Physician-Attended Births

The year 1900 was the first year in U.S. history in which the number of physician-attended births surpassed that of midwife-attended births.¹ In less than half a century, the changes wrought through this shift helped to create a new standard in the experiences and expectations of American women in childbirth. By the 1940s, physician-attended childbirth in the hospital had become the standard of care for over half the infants born to mothers in the United States. This marked an important departure from earlier cultural patterns and experiences in America when most women had given birth and breastfed their children at home. Attended by an informally trained midwife, surrounded by the support and experiential knowledge of their female family and friends, women participated in what historians have called “social childbirth” until changes in American medicine and motherhood took hold at the end of the 19th century.²

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Figure 1. Pioneer birth scene, 1887.

Courtesy National Library of Medicine Digital Collections, 101434275.

These included the expansion and normalization of physician-attended births, the rising importance of professional medical expertise and technologies alongside the diminishing role of traditional forms of female knowledge, and the movement of childbirth from the home to the hospital.

The rise of the American medical profession in general, and the medical specialties of gynecology and obstetrics at the end of the 19th century meant that more and more doctors sought entry into the birthing room than ever before. Women themselves were instrumental in bringing about this change. Childbirth had always posed risks to women’s lives, and even when it went well it typically involved excruciating pain and could result in lasting injuries to the mother. Childbirth-related death was such a common experience of pre-20th-century life in the United States that women often approached pregnancy and childbirth with extreme and realistic fear. Their legitimate concerns about the pain and potentially deadly outcomes from childbirth drove women to seek out the care and toolkits of trained physicians, who offered pain relief in the form of opiates, chloroform, and ether, and could be relied upon to assist in difficult births with forceps and even surgical procedures if necessary.

From Home Births to Hospital Births

Despite their sought-after ability to dispense pain-relief drugs and use forceps, early obstetricians did little to alleviate the dangers of childbirth. While the drugs they offered could temporarily ease women’s labor pains, they also worked to prolong labor by slowing down its progress, and they could have negative effects on the child. The over-eager and improper use of forceps by young and poorly trained physicians, too, could often result in birth injuries and the spread of deadly infections. Despite these problems, physicians continued to gain footing in the birthing room over the first decade of the 20th century as the cultural authority of modern medicine and scientific expertise offered mothers a sense of certainty alongside access to the latest in healthcare technologies.³ The rise of modern hospitals accelerated this change in this period. Hospitals emerged as convenient and often awe-inspiring modern spaces in which women could access not only the reassurance of an expertly trained physician, but also the increasingly wide array of medical technologies and supports that many believed made childbirth easier and safer.

By the early decades of the 20th century, more and more women found themselves in charge of households without the help of an extended network of female family, friends, or paid help. Moving to the hospital to give birth and to convalesce reflected women’s interest in access to pain relief and the medical expertise of scientifically trained physicians and nurses. However, it also reflected women’s need for a period of separation and relief from the demanding labor of their domestic obligations in the days following childbirth. Between 1910 and 1938, the number of childbirths in hospitals surpassed those that took place at home, despite little improvement in birth outcome or maternal mortality.

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Figure 2. Maternity ward, Lincoln Hospital and Home, New York, 1929.

Courtesy New York Public Library Digital Collections, b11922868.

In fact, maternal death rates climbed during the first two decades of the 20th century and remained high throughout the 1920s, a decade characterized by high rates of hospital births, particularly for women in urban areas.⁴

By the 1930s, medical specialists in obstetrics routinely expressed their dismay over what appeared to be their own role in the high maternal mortality rate. Dr. Joseph B. DeLee of the Chicago Lying-In Hospital, a pioneer in obstetrics, highlighted the deadly impact of infectious puerperal fever (also referred to as childbed fever), which the hospital environment appeared to nurture and help spread. He called for serious reforms in how hospitals managed childbirth, including separating obstetrics wards and severing all human and material communication between the maternity ward and other hospital departments. Although his peers reproached him for recommending such far-reaching changes, critics like DeLee helped spur the development and widespread adoption of standards for prenatal care and hospital care and hygiene that improved conditions for women and babies dramatically. By 1943, hospital births accounted for 72 percent of all births.⁵

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Figure 3. Nursery at Good Samaritan Hospital, West Palm Beach, Florida, 1959.

