Episode 27SN: How did We Get our Current Culture around Pregnancy & Birth: Ask the Historians of Science

Paulette: Hi, today I’m excited to welcome my guest, Dr. Judith Leavitt, who was the Ruth Blier Professor of History of Medicine history of science and Women’s Studies and the Associate Dean of Faculty at the medical school, University of Wisconsin Madison. She’s the author and editor of many books about women’s intersection with public health and medicine in America, and 2010 authored a book about changes over time and a father’s experience of birth. I feel lucky to get to talk to her today about how we find ourselves in the current birthing environment. Welcome Dr Leavitt. 

Dr. Leavitt: Thank you very much. 

P: So I’ve been reading your book brought to bed childbearing in America 1750 to 1950, which focuses on the experience of women mostly white middle class but it includes some details about immigrant women and women of color. These questions will all come from reading that which kind of blew my mind, in part because it’s shockingly relevant. Regrettably, so the first thing I want to ask is that in our not so distant past maternal mortality rates were super high, (accurately counting maternal deaths remains a tricky thing to do, even today, but according to dr leavitt’s book, she writes, “the statistics show that deaths from maternity related causes at eh turn of the twentieth century were approximately 65 times greater than they (were) in the 1980s”) and I’m wondering if women looked forward at all to start doing families like they do today or was the threat of their health, Overwhelming Do you have any sense of that.

Dr. L: I think women were very aware of the fact that childbirth was dangerous, and they were aware of it, not necessarily because they knew about national rates or any numbers around that but they did know and had experience with women who had difficulty, and had come close to death with childbirth and they also knew women who had died in childbirth or whose babies had died in childbirth, so they were certainly very aware and I’m talking now 18th century and 19th century, very aware that child birth was dangerous, I saw that worry very much in their writing. And let me say that I read women’s diaries and letters, for the most part to get their own point of view at the moment that it happened not and sometimes in the, in their memoirs and memories of past events but a lot of it was very current in their minds and they were very eager to have babies. They were scared, because they knew it was dangerous, and I think some of the choices that they made about what they wanted for their childbirth, had to do with that danger fright, that they had. But they were just enormously eager to have children. Also, and it didn’t seem to lessen that eagerness, the fact that it was dangerous, dangerous I think it did influence their choices, a lot, and one of the points of my book, I should say is that I think women’s choices is largely what drew changes in childbirth history over time, used to be thought that doctors kind of forced women into the changes that happen, and doctors certainly played an important role, especially in the 20th century, but my contention in my book is that it was women who made the choices that they made and they made them as you started out this conversation by saying because they were fearful that they might die or might get into some serious physical difficulty in childbirth. And those changes, you know, I always thought, unfortunately tended to medicalize childbirth more than it might have happened, traditional childbirth was an event that happened in women’s homes, and women were surrounded by women, other women who had had children, their mothers, their relatives, their aunts, their cousins, and their friends. And it was around that female birthing bed that male physicians started to enter the 18th century,In those situations, most frequently they were invited in when women were having a long and very difficult labor, and they thought that maybe physicians could help. And it was forceps that physicians first brought to that helping effort, and many physicians said all they had to do is rattle the forceps in their pockets to get the women’s labor to progress more without them. 

P: A little adrenaline, sure…

Dr. L: And that’s right exactly, and that they were invited in for those difficult kinds of childbirth, normal obstetrics wasn’t called obstetrics The ticket was called childbirth was midwife assisted and friend assisted and it was a very female event, and the physicians that did come in the male physicians were those that could enter a female, environment, and survive many didn’t many got scared by all the women around the birthing bed and left. Really, not, not doing much, 

P:  that’s super interesting I guess I didn’t, it didn’t occur to me that there was selection in the types of births that doctors first attended. So I imagine their success rate was low in part because they’re at the most challenging births,

Dr. L: right, except that they did have some success, obviously, helping birth. But midwives had a lot of tools in their kits, walking women around keeping them, mobile and and vertical was very helpful to a lot of women as they tried to get thrugh labor so midwives, had a lot of things they could do did do successfully midwives, it was really among the most important medical practitioners in the colonial period in America, by far, and they did more than just deliver babies they did a lot of other things that, because they were the, often the nearest and the most familiar of the health people that a woman, or family could call, they did call midwives to do other things, midwives. There’s a wonderful book on a colonial midwife by Laurel. LAUREL Thatcher over, called the midwives tale, and in we get a lot of what we know about late 18th century, early 19th century. Midwives from that. One of the things that we learned that was, I think, something we didn’t necessarily expect to learn is that midwives kept very very full, gardens, a lot of herbs that they would use in their medical treatments and some, some having to do a childbirth with them having to do with other diseases as well. So they were, pharmacists, as well as healers, and they were really very important part of whole scene around health and disease in the 18th and 19th centuries,

P: as women moved to the hospital in the 20th century is that the death knell for midwives because I feel like midwives are not nearly as common today.

