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THE RESURGENCE OF
BREASTFEEDING, 1975–2000
The transcript of a Witness Seminar held by the Wellcome Trust Centre
for the History of Medicine at UCL, London, on 24 April 2007
Edited by S M Crowther, L A Reynolds and E M Tansey
Volume 35 2009
©The Trustee of the Wellcome Trust, London, 2009
First published by the Wellcome Trust Centre
for the History of Medicine at UCL, 2009
The Wellcome Trust Centre for the History of Medicine
at UCL is funded by the Wellcome Trust, which is
a registered charity, no. 210183.
ISBN 978 085484 119 6
All volumes are freely available online following the links to Publications/Wellcome Witnesses at
www.ucl.ac.uk/histmed
Technology Transfer in Britain: The case of monoclonal antibodies; Self and Non-Self:
A history of autoimmunity; Endogenous Opiates; The Committee on Safety of Drugs •
Making the Human Body Transparent: The impact of NMR and MRI; Research in General
Practice; Drugs in Psychiatric Practice; The MRC Common Cold Unit • Early Hear t
Transplant Surgery in the UK • Haemophilia: Recent history of clinical management
• Looking at the Unborn: Historical aspects of obstetric ultrasound • Post Penicillin
Antibiotics: From acceptance to resistance? • Clinical Research in Britain, 1950–1980
• Intestinal Absorption • Origins of Neonatal Intensive Care in the UK • British
Contributions to Medical Research and Education in Africa after the Second World
War • Childhood Asthma and Beyond • Maternal Care • Population-based Research in
South Wales: The MRC Pneumoconiosis Research Unit and the MRC Epidemiology Unit
• Peptic Ulcer : Rise and fall • Leukaemia • The MRC Applied Psychology Unit • Genetic
Testing • Foot and Mouth Disease: The 1967 outbreak and its aftermath • Environmental
Toxicology: The legacy of Silent Spring • Cystic Fibrosis • Innovation in Pain Management
• The Rhesus Factor and Disease Prevention • The Recent History of Platelets in
Thrombosis and Other Disorders • Short-course Chemotherapy for Tuberculosis •
Prenatal Corticosteroids for Reducing Morbidity and Mortality after Preterm Birth •
Public Health in the 1980s and 1990s: Decline and rise? • Cholesterol, Atherosclerosis
and Coronary Disease in the UK, 1950–2000 • Development of Physics Applied to
Medicine in the UK, 1945–90 • The Early Development of Total Hip Replacement •
The Discover y, Use and Impact of Platinum Salts as Chemotherapy Agents for Cancer •
Medical Ethics Education in Britain, 1963–1993 • Superbugs and Superdrugs: A history
of MRSA • Clinical Pharmacology in the UK, c. 1950–2000: Inuences and institutions •
Clinical Pharmacology in the UK, c. 1950–2000: Industry and regulation• The Resurgence
of Breastfeeding, 1975–2000
CONTENTS
Illustrations and credits v
Abbreviations vii
Witness Seminars: Meetings and publications; Acknowledgements
E M Tansey, L A Reynolds and S M Crowther ix
Introduction
Rima Apple xxiii
Transcript
Edited by S M Crowther, L A Reynolds and E M Tansey 1
Appendix 1
Recommended feeding times as recorded in Mayes’ textbook,
Handbook of Midwifery, 1937–80 87
Appendix 2
Chairman’s reections after the event 89
References 91
Biographical notes 111
Glossary 125
Index 131
v
ILLUSTRATIONS AND CREDITS
Figure 1 A mother breastfeeding her child. Lithograph,
Wellcome Images. 5
Figure 2 Professor Patrice Jelliffe at the Jelliffe Memorial
Lecture, 1993, in memory of her husband, Professor
Derrick Jelliffe (1921–92), at the XVth International
Congress of Nutrition Conference, Adelaide,
Australia. Reproduced by permission of WABA. 6
Figure 3 The Oppé Report, 1974. Crown copyright;
reproduced under licence from the Office of Public
Sector Information. 10
Figure 4 Nestlé Milk nurses in South Africa, c. 1950. Provided
by Mrs Patti Rundall. 16
Figure 5 Good and poor attachment at the breast.
Provided by and reproduced with permission from
Dr Felicity Savage. 18
Figure 6 24-hour clock, designed by Sir F Truby King (1913).
Provided by Miss Chloe Fisher. 22
Figure 7 Aboriginal mother, aged 20 years, with her six
children. Provided by Professor Roger Short. 36
Figure 8 Dr Cicely Williams in India, 1950, with severely
malnourished child. Reproduced by permission of
Healthlink Worldwide. 47
Figure 9 The Royal College of Midwives’ practical guide, 1988. 50
Figure 10 Positioning the baby correctly. From the Royal College
of Midwives’ practical guide, Successful Breastfeeding,
1988. Provided by Dr Anthony Williams. 61
Figure 11 Breastfeeding uptake and duration in Norway, 1858
to 1998. Provided by Dr Elisabet Helsing. 63
vi
Figure 12 Comparison of the composition of cows’ milk with
infant formula. Reproduced with permission from
Cow and Gate. 71
Figure 13 Comparison of the composition of human milk with
infant formula. Reproduced with permission from
Cow and Gate. 71
vii
COMA Committee on Medical Aspects of Food and
Nutrition Policy (DHSS)
DoH Department of Health
DHSS Department of Health and Social Security
FAO Food and Agricultural Organization
HRP Human Reproduction Programme
IBFAN International Baby Food Action Network
ISRHML International Society of Research in
Human Milk and Lactation
LAM Lactation Amenorrhea Method (of contraception)
LLLI La Leche League International
LLLGB La Leche League Great Britain
NCT National Childbirth Trust
NICE National Institute for Health and Clinical Excellence
ONS Office for National Statistics
OPCS Office of Population Censuses and Surveys
PAG Protein-Calorie Advisory Group of the United Nations System
RDA Recommended Dietary Allowances
UNICEF United Nations International Children’s Emergency Fund
WABA World Alliance for Breastfeeding Action
WHO World Health Organization
ABBREVIATIONS
viii
ix
WITNESS SEMINARS:
MEETINGS AND PUBLICATIONS 1
In 1990 the Wellcome Trust created a History of Twentieth Century Medicine
Group, associated with the Academic Unit of the Wellcome Institute for the
History of Medicine, to bring together clinicians, scientists, historians and others
interested in contemporary medical history. Among a number of other initiatives
the format of Witness Seminars, used by the Institute of Contemporary British
History to address issues of recent political history, was adopted, to promote
interaction between these different groups, to emphasize the potential benefits
of working jointly, and to encourage the creation and deposit of archival sources
for present and future use. In June 1999 the Governors of the Wellcome Trust
decided that it would be appropriate for the Academic Unit to enjoy a more
formal academic affiliation and turned the Unit into the Wellcome Trust Centre
for the History of Medicine at UCL from 1 October 2000. The Wellcome
Trust continues to fund the Witness Seminar programme via its support for
the Centre.
The Witness Seminar is a particularly specialized form of oral history, where
several people associated with a particular set of circumstances or events are
invited to come together to discuss, debate, and agree or disagree about their
memories. To date, the History of Twentieth Century Medicine Group has held
more than 50 such meetings, most of which have been published, as listed on
pages xiii–xxi.
Subjects are usually proposed by, or through, members of the Programme
Committee of the Group, which includes professional historians of medicine,
practising scientists and clinicians, and once an appropriate topic has been
agreed, suitable participants are identified and invited. This inevitably leads to
further contacts, and more suggestions of people to invite. As the organization
of the meeting progresses, a flexible outline plan for the meeting is devised,
usually with assistance from the meeting’s chairman, and some participants are
invited to ‘set the ball rolling’ on particular themes, by speaking for a short
period to initiate and stimulate further discussion.
1 The following text also appears in the ‘Introduction’ to recent volumes of Wellcome Witnesses to Twentieth
Century Medicine published by the Wellcome Trust and the Wellcome Trust Centre for the History of
Medicine at UCL.
x
Each meeting is fully recorded, the tapes are transcribed and the unedited transcript
is sent to every participant. Each is asked to check his or her own contributions and
to provide brief biographical details. The editors turn the transcript into readable
text, and participants’ minor corrections and comments are incorporated into that
text, while biographical and bibliographical details are added as footnotes, as are
more substantial comments and additional material provided by participants. The
final scripts are then sent to every contributor, accompanied by forms assigning
copyright to the Wellcome Trust. Copies of all additional correspondence received
during the editorial process are deposited with the records of each meeting in
archives and manuscripts, Wellcome Library, London.
As with all our meetings, we hope that even if the precise details of some of the
technical sections are not clear to the non-specialist, the sense and significance
of the events will be understandable. Our aim is for the volumes that emerge
from these meetings to inform those with a general interest in the history of
modern medicine and medical science; to provide historians with new insights,
fresh material for study, and further themes for research; and to emphasize to
the participants that events of the recent past, of their own working lives, are of
proper and necessary concern to historians.
Members of the Programme Committee of the
History of Twentieth Century Medicine Group, 2008–09
Professor Tilli Tansey – Professor of the History of Modern Medical Sciences, Wellcome
Trust Centre for the History of Medicine at UCL (WTCHM) and Chair
Sir Christopher Booth – WTCHM, former Director, Clinical Research Centre,
Northwick Park Hospital, London
Mrs Lois Reynolds – Senior Research Assistant, WTCHM, and Organizing Secretary
Dr John Ford – Retired General Practitioner, Tonbridge
Professor Richard Himsworth – former Director of the Institute of Health,
University of Cambridge
Professor Mark Jackson – Centre for Medical History, Exeter
Professor John Pickstone – Wellcome Research Professor, University of Manchester
Dr Helga Satzinger – Reader in History of Twentieth Century Biomedicine, WTCHM
Professor Lawrence Weaver – Professor of Child Health, University of Glasgow, and
Consultant Paediatrician in the Royal Hospital for Sick Children, Glasgow
xi
ACKNOWLEDGEMENTS
‘The resurgence of breastfeeding, c. 1975-2000’ was suggested as a suitable
topic for a witness seminar by Professor Lawrence Weaver, who assisted us in
planning the meeting. We are very grateful to him for his input and for his
excellent chairing of the occasion. We are particularly grateful to Professor Rima
Apple for writing such a useful Introduction to these published proceedings.
We thank Mr James Akre, Professor Lars Hanson, Mrs Rachel O’Leary, Dr
Felicity Savage and Professor Lawrence Weaver for their help with the Glossary
and Dr Elisabet Helsing, Mrs Patti Rundall, Dr Felicity Savage, Miss Chloe
Fisher, Professor Roger Short, Dr Anthony Williams and Mr John Wells for
help with illustrations. For permission to reproduce images included here, we
thank the World Alliance for Breastfeeding Action, Healthlink Worldwide, the
Wellcome Trust and Cow and Gate.
As with all our meetings, we depend a great deal on our colleagues at the
Wellcome Trust to ensure their smooth running: the Audiovisual Department,
and the Medical Photographic Library; Mr Akio Morishima, who has supervised
the design and production of this volume; our indexer, Ms Liza Furnival; and
our readers, Mrs Sarah Beanland and Mr Simon Reynolds; Mrs Jaqui Carter is
our transcriber, and Mrs Wendy Kutner and Dr Daphne Christie assisted us in
running this meeting. Finally we thank the Wellcome Trust for supporting this
programme.
Tilli Tansey
Lois Reynolds
Stefania Crowther
Wellcome Trust Centre for the History of Medicine at UCL
xiii
HISTORY OF TWENTIETH CENTURY MEDICINE
WITNESS SEMINARS, 1993–2008
1993 Monoclonal antibodies
1994 The early history of renal transplantation
Pneumoconiosis of coal workers
1995 Self and non-self: A history of autoimmunity
Ashes to ashes: The history of smoking and health
Oral contraceptives
Endogenous opiates
1996 Committee on Safety of Drugs
Making the body more transparent: The impact of nuclear
magnetic resonance and magnetic resonance imaging
1997 Research in general practice
Drugs in psychiatric practice
The MRC Common Cold Unit
The first heart transplant in the UK
1998 Haemophilia: Recent history of clinical management
Obstetric ultrasound: Historical perspectives
Post penicillin antibiotics
Clinical research in Britain, 1950–1980
xiv
1999 Intestinal absorption
The MRC Epidemiology Unit (South Wales)
Neonatal intensive care
British contributions to medicine in Africa after the Second
World War
2000 Childhood asthma, and beyond
Peptic ulcer: Rise and fall
Maternal care
2001 Leukaemia
The MRC Applied Psychology Unit
Genetic testing
Foot and mouth disease: The 1967 outbreak and its aftermath
2002 Environmental toxicology: The legacy of Silent Spring
Cystic fibrosis
Innovation in pain management
2003 Thrombolysis
Beyond the asylum: Anti-psychiatry and care in the community
The Rhesus factor and disease prevention
The recent history of platelets: Measurements,
functions and applications in medicine
xv
2004 Short-course chemotherapy for tuberculosis
Prenatal corticosteroids for reducing morbidity and mortality
associated with preterm birth
Public health in the 1980s and 1990s: Decline and rise?
2005 The history of cholesterol, atherosclerosis and coronary disease
Development of physics applied to medicine in the UK,
1945–90
2006 Early development of total hip replacement
The discovery, use and impact of platinum salts as chemotherapy
agents for cancer
Medical ethics education in Britain, 1963–93
Superbugs and superdrugs: The history of MRSA
2007 The rise and fall of clinical pharmacology
in the UK, c. 1950–2000
The resurgence of breastfeeding, 1975–2000
DNA fingerprinting
The development of sports medicine in
twentieth-century Britain
2008 History of dialysis, c. 1950–2000
History of cervical cancer and the role of the human
papillomavirus over the last 25 years
Clinical genetics in Britain: Origins and development
xvi
PUBLISHED MEETINGS
‘…Few books are so intellectually stimulating or uplifting’.
Journal of the Royal Society of Medicine (1999) 92: 206–8,
review of vols 1 and 2
‘…This is oral history at its best…all the volumes make compulsive reading…they
are, primarily, important historical records’.
British Medical Journal (2002) 325: 1119, review of the series
Technology transfer in Britain: The case of monoclonal antibodies
Self and non-self: A history of autoimmunity
Endogenous opiates
The Committee on Safety of Drugs
Tansey E M, Catterall P P, Christie D A, Willhoft S V, Reynolds L A. (eds)
(1997) Wellcome Witnesses to Twentieth Century Medicine. Volume 1. London:
The Wellcome Trust, 135pp. ISBN 1 869835 79 4
Making the human body transparent: The impact of NMR and MRI
Research in general practice
Drugs in psychiatric practice
The MRC Common Cold Unit
Tansey E M, Christie D A, Reynolds L A. (eds) (1998) Wellcome
Witnesses to Twentieth Century Medicine. Volume 2. London: The Wellcome
Trust, 282pp. ISBN 1 869835 39 5
Early heart transplant surgery in the UK
Tansey E M, Reynolds L A. (eds) (1999) Wellcome Witnesses to
Twentieth Century Medicine. Volume 3. London: The Wellcome Trust, 72pp.
ISBN 1 841290 07 6
Haemophilia: Recent history of clinical management
Tansey E M, Christie D A. (eds) (1999) Wellcome Witnesses to
Twentieth Century Medicine. Volume 4. London: The Wellcome Trust, 90pp.
ISBN 1 841290 08 4
Looking at the unborn: Historical aspects of obstetric ultrasound
Tansey E M, Christie D A. (eds) (2000) Wellcome Witnesses to
Twentieth Century Medicine. Volume 5. London: The Wellcome Trust, 80pp.
ISBN 1 841290 11 4
xvii
Post penicillin antibiotics: From acceptance to resistance?
Tansey E M, Reynolds L A. (eds) (2000) Wellcome Witnesses to Twentieth
Century Medicine. Volume 6. London: The Wellcome Trust, 71pp.
ISBN 1 841290 12 2
Clinical research in Britain, 1950–1980
Reynolds L A, Tansey E M. (eds) (2000) Wellcome Witnesses to Twentieth
Century Medicine. Volume 7. London: The Wellcome Trust, 74pp.
ISBN 1 841290 16 5
Intestinal absorption
Christie D A, Tansey E M. (eds) (2000) Wellcome Witnesses to Twentieth
Century Medicine. Volume 8. London: The Wellcome Trust, 81pp.
ISBN 1 841290 17 3
Neonatal intensive care
Christie D A, Tansey E M. (eds) (2001) Wellcome Witnesses to Twentieth
Century Medicine. Volume 9. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 84pp. ISBN 0 854840 76 1
British contributions to medical research and education in Africa after the
Second World War
Reynolds L A, Tansey E M. (eds) (2001) Wellcome Witnesses to Twentieth
Century Medicine. Volume 10. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 93pp. ISBN 0 854840 77 X
Childhood asthma and beyond
Reynolds L A, Tansey E M. (eds) (2001) Wellcome Witnesses to Twentieth
Century Medicine. Volume 11. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 74pp. ISBN 0 854840 78 8
Maternal care
Christie D A, Tansey E M. (eds) (2001) Wellcome Witnesses to Twentieth
Century Medicine. Volume 12. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 88pp. ISBN 0 854840 79 6
Population-based research in south Wales: The MRC Pneumoconiosis
Research Unit and the MRC Epidemiology Unit
Ness A R, Reynolds L A, Tansey E M. (eds) (2002) Wellcome Witnesses to
Twentieth Century Medicine. Volume 13. London: The Wellcome Trust Centre
for the History of Medicine at UCL, 74pp. ISBN 0 854840 81 8
xviii
Peptic ulcer: Rise and fall
Christie D A, Tansey E M. (eds) (2002) Wellcome Witnesses to Twentieth
Century Medicine. Volume 14. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 143pp. ISBN 0 854840 84 2
Leukaemia
Christie D A, Tansey E M. (eds) (2003) Wellcome Witnesses to Twentieth
Century Medicine. Volume 15. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 86pp. ISBN 0 85484 087 7
The MRC Applied Psychology Unit
Reynolds L A, Tansey E M. (eds) (2003) Wellcome Witnesses to Twentieth
Century Medicine. Volume 16. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 94pp. ISBN 0 85484 088 5
Genetic testing
Christie D A, Tansey E M. (eds) (2003) Wellcome Witnesses to Twentieth
Century Medicine. Volume 17. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 130pp. ISBN 0 85484 094 X
Foot and mouth disease: The 1967 outbreak and its aftermath
Reynolds L A, Tansey E M. (eds) (2003) Wellcome Witnesses to Twentieth
Century Medicine. Volume 18. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 114pp. ISBN 0 85484 096 6
Environmental toxicology: The legacy of Silent Spring
Christie D A, Tansey E M. (eds) (2004) Wellcome Witnesses to Twentieth
Century Medicine. Volume 19. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 132pp. ISBN 0 85484 091 5
Cystic fibrosis
Christie D A, Tansey E M. (eds) (2004) Wellcome Witnesses to Twentieth
Century Medicine. Volume 20. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 120pp. ISBN 0 85484 086 9
Innovation in pain management
Reynolds L A, Tansey E M. (eds) (2004) Wellcome Witnesses to Twentieth
Century Medicine. Volume 21. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 125pp. ISBN 0 85484 097 4
xix
The Rhesus factor and disease prevention
Zallen D T, Christie D A, Tansey E M. (eds) (2004) Wellcome Witnesses to
Twentieth Century Medicine. Volume 22. London: The Wellcome Trust Centre
for the History of Medicine at UCL, 98pp. ISBN 0 85484 099 0
The recent history of platelets in thrombosis and other disorders
Reynolds L A, Tansey E M. (eds) (2005) Wellcome Witnesses to Twentieth
Century Medicine. Volume 23. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 186pp. ISBN 0 85484 103 2
Short-course chemotherapy for tuberculosis
Christie D A, Tansey E M. (eds) (2005) Wellcome Witnesses to Twentieth
Century Medicine. Volume 24. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 120pp. ISBN 0 85484 104 0
Prenatal corticosteroids for reducing morbidity and mortality after
preterm birth
Reynolds L A, Tansey E M. (eds) (2005) Wellcome Witnesses to Twentieth
Century Medicine. Volume 25. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 154pp. ISBN 0 85484 102 4
Public health in the 1980s and 1990s: Decline and rise?
Berridge V, Christie D A, Tansey E M. (eds) (2006) Wellcome Witnesses to
Twentieth Century Medicine. Volume 26. London: The Wellcome Trust Centre
for the History of Medicine at UCL, 101pp. ISBN 0 85484 106 7
Cholesterol, atherosclerosis and coronary disease in the UK, 1950–2000
Reynolds L A, Tansey E M. (eds) (2006) Wellcome Witnesses to Twentieth
Century Medicine. Volume 27. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 164pp. ISBN 0 85484 107 5
Development of physics applied to medicine in the UK, 1945–90
Christie D A, Tansey E M. (eds) (2006) Wellcome Witnesses to Twentieth
Century Medicine. Volume 28. The Wellcome Trust Centre for the History of
Medicine at UCL, 141pp. ISBN 0 85484 108 3
Early development of total hip replacement
Reynolds L A, Tansey E M. (eds) (2007) Wellcome Witnesses to Twentieth
Century Medicine. Volume 29. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 198pp. ISBN 978 085484 111 0
xx
The discovery, use and impact of platinum salts as chemotherapy agents
for cancer
Christie D A, Tansey E M. (eds) (2007) Wellcome Witnesses to Twentieth
Century Medicine. Volume 30. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 142pp. ISBN 978 085484 112 7
Medical Ethics Education in Britain, 1963–93
Reynolds L A, Tansey E M. (eds) (2007) Wellcome Witnesses to Twentieth
Century Medicine. Volume 31. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 241pp. ISBN 978 085484 113 4
Superbugs and superdrugs: A history of MRSA
Reynolds L A, Tansey E M. (eds) (2008) Wellcome Witnesses to Twentieth
Century Medicine. Volume 32. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 167pp. ISBN 978 085484 114 1
Clinical pharmacology in the UK, c. 1950–2000: Influences
and institutions
Reynolds L A, Tansey E M. (eds) (2008) Wellcome Witnesses to Twentieth
Century Medicine. Volume 33. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 148pp. ISBN 978 085484 117 2
Clinical pharmacology in the UK, c. 1950–2000: Industry and regulation
Reynolds L A, Tansey E M. (eds) (2008) Wellcome Witnesses to Twentieth
Century Medicine. Volume 34. London: The Wellcome Trust Centre for the
History of Medicine at UCL, 168pp. ISBN 978 085484 118 9
The resurgence of breastfeeding, 1975–2000
Crowther S M, Reynolds L A, Tansey E M. (eds) (2009) Wellcome Witnesses to
Twentieth Century Medicine. Volume 35. London: The Wellcome Trust Centre
for the History of Medicine at UCL (this volume). ISBN 978 085484 119 6
The development of sports medicine in twentieth century Britain
Reynolds L A, Tansey E M. (eds) (2009) Wellcome Witnesses to Twentieth
Century Medicine. Volume 36. London: The Wellcome Trust Centre for the
History of Medicine at UCL (in press). ISBN 978 085484 121 9
History of dialysis in the UK: c. 1950–2000
Crowther S M, Reynolds L A, Tansey E M. (eds) (2009) Wellcome Witnesses to
Twentieth Century Medicine. Volume 37. London: The Wellcome Trust Centre
for the History of Medicine at UCL (in press). ISBN 978 085484 122 6
xxi
History of cervical cancer and the role of the human papillomavirus over
the last 25 years
Reynolds L A, Tansey E M. (eds) (2009) Wellcome Witnesses to Twentieth
Century Medicine. Volume 38. London: The Wellcome Trust Centre for the
History of Medicine at UCL (in press). ISBN 978 085484 123 3
Hard copies of volumes 1–20 are now available for free, while stocks
last. We would be happy to send complete sets to libraries in developing
or restructuring countries. Available from Dr Carole Reeves at:
c.reeves@ucl.ac.uk
All volumes are freely available online at www.ucl.ac.uk/histmed/
publications/wellcome-witnesses/index.html or by following the links to
Publications/Wellcome Witnesses at www.ucl.ac.uk/histmed
A hard copy of volumes 21–35 can be ordered from www.amazon.co.uk;
www.amazon.com; and all good booksellers for £6/$10 plus postage, using
the ISBN.
xxii
OTHER PUBLICATIONS
Technology transfer in Britain: The case of monoclonal antibodies
In: Tansey E M, Catterall P P. (1993) Contemporary Record 9: 409–44.
Monoclonal antibodies: A witness seminar on contemporary
medical history
In: Tansey E M, Catterall P P. (1994) Medical History 38: 322–7.
Chronic pulmonary disease in South Wales coalmines: An eye-witness
account of the MRC surveys (1937–42)
In: D’Arcy Hart P, edited and annotated by E M Tansey. (1998) Social
History of Medicine 11: 459–68.
Ashes to Ashes – The history of smoking and health
In: Lock S P, Reynolds L A, Tansey E M. (eds) (1998) Amsterdam: Rodopi
BV, 228pp. ISBN 90420 0396 0 (Hfl 125) (hardback). Reprinted 2003.
Witnessing medical history. An interview with Dr Rosemary Biggs
Professor Christine Lee and Dr Charles Rizza (interviewers). (1998)
Haemophilia 4: 769–77.
Witnessing the Witnesses: Pitfalls and potentials of the Witness Seminar
in twentieth century medicine
By E M Tansey. In: Doel R, Soderqvist T. (eds) (2006) Writing Recent Science:
The historiography of contemporary science, technology and medicine. London:
Routledge, 260–78.
The Witness Seminar technique in modern medical History of Medicine
By E M Tansey. In: Cook H J, Bhattacharya S, Hardy A. (eds) (2009) History
of the Social Determinants of Health: Global histories, contemporary debates.
London: Orient BlackSwan, 279–95.
xxiii
INTRODUCTION
For millennia, infant feeding was breastfeeding and the nursing mother was idealized
as the source of strength, of power, of family. Before the nineteenth century, infants
denied breast-milk were not likely to survive. Medicine could provide a substitute
for mother’s milk, if absolutely necessary, but artificial feeding was a poor substitute
for breastfeeding. Yet, by the middle of the twentieth century, in many industrialized
countries, the overwhelming majority of infants were bottle-fed. In a popular 1957
childcare book, the chapter titled ‘Breastfeeding’ opens with the question: ‘Breast or
bottle?’ and answers: ‘This is something that every mother must decide for herself.’2
The good doctor–author explains that a mother might choose not to breastfeed
for many reasons: if she has tuberculosis; if she has had serious complications from
labour; if her breast is infected; and if she ‘dislikes the idea of nursing’. Moreover, he
assures the reader that:
A mother who cannot or does not wish to nurse, or a mother who
must return to a job should not feel that she is neglecting an important
duty… A bottle mother may still be a perfect mother.3
With developments in science, in clinical medicine and in commerce, with
changes in women’s roles in society and with the increasing concern over
the high rates of infant mortality and morbidity, by the first half of the
twentieth century, clinicians and researchers all agreed that ‘breast is best’. At
the same time, however, they insisted that with modern medicine, modern
technology, clean water and a careful mother, bottle-feeding was satisfactory for
most infants.
Mid-nineteenth-century medical science had generated increasingly sophisticated
analyses of milk – human milk, goats’ milk, cows’ milk and mares’ milk. Cows’
milk and human milk differed in more than chemical composition. Nursing
mothers and wet-nurses fed their infants directly from the breast, whereas cows’
milk, especially that sold in cities, passed through many hands and the product
bought by the consumer was often not pure. In addition, by the 1870s, those
aware of contemporary bacteriological research also worried about bacterial
contamination. To eliminate these problems doctors recommended heating the
milk. As physicians determined the differences among milks, they worked to
create a suitable match for human milk.
2 Holt (1957): 63.
3 Holt (1957): 65.
xxiv
By late in the century, extremely high infant mortality rates alarmed the
general public and galvanized medical researchers, who declared that the most
significant cause of infant deaths was poor diet. As Thomas Morgan Rotch, a
leading pediatrician and Harvard professor at the turn of the century stated:
The preventive medicine of early life is pre-eminently the intelligent
management of the nutriment which enables young human beings to
breathe and grow and live. In fact, it is a proper or improper nutriment
which makes or mars the perfection of the coming race. Infant feeding,
then, is the subject of all others which should interest and incite to
research all who are working in the preventive medicine of early life.4
Infant feeding studies became the raison d’être of paediatric research and
increasingly infant feeding became the focus of paediatric practice, too.
In addition to physicians, manufacturers also sought to create a substitute
for human milk. Some of these products, such as Liebig’s Food, which was
concocted by Justus Liebig in the 1860s, were intended to be dissolved in milk.
Others, such as Nestlé’s Milk Food, were complete foods, already containing
milk. These products flooded the market in the second half of the nineteenth
century, widely advertised in medical journals to physicians, and women’s and
general interest magazines to mothers.
Women were aware of the higher mortality rates for bottle-fed infants, yet
not every mother could or would nurse her child. Allegedly, increasing
numbers of women refused to breastfeed because nursing ‘tied them down’,
as changes in modern society not only altered women’s domestic roles but
also extended their activities outside the home. Though few women voiced
this sentiment themselves, no doubt some mothers felt constrained when
they had to stay at home to nurse an infant. Other women worried that
their milk supplies were inadequate, believing that physical conditions and
the effects of modern life could prevent successful lactation. Such women
wanted a convenient, safe and healthful alternative to mother’s milk. They
looked to science for the solution.
By the 1920s, bottle-feeding had become the generally accepted mode of infant
feeding. Physicians and other commentators continued to give lip-service to the
benefits of breast-milk, but they were willing and sometimes eager to replace the
mother’s breast with a bottle. As one mother related in 1926:
4 Rotch (1893): 505.
xxv
I have a fine baby boy, age 12 weeks, weight 12 pounds 6 oz. At first I
had more than enough milk for him but the last two weeks I have not
had enough, and had my doctor give me a formula for to feed him part
time – about two or three feedings a day. I do not understand why I
cannot nurse him as at first…. When I asked my doctor again about it,
he said: ‘Why don’t you wean him altogether?’5
With a bottle one could be certain of what the infant was receiving, both
qualitatively and quantitatively. Moreover, products such as SMA and Nestlé’s
were fortified with newly discovered and synthesized vitamins, which promised
protection against diseases such as rickets. When paediatric researchers
conducted studies comparing the health of breast- and bottle-fed babies, they
concluded that there was little difference in their health status, if the mother
followed carefully the rules laid out by her physician for feeding the child.
Another significant factor that promoted artificial infant feeding in the
twentieth century in developed countries was the increasingly common practice
of hospitalized childbirth. These institutions provided a prime educational
situation for isolated, nervous mothers who looked to modern, scientific
childcare to ensure the health of their families. As hospitalized childbirth
became increasingly popular, doctors and hospital administrators saw epidemics
sweeping through their maternity wards. Our knowledge about the spread
of diseases grew in the late nineteenth and early twentieth centuries when
scientists and doctors developed a greater understanding of the germ theory of
disease. However, knowledge of the transmission of disease did not immediately
lead to knowledge about the prevention of disease. The era of sulfa drugs and
antibiotics was decades away. Fearful of epidemics, hospitals would care for
newborns in sterile nurseries, safely separated from their mothers who saw them
only for feedings, every three or four hours. Visualize the typical situation of
the twentieth-century new mother: for most of her 7–10 days in the hospital
after childbirth she would peer through the window of the nursery looking at
her child. Every several hours, a nurse would bring the baby to the mother,
who carefully unwrapped the baby and tried to feed it. Within a few minutes,
the nurse would be back to whisk the baby away again. These procedures left
little time for the mother and baby to get acquainted or for the mother to feel
comfortable caring for her child. Additionally, acting on the medical profession’s
concern about the initial weight loss exhibited by many newborns, hospitals
5 Mrs C A, Detroit, Michigan, 2 March 1926, letter to the US Children’s Bureau, quoted in Ladd-Taylor
(1986): 77–8.
xxvi
often instituted automatic supplemental feeding programmes. Nursing mothers
were encouraged to sleep through the night and babies received night bottle-
feedings in the nursery. Thus, hospital conditions and practices discouraged
breastfeeding and encouraged the belief that bottle-feeding was as good as, if
not better than, mother’s milk.
Throughout the twentieth century, women in the developed world observed
the benefits of modern medical science. When their children faced previously
disastrous childhood diseases such as diphtheria and pneumonia, physicians
treated them with new discoveries like diphtheria antitoxin, sulfa drugs and
penicillin, and they thrived. Children who experienced nutritional deficiencies
improved dramatically through the use of newly found and synthesized vitamins
and other micronutrients. The manufacture of insulin enabled diabetic children
to survive and to live healthy lives. Consequently, mothers concerned for the
wellbeing of their families embraced bottle-feeding as the modern and scientific
way to ensure the health of their infants.
Many of the same scientific, medical, commercial and social factors that had
interested nineteenth-century physicians revived concerns about infant feeding
in the late twentieth century. At the same time, observers recognized that there
was a decline in maternal nursing in the developing world, a decline linked to
a significant worsening of already high infant mortality rates. Many physicians,
nurses, nutritionists and public health officials acknowledged this growing
problem and turned once again to the study of mother’s milk. Researchers
scrutinized the parameters of maternal nursing with the goal of establishing
the most healthful form of infant feeding. Given that breast-milk is best, for
how long should an infant be breastfed? For how long should the infant be
exclusively breastfed? What, if any, supplements are healthful? Necessary?
Under what conditions, if any, should a mother forego breastfeeding her child?
As in the earlier period, researchers also studied the mother’s ability to produce
appropriate breast-milk. Were some women unsuited for maternal nursing
because of their nutritional status or other physical condition? The questions
were similar to those posed a century earlier, but with newer, more sophisticated
laboratory assays, more complex analyses integrating scientific, social, cultural
and environmental factors, and more broadly drawn and clearly defined data
bases, the interdisciplinary studies conducted by researchers and clinicians, as
well as the participation of international agencies with their unavoidable political
agendas, made breastfeeding a critical topic of discussion in medical and public
health circles and brought renewed attention to those age-old questions.
xxvii
As this Witness Seminar documents, the admonition that ‘breast is best’ is not
a simple solution to the problem of infant mortality and morbidity. Maternal
nursing is a complex physiological process, shaped by environment, culture,
economics and politics. In recreating and debating their work over the past
quarter century, the Witness Seminar participants – researchers, medical
practitioners, midwives, industry representatives and breastfeeding activists
– remind us of the very important questions that have and that continue to
influence our study of health practices. The questions must and will be asked,
though we recognize that the answers are always contingent and they more
often than not give rise to still other questions. The testimonies at this Witness
Seminar clearly demonstrate that despite all the studies on the physiology of
maternal nursing, on the benefits of breast-milk and on the factors that inhibit
and encourage mothers’ nursing, breastfeeding is not an unquestioningly
accepted part of the children’s lives. But the drive to better understand the
process of breastfeeding will and must persist if we are to ensure the health and
well-being of future generations.
