SUPER-NATURAL BREASTFEEDING: HOW LACTATION CONSULTANTS IN HAWAI‘I DEMEDICALIZE AND RESHAPE WOMEN’S EMBODIED

EXPERIENCES

A DISSERTATION SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI‘I AT MĀNOA IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE DEGREE OF

DOCTOR OF PHILOSOPHY

IN

ANTHROPOLOGY

May 2021

By

Crystal Renee Cooper

Dissertation Committee:

Jan Brunson, Chairperson Carmen Linhares

Eirik Saethre Ty P. Kāwika Tengan

Aya Kimura

ii

Acknowledgements

This dissertation would not have been possible without the support and advice of my committee members, friends, and family. First, I would like to offer my thanks and appreciation to my committee members for their guidance. As my advisor and committee chair, Dr. Jan Brunson was especially helpful, providing me with exactly the right advice in addition to warm support. She somehow endured reading many bad early chapter drafts without expressing anxiety, and continually encouraged me to share these stories. Thank you, Dr. Brunson, for your kindness, wisdom, and sense of humor. I would also like to thank Dr. Eirik Saethre for teaching me so much over the years and for the best advice ever for how to start writing after you’ve been in the field. Thanks as well to Dr. Tengan, Dr. Kimura, and Dr. Linhares for sharing your knowledge and offering your encouragement.

A special acknowledgement is in order for Dr. Andrew Arno, a committee member who passed away before this dissertation was completed. Dr. Arno was always gracious with his time and attention and truly cared about students. He felt that this research was important and was invested in assisting my efforts. It would be hard to find a kinder man, and while his careful thought and interest was appreciated, his absence is missed. My deepest gratitude goes to all the women who agreed to be part of this dissertation research, and especially to the lactation consultants who so generously gave of their time and effort to help me become an IBCLC and allowed me to participate in and observe their work on behalf of mothers and babies. You all offered your time in the spirit of a sisterhood of support and taught me so much about care work and how women can uplift other women. It has been an honor to learn from you. Thank you to all of the other individuals who are too numerous to name but nonetheless were supportive of me along this journey, whether you offered encouragement, practical assistance, or a much-needed break. Finally, I owe an incredible amount of gratitude to my kids for the many years that they tolerated having a single mom who worked, attended school, and struggled to have much energy for them at the end of the day. You are the reason I did all of this, and as I worked with and wrote about mothers and babies I was reminded of all the struggles and joys we have shared that have made my life so rich. I thank you and love you with all of my heart.

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Abstract

Women’s difficulties and negative experiences with breastfeeding have prompted a

backlash in the U.S. against its promotion, as well as attempts to change the discourse to

say it is insignificant and potentially dangerous with benefits that are overstated. My

dissertation examines how lactation consultants in Hawai‘i confronted dominant

ideologies that affect breastfeeding and helped women having difficulties. Data was

collected over 2.5 years through participant observation at La Leche League meetings,

with 7 lactation consultants and their clients, IBCLC training with 4 of the lactation

consultants, and interviews of 8 lactation consultants and 15 clients. The research

uncovers the contrasting concepts of lactation consultants and breastfeeding mothers. It

demonstrates that dominant ideologies inform women’s concepts of the lactating body as

likely to fail, and this promotes medicalization and ignores structural barriers. It provides

insights into how lactation consultants help mothers form new concepts for positive

embodied experiences, and demedicalize breastfeeding from within medical

environments. It is significant for its contribution to efforts to improve maternal and

infant experiences and health outcomes, and its contributions to the anthropological

literature on medicalization, embodiment, and science as culture.

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TableofContents

ACKNOWLEDGEMENTS.........................................................................................................................................ii

ABSTRACT...............................................................................................................................................................iii

FORWARD........................................................................................................................................................vi-xiii

CHAPTERONE,INTRODUCTION.........................................................................................................................1

Introduction...............................................................................................................................................................................1Theoreticalframework..............................................................................................................................................................9Researchmethodsanddesign.........................................................................................................................................35Dissertationoutline.............................................................................................................................................................43

CHAPTERTWO,THERISEOFLALECHELEAGUEANDTHECREATIONOFTHEIBCLC.................49

Introduction............................................................................................................................................................................49TheEraoftheIBCLC............................................................................................................................................................49

Theresultsofbreastfeedingactivism.................................................................................................................65TheInfluenceofLaLecheLeagueontheCreationoftheIBCLC......................................................................72“Natural”ParentingandtheExpert..............................................................................................................................80

Infantcareandevolution............................................................................................................................................87Instinctsandsocialstructure....................................................................................................................................92

Conclusion………………………………………………………………………………………………………………………………...….97CHAPTERTHREE,BECOMINGALACTATIONCONSULTANT................................................................103

Introduction………………………………………………………………………………………………………………………….103IBCLCCertificationRequirements..............................................................................................................................103MySocializationintoaMedicalRole.........................................................................................................................105MyStory.................................................................................................................................................................................106TheLactationConsultants’StoriesAboutWhyTheyBecameIBCLCs.......................................................117

Mary..................................................................................................................................................................................118Karen.................................................................................................................................................................................121Tina....................................................................................................................................................................................124Sandra..............................................................................................................................................................................125Yui......................................................................................................................................................................................127WICIBCLCs.....................................................................................................................................................................131

TheTraining.........................................................................................................................................................................136Conclusion.............................................................................................................................................................................144

CHAPTERFOUR,SUPER-NATURALWHITEBLOOD:THECONCEPTSLACTATIONCONSULTANTSHAVEABOUTBREASTFEEDING.....................................................................................................................146

Introduction.........................................................................................................................................................................146Themagicalpowerofbreastmilk...................................................................................................................................147Theanthropologyofscience,technology,andthenatural..............................................................................165Howbreastmilkhasbeenconceptualizedaswhiteblood...............................................................................171‘PurityandDanger’...........................................................................................................................................................178Theexternalwombandthemakingofabiosocialbeing.................................................................................184

Themagicalhour........................................................................................................................................................187BreastfeedingandBonding.....................................................................................................................................194Drainedmothersandtheirbreastfeedingvampires....................................................................................201

Conclusion.............................................................................................................................................................................211

CHAPTERFIVE,BROKENMACHINES:THECONCEPTSMOTHERSHAVEABOUTBREASTFEEDING..................................................................................................................................................................................215

Introduction.........................................................................................................................................................................215

v

ThesocialconstructionoflactationpathologyandbreastfeedingnormsintheU.S...........................216Learninghowtobreastfeed..………………………………………………………………………………………………….225MeasuringMilk...................................................................................................................................................................238Ritualizedquantification................................................................................................................................................246Whatisasufficientsupply?...........................................................................................................................................251Trackinginputandoutput............................................................................................................................................252Measuringmilkwithapump.......................................................................................................................................254Preandpostbreastfeedingweights..........................................................................................................................254Growthcharts.....................................................................................................................................................................255

Breastfeedingandepistemology.................................................................................................................................256APhenomenologyofbreastfeeding……………………………………………………………………….........................266

Mysteriouspains................................................................................................................................................................266Emotions................................................................................................................................................................................275Conclusion.............................................................................................................................................................................277

CHAPTERSIX,LACTATIONCONSULTANTSHELPMOTHERSMAKE‘SENSE’OFBREASTFEEDING..................................................................................................................................................................................279

Introduction.........................................................................................................................................................................279Yui,intheJapaneselactationmassageclinic........................................................................................................281Tina,inthehospitalpostpartumunit.......................................................................................................................289

Karen,inthepediatricclinic.........................................................................................................................................302Sandra,inthenon-profitclinic....................................................................................................................................311

Conclusion...........................................................................................................................................................................321

CHAPTERSEVEN,CONCLUSION.....................................................................................................................325

BIBLIOGRAPHY...................................................................................................................................................331

vi

Forward

As I set out to do this research I watched as articles, books, blogs, and interviews

with academics and indignant mothers claimed that breastfeeding’s benefits have been

overstated. The academics (Balint et al. 2018; Grose 2014; Oster 2015; Jung 2015, 2016;

JB Wolf 2011) and journalist Hanna Rosin (2009), who were critical of the promotion of

breastfeeding, claimed that studies didn’t support definitive enough and large enough

health benefits to breastfeeding in developed countries to warrant promoting it. They also

argued that benefits to breastfeeding were likely because moms who tend to breastfeed

have a socioeconomic advantage. Thus, the type of mother who breastfeeds is more likely

to feed her children nutritious food and take them to doctor appointments, giving them a

greater health advantage due to those factors, and not breastmilk. Promoting

breastfeeding, some argued, makes women who can’t or don’t want to breastfeed feel

guilty, and the trade-off isn’t worth it.

Some lactation experts and advocates came back with their own arguments for

breastfeeding’s promotion, also using scientific arguments and research to make their

point, or by saying that the types of studies that would satisfy critics, randomized

controlled trials, would be unethical to do (Cassels 2015; Grayson 2016; Hausman 2013;

M. Martin 2014; Quinn 2014). Mostly, however, there was a deafening silence in the

media when it came to the support of breastfeeding or a critical analysis of research,

while they publicized opinions that it didn’t really matter from a health outcomes point of

view whether or not you breastfed your baby. “Lactivists,” a term created to describe

lactation activists who work towards reducing barriers to breastfeeding, often lactation

consultants, were blamed for making mothers feel guilty if they couldn’t or didn’t

vii

breastfeed and were accused of having an anti-feminist agenda (Curzer 2016; Jung 2015;

Steph 2016; Tuteur 2017).

In the meantime, I was going through the training process required to become an

International Board Certified Lactation Consultant (IBCLC) as part of my participant

observation of lactation consultants and their consultations with mothers1. I was attending

a lactation class in California since there wasn’t one offered in Hawai‘i at the time. One

day a woman in the class wore a t-shirt that listed the benefits of breastfeeding. She came

back from her lunch break distraught and said that while standing in line at Starbucks the

woman in front of her had turned around and contemptuously said to her, “I can’t believe

you are wearing that shirt!” The man behind her then added, “I can’t believe you are

wearing it either!” The women in the class wanted to know how she had responded to

this, but she said she was so stunned that anyone would be opposed to a shirt that she saw

as having a positive message that celebrated women’s bodies and was good for babies,

that she couldn’t think of anything to say at all. People were now publicly speaking out

against breastfeeding promotion or advocacy by shaming those who they considered

shamers. This spilled out into a social media group for lactation consultants who sought

advice and emotional support from each other in the face of what they considered being

bullied by backlashers online.

Time Magazine (Pickert 2012) had previously stoked the fire for the sake of profit

by featuring a woman breastfeeding a three-year-old on its cover under the provocative

1ThroughoutthisdissertationIusetheterms“breastfeeding”and“mothers.”Irecognizethattherearetransmasculineparentswhoprefertheterm“chestfeeding”orneutraltermssuchas“nursing,”and“parent.”Iprimarilyusetheterms“breastfeeding”and“mothers”inthisdissertation,however,becauseitisbasedonresearchthattomyknowledgedidnotincludeobservationsoftransmasculineindividuals.Also,IusethesetermstoreflectthatthediscourseIstudiedandrefertousestheterm“breastfeeding”andrefersto“mothers.”

viii

title, “Are you mom enough?” It prompted an angry response from women on social

media who saw it as a sign that indeed pressure on mothers had gone too far. Mostly,

though, people were appalled that a woman would breastfeed a three-year-old, adding

irony to the outrage over judging mothers. My sister, who lives in Missouri, looked

everywhere for the magazine and couldn’t find it on the shelves. A store manager told her

that no one would put it out for sale around there because it was incestuous. Other stores

around the country put a cover over it reminiscent of those placed on adult magazines

(Lipkin 2012). The shock value had reverberating effects, with mostly critical comments

and articles related to breastfeeding toddlers following (Ackerman 2012; Rosin 2012;

Wilson 2012). The cover had achieved further mainstream exposure when shows like

Saturday Night Live and The View discussed it. As much as people were repulsed by it,

they couldn’t stop looking at and arguing about it. A writer for The Washington Post

called it “mommy porn,” adding, “We want to watch you do it. We want to see pictures

and videos and read blog posts” (Petri 2012).

The formula company Similac then began profiting off of “mommy wars” with an

ad that showed various categories of mothers such as stay-at-home, working, stroller

using, baby wearing, breastfeeding, and formula feeding moms, in an angry showdown

where each group claimed superiority over the others. Then a stroller is shown rolling

down a hill and all the moms chase after it while the message that Similac gives is stop

judging, “we are parents first.” The ad quickly went viral, and the conversations that

followed online were about how much mothers felt judged rather than a critical look at

how the commercial was perpetuating what it claimed to be trying to stop and why, or

what structural forces were responsible for mothers “failing” and feeling shame. It was a

ix

masterful distraction away from ultimate causation and put the blame on women

themselves.

The commercial makes all mothers seem hysterical and implies that they should

be silent. It frames mommy wars as built on parenting choices rather than seeing

parenting practices as an outcome of structural forces. The focus on “choice” reinforces

guilt by not addressing the structural barriers that cause women to fail and then blame

themselves, and it reinforces the idea that other mothers are judging them. As long as

women are looking the other way and are blaming themselves or each other, those

barriers (including formula marketing) persist. Talking about it as “mommy wars” is to

see women divided into groups that are in conflict with one another, when in reality, they

are all confronting structural forces that make it difficult to mother. The fact that mothers

are reacting emotionally to these issues is a signpost that should say to us that something

is wrong, and we need to listen instead of silence them.

A majority of women now try breastfeeding, but sustaining it is another issue

(CDC 2016). Women who consider themselves part of the backlash against breastfeeding

promotion often see the world as hostile to mothers who do not breastfeed. When we talk

about breastfeeding as a choice, we ignore the fact that for some women there is no

choice at all for what is usually socioeconomic reasons. Breastfeeding mothers, on the

other hand, tend to see the world as hostile to them. For them breastfeeding may be

thought of as a choice, but a radical choice in which making it is to go against the grain of

our social values (Buskens 2001). This is evident in the quotes I include in chapter five in

which women talk about feeling unsupported in breastfeeding by those who are closest to

them and who object to them breastfeeding around others or breastfeeding a child beyond

x

a certain age. To go against your family is no small thing. It is also evident in the stories

of women who try to pump in a corporate environment where values are very different

from the values we expect of mothers.

The backlash against breastfeeding promotion may come across as an

empowering reaction to a biopolitical campaign that has made women feel pressured to

feed their babies a certain way, but that is myopic. As Tomori (2015) has argued, much

of the backlash actually reinforces neoliberal ideology. This is evident in the arguments

against public health advocacy for breastfeeding and in the idea that women should take

personal responsibility for their parenting and healthcare decisions by seeing them as

choices. In fact, the Trump administration refused to vote on a resolution to “protect,

promote, and support breastfeeding” and “limit the inaccurate or misleading marketing”

of infant formulas at the 2018 United Nations affiliated World Health Assembly, with

their objections couched in neoliberal terms (Jacobs 2018). A spokesperson for the

Department of Health and Human Services defended their stance on the resolution by

repeating words that have been used by critics of breastfeeding advocacy by stating that

“not all women are able to breastfeed,” implying a widespread problem of dysfunctional

bodies. They also said that infant feeding is a “choice,” that alternatives should be made

available, and women should not be “stigmatized” for their choices (Jacobs 2018). These

arguments not only downplay the importance of breastfeeding but also support a lack of

regulation of formula companies despite a history of exploitative acts. They also ignore

the fact that there are structural barriers that are responsible for many women being

unable to breastfeed and that these barriers emerge through ideological policies and

xi

practices that reinforce the dominance of patriarchy, biomedicine, institutional racism,

and capitalism.

This dissertation goes beyond Tomori’s (2015) argument and examines how such

ideologies affect breastfeeding mothers and the act of breastfeeding, and then in turn how

lactation consultants address ideologically created issues as they attend to those mothers.

As I spent time with lactation consultants I began to see them as similar to nurse

midwives, who were trying to protect the integrity of childbirth within a biomedical

system that caused women to mistrust their bodies and seek technological solutions when

they weren’t necessary and were in many cases harmful. What is surprising to me is that

midwives have been hailed as feminist heroes that empower mothers, while lactation

consultants have been denigrated as zealots who oppress women. The lactation

consultants I studied tended to straddle two worlds, trying to carefully use technology

only when necessary while encouraging women to trust their bodies and tune into their

embodied knowledge. Their activism is an attempt to change concepts at the individual

level within institutions, but also to target the ways that social structures fail to support

breastfeeding mothers. Policy changes, however, only go so far when social values

remain the same.

I contend that breastfeeding is socially significant because it is bound up in our

values and concepts. The trend has been to argue over whether or not breastfeeding lives

up to health claims without attention to the fact that both the barriers and solutions to

many of women’s difficulties are social. This research does not discount the health-

related significance of breastfeeding, however, and determines that the biological is in

fact social. Those who simply argue over breastfeeding’s degree of health benefits,

xii

however, are reducing it to a physiological process that has no social significance. For

example, breastfeeding is enacted in a different environment than our ancestors would

have breastfed in, where the social structure included alloparents who helped take the

burden off of individual mothers, and where women had the ability to take their infant to

work with them (Lancy 2015). We not only have a different social structure with values

that are incompatible to the characteristics we expect of mothers, but we have social

concepts about the breasts as sexual and the female body as likely to fail. These concepts

do not stand alone from our social structures but are constitutive of them and by them.

Social factors affect the body, the experience, and the outcomes of breastfeeding. This

study points to the scaffolding upon which our experience is built, to see that our

perception and embodied cognition are embedded in a sociocultural reality. An emotion

like guilt from not breastfeeding due to difficulties isn’t a passive reaction to events, but

an active making sense of the physiological condition of the body in the world (Feldman

Barrett 2017). In other words, you can’t separate the mind, the body, and the environment

and social world. This study looks at how sociocultural factors construct the concepts that

we form about breastfeeding, how those concepts affect women’s embodied experiences,

and how lactation consultants in this study helped women form new concepts for a

different embodied experience.

Torres (2014) points out that lactation consultants focus on empowering women

to believe that their bodies are not dysfunctional and can produce milk, but at the same

time appear to maintain the moral elevation of breastfeeding. Torres (2014) concludes,

however, that they medicalize breastfeeding in order to demedicalize it. In other words,

their medical authority allows them to influence institutional responses to breastfeeding

xiii

in order to normalize it rather than pathologize it, assist mothers in self-advocacy, and

restrict unnecessary interventions. This study supports Torres’ understanding of lactation

consultants de-medicalizing and also medicalizing to demedicalize, and expands upon it.

The lactation consultants in my study didn’t just advocate for changes in institutional

practices but took aim at the devaluation of women’s reproductive bodies and

breastfeeding that is behind the elevation of that which is technological, procedural, and

easy to manipulate and measure. Hereafter is an extended discussion of how lactation

consultants confront the confluence of ideology and embodiment to help women ‘make

sense’ of breastfeeding.

1

Chapter One

INTRODUCTION

An anxious mother bounced her fussing baby up and down while she paced the

room. She insisted that I tell her how to bring up her milk supply and exactly how many

ounces of formula she should be supplementing the baby with in the meantime. She

wanted to know how often and for how long she should be pumping, at what time of the

day she should pump, whether she should pump before or after the infant breastfed, and

how many ounces of milk she should aim to get from pumping sessions. She was the

mother of a 4-week-old and had come to a lactation clinic in Honolulu because she was

sure that she wasn’t producing enough breastmilk. Women who were concerned about

their milk supply were common among the clinic’s clientele. This woman told me that

she was certain that she didn’t have enough milk because although she nursed the

requisite number of times in a day, her breasts were no longer engorged the way that they

were when her milk came in. She had started topping her son off with a bottle of formula

after each breastfeeding session out of concern that he wasn’t getting enough breastmilk,

even though he had been gaining weight appropriately prior to this and had a habit of

spitting up the excess formula as if his stomach couldn’t hold any more.

I observed her breastfeeding while she sat on a loveseat and answered my

questions about the birth. The mother described a fairly standard hospital birth in which

she had delivered at 40 weeks, had been given an epidural for pain, and where IV fluids

had been administered during labor. She had struggled to get him to breastfeed after birth.

She thought that if only she had enough milk he might have wanted to nurse. Like most

babies he was sleepy on his first day of life and slept in the hospital bassinet for most of

2

that day. He had been supplemented with formula, but before they left the hospital he

latched on and breastfed just fine. His weight for all four weeks had been good.

As the mother nursed him, I looked for signs that he was properly latched onto the

breast, was transferring milk, and was satiated by the end, as I had been trained. I pointed

out to her that her infant was audibly and visibly swallowing milk the whole time and

was content. The breastfeeding session was unproblematic, so I explained to her that

breasts become engorged when the milk comes in at around 3-5 days after birth, but that

this engorgement doesn’t persist past a week or so. I told her that engorgement of the

breasts at that time is not just from milk, but also from a temporary increase in the blood

supply and edema. I emphasized to her that it was normal for women to have softer

breasts after a brief period of engorgement, and that this did not reflect how much milk

she had. In addition to the blood and edema receding after the initial engorgement, the

breasts adjusted the amount of milk they produced based upon how often the infant had

been nursing. This meant she would have enough milk without being overly full.

It was obvious from the woman’s exasperated sighs that she was not accepting

this. I tried explaining it to her in another way in case I hadn’t been clear, but she said

that she was sure that her breasts were not producing enough milk. She shook her head at

my explanations of why she didn’t need to pump or supplement and stated that she knew

that hard breasts meant that she was full of milk and soft breasts meant she had only a

little milk. My explanations were not convincing, and although she had come to her

conclusions by paying attention to changes in her breasts, she had decided that these

changes signified a problem. I asked an employee at the clinic who was also a

breastfeeding mom and had her infant with her at work to talk to the client as a peer.

3

I left the room while the two moms talked to each other and was happy to see

them both exiting the room soon after, smiling and laughing. To my surprise, the client

looked relieved and thanked me as she walked out of the clinic. I asked the employee

what had happened. She said she had simply lifted up her shirt, showed the mother her

breasts and said that she was exclusively breastfeeding her son. The client looked from

her non-engorged breasts to her big healthy baby and back again. Then, as if a light bulb

had gone off in her head, she said the woman had exclaimed, “Oh! It’s normal! You can

have soft breasts and still have enough milk! Thank you! Thank you!”

This woman’s fears about her milk supply, her automatic assumption that her

body had failed, and the desire to quantify and proceduralize her way to a solution, was

repeated many times with breastfeeding women that I encountered. This mother had

looked to her body to inform her about her milk supply but she came to the wrong

conclusion, one based in the expectation that we have grown accustomed to that women’s

bodies are likely to fail (Hall Smith, Hausman, and Labbok 2012). The biomedical

system believes that they are so likely to fail that they need monitoring by experts in

hospitals or clinics. I heard women express that they kept the sample of formula that they

received in the mail as a marketing ploy in the event that their breasts failed at 2am, and

that because their family members or friends had problems, they thought that they should

expect the same. At times women referred to their breasts as “broken,” and women who

sought the services of lactation consultants had sometimes interpreted normal functions,

such as how frequently the infant wanted to nurse, or the fact that one breast made more

milk than the other, as a signal that failing had commenced. Women tended to monitor

and discipline the likely to fail maternal body in the way that the hospital does, with

4

quantifying techniques, which are counter to the dynamic and relational aspects of

breastfeeding. I contend that biomedical ideology that makes women into docile bodies

and manages them under the notion that they are likely to fail, and the industrial and post-

industrial ideologies of efficiency, regimentation, data collection and quantification, a

focus on production over process, and the supremacy of technology and experts, are all

ways that ideology impact women’s concepts about breastfeeding. These dominant

ideologies either move mothers away from seeking embodied knowledge or when they do

turn to the body for knowledge, they tend to view it through an ideological lens.

Breastfeeding knowledge among women in the U.S. almost completely

disappeared when social and economic changes in society nearly erased the practice

(Jacqueline Wolf 2001). By 1972 the percentage of mothers who attempted to breastfeed

their infant at least one time was only 24% (Jacqueline Wolf 2001). In the late 19th

century doctors in the U.S. didn’t know enough about breastfeeding and often

recommended early weaning or formula to mothers who were concerned about their milk

quality or quantity. By 1930 Formula companies had convinced women in the U.S. that a

scientifically developed formula was preferable (Jacqueline Wolf 2001). This history is

detailed in chapter five.

In addition to a loss of breastfeeding knowledge among women because of

formula ubiquity, the medicalization of childbirth interrupted the ways in which mothers

and infants learned to use their bodies to facilitate breastfeeding together. An infant’s

ability to suckle at the breast can be impacted by drugs administered to the mother during

labor and from hospital procedures, sometimes impairing their ability to properly suckle

(Smith 2017). In a natural birth, biosocial signals are active between the mother and the

5

infant and are unaffected by the birth narcotics that would have otherwise made it into the

infant’s system and potentially suppressed the sucking reflex or made the infant too

drowsy (Smith 2017). Infants have autonomic and hormonal mechanisms that lead them

to go through 9 instinctual steps that result in self-attachment to the breast when left

prone on their mothers, skin to skin, in the immediate period after birth (Widström et al.

2011). Trevethan (2011) found that mothers having vaginal home births in all cultures

respond in predictable ways to newborns directly after birth. They tend to hold the infant

on the left side close to their heart, they touch the infant in specific manners, make eye-

to-eye contact, and talk to the infant in a high-pitched voice. She notes that there is

evidence to suggest that the high-pitched voice creates “arousal and orienting-quiet

responses” in the infant (Eisenberg et al. 1964, 264). Perhaps we can call these instinctive

actions by mothers since they seem to be unlearned, and maybe all of them facilitate a

regulatory state in the newborn that is conducive to breastfeeding. There is no evidence,

however, that women have instinctual breastfeeding behaviors outside of perhaps this

type of signaling to infants, which means breastfeeding for mothers is learned.

Women in populations where breastfeeding is ubiquitous and where they do not

experience biomedical practices that disrupt the mother and infant’s biosocial signals,

also seem to learn how to nurse in social situations. They may be exposed to other, often

topless women who are breastfeeding, which suggests learning by exposure to

breastfeeding. They may also receive help from female relatives. For example,

evolutionary anthropologist Brooke Scelza spent time with Himba pastoralists of

Namibia and interviewed 30 breastfeeding mothers. Many of the women reported that

there was a learning process they went through in order to successfully breastfeed. They

6

stay in their mother’s home for a period of months after giving birth, and she guides them

in how to breastfeed (Scelza and Hinde, K. 2018). In the Beng community, off the Ivory

Coast, various women visit a mother after she gives birth and those who have breastfed

before will give her advice (Gottlieb 2004). Additionally, these mothers and others would

have seen the changes that occur in the breasts, would have been exposed to variations in

breast anatomy, would have heard women tell stories about breastfeeding, and would

have seen the various ways that infants were held, how often they were nursed, how long

they nursed, and how they latched onto the breast. They might even have breastfed each

other’s infants at times and would have helped raise children communally to reduce the

burden on individuals (Lancy 2015). A Native Hawaiian lactation consultant told me

during my course of research that the ancestors of Native Hawaiians breastfed publicly

while topless and learned in this way. She said that today Native Hawaiians still practice

alloparenting and some nurse each other’s infants if the need arises. In all of these

cultures, young infants would have been worn by and breastfed by their mothers while

they worked, and an interdependence rather than independence would have been the

focus of early childrearing (Lancy 2015).

Marcel Mauss, in Techniques of the Body (1973), spoke of manners of moving or

posture that are socially learned through imitation and training. He called this the habitus,

and among his examples were that the positions women give birth in vary by culture, and

that each culture also has its own techniques for holding and caring for infants. This

collective knowledge was considered embodied by Mauss. In the above examples it

would have made breastfeeding seem “natural,” and would have hidden from awareness

7

the socially learned aspects of breastfeeding (See also Tomori, 2015 on a

“breastsleeping” habitus).

With the infant’s instinctual behaviors sometimes disrupted and an absence of

exposure to other breastfeeding mothers, women in this study sought knowledge through

what Bartlett (2002) calls “headwork,” which entailed reading books, attending

breastfeeding classes, consulting with experts, planning, and mentally working their

problems out. They also turned to technology and quantitative analysis of their

experience. Instead of thinking of the body as informative they tried to discipline it and

make it more productive through data collection, goals, regimens, and technology,

understanding successful breastfeeding to be a matter of preparation and the right mode

of thinking (see also Avishai, 2011 and Tomori, 2015). If they did look to the body, their

embodied experience was shaped by ideology that imagines the body as a machine to be

maintained. Other ethnographers have also found the biomedical model of childbirth and

breastfeeding to be based in industrial ideology with its focus on the product, technology,

and efficient production, and which views the body as a machine (Davis-Floyd 1992;

Dixon Whitaker 2000; Dykes 2005; 2009; Katz Rothman 2000; E. Martin 2001; Millard

1990).

This research establishes how mothers in the study that had breastfeeding

difficulties conceptualize and enact breastfeeding and then examines how lactation

consultants helped them use embodied knowledge to guide them. Lactation consultants

represent the major way that breastfeeding has been medicalized. The profession got its

start from the breastfeeding support group La Leche League, which was formed in 1956

when few women in the U.S. breastfed and those who did were seeking information and

8

support (Eden 2013). In 1985, La Leche League International created a panel of

healthcare professionals who were tasked with creating standards for a new profession

called the lactation consultant (Eden 2013). From this came the International Board of

Lactation Consultant Examiners, which certifies those who meet the standards as an

International Board Certified Lactation Consultant (IBCLC) (Eden 2013). To become

certified, one must undergo clinical training, have lactation education and other relevant

educational courses in health and science, and pass an examination. Lactation consultants

provide breastfeeding women with lactation education, counseling, and support in a

variety of settings, including hospitals, clinics, pediatrician’s offices, through the W.I.C.

program, and non-profit breastfeeding organizations (Thurman and Jackson Allen, 2008).

In chapter two I give a detailed account of the professionalization of the lactation

consultant.

In this study I underwent all of the requirements to become an IBCLC and both

learned about and observed how lactation consultants respond to the difficulties that

women have with breastfeeding. Because they are part of the medicalization of

breastfeeding one would suppose that they support that model. However, I noted as

Torres (2104) did, that they used their medical authority and position in medical

institutions to demedicalize breastfeeding from within. They selectively utilized

technology when they thought it was necessary and all but one lactation consultant that I

observed helped mothers turn to embodied knowledge. I present details in this

dissertation from participant observations to show how they did this. In cases like the one

at the beginning of this chapter in which the mother did look to her breasts to be a source

of information but mistakenly interpreted normal changes as a sign of dysfunction, I

9

describe ways in which lactation consultants drew women’s attention to particular

sensory elements of the experience. Those elements led women to see theirs and their

infant’s bodies as functional and informative. In cases where there was a problem, the

body was still shown to be a source of knowledge that could guide women through a

resolution.

Theoretical Framework

The theoretical framework for this dissertation draws upon theories pertaining to

the medicalization of women’s bodies, embodiment, ideology, and feminist theories of

mothering. This framework addresses the social realities in which breastfeeding is

enmeshed and how they affect biological functioning. The social and structural causes of

breastfeeding difficulties can be historically traced and theoretically understood.

Urbanization and subsequent social changes in U.S. society, including the rise of the

profession of obstetrics, caused the primary place to give birth to move from the home to

the hospital, with infant formula becoming the primary way to feed infants by the end of

the nineteenth century (Jacqueline Wolf 2001). This culminated in only 24% of mothers

in the U.S. breastfeeding upon leaving the hospital at the trends lowest point in 1972

(Wolf 2001, 197).

Medicalization is implicated here. For example, in 1930 a pediatrician noted that

women who gave birth at home with the assistance of a Chicago Presbyterian Hospital’s

outpatient program, seemed to be able to breastfeed without problems. Among mothers

who gave birth in the hospital, however, only 40% were still breastfeeding at discharge.

His investigation revealed that hospital nurses were weighing infants and giving them

10

formula out of concern for their weight loss after birth. When this practice was stopped,

the number of women breastfeeding at discharge went up to 85%. Other hospital

procedures such as administering medications, separating mothers and infants, and birth

interventions, have been blamed for having a negative impact on breastfeeding rates

(Smith 2017). Jacqueline Wolf (2001) notes that hospital births also meant that women

no longer attended each other’s births and gained and passed on knowledge. It

subsequently resulted in a loss of traditional knowledge among immigrant women as

well.

Urbanization also meant women began working outside of the home, and the

efficiency of the factory model was applied to breastfeeding with feeding schedules and

other regimentations used to teach infants self-control (Jacqueline Wolf 2001).

Additionally, the spread of germs in an urban environment along with germ theory meant

that the pasteurization of milk made cow milk seem safer than human milk and

introduced scientific mothering (Jacqueline Wolf 2001).

Biological anthropologist Katherine Dettwyler (1995) notes the effect that the

sexualization of the breasts in Western culture has had on the length of time that women

breastfeed. She states that most children in traditional societies wean between the ages of

2 and 4 years of age (1995). Erotic associations of the breast in the U.S., however, have

contributed to women limiting breastfeeding to young infants, as well as to women

refraining from breastfeeding in public where their breasts may be exposed. This arose

concurrently with other effects of urbanization as sex became associated with romance

rather than reproduction (Wolf, 2001).

In the 20th and 21st centuries, poor breastfeeding rates have been associated with

11

socioeconomic conditions with low-income minorities having the lowest rates (U.S.

2011). Breastfeeding duration is correlated with the number of hours a woman works per

week as well as the length of her maternity leave, with fewer work hours and longer

leaves showing increased duration rates (Fein and Roe 1998; Guendelman et al. 2009;

Mirkovic et al. 2014). Additionally, lower wage workers have reduced breastfeeding

duration rates when compared to professional, administrative, or managerial workers

(Galtry 1997; Hanson et al. 2003). Breastfeeding rates began to rise after the early 1970s

with the grassroots efforts of the La Leche League followed by government health

initiatives to improve maternal and child health (Wright & Schanler 2001; Grummer-

Strawn & Shealy 2009; Crowther & Tansey 2007). These initiatives relied upon scientific

studies that showed the health benefits of breastfeeding.

Today, despite such efforts, while 75% of mothers start breastfeeding after birth,

87% of those women are supplementing with formula before 6 months, with only 23% of

women still breastfeeding by one year (CDC 2010). Unlike other industrialized nations,

the U.S. has failed to implement enough policy changes that will help enable women to

breastfeed. While the Affordable Care Act works to have insurance companies reimburse

for lactation consultation, and make certain employers provide women with breaks for

breast pumping along with private areas to pump, there is still no mandate for universal

paid maternity or paternity leave2, maternity leaves are too short, there is a lack of

subsidized childcare or worksite daycares, and formula company regulation is lacking

(Tomori 2011; Calnen 2007 & 2010; Galtry 2000; Galtry & Callister 2005; Li et al.

2005). Thus, women with more privilege are better able to navigate the barriers than

2AsIfinishedthisdissertationtheU.S.Senatepassed,andthepresidentsigned,abillmandatingthatfederalworkersbegiven12weeksofpaidparentalleave.

12

others.

It is helpful to not only look at how ideas about and the experience of breastfeeding

have changed in the U.S. over time, but to understand how localized research fits into the

broader context of breastfeeding in the U.S. Anthropologists have written about women’s

experiences breastfeeding in other cultures, touching on various social and structural

issues that impact breastfeeding in localized ways (Gottlieb 2004; Gottschang 2008;

Hashimoto & McCourt 2009; Liamputtong 2007; 2010; Mabilia 2005; Maher 1992;

Scheper-Hughes 1993; Stuart-Macadam & Dettwyler 1995; Tomori, Palmquist, & Quinn

2018; Tsianakas 2007; Whitaker 2000; Zeitlyn & Rowshan 1997, Yimyam et al. 1999).

For example, Nancy Scheper-Hughes wrote about how formula marketing and

socioeconomic conditions that were specific to a shantytown in northeast Brazil,

contributed to women’s claims that they didn’t have enough breastmilk and influenced

their subsequent responses to hungry infants (1993). The strength of an anthropological

study is the ability of ethnographic research to uncover local variations and complexities

and yet relate how these are embedded in larger systems and trends. Because this study

was conducted in Hawai‘i, it uncovers such local variations as the popularity and practice

of Japanese lactation massage. Yet it is also relevant to the larger conversation about the

medicalization of breastfeeding and its effects, and methods for reducing barriers and

resolving breastfeeding issues.

Julie Kaomea (2005), a Native Hawaiian professor of education, claims that

settler colonialism has been “devaluing and supplanting indigenous Hawaiian child-

rearing knowledge and undermining Hawaiian families’ confidence in our ability to

successfully rear, nurture, and educate our young children” (79). Kaomea (2005)

13

illustrated this in part by describing her experience having a premature infant who spent

ten days after birth in an incubator in the NICU. Her supportive extended family was not

allowed in the NICU to help her care for her newborn, and she was considered an

extraneous factor:

Hawaiians have long acknowledged the benefits of breastfeeding, a topic that is recently vogue in child-rearing literature. We have a saying that health is as close as breast milk. But we recognize that it is not just the milk that is good for the baby. It is also the physical and emotional closeness, the poli aloha or circle of love made by the mother’s arms as she embraces her young child. Nevertheless, the point of the nurses’ comments was clear: As far as the NICU’s schedule was concerned, they wanted my milk but not necessarily my body. (83-84)

She noted that a majority of the families in the NICU were Native Hawaiian, which

didn’t surprise her given the statistics that say Indigenous people are at a higher risk of

premature birth. Yet the nurses who cared for the infants were mostly White and Asian

American. The nurses’ instructions and medical authority caused her to lose confidence

in her ability to know what was best for her infant, especially when she and her husband

had to demonstrate their ability to care for their infant before they were allowed to take

her home:

Upon bringing Mahina to my parents’ home, my husband and I tried to replicate the hospital environment as closely as possible. We washed our hands vigilantly and sterilized everything. We purchased a bassinet and an infant-weighing scale similar to the ones in the hospital. We stuck diligently to the 3-hour “change, feed, nap” hospital rotation. We copied a page of the nurses’ recording log and dutifully recorded Mahina’s intake and output, along with her temperature and weight to the nearest ounce—a practice that was difficult to keep up with just the two of us “nurses.” (I now longed for those monitors that I hated in the hospital.) Watching us, my parents tried to tell us to lighten up. “Take her outside in the sun and sit with her by the ocean,” my father suggested. “The sun will warm her body, and the sound of the ocean will soothe her.” “Let’s invite the family over,” offered my mother. “Everyone wants to meet her. Feeling the love and closeness of our family will help heal her.” But I had learned that parenting this tiny baby was much more complicated. I shrugged off my parents’ suggestions… (86)

14

There is an ‘ölelo no‘eau (Hawaiian proverb) that cautions: Mai käpae i ke a‘o a ka makua, aia he ola ma laila (Do not set aside the teachings of one’s parents for there is life there). As the days passed, I no longer yearned for the noisy alarms of the hospital monitors. I learned to tune in to my own instincts and the signals of my baby, and learned to listen once more to the gentle wisdom of our people, the ways that have sustained us for generations. (87)

Kaomea (2005) stressed that the discourse around public health statistics that show that

Native Hawaiians have a disproportionate amount of disease and premature birth, don’t

include an acknowledgement of the “exploitative history of imperialism and colonialism

that created our impoverished conditions…” (91). Those impoverished conditions, which

a disproportionate number of Native Hawaiians experience, are what is behind health

inequities (Kaomea 2005).

Before the arrival of Captain Cook in 1778, Hawaiians had a common-use land

tenure system. Under this system, the maka‘ainana (commoners) fished, hunted,

gathered, and practiced horticulture on land that they paid a tribute to the Ali‘i (chiefs)

for (Handy and Pukui 1998). The chief in turn was responsible to his people (Handy and

Pukui 1998). The Hawaiians practiced a system of purposeful cultivation and exchange

within the ‘ohana (family) and not by individual ownership (Handy and Pukui 1998).

‘Ohana dwellings ranged from the mountains down to the ocean within the ahupua‘a

(land division), and were the economic units of exchange (Handy and Pukui 1998). For

example, fishermen who wanted taro would get it from ‘ohana who cultivated taro further

inland, and those who lived further inland would go down to the ocean to get fish when

they needed it from the fishermen (Handy and Pukui 1998). During celebratory feasts

members of the ‘ohana would make contributions based upon what they cultivated,

fished, hunted, or crafted (Handy and Pukui 1998). War offerings and tribute given to the

15

ali‘i were given by the ‘ohana as a large collective, rather than by individuals or nuclear

family units (Handy and Pukui 1998).

King Kamehameha III enacted The Great Mahele in 1848, which ended the

shared use of land and introduced the concept of private property (Van Dyke 2007).

Under The Great Mahele, the land was divided between the mo‘i (king), the ali‘i, and the

maka ‘āinana, because Kamehameha III hoped this would keep the land from being taken

away from Native Hawaiians by foreigners, and also because western advisors had told

him that adopting a private property system would be economically advantageous for his

people (Van Dyke 2007) Unfortunately, neither of these things resulted from the Mahele.

Instead, land was taken in an illegal overthrow of the kingdom of Hawaiʻi by a group of

businessmen backed by the U.S government in 1893 (Van Dyke 2007) and Native

Hawaiians historically have had a lower mean income and more of them are living below

the poverty line than any other group in the islands (Kanaʻiaupuni, Malone, and Ishibashi

2005). Home prices are some of the highest in the nation and out of reach for many

Native Hawaiians who have thus been either pushed out of their own land or forced into

poverty.

For Hawaiians, land is about relationships (Arvin 2019; Roher 2016), and the land

itself is their ancestor (Arvin 2019). Arvin (2019) sees settler colonialism as focused on

exploiting land for profit and utilizing the law and ideology to possess it. In Hawai‘i,

possession has also occurred through the idea that Hawai‘i is a vacation paradise for the

enjoyment of White Americans (Arvin 2019). The position of Hawai‘i as a tourist

destination, keeps the political history and current struggles of Native Hawaiians hidden

(Fojas, Guevarra and Sharma 2018).

16

The Hawaiian creation chant, The Kumulipo (1972), tells us that the first

Hawaiian was nourished by the taro plant, his sibling, which was given by the ‘aina

(land). Sky Father, Wākea, married Earth Mother, Papahānaumoku. They had a daughter

named Hoʻohōkūkalani. Sky Father and Ho‘ohōkūkalani mated and had a stillborn infant

(Warren Beckwith 1972). The very first taro plant sprouted in the place where they had

buried that infant, springing from his body (Warren Beckwith 1972). They had another

child, Hāloa, who is considered the first Hawaiian person (Warren Beckwith 1972).

Hāloa was sustained by the taro plant that they fed to him and went on to be the ancestor

of all Hawaiian people (Warren Beckwith 1972). ‘Aina, ‘ohana (family), and food are all

intimately connected for Native Hawaiians, and this can be seen in the meaning of these

Hawaiian words (Handy and Pukui 1998):

The term ‘aina represented a concept essentially belonging to an agricultural people, deriving as it did from the verb ‘ai, to feed, with the substantive suffix na added so that it signified ‘that which feeds’ or ‘feeder.’ …The ‘buds’ or off-shoots of the taro plant which furnished the staple of life for the Hawaiian are called ‘oha. With the substantive suffix na added, ‘oha-na literally means “off-shoots,” or “that which is composed of off-shoots.” This term, then, as employed to signify the family, has, precisely, the meaning “the off-shoots of a family stock. …Elders and ancestors are kapuna, from kupu ‘to grow,’ with the suffix na added. (3)

Since taro was a staple plant for Hawaiians, ‘ai often referred to poi, which is made from

the taro plant (Handy and Pukui 1998). Taro is cultivated by breaking off the off-shoots

from the plant’s makua (corm), which translates to mean ‘father’ (Handy and Pukui

1998). Just as ‘ohana are the ones who feed, the informally adopted child is called kama

hanai, meaning feeding child (Handy and Pukui 1998). The adoptive parents are called

makua hanai, meaning feeding parents (Handy and Pukui 1998). This denotes the fact

17

that such adoptions involve the hanai child living in the home of the hanai parents and

becoming their responsibility (Handy and Pukui 1998).

The relationship between Hawaiians and the ‘aina is also evident in the ritual that

Hawaiian ancestors enacted when a woman needed her milk to flow (Handy and Pukui

1998):

When a mother’s milk was not flowing as it should a length of sweet potato vine was plucked with the right hand with a prayer to [the god] Ku, then another was snapped off with the left hand and a prayer to [the goddess] Hina. These two lengths of vine, with the latex or white sap looking like milk oozing out of the broken ends, were tied together and worn around the neck for several days. Or two pieces of the vine would be put into a calabash of water from a spring. Facing the east at dawn, the woman took a vine in her right hand and smote her right breast, with a prayer to Ku for a copious flow of milk. Then, taking the other vine in her left hand and smiting her left breast with it, she said a similar prayer to Hina. Both the milky sap, and the water from a flowing spring in which the vines were floated in the calabash, were believed to help induce the flow of milk for the baby. (pg. 88)

Ku was associated with the rising sun, and Hina with the setting sun. Thus a mother’s

milk was not something that her body alone bought forth, but was given through a

relationship with the ‘aina.

Christian missionaries who came to Hawai‘i tried to eliminate the ways ‘ohana

and alloparenting functioned for the Hawaiian people (Grimshaw 1989). A missionary

publication written in 1842 describes the frustration they experienced trying to get Native

Hawaiian mothers to parent in what they considered the correct way. They wrote that

mothers should not just walk off and leave their infants in the care of others, nor should

the infants be given to relatives to raise in their hanai system of informal adoption. They

emphasized the importance of the nuclear family in which the breadwinner husband

would seek employment outside the home, modeled on a capitalist system, and the wife

would be subservient to him, stay at home, and take care of the domestic sphere. They

18

tried to train Native Hawaiian women to make clothes and wash and iron them, sit on

chairs at tables, and use separate plates and utensils. Children were to be the domain of

their biological parents, who were to discipline them into obedience. To the missionaries,

mothers had an elevated status due to their sacred responsibility to bear and raise good

Christian children, but Native Hawaiian women didn’t seem to understand their

importance in this realm (Grimshaw 1989). One missionary wrote about how she had

tried and failed at making a list of Native Hawaiian mothers and their biological children

because several family members and community members would come forward claiming

to be a child’s mother. In the Hawaiian model, the burden on mothers was lessened

because others stepped in to help out (Grimshaw 1989).

According to Patricia Grimshaw (1989), the missionaries had tried to help Native

Hawaiian women to assimilate into American culture by giving them the skills necessary

to attain whatever power women were afforded within the American system. In doing

this, however, they had to strip Hawaiian women of the practices that gave them “some

level of autonomy within their own social system” (Grimshaw 1989, 44). This was a

clash of social and economic systems in which staying confined to the home, focusing on

raising your own children, and excelling at housework, was for Native Hawaiian women

to give up their communal system of support.

Native Hawaiians still maintain communal support, although it has been

challenging. I mentioned to Kehau, the Native Hawaiian lactation consultant who I

interviewed, that I had a conversation with Native Hawaiian students in a class I had

taught, in which they informed me that putting babies in cribs or strollers so that they

were seperated from you “is a White person thing to do.” She then added that Native

19

Hawaiians also practice “what in American terms would be called wet nursing. They do

that for their family.” I asked if this was done for a family member who was unable to

breastfeed, and she said yes, “or if you are away and they are babysitting.” Unlike the

history of wet nursing, however, this is not done as a source of employment and it does

not involve people of different social status. Kehau said, “They would breastfeed your

child. Like a sister to a sister. That’s common in our culture.” Native Hawaiians have a

history of alloparenting practices. They still practice informal adoptions of children called

“hanai.” Kehau explained hanai and alloparenting this way:

“In Hawaii, not just Native Hawaiians but Polynesians in general, we have a system which is called hanai, where everyone raises each other’s children and that’s just the natural way. Everyone takes each other [to be] auntie and uncle, even if you are a stranger. That’s just respect, and that’s how we were all raised so if someone has a need you help them whether you know them or not. For example, I’ve been doing this for 34 years. Over the years it’s been always the grandparents [that alloparent]. Like if the parents had to work. …Everybody just helps out, whoever can. Sometimes it’s the auntie or uncle. So, it’s whoever in the family… and it’s just one trust issue. You wanna have your family help as much as possible. Or just cost wise it’s so expensive to live in Hawaii. It’s just easier for a lot of people to live in one home. So, it’s usually generational that everybody lives together.”

This dissertation addresses the ideologies and epistemologies of breastfeeding

settlers in Hawai‘i, rather than of Native Hawaiians. I was only successful at getting one

Native Hawaiian mother to interview with me. The one Native Hawaiian lactation

consultant practicing on Oahu agreed to an interview but not to participant observation

with her in the largely Native Hawaiian community that she worked in. I was told by an

anthropology professor that the community had been over studied by researchers, and I

suspect this was a factor behind the reluctance I encountered. Tuhiwai Smith

acknowledges the reluctance to participate in research by Indigenous people, saying the

20

word research is “probably one of the dirtiest words in the indigenous world’s

vocabulary” because of the ways it has been associated with “the worst excesses of

colonialism” (2012:1).

Indigenous epistemologies are absent in settler public health initiatives and

biomedical practices. For example, in chapter four I quote a lactation consultant who is

concerned that medical personnel at the hospital she worked at were critical of a

Micronesian couple for their bedsharing practice and wanted them to get a crib. This is an

example of cultural ideology eliminating the beliefs and practices of Indigenous people

through the vehicle of institutions (Kaomea 2005; Rohrer 2016). In chapter two I discuss

another form of possession, through the belief that Indigenous people are closer to nature

(Arvin 2019). Because Indigenous parenting practices are considered based in nature and

not culture, it is assumed that anyone can adopt these “natural” modes of caring for

children. This belief also considers indigenous people to be primitive, undifferentiated

from other indigenous groups, and unchanging (Arvin 2019). It is the taking of

Indigenous parenting practices as one’s own but without the Indigenous epistemologies

and social structures that they are enmeshed in. This is an example of “Whiteness making

itself indigenous,” that Arvin (2019) discusses as a form of settler colonialism that occurs

in Hawai‘i.

My study of settlers in Hawai‘i, who mainly identify as White and Asian women,

demonstrates that concepts of breastfeeding as “natural” confront their own ideologies

and social structures that make learning and enacting breastfeeding difficult. White

claims to Indigenous parenting practices contributes to the backlash against “natural”

parenting (also at times called attachment parenting) because when stripped of

21

Indigenous epistemologies, values, and social structures, it leads to individual women

feeling burdened and shamed.

Those who participate in activism against breastfeeding promotion and policies

that aim to take away breastfeeding barriers, utilize neoliberal ideology to position

women as consumers who should be allowed to exercise choice. They aim to end

intensive mothering and protect women from a negative self-perception by being critical

of the moralization of breastfeeding and by encouraging further medicalization.

“Choice,” however, is a straw man since breastfeeding policy does not aim to take away

choice. Furthermore, one has to have enough privilege to enact a “choice.” Increased

medicalization may be one way of reducing a woman’s burden, but those who advocate

for it have enough privilege that any resultant reduction or cessation of breastfeeding

does not carry as much risk. Indigenous women have higher rates of preterm birth and

infant mortality (Smylie et al. 2010) and have more to lose from the activism of these

mostly White, middle class women.

On the other hand, one way breastfeeding activists have challenged claims that

breastfeeding’s benefits are overrated, has been to reinforce the idea of breastfeeding as

“natural.” Specifically, that science doesn’t necessarily need to prove breastfeeding’s

benefits because it points to breastfeeding as the evolutionary norm for the human

species. Arguing that contemporary women are doing what Indigenous people have been

doing throughout history, risks making the sociocultural context of breastfeeding

invisible, including the effects of colonization on indigenous health and ability to

breastfeed. Morgensen problemetizes a similar settler colonial logic in relation to

activism by examining how LGBTQ activists made themselves “analogous to racialized

22

or Native peoples” (2011:95) by identifying with indigenous homosexual and third-

gender practices and positioning “Native people as primordial to help non-Natives secure

settler citizenship” (2011:94). Both types of activism, an unproblematized understanding

of breastfeeding as “natural” and activism against breastfeeding promotion and policy,

mask the structural factors behind breastfeeding difficulties for all women.

Hawai‘i has a more diverse population and a social structure that Okamura (2008)

says is based on ethnicity rather than markers of race such as skin color. Thus differences

in beliefs, values, and cultural practices are the primary signifiers of group identity.

According to Okamura (2008), the privileged ethnicities in the islands are Chinese

Americans, Japanese Americans, and Whites.3 The less politically and economically

advantaged groups are mainly Pacific Islander and South East Asian ethnicities. This is

reflected in the group of fifteen mothers who agreed to be interviewed as part of this

research. They all self identified as middle class. When I talk about middle class mothers

in Hawai‘i, this includes a large number of Asian women even though this group is

underrepresented in the U.S. as a whole. The group of fifteen middle class mothers I

interviewed reflects Okamura’s (2008) observations of which ethnic groups have the

most privilege in Hawai‘i. While seven of the fifteen mothers claimed more than one

ethnic or racial identity, only two of the fifteen claimed to be neither White nor Asian.

Although during the course of this research I encountered some cultural beliefs

and practices that vary from what the dominant groups in the U.S. as a whole may engage

in, participants were still influenced by larger dominant ideologies and practices enacted

3I have chosen to capitalize the term “White” in this dissertation in recognition of it as a racial signifier that comes with privileges. Not capitalizing “White” gives the identifier power by making it a neutral standard. Ewing, Eve. 2020. “I’m a Black Scholar Who Studies Race. Here’s Why I Capitalize ‘White.’” Zora. July 2, 2020.

23

through local institutions. The majority of women in Hawai‘i are attended to in

pregnancy, birth, and postpartum in the biomedical healthcare system and live in an

economically stratified and globally connected world that places a high value on

technology and information. Therefore, all of the women who participated in this

research were affected by the ways that dominant ideologies are reinforced or resisted

through the medicalization of breastfeeding.

Several sociocultural anthropologists have written about women’s reproductive

health and its medicalization (Davis-Floyd 1992; Davis-Floyd and Sargent 1997; Davis-

Floyd and Christine Barbara Johnson 2006; Gammeltoft 2007; Ginsburg and Rapp 1991;

1995; Greenhalgh 1995; Inhorn 2007; Jordan and Davis-Floyd 1993; Kaufert and O’Neil

1990; Martin 2001; Rapp 2001; Van Hollen 2003; Wendland 2007; among others). The

medicalization of breastfeeding involves the formation of the lactation consultant

professional who manages breastfeeding issues in medical environments. While

anthropologists Robbie Davis-Floyd and Carolyn Sargent (1997) have edited a volume on

the effects of authoritative knowledge in childbirth, and many other authors have

examined the formation over time of its authoritative structures and knowledge

production in particular (Donnison 1999; Ehrenreich and English 2010; Murphy-Lawless

1998; Towler and Bramall 1986), there are only two studies besides this one to examine

the professionalization of the lactation consultant. Eden’s (2013) oral histories of the

founders of the IBCLC profession, is an anthropological study that examines the

professionalization and medicalization of breastfeeding. She found that lactation

consultants seek to be legitimized through biomedicine but work to empower mothers

and work against medicalization. Torres (2014) is a social scientist who also studied

24

lactation consultants and similarly concluded that they medicalize in order to

demedicalize. This study reinforces their findings and also contends that breastfeeding

mothers are influenced by the dominant ideologies of biomedicine that are enacted

through hospital practices and tend to experience the body as mechanical and defective as

others have noted (Davis-Floyd 1992; Katz Rothman 2000). In this study mothers were

encouraged to utilize disembodied techniques when it comes to breastfeeding, as Bartlett

(2002) found as well.

Anthropologists have also noted the ways in which the medicalization of women’s

reproductive functions has meant that the female body is objectified and thought of as

defective and in need of medical management (Davis-Floyd and Sargent 1997; Davis-

Floyd 1992; Eakins 1986; Hahn 1987; Kitzinger 2005; E. Martin 2001; Michaelson 1988;

Romalis 1981). Researchers believe that most women are physiologically able to

breastfeed and produce sufficient milk, and problems are most often related to

sociocultural factors rather than defective bodies (Gussler and Briesemeister 1980;

Trevathan 2010; Tully and Dewey 2010; Woolridge 1995). However, many women

maintain that they could not breastfeed because their body is defective, and they were

unable to make enough milk (Lauwers and Swisher 2011). The lactation consultants who

participated in this study believed a small number of women had a primary defect or

insufficiency, but the majority either had a secondary insufficiency that is induced by

certain practices, or had an adequate supply that they believed to be insufficient. This has

been called insufficient milk syndrome. Believing their bodies are defective can influence

women’s responses, which in turn can affect their milk supply. Mahon-Daly and

Andrews (2002) argue that it occurs in unsupportive environments where breastfeeding

25

may be marginalized, suggesting a connection between the biological and social. Bartlett

(2002) goes beyond unsupportive environments to suggest that a woman’s embodied

experience affects her biological responses, and that breastfeeding is often managed in

disembodied ways to poor affect. This study supports Bartlett’s conclusion but adds the

types of embodied methods that lactation consultants were observed using to successfully

help women with difficulties.

Despite these issues, breastfeeding rates are increasing, especially among middle

class white women, although exclusive breastfeeding and duration rates are still

considered low overall (CDC 2016). An increase in women initiating breastfeeding may

be due to a resurgence of women interested in natural childbirth and breastfeeding. This

change grew out of a movement to counter scientifically informed parenting, medical and

male control of women’s bodies, and to appropriate science (Bobel 2002; Klassen 2004;

Umansky 1996). The form this movement has ended up taking is intensive, exclusive

mothering (Chodorow, 1978; Hays 1998), sometimes also referred to as extensive or

immersion mothering, or associated with attachment parenting4. Exclusive mothering is a

term Nancy Chodorow (1978) first used to describe how gender roles in the U.S. are

organized so that mothers tend to be the exclusive caretakers of their children. Although

she went on to claim that this affected the personalities of children, more recently,

exclusive mothering has only been associated with mothers as primary caretakers in an

immersive style of parenting that Hays (1998) labeled intensive. To Hays (1998),

intensive mothering points to a style in which mothers are exclusively responsible for

4IuseChodorow’sterm“exclusivemothering”hereafterinordertoreflecthowthemodelisdifferentfromthatfoundintraditionalsocietiesinwhichalloparentingexists,meaningmothershadchildcareassistancefromextendedfamilyandothersinthecommunity.

26

how their children develop and practice a child-centered approach that is physically and

emotionally exhausting. Joan Wolf (2011) uses the term “total mothering” somewhat

similarly to talk about the practice of mothers devoting themselves to reducing every

possible risk for their children. Breastfeeding figures into exclusive, intensive

motherhood, as that which is best for babies and yet something only a mother can offer.

Critics claim that exclusive mothering demarcates good and bad mothers. The

ways in which breastfeeding becomes embroiled in the morality of mothers through its

promotion as what is “best” has been a part of that criticism (Blum 1999; Carter 1995;

Douglas and Michaels 2004; Jung 2015; Kukla 2005, 2006; S. J. Knaak 2006, 2010; R.

Lee 2018; E. Lee, Macvarish, and Bristow 2010; Law 2000; Lupton 2000; Murphy 1999,

2000, 2003; Rosin 2009; Schmied and Lupton 2001; Stearns 2010; JB Wolf 2011). These

scholars point out that women of color and poor and non-traditional mothers have

different experiences that are not taken into consideration, and they are often labeled as

the “bad” mothers because of their lack of resources or a different mindset about what

makes a “good” mother. They claim that exclusive mothering is a white, middle class

phenomenon that exists among women whose privileged status means they are able to

make the choice to fully devote themselves to intensive child rearing.

Linda Blum (1999) has specifically examined why African American women

have low breastfeeding rates. She relates it to an association with a history of slavery and

wet-nursing for white families, making racism central to her argument. She claims that a

history in which black reproductive bodies were not private and were exploited, as well

as current narratives of the black female body as dependent and oversexed, means they

have a different experience of embodiment than white women do. She concludes that

27

they will never experience the status that white women who are able to achieve exclusive

mothering achieve and often reject breastfeeding for all of these reasons.

Murphy et al. (1998) argues against talking about breastfeeding as a choice,

because it hides the constraints that make breastfeeding a difficult choice to make or

enact. Public health campaigns have attempted to persuade women to breastfeed under

the notion that it has health benefits, often without acknowledging those constraints.

Faircloth (2013) makes the case that affect and emotion explain more about women’s

choice making process. Tomori (2015) argues that those who challenge the science

behind breastfeeding promotion in order to present it as a choice out of concern that the

moralization of breastfeeding harms women, such as Rosin (2009) and Wolf (2007;

2011), are feeding into harmful ideologies. She believes that they incorrectly conclude

that breastfeeding benefits are overstated for developed countries and support a

technocratic view of formula. She further argues that in advocating the idea that

breastfeeding is a choice that women should make without the government stepping in to

support or recommend it, these critics end up advancing neoliberal, capitalist ideals.

Rippeyoung (2009) uses a similar type of argument aimed at those who advocate for

breastfeeding by connecting the promotion of breastfeeding to the idea of individual

responsibility for one’s own health. She argues that public health campaigns attempt to

present breastfeeding as a choice that becomes a woman’s individual responsibility in

order to evade dealing with the social problems that act as constraints. In this study, I

discuss the views of lactation consultants who believe that breastfeeding benefits are not

overstated, understand the power of emotions in the process of decision-making, and also

advocate for government actions that enable women to breastfeed.

28

This dissertation examines the concepts that lactation consultants have about

breastfeeding, which are in opposition to those of critics who claim breastfeeding’s

benefits are overstated. The lactation consultants in this study placed a high value on

establishing the benefits of breastmilk and breastfeeding through science. Medical

science education serves to give lactation consultants the authority to work in medical

institutions, and the scientific establishment of breastfeeding’s benefits is used as a basis

for research funding, advocating for breastfeeding friendly policies, and as a tool to

confront critics and counter the messages of formula marketing. They understand

breastfeeding and breast milk in complex ways, however, in which science legitimizes

and makes breastfeeding intelligible to a point, while also valuing breastmilk even more

because science and technology can’t fully explain or improve upon it. I utilize Rabinow

(1992) and Strathern’s (1992) analysis of the ways that biotechnology has modified that

which we have considered natural, and in the process has redefined the facts of life. In

redefining the facts of life, our definition of what is considered to be natural has changed,

and yet breastfeeding and breastmilk defy this and are a kind of super-natural. Its

dynamic, relational qualities make it special in a way that makes it most accessible in an

embodied way. Thus, most of the lactation consultants in the study helped women to tune

into their embodied knowledge rather than fill them with a lot of information or

procedural steps. This is both empirical and shifts the expertise to the woman herself. It

also shifts the center of intelligence from the brain to the body.

Some anthropologists (Tomori et. al. 2018) have looked at breastfeeding and

embodiment, with Tomori (2015; 2018) specifically discussing a habitus of

breastsleeping, by which she means techniques of sleeping next to your infant and

29

breastfeeding in the bed through the night. Tomori compares the biological and cultural

breastsleeping habitus of four cultures (2018) and she also examines how in the U.S.

breastsleeping developed into an embodied and relational practice that is morally

problematic (2015). She shows how the moral dilemmas either reinforce or disrupt ideas

of personhood, family relationships, and aspects of biomedicine and capitalism. In doing

so she articulates the embodied effects of these moral dilemmas which stigmatize all

women whether they successfully breastfeed or not, and relates the various ways they

negotiate them. Other social scientists have made a connection between negative

embodied experiences of breastfeeding, and early termination of breastfeeding (Avishai

2011; Bartlett 2005; Shaw & Bartlett 2010; Blum 1999; Britton 1998; Crossley 2007;

Dykes 2002, 2005; Gatrell 2007; Hausman 2007; Kelleher 2006; Murphy 1999; Schmied

& Barclay 1999; Schmied & Lupton 2001; Shaw 2004; Stearns 1999; Van Esterik 2002).

