A breastfeeding dyad is a beautiful, fascinating, complex organism. Mother and bab(ies) attend and respond to one another facilitating nourishment, the flow of hormones, immunity, learning and bonding, comfort, fun, an all-encompassing sensory experience that has generational impacts on social, emotional and physical health.
In this intimate depiction of a breastfeeding dyad, a world of collaborative intricacies occur: the undulation of baby’s tongue to help with milk removal, the contraction of myoepithelial cells thanks to oxytocin elicited by baby, the removal of milk to signal mother’s body to produce more, to name a few.
It’s clear that breastfeeding is so much more than “the healthiest feeding choice” nutritionally speaking. Take the following anecdotes for example.
Nikki Lee offers her commentary to this case report on infant botulism in an exclusively breastfed baby explaining how interactive feeding can save a baby’s life.
“One doesn’t have to ingest honey to contract botulism. Exclusively breastfed babies can get botulism. Some parts of the continental US have c.botulinum in the soil; construction stirs up the soil, and the germ floats in the air. The breastfeeding mother is the one to notice that the baby’s suck isn’t as strong. This is a reason that breastfed babies survive botulism, because they get diagnosed and treated sooner than bottle-fed babies.”
In this case, breastfeeding offered early detection of breast cancer in the mother because of her baby’s refusal to nurse from one side. This phenomenon is known as Goldsmith’s Sign.
To demonstrate the importance of the relationship that breastfeeding affords, we might consider the implications of separation. Lee again offers insight on the implications of mother baby separation in this piece.
Zooming out to view breastfeeding less individualistically and instead as a global food security system, we must recognize the collaboration necessary to support the breastfeeding dyad and abandon the idea that breastfeeding is a solitary act, a “one-woman job”.
In the U.S., WIC has created an interactive resource “to help reinforce the important role that family and friends play in supporting breastfeeding moms.” The resource invites WIC staff to “click through the prompts with parents, grandparents, and others discussing when and how to offer helpful support so that mom and baby continue to thrive.”
At an organizational level, the United States Breastfeeding Committee (USBC) uses a collective impact approach to manage multi-sectoral collaborations, working to protect, promote, and support breastfeeding and human milk feeding.
This week, in the body of the email, tell us: Who is your s/hero in the field of maternal child health?
Subsequent weeks will have a different prompt in the blog post.
We will conduct a new drawing each week over the 10-week period. Please email separately each week to be entered in the drawing. You may only win once. If your name is drawn, we will email a link with access to the learning module. The winner of the final week will score a grand finale swag bag.
Some days Susan Gold, RN, BSN, ACRN misses her ignorance. Since 2003, Gold has embarked on over 30 trips to various locations in East Africa where she teaches sexual and reproductive health and offers humanitarian aid.
Recalling one of her first visits to a clinic in Nairobi, Kenya, Gold describes a young mother, around 18-years-old, who arrived holding her severely malnourished infant against her breasts infected with such severe mastitis that her skin had split. This mother had been thrown out of her home for being HIV-positive and was breastfeeding and formula feeding her baby.
[Some background: Infant feeding has been complicated by the HIV epidemic. In the early 2000s, Gold explains that HIV-positive women were taught to formula feed to lower the risk of transmission to their babies, but with little to no access to clean water, babies were becoming severely ill. What’s more, in societies where breastfeeding is the norm, exclusive formula feeding is often an indication of one’s HIV status, which remains highly stigmatized. And formula is expensive, so many mothers choose mixed feeding, increasing the rate of HIV transmission, because formula irritates the GI system and gives the virus a pathway. By 2010, WHO issued new recommendations that stated that all mothers who tested positive should receive effective antiretroviral treatment (ART) which could lower risk of transmission during exclusive breastfeeding to virtually zero. In 2016, WHO extended the recommended duration of breastfeeding for HIV-positive mothers to 24 months. Effectiveness is dependent on consistency though, and Gold explains that mothers can develop resistance because there isn’t always access to ART.]
