Notes from the Field: When Breastmilk Isn’t Enough

Veronica and 4 month old Paulo

Today's post is a guest article from anthropologist Veronica Miranda. Veronica's "Notes from the Field" appeared in the most recent Council on Anthropology and Reproduction newsletter, and she has kindly allowed its reproduction here. In this post, she reflects on her time spent in the Yucatan while she was breastfeeding and conducting field research.


When Breastmilk Isn’t Enough

It was a hot and humid late July afternoon when I decided to pay a visit to one of the village midwives. I gathered my already-packed research bag and on the way out I said good-bye to my husband (a.k.a. field assistant and nanny) and kissed our three month old son. It was around three o’clock when I left. The heat was still unbearable as I walked through the rural Yucatec Maya pueblo of Saban, located in the southern interior of the peninsula.

When I arrived to the midwife’s house I was hot, sweaty, and thirsty. I was escorted by the midwife’s daughter to the large newly built thatched roof kitchen located behind the house. Elda, the midwife, was cooking lunch when I got there. She invited me to sit down and eat with her family. We had a simple but delicious lunch.

Elda served a thin soup of boiled Chaya (a dark leafy green high in calcium and folic acid) that was mixed with ground-up pumpkin seeds, sea salt, and a generous squeeze of fresh lemon juice. Her son had picked some avocados from the tree outside and made a big bowl of guacamole. And like all meals in the pueblo, our lunch was accompanied by fresh, handmade corn tortillas. It was one of my favorite meals. I ate two servings and savored every bite.

Elda was happy that I liked her cooking and she said I must always be hungry because I am breastfeeding. She told me she ate often when she breastfed her children many years ago. I asked her if she exclusively breastfed her three children—two girls and a boy. She said yes. In fact her son, the youngest, was the largest of all her babies. He was so big that many people thought he was a year old when he was only six months. We had already had many conversations in the past about the importance of breastfeeding for both baby and mother. Yet at that moment, I had to ask her a question that had been bothering me for some time. I asked, “Elda if I am exclusively breastfeeding my infant son and he is visibly a large and healthy baby, why are so many people in the community telling me I needed to supplement with formula? Why are they saying he needs more than breastmilk”?

Elda took a moment to think about what I had just said and then asked if my son cried a lot. As a young first-time mother away from my own familial support system, I was not really sure the average amount a baby cried. My son did cry often throughout the day and night but I was usually able to sooth him by breastfeeding. From the day he was born I nursed my son on demand—even at eight months he was still adamant about having breastmilk every two to four hours. In the end, I answered Elda’s question by saying “Yes, he does cry a little”. Her teenage son was intrigued by our conversation and asked me if my son had air in his belly? Assuming this was similar to colic I explained that this used to be an issue, but not anymore. Elda suggested that he could have mal de ojo. But she was leaning more to the idea that maybe I was not producing enough milk. She asked if my milk was soft or hard when it leaked through my shirt. I paused for a moment—I had never been asked this question before. Was she referring to my milk flow or the thickness of my milk? I probably will never know since I did not ask her to explain. Not completely understanding the question I said I think it comes out soft.  

She said that was it. My son cried a lot because he was hungry, she explained. My milk was too thin and he was not getting his fill. I asked her what I could do to fix this, and she responded by saying, “Usually if the mother has thin milk, about a month after the baby is born, she is told to drink a lot of agua de Chaya and follow a local remedy of placing boiled orange leaves over the her breast and taking a warm bath with the tea water. The mother must stay inside for three days, especially if it is cloudy outside. This will help increase the milk supply and make it thicker”. Unfortunately, I had missed my chance. My son was almost four months old and my best option now was to supplement with formula.

I thought about this conversation with Elda the rest of the time I was in the field. Just a generation ago, women in the community exclusively breastfed. The older and middle aged women who told me I needed to supplement with formula had exclusively breastfed their own children. Women have always breastfed. Breastfeeding continues to be widely practiced throughout the community. As Elda pointed out, local healers and midwives have used traditional remedies passed down from older generations to help a mother increase her milk supply and sooth a crying baby. But times have changed; today, breastmilk is no longer seen as enough. Many women firmly believe that infants need to be supplemented with formula. The idea that traditional medicine is no longer able to help women produce enough milk to feed their babies is relatively new. Formula, for many women, provides the necessary nutrients infants need to thrive. These beliefs are instilled through the advice of local doctors and nurses, and reinforced by widespread media and public health campaigns. Today the majority of new mothers believed that their infants would be healthier and happier if they had both breastmilk and formula.  

There is a wide array of literature that explains why indigenous and/or poor women choose to use infant formula. Some reasons include 1) the belief in corporate media messages proclaiming the superior health benefits of formula; 2) indigenous women’s internalization of the idea that their bodies are inadequate; 3) a rise in social status with the use of expensive formula; and 4) the adoption of the idea by indigenous and/or poor women that they are better mothers by offering formula to their children. I knew all of this going into my fieldwork. I have read the literature, and studied the political economic histories that have affected and shaped rural women’s choices. Yet, it was not until I personally experienced in the field the issue of supplementing with formula that I had a greater appreciation for the many ways in which women address on a daily basis the health of their children. As a young researcher eager to apply the scholarly knowledge I had gained I chose to focus heavily on the issue of breastmilk verses infant formula. But I was wrong. After many conversations with women in the community I was finally able to listen to them and understand that they did not see the two as a binary. It was until much later that I realized the women suggesting I supplement with formula were trying to help me deal with a situation and address a specific symptom—a crying baby. These rural Yucatec Maya women are bombarded with constant messages by doctors and from the media that their bodies are insufficient at meeting the needs of their unborn and infant children. As with childbirth, these women have not addressed their health and that of their children through an either/or dichotomy. Women are trying to make the most of all the resources they have and mixing practices allows them to ensure the wellbeing of their children. It was shocking to see how strong the outside messages of the inadequacy of women’s bodies had affected their beliefs, yes, but even within that these women are trying to find the best ways to raise healthy and happy children.


Veronica Miranda is a doctoral candidate in medical anthropology at the University of Kentucky. Her dissertation research focuses on how rural Yucatec Maya women, midwives, and state health care workers participate in the production of childbirth practices in relation to federal health policies and programs.

Breastfeeding Problems Linked to Mom's Post-Birth Meds?

"Evidence-based care acknowledges that, sometimes, having no intervention is safest, and, sometimes, having interventions is safest.... Advocating for evidence-based practices and interventions is not an ideology that interventions are bad. It's taking an objective look at scientific research and actually applying it to individuals, rather than basing care on outdated traditions, fear, and the ridiculous idea that women shouldn't be involved in their own health care." - ImprovingBirth.Org

A new study is out that takes a look at the effect of intramuscular injections mothers receive immediately after birth and their effect on breastfeeding. These are injections that occur during the third stage of labor (before or after delivery of the placenta) that are intended to help the uterus begin to contract down to normal size. This helps prevent postpartum hemorrhage.

