The Issue of Breast Massage and Milk Quality in Japan:
When Cultural Perspectives Differ
From: LEAVEN, Vol. 43 No. 1, January-February-March 2007, pp. 10-12
Many Japanese mothers believe that breast massage by midwives and/or breastfeeding counselors is universal around the world. They are surprised to hear that this massage practice is unique in Japanese culture and that Western mothers successfully breastfeed without it. In Western cultures, however, there is a tendency for some people to view medical and health-related topics from Asia as a more holistic approach to treating the human body.
LLLI-published Facts about Breastfeeding 2005 carried this introduction to several new studies: "Current scientific investigation discovers new information, validates previous research, and discredits non-research based practices." Under this heading there is an abstract of a study about the Japanese Oketani method of breast massage. Quoting from Facts about Breastfeeding 2005:
The Oketani method of breast massage, widely used in Japan and other Asian countries, changes the composition of human milk by increasing total solids, lipids, and casein concentration. Oxytocin and prolactin are thought to increase gross energy and lipid content, satisfying the infant and resulting in improved growth and development. Increased fat content may also induce an anti-allergic effect. (Foda, M.I. et al. Composition of milk obtained from unmassaged versus massaged breasts of lactating mothers. J Ped Gastro Nutr 04-5; 38(5):484-87.)
This particular abstract has raised concerns among LLL Leaders in Japan who are accustomed to receiving calls from mothers anxious about the quality of their milk. The Leaders are concerned that it may suggest that LLLI not only endorses breast massage, but also the Oketani method and theory of milk quality.
Why the Quality of Milk Matters to Japanese Mothers
In Japan, LLL Leaders often hear breastfeeding mothers make such comments as, "My baby cries a lot. Is the quality of my milk poor?" Or, "My baby bit me, probably because my milk tasted bad (or salty, or too sweet, or bitter, etc.)." The Leaders also hear mothers say, "I got a breast infection because what I ate yesterday may have caused my milk to turn bad." Or even, "I was told that feeding on demand would make my milk quality bad, and my baby would suffer." The list goes on and on.
The reason for this focus on milk quality is that many Japanese people believe that it can vary from good to bad. Japanese people living outside Japan may also have similar beliefs. Their thoughts are that if the milk is bad, then the baby may gain less weight, cry a lot, sleep too much, bite nipples, refuse breasts, or get a rash. There are several books and Web sites that tell mothers they need to improve milk quality for successful lactation.
The Oketani Theory and Method of Breast Massage
Breast massage for lactation purposes has been widely used in Japanese culture. Most Japanese people still believe that breast massage is essential for the mother to produce enough milk. The Oketani method of breast massage is one of the most famous methods. It was named after a midwife, the late Sotomi Oketani, who invented it. As other massages were often performed by unskilled people and might be painful, her method was considered painless and, so, was greatly welcomed by mothers. She and her successors developed the unique theory that the quality of milk could be enhanced by special breast massage. Mothers are encouraged to receive breast massage regularly during lactation to maintain the condition of the breasts and/or the taste of the mother's milk. The mothers have to pay for the massages.
Sotomi Oketani attended the LLLI Conference in 1983 and impressed people with her breast massage skills. Although the Japanese medical community has generally regarded the Oketani theory as unscientific, some enthusiastic doctors value this method of breast massage. However, the Oketani theory is not limited to breast massage and some of it clearly contradicts La Leche League information and recommendations.
According to the original theory, a mother needs to breastfeed her infant every two-and-a-half to three hours, day and night, depending on her natural "let-down" feelings. As explained in Sotomi Oketani's book, the "let-down" feelings should be felt every two-and-a-half hours if the breasts are in normal condition. Again, if they are normal, they should be producing bluish white milk with a good taste. Mothers are encouraged to look at their milk's color and to taste it. Furthermore, a mother is supposed to wake up her baby on schedule even if he sleeps during the night. Natural weaning is not considered a good choice because feeding at intervals of more than three hours during the weaning process would make the milk bad. It is suggested that mothers wean abruptly once the baby can walk. In order to keep milk quality good, breast massage by Oketani-certified midwives is recommended. She also mentions that frequent breastfeeding prevents monthly periods (Oketani 1985).
