I have many a tale to tell on this subject but I'll let the article stand on its own. From this week's New Yorker
If breast is best, why are women bottling their milk?
by Jill Lepore
January 19, 2009
There are some new rules governing what used to be called “mother’s milk,” or “breast milk,” including one about what to call it when it’s no longer in a mother’s breast. A term, then, nomenclatural: “expressed human milk” is milk that has been pressed, squeezed, or sucked out of a woman’s breast by hand or by machine and stored in a bottle or, for freezing, in a plastic bag secured with a twist tie. Matters, regulatory: Can a woman carry containers of her own milk on an airplane? Before the summer of 2007, not more than three ounces, because the Transportation Security Administration classed human milk with shampoo, toothpaste, and Gatorade, until a Minneapolis woman heading home after a business trip was reduced to tears when a security guard at LaGuardia poured a two-day supply of her milk into a garbage bin. Dr. Ruth Lawrence, of the breast-feeding committee of the American Academy of Pediatrics, promptly told the press, “She needs every drop of that precious golden fluid for her baby”; lactivists, who often stage “nurse-ins,” sent petitions; and the T.S.A. eventually reclassified human milk as “liquid medication.” Can a woman sell her milk on eBay? It has been done, and, so far, with no more consequence than the opprobrium of the blogosphere, at least until the F.D.A. decides to tackle this one. The Centers for Disease Control and Prevention, however, does provide a fact sheet on “What to Do If an Infant or Child Is Mistakenly Fed Another Woman’s Expressed Breast Milk,” which can happen at day-care centers where fridges are full of bags of milk, labelled in smudgeable ink. (The C.D.C. advises that a switch “should be treated just as if an accidental exposure to other bodily fluids had occurred.”) During a nine-hour exam, can a woman take a break to express the milk uncomfortably filling her breasts? No, because the Americans with Disabilities Act does not consider lactation to be a disability. Can a human-milk bank pay a woman for her milk? (Milk banks provide hospitals with pasteurized human milk.) No, because doing so would violate the ethical standards of the Human Milk Banking Association of North America. If a nursing woman drinks to excess—some alcohol flows from the bloodstream into the mammary glands—can she be charged with child abuse? Hasn’t happened yet, but there’s been talk. Meanwhile, women who are worried can test a few drops with a product called milkscreen; if the alcohol level is too high, you’re supposed to wait and test again, but the temptation is: pump and dump.
An observation, historical: all this is so new that people are making up the rules as they go along. Before the nineteen-nineties, electric breast pumps, sophisticated pieces of medical equipment, were generally available only in hospitals, where they are used to express milk from women with inverted nipples and from mothers of infants too weak and tiny to suck. Today, breast pumps are such a ubiquitous personal accessory that they’re more like cell phones than like catheters. Last July, Stephen Colbert hooked up to a breast pump on “The Colbert Report.” In August, the Republican Vice-Presidential nominee, Sarah Palin, told People that she has often found herself having to “put down the BlackBerries and pick up the breast pump.” Pumps, in short, abound.