Courtesy Library of Congress, LC-G613-73495.

Twilight Sleep and the Quest for Painless Childbirth

One of the most controversial medical practices to emerge during this period was the use of a drug called scopolamine, along with some morphine, to induce a state of “twilight sleep.” While earlier classes of pain relievers had alleviated labor pain, doctors often waited to administer them until the most painful part of the process was over, believing (wrongly) that women’s pain was greatest during the moment of birth.⁶ Scopolamine, however, did not inhibit muscle function the way other anesthetics did and therefore proponents argued that it could be administered earlier in the labor process without fear of prolonging the delivery. Instead of numbing the pain of childbirth, scopolamine essentially altered a woman’s consciousness, clouding her lucidity and acting as an amnesiac. In other words women could still experience the pain of labor and childbirth but scopolamine prevented them from remembering it.⁷ While many women applauded the introduction of the twilight sleep, those who witnessed it often found the process disturbing. Women reportedly screamed and yelled out in confusion and pain, thrashed around, and had to be strapped into “crib beds” to prevent them from self-injury during their violent suffering.

The weight of these observations was compounded by medical confusion about the drug’s safety for both the mother and the child. As early as 1906 doctors began to experiment with the scopolamine-morphine cocktail, and many eagerly championed the efficacy and safety of the method.⁸ Others, however, worried about the drug’s ability to cause hemorrhaging, stall labor, and even depress the baby’s breathing.⁹ Despite medical hesitation on the matter, scopolamine use spread after its introduction in the United States in the 1910s, largely because many women wanted it and asked for it.¹⁰ Early feminists identified it as an important women’s issue and formed the National Twilight Sleep Association. They demanded that Twilight Sleep should be made available to women who requested it. Within a few short years, however, the organized movement fell apart after the death of its leader, Mrs. Francis X. Carmody, during childbirth in 1915. While lay enthusiasm for the procedure waned in the absence of the movement’s leader, physicians continued to use scopolamine to erase women’s memories of childbirth well into the 1960s, and even later in some pockets of the country.¹¹

Despite its shortcomings, the twilight sleep’s popularity reflected a growing expectation by women at the time that childbirth ought to be painless, and that it was the job of the physician to make it so. Fear of childbirth pains and faith in medicine to alleviate them helped facilitate the historic shift from home birth to hospitals, and from midwives to physicians. The increased risks brought about by the use of pain-relief drugs during labor and delivery required careful measurement, administration, monitoring, and precautions that were best implemented in the hospital. In addition to hastening the declining role of midwives in American childbirth, this process also helped set apart the specialized knowledge and skill of obstetricians. Because it was widely agreed by advocates of scopolamine, for example, that the use of such a powerful drug had to be overseen by specially trained experts in the field, they argued against a reliance on general practitioners of medicine in the birthing room. By the 1930s, it was widely understood that physicians who attended women in childbirth required specialized training, particularly on methods of pain relief. The idea that childbirth must be both painful and dangerous had, by the mid-20th century, largely faded from the lives and expectations of most American mothers.¹²

In its place a firm belief took hold that childbirth required the specialized facilities and scientific knowledge that only trained physicians and nurses could provide in a hospital. This construction of medicalized childbirth served as a measure of social standing and class mobility, as middle-class white women led the move into the hospital and into the hands of the obstetrician. Seeking out a childbirth under these circumstances increasingly became an important part of Americanization for the groups of immigrants who entered the country in the early 20th century, while midwife-attended births continued to characterize the experiences of black women and many rural women throughout this period. Small state-sponsored efforts to provide better training to midwives who served these populations were scattered and largely served as stop-gap measures while the medical profession expanded in these regions.¹³

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Figure 4. Doctor, using a manikin, demonstrates delivery techniques to midwives, New Jersey State Health Department.

