by Suzanne Colson
© 1998 Midwifery Today, Inc. All Rights Reserved.
[Editor's note: This article originally appeared in Midwifery Today Issue 48, Winter 1998.]
British mothers are among the most reluctant in Europe to breastfeed their babies. In 1995, only 66 percent of babies were breastfed at birth, with rates dropping by 20 percent only two weeks later (Foster et al. 1997, 24). The reasons mothers give up breastfeeding include insufficient milk or a seemingly hungry baby, sore nipples, or painful breasts. Mothers' dissatisfaction with breastfeeding may be linked to the crippling effects of "Breastfeeding Nemesis."
Nemesis was the Greek goddess of retribution—or just punishment. In Greek mythology, lesser gods were often the personification of an abstract concept or emotion. Nemesis represented the concept of revenge and divine response to Hubris, another minor deity, who personified arrogance resulting from excessive pride. Nemesis lurked in the lairs of Hubris, ready to work the wrath of the gods and punish any mortal who dared trespass the measure of man.
The concept of revenge applied to medical technology likely would have remained in oblivion had it not been for theologian/philosopher Ivan Illich, who wrote a fierce critique of the impact of technology on everyday life and the dangers of the medicalisation of the life span. Central to Illichs ideology is the ever-increasing number of therapeutic side effects caused by iatrogenesis. Iatrogenesis, from the Greek words for physician (iatros) and origin (genesis), is defined as any disorder or condition caused by medical personnel or procedures, or through exposure to the environment of a health care facility. The significance of Illich's work is in the recognition and analysis of what he terms the "expropriation of health." In Illich's words: "The so-called health professionals have an even deeper, structurally health-denying effect insofar as they destroy the potential of people to deal with their human weakness, vulnerability and uniqueness in a personal and autonomous way" (Illich 1975, 26).
Illich's work explores the divide between the activities of daily living normally accomplished alone or through experience, or through mimicry or help from friends and family, as opposed to those activities of daily living that require professional advice.
Illich highlights the irony of a political and industrial takeover that engineers a so-called "better health" through fixed systems of technology, creating a three-tiered "clinical, social and structural" iatrogenesis. This results in the total suppression of healthy response to suffering. Instead, the "defenceless patient" suffers the consequences of undesirable and retributive side-effects, i.e., the punishment of Nemesis.
Oddly, there is a conspicuous absence of any allusion to birth, breastfeeding and reproductive technologies in Illich's work. Pioneering obstetrician Michel Odent attempted to make up for this oversight. Illich's ideology, along with Leboyer's poetry (1974), has shaped much of Odent's practice. He pursued the work of Illich in his first book (1976), which recounted his personal experience of the demedicalisation of childbirth. Odent was one of the first obstetricians to critically examine the role of the "obstetrical technician" and focus attention upon the sometimes devastating consequences of "obstetrical hubris." In sharp contrast to Illich's style of scathing contempt, Odent's style is descriptive. As a medical practitioner, he set out to demonstrate what it was potentially possible to achieve in a state-run maternity unit just by changing attitudes and priorities.
In this essay the medicalisation of breastfeeding will be examined in an attempt to clarify how nursing a baby became a complicated observable behavioural science. In one short century, breast milk has been transformed into "a human biological product" (Rothman 1982, 186). At best, the act of breastfeeding now requires midwifery supervision and instruction, or more extremely, expert medical advice as soon as it is deemed to have deviated from the norms dictated by the technological experts. This fixed system has created Breastfeeding Nemesis.
The Scientification of Infant Feeding
The technology of engineering an artificial feed of cow's milk in a bottle with a rubber teat literally initiated an unprecedented event in human history. Human mothers are the only mammals who have a choice about whether to give their own milk to their infants. The decision to use cow's milk was not based on any scientific investigation to compare the suitability of other mammals' milk for human consumption. Expediency was the priority, and cow's milk became the substitute of choice, mostly for economic reasons, as there was at least one cow available in every village farm. During the first 30 to 40 years of the twentieth century, cow's milk was diluted with water, and sugar was added to make it palatable to the infant. Because the proportion of the basic constituents of cow's milk are inappropriate to human needs (large amount of protein and small fat content, with no long chain fatty acids), constructing a safe formula using cow's milk as a breast milk substitute became the subject of intense medical scientific investigation.
It was the pure arrogance of the situation that provoked a response from Nemesis. Divine retribution to this scientific hubris was immediate. Breastfeeding Nemesis stealthily crept in with her disastrous side effects, punishing mothers and babies through soaring infant mortality rates. But the vanity of Hubris would heed no warning, and it was not long before infant feeding changed from an activity of daily living that had required no expert advice to one requiring its own specialised discourse. Discourse, a term central to the work of French social philosopher Michel Foucault, is the language used to structure dominant ideas, thus shaping the boundaries of a particular area of knowledge. The discourse of infant feeding was produced by agriculturists, scientists, medical doctors and commercial manufacturers. Through the expression of their dominant ideas, a science of infant feeding was created based upon the imperatives of formalising a feed of cow's milk safe enough for human infant consumption.
