Breastfeeding offers health benefits to mothers and children and reduces infant morbidity and mortality. Despite the recommendations of the World Health Organization and many national and international organizations, breastfeeding rates and exclusive breastfeeding rates at 6 months post birth continue to be lower than recommended and vary widely between cultures and communities.1 Most countries, notwithstanding their level of development and the growing body of evidence, have made little progress toward the 2025 global target of 50% established for 2025 by the World Health Assembly.
Therefore, and to raise awareness on the importance of this subject, the theme selected for the World Breastfeeding Week of 2021 was “Protect Breastfeeding: A Shared Responsibility”. The aim of this slogan was to convey to society that promoting and supporting breastfeeding is a responsibility we all share. Suboptimal breastfeeding practices are a public health problem that calls for effort and investment at the global level.2
Challenges for mother and childThe confidence of mothers in their own ability to initiate and maintain breastfeeding results from the interaction between reality and the personal expectations of the mother. Initiation of breastfeeding with realistic as opposed to idealised expectations contributes to successful breastfeeding. Many women intend to breastfeed and struggle from the beginning with physical challenges, such as problems with latching or the milk supply or poor experiences. And all struggle as they attempt to integrate breastfeeding in modern life.
Challenges for the familyFrom a woman-centred approach, the family is defined as any individual identified by the mother as someone with who they have a close relationship. The attitudes, beliefs and expectations of the family are important factors that contribute to decisions regarding breastfeeding. Women report that the support from partners and close family members has a positive or negative impact in breastfeeding initiation and duration, which seems to be the case independently of ethnicity, socioeconomic level or maternal age.
Challenges for the health care systemWomen frequently turn to health care professionals for support. However, in some cases the information provided by professionals does not improve the confidence of women in breastfeeding, and women may receive contradictory messages. Improving the training of professionals on breastfeeding and their skills to provide patient- and family-centred care is important.3 In addition to the evidence on the “why” of breastfeeding, women also greatly appreciate information on the “how”. They want someone with experience to spend time with them from the beginning to offer technical advice. It is clear that knowledge of its health benefits is not sufficient for women to be able to breastfeed.
Challenges for societyBreastfeeding is also a challenge for society. Public health professionals that develop initiatives to increase breastfeeding rates must think of breastfeeding in this broader context. Individuals do not make decisions regarding infant nutrition based solely on the scientific evidence of what is best for the health of the child. Rather, these decisions are integrated in everyday life and are informed and influenced by numerous factors, including social structures, norms, values, attitudes and beliefs. One of the greatest challenges is the creation of spaces where women may feel comfortable breastfeeding. Women constantly describe feeling isolated and excluded from society, mainly due to disapproval of breastfeeding in public spaces. In particular, workplaces are described as settings where women feel very uncomfortable both breastfeeding and pumping. As a result, many women stop breastfeeding earlier than expected and usually when they return to work. The development of workplace and public space policies and practices could contribute favourably to increasing breastfeeding rates.2
Challenges for the communityCulturally, breastfeeding is an activity that is embedded in an increasingly complex world. As the roles of women change in modern societies, tensions emerge between maternity and other roles that they perform. Men and women both are working outside the home in increasing numbers, and childrearing is a shared responsibility, as is the extended family. Many women cannot take long maternity leaves for economic or professional reasons, which may pose challenges to breastfeeding. In today’s society, maternity is a complex balancing act between safeguarding the health of children and the realities of everyday life. Although society has changed, breastfeeding is expected to stay the same. Starting a public conversation on how breastfeeding fits in the real world with all its complexities seems particularly important.
Challenges for scienceBreastfeeding and coronavirusThe coronavirus pandemic has affected breastfeeding in both positive and negative ways. Infection by SARS-CoV-2 has raised concerns in pregnant women and mothers. The current situation has had and continues to have a negative impact on the quality of perinatal care, mother and child health and breastfeeding promotion and advocacy. Scientists have had to collect data in record times to provide evidence in support of recommending breastfeeding and vaccination as being safe for both mother and child.
Breastfeeding in neonatal unitsBreast milk is the natural source of nutrition for all infants, including those who are ill or premature. The neonatal intensive care unit (NICU) setting poses significant challenges to breastfeeding, as the newborn is separated from the mother on account of the health condition of either the infant or the mother. During this critical period, administration of maternal milk is of vital importance, as it supports the immune system of the infant and reduces morbidity and mortality. The mothers of preterm infants experience physiological and emotional difficulties that have a negative impact on breastfeeding success, and therefore require support. The stress associated with the separation of mother and infant can increase the probability of complications. In addition, the rate of breastfeeding during the stay and at discharge from the neonatal unit is increasingly considered a key health care quality indicator.4
Human milk banksDonor human milk is a valuable resource when there is an insufficient supply of mother’s own milk, but it presents significant challenges, such as the need to develop more effective forms of pasteurization and prevent the loss of nutrients during processing and storage.5
Maintaining the activity of milk banks during the COVID-19 pandemic has also been challenging. The priority was to ensure a sufficient supply of milk for recipients while ensuring the safety of donors and donor milk.
Challenges concerning environmental sustainabilityBreast milk is a “natural and renewable food source”, environmentally rational and produced and delivered to the consumer without generating pollution or unnecessary packaging or waste. On the contrary, artificial formulas used to replace human milk have a large ecological footprint, require consumption of energy for manufacture, of materials for packaging, of fuel for distribution and of water and toxic cleaning products for its daily preparation. The contribution of human milk to more rational consumer behaviours makes it a valuable resource in the pursuit of targets established to address climate change.
Final summaryAfter analysing the current situation of breastfeeding and related challenges, we go back to the initial question: what are the perceptions and difficulties of mothers as regards the initiation and maintenance of breastfeeding?
Women put substantial stock in the evidence on the benefits of breastfeeding and are aware of potential challenges ranging from physical difficulties to family, sociocultural and political barriers, and, given proper support, they are more likely to successfully maintain breastfeeding.
In recent years, extraordinary advances in maternal reproductive health and child health have been achieved. Still, there is a pressing need for commitment and investment on the part of governments, research institutions and society at large to promote, protect and support breastfeeding to safeguard the health of women and children in upcoming years.
Please cite this article as: Ares Segura S. Los retos de la lactancia en un mundo complejo. An Pediatr (Barc). 2022;96:283–285.
