Rebuilding
breastfeeding
cultures in East Asia
Presentation for iLactation
Ted Greiner
Professor of Nutrition
Hanyang University
Seoul, South Korea
Table of contents
 First I will focus on doing a situation analysis :


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What’s actually going on?
What do people THINK is going on? (norms)
What resources are available
 Then I will examine issues related to
developing a strategy, particularly the use of
force fields
 Next I will enumerate the 4 components of a
strategy, describing one in detail
(normalization)
Table of Contents
 Next I go through 4 breastfeeding behaviors
that we could choose to work on
 For each one, I give some detail on some of
the campaign components that are
needed/useful, particularly focusing on the
support component
 Some of what I mention for one behavior will
of course work for the others as well
 Finally, I discuss some issues of specific
relevance to East Asia
Rebuilding a breastfeeding culture
 This is really the only way to get
breastfeeding back to high levels in society
because breastfeeding is too complex and
the culture supporting it is too damaged for
single-component breastfeeding promotion
programs to achieve very much
 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
 Understanding what’s involved will
allow us to do what we can—aiming
for the most strategic inputs based on our
situation
 Rebuilding does not mean going back to what
we had in the past
 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
 We must find new ways of designing culture
to fit the needs of the present, seeing how it is
with clear, unbiased vision
 For example, breastfeeding is easier if
women do not work
 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
 Find out what the current situation is and
how trends have changed with respect to:
 Rate of initiation
 Rate of early initiation
 Duration of exclusive
 Duration of predominant
 Types of supplements given in the first few
days and later in the early months of life
 Proportion who sustain breastfeeding for
various lengths of time (I avoid the term
“extended” because it sounds non-normative)
What should we focus on?
 Decide if it is only one or some or all of
these you want to focus on
 Exclusivity is usually the one farthest from the
ideal because it was not traditional anywhere
 In some societies, early initiation is not the
norm and most have lost awareness of the
“breastfeeding crawl” and even early initiation
 For such behaviors, we need to build cultural
support from scratch
 Knowledge per se is more important than for
other behaviors
Why/how did we lose breastfeeding?
 Often scientific or social scientific literature
speculates on why negative and positive
changes occurred in the past
 Find out what explanations are given by such
experts, by health workers and by mothers for
the changes that have occurred
 Try to go into depth on one or more key
issues that seem to have substantial
explanatory power
 The perceived insufficient milk syndrome is
usually important to understand
Insufficient milk
 This may be an excuse in situations when
women feel pressure to breast feed
 In Yemen women ask for a prescription from
their doctor for formula because they have
“no milk”
 Then they tell their mother in law (who is the
decision-maker on infant feeding) and
husband (who has to be the one to buy it)
that the doctor said her milk was bad
 Doctors may know the mother has milk but
don’t want to lose a “customer”
Insufficient milk
 When given as an honest concern, it is an
expression of lack of knowledge or
confidence in the breastfeeding process
 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
 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
 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?
 Don’t focus only on the negative side
 Look for “positive deviant” cultural strengths.
Why have some people/regions/groups
maintained their breastfeeding culture more
strongly than others?
 What resources already exist that you can
work with/build on?
 Which trends are going in the right direction,
even if ideal practices are still relatively rare?
What’s your level of ambition?
 Once you gain enough understanding of what
has happened in the past and what is gong
on now, a long-term vision will emerge with
rough ideas of some of the ways in which the
rebuilding might best take place
 Given your resources, build an informal
action plan
 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
 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
 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.
 Weakening an opposing force has the same
effect as strengthening a positive force!
The components
 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
What kind of support women need to maintain
and expand on or improve the behavior
How can you achieve a feeling in society that
this behavior is the norm?
How can you promote it? That is, create
awareness and build knowledge about its
benefits.
The Components
 Protection
 Making
the public
relations “cost” of
reducing breastfeeding
higher than the money
companies can make by
destroying it.
Countermarketing
and the Code
 Commercial discharge
packs reduce exclusive
breastfeeding
 Educational materials
from infant formula
companies reduce
exclusivity and duration
 The International Code forbids
advertising, free samples,
idealizing pictures on labels, gifts
to health workers, sales
incentives, and requires label
warnings
The Components
 Support
 Skilled, kindly, and
empowering health workers
 A human rights infrastructure to
support the needs of the working mother
(pumping is not a long-term strategy—it’s
a coping mechanism)
 Peer counseling, breastfeeding mother’s
groups, fathers’ groups
.
The components
 Normalization



