Rebuilding breastfeeding cultures in East Asia Presentation for

Rebuilding breastfeeding cultures in East Asia Presentation for i. Lactation Ted Greiner Professor of Nutrition Hanyang University Seoul, South Korea

Table of contents n First I will focus on doing a situation analysis : n What’s actually going on? n What do people THINK is going on? (norms) n What resources are available n Then I will examine issues related to developing a strategy, particularly the use of force fields n Next I will enumerate the 4 components of a strategy, describing one in detail (normalization)

Table of Contents n Next I go through 4 breastfeeding behaviors that we could choose to work on n For each one, I give some detail on some of the campaign components that are needed/useful, particularly focusing on the support component n Some of what I mention for one behavior will of course work for the others as well n Finally, I discuss some issues of specific relevance to East Asia

Rebuilding a breastfeeding culture n 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 much n So 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

What we want n Understanding what’s involved will allow us to do what we can—aiming for the most strategic inputs based on our situation n Rebuilding does not mean going back to what we had in the past n Some 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

Building means in the present n We must find new ways of designing culture to fit the needs of the present, seeing how it is with clear, unbiased vision n For example, breastfeeding is easier if women do not work n Clearly 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

Situation analysis n Find out what the current situation is and how trends have changed with respect to: n Rate of initiation n Rate of early initiation n Duration of exclusive n Duration of predominant n Types of supplements given in the first few days and later in the early months of life n Proportion who sustain breastfeeding for various lengths of time (I avoid the term “extended” because it sounds non-normative)

What should we focus on? n Decide if it is only one or some or all of these you want to focus on n Exclusivity is usually the one farthest from the ideal because it was not traditional anywhere n In some societies, early initiation is not the norm and most have lost awareness of the “breastfeeding crawl” and even early initiation n For such behaviors, we need to build cultural support from scratch n Knowledge per se is more important than for other behaviors

Why/how did we lose breastfeeding? n Often scientific or social scientific literature speculates on why negative and positive changes occurred in the past n Find out what explanations are given by such experts, by health workers and by mothers for the changes that have occurred n Try to go into depth on one or more key issues that seem to have substantial explanatory power n The perceived insufficient milk syndrome is usually important to understand

Insufficient milk n This may be an excuse in situations when women feel pressure to breast feed n In Yemen women ask for a prescription from their doctor formula because they have “no milk” n 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 bad n Doctors may know the mother has milk but don’t want to lose a “customer”

Insufficient milk n When given as an honest concern, it is an expression of lack of knowledge or confidence in the breastfeeding process n It 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

Insufficient milk n Baby food companies exploit and contribute to such myths, especially by overemphasizing the importance of a good (ie, expensive) maternal diet to make good or enough breast milk n Health 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

Why hasn’t it gotten worse? n Don’t focus only on the negative side n Look for “positive deviant” cultural strengths. Why have some people/regions/groups maintained their breastfeeding culture more strongly than others? n What resources already exist that you can work with/build on? n Which trends are going in the right direction, even if ideal practices are still relatively rare?

What’s your level of ambition? n 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 place n Given your resources, build an informal action plan n Match 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

Moving forward n For example, if you plan to try utilizing the mass media, you would choose different ones for local, provincial or national levels or action/influence n A 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. n Weakening an opposing force has the same effect as strengthening a positive force!

The components n For each breastfeeding behavior you decide to focus on, think about each of these four components, listed in order of priority: Protection of existing behavior n What kind of support women need to maintain and expand on or improve the behavior n How can you achieve a feeling in society that this behavior is the norm? n How can you promote it? That is, create awareness and build knowledge about its benefits. n

The Components n Protection n Making the public relations “cost” of reducing breastfeeding higher than the money companies can make by destroying it.

Countermarketing and the Code n Commercial discharge packs reduce exclusive breastfeeding n Educational materials from infant formula companies reduce exclusivity and duration n The International Code forbids advertising, free samples, idealizing pictures on labels, gifts to health workers, sales incentives, and requires label warnings

The Components n Support n Skilled, kindly, and empowering health workers n A human rights infrastructure to support the needs of the working mother (pumping is not a long-term strategy—it’s a coping mechanism) n Peer counseling, breastfeeding mother’s groups, fathers’ groups.

