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Asian Bioethics Review (2024) 16:249–266 https://doi.org/10.1007/s41649-023-00259-0

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ORIGINAL PAPER

Beyond Public Health and Private Choice: Breastfeeding, Embodiment and Public Health Ethics

Supriya Subramani1

Received: 30 May 2023 / Revised: 22 August 2023 / Accepted: 25 August 2023 / Published online: 26 October 2023 © The Author(s) 2023

Abstract The key objective of this paper is to emphasize the importance of acknowledging breastfeeding as an embodied social practice within interventions related to breast- feeding and lactation and illustrate how this recognition holds implications for public health ethics debates. Recent scholarship has shown that breastfeeding and lactation support interventions undermine women’s autonomy. However, substantial discourse is required to determine how to align with public health goals while also recogniz- ing the embodied experiences of breastfeeding and lactating individuals. Presently, interventions in this realm predominantly revolve around health-related messaging and the promotion of individual behaviors, often neglecting the systemic and struc- tural factors that influence choices and practices. I closely examine breastfeeding interventions in India, in particular Mothers’ Absolute Affection health promotion program, along with breastfeeding narratives. I argue that for such interventions to evolve, they must acknowledge the intrinsic embodied social nature of breastfeeding during their design and implementation. Furthermore, it is important to emphasize that achieving equity and justice objectives necessitates moving beyond the confines of both conventional public health frameworks and frameworks solely centered on private choices. Instead, a more encompassing approach that embraces the concept of embodiment should be adopted.

Keywords Breastfeeding intervention · Public health · India · Lived experiences · Embodiment

* Supriya Subramani [email protected]

1 Sydney Health Ethics, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

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Embracing Breastfeeding Mothers and Lactating Persons

In recent years, numerous studies have demonstrated the many health and social benefits of breastfeeding (Pérez-Escamilla 2020; Sankar et al. 2015; Victora et al. 2016). However, globally, only 41% of infants under 6 months of age are exclu- sively breastfed (Gupta et al. 2019). At 12 months, breastfeeding prevalence is the highest in South Asia, parts of Africa, and Latin America, while it is lowest in high-income countries, and indicators other than early initiation of breastfeeding decrease with national wealth (Victora et al. 2016). There are a number of factors that contribute to this concern, including social, cultural, political, and economic factors. A number of international and national organizations have proposed effective interventions and strategies in order to advance and promote breastfeed- ing. WHO/UNICEF’s Baby Friendly Hospital Initiative (BFHI) is an example.

Breastfeeding and lactation interventions have been criticized for failing to consider the experience and knowledge of a woman and lactating persons (Kukla 2006; MacKay 2021; Preston-Roedder et al. 2019; Shaw 2004; Wall 2001; Wolf 2007). Several scholars have criticized breastfeeding promotion, pointing that interventions have failed to take into account the social and material constraints that significantly influence infant feeding decisions (Barnhill and Morain 2015; MacKay 2021; Shaw 2004; Stearns 1999; Taylor and Wallace 2012; Wall 2001; Wolf 2007). Studies illustrate that mothers are viewed as solely responsible for the health of their children and that they are given moral pressure to breastfeed or risk being labelled as “bad mothers” if they do not (Kukla 2006, 2008; Lee 2018; Leeming et  al. 2013; Wall 2001). In order for breastfeeding interventions to be effective and ethical, women and lactating persons lived experiences and knowl- edge must be acknowledged, as it creates an opportunity for politics of mother- hood and infant feeding within a larger social, economic, cultural, and political context that prevents lactating persons from breastfeeding. Additionally, taking into consideration the social construction of target populations in public health interventions (Schneider and Ingram 1993), I argue that these interventions con- struct a certain target population based on assumptions shaped by ideology, poli- tics, and culture. Women who breastfeed are often targeted and constructed as “good mothers” by “good motherhood” ideology (Burns and Schmied 2017; Lock 2015). Moreover, breastfeeding and lactation interventions require an intersec- tional approach, since gender, class, caste, race, ethnicity, sexual orientation, and any other social identity have an impact on lactating bodies’ experiences within specific social, cultural and political contexts. Taking an intersectional approach to public health interventions such as breastfeeding interventions along with acknowledging the lived experiences of women and lactating persons allows us to critically examine the dominant choice paradigm.

