Public Health Doula

How college prepared me for being a doula

2012-01-30T09:00:00.000-05:00

Sometimes - often as I'm heading to or from a birth - I'll think about the skills I draw on as a doula, and how I wasn't expecting college to have prepared me so well in certain ways for the life of a doula. I think it often enough that I decided I should do a post about it. So from least to most important, here's how what I learned in college applies to doula work:

4) Epidemiology and other courses that taught me how to read and interpret scientific literature
My master's in public health certainly built on and added to these skills, but I got a very solid foundation in college. Nearly all of my courses emphasized critically reading and analyzing primary literature. I have really enjoyed sharing the benefits of this with my doula clients - helping them understand the evidence for and against various interventions in birth or other concerns they may have.

3) Medical anthropology
Without question one of the most generally life-changing courses I've ever taken, and very applicable to doula work. So much of what we do as doulas involves negotiating the boundaries between very different cultures of birth, and understanding (and sometimes critiquing) those cultures AND our own. The most important thing I learned in my med anthro class was that "Culture is to people as water is to fish...you can't see your own culture because you're in it". It's difficult to mentally step back and try to see your own culture, but it's as important for a doula to understand her own personal mindset and cultural values as it is for her to learn more about those of her clients, the hospital staff, etc.

2) Spanish
I have a whole separate post on Spanish coming, but to summarize I will say that when I was an AmeriCorps doula this was vital. In fact, the Spanish skills of the doulas on my team got us called into a lot more births than we might have been otherwise. The nurses were NOT supposed to call us as interpreters, but they knew that having us around helped make the Spanish-speaking only patients feel more comfortable...and it did make the nurses' jobs easier. And there is a cultural preference on the part of many Hispanic women for unmedicated birth - all the harder to accomplish through language barriers - so very often a doula was especially appropriate. I haven't been to a Spanish-speaking birth in a while, but I'm pretty sure it would all come flooding back to me: "La cervix es la boca de matriz. Tiene que abrir de zero a 10 centimetros..."

And the number one thing I learned in college...

1) All-nighters
No lie. (All you doulas know I'm not lying.) I remember the first time I tried to pull an all-nighter in college I physically could not do it. I had to quit around 3-4 am and go to bed. A few more practice nights and I was able to push that out to 5 am...then to 7 am...and then I could enable my natural procrastination with nonstop marathons to finish those final papers the night before the deadline. I learned to accept the physical effects of sleep deprivation (for me, nausea) and find remedies (protein!) And I learned to carefully assess the correct way to manage getting back on schedule (short nap in the afternoon? or just stay up and then go to bed early?) I also learned to do this all without the use of caffeine (I know, I know - I was the only freakish college student not chugging coffee.)

All of this proved invaluable when I started attending labors that could last for 24+ hours and/or begin just as I was about to go to bed. And when I became a doula I discovered that giving counterpressure at 4:30 am is a actually easier than constructing supporting arguments for a thesis. And that while turning in those 20-25 pages is certainly a satisfying feeling, it doesn't really compare to the adrenaline rush of attending a birth. So while I still use my skills from those days, doula all-nighters compare very favorably to college all-nighters!

I guess the moral of all this is that if you're in college and an aspiring doula, take epi, med anthro, Spanish, and don't write any of your papers for those classes until the last minute! (Note: staying up all night partying is not equivalent preparation, but feel free to do some of that too.)

The fantasy doula league

2012-01-29T04:23:00.003-05:00

Fantasy football is ending. Sad? You won't be after listening to this podcast which envisions...a fantasy doula league!

These dads are obviously quite familiar with the doula trade and are fantasy doula league experts. They really pick up on the crucial skills and stats of doula practice. And, then of course, there's the placenta-kiwi foam.

Fantasy Doula Report - Comedy from Jon Cragle on Vimeo.

"With Rebozo moves like this, she will not be available long!"

More on the UW midwifery program

2012-01-17T18:30:00.003-05:00

Seattle columnist advises you never to get between a midwife and a birthing baby:

Last month, the faculty there recommended eliminating the UW's 19-year-old midwife training program.

That isn't surprising on its own. Just about everything is on the chopping block these days.

It was their reasoning. It has angered midwives all over the region. Not to mention thousands of moms.

The nurse-midwife program was judged not to meet a "societal need." In fact, maternal and newborn health were not even on the list of societal needs drawn up by a UW committee looking to cull programs.

Surprisingly, this isn't directly about money. The students in the program pay more in fees than it costs to educate them. Plus midwives are a force that drives down birth-related health costs. ...

The UW hooked me up with Carol Landis, a professor in the nursing school who helped draft the recommendation. She said it was not an "arbitrary devaluing of midwives." Driven by state budget cuts, the School of Nursing is reducing the number of areas in which it is teaching- and training-focused (regrettably to her), she said. The emphasis is on high-level research, the kind that brings in grant money.

And Shari, a midwifery student at UW, commented with the following clarification to my last post:

I would like to clarify and issue with this proposal to cut our program. It is not because of the budget per se, as the Midwifery program is funded entirely from student funds. We are one of the only programs operating in the black. This is politcal decision that must be reversed! Please stand with us and sign the petition! Research dollars do not trump the health and welfare of women and children

The petition already has almost 2500 signatures - with a goal of 10,000!

Sign to save the UW midwifery program

2012-01-12T23:22:00.000-05:00

The nurse-midwifery program at the University of Washington is currently slated to be cut. I am shocked that in this day and age universities would be cutting, instead of expanding, nurse-midwifery programs. With our entire health system increasingly depending on mid-level providers, and with the excellent outcomes of nurse-midwives in caring for low-risk women, it seems like a bizarre decision. According the the ACNM website, this is one of only two midwifery education programs in Washington state.

If you would like to support the program you can sign a petition urging the University and the state government to reconsider their decision (you don't need to be a local).

"Doula" in the New York Times crossword puzzle!

2012-01-05T11:35:00.004-05:00

My family has always been big crossword puzzle fans - the New York Times crossword in particular. My grandmother, at eighty-seven, still completes the Sunday crossword every week. We're also, of course, Will Shortz (the crossword editor) fans in general; now that I'm working nights, I'm bummed that I miss out on listening to Weekend Edition on Sundays for his puzzles.

So imagine how excited I was to hear that "doula" was in this week's Monday puzzle: "58A: One providing nonmedical support for a woman in labor". Funny to read through the comments on a crossword blog about it - real mix of people who were very familiar with the term, and those who had never heard it before. But now they have!!

A few links to start the New Year

2012-01-03T16:50:00.001-05:00

Happy New Year! Here is a total mishmash (not even sorted! only sort of related!) of interesting links for your enjoyment. It feels good to start clearing out my starred list in Google Reader, at least!

Many perspectives on why to have a doula for your homebirth (and a few on why you might not have one).

Doulas serving the expat community (as well as locals) in South Korea

The Well-Rounded Mama posts a list of obesity and birth/breastfeeding research on her Christmas wish list. Any public health peeps out there want to get on it?

The amazing Cathy Genna has a page on tongue tie including pictures and posterior tongue ties.

One mother's struggle with getting her daughter's tongue tie (and lip tie) properly diagnosed and treated - she ended up traveling to Dr. Kotlow to get treatment. "My prayer is that it will not always be this difficult for tongue-tied babies and their mothers. It should not require so much time and so many resources to simply feed your baby."

Interesting and varied responses to the updated UK guidelines on c-section availability.

Knit your own baby-wearing coat extender!

A post on cultural issues and breastfeeding, specifically on diet. My preferred way to deal with this (right now) so as not to contradict any breastfeeding cultural traditions: when people ask me if there are foods they should eat/not eat, I say "Every culture seems to have their own foods that they say are good or bad!" and then I name some examples. Hispanic mothers are often surprised to hear that Americans think broccoli is bad, for instance. I say "If there are foods that your culture thinks are good or bad, then go ahead and do what is recommended. Unless you hate the food! Then you don't have to eat it."

"One thing that brings me joy"

2011-12-23T08:00:00.000-05:00

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?

2011-12-21T08:00:00.000-05:00

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

2011-12-16T16:43:00.003-05:00

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

2011-11-14T18:10:00.001-05:00

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

2011-10-23T15:09:00.003-04:00

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?

2011-10-07T08:21:00.005-04:00

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!

2011-10-05T11:50:00.001-04:00

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

2011-10-03T07:00:00.000-04:00

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

2011-10-01T07:00:00.001-04:00

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.)

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

2011-09-30T07:00:00.006-04:00

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?

2011-09-19T06:24:00.001-04:00

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

2011-09-07T00:53:00.001-04:00

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

2011-08-24T03:18:00.004-04:00

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

2011-08-10T01:46:00.006-04:00

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

2011-08-02T08:00:00.000-04:00

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!

2011-08-01T04:00:00.000-04:00

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

2011-07-31T03:55:00.000-04:00

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

2011-07-20T15:32:00.003-04:00

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.

How safe is your medication for breastfeeding? Another app - the InfantRisk app!

2011-07-20T13:52:00.006-04:00

I wrote last month about the availability of a free app from Lactmed, the similarly free website from the NIH, to help prescribers and mothers determine whether a medication is safe for breastfeeding.

Now Dr. Thomas Hale, author of the bible on this topic, "Medications and Mother's Milk" (aka "MMM") is coming out with an app version called InfantRisk, also for iPhone and Android. If you've ever used "MMM", you know what an amazing reference it is. Dr. Hale classifies drugs into 5 levels of risk category, from L1 (Safest) to L5 (Contraindicated), provides an extensive monograph on each, provides information such as time to peak plasma level in the blood (so a mother could time feedings/pumping around those peak times), and includes a lot of herbal and OTC meds that Lactmed does not.

Watching this video of the app, I was really impressed by how they've put a lot of value added into the app, even going beyond the information available in the book. "InfantRisk" really is the better term for this app, as each drug now has safety information for not only different stages of breastfeeding, but also for each trimester of pregnancy. You can also search based on specific patient parameters, set bookmarks, and get updates from the InfantRisk Center. There's also a quick way to call the InfantRisk Center for questions that you're still unsure about.

This app isn't free, and compared to other apps that I'm used to purchasing (usually $1.99, maybe $4.99 for something great that I'll use a lot) it's a pretty hefty price tag at $29.99. But after I saw the video, I realized it's a great deal for anyone who would otherwise purchase "MMM". For less than the price of the book ($36 on Amazon), you get the same information PLUS a lot of added functionality. With the pregnancy safety info, it would especially be a great investment for an obstetrician, midwife, or family practitioner who would use it both pre- and postnatally. I probably won't purchase it this second, as my work has the latest edition of "MMM", but I'll probably get it eventually for the convenience of having an updated reference at my fingertips. And also 'cause it looks so snazzy!

And don't forget that if you're not looking to invest in the app or the book, but have questions that aren't answered by a free resource like LactMed, anyone can call the InfantRisk Center helpline. They're available Monday-Friday, 8am-5pm central time: (806)-352-2519.

July link party!

2011-07-20T00:10:00.000-04:00

So many starred posts in my Google Reader! So much to share!

Science and Sensibility interviews Dr. Michael Lu on preconception care. Oh, does this warm my MCH public health heart! This man has done such amazing research and I am so excited to see his work getting connected to the birth advocacy communities via S&S:

Allen Rosenfield probably 30 years ago asked the question, “Where is the ‘M’ in MCH?” Where’s the “mother” in maternal and child health programs–because much of MCH has focused on children’s health and much less on maternal health. I think the question we’re asking today is where’s the ‘W’ in MCH—where’s the woman in maternal and children’s health? If we really want to improve maternal and child health in this country, we really have to start by improving women’s health. [Emphasis mine because this is SO IMPORTANT!]

I think it’s pretty much in alignment with what you’re saying; it’s not just about childbirth. If the natural childbirth movement is all about natural childbirth, it doesn’t have the kind of impact that it could have. The focus should really be on promoting women’s health over their life course continuum and how we would be a better society for doing that.

And he talks about reproductive life plans! Be still, my beating heart! Part One is here, Part Two is here, and I am eagerly awaiting Part Three!

The Gates Foundation did a blog series on stillbirth to accompany the publication of the Lancet stillbirth series.

From the Academy of Breastfeeding Medicine blog, a report from the Third Annual Summit on Breastfeeding.

Yup, US maternity leave policy really sucks.

Birth Sense talks induction for premature rupture of membranes when the mother is GBS positive - is it necessary? How soon does it need to happen?

Educational website on tongue tie, including a PowerPoint presentation to help train other doctors perform clips. The best part is lots of photos - there is nothing like seeing photos of tongue ties to help learn which type you are looking at and what are the more subtle signs of a tie. Crossing my fingers that this website helps more practitioners learn about and be willing to clip ties that are interfering with breastfeeding. I found the site via the Kellymom FB page where there are many stories of mothers struggling to find someone who will clip. (A post on tongue ties is coming soon in my breastfeeding-tips-for-doulas series.)

NPR's the Baby Project blogs about doulas! Check out the comments for stories from grateful moms who used doulas!

Another hand expression video. This one uses a similar although slightly different technique to the Jane Morton/Stanford technique, with the fingers slightly closer to the areola. It also shows breasts where the milk is in and engorgement is past. If you want to listen to awesome Norwegian, click on the first video; otherwise, scroll down for the second video with narration in English.

What every doula should know about breastfeeding: Tip #1: Hand expression

2011-07-13T18:50:00.002-04:00

I've learned a number of things as an LC that I wish I had known earlier as a doula, and that I would like to share with other doulas! I've decided to do a mini-series of tips called "What every doula should know about breastfeeding". All doulas get basic training in breastfeeding (and doulas are an evidence-based way to increase breastfeeding rates!) Doulas are generally excellent supports for helping normal breastfeeding get off to a good start. But 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!

A disclaimer: my breastfeeding tips for doulas aren't meant to turn you into an LC, or offer the same support as an LC does - one of my tips is going to be how to know when to refer to an LC and how to help your doula clients find advanced breastfeeding support (and you will find suggestions to refer to an LC liberally sprinkled throughout the tips as well!) They are meant to help you become a doula who is better at supporting breastfeeding in the doula role, and filling in some of the gaps in breastfeeding education and support that sadly still exist in our system.

So without further ado, the first tip of the series is... hand expression!

I had kinda sorta heard about hand expression before I became an LC. I knew you could theoretically express milk without a pump, but I confess to having wondered why you would WANT to. Couldn't a pump do the same thing, but faster and easier?

Now I teach hand expression on a daily basis, and I find it an incredibly useful tool. Yet many postpartum nurses, and even some LCs, don't know how to teach mothers how to hand express or when it can be useful. A knowledgeable doula can help fill that gap by recognizing when hand expression might be helpful and helping the mother learn how to do it.

WHEN and WHY to help with hand expression:

When are times that, as a doula, you might help a mother begin hand expression? Here are a few that I can think of:

1) The baby who doesn't latch. All doulas should have the training to help the mother get started breastfeeding just after birth, when the baby is most awake and alert. But sometimes, even with assistance, that first latch doesn't go as smoothly as we would like. The baby bobs around, mouths the nipple, pops on and off, or fusses at the breast and doesn't latch. Some babies just aren't ready to feed right away; for example, babies born with a vacuum-assist often seem to have trouble getting their suck organized at first, or a baby whose mother has had IV medication soon before the birth may be sleepy and not interested in latching.

Once that initial period of wakefulness has passed, the baby often falls into a deep sleep for hours and only wakes to feed a few times during the first day. Like so many breastfeeding "problems", it's not an actual problem for the baby, but it tends to cause anxiety for the parents and sometimes also prompts suggestions of supplementation from the medical staff. Sometimes the mother asks for a pump and is discouraged to see that after 15 minutes of pumping, all she has on the pump flange is a drop or two of colostrum. She starts to wonder if she really has any milk at all. If the baby is still struggling to latch, the next step is often a bottle, even when the mother really wanted to avoid formula, and the bottle can further compromise the baby's ability to latch.

If your doula client's baby hasn't latched by the time you leave, try teaching her hand expression so she has an alternative way to feed her baby. Pumps generally don't get out much colostrum compared to hand expression; a mother who pumps for 15 minutes to get a single drop can easily fill a teaspoon in a couple of minutes by hand expressing (and remember, a one-day-old baby's tummy is only made to hold a couple of teaspoons). All she needs is a plastic spoon from her meal tray to express into; when she's got a little colostrum in the spoon, she can spoon feed it to the baby or simply let the baby lick or suck drops off of her finger. A couple spoon feedings often reassure the mother and the nurse that the baby is taking food in, and give the baby time to rest and get ready to start latching and eating. When you leave the hospital after the birth and you know breastfeeding's not off to the perfect start, you can feel more confident that breastfeeding will ultimately go well if you've given the mom this tool to use.

2) Engorgement. This is particularly important for mothers who have had a highly interventive birth with lots of IV fluids - long inductions, many hours with an epidural, a c-section. These mothers tend to end up fluid-overloaded and their breasts fill up with extra fluid as well. When their milk comes in, they may have lumpy, hard, painful breasts that feel like they're full of milk, but only be able to pump a few drops. When you do your postpartum visit, you may discover this situation along with a very uncomfortable and unhappy mother.

I explain to these moms that they can think of their situation like this: There are a hundred people in a room, and they're all trying to get out one narrow door. They all pack around the door and squeeze up against it and there's just no room to open the door. We need to push some of the people away from the door so things can flow more freely. The breast is the room, and the people are the milk and intracellular fluid built up in her breasts. The pump may just pull more and more "people" towards the door. Instead, have her push back on her areolas for a few minutes to soften them (known as reverse pressure softening, with an excellent explanation and illustration here), then gently use hand expression to push a few "people" at a time towards the door. She can express into a bottle or cup to save the milk. Once the breast is somewhat softened, sometimes you can start the electric pump again, but sometimes you need to keep hand expressing for several sessions before the mother is able to pump.

I helped a mom like this recently. She was so engorged it took her an HOUR to soften a single breast with hand expression, but she got two and a half ounces when she was done! She said that neither the pump nor the baby had gotten more than a few drops since her milk came in. When I left she was starting the slow process of getting two+ ounces out of the other side, but at least she was able to move the milk out, get comfortable, and offer breastmilk to her baby.

I have never forgotten the big bold sentence in my breastfeeding educator training book that said "Unresolved engorgement is a breastfeeding emergency!!!" Unresolved engorgement can cause mastitis, compromise a mother's milk supply, and lead to nipple trauma if the baby is no longer latching well on the overfull breast. Hand expression can be a vital tool for working through severe engorgement. Be especially alert to the possibility of severe engorgement when you have seen a lot of IV fluids go into the mom and notice that her hands and feet are very puffy from the fluid retention; check in with her about her engorgement when you talk to her after the birth. If she is engorged and only getting advice to pump, pump, pump and not having much success, suggest hand expression as an alternative; and help her find a lactation consultant ASAP who can help her with issues that may be contributing to or caused by her engorgement.

3) NICU moms. Remember how I mentioned above that pumps are often not very effective at getting out colostrum? This is by far the most discouraging for the NICU mom whose baby is not able to go to breast due to prematurity or other medical complications. These moms may pump and pump and get almost nothing! Days of pumping a few drops at every pumping session are also discouraging and can lead the mom to cut back on her regular pumping schedule, which can compromise her supply. And the baby misses out on much of the colostrum which is one of the best medicines available!

