BREASTFEEDING AND BREASTMILK - FROM BIOCHEMISTRY TO IMPACT

A Multidisciplinary Introduction

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Breastfeeding Promotion: Politics and Policy Ashley M. Fox tghncollections.pubpub.org/pub/10-breastfeeding-promotion-politics-policy

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Ashley M. Fox, PhD, MA

“causal stories”, the chapter argues that the suc- ! Expected Key Learning Outcomes cess of breastfeeding advocacy groups at raising ● The key political discussion points in rela- attention to breastfeeding will hinge on the way erent Perspectives tion to breastfeeding the problem is framed, successful identification of ff ● ’ Di The main women s rights issues facing “villains”, and matching of solutions to the prob- wishing to breastfeed lem. As Stone [1] tells us: ● How focusing on the rights of the can have a negative impact ‘Problem definition is a process of image making, ● ff The e ect human rights campaign has had where the images have to do on breastfeeding fundamentally with attributing cause, blame, and ● The political actions that could support responsibility. Conditions, breastfeeding promotion difficulties, or issues thus do not have inherent properties that make them more or less likely to be seen as problems or to be ex- 10.1 panded. Rather, political actors Introduction deliberately portray them in ways calculated to gain support for their side. And To assess the barriers to more widespread adop- political actors, in turn, do not simply accept tion of breastfeeding promotion policies interna- causal models that are given from tionally, this chapter approaches the issue of hu- science or popular culture or any other source. man lactation from a political perspective. Re- They compose stories that describe ffi search has shown the benefits to survival of harms and di culties, attribute them to actions early and sustained breastfeeding, particularly in of other individuals or organizations, low- and middle-income countries (LMIC), as well and thereby claim the right to invoke government ’ as sustained benefits throughout the life cycle. power to stop the harm. UNICEF has boldly declared that ‘breastfeeding saves more lives than any other preventive inter- The chapter identifies three primary causal stories vention’ and the World Health Organization that have been used to frame breastfeeding as a ff (WHO) recommends exclusive breastfeeding for problem; each causal story describes di erent pri- ff the first six months of life. In spite of the pur- mary causes of the problem, which imply di erent ported health benefits of breastfeeding, policies potential policy solutions. These include framing “ ’ ” that protect and promote breastfeeding vary the problem from the angles of women s rights , “ ’ ” “ ” widely across countries and breastfeeding promo- children s rights , and global human rights . tion efforts face a number of obstacles. Breastfeeding promotion has passed through sev- “ ” This chapter reviews the literature on breast- eral frame contests (i.e., contested understand- feeding politics and policy. The paper suggests that ings of the nature of the problem) that have at breastfeeding promotion policies have not been times advanced the issue dramatically, and at oth- more widely adopted because of the different er times led to conflict. It is important to under- ff ways in which breastfeeding has been framed, and stand these di erent frames because knowing its degree of contentiousness, at specific time what factors draw attention to an issue, and which points in its history. Drawing on Stone’s concept of factors make the issue contentious and less attrac- 10 – Breastfeeding Promotion: Politics and Policy 164

tive, can influence the degree of traction the issue vocates look to work-related policies and protec- receives from governments and the success of tion in public spaces to normalise the act of breastfeeding promotion activities. breastfeeding and link it more broadly to gender These frames each place blame, cause, and re- equality and equal participation in society. sponsibility on different actors (including the so- By contrast, in the children’s rights frame, moth- called villains – ▶ Table 10.1). When framed as a ers who choose to work or to bottle feed rather women’s rights issue, gender inequality, patriar- than breastfeed for reasons of convenience are chal culture, and prudish Western attitudes to- considered the principle reason for low breast- wards breasts and women’s bodies become the feeding rates. Thus, efforts are targeted at making principle source of contention. Breastfeeding ad- replacement feeding less convenient and harder to

▶ Tab. 10.1 Summary of characteristics of different breastfeeding issue frames. Issue frame Villain Causal story Policy solutions Tensions/trade-offs

