Breast-Feeding Practices, Policies, and Politics in a Global Context

Karen M Kedrowski & Michael E Lipscomb. Women and Politics around the World: A Comparative History and Survey. Editor: Joyce Gelb & Marian Lief Palley. Volume 1: Issues. Santa Barbara, CA: ABC-CLIO, 2009.

Like all mammal species, human females engage in the biological production of milk to nourish their infants. Babies have a suckling instinct, and breast-feeding is a basic human capability. Yet the act of breast-feeding has led to cultural practices that vary from one culture to the next. In recent decades, with the development of commercially manufactured infant formulas, increased understanding of the health benefits of breast-feeding, and women’s entrance into the paid workforce, breast-feeding has become a controversial issue in many parts of the world. This essay is a brief summary of the international political and cultural issues that confront breast-feeding women and their infants worldwide.

Breast-Feeding: Biology and Practice

Breast-feeding advocates and medical experts agree that, in the vast majority of cases, breast milk provides myriad health benefits to infants, especially during the first months of life. Infants who are fed breast milk are at lower risk of developing a wide variety of ailments, including asthma, allergies, eczema, inner ear infections, intestinal infections, diarrhea, respiratory tract infections, diabetes, Crohn’s disease, and some forms of cancer. If they do become sick, breast-fed babies are considered likely to develop less severe illnesses. Mothers also receive health benefits from breastfeeding, including a faster return to prepregnancy weight, suppressed ovulation, and decreased risk of developing ovarian cancer, osteoporosis, and premenopausal breast cancer (Gartner and Eidelman 2005). In addition, such breast-feeding advocates as La Leche League International claim that the act of breast-feeding creates a close bond between mother and infant that contributes to their psychological well-being.

In the developing world, where supplies of clean water are scarce and commercial formula is very expensive, breast-feeding is literally lifesaving. In many developing countries, diarrhea is one of the leading causes of infant mortality. Many of these cases occur because infants are fed formula mixed with unclean water. The United Nations Children’s Fund (UNICEF) estimates that if all mothers exclusively breast-fed their babies for the first six months, some 1.6 million infant deaths worldwide would be prevented each year (UNICEF n.d.a).

Recognizing the importance of breast milk to infant and maternal health, the American Academy of Pediatrics recommends that infants be exclusively breast-fed for the first 6 months of life, breast-fed in part for at least 12 months, and that breastfeeding continue as long as desired by both mother and child (Gartner and Eidelman 2005). The World Health Organization’s (WHO) recommendation goes even further: it recommends exclusive breast-feeding for the first six months and continued breastfeeding through the child’s second year (WHO 2002, 56).

Breast-Feeding Rates Worldwide

Human infants have been breast-fed for the vast majority of human history. However, the biological function of lactation and the act of suckling became entwined with cultural meanings over time, and these cultural meanings vary from region to region. Some societies have introduced complementary and substitute foods, often based on local religious and social practices, whereas others have maintained breast-feeding to a greater degree. In general, though, breast-feeding rates have declined worldwide since the early part of the 20th century. Experts believe social and economic changes help account for the decline. One possible explanation is that greater numbers of women around the world have moved into paid employment outside the home, where the conflicting demands of breast-feeding and working create problems. Second, experts point to hospital practices that include the feeding of formula or a sugar solution to newborns immediately after birth, which can interfere with the establishment of the breastfeeding instinct; the distribution of formula samples by hospital personnel, sometimes accompanied by literature that describes breast-feeding as difficult; and a lack of support from health care workers. Third, experts note that in some regions of the world, women associate bottle-feeding with “modern” or “scientific” parenting practices. Moreover, in developing countries, women who have attained higher levels of education or who live in urban areas are less likely to breast-feed than women with less extensive education or those who live in rural areas (Wilmoth and Elder 1995).

Consequently, breast-feeding rates vary by region. Countries in Western Europe have breast-feeding initiation rates of 70-90 percent, and 15-30 percent of infants in the region are exclusively breast-fed at six months (the primary exception to this pattern is Ireland, which has a breast-feeding initiation rate of only 30-50 percent). Breast-feeding rates are similar in Australia, New Zealand, and some parts of the United States (LLLI Center for Breast-feeding Information 2003; U.S. Department of Health and Human Services 2007). Although breast-feeding is nearly universal immediately after birth in other regions of the world, exclusive breast-feeding for six months is less common. For instance, only about 20 percent of all mothers in western and central Africa and the states of the former Soviet Union were exclusively breastfeeding at six months in 2004. Rates of exclusive breast-feeding at six months were higher in the Middle East and North Africa (29 percent), South Asia (38 percent), eastern and southern Africa (41 percent), and East Asia and the Pacific region (43 percent). These data do not include statistics for Latin America and the Caribbean, although UNICEF reports in another document that 38 percent of infants were exclusively breast-fed in this region in 2000 (see UNICEF 2001).

