Saturday, August 30, 2008

Different cultures initiate breastfeeding at different times

A cornerstone of midwifery practice is that it attempts, as far as possible, to recapitulate nature. Actually, as we have discussed here many times, it does no such thing (Birth Fantasyland). Instead, it has simply created a new set of cultural constructs.

One of these cultural constructs is that breastfeeding must be initiated within the first hour after birth in order to be successful. The claim is that breastfeeding in nature is initiated almost immediately. However, an interesting cross cultural study shows that not only are there is great variation across cultures in the timing of breastfeeding initiation, there are two predominant patterns, one of early initiation (in the first several hours) and one of late initiation (after several days). The paper is Patterns for the Initiation of Breastfeeding in Humans by Holman and Grimes, Am. J. Hum. Biol. 15:765–780, 2003.

The authors start with a hypothesis that there is one "natural" time for the initiation of breastfeeding:
In this article we examine cross-cultural behavior in the initiation of breastfeeding. An attempt is made to uncover general patterns for the initiation of breastfeeding that are common to all humans... In short, this approach asks the following hypothetical question: If we could eliminate the effects of culturally mediated changes in the initiation of breastfeeding, how much time would elapse between parturition and initiation of breastfeeding? We expect that there exists an underlying distribution of times to initiation of breastfeeding that is shared by all Homo sapiens. Culturally mediated decisions on initiation of breastfeeding in contemporary humans may ordinarily mask some underlying pattern of natural breastfeeding.
After examining 25 separate studies comprising more than 25,000 mother-infant pairs from a variety of countries and cultures the authors found something unexpected. The paper is very complicated and the mathematical modeling is very arcane, but the basic point it this: the authors expected to find that breastfeeding was "naturally" initiated relatively shortly after birth, with the only exception being late initiation prescribed by particular cultural mores. In other words, when graphing initiation of breastfeeding by culture, each culture would have some pairs who initiated breastfeeding immediately, and some pairs who initiated breastfeeding at a culturally prescribed time, unique to each culture.
... [M]uch variation is found among cultures in the onset of breastfeeding. Cultural attitudes about the acceptability of colostrum are one important component that affects a mother’s decision about when to begin breastfeeding. In many settings, colostrum is viewed as harmful to the health of newborns; some women routinely delay breastfeeding for several days postpartum until a more mature breastmilk is expressed. Other culturally mediated factors that play a role in determining when a child is first breastfed include ... prelacteal feeding rituals.
Much to their suprise, the authors found that in every culture they studied, there were both early and late initiation pairs, but both early and late initiation did not vary across cultures. Some mother infant pairs initiated breastfeeding within the first several hours, while others initiated breastfeeding at approximately 66 hours postpartum, presumably coinciding with the production of true milk.

Every culture had a substantial proportion of mother-infant pairs who initiated breastfeeding almost 3 days after birth. The authors believe that this demonstrates that there are two distinct "natural" behaviors that are compatible with successful breastfeeding.
The results presented here strongly suggest that there are two distinct behavioral patterns in the timing of the initiation of breastfeeding. We began with a model in which the first subgroup represents a "natural" behavioral pattern, which might reflect a more general mammalian behavior expected to occur in the absence of culturally mediated changes in the onset of breastfeeding. If this first component were purely instinctual, then we would expect that it would not be affected by cultural covariates. Yet many of the covariates had some effect on this first component, some that caused substantial delays in time to onset of breastfeeding. We interpret this to mean that the behavior captured in the first component of the model is more complex than simply instinct. Contrary to a dichotomy of pure instinct for the first component and purely culturally mediated behaviors for the second, the results suggest that the first component is composed of both preprogrammed and culturally mediated behaviors directed toward the newborn.
The authors are not suggesting that breastfeeding initiation be deliberately delayed. They are simply pointing out that existing cross-cultural evidence does not support the claim that breastfeeding is "naturally" initiated in the first hours after birth.

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