This week the committee organising the 2012 Olympics in London caused widespread anger when it announced that breastfeeding mothers would have to buy an extra ticket to bring their babies into sports venues. Some venues have a few discounted tickets for children, but others don’t. One commentator posted on Mumsnet
that while she and her husband were lucky enough to get tickets to an equestrian event in August, organisers had told her there are no children’s tickets so she will have to pay £95 for a three-month old in a sling.
Those who can’t afford an extra ticket, or who lose out in the next round of ticket allocation, are advised to stay away. Unsurprisingly, Britain’s Equality and Human Rights Commission has suggested that this is potentially a case of ‘indirect sex discrimination’ because it will affect considerably more women than men.
This situation is ridiculous in so many ways. What angers me the most is that the Olympic committee took this decision in a country where the National Health Service advises that babies be breastfed exclusively for the first six months of life. The members of the committee seem either to think that women shouldn’t breastfeed in public – an irritating view about which I am going to be extraordinarily rude at some stage – or that mothers with babies have no desire to attend public events.
In the midst of the uproar, The Ecologist tweeted an article which it had published six years ago about the debate over whether women should breast- or bottle-feed their babies. It’s an argument that parents, doctors, and policy makers have been holding since at least the beginning of the twentieth century, and it’s to the credit of Pat Thomas that her piece provides a good overview of shifting attitudes towards infant feeding over the course of the past hundred years or so.
But it’s also a problematic piece of writing, and one which demonstrates particularly well why so many mothers feel bullied about how they decide to feed their babies. Thomas makes no attempt to hide her view that all mothers should breastfeed their children. She begins with a terrifying list of statistics:
The health consequences – twice the risk of dying in the first six weeks of life, five times the risk of gastroenteritis, twice the risk of developing eczema and diabetes and up to eight times the risk of developing lymphatic cancer – are staggering. With UK formula manufacturers spending around £20 per baby promoting this ‘baby junk food’, compared to the paltry 14 pence per baby the government spends promoting breastfeeding, can we ever hope to reverse the trend?
I’d love to know where she found these figures – particularly given her opening statement that women have breastfed for ‘nearly half a million years’. (How does she know this? Why the coy, qualifying ‘nearly’?) Thomas is, though, correct to point to the compelling evidence that breastfed babies tend to be healthier than those who are fed on formula, and that breastfed children may do better at school and have stronger immune systems. Also, there is a direct and proven link between the use of baby formula and high child mortality rates in the developing world.
She blames the slow decline of breastfeeding over the course of the twentieth century on the medicalization of childcare, and on the advertising strategies employed by formula companies – most notoriously Nestle. I have little to add to her second point, other that, broadly, I agree with her. The International Code of Marketing of Breastmilk Substitutes, a response to the Nestle Boycott of the late seventies, needs to be properly implemented. But her argument about the medicalization of women’s experiences of childbirth and childrearing is not entirely correct. She quotes Mary Renfrew from the Mother and Infant Research Unit at the University of York:
‘If you look at medical textbooks from the early part of the 20th century, you’ll find many quotes about making breastfeeding scientific and exact, and it’s out of these that you can see things beginning to fall apart.’ This falling apart, says Renfrew, is largely due to the fear and mistrust that science had of the natural process of breastfeeding.
In particular, the fact that a mother can put a baby on the breast and do something else while breastfeeding, and have the baby naturally come off the breast when it’s had enough, was seen as disorderly and inexact. The medical/scientific model replaced this natural situation with precise measurements – for instance, how many millilitres of milk a baby should ideally have at each sitting – which skewed the natural balance between mother and baby, and established bottlefeeding as a biological norm.
During the early years of twentieth century, global concern about high rates of child mortality animated a child welfare movement which aimed to improve the conditions in which children were raised. In Europe, North America, Australia, New Zealand, and parts of Africa and Latin America, medical professionals held up rational and scientific methods of feeding and caring for babies as the best means of eradicating the ‘ignorant’ practises which, many believed, caused babies to die. This new emphasis on hygiene, speedy medical intervention, and regular monitoring of babies’ development and health at clinics and hospitals did lower rates of morbidity – as did declining fertility rates, the control of infectious disease, economic prosperity, and increased attendance of school.
