Print version ISSN 0021-7557
J. Pediatr. (Rio J.) vol.80 no.5 suppl. Porto Alegre Nov. 2004
João Aprigio Guerra de AlmeidaI; Franz Reis NovakII
Instituto Fernandes Figueira IFF/Fundação Oswaldo Cruz. Coordinator
of the National Network of Human Milk Banks. Professor, IFF, Rio de Janeiro,
IIPhD., Universidade Federal do Rio de Janeiro (UFRJ). Member of the team of Human Milk Bank of IFF. Professor, IFF, Rio de Janeiro, RJ, Brazil
To contribute to the creation of a new theoretical synthesis about the relationship
between the biological and social dimensions of breastfeeding, categorizing
it as a nature-nurture hybrid.
SOURCES OF DATA: The methodological approach of the present article was based on the qualitative health research frame, and data were analyzed on the basis of dialectic-hermeneutic principles. Primary sources, comprising historical documents, books, scientific articles and medical theses written in the 19th and 20th centuries were analyzed.
SUMMARY OF THE FINDINGS: Depending on the moment in history and on the expectations that surround the act of breastfeeding, the aspects related to nature and nurture, i.e., to biology and society, sometimes separate out and sometimes intermingle. A comprehensive approach to breastfeeding makes possible to see that it had to be considered instinctive, natural and biological in order to be assimilated as a cultural habit, and thus, it is not open to any kind of questioning. On other occasions, particularly in the course of the past decade, there has been a steady tendency to supplant traditional biological reductionism, which yielded cultural interpretations that do not reduce the human being to the status of a mammal like any other. Under this point of view, breastfeeding, in addition to being biologically determined, is socially conditioned, and thus constitutes an act embedded in ideologies and determinants resulting from the concrete conditions of life. In real life, however, a process apparently so natural, so loaded with affection and emotion is, in fact, affected by the most aggressive market interests, very often presented as scientific knowledge and decked out as health provisions.
CONCLUSION: Breastfeeding focused as a nature-culture hybrid symbolizes the theoretical and methodological changes in the field, especially in the late 1990s. These changes reflect a renewed appreciation of biology and a more in-depth approach to interdisciplinary processes.
Key words: Breastfeeding, nature-culture relationship.
The issues related to breastfeeding practice have aroused the interest of different agents and social groups throughout history. At all times, human beings were forced to build alternative ways to meet the demand of women who, by option or imposition, chose early weaning of their infants. From the secular figure of the wet nurse to the emblematic scientific avant-garde constructed by the marketing of modified milk manufacturers, infant feeding has served purposes that are not only concerned with health issues, denoting, in many situations, interests related to the modulation of social behavior and to the opportunity to generate profits of all sorts.1
Breastfeeding, besides being biologically determined, is socioculturally conditioned, therefore constituting an act imbued with ideologies and determinants that result from concrete living conditions. By means of comprehensive analysis and in the view of historical realism, it is possible to define the social, economic, political and cultural factors that turned it into an act controlled by society.2 Depending on the social reality considered, the ambivalence towards breastfeeding and weaning may translate into a shock between health and disease, and we should understand that these processes combine with economic and social variables all the time. The dynamics of these relationships, with regard to structural issues, ends up configuring breastfeeding as one of the attributes that characterize maternity as a shared social asset.1
On the other hand, the now-established breastfeeding paradigm has its origin in a construction of the hygienist movement and dates back to the 19th century.2 Consequently, the commonly used strategies for breastfeeding promotion are filled with biological reductionism, a typical characteristic of the 19th-century model,3 marked by the woman's inability to deal with the ambivalence towards the desire to breastfeed and the ability to do so.4 The actions are characterized by the vertical nature of constructions and follow the ideology that reduces breastfeeding practice to a natural attribute, common to all mammalian species, symbolically translated in slogans such as "breastfeeding is natural, instinctive, biological and characteristic of the species." Having this as background, the advocated actions are invariably targeted at informing women about the advantages of breastfeeding and holding them responsible for future outcomes resulting either from success or failure.1 The idea of "informing before holding responsible" seeks to mold women's behavior in favor of breastfeeding, blaming them for early weaning, which is directly associated with aggravation of infant health.
