2130253 Hiranmayi Purushotham

Culture and Breastfeeding

The Impact of Culture on Emotions, Mental Health and Acculturation Regarding Breastfeeding Behaviour of South Asian Women

A Chromolithograp of Breastfeeding

Introduction

What is Breastfeeding?

Breastfeeding, also called nursing, is the process of feeding a mother's breast milk to her infant, either directly from the breast or by expressing (pumping out) the milk from the breast and bottle-feeding it to the infant. (National Institute of Child Health and Human Development, 2017) According to the Ministry of Women & Child Development under the Government of India, breastfeeding “fosters emotional security and affection, with a lifelong impact of psychosocial development. It is not only important for a young child’s survival, health, nutrition, the development of the baby’s trust and sense of security- but it also enhances brain development and learning readiness as well.” (National Guidelines on Infant and Young Child Feeding, 2004)

Additionally, the benefits of breastfeeding are not limited to the child alone. There are substantial short- and long-term beneficial effects of breastfeeding on maternal physical and mental health. (Del Ciampo and Del Ciampo, 2018)

Culture and Breastfeeding

The cultural context of the breastfeeding mother plays a pivotal role in shaping breastfeeding behavior and influencing the psychological well-being of the mother herself. We will be examining the cultural impact on the breastfeeding mother’s psychology, specifically in the South Asian context. A substantial body of work corroborates the impact of culture on breastfeeding behavior as well as the psychology of the mothers.

Woman Breastfeeding Baby: National Museum Of Beirut

As elucidated by Hirani et al. (2023), who examined the sociocultural factors affecting breastfeeding practices of mothers in rural Pakistan, “Multiple sociocultural factors were identified as either barriers or facilitators to these mothers’ capacities to breastfeed their children. Informal support, formal support, breastfeeding culture, and spiritual practices facilitated displaced mothers to sustain their breastfeeding practices. On the other hand, lack of privacy, cultural beliefs, practices and expectations, covert oppression, and lack of healthcare support served as barriers to the breastfeeding practices of South Asian mothers.” (Hirani et al., 2023) Cultural norms, expectations, and traditions often dictate the duration and exclusivity of breastfeeding. These norms have been studied to find correlations to the emotions and mental health of the mothers. The intricate relationship between culture, motherhood, and breastfeeding underscores the significance of examining how cultural factors influence breastfeeding behavior and the psychological well-being of mothers. By integrating previous research findings with established cultural psychological theories and models, such as Hofstede’s Cultural Dimensions Theory and Berry's Model of Acculturation, we are offered a comprehensive understanding of how culture shapes breastfeeding practices and the emotional well-being of mothers in South Asian cultures. The interplay of culture will be examined on the following psychological frameworks:

• Behavior- Breastfeeding behavior itself as examined under Hofstede’s Theory of Cultural Dimensions as well as Berry’s Model of Acculturation
• Emotions- Of breastfeeding mothers
• Mental Health- related to depression, anxiety, postpartum conditions, etc. of breastfeeding mothers.

Hofstede's Cultural Dimensions Theory

The most well-known approach to understanding cultural values comes from work by Geert Hofstede. He studied work-related values around the world, and to date has reported data from 72 countries involving the responses of more than 117,000 employees of a multinational business organization, spanning over 20 different languages and seven occupational levels to his 63 work-related values items (Matsumoto & Huang, 2013).

According to Hofstede, there are five value dimensions that differentiate cultures:

1. Individualism vs Collectivism: This dimension pertains to the extent to which cultures promote either self-reliance and the care of one's immediate family, or, conversely, the affiliation with groups that are expected to provide for their members in return for loyalty.
2. Power Distance: This dimension relates to how cultures promote the acceptance of unequal power distribution among group members.
3. Uncertainty Avoidance: This dimension assesses individuals' comfort with uncertainty and ambiguity and the extent to which they have established beliefs, institutions, or customs to mitigate these feelings.
4. Masculinity vs Femininity: This dimension spans from prioritizing material success and wealth on one end to emphasizing compassion, quality of life, and gender roles on the other. It deals with the allocation of emotional responsibilities between men and women.
5. Long vs. Short Term Orientation: This aspect pertains to how cultures promote the postponement of fulfilling material, social, and emotional desires within their populations.