In general, breastfeeding interventions can be categorized into three groups: protection, which limits the sale of infant formula; promotion, which educates and informs individuals and communities about breastfeeding’s benefits; and support, which reduces the social, economic, cultural, and political barriers women face when initiating and maintaining breastfeeding. There is a great deal of criticism

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focusing only on protection, prevention, and promotion interventions, without engaging much with support interventions (Smith 2018). Unless the social, cul- tural, economic, and political conditions of breastfeeding are addressed, desired breastfeeding rates become impossible and exclude the experiences of lactat- ing individuals. One needs to acknowledge that breastfeeding decisions happens within the backdrop of one’s cultural context (Hays 1996). Breastfeeding inter- ventions that target only individual behavior and make women and lactating per- sons feel shame and guilt have been criticized by several scholars recently (Dowl- ing et al. 2018; Leeming 2018; Taylor and Wallace 2012; Thomson et al. 2015). Recently, a Lancet series article emphasized the importance of political economy research that examines structural factors contributing to a lack of breastfeeding support in healthcare systems and, as part of the closing the breastfeeding rate gap, these authors stressed the importance of breastfeeding being regarded as care work (Pérez-Escamilla et  al. 2023). As long as supportive factors are not acknowledged and incorporated, breastfeeding would become a moralizing prac- tice perpetuating the “good mother” narrative (Lee 2018), and thus non-structural approach adopts “framework of blame” especially to mothers (Sridhar 2010).

I briefly discuss in the next section the importance of valuing the embodied lived experiences of breastfeeding women and lactating persons within the context of breastfeeding and lactation interventions. In India, women and lactating persons cite a lack of support systems as a reason for their inability to breastfeed (Jacob 2018; Sridhar 2010; Van Hollen 2003; Van Hollen 2011). So, in the “Missing Maternal Experiences: The Indian Context” section, I will examine how moralizing dis- courses about women and motherhood function within an Indian context and criti- cally evaluate national breastfeeding program—Mother Absolute Affection. In the “Breastfeeding, Embodiment and Public Health Ethics” section, I present normative justifications for acknowledging breastfeeding as an embodied social practice. This recognition has the potential to reshape the perception surrounding breastfeeding advocacy, promotion, and support. These efforts can then effectively contribute to broader public health objectives concerning maternal and infant well-being, tran- scending the dichotomized understanding of public health and personal choice.

Embodied Breastfeeding: Respecting Women and Lactating Person’s Lived Experiences

The concept of embodiment helps us to overcome the dualistic separation of mind/ body or self/other and emphasizes how one’s body is central to being in the world, and how it shapes one’s subjectivity (understanding of oneself and others) and rela- tionship to the world and with others. In other words, embodiment refers to the con- cept of our experiences, perceptions, emotions, and actions being deeply entwined with our physical bodies (Merleau-Ponty 2004). Informed by feminist scholars (Scully 2014; Fineman 2004; Young 2020), phenomenologists (Dolezal 2015; Sve- naeus 2017; Lee 2018; Merleau-Ponty 2004), and political philosopher (Sandel 1998), I see breastfeeding as an embodied social practice that unsettles the notion of subjectivity and demands us to rethink the notion of liberal conception of individual.