Rima D Apple
University of Wisconsin-Madison
THE RESURGENCE OF
BREASTFEEDING, 1975–2000
The transcript of a Witness Seminar held by the Wellcome Trust Centre
for the History of Medicine at UCL, London, on 24 April 2007
Edited by S M Crowther, L A Reynolds and E M Tansey
2
THE RESURGENCE OF
BREASTFEEDING, 1975–2000
Participants
Among those attending the meeting: Mrs Janette Allotey, Mrs Jane Britten,
Ms Charlotte Faircloth, Ms Rachel Hillman, Ms Naomi Lewis, Dr Rhona
McInnes, Professor John Walker-Smith
Apologies include: Professor Jaques Bindels, Professor Peter Elwood,
Professor Stewart Forsyth, Professor Armond Goldman, Ms Sheila Kitzinger,
Dr Penelope Leach, Professor Alan Lucas, Professor Pearay Ogra, Dr Andrew
Radford, Dr Aileen Robertson, Professor Wendy Savage, Dr Andrew Stanway,
Professor Daffyd Walters
Mr James Akre
Professor Elizabeth Alder
Mrs Phyll Buchanan
Professor Forrester Cockburn
Ms Rosie Dodds
Mrs Jill Dye
Professor Fiona Dykes
Ms Hilary English
Miss Chloe Fisher
Professor Anna Glasier
Professor Lars Hanson
Dr Elisabet Helsing
Dr Edmund Hey
Professor Peter Howie
Professor Alan McNeilly
Professor Kim Michaelsen
Mrs Rachel O’Leary
Ms Gabrielle Palmer
Professor Malcolm Peaker
Dr Ann Prentice
Professor Mary Renfrew
Mrs Patti Rundall
Ms Ellena Salariya
Dr Felicity Savage
Professor Roger Short
Dr Mary Smale
Dr Alison Spiro
Dr Penny Stanway
Dr Tilli Tansey
Mrs Jenny Warren
Professor Lawrence Weaver (chair)
Mr John Wells
Professor Brian Whar ton
Professor Roger Whitehead
Dr Anthony Williams
Miss Carol Williams
Dr Michael Woolridge
The Resurgence of Breastfeeding, 1975–2000
3
Dr Tilli Tansey: I am the convenor of the History of Twentieth Century
Medicine Group, which was started by the Wellcome Trust in 1990 to bring
together medical historians, medical practitioners and others who have
contributed to events in postwar medicine. Just over ten years ago we designed
these Witness Seminars, to get people who have been involved in particular
discoveries, debates or advances, to come and sit together in a chairman-led
meeting to discuss what really happened, how things did happen, and why they
happened the way they did.
The topics for these meetings are chosen by a programme committee of
scientists, clinicians and historians. There are usually 20 or 30 topics suggested
each year, and this topic was from Lawrence Weaver, who very kindly agreed to
chair this meeting today. So without further ado, I will hand over to Lawrence
to introduce the topic of the meeting and say something about the subject.
Professor Lawrence Weaver: Thank you everyone for coming. Breastfeeding
may seem a rather obscure and arcane subject for a history of medicine Witness
Seminar, but, of course, breastfeeding affects the early health, even survival, of
babies and can protect them from disease in childhood and in later life. This
Witness Seminar is devoted to what happened to breastfeeding over the last 30
years or so.
There seems to have been an upturn in the incidence of breastfeeding over the
last 25 years, after a steady decline during the first half of the last century. During
this period we have witnessed increasing concern about the declining numbers
of mothers who wished to breastfeed their babies and efforts have been made
to reverse this trend. This has brought together paediatricians, obstetricians,
nutritional scientists, lactational physiologists, public health professionals,
women’s organizations, the church, pressure groups and international agencies
in various combinations and alliances. These efforts have occurred against a
background of the development and promotion of breast-milk substitutes. Infant
formulae have become more refined to resemble human milk, are international
in use and brand-led. A few big companies now control the supply of baby
milks throughout the world.
Gathered here today are representatives of most of these groups and my hope
is that we can explore this story, covering the period we have lived and worked
through. I chose 1975 as a starting point because it represents a nadir in
breastfeeding rates;1 also, 1975 is about as far back as most of us can remember,
1 See note 8.
The Resurgence of Breastfeeding, 1975–2000
4
or should I say as far back as we are likely to have been professionally involved.
So, before we get going, I want to sketch out briefly how I think we reached
what we now probably all agree is a very dismal situation, a state of affairs
where the majority of mothers in this country, and also in parts of the US and
elsewhere, never nursed their babies, had no intention of doing so and were
given little support or help in suckling them, even if they had wished to do
so. Bottle-feeding had become regarded as normal, not just socially, but also
medically, and in the minds of some members of the medical profession, as
better than the breast for mothers and babies.
Let us go back 100 years, to try to identify how such a state of affairs came
about. Before the development of clean and nutritionally balanced human
milk substitutes, not being breastfed during the early months of life was pretty
much a death sentence. The Dublin Lying-in Hospital, for instance, in 1799
records a mortality rate of over 99 per cent in infants who were not suckled by
their mothers.2
By the end of the nineteenth century, knowledge of the nutrient composition
of human and cows’ milk, an understanding of the energy needs of the
newborn, along with recognition of the importance of clean milk with the
introduction of sterilization, hygienic storage, etc., meant that bottle-feeding
not only became possible, but saved lives. The growing employment of young
women in the labour force and their social emancipation meant that many
weaned their babies soon after birth. Feeding babies on artificial milk became
a weapon in the battle to control infant mortality – then around 150 per
thousand live births – and was given added urgency by the need to maintain a
supply of fit young men for the imperial armies of Europe. Efforts to humanize
bovine milk to mimic human milk brought together paediatricians, public
health clinicians, chemists and food technologists.3 Infant milk depots became
a rallying initiative across Europe and North America and, although designed
to promote and support breastfeeding, in many instances they became an
outlet for modified cows’ milk.4 As a public health initiative, the depots largely
2 Abt and Garrison wrote: ‘Of the 10 272 infants admitted to the Dublin Foundling Hospital during 21 years
(1775–96), only 45 survived, a mortality rate of 99.6 per cent’ (1965): 81. See also Routh (1879): 243; Fildes
(1985): 275, who quotes two earlier works, Forsyth (1911): note 39, and Wodsworth (1876): note 120.
3 See Weaver (2006); Mepham (1993). For earlier accounts of the infant welfare movement, see Newman
(1906); McCleary (1933).
4 Ferguson et al. (2006); Weaver (2008).
The Resurgence of Breastfeeding, 1975–2000
5
disappeared by the end of the First World War, and by then dried milk had
become widely available, formulae were on the market and the habit of bottle-
feeding had caught hold.5
The acceptability and practice of bottle-feeding extended across the social
classes, as it became regarded as safe, easy, convenient and affordable. The
interwar years saw the start of a long, steady decline in breastfeeding, set in
motion in part by the necessity of dealing with high infant mortality and poor
infant health with safe formula feeding, among a raft of other maternal and
child welfare initiatives.6
5 Professor Lawrence Weaver wrote: ‘The late nineteenth and early twentieth centuries saw the publication
of many books about infant feeding, which had the effect of promoting infant formula. See, for instance,
Cautley (1896); Cheadle (1889); Holt (1901); Dingwall-Fordyce (1908); Sadler (1909); Vincent (1910).’
Note on draft transcript, 20 October 2008.
6 Professor Lawrence Weaver wrote: ‘These maternal and infant welfare initiatives included health visiting,
maternity allowances, domestic science classes in schools and subsidized meals for young mothers. A
number of historians have written about the relations between maternal and infant welfare, childbirth,
infant feeding and efforts to control infant mortality. See, for instance, Apple (1986, 1987); Borst (1995);
Dwork (1987a and b); Meckel (1990).’ Note on draft transcript, 20 October 2008.
Figure 1: A mother breastfeeding her child, Lithograph, Wellcome Images.
The Resurgence of Breastfeeding, 1975–2000
6
By the 1960s a number of forces began to converge, or at least to excite the
attention of those who cared for mothers and their babies. Paediatricians and
nutritional scientists working in the developing world were not slow to appreciate
the life-saving properties of human milk. Infant malnutrition stared them in the
face and both public health initiatives and scientific research programmes began
to focus on infant feeding. Derrick (Dick) and Patrice (Pat) Jelliffe’s book, Human
Milk in the Modern World, published in 1978, was both a powerful statement of
the problem and a manifesto for action.7 Paediatricians in the developed world
were apparently too preoccupied with building up their subspecialties and even
neonatologists had scant interest in how their patients were fed, especially after they
had gone home. Obstetricians, in many cases, seemed primarily interested in safe
childbirth from the mother’s point of view and with it increasing hospitalization
and medical control. Moreover, the dominant responsibility of midwives was to
7 Jelliffe and Jelliffe (1978).
Figure 2: Professor E F Patrice Jelliffe at the Jelliffe Memorial Lecture, 1993, in memory of
her late husband, Professor Derrick Jelliffe (1921–92), at the XVth International Congress
of Nutrition Conference, Adelaide, Australia. L to R: Dr Michael Latham (presenter of
the keynote address); Professor Jelliffe, Dr C Gopalan, Professor Irwin Shorr (chair) and
Dr Elisabet Helsing. For further details, see www.waba.org.my/news/pat_jeliffe.htm
(visited 20 January 2009).
The Resurgence of Breastfeeding, 1975–2000
7
mothers and infant feeding seemed of little concern to them once the baby was
delivered safely. Then the simplest thing to do was to provide formula with proper
instructions on how to make up bottles and to leave mother and baby to get on
with it. Even in maternity units, and particularly in the so-called premier units,
such as the Simpson Memorial Maternity Pavilion in Edinburgh, breastfeeding
rates in mothers leaving the postnatal wards dropped to below 20 per cent around
1970. I don’t want to go into these figures in detail, but there is no doubt that
the 1970s represent a nadir in breastfeeding rates.8 Now this is a very broad-brush
sketch of events and is designed simply to set the scene for our starting point in
the mid-1970s. We may well pick up on some of these topics, even question my
interpretation. One or two people here have queried the appropriateness of the
term ‘resurgence’ of breastfeeding.9 This is a fair comment and at the heart of
the topics that I hope we will discuss. But, for whatever reason, it is a fact that
breastfeeding rates were much lower in the 1970s than in the decades before,
and lower than they are now. Perhaps the first question to ask is how we came to
recognize that there was a problem. One answer to this must be the work done
in the developing world and I am going to ask Roger Whitehead to set the ball
rolling in that area.
Professor Roger Whitehead: Although historically it has not always been so,
it is now widely accepted throughout the world that feeding a baby from the
breast represents the best form of nourishment for the young baby and thus
it is highly desirable. In the economically underprivileged populations of the
world, however, it is something more than that, it is often a matter of life or
death for the young child whether or not breastfeeding becomes established
and is then continued for an appropriate length of time. The reason is well
known to everyone here; there are no affordable alternative sources of food that
come anywhere near to matching the complex nutritional needs of the infant.
And this is compounded by the often impossible hygienic conditions that the
mother has to face when she tries to make up such foods.
8 See Table 1, page 9. Ms Rosie Dodds wrote: ‘There may have been a nadir in 1975, but initiation rates in
the UK remained almost completely unchanged as measured by successive Infant Feeding Surveys between
1980 and 2000, when rates started to increase in Scotland, so a resurgence in the UK is not evident [Bolling
et al. (2007)]. In England and Wales, 67 per cent of mothers breastfed their babies at birth in 1980, 65 per
cent in 1985 and 67 per cent in 2005, standardized for the age and educational level of women in 1985.
The rapid decline in breastfeeding in the early days and weeks is also markedly similar across the decades.’
E-mail to Ms Stefania Crowther, 9 December 2008. See discussion on pages 9–10.
9 See pages 9–10, 65–6, 78–9; Appendix 2, page 89; and note 8.
The Resurgence of Breastfeeding, 1975–2000
8
Closely linked with this issue has been the historical debate about the length
of time for which breastfeeding alone can satisfy the total nutritional needs of
the growing baby. Largely on empirical grounds, a period of four to six months
was suggested many years ago.10 But this was not universally accepted by any
means, not only by the food industry, of course, who had a vested interest, but,
I am afraid, also by the paediatric and child health professions as well.11 And, to
compound this problem, when one measured the breast-milk intake of babies
and compared these with the accepted energy requirements of young babies it
indicated that the period for which exclusive breastfeeding was adequate was
nearer to two to three months than four to six months. This was a scientific
challenge my colleagues and I set out to investigate.
To cut a long story short, using both traditional and novel stable isotope
techniques for measuring energy expenditure, we were able to show that between
two and six months the energy requirements of such babies had previously been
overestimated by as much as 25 per cent, and thus the average breast-milk intakes
that we were measuring in these growing babies was actually sufficient for four
to six months.12 This work is, in fact, still being investigated via a multicentre
study in Ann Prentice’s department. We have to make absolutely certain that we
have got everything right; it’s such an important issue. I am confident, however,
that what I have just said is much nearer to the truth than what was believed in
the past.13
The energy requirements that I have just been talking about have, of course,
now been revised by the World Health Organization (WHO) and the Food
and Agricultural Organization (FAO). As part of this work that I have been
discussing, we also thought it was important to re-investigate the growth of
healthy young babies. We were able to demonstrate that the reference data for
the growth of babies that had been used in the past were also misleading. The
older growth reference data was indicating the beginnings of growth faltering
and nutritional deficit in breastfed children much earlier than we now know
10 See, for example, Hytten (1954).
11 See Whitehead (1985).
12 See Coward et al. (1979).
13 Professor Roger Whitehead wrote: ‘The final analysis from this large study has not yet been published but
the results are compatible with what I have said.’ Note on draft transcript, 30 November 2008.
The Resurgence of Breastfeeding, 1975–2000
9
was correct.14 I am pleased to say that the growth reference data have now been
revised both nationally in the UK and internationally by the WHO.15
Weaver: Can we hear from the people with memories of actually what happened
at the time – Brian, perhaps, or people who were working in the developing
world – and how that might have impacted on what people were thinking about
breastfeeding? That’s a very helpful introduction, Roger, looking back to what
happened, but can we get a feeling from the people who were on the ground?
Professor Brian Wharton: My comments wouldn’t be about the developing
world. If I stay just with the UK, we do have this very impressive set of national
statistics collected by the Department of Health (DoH) and the Office of
Population Censuses and Surveys (OPCS) and so on.16 These showed that in
1975 about half of the mothers in England and Wales started off breastfeeding.
The Simpson Memorial Maternity Pavilion must have been very unusual with
20 per cent. By 12 weeks, it was down to 15 per cent. Five years later, there was
a quite definite change. When the 1980s arrived, about two-thirds of mothers
started off breastfeeding. And at 12 weeks the 15 per cent had gone up to 27
per cent. So, there are some big changes in infant feeding between 1975 and
1980. The mysterious thing is that in the UK the trend seems to have stagnated,
so, for example, if you take the figures for 2000, 71 per cent of women start off
breastfeeding. So, you think, well, that’s good, at least that’s greater than 67 per
cent. But the statisticians who write the OPCS report say that if you allow for
such factors – that mothers are older now and better educated – overall, there
14 Whitehead et al. (1981).
15 WHO Multicentre Growth Reference Study Group (2006); Sachs et al. (2005); Dewey et al. (1995).
16 DoH (2002); Bolling et al. (2007). The national survey has been conducted every five years since 1975.
Year Unstandardized results (%) Standardized for maternal age
and education (%)
1975 50
1980 67
1985 65 65
1990 64 62
1995 68 62
2000 71 62
2005 77 67
Table 1: Percentage of mothers who began to breastfeed their infants, England and Wales.
Source: Bolling et al. (2007).
The Resurgence of Breastfeeding, 1975–2000
10
has been no change.17 So, that is historical fact. And it is well documented in
national surveys.
The explanation: I don’t know, and in particular why you get a substantial
change from 1975 to 1980, and thereafter very little change. The evidence
suggests there has only been a limited resurgence in the UK since 1980.18
Weaver: Was there any cross-talk, as it were, between what was happening in
the developing world in the area that Roger Whitehead was talking about and
your experience in the UK?
17 See Table 1, page 9.
18 Professor Brian Wharton wrote: ‘There was a renaissance in the study of infant feeding, including
breastfeeding, and an appreciation of its importance in the 1970s. The first “Oppé report” as it came to be
known, was published in 1974 (Figure 3). There were subsequent reports with a similar title in 1980 and
1988 [DHSS (1980; 1988)].’ Note on draft transcript, 31 August 2007. See also Glossary, page 128.
Figure 3: The Oppé Report, 1974.
The Resurgence of Breastfeeding, 1975–2000
11
Wharton: I am not sure that there was in 1975. Everyone knew that it would
be extremely dangerous not to breastfeed in the developing world. What was
unusual was that an infant feeding report in 1974 said even in countries like
Britain the desirable thing is to breastfeed your baby.19 It doesn’t sound like
anything now, does it? But in 1974 it was comparatively revolutionary.
Dr Ann Prentice: You asked for a perspective on the developing world in the
1970s and the pressures in terms of policy with breastfeeding. At the time I
started working in the MRC Gambia, with Professor Whitehead, in 1978, the
prevailing idea there was that women living in underprivileged circumstances
with a limited diet were not able to sustain an adequate lactational performance
for more than about two to three months. So, combined with the ideas that we
have heard from Professor Wharton and Professor Whitehead here in terms of
the energy gap, these women were thought not to be able to produce milk of
adequate quantity or quality.20 I can remember attending a symposium with
paediatricians in Mexico where we were told that the prevailing policy there was
for health professionals to recommend women not to breastfeed if they had low
intakes of particular micronutrients, calcium in this particular instance, and so
women were being encouraged not to breastfeed or to wean their children at
three months of age on to complementary foods, because of this concern about
the gap.
As you know, infant growth faltering generally starts at around three to six
months and it was thought to be very much tied in with the woman’s ability to
produce good-quality breast-milk. Back in the mid-1970s the World Bank was
considering putting in place a number of feeding stations throughout Africa in
order to provide extra food for lactating women precisely in order to improve
their lactational performance, the quality of their milk and hence the growth
of the children.21 The work of the unit in the Gambia and elsewhere showed
that in fact although that may have benefited the women to some extent – and
that’s no small benefit – the lactational performance of those women living
in those circumstances, unless they were really on the edge of starvation, was
actually very good. So the child itself was protected and there must have been
other reasons for the growth faltering. In many ways I think that was the change
in mindset that went on in the developing world at the end of the 1970s and
19 Oppé et al. (1974).
20 Whitehead et al. (1978; 1981).
21 See Ronchi et al. (1976).
The Resurgence of Breastfeeding, 1975–2000
12
early 1980s in terms of the evidence that breastfeeding is best. Up until that
point, the policy people out there, I think, felt that most of the women could
not manage to breastfeed adequately for more than about two to three months.
There was quite a revolution in thinking.
Weaver: So there wasn’t any science before, and the sort of science that was
being produced was slow to impact or have any effect on people? Was this new
science, or a challenge to some sort of evidence-based thinking that existed
before?
Prentice: I think a number of things came together at that time and part of it was
new evidence about breast-milk volume using objective measures of milk intake
rather than the culturally insensitive ways of trying to measure milk volume
in the developing world that had been used up to then.22 It was recognized
that if you are analysing breast-milk for its quality you cannot use methods
that are standard in the dairy industry, because it is not the same material.23
There was a great push at that time to develop assay methods for looking at
both the nutritional and the non-nutritional factors in breast-milk. And then
there was the pioneering work on the antimicrobial properties of breast-milk,
– Professor Hanson is sitting here next to me, I shall pass the microphone to
him – the recognition that not only did breastfeeding protect in a passive way
against infection, but also in a very positive and constructive way, and that these
properties lasted longer than just during the colostral period. That was quite a
different way of thinking about things back in the late 1970s and early 1980s.
Professor Lars Hanson: It is quite striking that we hadn’t been aware of the
capacity of previous generations to survive and this remarkable arrangement of
the baby being delivered next to the anus of the mother to pick up the safest
kinds of bacteria around, which quickly propagate, reaching high numbers; they
cover the mucosal surfaces, especially in the gut, and keep away, or reduce the
numbers of, more dangerous bugs to start with. Then the milk, which contains a
very large number of protective components, protects against infection. But you
could also say it protects growth by keeping the baby in such a state that it can
utilize the nutrients provided by the milk, a much more refined and complicated
system than we had previously understood. It is striking, for instance, that when
we protect ourselves against infections, we almost always use mechanisms that
induce inflammation. The inflammation results from a number of signals from
22 Rowland et al. (1981); Coward et al. (1984).
23 See Jensen and Neville (eds) (1985).
The Resurgence of Breastfeeding, 1975–2000
13
our host defence. But breastfeeding protects without inducing inflammation, a
great advantage for the growing infant.
Weaver: Can you tell us about your personal experiences at the time and how
you were led to take these views? I don’t want you to theorize too much, I want
to hear what happened.
Hanson: Well, you force me to tell you about my PhD thesis, which indicated
that there was one major component in the milk, an antibody, which didn’t look
like other antibodies, and my thesis was accepted but the faculty said that this
was biologically improbable. The story was, in fact, that this antibody, which
was later labelled secretory IgA, makes up 80 per cent of all our antibodies. The
reason that it is present in such a high amount is that it covers our mucosal
membranes, and just the intestinal mucosa is about 400m2, so we need a lot
because of that. The breastfed baby will receive as much as some 0.5–1 g per day
of this protective component.
Weaver: So, this was a new and unique finding at the time. How was it
received?
Hanson: It was received with quite some interest, especially after we found out
that the secretory IgA antibodies in the milk were especially directed against the
bacteria in the mother’s gut. This makes a lot of sense because these bacteria
are the ones the baby is normally colonized with after the normal exposure to
them at delivery. The cells producing the secretory IgA antibodies migrate to the
mother’s mammary glands from special lymphocyte aggregates in her intestine,
the Peyer’s patches. Since the mother has been exposed to the microbes from her
surroundings, the breastfed baby receives a very broad and efficient protection
against microbes in its milk that otherwise could cause more or less severe
infections in early life. This is likely to be an important protective mechanism and
it has one aspect that is especially significant for the growing infant: in contrast to
other defence mechanisms in the blood and tissues, it protects without causing an
inflammatory response as most other defence mechanisms do. Inflammation has
several negative effects on a growing individual, including decreased appetite.
Weaver: Did these findings impact on thinking outside of where you were
working? How did they spread and did they affect thinking about breastfeeding
elsewhere in Europe?
Hanson: Well, in a way it became the start of a series of studies from different
places, showing that there are any number of components in the milk and some
The Resurgence of Breastfeeding, 1975–2000
14
of them are working in very remarkable ways. One of them, lactoferrin, an
iron-binding protein, is one of the major proteins of milk. Not only can it kill
bacteria and viruses on its own, but it stops inflammation. Thus, it takes the
risk of stopping this form of protective mechanism. This can take place because
lactoferrin can, together with many other components in milk, defend anyway,
and inflammation is the last thing the baby needs, because that inhibits growth
by reducing appetite. The secretory IgA antibodies in milk are thus supported
in this rather unique form of non-inflammatory host defence.
Whitehead: I will respond to one of your earlier points. One of the impacts,
of course, was that we had to explain why the growth of even healthy babies
appeared to be falling off at two to three months. If this really were true, then
of course we would have to have a major rethink about weaning advice and
weaning foods.
There is, however, another issue about the timing of weaning in the
developing world apart from nutritional adequacy that was being thought
about at the time. Even if the amount of milk produced by a mother in
the developing world did not quite measure up to the complete nutritional
needs of the child, it might be better to be left dietarily short rather than
to try to introduce the potentially hazardous weaning foods that tend to be
the only ones available in such economically deprived countries. This still
remains a complex issue. There is a parallel with HIV-AIDS and advice for
lactating women. Is it better for their babies to be breastfed, and thus risk the
transmission of the HIV and a child dying of AIDS, or is it better that they
be artificially fed and dyng from diarrhoeal disease if such feeds are not made
up in a hygienic manner?24
Weaver: So the validity of existing dietary energy requirements was the origin
of the ‘energy gap’ concept?
24 Mrs Patti Rundall wrote: ‘WHO held a technical consultation on HIV and infant feeding in Geneva
in October 2006, updating its recommendations on infant feeding. A new UN consensus statement was
adopted: “Exclusive breastfeeding is recommended for HIV-infected women for the first six months of life
unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants
before that time…. Breastfeeding mothers of infants and young children who are known to be HIV-infected
should be strongly encouraged to continue breastfeeding…. Governments should ensure that the package
of interventions referenced above, as well as the conditions described in current guidance, are available
before any distribution of free commercial infant formula is considered.”’ Letter to Dr Daphne Christie,
3 September 2007. See www.who.int/child_adolescent_health/documents/ pdfs/who_hiv_infant_feeding_
technical_consultation.pdf (visited 11 August 2008); Coovadia et al. (2007).
The Resurgence of Breastfeeding, 1975–2000
15
Whitehead: As I have said, the approach that we took was to find out, by
scientific re-investigation of the whole issue of infant energy requirements,
whether there really was an energy gap between requirement and what could
be satisfied by breastfeeding around two to six months. Once we found out
that previous estimates of energy requirements had been overestimated, the
practical dietary advice became more straightforward. The advice that exclusive
breastfeeding was normally adequate up to six months was correct.
In the late 1970s I had been a member of both Tom Oppé’s Department of
Health and Social Security (DHSS) Committee on Medical Aspects of Food
and Nutrition Policy (COMA) committee on infant feeding as well as on the
COMA committee that had been responsible for defining recommended dietary
allowances (RDA) for energy, and it was a tremendous embarrassment to me
when I realized that the two pieces of published advice were not mathematically
compatible. That is one reason for our involvement. The main driving force
for our ‘energy gap’ research, however, came from the developing world, where
there clearly was a scientific problem of major importance to health education
and child health planning that had to be faced.
Weaver: So this was really an indication of the ‘weanlings dilemma’, as it was
then called, and the fact that there was no real definition of the optimum time
to start weaning foods or to continue to breastfeed exclusively.25
Whitehead: Yes, we now know it is four to six months. The paediatrician Tom
Oppé always said four to six months and Tom Oppé was correct.
Weaver: Based on what?
Whitehead: Professor Oppé’s reasoning was mainly empirical, based upon
clinical common-sense, I suppose that was what one would call it. But it didn’t
fit with the RDAs of that time and we scientists had to go back to the drawing
board. By doing so we found out that we had been wrong.
Dr Edmund Hey: What we have already heard is that even today people are
saying that growth falters at three or four months. They use a value-loaded word.
What was really going on was that nobody had got growth standards, except
Jim Tanner in this country and a few epidemiologists in the US.26 These had
been obtained, almost exclusively, from bottle-fed babies, so the whole world
25 See Rowland (1986).
26 Tanner et al. (1966a and b); Tanner and Whitehouse (1973): 787–8. See also Waterlow and Thomson
(1979); Jelliffe and Jelliffe (1979); Waterlow et al. (1980); Whitehead and Paul (1984).
The Resurgence of Breastfeeding, 1975–2000
16
had become locked into what greedy bottle-fed babies will do when four or five
months old; you push a little extra milk into them when they won’t go to sleep.
Weaver: Was that truly the perception at the time? I think that is our perception
now.
Hey: I was curious that people still use the word ‘faltering’. It isn’t faltering, it’s a
natural decline. The maximum rate at which a baby grows is at about 28 weeks’
gestation in utero. At this time babies are growing at about 2 or 3 per cent a day,
and this rate then gradually tails off, and they don’t grow very much between
one and two years. But there isn’t a faltering, there is a natural decline.
Mrs Patti Rundall: I run Baby Milk Action and I only came into this work in
1980, but I just wanted to say that at that time Professor Whitehead’s work
was having a huge impact on people’s understanding of the developing world,
and we were extremely critical of it. Some of it was, I think, funded by the
food industry, and we were concerned that this might have had an influence
on the way the study was conducted and reported. The early research from the
Gambia was certainly quoted by Nestlé and other companies at that time. It
Figure 4: Nestlé Milk nurses in South Africa, c . 1950.
The Resurgence of Breastfeeding, 1975–2000
17
had a devastating impact on people’s understanding. Nestlé used it to say that
women could not breastfeed. They used it as an excuse, saying: ‘That’s why we
have to do what we are doing; that’s why we have to give free samples; that’s why
we have to do all these things.’ So it was a huge problem for us.27
Weaver: Was the science thought to be suspect as well?
Rundall: Oh, absolutely. And I was very interested in what Ann was saying about
the need to measure milk in a culturally sensitive way, which they did eventually.
But I remember that in the early days the researchers did not measure the night
feeding. So, this made us question how they could measure the volume of milk
and what they meant by this ‘faltering’. It was hugely controversial. Every time
we put messages out that women could breastfeed, Nestlé would come back
with a report from the Gambia proving that the companies were right.28
Weaver: I don’t want to stop this discussion, but I notice that Dr Savage wants
to say something. Are you going to stick with this topic?
Dr Felicity Savage: Absolutely. During this time I was working in Zambia and
later on in Indonesia as a practical paediatrician, not a researcher, but growth
monitoring of individual children was actively promoted. There was little
concern with breastfeeding in either country. When babies were breastfeeding
the growth tended to start decreasing from about the age of six months.
A majority of babies grew very well for the first six months and then their
weight gain would level off from about six months, with a clear cut-off time.
Malnutrition in children under the age of six months mainly occurred when there
was a real problem with breastfeeding and mothers were either mixed-feeding
or were formula-feeding and not breastfeeding at all.
27 Mrs Patti Rundall wrote: ‘The later work that Ann Prentice refers to was hugely significant and much
valued by the International Baby Food Action Network – the comments I made here related to the early
Gambia studies.’ Note on draft transcript, 3 September 2007.
28 Mrs Patti Rundall wrote: ‘This quotation from a Guardian article in 1990 gives an indication of the
pressures faced by those managing research institutes who are often forced to accept funds from inappropriate
sources: “The Director of the Dunn Nutrition Unit in Cambridge, Dr Roger Whitehead, has posted a notice
to staff saying: ‘At this moment in our fundraising programme, it is clearly important not to antagonize any
part of the food industry unnecessarily. If you are asked by the press to comment adversely on a particular
food product, can you please get in touch with me before proceeding.’ Dr Whitehead said he did not wish
to comment except to point out that the notice was a private message to senior colleagues, which only
reinforced the policy of the Medical Research Council” [Erlichman (1990)].’ Note on draft transcript,
3 September 2007.
The Resurgence of Breastfeeding, 1975–2000
18
In the population where I was working, mothers, when they had been
breastfeeding for about three or four months, sometimes decided that they
needed to go back to work, as their fields were getting neglected. They needed
to start doing some farming. They would try leaving the baby behind, without
breastfeeding during the day, so there were problems of growth then if they were
fed on animal milk or formula, depending on what was locally available.
But another thing that we forget is that, at that time, people did not understand
the management of breastfeeding. It was not appreciated that when a baby
started to breastfeed, how the baby was attached to the breast and how
frequently the baby fed, had a major impact on the production of milk.29 It
was always assumed if there was some concern about the quantity of milk that
a mother might be producing, that this was due to her nutrition. Ann Prentice
has already mentioned research that showed that this was not true. We really
didn’t understand the biology at that time.
Prentice: Three things: the first is to pick up again the points about growth
faltering and absolutely accept the point that in terms of a healthy child with a well-
nourished mother in good health care and so on, we now recognize that the pattern
for the breastfed child is different from that of the child who is not breastfed. The
new WHO growth charts show quite clearly that, even in the developing world
29 See Figure 5, above, and Figure 10, page 61.
Figure 5: Good and poor attachment at the breast.
Left: Baby well attached, mouth widely open; lower lip everted; chin close to the breast.
Milk can be efficiently removed.
Right: Baby poorly attached, mouth not widely open; lower lip not everted; chin away from
the breast. Baby is sucking mainly on the nipple; milk is not efficiently removed, and the
nipple is likely to be traumatized.
The Resurgence of Breastfeeding, 1975–2000
19
context, a child who is breastfed is likely to grow in the same way as if he had all
the advantages of a child in the developed world.30 So the growth faltering that I
was referring to and that Professor Whitehead referred to earlier was actually the
genuine growth faltering of children in the developing world who really do grow
badly in the second part of infancy, a weight-for-age of around about -2 standard
deviations (SDs) at one year, and height-for-age -1 SD. This is genuine growth
faltering. That’s what we were referring to.
Secondly, I don’t particularly want to exercise the discussion with Patti we have
been having for the last 25 years, but just to say that the work in the Gambia was
never funded by the food industry and the work that we have been describing
was an attempt to inject some objective measures into a debate that was definitely
raging at the time about the type of data that was coming from the developing
world.31 There wasn’t a recognition at that time of how inappropriate some of
the methods that were being used were, as I said, either because they were not
culturally sensitive – perhaps taking mothers away from their children during
the night and so on, as you mentioned – or that they were using methods for
analysing breast-milk which were not designed for human milk. And, I think,
one of Professor Whitehead’s legacies is his insistence on the real need to make
sure that we used validated, objective measures for all the work that we did, and
that has been seen with many other researchers as well, not just our group.32 But
that turned round a lot of the thinking, once we had some hard evidence that
was not prejudiced by subjectivity, which many of the earlier studies had been.
And the final point was to introduce the way in which the ideas which were
coming from the evidence from the developing world, which were designed to
try to address the growth faltering of developing world children, then translated
into the developed world. I started to see that happening in a number of ways.
There was another look at the dietary reference values for this country in the
30 Dr Ann Prentice wrote: ‘The WHO growth charts can be accessed at www.who.int/childgrowth. These
were obtained recently for children in different countries who were exclusively breastfed to six months. My
comment about different patterns of growth between breastfed and non-breastfed babies cannot, therefore,
be illustrated by providing a WHO growth chart. However, the history of growth charts and the differences
in growth between breast and bottle-fed infants has been discussed in detail in a recent report by the
Scientific Advisory Committee on Nutrition, Application of the WHO growth standards in the UK, available
at www.sacn.gov.uk/reports_position_statements/reports/application_of_the_who_growth_standards_in_
the_uk.html (visited 19 February 2009).’ Note on draft transcript, 27 October 2008.
