Despite apparently universal agreement that `breast is best`, rates of breastfeeding remain less than optimal. This is particularly so in westernised countries^{1, 2.} In the last decade, healthcare practitioners and policy makers in the UK, which has one of the lowest incidences of breastfeeding in Europe, have taken steps to remedy the situation^{3, 4.}

However, although there has been a substantial rise in breastfeeding rates in England (78% of women now initiate breastfeeding⁵) this might mask significant differences between ethnic groups. For example, a survey conducted on behalf of the Office for National Statistics (ONS)⁶ reported that whilst initiation rates among Pakistani women were comparable with those within the host community, rates were substantially higher among Bangladeshis (90%). However, the study also found that whilst more likely to initiate breastfeeding than their white counterparts, South Asian women were also more likely to have resorted to bottle-feeding by the time they left hospital and that, by eight weeks, more than half of them had stopped breastfeeding.

Cultural Sensitivity – reality or rhetoric?

A key component of a midwife`s professional role is that of `health educator`<sup>7</sup>. However, delivering health education in a multi-cultural context is a challenging endeavour. Even when strategies and resources are in place to address issues such as language or improving access for `difficult to reach women`; there remain wider issues about delivering `culturally-sensitive` care to women whose practices in relation to infant feeding may differ markedly not just from those of the majority host community but also from each other.

Differences among women from similar ethnic and cultural backgrounds highlight the challenges facing midwives and other professionals delivering healthcare to an increasingly diverse, multi-cultural caseload. Namely, if marked variations exist among women from similar ethnic/cultural backgrounds, how can midwives meet the particular needs of individual women from such diverse backgrounds?

In order to examine these issues and their implications for midwifery practice this paper focuses on one of the challenges faced by midwives – how to inform and support mothers to make feeding choices which will deliver optimum benefits for their babies. In this context, this paper suggests that whilst aspirational, the rhetoric of providing holistic, high quality, individualised maternity care (particularly in urban settings) might not match the complex reality of midwifery practice.

Benefits of breastfeeding

Breastfeeding is globally acknowledged as being the optimum means of providing nutrition for babies^8-10. Indeed, even women who do not breastfeed their babies share this perspective^9,11. According to the Department of Health, breastfeeding (especially if sustained for the first six months of a baby`s life), can make a major contribution to both maternal and infant health and child development¹². Additional health benefits of breastfeeding include reduced risk of gastrointestinal and respiratory diseases and reduced likelihood of childhood obesity^12-16.

Breastfeeding has also been linked with red belief that breastfeeding restores women`s figures and has contraceptive properties^3,12. In addition to purported psychological advantages such as enhanced bonding, there is empirical evidence that breastfeeding protects women from a range of illnesses including pre-menopausal breast and ovarian cancers^12,18.

The social nature of breastfeeding choices

Despite research evidence and generally positive attitudes to breastfeeding, strategies to increase initiation rates have met with limited success in delivering the government`s drive to achieve rates of breastfeeding comparable to those in countries like Sweden which has initiation rates of 98%. The reasons for comparatively lower rates in the UK are undoubtedly complex and multi-faceted.

In this context, it is important to remember that women do not make feeding choices in a vacuum but rather within the sociocultural circumstances in which they live¹⁹. Women are subject to a number of factors that influence their decisions about how, when, and what they feed their babies. The social nature of feeding choices is endorsed by the Department of Health`s (DH) attempt to challenge the myths that stop some women from breastfeeding¹². According to the DH, breastfeeding-related myths include the belief that breastfeeding comes naturally to some women and not to others – a perspective shared by 95% of women. Almost as many women (87%) believe that some women are physically incapable of producing sufficient milk to successfully breastfeed¹².

There is evidence to suggest that rates of breastfeeding among some groups of women (particularly those from socially deprived backgrounds) are strongly influenced by their cultural/ethnic backgrounds²⁰. However, there are difficulties in interpreting and extrapolating these findings due to the intersection between deprivation and culture/ethnicity in the UK. For example, it has been noted that although passages from the Koran can be interpreted as endorsing breastfeeding, Muslim women in the UK are less likely than white or Indian women to sustain breastfeeding beyond 3-4 months²¹. A report commissioned by the Department of Health reported that a significant proportion of immigrant Pakistani and Bangladeshi mothers in the UK who had either not initiated breastfeeding or given up early, stated they would have continued to breastfeed had they been in their country of origin²². This may be because, in the UK, the relatively low cost of bottle-feeding and ease of feed preparation such as the availability of clean drinking water and sterilising equipment makes bottle feeding (which may also be perceived as being more `advanced`) an attractive alternative for some ethnic minority women²³.

