Janelle Lamoreaux, August '16
World Breastfeeding Week (WBW) is upon us once again, celebrated annually from 1st -7th August. This is a week during which event founder and organizer, the World Alliance for Breastfeeding Action, hopes to mobilize institutions and individuals around the world to promote feeding babies from the breast. Each year WBW has a theme. Last year’s theme was Breastfeeding and Work: Let’s make it work! This year’s theme is Breastfeeding: a key to sustainable development and it is being explored in five different ways, one of which focuses on the relationship between breastfeeding and the environment. A flyer on the World Breastfeeding Week website (image 1) reads “Breastfeeding is the first practical step we can take to protect not only the health of babies and mothers but also the health of our planet – right from the start, by providing green and sustainable nourishment to babies.” With bold word choice, the flyer continues: “Artificial feeding contributes to global warming which is causing climate change, with catastrophic results.” This literature’s simple delineation of the artificial from natural, as well as the attribution of the climate change catastrophe to the “artificial feeding” of babies is especially interesting to me in light of ReproSoc’s Reproducing the Environment project, in which Katie Dow and I have been exploring how reproductive and environmental activisms and sciences often implicate one another. It is also interesting to me as a mom who straddles the artificial/natural boundary each time I breastfeed my child.
Image 1. Page from World Breastfeeding Week leaflet.
Though an event that has been occurring since 1991, I admit I had never heard of World Breastfeeding Week prior to my baby’s birth this January. Since then, and usually while pinned under the weight of a sleeping infant who has just fed, I’ve been reading all things breastfeeding – blogs that offer tips, advice and encouragement; critical academic articles about both cultural imperatives and social deterrents to breastfeeding; reports on rates and benefits of breastfeeding to certain durations. Given this intellectual intake during my own expression sessions, I’ve been thinking a lot about how to make sense of my sustained desire to breastfeed, despite the difficulties I’ve encountered along the way. This blogpost situates my personal feeding experience in the context of what appears to be the UK’s breastfeeding conundrum: while women in the UK face higher breastfeeding expectations than ever before, rates of breastfeeding here are some of the lowest, if not the lowest, in the world. The following is an exploration of this tension as I experienced it in the weeks after giving birth.
On January 29 of this year, when my new baby was just 15 days old, the BBC published an article calling UK mothers the “world’s worst breastfeeders”. As a new mom struggling to feed her child from the breast, the dramatic headline hit home. The news article followed from a study in the Lancet, also published in January, which highlights the United Kingdom as the country with the lowest rates worldwide, with only <1% of mothers still breastfeeding at 12 months. While the article points out that all “high income countries” have low breastfeeding rates compared to their middle and low income counterparts, the newspapers were quick to point out that U.K. rates were low even among higher income countries. As shown below (Image 2), all European countries have higher breastfeeding rates than the U.K. Even the United States, which does not have government mandated maternity leave, paid or unpaid, has a 27% 12-month breastfeeding rate. The article does not state why UK breastfeeding rates are so low, but states that not enough breastfeeding support is given. Based on my experience, and the experiences of a few other UK moms I’ve spoken with, I’d like to suggest that it is not a lack of support that results in low UK breastfeeding rates, but the type of support that is given.
Image 2. Percentage of children who receive any breastmilk at 12 months of age. From the article: “Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect.” Victora, Cesar G et al. The Lancet , Volume 387 , Issue 10017 , 475 – 490.
Mothers in the U.K. face an amazing amount of pressure to breastfeed “naturally” – from the breast exclusively and without technological assistance or supplementation. (This has been discussed and studied by Dr. Charlotte Faircloth and others, who refer to the contemporary moment as one of “intensive mothering.”) In my experience, much of this pressure unintentionally comes from well-intentioned systems of maternity support, which over-emphasize “natural” birth and breastfeeding in an effort to avoid the unnecessary medicalization of pregnant women. Upon falling pregnant in the UK I was excited to experience midwife led maternity care. I was eager to be a part of a medical system that encouraged home births, birthing pools, and gas and air as pain relief in an effort to avoid epidurals and c-sections. In the end, however, I came to see some drawbacks to the intense focus of this community on “the natural,” and to understand the strict delineation of natural from artificial as impacting my own early breastfeeding practices and likely that of others. More importantly, I believe this over-emphasis on the natural impacted my child’s health in his earliest days.
