Breastmilk Insufficiency: A Dance Between Biology & Culture

Breastmilk Insufficiency: A Dance Between Biology & Culture

©2020, Milton Herrera

All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review.

Cover description. Michelangelo Madonna and Child, by Cultural Pursuit blog (2017):

Michelangelo Buonarroti. Italian, Caprese 1475–1564, Rome. Unfinished cartoon for a Madonna and Child, Drawing 1525–30. Black and red chalk, white gouache, brush and brown wash sheet: 21 5/16 x 15 9/16 in. (54.1 x 39.6 cm) Casa Buonarroti, Florence 71F SL.6.2017.12.7. Image courtesy of The Metropolitan Museum of Art.

ISBN: 9781098342821

ISBN eBook: 9781098342838

To Pik Sai & Conrad

Contents

PROLOGUE

Parallel Evolution: Representation of Breastfeeding in the Arts and Sciences

INTRODUCTION

The Phenomenon

THE FOUNDATION

SECTIONS

CONTRIBUTIONS

PART I – RESEARCHERS

Predecessors

THE ROLE OF CULTURAL BELIEFS AND ATTITUDES

BIOLOGICAL CONSIDERATIONS

FROM CULTURAL OR BIOLOGICAL TO BIOCULTURAL

Ten Years After

FROM BIOCULTURAL TO CULBIOS

THE PRESS DISCOVERS BREASTFEEDING

PART II – RESEARCH

Research Site

CONSTRUCTION OF THE RESEARCH METHODS

FIRST OUTCOMES

Two Structures

BREASTFEEDING STRUCTURE

BREASTMILK CONSUMPTION STRUCTURE

Labeling Breastmilk Insufficiency

DEFINING MEASURED BREASTMILK INSUFFICIENCY

BIOETHNOGRAPHIC DATA

PERCEPTION IS REALITY

MOTHERS’ EXPLANATIONS OF BREASTMILK INSUFFICIENCY

PART III – ENCOUNTERS

The Economic Crisis of 1999

A NATURAL EXPERIMENT

SITE UPDATE

A Fussy World

BREASTFEEDING IN BROOKLYN

PRODUCERS, ACTORS, AND SPECTATORS

PART IV – APPROACHES

The Numbers

BREASTFEEDING, CULTURE, AND BREASTMILK PRODUCTION

Epistemic Framework For Investigating Breastmilk Insufficiency

THEORETICAL FRAMEWORKS

CONCEPTUAL FRAMEWORKS

PART V – THE DANCE

A Dance Between Biology and Culture

CULTURE AS A LIVED EXPERIENCE, NOT JUST A CONCEPT

THE CONCEPT OF BIOLOGY HAS MUTATED

CULBIOS

THE DANCE IS EVERYWHERE

BIBLIOGRAPHY

PROLOGUE

Parallel Evolution: Representation

of Breastfeeding in the Arts and Sciences

Throughout humans’ history as mammals, there have always been cases in which a mother could not breastfeed her newborn. Apart from the unavoidable consequences of the death of the mother or infant, there exist other cases which were perhaps avoidable, but came to be defined (in interaction with culture) as failure of lactation. Since ancient times, the mysterious nature of success or failure in lactation has led to cultural and scientific interest. The cultural interpretation of the phenomena of breastfeeding has become part of society’s traditional medical beliefs and practices as well as its art.

The act of breastfeeding is perhaps the part of the human life cycle most represented by artists and artisans of all types, across all cultures. As a subject, breastfeeding is a meditation on the theme of love, as warfare is a meditation on the theme of death. Breastfeeding serves as a physical representation of Natura, and embodied in the act itself is the connection of two powerful bodies or structures: mother-infant and culture-biology. It is an innocent yet powerful symbol of the constant interactions of culture and biology.

African legends, Indian fables, Chinese proverbs, Greek mythologies, and Amazonian cosmovisiones tell the origins of their respective peoples, nature, religion, culture, and overall concept of the universe. Woven among these narratives, a mother’s breastmilk is presented as the elemental body fluid, the continuator of life, creator of culture, and fertilizer of the universe.

Here I will briefly refer to certain archaeologies, sculptures, and paintings that reflect interactions of breastfeeding and culture. During my visit to Ecuador in 2018 and the local museums in Esmeraldas and Quito, I was amazed to see archeological pieces that depict women’s fertility, maternity, and lactation in many forms, from similar cultures but different time periods. In the city of Esmeraldas, for example, at the Museo y Centro Cultural Esmeraldas, one can observe a ceramic piece of a breastfeeding mother holding her infant in one arm, while her free hand squeezes her other breast (La Tolita ~ 600 BC-400 AD). At the Museo Nacional del Ecuador (MuNa) in Quito, among various pieces representing womanhood, you can see a beautiful ceramic piece of a woman with a child in her lap (~35cm high). The original colors have faded between a homogeneous pale brown and a dark solid brown (see Photo 1). The museum label, translated from the Spanish, describes the scene: mother with a child in offering attitude (Chorrera Culture 1000-300 BC).

