Breast-Feeding Advocacy, Risk Society and Health Moralism: A Decade’s Scholarship

Breast-Feeding Advocacy, Risk Society and HealthMoralism: A Decade’s Scholarship

Ellie Lee*University of Kent

Abstract

This article reviews research published this century that engages critically with the mantra ‘Breastis Best’ and the associated expansion of official breast-feeding promotion programmes. In recentyears there has been a marked increase in the number of such studies published. They mostlyexplore experience in English speaking, industrialised countries (the US, Canada, New Zealand,Australia and Great Britain) which are in some social and cultural respects dissimilar, yet wherevery similar developments and problems are detected in regards to breast-feeding promotion. Wehighlight how this exploration of breast-feeding promotion internationally has developed under-standing of wider sociological themes. This scholarship, we suggest, has provided a powerful illus-tration of the relation between risk society (more particularly a heightened consciousness of risk)and the evolution of a code of conduct that regulates behaviour, that has been termed ‘healthmoralizm’. The article covers three themes: ‘Science, risk society, authority and choice’; ‘Publichealth policy and infant feeding’; and ‘Moralization and women’s identity work’. We concludethat the research discussed shows how the sociological imagination continues to shed light on therelation between private troubles and public issues. We also suggest one conclusion that can bedrawn from this research is that official discourse and everyday maternal experience appearincreasingly distant from each other.

Introduction

This article reviews research published this century that engages critically with the mantra‘Breast is Best’ and the associated expansion of official (that is government funded andsupported) breast-feeding advocacy and promotion programmes. There has been amarked increase in the number of such studies published in recent years. Prior to 2000,the most notable (and widely cited) study of this kind was Pam Carter’s Feminism, breastsand breast-feeding published in 1995. This work considered policy developments in Britainand British women’s experience of breast-feeding, and in the book Carter aimed toaddress the fact that (in contrast to childbirth) feeding babies had, ‘triggered little [socio-logical] interest’. Noted Carter, in particular, ‘Feminist energy in relation to the politicsof breast-feeding as provided little challenge to the mainstream preoccupation: how toget more women to breastfeed for longer’ (1995, 1). Her aim was to address this deficitin scholarship, and provide an account that explored sociologically both the ‘mainstreampreoccupation’ with breast-feeding rates, and the reasons why most women do not feedtheir babies in the way policy makers suggest they should (that is, to only breastfeed for aminimum of several months following childbirth).

Since 1995, following Carter’s lead, more sociological energy was devoted to exploringthe issues and problems she identified. The article published in 1999 by British sociologistElizabeth Murphy, ‘ ‘‘Breast is best’’: Infant feeding decisions and maternal deviance’ was

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the first in a series of pieces she wrote on this topic and made an important contribution(Murphy 1999). Murphy linked research about women’s experiences of infant feeding, towider sociologies of risk, public health, and identity. In the United States, also in 1999,Linda Blum published At the Breast, Ideologies of Breast-feeding and Motherhood in the UnitedStates in which she wove together analysis of expert and policy recommendations aboutbreast-feeding, lay breast-feeding advocacy (focussing on the breast-feeding advocacyorganisation La Leche League), media representations of breast-feeding, and issues of‘race’ and ‘class’ in American culture. She took as her starting point the observation that,‘Motherhood and breast-feeding have been and continue to be public matters’ (1999, 2)and concluded that, ‘It matters whether women in the 21st century will have genuinefreedom in infant feeding choices’ (1999, 201). Blum contended that such freedom willonly be possible if the problems of breast-feeding promotion in its present form areexposed and interrogated. The insights of Murphy and Blum have formed a referencepoint for much of the subsequent work.