I did not read the article calling UK mothers the worlds worst breastfeeders when it was published. As you might imagine, I was rather busy, figuring out how to care for the 15-day-old life I had so recently birthed into a pool of water that sat in a birthing centre suite at a hospital within a city and country that still, especially at times like this, felt foreign to me. I was an American living in England. and as I sat in my rocking chair, looking out on our green grass garden spotted with apple trees while feeding my son a bottle of expressed milk that I had pumped from my breast an hour or so before, I felt very far away from home. My parents, who had been visiting for the birth, were now in London and would soon be making their way back to the states. My partner had popped out to the grocery store to stock up on milk and more prepared meals to get us through the next few days. It was the first time I was at home alone with my baby, and in this moment, even when I stared into the face of my baby contently suckling away on a bottle’s nipple, not only did I feel like a foreigner, I also felt like a failure. I felt only part of the mom (or should I say mum) that I was meant to be. It should be my breast, my skin, that provides him his food, not a plastic bottle. These are the thoughts that went through my mind, even as I fed my baby milk I had expressed from my own breast.
Sick of this feeling, I said fuck it. I’m sure I said it out loud, as brazen cursing always made me feel like I was properly standing out as an American in the U.K. I sat down the bottle of expressed milk and with baby in hand walked out of the room to find the box of feeding supplies stacked on a bench that had been converted into a baby zone in the hallway. I stirred through the contents and found the nipple shield: a small, transparent nipple-shaped silicone sheath that I had eventually been given by a community midwife who visited after we got home from the hospital the second time. I returned to my rocking chair and sat down with my baby, affixing the silicone shield to my breast like a decal onto a curved window. The “nipple” part, a rounded cone with five small holes in the end, stuck out where my own nipple did not.
I was haphazardly diagnosed with flat nipples shortly after giving birth when a midwife told me why my baby was having trouble latching: my nipples were “a bit flat.” Immediately after I gave birth I was able to feed my child; he latched on to the breast just a few minutes after being scooped out of the water and into my arms by an amazing midwife who, alongside an amazing partner, helped me through the last nine (of nineteen) hours in labour. We sat on the suite’s double bed, my baby attached to my nipple and staying on my breast, suckling just long enough to bring on a burst of meconium. Covered in this dark sticky poo, I gave my partner the baby in order to quickly shower while the midwives changed the sheets. It was, despite its messiness, such a happy moment. I had just given birth to a healthy baby the way I imagined I would – in the water with the help of only gas and air. The pain and tiredness that I had felt for the last 24 hours had left; I was giddy with adrenaline and love.
Soon after this first feed however, my breasts began swelling up and my already small nipples protruding less and less. Per midwife instruction, I was to demonstrate that I could feed him for at least five minutes three times before I could be discharged. But things were no longer going smoothly. When near the breast my poor babe repeatedly opened his mouth wide and closed it again, trying to find the nipple that would let him know he was in the right place, that he should clamp on and suck. The midwives were now changing shifts from day to evening, so there was little consistency in who was coming to help me or in their approach to breastfeeding. They came one after the other, each with different advice about how to “get him to latch”. I tried the cradle hold. The cross-cradle hold. The rugby (or football) hold. Finally, I tried the side-lying hold, which was especially popular with first time moms, I was told (Image 3). Every time a new midwife came I had to explain the situation. Some were kind, quipping that it’s called breastfeeding not nipplefeeding. Others seemed as frustrated as I was, and at a bit of a loss. After hours of intermittently trying to feed, adrenaline began to wear off and exhaustion to set in.
Image 3. Breastfeeding positions.
As the evening waned on, I was assigned one particular midwife. I told her we needed to sleep. “Fine, but…” she told me in a threatening tone “…set an alarm for two hours, and if you aren’t able to feed him this time I’ll have to give formula." I suppose I was to be motivated by this threat, so offended by the very possibility that my baby might be given an artificial substitute that I might try harder, or perhaps will my nipples to grow? When an hour and a half went by, before my two-hour alarm woke me up, the midwife came in the room, flipped on the light, and announced it was time for a feed. We tried to feed my little one, but he kept falling asleep after his struggles to find my nipple failed.
I asked my mom and partner to leave, to see if maybe having more privacy would help. It didn’t. In fact it made things worse, as the midwife quickly lost patience. After my baby had once again fallen asleep at the breast, she called him a lazy baby (yet another informal diagnosis that got repeated) and tucked him safely away in his bassinet so we could try hand expression. We were trying to collect colostrum by hand so that it could be given to the baby by syringe. “Everything you do now will help your baby later,” she said encouragingly. I went along with the painful kneading and squeezing of my breast as long as I could manage. Finally, exhausted from not having slept for at least 36 hours and overwhelmed by feelings of inadequacy, I demanded a break. “Don’t you want to feed your baby?” the midwife asked me. With that, I burst into tears, tears that were followed with anger.