31 Prentice et al. (1980).
32 See, for example, Whitehead and Prentice (eds) (1991).
The Resurgence of Breastfeeding, 1975–2000
20
late 1980s, when these concepts started to come through in terms of how one
sets recommended dietary allowances for infants – ‘reference nutrient intakes’
as we call them now – and there was a recognition that we did not set one for
breastfed children in the UK, in essence, and that for children who were not
being breastfed, we did.33 That was quite a change in thinking.
Another way that it impacted was in the way that women were supported to be
able to breastfeed during their careers and, indeed, during the necessity of going
out to work. I was very privileged to have been at a conference that was run at
the Pontifical Academy of Sciences in Italy jointly with the Royal Society in this
country. Professor Hanson was one of the organizers, so he could discuss that
more, but at that time it was really to try to synthesize current understanding
about lactational performance, about strictures, difficulties, limitations, barriers
to breastfeeding from the mechanical – if you like, the biological – right the way
through to the societal.34 This was an attempt to try to introduce (in a policy
way) through the Roman Catholic Church into areas like South America, the
idea that women should breastfeed, that there was good evidence that women
could breastfeed for three to six months or longer, and that it was good for the
baby to be breastfed for that long, but that women needed to be supported. So,
all of those things which came from the developing world to the transitional
world and then into the developed world really started to change thinking.
Professor Mary Renfrew: I’m from the University of York. I wanted to reflect
on how some of this discussion relates to my memories of being a student
midwife in the Simpson and the Western General Hospital in Edinburgh in
1977. There are real resonances, because one of the things that people were
starting to recognize at that time was a tremendous dissonance between what
was coming from some of the scientific research, if you like, raising questions,
undermining breastfeeding as an activity, and what some of the textbooks were
telling us that we should be doing in terms of supporting the management of
breastfeeding mothers, which was what it was called at that time. Therefore
what we were being taught to do clinically was to measure, monitor, restrict and
separate mothers and babies. That undermining message came both from the
work we have been talking about just now, in terms of mothers’ confidence in
33 Hopkins et al. (2007).
34 For the papers presented at the working group co-sponsored by the Pontifical Academy of Sciences
and the Royal Society that met in Vatican City, 11–13 May 1995, see the United Nations University
Press (1996), freely available at www.unu.edu/unupress/food/8f174e/8F174E00.htm#Contents (visited 11
August 2008). See also page 33.
The Resurgence of Breastfeeding, 1975–2000
21
breastfeeding and whether it was really enough, amplified by the undermining
message coming from the medical and midwifery textbooks about measurement.
As students we got this tremendous question: ‘Would it work? Would it not?’
This built a lack of confidence in breastfeeding that lots of people in this room
have been trying to tackle ever since.
There were two things that I was conscious of as a student midwife. The first
was that women’s reports of breastfeeding were not in the literature. I went
looking for them and, apart from Sheila Kitzinger’s, accounts of what it was like
to breastfeed in reality weren’t there.35 The second was the scientific evidence base
around lactation: the quantity of milk women produced left to their own devices,
when not monitored and measured and separated and so on. When I moved to
Edinburgh, into a hugely privileged period of my life, with the people sitting in
the row in front of me here,36 we were trying to answer some of those questions.
That was a huge step forward. But that dissonance between science and women’s
life experience and indeed the experience of some health professionals – and I am
sitting beside Chloe Fisher, a major moving force, who kept reminding us that
women really could do it, no matter what the scientists, medics and midwives
tried to do – burgeoned in the late 1970s–early 1980s.
Weaver: May I bookmark that point and go back to finish with what was going
on in the developing world? Maybe this is the moment for Lars Hanson to talk
about lactation. But we will come back to midwife training, because I think that
is the next big thing to concentrate on.
Hanson: I would like to ask a question. I think that we in the West have not
doubted that the baby should be breastfed from the beginning. Why is it that
so many traditional societies do not start at once? And this is a very dangerous
thing to do, and you may have seen the beautiful report from Ghana by Karen
Edmond and colleagues in Pediatrics just a few weeks ago, where she showed
that starting breastfeeding within one hour decreased mortality by 22 per cent
compared with starting on day three.37 We have seen, for instance, that in
Pakistan they give all kinds of things to the baby before breastfeeding starts one,
two or three days later. Why is this very dangerous thing going on? It has gone
on for a long time, or has it?
35 Kitzinger (1962; 1980).
36 Roger Short, Alan McNeilly, Anna Glasier and Peter Howie.
37 Edmond et al. (2006) reported that 16 per cent of neonatal deaths could be prevented if all infants were
breastfed from the first day and 22 per cent if breastfeeding started within the first hour after birth.
The Resurgence of Breastfeeding, 1975–2000
22
Weaver: Were these ideas recognized at the time?
Hanson: I think this is very old, but I don’t know, maybe somebody here can tell
me. Why is breastfeeding starting so late and where did the idea come from? It
is clearly very dangerous.
Ms Ellena Salariya: I’m from Dundee and I am, perhaps, the oldest person in
the room, so I go back quite a bit. I do remember very clearly what was being
advised regarding breastfeeding regimes when I began nurse training in 1950.
Mothers were instructed to put their babies to the breast after six to eight hours
if they were awake, as mothers were given sleeping pills routinely at this time.
All babies, breast and bottle-fed, were given dextrose 5 per cent to test the
patency of the oesophagus at four to six hours post-delivery. The few mothers
who had chosen to breastfeed were screened off in the Nightingale ward and
left to get on with it.38 Midwives appeared to have lost interest in any skills in
relation to this type of feeding.
38 A Nightingale ward can accommodate up to 30 patients, with beds arranged in two long lines, 15 on each
side, so that patients in the ward are all able to see one another, unless screens are used. See also page 64.
Figure 6: 24-hour clock, designed by Sir F Truby King (1913); reprinted 22 times up to 1932.
Revised and reprinted in New Zealand 1937, reprinted twice to 1940.
The Resurgence of Breastfeeding, 1975–2000
23
The mothers were advised, however, to ‘time’ the suckling and they all displayed
their watches or clocks nearby; on the first day, one minute on both breasts was
allowed at four-hourly intervals, this was increased to two minutes on day two,
three minutes on day three and so on until ten minutes was allowed.39 This
prescribed time had been arrived at because a bottle-fed infant would consume
formula milk from a bottle in 20 minutes.
I firmly believe that this is where many of our problems have stemmed from.
The breastfed infants did lose up to 10 per cent of their birth-weights, not
surprisingly, since they were being starved for several days after birth. This
birth-weight loss is still accepted today despite several studies demonstrating
that in the absence of early mismanagement of breastfeeding it is not normal
that breastfed infants lose more than up to 6 per cent of their birthweight before
beginning to regain the lost weight. Only this week I spoke with midwives at
Ninewells Hospital, Dundee, and they told me that it is now considered normal
for a breastfed infant to lose up to 11 per cent of his birthweight.
Weaver: So, this was the standard practice in teaching in maternity units and
lying-in wards in the 1970s. Let’s hear more about that.
Miss Chloe Fisher: This is modern: we move on to 1982, and this is a book
written by Dr Miriam Stoppard, A Complete Guide to Baby Care.
Introduce your breast gradually to the rigours of sucking. The first
breastfeed should be no longer than one minute at each breast and the
feed continued for this length of time throughout the first day. On the
second day you can increase the length of the feed to two minutes on
each breast, and on the third day to three minutes, so that by the end of
the week your baby will be feeding for ten minutes at each breast.
I didn’t know there were ten days in a week! But something that was never
mentioned in all this horrible time was the ‘pauses’. Babies pause when they
feed. And my breakthrough as a domiciliary midwife was to say: ‘But they didn’t
tell us what to do about the pauses: add a bit of extra time.’ And, of course, the
moment you start adding a bit of extra time you have broken down the barriers.
I thought I would just amuse, or shock, you with that one. Ten days in a week!
39 Miss Chloe Fisher wrote: ‘A quote I can’t help sending! “A clock is an essential piece of nursery furniture, and
the baby should be ‘fed’ by it. If it is asleep it should be wakened; and if, in spite of thorough rousing, it refuses
to suck, it should miss a meal.” From a lecture given by Frederick Langmead in 1915, published in National
Association for the Prevention of Infant Mortality (1915).’ Note on draft transcript, 13 October 2008.
The Resurgence of Breastfeeding, 1975–2000
24
Savage: May I respond to the earlier question about the delay in starting to
breastfeed? To my understanding this is old Brahminical and Galenical teaching
that spread to some parts of the world and not to others.40 There are some
communities where mothers start breastfeeding straightaway, for example in
much of Zambia; but in other countries, such as much of Indonesia, they delay,
either because they think that the colostrum looks like pus and is unhealthy,
or simply because there isn’t any milk there, so there is no point in feeding the
baby and they should give something else. Also, Valerie Fildes reported that
in eighteenth-century Britain the delayed start was common, until Cadogan
recommended that babies start to breastfeed within a few hours of delivery.41
Newborn mortality decreased when this practice was introduced, but there was
no accompanying decline in overall infant mortality, so it was apparent that
something special had happened in the first month.
Dr Elisabet Helsing: I’m from Norway. This is also to answer Professor Hanson’s
question. In Norway, in olden times, there was a habit of giving the baby a ritual
meal as an introduction to the world and to ensure ample food later in life. I
believe the ritual was common around the world. I know that it happened in
India, where honey and ghee and other things were given to the baby.
I also wanted to add to what others have been saying about the health workers’
contributions to breastfeeding. There was a nine-country study performed
by WHO in 1975–78, published in 1981, called Contemporary Patterns of
Breastfeeding, which reported that the more mothers in all of these countries
were in contact with their healthcare system, the less they breastfed. Now WHO
never highlighted this very much, it was hidden on page 149 of the published
report, but I think it is quite an important finding.42
Weaver: So when did WHO seriously start addressing these issues and what is
the origin of the breastfeeding initiative?
Helsing: It was actually the Protein–Calorie Advisory Group of the United
Nations System (PAG), which took up this issue in the early 1970s, and in
40 See Wickes (1953); Cadogan (1748).
41 Fildes (1985; 1998).
42 WHO (1981a).
The Resurgence of Breastfeeding, 1975–2000
25
this way brought it into the auspicious body of the UN.43 In 1974 the first
World Health Assembly resolution on the issue of breastfeeding and the
harmful promotion of infant formula was adopted, noting the general decline
in breastfeeding in many parts of the world. There are people here who could
give further detail on this.
Mr James Akre: I was at WHO from 1980 until 2004. Building on what
Elisabet Helsing has just said, the first World Health Assembly resolution to
use the word ‘breastfeeding’ was adopted in 197444 – to put that into historical
perspective, the first World Health Assembly took place in 1948 – and the
second was in 1978, and on both of these occasions there were general references
made to the reduced rate of breastfeeding prevalence and duration, and then
specific references to the impact of promotional activities and the inappropriate
marketing distribution of breast-milk substitutes.45 This in turn led to the
landmark October 1979 meeting on infant and young child feeding, jointly
organized by WHO and the United Nations Children’s Fund (UNICEF). I
will let Patti Rundall address this, but this was, in essence, the beginning of
the International Baby Food Action Network (IBFAN), various activist groups
have coalesced around what became IBFAN, since 1979/80.46 The Baby-
friendly Hospital Initiative was begun by WHO and UNICEF at a meeting of
43 World Health Assembly, Fourteenth Plenary Meeting, 23 May, 1974. For a list of publications, see Sachs
(ed.) (1975). The quarterly Food and Nutrition Bulletin (1978– ) incorporates and continues the PAG
Bulletin (1967–77) of the Protein–Calorie Advisory Group of the United Nations and is published by the
International Nutrition Foundation for the United Nations university in collaboration with the United
Nations system standing committee on nutrition (SCN).
44 The 27th World Health Assembly passed resolution WHA27.43 on ‘breastfeeding’ in 1974, (WHO
(1974).
45 Mr James Akre wrote: ‘The first occasion for WHO’s senior policy-making organ, the World Health
Assembly, to speak of breastfeeding occurred in 1974 when it noted “the general decline in breastfeeding in
many parts of the world related to sociocultural and other factors, including the promotion of manufactured
breast-milk substitutes.” The Health Assembly urged “member countries to review sales promotion
activities on baby foods and to introduce appropriate remedial measures, including advertisement codes
and legislation where necessary” (WHO 1974). The issue was taken up again in 1978 when the World
Health Assembly recommended that governments give priority to preventing malnutrition in infants and
young children by supporting and promoting breastfeeding, taking legislative and social action to facilitate
breastfeeding by working mothers, and “regulating inappropriate sales promotion of infant foods that can
be used to replace breast-milk” (WHO 1978).’ Note on draft transcript, 7 October 2008.
46 See Allain (1981). For the background to the establishment of IBFAN, see www.ibfan.org/site2005/
Pages/article.php?art_id=34&iui=1(visited 8 January 2009).
The Resurgence of Breastfeeding, 1975–2000
26
the International Paediatric Association in Ankara, Turkey, in 1991. This was
the brainchild of James Grant, who very directly put his stamp on it by taking
a joint statement on breastfeeding and maternity services which was published
in 1989 from the policy level and moving it right into the maternity wards and
hospitals of the world and branding it with the name we know so well today.47
Ms Gabrielle Palmer: To encapsulate this history: Valerie Fildes’ historical
research shows that breast-milk was always seen as a good thing.48 But the fact that
it came out of women was the problem. Breastfeeding women weren’t supposed
to have sex, to be temperamental or red-headed; if they did any of these things
their milk wouldn’t be good. Also, Rima Apple, who has done splendid work,
shows that the attitude was the same when doctors took over infant feeding in
the US.49 Chloe Fisher, who is here today, will know this quotation, ‘it is better
to have the vegetarian, nerveless cow,’ than a woman who has temper tantrums,
is weak, failing, or hasn’t eaten well.50
Then there was a lot of money to be made by the blossoming paediatric
profession in the US, which Rima Apple displays wonderfully.51 The whole
thing is that we know that women were told what to do and what was seen as
the right thing, but actually we don’t know to this day what women have done in
private. Women – and I would include myself here – lie to health professionals,
because we do what we think is best in the end anyway, if we have the confidence
to do so.
47 WHO/UNICEF (1989). See www.who.int/nutrition/topics/bfhi/en/index.html (visited 29 January 2009).
The Baby-friendly Hospital Initiative, a worldwide programme of WHO and UNICEF, established in 1991,
was followed in 1992 by the establishment of the UNICEF UK Baby Friendly Initiative, which was formally
launched in 1994. See www.babyfriendly.org.uk/page.asp?page=11 (visited 17 June 2008), pages 43–5, 51–2,
and Glossary, page 125. Dr Felicity Savage wrote: ‘In the UK, from the beginning Professor David Baum
wanted it to have a community component, so the word Hospital was dropped. It is hosted by UNICEF
in the UK and is called the UNICEF UK Baby Friendly Initiative, which started in 1992. The importance
of this is that it was considered important to make it a truly global programme, not just a programme
for developing countries, because breastfeeding rates are lower in developed countries than in developing
countries. However they are part of the same programme with the same aims and methods.’ E-mail to Ms
Stefania Crowther, 12 February 2009. For biographical information on James Grant see www.unicef.org/
about/who/index_bio_grant.html (visited 13 October 2008).
48 See, for example, Fildes (1998).
49 Apple (1980; 1987).
50 Ms Gabrielle Palmer wrote: ‘Miss Chloe Fisher has often used this quotation from Dr Eric Pritchard, an early
twentieth-century British paediatrician. [Pritchard (1907)]’ Note on draft transcript, 3 September 2007.
51 Apple (1994).
The Resurgence of Breastfeeding, 1975–2000
27
Historically, UNICEF and other international agencies so valued cows’ milk as
a wonder food that after the Second World War, they distributed milk on a large
scale worldwide.52 In non-milk-drinking societies, people naturally perceived
this as a breast-milk substitute.
Weaver: The work of Valerie Fildes and Rima Apple belongs to the early part
of the twentieth century. We want to concentrate on how we started going in a
different direction.
Palmer: If I may come to this, please, those philosophies and ideas are still here
today. People talk about ‘the breastfeeding type’, but there is no such woman.
Industry exploits this very well. Infant formula is being distributed in Iraq now
because the Iraqi people want it, because artificial feeding became established.53
I loved it that Elisabet Helsing brought out the point that the more contact
women have had with health workers the more breastfeeding has declined.54
Maybe this is because we humans sabotage and compete with each other, even
if it’s subliminal. We talk about ‘breastfeeding management’ and that midwives
are not interested, but in the past, infant feeding was something that women
did that was part of the family culture. Now it is a medicalized, health-service-
controlled matter. Women feel they need to read leaflets and ask a midwife,
nurse or doctor to help them breastfeed. This mega-cultural change across the
world has made women stop believing in their own bodies and this is a key
factor.55 I equate this lack of confidence with mass impotence in men. Maybe
now we have Viagra my argument no longer works.
Weaver: I want to hear from these people who were actually involved in the
maternity wards at the time. Roger Short, do you want to say something?
Professor Roger Short: Yes, if I could go back to the beginning and think
about the natural history of breastfeeding, which is something that nobody’s
mentioned yet, the key feature. We are, after all, mammals and the definition
52 See King and Ashworth (1987 a, b and c); Clark (1996).
53 Ms Gabrielle Palmer wrote: ‘Sources are Benyamin and Hassan (1998); personal communication
from Dr Sami Shubber, former senior legal counsel at WHO Geneva, 1995; personal communication
from Dr Naira Hasan, senior paediatrician, Baghdad Hospital, 1991; personal communication from
Dr Yvonne Grellety, former nutrition in emergencies officer, 1999.’ E-mail to Ms Stefania Crowther,
1 December 2008.
54 See page 24.
55 For Wendy Savage’s comments about the over-medicalization of childbirth, see Christie and Tansey (eds)
(2001b): 54–5.
The Resurgence of Breastfeeding, 1975–2000
28
of a mammal is that our young are exclusively, and I mean exclusively, fed with
breast-milk for a varying period of time, depending on the mammal. So, what is
the normal pattern of breastfeeding for humans? We have heard people talking
about developing countries and developed countries, but, of course, they are all
contaminated by western culture. When I was toying with the idea of leaving
Edinburgh in 1982 and going to Australia, everyone said: ‘Oh you are a silly
idiot to leave Edinburgh, you like history so much, and if you go to Australia,
it’s all so new.’ Somebody else said to me, ‘But, of course, there’s one thing about
Australia, people have lived in Australia ten times as long as they have ever lived
in the British Isles.’ And I said: ‘What?’ I couldn’t believe it.
When I arrived in Australia, I went to live with an Aboriginal group, the Jigalong
mob up in the north-west of Western Australia, just to see a traditional human
society that had only in the last couple of hundred years seen its first Europeans,
and learn how they breastfed. It’s an amazing experience and a vanishing one,
but basically, as we had learnt from the studies of the !Kung hunter-gatherers
in the Kalahari, surprise surprise, all women breastfeed, every single one; there
isn’t such a thing as a woman who can’t breastfeed; it would mean she wasn’t
a mammal. What the Aboriginals and the !Kung hunter-gatherers do is put
the baby to the breast immediately. It feeds for about one to two minutes per
feed, four times an hour, throughout the day and the night. That’s about 98
feeds per day and that is the normal pattern of breastfeeding for them.56 I took
on a very bright young American graduate from Harvard, Janet Rich, whom
I put to live with an Aboriginal community (on Elcho Island) up in the Gulf
of Carpentaria for a year and I said: ‘There are about 100 mothers and babies
there, and I would like you to study how they breastfeed. Let’s ask one or
two simple questions: how often in a day do you hear babies crying, and how
often do you see a baby suck its thumb?’ In one year, studying 100 children,
she never once saw a thumb being sucked, it was always the breast, and you’d
never hear a baby cry, because the nearest lactating mother would pick it up
and feed it. Until we go back to the beginning and look at societies like the
Australian Aboriginals, who have been in Australia for at least 45 000 years
and only in contact with western society for 200 years, we will never know
what normal breastfeeding represented. So I think we have got to go back to
our beginnings if we really are to understand normal breastfeeding, and the
horrific way in which we have abused it by giving the wrong advice down
the centuries.
56 Short (1992).
The Resurgence of Breastfeeding, 1975–2000
29
Weaver: So, did these sorts of ideas affect you, Mary Renfrew? You were saying
that you were looking around for inspiration and guidance. Was it this sort of
thinking that actually affected you at the time and answered your needs?
Renfrew: As a just-qualified midwife I didn’t quite know what to do with
myself, because I didn’t like the health service that we ran, it didn’t work for
women. It didn’t work for midwives, in my experience, either. And I was just
phenomenally lucky because a job was advertised in the MRC reproductive
biology unit, Queen’s Medical Research Institute, Edinburgh (CRB), which
Roger Short was directing at that time – working with Peter Howie and Alan
McNeilly. I got the job and quite a lot of the rest is history, because we spent
the next four years having immense fun doing a whole lot of studies which I am
hoping Peter and Alan are going to talk about, in which I learned about why we
should have confidence in breastfeeding physiologically, but also about the huge
cultural limitations to it, which refers to what Roger has just said, and about
women’s real lived experiences, which others have talked about.
Professor Peter Howie: I was working in Glasgow when a job came up in
Roger’s unit, at the MRC reproductive biology unit in Edinburgh, and David
Baird persuaded me that they needed a clinician to go through and, at a very
alcoholic evening, I agreed. David sent me the five-year programme for the
MRC unit and as I was very busy I hadn’t had a chance to read it. I was going
to see Roger, so I read it on the train journey between Glasgow and Edinburgh,
which is 45 minutes. The first section included one statement that lactational
amenorrhea protected against more pregnancies than all forms of artificial
contraception put together.57 I have to say that was the first time I had ever
heard of the idea. I went into Roger and he asked: ‘What are you interested
in?’ I replied: ‘This lactational amenorrhea’, and Roger said: ‘Splendid, you
are the man for the job’. He then sent me to see Alan McNeilly who had been
researching the physiological basis of lactational amenorrhea, really trying to
understand what happened when a baby suckled at the breast and the huge
impact of neural impulses going to the brain hypothalamus and what actually
happened thereafter. The MRC had been trying to understand that and now
they wanted to see, using translational research, what impact that had in the
clinical sphere. But before we talk about what we did clinically, we really have
to start thinking about what the physiology was saying, because that was really
the initial stimulus. Then I think that Roger wanted somebody like me to start
57 Professor Peter Howie wrote: ‘The document I referred to was an unpublished internal document of the
MRC reproductive biology unit. See Buchanan (1975).’ Letter to Mrs Lois Reynolds, 17 October 2008.
The Resurgence of Breastfeeding, 1975–2000
30
to help looking at what was happening to patients. So it was the physiological
understanding that was being explored first.
Weaver: And what year was this famous train journey?
Howie: 1978.
Professor Alan McNeilly: It was one of the best days of my life, Christmas 1975,
when Roger Short offered me a job at the MRC centre for reproductive biology
and I am still there. I should have kept the telegram that came to Winnipeg
offering me the job when I was on sabbatical, having been at Bart’s Hospital,
London, working on prolactin, which had only been discovered about four
years before, around 1971. People thought it was a growth hormone, because all
the bioassays that we used were animal bioassays, and human growth hormone
promotes lactation in animals, but doesn’t in humans. The whole purification
process was skewed by that. People didn’t even know that human prolactin
existed. There was a huge myth until about 1972 that humans were different
anyway.58 That was a starting point, because Roger had identified the concept
that the number of births that were prevented just by breastfeeding was far
exceeding anything until oral contraceptives came in. I had done some work
with Roger with his PhD student Ken McNatty, and we are still working
together now, on the effects of prolactin on the ovary. I went to Canada from
Bart’s and was recruited back to Roger’s unit in 1976. My first degree is in
agricultural science, and so is my second degree, and then I ended up at Bart’s
Hospital having to learn clinical endocrinology.
The reason I am telling you this is because when I was then asked by Roger Short
to investigate lactation and fertility, I was absolutely amazed at the ignorance
of the clinicians who were dealing with this. They had absolutely no idea how
lactation worked, even the basics of oxytocin release for milk ejection. Well,
of course, when the baby is born, to get the placenta out you give oxytocin
(Syntocinon), but actually the baby suckling releases oxytocin, it’s the natural
way to deliver the placenta. If you don’t do that, well, there will be problems.
But besides that, the whole concept of suppressed fertility in lactation was
considered a bit of a myth really, wasn’t it Roger?
People did not believe it, because they breastfed once a day and their menstrual
periods would come back. So, we had tried initially with an MD student,
Christine West, to get access to patients to actually track what was going on.
58 See Forsyth (1970); Bonnar et al. (1975); Short (1976).
The Resurgence of Breastfeeding, 1975–2000
31
At that time endocrinology was: we have a compound, we will inject it and see
what the compound generates. We inject gonadotropin-releasing hormone, see
how much hormone is coming out of the pituitary gland and we will relate that
to the onset of menses. The problem was that it was cross-sectional; we planned
to take 100 women, inject it and measure it at three months and six months
and try to understand what was happening. It was completely hopeless, but to
try to get any studies done in Edinburgh, or anywhere actually, tracking normal
women was almost impossible as well, because the will wasn’t there. I was going
to say because it wasn’t a conceived idea, but it just wasn’t on the radar. When
Peter arrived, we gelled immediately and I told him that we needed to track
normal women through their lactation. Roger had suggested it and then we
could do it.
We did a simple thing. We got our breastfeeding women to collect urine
specimens once a week. David Baird was the inspiration for this.59 This is how
he tracked infertility patients. We would do the same thing. Once a month we
would go back and collect the samples. They put the samples in the freezer.
Christine West and I had done an initial study to see how long women would
breastfeed.60 Well, they breastfed for two months. Peter and I worked out that
we needed 120 women, I think, to actually get statistically meaningful data.
We also did something which you shouldn’t do, we gave them a calendar on
which we asked them to record when they breastfed and for how long; what
menstrual periods they had; anything like this. It had never been done before.
So, we had real data from real women in real time and could relate these to
the resumption of menstruation with all these patterns. This was an amazing
difference, because it was, I think, the first-ever study of this kind that actually
showed that infertility did happen, that fertility was suppressed by breastfeeding.
It was very, very clear; it was unambiguous; you could not dispute it any more.
But, people still did.
Weaver: What connection or reference was there to the developing world, where
this was common practice? People must have observed this to be the case there.
McNeilly: My recollection – Roger can fill in better on this – is that the data
was so poor, so bad, that there was no point even looking at it, because it was
all cross-sectional, there was no tracking data. The problem that the effects
on fertility vary between women was the big thing that we came across. Peter
59 Baird (1979).
60 West and McNeilly (1979).
The Resurgence of Breastfeeding, 1975–2000
32
Howie could expand on this. I remember one day in the coffee room in the old
MRC centre for reproductive biology in Edinburgh we had a blinding flash of
inspiration related to supplementary food and the effect it had, and how the
system was actually working.
Howie: Yes, in fact we didn’t need 100 women, because the effect was so obvious
that when the women were suckling regularly without supplementary food,
they all suppressed all ovarian activity and did not menstruate. And it was just
abundantly clear that when supplementary food was introduced to the babies
it immediately signalled a reduction in the number of times mothers would
suckle their babies every day, and that was the point at which you started to see
some ovarian activity taking place. Some of the cycles were not normal, there
were inadequate luteal phases, but when ovarian activity started, you could have
break-through ovulation and the risk of pregnancy. So, the key point that came
out was that it’s the amount of suckling that actually controls the amenorrhea
and the infertility. The early introduction of supplementary food, which we
have heard about for nutritional reasons, was undoubtedly undermining the
effect of lactational amenorrhea, shortening the birth intervals and all the social
consequences that that led to. As a result of the understanding of the physiology
and the clear demonstration of what was happening biologically, there then
emerged a number of initiatives looking at the impact of feeding patterns on
birth spacing in developing world countries. Particularly the Bellagio Consensus,
which emerged as a very important event, with guidelines about the amount
of feeding that you require to maintain a very high chance of suppressing
ovulation.61 And also, WHO did a seven-country study that showed that the
suppression was true in whatever country, be it developing world, intermediate
world, or developed world. It was true across all cultures that if the mothers
suckled often enough, they suppressed ovulation. And the response to all this
was to get messages out that birth spacing through breastfeeding was still a very
important part of managing fertility control.
Weaver: I know Lars Hanson has an interest in this and was instrumental in it
affecting the thinking of the Catholic Church.
Hanson: It became very obvious in the 1970s and 1980s that the very high
infant mortality was closely related in poor parts of the world to high fertility.
And it was realized that reducing fertility to a spacing of more than two years
reduced infant mortality by 50 per cent. So it would be extremely important
61 Family Health International (1988). See also Short et al. (1991); and Glossary, page 125.
The Resurgence of Breastfeeding, 1975–2000
33
to spread information about this effect of promotion of breastfeeding and I felt
that the Pontifical Academy of Sciences would have the power to provide this
very broad message, getting around the fact that they, for religious reasons, could
not propagate other forms of hindrance of fertility. It took a very long time, it
actually took several years until it became possible to arrange the meeting that
Ann Prentice referred to.62 Actually a report resulted from the Academy that
supported this aim of ours, and I can’t tell you how efficient it was, but at least
it became an issue, also, for the Catholic Church.63
Weaver: And you met the Pope?
Hanson: Oh yes, that was part of it. Twice, actually.
McNeilly: Just one thing about the 120 women that we started with in the
Edinburgh study. Because of a certain Mary Renfrew who actually collected the
data, we reviewed the data after six months and we had only got data-complete
sets on about 20. We couldn’t understand this, and, of course, what was
happening was that Mary was acting as the buffer for problems that the mothers
were having during breastfeeding. She was being able to mentor them through
the problems. Also the diary sheet of each woman was very interesting, because
we found all sorts of things about their family lives, what they bought at Safeway,
what they didn’t, the problems with the cars and everything like that, and the life
history of these women was on this documentation, which was really important.
62 See discussion on page 20.
63 Professor Lars Hanson wrote: ‘I tried many channels to approach the Pope including through the
Archbishop of Vienna, and the vicar in the Pope’s own parish in Rome. Finally this resulted in an invitation
to a study week on resources and population at the Pontifical Academy of Sciences in the Vatican in 1991.
I was to be given the opportunity to present my case in ten minutes under the chairmanship of Professor
John C Waterlow. However, he fell ill the evening before this session was to take place and I was asked if I
could replace his lecture and give a 45-minute presentation about the role of breastfeeding in controlling
population growth and decreasing infant mortality. I did so using especially the data from our work in
Pakistan and Central America illustrating the problems with the rapid population increase coupled with
high infant mortality and often limited breastfeeding. A very intense discussion followed. During the study
week we met His Holiness Pope John Paul II.… However, nothing much happened after this, so I continued
to try to have the Vatican and its Pontifical Academy of Science act more efficiently in spreading the
message that breastfeeding could make a big difference in areas with much poverty, fast population growth
and limited breastfeeding. Ultimately there came about the renewed meeting at the Vatican’s Academy of
Science, which I attended in the company of Ann Prentice and Peter Howie. During that meeting we did
produce a statement supporting the use of breastfeeding for all its good effects. I believe that statement was
widely distributed, but I do not know how effective it was.’ Note on draft transcript, 12 September 2007.
See Pontifical Academy of Science working group (1994; 1995); Pope John Paul II (1995).
The Resurgence of Breastfeeding, 1975–2000
34
And it was such a simple thing, because it was an A4 sheet of paper; that’s all
it was; but we had there, documented, what really happened in their lives in
relation to those potential factors that affect fertility. Several things came out of
this, but I remember one of the key things was that we never actually achieved
the total number of 120 women. I think all the data we collected over the years
was from about 70 women all the way through, and then Anna Glasier joined
us and we did more intensive studies. Nevertheless, it was because the mothers
had somebody who knew what to do, how to fix the problems, and they knew
she would come to collect the samples and to talk to them. It made an enormous
difference. It could, of course, have screwed up the whole study, because if we
had needed 120, we would never actually have published anything.
Tansey: May I ask you where the data sheets are?
McNeilly: They are probably in a box in one of our animal houses, because that’s
the safest place to store them.64
Professor Anna Glasier: To take the story of the work that we were doing on
the resumption of fertility postpartum a little further. After Alan, Mary and
Peter started to publish the initial studies in Edinburgh, I, as an evil doctor
who knew absolutely nothing about the physiology of breastfeeding, was then
recruited to look in more detail at the hormonal changes underlying lactation
and fertility. I then became a member of the natural methods task force of the
human reproduction programme of the World Health Organization, and, of
course, breastfeeding is a natural method of contraception.
And so in that context we really did two things at WHO – they really did two
things at WHO, I was very peripheral to it – we set up a huge seven-country
study of over 4 000 women followed from childbirth until they had had two
normal menstrual periods – which for many of them was 18 months or so later –
looking at patterns of breastfeeding and the resumption of fertility postpartum.65
This confirmed the findings that had been published from Edinburgh, that
the resumption of fertility depended on how enthusiastically, how often, you
breastfed your baby, and when you introduced supplementary feeds.66 At the
64 Professor Alan McNeilly wrote: ‘At present, our searches for any of these forms have been unsuccessful.
The studies are now all more than ten years old and past the time that we are obliged to keep such
documentation. We do not have storage space for all the paperwork to be kept after this time and so any
may have been shredded.’ E-mail to Mrs Lois Reynolds, 13 August 2008.
65 See WHO Task Force on Methods for the Natural Regulation of Fertility (1998a and b; 1999a and b).
66 Howie et al. (1981).
The Resurgence of Breastfeeding, 1975–2000
35
same time that we were doing this study, the human reproduction programme
(HRP) and others, and particularly a group working in Chile with Horatio
Croxatto, a scientist at the Catholic University in Chile, and some people in
Washington DC who were interested in natural family planning methods,
attempted to turn breastfeeding into a kind of official method of contraception
by calling it the lactation amenorrhea method or LAM. That was really born
at another Bellagio Consensus conference and LAM is still a recognized formal
method of contraception in all WHO’s current publications on guidelines on
contraceptive use, LAM features as a method of contraception.67 And much of
the work that was done in the mid- to late 1980s, again often in Chile, to prove
the effectiveness of LAM has really never developed any further. LAM is there,
but I think all research on LAM really stopped in the early 1990s when the
proponents moved on to other things like emergency contraception.
Weaver: Who sponsored the Bellagio meeting? Was it WHO that initiated it?