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I will spend more time on this because it is
only recently getting attention
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
Now in most industrialized countries the bottle
is the norm
Changing this is probably the most
challenging, neglected, yet important task in
rebuilding a breastfeeding culture
Normalization
 Legislation ensuring
the right to breastfeed
 Making breastfeeding
visible in public
 Including
breastfeeding in
school curricula
 Too little research to
know about
effectiveness
Norms*
 Descriptive norms
relate to “what
everyone does”
 Injunctive norms put
pressure on us (via
the threat of social
sanctions)
 In both cases
perceived norms may
differ from actual
norms (as revealed
say in a national
survey)
*See: Lapinski and Rimal. An explication of social norms. Communication
Theory 15:127-147, 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
 Perception of benefit
(outcome expectations)
 Shared affinity with referent
group (strongly identifying
with the group)
 Culturally determined view of
the importance of the
collective vs the individual
 Extent to which an attitude or
behavior is viewed as central
to my self-concept
Moderators in the influence
of descriptive norms, II
 Ambiguity (new behavior; new culture)
heightens our use of others’ behavior as
a guide to our own (thus, reach women
before or during their 1st pregnancy and
women who have moved to a new
location)
 Whether the behavior is enacted in a
public or private setting (privacy
reduces our knowledge of norms and
eliminates injunctive norms)
Norms
 Most powerful:
combination of
descriptive norm and
perception of benefit
 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?
 This is an ad for men’s clothing in Brazil. It
clearly perpetrated the norm that violence
against women is okay.
 By exposing it on her blog (read by 2000
people, mainly women, daily) my wife got it
withdrawn by the company within 2 days
Achieving normalization
 Everyone has to get used to seeing babies
being breast fed
 It is bottle feeding that OUGHT to be
practiced in private!
 Achieving this is potentially controversial and
a bit painful but much of it will take place
naturally as indeed breastfeeding becomes
the norm
 In Norway and Sweden it is like this, which
leads to some women complaining that they
feel forced to breast feed
Achieving normalization
 Girls (and boys who play with dolls) should
play with dolls that breast feed. Avoid giving
them a doll with a baby bottle
 Do not allow officials or the media to use the
bottle instead of breast as the symbol for
babies or for baby-feeding
 Form a normalization group and develop a
standard letter and inundate them with
explanatory letters complaining when they do
this and asking for redress
 Try to get BF into soap operas, etc.
Breastfeeding in public
 In Korea breastfeeding is kept hidden in
special breastfeeding rooms that are very
common
 In particular, girls and women must see other
women breastfeeding before and after giving
birth
 Peer counseling is one powerful way,
especially mothers’ groups like La Leche
League
 Women should be referred to them routinely
during antenatal care (BFHI step 10)
Changing our language
 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)
 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
 The truth is, breastfeeding has no
advantages, it’s just the normal way of
feeding babies
Watch your language!
 Thus we should speak of formula’s risks, not
breastfeeding’s benefits
 We should also avoid saying “breast is best”
 This implies that other options, though
perhaps in some vague sense not best, are at
least good—and people are always asking
us, “which of the formulas is better than the
others?”
 That’s like asking: “If you don’t use a seat belt
on your child, where in the car is the safest
place to put him/her?”
The Components
 Promotion

