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Breast feeding yesterday and today
MIDWIFERY, 1985, l, I62 166 © Longman Group I985
I N F A N T FEEDING
Breast feeding yesterday and today Louise Silverton
T h i s article reviews the factors responsible for the previous decline a n d recent slight rise in the p o p u l a r i t y o f b r e a s t feeding, f r o m a historical s t a n d p o i n t , it considers the e c o n o m i c a n d social c h a n g e s w h i c h h a v e p r o d u c e d a r a p i d a l t e r a t i o n in the role of w o m e n leading to possible conflict with their biological position as mothers. C o m p a r i s o n s are m a d e b e t w e e n the situation c u r r e n t in the W e s t a n d t h a t w h i c h is n o w d e v e l o p i n g in the T h i r d World.
Lactation is a very ancient process, predating placental gestation, it stretches back over 200,000,000 years (Jelliffe, 1976). Lactation was ideally suited to man's role as a hunter and food gatherer, it is only in the last 10,000 years that agriculture has become increasingly important and man has become a tender of milk producing animals. There has been, over the years, a constant search to find a substitute for h u m a n breast milk, both as an aid to the survival of orphaned infants and to free women from the 'shackles' of lactation. The latter either for social reasons or to allow the woman to contribute to the economic activity of the family. Prior to the last 50 years, the only viable alternative was the employment of a wet nurse who would suckle the infant for payment, to the detriment of her own child (Jelliffe and Jelliffe, 1978). The wet nurse has played a very important role thoughout history, sometimes exercising influence over her charge long after the period of physical dependence had passed. From the Seventeenth Century it was rare for the wives of nobles or gentlemen to suckle their own Louise 8ilverton, 5, Okehampton Crescent, Sale, Cheshire. Manuscript accepted 20 Feb. 1985
162
children, a situation which persisted until after World W a r II (McLaren, 1978).
THE DECLINE IN BREAST FEEDING The reason for the decline in breast feeding in technological urban societies is muhifactorial. Meyer (1968) has demonstrated a decline in the levels of breast feeding from representative hospitals in the United States of America. At 10 year intervals the rate fell from 38% in 1946 to 21 °/o in 1956 and finally to 18% in 1966. Lactation would not have declined as fast or as far without the availability of acceptable substitutes, initially of unmodified cows milk but now extensively adapted to fit a quasi-human scientific formula. The work of Pasteur, the availability of a clean water supply and the improving educational standard of urban communities have helped to reduce the mortality of the artificially fed infant, which was initially considerably higher than that of the breast fed infant (Vahlquist, 1981). Harworth (1905), reviewing infant deaths in Derby, showed that whereas 7% of breast fed babies were dead by the end of their first year, the figure rose to 19.8% for those infants who were never breast fed. Even with improved public health in the Developed World, artificial feeding today is a far
MIDWIFERY
from simple procedure. Jones and Belsey (1978), in a survey of infant feeding practices in an inner London borough, showed that mistakes in preparation of artificial feeds were common, very few of the mothers following manufacturers advice and instructions. Feeds were both over and under concentrated, cereals and sugar were added to the bottles and concentration was sometimes guaged by the colour of the milk. It was noted that the frequency of errors increased with the parity of the mother.
