Is Breast Best?

Taking on the Breastfeeding Experts and the New High Stakes of Motherhood

Joan B. Wolf

• Publisher: NYU Press
• Year: 2010
• Print ISBN: 9781479838769
• eBook ISBN: 9780814784877
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Why has breastfeeding re-asserted itself over the last twenty years, and why are the government, the scientific and medical communities, and so many mothers so invested in the idea? In Is Breast Best? Joan B. Wolf challenges the widespread belief that breastfeeding is medically superior to bottle-feeding. Despite the fact that breastfeeding has become the ultimate expression of maternal dedication, Wolf writes, the conviction that breastfeeding provides babies unique health benefits and that formula feeding is a risky substitute is unsubstantiated by the evidence. In accessible prose, Wolf argues that a public obsession with health and what she calls "total motherhood" has made breastfeeding a cause célèbre, and that public discussions of breastfeeding say more about infatuation with personal responsibility and perfect mothering in America than they do about the concrete benefits of the breast.Parsing the rhetoric of expert advice, including the recent National Breastfeeding Awareness Campaign, and rigorously questioning the scientific evidence, Is Breast Best? uncovers a path by which a mother can feel informed and confident about how best to feed her thriving infant—whether flourishing by breast or by bottle.

1
Monitoring Mothers
A Recent History of Following the Doctor’s Orders

EVEN BEFORE THE creation of powder formulas, infant feeding was a morally charged practice. In colonial and postrevolutionary America, for example, women who did not nurse their babies were often considered to be selfish and unpatriotic. Nonetheless, many women sought alternative forms of feeding. The demand for wet nurses, socially disadvantaged women who breastfed other women’s children, was constant, and human milk was among the most advertised commodities.¹ Some mothers, particularly in the middle class, found breastfeeding distasteful or immodest, while others found it exhausting. Scientists, doctors, and clergymen believed that breastfeeding was superior to bottle feeding, but they also argued that emotions, diet, exercise, and various other environmental factors could have a negative impact on the quality of a woman’s milk. The belief that middle-class women were weak and unable to sustain breastfeeding, for example, “was a distinguishing characteristic of both the popular and professional medical literature.”² Employing a wet nurse remained a possibility throughout the nineteenth century, but a growing middle-class consciousness deterred most of these mothers from turning to lower-class women to feed their babies. Doctors, too, were concerned about the moral and physical suitability of the women who served as wet nurses, many of whom were single mothers, and they also worried that these women would not submit to doctors’ control. Cow’s milk was the most readily available substitute, but it did not have the same ingredients as breast milk, often carried bacteria, and was extracted, transported, and stored under filthy conditions. Boiling eliminated bacteria but was also feared to make the milk less nutritious. The absence of a safe and reliable surrogate for breast milk was widely blamed for high infant death rates, which, despite advances in disease theory and diagnostic tools, actually increased between 1850 and 1900. At the turn of the twentieth century, one-third of children living in cities died before the age of five years, and overall infant mortality hovered around 10 percent.³

At the same time, infant feeding began to play a significant role in the development and consolidation of pediatrics as a distinct branch of medicine.⁴ Indeed, as the century progressed, pediatricians were often referred to as “baby feeders,” and pediatrics became synonymous with infant nutrition. As a practical matter, doctors’ incomes were dependent on the number of patients they saw, and consultations regarding infant feeding provided a steady stream of revenue. Physicians presented themselves as uniquely qualified to oversee feeding and argued that infant mortality would decline only if mothers gave themselves over to their authority. They also argued that routine weight checks were essential to confirm normal growth; that the nurses, social workers, and lay reformers who dominated the child welfare movement did not have the medical training to evaluate the individual child’s development; and therefore that regular visits to the pediatrician’s office were necessary.⁵ Meanwhile, pediatric researchers produced various milk substitutes based on calories and different percentages of fat, protein, and sugar, and their endless tinkering with proportions reflected the competition among scientists to determine whose formula was best. It also served to legitimate pediatricians vis-à-vis other physicians who did not take seriously infant and child medicine as a distinct medical specialty. Professionalization also was enhanced by pediatricians’ supervision of milk stations, which distributed sterilized milk and prepared formula, and also the certification of cow’s milk, both methods of making milk safer that were far more expensive than pasteurization—which doctors feared destroyed some of milk’s nutritive qualities—but that guaranteed physicians’ services would be essential to infant feeding.

