"One thing that brings me joy"

You all know I love Centering Pregnancy. My involvement recently has been limited due to work schedules but I'm hoping to do at least a little co-facilitating soon. Watching this video got me so excited about getting back into Centering land! I can personally attest to the fact that Centering becomes a fun part of the week that I think everyone involved really looks forward to.

Check out what Centering providers, patients, and one of Centering's founders think about the model, and what it can do for perinatal outcomes:

What's the opposite of NaBloPoMo?

I thought several times during November how it was ironic that I was reading through the fruits of other people's daily posting regime while almost totally neglecting my own posts. It got me to think about why I've fallen off in the posting, a trend which has continued well into December.

I do WANT to post! I like writing and being part of a great community and talking about this stuff. I don't want this blog to go dormant long-term. But I've also never been a super-disciplined blogger in the sense that I set goals for viewership or try to earn something from this (ha!) or even necessarily have a specific goal for the things I'm writing. When I first started blogging, my main goals were to 1) get all the birth-y stuff off my private blog and into the world where they could stop annoying the friends who didn't want to read it (but allow the friends who did to follow me and get to learn more about my experiences with the birth-y world) and 2) to have a dedicated place to think about maternal and child health/public health/doula stuff as I started grad school for my MPH.

Now I'm in a different place and sometimes it gives me a mini-crisis of conscience about this blog (not to mention my career path). I am no longer in school or even necessarily in public health at the moment. I work full-time as a lactation consultant where my job is very clinically focused. I am involved with research projects on the side and am trying to shoehorn more of that into my job, but it's not actually in the job description. In the meantime, with a full-time job I have definitely cut back the doula side of my life.

When I come up with ideas for posts, they tend to be sparked by the stuff I'm working on at the moment, so right now that is breastfeeding, breastfeeding, breastfeeding. Which is certainly a topic I've always covered on this blog (and was a passion of mine before I became a doula) but I look at the title of my blog and think "Hmm, it says Public Health Doula, not Clinical Lactation Consultant". It might sounds a little silly to try to stick to a title I chose on the spur of the moment over three (!) years ago, but I want to maintain a diversity of blog posts not just because it's what I originally intended to do with this blog, but what I originally intended to do with my life. I LOVE being a lactation consultant and doing clinical work, and right now as a newbie I am learning a huge amount about hands-on support, but I do want to end up in a public health-oriented direction and want to keep my hand in that (thus all the research projects on the side.)

Finally, it's complicated (as many doula and other health care professionals know) to maintain confidentiality (both for HIPAA and for my own ethical considerations); I composite and change details and all that good stuff, but that's a lot harder than just being able to tell the story of the class discussion I had yesterday.

All that is to say, the things that I used to do that sparked more diverse blog posts are less a part of my life now; and the things I DO do, I tend to second-guess posting about.

However, I think the hiatus has given me a little more fuel for the writing fire. I've seen some neat public health breastfeeding- and birth-related stuff recently and gotten very interested in writing about some issues from a public health perspective (co-sleeping, anyone?) There's also definitely a big post o' links coming from my starred items in Google Reader. (Still waiting for a Reader replacement...)

I am also piloting a shared-call arrangement with two other doulas to be able to keep attending births while working and am super, super excited to be able to consistently take doula clients (even if it's not many) for the foreseeable future. Hopefully that will get my doula thoughts going too!

So, that's my life-via-blogging update. I know the holidays aren't going to exactly focus my thoughts on new posts (more like focus on cookies...mmm, cookies), but I'm thinking there will be more to come in the new year.

Too late for me, T-Rex

Dinosaur Comics may be - no, definitely is - my favorite webcomic. There may be - no, there definitely is - a Dino Comics whiteboard on my fridge.

[True story about how DC tied into my birth/breastfeeding/etc. life: whenever the newest comic is particularly great, I make it my Gmail status. Then people I was e-mailing professionally, like the midwife who ran the Centering program I volunteer for, started showing up on my Gchat list and I thought "Huh, they can see my status too; maybe that doesn't look very professional and I should stop doing that." The next time I saw that midwife she said, "Oh, I have to tell you - you have gotten me completely addicted to Dinosaur Comics."]

So you can imagine that I got special joy from today's comic:



Too late for me to heed T-Rex's advice! But some good points there.

(For more comics, the archives are here. Tip: hover the pointer over the comic to see the "alt-text" for extra commentary.)

P.S. There's a post coming soon about my long radio silence, not to mention a lot of links and even new content! It's been a busy month and I've been low on the posting mojo.

Nope, I won't bring you to a birth

Doulas and midwives probably get this a lot, and I get my share: "I am so fascinated by birth. I'm interested in becoming a midwife [or doula], but I'm not sure yet whether or not it's right for me. Can you help me find a way to attend a birth?" Sometimes people are asking specifically, "Can I come to a birth with you?"

My answer is always the same, "If you'd like to go to a birth, you should definitely do a doula training!" Doula training is a relatively low-cost and low-time investment, gives you a taste of learning about pregnancy/birth, and offers valuable knowledge about labor support if you plan to go into midwifery. Where I live, there is a local volunteer doula program that makes it easy for novice doulas to find their first clients. I tell people who ask that I am happy to be their "mentor" doula in the program (since the first birth they attend as a volunteer is always with a doula who has experience with the program), or to ask one of my doula clients if a doula trainee can come along to the birth.

I am surprised by how frequently people say "Oh yeah doula training, I thought about that, but..." The "but" usually has to do with lack of time or trouble scheduling or wanting to go to a birth sooner than the few months it will take to do the training and get set up with the volunteer program. They just don't have time, because they want to decide about midwifery real soon and go to a birth real quick.

I hear this enough and it starts to wear on me a little bit. I try to impress on the people who want to go to a birth, but skip the doula training, to think logically about the situation. There are a lot of people who want to be at a birth. Think about a hospital birth (since most births are hospital births). There's the mother's own family/friends/support people; there's the medical staff who need to be there (OB/midwife, nurse(s)); then there are other people who need to observe including medical and nursing students. For a midwife or doula to try to bring someone who's just curious to see a birth is usually not practical (and will probably exceed the hospital's visitor limits, which are often capped ridiculously low.)

Furthermore - and this is what I try to put gently to the people who ask me - to ask to attend a birth just because YOU want to see one, particularly just to ask to attend a birth of someone who is a stranger, is also unrealistic in terms of respecting the birthing woman's space. There are a few birthing women who have a welcoming "all-in" philosophy of birth - they don't mind having their whole extended family, neighbors, and FedEx guy watch them vocalize and pull off their clothes and push out a baby. Fantastic! It's their birth and they should have whoever they want there.

But most women want and DESERVE to hold a smaller space for their birth. They ask selected people to be there for a reason - because that person will have a lifelong connection with the baby, or because they rely on that personal for emotional security, or because that person offers them a great back massage and hip squeeze. Like I said, for a few women your curiosity in midwifery is reason enough to invite you to be present. I think that's totally fine. But for most, they're going to need something more.

I think the questioners do understand this on some level. That is why they don't generally call up pregnant women they happen to know and ask "Can I come to your birth?" They ask me to ask for them. And this is my bottom line: I won't ask. There's something that question that rankles in a way I had to separate out: beyond just trying to elbow into a private experience, it's specifically imposing on me as a doula. The questioner is asking me to use my experience as a doula and the trust I've built with a family for their own purposes, but is not going to invest their own time and energy to make that possible. To do a doula training gives you something to offer the birthing woman and a reason to be present; and it also gives me something important: honestly, I want to see, before I put myself out there, that you are serious about this interest in midwifery/doula-ing. Midwifery school and midwifery as a career are a huge commitment. It's not so much to ask to put in a couple months of prep as a doula to see if that's what you really want. If you won't, then I question whether this is just a passing idea.

Sticking to this policy, I've seen it pay off. The people who were serious and have continued to pursue midwifery, or doula-ing, became doulas without hesitation; the people who hemmed and hawed have discarded or put off the idea of birth work as a career.

Reading back over this post, I realize it sounds pretty negative to the idea of "just anyone" showing up for a birth. I want to re-emphasize that I am not opposed to a woman inviting whoever she wants to her birth - including someone she doesn't know very well, who has a passing interest in midwifery. And if someone out there has had the experience of asking and being happily invited to a birth in that scenario, more power to you - you're pretty lucky! But think hard before imagining that just getting to see a birth will help you decide about midwifery. After all, you can watch a million births on YouTube (I know, it's not the same, but still.) It's possible that what will really help you decide whether you want to be a midwife is not the 12 or 18 hours you watch one woman labor and birth; it is the experience and preparation that get you to that point.