As time passed, some Oketani-certified midwives realized the importance of evidence-based consultation. Several of them studied to become International Board Certified Lactation Consultants (IBCLC). Many of them now agree with the importance of cue feeding and a mother's right to choose natural weaning. While they are proud of their breast massage skills, some are skeptical of the idea of milk quality. Some Oketani-certified midwives no longer advise scheduled feedings, low-calorie diets (another component of the Oketani theory of milk quality), and/or abrupt weaning.
However, many other Oketani-certified midwives still maintain the theory of milk quality. They have tried to prove that their method enhances milk quality and have conducted several studies over the years. In most of these, they examined breast milk quality just before and immediately after massage (Japan Society of Breast Feeding Research 2005). Several health professionals have questioned the results of their research because the research has no control and the expressed milk before and after the massage reflects the difference between foremilk and hindmilk (Seo 2005). In a regular course of Oketani breast massage, milk is hand expressed by the midwives. Mothers report that the taste and color of their milk differ after massage. This may not be so much a result of the massage, but naturally reflects the difference between foremilk and hindmilk.
Statement from La Leche League Japan
One of the reasons mothers receive breast massage is to improve milk quality. Readers of Facts about Breastfeeding 2005 may ask their local LLL Leaders if LLLI endorses the Oketani method of breast massage. Leaders need to explain that LLLI does not endorse or recommend Oketani breast massage, or any other method of breast massage.
La Leche League Japan does not recommend or endorse Oketani breast massage because its effectiveness has not been scientifically proven. While the study Composition of Milk Obtained From Unmassaged Versus Massaged Breasts of Lactating Mothers appeared to validate the theory that the Oketani method of breast massage enhances milk quality, a professional researcher has raised questions about its validity. After publication of the abstract in Facts about Breastfeeding 2005, a review found that the original paper was not scientifically valid and its conclusions overstate its results (Hammerman, unpublished, 2005).
Daredemodekiru Bonyuikuji, the Japanese edition of THE WOMANLY ART OF BREASTFEEDING, is adapted from the 1997 English edition and reflects Japanese cultural beliefs where many mothers worry about milk quality as well as its color and taste.
Your body adapts to milk-making in many ways that are unseen. Just as with pregnancy, this is a time to marvel at how your body knows just what to do to nourish your baby. One thing you don't have to worry about is your milk. How much milk you make is controlled by how much your baby nurses, and how long he nurses. The quality of mother's milk is also something you can depend on. It is you who can make perfect milk for your baby, including nutrients and immunity. The colors and tastes of your milk change each feeding and even within one feeding as it goes from foremilk to hindmilk. Therefore your breastfed baby can experience a variety of tastes. For example, colostrum contains more sodium and may taste salty, but it is very important because it contains so many immunities. Sometimes the milk of mothers who have a breast infection may change in taste, but it is all right to nurse frequently as the milk contains factors (antibodies) protecting babies from the bacteria that may be causing infection. In some instances, a food that a breastfeeding mother eats will cause a reaction in her baby who may have a strong tendency toward developing allergies. But the quality of the mother's milk itself is not bad." (Daredemodekiru Bonyuikuji 2000)
While some mothers report they benefit from receiving professional breast massage, some of them become confused by the accompanying advice, such as scheduled feedings and strict diet, and lose self-confidence. Mothers need to know that "rules" suggesting strict diets and scheduled feedings are not absolute, but one opinion among many. Most mothers can enjoy breastfeeding without special rules, unless they have medical problems or unique situations. When the subject of breast massage is raised, many Leaders say,:
LLL recognizes that many mothers have been helped by midwives who massage their breasts. On the other hand, we know that many mothers can enjoy breastfeeding without special care, especially when they have correct information and supportive persons such as their families, friends, or La Leche League Leaders. (Eguchi 1998)
Often, mothers who have received advice about milk quality may be confused or perplexed when they see the difference between the information from La Leche League and what others have told them. Leaders suggest that mothers respond to baby's feeding cues, watch their baby and not the clock, and eat a variety of foods, as described in THE WOMANLY ART OF BREASTFEEDING. LLL Leaders always assure mothers that their milk is perfectly suitable for their babies, while trying to empower them to trust themselves and overcome any feelings of guilt.
