Barriers to exclusive breastfeeding

This paper was submitted to Brigham Young University in April 2011 and may not be reproduced in any way without my permission.

Across continents and cultures, women have a commonality in their ability to bear children. With this potential comes also the ability to provide nourishment for infants through breast milk. Research shows that exclusive breastfeeding in the first months of life medically benefits both the mother and child. Yet considerable global challenges exist to effective, sustained breastfeeding, in developed as well as in developing nations. Lack of information about the benefits of breastfeeding, lack of interest or economic ability to breastfeed, and lack of adequate health on the mother’s part all contribute to the low worldwide rate of exclusive breastfeeding. In order to overcome these issues, health workers and breastfeeding proponents must help provide feasible methods for combining employment and breastfeeding, tactfully address long-standing cultural beliefs and practices, and inform mothers of the enormous safeguards presented by breastfeeding, even for HIV-positive women.

Studies have repeatedly demonstrated that breast milk provides the optimal combination of food and nutrients for infants in the first six months of life. Evidence shows that breastfeeding reduces the risk of morbidity by protecting the infant from common bacterial and viral infections, many of which can be fatal in infants (Goldman, Hopkinson & Rassin, 2007). Breastfeeding can provide complete and sufficient nutrition, even for infants with low birth-weight. Exclusive breastfeeding encourages growth more quickly and effectively than alternative feeding methods in these infants (Labbok, 2006). This is most likely because breast milk contains specific proteins that help an infant’s immune system develop properly (Egalsh, Montgomery & Wood, 2008). This in turn leads to healthier children. Breastfeeding avoids much of the risk of potentially life-threatening conditions, including diarrhea, that arise when formula is prepared in poor sanitation settings (Arvelo et al., 2010).

Not only does breastfeeding positively affect the immediate health and growth of infants, numerous long-term health benefits exist for breastfed children. Breastfeeding as an infant negatively correlates with the risks of obesity, diabetes, and childhood leukemia (Eglash et al., 2008). Furthermore, breastfeeding positively affects a child’s mental development. Studies point to increased cognitive development in the early years of life for breastfed children (Goldman et al., 2007). Additionally, breastfed children display greater acceptance of new foods and of a wider variety of foods (Maier, Chabanet, Schaal, Leathwood & Issanchou, 2008). Exposure to a wider variety of foods ensures that children continue to receive the full spectrum of nutrients required for healthy, sustained growth.

Children are not the only individuals to reap the benefits of exclusive breastfeeding; breastfeeding positively affects women’s health, as well. Breastfeeding may substantially reduce the risk of several life-threatening diseases. Women who breastfeed their children experience lower incidences of both breast and ovarian cancer (Collaborative Group on Hormonal Factors in Breast Cancer, 2002; Hanna & Adams, 2006). Furthermore, studies demonstrate an inverse relationship between breastfeeding and the risk of developing type 2 diabetes (Ip et al., 2007). Breastfeeding positively correlates to an increase in women’s mental health . Mothers who breastfeed tend to have considerably shorter and less physically strenuous postpartum recoveries (Mezzacappa, Kelsey & Katkin, 2005).

The World Health Organization [WHO] recommends that women throughout the world provide only breast milk for their children for the first six months of life and continue to breastfeed, while introducing complementary foods, until children are two years old—or longer (WHO 2011). Despite this, surveys indicate that only 33% of mothers in the United States do breastfeed exclusively for at least six months (WHO Global Data Bank, 2010). The low rate of exclusive breastfeeding has several causes in developed countries. Both the personal preferences of the mother and external societal expectations can discourage breastfeeding. Qualitative studies have shown that some women prefer not to breastfeed because they feel it is less convenient than using formula (Raisler 2000). In some instances, women may be unaware of the benefits provided by breast milk that are not available through other sources (Miracle & Fredland, 2007). A survey of the change in attitudes toward breastfeeding in the United States found that people were increasingly likely, in the past decade, to agree that infant formula is as healthy as breast milk (Li, Rock & Grummer-Strawn, 2007).