Courtesy National Library of Medicine Digital Collections, 101441628.

The search for pain relief, however, led to a notable shift in the gendered power dynamics of the birthing room. Women had long exerted control over many aspects of their environment during their labors and deliveries when they occurred in their homes and in the company of their family and friends. Even after the physician became a normal presence in the birthing room at home, women maintained a significant advantage in asserting their preferences and their will. Women also pursued their own will when they sought access to twilight sleep and other pain relief measures, but in doing so they ultimately traded much of their power and autonomy over their experience to their doctors in exchange for the gift of amnesia. As birth moved into the hospital, physicians gained more and more power over the childbirth process, and female midwives were vilified as uneducated and dangerous.¹⁴ As a result, much of the history of childbirth in the second half of the 20th century traces the efforts of mothers to wrestle some degree of control back from the medical profession.¹⁵

Traditions of Breastfeeding

As childbirth practices shifted, so too did other processes surrounding maternal health and infant care, including breastfeeding. Long held as the norm in human infant feeding practices, breastfeeding slowly fell out of favor over the course of the late 19th and early 20th centuries, when cow’s milk, scientific formulas, and proprietary infant foods replaced breastfeeding as the “normal” sources of infant nutrition. Between 1890 and 1950 infant feeding practices shifted alongside broad changes in understandings of health and disease; the influence and authority of the medical professions; women’s domestic, economic, and political roles; and patterns of consumption and food production. All of these trends, alongside the rise of hospital births, contributed to a growth in faith and interest in scientific methods of infant feeding. Perhaps most important, this period also witnessed the dwindling faith by mothers and medical experts alike that the modern American woman even could breastfeed.

Throughout early U.S. history, breastfeeding, whether by the mother herself or a wet nurse, was widely understood to be the safest way to feed a baby.

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Figure 5. Gari Melchers, “Maternity” (Detroit Publishing Company, between 1900 and 1920).

Courtesy Library of Congress, LC-D416-604.

In the late 19th century, if a mother could not breastfeed her infant, doctors and well-to-do families did everything they could to procure a wet nurse in her stead. While wet nurses could literally nurse sick and starving infants back to health, tensions stemming from race- and class-based fears of women deemed “course, unruly, and ignorant,” drove physicians and their early-20th-century middle-class clients to seek other alternatives.¹⁶

Despite medical concerns about artificial feeding, which lingered well into the 1930s, most 20th-century mothers balked at hiring a wet nurse. Those who did work with wet nurses often complained to their physicians that they were difficult to manage and criticized them for their appearance and for their differing views toward childcare. Physicians often interceded on behalf of their wealthy clients to help monitor and discipline unruly wet nurses. Over time oversight of the wet nurse expanded as mothers, doctors, and other caregivers sought to distance infants from wet nurses by having the women express their milk so that it could be fed to babies in bottles in the hospital, in orphanages, or at home.¹⁷

Historically, wet nurses were often poor, immigrant, or black women who had to “put out” their own nursing infants to other families, where, deprived of their own mother’s milk, many became ill and died.¹⁸ Their wealthier white employers, in seeking breast milk for their own babies, helped fuel an early turn away from breastfeeding in poor and black communities that would have repercussions arguably through the end of the century. Racial, ethnic, and class prejudices and tensions ultimately played a role in the decline of the wet nurse as an alternative to maternal breastfeeding, as did expanding employment options for working-class women, the diminishing cost and increasing convenience of artificial infant foods, and the growing medicalization of infant feeding in general.¹⁹

The Modern Need for More Infant Feeding Options

By the beginning of the 20th century more and more American women had turned to breast milk substitutes and bottle feeding. Even while many public health reformers and physicians continued to encourage breastfeeding in these years, the agency of mothers themselves helped power the move away from breastfeeding.

