Presentation on theme: "Rebuilding breastfeeding cultures in East Asia"— Presentation transcript:
1Rebuilding breastfeeding cultures in East Asia Presentation for iLactationTed GreinerProfessor of NutritionHanyang UniversitySeoul, South Korea
2Table of contents First I will focus on doing a situation analysis : What’s actually going on?What do people THINK is going on? (norms)What resources are availableThen I will examine issues related to developing a strategy, particularly the use of force fieldsNext I will enumerate the 4 components of a strategy, describing one in detail (normalization)
3Table of ContentsNext I go through 4 breastfeeding behaviors that we could choose to work onFor each one, I give some detail on some of the campaign components that are needed/useful, particularly focusing on the support componentSome of what I mention for one behavior will of course work for the others as wellFinally, I discuss some issues of specific relevance to East Asia
4Rebuilding a breastfeeding culture This is really the only way to get breastfeeding back to high levels in society because breastfeeding is too complex and the culture supporting it is too damaged for single-component breastfeeding promotion programs to achieve very muchSo achieving such a huge change should be our long term goal, which means we should give some attention to what would be involved in achieving it
5What we want Understanding what’s involved will allow us to do what we can—aimingfor the most strategic inputs based on our situationRebuilding does not mean going back to what we had in the pastSome elements of the past will appeal to some people, so referring to it may be part of our approach but seriously attempting to take society back to a way of being that belonged to the past is unlikely to be productive
6Building means in the present We must find new ways of designing culture to fit the needs of the present, seeing how it is with clear, unbiased visionFor example, breastfeeding is easier if women do not workClearly we do not want to aim to go back to a time when they did not do so but rather create an empowered generation of women who force society to change in ways that meet their new needs
7Situation analysis Find out what the current situation is and how trends have changed with respect to:Rate of initiationRate of early initiationDuration of exclusiveDuration of predominantTypes of supplements given in the first few days and later in the early months of lifeProportion who sustain breastfeeding for various lengths of time (I avoid the term “extended” because it sounds non-normative)
8What should we focus on? Decide if it is only one or some or all of these you want to focus onExclusivity is usually the one farthest from the ideal because it was not traditional anywhereIn some societies, early initiation is not the norm and most have lost awareness of the “breastfeeding crawl” and even early initiationFor such behaviors, we need to build cultural support from scratchKnowledge per se is more important than for other behaviors
9Why/how did we lose breastfeeding? Often scientific or social scientific literature speculates on why negative and positive changes occurred in the pastFind out what explanations are given by such experts, by health workers and by mothers for the changes that have occurredTry to go into depth on one or more key issues that seem to have substantial explanatory powerThe perceived insufficient milk syndrome is usually important to understand
10Insufficient milkThis may be an excuse in situations when women feel pressure to breast feedIn Yemen women ask for a prescription from their doctor for formula because they have “no milk”Then they tell their mother in law (who is the decision-maker on infant feeding) and husband (who has to be the one to buy it) that the doctor said her milk was badDoctors may know the mother has milk but don’t want to lose a “customer”
11Insufficient milkWhen given as an honest concern, it is an expression of lack of knowledge or confidence in the breastfeeding processIt may be a self-fulfilling prophesy, related either to a family myth (“none of the women in this family have enough milk”) or a social one (“None of the women in this village have milk”), especially when the response is to supplement rather than breastfeeding more intensively
12Insufficient milkBaby food companies exploit and contribute to such myths, especially by over-emphasizing the importance of a good (ie, expensive) maternal diet to make good or enough breast milkHealth workers should give their lectures before and during pregnancy but during breastfeeding avoid pushing women too hard to (1) eat better, (2) stop smoking, (3) avoid alcohol, (4) avoid minor recreational drugs like marijuana
13Why hasn’t it gotten worse? Don’t focus only on the negative sideLook for “positive deviant” cultural strengths. Why have some people/regions/groups maintained their breastfeeding culture more strongly than others?What resources already exist that you can work with/build on?Which trends are going in the right direction, even if ideal practices are still relatively rare?
