Monday, June 29, 2009

How to find a bra that fits [Part 3, for nursing]

On to our third and last installment! Please ask questions if there's something I'm not making clear, or you're still wondering about. Or give your own experiences with shopping for/wearing bras!

Bras for nursing

Changes in cup size: Most women can wear their end-of-pregnancy bras for the first few days. When the mature milk comes in, engorgement can make your cup size can go way, way up for a day or two, then goes down a bit, then stabilizes and begins its months- (or years-)long descent down the other side of the hill.

A lot of women try to buy a couple of bras at the end of pregnancy to use for nursing. One suggestion I've heard a lot of is "get a bra that you can fit your fist into". Maybe that works for some people, but you've already heard my thinking about buying sizes you're assuming you'll grow into - what if you never get that big? My suggestion is to buy one or two comfort/sleep bras (discussed below) that fit you a little generously and have room to stretch. Let out the straps for extra space. Where are you going, anyway? Aren't you enjoying a babymoon, sitting around in bed with people bringing you breakfast on trays?? (Okay, or at least sticking to home while you get to know your newborn.)

Once your size has stabilized, start investing in bras that are fit properly to your actual size - not to some guess in week 38.

Changes in band size: Your band size - even if it was uncomfortable during the last part of pregnancy - should be back to its mid-pregnancy size and, again depending on your body and weight loss, will also go back down as the months pass. It's really easy to not notice that the band of your faithful standby nursing bra has gotten waaaay too big (it's easy even with regular bras) so keep fastening the hooks tighter and watch to see if the back is creeping up.

How fast the changes happen: Again, dependent on the individual but apart from the initial engorgement, generally slow and steady. Your breast size in particular may stay the same for a long time at first if you're nursing exclusively. Remember - during that time, if you're getting smaller band sizes you want to go UP a cup size. For example: a 38D=36DD=34DDD/F.

What bras to buy

The great debate of our time: underwire vs. non-underwire. Everyone has different opinions on whether underwires cause plugged ducts. You can find people who swear up and down that they don't, and others that they do.

Here's my take: I met a woman one time who could get a plugged duct from a seat belt across her chest on a long car ride. And I've met women who never once had a plugged duct, even wearing too-small underwire bras. So I think you should play it by ear. If you hate underwires or you think you're plugged-duct-inclined, avoid the wires. If you can wear them with no problem, more power to you. (However, I will put in a pitch for the unbelievable comfort of non-underwired bras, even for those who are not nursing. Soooo nice.)
Bra rec: Anita brand bras are good for non-underwire support. The 5051 is not pretty, but super comfortable and goes up to an I cup.

Sleeping/comfort bra?
Do you need a sleeping bra? If your breasts are tender and/or very full, then one might be nice, but it's not at all necessary. On the other hand, it is nice to have a stretchy, comfy, wear-around-the-house bra, and these are great for the first week of nursing when your size may be fluctuating greatly. If you're buying one bra to get you through the first week of nursing, a comfort bra is a good choice because it can more easily accommodate changes in cup size and will just be nice for sitting around the house, resting and nursing. And if you need something to sleep in, you've got it.
Bra rec: Virtually everyone I've talked to has loved the Bravado original bra. Some people like it so much they just wear it all the time. And if you want you can buy it in leopard print!
Also Bravado, and recently given a rave review on Blacktating, there is a deep and strong passion for the Silk Seamless. The catch: they don't really work above a D (or max, DD) cup. These can actually work well as regular day, wear-under-clothes bras or as comfort bras (although one more warning: they are not super low cut).

Regular day bras
As with your bras for pregnancy, try not to buy too much at any one size - maybe 1-3 bras at a time. And don't buy more than one of a particular style bra at a time (unless you already know it works.) If you love it in the store, wear it for a few days and make sure it's wearing well and still feels good. Then buy more of the same. You don't want to try to return milky bras that are no longer comfortable!

You should be able to find pretty bras you like, but keep in mind that the nursing bra spectrum is limited, especially when you get up to larger cup sizes. Do I think there should be more beautiful 32Is? Yes. Does ugly mean you shouldn't wear the right size? In the grand scheme of things, you won't be nursing so long. You have the rest of your life to wear lacy little dainties.
Bra rec:
For smaller cup sizes (A-D): YOU can wear lacy little dainties. Elle MacPherson tends to make the prettier, sexier nursing bras, like the Mere (if you don't mind lace). If you mind lace or anything itchy, people also rave about the Bravado Silk Seamless.

For larger cup sizes (D+): Not quite as dainty, but still lacy and pretty: another Elle MacPherson, the Maternelle. It's high cut, but the lace makes it look like a camisole under lower-cut clothing, and it goes up to an F (her E is really an F. I know, confusing.) Also see the Anita bras (mentioned above) for cup sizes through an I.