Tracing Culture's Role on Breastfeeding Behaviour through Hofstede's Theory

Hofstede's Cultural Dimensions Theory thus offers a comprehensive framework for understanding the cultural variations that exist between societies. In the context of exploring culture's impact on breastfeeding mothers, Ravi Philip Rajkumar’s study titled "The Relationship Between National Cultural Dimensions, Maternal Anxiety And Depression, And National Breastfeeding Rates" serves as a valuable resource. This research adopts Hofstede's cultural dimensions theory to examine the link between national cultural values and the emotional well-being of mothers engaged in breastfeeding.

The findings of this study reveal significant associations between cultural dimensions and lifetime breastfeeding rates. Specifically, the research identifies a link between three cultural dimensions: power distance, individualism-collectivism, and masculinity-femininity.

Countries with higher breastfeeding rates tend to exhibit greater power distance, increased collectivism, and a more feminine cultural orientation. According to the study, numerous mechanisms underlie how cultural values may influence breastfeeding rates. A collectivist cultural orientation such as in South Asian communities, tends to prioritize the mother-infant dyad, fostering greater family support for breastfeeding initiation and maintenance. Additionally, collectivist values often correlate with higher fertility rates, potentially leading to more successful breastfeeding outcomes.

In contrast, women in individualist cultures may experience pressure to resume academic or professional responsibilities soon after childbirth and might receive less social support. (Rajkumar, 2023)

The study also finds that cultures with a more feminine orientation, such as in South Asian countries like Sri Lanka, Nepal, Bhutan and Bangladesh, are more inclined toward successful breastfeeding, given their focus on nurturance, care for the vulnerable, and stable relationships. Feminine cultures also tend to foster greater responsiveness and support from husbands in childcare activities, which can contribute to improved breastfeeding outcomes. (Rajkumar, 2023)

Additionally, the study highlights a strong correlation between power distance, individualism-collectivism, and the prevalence of depression and anxiety disorders, further underlining the multifaceted interplay of cultural dimensions and their effects on maternal well-being and breastfeeding rates.

Description of Hofstede's cultural value dimensions and their potential relevance to breastfeeding initiation and maintenance.

Berry's Model of Acculturation

Acculturation refers to the process of individual change and adaptation as a result of continuous contact with a new, distinct culture. (Matsumoto & Huang, 2013)

One influential model of acculturation is Berry’s Model of Acculturation in which immigrants ask themselves two key questions: Do I value and want to maintain my home cultural identity and characteristics? Do I value and want to maintain relationships with people from the host culture as well? (Matsumoto & Huang, 2013) These two questions give rise to four acculturation strategies according to Berry: integration, assimilation, separation and marginalization.

Note. Image from Matsumoto, D., & Huang. (2013). Culture and Social Behavior. In Culture and Psychology (p. 234). Wadsworth.

Matsumoto and Huang explain how these strategies manifest by stating the following. “People who answer yes to the first but no to the second are known as separators, because they essentially live in their own immigrant communities, speaking their native language and interacting with their home-culture friends, with minimal contact with host-culture individuals. Individuals who answer no to the first and yes to the second are called assimilators; these individuals typically reject their home culture and totally assimilate to the host culture. They minimize interactions with people from their home culture, and typically speak the language of the host culture, even when interacting with people from their home culture. People who answer no to both questions are known as marginalizers. They reject both home and host cultures, and do not do well in either. They live on the fringes of both cultures, not really being able to immerse themselves in either. Finally, people who answer yes to both questions are known as integrators. These individuals are able to move from one cultural context to another, switching their cultural styles as they go along in accordance with the cultural system they are in. They are likely to be bilingual or multilingual as well as bicultural or multicultural.” (Matsumoto & Huang, 2013)

Examining Breastfeeding Behaviour in South Asian Women Who Have Migrated From Their Host Cultures through Berry's Model of Acculturation

According to Choudhry and Wallace (2010)’s study titled “‘Breast is not always best’: South Asian women's experiences of infant feeding in the UK within an acculturation framework”, acculturating has a negative impact on South Asian immigrant women's breastfeeding practices, particularly when coming from countries where breastfeeding rates are higher than Western countries. (Choudhry & Wallace, 2010)

The findings of this study align with Berry's Model of Acculturation by shedding light on how individuals adapt to a new culture.  