This verticalized and imposing healthcare model has lost its power, being unable to meet the demands of nursing mothers. The development of a new alternative necessarily includes the revision of concepts that sustain the breastfeeding paradigm that serves as a foundation for public health policies and creation of different social groups.1
Breastfeeding: reflections on its definition
An alternative to revise the definition that supports the current breastfeeding model is to search the scientific literature in order to answer the following basic question: Why breastfeed?
After this brief introduction, we note that scientific knowledge provides us with comprehensive answers, which go from particular properties of human milk to economic issues, which may have an effect on the family and on the government. These answers show the tremendous scope of the topic and unanimously present groupable attributes, which turn them into participants in the same model breastfeeding. The common link that allows for this interconnection, described by several authors, consists of the benefits of breastfeeding to infants, mothers, family and government.1 Thus, in light of scientific knowledge, the answer to the initial question is benefits. Why breastfeed? Because infants, mothers, family and government, all of them with no exception, benefit from breastfeeding.
However, at this point we have a paradox: weaning. Although the benefits of breastfeeding have been persuasively demonstrated by the scientific community, and despite the fact that breastfeeding rates substantially improved between the 1980s and 1990s in Brazil, we may observe an underlying tendency towards weaning, historically present in society, leading mothers to wean their infants very early on.5 Why is there such a tendency to discontinue a practice that brings several benefits and is regarded as matchless in infant feeding? How can we explain this paradox?
There has been an evidently growing imbalance between improved scientific knowledge which investigates and correlates the specific characteristics of human milk with the physiological particularities observed in an infant's metabolism and breastfeeding as a socially established practice. All the benefits of breastfeedings discovered by science and diffused in society have not been sufficient to guarantee the introjection of cultural values that can reverse the tendency towards weaning. In an attempt to overcome this paradoxical imbalance, several studies have been conducted in Brazil, especially after 1980. This quest for finding the reasons for such tendency gave rise to innumerable truths, giving weaning a multicausal nature. Orlandi points out the changes in family structure in modern urban society as one of the reasons for the lower rates of breastfeeding. Following the same line of thought, the author asserts that young mothers "no longer have the support, help and encouragement from older relatives (grandmothers, aunts, sisters, etc.), who used to make the breastfeeding practice easier."6
The attempt to tackle the early weaning problem has been a public health concern for decades. In Brazil, after 1981, such concern gave rise to the establishment of a government policy in favor of breastfeeding, materialized in the Brazilian Program for Breastfeeding Incentive (Programa Nacional de Incentivo ao Aleitamento Materno PNIAM).7 The actions undertaken by PNIAM sought to rescue the breastfeeding practice, regarded as nothing but a natural, instinctive, innate, and biological act characteristic of the mother-infant dyad, in which the nursing mother is in charge of looking after the health of her offspring, thus completely reproducing the hygienist idea of breastfeeding, established by the 19th-century medicine.2 The breastfeeding paradigm adopted by PNIAM relegated the issues relative to breastfeeding to the biological dimension and, when dealing with the weaning paradox, refuses to admit the asymmetry between humans and the other mammalian species, insisting that breastfeeding should be regarded as an instinctive, natural and biological act.5
The necessity to reverse the breastfeeding model adopted by the government policy became an object of study by many authors. Orlandi6 estimates that, albeit the important role of women in promoting breastfeeding is widely accepted, politics does not always reflect the viewpoint of nursing mothers. He concludes that:
"No matter what happens, breasts will keep arousing political interest for a long time. But one should recall that they belong to women and that they have not been allowed to give their opinion and make decisions about breastfeeding policies since the 18th century. In the 19th century, men continue to make the same mistakes."6
Nakano8 analyzed the representations of breastfeeding and corroborates the findings of Silva9 by concluding that women have an ambivalent and contradictory feeling, which ranges between the desire to breastfeed and the burden imposed by it. Even women who see breastfeeding as a biologically determined act perceive limits in its practice and feel the necessity to learn about it, thus showing that breastfeeding is not that instinctive.5
Almeida1, while working with health assistance opportunities targeted on fostering breastfeeding support, asked a non-biological mother about the reasons for the successful breastfeeding of her daughter, to which he received the following answer:
"I don't know the recipe for success, but I believe that, for a mother to breastfeed, regardless of the fact that she is the biological mother or not, first she needs to be assisted by a health professional (...) I think that in order to breastfeed she actually needs to be "breastfed," assisted, she needs breasts... breasts galore."