-When trying on bras, think about how much you change size between feedings. If you change a lot, try on bras when you're relatively full so you can make sure the bra will fit comfortably even right before a feeding.
-It's easy to get distracted and not really notice that your bras aren't fitting right anymore. Don't forget to make sure that you're comfortable and happy - the right size bra will make a difference.

To sum up: If you want to get a "starter bra", get a stretchy sleep/comfort bra to wear through your milk coming in. Wait until the engorgement has settled down to get more bras, then get a couple at a time. Decide if underwire works for you on an individual basis. Don't sacrifice comfort for looks, and make sure you have the right size and that you're paying attention to fit as your size changes.

I hope this little series has been informative! Again, if there's something I've forgotten to talk about, let me know. (And tell me if you go out and get a bra fitting...did you find out your real size?)

I'll just leave you with a pitch for GOOD nursing bras. A lot of new moms don't take care of themselves, putting themselves and their needs after their families'. But you also have to take care of yourself. Maybe you wear crap bras the rest of the time, but during nursing when your breasts are doing so much work - when they are, in fact, feeding your baby - isn't that a good time to treat your body and yourself extra nicely? Especially at a time when your breasts especially need the support, being full of milk and all? And your shoulders and back and neck could really use the help, being also busy carrying around a baby?

I fit so many women who just heaved a sigh of relief, looked in the mirror, said "I can't believe I waited this long!", and asked me to throw their old bra in the trash and cut the tags off their new one so they could wear it out. Don't wait! Don't settle for crap bras during nursing - get the right fit and get good ones!

Sunday, June 28, 2009

Nipple confusion is not a myth

I was thinking about the conflicting advice moms get about pregnancy/birth/breastfeeding. A lot of it, I can understand why there might be two perspectives. But why do people claim that nipple confusion doesn't exist? I can only assume that these people are coming from a place of great breastfeeding luxury, because I've seen it with my own eyes. Back when I worked for AmeriCorps, if I had a dime for every woman who told me in perplexion or sadness or exhaustion, "no quiere", I could start hiring some LCs for community health centers.

Will introducing a few bottles here and there to a successfully breastfeeding baby destroy their ability to latch? Almost certainly not, and if that's the "nipple confusion" we're talking about then fine, it's a myth. Are there babies out there who can switch easily back and forth from birth? If we only consider those babies then fine, it's a myth.

But can many bottles early in the nursing relationship interfere with breastfeeding? The evidence I've seen with my own eyes says "yes", and I would add that I think it's particularly strong for moms who don't have a lot of access to breastfeeding education and support. Many of those women assume that a baby who is fussy at the breast just "doesn't want it", and if nipple confusion is a myth then I guess they're right. But if it's real, then they are the least likely to have anyone to talk to them about why it's happening, help them get the baby latched and happy, and suggest limiting bottles until the baby is a successful nurser.

Instead they had the best help we could give - a consult at the clinic, follow-up phone calls, and repeat clinic visits if they had a way to get there and we had time to see them. Sometimes things worked out, sometimes they didn't, but either way I was pretty sure nipple confusion was alive and well. So the only explanation I can think of for health care professionals saying it's not real is that they've only ever seen babies whose mothers had all the support they needed for a successful transition between breast and bottle.

Saturday, June 27, 2009

How to find a bra that fits [Part 2, for pregnancy]

When we left off, we had just learned how to find a bra that fits you - the importance of band size, the changing nature of cup size, the glory of a bra that actually supports you. I also just ran across this post about cup size, with photographic illustration. It really helps show you how cup sizing works, and why your letter doesn't say anything about what your breasts look like!

On to bras for pregnancy... (I meant to do a combined post but I write too much, so I'm splitting pregnancy and nursing into separate posts.)

What happens to your breasts and bra size during pregnancy

Imagine the changes in your breasts/cup size during pregnancy and nursing as climbing a hill: they get larger throughout pregnancy until they hit the top of the hill the day your milk comes in. That's the biggest you're going to get. Once your milk supply stabilizes they, too, either stabilize or get somewhat smaller throughout nursing - descending the other side of the hill. After your child has weaned they finally return to where you started, at the bottom of the hill and at (or close to) your original size.

"OK, that is NOTHING like what happened to my breasts/bra size when I was pregnant/nursing." Every woman's body is different! The above is a general guideline and sadly, like with length of labor, if I could predict bra/cup size ahead of time I would be a rich woman.

But the hill visual is helpful, especially if you think that every woman's hill follows the same general structure but may be tall (lots of change) or short (less change), steep or gentle (quick or slow change).

Because bra size changes frequently during pregnancy and nursing, there are a few special things you want to keep in mind while choosing bras during this time.

