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The Impact of Culture on Breastfeeding Rates.

Regular readers of Breastfeeding Medicine have no doubt noted a shift in the Editorial policy of the Journal in the past year. The new policy has encouraged the submission and publication of structured clinical research studies of breastfeeding support programs with measurable end points in addition to basic science studies of the physiology of lactation and breastmilk. In parallel, there has been a deemphasis of descriptive articles of breastfeeding programs, especially if the activities described reflect the unique characteristics of a local geographic area. Such submissions are primarily relevant to the local health system and, thus, are of minimal interest to the Journal’s worldwide readership. And yet there are exceptions, particularly when the observations are unexpected and the implications can be generalized to other populations. Just such an article is the study of Odeny and colleagues from Kenya in this month’s issue of Breastfeeding Medicine. As we know, current recommendations for mothers in the developing world who are HIV positive are to combine retroviral therapy and exclusively breastfeeding of the infant. This regimen has the best chance of reducing the postpartum HIV transmission rate from the mother to the infant, better than partial breastfeeding or formula feeding. What Odeny reported was that ‘‘unexpectedly’’ HIV-positive mothers were not exclusively breastfeeding despite these recommendations. Apparently, the mothers concluded that if they exclusively breastfed, they would be labeled as HIV-positive women, resulting in a cultural stigma in their community. The end result was that the fear of personal stigmatization and its cultural consequences outweighed ‘‘neutral’’ health recommendation, and the result was less of the desired exclusive breastfeeding in both HIVpositive and HIV-negative mothers. It is clear that the implications for such a study are beyond the health issues of the Kenyan HIV-positive mothers. One cannot (and should not) ignore the cultural context of the mothers who are deciding how to feed their infants. Yes, breastfeeding should not be conceived as a lifestyle choice, but rather as a basic health issue; however, it is clear that these health issues cannot be addressed in a vacuum. As such, for example, appropriate programs that relate to adolescent mothers and their culture have to be developed if we want to improve breastfeeding rates in this very problematic age group, most particularly for adolescents in the developed world. No less so, on a more national level, the observation is that French mothers have lower rates of initiation and duration of breastfeeding despite extensive support programs both in the hospital and in the community. Clearly this is an expression of the special cultural context and priority of mothers reflecting their perception of breastfeeding, their concept of motherhood, and the self body image of the French mother. If we are talking about body image, the observation of Barros reported in this issue regarding the distribution of fat mass in infants who are or not breastfeeding is of interest, particularly as it relates to the amount of abdominal fat mass as opposed to the more benign locations of adipose tissue. No less of interest is the in vitro study of breastmilk from mothers whose diet is excessively rich in trans fat. Milk from such mothers in vitro had diminished potential for stimulating embryonic growth. Yes, what the mother eats does potentially make a difference and culture is probably the most critical variable in food selection. It is true what Mahatma Gandhi said: ‘‘A nation’s culture resides in the hearts and in the soul of its people,’’ but apparently what we put in our mouths is no less a vital and critical part of our culture.