How Did We Get Here?
To fully understand how women came to be so greatly influenced by both the action and inaction of obstetricians and pediatricians requires looking at how money, commerce, and even women themselves conspired to change our relationship to pediatricians and obstetricians. But first, a brief history lesson. For centuries, birthing and infant feeding were women’s domain, supervised by nurses and midwives. Birthing was not considered an event requiring constant medical supervision. Obstetricians were jokingly referred to as doctors for “standing by.” Pediatricians were in a similar situation. “Treating only children seemed de facto evidence of incompetence,” writes sociologist Jacqueline Wolf. “When seeking a physician for a child, parents judged doctors’ competence by their ability to heal adults. Medical professionals and laypeople alike consequently scorned pediatricians as ‘baby doctors.’”
Mothers breastfed for as long as their babies needed their milk. And when a mother died in childbirth or in the rare instance that breastfeeding was not possible, families hired a wet nurse or they relied on a kind lactating neighbor to feed the baby. However, starting with World War I, family patterns and working habits changed. Women entered the workforce in record numbers. With mothers away from their babies for many hours of the day, artificial milk feeding increased. But without proper pasteurization and refrigeration, homemade human milk substitutes and inadequate sanitation led to gastrointestinal ailments and skyrocketing infant death rates. As municipalities began compiling vital statistics, the high rates of infant mortality became a glaring public health problem that needed to be fixed.
As frequent witnesses to the gruesome deaths of infants from diarrhea caused by being artificially fed, pediatricians in the nineteenth century strongly advocated breastfeeding but also worked to secure the health of artificially fed babies by making breast milk substitutes safer. In addition to their work trying to “humanize” cows’ milk, pediatricians inspected dairy farms, lobbied municipal and state governments to pass pure milk laws, and distributed free pasteurized milk in urban neighborhoods. Pediatricians led the charge for milk reform. They spearheaded efforts to impose strict standards on the dairy industry and began to create “scientific” nonmilk substitutes so mothers could avoid the problems of unrefrigerated milk. In fact, the original members of the American Pediatric Society came together in 1888 with the sole mission of applying scientific medicine to artificially fed infants. Creating a replacement for mother’s milk was the foundation of the pediatric field.
In the 1890s, the Harvard pediatrician Thomas Rotch used mathematical formulas to instruct chemists how to alter the percentages of fat, protein, and milk sugar in cows’ milk according to the needs of a particular baby. This is where the word “formula” came from. These “formulas” incorporated variables such as the baby’s weight, energy level, physical ailment, and the smell, color, and texture of the baby’s stools. Rotch believed that even minute changes in percentages were significant to the digestion by the infant. The mother had to return every few weeks to have her baby’s formula adjusted. The process had the allure of scientific complexity, as each prescription-based “formula” was designed specifically for the needs of that individual infant.
The tide had turned for the pediatric industry—instead of being vilified and viewed as an unnecessary specialty, mothers now considered a pediatrician indispensable. Even breastfed babies were thought to need medical supervision since lactation appeared to be an unreliable body function.
In focusing on the needs of the rich, pediatricians saw the potential to gain respectability and make money. At the time, much of pediatric training centered on the intricacies of formula writing. But the custom-made formula turned out to be impractical, and, as the number of infants put on formula increased, individualizing prescriptions became too inconvenient and costly. In addition, the whole middle market of lower- and middle-class families, who could not afford private physician formulations, was being priced out of the physicians’ services.
As the pediatricians focused on the higher-end market, some of the first commercially made infant foods began to hit the stores. Nestlé Milk Food and Horlick’s Malted Milk were widely advertised in newspapers and magazines and were easier to prepare than the pediatricians’ complicated formulas, as they only needed to be mixed with hot water. As mothers purchased more ready-made milks, repeated doctor visits became unnecessary, and doctors in private practice saw a loss of income. As it turns out, commercial interests were smart to bank on the middle market. But doctors felt cut out of the deal, since they were the first to legitimize formula creation.
This was about power, not babies. It also meant the loss of prestige for pediatricians, who didn’t seem as critical to the infant-feeding equation when mothers could make substitute milk without the help of a doctor. In 1893, Dr. Rotch wrote: “The proper authority for establishing rules for substitute feeding should emanate from the medical profession, and not from non-medical capitalists. Yet when we study the history of substitute feeding as it is represented all over the world, the part which the family physician plays, in comparison with numberless patent and proprietary foods administered by the nurses, is a humiliating one, and one which should no longer be tolerated.” Doctors wanted to assert their dominance over infant feeding decisions. Meanwhile, public health officials continued to promote breastfeeding as the best alternative to the dirty and deadly cows’ milk. But by the mid-1920s, efforts to clean up the dairy industry were successful and many of the most egregious problems associated with substituting cows’ milk for human milk had dissipated. With the advent of pasteurization, refrigeration, and the bottling and sealing of milk, infant deaths from diarrhea decreased 84 percent in Chicago alone. It was presumed that cleaner food laws along with the scientific advances of formula put artificial milk on par with breastfeeding. Doctors hailed the cow as “the foster mother of the human race.” How children would fare under this “foster care” system was yet to be fully considered.
