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I'd like to make two comments. The first draft of the document to be used in Beijing for the International Women's Conference did not contain the word breastfeeding. Now, how can you write a document about women and empowerment of women and not even mention it? I understand that it has now been included.
No. I was at the preparatory conference, and I welcome a chance to bring you up to date. The fascinating thing is that breastfeeding was there in the regional conferences in South-East Asia and Latin America and the Vienna Conference on Human Rights. Breastfeeding was very clear because the World Assistance for Breastfeeding Action (WABA) lobbied to make sure, and it went in under "women's health," "human rights," and "employment," so that if it was removed in one section, it would be there in another. When those drafts came to New York, every reference to breastteeding was removed. So we went to the preparatory conference for Beijing and we lobbied, and we know for sure that one reference is in under "structural adjustment," because one of our WABA members is the Swaziland representative, and she stayed up until midnight when they were finishing, and she got it in there. But all the most important places-"human rights," "women's health," and "infant health"-were bracketed, which means they will not be discussed until Beijing. That document was not out until the last day of the preparatory conference, and so we have a lot of work to do.
I agree. But I also think it underscored part of my concern, and that is, it is part of a cultural context that eliminated it. When the documents came to New York, it was a different understanding of women that is perhaps local to ten square blocks of New York City that wrote the document and excluded that concept, because that's not part of their lexicon. The second comment I want to make is that you did not have to feel uncomfortable showing the Playboy pictures. In fact it's important to show them, because we in the United States face recurring court cases brought by women who have been excluded from restaurants or other places for breastteeding. They have to go to the courts to vindicate what seems to me ought to be a natural right. But you can walk into any drugstore, and what you have is mild compared with what you can get from the so-called girlie magazines.
Just a very brief comment on the Women's Conference in Beijing. I had a call from someone from New York asking if the Demographic and Health Survey could give an estimate of the burden that breastfeeding imposes on women. I think the reason for this question was to support an argument that it was difficult to breastfeed and perhaps that women shouldn't do it. I said that, first, I didn't think it was a burden. Second, I said there was no way we could provide that kind of quantification, although all they had to do was pick up our report and take whatever information they wanted from it. I also said that if a woman didn't breastfeed and didn't use contraception and conceived again very soon, that would be a much greater burden on her than breastteeding. She never contacted me again. Maybe she got an answer from someone else. I don't know.
Dr. Van Esterik
We had a major problem. The Health Caucus was controlled by someone who was very close to multinational companies, and we had BINGOs (Business Interest NonGovernmental Organizations) in that caucus, not women's interests NGOs. One thing that made it very difficult was that they went around to some people we were lobbying and talked about how people who were promoting breastfeeding were just trying to make women feel guilty if they couldn't breastfeed. They kept asking other people for statistics about how many women couldn't breastfeed. I will leave you with a popular article, as well as an academic one, arguing that breastfeeding is a feminist issue. The first is designed specifically for radical North American and European women's groups that do not usually think about breastfeeding, and the second is to tell them why they should consider breastfeeding as a feminist issue.
I think we would be unrealistic if we said that breastfeeding was not a burden. It is a burden if women are hassled in the ways that we have been talking about. It's made a burden, and I think that's exactly the kind of point we are addressing. These are burdens caused by culture, and many of the issues we need to address are making it comfortable, promoting an atmosphere, just as many people live in an atmosphere where their attempts to breastfeed are frowned upon and discouraged. My first kid was born in Bethesda Medical Center. Let me tell you, the fight to breastfeed 29 years ago was really something. Not many people have the energy. They are fighting too many other battles. What we need to say is that under the right circumstances, it is not a burden; it's much better, and it's much easier, but I think we have to recognize that.
I was going to make this comment in a later session, but I believe that now is the moment. We are all interested in promoting breastfeeding, but we have to remember that the breast is one of the most important sexual symbols of a woman's body. More than that, it is not only a symbol, it is a very important organ that participates in the sexual union. The nipple is especially important in a woman's orgasm. Thus, if somebody proved that it is true that breastfeeding destroys this symbol, this organ, we would have a great enemy. If it is not true, we have to teach women that it's not true. I do not know if it is true or not, but we have to keep in mind that the breast is not only a place where women produce milk. It is a very important organ in the sexual relationship of couples.
Dr. Van Esterik
Most of the work that I have been doing this month at the Bellagio Study Center concentrates on the cultural construction of women's bodies. I'd like to argue that the breast is not universally a sexual symbol. It could be buttocks or legs or other body parts that are considered most attractive about a woman. But I agree with you in terms of having to consider breasts as sex objects. Hundreds of years of Cartesian dualisms, mind versus body, sexuality versus nurturance, maternity is over here and sexuality is over there. Breastfeeding advocates have a lot of work to do to show that this is not an either/or situation. It is both.