A treatise, mercantile: Medela, a Swiss company that has long been a breast-pump industry leader, introduced its first non-hospital, electric-powered, vacuum-operated breast pump in the United States in 1991; five years later it launched the swank Pump In Style. Since then, its sales have quadrupled. The traffic in pumps is brisk, although accurate sales figures are hard to come by, not least because many people buy the top-of-the-line models secondhand. (Manufacturers argue that if you wouldn’t buy a used toothbrush you shouldn’t buy a used breast pump, but a toothbrush doesn’t cost three hundred dollars.) Then, there’s the swag. “Baby-friendly” maternity wards that used to send new mothers home with free samples of infant formula now give out manual pumps: plastic, one-breast-at-a-time gizmos that work like a cross between a straw and a bicycle pump. Wal-Mart sells an Evenflo electric pump for less than forty dollars. Philips makes one “featuring new iQ Technology”; the pitch is: the pump’s memory chip makes it smart, but the name also plays on dubious claims that human milk raises I.Q. scores. State-of-the-art pumps whose motors, tubes, and freeze packs are wedged into bags disguised to look like black leather Fendi briefcases and Gucci backpacks are a must-have at baby showers; the Medela Pump In Style Advanced Metro model—“the C.E.O. of breast pumps”—costs $329.99 at Target. Medela also sells Pump & Save storage bags and breast shields. (The shield is the plastic part of the contraption that fits over the breast; it looks like a horn of plenty.) Medela’s no-hands model can be powered by your car’s cigarette lighter. Strenuous motherhood is de rigueur. Duck into the ladies’ room at a conference of, say, professors and chances are you’ll find a flock of women with matching “briefcases,” waiting, none too patiently and, trust me, more than a little sheepishly, for a turn with the electric outlet. Pumps come with plastic sleeves, like the sleeves in a man’s wallet, into which a mother is supposed to slip a photograph of her baby, because, Pavlov-like, looking at the picture aids “let-down,” the release of milk normally triggered by the presence of the baby, its touch, its cry. Staring at that picture when your baby is miles away, well, it can make you cry, too. Pumping is no fun—whether it’s more boring or more lonesome I find hard to say—but it has recently become so common that even some women who are home with their babies all day long express their milk and feed it in a bottle. Behind closed doors, the nation begins to look like a giant human dairy farm.
This makes it all the more worrying that the evolving rules governing human milk, including the proposed Breastfeeding Promotion Act of 2007, look a muddle. They indulge in a nomenclatural sleight of hand, conflating “breastfeeding” and “feeding human milk.” They are purblind, unwilling to eye whether it’s his mother or her milk that matters more to a baby. They suffer from a category error. Is human milk an elixir, a commodity, a right? The question is, at heart, taxonomical. And it has been asked before.
In 1735, when the Swedish naturalist Carl Linnaeus first sorted out the animal kingdom, he classed humans in a category called Quadrupedia: four-footed beasts. Even those of Linnaeus’s contemporaries who conceded the animality of man averred that people have two feet, not four. Ah, but hands are just feet that can grip, Linnaeus countered. This proved unpersuasive. By 1758, in a process that the Stanford historian of science Londa Schiebinger has reconstructed, Linnaeus had abandoned Quadrupedia in favor of a word that he made up, Mammalia: animals with milk-producing nipples. (The Latin root, mamma, meaning breast, teat, or udder, is closely related to the onomatopoeic mama—“mother”—thought to derive from the sound that a baby makes while suckling.) As categories go, “mammal” is an improvement over “quadruped,” especially if you’re thinking about what we have in common with whales. But, for a while, at least, it was deemed scandalously erotic. (Linnaeus’s classification of plants based on their reproductive organs, stamens and pistils, fell prey to a similar attack. “Loathsome harlotry,” one botanist called it.) More important, the name falls something short of capacious: only female mammals lactate; males, strictly speaking, are not mammals. Plenty of other features distinguish mammals from Linnaeus’s five other animal classes—birds, amphibians, fish, insects, and worms. (Tetracoilia, animals with a four-chambered heart, proposed by a contemporary of Linnaeus’s, the Scottish surgeon John Hunter, was at least as good an idea.) Linnaeus had his reasons. Naysayers might doubt that humans are essentially four-footed (whether on scriptural or arithmetic grounds), but no man born of woman, he figured, would dare deny that he was nourished by mother’s milk.
Then, too, while Linnaeus was revising his “Systema Naturae” from the twelve-page pamphlet that he published in 1735 to the two-thousand-page opus of 1758—and abandoning Quadrupedia in favor of Mammalia—his wife was, not irrelevantly, lactating. Between 1741 and 1757, she bore and nursed seven children. Her husband, meanwhile, lectured and campaigned against the widespread custom of wet-nursing. The practice is ancient; contracts for wet nurses have been found on scrolls in Babylonia. A very small number of women can’t breast-feed, and wet nurses also save the lives of infants whose mothers die in childbirth. But, in Linnaeus’s time, extraordinary numbers of European mothers—as many as ninety per cent of Parisian women—refused to breast-feed their babies and hired servants to do the work. In 1752, Linnaeus wrote a treatise entitled “Step Nurse,” declaring wet-nursing a crime against nature. Even the fiercest beasts nurse their young, with the utmost tenderness; surely women who resisted their mammalian destiny were to be ranked as lowlier than the lowliest brute.
