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Conservative aspects of medicalisationOne of the most hotly debated topics by anthropologists is whether or not new re­productive technologies as well as other biomedical technologies might be the driving force for changes in concepts of kinship. This issue has gained some prominence in discussions on such issues as biomedical systems, surrogate motherhood (Rapp, 1988) and organ (Kalitzkus, 2001) and sperm donation. These technologies tend to catalyse or even energize family structures.1 We sometimes forget that certain aspects of biomedicine also have conservative effects on kinship matters, as demonstrated by the fact that the practice of breastfeeding is the preferred form of infant nutrition. What happens after the cutting of the umbilical cord depends on conservative ideas of gender, family and kinship2 in terms of nutrition, health and food.After presenting the research methodology, the author will analyse some conceptual peculiarities of breastfeeding relating to the nature/culture dichotomy. The central argument arises from the observation that some of the crucial characteristics of breastfeeding contradict these conceptual peculiarities: witness the fact that no other maternal milk is ever regarded as a suitable substitute for the mother’s own milk. Various remarks on the history of breastfeeding will show that this has more to do with popular conceptions of kinship, reproduction and female roles than with the discourse that is generally taken to justify contemporary breastfeeding practice. The concluding argument is that breastfeeding and the medicalisation of mothers’ milk combined with other social customs, are in fact instrumental in terminating women’s careers and reconciling mothers with traditional gender roles. Mother’s milk as a concept mediated through science in general and biomedicine in particular, may therefore be seen to help perpetuate traditional concepts of kinship, reproduction and gender.Methods and conceptsThe present article relies on the findings of a research project on pregnancy and birth, conducted by the author in 1999-2000 in a medium-size German university town. Qualitative, open-ended interviews were held approximately once a week with 22 women of different social background (mainly middle class) and geographic origin (equally divided between local and non-local German women and immigrants). All of the interviewees lived in or around the town from the beginning of their pregnancy or, in some cases, the first trimester, until the first few weeks after delivery. The research also included participant observation – joining in birth preparation courses and post-natal gymnastics so as to get to know the interviewees – and interviewing midwives, gynaecologists and nurses.Medical anthropologist Brigitte Jordan, in her cross-cultural study of childbearing “Birth in Four Cultures”, claims that core social values are displayed at birth and in the pre- and post-natal stages. Birth is therefore conceptualised as “biosocial”: biological, because birth is a physiological process of “(universal) biology”, and social because particular ideas and values shape the way we deal with critical life events such as birth (Jordan, 1978: 1). Jordan’s notion of “biosocial” does seem to be a relevant point of departure but it is not ideally suited to an analysis of breastfeeding. The author will show that, when looking at the phenomenon of mother’s milk, biology and culture are no longer entities that may be defined separately but interrelated domains that influence each other. As stated by the anthropologist Paul Rabinow with respect to gender: “It is not enough to question the universality and analytic utility of our implicit assumptions about sex differences. Rather, we need specific strategies to help us overcome our tendency to reinvent gendered analytic dichotomies” (Rabinow, 1996: 49). In other words, exaggerated claims about biology must be viewed with scepticism. Instead, Rabinow puts forward the concept of “biocultural”, based on ideas that reflect actual behaviour shaped by everyday reality, and he stresses a field of agency and intervention between these classical, dichotomised fields. He points the cultural manipulation of nature: “Quality of food is now not only judged by criteria like freshness and outlook, criteria of how close the products are to their natural origin. Criteria concerning consumers’ health are of equal relevance: content of food like vitamins, cholesterol, salt and so on” (Rabinow, 1996: 147). Rabinow, unlike Jordan, regards biology itself as a culturally shaped entity, an opinion that is central to my argument.In the discussion on breastfeeding biomedical knowledge is an important element. Drawing on Rabinow’s findings, the author will aim to show how biomedicine serves to strengthen the credibility of breastfeeding through the regulation and control of kinship and “traditional” gender roles. Current discourse on breastfeeding: an analysisThe present study focus was mainly on the process of becoming a mother (Kneuper, 2004a), with particular attention to the attitudes and behaviour shown by young mothers in relation to breastfeeding.We will start by looking at that unique substance commonly known as “mother’s milk”3. The most striking thing about the term “Muttermilch” was the apparently paradoxical way people referred to it. On the one hand, the interviewees regarded mother’s milk as something absolutely natural, the embodiment of nature so to speak. Or, as one of the interviewees put it: “Mother’s milk is the optimal form of nutrition for a suckling baby. It is something particular, something like a miracle.”On the other hand, the natural qualities of mother’s milk are praised in terms of bioscience. This is particularly surprising since, according to the German “nature-discourse” (Kneuper, 