Gold was able to give the mother antibiotics, but the care that she and her infant required was beyond what Gold could offer. Considering the dyad’s condition and Gold’s limited resources, she says she’s certain that they died.
Reflecting on the suffering she witnessed and lives lost, that’s when Gold misses her ignorance most, but she says, “To know is to do.”
“For me it’s not a news story I can ignore, it’s names and faces,” she remarks.
Most recently, Gold spent several weeks in Dar es Salaam, Tanzania on a Nelson Mandela Fellowship Reciprocal Exchange Fellowship Grant where she partnered with Dr. Omari Mahiza, a pediatrician at Amana Regional Referral Hospital, focusing their efforts on combating pediatric malnutrition and education on family planning.
Gold has found that most Americans hold a “shallow view” of the continent. Her frustration with the stereotypes associated with Africa runs deep.
“It’s either starving children or a safari,” she begins. “It’s so painful for me to see that displayed so many times. There is such a tendency [in America] to dehumanize people who are not like us… We set ourselves as the standard. Their culture is not a failed attempt to be our culture. Success doesn’t have to look like us or be measured against us.”
Alongside her humanitarian work, Gold hopes to shatter the stereotypes, to bring awareness to the paradox of direness and vibrancy in East Africa.
Gold reminisces: “I love the African sun on my face, the bright colors and motion, the culture that is built around the family and friends, that you’re never expected to do it alone, the generosity of spirit, the sounds and smells, the warm welcomes and the optimism.”
Acutely aware of “an inherent imbalance of power” and the concept of White Saviorism, Gold uses the Swahili term Tuko sawa, which means “We are all the same”, as the foundation of her work.
We all want healthy children and families and a future with opportunities to provide long, healthy, prosperous lives, she expounds.
Beyond this core belief, Gold says that she always develops relationships with the people she works with.
“I educate myself on the origins and current status of their culture. I don’t tell people what to do, I share my experiences and expertise. I always learn from them.”
Doing more with less
Ingenuity is something she’s gathered from working alongside East Africans.
For instance, Gold was struck by the engineering of incubators for very sick babies at St. Joseph’s Hospital in Moshi, Tanzania.
If there is electricity, she explains, the heat is controlled by the number of light bulbs lit. The wood absorbs the heat, the aluminum components absorb and reflect heat, the mattress absorbs heat but also protects the baby, and the lid retains the heat but allows for monitoring of the baby. Mosquito netting is fashioned around the system.
A recent Lancet Global Health Publication, Revealing the prevalence of “hidden hunger”, released estimates of two billion people worldwide with one or more micronutrient deficiencies, noting that this is a gross underestimate. The hunger and deficiencies that Gold and her colleagues witness are rarely hidden and often quite obvious.
Gold observes that all of the women breastfeed in the low-income neighborhoods she visits.
The struggle, she says, is getting enough nutrition for the women to sustain milk production and have energy to feed their babies. During her most recent visit, Gold reports that almost none of the 35 families had food in the home.
Reporters of the new estimates for micronutrient malnutrition point out that processed fortified foods and micronutrient powders can be an easy answer to hunger, but they don’t create sustainability of local and indigenous foods and create conflict of interest issues with industry.
Gold adds that low income community members can’t afford to buy industry developed foods consistently. Lack of access to clean water is also a barrier.
“And you can’t depend on outside groups to sustain you,” she continues.
“We didn’t see any processed food at all because there is no market for it,” Gold says of visiting seven different neighborhoods in the low income region of Dar es Salaam. Instead, small markets with locally-grown fruits and vegetables prevail, but access to protein is a challenge.
As medically indicated, ready-to-use therapeutic food (RUTF) packets of fortified peanut butter issued by UNICEF are given out through health clinics. But Gold notes that sometimes parents sell these packets for money.