Women’s Patriarchal/ Women would breast- Work-related policies Women may not want to take Rights puritanical/ feed more but male- (e.g., paid maternity time off to breastfeed; breast- male-domi- dominant, corporate leave, flex time, feeding reinforces gendered nant culture culture restricts their pumping breaks); re- division of labour; it assumes ability to do so; wom- form of indecency all women have equal choice en’s breasts have been laws and the creation sexualised; breast- of a supportive cul- feeding represents a ture and environ- woman’s re-appropri- ment for breast- ation of her body feeding; re-normalise breastfeeding Children’s Mothers who Women choose to Fear-factor approach, Privilege the child’s welfare Rights do not work for “conven- i.e., scare women in- over the mothers; use of breastfeed ience” rather than to to breastfeeding; ex- shame and fear to motivate breastfeed; women aggerate research action; research on the bene- may underestimate claims; promote fits of breast vs bottle is weak, their ability to breast- breastfeeding in hos- and is based more on ideology feed pitals; limit access to and cultural assumptions than feeding alternatives on solid evidence Global Hu- “Greedy” Under the guise of Global Policy Agree- Ignores the underlying prob- man transnational helping women that ments (e.g., Interna- lem of lack of clean water and formula cannot breastfeed and tional Code on the sanitation but instead scape- companies their babies, greedy Marketing of Breast goats formula companies; transnational compa- Milk Substitutes); In- glosses over the reality that nies spread their “le- nocenti Declaration; women in LMICs may also thal” wares (formula) Baby-Friendly Hospi- experience trouble breast- on unsuspecting tal Initiative feeding and that low rates of mothers. They are di- exclusive breastfeeding may rectly responsible for be due to causes other than millions of deaths formula; neglects the differ- globally that result ence between urban, affluent from unsafe use of women (whose risks are closer replacement feeding to those in the global North) and poor, illiterate, rural women; creates a double standard, i.e., the risk to ba- bies in HICs is not equivalent to the risks to babies in LMICs HIC = high-income countries; LMIC = low- and middle-income countries 10.2 The Three Frames of Breastfeeding Politics 165 10.2 accomplish by policies that include prescriptions for formula, and restricting the point of sale and The Three Frames of advertising of formula. Breastfeeding Politics “ ” In the global human rights frame, third world ’ women are depicted simultaneously as “good” 10.2.1 Breastfeeding as a Women s mothers for their relatively higher breastfeeding Rights Issue “ ” rates and as victims of greedy transnational cor- When framed as a women’s rights issue, gender porations seeking profit at the expense of the inequality, patriarchal culture, and prudish West- health and wellbeing of . Policies to pro- ern attitudes towards breasts and women’s bodies mote breastfeeding in this context include limiting become the principle arguments around breast- the availability of substitute feeding, implementa- feeding. Radical feminist thinking has embraced erent Perspectives “ ” ff tion of baby-friendly hospitals, and development breastfeeding, and considers it as a means of re- Di of the International Code of Marketing of Breast- appropriating and desexualising women’s breasts, milk Substitutes. However, this framing of the representing women’s rights to control their ffi problem may not be su ciently attentive to the bodies (Attar, 1988, cited in Carter 1995 [2]). Van needs of women in LMICs. For these women, re- Esterik’s tome on breastfeeding of 1989 [3] em- placement feeding is not merely a question of con- braces this framing. She refers to notions of venience or autonomy. It may be a matter of life “ power” in reclaiming natural woman- and death for their infants due to conditions of ex- hood of which women have been deprived as the treme poverty. Wider attention to policies that cultural context has shifted towards greater ac- confront these conditions of poverty and adapt ceptance of bottle over breast. Likewise, Marxist pro-breastfeeding messages to the social context feminists have focused attention on the ways in may be warranted. which capitalist development has led to commer- Across all three frames, the corporate villain is cialisation of products that devalue an easy and ready target, putting profit above the natural products like mother’s milk. Changing health and welfare of mothers and babies, and production modes have contributed to the devalu- aligns these three perspectives. The marketing, ad- ation of women’s unpaid work within the home vertising, and promotion of formula are targeted (including child care responsibilities and breast- as a convenient scapegoat. However, this villain feeding) as compared with paid work in the pri- identification may also gloss over important dif- vate sphere. Breastfeeding has thereby come into ferences in the problem definition and policy re- conflict with male-dominant workplace environ- sponses between high and low income settings. ments with little work-life flexibility or private This chapter provides a critical viewpoint on space for women to express milk. To gain accept- — ’ ’ these three frames women s rights, children s ance and equality in the workplace, and to keep rights, and global human rights. It suggests that up with the declining value of men’s paychecks, the breastfeeding advocacy movement adopt more women are increasingly torn between employed “ ” of a harm reduction approach to breastfeeding, work and family demands while workplace poli- balancing the benefits of exclusive breastfeeding cies have not evolved to meet this new reality [4]. against the real-life challenges of breastfeeding This framing views breastfeeding politics as an that make bottle-feeding appealing and some- expression of women’s empowerment and breast- times necessary. feeding promotion policies. Such politics are es- sential to giving women choices over how to use their bodies, with milk substitutes providing an “illusion of liberation” only [5]. For breastfeeding rights activists, or “lactivists”, breastfeeding repre- sents a protest against a culture that is friendly to- wards bottle feeding and hostile towards breast- feeding; it also represents a reclaiming of public spaces to make them less hostile towards infant feeding [6]. According to Hausman [7], lactivist 10 – Breastfeeding Promotion: Politics and Policy 166

