Witnessing Birth, Giving Birth, Researching Birth, Bettering Birth.

While the physiology of biological events such as conception, birth, and breastfeeding are largely identical across time, geography, and culture, the practices that shape women's experiences of conception, birth, and breastfeeding differ across time and place according to the ever-changing emphases of medical and popular culture. In the United States, as in most other wealthy countries, birth and infant feeding practices have changed continually and significantly in the last two centuries. In this essay, I reflect on how those changes have affected my life, first as a witness to friends' births, and eventually as a mother and a grandmother. Foremost, however, I explain how my personal experience with changing birth and breastfeeding practices shaped my interests as a historian of medicine, and how my professional interests and knowledge eventually shaped my daughter's experience of conception and birth.

Historical Research: The Origin of 'Formula': State of the Science, 1890s.

In 1900, 13% of infants in the United States died before their first birthday, most of dehydration from diarrhea. As part of a nationwide effort to "save the babies," pediatricians focused on several endeavors-experimenting with commercially made infant-food products; working with dairy farmers to clean up cows' milk; lobbying to pass municipal and state legislation regulating the dairy industry; and devising mathematical "formulas" that represented instructions to chemists on how to "humanize" cows' milk for the needs of a particular infant. Pediatricians dubbed the latter endeavor "percentage feeding" and, from the 1890s to the 1920s, they deemed percentage feeding a lifesaving scientific achievement. The complex, virtually infinite array of mathematical formulas that comprised this infant-feeding system is the origin of the word "formula" as used today to describe artificial baby milk.

Infant feeding among women with a history of breast cancer.

PURPOSE: Health professional organizations recommend exclusive breastfeeding for 6 months, but there are mothers, such as those with a history of breast cancer, who are unable to exclusively provide their milk for their infants. Minimal research has been published on mothers' experience with lactation, breastfeeding, and bottle-feeding after breast cancer. This study explored mothers' perspectives of infant feeding after a history of breast cancer. METHODS: Qualitative interviews were completed with 20 mothers who had experience with infant feeding after breast cancer, including exclusive breastfeeding, partial provision of human milk with formula supplementation, and exclusive formula feeding. RESULTS: Mothers shared their perceptions, barriers, and experiences of infant feeding. Four themes were identified: miracle of motherhood after breast cancer, medical misinformation or no available information contributing to the exacerbation of mothers' worries, post-breast-cancer feeding challenges, and desire for infant-feeding support rather than pressure. CONCLUSIONS: Mothers who have had breast cancer and have since given birth face specific challenges to infant feeding which are compounded by limited resources and knowledge among healthcare providers. Findings of the study highlight the importance of healthcare professionals becoming more educated to provide adequate support and evidence-based information on lactation and infant feeding for women with a history of breast cancer. IMPLICATIONS FOR CANCER SURVIVORS: Understanding the experiences of women who have given birth after breast cancer can help women in similar situations know that they are not alone, identify resources, access peer support, and seek evidence-based infant feeding advice from healthcare providers involved in their care.

The Journal of Human Lactation: A Reflective Discussion.

Research about lactation and breastfeeding has exploded since the Journal of Human Lactation (JHL) began publishing in 1985. To discuss the 3-decade-long role of the Journal in promoting, supporting, and disseminating lactation research, editors convened a multidisciplinary group of lactation researchers and providers which comprised three senior researchers and one clinical practitioner, all of whom have a long history of lactation advocacy. Their discussion took place on July 1, 2019. Dr Aimee Eden is a medical anthropologist who leads the qualitative research efforts in a small research department. Her dissertation research focused on the maternal and child healthcare workforce, and the professionalization of breastfeeding support. She served on the Board of Directors of the International Board of Lactation Examiners (2010-2016) and currently serves on the board of the Monetary Investment for Lactation Consultant Certification. Dr Karleen Gribble has been conducting research for 15 years about infant and young child feeding in emergencies, long-term breastfeeding, milk sharing, early childhood trauma, adoption, and fostering. She is an Australian Breastfeeding Association community educator and breastfeeding counselor and a member of the Infant and Young Child Feeding in Emergencies Core Group. Elien Rouw is a practicing physician in Germany specialized in healthy infant care, with a long-standing specialization in breastfeeding medicine. She serves on the Board of Directors of the Academy of Breastfeeding Medicine, is a member of the German National Breastfeeding Committee and their delegate to the World Alliance for Breastfeeding Action. Dr Jackie Wolf is an historian of medicine, whose research focuses on the history of childbirth and breastfeeding practices in the United States and how those practices have shaped women's and children's health, as well as public health, over time. Her latest book, published by Johns Hopkins University Press and funded by a 3 year grant from the National Institutes of Health, is Cesarean Section: An American History of Risk, Technology, and Consequence. Dr Sara Gill moderated the discussion. She was a member of the Board of Directors of the International Lactation Consultant Association for 5 years, and has been an Associate Editor of the Journal of Human Lactation for the past 4 years. Her research has focused on breastfeeding among vulnerable populations. (Participants' comments are noted as AE = Aimee Eden; SG = Sara Gill; KG = Karleen Gribble; ER = Elien Rouw; JW = Jacqueline Wolf).

