Breastfeeding in America

Isolation, pain and shame

My first round of mastitis (breast infection) started a couple weeks into my son’s life, and the infection settled deeply in my breast long before I had any idea what was going on. Night after night, I lay in bed on my right side, attempting to take pressure off my rock-hard left breast, shivering uncontrollably, unable to turn over or lift my left arm without searing pain. The breast pain resembled other infections I have had—the extreme rawness around an infected cut, for example—but it was expanded across half my chest and burst into flame with any small movement of any nearby body part. Notably, with me in this state, both my husband and I concluded that this was simply what breastfeeding a newborn was like. That this was our first instinct is insane to me now, but that’s how little we knew about breastfeeding, (and perhaps also points at how much we normalize a woman in pain). We made an appointment with a lactation consultant, but then my fever spiked to 103 and we called her to cancel, since it was clear to us that I must have caught COVID or flu somehow, despite having not left our house in over a week. The lactation consultant listened to my husband describe the situation and said flatly, 

“I can guarantee you that she has mastitis,” 

“Oh, okay…” I heard him say into the phone, from my position in bed under three blankets.

“I’m coming,” she said. Her assertiveness was like a golden arm reaching down into our dark and murky world, something we could grab onto, some beacon that might indicate to us how the hell to get out of here. 

She arrived that afternoon and pointed out the flaming red patch around my breast, then she put on gloves and squeezed the burning tissue while I yelled in agony. Drops of blood and pus oozed from my nipple. The idea was to move the infection through the breast and out, unblock the milk, and enable our son to suck out the rest of the infection as he fed. Because, that’s right, I had almost forgotten, throughout all this time there was a baby mounting my burning breast every couple hours and sucking on it, hard. My fever broke that night. That was my first bout of mastitis. There would be four more.

No one who saw me in that moment could reasonably argue that I was not willing to give every ounce of myself to try and breastfeed my baby. And yet, looking back, I cannot help think that I could have, should have, done more. 

***

There is an intense emphasis on breastfeeding in today’s medical culture and in many pockets of mom culture, like my own San Francisco mostly-white mom set. American hospitals, including the one where I delivered, are increasingly getting certified as Baby Friendly according to World Health Organization guidelines, which require that the hospital has practices in place for helping new moms to breastfeed—for example, discussing the “importance and management of breastfeeding with pregnant women and their families,” and enabling “immediate and uninterrupted skin-to-skin contact” after birth. In this pro-breastfeeding environment, breast milk can take on a mystical quality: it evolves with the baby to meet his nutritional needs perfectly at every stage of life, they say; it conveys protection against disease; it introduces him to new tastes that will shape his palette when he starts solid foods. Breast milk, I heard during my early weeks breastfeeding, is known to reduce the risk of infection and rashes in my baby, to develop his immune system, to increase our mother-child bond, and is also known to have cured cancer in one adult who drank breast milk smoothies. Separating fact and fiction in this context is, to say the least, difficult.

If I sound derisive about breastfeeding, I’m not. It seems to me that the return to a pro-breastfeeding culture after Nestle’s generation-long heist of baby nutrition seems to be unequivocally a move in the right direction. When I was pregnant and early postpartum, having reviewed what data I could manage, (we’ll get to this in a second), I really wanted to breastfeed, fully believing breast milk to be better than formula for my baby’s health. Among affluent moms—moms with nine or twelve weeks of maternity leave—it is rare these days to meet someone who isn’t planning to breastfeed, at least at first. Once in awhile, among my crowd, a story of a friend’s friend who used formula from day one would circulate, to be ogled at with surprise, or interest or respect-on-the-outside-but-reflexive-judgement-on-the-inside, the reaction I found myself having to such a story. I am startled and sad that, as breastfeeding became a topic in my world, I discovered some sort of implant in my brain, or so it felt, that automatically reduced breastfeeding issues to something probably minor—she stopped breastfeeding when she went back to work? She must not have cared much about continuing, my mind automatically concluded. “Breastfeeding is hard,” I had heard before trying it myself, but not that hard, I subconsciously filled in. Not hard in the way getting fired from a job is hard. Certainly not hard in the way death is hard.

