North American Culture: Undermining Breastfeeding

Part 1Part 2Part 3 Part 1 of 3 INTRODUCTION There is no substance that can come close to human milk. Infant formula, a synthetic human milk substitute, is not a healthy alternative to mother's milk. Formula is missing over 400 ingredients present in human milk, which cannot be duplicated by scientists in a laboratory. Every species produces milk designed specifically for its offspring. In addition to living white blood cells, human milk contains immunoglobulins (antibodies) which protect infants against illness. The protein in human milk is easily digestible, unlike the protein in cow's milk, the base of most infant formulas, which forms tough rubbery curds in a baby's tummy. A mother's milk contains all of the nutrients her baby needs to grow and develop properly, and changes from minute to minute, hour to hour, and month to month to meet a baby's changing needs. Human milk substitutes are static. They do not change in nutritional content to suit a baby's needs at each particular stage in his life, nor do they contain protective antibodies or living white blood cells to help infants fight infectious disease (La Leche League International, 1991). Technological advances have brought about social change in the twentieth century, unfortunately leading to a dramatic decline in the practice of breastfeeding, not only in the United States, but throughout the world. The national breastfeeding rate in the U.S. fell to 25 percent in 1973 (Brown RE, 1986). Although today there is a resurgence of women who initiate breastfeeding their infants in the United States, this revival pertains only to the initiation, not to the duration of breastfeeding. While nearly 60 percent of new mothers today will initiate breastfeeding their infants some time after birth, only 20 percent of them are still doing so by four months of age (Tamaro J, 1996), and many of these infants are receiving supplemental artificial feedings or early solids. Various social factors have contributed to the changes in infant feeding practices. FORMULA MARKETING Infant formula is a 1.6 billion dollar per year industry (Howard CR, 1994). The manufacturers of artificial infant milk engage in various forms of advertising, including free samples, television commercials, and coupons. These manufacturers strive to convince women that their product is almost as good as human milk when it is actually an inferior, expensive product. "Even the formula companies admit that human milk is the 'ideal food' and they are merely trying to emulate its nutritional content…" (Magnus PD, 1980:75). The World Health Organization International Code for Controlling the Marketing and Promotion of Infant Formula Products was adopted in 1981 by all countries who are members of the WHO except the United States. This code was developed to limit and monitor the marketing of artificial infant milk. When the U.S. failed to endorse the Code, the American Public Health Association endorsed a movement to boycott the products of Nestle, the most flagrant offender and most aggressive marketer of their artificial substitute for human milk (Brown RE, 1986). Formula companies supply hospitals with free formula and bottles to get the mother started on their brand. They also package diaper bags filled with coupons and samples of free formula for new mothers to take home. The breastfeeding pamphlets included in these packages contain outdated or inaccurate information on breastfeeding, such as recommending that a woman cleanse her nipples with cotton dipped in sterile water before feeding. These pamphlets also present a long list of cautions, such as foods to avoid while nursing, in order for a woman to breastfeed successfully (Valaitis RK, 1997), and are likely to cause problems rather than solve them. "Rarely do the information booklets warn the mother that giving bottles to young breastfeeding babies may result in serious breastfeeding problems, including breast rejection and failure to thrive," (Newman J, 1991:1089). Formula companies even get hospitals to sign contracts, which prohibit the hospital from accepting any other donated brand, and require the hospital to use that manufacturer's brand of formula exclusively. In addition, cash and other incentives such as vacations and luncheons are often part of the package. Formula companies provided $500,000 to the American Academy of Pediatrics for construction of a new national headquarters, and $1,000,000 to the Health and Hospitals Corporation of New York City for educational activities. This major funding makes it very difficult for such organizations to remain objective and publicly criticize advertisements for artificial baby milk. In addition, the formula industry's widespread financial support for research and conferences in teaching hospitals for educational activities "exerts a subtle influence on the medical practitioners who currently struggle under a reduction in both government and private foundation support for these activities," (Brown RE, 1986:239). Free cases of infant formula and hospital gift packs filled with free samples and coupons are detrimental to breastfeeding. Such "gifts" have been shown to "decrease the chances an infant will be breastfed even partially until four months of age," (Howard CR, 1994:103). PHYSICIANS Despite the fact that the American Academy of Pediatrics has recommended breastfeeding as the method of choice from the organization's inception, it recognizes the need for increasing educational measures, changes in formula advertising, changes in hospitals' and physicians' practices, and the need for environmental and occupational support systems (Howard CR, 1994). "In a poll conducted by the Journal of the American Medical Association, 55 percent of the doctors most likely to attend to you postnatally in the hospital admitted they don't know enough about breastfeeding. About the same number couldn't answer a simple series of questions asking them how they'd treat some common problems," (Tamaro J, 1996:20). Another poll published in the American Journal of Preventive Medicine indicated that physicians correctly answered only 53 percent of the questions in a breastfeeding survey. Only 14 percent of housestaff considered themselves "confident" or "very confident" in their knowledge of managing common breastfeeding problems. Only about 33 percent considered themselves "confident" or "very confident" by the third postgraduate year (Williams E, 1995). These results are not surprising considering the inadequate information physicians receive in medical school. Physicians must be educated in lactation management and