There is also some preliminary research from Dr. Jane Morton at Stanford University showing that "hands-on" pumping and hand expression after pumping can increase the supply of mothers who are exclusively pumping. This is so important for NICU mothers who so frequently struggle with supply!

If you work with a mother whose baby goes to the NICU after birth, help advocate for her by requesting a pump right away. Help her get set up with the pump and use it for 10-15 minutes. Then show her how to hand express afterwards. Ask for a very small container to express into - we use little vials that are just 10 ml. Much less is lost that way and the mother can really see that in comparison to her baby's tummy, she's actually getting a pretty big meal! Encourage your client to follow every pumping session with hand expression. If the pump is slow to arrive, encourage her to go ahead and hand express every 3 hours - don't wait to start until the pump arrives! The earlier she starts, the better for her supply.

HOW to teach hand expression:

Okay, so hand expression is great and all, but how do you DO it?

Hand expression is a learned skill, and not one I learned especially quickly, so be patient and encourage your doula clients to be patient as well.

The single best tool I have seen for learning and teaching hand expression is this video from Stanford's Newborn Nursery (featuring Dr. Morton who is doing the research on hand expression and increased supply!) Watch it - multiple times - and practice the technique on yourself or on a cloth breast model. When teaching, try to find a way for your doula clients to watch it as well - they may have brought a laptop with them, or there might be a computer in the room. (And tell me if you can figure out a way to get it to work on a smartphone.) If you can't have her watch the video, demonstrate (discreetly) on yourself, use a breast model (or even a soft pillow!), or offer with her permission to demonstrate directly on her breast.

The main tips I have for teaching hand expression, which are also highlighted in the video, are to help the mother keep her fingers well back from the areola. The instinctive thing to do seems to be to spread the fingers apart, and then squeeze in right up to the nipple, often pulling the nipple far forward. This generally makes the mother sore and doesn't get her much milk for her effort. If it's helpful, place your hand over hers as she practices and repeat the rhythm of "press, compress, relax" while keeping the fingers in the same place on her breast. That said, if the mother finds an easy comfortable way to express milk, and it's not the "right" way, she should do whatever is working for her and her body.

Sometimes the mother will report soreness or tenderness in the breast when I am trying to teach her how to hand express hands-on, even when I'm trying to be as gentle as possible. When that happens, I suggest the mother be the only person to do the hand expression. It is usually much more comfortable when she is the one doing the compressions on herself.

It's also normal to have some mothers who can easily hand express a lot of colostrum, and some who, even with good technique, still barely get a drop. Encourage the mother to keep practicing and to be patient. Reassure the mother that hands are better than pumps, but NOTHING is designed to get milk out like a baby! The colostrum IS there, and when her baby is ready to latch on well, it will flow. Hand expression is NOT a test to see "if there's anything there" - it's just a tool to see whether in the absence of the baby, we can still get more milk out and stimulate a better supply.

I hope you and your doula clients find this helpful! Please comment with thoughts and if you have had situations where you think hand expression would have been helpful, and if there are other scenarios in which you think your clients might use it.

Follow-up: who should get donor milk?

2011-07-01T18:00:00.001-04:00

So a while back I posted a question of who should be offered donor milk in the hospital. I was curious to see what people thought, and follow up with my own thoughts and current practice. I've been letting that follow-up languish, and the recent discussion about milk donation has finally nudged me into finishing it up. Here we go!

The comments were very interesting, and there seemed to be two main themes to the answers:

1) Only babies whose mothers are trying to produce breastmilk for them but are not able to (e.g. supply issues, adopted babies, etc.) should be offered donor milk

As Christie B. said:

...I have a hard time thinking that donor milk should be provided for free to women who are not trying their best to provide their own milk (if not contraindicated) for their own babies. If there is a medical issue, it makes sense for donor milk to be covered like a pharmaceutical but otherwise donor milk seems like a luxury good/service, like eating out instead of cooking.

2) Every baby should be offered donor milk as an alternative to formula, no matter the reason for supplementation (so even if mom is just not willing to breastfeed, the baby should still receive donor milk).

Burrowing In was of this mind:

As a mother whose baby was blessed by donor milk, I want to say that every baby should have access to it if necessary. Forget the mothers and their intentions and their shortcomings and their socioeconomic status. BABIES deserve that milk!

There were also ways to combine these two answers to some extent.

For example, Jespren suggested:

I feel that 1st dibs on donated breastmilk should go to NICU babies whose mothers have supply issues or have dried up and are unable to produce milk. Next I think it should be offered to mothers of healthy babies who can't physically produce any/enough milk. (This would include adopted babies whose new moms can't lactate) finally, if there is still milk availible, it should be offered to babies whose mothers chose not to breastfeed. ... But, for moms that have no physical reason not to breastfeed, they should have to purchase it, preferable at the same cost as formula. (I don't understand for a moment why DONATED breastmilk is so prohibitively expensive once it goes through a 'milk bank')*

So this prioritizes the babies who receive donor milk based on a judgment of BOTH the baby's need AND the mother's intent. Any babies whose mothers intend to breastfeed are prioritized over babies whose mothers don't intend to breastfeed.

Another comment comes from Molly who poses two questions, both of which I think are excellent:

The post's title asks two 'to whom' questions: "Who should get donor milk? Who should it be offered to?" In considering these questions, we should probably ask what 'whom's we mean: postpartum women, babies, families? You can't exactly offer a medical option to a baby, so in the second case presumably we mean the baby's parents (why only mothers, as some responses seem to suggest?). In the first question, the implication seems again to be that parents/mothers are the ones getting the milk: does it make any difference if we reconceptualize the question to mean, explicitly, 'which babies deserve access to donor milk (rather than formula)?'

This is a big piece that I struggle with. When we focus on the mother's intent, we're really asking which mothers deserve to get donor milk - not which babies. If one mother can't produce milk and one just doesn't want to, why is the first baby (not the mother) more deserving of donor milk than the second baby? Furthermore, it quickly becomes a tangled web of hairsplitting over who is "really" deserving. To tread into more politically controversial territory, over and over again I keep thinking of how it reminds me of debates on abortion and philosophical and legal attempts to determine which women are "deserving" of an abortion - women who are victims of nonconsensual sex? women who "just made a mistake this once"? etc.

In those abortion debates, I think it quickly becomes clear that it is not so much about abortion as it is deciding who is "good" and deserving of help, and who is "bad" and needs to "deal with the consequences". Similarly, trying to decide who deserves donor milk could easily be a twisty path. It's easy enough to think about a mother who says, "I'm not going to breastfeed, it's too hard, just bring me bottles of milk that some other woman has pumped" and decide that she'd be abusing the availability of donor milk, but in life, as usual, there are a lot more gray areas than black-and-white.

What about the NICU baby's mother who has a low supply, but it's low because she only pumps four times a day (knowing that she should be pumping more)? What if she only pumps four times a day because she has several other young children at home, and one has special needs? What if she's so exhausted by pumping and only getting 1/2 an ounce per session that she quits entirely? Would you feel differently if she had breastfed all of her other children for a year each, or if she had not breastfed them but had planned to breastfeed this baby, or had not planned to breastfeed this baby but changed her mind when it was born prematurely?

Or what about the mother of a healthy term baby who has a borderline supply, and has nursed and pumped diligently to keep her supply up but needs to supplement several times a day? What if she is offered medications that could bring her up to full production but declines them? Would you feel differently if she was declining them because she had a history of depression and was worried about side effects, or because she just doesn't like to take medications?

There's an element of thought experiment in some of this - in our current situation, generally only the most motivated moms who have exhausted all their resources seek out donor milk for long-term use outside of the hospital. Still, if we are aiming towards a future in which donor milk is more abundantly available to all, it's worth thinking about and examining our own assumptions about who "deserves" milk.

In the hospital, we can edge around this debate to some extent. For a healthy full-term baby the supplementation will generally be short-term (until the blood sugar stabilizes, until her milk comes in, etc.). If the mother is planning to exclusively breastfeed, we can argue that we are avoiding harmful effects on the infant gut of even a small amount of formula, assuming that soon the mother's own milk will be taking over and will be all the baby receives.

On the other hand, if the mother is planning to do some mixed feeding from very early on (as many mothers tell us they plan to do), there seems very little point in protecting the gut since they'll receive formula early on regardless.

But the way this plays out in practice makes Molly's second question very relevant:

How does class privilege play out here? Education, internet access, reading literacy, technological literacy, financial ability to purchase (and leisure time to read) books, access to high-quality mother-centered prenatal care, etc., etc.? If anyone can ASK for donor milk, should my baby get human milk simply because I'm an overeducated overprivileged English-speaking birth junkie who knows to ask the secret right question? Or, if limits on offering ought to be imposed (according to some standard of need or worth or whatever), is there any way to counteract that injustice?

Class and culture absolutely play out here, particularly in cultural terms, which are both linked to racial/ethnic background and to class. Most Hispanic moms tell us they are planning to do breast and formula, and are frequently asking for formula supplements on the first day (sometimes as soon as they come over from labor and delivery). Plans to supplement or switch to formula early are also common with African-American moms, younger moms, low-income moms... you get the idea. In fact, what the nurse asked me was whether we could offer donor milk to mothers on Medicaid. She assumed we couldn't, because she almost never saw them receiving it (just for the record, we can). She particularly wondered about why almost no Hispanic moms were ever using donor milk. But for a Hispanic baby, if we're at the point where they've lost 10% of birth weight and have not been supplemented yet, it is almost certainly because we have already deflected at least one request for formula on the part of the family over the course of the past several days.

So that's how it plays out: if we're only offering donor milk to the moms who are planning to exclusively breastfeed for at least the first couple of weeks, we end up with a real race/class imbalance of who ends up receiving donor milk. So then we tackle Molly's question of this imbalance - is it an injustice?

Part of me says yes - that everyone who asks for or needs supplementation should be offered donor milk and formula, check one. That part of me comes from knowing that there is definitely some power/educational stuff playing out here in that there is a real difference in patient vs. medical perceptions of when the baby needs to be supplemented. We, the hospital staff, have a short list of indications for supplementation, and the most common reasons are hypoglycemia and weight loss >10%. The parents have a longer list, and the most common reasons are that the baby is fussy even after breastfeeding for a long time, and the perception that the mother does not have enough milk. A mother does not necessarily plan to supplement with formula because she thinks it's better than breastmilk - she just thinks she won't have enough breastmilk (and since she has no idea that donor milk is available we have no idea if she would request that instead.) The more highly educated birth junkie types are much more aware of, and confident in, the fact that colostrum is generally all the baby needs for the first 2-3 days. They might need reassurance when the baby is fussy, but are willing to go with the medical staff's interpretation of baby's need for supplementation, whereas people from other cultural backgrounds are bringing their own perceptions of when the baby needs more.

So if we work with the families who really believe their baby needs something extra, and if we can't convince them of our worldview (that the baby is fine), do we do the baby and the family a service by offering donor milk? Does it emphasize the importance of human milk and avoiding supplementation with formula? Could it possibly help keep the mom from supplementing with formula in the future, once her milk is in? If we just accede to a request for formula without giving her the risks/benefits of both supplements available to her in the hospital, are we doing our own beliefs about the risk of formula use a disservice?

Then another part of me says, these families are very comfortable with formula use. They may be OK with donor milk and accept it in the hospital, but they are just as OK with formula and always will be. They will probably go straight to WIC for their first appointment and ask for supplemental formula. If we offer donor milk to those families, we are giving the babies a few more days of exclusive human milk feeding, but we are not really changing their overall situation that much, and we are using donor milk that could go to another baby. That's my view of the situation - is it reality, or is it just bias and perception on my part?

As you can see, I'm still struggling with this! Currently, I am sticking with only offering donor milk to babies with an indicated medical need, but I do generally discuss donor milk vs. formula for medically indicated supplementation even if the mother had previously talked about formula. Further thoughts or questions welcome!

* I think this reaction to the (prohibitive for most) cost of donor milk is fairly common. Having met and talked with people who run milk banks - the cost comes from the expenses of testing donors, paying for shipping, processing and testing the milk (which takes several time-consuming steps), sometimes space to physically host the milk bank, and of course materials and employees to do all of this. I have visited a milk bank - it was tiny! Just a couple little rooms and some very big freezers, and very committed mostly part-time employees. There seemed to be zero excess overhead going into this bank, and all HMBANA milk banks are not-for-profit. When all is said and done, there is a real cost to the shipping, safety testing and processing that donor milk goes through. If people are comfortable getting donor milk through a more informal route like Eats on Feets, they can absolutely get it cheaper (as cheap as free!), but they should understand what steps are being cut out of the process that are cutting the cost. Whether those are steps that are important to an individual mom, and/or important to every mom/baby/donor, is a whole separate discussion that I won't go into now!

Reply turned post: Milk bank or mother-to-mother - what's the "best" way to donate milk?

2011-06-28T15:58:00.004-04:00

Several commenters on my last post about where your milk donations are really going said they liked mom-to-mom milk donation in part because they know exactly where their milk is going. That got me thinking about mom-to-mom vs. milk bank, and before I knew it I had a reply-turned-post. As usual, revised and expanded below:

I think it's wonderful that you donate locally/mom-to-mom but let's remember that milk banking, done honestly and correctly, reaches babies that mom-to-mom donation cannot reach and who need human milk the most - the very sick and premature babies. Especially since Eats on Feets came on the scene, I feel like there has been a privileging of mom-to-mom over milk bank donation in some communities. Yes, it is usually much more fulfilling to meet a mother and baby and know your milk will be going directly to them. It is wonderful to give that mother milk for free or for a much lower cost than the milk banks, knowing she wouldn't be able to afford it otherwise. Done correctly and safely, I think mom-to-mom donation is great.

But (non-profit) milk banks are struggling for donations and there is absolutely value in what they do. I see milk banks sometimes getting slammed by the mom-to-mom donation community because of the price they have to charge for their milk. For people who think this way, please keep in mind that these banks are non-profit (unlike Prolacta!) They charge only what they have to in order to collect, process, store, and ship the milk. And they serve babies who would NOT receive milk through mom-to-mom donation. A 26-week premature infant in the NICU whose mother has a drug dependency, and cannot or will not provide her milk for her baby still needs human milk...he will not get it from mom-to-mom donation. A two-day-old late preterm infant who is jaundiced, not feeding effectively and needs a boost until her mom's milk comes in should still be able to receive human milk...but she won't get it from mom-to-mom donation.

I am perhaps biased because I work in a hospital where we have donor milk available and I see how important it is to the babies and to the parents. I am so grateful to the moms who donate to milk banks. That's why I think if you are able to donate to a milk bank - and I know not everyone can, because of the restrictions they have to place on their donors - you should try to do so. The mothers who are restricted from donating to banks for reasons that are still acceptable to recipients in their community (for example they are taking fenugreek, or don't meet the minimum donation amount for the milk bank) should absolutely pursue mother-to-mother donation. But let's remember that milk banks play a very important role for babies; just because a donor cannot meet or talk to the recipients, or because milk banks need to charge for their milk, does not mean milk bank donation is second-best.

Where is your donor milk going?

2011-06-24T17:50:00.003-04:00

I have never been a big fan of Prolacta, the for-profit donor milk company. I see some value in there finally being a profit motive behind marketing and using donor milk; I would like to see human milk-based fortifiers used for preemies, instead of the formula-based ones that are used now, and I can very much support that part of their mission. But the more I see of them, the less and less comfortable I become with their practices.

The things that have made me most uncomfortable about Prolacta are the way they recruit mothers. They have a network of recruiters - hospitals, independent LCs, doctors, etc. - who are encouraged, and sometimes paid, to suggest donating milk to mothers and route it to Prolacta. They also have various "milk banks" who serve, again, as essentially fronts for Prolacta: making the donations appear no different from those to non-profit milk banks, but obscuring the fact that the company will profit off of these donations. When non-profit HMBANA milk banks are in critical need of donations, this routes potential donors away from non-profit banks without giving those donors a chance to honestly assess where they would like their milk to go.

Amy West, at Just West of Crunchy has a great post up about this issue with Prolacta, as well as others. Such as the fact that Prolacta is partnering with Abbott Nutrition (a formula company) to market its products (alongside Abbott's own formulas), and now has an ex-Nestle exec on the board.

I encourage you to read the whole article as well as the comments, where Amy West addresses questions and concerns about her information and clarifies why, exactly, Prolacta's profit on donor milk is an issue. And if you have milk to donate, do your own research so you are clear on where your milk is going, who will receive it, and who, if anyone, will profit from it.

How safe is your medication for breastfeeding? New LactMed app!

2011-06-18T19:22:00.007-04:00

NOTE: Previously the LactMed app was not available on the Android Market - you had to go to the LactMed website to download it. It is now available on the Market directly - just search "LactMed".

I was talking to a doctor recently about a woman who is breastfeeding and newly diagnosed with a chronic health condition. The doctor said, "I want to prescribe her Drug Y, but she couldn't take that when she's breastfeeding, right?" Since the answer to "can she take that when breastfeeding" is almost always "yes", I suspected it was fine, and I made it a teachable moment. "I don't know, but I know how you can find out!" I said. I opened the LactMed website, typed in the drug, and voila! It was of minimal concern for a breastfeeding dyad, and I had spread knowledge about this resource to one more person.

I have written about the issue of breastfeeding and medications before and mentioned LactMed as an easily accessible, free resource from a very trusted source (the NIH). Now the exciting news is that LactMed is being made available as a free app for iPhones and Android phones. This is a fantastic addition as many doctors use apps to aid in prescribing, and some of the most popular apps like ePocrates and Micromedex are not nearly as comprehensive and accurate about breastfeeding information as they should be (check out this chart to see how widely varied different sources can be for the same list of commonly prescribed drugs.) Having a more accurate app on the screen right next to the prescribing app - instead of a website that you need to go and access - will hopefully help increase use of LactMed as a resource.

When doctors think they can't prescribe a drug for a breastfeeding woman, one of two things happens: 1) The baby is weaned early (sometimes very early) and unnecessarily, or 2) The woman is not treated because the doctor doesn't even offer the drug, or because when she is told she has to choose between breastfeeding and treatment, she chooses breastfeeding and - again unnecessarily - postpones or forgoes treatment. Do you know a doctor, pharmacist, or NP/CNM? Let's prevent these scenarios by spreading the word about an easy and accurate resource for medication safety!

Get a peek into the high-rollin' life of a WIC peer counselor

2011-06-17T01:49:00.002-04:00

Many of the patients I see as an LC in a hospital do not have a lot of support for breastfeeding after they go home. They may not have very supportive families - maybe no one in their family has ever breastfed. They may need to return to work very quickly in environments that are not breastfeeding-friendly. They may have concerns and issues with breastfeeding but cannot afford to see a private LC (even if they know that private LCs exist); or not be able to get transportation to any affordable resources; they may not feel comfortable attending peer-to-peer support groups like La Leche League because the moms there come from very different backgrounds. They may not speak any English.