The International Breastfeeding Journal notes:

Existing RCTs found no links between uterotonics administered in third stage of labour and breastfeeding. These trials were published ten and twenty years ago, and, to our knowledge, more recent trials have not examined the impact of uterotonics on breastfeeding. In the absence of trial data, observation studies and biological mechanisms assume greater importance.

This Brown and Jordan article notes the background information on the literature:

Analysis of a large birth cohort (n=48,366) indicated that intramuscular injection of oxytocin, with or without ergometrine, in the third stage of labor reduced breastfeeding rates at 48 hours by 6-8% (adjusted odds ratio [OR]= 0.75, 95% confidence interval [CI] = 0.61-0.9 1; adjusted OR=0.77, 95% CI=0.65- 0.9 1), consistent with other observational studies. A randomized controlled trial (n = 132) of active management of the third stage with intravenous ergometrine indicated an increase in supplementation and cessation of breastfeeding by 1 and 4 weeks postpartum, mainly because lactation was inadequate for the infants' needs.

The medications this 2014 Brown and Jordan study looked at included oxytocin and ergometrine. The study gave mothers who had a vaginal birth within the past 6 months a questionnaire that asked about whether they received uterotonic injections, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological. 82% of the mothers had received active management of the third stage, and 17% received physiological management.

Here are the study results:

No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty.

What this means is that their study might imply that uterotonic injections during the third stage of labor do not affect breastfeeding initiation, but may affect breastfeeding duration.

As with all research, we can say that this study showed an association between the injections and the cessation of breastfeeding due to physical reasons, but we cannot necessarily say it is causation. It is an important point to keep in mind when reading about research.

There is a great deal of evidence for the benefits of uterotonics for prevention of postpartum hemorrhage. Randomized control trials and metasyntheses of research by organizations such as the World Health Organization and the Cochrane Library have found that administration of oxytocin or other uterotonic are highly effective at reducing postpartum bleeding and prolonged third stage, with no apparent side effects for the baby. Ergometrine is associated with nausea for the mother.

The data for this study was collected by self-report on a questionnaire filled out by the mothers. Of course there are data collection errors, like selection bias and recall bias, involved in this type of study. It is not secondary data analysis (e.g. they did not look at medical charts to determine if an injection was received and then link it to data for the mother showing whether she stopped breastfeeding at a certain point in time). It is not a prospective randomized control trial (the gold standard of research, though not always possible).

Interestingly, they removed mothers who had intravenous oxytocin from their statistical analyses, as they were likely to have been receiving it during labor for induction, and also more likely to have an epidural. However, when they did analyze this small sample, they found that the finding was still significant: women who had the intramuscular injection compared to those receiving it intravenously were less likely to be breastfeeding at 2 and 6 weeks. So what is it about the injection, then?

Also, their psychological questions on reasons for stopping found that mothers who had an active third stage were significantly more likely to say they stopped breastfeeding for reasons of pain and/or embarrassment. Why would receiving uterotonics after labor contribute to difficulty latching or embarrassment? Perhaps they are correlated but not causational.  Or perhaps the medication affects the baby's ability to latch. The authors suppose the two are related: mothers who have trouble latching will be more embarrassed to nurse in front of others. This is all conjecture.

Brown and Jordan note in their discussion section that active management may not reduce postpartum hemorrhage for women at low risk of hemorrhage. This is a good argument for more risk assessment antenatally and upon birth admission. Many obstetric hemorrhage initiatives in the U.S. include this as a recommendation for hospitals. There is always the argument, however, that even low risk women sometimes hemorrhage after birth (there are instances of low risk home birth mothers transferring due to excessive bleeding). In rural or resource-poor settings, it may be beneficial to standardize receipt of prophylactic uterotonics when transfer could be life-threatening.

Furthermore, when care is not standardized, more health care mistakes are made. This is what the field of quality improvement in healthcare has found, and the reason standards of care are emphasized. It also means that everyone is doing the same thing, which reduces the receipt of poor care one place and better care at another. Standardization of care has been shown to reduce life-threatening errors in healthcare. There are times when we have to weigh the pros and cons (e.g. prophylatic uterotonics can reduce morbidity and mortality associated with hemorrhage, but may decrease breastfeeding success and duration). I work with a lot of doctors and nurses in my job in healthcare quality improvement, and I've learned a lot about the capabilities of the providers in our healthcare system. I've seen how changes are made in a system.

As a doula and a social researcher, I am also a strong proponent of patient-centered care. I think that care should also focus on what is right for each individual. Sometimes that means asking the patient what they want, though they may defer to the care provider to make the decision. The care provider may then decide that the pros outweigh the cons.

Another point is that women are more and more high risk for OB hemorrhage in industrialized countries. With the increase in medical conditions, inductions, cesarean sections, pitocin augmentation, use of pain medication and analgesia, advanced maternal age, etc., more women are going to be high risk and therefore more will receive active management of the third stage. So a great intervention would be to recognize that more women need assistance with breastfeeding in the first 2 - 6 weeks so that they can overcome latch issues, embarrassment, perceived low milk supply, and so on.

Moreover, how do we know that the women who have physiologic third stages are somehow different than the women who do not? Since active management is, at the moment, is the norm, and is in the population in this study, the women who "choose" to have no uterotonic injections may already be better informed on breastfeeding, better linked-into breastfeeding help networks, etc.

I did find their explanation of the interaction and possible mechanism behind uterotonics and breastfeeding. The authors speculate:

It is possible that disruption of neuroendocrine/paracrine pathways may lead to suboptimal latching, nipple trauma, pain, and feeding difficulty.

They explain a bit more in the discussion how ergometrine and oxytocin may disrupt hormone balance.

More research is needed on active management of the third stage and its effect on breastfeeding!

I definitely think this article contributes to what a lot of lactation professionals have been noticing, however: Interventions during labor have an effect on breastfeeding success, and we know that epidurals and pitocin augmentation during labor are associated with breastfeeding issues. But does the post-delivery dose have a large enough effect to change practice?

I don't think this particular research article should lead to full-scale changes in recommendations or standards of care at this time. I was inspired to write this article for just that reason - those who may think this is definitive evidence that we should stop promoting prophylactic uterotonics. We do a lot of things prophylactically in our lives. A prophylactic is something that is designed to prevent something from occurring. I think that a lot of birth and breastfeeding advocates are quick to judge all medical interventions as bad, and also to believe research that reinforces their beliefs, and not believe research that does not (well, most people do that). I have taught to be critical of research and to examine it from all sides.

I also think its unfair to blanket statement that all physicians and hospital medical professionals are the only ones to use interventions that may be harmful. Sometimes medical professionals close their eyes to the evidence of harm from routine interventions, but sometimes natural birth advocates (doulas, midwives) do to. 

"Midwives are often quick to criticize medical birth attendants for unwise interventions that disrupt normal birth and may cause harm. But how many of us are guilty of the same thing?" - Gail Hart

Even home birth midwives sometimes use supplements, herbs, etc that have not been tested or approved for effectiveness and safety. Doulas, too, make suggestions for some interventions for pregnant women and babies that we don't know are entirely safe or efficacious. We all have to pay close attention to good, solid evidence, and keep in mind that sometimes things are true even if they contradict what we believe. 

