Articles >> Postpartum >> Promoting Breastfeeding as an Experience

A Return to Promoting Breastfeeding as an Experience

by Ted Greiner, PhD

I imagine LLL brought me here as something of a curiosity. First, in today's efforts to achieve gender balance in everything, I certainly have an edge in the breastfeeding world. Second, as an American I have a better understanding for this largely American audience than many who have a more European perspective, as I suppose I do, having lived in Sweden for 17 years and in various developing countries for a few years more.

I work with nutrition in developing countries, and breastfeeding has always been a major component for me-though sadly only lip service for most of my colleagues. BFHI is the only thing so far that has come close to mainstreaming breastfeeding as more than lip service, though the Code has had a meaningful impact in many countries and the WBW in even more.

There is still a big divide between the "breastfeeding community" and the rest who work on health or nutrition in development. Now I am senior and experienced enough that I can be accepted as someone broadly knowledgeable in nutrition, but for years it was a disadvantage to be considered a "breastfeeding person," the assumption being that I therefore could not know anything else.

In any case, why LLL really asked me to give this talk is because they share my concern about promoting breastfeeding as breastfeeding, not as the provision of breast milk. In particular when that breastfeeding is exclusive, it is quite a challenge, both for the mother and for us who try to promote it. It is something new, at least in the minds of most scientists, health workers, and social engineers-if there is such a thing. It's strange that it did not occur to hardly anyone before the 1970s-as far as I know-since it would seem to be the "natural" thing that presumably was done by our most ancient ancestors. However, in recorded history, and by this I mean for thousands of years, it does not seem to have been understood or respected, and thus many assumed it was not possible or desirable, since it did not seem to be traditional.

Since we did not know it was possible, let alone desirable, we have not created a society which provides women the support they need to practice. Thus the challenge is broad, far beyond that of educating health workers, however important that may be.

Anyway, what I'd like to focus on now is about breastfeeding as opposed to breast milk feeding. Outside North America people might have trouble understanding what that meant, but I imagine all of you do. About 8 years ago I gave a talk in New York on the concepts of "protecting, supporting and promoting" breastfeeding. An old friend, one of my original research advisors in the 1970s, was in the audience and we discussed my talk afterwards. We talked for several minutes and it got stranger and stranger, as I realized we were not communicating. Finally we realized that this was because, to her, "exclusive breastfeeding" meant basically providing breast milk exclusively to the child, which in turn nearly always meant doing a lot of pumping. So the idea that the mother and child had to be together during this period had never occurred to her and the idea that they could be apart had never occurred to me. It had simply never occurred to me that for most women here that is the norm. Certainly in Sweden it is not. Women pump in rare circumstances, but most do so for a short time if at all. Why and what are the implications?

For Swedish women I would say that breastfeeding is now seen as part of the experience of having a family. Nearly all women work before and after each baby they have, but they breastfeed exclusively during the first 4-6 months. They have about a year of maternity and parental leave at about 80% pay, and the right to gradually go back to work, starting at ¼ time if they want. While many may start breastfeeding because they know it is better for the baby's health, sustained breastfeeding is not promoted in Sweden as particularly important for infant health. More and more women are breastfeeding for a longer period of time, but I think this is more because in the past decade there has been a change in attitude toward it. It is now accepted as something that is all right to do if you want to. Probably most women who do it, simply do not want to force the infant to stop when they see how important it is for the child. Even internationally, there is growing evidence that the decision to stop breastfeeding is often linked to the readiness of the child to stop, meaning that weaker and more slowly developing children are breast fed longer.

All of this I see as an expression by women that they and their children enjoy the breastfeeding experience, not that women are doing it out of a sense of duty or a sense that they provide certain biochemically-mediated advantages to their babies.

I recognize that it is for many the best solution. But perhaps one should counsel pregnant primiperas or those with newborns, if at all possible, to plan their lives in such a way as to avoid getting into pumping or expression. This is the same thing I would say regarding mixed feeding in general. It may at times be the best solution, but should not be viewed as "almost as good" or as a relatively unimportant decision. I wonder if many mothers assume that pumping will be a relatively painless way to "have your cake and eat it too," only to find out that it is more difficult than they expected. Or that it is fraught with expected risks, even leading at times to premature sevrage. The more time a mother spends away from her infant, the higher the risk.

At the very least, pumping is taking away something pleasurable from both mother and baby. Being a man I cannot comment on this from personal experience, but I have certainly seen how breastfeeding (not the consumption of breast milk) seemed to transport my sons to realms of bliss, even when they were up to three years of age. They never received much expressed breast milk and when they got hold of other children's bottles, they simply explored how one should play with such toys. In fact, they never received any commercial infant food of any kind, never had a pacifier stuck in their mouths, and for that matter never had to fall asleep at night alone. They slept in the same bad as their parents until the oldest was nearing the end of elementary school.