Now we wonder how many health professionals (in all sectors, including social and political) are prepared to meet demands such as the one described above.
In this regard, another study, which evaluated the self-performance of mothers/health professionals, encouraged breastfeeding before delivery and during the postnatal period. The results showed that 60% of interviewed women opted for surgical delivery without clinical indication and that 71.4% introduced industrialized milk before the baby's sixth month of life.1 The imbalance between theory and practice, between fact and hypothesis, leads us to the following saying: "do as I tell you, but not as I do." Why couldn't professional women able to assist other women in breastfeeding carry out the practice in themselves? Here is what some interviewees said:
"I think I didn't feel confident about asking others not to decide for me...I felt too fragile. I expected support from people who didn't give me any support... workmates (...)".
"I missed someone who could be there (...) not to say that ... breastmilk is this, milk letdown is that, this I know! You see? Maybe for the mother it is not important to know that breastmilk is produced in the alveoli, maybe this is not the most important."
In fact, women have to be assisted and followed up so that they can effectively play their new social role: woman-mother-feeder. To achieve that, healthcare structures have to be prepared to provide effective support to mothers and infants. The more effective the health service is in dealing with the mother's conflict between her ability and her desire to breastfeed, between taking risks or guaranteeing benefits, the more efficient the support will be.4
Breastfeeding: the relationship between biological and social factors
In an attempt to broaden the understanding of the factors that determine early weaning, several studies have been carried out in different time periods and in different Brazilian regions. Those studies that sought to elucidate weaning based on mothers' statements, in which they were allowed to express the actual reason for discontinuing breastfeeding, weak milk or little milk were the major explanatory factors.1 However, lactogenic dysfunctions are rare, which allows us to refute, with scientific evidence, the hypotheses of hypogalactia and existence of weak milk.1
Given this scenario, a pertinent question remains unanswered: if weak milk does not exist and hypogalactia is nothing but mere rhetoric, partial view or textual strategy, what is actually weak? Before some light can be shed on this issue, it is necessary to understand how the Brazilian society depicted breastfeeding throughout its history. We have to establish and understand the network that formed around breastfeeding,10 from the arrival of the first colonizers in Brazil, interconnecting the different cultural values that contributed to the creation of the Brazilian society in its different stages; government policies; medicine; economic issues; improvement of scientific knowledge about the issue; manufacturers of milk and milk-based formulas; health services and organized civil society, represented by non-governmental organizations and unions. Obviously, these factors have a distinct influential power and have a different weight in the context of breastfeeding construction.
By means of a comprehensive analysis of sociocultural factors, which can interfere in the production of knowledge and in breastfeeding practices, it is possible to establish a new form to discuss the topic in the context of public health and, thus contribute to the development of bases that allow for better resolubility in the formation of strategies for this area.
Brazil imports weaning culture
The letter written by Pero Vaz de Caminha to the Portuguese King contains what can be considered to be the first report on breastfeeding in Brazil "... with a boy or girl on her lap, tied in a cloth (no idea what it was made of) to the breasts..."9.