Doctors and specialists in the relatively new field of paediatrics were particularly interested in how babies were fed. Contrary to what Thomas suggests, the nineteenth-century orthodoxy that breastfeeding was the healthiest and best option for both mothers and babies lasted well into the 1940s. Innovations in artificial formulas provided mothers who couldn’t breastfeed – for whatever reason – with good alternatives, and doctors did recommend them. There were anxieties that malnourished mothers’ milk would not feed babies sufficiently, and doctors recommended ‘top ups’ with formula or other liquid.
The real difference between nineteenth- and twentieth-century attitudes towards breastfeeding was that it was increasingly controlled and patrolled by trained professionals. As Renfrew notes, mothers were told how much milk their babies needed at each feed, and there was a lot of debate in medical journals and in other professional forums about how and when babies should be fed.
The set of guidelines formulated by the incredibly influential, New Zealand-based Dr Truby King emphasised the importance of routine in feeding. King’s mothercraft movement – which established clinics and training centres around the British Empire during the first half of the twentieth century – taught mothers to feed ‘by the clock’. At five months, a baby was to be fed only five times per day – and at the same time every day – while one month-old babies had an extra, sixth feed.
Like many childcare professionals of the period, King believed that feeding on demand was not only unhealthy – it placed babies at risk of under- or overfeeding – but it was morally and intellectually damaging too. Babies who understood that crying would cause them to be fed would become spoilt, lazy children and adults. Indeed, this points to the infant welfare movement’s more general preoccupation with mothers and motherhood. As the interests of the state were seen, increasingly, as being linked to the proper rearing and education of children, the role of the mother grew in importance. King called his centres ‘shrines to motherhood’, for instance.
But the naturally fussy, over-cautious, and credulous mother was not to be trusted to follow her own instincts: authorities and professionals, who tended to be male, were to provide her with rational, scientific advice on raising her baby. It’s difficult to gauge mothers’ response to the information aimed at them. In her study of mothers in the United States in the 1920s and 1930s, Julia Grant concludes that mothers did heed childcare professionals, but modified their advice according to the views and experiences of their peers. Similarly, mothers in New Zealand took what they wanted from King’s pamphlets on childrearing.
Equally, mothercraft clinics and breastfeeding advice days were well attended by mothers and babies. Several mothercraft centres all over the world also included a dietetic wing, where nursing mothers could stay for up to a fortnight, learning how to breastfeed their babies. There, they would be taught how to breastfeed by the clock, and how to cope with mastitis and painful breasts and nipples. Wonderfully, hospital fees were means tested, so poor mothers could attend for free.
Throughout its existence, the Cape Town dietetic hospital never had an empty waiting list, and similar units in Britain, Australia, and New Zealand were as enthusiastically supported by women. Mothercraft seems to have been at its most successful when mothers could choose how and when they wanted to its advice and services.
While it’s true that the medicalization of breastfeeding transformed this act into a ‘science’ which needed to be re-taught to mothers – that it became possible to inform a mother that she was breastfeeding incorrectly – and that this was underpinned by misogynistic and eugenicist ideas around childhood, motherhood, and the nation, it is as true that mothers did respond positively to the advice provided by mothercraft and other organisations. Clearly, mothers wanted more advice about how to feed their babies – and that they altered it to suit their conditions and needs.
It’s for this reason that I think that Thomas is doing mothers a disservice. Encouraging more women to breastfeed needs to respect the fact that women’s choices about how to feed their babies are influenced by a variety of factors and considerations. Thomas – and other breastfeeding evangelicals – seems to buy into the same discourse of maternal irresponsibility as childcare professionals did in the early twentieth century: the belief that women somehow don’t really understand what’s best for their babies, and must be properly educated. Even if her – and others’ – motives are progressive and well-meaning, they still fail to take mothers seriously.
Sources cited here:
Rima D. Apple, Mothers and Medicine: A Social History of Infant Feeding, 1890-1950 (Madison: University of Wisconsin Press, 1987).
Linda Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare 1907-2000 (Auckland: Auckland University Press, 2003).
Julia Grant, Raising Baby by the Book: The Education of American Mothers (New Haven and London: Yale University Press, 1998).
Philippa Mein Smith, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia 1880-1950 (Basingstoke: Macmillan, 1997).