Concerning the unpopularity of breast feeding This next section contains a summary of some of the contributory factors to the decline in the numbers of women who start and continue to breast feed their babies. It has been freely adapted from work by Vahlquist (1975) and by Jelliffe (1976). The move from rural to urban societies (with increasing industrialisation and the changing status of women), begun in the years of the Industrial Revolution is still continuing in the West and is gathering pace in many areas in the Third World. The two World Wars promoted a more emancipated female role by using women's labour on a more extensive scale. Whereas the rural woman can take her child with her into the fields and markets, this is not possible for her factory employed urban sister. A consequence ofurbanisation is the increased mobility of families with a reduced likelihood of close support for the lactating mother from female relatives. This leaves the woman open to commercial influences which stress the alleged convenience of artificial feeding and the superiority of anything which is technical or scientific. The Western attitude to female breasts with stress on sexual rather than reproductive and lactational functions has led to a decline in feeding. Masters and Johnson (1966) noted that it was objections to feeding by the father which led over 60% of women in their study to cease breast feeding. Hall (1978) found that having seen a baby being breast fed is an important influence on the choice of feeding method. The increasing non-acceptance of feeding in public make the
163
chances of a girl seeing anyone other than a close relative suckling a baby rather rare (Hall, 1978). The International Labour Organisation has laid down a convention on the rights of the breast t~eding mother at work, this recommends flexible hours and feeding breaks (War on Want, 1979). Provision of feeding facilities is still a rare occurrence in the United Kingdom and United States of America, many women stopping feeding in order to return to work, assisted in their decision by the availability of subsidised formula feeds through hospitals or health centres (thus further increasing their acceptability). Health Education, to the general public, on breast feeding is at a minimum or absent especially through the mass media where babies are usually seen being bottle fed. Even children's dolls often come with a toy feeding bottle! War on Want (1979) have stressed the importance of a positive attitude to feeding by health workers, they deplore the recruiting of professionals to promote commercial milk products. The low priority given to breast feeding in many medical syllabi together with the prescribing of lactation inhibitors such as oral contraceptives have further hastened the decline in feeding rates (War on Want, 1979). Changing patterns in child birth in the 1960's and 70's such as hospital deliveries with separation of mother and baby and imposition of scheduled feeding regimes, (originally intended for use only when artificial feeding was employed) reduce the stimulation necessary for establishment of milk supply.
Recent trends in breast feeding The numbers of babies receiving any breast milk at all reached a low in the United Kingdom in the late 1960's. Since then there has been an upsurge of interest and a rising level of mothers breast feed their babies. In 1968 only 14% of babies discharged from an Edinburgh maternity hospital were being beast fed, by 1980 this had risen to approximately 60°/o (Howie and McNeilly, 1968). The prevalence of breast feeding amongst mothers in England and Wales in 1980 was greater at all ages (of babies) up to 9 months than it had been in 1975 (Martin and Monk, 1982).
164
MIDWIFERY
Despite this increase only 26% of women in the U.K., totally breast fed for as long as the four months recommended by the Department of Health and Social Security (1980), and 19% of mothers who began breast feeding in 1980 had stopped by 2 weeks after delivery (Martin and Monk, 1982). The World Health Organisation (W.H.O., 1981) states that most mothers should be capable of at least 6 months breast feeding, with supplementary foods introduced from 4 to 6 months. A study with more detailed recommendations concluded that unsupplemented breast milk is all that is required to maintain good growth and nutrition during the first 6 months of life for babies of well nourished mothers (that is--those who have produced babies with good food stores, have themselves sufficient stores including s u b c u taneous fat and are well nourished during lactation) (Jelliffe et al., 1975). Prolonged feeding is all the more important where there is no satisfactory weaning food and where its birth spacing effects are necessary to ensure the health of each child (Jelliffe and Jelliffe, 1978).
Who are the breast feeders? In the United Kingdom the mothers most likely to breast feed are of higher social class, have had longer schooling, are having their first babies, are older and are more likely to live in the South East of England (Martin and Monk, 1982). The greatest increase in breast feeding between 1975 and 1980 though was amongst mothers having their second or subsequent children, an 18% rise compared with an increase amongst first babies of 14%. Martin and Monk do not think it likely that the increase (which occurs across all categories of age, parity and social groups) occurs through a connection with the mothers' own characteristics. Their probable explanation is that it is due to changes in policies and practices of health professionals together with increased publicity about the health benefits of breast feeding. The part played by fashion trends has not yet been fully described but it may be considerable. Are we only now recovering from the low status ascribed to
breast feeding in the 1960's and its influence on the professionals who trained during that period? It is interesting to note that whilst primiparae are most likely to choose to breast feed, it is the multiparous woman who is most successful (Martinez and Nalezienski, 1979; Martin and Monk,
1982). There may be a physiological explanation in that repeated pregnancies led to improved breast and nipple development with improved lactation (Hytten, 1976). W h a t is impossible to quantify is the effect of the mother feeling more at ease with each subsequent child. Sjolin et al. (1977) found that mothers who fed longest enjoyed breast feeding, were well educated, over 25 years old, belonged to upper social classes and were married or co-habiting with the child's father, findings which have been repeated throughout the Western World.