Since 1999 the ‘mainstream preoccupation’ with getting more women to breastfeed forlonger has remained consistent. Indeed, ever more import has been attached by policymakers and medical authorities internationally to increasing the rate and duration ofbreast-feeding. Health authorities in many countries in the world have developed breast-feeding promotion policies, and also supported initiatives by non-governmental organisa-tions that aim to get more women to start breastfeeding following childbirth and carry ondoing so for longer. The Baby Friendly Initiative (BFI), initiated and administered byWHO ⁄UNICEF, is the most influential project of this kind, and in some countries (forexample England) it is officially recommended that hospitals change their practices in linewith the approach advocated by BFI. Under this scheme, hospitals can be accredited bythe BFI as ‘baby friendly’ if they show they have changed their practices to conform towhat they BFI considers best practice in the provision of hospital care to women in preg-nancy and following childbirth. This includes ensuring, for example, there are no groupdemonstrations offered on the use of infant formula and that individual women who indi-cate they want to feed their baby formula milk are provided with information about whatthe BFI considers to be the risks of doing so. Overall, the aim of the scheme is to pro-vide women with a context in which breastfeeding is represented and promoted as whatis normal and natural, and formula feeding as an artificial and self-consciously chosenalternative to this norm. In turn hundreds of social science papers have been publishedabout breast-feeding this century, and the majority reflect the mainstream assertion that,‘Breast is Best’. Such work considers policy, media representations, or women’s experi-ences of feeding babies, in order to identify barriers to breast-feeding and advocate waysto increase the incidence of the practice.

However, a smaller but markedly different literature on the topic has been publishedthis century. Following Carter, Blum and Murphy this work seeks not to advocate oneparticular form of infant feeding, but rather to research what the imperative to breastfeedtells us about the nature of contemporary society and culture, and explore the nature ofmotherhood in the early 21st century through considering the example of breast-feeding.Such work mostly explores experience in English speaking, industrialised countries (theUS, Canada, New Zealand, Australia and Great Britain) which are in some social andcultural respects dissimilar, yet where very similar developments and problems aredetected in regards to breast-feeding promotion.

We highlight here how this exploration of the example of breast-feeding promotionhas made an important contribution to scholarship by developing understanding of widersociological themes; this scholarship, we suggest, has provided a powerful illustration of

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the relation between risk society (more particularly a heightened consciousness of risk)and the evolution of a code of conduct that regulates behaviour, termed elsewhere ‘healthmoralism’ (Hunt 2003; Rozin 1997). Methodologically, it is notable that the majority ofthe studies considered have qualitative studies of mothers’ experiences of feeding babies attheir centre, from which insights emerge about the larger society and culture. In otherwords, they arguably follow in the tradition of C. Wright Mills (1959) in linking privatetroubles and public issues. In what follows we divide discussion into three themes: ‘Sci-ence, risk society, authority and choice’; ‘Public health policy and infant feeding’; and‘Moralisation and women’s identity work’.

Science, risk society, authority and choice

The mainstream claim made most strongly and frequently about breast-feeding is that inmyriad, proven ways the practice makes for better infant health (Sheehan and Schmeid2011). Evidence shows that formula feeding is harmful to health relative to breast-feeding, it is argued, and so the promotion of breast-feeding is represented as self-evidently necessary and right. In contrast to the notion that ‘Breast is Best’ is in this waya self-evident truth, however, some research has offered a competing perspective and tellsa different story.

US scholar Joan Wolf has recently developed sociological work in an important way(2011a,b). Wolf has brought together commentary on the methodology, findings andarguments of studies about health and infant feeding, with socio-cultural analysis of risksociety in general and contemporary motherhood in particular. Her work is innovative inrelation to the body of work reviewed here, as its starting point is detailed considerationof scientific research about the relation between breast-feeding and child health.

