Breastfeeding and the Effort to Re-Domesticate Women

It’s World Breastfeeding Week 2019 and it’s time to acknowledge that the predicted dividends of breastfeeding — lives and healthcare dollars saved, diseases and conditions averted — have failed to materialize. The reality is the benefits of breastfeeding for babies in industrialized countries are likely trivial.

So why are we still promoting breastfeeding so aggressively?

"Re-domesticating" (from the Latin word domus, meaning home), with its multiple meanings, captures the goal of some who promote breastfeeding.

To tame.
To cultivate.
To make fond of home life and housework.

That has been a goal since the inception of the contemporary breastfeeding movement: La Leche League was founded in 1956 by seven traditionalist Catholic women who strove to keep mothers out of the workforce by convincing them to breastfeed.

In the book La Leche League: At the Crossroads of Medicine, Feminism, and Religion, Jule DeJager Ward explains:

[A] central characteristic of La Leche League’s ideology is that it was born of Catholic moral discourse on family life … The League has very strong convictions about the needs of families. These convictions are the normative heart of its narrative… The League’s presentations and literature carry a strong suggestion that breast feeding is obligatory. Their message is simple: Nature intended mothers to nurse their babies; therefore, mothers ought to nurse …

It’s not a coincidence that their premier publication is named The Womanly Art of Breastfeeding, not the “motherly art.” Good women breastfeed. Bad, unwomanly mothers don’t.

As a recently published historical analysis of breastfeeding promotion notes:

… For [La Leche League], breastfeeding was about cultivating a certain kind of mother, a better mother, and so they advocated for practices that supported intensely close and time-intensive mother-infant relationships including rooming-in, demand feeding, and infant-led weaning.

But the way that you can really tell that a goal of breastfeeding promotion is to return women to the home is how the “benefits” of breastfeeding have become tied to increasingly rigid breastfeeding behaviors. Efforts include the demonization of infant formula, the medicalization of breastmilk, the insistence that breastfed babies love their mothers more, and — the newest front — criticism of breastmilk pumping.

The demonization of infant formula

From the 1960s through the 1990s, there was reason to believe that women could provide their infants with the benefits of breastmilk and also use formula when convenient; there was no research to show that the benefits of breastfeeding were in any way dose-dependent. In theory, working women could breastfeed while at home and childcare providers could give bottles of formula while mothers were at work.

Therefore, the demonization of formula became a critical element of breastfeeding promotion. It started with the demonization of formula companies because of their unethical behavior in Africa in the 1970s, an anti-corporatist bias that remains to this day. However, it has gradually been transformed to the claim that even one bottle of formula destroys the infant gut microbiome, the multitude of bacterial species that reside in the gastrointestinal tract of every individual.

This claim is supported — if at all —by extremely weak scientific evidence riddled with confounding variables. No one yet knows what the normal contents of the infant gut microbiome are supposed to be. No one knows whether differences between babies reflect clinically meaningful differences or merely individual variation. No matter. Avoiding formula at all costs has become a cornerstone of contemporary breastfeeding promotion.

The medicalization of breastmilk

While lactation professionals promote breastfeeding as best because it is natural, they cannot resist the impulse to medicalize breastmilk itself. It is no longer enough to say that breastmilk is “better” for babies, claims —largely unsubstantiated — are made that breastfeeding saves lives, prevents diseases and conditions and saves healthcare dollars.

In recent years, it has become possible to buy those benefits — real or imagined — by buying breastmilk either directly from others on the internet, or through breastmilk banks that vet the purity of the milk. And the women who make the most money, those who have jobs and careers, are most able to afford this extremely expensive commodity ($8/ounce or more). These women could have it all: work at demanding jobs for long hours without the hassle of pumping milk and still supply their babies with the “best” food.

But that possibility was undermined with the invocation of antibodies. Prof. Katie Hinde and other breastfeeding researchers have noted that when babies are sick, the antibody content of breastmilk rises. They’ve even proposed an extraordinary mechanism for how the baby communicates to its mother that it is sick. The theory is known as “spit backwash.” Baby saliva is supposedly sucked into the breast where the mother’s body senses the pathogen and makes antibodies in response.

