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In many societies, feeding is synonomous with care. Minimally, it is a metaphor for care. Consider the meanings of nurture in English. Child-feeding is a high-periodicity task; that is, it is non-postponable and must be undertaken frequently. It is generally seen as low-status work because it reduces the flexibility of the person assigned to this task. Although child-feeding is almost always considered the responsibility of the mother, she may delegate the task to a person of lower status, most commonly a young daughter.
The nutritional factors that influence dietary adequacy include: frequency of feeding;
-amount of food in meal;
-energy and nutrient content of food;
-utilization of food within the body.
These factors are part of the caregiver's strategy for integrating the feeding of a toddler into the feeding of the rest of the household. I refer to this as the process of integrating a child into the family circle. It has been demonstrated that the caregiver may not always have control over this process, but instead may allow the child to decide how much to eat [22].
Although much attention has been focused on the relationship between breastfeeding, hygiene, diarrhoeal diseases, and growth retardation [4], less attention has been focused on the number of meals per day that young children eat and the timing of these meals as indicators of nutrition status. A recent review of data from India documented hunger in terms of household meals per day (S. Zurbrigg, personal communication, 1994). Poor households do not have regular access to two meals a day of the local staple, and the poorest households do not have access to even one meal a day. Although two meals a day might meet basic caloric requirements, one meal is not enough, resulting in chronic hunger; no meals per day denotes acute hunger.
This starkly simple measure of household food security encompasses the two central types of hunger in human experience-chronic and acute. The implications for childfeeding are obvious. If meals are prepared only once a day, the odds of a toddler's being fed three or four times a day are very low. Goldman [23] found that children eating three meals a day obtained more calories than children eating two meals a day. Households dependent on seasonal employment or whose members become sick may easily drop from "nearly enough to eat" to "not nearly enough to eat" with subsequent risk to child survival.
The weaning interval
The weaning interval, the period between the first introduction of complementary foods and the completion of weaning, might be understood as an intensive period of food socialization. During this period, a number of important transformations take place in addition to the reduction of breastmilk intake. These include changes in feeding techniques, including the introduction and mastery of new objects such as spoons, bottles, cups, or utensils such as chopsticks;
-food provider, from the mother to the grandmother, sibling, or caretaker; foods consumed, from liquids to semi-solids and solids, and from finely ground to coarsely ground, to bite-sized chunks, and finally to adult foods; meal behaviour, from a passive, dependent infant to an individual expected to follow cultural rules about the correct way to eat.
These substitutions are not easily made, and can be thought of as trade-offs between the welfare of the mother (who may be pregnant or who may now have to give more time to other activities) and the toddler (who benefits from having the exclusive attention of the mother).
Circle of commensality
Infant-feeding has a dimension of commensality or food-sharing seldom recognized. Food is the context of the first social interaction experienced by all humans. This experience may be totally pleasurable or anxiety-producing. In fact, the pattern of infant feeding may set a pattern for food-sharing later in life. Infants begin to participate in a system of food sharing in utero, and at birth, with their lactating mothers (and possibly with close female relatives who may breastfeed them on occasion). In some societies, unrelated women breastfeed. each other's children for pay, as with wet nursing, or as part of cooperative work strategies among friends. Gradually, the circle of commensuality expands to other members of the family and beyond. The commensal circle includes only mother and infant during exclusive maternal breastfeeding and when mothers pre-chew food for their infants. For example, Thai mothers in Laos and northern and northeastern Thailand often pre-chew glutinous rice for their infants. Elsewhere mothers may squeeze fruit juice into an infant's mouth and then eat the pulp themselves.
The expansion of this circle of commensality is a key to understanding the transition to an adult diet. The next stage may be the ritual presentation of a highly valued food, either before or after breastfeeding begins. Honey, a common purifying substance according to Javanese mothers, is rapidly being replaced by glucose as hospital births increase. Glucose is routinely fed to newborns in hospitals in many third world countries. This second stage provides occasional tastes of key flavours in the adult diet: lemon, butter, banana, rice. The third stage includes special infant recipes not shared by other family members. Bubur (rice porridge) in Indonesia or pablum in Canada are examples of self-targeted complementary foods.
To this point infants and toddlers have protected access to the food supply, and as long as they are also breastfeeding, they are probably adequately fed. A crisis may occur when the circle of commensality enclosing mother and infant expands to include sharing food with other siblings and family members. For with this expansion, toddlers begin to lose protected access to their food supply. They are then most affected by the food system into which they are being socialized. Future research on young child-feeding should take into consideration the wide range of meal systems existing cross-culturally.
New questions
What are the implications of this approach to child feeding for the study of care? Most significant, perhaps, is that it opens up a new line of questioning. Is child survival enhanced more by delaying the newest family member's entry into the commensal circle, giving the child a longer period of protected access to special weaning foods, or by encouraging and accelerating the child's entry into the commensal circle without a period of "special" infant foods? Do toddlers who are breastfeeding have more protected access to family foods?
