Breast Intentions

The strength and ubiquity of the 'breast is best' message in New Zealand means there is greater awareness than ever of the benefits of breastfeeding, increasingly advocated as 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, Christchurch based counsellor Karen Holmes, is launching a counselling service 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." This grief therefore expresses itself in other ways, for example through anger at breastfeeding mothers or feelings of resentment at being let down by the health system.

Holmes offers counselling to those impacted by infant feeding grief, trauma or related concerns, including mothers and those who find themselves with issues in their work with mothers. Counselling could be historical, for example with grandmothers, as well as for contemporary issues. In addition to grief from not establishing breastfeeding, it can also arise when a child weans unexpectedly.

Mother of three, Charlotte, comments: "I breastfed my eldest for 23 months. I couldn't breastfeed my middle son and I had to bottle feed, it caused me a lot of negative psychological stress for a while, and I got it into my head that he didn't love me. My third son I breastfed for just over 6 months, then he decided he wasn't interested anymore and preferred food and a bottle. This was a bit of a shock at first."

Infant feeding issues may also arise in pregnancy. For example, one mother who had an eating disorder when younger, had recurring nightmares throughout her pregnancy that she would be unable to feed her baby.

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.

Feelings of loss at not breastfeeding may be compounded by guilt, and also rejection by having felt undermined by questions when attempts at breastfeeding were underway.

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 toward breastfeeding women. For example "are you sure you've got enough milk", "that baby's got you wrapped around it's little finger", and assumptions about the duration of breastfeeding and the need for supplementation from formula.

Anthropologist Sheila Kitzinger in Ourselves as Mothers (1992) stresses the importance of self-belief when she writes: "The firm expectation that (women from traditional cultures) will breastfeed successfully is much more important for a mother than any specific breastfeeding practices... women can breastfeed under apparently impossible conditions if they are convinced that they will be able to do so."

Breast vs Bottle Polarisation

The polarisation of breast versus bottle hurts mothers and the women at the frontline of breastfeeding promotion. Holmes comments: "There appears to be this big division between breast and bottle feeding, but there are multi-causal factors with infant feeding in Western culture today including historical, cultural, familial and political. In a culture that often wants to point the finger in one direction, in reality it serves no one to do this. I believe we need an honest look at where we are to acknowledge that the two camps have much in common."

Holmes continues: "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, undermining and interference to get to that point, just like a formula feeding mother. But yes, the breastfeeding mother's trauma may be alleviated by her eventual success."

Holmes herself experienced problems breastfeeding so knows first hand what women may go through. Holmes said she wanted to breastfeed her now grown-up daughter for economic reasons and because "it gave me an excuse to be close to my baby", a poignant testament to the independence expected between mothers and infants in Western society.

During the first few days of her daughter's life, and having difficulty feeding, Holmes was "constantly questioned" as to whether her baby was getting enough breastmilk and was "eventually worn down", and gave her baby formula. She then overheard someone saying of her "they just don't try very hard these days do they". However Holmes persevered, and with help from an LLL breastfeeding counsellor regarding positioning of the baby, she went on to breastfeed until her daughter was three years old.

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

Carol Bartle, coordinator of the Canterbury Breastfeeding Advocacy Service, comments "Breast pump marketing implies that all women need a breast pump to breastfeed, and the only pressing issue is finding out "which pump is right for you". However seductive the pump marketing messages are, with their impressions of the modern mother's need to get away from her baby, fathers' need to give bottles, and images of attractive women with their backpack and pump, the reality of pumping is that of a complex and time consuming practice that is hard to maintain. I have yet to meet a woman who enjoys pumping but have known hundreds who love to breastfeed once they have established breastfeeding".

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 of serious milk supply problems."

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 to ensure pumping is done effectively, and the milk supply is maintained, pumping needs to be done in combination with hand massage techniques. Something few women are aware of.

Barriers to breastfeeding

It is very clear that women should not take sole responsibility for their breastfeeding experiences. Holmes identifies that grief issues "depend on self-image and expectations", so that when women are given unrealistic ideas of breastfeeding and at the same time undermined on the way to achieving breastfeeding, the grief and sense of failure can be significant.

