Friday, December 31, 2010

Popular posts of 2010

I've seen several other bloggers do this in the last couple days, and it seemed like a fun idea! Below some of the posts I wrote this year that stirred discussion, links, and pageviews:

What to Expect When They're Making a Movie" Wow, this seems so long ago it's hard to believe it happened in 2010! Inspired by the news that the much-reviled "What to Expect When You're Expecting" was being made into a movie, I hosted a contest for the plot that would best represent the spirit of the book. Read the winning entry here.

Is it wrong to talk about the public health importance of breastfeeding? was by far one of my most commented and linked posts this year. After the Pediatrics article was published in which the authors estimated the financial and infant mortality costs of not breastfeeding, there were a number of online and offline commentators talking snidely about how this was just another guilt trip that the "breastfeeding bullies" were laying on women. I saw things just a little bit differently.

Los dos and an awesome new campaign discussed how I struggle with the mother's desire to do "los dos" - both breast and bottle - when working with Hispanic families. Its companion post Volumes - a huge problem discussed one of the reasons why this becomes so problematic.

Which growth chart to use seems to have gotten a lot of linkage as people learn more about the recommendation that breastfed babies be measured on the new WHO charts.

And people seem to be finding my series on Choosing and getting into MPH programs helpful. Final installment coming soon! (I swear!)

Notice a theme? First training and now working as an IBCLC, my posts this year have more and more tended towards topics around breastfeeding. It's just what I'm thinking and reading about most of my work-related time these days. Between work and travel, I haven't been able to take any doula clients since September although I'm hoping to have several this spring, so I've been getting out of a birth sphere of thinking. Being out of school, and in direct clinical practice, has also drawn away some of my focus on public health. I've started to feel like "Public Health Doula" is a bit of a misnomer for this blog, although I can't think of anything better at the moment! We'll see what 2011 holds for my career and for my posts. Have a Happy New Year!

Thursday, December 23, 2010

When and how to give formula to the developing world

Every new disaster in the developing world seems to bring e-mails to my inbox with appeals for donations, and every time one lists "infant formula" that I cringe, and ponder whether or not I should try to start a dialogue around the dangers of those donations and importance of providing them correctly.

Via the Motherwear Breastfeeding Blog, here's an example of when and how to offer infant formula appropriately: in a setting of acute medical need, under medical supervision, prepared safely and accurately by professionals, and - so importantly - in a way that is supportive of breastfeeding:

Helping Hospitals Treat Malnutrition in D.R. Congo from Action Against Hunger USA on Vimeo.

Watching the baby's eyes light up as it nursed away using the improvised supplemental nursing system reminded me so much of babies I've worked with in the hospital. We sometimes need to provide a supplement for babies who have lost more than 10% of birth weight. Often this is because the mom's milk is delayed coming in for some reason - very long labor and/or long pushing stage, or a lot of postpartum blood loss. Of course, taking the baby off the breast and giving the supplement by bottle has the potential to confuse the baby, demoralize the mom, and creates extra work for her having to pump to continue stimulating her breasts in order to get the milk in ASAP. We always prefer to use an SNS, assuming the baby is latching and nursing well - just put the baby to breast, get the suck going and then slide the tube in the corner of the mouth.

When you start the SNS you just see the babies' eyes fly open as they nurse away hungrily thinking "Hey! This is new!" A day or two of SNSing, and with all this continued stimulation mom's milk comes in, we pull the tube, and they're good to go. It feeds the baby while keeping everyone - baby and parents - breast-focused, and protects the milk supply. It's so neat to see it used half a world away for not-dissimilar purposes.

Friday, December 17, 2010

Books Ngram viewer: dangerously addictive

I've been on this for an extremely short time and I can already see how totally fascinating it is. Check it out:

(The "doula" references of previous centuries seem to be largely names, or transliterations of names.)

Thursday, December 16, 2010

Yes, Virginia, crappy OBs really do exist

I read and enjoy several blogs by physicians including OBs. One theme I hear frequently repeated by those doctors is (if I may paraphrase) "the natural birth community (particularly online) paints all OBs as evil/uncaring/c-section happy/in a rush to get to our golf game. I am not like that" - sometimes then there is a chorus of "well YOU are very rare and special" from the commenters - "and my colleagues are not like that. They are wonderful people who care about their patients."

I believe that there are caring, dedicated OBs out there and I believe they are in the majority. Keep in mind that this doesn't mean I believe their caring and dedication play out in ways that are always mother-friendly. I also believe there are OBs who routinely practice in a way that is based on informed consent, patient choice, and respectful communication even when the patient disagrees with them or wants to diverge from their standard practice; I sometimes have difficulty believing they're in the majority, but I don't believe they're rare, special pearls.

However, I do think that the proportion of non-evidence based, aggressive, and/or insensitive OBs is higher than the other OBs realize. They just don't routinely see each other in practice. In a teaching hospital where there are residents, fellows, attendings, etc. all working together this is less true, but once OBs are out in the community in their own practices, they're not following each other around to see what goes on inside the exam room or in L&D. So behavior like this happens to women, is reported by those women or by observers, and is disregarded by OBs as "My colleagues are good people. They're not like that." You can be a nice, caring person and still be like this:

Well, the OB feels this need to check her cervix again. After I just did the same thing less than 2 minutes before. I even said - "hey, I just checked her. She's still only 7-8 cm. But she's hurting bad in that one spot, so anesthesia is coming up to re-dose her."

"You think I can stretch her to 10cm?" he asks.

"No way. Cervix is too thick all the way around." I tell him as I cringe at the thought of manually opening her cervix when she is in such excruciating pain to begin with.

The OB insists on checking her again. And forces her cervix open another 1-2 cm. The woman is screaming at the top of her lungs through all of this. I'm giving the doc the evil eye, and telling him again - "anesthesia is coming up. This woman deserves some better pain relief!"

The OB is telling the woman to push through it.


I look at the woman and mouth "I'm so sorry" to her.

From labor nurse At Your Cervix.

I doubt that this doctor walks around with horns sprouting out of his head, or telling OB colleagues how much he hates his patients. He may even be lovely to some of his patients, or lovely in certain situations. But I think it's OK to admit that not everyone knows what goes on behind closed doors, and that when women tell their stories of inappropriate treatment, we should validate and honor those stories. The kneejerk response should not be "No one I know would do that - we are good people" (and neither should it be "All OBs are EVIIIIIL"). Because clearly, someone IS doing that - and why couldn't it be someone you know?

Wednesday, December 15, 2010

NPH on donor milk

Two of my favorite things, Neil Patrick Harris AND donor milk - TOGETHER?!? Thanks to Kellymom's Facebook page for the link:

(And yes, it was a little crass, but I laughed out loud at Craig Ferguson's offer.)

Consider this a lead-in to my next installment on thinking about who should get donor milk. NPH mentions one of the issues mentioned in the comments on my first post, on the expense of donor milk. Even though (as a television star) he can obviously afford it for his daughter, he notes how pricey it seems.

He also is a good illustration of several potential situations to consider when we think about how to prioritize donor milk: it sounds like his daughter has some formula intolerance (although not severe), and there is no parental milk supply available (he and his partner had these babies via surrogate, although I know some surrogates provide milk for a brief or more extended period of time).

Tuesday, December 14, 2010

NY Times on kangaroo care

A NY Times piece on kangaroo care, from their Fixes blog:

The babies stay warm, their own temperature regulated by the sympathetic biological responses that occur when mother and infant are in close physical contact. The mother’s breasts, in fact, heat up or cool down depending on what the baby needs. The upright position helps prevent reflux and apnea. Feeling the mother’s breathing and heartbeat helps the babies to stabilize their own heart and respiratory rates. They sleep more. They can breastfeed at will, and the constant contact encourages the mother to produce more milk. Babies breastfeed earlier and gain more weight. ...

Dr. Rey took a challenge that most people would assume requires more money, personnel and technology and solved it in a way that requires less of all three. I am not a romantic who wants to abandon modern medical care in favor of traditional solutions. People with AIDS in South Africa need antiretroviral therapy, not traditional healers’ home brews. If you are bitten by a cobra in India, you should not go to the temple. You should go to the hospital for antivenin. Modern medical care is essential and technology very often saves lives.

Kangaroo care, however, is modern medical care, by which I mean that its effectiveness is proven in randomized controlled trials — the strongest kind of evidence. And because it is powered by the human body alone, it is theoretically available to hundreds of millions of mothers who would otherwise have no hope of saving their babies.

Read the rest here.

I felt somewhat sad reading this because we had a meeting at work recently about feeding in the NICU and the nurses were saying that because of new bubble CPAP machines, it's becoming harder and harder to do any kangaroo care with many babies in our NICU. This photo illustrates why - it is difficult to position the baby in any way but with its head supported from behind. We were trying brainstorm ways to have baby facing out, although I don't think that would be as nice for the parents. Does anyone have experience with kangaroo care + bulky CPAP?

Tuesday, December 7, 2010

Surprise breech story

An amazing story from a classmate of the student midwife and L&D nurse At Your Cervix:

There are several nurses in the room readying for delivery. I lower the bottom of the bed, glove up and Mary hands me the amniohook. Nice hard vertex presentation, large bulging bag, just a bit of an anterior lip, then AROM, and clear fluid. It was going to be easy. Ana bears down, my fingers still in. But… something is just not quite right, palpate around, what is that at 3 o’clock? Lips? Nope. Ear? No. Scrotom? Yep!
I glance over to Mary and in a remarkably calm voice, say:

“Glove up”

“Huh?” says she.