If you're interested in learning more on how to be a critical reviewer of research, I suggest you peruse Science and Sensibility's series of posts on "Understanding Research."


Brown, Amy and Sue Jordan (2014) Breastfeeding Medicine. Vol 9, No 10. DOl: 10.1 089/bfm.2014.0048

Link Round Up to Hold You Over

You would think with graduation behind me I'd have a lot more free time to blog, but the opposite has been true!

I've got 3 part time jobs plus doula work while I apply for full-time jobs. I'm actually quite happy with this situation, as it keeps me on my toes and I can do some of it from home! And it is all related to my future career, so I still feel on-track. Furthermore, I've agreed to some other things, lately, that have been using up my free time - mainly spending time with my fiance, as I promised him I'd use all my free no-homework evenings with him (and wedding planning)! But don't worry, I've got several blog post ideas started in draft form that I plan to get to, eventually.

I missed posting anything for Mother's Day because I was with my mama, but HAPPY MOTHER'S DAY EVERYONE! Also, this past week was National Women's Health Week, and the month of May is International Doula Month.

I've been trying to still keep up with reading, tweeting, and posting on Facebook  though! So if you haven't been able to follow along over there, I'd thought I'd provide you with a link round-up to satisfy your love for all things birthy during my hiatus:

• The big news recently is the Listening to Mothers III survey results! The previous survey reports have been my go-to for so much information on maternity care in the U.S. over the past couple of years, and I am so nerdily excited for these new reports. I sat in on a live teleconference/webcast with Maureen Corry (Childbirth Connections), Eugene Declerq (Epidemiologist), several others who were involved with the survey, and a lot of other maternity care junkies like me :) Childbirth Connection has made the results really accessible - you don't have to read the whole report if you don't want to, they have several briefs and major survey findings documents. I tweeted a lot of the findings during the webcast, so you're welcome to go back to my #LTM3 tweets and skim through those! 
• What does this survey cover, you ask? Things like: maternal satisfaction with care; # who used doulas, midwives, OBs, other providers; # who did childbirth education; breastfeeding care received; disparities by ethnicity or health insurance; what interventions women received; treatment received and attitudes; and more! 

• A recent study in Pediatrics reported that early limited formula supplementation increased exclusive breastfeeding at 3 months. I've spoken about this study with an IBCLC who is a friend of mine and read through a lot of the analyses. This study is a great reminder to always be a critical reader! There are some flaws to this study, and the post from Best for Babes goes through almost all of them, and this post from Breastfeeding Medicine adds some more great points. Mainly, there could have been some errors and bias in the study that need to be understood before everyone jumps to the extreme that many of the news outlets have: How Formula Could Increase Breastfeeding Rates (TIME)

• This story is still going around - Disney made Merida from Brave "sexier" so that she could join the Disney Princess line of merchandise, and everyone flipped out. Several thousands signed a petition that included this great quote: "The redesign of Merida in advance of her official induction to the Disney Princess collection does a tremendous disservice to the millions of children for whom Merida is an empowering role model who speaks to girls' capacity to be change agents in the world rather than just trophies to be admired. Moreover, by making her skinnier, sexier and more mature in appearance, you are sending a message to girls that the original, realistic, teenage-appearing version of Merida is inferior; that for girls and women to have value — to be recognized as true princesses — they must conform to a narrow definition of beauty." 
• Disney said they are pulling back, and everyone rejoiced, and then they indicated that they were still going to sell the merchandise that they already made with sexy Merida on it. Most recent update is here.

• Another big story that went around was an ACOG Study on the adverse effects of Pitocin augmentation on full-term newborns. They found that Pitocin was an independent risk factor for NICU admission and low APGAR scores. 
• (Also, I found out that ACOG has a pretty good source for women's health news - "Today's Headlines)

• If you're into Science and want more Pregnancy and Childbirth news outlets, I read Science Daily's posts on those topics. If you're into social and political updates on Health issues in the U.S., check out Think Progress' health feed. 

• Currently Reading: The Business of Baby: What Doctors Don't Tell You, What Corporations Try to Sell You, and How to Put Your Pregnancy, Childbirth, and Baby Before Their Bottom Line. Stay tuned for a review!

Tongue-Tie in Breastfed Babies

Tongue-tie, or Ankyloglossia, is a condition that occurs in a small percentage of babies (about 4%) that makes it hard for them to breastfeed. It also exists among children and adolescents, but for the purposes of this blog, we will focus on newborns.

The frenulum, or the cord of tissue that connects from underneath your tongue to the bottom of your mouth, is sometimes too short or too tight in newborns (we also have a frenulum between our top lip and our top gums).

As a result of the tight frenulum, baby might not latch correctly, cause pain and nipple trauma for the mother and frustration for everyone. If the baby has trouble sucking, they will have poor weight gain and will be fussy all the time.

photo by Janelle Aby, MD

Symptoms
Anne Smith, IBCLC writes,

In addition to problems with nipple soreness and weight gain, some other signs that the baby may be having problems nursing effectively include breaking suction often during feedings, and making a clicking sound while nursing. Since these symptoms can also be caused by other problems, it’s a good idea to be evaluated by a knowledgeable health care provider (an IBCLC, if possible) to rule out causes other than tongue-tie. Tongue-tie should definitely be considered a possibility if breastfeeding doesn’t improve even after other measures such as adjustments in positioning have been tried.

Additionally, other signs of tongue-tie might include:

• Heart-shaped tongue tip. The tip of the tongue may be heart shaped or have a “v” shape indentation in the center when the baby sticks out the tongue or cries. (It is possible to have a restrictive frenulum without this classic symptom or to have a tongue that functions adequately, yet has the heart shaped tip.) 
• Square or round tongue tip. The tongue looks square, or round, on the tip instead of pointed when extended. Difficulty extending the tongue. If your baby is tongue tied 
• Your baby has difficulty extending the tongue past the gum line. Tapping the tip of the tongue should cause the tongue to come forward, where it should cross the gums. 
• Tongue does not cup well. When your little one sucks on your finger the tongue should wrap around it like a hot dog bun wraps around a hot dog. 
• Difficulty moving tongue from side to side. If you rub your baby’s lower gum, the tongue should follow your finger, side to side. 
• Frenulum is attached very close to the tip of the tongue. Some babies have frenulums attached near the front, but the frenulum is very elastic and allows effective breastfeeding without treatment.

Solutions
Because ankylogossia can cause problems for breastfeeding and cause failure to thrive in the infant, it is a good idea to have it taken care of. Tongue-tie can also cause speech problems for a child in the future.

A really quick out-patient surgery can be performed, where the frenulum is snipped (frenotomy)  and baby can go right back to breastfeeding. There is generally only 1 or 2 drops of blood, and no anesthesia is required.

This procedure has been associated with latch improvement and reduction in maternal pain during breastfeeding. 



