Is breast always best? Balancing benefits and choice?

Choice is not always about choosing between equals and this point needs to be held in mind when discussing breastfeeding. There exists little controversy regarding the significant benefits of this method of infant feeding, both in terms of nutritional and immunological advantages to the infant (Fisk et al., 2007; Oddy et al., 2011; Quigley, Kelly & Sacker, 2007) and the psychological benefits to the mother in terms of the developing mother–child relationship (Field, Hernandez‐Reif & Feijo, 2002). The huge weight of evidence in support of breastfeeding and the positivity bias towards this type of infant feeding implicit within contemporary Western culture currently frame desirable maternal attributes and underpin social policy (Marshall, Godfrey & Renfrew, 2007), although this position is not without its critics (Schulze & Carlisle, 2010). During the booking appointment, at which women are usually given their pregnancy notes, occurring at around 10–12 weeks of pregnancy, a key question is invariably asked regarding intention to breastfeed. Increasing the proportion of breastfeeding new mothers has represented an explicit clinical indicator for acute and primary care trusts providing maternity care in the UK and an objective in terms of interventions to support breastfeeding. What then of maternal choice? Since ‘Changing Childbirth’ (Department of Health, 1993), the choice of the mother has been emphasised in terms of where and with whom antenatal appointments take place and in options for place of birth and birth plans and also in relation to postnatal care and support. Given the incontrovertible evidence for the desirability to breastfeed, how does the maternal choice agenda sit with the dominant ‘breast is best’ position? What of mothers who try to breastfeed and, for a range of reasons, find this difficult or not possible for them? What also of mothers who choose not to breastfeed, perhaps based on previous experience, personal views or convenience (Skafida, 2011)? There are tensions and sometimes stresses and strains between the different policies at individual and organisational level. Yet, there is clear recognition of the public health benefits of breastfeeding and consequently the expression and support of maternal choice are clearly not in conflict where a woman chooses to breastfeed. While many women breastfeed their baby at least once after birth, significant proportions give up in the early days or weeks following (Henderson & Redshaw, 2011). Women may not initiate or continue to breastfeed either through difficulty or through choice and in the case of choice, this can represent a clash of policies and individual expression, giving rise to negative attributions regarding the mother (Hausman, 2009) and, in the case of mothers who cannot breastfeed, a perception of ‘having failed’. There is a view that egalitarian and broad cultures should embrace choice, yet what pressures does a mother who chooses not to breastfeed experience in terms of mechanisms of conformity to breastfeed, while orientated to an expectation of choice in their infant feeding decisions? It has been suggested that mothers who do not breastfeed may experience psychological burden and disadvantage. However, it is likely that disadvantage influences breastfeeding uptake, rather than being caused by not breastfeeding per se, and needs to be explored further in light of possibly conflicting policies and the social construction of breastfeeding as being central to the conceptualisation of the ‘good new mother’. Dispassionate research which looks at the needs and wishes of all women at what is a really important time in the lives of them, their infants and families, including women who do not breastfeed, may provide new insights into the mechanisms associated with disadvantage, perhaps even illuminating how such mothers could be disenfranchised by social policy and political correctness. A huge amount of research has been conducted on the impact of breastfeeding on the mother and infant; however, investigating what factors play a part in both the positive and more negative outcomes for children following quite different early infant feeding practices is critical (Hay et al., 2001; Sharp et al., 1995). Greater understanding of the psychological and emotional costs and benefits for women and their babies could only contribute to the promotion of exemplary evidenced‐based practice which supports the needs and choices of all mothers, those who breastfeed and those who do not.