3: THE TIE THAT BINDS: MATERNAL MILK

"What art can a woman be good at? Oh vain!
What art is she good at, but hurting her breast With the milk-teeth of babes, and a smile at the pain."

--E. B. BROWNING, Mother and Poet.

Western societies are preoccupied with the sexual-esthetic function of the female breast. The true magic and beauty of female breast, however, lies in its power to lactate, the maternal attribute which enabled hundreds of species to survive down through the centuries. The word "lactate" derives from lactose, the sugar unique to mammalian milks. The word "milk," from the Latin mulgeo, literally signifies to press out by handling or softening with hand. Mammals are animals who nourish their newborn and young by secreting milk. This category of warm-blooded creatures which ranges from cow to anteater and from man to kangaroo. Other features such as viviparity, the bearing and bringing forth living offsprings, and the presence of hair are variable among mammals. The German word for mammals is, very aptly, saugetierua or "suckling animals."

Mammals are mostly born relatively immature compared with non-mammalian species and require considerable warm contact and maternal protection for survival. The mammalian mother is a sole supplier of food in the form of milk produced by breasts, glands which have evolved from the sweat glands over time.

Lactation is a complex act, governed by physical, psychological, social and, in the 20th century, by economic factors. Human breast-feeding has always fascinated mankind;myths, taboos and misconceptions abound around it making it a topic of genuine curiosity. The offspring of mammals vary widely in their maturity ranging from the eggs of the spiny anteater to the pouch embryos of kangaroos and to the more mature newborns of other species. The maturity of the newborn depends on the period of gestation. For example, rabbits and mice have a very short gestation period and their newborns are highly immature as opposed to grazing animals and dolphins, whales and seals which have a very long gestation period and the newborns are highly mature. Man is, however, unique in this respect. There is a long gestation period but the newborn is so immature, that he or she cannot even reach the breast unaided. Even a piglet at birth is smarter than a human infant in this respect.

The lactating apparatus in mammals has developed over ages and it varies from flattened breasts of seals and walruses beneath the blubber to the recessed teats in the whales which are accessible over a slit, to the protruding human breasts, perhaps to provide the newborn an easy access.

The number of nipples and their location on the breasts is related to the average number in a litter and to the size of the mother and its offspring. For example, in humans they are ready for twins.

The biologic evolution of suckling is quite diverse. For example, the spiny anteater lays a single egg which lodges in the deep depression in the mother's abdominal wall over which the loose skin closes. The newborn, less than one-half inch long, remains in that pouch after hatching. A unique "letdown reflex" pumps down the heavy milk.

A kangaroo gives birth to bean-size, blind newborns, after only three to four weeks of gestation. They migrate within the mother's abdominal wall to her pouch and become permanently fixed to a nipple until they mature. The pouch continues to provide the protective shelter even after the newborn has fully developed. Kangaroo milk is pinkish and it's high protein concentration allows the newborn to grow rapidly from about 50 milligram to 50 grams, a thousand-times increase in less than 50 days. The kangaroo milk thins-out as the newborn grows and its nutritonal requirements dwindle. Different nipples on the kangaroo produce milk of different composition. The nipple used by the newborn is different from the one used a few days later. The kangaroo also has a letdown reflex which pumps the milk into the little newborn.

The suckling mechanism of the blue whales has adapted to the high caloric requirements of the large newborn and to the cold environment in which it lives. Whales pump the highly concentrated milk to their calf in short spurts since the calf can remain under water only for a short period.

Japanese monkeys have an interesting breast-feeding pattern. Infants are born in the springtime and are breast-fed until autumn when the mother leaves the infant to enrich itself with roots, wild berries, and nuts to fill her needs and provide winter storage. However, when snow falls the infant gets back on the mother's breast. At that time the mother has not been lactating for several months when a unique double-cycle lactation begins.The human breast is a large gland which seldom becomes activated in childless women. It is lavishly supplied with blood and nerves which control the milk producing glands. In contrast to cows and goats, women have no cisterns or milk-containing pouches or terminal ducts to store milk.

The areola around the nipple contains many sweat glands producing secretions that provide lubrication, antibacterial effect and an aroma which, like the sexual attractant function of other body secretions, guides the nursing baby to the breast. According to the ancient Talmud, even a blind child could recognize it's mother's milk, by smell and taste. The Talmud even describes an experiment to determine the age at which a baby recognizes its mother.