Many social scientists discuss ways that the lactating body knows. Hashimoto and

McCourt (2009) relate that women in Japan turn to their body and their infant’s body as a

source of knowledge. Bartlett (2002) points out that contrary to ideas in mothering books

that present the body as something unknowing, the letdown of milk is an example of

knowing located in the breast, and she wants to challenge the idea that we only think with

our brain. Similarly, Faircloth (2013) uses the metaphor “gut feelings” to establish that

bodily knowledge is communicated to us, but she cautions scholars not to make

breastfeeding mothers feel shame if they don’t use their instincts. In talking about let-

down, Bartlett (2002) sees the emotions as having major effects on the lactating body, but

states that breastfeeding books present emotions as negative forces that interfere with

breastfeeding and need to be controlled.

30

Other scholars have looked to embodiment to explain either how women learn to

breastfeed or as a suggestion for how they can best learn. Hashimoto and McCourt (2009)

look at how women in Japan distinguished between what it means to learn and to know

breastfeeding, with an understanding that learning takes place through instruction while

knowing is embodied. Knowing is described as a process that involves bodily practice

and a responsive relationship between the mother and infant where the mother can read

the signals of her body and that of her infant and follow bodily rhythms. In Ma’s (2018)

research, an interdependent understanding of breastfeeding where mothers read their

infant’s body signals, or cues, empowered mothers and helped them with breastfeeding

difficulties. Ma contrasts this with dis-embodying styles of learning, which can include a

focus on enumerations, information in books, and advice from experts. Bartlett is critical

of midwifery textbooks for presenting breastfeeding as something mothers need to be

taught through “headwork,” ultimately making success depend upon willpower instead of

embodiment. Ryan et al. (2010) showed that in women’s video narratives they described

pre-conceptual, embodied knowing when they were able to have an uninterrupted space

to breastfeed their infant.

Finally, some authors who write about embodiment and breastfeeding spoke of

the need for mothers to accept uncertainty (Hashimoto and Mccourt 2009; Ma 2018) due

to the dynamic nature of breastfeeding rather than try to control their lactating bodies

through measurements and timing (Ma 2018; Tomori 2015). Marion Young’s article on

pregnant embodiment can be applied to the dynamic nature of breastfeeding in that she

argues that phenomenological theory has not considered women’s embodied experiences,

31

and that the biomedical model leaves out women’s embodied experiences because it is

based on the idea that a healthy body is one that is unchanging in its states.

In this dissertation I draw upon and reinforce the findings that embodied knowing

in breastfeeding is a process of bodily practice and a responsive interbodied relationship

where moms listen to and respond to infant cues and their own bodily signals. I also

concur with Tomori (2015) that when breastfeeding goes against social values it has

embodied consequences. I found that lactation consultants believed that an uninterrupted

space was important for mothers and their infants, and in many instances they understood

dis-embodied styles of learning to be harmful. I add to this the idea of social learning in

the form of a habitus, as Tomori (2015) mentions.

This dissertation diverges from or presents more nuanced versions of the above

findings in a few ways. First, while many of the authors who write about breastfeeding

and embodiment are critical of medical professionals or experts, they do not specify

which professionals they are including in their conclusions, or assume all medical

professionals are the same and do not differentiate between the kind of lactation care one

gets from a doctor, nurse, midwife, lactation consultant, or other type of professional.

Bartlett (2002) is an exception to this because she examines lactation discourse in

midwifery textbooks. In my research I have specifically studied lactation consultants with

IBCLC certification, who are considered the premier experts on breastfeeding. Secondly,

I use constructivist theories of perception and emotion to suggest that emotions are

concepts; affective states that we have categorized and named. This allows for a more in-

depth theorizing in that I propose that all concepts have consequences for women’s

embodied experiences. Finally, while some authors (Hashimoto and Mccourt 2009; Ma

32

2018) speak of the need for breastfeeding mothers to come to accept uncertainty due to

the dynamic nature of breastfeeding, I offer a more nuanced understanding. I argue that

lactation consultants elevate the status of breastfeeding and breastmilk due to its dynamic

nature because this means it is relational, tailored to the individual infant’s needs, and in

some ways is beyond scientific understanding and bio-technical replication or

improvement. Yet, I also use ethnographic data to show how lactation consultants in this

study aimed to bring mothers certainty through embodied knowledge. I establish that they

believed that the senses help ‘make sense’ of breastfeeding. Thus, breastfeeding can both

be understood and defy understanding at the same time depending on its epistemic status.

I contribute to anthropological theories of the study of science as culture by

showing that lactation consultants understand breastmilk to hold special status as an

unmodifiable natural substance that cannot be fully replicated and whose components

can’t be effectively removed and used outside of the whole. This is because breastfeeding

is relational, and breastmilk is dynamic, responding to the specific bodies of both the

mother and the infant as they interact in a specific environment. Its components can’t be

extracted and used to the same effect outside of the whole because they are part of an

entire ecosystem with emergent properties. Rabinow (1992) and Strathern (1992) have

introduced the idea that biotechnology has modified that which we have considered

natural, and in the process has redefined the facts of life. In redefining the facts of life,

our definition of what is considered to be natural has changed. Breastmilk and

breastfeeding, however, defy this. I discuss how these ideas about breastfeeding as

dynamic, relational, and having a special status, motivated lactation consultants to help

33

the breastfeeding dyad, and to do so in very specific manners that aimed to demedicalize

breastfeeding and help mothers look to embodied knowledge to guide them.

I also contribute to the literature by looking at how mothers in this study who had

breastfeeding difficulties tended to have different concepts about breastfeeding than the

lactation consultants did. I show how ideological concepts affected women’s embodied

experience of breastfeeding. Ideologies are special kinds of concepts that make meaning.

I adopt Althusser’s notion of ideologies as ideas that contain and hide contradictions,

seeming to resolve them in order to maintain social order (Althusser 2014). According to

Althusser (2014), ideologies perpetuate inequalities by obscuring the ways that social

structures work against the interests of those who participate in them, and they are

disseminated through discursive avenues. The dominant ideologies of capitalism,

patriarchy and biomedicine produce individuals as subjects through institutional practices

(Althusser 2014). I show that this production happens at the perceptual level with

lactating mothers. The idea that breastfeeding is a choice hides the ways that women are

constrained through ideological apparatuses (Althusser 2014). I conclude that women’s

experience of breastfeeding is a perceptual construction that is often based in ideologies.

I then utilize Feldman Barrett’s (2009, 2017, 2017) constructivist theories of

perception and emotion to theorize about how women’s breastfeeding related perceptions

are constructed from concepts and how this shapes their embodied experience. I offer a

fine-grained phenomenological account of how the lactation consultants in this study

helped change women’s concepts and thus change their embodied experience for the

better. I show how they accomplished this by directing mothers’ attention to specific

34

elements of a sensory array and also used emotion to help mothers ‘make sense’ of

breastfeeding. I contrast this with an example of an authoritative, instructional model.

Finally, I also add to the literature with a symbolic analysis of breastfeeding and

breast milk concepts by drawing upon Douglas’s (1966) use of schemata to theorize

about the role of symbology and ritual in dealing with perceptual ambiguities. I use

ethnographic accounts to establish that many women resorted to ritualized quantifications

in the face of ambiguity in an attempt to create certainty.

This dissertation is thus an ethnographic study of how lactation consultants

confront dominant ideologies and re-shape women’s breastfeeding experiences. I

conclude that lactation consultants have concepts about breastfeeding as dynamic and

relational and the body as informative, which is in contrast to women’s ideologically

based concepts of the lactating body as likely to fail. Most of the lactation consultants in

the study demedicalized within medical environments and created new expectations to

help women access their embodied knowledge in order to improve the breastfeeding

experience.

This study is important for understanding the sociocultural influences on

breastfeeding experience, and for establishing what types of actions will help women

with breastfeeding difficulties. It is also relevant to current debates around breastfeeding

in which the trend is to change our concepts about breastfeeding to keep women who

can’t or don’t breastfeed from feeling guilt or shame, or to view breastfeeding as

dangerous in order to protect infants from unintentional starvation. These new concepts

consist of the idea that breastfeeding is not important because its health benefits have

been overstated, and have included attempts to increase breastfeeding’s medicalization

35

and make formula use more acceptable. Based on my findings, these new concepts feed

into established discourses that women’s bodies are dysfunctional and communicate that

there is nothing to appreciate about the embodied breastfeeding experience. Those who

perpetuate these new concepts ignore the social significance of breastfeeding and

exchange negative emotional experiences about mothering for increased negative

emotions about and estrangement from the body. They also do not acknowledge the

connection between a woman’s concepts about breastfeeding and her embodied

experience and actual breastfeeding outcomes. Accessing embodied knowledge is a way

that lactation consultants in this study tried to help mothers breastfeed, and understanding

how this occurs, provides a constructive way of confronting negative breastfeeding

experiences while empowering women.

Research Methods and Design

The idea of “giving back” to the community in which you conduct research was a

response to the criticism that researchers cannot justify their research on claims that they

are benefiting everyone through their knowledge production. The gaze of the Western

researcher over people considered “other,” has a history that has further served

imperialism and defined people according to Western cultural notions. Linda Tuhiwai

Smith (2012) suggests that knowledge production itself is based in Western ideas that it

should be objective and not take a stance, and yet is not neutral in its framing and effects.

Research methods in the positivist tradition are based on a particular epistemic cultural

model in which conclusions may differ from the way the subjects understand themselves.

Kim TallBear (2104) has stated that the idea of “giving back” in order to proclaim ethical

research, only makes clear that there is a divide between the researcher and the

36

researched and their objectives. She was moved to employ a different type of

methodology that she has called “standing with” and “speaking as faith.” By “standing

with” she builds and shares knowledge by researching up or across as a colleague instead

of down as an authority over subjects. She doesn’t intend to speak on behalf of those she

researches, but borrows Neferti Tadiar’s concept of sampalataya, which in Tagalog

means “act of faith,” to describe “furthering the claims of a people while refusing to be

excised from that people by some imperialistic, naïve notion of perfect representation.”

(2014, 4) In this she fulfills a feminist objective to care for her research subjects in a way

in which she is devoted to using her critiques to benefit their mutual cause, which in her

case is making Indigenous lives and institutions better.

With this research project I have adopted TallBear’s method of “standing with”

and “speaking as faith.” This research is of lactation consultations with lactation

consultants as the primary research subject, but mothers were also subjects as participants

in the consultations and some of them were interviewed to understand their difficulties

and the care they received as a result. I chose to undergo training and certification to

become a lactation consultant, and in this way I was able to “study up” and “study

across” because the lactation consultants who were part of this research were my

mentors, and they valued my own experiences and understandings of the field as an

addition to our endeavors. They had authority in the relationship and offered their time

and knowledge because they believed in a sisterhood of support in which women helping

other women also extended to co-constituted knowledge production and increasing the

number of IBCLCs available to mothers. With the mothers who were part of this research

I “studied across” as a trainee who was also a mother. We all had the same goal of

37

improving care for women by helping breastfeeding mothers. In offering my

observations, theory, and critiques in this dissertation, I aim to stand within a community

of women who care for other women and add my knowledge and care in service to

helping to support and improve the experience of breastfeeding.

My ability to gain access to research subjects and develop support was possible

because of my aim to “stand with.” When I set out to do this research, I was confident

that I could find women who would be willing to allow me to both train as an IBCLC

under them and would also participate in my research. This confidence came from my

understanding that I was essentially one of them. I was not a nurse or an IBCLC, but like

them, I had a background helping women as a former midwife apprentice, childbirth

educator, and a parent support paraprofessional. I had offered holistic support to women

while challenging harmful norms in the system and making them aware of their rights. I

knew that there were networks of women supporting women in maternal care and was

hopeful that a door that might be difficult for some people to open would be open for me.

I was able to gain access to the lactation consultants who were part of this

research by attending a breastfeeding conference in Hawai‘i. I didn’t know any of the

women in attendance, but the first woman I approached to explain who I was and what I

wanted to do, Mary5, became excited. Mary said that she believed that there needed to be

more breastfeeding related research and that it would be beneficial for researchers to also

be IBCLCs. It was important to her that more research came from within the community

of professionals, and so she was supportive. She told me that she knew most of the

women at the conference and would take it upon herself to talk to some of them and help

5Allnameshavebeenchangedtoprotecttheresearchsubject’sprivacy.

38

me out. Those women would later tell me that Mary had told them that it was their duty

to help other women who wanted to be IBCLCs just as they had once been helped, and

that researchers who were also IBCLCs were needed. It was important to Mary that

networks of women helping women were maintained, and the IBCLCs that she

approached agreed with this.

Although most mothers agreed to take part in the research, I found it difficult to

get mothers to respond to my efforts to interview them. All of the women who followed

through with an interview self-identified as middle-class. Several low-income mothers

who saw IBCLCs through WIC agreed in person to an interview and gave me their names

and phone numbers, but none of them returned my calls so that we could set one up. To

make sense of this I have considered what a lactation consultant told me about the low-

income WIC mothers I was trying to interview. This lactation consultant, the only Native

Hawaiian IBCLC on the island, told me that she was too overwhelmed at the time to

agree to participate in mentoring me, but she did agree to an interview.6 She relayed to

me her understanding that although there are barriers to breastfeeding for all women,

those who have more privilege than others have an easier time navigating around those

barriers. She told me that many of the mothers who are part of the WIC program in her

community in Waianae, in which the majority of residents identify as either Native

Hawaiian or Pacific Islander, are so socioeconomically disadvantaged that their biggest

concern is often keeping a roof over their family’s heads. This affected their so-called

infant feeding and care “choices,” of which socioeconomic conditions often dictated. I

6Becausethislactationconsultantwasonlyinterviewed,shehasnotbeenincludedinthecountof7lactationconsultantsthatIhaveclaimedparticipatedinthisresearchandwhosestoriesIhavetoldinassociationwiththeirmentorshipandobservationsoftheircare.

39

suspect the lack of response I got from low-income mothers was due to the

disproportionate burden they experienced and speaks to how a lack of privilege means

some mothers are limited in their ability to allocate time and energy to activities outside

of essential survival. However, the reluctance among Native Hawaiians to participate

may also have to do with a history of research being used to further the researchers

agenda and not benefiting Indigenous communities. My interviews with middle class

mothers may not represent the experiences of Indigenous and low-income mothers, but

both were present in observations at all research sites except for the Japanese lactation

massage clinic. That was the one location where mothers had to pay out of pocket. The

use of various methods and research locations enabled me to capture the experiences of

mothers who represented a variety of income levels and ethnicities.

The research methods I chose gave me the most comprehensive opportunity to

examine the difficulties that women have with breastfeeding and lactation consultants’

responses. This dissertation is based on 2.5 years of interviews and participant

observation of 7 International Board Certified Lactation Consultants (IBCLC) and their

clients, and was completed in 2015. Part of the research involved me undergoing 600

hours of IBCLC training and participant observation with 4 of the lactation consultants

and participant observation but no training with 3 of them. I chose IBCLC training to

allow for a more complete understanding of breastfeeding issues and approaches to care.

The research locations were in Hawai‘i in order to access a diverse population and

consisted of a hospital, pediatric clinic, non-profit clinic, WIC office, and a Japanese

lactation massage clinic. These locations were chosen to represent the various places

40

women received care from IBCLCs, but did not include home visits, which at the start of

the research were not being done by any lactation consultant on the island.

Fieldnotes were taken during and after participant observations. In addition to

participant observation, the 7 lactation consultants and 15 of the breastfeeding mothers

participated in tape recorded, in-person, in-depth interviews. The purpose of these

interviews was to obtain a more complete understanding of how lactation care functions

in the lives of women who are breastfeeding, and to explore participants’ experiences,

motivations, beliefs, and behaviors related to breastfeeding and lactation support. The

study received IRB approval and no incentives were given for participation. Lactation

consultants who participated in the study were convenience selected based upon their

employment at a chosen research location and their willingness to participate.

Breastfeeding mothers participated if they were a client of a participating lactation

consultant and agreed to take part in the study. Some breastfeeding mothers verbally

agreed that I could be present as a lactation consultant trainee but did not want to

participate in the study. Fieldnotes were not taken during interactions with these subjects.

The 15 breastfeeding mothers who agreed to be interviewed were part of a convenience

sampling selected due to their presence at one of the research sites, their use of a lactation

consultant, and their willingness to participate in an in-depth interview outside of the

research location. All participants were presented with a consent form that explained the

research. They signed the form if they agreed to participate. The consent form asked for

contact information and initials if participants further agreed to a one-time, tape recorded

interview. The number of breastfeeding women interviewed was kept small as part of an

in-depth qualitative strategy in order to understand complex social phenomena. These

41

study design elements allowed for the deeper, more contextual qualitative outcomes that

were sought.

Field notes and interview transcripts were reviewed for repeated elements and

these were coded. Patterns and causal relationships were extracted. I was the only one

involved in analysis of the data.

The methodology for this study is modeled on Emily Martin’s (1998) rhizomes as

a way to research science itself. In order to “capture the kind of discontinuous, fractured,

and non-linear relationships between science and the rest of the culture” (1998:31) she

borrows Deleuze’s image of the rhizome. The rhizome is a stem that moves horizontally

underground with several offshoots and roots. It works as the perfect metaphor for

Martin’s (1994) study of immunity where she does ethnographic research in several

locations, including labs, clinics, activist organizations, neighborhoods, and workplaces.

Likewise, she uses the rhizome model to research bipolar disorder where she does

ethnographic study in places as diverse as group therapy sessions and psychology classes

(2009). The rhizome as a model for research allows the ethnographer to justify not

staying in one place but moving around to various localities where connections to the

production of science can be made.

For the purposes of this study, the rhizome metaphor accounts for the various sites

in which I engaged in participant observation in lactation consultations, as well as the

choice to attend La Leche League meetings. These sites are places where breastfeeding

knowledge is reproduced and disseminated. Each site is unique in regard to who in the

community it reaches and how it does so, giving a more comprehensive understanding of

42

the knowledge of lactation, lactation care, and how that care functions in the individual

lives of women who are breastfeeding.

Ethnographic research is appropriate because it offers a holistic understanding of

the issues obtained through participant observation of breastfeeding women and lactation

consultants as they practice their profession in various settings, interacting with other

lactation consultants, clients, and medical professionals. Ethnography is especially well

suited for being able to get at the realities behind breastfeeding statistics, which do not

enhance our understanding of the social, economic, and healthcare dynamics that factor

into those rates.

Discourse analysis was an important component of the participant observation as

a way to understand how realities are produced. The term discourse is used here to mean

all manners of communication, be they spoken or written words, body language, or what

a person does. The discourses were analyzed not only for their role in the production of

knowledge, but also as a way to understand power relations. My field notes contained

information on the types of discourses at the various training sites. Discourse was

especially important for understanding how both lactation consultants and women

themselves resolve the various contradictions presented in breastfeeding. I have identified

these contradictions as the ways that breastfeeding is at odds with the cultural demands of

consumption and autonomy, how breastfeeding is considered both ethical and obscene,

how it is biological yet is socially and culturally learned and enacted, the ways it is both

described as natural and mechanical, is something that only women can provide yet

confronts a resistance to biological determinism, is considered a choice but has required

43

activism and laws to enable women to make the choice, and the ways breastfeeding is

both romanticized and spoken of in negative terms.

Finally, doing research while undergoing medical training was an important

aspect of my methodology. Other medical anthropologists, such as Paul Farmer, have

successfully combined medical training with research to further their objectives. In doing

so myself, I feel I earned the trust of healthcare professionals I was studying, had access

to clinical environments and intimate breastfeeding settings, came to understand the

experience and objectives of the lactation consultants.

Dissertation Outline

I begin in chapter two by giving a background of the professionalization of

breastfeeding that was part of an era of activism concerning women’s health. I show that

women involved with La Leche League put forth efforts to create a certified medical

professional who could work in hospitals helping breastfeeding moms. The idea was that

the lactation consultant would be respected as a professional working within a medical

environment, but would also make efforts to demedicalize in ways that were more

supportive of breastfeeding. Many lactation consultants and advocates worked to enact

policies that would counter predatory and harmful formula marketing efforts, pushed for

policies that would change harmful healthcare practices, and got laws passed that would

enable women to breastfeed in public and pump at work. However, despite this progress,

I discuss how breastfeeding policies haven’t changed dominant ideologies, including

those behind exclusive and intensive mothering, or workplace values. I theorize that this

has caused a backlash among women who still struggle to breastfeed and believe that

44

breastfeeding advocacy pressures women to breastfeed and takes away choice.

Additionally, the focus on health claims about breastfeeding, which have been necessary

to get people to take breastfeeding seriously for research funding, policy changes, and to

challenge false or harmful formula marketing narratives and practices, has opened public

health efforts up for criticism and has made them seem anti-woman.

Additionally, I link La Leche League’s values to the values and activism of

lactation consultants. This includes the league’s move away from technology and experts

towards “natural” parenting while simultaneously valuing science and making decisions

about how to help mothers after considering the political context and social consequences

of healthcare practices. The league contrasts with the lactation consultant’s activism

efforts, however, by moving to depoliticize their support groups in an effort to be non-

judgmental and focus on mother-to-mother support. This move, I argue, makes the league

less effective at avoiding making women feel that they personally are at fault for

breastfeeding difficulties.

After setting the background for how professionalization occurred, I discuss the

requirements for becoming an International Board Certified Lactation Consultant in

chapter three. I tell the story about how I came to a place where I wanted to do

breastfeeding research that involved becoming a lactation consultant myself. My own

positionality is important to discuss from a methodological perspective and thus my story

compliments that section of the chapter and shows how becoming a lactation consultant

was possible because I shared concepts with my mentors/research participants. I then

introduce the lactation consultants who participated in this research. I examine why they

chose the profession, and in doing so elucidate many of their concepts about

45

breastfeeding. As this was participant observation, I also detail the training I had to go

through in order to become an IBCLC, and how these women introduced me to the

profession.

In chapter four I discuss the concepts that lactation consultants have about

breastmilk, which ties into concepts in our historical imagination of breastmilk as white

blood. This is both a literal analogy since it is produced from the blood, and a symbolic

analogy since like blood, it is a liminal and life-giving substance whose ambiguities have

to be resolved to maintain social order. I call it “super-natural” because it is thought of

and described in supernatural terms, it both protects and heals, it transforms to address

the needs of the infant, it is understood to physically create an individual person in social

relation to another, and it remains in many ways mysterious. The hyphen in super-natural

distinguishes it as not only something considered miraculous or magical, but as a natural

substance that exemplifies the pure aspect of “natural” as something not created by

humans and so dynamic and complex that it completely defies imitation. This is because

its components can’t be effectively extracted and used outside of the whole, and it can’t

be improved upon by science. Understanding the concepts that lactation consultants have

about breastmilk and breastfeeding as dynamic, relational, and powerful, is necessary for

making sense in chapter six of how lactation consultants help mothers reconstruct their

concepts about breastfeeding in order to improve their experience with it.

In chapter five I explore dominant concepts about breastfeeding by mothers. I

begin with a historical look at how lactation became pathologized and how our current

breastfeeding norms were established in the U.S. I argue from Wolf’s (2001) historical

analysis that the pathologization was an outcome of urbanization, and conclude that the

46

effects of urbanization amounted to a breastfeeding knowledge loss. I contend that new

concepts were formed out of the dominant ideologies of patriarchy, capitalism, and

biomedicine. I describe the technocratic model of childbirth as an important outcome of

this, and specifically breastfeeding data collection and quantification as one aspect of the

idea that the body needs to be managed and controlled with technologies because they are

more trustworthy than the body. I explain how ritualized quantifications serve to reassert

ideological values.

This is followed by an analysis of data from my participant observation of

lactation consultants as they helped breastfeeding mothers, and interviews with

breastfeeding mothers who saw lactation consultants. I discuss my findings that many of

these mothers worried that they didn’t have enough breastmilk, often despite evidence to

the contrary. They had gaps in breastfeeding knowledge and were disconnected from

their lactating bodies and what its sensations signified. Sometimes women referred to

their bodies as “broken,” a mechanical analogy. The body was something to discipline in

order to create desired outcomes, rather than something that could be informative. They

turned to quantifying methods to create certainty, and often those methods became

ritualized to reduce anxiety. I argue that quantification can keep women from embodied

knowledge.

Because mothers often described having a breastfeeding knowledge gap, I next

explore how women learn to breastfeed. Findings from my participant observation and

interviews show that female family members have a great amount of influence on a

mother’s ideas about breastfeeding. Positively this could be supportive and negatively

included ideas about the lactating body as dysfunctional and prone to failure, and include

47

the social regulation of sexualized breasts. Women did not have opportunities to observe

other women breastfeeding, however, and attempts to deal with knowledge gaps involved

separating the mind from the body for mothers in this study. They understood successful

breastfeeding to be a matter of what Alison Bartlett (2002) calls “headwork” rather than

turning to the body. Finally, I found that women also turned to consumerism and

quantifying modalities to deal with difficulties. From this I conclude that dominant

ideologies affect women’s concepts about breastfeeding and subsequently their

experiences.

Lastly, I demonstrate how concepts construct our perceptions. I present this

through phenomenological accounts of cases from my participant observations of

incognizant and phantom let-downs, and mysterious breast pains. This lays the

groundwork for chapter six, where I give ethnographic accounts of how lactation

consultants sought to change women’s concepts to positively affect their breastfeeding

experiences.

In chapter six, I present case studies of four of the lactation consultants with

whom I was involved in participant observation research. This is done to offer a more

detailed illustration of the techniques they used to help mothers who were having

breastfeeding issues. It also serves as a way to compare and contrast the different

approaches they took. The lactation consultants all practiced in different settings and

showed variation in their practices, but the first three shared major similarities as well.

Those cases demonstrate how the lactation consultants believed the body to be

informative rather than dysfunctional, and how they directed women’s attention to the

body and what it could reveal. In each case the lactation consultants felt that it was

48

important for women to find embodied knowledge through attention to sensory

information. In addition to attention to sensory information, emotions were also

understood to be important because they were connected to a mother’s bodily state. This

chapter also details how the lactation consultants limited and tried to use technology

appropriately. The fourth case study is different from the first three in that it is a

transcript of a lactation consultant’s interaction with a single patient. In this interaction,

her method is an outlier from those used by the other lactation consultants I observed. I

include this case study in order to contrast this type of authoritative and instructional

technique with embodiment techniques.

Chapter seven, the conclusion, summarizes the findings of the previous chapters.

It explores how the findings are applicable to the current backlash to breastfeeding

promotion and the need for more support for breastfeeding mothers.

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Chapter Two

The Rise of La Leche League and the Creation of the IBCLC

Introduction

This chapter begins with a historical look at the era in which the IBCLC arose in

order to establish the environment in which a breastfeeding professional came to be. I

describe the philosophy of the group La Leche League, which created the IBCLC, and

how this influenced the direction of the lactation professional. This includes historical

information, information published by the league, and ethnographic data that came from

my observations of a La Leche League group over several months. Through all of these

avenues I investigated the focus the group puts on women helping women through

socially produced learning, on attachment parenting practices, and on a judgement free

atmosphere where women are to be given facts from which to make informed choices. I

connect these to the ways of knowing practiced by IBCLCs and also to the backlash

against breastfeeding which I believe to be due to a combination of the successes and

failures of the IBCLC as activist.

The Era of the IBCLC

The founding of La Leche League, a support group for breastfeeding mothers,

occurred during the 1950s when scopolamine or anesthesia was still given to women in

labor creating drowsy newborns with depressed nervous systems who were difficult to

breastfeed (Ward 2000; Wolf 2009). The mother herself was often too groggy to care for

her infant after birth and the two were separated and did not nurse for a while after (Wolf

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2009). Pediatricians tended to give poor advice about breastfeeding. Many believed that

women were not able to produce enough milk and would need to supplement with

formula on a schedule (Wolf 2001). They also believed that breastfeeding required

scientific and medical knowledge that was unavailable to most mothers (Wolf 2001).

Books on childcare that were written by experts at that time positioned formula as just as

good as breastmilk (Ward 2000). Formula manufacturers influenced a lot of opinions

about breastfeeding. Carnation, a company that produced one brand of formula, made

pamphlets available in maternity wards that touted scientific research that showed

formula fed infants were just as healthy as breastfed infants:

Most young mothers wonder whether or not they should nurse their babies. You do not have to nurse your child. Scientific evidence today indicates that children who have never been nursed are just as healthy, sometimes more healthy, both physically and emotionally, as children who are nursed. If you are reluctant to nurse your child, if it makes you feel tense or uncomfortable, do not attempt it. (Schuman 2015).

Given messages like this, it is no wonder that breastfeeding rates plummeted so low that

the founders of La Leche League, a group of breastfeeding mothers who attended church

together, found it unusual to come across other breastfeeding mothers and decided that

women needed support to breastfeed (Ward 2000).

The founders of La Leche League noted the ways that women’s breastfeeding

efforts were sabotaged by the medical system and believed that women learned how to

breastfeed best from other breastfeeding mothers (Ward 2000). They thought it was

important for women to tell their breastfeeding stories to one another but saw that

modeling breastfeeding was more effective than personal stories or an explanation of how

to do it (Ward 2000). They stated that La Leche League “carries with it the hope of

rescuing us from a sick technological age by the restoration of certain basic human

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relations leading to a more wholesome culture” (Ward 2000, 1). Much has been made of

La Leche League’s religious beginnings, and statements such as this have been used to

point to their heteronormative family values that saw a woman’s place as restricted to the

home and children (Bobel 2001; Hailey 2010; Weiner 1994). These ideas were common

in the 1950s, but what was radical of the founders at that time was a resistance towards

technology being applied as it was in regard to childbirth and breastfeeding (Ward 2000).

They did not completely reject science and medicine, however. One of the founding

members was married to a physician, Dr. White, who performed home births and

believed that women were capable of breastfeeding (Ward 2000). He noted that women

were more receptive to the advice of other mothers than they were of his authoritative

advice but realized that doctors still had a huge influence (Ward. 2000). The league

decided to reach out to doctors who were supportive of breastfeeding. They established a

professional advisory board that was made up of scientists and doctors with various

specialties (Ward 2000). Thus, while being critical of ways that biomedicine treats

breastfeeding mothers and infants, La Leche League embraced science as a way of

encouraging breastfeeding in an age when people looked to science for answers.

The 1950s were also a time when some middle and upper-class white mothers

were starting to become interested in natural childbirth. Dr. Grantly Dick-Read had

published Childbirth Without Fear in the 40s, followed by Dr. Robert Bradley and Dr.

Fernand Lamaze’s methods of natural childbirth (Craven 2010). These male physicians

proposed that the pain of childbirth could be changed with the correct mindset, and that

the techniques they proposed could help women to achieve a pain-free birth with no need

to be anesthetized (Craven 2010). As natural childbirth methods became more popular in

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the ‘60s and ‘70s, hospitals were pressured to make changes, like allowing fathers to be

present during labor, and giving women fewer interventions (Craven 2010).

By the ‘70s women’s dissatisfaction with their healthcare had created attempts to

educate themselves and take action to affect change. In 1970, a group of women who met

each other at a college women’s liberation conference, published a booklet that would

later become the more widely distributed book Our Bodies Ourselves.7 The booklet was

intended to be a collection of papers to be used to hold “classes” through which women

could educate other women on health issues and functions of their bodies3. It states, “We

discovered there were no ‘good’ doctors and we had to learn for ourselves. We talked

about our own experiences and we shared our own knowledge. We went to books and to

medically trained people for more information” (Candib et al. 1970). The women’s group

wrote papers on the topics they had researched and informed others who would use the

booklet that the knowledge contained within it was “not static,” or what was most

important (Candib et al. 1970). The most important thing was that women share their

experiences with each other and work to change the healthcare system (Candib et al.

1970).

The women who wrote the booklet had “experienced feelings of frustration and

anger toward the medical maze in general, and toward those doctors who were

condescending, paternalistic, judgmental, and uninformative in particular.” (Candib et al.

1970) The booklet quoted Marcuse as saying, “Health is a state defined by an elite”

7 Our Bodies Ourselves (formerly known as the Boston Women’s Health Book Collective), “Our Story,” Our Bodies Ourselves, 2020, https://www.ourbodiesourselves.org/our-story/

53

(Candib et al. 1970). It further explained how women’s healthcare was a form of social

control:

We have not had power to determine medical priorities; they are determined by the corporate medical industries (including drug companies, Blue Cross, the AMA and other profit making groups) and academic research. We have learned that we are not to blame for choosing a bad doctor or not having the money to even choose. Certainly, some doctors have learned medical skills better than others, but how good are technical skills if they are not practiced in a human [sic] way? (Candib et al. 1970)

Breastfeeding was one of the areas where doctors were uninformed and often gave poor

advice (Craven 2010). They did not learn about human lactation in medical school, and

there was little research being done in this area (Craven 2010). However, the first edition

of Our Bodies Ourselves did not address breastfeeding or midwifery, only stating that

there was a need for more midwives so that women could have the choice to birth at

home if they wanted to (Candib et al. 1970). Feminists were slow to fully embrace issues

related to childbirth and breastfeeding because the focus was on liberation from having

their identity tied to a biological imperative of motherhood (Craven 2010). Thus, abortion

and access to birth control were more central to the movement (Craven 2010).

Breastfeeding rates continued to decline in the U.S. with the early 70s having the

lowest rates with around 75% of all newborns receiving formula (Wolf 2001). In 1973 La

Leche League began holding seminars for doctors in order to educate them about

breastfeeding (Eden 2013). At that point in time, medical professionals were not only

uneducated about lactation, they also did not encourage it and were compliant with the

marketing efforts of formula companies (Eden 2013; Starr 2008). Despite low rates in the

U.S., the 1970s instead bought a larger focus on unethical practices by formula

companies in developing countries. Derrick and Patrice Jelliffe from the University of

54

California School of Public Health made observations of infant feeding practices in the

field and created the term “commerciogenic” to describe what they determined was infant

malnutrition due to unethical formula company practices in developing countries (1972).

In a 1977 journal article Dr. Derrick Jelliffe claimed that formula advertising in

developing countries convinced women to use formula as a matter of prestige in order to

be more like women in wealthier countries.

Formula company advertising also had a history of promoting the idea that

formula was either close enough to breastmilk that there was no substantial difference, or

that formula was a scientific improvement on breastmilk (Apple 1987). The statement

that breastfeeding is best had been made by the pharmacist Henri Nestle, the creator of

the first completely artificial commercial infant formula, in 1870 at a time when infant

mortality rates were high for women who did not breastfeed. By the 1990’s the Nestle

company would claim that they had “launched the ‘Breast is Best’ campaign worldwide

to promote breastfeeding” (Pfiffner 1993). A Wall Street Journal editorial from 1979

stated that Nestle’s advertisements claimed that breast is best [only] for the first three

months of an infant’s life. Nestle’s later use of “breast is best” was thus a way to seem

supportive of breastfeeding while undermining it at the same time. The Jelliffes published

an article in 1977 in the New England Journal of Medicine that discussed the use of the

phrase “breast is best.” They claimed that the phrase had been in use for decades and like

the breastfeeding backlash seen against the phrase today, they claimed that “breast is

best” accompanied the common belief that it was, however, unimportant:

Translated into actual behavior by health staff, the result became a cliché with self-defeating overtones: “Breast feeding is best, but not really of actual importance.” It was therefore foolish to bother too much, especially since the greater risk was believed to be from the inducing of guilt feelings in the mothers

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concerned. The relative consequences of the two methods were considered to be of no real importance in modern urban society, and, in any case, the practitioner had learned nothing concerning the process in his training. In practice, therefore, until recently the endorsement of breast feeding was likely to have been lukewarm, ambivalent and ill informed about the properties of human milk and the mechanisms responsible for lactation. By contrast, the well funded formula industry had obligingly filled the vacuum, and assumed the role of Delphic oracle, saturating both the profession and the public with astutely presented information, propaganda, persuasion and motivation. (1977, 912)

Thus, the issue has always been framed as weighing two different risks: the health risks

of not breastfeeding versus the risk of making mothers feel bad, with each side arguing

for or against breastfeeding’s health related importance in comparison to formula. The

article goes on to explain how science is catching up to corporate propaganda and is now

able to show us how different the properties of human milk are from formula. The

Jelliffes and others thought that through science, breastfeeding would be understood to be

not just best, but important, and the unscientific propaganda of the formula industry

would be challenged8.

Nestle’s formula marketing was targeted by activists who led a boycott against the

company that began in 1977 in the U.S. (Palmer 2009). The boycott had been instigated

by a report published in 1974 by a non-profit organization which was titled “The Baby

Killer” (Muller 1974). It exposed the harm the company was doing to infants. Nestle was

sending saleswomen, only some of whom were actually nurses, into poor areas of the

world dressed in nurse uniforms (Palmer 2009). The saleswomen went into hospitals and

8 Some 40 years later it is of interest to note that both the companies that manufacture formula and those who are critical of breastfeeding promotion, have also utilized science as a tool for promoting their product or arguments. Similarly, the phrase “breast is best,” which has been in circulation long before modern memory, has been wielded not just by public health officials, but has been used strategically in formula marketing. Critics of breastfeeding promotion, however, have only examined its use by public health professionals and have disapproved of it standing on the same belief propagated by formula marketers, that breastfeeding is unimportant.

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gave out samples of formula to mothers who had just given birth (Palmer 2009). They did

this in an effort to undermine breastfeeding and convinced women that medical

professionals supported the use of their formula (Palmer 2009). These practices targeted

poor women who were unable to afford formula and yet would be dependent upon it to

feed their infants if their use of formula caused a low milk supply or caused their

breastmilk to completely dry up9 (Palmer 2009). There was also the issue of formula

being mixed with unclean water in some areas, and sickening infants (Palmer 2009).

Developing countries were not alone in having low-income populations who

suffered from malnutrition. In 1974 WIC became a permanent program overseen by the

U.S. Department of Agriculture (Oliveira 2009). It grew out of studies from the 1960s

that showed that there were substantial amounts of hunger and malnutrition among low-

income Americans (Oliveira 2009). The WIC program was designed to provide nutritious

foods and nutrition education to low-income pregnant women, women postpartum, and

children aged 5 and under (Oliveira 2009). WIC was criticized, however, for promoting

formula (Blum 1999). They started encouraging women to breastfeed in the late 1980s,

while still providing the free formula to mothers who weren’t exclusively breastfeeding

(Oliveira 2009). In 2009 WIC started giving breastfeeding mothers extra food vouchers

to promote breastfeeding (National Academies of Sciences, Engineering, and Medicine et

al. 2016)10.

9 After the copious milk comes in, the body produces breastmilk according to how much stimulation the breast receives, either from a breastfeeding infant, a pump, or from hand expression. A reduction in stimulation reduces milk volume (Riordan and Wambach 2010). 10 This has been criticized as unfair to mothers who do not breastfeed by Courtney Jung (2015a), a critic of breastfeeding promotion, but one could argue that the extra food was offset by the free cans of formula given to non-breastfeeding mothers (National Academies of Sciences, Engineering, and Medicine et al. 2016). A WIC IBCLC nutritionist that I interviewed stated that the extra food and time in the program given to breastfeeding mothers provided the extra caloric needs of a mother making breastmilk.

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In 1981 the World Health Organization (WHO) created the International Code of

Marketing of Breastmilk Substitutes at the World Health Assembly in an effort to stop

harmful practices by infant formula manufacturers. The U.S. was the only country not to

vote for the measure after the formula industry lobbied president Reagan to vote no

(Palmer 2009). This prompted citizen protests and the resignation of two US Agency for

International Development officials (Palmer 2009).

La Leche League had started exploring the idea of a lactation professional in 1982

when they created a Lactation Consultant Department (Eden 2013). Then in 1984, NY

state wanted to mandate that hospitals had staff members on hand who could help women

with breastfeeding after they gave birth (Eden 2013). This motivated La Leche League to

move ahead with professionalization out of concern that NY hospitals would appoint

medical professionals who weren’t qualified (Eden 2013). They wanted to make sure that

achieving this new professional status didn’t require a medical background and thus leave

out La Leche League leaders, who they considered to have the most knowledge about

breastfeeding (Eden 2013). The IBCLC would need to include non-nurses, but also be

able to deal with more complex problems than what a La Leche League leader could

(Eden 2013). They would also need to challenge hospital practices that interfered with

breastfeeding and be able to utilize evidence-based practices (Eden 2013). Eventually

non-nurses could be certified but were required to have a health science background

(Eden 2013). To become accredited the IBLCE board they formed to control the exam

process would have to be separate from La Leche League, and so although La Leche

League founders initiated the professionalization of breastfeeding, the league would

remain a support group only (Eden 2013).

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In 1984, Science for the People, a publication that stated their purpose in each

issue as “exposing the class control of science and technology,” came out with an issue

dedicated to babies and science. It contained two articles about formula marketing

(Happe 1984; Wirtz 1984). The authors expressed the view that medical establishments

should use evidence-based practices rather than profit driven ones. The article titled

“Infant Formula Practices in the U.S.” stated that pharmaceutical companies made the

majority of infant formula in the U.S., and they had long established relationships within

the healthcare system within which they almost exclusively marketed their products

(Wirtz 1984). The article lists the services and kickbacks that the medical establishment

received from these companies in exchange for giving away formula and marketing

materials to patients:

Services provided free to hospitals and clinics include formula for in-hospital or clinic use, hospital discharge packages for distribution to bottle and breastfeeding women, hospital equipment large and small, architectural design services, funding for research, large quantities of promotional literature for distribution to women, printing services and other advertising gimmicks such as calendars, growth charts, baby name tags, note pads, etc. Several of these materials (e.g., formulas, discharge packs, “educational” literature) are simply distributed through the health care settings directly to pregnant women and new mothers with whatever “medical endorsement” such a procedure implies. Medical detailing also involves servicing individual health professionals with formula and/or gifts for personal use, research grants, support for travel or school, ad gimmicks, and social activities such as lunches and cocktail parties. Professional health organizations receive a variety of substantial financial incentives from the companies: sponsorship of meetings and conventions, financial assistance to organizations, printing services, and extensive advertising in professional journals. In addition, the industry sponsors yearly symposia, in-service training programs, and problem-solving services for health professionals and organizations. (1984, 15)

The author concluded that the practice “generates more than good will; it serves to keep

the name of the company in constant view (Wirtz 1984, 15). Although most may deny it,

reception of such services tends to establish, at least subconsciously, an ‘implied built-in

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reciprocity’” (Wirtz 1984, 15). This sense of reciprocity made it difficult for medical

establishments to reject the marketing (Wirtz 1984).

The author noted at least one instance revealed in research where a hospital didn’t

want to give the gift bags containing free formula to breastfeeding mothers. The formula

company then provided the hospital with gift bags for these mothers that contained only

baby bottles filled with sterile water, which although not formula, was also a way to

sabotage breastfeeding. Infants suck differently on bottles than they do on the breast,

potentially causing newborns breastfeeding issues (Watson Genna and Sandora 2017).

Additionally, filling hungry infants up with water was not only unnecessary, but a way to

reduce a mother’s milk supply by reducing time at the breast (Riordan and Wambach

2010). It was noted that hospital staff were reluctant to stop giving gift bags out at all;

doing so was thought of as “unfair” to mothers because it deprived them of something

(Wirtz 1984). Thus, in accordance with social gifting customs, there was a sense of

responsibility to formula manufacturers because of the gifts, as well as a desire to be

perceived as caring for patients by not depriving them of a gift11.

The author established the ways that formula manufacturers were expanding their

marketing to low-income mothers by infiltrating the WIC program (Wirtz 1984). WIC

was also receiving promotional materials, free formula, and kickbacks (Wirtz 1984). Ross

laboratories, which later changed their name to Abbott Nutrition, even produced a

newsletter for WIC clinics to give to clients. WIC at the time believed in creating a “non-

judgmental” atmosphere (Wirtz 1994, 17). Their training manual cautioned against

11 Mauss in 1922 published The Gift, in which gifting customs and the obligations that come with them are discussed. See also the U.S. Senate hearings on infant formula manufacturer’s marketing practices in 1978, in which the effects of gifts by formula manufacturers were considered.

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“alienating women who choose to bottle feed” (Wirtz 1994, 30). This often meant that

breastfeeding was not promoted at all (Wirtz 1994, 17, 30). Participating in formula

marketing was either not understood to be seen as an endorsement of formula or was

considered an unfortunate budget necessity in order to “save money for direct client care”

(Wirtz 1994, 17). Depriving needy, low-income moms of gifts and services was thought

of as an even greater wrong than participating in an unethical commercial relationship.12

The pharmaceutical formula manufacturers had an effect on research and policy

dealing with infant feeding (Wirtz 1994). One example given was how Ross Laboratories

sabotaged an infant feeding research project conducted by The National Council of

Churches and the Interfaith Center on Corporate Responsibility (ICCR), because they

thought the results might be harmful to their marketing efforts (Wirtz 1994). They

secretly acquired a copy of the survey ICCR was using and went to their research sites at

the time the research was being conducted with the intent to figure out how to discredit it

(Wirtz 1994). This disruption caused the ICCR to stop collecting data before they had

planned to (Wirtz 1994). Ross Laboratories then filed a Freedom of Information Act

petition in order to acquire their data (Wirtz 1994). The subsequent legal ruling in favor

of Ross Laboratories having access to the data before ICCR even had a chance to publish

the results, was called “a procedure unheard of in the scientific community” (Wirtz 1994,

30).

There was an ongoing movement though, seen through publications like Science

for the People and Our Bodies Ourselves, to call out the political context and social

12 According to the IBCLCs at WIC that I interviewed, WIC now disallows formula marketing materials but does still distribute formula. They viewed this supplemental distribution as a better alternative than mothers watering down formula or making their own homemade formula due to poverty.

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consequences of healthcare practices. There was an effort by women in particular to

reclaim authority over their bodies through educating themselves and activism. In 1985, a

year after the Science for the People articles, the first certifying exam for lactation

consultants took place (Eden 2012). Breastfeeding was now medicalized, and IBCLCs

would be able to help women with breastfeeding after they gave birth in the hospital.

The lactation consultants who participated in this research reported that hospitals

had been engaged in numerous practices other than complicity with formula marketing

that made it difficult for breastfeeding to be established, such as separating babies from

their mothers after birth; giving babies pacifiers, sugar, water bottles, or formula; putting

infants on feeding schedules; delaying breastfeeding and skin to skin contact so that

infants could be washed, measured, and weighed; and medicating mothers in labor.

Hospital practices weren’t the only thing that made breastfeeding difficult. The

sexualization of the breasts meant that women were often reluctant to breastfeed in

public. Also, more women had been entering the workforce and mothers who returned to

work after giving birth often had inflexible schedules, were not guaranteed pumping

breaks and could be fired or punished for taking them. Many women did not even have a

clean or private place to pump at their place of work. The earliest reference to the term

“mommy wars” that I could find came from a 1990 article in Newsweek titled “Mommy

vs. Mommy.” The article pinpoints the start of “mommy wars” as a conflict between

working mothers and stay at home mothers that began in the mid ‘80s. Like the portrayal

of today’s more expanded mommy wars, the working vs. stay at home mom drama was

“played out against a backdrop of frustration, insecurity, jealousy, and guilt.” Formula

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companies had a lot to gain because of the difficulties that continuing to breastfeed while

working presented, and still presents.

By the 1990s, activists started getting legislation passed in the states to ensure that

women could breastfeed in public without being asked to stop or leave a public place, and

to protect them from getting cited for public indecency (Kedrowski and Lipscomb, 2008).

Nurse-ins became a popular way to confront a business that had previously asked a

breastfeeding mother to cover up or leave (Dettwyler 1995b). Breastfeeding mothers

organized these nurse-ins and all showed up at the same time and place to publicly

breastfeed their children together.

In 1990 WHO and the United Nations Children’s Fund (UNICEF) created the

Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding that 30

governments signed onto, including the U.S. The document established goals for each of

the participating countries, which included an effort for every hospital to adopt Ten Steps

to Successful Breastfeeding (WHO and UNICEF 1989), and the protection of the rights

of breastfeeding women in the workplace. The Ten Steps to Successful Breastfeeding

were designed to promote breastfeeding, protect mothers from practices that could be

detrimental to breastfeeding, and support breastfeeding mothers in practices that are

beneficial to breastfeeding (WHO and UNICEF 1989). The 10 steps are13:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in the skills necessary to implement this policy.

13 WHO and UNICEF updated these 10 steps in 2018 to include adherence to the International Code of Marketing of Breast-milk Substitutes, the development of monitoring and data-management systems, immediate and uninterrupted skin-to-skin contact after birth, and some changes in word use. For example, you should no longer just discuss the benefits and management of breastfeeding with pregnant women, but also with their families. Instead of encouraging breastfeeding on demand, the language is changed to recognizing and responding to infant cues. As of this writing the Baby Friendly Hospital Initiative is implementing the original list of ten steps.

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3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are

separated from their infants. 6. Give infants no food or drink other than breast-milk, unless medically indicated. 7. Practice rooming in – allow mothers and infants to remain together 24 hours a

day. 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to

them on discharge from the hospital or birth center.

The Baby-Friendly Hospital initiative grew out of this in 1991. Spearheaded by

WHO and UNICEF, the initiative encourages hospitals to adopt the Ten Steps to

Successful Breastfeeding and abide by the International Code of Marketing of Breast-

milk Substitutes. The Baby-Friendly USA website states:

The BFHI has enabled tremendous progress in lactation support. Since its inception over two decades ago, we have seen maternity wards transform from places historically infused with enormous influence from formula companies and maternity care and infant feeding practices that undermined breastfeeding, to environments in which evidence-based care is provided, education is free from commercial interests, and mothers are supported in reaching their infant feeding goals. (https://www.babyfriendlyusa.org/about/ accessed 2/4/2020)

The mid ‘90s saw efforts to credential direct-entry midwives in the U.S. (Davis-

Floyd 2017). By 1997 the first Certified Midwives (CM) and Certified Professional

Midwives (CPM) had passed their exams in some states and were now certified

professionals (Davis-Floyd 2017). The CM credential required a college education but

women who sought this did not have to be nurses as Certified Nurse Midwives (CNM)

were (Davis-Floyd 2017). The CPM credential offered various routes to certification,

including a route that did not require a college education (Davis-Floyd 2017).

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The non-WIC IBCLCs that were a part of my research found themselves trying to

provide women with lactation care in the 90s in this environment that was at once

detrimental to women’s breastfeeding efforts while also being ripe for change. They were

activists trying to create change, only they didn’t look like what one typically thinks of

when they think of activists. They did not march in the streets and they were not seen as

counterculture. Instead, they were viewed as educated, credentialed, professionals who

were part of mainstream medical systems. They accomplished what Davis-Floyd (2006)

said postmodern midwives who were now “scientifically informed” had accomplished:

These midwives play with the paradigms, working to ensure that the uniquely woman-centered dimensions of midwifery are not subsumed by biomedicine. They are shape-shifters, knowing how to subvert the medical system while appearing to comply with it. (2006, 4)

Lactation consultants are still active at trying to make sure that the woman-centered

aspects of their care are not “subsumed by biomedicine.” They do this in the same way

that Davis-Floyd (2006) speaks of midwives subverting the medical system while a part

of it, but along with this the breastfeeding policies that have been put into place both

locally and nationally are the result of a more overt activism by lactation consultants and

others. They have medicalized breastfeeding in order to demedicalize aspects of it (Eden

2012, 2013; Torres 2014). At a breastfeeding course that I attended in California, I asked

one of the instructors about the possible licensure of IBCLCs or CLCs14 so that those

who were not also nurses could get reimbursed by insurance companies for providing

14 CLC stands for Certified Lactation Counselor. The course I attended certified students who passed an exam at the end to be a CLC. At the time in which I took the course, this certification was considered a lower level certification than the IBCLC, the latter of which required health education courses and a certain number of hours working with breastfeeding mothers. Some of the students in the CLC course were either using it as one of the lactation specific course requirements for getting their IBCLC, or were IBCLCs who were taking the course as a refresher.

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care to women. This particular instructor was on a panel that was deciding what to do

about the issue, which is still an active debate in the lactation community concerning

whether or not seeking licensure will be helpful and who should be able to get it. In

response to my question she told me that they didn’t want to medicalize breastfeeding,

and that it would be a fight with the American Medical Association, who believe only

physicians should be allowed to give breastfeeding help. The IBCLC was created in an

era that encouraged women-centered care and the activism necessary to achieve this, but

to be an IBCLC is still to be an activist even now as such efforts are still necessary.

The Results of Breastfeeding Activism

Lactation consultants started with enacting policies such as making it legal to

breastfeed in public, and efforts to protect women’s rights to pump at work, presumably

because that is easier than getting corporations and the government to give women

adequate and paid maternity leave.15 Despite some policy changes, there has been a

backlash against breastfeeding and against lactation consultants as promoters of

breastfeeding, presenting them as shamers of women who can’t or don’t breastfeed.

Breastfeeding friendly policies did not change institutional ideology or intensive,

exclusive mothering that continues to make women feel overwhelmed. Additionally,

much of the focus by lactation consultants and public health officials has been on making

health claims, which is necessary to get funding for research and for influencing policy

makers. A focus on the economic benefits of increasing breastfeeding rates has also been

a way to encourage pro breastfeeding policies. For example the pamphlet “The Business

15 Paid family leave has been a target by activists since legislation was first proposed in 2013, but has only now, as I write this dissertation, been approved by Congress for federal workers.

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Case For Breastfeeding” (2008) published by the U.S. Department of Health and Human

Services tells businesses that giving breastfeeding mothers an appropriate place to pump

along with pumping breaks will help them retain breastfeeding employees, reduce the

amount of sick time taken by parent employees who would otherwise take days off to

care for sick children, and that it will lower their health insurance costs.

Workplace laws that enable working mothers to continue to breastfeed are

important but limited, and as such they are a good example of why policy changes alone

are not enough. Being able to use a breast pump at least every three hours is essential for

women so that they can maintain their supply of breastmilk and have enough to feed the

infant in their absence (Riordan and Wambach 2010). Pumping is also necessary to avoid

the pain of engorgement, avoid getting plugged ducts or a breast infection, and to keep

the breasts from leaking milk while at work (Wambach 2010). It requires women to have

access to a clean, private room that has a locking door, and an electrical outlet. She also

needs access to a refrigerator so that she can store the pumped milk. Women usually need

at least twenty minutes for the actual pumping (Wambach 2010), but they also need time

to walk to and from the pump room, sanitize the pump parts, assemble and later

disassemble the pump parts, and wash the parts up when done.

In interviews and participant observations, breastfeeding participants who

returned to work but still planned to continue breastfeeding, talked about finding

pumping breastmilk to be challenging. This was despite the Affordable Care Act’s

requirements that employers with 50 or more employees provide women a suitable place

to pump, and that employers give women as many breaks and as much time as they need

in order to pump (Hawkins et al. 2015). Sometimes these challenges were related to

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having work environments with no clear non-bathroom location for pumping that was at

minimum private and had an electrical outlet. This was especially problematic for women

who worked outdoors, as was the case for a lifeguard and a wildlife biologist that I

interviewed. More often than not, however, women’s issues with pumping were less

about having a private place to pump and mostly about social expectations and conflict

between the values associated with mothering and those associated with the workplace

(Hays 1998).

Some women reported being told they could use their supervisor’s office to pump,

but that they felt hesitant to use it because it meant depriving a person of authority their

workspace, which goes against the social order. Others were given an adequate place to

pump and as many breaks as they wanted but felt that other employees would resent them

for interrupting the workday so often and seeming to work less even though in reality,

they were putting in just as many work hours as their coworkers. They were also

concerned that pumping breaks sometimes meant that a co-worker was left without their

help for a time, or that another co-worker had to take over their job for them while they

pumped. A breastfeeding woman’s pump breaks did not have to be explicitly disapproved

of by co-workers for her to change her behaviors out of social concern. For example, a

physician’s assistant who I interviewed said that she worried that her time away

negatively affected her co-workers, even though they appeared to be understanding. Her

concern caused her to stop pumping at work:

I hate pumping. I can’t do it. It’s very daunting. So, I’m happy [I’ve decided] I’m not pumping at work [anymore] . . . I work in surgery most of the days, so when I have to go pump it is in-between cases and when I am gone it puts pressure on my co-workers because they are picking up the slack for me. And they’ve all been wonderful and supportive, and no one’s ever given me a hard time, but I feel bad like leaving work for that.

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Other women had lots of work to do and did not want to give up their time for

pumping because that would mean they would have to work late and working later meant

they spent less time with their infant. There were several occasions where women

informed me that they pumped in the car while driving to and from the workplace so that

they wouldn’t have to take time out to pump at work and would only have to pump on

their lunch break. These women covered the pump with some type of cloth and worried

that they might get pulled over by a police officer and have to explain themselves. A

woman who worked in a building without an available private pumping room because it

was under construction, was given the suggestion to try pumping in her car. She declined

to pump at all, not because she didn’t like the idea of pumping in her car, but because the

extra time involved would mean less time with her infant:

Because we were under construction I had to park further away, and just to haul everything out there would have taken more time and I felt that the more time I stay away from my desk the longer I have to stay to get my work done, and I just want to leave as soon as I can to go back home to my baby.

Some women did a type of work in which an interruption in the workflow made things

unmanageable and they feared the ensuing issues would reflect poorly on their work

performance. These women were often worried that they would get passed over for

promotions or fired if pumping breaks interfered with their ability to manage the

workflow. They typically described their work environments as chaotic, such as this

school counselor:

As soon as I went back to work I pretty much dropped a lot [of breastmilk supply]. I’m still pumping. It’s hard. I work at a middle school. . . I’m a counselor. It’s just, you know, drama happens [at work] and I don’t have time to pump and I miss my window [for a break] . . . And sometimes I wouldn’t have lunch.

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Women’s refusal to pump when the workplace was busy, occurred even if they had

supportive supervisors:

A lot of my girlfriends, you know, they work in corporate. My girlfriend is a lawyer and she said it was very unnerving, and her partners, the other male lawyers, were not very understanding. Luckily, I work in a school environment where it is mostly women anyways, and I have a really awesome principal boss. So that wasn’t a problem, it’s just finding the time.

Not being able to find the time when supportive supervisors gave women the breaks they

needed, was due to the social obligation they felt to customers, clients, and co-workers, to

do their job well. Doing their job well was interpreted as responding immediately to

problems that arose as a way of putting the needs of others before their own. While this

seems unselfish, it is done in the service of the demands of the workplace and the need to

be competitive, efficient, and respectful of hierarchies in order to keep or advance in

one’s job. Women may have also been genuinely concerned about burdening their co-

workers whose work load might be increased by the mother’s pump break.

The importance of workplace relationships, the incompatibility between different

social expectations, a mother’s health, and how these all intersect with workflow,

workplace rules, and the efficiency and hierarchy values of the workplace, is made clear

by this nurse’s experience:

I’m a nurse working 12-hour shifts, so I am gone 14 hours, and I work in an ER . . . and we get 30 minutes for lunch break, and that is it. By contract we are supposed to get two 15-minute breaks, but by the time you sign your patients out to somebody else and then come back and get your patients, you’ve lost your break. Minimal support from management. I work on the ground floor. I’m supposed to go up to the tenth floor to our postpartum nursery for their pumping room, which usually has 2 or 3 ladies in line around lunch time, and eat, and be back within my half an hour lunch break, which is totally unrealistic.

The only way that I actually get to pump is because I have awesome co-workers who either are dads and have helped their wives get through it or have been moms and have gotten through it themselves. It’s the awesome co-workers who are in

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the same boat, which is how I get to pump. And we use the social workers office, so we actually have 2 ER social workers that I go knock on their door and tell them I have to use the pump. So, they let me use their office. I have a good rapport with one of the directors . . . and she has opened up a bed control office that we can use. She’s done it specifically for ER because we have several moms who are pumping right now. So, it’s not an official pumping room, but it’s at least a room we can use if we don’t want to kick out our social workers, which is hard when they are in the middle of doing all of their charting, you’re like, I’m sorry.

So, at the end of the day on a good day, I pump about 3 times. I get about a 10 -15-minute break in the morning. I do my lunch, [which is] half an hour, and then I try to do one in the afternoon depending on how chaotic it is. I just make it my own priority. I make sure that whoever my float nurses, charge nurses [are], whatever role I’m in, [I tell them] “I’ve gotta pump. You’ve gotta let me pump.” . . . My [breastmilk] supply definitely took a hit in the beginning . . . I have to admit there are some days that I have missed [pumping], especially in the last pumping [period] because from about 3-7pm is our really busiest time in the ER and it’s really hard to get away. And I just wanna cry; like I am so engorged, I am so uncomfortable. And when I come home I go straight to the shower rather than to [the baby]. So it takes me a good 45 minutes to be clean and dressed and ready to be with her. It’s actually after her bedtime so she may be asleep at that point. That’s hard. It’s really just disappointing.

The nurse made pumping at work under these circumstances possible by leveraging her

relationships with “co-workers who are in the same boat,” and a director she had

established a “good rapport with.” She also took advantage of the help of the hospital

social workers who were willing to help. In this way, she bypassed the unsupportive

managers and did not risk her standing with them by making demands. Despite these

efforts, there were still times she jeopardized her health and milk supply by skipping

pumping breaks when it was busy in the ER. At the end of the day she was often

painfully engorged, had less breastmilk for her infant, and was disappointed over having

less time with her. The nurse’s challenges were representative of those I heard over and

over again from women who encountered lactation problems after returning to work.

The hospital, for its part, followed the law by providing employees with a private,

locking room with an outlet for pumping breastmilk. It also gave employees designated

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break times. While it could have improved the situation by providing more pumping

rooms, it was not breaking the law unless the amount of time employees were given to

pump could be deemed unreasonable. The social expectations that women experience are

not addressed by the laws, and this contributes to the feeling of burden women have that

is central to the backlash. The working mother who breastfeeds has to navigate between

competing needs as Sharon Hays has noted (1998). On the one hand she has to respond to

biological functions, care for her infant, and maintain a bond with her infant. On the other

hand, she has to maintain a professional bond with co-workers by not seeming to have

special advantages, by respecting a workplace hierarchy, being efficient, not abandoning

work and her fellow employees for any reason when it gets busy, following the

workplace schedule, and maintaining the confidence of supervisors.

Negative responses to The Baby Friendly Hospital Initiative is another example of

a breastfeeding policy backlash. Women who are against it feel that the steps hospitals

adopt in order to be certified, such as having infants room in with mothers postpartum

instead of going to the nursery, or only giving infants formula if it is medically indicated,

take away their choice and is a way of pushing breastfeeding on women.16 As long as

exclusive and intensive mothering exists and solutions to women’s breastfeeding

difficulties only consist of better technology and no substantial structural changes,

breastfeeding will be seen as a contributor to the burden that women carry. For some

women this will mean that breastfeeding is a negative experience, and breastfeeding

promotion and activism will be rejected as a way of pushing another obligation on

16 One of the research locations for this dissertation was a BFHI certified hospital. If women said they didn’t want to breastfeed and requested formula for this reason, it was not denied to them. For women who wished to breastfeed, the rule about formula having to be medically necessary in order to be given out, made sure that women’s breastfeeding efforts weren’t sabotaged by formula given unnecessarily.

