Ethical Issues in Breastfeeding and Lactation Interventions: A Scoping Review

BACKGROUND

Infant feeding interventions that promote and support breastfeeding are considered important contributions to global public health. As these interventions often target private settings (e.g., individuals' homes) and involve vulnerable populations (e.g., pregnant women, infants, and underprivileged families), a keen awareness of ethical issues is crucial.

RESEARCH AIM

The purpose of this scoping review was to capture the key elements of the current ethical discourse regarding breastfeeding and lactation interventions.

METHOD

A scoping review was conducted using Arksey and O'Malley's (2005) methodology to identify the ethical issues of breastfeeding and lactation interventions as they are reflected in the scholarly literature published between January 1990 and October 2022. Abstracts (N = 3715) from PubMed, ScienceDirect, JSTOR and the Cochrane Database of Systematic Reviews were screened. The final sample consisted of 26 publications.

RESULTS

The recurring ethical issues identified in these studies were: the normative assumptions of motherhood; maternal autonomy and informed choice; information disclosure, balancing risks and benefits, and counseling practices; stigma and social context; ethics of health communication in breastfeeding campaigns; and the ethical acceptability of financial incentives in breastfeeding interventions.

CONCLUSION

This review illustrated that, while a wide range of ethical arguments were examined, the emphasis has been primarily on accounting for mothers' experiences and lactating persons' choices, as well as achieving public health objectives relating to infant nutrition in breastfeeding interventions. To effectively and ethically implement breastfeeding and lactation interventions, we must consider the social, economic, and cultural contexts in which they occur. One key learning identified was that women's experiences were missing in these interventions and, in response, we suggest moving beyond the dichotomous approach of individual health versus population health.

The Content and Sources of Breastfeeding Knowledge for New Mothers in the Netherlands

Background:

In the context of decreasing breastfeeding rates and unsuccessful breastfeeding promotion campaigns, a qualitative research project in the Northern part of the Netherlands was initiated.

Objectives:

As part of the overall project, the aim of this study was to explore the content and sources of breastfeeding knowledge among primiparous women. Identifying and categorizing the content and the sources of breastfeeding knowledge could guide professionals such as midwives and maternity nurses as well as others in the women’s surroundings to engage in disseminating knowledge and therefore support women in achieving their breastfeeding goals.

Methods:

We conducted 26 in-depth interviews from the emic perspective with 13 new mothers pre- and postpartum, up to saturation level. Transcripts were analysed applying thematic analysis. As sensitising concepts, the themes identified were divided into two categories: those gained from 'professional' sources and those obtained from 'popular' sources.

Results:

Five knowledge content themes were identified: (1) pros and cons of breastfeeding, (2) how breastfeeding works, (3) individual breastfeeding practice, (4) expressing milk, and (5) formula feeding. ‘Professional’ sources are perceived as more helpful than ‘popular’ sources, whereas ‘intuition’ was inductively identified as an important knowledge source.

Conclusion:

Limited breastfeeding practice exposure, along with the recommendations to breastfeed for six months and perceptions of breastfeeding as ‘natural’ at the same time, generates much pressure in women. Emphasizing all knowledge content in campaigns, addressing a variety of target groups in women’s social environment, and recognizing intuition as an adequate source of knowledge supported by professionals will facilitate women in making informed infant feeding decisions.

Public Health and the Virtues of Responsibility, Compassion and Humility

In contrast to medical care, which is focused on the individual patient, public health is focused on collective health. This article argues that, in order to better protect the individual, discussions of public health would benefit from incorporating the insights of virtue ethics. There are three reasons to for this. First, the collective focus may cause neglect of the effects of public health policy on the interests and rights of individuals and minorities. Second, whereas the one-on-one encounters in medical care facilitate a compassionate and caring attitude, public health involves a distance between professionals and the public. Therefore, public health professionals must use imagination and care to evaluate the effects of policies on individuals. Third, the relationship between public health professionals and the people who are affected by the policies they design is characterized by power asymmetry, demanding a high level of responsibility from those who wield them.

Against this background, it is argued that public health professionals should develop the virtues of responsibility, compassion and humility. The examples provided, i.e. breastfeeding information and vaccination policy, illustrate the importance of these virtues, which needed for normative as well as instrumental reasons, i.e. as a way to restore trust.