Genetics and caloric intake determine the pre-pregnancy size of the breast. The hormonal changes before and during puberty markedly increase breast and nipple size, adding more fat, connective tissues and milk ducts. During pregnancy the number of ducts increases under the influence of many hormones. The nipple length and its ability to stand up also increases. The breast starts to secrete colostrum, a slightly yellowish liquid, in small amounts during the last three months of pregnancy and continues secreting for several days after the delivery.

During pregnancy and during breast-feeding, the breasts grow in size and pendulousness. The breast size seems to be more affected, however, by diet, pregnancy, aging and the physical support given than by breast-feeding. The size of the breast has no relation to its functional capacity. Interestingly, the Aboriginal Juangs of India consider small flat breasts ("tiger breasts") as the most effective milk producers.

Although the size of the human breast has no effect on its function, it is important when it comes to the sexual attraction of the male. There are, however, different norms in different cultures and at different times in history. "In the 1940's in America, the jutting, pointed uplift of the pin-up girls were considered beautiful. Compare the buxom women of the Ruben's paintings in the Middle Ages, the flat-chested flappers of the Roaring '20s and the more natural shape and lack of concealment favored in the '70s and '80s," write Drs. Derrick and Patrice Jelliffe in their book, "Human Milk in the Modern World."

Human milk is also a subject of many taboos. Is milk a drink or a body secretion? The teachings of Talmud, Aristotle, Galen and later philosophers of the Middle-Ages say that milk comes from the transformation of retained menstrual blood. The human child is quite immature at birth. Perhaps, we should consider 18 months instead of nine as the correct gestation period for humans. Labor occurs after nine months because the infant's head has grown to its limit of passage through vagina.

The first nine months after birth, however, are important to the maturation of the infant and it is only at that point that he should be "weaned" off the mother. The word "weaning" is derived from wenin which means to accustom. However, it's broad meanings covers the process of adjusting to mixed diet and discontinuation of breast-feeding. The French and Spanish languages have specific words to signify the separation of the infant from the breast. In France they call it sevrage. In Spanish it is destetar.

All animals wean their off-spring at a fixed time peculiar to their species, except humans who continue to drink milk, if not their own mother's, then that of the mothers of other mammals.

Religious teachings are often quite clear on the timing of weaning. For example, according to the Hindu and Jain philosophy, infants should be weaned when they start to teeth. The Koran lays down the dictum that mothers shall suckle their children for two whole years. According to Talmud, the suggested duration of breast-feeding is also two years. One Sage states that it could be prolonged till the age of four or even five. All Sages, however, agree that if nursing is stopped for a few days after the age of 24 months, it is inadvisable to resume. However, if the interruption was due to disease, nursing may be resumed. The legal implication of this statement is that if a woman, while nursing a baby, is divorced or widowed, she is not allowed to marry again till the baby is two years old, lest she become pregnant and be obliged to wean the baby. It is doubtful whether the second husband will be ready to defray the costs of the "milk and eggs" for the infant who is not his own...(Bab. T., Nidda, II, 3). To breast-feed is the duty of the woman towards her husband, recites Talmud. Accordingly, a woman who has vowed not to nurse her child can be forced to do so. If she is divorced, her husband will have to pay for the nursing, but she will be forced to nurse the child. If the father would not let his wife nurse her child, but she desires to do so, the decision would be with her (Bab. T., Ketubot, fol. 59 b.)Early weaning has many disadvantages that go beyond the immediate health of the newborn. It affects the mother as well. Early weaning exposes the newborn to risks of obesity, hardening and blockage of arteries, allergies to foods, nutritional deficiencies and many other diseases including, probably, the Crib Death Syndrome (Sudden Infant Death Syndrome) and emotional maladjustments. For the new mother, early weaning means delay in uterine adjustments, chances of early repeat pregnancies and reduced emotional contact with the child, all affecting her physical and psychological health.Increasing production of milk has long been a topic of curiosity for man. Rubens's painting, "The Milky Way" shows Hera Zeus, with an exuberant and premature letdown reflex intended for her son but giving rise to the starry phenomenon known as the Milky Way.