Enlightenment doctors, philosophers, and legislators agreed: women should nurse their children. In “Émile” (1762), Rousseau prophesied, “When mothers deign to nurse their own children, then morals will reform themselves.” (Voltaire had a quibble or two about Rousseau’s own morals: the author of “Émile” had abandoned his five illegitimate children at birth, depositing them at a foundling hospital.) “There is no nurse like a mother,” Benjamin Franklin wrote in 1785, after discovering an infant-mortality rate of eighty-five per cent at the foundling hospital in Paris that relied on wet nurses (the hospital where Rousseau’s children all but certainly died), a discovery that explains why Franklin, in his autobiography, went to the trouble of remarking of his own mother, “She suckled all her 10 Children.” But wet nurses were not nearly as common in Colonial America as they were in eighteenth-century Europe. “Suckle your Infant your Self if you can,” Cotton Mather commanded from the pulpit. Puritans found milk divine: even the Good Book gave suck. “Spiritual Milk for Boston Babes, Drawn Out of the Breasts of Both Testaments” was the title of a popular catechism. By the end of the eighteenth century, breast-feeding had come to seem an act of citizenship. Mary Wollstonecraft, in her “Vindication of the Rights of Woman” (1792), scoffed that a mother who “neither suckles nor educates her children, scarcely deserves the name of a wife, and has no right to that of a citizen.” The following year, the French National Convention ruled that women who employed wet nurses could not apply for state aid; not long afterward, Prussia made breast-feeding a legal requirement.
There was also a soppy side to the Age of Reason. In 1794, Erasmus Darwin offered in “Zoonomia; or The Laws of Organic Life” a good summary of the eighteenth century’s passionate attitude toward the milky breast:
When the babe, soon after it is born into this cold world, is applied to its mother’s bosom; its sense of perceiving warmth is first agreeably affected; next its sense of smell is delighted with the odour of her milk; then its taste is gratified by the flavour of it; afterwards the appetites of hunger and of thirst afford pleasure by the possession of their objects, and by the subsequent digestion of the aliment; and, lastly, the sense of touch is delighted by the softness and smoothness of the milky fountain, the source of such variety and happiness.
A half century later, across the Atlantic, this kind of thing had turned into a cult of motherhood, abundantly illustrated in daguerreotypes from the eighteen-fifties that showed babies suckling beneath the unbuttoned bodices of prim, sober American matrons, looking half Emily Dickinson, half Leonardo’s “Madonna and Child.”
Then, bizarrely, American women ran out of milk. “Every physician is becoming convinced that the number of mothers able to nurse their own children is decreasing,” one doctor wrote in 1887. Another reported that there was “something wrong with the mammary glands of the mothers in this country.” It is no mere coincidence that this happened just when the first artificial infant foods were becoming commercially available. Cows were proclaimed the new “wet nurse for the human race,” as the historian Adrienne Berney has pointed out in a study of the “maternal breast.” Tragically, many babies fed on modified cow’s milk died. But blaming those deaths on a nefarious alliance of doctors and infant-food manufacturers, as has become commonplace, seems both unfair and unduly influenced by later twentieth-century scandals (most infamously, Nestlé’s deadly peddling of infant formula in Africa and elsewhere, which led, in 1981, to the landmark International Code for Marketing Breastmilk Substitutes). In the United States, nineteenth- and early-twentieth-century physicians, far from pressing formula on their patients, told women that they ought to breast-feed. Many women, however, refused. They insisted that they lacked for milk, mammals no more.
