Journal of ISSN: 2373-4426 JPNC

Pediatrics & Neonatal Care
Review Article
Volume 1 Issue 6 - 2014
Breastfeeding in Public: A Global Review of Different Attitudes towards It
Komodiki E, Kontogeorgou A, Papastavrou M, Volaki P, RMidw, Genitsaridi SM and Nicoletta Iacovidou*
Neonatal Department, National and Kapodistrian University of Athens, Greece
Received: September 30, 2014 | Published: November 06, 2014
*Corresponding author: Nicoletta Iacovidou, Assistant Professor of Pediatrics - Neonatology, Neonatal Department, National and Kapodistrian University of Athens, Medical School, Aretaieio Hospital, 3 Pavlou Mela str, Athens 16233, Greece, Tel: +306932400834; Email: @
Citation: Komodiki E, Kontogeorgou A, Papastavrou M, Volaki P, RMidw, et al. (2014) Breastfeeding in Public: A Global Review of Different Attitudes towards It. J Pediatr Neonatal Care 1(6): 00040. DOI: 10.15406/jpnc.2014.01.00040

Abstract

Breast milk is the best diet for infants and exclusive breastfeeding is strongly recommended. In order for breastfeeding to be exclusive, mothers will face situations where they will need to feed in public places whether they are indoors or outdoors. However, acceptance of breastfeeding in public is not always accepted. Many cultural, legal, social and religious factors play a role in acceptance of nursing in public. Public acceptance in turn may have an effect on the rate of breast feeding in communities and regions. Some countries in North Europe and North America have made legislative attempts to establish the legitimacy of breastfeeding in public as well as the right to feed their child or pump milk at the workplace. Moreover, some countries in the Western hemisphere use advertising to promote breastfeeding. On the other hand, some African and Asian countries discourage, or even criminalize public nursing. This review summarizes the different attitudes towards public breastfeeding worldwide and the current advertising campaigns around the world.
Keywords: Breastfeeding; Public; Legislation; Infant; Nutrition

Abbreviations

ACA: Affordable Care Acta; FLSA: Fair Labour Standards Act

Introduction

“I breastfeed my little girl for 5 months exclusively, I live in London and am glad to say I have never had anything but a sense of approval from passers-by or restaurant staff etc. The first time I attempted to breastfeed in public was in a restaurant and my baby was 10 days old. It’s a bit stressful the first few times but soon it becomes really natural”, “In England, by law, a woman is allowed to breast-feed in any public place and anybody who tries to stop her can be taken to court” according to breastfeeding women from England [1]. United Kingdom and many other developed countries are clearly in favour of public nursing and in some cases they support it with relative legislation. On the other hand, the majority of developing countries confuse the average breastfeeding mother as they lack clear direction for or against public breastfeeding. Actually, Prasanth from an Indian state called Kerala reveals that “Breastfeeding in public is not at all seen in my state. About ten years before, breastfeeding in public was common. Now breasts are considered as a sexual organ and so breastfeeding in public is considered as a sexual act. People are not hesitant to breastfeeding. But breastfeeding in public is considered as a sexual act”, while Juhi from Orissa, another Indian state, declares that “Breastfeeding in public in India is very common and people don’t even pay attention that much. I have a 2 year old son and I am still breastfeeding him. Sometimes I had to breastfeed him in park, shopping mall during air travel and I feel great and never shy as this is a natural way to do it. Nature gave us breast to feed our babies” [2].
Exclusive breastfeeding is considered the best diet for all newborns and infants. Exclusive nursing requires that the mother should be able to breast feed on demand by the child at any location. Hence it is inevitable that every nursing woman will need to breastfeed in public. Statistics and reviews have shown that the acceptance of public nursing is variable, even when it is protected by laws and policies. Numerous cultural and religious factors are thought to be responsible for this variation around the world. Presence or absence of protective legislation is another factor that may have an impact on public breastfeeding in each country. The negative attitude against breastfeeding in public is often considered responsible for the low breastfeeding rates in different parts of the world.