On the basis of this review she demonstrates how a plethora of methodological prob-lems pervade this breast-feeding research, especially in relation to causality. She draws theconclusion that, ‘‘while breastfed babies, on average, do appear to be slightly healthier,the science does not demonstrate compellingly that breast milk or breast-feeding is respon-sible.’’ (2011a,b, 21, our emphasis) Research thus provides the basis for neither the con-tention that a large range of major health benefits accrue from breast-feeding, nor that thechild health benefits that are associated with breast-feeding are caused by this practice. Wolffinds there is reliable evidence coupled with a plausible causal explanation for reducedlikelihood of gastrointestinal infection for breast-feeding. In general she argues, studies donot in contrast demonstrate causality. Rather, there are other possible explanations forassociations identified between breast-feeding and infant health. Some similar points aboutthe causal association between breast-feeding and infant health are also made by Balint(2009).

Wolf asks, on this basis, ‘‘[H]ow have scientists, doctors, powerful interest groups andthe general public come to be persuaded that breast-feeding is one of the most importantgifts a mother can give to her child?’’ (Wolf 2011a,b, xiii) In her search for an answershe turns to sociological theorisations of ‘risk society’ and of ‘the new public health’. Inregards to the former, she takes as her point of departure aspects of arguments made bythe sociologists Beck and Giddens. She highlights the problem confronting individuals inrisk society of how to manage and negotiate uncertainty and the relation between thisproblem and the nature of identity in contemporary culture. Wolf places emphasis on theway that decision-making in everyday life (for example about what to eat, who to have arelationship with) has become both centrally influenced by a consciousness of risk, andalso bound up with identity formation. From this perspective, her account of ‘the new

1060 Breast-Feeding Advocacy, Risk Society and Health


public health’ (Government led interventions purporting to improve health that empha-sise the need to change individuals’ lifestyle) emphasises arguments that perceive contem-porary public health programmes as highly individuating. Their point she contends, assuch programmes advise on how to reduce risks to health by changing habits and choices,is to encourage us all to, ‘internalize norms of appropriate behaviour, assume the onus ofself-administration, and expect the same from others’ (Wolf 2011a,b, 61).

By utilising these ideas, she explores the reasons why any possibility that risk to childhealth can be reduced by individual action by mothers is likely to be validated by con-temporary culture regardless of whether the scientific evidence is uncertain and evenimplausible. Through use of the concept ‘total motherhood’ Wolf explores in particularhow this emphasis on personal, maternal responsibility for reducing risks to health is sig-nificantly amplified when the risk concerned is to the health of the child, including whenstill ‘unborn’. ‘‘Total motherhood’’, she writes, ‘is a moral code in which mothers areexhorted to optimize every aspect of children’s lives, beginning with the womb’ (Wolf2011a,b, xv). ‘Breast is Best’ clearly emerges from Wolf’s work as a mantra better under-stood via the sociological imagination than through what medical science can tell us. Itappears less an incontrovertible fact, than a cultural trope that speaks to particular, con-temporary constructions of the mother, the child, personal responsibility, and power tomanage and control risks to health.

The relation between ‘scientific evidence’ and wider socio-cultural developments isalso a theme in other work. Jansson (2009) emphasises the contribution of definitiveclaims about the health benefits of breast-feeding for the legitimation of the work ofinternational organisations involved with health promotion. She notes that this ‘medical-ization’ of infant feeding encourages ‘depoliticisation’ of gender relations by allowingbreast-feeding to be constructed as a universal good for women, babies and the widersociety across the world. With a focus on Britain, Lee and Bristow (2009) also suggestbreast-feeding advocacy can viewed as an example of medicalization. They suggest thatthe authority of science and medicine is frequently borrowed by pro-breast-feeding lob-byists and campaigners who are, notably, in other ways hostile to medical science, forexample when it comes to childbirth. The use of the authority of science is a key themein Charlotte Faircloth’s investigation of attachment parenting (2010b). She shows howmothers who breastfeed their children for lengthy periods of time make very strongclaims about ‘what science says’ as a means to validate their particular orientation towardmotherhood.