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women. None of this means that policy changes are not worthwhile, rather that policy

changes alone are not sufficient. Understanding the backlash to breastfeeding promotion

and advocacy is important to the history and current standing of the IBCLC as a

breastfeeding advocate and activist, and also speaks to the issues that they confront when

helping breastfeeding mothers who are affected by an ideology of intensive mothering

and ideologies of capitalism (Hays 1998).

The Influence of La Leche League on the Creation of the IBCLC

I attended several La Leche League meetings in order to understand how the

certified lactation consultant profession might have arisen from the La Leche League

founders and how peer support might be different from the support of lactation

consultants. The meetings that I attended were from one group on Oahu and may not

resemble what meetings in other places are like. La Leche League, however, has a

structure that trained leaders have to follow, with restrictions on what they can and

cannot endorse or discuss. I wanted to see first-hand what this structure looked like and

how the mothers attending the meetings responded to it.

The meetings were held in a more affluent area of the island. When I arrived at

the beach park where I had been told the meetings were held, it was immediately clear

that I needed to make my way over to the circle of barefoot women sitting on blankets in

the grass under shade trees. Young children chased each other across the blankets and

disappeared into a grove of trees while infants either nursed, slept in their mother’s arms,

or were engrossed in chewing on a variety of soft toys. The moms seemed relaxed and

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easily engaged in small talk with each other, glancing occasionally at a crawling infant

who was sampling all the toys found on neighboring blankets.

I attended 9 monthly meetings. The number of mothers in attendance remained

fairly consistent across the meetings even though some women came to each meeting and

others did not. There seemed to always be at least one new face and people who came

consistently to only some of the meetings. Most of the mothers were White and lived in

the area, although a graduate student with a bi-racial infant and a woman of color showed

up at one of the later meetings. At the first meeting I counted five mothers with babies,

and three pregnant women. I assessed that they were middle class based upon

observations. I noted that all the babies at the meeting whose diapers were showing were

wearing cloth diapers, so I made small talk and asked the women if this had saved them

money, and how much their electric bill went up after they started washing and drying

cloth diapers, an issue which had been a concern to me as a low-income mother. Three

women who were sitting close to me responded to my question. Two of them said they

didn’t know because they had a solar powered hot water heater and electricy. The other

mother just hadn’t bothered to find out. This confirmed to me that they weren’t wearing

cloth diapers as a cost saving measure, and cost concerns had not entered their minds.

There was also a lot of name brand baby gear on display. From the discussions and

women’s interests, I guessed that they were college educated. There were also three

women who came now and then to meetings and said they were nurses. The pre-meeting

discussions included anti-fluoride views and talk by some about their belief that vaccines

should be spaced out and given at a later age rather than by the schedule pediatricians

recommended. The view that autism was caused by vaccinations was also expressed.

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These are topics and opinions that have been associated with some middle-class White

parents.

While I’m not sure if all of the women at the meetings held views associated with

the anti-vaccine movement, it made sense that La Leche League would be attractive to

those who did. Many who are involved in that movement believe that extended

breastfeeding will develop their child’s immune system and will provide them with

additional protection should they become infected with a disease they otherwise would

have been vaccinated against. Not vaccinating their child, or delaying vaccines,

diminishes the herd immunity effect in the community, but is seen as what is best for

their own child. This observation is supported by sociologist Jennifer Reich (2018), who

has studied the anti-vaccination movement. She has claimed that 20 – 25% of American

parents are part of this movement and are most likely to be educated Whites with a higher

than average income (Reich 2018). Reich determined that the movement is due to a

culture of individualist parenting and our emphasis on personal responsibility in

healthcare (Reich 2018). Most vaccine deniers she studied believed that vaccines are

effective, and thus weren’t actually science deniers, but didn’t believe that some or all of

them, or that early and simultaneous inoculations were best for their child (Reich 2018.

See also Brunson and Sobo 2017). They were found to often be mothers who put lots of

effort into the health and welfare of their own children but felt no sense of communal

responsibility (Reich 2018). Thus, the understanding that certain diseases their

unvaccinated child could acquire could be fatal to infants they came into contact with, did

not persuade them. They felt unsupported by social structures, including the healthcare

system, and didn’t trust pharmaceutical companies (Reich 2018). Thus, it was important

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to them to do their own “research,” which was partially based on reading expert advice,

while also not allowing themselves to be pressured by experts (Reich 2018). Getting

advice from other mothers was also important (Reich 2018). They felt they needed to

make informed choices because they were personally and exclusively responsible for

their children, reflecting intensive mothering (Reich 2018). While the women at these

meetings were not all necessarily anti-vaccine, they did subscribe to the idea that they

alone were responsible for their parenting and healthcare choices and that they needed to

research childcare topics in order to make the right choices. La Leche League had

attempted to reproduce alloparenting as a sense of community. I wondered if women who

felt no connection or responsibility towards the community were finding community

here.

The La Leche League leader was a tall, gregarious, blond haired mother who put

others at ease with her relaxed, judgment-free attitude. She started every meeting by

announcing that the meeting was a chance for moms to share whatever issues they

wanted to, “without people trying to solve it.” At this first meeting I attended she added,

“We’re here for support. It’s not diagnostic; it’s a sisterhood of support.” At another

meeting she said that as people shared, “you may hear things you don’t agree with, and

that’s just fine. Breastfeeding is a journey.” At each meeting she would then introduce a

topic, say a few words about it, and then open the discussion up. The topic at this first

meeting was the amount of sleep the mothers and their infants were getting. The leader

said, “We are going to talk about the amount of sleep without it being like a doctor asking

you how many glasses of wine you drank. Not everyone follows everything in the La

Leche League manual.” The women in attendance listened to each other without giving

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advice or being discernibly judgmental, and simply stated that they too could relate to the

experiences that other women shared.

At one meeting a woman spoke up and said that there was no right way to feed

your baby and that she had to supplement her baby with formula because he was still

hungry after breastfeeding. She told the other mothers that they shouldn’t feel bad about

it and should go ahead and give their baby formula if they needed to. I was interested in

how the leader would respond to this remark given La Leche League’s pro-breastfeeding

stance, and what my IBCLC training had taught me about how perceptions of low milk

supply are sometimes misinterpretations of infant cues and true low milk supplies can

often be remedied. I was surprised when she affirmed that there was no right or wrong

way to feed your baby and then said, “Don’t judge others because there is a lot of judging

out there.” Two moms then shared that they had cried and felt bad about it when they had

to give their babies formula. One of them referred to research on how breastmilk

develops an ideal microbial environment in the infant gut and said that as she gave her

baby formula she thought, “Now I’m going to ruin his stomach flora.” The leader

sarcastically quipped, “Oh, he won’t get into Harvard now! You did not just give your

kid a cigarette! Don’t worry about it.” The leader then noted that sometimes mothers

critically judge themselves, so judgement wasn’t always external. These types of

statements seemed to make women feel safe to share with the group and to admit to

things like using formula and cribs, that might otherwise be frowned upon in college

educated, middle class, White, attachment parenting environments.

The leader, despite saying there would be no advice giving, did occasionally

break this vow, especially when she had an opportunity to offer preventative tips to a

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pregnant woman who was worried that nursing would be painful. Overall, however, the

meeting consisted of women talking about their issues and getting support from other

mothers who said they too had gone through something similar. When a mother of a 3-

week-old infant said she had sore nipples and wanted help with the infant’s latch, the

leader remarked, “Maybe she slips off. We are just here for support, we’re not lactation

consultants. Does anyone have advice?” Mother’s then related their own stories of

dealing with sore nipples. The types of “advice” given were different from the types of

advice a medical expert would offer and ended up sounding more supportive than

directive. At one point the leader told us that she had to reiterate La Leche League’s

official recommendations but clarified that she only had to mention these as suggestions.

She added that she didn’t want to make anyone feel bad if they made other choices or had

other suggestions. She reassured the women that there was no reason to feel bad about

their choices, saying, “You’ll never achieve ideal motherhood.”

I asked the leader if she thought that this environment of non-judgement and

acceptance was unique to this group or was widespread among La Leche League groups.

She said she didn’t know, but that in a La Leche League group that she attended in

Florida, there was a mother who didn’t breastfeed at all who was accepted into the group

and would feed her infant a bottle of formula at the meetings. This mother came because

she liked the feeling of community and felt welcomed by the other mothers. The 2012

edition of the La Leche League Leader Applicant Resource Kit asks leaders to examine

their own biases, because otherwise they “may not be able to communicate the same

caring and unqualified acceptance as we offer to mothers whose choices, for whatever

reasons, are more like our own” (6). The kit further instructs that, “the leader’s goal is to

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empower the mother by giving her the facts she needs to make informed choices. We

need to support each mother as the expert on caring for her own baby” (6).This goal set

forth for all La Leche League leaders supports the notion that mothers are empowered

when they are educated and can then be expected to do the right thing for their infant.

Women thus don’t need to blindly follow what an expert says; they themselves are now

the expert.

Just how far the leaders would go with the idea of choice and refraining from

being judgmental was on display during a discussion about mothers returning to work. A

mother shared that she had to return to work in a few weeks and asked if anyone else had

done that. A second mother began to cry17 and expressed her dread about returning to

work. She said she didn’t want to leave her infant son. The secondary leader of the group,

who filled in when the regular leader was unavailable, told the story of a military family

who left their infant with someone in another state for a month while they got settled in

Hawai‘i. In addition, the mother was to be deployed for a time and wouldn’t see her baby

for the period of deployment. This secondary leader then said that she had to remind

herself that in those types of situations the baby chose to be born into that situation. Thus,

while such extended separation of the mother and infant was seen by her as potentially

damaging to their bond, she framed it as the infant’s spiritual choice as an experience she

decided to have before she even incarnated. This story was told in order to avoid making

mothers feel personally guilty or distressed about what was ultimately the outcome of the

government’s refusal to legislate paid and adequate maternity leave.

17 The amount of crying observed at the meetings, which were intended as a form of mother to mother support, substantiates the amount of struggle experienced and the importance that breastfeeding held for these mothers.

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I saw the erasure of the structural causes of infant care difficulties again at a

meeting where the topic was women breastfeeding in public, and nurse-ins were

mentioned. Nurse-ins are events in which activists have gathered at establishments that

have asked a woman not to breastfeed in public or have asked her to leave their

establishment for doing so. At the gathering the group of women defy this by

breastfeeding publicly together. The leader spoke up and told the women at the meeting

that La Leche League doesn’t support nurse-ins. She explained that the reason for this

was so that they remained a support group by not getting political.

The emphasis at the meetings on creating a safe environment where women didn’t

feel judged, and on putting limits on expert advice to the point that even La Leche

League’s official recommendations were just presented as suggestions, confused me at

first. At one meeting, after everyone had shared, the leader passed around an envelope

that contained sheets of paper with quotes typed on them. The quotes had come from a

book on nighttime parenting, which was a book written by an expert. We each pulled out

a folded-up quote and were told we could share our thoughts on what was written on our

piece of paper. My paper said that parent-led baby schedules were not a good idea. I read

it aloud. The leader offered up ideas on what parents could do if their baby kept waking

up at night, all of which adhered to attachment parenting philosophy and was contrary to

sleep training. She asked if anyone else had thoughts about or problems with night

waking. She then asked me what I thought of parent-led baby scheduling. I noted that the

quotes we were reading were in fact expert advice, so I started to give a professional

opinion. I was then struck with a wave of anxiety upon remembering that the meeting

was not supposed to involve expert advice. I told the women that it was perhaps better if I

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talked about my experience as a mother, even though my children were long past the age

of breastfeeding. After the meeting the leader said she was happy I was attending because

she enjoyed hearing my anthropological perspective and my knowledge as a lactation

consultant. It seemed that expert advice was not frowned upon because it wasn’t

respected, but because the purpose of the group was to make women feel comfortable in a

peer support setting. Thus, limited expert advice in that setting was suggestive and an

avenue for open-ended questions. It was an opportunity for women to openly share their

experiences with one another. Expert advice, on the other hand, could shut someone

down.

While some members of the group resisted expert advice in areas such as

vaccines, they were receptive to attachment parenting experts and lactation consultants.

In fact, the leader bought a lending library of attachment parenting books with her to the

meetings as suggestions for reading, which endorsed this type of expert advice. This also

seemed to be what the leader drew from in order to give women facts from which they

could make their own educated choices. To make sense of what I was observing, I turned

to that lending library of attachment parenting books. Although La Leche League

International does not say that it advocates for attachment parenting, the book they

publish, The Womanly Art of Breastfeeding, recommends all of the items that Dr. Sears

listed as essential attachment parenting practices18. This makes sense because these

practices help facilitate breastfeeding while other practices, such as sleep training, can

reduce your milk supply and fit in more with formula feeding (Tomori 2015). This was

18 Dr. Sears’ website: https://www.askdrsears.com/topics/parenting/attachment-parenting/attachment-parenting-babies Accessed 2/4/2020.

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essential to understanding how the IBCLC arose from La Leche League, as well as

understanding how the backlash to breastfeeding has come about, which I explore in the

next section.

“Natural” Parenting and the Expert

In the 1970s, at a time when few women in the U.S. even attempted to breastfeed,

psychologist Jean Liedloff wrote a book informing parents of the shock she experienced

seeing how happy Indigenous babies in Venezuela were compared to infants in the U.S.

The book was called The Continuum Concept: In Search of Happiness Lost and was a

response to her experience observing the parenting practices of the Yequana, Sanema,

and Tauripan hunter-gatherer tribes in the rainforests of Venezuela. Liedloff reported that

these Indigenous peoples indulged their infants’ needs and carried them frequently,

breastfed them whenever they wanted to, slept with them, and responded immediately to

their infant’s cues. She noted that these infants rarely cried, and she credited the

aforementioned parenting practices for this (Liedloff 1977). Her notion of Indigenous

people as closer to nature was a version of the racist “noble savage” idea that imagined

the tribes she spent time with as happier than “civilized” society because they were in her

view primitive. However, some of the practices she observed are undoubtedly beneficial

to mothers and infants, and these practices, along with Liedloff’s lasting impact on

discourses of mothering and breastfeeding, are worth discussing at length.

Liedloff (1977) compared the infant care of these tribes in Venezuela with

American childrearing practices and expert advice of that time period. Such sweeping

generalizations grossly homogenize both so-called groups, but the way in which a White

American psychologist was so taken by what she observed, and how it contrasted with

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dominant discourses and practices with which she was familiar, is worth exploring.

Women in “advanced countries,” she claimed, had unfortunately stopped trusting their

own instincts and had instead turned to male child rearing authorities for infant care

advice (18). Often the advice books instructed mothers to ignore their infant’s needs and

to separate themselves from their infants both physically and emotionally, she said:

It may be the current fashion to let the baby cry until its heart is broken and it gives up, goes numb, and becomes a ‘good baby’; or to pick it up when the mother feels like it and has nothing else to do in that moment, or, as one recent school of thought had it, to leave the baby in an emotional vacuum, untouched except for absolute necessity and then shown no facial expression, no pleasure, no smiles, no admiration, only a blank stare. …Crying must be ignored so as to show the baby who is boss…. What [the baby] has not come prepared for is a greater leap of any sort, let alone a leap into nothingness, non-life, a basket with cloth in it, or a plastic box without motion, sound, odor, or the feel of life. The violent tearing apart of the mother-child continuum, so strongly established during the phases that took place in the womb, may understandably result in depression for the mother, as well as agony for the infant. (1977, 35-36)

Liedloff decided that American women’s reluctance to trust their instincts in

regard to infant care, and the consequent disruption of the mother-infant bond, was

responsible for much of the psychological problems she saw in her practice. She

described the infant who is reared in “Western civilization” as deprived of sensory

stimulation and human affection such that it is akin to torture (63). She explained the

effect this has on the infant by giving a dramatic account of what the infant must

experience upon awakening alone in the hospital nursery:

He awakens in a mindless terror of the silence, the motionlessness. He screams. He is afire from head to foot with want, with desire, with intolerable impatience. He gasps for breath and screams until his head is filled and throbbing with the sound. He screams until his chest aches, until his throat is sore. He can bear the pain no more and his sobs weaken and subside. He listens. He opens and closes his fists. He rolls his head from side to side. Nothing helps. It is unbearable. He begins to cry again, but it is too much for his strained throat; he soon stops. He

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stiffens his desire-racked body and there is a shadow of relief. He waves his hands and kicks his feet. He stops, able to suffer, unable to think, unable to hope. (60)

Such dire descriptions of tortured infants who would become psychologically damaged

adults, made many mothers who read her book and had not raised their infants in a so-

called natural manner, feel guilty and depressed. In the introduction to a later edition of

her book she revealed what one mother had written to her about her suicidal thoughts

after reading the book:

I honestly believe that it was only while I thought that all the aggravation we go through was normal and unavoidable – ‘natural,’ to use a word one often hears by way of comfort from other mothers, child psychologists, and books – that it was endurable at all. Now that you have intruded into my mind the idea that it could be otherwise, well, I don’t mind telling you that for twenty-four hours after reading your book, not to mention during, I was so depressed I felt like shooting myself. (1977, xii-xiii)

Liedloff wrote that another mother named Rosalind, “told me how she had sunk into a

weeping depression for several days after reading the book. Her husband was

understanding and patiently took care of their two little girls, while Rosalind languished,

unable to continue her life in the new light” (1977, xiii).

Such feelings of guilt and depression are still reported by mothers who don’t

experience natural childbirth or who have difficulties breastfeeding. Women feel as

though failure in these areas reflect a failure of their ability to mother, rather than seeing

it as a consequence of our social structures. We have come to believe that what happens

to a person in infancy potentially affects the projection of their future life and well-being

as Liedoff thought, and so mothers are especially distressed when natural childbirth and

exclusive breastfeeding are not achieved.

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Although Liedloff may have encouraged guilt among mothers with such dramatic

descriptions of infant suffering that targeted what an individual mother does, she was not

without good reason to be concerned over certain practices. In Liedloff’s time, as she

describes it, childrearing practices involved not responding to infants’ needs and signals.

Many childrearing experts advanced the idea that child rearing should be efficient and

orderly with the parent as authority figure training the infant to conform to the parents’

needs (Liedloff 1977). Thus, infants were to be fed on a schedule, not whenever they

wanted to be fed (Millard 1990). They were to sleep through the night by being left to cry

so that they would figure out that no one would respond to their needs and thus give up

crying (Liedloff 1977). Parents were told that picking children up when they cried or

showing them too much affection was counterproductive and would create spoiled,

demanding children (Liedloff 1977). Formula feeding more easily fits into this type of

model since these practices often reduce a mother’s milk supply and because breastfed

infants require more frequent feeding (Riordan and Wambach 2010). Some of these ideas

are still prevalent today and are finding a resurgence in popularity after being

reformulated. For example, gentler sleep training methods referred to as “controlled

comforting” or “camping out,” where a parent gradually reduces their presence at night

after checking in on the infant occasionally, or leaves once they are asleep, are currently

popular (Shellenbarger 2018).

Concerns over the ways that sleep training impacted breastfeeding increased once

On Becoming Babywise (1995), a book that advocated putting infants on feeding

schedules and promised to get infants to sleep through the night, prompted a response

from the American Academy of Pediatrics (AAP) to its members in 1998:

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One such book, On Becoming Babywise, has raised concerns among pediatricians because it outlines an infant feeding program that has been associated with failure to thrive (FTT), poor milk supply failure, and involuntary early weaning. A Forsyth Medical Hospital Review Committee, in Winston-Salem N.C., has listed 11 areas in which the program is inadequately supported by conventional medical practice. The Child Abuse Prevention Council of Orange County, Calif., stated its concern after physicians called them with reports of dehydration, slow growth and development, and FTT associated with the program. And on Feb. 8, AAP District IV passed a resolution asking the Academy to investigate ‘Babywise,’ determine the extent of its effects on infant health and alert its members, other organizations and parents of its findings. (Aney 1998, 21)

Some mothers I helped told me their pediatricians were now recommending sleep

training, and starting at an even earlier age than had previously been recommended. I

assisted many mothers whose milk supply had severely dropped as soon as they had

gotten the baby to sleep through the night, not realizing that the body determines how

much milk needs to be produced based upon how much stimulation the breasts get. They

were dismayed to find that in order to bring their milk supply back up to the level their

infant required, they now needed to wake themselves up at night to pump, prompting

them to wonder what the logic behind getting the baby to sleep through the night had

been in the first place. Leidloff’s observations were important in that she caused people

to question the outcomes of childrearing practices of the time.

The Continuum Concept became a classic and influenced many parents to go back

to what they considered “natural” childrearing practices that were supposedly appropriate

to human evolution. Dr. William Sears, considered the father of attachment parenting,

was so greatly influenced by Liedloff that he repackaged her advice and called it

“immersion mothering ” (Sears 1982, 181; Pickert 2012). Sears published a book in 1982

that was titled Creative Parenting: How to use the New Continuum Concept to Raise

Children Successfully from Birth Through Adolescence. A later addition was re-titled so

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that the words “continuum concept” were replaced with “attachment parenting.”

Although Sears gets the credit, and his later retitling of the book was a reference to John

Bowlby’s attachment theory (Bretherton 1992), in reality, Liedloff started the attachment

parenting movement.

Even though parenting practices in the 70s tended to be aimed at making infants

conform to the parent’s needs, the idea that parenting practices have important impacts on

developing children was an idea spread through attachment theory (Bretherton 1992). It

is important to distinguish between attachment theory, and attachment parenting. They

are different, but both ascribe to the idea that what happens in early childhood can affect

a person’s social, emotional, and cognitive development. In the 1950s the psychologist

John Bowlby started studying abandoned children (1958). He believed that human infants

come into life with species-specific behaviors that are meant to illicit care as a means to

survive (1969). He called this attachment theory. Some of his findings were not

substantiated, and Bowlby’s theory did not suggest that mothers needed to carry their

infants, sleep with them, or continue breastfeeding until the child decides to wean on their

own, in order to achieve attachment. In fact, his theory was not about parenting practices.

Attachment parenting, on the other hand, suggests specific childrearing actions to help

one’s child form a healthy parental attachment (Sears and Sears 2001). Leidloff (1977)

was the one who gave Sears and others the means to leap from the idea that humans are

social beings who evolved to form attachments, to the idea that certain mothering

practices were the evolutionary response to this.

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On Dr. Sears’s website,19 he states that attachment parenting practices for infants

starts with facilitating bonding at birth to allow the “attachment-promoting behaviors of

the infant and the intuitive, biological, care-giving qualities of the mother to come

together.” He lists the practices involved in attachment parenting as breastfeeding on cue,

baby wearing, co-sleeping, responding to cries, and avoiding “convenience” parenting

advice such as sleep training. Such prescriptions for doing things that are mother

intensive, gave rise to criticism against practices associated with so-called “natural” or

“instinctive” parenting, including exclusive and extended breastfeeding (Badinter 2012;

Jong 2010; Jung 2015; Wolf 2011). Leidloff and attachment parenting advocates made

racist assumptions about Indigenous people as so close to nature that they were simple, or

primitive people. They failed to examine the differences between hunter-gatherer

societies and industrialized or post-industrialized societies. They even failed to note that

there can be differences between the ways that hunter-gatherer societies practice

parenting and breastfeeding (Lancy 2015; Sellen 2001). The guilt that many women

reportedly feel over failing to achieve attachment parenting ideals, is because our society

blames individuals for such failures rather than social structures that are incompatible

with the attachment parenting they are trying to practice.

Infant Care and Evolution:

To make sense of the attachment parenting philosophy and its practices and

beliefs surrounding breastfeeding, it is helpful to examine the basis for the idea that

19 https://www.askdrsears.com/topics/parenting/attachment-parenting/attachment-parenting-babies Accessed 2/4/2020.

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humans evolved to require the particular types of care that attachment parenting

advocates. Attachment parenting advocates often turn to anthropology for confirmation

that their beliefs and practices are scientifically grounded, so I will examine evolutionary

ideas in anthropology against how sociocultural observations speak to current challenges.

Biological anthropologists Karen Rosenberg (2016), Wenda Trevathan (2011, 2016), and

primatologist Sarah Blaffer Hrdy (1999), have noted that humans have evolved to require

extensive care in infancy. The scientific idea is that through evolution one’s genes are

passed on to future generations (Trevathan 2011). Reproductive strategies not only ensure

the survival of the individual, but the survival of the species itself (Trevathan 2011).

Scholars have noted that in humans across all time, there is not an effort to maximize

how many offspring we produce, but rather efforts to maximize the survival of our few

offspring (Hrdy 1999; Rosenberg and Trevathan 2016; Trevathan 2011). This is

accomplished by investing a lot of time and energy in a smaller number of offspring than

many other species in order to encourage greater intelligence and sociality in them (Hrdy

1999; Rosenberg and Trevathan 2016; Trevathan 2011). Trevathan (2011) points out that

sociality is an important component because it encourages sexual and caretaking

behaviors, which contribute to further reproductive success in generation after generation.

Our greater intelligence is reflected in encephalization and a long period of childhood,

that requires substantial care in infancy (Rosenberg and Trevathan 2016; Trevathan

2011).

If we look specifically at a mother’s milk, mammals produce milk that varies

between species in terms of its composition, and this composition in turn is said to be

reflective of mammal parenting styles (Ben Shaul 1962). For example, mother lions will

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leave their cubs in a den, returning to nurse them 6 to 8 hours later (Ben Shaul 1962).

Their milk is high in fat and protein, but low in carbohydrates, ensuring that the cubs will

remain full during the hours that the mother is away (Ben Shaul 1962). Similarly, mother

deer will leave their infants hidden in brush for long hours before returning to nurse them

(Ben Shaul 1962). The mother doesn’t have to feed the baby deer very often because of

the high fat and protein and low carbohydrate content of her milk (Ben Shaul 1962).

In contrast, chimpanzee infants cling to their mother’s fur and go everywhere with

her. Because they are in constant contact with their mother, they are easily able to nurse

on demand (Ben Shaul 1962). Thus, chimp mothers have milk composition that is dilute,

low in fat and protein, and high in carbohydrates, especially lactose (Ben Shaul 1962).

Mammals that fall into this category not only have continual contact with their mothers

but have slower growth patterns and do not need to ingest large amounts of fat in order to

stay warm (Trevathan, 2011). They also require frequent nursing (Trevathan 2011).

Humans have a milk composition that is similar to that of chimps when you look at fat,

protein, and lactose content (Ben Shaul 1962). Thus it has been determined that, like

primates, human infants biologically require frequent breastfeeding. New mothers in my

research were often surprised by how frequently their infants want to nurse and

sometimes incorrectly take this as a sign that their infant is hungry because their body is

not producing enough milk.

Observations of contemporary hunter-gatherer populations have been used as a

gauge for how humans evolved to care for their infants. This is controversial because it

assumes that hunter-gatherer cultures are all the same, and because Indigenous

populations may not represent the exact conditions and practices of their ancestors.

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Populations in which breastfeeding is normalized, however, are sometimes studied to

provide an idea of what such conditions and practices may have been like in the past.

It has been determined that they tend to practice a rate of frequent breastfeeding.

For example, among the Aka, a hunter-gatherer tribe that resides in the Central African

Republic, infants are breastfed on average four times an hour (Lancy 2015). This is in

contrast to standard advice given to mothers in the U.S. that their infants may want to

nurse as often as once every 1-3 hours for what amounts to about 20-30 minutes total for

each nursing session. The lactation consultants I observed often told mothers that “cluster

feeding,” in which the infant seemed to want to nurse all the time, was normal but a

limited behavior and shouldn’t be a constant expectation. The Aka, however, would not

be nursing 4 times an hour for 20 or 30 minutes each time, so the amount the Aka infant

and the American infant ingests equal out, but nursing in more frequent intervals is a

factor in increased milk production (Cregan et al. 2002; Rennie 2012) and delayed

ovulation for greater spacing between children (Taylor et al. 1999). Also, not all hunter-

gatherer populations nurse as frequently as the Aka, but do not go over the standard we

have established of nursing at least once every three hours (Lancy 2015). It is also not

necessarily true that because the Aka and other groups nurse frequently, that they have

nursed frequently throughout all of their history. Although there is variation in terms of

exactly how often mothers nurse in a given society, and for how long, it is still considered

frequent compared to mammals with less dilute milk. All of these factors have been

pointed to in order to establish that there is a need for frequent nursing among human

infants, and that humans have likely evolved to require being in substantial contact with

whoever is nursing them (Trevethan 2011).

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Another biological factor that has been pointed to as an indicator that human

infants need to be in substantial contact with a caregiver is their uninhibited urination and

defecation. Baby deer are protected from predators during their mother’s long hours away

because they have no odor (Trevathan 2011). Animals such as deer lick the genitals of

their young in order to stimulate urination and a bowel movement (Trevathan. 2011). The

mother then ingests the urine and stool to keep the odor from attracting predators

(Trevathan 2011). If human infants were fed a milk that allowed them to be left alone for

long periods, one would assume they would need to have evolved the ability to be able to

withhold elimination until they were in the presence of their caregiver in order to be safe

from predators. Parents who have gotten their infants to sleep through the night are most

likely leaving these infants in soiled diapers for many hours, which is only something that

has been made possible with modern diaper technology.

Our milk content, reflexes,20 infant urination and defecation patterns, and degree

of helplessness at birth have all been used as evidence of an evolutionary model that

requires continual contact with a mother or caregiver during early infancy. It is theorized

that upright walking made it difficult for human infants to continue clinging to their

mothers, so the plantar grasp and moro reflexes are vestiges of an evolutionary past that

are not useful to us anymore (Hrdy 1999). Putting our infants in diapers and a crib at

20 Like chimps, human infants also have palmar and plantar grasp and moro reflexes that are likely rudiments of our evolution past (Brown and Fredrickson 1977). The palmar and plantar reflexes cause the infant to grasp with hands and feet whenever the reflex is stimulated (Brown and Fredrickson 1977). The moro reflex causes the arms to extend and fingers to splay followed by adduction (Brown and Fredrickson 1977). This reflex is stimulated in response to a feeling of falling or tilting in the infant (Brown and Fredrickson 1977). These reflexes have also been observed in primates and seem to keep the infant clinging to its mother (Brown and Fredrickson 1977). Researchers have found that the palmar reflex is increased when a human newborn sucks (Brown and Fredrickson 1977; Pollack 1960) leading to the theory that these reflexes were especially useful for keeping the primate infants clinging to their mothers while nursing.

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night will not put them in danger of being eaten by a predator these days.21 It is also the

case that not all hunter-gatherer societies have engaged in exactly the same infant care

practices across time or when compared with each other. For example, where

breastfeeding is concerned, some of them have taboos against feeding newborns

colostrum and they have shown variances between societies in frequency of nursing

(Lancy 2015). However, it is also the case that overall the patterns are similar so that

even the frequency variances indicate that they do not go long periods (greater than 3

hours) between infant nursing.

Scholars agree that human infants are social beings who evolved to form

attachments and also require a substantial amount of care (Hrdy 1999; Trevathan and

Rosenberg 2016; Trevathan 2011). They also agree that if a person is going to breastfeed,

the infant will require frequent feeding due to human milk composition (Trevathan 2011).

It is important though, that various experts donʻt exclude the influence of sociocultural

factors when examining biological evolution or making conclusions about how we should

parent.

Instincts and Social Structure:

Leidloff (1977) said that women in the U.S. had stopped trusting their instincts

and had instead turned to experts who happened to be male, to tell them how to be a

mother. Dr. Sears believed that women have an innate mothering instinct that they utilize

to bond with their infants (Sears and Sears 2001). While it has been established that

infants have instincts that help them to elicit care from others (Bowlby 1958, 1969;

21 Which isn’t to say that cloth diapers and co-sleeping don’t have benefits.

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Trevathan 2011), no mothering instincts related to breastfeeding have also been

established. What is clear is that childrearing, or even more specifically the care given by

a mother, varies according to sociocultural factors.

Attachment parenting, which includes exclusive breastfeeding, is often a

challenge for women in post-industrial societies. However, it is also true that our altricial

infants really are incredibly helpless and necessarily require intensive caregiving

(Trevathan 2011). Leidloff’s (1977) observations of Indigenous infant care included an

often-overlooked passage that reveals that Yequana infants were not cared for all day

long by their exhausted mothers the way contemporary American mothers are expected

to. This is revealed in her attempt to explain why Yequana infants did not seem unsettled

after nursing and require burping:

Yequana babies never require special treatment after nourishing themselves – any more than do the young of other animals. Perhaps part of the explanation lies in the fact that they nurse much more often during the day and night than our civilized babes are permitted to do. It seems more likely, though, that the whole answer rests in our permanently stressed condition, for even when Yequana babies were cared for by children most of the day, and therefore unable to resort to their mothers at will, they showed no sign of colic. (56)

The Yequana, like observations of other hunter-gatherer societies, did not expect mothers

alone to provide care for their children (Lancy 2015). They didn’t even expect it to be

only divided between mothers and fathers, but in fact the whole village (Liedloff 1977).

Older children often became caretakers of infants once they were out of the “in-arms

phase” (Liedloff 1977).

Liedloff (1977) wrote that parenting like hunter-gatherer women was easy. All

American women had to do was to put down the parenting advice books written by male

authority figures, tune into their instincts, watch for their infant to tell them what his or

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her needs are, strap their infants on them so they are mostly held, and if they must return

to work have the infant’s caregiver do all of the above (Liedloff 1977). What she, Dr.

Sears and other attachment parenting experts have not understood, is that you cannot

easily take parenting practices from one social system and seamlessly transfer them into

another social system. In fact, Liedloff (1977) wrongly asserted that differences in our

way of life and that of hunter-gatherers were irrelevant:

The difference between our way of life and that of the Yequana is irrelevant to the principles of human nature we are considering. . . It would help immeasurably if we could see baby care as a nonactivity. We should learn to regard it as nothing to do. Working, shopping, cooking, cleaning, walking, and talking with friends are things to do, to make time for, to think of as activities. The baby (with other children) is simply brought along as a matter of course; no special time need be set aside for him, apart from the minutes devoted to changing diapers. His bath can be part of his mother’s. Breastfeeding need not stop all activity either (160-161).

Liedloff’s (1977) insistence that what she considered hunter-gatherer style infant care

could be so seamlessly integrated into our everyday lives, is a profound failure to

understand women’s social realities in a market based post-industrial society, as well as

to misunderstand the alloparenting practices among hunter-gatherers.

Hunter-gatherers who have been observed by anthropologists have an

alloparenting system like the ones Leidloff observed, where women aren’t expected to be

individually responsible for the parenting and health of their children (Hrdy 1999; Lancy

2015). Moms can wear their newborn and bring them to work, only the work they do and

the social structure of it are different from that of a post-industrial economy (Lancy

2015). Other women, usually grandmothers, would breastfeed your child in your absence,

and other community members, often older children, would help care for infants and

young children (Hrdy 1999; Lancy 2015). There is not a philosophy and practice of the

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individual mother parenting in isolation with no support from their extended families,

their community, or political and economic structures (Lancy 2015). Therefore, women

who breastfeed in a society without the support of alloparents are not exactly practicing

the same type of parenting as that they believe hunter-gatherers practice. Lactation

consultants believe that many of the difficulties that women report associated with

breastfeeding are due to a lack of support from families, government and private

institutions.

The La Leche League founders had the understanding that mothers learned best

when other mothers modeled breastfeeding for them (Eden 2013). This form of social

learning was more important than any kind of instruction or advice you could give. In

fact, the book they publish, The Womanly Art of Breastfeeding (2010), tells women this

by problematically referring to “traditional people:”

In traditional tribes, where babies are part of everyday life, the new mom and dad have been watching other parents since they were babies themselves, and they’ve absorbed most of the skills they need without even trying. They’ve had plenty of chances to practice, too, because they’ve been carrying and soothing and entertaining babies – their own siblings and cousins and neighbors – for many years. So the new mother in this traditional village is pretty confident about breastfeeding. She’s watched everyone else around her do it, she’s seen the variations, and she knows that sometimes people have challenges . . . but she’s also seen people solve those problems so she knows they can be fixed. She’s watched mothers breastfeeding in every imaginable position . . . and she has a mental image of the way that breastfeeding looks when it’s working well. (29).

The idea that in societies where breastfeeding was readily observed women “absorbed

most of the skills they need without even trying” (La Leche League 2020, 29), speaks to

the idea of a habitus, of embodied knowledge (Mauss 1973).

From my observations, the league was most effective as a form of socially

produced learning. A woman who attended the meetings and told me she came from a

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conservative family, had come to see breastfeeding a toddler as normal after being

exposed to breastfeeding toddlers at the meetings. She began to wear her baby as well,

even though previously she had identified these two things as something so-called

crunchy mothers did, which she certainly wasn’t. But she had observed how much calmer

babies were when they were worn by their mothers. The meetings gave women the

opportunity to see and understand what is “normal,” whether normal was a social

construction, or a bioevolutionary mechanism such as infant reflexes. This understanding

of what is normal was reassuring and calmed women’s anxieties and gave them

confidence. Also, many women breastfed in the group without covering up so you could

observe how it was done. A lactation consultant relayed to me how back when she had

become a mom, La Leche League had helped her to understand through observation that

babies could fuss for reasons other than hunger:

I went to my first La Leche League meeting when my oldest was 6 weeks old and had the revelation that she wasn’t a really fussy baby, and she was normal. Because I saw the other moms and all their babies, and I saw them nursing and then moms having to stand up and do the rocking and patting and I thought there was something wrong. I thought [my daughter] was supposed to nurse and fall asleep and be content. I didn’t know that they needed soothing stuff on top of breastfeeding . . . We haven’t been around other breastfeeding babies and their families . . . I remember going to that meeting and thinking “I’m going to wait until the meeting is, until everybody has done their thing because I have this really, really, really important question about why does my baby cry. What’s wrong with her?” And I didn’t have to ask her because I was like, all these babies are doing that same fussy thing that I thought was my major problem here.

The league’s ideas about breastfeeding being valuable because it was “natural” was tied

into a view of “traditional peoples” as closer to nature and therefore practicing what was

“natural.” The term “traditional peoples” is problematic because it is both imprecise and

can be used with racist assumptions that Indigenous people are primitive.

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La Leche League embraced science, as well as experts who spoke to how we

evolved, and how valuable breastmilk was to an infant’s psychological and physical

health. Relationships of support with other mothers was the way forward out of our “sick

technological age” (Ward 2000, 1) that was devoid of interpersonal relationships that

were so important. Natural bodily functions were not in need of medical management.

IBCLCs could not replace the socially produced learning model, but they could

demedicalize by integrating themselves into the medical system and creating change

(Eden 2012, 2013; Torres 2014). On the one hand, La Leche League remains blind to

certain social factors such as the way that efforts to create a non-judgmental atmosphere

and a lack of political involvement or focus erases the ways that ideological apparatuses

make breastfeeding difficult for women. This isn’t to suggest that mothers should be

blamed for breastfeeding difficulties or made to feel like bad moms for giving their

infants formula, but that efforts to not alienate mothers who give their infants formula has

in the past opened doors to formula marketing efforts that counted on the resultant silence

and lack of regulation to conduct predatory and harmful actions. La Leche League’s

oversimplification of “natural” parenting, which doesn’t acknowledge differences in

social structures between (and within) our society and that of hunter-gatherers, likewise

glosses over the struggles that breastfeeding women face that are rooted in structural

factors. Although their aim in creating a non-judgmental environment was likely meant in

part to counter criticisms of so-called pushy breastfeeding activists who make women

who can’t or don’t breastfeed feel guilty, not engaging with the structural causes of

breastfeeding difficulties could make mothers feel responsible. On the other hand, their

embrace of natural parenting methods while showing caution when it comes to

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technology and experts, while at the same time referencing science and understanding the

ways that women learn how to breastfeed, can be seen as influences on the creation of the

lactation professional. The activism of the lactation consultant will be further expanded in

chapter six in ethnographies that show how the lactation consultants in this study

confronted women’s ideological concepts.

Conclusion

The IBCLC arose from La Leche League’s desire to ensure that women were able

to get appropriate help with breastfeeding in the hospital. La Leche League’s mother to

mother support groups, however, were key to understanding the philosophy from which

the professional lactation consultant arose. Their attention to socially acquired learning

seemed to try to recapture elements of alloparenting that have been lost. La Leche

League’s founders also had both a respect for science combined with the view that most

doctors didn’t know enough about breastfeeding and couldn’t be trusted to adequately

help mothers with this. They were concerned that technology was pulling members of

post-industrial society away from interpersonal relationships, and that women helping

women and the encouragment of the mother-infant relationship through breastfeeding,

was the way the league wanted to change the culture.

My research conclusion is that La Leche League’s philosophy influenced the

professionalization of lactation consulting. The organization never intended for the

IBCLC to take the place of mother to mother socially acquired learning, and the IBCLCs

who were part of this research still maintain the original idea that women to women

support is important. This includes an activist type of support in which they feel obligated

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to help other women who want to become lactation consultants so that women as a whole

can benefit. It also includes women centered care in which their approach aims to

empower women, and knowledge accessible through touch is an important component of

this objective. Like the La Leche League founders, they believe technology is often used

inappropriately and interferes with breastfeeding, and that breastfeeding is relational.

They applied this in practice by using technology appropriately and only when necessary,

using evidence-based rather than profit-based medical practices, empowering women by

helping them to understand their body is a source of knowledge, seeing the infant and

mother as interdependent, encouraging bonding, and having an understanding of the

biological as social. These findings are discussed further in subsequent chapters. Like the

La Leche League mothers I observed, lactation consultants felt that attachment parenting

methods were best, but they were also aware of the barriers that existed for breastfeeding

mothers. Unlike La Leche League, they were often politically active in trying to change

national or state policies, and all of them tried to influence institutional practices.

As lactation consultants worked to change hospital practices and to create policy

that would decrease barriers to breastfeeding, they were stunned by an emerging backlash

against breastfeeding. This backlash portrayed them as anti-feminist zealots who were

pushing a particular form of motherhood down everyone’s throats, and who made women

feel unnecessarily guilty while science didn’t support the advantages that they claimed

breastfeeding provided. However, lactation consultants, La Leche League, those involved

in the backlash, and formula manufacturers all used science to make their arguments or

sell their product.

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The backlash has likely happened because some women involved in it seem not to

understand that while lactation consultants embrace some aspects of medicalization, they

medicalized in order to demedicalize (Torres 2014) as nurse midwives have. However,

there are also some mothers who desire medicalization and see it as a way to reduce their

burden. For example, those who have negative views of the Baby Friendly Hospital

Initiative (BFHI) see it as a way of taking away a woman’s choice and pressuring her to

breastfeed22 and room in with her infant (Preston-Roedder et al. 2019; Schmied et al.

2014). Some mothers want hospitals to bring back nurseries and end formula restrictions

because they view such restrictions as unfriendly to mothers who are trying to recover

from birth or who may need relief in the face of postpartum depression (Preston-Roedder

et al. 2019). As mentioned at the beginning of this chapter, without proper support and

structural changes, breastfeeding promotion and policies meant to make it possible to

breastfeed, are simply seen as adding to the expectations placed on women.

Despite changes that lactation advocates have helped to bring about, there are still

ways that breastfeeding is made difficult. There are social realities that breastfeeding

policy has not changed. Formula marketers have become cleverer and less obvious in

their attempts to undermine breastfeeding.23 The U.S. has opted to give every new mother

22 One of my research sites was a hospital that was Baby Friendly certified, and in this hospital I did not note pressure to breastfeed or a lack of choice. If a mother said that she did not want to breastfeed, the lactation consultants usually did not even enter her hospital room and interact with her, although presumably a nurse had already had a discussion with the mother that I was not privy to. I was told by the lactation consultants that it was that mother’s choice not to breastfeed and that would be respected. One even said that she doesn’t know what is best for a mother and that we shouldn’t judge women because we don’t know their whole story. If it was a slow day the lactation consultant might ask these mothers about their decision because they recognized that sometimes moms had misconceptions, such as ideas that if they didn’t have enough milk with their first child it meant that they wouldn’t with this infant. They would have a short dialogue, but I did not observe coercion. 23 For example, research on formula marketing that I analyzed in my Master’s thesis revealed covert efforts such as industry websites that appeared to support breastfeeding by saying it is best for your baby, while

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a breast pump rather than adequate and paid maternity leave, equal pay, rising wages,

maintaining or increasing access to birth control and family planning, affordable

childcare, and flexible workplace options. In other words, the changes lactation

consultants and advocates have helped to bring about and why they are important are

likely not obvious to a new generation of mothers who still face barriers to breastfeeding.

Many of them perceive the BFHI as an erosion of their choice or as something potentially

dangerous (Preston-Roedder et al. 2019). Prior to the BFHI efforts, separating mothers

and infants and allowing formula marketing and unnecessary formula supplementation

are examples of ways that hospitals were unfriendly to both infants and mothers who

were thus potentially subjected to greater difficulties with breastfeeding. The BFHI

developed out of such concerns for mothers and yet is now criticized as anti-mother

because harmful ideologies still make breastfeeding difficult and misconceptions about

the BFHI remain. The lactation consultants who participated in this research, as well as

the BFHI accrediting body,24 have maintained that the BFHI was meant to empower

mothers who choose to breastfeed, not restrict those who don’t, and it doesn’t require that

hospitals close their nurseries. Part of being empowered, they maintain, is having correct

information with which to make a choice and the support necessary so that women who

want to breastfeed don’t experience regret or a sense of failure if they don’t. La Leche

League itself has been subject to criticism by feminist scholars for essentialism and

offering information on how to breastfeed that contained numerous adjectives that repeatedly described nursing as painful and unpleasant. 24 The website for the accrediting body of the BFHI, Baby Friendly USA, contains a link titled “Common Misunderstandings” to address the numerous critiques presented in the media and by academics who have criticized the BFHI. https://www.babyfriendlyusa.org/about/common-misunderstandings/ Accessed 2/9/20.

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promoting traditional family roles (Bobel 2001; Hailey 2010; Weiner 1994). However,

they advanced the idea of networks of women supporting other women and de-

medicalizing breastfeeding through the lactation professional to counter medical practices

that make breastfeeding difficult.

Becoming a lactation consultant has involved confronting sociopolitical realities

that constrain women and continually making efforts to effect change. Those changes

have perhaps been the lactation advocates own undoing by now being associated with the

very constraints on women that they aim to fight. This may be why they are not valued as

pro-women in the ways that midwives have been. Women’s breastfeeding efforts are

sabotaged by persistent ideologies and what IBCLCs haven’t yet succeeded at, and thus

what they have succeeded at is misunderstood.

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Chapter Three

Becoming a Lactation Consultant

Introduction

In this chapter I discuss the requirements I had to complete in order to become an IBCLC

and my socialization into the role of being a lactation consultant. I share my background

and journey to acceptance by IBCLC mentors and introduce each of the IBCLCs who

were part of this research by telling about their own journeys to becoming an IBCLC.

Their stories, combined with an ethnographic description of my training, connects back to

the influences that La Leche League has had on the lactation professional. It also reflects

a woman centered care that elevates the importance of the body and the emotions.

IBCLC Certification Requirements

According to IBCLE25, the body that certifies IBCLCs, certification requires that

the applicant have health science education, lactation specific education, and lactation

specific clinical experience. If you are not already a medical professional, you have to

show evidence that you have completed courses from an accredited institution of higher

learning in biology, human anatomy and physiology, infant and child growth and

development, an introduction to clinical research, nutrition, psychology or counseling

skills or communication, sociology or cultural sensitivity or cultural anthropology, basic

life support, medical documentation, medical terminology, occupational safety and

security for health professionals, professional ethics for health professionals, and

25 According to the rules at the time of my certification in 2015, as posted on their website: https://iblce.org/

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universal safety precautions and infection control. Additionally, they require 90 hours of

lactation specific education that has been completed no more than five years prior to

taking the certifying exam.

The clinical experience that is required for certification depends upon which of

three pathways you decide to take. If you are already a health professional or

breastfeeding support counselor you can take pathway 1, which requires 1000 supervised

hours of clinical practice providing breastfeeding help. Although the 1000 hours sound

like a lot, those who take this pathway are able to count hours in the last five years that

they already spent working with breastfeeding women in the course of their employment.

Pathway 2 is for women who choose to attend an accredited lactation academic program

and requires 300 supervised hours working with breastfeeding mothers in a clinical

environment that is specific to lactation care. Pathway 3 requires 500 supervised hours

working with breastfeeding mothers in a clinical environment under the mentorship of an

IBCLC.

When I underwent the process to become certified, I chose pathway 3. At that

time the IBCLC mentors had to have been certified for at least 5 years. I took whatever

college courses were required that I had not already taken, and for research purposes

chose to work with as many different lactation consultant mentors in as many different

types of environments as possible. I was unable to find an opportunity to work with a

lactation consultant who did home visits because when I began there were none on

O‘ahu. I did, however, complete my 500 hours in a hospital, outpatient pediatric clinic,

and non-profit clinic. I later spent time in a private practice clinic run by an

IBCLC/midwife who offered Japanese lactation massage, and with IBCLCs who worked

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at a WIC clinic. These last two environments contributed to my research but were not

counted in my 500 hours for IBCLC certification. Thus, the hours I spent engaged in

participant observation of lactation consultations consisted of around 900 hours over 2.5

years.

My Socialization into a Medical Role

Most IBCLCs have a nursing background, although it isn’t a requirement that you

have this in order to be certified. If you are not a nurse who works with postpartum

women, it is difficult to find a way to achieve the 500 hours helping breastfeeding moms

and infants that you need as part of the certification requirements. It is also difficult for

non-nurse IBCLCs to find employment since most medical facilities require lactation

consultants to have both. I do not have a nursing background, but I do have a background

working in maternal care positions. This was useful for me as a researcher in being able

to have access to and relate to these women because in addition to being nurses, most

IBCLCs are women who were either formerly involved in other maternal care positions

in their life or had a circle of women in their lives who were. Such maternal care

positions included La Leche League leaders, WIC nutritionists, doulas, childbirth

teachers, and midwives. In fact, most of the IBCLCs whom I met, which included more

women than the ones I did participant observation with, expressed support for the

midwifery model of care. We had this in common as well.

I have heard from many women who would like to pursue IBCLC certification

and are not nurses, and who complained about not being able to find medical facilities

that would allow non-nurses to complete the hours of consultation with them necessary to

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become certified. I had an advantage not only because I was able to relate to the IBCLCs

who participated in this study, but also because I am a researcher. This enabled me to get

IRB approval from a hospital that also had outpatient clinics, to combine consultation

hours with conducting research. It also encouraged the IBCLCs to help me since research

is respected by them. They had hoped that my research would help further understanding

of the importance of what they are doing as consultants. Their openness to me also relied

upon me relating to them as a mother who had breastfed. I noted that the very first

question every one of them separately asked me was whether or not I had children that I

had breastfed, and what that was like for me. They wanted to know what my experiences

were, and through that to come to understand whether or not I had a drive to help support

mothers in situations where I may have to challenge the status quo in medical care and

society. I thus told them my story, to some in more detail than others. The telling of my

story established that we had similar experiences, concerns, and philosophies. It bonded

us and established trust. It showed me that the most important factor to my socialization

into this medical role was not my credentials or medical knowledge, but my prior

breastfeeding experience and subsequent drive to help other women. What follows is the

story I told, often in pieces told over time, with various pieces told or untold to various

lactation consultants. I present it here to show how I was able to relate to like-minded

women and transform from these happenings into a researcher and lactation consultant.

My Story

At age 20 I woke up every morning before sunrise in a swirl of bleary-eyed

queasiness and rushed to the bathroom to vomit before pulling on jeans and rubber boots.

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I nibbled on saltine crackers until the storm in my stomach was somewhat settled and

then navigated my way across a field in star speckled darkness. In that field I retrieved

dairy cows that trotted ahead of me, eager to have their udders relieved of growing

pressure. While I was coming to terms with my own unplanned pregnancy, my life was

consumed with cows giving birth and giving milk. I watched the birth of calves with a

sense of awe. I felt their heartbreak when they were weaned and separated, and the

mother and baby cried out to each other across fields and fences.

The cries of separated moms and babies was almost more than I could bear, but

their deaths in birth stirred up a more intense sense of injustice. I was horrified to one day

learn why I had stumbled across the carcasses of a cow and the calf that she had been

trying to birth. I discovered that the men on the farm had decided to try and help the

smaller cows deliver their babies by tying a rope to the calves’ feet and then trying to pull

them out with a tractor. The results of such excessive force were tragic in each case, and I

let it be known that this decision had angered me even though I knew the harm was not

intentional. There were measures that should have been taken to keep the young but

fertile cows separate from the bulls until they were bigger, and I was sure there were

more humane and effective ways of dealing with dystocia.

I was young and single when I discovered I was pregnant, and much like those

cows that were too young to be mothers, I had decided that it was not a good time for me

to have a baby. That changed one morning when I helped herd cows with pink eye into

stanchions so that the vet could put medication in their eyes. One of the cows was so

blinded by the pink eye that she was confused and had begun wandering away from the

herd. She became spooked when I put my hand on her backside to try and guide her. She

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bucked, and her hind legs met my abdomen with a force that sent me flying over the

field. I landed painfully on my back with the breath knocked out of me. My first thought

was not concern for my own well-being, but an instant panic for the life growing inside

of me. I was now perplexedly consumed with worry that I would miscarry. Based on this

experience, I decided that any decision other than keeping the baby would be too difficult

and emotional for me. Maternal feelings were stirring inside of me, no doubt encouraged

by my daily interactions on the farm.

I married the baby’s father when I was five months pregnant and moved from that

farm, which was a small intentional community in Missouri, to a neighborhood in

Kentucky. My husband had grown up on a commune in Tennessee called The Farm, with

the world’s most famous midwife, Ina May Gaskin. She and some of the other women in

the group who had formed the commune, received training from a friendly doctor so that

they would be able to attend to the births of the commune’s pregnant women. They

formed a team of midwives who attended all of the births in that community throughout

my husband’s childhood, so homebirth was something that he was comfortable and

familiar with. He also grew up with a village model of childcare. He described his family

living in a large home with two other commune families and all the kids being

collectively parented. My childhood had been completely different from this. My family

lived far from other relatives. In fact, my mother’s side of the family, with the exception

of one sister, resided in another country. My mother’s experiences with hospital

childbirth were full of technological interventions and were described by her as

miserable. Only my oldest sister had been breastfed, but briefly, because my mother

decided her milk wasn’t as good of quality as formula. As a child I fed my dolls the

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normal way – with bottles that contained magically disappearing milk when you tilted

them. Prior to meeting my husband, I had no idea what a midwife was, and milking cows

had been a brief adventure I had sought out after high school, and not part of a family

business.

I initially chose an obstetrician for my prenatal care and did so by leafing through

the yellow pages of the phone book where I picked one named Dr. Bronner because it

reminded me of an eccentric soap maker who made soap that the hippies on the commune

liked. I chose him only because the name made me laugh. The obstetrician, however,

made me cry. I asked him a lot of questions because I wanted to make the best choices,

but Dr. Bronner treated me as though I shouldn’t have any agency in my pregnancy and

birth at all. He told me that if I was the type of patient who wasn’t going to just listen to

him and do what he said, I should find another provider. I started reading books on

childbirth and was sure that Dr. Bronner was the type of doctor who would apply

unnecessary and possibly aggressive measures while I was giving birth, such as an

unnecessary c-section. I thought of the stories my family told about how my mother

feared I’d eventually get cancer from all the x-rays26 they had done on me in the womb,

how I “flew” out of my aggressively contracting mother after she had been given an

accidental overdose of Pitocin, and how my oldest sister had emerged bruised and with a

misshapen head after being pulled from our mother with forceps. Although I didn’t

expect my labor would be as dramatic, the dead calves who had been pulled out by

tractors flashed through my mind. Maybe, I thought, the women on the commune were

26 X-Raying pregnant women’s abdomens fell out of practice after 1975 when studies indicated it could harm the embryo or fetus (Benson and Doubilet 2014).

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on to something. My husband suggested a homebirth midwife, and I hired the only one

that I could find in Kentucky at the time.

The midwife, Maryann, was patient and supportive. She made me feel empowered

to give birth at home without an epidural. She let me know that how I birthed was my

choice and we could go to the hospital at any time if I changed my mind. My reference

for what birth would be like was my mother, who in her disapproval of my homebirth had

reminded me every time I spoke to her that childbirth was agonizing and dangerous.

During labor I heard her words in my head again as I experienced the pain as so

excruciating that I wished I could disassociate from my body. I was convinced that I must

be dying because I couldn’t conceive of pain that intense that wasn’t a sign that the body

was failing. In that moment I had accepted that my mother was right that childbirth was

dangerous, and our bodies failed us in these moments. I embarrassingly told the midwife

that I wanted my impending death to be over with quickly because I couldn’t take it

anymore. She assured me that I wasn’t dying and told me that if a prolonged labor was

not what I wanted I should relax and trust my body. I eventually listened to her because I

figured I had nothing to lose. This amazingly changed the level of pain I experienced as

well as my perception of the entire experience. I have since heard many women who have

had natural birth describe it as an empowering experience because it becomes something

that you accomplish, rather than something that is done to you facilitated by drugs,

equipment, and medical authorities, and that then leaves you feeling like your body is

dysfunctional. Some women said that it was the most amazing accomplishment of their

life, and if they could do that, they believed they were capable of anything. This is also

how I experienced childbirth. The medical sociologist Barbara Katz Rothman once said

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something that felt true to me in that moment: “Birth is not only about making babies.

Birth is about making mothers – strong, competent, capable mothers who trust

themselves and know their inner strength” (Katz-Rothman 1996, p. 254). This is the type

of transformation that should occur during important rites of passage, like becoming a

mother.

The homebirth was successful, but after giving birth I panicked because I didn’t

see any milk coming out of my breasts. I asked the midwife if I should have my husband

go buy formula and bottles. She showed me how to hold the baby and get her to latch on.

She assured me that I had colostrum and later told me that the tingling and pressure I felt

after my milk came in was a let-down of milk from the milk ducts. She described how

breastfeeding should feel and how it would proceed. Maryann also educated me on infant

care and development and taught me safe co-sleeping practices, suggesting I put the baby

in bed next to me so that I could get better sleep. She recommended the book La Leche

League had published, The Womanly Art of Breastfeeding. I didn’t know any other

breastfeeding moms at that point in my life and that book was all I had. It became well-

worn from looking up what to do about various issues that came up, but I credit most of

my success at breastfeeding with the midwife’s assistance.

I relayed to the lactation consultants how that summer I had encountered the

challenges of breastfeeding in public with a baby blanket flung over my shoulder that the

baby kept kicking off. Breastfeeding while pushing a grocery cart with one hand as the

baby kicked the blanket was especially challenging. They heard about the time I was

doing just that in a store when two little boys came up to me and asked to see my baby.

Before I could respond they had flung the blanket aside and gasped. Horrified to see a

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breast in my daughter’s mouth, they ran to their mother in the next aisle over and told her

that a lady was doing something really naughty to her baby. Later I would process this as

a sad consequence of the sexualization of the breasts. I would think about how most

people would be raised never seeing a woman breastfeed. In that moment, however, I was

embarrassed. Wanting to avoid any awkward scenes, I promptly left the store leaving the

full cart in the isle as if I had been doing something shameful. I talked about the irony of

how I had also been uncomfortable breastfeeding in a restaurant we ate at. What would

people think if I were feeding my baby in a place where people eat? I then struggled to

feed the baby in the restaurant’s smelly public bathroom because of course no one would

question feeding my baby in a place where people defecate. Then there was the story

about how painful the single, battery-operated pump was that I had purchased because it

was cheap, and we didn’t have much money. I worked as a waitress back then and hoped

that the milk leaking all over my uniform would not be noticed by restaurant patrons. I

would run to the bathroom now and then to pump just enough milk from my painfully

full breasts, and then dump it down the toilet because there was nowhere to store it. I

never got a break to fully pump and there was no refrigerator for an employee to store

milk in even though it was a restaurant.

Despite these trials I found breastfeeding to be more convenient than what I

thought it must be like to sterilize bottles and mix formula in the middle of the night. I

loved that I could so easily sooth my baby and wasn’t losing sleep like so many other

moms because I nursed her in the bed with me. When she seemed disinterested in

breastfeeding at a year of age, I didn’t push it; I decided breastfeeding for one year had

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been quite an accomplishment. I became more confident each time so that the next two

babies were breastfed longer.

Maryann had made me feel cared for and thus safe because she was fully focused

on what I needed and wanted. She had given me such a positive experience that I decided

that I wanted to be a midwife myself and I asked if I could apprentice with her. She had

taken on several apprentices because she was overwhelmed with clients and felt that

women needed more options. Nurse midwives, who were the only type of midwives

licensed to practice in Kentucky, only worked in hospitals despite a history where nurse

midwives once traveled to homes on horseback in areas of the state that were far from

hospitals. We all thought of ourselves as activists helping to bring a different maternal

care and birth experience to women who would have control over their bodies and births.

We found work-arounds for the barriers that would stand in our way. Some of the

apprentices practiced what they called “liberating” medical supplies from hospitals, such

as items needed for suturing27. I remember that the medical supplies midwives needed

were sometimes hard to get if you weren’t a licensed medical professional, and so

apprentices also looked through veterinarian catalogs and attempted to make supply

purchases from them.

Maryann held classes for us in the house of a woman who would later become an

executive director of Lamaze International. Without the educational materials one would

have available at a university, we examined donated placentas, practiced putting in

stitches on blocks of foam, and poured red Kool-Aid onto absorbent underpads to learn

how to ascertain blood loss amounts. We took turns measuring women’s swelling

27 Midwives don’t do routine episiotomies, so the suturing was for rare cases where an episiotomy was deemed necessary, or in cases where mothers experienced large tears of the perineum while giving birth.

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abdomens with measuring tape and took their blood pressure during prenatal

appointments. We also took turns attending births with Maryann. Those who were not

attending a prenatal visit or birth at a given time cared for the children of the apprentices

who were. This system eliminated the need to find someone willing to wake up and

babysit your children in the middle of the night when a client went into labor. In addition

to learning from Maryann, I also attended some classes with Ina May and the other

midwives on the commune in Tennessee. I was enthusiastic about women helping other

women in ways that went around the systems that often made us feel inadequate or made

it difficult to be a mother.

My dream of becoming a midwife ended with Maryann’s criminal indictment for

practicing midwifery. She was a certified professional midwife (CPM), but at that time

Kentucky refused to recognize the CPM credential, and her husband turned her in for

practicing midwifery during a contentious divorce. The police served her with a search

warrant and took her patient records and everything else from her home that had anything

to do with childbirth. I attended her trial along with a courtroom full of mothers and

babies, half of whom were Amish women in their black dresses and bonnets. The Amish

claimed that they would never give birth in a hospital and needed women like Maryann to

safeguard their births. There were also educated middle-class clients who didn’t like the

direction that childbirth had gone in – one in which profit, managing labor, and avoiding

lawsuits were more important than the birthing women. They feared that even a hospital

birth with a nurse midwife in attendance would not give them the environment and

choices they desired. Some of the women in attendance were low-income clients who had

no health insurance and had offered Maryann things like eggs from their chickens

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because they couldn’t afford her fee. They were supportive of Maryann because she was

caring and never turned anyone down because they couldn’t afford her; she only turned

down women who were too high risk for a homebirth.

In the end the judge spoke with an air of self-importance as someone presiding

over a case that had serious consequences for women. He announced that he had gotten

into law for cases such as this where he had the opportunity to improve people’s lives,

and for a second, I was hopeful. Then he pronounced Maryann guilty, fined her, and

ordered her to cease and desist the practice of midwifery. After the trial I ran across the

courthouse after her and asked if she was really going to cease and desist. She briefly

turned to me and defiantly replied “hell no,” before hurrying off with her attorney.