It seems there is something about breastfeeding pain, unlike, say, breaking a leg, or losing a loved pet, that makes it difficult to conceive of as real and serious, at least for me, (and looking at our country’s treatment of breastfeeding moms, it seems like I’m not the only one). Even more alarming is that my reaction today to my own breastfeeding story, even after all of that trauma (and I don’t use the word “trauma” lightly,) is still that same one: respect-on-the-outside-but-reflexive-judgement-on-the-inside. The power of the breastfeeding narrative is that strong, the cultural minimization of the effort it takes to breastfeed is that potent.

***

I remember one day of peak pain, maybe five weeks after my son was born, where each breastfeeding session was followed by thirty to forty-five minutes of shooting pains emanating from my left nipple due to a condition called Raynaud’s. Raynaud’s causes the vasculature in the nipples to constrict and sends pain radiating outward. This pain is like hooking one’s nipple up to electrical nodes and applying repeated major electric shocks; it’s like lying on your bed getting stabbed in the breast with a long, thick needle. If this sounds a bit exaggerated to you, I can assure you that it does to me too, but I am forcing myself to put it down here because it is definitively not an exaggeration, and if anything understates the level of the pain that I felt. 

This particular day I had already experience multiple Raynaud’s episodes, and it happened that my nose was stuffed up from a cold. I used some saline nasal drops to try and clear it, which, for whatever reason, caused my sinuses to suddenly light up with searing, burning pain: a random, shocking, horrible pain to add to all the other pain. With my face on fire and tears leaking out of my eyes, I ran to the bathroom and turned on the shower to steam up the room—something, anything, to try and to help the situation. My eyesight started going in and out, and the burning in my face increased, and my breasts were hard as rocks and throbbing from the most recent mastitis, and I knew that in less than an hour I would once again feed my baby and be thrust into an extended episode of electric shocks, which I could only endure curled on my bed in the fetal position. I remember in that moment, standing in the steamy bathroom, having a feeling that my self had left my body, that I was a hollowed out body with eyes and limbs but no longer with any coherent being inhabiting it. I felt delusional with pain, like my mind had been occupied and erased, like I was a freakishly balding animal with bulging, yellowed eyes, driven mad in a tiny cage. Perhaps the most horrible part of the breastfeeding pain was the relentlessness, the fact that I knew the cause (breastfeeding), and I also knew that I would breastfeed again within the next two hours. In her essay The Pain Scale, Eula Biss writes, 

“The pain scale measures only the intensity of pain, not the duration. This may be its greatest flaw. A measure of pain, I believe, requires at least two dimensions. The suffering of Hell is terrifying not because of any specific torture, but because it is eternal.” 

My pain was not eternal, but was perpetual until I stopped breastfeeding, and that gave me a strong feeling of being trapped in something endless. It also put the pain fully in my hands; it was incumbent on me to make the decision to stop breastfeeding my baby and thereby escape the pain.

***

Even at a baby-friendly hospital, even in the San Francisco culture where breastfeeding is widely considered paramount to baby’s health, even after the hospital-provided breastfeeding class had emphasized how critically important it is to get the baby to latch onto the breast in the first hour of life, how studies show that this improves breastfeeding outcomes, no one helped me breastfeed my baby for the first time. I found myself, minutes after my delivery, swimming in hormones, faces around me blurry from the ordeal, calling up this important fact: I must breastfeed now, it is critical. I turned to the nurse, who was bustling down near my vagina, and said, 

“Should I try to breastfeed?”

“Sure, you can try!” The she said, and went about her routine business down there. 

I did not, having never done it, know where to start. 

Numb, flustered, I tried to move this new human toward the vicinity of my nipple. I felt acutely embarrassed, not knowing what I was doing, ashamed that I didn’t know how to do this, feeling like I had already asked for help with it and could not ask again, not thinking straight, and suddenly unclear about whether all the information I had received was real. Maybe it wasn’t that important to breastfeed now? I nudged the tiny body around my chest, never having held a baby this young, never having seen a baby this young. Nothing happened. My son lay on my chest, sort of next to my nipple.

***

My breastfeeding journey was particularly onerous—shortly after the events above, my son was rushed to the NICU for health issues, which were ultimately fully resolved, but which set us back significantly on breastfeeding. Over the following months I experienced five rounds of mastitis (bacterial infection of the breast), two abscesses in my breast (collections of infection that form a hard ball of pus), the formation of two benign breast tumors, and two dozen or more episodes of Raynaud’s phenomenon of the nipple. This was overlaid with an all-consuming anxiety about my baby’s weight as he struggled to gain the recommended amounts in the first few weeks. As crazy as my breastfeeding pain list is, it doesn’t include many common forms of breastfeeding pain that I mercifully escaped: the babies who latch on in such a way that it is excruciating when they suck, the cracking and shredding nipples, the milk oversupply and the resulting pain of having one’s body stretched to bursting. 