Use of face to face and mass media
communication channels to increase
knowledge and change perceived norms
Spreading knowledge
 Most health and nutrition education focuses
only on spreading awareness, increasing
knowledge or building skills
 But this is useless among people who are not
motivated
 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
 IF comprehensive and
multifaceted
 Variety of audiences
(important to segment)
 Evidence of impact:


improves attitudes
Increases initiation rates
and possibly duration
Provision of information
 Providing printed materials
alone has no impact
 Nor does giving a simple
message to breastfeed or do so
for a longer period of time
 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
 Now I will go through the main breastfeeding
behaviors and mention some of these four
components for each
 Some components like protection are generic
and apply to all
 Others like support and promotion (providing
information) are specific to the practice
 Normalization is often generic, but COULD
focus on one particular behavior
1. Initiation of breastfeeding
 When women deliver in hospitals, the Baby
Friendly Hospital Initiative can have an
impact
 Caution: health workers can be unkind and
this will result in “side effects” such as
backlash and avoidance (home
delivery/private health care alternatives)
 So training and supervision must go beyond
just professional skills and knowledge
2. Early breastfeeding patterns
 There is much more involved than just getting
breastfeeding started:

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Babies can initiate breastfeeding on their own
( see and use the breastfeeding crawl videos)
Initiating breastfeeding soon after delivery is
so important that it can save lives
Colostrum is sometimes seen as “bad,”
particularly within traditional medicine
Prelacteal feeds are thought to be needed by
nearly all untrained modern AND traditional
practitioners
Promotion of better early practices
 UNICEF will (or should) support BFHI even in
rich countries—lobby them!
 It requires advocacy efforts and training,
which means funding
 Where women do not deliver in hospitals,
ways need to be found to improve early
feeding using traditional birth attendants
 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
 This is not a traditional norm
anywhere, though it is becoming
the norm in some countries now
 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
 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
 Europe got long paid family leaves
(often about a year) because:


Women voters made it a political issue
Women were unwilling to have any or many
babies unless they got it (low fertility rates)
 There was no link to breastfeeding, it was
done to achieve equality in the workplace
 Now there is pressure to require men to take
as much as women
 Paid maternity leave is commonly mandated
in Latin America and Africa too
Can we promote to old women and
to fathers instead?
 Old women are the infant feeding
decision-makers (or at least are
influential) in many cultures
 Virtually none of them exclusively
breastfed for long anywhere (but
extended predominant BF is common in
South Asia)
 Men usually have no involvement
Use the fathers
 But men often are
perceived as the decisionmakers when they want to
be
 Can we motivate them to
protect their wives from
their mothers?
 They seem to be able to
explain to their mother in a
kindly way when we ask
them to do so
Involve the fathers
 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
 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
 Mothers WANT the fathers to be more
involved
 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
Dad should be the introducer of solid foods
 In both cases they need not be done while
he’s at work
 They give him a chance to be the expert
Child care arrangements are crucial
 Some forces work in our favor—for example,
as families become nuclear, and fewer poor
women are available who are willing to work
as domestic labor, more women will be
searching for how to replace informal child
care arrangements with formal ones
 This provides an opportunity for the
breastfeeding community to influence what
arrangements are created by authorities at
various levels
Child care arrangements
 This is crucial to women’s possibilities to
achieve more intensive breastfeeding while
maintaining their careers
 The long-term goal should always be to
achieve the greatest duration of paid
maternity leave possible
 Unfortunately, achieving the legal right to this
has proven to be only part of the battle, as
Korea illustrates
 Actually taking it has to be “normalized”
What next?
 The second tier of our efforts depends on
how long the period of paid maternity leave is
that women actually take
 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
Second, where that fails, establish clean,
comfortable, private facilities where women
can express and store breast milk
Supporting them
 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
 They must know how to express, store and
feed breast milk
 They must understand how to maintain breast
stimulation and deal with excess/leakage
4. Promotion of
increased duration
 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
Health care worker ignorance
and lack of maternity support
are no longer as important
Normalizing sustained breastfeeding
 In Sweden in 1990, a member of the national
breastfeeding support group who worked at
the largest newspaper managed to get the
editor to place on the first page a large photo
of a women breastfeeding an 18 month old in
the central train station
 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
 Usually based on training
volunteers who schedule 615 postnatal home visits
during the early months
 Has been shown to lead to a
dramatic increase in
exclusivity, but not in the US
or the UK
 Probably more effective if
volunteers are organized in
“Care Groups”
Extra problems in
“disturbed” settings
 Mixed feeding from the outset becomes the
norm
 Free samples in hospital—this may be main
thing leading to the speed which with the
breastfeeding culture of China was destroyed
 Early intensive pacifier use becomes the
norm
 Concerns about infant sleep (where, amount,
waking at night)
 Maternal alcohol use
Alcohol and breastfeeding
 Occasional drinks are not a problem
 The mother can avoid BF for 2 hours after
taking a single drink (1 beer, one cup of wine,
one shot of strong drink)
 Otherwise (or if she drinks more regularly) it
will increase perceived infant restlessness or
dissatisfaction with breastfeeding, increasing
the “perceived breast milk insufficiency
syndrome” (it disturbs sleep and shifts it to
the daytime and reduces how much the infant
obtains per breast feed for several hours)
Support for doing it right
 In any culture 10-15% of babies are
incorrectly positioned, latching on is poor, or
there are physical problems with the breast or
nipples
 Health workers are rarely trained well, though
improving, especially in places where EBF is
now normative (parts of Scandinavia and
Canada)
 When initiation and duration increased in the
West in the1970s and in exclusivity in the
1990s, health worker capacity increased
AFTERWARDS
Support and promotion work
best when done together
 Increasing pressure to breastfeed exclusively
without providing the required support, will
give limited results and may cause backlash
 Investment in support ALONE also works
poorly:


Health workers in isolation (eg BFHI with too
little effort on Step 10) have limited impact
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)
Lack of confidence
 Confidence is not a trait women are
expected to seek to achieve in this
region
 We can see pictures of confident
women showing off their figure, but
not photos like this of a woman
confident or proud of breastfeeding
 Empowering women does not
appear to lead to a decline in
breastfeeding
 To the contrary, powerful women
transform society to meet their
reproductive as well and productive
needs
Confidence
 Harm may be unwittingly
done by over-emphasizing
the importance of good
diet during lactation
 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
 Small breasts


This need have no impact
on 24-hour breast milk
intake by infants
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
 Changes in breast shape and size



For some but far from all women,
breastfeeding enlarges the size of their
breasts
For many if not most of these women, this is
largely a temporary effect
Sagging breasts are mainly caused by:



Smoking
Short birth spaces
Having many children, whether or not breast fed
Special considerations in East Asia
 Weight loss




While breastfeeding exclusively, up to 750
calories a day goes into breast milk production
Of course exclusive breastfeeding for six
months is going to have a much bigger impact
It also increases hunger, so all the principles
of maintaining/losing weight still apply
Exercise and eating healthy foods (avoid
refined carbs, especially sweet drinks) are the
most important of these
Special considerations in East Asia
 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
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
Avoid alcohol, at least in the first month or two
Korea
 In Korea, the
“privacy problem”
has been solved, at
least in Seoul, by
creating lot of
breastfeeding rooms
in subway stations,
parks, etc.
 Clearly hiding it may
solve one problem
but creates another!
East Asia
 Breastfeeding in public
seems to be a serious
issue
 It deserves more
attention from the “breastfeeding community”
in each country
 If breastfeeding is only done in private,
women give birth never having seen it
 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
 Babies would demand that
society enable them to be with
mother in early life; and to be
breastfed or at least receive
breast milk
 They’d probably be
understanding in cases where it
caused serious conflicts or
problems for mom
 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