Meanwhile, the matter of whether medical authorities or commercial entities would drive infant feeding decision making was still unresolved. Manufacturers realized that doctors were more advantageous to their commercial interests as friends and not foes. Physicians realized that they needed to be involved with the mass distribution of artificial milk or miss out on the financial benefits of the work they started. An unholy alliance was formed. And strategic steps were taken to deliberately push mothers out of the process. One step was the mass production and widespread distribution of artificial milks—but with no directions on the package. The instructions simply advised consumers to consult their doctors before using the product. The information was that these commercial foods were dangerous if used without physician instruction, yet distribution was not restricted or controlled. The message sent to mothers was that everything would be fine, if you just went to your doctor first for his direction. In 1923 Mead Johnson, maker of Enfamil, boasted in a corporate document that their “ethical” marketing policy was “responsible in large measure for the advancement of the profession of pediatrics in this country because it brought control of infant feeding under the direction of the medical profession.”
The collusion between infant formula manufacturers grew deep. The formula makers used medical doctors for testimonials. Several manufacturers were owned by doctors and pharmacists. They wanted doctors to sanction their products, while doctors wanted to retain control over the distribution of formula and share in the profits from this new market.
With so much riding on doctors, the infant formula makers realized they were a more important target audience than mothers themselves. When the first commercial infant formula was introduced to the United States in the late 1860s, manufacturers advertised their new product directly to consumers in women’s magazines. Advertisements implied that babies needed more than just breast milk to achieve optimal health and nourishment, and they emphasized how closely formula approximated breast milk’s chemical compositi
on. As is still done today, formula companies attracted new customers with free samples and information on infant feeding and care.
The combination of skillful marketing and promotion efforts combined with physician promotion succeeded in giving artificial feeding an aura of medical legitimacy. Parents grew to believe that a commercial product could be as good as, or better than, the real thing. By the end of World War II, bottle feeding had become the standard method of infant feeding in the United States and, to a lesser extent, in Europe as well. The authors of a 1991 Scandinavian study reviewing hospital procedures surrounding breastfeeding said, “The interference of the medical profession in the twentieth century in the feeding of healthy, term infants may in the future be regarded as a puzzling, uncontrolled, less than well-founded medical experiment.”
The Impact of Time
Meanwhile, industrialization brought another revolution to America—mechanization of time. Scheduling became vital to factories and railroads. For much of middle America—used to structuring their lives around natural events like sunrise and sunset—it was an incredible shift to adjust their lives to a mechanical clock. So that babies adapted to this cultural development from birth, most of the infant care manuals of that time instructed mothers to care for infants according to the clock.
Following the advice of the top medical experts of the time, the U.S. Children’s Bureau produced a series of informational pamphlets for breastfeeding in the 1910s that included various suggestions and instructions. Included among the recommendations were that to breastfeed successfully a mother must sleep eight hours a night, nap midday, exercise, take fresh air for an hour each morning and evening, and nurse on a strict schedule. Feeding advice was also culturally biased: the nursing mother was instructed to eat a “bland” American diet and to keep a physical distance from her baby—ideas that were antithetical to many immigrant cultures, who ate spicy foods and often slept with their children. The advice offered from physicians also emphasized the need to avoid being nervous, or overcome with “fright, fatigue, grief or passion.” This type of physician advice went beyond helping a mother with the mechanics of nursing or suggesting time intervals for feeding and was about regulating women—their emotions, their cultural practices, their diet, and their bodies. These types of strict guidelines put pressure on women and succeeded in sabotaging confidence in breastfeeding.
Lactation is a self-limiting condition. Less breastfeeding meant less breast milk production. Less milk production meant more concerns about insufficient supply. At the time, doctors didn’t understand lactation enough to connect the dots between the stringent guidelines and the surge in insufficient milk. They had other theories, including assertions that “over-civilization” forced women to live unnatural lives and, therefore, their bodies were unable to perform natural functions like lactation. With women increasingly unable to breastfeed, pediatricians became even more in control of perfecting a replacement for human milk. Women became more dependent on medical professionals for information just as physicians’ knowledge of the science of lactation decreased. They did not know about lactation but about the science behind the formulas their colleagues helped create. Both mothers and doctors had forgotten the importance of human milk. Although in the past mothers consulted other mothers, clergy, kin, manuals, magazines and, as a last resort, physicians, by the early twentieth century the physician’s word was law.
