Breast is best? Let mothers decide
Why aren’t people angrier about the Lib-Con government’s desire to nudge new mums towards ‘good behaviour’?
The UK Department of Health proposal for ‘breastfeeding-friendly employment policies’ has caused a flurry of debate. But the unsavoury presumption that breastfeeding should be the norm has been left unchallenged.
The public health White Paper, Healthy Lives, Healthy People: Our strategy for public health in England, includes the idea that ‘[w]ider society, including employers, has a role to play in supporting families’ and proposes that the government ‘work in partnership with employers to encourage breastfeeding-friendly employment policies’.
The proposal has not come out of the blue. The European Parliament set a precedent by introducing the Pregnant Workers Directive, under which paid breastfeeding breaks for mothers are mandatory.
The health secretary for England, Andrew Lansley, has spoken enthusiastically about how this will make it easier for all women to breastfeed, and how it will address ‘health inequalities’ – that is, the fact that professional women are far more likely to breastfeed, and do so for longer, than women working in manual or service sector jobs.
The DoH argues that a woman at a workplace with an on-site nursery should be entitled to take time off throughout the day to breastfeed. In other cases, nannies or childminders would be allowed to bring babies to the workplace so that mothers can feed them. Alternatively, women could express milk at work using a breast pump, and they would be provided with a comfortable room and storage facilities.
Objections to the proposals have so far come almost exclusively from those representing ‘business interests’, who have not objected to the principle behind the proposal but have complained about extra costs and demands on space. In response, DoH spokespeople and lobby groups such as the National Childbirth Trust have emphasised the workability of the policy, claiming that it is what women commonly do in Europe.
So, on both sides, the new policy is seen as a good idea, with the devil in the detail. Unfortunately this means that a set of more substantial problems with the policy and where it is headed have not been raised.
First, there has been no discussion about the disparity between the DoH’s proposal and the reality of how British women feed their babies. The previous government’s research shows that going back to work is not a major contributor to women’s decision about whether to cut down on or to stop breastfeeding.
The latest Infant Feeding Survey (IFS), a comprehensive study conducted every five years, was published in 2007. It found that employment began to feature as a reason for stopping breastfeeding in later months, but it also noted that this was a less significant factor compared with findings from the previous IFS.
It found that, when it comes to women breastfeeding exclusively or combining breastfeeding with formula milk, ‘17% of mothers who breastfed initially had stopped at one week, with 6% having stopped at only two days. By six weeks, 63% of mothers who started breastfeeding were still doing so, while this had fallen to a third (33%) by six months’.
The IFS explained that the ‘fall-out rate’ among mothers returning to work before their baby was six months old was higher than amongst mothers returning to work later or not at all. It also noted that mothers who returned to work when their child was six months or older were no more likely to be breastfeeding exclusively at that point than stay-at-home mothers. So the association between employment and the incidence of exclusive breastfeeding is not strong.
This seems to suggest that while employment is a factor, it is not the predominant cause of decisions about how to feed. And insofar as employment impacts on what women do, it shapes decisions well after the early weeks following birth.
There is also a group of mothers who want to formula-feed from birth. Presumably it is this group that those who promote breastfeeding are most concerned about, yet only three per cent of these women cited employment as a reason for their decision.
Given that a central theme in contemporary public health strategies is the attention paid to ‘evidence’, it is surely reasonable to ask why the current government has decided to focus so heavily on what happens at work. It may be reasonable to argue for better arrangements for working women who breastfeed in later months. But it surely cannot be claimed that workplace legislation will change the feeding practices of mothers in general.
Nor, crucially, can it legitimately be based on strong claims about health benefits. While some women may carry on breastfeeding eight months or more after birth, their choice to do so can only really be defended on the grounds that they prefer to feed their babies this way. It does not mean that this is necessarily better than using formula milk.
By fudging the facts, policymakers have avoided addressing the actual experiences of large numbers of mothers. The questions of why the majority feed their babies formula milk, wholly or in part, well before they go back to work, and whether or not they experience this as a problem or as a solution to a problem, are not up for discussion.
Policymakers have also managed to get away with presenting a proposal that repeats and reinforces all of the problems of breastfeeding promotion under New Labour as a new, exciting alternative. This is the second issue that demands far greater debate.
As numerous studies now show, a central problem with the socio-cultural environment in which women feed their babies today is its moralised character. The sociologist Tina Miller and her colleagues have found that ‘perceived societal and peer pressure, the expectations of health professionals, and feelings of guilt and concern over the need to be a “good” mother profoundly shape not only the decisions and practices of women but also the accounts they offer of these’. How mothers feed their babies has become a ‘measure of motherhood’, as claims about the allegedly profound difference breastfeeding makes to physical and psychological health communicate a clear message about the quality of mothering provided by those who formula-feed.
This message was institutionalised under New Labour through its health and social policies. But it sparked, if not exactly a backlash, then certainly a fairly widespread discussion of how women are put under increasing pressure to breastfeed. Many have been made to feel guilty over finding breastfeeding difficult or undesirable. They tell of being bossed about by ‘breastazi’ health professionals, and how unreasonable it is that information about formula-feeding is no longer routinely provided by the NHS.
