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

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.

ii 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.

iii Table of Contents

ACKNOWLEDGEMENTS ...... ii ABSTRACT ...... iii FORWARD ...... vi -xiii CHAPTER ONE, INTRODUCTION ...... 1 Introduction ...... 1 Theoretical framework ...... 9 Research methods and design ...... 35 Dissertation outline ...... 43 CHAPTER TWO, THE RISE OF LA LECHE LEAGUE AND THE CREATION OF THE IBCLC ...... 49 Introduction ...... 49 The Era of the IBCLC ...... 49 The results of breastfeeding activism ...... 65 The Influence of La Leche League on the Creation of the IBCLC ...... 72 “Natural” Parenting and the Expert ...... 80 Infant care and evolution...... 87 Instincts and social structure ...... 92 Conclusion………………………………………………………………………………………………………………………………...….97 CHAPTER THREE, BECOMING A LACTATION CONSULTANT ...... 103 Introduction………………………………………………………………………………………………………………………….103 IBCLC Certification Requirements ...... 103 My Socialization into a Medical Role ...... 105 My Story ...... 106 The Lactation Consultants’ Stories About Why They Became IBCLCs ...... 117 Mary ...... 118 Karen ...... 121 Tina ...... 124 Sandra ...... 125 Yui ...... 127 WIC IBCLCs ...... 131 The Training ...... 136 Conclusion ...... 144 CHAPTER FOUR, SUPER-NATURAL WHITE BLOOD: THE CONCEPTS LACTATION CONSULTANTS HAVE ABOUT BREASTFEEDING ...... 146 Introduction ...... 146 The magical power of breastmilk ...... 147 The anthropology of science, technology, and the natural ...... 165 How breastmilk has been conceptualized as white blood ...... 171 ‘Purity and Danger’ ...... 178 The external womb and the making of a biosocial being ...... 184 The magical hour ...... 187 Breastfeeding and Bonding ...... 194 Drained mothers and their breastfeeding vampires ...... 201 Conclusion ...... 211 CHAPTER FIVE, BROKEN MACHINES: THE CONCEPTS MOTHERS HAVE ABOUT BREASTFEEDING ...... 215 Introduction ...... 215

iv The social construction of lactation pathology and breastfeeding norms in the U.S...... 216 Learning how to breastfeed..………………………………………………………………………………………………….225 Measuring Milk ...... 238 Ritualized quantification ...... 246 What is a sufficient supply? ...... 251 Tracking input and output ...... 252 Measuring milk with a pump ...... 254 Pre and post breastfeeding weights ...... 254 Growth charts ...... 255 Breastfeeding and epistemology ...... 256 A Phenomenology of breastfeeding………………………………………………………………………...... 266 Mysterious pains ...... 266 Emotions ...... 275 Conclusion ...... 277 CHAPTER SIX, LACTATION CONSULTANTS HELP MOTHERS MAKE ‘SENSE’ OF BREASTFEEDING ...... 279 Introduction ...... 279 Yui, in the Japanese lactation massage clinic ...... 281 Tina, in the hospital postpartum unit ...... 289 Karen, in the pediatric clinic ...... 302 Sandra, in the non-profit clinic ...... 311 Conclusion ...... 321 CHAPTER SEVEN, CONCLUSION ...... 325 BIBLIOGRAPHY ...... 331

v 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

vi 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

1 Throughout this dissertation I use the terms “breastfeeding” and “mothers.” I recognize that there are transmasculine parents who prefer the term “chestfeeding” or neutral terms such as “nursing,” and “parent.” I primarily use the terms “breastfeeding” and “mothers” in this dissertation, however, because it is based on research that to my knowledge did not include observations of transmasculine individuals. Also, I use these terms to reflect that the discourse I studied and refer to uses the term “breastfeeding” and refers to “mothers.”

vii 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

viii 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

ix 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

x 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,

xi 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

xii 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.

xiii 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

1 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.

2 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

3 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

4 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

5 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

6 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

7 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

8 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

9 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

10 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

2 As I finished this dissertation the U.S. Senate passed, and the president signed, a bill mandating that federal workers be given 12 weeks of paid parental leave.

