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Nutrition and public health

Psycho-social aspects of breast-feeding, including bonding


Psycho-social aspects of breast-feeding, including bonding

J.K. Harfouche
American University of Beirut, Republic of Lebanon


Breast-feeding, the natural way of feeding the human infant and the crucial determinant of growth and survival in the "extero-gestate phase" (birth to nine months), has a biological as well as a psycho-social base. The biological base is related to the anatomy and cellular structure of the mammary gland and to the physiology of lactation, including the quality and quantity of human milk. On the other hand, the practice of breast-feeding, although dependent on the integrity of the biological base, is largely determined by maternal psycho-social factors that control its initiation, maintenance, and adequacy as the natural method of infant feeding.

The holistic (wholistic) view of breast-feeding as a process taking root in the maternal biological base and unfolding as a reality by determinants in the maternal psycho-social matrix, brings to the forefront important and interrelated axioms for determining strategies and action plans directed to preserve, promote, and revitalize breast-feeding for nutritive, economic, and demographic reasons.

1. The biological mother is the ecological focus of the child. The mother-child "dyadic" interaction and bonding initiated during gestation are maintained after birth through breast-feeding and nurtured by maternal love and tender care. Hence, the declining incidence of breastfeeding and interventions to promote its resurgence cannot be considered in isolation from the psycho-social matrix of the biological mother.

2. Breast-feeding constitutes an integral part of child-rearing, and the maternal attitude toward nursing is intimately linked to the socialization process of young girls in their formative years. Thus, trends of change in breast. feeding and the modifications required should be based on a thorough understanding of child-rearing patterns in the local setting.

3. Breast-feeding reflects the "Ideal Cultural Image of the Mother" in traditional societies. When the cultural image is modified by modernity and the changing status of women, the role of "mothering" is obliterated by other roles and career alternatives. Resurgence of breast-feeding may be Party achieved by "gained knowledge" about the advantages of human milk and other measures, but full resurgence required revitalization of true "mothering."

4. The technology of bottle-feeding, comprising a new tool and related skills and knowledge, like all other modern technologies, is an important agent of psycho-social change, creating adverse effects on "mothering" and a hostile climate for breast-feeding.

Breast-Feeding: An Integral Part of Child-Rearing

What is meant by child-rearing?

Child-rearing is not a technical term with precise significance. It refers generally to all the face-to-face interactions between parents and their children at the family level. These interactions include the parents' altitudes, values, interests, and beliefs as well as their care-taking-feeding and weaning, cleansing, protecting-and training behaviour

Sociologists view these interactions as one separable class of events that prepare the child, intentionally or not, for continuing his life. Thus, they provide the offspring opportunity to develop the values and skills needed for living. If a society survives beyond one generation, it quite evidently has cared for some of its offspring, and has provided opportunity for them to develop the values and skills needed for living.

Child-rearing practices are universal, despite variations in their patterns among and within countries and regions. The ecology, economics, and socio-political organization of an area determine the maintenance system (e.g., the arrangement of people in space, the type of houses and household composition, basic economy, and the most elementary variables of social structure), and set the background for child-rearing practices. The techniques that the members of any society employ in the care and rearing of children are culturally patterned and will tend to be similar, although never identical, for families within the society.

Child-rearing practices and adult personality patterns

Personality, as the term is commonly used, is the cluster of potentialities for action that characterize the individual (e.g., interpersonal relationships, intellectual achievement, stole of movement, etc. )

A person's behaviour at any given time is a product of his native endowment, of his immediate situation, and the qualities of personality he has developed up to that moment in his life. Thus, personality may be viewed as a product of a lifetime of "dyadic" action, which has modified the individual's potentialities for further action. Both the personality and the actual behaviour displayed by the person are consequences of the interactive effects of all the influences, both constitutional and experiential, that have impinged on the child from birth onward, particularly in the formative years.

In any given society, common cultural themes affect the majority of the people and help to determine their child-rearing practices and personality patterns. In unchanged, traditional societies, child-rearing practices and adult structure are inseparable aspects of the social personality. But in rapidly changing cultures, discontinuities and uncertainties arise that make for instability and insecurity in parent-child relationships and rearing practices.

