Social influences upon breastfeeding Dr Amy Brown Overview

Social influences upon breastfeeding Dr Amy Brown

Overview • How others affect breastfeeding • Grandmothers • Fathers / partners • General public

We are a product of those around us Attitudes Knowledge Persuasion Criticism Ability to help Setting of normal behavior

She can’t be getting enough if she’s feeding again! Have you tied just not feeding her? It’s because you insist on breastfeeding her STILL Your milk must be skimmed! Just ignore her, she can’t be hungry at night ROD FOR YOUR OWN BACK! Of course she’s going to keep waking at night if you offer it to her!

Knowledge Attitudes Confidence Self efficacy Empowerment

Grandmothers One of the biggest influences on whether a mother breastfeeds is whether she was herself breastfed… especially if she knows how long for

Grandmothers – when it goes right • Able to help – knowledge and experience • Provide positive environment • Mothers really value practical and emotional support - want to feel their decision is accepted and supported Ekström A, Widström AM, Nissen E. Breastfeeding support from partners and grandmothers: perceptions of Swedish women. Birth. 2003 Dec 1; 30(4): 261 -6.

History of infant feeding • Infant formula milk first introduced at end of 19 th century … breastfeeding rates gradually dropped, especially with growth of advertising • In the UK… 1975: 51% initiation (15% at 3 months) 1990: 62% initiation (30% at 3 months) 2010: 81% initiation (40% at 3 months)

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Grandmothers – when it goes wrong • Unable to help or help in ‘wrong’ way • Difficult emotions • Deliberate sabotage Grassley J, Eschiti V. Grandmother breastfeeding support: what do mothers need and want? . Birth. 2008 Dec 1; 35(4): 329 -35. • Cultural traditions Kerr RB, Dakishoni L, Shumba L, Msachi R, Chirwa M. “We grandmothers know plenty”: breastfeeding, complementary feeding and the multifaceted role of grandmothers in Malawi. Social science & medicine. 2008 Mar 31; 66(5): 1095 -105. • One intervention to support younger mothers with breastfeeding only worked if the mother was living away from home Bica OC, Giugliani ER. Influence of counseling sessions on the prevalence of breastfeeding in the first year of life: a randomized clinical trial with adolescent mothers and grandmothers. Birth. 2014 Mar 1; 41(1): 39 -45.

A Grandmother’s tea? • Aim: to (re) educate daughters and their mothers together http: //www. illinoisbreastfeeding. org/21401/21464. html • Increased knowledge but unfortunately not attitudes or breastfeeding rates https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 340024 6/

Fathers & partners

Importance of support • A supportive partner is predictive of intention, initiation and duration • Mothers whose partner supports them feel empowered, confident and competent • Fathers most likely to support if they grew up around breastfeeding Tohotoa J, Maycock B, Hauck YL, Howat P, Burns S, Binns CW. Dads make a difference: an exploratory study of paternal support for breastfeeding in Perth, Western Australia. International breastfeeding journal. 2009 Nov 29; 4(1): 15.

Brown A, Davies R. Fathers' experiences of supporting breastfeeding: challenges for breastfeeding promotion and education. Maternal & child nutrition. 2014 Oct 1; 10(4): 510 -26. • 117 men • Baby 0 – 2 years • Partner had initiated breastfeeding

‘I really hoped ***** (name of partner) would breastfeed as I’d heard so much good stuff about it. Breast is best’ ‘Let’s see…getting up in the night versus making supportive noises and going back to sleep? No competition!!’ ‘I hadn’t thought about it much until she was pregnant but then reading about it I was very positive’ ‘Breastmilk is free … both my wallet and I wanted her to choose it!’

‘I’d heard from friends that their wives struggled and it hurt and was really difficult. I didn’t want her to do that’ ‘I didn’t see much difference between formula and breast milk. My friends had bottle- fed and they seemed fine. But she really wanted to and I’m glad she did’ ‘I’d heard from friends that their wives struggled and it hurt and was really difficult. I didn’t want her to do that’ I didn’t feel strongly either way. However my wife wanted to breastfeed and everyone else told her to so she did … I didn’t see how I could tell her what to do’

‘When I said to a nurse I felt helpless she said enjoy the break and laughed like it was nothing to do with me. ’ ‘It is really hard to see someone you love struggling and not to be able to do anything’ ‘I was jealous at some points. He seemed to enjoy feeding. He either slept or cried the rest of the time but feeding was the happy bit. I couldn’t do that. ’ I did worry about how much he felt and used to say to my wife, is he meant to be feeding again? ‘At first I freaked out about her feeding in front of people. I couldn’t stop thinking that she had her breast out in front of my father or my friends and that they were getting an eyeful. Thankfully I grew up though and realized you couldn’t really see anything and it was better than the screaming!’ ‘He kept crying. All he wanted was feeding. Not much I could do which made me feel rubbish. ’