"They Lacked the Right Food": A Brief History of Breastfeeding and the Quest for Social Justice.

In the late 19th-century United States and Europe, infants died at high rates from diarrhea. Physicians and social justice advocates responded to the public health crisis with attempts to clean up the water and cows' milk supplies, as well as social welfare legislation and assorted educational efforts to help mothers better care for their children. Most visible among the educational efforts were breastfeeding campaigns. A century later in developing countries, physicians and activists were confronted with a similar problem-infants dying from diarrhea due to the unethical advertising and marketing practices of formula companies. I argue in this article that crusades for social justice at the most basic level-to ensure that children will live to adulthood-have long been connected with efforts to safeguard mothers' ability to adequately breastfeed their children.

Risk and Reputation: Obstetricians, Cesareans, and Consent.

When physicians performed cesarean sections in the nineteenth century, they customarily sought agreement from all present before proceeding. In contrast, after the introduction of electronic fetal monitoring in the late 1960s, obstetricians obtained permission for a cesarean by offering a choice that ensured consent-give birth by cesarean or give birth vaginally to a damaged or dead baby. This article argues that the manner in which physicians obtained consent for cesareans in the nineteenth century was one factor that kept the cesarean rate low, while the manner in which physicians obtained consent in the late twentieth and early twenty-first centuries was one factor driving up the cesarean rate. The dissimilar approaches to consent did serve a common purpose, however. Each preserved physicians' reputations. With the surgery likely to end in a woman's death in the nineteenth century, consensus ensured that a bad outcome would be a shared burden. And because the fetal monitor, in exaggerating the risks of vaginal birth, changed the nature of the malpractice climate for obstetricians, the late-twentieth-century approach to consent similarly protected physicians. As one early twenty-first-century obstetrician quipped, "You don't get sued for doing a C-section. You get sued for not doing a C-section."

The Lake Wobegon effect: are all cancer patients above average?

CONTEXT: When elderly patients face a terminal illness such as lung cancer, most are unaware that what we term in this article "the Lake Wobegon effect" taints the treatment advice imparted to them by their oncologists. In framing treatment plans, cancer specialists tend to intimate that elderly patients are like the children living in Garrison Keillor's mythical Lake Wobegon: above average and thus likely to exceed expectations. In this article, we use the story of our mother's death from lung cancer to investigate the consequences of elderly people's inability to reconcile the grave reality of their illness with the overly optimistic predictions of their physicians. METHODS: In this narrative analysis, we examine the routine treatment of elderly, terminally ill cancer patients through alternating lenses: the lens of a historian of medicine who also teaches ethics to medical students and the lens of an actuary who is able to assess physicians' claims for the outcome of medical treatments. FINDINGS: We recognize that a desire to instill hope in patients shapes physicians' messages. We argue, however, that the automatic optimism conveyed to elderly, dying patients by cancer specialists prompts those patients to choose treatment that is ineffective and debilitating. Rather than primarily prolong life, treatments most notably diminish patients' quality of life, weaken the ability of patients and their families to prepare for their deaths, and contribute significantly to the unsustainable costs of the U.S. health care system. CONCLUSIONS: The case described in this article suggests how physicians can better help elderly, terminally ill patients make medical decisions that are less damaging to them and less costly to the health care system.

Got milk? Not in public!

The American focus on the sexual purpose of breasts, rather than the physiological function of breasts, has serious public health consequences. Discomfort with breastfeeding in public lowers breastfeeding rates, which in turn negatively affects women's and children's short- and long-term health.

Low breastfeeding rates and public health in the United States.

The medical community has orchestrated breastfeeding campaigns in response to low breastfeeding rates twice in US history. The first campaigns occurred in the early 20th century after reformers linked diarrhea, which caused the majority of infant deaths, to the use of cows' milk as an infant food. Today, given studies showing that numerous diseases and conditions can be prevented or limited in severity by prolonged breastfeeding, a practice shunned by most American mothers, the medical community is again inaugurating efforts to endorse breastfeeding as a preventive health measure. This article describes infant feeding practices and resulting public health campaigns in the early 20th and 21st centuries and finds lessons in the original campaigns for the promoters of breastfeeding today.