RIP Google Reader

I take a break from my (ir)regularly scheduled programming of birth & breastfeeding to go a little meta and lament the major changes coming to Google Reader. I know, what a nerd, right? But I am fairly Reader-dependent (ahem, addicted) and what I read, think about, and blog about is largely fueled by the blogs that come through my Reader.

One of my favorite things is the ability in Reader to follow, share, and comment on posts with others. Some of them are birth-y people, a lot of them are not. Some of the latter have said to me "I learn a lot from the things you share, they're um...real different from everybody else's!" I feel the same way about their shares. Some of it is adorable baby animals, some of it is urban planning or video games or meteorology. Sometimes it overlaps with my blog-reading areas of interest in surprising ways. Some of it, from the birth-y people, is birth-y stuff and I learn about blogs or topics I may not have been closely following. I enjoy the comments and interactions I have with other people - it's a nice mini-social network and so simply and seamlessly integrated into Reader. If I remember seeing something, or am trying to find a bunch of relevant posts on a topic, I can easily search the blogs I read AND the shared items back in time (search "cord clamping" for example).

I like Google Reader so much I created a bundle of my favorite Reader feeds to encourage people to use it. I always recommend Reader to people as a way to start following more blogs more easily.

However, in what seems to be an attempt to push people into using Google+, Google is going to cut a lot of the social functions from Reader and make them only available in G+:

we’re going to bring Reader and Google+ closer together, so you can share the best of your feeds with just the right circles.

As a result of these changes, we also think it's important to clean things up a bit. Many of Reader's social features will soon be available via Google+, so in a week's time we'll be retiring things like friending, following and shared link blogs inside of Reader.

Yes... a week. As another blogger put it:

after thinking about just how much I use Google Reader every day, I’m beginning to revise my initial forecast. Stay calm is quickly shifting toward full-bore Panic Mode.

First of all, how do you think I found Sarah’s piece? From a share in Google Reader. How did I easily and quickly archive both Austin’s and Sarah’s posts so that I could access them in the future for a post like this one? Again, Google Reader. How can I quickly search a variety of excellent sources, or dig back through my own writing in a quick and efficient manner? Yeah, you guessed it. As Sarah notes, Reader is a “carefully constructed “human curated” list of shares. It is, and will be up until the day it disappears, one of the most regular and enjoyable news consumption behaviors I engage in every day.”

Check, check, check. All exactly how I feel about this (right down to the part where I heard about this via a share). I am not interested in logging into Google+ to create groups to follow/share with, and I don't want the people who might follow me on Google+ to necessarily see my Reader shares. I'm not really interested in logging into Google+ at all - and this change will not make me any more likely to. Instead, I'm now searching (so far in vain) for a feed reader that will have the same social functions that Google Reader is getting rid of, WITHOUT forcing me to log into a separate social network. Poorly done, Google!

If anyone out there has reader suggestions, let me know...

Which part of baby-friendly do you have a problem with?

So since I wrote my screed, more has happened (all forwarded to me by the endlessly helpful Beth!) At the end of my last post, I linked to a post by Gina at Feminist Breeder called "Why I am a Feminist AND a Lactivist", responding to Jessica and talking about why she supports Baby-friendly. Apparently some Twitter activity around the past happened (I try to stay off Twitter - I'm already addicted to the Internet enough as it is!) Then Jessica Valenti wrote a response to the tweets (hard to tell if she actually read Gina's post). Jessica said:

I’m sympathetic to Catilin’s argument that there are problems with the way that formula companies market their products (there’s quite a long history there). That said, of course free formula in hospitals is done from a marketing perspective, not for the good of women. Companies are companies and they’re targeting their audience. But I’ll tell you what - when my breastmilk ran out while Layla was in the NICU, I was sure as shit glad there was formula there to feed her. ...

But the marketing/corporate aspect was not really what Hearts’ post and my response was about - we were addressing the hypocrisy of judging women who choose to formula feed and the way they are made to justify their choice. In this case, the fact that the hospital would make formula available to women who “medically” needed it - what constitutes medical need? And what if women simply didn’t want to breastfeed? Isn’t that her right, and shouldn’t she be equally supported for that decision in the same way a breastfeeding mom is?

Except, you know, that wasn't what Jessica's original post was about. Maybe that's what she THINKS it was about, because it triggered feelings around formula feeding, breastfeeding, guilt, shame, expectations, etc. But her original post was about Baby-friendly, and criticizing hospitals for "denying" women the opportunity to use formula. Gina was pointing out that she was incorrect; Baby-friendly is about denying formula companies the opportunity to use hospitals for marketing purposes, and getting hospitals to adopt best practices to support breastfeeding.

But Jessica also covers that in her second post (which is confusing because she also said in the second post that's not what the debate was about), and says she thinks limiting formula marketing is paternalistic:

... the argument that women are “vulnerable” to free formula is just plain insulting to women’s intelligence. I trust women to make their own decisions.

As Gina points out, that's not the case for a lot of other marketing efforts that feminists take issue with:

Feminists are constantly calling out “Pregnancy Crisis Centers” for being predatory. They snag women who may be alone, scared, and confused by a major reproductive choice, and they offer them freebies to gain their trust. They tell them they’re helping them make a decision about parenting, but what they’re really doing is piling their Anti-Choice agenda on them, promising the mothers they’ll help, and then vanishing when it comes time to foot the costs of raising this baby. Feminists recognize that these centers are preying on a woman during a vulnerable time in her life. We’re not saying these women are stupid or that they’re being duped. We’re not saying that one choice is better than the other. We’re saying that the marketing is absolutely unethical.

Feminists are constantly calling out and boycotting the beauty industry for shaming women about their bodies, their lifestyles, and their choices. Why do we do that IF we think women are immune to marketing influence? Isn’t a woman smart enough not to fall for that “skinny is better” imagery? Don’t we trust her to recognize the airbrushing for what it is?

I am very curious to see how (and if) Jessica responds to that argument. But in the meantime, let's move on to her conclusion:

Listen, I support breastfeeding women - long before I had my daughter I was blogging about the heinous lack of resources for breastfeeding mothers and the various ways they are discriminated against. I think we need mandated paid maternity leave, insurance that pays for lactation consultants and breast pumps, employers who are required to have a space and breaks for pumping moms, hospital- and state-funded breastfeeding support groups and more. But I also believe that formula feeding your child is just as valid and healthy a choice as breastfeeding - it’s not something women should have to justify or be denied resources for or access to.

I agree with her! Breastfeeding women deserve time, space, resources, and support? yes! Formula feeding as valid a choice as breastfeeding? Yes! As healthy or even MORE healthy than breastfeeding? Yes, sometimes! Should you have to justify it to anyone else? No! Should you be denied resources for formula feeding? No! Wow, look, me and Jessica agreeing on everything. Except the part where she slams me, the organizations I work with, and the work that we do. Because she still thinks Baby-friendly can "suck her left one". I wrote in my last post that she doesn't seem to actually understand what Baby-friendly is. But maybe it didn't get through. So here's a little review for Jessica Valenti and anyone else who's confused:

Here are the Ten Steps to Baby-Friendly, from the UNICEF Baby-Friendly page.

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7. Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

The Ten Steps prevent hospitals from doing things like routinely supplementing breastfed babies, not training their staff, routinely separating new babies from their mothers, and trying to force babies to feed on a schedule. Good stuff, right? So where is the issue here?

The current debate seems to center around Step 6, Give newborn infants no food or drink other than breastmilk, unless medically indicated. This is an international guideline, and in the U.S. Step 6 has been reworded as "Give breastfeed newborns no food or drink other than breastmilk, unless medically indicated." As the U.S. has a long history of formula marketing via hospital, Baby-Friendly USA has added this clarification to Step 6:

The Baby-Friendly Hospital Initiative supports the International Code on the Marketing of Breast-milk Substitutes ("WHO Code"). The WHO Code stipulates that health care facilities and professionals neither accept nor offer free or low-cost substitutes for human milk. In keeping with the Code, the Baby-Friendly Hospital Initiative asks facilities to purchase all infant formula in the same manner as it purchases all other supplies. Additionally, facilities should not give infant formula samples, literature, or other items bearing the name of an infant formula product to breastfeeding mothers.