Linda M. Blum, At the Breast: Ideologies of Breastfeeding and Motherhood in the Contemporary United States (Boston: Beacon Press, 1999).
Molly Ladd-Taylor, Mother-Work: Women, Child Welfare, and the State, 1890-1930 (Urbana and Chicago: University of Illinois Press, 1994).
Marilyn Yalom, A History of the Breast (New York: Ballantine Books, 1997).
Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.
One of the best things about being an academic is the stuff that people send you in the – usually entirely correct – belief that you’ll find it interesting. I’ve had emails about pink slime (for the blog) and on programmes about children’s literature (for my research). Recently, my friend Elizabeth, who’s a lawyer, forwarded me this from Legalbrief:
The proposed regulations, which fall under Section 15 (1) of the Foodstuffs, Cosmetics and Disinfectants Act, 1972, make for fascinating reading. Other than banning trans fats and artificial sweeteners in baby formula, their emphasis is on curtailing the advertising and promotion of artificial foods.
For instance, the packaging of baby formula may not have pictures of infants, young children, or any other ‘humanised figures,’ except for those included in instructions for preparing the product. Tins and containers may not ‘contain any information or make any negative claim relating to the nutritional content or other properties of human milk’, and they’re not allowed to include toys or gifts. Packaging must include in English, in bold letters at least 3mm tall, the message: ‘Breast milk is the best food for babies.’
The regulations will also radically limit the advertising of baby formula shops, in print and online, ban the distribution of gift packs and free samples, and prevent formula manufacturers from sponsoring or donating equipment bearing the logo of their products. These manufacturers may not
Nor may they give doctors, nurses, and health workers gifts, and ‘heads of health establishments, national, provincial and local health authorities shall take measures to promote, support and protect breastfeeding.’
It’s an ambitious piece of legislation, but one which is entirely in line with the World Health Organisation’s International Code on the Marketing of Breast Milk Substitutes. The Code was adapted in 1981, and places stringent regulations on how baby formula is advertised: it advises that baby milk formula should not be allowed to market products directly to pregnant women and mothers with young children, including handing out samples. Products should also state that breast milk is superior to formula.
Implementation of the Code has been slow, and there is evidence to suggest that it has been particularly poorly policed in developing nations where oversight of the activities of powerful multinationals is often lax. The South African regulations are far stricter than the Code, particularly as regards the relationship between the pharmaceuticals industry and academic research, but address a problem which campaigners have long identified: that there is a link between the way in which formula is advertised and how women feed their babies.
This isn’t to suggest that women should have their choices about how they feed their babies curtailed – or that it’s only advertising which causes women to choose to use baby formula. Far from it. The problem, though, is that, particularly in poor nations, advertising or other promotional methods encourage breastfeeding mothers to switch to baby formula when it’s unlikely that they’ll be able to afford to buy more formula, and where they may dilute formula with too much water to make it go further. This water may not be clean, and it’s difficult to keep bottles and teats sterile without electricity or plumbing.
The purpose of these regulations is to ensure that formula manufacturers don’t use the often less than ideal conditions in which mothers in developing nations raise their babies, to their own advantage.
We tend to associate the WHO’s Code with the Nestle Boycott, which was launched in 1977. The Boycott was based on a pamphlet published by War on Want in 1974, titled ‘The Baby Killer’ and, in Switzerland, ‘Nestle Kills Babies’. The charity alleged that Nestle’s advertising strategies were responsible for high rates of child mortality. After a legal tussle as well as an attempt to refute the Boycott’s allegations, Nestle agreed to implement the Code in 1984, although there remains some scepticism as to Nestle’s, and other companies’, commitment to this.
But concern about the advertising of baby formula predated the 1970s, and even the 1940s, when breastfeeding began to decline globally. As I’ve sat in the National Library over the past few months, reading Child Welfare and other child health magazines from the first half of the twentieth century, I’ve been struck by the number of advertisements for baby formula. They all feature fat, healthy babies and testimonials from relieved mothers who claim that the child was fed from birth on Lactogen or whichever other patent food.
Even Truby King, early twentieth-century breastfeeding evangelical and founder of the global mothercraft movement, developed artificial baby food which was produced in New Zealand and then shipped all over the world. Kariol, Karilac, and Karil were meant to be prescribed for babies who were not, for whatever reason, breastfed either as a supplement to cows’ milk, or to be taken on their own.