Many of these moms are discharged from the hospital with breastfeeding problems, and I watch them go with the feeling that I am watching them walk off a cliff. But if they are going home to a county that offers WIC peer counseling, I at least have the feeling that there is a safety net below hoping to catch them. The peer counselors offer support, encouragement, and basic breastfeeding help by phone, in the office, and sometimes even via home visits. They are mothers who themselves have breastfed, who have been on WIC, and who come from similar communities and backgrounds as the WIC moms they are assisting. They are absolutely passionate about their work and they are the ONLY breastfeeding help that many WIC moms EVER access. And they are evidence-based! Peer counseling has been shown in randomized controlled trials to be one of the most effective interventions in helping low-income women meet their breastfeeding goals.

When I heard about Rep. Virginia Foxx proposing to cut WIC peer counseling, I was sick. I imagined watching so many more women walk off that cliff. I am relieved that the proposal has been defeated, and in the meantime I really enjoyed a piece at The Leaky Boob - by a WIC peer counselor who wants to show Rep. Foxx the luxe life the congresswoman seems to imagine peer counselors are leading.

Now let’s look at a typical day in the life of me. I get to work, check voicemail, counsel prenatal moms about the benefits of breastfeeding, what to expect, and what to do when they go back to work. I rent our breastpumps. I do feeding assessments if moms are concerned about baby not getting enough. I call clients. I evaluate latches. I teach classes. I leave notes in the files so that other staff knows what is going on with the client. ...

At four, I do clock out. Then I turn on my cell phone – MY cell phone, Representative Foxx, the one that is not paid for by the company, thank you very much – and I run my own warmline for my clients. Sometimes, I don’t get a lot of calls. Sometimes I do. I have taken calls that have lasted hours. I have taken middle of the night calls. I have taken texts. I have taken calls on major holidays, most notably Christmas Eve. I took a call when my daughter was in the hospital and I was frazzled and upset and kind of really wanted to let it just go to voicemail. ...

I took this job for the clients I have. Man, they are amazing. I have students, and full time workers. I have moms who have babies in the NICU who are totally committed to breastfeeding, despite the challenges. I have moms whose babies never latched who have pumped and struggled for months on end because this is that important to them. I have moms with breast injuries that keep them from producing enough milk who still do as much as they can.. I have mothers who have lost their babies and are still pumping, donating milk, for other babies. My clients are diverse and wonderful. They are black and white and Asian and Hispanic. They are lesbian and straight. They are teen moms and forty somethings. They are incredible parents and they humble me every single day.

Thank you, WIC peer counselors, for everything that you do for moms! You are amazing!!

What's different about being a doula outside of the hospital?

2011-06-16T01:35:00.006-04:00

When I posted about attending my first home birth, one commenter asked:

"As a doula did you feel that your role was very different? I had both of my children at home; looking back I wish I had a doula. My midwives, are amazing but they are very hands off and quiet. I think a little more direct verbal support could have greatly shortened both of my labors."

I have been thinking about my response to that comment since attending another out-of-hospital birth and another hospital birth since then. Below are some thoughts, some of which were included in my reply to the original comment:

It has been most interesting to experience the feeling of having to do zero "defense", to not even have to prepare myself for the possibility of running interference. When all of a sudden I no longer had to have my guard up, I realized how much energy and attention I was spending on it. I didn't have to tense myself to find out if the next nurse or OB or midwife on shift was friendly or hostile, flexible or rules-obsessed. I didn't have to explain any birth plans to nurses or nag anyone to get the monitors off or try to soften the impact of discouraging words. I didn't have to help navigate decisions where the woman couldn't be sure whether she should trust her caregivers' recommendation. And in terms of my role, I knew I was totally welcomed and my role was perfectly understood by the midwives there. It was amazing just to toss all that defense aside, know that both the families and I were in a place they could trust, and be 100% focused on labor support.

I also felt very confident that I could let the midwives take over the role of suggesting position changes, etc. when they were around - that was a new feeling. Sometimes in the hospital, I feel like I am the only one taking responsibility for suggesting proactive things to progress labor, ensure optimal fetal positioning, etc., and again I am always on guard that those will be met with negative feedback by the nurses ("what's she doing on the TOILET?") or resistance by the mom ("do I have to move??") Outside of the hospital, the midwives were on top of that stuff, and they had the trust and authority to say "It's really important and I think it would help you, let's get you walking again". I sometimes suggested things as well if I sensed it was the right moment, but I never worried that I would be the only one or that the midwives would be reluctant to try anything the mom was up for.

So I would say the main difference has been in feeling real trust and confidence in the caregivers - that they were on exactly the same page as the family, that they had and used skills that I consider very important, and that everyone who would be there throughout the labor and birth would share those goals and skills.

While one of the reasons I encourage everyone to have a doula for a hospital birth - that guard/buffer role - was not necessary for the out-of-hospital births, I look back and think how much that freed me up to simply focus on the woman and fulfill all the other parts of my doula role. I think a helpful role that I played was in being there before it was time for the midwives to arrive: encouraging rest, suggesting position changes, giving feedback on where I thought labor was at, helping get the tub set up, etc. Many people are ready for some trained labor support before they're really ready to call the midwives. And after they got there I was still doing verbal support/encouragement, taking turns doing counterpressure, and of course the "gofer" role that doulas do so well. And like the commenter mentioned, sometimes your midwives give you wonderful care but their labor support is just not the kind that helps you the most. I would encourage anyone to have a doula at a home birth!

A childbirth educator's take on the state of birth and birthing classes

2011-06-15T14:35:00.004-04:00

I enjoyed this short but spot-on interview with Erica Lyon, a childbirth educator in New York. Everything she says is both true and clearly from deep experience, as well as full of compassion. Here are a few of my favorite quotes:

I’ve heard complaints that childbirth classes end up making women feel guilty or like failures if they get pain medication or c-sections. That’s no fun. What’s going on here?

Many childbirth educators work from a place of believing that if they give a woman enough information she will make the decision that the educator thinks is best—doctors and midwives and many clinicians do this as well. A truly educated and experienced health educator in this field no longer cares what you do, she only cares about her students’ compassionate growth and ability to participate in their own care. Its not empowering to be told how to do something. It’s empowering to make conscious decisions and receive support for them and realize one’s own potential by doing that.

What are some of the biggest misconceptions among your students about what will happen in childbirth?

That it will be short, that tearing is the worst thing ever, that husbands/partners will be grossed out or turned off or useless, that the epidural makes it totally a pain free experience, that providers who are dismissive and brief are the standard (and that they wont be like that in labor), that this is the worst pain one will ever feel, that she will be in control during the labor.

Something in me wants to take that last paragraph, blow it up to poster size, and laminate it and put it up on a wall somewhere...not sure why, maybe so I can add a tick mark next to each item every time I encounter or counsel someone about that particular misconception. Maybe because each surface concern speaks to a deeper issue in terms of our society's ideas about labor and birth.

If it was acceptable to cut and paste another person's entire post, I would do it! So instead I ask you to just click over and read it all.

How people find my blog, June edition

2011-06-10T02:35:00.005-04:00

I wasn't planning to do one of these again so soon, but looking through the list of search terms used en route to Public Health Doula just offered too many opportunities to resist. How have people been finding my blog this month? Let's see:

"public health boring"

Well, sometimes. Sorry, stroke prevention...I just can't get excited about you, as important as you are, but I'm sure the stroke prevention people find my work boring too, so I'm happy we've all found our bliss.

"documentary how do you know when a molly is about to give birth"

Is a "molly" some kind of animal? Or this just specifically for women named Molly? And there's a whole documentary about them?

"i want to breastfeed buy nicu has my baby on bottle what should i do"

This makes me sad because I see it so often. Short answer: Demand a visit with a lactation consultant, and if the hospital doesn't have any find an outside IBCLC who can help you. Join a La Leche League group for support, and stay committed - time and patience can do a lot in this situation.

"baby friendly initiative bullshit"

I'm assuming this was a search done by a bitter postpartum floor nurse. I think I might know a few of them. Sorry you're not a fan of evidence-based practices!

"how should you supplement a hypoglycemic baby"

Depends on the hypoglycemia and the baby, but in many situations the first choice should always be breastfeeding/the mother's own milk!

"hate directed pushing"

Me too!!!

"barbie doula"

Oh my god, I can't wait for Doula Barbie! Let's figure out an outfit for her. I'm thinking her accessories should definitely include a birth ball, a rice sock, and a tiny copy of "The Labor Progress Handbook".

Becoming a better doula...through the power of the INTERNET!

2011-06-09T04:00:00.000-04:00

When I first became a doula, I didn't know about many online resources for doulas; I don't know if they were even very common at that point. In terms of my continuing education as a doula, I learned from books, talking with doulas, midwives, and nurses, and of course hands-on from attending births! After taking a couple years' break from serious doula-ing, though, I was getting back into it, looking for more resources, and found a number of doula-related sites and listservs. Then I started reading blogs and discovered an even bigger world of blogs and resources.

In-person networking and sharing are still important, but I have learned so much from online resources that I almost think joining a single doula forum or listserv, at the very least, should be a requirement for being a doula. I am often surprised, in fact, by how little some doulas know about topics that I have seen extensively discussed in various online settings. We have a responsibility to ourselves and our clients to stay current with changes in maternity care practices, new research, and current events in the birth-o-sphere. So much of that is easily available online. And practicing solo, sometimes in hostile or isolated settings, can make it very difficult to generate the kind of community and collegial settings where doulas can share information and learn from each other. I have learned so much, and deepened my thinking, from reading information and debates on testing, interventions, informed consent, the doula's role, and more by participating in listservs and through the many great blogs by doulas, midwives, nurses, and other people interested in and passionate about birth.

That isn't to say every doula should become a blog junkie like me, though! Simply joining your local doula listserv often sends news items and discussion through your inbox, as well as connecting you to the local birth network. Usually those listservs will have "digest" settings so you can get all the messages sent each day packaged together in one e-mail. (I am already drowning in e-mail, so I set all listservs to arrive as digests or my inbox would be out of control!) If you don't have a good local listserv, I recommend Alldoulas.com where you can both connect with local people and interact with doulas from all over the world. I don't go on there very often, but the forums have been friendly, helpful, and a great resource for me when I needed them.

If you DO want to become a blog junkie like me (or just find a few good blogs to follow), I've created a "bundle" of my favorite blogs for those of you who use Google Reader. Click here to easily see and subscribe to all or some.

I should also say that I have also benefited hugely from the online resources available for communication among IBCLCs, specifically Lactnet. Reading about puzzling or complicated cases, the different takes of LCs from around the world on those cases or on issues of ethics and professional responsibility, and learning new tips and tricks has been fantastic and so educational. I sometimes see advice or techniques for situations I've encountered, and I print out them out and keep them on my clipboard at work in case I need them. (For example, I recently had great success with advice for how best to use reverse pressure softening with a very edematous mother.) As a new IBCLC, I know I have a huge amount left to learn and reading Lactnet is like getting to peer over the shoulder of more experienced LCs as they think and work with moms/babies.

What are your favorite doula/birthworker online supports or resources?

The breastfeeding police, or how what you don't know can hurt breastfeeding mothers

2011-06-02T02:52:00.002-04:00

Anne at Dou-la-la has a guest post up on The Leaky Boob and it is a gem. Here's a few excerpts:

YES, I do think that women who feel they ‘can’t’ produce enough milk have often been sabotaged (i.e. booby-trapped) in ways they are unaware of. And one of the things that most often thwarts them is misinformation.
HOWEVER. Statements that imply that really, everyone can breastfeed and if they didn’t succeed, they just didn’t try hard enough, mind over matter? EVERY BIT as misinformed as the bad advice that might have led a mom to undermine her supply or her belief in her supply. I know it’s highly unorthodox for a breastfeeding advocate to call other breastfeeding advocates out when their intentions really were good, but I see so much poor advice online that it’s really starting to get to me. ...

This does NOT mean that there is not a place for peer support. There so absolutely is is – La Leche League turned the tide on breastfeeding half a century ago and its very foundation was peer support. But part of being a trustworthy resource is knowing when something is beyond your knowledge – even for professionals, certain things are beyond one’s scope of practice, and it is crucial to have the honesty and humility to know when to refer.

I am a brand spankin' new IBCLC (just got my exam pass in October 2010). Before that I was trained as a breastfeeding educator (think peer counselor-type level) and as a doula, and I wrote my senior thesis on breastfeeding. I knew a fair amount about this whole feeding-babies-with-your-breast thing, I really did. But once I started training as an IBCLC, I suddenly realized how much I DIDN'T know...and when I started actually working as an IBCLC, I realized how much I STILL didn't know all OVER again. In fact, the more I learn the more I stop answering questions confidently, and instead turn to my mentor LCs (with their 5-20+ years of experience) and reference books to double- and triple-check what I THOUGHT I knew, before I give any answers. And in the meantime I hear loads of unhelpful or clueless "advice" being doled out left and right. (If I hear one more NICU nurse suggest "drinking lots of water" as a solution for low supply...)

As Anne says, this isn't a "leave it to the experts, ladies" kind of situation - there absolutely is a setting for educated, compassionate peer support and it it SO important. But let's have it be educated and compassionate - not rife with statements like "everyone can make enough milk" (I saw 2 women in the hospital this past week with classic signs of insufficient glandular tissue, and if they don't reach a full supply even with optimal milk removal, there will be a pretty darn good physiological reason that they CAN'T).

When they hear that I'm a lactation consultant a lot of people share their difficulties with breastfeeding with me (same goes for doula and birth!) I sometimes hear it as a defensive explanation, sometimes as a way of continuing to grieve/process the experience, sometimes as a simple "oh, you'll be interested in this" conversational topic. No matter what, it's hard to find a way to respond, but even when I hear something in their story that doesn't sound accurate or misguided, I try to focus on what I can simply validate and acknowledge. "Exclusively pumping is so hard, I'm impressed you stuck with it as long as you did", or "That sounds so painful, I'm sorry that happened to you". (One of my LC colleagues says, "I'm sorry things didn't work out; often people find breastfeeding is easier with the next baby" to help leave the door open for trying again in the future.)

What I don't do is ask questions or try to learn more about the situation. If a mother thinks things could have gone differently or wants to know how to change things with the next baby, she will ask me! In the meantime, support, empower, offer resources to help the mother learn more and get more advanced help - but let's stop assuming we know everything about a woman's situation, particularly after the fact. It doesn't do her any favors and it sets breastfeeding back as well.

Please read Anne's post for a thought-provoking discussion on this topic! And please share your thoughts - what do you say when a mother shares her difficult breastfeeding story? If you had challenges breastfeeding, what were helpful/unhelpful things that people said to you?

Boring factual infographic

2011-05-31T12:18:00.001-04:00

Via I Love Charts

Thanks to my friend (& LC-in-training) Allison for the link!

What do orangutans, dolphins, cats, and horses have to do with delayed cord clamping?

2011-05-26T20:52:00.006-04:00

I'm often reading through blogs in a time and/or place that I can't watch videos - particularly long ones - and when I put them aside for later viewing, they tend to pile up. I finally sat down to watch Dr. Nicholas Fogelson, who writes at Academic OB/GYN, do a Grand Rounds talk on delayed cord clamping. I wish every OB, midwife, and pediatrician would watch this! I still hear from doula clients that they are told the OB doesn't want to wait to clamp, or will only wait [45 seconds, 60 seconds, etc.] out of concern for polycythemia, jaundice, or some other pediatric concern. I think this talk effectively addresses those concerns, and very nicely lays out the evidence that we do not benefit babies, and instead create potential harm, when we - as standard practice - routinely phlebotomize babies of 40% of their blood volume (as Dr. Fogelson so succinctly puts it).

One thing he did not discuss - although he did touch on the topic - was the connection between breastfeeding, delayed cord clamping, and the "need" for supplemental iron in breastfed infants. While there is very good information and research out there to debunk the idea that breastmilk is "low" in iron and that all breastfed babies need routine iron supplementation, there is a small percentage of babies who become anemic and require supplementation. But when we look at one of the studies he cited, Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial, you can see that early clamping had a greater detrimental effect on the iron levels of 6-month-old babies who were exclusively breastfed; the breastfed babies who had delayed clamping had iron levels closer to those of the infants getting iron-fortified formula or milk. It makes sense to ask that if a breastfed infant DOES end up needing supplemental iron (based on a check of hemoglobin levels), could we have caused its anemia by early cord clamping, given that we have interfered with the normal system of providing a baby's iron in its first months of life?

Enough talk from me! I put off watching this in part because it's about 40 minutes long, but they were a very fast 40 minutes (and you can just listen, with an occasional glance at the slides, if you need to do something else while you're at it).

Here's Part 1, the following segments should pop up as you finish. If you have trouble finding them, you can take a look at Dr. Fogelson's original post; I recommend also reading the comments for discussion of various related topics including the practicalities of delayed cord clamping for preterm infants. (Oh, and all those animals in the title of this post? You'll have to watch to find out!)

When you're done watching, please share this video! I think Dr. Fogelson does a very good job making the argument that delayed cord clamping should not be a nice "add-on" that someone gets if they put it on their birth plan, or be seen as a hindrance instead of a help to neonatal resuscitation; it should be the standard of care in all but rare cases. But it cannot become the standard of care unless more people are aware of the evidence!

Guest Post: Mollie's path to pregnancy/birth (Part 3: Pregnancy and Birth)

2011-05-25T12:33:00.004-04:00

In Part 2, Mollie talked about learning how important her place of birth was and how she interviewed care providers. In the final installment read all about the part where she gets knocked up!

Part 3: Pregnancy and birth

I calculate my date of conception as August 7. This becomes important, as I learned very quickly to lie to the hospital’s ultrasound tech about the date of my last menstrual period (thanks to FAM, I knew I had ovulated on the 19th day, not the 14th day, and five days is a long time when one risks out of the birthing center at seven days overdue). As it turns out, it was a very good idea to pick out my midwife and go to their orientation night before I was even pregnant, because when I called at five weeks pregnant with a due date of April 30, they said they were already full. They said I would have to come in for the orientation before even getting on the wait list, so when I said I had already been to it, they begrudgingly took me on as a patient (again, this was the receptionist being a little snotty about my proactive approach).

There were a few times when the researchy side of me was an issue when it came to the pregnancy. First, when I went to my gynecologist’s office to confirm the pregnancy (I wasn’t going to see my midwife until about 9-10 weeks), they found a subchorionic hematoma but never told me. A few weeks later I picked up my chart to bring over to my midwife office, and of course I read through it (what sort of researcher would I be if I hadn’t?). I saw the note about the hematoma, and of course FREAKED OUT! (By the way, don’t Google subchorionic hematoma. Better yet, don’t Google anything. You’ll end up convinced that you’re about to bleed to death, guaranteed. In this case, TheBump.com forums, though I don’t recommend message boards in general, were actually more helpful and offered a quicker response than my doctor.) Another time, during my 20 week ultrasound, I asked the doctor if he could tell where the placenta was attached (I had just finished reading about placenta prevea and cord prolapse, so it was on my mind). Instead of just telling me, or politely asking me if I had reason to suspect an issue, he snapped at me with “WHY!?” I replied with a bewildered, “Um, because I read a lot and I know what can happen if it’s too low”, at which point he gruffly checked and said, “It’s fine.”