Photo 1

In the small town of Valdivia (which bears the same name as one of the oldest cultures that inhabited this region of South America), there is a kiosk that sells archaeological replicas of past cultures, including a figure very similar to the one I saw at the museum. I bought a colorful, hollow ceramic, about 35 centimeters tall and belonging to the Chorrera culture, representing a mother with an infant resting on the right side of her lap.

As we can see from the next picture, the woman has an elongated cranial modification, a feature which might indicate an important part of her identity and/or suggest her social status (Stothert and Cevallos 2007). The polished surface of what seems to be a helmet draws the viewer’s attention to the tattoos on her face and those covering her shoulders, breasts, and pelvic region. They are well illustrated with geometric patterns characterized by incised lines and dots. The piece is an intense red and yellowish brown, parts of her calf and feet a smoked black—colors commonly used by Chorrera artisans, according to Stothert and Cevallos, who tell us the tattoos served as protection from evil spirits. I believe they were also powerful symbols of motherhood, fertility, and femininity. The rigidity of the child, wrapped in a cloth cradleboard in the ancient technique of swaddling, strikes me. The infant is dormie, or it is dead. I cannot tell from the figure. Notice the protuberant and horizontal linear eyes of the mother and infant; their faces, to me, reveal neither happiness nor sadness.

Photo 2

At the Metropolitan Museum of Art in New York City, one can find a small but vibrant Tiffany-colored faience (17 cm. high) from Egypt (332-30 BC) depicting a smiling Isis. The goddess is shown with full breasts, breastfeeding an infant Horus, well-fed and likewise smiling. According to the museum’s description, the image was a symbol of rebirth. The figure doubles as a symbol and a message of the continuation of its people and, therefore, their culture.

Due to its significance in Christianity, European painters produced many works on the theme of breastfeeding, e.g., the multiple and diverse Madonnas and Child of Leonardo da Vinci, Michelangelo, Raphael, Caravaggio, El Greco, and many others. Artwork in Europe and elsewhere were also inspired by popular myths; an astounding number of paintings and sculptures, for example, depict the twin brothers Romulus and Remus nursed by a she-wolf. According to the legend (ca. 750 BC), the twins were abandoned in a cave called the Lupercal (in today’s Italy) by their mother to save them from being killed. They were raised by wolves in the wild until a peasant rescued them, bringing the twins to his wife to be suckled. Later in life, according to the myth, Romulus killed Remus and went on to found the city of Rome. Such is the irony of the twins’ survival, for one to ultimately die by the hand of his own wolf-brother (this could be what the expression bad-milk means in many cultures). Or consider The Origin of the Milky Way by Peter Paul Rubens (1637). It portrays a well-nourished white woman, the goddess Hera, holding a well-fed child, Heracles, and spilling her breastmilk into the sky as she tries to nurse him. Mighty Zeus, seen in the background of the painting, contemplates the act. According to Greek mythology, the god Zeus conceived Heracles with a mortal woman named Alcmene. The painting thus represents a wet-nurse case in reverse: a goddess breastfeeding a mortal, or a superordinate woman breastfeeding a child of subordinate nature. It is a resonating representation of equality through breastmilk, the love of a goddess for humans and, even more, the powers of mother’s milk as creator of our universe and maintainer of human life within it.

In Cimon and Pero (also called Roman Charity), another painting by Rubens (1612), a young woman, Cimon, breastfeeds an old man, Pero, who is her father, in the ultimate act of piety. We can see in the painting that Pero is in jail, and, according to the story, he has been condemned to starvation in ancient Rome. The image of the breastfeeding woman able to nourish a disordered society is indeed timeless and symbolically evocative across the centuries. Recall that in the final scene of the great 20th-century American novel The Grapes of Wrath by John Steinbeck, a young woman who has lost her baby breastfeeds a starving man. One more 17th-century example is La Mujer Barbuda by Jusepe de Rivera (1631), in which a bearded woman (who looks like an old man) is breastfeeding her child. The inscription on the painting says: Look, a great miracle of nature... A case of hirsutism, a hormonal disorder causing excessive hair growth in women, that in the artist’s eye made the woman look like a man—one of the apparent biological contradictions in nature. In the end, this painting is a powerful representation of humanity that, among other things, exposes the observer to the stereotypes we have, including the social construction of gender and its morphology.