made aware that although breastfeeding is a natural function, women must learn and be taught how to breastfeed. "It is unlikely that many mothers 80 or 100 years ago would have consulted the doctor on how to breastfeed…Mothers now do consult doctors about breastfeeding, but, unfortunately, the medical curriculum is such that doctors still do not know how to help them," (Newman J, 1991:1089). If physicians were interested only in the welfare of the infant, rather than acting in their own economic interests, they might promote breastfeeding as the only proven adequate method of feeding. "The financial benefit accrued by physicians when parents require medical assistance to feed their infants…" or when an infant becomes ill as a direct result of being fed artificially creates a "comfortable, symbiotic relationship with the formula companies," (Newman J, 1991:1089). Pediatricians and obstetricians routinely distribute free formula samples, even to mothers who express no interest in bottle feeding, just in case they change their minds or to save them the cost of a few bottles of formula. Instead, physicians would be doing a greater service by informing parents of the differences in breastfed versus artificially fed babies and educating parents to help avoid problems with breastfeeding. Free samples of synthetic milk generally do not save families money in the long run because their medical bills will usually be higher, and the cost of formula is over $1000 per year. In one study of 127 physicians' offices, magazines contravening the WHO Code were widely available in 91 physicians' offices (72 percent). One hundred one offices (80 percent) accepted free formula. Commercially produced pamphlets were twice as likely to be routinely distributed as pamphlets from nonprofit and governmental agencies and were available in 90 percent of the offices surveyed. Physicians are encouraged to use publications from the government or nonprofit organizations in order to abide by the WHO Code. In the majority of offices surveyed, physicians routinely distributed publications and products that do not abide by the WHO Code to "protect, promote, and support breastfeeding," (Valaitis RK, 1997). Further education about the WHO Code is necessary to help pediatricians and obstetricians regard breastfeeding as the norm, rather than the exception. Weight charts used in doctors' offices are based on bottle fed babies and were compiled by formula manufacturers. Breastfed babies have different growth patterns from infants who are fed synthetic milk. Breastfed babies tend to gain weight rather rapidly during the first four months, then taper off and become slimmer and leaner than their formula-fed counterparts by the age of eighteen months. Babies who are artificially fed will continue to gain weight rapidly and be heavier, on average, at eighteen months and throughout their lifetimes (Nutrition Unit, World Health Organization, Geneva, 1994). The continued use of these weight charts can cause alarm for many mothers who think their babies may not be getting enough milk because they continue to be in a low percentile on the weight charts. Pediatricians who strictly abide by these charts are doing their little patients a disservice. Dr. Jane Heinig of UC California at Davis Nutrition Department, Lactation Studies, says, "We've been able to show that breastfed babies are normal weight and artificially fed babies are overweight," (Tamaro J, 1996:140). EMPLOYMENT When women entered the workforce in large numbers during World War II, leaving their infants in someone else's care, it became necessary to find alternative ways to feed these infants. Expressing milk was not an option for the many women who were entering a man's world, and wet nurses were no longer a part of our culture. Thus, the prevalence of human milk substitutes arose. When breasts were no longer used to feed babies, women began to put their breasts to work in ways other than just feeding a baby, perhaps as a sign of liberation, and their breasts became sexual objects. A major obstacle to breastfeeding is the rate of women returning to work postpartum. Today, 52 percent of mothers with infants work outside the home (Kurinig N, 1989). For this reason, some women never attempt to breastfeed, while others stop when they return to work. The percentage of women breastfeeding increases the later the mother returns to work. Plans to return to work were given as a reason for not breastfeeding by 44 percent of women who did not choose to nurse (Scrimshaw SC, 1987). In a Washington, DC study, 80 percent of the black women and 91 percent of the white women worked during pregnancy Among white women, breastfeeding rates were significantly lower if the mother planned to return to work within two months postpartum. "After adjusting for maternal age, education, marital status, occupation, and planned timing of return to work; the only employment variable significantly associated with breastfeeding among black women was a planned return to part-time vs. full-time work…Among white women only, the later the return to work the longer the mean duration of breastfeeding," (Kurinij N, 1989:1248). Black women were more likely to return to work full-time than white women; consequently, this group had a lower rate of breastfeeding. Women in professional occupations were more likely to breastfeed for a longer duration of time. They appear to have more control over their work environment and can structure their jobs to accommodate breastfeeding a little more easily. Although white women were more likely to work in a professional or technical occupation, "breastfeeding rates did not differ between women who anticipated a return to work in the first year and those who did not, with or without adjustment for the effects of maternal education, age, and marital status…" (Kurinij N, 1989:1248). With the growth of the number of employed women, maternity leave and breastfeeding facilities in the workplace are important issues for employers to consider. Many women return to work in the early postpartum weeks out of necessity because there is no universal maternity leave policy in the United States. Expressing breast milk is difficult in many working environments due to lack of facilities or privacy, resulting in many mothers who choose to abandon breastfeeding altogether. One breast pump company has instituted a nationwide program for employers in order to provide breastfeeding support for their employees. This company has set up over 300 employer participants with private pumping rooms including breast pumps and lactation consultants (Bridges CB, 1997). Although some large