Around 12 weeks, we started looking for Doulas. Again, this is probably earlier than most normal people would start booking their help, but my experience with nearly getting shut out of my preferred midwife office had me spooked that we wouldn’t get “the good one” unless I started looking early. I asked for recommendations from friends, but mostly looked through the DONA website. You can search by location, and while there are a TON of doulas listen in the New York City area, I looked up a handful, gauged their experience (we decided we didn’t want a newbie), and emailed then. We met with a few, and chose one who best fit our personalities (plus, she had a really nice website).

The rest of the pregnancy was pretty straightforward – I threw up, I gained weight, I did my prenatal tests, and everything was fine. I never had any real surprises. My husband and I took the Childbirth Ed class, Newborn Care class, and Breastfeeding class, and did our best not to be the know-it-alls in the class. Planning like this is second nature to me, so often I would forget just how prepared we were. But there was one moment in class that really solidified it for me, and made me grateful for all my research. In Childbirth class one week, we discussed routine interventions, procedures, and regulations like Electronic Fetal Monitoring and restricted food and drink. The next week, during our “check-in”, one of the couples seemed so upset as they began to talk about their week. Mom was about 36 weeks along, and had just gone on the tour of the hospital. They had found out that the hospital required all laboring moms to stay in bed, on their backs, for their entire labor and delivery; IVs were mandatory, and all food and drink was prohibited; continuous Electronic Fetal Monitoring was required for all moms. They were devastated. They asked their OB if he had any flexibility regarding these rules, and he said no – the hospital’s rules were his rules. No one in class knew what to say to them; nearly all the coping strategies we had learned in class required SOME sort of movement.

I was discussing her situation with my husband that night. “Not to sound judgmental,” I said, “but how did she NOT know those were the rules until 36 weeks?” “Well,” he said to me, “you have to remember – you know more about this than anyone I’ve ever met. You’ve known this stuff for months. Other people don’t know that they don’t know.”

While there were times when I feel like I knew too much for my own good, there was one moment when all my studying felt worth it. Just before 4:00am on April 11, 2011, I was walking the halls of the Birthing Center at St. Luke’s Roosevelt Hospital, in labor, with my doula. At the height of one contraction, I finally let the words “I can’t do it” escape my lips. I cried, fearing that if it got any worse, I wouldn’t make it. After the contraction was over, my doula said to me, “Now I know you’ve done your homework. You know what ‘I can’t do it’ means.” And I did. I knew it meant Transition; I knew it meant it was almost over.

By the end of pregnancy, I had prepared everything as best I could. I had midwives whom I trusted, I had chosen a hospital that would allow me to have the kind of birth I wanted, and I had a doula who would guide me through it. It was a great comfort to know they respected my birth wishes, especially because at the very moment of my son’s birth, I was finally NOT in complete control of everything. None of my research could have prepared me for that moment, but at least I knew we were in good hands.

Baby Rowan was born April 11, 2011 at 3:54am.

Just a reminder that you can read the story of Rowan's birth on Mollie's blog, Tough Love Knitters. (You can also follow Rowan's current life and adventures at Little Red Rowan.) And check out Mollie feeding Rowan while he models her newest knitted creation. Congratulations Mollie! I can't wait to meet your adorable baby ASAP!

Home birth on the rise in the U.S.

2011-05-23T05:02:00.005-04:00

When I heard Eugene Declercq speak at the CIMS forum, I jotted down some notes on his data, but it was one of those "scribble it on the back of the conference program because you forgot to bring a notepad" situations, and he talked about so much interesting stuff I didn't have room or time to write it all down. One thing I was intrigued by was his statement that 1% of all births to white women are now happening at home. That seemed high to me, but he co-authored a new article out in the journal Birth, and it has that statistic plus a lot more info.

Some excerpts that were particularly interesting to me:

Large differences occurred in the percentage of home births by maternal race and ethnicity, and these differences widened over time... In 2008, 1.02 percent of births to non-Hispanic white women were home births, representing a 28 percent increase from 2004, when 0.80 percent of births to non-Hispanic white women were home births. In contrast, the percentage of home births declined slightly for non-Hispanic black women from 0.30 percent in 2004 to 0.28 percent in 2008. In 2008, the percentage of home births was 0.20 for Hispanic women and 0.38 for American Indian women, statistically unchanged from the 2004 figures. In 2008, the percentage of home births was 0.27 for Asian or Pacific Islander women, up from 0.24 percent in 2004. Approximately 94 percent of the increase in the overall percentage of home births from 2004 to 2008 was because of the increase for non-Hispanic white women. In 2008, 83 percent of home births were to non-Hispanic white women, compared with 54 percent of hospital births. [emphasis mine]

In 2008, Montana had the highest percentage of home births (2.18%), followed by Vermont (1.96%) and Oregon (1.91%). Three other states (Alaska, Pennsylvania, and Wisconsin) had a percentage of home births of 1.50 percent or above. An additional 10 states had 1.00 to 1.49 percent of home births. In contrast, 18 states had less than 0.50 percent of home births.

Interestingly, the recent increase in home births in the United States began before the release of a series of documentaries and newspaper articles about home birth... Such a development is not without precedent. In the United Kingdom, a government-endorsed movement called Changing Childbirth has been credited with leading to a growth in home births that has continued until the present. However, the home birth rate in the United Kingdom had already been increasing for five consecutive years before Changing Childbirth came into being... Women choosing home birth may be a harbinger, as much as a result, of increased activism related to childbirth...

These make me think about the highly culturally specific nature of the homebirth movement in the U.S. White women (in states with small minority populations) are accessing, promoting, and creating change around homebirth, and I would say I see a culture of normalcy arising around out-of-hospital birth in a certain segment of the population. (Overheard outside a prenatal yoga class: "Well, you don't have to pack a bag since you'll be staying at home, but what are YOU packing to bring to the birth center?") There is clearly a lot of privilege at work here...there are so very very few voices speaking to the non-educated-middle-class-white-woman demographic. I often think some of the Hispanic women I work with in CenteringPregnancy would be interested in having their babies in a setting other than the hospital - out-of-hospital birth with midwives being the standard in many countries they/their families come from - but there is simply no way for them to even know that homebirth is possible in the U.S., much less sort through the complicated process of finding and accessing it, insurance-wise. (And I can't pitch homebirth to them in my role, unfortunately!)

It comes back to my frustration that the people with privilege seek out the nurturing, mother-friendly, midwifery care; and the people who need that care the most, so frequently get a prenatal care through a health department or community health center, every visit with a different provider and then labor and delivery with another set of strangers, usually the general OB service at the hospital. I see basically zero outreach to low-income/minority communities from the birth community, and walking my delicate line between working in the system right now, I am guilty of that too. How do we fix this??

Guest Post: Mollie's path to pregnancy/birth (Part 2: Preparation)

2011-05-18T01:40:00.003-04:00

In Part 1, our intrepid heroine learned the secrets of her reproductive cycle and was blown away by a showing of "The Business of Being Born". Check out the next installment on...

Mollie's path to pregnancy/birth: Part 2: Preparation

So now my world had been turned upside down and I was looking for answers. Where did I go? The internet of course!!! I began following the Public Heath Doula’s blog, as well as anyone SHE followed. Soon I had a nice little list of Natural Birthing bloggers: Birth Faith, Our Bodies Our Blog, Science and Sensibility, The Unnecesarean, the Midwife Next Door, Enjoy Birth, and many others. And I read and I read and I read. I couldn’t get enough of it. Sometimes they were a little out there and scary, with a “if you give birth in a hospital you WILL end up with a cesarean”, but most of the time they were informative, and over time I learned about Doulas, episiotomy rates, c-section rates (and the vast discrepancy among hospitals in New York City, which range from 16% to 48%!), and most importantly, the questions to ask your care provider BEFORE you agree to work with them:

Questions to ask
A few more question
And a few more

Around this same time I also attended a talk given by the head of Parent Family Education from St. Luke Roosevelt Hospital. My company often holds mini lectures on topics like getting your kid into private school or how to reduce your stress at work. This one was called “Preparing for Pregnancy and Childbirth”, and thank goodness it had listed as one of the talking points “preconception” (I learned later that the instructor did not know she was expected to talk about preconception, but obliged because there were a few of us non-pregnants who showed up). The talk was basically a quick and dirty intro childbirth ed course, with an emphasis on “This is a really big deal, so after this, you should sign up for a real course.” But the most important thing that came up was this: pick your birth location BEFORE you pick your provider.

I’m going to say that last part again.

Pick your birth location BEFORE you pick your provider.

“Um, are you on crack?”, you must be thinking. “That makes no sense.” It sounded strange to me at first too, but the more I learned, the more I realized that the difference between hospitals – even hospitals within a few miles of each other – could drastically change the type of birth I would have. For example: St. Luke’s Roosevelt Hospital has an in-hospital Birthing Center, where many of the standard Labor and Delivery rules do not apply (e.g. there are no restrictions on eating or drinking, and continuous electronic fetal monitoring is not required). Approximately six miles away, Elmhurst Hospital requires every laboring woman to be confined to bed, on her back, with continuous EFM regardless of her risk assessment. The rules of the hospital would DRASTICALLY change not only my overall experience, but the specific ways I could cope with pain (if I’m not allowed out of bed except to go to the bathroom, I’m certainly not going to be allowed to walk the halls or labor on a ball).

“Well, my provider would never force me to stay in bed, and she can just meet me at the good hospital.” She could, if she has privileges there. I happen to love my gynecologist, but because of recent insurance changes, she only has privileges at Jamaica Hospital – not only inconvenient for me, but Jamaica Hospital has a 41% cesarean rate (as of 2008), compared to Roosevelt’s 28% (Read the stats here). You may decide that you want to do a home birth, but I highly doubt your OB/GYN is going to be your provider. Also, if your provider has privileges at multiple hospitals, he may have you meet him at the hospital where his current mom is laboring, not necessarily the one closest to you or the one with the amenities or rules best-suited for your desired labor experience. Now, this point may be moot if you only have one hospital or birthing center in your area, but if you live in a metropolitan area with many choices, it makes sense to get to know the hospitals first, and then ask the hospital or your insurance company for a list of practitioners with privileges at your favorite.

Ok, so I had my reproductive system down, I knew I had some options for hospitals, and I knew more about episiotomies than any child-less person should know. Over the three “preconception” months, we went on three hospital tours – Roosevelt, Lenox Hill, and The Brooklyn Birthing Center. I liked Roosevelt the best, so I asked them to send me a list of practitioners who had privileges in the Birthing Center. I narrowed down the ones covered by my insurance company (oh, side note: I called my insurance company and it was the opposite of helpful – the guy on the phone told me that midwives were illegal in the state of New York so they don’t cover them . . . oh Aetna customer service . . .), and set up consultation appointments. Now, I had no issues going on hospital tours while not yet pregnant, since they didn’t ask (I have heard rumors that some hospitals won’t let you come unless you’re pregnant, hoping to weed out trainee doulas and paparazzi I guess, but in that case, I imagine you can just lie). I got a little bit more push-back from the receptionists at the doctor’s offices (“Wait, you’re not even pregnant?!”) though thankfully, not from the doctors themselves; they knew exactly why I was meeting them so early, and even seemed to appreciate it. One midwife office (the ones I ended up choosing) actually had an orientation night, where they sat for an hour or so and talked about their practice and their birth philosophy, and where anyone could come and ask questions. I ranked my favorites, and now I was ready for baby-making!!!

Weekend at the movies: TED Talk on "Love, Breathe, Just Doula!"

2011-05-14T16:30:00.002-04:00

Really enjoyed this humorous and engaging Doula/Birth 101 by Ginny Phang, a doula in Singapore.

The only thing I disagreed with her on was she was maybe implying that first-time mothers can get a 3-4 hour labor by preparing and educating themselves...I think that preparation and relaxation can certainly help shorten labor, but I wouldn't want a mom who had worked hard to prepare for birth expect a 3-4 hour labor or feel like she had done something "wrong" because a first labor took longer. But she also talks about not knowing how long labor will take, being prepared for anything, and writing a comprehensive birth plan with Plans B, C, and D. It was a fun and inspiring little video, and I think will help people understand what a doula does and why it's important. (Also, catch the gasps when she talks about planning to breastfeed for a month, then mentions how long she actually breastfed her son!)

Should the ACNM become just the ACM?

2011-05-14T03:54:00.003-04:00

A long and thought-provoking interview with a CPM/CNM on the American College of Nurse-Midwives' proposal to become the American College of Midwives:

Erin: You have spoken out publicly against the proposed name change of the ACNM. Yet you have worked as both a CPM and CNM, and have previously spoken out for unification of the profession. Why would you be opposed to this move?

Hilary: I would only support this name change if the ACNM concurrently commits the organization to working in partnership with MANA, NARM and MEAC to create one unified midwifery profession in the US. Without this commitment, calling CNMs “midwives” will increase their potential for working in opposition to direct-entry midwives who are striving on the political front to have CPMs included in national health reform initiatives, and of their being at odds with legislative efforts in states where the CPM has not yet been recognized. If the ACNM is going to rename itself the American College of Midwives, is it going to wield this moniker for the betterment of ALL midwives, or is the organization going to promote only its own brand of midwifery? As a corollary, is it going to change the title of all its members to CM – Certified Midwife?

...

Erin: You’ve mentioned a merging of nurse-midwifery with direct-entry midwifery. How would one midwifery credential better serve childbearing women? Wouldn’t it mean less choice for them?

Hilary: It would only mean less choice if we allow the current model of nurse-midwifery to subsume direct entry.

A true merger takes the best of both worlds, and in the process gives the participants a greater societal voice. As long as we continue to put our focus on creating hierarchies within the midwifery community, rather than really listening to each other and learning how to work together, we will not be successful in building midwifery as an independent and powerful profession. If we choose instead to have one unified profession, where all midwives are educated to work in all settings, where the goal is to increase the profession until all women throughout the US can have access to a midwife, then we are creating more, not less, choice.

Read the whole thing here.

Guest Post: Mollie's path to pregnancy/birth (Part 1: Preconception)

2011-05-14T03:16:00.002-04:00

You may remember that a few weeks ago I posted about my friend Mollie's birth story, in which she had a lovely and exciting (in the good way) delivery in a birth center, attended by a midwife, with the support of her husband and doula. I also promised a guest post by Mollie. So now you know the end of the story, I'm delighted to bring you a three-part series that she's written about how she came to learn about her options for birth, decide what she wanted, and find her care providers and place of birth.

Of note, Mollie and I met a surprisingly large number of years ago (surprising to me at least! I don't feel that old!) living on the same dormitory hall, at a college known for having its students do a lot of independent, self-guided research. As you can see, Mollie learned these lessons very well!

Mollie's path to pregnancy/birth: Part 1: Preconception

The path to becoming a mother is different for everyone, as is the path to getting pregnant. My path was in many ways straightforward – get married, get settled, get pregnant, have baby. I did manage, however, to insert a step in the process which, for anyone who knows me well enough, was absolutely essential: I researched the crap out of it. I left no pregnancy book unread, no birthing blog un-lurked, and no midwife in a 10-mile radius without at least a hit on her website. I needed to know it all, and I needed to know it all before there was even a fetus to worry about.

It all started about 15 months or so before the baby was conceived. I was on The Pill and was interested in a non-hormonal form of birth control. I chatted with some friends and with my GYN, and ultimately picked up “Taking Charge of Your Fertility,” a fantastic how-to guide for the Fertility Awareness Method of both birth control and conception. I devoured this book! I couldn’t believe how much I realized I had never known about my own reproductive system. “Why didn’t they ever teach me this in health class?” I kept yelling! I couldn’t get enough of it. I charted my cycle for over a year before ever attempting to get pregnant, and I learned more about my hormones and my body in that year than in my previous 15 years as a reproductively mature female.

Now it was time to research conception, because who could POSSIBLY do that without adequately researching it!? [har har]. So I picked up a few books (and thank you New York Public Library, for allowing me my fill of research without having to purchase a single book). “Your Pregnancy: a 90-Day Preconception Guide” was pretty informative – a lot about nutrition and vitamins, exercise, and understanding genetic diseases. I went back to “Taking Charge of your Fertility” and reread the conception chapters. I also picked up “What to Expect Before You’re Expecting” . . . oy. If you thought the “When You’re Expecting” book was bad, the “Before You’re Expecting” may just give you an aneurism. Unless you’re not quite sure on the mechanics of sex leading to babies, don’t waste your time with this one.

Alright, so I had conception down. I had negotiated with the husband to start trying in September, so on June 1, 90 days out, I started my preconception routine: I was taking my prenatal vitamins (woo Folic Acid!), charting away, and trying to convince my husband that “no, I promise I won’t go crazy and tell you which days we have to have sex!” I made an appointment with my GYN to get checked out, talk through which medications were still fine to take, and discuss genetic testing.

At the same time I had the “Why didn’t I know this about my body” epiphany, I had the “Why didn’t I know this about childbirth” epiphany. The Public Heath Doula herself invited me on a little movie date one afternoon. “There’s this documentary about childbirth that’s supposed to be great!” she told me. Little did I know I would soon become one of those Natural Childbirth advocates who feel the need to educate the world about epidurals and yell at sitcoms which portray childbirth incorrectly. Because, you see, she took me to see “The Business of Being Born.” I’m not exaggerating when I say it changed my life, or at least my outlook on life. If you haven’t seen it, you need to. If you ignore everything else I write here, if you take away NOTHING . . . just see this film. It’s on Netflix instant-watch, and it’s only an hour or so long. I promise, it’s worth it. And get your partner to watch it too. I’m telling you, my husband was on the fence about this whole non-medicated thing (“If it makes the pain go away, why WOULDN’T you want it!?”) until I sat him down and made him watch this movie. He now excitedly educates his buddies about the side-effects of epidural analgesia and hospital policies on freedom of movement. (He still wasn’t sold on a home-birth, but he eased up on the opinion that I was effing crazy.)

Stay tuned for Part 2... Preparation!

Weekend at the movies: Midwives Diner

2011-05-07T21:27:00.001-04:00

What do you get when you go to the Midwives Diner? Well for starters, no IV and as much water as you want!

Living as a doula, making a living as a doula, and life without doula-ing

2011-05-03T21:10:00.003-04:00

When I heard Penny Simkin speak at the Breastfeeding & Feminism conference, she talked about the rising fees that doulas are charging and the conflict between doulas who do it for a living and doulas who do it as sideline income or even without any real financial need/goals. I've almost never met a doula who can support themselves on doula work alone, but Penny Simkin was talking about how for an increasing number of doulas this is their goal. They love doula work and they want to charge fees that enable them to support themselves/their families on their doula career alone.

For a little while I had the idea that I could be one of those doulas...I gave that up pretty fast. I realized how long it would take to build a consistent referral base to bring in new clients and how even when you think you've got a good cycle going, things happen... many doulas I knew in NYC were really impacted by the economic downturn there, when fewer parents felt financially able/willing to spend on doulas (you all know I think that's one of the most important things to spend on, but those parents didn't ask me!) I also saw how most doulas needed other sources of income to fallback on: many offer a whole set of services like childbirth ed, placenta encapsulation, birth photography, etc. etc. I'm not a personality who is happy patching things together that way long-term, and it didn't seem like it made sense for my personal financial health either. I decided to go back to grad school and get me a Real Grown-Up Job (tm).