Short: I was on the HRP as an adviser to WHO from 1972 to about 1985, I
think, and we got breastfeeding steered through as one of the priority areas for
the HRP study. The Director General of WHO – and Jim Akre will bear me out
on this – was Dr Halfdan Mahler, and I remember Mahler saying to me: ‘You
know, WHO made a big mistake. We came out with these recommendations
about the marketing of breast-milk substitutes but we didn’t first come out with
a statement about the advantages of breastfeeding.’ So it seemed very illogical,
here was WHO taking a position against infant formula without ever having
made the case as to why breastfeeding was better. And Mahler said that this was
one of the things that he would always regret, that WHO had made a policy
mistake in the order of its pronouncements.
But if I could just go back a moment, since we have raised the topic of fertility.
Another example that came to us – and Mary, Peter, Alan and Anna will remember
this clearly – was that we had a young Australian paediatrician working with us
in Edinburgh, John Cox, who had been working up in the north of Australia
and had carried out an amazing study of one Aboriginal woman – and I have her
photograph with me today – who by the age of 20 had six children (Figure 7).68 The
reason for this was that the Premier of the state of Queensland, where she lived,
had issued an edict that breastfeeding was primitive and all Aboriginal women
67 Family Health International (1988); Kennedy et al. (1989). See also Short et al. (1991); Finger (1996);
Labbok et al. (1997); Heinig (1998); Anon. (1988).
68 Cox (1978).
The Resurgence of Breastfeeding, 1975–2000
36
should come into hospital to have their babies and should feed them on infant
formula. John was able to document the birth weights, growth rates, moment
of introduction of supplements and subsequent reproductive activity of this
woman until the age of 20, by which time she had six children. That caused such
a scandal that it actually reached the ears of the Governor-General of Australia,
who changed Australian laws about what should be said to traditional Aboriginal
women, and that to force infant formula on them was an absolute disaster. So we
did actually change the practice, and although Australian Aboriginal women are
still severely disadvantaged, at least things are better than they were.
Dr Michael Woolridge: I wanted to add a date stamp to something that you were
talking about earlier. I became a researcher in this area, I am surprised to hear,
at about the same time as Peter Howie, about late 1978. A year earlier, in July
1977, our first child was born in Canada, and when we went to the bookshops
to look for books on how to breastfeed, on breastfeeding management, there was
only one single book on the shelves, and that was a fairly new Penguin book by
Sheila Kippley, entitled Breastfeeding and Natural Child Spacing, so quite clearly
there was a current of belief, although it hadn’t yet been adequately researched,
that a commitment to breastfeeding would establish effective natural child
spacing.69 The adverse effect of this for us was that as I was a trained zoologist
in quantitative research methods and Sheila Kippley’s book said the baby must
be fed for ten minutes on both breasts, every two hours, I would be there with a
69 Kippley (1973).
Figure 7: Aboriginal mother, aged 20 years, with her six children. Cox (1978).
The Resurgence of Breastfeeding, 1975–2000
37
stopwatch in the middle of the night, and if our baby came off after six minutes
I would try to encourage my wife to put her back on for another three or four
minutes. A year later I became a researcher in the area!
Professor Elizabeth Alder: I joined the MRC reproductive biology unit in
Edinburgh in the mid-1970s and was inspired by both Roger Whitehead and
Alan McNeilly, and then Peter Howie and Anna Glasier. I am a psychologist
and what was quite novel and one of the strengths of the unit was this
multidisciplinary team. I was also a lactating mother and at the time I had
breastfed three children. So I was aware of what was going on, and remember that
the resurgence of breastfeeding was very much class-related; it was education-
related, so my peers were beginning to breastfeed and I was happy breastfeeding.
But I was also hearing on the unit that there was a fear, even then in the 1970s,
of having fat children, and that breastfed babies would not be fat, and I don’t
know whether this is true or not, but that was the fear. This nutritional debate
that bottle-fed babies would be overfed was the incentive to breastfeed babies,
because there was a belief that you could not overfeed breastfed babies. That was
a great incentive. How that ties up with nutrition overseas I am not quite sure,
but it’s interesting.
The other is the aspect of the timing. I think earlier on, as Chloe said, ‘a
minute or two each side.’ I tried with the first child, after that with the other
children, not at all. Mothers simply ignored it. The third thing is the lactational
amenorrhea. I came trotting back to all my friends saying: ‘Don’t worry, if you
breastfeed for 20 minutes and so many times a day, you won’t conceive.’ They
would not believe it. We are so much a pill generation, so dependent on reliable
contraception, that I don’t believe that one of my contemporaries would have
trusted lactation amenorrhea. Remember too that the lifestyle that people have,
trying to get a baby to sleep through the night, not having them next to you in
your bed, was not the same as in the developing countries. So, the influences that
were coming from this kind of research weren’t necessarily having an impact on
mothers. I think it takes a long time to percolate down, and I think we should
try to remember this communication between research and what’s going on in
real life.
Mrs Rachel O’Leary: I would like to mention a subculture that was going on at
the same time. I was working as a breastfeeding mother in 1977 and in 1980 I
was accredited as a La Leche League leader. By that time we had published our
book The Womanly Art of Breastfeeding, which was the one that told you how to
The Resurgence of Breastfeeding, 1975–2000
38
breastfeed, written from mothers’ own experiences.70 Of course, it was imported
from the US, but we could handle that. It also told about suppressing periods
and how you might even not conceive. That was something that was mentioned
in that very old first edition of the book. It has been in print continuously
since then and you can get the seventh edition nowadays. But the culture being
built up was very much in spite of the health professionals. There was an air of
excitement at those early meetings where we would all cram into somebody’s
front room and hear: ‘Yes, it’s really OK to feed the baby as often as you want. Yes
it’s OK, people do sleep with their babies, babies are allowed to feed at night.’ All
of these odd ideas were coming out, and we looked at each other and thought:
‘Is it really true? Can we really do this? That woman over there, she does it.’ It
was really quite an amazing experience to be part of at that time. I have to say
it’s not that different now. We are still finding health professionals who are very
hard to convince that breastfeeding is really any different from formula feeding,
but nowadays we have a huge group of breastfeeding-aware scientists and health
professionals who are a huge help. In fact, throughout those years there have
been health professionals who have been terrifically helpful and given us advice
and inspiration. Well, starting with the Jelliffes.71 We had the Jelliffes’ book in
our La Leche League group library in 1977, and reading that opened people’s
eyes because we wanted to breastfeed because we liked it, it was convenient and
we thought it was probably better for the baby’s health. Seeing that babies were
actually dying because they were not being breastfed and hearing experiences
from developing world settings gave us fire in our bellies, which inspired us to
help each other and to continue that support for other breastfeeding mothers,
which is still really important.
Professor Malcolm Peaker: Speaking of the slightly developing world, but 1975
is pretty recent as far as I am concerned, because I started work on the mammary
gland in 1968 and that seems a lot longer ago than 1975. The interesting thing was
– and picking up on Alan’s point, one of the great problems with working on the
mammary gland in lactation – that all the previous work had been done in dairy
animals, a blessing for endocrinology, but an absolute curse for physiology. The
great problem was that the analyses were done in dairy terms by dairy chemists.
They were the British Standards, and it was solids that were measured, not fat, ash,
etc., which had no physiological conceptual basis whatsoever for any species. Like
Ann was saying, there was a great problem in devising analyses not only for human
70 La Leche League International (1963).
71 Jelliffe and Jelliffe (1978).
The Resurgence of Breastfeeding, 1975–2000
39
milk but for all milks. The traditional dairy chemist would not believe that we
could analyse 2 ml of milk and get all the information that we actually needed; they
would take a few litres. The other great problem was that dairy scientists analyse
bulk milk as you collect at the end of the milking from the entire period. People
took spot samples from wild animals, from zoo animals, from women, and thought
that represented the whole of the milk in that volume in the breast. Now, that is
certainly true in some species, but in most it is not, because of the rise in fat from
the alveoli milk. So there were these huge problems to overcome. At the same time
we had to explain all those dairy science findings in exocrine-secretion terms. And
we, Jim Linzell and I, really started – at Babraham Agricultural Research Council
Institute of Animal Physiology, Babraham, Cambridge – to get the mammary
gland recognized as an exocrine gland when the whole of physiology, if they worked
on glands at all, used salivary glands, which either switch on or off, whereas the
mammary gland, of course, secretes continuously when it is actually switched on
but at a very low rate (1–2 g per g of mammary tissue per day).
It is physiologically so boring that, after I had worked on the salt gland for my
PhD, I thought: ‘I will never stand working on this, it takes you days to get data.
It is five minutes for an experiment on the salt gland, wonderful.’ And so all this
exocrinology followed and it needed a new exocrinology because the mammary
gland is unusual in that it stores its secretion between what the dairy scientists
would call ‘let-downs’, but what Alan would now call ‘ejections’. This also created
the problem because, of course, it was thought that it was perfectly natural to leave
milk to accumulate to measure the secretory rate and things like that, whereas, of
course, in most species you can’t actually let milk accumulate, it switches off in
different periods. So that’s why many of the milk secretory rates – in women, rats,
mice and in pretty well anything you could mention – were wrong. Actually, a lot
of the published data from the 1950s, 1960s and 1970s defy all logic, because the
growth rate of the young is higher than the presumed secretory rate of every milk
constituent.72 So, essentially, everything had to be started from scratch to try to get
this on track as a piece of exocrinology to go alongside the endocrinology that was
going on, and then to link the systemic changes in the hormonal environment to
the tactical control of secretion, the minute-to-minute, hour-to-hour secretory
rates, which Peter Hartmann then picked up in Australia, to determine the
secretory rate in the shortest possible period by computer imaging the breast in
lactating women.73
72 Linzell (1972).
73 Daly et al. (1992).
The Resurgence of Breastfeeding, 1975–2000
40
Weaver: How was the link made between the animal physiology and human
lactation?
Peaker: Initially by Mavis Gunther, would you believe?74 She talked to Alfred
Cowie at the National Institute for Research in Dairying, Shinfield near Reading,
and then came to talk to us, saying: ‘All these people are poisoning all the infants
in Britain by making up milk too strong. You know something about osmolality
and tonicity and things, don’t you?’ So I then ended up getting interested in
human milk and the comparison with milk formulae. Then, of course, that
interest spread on to other aspects like lactogenesis, and my wife does wish me to
point out that her milk appeared in Nature in 1975, on the lactogenesis story.75
My third son says it was milk that was intended for him and he has suffered as
a consequence. But it was Mavis Gunther who was actually trying to make the
links because she was totally frustrated, on the clinical side, that people weren’t
actually taking any notice from the human medicine point of view.
Renfrew: Thank you; that contribution has brought a number of names to
mind that were terribly influential for me once we started thinking about the
breastfeeding physiology studies that we went on to do. One is Frank Hytten,
whose physiological studies were incredibly important;76 Harold Waller, whose
clinical studies were very influential, certainly to my thinking;77 and Mavis
Gunther, who has already been mentioned. But those three people gave us a
real headstart, and, for me, Mavis Gunther still stands head and shoulders above
most people in terms of her drawing out and describing the kinds of symptoms
of breastfeeding when there are problems and what to do about them. And she
really looked in great depth at nipple pain, bless her, in a way that very few
people have done, which was incredibly helpful.78
Weaver: How did her work become well known?
74 See Gunther (1963; 1975). See also pages 41, 51 and 56.
75 Peaker and Linzell (1975).
76 A series of 11 articles by Frank Hytten on ‘Clinical and Chemical Studies in Human Lactation’ appeared
in the British Medical Journal between 23 January and 18 December 1954. See, for example, Hytten (1954).
See also Thomson et al. (1970). Additional biographical and bibliographical information on Frank Hytten
has been provided by Dr Edmund Hey and will be deposited along with other records of this meeting in
archives and manuscripts, Wellcome Library, London, in GC/253.
77 Waller (1952).
78 Gunther (1953).
The Resurgence of Breastfeeding, 1975–2000
41
Renfrew: I am not sure that it did become well known. It was a well-kept secret.
There’s a Penguin book that was really hard to get but was given to me by
Christine West, whom Alan mentioned. When I started working at the MRC
reproductive biology unit in 1982, she said: ‘Read this.’79 It was actually quite
difficult to get hold of for a while. She became influential to some of us, and to
Maureen Minchin, indeed, who wrote Breastfeeding Matters, and was influential
in another way, internationally.80 Mavis Gunther inspired other people.
McNeilly: Related to what Malcolm Peaker was talking about and the dairy
industry and using cattle as a basis of research: they store milk in a big cistern,
the udder. As I had been milking cows, I knew that they would eject milk quite
happily as they walked along and it wasn’t difficult to get milk out of a cow’s
mammary gland. But women don’t store it in the same way. It’s stored in the alveoli
and they need oxytocin to release milk. If they don’t have oxytocin released then
they actually have trouble getting milk to the baby. If you watch babies suckle,
it’s quite clear when the milk ejection does occur and they get a lot of milk. This
is normal biology. This is physiology, and the person who did a lot of work on
this, Dennis Lincoln, had shown in rats that in fact it was the mother’s brain
that released the oxytocin and made the baby suckle.81 And one study that we
did in Edinburgh is related to this; we showed that the baby crying would release
oxytocin before the baby got to the breast.82 A completely different system from
what was in the textbooks then, and is still in the books, and is still wrong in lots
of the books. In parallel with Malcolm, my wife and I – in an article published in
the BMJ – showed milk ejection at absolutely precise intervals during lactation in
a mother who suckled twins, who happened to be my wife.83 This was 1978, and
yet this whole story is not out there either, but one of the key things to this is that
oxytocin is turned off by stress. If you stress somebody, you turn the oxytocin off,
you can cause problems and it’s a downward spiral. It doesn’t matter how many
times you say this to people, they chant: ‘This is just physiology, so what’s that
got to do with people?’
Mrs Jenny Warren: I was the National Breastfeeding Adviser for Scotland,
now very happily retired. I want to pick up when you mentioned Mavis
79 Gunther (1970).
80 Minchin (1989).
81 Wakerley and Lincoln (1971); Lincoln and Paisley (1982).
82 McNeilly et al. (1983).
83 McNeilly and McNeilly (1978).
The Resurgence of Breastfeeding, 1975–2000
42
Gunther. There are a lot of wonderful people at this meeting who have been
involved in research into lactation and associated aspects for many years. Early
in that time I was a young midwife and had no clue about breastfeeding, but
was lucky enough to come into contact with the National Childbirth Trust.
The voluntary organizations to do with childbirth and lactation were very
much working with mothers, and they then began to get together with the
midwives, because there was a lot of medical intervention in childbirth and I
think that was a very important time, bringing the health professionals, the
mothers and the voluntary organizations together. I think that was a hugely
important event in the late 1970s and early 1980s.
Weaver: Can you tell us who and where, or details of how that came about?
Warren: I assume everybody remembers the Wendy Savage events in 1985,
when she was accused of endangering women.84 I think she got a lot of support
from the voluntary organizations and from the mothers in their care. And I
think that was the beginning of those groups coming together, and working
with health professionals and that has gone on since that time. Certainly, I was
lucky enough to learn what I thought was a lot about breastfeeding, we heard
about your research and took that forward to mothers at grassroots. Obviously,
we were not knowledgeable in the way that you were, but working with women
at the grassroots and having the pleasure of saying: ‘Yes, this does help women’,
and seeing the satisfaction and joy that breastfeeding brought them, I think,
made us all much more committed as time went on, and many of us have
continued working with breastfeeding for a very long time. That was a hugely
important time. I don’t know if anybody else agrees with that, but I think it
started a movement where mothers, midwives, and voluntary organizations
started to work together and put women at the centre of what was going on.
Mrs Phyll Buchanan: I want to make a small point. I am now speaking from
the Breastfeeding Network, but partly it is recalling experiences from when I
was a junior midwife at the Simpson in 1978 and I think it was the height of
medical intervention. Something that really struck me as a young midwife was
the women coming into the labour wards for their routine shavings and enemas:
some women would come in and look at you straight in the face, and you knew
that they were from the National Childbirth Trust (NCT). More than that, their
case notes actually had ‘NCT’ in red letters on the front. As a student, I thought
there must be something in this, because they would sometimes challenge you.
84 See Savage (1986; 2007).
The Resurgence of Breastfeeding, 1975–2000
43
Weaver: And how did that come about so early?
Palmer: I am not an expert on the NCT, there are many in this room, for the
record, I gave birth in 1970 and 1972 and had no contact with the NCT. But
in 1972 I found a leaflet for the newly formed NCT breastfeeding promotion
group in an NHS mother and baby clinic. I joined because I thought what a
wonderful idea it was for women to help each other. I could not have afforded to
pay for any breastfeeding counselling training but I got good free training from
the NCT. I was given Mavis Gunther’s Infant Feeding, which changed my life.85
At that time there was some hostility towards health professionals by some NCT
women, and some would say vice versa. My local health visitor used me to give
breastfeeding classes and support to local women.
Weaver: We are going to stop for tea in a few minutes. I wanted to get to the
bottom of this: WHO and the Baby Friendly Initiative saw the interest in birth
spacing as separate from the interest in feeding.86 When did WHO properly
connect these together?
Akre: Things were done a bit backwards, because I don’t think WHO as an
organization understood the implications of everything that we have been talking
about for the last two hours. In fact, what precipitated the whole push towards
the International Code of Marketing of Breast-milk Substitutes goes back to the
1974 and 1978 Health Assembly resolutions and the 1979 meeting, which made
a number of recommendations, including that there should be an international
code.87 This seemed to focus mainly on developing countries because of the
deleterious impact of marketing and promotion of breast-milk substitutes in
these environments, and therefore in 1981 the WHO’s international code was
adopted, following its drafting jointly with UNICEF and, of course, with the
85 Gunther (1970).
86 DoH/UNICEF UK Baby Friendly Initiative (1993).
87 Mr James Akre wrote: ‘In October 1979 WHO and UNICEF held their landmark joint meeting on infant
and young child feeding in Geneva, attended by some 150 representatives of governments, nongovernmental
organizations, professional associations, scientists and manufacturers of infant foods. Discussions centered
on five themes: encouragement and support of breastfeeding; promotion and support of appropriate and
timely complementary feeding; strengthening of education, training and information on infant and young
child feeding; promotion of the health and social status of women in this connection; and appropriate
marketing and distribution of breast-milk substitutes. Participants in the October 1979 meeting included
Dr Elisabet Helsing, Professor Dick Jelliffe and Professor Pat Jelliffe. Baby Milk Action was a founding
member of IBFAN, several of whose members also participated in the WHO/UNICEF meeting in October
1979.’ Note on draft transcript, 7 October 2008.
The Resurgence of Breastfeeding, 1975–2000
44
participation of many organizations, including the activist groups, with some of
the very representatives present here today.88 After focusing on the marketing and
promotion of breast-milk substitutes, it was only in 1989 with the publication of a
joint statement on breastfeeding and maternity services that the role of maternity
services was directly considered, with the launching in 1991 of the Baby-friendly
Hospital Initiative.89 Here we are in 2007, with last year’s release of the new growth
reference standard.90 So, in a sense, all of it was done backwards, but the impetus,
historically, came from what was happening in developing countries before being
broadened to include all children, everywhere. Now we are talking about what’s
right for our species, and what’s physiologically appropriate feeding behaviour.
So, I think it is like looking through a telescope through the wrong end.
Weaver: Felicity, I don’t know when you joined WHO, but what are your
recollections of this period?
Savage: I joined WHO in 1993 but I had been doing consultancies for WHO
and UNICEF for some years before that. LAM was a very strong influence on
people’s interest in breastfeeding in the 1980s, and, for a time, promotion of
breastfeeding was emphasized in family planning programmes. Breastfeeding
tends to have piggy-backed on other programmes. In the 1990s it became
diarrhoeal disease control, when research showed that breastfeeding was the one
provable way of preventing diarrhoea in children, particularly if they breastfed
exclusively. Interest in breastfeeding was developing after the adoption of the
International Code of Marketing of Breast-milk Substitutes in 1981, but then
there was a lapse and there was little progress for several years, apart from the
activity of groups who were promoting the implementation of the code. Then
in 1986 UNICEF organized a meeting to discuss why so little was happening
to promote breastfeeding. This was part of UNICEF’s GOBI movement,
which addressed Growth monitoring, Oral rehydration, Breastfeeding and
Immunization.91 The immunization and oral rehydration aspects were very
successful but nothing was happening on breastfeeding, probably because
88 WHO (1981b). Freely available at www.ibfan.org/site2005/Pages/article.php?art_id=52&iui=1 (visited
22 January 2009).
89 See www.who.int/nutrition/topics/bfhi/en/index.html (visited 29 January 2009). See also Woolridge
(1994); Broadfoot et al. (2005) and note 47.
90 See www.who.int/childgrowth/standards/en (visited 13 October 2008).
91 UNICEF introduced the GOBI strategy of four child health interventions in 1992. Birth spacing/family
planning (F), food supplementation (F) and the promotion of female literacy (F) were added subsequently
(GOBI-FFF). See Claeson and Waldman (2000).
The Resurgence of Breastfeeding, 1975–2000
45
it wasn’t so easy to package. The UNICEF executive director, Jim Grant,
asked a group of experts to suggest what could be done about breastfeeding.
At about this time Michael Woolridge was researching the oral dynamics of
milk transfer and we were beginning to understand how to help mothers to
breastfeed. With the help of workers like Chloe Fisher, we were beginning to
realize that many mothers need help to breastfeed effectively, and to understand
how to help them. It took some time for this understanding to become more
widespread. However, in 1989 a joint WHO/UNICEF statement, Protecting,
Promoting and Supporting Breastfeeding: The special role of maternity services, was
produced, which drew attention to the importance of healthcare practices, and
gave us the Ten Steps to Successful Breastfeeding, which became the foundation
of the Baby-friendly Hospital Initiative.92 Subsequently, there was a series of
meetings on all the different aspects of breastfeeding: one in Copenhagen on
lactation management training organized by Elisabet Helsing, and others on
mother support, women’s employment, hospital practices, and the code. The
conclusions of these meetings were presented at another meeting in WHO,
Geneva on breastfeeding in the 1990s. This led to the Innocenti Declaration in
1991, at a meeting of policy makers in Florence, which was intended to make
a recommendation for the Convention on the Rights of the Child in the same
year.93 The Innocenti Declaration led to the concept and implementation of the
Baby-friendly Hospital Initiative.
Weaver: So, these were different sections in WHO that were coming together
now and again with these meetings that were sponsored by WHO?
Savage: Yes, there was UNICEF; the nutrition division in WHO, which took
a very leading role in the Baby Friendly Hospital Initiative; and the Diarrhoeal
Disease Control Programme, which was also promoting breastfeeding for the
prevention of diarrhoeal disease. They were separate divisions but contributing
to the same initiative.
92 WHO/UNICEF (1989). The ten steps are listed at www.unicef.org/newsline/tenstps.htm (visited 14
August 2008).
93 The Innocenti Declaration was produced and adopted at the WHO/UNICEF policymakers’ meeting,
Breastfeeding in the 1990s: A Global Initiative, co-sponsored by the US Agency for International Development
and the Swedish International Development Authority, at the Spedale degli Innocenti, Florence, Italy, 30 July –
1 August 1990. Freely available online at www.unicef.org/programme/breastfeeding/innocenti.htm (visited 22
January 2009). The infant formula and follow-on formula regulations came into force in the UK on 1 March
1995 to implement Commission Directive 91/321/EEC; see www.opsi.gov.uk/si/si1995/Uksi_19950077_
en_1.htm (visited 22 January 2009).
The Resurgence of Breastfeeding, 1975–2000
46
Weaver: This was GOBI?
Savage: That was a UNICEF initiative.
Weaver: I see, and was that when the public health significance of breastfeeding
with all its positive effects came together?
Savage: Yes, throughout the 1980s, these public health aspects began to come
together and the activity started with the preparatory meeting that led to the
Innocenti Declaration and the Convention on the Rights of the Child.
Rundall: I am sorry if my comment gave a misleading impression about this
funding.94 But, leaving aside the funding of the Gambia research, I do know
that there has certainly been some funding from the infant feeding industry
going into the MRC Dunn Nutrition Laboratory, Cambridge. I don’t want to
be disrespectful about people’s intentions when they do research. It’s obvious
that all researchers are trying to find solutions and trying to find the correct
situation impartially. And, the later work carried out by the Dunn was extremely
valuable.95 So it has been very interesting for me to hear all this, because, as I
said, in the late 1970s–1980 we came in and did pick up on what WHO and
the World Health Assembly were saying.
What was absolutely crucial for us was the evidence that babies were dying and
that appalling practices were being carried out by the baby food industry. We
were monitoring this, and we mustn’t forget that. IBFAN was formed in 1980
and action groups running the Nestlé boycott triggered much of this concern to
look at what was happening with breastfeeding and to look at what was called
‘commerciogenic malnutrition’ and actively do something about it. I think that
if the consumer groups had not exerted pressure like that, the code would not
have happened. It was essential to do something to try to stop the companies
from doing positive harm. I can remember in 1980 wondering why health
workers in developing countries didn’t do something, didn’t recognize what the
problem was. I met a midwife at the first IBFAN meeting. She said: ‘Babies
die and we don’t know why.’ She said she was getting the milk companies in to
do the training of the mothers, and was so rushed off her feet she didn’t realise
the harm. She just got them in to help. It was only when she got an IBFAN
questionnaire she realized that this was the cause of the problem. The wrong
94 See page 16.
95 Mrs Patti Rundall wrote: ‘My point is that inappropriate funding can have a damaging impact and can
silence those who should speak out.’ Note on draft transcript, 3 September 2007.
The Resurgence of Breastfeeding, 1975–2000
47
people were giving the advice in the healthcare system. Elisabet is quite right
about that; the healthcare systems were being invaded, even after the WHO
code came in the companies took the code and pretended that they were behind
it, which, of course, they were not. But they went all over the world promoting
their versions of the code. Some of these companies had about 11 versions,
confusing people and trying to get in as partners to help healthcare systems
manage breastfeeding.
Weaver: And Cicely Williams? Nobody has mentioned her. We always read
about her work being very much earlier, making these points.
Short: I am glad Cicely has been mentioned because I think she played an
enormous role.96 She was working in West Africa and brought to public attention
that lovely West African word ‘kwashiorkor’, which means ‘the evil eye of the
child in the womb, upon the child already born’. What a prophetic statement. It
wasn’t invented by her, it was an indigenous term throughout Nigeria and much
of the rest of West Africa; it was saying that if you have too short a birth interval,
the new pregnancy switches off the milk supply to the older child, who will die
96 See Williams (1933; 1935); Dally (1968).
Figure 8: Dr Cicely Williams in India, 1950, with severely malnourished child.
The Resurgence of Breastfeeding, 1975–2000
48
of malnutrition. I will never forget going for the first time to Port au Prince, in
Haiti, to the antenatal ward and looking at a row of about 20 mothers with their
children. All the mothers were pregnant, coming for an antenatal examination,
and there wasn’t a single sound from any of their children. The obstetrician
who was running the clinic said to me: ‘You see those children? They will all be
dead within six months. They have all got kwashiorkor.’ I could see with my
own eyes the evil eye of the child in the womb upon the child already born and
how a short birth interval was having a disastrous effect. This was known in the
developing world long before we discovered it.97
Weaver: Well, that’s a sombre note on which to end the first half of this
meeting.
Akre: To get in under the wire, because we are moving into another area, I would
like to confirm what Patti Rundall has said. The international code would never
have gone anywhere, it would never have got off the ground, if it hadn’t been for
the activist groups. So, we went from the particular to the collective summary
of knowledge and awareness in international public health policy terms; from
the international code in 1981 to the adoption of the Global Strategy for Infant
and Young Child Feeding in May 2002.98 And even if it’s not going to win any
literature prizes, I think that the global strategy pulls together all the disparate
bits that we have talked about, and is the result of all the research activities that
we have also discussed. In terms of public health policy, it was a combination of
these events that was driving what WHO as an international organization was
able to produce. So, things started with the particular, but ended with a much
broader approach, the global strategy, which is now being implemented in over
160 countries.
Weaver: We are going to move on now in the second half to think, talk, or
hear more about what happened in the UK in maternity units, neonatology
units and what the neonatologists were doing. I am going to ask Dr Anthony
Williams to start us off.
Dr Anthony Williams: I am going to give a slightly personal perspective as a way
of introducing the area. I qualified as a doctor in 1975, so as a medical student
and a young junior doctor in paediatric wards, the kind of practices we have
heard about earlier today were very familiar to me, and I well remember the
97 See also Reynolds and Tansey (eds) (2001b): 38.
98 The global strategy was formally published in 2003, see WHO (2003).
The Resurgence of Breastfeeding, 1975–2000
49
babies being congregated in nurseries for several hours a day, rather than with
their mothers. It’s clear when you look at the texts of the 1970s and the early
1980s even, that many paediatricians were very supportive at least of the use
of breast-milk in the neonatal units. I am thinking about the Medical Care of
Newborn Babies, the Hammersmith textbook, which was perhaps the first big
British textbook of neonatology.99 I remember as a senior house officer in the
1970s in Leicester, David Davies, who unfortunately isn’t able to be here today,
being very pro the use of breast-milk for the babies and opening a breast-milk
bank in Leicester. Of course, this was the era of setting up breast-milk banks in
a sense, and there are names like Harold Gamsu, David Harvey, Brian Wharton
with Sue Balmer in Birmingham and David Baum, to whom we shall come
back later.100
As a registrar in Liverpool I hardly saw any breastfeeding in the late 1970s, and
that reminds me of something quite important. I did my neonatal training in a
very poor area on the edge of Liverpool and perhaps something that we haven’t
explicitly said is that the way a mother feeds her baby is probably the strongest
measure of social and educational inequality that we have. Beth Alder referred
to the resurgence being in social class I mothers and there is still that very wide
divide. One of the important things that came out of the quinquennial Infant
Feeding Survey statistics, at least in recent years, is that the gap has narrowed a
bit.101 It is the women in the lower social classes who have shown some resurgence
in recent years. Also there’s been resurgence outside England: in Scotland, to
which Jenny Warren could attest, and in Northern Ireland and in Wales.
To come back to my career, I went from Liverpool to Oxford, and there I was
extremely privileged to work with David Baum for about the next seven or
eight years. Of course, there I also met Chloe Fisher. I must say that virtually
anything I know about breastfeeding, I have learnt from midwives, most of
whom are in this room. In my bag today I have still got my copy of Successful
Breastfeeding [Figure 9], which I think Chloe, Ellena Salariya and other
midwives here were instrumental in designing. As a result of that contact, I
feel I know a little bit more about the practical aspects of breastfeeding than I
otherwise would as a doctor.
99 Davies et al. (1972).
100 Sloper and Baum (1974); Baum (1979).
101 See Table 1, page 9; Bolling et al. (2007); www.babyfriendly.org.uk/page.asp?page=21 (visited
17 June 2008).
The Resurgence of Breastfeeding, 1975–2000
50
I was disappointed only quite recently to be teaching a group of senior
specialist registrars, one of whom was about to become a consultant in neonatal
medicine, about the mechanics of breastfeeding. He told me that this was the
first teaching he had ever had on breastfeeding in his entire training, so we
still have a considerable training gap in medical practice, and particularly with
neonatologists. In neonatology we have lost the sense of the general paediatrician.
David Baum was an example of somebody who was first and foremost a general
paediatrician and secondly a neonatologist, so he was able to see vividly the
wider importance of breastfeeding. There are other neonataologists that I could
mention again in that context. We have got Forrester Cockburn and Edmund
Hey here. The problem with many current neonatologists, I think, speaking as
one, is that they are much more focused on the care of the sick newborn. They
go from an intensive care unit to the normal newborn baby in hospital. This
produces a feeling that a baby has ‘requirements’, which must be met on ‘day
one’ and ‘day two’ and so on. So we are almost back to the prescriptive: ‘one
minute on the first day’, ‘two minutes on the second day’ and so on. People
want to stick things in the baby and measure numbers to make sure the baby
has got enough milk to prevent him or her falling apart within the first week
Figure 9: The Royal College of Midwives’ practical guide, 1988.
The Resurgence of Breastfeeding, 1975–2000
51
of life. So there is still, I think, a gap to be bridged where neonatologists are
concerned in terms of appreciating the difference between the normal newborn
baby and the baby in a neonatal unit. Perhaps I shouldn’t speak for them, but I
think that can apply to some neonatal nurses as well.
To go back to the 1980s for a minute, I was privileged to work with people
also like Mike Woolridge on the opposite side of the room here, and to learn
about the science of breast-milk transfer.102 We really began to understand a
number of things about that, and in many respects I think this has been the
least well-studied aspect of breastfeeding – how milk actually gets from the
mother into the baby. A lot of light was shed on that process in the 1980s,
much of it, I have to say, underpinning what Mavis Gunther had been saying
very much earlier in her book.103 But we have, if you like, a fuller scientific
validation now. It was also a time at which there was a lot of interest in learning
about breastfeeding, and Mike Woolridge, Chloe Fisher and I remember that
we were probably spending a considerable amount of time, often at weekends,
going to ‘breastfeeding roadshows’ and study days in postgraduate centres up
and down the country, which were usually crowded out with midwives eager to
learn more about breastfeeding. The later publication of Successful Breastfeeding
was an indication of that thirst, if you like, for the knowledge amongst the
midwifery community.