14What’s your level of ambition? Once you gain enough understanding of what has happened in the past and what is gong on now, a long-term vision will emerge with rough ideas of some of the ways in which the rebuilding might best take placeGiven your resources, build an informal action planMatch the components of your short-term plan of action also to your geographical/social level of ambition, dividing it into long-term for larger goals and short term on the way there
15Moving forwardFor example, if you plan to try utilizing the mass media, you would choose different ones for local, provincial or national levels or action/influenceA good way to help you prioritize what to work on is to develop a force field diagram listing all factors for and against each change you want to make, and estimating their power and importance.Weakening an opposing force has the same effect as strengthening a positive force!
19The componentsFor each breastfeeding behavior you decide to focus on, think about each of these four components, listed in order of priority:Protection of existing behaviorWhat kind of support women need to maintain and expand on or improve the behaviorHow can you achieve a feeling in society that this behavior is the norm?How can you promote it? That is, create awareness and build knowledge about its benefits.
20The Components Protection Making the public relations “cost” of reducing breastfeeding higher than the money companies can make by destroying it.
21Countermarketing and the Code Commercial discharge packs reduce exclusive breastfeedingEducational materials from infant formula companies reduce exclusivity and durationThe International Code forbids advertising, free samples, idealizing pictures on labels, gifts to health workers, sales incentives, and requires label warnings
22The Components Support Skilled, kindly, and empowering health workers A human rights infrastructure to support the needs of the working mother (pumping is not a long-term strategy—it’s a coping mechanism)Peer counseling, breastfeeding mother’s groups, fathers’ groups.
23The components Normalization I will spend more time on this because it is only recently getting attentionThe loss of our original breastfeeding culture happened quietly while no one was paying attention because of the myth that artificial feeding is safe and at least good if not bestNow in most industrialized countries the bottle is the normChanging this is probably the most challenging, neglected, yet important task in rebuilding a breastfeeding culture
24Normalization Legislation ensuring the right to breastfeed Making breastfeeding visible in publicIncluding breastfeeding in school curriculaToo little research to know about effectiveness
25Norms* Descriptive norms relate to “what everyone does” Injunctive norms put pressure on us (via the threat of social sanctions)In both cases perceived norms may differ from actual norms (as revealed say in a national survey)*See: Lapinski and Rimal. An explication of social norms. Communication Theory 15: , 2005.
26NormsMass media and face to face communication can influence our perception of what is the normOur goal is to change perceived norms, which is the first step—and easier to achieve, based on understanding the following
27Moderators in the influence of descriptive norms, I Perception of benefit (outcome expectations)Shared affinity with referent group (strongly identifying with the group)Culturally determined view of the importance of the collective vs the individualExtent to which an attitude or behavior is viewed as central to my self-concept
28Moderators in the influence of descriptive norms, II Ambiguity (new behavior; new culture) heightens our use of others’ behavior as a guide to our own (thus, reach women before or during their 1st pregnancy and women who have moved to a new location)Whether the behavior is enacted in a public or private setting (privacy reduces our knowledge of norms and eliminates injunctive norms)
29NormsMost powerful: combination of descriptive norm and perception of benefitThe threat of losing something is a greater motivator than opportunity to gain an equal amount, eg, “look what she’s enjoying with her baby”
30Can norms be changed?This is an ad for men’s clothing in Brazil. It clearly perpetrated the norm that violence against women is okay.By exposing it on her blog (read by 2000 people, mainly women, daily) my wife got it withdrawn by the company within 2 days
31Achieving normalization Everyone has to get used to seeing babies being breast fedIt is bottle feeding that OUGHT to be practiced in private!Achieving this is potentially controversial and a bit painful but much of it will take place naturally as indeed breastfeeding becomes the normIn Norway and Sweden it is like this, which leads to some women complaining that they feel forced to breast feed
32Achieving normalization Girls (and boys who play with dolls) should play with dolls that breast feed. Avoid giving them a doll with a baby bottleDo not allow officials or the media to use the bottle instead of breast as the symbol for babies or for baby-feedingForm a normalization group and develop a standard letter and inundate them with explanatory letters complaining when they do this and asking for redressTry to get BF into soap operas, etc.