I said something about how that is probably the worst possible thing to say to a new mom struggling to breastfeed, especially to one who obviously wants to breastfeed and is committed to doing so. I told her that it was not my fault that my nipples were flat, nor is it my “lazy” baby’s fault, and that if she might leave us alone for a minute perhaps I could figure out how to feed my child. Just then my partner and mother came back into the room. She apologized, played nice, swaddled my baby, jokingly remarked that he looked like an old lady, then left, to my great joy. However, the joy was short lived. I still wasn’t able to feed my little one, at least not much. Every other attempt he would latch for a minute or two. Every other hand expression session, small drops of colostrum would come. My partner and I would celebrate what began to feel like mini-feeding victories, but the midwives were not impressed, and they began feeding my baby formula every two hours. On the one hand, I didn’t mind. My priority was him getting the nourishment that he needed. On the other hand, they gave the formula after every failed or insufficient feed, stressing that they had to do so as a last resort and I began to strongly associate this “artificial food” with diminishing chances of ever being able to breastfeed.
Eventually on Friday morning, after 24 hours in the hospital, I was able to see the birth centre’s lactation consultant. She gave me advice, mostly based around the now trending breastfeeding approach called biological nurturing or “laid back” breastfeeding, which stresses the natural mammalian capacity of newborns to locate the breast from birth. Convinced by my efforts and my insistence that I’d be better off at home, she discharged us. She asked the midwives to teach my husband to feed any expressed breastmilk I might gather in between feeding sessions or (as a last resort) infant formula with an infant feeding cup. The cup feeding method replaces a syringe approach, and is meant to interfere with breastfeeding less than the syringe because it requires the infant to “work for the food,” lapping it up instead of simply swallowing it. All in all, the lactation consultant stressed approaches that were described as closer to nature, or less likely to cause “nipple confusion.” Though nervous about going home without breastfeeding truly established, I felt reassured that the forthcoming daily visits from community midwives would provide enough support and guidance to quickly get me and my baby into a feeding routine.
I spent every hour of Friday night either engaged in the painstaking work of hand expression or attempting to feed my baby from the breast, primarily in the biological nurturing position. I could tell from his crying at the breast and subsequent exhaustion that my efforts were not working, so we continued to feed him formula and whatever little colostrum I had expressed every few hours. The next day when the midwife visited I told her about my fears and frustrations. She sympathized, telling me she was never able to express milk by hand herself, but told us to stay the course, to keep doing what we were doing. She did not tell me to increase the amount of formula I was giving him or that the baby’s bilirubin levels (which increase with jaundice) were borderline, instead reporting that they were fine and that the midwife would be back tomorrow to check in.
Throughout that evening and into the night my breasts continued to swell as my milk came in, flattening my nipples even further and making it impossible for my little one to latch at all. Desperate for advice, at 3:00 a.m. I began emailing and calling every professional resource I could think of – the birthing centre, the National Childbirth Trust, La Leche League. No one answered the phone, but at 8:00a.m. on Sunday morning, after my fourth night of nearly no sleep, I began receiving phone calls and email responses. I was given advice such as “go back to the basics” and “build a nest”. Like the message of biological nurturing that I had received from midwives in the hospital, all of this advice privileged what is considered “natural” breastfeeding, breastfeeding without the aid of tools or technologies, breastfeeding skin-to-skin.
Image 4. http://wellcomeimages.org/indexplus/obf_images/60/04/463588d81569f79cb861edd3b7ab.jpgGallery: http://wellcomeimages.org/indexplus/image/L0035697.html, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36068659
I was also told that some women in my position would use nipple shields, but was immediately discouraged from this option. Archaeological evidence shows that nipple shields have been around since the 1500’s, though little is known about how they were used in the past. (Image 4) Today nipple shields are not recommended for longterm use, but as a temporary solution to common breastfeeding problems such as sore, cracked or flat nipples. I was told not to use shields, especially this early, because it would lead to “nipple confusion” and make it even more difficult for my baby to latch onto my flat nipples. I was then told that shields would result in only 70% milk production (due to reduced sensitivity to the nipples), potential lack of weight gain in my baby, and that “studies have shown” women who use shields stop producing milk between 3 or 6 months. I have since looked at those studies and they were conducted decades ago with women who used shields that are nothing like the ultrathin silicone devices available today. I have been breastfeeding my child with the assistance of nipple shields for the last six months and have had no problem with supply. Also, my baby has had no problem with weight gain. I have never been prouder than when the GP at my local surgery, who had no prior knowledge of my baby’s jaundice or of my use of nipple shields said to me at our 8-week check up, “well, there’s no question that’s he’s thriving.” Today, at six-months-old, my child is still thriving, exclusively breastfed a la nipple shield until the last few weeks when he discovered a love for avocados and bananas.
