What If the Biggest Barrier Isn't Milk? Rethinking Breastfeeding Through the Lens of Culture

As we celebrate World Breastfeeding Week (August 1-7), conversations around the world rightly focus on the remarkable benefits of breastfeeding. We highlight its role in infant nutrition, immunity, maternal health, and lifelong disease prevention. These conversations are important and well supported by evidence.

Yet this year, I find myself reflecting on something different.

Not the physiology of lactation.

Not the composition of breast milk.

Not even the mechanics of latching.

Instead, I want to talk about something I have witnessed repeatedly throughout my seven years of clinical practice as a physiotherapist and lactation consultant.

What if the biggest barrier to breastfeeding isn't milk at all?

What if it is the culture surrounding breastfeeding?

Over the years, I have worked with mothers from different communities, religions, languages, and socioeconomic backgrounds. Every family arrives with a different story, yet many leave with remarkably similar fears.

"Doctor, I don't have enough milk."

"My baby was admitted to the NICU for two weeks. My milk has dried up."

"The baby doesn't like the taste of my milk, so we're giving a few drops of formula first."

"I have a fever. I should stop breastfeeding."

These statements rarely reflect a physiological assessment of breastfeeding. More often, they reflect beliefs—beliefs shaped by family traditions, community practices, cultural expectations, and sometimes, even healthcare interactions.

Breastfeeding is a biological process, but breastfeeding decisions are profoundly social.

In many cultures, including my own, a woman does not begin motherhood alone. She is surrounded by parents, grandparents, mothers-in-law, neighbours, friends, and healthcare professionals. Each person genuinely wants the best for the baby. Each offers advice rooted in experience, love, or tradition.

That support can be incredibly valuable.

But it can also unintentionally undermine a mother's confidence.

One observation has stayed with me throughout these seven years.

In many healthcare settings, immediate breastfeeding still does not happen consistently.

The baby is weighed, observed, wrapped, and introduced to family members before anyone encourages skin-to-skin contact or the first breastfeed.

Equally striking is that many mothers never ask to breastfeed immediately—not because they are unwilling, but because no one has prepared them to believe that they can.

The World Health Organization (WHO) and UNICEF recommend initiating breastfeeding within the first hour after birth because early skin-to-skin contact and breastfeeding support neonatal adaptation, stimulate milk production, and improve exclusive breastfeeding rates. Yet implementation often depends on local practices, institutional routines, and cultural expectations rather than evidence alone.

This year's Breastfeeding Week programs revealed another recurring practice.

Several families proudly shared that they first offered "just two or three drops of formula" before breastfeeding.

Their reasons varied.

"The milk hasn't come in."

"The baby doesn't like the taste of breast milk."

"A little formula will satisfy the baby until the real milk comes."

These practices are rarely motivated by neglect.

They are motivated by love.

Families do what they believe is best based on what they have learned over generations.

However, current evidence suggests that, unless medically indicated, unnecessary formula supplementation during the early postpartum period may interfere with establishing exclusive breastfeeding by reducing breast stimulation and maternal confidence.

Perhaps the most emotionally difficult conversations occur with mothers whose babies require admission to a neonatal intensive care unit.

Many tell me that because they were separated from their newborn, they believe breastfeeding is no longer possible.

While separation certainly presents significant challenges, lactation is remarkably dynamic. Frequent milk removal, skin-to-skin care when feasible, and skilled lactation support can often help establish or rebuild milk supply. For many mothers, the greatest obstacle is not physiology—it is the belief that they have already failed.

As physical therapists, we often think of breastfeeding in terms of posture, musculoskeletal pain, ergonomics, breathing mechanics, or pelvic health. These aspects are important and deserve attention. Yet every intervention we provide exists within a larger social context.

A mother's posture can be corrected.

A painful latch can be assessed.

A breastfeeding position can be modified.

But restoring confidence requires something different.

It requires listening.

It requires understanding the beliefs surrounding the mother before attempting to change her behaviour.

Perhaps the most important lesson I have learned is that confidence is clinically significant.

When a trusted healthcare professional says, *"You don't have enough milk,"* those words can become a mother's reality, even before breastfeeding has been fully assessed.

Conversely, when healthcare professionals explain normal newborn feeding behaviour, reassure mothers about colostrum, and provide evidence-based support before recommending supplementation, they help protect not only breastfeeding but also maternal confidence.

Improving breastfeeding outcomes therefore requires more than educating mothers.

It requires educating families.

It requires culturally sensitive conversations with grandparents and partners.

It requires consistent messaging across healthcare disciplines.

And it requires clinicians to recognise that evidence alone does not change behaviour. Trust does.

After seven years of practice, I no longer believe the greatest barrier to breastfeeding is insufficient milk.

I believe it is insufficient confidence.

Confidence shaped by culture.

Confidence influenced by family traditions.

Confidence reinforced—or weakened—by healthcare systems.

As healthcare professionals, we have the privilege of influencing that confidence.

Perhaps the most meaningful intervention we can offer is not another protocol, but a conversation that reassures a mother that her body deserves an opportunity before it is judged.

Because when we protect a mother's confidence, we do more than support breastfeeding.

We strengthen the foundation of maternal and infant health.

References

1. World Health Organization. *Infant and young child feeding.* https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding

2. UNICEF. *Early initiation of breastfeeding.* https://www.unicef.org

3. Academy of Breastfeeding Medicine. *Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate.*

4. American Academy of Pediatrics. *Policy Statement: Breastfeeding and the Use of Human Milk.* *Pediatrics.* 2022;150(1):e2022057988.

Meet the Author

Shyamli Vikas Kulkarni, PT, MPT, BPT, Lactation Consultant, Certified Antenatal & Postnatal Exercise Specialist, Certified Pelvic Rehab Specialist

📍 Pune, India

Dr. Shyamli Kulkarni, MPT (Community Physiotherapy), is an Assistant Professor at MAEER's Physiotherapy College, Pune, India, with over seven years of clinical experience and five years of teaching experience. Her clinical and research interests include pelvic health, women's health physiotherapy, maternal wellness, community-based rehabilitation, and healthy ageing. Through her educational platform, MotherWise, she is committed to improving awareness of pelvic floor health and making evidence-based physiotherapy accessible to women, particularly in underserved communities.