By this time Mary is taking in the rather “unable to ignore” saucer- sized eyes that I’m exhibiting.

“We’re breech”

Read the rest here.

And if you have thoughts about who should get donor milk, or ideas for Blessingways, I am still happily welcoming comments on either!

Friday, December 3, 2010

Ask the readers: Blessingways!

True confession: doula and birth junkie that I am, I have never planned or even attended a blessingway. (I'm pretty sure that a VW van full of long-skirted, patchouli-scented wimmin just screeched up outside my house and they're about to start pounding on my door asking for my hippie card back.)

But with one of my former MPH classmates expecting a baby in February (I am starting to lose count of the people I know in person or online who are due February-April 2011), I started talking with several of our friends about doing something for her before the baby comes. I think I can be quoted as saying something like, "Oh, oh, WAIT! Instead of a shower, can we do a blessingway? PLEASE??" (And this being public health people, one of them already had experience with blessingways through her practicum placement at a perinatal substance abuse treatment program. The women there, who all lived together, would do a blessingway for each participant as she neared her due date.) So we're in the midst of planning and I'm getting very excited!

One thing I think would be really nice is the tradition of each placing a special bead on a string for the mother, along with a wish/prayer/affirmation/etc. for her. I especially like this because so many of our classmates have scattered to other states or continents post-graduation, and this is a way they can still participate by sending their beads from a distance.

This being an MCH event, there will also of course be lots and lots of delicious food!

But what else should we do? Have you attended or had a blessingway planned for you? What have been your favorite activities/traditions?

Wednesday, December 1, 2010

Who should get donor milk? Who should it be offered to?

Dou-la-la's post on encouraging the informed milk use of donor milk over formula supplementation got me thinking. At the hospital where I work, I have a lot of parents ask me about supplementation. They want to do los dos from the beginning, or they believe that the mother's colostrum isn't sufficient, or they're concerned that the fussy baby who wants to nurse constantly is starving, or they're tired of the fussy baby nursing constantly and just want to sleep. If they're really set on it, I encourage them to supplement at the breast vs. with a bottle, and not to give too much. If they're considering it but haven't decided yet, I do my best to educate them about risks of supplementation, including compromising future milk supply and altering the baby's gut. But in the end, it's their baby and their choice if they want to supplement.

Sometimes, I have to tell parents - even parents who don't particularly want to hear it - that we need to supplement. Because their baby has lost too much weight, or because there are latch difficulties, or because there is persistent hypoglycemia not helped by just direct breastfeeding. We do our best to supplement with only the mom's own expressed milk, but sometimes we have trouble getting enough of it out. In the end, those parents have to supplement - it's a medical necessity.

The thing is, no one at our hospital actually has to supplement with formula. We have banked, pasteurized human milk available for our NICU babies, and the term babies can access it as well if the parent requests it and gets a physician order. We don't need to ration it; the milk bank will tell us if they're running low and will ration appropriately on their own. We can offer it to anyone we want and they can use as much as they need while they're in the hospital, with the cost covered completely by the hospital, regardless of their insurance (or lack thereof). But once they go home, they have to purchase it from the milk bank directly themselves (unless they can convince their insurance provider to reimburse) or they have to find donor milk through other, less formal channels (as Dou-la-la discusses).

The other day one the nurses made an observation to me about who she usually sees using donor milk and who she doesn't. She asked if we offered it to everybody or if there was some discrimination going on. It got me thinking about it, and I talked to one of the other LCs about who gets offered donor milk and who should get offered donor milk. We had fairly similar feelings about it, but I won't say right now what we thought. I would like to ask all of you.

Since there's now a fairly active blogosphere conversation about donor milk being the ideal supplement for babies who are not being fully breastfed by their mothers for whatever reason: Who should be offered donor milk when the decision to supplement arises - for personal or medical reasons - and who should not? Why?

Tuesday, November 30, 2010

No BPA ban for baby bottles

My friend and political informant Adriane sent this along a couple weeks ago, and I let work and Thanksgiving get in the way of e-mail. So this news is now a couple weeks old, but still important:

Sen. Dianne Feinstein blames the chemical industry for killing her effort to secure, in the food safety bill, a ban on BPA in baby bottles and sippy cups. She said late Wednesday that a last-minute deal with Sen. Enzi to ban BPA in such items six months after the bill passed was scuttled by the chemical industry, which was able to get the support of some Republicans – she named Sen. Richard Burr in particular. Feinstein hoped to get Leader Reid’s approval to offer an amendment, but she told PULSE late Wednesday that her understanding was that he wouldn’t allow them.

“It’s very, very frustrating,” she said. “I cannot understand how a chemistry group would oppose taking out a chemical which at the very least may well impact the endocrine systems of infants because they want to make money.”

Original link here.

Thursday, November 18, 2010

A breastfeeding support home visit

The last Centering Pregnancy group I co-facilitated, the other co-fac was an experienced LC. Between the two of us, we told the midwife that she should let us know when the moms in the group deliver and we would help them with breastfeeding if they need it. Unfortunately, they deliver at a different hospital in town (not the one where I work) where lactation support is extremely minimal. That hospital also tells moms things like "Just let her cry, she'll figure it out eventually" and "Don't feed your baby more often than every 3 hours" and "Don't let them nurse more than 30 minutes". As you can imagine, a lot of breastfeeding problems result... not to mention jaundice readmits.

One of our Centering moms had help from the midwife at the hospital (including her jaundice readmit), and from the LC once at home. Baby would not latch consistently, and the LC e-mailed me today to say that she thought things had been going better but she had just found out they weren't. She was booked. Could I see this mom today?

It was good timing - I didn't work last night - so I called the mom and headed over. Pulling in to the apartment complex and going into her apartment was a total flashback to my AmeriCorps days* - three immigrant families packed into a single apartment, each with one bedroom of their own. The bedroom was even just like I remembered, cramped with a big TV in the corner.**

We spent a long time working on feeding, pumping, and talking about our plan. She has two problems - getting her baby to latch and maintaining a supply with just a hand pump (which wasn't getting used often enough). This mom told me her goal is "puro pecho" which if you've read my "los dos" post, you know isn't always the case with Hispanic moms! I am so determined to help her reach her goal - she is a committed mom who has been persistent where other people would have given up.

Still, it made me discouraged. A more privileged mom would hopefully have the education and resources to quickly identify breastfeeding problems and feel entitled to help; she would be able to hire a private lactation consultant to make multiple home visits; she would be able to rent a hospital-grade pump to maximize her supply.

This mom happened to do Centering and happened to have for facilitators two LCs with extra time on their hands. What about all the dozens and hundreds of other moms in her situation, who we don't know and can't see? In many other counties, I could refer her to a WIC peer counselor; her county's WIC has none and doesn't seem interested in getting any. At best she might be able to get a better pump from WIC (which she didn't realize - I knew to call and ask.) If not for the very rare happenstance of hands-on support, she'd just be left to struggle on her own, offering a screaming baby the breast 8 times a day and using the hand pump she got in the hospital to get what she can.

This is breastfeeding support in our country, to the most vulnerable moms who need help the most. This is why we need to talk about the public health risks of seeing formula as a perfectly good fall-back. This is totally unfair to mothers who WANT to breastfeed, who are working hard to breastfeed, and who do not have the resources to get the help they deserve.

*Bonus AmeriCorps story: Our supervisor did not love us doing home visits - you wouldn't either, if you were an experienced midwife with strong maternal instincts, in charge of a group of naive but enthusiastic young women. She approved home visits only in very specific circumstances and with lots of warnings. We also had to call when we got there and call when we left safely. Like I said, strong maternal instincts. So one of my teammates and I went to do a home visit one day after lots of dire warnings and promising to call. We are primed to be cautious. We get there and it's just mom and baby home. We start helping her... and her boyfriend walks in just home from work - with a six-pack of beer. Immediately we both get a little anxious. This is what our supervisor was most concerned about - boyfriends/husbands/other men around who would give us a hard time or see us as a target. We're having trouble getting the baby latched (all the while keeping one eye on the guy doing stuff in the kitchen) and we suggest to mom that she pump a little to get the milk flowing. Her boyfriend leaps into action, assembling the breastpump, bringing it to her, and then sits beside her, asking us a lot of concerned questions about how the baby is feeding. So much for our paranoid fantasies!

**For a long time I wondered about that - how could people only have enough money for one bedroom, but still enough to have a huge expensive TV? - until one of my AmeriCorps teammates explained to me that buying expensive electronics was how many people in South American countries keep liquid assets. Think about it - if you don't or can't get a bank account, how can you make sure you can get cash if you need it, without actually keeping all that cash on hand? One way is to buy something that will be easy to re-sell quickly. It's not a great investment, because it will depreciate instead of appreciate, but people only have so many options. I really appreciate the work that community-based organizations and credit unions do to help teach people about banking and make those options more accessible.

Sunday, November 14, 2010

Balancing the budget and thinking about health care

One of our MPH courses, we had to do an exercise in which we figured out how to balance the federal budget. We had to do it through making spending cuts alone, and it was unbelievably difficult. It's a good reality check to have to weigh what you want to have happen with the realities of what else would have to be sacrificed to get it. It's a reality check I think more people should engage in when talking about social and health-related programs, taxes, and what cuts and increases really mean when we stop playing year-to-year budget shell games.