Since the original story was about a UK hospital, I looked up the UK guidelines and found their page on Step 6. They have not reworded the guideline from the international version; they have set out the following criteria for following it:

No food or drink other than breastmilk should be given to breastfed babies unless:
- there is an acceptable clinical reason, the baby is unable to breastfeed and there is no/insufficient breastmilk available
- the mother has made a fully informed choice to feed her baby other than from the breast.

No promotion for infant food or drink other than breastmilk should be displayed or distributed to mothers or staff in the facility.

The hospital in the article that sparked all this seems to have drawn ire for asking mothers to bring in their own formula if they decide to formula feed without a clinical/medical reason. But that requirement is not part of Baby-friendly. It's not required in the international guideline, or in the U.S. interpretation, nor in the U.K. interpretation. This hospital has chosen to make this change part of going Baby-friendly, but it is not required. I said in my original post that I thought that whether was a good idea or not was a legitimate subject of debate, but it is not actually being made the subject of THIS debate. Instead I'm seeing people call Baby-friendly shaming and lump it together with the anti-formula douchery on Twitter and that's just plain wrong.

Saying, as Jessica Valenti did in her original post, that "refusing to give mothers access to formula is not “baby friendly” or helpful - it’s shaming and in some cases could be very dangerous" shows that she REALLY didn't understand what Baby-friendly was about, since apparently she never saw "unless medically indicated" in Step 6. No Baby-friendly hospital would put a baby in a "very dangerous" situation by denying them formula. "Medically indicated" is how we avoid "very dangerous". It really bothers me that someone would imply that LCs, nurses, and doctors and those hospitals would shrug and say "Sorry, no breastmilk no eat!"

I made this point before and I make it again now: Baby-friendly is not about you needing to justify your choice to formula feed to hospital staff. It is about the HOSPITAL having to justify its OWN reasons for supplementing breastfed babies. Yes, that hospital in the U.K. differentiates between medical and elective supplementation, and asks the elective supplementers to bring in their own formula, and that may seem judgy and we can talk about that. But let's talk about it WITHOUT bringing Baby-friendly into the mix and WITHOUT implying that health care professionals are starving babies.

I'm glad formula was there for Jessica's baby. I'm glad she likes formula feeding and that it was a healthy choice for her. I'm really sorry people are jerks about how women feed their babies. I just don't see the connection between all those things and Baby-friendly. As I said in my last post: they are different things. Jessica had the opportunity to say "Hey, I get what Baby-friendly is, I just have a problem with this part of it and let's talk about that", but instead off we go on the mommy-wars train to Stopjudgingmeville, complete with opportunities for self-proclaimed lactivists to show off their ugliest, judgiest sides. I get so depressed by how so many feminists hop on this train unquestioningly. Back to my conference proposal in an attempt to encourage more people to think about this in a more critical way...

Another screed on breastfeeding & guilt – this time with cussing!

Oh, this comes at a great time. This comes at a PERFECT time. I was literally in the middle of writing a conference proposal for a presentation on breastfeeding as a reproductive right, and I check my e-mail. My friend (thanks for loving Internet drama, Beth!) had forwarded me the following links on breastfeeding and baby-friendly:

The first was from a feminist blog called the F Word, by a guest blogger named Laurie Hearts, "Baby friendly - but is it woman friendly?":

Manchester's largest maternity unit, St Mary's, is set to become a Unicef-approved 'Baby Friendly' hospital by ceasing to provide free formula milk to the women who give birth there. ... Women who choose to formula feed at St Mary's will have to bring their own ready prepared milk in cartons from this November; powdered milk will be banned for health and safety reasons. ...

In an era when many feminists are (in my opinion rightly) dismayed by the suggestion that a woman's right to an abortion should be subject to conditions, I have been shocked by the high level of acceptance when it comes to the notion that women who formula feed should be forced to justify their choice, not only to medical staff, but to pro-breastfeeding women. While I have never seen anyone claim that formula is better than - or even equal to - breast milk, a large number of women are vociferously and uncompromisingly against a woman's right to choose formula milk. I have witnessed a sizeable number of women, some of whom are self-declared feminists, debating on one another's social media profiles and calling for formula to be made illegal.

The second was from Jessica Valenti's blog:

[F]or me, formula feeding was absolutely, 100% better than breastfeeding. Like, life changing better... refusing to give mothers access to formula is not "baby friendly or helpful - it’s shaming and in some cases could be very dangerous. Enough already.

I usually don’t swear very much on my blog (real life is a different story) but like all good screeds, this was written while I was feeling just a little riled up. So: Holy shit. Let’s just make this clear: baby-friendly is not about preventing you from formula feeding. I work in a hospital that is pursuing baby-friendly certification. Most women at our hospital plan to breastfeed. Some women plan to formula feed. A fairly significant percentage of the breastfeeders choose to use formula at some point. The straight-up formula feeders never hear a word about breastfeeding from us. You told us on admission you planned to formula feed, here are your bottles. The breastfeeders who need to use formula for medical reasons – and they are very clearly outlined, including hypoglycemia (low blood sugar) and excessive weight loss – get formula too (and we are very fortunate to be able to offer them the option of donor milk if they are not comfortable with formula.) The breastfeeders who ask to use formula – this happens not infrequently, often because “I think I don’t have enough milk” – get education and discussion, sign a consent form, and then are given formula too. (No, we don’t have them bring in their own formula like the hospital profiled; we can debate whether that’s any different from making them bring their own baby clothes, but I think there’s a legitimate debate there.)

However, while I have a lot of respect for Jessica Valenti, she and the other blogger are completely mischaracterizing the issue here. Baby-friendly is not part of the mommy wars, and I honestly think it is irresponsible to do so. What makes hospitals baby-friendly is not preventing women from choosing formula feeding, or refusing to give them formula when their babies need it. Baby-friendly is not about forcing mothers to do anything. Baby-friendly is about preventing HOSPITALS from shoving bottles and pacifiers into breastfed babies’ mouths and then sending their unknowing mothers home with a screaming, nipple-confused baby who won’t latch. Baby-friendly is about preventing HOSPITALS from accepting “free” formula and gift bags and samples from formula companies, turning the hospital into a shill for a for-profit company, and engaging in practices that research has shown make it less likely for women to reach their own breastfeeding goals. Baby-friendly is about forcing HOSPITALS to offer regular breastfeeding education to all their staff, including nurses and doctors, so they can help mothers and not give them crap advice. Baby-friendly is not about the mommy wars. It is not about trying to force any mother to breastfeed. It is about changing HOSPITAL practice, and whether or not you realize it, most hospitals in the U.S. have a long, long way to go. Baby-friendly is about offering evidence-based care to promote health.

“Who are you to decide that breastfeeding promotes health? Formula feeding can be lifesaving!” Hell yes it can. You think I don’t see that? I see that all the time. When women are dealing with a new baby, sleep deprivation, hormone shifts AND feeding issues, you are dealing with a potent cocktail for severe depression – you think I never meet women with serious PPD? You think I don’t see women with intense pain from feeding, or a history of low supply, or a baby who isn’t transferring milk well? You think I don’t see women who are BBAC (breastfeeding baby after challenges), who are having the same issues as their last hellish breastfeeding experience, where we talk through their situation and their emotions and their individual needs and they decide that on balance, formula feeding is the healthiest thing for them and their babies? You think I don’t see women with insufficient glandular tissue to make enough milk, whose babies will starve without supplementation? That I never meet women, like Jessica Valenti, who had life-threatening health issues and premature deliveries, who are pump dependent and struggle to make even a tiny supply? You think that because I work at a baby-friendly hospital I refuse to let any of those women use formula? Of COURSE I do. Of COURSE formula is lifesaving. And it doesn’t NEED to be lifesaving to be OK. I see women who just decide that breastfeeding isn’t for them. They don’t want to breastfeed. Maybe they said they wanted to because they wanted to give it a try, but they’re not that into it. I shrug and move on. As a lactation consultant and public health professional, I would love for more women to choose to breastfeed. The lady in Room 4 doesn’t want to? We gave her the spiel, and it’s her choice.

So “formula-should-be-illegal” Judgy McJudgersons out there (even though I think there are fewer of them out there than their reputation): Shut up. Yup, I said it. You can never know what’s really going on in a woman’s life. When you demand that a woman give you a good reason for not breastfeeding, you have no clue what you’re asking. How about this: “Well, I was sexually abused as a child and I had very frightening flashbacks every time I breastfed.” Is that the reason you need to hear? Women don’t need to justify their feeding choices to you. They don’t need formula to be made illegal “for their own protection”. Because even if a woman doesn’t have a “good”, “morally correct” reason to breastfeed (just like many women do not have “socially approved” reasons for having an abortion), “I just didn’t want to” is reason enough. “But if they were really informed – ” No. I know we don’t do a very good job with breastfeeding education in this country. Please, if you really care about educating women, do not do it by asking nosy questions of your pregnant friends or of the woman with a bottle next to you on a park bench, or post judgy comments on mommy wars-fueling news articles. Lobby our elected officials to stop slashing funding for maternal and child health programs. Volunteer to teach classes at a community center. Write a letter to your local hospitals encouraging them to become (gasp!) baby-friendly.