What bras to buy, or my screed against "maternity bras"

Let me say right up front: there is no such thing as a maternity bra. They don't exist. They are just regular bras hanging under a sign that says "maternity". Yes, they are bigger than "regular" bras. They are trading on this idea that a DD is freakishly large and only worn by pregnant women and Dolly Parton. But you already know this is not true. Don't spend money on maternity bras (unless you happen to find one you like in your correct size). Instead you have two options:

Buy regular bras in new sizes:
Advantages: They should be relatively easy to find, you can try to buy cheaper ones you don't love assuming you'll change again soon and will toss them.
Disadvantages: you will have to toss them once you grow out of them, because you will probably never wear them again. By the time you're done nursing you won't be those sizes anymore.

Buy nursing bras in new sizes:
Advantages: You can wear them again - when you're going back down the other side of the hill, while you're nursing, so the investment of buying good, comfortable ones will be worth it. You can also explore your nursing bra options before you're busy with a new baby, and hopefully you'll have a couple that fit right away or soon after your milk comes in.
Disadvantages: They may be harder to find and will probably be more expensive. If for some reason you skip a size on the way back down the hill, you may not get your money's worth out of them.

You can choose to do either one, or a mix of the two. Getting nursing bras seemed to work for a lot of pregnant women at my old store - the way I see it, if you buy a regular bra you're guaranteed to be buying a bra you can never wear again. Buying a nursing bra you at least have a shot at wearing it again. But ultimately, the most important thing is to feel comfortable.

My final zinger toward the maternity bra industry: maybe there are some good bra fitters at maternity clothing stores, but I've never heard of one. Where I used to work, women would come in having been fit by maternity store people who clearly just handed them a 36DD, then a 38DD, and so on until they found something plausible. Since you know maternity bras don't exist, there's no reason to shop for bras at maternity stores unless you can't find your size elsewhere. Better to get fit someplace good.

How to fit bras in pregnancy

You measure for size exactly the same way during pregnancy and nursing as at any other time. The real difference is what you do with that information - instead of using it to buy a bra at your exact current size, you're using to it try to get something that will work for you as your size changes. How do you do that?

Cup size: Most women find they gain several cup sizes during pregnancy. The "average" is 1-2. Of course, I've fit women who have not changed at all, and others who went from a DD to a K. Changes may happen slow and steady, or in "growth spurts".

Since you can't predict how much you'll grow (or when), don't buy way-too-big cups assuming you'll grow to fit. Instead, if you're on the edge of one cup size, buy the next one up. If you keep growing and your cup threaten to spilleth over, loosen the shoulder straps - that will give you some extra room, and buy you some extra time.

Remember to not get fixated on the cup size letters. Maybe you're used to being a B. Add two sizes to that, and now you're a D. Maybe you're used to being a D, or a DD. Now you're an F or a G. It can be hard to wrap your mind around letters that don't seem to match your idea of your body. Some people just reject the letter (and the right bra) out of hand. But remember, those letters don't say anything about your body! Ignore them and find a bra that really fits!

Band size: In my experience, most women gain maybe one, maybe two band sizes in pregnancy. It depends on how you carry, your weight gain, and how sensitive you are right up by your rib cage. However, it is NOT generally a huge gain.

"But I gained at least 3 band sizes during pregnancy!" Maybe you did! But most women think they are growing a lot in band size when in fact it's the cup size that does more of the changing. Because most people don't understand cup size, they keep putting on bigger bands to get bigger cups. They also assume that their bras are tight in the band because they're getting so big around, when in fact it's their cup size causing the strain. (But since you know how sizing works you'll know how to fit it properly.)

That said - you probably will need/feel more comfortable going up at least one band size during your pregnancy. When shopping, buy bras that fit comfortably on the tightest hook when you try them on in the store, so you can expand the band size as needed.

Especially towards the end of your pregnancy, a band that had fit OK or was a little tight might start feeling very uncomfortable. Your rib cage area generally goes down as soon as you give birth so buying a bigger band size just for the last 3-4 weeks might be a real waste if you're doing the nursing bra thing. Instead, you can get a bra extender (at bra shops or at a fabric store like Jo-Ann's). It hooks into your band and gives you another inch or two. Voila! Automatic temporary band expansion.

So to sum up: in pregnancy, buy bras sparingly at each size. Consider buying nursing bras, and don't waste extra money on "maternity" bras. Remember that your cup size is probably going up more than your band size, and fit accordingly. Buy bras that fit comfortably on the tightest hook, and use a bra extender if you're sure you just need more space in the band. If choosing between cup sizes, choose the bigger one, but don't buy too big - loosen the shoulder straps if you need more room.

Next up: nursing bras!

Friday, June 26, 2009

Pregnancy and birth stories, pictures, linky goodness

Pregnancy and natural childbirth from a father's perspective. It's a nice perspective, gently poking fun at some things he's surprised but generally curious and open-minded.

These are just beautiful pictures from labor and birth.

Beautiful vintage breastfeeding poster!

