Throughout my adulthood, I have been struck by the ways in which culture and societal norms color our understanding of reality. Have you ever paused in the middle of something that you do all the time and wondered why we do it that way? As a medical student, I have become especially intrigued by this concept as it relates to science and health. In the politically conservative community where I grew up, the pretenses imposed by antiquated tradition too often eclipse scientific fact in ways that are physically harmful and emotionally scarring. These traditions are frequently based in overly simplistic, patriarchal interpretations of religious doctrine.
A recent episode of “Freedom Road” podcast, by Lisa Sharon Harper, explores the intersections between religion, race, and reproductive justice. It includes evangelical journalist Andrea Lucado’s take on the matter. As Lucado explains the concept of “purity culture” in White Evangelical communities, she references the tendency for the female body to be used as a “scapegoat” throughout modern history.[1] Girls and women in evangelical circles are often taught that their bodies are objects of impure sexual desire and must be covered in order to protect boys and men from the sins of lust. In many religious communities like the Southern Baptist church where I grew up, the idea of “the flesh” is synonymous with sin. That is the mentality I once held as truth.
However, now as a physician in training, I have developed a deep appreciation for human anatomy, which has become foundational to my identity. Are we capable of sin and destruction? Absolutely. But to reside in a creationist theology and still view sin as the predominant quality of the human body grossly misinterprets and underestimates a complex and fascinating work of divine artistry. As the human body has become less taboo in my mind and as my perspectives on human life have expanded, I have begun to question… well… everything I ever accepted for certain.
Today I am pondering the influences of deep-seated cultural norms on our ideas about breastfeeding, both in my own culture of origin, and in others. I wonder if the stigma about breastfeeding in Southern Evangelical culture stems, at least in part, from the over-sexualization of female breasts. There are a multitude of opinions surrounding this natural process: about modesty, gender issues, policy, health, nutrition, and more. I wonder if the fact that my sister’s children are boys also adds to the stigma she experiences while breastfeeding them, as if a boy should begin to behave in a traditional, paternalistically “manly” way before he is even toilet trained. It seems bizarre, but I have heard the shaming comments myself, as relatives have repeatedly exerted their opinions that my 16-month-old nephew is too old to breastfeed. They mean to insinuate that he will somehow become a weaker adult for having been nursed for longer than 6 months. However, there is more evidence to suggest the opposite, as longer duration of breastfeeding has been correlated with increased intelligence[2] and decreased incidence of mental illness in adolescence and adulthood.[3] Longer durations of breastfeeding have also been associated with improved cognitive and motor development in young children.[4] It makes sense that these effects early in life would impact a person’s childhood and adolescent development in ways that would inform their sense of self and impact their life course, in avenues such as education attainment, relationship building, and overall efficacy.
The Surgeon General issued a call to action to support breastfeeding in 2011, citing the myriad of health benefits for the infant (protection from infections and lower risk of diseases such as asthma, obesity, and SIDS) and for the mother (decreased risk of breast and ovarian cancer). Their report also lists obvious economic advantages, with breastfeeding families saving $1,200 to $1,500 on infant formula in the first year, and an estimated $13 billion that the US would save annually from reduced medical and other costs if 90% of families breastfed for six months. It seems well known and widely accepted that an infant benefits from receiving human milk for the first six months of life. However, for the reasons I mentioned above, the World Health Organization, American Academy of Family Physicians, and American Academy of Pediatricians, all recommend that families continue to breastfeed for at least two years, continuing beyond that for “as long as mutually desired by mother and child.”[5]
Despite the evidence supporting breastfeeding, we know that stigma against breastfeeding still exists. And it differs considerably from one social context to another. Enslaved women in the Antebellum South were often forcefully separated from their own infants and forced to work as “wet nurses” breastfeeding slave owners’ children instead of their own.[6] I learned in a recent Grand Rounds on breastfeeding at St. Christopher’s Hospital that tales of these women’s plight have been passed down through generations in Black communities and are understandably entangled in the stigmas held against breastfeeding in the immediate and adjacent social circles of these women’s descendents. African American infants persistently demonstrate lower rates of breastfeeding, as compared with the general population.[7] This may be due in part to stigma stemming from injustices historically imposed upon enslaved African American women, but it is like compounded by systemic racism. Women in Black communities disproportionately experience social and financial barriers to breastfeeding, such as decreased social and workplace support and lack of financial resources. A scoping literature review in the Journal of Midwifery and Women’s Health highlights bias in the care of African American women. Healthcare providers’ assumptions that these mothers were less likely to breastfeed their infants resulted in decreased lactation support referrals.[8] Postpartum African American mothers also return to work sooner than any other ethnic group and are more likely to work in hourly wage positions, without paid maternity leave or supportive environments for lactation.[9] Clearly, we as a society have work to do.