Eighteenth century English milkmaids used to recite this charming verse in the hope of increasing production:

"Cushy cow, bonny, let down thy milk,

And I will give thee a gown of silk,

A gown of silk and a silver tea,

If thou will let down the milk."

The importance of the letdown reflex is also seen in religious quotes. According to Hindu mythology, "May four oceans, full of milk, constantly abide in both your breasts, you blessed one, for the increase of the strength of the child! Drinking of the milk, whose sap is the sap of immortal life divine, may your baby gain long life, as do the gods by feeding on the beverage of immortality! (Sasruta, III,10). When the children of Israel behave badly, they deserve the malediction announced by the prophet,"Give them, O Lord, what wilt Thou give them, Give them a womb that miscarries and dry breasts" (Hosea, 9, 14. The New English Bible). But the righteous shall deserve the benediction given by Jacob to his son Joseph, i.e., the "Blessings of the breasts and of the womb" (Genesis, 49, 25). Many factors affect the letdown reflex of milk production, either increasing or decreasing it. Physical stimulation of breasts triggers substantial response and in this regard the human breast is an unusual organ.

Artifacts from the ancient city of Ur depict milkmen trying to induce milk in the animals and even today a large number of measures are available for increasing milk production in mothers. These include hormones, nutritional elements, calming agents and mechanical techniques.

Herbs are effective in stimulating milk production, the modern medicine is beginning to recognize. Today, however, the use of herbs remains anecdotal but widely prescribed in some cultures. For example, sesame-seed cakes are reportedly used in Mexico to increase milk production in nursing mothers. Dehydrated "ixbut" or forage meal contains a very high concentration of calcium, an important dietary requirement for lactating women.

Several appetite-stimulating herbs have the reputation of increasing milk production. These include anise, fennel, goat's rue, star anise, and cotton seeds. Mothers in India cook fresh leaves of coral tree in coconut or goat's milk in and use it as health tonic to increase milk production.

In many parts of the world mothers chew herbs and beans for their hormonal activity to stimulate milk secretion. Examples of these herbs include peanut, garbanzo bean, coffee, licorice, rose of China, alfalfa, and olive.

According to Talmud, a woman who nurses her child eats more than normal, but she should not eat things that can have a bad influence on the milk. Some of the cited foods can cause the milk to become turbid, while others inhibit lactation such as: cuscuta (or hops), some herbs or lichens, little fishes, pumpkin, quince, green dates, and some sauces (Bab. T., Ketubot, fol. 60b). Throughout antiquity, special attention was given to the diet of the nursing woman prohibiting seasonings and most vegetables. One Sage suggested wine was good for the milk (Bab. T., Ketubot, fol. 65b).

Europeans use stout beer to stimulate milk production because fluids are good in themselves and the small quantity of alcohol in the beer tranquilizes the mother.

Lactation is inhibited if the mother is emotionally upset. Several plant compounds such as celery, holy basil (tulsi), and rauwolfia reduce anxiety and thereby increase lactation.

During the Renaissance nursing mothers were relaxed by soothing music. Peasant farmers of India and elsewhere recognize that the milk yield decreases if the cow or buffalo is upset or apprehensive or is milked by a stranger therefore, they try to induce a tranquil state by showing the cow a model calf made of stuffed skin.

Folklore is full of suggestions to stimulate milk production by applying herbal preparations to breasts. It is uncertain whether the effect is due to herbs or the stimulation of breasts. For example, older literature reports using plant poultices covered with heated stones to induce lactation in a 16-year-old virgin, and infusion and massage of plant ash into a breast incision, to induce lactation in a 20-year-old woman who apparently had weaned her two-year old child a month earlier.

An African case study reports that grandmothers who had allowed their grandchildren to suckle for the purpose of comforting were able to breast-feed the infants. Even in recent literature there are reports of lactation in childless women using massage, a heat lamp, spa, or a breast pump. A survey of American and British Commonwealth women shows most women stimulating their breast nipples by infant suckling, nipple exercises, and breast pumps.From the maternal viewpoint there are three acts involved in reproducing: coitus, childbirth, and breast-feeding. A full understanding of female sexuality begins with the understanding of behavior in these situations. Undoubtedly, women have a more varied heritage of sexual enjoyment than men. There is quite a similarity between natural childbirth and coital orgasm from breathing to uterine contraction to emotional response. Likewise, similarities exist between lactation and coitus including uterine contraction, which occurs both during suckling and sexual excitement. Breast stroking, nipple stimulation and erection occur both during breast-feeding and sexual foreplay. Emotional arousal in both sexual contact and breast-feeding increases flow of blood to the skin and a raises skin temperature. The ejection of milk itself is a reflex triggered not only by breast-feeding but also by sexual excitement. Masters and Johnson have observed it for the first three months after delivery. Nursing mothers, when relaxed, are easily aroused and have enhanced sexual libido.