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Breastfeeding as a dyadic act inherently involves caring for other/child but at the same time, it makes one bodily practice self-conscious within a particular context. As Hausman (2004) mentions “As a practice, breastfeeding is a daily pattern of embodied living; support for it is a recognition of the reproductive burden women experience through their bodies. p. 276.” The practice of breastfeeding transcends the public-private divide; it is an intersubjective experience. An understanding of breastfeeding based on social position and socioeconomic and cultural context situ- ates mothers and lactating individuals in a relationship to their bodies. The feminist literature sheds light on the larger patriarchal as well as capitalist mechanisms that oppress women and lactating persons and encourage breastfeeding to be viewed as an act of care and empowerment (Binns and Lee 2019; Lee 2018; Leeming et  al. 2013). Understanding this literature and the different perspectives requires a close examination of the lived experiences of breastfeeding women within the contexts in which they find themselves.

In some circles, breastfeeding is considered natural and morally correct. Although many scholars question the idea of “natural” and ask us to reflect on it (Martucci and Barnhill 2018), breastfeeding is still considered natural, causing many women to perceive themselves as “unnatural” or “bad mothers” when they cannot or decide not to breastfeed. Several feminist scholars have argued against this. Surrogacy and IVF, for example, challenge biological and natural conceptions of motherhood. Ide- ology is another significant constraint to breastfeeding. Ideology shapes women’s experiences of their bodies, making them feel like “good mothers or bad mothers.” The low supply of milk is perceived by women as a bodily failing, for example. Mothers’ evaluation of their role, fitness, and values are also influenced by recurring images of a “good mother” and “pure breastmilk” in interventions, policy, and legal discourse. Consequently, addressing dominant ideologies of motherhood and taking into consideration social, economic, and cultural barriers helps realize the right to breastfeed, respect maternal experience, and achieve public health goals.

Often, public health advocates overemphasize medical evidence without address- ing and incorporating the experiences of women and lactating persons in particular context. There has been a great deal of literature that demonstrates the larger struc- tural barriers to breastfeeding, for example the lack of support system when return- ing to work or the difficulties of breastfeeding in public. There is evidence from a number of ethnographic studies that breastfeeding causes women to feel shame, guilt, and anger (Burton et al. 2022; Dowling et al. 2018; Leeming 2018; Taylor and Wallace 2012; Thomson et al. 2015; Tomori et al. 2016). Therefore, breastfeeding experiences must be respected as part of the interventions, going beyond the choice framework and considering sociocultural and economic barriers. Recent studies show that most breastfeeding and lactation interventions are educational, focusing on behavior and action of individuals, rather than environmental or support-based, and they focus primarily on changing individual behavior especially breastfeeding mother or immediate family (Balogun et al. 2016; Khatib et al. 2023; Sinha et al. 2015). Health messaging and counseling, for example.

According to Buchanan (2019), public health interventions can be divided into educational and environmental interventions. The goal of educational interven- tions is to change the knowledge and beliefs of individuals or populations, and the

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goal of environmental interventions is to tackle the social determinants of health. Numerous randomized controlled trials have been conducted on various breast- feeding interventions in an effort to enhance breastfeeding practices. Despite these efforts, the global breastfeeding rate has remained relatively stable at around 40% since 1990. Although it is widely acknowledged that breastfeeding is influenced by a person’s lived experience, sociocultural economic context, and biology (Van Esterik 2012), many global health and public health interventions tend to focus on outcomes and determinants dominantly through educational interventions without much attention to larger systemic barriers. Furthermore, scholars point out that these interventions focus on the product, namely human milk, which is decontex- tualized, medicalized, and disembodied (Giles 2012; Lee 2018). The “one size fits all” approach or lumping all lactating women and bodies together would create a moral space based on how their goals align with public health objectives. In focus- ing only on disembodied agency or choice paradigm, these interventions ignore how women and breastfeeding practices are embedded in larger sociocultural structures. In later “Embracing breastfeeding mothers and lactating persons” section argues that it becomes necessary to take embodiment seriously in public health ethics discourse in order to achieve equity and social justice goals when planning and implementing interventions.