feminists tend to see a culture that favours infant ments to promote and normalise breastfeeding. formula and is beset by barriers to breastfeeding, The causal story views declining breastfeeding be it in homes, workplaces, or in public spaces rates as emanating from effective marketing cam- where the women’s right to feed their infants is paigns, workplace norms that lack accommodation frowned upon [8]. for breastfeeding mothers, and cultural ambiva- Moreover, in this framing of the problem, moth- lence about maternal bodies [7]. The locus of ers making decisions about infant feeding or blame in this framing is on the government and breastfeeding their newborns are faced with dis- their complicity in failing to bring the state’s regu- sonant messages. On the one hand, they recognise latory framework to take action, such as compel- the medical benefits to breastfeeding and desire ling employers to offer maternity leave and pro- the opportunity to provide this benefit to their in- vide private space for breast milk expression, and fants but, simultaneously, face the reality of social reform public decency codes to create areas for structures that erect barriers to its practice. The breastfeeding. choice to breastfeed is in this frame may therefore Available solutions therefore focus on efforts to be viewed as a form of protest that seeks to rede- provide breastfeeding-friendly public spaces, fine women’s bodies and the lines between public workplace accommodation for pumping, paid ma- and private spaces. ternity leave, and subsidies for breast pumps. Each Though often treated as separate from the natu- of these solutions are considered to advance wom- ral childbirth and “back to nature” movements, en’s rights and autonomy, and foster an environ- the choice to breastfeed can similarly be viewed as ment that goes beyond equality and include wom- a rejection of the medicalisation of childbirth [2]. en’s “capabilities” to breastfeed [9]. Cook (2015) The women’s liberation movement encouraged argues against a women’s “right to breastfeed”, women to gain knowledge and power, and avoid noting that legal rights alone may be inadequate unnecessary childbirth interventions. Resistance to counteract cultural attitudes against breastfeed- to formula feeding by lactivists has also been seen ing without an understanding of the lived experi- as a means to avoid unnecessary medicalisation of ence of breastfeeding mothers. She argues instead their infants and thereby reclaim breasts for their in favour of a liberal “capabilities” approach, draw- “primary” physiological function (as opposed to ing on the work of Martha Nussbaum. their secondary function as sexual objects) [2]. The “breastfeeding as a woman’s right” frame al- 10.2.2 Breastfeeding as a Children’s so points to the benefits of breastfeeding not only Rights Issue for the baby, but for the mother. Breastfeeding ad- vocacy movements employ a series of instrumen- A second framing of breastfeeding focusses on the tal arguments to convey breastfeeding benefits for baby. This framing is often written from the per- both infants and mothers. For example, such bene- spective of the medical community and organisa- fits include weight loss, uterus contraction for fast- tions dedicated to improving child health such as er postpartum recovery, cost-effectiveness, pro- UNICEF. It emphasises the health benefits of motion of infant bonding, and a possible risk re- breastfeeding for infants and children throughout duction for breast and cervical cancer. (See, e.g., the life span. Policy actors operating in this frame WebMD’s description of the benefits of breastfeed- build their case for breastfeeding on literature re- ing for women: http://www.webmd.com/parent- citing the purported health benefits associated ing/baby/nursing-basics). Breastfeeding is also with breast over bottle feeding. These include the framed in some circles as a form of activism prevention of dermatitis, allergies, sudden infant against a bottle-dominant, capitalist, convenience death syndrome, respiratory illnesses, malnutri- culture. In short, in this framing of the issue, tion, colic, eczema, Crohn’s disease, and asthma, breastfeeding is consistent with, and can be used and general strengthening of the immune system to elevate and advance, women’s autonomy. (thus reducing, for example, ear infections). Moth- The women’s rights frame blames a male-domi- ers who breastfeed will allegedly have more intel- nant, patriarchal culture that sexualises women’s ligent children than mothers who bottle feed, and breasts, and the insufficient action by govern- exclusively breastfed infants may benefit from 10.2 The Three Frames of Breastfeeding Politics 167 lower rates of future obesity and diabetes. These of breastfeeding was full of advice about why claims can be found in various official documents household orderliness was less significant than on infant feeding, for example: UNICEF (2011a, meeting children’s needs. J. Law remarks upon a 2011b) [23], [24]; UK NHS (2011a, 2011b) [25], Chicago-area bumper sticker that advertised ‘af- [26]; Stockholm Health Care Guide (2011a, 2011b) fordable healthcare begins with breastfeeding’ [27], [11]; (2006) [28] and are [13]. The statement suggests that a woman’s deci- more closely scrutinized by a set of critical litera- sion to breastfeed has implications well beyond ture presented later in the chapter. her own infant’s health, and more broadly attrib- Evidence for the superiority of breast milk over utes blame for wider societal issues including ris- bottle feeding also relies on “naturalising” breast- ing health care costs to non-breastfeeding moth- ’ ’