Social factors that influence women`s feeding choices include:

Sociodemographics

Research has found a strong and consistent link between sociodemographic factors and women`s feeding choices. For example, the likelihood of initiating and sustaining breastfeeding has been linked with socioeconomic status, educational attainment, and maternal age – older, primiparous, well-educated, better-off first time mums are most likely to initiate and sustain breastfeeding²⁴. Conversely, poor, young, under-educated women who smoke are least likely either to initiate breastfeeding or to continue beyond the first few weeks ^{5, 19.}

Maternal deprivation

Despite campaigns to increase awareness that replacing breastmilk with less nutritious foods increases the risk of illness, infections, and allergies¹⁷; women from more deprived backgrounds are more likely than more affluent women to wean their babies early²⁵. One of the factors implicated is receiving free samples of manufactured foods. For women on low incomes this is perhaps not surprising. In addition to economic constraints, low educational status (which is more common among women from deprived communities) means that poorer, younger mothers are less likely to have access to resources that will enable them to provide nutrient-rich diets, which are known to enhance the neurological and psychomotor development of their babies.

The role of fathers

Many fathers play an increasingly active role in early parenting. Perceptions of feeding as an important means of securing paternal involvement in shared childcare and child-rearing means that the role of fathers is an important consideration in women`s feeding choices. Although research suggests that the majority of fathers endorse breastfeeding, fear of excluding fathers from early childcare tasks might at least partly account for research suggesting that many women decide whether or not to breastfeed either during pregnancy or in the first few weeks following delivery¹. Once made, this decision is rarely reversed - despite input from healthcare professionals^9.

The role of the extended family

In common with other factors which influence women`s feeding choices, the role of the extended family is complex. On the one hand, research suggests that some women endorse the role of the extended family (particularly that of grandmothers) in giving help and advice<sup>26, 27</sup>. On the other hand, research suggests that family members (especially grandmothers) can have a negative impact – including influencing women to wean their babies early<sup>25.</sup> Among minority ethnic women, there is evidence that involvement of the extended family might generate `culture clash`. For example, in a Bristol study into South Asian grandmothers` influence on breastfeeding, grandmothers believed that colostrum is `old milk` which, having been stored in the breast for a long time, should be expressed and disposed of. Conversely, midwives and other health educators emphasise the importance of colostrum for developing immunity. However, both in this and other studies, there is evidence that, whilst remaining `the guardians of tradition`; grandmothers are not averse to change and remain an under-utilised resource in terms of health education and health promotion^25-27.

Negative perceptions

Whilst conceding that `breast is best`, some women experience profound feelings Where these feelings are underscored by negative attitudes from members of society, this can become a significant barrier to sustaining breastfeeding. However, according to the Department of Health, women greatly over-estimate public disapproval of breastfeeding. Whereas over two-thirds of women (67%) believe that people find breastfeeding in public unacceptable, the converse is true. The majority of people (84%) believe that it is acceptable for mothers to breastfeed their babies discreetly in public/in front of others.

The influence of midwives

Research suggests that midwives can impact both positively and negatively on a woman`s decision about whether or not to breastfeed. Inconsistency in antenatal education and incongruence between midwifery education and practice has led to both confusion and disaffection among some women<sup>9</sup>. For example, Black Caribbean women in the north of England complained that, despite the emphasis on breastfeeding in `parentcraft` classes and related positive images displayed in antenatal settings, their babies were sometimes bottle-fed by ward-based midwives against their wishes^28.

Such practices may reflect indications from the literature that there are gaps in some midwives` knowledge base<sup>29</sup> and that others lack understanding about their roles as health educators and/or the skills to adequately implement policy<sup>7</sup>. It has also been suggested that the `professionalisation` of breastfeeding has reduced women`s perception of breastfeeding as a `natural` activity which they can successfully undertake. This has led some critics to suggest that the `breast is best` rhetoric, which midwives and other healthcare professionals espouse, is not being translated into midwifery practice^2.

Despite this critique, there is also evidence that midwives have an important role to play in supporting government initiatives to increase rates of initiation and the numbers of women who sustain breastfeeding for the first six months of their infants` lives- the perios in which they derive maximum benefit³⁰. In order to do so, however, midwives have to negotiate the complex terrain around implementing breastfeeding policies and delivering flexible, individualised care to an increasingly diverse caseload. This requires them to utilise not only practical skills and knowledge but wider professionals skills such as liaison within the multi-disciplinary teams and education – not just of women but members of the community and other healthcare professionals. Providing leadership, developing and delivering policy, are well within the scope of most midwives. These skills are certainly at the forefront of government thinking in terms of improving and enhancing practice in relation to breastfeeding^{3, 12}.

Feeding choices and women from ethnic minority backgrounds

Although the UK`s population is predominantly ethnically White European, this is an increasingly multicultural society. Indeed, according to ONS31, in some UK cities, more than half of all babies are born to recently-arrived or settled immigrants or are of mixed ethnic background and this proportion is rising. Moreover, the range of ethnic and cultural groups to which significant numbers of mothers belong is increasing. Traditional perceptions of what constitutes `minority ethnic` groups are shifting not least with the arrival of European migrants from countries such as Poland and the former Soviet Union. Furthermore, ethnically diverse communities are no longer exclusively located in inner cities. The influx of economic migrants (particularly those from Eastern Europe) means that even midwives who practice in rural settings are increasingly likely to have ethnically and culturally diverse caseloads.

