The Big Letdown

by Kimberly Seals Allers

  The gaping omission was mostly due to a limited understanding of how important the birth to twenty-four-month period was to a person’s future health and well-being. That all changed when David Barker, a doctor and research scientist in England, was among the first to tie chronic disease in adulthood to growth patterns in early life. His work began in the 1980s while studying birth and death records in England, where he noticed a link between low birth weight and a risk of dying from coronary heart disease as an adult. He developed a hypothesis that early-life nutrition and growth is an important factor in determining whether a baby will grow up to be more or less vulnerable to chronic diseases like heart disease, high blood pressure, diabetes, and obesity later in life. This finding led to a new understanding that chronic adult diseases are “programmed” in the womb by malnutrition and other harmful influences and gave birth to what has become a major global research area referred to as Developmental Origins of Health and Disease (DoHaD). “Over the years there has been a growing demand to address the relationship of early nutrition to health outcomes throughout the life span due to its importance in public health. Dietary intake during the earliest stages of life requires an increased demand for nutrients to support growth and development and prevent long-term health problems,” said Angie Tagtow, executive director of the Center for Nutrition and Policy and Promotion, USDA, in an e-mail interview. “At CNPP, we are committed to our mission of improving the health and well-being of Americans by developing and promoting dietary guidance that links scientific research to the nutrition needs of consumers,” Tagtow said. The B-24 advisory committee, made up primarily of doctors, scientists, and nutritionists, has been charged with first reviewing the body of scientific and medical evidence in nutrition and then making recommendations. But the uptick in industry-sponsored research and the insidious practices of the infant formula companies has many wondering how objective these recommendations will be.

  If the most recent DGA is any indication, concerns may be justified. In January 2016, when the 2015–2020 DGA were released, nutritionists and food advocates expressed serious concern that the USDA eliminated restrictions on eggs and red meat—a decision, some food experts say, that was due to the influence of powerful food lobbies for dairy and beef and the growing amount of research that is sponsored by the egg industry. For forty years the government had cautioned against egg intake since eggs are the largest single source of cholesterol. Elevated cholesterol levels have been linked to coronary heart disease, type 2 diabetes, high blood pressure, and stroke. However, when governmental agencies are basing national nutrition recommendations on a body of scientific evidence that has been increasingly industry-sponsored, the potential for skewed research and therefore damaging policies are present.

  This is exactly what breastfeeding advocates fear with the so-called B-24 project (the plan to include birth to 24 months now in the dietary guidelines). That somewhere between the impact of industry-sponsored research muddling the landscape and the pattern of infant formula companies insinuating themselves into policy decisions regarding infant feeding, the end result won’t be optimal. Another policy letdown. Tagtow would not comment on the specifics of the process or any protections to prevent undue influence from breast milk substitute companies, only stating in her e-mailed comments, “We are proud to be embarking on this endeavor and paving the way to better health for our most vulnerable populations.” On a personal level, women look to science and important tools like the DGA to assist with decision making. They are often unaware of the behind-the-scenes factors that compromise the quality of the science and therefore the integrity of policy guidance. Without our traditional support circles or generations of women with breastfeeding knowledge, we increasingly turn to science for evidence to feed based on our biological norm.

  It should concern all women to see our natural instincts about our bodies and our children pushed to the background in favor of “science.” Yes, we live in a complex world without easy answers, so we can expect missteps and a body of expert knowledge that develops as it makes its way through difficult questions and unusual circumstances. But feeding based on our biological norm shouldn’t be one of those complex issues. Feeding children the way infants have been fed and the way that the species has survived for millions of years should not be one of the questions we have to turn to science to answer. Let’s leave those winding journeys to the real mysteries of our society, like figuring out cancer.

