attitudes of the changes to the woman’s breasts and an increase in sexual desirability. Certainly, regardless of side of the feeding debate, there is a significant focus on impact to attractiveness in making the decision whether or not to breastfeed.
In Johnston-Robledo & Fred’s 2008 study, women with higher scores on body shame factors, and with a more appearance-based physical self-concept, were more concerned that breastfeeding would be embarrassing, and have a negative impact on their bodies and sexuality. Even women who engaged in some breastfeeding, albeit not exclusively, had a higher degree of concern of the impact to their sexuality. In contrast, women who planned to breastfeed exclusively reported fewer concerns regarding their sexuality and bodies. In line with this research, women with clinically significant concerns of weight and body shape had less intention of breastfeeding their infants than women without these concerns (Johnston-Robledo, Wares, Fricker & Pasek, 2007). People with erotophobia – discomfort with sexuality – even consider breastfeeding mothers as less good mothers, that they have fewer positive personality traits, and do not possess traditional family values (Acker, 2009).
The various factors that affect breastfeeding initiation and duration among women, whether sociodemographic or psychosocial, are arguably all influenced, if not directly moderated, by a woman’s attitude and perception regarding public breastfeeding – its accessibility, appropriateness, and the perceived affect on others. Without the ability to breastfeed in public, and to do so with comfort and social support, women are often unable to achieve their breastfeeding goals or to even bother initiating it in the first place.
Stay tuned for Part 2, in which we will examine the existing research regarding breastfeeding in public, and how those attitudes may affect a mother’s ability to meet the breastfeeding recommendations set forth by the American Academy of Pediatrics and the World Health Organization.
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
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.