A challenge but not insurmountable
North of Dar es Salaam, in Moshi, Gold brings a portable printer that doesn’t require Wifi to the small hospital where she volunteers. She gifts each postpartum mother a printed 4×6 photo of herself and her baby.
“You don’t know how many of these babies are going to survive due to the high infant mortality rate.”
There’s a long moment of silence between us on the video call.
Then Gold expresses her frustration and anger, “The world can fix this, but chooses not to.”
She urges us to educate ourselves and others. Vote for people who have a vision of the world as one world, she says.
For those interested in making financial contributions or donations like baby clothes, children’s books, or toy cars, email Gold at email@example.com.
Follow Gold’s organization Talking Health Out Loud on Facebook here.
For an interesting discussion on Numeracy Bias, check out this episode of Hidden Brain. Numeracy bias is described this way: “…When you see one person suffering, you feel like, ‘Oh, I can do something for that person.’ But when you hear that a whole country has a refugee crisis, you tend not to get involved because you feel like, ‘Well, this is overwhelming. I don’t think I can do anything about this, so I’m not going to engage.’…It turns out that people who have experienced a high level of lifetime adversity are immune to this bias.”
Near the Amtrak Station in Milwaukee, there used to be an encampment created by people without housing. It went by the moniker “Tent City”. My kids and I used to pass by it often; and they had a lot of questions about the space and the people who stayed there.
I remember doing my best to explain homelessness to them. I attempted to answer their curiosities by posing questions back to them, to get a feel for what they understood. The conversation quickly led me to share what I know about mental health, drug and alcohol addiction, systemic racism, morality. I glanced into the rear-view mirror to find my young children, their mouths agape, eyebrows furrowed. I realized that what I had presented them with was like turning on the hose full-force and blasting them with a spray of freezing water.
Of course this framework confines us to a worldview shaped by the binary. Much of what I’ve come to understand about the human experience has been through the lens of maternal child health where very little, if not nothing is ‘black and white’.
That’s what I’m here to explore this week on Our Milky Way. In a way, these nuances remind me of ambiguous images or reversible figures where one individual may see one image and another makes out something totally different. For example, the German cartoon that asks, “Which animals are most like each other?” The answer is “rabbit and duck.”
Breastfeeding itself is a “rabbit and duck”.
“Breastfeeding refutes the cultural bent that breast’s primary function is as sex objects,” Chantal Molnar writes in Breastfeeding and Feminism. “America has an uneasy relationship with breastfeeding and has a hard time facing the duality inherent in breast’s function. Sex versus nurture, or sex and nurture? We don’t seem to have any problem with the duality of our mouths, which can be for sex and for eating. We do not make people cover their heads with a blanket when they are eating in public simply because the mouth is frequently used sexually.”
Similarly, Iris Marion Young writes in Breasted Experience that breasts are “a scandal for patriarchy because they disrupt the border between motherhood and sexuality, between love and desire.”
When Dr. Ricardo Herbert Jones, an advocate for the humanization of childbirth, spoke at the International Breastfeeding Conference several years back, he told this anecdote: An email was sent out to friends and colleagues with an image of a woman, but delayed loading revealed only portions of the woman– first her head, neck and shoulders. Her expression, most would have assumed she was amidst a sexual experience, but when the remainder of the image loaded, it showed the woman was giving birth.
A month after this conference, I was pregnant with my second child. Iris was born at home in the water, and I experienced an entanglement of intensity, euphoria, and empowerment, much like what was captured on the woman’s face in Dr. Jones’s anecdote. The sacred experience of birth is impossibly described as “either or”; instead birth is “both and.”
In Euro-American culture, the leap from what we have been accustomed to accept as normal birth– feet in stirrups, supine in a hospital bed, bellowing in agony (or not because of an epidural)– to euphoric birth, is almost inconceivable.
Kajsa Brimdyr has taken on the challenge of bridging this polarization and shows what is possible is her film Happy Birth Day.