Fast-forward to my Real Grown-Up Job (tm) doing something I love - working as an LC - and I am now feeling the tug between my doula work and said Real Job. I attended my second out-of-hospital birth ever today - hooray! It went so well and was such a wonderful experience with a lovely family. It really reminded me of why I LOVE being a doula - why it is my favorite thing in the world to do. But it was hard to work it around the Real Job in ways that show it really wouldn't be sustainable in the long-term to take doula clients. When I'm in the midst of being on-call for clients - phone always on and with me, can't go out of town, can't make concrete plans, etc. - it doesn't seem like such a sacrifice. But then I go to a birth, all those little annoyances fall away, and it breaks my heart to think about stopping.

I have thought about doing a partner doula system, where clients hire me & another doula together with the understanding that one of us is always on-call and at birthing time she could get either one, depending on our schedules. But it has been frustratingly difficult for me to find back-up doulas, and I don't really think that bodes well for finding a full-time partner. There might be some more flexibility in going back to volunteer doula work, but I recognize that will need to be fairly rare; I found myself getting burned out on 30+ hour volunteer births where I wasn't willing to leave but wasn't feeling a return on my energy and experience.

I have one more doula client coming up (yep, still on call!) Both today's and the next one hired me before I went permanent at Real Job. After that, I know I'll be happy to get some time off from the on-call routine...and then what?

What I missed

2011-04-30T01:34:00.002-04:00

You know you were (are) a Google Reader addict when you get back on after giving it up for Lent, and it's stopped counting new posts after "1000+". If I was going to be really true to my Lenten vow I would have marked them all as read and started afresh. But I did skim some of my faves. So while these links are probably old to everyone else, here are a few that jumped out at me:

Navelgazing Midwife on Touring L&D suites around the country and wondering what they say about what patients want...or are supposed to wait. I commented about how often hospitals seem to advertise "private rooms"... even in pretty dingy public hospitals I have yet to work with a doula client who got anything but a private room, whether L&D or postpartum. Is this just an advertising gimmick?

The Academy of Breastfeeding Medicine on audio galactagogues for mothers of babies in the NICU. I want to hand out little MP3 players to all the pumping NICU moms I see! It made me wonder whether a Hypnobirthing/Hypnobabies type of track targeted especially to NICU moms to listen to before or during milk expression would be helpful.

Alanna at Blood and Milk on how "helpful" postpartum visitors are a lot like "helpful" aid organizations.

Via Motherwear Breastfeeding Blog, a NY Times article on the deadly consequences of cultural beliefs that deprive babies of breastmilk in developing countries.

AmeriCorps doula job posting

2011-04-28T03:52:00.002-04:00

As I noted in my post on AmeriCorps doula opportunities, I don't generally have any info about what's currently out there. AmeriCorps programs and positions are constantly changing and I don't even know what's happening with my old program, much less anyone else's! But I have a friend looking for AmeriCorps positions in Seattle right now and she sent me this posting:

Member Duties : Two positions are offered for members who will train as a Birthing Doula with Seattle Midwifery School. Members will then serve as part of Seattle's MSS Department providing pre and post labor education as well as labor support to clients who lack a support system. This position requires independence, sensitivity, a willingness to work independently, and the ability to handle a demanding on-call schedule as well as bilingualism in Spanish and English. To learn more about the role of a Doula visit www.dona.org. IN ORDER TO COMPLETE YOUR AMERICORPS APPLICATION, PLEASE COMPLETE AND SUBMIT THE SUPPLEMENTAL QUESTIONS LOCATED ON THE SEA MAR WEBSITE. These questions can be found by clicking to www.seamar.org, then pulling down the menu "Jobs", clicking on "AmeriCorps" and clicking to "How To Apply".

Program Benefits :
Childcare assistance if eligible , Education award upon successful completion of service , Health Coverage , Living Allowance , Training .

Terms :
Permits attendance at school during off hours , Permits working at another job during off hours .

Service Areas :
Community Outreach , Education , Health

Just reading the job description brought back such wonderful memories of my work as an AmeriCorps doula! I still describe that job as, hands down, the best job I ever had. If you're interested, go for it! (I promise my friend won't be competing with you... she's more interested in estuarine ecology.)

Reply turned post: Bottle feeding, breastfeeding, and the NICU

2011-04-27T21:58:00.003-04:00

I vent a lot (maybe too much... trying to stay open to positive possibilities for education and cooperation) about the NICU & breastfeeding.

Because of those challenges, this post on My OB Said What caught my eye today: "You’ll get him home sooner if you just bottle feed," – NICU nurse to breastfeeding mother of a NICU baby. Many commenters chimed in to rightfully assert that the mother's breastmilk is much better than a bottle of formula, especially for a NICU baby, but I think this is not quite what the nurse meant. This was my comment:

"This is sad but true... the requirements for the NICU babies to go home is to take all feeds PO (by mouth), maintain their oxygen sats on room air, and maintain their temp. The PO feeding requirement leads to a lot of bottles because they are the easiest and fastest way to declare the baby capable of all-PO feeding. I have met very few moms able to avoid any bottles in the NICU. It basically means insisting on gavage feeding for every feed at which the mother is not present, and it is hard for the mother to be present 24/7 because the NICU is not set up for that. So it absolutely can mean that the baby stays longer. It is very frustrating because direct breastfeeding is best and least taxing for these babies."

It's a real catch-22. The way to prove the baby can do OK on all PO feeds is for the mother to breastfeed him/her around the clock. But there is often nowhere for the mother to sleep after she's discharged from the hospital herself. So to be with her baby 24 hours a day to breastfeed, she has to agree to bottle feeds to "prove" her baby can effectively take all feeds by mouth. The bottle feeds can and do cause issues with breastfeeding, but even for the most motivated mom, it can be a very difficult choice between agreeing to many bottles, and waiting extra days to take her baby home.

Recently, I saw a baby born at 32 weeks go to the NICU, have nothing but breastmilk and never have a single bottle touch her lips, and eventually go home feeding exclusively at the breast. Her mother was highly educated and motivated, had excellent family and community support, and really advocated for herself and her baby. As LCs, we were all so amazed and impressed by what they did. It was truly an accomplishment in a NICU environment... and it took bucketloads of privilege. Very few people are able to accomplish that without support from the staff, which the nurse quoted above was definitely not providing. Staff support is a huge issue. I have even heard a NICU nurse say "If they don't want to bottle feed, I just tell them 'We can put a tube down your baby's nose instead' [referring to gavage/NG tube feeding] - that changes their mind!'" A really inappropriate thing to say just to scare parents, given that this way of feeding may be necessary for certain babies who aren't able to safely do PO feeds.

In my perfect fantasy world, NICU babies who are ready to do PO feeds are moved to private or semi-private rooms that have a space for mom to sleep, so she can be with the baby 24/7 and breastfeed easily. She can stay there until the baby is ready to go home. Bottles are only given with explanation and consent, used appropriately, and stopped quickly if they begin to cause breastfeeding issues. Is this really such a crazy fantasy?

Short but sweet on why dads/partners should love doulas

2011-04-22T03:59:00.003-04:00

Trying to convince a reluctant family member of your need to have a doula? Try this quote on them, from an OB-GYN I know who had a doula at her first birth: "I can't say if having a doula shortened my labor, but it definitely lengthened my marriage!"

How people find my blog

2011-04-22T01:41:00.002-04:00

I was looking through my stats tonight and thought I'd do a runthrough (as I've seen and enjoyed other bloggers do) of some interesting search keywords/phrases that lead people to my blog. Some of them are pretty interesting, some just...puzzling.

"doula newspaper"
This made me think of how fun an all-doula newspaper would be, imagining breaking headlines like "Hospital X gets telemetry monitors!" and an advice column with questions like "My friends are tired of me talking about birth all the time, but I just want to educate them! Who is right?"

"was getting an MPH a mistake"
It is for some people, but I'm afraid Google's not going to help with the answer for you personally.

"should I get an MPH"
You should probably talk to the above person first!

"counting from 1 to 10 while pushing"
Don't.

"public health insomnia"
Pretty sure that's what I have when I lie awake at night constructing new prenatal education programs in my head.

"is breastmilk best for babies with downs syndrome"
YES! (As breastmilk is best for ALL babies, save a rare few with unusual metabolic disorders.)

"Why do nurses supplement formula to breastfeeding infants"
Pick any combination of the following: ignorance, misguided good intentions, hospital policy, habit, maternal request, laziness, active dislike of breastfeeding.

"doula unqualified neonatal nurses"
Act as a doula to unqualified neonatal nurses? Should unqualified neonatal nurses be doulas? This is one of the puzzlers.

It's Good Friday (just barely) which means 2 more days till I'm back reading blogs! I will confess I broke it just a teeny bit today to check up on Gina's labor/birth at The Feminist Breeder. Very happy for her and so interesting to see the liveblog as it unfolded! Go check it out.

Mollie's birth story

2011-04-19T17:48:00.002-04:00

My lovely friend Mollie just had her baby last week and I am so happy for her! She just posted her birth story on her blog. Before she had it written, she e-mailed me a teaser:

Chris is dozing in the room, I'm in the hall with the Doula, midwife had gone to lie down. We walk down the length of the hall, back to the other end, about half way back and then...
Chris tells it as "I was about to doze off, and then I hear her yelling, 'I can't do it, I can't do it, I'm pushing, make it stop, something came out!'"

Doesn't that make you want to read the whole thing? (Plus you get to see photos of that cute little baby.)

Stay tuned for a guest post by Mollie on how she went about choosing her care providers and place of birth, laying the foundation for a positive (and exciting - in the good way) birth experience!

Michael Latham, breastfeeding advocate

2011-04-14T22:36:00.002-04:00

From the NY Times:

Michael C. Latham, an expert on international nutrition and tropical health who waged a long campaign against the use of infant formula and for the practice of breastfeeding in developing countries, died on April 1 in Boston. He was 82 and lived in Newfield, N.Y.

The cause was pneumonia, his son Mark said.

Dr. Latham, who directed the Program in International Nutrition at Cornell University for 25 years, first encountered the problems of nutrition in the developing world while practicing medicine as a young doctor for the British colonial service in Tanganyika (now Tanzania).

After the country had gained its independence, he stayed on and was appointed the director of the nutrition unit of the public health ministry. He became alarmed at efforts by Western companies to expand their marketing of infant formula to underdeveloped countries, where high birth rates promised a growing consumer base, and he became one of the first and most forceful public health scientists to sound a warning.

In many poor countries, he pointed out, mothers mixed powdered baby formula with contaminated water, leading to diarrheal diseases. To make the formula last longer, they often used too little of the powder, depriving their babies of vital nutrients.

Bottle feeding was “incredibly difficult and extremely bad,” Dr. Latham wrote in a 1976 report with Ted Greiner, but “the media onslaught is terrific, the messages are powerful and the profits are high.”

“High also is the resultant human suffering,” they wrote.

Dr. Latham’s cause, taken up by several health groups, led the World Health Organization in 1981 to develop a set of guidelines, the International Code of Marketing of Breast-milk Substitutes, which was intended to govern the behavior of private companies. He was a prominent figure in the boycott of Nestlé, a leading manufacturer of infant formula, which agreed in 1984 to abide by the marketing code.

Read the rest here.

Link time! Research & investigation style

2011-04-10T05:01:00.005-04:00

In the news and/or my e-mail inbox:

* A new book "Sanctioning Pregnancy: A Psychological Perspective on the Paradoxes and Culture of Research" by Harriet Gross and Helen Pattinson. From their description: "Sanctioning Pregnancy offers a unique critique of sociocultural constructions of pregnancy and the ways in which it is represented in contemporary culture, and examines the common myths which exist about diet, exercise and work in pregnancy, alongside notions of risk and media portrayals of pregnant women." Google Books preview here.

* The FDA will be investigating nutritional claims by infant formula manufacturers.

* When do breastfed babies need extra iron?

* The Full Spectrum Doula Network (FSDN) has several members conducting research who are looking for participants - from the FDSN newsletter:

* FSDN member Ryan Pryor is conducting a study and oral history project of queer and gender non-conforming birth workers (link here)
* FSDN member Laurel Ripple Carpenter is conducting interviews of full spectrum and radical doulas for an ethnographic study at Burlington College and Mesa State College (link here)
* FSDN member Monica Brasile is conducting an online survey of doulas for her PhD research in Gender, Women's, and Sexuality Studies at the University of Iowa. She's especially interested in representing the voices of radical and full spectrum doulas. (link here)
* Erica Varlese is conducting interviews of doulas who offer pro-bono or volunteer services or who work specifically with marginalized groups of women. (link here)

I did an interview with Laurel and it was a great experience (and I'm really looking forward to reading her final product). If you're a doula who falls into one of these categories, please consider helping out!

Thoughts on IBCLC training, reimbursement, and where the profession is headed

2011-04-01T01:00:00.001-04:00

I don't remember when I first realized that the profession of "lactation consultant" existed. I must have encountered it at some point doing research for my undergrad senior thesis, which was (to make it very brief) a literature review and mixed-methods study on infant feeding decisions. The following year, when I did AmeriCorps, was my real introduction to the world of breastfeeding support: I did a 3-day training to become a Certified Breastfeeding Educator (taught by an IBCLC), began doing breastfeeding support in the clinics, and did some shadowing with in-hospital IBCLCs. That experience made me realize that I wanted to be an LC. One of my absolute favorite parts of the job was doing breastfeeding support, and I liked what I saw the LCs that I worked with getting to do. I enjoyed the one-on-one interaction, the clinical problem-solving, the feeling that you were working to help the mother achieve something that was important to her, and the satisfaction when something you suggested worked and - click! - for the first time, mom and baby had a successful feeding.

At the time, though, I looked into becoming an LC and couldn't imagine a way to get enough hours. At the time, IBLCE (the certifying organization for LCs) required thousands of hours of clinical practice to be eligible to sit the exam (for an interesting historical overview of IBCLC eligibility requirements, check out this presentation - opens as a PDF). When I was looking, the requirement was 2500 hours of clinical practice, which I would have to find a way to get independently (since apart from my one-year AmeriCorps term which was already over, I didn't have a job where I could get hours that would count towards my eligibility).

And I really considered how to make it happen. For years, I wanted to become an LC, and I would investigate ways to do it, and then I would give up again. And in this post I'm going to talk about why.

I've been putting off, mulling over, composing and revising this post for a long time. The seeds were sown when I first heard about the new requirements to sit the IBCLC exam, and when I read debates on Lactnet and other listservs; I've gotten e-mails and read other people's posts about this issue; but it's taken a while for me to figure out my thoughts about it.

The impetus to finally put this out there was sparked by some conversations I had at the Breastfeeding & Feminism conference with IBCLCs and IBCLC-wanna-bes. The wanna-bes talked with me about the difficulty of finding and funding training, the IBCLCs talked about their awareness of that difficulty, the limitations of the LC community in addressing the shortage of good training, and the issues with the current pathway system.

This is my current thinking and I'm very curious to hear what others think about it. I apologize for the length - it's quite possible it could be shorter and more succinct, but if I spend too much more time revising it will never get posted!

To start off, a little background about how you become an IBCLC: historically, there have been different pathways to qualifying to sit the exam. They have changed names and requirements more than once, but in my understanding they've all fallen under more or less two different routes:

1) Becoming an IBCLC already having some kind of medical/nursing/clinical degree. To qualify to sit the exam, these people have to have some lactation-specific education (although it is not standardized - hours from a vast array of providers and topics can count), and they also have to meet a minimum number of hours spent working with breastfeeding dyads. Importantly, these hours do not need to be under the direct supervision of an experienced IBCLC and can happen as part of the professional's regular work. So a nurse on a postpartum floor, a pediatrician, a dietitian at a WIC office - all of these people may be able to get their minimum hours through their work. (Pathway 1 in the current system.)

2) Becoming an IBCLC without having any kind of clinical degree. To qualify to sit the exam, these people have to also have lactation-specific education, and they need to meet a minimum hours requirement. However, their minimum hours need to be completed under the mentorship of one or more IBCLCs who have recertified at least once. (Pathway 3 in the current system.) These people can also do an educational program approved by IBLCE (Pathway 2), which provides the mentoring, hours, etc. all in one package, and requires somewhat fewer minimum hours, but those programs are few and far between.

Starting with those who will sit the exam in 2012, IBLCE is changing the requirements. From their information page on the upcoming changes:

IBLCE has identified eight subjects in which all first-time candidates must have completed the equivalent of one semester of higher education. These 8 higher education courses are:

* Biology
* Human Anatomy
* Human Physiology
* Infant and Child Growth and Development
* Nutrition
* Psychology or Counseling or Communication Skills
* Introduction to Research
* Sociology or Cultural Sensitivity or Cultural Anthropology

In addition, all first-time candidates must have completed continuing education in 6 subjects that health professionals typically will have studied as part of their professional training and/or are required for ongoing maintenance of their professional credentials. These 6 additional general education subjects are:

* Basic life support (e.g. CPR)
* Medical documentation
* Medical terminology
* Occupational safety, including security, for health professionals
* Professional ethics for health professionals (e.g. Code of Ethics)
* Universal safety precautions and infection control

The discussions I've seen online have covered a range of reactions. A lot of people are very upset about the new requirements. They argue that requiring all this essentially requires you to become an RN if you want to become an IBCLC (almost all of these are either required in nursing school or required prerequisites for nursing school). Some individuals from other countries have noted that there simply is no way for them to take these courses - they don't have community colleges or schools where you can just take a few credits here and there - unless they actually do enroll in a full-time academic program to become a nurse. Additionally, some people feel that lactation consulting is already becoming overmedicalized and is moving away from its unique roots in peer counseling, focus on empowering the mother, and in helping mothers find their own solutions vs. prescriptive "treatment", and this is accelerating that trend.

Other people are very supportive of the new requirements - even some people who came up through old, non-clinical pathways. They argue that if IBCLCs want to become respected as a clinical practice specialty, they need to have requirements that parallel other clinical degrees. MDs, RNs, OTs, PTs, etc. etc. - none of them begin practice, and most don't even begin their training, without taking basic courses in biology and anatomy, nor should they. An IBCLC who doesn't understand fundamentals of nutrition shouldn't be counseling a mother about appropriate complementary foods, and an IBCLC who can't read and communicate in medical terminology and documentation won't be respected by other clinical professionals that s/he is expected to work with.

IBLCE addressed some of these concerns directly in their FAQs page about the new requirements:

17. With these new requirements, it seems to me that IBLCE is discouraging those of us who are not health professionals from becoming IBCLCs. I know of several IBCLCs in my community who are not health professionals and they are well respected. Why has IBLCE placed so much focus on the new general education requirements?
IBLCE continues to support the long-standing practice of welcoming and encouraging practitioners, who are not health professionals, to prepare and become IBCLCs. The ability to actively listen and take the time to collaborate with mothers in developing an appropriate care plan and the dedication to supporting families beyond the early postpartum period are some of the well-developed competencies of candidates who are not health professionals.

As the lactation consultant profession has matured, it has become clear that it is necessary for all IBCLCs to be well-grounded in those subjects that are typically studied by health professionals. A strong foundation of knowledge in the health disciplines that are typically included in health profession curricula will position all IBCLCs to function as well-respected members of the maternal-child health team. In addition, employers and policy-makers will have increased confidence in the IBCLC credential. With this increased confidence in place, initiatives such as licensure, reimbursement and more jobs for IBCLCs are more likely to be successful.