The New York Times has a new interactive feature up letting you try that exercise, both by cutting programs and increasing various taxes, with an article explaining how they made their calculations and what the long-term implications of the deficit fight will be:

It [the long-term deficit] comes from the projected growth of Medicare, Medicaid and, to a lesser extent, Social Security. It is the result of baby boomers’ having paid far less in taxes than they will draw in benefits. “The reason we find ourselves in this situation,” said Mr. Bowles, the former chief of staff for President Bill Clinton, “is that we’ve made promises we can’t keep.”

The deficit puzzle focuses on the year 2030 because it is far enough away that the boomers’ retirement will weigh heavily on the budget but near enough that reasonable budget estimates exist. By 2030, the needed deficit cut will equal about 5.5 percent of annual economic output.

By comparison, domestic discretionary spending — all of it, including Head Start, college financial aid, the F.B.I., medical research and airline safety — will add up to about 3 percent of economic output, according to Congressional Budget Office projections. Military spending will equal about 4 percent.

So the solution will have to revolve around tax increases and changes to health care and Social Security. And the country cannot wait until 2030 to implement most of the changes, notes Alan Auerbach, an economics professor at the University of California at Berkeley. If it did, the interest on the national debt could become crushingly large. Deficit cutting will probably be a regular part of politics for the next couple of decades.

It's very popular to talk about cuts in discretionary spending - "let's cut Head Start", "let's stop spending on military technology and spend it on education" but the truth is, entitlement spending is by far our biggest budget item and health care makes up a big chunk of that. Thinking about how to contain health care costs and yes, how to ration health care (not whether to ration health care, since it is already rationed, but how) are going to be a big part of this debate.

Thursday, November 11, 2010

Choosing and getting into MPH programs: Part 4: Getting in

This is Part 4 in my series about choosing, getting into, and getting funded by MPH programs.
(Part 1 is here, Part 2 is here, and Part 3 is here.) Sorry this is taking me a gazillion years to get through. I was planning to finish the last piece in one installment. But in the interests of forward motion, I decided to go ahead and post what I have written at the moment (the "getting in" section) and then work on finishing the last bit ("getting funded") soon (soon, I promise!)

Getting in
I promise this will seem relevant in a minute: When I was an undergraduate, I worked for three years as a tour guide and general admissions office helper. I also sometimes assessed students' writing or art submissions and wrote up summaries for their admissions files. My senior year, I also got to start doing interviews of prospective students - those interviews also went into their admissions files. I had friends who worked at the admissions office as admissions counselors, and I had friends who read files as alumni readers. I knew a fair amount about what went into the admissions process.

I also belonged to an online forum for students, and every year prospective students would post asking for advice about how to get into the school. And all the current students would confidently post back information that was just plain wrong, or at best misguided. They would say things like "Your grades don't matter as long as you're passionate about something!" when in fact, the admissions office was busy turning away passionate kids who had transcripts full of Cs. Because the current students had gotten in themselves, they thought they understood why and how the admissions office made the decisions it did and how it would view other people...but really, a lot of them had no clue.

I tell you all this in order to say that as much as I want to give you advice about getting into graduate school based on my own experience and the experiences of the people I see around me, I won't. Because I've never been part of a public health graduate admissions process, and I might be wasting your time and telling you the wrong things.

Instead the advice I will give you is exactly what I used to post on that message board when I saw misinformation: Admissions officers are not shy. The admissions process may not be easily discernible, but it is not a secret either. They are not trying to hide their process from you. While they probably won't be willing to give you percentage odds on your personal chances, they can tell you what they're looking for and whether or not you fit it.

Informed by my undergraduate experience, when it came time for me to apply to grad school I sat down with multiple grad school admissions officers, as well as professors and/or other people from the departments I was applying to who participated in the admissions process. I said, "Here is my resume, here is my transcript, here are my interests. Is there anything I can do to strengthen my application to your school?" This is a nicer way of saying "Do I have a chance?" and also a way that enables you to, in fact, find ways to strengthen your application before you apply.

It's easy to make assumptions about what a program might want - they'll want their applicants to have classes in biology, or to have volunteered at a clinic, or to have worked abroad for at least a year, or to have X score on the GRE, etc. etc. But you don't actually know until you ask, and if you don't ask you could be setting yourself up for a lot of stress and effort wasted on one set of things, when you should have been focusing on others.

For example, I was stressing about how my (somewhat diverse) work/volunteer experiences would add up in the minds of admissions committees. When more than one told me "Yes, we consider that the work you've done fulfills our experience requirement", that put my mind at ease that I didn't need to try to shove anything more onto my resume before I applied. On the other hand, one of my top choice schools told me that because I had no undergraduate math courses (save one statistics course), they would want to see a good GRE math score - so I studied the crap out of that section.

And when I finally applied, I could feel confident that I had done absolutely everything I could to put together strong applications - because I had talked to the people who would be reading them.

So once again: don't assume what programs want, and don't take my advice, or any other random person's advice, about getting in. Go to the source(s), and ask*. Just call, find out who reads applications/coordinates the admissions process, and make an appointment (phone or in-person). It really is that simple. (P.S. As far as I'm concerned, this applies to all schools, all admissions processes, everywhere. Ask!!)

*Tip: One easy-access way to do this, and to scope out programs in general, is to get a student pass for the American Public Health Association annual conference's Public Health Expo. They have a whole section of schools/programs of public health exhibiting there. For the past few years, on one day of the conference, they've been offering students/prospective students free admission to the Expo room. So if you're in the vicinity of the APHA conference then check it out. I do NOT encourage you to buy a conference registration just to go to this, unless you are independently wealthy.

Questions to ask when you talk to them:

  • This is my educational background and my transcript. This is my work/volunteer background and my resume. What can I do to strengthen my application?

  • What are average/minimum GRE scores that you look for? How important are standardized test scores in the admissions process?

  • Do you have minimum work/experience requirements? Does what I've done so far fulfill them?

  • What do you look for the personal statement to cover?

  • Does it help to speak with professors? (Usually the answer is yes!) How would you suggest I find faculty in my interest areas/make contact with them?

  • What percentage of applicants did you admit last year? The year before?

  • What is a mistake you see applicants make frequently, and what could I do to avoid it?

The only other thing I'll say about getting in: I find that people applying to public health school are often anxious. They are anxious about getting in. I remember being pretty anxious too. I met with admissions staff, with professors, studied for the GRE, revised my personal statement a thousand times, not to mention my resume, and re-read my transcript with a critical eye (not that there was much I could do about it). And in the end, I got in at plenty enough places to boost my ego, and to have a good range of choices.

I wish the world was beating down the doors of public health. The truth is, it isn't a lucrative career and (given that nobody knows what it is!) it's not incredibly prestigious either. There are certainly competitive programs out there, but the insanity does not reach the level that most people accustom themselves to for undergraduate applications.

I say this not to make you feel overconfident (and then write me angry e-mails when you don't get admitted) because yes, people are rejected from MPH programs every year (I was also one of them - it's not like I got accepted everywhere). By all means, work very hard on your applications, but I will say that I think I spent too much time worrying about getting in, and not enough time worrying about how to get funding and where I should actually go. Then, once I was admitted, I kind of had to scramble to figure things out. A little bit of confidence that you will have options can help you prepare for what you'll do once you find out exactly what those options are. Again, just because you can get into a particular program doesn't mean you should do it!

Tuesday, November 2, 2010

Breastfeeding links

To get some links out of the way that have been piling up, and to celebrate my new IBCLC certification, a breastfeeding link party:

Normal Newborn Behavior, and Why Breastmilk Isn't Just Food" from the Lakeshore Medical Clinic

The Academy of Breastfeeding Medicine conference was last week - you can read conference updates and winners of their "clinical pearl" contest at their blog. (One of my favorites: "Give baby until 4 days past his due date to get the hang of breastfeeding." Not that you should give up on a baby after 4 days, but that with moms who are easily discouraged and with our epidemic of slightly early babies, this is a good target date to keep people moving forward until everyone catches on.)

Elita at Blacktating on whether her birth experience set her up to fail at breastfeeding. (Check out the comments for a lot of personal stories from others with the same question.)

The Motherwear Breastfeeding blog posts an ad to educate women in India about the importance of colostrum. (I love all the women going from store to store asking to buy colostrum!)

Public Health Doula, IBCLC!

Thursday night I got a text from one of my LC classmates that the IBCLC exam results were already up. I was standing in a suburban CVS, on a late-night pantyhose-and-makeup run to prep for a wedding. I grabbed my friend's iPhone and started trying to both find the results website and find where I'd e-mailed myself the code to see my results (while babbling "They weren't supposed to be up till tomorrow! Why are they already up! I was going to check tomorrow!") With my iPhone inexperience this took way longer than necessary, and my friends had to herd me to the front of the store to check out (my eyes never leaving the screen). There, standing in the CVS check-out line, I found out that I had passed and am, indeed, a real honest-to-goodness IBCLC.

Wow! I'm relieved, excited, and a little disbelieving. I've wanted to be an LC for so long, and there was a stretch of years where I couldn't imagine when and how it would be possible (a post on this may be forthcoming). That I really am an IBCLC now is kind of hard to believe - it doesn't feel quite real yet. Maybe because I've already been doing LC work at the hospital pending my results, so on the day-to-day level nothing will change (except my paycheck - all right!) But I think also because I recognize how far I still have to go. Back when I did tae kwon do, they used to tell us that becoming a black belt wasn't the end of your training - instead, it was starting all over with a whole new set of things to learn, knowing that you'll be learning them and refining them for the rest of your life. And that's where I feel like I'm at now - ready to step up to the next level with the recognition of how much I still can learn and practice.

Thanks to everyone for your good wishes and support! I have loved having this blog and the breastfeeding blogging community as part of my education throughout this journey.

