Rebuilding breastfeedingcultures in East Asia

Presentation for iLactationTed Greiner

Professor of NutritionHanyang UniversitySeoul, South Korea

Table of contents

First I will focus on doing a situation analysis : What’s actually going on? What do people THINK is going on? (norms) What resources are available

Then I will examine issues related to developing a strategy, particularly the use of force fields

Next I will enumerate the 4 components of a strategy, describing one in detail (normalization)

Table of Contents

Next I go through 4 breastfeeding behaviors that we could choose to work on

For each one, I give some detail on some of the campaign components that are needed/useful, particularly focusing on the support component

Some of what I mention for one behavior will of course work for the others as well

Finally, I discuss some issues of specific relevance to East Asia

Rebuilding a breastfeeding culture

This is really the only way to get breastfeeding back to high levels in society because breastfeeding is too complex and the culture supporting it is too damaged for single-component breastfeeding promotion programs to achieve very much

So achieving such a huge change should be our long term goal, which means we should give some attention to what would be involved in achieving it

What we want

Understanding what’s involved will

allow us to do what we can—aiming

for the most strategic inputs based on our situation Rebuilding does not mean going back to what we

had in the past Some elements of the past will appeal to some

people, so referring to it may be part of our approach but seriously attempting to take society back to a way of being that belonged to the past is unlikely to be productive

Building means in the present

We must find new ways of designing culture to fit the needs of the present, seeing how it is with clear, unbiased vision

For example, breastfeeding is easier if women do not work

Clearly we do not want to aim to go back to a time when they did not do so but rather create an empowered generation of women who force society to change in ways that meet their new needs

Situation analysis

Find out what the current situation is and

how trends have changed with respect to: Rate of initiation Rate of early initiation Duration of exclusive Duration of predominant Types of supplements given in the first few

days and later in the early months of life Proportion who sustain breastfeeding for

various lengths of time (I avoid the term “extended” because it sounds non-normative)

What should we focus on?

Decide if it is only one or some or all of

these you want to focus on Exclusivity is usually the one farthest from the ideal

because it was not traditional anywhere In some societies, early initiation is not the norm

and most have lost awareness of the “breastfeeding crawl” and even early initiation

For such behaviors, we need to build cultural support from scratch

Knowledge per se is more important than for other behaviors

Why/how did we lose breastfeeding?

Often scientific or social scientific literature speculates on why negative and positive changes occurred in the past

Find out what explanations are given by such experts, by health workers and by mothers for the changes that have occurred

Try to go into depth on one or more key issues that seem to have substantial explanatory power

The perceived insufficient milk syndrome is usually important to understand

Insufficient milk

This may be an excuse in situations when women feel pressure to breast feed

In Yemen women ask for a prescription from their doctor for formula because they have “no milk”

Then they tell their mother in law (who is the decision-maker on infant feeding) and husband (who has to be the one to buy it) that the doctor said her milk was bad

Doctors may know the mother has milk but don’t want to lose a “customer”

Insufficient milk

When given as an honest concern, it is an expression of lack of knowledge or confidence in the breastfeeding process

It may be a self-fulfilling prophesy, related either to a family myth (“none of the women in this family have enough milk”) or a social one (“None of the women in this village have milk”), especially when the response is to supplement rather than breastfeeding more intensively

Insufficient milk

Baby food companies exploit and contribute to such myths, especially by over-emphasizing the importance of a good (ie, expensive) maternal diet to make good or enough breast milk

Health workers should give their lectures before and during pregnancy but during breastfeeding avoid pushing women too hard to (1) eat better, (2) stop smoking, (3) avoid alcohol, (4) avoid minor recreational drugs like marijuana

Why hasn’t it gotten worse?

Don’t focus only on the negative side Look for “positive deviant” cultural strengths.

Why have some people/regions/groups maintained their breastfeeding culture more strongly than others?

What resources already exist that you can work with/build on?

Which trends are going in the right direction, even if ideal practices are still relatively rare?

What’s your level of ambition?