We can imagine the scene: A scholarly-looking gentleman speaks with conviction to a group of male experts seated around a large table. He focuses attention upon infant mortality statistics and the urgent need to make artificial feeding scientific. He stresses the benefits of rigorous exactitude not only in the formulation of infant food but also in parenting techniques to produce hardy rigorous youths. He stresses "ignorance and fecklessness of mothers" as major contributing factors to the unacceptably high death rate of Britain's future citizens (RCM 1988, 5). He emphasises the convenience of bottle feeding and predicts that very soon many mothers will no longer need to breastfeed. "We all know," he says, "that cow's milk given in a bottle is preferable for those mothers who are sick or too frail to breastfeed. But any mother who fears the physical and psychological trauma of sore nipples, or that she won't have enough milk, should have the choice. Furthermore, mothers will save money because they won't have to pay the wet nurse."
Zeus was furious. "How dare they! Pompous, arrogant medical technocrats," he mumbled. "Did they really think they could create a scientific formula to replace the golden nectar of the gods?"
The impact of Breastfeeding Nemesis was recognised in the early 1970s. At that time, the World Health Organisation voiced concerns about declining breastfeeding rates. In Britain, a Committee on the Medical Aspects of Food Policy Working Party (COMA 1974) reviewed infant feeding and advised that mothers breastfeed for four to six months. Mothers agreed that they would try to breastfeed. They gritted their teeth and persevered because it had been discovered to be so good for their babies. But ever since technology opened Pandora's box, the pain and misery of a forgotten art continued to make the bottlefeeding choice easier. Nemesis wreaked havoc. Some mothers were severely punished by the side effects of reduced milk supply, others by sore and cracked nipples, still others by postnatal depression! By 1985, breastfeeding statistics had plummeted. Following a meeting organised by the Royal Society of Medicine, the devastating effect of Breastfeeding Nemesis was acknowledged, and hope was expressed that midwives would set the standard for successful breastfeeding (RCM 1988). Nemesis continued to be relentless in her punishment of mothers and babies, only now midwives were responsible!
Midwifery failure is often evoked to account for consistently low breastfeeding rates. Rothman (1982), from a sociological perspective, observes two fundamentally different models in the provision of maternity care. The medical model focuses on the medical management of birth and originates from a male profession in the context of patriarchal society. This perspective can be seen to reflect a "man's eye view" of women's bodies (Rothman 1982, 23). However, it is the complete antithesis of Foucault's observational "gaze": "The purity of the gaze is bound up with a certain silence that enables the clinician to listen…the gaze will be fullfilled in its own truth and have access to the truth of things if it rests on them in silence" (Foucault 1973, 107-8).
The "man's eye view" perceives a body machine, and the male body is portrayed as the norm. From this perspective breastfeeding is, at best, a stress on the body system requiring medical management and treatment. At worst, the body machine breaks down, resulting in pathology ranging from sore, cracked nipples to mastitis and breast abscess. Expert doctor comes to the rescue with discourse, intervention or both. The "Anatomy of Infant Sucking," written by Dr. Michael Woolridge (1986) is an example of how male-dominated scientific discourse responds to the technologically created need for instruction in regard to infant feeding. Woolridge summarises his intention in the abstract to his article: "…armed with an appropriate understanding of the underlying processes by which milk is transferred from mother to baby, a midwife is best equipped to advise a mother regarding the correct technique for achieving trouble-free breastfeeding."
The term "trouble-free breastfeeding" aptly illustrates the technological quest for "better health" described by Illich. The Oxford dictionary defines technology as that branch of knowledge that deals with the mechanical arts or applied sciences and its discourse. By definition, technology is a means to enhance the quality of performance.
We must assume that the aim of Woolridge is to facilitate breastfeeding, but his metaphors speak of weaponry and equipment. The entire article reflects a technological perspective. Management and the mechanics of sucking are highlighted. In conclusion, the reader is reminded that a "sound understanding of the mechanisms of milk removal from the breast is essential if one is to advise mothers correctly on feed management." Milk is processed and transferred from mother to baby in the same fixed system of rigorous exactitude as the technology that underpins bottle feeding.
Before this technological takeover, breastfeeding had been an activity of daily living based upon mimicry and learning from family, as well as the hit and miss of the experience itself. All of a sudden it turned into a scientific battlefield requiring strategic study, with male experts demarcating the normal and the deviation. The mother-baby relationship of nursing is dismissed in favour of trouble-free achievement. The medical model redefines not only how the mother should experience the event but also how the midwife should teach the mother to experience the event.
