This is the third installment of the series from the University of Cape Town’s First Thousand Day Research Group. My research traces out the pathways of donated milk from donor to recipient in a state neonatal unit in South Africa (Waltz 2015), to show how care and technologies are interwoven in complex and sometimes surprising ways.
Breastfeeding is widely seen as the best infant feeding option for mother and baby. The dominant discourse in both the public and the medical realm presents breastfeeding as a natural behaviour, best for babies, best for mums. In a recent series, The Lancet claims that increasing breastfeeding worldwide could prevent over 800,000 child deaths every year (Victora et al. 2016). This position is reflected in state policy and official declarations of the World Health Organisation (WHO) and UNICEF. In South Africa, after a decade of promoting the use of formula milk to offset possible vertical (mother to child) HIV transmission, the state re-committed to facilitating breastfeeding in the Tshwane declaration of August 2011 (see also Doherty et al. 2010 for the revised WHO guidelines on breastfeeding). Breast milk is even more important in the case of premature or low birth weight babies, who are highly susceptible to necrotising enterocolitis, (a serious gastrointestinal condition) if fed on formula milk (Neu and Walker 2011). Here, breast milk is critical in securing life; ‘breast is best’ (Murphy 1999). Where the birth mother’s breast milk is not available, donated breast milk is the best alternative.
My research on the milk’s trajectories was wide-ranging. I interviewed donor mothers; members of milk banks associated with the collection, testing, packaging and distribution of donated milk; hospital staff responsible for its prescription and distribution; and mothers whose infants were receiving donated milk. I examined public documentation and social media representations of milk donation; explored national policy and its gaps; and considered issues relating to the import and distribution of bodily fluids. For this discussion, I concentrate on the intersections of technologies and care in the hospital.
Let me begin with a small example:
One Tuesday in April 2015 I watched as a five-week old baby was fed donor milk via a tube from his nose into his stomach. The tube was connected to a machine that slowly pushed donated breast milk from a syringe. The “feed change”, in which the empty syringe was replaced with a new one, took less than a minute and the baby seemed not to notice any possible interruption in his supply. The nurse who did the changing called over another nurse to sign off on the change; the dispensation of each syringe of donor milk required two signatures on information about the amount, donor number, date and time. The first nurse told the second, “I’ve done all the milks” and they left the infant, still intubated and ‘eating’. I checked the baby’s file, and saw his father had been contacted by the hospital a week before to see whether the infant’s mother could come to donate milk. The father had apparently said the mother would visit more often but she had not come at all in the intervening period.
Donated human milk has two values. As human milk, it is nutrient-rich. As donated milk, it is scarce. In South Africa, demand outstrips supply, so that careful and often difficult decisions must be made about who may receive milk. This vignette opens several important aspects of the process through which ‘deserving’ neonates receive milk. First, it is a highly regulated, carefully documented and properly traceable process, in which milk, donated mainly by off-premises, well-off women, is prescribed to neonates in a state hospital. While the breastfeeding relationship between mother and baby is often idealised as close, intimate, and private, the contrast between a mother breastfeeding and a nurse changing a syringe in a machine next to an incubator is remarkable. For breastfeeding mothers, the quantity of milk ingested often remains a mystery (see Avishai 2007; Lupton 2000; Schmied and Lupton 2001; Waltz 2013). By contrast, in the high-tech environment of a neonatal ICU (NICU), feeding is characterised by precise measurement, a calibrated, machine-driven intervention in which premature babies who were often unable to suck and feed were literally kept alive by the tubes and machines dispensing milk to them. That donor milk was considered beneficial even in such an abstracted form is indicative of its extraordinary life-giving properties (Bai et al. 2009; Hinde and German 2012; Victora et al. 2016).
In the NICU, technologies and care sometimes seem mutually exclusive, like when breastfeeding is replaced by a feeding machine. Yet the donor milk draws in new constellations of care in which technologies feature in various ways. The administration of donor milk is routine and mechanic, yet an element of care is transposed. Different registers of care are employed in NICUs: there is care as technology – routine and medicalised in the form of prescription – but forms of domestic care feature as well. This opens up questions of care: care for whom? What gets overridden in care?