Geographic Distribution

In Europe the situation regarding breastfeeding in public varies from country to country even though in the majority of countries it is legally protected. In the United Kingdom, the Sex Discrimination Act 1975 and the Equality Act 2010 clarified protection against discrimination or harassment in the provision of services when a woman breastfeeds in public a child of any age [3,4]. In 2005, the Scottish Parliament passed the Breastfeeding Act preserving the right to public nursing. The legislation imposes fines up to £2500 for preventing breastfeeding of a child up to 2 years old in any public location [5]. However, there is still a significant difference, since in Scotland women are more likely to breastfeed in public compared to those in England or Wales, where women still have mixed feelings due to possible embarrassment or judgement they may be subjected to [6]. In Germany, breastfeeding in public is widely accepted, yet there is no specific legislation [7]. In the Netherlands, it is common to nurse in public and there is specific legislation concerning breastfeeding at work, which obliges the employer to provide a suitable nursing room for the first 9 months after birth and allow for 25% of work time to be spent on breastfeeding while on pay [8]. Scandinavian women tend to be the European champions as far as breastfeeding is concerned. It is seriously promoted and mothers in Norway, Sweden and Finland are free to nurse in every public location as it is socially accepted. On the other hand, in France, which has one of the lowest breastfeeding rates in the western world, nursing in public is rare while perfectly legal. It seems that French, especially the younger ones tend to be less tolerant towards breastfeeding in public and it is more acceptable for a woman to breastfeed if her baby is up to 6 months old [9,10]. Around the Mediterranean, Spanish, Italian and Greek women even though they are encouraged to breastfeed in public, many mothers are still discreet about the issue. Pope Francis, in a ceremony in Vatican City, has recently encouraged women “to feed their babies anywhere, even in the Sistine Chapel, without thinking twice” [11]. Similar attitude is also observed in Balkans [1].
In North America breastfeeding in public is a social issue that is subjected to different management among different states [12]. In the USA there are two types of law related to breastfeeding. They either establish the right of breastfeeding in public or exclude breastfeeding from criminal statutes [13-15]. At present, 34 states have clear legislation from either category [16,17]. Virginia and North Carolina belong to those states that have legalized breastfeeding in public, while Alaska and Utah protect breastfeeding from potentially restrictive laws [18]. However, several states including Connecticut, New Jersey and Minnesota have vague legislation that lacks clarification of the circumstances under which breastfeeding in public is ethical and acceptable [19]. Additionally, some states lack legal framework for breastfeeding, and acceptance and support of breastfeeding in public depends on the convenience of each private operator. Actually, mothers in the USA breastfeed in public without hesitation while they remain discreet; this is generally accepted and welcome.
Breastfeeding at work is among others a great challenge for a new mother-employee. Sometimes, the working hours and the circumstances at work cultivate the unfavourable climate for breastfeeding. North America is relatively sensitive towards nursing during working hours. President Barack Obama signed the Affordable Care Acta (ACA) on March 30th, 2010. The section Fair Labour Standards Act (FLSA) is a federal law in the USA that requires employment rights on breastfeeding and on expressing breast-milk at workplace whenever needed [20-22]. The FLSA requires that the employer ensure working mothers time and an appropriate place to breastfeed or express milk every time it is necessary for the first year after birth. According to legislation, a nursing mother has the right to breastfeed or express milk at work without time limitation in a clean and private place other than a bathroom. However, small companies that employ less than 50 employees are exempted from this law. Compliance with this legislation varies from state to state in the USA. It is remarkable that 24 states implement it. Specifically, New York and California apply the legislation more thoroughly while Georgia and Oklahoma have more flexible arrangements on breastfeeding at work. Additionally, in most cases, it is not fully clarified if the provided time for nursing could be beyond the usual break times. In cases of disobedience, only 3 states provide penalties for employers. The pumping law is not always specific for time and place provided, yet it indisputably establishes a family-friendly workplace [23,24].
In Canada, public breastfeeding seems to be a public health issue and is generally accepted. Feeding Action Coalition Canada (INFACT), a national non-governmental organisation, has taken over the protection of infant and child by promoting and supporting breastfeeding. Mothers feel free to nurse anywhere and rarely experience any criticism [25].
In most countries in Central America, breastfeeding in public is considered as a common and ordinary activity. Mothers in Barbados, Guatemala, Honduras, Trinidad and El Salvador nurse their children everywhere but they usually cover up their breasts.
In South America in the majority of countries mothers have a confident-positive attitude concerning breastfeeding in public. In the 1980s, Peru was the first Latin American country to establish policy to protect breastfeeding in healthcare centres and public places [26]. In Chile, Brazil, Venezuela and Argentina mothers may nurse anywhere. In Colombia, in urban areas women often cover up, unlike in the rural areas [2].
In Asia each country represents a unique cultural and religious model and thus differentiates their attitude towards breastfeeding [27]. Breastfeeding in public seems to be widely accepted among Asian countries as long as discretion is maintained. Women can breastfeed without limitations in Israel, Bangladesh, Nepal, Jordan and Iran [28]. In Philippines breastfeeding in public is not prohibited, yet a woman nursing in public may take the risk to be declared unethical if her breast is partially covered and exposed [29]. China, Malaysia and Thailand basically accept breastfeeding in public, but there are differences from area to area attributed to educational and economic reasons [30,31]. Breastfeeding in public is more widespread in rural areas among low-education populations, compared to urban areas and among highly educated people. On the other hand, it is unusual to see a woman breastfeeding her baby in public in Taiwan, Hong Kong and Japan, even though it is not illegal. Pakistan has strict cultural standards for modesty and naked human skin is frowned upon due to religious reasons. However, Islamic rules of Pakistan accept and respect breastfeeding in public as long as it is done discretely [32]. A small minority of Asian countries criminalizes breastfeeding in public. Indeed, it is unacceptable and offensive to breastfeed in public places of Saudi Arabia and Bali [33].
In Africa again the attitude towards breastfeeding in public varies and the situation changes from country to country. Cultural anthropologist Kathrine Dettwyler says, “In most cultures around the world, breasts hold no sexual connotations for either men or women. Sexual behaviour does not involve breasts, which are perceived as existing for the sole purpose of feeding children”[34]. In the majority of regions, breastfeeding in public is considered to be a mundane activity and is widely accepted. Women from Kenya, Liberia, Morocco, Nigeria, Rwanda, Somalia, Uganda, Zambia and many other countries breastfeed on demand without any hesitation. Sometimes discretion may be necessary, depending on the environment. In Ghana especially - although a conservative country - a woman is expected to breastfeed her child if the need arises, while if she doesn’t then it is concluded that the baby is not hers. On the other hand, in Libya breastfeeding in public is not widespread and occasionally frowned upon, while in Egypt most women don’t breastfeed in public due to religion [2]. As for Oceania, countries support the right of a mother to breastfeed in public. In Australia, according to the Discrimination Act 1991, the National Anti-discrimination Legislation in 2010 and the Sex Discrimination Act 1984 amended in 2011, every woman is protected by law to breastfeed her child in public places and unfavourable treatment on the ground of breastfeeding is prohibited. Community acceptance of breastfeeding in public has grown over the past years and the law recognises that breastfeeding should be supported. In New Zealand, breastfeeding in public is also assured by law, is common and widely accepted. Many public places in both countries provide nursing rooms where mothers can comfortably change their baby, breastfeed or pump their milk [35].