In contrast to the medical model, Rothman (1982) extols the virtues of a "holistic, naturalistic" midwifery model that is the antithesis to the dominance, power and control inherent to the medical model. Rothman stresses that midwifery care embraces an integrated approach to women as they experience childbirth. Furthermore, this model views the female body as the norm and the woman and fetus as one. In that way, it aims to provide integrated care that satisfies the needs of both. In Britain, with the implementation of Changing Childbirth, midwives and mothers have worked together to tailor this kind of service to respond to perceived needs. What about midwifery hubris? How much of the "man's eye view" has been integrated into the midwifery model? To address this question, let us examine some midwifery breastfeeding discourse.
Written by three experts, BestFeeding, Getting Breastfeeding Right for You (Renfrew, Fisher and Arms 1990) is considered to be one of the most knowledgeable breastfeeding books to date. Let us examine the approach: "Breastfeeding is by far the best way to feed a baby. Most women know this…. But many women find it difficult to do without help, and it can be hard to find the right help" (Ibid., 1). Yet, "Many health workers do not really understand breastfeeding, even if they are supportive" (Ibid., 25). Nevertheless, "When you are ready to breastfeed her, ask for the help of a midwife, nurse or family member" (Ibid., 31). And then, if you do ask for help, the most likely thing to happen is: "Sadly, the most common remedy today is to give the baby a bottle, rather than try to solve the real problem" (Ibid., 3).
The constant warning that help is needed decreases a mother's confidence in her capability to even hold her baby, let alone breastfeed it. This discourse also classifies breastfeeding as one of those activities that requires help from an expert. In that way it expropriates breastfeeding and causes Nemesis.
A textbook for midwives, Management of Breastfeeding (Sweet 1997), addresses the reader this way: "The mother should feed her baby in whatever position she finds most comfortable" (Ibid., 807). Is it appropriate to have prescriptive advice like this in a midwifery textbook? Does the inclusion of this directive mean that some midwives have advised mothers to breastfeed in uncomfortable positions?
Further down the page: "The baby's body should be close to the mother's body with his head and shoulders facing her breast and his mouth at the same level as her nipple. To achieve this position the baby may be supported on a pillow on the mother's lap…. When properly fixed on the breast, the baby's mouth should be wide open with his lower lip curled back and below the base of the nipple. When feeding the baby's jaw action extends back to his ears with little movement seen in the cheeks…. The milk is then stripped from the ampullae and propelled toward the back of the babys mouth by peristaltic waves along the surface of the tongue" (Woolridge 1986a).
This whole passage reproduces the "Mechanics of Sucking" and indeed is referenced Woolridge 1986.
Breastfeeding is a relationship, and as in all relationships, there is no one way to do it. A midwifery black bag of instructions takes control and often conflicts with mothers' own ways.
Caesarean Birth in Britain (1993) is a book for health professionals and parents written by health professionals and parents. It includes advice on breastfeeding as part of the natural continuum of giving birth and is meant to be reassuring: "The woman will need help getting into a comfortable position so that the baby can feed without resting on the wound. This can be achieved by the woman either sitting up or lying down. Hospital beds are not ideal places to breastfeed, so she may need to experiment to find comfortable positions, with pillows and lots of help. If the woman needs to be propped upright following a general anaesthetic, she will need help with pillows to be able to feed in a good position without pulling the breast out of the baby's mouth. The back rest of the bed should be in its upright position with a pillow across her lap and the baby resting on the pillow. The pillow can be at her side and the baby lying on the pillow with its feet tucked under her arm (also known as the rugby hold or under arm position)." Another way for the baby to feed in hospital is lying on a pillow on the meal table that fits over the bed (Francome et al. 1993, 87).
The constant reference to the need for help reinforces a sick patient image. The text paints a frightening picture of a passive recipient of midwifery care. Of course, any mother who has had a caesarean section will need help; that is common sense. But saying it over and over again creates uncertainty and anxiety. Almost every midwife has seen a mother jump out of bed soon after caesarean section to have a cigarette in the day room! Karen Pryor, marine biologist, highlights a rewarding aspect of lactation that helps a mother take a personal and growing interest in her newborn. She discusses a flooding sense of peace and joy that some human mothers describe as their milk lets down. One mother says, "It's much more relaxing than a cigarette and just as habit-forming" (Pryor 1963, 70).
The Pillow: A Technology Inviting the Vengeance of Nemesis
The pillow is mentioned seven times in the short text above. A pillow figures in almost every picture showing mothers breastfeeding. In three years of intensive work as a breastfeeding facilitator, I observed up to 20 mothers a day in the first interactions with their new babies. I have noticed that laying the baby on a pillow generally encourages the baby to turn on his back and the mother to lean forward, often causing back strain and nipple pain. Mother's arms are designed to hold their babies so that they can access the breast. Just like when sleeping or watching television, a pillow is an excellent support for arms, back or neck. Neither midwives nor mothers need to be taught this.