Finally, let’s stop with the idea that women who tried to breastfeed – who wanted to breastfeed – and couldn’t breastfeed, shouldn’t be sad. Do I think they should feel guilty? That they should feel ashamed? HELL NO. But it’s OK for them to mourn something they had hoped to do, and couldn’t. It’s also OK for them NOT to mourn it, to just accept it and go on, to appreciate the things about formula feeding that are positive for them. Everyone is different. But women who had looked forward to providing milk for their baby, who planned to have a positive nursing relationship with their baby, can feel sad about the loss of those hopes. That does not mean that “boob nazis” made them feel guilty and should just stop it with the baby-friendly bullshit already. It doesn’t mean that formula is supernifty and that we should let formula companies engage in deceptive marketing practices and co-opt hospital staff. It means we should support those women and help them work through their sadness so that they can move forward feeling good about themselves as mothers. It means that we should work harder to offer donor milk so that if those mothers are helped by knowing their baby is still getting breastmilk, they have the option to choose it. It means we should continue to research ways to help women so that they ARE able to reach their breastfeeding goals.

I am just tired of this argument. I’ve said it before, and I’ll say it again: when we hate on breastfeeding initiatives like baby-friendly, we hate on the very things that make it possible for women to breastfeed. An individual woman’s feelings of being judged or of guilt are REAL issues that deserve their own space and time (that’s why I just gave them their own paragraphs). But they are not the same thing. They are different. Different things. The end.

(As I was finishing this up, I saw that Gina at the Feminist Breeder has also written a post prompted by those blogs, "Why I’m a Feminist AND a Lactivist", and I highly encourage you to go and check it out.)

Android apps for doulas

I got a smartphone for the first time in March of this year. I had wanted the iPhone for years, but was tired of waiting for it to come out on Sprint. (Of course, once I gave in, Sprint announced they were getting the iPhone. As much as I love Apple products though, I can't say for sure I'd switch to the iPhone once I'm ready for my next upgrade. I've gotten a little bit addicted to certain Android apps & features.)

I've found the phone mildly addictive in some ways (Google Reader on phone = bad idea?) and super helpful in many others - including doula work. I thought I'd do a post on a few of the apps I've found useful as a doula, and ask for app suggestions that others have discovered.

Navigation

When you're meeting up with clients at their houses, or various places out in the community, or driving to unfamiliar hospitals, navigation is wonderful! One of my favorite things about the Android is that Google Maps is your in-phone GPS. This is absolutely amazing, not just for the directions but for a lot of other little details. For example, when you arrive at your destination, it will show you the Google Maps street-level photo of the address you're looking for. I am using it constantly for both doula and non-doula navigational needs (I have a terrible sense of direction.)

Contraction Timer

I definitely don't spend a lot of time at births timing contractions (I don't spend a lot of time at births looking at the clock, period), since most of what you need to know about labor progress you can tell more from looking and listening than you can by timing. But there is the occasional situation where it's helpful to do a little contraction tracking, especially when getting ready to pass along information to the midwife or doctor. I found it helpful in dark, quiet room while the mom was resting with her eyes closed. There were no lights and no light-up clocks (other than my phone), but I felt like her contractions were lasting surprisingly long. I turned my screen brightness all the way down and was able to just hit the button silently whenever I heard her start or finish a contraction, and pass along the information to her midwife. This app is simple, free, and does exactly what you want it to: show duration and frequency of contractions.

LactMed

I've written about this app before, and now it's on the Android Market proper! Quick and easy look-up for medication safety & breastfeeding, from the comprehensive database maintained by the NIH. I make a point of using it and demoing it in front of the medical providers who should know about it - already got an ER doc to download it this way!

"Whitelist" call screening apps

The one holy grail app I am still searching for is a "whitelist" call screener. Especially since I work nights, I am at very high risk for getting phone calls when I'm sleeping. But when I'm on call, I cannot turn off my phone. All doulas face this problem in some form: you might be at movies, at work, in class, etc. You're willing to let your phone buzz or ring quietly for a client, (knowing it's highly unlikely they'll call during that time) but when the dentist calls to confirm your appointment it's kind of embarrassing. What you want is an app that screens calls, so that your clients' phone numbers are OK to ring through, and and all others will be sent to voicemail.

VIP Alert worked perfectly, but when the whitelist numbers rang through, the ring would just be a soft beep. That would work perfectly in a movie or meeting, but I needed something to wake me up! It now seems to have been updated so you can adjust the volume, but at the time I tried it, that was a no-go. I'd be curious to try it again.

I tried Profile Call Blocker, but it just did not work the way I wanted it to. No matter how I adjusted it, the blocked calls would still ring through briefly before getting blocked - long enough to wake me up. I e-mailed the developers and didn't hear back from them. It might work on a different model of phone than I have (HTC Hero) but I can't recommend it myself. Also, it had a lot of other features I didn't really need, just to get at the one thing I did need.

I haven't tried Semisilent since I just discovered it while doing research for this post, but it looks promising! Does anyone have experience with it?

Swype

OK, this isn't really a doula-specific app. Um, I'm listing it because it makes it faster to write e-mails to your clients? I'm just putting it in here because I love it so much. Seriously, it is the best typing/keyboard app I have tried, and I have tried multiple. Instead of tap-tap-tapping out each word, you just slide your finger from letter to letter and Swype magically guesses the word that you want (occasionally you have to correct it, but not often). I probably type 3-4x faster with this method than I ever did thumb-typing. You can't find it in the Market - you have to go to the Swype website. The trouble is worth it!

Other apps doulas have found useful? Feel free to list iPhone apps...maybe I can be tempted to switch!!

In the category of blogs that I am enjoying this week

Privilege Denying Dude!

I think privilege denying dude would also say related things like "If you don't want to have a baby in a hospital, don't get pregnant" and "Birth trauma is all in your mind" and "Maternity leave is discriminatory".

Of course, he would do it while condescendingly mansplaining.

(For the record, women can also be privilege denying dudes. Lest anyone think I'm being sexist.)

Bonus link: If you are having a baby, and don't want your baby's pee or your milk to get on your mattress, I can vouch for this mattress pad: Queen Size SafeRest Premium Hypoallergenic Waterproof Mattress Protector - Vinyl Free

What every doula should know about breastfeeding: Tip #4: Tongue ties

Preface: Often as a doula, before I became an LC, I would encounter situations in the hours after the baby was born, or at postpartum visits, where I wasn't quite sure what to suggest; or looking back, I realize I could have done something differently. I've decided to share some tips with other doulas about things that I wish I had known long ago! Today is Tip #4: Tongue-ties.

Let's start right off with an explanation of why I am even talking to doulas about tongue ties. Should a doula diagnose a tongue tie? NO! Should a doula even be the one to assess for a tongue tie? NO! So why even discuss tongue ties??

I am including this piece on tongue tie because the lack of education among medical providers and even some LCs about tongue tie makes it incredibly hard for mothers to even find out that their baby has a tongue tie, and often even harder to find someone to treat it. Yet tongue ties can cause serious breastfeeding problems including maternal nipple pain/trauma, poor milk transfer by the baby leading to low weight gain in the baby and low supply in the mother, and may also be related to problems related to feeding such as reflux and unwillingness to start solids. I hear stories of women going to multiple LCs, pediatricians, etc. with these issues and having the tie totally missed...sometimes for months.

As with other breastfeeding issues, the lack of awareness of tongue means there is a serious gap in terms of providing good care for breastfeeding mothers & babies. So while we're waiting for all health care providers to get educated about tongue ties, if the doula is going to be the one person to notice a possible tongue tie, I'll take it!

WHAT is a tongue tie, and WHY look for it?

