The Cultural Art of Breastfeeding

Cynthia Good Mojab, MS
Hillsboro, Oregon, USA
From: LEAVEN, Vol. 36 No. 5, October-November 2000, pp. 87-91

CORRECTION

The article, "The Cultural Art of Breastfeeding," in the Oct-Nov 2000 issue of LEAVEN contained an error. The author, Cynthia Good Mojab, intended to write "Christian concept" rather than "Judeo-Christian concept" in regard to "original sin." Also, the author and the LEAVEN editorial staff are grateful to the reader who explained that the term "Judeo-Christian" itself is problematic (and potentially offensive) in that its use tends to obscure and discount significant differences between Judaism and Christianity. They offer their regret and apologize for any offense the error or unintentional oversight may have caused.

The art of breastfeeding is a blend of biology and culture. In the global and historical spectrum of breastfeeding patterns, many variations work well for the nursing pair (Blum 1999; Goldsmith 1990; Kitzinger 1995; Small 1999). However, breastfeeding problems are often rooted in cultural beliefs and practices that do not match the biologically based needs of mother and child. When new breastfeeding information challenges a mother's culturally based beliefs, she may mistrust it and have difficulty acting on it. Leaders who understand the role of culture in breastfeeding will be able to provide more culturally sensitive support and information to mothers from their own and other cultural heritages.

Breastfeeding: A Social Behavior

Though breastfeeding is a natural act, many mothers have found it to be anything but instinctive. In the words of one mother who struggled with breastfeeding: "I thought it would be easy! I thought my baby would know what to do, but he didn't. And neither did I." Breastfeeding is a social behavior: we learn - or fail to learn - how to breastfeed from those around us. Many women today, in the United States and other countries, have simply not had the chance to learn how to breastfeed their babies.

When women become mothers in societies in which breastfeeding is the norm, they have societal support and approval, as well as ample models and reliable advisors in their own families. However, the mothers and aunts of women bearing children today may have little or no experience with breastfeeding. Due to complex cultural and economic factors, the lowest rates of breastfeeding ever seen in the US occurred during the 1960s. As formula manufacturers aggressively expanded their markets, breastfeeding rates dropped around the world and continue to decline globally today. In the developing world, only 44 percent of infants (even less in industrialized countries) are exclusively breastfed for any length of time (Good Mojab 1999).

When breastfeeding knowledge has been lost in individual families and entire societies, the techniques that are appropriate for formula feeding - such as scheduled, infrequent, time-limited, and measured feedings - are applied to breastfeeding (Good Mojab 1999). These techniques are compatible with - and derived from - the dominant cultural beliefs of Western societies, such as the United States. They are not, however, so compatible with breastfeeding.

Culture

Culture is a complex concept. It is commonly thought of as ethnicity, race, or nationality (Betancourt & Lopez 1993). However, even among people of similar ethnicity, race, or nationality, life experiences differ with gender, age, place of residence, social affiliations, language, education, religion, and socioeconomic status. Because of these variations, culture can be thought of as having multiple dimensions that reflect "worldview," how people see the world: their shared attitudes, beliefs, categorizations, expectations, norms, roles, self-definitions, and values (Triandis 1972; Dana 1993).

The concept of worldview provides a framework for understanding culture and its impact on the thoughts, emotions, and behaviors of people. We perceive the world and construct our own experience of reality according to our worldview. In turn, we recreate our sociocultural context, passing down our beliefs and customs to our children.

Culturally based components of worldview involve 1) socialization, 2) intergenerational transmission of ideas, 3) internalization of values based on childhood experiences, 4) consistent patterns of practices and concepts, 5) patterns that are maintained even when maladaptive, and 6) feelings of confusion or helplessness when the patterns are changed (Brislin 1980). They can be identified among people who share a geographic location, language, and historic period, are organized around a theme, and vary less within the culture than they do between cultures (Triandis 1993). Breastfeeding beliefs and behaviors meet these criteria. (see box below)

The Cultural Basis of Breastfeeding

Breastfeeding meets the criteria of a cultural construct. The diverse approaches to breastfeeding found between and within societies are largely based on cultural rather than individual differences.