The situation in developing countries In developing countries breast feeding is still more common amongst traditional rural communities and the urban poor than amongst the urban elite (professional and business groups). The latter have adopted western patterns ofbehaviour and, in the case of artificial feeding, without many of the necessary conditions for safe use having been met (W.H.O., 1981). It remains to be seen how long the poor in Third World Countries can resist the pressures to Westernise and the blandishments of the infant food manutacturers. This circumstance of increasing westernisation must be viewed in relation to the allocation of scarce resources. It is in order to squander scarce foreign exchange to purchase an expensive commercial substitute for a cheap, locally available product which is better on all grounds? Hally et al. (1984) emphasise the importance of social climate in the decisions about infant feeding; the strength of influences from peer and cultural groups should never be under-estimated. It has been shown amongst immigrant groups in Glasgow that traditional breast feeding behaviours are dropped soon after arrival, being replaced by artificial feeding as practised by the indigenous population (Goel et al., 1978). It is interesting to speculate whether there would have
MIDWIFERY
been similar changes in feeding m e t h o d if the mothers h a d moved into an a r e a where breast feeding p r e d o m i n a t e d .
Social climate Social aspects can affect the choice of feeding method. H a l l y et al. (1981) d e m o n s t r a t e d in Newcastle that there was a strong association with housing tenure; amongst o w n e r occupiers, 75% mothers chose to breast feed as d i d 70c}/o of mothers in privately rented a c c o m m o d a t i o n , b u t only 3 8 % of mothers in council owned p r o p e r t y breast fed their babies. T h e g r e a t e r the n u m b e r of persons in the house, the less likely the m o t h e r was to breast feed i n d i c a t i n g the i m p o r t a n c e of privacy. These findings m a y in p a r t be d u e to social class b u t they do not explain the difference between privately a n d council o w n e d rented accommodation. T h e social a c c e p t a b i l i t y of feeding m e t h o d in a specific society is i m p o r t a n t in influencing choice (Bentovim, 1976). W o m e n ' s L i b e r a t i o n (which h a d its greatest i m p a c t a m o n g s t b e t t e r e d u c a t e d women) has been a c c o m p a n i e d by a n increase in breast feeding amongst professional groups (Brack, 1975). W h e r e a w o m a n ' s friends were satisfied with their choice of breast feeding, she is more likely to a d o p t the same m e t h o d (Jones and Belsey, 1977). I n addition, Bacon a n d Wylie (1976) have d e m o n s t r a t e d the strong influence exerted by the feeding m e t h o d b y which the m o t h e r herself h a d been fed whilst a b a b y , breast fed babies become breast feeding mothers. W e now have two or three generations o f w o m e n who have not been breast fed, this means there is no core of knowledge a n d expertise to be h a n d e d on, p u t t i n g even more strain on the m o t h e r who a t t e m p t s to breast feed.
Times of hardship W o r k done following experiences d u r i n g W o r l d W a r I I has shown the most h e a l t h y (although possibly underfed) mothers can nurse successfully if inclined psychologically to do so. Despite ordeals amongst E u r o p e a n w o m e n in Singapore prisoner of w a r camps, of twenty babies b o r n in captivity, all were breast fed a n d all survived
165
(Williams, 1947). Similarly, R i c h a r d s o n (1960) showed that prior to G e r m a n o c c u p a t i o n only 38% of F r e n c h babies were breast fed whereas the figure rose to 9 0 % feeding successfully when artifical milk was scarce or unavailable.
CONCLUSION Whilst authorities are b e c o m i n g increasingly aware of the benefits of breast feeding, m a n y o f the factors discussed in this article are not a m e n able to professional intervention. T h a t being said there are certain Social reforms such as the statutory provision of feeding breaks in the w o r k place which would do m u c h to facilitate breast feeding. W o m e n in the W e s t e r n W o r l d are increasingly turning to lay self-help groups such as T h e N a t i o n a l C h i l d b i r t h T r u s t and the L a Leche League for s u p p o r t a n d guidance. T h e role of such organisations m i g h t be extended and help offered in c o m b i n a t i o n with professionals to give a more b a l a n c e d a p p r o a c h and encourage the furtherance of breast feeding on into the T w e n t y First Century.