The components n Normalization n I will spend more time on this because it is only recently getting attention n The 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 best n Now in most industrialized countries the bottle is the norm n Changing this is probably the most challenging, neglected, yet important task in rebuilding a breastfeeding culture

Normalization n Legislation ensuring the right to breastfeed n Making breastfeeding visible in public n Including breastfeeding in school curricula n Too little research to know about effectiveness

Norms* n Descriptive norms relate to “what everyone does” n Injunctive norms put pressure on us (via the threat of social sanctions) n 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: 127 -147, 2005.

Norms • Mass media and face to face communication can influence our perception of what is the norm Our goal is to change perceived norms, which is the first step—and easier to achieve, based on understanding the following

Moderators in the influence of descriptive norms, I n Perception of benefit (outcome expectations) n Shared affinity with referent group (strongly identifying with the group) n Culturally determined view of the importance of the collective vs the individual n Extent to which an attitude or behavior is viewed as central to my self-concept

Moderators in the influence of descriptive norms, II n Ambiguity (new behavior; new culture) heightens our use of others’ behavior as a guide to our own (thus, reach women before or during their 1 st pregnancy and women who have moved to a new location) n Whether the behavior is enacted in a public or private setting (privacy reduces our knowledge of norms and eliminates injunctive norms)

Norms n Most powerful: combination of descriptive norm and perception of benefit n The threat of losing something is a greater motivator than opportunity to gain an equal amount, eg, “look what she’s enjoying with her baby”

Can norms be changed? n This is an ad for men’s clothing in Brazil. It clearly perpetrated the norm that violence against women is okay. n By exposing it on her blog (read by 2000 people, mainly women, daily) my wife got it withdrawn by the company within 2 days

Achieving normalization n Everyone has to get used to seeing babies being breast fed n It is bottle feeding that OUGHT to be practiced in private! n Achieving this is potentially controversial and a bit painful but much of it will take place naturally as indeed breastfeeding becomes the norm n In Norway and Sweden it is like this, which leads to some women complaining that they feel forced to breast feed

Achieving normalization n Girls (and boys who play with dolls) should play with dolls that breast feed. Avoid giving them a doll with a baby bottle n Do not allow officials or the media to use the bottle instead of breast as the symbol for babies or for baby-feeding n Form a normalization group and develop a standard letter and inundate them with explanatory letters complaining when they do this and asking for redress n Try to get BF into soap operas, etc.

Breastfeeding in public n In Korea breastfeeding is kept hidden in special breastfeeding rooms that are very common n In particular, girls and women must see other women breastfeeding before and after giving birth n Peer counseling is one powerful way, especially mothers’ groups like La Leche League n Women should be referred to them routinely during antenatal care (BFHI step 10)

Changing our language n Subtlely 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) n 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 norm n The truth is, breastfeeding has no advantages, it’s just the normal way of feeding babies

Watch your language! n Thus we should speak of formula’s risks, not breastfeeding’s benefits n We should also avoid saying “breast is best” n 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? ” n 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? ”

The Components n Promotion n Use of face to face and mass media communication channels to increase knowledge and change perceived norms

Spreading knowledge n Most health and nutrition education focuses only on spreading awareness, increasing knowledge or building skills n But this is useless among people who are not motivated n So 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.