We are socialized to breastfeed - or not to breastfeed - our babies. Breastfeeding knowledge, when it exists, is passed down from mother to daughter in the form of consistent patterns of practices and concepts.

We internalize our childhood experiences regarding the feeding and nurturing of infants through observation, modeling, and play (e.g., feeding our dolls with bottles or breastfeeding them).

The need to change our approach to breastfeeding to avoid or solve breastfeeding difficulties can result in confusion as we struggle to reconcile new behaviors with old beliefs (e.g., nursing a baby on cue conflicts with the Western cultural norm of scheduling feedings).

Breastfeeding patterns vary with geographic region, language, and era. Breastfeeding beliefs and behaviors can be organized around the themes of cultural dimensions. Though biology imposes constraints on successful approaches to breastfeeding, breastfeeding attitudes and techniques vary between cultures.

Dimensions of Culture

People in every society must make sense of a variety of concepts that are fundamental to human life. Such cultural dimensions include beliefs that people hold about innate human nature, social relationships, the relationship between people and nature, time, and activity (Kluckholn & Strodtbeck 1961). These beliefs vary with such factors as urban-rural residence, socioeconomic status, the number of generations since immigration, and the extent of individual acculturation (cultural adaptation after immigration).

Certain beliefs occur with greater frequency in each society. They represent the cultural norm or "mainstream" worldview. The examples in this article of societies for which a particular belief is the norm are intended to illustrate how different cultures tend to manifest cultural dimensions (Dana 1993). To avoid the harmful effects of stereotyping, however, Leaders should never assume that a mother holds the most common beliefs of her society. Thinking about cultural dimensions instead of cultural groups will help the Leader more accurately understand a mother's actual beliefs.

Human nature. Human nature may be understood as innately bad (e.g., Western European, Anglo-American), good (e.g., Asian), or a mixture of good and bad (e.g., African American, Latino/a, and Native American). These understandings are both reflected in and created by religious beliefs. The Judeo-Christian concept of "original sin" is an example of the belief that human nature is innately bad.

Social relationships. Social relationships exist in all societies, but are conceived of and structured differently. Relationships with other people may be approached in two basic ways: individualistically or collectivistically. In individualistic cultures (e.g., Western European, Anglo-American, African American), people tend to strive toward independence, uniqueness, self-expression, and the promotion of personal goals. in collectivistic cultures (e.g., African, Asian, Middle Eastern, Latino/a), people tend to strive to belong, to occupy their proper place, and to promote others' goals (Hofstede 1980; Markus & Kitayama 1991; Triandis 1995). Though individualism and collectivism are not mutually exclusive, people generally prefer one approach over the other.

Relationship with nature. The relationship between people and nature can be described as subjugation to nature (e.g., Asian), harmony with nature (e.g., Native American, African, African American), or mastery over nature (e.g., Western European, Anglo-American). This relationship is reflected in how a society makes use of natural resources, protects or damages the environment, and responds to natural disasters.

Time. Cultures may focus on the present (e.g., Latino/a, Native American), past (e.g., Asian), or future (e.g., Western European, Anglo-American, African American ). A focus on the present yields a natural flow to the events of the day. An emphasis on the future yields planning and scheduling. A focus on the past is shown in reverence for one's elders and ancestors.

Activity. Human activity may be conceived of as "doing," "being-in-becoming," or "being." In cultures that emphasize "doing" (e.g., Western European, Anglo-American, African American), human activity means the accomplishment of something. "Being-in-becoming" (e.g., Asian) emphasizes personal development as human activity. Native American cultures tend to see activity as a mix of both "being" (a spontaneous expression of the personality) and "doing."

Other dimensions. The five cultural dimensions focused on in this article provide a good foundation for understanding the role that culture plays in breastfeeding. Other dimensions include cultural complexity (e.g., the number of relationships possible within a culture), technical specialization, levels of social stratification (i.e., caste, class, privilege, or status), tightness-looseness (i.e., clarity of norms for social interaction and how much deviation from those norms is tolerated), and heterogeneity-homogeneity (i.e., degree of exposure to different kinds of norms from which to choose to follow) (Pelto 1968; Triandis 1989, 1993).

