The decision to breastfeed is determined by a wide range of factors, including maternal demographic characteristics and biological, social, psychological and cultural variables (Thulier and Mercer, 2009; Meedya et al, 2010; Dieterich et al, 2013). Social and cultural contexts profoundly shape human health and behaviour (Napier et al, 2017), meaning, culture is a powerful element of a woman's attitude to breastfeeding (Wambach and Spencer, 2021), and breastfeeding is intrinsically related to postpartum social support (Okyay et al, 2022). Culture is a ‘socially transmitted system of shared knowledge, beliefs and/or practices that vary across groups, and individuals within those groups’ (Hruschka and Hadley, 2008; Hernandez and Gibb, 2019). In this context, social determinants of health play a crucial role.
The World Health Organizations (WHO) Commission on Social Determinants of Health (Marmot et al, 2008) defined social determinants of health as ‘the conditions in which people are born, grow, live, work and age’ and ‘the fundamental drivers of these conditions’. Current population health approaches are guided by models of social determinants of health, such as the Dahlgren and Whitehead (1993; 2007) model of health determinants. This health model considers the influence that social determinants of health, including cultural factors, have on human behaviour and health.
Intersectionality matters
Current global migratory movements are creating multicultural societies that demand culturally sensitive health professionals to care for women and families (Belintxon and López-Dicastillo, 2014). As a result, both parties often face struggles as a result of cultural, linguistic and health literacy difficulties, socioeconomic disadvantages or health providers’ prejudices and stereotyping (Belintxon and López-Dicastillo, 2014; Atanga and Ayong, 2017). In the case of people from under-represented groups, the intersections between socioeconomic status, ethnicity and racism promote inequalities in health (Marmot et al, 2020). Consequently, it is essential to embrace the influence of culture on breastfeeding by promoting cultural competence education for health professionals to tackle poor health outcomes as a result of health disparities and structural inequalities (Horvat et al, 2014). Given the importance of this topic, it is imperative that midwives and other healthcare professionals offering infant feeding support become aware, acknowledge and validate the effects that cultural factors can exert on the intention, initiation and continuation of breastfeeding.
Health professionals should also acknowledge the historical context in which certain feeding practices and choices could be rooted. For example, for Black women, breastfeeding has been historically linked with Black enslaved women used as wet nurses to breastfeed White women's babies (Roth, 2018). Nowadays, white supremacy is reflected in white normativity and the standard white body as default (Morris, 2016). This leads to an unequal representation of skin tones in medical images and limited medical knowledge as a result, with appalling consequences for medical education, care provision, health outcomes and patient experiences (Kaundinya and Kundu, 2021; Peter and Wheeler, 2022). In the context of breastfeeding, racism, bias and discrimination have been identified as barriers to breastfeeding (Robinson et al, 2019).
The United Nations Children's Fund (2022) and WHO (2022) recommend and promote exclusive breastfeeding for infants during the first 6 months of age and until the age of 2 years or beyond, as lactation is vital for infant survival, nutrition and development, as well as maternal health (WHO, 2018; 2021). From 6 months, infants should be offered safe and adequate complementary foods while continuing to breastfeed. Despite these worldwide recommendations, it is estimated that globally, 3 in 5 babies are not breastfed in the first hour of life and only 41% of infants aged 0—6 months are exclusively breastfed, while over 820 000 children could be saved every year if all infants between 0—23 months were optimally breastfed (WHO, 2021). Some cultural and religious practices are known to discourage exclusive breastfeeding, such as colostrum discarding, delay in breastfeeding initiation and the use of prelacteal feeds and complementary foods before the age of 6 months, which can jeopardise the safety of infants (Brown, 2018). Thus, a sensitive discussion is needed to explore cultural and religious practices.
The impact of culture
Some cultures and religions provide guidance on what foods to consume while breastfeeding or body exposure etiquette. Hence, healthcare services should understand and support these cultural practices to promote breastfeeding initiation (Wambach and Spencer, 2021).
To be able to promote these cultural and religious practices, healthcare professionals should increase their cultural awareness and become culturally competent practitioners, which will contribute to reducing and eliminating health disparities by promoting women-centred care (Abrishami, 2018).