A woman was arrested in Ontario for obscene behaviour for taking her shirt off, and I was an expert witness. I spent two hours on the stand trying to argue that I could comment on ordinary breasts, not just lactating breasts. I argued that men's breasts and nipples are also sexually responsive and are also important in sexual foreplay, and women have to sit there and control themselves if a man takes his shirt off, and it's not considered obscene behaviour. Although there are differences, the differences must be culturally constructed, because you can go to beaches in parts of Europe and it's not shocking, as you mentioned the other day. But a woman breastfeeding on a nude beach that's what's shocking. Basically, we have to change the whole way we've been thinking for the last 500 years, so we have a lot of work to do.
I will play the devil's advocate. In a way, I don't think what Professor Hanson has presented is social construction, because there is no cultural constructivism in immunology or in many other biological aspects of breastfeeding I worry that if we emphasize the social behavioural component of breastfeeding too much, where is the seed for cultural constructivism? There may be a possibility of losing some strength in the argument of how important breastfeeding is from a biological perspective, and although I agree with you that one goes with the other, we must try to evaluate whether, by putting too much emphasis on cultural construct, we may lose some strength in the argument for the biological importance of breastfeeding.
Dr. Van Esterik
I think you have made the biological points pretty clearly over the last few days.
Well, it's brief, but it's important, I hope. Because we've constructed most of this discussion around changing behaviours, I'd like you to talk a little about how we protect the social constructs that exist, because we saw data earlier showing that 50% to 90% of women are breastfeeding. Thus, we seem to have a significant advantage in protecting a practice that does exist. How do we use the cultural constructs that have maintained this for the last 20 to 25 years?
Dr. Van Esterik
I don't have a clear answer. It is very important that we work with very local and specific understandings of infant feeding. We should pay much more attention to language and linguistic issues within communication campaigns to ensure we are using the words of the women we want to influence. In other words, we should put much more emphasis on the experiences of women themselves. I would hope that these experiences, in fact, will be parallel discourses. In other words, the scientific and the biological discourse will be much better understood if they are related to women's experiences, so that women's breastfeeding experiences will be much more prominent. I think these narratives are absolutely critical. I don't know how they would fit in with your research designs, but I don't see that they would do any harm as illustrating another way of thinking alongside the scientific papers on this topic.
Veronica Valdés and Janine Schooley
Many of the factors that have contributed to the decline in breastfeeding around the world can be overcome by education and support. Examples of successful approaches to education at different levels (mother, health professional, institution) that impact breastfeeding are discussed. For example, because breastfeeding is a learned behaviour for both mother and baby, providing the mother with information, skills, and support for the breastfeeding process is integral to her ability to breastfeed successfully. In addition, because the health professional plays a pivotal role in the success or failure of breastfeeding it is essential I that education and training of health professionals be adequately addressed. By using an approach to healthprofessional education that builds on a highly trained core and spreads to all levels through a built-in multiplier effect, improvement of breastfeeding practices can be assured. In order to sustain these results, however, health-professional school curricula must include adequate information on the science of lactation and the clinical management of breastfeeding The experience of Chile's National Breastfeeding Programme is used to illustrate the power of education at each of these levels in influencing the success of breastfeeding and the feasibility of using education of both mothers and health professionals as a way of preserving this incredible natural resource.
Breastfeeding is a learned behaviour
Why does breastfeeding, something so biological, natural, and part of the essence of being a mammal, need to be taught and learned? Lactation occurs in every female after delivery as a biological response to hormones present in that period, and yet 38,000 infants die every day because they are not breastfed . Clearly breastfeeding is a behaviour that needs to be learned for the survival of the species .
In nature, young females observe their elders caring for and breastfeeding their offspring. That experience will allow them to take care of their own when they reach reproductive age. A good example of the power of this experience is the case of a female gorilla named Dolly who had been raised at the San Diego Zoo. When she delivered her first offspring, she did not know what to do. She hugged the placenta and was afraid to touch the baby, whom she was not able to breastfeed. During her second pregnancy, the curators decided to teach her about mothering and breastfeeding. They showed her videos of mother gorillas in the wild nursing their infants and gave her a doll to teach her to be gentle in holding and nursing a baby. The teaching programme was a success, and she has been able to nurse and care for several other babies since then.
Something similar occurs with women in modern society . With urbanization and the lack of extended families, most first-time mothers have not seen their mothers or relatives breastfeeding. Even worse, from everywhere around them they have been receiving the message that what is normal and modern is bottle-feeding. As young girls, they are given a doll and bottle to play with, and their mothers also probably bottle-fed. Formula companies advertise their products to the public, and for many women, this is their only source of information regarding infant feeding . As more deliveries occur in hospitals, more women are influenced by hospital practices that often interfere with breastfeeding . There, they do not receive the necessary support from the health-care team, because health professionals generally lack the knowledge and skills for good clinical management of breastfeeding . In addition, an increasing number of women are working away from their homes and their infants.
