Understanding and enabling breastfeeding in the context of maternal-infant needs.

Understanding and enabling breastfeeding is a public health priority. Although rates of breastfeeding initiation are relatively high in Western countries, exclusivity and duration outcomes are far below public health recommendations and women’s personal goals. In this chapter, we make the case for the use of multi-method research approaches to better understand infant feeding and women’s health experiences in the first three months postpartum, which we conceptualize as the “4 Trimester. ” This transition period is characterized by interrelated maternal-infant health needs that require timely and integrated support. We offer a conceptual model of breastfeeding decisions. This contextual approach to infant feeding focuses on multi-directional influences and the dynamic nature of the balance between self and infant care that women experience over time. The main hypothesis generated from our framework suggests that simultaneously addressing breastfeeding costs and benefits, in relation to how they are experienced by mothers, will enhance the effectiveness of interventions aimed at supporting women to meet their goals. Mothers and their infants are dyads, but mother-infant conflict (as explained by evolutionary parental investment theory), and therefore maternal trade-offs, are also an inherent part of their relationships. Using our research on breastfeeding after childbirth via caesarean section, conversations-based breastfeeding counselling, and the development of infant sidecar bassinets on the postnatal unit, we illustrate how a family-centered perspective that engages with the ways in which women might manage the costs of breastfeeding facilitates improvements in health care. Our studies indicate that we do women a disservice when we do not prepare them for 4 Trimester realities. Introduction Infant and young child feeding is the core of both maternal and child health. For infants, breastfeeding offers immune protection, complete nutrition, comfort, and a nourishing environment (AAP, 2012). For women, lactation is a predictable component of reproductive biology (Lawrence & Lawrence, 2005), is associated with positive health outcomes (Bartick et al., 2017b), and the breastfeeding relationship can be emotionally gratifying. Although rates of breastfeeding initiation are relatively high in the Western countries in which we have worked, exclusivity and duration outcomes fall far below public health recommendations and women’s personal goals (Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2013). In the United States, 81.1% of US mothers initiate breastfeeding, by 6 months postpartum, only 51.8% are still breastfeeding, and at one-year, 30.7% of infants are breastfed (CDC, 2016). Only 22.3% of American infants exclusively receive their mothers’ milk for the recommended 6 months. The United Kingdom displays a sharp drop-off in breastfeeding trajectories (Victora et al., 2016), which, like in the US, reflects significant disparities among sub-populations (CDC, 2013; NHS, 2014). Our objective as applied/medical anthropologists is in generating evidence for practice and implementing sustainable programs to improve the health and well-being of women, infants, and those important to them. Broadly, we are interested in understanding and supporting new families. In Western settings and elsewhere, new mothers experience physical, emotional, and professional challenges that intersect with culture, lived experiences (such as stress and discrimination), and other roles as partners and professionals (Tully, Stuebe, & Verbiest, In Press). The comparative approach of anthropology offers a holistic perspective that helps us to step outside our culturally constructed understandings of optimal health care and parenting practices. With an awareness of cross-cultural, cross-species, and historical investigations, as well as an understanding of developmental processes in context, we are able to imagine how clinical settings and methods of care might differ. For example, we have used evolutionary perspectives and various theoretical frameworks to advance conversations on Sudden Infant Death Syndrome (Volpe et al 2013, Ball & Volpe, 2013) and the contributors to caesarean section delivery (Tully & Ball, 2013a). Further, we are trained in unique skill sets for advancing understanding and support for the complex, multi-level processes known to affect breastfeeding outcomes. In this chapter we describe a theoretical model for considering maternal decision-making regarding infant feeding in Western settings, as well as an exploration of our multi-method anthropological approach for understanding women’s perinatal health experiences. Within Western health care systems, significant variations exist in understandings of birth processes and maternal-infant needs; maternity experiences, parenting practices, and continuing patient care consequently vary in ways that directly impact health outcomes. At