Is " 6 months of exclusive breastfeeding" appropriate and effective advice from the WHO? - a discussion.

 

Introduction

            The World Health Organisation recommends exclusive breastfeeding for the first six months of a child's life, and continuous breastfeeding for the first two years of life (WHO, 2023). This recommendation is based on copious evidence pertaining to the long-term health benefits of breastfeeding to both mother and child (Ibid.). In discussing how appropriate this advice is, and how effective it is in improving public health, this essay examines a case study by Charlick et al. (2017), as an example of the successful fulfillment of this advice to demonstrate the complexities of the lived experiences of women breastfeeding in Australia.        

Charlick et al. (2017) conducted an Interpretive Phenomenological Analysis (IPA) on their interviews with the exceptional case of Violet, first-time breastfeeding (BF) mother in Australia who was successful in breastfeeding exclusively for 6 months as per the guidelines of the World Health Organization (WHO, 2023). The interviews provided depth to the challenges of BF, and the components that made Violet successful, focusing on Violet's account of determination, repeatedly emphasising her strength of character. Arguably, the paper fixates on Violet's character as an extension of the intent and motivation to breastfeed indictor prominent in literature (Kestler-Peleg et al., 2015; Mitra et al., 2004) and negates to expand the problems faced by Violet even in her 'ideal' circumstances. The proponents of this, and other literature, insinuate that BF rates are a problem of self-efficacy and poor education about the benefits of BF (Noel‐Weiss et al., 2006; Wu et al., 2018). This problematic implication perpetuates what Feminist scholars refer to as a predisposition of medical literature to control women's bodies (Valdez, 2021) by ignoring the biological, structural, and embodied differences (Petteway et al., 2019; Shaw, 2004) that further explain the non-adherence to health advice beyond individual blame. 

Breastfeeding is established as an essential health intervention, lowering the risk of chronic disease and promoting healthy development in infants (Birch et al., 1993; CDC, 2023; Dewey et al., 1995; Harder et al., 2005; Kramer et al., 2008; Lee et al., 2016) and preventing chronic illness in mothers that BF (AAP, 2021; CDC, 2023). Due to this, the World Health Organisation has advised that women exclusively breastfeed for 6 months postpartum and continuously for 2 years (WHO, 2023). The consequences of exclusive breastfeeding at these recommendations can affect the life course of individuals and potentially save lives (Victora et al., 2016) in the prevention of chronic disease. In the case of Violet, she is an experienced midwife who has some knowledge of these benefits, which may have motivated her determined persistence. In addressing public health, however, one must consider why literature has shown that healthcare support, including education methods, has been ineffective in promoting breastfeeding among women globally (only 54% of women meet this metric (Persad & Mensinger, 2008)). In addition, it should also be considered whether it is an appropriate healthcare recommendation (care that proposes a net benefit (Sanmartin et al., 2008)) in the modernised global society. This essay expands on Violet's complaints and contrasts her circumstances to evaluate the appropriateness of the WHO recommendations. This essay employs these discussions to demonstrate why the recommendations are inappropriate and ineffective in increasing exclusive BF and the associated benefits to population health.

 

Health Advice and Biosocial Stress

 

Inconsistent healthcare advice and a lack of support can cause stress and interruption to BF as a complex biological process. For example, Violet had complained about "personal opinion" (pg 329) of doctors whilst suffering from gastroenteritis, including the insinuation that her breast milk was "really not that good" (pg 329) as a contrast to another doctor who told her she should keep breastfeeding. Violet expressed concern that this could have influenced her exclusive feeding (p.g 329). Meta-ethnographic research into breastfeeding experiences has shown reports of healthcare professionals providing inconsistent and conflicting advice and even being 'rude' (Burns et al., 2010). Communication problems in medicine stem from a linear transmission of information from an 'active' doctor to a 'passive' patient. This disengages doctors from what women try to express, and women feel that the following advice is inconsistent (Simmons, 2002). This poor practice is associated with a reduced duration of breastfeeding (Ibid.). Violet also describes a conflict in attitudes, whereby BF is not the social norm in Australia. Her BF behaviour is restricted to reduce the likelihood of confrontation, which is another barrier to BF commonly reported (Grant, 2021). This self-regulation indicates unequal power relations (Foucault, 2012), which socially affect BF in the West (Grant, 2021), making the recommendations socially inappropriate for a given environment.