33Breastfeeding in public In Korea breastfeeding is kept hidden in special breastfeeding rooms that are very commonIn particular, girls and women must see other women breastfeeding before and after giving birthPeer counseling is one powerful way, especially mothers’ groups like La Leche LeagueWomen should be referred to them routinely during antenatal care (BFHI step 10)
34Changing our languageSubtlely without thinking about it, we avoid using language that confronts bottle feeding for the risky practice that it is (See the suppressed US breastfeeding ads)But it is like cesarean section, something artificial that can save life when needed, but something which is not natural and should not be the normThe truth is, breastfeeding has no advantages, it’s just the normal way of feeding babies
35Watch your language!Thus we should speak of formula’s risks, not breastfeeding’s benefitsWe should also avoid saying “breast is best”This implies that other options, though perhaps in some vague sense not best, are at least good—and people are always asking us, “which of the formulas is better than the others?”That’s like asking: “If you don’t use a seat belt on your child, where in the car is the safest place to put him/her?”
36The Components Promotion Use of face to face and mass media communication channels to increase knowledge and change perceived norms
37Spreading knowledgeMost health and nutrition education focuses only on spreading awareness, increasing knowledge or building skillsBut this is useless among people who are not motivatedSo there IS, as discussed below, a good deal of knowledge that is needed to achieve optimal breastfeeding, but you must KNOW your audience and first build motivation if that is needed.
38Mass media and social marketing work IF comprehensive and multifacetedVariety of audiences (important to segment)Evidence of impact:improves attitudesIncreases initiation rates and possibly duration
39Provision of information Providing printed materials alone has no impactNor does giving a simple message to breastfeed or do so for a longer period of timeHotlines and web-based support have not been evaluated but like all information-sharing can presumably be useful if part of a larger strategy rather than the only thing that’s done
40Apply these to each behavior Now I will go through the main breastfeeding behaviors and mention some of these four components for eachSome components like protection are generic and apply to allOthers like support and promotion (providing information) are specific to the practiceNormalization is often generic, but COULD focus on one particular behavior
411. Initiation of breastfeeding When women deliver in hospitals, the Baby Friendly Hospital Initiative can have an impactCaution: health workers can be unkind and this will result in “side effects” such as backlash and avoidance (home delivery/private health care alternatives)So training and supervision must go beyond just professional skills and knowledge
422. Early breastfeeding patterns There is much more involved than just getting breastfeeding started:Babies can initiate breastfeeding on their own ( see and use the breastfeeding crawl videos)Initiating breastfeeding soon after delivery is so important that it can save livesColostrum is sometimes seen as “bad,” particularly within traditional medicinePrelacteal feeds are thought to be needed by nearly all untrained modern AND traditional practitioners
43Promotion of better early practices UNICEF will (or should) support BFHI even in rich countries—lobby them!It requires advocacy efforts and training, which means fundingWhere women do not deliver in hospitals, ways need to be found to improve early feeding using traditional birth attendantsA recent study in Bangladesh suggests this can be powerful, especially if supervision is added (but that greatly increases the cost)
443. Why don’t mothers breastfeed exclusively? Lack of knowledge (as exclusive breastfeeding becomes the norm, knowledge spreads and the search for more knowledge increases)Lack of support for the working mother to be with her babyPressure from women in the older generation to add traditional foods at the traditional times because this “worked” in their day (just look at how well the father turned out!)
45Why don’t mothers breastfeed exclusively? Lack of lactation management/breastfeed-ing counselingLack of confidence (confidence will naturally increase as knowledge increases and norms trend in the breastfeeding direction)
46Promotion of exclusive breastfeeding This is not a traditional norm anywhere, though it is becoming the norm in some countries nowWhere the norm is to breastfeed relatively exclusively for several weeks, extending this will be relatively simple but for most mothers achieving 6 months is a challengeNote the difference between levels of “current status EBF” and “EBF since birth”. You can track either one but current status is most common.