22. I'm an experienced IBCLC and hold no other credential in the health professions. If I were not already certified, I would not be able to qualify for the 2012 exam without returning to school. This does not seem fair and it appears that IBLCE is discouraging non-health professionals from applying. Did the IBLCE Board take this concern into consideration before making the changes?
Yes. The IBLCE Board gave quite a bit of consideration to your particular concern. In fact, there are a number of Board and staff members who are IBCLCs that hold no other credential in the health professions. The IBLCE Board holds the mother support background in such high esteem that the IBLCE By-laws require that no less than 51% of Board members have experience in mother support leadership. In spite of concerns similar to yours being expressed, the consensus of opinion was that improving the quality of the IBCLC credential was of utmost importance. The Board voted overwhelmingly to support the changes.

I see both ways on the new requirements piece. Unfortunately there are a lot of LCs out there who don't know what they're doing. And unfortunately I don't think it has very much to do with their educational backgrounds.

The way I see it, there are bad LCs out there who have medical backgrounds and never bothered to do more than count up their contact hours with mothers/babies and study for the exam, without doing any training with other LCs to improve their skills/knowledge base. There are also bad LCs out there who don't have medical backgrounds and did their training without understanding important basics of anatomy, physiology, how to read research, etc. and who have never pushed themselves to improve their skills/knowledge. (There are also bad LCs out there who have great education/experience through whatever pathway and are just bad. There are also bad doctors, nurses, etc. etc. - being able to get through a rigorous educational program and pass a test does not, unfortunately, necessarily make you good at your profession. Sigh.)

But I believe that all the challenges these new requirements pose for IBCLCs-in-training - in the U.S. at least - have less to do with the requirements themselves, and more to do with the educational pathways available. And in the end, it all comes inevitably back to licensure and reimbursement. How? Let me explain:

It may be standard and reasonable for RNs, MDs, PTs, etc. etc. to have these courses as prerequisites or as part of their professional education. However, they are generally not expected to come up with the entirety of their professional education on their own. They have educational programs which provide at least some of their educational requirements, along with things like student loans, work-study positions, fellowships, or other structured financial assistance that helps students get through their education without having to pay for it all up-front, out-of-pocket.

This is not true of IBCLCs-in-training. Along with all of these distribution requirements, they need to pay for 90 hours of IBLCE-certified lactation education (under the old requirements 45 hours). This education - which can be conferences, online courses, in-person workshops, etc. - is not cheap. Finally, they often have to pay private IBCLCs for mentorship (if they can even find one – frequently a very challenging undertaking, one of the main reasons being that the private LC is essentially training her own competition). Understandably, mentor IBCLCs need to be compensated for the extra time and effort they put in for teaching. This is another chunk of change.

When you look at all that, you are looking at a significant amount of $$$ to become an LC. (You are also looking at the exact reason that even though becoming an LC was my dream from the moment I met one, I never did it on my own. We'll get back to this in a moment.)

There are a very small number of IBLCE approved educational courses that provide a really standardized, all-in-one education the way a medical or nursing school does: you get your clinical education and your clinical rotations in a package. If they're through an accredited institution, you might even be able to get student loans to help pay for it.

This type of program was how I managed to finally get IBCLC training, because one happened to get started at my school while I happened to be there. This is why I was so excited and honestly in awe of the fact that I was getting to become an IBCLC. Why was it so amazing to me? Why did I hold off pursuing this dream?

And this is where we get back to licensure and reimbursement. (I know this is U.S.-centric, but the U.S. has a pretty large percentage of LCs and I think that LCs face this issue to varying degrees around the world. It's also one of IBLCE's justifications for changing the requirements.) Many people who look at the new requirements have said something along the lines of "Then I might as well go ahead and become a nurse". Why would they say that if they want to become LCs? Because nurses get paid. Nurses are part of standard care in a hundred different practice settings, they are licensed, and what they do is reimbursable through insurance. This is among the reasons that non-RN IBCLCs are not generally hired by hospitals, pediatric practices, etc. and among the reasons that private practice IBCLCs have trouble making a living. (The US Lactation Consultants Association has an excellent white paper on reimbursement - particularly relevant are pages 14-15).

There was no way I could justify, to myself, sinking thousands of dollars into an education that would take years and lead to a profession that could probably never be my sole source of financial support. I most definitely couldn't justify paying out-of-pocket for all that education or figure out a way to do it without decimating my future financial health and again - for what?

I think that the solution to all of these problems - training, education, experience, or lack thereof - is to have more standardized educational programs available through accredited schools. But I imagine schools, if/when they consider offering IBCLC training programs, will have financial concerns similar to the ones I had when contemplating the certification. Will they really have enough students willing to pay the amount of money needed to sustain those programs, now that these programs are about to get a lot more expensive?

The bottom line to me: you can get people to pay for years of nursing school, med school, etc. because they know they can pay back those loans eventually, and support themselves. The same promise is not there with LC work and until it is, more and more stringent educational requirements make it harder and harder for people to get into the profession without having some other professional credential that will get them reimbursed fairly for their work. An MPH student (not an RN) asked me at the conference whether I would recommend her doing the IBCLC course next year and because the cost of it has risen so much since I took it, I honestly couldn't give her a strong "yes" unless she is willing to commit to a life of private practice. She pointed out that I have a hospital position, but I assured her that I got it basically through sheer luck and those positions are few and far between.

I get that IBLCE is aiming for that eventuality of licensure and reimbursement and that they're hoping that changing the requirements will be a step in that direction. They say as much in the FAQs:

15. These new requirements will make becoming an IBCLC even more expensive. Are the IBLCE Board members concerned that the new requirements will reduce the number of applicants who are eligible to become IBCLCs?
The new requirements may result in a decreased number of exam candidates in the short term. However, the reason for making these changes is to increase the value of IBCLC certification. The IBLCE vision for the IBCLC credential is to "increase the number and improve the quality of IBCLCs."

IBLCE is the global authority in lactation consultant certification and raising the educational standards for the lactation consultant profession is crucial to the future growth and value of the IBCLC credential. While there may be a short-term drop in the number of prospective IBCLCs, the increased value of the credential will make IBCLC certification more highly desired by not only first-time candidates but also by recertifying IBCLCs.

But what’s not really acknowledged here is that a profession that was already fairly inaccessible without great financial privilege will now be almost totally inaccessible. A lot of IBCLCs have said to me, "Oh, we're so glad to see you! We see so much gray hair at LC conferences, we need young people in the profession!" But young people can't afford to go into the profession, to say nothing of other groups that may have greater financial and family struggles. I go to LC conferences and see almost all white faces. IBLCE acknowledges that fewer people may sit the exam under the new requirements, and they promise a future pay-off. But how far into the future?

So that's what I'm thinking right now. And one final slight tangent: the other thing that writing this post has made me realize really bothers me is the current requirement for practice hours for clinical professionals. I think the need for all this RN-like training especially digs at some people because those who come through non-clinical pathways train for hundreds - and, under previous pathways, sometimes thousands - of hours under experienced LCs (and paid for those hours). However, RNs get to count up hours they spend as part of their jobs - no LC supervision necessary - and then take the exam. I’m not saying this experience is not valuable, but we don’t say to nurses “Hey, you do a lot of things that are related to what doctors do – pass the medical boards and you can practice medicine!” And IBCLCs spend a lot of time talking through anxieties and emotions with their clients, but can’t just count up those hours, take an exam, and become licensed as therapists.

Let me clarify here that I am NOT saying that all, or even most, RN IBCLCs are unqualified! I have gotten my training almost exclusively from RN IBCLCs who I respect profoundly and are fantastic LCs. Several of them have, however, told me how lucky I am to be able to mentor with LCs because when they got their certification they had never worked with another LC and had to learn on their own a lot of what they're teaching me now. To my mind, if non-clinical professionals are now being asked to spend time and money getting the coursework that the clinical people already have, the clinical professionals should be required to spend the time and money on finding and using direct LC mentorship. I think that would be at least as big a step towards improving the quality of the profession as these new requirements.

And that's my more-than-two-cents! Other thoughts out there? Especially from prospective IBCLCs?

Breastfeeding and Feminism, Day 2 (...2 weeks later)

2011-03-24T02:00:00.001-04:00

My Lent resolution has apparently not yet translated into more posting! A few factors have contributed to that, among them my new full-time job(!) I have gone from per diem at the hospital working 24ish hours a week, to full-time working 36 hours a week (three 12-hour night shifts). Going from working 8-hour shifts to 12-hour shifts is a surprisingly big adjustment (although fortunately not as big an adjustment as beginning to work nights was.) There are drawbacks to my new schedule (less flexibility, losing several evenings, etc.) but the benefits are, well, the benefits! Apart from my grad school assistantships, I haven't had a job with health insurance since I was in AmeriCorps. I am looking forward to having good health insurance, along with retirement benefits. One of my goals in going to grad school was to finally get a "real" job with salary + benefits, and while it didn't happen in exactly the field I expected it to, I couldn't be more pleased (except for the part where I work nights. Hopefully someday I'll work days again!)

Now that I've made my excuses, long-delayed highlights from the second day of the Breastfeeding & Feminism conference:

* Possibly my favorite presentation of the day was Robbie Davis-Floyd's report on the International MotherBaby Childbirth Initiative. Based on the Baby-Friendly initiative, the IMBCI has outlined 10 Steps to optimal motherbaby maternity services, developed with the input of organizations around the world. Steps include treating every woman with respect and dignity, offering continuous labor support, providing evidence-based practices, and providing access to emergency OB care. Three sites have applied and been accepted to become demonstration sites, one each in Austria, Brazil, and Quebec, Canada. You can read more about the (very diverse!) demonstration sites here. She discussed more about the sites and more details of their applications. She also talked about sites that will be added soon, in South Africa, Mozambique, India, and - amazingly - the largest maternity hospital in the Philippines, which does 22,000 births a year (I cannot even imagine). It's inspirational to see institutions from countries with different levels of development and each with their own unique strengths and challenges, working on the aim of improving maternity care. I am so excited to see ow the demonstration projects go.

* Michelle Lauria, an OB-GYN from Dartmouth, gave a great talk on reducing late preterm birth, a project of the Northern New England Perinatal Quality Improvement Network. She also talked about eliminating elective inductions before 39 weeks, and in mothers who do not have a high enough Bishop's score. She said the key is to put power in the hands of the nursing staff with the hospital authorities backing them up; the doctors know if they send someone in for an induction who does not meet the guidelines, the charge nurse will send them right back home. She talked about the next step being setting stricter guidelines on ways that some doctors use to get around the restrictions; she gave the example of mildly elevated blood pressures without proteinuria being called pre-eclampsia and used as a reason to induce early.

She also discussed VBAC at some length. Her take on it was, in her region, it's all about the money - as in, medical malpractice insurance costs. In northern New England, which has a lot of isolated rural communities, she gave an example of a small regional hospital that wants to offer VBACs but would have to pay $120,000 more in malpractice insurance to do so. Given that they anticipate 2 VBACs a year, they would end up paying an extra $60,000 per VBAC. Her proposed solutions are both governmental: either medical malpractice reform of some kind, or for the government to coordinate regional VBAC centers. There would be one hospital in each region designated as the VBAC center, and all the other maternity hospitals would contribute towards the VBAC center's additional malpractice insurance. She considers this unrealistic without government intervention because of the nature of competition between hospitals.

* Beverly Rossman from Rush in Chicago did a very inspiring presentation on breastfeeding peer counselors in the NICU. The NICU breastfeeding peer counselors are truly peers - they are women who have personal breastfeeding experience with very low birthweight (VLBW) babies. She summarized some themes from qualitative interviews from mothers who worked with the peer counselors: instrumental support, emotional support, finding hope, empowerment, community, and emulation. Over and over again the interviewees talked about how much they identified with the peer counselors, how much hope they drew from seeing mothers who had been in their situation, and how important the emotional support was. It left me wanting a breastfeeding peer counselor program in our NICU so badly! (If you'd like to learn more and you have access to the Journal of Human Lactation, you can check out their journal article. Citation: Rossman, Meier, Engstrom, Verheed, Norr & Hill. "They've Walked in My Shoes": Mothers of Very Low Birth Weight Infants and Their Experiences with Breastfeeding Peer Counselors in the Neonatal Intensive Care Unit. JHL. 2011. 27(1):14-24.)

It was a great conferences with some great conversation! It was hard to choose between the CIMS and the BF & Feminism tracks sometimes because there was so much interesting stuff going on, but I'm glad they combined the conferences for the opportunity to pick and choose from both programs.

Sadly, I won't be able to go to the CLPP Reproductive Justice conference this year. Please, everyone who's going tell me all about it! I am determined to go next year.

Breastfeeding & Feminism: Day 1

2011-03-11T20:10:00.004-05:00

I really need to take more notes at these things! So here are a few notes pulled out of my very scattered information overloaded brain:

- Eugene Declercq gave a great keynote on statistical trends in C-sections, VBAC, and other birth-related stuff. One of the most interesting sections was on homebirth. Still very tiny numbers, so hard to identify a definite overall upward trend, but it seems to be on the rise. He then broke the trends out by race, and that was fascinating: homebirth rates were the same or dropping for all races except for white women, who are clearly seeing an uptick. He reports that in the latest stats, 1% of all births to white women happened at home. That seemed high to me, but apparently that's what the statistics are telling us. I am not at all surprised, however, by the disparity.

- Bettina Lauf Forbes and Danielle Rigg of Best for Babes spoke about reframing breastfeeding, including how much they dislike the phrase "protect, promote, and support breastfeeding" - they want to replace it with "inspire, prepare, and empower moms". They really have a marketing mindset of helping introduce moms to breastfeeding via common consumer culture avenues like celebrity profiles, then help educate them on avoiding the "booby traps". As they pointed out, we have very high BF intention rates - we need to help moms achieve their personal goals!

- Keren Epstein-Gilboa, who came all the way from Canada, gave a really dynamic talk on breastfeeding and envy. She first had us imagine something that we really, really wanted - a job, a person, a house, whatever - and say how it made us felt. (Great!) Then we had to think about how we couldn't have it - and how that made us feel. (Well, pretty crappy.) Now how did we feel about that thing, and the person who had that thing instead of us? We often tell ourselves we didn't want it anyway, or that it really isn't that great, or we try to break it into parts. She used that introduction to discuss her research on the relationship of fathers to breastfeeding, and how different societies treat mothers and by extension how they treat breastfeeding, and also what it means for women who try to breastfeeding and aren't able to. I only wish she'd had more than 15 minutes!

That's all for now - I've got to start recharging my brain for tomorrow...

Upcoming plans

2011-03-09T23:37:00.004-05:00

So last year, I gave up Facebook for Lent, deciding I was letting it suck too much of my time. It was a surprisingly scary thing to do at the beginning! I really, honestly found myself getting kind of anxious when the time came to log out for the last time. And then...yeah, it was totally fine. I kind of forgot it existed, and when the time came for me to get back on I would go days before remembering to log in again. It was nice!

Of course, since then my usage has crept up again and realizing Lent was coming up, I thought about it and decided to take another Facebook break this year. Along with an even scarier one... blog reading. I do love Google Reader... maybe a little too much. I find myself spending hours consuming and clicking and reading and thinking, which is all well and good, but can spiral into way too much time, and in the meantime I'll "star" a dozen more to go back and read in more depth, or as inspiration for a post of my own, etcetera and those just pile up. The productivity scale goes way down the farther I get sucked in. You all know how it is, right? This just seemed like a good opportunity to give it a break and see what else I can do with that time.

So if I'm a regular commenter on your blog and am quiet for the next, oh, 40 days or so - you have your explanation! And while I am giving up blog reading, I'm not giving up blog writing and in fact hoping that this break gives me more time to work on posts I've been letting sit for a long time. Hopefully you'll see a little more content here!

In non-Internet-related news (although hopefully a post-generating activity) I will be going to the Breastfeeding and Feminism/CIMS conference this Friday and Saturday. Very excited! Anyone else planning to go?

I am still thinking about attending the CLPP Reproductive Justice conference in April. I am really hoping to be able to go. I can't say enough good things about this conference - each time I've gone has been a fantastic experience. If I make it, I'll definitely be posting here about it!

That's all for tonight...just posted my Facebook farewell and am ready to begin my Internet fast!

"I would juggle speculums if they asked"

2011-03-05T04:40:00.003-05:00

Do yourself a favor and read this long, funny, and compelling article by an abortion-provider-in-training. Some of my favorite excerpts:

It all breaks down to this: no one is immune to mistakes, whether it’s a mistake of their own making or (more likely) an end effect of the system, especially our fucked-up broken medical system I hate representing. (Sorry, system! Had to say it.) If you think I am making too many excuses for my patients, I will let you know that I am often one of the first people to make excuses for them in their lives and am happy to do so for no fee whatsoever. I would juggle speculums if they asked. I have not yet been asked to do this.

...

Up until recently I’d come out of any closet I found myself in — queer, non-monogamous, I fucking love Tool still, whatever — not that I live to hear the drink-choking sound, but because, to me, coming out was just one of the ways I could pay back the privileges that had been arbitrarily bestowed upon me (educated! white-appearing! “normal!”). My responsibility to normalize as much as I could. But training as an abortion provider is the first thing in my life that I hold back on spilling about. At the core of it, there’s a huge gap between saying “I had one” and saying “I do them.” I don’t want to alienate people. And nothing else I’ve ever done or been has felt like a direct invitation to a motivated someone out there to kill me and get away with it.

...

I speak of my abortion as a positive experience, not to secure the “most awesome abortion” prize (hello judges…?) but to save a seat for the possibility that this doesn’t have to be the worst thing that ever happened to you in your whole life. I don’t want it to in any way represent anyone else’s experience or make them feel disavowed of their own. So let me say: this is my personal experience with abortion! It was positive in every respect. It made me want to help other people also have as positive an experience as possible, so I went into the business. If you think that’s a bullshit line, or it makes you uncomfortable to think about abortion as something that could possibly be positive for a person, think of why you're a person who doesn't want someone to do the best that they can under the circumstances they're in.

If you read the whole thing, you'll learn about how she handles pro-life patients who come for abortions, her interaction with a female soldier who had to fly back from Afghanistan for an abortion, and her reflections on the distinction the law makes between MDs and advanced nurse-practitioners, just for this one fairly simple procedure. I am blown away by her compassion and courage. Please read it!

I found this post through my friend Melissa's new blog in the Feministing community. Melissa comments:

Approaching reproductive justice from a position of love and respect for women means that we recognize the varied experiences women have. Certainly, abortion is a difficult and even harrowing choice for some. But for others, abortion is a positive move forward on their journey to being the person, the partner, or the mother they want to become. If we ignore the positive experiences of those women, we’re adding to the stigma of abortion. To put it simply, although no woman wants an abortion, not every abortion is a tragedy.

Keep an eye out for more posts by Melissa! She is awesome.

Choosing and getting into MPH programs: Part 5: Getting funded

2011-03-05T02:47:00.005-05:00

At long last, the conclusion to my MPH series! I hope it has been helpful to people out there. Here's the full list of the series:

Part 1: Should you even get an MPH?
Part 2: What is a Master's in Public Health, anyway?
Part 3: Which MPH program(s) should you apply to?
Part 4: Getting in

So! Getting funded.