Tongue-tie is becoming more and more commonly diagnosed, as lactation consultants and physicians are trained to recognize it, but it is still hard to find someone who can diagnose and treat it. I've known many mothers who have had to search for second and third opinions before someone would finally perform a frenotomy.

Go here for more resources on tongue-tie.


Was your baby tongue-tied? 

Bottled Up! Let's Change the Formula

Check out this new film "Bottled Up! The Film - Let's Change the Formula"

It is a very powerful video.
I think its incredible that such a large part of the population is made up by mothers (indeed, without mothers, we wouldn't be here at all), and yet such an enormous aspect of mothering is not protected or supported by our society.

BOTTLED UP! Sizzle from mire molnar on Vimeo.


In the most successful ad campaign in history, formula companies convinced mothers to trade in their breasts for bottles, and the baby bottle swiftly became the most recognizable symbol of infancy. The phenomenon of the nursing mother has all but disappeared from our cultural landscape as the sexual breast supplanted the mothering breast. The simple act of nursing a baby engenders a plethora of reactions from society, especially when done in public.

Conflicting advice abounds leaving new moms bewildered and wondering if they are doing it “right,” or they simply opt out entirely. Countering nearly a century of medical procedures that separated babies from their mothers and medical advice that informed women that their milk was not good enough, Bottled UP! captures how mothers can access their inner knowledge and trust their own body’s wisdom and why they should. Women’s stories, leading lactation professionals, archival footage, religious iconography, and formula advertisements, tell the story of how mothers relinquished authority to medical professionals, and succumbed to cultural pressure to forfeit their nourishing breasts in favor of a highly sexualized model.

This film shows how women can reclaim their birthright and restore the nursing mother archetype. More than a breastfeeding promotion film, this is a film by, for, and about women. It is about the knowledge that inherently resides in every woman, how to access that knowledge and how to trust what we already know. It is a film that will inspire women to say, “I can do that!” “I want to do that!

Bottled UP! is a documentary exposé about Breastfeeding in America. Our mission is to restore the Phenomenon of the Nursing Mother to the cultural landscape of America.

Reasonable Break Time for Nursing Mothers

Recently I was doing research on the economic and work policy effects on breastfeeding mothers in the U.S. The Patient Protection and Affordable Care Act that was signed by President Barack Obama in March of 2010 included an amendment to the Fair Labor Standards Act (FLSA) with a section on breastfeeding, going back to work, and break time for nursing mothers.

I've heard this law talked about for some time, so I knew what it was about, but I wanted to look deeper into it. My main question was on enforcement. As is so often the case, many breastfeeding laws are made but include no language about how they are enforced. For example, state laws that protect nursing mothers' right to breastfeed in public are on the books, but no one knows who should enforce them.

In my research I found out a few other details about the law that are good know. So, for an in-depth look into this new section of the Act that has to do with mother's expressing milk during work hours, read on!

What the Law Actually Says

SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS

An employer shall provide—
7 ‘‘(A) a reasonable break time for an employee to
8 express breast milk for her nursing child for 1 year
9 after the child’s birth each time such employee has
10 need to express the milk; and
11 ‘‘(B) a place, other than a bathroom, that is
12 shielded from view and free from intrusion from co-
13 workers and the public, which may be used by an em-
14 ployee to express breast milk.
15 ‘‘(2) An employer shall not be required to compensate
16 an employee receiving reasonable break time under para-
17 graph (1) for any work time spent for such purpose.

‘‘(3) An employer that employs less than 50 employees
19 shall not be subject to the requirements of this subsection,
20 if such requirements would impose an undue hardship by
21 causing the employer significant difficulty or expense when
22 considered in relation to the size, financial resources, na-
23 ture, or structure of the employer’s business.
24 ‘‘(4) Nothing in this subsection shall preempt a State
25 law that provides greater protections to employees than the
26 protections provided for under this subsection.’’.

Exploring More In-Depth

The United States Breastfeeding Committee has a great FAQ on Section 4207. I perused it and pulled out some information that I think clears up some things about this law.

The law only states that this break time is for employees to express breast milk; It provides no rights to the mother to take a break to physically go and nurse her child. Employers vary, but some do have on-site nurseries where mom can go nurse her child during break times.

The law does say that it is not just about the break time, but also the location. Additionally, it can't just provide for enough time to express the milk, but also the time it would take to walk to the private location, set up the pump, pump, clean the pump, and walk back.

In assessing the reasonableness of break time provided to a nursing employee, the Department will consider all the steps reasonably necessary to express breast milk, not merely the time required to express the milk itself.

The location must be "private," and include a place for the mother to sit, as well as somewhere to place the pump, other than the floor. Employers are NOT required, however, to provide a location with a refrigerator to store the milk, does not require that the location have an electrical outlet to power an electric pump, and does not require the room to be near a sink for cleaning the pump.

Where it is not practicable for an employer to provide a room, the requirement can be met by creating a space with partitions or curtains. Any windows in the designated room or space should be covered to ensure the space is "shielded from view.'' With any space provided for expressing milk, the employer must ensure the employee's privacy through means such as signs that designate when the space is in use, or a lock on the door.

While employers are not required to provide refrigeration options for nursing mothers for the purpose of storing expressed milk, they must allow a nursing mother to bring a pump and insulated food container to work for expressing and storing the milk and ensure there is a place where she can store the pump and insulated food container while she is at work.

Who is in charge of enforcing this law? The people who enforce the Federal Labor Standards Act, or the Department of Labor - Wage and Hour Division. Complaints are handled the same way any complaint to the Department of Labor would be.

If an employee would like to file a complaint because she believes her employer has violated the break time for nursing mothers requirement under the FLSA, she should call the toll-free WHD number 1-866-487-9243 and she will be directed to the nearest WHD office for assistance. The WHD Web site provides basic information about how to file a complaint and how the WHD will investigate complaints.

The law does not specify a penalty for an employer who violates this requirement, but complaints may be handled the way any complaint about the FLSA would be handled.

If an employer refuses to comply with the requirements, however, the Department may seek injunctive relief in federal district court, and may obtain reinstatement and lost wages for the employee. 

If an employer treats employees who take breaks to express breast milk differently than employees who take breaks for other personal reasons, the nursing employee may have a claim for disparate treatment under Title VII of the Civil Rights Act of 1964.

It is important to note that if a state has a law that provides more protection than this law does, the state law preempts the national law.

Breastfeeding and the Employer

The Business Case for Breastfeeding, put together by the Department of Health and Human Services, is

program designed to educate employers about the value of supporting employees in the workplace. The program highlights how such support contributes to the success of the entire business. The Business Case for Breastfeeding offers tools to help employers provide worksite lactation support and privacy for breastfeeding mothers to express milk. The program also offers guidance to employees on breastfeeding and working. Resources to help lactation specialists and health professionals to educate employers in their communities are also available.

I took a training by the Business Case for Breastfeeding a year ago. The program recommends that employers who choose to support breastfeeding employees provide 1. Milk expression breaks, 2. A clean place to express milk that is private, near a sink or provision of disinfectant wipes, an electrical outlet, and permission to store milk in a work refrigerator (or provision of a cooler/refrigerator for milk), 3. A hospital-grade electric pump, 4. Education for employees and staff support for breastfeeding employees.