More commonly, women must return to employment after their maternity leave ends, and they find it difficult to breastfeed while working full- or part-time. Mothers who work outside the home are less likely to initiate breastfeeding, and typically wean more quickly if they do breastfeed, compared with mothers who do not work outside the home (Berger, Hill & Waldfogel, 2005). While in some instances this may be attributed to a personal preference for formula feeding, a lack of lactation support in the workplace also contributes to the problem. A study of women in the United Kingdom found that “mothers were pressured by employers to return to work [before their maternity leave was over]—looking and behaving just as they had before childbirth” (Gatrell, 2007). These employers made little effort to make any real provision for the continuation of the maternal role through breastfeeding. Societal sensitivities to the act of breastfeeding creates a barrier to discussion with employers about lactation in the workplace. Researchers have found that there is a great deal of discomfort about breastfeeding due to “breasts’ sexual connotation in American society” (Kedrowski & Lipscomb, 2007).

The biggest challenge for women who wish to continue breastfeeding after their return to work is finding time to express milk. In the United States, legislation encourages employers to accommodate nursing mothers by permitting break time to breastfeed on-site or to express breast milk, and by providing lactation facilities. Although 23 states have enacted statutes relevant to breastfeeding in the workplace, only 12 of these statutes include any enforcement provision (Murtagh & Moulton, 2011). Suggestions by breastfeeding proponents that women request specific accommodation to pump milk at work seem far too optimistic. Women who are least likely to be able to effectively combine work and breastfeeding are those typically employed in low-income jobs where they may have little say in the organizational policies (Kimbro, 2006). Little real progress has been made toward breastfeeding-friendly workplaces (Rojjanasrirat, 2004).

Evidence shows that mothers who breastfeed their children demonstrate “reduced turnover, absenteeism, and health care costs, . . . fewer absences, fewer absences related to the illness of their children, and shorter absences when their children were ill” (Angeletti, 2009). This may be due to the fact that breastfed children are generally more healthy, and therefore the mother is less likely to require time off to care for a sick child. Even though employers benefit from employing women who breastfeed, a survey found that few employers saw any value in supporting breastfeeding in the work environment (Libbus & Bullock, 2002). Only three states have legislation in place permitting employers to take steps to be designated as “baby-friendly” or “mother-friendly,” and employers that are interested in such designations tend to employ salaried workers in white-collar positions. Unfortunately, low-income women are least likely to initiate breast feeding, least likely to be able to breastfeed or express breast milk at work, and least likely to have health insurance—all factors that eventually lead to increased costs for employers (Murtagh & Moulton, 2011). Information on the long-term cost reduction to employers of allowing breastfeeding or milk expression in the workplace should be made more public and readily available. Both employers and working mothers should be aware of state and federal legislation about lactation in the workplace. This will empower women to take advantage of the medical, emotional, and financial benefits of exclusive breastfeeding by helping them overcome resistance to or ignorance about expressing milk or breastfeeding at work.

Barriers to exclusive breastfeeding exist in other nations, as well. The overall rate of exclusive breastfeeding for at least six months is only 37% in the developing world, and 39% in the least developed countries (UNICEF, 2010). Studies indicate that there are multiple reasons for the low rate of breastfeeding in the international community. Long-standing traditions in diverse cultures discourage exclusive breastfeeding, or even using breast milk as a primary food source, because of cultural beliefs that breast milk is an inadequate nutrition source for infants. A qualitative study found that women in Cameroon initiated mixed feeding almost immediately after birth, partly due to tradition and partly due to the requirement that women work in the field, long distances from their homes—which made breastfeeding just as unfeasible for these women as for employed mothers in Westernized countries (Kakute et al., 2005). A group of mothers surveyed in Langa, South Africa reported no exclusive breastfeeding. Participants in the study indicated that mixed feeding was introduced within an infant’s first month of life, based on a belief that breast milk was an incomplete nutrient (Sibeko, Dhansay, Charlton, Johns & Gray-Donald, 2005). A similar culture belief was found in Tukey, where more than one-third of mothers in a study reported that they stopped breastfeeding before six months because they felt their milk would not provide adequate nutrition (Yesildal et al., 2008). Similarly, reliance on generational wisdom may discourage breastfeeding. Grandmothers in Malawi are likely to give or direct new mothers to give supplementary root infusions to infants based on the belief that breast milk alone would not satisfy an infant’s hunger (Kerr, Dakishoni, Shumba, Msachi & Chirwa, 2008). Vietnamese women supplement breastfeeding with water or formula on the basis of the perceived nutritional insufficiency of breast milk (Almroth, Arts, Quang, Hoa & Williams, 2008). Many cultures, then, are reluctant to promote exclusive breastfeeding at any age, since breast milk on its own is considered inadequate for proper infant growth and development.