References Bacon CJ, Wylie JM 1976 Mothers' attitudes to infant feeding at Newcastle General Hospital in Summer 1975, British Medical Journal 1:308 309 Brack DC 1975 Social forces, feminism, and breast feeding, Nursing Outlook 23: 8. 556 61 Bentovim A I976 Shame and other anxieties associated with breast feeding, In Breast feeding and the Mother p 159-78 Ciba Foundation symposium No 45, Elsevier, Excerpta Medica: North Holland Department of Health and Social Security 1980 Present day Practice in Infant Feeding Para 3,4,12. Report on Health and Social Subjects No 20, D.H.S.S. London Geol KM, House F Shanks RA 1978 Infant feeding practices among immigrants in Glasgow, British Medical Journal 2.1181-1183 Hall J 1978 Influencing breast feeding success,Journal of Obstetrical Gynaecological and Neonatal Nursing 7 Part 6 28-32 Hally MR, Bond J, Crawley J, Gregson BA, Philps P, Russell I 1981 A study of Infant Feeding, Report No. 21 Health Care Reserch Unit, University of Newcastle-upon-Tyne Hally MR, Bond J, Crawley J, Grcgson B, Philps P, Russell I 1984 What influences a mother's choice of infant feeding method?, Nursing Times 8:4 65-68 Harworth WJ t905 The influence of feeding on the Mortality of Infants, Lancet 2. 210 13 Howie PW, McNeilly AS 1980 Initiation of Lactation,
166
MIDWIFERY
Midwife and Health Visitor and Community Nurse 16:4 142 7 Hytten FE 1976 The physiology of lactation, Journal of Human Nutrition 30:225-232 Jeltiffe DB, Gurncy M, Jelliffe EFP 1975 Unsupplemented Human Milk as the sole food of the Exterogestate fetus, Proceedings of the IXth International Nutrition Congress, Mexico City, 2: p 77 August 1972. Jelliffe DB 1976 Community and sociopolitical considerations of breast feeding, In Breast feeding and the Mother p 231 55 Ciba foundation symposium No 45, Elsevier, Excerpta Medica: North Holland Jeffiffe DB, Jelliffc EFP 1978 Human Milk in the Modern World, Oxford University Press: Oxford Jones R, Belsey EM 1977 Breast feeding in an inner London Borough, a study of'cuhural [actors, Social Science and Medicine 11 175-179 Jones R, Belsey EMC 1978 Common Mistakes in Infant Feeding, Survey of a London Borough, British Medical Journal 2:112 114 Martin J, M o n k J 1982 Infant feeding 1980, Office of population censures and survey: London Martinez GA, Nalezienski J P 1979 The recent trend in breast t~eding, Pediatrics 64: 5. 686-92 Masters W, Johnson V 1966 Human Sexual Response, Little Brown, Boston
McLarcn D 1978 Fertility--inlhnt mortality and breast t~eding in the Seventeenth Century, Medical History 22: p 378-96 Meyer HF 1968 Breast feeding in the United States, Clinical Pediatrics 7:708-15 Richardson FH 1960 Breast feeding: Going or Coming? and Why? North Carolina Medical Journal March 1960 p 102 Sjolin S, Hofuander Y, Hillervik C 1977 Factors related to early termination of breast t~eding, Acta Paediatrica Scandanavia 66:505-11 Vahlquist B 1975 The evolution of breast feeding in Europe, Journal of Tropical Pediatrics and Environmental Child Health 22:50 Vahlquist B 1981 lntrocution. In Contemporary Patterns of Breast feeding, World Health Organisation, Geneva War on Want 1979 The Baby Killer Scandal, War on Want. London Williams CD 1947 Nutritional conditions among women and children in internment in the civilian camp in Singapore, Proceedings of the Nutritional Society 5: 127 132 World Health Organisation 1981 Contemporary Patterns of Breast feeding WHO. Geneva
I N F A N T FEEDING
Breast feeding yesterday and today Louise Silverton
T h i s article reviews the factors responsible for the previous decline a n d recent slight rise in the p o p u l a r i t y o f b r e a s t feeding, f r o m a historical s t a n d p o i n t , it considers the e c o n o m i c a n d social c h a n g e s w h i c h h a v e p r o d u c e d a r a p i d a l t e r a t i o n in the role of w o m e n leading to possible conflict with their biological position as mothers. C o m p a r i s o n s are m a d e b e t w e e n the situation c u r r e n t in the W e s t a n d t h a t w h i c h is n o w d e v e l o p i n g in the T h i r d World.