The term “cute aggression” refers to the urge some people feel to squeeze or bite cute things, “albeit without desire to cause harm.” It can be categorized as dimorphous expression which “refers to someone experiencing a strong emotion of one type (e.g., happy or sad) but expressing the opposite emotion.” [Stavropoulos, et al]
Here’s an excerpt from the Reply All episode [full transcript here]:
Aragón started studying cute aggression in the lab — she brought in volunteers…
ORIANA: And I hopped them up on baby photos. [laughing] And then I- I know, it was actually really fun to run.
She showed people photos of animal babies, human babies, human babies Photoshopped to make them extra cute–
ORIANA: Large foreheads, big eyes, small mouths, big cheeks.
And then she measured how people responded with brain scans, questionnaires, and even bubble wrap — like, how many bubbles does a person pop when they see a computer-manipulated super cute baby?
And she’s convinced that not only is cute aggression real, but it actually serves a useful function for people like Marie who tend to get all can’t-breathe-can’t-think-conked-out by cuteness.
ORIANA: The people who were like, “Err, you know, I want to pinch it”, those people come back down off that baby high [laughs], you know, faster than the people who didn’t.
SANYA: Just having that aggression helps you come down off the baby high.
ORIANA: Yes, yeah, exactly.
“Baby high.” People – get ripped – on baby. That is weird to me; and it gets even weirder. Oriana said that sometimes a “baby high” makes the brain produce another contradictory-seeming emotion: “cute sadness.”
ORIANA: The corners of their mouth will go completely down and they’ll go, “Oooh” [SANYA: Oh yeah!] like they’re, like, so sad. [SANYA: Right.] And even their forehead wrinkles. Like, it was just like they saw the most horrible thing, so if you snapshot that and show it to people and you say, “What are they feeling?” they’re like, “Oh they’re overwhelmingly sad right now, and it’s like, “No they saw a cute baby.”
Okay so at this point I’m lowkey spiraling, because, like duh, of course I’ve seen people do cute sadness – even done it myself – but I didn’t realize that it’s supposed to be an involuntary reflex.
I thought we were all doing it on purpose. You know, making a conscious choice to communicate, “Yes, I see and acknowledge that your baby is, in fact, cute.”
Oriana is saying no, no, no — for other people it’s happening involuntarily; their brains are trying to emotionally regulate, because they literally cannot function due to the cuteness. And even though it seems like cute aggression and cute sadness are just random levers that the brain is panic-pulling, Oriana thinks that each of them is actually signaling something distinct to whoever is observing.
So imagine you’re walking down the street with something conventionally cute, like, I don’t know, a human baby, and someone comes up and smiles.
ORIANA: I know that there’s positivity within their smile, and that they’re probably going to treat my baby well and there’s a really nice social signal.
But cute aggression and cute sadness are better signals. Let’s say someone comes up and they’re all like, “Oh my god, I just wanna pinch your baby’s chubby little cheeks!”
ORIANA: That’s giving extra information that they want to be extra sort of playful and rev that baby up, and they want to sort of roughhouse with my baby.
Which, maybe you’re like, “No thanks, it’s not rev up time, it’s actually nap time.” But if someone comes up and they’re like, “Awwww what a cute baby”, in kind of a sad way, they like your baby too but they’re calmer and they’re probably aren’t going to mess up the nap.
ORIANA: You just wanna see it and sort of marinate in the cuteness [laughs]. And that’s what our research shows. And so it might be the reason why it’s been evolutionarily preserved because it’s just a really good signal. A smile doesn’t deliver the extra information of how you’ll interact with the baby.
SANYA: The smile is actually the poker face in all these instances.
ORIANA: Yeah, exactly, yeah, it’s giving less information.
So, cute aggression, says Oriana — it’s a societal glue, a communication tool.
We want to know where “both and” shows up in your perinatal experiences. Email us your stories at firstname.lastname@example.org.