Whether newly-arrived or born in the UK, women from Black and minority ethnic (BME) backgrounds are subject both to the values of the wider society and to those from within their own social/family networks when making feeding choices – values which sometimes conflict. For example, most women from `developing countries` breastfeed their babies for the first month. However, in contrast to practice advocated by UK midwives, they tend to delay initiation beyond the first hour after delivery and rarely breastfeed exclusively17.

In the UK, BME women are most likely to live in areas of high deprivation, are less likely to access care and treatment, and most likely to be socially isolated not just because of language barriers but also economic constraints32 – factors which are known to militate against breastfeeding25. However, this picture does not obtain for all immigrant groups. Even within ethnic groups there are significant differences. For example, the homogenous label of `South Asians` masks significant differences between Indians (who have relatively high socio-economic status) and Bangladeshis who are among the most socio-economically disadvantaged communities in the UK31. It is therefore important that healthcare providers do not conflate culture/ethnicity with deprivation. Neither should they consider BMEwomen (or even sub-groups within them) as a homogenous group.

Additionally, persistent stereotypes of immigrant communities belonging to large, supportive social networks obfuscates differences between BME women such as the fact that women from the Caribbean often travel alone as do many migrants who arrive in the UK as refugees33. Even where BME women have access to family and social networks, the evidence suggests that, once in the UK, BME women sometimes reject `traditional` approaches to childrearing and adopt more western attitudes – including those to breastfeeding. This was highlighted in a study of South Asian grandmothers` influence on breastfeeding27 in which women preferentially turned to healthcare professionals for advice and support rather than to women from their own communities.

Implications for midwifery practice

Midwives` caseloads are increasingly culturally/ethnically diverse. In addition, the last decade has been one of unprecedented reform in the National Health Service (NHS). These changes have generated myriad policies and ushered in considerable cultural shifts in the delivery of services. For example, the NHS has become increasingly target-driven and developed a well-publicised choice agenda, which is committed to giving women greater choice and more autonomy in their maternity care.

This presents both challenges and opportunities for midwives. Among the challenges is the provision of holistic care to a diverse range of women in a target-focused but financially-constrained NHS, which is also experiencing a shortage of midwives^34,35. In addition, while endorsing an element of standardisation in order to deliver of high quality (outcome-focused) care, there is concern that this might militate against providing the individualised care that women want and midwives wish to provide.

However, the `new NHS` also provides midwives with considerable opportunities to enhance their roles as autonomous professionals. Both the government`s Children, Young People and Maternity Services National Service Framework (NSF)³⁶ and their Breastfeeding Priorities and Planning Framework (PPF)³ place midwives at the forefront of delivering high-quality perinatal care. The Royal College of Obstetricians and Gynaecologists (RCOG) also endorse plans for increasing the scope of midwifery practice³⁰ and calls for closer inter-agency working with other healthcare professionals⁷.

Key messages for midwives and other healthcare professionals

1. Even among women from similar backgrounds, there are differences both in expectations and experiences in relation to breastfeeding. This presents a considerable challenge for midwives as they care for women from an increasingly diverse range of ethnic/cultural groups – from refugees out of war-torn countries of Sub-Saharan Africa to economic migrants from Eastern Europe and the Near East.
2. In delivering high quality care to all women in their caseload, it is important that midwives do not to conflate to ethnicity and culture with social class/deprivation and poverty. It is also important that they look beyond more obvious differences between women such as language and dress to potentially more subtle but no less important social and cultural issues which impact their ability to establish effective working relationships with the women they care for.
3. In providing high quality care, midwives are often reminded that, when it comes to mothers and babies, `one size does not fit all`. This statement might also be interpreted to mean that an individual midwife might not be able to meet all the needs of all the women on his/her caseload. The NHS currently offers midwives the opportunity to become leaders in perinatal care and developing and delivering best practice and advocating for women in their care. It is therefore imperative that midwives maximise their roles within multi-agency/multi-disciplinary teams whilst making the most of opportunities to enhance their roles as autonomous professionals.
4. In their role as health educators, midwives are ideally placed to influence the short-term health and nutrition of babies and to reduce the risk of onset of a range of subsequent health problems by facilitating sustained breastfeeding. Furthermore, they can enhance the health and well-being of women through developing and implementing policies which facilitate delivery of flexible and responsive services capable of meeting the needs of individual women whilst meeting the highest standards of care for all. In so doing, midwives, who have long championed `breast is best`, can enable more women to give their babies the best possible start in life as breastfeeding not only provides optimum nutrition but also confers significant and lasting health benefits.
   

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