Once you gain enough understanding of what has happened in the past and what is gong on now, a long-term vision will emerge with rough ideas of some of the ways in which the rebuilding might best take place

Given your resources, build an informal action plan

Match the components of your short-term plan of action also to your geographical/social level of ambition, dividing it into long-term for larger goals and short term on the way there

Moving forward

For example, if you plan to try utilizing the mass media, you would choose different ones for local, provincial or national levels or action/influence

A good way to help you prioritize what to work on is to develop a force field diagram listing all factors for and against each change you want to make, and estimating their power and importance.

Weakening an opposing force has the same effect as strengthening a positive force!

The components

For each breastfeeding behavior you decide to focus on, think about each of these four components, listed in order of priority: Protection of existing behavior What kind of support women need to maintain

and expand on or improve the behavior How can you achieve a feeling in society that

this behavior is the norm? How can you promote it? That is, create

awareness and build knowledge about its benefits.

The Components

Protection Making the public relations “cost” of reducing breastfeeding

higher than the money companies can make by destroying it.

Countermarketing and the Code

Commercial discharge packs reduce exclusive breastfeeding

Educational materials from infant formula companies reduce exclusivity and duration

The International Code forbids advertising, free samples, idealizing pictures on labels, gifts to health workers, sales incentives, and requires label warnings

The Components

Support Skilled, kindly, and

empowering health workers A human rights infrastructure to

support the needs of the working mother (pumping is not a long-term strategy—it’s a coping mechanism)

Peer counseling, breastfeeding mother’s groups, fathers’ groups

.

The components

Normalization I will spend more time on this because it is only

recently getting attention The loss of our original breastfeeding culture

happened quietly while no one was paying attention because of the myth that artificial feeding is safe and at least good if not best

Now in most industrialized countries the bottle is the norm

Changing this is probably the most challenging, neglected, yet important task in rebuilding a breastfeeding culture

Normalization

Legislation ensuring the right to breastfeed

Making breastfeeding visible in public

Including breastfeeding in school curricula

Too little research to know about effectiveness

Norms* Descriptive norms relate

to “what everyone does” Injunctive norms put

pressure on us (via the threat of social sanctions)

In both cases perceived norms may differ from actual norms (as revealed say in a national survey)

*See: Lapinski and Rimal. An explication of social norms. Communication Theory 15:127-147, 2005.

Norms

• Mass media and face to face communication can influence our perception of what is the norm

Our goal is to change perceived norms, which is the first step—and easier to achieve, based on understanding the following

Moderators in the influence of descriptive norms, I

Perception of benefit (outcome expectations)

Shared affinity with referent group (strongly identifying with the group)

Culturally determined view of the importance of the collective vs the individual

Extent to which an attitude or behavior is viewed as central to my self-concept

Moderators in the influence of descriptive norms, II

Ambiguity (new behavior; new culture) heightens our use of others’ behavior as a guide to our own (thus, reach women before or during their 1st pregnancy and women who have moved to a new location)

Whether the behavior is enacted in a public or private setting (privacy reduces our knowledge of norms and eliminates injunctive norms)

Norms

Most powerful: combination of descriptive norm and perception of benefit

The threat of losing something is a greater motivator than opportunity to gain an equal amount, eg, “look what she’s enjoying with her baby”

Can norms be changed?

This is an ad for men’s clothing in Brazil. It clearly perpetrated the norm that violence against women is okay.

By exposing it on her blog (read by 2000 people, mainly women, daily) my wife got it withdrawn by the company within 2 days

Achieving normalization

Everyone has to get used to seeing babies being breast fed

It is bottle feeding that OUGHT to be practiced in private!

Achieving this is potentially controversial and a bit painful but much of it will take place naturally as indeed breastfeeding becomes the norm

In Norway and Sweden it is like this, which leads to some women complaining that they feel forced to breast feed

Achieving normalization

Girls (and boys who play with dolls) should play with dolls that breast feed. Avoid giving them a doll with a baby bottle

Do not allow officials or the media to use the bottle instead of breast as the symbol for babies or for baby-feeding

Form a normalization group and develop a standard letter and inundate them with explanatory letters complaining when they do this and asking for redress

Try to get BF into soap operas, etc.