Some Japanese mothers who live outside Japan may have the same concerns, and Leaders may be asked about milk quality and the necessity of breast massage. In these situations, Leaders need to acknowledge the mother's feelings, give appropriate information, and encourage the mother to make informed choices while listening to her heart.
Through the sharing of accurate information, LLL Leaders can empower mothers so that they do not question the quality of their milk.
Eguchi, M. Nyubou massage ni tsuite (About breast massage). Secretary News 1998; 9. (Published in Japanese.)
Facts about Breastfeeding 2005. La Leche League International. Publication No. 1644-17.
Foda, M.I. et al. Composition of milk obtained from unmassaged versus massaged breasts of lactating mothers. J Ped Gastro Nutr 04-5; 38(5):484-87.
Hammerman, C. Review: Composition of Milk Obtained From Unmassaged Versus Massaged Breasts of Lactating Mothers, Foda et al. J Ped Gastro Nutr 2004-05; 38(5):484-87 and Fact on Japanese Breast Massage found in the Facts about Breastfeeding 2005, LLLI. Unpublished, 2005. Posted at www.llljapan.com/binfo/review/HammermanReviewEnglish.pdf (English) and www.llljapan.com/binfo/review/HammermanReviewJapanese.pdf (Japanese).
Hongo, H. Oketanisiki Nyubo, Massage Ni Tsuite (About the Oketani Breast Massage presented on Facts about Breastfeeding in 2005). LLL Japan Area Leader’s Letter, August 2005. (Published in Japanese.)
Japan Society of Breast Feeding Research. Program booklet for Japan Society of Breast Feeding Research Conference, September 2005. (Published in Japanese.)
Daredemodekiru Bonyuikuji (THE WOMANLY ART OF BREASTFEEDING, Japanese version). Osaka, Japan: Medica, 2000.
Nakamura, K. and Hongo, H. Birth and Breastfeeding in Mothers of Japanese Heritage: Cultural Commonalities and Differences (Cultural Considerations with Japanese Breastfeeding Mothers), presented at La Leche League International Conference, July 2003 (published on CD-ROM).
Oketani, S. Oketani Sotomi No Bonyuikuji No Hon (a book on breastfeeding by Sotomi Oketani). Tokyo: Syufunotomosha, 1985. (Published in Japanese.)
Seo, T. Personal communication at Japan Society of Breast Feeding Research Conference, September 2005.
Hiroko Hongo is an LLL Leader in Tokyo, Japan, where she lives with her husband, Takahiro, and their two children, Masahiro (20), born and breastfed in Tokyo, and Manami (17), born and breastfed in Los Angeles, California, USA. She was accredited as a Leader in 1992 in Los Angeles where she led a Japanese-speaking Group. She was certified as the first Japanese IBCLC in 1995. She is currently a co-Leader for LLL Toshima, Area Professional Liaison for LLL Japan, and Communication Skills Training Facilitator/Facilitator Trainer. She is a co-founder and a board member of the Japanese Association of Lactation Consultants and the Breastfeeding Support Network of Japan. Hiroko writes, "Thanks to Toshi Jolliffe in Luxembourg, Coordinator of Leader Accreditation for LLL Japan, Chika Nakatsuka in USA, Area Publication Administrator for LLL Japan, and Iona Macnab in Japan, Regional Administrator of Leaders, for their helpful suggestions and proofreading. Their suggestions made me realize that the issue is not only for Japanese mothers in Japan, but also non-Japanese mothers living in Japan as well as Japanese people outside Japan. LLL Japan also greatly appreciates Devorah Schesch-Wernick, Division Professional Liaison Coordinator, and Katy Lebbing, Manager, Center for Breastfeeding Information, for their encouragement to deal with the issue affecting many mothers around the world."