Low acculturation levels, akin to Berry's "separators," signify a commitment to preserving their home culture's teachings about breastfeeding, emphasizing the psychological benefits of breast milk. Despite residing in a formula-feeding culture, these women primarily draw upon their South Asian cultural values when deciding to breastfeed, viewing it as more appropriate. They may opt for formula feeding only in response to conflicts they face concerning the information they receive about feeding methods or their roles as mothers and daughters-in-law. In this context, formula feeding serves as a conflict resolution strategy.  Consider the following responses from this study’s participants as evidences of low acculturation levels in South Asian breastfeeding mothers:

“I've heard a lot of that in our community (South Asian Culture) they see one woman bottle feeding then they have to do it too just because they've seen the lady down the road doing it. People around my area don't respect breastfeeding like they should and don't understand it's a gift you can give the child (Participant 5, Low acculturation)” “I thought if they're (Peers from the Anglo culture) doing it and there's no harm then there's no need for me to go through the pain of trying to breastfeed when I could give them the formula (Participant 18, low acculturation)”

On the other hand, highly acculturated and bicultural women, resembling Berry's "assimilators," sense the need to align their feeding decisions with the prevailing formula-feeding norms in the UK. They, too, experience information and role conflicts but are largely influenced by their awareness of the UK's formula-feeding culture. These women do not wish to deviate from the perceived feeding norm in the UK, conforming to societal expectations, and viewing formula feeding as the standard. Here, the influence of social norms is more pronounced and guides their final feeding choice. Consider the following responses from this study’s participants as evidences of highly acculturated women:

“I think when it comes to feeding your baby the first thing you think of is formula feeding because everyone seems to do it (reference to Anglo culture), you very rarely see women, especially in our community (peer from the South Asian culture), breastfeeding (Participant number 7, highly acculturated)” “When I was back home everyone breastfed their baby, here I don't see it as much (referring to the Anglo culture)you don't know what people might think of you when they see you doing it. I felt as if they might judge me or something because its something we do at home and its no that much common here I don't think (Participant 19, Highly acculturated)”

These findings emphasize the complexity of acculturation's impact on individuals navigating cultural transitions, extending beyond mere exposure to a culture and highlighting the importance of considering psychological changes influenced by involvement in the new culture. The research suggests that the acculturation process can yield "bicultural" individuals who maintain a strong connection to both their culture of origin and the host culture. This nuanced approach to acculturation can serve as a valuable framework for understanding and tailoring interventions related to infant feeding practices for South Asian women who migrate from their host cultures.

How Culture Interplays with the Emotions of South Asian Breastfeeding Mothers

Studies on the experienced emotions of women in relation to their breastfeeding behaviors have shown that self-conscious emotions play a role in breastfeeding experiences and infant feeding choice. (Russell et al., 2021) While basic emotions like anger, surprise or fear tend to happen without much cognitive processing, the self-conscious emotions, including shame, guilt and pride, are more complex. They require self-reflection and self-evaluation. (Weir, 2012)

The emotional experiences of South Asian breastfeeding mothers are closely intertwined with complex cultural dynamics, which can be illuminated through the insights gained from Russell et al. (2021b)'s comprehensive study, "The role of emotions and injunctive norms in breastfeeding: a systematic review and meta-analysis."

This study uncovered a profound connection between societal and moral norms and the emotions experienced by women during their breastfeeding journeys. These norms often created a sense that breastfeeding was not merely an individual choice but a social obligation, shaping women's emotional responses to their feeding choices.