feeding. According to proponents of the children s ers. In this framing, mothers decision to breast- erent Perspectives ’ ff rights frame, breastfeeding fulfils nature s in- feed becomes transformed from an individual de- Di tended purpose for the female breast, providing cision to a civic duty, responsible for ensuring not the perfect food that ‘emanates on demand from just the health of individual infants but the health the breast and is continuously changing to meet of the next generation [14]. the exact needs of both mother and child’ [10]. By Solutions that address breastfeeding as a child- contrast, proponents of the children’s rights frame ren’s rights issue include policies that prioritise denaturalize “artificial“ bottle feeding as ‘giving a the rights of the child, such as laws banning paci- child a processed fluid through a piece of rubber’ fiers, prohibiting the advertising and distribution [10]. of breast milk substitutes, and incentivising baby- The benefits of breastfeeding for the child iden- friendly hospitals. There have even been discus- tified in the biomedical literature have been dis- sions about whether breastfeeding may be consid- tilled into official state policy at both national and ered as part of children’s civil rights, which could global levels. The WHO and UNICEF promote lead to putative actions against mothers who fail breastfeeding, declaring that ‘exclusive breastfeed- to breastfeed [2]. As expressed in the following ing for 6 months is the optimal way of feeding in- post in the Wall Street Journal by Erica Jong fants’, and that ‘thereafter infants should receive (2010), ‘mandatory breast-feeding isn’t imminent, complementary foods with continued breastfeed- but it’s not hard to imagine that the ‘food police’ ing up to 2 years of age or beyond’. (See WHO might become something more than a punch line website on Exclusive Breastfeeding: http://www. about overreaching government. Mothers, after who.int/nutrition/topics/exclusive_breastfeeding/ all, are easy scapegoats’ (cited in Hausman 2013 en/). Moreover, to enable mothers to achieve this [7]). The ever-changing recommendations about goal, WHO and UNICEF recommend ‘breastfeeding what women should and should not eat and drink on demand — that is as often as the child wants, while breastfeeding, along with other disputed ac- day and night’, and ‘no use of bottles, teats or paci- tivities like hair dying, are additional examples of fiers’. The ‘Breast is Best’ slogan is a social market- how the children’s rights framing places the locus ing tool that has been used to promote breastfeed- of control and blame on the shoulders of mothers ing in the USA and the UK. The official Swedish and focusses attention on the impact of their ac- policy is that breastfeeding is the best option for tions on infants. babies and that formula should only be given if In this regard, the children’s rights framing and there is a problem [11]. Packages of formula in the protection policy that it implies may conflict with Netherlands are required to carry a message that the promotion of women’s autonomy, since such ‘breastfeeding is the best for your baby’ [12]. policies may inconvenience working mothers and In this framing, mother’s needs and constraints work against women’s equal participation in soci- are secondary to that of the child’s. Breastfeeding ety. Moreover, a focus on the mother as the central has declined because women have prioritised con- “actor/villain” in this policy narrative tends to in- venience, work, or “household orderliness” over dividualise the problem, distracting from the the maternal-child dyad. For instance, in early La broader structures that result in declining breast- Leche League publications, The League’s advocacy feeding rates. 10 – Breastfeeding Promotion: Politics and Policy 168

