Could Body Image Be a Barrier to Breastfeeding?
A Review of the Literature
Indiana PA USA
From: LEAVEN, Vol. 42 No. 1, February-March 2006, pp. 4-7.
Whether in a local meeting or in a worldwide online chat, Leaders are in contact with a diverse group of women. Life circumstances are often different from our own. Individual sociocultural situations influence decisions and behaviors that may differ from our values or worldview. Just as it is with everything in life, breastfeeding does not occur in a vacuum. Cultural standards, traditional family practices, religious teachings, and many other influences combine to create a woman's personality and form infant feeding decisions.
An integral part of a woman's personality is the way she perceives her own body. Is she comfortable and self- confident? Does she seem to value her body and nurse with ease? Does she have low self-esteem? Is she ashamed of her shape? How many Leaders have been in a meeting where talk has turned to regaining that pre-pregnant body shape? Body image literature abounds in many disciplines. Even in such a large research area, rarely are breasts addressed, let alone how a woman's feelings about her breasts may affect her decision to breastfeed. Likewise, though body image shapes a woman's self-concept, self-image has not been systematically represented in breastfeeding literature.
In their study of the breastfeeding practices of Australian women, researchers acknowledged that much of the current breastfeeding literature and education are based on only specific facets of the process and fail to take into account "the interdependence, interaction, and complexity of the breastfeeding experience." They asserted that, "Empirical work that focuses on women's social and emotional experience of breastfeeding is less common" (Schmied and Barclay 1999). A study published in the American Journal of Clinical Nutrition decades earlier supports this observation: "Perhaps if more emphasis were placed on the total feeding experience, rather than on the mechanical...more comprehensible relationships would be found" (Newton 1971). Taking this a step further, such sociocultural influences may stop a woman from beginning breastfeeding at all, or cause her to end it before she was ready, but for lack of study, the relationship between body image and the likelihood that it could influence breastfeeding decisions is lacking any statistical research.
Society defines women by their appearance. This cultural paradigm is so pervasive that women characterize their own worth by how they look. Individual body parts take on meanings and functions not necessarily based on biological purpose. This varies culturally and geographically, with one culture finding bizarre the ideals of another. A woman's breasts, for instance, are especially vulnerable to scrutiny because Western culture places so much erotic or sexual value on a body part whose function is infant nourishment. "Sexual references and excitement accompanying breastfeeding are unacceptable and in turn generate shame and anxiety, interfering with successful breastfeeding" (Hughes 1984). The basic nature of the breastfeeding relationship, however, is inherently sensual -- the touch of skin on skin, the sensations produced as the baby suckles, the feelings associated with the release of milk. This culturally based sexual taboo directly affects the initial infant feeding decision. Women's breasts are relegated to the category of sexuality, essentially to be used for the pleasure of the woman's partner. Many articles in popular parenting magazines perpetuate this notion with tips on how to treat the man's feelings about the baby using "his" breasts. This patriarchal attitude toward women's bodies can be dangerous to infant health if it leads to lower incidence of breastfeeding.
Body image can basically be defined as the mind's picture of the personal body and accompanying thoughts, feelings, and perceptions. Researchers further defined classifications of body image including body esteem (positive or negative feelings about one's body), body satisfaction (satisfaction with an aspect of one's body), and body distortion (size estimation accuracy). These researchers stated that not only personal perceptions, but also "social and interpersonal factors," have a tremendous impact on a woman's body image, with feelings such as fear of negative peer appraisal and social avoidance being predominant indications of body image disturbance (Thompson et al. 1999).
In relation to breastfeeding, body image disturbance traits may influence a woman's initial decision to breastfeed, as well as possibly promote discomfort within the breastfeeding relationship, causing early cessation. Women who are initially more conscious of social judgments of body image may not have the confidence to display their body as a vessel of infant nourishment, even in the relative privacy of their own homes, and thus, may opt for bottle-feeding in an effort to discourage a focus of attention on their bodies. Women who do breastfeed and encounter negative or sexual messages about their bodies during this time, whether real or imagined, may stop breastfeeding to shift the focus from themselves and to feel more comfortable about their own bodies.