The void of available medical support for all of these ailments was truly stunning to experience. The extent of ongoing support available at my Baby Friendly Hospital was a nurse-staffed hotline whose function, in my experience, was to either prescribe or not prescribe drugs based on one short phone call. I was prescribed the anti-fungal drug Fluconazole via phone for an alleged nipple yeast infection, which ended up likely being not a yeast infection but Raynaud’s Phenomenon (both involve shooting pain between feedings), and, as it turns out, fluconazole is thought to worsen Raynaud’s. When I called the hotline to report chills early on in my first bout of mastitis, they told me it was probably fine, since I wasn’t running a fever. Later, once the mastitis was undeniable, they prescribed me three courses of antibiotics without so much as a physical exam. It seems that the Baby Friendly Hospital requirement to ”support mothers to initiate and maintain breastfeeding and manage common difficulties” is a bit loosely held. This, by the way, was the experience of a breastfeeding white woman, and therefore drastically understates the difficulty experienced by black women in America who want to breastfeed. Studies indicate that black women receive less help breastfeeding at the hospital, and the breastfeeding initiation rate among black women is just under 70%, compared with nearly 86% of white women.

Desperate, I did what so many affluent moms do: I paid for a lactation consultant, totaling over a thousand dollars, which is truly an insane way to get basic breastfeeding support. In my case, the consultant probably saved me from much deeper depths, identifying early a breast abscess from one of my infections, and referring me to a doctor who could drain it for me before it grew into something more damaging. 

“There are two doctors in the Bay Area who do breastfeeding medicine,” the lactation consultant told me, “Dr. Lee Char at Sutter and Dr. Fullerton-Stone, but she’s like 45 minutes south.”

Two doctors that do breastfeeding medicine? This must be an exaggeration, I thought, we are in San Francisco, but whatever, I had to get some help. I made an appointment with Dr. Lee Char’s office, and found that she is a breast cancer specialist with a breastfeeding side project. So that’s when I started driving across the city to the Sutter Health Breast Cancer Center multiple times a week. The shunting of breastfeeding problems into the breast cancer center is such a perfect encapsulation of the issue here, oh, breast stuff—that all goes over there, we like to keep that all in one place. My treatment at the breast cancer center at the very least was inconvenient, but more than that, it endowed my breastfeeding problems, and me, with an aura of disease, malignancy, morbidity.

***

Ok, so, like, is breastfeeding worth all this? At the end of the day, are the benefits worth the lengths to which I went? As I wallowed in the pain, I tried to figure this out, halfheartedly (most of my heart being busy with some other important stuff.) I dutifully read Emily Oster, the economist who has made her name giving moms the real-talk about pregnancy and early childhood data; I Googled a little; I let opinions from women around me float into my consciousness. One interesting thing is that, despite the ardent pro-breastfeeding context in which I existed, as I descended into my long breastfeeding struggle, I started hearing one thread of advice a lot: it is totally fine to stop; there are basically no long-term effects of breastfeeding anyways; that idea linking breastfeeding and eczema isn’t even real; the positive effects of breastfeeding that show up in the data are all short term; my friend stopped and was so relieved; everyone I know who had trouble breastfeeding and ultimately switched to formula wished they had done it earlier; Emily Oster determined that formula is totally fine for your baby. Basically, I heard a bunch of stuff that was all pretty much exactly opposing everything else I had heard, and it was impossible to answer the question of breastfeeding’s value when I was in the depths of the experience. Furthermore, I am one of a minority of women who even has time to look into it, and it seems that if delirious googling is the primary way these difficult decisions get made, then something is very wrong.

Now that I have had a bit more time to think about it, I actually do have a pretty strong view on the question of exactly how important breastfeeding is to your baby. My current view is: we don’t really know. I would personally bet on some real long-term positive effects, at least for some babies, but ultimately we haven’t spent the research dollars required to know definitively the magnitude of the long-term benefit. There is some data on the short-term benefits of breastfeeding, particularly supporting the hypothesis that breastfeeding reduces gastrointestinal issues and rashes in babies in the early months. There is a pathetic lack of reliable data and information on the long-term effects of breastfeeding, because they are hard to study and we have not prioritized this knowledge in our research. In other words, in my reading there exists neither a trove of data warning us to breastfeed at all costs (what I was told before delivery), nor relieving us from it because it doesn’t matter (what I was told once I was struggling). As with many things in medicine, we just don’t know. 