In different ways, these studies commonly detect that it is scientific authority (ratherthan the generally uncertain and inconclusive findings of scientific research) which plays acentral role in breast-feeding promotion. For socio-cultural reasons, the claim ‘sciencesays’ trumps other notions about the merits of particular ways of feeding babies. A keyissue considered by these, and other, scholars, is the relation between such ‘scientisation’of parenthood and other forms of authority. Some have argued in this vein that thede-authorisation of the mother is the most important outcome of the scientisation of breast-feeding. Following Blum, the idea here is that the freedom of the mother to shape hermothering practices is compromised. As noted above, Wolf uses the term ‘total mother-hood’ in her account of this development. Others use the term ‘intensive motherhood’,with reference to Sharon Hays’ study The Cultural Contradictions of Motherhood (1996) (Leeand Bristow 2009; Wall 2001). From this perspective, breast-feeding promotion is alsounderstood as one part of a wider cultural trend in which providing parents (especiallymothers) with ‘expert’, and ‘scientific’ guidance about how to look after their childrenhas become central to modern parenting (Faircloth 2009; Lee et al. 2010).



Change and continuity is a theme in the relevant research exploring this idea, withsome noting historical continuity (Pain et al. 2001). The scientisation of infant feeding is,‘‘[J]just one aspect of the growing involvement of professional experts in all aspects ofchild-rearing and family life throughout the twentieth century’’, contends Murphy in herpiece on risk society and maternal ideology (2004, 207). Some emphasise, however, thatthe ‘rules’ governing parenting practices have become more extensive in recent years, andpolicy makers in particular have sought to play a far larger role in shaping parental behav-iour on allegedly ‘scientific grounds’ (Furedi 2008; Lee 2011). This literature describescontemporary culture as one that requires that the parent – the mother especially – payserious attention to scientific and expert guidance about ‘parenting’ in order to reducerisks to child health and welfare. Contemporary culture is thus one that requires parentsto agree – even if they do so ambiguously – that they will always put the child (and‘unborn child’) first, but also that they do not know best about what makes childrenthrive, and so will turn to experts and the evidence they provide to guide their parentingpractices.

For this reason, the question of what counts as ‘evidence’ is a theme in some work, inparticular that which considers of the provision of information to women. According toKnaak, policies regarding ‘informed choice’ should mean that women are provided withinformation that presents a fair and honest account of evidence about alternatives, to assistthem to come to a decision about a course of action. Yet ‘choice’ in infant feeding meth-ods is no longer something that is ‘actual’ she suggests, meaning individual mothers mightlegitimately decide between two alternatives each with benefits. There is, rather, acontext of what she terms ‘constrained choice’ because the evidence about the mainalternative to breast-feeding (formula feeding) is predominantly represented in very nega-tive ways (Knaak 2005; see also Knaak 2006, 2010). ‘‘[I]n general there is a failure toappropriately contextualise risk and benefit’’, found Knaak, of information she analysedprovided to Canadian women (2006, 413). She suggests, on the basis of her analysis thatbreast-feeding promotion is perhaps more accurately understood as a form of advertisingbreast-feeding, than of balanced education. The gap between what is represented as theobvious ‘informed choice’ a mother should make on the basis of ‘scientific evidence’about risk, and what qualitative research suggests about the lived reality of feeding babiesfor mothers is highlighted in work of this kind. North American ‘risk-based’ breast-feeding promotion programmes claiming to assist women make ‘informed choices’ havespecifically been the subject of important critiques along these lines (Kukla 2006; Wolf2007, 2011a,b).

The lived experience of breast-feeding was placed centre stage in the seminal work ofCarter (1995) and Blum (1999), who both explored the experience of groups with lowrates of breast-feeding (both researched white working class women and the latter addi-tionally researched working class African-American women). Their accounts of structuraland cultural influences that meant breast-feeding was not ‘best’ for these women, but wasin contrast for a variety of reasons ‘risky’, provide rich insights. Overall, research hashighlighted the dissonance between the determined focus on the importance of breast-feeding for reducing risks to child health and what Knaak describes as the ‘other healthand mothering considerations’ which mothers have to manage and address (Knaak 2006).