10.2.3 Breastfeeding as a Global Social mula companies. A key tactic of this anti-formula Justice Issue social movement, initiated in 1977 by the US- A third framing of the problem has focused atten- based Action Coalition (INFACT), tion on the contribution of bottle feeding to infant was to expose the practices of formula companies mortality in LMICs. The blame in this frame has and equate their actions (in no uncertain terms) to been placed on the global formula industry, epi- murder in the highest degree. Nestlé in particular tomised by the Swiss-based Nestlé corporation, became the focus of the global campaign and the which came to be the focus of a global boycott. To campaign did not mince words. One documentary, “ ” increase profits after saturating markets in devel- simply entitled The Baby Killer (originally re- oped countries post World War II, infant formula leased in 1974 and translated into multiple lan- companies began to expand their products into guages), made explicit the connection between developing countries, where the goal was to make the products of formula companies and infant bottle feeding the norm there as well [10]. death. A Swiss activist group retitled the docu- ‘ To sell their products to this new consumer mentary even more explicitly as Nestlé kills ba- ’ base, formula companies turned to colonial im- bies [10]. The campaign was at least in part suc- agery, portraying bottle feeding as “modern”, and cessful due to the easy identification of an irre- breastfeeding as “primitive” and associated with deemable villain, the formula industry, and the peasant life [10]. In addition to direct advertising, facile association of their marketing practices with radio spread the word to the illiterate while doc- a reprehensible wrongdoing (namely, the wilful tors and hospitals were bombarded with free sam- murder of babies). ples and gifts. Formula companies also utilised The culmination of this global action against for- “milk nurses”, i.e., trained nurses employed by the mula companies and their marketing tactics was infant food industries to visit new mothers to sell the adoption of the International Code of Market- formula. By associating medical authority with ing of Breast-Milk Substitutes, approved by the bottle feeding, these practices further contributed World Health Assembly in 1981. Later reinforced 1 to the “medicalisation of formula” or to the idea by the Innocenti Declaration in 1990, the Code ’ that it was superior to breast milk for child health. was the international community s policy re- ’ The fact that formula is used for infants with low sponse to formula manufacturers marketing prac- birth weight who are too weak to suckle only fur- tices in the developing world. The Code makes ther reinforced the image of infant formula as hav- several recommendations, including instructing ing medicinal qualities. health care workers to promote breastfeeding. It Soon after formula sales started to increase, a new “disease” emerged in many low-income countries known as “bottle-baby disease”. This en- 1 The Innocenti Declaration, which was drafted by WHO ’ compassed the rapid onset of diarrhoea, dehydra- and UNICEF in 1990, restates WHO s recommendation for breastfeeding duration and calls upon member countries tion, and malnutrition, resulting from exposure to to promote a "breastfeeding culture" rather than a "bot- water- and food-borne pathogens from unsafe tle-feeding culture”. The Declaration recommends creat- water and poor hygiene, respectively. Rates of in- ing national committees in member countries that bring together government agencies to coordinate their breast- fant mortality were already high in developing feeding promotion efforts. It asks member nations to fully countries, primarily due to these same causes, and implement the International Code of Marketing of Breast- breastfeeding practices that had sheltered many milk Substitutes to enact legislation promoting breast- feeding rights, to collect data and monitor national newborns from exposure to these pathogens were breastfeeding trends, and to promote the Baby-Friendly declining as replacement feeding caught on. Hospital Initiative (BFHI). The BFHI was launched by UNI- Throughout the 1970s, the international health CEF and WHO in 1991 and implements10 steps that can lead to an official designation as “baby-friendly”. These community, including physicians in developing include allowing women to initiate breastfeeding within countries, became increasingly concerned about the first 30 minutes of birth, “rooming in” between child these marketing practices. They eventually and mother as soon as possible, not feeding babies formu- la or water, not using pacifiers, and training staff to pro- launched one of the most successful global social vide support to breastfeeding mothers. According to UNI- movements in history against the practices of for- CEF, some 15,000 hospitals in 134 countries have earned baby-friendly status since 1991. 10.2 The Three Frames of Breastfeeding Politics 169 clearly states the hazards associated with use of oped a programme to distribute free packs of for- formula; banning the distribution of free formula mula in AIDS-affected countries [15]. samples to new mothers and the use of aggressive Eventually, in a situation of inadequate sanita- marketing practices; prohibiting the use of “milk tion, the scientific community agreed that the nurses”; and prohibiting formula company sales- large risks of not exclusively breastfeeding on in- persons from providing instruction on infant care fant mortality outweighed the more moderate risk to new mothers. Several countries acted immedi- of HIV infection. Guidelines from WHO, UNICEF, ately to implement the provisions of the Code, and and UNAIDS provided a reasonable framework formula companies came under significant pres- within which to make choices on infant feeding sure to conform to these international standards. appropriate to their socioeconomic circumstances.

The clear villain in this global social justice fram- Formula feeding was recommended for HIV-in- erent Perspectives ff

ing is powerful multinational corporations with an fected women only when the practice would be Di economic incentive to push their products on un- “culturally acceptable” (i.e., not raise stigma re- suspecting low-income mothers in resource poor garding HIV status) and where it would be possi- settings. This then becomes a larger issue of corpo- ble to prepare artificial milks hygienically. How- rate ethics and also a story of inequality between ever, the guidelines stated that where formula the global North (where breast milk substitutes feeding was not “acceptable, feasible, affordable, are not ideal, but are not deadly) and the global sustainable, and safe”, HIV-infected women were South, where it infant food source is a life or death recommended to breastfeed exclusively for the issue. Given the inequality in outcomes faced by first few months. The statement was based on evi- mothers in the global North and global South, pol- dence from randomised trials that promotion of icies to address this framing might be different be- exclusive breastfeeding was estimated to prevent tween developing and developed countries. Poli- 13% of current child deaths whereas use of Nevira- cies in developing countries might include specific pine and replacement feeding would only prevent attention to international regulations on multina- 2% of current global child deaths [16]. UNICEF tional corporations and their activities in LMICs, eventually ended its formula programme, but not and particularly focus on how conditions of ex- before significantly impeding breastfeeding pro- treme poverty significantly raise the stakes in the motion efforts in countries heavily affected by HIV breast versus bottle debate. [15]. Representatives in developing countries Human immunodeficiency virus (HIV) has fur- raised concerns about whether there should be ther complicated the politics of breastfeeding in two sets of policies: one for developed countries LMICs. Competition between the HIV community and another for areas where clean water for for- and child health community resulted in different mula feeding was scarce and if a 2% transmission standards for women in resource poor contexts. rate of HIV was an acceptable trade-off. When HIV emerged as a major global epidemic in These events are important on a broader scale in the early 2000s, tensions arose between advocates that they raise questions about the degree of risk and physicians in the HIV community who recom- posed by the failure to breastfeed exclusively in mended that HIV-positive women should not the global North versus the global South. In devel- breastfeed and the child health community that oped countries, breastfeeding is largely a luxury recommended exclusive breastfeeding despite the that is enjoyed by women of adequate means who small risk of HIV-infection [15]. As many women can afford to take time off of work while bottle living with HIV are only diagnosed following rou- feeding is more concentrated in lower income tine HIV testing during childbirth, with the expan- groups. Moreover, the choice to bottle-feed in de- sion of services to prevent mother-to-child trans- veloped countries, while perhaps less than ideal, mission during childbirth came recommendations does not carry deadly consequences with it. How- in some acquired immunodeficiency syndrome ever, in LMICs, where many households have inad- (AIDS)-affected countries to formula feed rather equate access to improved water and sanitation, than breastfeed. Early in the 2000s, UNICEF devel- breastfeeding exclusively can literally be a matter of life and death. For example, UNICEF estimates 10 – Breastfeeding Promotion: Politics and Policy 170