47Time with the babyEurope got long paid family leaves (often about a year) because:Women voters made it a political issueWomen were unwilling to have any or many babies unless they got it (low fertility rates)There was no link to breastfeeding, it was done to achieve equality in the workplaceNow there is pressure to require men to take as much as womenPaid maternity leave is commonly mandated in Latin America and Africa too
48Can we promote to old women and to fathers instead? Old women are the infant feeding decision-makers (or at least are influential) in many culturesVirtually none of them exclusively breastfed for long anywhere (but extended predominant BF is common in South Asia)Men usually have no involvement
49Use the fathersBut men often are perceived as the decision-makers when they want to beCan we motivate them to protect their wives from their mothers?They seem to be able to explain to their mother in a kindly way when we ask them to do so
50Involve the fathersAnecdotal reports and early research suggest that changing grandmothers can work, but I believe that with careful crafting, in many cultural settings it will prove to be simpler and may be more effective to involve menThey are a “blank slate” which is much easier to write on than to first get older women to unlearn what they think they know, in effect to get them to agree that there is a better way to do it than what they did
52Women will support this Mothers WANT the fathers to be more involvedBesides supporting exclusive breastfeeding I see two other excellent ways of doing this, that will WORK and win support from mothers:Dad should be the batherDad should be the introducer of solid foodsIn both cases they need not be done while he’s at workThey give him a chance to be the expert
53Child care arrangements are crucial Some forces work in our favor—for example, as families become nuclear, and fewer poor women are available who are willing to work as domestic labor, more women will be searching for how to replace informal child care arrangements with formal onesThis provides an opportunity for the breastfeeding community to influence what arrangements are created by authorities at various levels
54Child care arrangements This is crucial to women’s possibilities to achieve more intensive breastfeeding while maintaining their careersThe long-term goal should always be to achieve the greatest duration of paid maternity leave possibleUnfortunately, achieving the legal right to this has proven to be only part of the battle, as Korea illustratesActually taking it has to be “normalized”
55What next?The second tier of our efforts depends on how long the period of paid maternity leave is that women actually takeIf less than six months, we must strive toFirst, establish child care at or near the places of work so that women can take breastfeeding breaksSecond, where that fails, establish clean, comfortable, private facilities where women can express and store breast milk
56Supporting themWhatever arrangements exist, women will often need support in how to maintain the optimum possible level of breastfeeding intensity in combination with their work and child care arrangementsThey must know how to express, store and feed breast milkThey must understand how to maintain breast stimulation and deal with excess/leakage
574. Promotion of increased duration Extending the period of continued breastfeeding is the simplest breastfeeding behavior to influence but is usually ignoredSometimes one must address myths or taboos, especially when continuing beyond the currently perceived normHealth care worker ignorance and lack of maternity support are no longer as important
58Normalizing sustained breastfeeding In Sweden in 1990, a member of the national breastfeeding support group who worked at the largest newspaper managed to get the editor to place on the first page a large photo of a women breastfeeding an 18 month old in the central train stationThe message was not that this was good, simply “Swedish mothers forced to breastfeed in the closet.” It pointed out that this is actually common if secret (normalizing it) and even interviewed a 5 y/o still breastfeeding
60Peer counselingUsually based on training volunteers who schedule 6-15 postnatal home visits during the early monthsHas been shown to lead to a dramatic increase in exclusivity, but not in the US or the UKProbably more effective if volunteers are organized in “Care Groups”
61Extra problems in “disturbed” settings Mixed feeding from the outset becomes the normFree samples in hospital—this may be main thing leading to the speed which with the breastfeeding culture of China was destroyedEarly intensive pacifier use becomes the normConcerns about infant sleep (where, amount, waking at night)Maternal alcohol use