Throughout the first half of the twentieth century, pediatricians grew increasingly fond of “artificial feeding,” as bottle feeding was commonly known. As evidence developed to suggest little difference in health between breastfed and properly bottle-fed babies, pediatricians began to contend that feeding with evaporated milk or appropriately constituted formula, under a doctor’s supervision, could be as nutritious as breastfeeding. They did not directly dispute the notion that breastfeeding was optimal, but they relied heavily on their clinical experience, which indicated that babies developed normally on some form of mixed feeding or on manufactured foods alone. Like their predecessors, pediatricians argued that “relief bottles” could provide a respite for exhausted breastfeeding mothers. Nursing babies should receive one bottle a day, some advised, so mothers could have a modicum of freedom; if babies grew accustomed to bottles, these doctors reasoned, they might have an easier time with weaning. In addition, anxiety could adversely affect a mother’s milk supply, so bottles might even improve lactation. By the 1940s, pediatricians generally accepted the viability of generic milk substitutes, and they blamed any health problems on infants or mothers’ failure to follow doctors’ advice, not on the formula itself.

Regardless of its nutritional merits, supervised bottle feeding made doctors central to babies’ lives. Bottled milk, moreover, gave physicians the comfort of knowing exactly what and how much babies were consuming, and this reinforced their control over infant feeding. Some openly expressed their preference for “the young mother with a nutritionally untutored mind who frankly states that she knows nothing about babies and leaves the instruction to me” over a mother who had studied nutrition in college or was aware of competing opinions. One pediatrician stated frankly that it was “easier to control cows than women,” and by midcentury, some contended that an educated mother could be a threat to her child’s well-being.⁶ Medical schools devoted many more hours to teaching about artificial feeding than about breastfeeding, so the average physician knew more about the bottle than the breast and was ill prepared to counsel mothers struggling to breastfeed. Doctors’ misgivings about manufactured baby food pertained largely to mothers who fed without professional instruction. While these pediatricians were concerned about the health of these babies, they also recognized that unsupervised feeding reduced their function and income. At the same time, commercial food companies offered doctors free samples and calculators, and they stressed in mass advertising that formula should not be used without a doctor’s prescription. The American Medical Association eventually threatened to remove its seal of approval from products whose manufacturers included instructions on labels and that advertised directly to mothers. Those companies that failed to comply fared much worse than those that did. Both industry and pediatric practice ultimately benefited from the mutual affirmation that formula feeding required a doctor’s supervision. By emphasizing the indispensability of medical advice, formula companies bolstered the business of pediatrics, which then guaranteed that more women would be trained to use formula.

The emergence of pediatrics as a distinct field in medicine and the consolidation of doctors’ control over infant feeding reflected broader changes in the social value of science. In the latter half of the nineteenth century, as historian Charles Rosenberg argues in No Other Gods: On Science and American Social Thought, the “constantly shifting equilibrium between secular and religious imperatives” was tilting strongly toward the former.⁷ This meant not the delegitimation of religious or ethical concerns but the increasing role of science in pronouncing what was socially desirable. In addition to uncovering the putatively natural laws of any given process, science also determined what was virtuous; a scientist should not simply ascertain what was true but should establish what was appropriate.⁸ Doctors were perceived and understood themselves to be high-minded reformers, and they insisted that scientific expertise was needed to raise children.