that bottle-fed babies are as much as 25 times ance work and breastfeeding. The image of “third more likely to die in childhood than infants that world” women homebound with ample time for are exclusively breastfed in the first 6 months of suckling conflicts with research that shows wom- life (UNICEF 1990, cited in Carter 1995 [2]). Evi- en engage in informal and formal labour inside dence of the more minor morbidities associated and outside the home in various developing coun- with bottle feeding in industrialised countries (as try contexts. Furthermore, all women in low-in- previously discussed) is too easily joined with come countries are assumed to have poor sanita- these dire statistics from low-income countries. tion when in reality there is great diversity in the Putting these two very different breastfeeding experiences and social conditions of these women contexts on the same scale diminishes the sub- (i.e., not all women in poor countries are poor). In- stantial difference in the magnitude of risk be- stead, Van Esterik proposes that breastfeeding ad- tween these two settings. vocates examine four issues that influence infant This situation puts the magnitude of risk im- feeding paradigms in any given national or local plied by a failure to breastfeed exclusively in per- situation: poverty environments, empowerment spective globally and highlights the potentially of women, medicalisation of infant feeding, and skewed risk framing in late industrial “risk soci- the commoditisation of food [3]. eties”. Late industrial risk societies are marked by In sum, the global human rights framing of the the continuous production of data to support or breastfeeding issue has perhaps been the single revise risk determinations leading to a “culture of most successful breastfeeding promotion cam- fear”. As Joan B. Wolf describes, ‘everyday people paign. It constitutes a broader example of how a are bombarded with advice about how to reduce compelling causal story can bring policy attention their risk of everything from cancer to kidnapping’ and action to bear on an issue. The campaign [8]. That bottle feeding may be less risky for infant achieved this success mainly through clear identi- health than living in a polluted urban environment fication of a highly culpable villain (the profit- in a high income country, illustrates the successful seeking formula industry) that is easy to despise risk framing of breastfeeding promotion cam- in the context of its victim (innocent, defenceless paigns at engendering fear more than promoting a baby). The equation was simple and policy reform rational benefit-to-risk assessment [8]. ensued. However, the corporate villain frame may Moreover, concerns have been raised by envi- oversimplify the complex factors driving women ronmental activists about the potential for envi- to bottle-feed in both developed and developing ronmental pollution of breast milk, which theoret- country contexts. ically could amount to a greater risk to infants than formula [17]. The relative balance in the de- 10.3 gree of risk in different situations is rarely assessed or articulated in breastfeeding discussions. Critiques and Tensions in the While there is an unequal degree of risk from Three Frames bottle feeding in low versus high income coun- tries, some scholars suggest that the politics of While each of the three frames — the mother’s breastfeeding in developed and in developing con- rights, children’s rights, and global human rights texts are not clear cut. For instance, Van Esterik ad- frames — may offer compelling causal stories to vocates to apply the same rubric in developed and advance breastfeeding policy on national and in- developing countries to analyse how mothers' ternational agendas, the frames (and the policy “ ” choices must be placed in context to historical communities that support them) also conflict with events that have transformed the landscape of each other in unproductive ways. This is demon- mothering for all women [3]. Placing an emphasis strated by a recent landscape analysis of the global on the singularity of the problem in low-income breastfeeding promotion efforts conducted by ff countries also e aces the barriers to breastfeeding UNICEF [18]. This analysis found that a lack of co- that are shared between women of the global hesion over a common agenda with a shared vi- North and of the global South, such as how to bal- 10.3 Critiques and Tensions in the Three Frames 171 sion of change is constraining the breastfeeding health problems; not to breastfeed was equated to community’s ability to influence policy makers a variety of risky practices, such as logrolling and and raise resources. Discussed below are several riding a mechanical bull when pregnant. Based on tensions (conflicts) in each of the above framings messages of fear and blame, this social marketing regarding the problem of low breastfeeding rates. campaign directed at mothers precipitated a wave of controversy and negative feedback [8], [21]. This extreme version of the children’s rights frame 10.3.1 Tension 1: Trade-offs Between scapegoats women, and downplays the significant Mothers’ Rights and Children’s structural and social challenges women face in Rights Frame their capabilities to breastfeed.