Lack of information ‘I don’t recall breastfeeding ever being discussed in front of me’ ‘There was a leaflet that the midwife gave my wife. There were some posters up too in the doctors. ’ ‘I went to all the antenatal classes with her, but when it came to the breastfeeding session, we were all sent down the pub, with a wink, for a male bonding session. I could really have done with staying. ’

Or insulting information … ‘There was this poster up in the ward apparently trying to promote breastfeeding which told dads it was a good thing because they would get more sleep. It was awful – not all dads are lazy and uninvolved which is what I felt it was implying. I wanted to help. ’ ‘One midwife actually told me in front of my wife that breastfeeding was a good thing as it would make her breasts bigger. I’m not that shallow’

Health Professionals

‘I asked for help picking him up and latching him on as I was still so sore and I swear she rolled her eyes at me. She handled me quite roughly, latching him on for me, said there you go and walked off. I felt such a nuisance’ Versus ‘I couldn’t have done it without my midwife. She sat with me and helped me work out just what wasn’t quite right. She didn’t stop trying until he latched on beautifully, all the while making me feel like she had nothing else to do, even though I knew she was so busy’

What do mums want from professionals? • Continuity of care • Time: ‘Touching base’ (Dykes, 2005) • Empathy, affirmation, reassurance • Information • To be seen as a real person • Not ‘just’ a mother • To have their own needs considered Graffy J, Taylor J. What information, advice, and support do women want with breastfeeding? . Birth. 2005 Sep 1; 32(3): 17986.

‘I simply couldn’t have done it without her. She was my absolute rock. I must have called her over 10, 20 times when I was in hospital and every time she took the time to sit with me and reassure me. One time there was a bit of a lull in activity and she just sat with me watching him feed, reassuring me and telling me what a brilliant job I was doing. We chatted about what I would do when I got home and she told me about a great peer support group and a community midwife who would be able to help me. She made sure I felt confident in what I was doing and we talked about my fears for a bit. She didn’t have to do that. She could have had a well deserved break but she chose to give me that time. I will be forever grateful. ’

What support do midwives like to give? • Skilled companion Or • Technical expert Tend to have a preference Burns E, Fenwick J, Sheehan A, Schmied V. Mining for liquid gold: midwifery language and practices associated with early breastfeeding support. Maternal & child nutrition. 2013 Jan 1; 9(1): 57 -73.

Approaches that don’t work … • Insistence • Seeing the milk rather than the mother • Need to take into account circumstances • A higher proportion of mothers are more worried about telling their health professional they are not BF than concerned about the health impact for their baby. Lee E. Health, morality, and infant feeding: British mothers’ experiences of formula milk use in the early weeks. Sociology of health & illness. 2007 Nov 1; 29(7): 1075 -90.

‘Imagine a young man making his first attempt at sexual penetration. Ask him to set about the project in a special sex centre where there are ‘experts’ he has never met before, ready to supervise and tell him how it ought to be done. Presume that his partner is as inexperienced as himself, and that he is asked if he is going to ‘try and achieve an erection’. When he starts, a busy ‘expert’, who may never have personally experienced sexual relations, starts telling him how to do it and inspects his body with a critical expression, prodding him and his partner in an insensitive manner. By the bed is an artificial penis, put there, as the young man is told, ‘just in case you can’t manage it; many men can’t make it. It’s not their fault, nature often fails’. Everyone knows how vulnerable the male penis is to psychological stress, and how sensitive sexual partners must be in order to nurture the psyche, as well as the body, of the male. Yet such sensitivity has been conspicuously absent from the experience of most women giving birth in hospital’ Gabrielle Palmer, Politics of Breastfeeding

Barriers for midwives • • Time Staffing Priorities Resources Bottle as solution? However • • • Lack of training Some don’t believe Disagree with ‘new’ research See role to protect new mum Don’t want to pressurize

Midwives own experiences 'One midwife actually told me that although she would never say it in front of anyone else that she didn’t believe in promoting breastfeeding and thought it made no difference but she had to tell new mothers about it anway. She told me her babies had been formula fed and they were fine so not to worry about it. I was about to stop breastfeeding anyway at this point but even I was open mouthed at that one!’ • Whether a midwife has breastfed her baby, and her experience, can influence how she goes on to care for new mothers. • Those who have never had a baby of their own can be the most dogmatic • The most supportive midwives tend to be the ones who have had positive experiences of breastfeeding their own babies, or those who have been affected by negative experiences and want to help other mothers.