Dr. L: Well, midwives started to be replaced in the 19th century, so it was well still in the homebirth period that doctors wouldn’t be called increasingly for normal deliveries as opposed to difficult deliveries, and then it depended on who you were, how much money you had who you knew who you might call so doctors when they started coming to normal deliveries in the 19th century, they often came with midwives, that is midwives came and midwives might even call them and they’d be both of them around the birthing doctors are very kind of gradually taking over some normal births, especially urban ones in the 19th century, but it’s really in the 20th century when childbirth, moves to the hospital that midwives are most replaced by doctors and it’s really the midwives still in the south, well into the 20th century, in rural areas and in some rural areas in the north, especially immigrant rural areas but immigrants in the cities also might have tried to find an immigrant midwife who spoke their language and call her in before calling in a doctor before going to the hospital so midwives have been involved in childbirth. Always in American history, and are still. But as you know, a very small part but I think a slightly growing part of childbirth today, and it’s mostly, I think among some immigrant groups, Hispanic immigrant groups, for example in Texas are very user friendly to midwives and other rural groups. There’s a big Midwife center in Washington state, and is catching on around the country, again I think somewhat urban, as well as rural by a lot of middle class women who feel they have voice and who don’t choose to go to the hospital. So, midwives and birthing centers which are often run by midwives are increasingly used it’s still a small percentage of total births, but it is an increasing number. 

P: Yeah, on this podcast I’ve talked to a bunch of women, both from England and Australia, where it’s just a much more common practice to go to a midwife unless you have a complication and deliver birth there which I wonder if that contributes to their low C section or lower than ours. 

Dr. L: Probably. Yeah, wonderful book, new book on the history of homebirths that deals with 20th century home births and Midwifery, which you may want to look at by Wendy Klein. It’s really a good entry into that question. 

P: I’m wondering about all these journals that you read. If anybody talks about infertility, how that was handled.

Dr. L: If they did, I didn’t pay attention to it at the time I was looking at some I’m sorry, I think, I let me tell you that when I started this research, it was really very hard to find childbirth accounts everyone told me don’t even look, You’re not going to find anything people don’t write about it, it’s this kind of taboo subject even Well of course I knew that wasn’t true, but I, I had to find ways to find childbirth stories, and so what I did when I went to an archive for example is look at family papers, kind of scanning through family papers until it was a birth, and a child in the family. And then I would go back to the women of reproductive age in that family. Nine months or further to see their child birth experiences and when and how and when they got pregnant and so that’s when I found a lot of a lot of women writing about wanting to get pregnant about excitement about getting pregnant, and they wrote about, you know their excitement when they were getting married and their excitement that they would get pregnant and their excitement about getting pregnant. And those women I found because they had had babies so in terms of women who might have been infertile, I probably wouldn’t have found them in that way of searching, unless that same woman has some infertility issues in her, her own experience, Shannon Whitleycombhas written a wonderful book on the history of miscarriage and that is partly about insecurities

P: in brought to bed it says the women who did not lose any of her children either at birth, or in the early years of their lives was rare in 18th and 19th century, far more common to the woman’s experience was the necessity of accepting the deaths of numerous offspring. I was wondering if because that was such a reality if miscarriage didn’t get any attention. If it was you know relatively early like it does today because he was surrounded by the death of children.

Dr. L: No, absolutely, it did. In that sense it did but but the ones I was talking about were ones, women who had lost children they had live birth, yeah, yeah. So in that sense I was, I was not talking about those women and infant mortality was just spectacularly high. In those years, and women experienced that they sometimes didn’t name their babies until they were a year or  two old because they were worried that that would be kind of Jinx, their success and raising them, and very often they named babies, after baby who had already died,

P: that’s interesting

Dr. L: or a child who had already died so there was Elizabeth who was in the grave and Elizabeth who had just been born or had been born a few months before, when they were finally named so a lot of families, you know, made one of my it was one of my difficulties in searching out experiences because you might have had three Elisabeth’s in a family, and trying to figure out which one was the one that I might get a birth story from, 

P: yeah. Yeah

Dr. L: That’s hard.

