In 1978, Tennessee was the first state to pass a law requiring infants to be placed in an infant restraint system while driving in a car.  I don’t know if it caused an uproar or not, but as the years have passed, we’ve grown to realize exactly how important that decision was.  Within a few years, all other states had followed their lead[1] and nationwide we now see a 70% reduction in infant deaths from traffic accidents[2].  Given that children are regularly in cars these days, the reduction is even more remarkable.  Although I was unable to find exact numbers for nation-wide statistics, certain state statistics were available.  In Tennessee, over a six-year period from 1978 to 1983, 81 children under the age of 4 died in traffic-related accidents and 79 of them were not wearing restraints[3].  In Washington State between 1970 and 1979, prior to the implementation of a law requiring the use of infant car seats, 148 children aged 0 to 4 were killed, 146 of them were unrestrained[4].  A rough extrapolation to all 50 states might suggest that over a 10-year period, there were approximately 7,400 children under the age of 4 who died most of whom need not have.  That’s 1850 infants under the age of 1 (for the sake of an argument, assuming they’re equally distributed).  No wonder everyone today is on board with infant safety and laws requiring everyone to use infant restraint systems.  In fact, if anyone so much as suggested that we get rid of these laws, there would be riots in the streets, right?

But here’s the thing about this article, it actually isn’t about car seat safety at all.  It’s about breastfeeding.

Almost a year ago, Gisele Bundchen made a comment that there should be a worldwide law requiring mothers to breastfeed for the first six months of their baby’s life and took an amazing amount of heat for it[5].  She was criticized by many for suggesting such an outlandish thing – after all, isn’t the way we feed our babies our choice?  And while a law wouldn’t work for those who simply cannot breastfeed (though many laws have loopholes for situations where it simply is impossible to follow), I think she’s not horribly wrong in her comments, but I’m not supposed to admit that.

Hear me out: Sometimes laws have to change before we see the societal changes needed to make things happen.  Should breastfeeding be mandatory or legalized?  No.  But it’s ideas like this that sometimes force people to look at what’s broken in a system and try to fix it, which is why they are worth discussing.  If it’s so important that we talk about legalization, well, what measures need to be in place to make that happen?  Then we get to ask: Why not just put those measures in place for families to take advantage of?  Or why not make some changes that would allow people to think realistically about the societal effect of the push for formula, like prescription formula or making breastmilk banks more widely available or even more publicity for milk sharing or even just abiding by the WHO code to restrict the marketing of formula.

Last year, the Obama administration signed into law the Affordable Care Act which included provisions for mothers to pump at work in an effort to get more infants breastmilk, a good start if we want to see change for families looking to breastfeed.  In the UK, some hospitals are now ending the practice of providing mothers with free formula in order to try and increase breastfeeding rates[6].  Compared to other countries, the US and UK lag rather far behind on the breastfeeding scale.  For example, the percentage of women who ever breastfeed in Norway is 99%, in Brazil is 97%, in Mexico is 92%, and in Canada is 90%[7].  Why does this matter?  Outside of the benefits for general health and intelligence discussed elsewhere (see here), it has strong implications financially and even stronger mortality implications for infants.  A recent analysis of the cost of the lack of breastfeeding in the USA found that if 80% of mothers exclusively breastfed for the first six months, as per the World Health Organization’s recommendations and what Ms. Bundchen took so much heat for suggesting, the US would save $10.5 billion dollars per year and 741 lives, nearly all of which would be infant (< 1 year) lives[8].

I’m going to repeat that: $10.5 billion dollars and 741 lives.  If you can get the number to 90%, it becomes $13 billion dollars and 911 lives.

How is this?  Well, those are the numbers based on the diseases we know formula increases the risk for.  Even in our modern, Western, medicalized world.  These are numbers based on US families doing US things with US health care.  Because as much as people like to say that there aren’t really effects of using formula, at a population level there are.  (Remember that the population and individual level are very different things.)  And as such, even with all our advancements, the proliferation of formula use is killing babies.