corporations have begun to provide support for breastfeeding mothers in the form of pumping rooms, pumping breaks, refrigerators, on-site child care, and maternity benefits, most have not. In a survey published in the Journal of Human Lactation, only 17 percent of the employers surveyed agreed to support a woman if she wanted to nurse her infant or express milk in the workplace, and 40.6 percent actually thought that formula-fed and breastfed infants were equally healthy (Bridges CB, 1997). Employers do not need to compromise in order to support breastfeeding in the workplace. They need assistance in setting up programs and establishing policies to promote breastfeeding, exposure to other businesses who have successfully supported breastfeeding women, and reassurance that business and breastfeeding mothers do not have to conflict (Bridges CB, 1997). ETHNICITY AND SOCIAL CLASS "Whereas the middle and educated classes have begun a resurgence of breastfeeding, this renaissance is missing among the poor. Awareness, health education (by peer advocates), early intervention, and reassurance by all levels of health providers is suggested to prevent the dissolution of the lactation bond among the population least apt to breastfeed," (Abstract: Magnus PD, 1980). The World Health Organization's Division of Family Health reveals that, "The modification in breastfeeding trends in both developing and developed countries is explained by the model of 'cultural diffusion'; populations are described as passing through different stages of 'development-time.' Sub-population groups adopt artificial feeding methods, with the elite group being the first to pass through this stage, followed by the urban poor, and finally the population in the rural areas. Ultimately, a reversal point is reached during which the elite reinstitute breastfeeding, followed by the rest of the society." The U.S. is in the resurgence phase where the elite are preceding other classes. "When the final phase occurs in developing countries, the decline in morbidity and mortality would probably be substantial since urban poor and rural children suffer the most severe losses due to various infections, particularly gastroenteritis," (Brown RE, 1986:238). The national breastfeeding rate in the U.S. in 1956 at one week was 18 percent. In 1973 it was 25 percent, and by 1975 it had risen to 35 percent (Brown RE, 1986:238). Today approximately 50-60 percent of women will attempt to breastfeed. These percentages reflect the number of women who have initiated breastfeeding in the hospital or attempted to breastfeed, not necessarily those who are successful. Between 1984 and 1989, the rate of mothers who attempted to breastfeed their newborns dropped from 59.7 percent to 52.2 percent and mothers who were still breastfeeding six months later dropped from 23.8 percent to 18.1 percent (Williams EL, 1995). The increase in breastfeeding incidence follows "an expansion in the awareness and information at the upper socioeconomic levels and has progressed along class lines in much the same manner as described by the WHO model," (Brown RE, 1986:238). A study conducted in Florida found that most Puerto Ricans believed breastfeeding was better for their babies, but almost half the Cuban women thought bottle feeding was better (Bryant CA: Health Action Papers No. 1. Lexington KY: Lexington Fayette County Health Dept and University of KY Medical Behavioral Science Dept, 1984, cited in Scrimshaw SCM, 1987). The decline in the proportions of women breastfeeding in the U.S. began to reverse in the early 1960s, but this change appears to be occurring faster in Whites than in Latino, Asian, or Black populations. Prior to 1960, Black and Latino women typically nursed their babies, and did so longer than Whites (Scrimshaw SCM, 1987:467). Today breastfeeding is more prevalent among women who have more years of education. Rates of breastfeeding are higher in women who are married or planning to be married than in single women. The partner is an important influence on whether or not a woman will breastfeed. Part 2 of 3 BED SHARING Throughout human history, mother and child have entwined their sleep habits. Even today, most of the world's cultures practice some form of parent-infant co-sleeping; however, the United States is not one of them. It has only been in the last century or two, and mostly in Western cultures, that sleep and nighttime breastfeeding have been separated (McKenna JJ, 1997). In the United States, parents generally focus on getting baby to sleep through the night on his own within just a few weeks, and breastfed infants are less likely to do so at such an early age. Infants who are fed artificially eat less frequently because formula, usually based on cow's milk, forms rubbery curds in the infant's stomach, causing him to feel full longer. Thus, artificially fed infants have longer meal intervals, which may result in longer periods of sleep. "The mother's need for an uninterrupted night's sleep may be promoting the early cessation of breastfeeding" (Pinilla T, 1993:436). If more mothers elected to sleep in the same bed as their infants, arising for feedings in the middle of the night would be no more effort than rolling over and pulling baby close to nurse. Baby and mother can both drift off to sleep together and get a good night's rest. Sleep patterns of breastfed infants vary greatly from the sleep patterns of bottle fed infants. Breastfed infants typically begin sleeping through the night at a later age and wake frequently throughout the night, "…so breastfeeding mothers may be tempted to change their feeding regimen in order to get their infants to sleep through the night. Even in the popular press, sleeping through the night at an earlier age is quoted as one of the 'advantages' of formula-feeding," (Pinilla T, 1993:436). In a study of mother-infant pairs when the infants were 3-4 months old, infants who routinely slept in the same bed as their mothers nursed approximately three times longer during the night than infants who routinely slept separately. The number of nursing episodes was double and the duration of breastfeeding episodes was 39 percent longer in the mother-infant pairs who slept together (McKenna JJ, 1997). These findings are significant to breastfeeding success, because frequent nursing, especially at night, promotes an abundant milk supply, and low milk supply is the most common reason women give for quitting nursing (Gussler JD, 1980). In addition, breastfeeding at night is facilitated if the mother does not have to get out of bed to do so. Another common reason for discontinuing nursing is lack of rest, which