Mary Margaret Coates and Jan Riordan
Throughout the world today, an infant is apt to receive less breastmilk than at any time in the past. Until the 1940s, the prevalence of breastfeeding was high in nearly all societies. Although the feeding of manufactured milks and baby milks had begun before the turn of the century in parts of Europe and North America, the practice spread slowly during the next decades. It was still generally limited to segments of population elites, and it involved only a small percentage of the world's people. During the post-World War II era, however, the way in which most mothers in industrialized regions fed their infants began to change, and the export of these new practices to developing nations was underway.
How do we know what we "know" about the prevalence of breastfeeding? (The word prevalence is used here to mean the combined effect of breastfeeding initiation rates and breastfeeding continuance rates.) Before attempting to trace trends in infant feeding practices, let us consider the nature of the evidence.
National surveys that produce the kind of representative data that allow statistical evaluation have been available only since 1955. These surveys consist primarily of national fertility or natality surveys and of marketing surveys conducted by manufacturers of artificial baby milk. For most, exclusive breastfeeding is not a separate statistic. However, the percentage of exclusive breastmilk feedings at hospital discharge can be found in state birth certificate databases (Feldman-Winter et al., 2002). A brief description of national surveys conducted in the United States follows (Grummer-Strawn & Li, 2000):
• National Health Interview Survey: A personal interview is conducted in 43,000 households. Questions about incidence and duration of breastfeeding are asked.
• National Health and Nutrition Examination Survey (NHANES): Breastfeeding data are periodically collected from personal interviews in the home.
• National Survey of Family Growth (NSFG): Personal interviews are conducted every 6 years. Standard questions on incidence, duration, and exclusivity are included.
• Pediatric Nutrition Surveillance System (PedNSS): Statistics of breastfeeding incidence and duration in low-income populations are collected in public health clinics and reported annually. National, state, county, and clinic data are analyzed.
• WIC Participant Characteristics Study: Data on breastfeeding are collected each even-numbered year by the Department of Agriculture.
• Ross Laboratories Mothers Survey: Questionnaires are mailed to new mothers whose names are obtained from a national sample of hospitals and physicians. For marketing purposes, data on type of milk fed is collected for up to 12 months for a given cohort. Data are published on an ad hoc basis. The survey currently functions as a baseline and monitoring data source for breastfeeding goals in Healthy People 2010.
• Mead-Johnson Longitudinal Study of Infant Feeding Practices: For marketing purposes, a panel of infants is followed for 12 months. Data is collected on incidence of, duration of, and changes in breastfeeding frequencies.
Outside the United States, representative data for countries in Latin America, Asia, Africa, and the Middle East are derived from three sources. World Fertility Surveys are sponsored by the Office of Population within the United States Agency for International Development (USAID), the United Nations Fund for Population Activities, and the United Kingdom Office of Development Assistance (Light-bourne, Singh, & Green, 1982). The World Health Organization began ongoing surveys on infant feeding in the mid-1970s. Its Global Data Bank on Breast-Feeding pools information garnered from well-designed nutrition and breastfeeding surveys around the world; on the basis of these data, breastfeeding practices are periodically summarized. The most recent summary appeared in 2000 (WHO, 2000). Finally, demographic and health surveys were initiated in 1984; these ongoing surveys are sponsored jointly by USAID and governments of host countries in which the surveys are made.
Until the last several decades, breastfeeding was the unremarkable norm. Thus what we "know" about breastfeeding from much earlier times often must be inferred from evidence of other methods of feeding infants. Most historical material available in English-language literature derives from a rather limited geographic area: Western Europe, Asia Minor, the Middle East, and North Africa. Written materials, which include verses, legal statutes, religious tracts, personal correspondence, inscriptions, and medical literature, extend back to before 2000 bc.
Some of the earliest existing medical literature deals at least in passing with infant feeding. An Egyptian medical encyclopedia, the Papyrus Ebers (c. 1500 bc), contains recommendations for increasing a mother's milk supply (Fildes, 1986). The first writings to discuss infant feeding in detail are those of the physician Soranus, who practiced in Rome around ad 100; his views were widely repeated by other writers until the mid-1700s. It is not immediately apparent to what degree these early exhortations either reflected or influenced actual practices. Many writings before ad 1800 deal primarily with wet nurses or how to hand-feed infants.
Archeological evidence provides some information about infant feeding prior to 2000 bc. Some of the earliest artifacts are Middle Eastern pottery figurines that depict lactating goddesses, such as Ishtar of Babylon and Isis of Egypt. The abundance of this evidence suggests that lactation was held in high regard (Fildes, 1986). Such artifacts first appear in sites about 3000 bc, when pottery making first became widespread in that region. Information about infant feeding may also be derived from paintings, inscriptions, and infant feeding implements.
Modern ethnography has a place of special importance. By documenting the infant feeding practices of present-day nontechnological hunter-gatherer, herding, and farming societies, ethnographers expand our knowledge of the range of normal breastfeeding practices. At the same time, they provide a richer appreciation of cultural practices that enhance the prevalence of breastfeeding. Such studies are also our best window into breastfeeding practices that may be the biological norm for Homo sapiens sapiens.
In summary, the historical aspect of this chapter deals with limited data from a limited social stratum in a limited geographic region. However, the common threads of these data provide a useful context within which we may better understand modern breastfeeding practices, especially in Western cultures.
The Biological Norm in Infant Feeding
The class Mammalia is characterized principally by the presence of breasts (mammae), which secrete and release a fluid that for a time is the sole nourishment of the young. This manner of sustaining newborns is extremely ancient; it dates back to the late Mesozoic era, some 100 million years ago. (See Figure 1-1.) Hominid precursors first appeared about 4 million years ago; the genus Homo has existed for about 2 million years. The currently dominant human species, Homo sapiens sapiens, has existed for perhaps 40,000 years. Information about breastfeeding practices among our earliest ancestors is uncertain, although other information about Paleolithic societies that existed 10,000 or more years ago sheds light on this subject.
Early Breastfeeding Practices
Diets reconstructed by archeological methods reveal that the Late Paleolithic era, roughly 40,000 to
Lactating animals (mammals) already present
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