  Our trust in science needs to be particular and focused as we improve our ability to decipher good science from the bad. Even our reliance on good science should be balanced with other knowledge, including our natural mechanisms and our confidence in our maternal authority in regard to our family’s health. The current predicament of women, blindly relying on any science and making knee-jerk reactions to so-called breakthroughs about breastfeeding, even while infant formula has never been proved to be advantageous, is not solely our own doing. Women have been pushed into this corner by commercial interests, societal pressures, and a confounding lack of support. When women return to work two or three weeks after giving birth and then stop breastfeeding (or don’t bother starting) because it’s too difficult to pump and work, they end up using science to justify their infant formula use. After running up against a barrage of structural and social barriers, women use science to defend the circumstances they are forced into.

  • 4 •

  The Things Unseen: Battling Structural Barriers

  Out of sight, out of mind.

  —PROVERB

  The nurse told her that it wasn’t her fault.

  On July 18, 2013, Allison Montgomery gave birth to a beautiful eight-pound, four-ounce baby girl at a large New York City hospital. Her husband, Steven, was by her side. Thirty-seven minutes after giving birth, she was wheeled down a twenty-five-foot corridor to her room, while her baby, Jane, was taken to the nursery. Exhausted from seventeen hours of labor, Allison simply wanted to rest with her baby on her bosom. Instead, nurses whirled about, taking her vital signs. Machines beeped. Her baby was down the hall having all the state-required newborn screenings. The pink crib card on baby Jane’s bassinet said “I am breastfed.” What seemed like hours later, the nurse wheeled a crying baby Jane to her mother for feeding. Allison can still recall the feeling of placing her baby on her breast, remembering the books she read and the YouTube videos she watched about latch. Baby Jane sucked a few times and cried even harder. The mild-mannered nurse with her hair in a tidy bun gently told Allison not to feel bad. “Your milk probably hasn’t come in yet,” she said, and offered to bring her a bottle of formula to feed her with in the meantime. “You can try again when the lactation consultant is here tomorrow,” she said. And she did. And baby Jane nursed. When Allison was discharged, she was given a bag with free formula, formula coupons, and a booklet from the American Academy of Pediatrics.

  Two weeks later, the pediatrician blamed it on her breasts.

  It was Allison’s first time out of the house since delivery, and she had spent most of that time sitting on the couch constantly nursing. In the morning before he left for the office, Steven would prepare Allison’s lunch, either a salad, sandwich, or a plate that could be easily microwaved. He would also fill up the water pitcher next to the couch, so she could stay hydrated while nursing. When her husband came home from the office, she would take a ten-minute shower break, and then it seemed as if Baby Jane would start crying again, and Allison was right back to sitting and breastfeeding. She was determined to get it right. She had read the breastfeeding books, saw the pictures in glossy magazines, and bought the cute nursing bras and tanks. But nothing could prepare her for what happened at the doctor’s visit. There were lots of questions for the new parents, and then Baby Jane was weighed and measured. She had lost three pounds. At first, from the matter-of-fact way the doctor said it, Allison wasn’t sure if that was normal or a cause for concern, but she sensed it was the latter. Allison was devastated. She didn’t want to look at he
r husband. She said she feared she was not producing enough milk. That Jane was nursing constantly. Without any further questions, the pediatrician accepted Allison’s self-diagnosis and simply suggested that she supplement with formula. “This is very common with women. Many mothers don’t have enough milk to breastfeed. Don’t feel bad,” he said consolingly. But she did feel bad. On the way out, she noticed the familiar brown teddy bear logo on the weight chart. It was the same logo on the discharge bag she received from the hospital. She began to supplement once, then twice a day. Three weeks later, she was no longer breastfeeding at all.