Furthermore, exposing nature itself and the innocent oxygen of resilience are several artistic representations of Europe’s plague. In the painting The Plague of Ashdod (Louvre, Paris), by the painter Nicolas Poussin (1594-1665), one can perceive the anxiety in their faces and panic and chaos in the population. Bodies are lying in the square, people covering their noses and mouths with their hands, the rats running in disarray and forehead in the picture, we see the faded dead-mother, with two children at her sides, one lifeless and the other trying to suck a breast. Even more dramatic is the etching by the engraver Robert Pollard (1755-1838), entitled "The great plague in London, 1665" (Wellcome Library). In the image’s background, the observer could see bodies on a horse-cart and in the foreground, four women, dead or dying, and an infant dragging his small body to reach the dead mother’s breast. It seems to be the representation of life itself confronting death.

For an example of breastfeeing in Eastern art, we can look to the work of the Japanese artist Kitagawa Utamaro (1754-1806). In his paintings, you can see detailed portrayals of what seems to be an average day in the life of a Japanese mother and child enjoying each other’s company, reflective and without stress, representing that Zen stage of natural breastfeeding, which scholars mention as one of its effects. You can sometimes see a playful infant sucking one breast while playing with the other breast’s nipple (a reflex?), or an apparently distracted mother looking through the mirror at her suckling infant.

In ancient times, wet-nurses were generally slaves. During the Renaissance in Europe, it was rare for an aristocratic mother to breastfeed her children; it was just not in fashion and considered incompatible with her lifestyle. Breastfeeding was regarded as an activity uniquely reserved for a lower-status mother (Spence 1938, Stevens et al. 2009). Differential social status and power were part of the dynamics of subordination between wet-nurses and the biological mother, who always belonged to the superordinate group. This tells us something about what people thought about breastfeeding—an atavistic human behavior considered natural, mammalian, and egalitarian, and yet existing within inegalitarian societies. In other words, breastmilk is egalitarian, but clearly the system in which a person may hire another person to produce that breastmilk is far from it.

An excellent example of a painting that illustrates the complexity of bonds between wet-nurses, biological mothers, and their children is Farewell to the Wet-nurse, by Étienne Aubry (1776-1777). In the scene, a wet-nurse gives a child back to his biological mother. The child does not want to go with the biological mother and is trying to return to the wet-nurse with whom, we assume, the child has formed a deep physical and emotional connection. The social classes of the women involved in the painting are apparent, and the complexity of the emotions is reflected in all those who are present. Particularly remarkable is the anxious face of the infant leaving the wet-nurse.

The last painting I will mention is an unusual artistic portrayal called Feeding the Baby, by Adolf Von Becker (1874), in which a mature woman is bottle-feeding an infant. Most interesting in this painting is the illustration of the bottle used at that time; it has an inverted J shape, the curve ending at the mouth of the infant. We do not know if the woman who is holding the bottle is the mother, another relative, or a dry-nurse. This is the earliest illustration of a foreign object standing between a woman and an infant, who does not need to be physically attached/latching to a lactating breast at all. Let us remember that it was not until the nineteenth century that successful rubber-teat and bottle-feeding were introduced (Spence 1938).

In recent decades, with the advent of technology in food preservation, the infant feeding industry was able to develop the famous, or infamous, infant formula. Under aggressive advertising, it became the primary alternative option to breastfeeding (Stevens et al. 2009), suddenly introducing a new behavior to that atavistic activity. Across the world, it became an option or justification for lactation failure, as well as to display social status. Furthermore, the first cans of formula on the world market were artistically decorated with the images of a beautiful smiling white baby with pink cheeks and blue eyes –their model of a healthy baby. Those images were also sold, with an immense negative impact on the psyche of rich and poor societies.

It should not surprise us if future artistic representations are something like a fictional scenario in which we see a parent and their child in a transhumanistic urban environment, surrounded by devices with the technical capacity to monitor the diet and behavior of children. Devices like an OpenBCI (an open-source brain-computer interface) which transmits and tracks data from a large number of metrics per hour, per day, per week, per month to a central AI device, which in turn manages diet and registers human emotions—all based on new concepts of healthy-infant, healthy-people, or healthy-culture.