I went home and looked at my two young daughters and realized that for their

sakes I didn’t want to take the chance of getting prosecuted for helping women have the

kind of empowering birth that they wanted. I decided that teaching childbirth classes

would be a helpful thing to do that didn’t carry risk. By the time I underwent a training

program to become a childbirth educator I had moved yet again, this time to Hawai‘i. I

used all of this knowledge in jobs where I did developmental assessments on infants and

toddlers and helped parents with pregnancy, birth, breastfeeding and childrearing issues.

In the early 2000s, in my very first position, I worked in a hospital where several

of the postpartum nurses regularly handed out the book On Becoming Babywise (Ezzo

1995) to women with newborns. The book advocated things such as feeding schedules for

breastfed infants and infant sleep training that involved leaving them to cry at night

without responding. It was found to be associated with “failure to thrive (FFT), poor milk

supply failure, and involuntary early weaning” (Aney 1998) by the Academy of

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Pediatrics. Child abuse was even mentioned as a reported outcome of people following

the book’s advice (Aney 1998). Not only were the postpartum nurses giving bad advice

to breastfeeding moms, but two of my co-workers refused to promote breastfeeding or

help women who wanted to. Like me, they did home visits to support mothers from

pregnancy through age three, and made hospital visits to mothers when they gave birth.

They shared with me that they had both had difficulties breastfeeding their own infants

and had been made to feel guilty about weaning and giving their infants formula by

“breastfeeding Nazis.” They had since decided that they did not want to make any of the

women that we worked with feel guilty for their infant feeding choices and so had chosen

to not give them any information at all about breastfeeding. I asked them whether or not

they would refer a woman to one of the hospital lactation consultants if she wanted to

breastfeed but was struggling. They said that they would not even do that, because

lactation consultants were included in those considered “breastfeeding Nazis,” who

would pressure you to breastfeed and make you feel like a horrible mother if you

couldn’t.

I was shocked to hear this since the lactation consultant who worked with our

program seemed like one of the nicest women I knew at the time. I couldn’t imagine her

trying to impose her views on others. I recalled the caring midwife who helped me to

breastfeed after giving birth and how I had felt that had I received no help at all I likely

would have failed at breastfeeding because it was not instinctual. I decided that giving

women who wanted to breastfeed either no support, or poor support like the nurses

handing out Babywise books, was what was setting them up to feel like failures. Once

they felt like they themselves were a failure, guilt would naturally follow. I reasoned that

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those who didn’t help nursing moms were perpetuating guilt more than anyone who did

help. Also, this was a child abuse prevention program, and it seemed to me that

empowering mothers was a better tactic than allowing them to fail at something and feel

stress and possible resentment towards their infant. I believed that if our focus was caring

for mothers, that would give them the ability in turn to care for their infants in whatever

way was best for them. I went in the opposite direction as those two co-workers and

involved the lactation consultant in the care of my clients as much as possible, but this

conversation had troubled me for years. I wanted to know how it was that pejoratives

were used to describe women whose aim was to help mothers and newborns to

breastfeed, why women were struggling so much to breastfeed, and what society’s

responsibility towards them should be.

Telling my story to the IBCLCs not only built trust but was only fair since I was

going to ask them to tell me their stories. Their stories and my subsequent observations of

them working with mothers and infants answered those questions I had held onto for so

long.

The Lactation Consultants’ Stories About Why They Became IBCLCs

Women helping women in endeavors that aimed to give support to mothers and

were yet also progressive or challenging to certain norms, reminded me of Maryann and

the midwife apprentices. Lactation consultants are not always thought of as activists, and

yet as my interviews and participant observation with them revealed, they had entered the

medical system in order to help change the medical system. There were two important

themes that had come together to create the IBCLC. The first was women helping other

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women. La Leche League believed that breastfeeding mothers were helped the most by

other mothers who had breastfed. The second was recognition of the importance of

science and medical authority in our society. To be effective in helping more women,

they rationalized that they needed to combine these two elements. They created a medical

professional, a woman who would help other women to breastfeed, but in the hospital so

that they could be there when women first tried to breastfeed. These women would be

able to do this because they would be considered medical authorities. This is also what

happened to midwifery, when nurse midwives brought the midwifery model of care into

hospitals where most women were giving birth.

All but one of the IBCLCs in my study had been mothers before their experiences

had led them to dedicating their lives to helping other moms breastfeed. They had

recognized that women struggled to advocate for themselves within a system that made

breastfeeding difficult for them and then was quick to make them believe that their bodies

were at fault. Many of them were motivated to make a difference for women starting in

the 1980s and 1990s when breastfeeding initiation and duration rates were lower than

they are now. They chose to get IBCLC certification so that they would have credibility

and be able to make changes in practices within the medical system that were detrimental

to breastfeeding.

Mary

Mary28 was a White nurse who became a certified lactation consultant not long

after the credential had just been created and she was also the first IBCLC in the state of

28 The names of all the lactation consultants that I discuss in this dissertation have been changed to protect their privacy.

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Hawai‘i. She had been helping breastfeeding moms, but the certification would give her

credibility within the medical system. In 1995 she was hired as the one and only lactation

consultant in a large hospital. She talked about her struggles in the beginning with trying

to help women advocate for themselves and a doctor who wouldn’t take her advice as a

professional. Mary expressed that many doctors are often more interested in giving

women formula than learning about breastfeeding. She also related how she had

struggled herself as a breastfeeding mom and how this experience had motivated her to

help other mothers:

I felt like I was often giving information to women and trying to help them to advocate for themselves and their baby, which wasn’t always easy. You know? I mean because women are so vulnerable. I know myself, I was told, here I am I’m in graduate school, right? I’m a nurse, and I’m in graduate school learning all these various things. Had a baby. Extremely vulnerable. This woman, that I didn’t even know very well, came over and said, “The reason your baby is crying is because your milk’s not rich enough.” There’s the deal. Now where did she ever? I took it hook line and sinker Crystal. Hook, line, and sinker. And I’m a special person. I thought ‘Yep, that’s why [the baby’s] crying and upset and all that sort of thing.’ Yet it wasn’t that at all. You know, she gained 3 pounds in the first month. Everything was right with the little one and me. She never took some of my milk and analyzed it or anything. I took this whole thing emotionally, and these women are too. It’s hard for them to see that, you know, that that’s not it. That’s not it.

This experience deeply affected her and motivated her to help empower women when

they were in such a vulnerable state and had been made to feel like their bodies are faulty.

Mary summarized what her objective was as a lactation consultant by telling me

that she was about “giving power back to the woman rather than taking it away.” She

continued, “I don’t know what is best for a woman.” Empowerment was reached by

promoting the idea that the body was informative if you listened to it and trusted it. Once,

when a mother said she didn’t have enough milk when Mary saw that she did, she told

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her “Trust your body like you did when he was inside of you. You didn’t say, ‘Did I

make an eye today?’ You just trusted your body.” She continually directed women’s

attention to ways that they could know for themselves what their body and their baby was

communicating.

When I was awarded my IBCLC certification, Mary gave me a gift. It was a book

titled Humane Perinatal Care (Chalmers and Levin 2001). The book is unusual because

it asks for a reassessment of how we care for infants in the NICU, promoting a less

technological approach where the current thought is that technology is the answer to

saving these fragile infants. In the U.S. mothers are often separated from infants who

have to go to the NICU instead of rooming in with them, as is now popular with healthy,

term infants. It is especially difficult to breastfeed NICU infants given this separation,

combined with the limitations they often have in terms of energy and the developmental

maturity required to nurse. Donor milk from a milk bank is often not made available, and

supplementation of breastmilk is necessary so that premature infants receive all the

nutrients that an infant born early needs (Riordan and Wambach 2010). One of the

hardest things for me to observe during my research was NICU infants crying in

incubators with no one to comfort them and busy nurses who may or may not be able to

attend to their needs anytime soon. The NICU did not allow parents to room in or stay the

night and mothers often had to return to work.

The book Mary gave me was co-authored by a psychologist, Dr. Chalmers, and by

a neonatologist, Dr. Levin, who had developed a program in an NICU in Estonia that was

structured on the belief that sick and premature infants likely need their mothers and

breastmilk more, not less, than other infants (Chalmers and Levin 2001). Mothers in Dr.

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Levin’s NICU, room-in with their infants until they are ready to go home and they are

trained in how to provide most of the infant’s care. The mothers practice kangaroo care,

which means the infant is placed with skin to skin contact on their chest. Additionally,

technology is minimized to only what is necessary, and breastfeeding is encouraged. The

book states that the results of this type of care were more breastfeeding, greater weight

gain, and higher scores in psychosocial development measures among these infants than

in the control group (Chalmers and Levin 2001).

The fact that this was what Mary had chosen to give to me as a gift gave me a

window into what she felt was most important to pass along to me. The point seemed to

be that our assumptions that we could solve our problems with more and more

technological and impersonal rather than interpersonal interventions, especially when it

came to the most fragile infants, was wrong headed. It was also inhumane, as the book

title suggests. Bringing about the type of care in the U.S. that was described in the book

did not seem so radical; it was basically letting mothers stay with their newborns, hold

them, and breastfeed them. On the other hand, it was totally radical, and strange to

imagine that bringing about the type of care to infants that they had been receiving since

the beginning of time could be considered radical.

Karen

Karen was a White mother who wanted to help other mothers to breastfeed after

she realized that the help and support that women required in order to breastfeed

successfully was lacking:

I wanted to help moms with breastfeeding because I breastfed my babies and I realized that so many women were saying to me that they couldn’t breastfeed

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because they had sore nipples, their milk supply was too low… And I realized that if I could do it, I couldn’t understand why so many other women were having difficulties. And then I realized they just weren’t getting the help they needed, so I wanted to be able to help other women.

She was a La Leche League leader initially and had also started working at a non-profit

organization that helped breastfeeding mothers. She really wanted to work in the hospital,

however, because she believed that many hospital practices were setting women up for

failure from the very start:

I practiced in the community for a long time . . . and I kept feeling like I was, I’m undoing the damage that had been done in the hospital. And if I wanted to help moms, I needed to start at the start, in the hospital. There’s so much right off the bat that if you do it badly, you screw things up for these moms and babies so badly. You separate them right after they’re born, you keep the baby in the nursery, you feed him bottles of formula, you give him pacifiers. You bring him up to his mom for a peek at him and you expect them to be successfully breastfeeding. It’s not going to happen, and yet that’s the routine in so many places.

She also told me that when medical personnel work with sick or premature infants, they

start treating normal term infants as if they require the same type of monitoring and care,

which ultimately is harmful to those mothers and babies being able to sleep, bond, and

learn how to breastfeed:

I find that it works against normal . . . So if you are going to, you know, wake up a baby because you have to do something to them, [the nurse] would not ever even consider that maybe that’s not appropriate to do right now. [She should] fit it in when it’s not going to disrupt what’s going on for this baby. She’s looking at it from the task oriented, you know, this task being done at the right time in the right way will build up to a good outcome. And that’s true when you’re looking at a high-risk infant; you don’t have much leeway. But when you’re looking at a healthy term baby rooming in with the mother, those little tasks, they can be fidgeted, moved, figured out. How do we still get the information we want without disrupting this mom and baby?

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In order to work in the hospital, she had to have the proper credentials. She found support

for doing that in a network of activist women helping each other:

Looking at this nurse IBCLC, I was like, “That’s my goal. She’s my hero. If I could ever do that, that would be amazing.” I don’t know if I could ever do that, but what these women did for me was to say, “Not only is it necessary, but it’s doable, and this is how you do it, and these are the resources you need, and we will help you.” Women helping women. It was an amazing experience for me.

She became an IBCLC in 1991 when hospitals were willing to hire IBCLCs who were

not nurses, and then became an RN in 1995. She started out by working with mothers in

the postpartum ward of a hospital and then worked in an outpatient clinic. Karen was a

supporter of the midwifery model of care and her goal was to bring this model to

lactation care in medical settings:

Nursing itself is a holistic approach. We tend to forget that but that's really what nursing is about, looking at the whole person, their mental, spiritual, physical, all of it together as a package. Sometimes we forget but that's why I thought I could make an impact in the hospital because I was bringing a homebirth perspective to it. How can I make this as much like a homebirth as possible? And how do I get moms out of the hospital as quickly as possible into the home? And how do I help ensure there's a good transition and that she gets the support she needs at home? I found it ironic when one of my - a new director came on and she said, "You know, I see lactation as being there to assist a mom and baby toward their discharge home not in holding up their discharge." And I’m thinking to myself, “You don’t have to convince me.”

She wanted to change the practices that occurred within hospitals that made it difficult to

breastfeed as well but recognized that a hospital could never be a completely ideal place

for breastfeeding and bonding. Getting women home was thus an important part of what

she aimed to accomplish. At the time of this research she was working in the hospital’s

outpatient clinic where she provided support to women once they had been discharged.

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Tina

Tina was a White nurse who became an IBCLC in 1994 after working as a

postpartum nurse and becoming frustrated that so many nurses resented having to help

normal term infants breastfeed, and often treated all infants as if they were high-risk:

When I first started . . . we weren't Baby Friendly. We didn’t do mother-baby care, and the NICU and the term nursery were all in the same area. Like right now it's you're a mother-baby nurse or you're an NI[CU] nurse. That's not the way it was then . . . You had to be able to do everything. So you would come on for your shift and it would have, the assignments would be made . . . and if I knew Jane really didn’t like term-nursery I would say, "I'll switch with you," because I just hated to see these normal healthy newborns with nurses that hated breastfeeding. Some nurses, it's hard for them to switch gears and then if you're used to looking at sick and you go to normal then you see sick in normal and you mess up natural.

She also saw how hospital practices interfered with mothers being able to breastfeed their

babies:

And at that time we did bizarre stuff like we would – All the babies, like a baby would be born and it would go to probably an hour or two hours with its mom but then it came to the term nursery where it stayed for probably eight hours, got the bath, got given a bottle of sterile water to make sure the baby could suck, swallow. All these bizarre things. And then I just started seeing, "Oh this is not right."

Tina took advantage of the IBCLC credential as a way to help correct some of the harms

to breastfeeding that she saw occurring in the hospital.

I once observed her quietly talking to a patient who was getting discharged and

was crying. She thanked Tina over and over again for helping her out and said that she

knew things could have gone much worse for her if Tina had not stepped in. I had

assumed she was thanking her for help with breastfeeding, but after the woman left Tina

explained that the woman had transferred to the hospital after attempting a homebirth,

and some of the staff had treated her badly because of this. She told me that she was

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angry that hospital personnel sometimes treated homebirth mothers this way just because

they so strongly disapproved of the practice. She understood why some women made that

choice, and poor treatment by hospital staff reinforced those reasons.

After reflecting on the early days when she had first started working in the

hospital, she told me “We’ve come leaps and bounds in what we do, but we still, there’s

still work to be done.”

Sandra

Sandra was a White mother who had years of breastfeeding experience nursing

her own children. She was also a postpartum nurse that was skilled at helping moms with

breastfeeding because of those experiences. She had begun helping breastfeeding moms

in 1995 and by 2001 she became an IBCLC because she felt it made her more credible:

I was the person [at the hospital] who did all the breastfeeding education. I was the best one at getting the babies latched on and stuff like that. I went, “Okay if I have all of this, I need to get the credentials so I can be able to give my experience to those women and be able to have those letters after my name.” It’s more, not official, but credible to them to have that.

She also saw lactation work as a way to bring a holistic model to women in the hospital

and found she was often at odds with the system because of this. She said, “Being a nurse

and lactation consultant sometimes is a double-edged sword for me because I have a

medical model in my head and then I have also the holistic model in there.” Her way of

helping moms thus diverged and sometimes conflicted with the types of help or advice

that mothers got from other medical providers.

Sandra was used to patients getting different advice from various nurses and

doctors and wanted to be understood as the expert when patients would say “Why didn’t

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anybody else tell me that? How come the nurses – everyone told me a different thing.”

As an IBCLC her advice would be respected. She still, even now, had to be vigilant about

misinformation being disseminated by other medical professionals, but was happy to help

breastfeeding mothers out by correcting misconceptions.

Sandra recalled what it was like to work in a postpartum ward in the 90s when she

was trying to advocate for breastfeeding mothers:

Well, I worked in a military hospital. I mean there was definitely a lot of politics involved and there was such a big – back in ’95, when I first started with moms and babies, there was that big push to be Baby Friendly. That was when that was starting to come out. We had all the formula bags and all the pacifiers. I remember when they tried to start [Baby Friendly], it never got off the ground because we couldn't get rid of the formula out of the hospital . . . Part of the deal was we got that formula at one certain price. But part of the deal was, “Would you give out our bags?”

When the hospital expressed reluctance to give breastfeeding mother gift bags with free

formula in it, the formula manufacturer came up with a new tactic:

They tried to placate us by giving us breastfeeding bags versus the formula feeding momma bags. And in [the breastfeeding bags] were so many things that were really detrimental to keeping the breastfeeding relationship. Actually, I remember Similac came out with a bag. That was the first breastfeeding bag, and Enfamil followed. And they spent so much money.

For all of the money the companies were spending on gift bags, they had to have been

receiving a sizable return by successfully getting mothers to buy their product. She

related to me that one of the expensive items in the breastfeeding gift bags that she was

convinced was purposefully put there to get women to use formula was a hand pump that

didn’t work very well. She said, “You're giving them a faulty piece of equipment that's

going to make them think even more that they have nothing inside of their breast.” Once

women struggled with the handpump and got little to nothing out, her theory was, they’d

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succumb to thinking they had no milk and stop breastfeeding. The marketing gimmick

was that mothers would stop breastfeeding and because all of these gifts were associated

with a formula brand and the hospital, the mother would become loyal to that brand.

The efforts the hospital put into changing practices that were harmful to

breastfeeding in order to get closer to becoming Baby Friendly certified, were frequently

challenged by nurses:

We got rid of pacifiers. They became locked up finally. But [nurses] would still figure out how to get them out. So, we’d occasionally find them out there. Sweeties was another thing that [nurses] would use, and they would put it on the nipples, or they put formula on the nipples. There were a lot of makeshift devices. Because we did not have pacifiers available a lot of our really old nurses were trying to make pacifiers and they were taking the bottle nipples off of the formula bottles, stuffing them with gauze, and taping the back side of it. I mean it’s dangerous if it's swallowed. [A baby] could suck that gauze right out of the holes and choke. So yes, there was a lot of crazy stuff. I mean I’ve seen it go from that.

Like the other lactation consultants, she had worked in the hospital at a time when it was

much more difficult for women to successfully breastfeed after giving birth, but she felt

there are still obstacles that need to be addressed. At the time of this research she had

moved on to providing lactation consultations at a non-profit clinic that was located on

the grounds of a hospital but that saw women after they were discharged from the

hospital.

Yui

Yui described herself as a third-generation midwife. She grew up in Japan where

her grandmother and mother were both midwives and her father was an obstetrician. She

was around birth and the midwifery model of care every time she visited her

grandmother’s birthing home, where she learned a form of lactation massage that

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midwives in Japan practice on breastfeeding mothers. Since midwifery was in the family,

Yui described it as natural for her to become one herself.

In the early 90s she went to college in England and became a nurse midwife. In

London she did community nursing, where she would do postnatal checkups in the home.

During these postnatal home visits, she noticed that moms were struggling a lot with

breastfeeding and she recognized that breastfeeding rates in England weren’t very high at

that time. In Japan, however, she noted that women didn’t seem to be struggling as much

and breastfeeding was still the normal way to feed your baby. She came to a conclusion

about the problems moms in England were having with breastfeeding:

Then I suddenly started to realize, they don’t have proper breastfeeding care; meaning going through the education part. Although the midwife would go one on one [and establish] rapport and things, there was still something missing because [women] were still struggling. . . I noticed that there was still knowledge and technique lacking to [offer as] support. And because I was still working for National Health, there was a policy, a local hospital policy, that we were going after in the community and that didn’t allow breast massage. . . Although my supervisors and people like that knew the massage would help, they didn’t know the depths of what the breast massage would do.

I came to learn that this was more than just breast massage. It included a particular way

of understanding the body as an interconnected system, and the mother and infant as

interdependent. For example, she talked about breastfeeding as an extrauterine

continuation of what the placenta did in utero, and how in America medical professionals

didn’t think that way:

You can’t do the birth and then say, “Okay, let’s deal with the postnatal” . . . It’s lactation and birth. It should be linked. So, I think it has to be more continual care. If the society understands that – birth and feeding come together in order to support life that is. Mum was taking in nutrients through the placenta . . . so that was the lifeline. Once the lifeline comes out with the baby, then the baby needs to be feeding itself [at the breast]. And that’s the connection we really need to make.

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This requires thinking about the infant and mother as still linked together. She told me

that in Japan, helping moms with breastfeeding is considered part of midwifery care, and

so even though she is both a midwife and a certified lactation consultant, she just calls

herself a midwife. In Japan, lactation massage is performed by midwives on postpartum

mothers in the hospital. You didn’t just work on correcting an infant’s latch, you gave

attention to the flow of energy, milk, and emotion through the mother’s body as well.

You cared for mothers so that they in turn could care for their infants.

Another way that she saw the division of interrelated issues was in the way that

doctors are trained to treat a problem rather than figure out and address its cause. She

used the example of doctors prescribing antibiotics to women with mastitis without trying

to work out why they got mastitis in the first place. She said that this makes it easier for

them to just tell a woman to use formula. This, she claims, is like treating women as

machines.

Because she wasn’t able to offer women lactation massage during her work hours

in London, she began offering it on her own time. This became a niche business for her.

One day a midwifery supervisor in the community suggested she get IBCLC certification

to give her some credibility to be helping women with lactation and some authority if she

“gave a talk or whatever the case is.”

When Yui eventually moved to the U.S., her British midwifery license was not

recognized, and she was unable to work as a nurse midwife in the hospitals. Even though

her IBCLC certification was internationally valid, she couldn’t practice breast massage in

the hospital as a lactation consultant because it was only recognized as a legitimate

practice in Japan. Thus, she decided she would assist women who gave birth at home

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because homebirth was a legal gray area in Hawai‘i, where she now lived. She found that

there were more women who wanted help with breastfeeding than wanted homebirths,

however. Because Hawai‘i has a sizable Japanese population, Yui started providing

lactation massage to 10 to 12 Japanese clients a day. Eventually word spread about what

she did in the community and her clients became more diverse.

Although Yui believed that the practice of lactation massage itself had value that

was helpful to breastfeeding moms as a preventative or response to problems, she also

identified the difficulties women were having with breastfeeding as directly related to

formula marketing and a lack of alloparenting:

It’s now become a profession, and we have to have a certificate that says we can actually help you breastfeed . . . [but we have that] because we’re supposed to raise a kid in a village, and we don’t have that village . . . It would be easier when you are together with other moms because that power working together is greater.

Like Sandra, she pointed out that hospitals that want to become certified as Baby

Friendly are required to stop participating in formula marketing, but their participation in

that marketing is what allows them deep discounts on formula purchases:

There is a formula company that actually has more access and somehow power over pediatricians and doctors in the hospitals. I mean that's the battle. Therefore, there's a lot of encouragement to become a Baby Friendly hospital and things, and [adopt] policies [that encourage breastfeeding] by UNICEF and WHO and things like that, but I think initially it's really difficult.

She had started out trying to make a difference in the hospital and through community

nursing but was unable to change things enough to be able to give the type of care she felt

was necessary. At the time of this research, Yui owned her own private practice clinic.

She saw that the same philosophies that had made it difficult for women to breastfeed in

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the first place were still in place in hospitals and pediatric care, and formula marketing

was still a problem as well.

WIC IBCLCs

The WIC IBCLCs I conducted participant observation with for this research were

two White women with science degrees and lactation consultant certification. While WIC

encourages nutritionists to have a basic level of breastfeeding knowledge, it does not

require them to be IBCLCs. The WIC IBCLCs that were part of this research relayed to

me that they had pursued the certification in order to show their clients that they cared

and were willing to get as much breastfeeding education as possible in order to help

them. In doing this they felt they were filling a need by providing help that women

couldn’t get most other places:

Jen: I think I just wanted to feel more capable in my job. I wanted to feel more competent. I wanted the credential because I felt that it showed our clients that we're trying our best. It's just a desire to do a better job and show our clients that I care, [that] I’m doing the best that I can. Susan: In school we do not teach kids how lactation, how the boobs function. We don't really have, we've talked about this before with the gynecologist, they are worried about the downstairs parts. We have pediatricians and they are worried about the baby. But there is a huge disconnect there between the healthcare providers [when it comes to breastfeeding].

They provided a private breastfeeding space with a couch, and took as much time as

needed to help nursing mothers, unlike most other WIC clinics:

Jen: I have worked in some of the other clinics and I can tell you I have never once saw another nutritionist have a mom breastfeed in front of her for the purposes of assisting with latch . . . I think at other clinics . . . you've got these little 15 minutes slots per client and sometimes you just don't get to the point where you can really, [where] you've built enough trust or rapport needed for her to trust the information you're giving. And it's hard to do that in a small piece of time.

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Susan: We're also not officially IBCLC. It is not a job description. It is not part of our job description. We took this on ourselves to kind of go above and beyond what was expected outside our typical job duties . . . I think we are definitely unique here where we actually invite moms to come in to watch them breastfeed, to help with the positioning.

When they started helping moms at WIC, formula marketing had been successful at

convincing moms that there was no difference between breastmilk and formula. They

were part of efforts to change this idea. They said that women no longer believe it, but

they don’t know how to breastfeed:

We are seeing others, more and more moms breastfeeding every year . . . There is way more mom to mom online support and more moms are hearing about it. And I think even just in the few years I've been here, before, it really was seven years ago . . . like you had to tell moms like, there really is a difference between formula and breast milk, and tell them how great this stuff really was and how it really was different from formula. And now I find really a majority of the moms really want to breastfeed, they just have no clue how to do it, how to hold the baby, and the frequency of the feeds, the growth spurts, they just don't get it. They want to do it, they just don't know how to do it. So, I have noticed a huge shift.

They also noted that there were barriers that were especially difficult for their

population of low-income moms to overcome, including moms that had to return to work

soon after having their baby, and moms that had to take long bus rides to and from work

and yet had to pump. For women with insurmountable barriers, they told them that

supplementing with formula was an option. They also acknowledged that education alone

is not sufficient to help their clients if breastfeeding is not encouraged or is undermined in

their social worlds:

Susan: I think at some level it doesn’t matter how much we talk to the moms or try to educate moms on, you know, this is how the milk supply works, if they don’t have the support at home, at work. If they have people [around them] just [say] “Oh just give formula [because] the baby is going to sleep better.” Or doctors even . . . It’s a societal problem too. It’s just there’s not that consistent support everywhere

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they go. So we can talk to moms, we can help encourage, we can help inform, we can help support and motivate, but…

The WIC IBCLCs thus tried to create a social support group for women who wanted

to breastfeed by holding what they called “Heart to Heart” groups where pregnant women

in the WIC program could talk about their breastfeeding goals and could hear from moms

who had breastfed previously and ask them questions. While the backlash against

breastfeeding had focused on public health initiatives that the backlashers felt pressured

mothers into breastfeeding, the WIC IBCLCs saw pressures on mothers to give their infants

formula, and the subsequent effects this could have on low-income mothers in the U.S.

who couldn’t afford formula. I was told that WIC no longer allows formula marketing

materials to be present in their clinics. Their concern about pressures to use formula were

evident when I asked the WIC IBCLCs how they felt about criticisms of the program for

continuing to give women free formula and thus potentially discouraging breastfeeding:

Susan: It’s definitely a conflict of interest. Especially for us [as IBCLCs]. But I think you have to go back to the original reason why formula was developed is because people were making inadequate homemade formulas. So, for a mom who cannot breastfeed, or does not want to, or is struggling, we have a quality product to provide to that baby. That is going at least to allow that baby to stay alive . . . they are not going to be mixing the evaporated milk with Karo syrup and whatever. Jen: Or over diluting formula because they have to stretch it because they cannot pay for it.

Susan: I have still heard stories of moms diluting formula with WIC because . . . we don’t provide the whole amount [that their infant requires]. So that is an awkward situation.

Jen: Yes. There are kids that are failing to thrive because moms are over diluting.

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Susan: So I guess that is always, that you have to remember, like, formula exists for a purpose. I believe it is overused, but it is there for a reason. It is better than a homemade, inadequate preparation. Jen: And it is a federal guideline that we cannot have anything up on our walls that has a picture of formula . . . We can’t have cans of formula just sitting around and on display. Susan: If we do give a can or two out, actually we always put it in a bag. Sometimes we ask them on the phone, “Oh, if you bring formula in to exchange can you make sure it is in a bag? So, it’s not just being paraded through the office. So yeah, there’s no images of formula allowed.

Jen: Sometimes we are given some reading material from a source that may have ads in it for formula. I do not give that out. We don’t give those out.

These ideas about formula were not just unique to the WIC IBCLCs. All of the IBCLCs

that participated in this research were quick to suggest formula supplementation when it

was necessary and appreciated that formula had improved over time yet wanted

breastfeeding to be normalized. The WIC IBCLCs continually saw the barriers to

breastfeeding that more acutely affected low-income women. They encouraged women to

reach their own breastfeeding goals, whatever those were, and encouraged mixed feeding

options if barriers to breastfeeding discouraged moms from nursing:

Susan: I had a mom this morning, she put on her sheet, she wanted to breastfeed for a month, and baby was two and half weeks old. And that was her goal as a mom. And so I said, well, “How's breastfeeding going?” She's like, “Great.” I'm like, “Oh okay. What's your goal at this point?” And she goes, “Oh, well, a few months. It's just I have to go back to work and I don't want to pump.” And I said, “Oh, okay, I get that, it's kind of a pain.” And I said, “You know what, we have lots of moms actually that do formula feeding during the day, and they breastfeed when they're with the baby.” [She said] “I can do that?” [I replied,] “Yes, you can do that.” I think there's still this idea of it's all or nothing. And so, she seemed great with that. And so hopefully just from having that couple of minute conversation and not just saying, “Oh, you're going to breastfeed for a month, baby is two and a half weeks

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old, well, we've got to get you back in here for formula next month,” now that mom could continue to partially breastfeed for so long.

I interviewed another WIC IBCLC but didn’t engage in participant observation with her.

She was Native Hawaiian and worked with a low-income population in a largely Native

Hawaiian area of Oahu. She explained to me that while breastfeeding was difficult for all

women because of the barriers that exist, some women have more privilege than others

with which they are able to get through those difficulties. She discussed this specifically

in reference to the challenges faced by many Native Hawaiians that cause low

breastfeeding duration rates:

The lower socioeconomic status of native peoples in general usually causes that issue. The higher you are in socioeconomic status you understand the benefits [of breastfeeding] and are willing to put in that much more effort into “I weigh this is the benefits and these are the pros and cons and I am willing to put in that much more effort into this because this is so much more beneficial for my child.” Whereas, “I’ve got to survive, and this is too much of a struggle. So, I’m going to put that on the side and just give the bottle because I need to get to work, I need to feed the family, I need to make a living to put a roof over our heads so we won’t be homeless,” you know, those kinds of things. So, it’s just life choices.

She spoke of “life choices” as those things you have to do for survival because you

actually have no other option. In other words, she saw access to breastfeeding as a

structural problem. Some medical anthropologists have also been critical of the idea that

it is individual “choice” that effects health and wellness, and believe that the values that

underpin this notion reinforce social stratification (Kleinman et al. 1997; Singer and Baer

1995; among others). Paul Farmer stated, “For many, including most of my patients, and

informants, life choices are structured by racism, sexism, political violence, and grinding

poverty.” (Klienman et al. 1997, 263) The lactation consultant further explained how

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privilege played into the “choice” to breastfeed, saying, “Well, education which leads to a

job, which leads to higher pay, which makes life easier so you’re not struggling so hard,

all of those things compound to determine what your decisions might be.” The “life

choice” decisions were not just related to breastfeeding, but even substandard childcare

that a low-income mother may be forced to accept. She related, “I just had a mom tell me

that last week. ‘I don’t want these people watching my child, but I have no choice. I don’t

like the choices they are making around my child, but I have nothing else.’” Under

circumstances where women didn’t have the privilege to make the choice to breastfeed,

the IBCLC responded compassionately and didn’t want mothers to feel like failures:

One has to give. The easiest one . . . is give a bottle . . . It’s just life. What is the easiest to give up without giving up? We have lots of moms who do try to overcome the hurdles and do it all and just can’t. I mean I had one mom in here for two hours, trying and trying and she just felt like a failure because she was really trying, and she just couldn’t [breastfeed]. She just could not do it. And I just spent the whole time making her feel that it’s okay. It is okay.

The IBCLC distinguished between “life choices” and the “personal choice” to continue

breastfeeding or not because of pain. Pain was something someone could choose to

endure and get help for, while socioeconomic struggles were beyond one’s control:

If a woman wants to fight through the pain of sore nipples or engorgement or mastitis and still breastfeed she will. So, it’s always been personal choice, because I’ve seen moms come from all over to come here, and [they] succeed . . . It’s a personal choice. If the person truly inside themselves really wants to breastfeed [they will]. . . It’s every person’s right to choose.

She had reformulated the concept of “choice” to understand that although we talk about

women being given choices, structural factors create barriers that make it difficult for all

women and often impossible for those women with the least privilege.

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The Training

Even though I had breastfed my own children, I didn’t find it easy in the

beginning to help other women to breastfeed theirs. I felt like I needed to read the

lactation textbook I had from cover to cover and memorize everything contained in it

before I was competent enough. The lactation course for professionals that I attended in

California said that we needed to respect the different ways that women took in

information and learned. The course went over the 4 types of female knowers based on

research that was done through interviews of 135 women (Belenky et al. 1997). The 4

types were described as receivers of knowledge who trust authorities and want certainty;

subjective knowers who follow their intuition over logic or male authority figures;

procedural knowers who are like smart students who take in information from all sources

but question everything; and constructed knowers who can integrate various ideas, are

okay with ambiguity, are sensitive to what other people are going through, and want to

take action to empower them.

Almost all of the women in the class said that they identified the most with being

subjective knowers. Intuitive feeling was important to them, and they definitely didn’t

trust male authority figures. This insight was important to later understanding the

concepts about breastfeeding that lactation consultants held and how they chose to help

mothers. The middle-class mothers in my research who sought the help of lactation

consultants tended to approach breastfeeding as procedural knowers who prepared for

breastfeeding by doing research like students. They sought a set of procedures for

enacting breastfeeding successfully and looked to the opinions of experts but didn’t

always accept what they had to say. Almost all of the women who sought help seemed to

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want certainty, however, like receivers of knowledge. While some did not necessarily

find it in the authority of doctors, most women found it in the quantifying methodologies

that pediatricians and hospitals practiced.

When I started my mentorship hours, where I conducted consultations under

supervision as part of the certification process, I found myself acting like a procedural

knower. I approached the activity of helping women to breastfeed like a good student

who had to study up and read everything about breastfeeding and memorize the order of

procedures observed in my mentors. I did not feel comfortable with ambiguity, because

in the learning phase it was uncomfortable to not have clear answers for women who

were looking to me for help. This caused some problems for me, because my mentors and

the rules of mentorship set up by the certifying board, wanted me to jump in right away

with consultations, albeit under supervision and learning as we went along. I, on the other

hand, felt like I should know everything there was to know first before I helped anyone

because I was assuming this was a top down model in which I would simply give women

information and instruction.

I not only felt uncomfortable because I didn’t think I had enough information, but

also because the training required touching women’s breasts. This hesitancy wasn’t

because I was thinking of the breasts as sexual objects when I was working with women,

but because touching others is an intimate act, even if it isn’t sexual in nature. When I

explained to Tina that this was my hesitancy, she was thoughtful and said she was sure

this must be because I was not a nurse. Nurses, she explained, were comfortable with

touching patients because getting to that place was part of their training. Most IBCLCs

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had become nurses before they became lactation consultants, so perhaps the expectation

that you would jump right in was not too big of an expectation for them.

At first, I felt as though touching a woman was invasive of her space and person,

even though I was invited to. This is because it was apparent to me that touch was not

only how you demonstrated something, but touch was also a way that lactation

consultants understood women on an emotional level. While observing and imitating

lactation consultants as a trainee, I realized that a woman made herself vulnerable when

she allowed you to touch her, and this meant that you had to be sensitive to her. That

vulnerability made women react in ways that gave you emotional information and helped

to guide you in your care. Some women, for example, were uncomfortable with touching

themselves, and their attempts to hold their infants and their breast in order to facilitate

breastfeeding were awkward. Perhaps they were afraid they would do something the

wrong way in the presence of a practitioner. They seemed to become quickly frustrated if

a lactation consultant took over for them, as if confirming their feelings of ineptness.

Helping mothers required a careful dance in which the lactation consultant was reassuring

through words and touch rather than discouraging. It might require trying a different

position, such as an upright, laid-back one in which the infant found the breast and

latched on by themselves so that the mother could have confidence. A lactation

consultant was often just feeling for clogged milk ducts, squeezing out milk, or seeing

how the infant and the mother came together at the breast, but in each case, it revealed to

her a reaction or a response. This was informative.

I was told that my objective was to make women confident that they could

breastfeed their baby and this involved them being able to touch their breasts and baby

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with effective actions. Thus, it wasn’t about latching a baby onto the breast for them, in

which case they wouldn’t know what to do when the lactation consultant left. Helping

moms and babies have an effective interaction was all about understanding their

embodied experience and directing their attention towards the important aspects of a

sensory array. Getting at their embodied experience required intimacy and a focus on

process. Giving women the right factual information about breastfeeding by making sure

I had read the textbook from cover to cover, seemed to be the least important aspect of

care to my mentors. In fact, mentors spent time reviewing how we interacted with

patients, asking me what I observed about a mother’s way of holding and maneuvering

her baby and her body. The lactation consultant who did Japanese lactation massage

talked the most about her own way of touching and the information one received by

touch.

Mary was the only lactation consultant who told me that I should ask the patient

permission before I touched them. To the others it seemed implicit. The ways I observed

my mentors touch women varied. Some of them touched women only for some aspects of

the consultation, and some of them touched a lot. I noted that most women seemed to not

like a more aggressive way of touching and I decided I would not touch this way, but

then felt uncomfortable when I was being observed by a mentor who touched this way. I

wondered if she expected me to imitate her methods. What I found, however, was that the

mentors didn’t care as much about how I touched a woman as they cared that I hesitated

to touch patients. Touch, whether it was conservatively applied, frequent, gentle, or

confident, was an important part of being a lactation consultant and the way to receive

information as well as guide mothers. It wasn’t about giving a woman a set of

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instructions and was therefore why learning had to be through doing and not through

studying textbooks. I recall a nurse coming into the hospital room while I was standing

next to her lactating patient, hesitating. She told me to just “get right in there and do it.”

Mary, who was supervising me that day, shook her head and said in an exasperated tone,

“I’m trying with her. Lord knows I’m trying.”

The lactation class for professionals that I attended recommended that we not

touch women during a consultation. The idea of not touching was based on the same

ideas that I received from my mentors, however. It was explained that women needed to

learn how to use their bodies, understand their infant’s movements and signals, and

coordinate their two bodies in actions together to facilitate breastfeeding, and not have

this done for them. If a lactation consultant latched the baby on for the mother, she

wouldn’t learn as effectively. The other reason was because touch makes women

vulnerable and can potentially elicit or create negative emotions. Instead, we were to

demonstrate breastfeeding techniques to women using a fake demonstrator breast.

Avoiding eliciting or creating negative emotions in a mother was so important that we

were told not to use dolls to demonstrate breastfeeding techniques, but to use teddy bears

instead. Teddy bears elicited positive emotions because they are associated with comfort,

safety, and care. The decision of the instructors to recommend we not touch women

seemed to be a way of avoiding the possible negative outcomes that could happen if we

weren’t sensitive and responsive to how our touch was affecting a woman.

While I hesitated to touch women at first, I excelled at teaching them how to use

breast pumps. I realized that this was because it was far easier to take apart a machine and

explain how the parts worked, how to use it, and how to clean it. Machines had a fixed

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pattern of operation and there was nothing uncertain or intimate about them. Women,

however, were not machines, and breastfeeding was not enacted like a simple, universal

set of rules. I found that becoming a lactation consultant was about more than women

helping other women, it was about becoming intimate with other women in order to help

them. I became aware of their fears, their hopes, their histories, their vulnerabilities, and

how they thought of themselves, their bodies, and their babies. The subjective knowers

valued intuition, and this is how they saw themselves as providing something different

than male medical authority figures. Over time I became not only comfortable with this,

but proud of my ability to tune into a woman in order to respond in a way that would be

most helpful.

I learned that there were two kinds of touch. There was touch that happened when

I placed my hands on a woman’s body, and there was emotional touch that elicited strong

feelings in mothers. The latter could be achieved through physical touch or through what

I said to women and how I chose to say it. Mothers seemed the most satisfied with my

help when I was able to touch them in an emotional way. When I was able to make a

woman feel cared for and safe enough to open up, they often revealed fears that they

were inadequate mothers, as well as feeling overwhelmed and out of control of their

situation. Helping them to breastfeed was about more than technique or figuring out what

was causing a problem to occur but was also about coming to a catharsis in which

negative feelings and experiences would be replaced with positive ones. It was also about

giving women an experience that moved them. That movement signified bringing them

from one state to another and impressed the moment in their memory to guide them in

breastfeeding in the future.

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My IBCLC mentors had developed sensitivity to women in this way, some more

than others. They were sensitive to what other people were going through and wanted to

empower them, making them also like the so-called constructed knowers. Interestingly,

they not only valued emotion, but also reasoning. My mentors taught me the importance

of science to the IBCLC. Often my questions were answered by them with the directive

to “look it up” in Breastfeeding, A Guide for the Medical Professional, by Ruth

Lawrence. This go-to book examined research that had been done on various

breastfeeding related issues. Most of them owned a copy. They also talked about

interesting research articles that would come out in the latest edition of the Journal of

Human Lactation and would adjust their practice based upon findings. They justified

things that they did, such as giving nipple shields to some mothers of premature infants,

by referring to the research. I was expected to be guided not only by my sensitivity to a

particular woman, but also by lactation science. The use of touch and other senses to

gather information is itself empirical, and evidence-based practice was the way that

lactation consultants had countered the influence of formula manufacturers and medical

facilities. It was also how they influenced policy and had gained the authority to be a

medical professional.

Becoming a lactation consultant meant becoming comfortable with intimate

interactions with women in order to help them. It also meant taking on the mantle of

science in order to make lactation intelligible and to have authority that would be used to

help women. Having medical authority, however, was not always respected, and the

backlash to breastfeeding had undermined the idea that breast was best because science

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proved it. Lactation consultants, however, were engaged in helping women tune into their

own bodies and that of their infants in order find their own authority.

Conclusion

The lactation consultants who were part of this research, with the exception of

those who worked at WIC, helped breastfeeding mothers and became certified during the

‘90s, a time in which activists were trying to prompt changes in women’s healthcare. As

chapter two discussed, the profit-making agendas of formula manufacturers and various

players within the healthcare system had been seen as antithetical to the interests and

well-being of women and infants. The professionalization of the lactation consultant was

achieved with the ideals of women helping women, compassionate caring, and infiltrating

the medical system as an activist that didn’t look like an activist. Embracing science was

key, with a push for evidence-based practices rather than profit-based ones, and through

the advantages that the respect and authority afforded to IBCLCs as medical

professionals achieved.

It was because of these shared ideals and the belief in women support networks,

that I was able to gain the support of the IBCLCs who agreed to be my mentors and

participate in this research. This ethnography shows how the lactation consultants wanted

to change harmful policies, give women the sense that they were cared for, and empower

them. I shed further light on their methods for empowering women in discussing my

training experience, which revealed a focus on eliciting women’s emotions and creating

positive emotions. Emotions were valued as ways of gaining trust and information to

further provide care, and were sometimes elicited through physical touch of the body.

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Additionally, positive emotions were cultivated as a method for helping women

breastfeed. A focus on the body was also a focus on a woman’s emotions, and both touch

and emotion seemed more important to providing care than intellectual or procedural

information for many of the lactation consultants. However, a focus on science gave them

authority and access to women in medical environments.

WIC lactation consultants were not allowed to touch clients, and so the

observations I made about touch and emotion did not apply to them. They did, however,

relay a desire to show clients they cared about them and their socioeconomic

circumstances and that care was more important than an agenda.

The use of touch and emotion as a form of care that is discussed here sets the

topic of emotions up for further discussion in future chapters. It will be examined in

chapter four’s look at bonding and women who have negative experiences with

breastfeeding. Chapter five challenges traditional epistemology’s disregard for emotions

and looks at emotion as important to how we learn, know, and experience breastfeeding.

Additionally, emotion is reflected in chapter six’s case studies of the lactation consultants

helping women with breastfeeding issues.

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Chapter Four

Super-Natural White Blood: The Concepts Lactation Consultants Have

About Breastfeeding

“In an age where we can ‘grow’ human beings in a test tube, what is it about human

breast milk that is so miraculous it can’t be synthetically reproduced?” – Sara Rosenthal, The Breastfeeding Sourcebook (1995, 23)

“Breastmilk is magic and defies the logic of the ‘bean counters.’” – Dr. Jack Newman,

founder of the International Breastfeeding Centre29

Introduction In this chapter I argue that among lactation consultants, breastmilk is thought of

as more than nutrition or medicine and is considered super-natural. I call it super-natural

because it defies the notion that biotechnology can change what we have considered

natural by replicating or improving upon it. Breastmilk has resisted this because it is not a

fixed entity; its production involves a dynamic, complex system with emergent properties

that limits our ability to have knowledge of the system. I demonstrate that it is because of

this that it has also been referred to using supernatural30 terms, and I show how thinking

of it in both scientific and supernatural ways is not incongruent. Additionally, I argue that

as matter out of place breastmilk is elevated in status and has been thought of historically

and contemporarily by lactation consultants as white blood. Like blood, breastmilk is a

life-giving and sustaining fluid and also creates relationships. It creates relationships

29 From a public Facebook post by Jack Newman, posted on his page on October 18, 2013: https://www.facebook.com/DrJackNewman/posts/this-is-post-about-test-weights-weighing-a-baby-before-and-after-a-feeding-to-se/244983515652702/ 30 I have taken the hyphen out of supernatural in this instance because here I am speaking about supernatural terms such as magical or miraculous. I am not also referring to the way that breast milk is thought of as a natural substance that cannot be improved upon or replicated. The latter, however, is cause for the former.

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through symbolic, biochemical and microbial relational properties. It is thus socially

significant because it facilitates bonding, creates biosocial persons, and maintains social

order by diminishing uncertainty. However, when structural factors cause mothers to feel

overwhelmed and exhausted, they often report negative breastfeeding experiences and a

lack of bonding with their infant.

The Magical Power of Breastmilk

The entries read almost like ads on a dating site with their references to looks and age,

men seeking women, but for one strange request:

Hello there, 22 year old attractive and athletic male here looking to purchase breastmilk for $1/oz on a consistent basis. Looking to preserve my muscle while cutting some body fat…. Hi I’m Bill MWM 54 looking to purchase fresh, not frozen milk….

Hi, 21 year old male here interested in buying breastmilk for nutritional purpose . . . I’m including a blurred out picture of myself so you know I’m not some old creep lying, and can provide more of myself so you know exactly who I am if you would feel more comfortable that way…. White male 45. Looking to buy breast milk for my personal use . . . I’m not a weirdo just believe in the health benefits of it….

Most of them were body builders who believed that human breastmilk could help them to

grow muscle and were willing to pay women to ship their pumped milk to them. Some of

the people posting requests for breastmilk were there for reasons other than body building

though:

I am in weak health following two broken arms and it was recommended to me to drink breast milk.

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I need to buy fresh/frozen breastmilk to help my adult son recover from his illnesses. We are at our wits end with western doctors. He is in chronic pain and is willing to try live probiotics from breast milk. Hi i joined this site for my husband. He is 36 years old and was diagnosed with cancer… Ive done many hours of research on the benefits of breast milk with cancer. Not only does it help fight the cancer but it also helps protect his cells from the chemo and radiation.

I visited the website31 where I found these ads after hearing about it from Sandra,

a lactation consultant who had contemplated posting her own ad asking for breastmilk for

her lover, Dan, who had liver cancer. Sandra realized, however, that this was completely

unnecessary; she was a lactation consultant and had the knowledge that was needed to

cause her own body to produce breastmilk without ever becoming pregnant. In an

interview over coffee at Starbucks, Sandra told me how inducing lactation and giving

Dan her breastmilk had worked out:

And so, he's cured pretty much. I mean, liver cancer, you know he's got seeds in there and they'll probably wake up again but it's all so convenient. And his liver function is fantastic. It’s improved. I mean it's probably better than mine. And I cured his shingles with breastmilk in less than three days. He got the shingles. And I knew it was the shingles when I saw him. I was like, “Oh my God, you’ve got the shingles!” And it was coming down like this, and it was at this point in his eyelid. And he was like, “Get that breastmilk off of me!” And I'm like, “Shut up, you're getting breastmilk! It works!” And I did it three times a day. I just threw out an application of breastmilk on each lid with a little Q-Tip, and then it dried up in three days. And you know chicken pox and shingles usually takes like two weeks to dry up, and it was gone in three days.

Sandra’s ability to provide breastmilk for Dan was made possible by a different

internet source - foreign compounding pharmacies that would ship her an illegal

galactagogue32 called Domperidone. In 2004 the Food and Drug Administration (FDA)

31 www.onlythebreast.com, accessed in 2016 32 A galactagogue is a drug or other substance that increases one’s milk supply.

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became concerned that Domperidone might cause cardiac problems and thus possible

death in lactating women and made it illegal to market or compound the drug in the

United States (Lauwers and Swisher 2015). Nevertheless, Sandra enthusiastically told me

how effective and safe she thought it was in pill form. She told me that the U.S. is the

only country that has made the drug unavailable to lactating women and explained that it

was only found to cause problems in a few cases where the drug was taken as an

injection. She knew which countries would ship the drug and which sold it at a

reasonable cost. She also expounded upon how much more effective it was at causing

milk increases compared to what was legally available. Sandra thought a lot of women

could benefit from the drug if only the FDA would approve its use and lactation

consultants could recommend it.

Sandra began a pumping regimen after the drug arrived in her mail. She soon had

milk in her breasts, which was something she hadn’t experienced in years. This wasn’t

the first time she had used breastmilk for healing purposes - she had tried drinking her

own breastmilk years ago while she was recovering from surgery and had to pump milk

for her two-year-old. She believed in the healing powers of breastmilk so much that she

had recently started secretly giving breastmilk to sick loved ones other than Dan. She

didn’t ask their permission to do so because she felt they would react negatively:

The other day I made [my mother] cream of wheat, and I've done this a couple of times already, I made her cream of wheat and of course I made it with milk and butter and Splenda. But you know the milk you can pour on top of the cream of wheat? You can mix in breastmilk. So, I put it in and she doesn't know. The first time she ate it she goes, “Who made this cream of wheat?” And I said, “It was me,” and she said, “It's the best cream of wheat I ever had.” My son's girlfriend, her brother has cancer and he also had really bad psoriasis. And so, he's 16 now. He's 16 and has leukemia. He’s in remission right now. But anyways, he has these bad sores, and so I put the milk in different spots. So, he

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has no idea that it was breastmilk that they were putting on him every day and his psoriasis is getting better. But one day when he's an adult we'll tell him we were spraying breast milk on him. But he has no idea. I think maybe an adult can accept that, but a 16-year-old would be like, “Breast milk? I'm having breast milk?!”

Most adults seem to find the idea of ingesting breastmilk disgusting, but as in the

above examples, some seek it out. The body builders posting ads for breastmilk, and

some of those who were hoping to purchase it for healing purposes, considered the health

benefits of breastmilk in the same way that they might think of healthy foods. They drink

it because it contains growth hormones, or because it is high in calories and nutrients.

Some people think of it as more than nutritious food and consider it like a medicine.

Lactation consultants, however, think of breastmilk in a way that is different from any of

these categories: It is more than just a healthy food or even a medicine.

A pharmaceutical medicine is typically targeted to affect one specific ailment. It

frequently relieves symptoms, but often doesn’t prevent or cure, and can have negative

side effects. Lactation consultants considered breastmilk to be something greater than a

medicine because it is a living substance that can’t be fully replicated, it protects,

nourishes and heals as a complex adaptive system, it interacts with the infant’s body to

form body tissue or developing body systems, and it transforms to address the needs of

the infant. These special attributes of breastmilk were emphasized throughout my IBCLC

training, as was the importance of what science was uncovering and substantiating about

the qualities and benefits of breastmilk and breastfeeding. The milk a mother makes for a

premature infant, for example, will be different in composition from the milk that a

mother of a full-term infant makes because the needs of these infants are different

(Kedrowski and Lipscomb 2008). Also, milk content differs between individual infants

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(Ballard and Morrow 2013). Infant saliva makes its way into the nipple pores and mixes

with breastmilk to make substances that are ingested by the infant and control their gut

microbes (Al-Shehri et al. 2015). Because there is retrograde milk flow in which milk

mixed with infant saliva goes back into the breast (Geddes et al. 2008), and because

breastmilk provides an immune response when the infant but not the mother is ill

(Breakey et al. 2015), it is hypothesized that the mother’s body detects pathogens in the

infant’s saliva and responds with breastmilk properties targeted at those pathogens. Milk

changes over a 24-hour period as well (Ballard and Morrow 2013). For example, during

the night breastfed infants receive melatonin, a hormone that young children’s bodies

don’t make, but that their mothers provide to them in their milk (Cohen Engler et al.

2012). It is thought that the melatonin helps infants regulate their sleep cycles (Cohen

Engler et al. 2012).

Breastmilk protects and heals by providing antibodies to infants, but it also causes

the infant’s immune system to develop a memory of what it has been exposed to in the

past so that it can fight these substances it in the future (Riordan and Wambach 2010).

Because it is complex and adaptive, it can learn and changes according to what it learns.

There are about 4,000 white blood cells per centimeter of breastmilk that protect infants

from infectious diseases (Riordan and Wambach 2010). There are also substances in

breastmilk other than antibodies that confer protection to the infant. Complex sugars

called oligosaccharides, for example, keep harmful substances from attaching to the

intestinal track (Riordan and Wambach 2010). In doing so they also feed helpful gut

bacteria (Turney 2015).

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Another area where scientific research has formed the way that lactation

consultants think about breastfeeding is its ability to prevent or target cancer. Breastmilk

has been found to kill cancer cells in humans, but research is just getting started in human

trials to ascertain any possible long-term effects of using it therapeutically, and to try it

against different types of cancer.33 The anti-cancer agent in breastmilk is called

HAMLET, which is formed in the acidity of the infant’s stomach when alpha-

lactalbumin, an abundant protein in breastmilk, and oleic acid, an omega-9 fatty acid in

breastmilk, combine (Svanborg et al. 2003). HAMLET causes apoptosis in cancer cells

but does not touch non-cancerous cells (Svanborg et al. 2003). It does this by entering the

nucleus of the cancer cells and damaging them until they die (Svanborg et al. 2003).

HAMLET doesn’t just prevent and selectively kill cancer, however, it also causes

antibiotic-resistant bacteria to become susceptible to antibiotics (Marks, Clementi, and

Hakansson 2012).

Breastmilk also forms living tissue. It has been found to contain pluripotent stem

cells, which are the type found in human embryos (Wambach and Riordan 2016).

Pluripotent stem cells are different from regular stem cells because they have the ability

to become any specialized cell in the body. The human infant ingests anywhere from

10,000 to 13 million living stem cells for every milliliter of breastmilk (Wambach and

Riordan 2016). Their function in the infant’s body was unknown until recently, although

lactation consultants seemed certain they were there for a developmental purpose, which

would be revealed in time. We now know that these stem cells are another way that

33 In 2019 the first HAMLET trial was completed and showed promising results against bladder cancer in adults. https://www.prnewswire.com/news-releases/hamlet-pharma-announces-results-of-first-major-clinical-trial-for-a-new-cancer-killing-molecule-300888552.html

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breastfeeding is relational and challenges our ideas about what it means to be human. The

stem cells in breastmilk enter the infant’s gastrointestinal tract and from there enter into

the bloodstream where they are transported to change into the specialized cells of various

organs (Hassiotou et al. 2015). They can even cross the blood brain barrier in the infant’s

brain where they become either neuronal or glial brain cells (Aydin et al. 2018). In doing

this they are able to aid in the infant’s development (Kakulas 2019). They also make us a

kind of chimera. Live, pluripotent cells give us flexible and permeable bodies.

While article after article has claimed in recent years that the benefits of

breastmilk have been overstated, many researchers, pharmaceutical companies and

formula manufacturers seem to disagree because they are busy trying to work out how to

develop pharmaceuticals, better formulas, and infant supplements by extracting elements

of this complex system, such as the oligosaccharides (Petherick 2015, 2019; Pollack

2015; Ravindran 2017). It is believed that if beneficial bacteria and oligosaccharides

don’t colonize the gut sufficiently in infancy, harmful organisms can take hold (Harman

and Wakeford 2017), including those involved in necrotizing enterocolitis (NEC) which

can be deadly to infants, and in the U.S. affects 1-3 infants per 1000 births (Niño, Sodhi,

and Hackam 2016).

Efforts to extract and manufacture components of breastmilk for therapeutic use

or for inclusion in formula has proven to be problematic. In one case, researchers went to

Malawi and took a sample of microbes from the gut of a malnourished child and

transferred them into lab mice with germ-free guts (Charbonneau et al. 2016; Roehr

2016). When they introduced bovine milk derived oligosaccharides into the guts of these

mice, they began to gain weight (Charbonneau et al.; Roehr 2016). They then introduced

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b. infantis into their guts, which is a bacteria that is abundant in the guts of breastfed

infants (Turney 2016). The b. infantis did not survive and the guts of the mice were

populated with other types of bacteria that took over after feeding on the oligosaccharide

sugars (Charbonneau et al. 2016; Roehr 2016). The reason b. infantis failed to populate

the gut comes down to the complexities of the microbiome and the fact that it is a whole

system in which each component contributes to the function of the whole and is

dependent upon the right mix of conditions.

Mill, one of the researchers involved in the b. infantis study, is a founder of a

company that is selling an activated b. infantis powder as a probiotic to be mixed with

breastmilk and fed to infants as a supplement (Roehr 2016). Mill, however, stated that the

results of the b. infantis study had shown the possible dangers of simply supplementing

infants with just one component normally found in the breastfed infant’s gut because

supplementation with oligosaccharides, for example, could end up feeding harmful

bacteria instead of beneficial bacteria (Roehr 2016). Additionally, the b. infantis

supplement that the company sells is a single type of bacteria to be introduced into

varying infant microbiomes without enough known about the development of the infant

microbiome and immune system over time. Individual components of breastmilk given as

supplements or placed in formula often can’t fully function as intended because they are

deposited into a dynamic system that is responsive to many variables. For example, one

study found that supplementation with beneficial bacteria found in breastmilk actually

increased infections in infants (Quin et al. 2018). The authors hypothesized that the

reason for this was that introduced changes to the microbiome of the newborn “may

disturb the ‘normal’ development of the infant immune system” (Quin et al. 2018, 19).

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Another study in which breastfeeding mothers were supplemented with 3 different

beneficial bacteria, found that only one of the three was transferred to their infants via

their milk (Dotterud et al. 2015). The reason why some bacteria is able to be transferred

to infants via breastmilk and others cannot is unknown, with West and Jenmalm

commenting that “There is much complexity in this area of research as the effect of a

probiotic intervention is likely to be influenced by the complex interplay between

genetics, epigenetics, immunity, environmental exposures and global microbiota” (2015,

4). In another example, inconsistent results have been found from the addition of the

essential fatty acids DHA and ARA to formula in order to confer cognitive and visual

benefits to infants, which a report by the Committee on the Evaluation of the Addition of

Ingredients New to Infant Formula (2004) explained thus:

The reason for these inconsistent effects might be that these compounds do not work alone; rather the matrix of human milk includes general growth factors and specific neural growth factors. If there is a positive effect on neurodevelopment, it is likely that these factors work in concert with each other. (49)

Thus, the dynamic complexity of breastmilk in its interactions with the microbiome, and

the microbiome’s reliance on the community of microbes and its variance according to

environmental factors, means that a complete facsimile is impossible, and any product

will be inferior to the real thing.

Manufacturing breastmilk components is difficult and extracting and synthesizing

them is expensive (Newmark 2018). Most human milk oligosaccharides, as one example,

are too complex to be synthetically copied for formula (Ravindran 2015). They populate

breastmilk with hundreds of varieties, making them one of the more unique attributes of

human milk (Ravindran 2017). Any commercial pharmaceutical would likely have to

extract substances from bovine milk, which is species specific (Bode et al. 2016). While

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bovine milk contains oligosaccharides, it doesn’t have nearly the variety found in human

milk (Bode et al. 2016). Oligosaccharides have been extracted from plants and have been

included in formula as an inexpensive alternative (Ravindran 2017), but while they may

feed bacteria, they are structurally different and not found in any mammal milk, making

them unlikely to provide the immune benefits that the human varieties do (Bode et al.

2016). A study of the effects of the inclusion of plant or bovine milk based

oligosaccharides in formula showed that although the guts of the infants who received

these prebiotics developed bacteria similar to that of breastfed infants, the bacteria didn’t

perform the same in the gut (Baumann-Dudenhoeff et al. 2018). This deficit was

specifically related to amino acid synthesis (Baumann-Dudenhoeff et al. 2018). Currently

only one human oligosaccharide, 2’FL, has been added to formula (Ravindran 2015). The

2’FL is made in a lab via enzymes, but this method has so far only been able to produce

some of the simpler human oligosaccharides (Ravindran 2015).

There are only a few species of probiotic that have been added to formula out of

the hundreds found in human breastmilk, and many of those live organisms do not

survive processing and storage or the infant’s stomach acid and bile salts (Kent and

Doherty 2014). The sheer variety and complexity of probiotics in breastmilk makes them

as difficult to replicate in formula as the prebiotic oligosaccharides. Furthermore, because

each individual mother provides different microbes to her infant dependent on her

environment and diet, and the infant’s microbiome changes over time, how do you

choose which bacteria to manufacture and supplement all infants with (Harman and

Wakeford 2017)?

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A review of studies that looked at growth and various clinical outcomes in term

infants from symbiotic, prebiotic, and probiotic additives in formula found no evidence of

benefit and did not support routinely adding them to formula (Mugambi et al. 2012).

Even though there may be some benefits from supplements derived from breastmilk, such

as the lower incidences of NEC shown in premature infants given b. infantis (Underwood

et al. 2015), the focus on isolated components ignores the dynamic interbodied aspect of

immunity development between the infant, mother, and environment. Miller (2018)

rejects the passive immunity concept of breastfeeding, stating that “new research shows

that infants send information to their mothers and rely on maternal immune systems to

create immunity targeted to their own needs, forming a ‘collaborative immunity’ between

mother and infant” ( 27). Lactation consultants who were a part of this study believed in a

hierarchy of feeding methods based on benefit. They believed that breastmilk from the

infant’s mother obtained by breastfeeding was the most beneficial because the dynamic

interactions between mother, infant, and environment directly met the individual infant’s

needs at a particular time of day and developmental stage. Milk pumped from the mother

came second since it wasn’t specific to the conditions present at the time it was produced,

and donor milk came last but was preferable to formula. The fact that formula is as of yet

an inferior substitute, and that breastmilk’s complex, living and changing system can’t

effectively be untangled for replication or taken apart for the therapeutic use of its parts,

makes it all the more amazing to lactation consultants.