Unfortunately, Western society seldom recognizes the sensuous nature of breast-feeding. Fixed schedules in breast-feeding the newborn is a glaring example of our ignorance about maternal emotions. Most people would concede that it would cause coital frigidity if the sexual act is practiced only at scheduled times. It should, therefore, not come as a surprise that women fail to lactate when required to do so at fixed time intervals.

Breast-feeding is not a mere mechanical fueling process but a psycho-social communication, a behavioral exchange between the mother-baby duo. Breast-feeding is a highly complex process controlled by scores of hormones, psychological factors, and physical development of infant and mother. For example, unlike other mammals, human milk rapidly dries up following the shock of unpleasant news and the crying sound of a hungry baby is often all it takes to start milk flow in a lactating woman, even if she is not the mother. Some interesting anecdotes are also found in Talmud. A woman who nursed her baby suddenly died and her husband was too poor to defray the costs of a nurse. It then happened that his breasts filled up with milk and he nursed his baby himself (Bab. T., Shabbat, fol. 53b). Similar cases were reported by Aristotle, Albrecth von Haller, Hunter von Humbold and others.The survival of infant mammals depends not only on the presence of the mother, her ability to secrete milk but often on presence of a highly elaborate social system where the male protects the female during pregnancy, labor and subsequent periods while milk flow establishes. Mammals of all kinds, elephants, dophins, baboobs and man, need the supportive help.

This social system also includes female assistants--doulas--who assist during the birth process and after to take care of the newborn. The doulas also teach and provide emotional support.

Suckling is a two-way process and is mostly the result of instincts and reflexes. In higher mammals such as man and monkeys, it is less instinctive and learned either from doulas, or by observation and example. In 1920, two zoo-born chimpanzees died of starvation because they didn't know how to nurse and apparently the mother was also unaware of her role. Based on this incidence, when a gorilla gave birth in a California game park in 1974, she was shown films of gorillas nursing and this immediately helped her to adopt the nursing process. During the past 125 years, patterns of infant feeding have continually changed. Before the Industrial Revolution, breast-feeding was not only a normal female function but also an economic necessity. The Industrial Revolution brought rapid urbanization. The family structure altered as the family ties of rural society were fragmented into the more isolated families of the town. The roles of men and women changed. More women became factory workers altering their role once and for all. The feeding of young children and nursing became difficult resulting in fewer and fewer mothers opting to breast-feed.

During 1910-1960 in America, about half of the infants were nursing until age one, while in 1967 only one out of four newborn babies were breast-fed on leaving the hospital. The decline in breast-feeding was due to the same forces that followed in the Industrial Revolution, reinforced by some newer ones. For example, various feminist movements developed at the beginning this century initially involved the socially well-to-do. These movements suggested family planning, woman's equality in the job market and sexual equality with men. All of these led to the distraction of women from their essential role in rearing children. "As with cigarette smoking, bobbing the hair and the contraceptive diaphragm, the feeding bottle was often visualized by the "flapper" of the 20's as a symbol of such liberation and freedom," comment Drs. Jelliffe.The rise in bottle feeding also meant that the sexual-esthetic role of the female breast overshadowed its role in feeding infants. This lead to increased emphasis on breast-feeding only in privacy. Also the general concept of cleanliness and avoiding all body secretions made breast milk appear messy or "exuvia" in anthropological terms, which can be "noisome to ones clothes."

The rapidity of changes in breast-feeding trends are best studied in migrating populations. For example, breast-feeding is quite popular in Pakistan. However, the Pakistani women emigrating to Britain in the 1950's, soon adopted the feeding style of native English women. Bottle feeding symbolized for the emigres the new way of life and also appeared to be more economical and hygienic.