Breastfeeding in Public and Advertising

In addition to the legislation concerning breastfeeding in public, advertising campaigns promote the establishment of the right of women to nurse everywhere. “I believe that the only way to really begin to get rid of the stigma that surrounds breastfeeding in public begins with men,” wrote Hector Cruz, an American photographer, to his email to the Huffington Post. He was not allowed to attend breastfeeding classes in preparation of the birth of his daughter although he wanted to be supportive and comforting to his wife during her breastfeeding ‘journey’. His response to this still social taboo was Project Breastfeeding, a photo series of men holding their children in breastfeeding poses with the words “If I could, I would” imprinted on the images. His goal was to educate men, encourage women and destigmatise breastfeeding in public [36].
Along with this ad, another one comes, entitled When Nurture Calls. Kris Haro and Johnathan Wenske, art students from the University of Northern Texas, designed this campaign for a class project to support HB 1706, a bill in the Texas state legislature that protects breastfeeding mothers from harassment and discrimination. It consists of two parts, the posters and a mobile application. The print ads would be placed on the back of bathroom stalls so as to create a reflection of the stall facing it. They show mothers who have been harassed and feel their only option is to feed their babies in the restroom so as not to offend anyone. Breast Friends is the mobile application, designed especially for breastfeeding mothers. It allows them to search or give feedback for nearby public places that support nursing mothers [37].
Advertising campaigns may be the first step but should not be the only one promoting breastfeeding. So as to establish the right of breastfeeding, apart from the existing legislation, education is necessary. Starting from the young-ones to the elders, everyone must be informed of the importance of breastfeeding. Campaigns at schools and universities and projection through media - newspapers, television, internet, even social media are yet to be done. But first of all should be the mothers. They have to be well informed during pregnancy and be prepared to face any difficulties concerning breastfeeding. Hospitals and maternity homes should organise lessons for the mothers-to-be and provide a baby friendly environment after delivery. The benefits of breastfeeding for both mother and child are unquestionable and nursing should be considered again as the most normal beginning of a healthy nutrition.

Conclusions

Acceptance of public breastfeeding varies tremendously around the world. United States of America and some European countries accept and support breastfeeding in public both in theory and practise. These countries have recently established relevant legislation that protects breastfeeding in public places as well as at workplace. Since breast milk is critical for both maternal and child health, local, national and international public health organizations should consider promoting both legislative and marketing activities to promote acceptance of public nursing. Increase public acceptance of breast feeding in public would increase rates of exclusive breast feeding and improve health outcomes.

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