FIG. 1. Percentage of tbe mothers exclusively breastfeeding at six months according to presence or absence of prenatal group education and parity
Therefore, the natural behaviour of breastfeeding is subverted by a variety of forces, as reflected in the often abysmal rates of prevalence and duration of exclusive breastfeeding.
Educating women about breastfeeding has a positive effect on breastfeeding performance
One way to minimize this interference with breastfeeding is through the education and support of mothers. Several studies show that providing breastfeeding education for women has a positive impact on the success of breastfeeding [6-11]. This impact has been underscored by results achieved at the Hospital of the Pontifical Catholic University of Chile, which showed a significant increase in exclusive breastfeeding at six months post-partum among women who received prenatal group education . Eighty per cent of 59 women who received prenatal group education as part of a breastfeeding-promotion programme completed six months of exclusive breastfeeding versus 65% of the 363 who were part of the same study but did not receive prenatal group education (p < .003). This effect was even larger among primiparas, where only 57% of those who did not receive prenatal group education, versus 94% of those who did, were breastfeeding exclusively by the end of the sixth month (fig. 1).
These results were obtained in the context of a prospective study on the impact of a breastfeeding promotion programme on the duration of exclusive breastfeeding among lower-middle-class urban women. This study took place in the hospital and outpatient clinic of the Pontifical Catholic University in Santiago, Chile . The study included a control group of 313 mother-infant pairs and an intervention group of 422 mother-infant pairs. Both groups were followed monthly for six months. Thirty-two per cent of the control group were able to complete six months of exclusive breastfeeding. This was, in fact, a relatively high prevalence, because only 2% of infants that age were exclusively breastfed according to a national survey carried out by the Ministry of Health in 1986. The higher prevalence in this population was due to the fact that the hospital of the Pontifical Catholic University has always promoted breastfeeding and had rooming-in, and medical and nursing students are taught that breastfeeding is important.
Before recruiting the study population, there was a need to develop a comprehensive programme designed to promote exclusive breastfeeding. The breastfeedingpromotion programme involved educating all health-care providers at the institution who take care of mothers and infants; changing policies that interfere with breastfeeding to make them more supportive of optimal breastfeeding practices, such as immediate contact between mothers and infants; delaying supplements or solid foods until the end of the sixth month if the infant is growing well; creating a Lactation Clinic to prevent and solve breastfeeding problems; providing breastfeeding education for women during the prenatal and postnatal periods, including how to breastfeed and how to prevent problems; and emphasizing the effect of exclusive breastfeeding on delaying the return of fertility and the use of the lactation amenorrhoea method for child spacing.
FIG. 2. Duration of exclusive breastfeeding before (control) and after (intervention) completion of a breastfeeding-promotion programme at the Pontifical Catholic University of Chile in 1993.
FIG. 3. Feeding status at six months among infants of working women
After the implementation of the breastfeedingpromotion programme, 67% of the study population completed six months of exclusive breastfeeding (fig. 2). The prevalence has even improved in the broader population cared for at the hospital of the Pontifical Catholic University after the institution of the Lactation Clinic and the use of the lactation amenorrhoea method by an increasing number of women. Education and support activities were developed for women who work outside the home. When mothers were taught how to hand-express and store their own milk and were offered monthly clinical follow-up, 47% of the working mothers were able to feed their infants exclusively with their milk for six months, and fewer than 6% of the 170 motherinfant pairs who were followed weaned before six months (fig. 3). None of the women in the control group (those not receiving education and support) who continued to work completed six months of exclusive breastfeeding. All of this happened in an institution where the personnel thought they were already promoting breastfeeding, but the results show that much more could be done. What made the difference?
