'Following the line' : an ethnographic study of the influence of routine baby weighing on breastfeeding women in a town in the Northwest of England
Weight monitoring is an integral part of routine community child health care in the United Kingdom. An intensive focus on fluctuations in charted weight of young babies has been charged by some breastfeeding advocates with undermining continued breastfeeding. Concern has also been expressed by clinicians and women about the applicability of current growth charts to breastfed babies - a concern echoed by the World Health Organisation. This ethnographic study involved two phases. Six months' participant observation in a child health clinic in the Northwest of England was followed by longitudinal interviews with 14 breastfeeding women. Equal numbers of first and second-time mothers were included; they were interviewed two to three times in the first six months. Data were analysed using grounded theory, allowing an in-depth examination of the lived experiences of weighing and how these shaped on-going feeding decisions and the course of breastfeeding. Weighing babies was the major focus of clinic visits for women and for health visitors. Interactions centred on the concern that the baby's weight should 'follow the line' of the centiles on the chart. Mothers and health visitors also collaborated in efforts to achieve prescriptive routines of baby feeding and sleeping. Breastfeeding was treated as a milk production system, and required to measure up. If weight gain caused concern a variety of strategies were used, including formula supplements and 'worrying'. Techniques to improve the physical effectiveness of breastfeeding were not part of the routine approach to any feeding difficulty on the part of either mothers or health visitors. Using anthropological theory, the character of weighing as a ritual occasion is explored. Weighing sessions are shown to provide occasions to mark the rite of passage through the liminal time of early motherhood. Building on the observation of this ritual experience, it is suggested that the experience of breastfeeding is 'even more liminal', as our society treats formula feeding routines and growth as the implied norm for infants. Weight gain which conforms to chart centiles has become the measure and arbiter of breastfeeding adequacy. Minor fluctuations in weight were treated as potentially serious threats to infant health, while the maintenance of breastfeeding was considered secondary. Recommendations are offered for improving the practical conduct of routine weight monitoring to improve its ability to identify growth which should genuinely spark concern. At the same time, the need for rituals to ease women through their early months of motherhood and the experience of breastfeeding is highlighted. Currently breastfeeding as a method of feeding milk to babies is poorly supported with suggestions for improving physical effectiveness, while at the same time, breastfeeding as a social practice is pushed to the margins of normal everyday experience. This lived dilemma for women and the health visitors who support them deserves attention at national policy level and serious consideration in overall planning of services.