The final thing I would like to discuss, because it hasn’t been mentioned in
any depth so far, is the Baby Friendly Initiative in the UK.104 We went through
a couple of national initiatives, with the Department of Health, in the early
1990s. There was the Joint Breastfeeding Initiative, and then the National
Breastfeeding Working Group, and that gave rise to the National Infant Feeding
Coordinators later.105 About 1992/3 the Baby Friendly Initiative began in the
UK, and, again, it was David Baum together with Robert Smith at UNICEF
102 See Woolridge (1986).
103 Gunther (1970). See page 40.
104 See note 47.
105 The Minister of Health, Edwina Currie MP, challenged health professionals and voluntary organizations,
in 1987, to work together to promote and support breastfeeding, resulting in the Joint Breastfeeding Initiative
in England in 1987 and in Scotland in 1990. In England, the National Breastfeeding Working Group was
established by the Department of Health in 1992 and produced guidance for the NHS in 1995 [National
Breastfeeding Working Group (1995); Campbell and Jones (1994)]. For details of subsequent development in
Scotland, Wales and Northern Ireland see www.scotland.gov.uk/Publications/2006/04/03092034/8 (visited
19 February 2009); DoH, Scottish Office (1996); The National Assembly for Wales (2001); DHSS (2004).
The Resurgence of Breastfeeding, 1975–2000
52
who were the driving forces in getting that initiative going in the UK. Mike
Woolridge may be able to speak about this again as the first programme director
of the Baby Friendly Initiative in the UK. Now this initiative did many things
for breastfeeding, I think. One of the most important was that it began the
‘big tent’ for breastfeeding, where everybody could join in, and it dealt to some
extent with the divisions that there might have been between the healthcare
professionals, the mothers and everybody else. It almost provided, if you like,
a brand for breastfeeding, which was necessary in some respects in a partly
commercialized world. There’s no doubt from the international work that has
been done that the Baby-friendly Hospital Initiative is an extremely successful
way of increasing the proportion of mothers breastfeeding and reducing
preventable disease in the community. For example, the Belarus study was the
strongest evidence of that from a large-cluster randomized trial.106
I also think that in the UK we have some very good data that show how effective
the UNICEF Baby Friendly Initiative has been here. One of the great contributors
to that, I think, has been the precision and the accuracy of the data that’s been
collected in Scotland. It was Forrester Cockburn who published the paper on the
use of Guthrie cards to document whether women are breastfeeding at the end
of the first week.107 We still don’t have that kind of population data in the other
countries and it’s sorely needed. The Baby Friendly Initiative also has been an
unappreciated vehicle for midwifery training if you look at what the initiative
has done in its 10 or 12 years. I think I heard it’s trained thousands of midwives
and also junior doctors in hospitals that have become ‘baby friendly’. So it’s
undertaken a huge task and the fact that we now have something like 60 or
more Baby Friendly hospitals in the UK is evidence of that. I remember when it
started off in the 1990s people were asking why we were bothering with the Baby
Friendly Initiative in the UK. The testimony is that we have over 60 hospitals,
and many more working towards it, with certificates of commitment. I think
106 Kramer et al. (2001).
107 Professor Lawrence Weaver wrote: ‘Robert Guthrie was the inventor of a method for neonatal screening
for phenylketonuria’. Note on draft transcript, 20 October 2008. Professor Forrester Cockburn wrote:
‘Guthrie cards are used in Britain to screen all babies for inherited metabolic disease and hypothyroidism.
District midwives take blood from the heels of every baby seven days after birth and test it on the specially
absorbent card. They also routinely record on the card the feeding method used on the day the infant is
seen, the date of birth and address (including postcode) and the hospital of birth; only one method of
feeding, bottle or breast, is recorded as there is no scope for recording mixed feeding.’ Ferguson et al. (1994):
824. See also Tappin et al. (1991; 1993); Guthrie (1996).
The Resurgence of Breastfeeding, 1975–2000
53
that’s all I would like to say now and I will open this up for discussion. There are
things I haven’t mentioned, like the successive Committee on Medical Aspects of
Food and Nutrition Policy (COMA) reports, the grey books and the people who
were involved in producing those, but perhaps we can pick those up later.108
Weaver: You mentioned a number of topics that I think we would like to
pursue. I want to get back as early as possible historically, to the early 1970s.
You and I both qualified at about the same time and you said how our seniors
were not really interested in breastfeeding, except for one or two who are here,
so maybe we will put the spotlight on Forrester Cockburn.
Professor Forrester Cockburn: I was also in the Simpson Memorial Maternity
Pavilion, Edinburgh, but I had left by the time most of the work that Roger
Short and the others were talking about.109 One of the things that I remember
from the 1960s was, at that time, particularly after the withdrawal of National
Dried Milk, individual milk companies had contracts for the milk kitchens in
each of the major maternity units in this country.110 Each firm jealously guarded
and argued the need for its particular brand of milk to be in that hospital and
there were financial and other inducements, which had a major adverse effect on
breastfeeding to which paediatricians paid insufficient attention.111 One has to
remember that there were virtually no paediatricians in the late 1950s and early
1960s dealing full-time with the newborn.112 There was the occasional consultant
visit from the nearby children’s hospital, with a few exceptions like Bristol and
Birmingham. The whole attitude was not influenced by neonatal paediatricians
because there weren’t any so-called neonatal paediatricians before about 1968,
when paediatricians with knowledge of the physiology and biochemistry of the
newborn human infant began to appear for the first time.
I got involved partly because I was interested in inherited metabolic disease and
knew something about physiology and biochemistry. My interest in neonatal
nutrition started with phenylketonuria, because after 1957, when the treatment
of phenylketonuria was introduced, we had to produce a good infant milk with
a low protein, low phenylalanine and reasonable tyrosine levels. None of the
108 DHSS (1977; 1980); DoH (1994).
109 See pages 29–32.
110 See Glossary, page 128. See also Oppé et al. (1974); Baum and Harker (1975); Arneil et al. (1975).
111 See Church and Tansey (2007): 370–1.
112 See Walker-Smith (1997).
The Resurgence of Breastfeeding, 1975–2000
54
milks available at that time, which were largely high-protein, caseine-based,
were of much use. I was in the US working on the type of diet that might best
be suited to the infant with phenylketonuria. We showed that whey protein was
perhaps a better material on which to base infant formulae for children with
metabolic diseases generally, but in particular phenylketonuria. When I came
back to Edinburgh, I think it was Ron Hendey who got hold of my data and
instead of feeding whey protein to pigs, they decided to feed it to human beings
and stop using whole or caseine-based milks.113
When I came back to Edinburgh as a Wellcome senior research fellow from
Oxford, a major problem of the time was neonatal convulsions. Every winter
in the Simpson we had several hundred babies convulsing merrily, half of them
through hypoxia induced by various obstetric complications and the other half
due to hypocalcaemia and/or hypomagnesaemia, and the next biochemical
exercise was to work out what was happening. We found that the women in
Edinburgh at that time were vitamin D-deficient during the later winter/early
spring, and I think they still are today, and that this was the reason for the
seasonal prevalence of convulsions in the newborn, and that the high-phosphate
milks were the trigger to the convulsions.114 So I spent the rest of my life
telling milk companies that their products were biochemical rubbish as far as
the human infant was concerned. My latest research involved looking at the
lipids in the milk and showing that the composition of the brain of the human
infant that has been fed on cow milk formulae is completely different from that
of breastfed infants.115 There is a real need for formula milks for some infants
and for safe breast-milk substitutes, so my role has been that of being devil’s
advocate.
One little thing about the WHO and its code was that for a while we had
what was called the Code Monitoring Committee in the UK and the chairman
was Dame Alison Munro, who was quite formidable.116 As a point of historical
113 See Janas et al. (1985).
114 Cockburn et al. (1973).
115 See Farquharson et al. (1992; 1995).
116 The International Code of Practice [WHO (1981b)] was introduced in the UK in 1983 and was
supported by a Code Monitoring Committee on infant formulae consisting of eight members nominated
by the Government, four nominated by the Food Manufacturers Federation and Government-nominated
chairman Dame Alison Munro (1985–89). The code bans advertising to the general public except under the
control of the healthcare system and controls advertising to health professionals themselves. The committee
considers complaints against the international code.
The Resurgence of Breastfeeding, 1975–2000
55
interest, her brother was Ian Donald, who introduced ultrasound to medicine.117
She tried hard to keep the cartload of monkeys called the Food Manufacturers
Federation under control. But only four of the milk firms were involved and
eventually the whole thing fizzled out. I was on the committee at that time and
we eventually agreed to accept the whole of the WHO code.118 These are just a
few of my thoughts, but Edmund Hey was involved in another aspect of milk,
infant hypernatraemia, but he says: ‘No, it wasn’t hypernatraemia.’ Perhaps he
could carry on from here with that aspect of things that frightened women
about artificially feeding their babies.
Weaver: Yes, Edmund, please. I was your senior house officer in the late 1970s
and I remember being taught nothing about infant feeding at all.
Hey: No, I didn’t teach you anything about infant feeding. The control of feeding
was in the hands of the nursing staff and even in the premature babies they would
dictate who was fed, how and when, and they knew how to do it. It was not a
medical issue at all. It was kept from the medical staff. The nursing staff would
decide when to start, when to stop and how much to give. I really think that we
should never have entered the field, that is my view. I spent my time encouraging
the nurses that this was an area where they really did know better and if they could
only think of scientific reasons rather than just say: ‘Well, because I know it’s true’,
they would actually earn the respect of the medical staff, the confidence of the
women and keep this as something that women can teach women better. What’s
nursing about? It’s a strange word, isn’t it.119 And a skill that midwives should have
retained all along. We as neonatologists should never have entered into it.
I wasn’t a neonatologist; I tried to be a paediatrician. Yes, I do recall being in
Newcastle at the stage when milks contained too much phosphate and also
117 See Tansey and Christie (eds) (2000); Willocks and Barr (2004).
118 Mrs Patti Rundall wrote: ‘Professor Cockburn refers to the monitoring committee fizzling out and then
going straight to the whole of the WHO code. Sadly this wasn’t the case. The UK has never implemented
the whole code and has allowed advertising to persist to this day. An NCT/UNICEF survey carried out in
2005 showed the impact of this marketing and found more than one-third of mothers thought that the
advertising conveyed the message that formula was “as good” or “better than” breast-milk.’ Letter to Dr
Daphne Christie, 3 September 2007. See NCT/UNICEF (2005), which includes details of the results of
the 1000 telephone interviews conducted 16–22 August 2005.
119 Dr Edmund Hey wrote: ‘When someone spoke 200 years ago about a baby being “nursed” they were
saying it was being fed, or suckled. It is sad to think that, although nurses have now acquired many new
and invaluable skills, they seem to be at risk of losing the oldest one of all.’ Note on draft transcript, 10
September 2007.
The Resurgence of Breastfeeding, 1975–2000
56
contained too much sodium, so that if the baby got the squitters, you ended
up with hypernatraemia.120 The early formula milks were pretty alarming when
the baby’s physiology was under stress. Even now, of course, people are worried
about breastfeeding, the fact that if the intake isn’t very good and the weight
drops away, maybe the baby should be weighed every day. I am not sure what
Dr Anthony Williams thinks about weighing at regular intervals, but there are
1 or 2 per cent of breastfed babies crashing into hospital with quite serious
weight loss now, who are hypernatraemic and if you read some of the papers
on the subject, they imply that it’s because there’s too much sodium in the milk
that the mother is giving. It’s all upside down. The problem is that the baby has
not had enough water, not that it has had too much salt. It’s the ratio that you
are looking at. When you say: ‘Oh dear, this baby has got high sodium.’ No, he
hasn’t, he hasn’t got enough water to dilute the sodium. I will end at that point.
I really do think that this is an area that should be de-medicalized, and I am glad
to see a whole host of midwives here today.
Weaver: Mike Woolridge, it has been suggested that you would tell us more
about Baby Friendly issues.
Woolridge: I could do, but I simply wanted to say that I actually arrived in this
field as an interloper, because I have no medical allegiance, I am not medically
qualified, I am not a paediatrician or an obstetrician; I am a zoologist, somebody
who has never been involved in veterinary practice or dairy science. It occurred
to me when I arrived that paediatricians have a responsibility and an interest in
the newborn, so they study the newborn in isolation. Obstetricians, to a certain
extent, seem to study the mother and her makeup in isolation. The zoologist
looks at the interaction between the two animals as perfectly natural, so I found
it very easy to look at the interaction between mothers and babies. I suppose I
was gratified scientifically to see that the research going on in Edinburgh and
Cambridge was at least looking at the process of the interaction between mother
and baby, rather than looking at milk output of dairy animals. That is not to
disparage that at all, but animal research was something that I was never familiar
with or comfortable with.
Weaver: So how did you take up the reins of the Baby Friendly Initiative?
Woolridge: Well, I don’t know how, but with horror, because my initial reaction
was that this was a very rigid, prescriptive scheme that would be imposed on
120 Anand et al. (2002); Morton (1989); Oddie et al. (2001); Laing and Wong (2002); Richmond (2003);
Iyer et al. (2007); Crossland et al. (2008).
The Resurgence of Breastfeeding, 1975–2000
57
women and I thought it would be received with a degree of unrest. However, the
more I looked into it and the more I found that it was delivered in a sympathetic,
more flexible way, the more I came to appreciate its potential benefits. I suppose
in the early days of the Baby Friendly Initiative in this country it was developed
and implemented in a very flexible manner. I think, looking at the national
data, I would currently attribute the most recent change from 2000 to 2005
to the impact of national policy changes through the Baby Friendly Initiative,
not governmentally introduced, but through this sort of overall cultural impact
of the UK Baby Friendly Initiative. Looking back to 1975–80, I don’t think it
was professionally induced change, I think it was a cultural revolution that was
taking place. I know Elisabet will probably acknowledge that in Europe what
is called a Green Wave led to a cultural shift in the population, and although a
lot of people would like to claim credit for it, I think it is a largely independent
cultural change amongst women, probably supported and encouraged by lay
support groups.121
Howie: I’m from Dundee. We have been talking about neonatal paediatricians
but not much about obstetricians, of which I am one. Of course, the
obstetricians do have quite an important influence on women in the antenatal
and immediate postnatal period. When I went to Dundee I took my interest
in breastfeeding from Edinburgh but was told repeatedly by my colleagues
that I should not pursue it because I was making their patients feel guilty.
This has not been mentioned very much, but I was told that mothers who
were inclined initially to choose to bottle-feed should not be leant upon or
persuaded because if they continued to bottle-feed and make that their choice,
they would feel guilty. Indeed, that was a major stimulus for undertaking
the infant feeding and health study, which may be appropriate to talk about
later on.122 Many of my colleagues said: ‘And in any case, it doesn’t make the
slightest difference at the end of the day whether the mother bottle-feeds or
breastfeeds.’ When I went to Edinburgh in the late 1980s, I would have said
that was the predominant attitude amongst obstetricians, and also amongst
quite a lot of midwives. Many other midwives took an exact opposite feeling
and were very enthusiastic about breastfeeding, but I think midwives, if they
are honest, would say that they were divided. But this ‘don’t make the mothers
feel guilty’ was a very powerful motive.
121 See Rosenberg (1989).
122 See Howie et al. (1990) and pages 74–5.
The Resurgence of Breastfeeding, 1975–2000
58
Salariya: I concur with Peter Howie’s thoughts about people being against
breastfeeding. As a student midwife in Glasgow in the 1950s, and later in
Dundee as a staff midwife, one had to be on one’s guard about mentioning
breastfeeding, as bottle-feeding mothers would feel guilty. Supplementary
and complementary bottle-feeds of formula milk were given to the breastfed
infants secretly by midwives and nursing staff. When my first baby was born in
1954 I insisted that he remain in the room with me at all times. I was not
popular and was considered somewhat of a rebel, but I simply could not trust
the staff that he would not receive formula milk. I breastfed the baby when he
needed to be fed and had no problems.
Later, as a community midwife, I advised mothers at home to breastfeed their
babies as soon after delivery as was practical. I personally supervised the initial
latching-on process and had no problems. The infants passed meconium early
and we never admitted a breastfed infant to hospital because of ‘jaundice’ or
excessive weight loss or dehydration.
During the 1960s I was appointed sister in the labour suite at Dundee Royal
Infirmary. This was when intra partum continuous monitoring was in its infancy
using Hewlett-Packard machines. Obstetricians and midwives were fascinated
with the new technology and some of the midwives even began to have
screwdrivers in the top pockets of their uniforms, to adjust the temperamental
apparatus when required.
I helped a mother to deliver her baby – she indicated that she was keen to give
breastfeeding a try and when I enquired when this could be initiated I was told
‘we certainly do not have the time to be bothered with that in the labour suite’.
I was then made aware of the ‘regime’. There was the one minute at each side
performance six to eight hours post-delivery – nothing had changed!
I indicated that I was interested in carrying out some research and requested to
be appointed to a postnatal ward at the same hospital. It does seem unrealistic
now that my argument that the lactation process and what was being carried
out in practice did not make sense and my request was rejected by both medical
and midwifery hierarchy.
After discussion with newly delivered mothers and ward midwives we began
to initiate breastfeeding whenever the mothers arrived from the labour suite
after delivery. A member of ward staff ‘guarded’ the ward entrance and mothers
were ‘screened off’ to begin with. After a time the screens were not used and
several bottle-feeding mothers in the Nightingale ward requested to change to
The Resurgence of Breastfeeding, 1975–2000
59
breastfeeding. The ward midwives became very competitive about their abilities
to assist with the initial latching-on process, although it was still being done
in ‘secret’.
One day a new consultant paediatrician, Dr John Cater, came to do a ward
round after visiting the other two postnatal wards. As he was about to leave
he enquired: ‘Is this the breastfeeding ward?’ I simply could not believe my
ears and immediately thought: ‘Oh – this is my man.’ He later listened to my
‘theory’ and said: ‘Prove it.’ I received my greatest encouragement from John
and I shall be forever grateful for his wise and learned counselling.
I was asked to speak at a ‘medical’ meeting later at Ninewells Hospital about
breastfeeding and was in great awe. I asked my brother, a medic, what he had
been taught as a student about the subject – he thought for a moment and
replied: ‘A baby requires two and a half ounces of milk per pound of body
weight per day’. End of story.
I went on to carry out a study showing that the earlier a baby is put to the breast
and the more frequently he is fed during the early days, the longer breastfeeding
will continue to take place.123
Hey: The important thing to say is that she got that paper published in the
Lancet.
Weaver: Why didn’t that paper influence midwives elsewhere?
Hey: Because they don’t read the Lancet, but it did have an impact on the medical
profession, a really profound one. I want to know who encouraged you to go for
the Lancet. It was a monumental step.
Salariya: It was suggested by John Cater that I offer it to the Lancet for publication.
I received a ‘nice’ letter rejecting the study, saying that as I wasn’t a medical
practitioner they could not accept it. So John decided to be the third named author
and that’s how we got it into the Lancet in 1978. Again, I thank Dr Cater.
Weaver: Now, the midwives please. I want to know why the professionals were
not taking up these ideas. Why this wasn’t happening elsewhere? Or how did it
start happening elsewhere?
Renfrew: I will start, but there are many others with lots of stories. I think there
was a great division in midwifery, where you were aligned either with wanting
123 Salariya et al. (1978).
The Resurgence of Breastfeeding, 1975–2000
60
to pick up ideas like this, or you were kind of stuck with what you had been
taught. The sheer power, the dominance, of the timed feeds and the separation
between mothers and babies was fiercely difficult to shift. I remember many,
many occasions when I was working with my colleagues from the MRC – I had
a joint appointment in the Simpson – I went round the postnatal wards, trying
to say: ‘Can’t we stop the timing? Can we stop using the Rotersept spray, because
that’s actually not going to stop the sore nipples? Can’t we just have mothers
with babies?’ And there was a sheer weight of dominance that was partly from
the midwives who were responsible for the wards, but here my experience is
different from Ed Hey’s; the pressure was also from the paediatricians, who
really wanted to see this kind of absolute medicalized policy in place. It wasn’t
just Ellena’s work that people were ignoring. The demand feeding-paper by
Illingworth and Stone that was published in 1952 had made no impact either.124
We came later to review the papers for what became Effective Care in Pregnancy
and Childbirth and then the Cochrane Collaboration pregnancy and childbirth
reviews.125 When we started reviewing this, it was amazing to find the Illingworth
and Stone paper from 1952 and other papers that had been out there quite a
long time that hadn’t made it through into practice.
I actually think one of the reasons it didn’t make a difference was that people didn’t
know how to do it. They actually didn’t know about positioning [Figure 10] –
I am going to hand this microphone to Chloe in a minute. They didn’t know
that you could put a baby to the breast so it didn’t hurt.126 I think a common
experience for midwives was they gave the baby to the mother, the mother
tried to put the baby to the breast and it hurt like heck, and they actually didn’t
know what to do about that. Therefore they needed the Rotersept, because their
nipples were getting sore. Therefore you had to time the feeds so the nipples
didn’t get sore. It was all self-perpetuating. And you had to be really lucky to
work with a practitioner like Ellena or Chloe, who somehow had figured this
out for themselves. How did you do it?
Fisher: Very difficult to say. I qualified in 1956 and I was not going to be a
midwife unless I could be a midwife outside of hospitals. What I saw happening
to mothers and babies in my part two training had me cycling home crying.
124 Illingworth et al. (1952).
125 Chalmers et al. (eds) (1989). For details of the Cochrane Collaboration, see www.cochrane.org/
evidenceaid/pregnancyandchildbirth/ (visited 7 August 2008); see also Reynolds and Tansey (eds) (2005).
126 See Figure 5, page 18.
The Resurgence of Breastfeeding, 1975–2000
61
I thought: ‘If I can’t do something about this, then I am going to take up
horticulture.’ Anyway, I then did my experience training in the home and
found it a totally different experience. When I first started among the women in
Oxford who had delivered at home – that was 40 per cent of our population –
85 per cent of them were exclusively breastfeeding at two weeks, compared with
institutional deliveries of 76 per cent. So, if you see, where I came from, where
it was simply normal to breastfeed, this was in Oxford, the population I was
working with, the dons and in the slums, everybody breastfed. As a midwife, if
a woman had a problem I had the responsibility to sort it out. It never occurred
to me that breastfeeding wasn’t as important as giving birth.
Weaver: And how would you assume that responsibility?
Fisher: Intuition – no, I mean it wasn’t official – but just because I was a midwife,
and as a domiciliary midwife I was responsible for my mothers for 14 days after
delivery, and if they intended to breastfeed and they had a problem, I had to try
to figure out how to help them. That’s when I first got on to the importance of
correctly attaching babies to the breast. I began to think that this was incredibly
Figure 10: Positioning the baby correctly. From the Royal College of Midwives’
practical guide, Successful Breastfeeding, 1988.
The Resurgence of Breastfeeding, 1975–2000
62
important, and I absolutely couldn’t understand why everybody didn’t know
about it.
Weaver: Did you work in an environment where there wasn’t infant formula in
the lying-in ward?
Fisher: I was working in women’s homes. I always remained community-based.
Just one little story, because I could go on for ever. When we started having
official early discharges from the hospitals, which was happening in the 1960s,
we were starting to have healthy women coming home for most of their care.
I could take you to the house still where a mother was allowing her beautiful
large baby to stay on the breast precisely ten minutes and then topping it up
with formula as she had been advised by the hospital. She had gallons of milk
in her breasts. It just reminded me how awful breastfeeding practice in hospital
was, and I am afraid I have sat on the edge of it ever since.127 I have always been
community-based. I haven’t done what anybody else has told me to do, but I
have worked with the mothers and with the babies and done my absolute best
to solve problems for them and then they go on to continue to breastfeed.
Helsing: Hospitals were never made for births and that certainly is the case in
our country and maybe here too. I can see people nodding. And therefore the
medical training is geared towards neither birth nor breastfeeding. In fact, it
happened very slowly that births got into hospitals. It only began in my country,
Norway – a typical middle-income European country at the time – around the
middle of the nineteenth century, when the mothers-to-be found their way
into the hospitals. But hospital routines are for sick people and women who
give birth are not sick. In health workers’ training, breastfeeding was simply
not an issue. Health workers consequently were of the opinion that either
mothers managed to breastfeed or they didn’t, and if they didn’t, it was just too
bad, and that was the end of the story. I am sorry to say that health workers
were not too helpful in the resurgence of breastfeeding, at least in Scandinavia.
Mother-led resurgence of breastfeeding can be very successful and has been in
Norway [see Figure 11].
127 Miss Chloe Fisher wrote: ‘This is an example from the tragically misguided era during which mothers
were urged to look at clocks instead of at their babies. It has its origin early in the twentieth century and,
sadly, continues to this day, where it is now known as “traditional”. Artificially imposed restrictions on the
duration and frequency of feeds, practices which had become firmly rooted in most maternity hospitals,
must have played a major part in the rapid decline in the incidence of breastfeeding in the 1960s, which was
when women were urged to give birth in hospital instead of at home.’ Note on draft transcript, 4 September
2007. See Appendix 1; Woolridge and Ingram (2007).
The Resurgence of Breastfeeding, 1975–2000
63
1 uke
3 mnd.
6 mnd.
9 mnd.
12 mnd.
18 mnd.
0
20
40
60
80
100
1858
1868
1878
1888
1898
1908
1918
1928
1938
1948
1958
1968
1978
1988
1998
Year of birth
Percentage breastfeeding mothers
Figure 11: Breastfeeding uptake and duration in Norway, 1858 to 1998,
in weeks (uke) and months (mnd).128
Savage: Before we move on too far, I would like to point out that Ellena
Salariya’s paper, the Illingworth paper and the publications by Chloe Fisher
and others that have been mentioned may not have had an immediate impact
on healthcare practices, but when they are all gathered together, these were
very important background evidence on which the ‘ten steps’ were based.129 If
you say: ‘Well, cut the doctors out, leave the midwives to it’, the midwives are
undoubtedly much better, but they need the support and leadership of doctors
or by themselves they won’t be able to make the necessary changes. So, doctors
have to accept responsibility for not permitting the necessary changes to be
introduced into policy and practice.
Professor Fiona Dykes: I’m from the University of Central Lancashire and also
a midwife. I want to pick up on the notion of the power of the institution. I
remember when I first trained as a midwife in the 1980s in Chatham, Kent,
128 Data from 9150 women delivering in the major hospitals in Oslo, Bergen and Trondheim between 1858
and 1988 from mothers’ responses to routine questions asked about their previous child [Rosenberg (1991)],
using data originally published in Liestøl et al. (1988). Information updated for 1988–1998 from accessible
data based on a representative selection of children in a number of provinces with some adjustments to take
account of a 1998 nationwide study by the Norwegian Nutrition Council. See Lande (2003). Details of
this study will be deposited along with other records of this meeting in archives and manuscripts, Wellcome
Library, London, in GC/253.
129 Illingworth et al. (1952); Salariya et al. (1978); Fisher (1985); Vallena and Savage (1998).
The Resurgence of Breastfeeding, 1975–2000
64
walking on to a Victorian-style, Florence Nightingale ward, where the women
were lined up on either side of the ward and the whole emphasis was on
orderliness and along the middle of the ward there were trolleys of milk and
the noisy or disorderly babies were in a nursery.130 The whole emphasis was on
timing and control. There was a real fear of any sort of chaos, anything that
disrupted orderliness, and I would suggest that this relates to very strong western
values around the clock and timing. It’s not surprising that the predominant
icon in the UK is Big Ben. Even now, although we talk about demand feeding,
there’s still a sense of midwives going to women and saying: ‘Oh, good, you are
demand feeding. How often are you demand feeding? How long is the baby
feeding for? But, good, you are feeding on demand.’ Women are asking what
demand feeding really means. So, you know, comparing what is understood
in the UK to be demand feeding with the examples we have been given of the
Aborigine communities, or the Kalahari Desert Wanderers, they are poles apart;
and I feel it is important that we really understand the power of our culturally
embedded desire for orderliness and timeliness.131
Weaver: Who was maintaining this culture in Chatham? The teacher–midwife?
Why weren’t the medical staff involved?
Dykes: It’s broader than just the institution, it’s deeply culturally based, but
the hospital is based on a factory. If we look at the development of the hospital
historically, it was very similar to the factory or even to the prison. Everybody
could be seen, including the staff, including the people who were availing
themselves of this service, and hospitals were run on sort of factory- or prison-
based guidelines and that is deeply entrenched. I don’t think you can single out
any one disciplinary group, doctors, paediatricians or midwives. The factory
principles were deeply culturally ingrained and everyone has been wrapped up
in that particular institutional culture.132
Weaver: Well, there’s a paediatrician here. Brian wants to say something.
Wharton: It’s very interesting, very illuminating listening to what people have
done and their own individual services, and we have all read a lot about what
130 See note 38.
131 See discussion on pages 22–3.
132 See Baker (1956); Granshaw and Porter (1989); Gallivan (2000); www.nationalarchives.gov.uk/
ERORecords/JA/4/1/Documents/Gallivanreportonmonitoringclinicalperformance (visited 8 July 2008).
The Resurgence of Breastfeeding, 1975–2000
65
they have done and learned from it. If you take an overall national view, there
was a big change between 1975 and 1980, quite a substantial one and very
little since 1980. So that would need some explanation. I agree that is perhaps
not part of the Witness event that we are taking part in now, where we are
all telling it as we saw it. I think we could get our optimistic blinkers on if
we think all of these programmes which enthusiasts have introduced and have
been very successful and which are having much national impact. Because I
don’t see that the figures support it. Nor do I understand why there was this
great improvement between 1975 and 1980, a sense of euphoria, and then for
some reason since 1980 the movements have been very, very small. As I say,
statisticians think they are explained by other demographic changes.
Dr Alison Spiro: I am a health visitor and an anthropologist. I would just like
to follow on from what Fiona was saying about the time constraints put on
breastfeeding and where they all come from. I moved into anthropology because
I felt I wasn’t getting the answers through biomedicine as to why women weren’t
breastfeeding. I have done work with an Indian community in Harrow, the
Gujarati community, and I have done work in India as well. Indian women I
have spoken to say that there’s no time for breastfeeding in this country. For
them there are too many other things that impact on their lives, but in India
there’s time for breastfeeding. Here it’s much more difficult. The other thing
that I would like to say follows on from what Fiona said about the metaphors
of production that we use. The terminology of supply and demand and a whole
load of other examples show that the way we see breastfeeding is as a mechanistic
transfer of milk from the mother to the baby. I think those of us who have been
looking at breastfeeding all know that what goes on in the mother’s social life is
absolutely crucial to whether the baby actually gets the milk transferred.
In my work in anthropology, I found that breastfeeding pervades every single
aspect of social life, whether it is gender relations, politics, rituals; the rituals
about evil eye, the rituals about colostrum and lots of these things are very,
very important. I think that we need to look at the whole context, not just the
biomedical transfer of milk.
Ms Rosie Dodds: I’m from the National Childbirth Trust. I would like to pick
up on what Professor Wharton was saying and Tony and Mike’s references
to the statistics on breastfeeding in this country. I think we have to turn the
question on its head. There’s so much evidence that we are now aware of about
the major impact that breastfeeding has on each individual baby, but also
on the mother from a public health perspective, and on the wider society,
The Resurgence of Breastfeeding, 1975–2000
66
reducing inequalities in health. Many people now recognize the social class
divide in this country, that women are more likely to breastfeed if they are
older and if they have got more years of education, changes to that culture
would do a lot to reduce health inequalities. Also, whether we are talking
about breastfeeding in the UK, breastfeeding in England, or breastfeeding
across the world, breastfeeding has been recognized as the most effective way
to reduce child mortality. The deaths of 13 per cent of babies who die in the
poorest countries, at least, could be prevented by breastfeeding, and further
deaths could be prevented by adequate complementary feeding and continued
breastfeeding.133 So the question is not why breastfeeding increased in this
country, but why breastfeeding rates are so low and why they are not increasing
more. What are the influences, particularly following the point about the Baby
Friendly Initiative, increasing breastfeeding rates in hospitals? And there’s good
evidence that this is the case.134 We don’t know yet the long-term impact in this
country but evidence from Italy, Sweden and the Belarus studies show that the
continuation rates are better there.135 But will they be better in this country or
is the social support and public support so poor that women really don’t have
a chance to carry on breastfeeding?
Michaelsen: A short comment: I am a paediatrician from Copenhagen working
mainly with nutrition. Some years ago I wrote a book for WHO and UNICEF
with Lawrence Weaver, Aileen Robertson and Francesco Branca on guidelines
in infant feeding.136 It was for the WHO European region, which also includes
the former Soviet republics. We were exploring what the recommendations
were in the Soviet Union. The recommendations on timing of breastfeeding
were very strict. We have talked about rigid time limits here.137 There the official
recommendations were that you had to breastfeed every two hours for the first
month, and then every three hours. We had a doctor from Lithuania helping us
to explore the literature in Russian and she found a paper saying that perhaps
you didn’t have to be so rigid, that you could relax a bit from these time frames,
and plus or minus 15 minutes would be all right.
133 Jones et al. (2003): 67.
134 Bartington et al. (2006).
135 Cattaneo and Buzzetti (2001); Hofvander (2005); Kramer et al. (2001).
136 Michaelsen et al. (eds) (2003).
137 Pages 22–3, 62 and 64.
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Weaver: Do you want to say anything about the International Society for
Research in Human Milk and Lactation and how that came in from the side
and brought together a new lot of people?
Michaelsen: That is the International Society of Research in Human Milk and
Lactation, a very long name, also called ISRHML.138 It was established in the
1980s as a research society and has always been a small one, with 200–300
members who meet every two years. The first two were in Costa Rica and
California. There have been many meetings and for most of them there has
been a book published which has had very useful background information on
the research.139 One of the last meetings was in Cambridge, arranged by Ann
Prentice among others. Among those who have been involved in the society from
the beginning are: Armond Goldman, Margit Hamosh, Stephanie Atkinson
and Bo Lönnerdal. There was a recent meeting in Toronto and the next will
be in Perth in February 2008. The society has mainly focused on physiological
aspects, bioactive components in breast-milk and the effects on offspring and
the mother. For the last one and a half years, we have given out bibliographies
every three months, including titles and abstracts of all those publications on
breastfeeding that appear on Medline.140 They are freely available on our website.
There is an impressive number of publications on breastfeeding, at least 50–60
relevant papers every month. We do not sort them according to quality, but
classify them according to topic.
Weaver: Do you think the society has been influential or just a forum?
Michaelsen: It has been a small scientific society, so I think it’s been influential
on the science side, but it has not taken on the public-health aspect. They have
tried to concentrate on the physiological or scientific aspects.
Hanson: A brief comment going back to the 1950s. When I started to collect
my first breast-milk samples, it was rather difficult. I was regarded as a rather
strange creature; why on earth would I be interested in human milk? Bovine
milk would have been alright. Good nurses and midwives helped me, and it
has been rather interesting to follow through the decades that the attitudes have
138 For the history of ISRHML, see www.isrhml.org.umu.se/. Bibliographies can be found under Publications
(visited 8 June 2008).
139 See www.isrhml.org.umu.se/publications/, published monographs of the society’s past meetings (visited
9 January 2009).
140 Medline is the US National Library of Medicine's premier bibliographic database and is the largest
component of PubMed; see www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed (visited 26 November 2008).
The Resurgence of Breastfeeding, 1975–2000
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totally changed and I think this is in parallel with the advancement of women
in societies.
O’Leary: We have been looking at various different branches of science and
the effects that they have had or not had on breastfeeding practice in society
and on the wards. But there is one branch of science that we have omitted,
which is the science of marketing, and that’s a science which has developed
in width, breadth and depth in the last 20 or 30 years in an incredible way.
Our mothers and grandmothers were not brand-aware in the way that we are
and our children are. Marketing has taken on a wider significance than just
advertising. There have been instances of marketing personnel helping to train
health professionals and this must have some effect on what is found, what is
thought to be normal, what is just considered the usual thing that people do.