From the early twentieth century until the late 1980s, most formula companies abandoned direct-to-consumer advertising and used the medical community as their sole advertising vehicle. Why bother talking to mothers when doctors made the nutrition decisions for their babies? By making sure their products directed women back to the doctor for guidance, the infant formula makers provided a steady flow of income for the physicians. They further engendered physicians’ goodwill by sponsoring scientific conferences and research on infant nutrition. Doctors retained their role as the undisputed advisors on infant health and feeding, despite their limited medical knowledge on lactation, while simultaneously providing product referrals for formula purchase and serving as a credible advertising source.
At the same time, big changes in how women gave birth were taking place, which would influence how mothers fed. Remember, for years birth was considered a normal physiologic process; women did not need a doctor with special skills in order to give birth. Delivering babies was viewed as the work of midwives. Obstetricians were laughed at by other doctors for doing “nothing.” Giving birth may not always require a doctor, but there is pain. As the women’s rights movement picked up steam, in 1913 two wealthy American women took up the cause of urging other women around the country to battle for their right to a painless childbirth, in the form of Twilight Sleep—a way of giving birth in a heavily sedated state that had been developed in Germany. A woman simply woke to a baby—with no memory of the labor of birth. Two female reporters from McClure’s Magazine in New York, who had been previously denied interviews by German doctors, hatched an undercover plan to send a pregnant friend to Freiburg, Germany, to have a Twilight Sleep birth. The women, staunch feminists, planned to make Americans aware of this “miracle” discovery. The three women decided to liberate American women through Twilight Sleep, urging them to rise up against the oppression of medical men. The 1914 article sparked a call to action among feminists, making the right to a painless birth a key women’s rights issue. Feminists saw maternal health care as a significant area that needed improvements. The only problem was that feminists focused on the pain and discomfort of the labor of childbirth. In their minds, the pain was the problem, and freeing women from pain meant liberation from men. Among anti-feminists, the thought was that Twilight Sleep would encourage upper-class women to have more babies. But the pain of laboring was nothing compared with the so-called solution. The sedation of Twilight Sleep was created by two powerful drugs, morphine and scopolamine, which didn’t suppress pain but created retroactive memory loss with psychotic side effects. Yes, women woke up with a baby and no memory of the pain of childbirth. But the comfort came at a cost. They also did not remember the psychotic fits and thrashing that were common with these drugs, causing injuries to their heads. So their heads were wrapped with blankets or towels to cushion the blows. The drugs caused women to attempt to claw at the walls or their medical providers, so they were put in straightjackets or their wrists were strapped to the beds. Then, so that they would not fall out of bed, they were put in “labor cribs” and were allowed to go into labor, screaming, tied down, blinded and bound—often in their own urine and feces, and sometimes for days on end, until it was time to give birth. The women had no memory of this. Husbands were not allowed in to see their wives during this era so they didn’t know what was happening. Yet, when the woman awoke, everyone was happy. With the advent of Twilight Sleep, the practice of obstetrics suddenly became complex. Every woman desiring Twilight Sleep had to be hospitalized, anesthetized for days, and monitored closely by a doctor in order to give birth. This was a dramatic shift: birth went from being primarily an event with minimal medical intervention to an event that required days of medical and pharmaceutical supervision. The job of delivering healthy babies shifted to the job of removing pain, avoiding death from drug-related complications, and keeping visible bruises to a minimum. Instead of midwives or regular obstetricians, women needed specialized doctors in order to have the birth experience they wanted. Despite doctors’ antipathy toward Twilight Sleep and their outrage at women’s demands, Twilight Sleep was an avenue for the attention and respect that previously eluded obstetricians.
Most U.S. doctors were anti–Twilight Sleep and angry at the avalanche of demand from women’s magazines like McClure’s, Reader’s Digest, and Ladies’ Home Journal. While the media raved, the 1914 New York Medical Journal warned that doctors were being rushed into “indiscriminate administration” of a procedure “tested and found wanting.” But the speed of demand was unstoppable, as the popular media simultaneously presented onl
y huge local successes. Between 1914 and 1945, America became a Twilight nation. Movies such as Science’s Greatest Triumph were shown throughout the U.S. and the National Twilight Sleep Association was formed. With enormous public pressure and potential loss of clients who were switching to doctors offering the “Freiburg Miracle,” hospitals from New York to San Francisco began scrambling together Twilight Sleep units. The pressure continued until one of the movement’s staunchest advocates, who organized rallies for the procedure, died during her Twilight Sleep childbirth. Although there had been numerous women who had died under Twilight Sleep, the woman, Frances Carmody, was the wife of a Brooklyn lawyer. Her husband and her obstetrician assured everyone that her death had nothing to do with Twilight Sleep. But with a key organizer of Twilight Sleep dead, likely because of the procedure itself, support for it began to fall apart.
The Big Letdown Page 3