makes mothering more difficult and can decrease the milk supply as well. Co-sleeping is not a good idea for people who have waterbeds, who smoke, or who are intoxicated or taking medication. A study in New Zealand discovered that joint exposure to bed sharing and maternal smoking were associated with a statistically significant increased risk of SIDS, but appears to be a risk only to infants of mothers who smoke. In fact, it is hypothesized that the frequent arousals associated with infant-parent bed sharing might actually protect infants against SIDS (Mosko S, 1997). In addition, breast milk itself has been show to have a protective effect (McKenna JJ, 1997). DOULAS A doula is a woman who is trained to provide continuous support to a laboring woman in the form of praise, encouragement, reassurance, comfort measures, physical contact, and explanations about labor's progress. The doula may also provide support to the mother at home after the baby is born, helping with the house and assisting with breastfeeding. Studies show a reduction in the duration of labor, use of drugs, use of forceps, rate of episiotomy, and incidence of cesarean section when a doula is present. Studies also show a higher rate of mothers who are breastfeeding six weeks after delivery, as well as greater self-esteem, less depression, and a more positive attitude toward their infants and their ability to care for them (Klaus, 1993). An uncomplicated birth facilitates breastfeeding. The incision from cesarean surgery is painful and the fatigue, discomfort, and pain-relieving drugs often make breastfeeding difficult. In addition, increased self-esteem and reduced rates of depression make it likely that a woman will continue to breastfeed, although breastfeeding itself may be somewhat responsible for higher self-esteem, reduced depression, and increased affection toward the infant. Regardless, a doula during labor certainly produces striking differences in rates of breastfeeding, but sadly most women in the United States do not have a doula present during labor or postpartum (Klaus, 1993). While almost all societies have a system for helping parents through the postpartum period, the United States has lost this system. A mother's mother or other female relatives may be unable to provide this assistance due to work constraints. In many cultures around the world with high rates of breastfeeding, the mother has relatives in her household or who live nearby to support her. The more the mother is cared for and supported, the easier it will be for her to breastfeed. Assistance with the multiple challenges and adjustments of motherhood free the new mother up to get to know her new baby and learn to breastfeed. A doula "can ease a mother's anxieties and produce an environment wherein successful lactation can be established and maintained," (Gussler JD, 1980:149). HOSPITALS AND HOSPITAL NURSERIES Immediate mother-infant contact after delivery directly correlates with breastfeeding success (Scrimshaw SCM, 1987) (Zimmerman DR, 1996). The sooner after delivery mothers start breastfeeding, the more bonding is facilitated and the better the mother's milk supply and baby's weight gain (DeCarvalho M, Robertson S, Friedman A, Klaus M. "Effect of Frequent Breast-feeding on Early Milk Production and Infant Weight Gain." Pediatrics, 1983; 72:307-311, cited in Klaus, 1993). Routine separation of mother and baby for 24 hours was not uncommon in the past. Even today many hospitals immediately remove a new baby from his mother's arms and whisk him straight to the nursery for tests and observation. More and more hospitals are offering rooming-in and have no nursery in order to facilitate breastfeeding and bonding. However, there are still many hospitals not practicing according to the Baby Friendly Hospital Initiative, enacted in 1989 by the WHO and UNICEF in order to promote breastfeeding. This initiative provides ten guidelines such as helping mothers initiate breastfeeding within a half hour of birth, giving the newborn only his mother's milk unless it is medically necessary to do otherwise, and rooming-in 24 hours a day (Zimmerman DR, 1996). One study conducted in Los Angeles, California, compared breastfeeding rates of two hospitals. One was a university hospital with two patients to a postpartum room and rooming-in arrangements in the absence of medical complications, and the other was a county hospital with four patients to a room and babies brought to their mothers only for scheduled feedings. More of the university hospital women first nursed their babies in the delivery or recovery room, while more women in the county hospital first nursed in the postpartum room or did not have the opportunity to nurse in the hospital at all. Both hospitals were teaching hospitals associated with the same medical school. There were no significant differences in education, acculturation, marital status, or any other relevant variables. There was no difference in breastfeeding plans between women delivering in either hospital; prenatally, 82 percent of the women in both groups intended to breastfeed. Nonetheless, the percentage of women breastfeeding at their postpartum interview had dropped to 70 percent in the county hospital, yet had remained unchanged for the participants in the university hospital (Scrimshaw SCM, 1987). Although increasing numbers of hospitals are providing lactation consultants as a service, new mothers now go home within a day or two after giving birth. If instructions are given to the mother in this period of time, she may retain little information due to the physical and emotional demands of the adjustment period. Early discharge from the hospital may lead parents to feel overwhelmed by the new situation. A home visit from a lactation consultant or home health nurse is vital to the success of new nursing mothers. However, many insurance plans do not cover this service (Klaus, 1993), nor will many physicians provide authorization for this service even if it is covered by insurance. Free samples of artificial milk given at the hospital imply that the hospital and physicians support the use of the product - a very powerful persuasion. The information pamphlets distributed with these samples subtly inform mothers that although breast is best, not everyone can breastfeed; that breastfeeding can be a tiring, difficult, painful, complex, and even dangerous process; and that most women will at some time need to supplement with a human milk substitute (Newman J, 1991). On the other hand, these pamphlets may also suggest that breastfeeding is easy and that most women have no problem nursing, implying that