A baby born in the caul, under water! If it's true that babies born in the caul are specially gifted, then there are few babies in this country getting that gift these days...

Singing in labor - much as I'd like to imagine someday singing beautiful music all through labor, since I can't sing it now I think I'll have to abandon that dream!

Another nice birth story with lovely pictures. I especially like the one of the dad cuddling his newborn skin-to-skin.

As I've said before, I'm trying to post the positive and beautiful - not just the maddening and intolerable. I hope these links provide some uplift :-) (Along with the new bras you're buying, right?)

Wednesday, June 24, 2009

Should we keep talking about obesity in public health?

Dr. Dinosaur has a good post on Why Obesity is NOT a Disease. Unfortunately, I think this is news to a lot of people, including many health care professionals. In public health, obesity=disease is accepted as a given and this often makes me uncomfortable. I feel fortunate that I have been exposed to the writing, speaking, and work of fat activists and research from scientists who are questioning the “obesity epidemic” - but only in a limited way. I don’t really feel confident enough to fight a lot of the generalizations that are made about overweight/obesity in class lectures and discussions. In public health, at least, while the outcome focus may be on reducing obesity, the methods are generally not focused narrowly on weight loss. Public health tends to go for more walking paths, better food options, and other interventions to help people lead overall healthier lifestyles.

On the other hand, continuing the data collection focus on overweight/obesity concerns me. I’m running some data for my internship right now on preconception and prenatal risk factors for women who have experienced a fetal loss or infant death. I noticed that while prepregnancy weight BMI data gave us all 4 categories (underweight, normal weight, overweight, obese) last year’s report only reported percent of women who were overweight and obese. Yet 10% of our sample had been underweight, which seemed like a pretty big number. I decided to do a little literature search on risks of prepregnancy underweight and found that they were not insignificant – and included increased risks of preterm birth and low birth weight, which were two of the main causes of infant death in the group we’re looking at. It’s moments like this when our lopsided obsession with BMI really becomes clear, and I feel like I should speak up more in class. As it is, I added a sentence to this year’s report discussing underweight. Of course, I couldn’t have a nice little box comparing it to the Healthy People 2010 goals (the way I did for obesity) because wouldn’t you know it – there is no HP 2010 goal regarding underweight.

For great posts on what this focus on weight means to pregnant women, and resources to educate yourself more on pregnancy and women of size (along with great posts on other topics like cesarean prevention) check out The Well-Rounded Mama (the list of “Top Posts” to the right of her current posts is a good place to start).

(P.S. Nursing bra post coming soon!)

Friday, June 19, 2009

How to find a bra that fits [Part 1, not for pregnancy or nursing]

I used to work as a bra fitter. Not just any bras - nursing bras. That's right - just in case being a doula, going through a breastfeeding educator course, and then doing dozens of breastfeeding consults during my AmeriCorps stint hadn't provided me with more than my lifetime quota of boob-viewing. Still, it was a good set-up for doula work because they were flexible if I, or the other doula working there, needed to call in "birth". (You would think we'd have also gotten clients from there but it wasn't as great a networking spot as you'd think.)

Anyway, I had never really understood how bra sizing worked before I got hired there. I had, when I was about 14, tried on bras in a JC Penney's dressing room until I found a size that seemed to work, and stuck with that size for well over the next decade. Sometimes I'd try slightly different sizes, because Oprah said that 80% of women were wearing the wrong bra size, but the ones I picked seemed too small or too big. I got measured at a Victoria's Secret one time and tried on their recommended size - that was a joke. I stuck to my old size.

A month into working at the store, I realized how I had been wearing a laughably wrong bra size for years. After a few more months, I realized how EVERYbody (or at least 80% - just like Oprah said!) else had been too.

One day during that time, I saw a picture of Dolly Parton and it got me wondering - what was her bra size? I had fit people resembling her, so I thought I had a pretty good guess. Googling around, however, I got mostly the same figure - one that I just could not believe. If a woman who looked like her walked into the store I used to work in and said she was a 40DD, every fitter in the room would turn around and raise their eyebrows.

But yet this "40DD" was repeated over and over on different websites with absolutely no questions asked. And it got me thinking about the fact that most of the world doesn't understand how bra size works - heck, I didn't until I started working as a fitter. I feel like bra sizing is this secret that's not hard to understand, but somehow concealed from women worldwide (possibly so we won't demand any sizes outside of 32-34-36 A-B-C). So I want to do a little explanation, because understanding this has changed my bras (and my life - really) for the better. I wrote a version of this a while ago for my my personal blog and had a lot of friends ask me questions and go for fittings. After this post, I'll do another one specifically on what I've learned about buying bras for pregnancy and nursing.

Your band size

The first part of your bra size - the number, aka the "band size" - has nothing to do with your breast size. Nothing. It has to do with your ribcage size. Wrap a measuring tape around your body just under your armpits, and pull tight (actually, have someone else do this for you). That's the number you're looking for. It's likely to be smaller than what you're wearing now.