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Figure 6. Erik Hans Krause, Nurse the baby. Your protection against trouble: Inform yourself through the Health Bureau publications and consult your doctor (New York: WPA federal art project, between 1936 and 1938).

Courtesy Library of Congress, POS-WPA-NY.K737, no. 6.

The Progressive Era’s focus on urban reform fueled by the application of scientific expertise and the rise of hospitalized childbirth alongside a growing consumer culture all serve as important historical context for this shift away from breastfeeding.

In a complicated web of causation, public health reformers advocated for and established healthier supplies of cow’s milk for urban children. Their success made cow’s milk substitutes for infant feeding far safer for urban mothers than it had been previously. The marketing and sale of patented infant foods directly to consumers without medical oversight also played an important role in women’s shifting interests from breast to bottle in the early 20th century. These products often claimed to produce healthy babies as well as, if not better than, breastmilk. The market for patented infant foods expanded alongside a growing U.S. consumer culture, and physicians and scientists increasingly sought to exert influence and control over infant feeding practices.

At the same time, scientists and physicians worked to regulate and produce infant feeding alternatives that were safer, were healthier, and provided better approximations of breast milk using cutting-edge science in nutrition. As the scientific study of nutrition and diet progressed, physicians came to fear that breast milk might be deficient in what they identified as key nutrients, particularly Vitamin C and D.²⁰ As a result of their imperfect understanding of breast milk and the nutritional requirements of infants, doctors increasingly encouraged breastfeeding mothers to supplement their children’s diets. As more and more mothers had their babies in hospitals, the reach of these ideas about scientific infant feeding expanded. Nurses, too, played an important role in disseminating and teaching information to mothers about how to prepare infant formula safely.

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Figure 7. Infant welfare nurse instructing a mother in the preparation of milk formulas, June 28, 1919.

Courtesy Library of Congress, American National Red Cross Collection, LC-DIG-anrc-02686.

Together, these efforts slowly eroded women’s belief in their bodies’ abilities to provide adequate nourishment for their infants without supplementation. Over time, cultural attitudes about the healthfulness of breastfeeding shifted, and mothers worried about the problem of “insufficient milk” as they grew more and more insecure about being able to produce enough healthy milk to meet all their babies’ needs.²¹

Over the first half of the 20th century it gradually became common for physicians and mothers alike to believe that infant formula was not just a safe alternative but was in many ways superior to breastfeeding. This turn toward the widespread embrace of formula feeding as the normal way to feed a baby had harmful consequences particularly for poor, rural, and minority mothers and their babies. Because formula was a luxury purchase and associated with scientific modernism, buying and using formula became a status symbol. As a result, breastfeeding became viewed by many people as old-fashioned, primitive, and even animal-like. Meanwhile, proponents of formula in this era championed its ease and the degree to which it kept infants full and happy longer (thereby allowing for improved and more manageable sleep schedules). Physicians and mothers alike also enjoyed being able to closely monitor the amount of food infants consumed and to standardize measures of infant growth in the aggregate.

By mid-century, breastfeeding became so uncommon that most mothers who had babies in the 1950s and 1960s would have never seen another mother breastfeeding. The lack of a female network of experience and knowledge around breastfeeding coupled with the medical establishment’s support of infant formula meant that most mothers who attempted to breastfeed during these decades were far more likely to end up bottle-feeding.