It will be difficult to surmount this cultural opposition to exclusive breastfeeding, despite research that supports the claim that exclusive breastfeeding significantly benefits the health of both the mother and baby and that breast milk is a complete nutrient for an infant’s first six months of life. Health workers must proceed cautiously in trying to combat years of tradition that discourage exclusive breastfeeding. Informing women of the advantages of breast milk requires sensitivity to cultural norms and practices. The effort to overcome these barriers to breastfeeding should focus on education for women.

Even where cultural barriers to exclusive breastfeeding are not as strong, there may still be other issues preventing the practice. Because an HIV-positive mother can transmit the virus to her infant through breast milk, health experts have debated the risks involved with breastfeeding (Coutsoudis, 2005). A randomized study in Kenya found that the HIV transmission rate through breastfeeding is 16.2% by age two years (Nduati et al., 2000). Early research on the possibility of HIV transmission through breast milk motivated many health care organizations to urge HIV-positive mothers not to breastfeed their infants (Hankins, 2000). However, the risks of formula-feeding may outweigh the risk of transmitting HIV through breast milk. A study in Botswana showed that non-breastfed babies were at a higher risk for a variety of communicable diseases because formula or other alternative foods were prepared with unsanitary, contaminated water (Arvelo et al., 2010). United Nations guidelines now “recommend exclusive breastfeeding for HIV-infected women for the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe . . . before that time” (UNICEF, 2009). In developed nations, these criteria can be met with relative ease; however, in resource-scarce nations, formula feeding is often not an option. Easy contamination of formula and other foods increases the risk of disease—and this risk of contamination is substantially higher than the risk of HIV-positive mothers transmitting the virus to their children via breast milk (Kuhn, Stein & Susser, 2004). Yet the information disseminated to women on the risks of formula-feeding versus breastfeeding is often conflicting or unclear, particularly as the research in this area is still new. Mothers may face the choice between higher risk of disease and higher risk of HIV transmission without being fully informed about either alternative.

Where possible, exclusive breastfeeding is the most favorable feeding method. In an infant’s first months it leads to short- and long-term health benefits. Women who breastfeed also experience a variety of health benefits. However, worldwide rates of exclusive breastfeeding rates are extremely low. For many women, a lack of reliable information prevents the practice. In the United States, there is a growing belief that infant formula provides the same nutrients and benefits as breast milk. Cultures across the globe recommend early mixed feeding to supplement breast milk, which is perceived as insufficient for proper infant growth. Education would help these women, as well as women in HIV-stricken countries who have received conflicting information on the risks and benefits of breastfeeding for HIV-positive mothers.

Where there is already a large body of knowledge in developed nations on the advantages of breastfeeding, addressing lactation in the workplace will enable women to initiate and continue breastfeeding even while they are working part- or full-time. Additional research on the effects of breastfeeding-friendly workplaces would aid breastfeeding proponents in recommending further legislation to encourage or require employers to accommodate lactating mothers. For all women who face barriers to exclusive breastfeeding, as well as for their families and employers, research and education will help address these challenges, providing a better life experience for mothers and a better future for their children.