The need to address pain, discomfort and tiredness feature prominently in some moth-ers’ accounts of breast-feeding and explain the decision made by many to formula feed(Bailey and Pain 2001; Lee 2007a,b; Miller et al. 2007; Murphy 1999; Murphy et al.1999; Schmeid and Lupton 2001; Stapleton et al. 2008). Tensions between the socialnorm of mothers doing paid work and breast-feeding are identified, and formula feeding



from a fairly early point after birth appears to be ‘an inevitability’ rather than ‘a choice’for some for this reason, argue Pain et al. 2001. Other studies report a positive identifica-tion with paid work on the part of mothers, with formula feeding considered a valuedmeans to an end (Lee 2007b). Feeding a baby with formula milk rather than breast-feed-ing is described by some mothers as having benefits (rather than risks) in other ways,providing a means of ‘getting back to normal’, ‘having freedom’ from the baby, re-estab-lishing their identity as ‘non-mothers’, and as ‘convenient’ and ‘easy’ (Earle 2002; Lee2007b). Paternal involvement is identified in some research as a positive reason womengive for formula feeding, both to enable the work of infant feeding to be shared, and alsoas a pleasurable and so valued aspect of parental experience (Earle 2000; Pain et al. 2001;Schmidt 2008). In all of these ways, formula feeding emerges as a way of reducing or man-aging risks of various kinds, suggesting a significant dissonance with mainstream represen-tations of ‘evidence’ about the practice.

Public health policy and infant feeding

The evolution of government policy about breast-feeding is a topic of academic interest.Contributions that have analysed the history of policy in this area detect continuity, iden-tifying a long-standing tendency to represent individual maternal behaviour as an impor-tant cause of major health and social problems. Changing the way mothers feed theirbabies, it is thus argued, was perceived by policy makers in the past as well as in the pres-ent, as a way of addressing and ameliorating these problems. In this way, infant feeding isconsidered to stand as a paradigmatic example of the wider tendency of modern societyto individualise social problems, and seek solutions through interventions that influencepeople at an individual level (Balint 2009; Murphy 1999, 2004; Wolf 2011a,b). Yetalthough significant continuity has been identified in this way, attention has also beendrawn to notable changes in the way attempts to influence maternal behaviour have beenjustified and enacted.

In Britain in the late 19th and early 20th centuries, as political concern grew aboutinfant mortality and morbidity, the education of ‘ignorant’ mothers who did not breast-feed but used wet-nurses was represented as a route to improving the health of the nationand halting perceived ‘national decline’ (Carter 1995; Murphy 2004). Whilst ‘‘politicallyexpedient’’, this rendered ‘‘other sources of infant morbidity and mortality less visible’’,explains Murphy (2004, 205). Studies of other Western countries have drawn attentionto similar developments historically, where the propensity of women to breastfeed and‘the state of the nation’ were connected in the political imagination. Maternal attitudesand traits including vanity, ignorance and selfishness were the subject of concern andeducational initiatives (Kukla 2005; Wolf 2011a,b). Taking into account very obvious dif-ferences between the past and the present (including huge declines in infant mortality andmalnutrition, and the emergence of infant feeding with formula milk as the main alterna-tive to breast-feeding) the following observations have been made about later policy mea-sures.

Carter (1995) showed how breast-feeding rates featured in a new way in the contextof the rise of ‘health inequality’ as a policy concern the 1980s (as part of ‘the new publichealth’ referred to above). The framing of the problem of breast-feeding rates by thistime as one of ‘inequality’ was an important development, with international relevance.In general, the language used about women who do not breastfeed at all or for very longwas no longer explicitly negative; ‘non breast-feeders’ were not labelled ‘ignorant’ by thistime, as they had been earlier in the 20th century (Carter 1995, 61). Rather, they were



(and have continued to be) construed ill-informed and under-supported by breast-feedingpromotion initiatives. Recent efforts to increase breast-feeding rates thus make referenceto increasing ‘awareness’, and providing ‘information’ and ‘support’, rather than crusadingagainst ‘ignorance’ and ‘carelessness’ (Murphy 2004). However, the individualisation ofhealth problems continued, it is argued, despite this shift, as it was maternal ‘habits andattitudes’ that were the main focus for ‘new public health’ initiatives, rather than struc-tural and material conditions that might impact on health (Jansson 2009; Murphy 2003).Contemporary approaches thus remain fundamentally consistent with the past, in thatthey leave these conditions unaffected.