If I’m looking at this, personally, given that the short-term effects of breastfeeding seem to play out in the gut and on the skin, my own next hypothesis would be that these same systems could be affected in the long term, too. Or not. We don’t know. Or maybe breastfeeding is more beneficial for some babies who are predisposed for problems in these areas (seems likely), and doesn’t matter much for others. We don’t know. But since gut and skin are two body systems where I know I am personally predisposed to problems, having Small Intestine Bacterial Overgrowth (SIBO) and eczema myself, I would rather not gamble on formula in the early days, and I would have very much liked to exclusively breastfeed my baby longer than I did, in case it could help him. That’s just me, with my particular health issues, my particular orientation, my particular resources, my particular read on the current research (a layperson’s read, at that).

But I couldn’t breastfeed longer than I did (a little voice still says, well you could have, technically…), and I can’t ever know the impact of that. I will also, during my son’s life, take countless more actions that will affect him, and some will be positive and some negative, and some of my decisions I will have control over and some I won’t, and breastfeeding falls within this basket. But it is so scary to acknowledge that we don’t really know all the ways we are impacting our children, that it is tempting to tell a story that supports whatever our choices happen to be: if we’re breastfeeding, it is ultra-important to breastfeed; if we’re not breastfeeding, it doesn’t matter. There are also, I assume, so many ways I will unknowingly influence my child in a positive way, unknowingly strengthen him or expand his world or help to wire his nervous system for love. Or maybe most of our choices as parents don’t matter, as some nature-over-nurture believers will argue, citing twin studies. I would say that we just don’t really know. We have some directional indicators in the data, but it’s complicated, and we mostly don’t know.

***

There is one thing I do know for sure, though: it is absolute insanity and inhumane to create a cultural norm of breastfeeding and a narrative of formula-as-poison without an iota of public support for the work that a breastfeeding mother does. I delivered my baby in a major city at a top hospital, I paid for a breastfeeding class and a lactation consultant, I had six months at home with my baby, and I had some bad luck on the breastfeeding front and simply no chance of long-term breastfeeding success. Now tell a woman with an hourly wage and no maternity leave and a second child at home to breastfeed? Excuse me, but are you f*cking kidding me? It is delusional.

There is a common refrain that breastfeeding saves money, proclaimed in such places as the Department of Health and Human Services Surgeon General’s Report on breastfeeding: $1200-$1500 can be saved on formula in the first year alone! This is a deeply offensive statistic, as it values a woman’s time at essentially nothing, and erases completely the questions of her comfort and sanity. These numbers are regularly countered by estimating of the cost of breastfeeding hours, supplies and support, which easily outstrips the formula costs. But that’s so not the point. If we are even trying to measure the effort of breastfeeding in dollars and cents we are woefully far down the wrong path. Breastfeeding is an individual act of love towards our babies. Genuinely supporting breastfeeding mothers would be a national act of love towards mothers and children (which, at some point or another, is everybody). 

So where are we on this project, this act of love? The current Surgeon General’s Call to Action Factsheet on breastfeeding published by HHS suggests four things that policymakers can do to support breastfeeding mothers:

• Support small nonprofit organizations that promote breastfeeding in African-American communities.

• Support compliance with the International Code of Marketing of Breast-milk Substitutes.

• Increase funding of high-quality research on breastfeeding.

• Support better tracking of breastfeeding rates as well as factors that affect breastfeeding.

I would say, first of all, what the hell?, and second, um, I think supporting breastfeeding moms will require thinking just a tad bigger. How about we delete all four of those insultingly diluted bullet points in favor of guaranteed paid parental leave for every American parent, employee and contractor alike, the absolute most basic requirement to enable new mothers to breastfeed. How about federally funded dedicated medical and non-medical support for postpartum mothers. Look, I believed in all this stuff before I tried out breastfeeding for myself. But, dang, laying in one’s own bed in agony wondering how one will possibly endure the next attempt to feed one’s own baby—that experience certainly throws the absurdity of the status quo into sharp relief. It is a special type of cruel to set up hospital programs that emphasize the critical importance of breastfeeding to your baby’s health, to educate women on how damaging it might be to use formula, to set national goals for breastfeeding and call them “Healthy People 2020” (82% of babies ever breastfed, 61% at six months, 34% at one year), and then to send women home from the hospital after two days into a context where it is so literally impossible for most women to breastfeed as recommended. We are setting up women to fail by the millions. 