In the Journal of Psychosomatic Research, Foster et al. stated that, "In nonpregnant women, body satisfaction has a fundamental association with mood, self-esteem, relationships, and eating behavior." Other researchers have found that women who have a positive self-image will be more secure in sexual relationships and intimate situations (Hoyt and Kogan 2001). As a continuum of pregnancy and birth, breastfeeding is considered an intimate act within the realm of a woman's sexuality. Foster et al. concluded that a correlation exists between body satisfaction and choice of infant feeding method. Monteath and McCabe (1997) suggested that although societal ideals influence a woman's body satisfaction, the degree of sway is balanced by a woman's self-esteem. Breastfeeding may increase a woman's self-esteem and may therefore act as a mediating factor for body satisfaction in the postpartum period. The differences in conclusions of these two studies highlight the need to form connections between body awareness, self-esteem, and breastfeeding through methodical study.
Many body image studies have been performed to evaluate how women feel about individual body parts, as well as the body as a whole. McAllister and Caltibiano (1994) confirmed that women are more sensitive to any perceived departure from the norm and base self-esteem on their weight, relative to the current ideal. Very few of these experiments, though, focus on breasts. What factors, then, determine a woman's satisfaction with her breasts in particular?
In Breastfeeding and Human Lactation, breasts are described as "Part of a woman's internalized body image...represent[ing] a woman's deepest sense of womanhood. Any change in her breasts... threatens this feminine internal view of self" (Riordan and Auerbach 2005). Breast size has been found to be an indicator of female attractiveness in the context of Western culture (Furnham, Dias, and McClelland 1998; Jones 2004; Latteier 1998). A study published in Issues in Comprehensive Pediatric Nursing found a relationship between breastfeeding and a woman's perception of how society judges her breasts. The changes associated with lactation alter the way women perceive a part of themselves, thus, their feeling of attractiveness. The need to redefine the breasts based on the changes taking place then shapes the decision made about infant feeding method (Hughes 1984).
Researchers in Italy (Pisacane and Continislo 2004), however, found that while women notice breast changes, they are not associated with whether or not breastfeeding is chosen in this population. Another study, this time in Israel, also found body image unrelated to the breast or bottle-feeding variable, though the measure they used may not have been adequate to judge body image disturbance (Tzuriel and Weller 1990). The question that comes from this is what might make women in one culture less susceptible to the influence of body image on breastfeeding than in other cultures.
Several studies of body image provide details of its relationship to breastfeeding. One group of researchers determined that women who are more concerned with the shape of their bodies are "less likely to express intentions to breastfeed." These researchers found that women without body image disturbance were 1.25 times more likely to breastfeed than "women who had marked concerns about their body shape," with this effect presenting itself up to four weeks postpartum. The study also found that while concern about body shape was a predictor of breastfeeding behavior, maternal weight concern had a very small effect (Barnes et al. 1997). Other researchers found that though women exhibited body dissatisfaction in the postpartum period, "none of body satisfaction . . . variables correlated significantly with intended breastfeeding duration" (Abrahams and Fawkner 1999). In a 2004 study of the interrelationship between infant feeding decision, body image, and attachment, researchers found that "women who chose breastfeeding had a more positive pre-pregnancy body image than women who chose bottle-feeding" (Huang, Wang, and Chen 2004).
In her study of body image in pregnancy and the postpartum period, McCarthy found that "despite the dramatic body-altering experience of pregnancy, pregnant women's affective evaluations of their body...did not change over time." Although she did not find a correlation between body image and breastfeeding, her research did conclude "traditional assumptions about why women do not breastfeed (i.e., lack of education about the benefits) were not borne out by this study." Because McCarthy did not focus primarily on breastfeeding, but included it as a measure of maternal adjustment, the scales she used may have been ineffective in detecting a relationship. McCarthy noted that in free response sections of her questionnaires, women cited the following reasons for not breastfeeding: "embarrassment at exposing their breasts," "ambivalence about breasts as sexual and nutritional," "lack of confidence in their milk supply," and "worries that nursing will damage their breasts." Though she found no direct correlation between breastfeeding and body image, McCarthy's anecdotal evidence for a connection is important as a guiding factor for further study.
A study published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing established that body dissatisfaction contributes to the "critical nature of the postpartum period" (Strang and Sullivan 1983). Researchers report that women with a higher body mass index stop breastfeeding sooner (Hilson 2004; Lauwers and Swisher 2005). Breastfeeding: A Guide for the Medical Profession notes, however, at one month postpartum, women who breastfeed feel less stress and are adapting better to life with a baby (Lawrence and Lawrence 2005). Stress is problematic in nursing mothers. Stress impairs the onset of lactation (Dewey 2001) as well as possibly affecting the success women have in maintaining a favorable milk supply. General body image research has documented a positive correlation between body dissatisfaction and stress (Campbell and Chow 2000). Other researchers remark that body dissatisfaction may lead to depression (Walker and Wilging 2000; Tiggeman and Lynch 2001). Stress and depression associated with body image may be mediated by breastfeeding, or breastfeeding may not be initiated because of stress and depression. These reciprocal relationships should be studied to determine their validity.