Having alluded to the fact that indigenous women breastfed their babies demonstrates the astonishment of "discoverers" at a practice of the "new world," which the European civilization had already banned. Historically, here we have the first cultural shock involving breastfeeding in Brazil. The act of nursing directly at the breast, a tradition cultivated by Tupinambá indians, was certainly perceived by the Portuguese as an instinctive and natural behavior, inappropriate for civilized man, whose behavioral standards were restricted to European habits and customs.1
The eating behavior of infants in the year 1500 followed the development of walking skills. In the lap phase, infants basically fed at the breast, even though they received a chewed mass of corn grains (predigested by ptyalin) from their mothers. However, indigenous women did not stimulate the appetite of their babies. The starch mass was placed in the baby's hand, and he/she would decide to eat or not the food within his/her reach. After the infants began to walk, they ate the same food as the adults, but still nursed at the breast.9
Breastfeeding lasted two years, and curiously enough, weaning occurred because of the parent's diet, thus respecting the family's eating habits. Despite the extensive review of the literature, no records could be retrieved showing the utilization of milk from other animal species in the course of weaning, among indians, at the time of the discovery of Brazil. Reports on malnutrition and infant mortality among Brazilian indians were only made available when the contact with the white civilization expanded.1
The occurrence of early weaning was restricted to three situations: maternal death, severe maternal death or in cases determined by culture. Culture prohibited breastfeeding in situations in which the infant was considered undesirable, i.e., when the infant was born from a relationship between a tribe woman and an enemy of the tribe or born of an indian woman who had sexual intercourse with more than one partner.9 Maternal work was not an acceptable reason for weaning, although the indigenous society imposed a heavier workload on women than on men. With a sling, the indian mother was able to accomplish her tasks as a mother/feeder and as a working woman.9
Thus, in Brazil, breastfeeding among Tupinambá indians was the general rule until before the arrival of European colonizers, who brought the habit of weaning along with them. At that time, for European women, who belonged to the dominant upper class, maternal love did not have a social and moral value, and consequently, breastfeeding was regarded as an improper task for a lady. This behavior tended to be imitated by other classes as a way of social distinction.11 In Lisbon, exploitative breastfeeding was a socially accepted practice, and the saloias, peasant women who lived in the suburbs, were in charge of breastfeeding the infants of women from dominant social classes.1
In brief, Portugal brought to Brazil the custom of rich mothers not breastfeeding their infants and, consequently, the necessity of hiring a saloia. Cunhã indians were the first version of Brazilian saloias; however, because of cultural rejection, they were replaced by African slaves.1 Later on, urbanization helped spread the work of wet nurses among the new social layers and soon black wet nurses became common.3 The importance given to this new social actor was so high that some slaveowners admitted that raising black slaves and renting them as wet nurses was more profitable than planting coffee.12 This new version of exploitative breastfeeding, imbued with a commercialistic strategy, was exerted in Brazil in a historical period, very long before the appearance of industrialized milk. The tendency to make profit out of practices related to breastfeeding is century-old, and intentionally stimulates early weaning.1
Breastfeeding in the view of hygienist medicine
The 19th century was marked, among others, by the consolidation of the new social role of medicine, allowing it to expand its boundaries far beyond the exclusive concern with the human body. Nutrition, environmental conditions and human behavior were now new objects of medical concern, which would search solutions to problems such as infant mortality. This trajectory, from the very beginning, was characterized by the formulation of strict rules, imposed on the family and especially on women-mothers, with the aim of molding their behavior in favor of infant health.1
This group of persuasion techniques and attack strategies is known in social medicine as family hygiene. Among the basic rules, the mother-infant dyad was one of the most brilliant contributions from hygienists and, because of them, hygiene elevated women to the position of mediators between children and government. Hygienists socially constructed the biology of the pregnancy-puerperium cycle, seeking to rescue maternity and breastfeeding as vital factors for infant survival.1 Hygienists began to fiercely condemn the hiring of slaves as wet nurses. Most criticisms against infant mortality were made through medical studies about breastfeeding, whose gist did not concern the destiny of slave infants, but the health of well-born infants.1
Breastfeeding served to control a woman's life in the disciplinary universe imposed by hygiene normalization. In this regard, the primary disciplinary aim of breastfeeding was to regulate the woman's free time at home, ridding her from idleness and pastimes that ran counter to the good morals and family values. Breastfeeding also served to confine the woman to the household and suppress women's liberation, due to patriarchal emancipation. The hygienist speech about breastfeeding lured women into male chauvinistic politics, and fooled them into believing in the noble role of breastfeeding.3 The restriction of female sexuality to the hygienist control zone included several maneuvers and the limitation on the number of sexual relationships during breastfeeding was one of the most successful measures. According to social medicine, these restrictions were appropriate, as they sought to prevent a new pregnancy, which could compromise milk secretion, and also because the sexual intercourse could interfere with milk properties.1
Hygienist medicine used breastfeeding as a way to grow stronger in society and progressively colonize the family, making them increasingly dependent on educational-therapeutic agents. Breastfeeding was socially constructed using natural and instinctive attributes, common to mammals. Therefore, to fulfill strategic purposes, social medicine created natural breastfeeding, with the support of biological determinism, intentionally disregarding, according to its interests, the magnitude of sociocultural factors related to this practice.