P: Yeah, it’s hard to imagine that, I mean obviously we kind of know, we know that intellectually but it’s hard to imagine what life was like with those editions, and that threat.

Dr. L: Exactly. And there have been people have written about it as if women didn’t love their children until they were a certain age because they were afraid to emotionally commit. And I don’t think that was true at all. I think women committed. The incident of birth, most of them are certainly in the first year of life.

P: In my first pregnancy halfway through the pregnancy. Doctors found that I had an autoimmune condition that was attacking the fetal heart. And so for the last three months they kept saying she’s not going to survive, she’s not going to survive and I had this struggle, on the one hand, you might try not to get attached to the idea of this baby. Although you’re already very pregnant with her. On the other hand, I thought, That’s not realistic. I’m already attached, and there will be no way to dampen the pain by waiting to name her. I’m sympathetic to the idea that naming someone makes them more real and more embodied, not naming them doesn’t make them any less real For me, that idea I can connect to. I myself was not able to say, and she’s fine. By the way she’s so good 19 Freshman. Freshman in college. 

Dr. L: Good for you for sticking it out. That must have been very difficult. 

P: It was super stressful, but you know, not naming a child, you’re still in love with the child right there’s no, no getting around that. 

Dr. L: Right. 

P: so another thing you mentioned in your book is that, women moved to hospitals to deliver before the death rate in hospitals, actually dropped below the death rate in home births and you have that great graphic of urban versus rural death rates which will forever be emblazoned in my mind, and I’m wondering if that was an issue of failure to communicate information effectively, how was that gap created. 

Dr. L: No, it was the same thing I had talked about for the earlier period women were always seeking out something that was going to make their childbirth experience better. And they always thought that paying attention to what was the most advanced in medicine was going to help them the most. So that’s why they got doctors involved in the first place with with difficult births, it’s why they have kept doctors involved for normal births, so called normal verse in the 19th century. What was interesting, it wasn’t just give me everything you have, I’ll take it with the doctors, the women always remained very critical of what doctors would do they were, they wanted the forceps, but they didn’t want the forcepts. 

P: Yeah, 

Dr. L: they wanted something that anesthesia for example, women really really wanted anesthesia after the middle of the 19th century, and yet, they wanted to be the ones in control of it not necessarily give that control to doctors. So there’s constant push and pull between women and physicians, even though it’s women who wanted the physicians and what they had to offer. You can’t really think of this as something kind of straightforward, so the move to the hospital was part of that, that women thought that the hospitals would have something to offer and one of the things that hospitals had to offer was around the clock care, which women were having a harder and harder time finding at home, it used to be that relatives would come they’d move in for, you know, maybe months to help you around childbirth and early childhood for the babies and your sister would come and it would be easy, relatively easy to have somebody with you all the time for all the help that you needed. Well that became harder and harder as the 19th century wore on, as women were in the workforce more as families who are more mobile and moved away from their original family. So women had that real drive to look for some place that they could go and have care that they didn’t have to worry about. So that was a big part of it. Another part of it was the physicians once surgery was getting established in hospitals, physicians themselves were moving into hospitals, instead of doing office care and home care. So it was harder to get physicians to attend you if you wanted a physician. If you stay at home so that that was part of what women wanted and it was also that part of it was something physicians wanted it was a lot easier for them to have nurses on call and everybody ready and they just run in and hold out their hands and deliver the baby, where everyone else had done all the work so that was easier for them they didn’t have to worry about the horse and buggy, they didn’t have to worry about cranking up their early automobile they were set in the hospital and had a much easier time too, so it was really a push and pull from physicians and then from women’s  end wanting to move birth into the hospital, they didn’t, I think realize as you put it about that mortality might still have been high in the hospital that infection was still an issue in fact is a bigger issue in the hospital than it was home. If they knew about it, it wasn’t the predominant thing in their minds they were looking for what they hoped would be a safe experience with people who knew what they were doing around them. What they didn’t realize that first generation that went into the hospital and it wasn’t the whole generation obviously all at once. The first women who went into that school didn’t realize consciously, what they were leaving behind. They didn’t realize the female world that they had created at home, which had been such a comfort to them and had eased the birth transition so well. They didn’t realize they were losing that if they went to the hospital, hospitals, they labored, if you can imagine this we don’t do this anymore they labored alone delivery room obviously there are people around them, the physician and probably the anesthesiologists and nurses in the labor room they were mostly alone nurses would come in from time to time to check if they were dilating, how far dilated, they were to check that they were okay maybe offer them some ice cubes, maybe not even that. Otherwise they’d be alone. And that was really, really hard to make that transition from being in the comfort of your family and friends to being alone as they put it, alone among strangers that’s why I named my book brought to bear because in the early period women were brought to bed by their friends by their relatives by people they loved and who loved them. In the hospital, they were alone among strangers, women in labor rooms would talk about listening to doctors and nurses talking outside in the corridor. they might come to the door and look at you, but they wouldn’t really come in and hold your hand and give you the kind of comfort that you wanted and needed if you if  labor was going to progress. Well, so it was a very difficult transition in that sense, but as I say women didn’t know they missed it until they missed it, and then they missed it badly.