The Lib-Con coalition government tends to deride New Labour’s ‘nanny state’ approach. Public health policy, it is claimed, has been far too hectoring, and the current government ‘will take a less intrusive approach, staying out of people’s everyday lives wherever possible’. We are told that the government will focus its attention on making practical changes to the social environment and, by doing so, it will ‘nudge’ us into making the medically sanctioned, ‘right’ choices. ‘Nudge’ is presented as the grown-up, practical and thus unobjectionable alternative to nannying health promotion initiatives.
It is for this reason that the workplace is at the centre of the policies Lansley has developed. It should be noted that he plans to involve ‘wider society’ in promoting breastfeeding ‘through pilots involving an acute NHS trust, over 300 children’s centres in areas with low breastfeeding rates, a primary school and a secondary school’. The argument is that through changing ‘the environment’ in this way, women will be given ‘genuine help’ to address breastfeeding difficulties, and so have no outstanding excuse for not breastfeeding. They can be nudged into doing the best thing.
The logic of this idea goes as follows: We move to a position where women are, in general, encouraged to breastfeed at work; where women are informed about breastfeeding and assisted to do it when attending children’s centres, presumably by breastfeeding buddies, lactation consultants or peer breastfeeding supporters (if they are sufficiently socially deprived to live in an area which has a centre); and education about the benefits of breastfeeding begins in schools. By changing the cultural environment, so the argument goes, more women will happily breastfeed and breastfeed for longer (without feeling pressurised or undermined).
A version of this case has, in fact, been made for many years by those involved with pro-breastfeeding campaigns. Breast is not ‘best’ because it is a better alternative to another less good option, formula feeding, they argue. Rather it is the biological and evolutionary norm, and the only reason anyone would think otherwise is because culture and society have conspired to undermine the norm. Hence, a woman feeds her baby formula milk, not because she really chooses to, but because society and culture make her do so. So what is really needed is to ‘change the culture’ by reorganising society around breastfeeding. If this happens, women will choose what they really want to choose to do, namely breastfeed. When it comes to breastfeeding, nudge is just the Lib-Con policy wonks’ term for the belief system which views breastfeeding as not ‘best’ but ‘normal’.
It is astounding that it is possible to claim that a programme of action based on this way of thinking constitutes ‘staying out of people’s everyday lives’ and can be considered in any genuine way a departure from moralising and patronising breastfeeding promotion. It could only be seen as an advance on what has gone before if the idea informing policy is that the decision to feed a baby formula milk is, in fact, not a private matter, not a choice for a woman to make (especially if she is from a socially deprived area), and so not part of ‘everyday life’.
It could only make sense if, in the worst way possible, the personal has become political, and areas of ‘everyday life’ that were previously considered not to be the business of policymakers are now viewed quite differently. Indeed, it should be noted that the breastfeeding proposals form just one part of a larger set of policies under the rubric ‘Starting Well’, which seek to modify ‘the health and wellbeing of women before, during and after pregnancy’.
In this regard, how women behave during their entire potential reproductive life is represented by the current government as a legitimate matter for policy intervention. To achieve ‘Healthy Lives, Healthy People’ requires conceiving of new mothers as breeders of the next generation, whose lactation needs to be skilfully managed by somebody else. We should not let ourselves be so easily led. These presumptions about what is private and what is a matter for policy intervention require serious debate.
In turn, the direction of current thinking about what is public is the third area that needs to be brought out into the open and debated. We need to pay attention to what the new breastfeeding policies imply about the wider issue of who should be caring for children.
Lansley claims that his initiatives around breastfeeding at work reflect a serious intent to create a ‘family-friendly’ society. Yet this can be interpreted very differently. It can be understood as yet another measure that will, in the terms of sociologist Sharon Hays, ‘intensify’ motherhood.
In her 1996 book The Cultural Contradictions of Motherhood, Hays observed that in the US, regardless of their employment arrangements, women viewed themselves as primarily responsible for the wellbeing of their children. Despite women’s entry into the workforce in large numbers, Hays explained, mothering was experienced in a highly individualised way. Regardless of their occupations and responsibilities at work, women always felt like they must be mothers first, making life as a working mother full of tension and difficulty.
Hays’ observations are pertinent for Britain, in the light of an emergent policy regime that seems intent on representing childcare provided by nursery staff, nannies and so on as distinctly second best. Indeed, it is notable that while a great deal of effort is being made to validate breastfeeding at work, nothing has been said about the significance of an affordable, reliable system of childcare provision for working parents.
It’s a cliché, but a genuinely ‘family-friendly’ society recognises that it ‘takes a village’ to bring a child up. A genuinely family-friendly society would seek proactively to ‘change the culture’ by developing and fostering the idea that it is positive and right that people other than mothers help look after babies and children.
Healthy Lives, Healthy People takes us in the opposite direction.
Ellie Lee is senior lecturer in social policy at Kent University. She is the director of Parenting Culture Studies and author of Abortion, Motherhood and Mental Health, Medicalizing Reproduction in the United States and Great Britain. (Buy this book from Amazon(UK).)