I don't think we need research for this kind of thing to obtain status and importance. For those interested in research, I can report that in my family research project with a sample size of two, the children have always been healthy, their teeth remained strong and free of cavities, they were, if anything very independent young children and now young men, and they have had relationships with girls and women that fit well within the Swedish norm. Nor did seven years of breastfeeding do any harm, that we could observe, to their mother. She enjoyed breastfeeding, and felt a bit sad when the boys grew out of it. She did it anywhere she liked as we traveled all over the world, including graduate student seminars at Cornell, unashamed but in an unprovocative way. As far as I know, she received very few comments about this, and they were only positive. When the children got old enough to understand language, she asked them to wait until they were in private-to avoid provoking people, for her and the children's sake. As to the impact of the family bed, this N of 2 were never afraid of the dark, never were interested in teddy bears and never sucked their thumbs much. But they did breastfeed a lot!

To increase the chances that we communicate well on this and that I am not so provocative that I turn some people off, let me begin by saying that in my nutrition work, I find it very useful to divide up plans for program and policy work into two categories-long term and short term. In the long term we may talk about more advanced types of nutrition programs, but in the short term we focus on what the country has the capacity to do now and is likely to be able to do in the near future with enough money. Capacity is the limiting factor often, more so than money.

But when I talk about breastfeeding to Americans I like to focus on the long-term goals. In political work, which breastfeeding promotion is, it seems to me that we Americans have somehow learned to be masters of the short-term, probably because in such a large and heterogeneous country, that's the best we can do, all we can cope with. But sadly, I think that in doing so we all too often lose sight of the long-term goal. I'm here to remind you of what life for mothers and babies COULD be like. If we cared. And fought.

I am very sad to have to say this, but frankly, I think there is only a small minority of babies in the world, not just Europe, who get a worse start in life than the majority of American babies. It amazes me time and time again how unaware Americans are of this. How it never seems to occur to policy makers and political workers that in this case it is not at all so that the rest of the world is striving to achieve the "American way." To the contrary, the outside world is surprised at how difficult it seems for the American establishment to grasp the relatively simple concepts accepted elsewhere regarding how society should meet the needs of mothers and babies. And many wonder if this may be part of the explanation for the more serious social and psychological problems of various kinds that America seems to be saddled with.

Part of the reason America is this way is because of the distrust of government we inherited from the founders of our country. Most of the world actually believes that government has an obligation, to the extent it can be afforded, not only to respect but to fulfill its citizens' economic, social and cultural rights. In explaining why the US would remain with Somalia as the only country not to ratify the Convention on the Rights of the Child, President Bush recently stated that the US opposes the very concept that such rights exist.

From this perspective, I'm afraid that it really will take a long-term effort to achieve what most mothers in the world take for granted, for example several months of legally-mandated paid maternity leave. No doubt most of you in the audience who work have access to it, but certainly the lower socio-economic groups never will as long as access to such an entitlement is decided on by the employer rather than mandated by the government.

The best way to understand the implication of breastfeeding as a right is to think about the constraints to achieving more maternity leave. When Sweden was debating 85 years ago whether women should get the vote, one argument against it was that elections would cost twice as much! We smile at that today only because human rights thinking has come a long way since then. Voting was not a right in Sweden or the US in 1910, it was a privilege that those who had the most power in society kept for themselves. Now we do not see personal power or wealth as being a criteria for who should get to vote-it is a right. That does not mean you HAVE to vote, just that no one has the right to stop you from doing it if you want to.

Two hundred years ago there was a debate about the economic consequences of doing away with slavery. Now, even though it still would benefit everyone who was not a slave, we do not entertain even the thought of it. Similarly for the worst forms of child labor. We only got an International Labor Organization Convention against it a couple years ago. But already no one would argue that it is too expensive to implement. The money will simply have to be found to allow all children to attend school and not work under the slave-like conditions that many live under today. Carpets will have to cost more.

My friends, babies have not only a need but a right to be with their mothers during the first months of life. This is not just a breastfeeding issue. Babies get confused by having too many caregivers too soon before they have had a chance to bond with one person. The great expert on infant development, Uri Bronfenbrenner, once said that a child can do well without even having a mother, but EVERY child needs someone who is crazy about them-who delights and shows that delight at every little developmental step they take. Should that person be someone who is a hired hand in the household? It was in the old days among the aristocrats. Apart from that, I suppose the largest experiment in having a hired person take care of young infants is still going on in the USA-and among ever greater numbers, as more and more women develop careers or have to work.