Breastfeeding in public

In Korea breastfeeding is kept hidden in special breastfeeding rooms that are very common

In particular, girls and women must see other women breastfeeding before and after giving birth

Peer counseling is one powerful way, especially mothers’ groups like La Leche League

Women should be referred to them routinely during antenatal care (BFHI step 10)

Changing our language

Subtlely without thinking about it, we avoid using language that confronts bottle feeding for the risky practice that it is (See the suppressed US breastfeeding ads)

But it is like cesarean section, something artificial that can save life when needed, but something which is not natural and should not be the norm

The truth is, breastfeeding has no advantages, it’s just the normal way of feeding babies

Watch your language!

Thus we should speak of formula’s risks, not breastfeeding’s benefits

We should also avoid saying “breast is best” This implies that other options, though perhaps

in some vague sense not best, are at least good—and people are always asking us, “which of the formulas is better than the others?”

That’s like asking: “If you don’t use a seat belt on your child, where in the car is the safest place to put him/her?”

The Components

Promotion Use of face to face and mass media

communication channels to increase knowledge and change perceived norms

Spreading knowledge

Most health and nutrition education focuses only on spreading awareness, increasing knowledge or building skills

But this is useless among people who are not motivated

So there IS, as discussed below, a good deal of knowledge that is needed to achieve optimal breastfeeding, but you must KNOW your audience and first build motivation if that is needed.

Mass media and social marketing work

IF comprehensive and multifaceted

Variety of audiences (important to segment)

Evidence of impact: improves attitudes Increases initiation rates

and possibly duration

Provision of information

Providing printed materials alone has no impact

Nor does giving a simple message to breastfeed or do so for a longer period of time

Hotlines and web-based support have not been evaluated but like all information-sharing can presumably be useful if part of a larger strategy rather than the only thing that’s done

Apply these to each behavior

Now I will go through the main breastfeeding behaviors and mention some of these four components for each

Some components like protection are generic and apply to all

Others like support and promotion (providing information) are specific to the practice

Normalization is often generic, but COULD focus on one particular behavior

1. Initiation of breastfeeding

When women deliver in hospitals, the Baby Friendly Hospital Initiative can have an impact

Caution: health workers can be unkind and this will result in “side effects” such as backlash and avoidance (home delivery/private health care alternatives)

So training and supervision must go beyond just professional skills and knowledge

2. Early breastfeeding patterns

There is much more involved than just getting breastfeeding started: Babies can initiate breastfeeding on their own

( see and use the breastfeeding crawl videos) Initiating breastfeeding soon after delivery is so

important that it can save lives Colostrum is sometimes seen as “bad,”

particularly within traditional medicine Prelacteal feeds are thought to be needed by

nearly all untrained modern AND traditional practitioners

Promotion of better early practices

UNICEF will (or should) support BFHI even in rich countries—lobby them!

It requires advocacy efforts and training, which means funding

Where women do not deliver in hospitals, ways need to be found to improve early feeding using traditional birth attendants

A recent study in Bangladesh suggests this can be powerful, especially if supervision is added (but that greatly increases the cost)

3. Why don’t mothers breastfeed exclusively?

• Lack of knowledge (as exclusive breastfeeding becomes the norm, knowledge spreads and the search for moreknowledge increases)

• Lack of support for the working mother to be with her baby

• Pressure from women in the older generation to add traditional foods at the traditional times because this “worked” in their day (just look at how well the father turned out!)

Why don’t mothers breastfeed exclusively?

• Lack of lactation management/breastfeed-ing counseling

• Lack of confidence (confidence will naturally increase as knowledge increases and norms trend in the breastfeeding direction)

Promotion of exclusive breastfeeding

This is not a traditional norm anywhere, though it is becoming the norm in some countries now

Where the norm is to breastfeed relatively exclusively for several weeks, extending this will be relatively simple but for most mothers achieving 6 months is a challenge

Note the difference between levels of “current status EBF” and “EBF since birth”. You can track either one but current status is most common.