Furthermore, the idea of a baby lying on a pillow on a meal table is so contrived and far-fetched that it surpasses all comment. Instruction on the use of the pillow is an artefact and a prime example of how to obliterate normal common sense. For many mothers the pillow is a technological tool that has become a tyrant.
Breastfeeding Metaphors: Gender Dominance
How many mothers or midwives have ever held a rugby ball? The "rugby hold" is the ultimate in male dominance and control of a uniquely feminine act. To instruct a new mother to hold her baby like a rugby ball or like a football has been responsible for much Breastfeeding Nemesis. Mothers and babies are punished by the unwanted side effects of nipple pain and general malaise.
Management, instructions, supervision, help, expert, advice, weaponry, equipment—is it not time to become aware of a "midwife technician"?
Breastfeeding Nemesis has robbed many mothers of the healthy stresses of the first days with a new baby. Karen Pryor (1963) describes how animals learn mothering this way: "Mammal mothers do not do a perfect job the first time…. Innate elements of (maternal) behavior are merely a rough framework. Experience provides the details and finesse. How much of the behavior is innate may vary from species to species, but the dismaying sense of ignorance seems to be universal."
"In 1850 a new mother learning to take care of her first baby may have felt nervous, but she was bolstered by the firm conviction that whatever she did was right."
Breastfeeding Nemesis is resistant to current midwifery care. It is probably as easy to reverse Breastfeeding Nemesis as it is to introduce new ways of thinking about breastfeeding. Differences in perception of the word resource can illustrate this. The thought patterns usually associated with midwifery resourcing evoke cost effectiveness on the one hand and emphasise the acquisition of midwifery knowledge, skills, values and techniques on the other. The central role of the midwife as knowledgeable and expert implies a knowledge base, consistent advice, and the use of technology to enhance performance. In many aspects of midwifery care, this is appropriate. Concerning breastfeeding, these terms are "thinking blinders." Let us put these usual thought patterns aside.
A New Mindset
The Oxford dictionary states "to recover" as a primary definition of the infinitive "to resource." In other words, to resource someone involves a return to origins or a return to "the source." We all come from different origins and this may be one way to step out of the "expert, consistent knowledge and advise role" involved in traditional paradigms of midwifery care.
Resourcing Midwives to Resource Mothers
Breastfeeding is an integral part of the reproductive cycle, and a first step in slowing down nemesis may be to recover this integrity and return the newborn baby to its mother's arms. In the first moments and hours following birth, putting the mother's arms and body in as much skin to skin contact as desired is a breastfeeding resource for both mother and baby (Odent 1977; Righard 1990; Colson 1997).
Passive observation of this interaction is a humbling learning experience. "The observing gaze refrains from intervening: it is silent and gestureless" (Foucault 1973:107).
Part of resourcing is to recover the role of the midwife ethologist.
- Colson, S. (1997). Some perspectives on breastfeeding with particular reference to caesarean section. New Generation Digest (NCY), December 1997: 9-11.
- Foster, K., Lader, D., and Cheesbrough, S. (1997). Infant Feeding 1995. London: Crown, copyright HMSO.
- Foucault, M. (1973). The Birth of the Clinic. London: Routledge.
- Francome, C., Savage, W., Churchill, H., and Lewison, H. (1993). Caesarean Birth in Britain. Bounds Green, London: Middlesex University Press.
- Illich, I. (1975). Medical Nemesis: The Expropriation of Health. London: Marion Boyars.
- Leboyer, F. (1974). Pour une naissance sans violence. Paris: Editions Le seuil.
- Odent, M. (1976). Bien Naitre. Paris: Editions de Seuil. (Entering the World. 1985). Penguin Books.
- Odent, M. (1997). The early expression of the rooting reflex. Paper presented at the 5th International Congress of Psychosomatic Obstetrics and Gynaecology, Rome, 1977. London: Academic Press.
- Pryor, K. (1963). Nursing Your Baby. Harper and Row.
- Righard, L., and Alade, O.M. (1990). Effects of delivery room routines on success of first feed. The Lancet, 336: 1105-07.
- Rothman, B.K. (1982). In Labour Women and Power in the Birthplace. London: Junction Books.
- Royal College of Midwives. (1988). Successful Breastfeeding. London: Churchill Livingstone.
- Sweet, B.R. with Tiran, D. (1997) Mayes' Midwifery. London: Balliere Tindall.
- Woolridge, M.W. (1986). The anatomy of infant sucking. Midwifery, 2: 164-171.
If you enjoyed this article, you'll enjoy Midwifery Today magazine! Subscribe now!