Public attitudes http: //www. cell. com/trends/molecular-medicine/pdf/S 1471 -4914(14)00201 -9. pdf

We think its best… • 1% of participants in a UK survey believed formula milk was a better choice than breastfeeding • In the USA, the annual Health Styles survey found that over 96% of respondents believed that breast milk was the perfect food for a baby • A global survey of mothers in nine countries including Europe, China and the USA found over 98% agreed that ‘breast is best’

… but we don’t want to see it • A You. Gov survey in the UK found that 34% of the public agreed women breastfeeding in public was embarrassing for others and should not be done. • USA [57%], Australia [30%] and France [44%]. • In Australia 82% believed that formula feeding was more acceptable than breastfeeding in public. • In the UK more people believe it is acceptable for a woman to breastfeed in a toilet than it is in a restaurant or on public transport. • Sweden = 4% !!

Can’t you feed him before you come out? I’m not allowed to flash my penis in public! You can feed in the toilet! I don’t urinate in public I don’t want to see naked breasts when drinking my coffee! Exhibitionism! You’re trying to get the attention of my husband!

A thought… Why is it called breastfeeding in public? Why not simply a baby eating? Why do we make it about the actions of women? To allow us to criticise?

Nigel Farage (MP) ‘I’m not particularly bothered about it, but I know a lot of people do feel very uncomfortable, and look, this is just a matter of common sense, isn’t it? I think that, given that some people feel very embarrassed by it, it isn’t too difficult to breastfeed a baby in a way that’s not openly ostentatious… it’s not an issue that I get terribly hung up about, but I know particularly people of the older generation feel awkward and embarrassed by it. ” https: //www. theguardian. com/politics/2014/dec/05/nigel-farageukip-claridges-breastfeeding-mothers

College students most critical • 80% of college students in Canada believed breastfeeding was an intimate act that should be private • In another study 65% believed that breastfeeding in public was not acceptable. • 91% of a US student sample believed that the US should promote a breastfeeding friendly culture whilst 78% believed breastfeeding should only take place in private. Spear HJ. College students’ experiences and attitudes regarding middle and high school–based breastfeeding education. The Journal of School Nursing. 2007 Oct; 23(5): 276 -82.

Women are more critical than men • In a global survey, agreement of mothers that ‘breastfeeding in public was perfectly natural’ • 63% UK • 57% US • 55% Brazil • 35% France • 19% China https: //www. lansinoh. co. uk/blog/breastfeeding-survey-results-2015

Sexualisation and sexism • In a US study, only 48% of men felt it was appropriate to show a woman breastfeeding on a magazine cover, 37% on a billboard or poster and 46% on a family television show. • The higher a man scores on traits of sexism, the less likely he is to support breastfeeding in public • Page 3 (UK) ‘An institution that has been there for more than 40 years …Britain’s most valued heritage … the freedom to choose’ Acker M. Breast is best… but not everywhere: ambivalent sexism and attitudes toward private and public breastfeeding. Sex roles. 2009 Oct 1; 61(7 -8): 476 -90.

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Contamination? • In one survey of UK Sunday Times readers 65% believed it was acceptable to breastfeed her baby by the side of the pool … yet 64% believed it unacceptable to breastfeed whilst sat in the pool. • Concept of bodily fluids – often associated with illness (or even seen as sexual fluids) • Squeamish about human milk but not cows milk? ! Shildrick M. Leaky bodies and boundaries: Feminism, postmodernism and (bio) ethics. Routledge; 2015 Dec 22.

Does this affect women? In 2009 a survey of over 1200 mothers in the UK by Mother and Baby Magazine found that: • 60% of mothers felt that the UK was not breastfeeding friendly • 65% found breastfeeding in public a stressful experience • 54% had directly received negative comments or actions.

How women feel matters • Perceiving breastfeeding in public to be embarrassing or threatening predicts a lower intention and likelihood of breastfeeding • Fear it might happen • Feelings of disapproval • Worry about being confronted • Anxiety can make it more difficult • Ties in with body image issues • Trying to delay feeds impacts upon supply

How many do so? • Only 58% of mothers who breastfeed in the UK did so in public • Only 36% of Italian women breastfeeding women do so in public • Only 8% of mothers in UK felt comfortable breastfeeding wherever they wanted. • In Sweden nearly 80% of mothers with a baby aged 6 weeks old had breastfed in a public place

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