These go above and beyond what the new Act calls for, but they are indeed what nursing mothers need when nursing at work. And these programs provide benefits for the employer:

The Business Case for Breastfeeding, published in 2008 by DHHS, demonstrates an impressive return on investment for employers that provide workplace lactation support, including lower health care costs, absenteeism, and turnover rates. Employees whose companies provide breastfeeding support consistently report improved morale, better satisfaction with their jobs, and higher productivity. As part of The Business Case for Breastfeeding initiative, coalitions in 32 states and territories received training to assist employers in establishing lactation support programs.

The National Business Group on Health, a nonprofit organization representing large employers on national health policy issues, says that creating a breastfeeding-friendly work environment reduces the risk of long-term health problems for women and children, decreases employee absenteeism, reduces health claims to employers, and increases retention of female employees.

Is any of this a surprise to you?

Weekend Movie: Nursing a Toddler in Public

So, having to spend much of my time these days self-regulating myself to research and write my thesis means I also have more time to spend procrastinating on the internet. Because I've been doing a lot of searching for breastfeeding things and then get sucked into topics that I want to blog about.

I came across this "What Would You Do?" video where the show does an experiment - they place a mom nursing a toddler in a coffee shop along with an actress who berates her for nursing a child that old. The idea is to get a reaction from the other patrons in the shop on the subject.

This is somewhat of a follow-up to a "What Would You Do?" where a mom nursing in a restaurant gets yelled at by the manager.

I have to admit that I was really nervous when I hit play...



... but this actually really gives me hope!

What do you think of this video? Did the people react how you expected? 

WHO Code, No Nestle, Conflict of Interest

Recently, news broke that the World Health Organization accepted money from corporate sponsors such as fast giants, such as Nestle, to fund its obesity-fighting campaigns. Oh, the irony.

A Reuters investigation found that WHO's regional office has turned to the very companies whose sugary drinks and salty foods are linked to many of the maladies it's trying to prevent.
The office, the Pan American Health Organization, not only is relying on the food and beverage industry for advice on how to fight obesity. For the first time in its 110-year history, it has taken hundreds of thousands of dollars in money from the industry.
Accepting industry funding goes against WHO's worldwide policies. Its Geneva headquarters and five other regional offices have been prohibited from accepting money from the food and soda industries, among others. 

This is a conflict of interest - Food and beverage companies donating money to nonprofit groups that are fighting the very diseases that their products have helped to create. The WHO is unwilling to accept money from tobacco agencies, why should this situation be different? 

The news went viral, and social media users began to tweet their outrage:

From the article on Breastfeeding Science Outrage sparks Twitter battle between UN health watchdogs WHO, PAHO:

After fighting industry for years to uphold an international code to protect moms and babies from predatory marketing, there was outrage when it was learned PAHO accepted $150,000 from Nestlé. This is a direct violation of what is known as the WHO Code and moms and breastfeeding support workers are furious.

No Nestle
Nestle violates the WHO/UNICEF International Code of Marketing Breast-milk Substitutes, which it agreed to abide by in 1984. Nestle unethically markets infant formula to poor mothers in developing countries, where babies are more likely to suffer and die from gastrointestinal issues caused my feeding their babies formula (often with un-clean water) than breast milk (which protects the baby from illness). They promote infant formula unethically, providing gifts to health providers to promote their product, and they distribute free formula in hospitals (disrupting lactation) which poor families must then continue to pay for after there are no more freebies. (Click for more on the Nestle boycott)

Using Social Media for Powerful Change
The Lactation Matters blog, in the post  World Wide Impact in 10 Minutes or Less: Using Social Media for Powerful Change, wrote that the WHO began to respond to tweets:

Breastfeeding Science posted a tweet where PAHO responded to the WHO, but interestingly, it has been deleted from their Twitter page. PAHO does have different standards than the WHO regarding business partners, and they have been cash-strapped on programs dealing with obesity due to budget cuts.

Clearly, social media can have an impact. As Anthropologist Margaret Mead is famously quoted “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” 

Join the conversation!
1. By joining the Facebook group Friends of the WHO Code and 
2. Tweeting about it! This is one example of how Twitter can be really useful. If you have a twitter account, just copy and paste:


#WHOCode protects women&babies from predatory marketing. Shame @Nestle for trying to buy seat at the @PAHOWHO table #nonestle #breastfeeding

Tell @PAHOWHO to give back @Nestle $150K #nonestle #WHOCode #breastfeeding #conflictofinterest http://t.co/nnWJCIfX @WHO

We will not be bought! @PAHOWHO please return the money to @nestle Stand up for mothers and babies. #WHOCode #breastfeeding #nonestle

Regulation
It is important to note that the WHO has no regulatory authority, and many nations lack legislative reinforcement. So while this is a conflict of interest, pressure on PAHO and especially Nestle may be the biggest ways to have an impact. Don't let this move undermine the Code. 

You Learn Something New Every Birth

artwork (c) Amy Haderer mandalajourney.com

I'll admit, I don't usually back my doula bag until my client's are 40 weeks. I know this isn't perfect doula practice, but there are two reasons: 1. My bag stays almost entirely packed with my doula tools all the time anyway (I just have to add things like toiletries, snacks, medications, phone charger, sweater, etc), and 2. My clients never seem to go into labor before 40 weeks.

This is another reason that I find the whole "40 weeks is your due date and then after that you're late" thought-process to be completely flawed. Nearly all my clients have gone into labor AFTER their 40 week mark. There is no timer to go "ding!" that means you are "done" at 40 weeks! (but for more on estimated due dates, see this other post, or this one)  And not just first time moms!

Back when I was a brand new doula, my bag used to be packed at exactly at the 38 week mark. I was also more paranoid in general - not a single drink during my on-call period, no foods with onion or garlic (so my breath wouldn't smell bad), obsession with checking my phone all the time and with every single plan I made (can I go to the movies?), and so forth. I remember each birth that occurred prior to the due date:

I had a first time mom go into labor before 40 weeks, but that was an effort on her part - she asked her midwife to sweep her membranes at around 39 weeks (see bottom of post for an explanation if you don't know what this is), and it worked the very same day. I knew in advance why she wanted to go into labor earlier than her due date and she kept me informed of her techniques.
A third time mom went into labor at 38 weeks, a week after I met her and she hired me.
I also had a first time mom go into labor on her exact due date, which is so rare that it was shocking.

And then just recently, with no warning at all, I got a phone call in the middle of the night from a mom who had no major warning sign that she would give birth before 40 weeks (other than the fact that she really didn't want to be pregnant anymore, which is like most women), and had to scramble around and pack my bag! I found out that she was taking evening primrose oil capsules, on her midwife's advice. I'm not sure why she was taking them, or why the midwife advised her to take them, prior to her estimated due date. Perhaps the midwife always prescribes it. Perhaps the mom was incredibly impatient and so that's why the midwife suggested it.