There are, as far as I can tell, the following ways to get funded for your MPH:
1) Loans (federal or private). Obviously, these are the least preferable as you will have to pay them back!
2) Grants: the school pays part of your tuition, and you are not obliged to pay them back.
3) Assistantships/fellowships/etc.: these come under several different names, but you are generally employed by the university - doing something like working on a research project, assisting professors, TAing classes - and in return get some or all of your tuition paid for. Sometimes these also come with a monthly stipend.
4) Outside fellowships/scholarships: Funding you apply for completely independently of the university
5) Tuition assistance as an employee of the university: Many schools will let employees take one free course a semester, and/or offer a discount for classes
6) Tuition assistance as an employee of a lovely, generous outside company: Some companies/organizations will pay for their employees to take classes or pursue a particular degree that is relevant to their workplace

(Does anyone have other sources to add to this list?)

So how do you sort this all out and figure out how YOU will pay for school?

Again, I'll tell you a little story to start. When I applied to schools, I basically figured nobody would offer me a full ride, and nobody would offer me zero aid at all - they would all offer me some variable amount of aid. I also figured I had relatively little control over whether or not I got said aid.

Come decision-time, I discovered that what I thought was my first choice was offering me basically nothing. They just deducted the expected family contribution from their tuition, and offered me the rest in loans. That really dampened my enthusiasm, along with a campus visit that made me realize this wasn't really the ideal program I'd thought it would be. On the heels of that realization I got an offer from another school for a full fellowship my first year, with the possibility of finding more funding my second. I then visited the school that had been my second choice, had great interactions with some faculty there, told them about my full-funding offer from the other school, and they offered me what amounted to a third of their tuition in grants - the rest I would still need to cover or take out loans for.

So, so much for my ideas that I would get all the same funding offers and had no control over the process! I basically lucked my way into a great situation, despite having started the process with a lot of misconceptions. (If you're wondering what the end of the story is - I weighed my options with no small amount of agonizing, and ended up taking the fellowship. And I've never regretted it!) So let's talk about a few things I learned:

You do have control in some situations - and if you don't, you should find out.

At What-I-Thought-Was-My-First-Choice, I talked with a faculty member, with the administrative director of the program I was applying to, and with a financial aid officer. I also talked to a student there I happened to know. Everyone told me the same thing: you can only avoid paying full price if you find a position as a full-time employee, and go to school part-time using your employee tuition remission. There were literally hundreds of applications for every posted position. I had very little control in that situation! I was not one of the people at their accepted students day still asking about how to get funding - I already knew the score.

Talk with students, administrators, and faculty realistically to get an honest assessment of whether this program could be affordable for you. Even if you don't have control, at least you'll know about it.

At Second-Choice, I had more control than I realized. By meeting with faculty and expressing my enthusiasm for their program and talking to them about my other offer, I was able to get an offer of more grants - although still not what I would have liked.

If you get competing offers, let the other schools know diplomatically, while letting them know how much you'd like to be able to attend their program.

At Where-I-Ended-Up-Going, I had way more control than I realized until I got to campus. I had a fellowship that gave me tuition remission + a stipend, but other students had assistantships that gave them the same thing, and they had come to campus to meet with faculty and network for assistantships before they were even accepted. Knowing I would need something for my second year, I did the same and my fantastic advisor helped me find an assistantship for my second year.

At our school, not everyone was promised an assistantship, and the positions weren't generally posted - your advisor might talk to somebody who had one to offer, or you might hear from a friend that she was quitting hers for a different position. Networking was a necessity! At a couple other schools I applied to, they more or less said upfront that they would help anyone who wanted an assistantship find one.

Again, talk to faculty, students, and administrators to find out how you can get funding, and network, network, network! I told everyone I talked to at the end of my first year that I was looking for funding. Don't be shy!

Continuing in the networking theme, look for funding sources outside your department. If you speak German, a TAship in the German department could get you just as much tuition remission as one in the MPH program. If your school offers employee tuition assistance, working for the admissions office full-time won't get you through school as quickly, but it could mean a lot of $$ saved.

If you'd like to try to get funding from an outside source, many schools have a listserv that lists opportunities for outside fellowships and funding you can apply for. Also keep an eye out for programs that the university administers, but come from outside sources: I could kick myself for not applying to the Foreign Language Area Studies Program.

Important consideration for public universities: It's important to find out who can be considered a resident for tuition purposes, and how to establish your residency. Some states are huge sticklers - you have to be living there for many years before you can be a resident and provide signed proof from your landlord, your great-grandmother, and God. Some are much more relaxed, with shorter terms and less proof needed. The difference between in-state and out-of-state can be huge, so investigate this carefully. (Also check to see if the new state has an education compact with your home state, where the states agree to offer in-state tuition reciprocally to each other's residents.)

Finally, be realistic about where this program will get you financially and what you're able to pay back if you'll need to take out loans. I found the NY Times article Is Law School a Losing Game?, to be great reading for anyone considering any type of graduate school. Here's an excerpt:

Compared with the life he left four years ago, he has lost ground. That research position in Newark, he figures, would pay him $60,000 a year now, with benefits. Instead, he’s vying with a crowd for jobs that pay at rates just a little higher, but that last only a few weeks at a time, with no benefits. And he’s a quarter-million dollars in the hole.

At least no MPH will put you a quarter-million dollars in debt! But let's be real: we're not in a good economy right now. Think carefully about whether graduate school will put you in a better situation - financially, career-wise, health-and-happiness-wise - before you commit to the debt it can entail. Don't just ignore a lower-cost program that you love less. I loved What-I-Thought-Was-My-First-Choice; then I loved Second-Choice; I was really unsure about Where-I-Ended-Up-Going. I finally made the decision by saying to myself, "Any school you go to, some parts of it are going to make you pissed off or seem useless or that you just hate. You might as well hate them for free." Like I said, I've never regretted that choice! (Just to clarify, I ended up liking my program just fine, but there were of course parts that drove me nuts.)

This concludes my extremely long-drawn-out series! I hope it's been helpful to people out there (and continues to be). (If you're thinking about e-mailing me with questions, please read through the whole series to see if I've already answered them.)

Best of luck with your MPH journey!

Happy IBCLC Day!

2011-03-02T18:50:00.002-05:00

Happy IBCLC Day! Since I didn't get around to be preparing a post, I'm throwing another breastfeeding-theme link party:

* Dou-la-la on loving her IBCLC, finding a good one, and why we need them.

* More about telling the real IBCLCs from the not-so-real.

* ILCA has an appreciation certificate to give to your favorite IBCLC.

* An IBCLC shares her personal story of overcoming challenges breastfeeding a baby with Kabuki syndrome.

Many mothers are talking today about how grateful they are for the IBCLCs who helped them feed their babies. I have a bit of a different take: I want to reiterate my gratitude for the IBCLCs who are stepping up to help train the next generation -- especially the ones who inspired and trained me, and continue to teach me every time I work with them. Without them, I could never have achieved my dream and I am so grateful!

Congresswomen speak out

2011-02-28T01:35:00.003-05:00

In the debate over defunding Planned Parenthood, two Congresswomen have taken the floor to share personal experiences in a way I found very moving.

First there was Rep. Jackie Speier. Rep. Chris Smith, a Republic from New Jersey, took the floor to read aloud a description of a second-trimester abortion procedure. Rep. Speier stood up immediately after he spoke.

"I really planned to speak about something else. But the gentleman from New Jersey just put my stomach in knots. Because I'm one of those women he spoke about just now."

Rep. Speier:

Brave, honest, amazing.

Then there was Rep. Gwen Moore. From Salon's summary:

[L]ate Thursday night, Georgia Republican Rep. Paul Broun had trotted out the old canard about Planned Parenthood being a bunch of eugenically motivated abortion enthusiasts, pointing out that "there are more black babies killed through abortion proportionally than there are white babies or any other colored babies."

Responding to Broun's deep concern for the well-being of black babies (a concern that apparently ends when those black babies grow up to need breast exams or cervical screenings) Wisconsin Democrat Gwen Moore said, "I know a lot about having black babies. I’ve had three of them. And I had my first one ... at the ripe old age of 18.
An unplanned pregnancy."

Rep. Moore:

These are not men talking about lives, decisions, and responsibilities that will never ever be theirs. These are women baring difficult parts of their lives to bring some honesty and reality to the discussion. Thank you Congresswomen - for being our voices of women's real, lived experiences in the U.S. Congress, and for standing up for everyone's access to affordable care.

I still hate directed pushing

2011-02-28T00:47:00.003-05:00

Navelgazing Midwife has a great post up about doula-ing the birth of a woman with epilepsy. I think it's a very educational post for doulas, touching on aspects of working with women with chronic medical conditions, women who are not opposed to intervention, and women with very interesting ways of coping with their contractions!

My attention was caught by another illustration of one of my pet peeves, directed pushing:

Now it was time to push. Now that the stage was set for everyone else. Never mind she’d been pushing for a few minutes already. And the head had come down fantastically without any coaching whatsoever. No, now she needed direction and education. Really? Let the cheerleading begin.

When I talked to my client afterwards, she said she was only focused on the doctor, her husband and me, so she was protected from the chaotic yelling at her to push. The woman had a ten minute second stage. And it took three minutes for the baby to be born from the time we first saw her head. Yet, every nurse there, as well as the doctor kept trying to tell her how to push. I’m serious.

“Take a deep breath. Let it out. Take a deep breath. And push, counting to ten.”

Are you kidding me? The woman coughs and a quarter of the head gooshes out!

“No, not like that. You’re wasting your energy.”

I couldn’t believe the surreality of the situation; it was so absurd I really could barely accept they were instructing her this way. I kept whispering to her, “You’re doing great. Exactly like that. Yes… you’re doing great.” She told me that’s all she heard. Thank goodness the cacophony of shrieking nurses remained in the background of this mama’s perception.

I wrote about this in my post on how much I hate directed pushing:

Everything goes great until pushing and then BAM, all of a sudden we're back to the worst of the medicalized model. The second a woman is judged to be "complete", everyone in the room suddenly gets license to, quite frankly, be a total jerk to her. Before she has pushed even once, there is the presumption that she is going to push "wrong". She is never even given a chance to try pushing in different positions or for a few contractions to get the hang of it. Instead, the nurse spells out the position she should assume (chin to chest, pulling back on her thighs, on her back? but of course!), support people are given her legs to hold, and she gets the 3-pushes-per-contraction speech. Then from the first push she is loudly coached, counted off, and urged on MORE MORE MORE KEEP GOING PUSH HARDER HARDER HARDER and that's about when I start grinding my teeth.

In comparison, what happened at the homebirth I attended this month?

As the mom hit transition, she started to make sounds that the midwives and I recognized as "pushiness". The midwife just talked quietly to the mom about how she was moving through transition, acknowledged this was a very intense time, and reassured her. Once mom finished transition and instinctively began to push (there was one cervical check not long before she hit 10 centimeters to check progress, but there was no check to ritually declare her complete) the midwife again quietly spoke to her and encouraged her to let the baby push down with contractions, and let her body be the guide about when she should begin to actively push. That's exactly what she did, pushing in short bursts at first, and then longer as she felt increasing pressure. She started on her side in bed, then got up on her hands and knees. The midwives watched her and would let her know when they saw a very effective push, giving her nothing but gentle praise and encouragement. As the baby began to crown, the midwife again quietly told her to listen carefully as the head emerged, because the midwife might tell her to slow down or breathe through a contraction (although baby came barreling out so quickly I'm not sure the midwife got a chance to get a word in edgewise!)

End result: a good-sized baby born to a first-time mom in almost exactly an hour of pushing. This result achieved with no need for yelling, cheerleading, counting, special magical pushing positions, or other forms of, as NGM so aptly puts it, this "odd ritual".

Just say no to the pushing police!

Tips on studying for the IBCLC exam

2011-02-24T17:37:00.001-05:00

I wrote down all my studying methods and resources just after I took the LC exam, but was superstitiously unwilling to post anything until I knew I passed. (Plus, who knew if it was good study advice or not??)

It's now a long time since I found out that I had passed, but I'm trying to work through my backlog of half-finished posts and realized that this one has just been sitting forgotten for months! I did my best to finish it up with what I still remember about my studying. So if you're preparing for the IBCLC exam, here are my study suggestions:

Books:
Breastfeeding and Human Lactation (4th ed), by Jan Riordan and Karen Wambach
and the 4th edition study guide/CD-ROM

This book is excellent. I like the arrangement and division of the chapters, the clear writing, the in-text research citations (so you can see what the most recent support literature is) and the overall comprehensiveness. The accompanying practice tests are also good. The CD-ROM has one for each chapter, so you can study a chapter and quiz yourself, or take the tests beforehand and find out where your weaknesses are.

My main complaint about the book is that, I think because there are different contributors to different chapters, it sometimes contradicts itself. The tests sometimes contradict each other as well. That makes it hard to figure out what the "right" answer is, especially in situations where there probably isn't one "right" answer, but people are still trying to set a general guideline or recommendation and aren't setting the same one.

In general though, almost everyone seems to use Riordan to study. I wish we'd had this for our LC class textbook, and the current year's class is using it. If I had it to do over, I'd have started studying this chapter-by-chapter a lot earlier so I could have really drilled in each subject.

Core Curriculum for Lactation Consultant Practice, edited by Rebecca Mannel, Patricia J. Martens, and Marsha Walker, published by the International Lactation Consultant Association (ILCA).

This book is set up in an "outline" format that makes it easy to quickly move through information and get the clean, simple facts. I found that if I read the Riordan + this book for each topic that I focused on, I felt like I was on solid ground: two different takes on the same information by leaders of the field. I will definitely use this book in my practice as a guide and reference.

My main complaint with this book is, again, contradictions! Understandable in a field that still has a relatively small research base, but it is frustrating to have chapters contradict each other. It's also a little harder to study from as the blueprint for the IBCLC exam doesn't match up with the chapters - they have an outline for which chapters go with which parts of the blueprint, but it will be a little bit each from chapters 5, 6, 8, 14, 20, and 21, and you have to find them. So it's good if you're looking to find a specific set of information (for example, cranial nerves) but to get an overview of all of anatomy & physiology you're doing a lot of skipping around.

Comprehensive Lactation Consult Exam Review, by Linda Smith

I borrowed this book and the paper tests were already all marked up, so I just used the two full-length tests on the CD-ROM. Many people told me that the tests were helpful in that they were harder than the real test; in practice, I found that they were about AS hard as the real test (or at least they felt that way). I no longer remember what my main complaints, if any, were about this book, although I'm sure I had at least a couple!

Other practice:

Health e-Learning practice tests: A lot of people seem to sign up for these online, with the added benefit that you also get access to their forums to discuss the topics and the answers. I liked that they had photos; since the photo-based part of the exam has increased, I felt like it was important to get practice with that.

Flashcards: I used the old-fashioned index card method, but I just got an Android-based smartphone and came across a flashcard app called "AnkiDroid" that I think would have been helpful. You can make your own deck (also share decks and download other people's), and it will automatically bring hard cards up more frequently, and push ones that you've mastered to be less and less frequent. (Also, it's harder to drop all over the floor and spend a long time picking up and putting back in order.)

General sharing and support:

- The IBCLC2B Yahoo group was worth joining for asking questions and sharing study advice
- Studying in a group with other people planning to take the exam was good for keeping us all on track. For a while we had one person assigned to make a study guide for each part of the exam blueprint, then that kind of fell apart. After that, we would generally assign a chapter or topic, then quiz each other on it. We also took practice exams together and discussed the options.
- The main piece of advice that I got from experienced exam takers was that an answer involving advanced technology is rarely the right one, because this is an international exam meant for people in societies with various levels of technology. If one of the answers to a question is "Get the mother a double electric pump", it's probably not the right answer. I was also advised not to overthink the questions... don't get caught up into thinking "Well, but it doesn't say how many weeks gestation this baby was born at, and if it was X then I would answer Y..." Just use the information you're given to pick the best answer.

If you're planning to take the exam, good luck! I found it challenging but not so hard as to be terrifying. Start studying early and you'll feel much better when exam day arrives!

Please stand with Planned Parenthood

2011-02-19T00:28:00.004-05:00

I am sickened by the nakedly ideological attack by the Republican party on Planned Parenthood.

I cannot count the number of friends I know who have used Planned Parenthood as their ONLY affordable, accessible resource for gynecological care, birth control, STI testing, emergency contraception, and yes, also abortion. Those are services that save women's lives, and allow them to protect their current health and protect their future fertility. Regardless of what anyone may think of Planned Parenthood's provision of abortion services (a LEGAL service for which they use NO federal money, and to which all of 3% of their total funds go) the Republicans are attempting to defund a major source of Americans' access to primary health care. Not just reproductive health care - primary health care, period. For many people - especially women - Planned Parenthood is their primary care provider: they have nowhere else to go.

There is a conception by conservatives I have spoken to that Planned Parenthood pushes abortions and promiscuous sex (via "pushing" birth control?) and relies on somehow manipulating their consumers into these choices, all to make a profit (I guess the fact that they are a non-profit organization is just a minor detail.)

I knew someone exposed to this propaganda who was shocked - shocked - when she met a nurse who worked at Planned Parenthood and found out that this nurse was a normal, nice person who cared about mothers and babies. It was so completely different from the idea of Planned Parenthood that had been marketed to her by conservative religious organizations. It is an idea that is so ludicrous and at odds with my experiences and those of everyone I know who has used Planned Parenthood's services, or worked for their organization.

It's disgusting and disturbing, a ridiculous foundation for legislation, and I cannot imagine where millions of Americans will turn for these services if Planned Parenthood loses their federal funding.

Please stand with me in standing with Planned Parenthood and sign this petition now. Please share it with your friends on your blog, on Facebook, and/or via e-mail.

And please watch this video of a brave and honest woman sharing her personal experience, on the House floor:

How much are spending cuts really cutting, and what would we lose?

2011-02-10T21:58:00.004-05:00

Sociological Images has a nice breakdown of Republicans' proposed spending cuts. Check out the post for a full discussion, but here is a helpful graphic:

So, in cutting 4/10s of 1 percent from the budget, what do we lose? Proposed cuts of over $1 billion to community health centers and the National Institutes of Health, among others. Oh, and let's not forget cutting the entire Title X family planning program. And $758 million from WIC.

I am so sick of the hypocrisy. This money spent on health and prevention prevents us from needing to spend much bigger sums elsewhere in the budget. Slash it, and watch other expenses rise. Or refuse to pay those expenses either, and let a huge swath of America suffer. Just to score political points ("we're not funding that horrible Planned Parenthood anymore!") for what amounts to a miniscule amount of total expenditures and doing very little towards deficit reduction.

My first homebirth as a doula

2011-02-09T23:17:00.005-05:00

Yesterday I was privileged to attend my first homebirth as a doula! I've been to so many births, and none outside of the hospital - until now. It was such a lovely experience for me and, I think, for the family - although, like any birth, a lot of hard work for the laboring woman! And she was a rockstar!! It ended with a perfect healthy happy baby (born in the caul - another first for me!) and an amazing healthy happy new mother - the best outcomes possible.

