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Exclusive breastfeeding of infants for the first 6 months of life with continued breastfeeding for at least 6 more months occurs only 11.9% of the time in the United States. Efforts of the past 30 years to promote optimal breastfeeding practices have had little impact. In order to create significant change in the way we feed infants in this country, we need to change the way we look at this public health issue and examine the cultural logic that makes bottle feeding the preferred choice of most U.S. women. This article analyzes the term “inadequate” not just as self-description of a woman's milk supply, but also as a metaphor for the lives of low-income women in the United States, the group least likely to breastfeed. Low-income women in the United States not only have inadequate incomes as compared to the general population, but inadequate child care, education, preventive health services, inadequate lifespans, and lives saturated with violence, leaving them inadequately safe even in their own homes. Here we outline a research agenda to explore the relationship between socially determined inadequacies and the cultural logic that makes bottle feeding a preferred form of infant feeding.
Exclusive breastfeeding of infants for the first 6 months of life with continued breastfeeding for at least 6 more months occurs only 11.9% of the time in the United States.1 The prevalence of exclusive breastfeeding for 6 months among low-income women in the United States is particularly low, with only 9.6% of women achieving this goal.2 Efforts of the past 30 years to promote optimal breastfeeding practices have had little impact. In order to create significant change in the way we feed infants in this country, we need to change the way we look at this public health issue and ask a fundamentally different set of questions so that we might better understand the cultural logic that makes bottle feeding the preferred choice for feeding infants. The work of the anthropologist Nancy Scheper-Hughes (1992) is helpful here.3 Her complex, layered analysis of the changes in infant feeding practices among poor women of northeast Brazil provides us with a different lens with which to reconsider infant feeding practices in the United States.
When [poor women] refer to their own milk as scant, bitter, curdled, sour, breast milk is a powerful metaphor speaking to the scarcity and bitterness of their lives as women.
—Nancy Scheper-Hughes, Death Without Weeping (1992)3
Throughout the 1980s Nancy Scheper-Hughes conducted ethnographic field work in northeast Brazil in one of the largest slums in the world, trying to understand the social and cultural conditions that produced unexpectedly high rates of infant mortality.3 As part of that 1992 study Scheper-Hughes asked why poor Brazilian mothers seldom breastfed their infants. When Scheper-Hughes first came to Brazil in the 1960s as a Peace Corps worker, she distributed canned milk for mothers to give to their babies. Brazilian mothers refused, telling her that it was not appropriate food for infants. Instead, women used the canned milk in their morning coffee and continued to breastfeed. When Scheper-Hughes returned as an anthropologist 20 years later, almost no one was breastfeeding their infants.
She asked what social changes had occurred in the past 20 years that could account for the differences in infant feeding practices. Given the extreme dangers of bottle feeding in an environment of no clean water and rampant infectious disease, what made bottle feeding the more desirable choice for infant feeding? What were the economic benefits of formula feeding given the extreme poverty of these mothers? She did not ask how these mothers could be better educated about the benefits of breastfeeding. The Brazilian mothers of her study knew that breastmilk was the right food for infants. Instead, Scheper-Hughes asked about the environmental and contextual factors that supported formula feeding as opposed to breastfeeding.
Her analysis implicated a number of interrelated phenomena in the switch from breastfeeding to formula feeding in this population. The economic constraints that had developed in the region were especially significant for the way women thought about and practiced infant feeding. Multinational sugar companies had developed a monopoly on employment in the area, allowing them to set the wages below subsistence level for most families. There were few alternatives to wage-labor in the community, aside from working as domestic servants in the households of the upper-middle class. In neither employment situation could women bring breastfeeding infants. Leaking milk while at work was viewed as especially unacceptable among those who worked as household servants, and women in this situation often weaned children to avoid this. The sugar industry also held a monopoly on land, forcing homes onto smaller and smaller lots, making subsistent gardening impossible. Diets were no longer supplemented with garden produce, leaving women believing that their own inadequate nutrition rendered their milk of too low quality to sustain infants.
These factors pushed women away from breastfeeding while a host of other factors made formula feeding more attractive. Formula was heavily promoted at local supermarkets. Wages were so low that men often could not live in the same households as their families. Supplying the new mother and infant with store-bought formula became a way to publicly claim support for and commitment to the mother–infant pair. Significantly, Scheper-Hughes notes that the way poor women talked about their breastmilk as sour and bitter was a metaphor for their own precarious and difficult lives under conditions of extreme poverty. If breastmilk described as sour and bitter is a powerful metaphor for the scarcity and bitterness of impoverished Brazilian women's lives, how do low-income women in the United States describe their breastmilk? What might descriptions of their breastmilk tell us about their lives and infant feeding decisions?
in ad e quate (adjective)
—www.dictionary.com (accessed October 15, 2008)
Poor Mother (def.)