Child-rearing and personality development

The three well-known theories of child development-the emotional theory of Erik H. Erikson, the intellectual or cognitive theory of Jean Piaget, and the learning theory of behaviour of Robert R. Sears-all make use of developmental phases rather than exact age norms, and suggest that in the continuum of development, whatever the individual does, thinks, or feels in any area of his life at any given point in time is "intrinsically linked" to the person's image of himself, his family, and his key reference groups. Each individual is inwardly dealing with his own inner experiences, his primary environment, and his secondary environment. He can only relate to these three spheres in the way they are integrated by him, regardless of the image others may hold of him.

According to Sears' learning theory of behaviour, development may be viewed as a continuous, orderly sequence of conditions that create actions, new motives for actions, and eventual patterns of behaviour. Therefore, social conditions dictate the existence of three developmental phases: a. the phase of rudimentary (asocial) behaviour, or the period of pre-socialization, which is based upon native needs and learning in early infancy (first six months of life); b. the phase of secondary motivational systems which is based upon family-centred learning, covering most of the impact of socialization in early childhood (six months to five years of age): c. the phase of secondary motivational systems which is based upon learning beyond the family.

The three phases of development may be described as three expanding circles on a pool of water into which a stone has been dropped. The first, innermost circle represents the child's most intimate parental environment: The next circle stands for the child's emergence into a larger family environment. The outermost circle emphasizes the child's gradual social penetration into his neighbourhood. Each circle, as it expands, blends into the next larger circle, thereby losing its original limited separateness. Similarly, the expansion of each developmental phase, like converging circles, encompasses a larger sphere of learning.

The five major motivational systems are: dependence, feeding, toileting, sex, and aggression.

The most important processes in development are: identification, play, mobility, reasoning, and conscience.

The social factors within the family setting that receive most consideration are: parents' own status, sex of the child and ordinal position, social class, education, and cultural heritage.

"Dyadic" interactions and bonding in the pre-socialization period (first six months)

The child's first relationships with his environment are of crucial importance in forming the bases of subsequent personality development. The pre-socialization period (first six months) connects the biological environment of the new-born infant with that of his social environment, and provides the foundation for ever-increasing interactions with this environment.

The newborn infant has various biological needs that result in primary drives or "cues for action": hunger, thirst, sleep, fatigue, sex tension, need for waste elimination, activity, optimum temperature maintenance. These drives make up a complex and are instigators of social learning.

The newborn is also endowed with potentialities for securing many forms of gratification from his world. He can eat, eliminate, be warmed or cooled, and can be fondled and loved. These experiences are not only gratifying, they are also the sources of learning. Simultaneously, the way in which the innate biological needs are met introduces environmental learning experiences. These nurturing experiences are increasingly related to the physiological stimulations until social learning becomes the primary instigator of behaviour.

Breast-feeding and bonding

Hunger produces tension that seeks reduction through any gratifying response. Thus, the "cue of hunger" becomes associated with the action response-crying and breast with hunger-reducing fluid. Repeatedly satisfied responses and the attendant events that lead to the satisfaction are received together as rewarding experiences. The mother's promptness, dependability, regularity, and personal warmth (e.g., fondling, dose body contacts, etc.) provide the essential reinforcement. A mother who devotes much appropriate attention to her child at the times he needs her is supportively reinforcing. The child, in turn, is more apt to adapt his behaviour to those forms that will assure his mother's consistent attention. There is more common interaction and guidance from a truly loving mother than from a less available, or less loving, mother.

The key to control is embedded in this "dyadic" relationship. The infant learns both to control and to be controlled. As a quick learner, he soon develops his techniques of co-operating with those who care for him, and of controlling them and ensuring their nurturance. Successful development is characterized by a decrease in autism and innate need-centred actions and by an increase in "dyadic," socially-centred behaviour. His actions become more and more learned behaviour, instead of occurring by trial and error, and then become part of an action sequence with a learned, goal-directed response. Failure to develop results in a lack of movement, or in a reversal of the trends mentioned above.

Dependence and ''dyadic reinforcement"

Dependence is considered as a most essential component of learning or motivational systems. The infant reveals dependent tendencies from birth because of immaturity. Initially, dependency, like other motivational systems such as feeding, starts with the child's participating passively with help from the adult as the major reinforcing agent, until he can later actively maintain his dependency, in which the adult no longer plays a major role. The latter, however, does not occur until the next developmental phase (e.g., six months to five years of age). The adult handling of dependency and control provides the beginning for the process of identification.