Cultural Dimensions of Breastfeeding

Like culture itself, breastfeeding can be thought of as having dimensions. When a Leader works with a mother from her own or another cultural heritage, she can listen for clues as to how the cultural dimensions of breastfeeding are being manifested in the mother's worldview.

Nurslings, nature. Nurslings may be viewed as innately good, bad, or as a combination of both. A mother's description of her infant as "manipulative," for example, reflects a cultural belief in human nature as innately bad.

Mother-nursling relationship. The nursing pair can be viewed as a unit, with the nursling appropriately dependent on the mother. Mother and baby can also be seen as two separate individuals in need of independence from each other. A mother who describes her baby as "clingy" or who is regularly separated from her baby is likely to hold the individualistic value of independence in high regard.

Relationship with breastfeeding. Nursing is a natural act. As such, breastfeeding can be viewed as a process to be controlled, to be in harmony with, or to which mothers are subjugated. Mothers who feel in subjugation to breastfeeding tend to believe that whatever happens in the course of nursing cannot be controlled by them. If they seek breastfeeding help, they may feel little confidence that the Leader's suggestions will result in improved breastfeeding outcome.

Beliefs about the nature of nurturing and child development also impact breastfeeding. Mothers may feel little trust in themselves or their babies in the course of child rearing, relying on rules and advice from perceived experts. Alternatively, they may respond to their babies' needs, learning to watch for cues and to trust their child's natural course of development.

The timing of breastfeeding. Mothers can breastfeed on a schedule (imposing limits to the frequency and length of feedings and on the duration of breastfeeding), on the baby's cue, or at the mother's opportunity. Cue feeding is also called "demand feeding," reflecting Western perceptions of the nature of nurslings. "Opportunity feeding" occurs in some groups (Oomen & Malcolm 1958; Jelliffe 1962), as mothers weave breastfeeding into daily life. A mother who is frustrated that her baby is "still" breastfeeding or breastfeeds irregularly, with high frequency, or for long periods may hold beliefs about time that focus on the future and emphasize scheduling.

The activity of breastfeeding. Breastfeeding may or may not be viewed as meeting the cultural criteria of human activity. A mother who complains that she "can't get anything done" because she is always breastfeeding her baby is likely to see human activity as "doing." Her complaint expresses that breastfeeding is not the accomplishment of something according to her worldview.

Breastfeeding Worldview and Biology: Match or Mismatch?

The manifestation of cultural dimensions varies greatly between societies. The biology of breastfeeding varies little (see "The Biological Basis of Breastfeeding", below). While there is no one right way to breastfeed, some cultures are better matched with biology than are others. The greater the dissonance between breastfeeding worldview and breastfeeding biology, the more likely a mother is to experience difficulty or dissatisfaction with breastfeeding.

In non-industrial societies like the !Kung San, the Amele of Papua New Guinea and the Indonesians of Central Java, mothers tend to breastfeed their babies on cue, in short intervals, and throughout the day and night (Hull & Simpson 1985, Small 1999). These societies are generally well matched with breastfeeding. Other societies, particularly the dominant cultures of Western Europe and people of Western European origin (e.g., USA, Canada, Australia, New Zealand), are less well matched with the biologically based needs of mother and nursling.

Even women in societies that are otherwise culturally compatible with breastfeeding may hold beliefs that create breastfeeding difficulties. Westernization (the adoption of Western cultural beliefs and behaviors) has occurred with colonialization, military occupation, export of Western products, immigration, and a global mass media. One route of Westernization - with profoundly detrimental effects on breastfeeding - is the global marketing of breast milk substitutes. For decades, formula industries have marketed their products as modern, superior, and enabling the independence of mothers; their tactics reflect, exploit, and create Western breastfeeding beliefs around the world.

Sometimes mothers believe in the infallibility of health care providers, religious leaders, or others perceived to be experts in the field of child rearing. Such a belief may override a mother's otherwise breastfeeding-friendly worldview, causing her to follow - often with emotional discomfort - advice that undermines breastfeeding. This may occur more frequently when the "expert" has been trained in a Western model of medicine, religion, or psychology and does not take the biological aspects of breastfeeding into consideration.