***

The instructor of my hospital breastfeeding class opened cheerily by saying, “my goal is to ensure that none of you go through a breastfeeding nightmare!” This encapsulates, I think, the standard (and very American) outlook on the whole thing: your breastfeeding success or failure is up to you, and a result of your actions, and if you just ace this class, you can ensure that you have no issues. In a country and system where there is so little support for breastfeeding women, where we frame breastfeeding as a personal project that each mom does herself, the main product of our emphasis on breastfeeding is likely not going to be a generation of happily breastfed babies, but a generation of shamed moms. It is institutionalized mom-shaming.

I wanted to breastfeed my baby for health reasons. But in a context where the benefits of breastfeeding are largely hypotheses, I think that there had to be something else keeping me going when it got so very bad, other than concern for my child’s health. It seems to me now that at each stage, I was subconsciously evaluating the physical pain I was presently experiencing against the pain of the shame I would feel if I stopped. This might be the best way to illustrate how strong that shame can be: by laying out the lengths I was willing to go to avoid it.

***

At six weeks postpartum, I had a routine OB-GYN appointment.

“How’s it going?” My doctor asked. I hesitantly listed off my breastfeeding struggles, and she typed them in to the computer, then looked at me. 

“Wow. Who is helping you with this?” She asked.

“I have a doctor at Sutter, Dr. Lee Char,” I replied.

“Ah, good, that’s who I send people to” she said, “OBs are just not trained in breastfeeding. Neither are the Peds.” She sounded sorry, like this was obviously a bizarre oversight. I would put it more strongly: that it is gross negligence perpetrated across all of medical education for two centuries.

She remembered something:

“There is one other doctor in the area, she’s a dermatologist but also does breastfeeding medicine. But she’s a bit far to the south.”

“Is it Dr. Fullerton-Stone?” I asked. 

“Yep,” she said, and we exchanged a look of sorrow.

***

How to sum up my experience of breastfeeding? It was one of tumbling exhausted into a chamber of pain without knowing where I was heading, and then realizing too late that every waking moment was agony and there was no way out; it was a slow dawning realization of being chained hand and foot alone in the bottom of a well where all the rules had changed and every movement was excruciating; it was an experience of being trapped in a maze of torture where every wrong turn opened into a new, even larger maze, with even more vicious contraptions of pain. But whenever I glimpsed an exit, I felt certain that leaving would be worse than staying.

Given this, given what I gave my son, given what I didn’t give him, given that I will never be able to solve that equation once and for all, the only answer that makes sense to me is to shift the frame of the breastfeeding conversation away from the faux-precise calculation of how much damage is done to whom. I can only make sense of my breastfeeding experience by viewing breastfeeding as a gift I gave my son, one of the biggest gifts I’ve ever given; I can only view his ability and flexibility to switch to formula as a gift he also gave me, how he broke me out of some of my most agonizing months. This is such a more gratifying way to think of that interaction, a deeply loving exchange of gifts, rather than a landscape of scarcity where everyone sacrificed exactly some portion of their health.

***

And yet, still, deep down, if I’m being honest, I tend toward the the other narrative, the one where I didn’t do enough. It is yet another example of how I can strongly believe one thing and at the same time, on an even deeper level, believe the opposite. I breastfed my son for two months, then switched to exclusive pumping and supplemented with formula, since pumping was less likely to trigger the Raynaud’s episodes. (Exclusive pumping, by the way, is totally awful and a whole other topic.) I pumped until he was almost six months, decreasing the pumping and increasing the formula throughout that time, and then I stopped fully. You can see that I saved the specifics of how long and how much I breastfed until the end here; I hold my breastfeeding stats close to the chest (no pun intended). In telling you, I still feel compelled to emphasize, once again, just how bad it was, how unbearable, and how it was worse than what you experienced, and thereby reassuring myself that I couldn’t have possibly done any more. 

What I’m really doing here, is I’m trying to ward off the shame.

Header image drawn by Stephanie Davidson, @asiwillit