As elucidated in the study, “Negative emotions, namely embarrassment, were found to result from some women, more so from countries like Thailand, Bhutan, Nepal and Sri Lanka, reporting feeling external pressure regarding their infant feeding choice from significant others (friends and family) and perceived societal norms” (Russell et al., 2021b) The study also found that the emotional burden of feeling like a failure due to the dissonance between moral obligations and actual breastfeeding experiences became apparent. These implications are evident in the participants responses cited in the study:

“I’d also try to keep my awareness of how other people feel because I know that some people find it really embarrassing. In our country, or most South Asian communities, breastfeeding is encouraged and even glorified, but then it is stigmatized at the same time. As though I should do it to be a “good” mother, but if I do it in front of others, it is indecent. (Murphy, 1999)” “The mindset here is that people think that only those mothers who have low educational background will breastfeed their babies … . (Tarrant et al., 2004)”

Positive emotions, including satisfaction and emotional bonding, were only reported when women could disengage from these social pressures and prioritize their own beliefs and desires regarding infant feeding. (Russell et al., 2021b) Embarrassment was a recurrent negative emotion stemming from societal norms and external pressures, especially from friends and family, regarding infant feeding choices. This discomfort was felt by some due to the sexualisation of breasts. (Russell et al., 2021b) It even dissuaded expectant mothers intending to breastfeed, as they anticipated feelings of embarrassment and discomfort if they had to nurse in front of others. Embarrassment also influenced breastfeeding initiation, “as those who perceived breastfeeding as embarrassing were less likely to start breastfeeding than those who did not see it as embarrassing” (Russell et al., 2021b) This emotional hurdle persisted as a barrier to breastfeeding duration, causing some women to switch feeding methods or discontinue breastfeeding. Fear of public disapproval for formula-feeding added to this emotional burden.

“Breastfeeding […] is pushed down your throat and out of guilt you are made to feel if you don't do it, you are doing your child a mis-justice. Everybody everywhere pushes breastfeeding, and [I] feel they look down your nose at you if you don't. (Thomson et al., 2015)”

When it came to the barriers of breastfeeding behavior in the context of emotions, Russell et al. (2021b) found the following: “Mothers in collectivist cultures experienced feelings of guilt, regret, and disappointment because of the perceived difference between their expectation of motherhood, which for many involved breastfeeding, and the reality of being a mother and actually breastfeeding. The disconnect between expectations and reality led to shorter duration of breastfeeding than intended and feelings of guilt. Mothers also experienced self-conscious emotions, such as shame, disappointment, and guilt, when they stopped exclusive breastfeeding, did not achieve their breastfeeding goals or anticipated that they would feel these negative emotions. Anxiety and fear about physical aspects of breastfeeding were also reported as barriers to actual breastfeeding behavior.”  (Russell et al., 2021b)

These findings shed light on the intricate relationship between culture and the emotions experienced by South Asian breastfeeding mothers, or in extension those in collectivist cultures, emphasizing the need for a nuanced understanding of the cultural interplay in maternal infant feeding practices.

Culture's Role in the Mental Health of Breastfeeding Mothers

Another key aspect of the previously cited Rajkumar (2023) study concerned itself with how culture, breastfeeding, and mental health conditions interact with each other. A substantial body of work has already recognised the prevalence of significant mental health problems in mothers of new-borns, both pre and postnatally. These factors act as a significant barrier to successful breastfeeding. (Rajkumar, 2023)

Another study that was also previously explored here, Russell et al. (2021b)'s "The role of emotions and injunctive norms in breastfeeding: a systematic review and meta-analysis”, has also corroborated the same by stating, “successful breastfeeding depends crucially on both the mother's emotional state and the support and advice provided by those in her immediate social circle” (Russell et al., 2021b)

There has been recurring evidence that maternal depression, anxiety and post-traumatic stress disorder can all reduce the likelihood of initiation as well as the successful maintenance of breastfeeding. (Rajkumar, 2023)

Building upon the intersection of culture, mental health, and breastfeeding, Rajkumar's study (2023) unveils that while maternal mental health is often an overlooked facet of maternal and child health, especially in South Asian contexts, it exerts a profound influence on breastfeeding practices (Rahman et al., 2008; Nakku et al., 2016). Findings reveal that maternal depression and anxiety disrupt the vital bonding between mother and child, a crucial aspect of breastfeeding (Rajkumar, 2023).