Several limitations to the study of body image and breastfeeding need to be addressed. African-American women have the lowest rates of breastfeeding at all time periods measured (Department of Health and Human Services 2000). Studies have shown, however, that African-American women are less likely to suffer from eating disorders than their Caucasian counterparts, and are more likely to have a better estimation of their body size (less body image distortion) (Wildes, Emery, and Simons 2001). Body image, therefore, is not a target area for increasing breastfeeding rates within this subgroup. The number of times a woman has given birth may also influence the level of body image disturbance. In 1985, Strang and Sullivan found that women having had more than one baby are less likely than first-time mothers to exhibit concern over body changes occurring with pregnancy and the postpartum period. The researchers attributed this to two possible causes, one being more realistic expectations based on experience for the mother of more than one child, and the other being a shift in priorities for this group trying to juggle the demands of other children along with a new infant. Because first-time mothers have no experience with the postpartum adjustment, they are more likely to exhibit body image disturbance symptoms when they do not return to their pre-pregnant shape as soon as they would like. Other factors that prove difficult to measure, however, could have a direct influence on infant feeding decisions in relation to body image, including exposure to mass media depictions of beauty ideals and personal exposure to other breastfeeding mothers before pregnancy. These areas deserve study in their own right.
Finding an association between body image and breastfeeding could have a very practical application. By screening women prenatally, health professionals can identify those whose body image disturbance is enough to affect the infant feeding decision and target them for intervention. Programs can be tailored to individual women to help them redirect their body image behaviors, or to help them become more comfortable with their own bodies. Barnes et al. (1997) proposed that since eating disturbances have proven treatable with cognitive therapy, body image disturbance during the perinatal period (e.g. that period prior to and following birth) could be effectively remedied with the same treatments. By determining the ways a woman's perception of herself might affect her decision-making about infant feeding, breastfeeding counselors and advocates can create programs to more effectively target the concerns and meet the needs of new mothers.
Foster, Slade, and Wilson (1996) reported that the much relied upon educational campaigns may no longer be able to increase breastfeeding rates. According to 1998 statistics from the United States Department of Health and Human Services, 64 percent of women in the United States breastfeed in the early postpartum period, with that number dropping to 29 percent and 16 percent at six months and one year, respectively. These numbers fall short of the goals set in the Healthy People 2010 agenda and reflect the trends in some other nations, though not all. The Department of Health and Human Services concluded their paper with the recommendation that professionals "conduct research that identifies the social, cultural, economic, and psychological factors that influence infant feeding behaviors."
While the educational programs launched to convey the benefits of breastfeeding often focus on the health of the baby, the focus needs to shift to the decision-making process that mothers go through in making infant feeding choices, including the effect body image has on breastfeeding initiation and duration. The importance of undertaking studies to determine the sociocultural influences on breastfeeding decisions is a prerequisite for development of new educational programs and interventions. Before any increases in breastfeeding rates can occur, true underlying causes of breastfeeding attrition, as well as barriers to breastfeeding initiation, must be identified and addressed to best meet the needs of mothers and to best provide for the health of future generations.
How can we as Leaders make sense of all of this conflicting information? Until the right questions are asked and the consistent definitions are used, we may never see studies that show a clear relationship between breastfeeding success and positive body image. Perhaps the correlation is weak. But perhaps not. And we owe it to women and babies to find out.
As Leaders, one of the most important points we can take from this information is the essential need to "meet women where they are." Self-image is a complex and deeply seated aspect of personality that is formed for most women long before they face decisions about breastfeeding. LLL Leaders are unlikely to have the skills or influence to make much of a dent in another woman's self image. We do not often have the chance to influence the decision to initiate breastfeeding unless women come to meetings when they are pregnant, or seek our assistance immediately after birth. We can, however, project a positive breastfeeding image for the benefit of anyone we interact with. The way we confidently use our breasts for their original intent -- the way we breastfeed naturally -- says more than any interventions or conversation could ever possibly convey.
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