Scientific Motherhood and Infant Feeding

At the root of these complicated early-20th-century trends in childbirth and breastfeeding is the emergence of an ideology of scientific motherhood.²² Scientific motherhood was at once a tool of public health reform as well as a worldview. At the end of the 19th century, the scientific understanding of disease coalesced around the field of bacteriology and its promise to find a germ for every illness. As knowledge of bacteria and contagion expanded, Progressive Era reformers identified mothers as the first line of defense in the new era of public health. Mothers received targeted education about home hygiene, health habits, and child rearing from health reformers, public health nurses, women’s magazines, physicians, and the U.S. Children’s Bureau. These new scientific methods for managing one’s home and children helped construct a new kind of motherhood, one that on the one hand was scientifically informed and knowledgeable, but on the other relied upon the expertise and guidance of scientific and medical professionals.²³

The belief in modern science and medicine as tools for personal and social betterment was extremely strong during the first half of the 20th century. Middle- and upper-class white mothers were among the first to adopt this new ideology of motherhood, and they worked and organized to spread their vision of reform to poor, working-class, and minority women. Their expanding faith in science as the source of knowledge about their own bodies and their children’s bodies played a foundational role in the shift to hospital births and away from breastfeeding by the 1950s.

The Rise of Natural Motherhood

Despite the widespread success and entrenchment of scientific motherhood in the early decades of the 20th century, a competing framework for thinking about motherhood began to emerge as early as the 1930s. Rooted in the scientific theories and research of psychologists, psychiatrists, anthropologists, and ethologists, a new ideology of motherhood built on a belief in the authority of nature as a source of knowledge and expertise. The ideology of natural motherhood reflected a set of scientific and cultural beliefs that treated women’s bodies as repositories of instinctual knowledge that could be accessed through natural behaviors like childbirth and breastfeeding. Unlike scientific motherhood, which relied upon people’s faith in the superiority of the knowledge and technologies of scientific experts, natural motherhood embraced the authority of embodied maternal knowledge, particularly over childbirth and infant feeding. It built on accepted scientific research surrounding maternal and infant behavior and instinct at that time, which suggested that technological meddling could irreparably harm the evolutionarily perfected, “natural” connections between mother and child. In the context of childbirth and breastfeeding, the ideology of natural motherhood provided a framework on which women could argue for greater autonomy over their own maternal bodies.²⁴

Natural Childbirth and Breastfeeding

The 1942 book Childbirth without Fear, by British obstetrician Grantly Dick-Read, became an international bestseller and helped promote the idea of childbirth as a natural process that did not require heavy sedation. As women learned more about childbirth, child development, and theories of maternal instinct, they became increasingly uncomfortable with the widespread practices of heavily drugged labors and forceps deliveries that had become normalized in the first half of the century. Women’s interests in alternative options grew in the postwar years. Enthusiasm for breastfeeding, too, gradually expanded in connection to this mid-century move toward natural motherhood practices. By the early 1950s, organizations like the Boston Association for Childbirth Education (BACE) were receiving requests from mothers and other maternal health organizations who wanted information about natural childbirth as well as breastfeeding.

Dick-Read’s work was in many ways a catalyst for a broad cultural response in the United States, as individual women discovered Childbirth Without Fear, experienced transformative labor and deliveries using his methods, and sought to expand women’s access to these options. Inspired by Dick-Read, childbirth education associations began to spring up all around the country, with some of the earliest forming in Boston and the Great Lakes region. In 1960 several of these groups met to form the International Childbirth Education Association (ICEA), creating a network of knowledge and resource exchange on what they called “family centered maternity care” across the United States and Canada. The group sought to join those in “both parent and professional” communities who were interested in “preparation for childbirth, breastfeeding,” and in allowing “fathers in the birth room.”²⁵ By the mid-1960s, the Lamaze birth method, introduced in France in 1951 by Fernand Lamaze, had overtaken the success of Dick-Read’s method and was widely integrated into childbirth education classes and delivery practices. By the 1970s, these early groups and advocates had helped launch a widespread natural birth movement that sought to wrest power over childbirth away from physicians and medical institutions and return it to women themselves.²⁶

In addition to minimizing medical interventions during childbirth, mothers also sought to bring their loved ones into the labor and delivery room with them. Reform efforts to humanize women’s childbirth experiences led to a gradual shift in hospital policies that allowed women’s spouses to accompany them in the labor and delivery rooms. Long banished to the maternity ward waiting rooms, fathers were the first family members to gain entrance into these exclusive spaces. Eventually, however, these policies expanded to include a long list of friends and family members of the mother’s choosing.²⁷