A tongue tie (the medical term for tongue tie is "ankyloglossia") is when the frenulum, the thin band of skin under the tongue, is very close to the front of the baby's tongue and/or very tight. This prevents the baby from properly sticking out and/or lifting the tongue. The tongue is a crucial part of breastfeeding! It helps stabilize the breast in the baby's mouth, and moves in a wavelike pattern to generate suction and move milk from the breast into the baby's mouth. It also moves the milk to the back of the mouth to be swallowed. To do this, the tongue needs to be able to stick out past the baby's lower gumline, cup the breast, and elevate up towards the roof of the mouth. A tongue tie can impair one or more of these functions, making it hard for the baby to nurse comfortably and effectively.

A tongue tie may cause pain for the mother because the baby can't extend the tongue past the gumline, so it ends up biting the nipple; or because the tongue is restricted, it keeps humping up in back and bumping the end of her nipple. It may keep the baby from moving milk out of the breast effectively, because it cannot latch properly. This can lead to a decreased milk supply because the mother's breasts are not being drained sufficiently. The baby may become very fussy at the breast and even refuse to latch at all because it is so difficult to latch and remove milk. Or tongue tie may cause other issues down the line, or it may cause no issues at all! Next I'll talk about when to look out for tongue tie, and what to do if you suspect a baby is tongue tied.

A tongue tie can be easily and fairly painlessly clipped, especially if it is done in the newborn period. The clip is usually done by a pediatrician, ear-nose-throat (ENT) doctor, family practitioner, midwife, or dentist. I want to emphasize how simple, quick, and no-fuss this procedure can be! I find that people often find the idea of clipping off-putting at first. (I call it the "scissors in a baby's mouth" problem. I need a new name for the problem.) When the parents actually see it done, they are often surprised by how insignificant it seems to them AND to the baby. I will talk some more below about helping parents think through whether or not to clip.


WHEN to look out for tongue tie:

As an LC, I look under every single baby's tongue, because that's my job! As the doula, it is not your job to look for or assess for tongue tie. A baby doesn't need a tongue tie assessment before it latches on the first time, nor do you need to make a routine part of your doula services to check any client's baby for tongue tie if they are nursing well.

What about the client's baby who is having trouble? Ideally, all babies who are having trouble nursing have had their tongues checked by a knowledgeable LC and/or pediatrician. However, as I noted above I am writing this post because not all your doula clients will have access to those providers. They may even have noticed something different about the baby's tongue and been told by a health professional "Oh, it's not a big deal" or "That has nothing to do with it".

As the doula, if you know your client is having trouble nursing and the baby has NOT been checked out by someone knowledgeable, it is worth taking a look. Or if you are holding the baby or looking at the baby's mouth and notice it might be tongue tied, it is worth looking more closely. You can be the "breastfeeding first responder" to identify a possible tongue tie and get the mother to advanced help. My post on referring to advanced care is here. You may need to do some extra research to help the mother identify good local resources for tongue tie. Use your fellow doulas as resources, call La Leche League, and network with local LCs to help your client.


HOW to look for tongue tie:

When it comes to learning to identify tongue ties, a picture is worth a thousand words; and many pictures are worth a whole blog post! I'm not going to include a single picture of tongue tie here - that's so that no one looks at one photo and thinks "Oh, that's what a tongue tie looks like". Tongue ties can present in many different ways; you should see many to get a feel for them. To learn more about different presentations of tongue tie I highly recommend the following resources:


Clip It, a resource for helping identify tongue ties and to teach medical professionals how to do clips. They have a number of tongue tie photos and videos, and a long and informative PowerPoint presentation

Dr. Lawrence Kotlow's website has a number of his publications that have photos of tongue tie, including a presentation for health professionals and this handout for parents.

Cathy Watson Genna, IBCLC extraordinaire, has a fantastic book called "Supporting Sucking Skills in Breastfeeding Infants". It's probably not at your local library (or even your local medical library, although you never know) but parts of it, including many tongue tie photos, are available on Google Books - go to chapter 8. (And if you are interested in learning more about a wide range of sucking/feeding skills in breastfeeding infants, this book is an amazing investment! Although I hear there's a new edition coming soon, so you might want to wait to get it.)

Keep looking! If you find more tongue tie resources, look at those photos too. The more pictures you see, the more you'll be able to notice normal vs. abnormal frenulums. Take a close look when you find pictures of posterior frenulums - they are the hardest to see and so frequently get missed.

And once you're starting to notice tongue ties? Remember, even if you see what seems to be a very obvious tongue tie, it's probably not helpful to your client to hear from you: "Your baby is tongue tied, I've found your problem" - nor is it in your doula scope of practice. Your role is to let her know what you see, and provide her with the education and resources she needs to make the right decision for herself and her baby. For example: "It looks like the skin under her tongue - her frenulum - is tight, and is making it hard for her to lift her tongue. I know that can sometimes cause breastfeeding problems, and a lactation consultant can help diagnose it. Would you like the contact information for someone who is very experienced with this issue?" Again, you should have a good list of local breastfeeding resources that can serve as referrals if you suspect tongue tie.

And it is DEFINITELY not the doula's role to rule out a tongue tie! You don't want your clients saying "Oh, my doula looked at the baby's tongue and said it was fine." If your client has unresolved breastfeeding issues, she should be in a good lactation consultant's office saying, "My doula is not sure what the problem is, but she helped me all she could and referred me to you."

I will also emphasize that tongue ties do NOT always cause problems. When I had just learned about tongue ties, I had a doula client whose baby was tongue tied. I noticed it within 15 minutes of the birth - the baby could extend his tongue over his lower lip, but it was clearly heart-shaped. I think it was the first tongue tie I ever identified by myself, so I was on high alert.

I could have leapt up on a chair and yelled "Call the doctor! Get that sucker clipped!!" I am proud to say I did not! I mentioned it when I saw it, and checked in with her several times during the first nursing to make sure they had a good latch and that she was comfortable. Later, I talked with her about the possibility of pain with nursing or issues with milk supply/weight gain, just as an FYI to keep an eye out for those issues; she did keep an eye out, and saw zero problems. Since then I have worked with other tongue tied babies who had no problems nursing. Some tongue ties are functional; even some babies with what appear to be fairly severe tongue ties may "fit" with their mother's nipple so that it is not an issue. If you see a tie, you can inform your clients in a way that doesn't make them overly anxious, and always have more information on hand so they can find out more if they are curious.


WHAT happens if a tongue tie is diagnosed?

If your client's baby has a tongue tie diagnosed, there are several things the parents can choose to do. Most parents do not say "Yes! Clip it!" immediately; and most doula clients, being informed consumers of healthcare, do want to spend at least a short amount of time evaluating the risks and benefits of a clipping (which goes by many different medical terms, including "frenotomy", "frenulotomy", and "frenuloplasty").

You can be available to help your clients think through the options. Help them think through what questions to ask: How long does the procedure take? What happens during the clipping? What will the baby experience? What are the benefits for breastfeeding? What are other possible benefits? What are the risks? Can the parents be present for the procedure? Will the baby be put to breast immediately after the procedure? (Most professionals who clip recommend this.) What does the provider recommend if they decide not to clip? If they change their minds later about clipping, what are the options?

If there are no or mild issues, and they are willing to see if those issues resolve on their own, the parents can decide not to clip. If they are unsure, you might help them think through options like "We'll revisit the idea if the issues are still here in [X] weeks" or "We'll clip if the baby does not gain [X amount of weight] by next Friday." A lactation consultant can help refine the latch and find positions to help the baby nurse better.

If they would like to go ahead and do the clipping, you can be a resource to help them find someone to do the clipping. As I mentioned above, those can be health professionals from midwives to ENTs to dentists. Posterior tongue ties, in particular, are often the most challenging to find a provider to clip for; the parents may need to travel several hours to get to someone familiar and experienced with posterior ties. Help your clients get past stonewalling like "Yes, your baby is tongue tied, but no one will clip it" - this is untrue and denies the parents the opportunity to pursue appropriate care for their baby.


Below, is a video of tongue tie evaluation, clipping, and breastfeeding after if you're interested in learning more.

You can also see Dr. Jim Sears discuss tongue tie on "The Doctors" (sorry, can't embed.)
Please feel free to comment with other resources and personal experiences!

Doulas & social media use - what are your rules?

My apologies for the looong blog silence. Note to self: just because you CAN go on a week-long trip and take no time off of work, by working 6 out of 7 nights when you get back...well, that doesn't mean you SHOULD. Especially when those 6 nights are very very busy! But I am (mostly) recovered and ready to get back to writing.

A topic that's been rolling around in my head since my trip was the question of doulas & social media. This has been brought up recently with doulas I know locally to me. I also had a conversation with a doula friend who I visited with while traveling. Apparently it's been a subject of debate/discussion in the doula community in her area as well.