In the following section, I will outline the underlying ideology of Indian breast- feeding interventions. I will illustrate how the promotion effort adopts a choice framework focusing on mothers and their responsibilities as natural and instinctive as they ensure the proper development of their children through Mothers’ Absolute Affection program. Furthermore, by contextualizing the program within the Indian socio-economic, cultural, and political context, I will show it overlooks crucial social, cultural and material obstacles to breastfeeding, and treats breastfeeding as dominantly a mother’s responsibility.

Missing Maternal Experiences: The Indian Context

(Breastmilk is nature’s gift) (Mother’s milk is nectar) Breastfeeding and Breastmilk promotional slogans Department of Health and Family Welfare Services, Government of Karnataka It is similar to the early European ideal of natural motherhood and breastfeeding

as a womanly duty that was valorized by early European scholars (Golden 1996), where identity of motherhood and mothering were important socialisation processes for Indian women, and regarded as natural. In much of Indian literature and mythol- ogy, mother is deified, and mother is a metaphor for nation and language (Krishnaraj 2010; Mitra 2020). In these discussions, the mother’s natural role is to nurture her child, especially a male child. As a reflection on this archetype of the mother, some scholars have critically reflected on how women are viewed as “objects” and breast- feeding becomes a form of labour (Mitra 2020). Breastfeeding is heavily moralized, as we have seen in feminist academic debates in the US, Canada, and UK, as being a “natural and maternal duty” (Shaw 2004; Stearns 1999; Wall 2001; Wolf 2007).

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While recently, it is much admiring to see a passionate push to breastfeeding to transform maternal and childcare (Jindal 2020), especially in rural India, the larger cultural context and the embodied experience of women coming from diverse set- tings is yet to be explored critically.

There are regional differences between breastfeeding practices in India, with the highest prevalence of Exclusive Breastfeeding (EBF), 79.2% at 0–4 months, occur- ring in the southern region and the lowest prevalence (68%) occurring in the north- eastern region (Ogbo et  al. 2019), which is much above the global breastfeeding rate. A significant finding is that exclusive breastfeeding in the south fell faster at 5 months, to 43.7%, than in the north-east (54%). In addition, exclusive breastfeeding and continued breastfeeding rates in urban areas are lower than in socio-economi- cally depressed eastern and north-eastern areas of the country (Ogbo et al. 2019). It has been demonstrated in the global breastfeeding literature that higher income and education are associated with better breastfeeding practices (Birhan et al. 2022; Holowko et al. 2016; Standish and Parker 2022). It should be noted that in India, the relationship between education and breastfeeding is complex. In the southern region of India, higher maternal education was associated with low breastfeeding, whereas in the central region of India, higher maternal education was associated with exclu- sive breastfeeding (Ogbo et al. 2019). This demands us to look critically at existing breastfeeding interventions at national and state levels. According to some studies, there are several reasons for this difference, including obesity among urban women, lack of breastfeeding opportunities, the ability to arrange infant formula economi- cally, increased work involvement, inflexible schedules, and limited childcare leave and concerns regarding privacy or safety (Bhanderi et al. 2019; Ogbo et al. 2019; Ramani et al. 2019). Furthermore, Jacob (2018) highlights through Sridhar’s work on the Tamil Nadu Integrated Nutrition Project that the underlying assumptions of interventions and programs do not accommodate structural inequalities and limita- tions and are based upon narrow biomedical and health economic models. As an example, many women and respondents do not breastfeed due to ignorance, but because of poverty, domestic violence, lack of financial autonomy or the existing labour system (Shroff et al. 2011; Zureick-Brown et al. 2013). While these studies provide important insights into the experience of breastfeeding and lactating indi- viduals, there is a lack of in-depth qualitative research on the lived experiences of lactating persons within the Indian context when it comes to nutrition and breast- feeding research.