The introduction of solid and semi-solid foods regularly into children's diet is typically delayed in Egypt. In Manshiet Nasser, mothers began to introduce solid foods regularly, on average, by around the ninth month. In terms of breastfeeding patterns, children receiving breastmilk sustain better weight-for-age than those who do not breastfeed during infancy [5].
The pattern of undernutrition among breastfeeding children in the second and third year of life suggests that in this urban context, breastmilk tends to replace rather than complement other items in the diets of young children, and it is also associated with less frequent feeding with outside foods. It is possible that once the child is no longer receiving breastmilk, mothers and others around the child make a greater effort to feed the child, to make sure it gets enough food, because it is no longer receiving mother's milk [5].
Are breastfed toddlers spared the need to compete with their other siblings until they are larger and stronger? Do these questions suggest alternative approaches to researching growth- faltering in children? The concept of care encourages us to consider the "how" and "why" of young child-feeding in addition to the "what" and "when."
Action
Anderson's touching story of the death of Alicia's ten-month-old daughter in the shanty town of Lima, Peru, underscores the danger of assuming that forming women's groups or providing more health education will solve the problem of care. While Alicia was at a meeting of her community women's council, where she participated in the primary health promoter's group, her daughter became dehydrated and, the following day, died. Even after health training, Alicia was not able to respond quickly enough to the symptoms of dehydration to use the therapies she had just learned. She took her mothering tasks seriously, but she left her 12-year-old daughter to care for the baby. Mothers' participation in these community-based self-help groups did not result in more favourable weight-to-age ratios or improved child development [24].
This study is a reminder of the fluid and ethically complex relationship between care, self-help, charity, and welfare. Meillassoux reminds us of the relation between the acts of caring that reproduce the patriarchal family, charity, public assistance, mutual aid, social security, and welfare [25]. Interventions to promote care must negotiate the different levels of analysis where care is institutionalized. Policy terminology, too, implies a kind of caring-intervention, protection, promotion, advocacy-without considering the different political and conceptual bases for each. Strategies to ensure care take place at several different levels.
Individual strategies
The biomedical literature provides very little evidence regarding women's experiences combining work and caring activities. However, ethnographic evidence suggests that there are always trade-offs in caring and coping. Most strategies are individual and short-term, entailing no institutional changes or community support. This reflects the fact that successful integration of caring activities and other work requires a strong, determined woman who can overcome obstacles. Women in industrialized societies who are highly motivated to breastfeed, for example, often take on multiple responsibilities as individual "superwomen," neither expecting, requesting, nor receiving assistance from other people, their institutions, or their communities. This "superwoman" model of care is totally inappropriate for export cross-culturally, and in fact has also been responsible for breastfeeding's being considered an unattainable mode of care for low-income mothers and immigrants to North America. "If you're not a superwoman, don't try it."
Cultural strategies
Cultural strategies are distinguished from individual strategies because they refer to beliefs and practices that may be widely shared in a society. They are thus indigenous resources that may be utilized by some individuals and not by others, and may also form the basis for culturally appropriate interventions.
Surrogate mothering and postpartum seclusion are cultural practices that in many cases assist mothers in learning to care for their children. Wet-nursing has a long history as a coping strategy. Now, however, wet nursing is most common within families in small scale and peasant societies. Even breastfeeding advocates express concern about the dangers of cross infections or of the infant's "bonding" to someone other than the mother.
Nevertheless, there is anecdotal evidence that wet nursing is far from rare when women with similar aged children organize for support and cooperative child care. Some wet-nursing exists among student mothers and others who work in unstructured jobs. In the Philippines, employed women organized a baby-care cooperative where babies were breastfed by surrogate mothers whose babies were also at the centre. Shared breastfeeding is the most intensive form of shared child care, and the practice emerges out of intimacy, mutual concern, cooperative work, and, usually, strong bonds of affection. Grandmothers who breastfeed their grandchildren may represent a more widespread caring strategy than many acknowledge. Support for cooperative child care may foster this practice, but shared breastfeeding is seldom openly discussed in planning and policy meetings, particularly in the era of AIDS.
Mothers of infants suffer from fatigue and, in some cases, excessive energy demands. However, fatigue is also a major complaint of mothers who are not employed outside the home and of women who are not breastfeeding. Any practices that encourage a period of social seclusion, rest, and special foods for mothers for the first few weeks postpartum will probably assist in breastfeeding. Religious texts often support a period of seclusion of women after birth, usually around 40 days, the period necessary to establish full lactation.
However, the advent of Western biomedical practice in many parts of the world has hastened the decline of these so-called traditional practices. In fact, these practices probably sustained breastfeeding through countless generations. It is difficult to turn back the clock and tell the Malay or Thai midwives and traditional healers that the "old ways" had some useful features. However, with the recent sensitivity to indigenous medical practices in many parts of the world, it is worth reinforcing those cultural practices that encouraged women to rest, eat well, and be relieved of work in the first few weeks after birth.