62Alcohol and breastfeeding Occasional drinks are not a problemThe mother can avoid BF for 2 hours after taking a single drink (1 beer, one cup of wine, one shot of strong drink)Otherwise (or if she drinks more regularly) it will increase perceived infant restlessness or dissatisfaction with breastfeeding, increasing the “perceived breast milk insufficiency syndrome” (it disturbs sleep and shifts it to the daytime and reduces how much the infant obtains per breast feed for several hours)
63Support for doing it right In any culture 10-15% of babies are incorrectly positioned, latching on is poor, or there are physical problems with the breast or nipplesHealth workers are rarely trained well, though improving, especially in places where EBF is now normative (parts of Scandinavia and Canada)When initiation and duration increased in the West in the1970s and in exclusivity in the 1990s, health worker capacity increased AFTERWARDS
65Support and promotion work best when done together Increasing pressure to breastfeed exclusively without providing the required support, will give limited results and may cause backlashInvestment in support ALONE also works poorly:Health workers in isolation (eg BFHI with too little effort on Step 10) have limited impactImproved maternity protection alone will have little impact (especially if <6 mo paid maternity leave and day care is near the home, which is what mothers prefer)
66Lack of confidenceConfidence is not a trait women are expected to seek to achieve in this regionWe can see pictures of confident women showing off their figure, but not photos like this of a woman confident or proud of breastfeedingEmpowering women does not appear to lead to a decline in breastfeedingTo the contrary, powerful women transform society to meet their reproductive as well and productive needs
67ConfidenceHarm may be unwittingly done by over-emphasizing the importance of good diet during lactationHealth workers almost never empower (partial exception: midwives)Even in the West, excessive confidence in women is seen as provocativeSince confidence IS necessary for breastfeeding to work well, we need to promote women as achievers without showing off like this controversial photo and article
68Special considerations in East Asia Small breastsThis need have no impact on 24-hour breast milk intake by infantsBut women with small storage capacity (partially but not completely linked to external breast size), must be prepared to breast feed more often day and night
69Special considerations in East Asia Changes in breast shape and sizeFor some but far from all women, breastfeeding enlarges the size of their breastsFor many if not most of these women, this is largely a temporary effectSagging breasts are mainly caused by:SmokingShort birth spacesHaving many children, whether or not breast fed
70Special considerations in East Asia Weight lossWhile breastfeeding exclusively, up to 750 calories a day goes into breast milk productionOf course exclusive breastfeeding for six months is going to have a much bigger impactIt also increases hunger, so all the principles of maintaining/losing weight still applyExercise and eating healthy foods (avoid refined carbs, especially sweet drinks) are the most important of these
71Special considerations in East Asia Small or thin women do not produce inferior quality breast milkA woman should get a healthy diet before, during and after pregnancy for her own sakeIn most of East Asia there is little risk that a poor diet will have any negative impact on breast milk quantity or quality except possibly women suffering from bulimia or anorexia nervosaAvoid alcohol, at least in the first month or two
72KoreaIn Korea, the “privacy problem” has been solved, at least in Seoul, by creating lot of breastfeeding rooms in subway stations, parks, etc.Clearly hiding it may solve one problem but creates another!
73East Asia Breastfeeding in public seems to be a serious issue It deserves moreattention from the “breastfeeding community” in each countryIf breastfeeding is only done in private, women give birth never having seen itAchieving it as the “perceived norm” will take special efforts if it’s never done in public
75One of the all-time best images of breastfeeding as the infant’s norm—from a Korean museum
76Who’s against breastfeeding promotion? People who’ve been treated cruellyPeople who feel guiltyPeople with a free market political agendaBaby food companies and others like health workers they support who have vested interestsEfforts to reduce backlash should focus on reducing 1, sympathizing with 2, and exposing the true motives of 3 and 4
77From the baby’s point of view Babies would demand that society enable them to be with mother in early life; and to be breastfed or at least receive breast milkThey’d probably be understanding in cases where it caused serious conflicts or problems for momTake home lesson: put pressure on everyone else, but not mom!
78Thank you! Ted Greiner Professor of Nutrition Hanyang University Seoul, South Korea