Some of the ways that breastmilk interacts with the body to form developing body

systems are proven and explained by medical science, and others are still mysteries. For

example, there are hormones in breastmilk that are believed to influence infant behavior,

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metabolism, and the nervous system, but we don’t yet fully know what effects these

hormones are having (Wambach and Riordan 2016). As one example, we know that the

hormone leptin regulates our appetite and because it is found in breastmilk but not

formula, there is speculation that this may be why those who are breastfed have lower

levels of obesity (Wambach and Riordan 2016). Studies with monkeys have shown that

the hormone cortisol acts as a chemical signal sent from the mother to the infant through

her milk (Hinde et al. 2015). Cortisol is released by mothers when they are under stress

and works to prepare us for danger (Hinde et al. 2015). Breastfed infants develop cortisol

receptors in their intestines in order to read the cortisol signals from the mother (Hinde et

al. 2015). The monkey infants’ regulated their energy use according to the level of

cortisol released by their mothers into the milk (Hinde et al. 2015). The levels of the

hormone in the milk seemed to affect the temperament of the monkey infants as well

(Hinde et al. 2015). We do not fully know how cortisol or other hormonal signals in

human milk might affect human infants as of yet, but it is thought that they may regulate

infant behaviors (Hinde et al. 2015). If so, this contributes to the social importance of

breastfeeding.

Katie Hinde, Associate Professor at Arizona State University’s Center for

Evolution and Medicine, conducts research on the constituents of breastmilk and how

they contribute to infant development and behavior. In a talk she gave at Harvard, Hinde

said that human milk is like a “magic potion” and “is freaking amazing” (Hinde 2013).

Even with all that Hinde knows about breastmilk, she still seems both awed and disturbed

by what is still unknown:

Milk contains hundreds, likely thousands, of bioactive constituents. But… we don’t know exactly what all is in milk, how it all gets there, and what those

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constituents do when ingested by the infant… The devastating big picture is that there is relatively little research on mother’s milk. (Hinde 2013) Lactation consultants are not deterred by the many unknowns about breastmilk.

Their training and experience give them more information than the general public about

what is in it and how it functions. The living milk and dynamic processes of

breastfeeding made breastfeeding and breastmilk’s importance irrefutable to them. The

idea that the benefits of breastmilk are overstated seems nonsensical to someone who has

information about HAMLET, stem cells, the microbiome, personalized antibodies, and

the rest. One lactation consultant summed the sentiment up when she said, “I just believe

in the power of breast milk.” When I asked a La Leche League leader what her thoughts

were about the importance of breastfeeding she responded by telling me she had a t-shirt

that said, “I make milk, what’s your superpower?” References to breastmilk as magical or

miraculous among lactation consultants usually showed up in reference to a scientifically

examined and explained property of breastfeeding. These were often comments about

scientific articles shared on social media, like a study that showed that a component of

breastmilk dissolves cancerous tumors (Knapton 2019). In another example, a post from a

lactation consultant’s blog titled, “My Magical Breast,” was shared (Mohrbacher 2016).

It tells the lactation consultant’s story of having an absent, undeveloped breast that grew

after she let her nursing babies suckle on it:

Science tells us that a woman’s milk-making glands grow and develop during pregnancy, and after birth this milk-making tissue continues to grow. We also know that with breast stimulation, women who have never been pregnant can grow functioning breast tissue and produce milk for adopted babies. I was aware of all of this when my mammogram tech gave me the news, and I knew immediately that my 12 years of nursing had gradually grown a real right breast where none had grown before (Mohrbacher 2016).

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The awe the lactation consultants had for breastfeeding and breastmilk stood in stark

contrast to the views expressed by critics involved in a backlash against breastfeeding

promotion.

In the debate over whether or not the benefits of breastmilk are overstated, both

sides utilize scientific claims to support their stance and are critical of other conclusions.

One of the more explosive debates was over a study (Colen and Ramey 2014) that looked

at siblings in which one had been breastfed and the other had not. This design allowed

researchers to look at subjects with similar genes and environment so that they could

more confidently claim that breastfeeding was responsible for outcomes they were testing

for. The study’s authors were reported to have concluded that there are no beneficial

long-term effects from breastfeeding over formula feeding. Lactation experts and

advocates pointed out that despite sensational headlines in the media that suggest that

breastmilk makes no difference34, the outcomes tested for were limited (Brady 2014;

Cassels 2014; Flanders 2014; Hinde and Martin 2014; Rhodes 2014; Schwarz and Stuebe

2014; Quinn 2014). Also, the focus of this and so much of the research that has been used

to conclude that breastfeeding is overstated is on long-term outcomes rather than short-

term outcomes (Brady 2014; Cassels 2014; Flanders 2014; Hinde and Martin 2014;

Rhodes 2014; Schwarz and Stuebe 2014; Quinn 2014). Additionally, they pointed out

that the benefits of breastfeeding to mothers, or reasons why the mothers in this study

only breastfed one child, were not explored (Brady 2014; Cassels 2014; Flanders 2014;

Hinde and Martin 2014; Rhodes 2014; Schwarz and Stuebe 2014; Quinn 2014). Nor did

34 Examples of sensationalist news headlines about the study included Slate’s “New Study Confirms It: Breast-feeding Benefits Have Been Drastically Overstated”(Grose 2014) and the Daily Mail’s headline “Breast milk is ‘no better for a baby than bottled milk’ – and it INCREASES the risk of asthma, expert claims” (Innes 2014).

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the study control for the length of time a mother breastfed one sibling, so it could be

comparing a sibling breastfed for only two weeks against a formula fed sibling (Brady

2014; Cassels 2014; Flanders 2014; Hinde and Martin 2014; Rhodes 2014; Schwarz and

Stuebe 2014; Quinn 2014).

Lactation consultants who were part of this dissertation study spoke about being

frustrated by both the lack of well-designed studies and what they saw as these types of

problematic conclusions being drawn from studies. They felt that it was impossible to

truly win over skeptics because the types of study designs that would satisfy them,

randomized controlled trials, were unethical to do and it was difficult to control for

confounding variables. They pointed out that breastfeeding outcomes are dose dependent,

and that studies frequently didn’t take into account how long an infant was breastfed for,

or whether or not the infant received a mix of formula and breastmilk. Many of the

infants who are studied are only briefly breastfed or there are only small numbers who

are exclusively breastfed, because of low rates overall in most populations.

Of course, the criticisms of research results based upon weak study design were

also engaged in by those who believed that the benefits of breastmilk are overstated. The

difference was that critics of breastfeeding promotion saw poorly designed studies or an

inability to have randomized controlled studies as a reason to doubt or downplay the

benefits of breastfeeding while being less critical of research like the Colin and Ramey

(2014) sibling study. Lactation consultants and experts, on the other hand, pointed to

what they considered well-designed studies that supported the benefits of breastfeeding

while also accepting the limitations of studies. At a breastfeeding class that I took for my

IBCLC certification, a lactation consultant who was involved with research told me that

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she believed that there were lots of poorly designed studies on breastfeeding and far

fewer well designed studies. She insisted, however, that good studies exist even though

there weren’t enough of them. She emphasized looking at the Cochrane Database of

Systemic Reviews for well-designed studies. The need for quality studies, in fact, was a

reason why the lactation consultants who participated in this research agreed to do so.

Mary, the lactation consultant who encouraged others to join the study and become

mentors for my IBCLC certification, was motivated by the need for quality research and

the belief that someone who was both an IBCLC and a researcher would know what

kinds of studies were needed and how best to design them.

Study results that prompt critics to claim that breastfeeding is overstated were not

definitive to lactation consultants but meant that we need better study designs and a

recognition that because breastfeeding is embedded in environmental and social contexts,

it is difficult to untangle webs of association and isolate causes. In the latter case,

lactation consultants pointed out that breastmilk is species specific and the product of

evolutionary shaping, and therefore its many components must have a purpose, making it

by nature superior to formula, which is much simpler. In fact, lists of known components

of breastmilk have been compared to the ingredients in formula as a way of promoting

breastfeeding. The logic is, why else would pluripotent stem cells be present in

breastmilk if they weren’t to aid in infant development, for example? Or, because there

are components with neurodevelopmental properties in breastmilk, of course breastfed

infants will have a cognitive advantage over formula fed infants, and of course

advantages can’t all be attributed to confounding variables.

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Narratives around research outcomes could reveal someone’s personal biases and

worldview. For example, one breastfeeding expert35 pointed out that there was a huge

outcry over a few points of IQ reduction from children exposed to lead when the nation

was discussing lead in Flint Michigan’s drinking water. It was said that this was going to

negatively affect the rest of the Flint children’s lives, and the public demanded that the

government do something about it. She noted that when studies showed that about the

same amount of IQ points were gained by infants who had been breastfed over formula

fed, critics were quick to proclaim that this was a small, inconsequential amount that

didn’t support the promotion of breastfeeding. There is a drop of four IQ points in lead

exposed children who have 10 micrograms of lead per deciliter of blood, and a seven

point reduction in those who have 30 micrograms of lead per deciliter of blood (Lanphear

et al. 2005). In Flint Michigan, the mean blood lead levels in children went from 1.19

micrograms per deciliter in 2014 to 1.3 in 2015 during the water crisis (Gomez et al.

2018). However, it was reported that 3.7 percent of the children had levels higher than 5

micrograms per deciliter (Gomez et al. 2018). Infants fed formula mixed with the tap

water were considered to be at the highest risk (Hanna-Attisha et al. 2016). A review of

studies found an IQ advantage in breastfed infants of 2-5 points in term infants and 8

points in low-birthweight infants (Drane and Logemann 2000). Regardless of whether

one can argue that these studies did not include a measure of how long women breastfed

for, that IQ tests are problematic biased measures, or that confounding variables could

35 Kathy Dettwyler, a biological anthropologist and breastfeeding researcher, made this argument about the Flint water crisis on her Facebook page, but later discontinued her account. Prior to the Flint water crisis she mentioned the issue of IQ points in relation to lead and breastfeeding in Beauty and the Breast (1995).

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account for the results, the fact remains that what we see in them and how we use science

reflects our concepts.

In another example, lactation consultants relayed to me that because of the

deadliness of NEC in infants, any number you came up with for a relative risk reduction

for NEC among breastfed infants made it worthwhile to breastfeed. This is different from

the views of critics who say that breastfeeding does confer benefits, but that those

benefits are not great enough to warrant its promotion.

While the critics of studies with positive breastfeeding outcomes point out their

weaknesses, they do not go so far as to proclaim that formula is just as good as breastmilk

for babies. Instead they focus their argument on the belief that the benefits of

breastfeeding are modest and are dismissive of some of the benefit claims. They use

scientific studies and arguments to counter what they see as a “moral fervor” over

breastfeeding they believe is damaging to women. Lactation consultants, on the other

hand, do not see the benefits of breastfeeding as modest, also wield science to make their

point, and believe that the fault for breastfeeding failures does not belong to women but

to structural factors. In this dissertation I have not set out to scrutinize breastfeeding

studies and enter the debate over whether or not the benefits justify the promotion of

breastfeeding, but have set out to understand why lactation consultants are in the category

of persons who would, for example, find the IQ points gained from breastfeeding

compelling and its ability to protect against NEC worth its promotion when some others

do not. In other words, I thought the more interesting questions to ask is why and how is

breastfeeding important to lactation consultants, and how do their concepts affect how

they help women with breastfeeding difficulties?

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The Anthropology of Science, Technology, and The Natural

The lactation consultants in this study based their confidence in breastmilk on

science, but also accepted the limitations of our science to fully know it. They thus

understood it to be imbued with mystery, resulting in feelings of awe and a sense of

breastfeeding being something removed from the ordinary. It is sometimes referred to as

miraculous or magical, and a lactation consultant who participated in this study referred

to it as having a power. The “power” of breastmilk is based in the fact that it is part of a

complex system and thus resists reductionism, and replication. This is what makes

breastmilk more than a food, and more than a medicine. There are foods and medicines

that sustain life, but breastfeeding is different because breastmilk is made up of living

substances that act as a whole system that can’t be untangled, and transforms and

responds in the moment to infant needs. Its complexity and dynamic properties make it

elusive to causal understandings. The answer to my question, why is breastfeeding

important to the lactation consultant, is ultimately epistemological. How do you know

things with emergent and relational properties? Breastfeeding is relational on various

levels. As I will show, it is learned socially; it is intimately one person dissolving her

body and feeding it to another; it facilitates bonds; it physiologically influences social

behavior; it is dynamic because it operates on an interconnected feedback system

between mother and baby, and breastmilk’s components act in concert with the

ecosystems of two bodies, blurring the boundaries between self and other.

The importance that lactation consultants put on understanding the science of

breastmilk and breastfeeding, and their descriptions of breastmilk as magical or

miraculous, are not incongruent. Their feelings of awe over breastfeeding are not the type

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of new age holism that says we are all interconnected, but a holism grounded in science

and that accomplishes with science this same notion of relationality. The awe they have

for what science unveils about breastfeeding and breastmilk is a kind of reverence that is

usually reserved for what we hold sacred, and has only grown as scientists have focused

on it more. Science unveils the mysterious, but it also generates it because as it unveils

one mystery it discovers another in the process (Lyotard 1984). The science of

development and immunology, of which breastfeeding is a component, reveals behaviors

reminiscent of vitalism in complex systems and microchimerism, both of which reveal

our interconnectedness and defy the notion of individuated, mechanical bodies in which

causation is evident.

Emily Martin (1994) bought attention to the ways in which immunological

descriptions have evolved to reflect complex systems theories. According to Martin,

immune system metaphors reflect cultural ideologies, which in the past reflected a desire

to defend self from non-self so that the immune system, like soldiers, was imagined as

defending our borders. She contended that globalization is reflected in new metaphors of

the immune system, in which bacteria and other microbes exist in a beneficial, symbiotic

relationship with humans. The science of complex systems describes such systems as

having qualities that also describe the breastfeeding immunological matrix:

“characterized by permanent novelty and incessant adaptation, dispersed multi-level

interactions, and the absence of a global controller,” as well as having emergent

properties (Dishaw and Litman 2019, 118). An emergent property is a property that

comes about as the result of a collective action but is not a property possessed by the

individual actors (Gilbert and Sarkar 2000). In complex systems, an emergent property is

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the result of the interactions of multiple actors in a complex relationship that limits our

ability to have knowledge of the system (Gilbert and Sarkar 2000). Emergent means that

something emerges from rather than is the result of a linear, causal/mechanical

explanation. Consciousness is a popular example. How does consciousness emerge from

the collective activities of neurons that don’t possess the property of consciousness

individually (Gilbert and Sarkar 2000)? One can ponder the emergence of life in this way

as well (Gilbert and Sarkar 2000). Emergent properties seem magically produced.

The idea of emergence is different from and yet can be thought of as similar to

vitalism. The difference is that vitalism supposes that there is a non-physical directing

principle within a living organism, like an energy, a soul, or chi (Gilbert and Sarkar

2000). Those who subscribe to emergentism reject a vital substance (Gilbert and Sarkar

2000), but the unknowable that causes the emergence of properties in a complex system

is similar to the mysteriousness of vital qualities. Donna Haraway (2004) saw the

development of organicism in the first half of the 20th century as a kind of answer to the

vitalism versus mechanism debate in developmental biology. To the organicist, the way

that physics and chemistry reduced nature to material with simple mechanical causes was

insufficient for explaining the complexities of developmental biology, most specifically

how the properties of determination and regulation in the embryo could be explained

(Haraway 2004). Both vitalism and organicism saw understanding the whole organism as

essential for understanding the behavior of its parts during development, as they

interacted with the whole (Haraway 2004). The structure of the interconnected whole

would reveal process in a move opposite from reductionistic atomism (Haraway 2004).

Haraway (2004) explains how organicism held onto vital-like qualities, saying, “…both

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organicists and vitalists stress the teleological behavior of organisms: there is at least the

appearance of goal-directedness and design in biological phenomena (34).” Yet she also

saw how organicists also embraced science as explanatory, saying that organicists

differed from vitalists in an important way:

Organicists declare that it will be possible to state positive, unambiguous, empirically grounded laws for all aspects of the behavior of organisms. Form and organization are not mysteries, but challenges. Nevertheless, Hein is correct in insisting strongly that essential elements of a very traditional dispute are retained in contemporary biology. (197)

Lactation consultants, similarly, saw breastfeeding as a dynamic, complex system that

had vital-like qualities that made it seem magical while at the same time adhering to the

idea that breastfeeding’s dynamic complexities exist as challenges for science rather than

magic per se. Thus, although currently unknowable to humans, there are complex but

causal explanations that for as long as they are unknowable to us behave mysteriously.

The microbiome is developed by and heavily influenced by breastmilk, as I will

discuss in more detail later (Harman and Wakeford 2017). For now, we can use the

microbiome as one example of vital-like behavior. The microbes in our guts change at

times, and these changes can seem to occur with no external factor causing them (Pepper

and Rosenfield 2012). Researchers have found that introducing the same kind of

disrupting element into the microbiomes of various subjects do not produce the same

results. As one study explains:

In the standard paradigm of simple causation, a system can not be understood until experiments can be replicated and repeatable results produced. Thus, it is perplexing that different individuals responded differently to the same experimental treatment of perturbing their gut microbiome. A key consequence of multistability is that different instances of the same type of system, such as different individual gut microbiomes, may show very different responses to the same perturbation. Even within the same individual, a repeated treatment

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sometimes produced a different response each time. (Pepper & Rosenfeld 2012, 4)

There are about a thousand different species of bacteria in our guts, creating a multitude

of possible variations that create complex relationships (Singer 2016). The fact that the

microbiome is unknowable via reductionist methods and has seemingly non-physical

properties in its resistance to empiricism, give it the qualities of vital causes or behavior.

The developmental biologists that Haraway (2004) wrote about who turned to

organicism, could not see a reductionist model explaining determinism and regulation of

the embryo. Breastmilk’s pluripotent stem cells regulate infant development, and it is also

thought that the hormones and RNA molecules that are in breastmilk also regulate infant

development (Power and Schulkin 2016). Importantly, it is thought that they act

dynamically so that changing circumstances bring about different types of developmental

signaling (Power and Schulkin 2016). These complex components of breastfeeding can’t

be reduced to simple cause and effect mechanisms. One can see from these examples that

references to breastmilk as miraculous, magical, or otherwise supernatural, can be fitting.

Yet emergent properties are the scientific answer to vitalism that allows one to

conceptualize about such properties without abandoning science (Gilbert and Sarkar

2000).

Anthropologists have studied scientific practice in labs, and they have studied

science as culture. Franklin (2002) defines “science as culture” (350) as understanding

what science’s “meanings and effects” (350) are, how it crosses cultures and is changed,

and how it affects and is affected by social factors. Rabinow (1992) and Strathern (1992)

introduced the idea that biotechnology has modified that which we have considered

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natural, and in the process has redefined the facts of life. In redefining the facts of life,

our definition of what is considered to be natural has changed. For Rabinow (1992), the

modifications he observed molecular biologists making was to genetic materials, in order

to be able to efficiently reproduce segments for use in medical experiments. Strathern’s

(1992) focus was how reproductive technologies have assisted conception, changed the

way life can be brought forth, and in turn have affected ideas of kinship and genealogy.

Rabinow (1992) stated that “…the object to be known – the human genome – will be

known in such a way that it can be changed.” (1992,7) Breastmilk cannot be fully known

in this way, not only because we still don’t know all of its components and what their

functions are, and how they interact as an ecosystem, but because it is a dynamic fluid

that changes in accordance to the needs of the infant, the mother’s environment, and the

behaviors of the mother and infant in relationship to each other (Raju 2011).

Biotechnology, in the case of breastmilk, has not succeeded in modifying it in

order to make it better, more useful, or in replicating it. Breastmilk has proven resistant to

the ability of scientists to extract its components and make them very useful, independent

of the whole ecosystem of the infant gut and in isolation from other components of

breastmilk (Bode et al. 2016; Newmark 2018; Ravindran 2015). Although infant formula

is an adequate product for infant nutrition and survival that contains some components

and functions of breastmilk, mainly nutritional, scientists have not been able to replicate

or improve upon breastmilk. Formula can never replicate or improve upon breastmilk

because you can’t extract individual components from breastmilk and expect them to act

in formula as they do when they are part of a microbiome that depends on interactions

with other microbes and biological factors to produce results (Newman 2018). It can

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never be replicated because formula cannot sense and respond to a virus an infant has

been exposed to and produce antibodies specific to that virus (Garbes 2015). It can’t be

replicated because formula does not come from a mother whose body is responsive to her

individual environment and produces particular hormones that send signals to the infant

through her milk to affect infant behavior and development (Hinde 2015; Power and

Schulkin 2016). The substance of formula is not based on complex relationships, and it

does not create relationships. Formula also does not transform parts of itself into infant

tissue the way breastmilk stem cells do (Aydin et al. 2018; Hassiotou et al. 2015), nor is it

one living body dissolving itself to form the body of another (Garbes 2015).

Thus, in the context of changing considerations of what is natural due to

biotechnical modifications, breastmilk becomes super-natural both because it represents

an enduring, unmodified “natural,” and because it has also been thought of and described

in supernatural ways. As a body fluid involved in life giving functions, it exists at the

threshold of life and death matters and is therefore a liminal substance that does not

remain contained within the body. In fact, it has been thought of as white blood by

lactation consultants, and in our historical imaginations. Like blood, it appeals to notions

of having vital properties and relationality.

How Breastmilk Has Been Conceptualized as White Blood

Breastmilk has been thought of by lactation consultants as a miraculous, healing,

body fluid. Symbolically, breastmilk has been called blood, a body fluid long considered

imbued with vital essence. Thinking of breastmilk as blood is a perfect way to understand

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the power it is imbued with. A popular lactation textbook describes breastmilk as white

blood while also grounding this idea in science:

Breastmilk is sometimes referred to as white blood, because it is considered similar to placental blood of intrauterine life. Indeed, human milk is similar to unstructured living tissue, such as blood, and is capable of transporting nutrients, affecting biochemical systems, enhancing immunity, and destroying pathogens. With the use of sophisticated laboratory techniques, many scientific investigators have substantiated the life-sustaining properties of breastmilk. (Riordan and Wambach 2010, 117)

A lactation consultant I interviewed who was discussing the Japanese style of breast

massage that she practices, not only described breastmilk as blood but touched on how

there is an aversion to the emergence of milk as there is to blood:

Sometimes I’m doing the [breast] massage and they are like “Ew, ew, ew, it’s spraying!” And I say “Well open the mouth” and they say “Ew, that’s gross!” [I say] “taste it, it’s your milk. ...How many times would you get cut and then suck the blood? Same thing. It probably tastes better than blood although it is the same kind of blood production you know.”

I also observed lactation consultants explain to breastfeeding mothers at times that their

milk is made from their blood. La Leche League’s book, The Womanly Art of

Breastfeeding (2010) even instructs mothers that “…since milk is made directly from

blood, ‘milk quality’ is no more suspect than ‘blood quality’” (225).

Breastmilk has been associated with blood for quite some time in Western history,

with the Greeks believing that breastmilk was blood made white by the addition of the

breath of life agitating it into a white froth (Alexandria 2016). Breastfeeding problems

were even treated in the same fashion as stagnant or excessive blood flow was. In 1909

the Journal of the American Medical Association published an article that recommended

cupping in order to get milk to flow from lactating breasts, and as a treatment for mastitis

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and retracted nipples (Stein 1909). Cupping is a form of bloodletting and has been

practiced in much of the world (Carter 2017). Dry cupping involves applying heat to

glass cups in order to create a vacuum, placing the cups on the skin, and waiting for the

blood to collect just beneath the skin (Appel and Davis 2019). Wet cupping goes a step

further. The practitioner removes the cups, makes cuts in the purple skin where the blood

has collected, reapplies the cups, and allows the vacuum created to draw the blood out of

the body and into the cup (Appel and Davis 2019). When applied to lactating breasts,

cuts were not made in the skin because what was to be released by cupping was milk, and

that would be released through the nipple pores (Appel and Davis 2019).

The use of bloodletting techniques for lactation issues was so prominent that the

first breast pump to be patented in 1834 was a cupping device (Appel and Davis 2019).

Illustrated designs for glass cupping devices to suction milk from the breast date back to

the 18th century, although the Wellcome Historical Medical Museum has a few actual

cupping pumps purportedly made centuries earlier than this (Appel and Davis 2019).

Varieties of cupping tools that were invented to remove milk from the breasts included a

glass cup that had a long pipe-like mouthpiece that the mother sucked on to create the

suction herself, without the application of heat (Appel and Davis 2019). Some had a

piston attached to the cup that was much like a hypodermic needle and created a vacuum

when pulled upon (Appel and Davis 2019). In 1872, after vulcanized rubber was

invented, suction was created in a horn shaped glass cup by squeezing a rubber bulb

attached to the end (United States Patent Office 1874). A lactation consultant who

participated in this research collected antique breastfeeding devices and showed me one

of these early rubber bulb cupping pumps. It resembled a bicycle horn, but with a small

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pocket in the glass for collecting the milk. Leeches were sometimes used on the breasts

instead of cups to relieve milk congestion or to drain abscessed breasts of milk and pus

(Appel and Davis 2019). If a leech was reluctant to bite when used for any type of

medical problem, it would be enticed to do so with either a drop of blood or milk on the

area where the physician wanted the bloodletting to occur (Appel and Davis 2019). Even

leeches did not discriminate between the two substances.

Today technology enables infants to survive at earlier and earlier points of

gestation, and mother’s milk is valued the most when it helps sustain the life of infants

who are literally on the edge of life and death. Milk banks, like blood banks, have been

primarily used for the survival of the sickest and most premature infants (Huggins 2017).

The discourse around the power of milk is most evident in cases of infants with NEC,

which is one of the leading causes of death in premature infants, affecting around 5% of

them (Zani and Pierro 2015). NEC has a 30-50% mortality rate (Zani and Pierro 2015).

Infants acquire it after birth, when its characteristics - distended abdomen, vomiting, and

bloody stool - show up (Zani and Pierro 2015). These are symptoms of damaged and

necrotic areas of the intestines (Zani and Pierro 2015). The lactation consultants involved

in this study believed that infants in neonatal intensive care units should have access to

breastmilk, and that hospitals should provide donor breastmilk from a milk bank in cases

where mothers couldn’t produce enough or didn’t want to breastfeed. This was in part

because of the deadliness of NEC and breastmilk’s success at preventing it.

The Miracle Milk Stroll is a national event that is sponsored by The NEC Society

and other organizations, with the objective of bringing awareness to the benefits of donor

breastmilk for NEC prevention. The stroll consists of breastmilk advocates walking down

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city streets together once a year while wearing “Miracle Milk” shirts. Their website36

states that breastmilk reduces the incidence of NEC by 79%, and their aim is to get the

60% of NICUs that don’t use donor breastmilk to do so. Not only do they describe

breastmilk as a “miracle,” but they also call it “extra-ordinary” and state that many

NICUs and insurance companies don’t recognize the “LIFE SAVING POWER of donor

milk” (emphasis not mine). The website also makes a connection between lifesaving

human milk donations and blood banks:

Donor milk suitable for use in the NICU comes from milk banks and is screened, tested and processed rigorously, just like donor blood. In fact, at least two blood banks (one in the U.S., one in Canada) are considering opening milk banks to meet the needs of NICU babies.

Thus, the use of donor milk from a milk bank carries the same ethical considerations as

donating and using blood from a blood bank and there are enough similarities between

the two fluids that blood banks are considering processing milk in addition to blood.

According to the Healthy Children Project’s The Lactation Counselor Certificate

Training Program Course Manual (Cadwell and Turner-Maffei 2012), donor milk from

milk banks is only available by doctor’s prescription and for certain problems such as

failure to thrive, feeding intolerance, or damaged tissues or organ systems. They state that

sometimes milk banks will also allow their milk to go to mothers whose babies are

healthy but have been adopted, if the mother has a rare biological reason for insufficient

milk production, or if she has died (Caldwell and Turner-Maffei 2012). If the milk bank

has enough milk on hand, they will occasionally allow adults to get breastmilk with a

prescription if they are using it to treat certain conditions (Caldwell and Turner-Maffei

36 http://www.miraclemilk.org accessed in 2016.

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2012). The list of medical or therapeutic uses of donor human milk listed by the

organization is long: “Treatment for infectious diseases, post-surgical healing,

immunodeficiency diseases, inborn errors of metabolism, solid organ transplants, non-

infectious intestinal disorders, burn therapies, adjunct cancer therapy, prevention of

necrotizing enterocolitis, feeding intolerance, crohn’s disease, colitis, and use during

immune suppression therapy” (Caldwell and Turner-Maffei 2012,125-126).

One of the issues with getting hospitals and insurance companies to go along with

making donor milk available in the NICU is that it costs more than formula, although it

may save money if it reduces incidents of NEC and all the surgeries that are usually

required with it (Buckle and Taylor 2017). One of the lactation consultants in this study

was so passionate about the use of breastmilk as a NEC preventative, that she specifically

took me to the NICU to see what she called the worst case of NEC she’s ever seen. She

wanted me to understand what was at stake by seeing it for myself.

The NICU had two barriers that kept people from automatically entering in

recognition that the infants inside were medically fragile and in need of special

consideration. The first was a set of double doors with a camera mounted outside and an

intercom system in which you had to press a button, state why you wanted entry, and then

waited to be buzzed in. The second barrier was just beyond these doors and consisted of a

stainless-steel washbasin, antibacterial soap, and scrub brushes with instructions for all

who entered to scrub their hands thoroughly for the sake of protecting the infants, who

were just inside yet another set of double doors.

On this day the lactation consultant told me with a tone of quiet seriousness that I

should be sure to thoroughly use the provided disinfectant before visiting the infant with

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NEC, since the death rate for these infants is so high, and because this one had an open

wound. The infant was lying still and sedated with a hole cut into her abdomen so that the

intestines could protrude. They were suspended outside of the body in a “silo” bag type

of contraption, through which you could see the blackened, dead areas of the intestine

here and there. The lactation consultant told me that the surgeon had worked out how to

keep her intestines suspended and that they would be doing surgery on the infant soon to

cut out the necrotic areas. She was upset by the fact that the mother had stopped pumping

her milk and there was no donor milk for this infant. Given the severity of the NEC, she

feared the infant wouldn’t make it.

The moment was poignant. I had been in an anatomy lab and had seen dead

bodies, body parts, and even dead fetuses with their chests cut open and their insides

exposed, which I had responded to with a sense of wonderment. There had been no glee

like I had experienced observing life bloom in the fertilization of a mouse egg in a petri

dish, but rather a respectful but excited curiosity. To see a live infant with dead bits of

intestine protruding from her body was a different emotional experience altogether; it was

an arousal of horror at the lack of a bounded living body, and empathy for imagined

infant pain and parental sorrow, as well as the concern that I had absorbed from the

lactation consultant. I understood how she could feel so strongly about infants receiving

breastmilk. This baby needed the miracle that breastmilk could provide. Given the fragile

state of this infant’s life, I was reminded of Malinowski’s (1954) view that magic is

resorted to when there is danger and uncertainty. Breastmilk was thought of by the

lactation consultant as miraculous in its ability to protect infants from NEC, and like

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blood, the lifesaving substance that a milk bank should have been providing under the

circumstances.

‘Purity and Danger’

Prior to Mary Douglas, it was often thought that rules about what types of foods

are clean or unclean, or what can or cannot be eaten, were created to keep us from

ingesting things that are unhealthy or harmful (Douglas 1966). Douglas, however, felt

that this explanation did not suffice to explain many categories of unclean foods (Douglas

1966). Instead, she came up with a more plausible explanation by turning to the idea of

schemata from the field of cognitive psychology (Douglas 1966). The concept of

schemata explains how humans organize information into categories based upon patterns

and relationships between items (Douglas 1966). Schemata are used to process and

identify what we perceive (Douglas 1966). It is an active process of evaluating what is

experienced against existing schemata to see if there is a match (Douglas 1966). Items

that are ambiguous, however, create difficulties for us in categorization and in deciding

our appropriate behavioral responses (Douglas 1966).

Douglas’ (1966) work examined how we symbolically assign these ambiguities.

According to her book Purity and Danger: An analysis of the concepts of pollution and

taboo (1966), “There are several ways of treating anomalies. Negatively, we can ignore,

just not perceive them, or perceiving, we can condemn. Positively we can deliberately

confront the anomaly and try to create a new pattern of reality in which it has a place”

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(29). Thus, we can either classify an ambiguity as a pollutant, or we can transform its

status into something sacred (Douglas 1966). Douglas noted that the root of the word

“holiness” means “set apart” (51). She also mentions that the sacred is that which is

subject to restrictions (Douglas 1966). The term sacred is used here in the context of

breastmilk and breastfeeding to say that they are morally elevated and set apart from the

everyday, rather than to necessarily suggest that they are religious symbols. Restrictions

placed on them are meant to either protect what is sacred from that which is not, or to

protect what is not sacred from that which is (Douglas 1966).

Douglas (1966) considers anomalies, or any item that transgresses boundaries,

“matter out of place” (36). She describes body fluids, including milk, as symbolically

potent when they are matter out of place, and they are out of place when they are no

longer inside of the body (Douglas 1966). Typically, the ingestion of body fluids causes

revulsion because it is considered polluting: “Anything issuing from the body is never to

be readmitted, but strictly avoided. The most dangerous pollution is for anything which

has once emerged gaining re-entry” (Douglas 1966:124). This explains why people

generally react to the ingestion of breastmilk by adults with disgust; here it is restricted in

order to protect the adult. Infants are the intended recipients of breastmilk, however, so

the response is different.

By making the anomaly pure or impure, you reduce the ambiguity and put

boundaries around it to control it. This brings about social order, which is needed because

ambiguities can dangerously create questions about the social rules (Douglas 1966).

Douglas (1966) points out that “food is not dirty in itself, but it is dirty to leave cooking

utensils in the bedroom, or food bespattered on clothing” (37). The context is thus

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important. Perhaps this is why body builders who wish to purchase breastmilk must

communicate the context in which they wish to ingest the milk in order for the

transaction to be legitimated. Many of them are quick to say that they are not perverts and

wish to purchase breastmilk for nutritional, muscle growing purposes only. They may

also include personal information in an attempt to draw the reader away from ideas that

they might have a sexual nursing fetish and thus want to hide their identity in order to

escape shame or rejection.

If breastmilk is thought of as a product to grow the body as the body builders see

it, or if it is thought of as a miraculous healing substance, it will not be taboo or revolting,

but only if others agree with its categorization. Thus, the lactation consultant secretly

dosed sick people with breastmilk because even though she views it as a miraculous

healing substance, the receivers may still view it as a pollutant. She also felt comfortable

with the knowledge that she had no diseases that could be transferred through her milk in

a way that another person may not. The lactation consultants with whom I discussed the

practice of online breastmilk exchanges, however, reacted with disapproval because the

unpasteurized milk of a stranger was a possible hazard that could harbor contagions.

Additionally, because they thought of it as more than a nutritious food, they believed that

the proper use of that milk was for it to be donated to a milk bank where it would be

pasteurized and given to babies in need. In other words, they did not deny that outside of

its potential to deliver pathogens, breastmilk might be useful for the body builder, but its

use as a healing substance was elevated above its use as a nutritional supplement. These

examples show how breastmilk is difficult to categorize and can be both a dangerous

substance and a force for good.

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The ambiguous nature of breastmilk extends beyond the discussion of it as either

a nutritional food, a healing substance, or a carrier of contagions. Breastfeeding is highly

regarded, yet at odds with the cultural values of consumption and autonomy; it is thought

of as both ethical and obscene; it is biological, but socially and culturally learned and

enacted; it is both natural and mechanical; is something that only women can provide, yet

confronts a resistance to biological determinism; is considered a choice, but has required

activism and laws to enable women to make the choice; and it is often either

romanticized or a negative experience37. Douglas is informative here when she said, “The

final paradox of the search for purity is that it is an attempt to force experience into

logical categories of non-contradiction” (163).

The sacred status of breastmilk is reflected in its categorization as white blood. It

is liminal in ways that blood is considered liminal. Blood is an intermediary between the

material and spiritual realms, and as such has a long history of being thought of as a

conduit for vital essence. Leviticus 17:11 says, “The life of the flesh is in the blood.”

Blood sacrifices have been practiced in numerous cultures as a gift to the gods and as

forms of divine communication (van Baal 1976). Gladiator blood was administered as a

magical remedy for epileptics in ancient Rome and for gaining strength (Temkin 1994).

During the Renaissance, Marsilio Ficino wrote books on medicine and magic that

recommended both drinking milk from a young girl’s breasts and sucking blood from

young people as a cure for aging because of the vital essence they contained (Calenza

2006). The Eucharist is the Christian version of a blood sacrifice in which salvation is

accomplished and those who are saved have consumed the blood and body of Christ (Jay

37 Joan Wolf (2011) mentions that breastfeeding is laden with contradictions, but she expresses this as the differing feminist stances on breastfeeding as either liberating or gender role essentializing.

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1992). Various cultures have used menstrual blood as a creative power in fertility rituals,

and even where menstrual blood is understood to be a pollutant, it is thought to be a

powerful force, often holding dual status as both polluting and purifying (Buckley and

Gottlieb 1988). Bloodletting was practiced in many cultures as a form of healing to move

or remove stagnant blood or to create a balance in the humors of the body (Carter 2017).

Even today, the existence of blood banks and blood drives place a moral obligation on

individuals to donate their blood in order to save lives. It is this status as the liminal fluid

in which vital essence resides, that sets blood apart and gives it the potential to be sacred.

Given breastmilk’s status as white blood, there are numerous examples of its

consideration as a sacred substance and carrier of vital essence as well. Some of these

examples are ways in which breastmilk is a religious symbol, and although much of this

is historical, there are some examples that relate to it as a potent religious symbol still

today. There is a cave in Bethlehem, for example, where it is believed that Mary and

Joseph hid with the baby Jesus while fleeing from King Herod. Jesus is said to have

breastfed in the cave, and it is believed that in the process Mary’s milk dripped onto the

red rock, miraculously causing the entire cave to turn white (Young 2011). Infertile

couples from all over the world go there to ingest the white dust while praying the third

joyful mystery of the rosary (Young 2011). This is to be done for nine days with the

belief that the miracle of the milk will cause them to conceive (Young 2011). Some

women come in the hopes that the white powder will increase the amount of milk that

they have for their babies (Young 2011). The cave contains hundreds of testimonies in

the form of pictures and letters from those who claim their infertility was cured here

(Young 2011). Stories of the healing power of Mary’s milk were especially prevalent in

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the 12th century (Maillet 2017), but the Milk Grotto is one example of how this idea has

continued to this day.

In some earlier cases Mary’s milk has been considered symbolically similar to the

blood of Christ (Bynum 1988). For example, a painting made in Florence around 1400

titled The Intercession of Christ and the Virgin, depicts Jesus and Mary interceding with

God on behalf of eight figures kneeling between them (Rancour-Laferriere 2017). Christ

holds out a bloodied hand and points to the wound in his side with the other and says

“My Father, let those be saved for whom you wished me to suffer the Passion.” Mary

holds her breast in one hand and points to the people with her other and says “Dearest

son, because of the milk that I gave you, have mercy on them” (Rancour-Laferriere 2017,

269). Mary, like all mothers and like Christ, sacrifices the self and suffers for others

(Bynum 1988). In fact, because during the medieval period it was believed that

breastmilk was processed blood, breastfeeding mothers were lovingly shedding their

blood to nourish their infants (Bynum 1988). Another medieval painting, Quirizio da

Murano’s The Savior, shows a feminine looking Jesus with the blood of the Eucharist

coming from his breast (Bynum 1988). St. Catherine of Siene saw visions of herself

“drinking blood from the breast of mother Jesus” (Bynum 1988, 271). It is claimed that

the Apostle Paul and Saint Catherine of Alexandria both spurted milk instead of blood

when beheaded, and St. Victor bled both substances (Valenze and Valenze 2011).

Clement of Alexandria, a Greek who was a Christian convert born in 150 AD,

described how every mother’s milk is imbued with the spirit because it is a white blood:

For the blood is found to be an original product in man, and some have consequently ventured to call it the substance of the soul. For whether it be the blood supplied to the foetus, and sent through the navel of the mother, or whether it be the menses themselves shut out from their proper passage, and by a natural

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diffusion, bidden by the all-nourishing and creating God to proceed to the already swelling breasts, and by the heat of the spirit transmuted, [whether it be the one or the other] that is formed into food desirable for the babe, that which is changed is the blood. …the blood from the veins in the vicinity of the breasts, which have been opened in pregnancy, is poured into the natural hollows of the breasts, and the spirit is discharged from the neighboring arteries being mixed with it, the substance of the blood, still remaining pure, it becomes white by being agitated like a wave; …. the blood is converted into that very bright and white substance by breath! (St. Clement 1867, 140-141)

Being Greek, Clement shared the classical Greek view that the breath of life (pneuma) is

in the blood, and pneuma provides heat (Kuriyama 2002). This is evident because those

who are dead are without breath, and their bodies are cold (Kuriyama 2002). Breastmilk

is thus blood, which the Greeks believed was carried by the veins (Kuriyama 2002). It is

turned white from the foam that is created when pneuma, which is carried in the arteries,

mixes with it (Kuriyama 2002).

This idea, although belonging to a different time period, is not so different from

the words of lactation consultants who explained to women who were part of this

research that milk is made from your blood. Indeed, the secretory cells in the breasts

extract components from the blood and turn them into milk (Riordan and Wambach

2010). Breastmilk is like blood in another way as well, in that it creates bonding and

kinship.

The External Womb and the Making of a Biosocial Being

Lactation consultants frequently talk about the importance of “kangaroo care” for

premature infants, a metaphor which speaks to the protection and skin to skin contact that

the immature newborn has in its mother’s pouch where it completes its development in a

kind of external womb. One lactation consultant used the term “cocoon” to describe the

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protected space she wanted to create not only for the infant or even just a premature

infant, but for each mother and infant together. Hers was an image of mutual

transformation of two beings who needed protection as they learned how to breastfeed

without outside interruptions. I didn’t hear the term cocoon used by anyone else, but the

lactation consultants in this study had described this same desire to create such protected

spaces for all breastfeeding infants and mothers, where contact was so close it was skin to

skin, and medicalization did not intrude.

The kangaroo pouch, unlike the cocoon, is relational because it is an external

womb that is part of the mother’s body. However, it creates the idea that the mother is the

protective space and that she herself is not in need of such space. Kangaroo care is

considered most important for premature infants who are less stable, but is also

considered beneficial to term infants, although in the latter case it is usually only

described as skin-to-skin contact. In talking about the cocoon as a type of external womb

I hope to relate what the lactation consultant meant when she said, “I would love just for

moms and babies to just be able to, after they give birth, go into this little cocoon and

hibernate for a while.” The cocoon was thus a protective space for two which would be

like a hibernation, meaning breastfeeding wouldn’t be rushed because it could unfold

over time for both the mother and the baby without interference or interruption. It also

represented interembodied transformation. It was relational because it bonded the mother

and the infant, and for bonding to occur it required getting to know one another in a way

that enabled a neuro-physical dance that created entrainment and homeostasis.

In my training I learned that when held skin-to-skin, the infant’s heart rate

synchronizes with the mother’s (Van Puyvelde et al. 2015) and their temperature is

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regulated and stabilizes (Moore et al. 2012). Respiration and blood sugar levels are also

regulated (Moore et al. 2012). A chapter in a lactation textbook (Bergman 2017) quotes

Gallagher (1992) describing the “private” sensory space that is necessary for a mother

and infant to accomplish the neuro-physical dance:

The mere presence of the mother not only ensures the infant’s well-being, but also creates a kind of invisible hothouse in which the infant’s development can unfold. This is a private realm of sensory stimulation constructed by the mother and infant from numberless exchanges of subtle clues. For a baby the environment is the mother. What seems to be a single physiological function, such as grooming or nursing, is actually a kind of umbrella that covers stimuli of touch, balance, smell, hearing and vision, each with a specific effect on the infant. Through “hidden maternal regulators” a mother precisely controls every element of her infant’s physiology, from its heart rate to its release of hormones, from its appetite to the intensity of its activity. (57)

Breastfeeding is not usually examined by researchers of bonding (Lawrence and

Lawrence 2011), however, a review of bonding studies that do study it indicates that

breastfeeding mothers interact more with their infants and have more affectionate

responses than bottle feeding mothers (Johnson 2013). The review supports the theory

that bonding requires responsiveness, which develops from synchrony between the

mother and infant (Johnson 2013). Feldman (2007) defines maternal-infant synchrony as

a process that starts with the fetus and ends with weaning. It is described as “an

overarching process that coordinates the ongoing exchanges of sensory, hormonal, and

physiological stimuli between parent and child during social interactions, providing

critical inputs for growth and development of the young” (Feldman 2007, 340). The

lactation consultants in this study believed that breastfeeding relied upon synchrony in

which the mother was attentive to and understood infant cues and infants responded to

the mother’s biological rhythms as they breastfed and were skin to skin. They spoke of

breastfeeding without outside interruptions as facilitating an “organized state” in the

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infant, which meant that physiological functions such as sensory input, autonomic

systems regulation, and hormonal mechanisms would be integrated with behaviors that

made breastfeeding possible. The ideal external womb environment for the mother and

newborn would be free from medicalized influences that would disrupt the development

of synchrony.

The Magical Hour:

Once, while doing rounds at the hospital with a lactation consultant, I asked why

the remodeling of the NICU included private rooms and showers but no bed for parents

to sleep on in order to stay overnight with their infants. The lactation consultant spoke

with great passion about how upset she was about this turn of events. Apparently, the

remodeling was supposed to allow for overnight stays but at the last minute the plan was

changed. When I asked her why, she said that she believed the staff did not want to be

bothered with parents. Parents disturbed their routines and their system. This lactation

consultant, and all of the ones that I spent time with, promoted the benefits of kangaroo

care for premature infants. They said that premature infants who have kangaroo care have

been shown to do better all-around and are often discharged earlier than premature babies

who don’t get skin-to-skin time. Allowing parents to stay in the NICU as much as

possible, would allow babies to get maximum skin-to-skin time and more attempts at

breastfeeding.

The Lactation consultants considered skin-to-skin time important for all babies,

especially in the hour or so directly following birth. One of the lactation consultants who

mentored me made sure that I observed a normal hospital birth with a nurse midwife in

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attendance so that I could see immediate skin-to-skin contact put into action. At the

lactation class that I attended, the IBCLCs who facilitated the class promoted a post-birth

skin-to-skin hour, saying it has been shown to result in better latches, increases the

number of infants who end up being exclusively breastfed, results in women

breastfeeding for a longer period of time, improves infant sleep, helps with bonding and

milk production and where practiced had even halved the rate of infant abandonment.

The facilitators brought a video with them that we could purchase called The Magical

Hour (Brimdyr 2011), which went over 9 sequential behaviors that all infants enact when

they are placed skin to skin, prone, on top of their mother directly after birth. Because all

infants have been shown to enact these 9 behaviors in the first hour or two after birth,

they have been considered evolutionary mechanisms that result in self-attachment at the

breast (Moore et al. 2012). It is believed that the couple of hours after birth “may

represent a psychophysiologically ‘sensitive period’ for programming future physiology

behavior” (Moore et al. 2012, 1). Infants who received drugs via a medicated birth,

however, had difficulty with self-attachment during the magical hour and often failed to

latch on (Lawrence and Lawrence 2011).

The experience of the infant during the “magical hour” is described as highly

sensory. The baby, we were told, could hear their mother’s breath, heart rate, and voice;

could feel her touch and her chest rise and fall; and could smell their way to the breast.

They would actually crawl up to the nipple and latch on and suckle, being attracted to it

because it smelled like amniotic fluid. This is the type of sensory experience that infants

in the NICU are often deprived of without kangaroo care. In fact, they are often subjected

to artificial warmth, the stress of tubes inserted into their bodies, electrodes stuck to their

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skin, and a noisy, disruptive environment, with very little touch outside of diaper

changing and painful or stressful procedures. The lactation consultants felt that

disruptions had real life consequences that not only affected infants, but made mothers

anxious, frustrated, exhausted, caused them unnecessary pain, and interfered with

bonding with their infants.

Lactation consultants understood skin-to-skin contact as important for another

important reason: placing the baby directly on the mother in the “magical hour” after

birth allowed the infant to be colonized by the bacteria on her skin rather than the bacteria

in the hospital room or from a nurse or doctor. This concept requires an explanation of

what the microbiome is and does, in order to understand how bacteria connect to how

lactation consultants think about breastmilk and bonding.

The human microbiome is the collective of all the microorganisms that live on

and inside your body (Harman and Wakeford 2017). Even though it consists of fungi,

viruses, archaea, and protozoa, it is mainly made up of bacteria (Harman and Wakeford

2017). We have way more bacteria cells than human cells in our bodies (Turney 2015).

Although it is hard to come up with an exact figure, it is often said that we have 100

trillion bacteria cells in our bodies compared to 10 trillion human cells, but individuals

differ and we could have as many as 400 trillion bacterial cells living in us (Turney 2015,

6-7). In addition to this, the microbes in our bodies contain one hundred times more

genes than we have in our own cells (Turney 2015, 6-7). The largest number of microbes

in the body are found in the gut (Turney 2015, 91). It is the bacteria in the gut that direct

the development of the immune system, and this is where breastmilk becomes important

(Turney 2015).

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I read about the microbiome in the “green book” while sitting in the lactation

office at the hospital after a discussion with a lactation consultant on the topic of

protective bacteria. My lactation consultant informants coveted “the green book,” which

was Ruth Lawrence’s Breastfeeding, A Guide for the Medical Professional (2011). The

book was a reference guide that contained the results of all the latest studies concerning

breastfeeding and lactation. During my mentorship, if I had a complex question or a

question dealing with scientific studies, they would tell me to go get “the green book”

and look up what it had to say. The lactation consultants referred to it often. The next

edition stressed that the microbiome had a much larger influence on the infant immune

system and was a far more important factor in their health than the antibodies that

everyone talks about being present in breastmilk (Lawrence and Lawrence 2015).

I also learned about beneficial bacteria and the development of the gut directly

from my lactation consultants mentors. One of them told me that breastfeeding activates

the parasympathetic nervous system, which is involuntary, slows the heart rate, increases

intestinal and glandular activity, and relaxes the sphincter muscles of the infant. This

means that suckling and the gut are connected. Another lactation consultant taught me

that premature infants are an exception to the idea that pacifiers shouldn’t be used until

breastfeeding is well established. This is because their digestive system is very immature

and the act of sucking actually helps it to mature, once again reinforcing the ways that

breastfeeding can impact the development of the gut. Two lactation consultants took this

idea of the breastfeeding and gut connection further, however, by stressing to me in my

training that the gut is the “second brain.” What happens in the gut, they explained, was

essential to the health of the entire body, and this was tied up in the action of

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breastfeeding and the microbial components of breastmilk. Yet another lactation

consultant discussed her befuddlement over a doctor’s comment that infant formula

would give beneficial probiotics to infants as if he didn’t know that breastmilk was full of

probiotics and did a much better job of creating an appropriate infant microbiome than

anything added into formula. The importance of skin-to-skin contact between the infant

and their mother and father as a way to colonize the infant with their bacteria was also

something the lactation consultants shared with their patients.

The more technical explanation of the importance of a mother’s bacteria to infants

starts in the womb. Fetuses exist in a nearly sterile environment in the womb (Harman

and Wakeford 2017). With a vaginal birth, infants are bathed in their mother’s vaginal

bacteria (Harman and Wakeford 2017). This is the start of “seeding” the microbiome

(Harman and Wakeford 2017). Some of the vaginal bacteria end up in the infant’s gut

(Harman and Wakeford 2017). The bacteria that land there from the mother’s vagina are

facultative anaerobes that consume all the oxygen in the gut in order to prepare for the

obligate anaerobes found in breastmilk, which are bacteria that can only thrive in an

oxygen free environment (Harman and Wakeford 2017). This sequential seeding process

is important, because any disruption, such as a cesarean birth, can change what bacteria

ultimately populate the gut (Harman and Wakeford 2017). If the infant has been bathed in

vaginal bacteria, the gut environment is perfect for the bifidobacteria in breastmilk to

multiply so that harmful pathogens are unable to take hold there (Harman and Wakeford

2017). Oligosaccharides, which are sugars found in breastmilk, are there solely to feed

the good bacteria in the gut (Harman and Wakeford 2017).

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The initial bacteria that seed the infant gut via the mother’s vagina and breastmilk

teach the immune system what to allow in the body, so that if the wrong types of bacteria

take hold, the immune system may not function properly (Harman and Wakeford 2017).

Scientists have found that mice that are not properly seeded develop chronic diseases and

they believe that a poorly seeded microbiome may be responsible for much of our chronic

diseases and immune system disorders (Dietert 2016). Additionally, it is believed that the

infant’s immune system develops in stages, and there are windows that can be missed so

that trying to change the microbiome later by introducing particular elements will be

unsuccessful (Dietert 2016). For example, in one study researchers found that

Bacteroides fragilis had to be present in the guts of mice by 1 week of age in order to

prevent them from getting colitis (Dietert 2016). Subsequent introductions did not

prevent colitis because fragilis had missed its chance to suppress the proliferation of

invariant natural killer T cells, which were what made the mice susceptible to the disease

(Dietert 2016).

The focus on the microbiome has been a more recent occurrence as science is

starting to give attention to its significance. Formula companies started adding a couple

of probiotics to their formula and are experimenting with an oligosaccharide (Petherick

2015; Ravindran 2015, 2017). Lactation conferences have started offering sessions on

this topic, and it has become a hot subject for discussion online. New information on it is

coming out so frequently that one lactation consultant who talked to me about her interest

in how the mother’s microbiome affects the infant’s microbiome, said she still had a lot

more catching up to do on the subject. Other lactation consultants told me that a single

bottle of formula could substantially disrupt the microbiome in the infant gut. A lactation

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consultant who wrote a book about breastfeeding for clinicians wrote about this, stating

that if an infant was given one bottle of formula and then exclusively breastfed thereafter,

it would take 2-4 weeks for the gut to return to its previous state (Walker 2016, 18-19).

Thus, supplementing an infant with formula before the point in which the permeability of

the intestines decreases, should not be done without great consideration (Walker 2016).

The super-natural status of breastmilk is not just based on its inability to be

extracted, replicated, or improved upon, but on the ways that breastmilk makes what is

biological, social. Microbes and the hormone oxytocin are involved in our sociality and

breastfeeding plays a major role in this. A lactation consultant made me aware of a New

York Times article titled “Microbes, a Love Story” (Velasquez-Manoff 2017). It mentions

a study done by Susan Erdman, who is a microbiologist at M.I.T. Dr. Erdman connected

the development of mammals with microbes:

She suspects, in fact, that the mammalian innovations of birthing live young and feeding them milk secreted from what was, millions of years ago, a sweat gland (the proto breast) helped us gain tighter control over the microbes we pass from one generation to the next – to our benefit. And because oxytocin, the ‘love’ hormone unique to mammals, underlies so much of this behavior, and because microbes affect oxytocin levels, Dr. Erdman likes to say that “Microbes invented mammals.” (Velasquez-Manoff 2017)

The notion that microbes connect us to each other and the greater world, that they

help us to bond with one another, and may be responsible in an evolutionary sense for our

reproductive success (Velasquez-Manoff 2017), is key to understanding the social and

biological communion that is associated with breastfeeding. It also brings up

philosophical questions about what it means to be a person, and how breastfeeding

creates fuzzy boundaries between mother and infant while it creates a person embedded

in a sociocultural reality.

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Breastfeeding and Bonding:

Breastmilk is super-natural in how, like blood relations or bloodlines, it bonds us.

Even though Mary’s sacred milk is no longer emphasized to the extent that it was in

medieval times, many American mothers are familiar with images of the Madonna

nursing baby Jesus as the ideal vision of motherhood. Numerous paintings of the dyad

depict peaceful scenes of Jesus in Mary’s arms, often with Mary’s eyes lowered, gazing

lovingly at her son. The Madonna ideal is that of the special relationship between mother

and child that is enacted through the intimate act of giving your body to another in order

to sustain them, but there can be no question that because this is no ordinary child,

Mary’s maternal status is elevated. In fact, through Mary, motherhood itself is elevated.

In current American discourse mothers are important because they create a well-adjusted

human being through bonding. The special bond between a mother and her infant is

supposed to be facilitated or enhanced by breastfeeding, and if breastfeeding doesn’t go

as planned it is thought that bonding can be disrupted and ideal motherhood thwarted.

The hormone oxytocin was the most often discussed component of breastfeeding

that facilitated bonding by the lactation consultants in this study. Suckling causes the

body to release the hormone oxytocin, which causes contractions in the alveoli of the

breasts and pushes milk down from the duct to the nipple (Riordan and Wambach 2010).

Oxytocin is also the hormone responsible for uterine contractions, so that breastfeeding

encourages and quickens involution of the uterus, preventing hemorrhage (Riordan and

Wambach 2010). The hormone is best known, however, as encouraging sociality and

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attachment. A popular lactation textbook explains its relation to breastfeeding and

bonding thus:

When oxytocin was administered intranasally to humans, it played a key role in social attachment thus increasing the benefits from social interactions. It specifically affects a person’s willingness to accept social risks and causes a substantial increase in trust among humans. The mother-infant bond depends upon human trust. Studies using animals have confirmed the effects of oxytocin on the regulation of behavior. In pregnancy and postpartum oxytocin affects bonding and parenting behaviors. . . Results suggest that breastfeeding within 1 hour of birth, when oxytocin levels are high, causes long lasting enhancement of bonding and interactive behavior between mother and infant. . . Oxytocin levels were thought to be related to bonding behaviors [in mothers] such as gaze, vocalizations, and affectionate touch. (Lawrence and Lawrence 2015, 203)

Thus breastfeeding not only released oxytocin and facilitated bonding, but the higher

amount of oxytocin released in the immediate postpartum period was seen as critical to

helping moms bond with their infants. Breastfeeding within two hours after giving birth

while skin-to-skin and while the uterus was heavily contracting would ensure a high level

of oxytocin release and was encouraged.

Christine, a woman I met who saw two different lactation consultants on a regular

basis in order to make milk flow from her breasts, powerfully illustrates the idea that

breastfeeding facilitates bonding. Christine had been on the verge of death, having lost

half of her blood in childbirth while undergoing a c-section, necessitating a hysterectomy

and a blood transfusion. There was concern that the large loss of blood would impact her

ability to make breastmilk, a condition known as Sheehan’s Syndrome, which occurs

when excessive blood loss causes pituitary necrosis and subsequently a lack of prolactin,

the milk-producing hormone. The problem for her was not a lack of milk, however, but

the impact the blood loss and hysterectomy had on her ability to care for her infant. She

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expressed a profound sense of loss from not being able to bond with her baby under the

circumstances, and describes her postpartum state as an absence of self:

I think for me it’s just that I was checked out mentally. Mentally I was checked out. I couldn’t even care for myself let alone my little one. … I didn’t have too much pain, and I think part of it was I had meds, at the same time there comes a point where you are not there, that you don’t feel anything. You know, I didn’t eat for seven days. You know what I mean? They were trying to have me eat and you know, I drank stuff. So, like literally I went from like lots of milk to like probably nothing, you know what I mean, because I just was not producing at that time because I just wasn’t, I kind of wasn’t there. So when I got all of my faculties and I was able to then you know like bathe myself and didn’t need help, you know, she wouldn’t take to the [breast] nipple [because] she was so used to the bottle. And I was, I tried to do nipple shields [on my breast] and like pretend that it was a bottle. …And I just really felt like a really deep sense of loss because I didn’t get, you know obviously I lost, um, the ability to have children. So, compounded with that I’m like, I didn’t even take care of my first born and we didn’t get to breastfeed like how I had planned to, and now she’s rejecting me. And so there was a really big, um, really big sense of loss.

In this profound state of absence, Christine said she “was not producing” milk

because she “wasn’t there,” meaning she lost her milk supply due to the physiological

consequence of the lack of stimulation to her breasts. At the same time, what happened to

her was not just a loss of blood and milk, but a loss of self. This loss of self wasn’t

merely due to illness and the haze of medication, but from a loss of her maternal identity

facilitated by the removal of her uterus, and alienation from her infant. Years later, in an

effort to have that maternal experience, she asked a friend if she would be a surrogate

mother for her next child, with the hope that she could at least nurture that child at her

breast.

Prior to the surrogate birth, Christine started a pumping regimen. She didn’t hold

out hope that her non-pregnant body could produce sufficient amounts of milk to fully

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nourish the infant. Her main concern was that she would be able to put the baby to the

breast in order to establish a relationship with her. “My whole thing was I wanted the

bond. I wanted to experience that because I had missed out on it.” She put a lot of effort

into producing milk. A month before the baby was born she took various herbs and ate

foods, like oatmeal, that many women think increases their milk supply. She also pumped

her breasts with a hospital grade pump every 2 or 3 hours around the clock. When her

family went to Disney Land for vacation, she bought a portable pump with her and

pumped between the amusement park rides as well as on the airplane. Finally, on the day

of the infant’s birth, she saw the first signs of milk:

It’s literally your pumping and like nothing comes out. But, you know, you just go through it, and it’s just like a month into it there was nothing, then there’s like a tiny drop of something. And everybody at the hospital celebrated, they were like oh my goodness! And you know, it was pretty crazy. It was nuts.

The surrogate mother breastfed the baby, but also pumped her milk so that

Christine could have the chance to nurse her. Christine was able to do this by using a

device called a supplemental nursing system (SNS). The SNS looks like a bottle that is

worn around the neck like a necklace. It has two tubes that emerge from it and are taped

onto the mother’s nipples with medical tape. These tubes carry formula or pumped

breastmilk from the bottle to the mother’s nipples. When the infant suckles at the breast,

they are satisfied with the immediate release of milk from the tubes, while at the same

time providing the breast with the stimulation necessary for it to increase the amount of

milk produced. The surrogate’s pumped milk was placed in the SNS in order to stimulate

Christine’s breasts to make more milk. In this way, the infant received milk from both

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women simultaneously. In order to accomplish this Christine spent every day at the

surrogate’s house for the first couple of months.

Christine described the whole process as one that built relationships not just

between her and the baby, but between the two families:

When we went through the psych eval there was some concerns about how are you going to feel if you see her with your baby, and mixed emotions, and you know vice versa. We actually had no problems with any of that, I mean with any jealousy factor or just feeling bad, you know what I mean. It was a really nice transition. …I was hanging out with [the surrogate] while she was recovering and stuff, so it was a really good bonding process. And it was good for her kids too, like they understood how everything worked, and so we’re closer than we used to be…. It was this huge, like, extended family thing.

This experience was extremely rewarding for Christine. Through breastfeeding she was

able to feel maternal and bond with her baby without the struggle that she had bonding

with her first born. This bonding was accomplished even though she didn’t carry the baby

through pregnancy or give birth to her. It is worth noting that she didn’t bond right away

with her first child, even though she was able to experience pregnancy and labor with her;

breastfeeding was the missing factor. That bond took longer to develop. The embodied

experience of breastfeeding had allowed her to identify with the maternal experience and

thus not feel alienated from her infant. This shared milk experience had also allowed her

to bond to an even greater extent with the surrogate and her family so that they became

like one family.