All hope is not lost, though! In her TED talk, co-founder of Mamava lactation suites Sascha Mayer explores the visibility of breastfeeding mothers. She contrasts her own breastfeeding experience, in a supportive, progressive corporate work environment, with the experiences of mothers whose jobs do not provide a clean place to sit and pump breast milk, much less allow for paid maternity leave. She acknowledges the need for normalizing breastfeeding and supporting breastfeeding mothers in all walks of life, so that this essential part of the human life cycle will be a right, not a privilege. She then elegantly notes that innovation happens when people who are living in the world help to redesign the world. Problems are solved when people notice, think about, and discuss them.
On that note, if you are like me, you may be wondering, what can I do to help? A Google search for “how to support breastfeeding mothers” returns a solid set of starting points, for family members and strangers alike. A blog post from The Bump offers a few simple and practical ways to help, including ideas for what to say and what not to say to a breastfeeding mom. (Hint: encouragement and strength identification is much more welcomed than unsolicited advice.) And if you’re interested in a slightly deeper dive, I recommend the CDC’s 60 page guide on the topic, which covers strategies for supporting breastfeeding moms in six different settings, as well as ideas for education and marketing. The guide is fittingly filed under the CDC umbrellas of “strategies to prevent obesity and other chronic diseases.”
In summary, breastfeeding is a personal choice, but it is also a fundamental right and an integral element of human existence that is unfortunately not equally available to all. For the majority of individuals, the benefits of breastfeeding are well-studied and long-lasting. The consensus among leading professional health organizations is that children should breastfeed at least until age two years, and as long after that as the mother and child desire. (Of note, adjacent to the scope of this discussion, there is a short list of medical contraindications to breastfeeding, and in those cases, families have many options for appropriate nutritional substitutions.) Despite the numerous benefits to breastfeeding, it remains fraught with stigma in many cultures. Improving public awareness of the benefits of breastfeeding as well as the working to eliminate social and structural barriers will hopefully lead to progress in terms of access, acceptance, and support.
REFERENCES
[1] Harper LS (Host). Freedom Road: It’s Time to Talk About Abortion and Reproductive Justice [Audio podcast]. United States. 2020. Retrieved from https://freedomroad.us/2020/03/abortionreprojustice/
[2] Mortensen EL. Lifecourse Consequences of Breastfeeding. Lancet Global Health, 2015;3(4). doi:10.1016/S2214-109X(15)70078-1
[3] Oddy WH, Kendall GE, Li J, et al. The Long-Term Effects of Breastfeeding on Child and Adolescent Mental Health: A Pregnancy Cohort Study Followed for 14 Years. The Journal of Pediatrics. 2010;156(4):568-574. doi:10.1016/j.jpeds.2009.10.020
[4] Bernard JY, Agostini MD, Forhan A, et al. Breastfeeding Duration and Cognitive Development at 2 and 3 Years of Age in the EDEN Mother–Child Cohort. The Journal of Pediatrics. 2013;163(1). doi:10.1016/j.jpeds.2012.11.090
[5] American Academy of Family Physicians. (2020). Breastfeeding, Family Physicians Supporting (Position Paper). Retrieved from https://www.aafp.org/about/policies/all/breastfeeding-position-paper.html#keyrecommendations
[6] West, E., & Knight, R. J. (2017). Mothers’ milk: slavery, wet-nursing, and black and white women in the antebellum South. Journal of Southern History, 83(1), 37+. https://link.gale.com/apps/doc/A481354129/AONE?u=drexel_main&sid=AONE&xid=38411e8f
[7] Office of the Surgeon General. (2011). Breastfeeding: Surgeon General’s Call to Action. Retrieved from: https://www.hhs.gov/surgeongeneral/reports-and-publications/breastfeeding/factsheet/index.html
[8] Robinson, K., Fial, A. and Hanson, L. (2019), Racism, Bias, and Discrimination as Modifiable Barriers to Breastfeeding for African American Women: A Scoping Review of the Literature. Journal of Midwifery & Women’s Health, 64: 734-742. doi:10.1111/jmwh.13058
[9] Researchers from University of Michigan Describe Findings in Breastfeeding (Overcoming Workplace Barriers: A Focus Group Study Exploring African American Mothers’ Needs for Workplace Breastfeeding Support). (2015, August 20). Women’s Health Weekly, 2987. https://link.gale.com/apps/doc/A425591399/AONE?u=drexel_main&sid=AONE&xid=b5df7e72