Another reason breast-feeding declined in America was the lack of information and examples available to young mothers of America in contrast with other societies where the extended family unit is still traditional. The new mother today wishes to return to her chores, domestic as well as professional, as quickly as possible, ignoring the physiologic and psychologic needs of the infant and of her own body.

It is not uncommon in many Eastern societies and under-developed countries for women to feed their siblings on their breast. This results when childbearing is prolonged and older daughters start bearing children while their mothers are also procreating. It is not uncommon then for the new mother to offer her breast to her infant brother or sister. Also, in many African societies, women feed animals on their breasts, such as deerlings. Also in many societies where tunics are used it is not uncommon to see two infants feeding simultaneously on the two breasts. All of these practices point to a more casual approach--a more natural approach toward making the best use of a body organ.In recent years in many Western countries, especially the U.S., there has been a trend towards "naturalism," ranging from yuppies to "flower children." Regardless of whether these movements are transitory or permanent they are all headed back to nature in what Drs. Jelliffe call a "curvilinear compromise."

Nowhere has this "naturalism" been more apparent than in child-birth and rearing. The Lamaze Technique of natural child-birth, home deliveries, back-carrying of babies, home-made weaning foods and, most of all, return to breast-feeding exemplify this "naturalism."

There seems also to be a more relaxed, natural attitude towards female breasts. In this country our puritanical attitudes kept breasts hidden and gave them an unnatural mystery. About 10 years ago, a woman was arrested for breast-feeding her baby outside the John F. Kennedy Center for the Performing Arts. Today, on television and in movies it has become more fashionable to show female breasts, nursing or otherwise, and the "bra-less look" rather than the cantilevered appearance of 1950s, has become more acceptable.

Advice given by "Dear Abbey", a few years ago, sums up the changing trends: "Breast-feeding a baby is natural and beautiful, but if you have a choice, do it privately. If you do nurse your baby in public, wear a shawl that can be lightly tossed over your bosom while your baby nurses and be as inconspicuous as possible." The teachings of religion however, could be very different. According to Talmud, if a woman nurses her baby in the street, this is a shameful and scandalous deed, and her husband could claim for divorce (Bab. T., Gittin fol. 89a).American attitudes still differ sharply from those in Europe, where open breast-feeding is proper. In Europe they call it breast-feeding, in the U.S., it is nursing. To most Americans breast-feeding in public is not as natural as it is to Europeans. "A lot can be said about this transatlantic coyness," write Drs. Jelliffe.

How siblings and husbands accept breast-feeding is another story. Most siblings feel curious and somewhat jealous in the beginning but if the situation is properly handled by the parents they soon overcome both. For husbands, though it is extremely convenient not be part of night feeding, there is indication that some jealousy develops. Some men find it difficult to see this baby seize their wife's breasts. However, this jealousy usually subsides as the father-child bond develops.The most common excuse for switching to bottle feeding is the inability to lactate whereas it is the convenience of the bottle that makes it easier for a woman to give up than to breast-feed. Indeed, the bottle has become the 20th century wet-nurse.

Wet-nurses, or women who nursed other women's babies were popular during the Renaissance when women of nobility sought relief from what they considered a burdensome chore. The religious books frequently mention wet nurses. Prophet Mohammad was sent for nursing for two years before returning to his parents. When the child Moses was found by Pharaoh's daughter, Miriam speedily called for her mother and said unto her: Take this child and nurse it for me And I will give (thee) thy wages (Exodus, 2,9).

Also, if a woman has given birth to twins, she cannot be forced to nurse both of them. She should nurse one and a nurse should be hired for the second child (Jerus. T., Ketubot, V, 39). And if ye wish to give your children out to nurse, it is no sin for you, provided that ye pay what is due from you in kindness" (Koran 2:233).Medical scientists believe that 90 percent of women should be able to breast-feed adequately if properly trained, nutritioned and motivated. Numerous voluntary groups around the world are now helping to make childbirth and infant rearing a natural process (appendix 3.1). The importance of these groups to new mothers cannot be over emphasized. These volunteer groups publish useful literature for mothers. For example La Leche League proposes to begin breast-feeding immediately after birth witholding all other foods for at least six months. They also recommend breast-feeding for as along as mutually agreeable between mother and infant--from one to three years.Statistically, impoverished or malnutritioned societies rely more heavily on breast-feeding than prosperous societies. Since the health of the mother has a lot to do with the nutrition she can provide her infant, preparation should begin well before the baby arrives. The whole process of Pregnancy and lactation are extremely hard on the health of women and it is hardest on those who can least afford it, such as in the Third World countries. Ironically Western woman is better prepared to accept this rigor, but she chooses not to.