P: Yeah, no kidding that that sounds really dramatic I talked to a woman yesterday who was born in Britain but her family’s from Nigeria. And she was saying when she got home from the hospital, her mother was with her for living with her for a month and you know that her mother in law came and she was saying in Nigeria that is the common practice that exactly what you described, which is that someone moves in with you to take care of everything, and the mother’s feet are not to hit the ground and, which sounds kind of amazing and she herself was saying, it’s much harder to do you know that we live in England because everyone has a job. So, you know, my mom can’t live with me anymore because she has to go to work.

Dr. L: so I recreated that a little bit when I had my first child, I’ll tell you this experience, it was on the delivery table, literally the delivery table when I was pushing, I’m working so hard that I realized the birthing mother is the most important person in that room, and, of course, working the hardest of anybody in the room. And the story historically from her point of view had not been told we knew about the doctors we knew about the nurses we knew about the midwives, you know less about the nurses and midwives and we have since come to know but we knew about childbirth from the medical point of view and we did not know it from the birthing woman’s point of view. And that’s right there is where my book was conceived as my child was pushing her way into the world, I knew I had to tell, try to tell the story from my point of view my working hard point of view. And the other thing that happened which was totally inadvertent but quite wonderful. In my first birthing experience was that I was doing a Lamaze delivery which was in, in my day a little unusual, 

P: the lamaze method was developed in 1950 by a french obstetrician and it was a natural birthing technique that focused on regimented breathing for each stage of labor

Dr. L: and the nursing student class heard about it and wanted to come in and see it. And so I had about 10 nursing students around my bed, all female. So, other than my husband who was there, I had recreated without knowing it, the female part of the experience, and it did help they all saying happy birthday when Sarah came out and it was, you know, it was quite a party in that sense in the same way as it had been what we used to call social childbirth, it was a social childbirth and a female social childbirth. 

P: That seems fitting. 

Dr.L: Yeah, it was but I didn’t know it at the time.

P: Let’s talk a little bit about Twilight sleep if it seemed as though, women were edging away from that social circle that was so helpful. It sounds like Twilight sleep was just the end of that.

Dr. L: it was, but one of many things in the hospital that ended that Twilight sleep was seemed very very attractive to women women, as I found out who call themselves feminists who wanted to imbibe that they men, choosing the way they wanted to have birth. When I was a feminist writing this book, I was thinking of feminism as something that meant I controlled the birth itself and that was a slightly different use of the word feminist but they were feminist and they wanted to choose and they had heard about this method this we’re talking about the second decade of the 20th century, in the 19 teens, and they had heard about this childbirth technique in Germany and wanted to bring it to America, and basically it was giving the laboring woman, a combination of scopolamine and morphine which would morphine to dull the pain and scopolamine to help you forget it, and it would kind of put you into this totally relaxed state of sedation and not really knowing what’s happening to you, and you would deliver your baby and then you would wake up and some women who did that. I remember having had a baby they didn’t know they had had a baby, so he missed the whole thing, which for me was really terrible because I loved the whole thing, I loved it, not in the kind of romantic, fuzzy pink way. 