if a mother does encounter difficulties, she is alone. Thus the mother is likely to turn to a bottle rather than seek help to solve her problems. Studies show that starter packages distributed in hospitals decrease the duration of breastfeeding. "How anyone can turn logic on its head and suppose that starter packages do not constitute direct advertising to the lay public is beyond comprehension. There is no doubt that the starter packages are designed to 'hook' the mother and baby onto formula feeding and then…" (Newman J, 1991:1089). The free sample is a low cost investment for the formula company considering the hundreds of dollars new parents will spend to feed their baby a substitute for human milk. Hospital nurseries often allow babies to nurse only according to artificial time constraints. Nurses are often too busy to bring each baby to his mother whenever he cries, so babies are fed on schedules. This frequently means babies are given pacifiers or bottles of sugar water between feedings. There is no reason to give water to a healthy newborn, and in fact, bottles of water are harmful to breastfeeding success and can lead to nipple confusion, nipple preference, or breast rejection (Zimmerman DR, 1996). A newborn baby must learn to suck from the breast, which is different from sucking from a bottle. The milk flows freely out of a bottle, but a baby's jaw and tongue must work diligently to get milk out of a breast. If the milk comes easily out of a bottle, some babies will not want to work to get milk from the breast. Others will develop a poor suck and become unable to get milk from the breast, learn faulty suck patterns which causes the mother to have sore nipples, or fail to stimulate the mother's milk supply. Phenylketonuria (PKU) is a disorder in which the body cannot process phenylalanines present in food, including milk. The PKU test is a routine newborn test and can easily be done on a completely breastfed baby. The problem is that many hospitals routinely require that babies be given a bottle or two of formula before the test is run. Even one bottle can lead to nipple confusion in some infants. Many hospitals routinely give infants in the nursery bottles of formula. This leads to a baby who is already full when brought to his mother and doesn't want to nurse, and additionally may be already accustomed to sucking on a hard rubber nipple and unable to suck properly at his mother's breast. "The abandonment of rigid hospital practices and…the reeducation of both mothers and physicians will certainly contribute to the success of lactation," (DeCarvalho M, 1984:573). SCHEDULED FEEDING Infant weight gain and maternal milk supply can be significantly increased early in the lactation period by simply allowing the infant to nurse frequently on demand, as suggested in the WHO/UNICEF Ten Steps to Successful Breastfeeding (Zimmerman DR, 1996). Artificial time constraints interfere with normal nursing patterns since the mother's milk supply is directly proportionate to the suckling frequency of her infant (Gussler JD, 1980). The more the infant sucks, the greater the milk supply. At the turn of the century, it became common practice to limit feedings to three or four hour intervals; however, feeding schedules were rarely practiced until then. Many tribal cultures, such as the !Kung San Bushman in Africa, practice unrestricted breastfeeding where mothers wear their children in slings on their body, the child typically nurses several times per hour, and feedings are unrestricted. Typical duration of breastfeeding in such cultures is usually at least two years (Gussler JD, 1980). Dr. Manoel DeCarvalho of Rainbow Babies & Children's Hospital in Cleveland Ohio elaborates, "The industrial revolution and the significant changes in the sociologic, economic, and cultural conditions of women may all have contributed to changing the recommendations on feeding schedules. Rigid three- to four-hour schedules, which have only recently become part of our tradition, have probably contributed to many failures in lactation. In modern societies in which time is structured and measured, the clock and not the infant's hunger cues determine when feeding will take place, and the baby often fusses and cries between feedings. The biological component of the biobehavioral system has not changed, while the behavioral component has," (DeCarvalho M, 1984:573). Putting baby to the breast only at scheduled intervals can lead to engorgement of the mother's breasts, which is not only painful, but makes it extremely difficult for the baby to latch on properly. Long intervals between feedings may cause the baby to become ravenous and suck too vigorously. Intense sucking and improper latch-on can lead to sore nipples, further disrupting the maternal-infant attachment, and improper latch-on can lead to insufficient milk intake and poor weight gain (Gussler JD, 1980). Newborn babies need to nurse frequently, often every hour, in order to help the mother's milk come in, because they have very small stomachs and need frequent feedings, and because breast milk is absorbed very efficiently. Frequent nursing also helps prevent or quickly cure jaundice. In the American culture, from the time the umbilical cord is cut, an infant is expected to begin to learn independence. In more traditional societies, children are often carried close to the mother's body in a cloth sling and breastfed until they are two or three years old. The mother wears loosely draped clothing in order to facilitate frequent nursing and skin-to-skin contact. The children in these societies rarely cry, rapidly develop their motor skills, and demonstrate a high degree of security (Gussler JD, 1980). Babies born in hospitals in the United States are usually kept in a plastic box rather than in their mothers' arms. Then these babies are put to sleep in a crib at home, transported in portable plastic carrier seats, placed in a carriage or stroller for outings, and set in a high chair at mealtime. Infants rarely come into skin-to-skin contact with their mothers. The mother's daily activities take precedence over her baby's subtle cues and the feeding response is delayed. Some mothers may believe that too much holding spoils a child and therefore delay picking up the child when he cries. In developing countries where children are "worn" 80 to 90 percent of the time, an infant reaches for the breast when he wants to nurse. Nursing is practically continuous, it is rare for babies to cry, and mothers rarely report insufficient milk supplies. When babies in modern cultures cry or want to nurse continuously, the mothers often perceive they are not