But there is another far simpler, far more likely explanation. It’s hard for two people to be much closer than a mother and her feeding infant. If a baby has a cold, for example, the mother can simply breathe in the virus expelled when the baby sneezes and make antibodies to the virus to protect herself from the cold. Those antibodies then end up in the breastmilk incidentally as a result of being in the mother’s bloodstream.

When I publicly questioned Hinde on her claim and offered the simpler alternative explanation to spit backwash, she replied:

I agree that there are reasons for maternal antibodies to be protecting the mammary gland & things can be byproducts… [My] article discusses this as one potential pathway… but doesn’t make arguments that it the ONLY pathway or that this is the ONE function of that pathway.

This is a far more nuanced view, but hardly the view that she has been presenting in her interviews and writing for laypeople where she insists that “mammary gland receptors detect the presence of pathogens, they compel the mother’s body to produce antibodies to fight it, and those antibodies travel through breast milk back into the baby’s body, where they target the infection.”

What does this mean? Even the mother who can afford to buy breastmilk shouldn’t do so; breastmilk must be custom made by the stay at home mother to meet the specific immunological needs of her infant.

The insistence that breastfed babies love their mothers more

Of course no one is crass enough to say it this way. The preferred phrasing is that breastfeeding promotes bonding. There is no evidence for this. Ironically, it is justified by appeals to Attachment Theory though attachment research showed precisely the opposite: mothers matter more than milk.

Harry Harlow’s classic monkey experiments demonstrated that baby monkeys, when given a choice between wire mother substitutes that provided milk and warm, cloth mother substitutes that couldn’t provide food, the babies greatly preferred the cloth “mother.”

In his paper, The Nature of Love, Harlow wrote:

These data make it obvious that contact comfort is a variable of overwhelming importance in the development of affectional response, whereas lactation is a variable of negligible importance. With age and opportunity to learn, subjects with the lactating wire mother showed decreasing responsiveness to her and increasing responsiveness to the nonlactating cloth mother …

No matter. The unsubstantiated — and indeed contradicted — claim that breastfeeding facilitates bonding is another cornerstone of breastfeeding promotion.

Criticism of breastmilk pumping, the latest front

When La Leche League was founded, there was no practical way for mothers to combine breastfeeding and working because the breast pump didn’t exist. When it did become widely available, it was initially greeted with enthusiasm. Lactation professionals routinely recommend pumping regimens as an addition to breastfeeding itself to boost breastmilk supply for those who aren’t making enough breastmilk to fully nourish an infant. They also recommend pumping and freezing extra breastmilk, either to be used when mothers returned to work or to be donated to babies whose mothers cannot produce enough.

There have been aggressive legal efforts — largely successful — to increase women’s access to clean, private spaces to pump breastmilk while at work and to make sure they aren’t penalized for taking time to do so. That has made it possible for ever more women to give their babies custom made breastmilk while simultaneously working nearly limitless hours outside the home. Great, right? Not any more!

A recent piece in The Atlantic, titled Pumping Milk and Nursing Are Not the Same is a shot across the bow.

Annie Lowrey writes:

But while pumping might support direct nursing, it is not equivalent to direct nursing, researchers have found. The microbiome of expressed breast milk is different, for one. “Indirect breastfeeding” is associated with a greater prevalence of pathogens, which “could pose a risk of respiratory infection in the infant … Plus, breast milk degrades when it is cooled, as it often is when stored for bottle-feeding. There is also the risk of contamination, given that dangerous bacteria flourish on pump parts.

She also writes:

Researchers also sense that the experience of breastfeeding—the eye-gazing, the cuddling—is a big part of the benefit of breastfeeding for the baby, and a big part of the joy of breastfeeding for the mother. How does bottle-feeding change the equation?

How does bottlefeeding change the equation? There’s no evidence that it does and no reason to think it does: Eye-gazing and cuddling are as intrinsic to bottlefeeding as they are to breastfeeding.

Exclusive breastfeeding has become the leading risk factor for newborn hospital readmission. A startling 1 in 71 breastfed newborns is readmitted to the hospital for dehydration, jaundice and other complications of insufficient breastmilk. Literally tens of thousands of newborns are hospitalized at a cost of hundreds of millions of dollars each year.

During World Breastfeeding Week 2019, we should admit that breastfeeding promotion has failed to produce the predicted benefits and that it can have significant harms. If it were really about what is best for babies, we would be engaged in frantic efforts to reduce those harms.