The role of breastfeeding in bonding is not only based on neurobehavioral

mechanisms or physiological properties but is also symbolic of the way that body fluids

create relationships. This can be seen in the ways that we use the word “blood” to refer to

blood relations. Different cultures have expressed this idea through various types of milk

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bonds. Palmquist (2018) examined milksharing among mothers in the U.S., in which

breastmilk was shared with those who didn’t have the ability to make any or enough

breastmilk for their infants. Mothers who received shared milk spoke of the various

microbes their infants would be exposed to from various women, and how this would not

only help develop their infant’s immune system but would also build relationships.

Breastfeeding not only establishes bonds but can be considered a form of kinship

cannibalism. In cultures where cannibalism is practiced it often holds a dual status

depending upon the context in which it is practiced. Porter Poole (1983) described

cannibalism in a New Guinea tribe as either “an inhuman, ghoulish nightmare or as a

sacred moral duty” (31). Sanday (1986) notes that cannibalism that is done out of hunger

is condemned and treated with disgust with few exceptions. Thus, cannibalism may

generally be considered acceptable in situations where the ingestion of the substance is

transformed from something polluted. This goes along with Douglas’ claims that such

reclassification can occur as a remedy to things out of place by transforming them into

something sacred. Cannibalism is sacred and acceptable when it is done to commune with

the divine, to take the power of your enemy, or as a loving act of kiniship (Sugg 2008),

all of which are acts that maintain the social order.

Cannibalism in the form of the Eucharist, illustrates that what is substance and

what is symbolic are fluid, transformative categories. Through transubstantiation, bread

and wine, which are symbolic of the body and blood of Christ, transform into the actual

body and blood of Christ once ingested. Breastmilk can be both symbolically blood and

have actual physical properties of blood. With lactation, the body of the mother becomes

milk and the milk then transforms into the material substance of the body of the

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developing infant once it is ingested. Katie Hinde argues that this is a biological fact

(Garbes 2015), but it also serves to further the notion of breastmilk in its symbolic role as

the carrier of vital properties and as kinship maker. Breastfeeding is actually described as

a form of cannibalism by Hinde, who in trying to simplify the science of it to a journalist

stated, “In mammals, females dissolve parts of themselves to feed their babies” (Garbes

2015).

For Hinde, breastfeeding is a form of personal, biological communion, a concept

she explained with the example of a woman who is now a vegetarian but as a teenager

had eaten meat (Garbes 2015). That woman, she explained, would have fatty acids

specific to animal meat stored in her body that would get passed on to her infant in her

breastmilk (Garbes 2015). "You have information about your whole life span that could

be in your milk. Milk is telling the baby about the world its mother has lived in" (Garbes

2015). This prompted the journalist who interviewed her to state “I am moved by the idea

that, without words, I am telling my daughter about myself, my life” (Garbes 2015). This

description sounds strikingly like the practice of endocannibalism, which is a way of

carrying within you something of the life of a loved one (Vilaca 2000), except in

breastfeeding it involves life instead of death. Endocannibalism ensures that the loved

one’s essence or qualities become a part of the one who consumes them, so that in this

way they remain a part of their kin or tribe (Vilaca 2000).

While lactation consultants don’t think of breastfeeding as cannibalism per se,

there is no doubt that the act is seen as an intimate giving of one’s material self that

facilitates bonding. With negative breastfeeding experiences, however, this may not be

the case. Lactation consultants see women who are having problems with breastfeeding,

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and who thus experience it as less than a beautiful communion of bonding. Lactation

consultants are asked to help women who are having difficulties breastfeeding and who

may have different concepts about it than they do. How lactation consultants reconcile

this is informative.

Drained Mothers and Their Breastfeeding Vampires:

In my fieldwork I encountered women with fissured, excoriated, and bleeding

nipples who desperately sought out lactation consultants for relief. They were far from

the image of the serene Madonna. A woman I interviewed described such an experience

this way:

I remember it felt tender all the time and I was always, I was bleeding, and it was raw. I was really raw. … he was gaining weight. He was getting enough but I was struggling, and I was in a lot of pain. My mother, who was visiting, was telling me to stop because she saw my bloody breast and my raw nipples. …he was just chomping on my nipple.

Such examples of disrupted breastfeeding sometimes led mothers to turn to formula

because they said that the pain or the amount of pumping that they had to endure kept

them from appreciating or enjoying their baby. In other words, when breastfeeding was

disrupted, it wasn’t necessarily the suffering itself that caused mothers to stop, but the

fact that bonding was not occurring. In one of the more desperate cases I experienced, a

mother had decided to forgo her antidepressant medication because she feared it would

get into her breastmilk and negatively affect her baby. Without her medication she was

severely depressed. She pleaded with her mother and husband to stop trying to get her to

seek help from lactation consultants for the infant’s painful latches. She said that she

wanted to stop breastfeeding, but not because she couldn’t endure the pain or depression,

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but because both of these factors caused her to resent her baby and have horrible thoughts

about her.

Another mom described painful nursing and exhaustion that had caused her to

swear and yell at her baby:

I would rather give birth a hundred times again than breastfeed. I had a horrible start to breastfeeding. . . I know the first 8 weeks were hell. I pretty much was crying every day. I was to the point where I was swearing at him in pain. I was like, “Open your mouth!” I was yelling at him . . . He would take like an hour to nurse and then he might fall asleep for half an hour and then wake up screaming again. And I was like, “Oh my god this sucks!” . . . I was like, “I am going to die!” like, “What did I do? I just ruined my life!”

There was no bonding occurring between the mother and the infant because the mother

was depleted and so there was no reciprocity or synchrony occurring. This infant who

seemed to have insatiable hunger and caused his mother to exclaim that she was “going

to die,” and the baby who was gaining weight while his mother suffered, symbolically

exemplified the image of a parasitic breastfeeder. Insight can be gained by not only

examining the metaphor of the external womb that facilitates bonding and transformation,

but the opposite of a synchrony and its reciprocal benefit. At a lactation training that I

attended we were shown a slideshow of emaciated women from areas of famine or war-

torn regions who all held plump, healthy looking, breastfed infants. The instructors told

us that the idea that a woman has to eat well in order to produce enough milk is false, and

that the body will always provide for the infant, even if it takes from the mother’s reserve

stores. Women even breastfed in concentration camps, they said. Telling women to eat

well, we were told, is for her sake not the infant’s.

The parasitic breastfeeder is reflected in some vampire legends. If we consider

Douglas’ (1966) description of body fluids as matter out of place, and such matter as a

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representation of social disorder, vampirism is the perfect metaphor for pollution and

boundary transgressions that don’t get transformed into something sacred, but still

maintain the status of being powerful. There are European vampires who were said to

drink milk and/or blood from the breast (Dundes 1998). Even Bram Stoker’s (1897)

Dracula novel imagined Dracula’s victim Mina, suckling blood at the breast. Presumably

that is because the heart is in the vicinity of the breast, but the symbology of the image is

significant. The majority of vampire legends contain two repetitive threads, according to

Alan Dundes: the vampires tend to attack their family members, and they often suck milk

(1998). In fact, Dundes notes that German vampires sucked cows milk or breastmilk

more frequently than they suck blood (1998).

The most interesting example of a milk-sucking vampire is the doppelsauger

(German for “double sucker”), a vampire who was weaned from the breast as a child but

couldn’t stop nursing and returned to breastfeeding (Maberry and Kramer 2009). Once

that person died, they would experience insatiable hunger and would have to eat their

own breast in order to gain the power to claw their way out of the grave (Maberry and

Kramer 2009). After the revenant emerged from the grave, it attacked its family members

by suckling at their breasts (Mayberry and Kramer 2009). The insatiably hungry

doppelsauger was supposed to have successfully weaned in their human state and have

gained independence from their mother (Mayberry and Kramer 2009).

Breastfeeding vampires do not seem so strange when you consider the concerns

and advice given to mothers at the time. The Book of Household Management was

published in 1861 and was a bestseller in its time. A passage from the book describes the

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infant as a “vampire” who will deplete the mother if allowed to nurse at night via bed

sharing:

The evil we now allude to is that most injurious practice of letting the child suck after the mother has fallen asleep…. [As a consequence] the mother wakes in a state of clammy exhaustion, with giddiness, dimness of sight, nausea, loss of appetite, and a dull aching pain through the back and between the shoulders. In fact, she wakes languid and unrefreshed from her sleep, with febrile symptoms and hectic flushes, caused by her baby vampire, who while dragging from her health and strength, has excited in itself a set of symptoms directly opposite, but fraught with the same injurious consequences – functional derangement. (1034)

This example of the vampire infant depleting the mother and depriving her of sleep, is not

simply a nineteenth century concern, but one that still influences women today to stop

breastfeeding during the middle of the night. While I never heard a mother refer to her

infant as a vampire, sometimes mothers referred to their infant as a “barracuda” to

similarly reflect a foroceous appetite. Many women sought lactation consultation for a

low milk supply and upon questioning revealed that they had stopped or reduced night

nursing due to exhaustion, because they were returning to work and needed a good

night’s rest, or because the pediatrician recommended it out of sympathy for the depleted

mother. This practice was a substantial contributor to the number of women complaining

of a low milk supply since the amount of milk the body makes is dependent upon how

much stimulation is given to the breast, and also because the milk producing hormone,

prolactin, peaks during the middle of the night hours (Riordan and Wambach 2010).

Like The Book of Household Management (1861) suggests, many women I

encountered who had negative experiences of breastfeeding described it as associated

with the exhaustion they experienced from the amount of time they needed to give of

themselves physically to their infants. These overwhelmed women spoke of the stress and

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anxiety that this caused them. One woman described getting through the experience by

reminding herself she wouldn’t be breastfeeding forever:

Some days it was just difficult to have to stop what you are doing and you know, tend to him. …I guess with my first one I was thinking “When’s it gonna end? When’s it gonna end?” But when it ended, like everything was fine. So, with my second one, I kind of knew, okay, eventually it’s going to end. …I guess the most [challenging] was the time-consuming part. I didn’t pump, so I had to be the one to always wake up person, and that was just like 24 hours a day. That went on for days and days and days.

Another mom similarly described focusing on getting through one feeding at a time, but

because the pain was what was overwhelming:

The first week was rough. It was really painful. . . It was one of those things, ‘I’ve just got to do one more feeding. One more feeding. One more feeding. Let me just get through this day,’ or whatever.

A mother described the exhaustion and time involved with nursing a baby when she had a

low milk supply and how the pain she experienced was because the infant spent so much

time nursing:

I started supplementing [with formula] at 2 days old because she was crying. Constantly, constantly, constantly crying, and this was after hours of [breast] feeding. And I was in a lot of pain [from] the hematoma, and my nipples were sore too. They said [it was] because she was nursing so long. …I was nursing and then giving a bottle. But then of course it would be for 2 hours at a time that I would nurse and I felt like, 20 minutes later she’s going to start crying again because she’s hungry. …She was on me for two hours, so I would do 15, 15, 15, or 20, 20, 20. You know, keep switching her back and forth [between breasts] because you know they said [nurse] 15 minutes then take her off. But she was still, she was still, what do you call it? She was still looking for it. …So what the [lactation consultant] did was she gave me the nursing aid, and it was that bottle with tubes, and I had to supplement. …It was cumbersome. …It was tedious work when you have a screaming baby. It was just, it was hard work. …I guess I was frustrated a lot of the time. I thought it, I had the impression that it would come much more naturally than it did. It was a very natural birth, so I don’t know if [trouble breastfeeding] is normal. …It was kind of like a tidal wave. How do you tell a tidal wave, “Stop! This is where the evacuation line is so don’t come

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beyond this!” So, it was just kind of, it didn’t make sense to me and it was the source for a lot of heartburn, you know worry or anxiety. I just couldn’t help it.

When I asked the above mother about weaning her baby, she told me that her

daughter was no longer interested in breastfeeding at 6 months of age. She added, “I was

so relieved. I was so relieved when she did that because I was so exhausted.” Her analogy

of a tidal wave washing over the evacuation line implied the feeling of being consumed

by the overwhelming nature of a situation that seemed out of her control leaving her

without the ability to escape from it.

There was often a sense of ambivalence that was expressed by these mothers. For

example, a mom conveyed this ambivalence by talking positively about her decision to

breastfeed because of its benefits, but when it became overwhelming she quit night

nursing, dismissed her infant’s screaming, and disaffectionately called him “buddy”:

So at night I would let him breastfeed whenever he wanted just to kind of keep the milk [supply] up, but then I was just like, “Okay, I’m too tired, I’m giving up on this.” … [Giving it up was] helping both of us sleep more. But he screamed the first two nights though. It’s like, “Sorry buddy, mom’s done.”

The idea that was expressed by so many, that they thought breastfeeding was supposed to

be natural, was another way of saying that they expected it to be easy. Without enough

help and support these mothers had negative breastfeeding experiences in which the

status of being overwhelmed lived in their bodies as physical and mental suffering and

often caused a lack of bonding.

Women who stop middle of the night nursings sometimes have infants who will

sleep through the night without any effort on the parent’s part, but more often than not

they accomplish this feat by sleep training. Sleep training is the term used for getting

infants to sleep through the night by letting them “cry it out” thereby training them to

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give up on crying and go to sleep through the realization that the parent will not respond

to their cries. Sleep training requires that the infant be placed in a crib in a separate room

from the parents in order to be successful, although some more recent methods consist of

the parent checking in at intervals or more gradually leaving the room. Some

pediatricians are recommending that parents start sleep training as early as two months of

age because they believe that it is easier to accomplish when done at an early age.

The lactation consultants in this study adhered to attachment parenting

philosophy, which considers the “cry it out” method to be harmful to babies. In his book

about infant sleep, Dr. Sears (2008), arguably the father of attachment parenting

philosophy, tells about a couple who brought their sleep-trained 3-month-old to his

pediatric practice. They sleep trained their infant so that they could get better sleep and so

that the infant wouldn’t control them (Sears 2008). Sears explained that this was harmful

to the baby because not only was he not getting enough to eat, but the baby had shut

down, meaning he had given up trying to have his needs attended to (Sears 2008). The

move towards sleep and feeding schedules as a form of control over their overwhelming

and exhausting situation, was one form of response that mothers in this study adopted as

well. The Lactation consultants were concerned about bonding and agreed with Dr.

Sears’ assessment that “cry it out” sleep training can have profound effects on the infant’s

ability to trust and form an attachment with their caregiver (Sears 2008). Lactation

consultants who worked within the WIC program told me that they see a lot of low-

income mothers who have asked their husbands to feed the baby with a bottle at night so

that they can sleep. Their decision was spurred on by the fact that they don’t want the

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baby to be too dependent upon them because this would cause sleep interference. They

described to me what the mothers tell them:

Susan: Can’t let ‘em get too attached. We hear that. Jen: Oh no, yes, can’t let them get too attached. Susan: Or you’ll spoil them! It’s still out there, that idea.

These lactation consultants were not without sympathy to the depleted low-income

mother and spoke of the difficulties some of them experienced such as having to return to

work soon after giving birth or taking long bus rides to and from work that made

pumping schedules difficult. Bonding in the form of responsiveness and indulgence to a

dependent baby was harmful to the drained parent with multiple structural factors

creating socioeconomic stresses, and thus was not as available to her as it was to women

with more privilege. Like the other lactation consultants in this study, they did not

pressure women to breastfeed, respected women’s choices, and felt that the many barriers

that existed were what they needed to change in order to help women.

Sleep training is often done on the advice of medical authorities and childrearing

experts, who don’t consider the negative impact it can have on the milk supply of some

mothers, and who believe that co-sleeping is harmful to infants (McKenna et al. 2007).

Those experts who recommend sleep training agree with the notion that parents must

control infant sleep in order to ensure they, the parent, aren’t sleep deprived, despite co-

sleeping mothers reporting better quality sleep than solitary sleepers (McKenna et al.

2007). They do so while simultaneously not supporting safe co-sleeping that the lactation

consultants believed would improve the sleep of both the parents and the baby. For the

lactation consultants I spent time with, bonding is tied to unrestricted access to

breastfeeding, so that forcing a breastfed infant to sleep alone in a separate room and

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depriving the infant of breastmilk during that time, was misguided because of the cultural

emphasis on fostering independence instead of interdependence in infants. They also

believed it was due to doctors telling parents not to co-sleep with their infants rather than

telling them how to safely co-sleep. They believed that sleep training resulted in the

release of stress hormones in the infant and a sense of alienation.

Biological anthropologists who have studied infant and mother pairs in a sleep

lab, claim that biologically infants are not meant to sleep through the night even though

we can train them to do so (McKenna et al. 2007). They connect a lack of nighttime

arousals found in infants sleeping separate from a caregiver to SIDS (McKenna et al.

2007). The American Academy of Pediatrics (AAP) has stated that you shouldn’t bed

share with your baby because it is dangerous (American Academy of Pediatrics Task

Force on Sudden Infant Death Syndrome 2016). McKenna et al. (2007) points out that

mothers and infants have co-slept throughout history and still do in non-Western

countries. They further point out that most cases of infants dying due to co-sleeping can

be connected to a parent who was under the influence, a mother who smoked, or sleeping

on an unsafe sleep surface like a sofa (McKenna et al. 2007). They disagree with the

AAPs (2016) blanket statement that no one should co-sleep with their infant and thinks

pediatricians should tell parents how to do it safely (McKenna et al. 2007).38

Many of the lactation consultants in my research discussed having co-slept with

their own infants and having determined that it allowed them to sleep better at night.

38 Tomori’s (2015) research on the moral dilemmas of breastsleeping points to the no-win situation that mothers end up in. They feel stigmatized if they don’t breastfeed or struggle to breastfeed, yet if they put the baby in bed with them in order to be able to breastfeed and get better sleep, they are stigmatized for doing something dangerous. She recounts a story of a woman who practiced co-sleeping but then was unable to sleep because she worried she might roll over on the infant.

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Their thoughts about infants needing to sleep with their mother and nurse at night was not

thought of as insensitive to exhausted mothers. One lactation consultant explained her

thoughts to me about how giving nursing mothers and babies as much contact as possible

by leaving them in the bed together, would not only foster correct breastfeeding, but

would actually help both the mother and the baby sleep better rather than worse, and

would cut down on child abuse:

If we had a culture of this baby staying with its mother instead of being in the crib, if this mother had maybe seen other people nursing, would that have made her experience different? Because I think sometimes too, just babies, if we would encourage them to stay with their moms… I mean you hear how they do it like in other countries where the mom stays in bed. People come to her and serve her. The baby’s there with her. [By doing this] I think that they probably could have worked [breastfeeding] out themselves. …I hate that we have to tell the mothers you can’t sleep with your baby. …this whole sleeping thing, it really bothers me. Well you look at other, we just had this baby, the parents are from Micronesia, and [the hospital is] quizzing them about ‘Where’s the baby going to sleep when you go home?’ Well, they were all concerned because the baby didn’t have the right type of crib. I’m like, not everyone sleeps the way we do here, and I don’t even know if we do it right. I mean if they were in Micronesia, the baby would sleep right beside his mom… I think actually maybe child abuse is even, like could go up if [you don’t bed share] because I think sleeping with your baby helps. …I just think they sleep better a lot of times. And you probably get more sleep.

Lactation consultants were highly sympathetic to the plight of the sleep deprived

mother and blamed the system for not giving women adequate or paid maternity leave, or

the doctor and childrearing expert who failed to encourage other methods for helping

infants sleep, and who rejected studies that show positive effects from bed sharing done

safely. A lack of support, a culture that values independence, and the effects of hospital

practices, were also pointed to as being disruptive to bonding. One lactation consultant

said:

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Lack of privacy, routine… Institutions have things that they want to do, the way they want to do them. They want to do their vital signs when it’s convenient for them, not when it’s good for moms and babies. …And you want to do this healthy bonding thing and this healthy breastfeeding thing and this family, this whole family bonding thing, but just the fact that you have to do it in the hospital messes with that, and then you’re intruding upon it.

Conclusion

Douglas (1966) turned to theories in cognitive psychology to explain what people

do when something doesn’t fit with their understanding of things, or schemata. When

there are contradictions present or when something doesn’t match your preconceived

ideas, theory about schemata says that you either ignore that information and fail to

perceive, you make it fit your expectation through assimilation, or you accommodate by

creating new explanations or adjusting the old schema (Douglas 1966). You can respond

to the anomaly either positively or negatively, and Douglas (1966) paired these ideas with

symbology and ritual. Through such theoretical tools the concepts of lactation consultants

are realized and related to the experiences of breastfeeding mothers.

The lactation consultants involved in this research thought of breastmilk as

symbolically similar to blood and also related to the biological fact that breastmilk is

made from blood (Riordan and Wambach 2010). They relied on science to form their

concepts about breastmilk and breastfeeding. Breastmilk and breastfeeding were elevated

in status to become super-natural when science was unable to adequately explain their

mysterious or complex aspects. Science was then able to accommodate complexity and

mystery. Bonding understood from a bioevolutionary perspective could be described as

that which facilitates an intimate, sensory connection with the infant, and in return, the

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stimulation of neurological and hormonal responses. We can now add to this the ancestral

contribution of a mother’s bacteria and its role in forming the infant as a biosocial person.

Yet despite this scientific understanding of bonding, lactation consultants used the term

“magical hour” to describe a process that ended with breastfeeding and facilitated

bonding, just as milk itself is understood in biological terms and yet is also considered a

“miracle,” “extra-ordinary,” or “magical.” Breastfeeding thus isn’t natural but is super-

natural. It is super-natural because it is so complex, dynamic, and interconnected as an

ecosystem that you cannot extract, reproduce, or improve upon breastmilk or

breastfeeding with technology. As a complex system it displays emergent, or vital-like

properties. It is also super-natural because with breastmilk and breastfeeding, the

biological is understood to be social; they are entwined. This produces a sense of awe for

the way that undisrupted breastfeeding that is allowed to develop apart from medical

interferences and concepts creates kinship and forms social persons.

Lactation consultants most often help women who are having difficulties with

breastfeeding, however, and many of those women experience breastfeeding in negative

ways that conflict with the elevated conceptions of breastfeeding that lactation

consultants hold. Some women experienced breastfeeding as what was interfering with

their ability to bond with their infants and told lactation consultants about their

exhaustion and pain.

The scientific understanding of breastfeeding in public health information and

popular discourse has been presented to mothers as informational. In other words,

breastfeeding is presented as conferring health benefits and with little actual knowledge

about its more technical aspects, one is supposed to make a decision about whether or not

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to breastfeed or whether or not to wean. It is therefore unsurprising that articles that

proclaim that breastfeeding’s health benefits are overstated have been persuasive,

especially when the authors claim to have come to this conclusion because they are able

to understand the scientific studies and have revealed what they actually tell us about

breastfeeding. They are also persuasive because they give mothers a way to expunge

negative feelings about mothering by dismissing breastfeeding as insignificant. What is

lost in these narratives is what I have described here concerning the discoveries about

breastmilk that make it super-natural and do not translate to a simple quantitative

statement about, for example, how many fewer ear infections a breastfed infant is likely

to get.

For women like Christine, however, bonding was not achieved with her first child

because not being able to breastfeed meant she felt a loss of maternal identity. For her,

the ideal mother/baby dyad is elevated, similarly to Christ and the Madonna, whose

excess is sacred, provides healing, and facilitates kinship through a bonding connection.

Her positive experience reflects the ideals of attachment parenting that the lactation

consultants adhered to. Whether a mother views breastfeeding positively or not, most do

not consider the complexities of the immune system and the marvel of pluripotent stem

cells, nor are they haunted by images of infants with rotting intestines. As I will explore

in chapter five, parents don’t think of breastfeeding as a dynamic process, but turn to

schedules, enumerations, and disciplining tasks in an effort to control the lactating body

or their baby. Chapter five will explore women’s concepts of breastfeeding in an in-depth

manner and will address how lactation consultants change the concepts that women hold

as they direct their attention towards sensory signals for embodied knowledge. Embodied

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knowledge allows women to understand the dynamic nature of breastfeeding without the

scientific discourse.

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Chapter Five

Broken Machines: The Concepts Mothers Have About Breastfeeding

“So I became obsessed with increasing my milk supply, to the point that I would literally fantasize about becoming a bountiful milk machine, my breasts spraying milk in slender arcs like an Austin Powers fembot assassinating her victims. Gradually, the amount of milk I produced per pumping session became a litmus test of my self-worth, officially

replacing my weight or my age or my cup size as a quantification of my value as a woman.” – E. J. Dickson, from Inside the Mommy-Friendly, Scientifically Sketchy World

of Breastfeeding Supplements

Introduction

In this chapter I argue that breastfeeding is situated in a sociocultural context with

historical underpinnings that have pathologized and medicalized it, contributing to

concepts and practices that undermine women’s experiences with breastfeeding. I

demonstrate that the result of this undermining in research subjects is that breastfeeding

mothers who sought the services of lactation consultants either lacked embodied concepts

related to breastfeeding or their embodied concepts came from ideologically based beliefs

that viewed the lactating body as mechanical or pathological. Middle class mothers

tended to respond to breastfeeding as a project, reading books, taking classes, and turning

to experts, technology, and consumerism. They believed that getting through

breastfeeding difficulties was a matter of the right mindset and effort. Mothers of all

economic levels overwhelmingly turned to quantifying techniques of milk measurement

in order to achieve certainty. Using mental skills to figure breastfeeding out and manage

it were far more prevalent than turning to the body and seeing it as informative. I further

demonstrate that quantifying techniques become ritualized and can further separate

mothers from embodied knowledge. On the other hand, the efforts of lactation

consultants to change women’s expectations and bring women’s attention to particular

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perceptual elements of breastfeeding can change women’s embodied experiences and can

aid them in enacting breastfeeding.

The Social Construction of Lactation Pathology and Breastfeeding Norms in the U.S.

A page in my field notes, written after I had finished spending a day in the

postpartum ward of a hospital and then the NICU, says, “All I heard was a blur of

numbers being thrown around and calculated and repeated and explained, and my brain

checked out.” It was as if I had given up on making any sense of the events of the day.

What I had registered in my exhaustion was how numerical it all was. Newborns were

weighed and measured and then weighed some more. There was no consideration that

there might be a wide range of “normal.” Instead, what was “normal” was extrapolated

from data and averages, so that a 7% weight loss in any infant would raise fears about

breastmilk sufficiency and necessitate the consideration of formula supplementation.

Mothers were given forms to log every feeding and number of infant bowel movements

and urinations. Attempts at sleep were interrupted so that nurses could take the mom and

baby’s vitals. The NICU had infants on feeding schedules so that when their mothers

visited, they had to breastfeed in alignment with the NICU’s scheduled times.

Babies in the NICU have health conditions that require interventions that are often

not necessary in healthy, term infants. It was necessary that these infants be weighed and

often supplemented. The lactation consultants believed, like midwives who understand

that there is a place for birth interventions, that this was appropriate. Yet even here the

sentiment from Tina, the lactation consultant who had worked in the NICU for many

years, was that those who constantly saw babies with health concerns often saw problems

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and the need for heavy interventions without discretion. The concerns of doctors and

nurses both in and out of the NICU bled into how they thought of healthy infants and

often led to unnecessary interventions in these infants. Additionally, Tina felt that

mothers of NICU babies were often disregarded.

The mothers seemed at times to me like a feeding machine to plug the baby into

when she showed up to the NICU. Her presence wasn’t necessary; a regimented system

saw her as an extraneous factor to fit into the line-up. This is why Tina commented that

the NICU didn’t like having to deal with parents; they messed up their system. In fact,

one mother who had been pumping her milk that day had completed the move from using

a machine to being a machine when she exclaimed as her milk squirted into the pump,

“It’s just coming out like a machine!” Mechanical metaphors like this were occasionally

expressed by mothers. Sometimes a woman would say she felt like a dairy cow, in

reference to an industrial dairy model where what is important is the product and not the

cow, or in this case the mother. Mother’s in both the postpartum unit and NICU

frequently complained that one or both of their breasts were “broken.” All ‘machines’

were numerically monitored and maintained by experts to make sure they were not

breaking down. Questions swirled. How often were the babies fed? How much milk were

they getting at the breast? How much milk did the mother pump? How much pumped

milk did the infants get? At what intervals? Most mothers fretted over whether or not

they had enough milk. The fretting seemed linked back to the institution’s attempts to

quantify the newborn’s status, which included breastmilk intake. Writings about the

female body in the social sciences reinforce what I observed, that the biomedical system

makes women feel as if their bodies are machines liable to break down and are thus in

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need of medical management (Davis-Floyd 1992; Dixon Whitaker 2000; Dykes 2005;

2009; Katz-Rothman 2000; Martin 2001; Millard 1990).

Spending time with lactation consultants revealed a different pattern. In those

same fieldnotes I recorded a mother asking how many hours her infant should be

sleeping. A lactation consultant told her, “They don’t have a certain amount at this age.”

The same mother was worried about her infant’s weight loss but had been told by the

pediatrician that it was normal. She was told by the lactation consultant that she didn’t

need to supplement her infant with formula because she had enough milk. The mother

was still worried and asked how she could quantifiably know that she was making

enough milk. The lactation consultant said, “That’s the beauty of breastmilk, you don’t

have to look for amounts. It’s always there.” When the mother then pointed to how much

milk she had pumped out and asked whether this was a way she could gauge her supply,

the lactation consultant replied, “The pump? That’s not what’s in your breast. Those two

ounces? You have more.” When the mother next pointed out that her son was sometimes

fussy and this must be because she really didn’t have enough milk, the lactation

consultant reassured her, “If he gets excited and you can’t calm him down, always know

that you have enough milk. It’s just something going on with him when he gets excited

like that.” When the mother next asked how long each breastfeeding session should be,

she was told, “Don’t watch the clock, just make sure he’s really drinking with you.”

The lactation consultant proceeded to tell the mother not to use a feeding schedule

and to feed the baby when he showed signs that he was hungry. Lactation consultants

understood that mothers who didn’t have enough breastmilk and infants who didn’t

transfer milk adequately from the breast existed, and they were careful to assess for this.

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The redirection of mothers away from quantifying modalities did not mean that lactation

consultants did not make use of quantifying modalities in certain situations, or did not

give mothers some ways to gauge milk intake. In this case it was explained that when the

infant was hungry, he would root for the breast with his head turned to the side, he might

make sucking motions, or move his hand to his mouth. He might cry, the lactation

consultant said, but this is a late sign that the baby will give if the other signs aren’t

attended to. The mother was directed to look down at her baby while he was nursing just

then. The lactation consultant said to notice that the baby was starting the nursing session

out with clenched fists. She asked the mother if she could hear and see him swallowing

milk and was told to observe that at the end of the nursing session, when he has had

enough milk, his fists would open. At this time his swallows would either stop, or he

would suck with longer pauses and without swallowing. He might take himself off the

breast when he is full, she said, and he will not be giving anymore hunger cues but will

be visibly relaxed or sleeping.

Alternative ways of knowing were encouraged to uncover the mother and the

infant’s own knowledge of breastfeeding, or at least their capacity to know without expert

advice, or enumerating techniques. This was the case even though the lactation consultant

is herself an expert. They established that the woman’s body is functional and whole and

has important information for her. Through my research I saw breastfeeding in

epistemological terms, situated in a sociocultural context with historical underpinnings.

How the U.S. came to be a place in which breastfeeding is pathologized and medicalized

can be historically established and linked to current concepts and practices, and women’s

breastfeeding difficulties. This history is important for understanding why so many

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women in the U.S. have problems with breastfeeding and why lactation consultants

respond by trying to demedicalize breastfeeding from within a medical environment.

Jacqueline Wolf (2001) details changes in infant feeding in the U.S. that started in

the late nineteenth century, a time in which many women began complaining that they

had either qualitatively or quantitatively insufficient milk. Infants who were given cow

milk as a substitute often died from diarrhea because there was no refrigeration or

pasteurization of cow milk available (Jaqueline Wolf 2001). Wolf establishes that

urbanization was the reason behind women abandoning breastfeeding despite the high

infant mortality rate that followed. She mentions many factors associated with

urbanization that prompted changes in infant feeding and included changes in women’s

work that took many away from home and left infants in the care of older children; the

fashion of upper class women using servants to care for their infants; the influx of

immigrant families that were removed from traditional knowledge; the move of birth

from home to hospital where women no longer attended each other’s births nor supported

each other with breastfeeding afterwards; the reduction in household size to nuclear

families; women no longer nursing each other’s infants; the sexualization of the breasts

when marriage for love and romance became the norm; the way that feeding schedules fit

with urban lifestyles; the emphasis on efficiency and teaching children self-control

through scheduling that was influenced by the ideology of industrialization; that germ

theory influenced the pasteurization of milk and made women believe that it was safer

than breastmilk, and likewise how doctors begin to think about breastmilk as likely to

spoil in the breast.

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During this time doctor’s also saw urbanization as the reason why so many

women had insufficient milk, but for different reasons than the ones described above.

According to Wolf (2001), they believed that urban women had weakened compositions

and nerves. This explanation was published in women’s magazines and reinforced

women’s beliefs that their bodies were likely to fail. Wolf shows how industrial ideology

alone would have been responsible for a very real decrease in women’s milk supplies,

quoting the advice of the Chicago Department of Health to mothers in 1926:

…a clock in the baby’s room is as important to the mother and baby as a good watch is to a railroad engineer. . . Spoiling the baby often begins in the first few days. Doing things by the clock develops the habit of doing things on time and at the same time makes a baby with good habits. (Jacqueline Wolf 2001, 32)

These ideas about women being weak and the accompanying application of efficiency

models had taken root in the late 19th century. Women were sometimes instructed by

doctors that feeding infants at night instead of establishing good sleeping habits would

reduce their milk supply (Jacqueline Wolf 2001). Most women and their doctors did not

realize that the breast makes milk according to how much stimulation it gets, and

decreasing this stimulation with increased intervals between feedings and refusing night

feedings, could actually decrease the amount of milk that mothers had available

(Jacqueline Wolf 2001). Thus, their methods for ensuring there was breastmilk for babies

actually caused the problem of insufficient milk to worsen (Jacqueline Wolf 2001).

A decrease in breastfeeding meant that infant mortality rates at this time became

an urgent matter that helped legitimize the new profession of pediatrics (Jacqueline Wolf

2001). The name “formula,” applied to artificial human milk, came from Thomas Rotch’s

“percentage feeding,” also called the “American method,” that became popular starting in

the 1890s (Jacqueline Wolf 2001, 82-83). The decline of breastfeeding and subsequent

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infant mortality rates created the need for better human milk substitutes, and Rotch

started the trend of doctors applying various mathematical formulas to creating

specialized milk appropriate for each individual infant’s needs (Jacqueline Wolf 2001).

These formulas determined the percentages of various cow milk components and calories

that would be needed for an individual baby at a particular point in time, and would have

to be adjusted as the baby grew and developed (Jacqueline Wolf 2001). Mothers were

reliant upon pediatricians to give them prescriptions for these specialized formulations

that were produced by chemists in pharmacies (Jacqueline Wolf 2001). Not only were

mothers in this situation without the knowledge and skills to feed their babies on their

own, but even doctors struggled with the complexities they had created (Jacqueline Wolf

2001). The formulations became so complicated that they generated articles that were

“terrifyingly like treatises on mathematics or higher astronomy” (Jacqueline Wolf 2001,

86). The American Method went out of style because of this, but a focus on scientific

mothering had been established in its wake (Jacqueline Wolf 2001).

According to Wolf (2001), scientific mothering necessitated the medicalization of

infant feeding because it required the monitoring and advice of men of medical science.

Pediatricians at that time decided it was necessary to weigh breastfed infants before and

after their mothers nursed them in order to determine how much milk they got at the

breast (Jacqueline Wolf 2001). Breastmilk was also examined “either microscopically or

chemically, for potential irregularities.” (Jacqueline Wolf 2001, 87) So were infant stools,

which were deemed an indicator of the quality, rather than the quantity of a mother’s

breastmilk for her baby (Jaqueline Wolf 2001). Wolf (2001) claims doctors “counted,

smelled, dissected, chemically analyzed, weighed, and photographed babies’ bowel

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movements” (95). Quantifying modalities, an emphasis on scientific mothering, and

concern over insufficient quantities of milk has persisted to this day. As this chapter aims

to show, there is also still a general lack of awareness that quantifying practices can

sometimes exacerbate the breastfeeding issues they aim to help or can cause the problem

that was presupposed.

Early 19th century Italy can be used as a comparison to show similar outcomes

from a focus on regimented breastfeeding methods and enumerations. Dixon Whitaker

(2000) explored the cause of insufficient milk in fascist Italy beginning in the 1920s.

Fascist leaders decided that infant mortality rates were caused by undisciplined

breastfeeding on the part of mothers (Dixon Whitaker 2000). Regimented techniques that

included the weighing of infants before and after breastfeeding session, and putting

infants on feeding schedules, were put into place in an effort “to reduce infant mortality

rates and improve the quality of the population” (Dixon Whitaker 2000,1). Dixon

Whitaker (2000), like Wolf (2001), explains that these changes occurred along with the

move from an agricultural society to an industrial one with similar modes of causation.

Additionally, as in the U.S., biomedicine saw the individual as responsible for health

issues, requiring disciplining of the body (Foucault 1977, 1978).

In Italy, the disciplining of the body was to be accomplished through

regimentation by mothers who would adopt infant feeding and sleep schedules with

precise intervals, along with the ritualization of infant weighing (Dixon Whitaker 2000).

Scientists had measured the capacity of the infant stomach, and this had encouraged them

to schedule feedings to coincide with the rate of stomach emptying with the idea that the

stomach required a rest period (Dixon Whitaker 2000). Dixon Whitaker (2000) notes that

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the scale that weighed the infant before and after breastfeeding was called an “instrument

of control,” and parents who could afford to buy one weighed their infants obsessively

(185, 232). If parents couldn’t afford their own, they resorted to frequent clinic visits for

weighing (Dixon Whitaker 2000). Doctors claimed that only they were able to interpret

the weights, however (Dixon Whitaker 2000, 186). They sometimes sent a mother’s milk

to labs for testing to see if it was defective, because women’s bodies could be faulty and

only the doctor had the ability to determine whether or not a woman could breastfeed

(Dixon Whitaker 2000, 186). Just as in the U.S., the need to monitor mothers and milk

made doctors indispensable as a mother’s own knowledge and adequacy was diminished

(Dixon Whitaker 2000).

According to Dixon Whitaker (2000) the industrial values of discipline and

efficiency and the enumerations of science applied to breastfeeding, alienated women

from their milk and their babies. Breastmilk and babies were considered products to be

produced in an orderly and efficient way with regimented methods that would ensure

quality control (Dixon Whitaker 2000). While these methods were thought to teach

infants self-control, mothers’ bodies also had to be disciplined in order to ensure

qualitatively and quantitatively sufficient milk. These methods are antithetical to the

dynamic nature of breastfeeding in which the infant regulates the milk quantity and

quality according to its needs in an interdependent relationship with the mother (Riordan

2009). Additionally, the mother’s focus on enumerations often comes at the expense of

noticing and learning about infant behaviors and responding according to their signals in

a reciprocal dance. Expert knowledge is part of the technocratic model of birth that is the

legacy of this history (Davis-Floyd 1992).

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Learning How to Breastfeed

Learning from experts is one way to understand breastfeeding, but prior to

medicalization other mothers were the experts. Modeling is important for learning and

can occur by observing, having a behavior described to you, or it can be something

symbolically demonstrated (Bandura 1977). One example of modeling comes from a

story that was told in a La Leche League meeting research site, about a mother gorilla at

the Ohio zoo who had been raised in captivity and had never observed breastfeeding, so

she had no concept of it. The story isn’t about humans but was used to instruct mothers

that humans, like gorillas, learn about breastfeeding by observing breastfeeding. After the

gorilla at the zoo gave birth, she was kind to her baby but did not nurse her. When she

became pregnant for a second time, the zoo brought in breastfeeding mothers from a local

La Leche League group and had the gorilla observe how they fed their infants. As the

story goes, after the gorilla gave birth, she knew what to do because she had observed

these other mothers, and she then successfully breastfed her baby. The story is also

referenced in a breastfeeding book for mothers (Mohrbacher and Kendall-Tackett 2010)

and by Jack Hanna (“‘Countdown with Keith Olbermann’ for Feb. 21” 2005), who was

the director of the Columbus zoo, in an interview where he claims to have been a part of

the project. He stated that all the female gorillas at the Ohio zoo were exposed to the

breastfeeding La Leche League mothers in the hope that they would learn what to do,

having never been exposed to breastfeeding before. What is true for gorillas may not

necessarily be true for humans, but it is the case that in cultures where the breast is not

sexualized and breastfeeding is normalized and ubiquitous, breastfeeding is commonly

observed in contrast to the U.S., as I show below. Additionally, women tend to get advice

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or instruction from other experienced mothers, often grandmothers (Scelza and Hinde

2019; Dennis et al. 2007).

A lactation consultant once advised me not to be concerned about the way that

Micronesian women held their babies while breastfeeding them in the hospital. She

explained that she had never seen other women hold their babies the way that they did,

but that they breastfed effectively and seemed to have learned to do it this way from

watching one another. The Micronesian women were a tight community that had recently

immigrated from their Pacific atolls to Hawai‘i. Presumably they were not holding their

babies the same way because it was instinctual to them, but because it was learned in a

communal social context. In contrast, I found from my observations at a hospital that the

majority of women had not closely observed breastfeeding and had to be shown how to

hold their infants in order to nurse them. There were even names for the various ways one

could hold a baby for teaching purposes, such as the cross-cradle or the football hold.

Another example of how mothering is learned comes from Fulani families who

are pastoralists in West Africa. The example points to the widespread use of alloparents

in hunter-gatherer or pastoralist societies and how modeling reproduced through

alloparenting prepares a female for caring for a child of her own:

All women caring for their first babies will have had years of experience taking care of babies . . . under the watchful eye and sometimes severe eyes of their mothers, aunts, cousins or older sisters. The other women . . . will immediately notice, comment on, and perhaps strongly criticize any departure from customary behavior on the part of the mother. (Riesman 1992,111)

Breastfeeding is readily observed in societies where it is the norm and the breast is not

sexualized so that learning how can be partially acquired through observation, or through

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listening in as other women instructed or described their experiences, or by being directly

instructed:

Unlike other primates, women imagine ahead of time what it will be like to give birth and to be a mother. Their expectations are built not just on what they themselves have experienced, and from observing others and practicing with their babies, but from what others (especially other women) tell them it should be like. . . Even though nerve signals work the same way, something as obviously biological as pain in childbirth is experienced differently depending on cultural expectations. Women develop expectations not just about how they should respond but about how they should experience their own sensations and emotions. (Blaffer Hrdy 1999, 164-165)

In many of these societies the new mother and infant are isolated in the home for a time

and are taken care of by female relatives who might help her with breastfeeding

difficulties (Dennis et al. 2007). Data is lacking, however, about how women in societies

that resemble those we evolved from learn to breastfeed (Scelza and Hinde 2019),

creating a question of whether or not breastfeeding is instinctual and therefore doesn’t

need to be learned. A study of a group of Indigenous pastoralists in Namibia who call

themselves Himba, however, suggests that breastfeeding is a learned activity for all

Himba mothers since they maintain traditional practices that are enacted in conditions

considered consistent with those we evolved under (Scelza and Hinde 2019)39. These

conditions are not affected by aspects of industrialization that affect women’s

breastfeeding experiences in the U.S. For Himba mothers, breastfeeding is universally

practiced, babies are fed on demand, and breastfeeding is seen publicly with women’s

breasts exposed (Scelza and Hinde 2019). Himba women reside in their mother’s hut for

1 to 2 weeks postpartum (Scelza and Hinde 2019). They most commonly reported having

39 Subsistence populations like the Himba cannot be said to represent the exact conditions and practices of their ancestors, however, as Scelza and Hinde (2019) point out, because breastfeeding is normalized in this population, they can represent an “adaptively relevant environment in which the human neonate evolved.” (Scelza and Hinde 2019)

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issues with latch/positioning, and either an over or under supply of milk (Scelza and

Hinde 2019). During this postpartum period, they were instructed in how to breastfeed by

their mothers, and the instruction was either verbal, hands on, or teaching through

gesturing (Scelza and Hinde 2019). Only a few women claimed they did not need

instruction, with one of those mothers saying she had learned how to breastfeed from

observing other mothers (Scelza and Hinde 2019). Many reported feeling anxiety and

said they had lacked knowledge of breastfeeding just as the women who saw lactation

consultants in this study did (Scelza and Hinde 2019). I argue that breastfeeding is not

instinctual for mothers, and modeling by observation or instruction is one way that we

learn how to enact it.

Women I interviewed in my study come from a society in which breastfeeding is

not ubiquitous, and yet they also looked to their female family members for information

on what breastfeeding would be like. We have lost generations of breastfeeding

knowledge in the U.S. due to the changes brought by urbanization and the popularity of

formula. The tendency to turn to family, their influence on women, and often their lack of

ability to guide breastfeeding mothers in this study is expressed in these two examples:

What scared me the most by far was breastfeeding . . . It really freaked me out because my mom had five kids and she tried to breastfeed but the first couple it didn’t work. She said she didn’t make enough milk, so I just thought it was going to be the same for me.

When I talk to the women in my family, they all had difficulties breastfeeding. They all supplemented with formula. It was interesting to me to find out that they didn’t have an expectation for me to breastfeed . . . So, I don’t know if [the difficulty I had] was genetic….

It is interesting to note that the woman above had no context for why she or other women

in her family had difficulties breastfeeding and considered that it could be genetic. This

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was a common assumption among women in this study who struggled. They often

decided that there was something fundamentally wrong with their bodies, and these

dysfunctions were shared among kin. In contrast, family members and other women in

one’s social circle who did breastfeed can have a positive influence on a women’s idea of

what is normal and achievable as exemplified by these two examples:

I have a couple of friends who breastfed until their kids were two or three, so maybe I thought subconsciously that’s what people do. I am also wondering if our mothers make a difference, because my mother breastfed all of us . . . I think also, hearing that I thought, well, I’ll do the same.

Knowing what is “normal” also involves social pressure to conform to what the group

does. Sometimes women decided to breastfeed and their family members who did not

breastfeed or struggled to breastfeed were discouraging. Despite hearing public health

messages about the benefits of breastfeeding, women often doubted their decisions if they

went against the beliefs and practices of those closest to them. In such instances,

breastfeeding was like a radical act. Messages such as “cover up” were seen by them as a

rejection of breastfeeding by making it clear that breastfeeding was shameful or

abnormal:

I’m actually the only one in my family that breastfeeds. It’s kind of me against 50 of them . . . It is hard, I should say. I think the challenging part for me was breastfeeding knowing that I’m the only one in my circle that breastfeeds . . . so I think that was the toughest part for me was staying in that crowd and knowing that what I was doing was right. You know, even with my fourth I still have that. Some family members will say, you know like, cover up.

While mothers found it difficult to go against what the other women in their families did,

one mother I interviewed experienced the radical act of breastfeeding as empowering:

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I would sometimes be, with the first one I was so intoxicatedly engaged. I was a little crazy because I had the new identity of mother that I desired so badly, and then I became a breastfeeding mom. I really, [breastfeeding] was much more against where I was raised, and my mother, sometimes she would want to cover me, and I was clear that this is my route [to motherhood]. And that was really empowering there too, of just really finding my own voice.

As with this mother, so many of the women in my study felt that success at breastfeeding

was important to their identity as a mother, so that not succeeding became a personal

failure.

Another mother I interviewed showed how “normal” can shift depending on how

you are socialized at a given time. When this mother moved to Hawai‘i and attended a

breastfeeding support group where women wore their infants and breastfed beyond 6

months, she changed her practices and now saw her family’s breastfeeding practices as

strange:

I come from like Michigan, extremely conservative. The way I raise her, and the breastfeeding, none of this is normal. I’m weird. Even wearing her is weird. So, when I first went to the meeting and everyone’s just breastfeeding, no cover, I almost had like anxiety . . . Even all of my cousins, the fact that I’m still breastfeeding her at seven months is like very weird . . . I think it’s the culture. People don’t breastfeed that long at home. If you breastfeed three months, you’re good. Even talking to a lot of my aunts, and my grandma, like nobody really breastfed past that if they breastfed at all. It’s interesting . . . My family is not a low-socioeconomic status at home either. It’s definitely not that. And even me, you know, I have a master’s degree and I’m educated but [at first] I was like once I get to six months, I’ll be happy. And now I’m like, man that’s like nothing.

Because women felt they needed support from those women closest to them in order to

breastfeed, they sometimes sought out groups of breastfeeding mothers to reinforce their

beliefs and breastfeeding practices. The two mothers I quote below had sought out La

Leche League meetings as a way to have a communal model of breastfeeding. The first

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mother, who was a nurse, was socially influenced to doubt herself despite her medical

knowledge, and went to the meetings for reassurance of “normal”:

My support system, everyone who had been supportive of me nursing an infant were suddenly not supportive of me nursing an 18-month-old. [It was] family; mom and sisters. My one sister was just appalled that he was still nursing. I referred to it one time as like closet nursing where after a point nobody asks . . . Like I am sure most of the family thinks [he] is done. But it’s not something we really talk about after a certain point . . . So, I went to the [La Leche League] meetings because I needed someone to tell me that it was okay that he was still nursing. That it was normal, that there wasn’t anything wrong with him, there wasn’t anything wrong with me. I knew all of those things from being a nurse, that like my milk was still good. But when so many people start to question you, you know “Is your milk still good?” and everything, I just found that I needed to have some reassurance.

The community shows you what is “normal” and reinforces this, and “real moms” seem

to have more influence than medical professionals in this regard:

I kind of like La Leche League . . . it’s just nice to hear other moms say, yeah, that’s normal . . . We co-sleep and he nurses a lot still at night and it’s nice to hear other people say, yeah, we do too . . . You have like real moms versus professionals in the hospital.

Both of the mothers above faced sexual taboos that have been associated with

breastfeeding an older infant and putting the infant in the bed with you for nursing

throughout the night. The idea that a woman’s milk would not be “good” once their infant

reaches a certain age speaks to the false notion that breasts are designed for a sexual

purpose and are universally erotic. It follows that if this were a biological truth women’s

bodies would naturally stop producing suitable milk once the infant became old enough

that nature intended them to follow sexual norms. The American Academy of Pediatrics

advises against co-sleeping40, stating it is dangerous (AAP Task Force on Sudden Infant

40 The term “breastsleeping” has been introduced to describe co-sleeping that is practiced by breastfeeding mothers (Tomori 2015), and to destigmatize the practice since co-sleeping has been discouraged by the

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Death Syndrome 2016) despite evidence that done the right way it can be protective

against SIDS and is helpful for breastfeeding, suggesting a social bias (Blair et al. 2014;

Ball and Russell 2014; Marinelli et al. 2019). The co-sleeping mother was therefore not

only subject to sleeping arrangement stigmas, but also experts telling her she was doing

something harmful to her baby.

The influence of other mothers applied to all women, not just women who

attended La Leche League meetings. When women aren’t regularly exposed to certain

breastfeeding practices, they see them as abnormal and without being exposed to it can’t

imagine it, as this mother indicates:

A lot of coworkers . . . I get a lot of feedback from them, like “What? He’s not sleeping through the night?” None of them breastfeed . . . I’ve gotten to the point where I’ve kind of stopped talking about it . . . Someone just asked me . . . are you still pumping? And I said yeah. And she said, “Are you going to pump for a year?” And I said yeah, and after. And it was more like surprise or shock. It wasn’t judgement.

Mothers aren’t just directly learning the technical aspects of getting milk into their baby.

Normalized social practices around breastfeeding have an impact on both the baby

getting breastmilk and the mother’s embodied experience.

Social influence had a powerful effect on women’s decisions and experiences but

knowing how to breastfeed was still a challenge for many. I noted that numerous women

displayed a profound lack of embodied knowledge of lactation or interpreted bodily

signals through an ideological lens. In referring to these women’s experiences as a lack of

embodied knowledge of breastfeeding, I am pointing to the ways that women either had

inattentional blindness and did not recognize or experience particular elements of

AAP (Marinelli et al. 2019). I use the term “co-sleeping” here to describe the AAP’s position and then in the following sentence for consistency.

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breastfeeding that were available to their senses, or did not make sense of their sensory

experiences. For example, many women who saw lactation consultants in my study were

unsure if they had enough milk even if it was leaking or spraying out in large amounts.

Incorrect conclusions that they don’t have enough breastmilk, referred to as perceived

insufficient milk (Neifert and Bunik 2013), is one of the most prevalent reasons mothers

supplement with formula or stop breastfeeding (Gatti 2008; Li et al. 2008). Many women

also didn’t know if their baby was drinking at the breast, did not know if what they felt

while breastfeeding was normal, and reported that they did not feel or identify signs of

their milk letting down. In this study women’s milk ejection reflex were not inhibited

because the lactation consultant could observe that it was active even though women

were unaware of it.

During the letdown, also referred to as the milk ejection reflex, the hormone

oxytocin is secreted and stimulates the smooth muscles of the alveoli in the breast

(Riordan and Wambach 2010). The alveoli then contract so that the milk that has

collected in them is ejected into the lactiferous ducts (Riordan and Wambach 2010).

These ducts dilate in response to intra-ductal pressure, and the milk flows through them

towards the nipple (Riordan and Wambach 2010). This produces particular sensations

and a change that one can see in how the milk flows from the nipple (Britton 1998). From

my lactation consultant training and observations, I learned that if the letdown happens

when the infant is not latched on, one can see the milk start to drip and then spray from

the nipple. This is especially noticeable when a woman pumps, and the milk changes

from a slow drip to a stream or spray when the letdown occurs. If the baby is latched on

when it occurs, a change in swallowing, jaw movements, and the rhythm of suckling can

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be seen and heard. If the flow is too heavy, the infant sometimes chokes or pulls off and

the spray can be seen. Heavier milk volume is likely responsible for more intense

letdown sensations (Lauwers and Swisher 2015). Also, during a letdown, milk can often

be seen dripping out of the opposite breast because the letdown is bilateral (Lauwers and

Swisher 2015). After giving birth, the letdown coincides with uterine contractions and

blood flowing out of the uterus since the hormone oxytocin, which causes contraction of

the alveoli, is released into the bloodstream and also causes uterine contractions (Riordan

and Wambach 2010). Furthermore, the letdown is both stimulated by suckling and is a

conditioned response, meaning that it is often triggered by a cue, such as hearing a baby

cry (Riordan and Wambach 2010). One could notice that every time a particular cue

occurred, a sensation was felt in the breast and/or they could observe or feel their milk

dripping out.

Despite these numerous and readily available and sensory ways of knowing that

the letdown is occurring, a common question that women asked lactation consultants was

what a letdown was supposed to feel like, and how they could know if they were having

one. They had an idea of letdown as milk coming out but didn’t know its features or

feeling. In addition to offering a description of the sensation, the lactation consultant

would often ask women if they had noticed the changes in how the milk moves from a

drip to a spray when they pump, or if they noticed changes in the ways that the infant

suckled that could be felt in the breast or seen in the baby’s jaw, as evidence of the

letdown. Numerous women, however, were not making these connections on their own.

They were able to feel pain in the first few seconds of latching or when the latch was bad,

as well as a tugging sensation on the breast when the infant latched on normally, but they

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were often not sure if what they felt was normal. I theorize that some women had a non-

experience of letdown despite the fact that it was happening and there were many ways to

know it was happening, because they had no concept for it, which would have directed

their attention to its features.

Absent adequate knowledge, many middle-class women in my study tried to

willfully gain control over their lactating bodies by what Miriam Waltz (2014) calls

treating breastfeeding as a “project” to be “managed,” and through what Alison Bartlett

(2002) calls “headwork.” Educated, middle class mothers who took part in this research

often turned to books, classes, experts, technology, consumerism, and regimented ways

of managing breastfeeding as if it were an intellectual or work project (See also Avishai

2007, 2011; Tomori 2015). Some of them said that they regretted not preparing for

breastfeeding while pregnant, having assumed they wouldn’t need to, but others had

spent a great deal of time preparing. One mother I interviewed who regretted not

preparing, saw 5 different lactation consultants, went to two breastfeeding support

groups, and saw a psychologist and an osteopath for breastfeeding help. She also had no

reference for what breastfeeding was supposed to be like and thought she had insufficient

milk even though she had been told that she did not:

I was like, okay, is this what it is supposed to feel like? I heard they are supposed to wiggle up there on their own, but that didn’t happen. It was weird, but I thought, okay, I’ve never done this before . . . I think I prepared so much for this natural birth and . . . then breastfeeding happened and I was like, oh my god I didn’t prepare at all for this!

Her description of breastfeeding as taking her by surprise and her disconnect from what

was happening was not uncommon. She expressed a vacuum of knowledge about how to

enact breastfeeding, as did many moms. Another mother I interviewed talked about using

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the internet as a source for researching breastfeeding and gathering information from

experts. It was also a way to watch videos of women breastfeeding in order to determine

if she was doing it right. Videos in this case were one way that she could learn how to

breastfeed by watching other mothers since in all other situations breastfeeding is largely

unseen in our society:

I would still, like, YouTube “latch” and stuff to make sure that it was a good latch. I would try to change things a little bit and try different holds [that I saw] . . . I’ve read so much about infancy . . . On Facebook I saw a little, like Pinky McKay, [and] there’s some [other] lactation consultants and some attachment parenting groups [online] that have been really helpful . . . so I read a lot of articles.

Middle-class mothers tended to think of breastfeeding as something to tackle with

the right mindset as if it were a matter of willpower and cognition. They used phrases

such as needing to “put my mind to it,” and thought of it as a thing that they needed to

strategize and “work through.” A mother whose visual reference for breastfeeding was

not women in her family or community, but images of tribal women she likely associated

with ‘natural’ acts, tried to remain “topless like I was in Africa” while confined to her

home. That mother in the end, however, decided to manage breastfeeding as many others

did:

In the beginning I didn’t even know if he was getting any milk. I guess I just needed to be shown that I was doing it right because I was uncomfortable . . . because in the beginning everything felt awkward. Am I doing this right? . . . I walked around house topless like I was in Africa . . . And [then] I was like, ok, I just put my mind to it.

The novel sensations of breastfeeding caused the mother to feel “uncomfortable” and

“awkward” rather than feeling natural, which gets conflated with instinctual. For these

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women, this awkward bodily act for which they had no reference needed to be managed

not only with the right “mindset” but also through “research”:

I was like, okay, you know I’m in a good mindset. I’ve had all of this time to like – I researched everything. I researched like what kinds of things I could be doing [to increase milk supply], like, you know, eating oatmeal, and just the smallest little things [like] increasing certain types of foods.

Women often began doing research as preparation for breastfeeding by educating

themselves while they were pregnant. This information along with the right mindset was

then drawn upon to strategize managing breastfeeding difficulties that occurred despite

having laid the proper groundwork to prevent problems in the first place:

I went to every [breastfeeding] class . . . and I read books . . . I think [doing] that was kind of helpful, to realize, no I have to do this. I just have to work through the problem.

Sometimes middle-class moms resorted to consumerism and would ask where they could

buy the scale or the chair that a clinic that was one of my research locations provided for

them to breastfeed in. One mother discussed how after being unable to “figure it out” she

had purchased the actual brand of chair, pillow, and footstool that were used in the clinic.

While the chair, pillow, and stool were presumably to help her comfortably engage with

different body techniques, breastfeeding can be successfully accomplished without

special pillows and other items. Consumerism, however, was often a way that women

sought to deal with breastfeeding difficulties:

I didn’t really know what, you know. I didn’t really know. I’ve never breastfed before and no one really ever talked to me about it except I read some books, but the actual feeling of him on my breast . . . I didn’t really know what it was supposed to feel like . . . [I was trying] all these techniques, and you’re just, you’re just so tired and you are just trying to like, you know, [get out] the whip, and you’re trying to figure it out . . . I bought a chair, and that really helped a lot.

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It was the same kind of chair that they had at [the lactation clinic]. It’s awesome. It was just so perfect you know with the pillows [they have there]. So, I bought [them], and I bought the stool for my feet because I’m short. That made a huge difference, and then I was trying to practice the cradle and football [breastfeeding holds] and so I just do that with my pillows and that helped a lot.

While middle class mothers tended to strategize and turn to research and consumerism,

mothers of all socioeconomic statuses overwhelmingly turned to quantifying methods to

make sure that they had enough milk or that the baby was transferring enough milk from

the breast. Ideologically based social values of technology, data collection, and

quantification, all of which are reflected in hospital practices, encouraged this.

Measuring Milk

The sense of certainty that American society affords to quantification influenced

women’s responses to the uncertainties of breastfeeding. Breastmilk insufficiency was a

common complaint that women in my study came to lactation consultants for. One

mother that I interviewed stated that the weighing of her baby before and after she

breastfed to determine his milk intake was what convinced her that she had enough milk.

She said that prior to the weighing she didn’t believe she had enough milk even though

on reflection “I just had milk everywhere. I just kept leaking everywhere . . . I just had

plentiful. It was overflowing. We were wiping it off the floor as I walked down the hall.”

Another mother I interviewed talked about having a gap in understanding what

breastfeeding was supposed to be like and having perceived insufficient milk when she

pumped. She discussed this as a lack of trust in her instincts that the lactation consultant

was helping her find versus her doubts in her supply that were encouraged by the pump:

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How much I pump was like my gauge of what my supply was. Every time I see [the lactation consultant] still even she’s like, “No, you have lots of milk.” Because I was like, “I think my supply is going down,” and my milk is like shhhh spraying all over her face and everything . . . I feel in a way maybe that [the lactation consultant is] kind of helping me to trust my own instincts.

Women that I interviewed overwhelmingly talked about having a gap in

breastfeeding knowledge, and not knowing whether or not their milk supply was

sufficient was a reccurring theme I saw as prevalent in participant observations. Moms

mentioned not knowing what breastfeeding was supposed to feel like or look like, and

often showed a disconnect with the sensations they were experiencing and an

understanding of what these sensations signified. Like the woman above who thought she

didn’t have enough milk despite “wiping it off the floor,” in the following example, a

mother still saw the milk she pumped as “so little” even though she had been told by

medical professionals that she had enough:

The milk supply also worried me because I didn’t know how much is enough. It seemed like so little. So, I never knew how much is enough . . . I was scraping it out of the [breast pump] funnel thing, trying to get every drop because it was so little . . . I think I was still concerned only because it seemed so little even though they said it was enough.

Mothers turned to quantifying techniques for certainty. Breastfeeding logs given to

women in the hospital were often continued at home and were at times downloaded via

apps that allow parents to log all types of data on breastfeeding. One father proudly

showed me a spreadsheet that he had created so that his wife could log breastfeeding

data. A mother who was concerned about her baby’s weight talked about logging data as

something that required discipline:

I had the chart [where I recorded] what side I nursed on. It was much more keeping track of all that. I’m not disciplined enough to count poopy diapers. I’m

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not that crazy. But the weight issue was a concern until my mother-in-law stayed with us, who is a pediatrician. She was always saying “She’s a good color, she’s bright eyed, she’s fine.”

Interestingly, in this case, the pediatrician/mother-in-law provided the mother with

another way to assess the well-being of her infant that saw the body as informative and

was not associated with enumerations. For many women, their objective was to try to

discipline the body rather than to listen to it as if it has information to offer (Foucault

1977, 1978).

Early beliefs in breastmilk insufficiency sometimes happen if women don’t expect

colostrum to be produced in small amounts or because they don’t see the colostrum.