producing enough milk and that their babies are hungry. In fact, a fussy infant usually does not mean something is wrong with his mother's milk, but that his mother has missed his hunger cues, he needs to nurse more frequently, or he needs to be held more. "Over time, mammalian evolution has provided several solutions to the problem of feeding the young, while at the same time allowing for maternal food getting," (Gussler JD, 1980:151). The milk of a lioness is concentrated with a high content of fat so that she can leave her cubs for long intervals in order to hunt for food. Humans are a "carrier" species, meaning we carry our young, and human young are designed to be in close proximity to their mothers at all times. Therefore, human milk is relatively lower in fat and protein content than other mammals, making it easily digestible and rapidly absorbed. Frequent feeding allows for continuous feedback between mother and child and provides constant stimulation, which is essential to an infant's development (Gussler JD, 1980), but this continuous contact is missing in most mother-infant relationships in the Western world. Part 3 of 3 MODERN CHILDBIRTH PRACTICES Most women who give birth in America today use some form of drugs for pain relief. In some hospitals the epidural rate is as high as 90 percent or more. When an epidural is administered, a needle filled with synthetic cocaine is inserted into the epidural space of a woman's spine. The epidural and other commonly used drugs such as stadol and morphine, which are usually given intravenously, contribute to breastfeeding failure in several ways. The epidural substantially increases the incidence of cesarean sections for infant malposition and dystocia, or slow labor, (Thorp, 1993). Other maternal complications of epidurals, which may result in cesarean section, include maternal hypotension (which reduces placental blood supply and can cause fetal distress), cardiac arrest, allergic shock, increased maternal core temperature, convulsions, and respiratory paralysis (Uitvlugt A, 1990). Epidurals may also cause abnormal fetal heart rate, sometimes severe, necessitating cesarean surgery (Stavrou C, 1990). Cesarean surgery inhibits women from breastfeeding for several reasons. The pain from such major surgery prevents many mothers from getting into a comfortable position to nurse. Pain medication may make a mother drowsy and uninterested in nursing. She may also suffer loss of confidence in her body's natural abilities. Her body "failed" to give birth properly; now she questions her body's ability to produce an adequate milk supply. Women who undergo cesarean delivery are often separated from their infants after birth and have a harder time getting access to their infants and are therefore frequently unable to breastfeed immediately (Scrimshaw SCM, 1987). All drugs administered during labor and birth reach the baby (Haire D, 1987), and "high blood concentrations of local anesthetics can cause central nervous system and cardiovascular toxicity" (Uitvlugt A, 1990:13). An infant who must be resuscitated cannot nurse immediately and may be separated from his mother in the NICU. Other side effects, such as drowsiness and reduced muscle tone, may lead to sucking problems or a lethargic baby and create difficult obstacles to overcome when both mother and baby need to learn to nurse. Additionally, mothers who have had an epidural for pain relief are more likely to suffer postpartum fever, which is often construed as a sign of infection. This frequently leads to a longer hospitalization for the mother and a nursery stay for the baby so he can also be monitored for signs of infection. Often women and babies with fevers are separated from each other and are not permitted to nurse. Epidurals are correlated with neonatal jaundice (Clark, 1985). Many physicians incorrectly recommend that mothers stop nursing and give formula or water to jaundiced babies, keeping the babies under bilirubin lights in the hospital where the baby cannot nurse. In fact, the best treatment for jaundice is usually frequent nursing and indirect exposure to sunlight. Breast milk and colostrum, the early milk in the first few days after baby is born, bind to the bilirubin which causes jaundice and help flush it out of the baby's system (La Leche League International, 1991). Even when normal labor and birth ensue, many hospitals routinely give mothers unnecessary pain medication, which may affect their ability to nurse. The mothers may become drowsy and uninterested in or unable to nurse. Currently many hospitals prescribe routine medication following normal childbirth, which can interrupt maternal-infant attachment. New mothers may be unaware that they can refuse routine medications, which are not necessary in the course of normal childbirth. Home birth is an alternative to preventing the routine and unnecessary use of drugs and cesarean sections. Only about one percent of all births in this country occur at home, despite widespread data on the safety of healthy, low-risk women giving birth at home with a skilled midwife. The maternal and neonatal mortality rates for home birth are approximately one half that of hospital births, and cesarean surgery is necessary only one fourth as often. In addition, drugs are not used in home births. Babies and mothers are not separated at home, therefore facilitating bonding and breastfeeding. Women choosing home birth accept a certain degree of responsibility for their own health and the normal functioning of their bodies, instilling confidence in themselves and nature, which in turn instills a level of confidence in their ability to nourish their babies and to breastfeed. SOCIAL STIGMA Almost every baby doll comes with a bottle. Women on television are shown giving their babies bottles rather than breastfeeding. Calendars and magazines depict cleavage as a man's toy, not tools for feeding babies. Baby shower giftwrap is imprinted with baby bottle motifs. Can you imagine a gift wrapped in paper covered with pictures of breasts? The duration of breastfeeding is greatly influenced by social factors. Many people have negative attitudes toward long-term breastfeeding. "Long-term" means different things to different people. For some, "long-term" means six months, for others it means one year, and for still others "long-term" means two years or more. The American Academy of Pediatrics recommends all babies be breastfed for at least one year, and the World Health Organization recommends at least two years. The number of women in the United States who nurse their babies for at least one year is so small that it is statistically