P: Yeah, 

Dr. L: but in a way that helped that I understood the power of my body in a way that I hadn’t understood it before I had a baby. And that was incredible to me that a body, a woman’s body can do that, and I wanted every minute of that experience I wanted to be awake and alert for it, which is why I didn’t want medications but in, in the twilight sleep. Example women wanted that medication wanting to forget it wanted to wake up with a baby and not knowing it and not having felt it, and they did that until they realized that the dosages in those early years of using scopolamine and morphine the doses weren’t well regulated were, weren’t well understood and some of the babies were very lethargic after being born and the women not necessarily in great shape themselves so it was something that fell by the wayside pretty quickly in that form, but was continued to you be used once they understood dose medication, well into the 1960s. You may be still being used in places, my sister in law had a scopolamine Birth in the 70s but it was a way to medicate women without them, understanding it as medication per se. I think anyway they liked it and they came to the hospital for it so yeah they ended up one of the things you did under the effects of it was thrash about a lot and so they would put women into these into bed, high Canvas sheets so they couldn’t see and they couldn’t fall out, which also, you know freaked me out because you’re really alone in that environment, and I didn’t like that but they loved it, so.

P: Yeah, it sounds like horse blinders I’m not for that. And do you have any insight on abortion was it handled by midwives, was it a political issue, or the 18th The 19th 

Dr. L: well, yes and no. I mean, in traditional societies and including our own life was not seen to exist before quickening between the 16th and 20th week of pregnancy. So until a woman felt movement, you didn’t worry about that and yes women tried to get abortions if they didn’t want to have their babies and they helped each other do that. Midwives sometimes helped some, some absolutely refused to help, and doctors got into the act and helped, and then some also absolutely refused to help, until the late 19th century was seen as perfectly fine for quickening because it wasn’t seen as you had life yet. Technically, so people did it and, and the problem was finding a way to do it successfully. And of course, there weren’t a lot of very successful remedies. Then, and the same with birth control, you know, they tried all sorts of things for birth control and weren’t necessarily successful, 

P: that is super interesting to see how many historical lines from the past are still totally relevant today.

Dr. L: I do think that we are re experiencing many of the things we as individual women are really experiencing many of the things that women in the past have and we have some of the same concerns they may be manifesting slightly differently today but they are. There’s a lot of a lot we can learn from women in the past.

P: Yeah, the issue of control is so, fundamental to every woman who talks about her story about control over her bodyand almost everyone universally says, when they feel a loss of that sense when things are being done to them, it feels terrible and not natural and, and that seems true forever and I can see why women fought so hard to have people with them.

 

Dr. L: People with them and to make birth plans, even though a lot of women know that the birth plans can get thrown out…maybe too easily. They make them and they, they put a lot of stake in them, because they really do think about what they want in a childbirth experience, and of course many doctors really try to give them that. And pay attention to their birth plans and help them with that. And others just say dear, dear, I know more about this than you do, don’t worry just put it in my hands. So, you know we have those experiences, right away first in the hospital in the early 20th century and we still have today. You know, it’s something that we can look back on and see how did women, those women who kept control how did they do it. Yeah, and we can learn from that.

P: Oh, thank you so much for taking us on this tour of where we’ve been and hopefully where we’re going.

Dr.L: Well thank you for asking me. I hope that was useful.

P: Yeah, it was great. Thank you

P: and now a little bit more on where breastfeeding fits into the current day picture:

A special welcome to Dr Janet golden, a professor at Rutgers who specializes in the history of medicine, history of childhood, women’s history, and the American social history. She’s the author of several books, including most recently, babies made us modern how infants brought America into the 20th century, which is a very intriguing title, thank you so much for coming on Dr. Rosen. 

Dr. Golden: Oh, thank you for inviting me. 

P: One thing I want to talk about today is breastfeeding and sort of how we got where we are now culturally, I think there was no push to get my mother to breastfeed, as opposed to my kids when I, when they were born, there was an enormous push to breastfeed. So I’m wondering if you could kind of walk us through how we got here.

 

Dr. G: All right, that’s it, that’s a great question and I think we can say that there’s a very long history of forces, promoting breastfeeding and forces opposing breastfeeding, it’s very different in the United States than in other places, of course, where, just as an example. The French were very concerned to promote breastfeeding and for reasons of health because they were being outnumbered by the Germans and they wanted to build a strong healthy population that can then it becomes out of fashion to breastfeed everybody wants to have a wet nurse or send a baby out to a wet nurse so there are constant changes in this history 

In the United States, you know for most women in the early centuries of what we will call United States history, you pretty much had a choice of breastfeeding or using animal milks which weren’t as well formulated as they might be today, and most people simply didn’t have the means to purchase them out to maintain it properly if they did purchase it, they didn’t have refrigeration so breastfeeding was really the way to go until these canned formulas developed and then the formula companies jumped in and said get rid of wet nurses. Feed your baby the scientific way and go with melons, baby food or go with Borden’s condensed milk in a formula. So there was pressure in the other direction 

P: is that like 1950s When is that?