(P.S. Wedding was great, I'm back from my trip, and hopefully there will be more posts soon!)

Tuesday, October 26, 2010

On the road

Posting lull as I'm on the road - visiting family and friends, then heading to a wedding. Welcome to any of you finding this blog through Facebook - one of my favorite posts on "trying" to have a natural birth is making the rounds, I see!

More posts when I get home again, including (maybe? could it be?) the end of my MPH series.

In the meantime, enjoy some talk about women's bodies and the responsibility society places on women to police their own sexuality:

The lesson, ladies, is that great cleavage comes with great responsibility. People who shame women for wearing “too-revealing” clothes like to center their objections on women’s clothing “choices,” but make no mistake—this is not about what we choose. This is about the things we don’t choose—having chests or butts or legs or necks or hair or any other part of our human bodies that others decide to project their particular sexual interests—and their slut-shaming—upon. The man who is horrified at a woman’s “overly exposed” breasts will likely never have to worry about wearing one shirt—one shirt out of a lifetime of shirts—that happens to accidentally set off some random person’s slut meter, because of the way his body just is. And because my breasts are smaller, less visible, less imposing than other women’s breasts—because there’s less boob there—I can feel free to wear the more revealing top without attracting claims of public obscenity. It seems that some women’s bodies are just naturally sluttier than other women’s bodies—and all women’s bodies are naturally sluttier than men’s bodies.

This is also about the things we "choose", like "choosing" to breastfeed, which is a normal and physiological part of mothering, having all this same b.s. projected on them. It's a shame we ladies are just so normally and physiologically slutty.

Tuesday, October 12, 2010

Opportunities for doula work internationally?

It's ask-the-readers time! I recently got this e-mail from Leila:
I live in the Boston area and am currently in the process of becoming a doula. I also plan on getting my masters in public health soon after I finish college. Your blog brings me lot of hope and excitement as I wet my feet in the field of public health! Maybe you can offer me some advice- I'm trying to find ways of working/volunteering as a doula somewhere in the Third World and I can't find anything! Do you have ideas or know of organizations I could look into that might offer such positions?
I had only one or two possible leads, and I have heard similar inquires in the past and not really known where to send people then either. Does anyone out there have suggestions for her?

Reply turned post, on a 360-degree view of the doula's role

Birthday Nurse wrote a post recently on, in part, the role of the doula in the birthing room:

One thing I always seem to struggle with when I have patients who have doulas is when they ask their doulas for "permission" before they do anything. The patient was thinking about getting an epidural after 10+hrs of backlabor and no real cervical change. She had been talking about it and going back and forth and I asked her if she wanted me to start her fluid bolus prior to her block. She looked right at her doula and said "what do you think?" When her doctor wanted to start pitocin a few hours later after she was comfortable and still not changing her cervix...again she looked at her doula and said "what do you think?" (after waking her doula up from the nap she had been taking on the pull-out mattress) HELLO!! This is not your doula's labor! This is your labor, your baby, your body, your experience! You don't need your doula's permission!!! Doula's are great support people, they're awesome, don't get me wrong. But (most of them...and especially not the one in the previous scenario) they're not trained medical personnel...they're not your doctor or your nurse...don't ask their "permission"!

My reply turned into a post of its own, here in somewhat edited form:

I have a couple perspectives to share on the "permission" thing. Sometimes as a doula I get clients looking to me for "permission". I understand what they're doing, they hired me in part to be a sounding board and an independent voice, and they want to know what I think. Because it's not my role to give them medical advice, I generally try to turn it around and talk them through the situation and ask what more information THEY need to make a good decision. I wouldn't want a client asking me for actual permission if her doctor told her she needed a c-section. But if she turned to me and asked what I thought, and it meant I could help her talk through the facts that baby was showing no distress and that her progress was slow but was happening, that might be a good thing for her having what she needs to make an informed decision about whether or not she wanted to consent to the section. If you have the independence as a nurse to give her the space, time, and support to potentially question her doctor's recommendation, that's fabulous! But many nurses don't, or won't, and I feel that's where the doula's ability to be an independent sounding board comes in.

And sometimes I also recognize that as someone they shared their birth plan with, and trust, they just need emotional validation for the path they're about to choose. It would be nice if they could get that validation from the medical staff, but unfortunately many people who hire doulas are doing so because they do not completely trust the medical staff - and sadly, with good reason in some cases (this brings us back to the need for an independent sounding board.) They need someone who they know is totally on board with their birth plan to affirm that it's OK to deviate from it. So in those cases I can be the one to say "You seem so exhausted, I agree an epidural sounds like a great idea", or whatever it is they need to hear to feel good about their decision. A doula friend told me recently that she actually asks her clients, "Do you need me to give you permission to _______?" as in, do they just need some help to feel OK about their decision?

I have experienced this from the other side (albeit less often) doing lactation support where the mom looks to her doula when I recommend, for example, a nipple shield. "Do you think I should try it?" And I get this flash of irritation - "Your doula didn't train for this work and take the LC exam and work with hundreds of breastfeeding dyads, why are you asking HER?" - and then I go "aha, this is what the L&D staff must feel like when my doula client turns to me!" So in that moment I remind myself that I have just met this woman - why should she trust me? She trusts the person who she met and has been working with for weeks, and just went through many hours of labor with, and she is trying to make an informed decision that (gasp) may not be what I recommend. She is going to consider her options and make a decision instead of just agreeing with what I suggest, which is a strange feeling for me but a good one to get used to. I may not agree with her decision but she will be the one who lives with the consequences, not me, and I have to make room for the possibility that I am wrong and she is right. That this is so uncomfortable for me to do has been an excellent learning experience and given me a lot more sympathy for all sides!

Thursday, October 7, 2010

Which growth chart to use?

In the past few months, I have happened to talk with three different mothers who told me about their breastfed children's growth "slowing down" around 4 months - the baby's weight percentile dropping and the baby slipping down the growth curve. Somewhat fortunately, all of these mothers were told by their pediatricians that this was "common" or "normal", and none of the pediatricians pushed supplementation or were very aggressive about starting solids.

Unfortunately, while the pediatricians were right not to change the baby's diet, they were wrong in giving moms the impression that their child's growth slowing - while perhaps "common" - was "normal". In fact, they were wrong in giving moms the impression that it was slowing at all! And once that idea is planted in a mother's head, it's hard to erase the underlying anxiety she might have, despite reassurance to the contrary, that her milk is no longer quite keeping up with her baby's needs.

The fact is, many pediatricians' offices still use growth charts developed in 1977, based on a small sample of babies in Ohio who were primarily formula fed. Similarly, even the 2000 Centers for Disease Control (CDC) growth charts are based on a sample of mixed breast/formula feeders. Formula fed babies grow more slowly than breastfed babies in their first few months of life, then begin to grow more quickly than breastfed babies. When we chart breastfed babies on the formula fed growth chart, it makes breastfed babies look nice and high on the chart for the first few months, and then start to look like they are faltering.

What does it look like when breastfed babies are tracked on charts that accurately reflect their growth? To do that, the newest World Health Organization (WHO) growth charts are a far better choice than any of the CDC charts. The WHO charts are based on a worldwide sample of infants who received optimal breastfeeding and complementary feeding.

This article from the Journal of Nutrition does an excellent job of discussing some of the differences between the CDC and WHO growth charts. They have several great illustrations as well to help you visualize how the growth charts differ:

This chart shows the difference between weight-for-age curves in boys ages 0-60 months. You can see how around 4-6 months, the CDC chart line crosses over the WHO line and generally stays above - sometimes quite high above - the WHO line up through age 5.

I like this chart even better, which shows how an average infant from the WHO sample would track on each chart. A baby who tracks normally on the WHO chart (staying fairly even in growth after an initial drop) looks very different on the CDC chart: after an initial rise the baby appears to slowly fall down the growth curve from the age of 2 months on.

One of the moms I talked to went back and plotted her children's growth on the WHO charts and was pleased to see that all of a sudden, instead of slipping down the chart, they were tracking beautifully along the growth curves. She knew all along that they were healthy and feeding well, but it's always nice to have it confirmed that the charts were wrong - and mom was right.

Happily, the CDC is now formally recommending that all clinicians switch to the new WHO growth charts for ALL infants and toddlers up to 2 years of age. (Note that this means not just breastfed babies - the CDC recognizes that those charts reflect optimal infant growth, and that the more rapid growth of formula fed babies is a potential cause for concern.) If you have kids, do you know which charts their pediatrician or family doc is using? Do your care providers know about the CDC encouraging the growth chart switch?

P.S. Let's also keep in mind the relative importance of growth charts. I've had some great conversations in breastfeeding-related courses about the overall silliness of the American obsession with having every baby "above average" on the growth charts. It's as if scoring 95th percentile on the growth chart is like getting an A on an important test. Growth charts are tools to be used in conjunction with other indicators of a baby's health and intake, they do not reflect the normal growth of every child, and it is just as normal and healthy for a baby to consistently be in the 5th percentile as in the 95th. Phew! I've said my piece.

Saturday, September 25, 2010

Take the challenge!

Are you familiar with the Quintessence Breastfeeding Challenge? Organized by the Quintessence Foundation of Canada, this is an international event held every year on the first Saturday in October.

From their website:

Join us to celebrate breastfeeding in a fun “competition” where every child “wins” because they are breastfed!

... This fun event is a challenge for which geographic area (province, state or territory) has the most breastfeeding babies, as a percentage of the birthrate, “latched on” at 11am local time.

