perinatal health and history
I wrote the essay A little extra something when I lived in Bullaburra, in the Blue Mountains. My children were very young. It took me a good six months and I thought about it day and night. In every spare moment, when my children were asleep or in someone else’s care, I sat in my cramped study overlooking the wild green Bullaburra gully with its raucous flocks of sulphur-crested cockatoos, dreaming and writing, writing and dreaming, urgently. ...Then when I finished it in August 1994, I didn’t publish it. I had no idea who might be interested. I’ll never forget that Maureen Minchin kindly read every word and phoned me to say she really liked it. After we hung up, I shouted out with happiness into the bright gully air.
The fertile breast
These are artistic close-ups: soft focus and arrestingly intimate.
Sepia portraits of newborn babies have appeared as double-A4-page spreads in the Medical Observer, Australian Doctor, Modern Medicine and Australian Family Physician week after week for many months now. Eyes down-turned into shadow, tendrils of moist hair, mottled moist skin of the frail little arm of a just-born: the physicality of these photographs arouses in us an ancient instinct to protect and nurture. Even the most harried GP, flicking the pages in a lunch-break, could hardly fail to register a brief swell of feeling for this most vulnerable and most nascent of our species, the tiny baby.
A little extra something.
S-26 from Wyeth.
Wyeth spends between $4600 and $7200 an advertisement because advertising to the health professions has proven the most effective way to increase sales.
We doctors are, after all, the ones the mother comes to when she has been told by the clinic sister that the baby has not gained enough weight, or when the mother can no longer tolerate excruciating nipple pain, or when the mother complains of not enough milk, or her nipples seem too flat, or she has rock-hard breasts each morning, or a sore breast-lump and fever.
She comes to us when the baby's screams are as loud as the screams inside her head, hour after hour, day after day. No-one told me, she says, that it was quite like this. Babies with frothy stool and tight little bellies, babies that choke on the milk, babies that prefer the bottle, babies that refuse the breast: they come to us, that stream of breastfeeding mothers and babies in difficulty.
These women have tried what the midwife at the hospital and the sister at the clinic said. The advice from the counsellor at the nursing mothers’ association didn't work this time. The next-door neighbour said they should see a doctor. Doctor, can you help?
We sincerely want to help. And so does Wyeth.
We have a fifteen minute appointment with a mother and her crying baby and her five-year-old who pulls apart the sphygmo and the toddler who scrambles into her lap insisting "home, Mummy, home".
For the past 200,000 years, Homo sapiens women have fed their babies abundantly from their own breasts through the first months of life and have continued to breastfeed for at least two years, even in the circumstance of malnourishment and overwork. The survival of the human race depended on it.
We are mammals. We are defined by female biology: we feed our young from a woman's mammary glands. Lactation is a robust and fundamental physiological mechanism, not easily disrupted.
The male-dominated medical profession took over birth and breastfeeding from community-based midwives
You can find out about the rise of my own profession here.
From the early 20th century, the medical profession vigorously promoted the concept of "scientific motherhood". True to the mechanistic worldview of the Industrial Age, we argued that the female body and a breastfeeding baby were capricious and without inherent and healthful order, that the natural could not be trusted and needed to be controlled: routinised and rigidly measured.
We separated mother and baby at birth (to examine and clean and weigh, we said) although the loss of that first hour when the baby is primed to suckle the breast correctly is clearly related to the failure of lactation.
We instigated the four-hourly, or later three-hourly, breastfeed (to prevent "overfeeding" we said), and because good supply depends on painlessly positioned and unrestricted suckling, undersupply remains a widespread problem.
We roomed the mother and baby separately (so that mother can sleep we said), and because fifty percent of the newborn's suckling occurs in the night-hours, the mother's supply of milk is further compromised.
We used bottles of formula routinely in the nursery (to feed the hungry baby, we said), although comping with water or formula is strongly associated with ensuing lactation failure and even just one bottle of formula may cause ongoing morbidity from cow's milk protein intolerance.
We timed and limited the duration of a feed and insisted that mothers change breasts by the clock (to prevent sore nipples we said), although sore nipples are a sign of poor positioning, and limited suckling limits the baby's intake of milk, resulting in poor weight gains.
We insisted on frequent test-weighing (to check baby is getting enough milk we said) although the intake of breastmilk is highly variable and regulated by the baby according to need, although test-weighing is notoriously unreliable when used as a one-off clinical tool.