"But I'm a 36! I've worn a 36 my whole life! It fits!" Take a look in the mirror. Do your bras ride up in the back? The back should be exactly level with the front of the bra. If they're riding up, they are TOO BIG. Period. "But I put on a 34 and it felt soooo tight!" Of course it will. You've been wearing 36s for your whole life. Wear the right size for 3 days and after 3 days it will no longer feel tight. Then put on your old bras and see how uncomfortable they really are - how they don't lie flat against your ribs, how they ride up underneath your breasts, how the straps are always falling down. (Right? You thought it was because you didn't tighten the straps enough. But since I started wearing the right band size, I can count on one hand the number of times my straps have fallen.) They don't give you any support underneath, so all the weight is hanging from your shoulders. They're Bad. You'll throw them out (just like I did) and be happier for it.

"But my band size is less than 32. So I'm a 32, right?" While a store like Wal-Mart will carry up to about a 44 band size, and a lot of plus-size stores will carry larger band sizes, finding very small band sizes is harder. That does not, however, mean that you should wear the wrong size. 30s and 28s are out there - mostly online, in specialty stores, and at Nordstroms. "But that will be expensive!" It is hard when you're used to buying $15 bras and discover that they weren't really doing you any favors and you have to shell out some more. But think about this: unless you have a smaller cup size and don't need it all the time, you probably wear your bra all day, every day. (Cost it out over total hours worn and you may see things differently.) It is what makes your clothes look good, makes you feel comfortable, and can help relieve back and neck pain. Treat your bras nicely and they will last longer, but regardless of lifespan they are worth the investment!

How important is the exact right band size?

If you're an A or B cup, do you really need to wear a nice tight band? Probably not, because you don't need as much support. If you're "supposed to be" a 32 but you like 34s better - not such a big deal. If you DO need the support, however, you want a tight, supportive band. It's a nice secure shelf under your breasts.

Can we talk about cup size now, please?

OK, we've got the band size taken care of. Now for the cup size. The cup size is the letter. It is the difference between your band size (around your ribcage) and your bust size (around the fullest part of your breasts). A few things about cup size: it is not absolute. Because it's about the DIFFERENCE between sizes, someone who is a 32C will have smaller breasts than a 40C. Cup size is all about proportion. This is why if you have a small band size, you are more likely to have a big cup size: the breasts that are a C on your sister who has a 38 ribcage will be a DD on your 34 ribcage.

"I'm a DD, that's so huge!" No, it's not. It's just a different proportion. When you start being realistic about your band size, you will inevitably go up in cup size (I have never met anyone who was wearing a band that was too small - most people are wearing a band that is too big).

I don't hold with measuring for cup size except as a general guide. Use it to get you in the right zone, but one measurement shouldn't be taken as gospel. Once you have a band size that you know works, just keep trying on larger cup sizes until you get one that fits you smoothly (no wrinkles) and doesn't create a double-boob on top by cutting into you. Ignore the letters - no really, ignore them! They will only distract you with preconceived notions of what that particular letter looks like on someone's body.

"But I CAN'T be a DD!" Why not? "Because that's so HUGE! I mean, Dolly Parton is a DD!" No, she's not. She obviously doesn't want to freak people out, but looking at her I would guess she's a 34H, minimum (and she's so tiny - she has to be a 32 or less). If she's making up for it by wearing 40DD, no wonder she has back problems.

"I've never heard of an H!" In German sizing (we carried a lot of bras from Germany in the store where I worked) they don't screw around with all these double letters. Americans seem to have a mental block about the letter "D" - we can't go beyond it. People will be DDDD's, but they won't just go ahead and be a G, whereas in Germany they just march inexorably down the alphabet. (In England they seem to split the difference by doubling every letter once - D, DD, E, EE and so on - but at least only once.) No one seems to want to hear these letters. Because so many women are wearing the wrong size, we have attached letters like "DD" to Dolly Parton and can't see ourselves realistically.

"But if I'm more than a DD then where do I find my bras?" See above re: small band sizes. They will be harder to find, and more expensive, and yet you will be glad. My recommended bra-shopping websites:,, and (the last is UK-only store although they will ship to the US. I have never ordered from them, but I hear great reviews and they have a good explanation of how to visually assess whether your bra is the right fit.)

One more thing - bra fitters
With all this explanation about how to fit yourself, I can't emphasize enough how helpful a good, experienced fitter can be. And that's why you can't go to Victoria's Secret. A bra store can only put you in sizes they have. Vicky's doesn't have much. Nordstrom's has a much wider range, and in this country is a lot of people's only nearby bricks-and-mortar resource. Local specialty stores are also a good bet if you have one - but check to see if they have the size range you think you're looking in. Always bring your own judgment - it's normal for a smaller band to feel tight, but it shouldn't require a crowbar to fasten, and if something is just not working then say so.