2004a: 236-255), bioscience is seen as the opposite of nature. It is argued that the link between “Muttermilch” and nature is one of the reasons why mother’s milk may be regarded as a “miracle”. Its ingredients are analytically proven to be perfectly suited to a baby’s needs, changing in composition as the infant develops and strengthening the newborn’s immune system. “Muttermilch” is even recommended for premature infants. Things have changed dramatically since the Middle Ages, say, when there was simply no alternative to breastfeeding and no reason whatsoever to question its usefulness was “self-evident” and unquestioned. These days, scientists are more concerned with the beneficial properties of breast-milk than with its natural quality (Kneuper, 2003).Considerable emphasis has been placed on the naturalness of breastfeeding. It not only forms the subject of countless scientific studies4, but has also become a technical skill, taught in minute detail as part of the almost mandatory courses that prepare future parents in Germany for birth and motherhood (Lutz, 2000a, 2000b). For at least one out of seven 90-minute classes, the expert will deal with such questions as: when, how long and how often to feed the baby; how to hold the baby and what position the mother should adopt; what effect infant temperament has on breastfeeding; what the mother should eat while lactating or to prevent flatulence with the infant; and what may prevent a mother from breastfeeding. Prior to these sessions, future parents are provided with a wealth of written background material. What is striking is the extent to which the knowledge and techniques regarded as relevant for breastfeeding – which means biomedical knowledge – are now taught by specially trained professionals in preference to more informal advisors.One of the central topics when teaching infant nutrition is how to handle common obstacles to breastfeeding such as mastitis, irregular milk flow or even slip nipples. All of these may now be overcome and thanks to breast pumps, refrigeration and hot running water, almost every young mother may now breastfeed if she wants to (Landweer, 1989). All of the 22 interviewees planned from the outset to feed their babies exclusively on breast-milk and were eventually able to do so. Only one interviewee, Susanne, introduced a mixture of breast-milk and formula after a few weeks. None of the interviewees planned NOT to breastfeed, and mixed feeding was reserved for “emergency cases”. As confirmed by interviews with midwives and advisory literature (eg Lathrop, 1984), these data represent the current trend in West Germany.One of the remarkable aspects of contemporary maternal perceptions on breastfeeding, however, is that mothers will only use their own breast-milk to feed their baby. The alternative, for mothers who for some reason cannot breastfeed, is industrially-produced milk products (infant formula) rather than the milk provided by another new mother. This is despite the fact that human milk is generally acknowledged to be far more suitable than infant formula which, although produced according to scientific standards and nutritional quality control procedures, comes a poor second. Remember too, that until the early 19th century, noblewomen throughout Europe commonly employed wet-nurses to feed their babies and that women in other cultures still ask relatives and neighbours to wet-nurse their babies. Mother’s milk, unlike blood, sperm and organs, is not an exchangeable commodity, never entering into the free circulation of goods but remaining within the intimate mother and child relationship. As declared by one of the interviewees: “My baby, being fed by another women – no, I can’t imagine that”.We should bear in mind, however, that obtaining and storing human breast-milk is as technologically feasible as blood transmissions or treating mastitis. Nevertheless, while we expend considerable effort on facilitating breastfeeding, we give little or no consideration to the idea of exchanging breast-milk. What this seems to indicate is that there is more than feeding at stake here. As rightly observed by anthropologist Anette Weiner, in Euro-American societies the “products” of important female activities – giving birth and raising children – do not enter into economic circulation. This is due to the division of human interactions into a private and a public sphere (Weiner, 1992, 1995). Whereas politics and economics are known to belong in the public domain, privacy is essentially the preserve of the family. Breast-feeding must therefore be analysed in the context of what constitutes the private – as opposed to the public – sphere.To get some idea of what is meant by breastfeeding, consider the following quotation from a German manual for midwives on breastfeeding and motherhood: “The mother is called Mum by her baby. On the other hand, Mamma is the Latin word for the female breast, designed to produce mother’s milk as nature intended (“Muttermilch”). What this suggests is that the mamma (mum) can perfectly satisfy an infant’s needs” (Lutz, 2000a: 404, translation E.K.).The highly metaphorical style of this passage is in striking contrast with the more objective, even functional approach adopted by the rest of the book. The equation “mum = mamma” stands for a chain of association in which mum = mamma = the female breast = human milk. “Mum” or “mother” as the point of departure denotes firstly a kin relationship and, secondly, a gender role. There is a correlation here between mother’s milk and the mother’s relationship with her infant: breast-milk is seen as an expression of affection and affiliation in terms of feeding and being fed. As it will be shown in the following chapters, this way of thinking underlies many aspects of past practice and theory, despite all the highly scientific arguments in