Lactation is a very ancient process, predating placental gestation, it stretches back over 200,000,000 years (Jelliffe, 1976). Lactation was ideally suited to man's role as a hunter and food gatherer, it is only in the last 10,000 years that agriculture has become increasingly important and man has become a tender of milk producing animals. There has been, over the years, a constant search to find a substitute for h u m a n breast milk, both as an aid to the survival of orphaned infants and to free women from the 'shackles' of lactation. The latter either for social reasons or to allow the woman to contribute to the economic activity of the family. Prior to the last 50 years, the only viable alternative was the employment of a wet nurse who would suckle the infant for payment, to the detriment of her own child (Jelliffe and Jelliffe, 1978). The wet nurse has played a very important role thoughout history, sometimes exercising influence over her charge long after the period of physical dependence had passed. From the Seventeenth Century it was rare for the wives of nobles or gentlemen to suckle their own Louise 8ilverton, 5, Okehampton Crescent, Sale, Cheshire. Manuscript accepted 20 Feb. 1985
162
children, a situation which persisted until after World W a r II (McLaren, 1978).
THE DECLINE IN BREAST FEEDING The reason for the decline in breast feeding in technological urban societies is muhifactorial. Meyer (1968) has demonstrated a decline in the levels of breast feeding from representative hospitals in the United States of America. At 10 year intervals the rate fell from 38% in 1946 to 21 °/o in 1956 and finally to 18% in 1966. Lactation would not have declined as fast or as far without the availability of acceptable substitutes, initially of unmodified cows milk but now extensively adapted to fit a quasi-human scientific formula. The work of Pasteur, the availability of a clean water supply and the improving educational standard of urban communities have helped to reduce the mortality of the artificially fed infant, which was initially considerably higher than that of the breast fed infant (Vahlquist, 1981). Harworth (1905), reviewing infant deaths in Derby, showed that whereas 7% of breast fed babies were dead by the end of their first year, the figure rose to 19.8% for those infants who were never breast fed. Even with improved public health in the Developed World, artificial feeding today is a far
MIDWIFERY
from simple procedure. Jones and Belsey (1978), in a survey of infant feeding practices in an inner London borough, showed that mistakes in preparation of artificial feeds were common, very few of the mothers following manufacturers advice and instructions. Feeds were both over and under concentrated, cereals and sugar were added to the bottles and concentration was sometimes guaged by the colour of the milk. It was noted that the frequency of errors increased with the parity of the mother.
Concerning the unpopularity of breast feeding This next section contains a summary of some of the contributory factors to the decline in the numbers of women who start and continue to breast feed their babies. It has been freely adapted from work by Vahlquist (1975) and by Jelliffe (1976). The move from rural to urban societies (with increasing industrialisation and the changing status of women), begun in the years of the Industrial Revolution is still continuing in the West and is gathering pace in many areas in the Third World. The two World Wars promoted a more emancipated female role by using women's labour on a more extensive scale. Whereas the rural woman can take her child with her into the fields and markets, this is not possible for her factory employed urban sister. A consequence ofurbanisation is the increased mobility of families with a reduced likelihood of close support for the lactating mother from female relatives. This leaves the woman open to commercial influences which stress the alleged convenience of artificial feeding and the superiority of anything which is technical or scientific. The Western attitude to female breasts with stress on sexual rather than reproductive and lactational functions has led to a decline in feeding. Masters and Johnson (1966) noted that it was objections to feeding by the father which led over 60% of women in their study to cease breast feeding. Hall (1978) found that having seen a baby being breast fed is an important influence on the choice of feeding method. The increasing non-acceptance of feeding in public make the
163
chances of a girl seeing anyone other than a close relative suckling a baby rather rare (Hall, 1978). The International Labour Organisation has laid down a convention on the rights of the breast t~eding mother at work, this recommends flexible hours and feeding breaks (War on Want, 1979). Provision of feeding facilities is still a rare occurrence in the United Kingdom and United States of America, many women stopping feeding in order to return to work, assisted in their decision by the availability of subsidised formula feeds through hospitals or health centres (thus further increasing their acceptability). Health Education, to the general public, on breast feeding is at a minimum or absent especially through the mass media where babies are usually seen being bottle fed. Even children's dolls often come with a toy feeding bottle! War on Want (1979) have stressed the importance of a positive attitude to feeding by health workers, they deplore the recruiting of professionals to promote commercial milk products. The low priority given to breast feeding in many medical syllabi together with the prescribing of lactation inhibitors such as oral contraceptives have further hastened the decline in feeding rates (War on Want, 1979). Changing patterns in child birth in the 1960's and 70's such as hospital deliveries with separation of mother and baby and imposition of scheduled feeding regimes, (originally intended for use only when artificial feeding was employed) reduce the stimulation necessary for establishment of milk supply.