The Nestlé Boycott and International Responses

For a variety of reasons, babies have long been fed a combination of milk, cereals, teas, and other foods in addition to, or as a substitute for, breast milk. The first commercially manufactured infant formula was invented in 1867 by Henri Nestlé, the founder of the Switzerland-based Nestlé Corporation. He claimed this food saved the life of a neighbor’s child (Nestlé n.d.), but medical professionals have long observed that infants who are not fed breast milk have a higher mortality rate than those who are breast-fed (Baumslag and Michels 1995). As early as 1900, a Chicago public health campaign encouraged mothers to breast-feed using the slogan, “Don’t Kill Your Baby!” (Wolf 2003). However, the dangers posed by artificial baby foods waned with the widespread adoption of the pasteurization process, water treatment, and sewer systems in many developed countries. These advances provided bacteria-free milk and a plentiful supply of safe, clean water that could be used to mix formulas.

By 1970, these developments had led to a worldwide drop in breast-feeding rates, and Nestlé had become a major manufacturer of infant formula sold in the developing world. That year, physicians working in the developing world alerted the United Nations about rising rates of infant death and malnutrition among formula-fed infants. In 1977, in response to growing international concern, the U.S.-based Infant Formula Action Coalition (INFACT) initiated a boycott against the Nestlé Corporation (Baby Milk Action n.d.). INFACT charged that Nestlé’s aggressive marketing practices in the developing world led women to use infant formula rather than breast-feed their babies. These marketing practices included extensive use of advertising through mass media, distribution of formula in hospitals, and the use of “milk nurses,” who were hired to sell formula on commission and visited mothers in hospital maternity wards wearing nurses’ uniforms, which was meant to convey the medical and scientific validity of formula (Post 1985).

Once a woman begins to use infant formula, she will eventually be unable to produce breast milk to feed her baby—the capacity to breast-feed is a “use it or lose it” proposition. Infant formula is expensive, though, and mothers would often overdilute the formula to make it last longer, or feed their infants cow’s milk, or use corn starch or other “milky looking” substitutes instead of formula. As a result, many infants became severely malnourished. Moreover, clean water is in short supply in many regions of the world, and formula mixed with contaminated water or placed in bottles that were not cleaned sufficiently caused diarrhea (Post 1985).

The boycott received a boost in 1978 when U.S. senator Edward Kennedy (D-MA) held Senate hearings on the marketing practices used by Nestlé and other infant formula manufacturers in the developing world. In 1981, the WHO adopted the International Code of Marketing of Breast-milk Substitutes by a final vote of 118-1, with three abstentions (WHO 1981). The Code includes several recommendations and restrictions, including resolutions to instruct health care workers to promote breastfeeding and clearly state the hazards associated with use of formula, ban the distribution of free formula samples to new mothers, ban the use of aggressive marketing practices, prohibit the use of milk nurses, and forbid formula company salespersons from providing instruction on infant care to new mothers. Several countries acted immediately to implement the provisions of the Code, and formula companies came under significant pressure to conform to these international standards.

In 1990, the United Nations drafted and passed the Innocenti Declaration. This declaration restates the WHO’s recommendation for breast-feeding duration, and calls on member countries to promote a “breast-feeding culture” rather than a “bottle-feeding culture.” Specific recommended actions of the Innocenti Declaration include the creation in member countries of national committees that can bring government agencies together to coordinate their breast-feeding promotion efforts, full implementation of the International Code of Marketing of Breast-milk Substitutes, passage of legislation promoting breast-feeding rights, collection of data and monitoring of national breastfeeding trends, and promotion of the Baby-Friendly Hospital Initiative (BFHI) (UNICEF 1990). The BFHI, launched by UNICEF and WHO in 1991, articulates 10 steps hospitals can take to earn a baby-friendly designation. These include allowing women to initiate breast-feeding within a half hour of birth, rooming the child with the mother as soon as possible, not feeding babies formula or water, not using pacifiers, properly training staff, and providing support to breast-feeding mothers. According to UNICEF, some 15,000 hospitals in 134 countries have earned baby-friendly status since 1991 (UNICEF n.d.b).