National strategies
There is great variation in national legislation on maternity protection, some providing better coverage than the International Labour Organization (ILO) legislation, some worse coverage. The Brasilia workshop on breastfeeding and women's work reviewed a number of national initiatives in Latin America that were intended to provide strategic help for breastfeeding mothers.
In Honduras, enterprises employing more than 20 women are required to provide a suitable place for mothers to breastfeed their children. In Uruguay, workers in the public sector are allowed to work half time so they may breastfeed their infants for the first six months of life. Brazil's national breastfeeding programme established a committee to review women's employment and breastfeeding. The committee surveyed existing legislation and found that it was not uniform across federal, state, and municipal levels. It also developed a programme to teach mothers to express their breastmilk in order to take advantage of nursing breaks. Mexico offers examples of workers who have negotiated better contracts with provisions for child care [26].
Socialist approaches to the work of care should provide evidence for the successful integration of caring work with productive work. In theory, men and women are considered equal under socialism, although in China, as in many other socialist countries, behaviour does not always follow rhetoric. Generally, maternity entitlements are guaranteed and the competitive promotion of infant formula is discouraged. However, these conditions are changing rapidly with the collapse of socialist regimes. With regard to maternity entitlements and child care in socialist countries, it is difficult to determine "how much is owed to realistic planning and how much to totalitarian power structure" [27]. We might also ask how restricted access to commercial infant formula has affected breastfeeding rates in socialist countries.
International strategies
International actions should build on existing international instruments such as the Innocenti Declaration, the Code for the Marketing of Breastmilk Substitutes, the Rights of the Child, and conventions to eliminate discrimination against women. The Clearinghouse on Infant Feeding and Maternal Nutrition regularly reports on existing legislation and policies to support breastfeeding mothers in the workplace, including information on maternity leave policy, salary during leave, provisions for nurseries, nursing breaks, and other considerations.
However, it is likely that data at the national level are unreliable and should be used only when confirmed by local professionals. Neither maternity entitlements nor lactation breaks are regularly implemented for formally employed women, and most working women are ineligible for these benefits because they work in subsistence agriculture or home based production, or are self-employed in a wide range of activities in the informal economy. Reviews of maternity legislation seldom specify how the laws are monitored at the local or national level.
The ILO is considering whether the best strategy is to revise the conventions on maternity protection legislation, encourage more countries to ratify and implement it, or develop policies on parental rights. Employed women with job security, maternity entitlements, and facilities for breastfeeding are exceptionally few in number in both developed and developing countries.
Policy challenges
Elimination of all forms of discrimination against women is a requirement for addressing caregiving and the rights of the child. Agencies providing nutrition interventions recognize the need for a life-cycle approach to women's health. Any projects that empower mothers, support effective local practices, and provide care to caregivers are likely to be useful, particularly those that improve the health and nutrition status of women [28].
But women are often mentioned in the nutrition literature as a risk group or a target group for needed interventions rather than as gatekeepers of family health. The recent International Congress of Nutrition (ICN) guidelines are a notable exception. The ICN World Declaration and Plan of Action for Nutrition is unusually sensitive to the importance of women as caregivers. The document explicitly recognizes that nutritional well-being is hindered by the continuation of social, economic, and gender disparities and discriminatory practices and laws. "All forms of discrimination including detrimental traditional practices against women must be eliminated in accordance with the 1979 Convention on Elimination of all forms of Discrimination Against Women" [29].
Women's nutritional needs should be met not simply because they are caregivers. "Women are inherently entitled to adequate nutrition in their own right as individuals" [29]. For women to provide the necessary care of others, priority must be given to enhancing the "legal and social status of women from birth onwards, assuring them of respect and equal access to caring, education, training, land, credit, equity in wages and renumeration and other services, including family planning services, and empower them economically so that they have better control over the family resources" [29]. Adding the concept of care to UNICEF's model of the determinants of undernutrition raises the possibility of a whole new approach to integrating gender concerns with child survival policies. But it raises many difficult questions, such as:
-How do we understand the extent of caregiver distress, a core concept of burden, when caregivers in many societies are socialized to downplay their distress?
-What policies will support women as caregivers without using them as an unpaid workforce, a cost-saving measure?
-How can we organize society to make care for dependants more just and humane, when current policy focuses on adjustment of caregivers rather than the adjustment of society?
-How can we insure that international caregiving does not undercut existing household and community caregiving strategies, particularly those based on reciprocity and commensality?
- How do we avoid masculinizing care, over bureaucratizing it, and proposing technology to solve human problems?
Acknowledgements
This paper has been prepared with the research assistance of Maggie MacDonald, a doctoral candidate in Social Anthropology, York University, and the suggestions of Dr. Pattanee Winichakul, Institute of Nutrition, Mahidol University, Thailand.
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