Recent trends in breast feeding The numbers of babies receiving any breast milk at all reached a low in the United Kingdom in the late 1960's. Since then there has been an upsurge of interest and a rising level of mothers breast feed their babies. In 1968 only 14% of babies discharged from an Edinburgh maternity hospital were being beast fed, by 1980 this had risen to approximately 60°/o (Howie and McNeilly, 1968). The prevalence of breast feeding amongst mothers in England and Wales in 1980 was greater at all ages (of babies) up to 9 months than it had been in 1975 (Martin and Monk, 1982).
164
MIDWIFERY
Despite this increase only 26% of women in the U.K., totally breast fed for as long as the four months recommended by the Department of Health and Social Security (1980), and 19% of mothers who began breast feeding in 1980 had stopped by 2 weeks after delivery (Martin and Monk, 1982). The World Health Organisation (W.H.O., 1981) states that most mothers should be capable of at least 6 months breast feeding, with supplementary foods introduced from 4 to 6 months. A study with more detailed recommendations concluded that unsupplemented breast milk is all that is required to maintain good growth and nutrition during the first 6 months of life for babies of well nourished mothers (that is--those who have produced babies with good food stores, have themselves sufficient stores including s u b c u taneous fat and are well nourished during lactation) (Jelliffe et al., 1975). Prolonged feeding is all the more important where there is no satisfactory weaning food and where its birth spacing effects are necessary to ensure the health of each child (Jelliffe and Jelliffe, 1978).
Who are the breast feeders? In the United Kingdom the mothers most likely to breast feed are of higher social class, have had longer schooling, are having their first babies, are older and are more likely to live in the South East of England (Martin and Monk, 1982). The greatest increase in breast feeding between 1975 and 1980 though was amongst mothers having their second or subsequent children, an 18% rise compared with an increase amongst first babies of 14%. Martin and Monk do not think it likely that the increase (which occurs across all categories of age, parity and social groups) occurs through a connection with the mothers' own characteristics. Their probable explanation is that it is due to changes in policies and practices of health professionals together with increased publicity about the health benefits of breast feeding. The part played by fashion trends has not yet been fully described but it may be considerable. Are we only now recovering from the low status ascribed to
breast feeding in the 1960's and its influence on the professionals who trained during that period? It is interesting to note that whilst primiparae are most likely to choose to breast feed, it is the multiparous woman who is most successful (Martinez and Nalezienski, 1979; Martin and Monk,
1982). There may be a physiological explanation in that repeated pregnancies led to improved breast and nipple development with improved lactation (Hytten, 1976). W h a t is impossible to quantify is the effect of the mother feeling more at ease with each subsequent child. Sjolin et al. (1977) found that mothers who fed longest enjoyed breast feeding, were well educated, over 25 years old, belonged to upper social classes and were married or co-habiting with the child's father, findings which have been repeated throughout the Western World.
The situation in developing countries In developing countries breast feeding is still more common amongst traditional rural communities and the urban poor than amongst the urban elite (professional and business groups). The latter have adopted western patterns ofbehaviour and, in the case of artificial feeding, without many of the necessary conditions for safe use having been met (W.H.O., 1981). It remains to be seen how long the poor in Third World Countries can resist the pressures to Westernise and the blandishments of the infant food manutacturers. This circumstance of increasing westernisation must be viewed in relation to the allocation of scarce resources. It is in order to squander scarce foreign exchange to purchase an expensive commercial substitute for a cheap, locally available product which is better on all grounds? Hally et al. (1984) emphasise the importance of social climate in the decisions about infant feeding; the strength of influences from peer and cultural groups should never be under-estimated. It has been shown amongst immigrant groups in Glasgow that traditional breast feeding behaviours are dropped soon after arrival, being replaced by artificial feeding as practised by the indigenous population (Goel et al., 1978). It is interesting to speculate whether there would have
MIDWIFERY
been similar changes in feeding m e t h o d if the mothers h a d moved into an a r e a where breast feeding p r e d o m i n a t e d .