If you compare these numbers to those of infants who died because of a lack of restraint in car seats, it’s four times the number of lives saved in that age group – approximately 1850 infants under the age of 1 in car seats, and 7400 infants, most under the age of 1, for breastfeeding.  And yet, as a society and even on an individual basis, this doesn’t seem to concern us.  If you ask the same person whether babies should be able to sit in a car unrestrained and whether society needs to do more to increase the number of women who breastfeed for six months, you’ll probably get equally emphatic no’s to both questions, yet the lives saved are greater in the second case.  Now, one might argue that the numbers for car deaths would increase as we use cars more than we did when the first analyses were done in the 1970s and 80s and I’ll happily agree to that.  But those deaths would have to quadruple to hit the level of deaths that are occurring because of a failure to breastfeed which isn’t the case – in fact, the US Department of Transportation has claimed that, “In 2008, an estimated 244 lives were saved by the use of child restraints”[22], far less than the number that would be saved by exclusive breastfeeding.

I have to ask: how did we get here?

For years, women simply breastfed.  And those who could not breastfeed for whatever reason had others in their community who would feed their child or, as society became more complex and industrial, they employed a wet nurse.  However, as wet nurses fell out of style, people started replacing breastmilk with animal milk, and this trend continued to rise after the invention of the rubber nipple in 1845[9]. But even in the early 20th century, breastfeeding remained the primary way to feed babies with other supplementation only occurring when necessary[10].  However, changes were taking place that would soon lead to the drastic decline of breastfeeding in Western societies we’re now trying to fix.

One of the most notable changes was the growth of pediatrics as a medical specialty.  While pediatrics first emerged in the mid-19th century with Arthur Jacobi being considered the first pediatric doctor[11], it took a while for this field to expand and take root in most communities.  The American Academy of Pediatrics wasn’t formed until 1930, and it has since exploded with membership increasing from 35 in 1930 to more than 60,000 today[12].  While the development of the pediatrics was great for the general health of children (as doctors learned to treat children as children and not adults), it seems that the effects on breastfeeding were less than desirable, despite the fact that the initial work that led to formula came from a need to have an alternate supply of breastmilk for babies that didn’t require moms (freezing storage of breastmilk was still not developed)[13].  While wet-nurses had been the go-to for the vast majority of civilization, they posed problems for pediatricians.  As wonderfully put by Kara Swanson, “[Wet nurses] represented the all-female world of practical expertise that the pediatricians were attempting to supplant with their scientific knowledge in order to establish themselves as a profession”[14].  Arguably then, the biggest side effect of this emergence of pediatrics was the scientific focus suddenly put on breastfeeding.  This was highlighted in 1922 by the development of a machine to powder human milk by two undergraduate students at MIT[15].  While this device itself posed no problems to breastfeeding, and in fact was developed to help preserve breastmilk for babies, it seems to have triggered the idea that milk should become a technology.  That science can do better than moms in what it creates.  The idea was that if you break it down enough, you can figure out what’s going on and then improve upon it.  And for a while there, doctors actually believed that science had done just that.  By the early 1970s, less than a quarter of women were breastfeeding at birth[16], with doctors and hospitals pushing the use of infant formula on new mothers (a practice which still continues today in some places) because of their belief that it was superior to mother’s own milk.  We now know this not to be the case, but the damage was done.

But it’s unfair to place the majority of the blame on doctors because they were simply responding to the needs of a time.  It is possible that eventually they would have become interested in breastfeeding and science would have taken its course and developed formula, but I’d be negligent to place the blame squarely on the shoulders of doctors and scientists.  They were simply responding to a larger problem that really can be seen as the foundation of the problem for breastfeeding – the industrialization of society.  You see, in the early twentieth century, standard medical advice was to breastfeed – all doctors were promoting it because they saw the deleterious effects on infants who were not breastfed.  However, more and more women were weaning their children early and being forced to put their infants on a non-breastmilk diet because of one major problem – employment[17][18].  Women had to work for wages and without community support, a wet nurse, or pumping, they had little choice but to find an alternative to breastmilk.  This had been an ongoing problem for some years and thus doctors were left with little choice but to begin the hunt for an alternative.  As with most aspects of parenting, the Industrial Revolution truly altered the way in which we approached child-rearing, starting with the most basic problem of how to feed a child when mom can’t be there.  Unfortunately, it perhaps would have been possible to fight the government at the time to push for better laws to help families, but there’s one more factor that needs to be explored: Women.