The Biological Basis of Breastfeeding

Breastfeeding is a biological process that continues the physiological and psychological entwinement of mother and child after birth. Colostrum is automatically available to the newborn at birth and meets all his nutritional needs while providing immunological protection. Newborns have rooting, sucking and swallowing reflexes that help them learn how to breastfeed. Breastfeeding helps expel the placenta and return the uterus to its prepregnancy state.

The hormones of prolactin and oxytocin are created in response to suckling. The more a baby suckles, the higher the level of prolactin, and the more milk is produced. Oxytocin enables the delivery of milk via the milk ejection or "let-down" reflex. Mothers often experience a let-down of milk whenever they hear their babies cry.

When babies are breastfed on cue, they self-regulate the quantity and quality of the milk at each breastfeeding. Feedings of long duration have a higher fat content than do short feedings. Frequent feedings increase milk fat concentration and milk volume. Babies wisely want to breastfeed often throughout the day and night due, in part, to the rapid digestion of breast milk and the enhanced quantity and quality of their mothers' milk.

The benefits of nursing extend to both mother and child. Babies who are breastfed have a lower risk of illness and disease, including allergies, childhood cancer, diabetes, and Sudden Infant Death Syndrome (SIDS). Mothers who breastfeed have less risk of breast, endometrial and ovarian cancer, anemia, and osteoporosis.

The nutritional, immunological, and psychological benefits of breastfeeding continue throughout any duration of breastfeeding. Anthropologist Katherine Dettwyler estimates that if culture did not tell us to do otherwise, weaning would occur somewhere between 2.5 and 7 years of age (Dettwyler 1995).

Mainstream American Breastfeeding Worldview

Mainstream American culture, in particular, poses major challenges to breastfeeding. Recall the worldview of the majority of people in the US: people are innately bad, independence is highly valued, human beings are masters of nature, the time focus is the future, and human activity means accomplishing something (Dana 1993; Triandis 1994). Mothers of Western European cultural heritage or living in Westernized societies are likely to have at least some similar breastfeeding beliefs (See Editor's Note below).

Nurslings' nature. In the US, the belief that children - even newborns - are manipulative of their parents is quite common. Mothers must resist "giving in" to their babies' (unreasonable) "demands" for fear of spoiling them. Babies cannot be trusted to know and communicate their fundamental physiological, psychological, and developmental needs.

Beliefs such as these can make it very difficult for a mother to comfortably respond to her own biological urge to pick up her baby and breastfeed him whenever he roots or cries.

Mother-nursling relationship. Independence is highly valued in mainstream American society. Mothers commonly believe that children must be taught from early infancy to be independent. Bottles are introduced so that others can feed the baby, facilitating the separation of mother and child. Thumb sucking is not perceived as a nursing or nurturing cue, rather as a step toward independent self-comfort. Pacifiers (dummies or soothers) are introduced so the child will not depend on mother for all his suckling needs. The use of cribs and playpens, strollers, infant seats, and infant carriers with handles all serve to physically separate mother and baby even when the mother is present. Babies and children commonly sleep in a separate bed and room from their parents where they are expected to sleep through the night without "disturbing" their parents.

Many American mothers and babies routinely spend time away from each other through the use of daycare and babysitters (child minders). Married mothers are encouraged to "get away" from the baby "for the sake of the marriage." Weekend - or longer - vacations without baby are considered acceptable. The great majority of workplaces in the United States are not compatible with mothering or breastfeeding. Employed mothers usually must leave their babies and children elsewhere and provide pumped breast milk, if they breastfeed at all.

Beliefs and practices such as these can make it very difficult for a mother to comfortably accept and respond to the profound need a nursling has to be with her and to breastfeed frequently, for long periods, and at night. The greater the separation of mother and child, the less opportunity for mothers to see, learn, and respond to nursing and nurturing cues.

Relationship with breastfeeding. The American reverence for science is rooted, in part, in the belief that humans are the masters of nature - which cannot be trusted to properly manage itself. Scientists, it is believed, can create an infant food that is superior - or at least equivalent - to the milk produced by nature. Countless mothers have fed their children with formula, trusting that it was as - or more - hygienic and nutritious than their own milk. Infant feeding with breast milk substitutes can be controlled: mothers can measure how much their babies have consumed and the content is (in theory) known.