Breast-feeding promotion policy has thus been critiqued because of the connection itmakes between addressing health and social ‘inequalities’, and changing the way womenfeed their babies. Scholars have also drawn attention to the way such policy can generatea view of society that effaces the reality and effects of inequality, by failing to be honestabout what is required if women are to breastfeed exclusively for many weeks. ‘‘Suchsupport [provided by breast-feeding promotion programmes] is generally just verbalencouragement and advice’’, states Murphy (2004, 207). Set against this, she contends, amother’s ability to meet the demands of exclusive breast-feeding, ‘‘is inextricably linkedto the availability of human and material resources’’, which include someone else takingon running the home, looking after other children, and giving the mother time to rest.This point is made particularly strongly in studies of US risk-based campaigns referred toabove, and the way they (mis)represent the lives and experiences of low-income women.These critiques of some breast-feeding promotion initiatives make powerful points aboutthe way they poor mothers, who have very limited material and social resources, are con-strued personally responsible for their children’s health and other problems by these initai-ves, because they do not breastfeed enough (Kukla 2006; Wolf 2007, 2011a,b).

Jannson’s interesting contribution about policy at an international level, which explainshow, ‘individual behaviour rather than structural problems’ is central to policy-making,also explores this point (Jansson 2009). Drawing on the work of the US sociologist LindaBlum (1999), this commentary draws attention to the way that the language of support,protection, and empowerment of women and children is especially notable in breast-feed-ing promotion policies developed by the World Health Organisation and other interna-tional agencies. One important point made in this analysis is that within this framework,women’s willingness to breastfeed, ‘is assumed’, with their failure to do so consideredentirely a product of the negative influence of, ‘a bottle feeding culture’ which they arevictims of. In this approach, women are considered empowered through schemes thatcombat a ‘bottle feeding culture’ (see also Lee and Bristow 2009). Hence their breast-feeding behaviour is ‘constructed as a means to an end’. The idea ‘of mothers as a meansfor someone else’s wellbeing’, and ‘as tools’ for the implementation of policy seeking toaddress social problems (including global inequality), are ‘made fully legitimate’ throughtheir iteration in international policy (Jansson 2009, 245).

Moralisation and women’s identity work

The idea that there is a ‘moral context’ for infant feeding is upheld by virtually all studiesabout maternal experience. Miller et al. (2007) suggest this is a dominant theme thatemerges from the qualitative literature:

The literature suggests that perceived societal and peer pressure, the expectations of health pro-fessionals, and feelings of guilt and concern over the need to be a ‘‘good’’ mother profoundly



shape not only the decisions and practices of women but also the accounts they offer of these(2007, 216).

Research has detected, notably, that infant feeding is frequently experienced this way,regardless of the actual feeding strategies mothers adopt. Pain et al. (2001) note that themothers in their study, some of whom formula fed and some of whom breastfed:

[F]elt under pressure to live up to certain ideas about good mothering. Frequently they feltjudged by others, including health professionals, friends, family members and strangers. (2001,265)

How a baby is fed constitutes in this way a ‘measure of motherhood’ (Kukla 2009) andthe ‘identity work’ mothers perform because of this is explored in several studies (forexample Murphy 1999).