These representations all serve to tell the story of the evolutionary history of the constant dance between biology and culture. Moreover, the archaeological and artistic pieces could be perceived as cultural representations of the natural and supernatural worlds, but they must also be seen, interpreted or understood, as "biocultural-efferents" (from the Latin efferent) because they carry biocultural information to the observer. A visual language of what was learned or must be learned and repeated within a particular culture and time, that, among other messages, elucidates key biological activities of humans and nature.

To close this prologue, let us say that continuous and parallel subtle interactions of biological and cultural bodies are captured, represented, interpreted and transmitted in different ways by artists and scholars alike. In the end, it is nothing more than the interpretation of pure human biological nature and behavior. Biological factors and cultural actors are entwined, and over time they can be deciphered as having a parallel evolution. Cultural changes can modify biological structures, and as a result, culture generates new biology. All to continue dancing together. And whether consciously or not, artists and scientists will continue to investigate, interpret, and recreate this long and elegant dance.

NYC

March 2019

INTRODUCTION

The Phenomenon

The primary focus of this book is the phenomenon of breastmilk insufficiency. Although breastmilk has been the sole source of infant nutrition throughout human history and "historically and culturally most of the world’s children have been breastfed ad libitum " (Minchin 1985:191), the phenomenon of mothers’ breastmilk insufficiency has become a health threat to the mother-infant dyad, women’s reproduction, infant health, the community, and the entire population. Breastmilk insufficiency can trigger a chain of events that ends in early weaning, early supplementation, and infant obesity (Harder et al. 2005). It is a major developmental problem due to its economic and health implications, and the effects on child health and survival are even greater in developing countries. Bottle-fed infants carry a mortality risk at least ten times higher than the risk for breastfed infants, and the relative risk of fatal and nonfatal respiratory infections is two- to five-fold higher among bottle-fed infants (Cunningham 1995). We know the consequences, but we do not know the multiple causes, academically speaking. It is imperative that researchers from both the natural and social sciences work together to decipher this phenomenon.

As we might expect, the concept of breastmilk volume is as puzzling to breastfeeding mothers as it is to researchers, since the amount of breastmilk an infant consumes when breastfeeding is generally impossible for the breastfeeding mother to know exactly. So the phenomenon of breastmilk insufficiency is basically the perception by the mother of not having enough breastmilk for her infant at some point during lactation. The implication of this perception can be devastating when mothers eventually stop breastfeeding altogether. Unfortunately, the perception of breastmilk insufficiency is increasing worldwide, and, more than ever, we need to understand the causation of the phenomenon in order to take concrete measures to curb it. There is also a need to examine variation in breastfeeding patterns in different cultures. Many academic studies and popular media seek to ascertain the prevalence of breastfeeding but lack details on various aspects of breastfeeding structure and culture. One consequence of not having a well-defined description of local breastfeeding structure is the difficulty in comparing studies.

There should not be a generalized assessment that defines breastmilk insufficiency; the causations are so vast and intertwined with many external factors that any circumscribed definition will blind the reader from the full spectrum of the problem. Unfortunately, theoretical and methodological divisions between different academic fields (like social and natural sciences) reduce the scope of explanations/methods to only a single-field approach. This book is an attempt to mitigate that problem.

Based on research, I define breastmilk insufficiency, culturally speaking, as the mother’s perception at any moment during lactation that she does not have enough breastmilk for her infant. I call this perception Breastmilk Insufficiency Complaint (BIC). Biologically speaking, I define breastmilk insufficiency as the mother’s production of less than or equal to half of the average amount of breastmilk produced in a particular population. Bioculturally speaking, breastmilk insufficiency is the combination of the two: reduced breastmilk production accompanied by BIC.

Theoretical Frameworks

Although there are no clear lines dividing cultural, biological, and biocultural approaches, I use these distinctions as markers to reflect the theoretical debates between scholars. Research on the problem is genuinely multidisciplinary and springs from the fields of anthropology, demographics, endocrinology, epidemiology, medicine, neonatology, nursery, nutrition, obstetrics, pediatrics, physiology, psychology, public health, sociology, art, and the media. In the reviewed literature we find terms like inadequate milk syndrome; insufficient milk supply; insufficient milk syndrome; insufficient milk supply syndrome; milk insufficiency; lactation failure; oligogalactia; perceived milk insufficiency; primary milk insufficiency; perceived milk supply; reported milk insufficiency and what I call here Breastmilk Insufficiency (BI). All of these terms reveal only one thing: that we do not know clearly what this phenomenon is. Regardless of their nomenclature, they do not necessarily signal that breastmilk has been measured, that breastmilk insufficiency has been established as such or defined, or that the problem was then established from the researcher’s point of view. This gives rise to a second problem: even if researchers have measured breastmilk volume, what values can be used