It is important to recognise that knowledge based on common facts or generalised behaviours of certain cultural or religious groups (Long, 2012) could increase the risk of stereotyping and dismissing individual differences and needs (Seeleman, 2009). Thus, caution should be taken when caring for women and families from under-represented groups, to avoid focusing on generalised cultural and religious traits. Instead, professionals should individually identify and acknowledge unique experiences, circumstances and cultural practices.
Healthcare professionals being updated on breastfeeding support is a crucial aspect of successful breastfeeding education for women (Chrásková and Boledovičová, 2015). Practising according to the latest evidence-based recommendations diminishes the risk of providing conflicting and incorrect advice for lactating women and advocates for a successful breastfeeding experience.
While there is existing evidence demonstrating that perceptions of pain and lack of milk are the most common barriers to breastfeeding irrespective of a woman's ethnicity (Cook et al, 2021), these perceptions vary across cultures. Hence, it is essential to address culturally specific misconceptions around milk supply, preferably during the antenatal period, and barriers to breastfeeding, access and engagement with health services.
A woman's cultural and religious beliefs impact the perceived value of breastfeeding and its normalisation (Cook et al, 2021). As a result, it is essential to provide culturally tailored breastfeeding promotion to address clashes between cultural or religious beliefs and breastfeeding beliefs, since women and families often see formula feeding as a remedy to eliminate these confrontations (Rayment et al, 2016). It is also important to acknowledge the impact of acculturation while living in a country with a strong formula culture (Choudhry and Wallace, 2012), where the perception of formula milk being synonymous with modernity can reinforce formula culture (Rayment et al, 2016).
A shared responsibility
Low breastfeeding rates in the UK are considered a public health issue. The United Nations Children's Fund (2022) urges the UK and devolved governments to stop blaming women and calls for shared responsibility among the government, policymakers, communities and families. However, in the UK, there is currently a lack of legislation to protect breastfeeding practices at work, for example, and the only requirement by law is for organisations to provide a room to rest for breastfeeding women (Health and Safety Executive, 2013). As a result, to normalise breastfeeding in society, more robust and visible policies should be in place.
Culture, which is understood as an essential part of wider social determinants of health, shapes feeding decisions and influences expectations and experiences (Bailey et al, 2004). Accordingly, breastfeeding is a shared responsibility, since communities and societies have the power to accept or reject breastfeeding behaviours (Labbok, 2010). Nevertheless, many western countries lack awareness and ignore the value and support of breastfeeding (Dungy et al, 2008). Consequently, population health campaigns need to raise awareness of the importance of breastfeeding, modify and de-sexualise current perceptions and normalise lactating in public (Brown, 2017).
Population health strategies could be addressed by introducing breastfeeding education at school level, to ameliorate the lack of exposure to breastfeeding (Brown, 2016). Another important measure is to involve partners/fathers in breastfeeding programmes to improve breastfeeding practices (Ogbo et al, 2020). With the current impact that social media has on people's lives, online awareness could also be an asset to campaign for the normalisation of breastfeeding (Wolynn, 2012).
Conclusion
Culture crucially impacts breastfeeding, and lactation professionals should routinely assess cultural practices, ideally during the antenatal period. Healthcare professionals have the moral and professional responsibility to provide holistic care to women, infants and their families, and should aim to enquire, acknowledge, validate and support optimal lactation practices that promote breastfeeding. When cultural beliefs and practices conflict with evidence-based recommendations, respectful health promotion conversations and tailored interventions should occur. Motivational interviewing techniques have been proven effective in this endeavour, and their use is advised. In addition, cultural awareness, sensitivity and competence must be embedded in lactation professional education curricula and should be a requirement for anyone providing breastfeeding support.
Since breastfeeding is a shared responsibility, societies, health and social services, governments and policymakers should remove the burden placed on women for this significant public health issue and accept their own responsibility. It is time to eliminate the white supremacy culture and embrace diversity in its own right by becoming culturally competent professionals and eliminating health inequalities and racism. It is everyone's business to guarantee the best possible start in life for tomorrow's generations.