Experience of non-breastfeeding mothers

Background:

Breastfeeding is currently strongly recommended by midwives and paediatricians, and the recommendations are based on documents provided by the World Health Organization and public health authorities worldwide.

Research question:

The underlying question is, how are non-breastfeeding mothers affected emotionally when informed that breastfeeding is the safest and healthiest option?

Research design:

The method used is an anonymous web-based qualitative survey exploring the narratives of non-breastfeeding mothers, published on Thesistools.com . The aim is to achieve qualitative knowledge about the emotions of non-breastfeeding mothers.

Participants and research context:

Participants were based in Sweden, the United Kingdom and the Netherlands and were selected through a purposeful sample.

Ethical considerations:

The online survey anonymizes responses automatically, and all respondents had to tick a box agreeing to be quoted anonymously in scientific articles. The study conforms to research ethics guidelines.

Findings:

Respondents describe how they were affected, and the following themes emerged in studying their descriptions: depression, anxiety and pain, feeling failed as a mother and woman, loss of freedom/feeling trapped, relief and guilt.

Discussion:

The themes are discussed against the background of the ethics of care and a theory of ethically responsible risk communication.

Conclusion:

Three conclusions are made. First, the message should become more empathetic. Second, information should be given in an attentive dialogue. Third, information providers should evaluate effects in a more inclusive way.

It takes a mother to practise breastfeeding: Women's perceptions of breastfeeding during the period of intention

BACKGROUND

In the Netherlands, 81% of mothers initiate breastfeeding. After one month the percentage of mothers still breastfeeding drops, despite positive intentions. Little is known about women's perceptions of breastfeeding during the period of intention.

AIM

This qualitative study aimed to gain insight into these perceptions among first-time mothers from middle and high socioeconomic backgrounds in the northern part of the Netherlands.

METHODS

We used the theory of planned behaviour as the deductive model. In 2008, 16 in-depth interviews were conducted with 8 mothers who intended to breastfeed. The interviews were conducted at two time points (prepartum and postpartum) and covered the same period (that is, from the time when the intention was formed until after childbirth). The interviews were transcribed verbatim and analysed using grounded theory.

FINDINGS

Five inductive themes were identified: combining breastfeeding with work, learning about breastfeeding, making arrangements for childbirth, reflecting on the intention, and becoming a mother. During the extended period of intention, the women anticipated breastfeeding, but were cautious in expressing their intentions. They felt that the experience of becoming a mother would be critical to their breastfeeding outcomes.

CONCLUSION

The theory of planned behaviour has been widely used in breastfeeding research. However, the period of intention is relatively long for breastfeeding. Rather than recommending an intensification of antenatal breastfeeding education, recommendations must incorporate the awareness that practising breastfeeding should not be considered the continuous outcome of the intention to do so - it takes a mother to practise breastfeeding.

Goals, dilemmas and assumptions in infant feeding education and support. Applying theory of constraints thinking tools to develop new priorities for action

Three important infant feeding support problems are addressed: (1) mothers who use formula milk can feel undersupported and judged; (2) mothers can feel underprepared for problems with breastfeeding; and (3) many mothers who might benefit from breastfeeding support do not access help. Theory of constraints (TOC) is used to examine these problems in relation to ante‐natal education and post‐natal support. TOC suggests that long‐standing unresolved problems or ‘undesirable effects’ in any system (in this case a system to provide education and support) are caused by conflicts, or dilemmas, within the system, which might not be explicitly acknowledged. Potential solutions are missed by failure to question assumptions which, when interrogated, often turn out to be invalid. Three core dilemmas relating to the three problems are identified, articulated and explored using TOC methodology. These are whether to: (1) promote feeding choice or to promote breastfeeding; (2) present breastfeeding positively, as straightforward and rewarding, or focus on preparing mothers for problems; and (3) offer support proactively or ensure that mothers themselves initiate requests for support. Assumptions are identified and interrogated, leading to clarified priorities for action relating to each problem. These are (1) shift the focus from initial decision‐making towards support for mothers throughout their feeding journeys, enabling and protecting decisions to breastfeed as one aspect of ongoing support; (2) to promote the concept of an early‐weeks investment and adjustment period during which breastfeeding is established; and (3) to develop more proactive mother‐centred models of support for all forms of infant feeding.