Mass media and social marketing work n IF comprehensive and multifaceted n Variety of audiences (important to segment) n Evidence of impact: improves attitudes n Increases initiation rates and possibly duration n

Provision of information n Providing printed materials alone has no impact n Nor does giving a simple message to breastfeed or do so for a longer period of time n Hotlines 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

Apply these to each behavior n Now I will go through the main breastfeeding behaviors and mention some of these four components for each n Some components like protection are generic and apply to all n Others like support and promotion (providing information) are specific to the practice n Normalization is often generic, but COULD focus on one particular behavior

1. Initiation of breastfeeding n When women deliver in hospitals, the Baby Friendly Hospital Initiative can have an impact n Caution: health workers can be unkind and this will result in “side effects” such as backlash and avoidance (home delivery/private health care alternatives) n So training and supervision must go beyond just professional skills and knowledge

2. Early breastfeeding patterns n There is much more involved than just getting breastfeeding started: Babies can initiate breastfeeding on their own ( see and use the breastfeeding crawl videos) n Initiating breastfeeding soon after delivery is so important that it can save lives n Colostrum is sometimes seen as “bad, ” particularly within traditional medicine n Prelacteal feeds are thought to be needed by nearly all untrained modern AND traditional practitioners n

Promotion of better early practices n UNICEF will (or should) support BFHI even in rich countries—lobby them! n It requires advocacy efforts and training, which means funding n Where women do not deliver in hospitals, ways need to be found to improve early feeding using traditional birth attendants n A recent study in Bangladesh suggests this can be powerful, especially if supervision is added (but that greatly increases the cost)

3. 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 baby Pressure 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!)

Why don’t mothers breastfeed exclusively? • • Lack of lactation management/breastfeeding counseling Lack of confidence (confidence will naturally increase as knowledge increases and norms trend in the breastfeeding direction)

Promotion of exclusive breastfeeding n This is not a traditional norm anywhere, though it is becoming the norm in some countries now n Where 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 challenge n Note the difference between levels of “current status EBF” and “EBF since birth”. You can track either one but current status is most common.

Time with the baby n Europe got long paid family leaves (often about a year) because: Women voters made it a political issue n Women were unwilling to have any or many babies unless they got it (low fertility rates) n n There was no link to breastfeeding, it was done to achieve equality in the workplace n Now there is pressure to require men to take as much as women n Paid maternity leave is commonly mandated in Latin America and Africa too

Can we promote to old women and to fathers instead? n Old women are the infant feeding decision-makers (or at least are influential) in many cultures n Virtually none of them exclusively breastfed for long anywhere (but extended predominant BF is common in South Asia) n Men usually have no involvement

Use the fathers n But men often are perceived as the decisionmakers when they want to be n Can we motivate them to protect their wives from their mothers? n They seem to be able to explain to their mother in a kindly way when we ask them to do so

Involve the fathers n Anecdotal 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 men n They 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

Women will support this n Mothers WANT the fathers to be more involved n Besides supporting exclusive breastfeeding I see two other excellent ways of doing this, that will WORK and win support from mothers: Dad should be the bather n Dad should be the introducer of solid foods n n In both cases they need not be done while he’s at work n They give him a chance to be the expert

Child care arrangements are crucial n 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 ones n This provides an opportunity for the breastfeeding community to influence what arrangements are created by authorities at various levels

Child care arrangements n This is crucial to women’s possibilities to achieve more intensive breastfeeding while maintaining their careers n The long-term goal should always be to achieve the greatest duration of paid maternity leave possible n Unfortunately, achieving the legal right to this has proven to be only part of the battle, as Korea illustrates n Actually taking it has to be “normalized”

What next? n The second tier of our efforts depends on how long the period of paid maternity leave is that women actually take n If less than six months, we must strive to First, establish child care at or near the places of work so that women can take breastfeeding breaks n Second, where that fails, establish clean, comfortable, private facilities where women can express and store breast milk n

Supporting them n Whatever 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 arrangements n They must know how to express, store and feed breast milk n They must understand how to maintain breast stimulation and deal with excess/leakage

4. Promotion of increased duration n Extending the period of continued breastfeeding is the simplest breastfeeding behavior to influence but is usually ignored Sometimes one must address myths or taboos, especially when continuing beyond the currently perceived norm n Health care worker ignorance and lack of maternity support are no longer as important n

Normalizing sustained breastfeeding n 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 station n The 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

Peer counseling n Usually based on training volunteers who schedule 6 -15 postnatal home visits during the early months n Has been shown to lead to a dramatic increase in exclusivity, but not in the US or the UK n Probably more effective if volunteers are organized in “Care Groups”