Feldman Winter offers, “… We need to ask, ‘how do we better support breastfeeding among gender nonconforming individuals and nontraditional partners?’ so we don’t alienate anyone when it comes to breastfeeding. It starts with being more inclusive and acknowledging that the benefits of breastfeeding aren’t all tied to the concept of the ‘breast’ itself. Breastfeeding is a complex compilation of systems including biological benefits from skin-to-skin touching and nurturing; nutrients from human milk that can be breast- or bottle-fed; and benefits that come directly from the flora on a lactating/nursing breast.
There are multiple ways to look at breastfeeding and understand its benefits, Feldman Winter continues.
For instance “a chest that may not be able to produce milk can still nurture babies through the benefits of skin-to-skin contact,” she’s quoted in the NICHQ piece. “People who don’t produce breastmilk can still provide human milk through donor milk and bottle feeding. Transgender men and gender nonconforming parents and caregivers may still breastfeed safely if they choose to, and may prefer the term chestfeeding over breastfeeding because it respects their identity. All kinds of arrangements can be made to truly provide an equitable support system. As clinicians and scientists, we need to keep an open mind as we look at breastfeeding and explore how to optimize the health and well-being of all babies and families.”
The authors acknowledge that “Desexing the language of female reproduction has been done with a view to being sensitive to individual needs and as beneficial, kind, and inclusive.”
They go on, “Yet, this kindness has delivered unintended consequences that have serious implications for women and children. These include: decreasing overall inclusivity; dehumanizing; including people who should be excluded; being imprecise, inaccurate or misleading; and disembodying and undermining breastfeeding. In addition, avoidance of the term ‘mother’ in its sexed sense, risks reducing recognition and the right to protection of the mother-infant dyad.”
Heidi Brooks, Chief Operating Officer at NICHQ writes, “NICHQ is not abandoning the traditional use of the terms ‘mother’ and ‘maternal.’ We are embracing the inclusive language of ‘birthing person/people’ across our work. A move toward inclusive language does not force us to stop using language that so many people identify with; at its core, inclusion is about creating more space for one another. We are taking care to expand the use of these terms in our communications, on our website, in our resources, and eventually, in all our projects. This evolution is another aspect of NICHQ’s commitment to equity in all forms, including race, nationality, gender identity, sexual orientation, and ability.”
The Academy of Breastfeeding Medicine (ABM) put out its Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients in May 2020 to help guide lactation care providers through items like language, creating a respectful health care environment, through the effects of transition-related health care on pregnancy and breast/chestfeeding, fertility options, induced lactation and colactation and milk sharing, as well as put out a call out for future research to better inform practice.
Check out past Our Milky Way coverage on LGBTQIA health
FMCH works to empower families from vulnerable communities with actionable information and services, resulting in health seeking behavior and nutritious food choices in order to tackle maternal child malnutrition, ultimately breaking the cycle of poverty.
“FMCH India’s work empowers women – it gives confidence and encouragement to an FMCH field officer, adds to the skills and knowledge of a government frontline worker, and builds agency and support for mothers in the community,” Shruthi Iyer, CEO and Co-founder, FMCH India tells Our Milky Way.
Most recently, in the last year, FMCH “worked with close to 25,000 families, and recorded an increase in early initiation of breastfeeding – 74% from 59%… The national average is 57%,” documented in the latest Annual Report. What’s more, 70 percent of mothers started complementary feeding at the appropriate age of six months.
FMCH’s most recent annual report describes the success stories of health care providers and the families they serve. Explore them here.
Iyer says the way forward is to establish more direct interventions, build out indicators for their theory of change and to conduct more trainings for Anganwadi workers. (Anganwadis are rural child care centers started by the Indian government as part of the Integrated Child Development Services program.)
In the earliest Indian literature, the Vedas (a large body of religious texts originating in ancient India) recognize the life-giving powers of breastmilk.
Extolling breastmilk in modern India and globally, through programs like FMCH, is like the light over darkness during Diwali, the FMCH vision achieved: “Healthy mothers and thriving children for a world of unlimited possibilities.”