This year’s World Breastfeeding Week falls a few days before national Women’s Day and a few weeks after parts of the country erupted in violence. In response, members of civil society mobilised and gathered donations to send to affected areas. Included in calls for donations were requests for infant formula. As breastfeeding champions and supporters of mothers and mothering, we were surprised and dismayed by the response issued by the KwaZulu-Natal, Gauteng and national departments of health, warning against soliciting donations of infant formula and framing such donations and distributions thereof as “illegal” and “undermining breastfeeding”. We were also concerned by the lack of nuance in the statement.
It failed to acknowledge that many of the children who needed formula supplies during the protests would have either never been breastfed, or would have switched to formula many months ago, thus making it extremely difficult, if not impossible, to switch to breastmilk and breastfeeding suddenly. In addition, many of these children, especially in rural KwaZulu-Natal, would have been living far from health facilities, making it unrealistic to expect them to easily access formula from local health facilities in the middle of riots.
A more thoughtful statement would have considered the complex context in which infant feeding occurs in South Africa. It would have discouraged opportunistic involvement and donations from formula manufacturers, without abdicating the state’s responsibility to ensure that children with no other alternative to formula feeding, were able to do so safely, without impeding access.
While it is indisputable that the formula industry has harmed the promotion of breastfeeding in South Africa and elsewhere, the work of many local and international researchers* has shown time and again that the availability of infant formula is not the only reason for our country’s low breastfeeding rates, nor should it be the sole focus of our efforts to improve breastfeeding rates.
So, why are our breastfeeding rates relatively low?
1. Unsupportive workplace policies and support
South African labour law does not mandate support for breastfeeding employees. Instead, our laws are supplemented by the code of good practice on the protection of employees during pregnancy and after the birth of a child. This is not a set of regulations compelling employers to ensure that breastfeeding employees are supported. Instead, it is a “guide” intended more to encourage than to enforce compliance. It is therefore not uniformly monitored or enforced by the Department of Labour.
One mother shared her experience with Embrace: “Our office is open with zero facilities for me to pump and store my milk. After being on maternity leave, I didn’t feel I had the right to ask for any more accommodations from my boss or team members. It was clear people thought it was a luxury holiday. After two weeks of only being able to breastfeed in the nights and early mornings, my supply dropped and I felt defeated. I feel a lot of guilt that I didn’t try harder to put my daughter before my boss.”
2. Harmful attitudes towards women’s bodies
Breastfeeding is a deeply personal process that occurs within our social context. It involves the body of a person who has just gone through pregnancy and childbirth and is navigating a healing, postpartum body whilst figuring out the mechanics of feeding an infant.
If you are in a household in which you are made to feel shame every time you breastfeed, and are urged to cover up or made to question your body’s ability to create sufficient supply for your baby, this will affect the trajectory of your breastfeeding experience. A relationship with a partner who insists that she gives up breastfeeding in order to resume sexual activity, will increase the likelihood of a mother introducing infant formula. By failing to acknowledge the way reductive and harmful attitudes towards women’s bodies play a role in how they feel about their bodies and why they choose to share them through breastfeeding, we do women a disservice.
Furthermore, it is crucial that in the South African context, where we have very high rates of sexual and gender-based violence, we acknowledge the role that trauma can play in complicating breastfeeding. Many survivors of sexual abuse find the experience of pregnancy and breastfeeding, as well as the loss of control and autonomy over one’s body, traumatic and triggering.
3. Lack of time in poor households focussed on survival
Oversimplified messaging on infant feeding demonstrates a lack of familiarity with the struggles of motherhood under the constraints of poverty and informal work. One of the most critical enablers for exclusive breastfeeding is time; time to be available to breastfeed directly, or to express milk and engage in all the practices that come with the exercise, including washing and sterilising all the implements used in the process. Yet time is one of the scarcest resources for low-income women working in the informal economy. Research with mothers in the informal sector tells us of women who leave their homes before their children are awake and return just as they are about to go to sleep. In this context, the decision to formula feed is sometimes made.
4. Traumatic birth experiences
Some women, especially low-income women, experience poor care ranging from neglect to ill-treatment while pregnant and when they give birth. This affects the health of the mother and child, including the release of the hormone oxytocin, which is central to establishing early supply of colostrum and breastmilk. Births in which mothers experience a lack of support or appropriate care, complicate the postnatal period and lead to significant challenges with breastfeeding.
Mothers are not the enemy, they are the choir
It is clear from research that mothers are aware that breastmilk is the best source of nutrition for infants. There is plenty of focus on driving that message home in public health messaging. Mothers who give birth in public hospitals tell stories of having bottles and dummies confiscated and receiving little to no lactation support or education.
By focussing only on formula, we fail to notice that mothers have received the message “breast is best” loud and clear. They are the choir, not the enemy. What is missing is adequate follow-up support and encouragement.
How we speak to mothers matters as much as what we speak about
One of the reasons the WHO and our departments of health restrict infant formula advertisement is because they know how effective the marketing language of formula companies can be. Formula companies have appropriated the language of online mom communities and issued adverts urging us to “end the Mommy wars” and accept that “fed is best”. These are maxims lifted directly from conversations between mothers who find themselves increasingly isolated and overwhelmed by the demands of modern motherhood.
Formula companies weaponise these as they vie for attention and money.
Our public health messaging may not be developed in plush marketing agencies’ boardrooms, but it can certainly attempt to tap into the language that mothers speak.
Currently, the messaging relies heavily on driving home the benefits of breastmilk and the nutritional importance of breastfeeding. There does not seem to be room within this sharp focus to acknowledge the real challenges confronting mothers. While public health communicators may not want to discourage mothers, failing to reflect the reality many women face can be alienating. This may make mothers more receptive to the glossy and trendy messaging of formula-adjacent companies; not because they want to use infant formula, but because they see and hear their experiences reflected in the messaging these companies are so adept at packaging.
Even adjusting messaging slightly to speak to employers, partners and families and acknowledge the importance of a supportive network for breastfeeding mothers, would go a long way towards bridging the information gap on which formula companies capitalise.
Focussing on what mothers know or do not know implies that breastfeeding is only an individual choice. It fails to speak to the reality that the success of breastfeeding partly depends on the circumstances and support networks available to a mother.
How can we improve breastfeeding rates?
If we are to realise the collective dream of a 100% breastfeeding rate, we need to resist narrow conceptions and understandings of the experiences of mothers. We need to resist any actions or words which could result in feelings of personal failure and shame. We need to address each of the barriers mentioned above which reside at the structural, societal, and health systems level.
We need to focus on committing ourselves to the support and promotion of the mother-child breastfeeding relationship — respecting the dignity of two whole people navigating this journey. Let us not allow a myopic focus on formula to obscure the human stories and experiences that will be at the heart of any improvement we make in our national breastfeeding rates.
*The authors erroneously referred to the research as being the work of the Nutrition Society of South Africa in the original version of this story, which also appeared in print.