Of course it has an influence on the mothers as well. You only have to walk into
a supermarket to see the usual way of feeding a baby. You see it all around, the
equipment and gadgets and the things on display as well as the milk. So I think
this social science of marketing has probably been more influential than any of
our efforts, unfortunately, to tell the truth about the value of breastfeeding and
breast-milk.
Woolridge: One thing that has been clear is that the rules that are entrenched
within Baby Friendly hospitals were in existence and being practised in this
country long before that. Because certainly one thing the COMA report did
do was to set down building blocks by entrenching demand feeding, and
uninterrupted contact between the mother and baby. The nice thing about the
OPCS and ONS reports is that not only did they document changes in the rate
but also changes in practice.141 These incremental changes in practice coincided
with the changes in the rate. One thing I have never been clear on is whether
they have actually driven the changes in practice, or whether they created an
atmosphere which reflected what was naturally happening.
I think something that is relevant to what Rachel has just said is that the very
first hospital to put itself forward for accreditation as Baby Friendly was very
much a guinea pig. Cynthia Rickett put forward Sunderland District General
Hospital to be evaluated and because we were unused to the process we had a
midwife from Sweden, Anna-Berit Ransjö-Arvidson, come over to help make
sure we were doing things properly. When she walked on to the wards at a
British hospital she came across, for the first time in her life, ‘ready-to-feed’
141 See note 16.
The Resurgence of Breastfeeding, 1975–2000
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bottles of formula. Little tiny baby bottles, which she found captivating and
wanted to take back purely for their interest value.142 This part of the commercial
promotion of formula is also found to be a very attractive vehicle in which to
make formulae available for hospitals, both practical and convenient, and very
attractive for mothers to use. I think there is an important issue in looking
at the commercial influence in hospitals as to whether it was an unavoidable
conducive element for mothers.
Dr Mary Smale: I’m a National Childbirth Trust breastfeeding counsellor. I am
taking up the issue of branding. I was told from a very young age by my bottle-
feeding mother that I was given Cow and Gate in 1943 because that was what
the Queen was given. The young princesses were fed on this, which was far
superior, of course, to National Dried Milk and which was what we as a middle
class family could afford.143
I think maybe if we did lots and lots of oral history on this we’d find the
meanings of all sorts of things that would be very interesting. I would also like
to ask a question. Who owns time? And the other thing is why the changes
may be happening? To give you a small example: before I moved to the south
of England I spent 30 years in the Humberside area, and in north Hull the
starting rate for breastfeeding in one area was 14 per cent. After the peer support
training scheme that I taught we had a report back from a mother who said she
had asked someone whether they were going to breastfeed and this young mum
said: ‘Yeah, it’s dead trendy now.’144
Weaver: Shall we go back to the early days again and to some of the official
reports? Thinking about that; there was the present-day practice document in
1974. John, can you tell us a little bit about that?
Mr John Wells: I think I am one of the monkeys in the barrel that was referred
to previously.145 I am a paediatric nutritionist and I came into industry in the
142 The Symons collection in the museum of the Royal College of Physicians contains a collection of infant
feeding cups, as well as nipple shields. See www.rcplondon.ac.uk/heritage/medicalInstruments/ (visited 23
October 2008).
143 See note 110.
144 Dr Mary Smale wrote: ‘A peer support training scheme was delivered by me as an NCT breastfeeding
counsellor funded by North Hull Surestart to local women in early 2001.’ E-mail to Mrs Lois Reynolds,
29 October 2008.
145 See page 55.
The Resurgence of Breastfeeding, 1975–2000
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late 1960s and focused on paediatric nutrition with Cow and Gate and latterly
Nutricia. It’s very clear to me when I joined the company that the first Present-Day
Practice in Infant Feeding report had a very dramatic impact on the way industry
was being viewed and that the products had many shortcomings in terms of
their composition.146 Some of these have been referred to in terms of too high
solutes, particularly sodium, high phosphate, the use of sugar in reconstituting
feeds and very complex making-up instructions, which mothers found difficult
to follow and as a result invariably had a tendency to over-concentrate. There
were a number of common problems that were found at the time and seen by
paediatricians, such as dehydration, hypernatraemia, hypocalcaemic tetany and
infantile obesity, which were attributed to the use of formulae at that time.
It was clear that industry had to react to this. It’s quite interesting to go back for
just a moment to consider how this report actually originated, because although
I wasn’t at the meeting in Cambridge, my understanding was that the British
Nutrition Foundation had a meeting on nutrition in Cambridge in the early
1970s where these problems in infants were being aired, particularly in relation
to the shortcomings of infant formulae and the poor take-up of breastfeeding in
the nation. And one or two of the industry members got up and said: ‘Well, if
the medical profession can tell us what to do, we will get on and do it.’ It fell on
the then Department of Health and Social Security to convene a panel on child
nutrition and from that emerged the first Present-Day Practice in Infant Feeding
report.147 So I think that was a very important outcome of the meeting of the
British Nutrition Foundation in Cambridge.
Once the shortcomings were confirmed in a COMA grey report, industry got
full cooperation with the paediatric profession, particularly the paediatricians,
to sort out these irregularities in composition so that by the early 1980s when I
became involved in the science of infant formulae, these were, in fact, resolved.
This led to a very competitive communication to health professionals in infant
formula brochures about whose formula was closest to breast-milk [see Figures
12 and 13]. In those days the comparisons were rather at a ridiculous level,
where 1–2 milligrams of sodium per decilitre were considered to be superior if
they were lower and closer to human milk composition than in another brand.
But in fact it would appear at that time that health professionals did actually
146 Oppé et al. (1974). See also DHSS (1977); Macy et al. (1953).
147 DHSS COMA Working Party on the Composition of Foods for Infants and Young Children. Professor
Thomas Oppé was the chairman.
The Resurgence of Breastfeeding, 1975–2000
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Figure 12: Comparison of the composition of cows’ milk with infant formula
in 1974. Source: Cow and Gate (1989).
Figure 13: Comparison of the composition of human milk with infant formula in
the early 1980s. Source: Cow and Gate (1989).
The Resurgence of Breastfeeding, 1975–2000
72
make or base some of their recommendations on these types of comparisons,
and the industry fed them this sort of information.
During the 1980s and 1990s, of course, as the call for mothers to breastfeed
strengthened, the whole issue became much more politicized and the industry
through the offices of the UK Food and Drink Federation set up a forum called
the Infant and Dietetic Food Association. There the views of industry were
collected and used, in a way, to explain the industry viewpoint on the various
issues of the day.148 This would involve responding to government reports, to
proposed legislation, and other issues such as the distribution of literature. Also,
at that time it was becoming clear that the employees of the infant formulae
companies were finding it more difficult to communicate changes in infant
formulae to health professionals. It was more difficult for representatives to
access maternity wards and neonatal units, paediatricians were less available for
discussion on infant nutrition issues. There was either a lessening or an absence
of instruction on the preparation of infant formulae to mothers in antenatal
clinics. And there was an attitude that was picked up that advances in infant
formula design, which brought it closer to human milk, were in some way
resented by some health professionals, because this diminished the superiority
of human milk.
Lastly, one of the consequences of having reduced access to the medical
profession was that it was more difficult to carry out legitimate studies that
had been through proper ethics committees and so on, and this was partly due
to the fact that nursing staff were particularly concerned that if a mother was
seen to be participating in a study, getting study formula which would be free
of charge, then this could negatively influence breastfeeding mothers, or some
nurses just did not want to cooperate or be seen to be cooperating with an
infant formula company. So these are some of the situations that arose during
my time with Nutricia.149
Weaver: There may be some reaction to that, but I also want to talk about the
other important reports in a minute.
Akre: We are not going to have time to do anything about it this evening, but
I want to suggest building on what the last speaker said by asking how we are
going to move infant formula, which started out as an emergency nutrition
148 See www.idfa.org.uk/about.aspx (visited 7 August 2008).
149 Nutricia Ltd has been part of the Danone Group of companies since 2007. It specializes in developing
and manufacturing infant milk formula and nutritional supplements for medicinal use.
The Resurgence of Breastfeeding, 1975–2000
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intervention, from the kitchen pantry back into the medicine cabinet or first aid
kit, where it got its start. That is the challenge we face.
We talk a lot about morbidity and mortality, and prevalence and duration of
breastfeeding in developing countries and so-called developed countries. That’s not
a bad place to start the conversation, but I think we need to project, individually
and collectively, how we want the next generation to proceed. All governments
are commercial-interest friendly, by definition, for a variety of reasons, including
employment creation, improved balance of payments, income generation, all
sorts of things. So, how are we going to convince governments that it is in their
best interest, in the short and longer term, to promote nature’s food, not just as a
way of feeding today’s babies, but having an impact on health throughout the life
course, not only of babies, but of today’s and tomorrow’s mothers as well.
Smale: I am very aware of a huge paradox here. You want to go from the pantry
to the medicine cupboard, yes? But in doing that you actually cut lots of people
out and I would say today that the main group who have been left out are the
mothers.150 I have to say that today’s meeting has been progressed by a largely
masculine-led group, and if you go from the pantry to the medicine cupboard
you gain some things and you lose some things, and that needs looking at. It
can be looked at historically; if you look at Jacqueline Wolf’s description of
the pathologization of breastfeeding you will see that almost every discovery
in breastfeeding has unfortunately then become pathologized.151 You only have
to identify ‘let down’ or ‘ejection reflex’ to find, amazingly, it doesn’t work, but
it frighteningly and alarmingly disappears under any sort of stress, which I am
afraid is nonsense, isn’t it? Women in the audience who have been breastfeeding
mothers have been quite upset from time to time, but amazingly, astonishingly,
mothers managed to continue to breastfeed in spite of this. And it is frightening
to be told that it’s their anxiety that’s frightening away their breastfeeding. And
then if we talk about the foremilk/hindmilk divide, if there is such a thing,
which there isn’t – thank goodness for Mike’s research – it’s a graduation thing,
but if we talk about that we suddenly get a whole host of mothers ringing up
saying they are frightened to death about not giving the baby enough hindmilk.
How long should I be letting him stay on to get to the hindmilk? So what we
do is we pathologize. We have a huge paradox.
150 Dr Mary Smale wrote: ‘My main concern is that today’s discussion mainly, though not exclusively,
portrays women as “acted upon”, while scientific careers were forged elsewhere, defining terms, rather than
listening to women.’ Note on draft transcript, 7 September 2007.
151 Wolf (2001).
The Resurgence of Breastfeeding, 1975–2000
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Weaver: That’s a very clear point. There’s a bit of pathology that I would like to
hear a bit about that I think is from a different category and that’s Peter Howie’s
work and the public health impact of their studies that reinforced the value of
breast-milk.
Howie: When I went to Dundee, one day I was approached by a student midwife
who wanted to do a project on the benefits of breastfeeding. She asked if I could
provide information that showed that breastfeeding was healthier for the baby. I
thought about it, and then went to the literature, and actually it was quite difficult
to find – this was in 1984. In fact, just then there had been a publication by
Howard Bauchner and his colleagues from the US, which had reviewed all the
articles in the English language literature between 1970 and 1984, which had the
objective of looking at the relationship between breastfeeding and prevention of
infectious disease, especially diarrhoeal and respiratory disease.152 They looked at
all the papers and applied four methodological criteria to evaluate the robustness
of the studies: (i) whether the studies had defined what they meant by full, partial,
or token breastfeeding; (ii) whether they defined what was meant by illness; (iii)
whether they had a study that made sure that observer bias didn’t distort the results;
and, most importantly, (iv) that they had taken into account the confounding
variables, particularly social class, or whether there was another, older child in
the family. After they applied these four criteria to all the studies they found that
every one of them, bar two, was deficient methodologically; and the two that
were thought to be methodologically OK had sample sizes of only 40 and 60
patients respectively. When we looked at it, we thought that the minimal sample
size for a satisfactory study was 560. We thought that even these two studies were
methodologically unsound. It came to the point that everyone was saying, ‘breast
is best’, and there was actually no sound evidence to back that up.
Now, I think that shows that it’s very wrong to have study after study which
is methodologically unsound, and that was a major problem for breastfeeding.
We thought that what was needed was a study that met the methodological
criteria set down by Bauchner and colleagues and that’s what we did. I recruited
Stewart Forsyth, who can’t be here today, to give us paediatric expertise, and
Charles Florey, an epidemiologist, to make sure that the construction of the
study and the statistics were done properly.153 When we did the study in view
of what Bauchner had found, I thought we would find trivial differences, but
152 Bauchner et al. (1986).
153 See, for example, Anderson et al. (2001); Alder et al. (2004).
The Resurgence of Breastfeeding, 1975–2000
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in point of fact we found, comparing women who had been breastfeeding for
13 weeks against women who had bottle-fed right from the start, that there was
an eightfold difference in significant diarrhoeal disease and hospital admission.
If you then allowed for confounding variables, the difference narrowed to
fivefold; still a huge difference. We came to the conclusion that this showed very
strong evidence that breastfeeding did make a difference in a country such as
our own.
It’s quite interesting that Pediatrics, of three weeks ago, carried a publication
showing (somewhat ‘surprisingly,’ it says) that breastfeeding reduces diarrhoeal
and respiratory infection.154 This paper in Pediatrics may be of great interest to
the people here today, particularly those who are promoting breastfeeding: it is
the UK millennium cohort study, published by Maria Quigley, Yvonne Kelly
and Amanda Sacker from the national perinatal epidemiology unit in Oxford
and the department of epidemiology and public health at UCL. The sample size
is almost 16 000 and it says that full prolonged breastfeeding reduces hospital
admissions for diarrhoeal disease by 50 per cent and respiratory infections by 27
per cent, and the conclusion, if I could just read out:
Our findings confirm that breastfeeding, particularly when exclusive
and prolonged, protects against severe morbidity in contemporary UK.
In our study, only 1.2 per cent of infants were exclusively breastfed for
at least six months, and the protective effects of breastfeeding were large;
a population-level increase in exclusive, prolonged breastfeeding would
be of great public health benefit.155
Now they happily refer to our paper and the findings are exactly comparable.156
I think it was James Akre who said: ‘Can we bring a lever on public health
policy?’ To my mind, this might well be the lever. This is a large study, saying
that universal breastfeeding would have a major impact on infant health.
Weaver: This is an example of the Americans not wanting to read the European
literature, isn’t it?
154 Quigley et al. (2007).
155 Quigley et al. (2007): 841. The study included 15 890 healthy, singleton, full-term infants who were born
in 2000–02. See also Smith and Joshi (2002); Plewis (2004). Further details available at www.data-archive.
ac.uk/findingdata/snDescription.asp?sn=4683&key=Millennium+Cohort+Study (visited 18 June 2008).
156 Howie et al. (1990).
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Howie: This is in Pediatrics, the journal of the American Academy of Pediatrics,
of 4 April 2007.
Weaver: Peter’s work gave evidence and support for some of the
recommendations of your report, Forrester Cockburn, in 1994, which was
quite an important document, I think.
Cockburn: The report was Weaning and the Weaning Diet.157 You asked me
earlier how it came about. Mainly it came about because of the health visitors at
the clinic I used to do on Friday afternoons at Drumchapel, who said: ‘We need
clear guidance.’ I replied: ‘You know more about weaning than I do.’ I didn’t
want to take on this topic of weaning and the weaning diet, because I knew it
had many pitfalls. At the time I was chairman of the panel on child nutrition of
COMA, following on after Tom Oppé.158 Quite a few people in this room today
were on that committee – midwives, scientists of various sorts, paediatricians –
joined me to produce that report under the eagle eye of the late Petra Clarke.
We wanted to emphasize that weaning was not stopping breastfeeding; weaning
was introducing new elements of diet at the right time to a breastfeeding infant.
We did not wish midwives and others to think that weaning was stopping
breastfeeding. Just as breast-milk protects against infections, as Peter was
saying, it also protects against some of the foodstuffs that perhaps are not always
the best thing for infants. It’s important that breast-milk and the new food
substances that are being introduced are given together for some time. So we
looked not just at weaning and weaning foods; we looked at the whole process
of weaning, and tried to come up with some guidance. But, I think the thing
we wanted to emphasize was that weaning was not stopping breastfeeding, but
the introduction of other elements of diet which are important to bottle and
breastfed infants as they get bigger and require different foods.
Weaver: Was this influential and did it affect midwives?
Dr Penny Stanway: I wrote Breast is Best in 1978 as a handbook for mothers,
because I had been working in community paediatrics and was appalled at what
was taught about breastfeeding.159 May I make a big plea for the full half-hour
to discuss mother-to-mother support groups, please? The allotted 30 minutes
looks like being 25 minutes short, and going with that would be a great pity and
157 DoH (1994).
158 See page 70 and note 108.
159 Stanway and Stanway (1978).
The Resurgence of Breastfeeding, 1975–2000
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reflect a lack of recognition of the balance of contributions to the resurgence of
breastfeeding.160
I’d like to point out that breastfeeding – which incidentally should be all one
word, not hyphenated – is a physiological process that relies on mother–baby
and baby–mother interactions. It also has heaps of non-medical benefits not
just to babies and mothers, but also to fathers and society as a whole. And it’s
terribly important not to over-medicalize it.
Today’s discussions have been very interesting but very medical, and I feel
annoyed that over-runs on the timing of several discussions may stop us giving
fair consideration to the vital contributions of mother-to-mother groups. These
embody a growing base of experience, skills and knowledge about how women
can empower, encourage and support each other while making choices and
learning how to breastfeed successfully, and how men can help. So, may I repeat
my plea for adequate time for them?
Alder: Not just self-help groups. I am a psychologist and I think the psychological
aspect is hugely important. Now, I think that there were more influences. My
research was in Edinburgh in the 1970s and the 1980s; demand feeding was
becoming much more popular. Once you remove that time constraint, mothers
are then exposed to their babies – demand means demand – so the babies make
demands on the mothers. Therefore we have a consequence for the mothers. One
of the consequences is increased fatigue, breastfed babies wake more often in the
night and for longer. So, this is a considerable demand. Without social support,
without support groups, it is very difficult. I think one of the consequences
of the medical research and the demand feeding, and it was all worked out
physiologically, is that you have then got a different social situation for the
mother. I was looking particularly at sexuality, and at the MRC reproductive
biology unit I was supposed to be looking at hormone effects of sexuality in
the postnatal period, which is very important for mothers and for couples. I
found that fatigue was much more important. I think it is possible then that the
increase in numbers of mothers breastfeeding was a result of the support groups,
because the mothers needed support. You can’t have a mother in our society
breastfeeding on demand, frequently, exclusively, with nobody else doing it,
160 A general draft outline of each Witness Seminar is circulated among all participants prior to the meeting.
The specific timings given on the outline are flexible and on this occasion a number of the earlier topics were
discussed for longer than anticipated so that not all of the issues listed could be covered in the same depth.
We hope that even an inadequate discussion will signal their importance for future study. See Appendix 2
for the chairman’s reflection on this issue.
The Resurgence of Breastfeeding, 1975–2000
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because it’s not that easy to express often. So I think the support groups could
have been extremely influential. Maybe that’s why there was a lag, and I would
like Jenny Warren to come in and say why we are now getting some increase.
Warren: I do want to join in. I am rather disappointed that we have
concentrated a lot on the medical side as well. But I would acknowledge that a
lot of the papers that have been published and documents written have allowed
many of us to engage with the powers that be to try to establish support for
breastfeeding. We have mentioned the Joint Breastfeeding Initiative which is
where Edwina Currie challenged the health professionals and the voluntary
organizations to get together and support breastfeeding together and I think it
was crucially important that that happened throughout the UK.161 In Scotland
we certainly went on from the concept of the Joint Breastfeeding Initiative; it
was a multidisciplinary input and mothers were on these groups. We moved
on to a strategic approach. We included the Baby Friendly Initiative in that
strategic approach. But we did have this multifaceted approach and we had
strategy groups all over Scotland, who were implementing strategy broadly
based on the breastfeeding in Scotland paper written by Campbell and Jones
in 1994.162 So a lot of the good work was done in Scotland and was achieved
through cooperation and real commitment and enthusiasm rather than through
financial support from government. I would be disappointed if that’s not
acknowledged in The Resurgence of Breastfeeding (this volume).
Weaver: We want to hear what happened.
Miss Carol Williams: I think my point follows on quite nicely from Jenny
Warren. I felt we needed also to acknowledge that although we have had lots of
discussion on the science involved, if we actually look back since 1975, I think
breastfeeding support is evident as being almost like a Cinderella service. There’s
been very scant commitment of resources and we know that we have studies that
prove that mother-to-mother support is often the most effective, but I think that
it’s been used as a kind of get-out clause for not actually putting money there. I
have had situations locally where if one of my peer supporters does Reiki healing
with women in deprived areas, they can be paid £40 an hour, but if they go to do
breastfeeding support, it has got to be voluntary. It’s just ridiculous and I really
question, when we talk about resurgence of breastfeeding, whether we have got
a resurgence of policy commitment. Again, if you look back historically I think
161 See note 105.
162 Campbell and Jones (1994). See also Britten and McInnes (1999).
The Resurgence of Breastfeeding, 1975–2000
79
it’s quite useful to bear in mind that for 35 years we had National Dried Milk,
and my understanding is that when National Dried Milk finally disappeared
in 1976, it was more to do with concern about unfair competition with the
milk companies than any kind of conviction that it wasn’t a good idea in itself.
If we come to today and this alleged resurgence of interest (if it is interest) in
breastfeeding, is it because of the connection with obesity? Somewhere along the
line the fact that breastfeeding is good in its own right has not been enough. And
historically, that question has been there all the way through.
Mrs Jill Dye: I am from the La Leche League so I do want to talk about breastfeeding
support groups. You can breastfeed without a support group; it is possible to do it.
It was Penny Stanway’s book that actually helped me the most with my first two
children because I read that it was OK, not that I had to, but OK to exclusively
feed for six months, and OK to breastfeed for two years.163 So that got me through.
With my third I had tremendous problems, it was not the milk; I didn’t think I
had any milk, but I wanted to breastfeed him. It was a voluntary group, and I
thought: ‘They can help me feed my baby at the breast even if I don’t have any
milk.’ So I got the: ‘You are going to be able to do it, you are going to get the
milk, it’s going to happen.’ Wonderful. It did. I kept on going to the group and I
am still involved. But it was wonderful. We help hundreds of mothers. I probably
help, personally, several hundreds of mothers a year and I find it’s an incredible
burden in a way because it’s all down to me and women like me trying to do this
and we are but a drop in the ocean. We cannot do it by ourselves. We should all
be working together to normalize breastfeeding, which is what did not happen in
the 1980s when we tried to get together. I was on the Joint Breastfeeding Initiative
executive group. Rachel O’Leary was on that and there are other people in this
room who were in that group as well. We all tried to work very hard together. I can
remember Tony Williams saying: ‘We have to stop talking about making women
feel guilty and start telling them the truth.’ This was in 1989, I think, and we have
been trying all this time. A very important thing is that if there is anything to do
with the resurgence of breastfeeding we have been working together, but it doesn’t
seem to have changed. Here we are, 30 years later, and it has not changed.
Weaver: I hoped we would concentrate on the question, towards the end,
whether or not there has been a resurgence of breastfeeding?
Ms Hilary English: I am a National Childbirth Trust breastfeeding counsellor
and tutor; I have been on Royal College of Midwives working parties to help
163 Stanway and Stanway (1978).
The Resurgence of Breastfeeding, 1975–2000
80
with breastfeeding and a lactation consultant, etc. and I am a volunteer. Mostly
I am a volunteer. I support a lot of women and hopefully I pick up some of
the pieces that the health professionals, with great respect, leave behind. I
wanted to pick up on Carol Williams’s point about the respect that is given to
breastfeeding. At the moment, breastfeeding is being looked after in my area
by auxiliaries because the midwives are too busy. There is not enough time
for a midwife to help with breastfeeding. Not even to get a baby attached, let
alone to stay through one feed. This is being left to auxiliary staff who are
low-paid workers. Breastfeeding status is absolutely minimal and until this is
corrected and the value of breastfeeding, the health value, even the economic
value and medical value, whatever, is given some recognition we will not
get anywhere.
Palmer: I’m a nutritionist at the London School of Hygiene and Tropical
Medicine but I’m interested in the social, political and human side of this
subject. I keep hearing: ‘How can we persuade?’ Or: ‘Why doesn’t the NHS
do and such and such?’ I don’t think we need to persuade or promote but
to remove the enormous constraints on breastfeeding. Social and cultural
influences are powerful. When I worked in Mozambique in the early 1980s,
UNICEF were providing infant formula in bottles which were lethal, yet that
was the state of UNICEF’s awareness at that time.164 Later UNICEF became a
leading advocate for control of such harmful distribution. I am saying this to
illustrate that the idea that women as individuals choose their feeding method
is false. Only educated women in Mozambique ever dreamed of bottle-feeding,
whereas in the UK these are the women who want to breastfeed. This decision
is often influenced artificially through the pressures of vested interests.
I am interested to see an industry representative here today. One of my students
did an investigation of infant feeding product promotion in popular parents’
magazines for her dissertation. The editorial followed along a culture of branded-
product loyalty focused on pregnant women and new parents. Miriam Stoppard
164 Ms Gabrielle Palmer wrote: ‘Artificial feeding has at least a sixfold mortality risk. See WHO Collaborative
Study Team (2000) on the role of breastfeeding in the prevention of infant mortality. The link between
artificial feeding and high mortality was documented throughout the twentieth century, especially in
developing countries [Scrimshaw et al. (1968)]. I was working in Mozambique between 1981 and 1983
and by then there was substantial literature and widespread international media coverage of the lethal effects
of artificial feeding. Chetley (1979) has a 280-article bibliography on the topic. In 1980 Papua New Guinea
had already introduced legislation to restrict the sale of feeding bottles there [Biddulph (1980)]. My point is
that it was an embarrassment for UNICEF to have displayed such lack of awareness.’ E-mail to Ms Stefania
Crowther, 1 December 2008.
The Resurgence of Breastfeeding, 1975–2000
81
wrote an editorial that echoed the marketing. It is the little points that are so
insidious, such as: ‘You won’t want to feed your baby on demand all the time.’165
Also there has been a move that has been led by the commercial promotion
of breast pumps. I was interested in Roger Short’s information about women
feeding 98 times a day. This contrasts with the trend, certainly in the US and
more and more so here, that breastfeeding equates with pumping breast-milk.
Of course it doesn’t. In the US, six million breast pumps are sold each year.
That is one and a half breast pumps per baby. That is not breastfeeding: the
baby does not have the psychological warmth, it’s not having the skin contact,
which changes both the mother’s and baby’s hormones. It’s making money all
the time. Certainly in this country if you read all the magazines, they present
a lifestyle that is not conducive to breastfeeding. Maybe a little bit, but mostly
they promote pumping and getting your husband to give pumped breast-milk
in a bottle at night. We are all victims of it. We are leaving this out and behaving
as though people do what is said in the Lancet. People don’t do what they say
in the Lancet; people do what Vogue tells them to do, or Cosmo, or Parents and
Babies. I think we are forgetting a big pressure that changes us much more
powerfully and subtly than any of the good scientific evidence.
Weaver: We have just touched on this subject, but it is a very complex and wide
one. I think we have heard about many dimensions of the whole topic. There’s
no way that I can summarize, nor is it appropriate for me to do so, but I am
going to ask Mary Renfrew to wind up.
Renfrew: I am not going to attempt to summarize, but I do want to take
another few minutes to expand the discussion. I completely agree with Penny’s
statement a minute ago about the fundamental importance of support groups.
I just want to take a few minutes to focus on what I think the biggest problems
are here, and therefore why women as women and women working together are
a huge part of the emphasis and have been over the last 25 years. We are facing
a very strange culture in this country, where, in a study that I did a few years ago
with Mike Woolridge, teenagers told us that, yes, they felt that the right thing to
do was breastfeed their babies, but they actually thought the act of breastfeeding
was immoral, to expose a breast in public was something that was wrong and
perverted, and to be seen to be was perverted. Now, if we take that as a starting
point – the very bizarre society that we live in in the UK – what I have seen,
working with and experiencing the National Childbirth Trust, La Leche League,
165 See Wake (2006).
The Resurgence of Breastfeeding, 1975–2000
82
the Breastfeeding Network and the Association of Breastfeeding Mothers, over
the last 25–30 years, has been a huge force for good trying hard to counter those
societal forces so that women can do what women are, in part, born to do. They
are born to do many other things too, but one of them is breastfeed the baby.
The impact of the support groups on women’s lives and indeed on the psyche
of the health service, among others has been fundamentally important and I
would hate to think that this history today is going to miss that.
We have heard lots of bits through the day, people have interjected, but to try
to pull that together: support groups have been important in educating health
professionals, they have been important to training counsellors – thousands
of them, leaders and counsellors across the country today, supporting tens of
thousands of women, millions over the years – when the health service had
abandoned them, and that was all that they had. They have informed policy, they
are increasingly being built into policy decisions and included in consultations on
policies at a national level and indeed at international level. They have informed
research, and, in my own experience, actually participated in research. I think we
ran the first ever randomized controlled trial in which women were randomized
by a consumer support group and took part in the trial and were followed up
by a consumer support group; the first example of a randomized trial by a lay
group, the National Childbirth Trust.166 In peer reviewing research, the most
astute comments I ever get from any of my research reports are always from
my consumer support group colleagues, who have been incredibly valuable.167
The Cochrane reviews, the NICE reports and so on, the Department of Health
reports, over the years, I have learned from support groups to keep women at
the heart of everything; they do it all the time and they have done it brilliantly
today, although not as much as we could have. They are sitting right in the
middle of everything. Women’s experiences, women’s feelings, women’s real
lived experiences, reflected against or beside the realities of research, and that’s
always important. They also have this tremendous commitment to the evidence
base, to the accuracy of information, making sure that whatever happens does
not harm and does good, and in my whole experience they have been absolutely
radical about that. They have been proponents of peer support from the very,
very earliest period of La Leche League peer support schemes and through into
the much, much bigger, National Childbirth Trust and Breastfeeding Network
peer support groups, which in my experience are now reaching the poorest part
166 The MAIN Trial Collaborative Group (1994); Renfrew and McCandlish (1992).
167 Allain and Kean (2007). See www.ibfan.org (visited 11 August 2008).
The Resurgence of Breastfeeding, 1975–2000
83
of this country in the way that the health service is struggling to do. Find a Baby
Café somewhere in a very poor multiethnic part of an urban conglomeration
and there you will find a support group, with trained peer supporters, and
they are making that happen fantastically. There are people in this room who
have been hugely instrumental in that. That’s where we are going to make the
difference. The resistance rates have been in the youngest, the poorest, the white
communities in this country, and that’s where the difference is going to come. I
think we are about to see a resurgence of breastfeeding because a lot of the pieces
are now in place in policy terms and the support groups working hand-in-hand
with the health service are there. They were ahead of the health service all the
way. They have retained local roots, these national organizations, in forming
policy, local routes right down to the breastfeeding women.
We can all learn advocacy also from the support groups, who are fighting, going
out to support real women when they have been put out of restaurants and
told not to breastfeed in public, and we need all the support groups to make
sure that doesn’t continue to happen. They have been linked in with the overall
philosophy of natural childbearing, which I think is a hugely important issue
that we have touched on today in part, but it’s very important and needs more
discussion. I really notice the difference when I go to countries that don’t have
support groups. I have done a lot of work in the Netherlands and some in
Germany, for example, where there is no tradition of support groups. They
don’t know how to create change, and if we ask Elisabet Helsing about mother-
to-mother groups in Norway, that’s how they did it there and I absolutely agree:
that’s how we are going to do it here. The support groups have been fed by the
science and they have taken it up and they have championed it (and that’s where
the links are and that’s where I think that happens). We can do whatever we
like in our research studies, nothing is going to happen unless women and their
supporting men get out there and actually make those changes happen at policy
level, at practice level and in women’s own homes, on the streets, in the shops
and on the buses, where women need to be feeding their babies and travelling.
Just one thing to mention, one of the things that we identified when we did
our work for NICE over the last couple of years and produced a report.168 The
response to the evidence-based review and the national consultation that we
carried out to do that was incredibly strong and it said that in order to make all
the kinds of changes that are needed, first of all you have got to create change in
168 NICE (2008). See also Renfrew and Hall (2008).
The Resurgence of Breastfeeding, 1975–2000
84
society. You have got to educate children, you have got to help women combine
work and breastfeeding. You have got to have a national strategy to lead it and
make sure it reaches all the parts across government. You have got to facilitate
breastfeeding in public and so on. I am smiling at Jenny because they have done
so much of this in Scotland already. But that was what our work said. Now in
fact NICE wouldn’t act on that, because it’s not mandated to that societal level, it
can only at the moment speak to the health service, but those recommendations
have been taken up by a new group called the Breastfeeding Manifesto Coalition
which is a coalition of all the support groups, with all the Royal Colleges, with
other groups like UNISON and other organizations that have come together
under the leadership of an amazing woman called Alison Baum, who happens
to be David Baum’s niece, which is an interesting circle here. She comes from a
support group background and not from a health professional background, and
has tied together over 30 organizations, who have already met with the public
health minister, who have already got MPs in to talk to Tony Blair, they have
already got Gordon Brown standing up and talking about this organization at
policy level. I am hugely inspired by that, and that organization is dedicated to
addressing inequalities in health and tackling the problems of breastfeeding in
the communities where the rates are lowest, which is what I think we should be
doing for the next 25 years, bringing to bear all the evidence-based strategies
we now know work, funding them properly, making them happen and using
the policy doors which are currently open. Working together as the support
groups have modelled for years, working together with each other and working
together with health professionals and anybody who would work with them to
create real change for women and I want that to be the legacy of the support
groups: to remember that we are talking about women and babies.
Weaver: Roger wants to say something before we close.
Short: I think we know enough to insist that there should be a health warning on
every packet of infant formula sold in Britain or anywhere else in the world.
Weaver: The time is up. Clearly this is a very broad, interesting subject and I
think it will be the historians in another 50 years who will have to look back and
say whether we were talking about a resurgence of breastfeeding, the beginning,
the middle, the end, and what we mean about resurgence of breastfeeding. But
I am very grateful to everyone who has come. Daphne will be in touch with us
all about the proceedings of this meeting and I hope everyone will be happy to
contribute and edit their contributions and so on.
The Resurgence of Breastfeeding, 1975–2000
85
Howie: I am sure I speak for everybody here when I thank the History of
Twentieth Century Medicine Group of the Wellcome Trust Centre for setting
up this meeting. I was delighted to see that they have thought that this was one
of the priorities amongst all the possibilities that come forward, and I think they
deserve enormous credit and thanks for doing so.