  On August 19, 2013, more than three thousand miles across the Atlantic Ocean, Christina Cooper gave birth to a healthy ten-pound, eleven-ounce baby girl named Grace in a hospital outside London. She delivered with a midwife, as is the custom in England unless there are medical complications. Two weeks later, Grace’s weight had dipped to seven pounds, nine ounces—slightly more than the usual postbirth weight loss. The visiting nurse told her to consider supplementing because her breasts may not be producing enough milk. But Christina was also determined to get it right. She walked down the block to the local health center for a breastfeeding support group two or three times a week. From other women Christina learned what breastfeeding looked and felt like. And she began to sense something was wrong. And then Christina began to notice it with her own eyes. One of her breasts just didn’t look like the other. The right breast was conspicuously smaller than the left. Even at times when both breasts should be full and leaking—only one was. She noticed her baby didn’t have the satisfied “milk coma” look on her face when she fed off the right breast. When she squeezed her right nipple to express milk, very little came out. Christina didn’t know the medical term for her lactation failure, but she knew that one breast was not producing. The doctor had never seen this before but repeatedly told her that one breast could never produce enough milk to sustain a child. The nurses told her to supplement, “just to be sure.” Her mother-in-law pressured her to formula feed. But Christina was determined and confident. She asked the other mothers and read everything she could to learn about increasing and fortifying her milk supply. She ate halva, a Middle Eastern dessert, and drank lots of water. It was the next doctor’s visit that she will never forget. Grace had gained two pounds. It was just the boost of confidence she needed. Sixteen months later, Christina was still breastfeeding her plump and thriving daughter with only one properly lactating breast. Three years later, she gave birth to her son, and breastfed him, too, for eighteen months with one breast.

  There’s a reason why one woman with two functioning breasts is convinced she has insufficient milk while another woman successfully breastfeeds for over a year with only one properly lactating breast. Studies show that less than 5 percent of women are actually physically incapable of breastfeeding—a negligible number compared with the many women who are diagnosed with low milk supply. If you look at more traditional societies, the rate of mothers successfully breastfeeding their babies is near 100 percent. The so-called insufficient milk phenomenon is primarily a plague of “modern” societies, most notably in the United States. The problem has very little to do with a biological or physiological failure and almost everything to do with the psychological, social, and cultural forces that suffocate our normal infant feeding rhythms.

  I often say that women don’t breastfeed, cultures do. The prevailing cultural norms create an environment that either supports breastfeeding or discourages it. That is why talking about breastfeeding ultimately leads to talking about the structure of society. That includes hospital maternity care, the quality of maternity leave policies, and the availability of viable options for flexible work scheduling. Add to that an industrialized infant feeding system, a culture that glorifies breast-baring Victoria’s Secret ads but that still deems breastfeeding photos on Facebook to be controversial, and a health care system where infant formula is given out for free at hospitals and a high-quality breast pump costs $350. Then, somehow, mothers or their bodies are blamed for any breastfeeding failure, when, in fact, the odds are stacked against women before they even begin. We may feel we are pushing breastfeeding as a message, but we aren’t embracing or supporting it as a culture. The sobering reality is that, given our societal structures and cultural contradictions, breastfeeding is nearly impossible.

  In my work traveling and talking to mothers, as a rule I never “sell” breastfeeding on the fact that it is free. Yes, the costs of breastfeeding in terms of a good pump and a few good nursing bras pale in comparison to the costs of a year’s worth of formula, but breastfeeding is a huge time commitment. And time is money. A mother who is exclusively breastfeeding can easily spend up to six hours nursing per twenty-four hours. This doesn’t account for those critical two-week and six-week growth spurts where nursing can occur even more frequently. Even at a proposed federal minimum wage of $15 per hour, that’s $90 per day, $2,700 per month, or $16,200 for six months of exclusive breastfeeding, if we had to pay for breastfeeding on a time-spent basis. That’s up to $32,400 for the year if you meet the American Academy of Pediatrics’ recommended twelve months of breastfeeding. That’s a basic minimum compensation that nobody is willing to pay mothers yet it is much less than what you will pay for a nanny in places like Brooklyn, New York. According to the Park Slope Parents 2015 Nanny Compensation Survey, the hourly rate paid to nannies ranged from $14 to $20 in that year, with an average of $16.61 per hour, or $34,548 per year based on a forty-hour week. A quick scan of the job-seeking Web site Indeed.com, found salaried positions with a $32,000 annual salary included an ice cream shop manager in Park City, Utah, or an area supervisor for a custodial company in Montgomery, Alabama. Those are real jobs—but mothering and providing the preventive health benefits of breastfeeding isn’t viewed as valuable work. No one will pay a woman even minimum wage for mothering.