Medical professionals moved in and out of relations or terms with regard to the babies in the neonatal unit. While their relationships with neonates were ostensibly formal, objective and distanced, as demanded by medical protocols, I saw also a more personal engagement between practitioners and neonates. This was primarily reflected in how people described the babies; many doctors and nurses routinely referred to their infant patients as ‘my babies’. Despite their shows of affection for neonates, and their concern, there were nevertheless limits to what hospital staff could do. For example, on my first day in the neonatal unit I noticed that a baby had not stopped crying since being fed from a cup. One of the nursing sisters on duty heard the calls and thought he was still hungry, but knew that he would have to wait two hours until his next feed, because she could not overrule the prescribed routine of feeds and quantities; that is, feeding could not be particularised to this baby’s needs at this time. The need to carefully balance feeds for premature at-risk babies makes routines critical. As I have argued, in effect prescription stabilised a particular form of care – biomedical care rather than affective care – despite the obvious concern that staff showed for the infants in their care. Thus, while prescription offered an intervention and had a positive event horizon, it at the same time posed a limit to care.
Sometimes these decisions are based on the needs of the infant. At other times, infant needs have to be weighed up in relation to those of others in a context of scarcity. I witnessed staff making a decision to discontinue donor milk provision for one neonate. The infant’s mother was still resident in the hospital’s labour ward after a difficult labour, but she was too sick or exhausted to breastfeed. Nevertheless, other babies were present in the ward whose needs had to be met. One of the medical staff, Sister Williams, found herself in a difficult position because there was no milk from the mother, but without a prescription she also could not give either formula or donor milk. She asked one of the doctors what she should do and was told that the doctors had talked to the mother, who had requested that the hospital give formula, but the doctors told her, ‘that’s not good for the baby’. The nurse felt trapped between the doctor’s prescriptions and the patient’s wishes. The mother had not expressed breast milk and the baby needed feeding. A doctor told Sister Williams that the mother had to express and the nurse conceded, and went to help the woman hand-express milk for the infant, a task she undertook three or four times a day for the whole weekend.
Medical practitioners’ care and affect were not accounted for in the protocols that are observed in the neonatal unit, but they were crucial for its everyday functioning. Expressed through a language of appropriation, medical practitioners cared for patients in ways that blurred what should be expected of them. Often this was necessary to resolve tensions between the protocol and patients’ ability or wish to comply – informed compliance (Schwennesen et al. 2010) became a process of aligning patients’ behaviours with medical practitioners’ ideas of ‘what’s best’ grounded in scientific recommendations and a model of scarcity pertaining to breast milk. Economic calculations around production of milk and ‘effort’ put into it were implicated in who ‘deserved’ donor milk and who did not. For some women working in the neonatal unit in different capacities, caring for patients and their understanding of care was tied to notions of motherhood, and ideas around a model of what constitutes a ‘good mother’ found their way into the decision-making process around donor milk prescription.
Medicine tries to stay objective, stabilising objects as objects, and stabilising care as an object that is taught and follows a routine. Babies are not named or fed on demand, but are numbered and fed by prescription (Waltz 2015). The practical dimensions of ‘care’, – changing nappies, rearranging babies, making sure they are comfortable, changing their bedding, falls under the rubric of ‘observations’, drawing everyday domestic practices into medicalised language. Yet, many of these everyday clinical practices nonetheless had a semblance of domesticity and intimacy. As both doctors and nurses explained, in spite of the limits of the hospital context, it was ‘as a mother’ that they cared.
[All names are pseudonyms.]
Miriam Waltz works as a research assistant at the Sustainable Livelihoods Foundation in Cape Town, South Africa. She completed her Masters degree in Social Anthropology at the University of Cape Town in December 2015. This work draws on her thesis, titled ‘Milk, Meaning and Morality: Tracing Donated Breast Milk from Donor to Baby and in between.’
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Bai, Y.K. et al. 2009. Psychosocial factors underlying the mother’s decision to continue exclusive breastfeeding for 6 months: an elicitation study. Journal of Human Nutrition and Dietetics, 22(2), pp.134–140.
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Victora, C., Bahl, R., Barros, A., França, G., Horton, S., Krasevec, J., Murch, S., Jeeva Sankar, M., Walker, N. and Rollins, N. 2016. Breastfeeding in the 21st Century: Epidemiology, mechanisms, and lifelong effect. The Lancet. 387(10017): 475-490.
Waltz, M. 2013. ‘Making a Person’: Experiences of Breastfeeding among Middle class women in Cape Town, South Africa. Unpublished Honours Thesis. University of Cape Town: Cape Town.
Waltz, M. 2015. Milk, Meaning and Morality: Tracing Donated Breast Milk from Donor to Baby and in between. Unpublished Masters Thesis. University of Cape Town: Cape Town.
WHO 2011. Guidelines on HIV and infant feeding for child survival in South Africa. Bulletin World Health Organisation 2011 89: 62-67.
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