Maithreyi Krishnaraj (2010) edited “Motherhood in India: Glorification with- out Empowerment?” which explores the ideology of motherhood in the context of Indian women’s experiences as mothers. There is much evidence in this work that women’s reproductive biology, particularly their ability to bear and nourish children through breastfeeding, has influenced not only the status of women within their fam- ilies and kin groups but also the policy and program of the government (Krishnaraj 2010). In literary texts, motherhood is often depicted as a site of sanctity, purity, and divinity. The Tamil literature, for instance, depicts mothers as possessing certain mystical qualities that enable them to produce “the milk of valour” for their sons. Hence, they are made warriors by infusing their blood with bravery and courage. Present-day rituals and everyday practices surrounding pregnancy and mothering

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revolve around diet, feeding children, movement, place of delivery—all matters that affect the entire family, not just the mother. Experiences of pregnant women and breastfeeding reveal the complex social-cultural context of this process. This is because these practices are embedded in a larger set of cultural norms and values. For example, the type of food a pregnant woman is expected to eat is determined by the culture she is a part of, as is the way she is expected to move and the place where she will give birth. All of these practices are shaped by the culture in which she lives and her family’s expectations, and this influences her breastfeeding practices. The following excerpt from an ethnography from Malad (suburb of Mumbai) by Pandey (2010) best illustrates this point.

Nirmala is a mother of four daughters and two sons. In her caste, the daughter-in- law does not go for the first delivery to her natal home. Nirmala did not observe the caste rules and brought ‘bad luck’ to the family by delivering two daughters. Sub- sequently, the later two deliveries were handled by the mother-in-law who was very superstitious. The last delivery dealt a blow to Nirmala’s health. No one seems to be much concerned about Nirmala’s constant health problems after the last delivery. She has a constant problem of body ache and weakness. ‘I had to breastfeed all my chil- dren till fifteen months. My mother-in-law feels that breast milk increases children’s self-confidence, but this has affected my health,’ she complained. (Pandey 2010, 306)

In India, like elsewhere, breastfeeding in public and the idea of breastfeed- ing among women and the general public raise important questions regarding women’s bodies, sexuality, and parenthood. It becomes a contested space when it comes to the public and private perception of women’s bodies when breastfeed- ing. Recently, a number of incidents have been reported involving breastfeeding in public places. In south Kolkata (Mahara 2018), a young woman wrote about her terrible experience on Facebook and the mall authorities responded as fol- lows: “Funny you found this to be an issue because breastfeeding is not allowed on the floor for a number of reasons… please make sure you do your home chores at home and not in the mall … It’s not like your baby needs to be breastfed at any moment so you need arrangements to be made for you at any public area to breastfeed your child anywhere you wish to … we cannot compromise the pri- vacy of other people in public places can we?”

Breastfeeding leaves contradictory messages regarding women’s breasts and breastfeeding as can be seen from the above excerpt and women’s experiences cap- tured in social media and the news. The concept of privacy is bizarrely understood, and breastfeeding is viewed as a domestic chore that can only be done in a private room or home. It is important to note that the male and sexual gaze on the breast, and responses such as “indecent” and “domestic chore,” private and accommodat- ing others’ perceived comforts restrict women from expressing their right to breast- feed and act as a significant barrier to breastfeeding. It is particularly challenging for urban working women, especially in the informal economy, who do not have the opportunity to breastfeed. In one sense, the act and the breast milk are considered natural, pure, and a sign of maternal love, while in the other sense, they are regarded as impure, indecent, and sexual. It is important to note that when breastfeeding in public is not socially and culturally acceptable, it becomes a vulnerable act that can be distressing for a woman, thus negatively affecting her decision to continue

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nursing. Breastfeeding women and lactating persons experience their surroundings very differently, as the boundaries between private and public spaces blur. For exam- ple, breastfeeding women must negotiate their space and their bodies in the process of breastfeeding. Therefore, identity, power, and social structures have a significant influence on how women negotiate their bodies and make decisions, and thus impact their capacity to exercise their decisions. Generally, it has been difficult for women to occupy public space in India (Phadke et al. 2011; Roy and Bailey 2021), and even those predominant spaces, such as malls, parks, public transportation, and bus stops, are difficult for women to breastfeed since these spaces are experienced differently at various times by women from diverse socio-economic backgrounds.