favour of breastfeeding.A few comments on the history of breastfeedingMotherhood and breastfeeding in German speaking Europe have long been the focus of moralizing and disciplinary discourse. The Age of Reformation played a prominent role in shaping contemporary practice in Germany. According to Honegger (1978), the Lutheran reformation led to a dramatic change in the role of sexuality within German morality, legitimising sexual intercourse as a means of producing offspring rather than something to be condemned. This view was partly endorsed by the Roman Catholic Church but only insofar as it helped to reinforce the religious dimension of celibacy. For Protestant women, the bond between themselves and their infants took on even greater significance linked to a moral view of sexuality that may be assumed to have affected the practice of breastfeeding – although to what extent, this remains unclear. The Age of Enlightenment was another turning point. As pointed out by medical historian, Iris Ritzmann, 18th century medical academics “invented” the concept of the infant as patient as a means of gaining access to the nursing of newborn children and women’s reproductive health (Ritzmann, 2004). The result was that breastfeeding became a focus of public discourse. Well-known authors like Jean-Jacques Rousseau regarded mother’s milk (“lait maternel”) as natural, arguing that young mothers were subject to rules of conduct that were neither religious nor judicial in origin but dictated by nature in accordance with the findings of 18th century “modern” science. Anthropologist Carol MacCormack argues that the male supremacist leaders of the French Revolution took to the identification of women with nature as opposed to the identification of men with culture by aiming at the rejection of women’s rights. But rather than theory alone, it was socio-economic change combined with theory that prompted women – and men – to adopt these ideas (MacCormack, 1980). As a matter of fact, it is “body politics” in conjunction with the social and economic dynamics of the “social body” (Scheper-Hughes and Lock, 1987), that has a particular impact on these processes whose effects are in turn subject to historical dynamics.The situation that exists today started with the invention of milk substitutes. In the 18th and the first half of the 19th century, academic medicine focused more on breastfeeding and the behaviour of new mothers (and not only towards their infants) than on the substance of infant nutrition itself. In fact, this only started to become a subject of medicalisation from 1865 onwards, partly due to the recipes for breast-milk substitutes published by chemist Justus Liebig and other scientists. Their endeavours were supported by scientific research into human milk which increasingly turned breast-milk into a biosocial product – a natural product which natural qualities are mediated by scientific analysis – and just one of several alternatives among others (Orland, 2004). As a result, “wet nurses” gradually became redundant.Naturally, the process of medicalisation had an impact. In France the medicalisation of wet nursing was only discussed between experts. In German-speaking medical circles, by contrast, the medicalisation of birth and early childhood was almost exclusively regarded as an issue for young mothers. We know that 19th century wet nurses were predominantly employed by the aristocracy but we also know that German nobility took up certain bourgeois habits, including breastfeeding, from the very beginning of the 19th century (de Bruyn, 2001: 71-98). Furthermore, in countries where the advent of breast-milk substitutes made wet nurses redundant (even for women who could not breastfeed themselves), wet nursing disappeared long before breastfeeding came to symbolise what it does today. Transformed into a symbol of chastity and the family by the Reformation, breast-milk would later link together notions of purity, nature, women and – with the development of the bourgeois family – privacy as well. So it was that within the private/public and female/male dichotomies breast-milk would come to signify both private and female and withdraw itself from the exchange process in general, and in particular from the economical exchange that belonged in the public sphere.Breastfeeding and a woman’s careerAs we saw earlier, the exaggerated symbolic surplus of breastfeeding is evident from the fact that mothers refuse to use any breast-milk except their own. Bearing this in mind, we can decipher the second “disciplinary” message encoded in the breastfeeding concept. Its effectiveness essentially hinges on the biomedical imperative that a mother’s behaviour must minimise any risk for the suckling infant’s health. Not to breastfeed means to increase the infant’s chances of becoming ill, developing a weaker immune system and so on. Risk is a statistical concept but the way in which it is applied – and not only in lay biomedical discourse – makes risk similar to quantities that function by determinism.5 Accordingly, as commented by one of the mothers in this study, illness seems almost inevitable for any infant not fed with mother’s milk: “Of course I give him mother’s milk – otherwise he will fall ill”.Breastfeeding may therefore be seen as a moral postulate and the following example may help to explain why. One of the interviewees, whom we shall call Susanne, decided to wean her eight-week old baby. Up to that point, she had been a member of a breastfeeding group6. These are self-help groups for breastfeeding mothers, often supported by institutions such as churches or community centres. There are regular meetings several times a week, sometimes attended by expert midwives who are paid either by the community or by the group members or by health insurance companies. Susanne, a young researcher at the university, had