—Fine and Weiss (1998), p. 1864
In 2007, Solomonik (unpublished data) conducted interviews with Special Supplemental Nutrition Program for Women, Infants and Children (WIC) mothers at a western New York site about their reasons for switching from breastfeeding to bottle feeding; responses included: “Unfortunately, I did not have enough milk”; “My baby was still hungry”; and “I dried up shortly after birth.” Often their answers took this form, “I know breastfeeding is really good but,—[personal failure]—and I ended up formula feeding.” Women endorsed breastfeeding as the best option while asserting that their decision to discontinue breastfeeding was unfortunate, anomalous, and out of their direct control; it was rooted in biological, not social circumstances.
The mothers in Solomonik's study are not unusual. An insufficient milk supply is the most common reason women give for discontinuing breastfeeding,5–10 and yet physical problems that inhibit milk production are very rare, with only about 4% of women thought to have this condition.9 A number of investigators refer to this as inadequate milk syndrome, a condition that spans a biopsychosocial continuum from a rare physiological situation to a condition embedded in psychological and social circumstances.4–8 Most analysts have traced social circumstances of too little time and not enough support to physiological responses that would reduce milk supply. Here we argue “inadequate” is an oblique reference to their lives as low-income women in U.S. society, not just a physiological response.
In what ways are the lives of low-income women inadequate, and how might this be related to their decisions to formula feed? The question of inadequacy has dual significance for social life. On the one hand, we can ask if the lives of low-income women are inadequate in terms of material items we as U.S. citizens deem minimal for negotiating daily life, such as housing, safe neighborhoods, transportation, health care, training, and employment. On the other hand, we can ask if low-income women feel inadequate in fulfilling the multiple social roles that are demanded of them as workers, mothers, partners, and family members. The goal here is not to come to definitive conclusions, but to generate hypotheses to be tested in later studies.
We know that low-income women in the United States do not have adequate material resources. Studies have documented inadequate preventive health services, inadequate health insurance, inadequate child care, and inadequate food security. What was unexpected in the literature about the lives of low-income women, however, is that across a number of ethnographic studies, low-income women report inadequate safety, with a high frequency of violence in their lives.11–14 The quantitative literature supports this. A 2005 study by McDonnell et al.,15 for example, surveyed 455 low-income women in Baltimore, MD looking for correlations between experiences of interpersonal violence (IPV) and health-related quality of life. Nearly two-thirds of the women had experienced IPV either in the past year or over their lifetime. There was a high negative correlation between their experiences of violence and decreased health-related quality of life.
Violence, or inadequate safety, emerged in the ethnographic literature on three different levels: at the level of the household as domestic violence both witnessed and experienced; at the level of the community as street violence; and at the institutional level of law enforcement and of health and human service agencies. One research team, reporting on the lives of the low-income women in Jersey City, NJ and Buffalo, NY, noted that women's lives were “saturated with domestic terror (p. 134).”4 Community-level violence may consist of shootings, stabbings, gang warfare, drug houses, and vandalism. Institutional violence can include police brutality and corruption and health and human services organizations that are seen as not as mechanisms of social support but as mechanisms of social control, continually monitoring the activities of low-income women with the implicit threat of taking their children from them should they be deemed inadequate mothers. Low-income women, Fine and Weis4 argue, live in fear.
Can these repeated instances of violence and punitive surveillance be construed as constant reminders to women that they are inadequate in fulfilling (unrealistic) role expectations under conditions of inadequate resources? With the constant threat of violence, is a sense of inadequacy inculcated into women, making formula feeding just one small way to reassure them that they are fulfilling the role of mothering? Within this context of inadequate safety and constant fear, do women feel too vulnerable to uncover themselves enough to breastfeed even in the privacy of their own homes? Does it make uncovering in public to breastfeed untenable? Does an unsafe environment and sense of inadequacy push women to stop breastfeeding as soon as they encounter difficulties while learning how to breastfeed?
What we are outlining here is a research agenda that asks if there is a relationship between women's experiences of violence and the decision to formula feed their infants. Are women who report violence in their lives more likely to use formula than those who do not, and if so, why? Are neighborhoods with high homicide rates sites of lower breastfeeding rates? Are mothers' impressions of social service agencies as supportive or hostile related to their ability to breastfeed?
Paul Farmer16 has written eloquently of structural violence—the large scale social forces that become embodied within the lives of the poor. He calls for research that focuses on the “gritty biographical details of life” as a way to better understand the how violence is manifested in the lives of the poor and what its consequences are. We do not have that level of detail about the lives of poor U.S. mothers who choose formula feeding over breastfeeding. Both Farmer16 and Scheper-Hughes,3 however, offer similar structural insights that call on us to look beyond an American focus on the individual woman as the social agent who can choose what is best for her child, i.e., breastfeeding, divorced from the rest of her reality. Women's infant feeding decisions must be understood within the higher-order social structures that constrain their ability to breastfeed and which in circumstances of violence may make formula feeding the most logical choice.
We thank Ann Dozier, Cynthia Childs, and Ayala Emmett for commenting on earlier versions of this paper. This investigation was supported by U.S. Public Health Service grant number RO1-HD055191, Community Partnership for Breastfeeding Promotion and Support.
No competing financial interests exist.