Breastfeeding followed a similar path back to popularity. La Leche League, founded in 1956 by seven mothers living in the Chicago suburbs, was the first group devoted exclusively to providing breastfeeding information and support, but it was not alone.²⁸ BACE and other childbirth education organizations, like ICEA, offered advice for mothers who wished to nurse their infants, and Catholic organizations and physicians worked to integrate the science of breastfeeding into practice. By 1962, La Leche League was just one of a dozen organizations functioning throughout the United States stressing the tenets of natural motherhood in their mothering advice. While breastfeeding rates remained low throughout the 1950s and 1960s, growing numbers of white middle-class mothers began to push for a return to breastfeeding.

Breastfeeding and Feminism

As the percentage of breastfed babies climbed during the 1970s, women struggled with the implications of attempting to live, mother, and breastfeed “naturally” in a modern world. And as mothers continued to seek empowerment and purpose through the pursuit of an identity tied to nature, many women discovered that living a “simpler” “more natural” life was often anything but simple. As the women’s movement expanded in these years, second-wave feminists struggled to fit breastfeeding into their growing call for gender equality. On the one hand, the members of the feminist health organization the Boston Women’s Health Book Collective overwhelmingly chose breastfeeding for themselves. “We did it because we wanted that experience, and also because we were feeling proud of our bodies and glad as women that our bodies can provide nourishment for our children,” they wrote. On the other hand, they acknowledged that breastfeeding also came with drawbacks that not all women would be willing to accept, including giving up a degree of bodily autonomy and the intensity of what they called “total mothering.” Given the trade-offs, the Collective highlighted that for women who might not want the restrictions that came with breastfeeding, bottle-feeding could “diffuse the exclusive power to meet your baby’s needs.”²⁹

Even La Leche League’s committed membership experienced strife and growing pains during this tumultuous decade, as League leaders struggled over the organization’s “Third Concept,” which stated: “The baby has a basic need for his mother’s love and presence which is as intense as his need for food. This need remains even though his mother may be absent for a period of time for needs or reasons of her own.”³⁰ By the 1970s, this concept, which had been radical in the 1950s for its emphasis on mother love as a biological and instinctual need, was seen by growing numbers of feminist-minded women as too conservative. By the end of 1970s, the League erupted into a passionate internal debate over working motherhood. Group leaders at the time were not supposed to work while nursing their infants, an expectation that grew out of the increasingly controversial Third Concept.

By the early 1980s, however, it was becoming increasingly clear that the number of working mothers with young infants would continue to grow. As the cultural and political debate about working mothers versus stay-at-home mothers picked up steam, the dominant feminist position on breastfeeding coalesced around a rhetoric of personal choice that also supported women’s work and access to abortion and birth control. To many at the time breastfeeding seemed to be logistically incompatible with working, and because feminists had fought long and hard for women to have equal access to the workplace, arguing for breastfeeding in any stronger terms would have been counterproductive to feminist aims. On the other hand, breastfeeding itself had an established history of being a radical and empowering act, and so it too fell under the umbrella of feminism in the sense that it allowed women to embrace and celebrate their bodies. By the dawn of the 1980s, women who navigated the world of infant feeding did so within a context of heightened expectations and a far more complex web of meanings and politics than had their foremothers.³¹

Rise of Cesarean Births

Delivery by cesarean section is a surgical procedure by which a viable child is removed from the mother via an incision through the abdominal wall and uterus. Medical reports of this procedure date back to the Renaissance period in Europe, though there is evidence it originated much earlier in Ancient Egypt, India, and Greece. For most of the history of its use, the cesarean section served as a heroic means to save the life of the child when the mother died. Efforts to conduct the surgery on living women were undertaken sporadically and with great trepidation after the 16th century, but it was not until the advances of 19th-century surgeons that the procedure offered much hope of survival for mothers.³²