At its height, the Nestlé boycott was managed by the International Baby Food Action Network and included 35 organizations working across 10 countries. The boycott was suspended in 1984, after Nestlé agreed to change its marketing practices (Fox 1984; Allain 1991; Baby Milk Action n.d.). Though rates of breast-feeding initiation and duration are now increasing worldwide, problems remain. Breast-feeding advocates charge that some formula manufacturers violate the provisions of the International Code of Marketing of Breast-milk Substitutes or look for loopholes to exploit. In 1988, the Nestlé boycott was resumed on these grounds. Nestlé denies that it violates any provisions of the Code and supports its implementation worldwide. The company also trains staff to ensure that the Code’s practices are followed (Dillner 1993; Drotz 2004; Moorhead 2007).

Breast-Feeding in the Context of Employment and Human Rights

As noted earlier, the Innocenti Declaration emphasized the creation of a viable breastfeeding culture. Creating such a culture entails recognizing the physiological realities of breast-feeding and thinking about how those realities might be accommodated within the structure of various types of employment. Breast-feeding is an intensive activity, one that requires close proximity between mother and child and frequent nursing or expression of milk to maintain the mother’s milk supply. Simultaneously balancing the biological demands of breast-feeding and the time and activity demands of paid employment is difficult for many women. Some workplaces are not safe for children, and mechanical milk expression methods can be expensive, requiring the purchase of a pump and bottles to store the milk in. It can also be difficult to find a suitably cool location to keep the milk. Consequently, one of the predictors of how long a woman breast-feeds is the length of maternity leave available to her (Berger, Hill, and Waldfogel 2005; Fein and Roe 1998; Galtry 1997, 2003).

According to the International Labour Organization (ILO), a branch of the United Nations, 152 countries have enacted some form of maternity leave mandate. The duration of these leaves varies dramatically by country. Tunisia guarantees the shortest leave—30 days—whereas Australia allows 52 weeks. In 29 countries, maternity leave is less than the 12-week standard recommended by the ILO (ILO 1999; WABA 2006). In most countries, maternity leave is paid for by some combination of funds provided by the government, the employer, or other organizations. In three countries, the law guarantees only unpaid leave—Lesotho, the United States, and Australia. In the United States, however, some employers provide paid leave voluntarily. Although some countries provide pay for maternity leave that is equal to the mother’s earnings before taking leave, many countries pay less. According to the ILO, most mothers do not receive full replacement salary during their leave period (ILO 1999).

Another policy some countries have enacted to lengthen breast-feeding duration is to provide break time for mothers to nurse or express milk. According to the World Alliance for Breast-Feeding Action (WABA), 119 countries allow mothers to take breast-feeding breaks during the work period, and in 109 countries, this break time is paid. Most of these countries allow women to pump or nurse for 60 minutes each day. Some countries limit these breaks to a period of one year or 18 months; in other countries, the benefit is open ended (WABA 2006).

Of course, any claims to expand or implement paid maternity leave practices and paid breast-feeding breaks in the workplace will have more traction if these policies can be tied more generally to the language of rights. George Kent of the University of Hawaii has argued that breast-feeding should be considered an essential human right, based on the human right to have adequate food. Because children are a particularly vulnerable population, Kent argues that human rights advocates should frame the issue as one of state interference with the right of children to engage in natural, healthy feeding practices (Kent 2006). The United Nations agrees with this logic and promotes breast-feeding as part of its larger efforts to provide for children’s health and security (UNICEF 1998).

In some countries, the discussion of breast-feeding rights has centered on the human rights of the child, but in the United States the right has been articulated as the mother’s right to breast-feed. This right is protected at the national level if a woman is breast-feeding on federal property. A mother’s right to breast-feed is usually also protected by state level legislation, although some of these protections are weak. However, fully exercising these rights is problematic. Many women have encountered social pressure to not breast-feed in public or at the workplace, and U.S. courts have often ruled against mothers when confronted with cases involving breast-feeding (Kedrowski and Lipscomb 2007).