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, societal expectations about the acceptable duration of breastfeeding, a culture that portrays bottle-feeding as normal, and returning to work, by choice or through financial necessity.

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.

Holmes comments: "Many bottle feeding mums feel extremely traumatised by their persistent efforts to breastfeed to the point where they will not ever try again with subsequent babies. Sadly much of this experience is due to inaccurate breastfeeding information. However, there are successful breastfeeding experiences after some extreme circumstances. This is done knowing how breastfeeding works and that others have done it successfully."

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. Three-quarters of breastfeeding mothers... said they would have preferred to breastfeed for longer had they been able. These findings suggest that most women who start to breastfeed are committed to it but stop because they encounter problems and find that skilled support is not readily available."

In recognition of this, the Canterbury Breastfeeding Advocacy Service provides not just information about breastfeeding but practical support in the form of networks between health care professionals, local groups and mothers. Bartle comments "We are trying to shift the culture to one that supports and protects breastfeeding women, rather than just promoting breastfeeding without support structures in place to really make a difference. For example, I have just been working with a mother who said that the most useful assistance she could have received while trying to establish her preterm baby on the breast after going home from the hospital, was home help."

Meanwhile, commenting on the national situation 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."

Many problems need not prohibit breastfeeding were they seen as part of the breastfeeding journey and if consistent support and information were on hand in the crucial first days and weeks. Denise Digman in Breastfeeding in New Zealand: Practice, Problems and Policy (1998), says the medicalisation of breastfeeding has detracted from "perceiving the range of physical sensations and difficulties experienced while breastfeeding as part of the normal spectrum of events". This is echoed by NBAC which talks of "insufficient knowledge about the normal course of breastfeeding, including common problems and the solutions".

Holmes gives an example from her own life to illustrate this point: "In her first weeks, my youngest daughter was putting on very little weight and this was of concern to the Plunket nurse. I explored what factor might be creating the problem and discovered a cowsmilk intolerance. As soon as this was eliminated from my diet her weight gain improved. Without this knowledge, this could have turned into a safety issue."

New Zealand's breastfeeding rates compare favorably with those of 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% at 8 months; Canada 2008 14.4% at 6 months, Australia 2007 14% at 6 months, USA 2006 13.6% at 6 months, UK 2005 less than 1% at 6 months.

However seen globally, it is clear the impact Western values may have on breastfeeding. 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".

The top 5 countries for exclusive breastfeeding at 6 months (Unicef 2008) are Rwanda 88%, Kiribati 80%, Sri Lanka 76%, Solomon Islands 74%, and Peru 69%. At aged 20-23 months, Sri Lanka, Burkina Faso, Ethiopia, Bangladesh and Nepal all had breastfeeding rates of over 80%, with Nepal at 95%.

In New Zealand, rates for Maori and young mothers are much lower than average, and Maori currently have the lowest exclusive breastfeeding rates in the country. This is also a hallmark of Western society: As Glover et al explain in Maori Women and Breasfeeding (2008) "Beliefs and practices introduced to Maori by European immigrants to New Zealand have supplanted Maori infant feeding practices". The report therefore recommends that "promotion of breastfeeding to Maori should focus on re-establishing breastfeeding as a tikanga (right cultural practice)".

As well as Karen Holmes new counselling service, Christchurch is fortunate in having the Young Parents' Breastfeeding Group Whangai U "Matua Puhou". Headed by public health advocate and breastfeeding peer counselling administrator Susan Procter, the group has over 20 regular members and meets regularly to support breastfeeding families where the mother is aged under 25.

Procter comments: "The impact the group has had is enormous, both in terms of breastfeeding success and also in giving several of the mums a passion and motivation to apply to enter the health care professions to advocate for breastfeeding and to support other young mothers."

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, the archetypal female domain, 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 cesarean 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 "to help the mothers and save the babies" 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 4 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 foods 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 continues "It is with this that I want to work, for example validating grief, feelings, impacts. Helping women to understand what creates these conflicts and giving them permission to feel what they feel. I would hope also that in doing this women may regain a sense of their own wisdom and feel empowered to make informed choices."

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 honored in their experiences around infant feeding. That mothers feel supported, valued and confident in their own ability as a mother."