Time with the baby

Europe got long paid family leaves (often about a year) because: Women voters made it a political issue Women were unwilling to have any or many babies unless

they got it (low fertility rates) There was no link to breastfeeding, it was done to

achieve equality in the workplace Now there is pressure to require men to take as much as

women Paid maternity leave is commonly mandated in Latin

America and Africa too

Can we promote to old women and to fathers instead? Old women are the infant feeding

decision-makers (or at least are influential) in many cultures

Virtually none of them exclusively breastfed for long anywhere (but extended predominant BF is common in South Asia)

Men usually have no involvement

Use the fathers

But men often are perceived as the decision-makers when they want to be

Can we motivate them to protect their wives from their mothers?

They seem to be able to explain to their mother in a kindly way when we ask them to do so

Involve the fathers

Anecdotal reports and early research suggest that changing grandmothers can work, but I believe that with careful crafting, in many cultural settings it will prove to be simpler and may be more effective to involve men

They are a “blank slate” which is much easier to write on than to first get older women to unlearn what they think they know, in effect to get them to agree that there is a better way to do it than what they did

Women will support this

Mothers WANT the fathers to be more involved

Besides supporting exclusive breastfeeding I see two other excellent ways of doing this, that will WORK and win support from mothers: Dad should be the bather Dad should be the introducer of solid foods

In both cases they need not be done while he’s at work

They give him a chance to be the expert

Child care arrangements are crucial

Some forces work in our favor—for example, as families become nuclear, and fewer poor women are available who are willing to work as domestic labor, more women will be searching for how to replace informal child care arrangements with formal ones

This provides an opportunity for the breastfeeding community to influence what arrangements are created by authorities at various levels

Child care arrangements

This is crucial to women’s possibilities to achieve more intensive breastfeeding while maintaining their careers

The long-term goal should always be to achieve the greatest duration of paid maternity leave possible

Unfortunately, achieving the legal right to this has proven to be only part of the battle, as Korea illustrates

Actually taking it has to be “normalized”

What next?

The second tier of our efforts depends on how long the period of paid maternity leave is that women actually take

If less than six months, we must strive to First, establish child care at or near the places

of work so that women can take breastfeeding breaks

Second, where that fails, establish clean, comfortable, private facilities where women can express and store breast milk

Supporting them

Whatever arrangements exist, women will often need support in how to maintain the optimum possible level of breastfeeding intensity in combination with their work and child care arrangements

They must know how to express, store and feed breast milk

They must understand how to maintain breast stimulation and deal with excess/leakage

4. Promotion of increased duration

Extending the period of continued breastfeeding is the simplest breastfeeding behavior to influence but is usually ignored Sometimes one must address myths

or taboos, especially when continuing beyond the currently perceived norm

Health care worker ignorance and lack of maternity support are no longer as important

Normalizing sustained breastfeeding

In Sweden in 1990, a member of the national breastfeeding support group who worked at the largest newspaper managed to get the editor to place on the first page a large photo of a women breastfeeding an 18 month old in the central train station

The message was not that this was good, simply “Swedish mothers forced to breastfeed in the closet.” It pointed out that this is actually common if secret (normalizing it) and even interviewed a 5 y/o still breastfeeding

Peer counseling

Usually based on training volunteers who schedule 6-15 postnatal home visits during the early months

Has been shown to lead to a dramatic increase in exclusivity, but not in the US or the UK

Probably more effective if volunteers are organized in “Care Groups”

Extra problems in “disturbed” settings

Mixed feeding from the outset becomes the norm Free samples in hospital—this may be main

thing leading to the speed which with the breastfeeding culture of China was destroyed

Early intensive pacifier use becomes the norm Concerns about infant sleep (where, amount,

waking at night) Maternal alcohol use

Alcohol and breastfeeding

Occasional drinks are not a problem The mother can avoid BF for 2 hours after taking

a single drink (1 beer, one cup of wine, one shot of strong drink)