Biological Causes

Neuroendocrine cell

The neuroendocrine alterations associated with these conditions, including cortisol dysregulation, altered insulin sensitivity, and diminished oxytocin release, further impede breastfeeding. The study also found that mothers experiencing depression are also more prone to discontinuing breastfeeding prematurely. Additionally, the prevalence of significant anxiety symptoms can interfere with milk production and ejection via elevated cortisol, insulin resistance, and reduced oxytocin (Nagel et al., 2022).

Rajkumar's comprehensive study unveils an inverse correlation between breastfeeding rates and the prevalence of depression and anxiety disorders in women aged 15–49. This association, notably stronger for anxiety disorders than depression, remains significant even after controlling for variables closely linked to breastfeeding outcomes.

According to the findings, for low and middle-income South Asian countries, the prevalence of significant anxiety symptoms during this period ranges from 25–30%, with 8% receiving an anxiety disorder diagnosis during pregnancy and 16% postnatally. Such anxiety can diminish a mother's self-efficacy, significantly affecting her confidence in maintaining breastfeeding over time (Rajkumar, 2023) It was found to affect initiation of breastfeeding, sustaining the activity, as well as exclusivity of breastfeeding (feeding only mother’s breast milk and not substituting with other milk)  

The implications of these findings are of utmost significance, resonating with research highlighting the substantial impact of cultural values and individual factors on breastfeeding decisions and behaviors.  

Suggestive Frameworks

Based on the learnings drawn from the above concepts and studies, what are some ways in which we can help South Asian mothers in the context of breastfeeding? Here are some suggestions:

1. Create a training program for healthcare providers that focuses on understanding and respecting cultural variations in breastfeeding practices.
2. Wisely utilize popular media like films and TV shows to destigmatize breastfeeding in public, or the choice of a mother to bottle-feed, and also to spread awareness on breastfeeding and how cultural traditions interact with the same.
3. Emphasize the significance of mental health awareness, especially with regards to pre and postnatal conditions, within specific cultural contexts, considering the interplay with cultural norms.
4. Develop positive breastfeeding support networks. Such as support groups composed of mothers of newborns that are clinically moderated by psychological and health professionals.
5. Educate mothers on the influence of cultural norms, mental health conditions, and emotional aspects in breastfeeding experiences, right from the initial consultation periods.
6. Establish community-based programs that target maternal mental health, emphasizing the prevention and management of anxiety and depression given their high prevalence. Make sure to include culturally sensitive approaches in these programs.  
7. Implement screening programs during prenatal and postnatal care to identify and address maternal mental health issues promptly.
8. Encourage governments to prioritize research and support for maternal mental health for culturally diverse populations.

Conclusion

Culture is an integral component of the breastfeeding experience. A deeper understanding of culture-imbued factors can lead to more effective and inclusive support structures for breastfeeding mothers, ensuring the well-being of both mothers and infants. The complex interplay of culture, maternal mental health, and breastfeeding practices underscores the need for a holistic and culturally sensitive approach to support mothers in their breastfeeding journey. Through the above-explored discussions, it becomes evident that the emotional well-being of mothers, shaped by their culture-specific norms and practices, significantly influences breastfeeding behavior and feeding experiences. Culture also impacts maternal mental health in unique ways, particularly conditions like depression and anxiety, which in turn play pivotal roles in the initiation, maintenance and success of breastfeeding.

By acknowledging the cultural contexts in which mothers make feeding decisions and recognizing the potential mental health challenges they face, healthcare providers, policymakers, and communities can offer targeted support. Strategies to promote the same have been discussed.  

Ultimately, nurturing an environment that respects and celebrates cultural diversity while addressing maternal mental health concerns is key to advancing the cause of breastfeeding worldwide.