  I also never, ever tell women breastfeeding is easy. Yes, compared to the logistics of mixing formula, sterilizing bottles, and traveling with extra bottles, nipples, and formula cans, the act of breastfeeding is certainly easier to manage. But the lived experience of breastfeeding for any meaningful duration is damn hard given all the structural barriers women face. Those barriers create insurmountable obstacles for many women.

  The barriers begin in ob-gyn offices, where obstetricians display magazines laden with formula advertising, offer coupons for formula, and barely educate mothers prenatally on the benefits of breastfeeding. When it’s time to deliver, you head to a hospital, where even the process of how we birth our babies poses another barrier. Historically, hospitals have played a pivotal role in supporting or discouraging breastfeeding. Decades ago, the medicalization of birth, a practice led by physicians and supported by pharmaceutical companies, meant the introduction of the clock—timed feedings at prescribed intervals—which completely destroyed the natural flow of nursing and perpetuated incorrect information about how babies eat. Hospitals remain notorious for regularly giving supplemental bottles of formula when a mother’s milk supply is dependent on the frequency and amount of suckling, especially in the early days.

  Today other common medical practices sabotage breastfeeding. Minutes after giving birth, our newborns are wheeled away for tests that could be completed at other times but aren’t, despite overwhelming evidence that those precious moments after birth are critical for immediate skin-to-skin contact and for the newborn to act on its natural instincts to suck and establish the breastfeeding relationship. A mother’s physical contact with her baby stimulates the production of prolactin, the milk-making hormone. With babies separated from mothers in hospital maternity wards, important instinctive knowledge is also lost and subtle feeding cues are impossible for nurses attending to several babies to notice.

  Not only are mother and baby separated after birth, but their care also is immediately divvied up. The infant goes into the care of a pediatrician. The uterus is assigned to the obstetrician. And our breasts are left to the lactation consul
tant. (If sometime in the future there is a problem, such as cancer, then that is assigned to a surgeon.) We become the sum of our anatomical parts, but that whole person—that mother—is often left to fend for herself. Women are given a pamphlet; if lucky, a pep talk; a demonstration here or there; and perhaps a warning that her hormones may be out of whack for a little while. Within a day or two, the mother is rushed out of the hospital in order to satisfy the requirements of the health insurance companies. The baby receives attention. The mother receives lectures.

  As you are discharged with samples of formula and coupons for more, friends, professionals, and even books warn women not to be too disappointed if they don’t succeed at breastfeeding and emphasize how common it is for a woman to not have enough milk. The messages mothers receive around breastfeeding also include notions that nursing will exclude the father and damage any paternal-child bonding. Meanwhile, social media abounds with horror stories of cracked nipples, bloody nipples, and, even worse, children who bite.

  The pressure and anxiety of it all causes many women to claim insufficient milk. In fact, when mothers self-diagnose that they have no milk, doctors mostly benignly accept that conclusion—a sudden and odd reversal of who is diagnosing whom. Especially since there is not an established diagnosis for breastfeeding problems. Lactation dysfunction doesn’t even exist as a diagnosis and has no accompanying health insurance code for which doctors can bill. Within the database of federally funded medical research for 2014–16, there are fifty-eight studies on erectile dysfunction and thirteen on lactation failure. It doesn’t need pointing out that erectile dysfunction is within the purview of many doctors’ services and that insurance will cover the cost of Viagra. It is no wonder, then, that far too many women are quickly advised by their physicians to stop breastfeeding at the first sign of problems and consoled that their baby will be “just fine.” The complexities of lactation failure are so little studied and so often misunderstood that women often feel that they are at fault, as if they are failing instead of suffering from a medical issue.