I have no doubt that without the use of nipple shields my baby would still be fine. We would have managed to feed him properly, either with expressed breast milk or formula or a combination of both. But it pains me to think that the advice I received in the early days of his life – to avoid nipple shields at all costs – might have actually cost me the chance to breastfeed in the cyborg-like way that I do. I did not use nipple shields for the first two weeks of my baby’s life essentially because I was frightened away from this simple yet “artificial” device by some well-intentioned midwives who stressed that the unencumbered breast is best.
On top of just being a frustrating experience, not using nipple shields in those early days played a part in the hospitalization of my baby on the third day of his life. Because I was unable to hand express a large enough quantity of milk and did not supplement with enough of that “last resort” formula, my baby jaundiced severely. He was hospitalized for three nights, not only because he needed to be under lights, but also because of the battery of tests and course of antibiotics that the lovely (and I do mean lovely, they were excellent!) doctors and nurses in the neo-natal ICU insisted upon. Because my little one was born at 40 weeks and was otherwise healthy, at first they thought that his high jaundice levels might be caused by mother-infant blood incompatibility. They then thought that he might have an infection, and started him on antibiotics just in case. They also had to rule out meningitis. Eventually I was told that my baby “was not poorly,” and that this was a case of breastfeeding jaundice that was mostly remedied by the lights and feeding supplementation and that it would continue to clear up with regular feedings.
Six months into feeding my baby with nipple shields, I now believe that this whole episode could have been easily avoided. My baby likely would never have been rushed to the emergency room; admitted to the neo-natal ICU; put on and under therapy lights; fitted with an IV, feeding tube, breathing tube and electronic heart monitors; pinpricked on the heel every 3-4 hours for 72 hours to check for bilirubin levels; and given a spinal tap to check for meningitis. One £2.50 silicone nipple shield might have saved the NHS the thousands of dollars it spent on this hospital care. Am I grateful for the treatment my infant received, and the supportive atmosphere that the ICU offered to parents? Of course. But I can’t help but wonder if the smallest artificial thing - a simple nipple shield – might have saved me, my partner, my mother and most importantly my little one the physical and emotional stress that we experienced during his first days. He was exposed to so many “artificial” things during this hospitalization, nevermind having to be in what might be considered an “artificial” environment, away from the arms of his mother and in a plastic incubator while we waited for his jaundice to dissipate.
Image 5. My little one, under the lights.
I believe I was not offered a nipple shield by midwives until after I returned from the hospital because at this point I was already engaged in what they considered “artificial feeding”. I was expressing breastmilk and we were feeding my baby from silicone teets and plastic bottles that were sterilized in plastic bags specially designed for use in microwaves. We were so far away from the “biological nurturing” position I was taught in the hospital that offering a nipple shield would now, in their mind it seems, get me closer to“natural" than "artificial" feeding.
How does my breastfeeding experience come back to the environmental concerns brought to the table by the organizers of this year’s World Breastfeeding Week? The advice I was given, to not use a nipple shield, to avoid formula at all costs, to nurture my child “biologically,” is rooted in the same theoretical foundation as the WBW’s environment and climate change campaign which divides everything, including feeding ones child, into two exclusive types: natural or artificial. Pointing to “artificial feeding” as a cause of climate change is a rhetorical move that continues to polarize the behaviour of mothers and those who care for them into extremes. It also solidifies the artificial/natural boundary as the pivot point on which breastfeeding and environmental activisms occur. So how, in light of this recognition, to encourage women to breastfeed in the UK and other high-income countries? Probably by fostering institutional and intellectual environments that not only support moms, but do so in a way that does not divide the artificial from the natural, but that teaches a range of practices and makes a range of resources – from the plastic to the silicone to the skin-on-skin – available and accessible.