1. Context
he duration, frequency, and techniques of breastfeeding are under influence of many geographic, sociocultural, religious, and economic factors and various practices are seen across countries (1). However, the information about social and cultural factors such as religion is little and few studies have investigated the role of religious connections with the experience of breastfeeding (2, 3). Studies often focus on the physical needs of the infants or mothers while the spiritual nature of unborn babies should be acknowledged during pregnancy and spiritual needs should be recognized within neonatal care as well (4, 5). Studies have shown that socioeconomic, demographic, and cultural differences in breastfeeding behaviors are very important (6, 7, 8, 9). Recently studies have shown interest in religious and spiritual aspects of breastfeeding given the further benefits of breast milk (10).
Spiritual health is one of the characteristics of health that has been presented by the World Health Organization (WHO) as a definition of health and the spiritual element has a valuable role in people’s achievement in all parts of life (11). Spiritual health has two dimensions of religion and existential (12). Improving in spiritual health may influence the breastfeeding self-efficacy of mothers (13). 
Breastfeeding has a religious basis in different societies (14, 15). On the other hand, social and cultural factors are associated with the initiation and continuation of breastfeeding (16). Therefore breastfeeding is a complex practice not only because of its physical and biological nature but also because of its roots within society’s social, spiritual, and cultural construct (17). In recent studies, breast milk has been introduced as the best love biotic besides its other values (18). The literature in the spirituality interventions is limited but evidence has demonstrated spirituality as integrative energy to promote health (19). This review aims to evaluate breastfeeding from a spiritual perspective. In this article, the research related to religious or spiritual aspects of breastfeeding was investigated from two dimensions of the effect of breastfeeding practice on the spiritual status of mothers and the influence of spirituality or religious beliefs on breastfeeding behaviors.
2. Evidence acquisition
The present article conducted a narrative review of the research studies about spiritual aspects of breastfeeding. This review included all articles which investigated the relationship between breastfeeding practices with the spiritual or religious status of mothers in different societies that were indexed in PubMed, Google Scholar, and Cochrane from 2000 to 2018. The keyword terms were spiritual, religious, breast milk, initiation, duration, and a combination of these with breastfeeding. All study types written in English were included. Based on the PICO (Problem/Patient/Population, Intervention/Indicator, Comparison, Outcome, and [optional] Time element or Type of Study) format the study population was nursing mothers, the intervention was breastfeeding, the comparison variable was spiritual care during breastfeeding, and the evaluated outcome was the effect of spirituality on breastfeeding behaviors. Studies on the evaluation of purely cultural or regional-based backgrounds, spiritual aspects beyond the infancy period, and non-English articles were excluded. 
First, the papers were searched based on their titles. Then the abstract sections of all articles were reviewed by the neonatologist author. In the primary search, 359 articles related to religious or spiritual aspects of breastfeeding were found. After the initial screening of titles and abstracts, 69 related studies were selected which in the second full texts review, 9 papers were finally identified matching with the review inclusion criteria. 
3. Results
Nine articles about the spiritual and religious aspects of breastfeeding were finally reviewed. Table 1 presents the data extracted from each article per type of article, design, country of origin, year of publication, assessed outcomes, and religion. 



Only one article was about the influence of breastfeeding practice on the spiritual status and the 8 others were about the effect of religious or spiritual beliefs on breastfeeding. They consisted of 3 review articles (33.5%), 5 descriptive (55.5%), and one prospective cohort (11%) study. The studied population was from the USA (2 articles), the UK (1 article), Malaysia (1 article), India (1 article), Iran (1 article), and western countries (1 article). Two review articles were not from any specific country. Different outcomes and subjects were reported in the published articles in different religions. These different effects are separately discussed below. 
3.1. Influence of breastfeeding on the spiritual status of mothers
Undoubtedly, breastfeeding is considered as a physical act. However, it may have an emotional, mental, or spiritual feature as well. Breastfeeding in Christianity has been implicated generally with regard to the Virgin Mary and her child Jesus and Mary’s breast milk contained spirituality. Various Jewish religious sources also imply to breastfeeding. In the book of Genesis, successful breastfeeding has been noted as a benediction (1). In this review, only one paper was found about the subject that introduced breastfeeding as a spiritual activity. Williamson et al. in a study, based on data collection using semi-structured interview on British Muslim women showed that women from Muslim backgrounds often reflect spiritual understandings around breastfeeding behaviors and in their opinion, breastfeeding is a deeply spiritual act that through which the mother as a good Muslim can feed the baby and promote the baby’s moral development according to sacred Islamic texts such as the Quran and Hadith (sayings and teachings of Prophet Mohammad). 