The breastfeeding promotion literature is careful More broadly and surprisingly neglectful of the erent Perspectives “ ff to recommend promoting policies that are moth- breastfeeding issue overall, feminist literature Di er-centred” (See Alive and Thrive website: http:// centres around two visions of breastfeeding – with aliveandthrive.org/). However, breastfeeding pro- breastfeeding viewed from one standpoint as a motion efforts have at times applied unsubtle so- reclamation of women’s bodies and identities, and cial pressure to shame bottle-feeding women is from the other as undermining women’s equality applied to denormalise bottle feeding by making by assigning a laborious, gender-specific task [4], formula difficult to access, banning pacifiers, and [2], [7]. unequivocally advocating “breast is best”. Taylor & This conflict epitomises the “central dilemma of Wallace note that while studies often focus on ma- feminism”: on the one hand to minimise gender ternal “guilt”, shaming is a more appropriate de- differences and foster androgyny between the scriptor of the emotions that women experience sexes, and on the other to embrace and enhance in their choice of breast over bottle [19]. They sug- gender difference and fight to remove constraints gest that women should not be shamed for either and transform patriarchal cultures [2]. Early liberal choice. Proponents of a women’s rights frame also and Marxist feminist thinking on breastfeeding suggest that breastfeeding promotion campaigns viewed breastfeeding as a barrier to gender equal- focus on promoting women’s autonomy and on ity, with breastfeeding naturalising the sexual di- providing honest information on risks and benefits vision of labour within the home [4]. Milk substi- [20]. This, they propose, is preferable to reiterating tutes levelled the playing field in the sexual divi- scientific evidence that “breast is best”, especially sion of labour by enabling men to attend to infants since this evidence in developed countries is con- equally and women to participate more equally in sidered to be of dubious quality [8], [14]. the job market. However, recent feminist work has Efforts to normalise breast feeding may not be returned to the paternalistic, patronizing, and nat- particularly harmful. However, an abundance of uralising views on lactation in medical literature, critical literature on the politics of breastfeeding which acts as a form of control over women, their has indicated the various ways in which the chil- bodies, and their reproductive choices. dren’s rights frame has led to overemphasis on the Recent feminist work tries to resolve these two benefits of breastfeeding for children with little at- poles by turning the focus from individualised tention to balancing these benefits with the needs mother shaming tactics to how structural con- of mothers. This literature recognises that there straints inhibit women’s capabilities to make in- are often trade-offs between what is best for formed, autonomous decisions [7]. For example, mothers and what is best for babies (i.e., what is the American Academy of Pediatrics suggests ex- good for the goose is not always good for the gan- clusive breastfeeding for the baby’s first six der). months and then complementary feeding accom- This conflict is most evident in the US Depart- panied by breastfeeding for at least the baby’s first ment of Health and Human Services sponsored year or “as long as is mutually desired” [22]. How- National Breastfeeding Awareness Campaign ever, there is little logic in this recommendation. (NBAC). Their warning was that women who did Most American workplaces offer either no paid not breastfeed put their babies at risk of various maternity leave or 6–8 weeks only and lack sup- 10 – Breastfeeding Promotion: Politics and Policy 172