Why: To celebrate breastfeeding and milk-banking, and demonstrate promotion, protection and support for breastfeeding women and their families. It’s a chance for education and peer support done in a fun social way.

I have helped coordinate one of these in the past and it was very fun! Our group included one woman who drove several hours from her small, rural town to participate. She was still breastfeeding her toddler and didn't have any friends or social support for breastfeeding locally, much less continuing to nurse her baby long-term. She was so excited to come meet other breastfeeding moms, and we were so excited to meet her. It reinforced for me that these events are a great form of peer support.

If you're interested in participating, think creatively - maybe this could be used as a chance to celebrate WIC participants who are breastfeeding, or as a special occasion for a La Leche League group, or even be done on a hospital postpartum floor (encouraging all the moms to get their babies latched on in their rooms and sharing the final number with them so that they feel part of a shared experience). Or if you're in a small town or don't have the resources to coordinate a big event, you can invite as many nursing women as you know to a smaller get-together at someone's home - it still counts!

If it's a public event, you consider inviting the media to help spread awareness of breastfeeding support programs in your community. To help make it a fun, family-centered event, you can ask local birth/breastfeeding/etc. stores for donations for a raffle/door prizes, and local grocery stores for donations for snacks. Some activities for older kids help too - they can be simple like macaroni necklaces, coloring stations, or bubbles.

Let me know if you or a group you're involved with is doing Quintessence! I'd love to hear about it.

The NY Times on direct-entry midwifery legislation in Illinois

Use of Midwives Rises, Challenging the State to Respond:

Each year, 700 to 1,000 babies are born at home in Illinois, many of them in rural locations, according to the Illinois Department of Vital Health Statistics. Licensed home-birth practitioners work in just 7 of the state’s 102 counties, and most are concentrated in Lake and Cook Counties, leaving the majority of Illinois home births unattended, or attended illegally by someone whose education and licensing are unregulated.

That could change as early as November. After 30 years of trying to get the legislature to license direct-entry midwives, Illinois’s midwifery organizations are guardedly optimistic. In May, the State Senate passed the Home Birth Safety Act. A House vote is pending.

Check out the rest of the article, including their allusion to the fact that not all DEMs want licensure, and a choice quote from the OB/GYN on "natural birth plans". Hey, he's tellin' it like it is!

Wednesday, September 22, 2010

Linky goodness: to VBAC or not to VBAC, birth videos, and more!

Time to clear out the starred posts in my blog reader! Sorry, some of them are a few weeks old but of course, still great:

Robin Marty of RH Reality Check on the many reasons she's choosing an elective repeat c-section over a VBAC attempt.

Birth Sense introduces you to the handsome, charming Dr. Justin Case.

Video of baby born in the caul, via Homebirth: A Midwife Mutiny.

Video of frank breech home birth via Gloria Lemay.

Dou-la-la channels Don Draper in explaining why those nice formula companies are so darned excited about breastfeeding.

Why African Babies Don't Cry, via Blacktating.

Mom's Tinfoil Hat linked to a post on abortion and parental notification laws that, very sadly, is no longer up (the author decided to make posts about her work private - I struggle with walking the same line, and totally understand). However, you can still read an excerpt and a long comment from the author in MomTFH's post.

Not birth-related, but something that really touched me to see today: Dan Savage's It Gets Better Project: a collection of videos of adults telling gay teenagers that high school ends and their lives will improve. Read an interview with Dan Savage here, including the reason he decided to start this project.

Sunday, September 19, 2010

Feminist reading group on pregnancy, birth, and parenting

Molly at First the Egg is starting up a Goodreads-based reading group on pregnancy, birth, and parenting from a feminist perspective. Books she suggests (click through for the full list) are a nice mix including memoirs, social/cultural criticism and academic texts, and a variety of different topics.

I am really excited about this (as you can see from my overenthusiastic suggestion of new titles for the list at every opportunity) and encourage others to join! As I said in my intro post to the group, I don't get a lot of opportunities to talk about this stuff with people in my offline life right now. That's not to say I don't have access to smart people who think critically about these issues, but we tend to be talking more about "how do we get more people to enroll in our study" vs. "hey, let's have a cup of tea and talk about gendered bodies in reproductive spaces". So having an online group for that is something I'm very much looking forward to.

To go directly to the Goodreads group, join, and introduce yourself, just click here.

One man's take on breastfeeding in public

One man objects to public breastfeeding, but not for the reasons you might expect.

Wednesday, September 15, 2010

Take action to support federal funding for community-based doula programs

From Health Connect One (formerly the Chicago Health Connection, which piloted some of the most prominent and impressive models for community-based doula programs!):

"Help ensure continued funding for community-based doulas!
Email your elected officials today

We have received confirmation from staff with Senator Richard J. Durbin and Congressman Jesse L. Jackson Jr. that both Senate and House Appropriation Committee FY11 U.S. DHHS reports include funding for the community-based doula program at its current level of $1.5 million. The Senate Appropriations Committee specific language is as follows: “$93,999,263 for the Special Projects of Regional and National Significance [SPRANS]. Within that total, the Committee recommendation includes sufficient funding to continue the set-asides for oral health, epilepsy, sickle cell, doula programs, and fetal alcohol syndrome at no less than last year's level.” In addition, although the House Appropriations Committee has not released its report, we know the House bill includes funding for doulas.

It is anticipated that after the November elections, a Conference Committee, made up of members of the House and Senate Appropriations Committees, will create a final bill. We need you to contact your Senators and Representatives and encourage them to keep the doula funding in the final bill."

Click here to easily contact all of your reps + the president - it takes all of 3 minutes to write an e-mail and send it along!

"Help! My husband/partner/family doesn't want a doula"

If I had a nickel for every time I heard a mom say, "I would love to have a doula, but my husband [or partner, or mom, or whoever is going to be the primary support person] is against it" - well, I would be a much richer doula! In these situations, unfortunately, their support person's opposition usually wins out over mom's desire for a doula - and more unfortunately, I sometimes hear mom saying later that she regrets letting herself be overruled.

Much of the resistance seems to be based in the idea that the doula will take over the family's role. I think they envision the doula hovering around mom - getting her everything she needs, rubbing her back, talking with her - while her family sits in the corner watching, excluded from being hands-on.

What I try to express to people who envision that is that this is almost NEVER the picture you truly see at a doula-assisted birth - instead, it's what I see happening when I first walk in the room! Mom is often lying in bed, and her family/friends are lined up on the couch watching her like a TV show, wanting to help but not sure what to do; or slightly better, standing next to her as she vocalizes through a contraction but not sure what to say or how to help.

My goal is to change that picture, but not in the way the family is envisioning. In fact, my ideal picture is for the people who love the laboring woman the most to be the ones who are massaging her lower back, who are whispering encouragement in her ear, who she leans on during a contraction; if there's anyone sitting on the couch watching, it's me!

To get to this picture, there are a few key things I do as a doula that I think are so important: first, I help the support people understand what's normal. They may be very anxious about noises mom is making, or the length of labor, or baby's heartrate. I can help them understand that things are going normally, which gives them the space and confidence to reassure the laboring woman and keep her going. It sounds simple, but I think it's absolutely one of the most important things I do. You can watch a dozen birth videos and still find the actual process and presence of labor intimidating; it takes a little while to get comfortable with its rhythms and sounds and, ahem, bodily fluids. Just having a calm, confident presence frees up so much energy that is otherwise in anxiety and helps everyone enjoy the birth experience without fear.

Second, I know the ins and outs of the labor room. I know where the volume control is on the fetal monitor (and that it's perfectly fine to turn it down), where to find the birth balls (and how to get mom onto one without disturbing the monitors and IVs if she can't get them disconnected), how long that fetal monitor really needs to run before she can take it off and start intermittent monitoring (and I'll happily be the one to push the call button and ask the nurse to come in and take mom off).

Third, I remind and reinforce what they may already know. For example, I find more and more that there's some point in labor where I sense that mom needs to get in the tub or shower. She's starting to get totally overwhelmed and I can see incipient panic in the eyes of her support team. Sure, they learned that water can be helpful in labor; it's probably on their birth plan. But in the moment, they just don't think of it. Often, mom is reluctant to try it (remember, she's totally overwhelmed and even walking one step seems impossible), but I encourage her, get the tub all set up, she decides to give it a shot, and... aaaah. She relaxes into the water and gets her second wind. The bathroom is tiny, so her partner kneels by the tub to coach her through contractions and I retreat into the L&D room to just listen in case they need anything. This is often when mom is going through transition and I love getting to facilitate those last intimate moments between the parents before she starts to push and they get ready to meet their baby.

Finally, while I'm happy to sit on the couch and hang out if that's all that's needed, I should add I don't need to be hands-on to be busy as a doula! I can be running down the hall for more ice or to heat up the rice pack or getting snacks for mom/support people; bringing fresh washcloths for mom's forehead; catching medical staff at the door so if they've just come to "check in" I can update them without them having to interrupt the laboring woman's space; searching out birth balls, rocking chairs, squat bars, etc.; plugging and unplugging portable IVs, fetal monitors, etc. if mom is moving around/headed to the bathroom; and on and on. Again, these are things that the other support people might be hesitant to do or not know their way around well enough to do confidently; I can take care of that stuff and free the family up for focusing on mom and baby.

In short, a doula does not and cannot replace a woman's own family and friends - and doesn't want to! She is there to make everyone's experience better. Once your support team understands this, they're usually much more open to having a doula at the birth.