Once you have bras that fit, spread the gospel! I've talked to a lot of women who feel so frustrated and demoralized by bra shopping. It makes them feel bad about their bodies and insecure about what they "should" look like or what size "normal" people wear. I wish more women understood sizing and accepted their bodies and breasts as they are - normal and fabulous - and useful for feeding babies if you get the chance :-)

Where do our ideas about breastfeeding come from?

What does a mother tend to hear if she smokes? Has food poisoning? Has a beer? Is taking anti-depressants or even anti-virals or antibiotics? "You should stop breastfeeding – just to be on the safe side."

Now see what the WHO says are contraindications (opens a PDF). Note how very, very short it is. (Could we print this out and hang it up in every medical office? It wouldn’t take much space.)

What is the underlying message when mothers hear the stop-to-be-safe line? That breastmilk is best – but it is also very easy to ruin in which case it is DANGEROUS! Formula, on the other hand, is basically as good as breastmilk, and always, always safe (Har.)

This message undermines breastfeeding. It gets into people’s heads and stays there. I did a focus group with med students about breastfeeding promotion and one aspiring pediatrician said, “Of course, lots of women can’t breastfeed, because they’re on medication.” The others all nodded and agreed. (This is one of the reasons I want to start a breastfeeding workshop for med students at my school, but I digress.)

This message works because we have internalized another message, that formula is normal and breastfeeding is “special” in that it confers “extra” benefits. If breastfeeding is normal, then instead of breastfeeding’s benefits (lower risk of allergy, diabetes, etc.) we would talk about formula’s risks (increased risk of allergy, diabetes, etc.) So when any risk, even minor, is introduced into breastfeeding (ooh, you had a glass of wine? Better pump and dump), it’s better to go with something that you know is totally safe. Right?

Where did THAT message come from? Why do we see breastmilk as so fundamentally untrustworthy? Jacqueline Wolf is a professor of the history of medicine and has done some fabulous research on the history of breastfeeding and artificial feeding in the U.S. Her article, “The Social and Medical Construction of Lactation Pathology” (Women & Health, 2000. 30:3,93-110) explores how and why we started constructing this idea of breastmilk as easily spoiled and dangerous:

Women’s accounts of their breastfeeding travails and their consequent need for galactagogues and human milk substitutes engaged early twentieth century pediatricians like no other medical crisis. Despite doctors’ universal support of breastfeeding--and their consistent condemnation of artificial feeding--they began to corroborate mothers’ frequent reports of too-little, or bad, breast, milk.

Note: She has also done research on why there was a growing epidemic of “bad” or insufficient milk starting in the 1880s, and concludes that it was due to the rising popularity of regimented feeding schedules (often feeding every 4 hours) which lead to low milk supply.

Physicians publicly advised women of the dangerous propensity of human milk to metamorphose within women’s bodies. When F. W. Reilly, the Chicago Assistant Commissioner of Health, urged mothers in 1895 to nurse their babies in order to keep them healthy, he coupled the decree with an equally stern caveat. Under certain conditions, Reilly warned, "even breast milk" caused babies severe digestive distress. If a mother is overheated, he explained, she should express and discard a teaspoon of milk before breastfeeding, implying that the milk nearest the surface of mothers’ bodies could easily sour--like cow’s milk left on a porch during the summer. …

Although the medical community continued to declare breastfeeding the optimum practice after a birth in principle, doctors now counseled mothers and each other that human milk was best only if a mother supplied her baby with, not just any breast milk, but an "average" breast milk (Churchill, 1896). "Below-average" or "too-rich" human milk, they contended, posed as great a peril to babies as breast milk substitutes. An editor of an infant-care magazine reminded mothers, "Remember that to-day the best artificial food is quite as safe as a poor quality of human milk" (Nursery Problems, October 1887).

So now, even when we understand the principles of milk production and how to ensure a healthy milk supply, we’re still left with the idea of breastmilk as a touchy, easily spoiled substance and mothers’ bodies as unreliable. (If you want to read more about this I highly recommend Jacqueline Wolf’s book, Don’t Kill Your Baby: Public Health and the Decline of Breastfeeding in the 19th and 20th Centuries. She also has a new book out about the history of obstetrical anesthesia, which I am really excited to read.)

We need to get a new mindset in – from “if there’s anything potentially wrong, stop breastfeeding” to “there’s very little so bad that it can outweigh all the good things breastfeeding provides”. Otherwise, we’ll keep getting women advised to stop breastfeeding because they have food poisoning, have had a beer, smoke, is taking anti-virals, or because the “baby is gaining weight too quickly” – all reasons I have heard personally from medical professionals or the mothers the advice was given to. And that's just not helping.