The proliferation and moral elevation of science meant that mothers became subject to a reign of expertise in areas that long had been considered somewhat mundane. As homemaking became a domestic science, for example, women sought education in home economics and the science of housework. It was in this era of “scientific motherhood”⁹ that scientists began to make careers of advising mothers about what women had been doing largely on their own for centuries. Experts took their place alongside—and sometimes supplanted—customary female networks composed of midwives, relatives, and friends. Exhorting mothers to “Add Science to Love and be a ‘Perfect Mother,’” an advertisement for a twenty-six-part child care course in Parents Magazine in 1938, made clear the growing reach and appeal of scientific authority. According to the advertisement, this course was written by

one of America’s greatest Child Authorities—Dr. Grace Langdon, Specialist and Adviser to the U.S. Government on such subjects as Parent Education, Nursery Schools and Homemaking. She has 1,500 government nursery schools under her direct supervision. She has the entire wealth of the latest Scientific advances in Child Training at her fingertips—and she makes it all available to YOU!

Low-income mothers were educated at public clinics, and government information, child care manuals, and visiting nurses in rural and urban areas stressed the need for scientific advice on all matters having to do with infants and children.¹⁰

In the context of scientific motherhood, mothers had even more reason to believe that the advice of pediatricians was essential to infant feeding; and in the early years of the twentieth century, if physicians and other experts in the science of child care continued to advocate breastfeeding, by the end of World War I they appeared to assume that most mothers, for a variety of reasons, would bottle-feed. Doctors’ visits, home economics courses, hospital routines, and advice columns were increasingly dedicated to proper artificial feeding practices, giving the impression that the bottle was just as healthful as the breast. Science was equated with medicine and scientists with doctors, and this translated into the normalization of doctor-directed bottle feeding. In practice, each woman had to navigate her own way through the counsel of experts, her mother, and friends; she was, in the puzzling formation of child care expert Dr. Benjamin Spock, to trust her instincts and follow her doctor’s advice.¹¹ Whatever her instincts, public discourse was dominated by the recommendations of child care experts who presented bottle feeding as a suitable alternative to breastfeeding. As doctor-supervised formula feeding became the norm, pediatricians also began to see babies and young children for regular checkups. These “well checks,” originally designed in the 1920s to provide education and care for immigrant mothers and children in public clinics, eventually became the envy of middle-class mothers who wanted their children to have the same care and were willing to pay for it. When pediatricians realized that well care could provide a substantial and steady income, they moved these visits to their private practices and eventually helped force the closing of public clinics. The privatization of well-child medicine marked the beginning of routine and preventive care in pediatrics, which was estimated to comprise at least half the pediatric service provided in the 1950s and became central to the mission of pediatrics in the last decades of the twentieth century.¹²

This orientation toward prevention was significant in two seemingly contradictory ways. On one hand, it provoked a crisis of boredom: many pediatricians, who already found themselves near the bottom of the physicians’ pay scale, grew frustrated at the absence of challenge or stimulation in routine checkups, especially as several of the major childhood infections and diseases either had disappeared or had been brought under control. What developed was “dissatisfied pediatrician syndrome,” as practitioners called it, and it aroused such profound despair that many wondered whether pediatrics would survive.¹³ On the other hand, the shift in focus made it possible to conceptualize anew the mission of pediatrics. Acrimonious professional debates took place in the 1960s and 1970s over what, if anything, pediatrics contributed to the practice of medicine that could not be provided by general physicians and pediatric nurse practitioners. This dilemma, along with a new, biopsychosocial model of health developing throughout clinical medicine, resulted in a sweeping notion of well care, which eventually came to encompass children’s whole well-being. A variety of childhood experiences became medicalized, or were recast as potential pathologies that required the intervention and expertise of pediatricians. “Well” children were to be physically as well as socially and emotionally healthy. By 1975, pediatricians were speaking of a “new morbidity,” which included chronic disabilities, such as asthma and allergies, and also learning, behavioral, and social impairments. The framing of these challenges as illnesses, and not simply as “problems” or “difficulties,” gave them a medical cachet designed in part to persuade pediatricians reluctant to stretch the boundaries of child medicine. This comprehensive concept of well care divided childhood into different components that needed constant monitoring, and in the process, it solidified pediatrics as an independent branch of medicine.¹⁴