insignificant. American cultural beliefs pressure women against long-term breastfeeding, and most infants are weaned from the breast by four months of age. Social coercion to wean usually begins when the infant is about six months old. Some women actually experience direct confrontation from strangers for breastfeeding in public. In fact, it appears that "cultural attitudes towards long-term breastfeeding have not changed substantially over the last 20 years," (Kendall-Tackett KA, 1995:182). Janet Tamaro (1996), author of So That's What They're For! Breastfeeding Basics, tells a story of an American doctor in a Muslim hospital. As he walked through the maternity ward, he walked in on a group of new mothers sitting around talking and nursing their newborns. When they saw a Western male, they rushed, fabric flying everywhere, to cover…their heads. Not one of them covered their breasts. "In their country, it was their heads and faces that strange men weren't supposed to see. Not their breasts. Heck, those were just like feet and hands to these women." MEDICAL CONSEQUENCES OF ARTIFICIAL FEEDING About four out of every one thousand babies in the U.S. dies every year as a direct result of not being breastfed (Tamaro J, 1996). It is estimated that up to 30% of type I diabetes cases could be prevented by avoiding cow's milk in an infants diet in the first 3 months of life (Gerstein HC, 1994). Cow's milk is the main component of most infant formulas. Exposure to the protein in cow's milk has been implicated as a trigger for the autoimmune response that results in type I diabetes. Gerstein concluded that the incidence of type I diabetes was twice as high in children who were artificially fed or breastfed exclusively for less than 2 months. "It is postulated that insufficient breastfeeding of genetically susceptible newborn infants may lead to beta-cell infection and IDDM later in life," (Borch-Johnsen K, 1984:1083). Children who were not breastfed are eight times more susceptible to childhood lymphoma (Davis M, 1988). Artificial feeding deprives infants of immunities which fight off carcinogens. Short-term breastfeeding affords no more protection against childhood cancer than artificial feeding. Many studies have confirmed the increased rate of allergies in children who received cow's milk or synthetic human milk substitutes in the early months. These allergies include ulcerative colitis, food allergy, respiratory allergy, eczema, and hayfever. Breastfeeding for at least one month without other milk supplements significantly reduces the incidence of food allergy. Formula fed infants suffer from higher rates of wheezing, diarrhea, vomiting, and prolonged colds. In a study in Finland, there were significant long-term differences in severity of childhood asthma in children who were breastfed for at least two months compared with children who were nursed for one week or less. Many of these differences were still demonstrably evident at 17 years of age in groups of children who were breastfed versus those who were not (Saarinen UM, 1995). The absence of human milk in an infants diet contributes to increased incidences of gastrointestinal infections. A 1984 study showed the rate of gastroenteritis in formula-fed infants was double (119 cases) that of breastfed infants (61 cases) at birth. At four months of age, the number of gastroenteritis cases reported for formula-fed babies (119) was 600% that of breastfed babies (19) (Duffy LC, 1986). A WIC study found that there is a 51-71 percent reduction in gastrointestinal infections in infants who are breastfed at least three months (Tuttle CR, 1996). Breastfed infants who do get diarrhea are less likely to become dehydrated due to the rapid absorption of breast milk. Infants less than two months of age who have never received breast milk have a 23.3 times greater chance of dying from diarrhea than infants who are breastfed. The odds that a non-breastfed infant will die after contracting diarrhea drops to 5.3 times that of a breastfed infant after two months of age. Infants who receive non-breast milk supplements in addition to breast milk are at higher risk than those who are exclusively breastfed (Victoria CG, 1989). Crohn's disease is more prevalent in children who were not breastfed. Adults affected by Crohn's disease were more often not breastfed at all or breastfed for a shorter duration than controls (Koletzko S, 1989). A study of premature infants found that the infants who were not breastfed had lower developmental scores at 18 months of age and lower IQ scores at 7-8 years of age than the children who were breastfed (Lucas A, 1992). Women who have never breastfed have higher rates of breast cancer compared with women who have had a prolonged duration of lactation (Byers T, 1985) (Siskind V, 1989) (Layde PM, 1989). Women who were not breastfed as infants have higher rates of breast cancer as well (Freudenheim JL, 1994). The immunities in breast milk, as well as frequent sleep arousals which occur during co-sleeping, provide protection against SIDS. Societies with high rates of breastfeeding often sleep with their infants in order to facilitate nighttime nursing. Incidences of SIDS are higher in countries where infants do not breastfeed and do not sleep in the same bed as their parents (Mosko S, 1997). SOCIAL CONSEQUENCES OF ARTIFICIAL FEEDING Billions of dollars are spent in the United States, both directly and indirectly, to pay for formula, and for the additional medical costs of the infants who ingest the product. Taxpayers spend over $500 million annually for formula given to 37 percent of the infants born in this country by federal programs such as WIC, the largest purchaser of formula in the U.S. (Baumslag N, 1995). WIC purchases 40 percent of all the formula sold in the United States each year (Tuttle CR, 1996). Ecological consequences of artificial baby milk include destruction of water, land, and air when cow manure and urine pollute rivers and groundwater, while nitrate fertilizers used to grow their feed leaches into rivers and water. Methane gas from cow flatulence contributes to the destruction of the ozone layer. Forests are often cleared for land used for pastures. Promotion, production, distribution, manufacturing and packaging of bottles, nipples, and formula containers made of plastic, glass, rubber, and cardboard causes pollution and uses valuable natural resources. Mothers who do not breastfeed may miss more time from work as a result of staying home to care for a sick infant more often. Employee absenteeism results in increased costs to employers. CONCLUSION Our language influences how society sees