one of the very rare jobs as a young researcher at university and felt she had to return to work shortly after giving birth. Her colleagues at the university would not have minded if she had breastfed at work but since there were no (private) breastfeeding facilities as such, she decided to wean the baby onto infant formula. Her decision was greeted by disapproval by the rest of the group: “They kept criticising me, they did not understand my situation. To them, I was just a bad mother (“Rabenmutter”). Didn’t I know that milk substitutes were bad for the baby? Nobody realized how hard it was for me at the time, reaching that decision and weaning the baby”. The mutual support that is supposed to be the aim of every breastfeeding group was of no assistance in this case: it seems that whatever a mother’s personal or financial problems, there can be no excuse for not breastfeeding.Turning now to the economics of breastfeeding, it is often argued that it costs less to breastfeed than it does to produce milk substitutes. However, as shown by anthropologist Vanessa Maher, this line of thinking is at least questionable (Maher, 1992a, 1992b) since not only do breastfeeding mothers have to consume more (possibly a negligible consideration in Germany) but they also have to withdraw from the workforce. It is probably true to say that in European societies, a mother’s income from a paid job would normally exceed the savings made from breastfeeding.The inherent conflict of interests here might never arise in the first place if all employers could provide breastfeeding facilities at work. My own data contains two examples of employers who accepted breastfeeding as part of the firm’s “corporate identity”.7 In theory, all employers are obliged by law to provide suitable breastfeeding facilities but in practice many merely pay lip service to these obligations8. Mothers whose needs are neither accommodated nor respected often find it almost impossible to reconcile fulltime employment with breastfeeding. Witness Susanne’s comment: “There is no room available for breastfeeding, and to breastfeed right there in the office is out of question”.According to federal law, new mothers are entitled to two years maternity leave, extendable to three years (for new mothers and fathers) in Baden-Württemberg9. However, those who do interrupt their careers for three years often find that their old employer is reluctant to take them back. Women who return after a second period of maternity leave are met with at best displeasure and at worst aggression. The breastfeeding period is thus precisely when many German women give up their career (Notz, 1991), therefore becoming dependent on their husbands, partners or state social welfare. Additionally, having left the job for which they were originally trained, they also jeopardize their pension benefits (Hoecklin, 2002). Breastfeeding is by no means the crux of the matter but it does affect it in two significant ways. First, it discriminates between women and men in terms of nature and necessity: the fact that only the mother can provide suitable nutrition (breast-milk or “Muttermilch”) makes her the primary caregiver for at least the first six, eight or twelve months of the baby’s life. Second, breastfeeding serves as an argument to imply that child rearing is the job of the mother in general. This argument forms part of a more comprehensive view of nature and culture that associates women with nature and as a result attaches little or no importance to their earning or career potential.ConclusionBased on these data, we may conclude that what breastfeeding discourse highlights is the special nature of the mother-baby relationship. The mother and suckling baby are at the core of kinship relations, with underlying ideas of kinship and motherhood being mirrored in contemporary breastfeeding practices that have a direct effect on the mothers’ lives. The data also provide convincing evidence that in the southern part of Germany at least, breastfeeding reinforces traditional female roles. In contrast to the post-World War II period, when marriage was the decisive step towards becoming a housewife, in contemporary Germany it is the first baby who terminates or at least interrupts a woman’s career and turns her into a housewife. And it is breastfeeding and the medicalisation of mother’s milk that brings about this major transformation.There are, of course, several factors at work here. Most important, the relative lack of state-run day nurseries means that one parent – invariably the mother – has to give up work to look after the baby. In the federal state of Baden-Württemberg, for instance, in southwest Germany, a mere 0.5% of children between the ages of six months and three years are looked after in public day nurseries. Another factor is that the income tax system favours married couples with only one wage earner. On the whole, however, what the underlying discourse turns on is breastfeeding. Viewed from this perspective, Rabinow’s concept of “biocultural” may be regarded as justified: on the one hand, nature and culture are increasingly interrelated as mutually mediated concepts. Nature, or rather what we consider as “nature”, is perfected and supported by science and breastfeeding is a case in point. On the other hand, we make use of “nature” and “culture” to justify social practices.What this clearly reveals is how science, through biomedical discourse in particular, exerts its more conservative effects: for all the discourse on mother’s milk, breastfeeding in southwest Germany still serves to define a woman’s natural role as a housewife, in a private household. Breast-milk (“Muttermilch”) plays a crucial role in all this, coining ideas linked to family, kinship, affection, privacy and the political subordination of women as it is practised and conveyed in social context