Such cultural beliefs are often the basis of the distrust that many American mothers have in the quality and quantity of their own milk. This distrust may lead to supplementation with formula, the early introduction of solids, the administration of vitamin and mineral supplements to the infant, "insufficient milk syndrome," and early weaning.

The timing of breastfeeding. The emphasis on time management in the United States demonstrates a focus on the future. This time emphasis is extended to infant feeding and nurturing. Western child rearing "experts" have long urged parents to impose schedules on the sleep, play, and feeding of babies and children lest they never learn self-discipline (Kitzinger 1995). Breastfeeding should be done according to the clock and calendar, rather than according to what the breast or nursling needs. Mothers working outside the home must pump their milk or breastfeed their babies during scheduled breaks. Babies who need to breastfeed more frequently than the cultural norm are labeled "high need" or are perceived as being hungry because the mother has "insufficient" or "weak" milk. The nursling who does not easily wean at a socially expected (early) age is seen as overly dependent, demanding, and spoiled.

The activity of breastfeeding. In societies like the US in which human activity must involve accomplishing something, motherhood is often a difficult stage of life. Before becoming mothers, women are productive in school, community, workforce, and home; recognition is given for tangible projects completed (particularly projects outside of the home). As mothers, women often feel unproductive - as though they have gone the whole day "doing nothing." Mothers may feel restless or resentful as they sit nursing a baby frequently or for a long time, particularly during growth spurts: they are supposed to be "doing something." The nurturing of children, including breastfeeding, is not seen as an accomplishment. There is little or no social recognition for cuddling a child, nursing on cue, or otherwise nurturing a young human being. Breastfeeding and mothering simply do not meet the criteria of (productive) human activity in American society.

*Editors Note: A single detailed example of a mainstream breastfeeding culture is included in this article to help illustrate abstract cultural concepts. Mainstream American culture was selected, in part due to the familiarity of many Leaders (including the author) with it. Other Western European and Westernized cultures, though sharing some of the beliefs and practices described here, were not included so as to avoid potentially inaccurate generalizations about the many quantitative and qualitative differences among them.

Implications for La Leche League Leaders

Mothers may contact LLL Leaders when they are dissatisfied with breastfeeding or are experiencing breastfeeding difficulties. Leaders are well trained to offer information and support as modeled in THE WOMANLY ART OF BREASTFEEDING and the BREASTFEEDING ANSWER BOOK. Sensitivity to the ever-present impact of culture on breastfeeding will help the Leader even more effectively provide information and support (see "Assessing Breastfeeding Worldview", below).

Validating. When a Leader actively listens to a mother, she helps her vent emotion and feel understood and valued. This is particularly important when culturally based parenting differences exist between the mother and Leader. "You wish the baby would develop a schedule so you could get something done without interruption. You feel frustrated that you can't accomplish things the way you did before the baby was born."

Normalizing. After a mother feels understood and valued, the Leader can normalize the mother's experience of breastfeeding and mothering. "Babies go through growth spurts during which they need to breastfeed more frequently. It doesn't mean you don't have enough milk or your milk isn't good. The more frequently you breastfeed your baby, the more milk you will have." Normalizing - after validating a mother's emotions - helps lessen pressures for the mother and her baby to conform to any biologically incompatible cultural norms of breastfeeding or child rearing.

Respecting cultural distress. For mothers who are very distressed by the challenges that breastfeeding poses to their cultural beliefs, small changes may be more comfortable than large ones. A mother who strongly believes in scheduling may not feel comfortable nursing on cue, for example, even if her baby is not gaining weight well. She may, however, feel comfortable nursing every two hours instead of every four hours as she was doing. Such a suggestion respects the cultural beliefs and distress of the mother while yielding an improved breastfeeding outcome: better weight gain in the baby.

Addressing overriding beliefs. At times Leaders may be more effective if they present breastfeeding information that addresses an overriding cultural belief. For example, a mother may value scientific knowledge more than scheduling, though both are part of her worldview. If a scheduled approach to breastfeeding is causing breastfeeding difficulties, a Leader can cite scientific research that supports on-cue nursing.

