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!

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.

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.)

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.

Fucker.

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?

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).

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?

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!

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?

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?