Weak milk: a rule for the exception
The whole set of rules could be emblematically summarized in one single slogan, which certainly translates all the spirit of the hygienist philosophy behind breastfeeding: "The health of your child is your responsibility. Breastfeed."1
Along with the rules came the exceptions. Records of 1869 revealed that certain groups of women were not able to breastfeed due to their low milk production, because their milk was weak or because it dried up easily. This situation of failure, after all rules had been followed, became a problem to which the hygienist model had no solution. To circumvent this paradigmatic crisis, hygienism created and introduced the figure of weak milk into the Brazilian culture.1 However, since the process of diffusion of a cultural element consists of three stages: presentation, acceptance and integration,13 the factors present in the recipient culture that favor the integration of this new element should be questioned.
An explanatory model can be formulated, confronting maternal difficulty in accepting the failure in breastfeeding with the strong social censorship regarding weaning imposed by hygienists. Inability to breastfeed would make the nonaccomplishment of a "natural function and sacred duty" public, denigrating the woman before society. On the other hand, an "epidemic" of exceptions would bring chaos to the hygienist paradigm, which is unable to solve these new problems with the established rules. Thus, it is at least reasonable to suppose that the introduction of the figure of a new social actor, able to take on all the blame, would be an interesting strategy to circumvent the problem. This type of alternative would not only lighten maternal responsibility, but would also keep the hygienist breastfeeding model untarnished.1
The preliminary effects of urbanization
Changes in Brazilian economic activities, as a result of the official slavery abolishment, ended up ascribing an economic and political importance to breastfeeding, causing the government to come in defense of poor children. Due to the fact that breastfeeding is considered a powerful way to help infant survival, authorities proposed that it should be encouraged in the poorest segments of the society, as a strategy to expand the labor force for exporting capitalism.14
On the other hand, the social pressures of urbanization and the increasing insertion of poor women in the labor market created a favorable scenario to weaning. Amidst such changes, the consumer society developed and along with it came bottle-feeding, one of the new symbols of modern times and urbanism.15 At that time, the first shipments of condensed milk and flour-based formula arrived from Switzerland. The mixture of these two ingredients, baby bottle and industrialized milk, allowed for a therapeutic alternative to the inability to breastfeed because of weak milk. Thus, supported by scientific knowledge, a new disease hypogalactia arose, which became one of the major concerns for Medicine in the early 20th century and served as a mediator that allowed the institutionalization of early weaning as a sociocultural practice, supported by Medicine.1
Scientific avant-garde and modernity: the symbol of industrialized milks
The deceitful advertisement of breastmilk substitutes in specialized magazines and journals, the utilization of health professionals as sales promoters in hospitals, the publication of technical leaflets especially targeted at pediatricians and the promotion of scientific events have been used, until recently, as marketing strategies by manufacturing companies. As a result, physicians completely internalized the idea that breastmilk needed to be complemented, even in situations in which hypogalactia was not diagnosed. The frequent prescription of industrialized milk was settled into the routine prophylaxis of childhood malnutrition.15
Industry built cultural elements for the valuation of powdered milk, launched in the Brazilian society by way of strategies mainly targeted at those who have the power to prescribe dietary regimens for infants: pediatricians. The new products were advertised as the response to discoveries about nutritional requirements resulting from the improved scientific knowledge about the peculiarities of infants' metabolism. Therefore, if scientific knowledge was improving, the daily practice of pediatricians should follow suit. Thus, the industry made use of nutrition sciences and created semiotic rhetoric and approaches in order to fabricate the truth about their products.1
Collective institutions for social solidarity also contributed to the recommendation of early weaning. The government employed its social agencies and health centers to implement programs for the distribution of powdered milk to low-income families.16 The changes in the roles of women in society, women's liberation, contradictions about work and reproductive life constituted another group of factors that simultaneously interfered in the sociocultural conditioning of breastfeeding.11 These factors were used by modified milk manufacturers in order to provide sociocultural evidence for the commerciogenic weaning paradigm, which guided infant feeding until the late 1970s.1
Changes in social perceptions