You could also try this quote on them, from an OB-GYN who had a doula at her first birth: "I can't say if having a doula shortened my labor, but it definitely lengthened my marriage!"

Do you have family and/or friends who are planning to be at your birth, but are resistant to the idea of a doula? Here are a few things for them to read to get educated about a doula's role at a birth:

From DONA:

From Penny Simkin, doula extraordinaire: Myths about Dads and Doulas

Written by a dad: 5 Reasons Dads Should Demand a Doula

Do Doulas Replace Dads? includes a nice chart on what kind of support each person in the birthing room provides, and where doulas do and don't overlap.

(I apologize for the heteronormativity of all these links! I have tried in this post to use language that's inclusive of different types of family structures. Hopefully regardless of what label your support people fall under, they can find this information helpful.)

In the end, remind yourself and your support people - this is YOUR birth. Just as you have the right to say that no, your mother-in-law and all your second cousins are NOT welcome in the delivery room - you have the right to say that you WOULD like a doula there. If this is truly important to you, your support people should respect that and work with you to find a doula they feel confident will empower them, and you, during the birth.

Sunday, September 12, 2010

Technically birth-related

I just thought this was so cool:

Evolution in Action: Lizard Moving From Eggs to Live Birth

Evolution has been caught in the act, according to scientists who are decoding how a species of Australian lizard is abandoning egg-laying in favor of live birth.

Along the warm coastal lowlands of New South Wales, the yellow-bellied three-toed skink lays eggs to reproduce. But individuals of the same species living in the state's higher, colder mountains are almost all giving birth to live young.

Only two other modern reptiles—another skink species and a European lizard—use both types of reproduction.

Evolutionary records shows that nearly a hundred reptile lineages have independently made the transition from egg-laying to live birth in the past, and today about 20 percent of all living snakes and lizards give birth to live young only.

But modern reptiles that have live young provide only a single snapshot on a long evolutionary time line, said study co-author James Stewart, a biologist at East Tennessee State University. The dual behavior of the yellow-bellied three-toed skink therefore offers scientists a rare opportunity.

"By studying differences among populations that are in different stages of this process, you can begin to put together what looks like the transition from one [birth style] to the other."

Thursday, September 9, 2010

What makes a doula "experienced"?

I was talking with someone at a party last weekend who is in the midst of interviewing doulas. (Yes, I was voted "Most likely to talk about childbirth at a party" by my MCH cohort - what of it?) She wanted someone who was "experienced" and asked me how many births I thought made someone experienced. I was brought up short - truth to tell, I wasn't really sure. I thought well, I consider myself experienced - how many births have I been to? How many did it take before I felt more "experienced"?

I had kind of been losing track of the number of births I'd been to - I had them all recorded in one place or another, but hadn't been keeping a running total like I used to. I keep saying "oh, probably around 45" so I finally sat down and totaled them all up the other day. My accounting may still not be exact, but it looks like I've attended 42 births at this point.

So, 42: not bad at all - and I'm proud that those were a very diverse group of births: high- and low-risk, women from all backgrounds, with all kinds of birth plans (or no plan at all), with a range of different providers and settings. So I feel "experienced".

And yet I know I learn something new at every birth, and almost always think of something I wish I had done different; and I also know doulas who have attended hundreds of births. So maybe I'm only medium-experienced? And so how can I say exactly when I did cross the line from "novice" to "medium-experienced"? Ten births? Fifteen? Twenty?

On top of that, did I become a "better" doula when I became more "experienced"? Certainly my comfort and confidence have increased the more I've done this work, and I hope that both my greater confidence along with my growing knowledge and skills have helped my clients. But when so much of attending births as a doula has to do with "being" instead of "doing", there may not be that big a gap between me as a novice doula and me as an experienced doula as I think.

What do you think? Is an experienced doula important to you? Doulas, what differences do you see between your novice self and your more experienced self? Do you think there are any special strengths of being a novice doula at births?

Sunday, September 5, 2010

US Dept. of Labor offers guidelines on break time for nursing mothers

The U.S. Department of Labor's Wage and Hour Division has a fact sheet out for employers and employees, explaining more about the break time for pumping mandated in the health care reform law. Here's an excerpt on the space requirements:

Employers are required to provide a reasonable amount of break time to express milk as frequently as needed by the nursing mother. The frequency of breaks needed to express milk as well as the duration of each break will likely vary.

A bathroom, even if private, is not a permissible location under the Act. The location provided must be functional as a space for expressing breast milk. If the space is not dedicated to the nursing mother's use, it must be available when needed in order to meet the statutory requirement. A space temporarily created or converted into a space for expressing milk or made available when needed by the nursing mother is sufficient provided that the space is shielded from view, and free from any intrusion from co-workers and the public.

Read the rest here.

Saturday, September 4, 2010

Score another one for the big babies!

I haven't had a lot of doula/birthy posts lately, probably not enough to justify the name of this blog! That's in part because I hadn't been to any births recently. But the past few weeks I've been waiting on two births, due about a week apart but of course delivered only about 24 hours apart. So it's been busy!

The second labor was definitely another score for the big babies. Fast labor, basically no pushing - more breathing the baby down while trying NOT to push (I was a little concerned baby might be born in the car, but I have yet to hit that doula milestone!) - and fast delivery. Well over nine pounds! The midwife said the shoulders were a little sticky but because mom was already on hands and knees (which she chose instinctively for labor and pushing), it all went very smoothly.

Let me say it again: Big babies can be born vaginally! They can be born quickly! They can be born easily! Don't trust scare tactics about a big baby - read the research, and hear the positive stories.

So now I am coming down off my post-two-births high and thankful to go off call for a little while. I know I'll start jonesing to attend another birth soon!

Wednesday, September 1, 2010

Fewer Swedish babies breastfed, still way more Swedish babies breastfed than American babies

Every so often...okay, not often, but once in a blue Swedish skills come in handy. And today I got the chance to put them to use, reading this report from the Swedish government on changes in breastfeeding rates from 2004 to 2008. While their recent decreases in breastfeeding are a problem (drops of more than 4% for some indicators) I was also struck by how insanely high most of their numbers seem to someone from the U.S.:

Exclusive breastfeeding at 1 week: 85% (down 4.3% from 2004)
Partial breastfeeding at 1 week: 12% (up 3.5% from 2004 - so there seems to be more early supplementation going on)
Adding these up, only about 3% of babies at one week are exclusively formula fed

Contrast this to the U.S. where over a quarter of infants are supplemented with formula before 2 days.

The drop becomes more pronounced the older children are (makes sense with an increase in early supplementation). At 6 months, 66.5% children are still exclusively or partially breastfed, down 6% from 2004. (But still, compare to 43% in the U.S.)

The one data point I found contradicting this pattern was breastfeeding to a year. While this report doesn't give national numbers, it notes that any breastfeeding at 12 months ranged from 11-22% in different regions of the country. That actually compares favorably in the U.S. with about 22% of babies being breastfed at 12 months here. It seems counterintuitive, given that one of the great supports Sweden gives to nursing mothers is their year of "mammaledig" - maternity leave. It makes me want to ask my Swedish friends more about how long they planned to breastfeed and when the cultural expectation is that they'll wean.

The researchers note that they don't know why breastfeeding is decreasing, because it hasn't been studied yet in relation to social and demographic factors. I've heard that "pappaledig" - paternity leave - has been increasing in popularity and fathers are increasingly taking a larger share of the time off. Could this be a contributor? Again, I'll have to investigate...

Wednesday, August 25, 2010

Volumes: a huge problem

The response to my last post on "los dos" pushed me into finally finishing this one! The volumes given to babies are a huge part of what makes "los dos" so problematic, but are a problem on their own as well. We don't know exactly why breastfeeding is protective against obesity, but a big part of it may be the part with the breast. It's harder (although by no means impossible) to overfeed a baby at the breast. When you're giving a bottle, it's much easier to overfeed a baby and to override their own feelings of satiety/being full by persuading them to just finish what's left in the bottle, or what we think they should be taking.

This problem, unfortunately, frequently starts on the first day of a baby's life. Have you ever seen the belly balls made by Ameda? I think they are a nice way to visualize the size of a newborn's stomach on days 1, 3, and 10. Day 1 is a shooter marble, representing 5-7 milliliters(ml), and Day 3 is a ping-pong ball, representing 22-27 ml. As a frame of reference for those of us not used to metric, 1 fluid ounce = 30 ml, and 1 teaspoon = 5 ml.

These are tiny volumes, as is appropriate for tiny babies with tiny stomachs designed to handle small volumes of colostrum that empty quickly (the gastric emptying time of breastmilk is about half that of formula).

These volumes mean that at one feeding, even on Day 3, a baby should be getting a maximum of 1 ounce.

And yet over and over in the hospital and out of it, I am absolutely boggled (and sometimes horrified) by the volumes that people are able to push to a baby via bottle. I walked into a room the other night and a mom had breastfed her 1-day-old baby on both sides, and THEN given him 40 ml via bottle. All of us routinely see parents who are able to get babies to take 45 ml or more at nearly every feed. Even at day 3, these babies are literally eating double what they're supposed to.

What happens when babies get fed such huge volumes? First of all, they spit up. Give a brand-new baby a 10 ml feed (and remember, this is just 2 teaspoons!) and you may find most of it spilled down her front. It can be scary for the parents and probably doesn't feel that great to the baby.

Second of all, they don't eat. New babies forced to take one huge feed may not eat again for the rest of the day, spitting up constantly with distended abdomens. Babies consistently getting supplemented after breastfeeding, even with smaller volumes, take longer to wait for the next feed -- maybe 4-5 hours instead of 2-3. Physiologically, this isn't sufficient to establish a good milk supply in most women.