Despite expanding surgical practices of antisepsis and asepsis, cesarean deliveries remained highly risky procedures with high mortality rates until the turn of the 20th century. Physicians turned to cesarean section only as a last-resort when all other options had been exhausted and the lives of the mother and child were at grave risk. For hundreds of years, physicians had overwhelmingly refrained from using sutures to close the incision in the uterus after removing the child, believing that doing so would be unnecessary and potentially harmful given the organ’s need to contract after birth. Due to this lack of suturing, however, most patients died from hemorrhage and infection. J. Marion Sims’s innovation of silver sutures³³ and improvements in technique by the end of the 19th century, along with clinical observations of successful suturing, eventually led to the standardization of internal stitches, which were championed by German physician Max Sänger in the 1880s. By the early 20th century, cesarean sections had become a viable surgical option that could save the lives of mothers and their babies. The rise of the cesarean section helped usher out what had been a longstanding medical reliance on craniotomy (which required breaking the skull of the fetus, and thus killing it, to extract it from the birth canal) as a means of saving the mother’s life in intractable deliveries.³⁴

In the early 20th century, many obstetricians encountered pelvic deformities in their patients caused by rickets, an exceedingly common disease at the time that stems from vitamin D deficiency. Lack of appropriate levels of vitamin D in childhood lead to improper bone development and skeletal malformations. These in turn could result in obstructed birth passages in mothers later in life. Common pelvic malformations necessitated the use of cesarean section during labor for growing numbers of women at the turn of the 20th century, particularly those living in America’s growing urban centers.³⁵

Throughout the first three decades of the century, the indications for cesarean section remained limited primarily to pelvic deformities, but by the 1950s, obstetrical text books had expanded their cesarean section criteria to include additional scenarios, including “pre-eclampsia,” “breech presentations,” and “first-time mothers older than forty.”³⁶ As medical confidence in the procedure grew and indications for its usage expanded, cesarean sections became more and more common. The introduction of the electronic fetal monitor (EFM) in 1965 contributed to further reliance on the cesarean method. The EFM heightened concern about fetal distress, making cesarean sections more likely, while it also eased concerns surrounding the impact of pain medication (especially epidurals) on the fetus because it allowed physicians to closely monitor its vital signs. The expansion of reliance on the epidural made the medical decision to perform a cesarean easier and more likely because it not only made women’s labors more medically complex, but also helped institutionalize the role of the anesthesiologist in the birthing room.³⁷

By the beginning of the 21st century, the cesarean rate in the United States was at an all-time high of 32 percent. Nearly one-third of all children born in the United States in 2007 were delivered via cesarean section, a 53 percent increase over the previous ten-year period. An even more staggering increase occurred between 1965 and 1987, when the rate of birth by cesarean section increased by 455 percent. Interestingly, during both periods of heightened increase there was a parallel surge in popular interest in natural childbirth practices.³⁸

The Breast Pump

Long before the back-to-the-breast movement began in the 1950s, breastfeeding mothers had sought help from breast pumps. Throughout the first half of the 20th century, however, lay interest in these remained minimal, especially given the growth in the acceptance and safety of formula-feeding. In the 1950s and 1960s, breast pumps were primarily understood as medical devices, sophisticated technologies that were to be implemented under the care and direction of a physician. Physicians employed breast pumps in cases of orphaned, premature, or sick babies, or when a mother required hospitalization and thus separation from her newborn. Over time, however, mothers discovered the benefits that having a breast pump could bestow on their breastfeeding efforts. These included storing up extra supplies of mother’s milk for times when mothers and babies had to be separated, or when they were having oversupply or undersupply issues, or cracked and injured nipples or abscesses, which made nursing painful. As the breastfeeding movement expanded, interest in direct-to-consumer pumps grew, and by the end of the 1970s, all sorts of manual, hand-operated models of breast pumps could be purchased at drug stores. The real turn in breast pump usage, however, did not occur until the 1990s, when the now ubiquitous electrical and personal home-use pump came on the market. With the expansion of breast pump technology, the device’s uses grew well beyond those of a standard medical technology.