In 1871, Erasmus Darwin’s grandson Charles published “Descent of Man,” in which he speculated that the anomalous occurrence in humans of extra nipples represented a reversion to an earlier stage of evolution. If our ancestors once suckled litters of four or six, and if—as was supposed—men had nipples because male mammals once produced milk, maybe women, too, were evolving out of the whole business. In 1904, one Chicago pediatrician argued that “the nursing function is destined gradually to disappear.” Gilded Age American women were so refined, so civilized, so delicate. How could they suckle like a barnyard animal? (By the turn of the century, the cow’s udder, or, more often, its head, had replaced the female human breast as the icon of milk.) Behind this question lay another: how could a white woman nurse a baby the way a black woman did? (Generations of black women, slave and free alike, not only nursed their own infants but also served as wet nurses to white babies.) Racial theorists ran microscopic tests of human milk: the whiter the mother, chemists claimed, the less nutritious her milk. On downy white breasts, rosy-red nipples had become all but vestigial. It was hardly surprising, then, that well-heeled women told their doctors that they had insufficient milk. By the nineteen-tens, a study of a thousand Boston women reported that ninety per cent of the poor mothers breast-fed, while only seventeen per cent of the wealthy mothers did. (Just about the opposite of the situation today.) Doctors, pointing out that evolution doesn’t happen so fast, tried to persuade these Brahmins to breast-feed, but by then it was too late.
The American epidemic of lactation failure depended, too, on the evolving design of baby bottles: so sleek, so clean, so scientific, so modern. The first U.S. patent for a baby bottle was issued in 1841; the device, shaped like a breast, could be held close to a mother’s chest, almost like a prosthetic. Year by year, bottles became less like breasts. The familial cylindrical bottle, called the Stork Nurser, dates from 1910 and is tied to the rise of the stork myth: milk comes from the milkman; babies come from storks. Perversely, Freud’s insistence that infants experience suckling as sexual pleasure proved a boon to stork-style repression, too: mothers, eager to keep infantile incestuous desire at arm’s length, propped their babies up in high chairs and handed them bottles.
Meanwhile, more and more women were giving birth in hospitals, which meant that, for the first time in human history, infants born prematurely, or very small, had a chance of survival—if only there were enough milk and a way to get it into the belly of a baby that was too tiny to suck at the breast.
In 1910, a Boston doctor, Fritz Talbot, spent three days searching for a wet nurse. He failed. Exasperated, Talbot established a placement service, the Boston Wet Nurse Directory. Across town, Francis Parkman Denny, caring for a sick baby, asked a neighbor to hand-express her milk for him. When the infant improved after drinking just three ounces, Denny, a bacteriologist, became convinced of the “bactericidal power” of human milk. The year after Talbot started his Wet Nurse Directory, Denny opened the first human-milk bank in the United States, collecting milk from donors using a breast pump whose design was inspired by bovine milking machines. (Milking machines are still cited in breast-pump patents; mechanically, Medela’s Pump In Style has much in common with DairyMaster’s Swiftflo.) Denny’s plan worked better: families who needed and could afford human milk did not generally like having poor women live with them; they preferred to have the milk delivered in bottles. Talbot stopped placing wet nurses and instead began distributing their milk; he renamed his agency the Directory of Mother’s Milk.
Once milk banks replaced wet nurses, human milk came to be treated, more and more, as a medicine, something to be prescribed and researched, tested and measured in flasks and beakers. Denny’s bottled, epidemiological model prevailed. Laboratory-made formulas improved, and aggressive marketing of processed infant food—not just bottles of formula but jars of mush and all manner of needless pap—grew to something between badgering and downright coercion. By the middle of the twentieth century, the majority of American women were feeding their babies formula. But, all the while, Erasmus Darwin’s rhapsodic view of the milky breast endured. “With his small head pillowed against your breast and your milk warming his insides, your baby knows a special closeness to you,” advised “The Womanly Art of Breastfeeding,” originally published by La Leche League in 1958, just two years after the league’s first meeting. “He is gaining a firm foundation in an important area of life—he is learning about love.” In the nineteen-sixties, nursing as a mammalian love-in began making a comeback, at least among wealthier women. (A brief history of food: when the rich eat white bread and buy formula, the poor eat brown bread and breast-feed; then they trade places.) In the decades since, the womanly art of breast-feeding has yielded, slowly but surely, to the medical science of human milk.