the core of these issues is equity – families experience differential access to health care, prioritize their needs differently and face different barriers to achieving personal goals. This focus on underlying contributors to health disparities is vital if we aim to implement programs that support marginalized groups, and thereby elevate care for all. This chapter is focused on translating biocultural perspectives into practice. Understanding and enabling breastfeeding is a public health priority, however mother-infant issues such as breastfeeding are poorly addressed by current systems of care that divide maternal and infant health care across multiple providers (Tully et al., In Press). Below we address strategies for optimizing knowledge and provide examples of ongoing implementation to advance patient-centered, family care where maternal and infant needs are considered holistically. Modeling breastfeeding decisions In considering infant feeding decisions, we have employed evolutionary theory to propose a new conceptual model for how breastfeeding costs and benefits are experienced by mothers, and might be manipulated to facilitate meeting their breastfeeding goals (Tully & Ball, 2013b). Infant feeding is one form of parental investment (Trivers 1972) that requires the investment of extensive maternal time and energy, limiting a mother’s ability to use her time and energy for investment in herself, in other existing offspring, or in future reproductive opportunities. This has been the case throughout mammalian, primate, and hominin existence, although the interconnected physiological, psychological, and behavioral effects of the “4 Trimester” on human mothers (Kitzinger, 1975, Ball and Russell 2012) are often not recognized or supported in contemporary Western settings. A 4 Trimester perspective acknowledges that intensive caregiving is necessitated by infants’ biological needs and requires substantial adjustments and sustained investment by primary caregivers, usually mothers. Infants are as dependent on their caregivers in the weeks and months after birth as they were leading up to delivery. Infants expect to be held and cared for, but our cultural ideology that infants function like little adults is generally mismatched to these needs (Russell, Volpe and Ball 2016). We do not sufficiently acknowledge and facilitate this transition period, in which mothers and infants shape one another’s health and wellbeing (Verbiest, Tully, & Stuebe, In Press). Verbiest and colleagues (In Press) further describe that in practice, clinicians, home visitors, and other practitioners typically assess either the needs of the child or the needs of the woman; instead, we must consider these needs in the context of the dyad. In both the UK and US, many women report having simultaneously positive and negative feelings about breastfeeding (Andrew & Harvey, 2011; Forster & McLachlan, 2010), illustrating that they are negotiating trade-offs over the course of infant and young child feeding. The multi-directional influences that contribute to women’s strength of breastfeeding intent interact with factors affecting their perseverance (Tully & Ball, 2013b). Mothers can devote personal time and effort into breastfeeding their current infant, or they can employ alternate pathways that are less personally costly for infant feeding such as human milk substitutes, donor human milk, or wet nursing. The balance is influenced by factors both intrinsic and extrinsic to the mother-infant dyad. The economic concept of marginal returns is helpful here; in this case, marginal returns on breastfeeding ‘investment’ reflect the degree to which breastfeeding is ‘worth it’ in a given context (Tully & Ball, 2013b). For all women, there is theoretically a maximum ‘profit’ where the difference between the benefit to the infant and the cost to herself is greatest. The hypotheses generated from this model are: (1) reduction in maternal cost (real or perceived) promotes breastfeeding; (2) increase in infant benefit (or perception of benefit) promotes breastfeeding; and (3) reduction in maternal cost and increase in infant benefit (or perceptions thereof) will be more effective in supporting continued breastfeeding than addressing either maternal cost or infant benefit in isolation. We suggest (Tully & Ball, 2013b) that conceptualization of breastfeeding in the form of a cost-benefit model is a useful tool for consolidating existing knowledge and offering testable hypotheses for breastfeeding interventions. Both infant and maternal factors matter for outcomes. The developmental science concept of equifinality (Cicchetti & Rogosch, 1996) is relevant to understanding breastfeeding trajectories because it identifies that the same end state (such as non-exclusive breastfeeding) can occur through a variety of different initial conditions (like reasons for breastfeeding intent) and through different processes (like the particular challenges mother-infant dyads face). Although there is clear evidence of the