11 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)

12 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)

13

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

14 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).

15 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

16 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

17 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

18 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

19 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

20 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

21 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

3 I 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.

22 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

23 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

24 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

4 I use Chodorow’s term “exclusive mothering” hereafter in order to reflect how the model is different from that found in traditional societies in which alloparenting exists, meaning mothers had childcare assistance from extended family and others in the community.

25 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

26 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.

27 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

28 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.

29 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,

30 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

31 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

32 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

33 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

34 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

35 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

36 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

5 All names have been changed to protect the research subject’s privacy.

37 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

6 Because this lactation consultant was only interviewed, she has not been included in the count of 7 lactation consultants that I have claimed participated in this research and whose stories I have told in association with their mentorship and observations of their care.

38 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

39 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

40 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

41 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

42 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

43 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

44 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

45 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

46 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

47 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.

48 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

49 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

50 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

51 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/

52 (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

53 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

54 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.

55 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.

56 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).

57 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

58 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.

59 “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.

60 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

61 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.

62 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).

63 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.

64 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.

65 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

66 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.

67

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.

68 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

69 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

70 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.

71 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

72 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.

73 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

74 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

75 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

76 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

77 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.

78 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

79 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.

80 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

81 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

82 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.

83 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:

84 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

85 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.

86 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.

87 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

88 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.

89 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).

90 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.

91 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.

92 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

93 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

94 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

95 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.

96 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

97 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

98 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.

99 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

100 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.

101 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.

102 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/

103 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

104 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

105 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.

106 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

107 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

108 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).

109 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

110 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

111 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

112 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.

113 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

114 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

115 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

116 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

117 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.

118 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

119 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.

120 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

121 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?

122 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.

123

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

124 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

125 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

126 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

127 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.

128 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

129 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

130 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.

131 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

132 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.

133 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

134 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

135 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.

136 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

137 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

138 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

139 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

140 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

141 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.

142 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

143 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.

144 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.

145 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.

146 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.

147 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.

148 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

149 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

150 (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).

151 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

152 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

153 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).

154 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

155 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)?

156 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,

157 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

158 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).

159 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).

160 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

161 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.

162 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).

163 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?

164 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

165 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

166 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

167 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

168 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

169 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

170 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

171 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

172 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

173 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

174 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.

175 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

176 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

177 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”

178 (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

179 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.

180 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.

181 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

182 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

183 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

184 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

185 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

186 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

187 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

188 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).

189 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

190 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).

191 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

192 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.

193

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

194 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

195 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

196 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

197 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

198 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

199 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,

200 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,

201 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

202 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

203 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

204 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

205 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

206 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

207 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

208 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.

209 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:

210 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

211 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

212 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

213 knowledge allows women to understand the dynamic nature of breastfeeding without the scientific discourse.

214 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

215 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

216 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

217 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.

218 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

219 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.

220 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

221 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

222 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

223 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).

224 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

225 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

226 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)

227 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

228 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:

229 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

230 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

231 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.

232 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

233 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

234 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

235 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

236 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.

237 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:

238 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

239 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

240 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

241 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

242 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.

243 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).

244 “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

245 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

246 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

247 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

248 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

249 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

250 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.

251 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.

252 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

253 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

254 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

255 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

256 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

257 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.

258 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-

259 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

260 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

261 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

262 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

263 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

264 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

265 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

266 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

267 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).

268 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.

269 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

270 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

271 “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).

272 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.

273 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

274 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.

275 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

276 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

277 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.

278 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

279 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

280 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.

281 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

282 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.

283 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.

284 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.

285 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

286 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.

287 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.”

288 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

289 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 –

290 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

291 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

292 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

293 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

294 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

295 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

296 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:

297 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:

298 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

299 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

300 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

301 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

302 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

303 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

304 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

305 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

306 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

307 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

308 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).

309 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

310 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

311 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.

312

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.

313

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.

314 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!

315 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.

316 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

317 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.

318 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

319 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

320 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,

321 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

322 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

323 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.

324 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.

325 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

326 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.

327 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.

328 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

329 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.

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