In 1997, the American Academy of Pediatrics issued a policy statement on “Breastfeeding and the Use of Human Milk,” declaring human milk to be “species-specific” and recommending it as the exclusive food for the first six months of a baby’s life, to be followed by a mixed diet of solid foods and human milk until at least the end of the first year. In that statement, and in a subsequent revision, the A.A.P. cited research linking breast-feeding to the reduced incidence and severity of, among other things, bacterial meningitis, diarrhea, respiratory-tract infection, ear infection, urinary-tract infection, sudden-infant-death syndrome, diabetes mellitus, lymphoma, leukemia, Hodgkin’s disease, obesity, and asthma. The benefits of breast-feeding are unrivalled; breast-feeding rates in the United States are low; the combination makes for a public-health dilemma. In 2000, the Department of Health and Human Services announced its goal of increasing the proportion of mothers who breast-feed their babies “at initiation” (i.e., before they leave the hospital) from a 1998 baseline of sixty-four per cent to a 2010 target of seventy-five per cent; until the age of six months, from twenty-nine per cent to fifty per cent; at one year, from sixteen per cent to twenty-five per cent. (The same targets were announced in 1990; they were not reached.) Attempts to improve initiation rates have met with much, if spotty, success. The Rush University Medical Center, in Chicago, which runs a peer-counselling program called the Mother’s Milk Club, has achieved an astonishing initiation rate of ninety-five per cent; nationally, the rate is not quite seventy-five per cent. More difficult has been raising the rates at six and twelve months. The C.D.C., which issues an annual Breastfeeding Report Card, has announced that for babies born in 2005 the rate of exclusive breast-feeding at six months was only twelve per cent (although the rate of some breast-feeding at six months had risen to forty-three per cent).
One big reason so many women stop breast-feeding is that more than half of mothers of infants under six months old go to work. The 1993 Family and Medical Leave Act guarantees only twelve weeks of (unpaid) maternity leave and, in marked contrast to established practice in other industrial nations, neither the government nor the typical employer offers much more. To follow a doctor’s orders, a woman who returns to work twelve weeks after childbirth has to find a way to feed her baby her own milk for another nine months. The nation suffers, in short, from a Human Milk Gap.
There are three ways to bridge that gap: longer maternity leaves, on-site infant child care, and pumps. Much effort has been spent implementing option No. 3, the cheap way out. Medela distributes pumps in more than ninety countries, but its biggest market, by far, is the United States, where maternity leaves are so stinting that many women—blue-, pink-, and white-collar alike—return to work just weeks after giving birth. (Breasts supply milk in response to demand; if a woman is unable to put her baby to her breast regularly, she will stop producing milk regularly. Expressing not only provides milk to be stored for times when she is away; it also makes it possible for a working woman to keep nursing her baby at night and on weekends.) In 1998, Congress authorized states to use food-stamp funds granted to the U.S.D.A.’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to buy or rent breast pumps for eligible mothers. Breast-feeding rates rise with maternal age, education, and income. Medela offers a Corporate Lactation Program, free advice for employers seeking to reduce absenteeism and health-insurance costs by establishing “Mother’s Rooms,” equipped, ideally, with super-duper electric pumps, because “breastpumps with double-pumping options save time and can even help increase a mother’s milk supply.” The loss of productivity, Medela promises, is slight: “If each employee uses safe, effective, autocycling breastpumps, each visit to the Mother’s Room should last no longer than 10 to 15 minutes.”
Even more intensive has been the energy directed toward legislative reform. Many states have recently passed laws about breast-feeding, having to do with option No. 3. Must companies supply employees with refrigerators to store milk expressed during the workday? Twenty-one states, along with Puerto Rico and the District of Columbia, require employers to make a “reasonable effort” to accommodate nursing mothers and their bottled milk, although these laws are, generally, toothless. As a rule, the posher the employer, the plusher the pump station. Traders at Goldman Sachs can use an online booking service to reserve time in dedicated lactation rooms, equipped with pumps and chairs; baristas at Starbucks are left to line up to use the customers’ loo. In 2007, Oregon became the first state to pass a law requiring companies with more than twenty-five employees to provide “non-bathroom” lactation rooms. (A national media campaign asks, reasonably enough, if you wouldn’t make your kid a sandwich in a public rest room, why would you expect a woman to bottle her baby’s milk in one?) Virginia and Maryland recently joined twenty-three other states and the Virgin Islands in exempting women who expose their breasts while suckling infants from indecency laws. Whether pumping in public is obscene has not yet been tested—honestly, who would want to?—but, what with all these lactation rooms, maybe that won’t come up.