I have always felt very scrupulous about HIPAA and protecting patient privacy. My first experience in clinical care was interning at a reproductive health clinic. We specifically asked clients if we could call them at home; if we could say we were calling from the clinic; and if we could leave them messages; and if we could say the messages were from the clinic. Some of our clients were getting care without the knowledge of their families and/or partners, and preserving their privacy was important to their safety. That experience made me cautious from the beginning about anything that could identify people I worked with in a healthcare capacity. I will only talk about stories of births, or breastfeeding situations, with the details changed, de-identified, without any way for someone to trace the story back to the person.

But our conversation made me think twice about posting even the very general statuses that I have posted about attending births on Facebook (like referencing that I've been busy because I just attended several births, without any specifics about who/where/exactly when). No matter if you live in a very populous area or a big city - communities are still small! I worked with a family recently thinking that we didn't know anyone in common on places like Facebook or blogs. Just before the birth, it turned out that couple were friends with an acquaintance (and social media "friend") of mine. It was a neat connection to discover, but I could have written (although I never did) even general things about them or their birth assuming we had no friends in common, and been very wrong.

My doula friend also pointed out several things I hadn't thought of that could become an issue, including the idea that even when clients are OK with us writing about their births, we have to think about the messages we are sending. She talked about a doula who had worked with a client and posted something lovely and positive on FB like "Beautiful vaginal birth! So honored to be there." This client's friend hired the same doula, and after her (long and difficult) birth she was expecting the doula to post something similarly celebratory about her birth...and the doula never did.

Now we know that the doula may have run straight to another 40-hour labor, or been trying to catch up on the rest of her life, or just not thought to post this time... she probably had no idea this mother was looking for that kind of affirmation (having already seen her friend get it.) But it made the mother wonder whether her friend had a "better" or more "beautiful" (perhaps more "vaginal"?) birth that was deserving of an update.

Another issue is that while one client may have no issues with it, and even be excited to be part of a doula's post, another client may not. Seeing a doula post about attending births and sharing details may turn potential clients off, because they don't want to be part of the news feed.

When this comes up I have heard other doulas defend their use of social media. They feel that their use is appropriate, and/or that they get permission from their clients for all posts, and/or that they work in large enough areas that their social network circles don't overlap. Many doulas use social media as one of their marketing tools. I was actually surprised to hear about the number of doulas who post far more personal detail on Facebook than I would ever dream of doing.

What are your thoughts on this issue? What are your personal rules for social media posts about doula clients?

Post-Labor Day link party

Back from another trip and about to work...a lot. I know my latest posts have been sporadic and all link parties. I am sorry! More actual content is coming! While traveling, my lovely smartphone (got it in February and just seem to find more and more uses for it!) has helped me keep updated on reading. Here are some links while I'm catching up with the rest of life:

- Erykah Badu is a doula and wants to become a midwife. I read this one flipping through People magazine in an airport kiosk. Just seeing the word DOULA printed huge in a headline in People magazine made me all excited! The article itself, unfortunately, did not do the greatest job of accurately representing what a doula is/does. Someone reading it would come away with the distinct impression that doulas are 1) definitely only for mothers who want unmedicated births, 2) possibly only for mothers who use midwives, and 3) deliver babies (people are ALWAYS saying "oh, you deliver babies!" No, I do not! The midwife or doctor does! I just support the family.) But hopefully this will get more people aware of doulas and more accurate education can follow. And - Erykah Badoula? How great is that?

- JAMA publishes an article on "Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education", and I am proud to say I know one of the authors! Via Bellies and Babies, some waterbirth videos for the birth video addict!

- PhD in Parenting on Evenflo's quick transition from Code supporter, to a marketer that emphasizes pumping and bottle feeding as superior (and less icky and embarrassing, of course!) than direct breastfeeding. Depressing, but Evenflo's Facebook update today shows that the attention has gotten them to take one of the offending videos down.

Link party, August blogcation

I guess my blogging is on an August hiatus? Between traveling and bracketing the traveling with long shifts at work, I am not doing much blogging (also, my e-mail inbox hates me - at least, I assume the feeling is mutual. So if you've e-mailed me and not heard back, that may be a factor.) Early September may not be much better, but I promise to post again soon!

In the meantime, some links:

* Jessica Valenti on learning to love her baby through a harrowing delivery and long NICU stay


* From Birthing Beautiful Ideas, these are many of the reasons that I too love being a doula!


* Elita at Blacktating ponders the idea of the "relief bottle".


* A doula's birth story that highlights some of the ways a doula can play an important role in a planned cesarean


* The Unnecesarean links to this excellent piece on the co-opting of "pregnancy is not a disease" by anti-contraception organizations, and then breaks it down:

...this whole conversation is ridiculous. We are only having it because somebody, somewhere, is upset that women are having sexy non-babymaking funtimes they don’t approve of, and they’re determined to make us all pay for their inability to deal with not everybody agreeing with them that this is bad.

Go on, read the whole thing!


* And for the lighter side of things... I've just discovered the webcomic Married to the Sea, and in celebration they clearly did a comic just for me:



There are lots more!

Link party! CBACs, Fulbrights, and bras

I am on the road! Excited to be traveling to a favorite city to help with and attend the wedding of a great friend. I have several posts in the "What every doula should know about breastfeeding" series in progress, but I don't know how much work I'll get done on them in the next week. So in the meantime, a few links!

A planned, empowered, and enjoyable CBAC story (by a mother who had already had one c-section and a VBAC). "I will never forget these moments. Ever. They were beyond perfect. At last a very beautiful, calm and positive birth experience. I felt fully supported, I felt my son and I were in good hands. My husband and I were respected, and the birth truly was a celebration."

A step-by-step guide for applying for a Fulbright. I am so proud of my sister who has a Fulbright next year to study sustainable agriculture in west Africa! Have you ever thought about wanting to research issues related to reproductive health or other related issues in another country? A Fulbright can fund you for a year, on huge range of research topics!

I've been getting into some different bra blogs lately! They are written by women who have "unusual" sizes (in quotes because it's not unusual for women to BE these sizes, it's just unusual for them to KNOW they are these sizes). This is a great post on how many women are fitted poorly into bras and how the many different shapes and sizes that we come in are not respected:"The War on Plus Four": "...for some women, the fact that they might need a 30 or even 28 band and a significantly larger cup might seem like an alien concept as we generally have it drummed into us that a 32 is the smallest band available, and anything below this should be considered a ‘specialist’ size. Or an ‘awkward’/'odd’ size (I’ve heard it described as such and everything in-between). Even the idea that going down a band size (or even multiple sizes) makes people shudder. "

That's all for now!

What every doula should know about breastfeeding: Tip #3: A few must-knows for pumping

Preface: Often as a doula, before I became an LC, I would encounter situations in the hours after the baby was born, or at postpartum visits, where I wasn't quite sure what to suggest; or looking back, I realize I could have done something differently. I've decided to share some tips with other doulas about things that I wish I had known long ago! Today is Tip #3: A few must-knows for pumping.

There are a number of reasons your doula client may want or need to pump, including increasing her milk supply/getting additional stimulation to bring in a good supply, and pumping for a baby who can't latch and/or is in the NICU. Some mothers will end up (short- or long-term) exclusively pumping, aka EPing. If your client is EPing because of latch issues including difficulty getting the baby to latch or pain with nursing, make sure she sees a good LC fast!

Like some other topics in this series, I am bummed to have to give many of these pumping tips to doulas, not because I don't think doulas should know this stuff, but because EVERYONE involved in caring for new moms/babies should know this stuff! Moms often do not get the support they need to make pumping successful. But knowing that doulas are there to fill in the gap, these are important things that you may be the only one to discuss.

These tips are by no means all anyone needs to know about pumping, but they are opportunities for the doula to fill in gaps in knowledge:

With that thought in mind, I am putting two very simple, very important tips first:

#1: Cleaning: On a Medela, the valve and flange come preassembled, like this:

So nobody realizes that the yellow valve and white membrane come off and come apart, like this:

On an Ameda, the valve and flange also come preassembled; their valve looks like this:

Every time the mother uses the pump, those parts should be completely taken apart, washed, and dried separately. If those pieces are not taken apart, milk and moisture can accumulate between them and cause problems like poor pump suction and mold growth (EW, I know.)

People just do not know this; I know people who pump for months or YEARS and do not know this. Tell your doula clients! Tell all your friends! Rent out a billboard! Pump valves come OFF THE PUMP!

#2) Flange fit.