Dr. G: that really gets going in the end the first formula is get going in the late 1860s 70s 80s 

P: Oh, Wow, 

Dr. G: so they start pushing that only a few people can afford it, of course, the breast, but breastfeeding begins to look unscientific and so there’s, you know, we start selling the, the sugar formulas that go into the milk formulas, and of course once you have running water clean water indoors, you have electricity or gas heat to boil things, it just becomes a lot safer to do that. Now obviously, there is some controversy when formula companies are promoting these powdered formulas in countries where people don’t have access to clean water, low income they have to dilute the formulas so they’re not healthy for babies but we’re not, we’re not going to talk about that so we’re really gonna say that by the post war period 1950s Breastfeeding is just out of fashion it seems primitive It seems something that poor women do. The modern scientific ways is to bottle feed, and then it’s very precise you can measure how many ounces did my baby, drink some baby books had you weigh the baby before you fed the baby and then feed the baby and see how many ounces, they took in, and then people began to push back against that and saying no. Why should this commercialized enterprise these be in charge, why should medical authority dictate over what’s natural for women, let’s go back to breastfeeding and of course there is good scientific literature that says it’s, it’s a better alternative, you know, cows make milk for calves women make milk for babies, you know it’s it’s a natural correctly designed product, but of course not everybody can do it and not everybody wants to do it so we live in a world now where two things are true. One is that I think we can stipulate that scientifically medically speaking babies are better off drinking milk, designed for babies, which is from human females, But we can also say that. Secondly, we live in a world where we get clean water, we can properly prepare our formulas the formulas are well designed, and not everybody can or wants to breastfeed their baby so both things are true, and we’ve gone in the direction of making it easier to promote breastfeeding in hospitals, maybe a little too pushy on that as you can explain, and we’ve also reformulated to use a bad pun there are our WIC program and other things to support breastfeeding and we’ve put in, in places that employ large numbers of people we put in stations where women can pump their milk store their milk etc so we’ve made it certainly made it easier to be a breast feeding person, but that that has, I think shaded over for some people to be almost a command, and making people very resentful and unhappy with that, you know, I guess we live in a world where everything is polarized nowadays even taking care of infants.

P: yeah, That seems to be the case and a lot of women describe how they expected breastfeeding to be easy, because it is natural, but I don’t know that those two things go hand in hand, and once it is difficult, then there, then they think it’s something that’s wrong with them and all of a sudden it’s a comment about their ability to be a mother…after you give birth, that is the first thing that you’re doing. So, it’s challenging to have the first thing be something that’s not necessarily super easy. Do you have any sense of how common it is to have trouble breastfeeding.

Dr. G: I really don’t know because I think I’m sure there are studies on that I’m sure it’s difficult in the beginning I believe it’s harder for women who’ve had cesarean sections and have had some anaesthesia in their system, I believe it gets easier with second and third and fourth. So on children. But certainly, initiating breastfeeding it’s often better done if you have a mom or a support person who can get you through it it’s, it can be, you know it can be painful. Problems do develop you need support breastfeeding may be natural, your body may be designed to do it but that doesn’t mean you necessarily know how to do it. Some infants have trouble sucking latching on, you know it’s not, it’s not a perfect and easy thing to do, but I think what makes it so hard for people is the, the weight of expectations and judgment, you know, we live in a culture, I think it’s fair to say that the easiest people in the world to pass judgment on are either people like us who we feel we can do better than other moms in the, in the hospital with us or in the birthing center with us, and then people who are different from us and who behave differently from us and we can say oh they’re different and there’s something wrong with them. And oftentimes that judgment is really about women and about mothers and about child rearing. And that I think makes it all the harder, all that judgment that goes on and, and political divisiveness,

P: Yeah, and what I find, talking to people is that it’s not always on the surface, sometimes it is a it is a buried expectation that you don’t realize until you don’t meet it. Many women have come on the show and talked about how breastfeeding is the super painful and difficult thing and the latch didn’t quite work and the baby wasn’t getting enough milk, but it was still hard to give up, Because her expectation was, you know, good moms breastfeed.