During the first six months, the child's self-control comes from the control of his parents. Rewarding reinforcement in all "dyadic" situations depends upon the child's having consistent contacts with one or more persons. The essential relationship has its beginning in the earliest child-mother contacts when the child shifts his processes of learning from those based on trial and error to those based upon "dyadic reinforcement." A "dyadic" relationship fosters dependency and, thus, reinforces it. The dependency is nurtured through the "dyadic" relationships of feeding during the fourth to twelfth months. Once appropriate behaviour assures dependency, a truly "dyadic" relationship exists.

The child's innate need for the reduction of his hunger becomes quickly associated with two essential and interrelated components of his food-intake sequence: to suck and to be near the nursing person. The mother bringing food then fosters a "dyadic" relationship and simultaneously reinforces dependency on herself as the caring adult. The mother is #en as an indispensable part of the activity of sucking and the intake of all food. Her image, smell, feel, voice, etc., are closely associated with gratification. The child not only learns to expect her to come when he is hungry, he also learns that he needs her. It is this link between the drive for food and the desire for the mother that is essential to this phase of development. The child's natural desire to eliminate and to express himself sexually remain asocial desires.

By the time a child is one year old, he has become related to his mother in such a way that not only do many of his satisfying actions require her presence and co-operation, but her very orientation toward him-indeed, her simple existence near him-is a source of satisfaction. He loves his mother; he is emotionally dependent on her.

Family-centred learning, secondary motivational systems and socialization

After the first six months, the family is the cause of all subsequent learning for the infant, and a study of a child's family leads to a description of his early childhood development.

The phase of secondary motivational systems, which is based upon family-centred learning, covers most of the impact of socialization in early childhood (six months to five years). Essentially, during this phase the child develops his own personality as directed by his elders through their child-rearing efforts.

Socialization process

The socialization process is that process by which the infant learns the ways (life-styles) of a given social grouping and is "moulded" into an effective participant of that group. The individual learns of the values, attitudes, norms, and other attributes of his culture; in time he becomes a social being. It is a long, tortuous process, and the individual travels the route in his own unique way, and acquires those minimal personality qualities or traits deemed appropriate by the group. This is not to say that he becomes an exact replica of the expectations of his fellow members. It is impossible to duplicate the experiences, perceptions, and interpretations of any given member of a group, even with twins. Therefore, each individual is unique at the same time as he has commonalities with his group.

Secondary motivational systems

During the socialization period, the child's primary needs continue to motivate him. These, however, are gradually incorporated into repeatedly reinforced social learning, or secondary drives. Thus, these secondary drives will be his main motives to action unless his social environment fails to provide the necessary reinforcement.

The mother continues to be the major reinforcing agent during the early stage of this phase. She perceives behaviour that should be changed and establishes standards for more mature forms of action. The mother, however, must first instil in the child a desire to become socialized. If she accomplishes this successfully, the child's learned desire toward accepted social behaviour will lead him in the direction of more mature activity and response. The child becomes aware that his personal happiness depends upon his readiness to do as he is expected, and eventually his actions become self voted.

At this stage, punishment, rather than reward, becomes an important factor in the process of socialization. Contrary to its intent, however, punishment as used in this context does not alter behaviour, it merely serves as a clear sign of refusal to support a behavioural event.

Some of the successful withdrawal of care occurs at this time (e.g., mother's preparation for a new sibling, or her return to work), because the child will have learned by spontaneous imitation of an action sequence previously carried out by his mother to fill his own needs to some extent. Imitation occurs and is reinforced by the child's self-activated goal-achieving response.

With less dependence on a caring person, the child becomes freer to compete with others (e.g., the motivational drive of competition develops). He gradually learns that nothing is his sole monopoly and he has to compete for his desired goals.

However, for the child, a sudden or untimely withdrawal of support of his dependency means: I no longer care for you. In infancy, actual feeding and the nurturing of dependency needs are intimately woven together. If the mother tries to change feeding habits, she not only interferes with strong habits of obtaining food, but also disrupts the dependent relationship. Change in feeding practices involves modification of recently entrenched motivational systems. The child's degree of sensitivity toward weaning is clearly related to his age when weaning begins and to the preparation for the final step of weaning. At the point when dependency is a well-established drive-roughly at the age of 20 months-weaning is less of a threat to his existence.

At about the age of two years, the child gains more and more self-control over his impulses, supported by parental guidance. Self-control is a process in which the child gradually adopts his parent's wishes and standards as his own and develops a conscience. The child tends to imitate those qualities in his parents that are most sensitive and are apt to be censored by withdrawal of parental love. More and more of the parents' qualities of behaviour and standards of conduct are incorporated within the child's own repertory of action.