Breast-Feeding Advocacy: La Leche League and Her Sisters

WHO, UNICEF, and other public health agencies want to increase breast-feeding rates worldwide. These groups believe breast-feeding is crucial to infant, child, and maternal health. They are joined in these efforts by a wide array of advocacy groups that promote breast-feeding practices across a wide range of local contexts. Some advocacy groups work to promote breast-feeding in developed, postindustrial countries, where breast-feeding is most profoundly affected by the mother’s employment circumstances. Other groups promote breast-feeding in developing nations, where the ability to breast-feed, and sometimes the decision on whether or not to breast-feed, is often a matter of life and death. Some of the most important advocacy groups include the International Lactation Consultant Association, a worldwide network of lactation professionals whose “mission is to advance the profession of lactation consulting worldwide through leadership, advocacy, professional development, and research” (International Lactation Consultant Association n.d.); the World Alliance for Breast-Feeding Action (WABA), which seeks to coordinate the activities of anyone “committed to a breastfeeding culture,” including “non-governmental organizations, community activists, health care workers, professional associations, university teaching staff, researchers, health officials and others” (WABA n.d.); and Well Start International, which seeks “to advance the knowledge, skills, and ability of health care providers regarding the promotion, protection, and support of optimal infant and maternal health and nutrition from conception through the completion of weaning” (Well Start International n.d.).

Another notable group is La Leche League, which was formed in 1957 by seven Roman Catholic women in Chicago, Illinois. By 2001, the group had grown into a major international organization (now known as La Leche League International, or LLLI), channeling breast-feeding information to 750,000 American mothers every year and serving an additional 240,000 people a year worldwide (Bobel 2001). Translated into eight languages (including Braille), the LLLI publication The Womanly Art of Breastfeeding now has a worldwide circulation exceeding 2.5 million copies (Bobel 2001, 131). The rise of LLLI illustrates the broad strategies of appeal that characterize the rhetoric of advocacy in the developed world.

LLLI’s success is partly based on appeals to the scientifically demonstrable health benefits of breast-feeding that accrue to both mothers and children, but the group also emphasizes the importance of the intimate, bonding contact that develops between breast-feeding mothers and their children (which ideally occurs with the support of a caring husband and father). Incorporating elements of modern medical science, the second wave of feminism, and the traditions of the Roman Catholic Church (Ward 2000, 3), LLLI and the worldwide breast-feeding advocacy movement have been successful at promoting breast-feeding as one part of a larger set of lifestyle concerns represented by the natural mothering and attachment parenting movements (Karen 1994). These movements, emerging in the late 1960s, emphasized the bond between mother and child as a better, more natural, alternative to the antiseptic, distancing regimens of scientific mothering organized around bottle feeding, feeding schedules, and the expertise of male practitioners. The attached parenting movement, as articulated by advocates such as William and Martha Sears, suggests that mothers cultivate this bond by carrying their babies close to their bodies in baby slings, by sleeping with their babies, and, of course, by breast-feeding (Bobel 2001; Kedrowski and Lipscomb 2008).

Yet such idealized depictions of motherhood have sometimes been criticized from a feminist perspective, despite their value as a corrective to predominant medical models of scientific mothering. Opponents assert that the “traditional heterosexual family structure, replete with economic support from the male spouse and idealized financial dependence on the part of the mother” (Hausman 2003, 14) that is assumed by many of these advocates masks the different kinds of choices available to women in other situations. Some women have economic support, and are potentially free from certain kinds of work, allowing them the choice of intensive breast-feeding, but not all mothers have this kind of support. Also, a wholesale embrace of the male-led family and the dictates of traditional mothering may not be consonant with feminist demands for independence across all spheres of life (Bobel 2001).

Such a critical feminist perspective signals concern about the marginalization of women who make reasonable or necessary choices not to breast-feed. Particularly in differing global contexts, the conclusion that “breast is best” is not always as straightforward as it appears. Women might legitimately choose not to breast-feed because of a variety of physiological challenges, including cracked nipples, abscesses, and breast lesions; such environmental factors as the contamination of milk by pollutants or drugs; or economic realities like career or work obligations. The increasingly common notion that those who breast-feed are good mothers and those who do not are negligent or selfish runs the risk of stigmatizing women who choose not to breast-feed. The amount of time a woman is able to take off from work is the best predictor of how long she will breast-feed, so it is very important to note that not all women have an equal choice to breast-feed. Even though breast-feeding is, in most cases, the healthiest method of infant feeding, other situations and choices can limit the feasibility of breast-feeding for some women.

Current Challenges: Environmental Contamination and HIV/AIDS

The question of whether breast-feeding is appropriate is particularly vexing in light of growing concerns about environmental pollutants and HIV infection. On the one hand, both of these circumstances seem to make breast-feeding problematic. On the other hand, total commitment to the ethos of mothering championed by the natural mothering movement could be threatened by some of the implications of women’s broader struggles for environmental and social justice (for a classic statement of the environmental justice ethos, see Bullard 2000).