Dr. G: Right. Just like when other women wanting to breastfeed and the 50s and the expectation was you’re a bad mom. Because you’re not buying the most up to date formulas and the fancy bottles that go with it. So, if we took the judgment, out of it. I think it would be easier for people to breastfeed it would be easier for people who didn’t want to breastfeed to bottle feed, it will be easier for people who want to partially breastfeed and partially bottle feed to be comfortable with that, but there’s the idea that we, that we have to pass judgment on this and make people uncomfortable about their choices. It’s always been that way, but it doesn’t have to be that way.

P: Well that’s interesting to hear that that is always the case so even when the pendulum swung the other way and people were being discouraged from breastfeeding, you were made to feel bad if you breastfed.

Dr. G: You were made to feel bad and there are many many stories of women who said I want to breastfeed my babies and the nurses would would only would start the babies on bottles without telling you so it was hard for them to latch on and then they would only bring you the babies every four hours even if babies were hungry and they’d cry themselves to sleep, and then they start wiping down your breasts with alcohol and other antiseptics. Oh they made it, you know, because it seemed like you were doing it seemed dirty if I can put it that way to put your baby on a breast and when you could have a scientific bottle that was you know had been sterilized to the right degree and gotten out all the germs so. As difficult as women today have it who choose not to breastfeed and get judged by nurses or by their friends or their doctors, it was a different way, maybe 50 6070 years ago.

P: That’s sort of shocking and I guess I don’t know whether I would call that marketing exceedingly creative because suggests that the scientific way is to do something that’s made in a lab, as opposed to what your body has produced, that’s sort of amazing.

Dr. G: Well, that you know we were very into measurement. So, how much is your baby weigh how much did How big was your baby how fast is it growing so if you can measure how many ounces your baby drank and write that down, which a lot of moms had charts to do that that just seemed like a very scientific thing to do.

P: Yeah, that that’s fair and I’m sympathetic to that and actually I don’t know if you’ve heard of a company called hatch. No, they have a very special changing pad with really sensitive monitors in it so that you can weigh your Baby and breastfeed and weigh them again, and it’s there’s an app on your phone and you can check it out and and it is for that purpose explicitly because so many women who breastfeed say I have no idea how much they got or if they drink anything or you know what’s going on so it’s funny that science has come to meet that demand another way.

Dr. G: Right, well, you know, our medical world is always in part about marketing, They’re very much intertwined, because you can sell people on science, whether it’s the science of hygiene and cleanliness or it’s the science of measuring your baby for a time women, middle class, upper class women were encouraged to buy scales and weigh their baby every day and write it down you know because measuring is science. So, and then the marketers got very into this our department stores have infants departments, they used to have nurses who works there who would tell you the right things to buy and give you medical advice so you know that that the world of science which has brought us many, many wonderful advances is also about the world of marketing which has brought us many, many products and they do get tied up together and help to sell each other.

P: That’s shocking to hear that there were nurses at department stores, impossible to imagine, and I guess a great way to sell stuff. 

So let’s talk for a little bit about these baby friendly designated hospitals, the impetus for this came from the WHO World Health Organization, 

Dr. G: right, it’s a worldwide effort

P: in the 90s, and then I’m sure it looks different here than it does in other countries, in 2007, it says that less than 3% of United States births occurred in 60 Baby Friendly designated facilities, but by 2019 28% of births are in 600 Baby Friendly facilities and Baby Friendly is a designation you get if you follow this 10 step approach to encouraging breastfeeding, but it sounds like it’s almost aggressively to the exclusion of anything else. 

Dr. G: Well, I would, I would say two things about that one is it’s fascinating to see how much it’s grown and I’m sure that has a lot to do with the marketing of the hospitals, right, if you have health insurance and you pick that hospital, because it’s a Baby Friendly Hospital and you like it, you’ll continue to bring your insurance cards when and go back to that hospital so that’s that’s good for the hospital. It is probably good for hospitals to move away from promoting bottle feeding to supporting breastfeeding, that how aggressively they do that, I would assume is to some degree determined by the, the nurses on the obstetrics floors, and how seriously they promote breastfeeding over bottle feeding, and if you think about it from the nurses perspective, if you have rooming in and a mom can pick up her baby and breastfeed on demand, then that’s a lot less work for the nurse taking the baby back to the baby part of the hospital and feeding the baby, him or herself. So there are all sorts of incentives built in for the hospitals for the staffing of the hospitals for the baby, certainly, you know if you’re going to support breastfeeding, which is a good thing overall, But how you handle that I’m sure it’s very idiosyncratic, and it may depend on whether you have the night nurses or the day nurses and are they new hires are they the older hires how they feel about it.