Extra problems in “disturbed” settings n Mixed feeding from the outset becomes the norm n Free samples in hospital—this may be main thing leading to the speed which with the breastfeeding culture of China was destroyed n Early intensive pacifier use becomes the norm n Concerns about infant sleep (where, amount, waking at night) n Maternal alcohol use

Alcohol and breastfeeding n Occasional drinks are not a problem n The mother can avoid BF for 2 hours after taking a single drink (1 beer, one cup of wine, one shot of strong drink) n 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)

Support for doing it right n In any culture 10 -15% of babies are incorrectly positioned, latching on is poor, or there are physical problems with the breast or nipples n Health workers are rarely trained well, though improving, especially in places where EBF is now normative (parts of Scandinavia and Canada) n When initiation and duration increased in the West in the 1970 s and in exclusivity in the 1990 s, health worker capacity increased AFTERWARDS

Support and promotion work best when done together n Increasing pressure to breastfeed exclusively without providing the required support, will give limited results and may cause backlash n Investment in support ALONE also works poorly: Health workers in isolation (eg BFHI with too little effort on Step 10) have limited impact n Improved 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) n

Lack of confidence n Confidence is not a trait women are expected to seek to achieve in this region n We can see pictures of confident women showing off their figure, but not photos like this of a woman confident or proud of breastfeeding n Empowering women does not appear to lead to a decline in breastfeeding n To the contrary, powerful women transform society to meet their reproductive as well and productive needs

Confidence n Harm may be unwittingly done by over-emphasizing the importance of good diet during lactation n Health workers almost never empower (partial exception: midwives) • Even in the West, excessive confidence in women is seen as provocative • Since confidence IS necessary for breastfeeding to work well, we need to promote women as achievers without showing off like this controversial photo and article

Special considerations in East Asia n Small breasts n This need have no impact on 24 -hour breast milk intake by infants n But 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

Special considerations in East Asia n Changes in breast shape and size n For some but far from all women, breastfeeding enlarges the size of their breasts n For many if not most of these women, this is largely a temporary effect n Sagging breasts are mainly caused by: n n n Smoking Short birth spaces Having many children, whether or not breast fed

Special considerations in East Asia n Weight loss n While breastfeeding exclusively, up to 750 calories a day goes into breast milk production n Of course exclusive breastfeeding for six months is going to have a much bigger impact n It also increases hunger, so all the principles of maintaining/losing weight still apply n Exercise and eating healthy foods (avoid refined carbs, especially sweet drinks) are the most important of these

Special considerations in East Asia n Small or thin women do not produce inferior quality breast milk A woman should get a healthy diet before, during and after pregnancy for her own sake n In 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 nervosa n Avoid alcohol, at least in the first month or two n

Korea n In Korea, the “privacy problem” has been solved, at least in Seoul, by creating lot of breastfeeding rooms in subway stations, parks, etc. n Clearly hiding it may solve one problem but creates another!

East Asia n Breastfeeding in public seems to be a serious issue n It deserves more attention from the “breastfeeding community” in each country n If breastfeeding is only done in private, women give birth never having seen it n Achieving it as the “perceived norm” will take special efforts if it’s never done in public

One of the all -time best images of breastfeeding as the infant’s norm—from a Korean museum

Who’s against breastfeeding promotion? People who’ve been treated cruelly People who feel guilty People with a free market political agenda Baby food companies and others like health workers they support who have vested interests 5. Efforts to reduce backlash should focus on reducing 1, sympathizing with 2, and exposing the true motives of 3 and 4 1. 2. 3. 4.

From the baby’s point of view n Babies would demand that society enable them to be with mother in early life; and to be breastfed or at least receive breast milk n They’d probably be understanding in cases where it caused serious conflicts or problems for mom n Take home lesson: put pressure on everyone else, but not mom!

Thank you! Ted Greiner Professor of Nutrition Hanyang University Seoul, South Korea tedgreiner@yahoo. com