As far back as the Industrial Revolution, even middle- and upper-class women were opting for alternative means to feed their infants, against the advice of midwives and doctors at the time[19].  And this was not because they had to work, but simply out of a desire to return to activities they had previously been doing, putting forth the notion that breastfeeding is simply a burden.  By pushing so hard for an alternative, they let business avoid any moral or legal obligation to do what is best for a family and they let science take over the role of feeding their children.  It’s difficult to disentangle the role of women, doctors, and business during the mid-twentieth century as they all had strong interests in keeping babies formula-fed, but when we return to the debate today, it is very squarely centered on a woman’s right to choose how to feed her child and somehow this has led to fights against systems to help breastfeeding.

Today, the issue of employment rears its ugly head yet again.  Politicians and businesses continue to fight against laws that would force them to enact other family- and baby-friendly measures like extended maternity leaves or bringing baby to work allowances, all of which benefit mom and baby by more than just increasing breastfeeding.  I imagine they all believe it would be less “efficient”, if we want to go ahead and talk in euphemisms (which politicians always do), and they’d probably be so dramatic as to argue that the entire economy would suffer.  (Bullsh!t. Other countries with extended leaves do just fine, thank you very much.)  However, there were battles when states started implementing car seat laws.  In Tennessee, the law was enacted in 1978 and yet in 1983 only 30% of babies were restrained while driving[20].  Across the US, despite massive educational campaigns, only half of children were restrained in 1984[21].  But because of the importance of saving children’s lives and avoiding serious injury, those in charge continued to persist in not only passing laws requiring parents to purchase and install car seats, but in enforcing the law and educating parents about why this was so important.

We seem to have finally begun the educational campaign in favour of breastfeeding with some levels of success.  After all the damage we did in the mid-twentieth century, we’re just beginning to recover.  But it’s a long road, with no legal standing to help the infants who would benefit most from breastmilk, and as such it becomes a much harder sell than the car seat, despite the greater benefits.  In short, there are plenty of barriers to increasing breastfeeding rates and plenty of work to be done to improve them.  But by looking back as to how we got to this stage, hopefully we can see the folly in some of the excuses going forward and finally give all families the support they need to breastfeed or to obtain breastmilk for their babies.

 


[1] Margolis LH, Wagenaar AC, & Liu W. The effects of mandatory child restraint law on injuries requiring hospitalization.  AJDC (1988); 142: 1099-1103.

[2] Weber K. Crash protection for child passengers: A review of best practice. UMTRI Research Review (2000); 31: 1-28.

[3] Decker MD, Dewey MJ, Hutcheson RH, & Schaffner W. The use and efficacy of child restraint devices: The Tennessee experience 1982 and 1983.  Journal of the American Medical Association (1984); 252: 2571-2575.

[4] Scherz RG. Fatal motor vehicle accidents of child passengers from birth through 4 years of age in Washington state. Pediatrics (1981); 68: 572-575.

[7] Drago RD, Hayes J, Yi Y. Better health for mothers and children: Breastfeeding accommodations under the Affordable Care Act (2010). Institute for Women’s Policy Research: Washington, DC.

[8] Bartick, Melissa, and Arnold Reinhold. The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics 2009; 125: 1048-56.

[12] Ibid.

[13] Swanson KW. Human milk as technology and technologies of human milk: Medical imaginings in the early twentieth-century United States. Women’s Studies Quarterly (2009); 37: 21-37.

[14] Ibid, pg. 24

[15] Young WH Jr. & Sutherland KR. “The Design of a Machine to Powder Milk.” (1922) BS thesis, Massachusetts Institute of Technology.

[16] Wright AL. The rise of breastfeeding in the United States. Pediatric Clinics of North America (2001); 48: 1-12.

[17] Swanson KW.

[18] Galanakis E. History of breastfeeding and medical profession. The Lancet (1999); 354: 77-78.

[19] Swanson KW.

[20] Decker MD et al.

[21] http://www.thehistoryof.net/history-of-car-seats.html (Accessed June 16, 2011)

[22] http://www-nrd.nhtsa.dot.gov/Pubs/811346.pdf (Accessed November 14, 2011)

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