Creating community. Mothers whose worldview is compatible with breastfeeding may live in societies whose dominant worldview is not breastfeeding friendly. These mothers may contact Leaders for support and encouragement as they struggle

to "swim upstream" in their culture. The reassurance and information that Leaders provide can help mothers effectively educate others (physicians, family members) about breastfeeding. La Leche League meetings are often a critical source of community for mothers living in societies in which breastfeeding is not the norm. Women develop a sense of belonging and connection, gain access to information and role models, and find emotional and practical support. Such community is essential to the development and well-being of all mothers (Kitzinger 1989).

Accommodating coping style. Culture affects coping style-the way in which people deal with the challenges in their lives. For example, people with individualistic worldviews (e.g., Western European, Anglo-American) are less likely to reach out to others for help than are people with collectivistic worldviews (e.g., Mexican, Iranian) (Good Mojab 1996). When working with mothers who have an individualistic worldview, Leaders may need to be particularly careful to convey a respect for the mother's autonomy and right to make her own decisions about breastfeeding. When working with mothers who have a collectivistic worldview, Leaders may need to take into greater account the needs, beliefs, and roles of important people in the mother's family.

Letting go. Leaders sometimes experience a helping situation in which a mother's beliefs or choices are dramatically different from their own or in which they feel that they were not able to help a mother. Culture almost always plays a major role in such situations. It can be helpful to remember that a Leader's responsibility is to provide information and support - not to change a mother's beliefs or choices, whether they are personally or culturally based.

Assessing Breastfeeding Worldview

Leaders can more effectively provide breastfeeding support and information if they understand a mother's breastfeeding worldview. Once a Leader knows what to listen for, a mother's beliefs are often evident in her description of her feelings and situations. If a mother's worldview is not clear, a few culturally based questions might help clarify it. For example:

"How are you feeling about your baby?" may yield information on a mother's beliefs about her nursling's nature or the mother- nursling relationship.

"How are you feeling about your baby's breastfeeding pattern?" may help the Leader understand a mother's beliefs about the timing of breastfeeding.

"How are you feeling about breastfeeding?" may clarify the mother's beliefs about the activity of breastfeeding and her relationship with breastfeeding.

"How do you feel about these suggestions?" gives the mother a chance to express whether new breastfeeding information matches her worldview and/or life situation.

Embracing Diversity, Supporting Breastfeeding

Huge variations exist in all of human behavior, including breastfeeding. While some cultural beliefs and practices create breastfeeding difficulties, others do not. Leaders must be careful to distinguish "different" from "harmful" when they encounter breastfeeding beliefs and practices from another culture. For example, nursing a newborn on a strict four-hour schedule will undermine breastfeeding. However, the traditional avoidance of certain foods during breastfeeding is likely to just be "different" between mothers of diverse cultural backgrounds.

Every mother breastfeeds and mothers her child to the best of her ability based on her own experiences, worldview, and the resources available to her. What works well with one breastfeeding pair, in one family, in one society, at one point in history may not work well for other breastfeeding pairs in different circumstances. There is strength in this diversity: mothers and nurslings have survived and thrived in a variety of living situations around the world and throughout time. By assessing the cultural dimensions of breastfeeding, Leaders can provide information and support that respects and effectively responds to a mother's worldview while encouraging and protecting breastfeeding.

Cynthia Good Mojab, MS, has been an LLL Leader since 1998 and currently works as Research Associate in the LLLI Publications Department. She is a researcher and author, specializing in the areas of psychology, culture, and the family. Cynthia has experience providing cross-cultural breastfeeding and psychological counseling. Her website, Ammawell, provides information and support to parents through forums, reading lists, parenting links, publications, and an art gallery celebrating breastfeeding. She lives biculturally and bilingually in Hilsboro, Oregon, USA with her husband, Ezzie, and their four-year-old daughter, Denná.

Research on Culture and Breastfeeding

Cynthia Good Mojab is conducting research on culture and breastfeeding. Mothers of any cultural background who have breastfed are welcome to participate. For a questionnaire or more information, please contact her at: Cynthia Good Mojab, PO Box 5803, Aloha, OR 97006 USA; cgoodmojab at msn.com (email); home.comcast.net/~ammawell/.

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