The Stigma of Not Breastfeeding
by Anne Eglash MD, IBCLC, FABM
The researchers for this week’s article conducted a survey among 250 mothers with infants up to 9 months of age, who were feeding their infants formula and not breastfeeding. The study sought to explore their feelings associated with not breastfeeding, including internalized stigma and their perception of stigma from others, their feelings of warmth towards the infant, and whether they were hiding formula use. Most of the mothers interviewed had a high school or 2-year college degree, and only a small percentage had an advanced degree. The average income was $33,000. Nearly all families gave birth at a Baby Friendly Hospital. Eighty-one participants chose to use formula, 125 were unable to breastfeed and 17 reported that their infants could not breastfeed.
The authors’ premise is that public health messaging promoting breastfeeding as the gold standard for infant feeding and maternal health implies that women who choose to not breastfeed are giving their infants substandard nutrition. The consequence may be emotional turmoil, leading formula feeding mothers to feel guilt and stigma over the feeding decision. Stigma, whether personal or social, is defined in this study as perception of behaviors that have problematic physical, social and moral consequences, and may be perceived thru verbal and non-verbal messaging, as well as behaviors such as exclusion.
- Women who chose to formula feed were less likely to feel personally guilty or inadequate as compared to women who were unable to breastfeed.
- Women who chose to formula feed were less likely to feel a sense of bias against them by others, as compared to those who were unable to breastfeed.
- Women who chose to feed formula did not perceive any social stigma regarding formula feeding.
- Mothers who internalized their stigma for not breastfeeding felt less connected with their infants.
- Women who more strongly internalized social stigma for not breastfeeding were more likely to hide use of formula.
See the Answer
Breastfeeding has become the recognized standard for good parenting, with social costs for not breastfeeding, but not every mother wants to or is able to breastfeed.
This study investigated social and personal costs with no breastfeeding. Materials and Methods: An in-depth survey was conducted with 250 mothers with infants who were not breastfeeding. Situated in the Framework Integrating Normative Influences on Stigma model for stigma, the study analyzed internalized stigma and perception of stigma from others, maternal feelings of warmth for the infant, and hiding formula use.
Mothers who chose not to breastfeed reported little personal or public stigma. In comparison, mothers who were unable to breastfeed experienced relatively more internalized stigma and perceived that other people saw them as failures. Mothers who experienced more internalized and perceived social network stigma were likely to hide use of infant formula from others and had lower feelings of warmth for their infants. Knowledge about formula use and availability of support resulted in less stigma and more warmth for the infant.
These results suggest that public responses causing a mother to feel guilty for using infant formula result in negative feelings of self-worth and dysfunctional maternal behaviors.
Women who chose to formula feed, just like women who intended to breastfeed but were unable to, experienced social stigma from not breastfeeding.
Over the years, it has become increasingly common to see women in my breastfeeding medicine clinic who would like to re-establish lactation. These women describe different reasons for their interest in relactation, such as feeling that they were in a different state of mind when they weaned early postpartum, or they had a medical issue that lead to premature weaning. Other women have chosen to explore relactation because of stigma sensed from their friends, within their mother-baby support group, and/or alongside their work colleagues as the only formula feeding mother.
The hardest conversation I have with breastfeeding mothers are those with severe insufficient glandular tissue who were highly committed to breastfeeding. Those without a milk donor(s) express their sadness and worry for their health of their infants.
The authors of this study state in their discussion that there should be more support for organizations that destigmatize formula feeding. While it is very important that we support families no matter how they feed their infants, it would be morally and ethically irresponsible to NOT promote breastfeeding as optimal infant feeding, since this is evidence-based public health information, as breastmilk provides for the greatest opportunity for optimal health and has been shown to provide the basis for long term educational and financial success.
Interestingly, at least half of the mothers in this study had an intention to breastfeed, and for various health and psychosocial reasons, were not successful. More societal support for breastfeeding, and availability of safe affordable donor human milk for families would go a long way to increasing breastfeeding rates, and decreasing the issue of stigma regarding infant feeding.