Evening Primrose Oil is a supplement that can ripen the cervix because it is high in prostaglandins. Prostaglandins are sometimes administered directly in the vagina by a doctor to prepare for a labor induction. Semen also contains prostaglandins, which is one reason why they say sex can start labor! Evening primrose oil doesn't exactly induce labor; it helps soften the cervix in preparation for labor. I don't know much about EPO so I asked about it on twitter.  Respondents said that it can have side effects and should not be used routinely and perhaps not unless an induction is looming for post dates, and that there is not a lot of research on EPO. Apparently side effects can include upset stomach and headaches.

A quick survey of the literature came up with a retrospective quasi experimental study of 108 low-risk nulliparous women that found:

Findings suggest that the oral administration of evening primrose oil from the 37th gestational week until birth does not shorten gestation or decrease the overall length of labor. Further, the use of orally administered evening primrose oil may be associated with an increase in the incidence of prolonged rupture of membranes, oxytocin augmentation, arrest of descent, and vacuum extraction.

Another article on midwives' use of herbal preparation for stimulation of labor found that there were no reported complications in the use of evening primrose oil or red raspberry leaf tea and that evening primrose oil was the most efficacious herbal preparation for cervical ripening. Most else of what I could find just says that there is a lack of evidence. Basically, that more research is needed.

Anyway! She went into labor prior to 40 weeks and the labor and the birth went well. I always tell my clients that I will come when they feel they need me. Sometimes in the middle of the night I really hope that even though they're calling me, they'll see that their contractions are still "early labor" contractions and they won't "need me" right now. With this one, I did end up getting to her house a bit before an active labor pattern was established. This has happening to me a couple times. This is hard for a couple reasons: First, now everyone feels like we're in active labor mode and it's hard to not feel rushed once the doula is there and you feel like everyone is waiting on you and watching you labor. Second, it would be nice if everyone (mom, partner, and doula) all got some more sleep, but now sleeping arrangements are awkward. And third, several other things are also awkward - instead of needing active help all the time, we're hanging around at home watching TV and making lunch, etc. But the second ones are more about me, and so... see number one!

But it is also highly beneficial for me to come early in several instances. Once, it was because mom and dad had me meet them at the hospital and mom was only about 4 cm dilated. They walked around trying to decide what to do: Be admitted and be in the hospital the entire labor, being pressed for time and to adhere to the ridiculous "1 cm per hour" rule? Or go home and try to sleep, and hope that in their own environment labor would move along at a comfortable, un-stressed pace. Perhaps if I hadn't been there at the hospital to discuss things they wouldn't have gone home (and ended up having a great labor!)

Most recently, I was glad to sacrifice my time/comfort/sleep/whatever to be with mom and dad early in order to reassure them and keep them at home. This is a big one. I have been told so many times, "if it weren't for you, we would have just gone to the hospital at [2 am, 4 am, etc]!" And mind you, this is JUST after labor contractions start. You really shouldn't go to the hospital at the start of labor, for a multitude of reasons. 1. they might send you home if you're not 4 cm or more anyway, 2. hospitals can be stressful places where labor actually slows, 3. if you want a natural labor, the longer you are in the hospital the more likely things will be done that make this harder (i.e. stay in bed the whole time, pressure to get pain meds, you aren't allowed to [eat, drink, pee, use the shower for pain relief, etc], let's manage this labor a bit more with drugs, etc), 4. you will be rushed for time (it's been ___ hours since ___ so we need to do ___) even though there is no medical reason to do so, and 5. I could probably think of more if I wanted but I'll stop there.

Several times if I hadn't showed up right away mom and dad would have just listened to some direction (that always changes) like, "come in when contractions are 5, 1, 1" or "come in when your water breaks" or "come in so we can see how far you've progressed" which have no basis other than they just want to manage labor. I have been told a million times, "I am so glad we labored at home," and "this is really great laboring at home," and "I'm glad we didn't go to the hospital right away." And even from hospital midwives, who are impressed that the mom comes in at 8 cm or 10 cm because that is so rare for them (and I've even got a "way to go, doula!"). But it is hard, especially for first time parents, to want someone there with them to can reassure them about what is normal and answer a million questions about labor positions, eating and drinking, whether or not they should try sleeping or walking, and of course the big one - when should we go to the hospital? [And in this instance, interestingly, many a question was answered along the vein of "is this going to make the contractions worse? Such as "Is a cold beverage going to make the contractions worse?" and "Is a shower going to make the contractions stronger?"] I have witnessed many many more labors than they have and I know what a contraction pattern or mom's temperament means.

Just as an aside, I always let the couple decide when it is time to go to the hospital. I give advice if asked, but if they feel it is time, we go. The only instances in which I say "ok it's time to go now" are when mom says her first "I feel the urge to push"! And I should also add, here, that we've left while mom felt like pushing many times and always made it to the hospital in time (even with a third time mom); They have all still had to actively push for a period of time in the hospital. This is always a big worry, but the stories you hear about babies being delivered in the car are rare (though I'm not denying that is possible to wait too long to go, or to have an exceedingly fast labor).

Talking about doula self-sacrifice - my body was really aching after my last doula labor! Whoever thought that becoming a doula was all fun and babies, you should really recognize how hard being a doula can be, sometimes.

I also wanted to mention that a recent labor was attended at a Baby Friendly Hospital. I want to share this experience, because it wasn't quite what I thought it would be. Firstly, the nurses asked the mom immediately after delivery if she would be bottle feeding or breastfeeding. This is interesting in two ways:  1. I did actually think it odd that a hospital with the highest support for breastfeeding there currently is is even asking a mom if she is breastfeeding, instead of assuming that she would do the norm (and yes, wanting to breastfeed is the 'norm' - 75% of women in the U.S. initiate) and only require formula in case of complications (which is what formula should be used for), but...  2. For the people who say that going baby friendly hurts moms who want to bottle feed because it pushes breastfeeding on everyone, clearly if they are asking moms, this isn't true.

Secondly, I was under the impression that BFH's do uninterrupted skin-to-skin and make sure mom has help in trying to initiate breastfeeding in the first hour after birth. I was under that impression... (Perhaps you see where I am going with this?) This mom had her baby on her maybe 20 minutes of the entire first hour and twenty minutes of baby's life. They were doing the usual - weighing, measuring, drawing blood, eye ointment, letting dad take photos, etc in the baby warmer instead of letting all that wait and giving mom the chance to warm and feed and bond with the baby, all of which is good for both the baby's blood glucose levels and the breastfeeding relationship. Oh, and they did the typical swaddle the baby and we had to un-swaddle him to put him back on mom, and then they took him off a second time. And the entire time no one was helping with breastfeeding but me! Until finally a baby nurse came back in and then repeated EVERYTHING I had just been saying and doing. Grr. So frustrating. I do think this nurse was trained in lactation, luckily, but I don't know if all the nurses are, because all she said is "you can ask any nurse for help with breastfeeding." Which is what they all say everywhere, even if the nurses aren't trained in lactation.