Otherwise (or if she drinks more regularly) it will increase perceived infant restlessness or dissatisfaction with breastfeeding, increasing the “perceived breast milk insufficiency syndrome” (it disturbs sleep and shifts it to the daytime and reduces how much the infant obtains per breast feed for several hours)

Support for doing it right

In any culture 10-15% of babies are incorrectly positioned, latching on is poor, or there are physical problems with the breast or nipples

Health workers are rarely trained well, though improving, especially in places where EBF is now normative (parts of Scandinavia and Canada)

When initiation and duration increased in the West in the1970s and in exclusivity in the 1990s, health worker capacity increased AFTERWARDS

Support and promotion work best when done together

Increasing pressure to breastfeed exclusively without providing the required support, will give limited results and may cause backlash

Investment in support ALONE also works poorly: Health workers in isolation (eg BFHI with too

little effort on Step 10) have limited impact Improved maternity protection alone will have

little impact (especially if <6 mo paid maternity leave and day care is near the home, which is what mothers prefer)

Lack of confidence

Confidence is not a trait women are expected to seek to achieve in this region

We can see pictures of confident women showing off their figure, but not photos like this of a woman confident or proud of breastfeeding

Empowering women does not appear to lead to a decline in breastfeeding

To the contrary, powerful women transform society to meet their reproductive as well and productive needs

Confidence

Harm may be unwittingly done by over-emphasizing the importance of good diet during lactation

Health workers almost never empower (partial exception: midwives)

•Even in the West, excessive confidence in women is seen as provocative•Since confidence IS necessary for breastfeeding to work well, we need to promote women as achievers without showing off like this controversial photo and article

Special considerations in East Asia

Small breasts This need have no impact

on 24-hour breast milk intake by infants

But women with small storage capacity (partially but not completely linked to external breast size), must be prepared to breast feed more often day and night

Special considerations in East Asia

Changes in breast shape and size For some but far from all women,

breastfeeding enlarges the size of their breasts

For many if not most of these women, this is largely a temporary effect

Sagging breasts are mainly caused by: Smoking Short birth spaces Having many children, whether or not breast fed

Special considerations in East Asia

Weight loss While breastfeeding exclusively, up to 750

calories a day goes into breast milk production Of course exclusive breastfeeding for six

months is going to have a much bigger impact It also increases hunger, so all the principles

of maintaining/losing weight still apply Exercise and eating healthy foods (avoid

refined carbs, especially sweet drinks) are the most important of these

Special considerations in East Asia

Small or thin women do not produce inferior quality breast milk A woman should get a healthy diet before,

during and after pregnancy for her own sake In most of East Asia there is little risk that a

poor diet will have any negative impact on breast milk quantity or quality except possibly women suffering from bulimia or anorexia nervosa

Avoid alcohol, at least in the first month or two

Korea

In Korea, the “privacy problem” has been solved, at least in Seoul, by creating lot of breastfeeding rooms in subway stations, parks, etc.

Clearly hiding it may solve one problem but creates another!

East Asia

Breastfeeding in public

seems to be a serious

issue It deserves more

attention from the “breastfeeding community” in each country

If breastfeeding is only done in private, women give birth never having seen it

Achieving it as the “perceived norm” will take special efforts if it’s never done in public

One of the all-time best images of

breastfeeding as the

infant’s norm—from a Korean

museum

Who’s against breastfeeding promotion?

1. People who’ve been treated cruelly2. People who feel guilty3. People with a free market political agenda4. Baby food companies and others like health

workers they support who have vested interests

5. Efforts to reduce backlash should focus on reducing 1, sympathizing with 2, and exposing the true motives of 3 and 4

From the baby’s point of view

Babies would demand that society enable them to be with mother in early life; and to be breastfed or at least receive breast milk

They’d probably be understanding in cases where it caused serious conflicts or problems for mom

Take home lesson: put pressure on everyone else, but not mom!

Thank you!

Ted GreinerProfessor of NutritionHanyang UniversitySeoul, South Koreatedgreiner@yahoo.com