***ATTENTION: PUMP FLANGES COME IN DIFFERENT SIZES.***

Look at this picture:

GOOD FIT

Now look at this one:

TIGHT FIT

(Both images taken from this simple, lovely page by Ameda.)

I carry a copy of these two pictures around with me at work (I know, I know... my job is so cool!) Any pumping mother, when asked, can tell you whether her pumping sessions look more like the first photo or the second photo (occasionally they'll say "well, kind of halfway between the two" which still suggests a tight fit.)

The wrong size flange can cause pain and low supply. Once again, mothers pump for YEARS with the wrong flange and say "The pump never worked very well for me" or "Pumping always hurt for me", never knowing there was any size flange but the one that came with the pump!

If you know a mother will be pumping a lot, show her these pictures and tell her in advance to keep an eye on flange fit (consider printing the pictures out and keeping them in your doula bag). Mothers may start out a pumping session with what looks like a good fit, and end it with a tight fit; those women should get a bigger flange. They may also be OK on one size for a while, then start to need a bigger size after a few days or weeks of pumping; those women should also get a bigger flange.

The "standard" size in the box is the 24mm flange. Both Medela and Ameda manufacture various sizes up to a 36mm flange, and Medela also makes a 40mm flange. They can be purchased at stores like Buy Buy Baby, Babies R Us, Target, local lactation consultants, or baby boutiques; or they can be ordered online.

Many mothers find that the Pumpin Pals brand shields are more comfortable for long-term use than the standard flange that comes with their pump kit; Pumpin Pals flanges can be used with a number of different pump brands. They're angled and more curved than standard flanges, so many mothers report they feel gentler on the breast, and they also allow the mother to lean farther back when she's pumping.


#3) Early pumping: As I noted in my hand expression post, pumps are usually NOT very effective at removing milk in the early days. Mothers of a fussy baby may sometimes ask to pump to see "if there's anything there". The pump will not help her with that! Counsel the mother who wants or needs to pump in the first 1-3 days that she may not see much with the pump, and help her learn hand expression to maximize the amount she can get out. Mothers who are totally pump-dependent are understandably discouraged by pumping and pumping and getting a single drop. Give them lots of cheerleading and support, and reassure them that they will see more milk within a few days.


#4) She needs a great pump, aka not all pumps are created equal: If your doula client needs to or decides to EP, DO NOT let her buy a crappy, low-power pump. I usually don't talk in such absolutes, but it has to be said. There are some women who can get and maintain a great supply on those $70 pumps; they are in the tiny minority. Usually women buy one of those pumps because they see the price of a Medela or Ameda as prohibitive, but once they've bought a crap pump they've now sunk $70 into something that causes supply issues, and quite possibly nipple trauma (I'm looking at you here, Early First Years pump) AND they're looking at spending again on a high-quality pump. These situations just about break my heart. If the mother wants to provide exclusive breast milk, she needs a better pump.

She should also NOT get a single-sided pump, or anything with a little motor like the Medela Freestyle. These pumps are OK for the occasional pumper, not for the EPer. Once again, some women can maintain a supply on these pumps, but if they can't they've just wasted a lot of money and are going to have to spend even more. If she chooses to rent a pump instead of buy, you are on safer ground as she will be renting a hospital-grade pump which are all double electrics and have good suction/motors. (If she is struggling with supply and using a good consumer-grade pump like a Medela Pump in Style, she should also consider upgrading to a hospital-grade rental. Moms with supply issues need the best stimulation possible!) When thinking about pump prices, help her think about the value of the milk she will be pumping out. Good pumps are expensive - but so is formula.

If your doula client has difficulty affording a pump, check to see if she is enrolled in WIC, and if not encourage her to try to enroll. Any mother on Medicaid will be eligible for WIC, but even if she is not on Medicaid her income may still qualify her. (She does NOT need to be a US citizen or resident to enroll in WIC; after all, her baby, the one who will be getting the milk, is a citizen.) Many WIC offices have loaner pumps available for mothers who need to pump for medical reasons. If she tells the WIC office she is enrolling because she needs a pump, they may expedite her enrollment to make sure she gets the pump quickly.

#5: Support! EPing is not easy (even though to some moms it may seem like a quicker fix for latch issues in the beginning.) These moms often struggle with low supply, and with the extra time and work it takes to clean pump parts, bottles, carry the pump everywhere, etc. Suggest EPing moms join an online support group - they can really use the support and camaraderie, and it is easy for them to feel like they are all alone when they don't know other pumping moms nearby.

Mothers who have issues with supply or pain issues while EPing should of course be referred to your favorite local lactation consultant! LCs are not just for direct breastfeeding; they can have excellent resources and advice on pumping comfort, ways to build supply, and may even be able to help get the baby back to the breast if that's possible.

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I bet there are some long-term pumpers out there - what do you wish doulas (or birth professionals in general) knew about pumping?

Conferences, everywhere!

With a number of my work colleagues just returned from the International Lactation Consultant Association (ILCA) conference, I've started pondering about how to use the education $$ available from our department to go to a conference myself.

The APHA conference is coming up...ooh, the chance to check out lots of breastfeeding and MCH-related public health workshops/connections! (And let's just say, that conference is not cheap. I would love for my work to cover it!) That is late Oct/early Nov.

Then there's the Academy of Breastfeeding Medicine conference, also in early Nov. They have a track for non-physicians that I would love to attend. So much fascinating stuff on international issues!

If Health Connect One has another conference, I would be so excited to attend...hoping they announce one soon.

Let's not forget the next ILCA conference is a year from now in Orlando!

And although it wouldn't be connected directly enough with my job (so I'd have to pay my own way) - having missed this year's, I am really determined to attend next year's CLPP conference (and I'd like to do a workshop - I am brainstorming ideas at the intersection of birth/breastfeeding/reproductive justice if anyone would like to collaborate!)

Any other conferences out there you'd suggest, or planning on going to?

What every doula should know about breastfeeding: Tip #2: When to refer, how to refer

Preface: Often as a doula, before I became an LC, I would encounter situations in the hours after the baby was born, or at postpartum visits, where I wasn't quite sure what to suggest; or looking back, I realize I could have done something differently. I've decided to share some tips with other doulas about things that I wish I had known long ago! Today is Tip #2: Referring to advanced support.

Knowing when to refer and how to refer mothers to advanced breastfeeding support is a vital part of a doula's role in supporting breastfeeding.

WHY to refer:

As doulas, we spend hours, sometimes days with our clients through one of the most intense experiences of their lives. You often end up very bonded and very invested, and when breastfeeding issues arise you're ready to jump in and do everything to make it work.

Resist the temptation to solve everything for your client!

On doula listservs I sometimes see questions like, "My client's baby's weight is down 12% and she's having to supplement with formula. What can I do to help her?" or "My client's baby just won't latch, should I suggest she do a lot of skin-to-skin?" You can give so much to a client in this situation: compassion, practical support, a listening ear at 2 a.m.; but the most important thing you can give her is a referral to a lactation consultant and the encouragement to call ASAP. She has a problem that needs quick professional help; it will probably not be helpful to her for you to come back in a couple days with tips from people who have never met her.

A 3-5 day CLC/CLE/CBE etc. course is wonderful (as is years of experience breastfeeding your own babies, helping friends, etc.) but KNOW YOUR SCOPE and be careful about venturing slowly into deeper and deeper waters where suddenly you discover you're in way over your head. It is so easy to get drawn into helping beyond your expertise. I speak from experience! I have written about how the more I learn, the more I realized I didn't know. I say this knowing that I, myself, would sometimes get in over my head when helping clients in AmeriCorps; our supervisor was a midwife who could help out when we were stuck, but she wasn't always available and I was trying to fix things knowing the patients might not be able to come back for a follow-up visit. I honestly cringe at some of the advice I used to give! It wasn't terrible or harmful, but it was probably really unhelpful.

In general, think of yourself as a "breastfeeding emergency first responder". You should provide the same services as any emergency first responder - do what you can at the moment to help the patient, offer them comfort and support, and then get them to advanced care. So absolutely suggest that the mom whose baby isn't latching do lots of skin-to-skin - and then help her find an LC who can assess why this is happening and how to fix it.

In the meantime, support the mother and remember the rules:
Rule 1) FEED THE BABY (in whatever way is necessary; sometimes bottles and formula ARE necessary);
Rule 2) Protect the milk supply (through pumping and/or hand expression if the baby is not feeding effectively at the breast).