The development of the Brazilian Program for Breastfeeding Incentive (PNIAM) led to the valuation of the breastfeeding practice in the Brazilian society after the early 1980s. Superiority of breastmilk was a unanimous agreement in the scientific community and was widely advertised for the general public through mass media campaigns. Medicine, especially Pediatrics, rediscovered the benefits of breastfeeding and, with scientific support, redesigned knowledge, so as to match the physiological peculiarities of infants' metabolism with the discoveries about the unsurpassable biological properties of human milk. In addition to nutritional and immunological aspects that bring benefits to infants, the advantages of breastfeeding for mothers, family, society and government were brought into the spotlight and turned into marketing tools for breastfeeding promotion.17
The social movement in favor of breastfeeding was one of the highlights in the promotion of breastfeeding in Brazil. PNIAM was able to organize and gather effort from different segments of the Brazilian society. Government bodies, unions, non-governmental organizations, private companies, mass media and community associations formed an "ideological tower of Babel," conferring what is seen as the richest contributions to breastfeeding actions: plurality.1
Therefore, the industry lost its traditional space and had to cope with a growing market shrinkage. Since modified milk manufacturers cannot contest the benefits of natural breastfeeding with scientific evidence, they chose a new market niche, socially constructing the biology of exception in the breastfeeding scenario. This new category allowed reissuing the old "scientific avant-garde" formula in the field of infant feeding and nutrition.1 The main difference between the two models, commerciogenic weaning, employed between the 1940s and 1970s, and the current model, lies in the subject-object of the construction of "scientific avant-garde." The commerciogenic weaning paradigm contemplated all newborn infants as potential consumers, whereas the current model is aimed at those who experience specific problems, for instance, prematurity and food allergies. The industry gave some space for the fabrication of truths supposedly confirmed by science, all of which were favorable to their products and indirectly contrary to the use of human milk.1 These new truths were constructed with specific pieces of scientific knowledge, and were partially approached by marketing strategies.18
The implementation of the Baby-Friendly Hospital Initiative in Brazil in 1992, brought fresh hope to breastfeeding in the context of public policies. Despite the restrictions on the model, among which is the inobservance of the Brazilian health network hierarchization, it is important to mention that this initiative added the meaning of protection and support to breastfeeding, differently from previous formulations, which only contemplated aspects related to breastfeeding promotion. By considering the breastfeeding triad promotion-protection-support we can see the attributes that characterize breastfeeding as a social act, thus showing that policies which regarded it as a natural practice were incorrect.1
This new way to look at breastfeeding is more comprehensive and requires that a new focus be established on women, who cannot be treated as synonymous with mother/feeder, responsible for the success of breastfeeding and blamed for the weaning. The challenge to build a model that deals with this matter, linking breastfeeding issues to circumstances that result from post-modernity, necessarily includes the capacity to match biological determinants with sociocultural factors, configuring breastfeeding as a hybrid category between nature and culture.
The nature-culture hybrid: final remarks
From the letter of Pero Vaz de Caminha written to the Portuguese King to the emblematic scientific avant-garde socially constructed by modified milk manufacturers, breastfeeding revealed and reveals different meanings, which revolve around two poles: nature and culture. Depending on the moment and on the purpose of their use, these meanings sometimes drive away from each other and sometimes mingle. At times, these two aspects combine so intensely that one becomes the other. In other words, for breastfeeding to be perpetuated as a cultural habit, it must be assimilated as something that is part of nature, with no room for disagreement. Some other times, we are faced with cultural interpretations that do not admit describing a human being as any other mammal, redirecting and restructuring the natural movement of human species.
In search of a position that refutes reduction in both biological and social dimension, the categorization of breastfeeding as a nature-culture hybrid seeks to approach breastfeeding as the reflection of biological determinants and social, economic, political and cultural factors. This movement, contrary to the usual dichotomy between biological and social, generates new theoretical and methodological opportunities regarding the management of issues related to breastfeeding, allowing the revaluation of biology and an in-depth analysis of the interdisciplinary processes that permeate the topic.
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João Aprígio Guerra de Almeida
Av. Rui Barbosa, 716, Flamengo
CEP 22250-020 Rio de Janeiro, RJ
Phone/Fax: +55 (21) 553.5669