Introduction
It's time that we abandon simple solutions and simple slogans, and grapple with the nuance. (Hinde, 2017)
Breastfeeding has become a major global public health priority, with concerted efforts well underway to raise rates across the world (WHO and Unicef, 1989; WHO, 2003). However, only 37% of infants on average are exclusively breastfed at six months in low- and middle-income countries, where the protective effects of breastfeeding for infant and child health are well known. Over 80% of infants are initially breastfed at birth in high-income countries but by the end of the first year, this has dropped to an average of 20%. The UK has one of the lowest rates in the world, with less than 1% of infants breastfed at 12 months in 2010 (McAndrew et al, 2012), in contrast to 27% in the US and 35% in Norway (Victora et al, 2016). The relationship between breastfeeding and global economic inequality is clear from the recent comparative work carried out by Victora et al, which demonstrates that ‘for each doubling in the gross domestic product per head, breastfeeding prevalence at 12 months decreased by ten percentage points’ (Victora et al, 2016: 477).
Local inequalities also shape patterns of breastfeeding. The relationship between rates of sustained breastfeeding and patterns of inequality are well known within the UK (McAndrew et al, 2012). Those most likely to breastfeed are mothers from all minority ethnic backgrounds, and women aged 30 or over in managerial or professional occupations with educational qualifications beyond second level (McAndrew et al, 2012). Regional dynamics are also significant: Northern Ireland has the lowest rates of breastfeeding of the four UK countries, and consequently the world.
Public health researchers have examined the relationship between breastfeeding attitudes and social inequalities (Miracle and Fredland, 2007; Strong, 2013), the physical challenges to breastfeeding (Kelleher, 2006; Ryan et al, 2013), and the effects of medicalisation (Thompson et al, 2011). Emotional support from family and friends (Wambach and Cohen, 2009), and practical support from health professionals, male partners and employers is important for developing effective interventions to improve breastfeeding rates (Chuang et al, 2010; Dykes and Flacking, 2010; Van Wagenen et al, 2015).