Health-professional education is the cornerstone of improvement in breastfeeding practices
The difference was due to the intensive education of a core team of health professionals in the science of lactation and the clinical management of breastfeeding, and the resulting multiplier effect . Before implementing the breastfeedingpromotion programme, a multidisciplinary team composed of a paediatrician and an obstetrician participated in Wellstart International's lactation management education programme. During their trip to San Diego for the course that would initiate their participation in the lactation management education programme, these professionals, like the hundreds of others throughout the world who have participated in the programme, asked themselves, "What can we learn that is new about breastfeeding and lactation during a whole month?" At the end of the four-week course, like all the others who have participated in the programme, they had acquired new knowledge and skills, shared experiences, and realized that lactation was such a broad topic that they had only just begun to learn. Wellstart's lactation management education programme is designed to develop core resources of expertise that can form the basis of teaching and promotion programmes at the institutional, national, and regional levels, using the following approach:
The lactation management education programme has had an impact throughout the world, not so much because of what it has done, but because of the galvanizing effect its approach has had on others. By putting essential tools and resources into the hands of teachers and decision makers, the programme has served as a catalyst for a powerful multiplier effect in a number of countries. More than 550 associates from over 50 countries have participated in the lactation management education programme. In part because of their participation, National Breastfeeding Programmes are developing in more than 20 countries, National Training Centres in 13 countries, and Regional Training Centres in 5 countries. The impact is particularly great in countries where the UNICEF/WHO Baby-Friendly Hospital Initiative is under way, and many positive influences are at work. Chile provides an excellent example of the effect of health-professional education on breastfeeding. In October 1990 the results of the research project "The effect of a breastfeeding promotion program on the fertility of urban women in Santiago, Chile"  were presented in a three-day breastfeeding course for health professionals. The course was designed to offer participants basic knowledge on the anatomy and physiology of the mammary gland, clinical management of breastfeeding, updated benefits of breastmilk and breastfeeding, and the relation between fertility and breastfeeding, along with the results of the above-mentioned project and several others. Two years later, a questionnaire was sent to the participants to see if the course had had an impact on their actual practices and recommendations regarding breastfeeding. The results showed there were significant increases in clinical practices supporting breastfeeding, which included teaching the mothers and supervising breastfeeding techniques. The weaning recommendations given to mothers, including when to begin weaning foods and milk supplements and when to complete weaning, reflected a postponement of over two months compared with earlier practices (fig. 4) .
This course was also the beginning of a process of creating a critical mass of people with knowledge and interest in promoting and supporting breastfeeding throughout the country. By adopting many of the approaches used in the lactation management education programme, Chile developed its own cascade effect. In 1992, after the Innocenti Declaration and the World Summit for Children, the Chilean government created a National Breastfeeding Commission to develop a National Breastfeeding Programme. As part of that programme, the Baby-Friendly Hospital Initiative was launched in Chile with the support of UNICEF. The main emphasis and activities of the National Breastfeeding Programme, with the participation of the six Wellstart associates, have been educating health-professional teams on breastfeeding and developing teaching materials to help them disseminate that training. In 1992, 34 professionals, including teams from three hospitals, participated in the first Baby-Friendly Hospital Initiative Training for Trainers Workshop. These teams received teaching materials such as slides, videos, books, and syllabi to replicate the teaching at their institutions.. Since then two new workshops have been developed, attended by 142 new trainers who are now teaching the health teams in their own and neighbouring institutions.. By the end of 1994, more than 4,500 health workers had been trained throughout the country in replicated, 18-hour courses (fig. 5). Eleven hospitals have been designated as Baby-Friendly owing to their supportive practices for breastfeeding. In 1994 approximately 290,000 infants were born in Chile, with 52,000 of these births occurring in Baby-Friendly Hospitals.
FIG. 4. Recommended ages for initiating weaning, introducing cow's milk-based supplements, and completing weaning before professionals complete breastfeeding education course
FIG. 5. Numbers of health workers trained in Baby-Friendly Hospital Initiative workshops in Chile 1992-94
A national survey carried out at the end of 1993 showed that the prevalence of exclusive breastfeeding at six months had increased from 2% in 1985 to 25% in 1993 (fig. 6). In areas of the country where health workers in hospitals and community clinics have been trained, the percentage of exclusive breastfeeding at six months is more than 60%. These results show that there actually was a lack of knowledge among health workers on how to promote and support breastfeeding [17, 18], and that when they learn, they change their practices, which then have an impact on the prevalence and duration of breastfeeding in the community.
FIG. 6. Percentage of children and partially breastfed in Chile in 1993 according to age. Source: Ministry of Health National Breastfeeding Survey
The next step is to make this effort sustainable and costeffective. The only way to do this is to change what is taught at the university level and to include the scientific basis and clinical management of breastfeeding in the curricula of health-professional schools [19, 20]. This effort has already begun in many countries. A curriculum guide for medical, nursing, and nutrition training programmes has been developed by Wellstart and is beginning to be used in several universities in the United States, Latin America, and Africa. In Latin America two subregional workshops were hod for this purpose, one in Guatemala and another in Paraguay. A national pre-service curriculum workshop was held in the Pontifical Catholic University in Chile as the first activity of the National Breastfeeding Training Centre. The participants included representatives from schools of medicine, nursing, midwifery, nutrition, pharmacy, and dentistry from all the Chilean universities. In Africa a similar process is under way with the participation of 10 countries in east, central, and southern Africa.
Heal to-professional education is critical to making any kind of long-term-change in the way breastfeeding is promoted, supported, and protected. When health professionals are convinced that a breastfed child has the best start in life and really understand how breastfeeding works, they will send the right messages and give the needed support. Only then will the impact on the community be sustainable and something as natural as breastfeeding be preserved.
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