Social climate Social aspects can affect the choice of feeding method. H a l l y et al. (1981) d e m o n s t r a t e d in Newcastle that there was a strong association with housing tenure; amongst o w n e r occupiers, 75% mothers chose to breast feed as d i d 70c}/o of mothers in privately rented a c c o m m o d a t i o n , b u t only 3 8 % of mothers in council owned p r o p e r t y breast fed their babies. T h e g r e a t e r the n u m b e r of persons in the house, the less likely the m o t h e r was to breast feed i n d i c a t i n g the i m p o r t a n c e of privacy. These findings m a y in p a r t be d u e to social class b u t they do not explain the difference between privately a n d council o w n e d rented accommodation. T h e social a c c e p t a b i l i t y of feeding m e t h o d in a specific society is i m p o r t a n t in influencing choice (Bentovim, 1976). W o m e n ' s L i b e r a t i o n (which h a d its greatest i m p a c t a m o n g s t b e t t e r e d u c a t e d women) has been a c c o m p a n i e d by a n increase in breast feeding amongst professional groups (Brack, 1975). W h e r e a w o m a n ' s friends were satisfied with their choice of breast feeding, she is more likely to a d o p t the same m e t h o d (Jones and Belsey, 1977). I n addition, Bacon a n d Wylie (1976) have d e m o n s t r a t e d the strong influence exerted by the feeding m e t h o d b y which the m o t h e r herself h a d been fed whilst a b a b y , breast fed babies become breast feeding mothers. W e now have two or three generations o f w o m e n who have not been breast fed, this means there is no core of knowledge a n d expertise to be h a n d e d on, p u t t i n g even more strain on the m o t h e r who a t t e m p t s to breast feed.
Times of hardship W o r k done following experiences d u r i n g W o r l d W a r I I has shown the most h e a l t h y (although possibly underfed) mothers can nurse successfully if inclined psychologically to do so. Despite ordeals amongst E u r o p e a n w o m e n in Singapore prisoner of w a r camps, of twenty babies b o r n in captivity, all were breast fed a n d all survived
165
(Williams, 1947). Similarly, R i c h a r d s o n (1960) showed that prior to G e r m a n o c c u p a t i o n only 38% of F r e n c h babies were breast fed whereas the figure rose to 9 0 % feeding successfully when artifical milk was scarce or unavailable.
CONCLUSION Whilst authorities are b e c o m i n g increasingly aware of the benefits of breast feeding, m a n y o f the factors discussed in this article are not a m e n able to professional intervention. T h a t being said there are certain Social reforms such as the statutory provision of feeding breaks in the w o r k place which would do m u c h to facilitate breast feeding. W o m e n in the W e s t e r n W o r l d are increasingly turning to lay self-help groups such as T h e N a t i o n a l C h i l d b i r t h T r u s t and the L a Leche League for s u p p o r t a n d guidance. T h e role of such organisations m i g h t be extended and help offered in c o m b i n a t i o n with professionals to give a more b a l a n c e d a p p r o a c h and encourage the furtherance of breast feeding on into the T w e n t y First Century.
References Bacon CJ, Wylie JM 1976 Mothers' attitudes to infant feeding at Newcastle General Hospital in Summer 1975, British Medical Journal 1:308 309 Brack DC 1975 Social forces, feminism, and breast feeding, Nursing Outlook 23: 8. 556 61 Bentovim A I976 Shame and other anxieties associated with breast feeding, In Breast feeding and the Mother p 159-78 Ciba Foundation symposium No 45, Elsevier, Excerpta Medica: North Holland Department of Health and Social Security 1980 Present day Practice in Infant Feeding Para 3,4,12. Report on Health and Social Subjects No 20, D.H.S.S. London Geol KM, House F Shanks RA 1978 Infant feeding practices among immigrants in Glasgow, British Medical Journal 2.1181-1183 Hall J 1978 Influencing breast feeding success,Journal of Obstetrical Gynaecological and Neonatal Nursing 7 Part 6 28-32 Hally MR, Bond J, Crawley J, Gregson BA, Philps P, Russell I 1981 A study of Infant Feeding, Report No. 21 Health Care Reserch Unit, University of Newcastle-upon-Tyne Hally MR, Bond J, Crawley J, Grcgson B, Philps P, Russell I 1984 What influences a mother's choice of infant feeding method?, Nursing Times 8:4 65-68 Harworth WJ t905 The influence of feeding on the Mortality of Infants, Lancet 2. 210 13 Howie PW, McNeilly AS 1980 Initiation of Lactation,
166
MIDWIFERY
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