P: Yeah, it’s interesting to see sort of what’s developing and just so interesting to me that there’s this cultural shift that happens you know almost on its own cycle, where it goes back and forth. So, can you imagine at some point in the future where breastfeeding will be out of fashion.

Dr. G: It may well change because now, you know, now we’re beginning to see what uh what environmental pollutants are in women’s bodies and in breast milk so maybe they’ll have formulas that don’t have those pollutants and we’ll move away from it. When we talk about breastfeeding we’re talking about the health of a woman and a baby and a family and workplace issues and social issues and environmental issues, and it all gets encapsulated in this tiny realm of Will you or won’t you breastfeed, but there really so many bigger surrounding issues is breastfeeding supported by do we have six months of paid family leave in this country. No we do not, you know, that might be a better support for breastfeeding or partial breastfeeding, then what happens in a Baby Friendly Hospital or a baby unfriendly hospital if we want to label the other ones

P: that oh that sounds much more expensive, potentially, potentially much more helpful but much more expensive. 

Dr. G: Right. 

P: The other thing that seems tricky about maternal health and newborn health is that I feel like it has not received as much medical attention. You know all the issues that come with pregnancy, many of which remain a black box preeclampsia we’ve known about for hundreds of years, we’ll still know kind of how that works. So it’s, it’s tricky to see what will be the lever that will encourage a shift in one way or the other to change.

Dr. G: Right, I mean we still have many many women who’s who are uninsured. 

P: Yeah, 

Dr. G: even with our expanded Medicaid and programs there. We have undocumented women, who I believe if they call up a center, they can get prenatal care, and they’re supposed to not wait more than six weeks but in fact I think there is not enough services for them, their children are going to be Americans. They’re here. And yet we’re denying them a kind of Healthy Start There are so many complicated issues around pregnancy and birth that are much more expensive as you say, not necessarily harder to solve because the rest of the world seems to solve them. But if we don’t have those conversations then we bring it back to this individual well that mom didn’t breastfeed or that mom should breastfeed or why is she fully breastfeeding and leaving the baby formula when she goes to work We’re talking about individual decisions, but we’re not talking about the structure in which they’re made. 

P: Well, so you bring up a good point other than vastly more generous medical supports that other countries give their women. Is there any do you have any sense a theory about, you know why culturally in America, you know postpartum care is one visit at six weeks, and I as far as I can tell, you know, after you’ve been through, almost 10 months of pregnancy and an exceedingly challenging delivery, you could, you could use care before then, but we, but we don’t do it that way. Do you have a sense of like, what else is driving those differences between US and other countries.

Dr. G: Well, you know we have a for profit healthcare system. So, I believe that if you’re an insurance company said, Is there any data to say you need continuing care that, you know, first year after giving birth. Well, no their baby will go to the pediatrician and you as the mom, you’ve had your one postpartum visit you’re done. Why do we have to pay for another visit for you. So we have that problem right there. Yeah. And, and I think that there’s just a sense of, you know you’re you’ve become. you go from being the vessel for the baby you deliver the baby then the baby is going to get that the S chips care the Medicaid care the private insurance care the clinic care, but you as the mom you’re kind of done to your next pregnancy I guess, Or your annual gynecological checkup. We don’t and so we have a very high maternal mortality rate in this country as a result of that, but we have a strong tradition, really, I would say from the post world war two period of saying, everything is a private matter, you know, It’s for you to go to your doctor. It’s for you to decide if you want to be pregnant or not pregnant, we don’t, we don’t have a system that says, we have some responsibility to our citizens and non citizens who are here and who should have good healthcare.

P: Dr golden thanks so much for coming on and talking to us today. I feel like I’ve learned a ton.

Dr. G: Okay, well it’s been wonderful to talk to you.

P: Thank you again to Dr. Judith Leavitt and Dr. Janet Golden for giving us a sense of the factors over time that have come together to contribute to the pregnancy and birth culture we have today. Thank you for listening, and if you liked this episode, please consider sharing the podcast with your friends.  The next episode is a return to a birth story…and this story is really, in some sense, a loveletter to becoming a parent–it showcases the many challenges that sometimes have to be overcome to get there…