Indeed, this spiritual attachment which is achieved through breastfeeding transmits spiritual nourishment to the infant and the act of suckling at the breast leads to the religious wellbeing of the child (3). Muslim mothers believed that breastfeeding is a sign of blessing and they will be blessed with spiritual rewards by angels as a gift of God and will have their sins forgiven during the 2 years of breastfeeding based on a Hadith from Prophet Mohammad (1, 23). Religious participation of women increases after childbearing; moreover, in Islamic regions breastfeeding is considered as an enshrined religious act with the ability of transmission of moral traits by breast milk as well (1, 24).
3.2. practice
Initiation and duration of breastfeeding
It has been proved that many factors are effective in starting and continuing breastfeeding (25). The decision to initiate and continue breastfeeding may be influenced by several factors such as behavioral and cultural factors (26). Guidance from the World Health Organization (WHO) suggests exclusive breastfeeding for at least 6 months as a gold standard and provision of some breast milk for the first 2 years of life. This contemporary health promotion about the superiority of breast milk is compatible and similar to Islamic teaching (3). 
Breastfeeding has a religious basis in Islam according to sacred Islamic texts such as the Holy Quran and Hadith. A mother should suckle her offspring for 2 years if possible and health education based on spirituality should be given to mothers for giving breast milk for 2 years to their babies (1, 15, 19). So breastfeeding promotion programs may be better accepted in Muslim communities (15). Like the Quran, the Bible has recommended many references with regard to the optimal timing for breast milk weaning (1). However, few studies have investigated the association between maternal religious involvement and breastfeeding initiation and duration (3). Burdette et al. by using the data from a longitudinal birth cohort study revealed that frequent religious attendance in Church is associated with an increased odds of breastfeeding initiation but a weaker association with breastfeeding duration (10). 
Bernard et al. carried out an ecological study to compare the rate of breastfeeding initiation between Catholics and Protestants across 5 western countries of Ireland, the UK, Canada, the USA, and France. Their results showed a negative correlation (r=-0.30) between the proportion of Catholics and the rate of breastfeeding initiation (2). Countries with breastfeeding initiation rates of less than 80% are historically Catholic (2). In a recent study, Stroope et al. assessed the relationship between religious affiliation and breastfeeding behavior in a prospective cohort study in the USA. They introduced their research as the most generalizable study of religions and breastfeeding to date. 
They found that except for black Protestants, all religious groups had higher odds of breastfeeding initiation in comparison with conservative Protestants (OR=1.43-3.01; P<0.1). On the other hand, all groups also had a longer duration of breastfeeding than conservative Protestants except for black Protestants and Catholics. Besides the results showed that frequent religious attendance prolonged the breastfeeding duration among mothers who had first birth at a later age. The authors suggested that further research is necessary to evaluate the overall role of religious attendance in breastfeeding practice (22). 
“Breast is best”
“Breast is best” is the message of breastfeeding advertising campaigns (3). Many religions believe in this message. Breast milk has been thought to have wonderful power that is stressed in selected quotations from the different religious texts (14). The Hindus population believes that breast and milk are a symbol of nectarine sweetness and longevity to the base of the earliest Indian literature (14). The study of Williamson et al. showed that Muslim women made reference to the “Breast is best” message as well and spoke positively about the role of breastfeeding as spiritual nourishment from mother to infant (3). 
However, obsessive use of the hegemonic “breast is best” may lead to adverse or harmful effects on women who are struggling with breastfeeding (27). Muslim mothers who experience breastfeeding difficulties or unable to breastfeed may be recognized as bad mothers and be at particular risk of mental health problems. So interventions mustn’t inadvertently cause these harmful effects and attention should be paid more to the knowledge and attitude of mothers about exclusive breastfeeding (3, 28).
Colostrum
Colostrum is the first yellowish colored milk after delivery. Beliefs about colostrum show a discrepancy in different religions and communities. Many mothers in the Hindu population believe that colostrum is harmful to the baby and discard colostrum so the infants may be fed with cow’s milk, honey, or water during this period (14). Like Hindu, some Muslim communities believe that colostrum has insufficient nutritional value and newborn maybe afford water supplements or honey (15). However, this initial period is very important for the establishment of lactation. This may be a cultural practice without religious bases (15, 16). This distinction between religious beliefs and cultural practices can be used by clinicians to reinforce the above practice of avoiding such supplemented feeding during the first days of life (15).