The point of all this is... you learn something new every birth. Or many somethings. For instance, I also learned that if a mom is GBS+ she should really get the IV antibiotics in her system at least 4 hours before delivery (so don't wait too long to go to the hospital with a GBS+ mom).

Or sometimes, many things are affirmed. For instance, you really can't tell if a mom is going to take one hour or several hours to go from ___ cm to 10 cm. Or like how sometimes L&D nurses are all the same. And sometimes they're idiots (Sorry, just really annoyed at an L&D nurse who told my client to tell her if she had a continual urge to push,  even in between contractions, which is NOT how it works. And then wouldn't let mom stand beside the bed when she felt pushy because she was afraid she'd have the baby on the floor, even though she had just checked her and she was only 8 cm and was not going to push a baby out that fast. Ok, rant over).

Ok, POST OVER! Thanks for sticking with it til the end :)


--> A membrane sweep, or stripping the membranes, is not the same as breaking the bag of waters (amniotic sac). It is done by inserting a finger between the membrane that goes around the amniotic sac and the wall of the uterus to loosen the membranes from the wall. Sometimes this stimulation of the uterine wall can help to start labor. It doesn't work for everyone, may or may not be uncomfortable, and can sometimes cause the water to break.

Current Research Round-Up

I haven't done a link round-up in a while, mostly due to the fact that I can barely keep up with reading my google reader blogs, let alone blog about them! But I am always reading and always following the latest research. Here is some of what I've come across lately:

• Determining fetal gender at 6 weeks with chorionic villi or The Relationship Between Placental Location and Fetal Gender Ramzi Ismail, Saad

Robin Elise Weiss wrote about really interesting research that found that you can actually determine the gender of the fetus at 6 weeks! It's called the Ramzi's method. In using this data, Dr. Ramzi Ismail concluded that at six weeks gestation, 97.2% of the male fetuses had a placenta or chorionic villi on the right side of the uterus. When it came to female fetuses, there were 97.5% of the chorionic villi or placenta on the left side of the uterus. Robin writes,

"This is amazingly accurate and has nothing to do with actual visualization of the sex organs, which is impossible this early in pregnancy. Parents want to know the sex of their baby for many reasons, including to figure out how to manage a pregnancy when there may be certain sex linked diseases complicating it. Though the author encourages this to be used as a soft marker to be used between the physician and patient when earlier knowledge can help the team with decision making.

The biggest advantage here is that the use of 2D ultrasound does not pose the risks that other methods do to the pregnancy. It can also easily be incorporated into the first trimester screenings and the results are immediately available. This can also prevent the waiting times that can cause much anxiety for families.

Though this is not widely used anywhere currently, parents wishing to know the sex of their baby may be trying to figure this out any way. If you have an early ultrasound and are not trained, you may misinterpret the results, even if you can clearly see the screen. You would be better off asking the person doing the ultrasound which side the placenta is on, than trying to guess yourself."

But she cautions that "it would be wise not to make decisions that are irreparable because of this knowledge. I'm not even sure if I'd paint a nursery with this answer."
 

•  Fetal exposure to synthetic oxytocin and the relationship with prefeeding cues within one hour postbirth. Aleeca F., B., Rosemary, W., &  Kristin, R. (n.d). Early Human Development 

 Can't find the actual article for this, just the abstract.  What it says is that there were fewer prefeeding cues observed in infants who were exposed to Pitocin than those who weren't, especially hand-to-mouth cues. Pitocin-exposed infants also had what the authors called "a low level of prefeeding organization," as evidenced by frequency of 8 prefeeding cues.

• Patient-Initiated Elective Cesarean Section of Nulliparous Women in British Columbia, Canada Hutton, EK; Kornelsen, J BIRTH-ISSUES IN PERINATAL CARE, 39 (3):175-182; SEP 2012

Another article demonstrating that it's not patient-requested C-sections that is driving the increasing cesarean rate. Authors found that those judged to have selected an elective cesarean were significantly older and had babies with a lower gestational age than women with a nonelective cesarean section. No significant differences between the two groups were found with respect to maternal weight, length of stay for the mother or baby, newborn birthweight, or special care nursery days. Overall, the prevalence of nulliparous women judged to have had a patient-initiated elective cesarean was found to be low and is not likely to be substantially contributing to the rising proportion of cesarean births.

• Remote Midwifery in Nunavik, Quebec, Canada: Outcomes of Perinatal Care for the Inuulitsivik Health Centre, 2000-2007 Wagner, V; Osepchook, C; Harney, E; Crosbie, C; Tulugak, M BIRTH-ISSUES IN PERINATAL CARE 39 (3):230-237; SEP 2012

An article on outcomes of Inuit births in Canada. The authors' conclusions are:  The success of the Innulitsivik midwifery service rests on the knowledge and skills of the Inuit midwives, and support of an interprofessional health team. Our study points to the potential for safe, culturally competent local care in remote communities without cesarean section capacity. Our findings support recommendations for integration of midwifery services and Aboriginal midwifery education programs in remote communities.

• Are You Baby-Friendly? Knowledge Deficit among US Maternity Staff Sadacharan, R; Santana, S; Sanchez, E; Matlak, S; Grossman, X; Makrigiorgos, G; Merewood, A. JOURNAL OF HUMAN LACTATION, 28 (3):359-362; AUG 2012

Only 3% of babies were Baby Friendly in 2010. The researchers in this study basically called all maternity hospitals in the US and asked to be connected to the maternity service. Then the person answering the maternity service phone was asked: "Is your hospital a Baby-Friendly hospital?" They found that Although the Baby-Friendly Hospital Initiative was established over 20 years ago, most US maternity staff responding to a telephone survey either incorrectly believed their hospital to be Baby-Friendly certified or were unaware of the meaning of "Baby-Friendly hospital."

This research is begging for follow-up studies. What do the maternity staff thing Baby Friendly means? Why do they think they are or they aren't BF?  Why are IBCLC's only correct 89% of the time in knowing if their hospital is BF?

Breastfeeding and the Working Mom

I recently attended an occupational health presentation entitled "Breastfeeding and the Working Mom: The Impact of Perceived Breastfeeding Support at Work on the Well-Being and Job Attitudes of Women"

This was a presentation on a study from an occupational health and psychology perspective. The presenter, Dr. Bruk-Lee, explained that much of the research on women pumping at work focuses on evaluating lactation programs and their effectiveness, and the work-family conflict interventions/policies. The purpose of her particular study was to investigate the impact of perceived breastfeeding support at work on the job attitudes and psychological well-being of women who express milk at work.

Psychological 'well-being' encompassed burnout, postnatal depression, work family conflict, and job satisfaction. 'Job attitudes' related to performance, turnover, commitment, counterproductive behaviors, and organizational citizenship. Breastfeeding support came either from the organization (policies, physical accommodations, etc), or from supervisors and co-workers.

Interestingly, 82% felt they could often or always express all of the milk the baby required during the workday. 62% reported no company designated place for women to breastfeed or pump (and these were women in a variety of professions and settings). Reasons they stopped expressing breast milk (on average when babies were 33 weeks old): 54% personal choice; 26% employer; 14% supervisor; 6% health care provider.

