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
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
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
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
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
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"
Part of resourcing is to recover the role of the midwife ethologist.
Suzanne Colson is a research Midwife and
lactation midwife at East Kent NHS Trust. England. Click here for complete biography.
- 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.
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