Dr Daphne Christie: Unfortunately, Dr Tansey has had to leave the meeting
early, and therefore on behalf of the Wellcome Trust Centre for the History
of Medicine at UCL, I would like to thank you all for coming along and
participating in today’s seminar and to thank Professor Lawrence Weaver for his
excellent chairing of the meeting.
The Resurgence of Breastfeeding, 1975–2000 – Appendix 1
87
Appendix 1
Recommended breastfeeding times as recorded in Mary Mayes’
Handbook of Midwifery, 1937–80
Collated by Chloe Fisher
Mayes’ Handbook of Midwifery1
1st edition 1937 Mary Mayes
1st day 5 minutes at each breast 8 hourly + boiled water
2nd day 7 minutes at each breast 6 hourly
3rd day 15 minutes at one breast 3 hourly
4th day 20 minutes at one breast 3 hourly
2nd edition, 1938, revised by Mrs M A Gannon
1st day 5 minutes at each breast 8 hourly + boiled water
2nd day 7 minutes at each breast 6 hourly
3rd day 15 minutes at one breast 3 hourly
4th day 20 minutes at one breast 3 hourly
3rd edition, 1941, revised by Mrs M A Gannon
1st day 5 minutes at each breast 8 hourly + boiled water
2nd day 7 minutes at each breast 6 hourly
3rd day 15 minutes at one breast 3 hourly
4th day 20 minutes at one breast 3 hourly
4th edition, 1953, revised by Mrs F D Thomas
1st day 2 minutes at each breast 8 hourly
2nd day 4 minutes at each breast 6 hourly
3rd day 6 minutes at each breast 4 hourly
4th day 8–10 minutes at each breast 4 hourly
5th edition, 1955, revised by Mrs F D Thomas
1st day 2 minutes at each breast 8 hourly
2nd day 4 minutes at each breast 6 hourly
3rd day 6 minutes at each breast 4 hourly
4th day 8–10 minutes at each breast 4 hourly
The Resurgence of Breastfeeding, 1975–2000 – Appendix 1
88
Mayes’ Handbook for Midwives and Maternity Nurses
6th edition, 1959, revised by Mrs F D Thomas
1st day 2 minutes at each breast 8 hourly
2nd day 4 minutes at each breast 6 hourly
3rd day 6 minutes at each breast 4 hourly
4th day 8–10 minutes at each breast 4 hourly
7th edition, 1967, revised by Vera Da Cruz
1st day 2 minutes at each breast 8 hourly
2nd day 4 minutes at each breast 6 hourly
3rd day 6 minutes at each breast 4 hourly
4th day 8–10 minutes at each breast 4 hourly
Mayes’ Midwifery: A Textbook for Midwives
8th edition, 1972, revised by Rosemary Bailey
1st day 2 minutes at each breast 8 hourly
2nd day 4 minutes at each breast 6 hourly
3rd day 6 minutes at each breast 4 hourly
4th day 8–10 minutes at each breast 4 hourly
9th edition, 1976, revised by Rosemary Bailey
1st day 2 minutes at each breast 8 hourly
2nd day 4 minutes at each breast 6 hourly
3rd day 6 minutes at each breast 4 hourly
4th day 8-10 minutes at each breast 4 hourly
10th edition, 1980, revised by Betty R Sweet
There should be no restriction on time at the breast.
The baby sucks until he is satisfied.
Complementary feeds should not be required.
The Resurgence of Breastfeeding, 1975–2000 – Appendix 2
89
Appendix 2
Resurgence of breastfeeding: metaphor and microcosm.
Chairman’s reflections after the event
Lawrence Weaver, May 2007
The title of this Seminar – The Resurgence of Breastfeeding – implies a process
occurring over time. In this respect the Witness Seminar differed from others
that have focused on a discrete topic, such as a discovery, advance or innovation
(ultrasound, peptic ulcer or genetic testing, for instance). Although a resurgence
might properly be assumed to have a duration, a beginning and an end, an
upward trajectory is its chief characteristic. In the event, the assumption that
breastfeeding has been on the rise was called into question. Even if it were
possible to trace an upturn in breastfeeding rates set in motion by changing
maternal practices or professional attitudes, its trajectory has been far from
linear. Participants representing different interests perceived the significance of
‘key events’ that might have powered the resurgence in very different ways. And,
most significantly, there was a concern expressed by some that there has been no
resurgence at all: a stasis in breastfeeding?
Nevertheless, the lack of unanimity about what ‘happened’ between 1975 and
2000 made for a lively debate. Starting with a survey of the science (or lack
of it) thitherto underpinning rational advice about breastfeeding, an account
of work done in the developing world generated shared memories by those
involved, and led on to reflections by animal and human physiologists on
their contributions, concentrating largely on the work of ‘professionals’. As the
seminar got going we heard from midwives and neonatologists, from national
and international activists. As each spoke, the debate moved from recollection
of what had happened to statements of what should have happened; voicing
views more than involvement. This development reflected the nature of a topic
that belongs to no single group exclusively (apart from mothers themselves).
Although the interests of many participants overlapped, few were congruent.
An example of this emerged with the parallel accounts of those involved in
studying the nutritional contributions of breastfeeding to babies, and those
interested in its contraceptive effects on mothers. These separate but parallel
stories, even when they came together in WHO deliberations, were represented
by separate people from different backgrounds.
The Resurgence of Breastfeeding, 1975–2000 – Appendix 2
90
The disjunction between the work of reproductive and lactational physiologists
mirrored that between obstetricians and neonatologists, and between
paediatricians and midwives, revealing a gender divide that might be said to
begin and belong to the moment of birth. Those most intimately involved with
the act of birth – mother and baby – are cared for by midwives and doctors,
who if not both in attendance, certainly exercise control. Their strongest
advocates, the breastfeeding support groups, articulated this view. Indeed, the
powerlessness of mothers in a medical environment prompted a ‘Foucaultian’
view of how the medical gaze puts the event of ‘birth’ so firmly in the ‘clinic’.
The voices unrepresented were those of breastfeeding mothers themselves.
There was a feeling that those concerned with supporting them were not
‘heard’ in a Witness Seminar chaired by a middle-aged professional man prone
to concentrate on the science and official reports that presented themselves as
handy milestones with which to steer the debate along an uncertain trajectory.
The meeting was both a metaphor and microcosm of how the subject of
breastfeeding is seen by different groups, and the untidy discussion, which at
times lost touch with events and tended to the polemical, reflected the real
nature of the wider current debate. Indeed, the Seminar made it abundantly
clear that breastfeeding is still a very live issue, and whether or not there has
been a resurgence, its course has been far from straight, strong, upwards or
fully run. Indeed, in the eyes of the support groups it has hardly begun. Nor
was it clear what were the forces that had, or had not, driven the ‘resurgence’.
The focus on the science and policy behind breastfeeding promotion perhaps
drowned the quieter voices of those closer to mothers and their concerns.
The de-medicalization of childbirth, the support of mothers in hospital, the
women’s movement, were subjects hardly touched on in a Witness Seminar,
which covered such a wide range and encompassed so many different groups.
Some were left with a sense of frustration, even disappointment, about what did
not happen, rather than what happened.
The Resurgence of Breastfeeding, 1975–2000 – References
91
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The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
111
Mr James Akre
(b. 1944) began his health-and-
development career working
with rural populations in Turkey
and Cameroon (1966–71). After
obtaining an MSc in economic and
social development (University of
Pittsburgh, 1972), he continued
his international focus in three
UN agencies, including the WHO
where he has served for 25 years as
technical officer in the department
of nutrition. In this capacity
he participated in drafting and
promoting the adoption of the
International Code of Marketing of
Breast-milk Substitutes (1981); the
joint WHO/UNICEF statement on
breastfeeding and the special role
of maternity services (1989), the
foundation for the Baby-friendly
Hospital Initiative; and the Global
Strategy for Infant and Young Child
Feeding (2003). Upon retirement in
2004 he was elected to the board of
directors of the International Board
of Lactation Consultant Examiners
(IBLCE).
Professor Elizabeth (Beth) Alder
PhD FBPsS (b. 1944) graduated
in psychology at the University
of Aberdeen in 1967 and gained
a doctorate at the University of
Edinburgh in 1971. She worked
part-time at the MRC reproductive
biology unit, Edinburgh (1975–87)
and subsequently held academic
posts at Queen Margaret College
(1987–95) and Dundee University
Medical School (1995–2000)
before becoming professor and
director of research in the faculty
of health sciences at Napier
University, Edinburgh. She was
president of the International
Society of Psychosomatic Obstetrics
and Gynaecology (2004–07) and
chaired the NHS Health Scotland’s
breastfeeding expert group in 2006.
Professor Rima D Apple
(b. 1944) received her PhD from
the University of Wisconsin-
Madison. She was lecturer, State
University of New York at Stony
Brook (1981–83); member,
women’s studies program (1983–
92) and fellow, department of the
history of medicine (1985–92),
at the University of Wisconsin-
Madison. She subsequently
held joint appointments at the
University of Wisconsin-Madison
school of human ecology, as
professor of consumer science
(1992–2007); interdisciplinary
Biographical notes*
* Contributors are asked to supply details; other entries are compiled from conventional
biographical sources.
112
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
studies in human ecology (1996–
2007); women’s studies (1983–
2007) and science and technology
(2001–07); and has been an
affiliate of the department of the
medical history and bioethics since
1992. She was researcher, Wellcome
Trust Centre for the History of
Medicine at UCL (2004–08);
and co-editor of Advancing the
Consumer Interest (1994–98). and
was the ACOG-Ortho fellow in the
history of American obstetrics and
gynaecology, American College of
Obstetricians and Gynaecologists
(1996). See Apple (1997, 2006).
Professor John David Baum
FRCP FRCPCH FRCPE
(1940–99) qualified and trained
at the university of Birmingham
and joined the Hammersmith
Hospital, London, as senior house
officer and then research fellow,
working for Peter Tizard, who
was then developing the specialty
of neonatal medicine. He moved
to the University of Oxford’s
department of paediatrics where
Tizard become chair in 1972 and
became interested in nutrition and
maternal breast-milks, working with
medical physicists and bioengineers
in the development of instruments
to measure breast-milk flow during
feeding. In 1985 he was appointed
to the chair of child health at the
University of Bristol until his
sudden death on a sponsored bike
ride to raise money to help children
in the Balkans. He was president
of the Royal College of Paediatrics
and Child Health (1997–99). See
Chambers (1999).
Mrs Phyll Buchanan
(b. 1957) trained as a nurse and
midwife in the 1970s and worked
as a sister in intensive care at
Guy’s Hospital (1982–84). She
has worked in the voluntary sector
supporting breastfeeding women
for nearly two decades. She was
a founder member and trustee of
the NCT Breastfeeding Network.
As a tutor she has trained and
supervised peer supporters in
various communities in England
and Wales. With her colleague
Lorna Hartwell, she has recently
been seconded to the Department
of Health as an infant feeding best
practice adviser.
Professor Forrester Cockburn
CBE FRSE FRCPGlas FRCPEd
HonFRCPCH HonFRCSEd
(b. 1934) qualified at the University
of Edinburgh in 1959 and had
general professional and paediatric
training in the Royal Infirmary,
Simpson Memorial Maternity
Pavilion and Royal Hospital for Sick
Children, Edinburgh. Thereafter he
was Huntingdon-Hartford research
fellow in paediatric metabolic disease,
University of Boston, Massachusetts;
Nuffield senior research fellow
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
113
in neonatal and fetal physiology,
University of Oxford; Wellcome
senior research fellow in neonatal
and paediatric research, University of
Edinburgh; senior lecturer, University
of Edinburgh; and Samson-Gemmell
professor, department of child health,
Universtiy of Glasgow (1977–96).
He has been chairman of Yorkhill
NHS Trust panel on child nutrition,
DoH (1985–96); the MRC/DoH
phenylketonuria/hypothyroid
screening committee (1984–94);
the ethics committee of the British
Paediatric Association (1978–85);
and president of the British
(1987–90) and European (1996–98)
Associations of Perinatal Medicine;
and the Scottish Paediatric Society
(1993/4).
Dr Alfred T Cowie
PhD DSc FBiol FRCVS (1916–
2003), endocrinologist, qualified
at the Royal Veterinary College,
Edinburgh, moving to Sir Joseph
Barcroft’s Cambridge laboratory
as a research fellow, working for
him and D H Barron on the
physiology of fetal sheep. Returning
to Edinburgh he continued to
study the energy metabolism of
pregnant sheep and the digestibility
of alkali-treated straw. In 1941
he was appointed to the National
Institute for Research in Dairying
at Shinfield, near Reading, where
he worked with S J Folley and
G W Scott-Blair on a pregnancy
test for cattle, later becoming
interested in lactation. During
the war, he worked to improve
the productivity of dairy herds by
inducing lactation in barren cattle.
He was a member of the Ministry
of Agriculture, Fisheries and Food’s
veterinary products committee
(1970–77) and editor of the Journal
of Endocrinology (1981–84). See
Cowie (1999); Forsyth (2003).
Ms Rosie Dodds
is a graduate in nutrition and
dietetics (1980), with an interest
in injustice. Following travel and
work in India, Egypt and Sudan,
she worked in research preventing
postoperative thrombosis and the
complications of diabetes. The birth
of her son in 1988 prompted her to
train as a breastfeeding counsellor
with the NCT. This led to work
in policy research at the NCT and
lobbying to improve support for
breastfeeding in the UK.
Mrs Jill Dye
IBCLC (b. 1949) graduated in
anthropology from the University
of California, Berkeley, (1976) and
gained a masters in archaeological
sciences at the University of
Bradford (1978). As the mother
of three children she realized that
archaeology was not the career for
her and moved into the voluntary
sector. In 1988 she became a La
Leche League leader; served on the
114
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
council of directors of La Leche
League Great Britain (LLLGB)
as director of publications;
representated LLLGB on the Joint
Breastfeeding Initiative executive
committee and steering group;
represented LLLGB on the national
breastfeeding working group
and on the national network of
breastfeeding coordinators. She
is currently representing LLLGB
on the UNICEF Baby Friendly
Initiative steering group and is
a lactation consultant in private
practice in the London area.
Professor Fiona Dykes
ADM RM RGN Cert Ed PhD
(b. 1960) qualified as a midwife
in 1984 in Chatham, Kent. She
practised as a midwife in Kent
and East Lancashire. She gained
an MA in health research in
1998 at Lancaster University
and a PhD from the faculty
of medicine at University of
Sheffield in 2004. She conducted
a critical medical anthropological
study of institutional practices of
breastfeeding mothers in maternity
hospitals in north-west England,
later published (Dykes, 2006). She
is currently director of the maternal
and infant nutrition and nurture
unit at the University of Central
Lancashire, which she founded
in 2000; and adjunct professor
at the University of Western
Sydney; facilitator for the WHO/
UNICEF Global Strategy for Infant
and Young Child Feeding (2003)
and is currently domain editor for
Maternal and Child Nutrition.
Ms Hilary English
IBCLC is a breastfeeding counsellor
with the National Childbirth Trust,
and tutored for them (1987–2008).
She was a member of the Royal
College of Midwives breastfeeding
working group (2000–03). She
produces promotional material,
photographs and graphics, and
trains health professionals in private
practice.
Miss Chloe Fisher
MBE NNEB RN RM MTD
(b. 1932), a midwife for over 50
years, was the clinical specialist in
infant feeding at the John Radcliffe
Hospital, Oxford (1991–97). In
1996 she was appointed MBE for
her services to infant healthcare, and
honorary fellow, Oxford Brookes
University (1997). Although retired,
she is a volunteer at the Oxford
breastfeeding clinic; vice-president
of the Royal College of Midwives;
an adviser to Le Leche League
GB; and was a former adviser
to the International Lactation
Consultants Association. She is
an honorary life member of the
National Childbirth Trust; and was
consultant to UNICEF/WHO
in former Yugoslavia, (1992–97).
She has lectured on breastfeeding
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
115
and chaired the Royal College of
Midwives, breastfeeding working
group (1988), which produced
Successful Breastfeeding. See Renfrew
et al. (2004).
Professor Anna Glasier
CBE MD DSc (b. 1950) trained
in obstetrics and gynaecology at
Edinburgh and Winchester after
qualifying from Bristol University.
She subspecialized in reproductive
medicine and was a clinical scientist
at the MRC unit of reproductive
biology, Edinburgh (1989–90).
She is lead clinician for sexual
health in NHS Lothian region and
holds honorary professorships at
the universities of Edinburgh and
London. She chaired the scientific
and technical advisory group of
the WHO’s human reproductive
programme (2004–08).
Professor Lars Hanson
MD PhD HonFRCPCH (b. 1934)
trained at Institute Pasteur, Paris,
(1958) and the Rockefeller Institute,
New York, (1962/3), and interned
in paediatrics at Göteborg Hospital
and the department of paediatrics,
Karolinska Institute, Stockholm,
Sweden. He has been a specialist in
paediatrics since 1969 and in clinical
immunology since 1977; head of
the department of immunology,
Göteborg University (1969–77);
head of the department of clinical
immunology (1978–2000), and was
a consultant in paediatrics, Göteborg
Children’s Hospital, until 2000. See
Hanson (2004).
Dr Elisabet Helsing
DrMedSci (b. 1940) trained in
nutrition physiology at the University
of Oslo; was responsible for changes
in breastfeeding frequency in Norway
where she wrote the pamphlet How
You Breastfeed Your Child: Some
advice for the early days in 1968;
started a mother-to-mother support
association in 1968, and wrote The
Book About Breastfeeding in 1970.
She became responsible for nutrition
in the WHO regional office for
Europe (1984–96); received the first
Grande Covian Award from the
Mediterranean Diet Foundation,
Barcelona (1996); the Norwegian
King’s Gold Medal for services to
the people (2003); is an honorary
member of the Norwegian (1988)
and the Swedish (2003) mother-
to-mother breastfeeding support
organization; president of the 8th
European Nutrition Conference,
Lillehammer, Norway (1996–99);
and president of the Federation
of European Nutrition Societies
(FENS) (1999–2003). See Helsing
and Häggkvist (2009); Helsing and
Savage (1982). See also Figure 2.
Dr Edmund Hey
DM DPhil FRCP (b. 1934) trained
as a respiratory physiologist in
Oxford and worked for the MRC
116
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
with Kenneth Cross, Geoffrey
Dawes and Elsie Widdowson
for some years before moving
to Newcastle for a grounding in
paediatrics in 1968. He established
a respiratory intensive care service
at Great Ormond Street Hospital,
London, in 1973, before returning
to Newcastle to set up a network
of neonatal services for the north
of England in 1977. Epidemiology,
neonatal pharmacokinetics, and the
conduct of controlled clinical trials
have been his main research since
his retirement in 1994.
Professor Peter Howie
MD FRCOG FRSE (b. 1939)
trained in obstetrics and
gynaecology at the University of
Glasgow and was senior lecturer
there (1974–78). At the MRC
reproductive biology unit in
Edinburgh as clinical consultant
he developed a major interest in
breastfeeding research (1978–81).
He moved to chair of obstetrics
and gynaecology at the University
of Dundee (1981–2000) and
became dean of faculty and deputy
principal; held positions with
WHO as task force chairman and
was chair of the Scottish Council
for Postgraduate Medical and
Dental Education (1996–2002).
Professor Derrick (Dick) Jelliffe
(d. 1992) qualified in medicine at
the Middlesex Hospital, London,
and worked as an academic
paediatrician in Sudan and Uganda
as a district medical officer. He was
professor of paediatrics at University
College, Ibadan, Nigeria (1948–
52); senior lecturer in paediatrics at
the University College of the West
Indies (1953/4), the University of
Calcutta (1954–56) and in New
Orleans, Louisiana (1956–59).
He was UNICEF professor of
paediatrics and child health at the
University of East Africa, Kampala,
Uganda (1959–66), before his
appointment as director of the new
Caribbean Food and Nutrition
Institute, University of the West
Indies, established by the Pan-
American Health Organization. He
moved to a chair in public health
and paediatrics at the School of
Medicine, University of California
Los Angeles (1972–90) and
directed the international health
programme there (1989–91); and
was founder editor of the Journal of
Tropical Paediatrics. See Laurence
(1994); additional information
from Professor John Waterlow,
27 November 2000 and Professor
Gerry Shaper, 6 December 2000.
See also Trowell and Jelliffe (1958);
Williams and Jelliffe (1972).
Professor Patrice Jelliffe
(d. 2007) a nurse and later
laboratory technologist, was at the
Makerere University in the 1960s
with her husband Derrick Jelliffe.
She took higher degrees in public
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
117
health and was appointed to a chair
at the University of California,
Los Angeles. See Jelliffe and Jelliffe
(1978); Latham (2007). See also
www.waba.org.my/pdf/Tributo_a_
Pat_Jelliffe.pdf (visited 11 August
2008); Figure 2.
Professor Alan McNeilly
PhD DSc FRSE (b. 1947)
trained in agricultural science at
Nottingham and Reading with
a doctorate in lactation at the
National Institute for Research in
Dairying, Shinfield with Professor
John Folley and Dr Alfred
Cowie. He joined the department
of reproductive medicine,
St Bartholomew’s Hospital,
London, in 1971 and developed
radioimmunoassays for human
prolactin and gonadotrophins for
clinical application with Professors
Tim Chard and Mike Besser.
After a sabbatical in Winnipeg,
Canada (1975/6), he joined Roger
Short and David Baird in the
MRC reproductive biology unit,
Edinburgh, in 1976, to study
lactational amenorrhea with Peter
Howie. He has been a principal
investigator in the renamed MRC
human reproductive sciences
unit in Edinburgh, since 1984.
He was editor in chief, Journal
of Endocrinology (1995–2000);
chairman of the Society for
Reproduction and Fertility
(1994–2004); Dale medalist of the
Society for Endocrinology (2008)
and Marshall medalist, Society for
Reproduction and Fertility (2008).
Professor Kim Michaelsen
MD DrMedSci (b. 1948) has been
professor of paediatric nutrition at
the department of human nutrition,
faculty of life sciences, University
of Copenhagen; senior consultant
at the paediatric nutrition unit
at Rigshospitalet, University of
Copenhagen, since 1998, heading
a research group working with
paediatric and international
nutrition focusing on the short-
and long-term effects of nutrition
in early life in industrialized and
developing countries. He was
president of the International
Society of Research in Human Milk
and Nutrition (2004/5).
Mrs Rachel O’Leary
MA PGCE IBCLC (b. 1949) was
accredited as a La Leche League
(LLL) leader in 1980 and continues
to support mothers learning to
breastfeed in paid and voluntary
posts. She has served in LLL
publications departments and on
the LLLI board of directors, as
well as organizing local mother-
to-mother support groups. She is
employed by Cambridge University
Hospital Trust and by children’s
centres in Cambridge and is a
member of the board of directors of
Baby Milk Action.
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The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
Professor Thomas Ernest Oppé
CBE FRCP (1925–2007) qualified
at Guy’s Hospital, did his National
Service in the Royal Navy and
trained at Great Ormond Street
Children’s Hospital, Harvard and St
Mary’s. He was a lecturer in child
health, University of Bristol (1956–
60); consultant paediatrician,
United Bristol Hospitals, 1960;
assistant director (1960–64) and
director (1964–69) of the paediatric
unit, St Mary’s Hospital Medical
School, consultant paediatrician,
St Mary’s Hospital (1960–90) and
professor of paediatrics, University
of London, at St Mary’s Hospital
Medical School (1969–90), later
emeritus. He was consultant adviser
in paediatrics, DHSS (1971–86),
member, DHSS committees on
safety of medicines (1974–79),
medical aspects of food policy
COMA (1966–88); chairman of the
panel on child nutrition, COMA;
child health services, (1973–76).
See Oppé (1961).
Ms Gabrielle Palmer
MSc HumNut (b. 1947) set up
the UK action group, Baby Milk
Action, in 1980 and has worked
with this organization for ten
years. She published The Politics
of Breastfeeding (1989), a key
text for advocates for safer infant
feeding practices. She joined Dr
Felicity Savage as co-director of the
breastfeeding: practice and policy
course in 1992, Institute of Child
Health, UCL. In 1999 she was
appointed HIV and infant feeding
officer for UNICEF. She was
a lecturer in the public health
nutrition unit at the London
School of Hygiene and Tropical
Medicine (2001–07), and serves on
the UNICEF UK Baby Friendly
designation committee (2007–09).
Dr Malcolm Peaker
DSc FRS FRSE (b. 1943)
graduated in zoology from the
University of Sheffield and was
a postgraduate student at the
University of Hong Kong. He
joined the Institute of Animal
Physiology, Babraham Institute,
Babraham, Cambridge, in 1968;
was appointed to the Hannah
Research Institute, Ayr, in 1978,
first as head of physiology and
subsequently as director and
Hannah professor in the University
of Glasgow (1981–2003).
Dr Ann Prentice
OBE PhD (b. 1952) read chemistry
at Oxford University, medical
physics at Surrey University and
natural sciences at Cambridge
University. She has worked for the
MRC since 1978, researching the
nutritional requirements of women
and children with projects based
in Gambia, China and the UK.
She has been director of the MRC
collaborative centre for human
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
119
nutrition research in Cambridge
since 1998. She sits on the UK
scientific advisory committee in
Nutrition and was president of the
Nutrition Society (2004–07).
Professor Mary Renfrew
RGN SCM PhD (b. 1955)
graduated from the University of
Edinburgh in 1975, qualified in
nursing in 1977 and in midwifery
in 1978, and gained her PhD
working on breastfeeding with
the MRC reproductive biology
unit, Edinburgh in 1982. She
established the national midwifery
research initiative at the national
perinatal epidemiology unit in
Oxford (1988–1994); was professor
of midwifery at the University of
Leeds (1994–2003), and has been
professor of mother and infant
health at the University of York since
2003. She established and directs
the multidisciplinary mother and
infant research unit (1996– ); wrote
a series of reviews of breastfeeding
published by the Cochrane Library,
the WHO Reproductive Health
Library, the HTA programme, the
DoH and NICE; and has been chair
of the WHO maternal and newborn
health strategic committee.
Mrs Patti Rundall
OBE (b. 1950) trained as an artist
and teacher at Camberwell School
of Art and Goldsmith’s College,
London, but switched careers,
prompted by Gabrielle Palmer, to
work on the baby food issue and
she has been policy director of Baby
Milk Action since 1980. She is a
leader of the international Nestlé
boycott, active in 20 countries; a
coordinator of IBFAN’s campaign
to strengthen EU legislation on
baby foods; a trustee of Sustain
and on the secretariat of the Baby
Feeding Law Group, a coalition
of UK health professional and lay
organizations.
Ms Ellena Salariya
RGN RM (b. 1931) trained in
nursing and midwifery at Dundee
and Glasgow; gained an MPhil at
Abertay University and Ninewells
Hospital and Medical School,
Dundee. She has been a midwife
in maternity wards, labour suites
and the community in Dundee
and latterly was post-graduation
education and research officer at
and Ninewells Hospital (1982–
93). Her published work covers
breastfeeding patterns; umbilical
cord care; smoking habits in
hospitalized antenatal women;
development of a stool colour
comparator; gut transit time of
meconium in the breastfed infant
in relation to weight loss; and
the development and testing of a
tool to measure the mother–child
relationship during the first five
days of life. See also Royal College
of Midwives (1988).
120
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
Dr Felicity Savage
FRCP FRCPCH FFPH (b. 1939)
worked in community child
health in Zambia, Indonesia and
Kenya (1966–84); as a medical
officer with WHO specializing in
policy development and training
in breastfeeding (1993–2001);
an honorary senior lecturer at the
Institute of Child Health, UCL,
and director of the breastfeeding
practice and policy course; and has
been chair of World Alliance for
Breastfeeding Action since 2006.
Professor Roger Short
AM ScD FRCVS FRCOG FAA
FRS (b. 1930), reproductive
biologist, was lecturer, then reader
at the University of Cambridge
(1956–72); director of the MRC
unit of reproductive biology,
Edinburgh (1972–82); professor
at the department of physiology,
Monash University, Melbourne,
Australia (1982–95); professorial
fellow, department of obstetrics
and gynaecology, University of
Melbourne, Australia (1996–2005);
and has been honorary professorial
fellow, faculty of medicine,
University of Melbourne, Australia,
since 2006.
Dr Mary Smale
PhD (b. 1943) trained as a
teacher and works as a voluntary
breastfeeding counsellor for the
National Childbirth Trust. She
was an honorary research fellow
in the mother and infant research
unit, University of Leeds and has
authored and co-authored several
chapters and papers. She has
published a pack to help with the
training of breastfeeding supporters
(Smale (2004)).
Dr Alison Spiro
PhD MSc RHV RGN (b. 1949)
trained as a nurse in 1971 and a
health visitor in 1973; worked as a
voluntary breastfeeding counsellor
for the National Childbirth Trust
(1977–2007); has been a health
visitor in Harrow since 1984
and has published in the nursing
press. She completed an MSc in
medical anthropology in 1994,
studying breastfeeding in the
Gujarati community, she continued
these studies for a PhD in social
anthropology and has carried out
field work in Harrow and India.
She is also a specialist health visitor
lead for breastfeeding in Harrow
and Northwick Park Hospital.
Dr Penny Stanway
(b. 1946) trained in general
practice and worked in child health
in Croydon (1971–76), becoming
a senior medical officer. Since
then she has written many books
for the public on breastfeeding,
childcare and nutrition and edited
and contributed to various health
partworks and encyclopaedias. She
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
121
was health columnist for Woman’s
Weekly for 15 years and is on the
professional advisory board of the
La Leche League.
Jenny Warren
OBE RGN RM HV (b. 1946)
worked as a nurse, midwife and
health visitor before taking up post
as coordinator to the Scottish Joint
Breastfeeding Initiative (1992–95),
then national breastfeeding adviser
for Scotland (1995–2005); she
worked as a voluntary counsellor
and tutor for the National
Childbirth Trust and later as
breastfeeding supporter for the
Breastfeeding Network. She also
acted as consultant and course
tutor to the UNICEF UK Baby
Friendly Initiative as well as serving
on its various committees. She was
appointed OBE in 2000 for her
work to encourage breastfeeding.
Professor Lawrence Weaver
MD DSc FRCP FRCPCH
(b. 1948) was educated at
Cambridge and St Thomas’ before a
career in paediatrics. He developed
a special interest in infant nutrition
at the MRC Dunn nutrition
unit, Addenbrooke’s Hospital,
Cambridge, and Harvard Medical
School (1984–93), before moving to
the University of Glasgow as reader
in human nutrition and has been
the Samson Gemmell professor of
child health there since 1996. He is
also a senior research fellow in the
Wellcome Centre for the History of
Medicine, University of Glasgow.
Mr John Wells
BSc Nutrition (b. 1944) graduated
from the University of London in
1966 and started his career as a
Voluntary Service Overseas officer in
Guyana, where he participated in a
WHO project. On returning to the
UK he joined H J Heinz Co. where
he initially worked as an analytical
research chemist and was later
appointed as company nutritionist.
In 1980 he moved to Cow & Gate
where he worked on the formulation
and clinical assessment of baby
milks intended for infants with
special dietary requirements and also
on updating the recipes of infant
weaning foods. He served on a DoH
committee advising government on
aspects concerning the nutritional
assessment of infant formulae
(1995/6) and worked on scientific
communication projects with staff
at the Nutricia head office in both
Friedrichsdorf and Amsterdam
(1999–2006).
Professor Brian Wharton
DSc FRCP FRCPCH (b. 1937)
graduated in medicine at
Birmingham in 1960. While training
as a paediatrician his first nutritional
paper concerned the feeding of
preterm babies. He spent two years
at the MRC unit in Uganda studying
kwashiorkor, the subject of his MD
thesis. Subsequent paediatric posts
122
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
were at the Institute of Child Health,
University of Bristol; the Queen
Elizabeth Hospital for Children,
Great Ormond Street Hospital,
Institute of Child Health, UCL
(1969–73); the Sorrento Maternity
Hospital Birmingham (1973–88);
and King Fahd University, Riyadh,
Saudi Arabia (1984). He was the
foundation Rank professor of
human nutrition at the University
of Glasgow (1988–92) and director
of the British Nutrition Foundation
(1994–97). He is part-time honorary
professor at the MRC childhood
nutrition research centre, Institute of
Child Health, UCL, and honorary
research fellow at the Institute of
Child Health, Birmingham.
Professor Roger Whitehead
CBE FBiol (b. 1933) joined the
scientific staff of the MRC in 1959,
becoming director of the MRC
child nutrition unit in Kampala,
Uganda, in 1968. He was director of
the MRC Dunn nutrition centre at
Cambridge and at Keneba, Gambia
(1973–98). See Whitehead (1969).
Dr Anthony Williams
DPhil FRCP FRCPCH (b. 1951)
trained in medicine at University
College and Westminster Hospital
Medical School, University of
London, graduating in 1975. He
was appointed research fellow in
the department of paediatrics,
University of Oxford, in 1980
following initial paediatric training
in London, Leicester and Liverpool.
In 1985 he moved to the University
of Bristol as lecturer in paediatrics
and has been a consultant
paediatrician at St George’s,
University of London, since 1987.
Ms Carol Williams
is a public health nutritionist and
infant feeding specialist. She trained
originally in agricultural botany
at the University of Reading, but
moved into public health nutrition
after working for the Voluntary
Service Organization in Kenya. She
has worked in emergency relief,
health promotion and consumer
advocacy and, since 1993, has
combined consultancy work with
part-time university teaching. She is
co-director of the WHO/UNICEF
collaborative breastfeeding practice
and policy course at the Institute
of Child Health, UCL, and teaches
nutrition policy and infant feeding
modules at the University of
Westminster, London School of
Hygiene and Tropical Medicine
and Brighton and Sussex Medical
School. She has worked as a trainer
and consultant on infant feeding
internationally, for UNICEF, World
Alliance for Breastfeeding Action
and Emergency Nutrition Network.
She is a member of a mother-led
breastfeeding drop-in charity, and
the breastfeeding strategy group,
Brighton and Hove.
The Resurgence of Breastfeeding, 1975–2000 – Biographical Notes
123
Dr Cicely Williams
CMG FRCP (1893–1992),
paediatrician and nutritionist, was
the first paediatrician appointed to
the Colonial Medical Service. See
Dally (1968). The personal papers
of Cicely Delphine Williams are
held as PP/CDW in archives and
manuscripts, Wellcome Library,
London.