An online survey conducted by Momspresso (Dhoop 2019), investigated the pri- mary challenges faced by breastfeeding Indian mothers. While most of the partic- ipants who did the survey were middle and upper class, the main concerns were social stigmas, particularly perceived as “shameful, disgrace, indecent or embarrass- ing” as society views the female breast as an object of sexual desire, and the lack of clean and hygienic nursing facilities. As indicated in the survey media (Momspresso 2019) and in several incidents captured by, breastfeeding is perceived as a feminine, private, and domestic activity, which makes it difficult for women to access public spaces and limits their autonomy. Therefore, it becomes necessary to gain a deeper understanding of the experiences and challenges women face within a particular social and cultural context. The need to critically examine how women perceive their bodies and the act of breastfeeding across different socio-economic groups becomes imperative, as well as the challenges they face. While formal female labour participation in India has declined from 32% in 2005 to 19% in 2021 (International Labour Organization 2023), many women are employed in the informal sector and are not documented. In the informal sector, most working women are exposed to exploitation as a result of a lack of formal protections, such as maternity benefits, child care access, and employment protections (Horwood et al. 2020).

Several programs have been implemented by the Indian government to improve maternal and child health, including the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), the Pradhan Mantri Matru Vandana Yojana (PMMVY), the Maternity Leave Incentive Scheme, and the Pan-India Maternity Benefit Program (Kiran et al. 2022). In spite of its strong commitment to infant and young child feeding, India only scored moderately in terms of policies, programs, and practices. As a result of these initiatives, India launched the Mothers’ Absolute Affection (MAA) pro- gram (2016) in order to enhance the skills and capacities of health care professionals so as to enhance their ability to promote, protect, and support women and lactat- ing mothers. The Indian national breastfeeding program “Mothers’ Absolute Affec- tion,” as well as various state government posters, flyers, and advertisements and private organizations aimed at promoting breastfeeding, primarily target individual women’s behaviors and choices. These educational interventions, along with the larger moral climates of motherhood in patriarchal society, suggest that breastfeed- ing and human milk are absolute responsibilities of mothers and lactating bodies and are intertwined with the concept of mothers’ love and affection. The conception of breastfeeding as a symbol of infinite love and selflessness has been criticized by a number of scholars. Guenther (2006) argues that infinite responsibility confirms the

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patriarchal ideal of the self-sacrificing woman, and the moral motherhood associated with breastfeeding. Breastfeeding is not an ethical necessity or an obligation neces- sary to maintain woman’s identity or to be a good mother. The idea of breastfeeding as an embodied social practice allows us to open up a dialogue and challenge the notion of “good mother,” “good woman,” or “maternal body” within a given con- text and reflect on the larger socio-economic, ideological, and political factors that impact lactating individuals’ choices and decisions. Recently, maternal subjectivity is examined within breastfeeding context. Lee (2018), have delved deeply into the ethics of subjectivity and the construction of maternal subjectivity. Lee draws inspi- ration from Levinas proposing that breastfeeding serves as a response to hunger and embodies a sense of responsibility towards the other. Moreover, Lee’s exploration of subjectivity is rooted in the ethical and poetic dimensions of breastfeeding. The pur- pose of this article is not to go in detail about this conceptual and theoretical work, but rather to argue that breastfeeding should be considered as an embodied social practice within breastfeeding interventions and illustrate why it matters to public health ethics debates.

In the Indian context, breastfeeding literature typically focuses on captur- ing breastfeeding rates, as well as identifying the key determinants and barriers to achieve public health objectives and some of them engage in critical analysis of policy (Bha