Oh, and when I did a google search for “reasons to stop breastfeeding”, what was the first ad to come up?

Stop Breastfeeding
Get a Free breastfeeding support
kit w/ important DHA supplement.

Wednesday, June 17, 2009

New breech guidelines from Canada

The Society of Obstetricians and Gynecologists of Canada has come out with new guidelines for breech birth, saying that the automatic c-section is not an evidence-based practice and that all breeches should be evaluated and offered vaginal delivery if appropriate. New guidelines are here. I was curious to read through the guidelines, but as I read them I thought “What doctor is going to be willing to go through this checklist when they could just schedule another c-section and be done with it?” That’s why I liked an article that accompanies the published guidelines, by Dr. Andrew Kotaska, called titled, “Breech Birth Can Be Safe, But Is It Worth the Effort?”: (all the emphasis is mine)

Whether term vaginal breech birth is safe is no longer a question. The PREMODA study has clearly shown that with careful selection and management by average maternity units, breech birth can be safe. …

In the PREMODA study, the overall vaginal birth rate was only 23%. Is it important to mount the significant effort required to offer women breech birth if only one quarter will thereby avoid Caesarean section? … In North America, over 100 000 women have pregnancies that remain breech at term annually. With a success rate similar to that of the PREMODA study, some 25 000 could safely avoid Caesarean section.

…[T]he current practice of “not offering” women a trial of labour while providing ready access to Caesarean section is coercive, especially given the equivalency of long-term neonatal outcome. Now, with a more comprehensive understanding of the components required to make short-term outcomes of vaginal breech birth equivalent as well, it would be unethical not to provide this information to women. Although it may be difficult in some settings to offer vaginal breech birth routinely, its availability elsewhere should be disclosed and assistance offered to obtain it if requested. To offer only Caesarean section is ethically and legally difficult to justify if a reasonable alternative is available.

This is really the crux of it, and the guidelines even state that women who refuse a c-section recommendation must still be given care (why does this even need to be said?) Why is it OK to providers to offer one option and not the other? What if no c-sections were offered and all women were required to deliver breech vaginally, regardless of the risks – would anyone be ethically down with that?

I think the next big step is to change the attitude that offering women one choice (to be accurate, no choice at all) is acceptable. After some new evidence came out about Term Breech Trial and other breech trials in 2006, ACOG did a weak “we guess maybe you could try vaginal breech if you REALLY REALLY want to” policy change, and I think everyone would agree it didn’t change much here. The Canadian guidelines, on the other hand, are actual guidelines with specific recommendations on how to safely offer and assist breech deliveries, along with a recommendation to train more providers in breech skills. But without strong advocacy the status quo seems likely to persist there as it does here. Will there be loud enough voices in Canada demanding that those guidelines be applied?

Monday, June 15, 2009

'Birth Beyond Belief' - Homebirth on TV

I got this through a doula listserv. Here's the press release:

We are excited to announce the premiere of Births Beyond Belief, a reality program which airs on Discovery Health June 16th at 7pm CST. The show, created and produced by Video Arts, explores the ups and downs of homebirth by following three separate mothers in Hawaii, Los Angeles, and New Jersey. Rarely is homebirth highlighted on such a large stage in mass media like Discovery Health, which is broadcast in over 68 million households.

Demi Moore and Ashton Kutcher's full time chef, Grace GlennAnthony, pursued a home birth with their support. The Video Arts crew documented Grace working in the celebrities' Beverly Hills home. Grace's baby was in the breech position making homebirth an illegal option according to California law. She was forced to choose between sacrificing her dream birth and breaking the law.

Hawaii couple, Jason and Kollette Stith, gave birth on their organic coffee bean farm deep in the mountains in a Mongolian tent known as a yurt. The delivery was complicated by the fact that their remote location is only accessible by four-wheel drive vehicles and does not have running water or electricity.

A New Jersey couple, Soyini and Esu Ma'at, were expecting their second child. The Video Arts crew documented Soyini in a temple in Brooklyn using sacred Egyptian meditations to prepare for birth. The birth took a dramatic turn when Soyini requested to move from the floor of her bedroom to a birthing tub to deliver after the baby's head had crowned.

Don't miss this engaging documentary produced right here in Fargo, ND by Video Arts Studios on Tuesday, June 16th at 8pm (EST/PST), 7pm (CST).

Do I smell a little sensationalization here? A breech birth, a remote location, and obviously a stretch for the third one - "Oh no! She wanted to move! You can't MOVE!" It's frustrating because the press release makes it sound like it's so great that they're showing homebirths, and then goes on to spin all three births as only something only those crazy, "beyond the pale" types do. Why does home birth have to be "beyond belief" or "dramatic"?