breastfeeding. There are no "benefits" to breastfeeding - breastfeeding is a normal and necessary part of life. Optimal, perfect, and ideal are words often used to try to promote breastfeeding but may actually be discouraging it. No mother is perfect and probably doesn't expect to be, so formula, which is perceived as second best, is seen as an acceptable alternative. The truth is that there is no healthy alternative to human milk. When society can again start to see breastfeeding as the norm and bottle feeding as abnormal, there may be a dramatic increase in the number of babies in the United States and throughout the world who receive their mother's milk. References: BIBLIOGRAPHY Baumslag N & Michels D: Milk, Money & Madness: The Culture and Politics of Breastfeeding. Connecticut: Bergin & Garvey, 1995. Borch-Johnsen K, Joner G, Mandrup-Poulsen T, Christy M, Zachau-Christiansen B, Kastrup K, Nerup J: "Relation Between Breast-feeding and Incidence Rates of Insulin-dependent Diabetes Mellitus." The Lancet, 1984; 2(8411):1083-1086. Bridges CB, Frank DI, Curtin J: "Employer Attitudes Toward Breastfeeding in the Workplace." Journal of Human Lactation, 1997; 13(3):215-219. Brown RE: "Breastfeeding Trends." American Journal of Public Health, 1986; 76(3):238-240. Byers T, Graham S, Rzepka T, & Marshall J: "Lactation and Breast Cancer: Evidence for a Negative Association in Premenopausal Women." American Journal of Epidemiology, 1985; 121: 664-674. Clark DA & Landaw SA: "Bupivacaine Alters Red Blood Cell Properties: A Possible Explanation for Neonatal Jaundice Associated With Maternal Anesthesia." Pediatric Research, 1985; 19(4):341-343. Davis MK, Savitz DA, & Graubard BI: "Infant Feeding and Childhood Cancer." The Lancet, 1988; 2:365-368. DeCarvalho M: "Everybody Needs Reeducation - In Reply." Pediatrics, 1984; 73(4):572-573. Duffy Linda C, Byers TE, Riepenhoff-Talty M, LaScolea LJ, Zielezny M, Ogra PL. "The Effects of Infant Feeding on Rotavirus-Induced Gastroenteritis: A Prospective Study." American Journal of Public Health, 1986; 76(3):259-263. Freudenheim JL, Marshall JR, Graham S, Laughlin R, Zena JE, Bandera E, Muti P, Swanson M, Nemoto T: "Exposure to Breast Milk in Infancy and the Risk of Breast Cancer." Epidemiology, 1994; 5:324-331. Gerstein HC: "Cow's Milk Exposure and Type I Diabetes Mellitus." Diabetes Care, 1994; 17:13-19. Gussler JD & Briesemeister LH: "The Insufficient Milk Syndrome: A Biocultural Explanation." Medical Anthropology, 1980;4:145-162. Haire D: "Drugs in Labor and Birth." Childbirth Educator, Spring 1987:499-505. Howard CR, Howard FM, Weitzman M, Lawrence R: "Antenatal Formula Advertising: Another Potential Threat to Breast-feeding." Pediatrics, 1994; 94(1):102-104. Kendall-Tackett DA & Sugarman M. "The Social Consequences of Long-Term Breastfeeding." Journal of Human Lactation, 1995; 11(3):179-183. Klaus MH, Kennell JH, Klaus PH: Mothering the Mother. Massachusetts: Addison-Wesley Publishing Company, 1993. Koletzko S, Sherman P, Corey M, Griffiths A, & Smith C: "Role of Infant Feeding Practices in Development of Crohn's Disease in Childhood." British Medical Journal, 1989; 298:1617-18. Kurinij N, Shiono P, Ezrine S, & Rhoads G: "Does Maternal Employment Affect Breast-Feeding?" American Journal of Public Health, 1989; 79:1247-1250. La Leche League International: The Womanly Art of Breastfeeding. New York: Penguin Books, 1991. Layde PM, Webster LA, Baughman AL, Wingo PA, Rubin GL, Ory HW, & The Cancer and Steroid Hormone Study Group: "The Independent Associations of Parity, Age at First Full Term Pregnancy, and Duration of Breastfeeding With the Risk of Breast Cancer." Journal of Clinical Epidemiology, 1989; 42:963-973. Lucas A, Morley R, Cole TJ, Lister G, Leeson-Payne C. "Breast Milk and Subsequent Intelligence Quotient in Children Born Preterm." The Lancet, 1992; 339:261-264. Magnus PD & Galindo S: "The Paucity of Breast-Feeding in an Urban Clinic Population." American Journal of Public Health, 1980; 70(1):75-76. McKenna JJ, Mosko SS, Richard CA: "Bedsharing Promotes Breastfeeding." Pediatrics, 1997; 100(2):214-219. Mosko S, Richard C, McKenna J: "Infant Arousals During Mother-infant Bed Sharing: Implications for Infant Sleep and Sudden Death Syndrome Research." Pediatrics, 1997; 100(5): 841-849. Newman J: "Formula Companies and the Medical Profession." The Pediatric Forum, 1991; 1088-1090. Pinilla T & Birch L: "Help Me Make It Through the Night: Behavioral Entrainment of Breast-Fed Infants' Sleep Patterns." Pediatrics, 1993; 91(2):436-444. Saarinen UM & Kajosaari M: "Breastfeeding as Prophylaxis Against Atopic Disease: Prospective Follow-up Study Until 17 Years Old." The Lancet, 1995; 346:1065-69. Scrimshaw SCM, Engle PL, Arnold L, & Haynes K: "Factors Affecting Breastfeeding Among Women of Mexican Origin or Descent in Los Angeles." American Journal of Public Health, 1987; 77(4):467-470. Siskind V, Schofield F, Rice D, Bain C: "Breast Cancer and Breastfeeding: Results from an Australian Case-control Study." American Journal of Epidemiology, 1989; 130:229-36. Stavrou C, Hofmeyr GJ, Boezaart AP: "Prolonged Fetal Bradycardia During Epidural Analgesia." South African Medical Journal, 1990; 77:66-68. Tamaro, Janet. So That's What They're For! Breastfeeding Basics. Massachusetts: Adams Media Corporation, 1996. Thorp JA, Ha DH, Albin RM, NcNitt J, Meyer BA, Cohen GR, Yeast JD: "The Effect of Intrapartum Epidural Analgesia on Nulliparous Labor: A Randomized, Controlled, Prospective Trial." American Journal of Obstetrics and Gynecology, 1993; 169(4):851-858. Tuttle CR & Dewey KG. "Potential Cost Savings for Medi-Cal, AFDC, Food Stamps, and WIC Programs Associated With Increasing Breast-feeding Among Low-income Hmong Women in California." Journal of the American Dietetic Association, 1996; 96(9):885-890. Uitvlugt A: "Managing Complications of Epidural Analgesia." International Anesthesiology Clinics, 1990; 28(1):11-16. Valaitis RK, Sheeshka JD, O'Brien MF: "Do Consumer Infant Feeding Publications and Products Available in Physicians' Offices Protect, Promote, and Support Breastfeeding?" Journal of Human Lactation, 1997; 13(3):203-208. Victoria CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AMB, Fuchs SC, Moreira LB, Gigante LP, Barros FC. "Infant Feeding and Deaths Due to Diarrhea." American Journal of Epidemiology, 1989; 129(5):1032-1041. Williams EL & Hammer LD: "Breastfeeding Attitudes and Knowledge of Pediatricians-in-Training." American Journal of Preventive Medicine, 1995; 11(1):26-33. Zimmerman DR & Bernstein WR: "Standing Feeding Orders in a Well-Baby Nursery: 'Water, Water Everywhere…' " Journal of Human Lactation, 1996; 12(3):189-192.