We introduced routine glucose water feeds (to prevent jaundice we said), although this practice increases the incidence and extent of jaundice, and increases the risk of lactation failure.
We used pacifiers (to calm the baby and spare the mother we said), although the dummy can further limit the suckling necessary for establishment of good supply.
And of course, in the inevitable case of undersupply, we recommended the new "scientific" formulas. We quietly promoted breastmilk substitutes and, tacitly, the unreliability of the breast, in hospital nurseries for decades. We allowed manufacturers to trial their products on the nursery newborns, and in the 1960's and 70's we allowed the biggest companies to keep their stranglehold on the market by giving free supplies and gifts to the hospital, on the condition that mothers went home with their kit.
We promoted breastmilk substitutes and, tacitly, the unreliability of the breast, in our consulting rooms, by using items donated by the industry and distributing more free samples. Our liaison with the breastmilk substitute industry of the 20th century has been embarrassingly intimate, benefiting us both financially.
Formula is so-called because at first complicated and meaningless formulas, like M=Qb-bC/b C=L9b1F-a1P/ab1-a1b C=(2F+S+P) x l 1/4/Q were calculated by the doctor to custom-make the artificial feed for the particular age and characteristics of the baby. In this way, regular specialist consultation, measurement and calculation became imperative in the early months of life.
In the 1920's as the emphasis shifted to standard, commercially available preparations, instructions for the use of the substitutes were made available only to doctors. The products could be purchased by prescription or at least used only with a doctor's directions. Mead Johnson boasted in 1923 that this "ethical" marketing policy was "responsible in large measure for the advancement of the profession of paediatrics ... because it brought infant feeding under the direct control of the medical profession". As late as 1932 the American Medical Association required baby-milk manufacturers to advertise only to doctors. Still today the name S-26 has an efficient, quantifiable, scientific ring, a stream-lined formula for a stream-lined era.
Our confidence as a profession in those things that we can measure, control, package and weigh, our confidence that we can control the natural process of lactation to the benefit of the woman and baby, prevailed over trust in the organic unfolding of a mother-baby relationship, which had been supported by women in diverse cultures across the planet for millennia. We persisted despite the appalling statistics initially associated with bottle-feeding and known to paediatricians from the first decades of the use of breastmilk substitutes this century.
Formula in low income economies
The impact of rampant and unscrupulous promotion of artificial feeding in low income economies, in the context of rapid social change and the practices of our profession, has resulted in global lactation tragedy. A primary cause of the overwhelming population explosion of developing nations is the loss of the child-spacing effects of lactational infertility once formula-feeding became widespread.
Millions of formula-fed babies have died in low and middle income countries over the past century, mostly of diarrheal illnesses, due to formula use promoted unethically by corporations hungry for profit. Global offensives by the WHO and UNICEF to stem the diarrhoea-sodden tides of death have helped but many babies still die unnecesarily each year in low and middle income countries because they don't receive human milk.
Formula use in advanced economies
In advanced economies, the loss of life has been less devastating as the twentieth century progressed and our sanitation and resources for rescuing ill babies improved. Yet there remains still, apart from substantial morbidity, over 800,000 child and 20,000 maternal deaths annually attributable to suboptimal breastfeeding globally.
Most women are in the first days physiologically primed to breastfeed twins, and oversupply has emerged as a significant non-iatrogenic cause of breastfeeding difficulty. Yet the doctor's outspoken fear of this same abundance just decades ago, which we named "overfeeding", and subsequent imposition of rigid timing of feeds, has caused the breast of the mother to dry up. Across the planet "insufficient milk" is the most common reason given by mothers for the use of formula.
Our mistrust of the unrestrained, of the wildly abundant, our medical mistrust of the chaotic, hotly desirous nature of a baby suckling the breast has fundamentally and biologically affected the human being over the past century. Such spectacular wounding of the biological, inflicted by the healing professions and by powerful corporations, must give us great pause.
Nevertheless, a powerful tension towards paradigmatic rupture and re-formation is building across a diverse spectrum of scientific communities in the West. Medical research, too, inexorably draws us toward a dramatic paradigm shift, back to a recognition of the innate wisdom of the body using the lens of evolutionary biology and complexity science, teaching technology its proper place as the masterful and sometimes miraculous servant of a fundamental and ancient reverence for the natural.