Obstetrics and the Ecology of Pregnancy

Similar developments in patient monitoring also helped legitimize obstetrics as a distinct discipline and medical practice. General physicians and midwives argued that they had the skills to provide women’s reproductive health care, and like pediatricians, obstetricians faced doubts about the need for the kind of specialization they represented. It was, in part, the emergence of “the fetus” as a separate patient that helped establish bounded intellectual and clinical territory for obstetricians. In the late nineteenth century, public health workers, scientists, doctors, and others engaged in social action began to speak of “infant mortality” as a specific phenomenon.¹⁵ In the early twentieth century, “the public fetus”—“a life” with a distinct conceptual existence whose protection required the social surveillance of pregnant women—began to emerge.¹⁶ Urban public health institutions, devoted to reducing both infant and maternal mortality, began to target the prenatal period. In 1916, for example, New York City’s milk stations were renamed “baby health stations,” and the new centers included care focused on the fetus.¹⁷ By midcentury, major obstetrics textbooks were speaking of the fetus and “fetal stress.” Meanwhile, the “perinatal period,” which referred to the time surrounding birth, developed as a clinical concept. Reasoning that deaths before, during, and shortly after birth had similar causes, obstetricians began to focus on monitoring the fetus. The concept of perinatal mortality conjured up a living subject before and during birth and encouraged doctors to optimize fetal life in order to maximize infant health. This new subject shook the relationship between inside and outside and reoriented the pregnant woman, the living subject, and the experts charged with their care.¹⁸

Simultaneously, a new approach to disease, which dramatically expanded the definition of what was “medical,” began to take shape. In this paradigm, health and well-being were conceptualized ecologically, which meant that everything about individual lives was potentially significant to health status or was a possible risk factor for poor medical outcomes. This shift from a biomedical to a biopsychosocial model of medicine was welcomed by most health professionals and activists as a positive step toward a more integrated notion of health; increased knowledge would enable patients to make better choices and exercise more control over their well-being. But it also meant that nothing should be shielded from medical scrutiny. Where a person lived and worked, what she ate and breathed, her personal habits and social relationships—every behavior could be measured and monitored by a medical professional. By the late 1960s, virtually all aspects of women’s lives came to be viewed as potentially risky to the fetus. As William Arney argued in Power and the Profession of Obstetrics, obstetricians contended that “absolutely everything must be made visible to medicine, be subject to observation, and recorded,” and they collected copious data from each patient as much to confirm normalcy as to identify pathology. Pregnancies and births were to be “separated, individualized, subjected to constant and total visibility, and then offered technologies of normalization to guarantee an optimal experience, not necessarily for the individual, but for the system as a whole or, more precisely, for the individual considered in relationship to other components of the system.”¹⁹

In other words, each pregnancy was to be tracked in relation to others, and deviations were cause for concern, not because they indicated danger, but simply because they were different. As “the notion of risk was transformed from a dichotomy to a continuum,” pregnant women were categorized as high or low risk, which meant that no one was without risk and every pregnancy had “pathological potential.”²⁰ The distinction between abnormality and normality became increasingly difficult to define, and “healthy” pregnancy and childbirth became even more dependent on the obstetrician’s expertise and judgment. Moreover, “whereas earlier forms of prenatal care had been about maternal health, and prenatal education about the health of infants, risk assessment was novel in its attention to the health of the fetus.”²¹ New specialties developed in perinatology, embryology, and maternal-fetal medicine. By the last quarter of the twentieth century, the fetus was as much the obstetrician’s patient as was the pregnant woman, and obstetrical work depended to a great extent on prenatal care.²²

The fetus also aided obstet...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Preface: Why Breastfeeding?
• 1 Monitoring Mothers
• 2 The Science
• 3 Minding Your Own (Risky) Business
• 4 From the Womb to the Breast
• 5 Scaring Mothers
• 6 Conclusion
• Notes
• Bibliography
• Index
• About the Author