Infants are usually in the hospital for only 2 or 3 days, and at this time mothers have only

drops of colostrum that match the newborn’s small stomach capacity (Lawrence and

Lawrence 2011). The mother’s copious milk often does not come in until after hospital

discharge. Women produce colostrum during pregnancy, but because it is thick it doesn’t

readily leak out and they may not notice it (Lawrence and Lawrence 2011). An infant

may have trouble transferring the colostrum from the breast, and keeping a record of

breastfeeding times is not an indicator of how much the infant drank in a breastfeeding

session. The infant is hydrated immediately after birth, having received fluids in the

womb via the placenta. Pediatricians are supposed to see infants within 48 to 72 hours

after hospital discharge, at which time copious milk should be in and the amount of

weight loss and any feeding issues are assessed again (AAP 2012).

Parents may be more focused on counting and recording infant output than

observing infant behaviors if the message they get from the hospital or medical

professionals is that data collection is what is important. Helping women to understand

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normal breastfeeding infant behavior and the signals of their own lactating bodies is

likely to be more effective than numerical methods of determining successful

breastfeeding for three reasons. First, numerical methods of determining breastmilk

intake can be faulty. It’s possible for other methods of knowing to fail at times as well,

but breastfeeding is dynamic and interdependent, making understanding the behaviors of

a dynamic system more likely to capture important variables than a one-dimensional

measurement. Secondly, an excessive amount of infant weight loss becomes apparent

long after other signs of ineffective breastfeeding are present. Finally, the request to have

parents record numerically based data and a focus on infant weight signals to mothers

that the institution is worried that she may not have enough breastmilk and therefore she

should be vigilant against this possibility. The seed of doubt is sown. This has the

potential to change a mother’s concepts and behaviors in ways that end up undermining

breastfeeding and actually reducing her supply of breastmilk, which is then taken as proof

that her body had indeed failed her. While it is important that mothers with primary

breastmilk insufficiency are promptly recognized and supported, methods that lead to

secondary breastmilk sufficiency can end up creating the problem you were trying to

guard against in the first place.

This isn’t to say that quantifying modalities are never useful, just as formula is at

times a better option but not when used inappropriately or recommended by medical

professionals for the wrong reasons. Lactation consultants in my study were quick to tell

a mother to supplement with formula if she had an actual insufficient supply of milk or

had a baby who was losing too much weight. They also tried to help mothers navigate the

system when a doctor was unnecessarily causing a woman to be concerned about

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numbers. One mother talked about having to go in and get her baby weighed again as if it

were a test that she had to pass or else she would be pressured into unnecessarily giving

her baby formula:

an IBCLC . . . was like go home and nurse that kid around the clock and before that next weigh-in and hope she doesn’t poop. And we passed the weigh in and they kind of laid off.

Women who were dedicated to exclusive breastfeeding as this mother was, were often

devastated by the idea of having to give their infant formula and saw it as a personal

failure.

The technocratic model makes women feel broken and in need of the help of

experts and technology, but it is also the only source of information and practice that

many women turn to and trust (Davis-Floyd 1992, 2001). This is indicative of the cultural

significance placed on measuring, quantifying, and trusting technology more than one’s

own body as a source of information. Furthermore, the idea that the female body is likely

to fail often means that feeding concerns can become overly focused on possible

dysfunctions of the mother’s body. As an example of this, a mother told me that her

pediatrician asked her to pump for 24 hours without breastfeeding and record how much

milk she pumped in total during that time and calculate the amount of calories in the

milk. He had her do this because he was concerned that her 6-month-old daughter had

been losing weight. The calculations used would have measured calories according to the

average amount found in breastmilk according to volume and did not reveal the calorie

amount in this individual mother’s milk. The doctor didn’t order tests for infant disorders,

consider infant illness, or assess the ability of the infant to intake milk at the breast. His

focus on the quality of the mother’s milk made her doubt herself. Studies show that it is

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the volume of milk intake and not the amount of fat/calories in the milk that are

correlated with weight gain, making the investigation of the quality of the mother’s milk

inexplicable (Aksit 2002, Butte 1984, Cregan 1999, Mitoulas 2003, Mitoulas 2002). The

mother explained what the pediatrician requested of her:

Over 24 hours I figured out how many calories per oz of breastmilk, did all the calculations, and she was where she needed to be. I made 29, 30 oz for a 24-hour period but she’s extremely active, like crawling at four and a half months, doesn’t sit still, so she just burns more than what she, you know… At 6 months is when he had me do it. He was like, “Alright, she can have solid foods now, so do this, you know, the 24-hour thing, um, to see how much you make. Here’s the range, you know, 28 to 32 ounces is normal. Then you multiply that and do the weight.”

I thought that this mother would have found this a cumbersome exercise, but she

surprised me by saying “I like that kind of thing.” She found the exercise to be

reassuring to her. She told me that at first, she suspected she had enough milk based upon

using the pump as a measure:

I told him I thought I had enough milk because he said, “If you pumped instead of fed her, how much would you get out?” And I said, “It depends but basically 3.5 to 5 [ounces] after 3 or 4 hours.” And he’d say “Oh, that’s great.” But then I’d see him again like the next time and she’d continue to drop [weight].

Despite the amount that she was pumping, the weight loss prompted this mother

to have concerns about her body rather than consider other possibilities, and she

described that thought process:

You know, maybe I wasn’t making enough. Maybe. What was interesting to me was I thought I made enough when I did get the 4-6 ounces [each time I pumped] but uh, I didn’t think I made as much during the night. You know I’m not drinking any water. I don’t know, I just thought she got less, and she got just as much if not more at night, so I thought that was kind of interesting.

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The relief she experienced from the 24-hour pumping her doctor prescribed was because

the additional pumping, recording, and calculating made her certain of her milk quality

and quantity. The repeated visits to the pediatrician involved taking the infant’s weight

and hearing the doctor’s concerns, each time. This caused her to feel like all the hard

work she was putting into mothering was without result, claiming she felt “defeated.”

Numerical techniques could sometimes reassure after they caused a woman to feel

doubts, but in this they continue to reinforce a system that keeps women from turning to

and understanding the lactating body and their infant’s signals. It is interesting to note

that the 28-32 ounces that Melissa’s doctor said was normal for her to produce in 24

hours at that age does not reflect what is normal breastmilk volume and intake for

breastfed infants and is more appropriate for formula fed infants who have a higher intake

(Wambach and Riordan 2010)41. Thus, the doctor’s notions of what was supposed to be

normal was based upon formula fed infants and further demonstrates how quantification

is often faulty in how it is applied.

Breastfed infants gain weight differently than formula fed infants, and this

sometimes can cause pediatricians and parents to worry unnecessarily (Wambach and

Riordan 2010). A breastfed infant’s weight trajectory is usually slower after 4 months of

age (Wambach and Riordan 2010). A mother discussed how a lactation consultant helped

her to understand that her infant’s slower but consistent weight gain was not a sign that

something was wrong:

I was going in weekly to the pediatrician as well and [saying to the lactation consultant], okay [the doctor] said she’d only gained this much, and she’d say

41 Wombach and Riordan (2010) state that the average intake of a breastfed infant after 1 month of age is 25 to 27 oz., while the milk volume can range between 18 to 38 oz. Formula fed infants have greater intake because formula isn’t as effectively metabolized as breastmilk (Motil et al. 1997). Breastmilk contains hormones that aid in metabolization and regulate the appetite (Savion et al. 2009).

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“This is what you don’t understand, she’s gaining. You’re doing fine. As long as she’s gaining she’s okay, you don’t have to have gained, she doesn’t have to have gained within a specific time frame.” And I think doctors are like, within this specific time frame you have to get back to that weight or else it’s – they don’t tell you or else, but they make you feel like you’ve got to get there and if you don’t get there, there is something wrong. And [the lactation consultant] is like, you’re doing fine. As long as there is forward movement.

To clarify, some infants gain weight slowly but consistently for genetic reasons. If an

infant doesn’t regain their birth weight by two weeks of age, it is a sign that there may be

a problem. If IV fluids falsely inflated the birthweight during labor, or if the baby was

initially not getting adequate milk intake but starts doing well within the two-week time

frame and just needs more catch up time, it can confuse the issue. Lactation consultants

in my study were careful to make sure that the infant whose weight gain was in question

was transferring an adequate amount of milk at the breast and didn’t have other signs that

something could be wrong. They determine when a technology was appropriate and when

it could cause more harm than good.

When the Affordable Care Act mandated that insurance companies pay for all

women to obtain a breast pump after giving birth, the lactation consultants were both

elated and concerned. The elation was because low-income women would now have

access to pumps that they ordinarily couldn’t afford, and women would find it easier to

go back to work and have a reliable pump to help keep their milk supply up. At the

hospital where I did research, the pumps were to be given to women before they were

discharged home. This meant that those women with difficulties that required the use of a

pump would have immediate access to one and their milk supply would not be

compromised by a wait. Their concern was that this would now make all women feel like

a pump was a necessary component of breastfeeding in all cases because women’s

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breasts couldn’t produce enough milk on their own without the use of technology. They

also worried that it might increase the number of women who excessively pumped. That,

in turn, might lead to an oversupply and consequent plugged ducts and mastitis. Another

concern was that women who felt they needed to pump when they didn’t, would be

discouraged from breastfeeding at all, seeing it as more difficult and burdensome. The

lactation consultants wanted to be cautiously optimistic because giving every woman a

pump could be another reinforcer of technology misuse. Like nurse midwives, they saw

technology and enumerating techniques as sometimes useful and sometimes harmful and

in need of contextual and evidence-based use.

The experiences of women I describe above reveal a gap in knowledge about

breastfeeding and a turn to “headwork” and the type of knowledge that quantification

offered. The supremacy of the mind, technology, and quantification over the body as a

source of knowledge are all values that are communicated through the technocratic model

of birth and that are reinforced through ritual.

Ritualized Quantification

Ritual is what mediates the transition from one status to another and brings danger

under control (Douglas 1996). Hospital rituals offer a sense of order and safety by

reinforcing the technocratic model and its values (Davis-Floyd 1992). Davis-Floyd

describes the technocratic model of birth as a reinforcement of ideas and values that view

the body as mechanical, secondary to the mind, untrustworthy, and controllable with

technology. It does not acknowledge a woman’s own knowledge of her body (Davis-

Floyd 2001). Strange making is the term used to describe what the technocratic model

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does to disconnect the mind from what the body is doing in labor, so that embodied

knowledge is not a possible guide through the process. Under this model women become

dependent upon the experts and the institution to help her complete the birth (Davis-

Floyd 1992).

Metrics act as a kind of strange making when it comes to breastfeeding. After a

baby is born, they are measured and weighed. Parents eagerly await the announced

weight after birth. The name, sex, date of birth, weight, length, and time of birth are

usually the only items parents identify newborns with on birth announcements. At first,

they are a bundle of weight to be monitored and fed at the right intervals for the right

length of time with the hope that the mother has enough milk. Experts are consulted

because women are made to believe that because they don’t know enough about

breastfeeding they need to be managed by a professional. In all of these ways the mind is

disconnected from the lactating body and instead of observing the infant’s signals, or

their own bodily processes and biological rhythms, mothers might check the clock to see

how long they’ve been breastfeeding for or check their pump as a measure of milk

amount. They then often write that information into their breastfeeding log or record it

with their tracking app. The mother’s embodied knowledge is absent in all of this;

breastfeeding becomes a mental task and a matter for experts. Measurement is used as an

instrument of control. It does not observe social and biological variables but is part of an

effort to standardize and compartmentalize infant intake and output in order to create

certainty rather than deal with the flexibility and contextuality of dynamic functions.

A common ritual of milk quantification that many women practiced was daily

pumping regimens to build a large stash of breastmilk. I observed a woman drag herself

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into a lactation clinic and plop down into the comfortable, blue recliner looking miserable

one day. She was fevered and achy with mastitis and winced as the lactation consultant

felt the red, hardened areas of her infected breast. The lactation consultant, Karen, asked

her questions to try to understand what was going on in this mother’s life that would have

encouraged the mastitis to develop. The questioning revealed that she was a working

mother of three children who also found time to breastfeed and pump every 2 to 3 hours,

plus lift weights and run ten miles a day. She pumped regularly and frequently because

she saw it as an opportunity to store up frozen breastmilk just in case she needed it, and

because she believed that her breasts didn’t produce very much milk. She informed us

that her left breast “is the broken one; it always makes less milk.” Most women have one

breast that produces more milk than the other, so this was not unusual, but reflected the

message conveyed in the technocratic model of birth that a woman’s body is a defective

machine.

Contrary to her opinion that she didn’t produce enough milk, the amount the

woman was producing was so great that it had caused her to develop plugged milk ducts

and a breast infection, a fact that had been overridden by internalized messages of

inadequacy. Her efforts to counter her milk supply concerns were so extreme that the

pumping occurred around the clock after nursing her baby so that she was even pumping

at midnight and 4am. Her pile of frozen milk grew so large that she told us she had to

purchase a stand-alone freezer to store it all, and on that day it had 250 bags of frozen

breastmilk in it.

Many women who collect a large stash of breastmilk post photos of their freezers

overflowing with breastmilk on social media, prompting a woman at a breastfeeding

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support group that I attended to warn the other mothers against it so that they didn’t make

those struggling with their milk supply feel inadequate. It seems they posted images of

their stashes because they saw them as a mothering achievement; a result of lots of time,

planning, and effort that they sacrificed that becomes a visible and measurable success.

Milk stashes were sometimes started by mothers who were trying to collect a supply in

preparation for returning to work, however, many mothers talked about starting stashes

specifically as a way to deal with their anxiety that someday their breasts would just stop

producing enough milk. Also, making stashes simply to prepare for a return to work

doesn’t explain the extreme and ritualistic lengths that many mothers went to. Working

mothers, or mothers who might want to be able to go out on occasion and leave the infant

with a babysitter, don’t need 250 plus bags of milk that will expire after 6 months in the

freezer. Regularly pumping and collecting large amounts of breastmilk, however, gives

many women a sense of reassurance that there will always be breastmilk for their infant,

no matter what happens. The collection isn’t a casual affair – the mothers posting their

stashes on social media keep a running count of how many bags or how many ounces

they have collected. A La Leche League leader told me that women get panicked over

variability in pumped milk volumes, which aren’t necessarily an indicator of low supply:

That’s another thing that I get as a leader . . . The baby’s 5 days old and one day they’ve got 4 ounces and the next day they get a half an ounce and they are panicked. And I’m like, I just have to talk them off to put the pumps away for a minute. And some want to pump right away to get their stash going and it’s almost a competition, who can pump the biggest stash.

Women who pumped were often so focused on how much milk was filling the bottle, that

lactation consultants sometimes told worried mothers to cover their pump with a towel in

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order to reduce their anxiety. Pumping rituals, however, were performed by women in

order to reduce anxiety. The pump isn’t a reliable measure of how much breastmilk a

woman has, because it isn’t as effective as an infant at removing milk from the breast

(Riordan and Wombach 2010). Also, some women’s bodies don’t respond well to pumps

(Riordan and Wombach 2010).

Quantifying techniques that become ritualized serve to reinforce the technocratic

model and its values. This is evident because like in the example of the breastmilk

stashes, it isn’t necessary for breastfeeding. Also, enumeration does not always advance

the well-being of infants or make breastfeeding easier (Dixon-Whitaker 2000). As ritual

it is an avenue for reasserting values rather than providing an objective truth.

Enumeration, however, is thought to lead to certainty because it is a practice that is

supposedly outside of culture (Adams 2016; Brunson and Suh 2020). A comparison with

a society that does not utilize quantifying modalities, illuminates how it is value laden.

The Khmir peoples of Northern Tunisia did not traditionally practice counting,

where it is now restricted to the marketplace and is associated with inequality (Creyghton

1992). Enumerating is considered incompatible with their concepts of baraka, the life

force that is transmitted through breastmilk, and sharing, which maintains equality within

the family (Creyghton 1992). Thus, when breastfeeding problems are encountered, it is

considered a qualitative problem with the milk, and not a quantitative problem

(Creyghton 1992). Rituals of enumeration in the U.S. reinforce the inadequacy of the

mother’s body, and their focus on efficiency alienates women from their bodies, causing

them to view it as an object that is part of a system outside of themselves. We tend not to

view milk as qualitatively deficient but are obsessed with whether or not there is enough

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milk. The Khmir perform a ritual when there is a breastfeeding problem that reasserts the

ability of the mother to make milk that is full of life-giving force and reasserts her ability

to maintain the well-being of her family. (Creyghton 1992). Technocratic rituals, on the

other hand, separate women from their body processes and make them feel their body is a

machine liable to fail and in need of management to insure enough product. (Davis-Floyd

1992) Thus, one culture’s ritual reasserts a mother’s power and the other reinforces the

idea that she is inadequate. The values associated with the Khmir ritual are reciprocity

and equality (Creyghton 1992) while the values associated with breastfeeding

quantification modalities are the hierarchy and inequality that biomedical expert

knowledge entails.

Quantifying infant well-being can fail to live up to the efficiency and certainty

that it purports to do. I examine how this is so not to suggest metrics are never warranted

or never give useful information, but to show that these practices can be ritual practices

that are culturally constructed.

What is a sufficient supply?

Determining what constitutes a sufficient supply of breastmilk has been

approached by trying to measure how much breastmilk a baby with adequate weight gain

consumes. Studies that have tried to determine this have varying ideas of what constitute

appropriate weight gain in breastfed infants and have not agreed on when those

measurements should be taken (de Onis et al. 2004; Dewey et al. 2003; Lukefahr 1990;

M. Neifert et al. 1990). There is also not a standard definition for what constitutes an

insufficient supply of milk (N. F. Butte et al. 1984; Dewey et al. 2003; M. Neifert et al.

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1990; Neville et al. 1988; Stuff and Nichols 1989). Because we do not have an agreement

on these standards, measurements of milk volume cannot be said to represent a clear-cut

indicator of a sufficient supply or that a baby is transferring an adequate amount from the

breast.

Tracking input and output

A reliance on tracking infant intake and output is encouraged in the hospital. After

giving birth, women in the postpartum ward may be given logs to keep track of how often

the infant fed, how they were fed, how long they fed, whether they fed from one breast or

two, and how many wet and soiled diapers the baby had in a 24-hour period (AAP 2005).

Keeping a record of breastfeeding times is not an indicator of how much the infant drank

in a breastfeeding session. Mothers may mistake frequent feeds in the first month, also

called cluster feeding, as evidence that the baby is hungry and not getting enough milk.

Cluster feeding, however, is a normal method that infants use during this time of rapid

growth to increase the supply. Likewise, mothers may suspect they don’t have enough

milk when infants developmentally become more easily distracted at three months of age

and may breastfeed more frequently but for much shorter periods of time.

The amount of wet or soiled diapers a baby goes through in a day are counted as a

measure that is supposed to reflect the amount of milk taken in (AAP 2005). Nurses or

lactation consultants record this information along with the infant’s weight in the

patient’s computerized chart in order to get an idea of whether or not the infant is getting

enough breastmilk (AAP 2005). This system can be problematic for getting useful data.

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Women who are given IV fluids during labor will have a baby who is born with extra

fluids in their system (Noel-Weiss et al. 2011). The infant receives fluids in the womb

through the placenta, and the urine output will not accurately reflect the amount of

colostrum that is ingested for sometimes up to three days postpartum (Riordan and

Wambach 2010). The infant is typically weighed right after birth and the weight is

inflated due to those extra IV fluids (Noel-Weiss et al. 2011). Eventually the infant

urinates the extra fluid out, making the normal postpartum weight loss seem more

extreme than it really is (Noel-Weiss et al. 2011). Mothers are then made to unnecessarily

worry about their milk supply, with some doctors telling women whose infants have a 7%

or greater weight loss to supplement the infant with formula (AAP 2005).

Recording stools and expecting it to accurately reflect breastmilk intake is also

problematic. A study found that the daily recording of the number of stools an infant

produced was not correlated with weight loss, but the total amount over a two-week

period did predict whether birth weight was regained sooner or later (Shrago, Reifsnider,

and Insel 2006). Another study found that during the first two weeks of life, “diaper

output measures, when applied in the home setting, show too much overlap between

infants with adequate versus inadequate breast milk intake to serve as stand-alone

indicators of breastfeeding adequacy” (Nommsen-Rivers et al. 2008). Color changes in

the stool may be a more accurate way of using the stool as a way to determine infant

intake after birth (Shrago, Reifsnider, and Insel 2006).

During my participant observation at a hospital there was a lactation consultant

who was skilled at getting infants who had not stooled to defecate with rectal stimulation.

She said that many of them were producing stool, it just hadn’t been excreted. If these

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infants hadn’t passed enough stool they likely would have been supplemented and

mothers would have internalized the idea that they had faulty bodies.

Measuring milk with a pump

The pump is a poor measure of how much breastmilk a woman has because it

may not be as effective as an infant at removing milk from the breast. Also, some

women’s bodies don’t respond well to pumps and may get little to no breastmilk out

while using one despite having plenty of milk (Riordan and Wambach 2010). Mothers

may also expect pumped amounts to increase as the baby grows, but while the newborn

increases the amount of breastmilk that they drink during the first month, the volume of

intake stays the same from one month of age until the infant starts eating solid foods

(Nancy F. Butte 2005). This means that a 5 months old infant drinks the same amount of

breastmilk as they did at 1 month of age and yet they grow and gain weight. This is

because breastfed infants grow rapidly at first, but then their growth rate slows down

(Nancy F. Butte 2005). Mothers who pump milk and expect the amount to increase over

time may resort to giving their infants increasing volumes of their breastmilk in a bottle

or feel they need to supplement with formula.

Pre and post breastfeeding weights

Lactation consultants sometimes weigh an infant before they nurse and weigh

them again after they nurse. The difference in weights represents breastmilk intake. One

of the problems with doing pre and post breastfeeding weights on infants is that

breastmilk itself is ever changing. A mother produces different amounts of breastmilk

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throughout the day (Lawrence and Lawrence 2011). The fat content in each feeding also

varies, and if an infant gets less fat in one feeding they will be hungry sooner (Riordan

and Wambach 2010). If a mother is nervous it can inhibit her milk ejection reflex so that

a pre and post weight would not reflect a breastfeeding session where the milk flows

freely in a relaxed environment (Uvnäs-Moberg et al. 1990). Growth spurts and

consequent cluster feedings can also confuse since an infant will intake more milk at

these times than they normally do. Breastfed infants regulate their own intake according

to their needs (Lawrence and Lawrence 2011). Parents, however, will often be lured to

breastfeeding support groups by the suggestion that they can have their baby weighed,

and will sometimes inquire about or actually purchase infant scales.

Growth charts

Breastfed infants gain weight differently than formula fed infants. Their weight

trajectory is usually slower after 4 months of age than formula fed infants (Grummer-

Strawn et al. 2010). Pediatricians either use the CDC growth chart, which is based off of

a measure of children of various ethnicities and incomes in the U.S. who were fed either

formula or breastmilk; or The World Health Organization (WHO) chart, which is based

off of the measurements of exclusively breastfed children in selected countries

(Grummer-Strawn et al. 2010). WHO wanted to determine what the biological norm was

by recording the growth of exclusively breastfed infants only (Grummer-Strawn et al.

2010). If pediatricians use any chart other than the WHO chart in infancy, they may

determine that breastfed infants have an inadequate growth pattern. Furthermore, parents

may not understand how to interpret growth charts and they may focus on whether or not

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the infant is following a high or low centile rather than focusing on consistent growth

(Sachs, Dykes, and Carter 2006). They tend to value a high weight gain in comparison to

other infants over consistent growth in their infant. Thus, a relatively small child who

nonetheless is growing consistently, often gives rise to parental concern (Sachs et al.

2006).

Reliance on the above quantifying modalities does not always offer the clear-cut

objectivity and certainty that people believe that they do. Entering into quantifying

practices with the understanding of their possible weaknesses, and analyzing a situation

using various types of available data and not quantifying data alone, would seem to be

sensible. However, to do so is to give up the feeling of certainty that the quantification

offers.

Breastfeeding and Epistemology

When I began this research, it had been many years since I myself had breastfed,

yet I could still recall the unique sensation of the letdown of milk into the milk ducts. I

had experienced this sensation as incredibly intense and relieving, followed by a sense of

whole-body relaxation. A tingling type of sensation accompanied a sense of pressure that

always preceded the letdown. I could feel warmth and a kind of euphoria spread through

my body as the feeling of pressure released along with a strong spray of milk. It was an

intensely physical sensation and yet it had an emotional component as I felt both physical

and emotional warmth and good feelings wash over me. I felt such love for my babies as

I felt my milk, like liquid self, being given to them as an act of nurturance. I was thus

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surprised when during my ethnographic research and many years after I had weaned my

last child, I experienced the letdown sensation all over again, but without the milk.

At the time of the phantom letdown, I had just begun observing mothers and

babies enacting breastfeeding. I was there to help them, and yet in the beginning I had felt

insecure about how to go about informing mothers as to what to do. My body, of course,

knew what to do in the same way that I knew how to walk or ride a bicycle; I did these

activities without conscious thought and my body maintained a memory of how to do it.

How to break that down into steps that could be taught, however, was another matter. I

had not been taught how to walk or ride a bicycle with instruction. I simply tried to

mimic what I had seen other people do, lost my balance, and fell repeatedly until I slowly

gained a sense of balance through trial and error. This type of learning is both social, in

that I observed what riding a bike looked like, and was also dependent upon the active

use of my body. As I looked at the babies and saw all of those tiny, hungry mouths

gaping as heads turned, saw the legs cycling, and the fists coming to the mouth, my body

responded because it knew. My body knew how to respond to those signals with a

reflexive memory, and I found myself time and again taken aback and unable to speak for

a moment as I felt the familiar tingling, the pressure, the warmth, and braced myself for a

sudden spray of milk that never came. I wondered if I should start putting pads in my bra

when I worked with mothers just in case I actually started leaking milk.

I didn’t mention this phantom letdown sensation to anyone because it seemed like

something that shouldn’t be happening, and I thought I would sound crazy if I mentioned

it. As part of my certification requirements I registered for a lactation class that I had to

fly to California to take. One day the instructors discussed the let-down sensation with

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the class. We were told that this was a partially conditioned reflex that can occur

following a repeated signal. Normally, the let-down is triggered by the infant suckling

and stimulating nerves in the breast. These send a signal to the brain to release certain

hormones into the blood that then cause the milk to eject into the milk ducts and out the

nipple pores. Often, however, breastfeeding mothers will have a let-down just from

hearing a baby cry, even if it isn’t nursing or isn’t their own. We also learned that the

letdown reflex can be impeded by stress related emotions such as anger, anxiety, or

embarrassment. It could also be impeded by pain. In such a case we were told it helped if

mothers could relax. Pumps could also make it hard for some mothers to have a letdown.

The instructors recommended telling the pumping mother to focus on the sensory aspects

of their infant. It was suggested, for example, to have a photo of the baby to look at, a

piece of the infant’s clothing to smell, or a recording of the infant crying. Without these

objects a mother could visualize these things. She would hopefully register these sensory

stimuli as belonging to her baby, and her body would respond with a letdown.

I too had experienced the letdown reflex from hearing other babies cry when I

was a breastfeeding mom, and I had experienced this unexpectedly since no one had told

me it could occur. I also had no control over the stimulus or the letdown response. My

milk would letdown without warning and usually only then would I consciously register

that someone’s baby was crying. I would feel the urge to feed the baby and would remind

myself that feeding strangers’ babies wasn’t socially acceptable. The urge was

accompanied by a discomfort that a baby was distressed. Hearing the baby cry while my

breasts were releasing milk intended for it that it was not getting would unnerve me, and I

would have to walk away.

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When the class took a break, a woman who was also working towards her

certification, reported that a strange thing had happened to her as she had begun working

with moms and babies. She was finding herself having phantom letdowns around the

babies, as if she were actually lactating, except that she wasn’t. Like me, she had once

breastfed but was no longer, and the fact that what she was experiencing was the letdown

sensation was unmistakable. I felt brave enough at that moment to share that I too was

experiencing this and asked if there was anyone else in the class who had. We were the

only two. I found only one mention of the phantom letdown in subsequent research. It

was reported in a breastfeeding textbook that referenced a doctor who had reported that

some women had this experience when they were no longer lactating (Lawrence and

Lawrence 2016, 265). The textbook said that this sensation had even been reported in

post-menopausal women and included the letdown’s “tingling and turgescence” when

they heard an infant cry or experienced some other baby related stimulus (Lawrence and

Lawrence 2016, 265). It stated that it did not result in actual milk being secreted

(Lawrence and Lawrence 2016). Some women are able to induce lactation without

having given birth, but to do so requires frequent breast stimulation by a suckling infant

or the use of a pump (Riordan and Wambach 2010), which isn’t the case for phantom

letdown, which is sensation without consistent manual stimulation or actual milk

produced (Lawrence and Lawrence 2016).

The phantom letdown is significant because it shows that our perceptions are

constructed. It is an embodied experience in which memory of past sensations within a

context are experienced as material, in the same way that a phantom limb is an

experience of a part of the body that no longer exists. There is no actual milk in the non-

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lactating breast that experiences the sensation of milk moving down into the milk ducts.

Perhaps what one feels is not the milk moving down per se, but the contractions of the

alveoli that cause the milk to move. However, even this is dependent upon hormonal

conditions that are seemingly not present in the non-lactation breast, and certainly the

sensation of pressure would likely be dependent upon a buildup of milk (Lauwers and

Swisher 2015). The textbook did not explain why or how this occurs, but for me it was

clear that my body was responding to hungry infants without my conscious direction,

much like the conditioned response of the lactating mother to a stranger’s crying baby.

Only in the phantom letdown, my mind/body was causing me to experience a sensation

that couldn’t physically exist, and in doing so it was offering me a response to the hungry

infant’s expression of affect. The stimulus for that response was a cry, but women have

been able to purposefully use a variety of sensory stimuli that are related to the nurturing

of infants to cause letdowns when they need to pump (Lauwers and Swisher 2015). For

example, one mother who participated in this research talked about sniffing baby powder

to stimulate a letdown because it smelled like her infant.

My body’s automatic response to hungry infants and its ability to produce a

simulation of reality that seemed material and lived in my body, calls into question how

knowledge is produced, what it means to be embodied, and what embodied knowledge is.

Exploring these answers in the context of breastfeeding helped me to understand

women’s experiences of breastfeeding and the ways that I frequently observed lactation

consultants help them with breastfeeding difficulties.

There are feminist objections to traditional epistemology. Cartesian epistemology

allows for a disembodied knowing, and propositional knowledge presumes a male

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knower. Traditional epistemology is not situational and does not attend to how we are

constituted as subjects, which entails who gets to know and how authoritative knowledge

is constructed. Knowledge, as Donna Haraway (1988) points out, is always situated

because the knower is an embodied person in a particular place in a particular time

period, and their perception is formed and changes according to these particularities.

Susan Hekman (1997) calls for a feminist epistemology that destabilizes dualist

categories that are present in Cartesian epistemology, such as nature/culture,

rational/irrational, and subject/object.

Lorraine Code (1991) argues that propositional knowledge assumes an individual

male knower in that it is based on gendered stereotypes. “S knows that P” is detached

from emotion and is based on an individual knower who knows objects objectively

instead of subjects subjectively. In addition to distinguishing between knowing – that and

knowing – how, epistemologists have recognized the category of knowing persons, or

familiarity. This type of knowing, as well as knowing – how, is usually ignored in favor

of a focus on propositional knowledge. Lynn Hankinson Nelson (1990) draws attention to

interdependence in the production of knowledge rather than the Cartesian individual.

Knowledge production is collaborative and justified true belief comes from a social

reality that determines what and who we believe. It is important to consider the context in

which the knower is enmeshed.

Code (1991) argues that knowing others is relational and requires empathy,

intimacy, and sociality, which are based in gender stereotypes associated with females,

while propositional knowledge is rational and thus feeds into male stereotypes. Susan

Bordo (1990) and Genevieve Lloyd (1984) looked at how emotions have been excluded

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from rationality in the philosophic tradition. Because they are associated with femininity

and irrationality, they have been seen as unimportant, and things to control. Carol

Gilligan (1982) claimed that male and female socialization accounts for differences in

moral reasoning styles between the genders. Those differences were concerns with

relationships and a more permeable boundary to the self among females, that lead to a

moral reasoning based in relationality and emotion.

Marion Young (2005) also points to the permeability of boundaries in reference to

pregnant embodiment. She is critical of existential phenomenological perspectives that

exclude the experiences of women’s bodily experiences. While authors like Merleau-

Ponty (1962, 1968) challenged Cartesianism, they also identify with a “unified subject,”

while Young (2005) speaks of pregnancy as “a body subjectivity that is decentered,

myself in the mode of not being myself” (49).

The privileging of male voices in epistemology means that one idea of rationality,

justification, and knowledge is presented without consideration for the role of affect,

emotion, the body, and relationality in cognition. This itself is one way of seeing how

epistemic theories and practices are biased by power relations. Knowledge claims are

assumed to be objective truth, which is another way in practice of reinforcing hegemonies

of authoritative knowers, such as doctors.

Just as we can make a case that knowledge production is collaborative and

relational, we can also make a case that embodiment is relational because it begins

through interaction with a caregiver. Because infants are unable to regulate their own

nervous systems, they rely on a caregiver to do this for them (Bergman 2017; Feldman

Barrett 2017b). When a caregiver makes an infant feel comfortable, she or he does so

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within an environmental and cultural context. The infant learns these contextual allostatic

responses to changes in the body and this wires the brain so that eventually they will be

able to regulate their own body (Bergman 2017; Feldman Barrett 2017b). For example,

skin-to-skin contact facilitates neuro-feedback mechanisms between the infant and the

mother (Moore et al. 2012). It helps regulate the infant’s temperature and heartrate and

reduces stress (Moore et al. 2012). The infant who cannot self-regulate and is denied

touch, “exhibits disassociation, conserves energy and, to foster survival, will feign death,

a passive state of profound detachment where blunting endogenous opiates are elevated

and the heart rate and blood pressure are decreased” (Marmet and Shell 2017, 401). We

can thus say that it is through the touch and responsiveness of another that the infant is

embodied instead of detached. The embodied infant forms a sense of self in relation to

another, and the infant and caregiver relate in an interbodied way (Ryan et al. 2010).

Neural pathways are formed towards the goal of eventually achieving self-regulation of

bodily systems (Bergman 2017).

We continue to affect each other’s bodies past infancy, making the individual

embodied experience personal yet socially influenced. Breastfeeding is learned, and

women have what is often unappreciated and unrealized embodied knowledge that can

guide them. This isn’t the same as instinct, which is preprogrammed, but is acquired as

the body, through action, interacts with the world. From a phenomenological perspective,

our senses make sense of the world (Merleau-Ponty 1962). To the phenomenologist

Merleau-Ponty (1962), we relate to the world through our bodies and sense experience is

the first way we encounter the world (Merleau-Ponty. 1962). Understanding grows out of

our body’s experience in the world and is therefore embodied. The sociocultural aspect of

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perception that influences what is available to your senses and also provides that stimulus

within a context, is what Merleau-Ponty (1962) referred to when he said that affect is

asocial but not presocial. It isn’t presocial because we are born into culture and can’t

remove ourselves from it.

Preconceptual, embodied experience will become categorized and interpreted

based upon the concepts we hold, and this too is socially influenced. We form

expectations based upon past experiences that have occurred in particular contexts, and

this allows us to filter out noise and direct our attention to elements of the sensory array

that are relevant to our expectation (Feldman Barrett 2017b).

Although there is a real world that our senses help us to make sense of, everything

we learn is learned with a body in a social context. This includes what Marcel Mauss

(1973) referred to as the habitus, his term for a kind of know-how; techniques of the

body, or manners of moving or posture that are socially formed through imitation and

training. Among his examples were ways that the positions that women give birth in vary

by culture, and that each culture also has its own techniques for holding and caring for

infants. Its postures, body skills, tastes and mannerisms are dispositions that seem natural

to us rather than inculcated (Bourdieu 1977, Mauss 1973).

Tomori (2018) refers to breastfeeding as habitus but adds that it represents an

“intercorporeal body technique” (56). Thus, both the mother and the infant enact it

together. Breastfeeding isn’t often publicly seen in the U.S., giving women few

opportunities to view its techniques. While modeling actions can be attempted by having

someone verbally instruct you in how to breastfeed, or by reading about how to do it and

then recreating what you have read, this becomes more like a set of instructions and

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misses the dynamic nature of breastfeeding as well as the body form and signals that are

tacitly produced. There is an embodied aspect to socially produced learning, meaning it

lives in the body.

Mirror neurons fire whenever we perform an action, but they also fire when we

see someone else perform that action (Rizzolatti and Craighero 2004). It is thought that

the neuron “mirrors” the other’s action in a kind of simulation as if the observer is the

one performing the action observed (Rizzolatti and Craighero 2004). The simulation we

create causes a response in the muscles needed to perform the action. This is an

unconscious process (Rizzolatti and Craighero 2004) and is different from a verbal,

instructional form of modeling.

Breastfeeding is both highly relational and physical and embodied knowledge

offers a different kind of knowledge than headwork or propositional facts that are

logically deduced. Breastfeeding is dynamic; milk composition, immunological

properties, and volume adjust in response to changing infant needs (Riordan and

Wambach 2010). The body can be a source of information through its feedback to infant

and mother behaviors. As a dynamic, complex system, it is not just breastmilk void of the

woman who is breastfeeding an infant. The milk comes from her body, but I argue that

her environment and concepts influence behaviors and impact breastfeeding outcomes. A

lactation consultant who I interviewed expressed this idea by referring to differing

cultural concepts and headwork versus embodied knowledge:

I think that [moms] get over educated sometimes too. And so, they’ve got so much knowledge in their heads, they think everything is a problem. And I think that in other cultures breastfeeding is so widely accepted, and your mom and your sister all breastfed and they’re there helping you . . . I am sure that there are women in these Indigenous cultures that have got inverted nipples, but do they know anything? Is there anything for them to read online that says “Oh, you’re

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going to have trouble breastfeeding when you have inverted nipples?” So, women just probably have their own ways of dealing with that inverted nipple and getting it pulled out . . . [breastfeeding problems are] induced by our society.

Not all cultures think of women’s bodies as dysfunctional and likely to fail (Davis-Floyd

and Cheyney 2019) The concept of the likely to fail female body focuses women’s

attention away from the ways that the technocratic model is making them into docile

bodies. With their attention focused on potential failures of the body, the body either no

longer becomes a source of knowledge, or what it is saying is interpreted through an

ideological lens.

A Phenomenology of Breastfeeding

Csordas (1990) advises that the goal of a phenomenological anthropology is to

“capture that moment of transcendence in which perception begins, and, in the midst of

arbitrariness and indeterminacy, constitutes and is constituted by culture.” (p. 9) I use my

ethnographic data to attempt this process in order to show how the experience of

breastfeeding is culturally formed in order to make sense of women’s experiences and the

responses of lactation consultants. In order to accomplish this, I will examine cases

pertaining to letdown and mysterious breast pain related to lactation. Perceptual errors,

ambiguities, and novel experiences may be usefully examined in order to understand how

culture forms our concepts and to better support breastfeeding women.

Mysterious Pains

During my ethnographic research I noted that not only were women often

confused about what a letdown was supposed to feel like and whether or not they were

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having them, but there were also times when they described deep breast pain that

confused them. The pains that were described occurred in a manner that caused me to

believe these women were likely experiencing a letdown sensation but hadn’t identified it

as such. This is because the descriptions were those of a more intense letdown sensation,

and because they occurred either right before or at the beginning of breastfeeding or

pumping, or in between nursing sessions when there could be a stimulus that triggers a

letdown. These cases also did not show visible signs of infection and there was no nipple

blanching or nipple pain, which could indicate a different cause. The letdown can occur

just before breastfeeding if it is occurring in response to the stimulus of infant cues rather

than after the infant has initiated suckling (Riordan and Wambach 2010). Letdowns just

before or at the beginning of nursing are generally more intense and subsequent letdowns

that happen during feeding are often not felt, which would explain why some women

didn’t report the sensations occurring while breastfeeding (Lauwers and Swisher 2015).

Lactation consultants sometimes interpreted the mystery sensations as possible

vasospasms or thrush (yeast infection) of the breast based upon the descriptions that

women gave, but most often they considered them mysterious and their conclusions a

guess since the descriptions didn’t quite match any of these precisely.

Whether or not these sensations really were letdown or not is not the focus here,

rather the focus is on the disconnect women felt with what was happening in their bodies,

and how they make sense of novel or confusing sensations. This disconnect in making

connections between sensations and their bodily processes, is not out of place when

women are feeling a new sensation they have never felt before, and that doesn’t

necessarily fit with their expectations. As children we learn what various interoceptive

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sensations represent (Feldman Barrett 2017b). With novel sensations we have not yet

experienced or learned, the brain tries to assign it to something it is similar to by

matching the current pattern against past patterns (Feldman Barrett. 2017b). If the

incoming sensory information does not adequately match the concept you have, the brain

might correct the error of miss predicting, but sometimes it won’t (Feldman Barrett

2017b).

Feldman Barrett (2017a, 2017b) and Feldman Barrett and Bliss-Moreau (2009)

describe the mechanisms behind perception from research in neuroscience. They state

that neurons in the brain are intrinsically active, anticipating sensory input before it

happens in reality. Thus, we are not passive recipients of sense data that stimulate our

senses so that we have a direct experience of reality. Rather, our brain continuously

makes predictions about what we will encounter based upon memory of similar instances

that have occurred in the past (Feldman Barrett and Bliss-Moreau 2009; Feldman Barrett

2017a, 2017b). We construct a simulation of the predicted reality through concepts and

then react from that conceptualization (Feldman Barrett and Bliss-Moreau 2009; Feldman

Barrett 2017a, 2017b). We feel sensations based upon these predictions, before the

sensory stimulus ever reaches our brain (Feldman Barrett and Bliss-Moreau 2009;

Feldman Barrett 2017a, 2017b). Once the stimulus reaches the brain, we are able to

determine whether or not the prediction is correct (Feldman Barrett and Bliss-Moreau

2009; Feldman Barrett 2017a, 2017b). Cases such as phantom limbs, PTSD, or chronic

pain are thought to be instances where the false prediction is never corrected (Feldman

Barrett 2017b).

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If a concept does not exist in a culture, it will not be experienced (Feldman Barrett

2017b). Something novel, however, can be similar to something you have previously

experienced and have a concept for. The brain is not trying to determine what an object

or experience is exactly, but what it is most similar to in your past experiences (Feldman

Barrett and Bliss- Moreau 2009; Feldman Barrett 2017a, 2017b). This becomes important

when we try to understand how we make meaning out of novel experiences.

Anthropologists have debated definitions for culture, but in this dissertation, I use

it to indicate systems of meaning making that are shared in localized groups. The

categorization of affective states that occur in particular contexts enables us to

communicate with others who share our concepts, or in this case emotion concepts.

Concepts make meaning and if they are shared by others, they allow us to be understood

(Feldman Barrett 2017b). A display of emotions, for example, signals your internal state

to others if you have culturally shared concepts and exhibitions, and creates a bodily

response in them as well (Feldman Barrett 2017b).

The example of letdown shows that the body thinks and responds before we are

conscious of it. This does not mean that the brain is not involved, however, but that there

is a feedback loop between the sensory stimulus and the brain that considers sensory

information, expectation, and likelihood that we are not consciously aware of. For

example, we may flinch before we consciously register that we flinched because we

thought we detected a spider, only to then correct this error when we discover that the

“spider” is actually a piece of fuzz hanging off of an object. Both cognition and motor

systems are thought to have co-evolved and are interdependent (Leisman et al. 2016) The

brain is not separate from the body, but a part of the body.

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In terms of what a woman might expect a letdown to feel like, it is usually

described using the words tingling sensation, pins and needles, a feeling of warmth, and

pressure (Britton 1998). It is not usually described as painful in most material that

mothers might read (Britton1998). Cathryn Britton’s (1998) research found that women

often read about letdown, but the materials that they read present it in consistent terms

even though women’s own experiences varied, and many had difficulties describing the

sensation. The degree of intensity of the feeling is likely related to the volume of milk

being ejected and moving through the milk ducts (Lauwers and Swisher 2015). A

lactation consultant mentor taught me that if the letdown is too forceful, the baby might

compress the breast with their jaw in an attempt to staunch the flow and this will cause

pain during the letdown. The letdown occurs more than once in a breastfeeding session

and often women will only feel the first one, which may contain the most milk volume,

and is a likely explanation for this (Lauwers and Swisher 2015). The only physical

intensity usually described in materials women read about breastfeeding is associated

with nipple pain from bad infant latches, plugged milk ducts, or mastitis. The intensity of

the letdown along with the variations in how they experienced it, often took women by

surprise. Thus, women interpreted these mysterious sensations as a problem rather than a

normal variation because the sensations did not correspond to an identifiable pattern that

they might have heard or read about.

Expectation is what determines our perception, and during perceptual processing

expectation can suppress reality, or we can learn from the error and correct it (Bruner and

Minturn 1955; Bugelski and Alampay 1961; Feldman Barrett 2017b). The famous

example of research subjects not seeing a man in a gorilla suit walk across a basketball

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court because they did not expect it, is one example of this inattentional blindness

(Chabris and Simons 2011). When those subjects were told that they missed the gorilla

and were shown the video a second time, the man in the gorilla suit was detected because

they now expected it (Chabris and Simons 2011). When women were unaware of when

they were experiencing a letdown, the lactation consultants often directed women’s

attention to the particular parts of the sensory experience that were important letdown

signs, such as having a woman observe how her milk transitions from a drip to a spray

and asked if she felt tingling in the breast during the moment of transition. This amplified

those details and the top-down processing no longer suppressed the experience of that

sensory information since there was now concept formation of what a letdown experience

is like. The novel sensations women reported were not always easily identifiable though.

One mother said she has a “sharp, deep pain” that usually occurs when she starts

pumping or when the baby is crying. It occurs on both sides. While the moments that it

occurs along with its bilateral nature fits with a letdown, the descriptor of the sensation as

“sharp” is not a descriptor most people associate with letdown. This could account for the

confusion over what the sensations signified. When women were prompted to further

describe these sensations, they sounded like a more intense version of what is typically

described as a letdown. For example, a mother reported a “burning” sensation at times

when she wasn’t breastfeeding and said it was accompanied by a “sharp pain.” She said it

hurt on the “inside” and “all the way around” the breasts. When she tried to offer more

detail about the “sharp pain” she described the sensation as “kind of like electric shock,

or like a needle poking in.” This electricity that feels sharp could be an intensification of

the tingling that women typically report. Likewise, her description of it feeling like a

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“poking” needle going into the body coincides with the less intense description of “pins

and needles,” a metaphor that women sometimes use to describe the sensation.

Additionally, the “burning” sensation she reported, could be seen as an intensification of

the warmth that is often described in relation to the letdown. One woman reported feeling

“sore.” Many women describe breastfeeding pain as “sore,” and without further

elaboration her description would likely be assumed to be caused by the pain of a bad

latch or the start of a breast infection. Upon further exploration of what she meant,

however, she said that she experienced sensations within the breast that felt like

“electricity” and an “ache” that happened at times while breastfeeding, and at times when

the baby was not attached. It was not a constant sensation but was episodic.

The difficulties of finding the appropriate language to describe a novel sensation,

can be seen in a woman who reversed the trend above of describing an increased intensity

of a feeling quality she was concerned about. She reported mysterious “pains” that she

described as “tingling.” She described the sensation as painful, but she also used the

descriptor of “tingling” which is a common description used to describe a letdown that is

usually not associated with pain. Her description of the sensation did not match the

intensity of pain she reported, and in describing it this way she exposed the possibilities

for what is happening here. Her description is as odd as saying that someone brushed

their fingers across your skin and the brushing sensation was painful. It is not odd,

however, if you consider the research done on sensory expectations in regard to taste, in

which subjects expecting salmon flavored ice cream to be strawberry flavored, reacted

with disgust while those expecting it to taste like salmon mousse enjoyed it (Yeomans et

al. 2008).

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Research shows that if there is a small difference between expectation and

sensory information, the brain will make an adjustment to align the two (Barrett and

Simmons 2015; Feldman Barrett 2017; Cardello 2007; Schifferstein 2001; Chennu et al.

2013; Kok and de Lange 2014). If the difference is large, however, the hedonic appraisal,

or the degree of unpleasantness, will be greater and that difference is amplified so that the

food in this example is experienced as disgusting (Barrett and Simmons 2015; Feldman

Barrett 2017; Cardello 2007; Schifferstein 2001; Chennu et al. 2013; Kok and de Lange

2014). This has been shown to apply to other examples besides taste experience. In

medicine, for example, research on placebos and nocebos has shown that a patient’s

expectations are important determinants for the outcomes of medical treatments (Enck et

al. 2013; Schedlowski et al. 2015). Other studies have shown a link between chronic pain

and expectation. (Gehrt et al. 2015; Holm et al. 2008) An expectation is a prediction, and

a construct. If a letdown sensation is experienced as a thing you don’t expect in a way

you don’t expect it, the unexpected can not only be thought of as an alarming dysfunction

of the body but also experienced as highly unpleasant.

Feldman Barrett (2017b) illuminates other ways that cultural context constructs

our interoceptive experiences with the example of the feeling of a churning stomach. That

churning stomach will be interpreted by us as a positive experience of hunger if we are

standing in a bakery when it occurs and are about to satisfy the hunger with a cookie. It

will be interpreted negatively as anxiety, however, if we experience the sensation while

we are in the hospital. The churning of the stomach in each case, however, is the same

prior to conceptualization; gastric juices are being secreted in response to a stimulus. The

construction of the sensation relies upon context.

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This example can help us understand how women make sense of lactation related

sensations and how this informs their choices. The context in which women first

breastfeed in the U.S. is usually a hospital. The technocratic model encourages women to

expect their body to malfunction (Davis-Floyd 2001). It also considers pain to always be

a problem that needs to be fixed or medicated (Davis-Floyd 2001). Hospital procedures

such as the weighing of infants, and the tendency for middle class mothers to research

what breastfeeding is supposed to be like through reading material, assumes simple cause

and effect patterns between identifiable facts in a reductionist model that fits our need to

clearly categorize and quantify. Thus, mysterious sensations that don’t follow the typical

pattern a woman expects may be thought of by her as problems. Problems like thrush are

always a possibility, but painful letdowns on their own are not cause for alarm. In

reference to the many women who were confused and concerned about an intense

letdown sensation, the absence of an identifiable letdown sensation, or letdown

sensations that seem to be episodic, these are all within a range of normal variation and

are not problematic. Additionally, putting together that a change in milk spray, suckling

speed, swallows, and a particular sensation are in fact a letdown, is difficult when the

focus within biomedical contexts and in society in general is on the volume of product

rather than on process (Davis-Floyd 2001; Ma 2018; Van Esterik 2012). In this research,

when women could not determine when they were having letdowns despite readily

available evidence, they often panicked and believed that they likely didn’t have enough

milk. When they noticed sensations that occurred at times or in ways they weren’t

expecting, they interpreted and experienced these sensations as some type of alarming

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dysfunction. Consequently, they tried to control the body with methods of quantification

and regimentation.

In biomedicine there is a focus on pain being a negative experience and a sign of

dysfunction. Women are told that breastfeeding isn’t supposed to be painful and pain

means a bad latch (Lauwers and Swisher 2015). Therefore, it is less likely that

breastfeeding mothers or lactation consultants would conclude that sometimes

breastfeeding is painful while the infant’s latch and the mother’s body are performing as

they should. This is likely even though there are atypical cases of painful but benign

letdown reported in textbooks. Because those in pain tend to respond to it with alarm and

the expectation that the pain will be treated, lactation consultants may be more likely to

reach a conclusion that would offer the mother a way to treat the pain and heal. In fact, in

all but one of the instances I have described here as possible letdown, the lactation

consultant I was observing told the mother that she likely had thrush and gave her

treatment instructions. In one case the possibility that it was letdown was presented, but

treatment for a possible case of thrush was offered just in case it wasn’t. Other instances

of complaints or problems that were not mysterious to lactation consultants because they

fit a known pattern, were usually treated differently in that the cause was clear. In those

instances, lactation consultants were able to help women focus on what their body was

revealing.

Emotions

Lactation consultants in this study, in confronting inattentional blindness among

breastfeeding women, were also trying to positively impact their feelings of self-worth.

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Women’s self-worth is often linked to their mothering accomplishments, including

breastfeeding. While doing this research I noted that when women experienced

breastfeeding difficulties they tended to express negative self-perception. The lactation

consultants in this study helped mothers who struggled to breastfeed in large part by

attempting to change women’s concepts, which included being attentive to their

emotional experience. Their emotional state and embodied experience were entwined in

ways that Feldman Barrett’s (2009, 2017a, 2017b) understanding of affect is able to

elucidate.

Affect is defined as simple feelings that are on two scales. One scale goes from

pleasure to displeasure, and the other scale goes from low to high arousal (Feldman

Barrett and Bliss-Moreau 2009). We perceive both exteroceptive stimuli and

interoceptive states, and affect arises from the integration of these (Feldman Barrett and

Bliss-Moreau 2009). Unlike affect, emotion can be considered a feeling that we have

given a name to, like anger. We have a name for it because we have categorized the

affect state based on concepts that are socially shared (Feldman Barrett and Bliss-Moreau

2009). Infants then can have affect but not emotion because emotion requires prior

experiences with which to differentiate between sensations in a cognitive process, and the

use of language (Feldman Barrett and Bliss-Moreau 2009).

The Theory of Constructed Emotion posits that emotions like happiness and anger

are not represented in the brain but are created (Feldman Barrett 2009, 2017a, 2017b).

Anthropologists support a constructivist rather than universal theory of emotions as well,

recognizing variations in how emotions are understood, experienced, and expressed in

various cultures (Briggs 1970; Reddy 2012; Beatty 2019; Lutz and White 1986; among

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others). Emotions are learned, are not universal, and emotion is a concept, not a reaction

(Feldman Barrett 2017b). Not only are particular emotions not universal, but even how

we define the word “emotion” varies, with some cultures believing emotion is created

with others rather than being an individual experience (Uchida et al. 2009).

Because emotions are concepts, a woman’s emotional state can influence what

she perceives. Thus, providing breastfeeding women with emotional support was one of

the important aspects of support that lactation consultants in this study aimed to provide.

It was also important that women’s measure of self-worth was not coming from a system

that by its nature made her feel like a failure.

Conclusion

I have shown that culture influences what is available to our senses and provides

sensory stimuli within a context. Our preconceptual, embodied experience will become

categorized and interpreted based upon the concepts that we hold, which are socially

influenced. Embodied knowledge can also be ignored or interpreted through an

ideological lens. However, this doesn’t mean that the body, or the world for that matter,

are not ever accessible or informative. Embodied knowledge is acquired as our body

actively interacts with the world, and as our senses and concepts help us make sense of

the world. The lactating body provides women with the opportunity to understand its

relationality and dynamic functions through the feedback it offers.

When women don’t recognize the signs of letdown, mistake the sensation of

letdown for a dysfunction, when they think that their milk supply is insufficient when it is

not, or when they mistake their baby’s signals as hunger cues when they are an indicator

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of something else, these are not individual failures, but examples of how perception is

embedded in a cultural milieu. Social structure and ideology are what has created the

possibility for these perceptual failures, and a change in discourse is necessary.

The concepts women formed about breastfeeding and themselves as breastfeeding

mothers, came from other women, the research they did, and the environment of the

hospital and its symbolic messages relayed through the technocratic system of birth.

What women expected breastfeeding to feel like or be like had an influence on what their

actual experience was. Most of the lactation consultants that I observed were asking, is

the story the woman is being told or tells herself causing suffering or empowerment?

Through this they were selective about technologies and methodologies that they

employed and tried to present a different story that countered the idea that the female

body is dysfunctional. As I show in the next chapter, they used techniques that

encouraged women to focus on their embodied experience in a way that uncovered the

inattentional blindness that had been encouraged by ideological concepts.

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Chapter Six

Lactation Consultants Help Make ‘Sense’ of Breastfeeding

Introduction

This chapter presents case studies of lactation consultants that I observed

disrupting messages of body inadequacy that women carried. I observed how they limited

or selectively used technology and turned to approaches that would help women gain

embodied knowledge and confidence. I have argued that the body is informative, but our

embodied experience is constructed from culturally influenced concepts and many of

those concepts cause women to expect their bodies to fail and thus interpret their

experiences as instances of failure. In this chapter I show how turning to the body can be

empowering for women and present case studies that demonstrate how lactation

consultants in my study carried out this task while reshaping women’s concepts about

breastfeeding to positively change their experiences. This involved directing women’s

attention to particular aspects of their sensory experiences in order to ‘make sense’ of

breastfeeding.

While I engaged in participant observation with seven lactation consultants, I

highlight four case studies here. Quotes and stories from all of the lactation consultants

are placed throughout this dissertation, however, and many of those also address

embodied knowledge.

My observations of lactation consultants de-medicalizing and appealing to

embodied knowledge may not necessarily apply to all lactation consultants, or lactation

consultants at all times. For example, the prevalence of posterior ankyloglossia, also

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known as posterior tongue tie, is currently a controversial debate in the field. Some feel it

is being over identified and diagnosed and that infants suspected of having it should be

more cautiously examined over a period of time for related functional deficits before the

lactation consultant recommends a referral to a practitioner who can diagnose and treat it.

They note that the treatment is a procedure where the lingual frenulum under the tongue

is cut or lasered, making it not only painful but in some cases has caused infants to have

oral aversions. Additionally, they argue that claims and treatments are pushing ahead of

available evidence and more research is needed. Other lactation consultants believe that

posterior tongue tie is overlooked too often, and thus there isn’t enough proactive

treatment of it. There is a debate occurring about the topic because many lactation

consultants are cautious about anything that seems to medicalize breastfeeding more. The

use of nipple shields has gone through a similar evaluative debate about whether or not

they are overused by some as an easier way to deal with latch issues. Additionally, most

lactation consultants seem to utilize pre and post breastfeeding weights at least some of

the time and encourage mothers to keep breastfeeding logs while simultaneously de-

medicalizing in other ways. Although I have been critical of quantifying modalities, more

precisely, I argue that one should be critical of any medical modality when it is

unnecessarily or inappropriately used with the recognition that it may be appropriate in

some cases. I have therefore included in these case studies one example of a lactation

consultant who utilized pre and post breastfeeding weights with every breastfeeding

mother and yet was critical of the overuse of technology, saw de-medicalizing as one of

her aims, and practiced de-medicalization in other forms. Her case study was included in

order to offer context for how these types of decisions are made. Included in these case

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studies is also an account of participant observations at a clinic where Japanese lactation

massage was practiced. The Japanese lactation consultant who started this clinic

introduced the practice to Hawai‘i where it has become popular among the large Japanese

population, but is otherwise not commonly found in the U.S. It is, however, an example

of the use of techniques that draw women’s attention to their bodies as sources of

information. These case studies are important because they show how lactation

consultants perform their jobs, and how various embodied modalities are practiced to

counter disembodied practices and their messages.

Yui, in the Japanese Lactation Massage Clinic

I walked out of the Japanese lactation massage clinic in Honolulu with a first-time

client walking beside me. We made our way into the hot parking garage breathing in stale

air permeated with exhaust fumes, but the client was caught up in a kind of rapture and

seemed unaware of her surroundings. “That was amazing! That was amazing! That was

soooo amazing!” she said. “I could see my milk flying everywhere! I think I need to hug

you now or something. I’m having a moment!” She then grabbed ahold of me, a stranger,

and squeezed me in a tight embrace oblivious to the cars that screeched past us as they

tried to make the sharp turn without running us over. Just moments earlier she had come

into the clinic convinced that she had failed as a mother because her baby’s fussiness was

surely proof that her body was broken and she couldn’t do anything right. Seeing her

breastmilk spray out and splatter on the wall during the massage had upturned all the

messages of inadequacy that she had internalized and convinced her that she had enough

milk and her body was functioning properly.

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Inside the clinic, the enticing scent of essential oils, the stunning ocean view, and

the waiting area that was carefully put together to be comfortable and relaxing, belied the

frequent cries of distress and the curled fingers that often clutched at a massage table

behind closed doors. Yui, one of the three Japanese midwives and IBCLCs who provided

lactation massage during my time here, used a style of massage that was considered

painful. She was frequently requested, however, because many clients believed that the

massage wasn’t truly effective unless it hurt.

These practitioners received lactation massage training in Japan, which is taught

to midwives as part of regular post-partum care of women. Even though they were all

also IBCLCs, they preferred to be called midwives because of the idea in Japan that

lactation care is an extension of pregnancy and childbirth that is the purview of

midwives. Women stay in the hospital from 4-10 days after giving birth in Japan, in part

to make sure there are no issues with breastfeeding. In some hospitals, midwives offer

lactation massage during that postpartum period in cases where they think it may be

needed.

There are various styles of Japanese breast massage that one can learn. In the

forms that I observed, however, the massage resulted in streams and fountains of milk

spurting from the nipples, and at times it covered the walls and floor. The consultants

wore Japanese style smocks – which are like U.S. hospital gowns but more stylish – but

often emerged with a white frosting on their hair, and splatter on their arms and face.

Sometimes Yui massaged the milk splatter into the skin of her face, claiming it would

give her healthy skin. The mothers remained in their own clothes but were only clothed

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from the waist down. They brought several towels with them to mop up milk or keep it

off of their clothing.

Women often came to the clinic with complaints of plugged milk ducts or

mastitis, the latter of which is breast inflammation that can occur if the flow is obstructed

or if infection is present. Mastitis and plugged ducts often occur when women go too long

without emptying the breast. Some women came to the clinic because they had problems

with their milk supply, and the massage was a form of stimulation that would signal the

body to make more milk. The massage was also said to target adhesions in women with

inverted nipples so that the nipple could evert. Even though breastmilk was revered here

for its healing qualities, it was believed that it could also go “sour” if it sat too long in the

breast. Thus “maintenance” of the breasts was considered important to keep the milk

draining well and the ducts clear of the “debris” that would accumulate if milk stasis was

an ongoing issue for some women.

The clients’ who had mastitis came to the clinic in a state of desperation with hot,

red breasts that were as firm as a rock and extremely tender to the touch. They had fevers

and the chills, claiming the experience was like having “the worst flu” ever. Plugged

ducts presented as localized areas of hardness in the breast that were tender, and the

massage sometimes produced cheese-like strings of milk, or sand-like, gritty

calcifications. If the baby cried while the massage was in progress, they were sat with

their legs crossed like a “little Buddha” at the mother’s side and were bent at the waist to

nurse atop the breast that had already been massaged. The lactation consultant would

croon to the baby about how yummy the fresh milk must taste now that it was no longer

sour or sticky.

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Since sour and sticky milk is a product of milk stasis, the remedy is to remove the

milk and improve the flow. The lactation consultants took a highly sensorial, whole body

approach. Not only did the color and consistency of the milk provide important clues that

let them know when they had sufficiently extracted enough milk, but the muscles of the

entire body were felt for tightness that could be a form of restriction, the lymph nodes

were felt for enlargement, and the temperature of the skin on the chest, feet, and legs, was

also considered.

I was taught how to feel the difference between breast muscle and tight or slack

ligaments, and to even distinguish between different textures of muscle, with Yui once

having me feel a woman’s chest muscle that she felt was a good example of the type that

is especially “gristly, like gristle on steak.” She told me that the lymph is all connected,

even to the breast, and edema in the legs shows that the circulation is poor. When the

breast is drained of milk, she said you would notice that swelling would go down in the

feet and legs. She also stressed the importance of knowing “your landmarks and maps”

in the body that can be stimulated in what she called an “Eastern medical model.”