port mechanisms for breastfeeding mothers. This equate breastfeeding, time pressures, the need to situation makes it difficult for the majority of work to survive, and exhaustion. Additional to mothers to combine paid employment with lacta- this, many breastfeeding women in low-income tion. The contradictions between the scientific ad- countries are themselves malnourished. Studies in vice and absence of institutional supports to real- the child health frame report that malnourished ise this goal produces concerning dissonance. women are able to produce adequate amounts of In this way, the frames of maternal and child milk of reasonable quality to sufficiently breast- rights can and do collide. Policies that fail to take feed, but pay little attention to the cost to the into account women’s needs, and play on feelings mother’s health. R. Kukla raises questions about of maternal guilt and shame, draw on fear and the increased risk of osteoporosis from breastfeed- overstate the degree of risk and implore women to ing in developed countries [14]. The risk of malnu- breastfeed without providing the necessary struc- trition and immune system weakness in malnour- tural conditions to achieve this goal, can lead to ished breastfeeding women should be an addi- dissonance and be counterproductive to efforts to tional consideration for a more balanced approach promote breastfeeding. On the other hand, policies to the women’s rights and children’s rights frames. that are too pro-formula slip easily into a hegem- Appreciation of these challenges may also partially onic bottle-feeding culture. explain why exclusive breastfeeding rates and du- rations remain so low in much of the developing world where there are much higher rates and du- 10.3.2 Tension 2: Different Standards rations of mixed feeding (i.e., breastfeeding as well for Developed and Developing as feeding with water and foods). While “tradi- Countries? tional practices” and overbearing mothers-in-law The global human rights frame has been very suc- are frequently the scapegoats in these discussions, cessful at galvanising international attention and women’s everyday realities and the simple incon- outrage towards formula companies. However, this venience of breastfeeding may play an underap- successful framing of the issue has glossed over preciated role in the practice of supplementary the important issue of why breast is so much bet- breastfeeding. ter than formula in low-income country settings — Persistent promotion of exclusive breastfeeding namely, the role of contaminated water in infant without attention to everyday challenges to realise death. It is the unclean water used to mix the for- this ideal may undermine efforts to reach this goal. mula that is killing babies rather than the formula An alternative framing from this “breastfeed or per se. If the goal is to improve child health and re- bust” approach could be to take a “harm reduc- duce child mortality (children’s rights frame), then tion” approach. This might include making bottled a priority must also be to attend to the conditions water and disposable bottles more widely avail- that give rise to contaminated drinking water and able for women who do not breastfeed, much in unsafe complementary feeding. the same way as clean needles are distributed to Furthermore, while it is true that “third world” injection drug users. Thus, the means to bottle women breastfeed much more than their “first feed safely could be made more widely available in world” counterparts, the global formula villain resource-poor settings where there is substandard frame ignores the reality that this may be the re- sanitation. Additionally, single-use premixed for- sult of a lack of alternatives [2]. What tends to be mula that does not require mixing with water and glossed over in overly naturalised discussions is that can be stored unopened without refrigeration that poor women in poor countries breastfeed could be sold. For women who wish to breastfeed largely out of necessity, because they have little exclusively, the provision of accurate information other means by which to nourish their infants. In about the challenges that this might entail should reality, women in low-income countries face simi- support their decision. lar challenges to breastfeeding to those of women Indeed, harm reduction approaches are in line in developed countries. Such challenges include with current language. This approach to breast- sore nipples, flat or inverted nipples impeding ad- feeding could help to equalise the stakes in the 10.4 Conclusion 173 breast versus bottle debate between high-income motion and is likely to prompt negative reactions. and low-income settings, fostering women’s Likewise, an overemphasis on the joys of breast- autonomy and balancing the women’s rights frame feeding and its association with women’s rights more evenly against the children’s rights frame. A that assigns blame to patriarchal norms ignores harm reduction approach can simultaneously ad- other feminist views that pro-breastfeeding cul- vocate for changes in structural conditions imped- ture shames women that cannot or will not ing breastfeeding (e.g., workplace policies) while breastfeed and inflates the benefits of breast over by acknowledging the role of everyday constraints bottle. on the practice of exclusive breastfeeding [6]. Moreover, the global human rights frame has simplistically outlined the problem as formula

promotion by corporate villains without adequate erent Perspectives 10.4 “ ff

attention to the broader underlying cause of bot- Di Conclusion tle-baby disease”, which is unclean water and lack of sanitation. Reframing the issue of bottle feeding Balancing women’s rights, children’s rights, and in developing countries that focusses attention on global human rights in making ethical and evi- unsafe water would implicate a broader set of vil- dence-based breastfeeding policy recommenda- lains – governments, global development agencies, tions and perhaps even global capitalism that keeps poor countries poor. While this framing is likely to We began this chapter suggesting that policy is- be less effective because the villain or cause is too sues and their solutions are driven by the concept diffuse, a harm reduction approach to breastfeed- of causal stories, i.e., the attribution of cause, ing could focus attention on how to bottle feed blame, and responsibility on different actors. Stone safely when breastfeeding is not an option. reminds us that there are many strategies for A harm reduction approach to breastfeeding pushing responsibility onto someone else [1]: promotion suggests that advocates of breastfeed- ing should acknowledge that the risks of bottle ‘Books and studies that catalyse public issues feeding are not equivalent between developed and have a common structure to their argument. They developing countries. They should more directly claim that a condition formerly interpreted as ac- target the mechanisms in developing countries cident is actually the result of human will, either that are making babies sick. This includes increas- indirectly (mechanical or inadvertent cause) or ing the availability of safer tools for replacement directly (intentional cause); or they show that a feeding and addressing feeding practices that condition formerly interpreted as indirectly undermine exclusive breastfeeding, such as giving caused is actually pure intent’. water to breastfeeding infants not in the context of bottle feeding. The breastfeeding community has drawn mainly In sum, efforts at breastfeeding promotion are on three causal stories or “issue frames” to ad- hindered by specific politics of breastfeeding poli- vance breastfeeding promotion policy, namely, the cy. Recognition of the trade-offs in the different women’s rights frame, the children’s rights frame, framings of the issue and identification of who is and the global human rights frame. The global hu- to blame can assist in developing more effective man rights frame has been the most successful at breastfeeding promotion campaigns. painting a clear story of an intentional cause to the problem of declining breastfeeding rates and its : Key Points dire consequences. By contrast, the children’s ● Political discussions follow three frameworks – rights frame has struggled because an overempha- women’s rights, children’s rights and global human sis on children’s rights implies an insensitivity or rights. Each requires clear policy focus if breast- inattention to women’s rights and needs. Portray- feeding rates are to increase ing mothers as villains even if indirectly has not ● Mothers recognise the medical benefits for breast- been a successful strategy for breastfeeding pro- feeding, but often face the reality of gender in- 10 – Breastfeeding Promotion: Politics and Policy 174

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