More rules are under consideration. Can a woman or her employer get a tax break for producing or storing milk? Maryland exempts breast pumps from its sales tax, but a congressional sub-committee is still mulling over the Breastfeeding Promotion Act. The goals of the bill are to add the word “lactation”—defined as “the feeding of a child directly from the breast or the expressing of milk from the breast”—to the Civil Rights Act of 1964, and to allow a tax credit of up to ten thousand dollars per year to companies that provide their employees with pumps or pump rooms. A better title for the proposed legislation might be the Breast Pump Promotion Act.
The cynical politics of pump promotion would seem, at first, to be obvious. Breast pumps can be useful, even indispensable and, in some cases, lifesaving. But a thing doesn’t have to be underhanded to feel cold-blooded. Non-bathroom lactation rooms are such a paltry substitute for maternity leave, you might think that the craze for pumps—especially pressing them on poor women while giving tax breaks to big businesses—would be met with skepticism in some quarters. Not so. The National Organization for Women wants more pumps at work: NOW’s president, Kim Gandy, complains that “only one-third of mega-corporations provide a safe and private location for women to pump breast milk for their babies.” (When did “women’s rights” turn into “the right to work”?) The stark difference between employer-sponsored lactation programs and flesh-and-blood family life is difficult to overstate. Pumps put milk into bottles, even though many of breast-feeding’s benefits to the baby, and all of its social and emotional benefits, come not from the liquid itself but from the smiling and cuddling (stuff that people who aren’t breast-feeding can give babies, too). Breast-feeding involves cradling your baby; pumping involves cupping plastic shields on your breasts and watching your nipples squirt milk down a tube. But this truth isn’t just rarely overstated; it’s rarely stated at all. In 2004, when Playtex débuted a breast pump called the Embrace, no one bothered to point out that something you plug into a wall socket is a far cry from a whisper and a kiss. Rhode Island’s Physicians’ Committee for Breastfeeding gives an annual award for the most “Breastfeeding-Friendly Workplace,” a merit measured, in the main, by the comforts provided in pumping rooms, like the gold-medal winner’s “soothing room,” equipped with “a sink, a lock on the door, and literature.” It appears no longer within the realm of the imaginable that, instead of running water and a stack of magazines, “breastfeeding-friendly” could mean making it possible for women and their babies to be together. Some lactation rooms even make a point of banning infants and toddlers, lest mothers smuggle them in for a quick nip. At the University of Minnesota, staff with keys can pump their milk at the Expression Connection, but the sign on the door warns: “This room is not intended for mothers who need a space to nurse their babies.”
Lately, some WIC officers have begun to worry that pump promotion might be backfiring, having “the unintended effect of discouraging breastfeeding.” But such cautions have hardly stopped the anti-formula fire and brimstone. Between 2004 and 2006, a National Breastfeeding Awareness Campaign included TV ads that likened a mother feeding her baby formula to a pregnant woman riding a mechanical bull: “You’d never take risks before your baby is born. Why start after?” No one seems especially worried about women whose risk assessment looks like this: “Should I take three twenty-minute pumping ‘breaks’ during my workday, or use formula and get home to my baby an hour earlier?”
Pumps can be handy; they’re also a handy way to avoid privately agonizing and publicly unpalatable questions: is it the mother, or her milk, that matters more to the baby? Gadgets are one of the few ways to “promote breast-feeding” while avoiding harder—and divisive and more stubborn—social and economic issues. Is milk medicine? Is suckling love? Taxonomical questions are tricky. Meanwhile, mamma ex machina. Medela’s newest models offer breakthrough “2-Phase Expression” technology: phase one “simulates the baby’s initial rapid suckling to initiate faster milk flow”; phase two “simulates the baby’s slower, deeper suckling for maximum milk flow in less time.” These newest machines, the company promises, “work less like a pump and more like a baby.” More like a baby? Holy cow. We are become our own wet nurses. ♦
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