Although King’s patent foods seemed to contradict his enthusiasm for breastfeeding – and he came under enormous criticism in New Zealand and Australia for his promotion of Kariol and Karilac – there was a certain logic to his decision to manufacture wholesome baby formula. During the early decades of the twentieth century, doctors in Britain and the United States noticed that bottle-fed babies were considerably more likely to die during early infancy than those who were breastfed. Artificial foods – which ranged from thin porridges and condensed milk to baby formulas – were often nutritionally inadequate, particularly in poor families who could not afford better and more expensive substitutes.
But they also identified a link between bottle feeding and diarrhoea, then, as now, one of the main causes of death in infancy. William J. Howarth, the Medical Officer of Health for Derby
The results of the study, published in 1905, were telling. Of the infants surveyed, 63% were breastfeed, 17% were partly bottle-fed, and 19% entirely bottle-fed:
Howarth concluded: ‘In not one single instance does the death-rate in any class of disease among hand-fed children even approximate that recorded among children who are breastfed; the rate is invariably higher.’
The problem, in terms of the link between bottle feeding and diarrhoea, was not so much the nutritional content of artificial foods, but the difficulties in keeping them free from contamination, and particularly during summer when infant mortality rates soared.
Indeed, South African advertisements for Lactogen emphasised that the product did not spoil in warm weather. As criticism of artificial foods grew louder, so advertising became more subtle, and better adept at appealing to mothers aware of the potential problems of bottle feeding. Doctors were, though, also aware of the effects of advertising on mothers’ choices, as a medical officer based in Johannesburg wrote in 1925:
But not only mothers were influenced by this advertising. He admitted that it was ‘only too true that many medical men and trained nurses are also gulled by such advertisements and circulars’. Dr Cicely Williams, best known for her identification of the condition kwashiorkor in the 1930s, worked in the Colonial Medical Service in West Africa and southeast Asia before World War II and became particularly interested in the treatment of the diseases of early infancy.
She was critical of the introduction of baby formula to Singapore and Malaya, where white-coated sales reps distributed samples of artificial foods to poor mothers. In 1939 she published a pamphlet, ‘Milk and Murder,’ in which she pointed out the benefits to both mothers and babies of breastfeeding.
Nevertheless, Nestle and other companies were still using the same strategies to convince mothers in developing nations to use baby formula in the 1970s, and there are still concerns that they are not fully compliant with the Code on breast milk substitutes. The new South African regulations, if passed, are aimed at remedying this.
The cause for these new regulations and other measures introduced internationally to encourage mothers to breastfeed for the first six months of life, is a concern that rates of breastfeeding remain low in comparison to what they were during the early twentieth century. For all the good that the Code and other laws have done, it remains the exception, rather than the rule, for women to breastfeed for such an extended period of time.
However true it may be that advertising does have an impact on women’s choices, it’s certainly not the only factor which influences how women feed their babies. What’s missing from these measures is any attempt to communicate with mothers themselves. As doctors in the early twentieth century believed that mothers, whom they characterised as emotional and irrational, simply followed any and all advice which they read or heard, so campaigners and governments today seem to be too quick to seek only one reason for women’s decision to breast- or bottle-feed.
In fact, we need to make it easier for women to choose to breastfeed: to eliminate the ridiculous prejudice against breastfeeding in public spaces; for work and childcare not to be mutually exclusive; and for sympathetic advice and information to be made available for all new mothers.
Texts cited here:
Linda Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare, 1907-2000 (Auckland: University of Auckland Press, 2003).
Deborah Dwork, War is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England, 1898-1918 (London and New York: Tavistock Publications, 1987).
Philippa Mein Smith, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia, 1880-1950 (Basingstoke: Macmillan, 1997).
Rima D. Apple, Mothers and Medicine: A Social History of Infant Feeding (Madison: University of Wisconsin Press, 1987).
Linda M. Blum, At the Brast: Ideologies of Breastfeeding and Motherhood in the Contemporary United States (Boston: Beacon Press, 1999).
Marulyn Yalom, A History of the Breast (New York: Ballantine Books, 1997).
Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.