The concept of ‘identity’ has a long trajectory in the social sciences (Giddens 1991;Jenkins 1996; Mead 1934; Strathern 1992; Stryker 1968) and is a term typically used todenote an individual’s comprehension of selfhood. In particular, there has been a focus inthe literature on the ways in which individuals (and indeed groups) constitute their iden-tity in negotiation with wider society. For Stryker, for example, the purpose of ‘identitynegotiation’ (that is, between individual and society) is to develop a consistent set ofbehaviours that reinforce the identity of the person within the wider social context (Stry-ker 1968). To this end, much of the literature around infant feeding has focused on theconcept of ‘identity work’ (which comes via Goffman 1959) as a means of exploring themechanisms by which this concept of identity is discernible. Whilst ‘identity’ itself maybe an abstract entity, its manifestations and are often open to view: in language, dress,behaviour, use of space and so forth. During social encounters individuals assert elementsof their identity through these mechanisms, and it is in this sense that ‘identity work’ isused to refer to the range of activities individuals engage in to create, present and sustainpersonal identities, with particular reference to the constitution of selfhood.

In work exploring motherhood, ‘identity work’ is associated with the widespread sensethat ‘good motherhood’ is linked with infant feeding practices and decisions; studies illus-trate the emotionally demanding ‘struggles’ of mothers working to maintain their identityas good mothers (Avishai 2011; Lee 2007a,b; Murphy 1999). The evidence, explainMiller et al.:

‘‘[P]oints to the struggles that women engage in to maintain their status as ‘good mothers’which lead them to produce accounts of infant feeding aimed at protecting the moral defensi-bility of their decisions and practices, regardless of what these are.’’ (2007, 224)

Some have drawn attention to the paradox that women can face when they are discur-sively encouraged to breastfeed by policy agendas and medical authorities, and then leftwithout sufficient practical support to make this feasible. Wallace and Chason, for exam-ple, found in their research that, ‘Mothers described a classic ‘‘double-bind,’’ with socialsettings and norms working against messages from medical authorities that ‘‘breast isbest’’ ’ (2007, 405). Other work focused on women’s decision-making around formulafeeding has shown that starting to formula feed is often experienced as an extremely pow-erful challenge to a mothers’ positive sense of their mothering practices (Lee 2007a,2008; Murphy 1999; Stapleton et al. 2008). It has therefore been argued that the normal-ity of formula feeding (in Great Britain, the US, Canada, Australia and New Zealand amajority of women formula feed wholly or in part before official guidance recommendsthey should) offers little protection against the power of professional and policy-based



presumption that deem this feeding method inferior and even risky to child health (Mur-phy 2003).

At the other end of the spectrum, research has shown that the official validation ofbreast-feeding and the relentless stream of initiatives to promote it and change behaviourdo not, in fact, make the experience of women who breastfeed unproblematic. On thecontrary, the small percentage of women who do breastfeed according to policy recom-mendations (exclusively for 6 months, and up to 2 years or beyond, in conjunction withother foods) sit at a juncture between affirmation and marginalisation, highlighting a sig-nificant dissonance between statistical, ideological and cultural norms. Feelings of stigmat-isation and isolation are reported by women who breastfeed toddlers and older children(Faircloth 2010b). Related literature considers the identity work women do to justifybreast-feeding in familial or community contexts where bottle feeding is considered lesstroublesome than breast-feeding; where mothers breastfeed for longer than a few months;and where breast-feeding is not going to plan, meaning that babies are not gaining weightvery fast (Bailey et al. 2004; Murphy 2004; Marshall et al. 2007; Faircloth 2010a,b).

The major point to emerge from this literature is the observation that the need to per-form identity work to uphold moral status pertains regardless of how women actually feedtheir baby. Those who breastfeed for a relatively lengthy period are susceptible in thesame way as those who formula feed from birth to accusations that they are harming theirchild, albeit on different grounds. However, research suggests that common features thatshape the experience of mothers are rarely articulated. Rather ‘scientisation’ amplified bypolicy initiatives discussed above appears to have proceeded in a way that amplifies ten-sions between various ‘tribes’ of mothers (Faircloth 2010a,b).