Modesty navigation
Respecting the privacy of mothers during breastfeeding is important across all cultures. This concern is augmented by religious beliefs in Muslim mothers (15). In Islam, according to religious instructions, women should cover their bodies (except for the hands and face) in the presence of men who are not close family. So, Muslim women may have uncomfortable breastfeeding in public areas (20). ‘‘Modesty” signifies an important concept in Islam which is usually made simpler in western countries about how Muslim women wear (3). Due to these concerns, the Muslim mother may bottle-feed her infant with formula or expressed breast milk in public or even in neonatal intensive care unit settings in which the mother may not have a private place to breastfed (15). 
Mohamad et al. carried out a study that focuses on Malay Muslim women for the understanding of modesty in Islam and how this may affect the breastfeeding practice in a public area. The study found that modesty as a religious matter has discouraged Malay women to breastfeed in public and findings of this study showed that religion plays a significant role in the structure of breastfeeding in Malay societies (20). The results of the Williamson et al. study with regard to modesty showed similar findings through British Muslim mothers. So, an understanding of this concern, its effects, and salience are necessary for health practitioners working with Muslim mothers (3).
Wet nursing
Wet nursing or the breastfeeding of another woman’s baby occurred in all civilizations due to the death of mothers but this was not the only cause. Religious factors played a key role in this issue. Wet nursing was a highly organized practice among certain classes of the population and wet nurses and parents were subject to their religion. One of the oldest religious stories on wet nursing is related to the Jewish religion in Exodus when Pharaoh sends a person to call for a wet nurse for baby Moses (1). Among Hindus, wet nursing has a historic document when the mother was not able to breastfeed her infant but this practice is mainly given to kings and their families. Otherwise, wet nursing was done in a special situation (14).
One type of kinship in Islamic law is defined by milk and wet nursing. Milk parents have no duty to maintain their milk babies and milk kin cannot be inherited from each other but in case a boy and a girl nursed by a common wife, they cannot marry together. Indeed, they became their milk siblings (1). This may be an important issue when forming human milk donor programs in Muslim countries. Muslim women who donate breast milk should know the identity of the baby who will be fed by their milk (15). The Prophet Mohammad instructs Muslims to avoid their babies from drinking the milk of “adulteresses” or insane and consider their milk infectious. Now the potency of human milk in the transmission of infectious diseases has been recognized (15).
Overall, the selection of wet nursing can be a key to the health of babies who cannot be breastfed by their biological mothers. This proves the preference for feeding the baby with human milk instead of animal milk.
Non-puerperal lactation 
Non-puerperal lactation is wet nursing by a woman who has never given birth or has never been pregnant (1). An earlier account of non-puerperal lactation has been described on several occasions in Christianity (1). Therefore, induction of lactation is not a new concept and it has been described from the earliest time. Until recently, the evidence-based reports about the induction of lactation are anecdotally or scattered (11, 29). Today this concept has gained much value in the modern world in the case of adopted or surrogate mothers (29). This technique has received much attention in Islamic societies both socially and religiously because the nurture of infants with breast milk has intentionally assumed a religious role in the case of Islam. Indeed, breastfeeding without pregnancy serves a good example of the value of using contemporary scientific knowledge to elucidate the origin and evolvement of an ancient religious-based myth (1). 
Mother’s self-efficacy
Elevation of self-worth is closely related to spiritual wellbeing (30). The role of spiritual leadership is an important issue in health care contexts because it is based on confidence, carefulness, honor, and compassion (31). One of these contexts is the breastfeeding practice. Didarloo et al. in a study on 150 eligible mothers showed that the variable of the spiritual health of mothers had a statistically significant relationship with breastfeeding self-efficacy score (21). That was the first research in Iran to investigate the relationship between spiritual wellbeing and breastfeeding self-efficacy of mothers. So caregivers can focus on spiritual health to improve breastfeeding self-efficacy in mothers (21). On the other hand, close skin to skin contact between mother and infant has a crucial effect on children’s physical and mental health (32). 
Lack of evidence contributed to some limitations for this review. Religious beliefs on culture or social networks were not analyzed. There are multifaceted links between races, regions, and religions that are historically interweaved. On the other hand, this study did not comprise small religious minorities.
4. Conclusion
Results of our review study show that the prominence of breastfeeding goes beyond the providing of breast milk for the infant and the breastfeeding practice appeared to be necessary to the spiritual and psychological nourishment of children. A combination of religious or culturally specific rituals and spirituality with modern medicine can influence the management and shaping of breastfeeding behavior. Clinicians by respecting the different religious beliefs and by differentiating them from cultural practices can support breastfeeding as a meditative and spiritual act.
Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 
Conflicts of interest
The author declared no conflicts of interest.


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