In the exhilarating and often hazy moments after giving birth, many women find that suckling a newborn is more complicated than those Madonna and Child paintings would imply. Most new mothers and their babies need a little help with the basics of breastfeeding.
It's a service Marla Newmark is happy to provide. As director of the lactation center at Greater Baltimore Medical Center -- the hospital with highest delivery rate in the Baltimore area -- and as a mother who has breastfed her 11 living children, Mrs. Newmark brings lots of knowledge to the subject. She and another lactation consultant are available to help roughly 4,500 new mothers and babies with breastfeeding each year and to take their calls after they leave the hospital.
Almost three-quarters of the new mothers at GBMC show an interest in learning how to breastfeed while they are in the hospital, Mrs. Newmark says.
"Breastfeeding can be a lot of hard work at the beginning. Most babies have to be taught how to nurse -- and mothers too. Breastfeeding is a commitment, but so is having a child."
The American Academy of Pediatrics, which has advocated breastfeeding since the organization was founded in 1930, recommended specifically last year that babies be breastfed for the first six to 12 months of their lives. (The organization says iron-fortified formula is the only acceptable alternative.)
Breastfeeding trends in the United States have changed dramatically during the past 40 years: In 1955, 22 percent of new mothers breastfed their babie; 1979 saw a high of 60 percent of new mothers breastfeeding in the hospital.
During the 1980s, however, breastfeeding declined. In 1989, about 52 percent of new mothers learned how to breastfeed, according to studies by Ross Laboratories, makers of infant formula.
Lactation consultants have recently seen another rise in breastfeeding, which they attribute, in part, to the appearance of certified breastfeeding specialists offering new mothers information and instruction at hospitals.
Mostly female, many lactation consultants have worked as nurses; most have breastfed their own babies. Since 1985, the field has offered specialty certification in preventing, identifying and solving breastfeeding problems. To qualify for the examination, lactation consultants usually have either a bachelor's degree and 2,500 hours of clinical experience with nursing mothers and babies, or a two-year degree and 4,000 hours of experience.
During the past few years, lactation education programs have started at Johns Hopkins, University, Union Memorial, Franklin Square, Francis Scott Key, Mercy and Maryland General hospitals.
When Bernadine Geary started working with new mothers at University Hospital a little more than a year ago, less than 10 percent of the women showed interest in breastfeeding. Now 25 percent of the women with normal deliveries learn how to breastfeed. Ms. Geary attributes the increase directly to mother education.
At Johns Hopkins Hospital, more teen-age mothers and economically disadvantaged women have begun nursing, says lactation specialist Judy Vogelhut.
"I couldn't tell you how long they'll continue, I'm just delighted that they try. Any of the milk those babies get and any of that intense bonding is better than none at all.
"My definition of breastfeeding is: however much milk you provided for your baby for however long. It could be a week for one mother and a month for another and a year for a third, but all those babies were breastfed. I think to consider any length of time as an indicator is wrong because any breastfeeding is good for the child."
Specialists say part of women's reluctance to try breastfeeding comes from certain misconceptions. They say:
Breastfeeding does not hurt if the baby is correctly positioned.
Breastfeeding will not make breasts sag; pregnancy is responsible for any changes.
Breastfeeding will give the baby enough nourishment, "even though the breast doesn't come with ounce marks" says Ms. Vogelhut.
The biggest barrier to breastfeeding, however, is the lack of cultural support. Not only have many workplaces been slow to acknowledge the need for breastfeeding mothers to pump milk at work, but many people consider public breastfeeding to be indecent exposure: Florida recently became the first state to guarantee a woman's right to breastfeed her child in public.
"There has been a lot of harassment of breastfeeding women," says childbirth educator Carl Jones, author of "Breastfeeding Your Baby: A Guide for the Contemporary Family." "Public facilities have discouraged women from breastfeeding. To me, that's harassment to expect a woman to feed her infant in the place where other people defecate and urinate."
Marla Newmark recalls the time she was standing behind a new mother in an endless line at the supermarket checkout counter. When the infant began to whimper, the woman unobtrusively put her baby to her breast and it suckled contentedly.
Later as the cashier was bagging Mrs. Newmark's groceries, he remarked how impressed he had been by the quiet infant who had to endure such a long wait.
When Mrs. Newmark pointed out that the woman had been breastfeeding her baby, the man's jaw dropped in horror.
"That's absolutely disgusting," he said.
"And this is somehow better?" Mrs. Newmark asked, pointing to a Cosmopolitan magazine next to the register that sported a scantily clad cover girl.
"We're part of a bottle-feeding culture where almost all of the baby dolls come with a bottle," says Barbara Heiser, a private lactation consultant and owner of the Lactation Center and Breastfeeding Education Association in Ellicott City.
"It's OK for a cocktail waitress to come out without a top, but a woman can't discreetly nurse in public without being asked to go the bathroom."
As an official with La Leche League, an international breastfeeding advocacy group, Ms. Heiser says she has received complaints from women asked to leave Baltimore banks, restaurants and tourist attractions when they began to breastfeed.
"It makes moms feel that they have to be closet nursers, that if they're going to nurse they have to stay at home," she says.
Some of the cultural misunderstanding about the importance of breastfeeding has also spilled over into custody battles, says Ms. Heiser, who often serves as a witness for nursing mothers.
"There was one case that charged the mother with sexual abuse for nursing a 16-month-old," she says. "I've gone into court to say there is nothing unusual about a mother nursing an 18-month-old. . . . There is nothing unusual with breastfeeding older children -- I believe the global average for nursing infants is 4.3 years. We've made it that way."
She says some custody cases try to require mothers to wean babies -- even newborns -- prematurely so that fathers can have equal visitation rights. She points out that it is against the law in many states, including Maryland, to take a puppy from its mother before it is eight weeks old, while there are no corresponding laws protecting human babies.
"We constantly hear in this culture that breast and bottle are equal. That is not true," she says.
"Breast milk is a living fluid, with living cells in it, that you can't substitute."
Breast milk best, doctors say
Breastfeeding advocates underline the psychological benefits of breastfeeding as uniting mother and child in a symbiotic relationship. There are immediate physical benefits as well:
For human babies, human milk is simply the best possible food. According to "Caring for Your Baby and Young Child: Birth to Age 5," a book by the American Academy of Pediatrics, the major ingredients of breast milk are sugar, easily digestible protein and fat -- all balanced to suit the baby. In addition, minerals, vitamins and enzymes may aid the digestive process. (Although formulas can approximate the combination of nutrients, they cannot provide enzymes, antibodies and other valuable ingredients.)
"Babies that are breastfed are less susceptible to various infections -- gastroenteritis is probably the first one -- many of the stomach viruses and also possibly respiratory illnesses and ear infections," says pediatrician John Boscia, assistant chairman of thedepartment of pediatrics at Greater Baltimore Medical Center. "They have a decreased incidence of food allergies as well.
Other pluses are the skin-to-skin contact, which is soothing to the baby, and the feeding activity, which offers an opportunity for closeness between mother and child. Also, some studies suggest that breastfeeding can decrease the chance of infantile obesity and perhaps increase IQs.
There are also physical benefits to the mother, according to obstetrician Frank Witter, co-director of the Breastfeeding Center at Johns Hopkins Hospital:
* The uterus returns to its pre-pregnancy shape more quickly, reducing postpartum bleeding.
* Because breastfeeding requires an average of 500 extra calories a day, mothers return to their pre-pregnant weights more quickly.
* Positive feelings from nurturing an infant increase a new mother's self-confidence.