This sensorial, holistic approach included the emotional state of the mother, with

the consultant mentioning that congestion in the breast could also be associated with

holding the emotions in. When women cried out from pain during the massage, this was

considered a part of the entire release process that was essential to milk flow. As the milk

flowed, sometimes tears unrelated to physical pain flowed as well, with mother’s

expressing their difficulties with breastfeeding in particular and motherhood in general.

Their sufferings were embodied and were expressed through milk and tears. They were

massaged out with the old milk to make way for the new.

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A woman I interviewed who had been massaged by two different IBCLC

midwives at the clinic, explained her preference for Yui’s painful style of massage this

way:

In some sense I’m like, it needs to hurt to be right, you know, that kind of thing. You need to be getting the deep [places] that are hurting. …[The other lactation consultant] does a very good job, [and] I do, I feel emptied [when she massages me]. I feel like ready to start breastfeeding again, yeah; I feel very good when I leave. It is a totally different sense of touch [though]. It doesn’t hurt at all, it’s like barely even – it’s much more of a massage, you know, kind of thing. With [Yui] it definitely hurt. She’s a lot faster, and a lot rougher. I guess I felt like [Yui’s] hands had much more of the intuitive and the experienced fingers to them.

Yui’s ability to reach the deep and painful places was interpreted as a sign of intuition

and experience, but in her ability to know by touch. Her approach extended to the baby as

well, and the interconnection between the mother and baby’s bodies. Yui often explained

to mothers that the parasympathetic nervous system connects the mouth and the gut so

that when a baby latches well and nurses, the sucking stimulates a bowel movement.

Infant suckling also causes the mother’s gut to churn, she said, and moves yeast out.

Their bodies are connected in this symbiosis. A mother explained that she had come to

Yui because her baby wasn’t having bowel movements. Yui taught her how to massage

the infant’s abdominal area to encourage bowel movements:

She sat with me and helped me feel [the baby’s] intestines. …You could feel the poop building up in there, and I could feel, okay, like this is the abdominal muscle. …[The pediatrician] never made a referral to us for a lactation consultant one way or another. I don’t think he saw it as a breastfeeding issue, so it wasn’t a lactation issue, it was a GI issue for baby kind of thing. And my sense was, I feel like the input and the output is related; it’s a system.

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The lactation consultant understood the connection between milk and elimination in a

way that the physician could not because, as the client noted, Yui viewed the body

holistically.

Yui is so keen on using the senses as a way of knowing and reading the signs of

the body that she told me how disappointed she is that women often don’t know what

their infants are communicating. She told me the story of a musician who was able to

decipher what her infant wanted based upon the different types of cries she gave, as an

illustration of how out of touch most parents are who consult with experts instead of just

listening to their own babies. She then relayed to me her experience with a blind woman

who was able to breastfeed perfectly and didn’t need any help. Yui had been asked to

assess the blind mother’s care giving ability when she worked for a hospital that was

concerned about whether or not a blind woman could know what to do with her baby.

She attributed the ability of the blind mother to breastfeed her infant to her ability to

relate with her baby through focused use of her other senses and skillful use of her body.

Yui said, “The baby was calm too. I thought, if the blind mom can do this, look at the

women who have sight, they do not see.” One of her aims was thus to help women to

tune into and trust their bodies and their senses. She claimed that women were too over-

stimulated by technology to focus their senses in on their infants in order to understand

them, saying, “Do they have eye contact? Do they actually see? Do they have full

attention, or are they texting? . . . Those everyday things link with baby’s communication

because baby is communicating.”

Yui criticized the biomedical model for this same reliance on technology and

neglect of reading the signs and how this initiates and perpetuates women’s distrust in

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their bodies. Yui described how many physicians just give women formula when they say

that they don’t have enough milk, and said she thought that was “really degrading” to

women. Since Yui considers breastfeeding to be part of midwifery care she made the

argument that the biomedical model gives woman a clear message of “Well, you can’t

birth, let us birth you,” warning doctors, “Don’t turn the woman into a birthing machine.”

She talked about both the allure of technology such as formula or electronic fetal heart

monitors that can be inappropriately used, and how the body is viewed and treated as a

machine rather than a living organism that is dynamic and informative.

During my interview with her, Yui often expressed thoughts such as, “Hearing is

one thing, listening is another thing. …When you see things and don’t see what you are

supposed to see, you’re blind as a bat.” In these phrases, Yui helps us understand what is

happening when she massages mothers. We can be presented with an array of sensory

information that is available to us, but that data is full of noise, so how do you sift

through it so that you know which parts to tune into and which parts to tune out? If our

concepts are what direct our attention to the components of the experience that are

important, we will, to use an analogy, ‘see what we want to see.’ The mother who

thought she didn’t have enough milk had evidence for this. She saw her infant’s crying as

a clear indicator that her body was broken and wasn’t producing enough milk. The idea

that her body was broken, however, came from dominant ideologies about women’s

bodies as dysfunctional. This was a concept she had, and this concept then constructed

her perceptual experience. When Yui massaged her and told her to look at all the milk

spraying out, and how abundant it was, she was directing her attention to the aspect of the

sensory experience that would help the woman to form a new concept about her body.

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An example of how this trust the senses over technology approach worked with

Yui is illustrated by the story of another woman who came into the clinic convinced that

she didn’t have enough milk. I was going to do pre and post feeding weights on a

lactation scale to give the mother a sense of certainty about how much milk her baby got

while breastfeeding. I asked Yui if she had a scale and she said she did, but she didn’t

remember where she had put it. I searched all over the clinic and finally found it pushed

into the back of a cabinet in the kitchen with items stored on top of it. Clearly, she hadn’t

used it in quite some time. Yui rarely used the scale, saying it made her “feel like a

statistician…. They get that enough in the pediatrician.” She could tell what a woman’s

milk supply was like by touch and by seeing how much milk was extracted during the

massage. Like the other lactation consultants I observed, she also listened for the nursing

infant to swallow, watched their jaw movements, and checked their hands to see if they

were opening up from their initial fisted state or not. These signs told her whether or not

the infant transferred an adequate amount of milk out of the breast. She directed mothers’

attention to these signs and helped women to understand what they indicated.

I learned that most women who came into the clinic were reassured about their

milk supply once milk sprayed out of their breasts during the massage and Yui directed

them to look and see the abundance. A client described how Yui’s approach convinced

her that the massage was helping to get her milk flowing when she had plugged ducts,

saying the milk “was just like, it was there. You could smell it, and it looked different,

and I could see like the crunchy stuff coming out. That to me was like, okay, this is

working.”

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I observed Yui time and again direct a mother’s attention to the color of her milk. She

would also have them touch it and feel its consistency and would sometimes direct them

to smell it, often at different points in the massage for comparison. She would explain to

them what they could learn about their body from what the milk was indicating. Infants

invariably soiled their diaper after breastfeeding and she would sometimes point out what

the consistency, color and smell of their bowel movement revealed as well.

Women who came to the clinic for the first time often didn’t quite know what to

expect but often left feeling so excited about the experience that they came back

repeatedly and told every breastfeeding mother they knew about it. The clinic did not

advertise at all but was so busy from word of mouth referrals by satisfied mothers that

Yui could barely keep up.

Tina, in the Hospital Postpartum Unit

Despite the trend by hospitals to make birthing rooms more home-like in design,

the postpartum ward of the hospital I conducted research in did not seem very relaxing

and homey. The hospital bed was the centerpiece of the room and behind it, where a

headboard and painting might be in one’s bedroom, was a wall with an incredible number

of switches, and connectors and outlets to hook up medical equipment should they be

needed. I counted at least 16, and there were more built into the hospital bed. It gave one

the feeling that the mother’s health could be in danger at any moment. The walls were

bare except for a clock, glove dispensers, a needle disposal container, and a chart that

said in large letters “Your Journey Home,” reinforcing the reality that you were not at

home, you were in an institution. The chart listed what types of risk averting procedures

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and monitoring of mother and baby would have to occur before they could be discharged.

Nurses would check off the items on the chart, which appeared in large boxes and

consisted of the following items: newborn exam, hearing screening, immunizations,

mother-baby education, newborn screening, newborn photos, Lab work for mom, birth

certificate, c-section care, mom’s discharge exam, transportation home, healthcare

enrollment, and follow up appointments. The hospital was undergoing renovations, but

all of the above features would remain. They reflected the value the institution placed on

risk aversion and procedure, and gave you the sense that something could go wrong at

any time and vigilance was necessary.

The lactation consultants’ office was temporarily placed in the circumcision area

while renovations were taking place. The circumcision room was presumably placed

where it was to be out of sight and earshot of parents. To get to it you had to go through

the nurses’ station and open a door into a large storage area. In the back of the storage

area was a small room where infants were strapped to an immobilizing table with a bright

surgical light over top. The lactation consultant desk was placed in the back of the storage

room, just feet from the circumcision room door with a clear view of the procedure. This

door was always left open because otherwise there would be no room for both a nurse

and a doctor in the tiny closet-like space.

In contrast to the repeated scenes we witnessed there of wailing infants strapped

to the table having genital skin removed, the lactation desk was decorated with a few

photos of relaxed babies in their mother’s arms nursing. There was also a calendar on the

wall behind the desk that showed women breastfeeding in beautiful Hawaii settings with

the ocean or waterfalls in the background. The juxtaposition of these two scenes –

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medicalized altering of the reproductive body through cutting versus nurturing scenes of

women and infants in serene nature – was striking.

Tina, an IBCLC who worked at this hospital, would leave the office that was

filled with the cries of circumcision, make her way down the hall, and try to bound

cheerfully into the rooms of exhausted mothers. Here she would attempt to create a

positive environment where women felt okay to just recover and enjoy their babies

without worry. I kept a small notebook with me as we visited patients in their rooms, and

sometimes wrote down what was said. An example of how a woman might respond to

Tina’s encouragement was captured in an exchange where Tina told a patient “You have

a lot of milk and the baby will learn to get it on his own. You’re doing a fantastic job!”

The patient then gave an audible sigh of relief and said, “I was worried I wouldn’t have

enough.” Such affirming expressions had the potential to relieve women of their

anxieties and help them to trust their bodies. For Tina, praising women is the most

important aspect of her job because she believes that in doing this, she moves women

away from their fears and frustrations and she gives them confidence. When women lose

confidence and don’t trust themselves, they give in to a system that is ready to confirm

their doubts and hold formula up as the answer to their problems.

Tina was consciously working against the ways that the hospital rushed newborns

into being “stellar” breastfeeders before they were ready, causing parents undue anxiety. I

learned from her that the issue with rushing this process is three-fold: First, many infants

are born with drugs in their system from a medicated labor that could make them extra

sleepy or could make it difficult for them to coordinate the suck, swallow, breath

mechanisms or tongue movements that are needed to successfully breastfeed. The

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circumcisions that take place on the second day of life also interfere because they prompt

male infants to “check out” all day after the procedure, and they cannot be aroused to

breastfeed. Secondly, breastfeeding is not instinctual for mothers and has to be learned,

and while infants have instinctual breast seeking behaviors and ways to illicit care, they

don’t always latch on right to the breast. Hospital procedures such as repeated

interruptions, bottles and pacifiers (because they require a different type of suck), or the

separation of moms and babies, can interfere with the dyad learning the breastfeeding

dance. Learning this dance required becoming familiar with each other’s bodies, and was

best facilitated through uninterrupted skin to skin contact and the knowledge that was

imparted through touch. Importantly, Tina believed that the hospital diminishes a

mother’s confidence in the ability of her body to make enough milk and of her ability to

feed and nurture her infant with it. Thirdly, women and their newborns are usually

discharged from the hospital before their milk comes in and breastfeeding is fully

established. Tina believed that instead of helping, this impatience with breastfeeding

perpetuated breastfeeding problems:

In our hospital, I think that we have such high expectations of our babies. We rush them. We expect them all to be the same, we expect them all to have latched on by a certain time and be doing like these stellar breastfeeding sessions when they’ve just come through a lot. In some babies it takes longer, so I think there’s a lot of pressure. I think, also, just in the type of society we live in, legally too, I think everybody is scared. What if this baby goes home and it’s really not nursing well? It’s hard to be – what am I trying to say? It’s hard to just sit and wait sometimes because, sometimes you give a baby 24 hours and it can be the difference between night and day. This baby could maybe not be latching at all at 12 hours of age, but then at 40 hours of age it’s like a totally great breastfeeder. But in the interim, there’s a lot that can happen because you have pediatricians that are panicking that the baby is not doing this and they want to [say], “Okay, well, maybe we need to get some formula supplementation.” Where if we would just wait it out, give the baby a little bit more time, I think time and I think – in the hospital just, so many interruptions, visitors… I would love just for moms and

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babies to just be able to, after they give birth, go into this little cocoon and hibernate for a while.

She continued, addressing how parents can also have unrealistic expectations and worry

that the mother doesn’t have enough colostrum:

I think, somehow, the expectations of parents today, a lot of people don’t know normal. They don’t know that babies are really sleepy the first 24 hours, so they’re not going to eat a lot. They don’t know that babies don’t need a lot, so they’re all panicked wondering if baby is getting enough.

Her approach is to do less intellectual education and instruction with parents and

more praising and body adjustments that women can experience in an embodied way

rather than through intellect. She explained how intellectual approaches are ineffective:

If I start telling them about how small their baby’s stomach is and such, it’s like shoo, it goes over their heads. But what they will remember is you telling them or praising them, “You’re doing a great job! You’re off to an awesome start! Your baby is so lucky to have you!” Stuff like that.

Tina would focus on the mother’s emotions and encouraged them to identify them and

express them by saying things such as, “If you feel like crying, cry” and “You’ve come a

long way! How do you feel?” Contrary to the idea that breastfeeding is natural and

therefore instinctual, Tina let women know that it was their bodily practice and

engagement with the baby that was making their progress with breastfeeding possible.

She didn’t just have women focus on how they felt emotionally, and try to give

them a positive emotional experience, but she also had them think about how they felt

physically. When the baby latched on to the breast and started to suckle, Tina would say,

“How does that feel?” Mothers would then pause and consider how it felt before

answering. Tina would tell them that it might feel painful or uncomfortable in the first

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few seconds that the newborn latches on, but that after that only the sensation of a tug

should persist. If there was pain after the first few seconds, then they would need to make

positional adjustments with either their body or the infant’s body. If they expressed that

they felt pain or if she saw a mother holding her baby in such a way that it would make a

good latch difficult, she would use her hands to adjust the two of them and would say

things like, “Oh wait. Here, let me tweak that for you. This will make it easier.” Or,

“Here, why don’t you try just turning the baby a little bit more like this?” These physical

adjustments were ways to get mothers to focus on what their bodies or the bodies of their

infant were doing. She also removed the mittens from infantsʻ hands and unswaddled

them when it was time to breastfeed, telling mothers that infants needed to be able to

touch their mom when nursing because it gave the infant sensory information.

Another way that Tina had mothers use their senses to give attention to their

bodily processes was by expressing colostrum from their breast and then telling the

mother to look and see that she had some. This was always the first thing that she did

before she had the mother breastfeed. Tina recognized that seeing the colostrum helped

worried mothers know that they had something to feed to their baby. Tina would point

out that the colostrum acted differently than regular milk because it was thick like honey,

which was why it wasn’t just dripping out. She told women to watch for a change in

consistency and for when the color changed from clear or yellowish to more of a white

color in a few days, as a sign that their milk was starting to come in. Women often

expressed surprise and relief when they saw the colostrum come out of their breast.

Tina was aware that babies used their hands to knead the breast and stimulate the

milk to flow, that they would touch the breast and then taste the milk on their hand or

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smell the scent of the oil that came from a mother’s Montgomery glands to find the

breast. She knew that infants were calmed by the sound of their mother’s heartbeat, that

their temperature was regulated by her body heat, and that they regulated their breathing

in tune with her mother’s respirations. In other words, she knew that infants are

biologically regulated and are oriented by the sensory experience of the mother’s body,

and this brings out their instinctive breast seeking behaviors. Tina also knew that humans

can’t swallow effectively with their chin on their chest and that infants had to have their

head flexed back while breastfeeding, just as we do when we drink from a cup. They also

needed to have their tummy pressed against the mother’s body to effectively nurse, rather

than have it pointed up with their neck uncomfortably stretched to the side. She also

knew that for nursing to be effective and not hurt, the baby needed to have a deep

asymmetrical latch with the mother’s nipple stretched back to the hard and soft palate

junction. Also, the infant’s tongue had to be able to stretch beyond the gum line and raise

up in the back. While she looked for all of this, she didn’t explain all of this to mothers,

she just made bodily adjustments and asked, “How does that feel?” In this way mothers

learned how to breastfeed by focusing on physical sensations. Like the infant, they would

navigate breastfeeding and orient themselves sensorially. She then praised the mother and

said something positive about her ability to make milk.

The idea that women mostly remember an emotional experience rather than

breastfeeding information, was something I had also heard from an instructor of a

lactation course I took in order to fulfill the requirements for IBCLC certification. The

instructor had made a point to mention that breastfeeding classes for pregnant women

didn’t seem to make a difference in breastfeeding duration, but that praise did. A lack of

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confidence could be reinforced by focusing on things that triggered a negative emotional

reaction. Alternatively, confidence could be gained through the positive emotional

experience that comes with praise. We were made to memorize lyrics sung to the tune of

Frere Jacques that we sang at the beginning of every class:

When you counsel When you counsel Never judge Never judge Praise mother and baby Praise mother and baby Don’t command Do suggest

The training manual we were given states, “Research tells us that the decision to

breastfeed is influenced more by embodied knowledge than theoretical knowledge,” and

it “does not come from prenatal education.” We were told that oxytocin, the hormone that

facilitated bonding and caused the let-down, was released when people felt warmth and

touch and was blocked by fear, anger, and frustration. We were instructed to “empower

her and boost her confidence,” to involve mothers in the plan of care to make sure we did

not impose our “agenda” on her, and to use technology “very carefully.” Technology

took one away from embodied knowledge. Tina was one of the lactation consultants who

had attended this same class at an earlier time and had recommended it to me. She said

she had found this information transformative for her practice.

Tina’s belief that moms and newborns need time to recover from birth and figure

out how to use their bodies together to make breastfeeding work, and that if you give

them time together to access embodied knowledge they will eventually be able to

breastfeed without difficulty, is in conflict with biomedical management. One form of

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biomedical management was medicating mothers during labor and postpartum. Embodied

knowledge could be unavailable to mothers who were heavily medicated. This is the

strange making that Davis-Floyd describes that separates women’s minds from what their

bodies are doing. Tina was concerned that hospitals were unnecessarily medicating

mothers with opioids after they gave birth:

And that’s another thing that bugs me, this whole thing about pain control. It’s such a big issue, and it’s like, I don’t really know if these mothers that have had vaginal delivery really need all these Percocets . . . Because the whole thing about, you don’t want your patients to experience any pain. Some doctors, or just our whole Western medicine gives a pill instead of…. And I just hate it.

She agreed with giving opioids to mothers after they’ve had a caesarean section, she just

believed that our culture is too quick to medicate anytime we feel discomfort. She was

concerned that being so out of it while on these medications, would make it dangerous for

women to do things like have the baby in the bed with them. It interfered with her idea of

leaving mothers and babies undisturbed in a “cocoon” after birth where they could get to

know each other and learn to breastfeed.

Tina had told me that the hospital makes breastfeeding difficult because it is “all

about interruptions and interferences, taking vitals and charting.” Interruptions take

moms and babies out of the “cocoon.” Monitoring by data collection and quantification

are disembodied ways of knowing. Worried medical professionals and parents might

offer a baby a bottle of formula because it gives them a sense of certainty that this type of

knowledge provides. When I interviewed Tina, she discussed the overuse of formula,

especially in the NICU where babies had more issues and would benefit the most from

breastmilk, saying:

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The people that go into NICU [work] . . . are probably a little bit more analytical and into numbers and things like that. Not everyone, but a lot of them, and they like their numbers. They like to see certain things . . . It’s very easy to take formula and know exactly what’s in this formula – how many calories, how many grams of calcium, etcetera. You can’t totally do that with breastmilk, and as we take care of smaller and smaller babies, there’s different theories on what this baby needs, and I just believe in the power of breastmilk.

Formula offered a sense of certainty that an infant would receive nutrition while it

could simultaneously cut a woman off from her body and a sense of what it was capable

of. One such mother told Tina that a nurse had told her that she might have to use

formula because she didn’t have good nipples for breastfeeding. The woman had

assumed the nurse had authoritative knowledge on nipple types that were or were not

conducive to breastfeeding, as if there existed a medical classification of nipple

hierarchies, some variations functional and others abnormal and inadequate. What I had

observed was that the same nipple variation in any two women may or may not cause

difficulties, and when it did this was often overcome with physical adjustments. This

mother had already come to terms with the idea that she was defective and wouldn’t be

able to breastfeed because of what the nurse had told her. She was thus stunned when

Tina silently placed the baby in her arms and the baby latched on by himself and nursed

effectively from her breasts. Surprised reactions happened regularly when women who

were surrounded by signals and messages of body dysfunction encountered Tina’s

reverse messaging and support, but sometimes hospital procedures made this difficult.

The combination of medical training and seeing bad outcomes can cause you to react to

all situations as potential risks. This in turn causes medical professionals to use

quantifying strategies to manage that risk, and can be detrimental to breastfeeding as Tina

related when discussing how this is exacerbated in the NICU:

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I hate it when a term baby will go to NI[CU] for, oh, the baby’s having a little, maybe slight lump or—or slightly elevated respiration, and they’re just going to watch it. Because it’s almost like the death of breastfeeding. Because the first thing they want to do is, “Oh this baby’s dry.” Or, “This baby’s only peed one time in 24 hours.” That’s normal for a one-day-old baby, but they don’t think normal, they think – I think the more you see bad things then it scares you, and you don’t see normal then. I mean because we’ve had to remind . . . our neonatologists, . . . and different ones are different, but, they want all their babies to be gaining weight by the time they go home. And it’s like, this baby’s four days old, this baby’s not going to have gained weight. Or, it might just be plateauing and it’s going to start going up. But they want to see weight gain. It’s like that’s not normal. So, and I don’t think that in med schools, I don’t think they’re taught what normal is.

The tendency to see problems where there are none, or to engage in unnecessary

interferences in the hospital, carries over to create problems when parents are at home.

When women receive the message that their bodies are broken, this idea tends to stick

and a lack of confidence will affect their choices. Some moms will give their baby

formula after or instead of breastfeeding, for example, because they are unsure that they

have enough milk. The reason why giving babies formula can cause problems for

breastfeeding is because the breast produces milk according to how much stimulation it

gets. Formula supplementation will cause a reduction in the milk supply absent sufficient

pumping, and this in turn confirms the mothers’ fears that they didn’t have enough milk

and had “broken” bodies to begin with. Well-intentioned nurses are often guilty of

starting this train of fear, formula, actual problem created, fear actualized, formula

necessitated.

At the hospital where Tina worked, the Joint Commission, the organization that

accredits healthcare institutions, had determined that there was too much unnecessary

formula supplementation occurring. Administrators consulted with the lactation

consultants, and the decision was made to keep formula under lock and key and make

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nurses sign out for it with the lactation consultant, who had the key. After the policy had

been enacted, exclusive breastfeeding rates in the postpartum unit rose to the highest

level ever. Another lactation consultant pulled Tina aside into an empty room, however,

and told her that the nurses in the NICU were complaining about having to sign formula

out now. She overheard them say that they didn’t stick to the amount of formula they

were told to supplement premature babies with by the lactation consultants and had been

giving extra formula to the babies.

Fighting unnecessary formula supplementation was an ongoing battle in both the

postpartum unit and the NICU. Tina complained that one paediatrician was blaming

breastmilk for a baby’s watery stools, saying the infant must be allergic to lactose and

milk proteins in the mother’s milk. Tina told him the amoxicillin the infant was on was

the culprit and that infants don’t have lactose intolerance because they all produce

lactase, the enzyme that breaks down lactose. Lactation consultants who work in

hospitals are under doctor supervision and cannot overrule their decisions. Even if this

doctor listened to her, however, the mother had already been given the message that her

milk was not good for her baby. Sometimes Tina would try to find another doctor with

opposing views and have them give the mother a different opinion as a way to get around

the fact that she couldn’t overrule a doctor’s orders.

In another case, a mother who had a c-section had a delay in her milk coming in,

which is more prevalent in c-section births since prolactin, the milk making hormone, is

at lower levels after c-sections. Her doctor ordered formula supplementation because the

infant was at a 6% weight loss, even though that decision was usually made when the

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infant surpassed a 7% loss, and Tina was sure that most of the time it was because the

infant’s birth weight had been inflated by the IV fluids the mother got during labor.

Referring to the large number of infants that were being supplemented with formula for

this reason, she one day exclaimed in frustration, “Is anyone [considered] normal

anymore?”

When a mother’s milk was truly delayed in coming in, Tina thought of the

mother-baby cocoon again. “I just think, you know, if this woman was in a birth center

and we just left her alone…” she said to me, knowing that extended skin to skin time

after birth was known to increase prolactin levels, and with the belief that through

uninterrupted touch time they’d navigate sensorily and emerge with embodied knowledge

and would be breastfeeding without issue. She continued, “If I didn’t work in a hospital,

I’d say, let’s just wait and see what happens. That’s what I hate about this. We are too

numbers oriented.” The lactation consultants’ attempts to limit formula to only what was

necessary under abnormal circumstances in order to restore normality, met resistance. For

Tina, limiting the medicalization of breastfeeding was a constant battle.

The question, “What does that feel like?” when the infant suckles, prompts the

mother to see her body and its sensations as a source of information that is brought about

by her baby’s touch. Tina also saw skin-to-skin time as a way that the mother and her

baby become synchronized in bodily functions and coordinated in movements, and

responses. The medicalization of birth and breastfeeding means the body is seen as

imperfect and dysfunctional, at risk of disease and disorder, and thus in need of medical

intervention and alteration. It encourages disembodied techniques: enumerations and

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technologies that pull us away from what the body is experiencing. This was why Tina

continually drew a mother’s attention to her body, and cheerfully relayed positive

information about it as functional and capable.

Karen, in the Pediatric Clinic

Karen was an IBCLC who worked in an outpatient, pediatric, managed care clinic

where a large percentage of the mothers and babies she saw came for their well-baby

checkups after being discharged from the hospital. When women got off of the elevator

on the pediatric floor, they checked in at a desk directly across from the elevators and

were directed to a waiting area to the right and forward. The waiting room contained

comfortable chairs and toys for children to play with as they waited and a television.

Karen’s clinic room consisted of a comfortable chair for the breastfeeding mother

to sit in, a couple of chairs along the side wall for fathers or other family members who

might come with her, a sink, a scale, a baby changing table, and a computer monitor that

was on an extending arm that came out from the wall. Karen sat on a stool that had

wheels on it so she could move back and forth from the mother’s side to the computer

where she looked up patient information and logged notes. On the wall facing the mother

she had hung various types of bottle nipples to show parents who needed to supplement,

which types of nipples were more likely to cause problems for breastfeeding infants.

Because women were discharged from the hospital before their milk came in,

their visit with Karen necessarily involved making sure the milk supply was adequate and

the infant was functionally able to remove it from the breast. She was seeing a good deal

of moms and babies in the gap space where an inadequate milk supply or a baby who

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wasn’t able to remove the milk that was there, could cause dehydration if it wasn’t

attended to. Thus, Karen checked infants for jaundice and did pre and post breastfeeding

weights on every infant she saw. Part of my training with her consisted of learning

mathematical formulas to convert ounces into grams, to figure out how much weight a

baby had gained over a particular period of time, or to get at the percentage of weight loss

an infant had experienced since birth. Karen used the scale more than other lactation

consultants I had observed. She told me that every once in a while, she would come

across an infant who would fool her and the scale gave her a sense of certainty. She

qualified her response, however, saying about hospital charting in general, “I really do

like my objective data, but so much of this charting is just baloney. It’s all about billing,

that’s what it is.” She also held the belief that technology was to be used with caution.

She saw the scale as a necessary tool in that clinic, but in other ways her approach was to

demedicalize as much as possible. She expressed regret that much of what was done in

hospitals and clinics was done for the benefit of the institution and not the patient,

including at times data collection such as taking weights:

A good example is just recently we changed the midnight weights to a 24-hour weight [in the postpartum unit] . . . and I think mothers are happier not being, you know, burst in on at midnight because the babies need to be weighed. Often times they’ve just finally got that baby settled and then like, [the baby is] stripped naked, put on a scale, screaming, wide awake, and headed back to their moms.

In fact, Karen used the word “shell shocked” to describe the effects of medicalization on

mothers, explaining here what the surveillance actions and technocratic responses of the

system says to mothers:

“Well, it doesn’t look like you have a problem, but you’d better come back because in the meanwhile you might screw up big time. We need to catch that and fix you.” It happens with pregnancy that women get disempowered. They go in

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the hospital and we wonder why they are shell shocked. I mean, it’s why they can’t even hold their own babies sometimes. They are afraid of doing it wrong . . . I’ve had moms come back and they said that they felt that the best way that I had helped them was by making them feel confident that they could do it.

The fear of “doing it wrong” is a result of the distrust of the body that she saw occurring,

and she tried to give mothers a different message.

Karen talked extensively about the value of the midwifery model of care, and her

desire to emulate it. She thought of lactation consultants as helping women get out of the

hospital sooner. Despite her heavy reliance on pre and post breastfeeding weights, there

were other ways that I observed her limiting the use of technology. For example, she

rarely gave mom’s nipple shields to use. A nipple shield is a silicone nipple with holes in

it that is placed over the areola and nipple. It is stiffer than the mother’s natural nipple

and is wider and more elongated than her nipple is when it isn’t stretched in an infant’s

mouth. If an infant isn’t doing the necessary moves to appropriately stretch the nipple and

compress the breast, they won’t get sufficient milk out, nor will they stay latched on

without making their mother sore. The nipple shield is designed to keep an infant latched

on and usually reduces any soreness a mother may be experiencing. Karen had repeatedly

expressed her displeasure with what she thought was their overuse. She believed that

latching issues were solvable if you paid attention to what the baby was doing at the

breast.

Other lactation consultants in my study regarded Karen as highly intelligent and

skilled at what she did. I came away with this impression as well since Karen taught me

more than any other lactation consultant about how to look and listen for signs that would

indicate where and how an infant was placing and moving their tongue or gums during a

nursing session. She checked the shape and movements of the infant’s head and jaws to

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look for signs of torticollis, noting that an infant with torticollis will sometimes nurse fine

on one breast but not the other. She also assessed the infants suck by putting a gloved

finger in their mouth to suck on and examined the movements of the infant’s tongue.

Additionally, she asked mothers how it felt when the infant was suckling at the breast.

These were standard procedures for a lactation consultant, but she was skilled at being

able to home in on issues using sensory clues and then explaining what she was

observing, hearing, or feeling to mothers. She used the pre and post weights to back up

what her observations were during the breastfeeding session in which she continually

dialogued with mothers to make sure they understood how to know through their own

senses what their lactating bodies and that of their infants were indicating.

An example of how this worked was observed when a couple bought in their

eight-day-old infant who was having problems staying latched to the breast when the

mother breastfed without using a nipple shield. The mother said the baby kept “slipping

off” without it. Karen worked out the angles and motions made by the infant’s jaw and

tongue to create a visual field of actions and interactions between the mom and baby, and

then between the parent, baby, and bottle that was causative. She then verbalized out loud

to the mother what that visual field looked like in her mind.

Because the infant was not latching well and wasn’t getting much milk even when

using the nipple shield, the mother had been pumping and feeding the baby pumped milk

with a bottle. Karen had the mother attempt breastfeeding. She did not touch her, but let

her do this her own way and then asked her how it felt when the infant latched on and

suckled. The woman said it felt like the nipple was being pinched. Karen then had the

mother listen to see if she could hear swallowing sounds coming from the infant, and the

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mother said she could not. She then pointed out that the infant’s lower jaw was not

dropping down low every few suckles the way that it would if she were swallowing milk.

Instead, she pointed out that the infant had a “chompy” suck and was not bringing the

skin of the areola into her mouth, which would have required her to open her mouth

wider before latching on. She asked the mother to notice what the “chompy” suck felt

like and to look at what it looked like. She then asked the mother if she had a lot of IV

fluids when she was in labor, to which the mother replied that she had. Karen then asked

the father to show her the bottle they were feeding the infant pumped milk with. He

pulled a bottle out of the diaper bag that had a small, straight nipple with little width at

the base.

Karen put the puzzle pieces all together and described the visual field she had

created in her mind that reminded me of the character Sherlock, solving a crime. The

mother, she concluded, likely had experienced swelling around the areola after giving

birth because of all the IV fluids she had been given in labor. That swelling made it hard

for the infant to get the skin of the areola into her mouth and get a good latch onto the

breast, which is why the mother described her as “slipping off.” The baby was never able

to get a good latch from the beginning, and when the mother’s milk came in and her

breasts became engorged, the infant had continued to struggle to get a good hold on the

swollen breast. The parents supplemented the infant with pumped milk in a bottle, but the

bottle reinforced a shallow latch because it did not have a wide base that would

encourage the infant to open her mouth wide. Whenever the mother tried to breastfeed,

the infant grasped onto the mother’s nipple only. This was painful for the mother, but the

infant was doing something else that was causing her pain as well. Karen then had the

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mother look at her just nursed on nipple and see that there was a line across it. The

feeling of being pinched was an indicator that her nipple really was being pinched

between the infant’s gums, and this line was another sign of it. The pinching told Karen

that the flow of milk coming out of the bottle nipple was excessive and the infant was

pinching off the flow by biting down when it got to be too much. The infant was not

treating the mother’s breast any differently than the bottle, and expecting an

overwhelming flow of milk since this was what she was used to, she was biting down to

staunch the flow when she felt the mother’s milk let-down. She told the mother that this

cascade of events was not her fault, and her body was fully functional and able to make

enough milk for her baby. It was the result of hospital practices and the marketing and

manufacturing of bottles that make breastfeeding difficult. The problem could be

remedied by teaching the infant how to latch properly.

Re-teaching the infant required the mother to engage with how her body felt and

to allow the infant to use her instincts. Karen had the mother lean back in the chair so that

the baby was more atop the breast. In this position, gravity encouraged the infant to have

her mouth open wider and made it harder to bite the nipple. Atop the breast, the infant

was allowed to find the nipple and latch on by herself in her own time and with neither

the mother nor the lactation consultant interfering. Karen asked the mother if this felt

different from the chompy, sore, pinching latch. The mother replied that it did not hurt at

all, and Karen told her this was one way she could tell if the baby was doing what she

wanted her to do. She was then directed to look at how much of the breast was in the

infant’s mouth, what the infant’s jaw was doing, and to listen to the swallows that could

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now be heard. Then the mother was told that for the baby, relearning how to breastfeed

would require practice. If it felt wrong, she would need to take the baby off and try again.

Helping mothers to understand infant cues and to use their senses to breastfeed

was important to Karen, who was disturbed by how out of touch most women were with

their own bodies. It connected back to women being too afraid to engage with how their

bodies feel and how their body and that of their infant’s learned together because of that

“shell shock” fear of doing it wrong. It was also due to the over-value we place on

technology. In an interview she complained about the reliance moms had on technology:

Karen: Okay, here’s what kills me: “When did your baby nurse?”

Researcher: They get on their phone [to find out].

Karen: I’m thinking to myself, “Seriously? You seriously have no idea when your baby last nursed, and you have to check [the app on] your phone?” You know what I’m going to start doing? I’m going to start saying “No, I don’t want you to use your app for that. I want to see how well can you remember when you last fed your baby.” You know, I’m going to start doing that. I swear I am, because as it is, I just sit there being highly annoyed and incredulous and try not to show it, but now I’m going to say, “Oh, are you checking your phone? You know what, put that away because I want you to feel when was the last time you nursed your baby. Give me an approximation by how you feel and then see how well you can recall.” Researcher: I used to be able to tell by the weight of my breasts.

Karen: Yes! Exactly!

Researcher: Did you ever do that when you were nursing?

Karen: Yes.

Researcher: If I forgot I would be like, it’s not quite there yet, because I’d know how heavy they’d get when I was closer to…. Karen: Yes! Exactly! And you know one of the things when I was pregnant the first time, one of my fears, I had a nightmare about it, was that I put the baby to sleep and forgot to feed her and forgot all about her . . . And when I woke up in a

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panic, the one reassuring thought was that can’t happen to me; I’m breastfeeding, and my breast will remind me that I can’t forget to feed my baby.

Although Karen seemed annoyed with mothers in this conversation, she did not blame

them personally for poor breastfeeding outcomes. She had relayed to me that the value

our society places on technology and other aspects of the medical system, sets mothers up

to not trust their bodies or their senses, and directly causes obstacles to breastfeeding. She

told me that she thought that most of the infant suck problems we see are due to the drugs

women get in their epidurals, especially fentanyl, which she said suppresses the sucking

reflex for 12 hours after birth and causes infants to then start biting down on the breast.

She told me this was supported by research and I should look it up.42 To her, the scale

was essential to use on these infants that she saw in the gap space because they were at

risk due to biomedical and commercial actions, not because their bodies were faulty. It

was the medical system itself which had placed mothers and babies in this position.

Karen had decided that the way back to normalcy after a problem was established,

was to reconnect to what the body was feeling and doing. One way of doing this was to

make mothers comfortable and to offer them emotional support. She told me that when

she had worked in the postpartum unit of a hospital, if a mom was in too much pain, was

frustrated or was too tired, she didn’t try to get her to breastfeed at that moment. Instead,

she would lay the mother back on the bed, would place the baby skin to skin on her chest,

and would cover the two of them up. She would turn out the light and close the door and

tell the mother that she would come back later. She said that when she made the mother

42 This was also something I was taught in the lactation course I took to become certified. The instructor had specifically singled out fentanyl as having the worst outcomes, suppressing the sucking reflex in the period just after birth. A recent systematic review of research done on the effects of labor epidural analgesia on breastfeeding found mixed results and several study limitations (French et al. 2016).

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comfortable in this way, avoiding distressing intrusions, she found that when she came

back later the mother and baby would be nursing just fine. This idea is similar to Tina’s

belief that mothers and babies need to be in a “cocoon” where they are undisturbed and

can learn about each other and work out breastfeeding. Leaving a mom and baby

together, skin to skin, without stressful interruptions, instructions, or interference, was

getting back to the body.

Karen also thought that positive emotional support was important. This included

pointing out the positive aspects of a mother’s situation and what she was doing right. It

also meant reducing women’s stressors when she could. She told me a story about a

patient who had left an impression on her and said the story was an illustration of how

stress and anxiety affect milk supply. The patient had told the lactation consultant that her

husband was deployed by the military while she was home alone with her new baby. She

had a low milk supply and was pumping her milk but only getting about one milliliter

each time. She stopped pumping the weekend her husband was to return home, having

decided to quit her breastfeeding efforts given her low supply. As soon as her husband

arrived home, her breasts started dripping milk, so she decided to pump just then and got

a full supply. She had no more supply issues from that point forward. From this story

Karen linked milk supply and feelings together and applied this idea to other instances to

suggest that often the cause of low milk supply was mothers reacting to a world that

expects too much of them and does not offer them support.

In Karen’s view, breastfeeding mothers were at risk, but not from their own

bodies in the way that the technocratic biomedical system would have them believe. It

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was the system itself that created risk, and ultimately the only way out of that space was

through the body.

Sandra, in the non-profit clinic

Sandra’s methods are described here as a counter example to the above methods

of turning to a mother’s embodied knowledge. Her methods were both highly instructive

and authoritative and were the one outlier among the lactation consultants that took part

in this research. Including a transcript of her interaction with a mother shows that not all

lactation consultants are universal in their methods and approaches to breastfeeding

problems. Additionally, her counter example exists as a comparison and points to the

interactions and results of a non-embodied methodology.

A Japanese-Korean mother who spoke English as a second language and her

White husband, who was a native English speaker, brought their one-month-old infant

into the clinic where Sandra worked. The mother was pumping her milk and also

supplementing that with formula because her baby had lost 10% of her birth weight and

was now reluctant to breastfeed at all because she preferred the ease of removing milk

from a bottle compared to the breast. The mother was pumping her milk in order to keep

her milk supply up.

Sandra had the mother sit in a comfortable chair with her husband beside her. She

instructed the mother to begin the process of trying to nurse her infant as she normally

did. I wrote down the dialogue and behaviors as they were occurring but directly after the

event took place, I filled in more of the behaviors I remember observing. The interaction

was tense for reasons that Sandra thought were due to a language barrier, but that I had

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interpreted as the mother’s resistance to the methodology. I felt it was resistance because

of the mother’s body language and because she seemed to be able to speak and

understand English well enough, and she responded to the lactation consultant’s requests

in the beginning. The mother tensed up and looked upset every time Sandra pushed the

baby onto the breast in a quick move that appeared aggressive. Sandra’s hand was always

on the infant’s shoulders when she did this. It was a method she used with every client,

and although none of the infants that Sandra did this to seemed injured, parents tended to

verbally and bodily express their disapproval. Many of them used the word “shove” to

describe what I am calling a “push” here, although neither accurately describes the

motion since Sandra’s hand never left the infant. It is forceful, which is the most

important descriptor. In the dialogue below, I also describe the mother as “pushing” on

the back of the infant’s head, but the push of the mother is slow in comparison to the

push of the lactation consultant. In both cases there is a force exerted in order to bring the

baby to the breast rather than let the baby come to the breast on her own. The mother

starts off bringing her breast to the infant’s mouth the way you would a bottle. The

mother remains largely silent in the following dialogue, only speaking once to Sandra to

explain that the issue she is having is that the baby prefers bottles:

The mother attempts breastfeeding by leaning over her baby and bringing her breast to

her rather than bringing the baby up to her breast.

Sandra: No, don’t bring your breast over. No, no, no! Leave your breast where it

belongs.

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The mother, understanding Sandra, sits up. She then adjusts how she is holding the infant

so that now one hand is holding her head instead of being at her shoulders. She then tries

bringing the baby’s head up to her breast.

Sandra: No pushing the head from back here. When you push the head, they don’t like

it.

The mother looks tense, having been told that neither way of moving her body and

holding and moving her infant are correct. The baby, who is not yet attached to the

breast, begins to fuss. The mother calms her in a high-pitched, singsong voice.

Mother: Oh baby! Oh, oh!

The mother tries again to latch the baby, this time grasping her breast with one hand and

the infant with the other, but her fingers are too close to her nipple and the infant can’t

get enough of the breast in her mouth because they are in the way.

Sandra: No fingers! Don’t put your fingers here. Hold your breast, but we don’t want your fingers near the nipple.

The mother adjusts her finger placement and tries again to latch the infant. The baby

continually pulls off once she gets her on. Sandra decides to squeeze milk out of the

mother’s breast to entice the infant to want to nurse.

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Sandra: You don’t want baby to just go on the tip. I’m trying to squirt it.

The baby fusses some more and the mother explains that the baby is used to the bottle

and hasn’t breastfed for three days, in an attempt to tell Sandra that she thinks the issue

isn’t about how she is holding her breast and the baby but is about the baby getting used

to the bottle. Sandra doesn’t respond to this comment. She grasps the woman’s breast

with one hand and the baby’s shoulders with the other and says “wait” to indicate that

the baby needs to have a wide-open mouth before she is bought to the breast. She

proceeds to move the mother’s breast up and down so that the nipple is tickling the

baby’s lip in an attempt to get her to open her mouth.

Sandra: Wait. Wait. Tickle.

The mother laughs nervously and when the infant’s mouth is wide open, Sandra quickly

pushes the baby onto the breast from her shoulders. The mother tenses up when she

makes this move. With the infant now suckling at the breast, Sandra instructs the mother

to compress the breast rhythmically to increase the milk flow so that the baby will be

motivated to stay on. The mother is squeezing too fast. Sandra looks and sounds annoyed.

Sandra: Ok, don’t squeeze it too much. She’s off of it again. She’s just got her lips on top of the nipple. You’ve got to take her off and start over again.

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The mother takes the baby off and tries again. The baby puts the breast in her mouth but

then closes her eyes, doesn’t suckle, and is unresponsive.

Sandra: We’ll have to pull her off now. She’s not really sleeping, she’s just shut down.

She’s saying, “Forget this!” Do you want to try her on the other [breast]?

Despite the lactation consultant recognizing that the infant has shut down, she continues.

The mother moves the baby over to the other breast and Sandra once again pushes the

baby onto the breast when her mouth is opened wide. The baby suckles, but the mother

becomes concerned that she is unable to breathe well out of her nose, so she places a

finger in front of the infant’s nose and pushes it down so that the breast is not directly

against it. When pressed against a breast, infant nostril placement is at the side so that

they can safely breathe, but if their breathing is noisy, this often concerns mothers who

think the infant is suffocating.

Sandra: Don’t worry about the nose.

The mother now ignores Sandra’s directives in silent defiance and keeps her finger in

place.

Sandra: Don’t worry about the nose! You’re gonna pull the nipple out! Don’t push her head! Push over here. Don’t let her pull off!

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The baby sucks some more and then fusses and tries to pull off again. Sandra keeps her

on with more breast compressions. The mother still has her finger in front of the infant’s

nose.

Sandra: Don’t worry about her nose.

The baby once again shuts down, closing her eyes and not suckling. Sandra begins

vigorously rubbing her body to try to get her to be responsive. The mother looks

disturbed over this action as if she feels Sandra’s methods are too aggressive and are the

cause of the infant shutting down. She says nothing but when Sandra stops, she gently

strokes her baby’s head as if to comfort or try a less aggressive way of getting the baby to

be responsive. The baby opens her eyes but still does not try to suck.

Sandra: Her eyes are open, she’s just refusing.

They remove her from the breast and try to get her to latch on again. The mother leans

over to bring the breast to the baby rather than the baby to the breast, as she did in the

very beginning. I wonder to myself if she is doing this to keep Sandra from pushing the

baby onto her breast again.

Sandra: Okay, you need to lean back a bit because you’re kind of laying on her. Don’t bring your breast to her.

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The mother sits back up, but keeps the baby a distance away from her and looks defeated,

as if she has given up.

Sandra: She’s out too far [from your body]. I don’t want you to have to come back

[here].

Sandra, frustrated that the mother isn’t doing all of the things that she wants her to do, or

in the way that she wants her to do them, now addresses the father. She demonstrates the

positioning she wants the mother to use and also shows him what the mother is doing

wrong. Sandra tells me later that she did this because she assumed the mother didn’t

understand her and she hoped the father would find a way to communicate this

information to his wife in a way she would understand. This does not happen during the

clinic visit, and from my observations I believe the mother does understand Sandra. What

she describes to the father is that when the mother puts her hand on the back of the

baby’s head to bring her to the breast, the baby pushes her head back against the hand

and thus isn’t moving towards the breast. This is a common response that infants give if

you put your hand on their head and push it forward.

Sandra: She’s pushing out. See, you want the baby to go like this, because mom is pushing her like this.

Sandra decides to once again demonstrate the proper way to get the baby to latch onto

the breast by placing her hand on the baby’s shoulders and waiting for the baby to open

her mouth wide and then swiftly pushing her onto the breast. The baby did not like this

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and fussed. The mother looked upset and tried to soothe the baby again by gently stroking

her head and vocalizing.

Mother: Oooh!

The mother tries to get the baby to latch again once she has her calmed down.

Sandra: Don’t push her head! Don’t bring her in. Don’t bring her in!

The mother pauses as instructed and Sandra squeezes milk out of her breast.

Dad: She’s squirting the milk.

Sandra: I’m squirting the milk. I want her to open up real big.

This time the baby stops fussing, latches on, and starts suckling at the breast. Sandra

continues to do rhythmic compressions of the breast to keep the milk flowing at a higher

rate as it would from a bottle.

Sandra: Good baby. She likes it when she gets some squirts.

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The baby doesn’t stay latched on for very long, however, despite the breast compressions.

The mother tries to get the baby to latch back on again by doing it her own way, leaning

over the baby and moving her breast over to his mouth, one last time.

Sandra: You’re bringing your breast over. It needs to be that way. Your bringing your breast over again. Leave your breast where it belongs, okay! Over there!

The next appointment has arrived, and Sandra once again turns to the father and

instructs him on how the mother should be positioning her body and the infant’s body in

order to effectively breastfeed.

In this interaction, the mother came into the clinic with an idea of why the infant

was not wanting to breastfeed that seemed to be accurate. She stated that the baby was

used to the bottle and this was why she was refusing the breast. Not all, but many

newborns, have this response because it is easier to remove milk from a fast-flowing

bottle nipple than from the breast where the infant has to work harder to get milk out.

This is true even when the bottle is sold as “slow flow.” A question remains, however, as

to why the infant lost 10% of his birth weight. There are various possibilities, and the

lactation consultant in this case focused on how the mother positioned her body when

breastfeeding as an indicator that the infant likely had a bad latch that prevented him

from effectively nursing.

In adopting an authoritative and instructional approach instead of a baby and

mother led approach, the mother and the infant both became defensive or too distressed

to utilize what has been described as instinct or intuition. They both began “refusing” the

lactation consultant’s directives. Although the mother knew her infant was distressed and

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was not responding well to being forced onto the breast, although she knew that the infant

had a preference for the bottle, and although she knew how to soothe and calm her infant,

she was unlikely to come away from this interaction with confidence that she had any

knowledge at all about her body or her baby, or had any ability to breastfeed. Although

attempting to give the infant the breast in the way that you give a baby a bottle was

ineffective, it was a rational decision on the mother’s part. Without self-confidence or

success at getting the infant to latch, there is a likelihood that this mother might have

given up on breastfeeding. She might have also felt that she was personally responsible

for breastfeeding’s failure, because the message she got in the above interaction was that

she wasn’t able to properly enact breastfeeding according to the instructions given to her.

One lactation textbook states:

Babies who have been repeatedly pushed forcefully to the breast, bypassing their instincts, may learn to associate distress with the breast. Thus when placed skin-on-skin, these babies will usually still search for the breast and move toward the nipple, but when they get close to the areola they can suddenly become disorganized, their tongues rise to their palates (Widstrom 1993), and they become so tense and distressed that they are unable to follow through to grasp the breast. They may even arch, cry, or pull away from the breast. Although many term this breast refusal, it is not clear whether the infant is actually refusing the breast or simply distressed at being too disorganized to feed . . . If her baby gets on the breast and immediately comes off, only to try again, she may be confused and think her baby is doing something wrong . . . Whatever is going on, it is instinct at work, so the clinician can always reinterpret the behavior for the mother as normal and as positive . . . It helps to tell the mother that her job is not to learn to breastfeed, nor to make her baby learn. Her job is simply to keep her infant calm, relaxed, and comfortable so her baby can learn. (Smillie 2016, 106-108)

Sandra’s methods were partly due to the restrictions on the amount of time she had with

mothers, and because she was often successful at getting infants latched onto the breast

this way. Mothers, however, often had difficulty reproducing the same success and did

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not appear empowered from her methods. The mother in the above example already had

the knowledge that the infant was preferring the bottle, and her response was to try to

give her infant the breast as if she were feeding the infant a bottle. Both methods, either

putting the breast in the infant’s mouth, or forcing the infant onto the breast, were

overriding infant instincts that lead to self-attachment at the breast according to baby-led

methods.

Conclusion

When it comes to breastfeeding, the allure of technology, feeding schedules,

interventions, or anything that accomplishes what Yui describes as the degrading act of

turning women into machines, is a form of reassurance the biomedical system offers.

That reassurance is the idea that experts and technology know better than you do and will

save you from dangers. They prevent parents from using their senses to read the signs,

and from trusting themselves and their bodies. These repetitive rituals give the

appearance of social order by relieving parents of their worries through the feeling that

everything is under control. Ironically, this research and the opinions of lactation

consultants in this study shows that this is how breastfeeding falls apart. Women tend not

to consider that it is the system’s fault for setting them up for failure, instead they

internalize the idea that something is wrong with their body or their ability to mother. I

heard many breastfeeding mothers who had difficulties and had sought a lactation

consultant say time and again, “I feel like I just can’t do anything right.”

Both Karen and Tina believed that women just needed a “cocoon,” or a quiet,

comfortable place where they could be left alone with their infant without interruption,

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and through which breastfeeding would emerge. This is supported by the findings of a

study (Ryan et al. 2010) that determined from women’s video narratives that they already

had embodied knowledge of breastfeeding and they just needed to be in a conducive

environment without interruptions in order to “fulfill the embodied calling.” If one is

relaxed, the let-down can occur since it is believed that negative emotions can impede

letdown (Britton 1998). Yui, Karen and Tina believed that emotions were important

signposts that were useful in the way that Feldman Barrett and Bliss-Moreau (2009)

claims “core affect can be thought of as a neurophysiologic barometer of the individual’s

relationship to an environment at any given point in time, with self-reported feelings as

barometer readings” (p. 173). Negative emotions like guilt, shame, or other emotions

related to a mother’s thought that she can’t do anything right, or that her body is

dysfunctional, are signs of disempowerment. As Tina pointed out, women remembered

emotional experiences, so if the lactation consultant gave women reasons to feel good

while directing them to particular elements of their sensory experience, this would help

them to learn and would positively affect how they thought of their bodies.

Yui, Karen and Tina knew something that psychologists who study perception

understand, although not in such a scientific way. We don’t experience all of a sensory

array that bombards us in a given moment but perceive what our brain has predicted is

important to focus on in a given moment (Feldman Barrett 2017). Our brain has to choose

what sensory information to focus on amidst all the noise. It looks for patterns based on

past experiences, and environmental context and cultural expectations are important

elements (Feldman Barrett 2017). When you categorize things according to their

similarities, what you choose to identify as a pattern is constructed (Feldman Barrett

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2017). Furthermore, what we choose to focus on is linked to affect (Feldman Barrett

2017). Because we are social, we all have an influence on each other’s nervous systems

and can actually affect each other’s bodies through the various ways that we

communicate (Feldman Barrett 2017). This can be through touch, the way we look at

someone, or through our words – which describe our concepts and emotions. We have the

ability to direct people’s attention and thus change their embodied experience.

When a mother’s attention is brought to her milk spraying out during lactation

massage or hand expression, she knows she has a sufficient amount. When a mother’s

attention is on how she feels physically and emotionally, she has a useful guide. When

she feels the pain of the blocked milk moving out of the tender areas, she knows her milk

will flow. When the lactation consultant demonstrates watching and listening for infant

cues, has a mother listen for swallowing sounds, has her examine the angle of the infant’s

mouth while latching, or notice the movements of the infant’s jaw, feel the weight of her

breast, or observe the shape of her nipple after a feeding, the mother learns to read the

signs and trust herself, and then becomes her own authority. When a lactation consultant

combines these attentions to sensory experience with words that elicit positive feelings,

she helps create a pleasant, directed experience that will be remembered each time the

mother breastfeeds, to reconstruct meaning.

When the lactation consultant involves the mother in the plan for her care and

understands that she doesn’t know what is best for a woman, she empowers them. When

embodied knowledge is valued, and when pain is seen as having a purpose, a holistic

sense that the whole body is connected and that breastfeeding is done with the whole self,

is established. When a woman is told that it is her practice and attention to infant cues

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that is making breastfeeding successful, she does not feel like a machine that is broken.

Technology then becomes a source of support when needed, but not a necessity in all

cases. These examples directly counter the messages given by Davis-Floyd’s (2001)

tenants of the technocratic model and offer a new kind of reassurance based in embodied

knowledge.

The final case study is also instructive because the authoritative directives of the

lactation consultant were not mother and baby led and did not refer to sensory elements

that could provide insight to the mother. In fact, the methods used resulted in a “shut

down,” in the infant and mother who both responded with refusal behaviors. The refusal

behaviors are a turning attention away from gaining possible insight through sensory

elements of the experience. Instead, the methodology repeatedly bought attention to what

the mother was not doing right. This creates negative emotions, and what was likely

learned and remembered by the mother was that she was a failure at breastfeeding, and

thus mothering. Neither the mother nor the baby left the appointment with the ability to

facilitate breastfeeding, nor did there seem to be improvement in their ability.

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Chapter Seven

Conclusion

In this dissertation I have argued that understanding the discourse associated with

breastfeeding is important because concepts form our experiences. Therefore, if we

understand the concepts, women’s experiences can be improved. This is demonstrated by

how lactation consultants who took part in this research attended to the difficulties of

breastfeeding mothers. The concepts that form lactation consultants’ understandings of

breastfeeding are important because they influence the redirected attention of mothers

having breastfeeding difficulties and determine whether or not a mother’s reconstructed

concepts are helpful.

Using ethnographic research, I investigated how lactation consultants’ concepts

were formed and found that they used science to understand lactation, but also accepted

that there is a limit to how much science is able to untangle when it comes to

breastfeeding’s dynamic complexity. The science of biology brought them to a

celebration of the capabilities of the female body, and science was not to be used in

service of greater medicalization, but in service of female empowerment. This way of

understanding science could be described as a postmodern science of instabilities

(Lyotard 1984) based in the dynamic, relational, and mysterious aspects of breastfeeding.

As the neuroscientist Robert Sapolsky (2004) has said, “Science is not meant to cure us

of mystery, but to reinvent and reinvigorate it” (xii). Science was foundational for their

practice as a medical authority, but intuition was also important because inference and

reason did not always help make sense of everything.

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The concepts that lactation consultants had about the lactating body and

breastfeeding often differed from the concepts that the women who sought their help with

breastfeeding difficulties held. Women’s concepts came from their social circle and

biomedicine—in particular the hospital environment in which they had their first

experiences of breastfeeding. The technocratic model enacted by the hospital gave

women the message that their bodies were likely to fail and were in need of medical

management. These concepts could cause women to interpret breastfeeding related

stimuli as a sign that the body was failing even in cases where, for example, women had

an adequate supply of milk. They further affected women’s behaviors, which at times

fulfilled the expectation of failure. Women also had difficulties that were not a

misperception, but even in these cases the body was not seen as informative but was

conceptualized as a broken machine. Machines are not dynamic and relational and

therefore were thought to respond to simple, reductionist methods such as quantifying

techniques of monitoring that often became ritual. These understandings of the body and

subsequent responses, created and perpetuated negative embodied experiences.

In my participant observation with lactation consultants I saw how they often tried

to change women’s concepts by steering them away from disembodied, technological and

numerical ways of monitoring and measuring their milk that reinforced existing harmful

concepts. Even in situations where technology and quantifications were deemed

appropriate, it tended to be with limited or specific application. Lactation consultants

bought women’s attention to the elements of the sensory array that were important for

forming new concepts that were empowering. They helped women to see that in most

cases their bodies were whole and functional, and had important information to provide

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to them, giving them a different embodied experience of breastfeeding. They found touch

and emotions to be useful to the reasoning process and relationship building, while

emotions were also important for information retention. Thus touch, the release of

emotions and the creation of positive emotions were tools they used to help breastfeeding

women. Breastfeeding was also seen as a relational process that unfolds rather than steps

you should automatically be able to perform.

This study contributes to the literature on the influence of sociocultural and

structural factors on women’s breastfeeding experiences. It also contributes to

understanding what types of actions will help women with breastfeeding difficulties. In

this way it speaks to possibilities for changes in policy and institutional practices that take

into consideration how women effectively learn to breastfeed and what elements of

policy and practice are detrimental to breastfeeding.

The conclusions of this study are relevant to current debates about breastfeeding

in which the trend is to change our concepts about it from important and beneficial to

unimportant and insignificantly beneficial so that women who can’t or don’t breastfeed

won’t feel shame or guilt. It is also relevant to current debates that aim to change our

concept of breastfeeding so that it is conceptualized as risky, in order to protect infants

from unintentional starvation. Lactation consultants have been a target of these debates

because they are considered a cause of women feeling guilty if they can’t or don’t

breastfeed their infant, and a cause of mothers not using formula in cases where an infant

isn’t getting enough breastmilk43. The conclusions of this study are also relevant to the

43 This refers to the opinions of those associated with the organization Fed Is Best (FIB) See https://fedisbest.org/. During my ethnographic research I noted that, contrary to these beliefs, lactation consultants were always quick to recommended formula when it was needed. In my training I was taught to assess for milk supply and transfer and feed the baby and protect the mother’s milk supply above all else.

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trend to claim that the benefits of breastfeeding are not large enough to warrant it as a

public health priority, and the idea that efforts to increase breastfeeding success in

hospitals takes away women’s choices and contributes to intensive mothering.

In closing, I offer thoughts about how this dissertation can speak to those issues. I

have established that our concepts shape our perception and thus our experience of

breastfeeding. A discourse that understands breastfeeding to be unimportant,

insignificantly beneficial, and a risk to infants, feeds into present ideologies that have

disparaged the female body by treating it as problematic, likely to fail, and in need of

medical management. It gives us no reason to think positively about the female body and

every reason to continue to control it. Doing so will contribute to struggles that mothers

have with breastfeeding. Furthermore, it takes away the empowerment that many mothers

experience when they breastfeed and the satisfaction of having a rich and satisfactory

embodied experience, and interbodied experience with their infant. Additionally, the

backlash to the promotion and support of breastfeeding has been initiated by middle-class

White women whose privilege means the consequences of not breastfeeding for them are

not as great as it is for low-income and persons of color. The latter are disproportionately

affected by diseases, premature birth, and mortality rates that breastfeeding can reduce.

The way to move forward to make breastfeeding possible and a positive

experience for mothers is through more demedicalized, women-centered care like that

described in this dissertation. Structural changes are necessary as well, such as paid and

adequate maternity leave for all mothers and alloparenting solutions. It is also important

Feeding the baby meant formula when breastmilk was not available. There may be isolated examples where proper care was not provided to breastfeeding mothers who fell through the cracks that are associated with the bad outcomes that this organization refers to.

329

to have a national discourse about the structural causes of breastfeeding difficulties

instead of a discourse of “mommy wars,” and attacks on breastfeeding advocates. This

discourse should include a focus on dominant ideological concepts and how these are

disseminated and negatively affect women’s breastfeeding experiences.

Dykes and Flacking (2010) have recommended a move away from focusing on

breastfeeding’s health benefits to a focus on its relational aspects and benefits in order to

relieve women of the pressure to breastfeed and subsequent feelings of failure when they

have difficulties. However, as the lactation consultants in this study have shown, the

health and relational aspects needn’t be separated if we view the biological as social. The

term “super-natural” understands breastfeeding’s specialness to be its dynamic and

relational aspects. The mother and infant together in interbodied actions, create milk that

contains living substances and is ever changing to meet the specific needs of each

individual infant at each stage of development.

If all of the above suggestions are implemented, it will help mothers to breastfeed

but won’t take away every woman’s struggle with it. In fact, the metaphor of the

“cocoon” in which mothers and their infants are given a quiet space without interruptions

to get to know each other and work breastfeeding out, is an idea that breastfeeding is a

process that unfolds over time. Relationships take time to develop because you can’t

know someone immediately. In this model breastfeeding isn’t “natural” as in instinctual,

but is learned in an embodied way, and breastfeeding involves some struggle as the

learning unfolds. This does not imply that the body is dysfunctional or broken, rather the

unfolding represents the process working as it should. This concept of breastfeeding as a

process (Davis-Floyd 2001; Ma 2018; Van Estrik 2012) is also inclusive of special

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circumstances, such as premature infants who need more time than term infants to be

developmentally able to breastfeed, or infants who need to be supplemented due to

various issues. It therefore has the potential to end feelings of guilt or shame in women

who struggle, because their experience is one of becoming, and is a normal process.

331

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