Environmental pollutants contaminate mothers’ breast milk and can be passed along to their children. Most of these pollutants, including polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers, are industrial chemicals that are stored in human fatty tissue. In heavily industrialized countries, concerns have been raised about the links between contaminated breast milk and damage to breast-feeding infants. One study suggests that PCBs passed along in breast milk may lead to neuropsychological problems in later childhood (Bailey 2004). The women and children who continue to ingest these toxins rarely have knowledge of the toxicity levels and their effects or do not have the means to prevent their ingestion. Poorer women, and thus a disproportionate number of women from ethnic minority groups, are more likely to be exposed to these toxins. These issues link the struggle for breast-feeding rights to the struggle for environmental justice.

At first glance, the connection between breast-feeding and environmental protection seems obvious—breast-feeding women should want an environment that does not pollute the breast milk they are feeding their children—but many breast-feeding advocates have been wary of endorsing or emphasizing the link (Boswell-Penc 2006, 6-7). Faced with what they perceive as a medical and cultural atmosphere that remains hostile to breast-feeding, these advocates fear that talk about toxins in breast milk could discourage women from breast-feeding. Such breast-feeding advocates argue that in almost all cases where toxins are present in breast milk, the health benefits of breastfeeding still outweigh the negative impacts of the toxins (LLLI 2003).

Similarly, there is division among breast-feeding advocates about how to reconcile their support for breast-feeding with the challenges presented by the global HIV/AIDS crisis. More than 38 million people worldwide are infected with HIV (UNAIDS 2006, 8), and about half of those infected are women (UNAIDS n.d.). Sub-Saharan Africa has been hit particularly hard—24.5 million adults and children in that region are infected with the virus. In 2004, 12.7 million women had been infected; by 2006, that number had risen to 13.2 million (UNAIDS 2006, 15).

Throughout Sub-Saharan Africa, infection rates between 10 percent and 30 percent are commonly reported for young, pregnant women, and in several places the rate of infection among pregnant women is much higher. In Swaziland and Caprivi, Namibia, for example, a staggering 42 percent infection rate has been observed among pregnant women (UNAIDS 2006, 18). Although the rate of HIV infection among young, pregnant women seems to be declining in many nations, the data remain troubling. Botswana saw a recent decline in the percentage of infected pregnant women, but 34 percent of the pregnant female population was HIV positive in 2005; in South Africa, an infection rate of 33 percent among women attending prenatal clinics has recently been noted (UNAIDS 2006, 17).

Research accepted by most of the medical community indicates that HIV-infected women who breast-feed double the risk of infecting their children with the virus. The estimated risk of transmitting HIV “by an infected mother occurring before or during birth (without interventions to reduce transmission) is 15-25%. Breastfeeding by an infected mother increases the risk by 5-20% to a total of 20-45%” (WHO 2004). This finding has created a dilemma for breast-feeding advocates, particularly those in developing countries where unsafe and unreliable water supplies make breast-feeding particularly important for children’s development. Discouraging breast-feeding and promoting formula use in such places in order to curb the spread of this devastating virus could put children at risk of malnutrition or death from diarrhea (White 1999). Some breast-feeding advocates therefore argue that children of HIV-infected women should breast-feed, as their children may live longer before developing AIDS than they will if they develop diarrhea. This quandary is further complicated by findings suggesting that exclusively breast-fed babies are less likely to be infected with HIV than children whose feeding has been supplemented with other foods. The WHO has argued that infected breast-feeding women should breast-feed “exclusively for the first six months of an infant’s life unless replacement feeding, like cow’s milk, is acceptable, feasible, affordable, sustainable, and safe for both mother and infant before the end of the six-month period. The mother’s decision should be based on her circumstances” (Altman 2007).

The scientific evidence today clearly suggests that in most circumstances breastfeeding is the optimal form of infant feeding. As the cases of environmental toxins and HIV infection suggest, however, the contexts in which infant feeding occurs are not always equal, and these unequal circumstances must be addressed by scientists, advocates, and politicians if the possibilities of breast-feeding are to be available to all women. Though the body of legal precedent in the United States clearly indicates that the right to breast-feed is considered a right of the mother to choose how best to feed her child, Kent’s call for recasting the demand for breast-feeding rights as a child’s right to receive the optimal feeding option points to a possible way forward. Feminists may worry about the ways in which a strategy that gives legal status to children uneasily coalesces with the logic of antiabortion laws and rhetoric, but few will deny that the interests of children are at stake, given the scientific consensus on the benefits of breast-feeding. Advocates will continue to work within this framework to give all women the option to breast-feed their children.