Third of all, they get hungry. Forced to take huge volumes over and over again, they start expecting huge volumes. Mom's colostrum can't possibly keep up, which leads to a fussy baby, which leads to more supplements, which leads to less breastfeeding, which leads to lower see where this is going.

Huge volumes are one of the banes of the hospital LC's existence, as far as I'm concerned. And yet it's so hard to address.

I don't want to be the mean LC who tells the parents they just overfed their baby and doomed breastfeeding, but I do want to educate appropriately on volumes. I want to tell parents that this is too much for a baby's stomach, and that it can create problems with breastfeeding. I want to convince the parents that such huge volumes are a bad idea.

Unfortunately, the babies don't cooperate.

Parents seem to expect a baby who takes a large feed quickly and then sleeps soundly for at least 2 hours and preferably 3 or more, and overfed babies do this very well. "Baby doesn't wake up to feed as often" doesn't really sound like a problem to them. And yet once I cross the line into warning her "You can compromise your milk supply" that risks mom hearing what she probably already believes, which is that she won't produce enough milk. AND I hear the eye-rolling message boards of the Internets in my head. ("The lactation person in the hospital told me if I gave my baby ONE BOTTLE of formula, I would NEVER produce enough milk! Boob nazi!")

Parents also expect that if the baby is hungry, she/he will keep sucking, or will be willing to take a bottle back into his/her mouth. Overfed babies will most certainly keep sucking if they have a constant flow of liquid down their throat (the bottle will flow by itself without any help from them) -- in fact, it's hard for them to stop because then they would choke -- and they have a firm stimulus in the back of their mouths. They will do this regardless of their own feelings of hunger or satiety. You can also often get an unwilling baby to accept a bottle nipple back in if you play around long enough (less frequently true for the breast).

I know that responsiveness to hunger/satiety cues is an issue identified, and under research, by people out there in the infant feeding world. I think a key piece is being able to interpret NORMAL newborn behavior (fussy does not always equal hungry! frequent waking is not pathological!) and respond to a baby's cues instead of overwhelming them.

What do we do at the hospital to solve this? We try so hard to educate everyone at their first hi-I'm-the-LC visit if they are planning to do any supplementation. (Obviously we also try to educate them about exclusively breastfeeding, but this is harm reduction.) This takes different approaches, generally from the "your baby's stomach is only this big!" school of thinking.

I've also started taking a more direct route. If I'm the one bringing the bottle (you can't win every time) I pour out everything but what they baby should take at that feeding. (That a 2 oz bottle is considered the standard for a newborn nursery just shows how insidious the formula industry is). We would not give 4 pain pills to a mom and say "but only take one". Neither should we hand her a 60 ml bottle and say "but only give 10" especially because if baby keeps sucking they interpret that as "still hungry". This also prevents the practice of re-using the same bottle for multiple feedings (this happens all the time even though the bottle clearly says it should be discarded after an hour.)

It also helps to at least ask moms to give supplements via a supplementing tube at the breast (you can rig up a cheap, easy one with a 10 ml syringe and a 5 french feeding tube) or a similarly-sized dental syringe. The 10 ml syringe makes that amount look like a large amount, we have parents push it very slowly, and it at least keeps baby stimulating the breast.

I'm trying to get the nurses to do the same although this is more challenging -- I am winning a few interested parties over to trying it. Unfortunately, not every nurse sees these volumes as an issue, which leads me into my second group of overfeeders: the hospital staff.

Oh man, I wish with all this I could say that it was only the parents. But no, if a partially-breastfeeding (or even exclusively formula feeding) mom has asked baby to get a bottle in the nursery, there are nurses who will give 25 ml on Day 1 just like anyone else. (Or more, to the point of pathological...) One of the nurses who is now an LC told me it used to be a point of pride for her that she could get babies to finish the bottle, and I've heard similar stories elsewhere from nursery nurses -- getting that baby to eat who just wouldn't was (and sometimes still is) a valued skill, and getting them to eat a lot meant full, happy, healthy babies filling your nursery.

I will say, not all nurses do this! They will come to me and say "she asked me to give a bottle so I only gave him 10 ml, why don't you go see if he's hungry again and wants to breastfeed" or "she asked me to give a bottle before she came upstairs from L&D but I just made his bath take an extra long time, maybe you could get her started breastfeeding". They tell parents independently not to give too much and that it interferes with breastfeeding, or set them up with a dental syringe with a tiny amount of formula if they insist on supplementing, and they don't hand them 3 or 4 bottles at a time. Thank you, wonderful nurses!

How to solve this problem in the long-term? I heard the prolific and very smart breastfeeding researcher Kay Dewey speak last year, and she talked about her research trying to teach parents to interpret feeding cues correctly. Unfortunately, that education (done with WIC participants) was found to be ineffective at reducing overfeeding. It sounded like their next step with that research, to expand the education from just feeding cues to teaching parents how to interpret their babies' cues generally, was going much more successfully. I'm looking forward to reading more about it as they complete their research. I think it's the right direction to go in -- I believe a big part of the issue with volumes is the unrealistic expectations for "satisfied" baby behavior. Getting it to parents, however, will be a big step and take a long time.

In the meantime, what do you do to discourage parents from giving big volumes? Did you know how much babies were supposed to take in their early days?

Tuesday, August 24, 2010

"Los dos" and an awesome new campaign

From the moment my AmeriCorps team started doing breastfeeding education and support in Denver, we came up against "los dos" (literally "the two", better translated as "both"). The majority of our clients, particularly at newborn visits, were Hispanic (largely from Mexico). When we asked them if they were breastfeeding/planning to breastfeed, the answer was almost invariably "los dos" - both breastfeeding, and giving formula by bottle.

I've had a post coming about this for a while - it's a very frustrating thing to deal with and as an inner venting strategy I've composed this post many times in my head.

Why so frustrating? Well, at my current work I see that often "los dos" begins in the hospital. Moms tell me "es que no tengo leche" - "It's that I don't have any milk" - even when I help them hand express abundant colostrum, they don't believe that their colostrum will be enough to sustain baby until their milk comes in. This supplementation often tends to feature HUGE volumes given by bottle (think 1.5 ounces on Day 1, with a baby whose largest feed should probably be 1/3 of an ounce. There is a separate, also long, post about volumes coming - not just about Hispanic moms either.)

Babies get used to the fast flow and firm nipple of the bottle, and they come to expect huge volumes which colostrum cannot provide the first few days. They become fussy at the breast and the mother tells me "es que no quiere el pecho" - "he doesn't want the breast" or "he's refusing it". There seems to be a perception (and believe me, this needs a lot more research) that a large percentage of babies just don't want the breast - with no specific cause or cure - and that if not, you should just give up and bottle feed.

(This, as a side note, is why I think all the people who say nipple confusion is a "myth" are full of it. Over and over again at the newborn clinic in Denver, we'd hear "es que no quiere", slap a nipple shield on, and baby would nurse happily with mom's newly-in milk supply and a nipple that felt more like what they were used to.)

If baby doesn't become nipple preferenced (which some manage to avoid) then continued supplementation often starts to affect milk supply. Mothers tell me they weaned their last babies at one or two months because "no tenía leche" - "I didn't have milk", and "se desesperó" - "he got frustrated" (although used slightly differently it would be mean "to lose hope" which seems so fitting for those babies!)

There seems to be a strong emphasis on babies getting fed a lot, as often as possible, and it's hard to convince/convey to many Hispanic mothers that their babies will get MORE breastmilk if they supplement LESS. Instead, the response to this frustration and dropping milk supply is of course to offer more bottles and fewer breastfeedings. Baby quickly learns where the real supply is coming from and the mother tells me that with her last baby after a few weeks, "no quiso el pecho" - "he refused the breast".

To me all of this is particularly notable as Hispanic moms almost universally tend to want to breastfeed, and when given cooperative babies and milk supplies will generally nurse for a long time - particularly as many stay home to take care of their children. Moms who give up on a nipple preferenced baby will happily nurse the ones who do tolerate "los dos" for a year or two. While many Hispanic moms have yet to make the connection between supplementation and early weaning, I think most of them would prefer to breastfeed longer.

So why is this connection not made? Why is there so much supplementation and so much expectation of "no quiere"? Almost every night at work I dream of rustling up an MPH student to do some focus groups with Hispanic moms on what it means to them to "have milk", for the baby to be satisfied, what they think formula adds to the baby's satisfaction/health, what it means when the baby "doesn't want" the breast, how milk supply is perceived to be driven, etc. etc.

That's still in fantasyland though, so I am so excited that the Massachusetts Breastfeeding Coalition has a new campaign going - the first that I've heard about - targeting "los dos". (Interestingly, they call it "LAS dos" which I've never heard, but maybe it just varies from person to person.)

One poster for the ad campaign has a picture of a baby and a speech bubble saying (in Spanish): "Both (lit. "the two")? Mama, you already have the only two I need! If you give me formula, you won't make enough milk for me." Below it says "Give me only the breast."

Another has the same dialogue with two smiley-faced breasts and a frowny-faced bottle - I love the happy breasts!

And check out the fun story behind the slogan at the Motherwear Breastfeeding Blog!

Will it work? Will moms like it? I hope to hear more about this... and if any MPH/anthropology/sociology/etc. students out there want to get a little qualitative research experience, PLEASE consider this topic!!