One striking contribution illustrating this point comes from Crossley (2009). She usesher own experience to draw attention to how internalised cultural expectations regardingbreast-feeding can play out. She describes the ordeal of accepting her ‘failure’ as a motherby formula feeding, in the face of her baby consistently failing to gain enough weightover a period of 12 weeks’ exclusive breast-feeding. Her account includes importantinsights about how this ‘failure’ made her feel. She draws the conclusion that breast-feed-ing has become for some women an activity, ‘‘fraught with tension’’, as a ‘‘normalisedmoral imperative’’. Crossley also identifies how infant feeding decisions and practices canimpact on relations between mothers:

‘‘It is not surprising that I felt that the other women in my [National Childbirth Trust] groupwould think of me as a failure. After all this is how I had privately judged others who had failedin their attempt to breastfeed’’ (2009, 82).

Others have also noted how mothers covertly (and sometimes overtly) make moralisedjudgements about each other based on how they feed their babies (Knaak 2005, 2010;Lee 2007a,b).

One important outcome presently associated with breast-feeding promotion, the litera-ture thus suggests, is that some mothers have come to consider feeding babies as notonly a task but as a project closely bound up with the development of their ‘identitywork’ as a certain sort of ‘good’ mother (Avishai 2007, 2011; Knaak 2010; Kukla 2009).Some have internalised the idea that how babies are fed is a legitimate measure of moth-erhood, and they consciously or unconsciously judge other mothers accordingly. Thusdeparting in feeding practice from what is ‘best’ – breast-feeding – is not experienced asacceptable and uncontroversial on pragmatic grounds, but as somehow symptomatic ofan individual woman’s failure as a mother. One interpretation of this finding is that as



long as heightened concerns regarding the effects of feeding practices for child welfareare so strongly validated, including through policy, women will find it difficult to gainacceptance of their choices and decisions from others.

Conclusions

In this article we have discussed three linked themes that emerge from the literatureconsidered: ‘Science, risk society, authority and choice’; ‘Public health policy and infantfeeding’; and ‘Moralisation and women’s identity work’. The research discussed showshow the sociological imagination continues to shed light on the relation between privatetroubles and public issues. Following the lead of the seminal work done by Carter(1995), Blum (1999) and Murphy (1999), scholarship this century about breast-feedingpromotion has shown how well-designed, sensitive scholarship about a very everydayexperience can tell us a great deal about the nature of our society more generally. It hasshown clearly that there are important tensions between the ‘mainstream preoccupation’with increasing breast-feeding rates and the experience of mothers. One conclusion thatcan be drawn is that official discourse and everyday experience appear increasingly distantfrom each other.

Acknowledgement

I would like to thank my colleague Charlotte Faircloth for her input into the paper in itsvarious incarnations, and especially for her comments on identity and identity work.

Short Biography

Ellie Lee is a Senior Lecturer in the School of Social Policy, Sociology and SocialResearch at the University of Kent, England. She is Director of the Centre for ParentingCulture Studies, based in the School https://blogs.kent.ac.uk/parentingculturestudies/.She worked previously as a Research Fellow at the University of Southampton. She haspublished studies about abortion, contraception, teenage pregnancy, and motherhood,and her research addresses the sociological themes of the construction of social problemsand the process of medicalization. Her published work includes the monograph Abortion,Motherhood and Mental Health: The Medicalization of Reproduction in the U.S. and Britain(2003, Aldine Transaction), and papers in journals including Sociology of Health and Illness,Health, Risk and Society, Sociological Research On-line and International Journal of Law, Policyand the Family. She is currently working on studies about infant feeding, alcohol andpregnancy, the provision of assisted conception services, abortion counselling, and parent-ing policy.

Note

* Correspondence address: Ellie Lee, SSPSSR, University of Kent, Cornwallis NE, Canterbury, Kent CT2 7NY,UK. E-mail: [email protected]

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