Dr Michael Woolridge
DPhil (b. 1950) trained in zoology
and secured his DPhil in animal
behaviour, supervised by Richard
Dawkins. In 1979 he joined a
multidisciplinary research team
at the John Radcliffe Hospital,
Oxford, co-directed by David
Baum (paediatrics, Oxford) and
Robert Drewett (psychology,
Durham). In 1985 his research
relocated to the Institute of Child
Health, Bristol. He was the first
national director of the UNICEF
UK Baby Friendly Initiative
(1993–95). Since 1996 he has been
senior lecturer in infant feeding at
the University of Leeds. All four
of his children were successfully
breastfed despite his intrusion.
The Resurgence of Breastfeeding, 1975–2000 – Glossary
125
Baby Milk Action
The UK member of the
International Baby Food Action
Network, responsible for co-
ordinating the international Nestlé
boycott.
Baby-friendly Hospital Initiative.
A worldwide programme of WHO
and UNICEF, established in 1991,
to encourage maternity wards and
clinics to implement the Ten Steps
to Successful Breastfeeding (www.
unicef.org/newsline/tenstps.htm)
and to practise in accordance with
the International Code of Marketing
of Breast-milk Substitutes (WHO
(1981b)). The UNICEF UK Baby
Friendly Initiative began in 1992
and was formally launched in
1994. Its principles were extended
to community healthcare services
in the Seven Point Plan for the
Promotion, Protection and Support
of Breastfeeding in Community
Health Care Settings in 1998
(www.babyfriendly.org.uk/pdfs/
Community_Initiative_Review_
consultation_document.pdf ). See
www.babyfriendly.org.uk/page.
asp?page=11 (all visited 17 June
2008).
Bellagio Consensus
The conclusion reached at a
meeting of scientists in Bellagio,
Italy, in 1988, sponsored by
Family Health International,
the Rockefeller Foundation, and
WHO, that breastfeeding provides
more than 98 per cent protection
from pregnancy during the first six
months postpartum if the mother
is fully or nearly fully breastfeeding.
The experts urged family planning
providers to offer women the
option of using breastfeeding to
space births and to delay the use
of other contraceptives (Family
Health International (1988)). A
second conference in Bellagio,
11–14 December 1995, sponsored
by WHO, Family Health
International, and the Georgetown
University institute for reproductive
health, and supported by the
Rockefeller Foundation, reviewed
research to test the 1988 consensus
and concluded in its favour. See
Kennedy et al. (1989); Short et
al. (1991); Heinig (1998); www.
who.int/reproductive-health/hrp/
progress/55/news55_1.en.html;
www.fhi.org/en/RH/Pubs/
booksReports/LAMconsensus.htm
(both visited 14 February 2009).
Glossary*
* Terms in bold appear in the Glossary as separate entries
126
The Resurgence of Breastfeeding, 1975–2000 – Glossary
The Breastfeeding Network
A UK-wide voluntary organization,
established in 1997 to provide
independent information and
support to breastfeeding mothers
and those involved in their care.
It trains peer supporters, offering
externally moderated training
with the Open College Network.
Together with the Association of
Breastfeeding Mothers it operates
the national breastfeeding helpline
launched in February 2008, in
addition to the Breastfeeding
Network’s own helpline which had
20 000 calls last year. Other services
include a drugline, a drugs in breast-
milk helpline and supporterline
in Bengali/Sylheti. See www.
breastfeedingnetwork.org.uk (visited
8 January 2008).
confounding variables
The association of a disease and a
study factor with a third variable
causing a spurious difference
between cases and controls.
Convention on the Rights
of the Child
The first legally binding
international document to
incorporate the full range of human
rights – civil, cultural, economic,
political and social – to children.
It was adopted by the General
Assembly of the United Nations by
its resolution 44/25 of 20 November
1989 and came into force on 2
September 1990. It was ratified by
the UK on 16 December 1991.
Article 43 established a Committee
on the Rights of the Child, which
first met in October 1991 and
currently holds three sessions a year,
supported by the United Nations
Centre for Human Rights in
Geneva. See www.unhchr.ch/html/
menu3/b/k2crc.htm; www.unicef.
org/crc/; www2.ohchr.org/english/
bodies/crc/index.htm (all visited 15
February 2009).
gonadotropin-releasing hormone
A 10-amino acid protein that is
produced in the hypothalamus and
acts on cells in the anterior pituitary
to stimulate secretion of luteinizing
hormone and follicle-stimulating
hormone. It plays a pivotal role in
the regulation of reproduction. See
www.hrsu.mrc.ac.uk/glossary.php
(visited 4 August 2008).
International Baby Food Action
Network (IBFAN)
Formed in 1979 by six of the
groups present at the WHO/
UNICEF meeting on infant
and young child feeding (1979),
IBFAN is an umbrella organization
with more than 200 citizen groups
in more than 100 countries that
monitor the baby food industry
to strengthen controls on its
marketing in accordance with the
International Code of Marketing of
Breast-milk substitutes.
The Resurgence of Breastfeeding, 1975–2000 – Glossary
127
La Leche League International
(LLLI)
A private voluntary organization,
established in 1956 by seven
women who met to support
each other in mothering through
breastfeeding. Registered as a not-
for-profit organization in Illinois,
the network has now grown to
include groups in over 60 countries.
Accreditation is valid world-wide.
Volunteer leaders offer breastfeeding
counselling one-to-one by phone, in
person and by e-mail, facilitate local
mother-to-mother support groups,
assist at drop-ins and breastfeeding
cafés and can provide classes and
sessions for antenatal education.
Publications include The Womanly
Art of Breastfeeding, journals for
parents and health professionals,
and information sheets on many
topics. See www.lalecheleague.org
(visited 8 January 2008).
La Leche League Great Britain
An affiliate of LLLI, with about
100 groups currently in GB, and
over 200 leaders. Since the 1970s
these groups have encouraged and
supported many thousands of
women to meet their own personal
breastfeeding goals, overcome
difficulties, enable babies to begin
solid foods around the middle of
the first year of life and to continue
the breastfeeding relationship for as
long as they wish to.
lactation
Requires two physiological
mechanisms: milk secretion
and milk ejection. Secretion
is controlled by the release of
prolactin from the anterior
pituitary in response to the
stimulus of suckling; the ejection
is a neuroendocrine reflex when
oxytocin is released from the
posterior pituitary in response
to suckling, which causes the
contraction of the alveoli of the
breast and release through the
mammary ducts and nipple. See
McNeilly and McNeilly (1978).
lactoferrin
An iron-binding protein found in
human (and other mammalian)
milks. It protects against infections
by depriving bacteria of iron, which
is an essential element for their
proliferation and function.
MRC reproductive biology unit,
Edinburgh (CRB)
Established in 1972 at the
Queen’s Medical Research Centre,
Edinburgh, comprising the division
of reproductive and developmental
sciences (school of clinical sciences
and community health, college of
medicine and veterinary medicine)
and the MRC human reproductive
sciences unit. In 1989 it became a
WHO collaborating centre and has
strong links with the reproductive
medicine laboratory in the adjacent
128
The Resurgence of Breastfeeding, 1975–2000 – Glossary
Royal Infirmary of Edinburgh.
See www.crb.ed.ac.uk/about.php
(visited 7 January 2008)
National Childbirth Trust (NCT)
An association of interested parents
and healthcare professionals,
started in 1956 when Prunella
Briance placed an advertisement
in the personal columns of The
Times and The Daily Telegraph
suggesting the formation of an
association to promote and better
understand the system of natural
childbirth described by Dr Grantly
Dick-Read (1890–1959) (Dick-
Read (1942)). The responses
became the nucleus of the Natural
Childbirth Association, later
becoming the National Childbirth
Trust, to which charitable status
was granted in 1961. See www.
nctpregnancyandbabycare.com/
about-us/who-we-are/history
(visited 6 August 2008).
National Dried Milk
The National Dried Milk scheme
was introduced in December
1941, a month after liquid milk
was rationed. It was available for
children under one year of age and
later to those under two years. It
continued to be sold in tins until
1976, being subsidized to those on
benefits in the 1960s and was used
for infant feeding.
Oppé Report, 1974
The DHSS Committee on Medical
Aspects of Food Policy (COMA)
Panel on Child Nutrition convened
a working party on infant feeding
in 1971, under the chairmanship
of Professor Tom Oppé. Other
members were: Professor G C
Arneil, Dr R D G Creery, Dr J
K Lloyd, Professor C E Stroud,
Dr Brian Wharton and Dr Elsie
Widdowson, with Dr D H Buss,
Miss D M Radford and Dr E M
Ring as assessors. It published its
first report in 1974, unanimously
recommending that the ‘best food
for babies is human breast-milk’,
and feeding in this way for four
to six months’ duration would
‘safeguard the infant from the
adverse conditions which are or
may be associated with artificial
feeding’, but that even two
weeks’ duration would offer a real
advantage. No universal cause for
the unpopularity of breastfeeding
was found, but cultural changes in
attitudes toward female sexuality,
motherhood and the role of
women were identified, along
with the provision and promotion
of artificial feeds. The report
recommended a survey of infant
feeding practices and stated that
working party members ‘deprecate
the advertisement or promotion
of infant milks in any way which
suggests that a substitute milk is
The Resurgence of Breastfeeding, 1975–2000 – Glossary
129
equivalent or superior to breast-
milk as a food for infants’. See
DHSS (1974); Figure 3. A second
report was published in 1980
(DHSS (1980)).
phenylketonuria (PKU)
A recessive disorder in humans
associated with the inability to
metabolize phenylalanine, usually
due to the absence of phenylalanine
hydroxylase, which causes raised
levels of phenylalanine in the
blood and impairs early neuronal
development if not managed
from the first weeks of life. The
condition can be controlled by diet.
Rotersept (chlorhexidine)
A topical antimicrobial agent used
in the treatment of mastitis, and as
a general disinfectant in solutions,
creams, gels and aerosols.
secretory IgA
An immunoglobulin (antibody)
that protects mucosal surfaces,
especially those of the
gastrointestinal and respiratory
tracts, against bacterial infections.
It is secreted by the salivary
glands and Brunner’s glands, in
the duodenum, and is abundant
in human milk, especially in
colostrum, which contains several
g/L of IgA. Human milk IgA is
important to the breastfed baby
during the early months when
its own ability to secrete this
immunoglobulin is limited and
developing.
The Resurgence of Breastfeeding, 1975–2000 – Index
131
AIDS, 14
amenorrhea, lactational, 29–37, 38
antibodies, 13, 14
Association of Breastfeeding
Mothers, 82
Australian Aborigines, 28, 35–6
auxiliaries, nursing, 80
Babraham Agricultural Research
Council Institute of Animal
Physiology, Cambridge, 39
Baby Café, 82–3
Baby-friendly Hospitals Initiative,
WHO, UNICEF, 25–6, 44,
45, 125
Baby Friendly Initiative, UNICEF UK,
26, 43, 51–3, 56–7, 66, 68–9,
78, 125
Baby Milk Action, 16–17, 125
bacterial contamination, cows’
milk, xxiii
Bart’s see St Bartholomew’s
Hospital, London
Belarus study, 52, 66
Bellagio Consensus, 32, 35, 125
benefits of breastfeeding
infant health/mortality, 6, 12–14,
74–5, 80
non-medical, 65–6, 77
suppression of fertility, 29–37,
38, 44
bottle-feeding
attitudes in hospitals, 7, 57–8
enforced, in Australia, 36
infant growth and, 15–16, 37
maternal guilt, 57, 58, 79
nineteenth century, xxiii–xxiv, 4
supplementary see supplementary
feeding
twentieth century, xxiv–xxv, 4–6
see also breast-milk substitutes
bovine milk see cows’ milk
breast, attachment to (latching-on),
18, 58, 59, 61–2
Breast is Best (Stanway), 76, 79
breast pumps, 81
breastfeeding
benefits see benefits of breastfeeding
duration, 8, 15
feed timings see breastfeeding
regimes
first feed, 21–2, 24, 58–9
natural pattern, 27–8
Breastfeeding and Natural Child Spacing
(Kippley), 36–7
Breastfeeding Manifesto Coalition, 84
Breastfeeding Matters (Minchin), 41
Breastfeeding Network, 42, 81–2, 126
breastfeeding rates, 3–4, 9–10
documentation, 9, 52, 68
evidence for resurgence, 7, 10, 89
factors affecting, 4–7, 62, 65–6
impact of healthcare system, 24, 27
Norway, 63
specific areas of UK, 7, 9, 61, 69
breastfeeding regimes, 22–3, 58,
60, 62
former Soviet Union, 66
specific books, 23, 36–7, 87–9
breast-milk, xxiii
antimicrobial properties, 12–14
banks, 49
scientific studies, 12–14, 19, 38–9,
67–8
transfer (to baby), 51
volume, 12, 17
breast-milk substitutes (infant
formulae), 3, 4–5
Index: Subject
132
The Resurgence of Breastfeeding, 1975–2000 – Index
composition, 53–4, 55–6, 70–2
development, 71–3
distribution in developing countries,
27, 80
early history, xxiv, xxv
manufacturers see food industry
marketing see marketing of breast-
milk substitutes
over-concentration, 40, 70
ready-to-feed bottles, 68–9
supply to hospitals, 7, 53, 68–9
WHO policy, 25, 26, 35, 43–4, 47
British Medical Journal (BMJ), 41
British Nutrition Foundation, 70
calcium, 11
Cambridge, 17, 39, 46, 56, 67, 70
Canada, 30, 36
Catholic Church see Roman
Catholic Church
Catholic University, Chile, 35
Chatham, Kent, 63–4
child welfare initiatives, 6
childbirth, medicalized, 42, 58
Chile, 35
Cochrane Collaboration, 60, 82
Code Monitoring Committee,
UK, 54–5
See also International Code of Marketing
of Breast-milk Substitutes
colostrum, 24
COMA see Committee on Medical
Aspects of Food and Nutrition
Policy, DHSS
commerciogenic malnutrition, 46
Committee on Medical Aspects of
Food and Nutrition Policy, DHSS
(COMA), 15
child nutrition panel, 76
grey reports, 53, 68, 70
Weaning and the Weaning Diet
(1994), 76
see also Oppé Report
community midwives, 58, 60–2
A Complete Guide to Baby Care
(Stoppard), 23
confounding variables, 74, 127
contraception, natural, 29–37, 38, 44
Convention on the Rights of the
Child, United Nations (1991) 45,
46, 126
convulsions, neonatal, 54
Cow and Gate, 69, 70, 72
cows, 41
cows’ milk, xxiii, 4–5, 27, 72
dairy science, 38–9, 40, 41
dehydration, 58, 70
demand feeding, 60, 64, 68, 77–8
Department of Health (DoH), 9,
51, 82
Department of Health and Social
Security (DHSS), 15, 70
Committee on Medical Aspects
of Food Policy (COMA), see
Committee on Medical Aspects of
Food Policy, DHSS
developing countries, xxvi, 6–7
growth of breastfed infants, 17–19
importance of breastfeeding, 7,
10–11
infant/child malnutrition, 6–7, 17,
46, 47–8
lactational amenorrhea, 31–2
marketing/supply of infant formula,
16–17, 27, 43–4, 46–7, 80
maternal nutrition, 11–12
weaning, 11, 14, 15
dextrose, 5 per cent, 22
diarrhoeal disease, 14, 44, 45, 74, 75
diary study, lactational amenorrhea,
31, 33–4
doctors, 26, 63, 91
training, 50, 52, 55, 59
see also neonatologists; obstetricians;
paediatricians
The Resurgence of Breastfeeding, 1975–2000 – Index
133
Dublin Foundling Hospital, 4
Dublin Lying-in Hospital, 4
Dundee, 22, 23, 57–9, 74
Dundee Royal Infirmary, 58
Dunn Human Nutrition Unit,
Cambridge, 17, 46
Edinburgh, 20–1, 29–32, 33–4, 41,
57, 77
Effective Care in Pregnancy and
Childbirth (Chalmers et al.), 60
Elcho Island, Australia, 28
endocrinology, 30–1, 39
energy gap concept, 11, 14–15
energy requirements, infant, 8, 14–15
England, 4, 9, 49, 51
exocrinology, 39
family planning, 29–37, 38, 44
fatigue, maternal, 77
fertility, suppression of, 29–37, 38, 44
Food and Agriculture Organization
(FAO), United Nations, 8
Food and Drink Federation, UK, 72
food industry, 3, 8, 53, 69–72
in developing countries, 16–17,
46–7
marketing by see marketing of
breast-milk substitutes
research funding, 16, 19, 46
see also breast-milk substitutes
Food Manufacturers Federation, UK,
54, 55
foremilk, 73
Gambia, 11, 16–17, 19
germ theory, xxv
Germany, 83
Ghana, 21
Glasgow, 57–8
Global Strategy for Infant and Young
Child Feeding (WHO, 2003), 48
GOBI strategy, UNICEF, 44–5, 46
gonadotrophin-releasing hormone,
31, 127
grey books (COMA reports), 53,
68, 70
growth, infant
faltering, 11, 14, 15–16, 17–19
reference data, 8–9, 15–16,
18–19, 44
guilt, maternal, 57, 58, 79
Guthrie cards, 52
Haiti, 48
Handbook of Midwifery (Mayes), 87–9
health professionals
attitudes to infant feeding, 7, 38,
57–8, 62
impact on breastfeeding rates, 24, 27
relations with food industry, 46–7,
70–1
see also doctors; midwives;
neonatologists; obstetricians;
paediatricians
health visitors, 43, 76
hindmilk, 73
History of Twentieth Century
Medicine Group, UCL, 3, 85
HIV infection, 14
hospitals, xxv–xxvi, 48–9
breastfeeding regimes, 22–3, 58,
60, 62
institutional culture, 63–4
responsibility for infant feeding, 7,
55, 62
supply of infant formula, 7, 53,
68–9
see also Baby-friendly Hospitals
Initiative; Baby Friendly Initiative
Hull, 69
human milk see breast-milk
Human Milk in the Modern World
(Jelliffe & Jelliffe), 6–7, 38
134
The Resurgence of Breastfeeding, 1975–2000 – Index
Human Reproduction Programme
(HRP), 35
hypernatraemia, 55, 56, 70
hypocalcaemia, 54, 70
hypomagnesaemia, 54
IBFAN see International Baby Food
Action Network
IgA, secretory, 13, 14, 129
India, 24, 65
Indonesia, 17, 24
Infant and Dietetic Food
Association, 71
infant feeding
HIV-infected mothers, 14
nineteenth century, xxiii–xxiv, 4
twentieth century, xxiv–xxvi, 3
see also bottle-feeding; breastfeeding
Infant Feeding (Gunther), 40–1, 43, 51
Infant Feeding Surveys, 7, 49
infant formulae see breast-milk
substitutes
infant milk depots, 5
infant mortality, 66
benefits of breastfeeding, 6, 80
fertility control and, 32–3
rates, xxiv, 4
time of first feed and, 21, 24
infection, protection against, 12–14,
74, 75
inflammation, 12–13, 14
Innocenti Declaration (1991), 45, 46
Institute of Animal Physiology,
Babraham, Cambridge, 39
institutions, power of, 63–4
International Baby Food Action
Network (IBFAN), 17, 25,
46–7, 126
International Code of Marketing of
Breast-milk Substitutes, 26, 43, 47,
48, 54–5
International Paediatric Association,
25–6
International Society of Research
in Human Milk and Lactation
(ISRHML), 67
Iraq, 27
Italy, 20, 45, 66
Joint Breastfeeding Initiative, UK, 51,
78, 79
!Kung, 28
kwashiorkor, 47–8
La Leche League, 37–8, 79, 81–2
La Leche League Great Britain, 127
La Leche League International, 127
labour suite, 58
lactation, 128
physiology, 29–32, 34, 38–41, 67
lactational amenorrhea, 29–37, 38
lactational amenorrhea method
(LAM), 35, 44
lactoferrin, 14, 128
lactogenesis, 40
LAM see lactational amenorrhea
method
Lancet, 41, 59, 81
latching-on (attachment to breast), 18,
58, 59, 61–2
let-down (milk ejection reflex), 30, 39,
41, 73
Liebig’s Food, xxiv
lipids, infant formula, 54
Liverpool, 49
magazines, 80–1
MAIN trial collaborative group, 82
malnutrition, infant/child, 6–7, 17,
46, 47–8
mammals, 27–8
marketing of breast-milk substitutes,
25, 68
developing countries, 16–17, 43–4,
46–7
The Resurgence of Breastfeeding, 1975–2000 – Index
135
international code see International
Code of Marketing of Breast-milk
Substitutes
UK, 53, 68–9, 80–1
see also food industry
maternal and child welfare initiatives, 6
maternity services, role of, 44, 45
maternity units, 7, 53
see also hospitals
Medical Care of Newborn Babies
(Davies), 49
Medical Research Council (MRC)
Dunn Human Nutrition Unit,
Cambridge, 17, 46
Gambia, 11
reproductive biology unit,
Edinburgh, 29–32, 37, 41, 60,
77, 127–8
Medline (now PubMed), 67
metabolic diseases, inherited, 52, 53–4
methodologies, study, 19, 74–5
Mexico, 11
midwives
attitudes to breastfeeding, 7, 22,
57–8, 63–4
relations with support groups, 42
support for breastfeeding, 49, 58–9,
60–2, 80
training, 20–1, 22–3, 51, 52
milk-ejection reflex, 30, 39, 41, 73
millennium cohort study, UK, 75
mother–baby interaction, 56, 77
mothers
effects of breastfeeding on, 77
listening to, 73
nutrition, 11–12
powerlessness, 91
return to work, 18, 20
separation from newborn, xxv–xxvi,
49, 58, 60
supporting see support for
breastfeeding
see also women
Mozambique, 80
MRC see Medical Research Council
National Breastfeeding Adviser,
Scotland, 41–2
National Breastfeeding Working
Group, UK, 51
National Childbirth Trust (NCT), UK,
42–3, 69, 79–80, 81–2, 128
National Dried Milk, 53, 69, 79, 128
National Infant Feeding Coordinators,
DoH, UK, 51
National Institute for Health and
Clinical Excellence (NICE), 82,
83–4
National Institute for Research in
Dairying, Shinfield, Reading, 40
national perinatal epidemiology unit,
Oxford, 75
Nature, 40
NCT see National Childbirth Trust
neonatal convulsions, 54
neonatal units, 49, 50–1
neonates see newborn babies
neonatologists, 7, 48–51, 53, 55–6
Nestlé, 16–17, 46
infant formulae, xxiv, xxv
Nestlé’s Milk Food, xxiv
Netherlands, 83
newborn babies
foods given to, 21, 22, 24
initial weight loss, xxv–xxvi, 23, 56
screening (Guthrie cards), 52
separation from mothers, xxv–xxvi,
49, 58, 60
time of starting breastfeeding, 21–2,
24, 58–9
NICE see National Institute for Health
and Clinical Excellence
Nigeria, 47–8
Nightingale wards, 22, 58–9, 64
Ninewells Hospital, Dundee, 23, 59
nipple pain, 40, 60
136
The Resurgence of Breastfeeding, 1975–2000 – Index
Norway, 24, 62, 63, 83
nurseries, newborn babies, xxv–xxvi,
49, 64
nursing staff, 55
Nutricia Ltd, 70, 71
nutrition, maternal, 11–12
nutritionists, 6–7, 69–71, 80
obesity, bottle-fed babies, 37, 70, 79
obstetricians, 7, 56, 57, 58
Office for National Statistics (ONS),
UK, 68
Office of Population Censuses and
Surveys (OPCS), UK, 9–10, 68
ONS see Office for National Statistics
OPCS see Office of Population
Censuses and Surveys
Oppé Report (Present-Day Practice in
Infant Feeding, 1974), 10, 11,
69–70, 128–9
Oxford, 49, 61, 75
oxytocin, 30, 41
paediatricians, 6–7, 48–9, 50, 55–6,
60, 71
see also neonatologists
PAG see Protein–Calorie Advisory
Group
Pakistan, 21
Papua New Guinea, 80
pathologization of breastfeeding, 73
Pediatrics, 21, 75–6
Peyer’s patches, 13
phenylketonuria, 52, 53–4, 129
phosphate content, infant formula, 54,
55–6, 70
physiology, lactational, 29–32, 34,
38–41, 67
Pontificial Academy of Sciences, Italy,
20, 33
positioning, breastfeeding mothers,
60, 61
premature babies, 55
Present-Day Practice in Infant
Feeding (Oppé et al. 1974)
see Oppé Report
prolactin, 30
promotion see marketing
Protein–Calorie Advisory Group
(PAG), United Nations, 24–5
public, breastfeeding in, 81, 83, 84
Queensland, Australia, 35–6
randomized controlled trials, 52, 82
recommended dietary allowances
(RDA), 15, 20
reference nutrient intakes, 20
reproductive biology unit, MRC,
Edinburgh, 29–32, 37, 41, 60,
77, 127
respiratory infections, 74, 75
rickets, xxv
Roman Catholic Church, 20, 32–3
Rotersept spray, 60
Royal College of Midwives, 79–80
practical guide see Successful
Breastfeeding
Royal Society, 20
Scotland, 4, 49, 51, 52, 57–8, 78
secretory IgA, 13, 14, 129
sexuality, postnatal, 77
Simpson Memorial Maternity Pavilion,
Edinburgh, 7, 9, 20–1, 53–4, 60
SMA, xxv
social class differences, 37, 49, 61, 83
social context, 65
societal influences, 4, 81–2, 83–4
sodium content, infant formulae,
56, 70
Soviet Union, former, 66
St Bartholomew’s Hospital, London
(Bart’s), 30
The Resurgence of Breastfeeding, 1975–2000 – Index
137
stress, 41, 73
Successful Breastfeeding (Royal College
of Midwives, 1988), 49, 50,
51, 61
Sunderland District General Hospital,
68–9
supplementary feeding
hospital practice, xxvi, 58, 62
resumption of fertility, 32, 34–5
support for breastfeeding, 43, 58–62
need for, 20–1, 45
role of midwives, 49, 58–9,
60–2, 80
support groups, 76–80, 81–4, 91
Sweden, 66, 68
Symons collection, Royal College of
Physicians, 69
Syntocinon (synthetic oxytocin), 30
Ten Steps to Successful Breastfeeding
(WHO /UNICEF, 1989), 26,
45, 63
thumb sucking, 28
traditional infant feeding practices,
21–2, 24, 28
UCL see University College London
UNICEF, 25–6, 43–5, 51–2
Baby-friendly Hospital Initiative see
Baby-friendly Hospital Initiative
Baby Friendly Initiative UK see Baby
Friendly Initiative
distribution of breast-milk
substitutes, 27, 80
European guidelines, 66
GOBI strategy, 44–5, 46
see also Baby-friendly Hospital
Initiative; Baby Friendly Initiative
United Nations (UN), Protein–Calorie
Advisory Group, 24–5
United Nations Children’s Fund see
UNICEF
United Nations Children’s
Emergency Fund (now United
Nations Children’s Fund)
see UNICEF
University College London (UCL),
75, 85
vitamin D deficiency, 54
voluntary organizations
see support groups
Wales, 4, 9, 49, 51
water intake, 56
weaning, 11, 14, 15, 76
Weaning and the Weaning Diet (DoH
1994), 76
weight loss, newborn babies, xxv–xxvi,
23, 56
Wellcome Trust, 3, 85
West Africa, 47–8
Western General Hospital,
Edinburgh, 20–1
whey protein, 54
WHO see World Health Organization
The Womanly Art of Breastfeeding
(La Leche League), 37–8
women
accounts of breastfeeding, 21
attitudes to breastfeeding, xxiv, 57–8
lack of confidence, 20–1, 27
as the problem, 26
see also mothers
work, mothers returning to, 18, 20
World Bank, 11
World Health Organization (WHO)
Baby-friendly Hospital Initiative see
Baby-friendly Hospital Initiative
breastfeeding initiatives/policies,
24–6, 35, 43–6, 47, 48
code on breast-milk substitutes see
International Code of Marketing of
Breast-milk Substitutes
138
The Resurgence of Breastfeeding, 1975–2000 – Index
energy requirements of infants,
guidelines, 8
European infant feeding guidelines,
66
fertility control, 32, 35, 43, 44
growth reference data, 9, 18–19
HIV and infant feeding, policy,14
Zambia, 17, 24
The Resurgence of Breastfeeding, 1975–2000 – Index
139
Abt, A F, 4
Akre, James (Jim), 25–6, 35, 43–4, 48,
71–3, 75, 111
Alder, Elizabeth (Beth), 37, 49, 77–8,
111
Apple, Rima D, xxiii–xxvii, 26, 27,
111–12
Atkinson, Stephanie, 67
Baird, David, 29, 31
Balmer, Sue, 49
Bauchner, Howard, 74–5
Baum, Alison, 84
Baum, John David, 49, 50, 51–2, 84,
112
Blair, Tony, 84
Branca, Francesco, 66
Brown, Gordon, 84
Buchanan, Phyll, 42, 112
Cadogan, W, 24
Campbell, H, 78
Cater, John, 59
Christie, Daphne, 84, 85
Clarke, Petra, 76
Cockburn, Forrester, 50, 52, 53–5, 76,
112–13
Cowie, Alfred T, 40, 113
Cox, John, 35–6
Croxatto, Horatio, 35
Currie, Edwina, 51, 78
Davies, David, 49
Dodds, Rosie, 4, 65–6, 113
Donald, Ian, 55
Dye, Jill, 79, 113–14
Dykes, Fiona, 63–4, 65, 114
Edmond, Karen, 21
English, Hilary, 79–80, 114
Fildes, Valerie, 24, 26, 27
Fisher, Chloe, 21, 23, 26, 37, 45, 49,
51, 60–2, 63, 114–15
Florey, Charles, 74–5
Forsyth, Stewart, 74–5
Gamsu, Harold, 49
Garrison, F H, 4
Glasier, Anna, 34–5, 37, 115
Goldman, Armond, 67
Gopalan, C, 6
Grant, James, 26, 45
Gunther, Mavis, 40, 41–2, 43, 51
Guthrie, Robert, 52
Hamosh, Margit, 67
Hanson, Lars, 12–14, 20, 21, 22, 24,
32–3, 67–8, 115
Hartmann, Peter, 39
Harvey, David, 49
Helsing, Elisabet, 6, 24–5, 27, 43, 45,
47, 57, 62, 83, 115
Hendey, Ron, 54
Hey, Edmund, 15–16, 50, 55–6, 59,
60, 115–16
Howie, Peter, 29–30, 31–2, 33, 34, 35,
36, 37, 57, 74–5, 76, 85, 116
Hytten, Frank, 40
Illingworth, R S, 60, 63
Jelliffe, Derrick (Dick), 6–7, 38, 43,
116
Index: Names
Biographical notes appear in bold
140
The Resurgence of Breastfeeding, 1975–2000 – Index
Jelliffe, E F Patrice (Pat), 6–7, 38, 43,
116–17
John Paul II, Pope, 33
Jones, I G, 78
Kelly, Yvonne, 75
Kippley, Sheila, 36–7
Kitzinger, Sheila, 21
Langmead, Frederick, 23
Latham, Michael, 6
Liebig, Justus, xxiv
Lincoln, Dennis, 41
Linzell, Jim, 39
Lönnerdal, Bo, 67
Mahler, Halfdan, 35
Mayes, Mary, 87
McNatty, Ken, 30
McNeilly, Alan, 29, 30–2, 33–4, 35,
37, 39, 41, 117
Michaelsen, Kim Fleischer, 66, 67,
117
Minchin, Maureen, 41
Munro, Dame Alison, 54–5
O’Leary, Rachel, 37–8, 68, 79, 117
Oppé, Thomas Ernest (Tom), 15, 76,
118
Palmer, Gabrielle, 26–7, 43, 80–1, 118
Peaker, Malcolm, 38–9, 40, 41, 118
Prentice, Ann, 8, 11–12, 17, 18–20,
33, 35, 38–9, 67, 118-19
Pritchard, Eric, 26
Quigley, Maria, 75
Ransjö-Arvidson, Anna-Berit, 68–9
Renfrew, Mary, 20–1, 29, 33, 34, 35,
40–1, 59–60, 81–4, 119
Rich, Janet, 28
Rickett, Cynthia, 68
Robertson, Aileen, 66
Rotch, Thomas Morgan, xxiv
Rundall, Patti, 14, 16–17, 19, 25,
46–7, 48, 55, 119
Sacker, Amanda, 75
Salariya, Ellena, 22–3, 49, 57–9, 60,
63, 119
Savage, Felicity, 17–18, 24, 44–5, 46,
63, 120
Savage, Wendy, 42
Shorr, Irwin, 6
Short, Roger, 27–8, 29–30, 31, 35–6,
53, 81, 84, 120
Smale, Mary, 69, 73, 120
Smith, Robert, 51–2
Spiro, Alison, 65, 120
Stanway, Penny, 76–7, 79, 81, 120–21
Stone, D G, 60
Stoppard, Miriam, 23, 80–1
Tanner, Jim, 15
Tansey, E M (Tilli), 3, 34
Truby King, Sir Frederic, 22
Waller, Harold, 40
Warren, Jenny, 41–2, 49, 78, 84, 121
Waterlow, John C, 33
Weaver, Lawrence, 3–7, 9, 10, 12, 13,
14, 15, 16, 17, 21, 22, 23, 24,
27, 29, 30, 31, 32, 33, 35, 40,
42, 43, 44, 45, 46, 47, 48, 53,
55, 56, 59, 61, 62, 64, 66, 67,
69, 71, 74, 75, 76, 78, 79, 81,
84, 85, 90–1, 121
Wells, John, 69–71, 121
West, Christine, 30–1, 41
Wharton, Brian, 9–10, 11, 49, 64–5,
121–2
The Resurgence of Breastfeeding, 1975–2000 – Index
141
Whitehead, Roger, 7–9, 10, 11, 14,
15, 16, 17, 19, 37, 122
Williams, Anthony (Tony), 48–53, 56,
79, 122
Williams, Carol, 78–9, 80, 122
Williams, Cicely, 47, 123
Wolf, Jacqueline, 73
Woolridge, Michael, 36–7, 45, 51, 52,
56–7, 68–9, 73, 81, 123
Key to cover photographs
Front cover, top to bottom
Professor Lawrence Weaver (chair)
Dr Elisabet Helsing
Dr Felicity Savage
Miss Chloe Fisher
Back cover, top to bottom
Professor Lars Hanson, Professor Brian Wharton
Ms Ellena M Salariya, Mrs Rachel O’Leary,
Mr John Wells, Professor Roger Whitehead
Professor Anna Glasier, Professor Elizabeth Alder,
Professor Roger Short
Professor Peter Howie, Professor Mary Renfrew,
Professor Alan McNeilly