Someday I'm going to make a documentary about hospital birth called "Sadly, Births That Are All Too Common". Instead of dramatizing un-dramatic things, it will do the opposite. When someone yells in a mom's face to push, the camera will zoom in on reassuring FHTs and a pop-up will offer the factoid that purple pushing is not evidence-based. When a mother is told her labor is progressing too slowly and she requires an "emergency" c-section, we'll cut to a review of the research on labor dystocia. Fun!

I am currently cable-less, but given that Discovery Health re-airs things often, I'm hoping to catch this show again in the future. If anyone out there watches it first, I'd like to hear a review!

Sunday, June 14, 2009

Maternal mortality in NY state under review

The Poughkeepsie Journal notes efforts in NY state to investigate rising maternal death rates and notes that they have risen along with cesarean rates.

A few thoughts about this: it's easy to say "more women have cesarean sections because more women are high risk" (this is essentially what one OB in the article says). Very true - sing it with me, "Correlation does not imply causation". (By far the most important thing you learn in epidemiology.) High-risk women are more likely to have c-sections, and also more likely to suffer serious complications. But research also shows that cesarean section rates have risen for ALL women in ALL risk categories. So yes - it's not just that there are more high risk women, it's that there are more c-sections done on them.

I also wish the article had been willing to make it clear - c-sections DO carry a higher risk of maternal mortality. Maternal mortality is very rare - that's why it's measured per 100,000 (vs. infant mortality, which is measured per 1,000), so an increase may not be quickly visible because the rise in absolute numbers is very small. But if we get to a 40% cesarean rate, or 70% cesarean rate, or 100% like in some places in Brazil - we may not be able to say for sure which deaths were caused by cesarean, and which would have happened anyway, but it will be statistically guaranteed that some women will die from unnecessary cesarean surgeries. It doesn't really seem debatable.

Finally, as a caveat to all this and the entire article - I was curious to know whether New York state maternal mortality reporting has changed in the decade in question. Many states have adopted new death certificates and new reporting rules that have really upped the number of pregnancy-related deaths reported. The changes in reporting have made it really challenging to say anything reliable about national trends, and I wonder if the same holds true for NY.

Friday, June 12, 2009

OK, that wasn't quite all for today

Thanks to Jill's link giving the Times Online three dramatic chipmunks for their misleading homebirth headline, I was reminded that I wanted to post this:

The Science News Cycle. Oh yeah, this definitely applies to birth!

Public health doula is BACK!

This has been quite the radio silence! There's been a lot going on - moving, traveling, settling into my new city and my summer internship...and then my computer died. More accurately, my hard drive. So after getting it replaced, trying to get the data off the old one (note: back up your hard drive, or you will regret it), and formatting and installing everything on the new one...I am back.

I have a crazy backlog of posts in mind and will probably never ever catch up on all of them. So for now I'll just share a little bit about my work this summer. My internship is in a large metro-area county health department - keep in mind that this is a county that has more population than most states, so it's not a typical county health department! I'm working with the data people - that means a lot of taking big datasets and running the numbers to generate reports and answer information requests from outside. The data that we're working with is MCH-related, so that's been very interesting for me to work with - playing around with breastfeeding stats is always fun. It's also educational to see how the sausage is made, statistically - for example, how information from birth certificates is transformed into usable data. My co-workers are very helpful and I'm already learning a huge amount about statistical analysis software, how large surveys are run, the ins and outs of survey design and data collection - all things I know I didn't have experience with, and wanted to add to my skill set.

Still and all, after a few weeks in front of the computer crunching numbers, I can tell that this work isn't about to jump out and seize my interest. It's challenging and interesting to figure out how to get the data someone needs, and it's incredibly important and useful, but I'm not a big one for abstractions. I like people. As a doula, that's a helpful asset. I hope to locate my public health career somewhere in between the one-to-one of direct service as a doula, and sitting in an office cubicle analyzing hundreds of thousands of births. The next step is to figure out exactly where in that in-between space I'd like to be.

As I left off with a link dump, I'll do another one to clear out some of the (many great) posts that have been getting starred and stored in my Google Reader. Mixed in here a couple of really lovely birth stories/videos/photos - I am renewing my vow to post the good and not just the bad!

Jive Turkey tells her birth story:
Part One and Part Two. She has a pretty funny take on the experience. She's also posted a "what you need to have a baby" and suggests that to the hospital, you bring "YOUR BALLS". Amen.

Guestblog on Radical Doula about ICTC Doula Training. It makes me wish I'd taken my doula training with them! If you're interested in doula-ing with a social justice/community focus, check this out.

Birth Faith talks about why giving birth without medications doesn't make her a hero. The "don't be a martyr" line sets my teeth on edge because no woman has ever said to me, "I'd like to give birth unmedicated because I've always dreamed of being a martyr."

Preggy Blonde's birth story with a couple of really lovely photos.

Amazing birth story in photos via Birth at Home in Arizona, who also posts a link to a a beautiful home birth video.

That's all for today!