Societies in transition

In the developing countries, societies in transition are now the most important target for the infiltration of modernity and new life-styles. Young mothers in these societies are, radical change in the cultural "Image of the Mother and Mothering," with a progressive adverse effect on maternal behaviour and the practice of breast-feeding. Thus, in setting strategies and action plans for the preservation, promotion, and resurgence of breast-feeding, a high priority should be given to pert-urban and newly urbanized population groups, particularly in the poverty pockets.

Prior to the implementation of general or direct interventions, it is most essential to have a thorough understanding of the psycho-social matrix of young girls (mothers-to-be), including the cultural image (self and public!, child-rearing practices, and key modernizing forces and factors inducing the negative change. Such effort is particularly important in planning and implementing educational programmes (formal, informal, and non-formal) before the pendulum of change goes too far. All other relevant measures, including legislation and occupational adjustment, would be of secondary importance unless society and the "mother-to-be" continue to accept some features of the "ideal cultural image of mothering," and attest by attitude, word, and practice that this is feasible and possible, without adverse impingement on the "career" or "vocational" role. Women's active participation in this effort, including decision-making at all levels, is essential.

The resurgence of breast-feeding, recently observed in some of the industrialized countries, appears to be mostly a result of improved information about the advantages of human milk and breast-feeding, a resurgence begun by women and for women, as in the case of the La Leche League. High motivation by an informed, organized, dedicated, and supportive group must have induced in other adult women acceptance and revitalization of the old "ideal image of mothering," creating, in turn, a strong desire for its fulfilment through breast-feeding. This shift in the self-image was associated with a remarkable capacity for lactation, even among several non-biological mothers, who had succeeded in nursing their adopted children.

The Technology of Bottle-Feeding as an Agent of Psycho Social Change

Bottle-feeding, as a form of modern technology, comprising a new tool as a substitute for the breast, artificial milk, and related skills and knowledge of bottle-boiling and formula preparation may be considered as the most important agent of change in the mothering role and maternal attitude toward breast-feeding.

A new technology introduces with it a new cultural and psycho-social change affecting values, customs, beliefs, attitudes, and life-styles. It is true that egalitarianism created a demand for a breast substitute, but the mere availability of the bottle made the demand much more acute, because many of its users have no career other than mother) e.g.

The bottle as a modern device for infant feeding became very fashinable in a short time, and took on a special aura conveying a new symbolization process that went far beyond its functions. In an abstract sense, the bottle is often perceived by newly urbanized mothers in traditional societies as a "precious" and even "sacred" device, because it represents "the magic of industrial society" to which only a few have access. To the emancipated woman in modern society, it is a symbol of "freedom" and "liberation." Breast-feeding immobilizes the mother, but the bottle liberates her. It enhances her mobility, releases her from the closed domestic sphere, and allows her more time for leisure, travel, career achievement, and self-realization. When bottle-feeding was first introduced, the women who wanted so desperately to be "liberated" and to use bottles for their infants were denounced as selfish and cruel. Today, the transfer to the bottle and cow's milk has become an accepted life-style by the vast majority of women in the world. Most of these women are physically fit, have well-developed mammary glands, and are potentially efficient lactators. Hence, deficiency is not the root cause of bottle-feeding; rather the cause is a lack of determination to breast-feed.

In many countries, the bottle culture has already succeeded over the breast culture through psycho-social weapons, and more success is expected unless some psycho-social counterbalance occurs. The crucial questions are What? and How?

Bottles are not only here to stay, but have generated a hostile climate for breast-feeding. Modernized mothers cease to think of breast-feeding as a physiological process and a natural phase of the reproductive life cycle. They typically equate the breast with a "faucet" that can be turned on or off at one's convenience, and fear it as a target organ for potential cancer.

Breast-feeding is perceived as an "uncivilized" activity and as an "old-fashioned" life-style. Extreme disapproval may sometimes be expressed in terms such as "animalistic," "disgusting," "not for people," "not done!"

In confronting the bottle culture, it is necessary to understand how women come to adopt ways of life, standards of evaluation, and self-perception associated with a modern lifestyle. How do women who migrate from the traditional to the modern universe adjust to new situations, adopt new attitudes and patterns of behaviour? Moreover, it is necessary to know the "agents of change" and the "social passages" or "turning points" associated with the "critical attitude," the most crucial element in the process of modernization.

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