Fortunately, breast-feeding is gaining favor in many industrialized countries. In the United States, the proportion of mothers initiating breast-feeding was around 25 percent in 1970 and around 50 percent in 1978. More mothers are feeding for longer periods than ever before. Mothers breast-feeding for five to six months has risen from about five percent in 1971 to about 21 percent in 1978. Comparisons of Caucasian white women with black women show a decidedly higher rate of breast-feeding in white women. Women with higher education have the highest rate of breast-feeding.

In developing nations such as Bangladesh, India, and Haiti breast-feeding is very popular and practiced for up to two years. In India, about 50 percent of urban poor women breast-feed for up to two years. This percentage and duration of breast-feeding declines with affluence. In with educated and prosperous women weaning their infants much earlier. It is interesting and ironic at the same time that while the affluent in developing nations are turning to bottle-feeding, their contemporaries in the already developed nations are returning to breast-feeding.

Contrary to popular belief, prevalence of infant formulas has not affected the decisions of Western woman on how long, or if at all, to breast-feed. Some claims exploitation of poor populations of the world by the infant-formula manufacturers but it has never been proven, despite some mishaps because of deficiencies in the formulas. In all instances the formula manufacturers responded quickly to rescue. However, no shortcomings, albeit unintentional, are acceptable when it comes to providing nutrition for infants. Though some have gone overboard in chiding the formula manufacturers, some adominishing is in order.Since human milk is not a commercially salable commodity, most people do not consider it a food. As a result, the economics of milk trade have not been worked out. How much is a gallon of human milk worth, few of us can answer. However, in Britain in 1973, a pint of expressed breast milk sold to newborn nurseries for the equivalent of 22 cents and one woman reported to have earned $1,500 during one year supplying a bank with breast milk not required by her own baby.

More interesting statistics and suggestion came from Indian researchers. Cattle in India produce only 65 gallons of milk per year whereas even the poorly nourished Indian women can secrete almost 55 gallons in the first year of lactation. Why not organize milk trade for the two hundred million lactating women of India. Even though the idea seems bizarre at first, it is no different from selling blood or sperm. The Indian women, or for that matter, women around the world can generate a substantial financial resource for them. In India alone, it would amount to several billion dollars worth of product, much of it exportable to earn the valuable foreign exchange. The economics aside, sharing milk is perhaps the noblest of all philanthropic activites. All women should consider this.Maternal milk and the organ which produces it form the vital link of life. Understanding the intricacies involved in this link can only improve the health of the newborn and the mother. There is a dire need to educate prospective mothers, a difficult task because of the deeply embedded misconceptions, stereotype thinking and prejudices, both religious and social. In America, we need to cultivate a more casual approach to human milk and human breast if we are to see this complex problem solved.

APPENDIX 3.1WORLDWIDE VOLUNTARY SUPPORT GROUPS FOR NEW MOTHERS

Ammehjelpen, Postboks 15, Holmen, Oslo 3, NorwayArbeitsgruppe und Dritte Welt, Postfach 1007, Bern 300, Switzerland.

Association for Improvement of Maternity Services, 61 Dartmouth Park Road, London NW5, UK.Baby Foods Action Group, 103 Gower Street, London WC1E6AW,

UK.Center for Science in the Public Interest, 1779 ChurchSteet N.W., Washington, D.C. 20036 USA.

La Leche League International, 9616 Minneapolis Avenue,Franklin Park, Illinois 60131. USA.

National Childbirth Trust, Breast-feeding Promotion Group, 9 Queensborough Terrace, London W23TB. U.K.

Nursing Mothers' Association of Australia, 99 Burwood Road, Hawthorn, Victoria, Australia 3122.

Nu Nu, ArgentinaPPI, Malaysia.Parents Centers of Australia, 148 Hereford Street, Forest Lodge, N. S. W. Australia 2229.

International Childbirth Education Association, 2763 NW 70th Street, Seattle, Washington 98167. USA.

Singapore Breast Feeding Mothers' Group, Singapore.War on Want, 467 Caledonian Road, London N7, UK.