In Violet's case, the stress of healthcare interactions, and social expectations for early supplementary feeding, as the norm in her community and Australia in general (Charlick et al., 2017), was mediated by her husband's moral support and her sister's experienced-based advice. However, stress has a biological effect on breastfeeding ability by reducing the release of oxytocin during a feed and disrupting the milk ejection reflex (Dewey et al., 1995). The stress of a prolonged or caesarean delivery is also associated with delayed onset of lactation (Ibid.). Healthcare information which is inconsistent with the lived experience of BF also contributes to the stress of BF because mothers expect that the process is 'easy'. After all, BF is described as 'best' and 'natural', according to Burns et al.'s (2010) meta-ethnography. Conflicting advice can be further discussed in relation to Violet's story, as she describes inconsistent 'signs' that her baby was interested in solid food before the 6 month recommendation. Charlick et al. (2017) point out that the WHO extend their advice by implicating 'signs' for weaning which sometimes occur before the end of the 6 months. As evidenced in Violet's case and Burns' (2010) study, conflicting advice from practitioners and the inconsistencies between the 'easy' expectation and the complex realities of BF contribute to stress surrounding BF and can have a negative interactive effect on the body. Mothers report self-blame associated with a feeling of 'failure', as sentiment linked to the universally 'natural' BF narrative. This biomedical universality implicit in public healthcare advice implies a burden of individual responsibility on the mother. Valdez (2021) argues that clinical trials focus on controlling women's behaviour and placing health secondary to their children. This explains why the recommendations are ineffective in improving global health by increasing BF practices. Stress can affect the BF's hormonal mechanism (for evidence of hormonal interaction with circumstance, see Sriraman, 2017). Establishing breastfeeding as an interactive biological and psychological proponent, biosocial anthropology could imply that breastfeeding is too affected by and interrelated to an embodied environment (Shaw, 2004), extending further the implications of stress to include factors of biosocial difference.

 

Biosocial difference: Race, Poverty and Embodied Environment on Breastfeeding

 

Violet expressed her gratitude for the support and advice she gained from her friends, family and neighbours, which helped her preserve her goal. Her age, marital status, education and high income also made her a likely candidate to succeed in her BF goal (Meedya et al., 2010). To contrast with Violet as a successful case, what accounts for the differences in BF rates across populations? While BF intention is the same across ethnicities, there are considerable differences in initiation, duration and exclusivity between white and black infants, for example (Bernard et al., 2013). For black mothers, ethnographic research has found barriers, including lack of access to lactation support and supplies, difficulties with pumping, problems with latching, stigma and the perception that BF is time-consuming (Tran et al., 2023), some issues which Violet did not express. In Tran et al.'s (2023) study, multicomponent interventions were recommended to address these barriers for black mothers in Connecticut, USA (Ibid.). In addition, BF can interact with other factors of health; for instance, HIV is a significant barrier to facilitating breastfeeding in a peri-urban community in South Africa because mixed feeding can increase the risk of contracting HIV. This interacts with the social circumstances of young mothers who require their freedom to attend school and otherwise value their autonomy (Ijumba et al., 2014). Therefore, a demanding practice like exclusive BF is inappropriate for this community because it is impractical and proposes additional health risks.

Furthermore, disparities in health across populations have been explained in terms of syndemic theory, proposing that the comorbidity of two diseases is due to a co-constructed interaction between contextual and social factors (Mendenhall, 2015). Chronic illness, for example, is unevenly clustered in black (Kuzawa & Sweet, 2009) and indigenous populations (Ferzacca, 2012; Mendenhall, 2016) as is exclusive BF (Tran et al., 2023). Although this makes BF an essential and thereby appropriate preventative intervention, it is crucial to consider the social realities that constitute health and BF disparities because lactation is affected by nutrition and stress and requires a good initiation to be successful (Dewey et al., 1995; Sriraman, 2017; Tsutaya & Mizushima, 2023; Tully & Ball, 2013). These multifaceted considerations could further indicate why there is uncertainty surrounding the effectiveness of BF trial interventions (Hoddinott et al., 2011).

 

Conclusion

In conclusion, the WHO recommendations are, from a biosocial perspective, ineffective in practice because of the implementation of related healthcare interventions, which can comprise conflicting advice. The essay elaborated on this by proposing integrated explanatory mechanisms in biosocial research, such as embodiment and syndemic theory pertaining to stress, inequalities, and social expectations of breastfeeding. In doing so, the multifactorial determinants of breastfeeding practices are highlighted (Rollins et al., 2016), such as social norms, access to facilities, and family support. As such, these recommendations need to be more appropriate and effective through consideration of the matters discussed in achieving their aim: improving global health.

 

 Melissa Evans

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