WHEN to refer:

Not sure if your client is having just some normal latch pain and things are going to get better? Not sure if the weight is a real concern or just a temporary dip?

Here's a (partial) list of situations in which your client should DEFINITELY be referred to an LC (do not pass Go, do not collect $200):

• Painful nipples throughout the feeding...
• ....especially with any signs of nipple trauma (cracking, bleeding, blisters)
• ....especially if the mother tells you she "dreads" feedings, that she cries from pain during the feeding, that she puts off feedings or limits their length because of pain, or that she is exclusively pumping because of latch pain
  
• Excessive weight loss or poor weight gain in the baby, or any concern for weight that leads the baby's doctor to recommend supplementation
• A mother who was sent home from the hospital supplementing the baby (via any method, not just bottles) without clear further instructions about when/how to stop supplementing
  
• A baby who refuses to latch or does not latch consistently; the mother may describe feedings as "battles" or "fights" that drag out, sometimes for over an hour

(Does anyone have additions or modifications for this list?)


HOW to refer:

To refer your clients, you need to know about the lay of the land in your community. Who are the lactation consultants? Where are they based - pediatric offices, hospitals, private practice? Does the mother have to go to them, or do they do home visits? What do they charge and how do they bill the mother's insurance? (For example, at our hospitals outpatients' insurance is billed for a nurse visit and the mother has a small co-pay; a private practice LC will generally be paid up front and the mother must apply for reimbursement.) For lower-income mothers, is there a WIC breastfeeding support program that has an IBCLC?

As you're getting to know the lactation support resources in your community, please read Best for Babes' Is Your Lactation Specialist an Imposter? Not all lactation "helpers" are lactation consultants; and sad to say, not all lactation consultants are supporting moms the way they should. This is true of every profession; hopefully, you would not refer your doula clients to a midwife just because she had "CNM" or "CPM" after her name, assuming she provided optimal midwifery care, because not all midwives practice in ways that are consistent with a compassionate, evidence-based midwifery model of care. You would want to talk with other doulas, mothers, and providers - or work with the midwife directly - to know that she provided the kind of care you were comfortable recommending. I have worked with midwives I would refer my clients to, and midwives I would warn them away from; the same goes for LCs. You help your clients by finding trusted people you can refer to.

Ask local La Leche League leaders, mothers, doulas, midwives, doctors, and other community resources who they trust and recommend. Listen for specifics of how they deal with different issues, and whether the mothers who use them found them to be sympathetic and helpful. And, while this is a little delicate, keep your ear to the ground for the people who are not recommended or who you hear about giving questionable advice. Of course, even the best provider will have some dissatisfied patients (again, you may have an absolute favorite midwife and meet someone who had a bad experience with her - maybe it just wasn't a good personality fit, or a bad day.) But when you hear the same poor feedback over and over about somebody, it could be a sign to have your ears perked if your client mentions working with that person. (And if you know a hospital doesn't have LCs on staff, and the mother says "But the lactation consultant in the hospital said her latch was perfect!"...be skeptical.)

If you develop a relationship with an LC, or a few LCs, that you consistently refer to, you may also develop a referral system. Many LCs will welcome a phone message or e-mail from a doula or other professional working with the mother, who can offer an outside perspective on what has been happening and why the mother is being referred. Talk to the LCs you work with about whether this would be helpful.

Even when you've helped your client find a great LC, your client may be hesitant to pay for a lactation consultant - especially since with a private practice LC they will need to pay up front. Help her think through the cost of formula, or even of exclusive pumping (which some women seem to regard as a quick solution for any breastfeeding problem, without understanding that it brings its own distinct challenges.) Talk to her about how she saw the value in hiring a trained labor support person; hopefully she will see the same value in finding professional breastfeeding support.

A lot of women seem to feel guilt or frustration for needing to turn to someone for help at what is supposed to be "natural" (I say "it might be natural, but it doesn't always come naturally!") You can discuss some women's need for lactation support with your client at prenatal visits, so your clients who need LCs know in advance that they're not "failing" or somehow strange for needing an LC. You can include information about LCs you recommend in your prenatal information packets.

If you can, follow up with the mother about the LC visit, how it went, and how things are progressing; or encourage her to call you if things are still not going well. If the mother did not feel helped by the first LC she sees, offer to help her find someone else, especially if you are not sure about that LC's qualifications. And of course, support and empower her in whatever challenges she is facing, and listen to and validate her concerns.

Note for community-based and/or volunteer doulas:
If you are working with low-income women, they may be in a very difficult situation. We confronted this issue a lot when I was working in AmeriCorps. Ask around for low-cost resources like WIC, LCs who are willing to do pro bono work (especially if it is referred by a doula who knows the mother's financial situation), LCs working at hospital-based clinics that may take Medicaid, and free mother-to-mother support groups that the mother would be comfortable attending (keep in mind some women may feel out of place in settings like La Leche League meetings). Be proactive about helping the mother get in touch with these resources.

If you are the only help available to a mom, ask around for LCs/LLLLs/other resources who might be willing to talk you through problems or offer suggestions, and again be very careful about not overstepping your boundaries. While it's hard to see a situation go down the tubes, and you want to throw every idea you have at the problem to fix it, it is actually better for a mother to give up breastfeeding than for her or her baby to be harmed by poor advice... and it's hard to know what's poor advice if you're stepping outside your scope of practice.

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I loved the feedback on the last post, and welcome comments on this one! More tips to come!

The IUD comeback

When I was in college, I remember IUDs being completely dismissed as a form of contraception - they were barely even discussed, but I got the impression that they were some quasi-medieval little device that was only used by women who had already had at least 4 children.

Come grad school, IUDs were a hot topic in my MCH class, both academically and personally. For the personal side, at least a third of our cohort got IUDs, and academically they came up in almost every class discussion of family planning as an increasingly popular and very effective method of long-term contraception.

This Wired article does a nice job of summarizing the history behind the rise, fall, and rise again of the IUD.

By the early 1970s, 17 IUDs were under development by 15 different companies. The problems started with the fourth one to actually hit the market: the Dalkon Shield. AH Robins (which also made ChapStick and Robitussin) marketed one version of it as a smaller option for women who didn’t have children. Like all medical devices at the time, the Shield wasn’t vetted by the FDA. While drugs got careful screening, safety and efficacy claims on device labels did not. The FDA stepped in only if people started reporting problems. And report they did. ...

The new research [in the 90s] and thinking on IUDs had important implications for the future of the device. For one thing, it’s clear that doctors should not put it into women who have an active STD infection. (And even then, it’s only bacterial infections like chlamydia and gonorrhea that are problems; infection with the widespread human papillomavirus doesn’t disqualify anyone.) For another, inserting it under sterile conditions is paramount. To the people running these studies—and the doctors who read them in medical journals—the results were reassuring. There was nothing wrong with IUDs as a technology. ...

IUDs are on the verge of a remarkable return to popularity. Nationally, 5.5 percent of women using contraception choose them. That sounds unimpressive, but it’s the first time in more than 20 years that the number has risen above 2 percent; in 1995, it was 1.3 percent. By that baseline, 5.5 percent represents a sea change. And a few pharmaceutical companies believe that number is poised to grow.

There is plenty of reason to believe that more American women will be adopting the IUD when you compare our IUD use prevalence to that of other European countries, including Norway which tops out at 27% prevalence IUD use!

One interesting note is the price of getting an IUD in the U.S.

Also, the devices are expensive—the ParaGard costs $500, the Mirena $850. “It’s absolute highway robbery that these companies charge so much,” Espey says. “If you went to Home Depot and got the raw materials for a copper IUD, it would cost less than 5 cents.” And the hormones don’t contribute much more to the cost, she adds.

In fact, amortized over years of use—10 for the ParaGard and five for the Mirena—an IUD is far cheaper than birth control pills, which can cost $30 or more a month. But the initial outlay is difficult for some women to manage, and it’s not always covered by insurance. Schnuriger, who comes from a working-class St. Louis family, split the $450 cost of her IUD with her boyfriend. She used money earned from a work-study job to pay her half. If she keeps the ParaGard the full 10 years, it will end up having cost $3.75 a month.

Most people I know had insurance that did cover a pretty decent amount for the IUD and the appointment to get it inserted. But if you're paying out-of-pocket, it is a big investment even knowing that in the end it will probably be cheaper than other methods. Compare the prices we are paying in the U.S. with this: I have a friend working on an IUD project in West Africa. They offer only the Paragard (copper) IUDs. Price for the IUD + insertion? $3. Her expat friends get their IUDs before they come back to the U.S.