My first child was born in 1979 while I was a PhD student at what I do think was an enlightened department of nutrition at Cornell University. The same day a secretary there gave birth. Two weeks later, after taking her annual leave, she was back at work full time. That would not happen to the infant of a university employee in hardly any other country in the world, industrialized or developing. Even the poorest countries are not so stingy to their mothers and babies.

I have a relative who I love dearly and is a psychiatrist. I happened to be at her home when she completed her psychiatric training. My father was a psychiatrist, so I was not surprised to see, while staying with her, that her two-year old child had some pretty severe psychological problems! I saw her hit her mother and say she hated her. I asked her mother what she was going to do now and she said she had been accepted into a private practice. Unfortunately, since she knew her daughter still needed her, this would not pay well enough, and she would have to work a lot of overtime from the outset. I was aghast, knowing that her husband must be earning at least $80,000 a year, more than all but a couple percent of Swedish families live on, especially given the low taxes here in the US. I managed to catch my breath and ask how much that entry salary would be and she said, "only $84,000."

You've all seen bumper stickers about the meaning of life with texts like "the one who dies with the most toys wins." I realized then that in the US one might amend it to be, "the one with the most toys and the most miserable children wins."

Even in the 1970s I was very uneasy with many breastfeeding experts' assumption that just one more new bit of evidence of the biochemical superiority of breast milk was going to turn the tide and bring around the doctors. I felt like saying, "so what?" I've never met a health professional who did not already think they were great breastfeeding supporters and possessed the entire world's storehouse of knowledge about it to boot. Even the UN people have that attitude-I will give an example in my presentation this evening of how this is today leading to the greatest harm ever done to breastfeeding in the world.

But more importantly, breastfeeding does not need doctors. It needs empowered women. When they need it, they will get help from health professionals, and where possible reject or educate those they encounter that say and do breastfeeding-unfriendly things. Even if basic research DID convince all the health professionals about breastfeeding, they are going to need a complete sea change in their mentality before they are the right people to depend on to empower anyone about anything.

Some day in the future, you will be able to say that you heard the first warning here: we desperately need more research on the importance of the mother and infant being together during the early months. The giant multinational companies of the world are being completely honest when they tell us they are just giving us what we want. If all you want is the biochemical benefits of breast milk, the brave new future is already here. There are patents already for stuff pretty close to human milk made from human genes implanted in mice. You can find such patents on the internet. The baby milk companies are on the starting blocks. I assure you that in many of their headquarters today, they are shaking their heads at the gene modification disaster created by Monsanto, and patiently laying up long-term plans for how to get the mothers of the world to accept human milk made in mice-or other animals. Then, unless we have a lot more research on mother-infant proximity, there will no longer be any need to breastfeed at all. For some people, this is already the idea. We had a movie star in Sweden recently who openly bottle fed in public and said she wanted only the fun parts of having a baby. Six hundred people wrote into the newspaper in response. One said, "get a dog." Here is a picture advertising a consumer cooperative, made by someone who probably unconsciously is promoting the same ideal or norm.

If children raised on perfect food without their mother's presence is not your idea of a utopia, I suggest we all stop focusing so much on the wonders of breast milk and look more closely at the issues involved in exclusive breastfeeding and in mother-infant proximity. Breast milk is not magic. It's as normal and ordinary as sex and pregnancy; like masturbation and caesarian section, artificial feeding has its place, but is inherently inferior and should only be used when the natural alternative is not available. Similarly, the expression and pumping of breast milk should be recognized as something inherently inferior, and used only when required. A country where women are so put down that pumping is the norm has serious problems, and breastfeeding advocates should seek allies in making broader social change. Together we should plan for short-term measures to deal with this situation in which the rights of mothers and infants are being violated: crèches at the work place, time and space for pumping at the work place, etc. But such short-term approaches should not take resources away from the long-term work needed to create a society which recognizes and facilitates the mother being with her infant for at least the first six months of life.

I am sometimes confronted by women who find this provocative. They point out that many women have to pump and many want and need to be away from their babies. Let me deal with this kind of statement now:

• I am not saying pumping is bad. Unlike many in the breastfeeding community, I also do not think infant formula is bad. It can be life-saving, just like caesarian section can. Hurray for us human beings who can in that sense play god and save babies who otherwise might die! All I'm saying is that these things are for emergency use and should not be the norm. In saying they are inferior to nature, I am stating a fact, not trying to hurt anyone's feelings.
  
  
• Women do not have to go back to work soon after giving birth in a society that respects their and their babies' rights.
  
  
• Very few women will want to go back to work when their baby is less than six months of age if they are receiving something close to the same pay to be at home with the baby and ensured of returning to the same or an equivalent job without losing seniority. In Sweden, your pension is not even reduced much if you take off less than four years to be with each child.

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