Organizational policies affect more than breastfeeding duration, i.e. psychosocial work environment and performance. What the study concluded overall was that co-workers/supervisor support was more important for levels of well-being and good job attitude than the organizational support (like physical spaces to pump). Breastfeeding support offered by supervisors and coworkers was a stronger predictor of outcomes than other forms of support.

Much of the focus on improving breastfeeding support for working moms is targeted at adding reasonable break time for moms to express milk and the provision of a private non-bathroom space in which to do so. This is important, but this study shows that this organizational support is not as effective at improving mom's psychosocial well-being, work performance, turnover rates, etc as coworkers and supervisor social support.

So what can be done? What should we be doing to improve this aspect of work support? Giving workshops on lactation? That might never happen in most work environments.
The presenter had no solutions. The answer is basically that it will take cultural change, which takes time. But we clearly can't remain focused solely on the physical space. Perhaps, though, having a space, and breaks times, etc, will make it more the norm, which will contribute to changing attitudes about expressing milk at work.

What are your thoughts?

Link Round-up: World Breastfeeding Week 2012

Here are a couple of links from this past week's world celebration of breastfeeding!

I really like Donna's (Banned from Baby Showers) post on why Breastfeeding would be the one topic she'd preach on, if she had to pick only one platform. She lists why this issue, over intactivism or natural birth, because of the multitude of benefits that you can't get any other way (and a few personal reasons).

Both Annie from PhD in Parenting and Rebecca from Public Health Doula wrote about the controversy over NY Mayor Bloomgberg's Latch On campaign to implement Baby Friendly hospital practices in NYC. Basically, there has been a lot of misunderstanding about why he wants the formula to be regulated more tightly in hospitals, and commentators have been up in arms about how babies are going to go hungry. What it's really about is changing staff practices such as limiting staff access to formula, not advertise formula, and not give free formula samples. Annie's post describes why this is important for moms who want to breastfeed, and Rebecca explains what this really looks like when a hospital follows these practices and how it does not harm women who want to formula-feed.

An article at Women's E-News on why Lactation Consultants need to Diversify:

"Black women often find it easier to speak to my black lactation consultants or nurses. They understand each other from a cultural perspective and can relate to them in a different way than they are able to relate to me," says Sylvia Edwards, manager of lactation services at the University of Alabama Birmingham hospital and co-chair of the Alabama Breastfeeding Coalition.

The Huffington Post blog - World Breastfeeding Week Sucks According to this Lactation Consultant:

I really hate World Breastfeeding Week because much of the media takes it as an opportunity to attack those who wish to support mothers who breastfeed rather than celebrate their efforts to improve infant feeding. Every year I hope I will not have to read more faux feminist manifestos that denigrate the value of women who enjoy their care-giving roles.

A new bill in Israel states that "hospitals will now have to purchase formula by tender and that the formula provided to mothers who choose not to breastfeed will NOT be limited to one specific brand."

The blog of the International Lactation Consultant Association posted each day this week on a breastfeeding in a different country - Breastfeeding in Papua New Guinea, Hmong Women in California, Breastfeeding in Ireland, and Donor Milk for Babies in Canada

Breastfeeding Year In Review

Since last year's World Breastfeeding Week, I have...


Discussed Breastfeeding (and birth) in my Anthropology of Reproductive Health class 

Enjoyed this Breastfeeding Song and Dance

Learned about what "Just One Bottle" and Formula can Result in

Was intrigued by this Ad on the Legality of Nursing in Public

Watched these Breastfeeding Public Service Announcements aimed at African Americans

Attended a symposium on Breastfeeding and Feminism

Laughed at the Baby Friendly Rap

Reported on all the Breastfeeding topics that were in the News

Became a Certified Lactation Counselor

Blogged about new research on HIV and Breastfeeding

U.S. Breastfeeding Rates

In celebration of World Breastfeeding Week, the Journal of Human Lactation is available online  FREE for the month of August! And so is the Breastfeeding Medicine journal! Be sure to check it out.


The Centers for Disease Control and Prevention have release the U.S. date on breastfeeding from the cohort of babies born in 2008 and 2009 (some data still being collected for 2009).

The data show that breastfeeding rates have increased! yay! The CDC report card states:

Breastfeeding rates continue to rise, with increases of about 2 percentage points in breastfeeding initiation, and breastfeeding at 6 and 12 months. Breastfeeding initiation increased from 74.6% in 2008 to 76.9% in 2009 births. This improvement in initiation represents the largest annual increase over the previous decade. Breastfeeding at 6 months increased from 44.3% to 47.2%; breastfeeding at 12 months increased from 23.8% to 25.5%.

Further good news is that

The last few years also have seen acceleration in the percent of babies that are born in hospitals designated as Baby-Friendly, an international recognition of best practices in maternity care.  In 2008, less than 2% of births occurred in Baby Friendly facilities. In the last 4 years that number has more than tripled to 6%.

The number of infants who are supplemented with infant formula has eked downward by tenths of a percentage. The Healthy People 2020 goals haven't been met, but it's a step in the right direction. 

Of course these increases are not huge, and the vast majority of mothers and babies are not receiving the best quality of care to help them reach their breastfeeding goals, but it's still good news. I think it means that the hard work we are all doing in the lactivist world is paying off!

If you'd like to see the data charts, go to the CDC data site here.

The CDC Report Card lists how every state did on all of the study's indicators, including Average mPIScore, Percent of live births occuring at Baby Friendly Facilities, Percent of breastfed infants receiving formula before 2 days of age, Number of La Leche League Leaders per 1,000 live births, Number of IBCLCs per 1,000 live births, and  whether States child care regulation supports onsite breastfeeding.

If you'd like to find your state in the CDC Breastfeeding Report Card, go here.

New Jersey has the highest percentage of infants receiving formula, and New Hampshire has the least. Louisiana has the lowest percentage of babies breastfeeding at 6 months, and Oregon has the highest!

To access breastfeeding report cards from previous years, or to get more information about the CDC's survey, visit this website.

Happy World Breastfeeding Week 2012!

World Breastfeeding Week celebrates its twentieth anniversary in 2012.  This time it focuses  on the progress that has been made on the implementation of the Global Strategy for Infant and Young Child Feeding which was adopted by the World Health Organisation (WHO) and UNICEF ten years ago.  Implementing the Global Strategy effectively is essential to increase breastfeeding rates: especially exclusive breastfeeding for the first six months, and to reach Millennium Development Goal (MDG) 4 (to reduce under five mortality by two thirds).Twenty years ago the World Alliance for Breastfeeding Action (WABA) launched the World Breastfeeding Week campaign to focus and facilitate actions to protect, promote and support breastfeeding.  Since then, each year, WBW has put the spotlight on various breastfeeding issues.

The WBW holds a Photo Contest, and the beautiful photos of the winners are up here.

Here are some of my favorites:

Nursing twins

Initiating breastfeeding during a C-section

Nursing while working!