Wednesday, August 18, 2010

Pertussis vaccine for parents

From Tara Parker-Pope's Well blog of the NY Times, Vaccination is steady but pertussis is surging:

There are several explanations for the rise in pertussis, but the most likely is waning immunity after vaccination. “Immunity wears off, especially for adults who are decades past their most recent vaccination,” said Dr. Tom Clark, an epidemiologist with the C.D.C.

Moreover, adults and adolescents often wait weeks before seeking treatment for a chronic cough — and even then, doctors may not recognize it as pertussis.

This is especially important to note for parents of infants. Tara Parker-Pope talks about almost reaching for the phone to call 911 because her 11-year-old daughter's coughing fits are so frightening. For an infant, pertussis can mean far more serious illness including weeks of hospitalization - but they're harder to protect because they can't be fully immunized for months.

One way to protect them is for all the adults and older children who regularly come in contact with them to update their pertussis vaccinations, so that those people can't transmit it to the baby. The pertussis vaccine is often given in combination with the tetanus vaccine now; check to see if you've had a "Tdap" shot in the past few years.

The hospital where I work, and many pediatricians' offices, are now checking with parents about their immunization status - but if yours doesn't, make sure you do it on your own! And if someone else (relative, friend, etc.) is regularly coming in contact with your baby, ask them to check their immunization status too. I encourage doulas and anyone else who regularly comes into contact with moms and babies to do the same, to protect their clients. I got a Tdap update when I started working at the hospital. I didn't love the sore arm, but it was worth it. And that's your public health message of the day!

Wednesday, August 11, 2010

Choosing and getting into MPH programs: Part 3: Which MPH program(s) should you apply to?

This is Part 3 in my series about choosing and getting into (and funded by!) MPH programs.
(Part 1 is here, Part 2 is here.)

So you've decided you want to go to grad school, and that you want an MPH, and now the question is - where?

I am going to assume, for the purposes of this series & the people I imagine are reading it, that you are interested in maternal and child health in some aspect and want that to be incorporated into, or at least relevant to, your MPH program.

Still, let me start with a disclaimer: I have done only one MPH, and that was in a maternal and child health track. While I applied to a range of concentrations and schools, I could only enroll in one department at one school. I can't speak personally to the pros and cons of all the paths I didn't take. So this post, in true doula style, is more about raising the questions that you should ask yourself or others when choosing programs, than about telling you what you should or shouldn't do.

So what are the questions you should be asking? When you apply, you generally apply to a specific track at a specific place - it's not like undergraduate where you can just apply to the school and then pick your concentration later. Individual departments/tracks make their own admissions decisions, and you can even apply to multiple departments in the same school at the same time. So you have 2 questions to answer: 1) Which type of track/department(s) do you want to apply to, and 2) At which school(s)/program(s) do you want to apply to do them?

So, question 1: Which type of track/department(s) should you apply to?

MCH is somewhat unique in terms of public health specialties in that it is defined by a content area instead of a methodology. People in epidemiology or health behavior may apply their skills to MCH topics, or to any public health topics, but MCH thinks about content first, and then what skills you might need to deal with that content second. I'm sure there's an interesting history to why things evolved the way they did, but right now that's just the way it is.

So if you're interested in MCH, that doesn't necessarily mean you should be applying to only MCH tracks/departments. I also applied to tracks in health behavior/health education, general public health, international health, community-based health, etc. with the idea of applying the methodologies of those fields to my specific interests.

Public health schools offer all of these tracks and more - and sometimes don't even have an MCH track/department. If there's somewhere you really want to be/stay, you may need to think about whether the non-MCH options available will give you what you're looking for. Also be open to degrees offered by public health programs that aren't MPHs but are fairly similar; they tend to go by names like Masters of Health Science.

Consider your current skills and the ones you want to gain: Do you love number-crunching? Do you have a very strong interest in global health? Do you want to be very research-focused, or very practice-focused? Different tracks will have different focuses.

They will also afford you more or less flexibility to pursue your own individual interests. Some tracks are very prescribed and have few electives. Some are have a few requirements and for your other courses you can select anything else you want in the school of public health, or at the whole university. Consider whether the track you're looking at will give you enough wiggle room to get into your MCH interests, and if not whether there's another way you could pursue those interests (e.g. student group, volunteering, research with a professor, etc.)

I ended up choosing an MCH department for several different reasons, including the knowledge that I would be able to easily focus on the topics I felt most passionately about. Even our more general methods classes in the department used examples from MCH-related issues, and I really liked that. I also liked that the department had relatively few requirements and I would be able to design my own educational program a little more freely.

On the other hand, I know very MCH-oriented people who felt like they knew the MCH content area well and chose, say, health behavior/health education. They wanted to focus on familiar areas with new skills. So keep an open mind about departments and consider other tracks besides MCH - they could be a good fit.

Important questions to ask when considering a track:
  • What is the class schedule like? (mostly evening classes for people coming after work? mostly day classes, so you can only work part-time at most?)
  • What are opportunities to work on research or other activities with faculty in the department? What about in your specific areas of interest?
  • What are the required courses/core curriculum, and how many of the total required credits will they make up? How many electives are available, and what do you have to choose from? (ask to see a current course schedule or a link to their course catalog)
  • What is the educational philosophy, especially in core classes? (lecture, discussion, problem-based learning, etc.) How many students per class on average?
  • Is a practicum/field placement required? (The answer is almost 100% yes, so then you need to know:) How many placements are required? How long are they required to last? When is it usually done? What kind of assistance does the school give in finding placements? Where do students usually work?
  • Is a thesis or master's paper/project required? What is the time frame for this? How intensive does it tend to be, and what types of work/research do students tend to do? Who mentors/approves it and how long does completion usually take?
  • Are there comprehensive exams (aka "comps") for masters' students? What form do they take (oral, written, etc.)? How much time do students generally dedicate to preparing for them?
  • How many semesters do students usually take to graduate? Is it possible to graduate early and if so, how often is it done?
  • If you're interested in continuingon to a doctoral program, does the program prefer to accept doc students from their own graduates, or prefer not to accept doc students from their own graduates?

On to question 2: What school(s)/program(s) should you apply to?

A bit of a primer on something that confused me initially: there are schools of public health and there are programs in public health - what was the difference? The Council on Education in Public Health (CEPH) accredits both schools and programs of public health. They state that:

"The major difference visible to prospective students would be that schools of public health generally offer many more concentrations or specializations and degree offerings than public health programs. Schools must offer at least the MPH in the five areas of public health knowledge defined as core areas. Programs are only required to offer a single MPH degree; though many programs choose to offer multiple concentrations, they are not required to. Also, schools must offer doctoral programs, while programs are not required to. As a result, schools are often larger than programs."

As you can see from CEPH's list by accreditation category (opens a PDF), there are understandably many more programs than schools.

(For the purposes of the rest of this series, when I refer to MPH "programs" I'm referring to both classifications. I know, I know, it's confusing.)

I applied to both programs and schools, although many more schools than programs; programs tend not to have an MCH concentration, or many specific concentrations in general, and the resources of a larger school were attractive to me. However, I seriously considered one program, in part for the benefits of how it seemed very small and collegial. There are benefits and disadvantages to both.

Where you go is most obviously limited by geography and money. If you are not very geographically flexible for family or other reasons, you need to either find your best option in the area accessible to you, or look into online programs - more and more accredited public health schools/programs are offering online MPHs. (However, based on what I know about online for-profit, non-accredited programs in general, I would encourage you to avoid them.)

You also may have a dream school and feel limited by funds. I encourage people to apply to every school they're interested in if they can afford the application fees - you don't know whether they're going to offer you financial aid or not, and how much. I was surprised by some of my offers (in both good and bad ways). But in the end your options may be limited by whether or not you want to take on loans with many zeros at the end. I'll discuss more on getting in/getting funding in the next installment.

If you have the choice of multiple schools, consider asking some of the following questions:
  • What are the tuition and fees per year? If it's a state school and you are not a resident, how likely is it you could get residency while you're still in school?
  • What kind of help with job placement/career advising is offered? Are faculty accessible to students for contacts and networking?
  • What partnerships with outside organizations do you have - is there a pipeline for graduates to certain organizations in the area or internationally that can be helpful in getting practicum placements/jobs?
  • What's the student life like? Is there a student association/government? Does anyone organize social events and do students tend to socialize outside of class?
  • How is campus safety, particularly if you'll be attending a lot of evening classes? Are there affordable/safe housing options nearby? Is there parking nearby, (nearly 100% of the time: no, so:) is campus easily accessible by public transportation/bike?
For both the above lists of questions, please post more questions that I'm not thinking of in the comments! This is a mix of questions that I have noted from my own grad school search and ones I look back and think I should have asked, but I may still be missing some important ones. Particularly post ones that I may not think of coming from a fairly privileged perspective - white middle-class girls from liberal arts colleges are the rock-solid majority in public health programs.

When all is said and done, my most important recommendation on choosing schools to apply to is to think as a consumer. It's easy (I made this mistake too) to focus on whether you'll get in or not. Just because you can get into a competitive school does not mean it's the right place for you! When looking at schools, imagine you're guaranteed acceptance and then decide whether you would actually want to go there or not. Is it worth your application time and money?

Last, a list of programs that were recommended to me or that I looked at, to start your search:

Specifically for MCH:
Columbia University
University of Washington
University of North Carolina
UC Berkeley
University of South Florida
Emory University
Boston University
University of Illinois - Chicago

Recommended in general:
Johns Hopkins
University of Minnesota
University of Michigan
Oregon State
George Washington University
University of Arizona
New York University

Again, please add further recommendations or personal experiences in the comments!