The rise of the breast pump has not been without consequence. As breast pumping became more and more common at the end of the 20th century, it raised questions about equality for women in the workplace and in the home. Working mothers found that their efforts to maintain breastfeeding alongside careers were often thwarted by workplaces that did not support their need to pump frequently and in privacy, or their need for places to store their milk. Many also found using the pumps unpleasant, time-consuming, and labor-intensive. The experience of pumping for many also lacked the emotional rewards that came from nursing a baby at their breast. At the same time, breast pumping allowed breastfeeding mothers to share the duties of feeding and caring for infants with partners and other caregivers, thus allowing them more freedom and control over their schedules and lives. Despite its complicated place in mothers’ lives, feeding babies pumped breast milk from a bottle became almost synonymous with breastfeeding itself by the 2010s.³⁹

Breastfeeding and Public Health

In 2011 nearly 80 percent of mothers of newborns set out with the intention of breastfeeding, but by six months exclusive breastfeeding rates dropped to under 19 percent.⁴⁰ Despite this drop-off in long-term breastfeeding, getting to these numbers is often seen as evidence of the success of large-scale public health efforts since the 1980s. Although public health interest in breastfeeding has its roots in the late 19th and early 20th century, this interest waned alongside the rise in formula feeding by mid-century and did not re-emerge in earnest until the 1980s.

Pediatricians as a professional group and the American public health apparatus in general did not begin actively mobilizing around breastfeeding as a public health concern until the 1980s. In 1981, the World Health Organization (WHO) issued its Code of Marketing of Breast-Milk Substitutes, an effort to rein in unethical practices in the formula industry’s marketing and sale of its products in poor and developing nations. After the publication of the WHO report, the American Academy of Pediatrics established its Task Force on the Promotion of Breastfeeding. In 1982 the Task Force issued a series of recommendations aimed at increasing breastfeeding rates, including improving pediatric training on breastfeeding, changing the hospital environment to be more breastfeeding-friendly, improving patient education, and identifying ways to improve mothers’ support systems once they left the hospital.

Throughout the 1980s, efforts to increase breastfeeding rates grew, particularly through the expanding role of the Supplementary Food Program for Women, Infants, and Children (WIC) in promoting and supporting breastfeeding among low-income mothers. In 1990, the public health push to increase breastfeeding rates again expanded after the WHO and the United Nations Children’s Fund (UNICEF) met to produce the Innocenti Declaration. The Innocenti Declaration stated that mothers everywhere should exclusively breastfeed for the first four to six months, and that breastfeeding should continue as a complementary food source for children up to two years of age or more. Following the Innocenti Declaration, the U.S. Department of Health and Human Services began including breastfeeding among its national Healthy People objectives, and the WHO and UNICEF launched the Baby Friendly Hospital Initiative (BFHI) in 1991. The BFHI laid out criteria and an external review system through which maternity centers and hospitals could claim the “Baby-Friendly” designation if they adequately supported breastfeeding and mother-baby bonding. In the United States the initiative appears to have spurred a continuing climb in breastfeeding initiation rates, as the number of BFHI-designated hospitals and birth centers reached 392 in 2016, and oversaw over 19 percent of all births.

In addition to increasing the rates of breastfeeding initiation, public health goals since the 1990s have also attempted to increase the duration of breastfeeding. In 1997, the American Academy of Pediatrics (AAP) updated its recommendations on breastfeeding, bringing them more in line with those outlined in the Innocenti Declaration. Its 1997 report recommended that mothers breastfeed exclusively for six months, and thereafter up to a year or more in conjunction with other appropriate foods. In 2012, the AAP reaffirmed its 1997 statement.