The family and woman-centered-ness I saw in the midwives' care was so exceptional. What the midwives needed to do, they did as quietly and unobtrusively as you could imagine. Most conversation between the birth team took place in hand signals or sub-whispers. Every question and transition was explained simply, quietly, and calmly. And being a healthy, progressing labor they didn't need to do much - so they didn't. There wasn't constant pressure to monitor progress (except by observing and listening), no restrictions on movement or food or with cords and wires, and there wasn't a constant battle to fight those things off either. It was just labor, unique to that particular person, but a familiar sight.

I can't express how different in tone and attitude it felt from a hospital birth. Having experienced it, I see why some doulas have a hard time going back to hospital births after attending home births. (The only hospital birth I've been to that has ever come close is this one, which had a fortuitous constellation of a fast labor, great nurse, two doulas, and one of my favorite midwives ever, at the most mother-friendly hospital I've ever seen. And even then - just not the same.) The respect, the privacy, the autonomy, the gentle guidance, the comfort and calm and normalcy, I have never seen replicated in any hospital (although I so deeply wish they were). It was a powerful experience.

In case you can't tell, I'm still riding the lovely wave of good feeling and harmony that comes with seeing a new life come into the world. Thank you to my friends for inviting me to be present. I was honored to be there. Your new family is great and I can't wait to see this baby grow up!

Lovely Blessingway!

2011-02-07T01:30:00.000-05:00

I posted a while back about how I was planning a baby shower/Blessingway (thank you so much to readers who had suggestions or rituals of their own to share). I'm happy to report that it went off fantastically! We decided to make Blessingway portion of the shower very simple but hopefully meaningful. In the Evite we sent out to the invitees, I explained the plan (bring a bead and think of a wish/hope/thought to say for the new mom/parents) and I sent several reminders to people to bring a bead. Since the shower was for one of my fellow MCHers, we put a lot of far-flung alums on the guest list and suggested that people who couldn't attend still send a bead and a note.

Despite all the reminders, for some reason I couldn't really believe that people would actually bring a bead or take the ceremony too seriously. As the organizer, I myself ended up running over to the bead store the morning of (where I found a big lovely rainbow-striped bead). We brought some extras assuming most people would forget or not have time.

It turned out we had about 21 people attending and I think almost every one of them brought their own bead! Not only that, but we had several long-distance contributions including an MCH alum who mailed us her bead and then Skyped in live from the country of Mali to speak. As we went around and each person placed her bead on the string, I was so pleasantly amazed and touched by the heartfelt thought and wishes each one put into their little speech. Some people talked about the treasured friendship they had with the parents-to-be, others had wishes for health and happiness, others talked about why they knew the couple would be wonderful parents. There was a lot of laughter and some tears too. Each bead was so beautiful and when it was over, the necklace was so lovely with all of them placed together.

One of the things I most enjoyed about it, which I didn't really think about in advance, was the chance for a non-material focus as part of the shower. While there were many great gifts, the part that felt really special was the part where people talked about their love and hopes for the new family. It was a good reminder that while swaddling blankets and slings are needed and great, a caring community of friends is at least as important. It was really just a wonderful experience, and multiple people said it was their favorite part.

I don't think a ritual like this would work at every shower, but I hope to incorporate it into future baby-celebrations that I plan!

100% real life, as seen by doulas

2011-02-06T01:53:00.005-05:00

Gina at the Feminist Breeder posted a most excellent angry rant about the Lifetime TV show L&D reality show, "One Born Every Minute". She had some issues with the way a couple planning an unmedicated birth was portrayed in the documentary, but this is what she had to say about the medical staff's attitude towards them:

And now thankfully the show is over, and I never have to see that nonsense again. Except that I do — in real life — every time I attend a birth at a hospital with a high rate of unnecessary interventions. As a doula, I can tell you that Lifetime’s “One Born Every Minute” is 100% REAL LIFE, and the things happening on that show are absolutely representative of what’s going on in EVERY labor and delivery unit where the staff and providers do not practice evidence-based medicine or the midwifery model of care.

YES. YES YES YES.

You can read the post for a blow-by-blow of each interaction these parents have with the nurse Gina terms "Nurse Dread". In a follow-up post, Gina has a clip of one of their interactions with said nurse - or more accurately, their doula's interactions with the nurse. If you are planning to give birth in a hospital setting you suspect or know will be hostile to an unmedicated, low-intervention labor, you need to watch this:

This is what doulas want you to understand: as Gina puts it, this is 100% REAL LIFE. The nurse's tone, attitude, demeanor, were so intensely familiar to me.

This is how it is. Bleeding from a thousand passive-aggressive cuts. "I'm trying to take care of ALL of you, especially your BABY, and I can't do my job! Haha, I'm laughing, YOU'RE RISKING YOUR BABY'S LIFE. Here's the monitors laid out nicely [those are the belts she's messing with], why don't you get back in the bed now." And I guarantee you she'll be back every 10 minutes with a variation of the same speech. "You know, when you're making such slow progress, we just get very worried about the baby. We want what's best for both of you, you know that. Right?? Mommy and baby, we care about you both so much! We just really need to be able to know what's going on in order to do that." And on. And on. And ON.

This is not because the nurses are evil horrible people bent on ruining birth. I bet this nurse is a wonderful person and takes excellent care of her patients. But she is made so profoundly uncomfortable by a labor that goes off her standard script that she cannot handle the situation respectfully or gracefully. She is constantly trying to nudge it back to what she's used to seeing, so she can get back on-script and go on with her life.

And this is why you need a doula. In this clip, the the parents aren't even seen; the doula's the one to deal with the aggro, then go in to communicate the situation to the parents (and probably discuss with them how to negotiate the next steps). Listen to how the doula is working to defuse the situation, acknowledging the nurse's concerns, reminding her the parents' priority is a healthy baby, and offering her some alternative ways to think about the situation ("people have different pathways"). The mother portrayed talks in an interview with Gina about how the doula was, in fact, the person handling most of the stressful interactions with the nurse:

[talking about her disappointment with the way the show handled things]:

I wish two things: 1. that they’d portrayed our doula in a better light. She was incredibly supportive, and had to field the majority of our conflict with Pam. AND, she did everything on zero sleep, since she came directly from another long birth, and 2. that they hadn’t insinuated that Eleanor was in trouble, and that we were putting her at risk. Every time we were on the monitor (which was 20 minutes of every hour), she was tolerating perfectly well, and even when we were pushing, her heartrate stayed up. There was never any danger.

From now on, whenever I'm trying to explain to someone why it's important to have a doula when you're planning an unmedicated and/or low-intervention birth, I'm going to point them to this show. You need someone between you and those negative attitudes to absorb as much as possible for you, and to keep the comments that do hit home from sapping you of your confidence and energy. Please, please, don't try to do it alone - find someone who can help protect you, and keep you feeling in control and confident, no matter how things go.

The doula's first-time mama advice kit

2011-02-03T23:36:00.009-05:00

Just about everyone who knows me knows I like to talk. Very quickly they generally find out that I am especially talkative on some of my favorite subjects of birth and breastfeeding. (I am so proud of myself last month that I went to a New Year's Eve party and only ended up talking about breastfeeding once, and very briefly at that!)

So when friends and acquaintances get pregnant, they often come to me for advice. (Sometimes I hear in their voice a kind of loving "OK, know-it-all, NOW you can tell me" tone!)

While I always try to tailor my advice to their specific questions (in part so as not to overwhelm them!) I do find myself answering similar questions and requests more than once. I've been thinking about putting together a set of the links, books, and resources I recommend to the newly pregnant woman (as opposed to the packets of info and resources I put together for my doula clients). That way I won't forget anything and will have it all conveniently in one place, so I can answer specific questions and then say "If you want more information, here's the link".

Here's a preliminary set of the info I'd give to a newly pregnant woman:

Suggested for everyone before they do anything else

The very first thing to do - before ANYTHING else - is read my post on What I Want My Friends to Know.

Next, unless said friend has put up with a lot of my rants or been following my blog for a long time (hi guys! hope you have been!), it's time to start researching options for birth.

So secondly, watch The Business of Being Born (also available on instant view from Netflix). Seriously, this is the first thing I think any pregnant woman and her family can do to help them understand the lay of the land in the U.S. right now, birth-wise.

(Reading "Pushed" by Jennifer Block is also great but not as easy as sitting down to a (very well-made) movie for a couple hours.)

Choosing a care provider and birth setting:

Often the first care provider someone goes to after finding out about the pregnancy (or to confirm pregnancy) is the person's regular GYN provider. That may be a gynecologist, an ob/gyn, a nurse practitioner, a family practice doc, a midwife, etc. If that provider offers obstetric services, the woman may begin her prenatal care with that provider, but wonder if she should investigate other options. If that provider does not offer obstetric care, she'll definitely be looking for a place to get prenatal care and deliver (since the two generally go hand in hand). So people frequently talk to me about how to go about researching and choosing a provider and birth setting.

What I say is that when looking for a care provider and birth setting, it's important that they match YOUR philosophy and what YOU want out of your birth experience... which can be hard to formulate when you're all of 5 weeks pregnant and have never thought about this before! So it's OK to establish care with someone knowing you might switch later.

In the meantime, gather your information and investigate your options carefully.

Why it's important to investigate and choose carefully

The First Birth - No Do-Overs Currently Available - just found this via Birth at Home in Arizona and love it. Make sure to read the comments as well.

You buy the hospital ticket, you go for the hospital ride by Navelgazing Midwife is an honest assessment of why it's so important to look very closely and be realistic about whether a particular birth setting will be right for you.

Information to gather and questions to ask about a care provider/setting

Their state's hospitals' c-section rates if available, from The Unnecesarean.

From Childbirth Connection:
Choosing a caregiver
Questions to ask a health care provider
Choosing a place of birth
Tips and tools for choosing a place of birth

From Birth Sense:
In Search of Dr. Right: 11 Questions to Ask and One More Question to Ask

Considering a home birth? Here are some links for thought specifically to help you interview potential homebirth midwives:

A short discussion and links about the fact that all midwives practice differently, and you will still need to find someone who has the right practice style for you.

From Navelgazing Midwife, advice on interviewing homebirth midwives: Part 1, Part 2, Part 3, Part 4, Part 5. (Note that the series is not complete - check back on her website for updates, and I will do my best to update this page when the rest is posted.) A commentary she wrote while posting the series is here

My biggest piece of advice is to find experienced local doulas and talk to them about your options. They will know not just what local maternity care providers say they will do, but also what they actually do, which can help avoid the problem of the doctor or midwife who seems lovely and then becomes a totally different personality in the delivery room, or claims they practice one way and end up doing something very different. If you aren't ready to commit to hiring a doula or a specific doula, I think most doulas would be open to meeting with you for an hour or two, with the offer of compensation for their time based on the understanding that you may not hire them for the birth. (Doulas understandably feel poorly used when people act like they're going to hire them, spend a long time "interviewing" them while getting lots of advice/information/resources with no compensation, then never call again.)

If I know you personally, I'll usually get on a doula forum or two and ask for local suggestions from the doulas there - so hit me up!

Finally, go into this keeping an open mind. You may think you've found Dr. Right and then when you finish your birthing class at 32 weeks, realize that person is not the right fit for you. That's OK; there is still time to switch. Please don't fall into the trap of thinking that you can't switch after some magic number of weeks! Every doula can tell you the story of the client who switched at [34 weeks, 37 weeks, 41 weeks, in early labor, in active labor, etc.] It's only too late to switch after you've had the baby... and are regretting not switching before.

Here are the instructions for how to switch if you need them.

I'm not done talking about switching care providers, because I can hear people saying "I know I COULD switch, but it just seems too complicated/confusing/difficult/scary... I don't love this person, so I think maybe for my NEXT birth I will choose someone different/a home birth/a new hospital/etc." Do you hear yourself saying that? Stop and go back and read The First Birth - No Do-Overs Currently Available.

Now read the Unnecesarean's post of mothers who did (and didn't) make the switch.

Have you done those two things? Go and do them right now. Okay, REALLY done them now?

Then one more thing to remember: you may never have as many options as you do now - carrying scars, emotional or physical, from your first birth may impact your second in ways you may find hard to think about right now. Do not make excuses for care that does not live up to what you know you want and need! Do not put yourself and your needs off into the future - address them now in whatever ways you deserve.

Books

Along with advice about bras, probably the most frequently asked question - what to read?

Standard warning: NOT "What to Expect When You're Expecting". 'Nuff said.

My favorite suggestion lists for books: What Not to Read, from Bellies and Babies. Along with each book she thinks women should avoid, she has 3 suggestions for better books on that topic.

Childbirth classes

I can't emphasize enough not taking the hospital classes. No matter how great the teacher is or how much freedom she seems to have - she is limited by hospital policy and you cannot be sure exactly what those limitations are.

An independent childbirth class with at least 5-6 sessions is a far better choice. Research a little bit about the philosophy of instructor and the class before signing up - there are many options (e.g. Bradley, Hypnobirthing, Hypnobabies, Lamaze, etc.) This post at Bellies and Babieshas a nice overview of the most common/popular childbirth ed programs.

If you live in an isolated area and can't find local classes, some independent instructors offer DVDs of their classes, and Hypnobabies has a full home study kit.

I have heard several childbirth educators recently saying plaintively that parents are looking for a small number of sessions, or preferring weekend workshops with a lot of information packed into 1-2 long days. I agree with them that it's very challenging to get all the information you need AND (more important) absorb and process it with these kinds of classes. If that's all you can do, go for it - but really try to make the time for something with a slower, calmer pace.

If you have trouble finding affordable birthing classes, ask around for childbirth educators in training, and talk to your local health department and/or community health center - they sometimes offer low-cost options.

Bras

By far one of my most frequently asked questions. Fortunately I wrote a series on this!

Breastfeeding

I recommend, if the mom feels comfortable, going to a couple La Leche League meetings while pregnant. They are a great place to see other women breastfeeding, hearing their questions, and getting advice. And they're free!

You might also think about taking a breastfeeding class. Oftentimes local maternity stores, hospitals, private lactation consultants, etc. will offer them. I currently teach one at a local yoga/wellness studio. No matter who teaches it, you can almost always look forward to practicing latch and position with baby dolls!

Rixa at Stand and Deliver has some excellent suggestions on A Proactive Approach to Breastfeeding.

You'll see a note from me in the comments encouraging confidence. Many of my friends ask me tentatively "How often do women have problems nursing?" or "What percentage of women can't make enough milk?" These are normal concerns coming from a culture where so many women seem to struggle with latch and supply. These are real issues, many stemming from institutional and systemic factors like birthing practices and hospital policies (see more at Rixa's post). But the biggest predictor of breastfeeding success is confidence, and the perseverance to overcome whatever challenges arise.

(And again, if we know each other you know you can call me any time about any breastfeeding question! Seriously. Any time. I have a bizarre sleep schedule anyway.)

**

Phew! That's all I have for now. Readers, what would you add to this list? What are your first recommendations for a newly pregnant mom?

Breastfeeding and Down syndrome

2011-01-29T14:56:00.005-05:00

About a month ago I worked with a baby with Down syndrome in the hospital for the first time. The family knew about baby's diagnosis in advance, and were prepared for the idea that nursing might not go quite as smoothly as with their other babies. While like many Down syndrome babies, this one appeared to have some low muscle tone, in the course of a single night we were able to transition him from finger feeding to breastfeeding with a shield to breastfeeding with no devices. It's likely that wasn't the end of their nursing story/challenges - I don't know because they were discharged the next day, and planned to follow up with LCs closer to their home - but it was really nice to see this baby getting off to a great start despite early concerns.

The Down Syndrome Pregnancy organization provides resources and support to families who have received a prenatal diagnosis of Down syndrome, and has a book called "Diagnosis to Delivery". According to their blog, the book has a whole chapter on breastfeeding, and they ask for additional stories from moms who worked on breastfeeding their babies with Down syndrome. The comments are a sampling of a huge range of experiences...from easy breastfeeding relationships, to challenges overcome both at the beginning and as breastfeeding progresses, to very significant issues that disrupted the breastfeeding relationship the mom hoped for and still grieves. There were also challenges common, although not unique, to Down syndrome infants, like cardiac concerns, prolonged NICU stays, and milk transfer/milk supply/weight gain concerns. Some excerpts:

At 3 months, she seemed to be less and less satisfied and my milk supply seemed to be going down. I did breast compressions but she then seemed to be sucking less hard and it was a downward spiral. At 4 months, I decided to supplement formula once a day.

I was then able to be prescribed Domperidone (not in USA)to improve my milk supply so at 5 months we were back to exclusive bf again and I was able to relax. She is now 6 months now, feeding great, and starting other foods.

*

Once she was out of the hospital, I worked on nursing again. It wasn’t going well, so I called in a lactation consultant and she got us on the right track. We used a shield for a while so Amélie could latch on and control the flow. As her strength grew, she weaned herself off the shield. I ended up nursing her for about 21 months.

*

I pumped and pumped and put her on the breast as much as I could and I still produced almost nothing. I fed her what little came out with a bottle.
On day 10 (at home) I was beyond frustrated and teary. My husband found Kellymom.com (a godsend!!) and learned about “nurse ins” — basically you get into bed, have lots of skin to skin contact with your baby and nurse and nurse and nurse for a whole weekend to get a relationship established. It was hard, but it worked! We literally didn’t leave the bed – I even got served meals there. After 2.5 days, Emlyn “got it” and my body kicked in and we nursed like champs.

*

I pumped for her and she was tube fed. I still put her on the breast but the nurses convinced me that it wouldn’t work. I continued pumping for 6 months and kept tube feeding her at home with calories added.

I thought that after her heart surgery she might breastfeed but she never did. I was very upset and felt like a failure but the truth was that she got breastmilk for 6 months anyway.

I still think that if I had persevered she may have taken to it down the track. She is 5 now and wonderfully healthy and active so really it is just me second guessing my decision.

*

She had an ASD and also couldn’t get her blood oxygen up. She wouldn’t nurse so on Day 3 we made the decision with her medical team to put her on a nasal feeding tube. I started pumping immediately and kept trying to nurse, but she just wouldn’t latch on and my anxiety and blood pressure went through the roof. Having nursed my older children successfully, I was very upset. She was able to get off the feeding tube by her due date and come home, but still wouldn’t nurse. So I pumped and gave her bottles eventually supplementing with formula for 6 months. Brigid never had a problem with food or formula and has been the healthiest of my 3 kids.

*

When Calvin was 9 days post op, 4 months old, I put the bottles away and he has been nursing since! I weighed him before and after feedings to monitor his intake. He does not nurse as efficiently as my others. I have a blanket for drips and it takes a bit longer, but he is gaining weight and is happy.

*

Ethan didn’t have any problems breastfeeding at first, but when i went back to work he had trouble switching back and forth between breast and bottle. I ended up having to stop because it became very hard on him. I pumped and fed him the breast milk strictly from the bottle but then had production problems. I breastfed my other children and think this helped (knowing how to breastfeed).

Many moms mention the importance of support from family, friends, and medical providers including nurses, pediatricians, and LCs. Any mother should try to surround herself with knowledgeable support, but it is particularly important for mothers of babies with Down syndrome or any special challenges. It's easy for family or medical staff, trying to be helpful, to discourage trying to breastfeed or to suggest that some babies "just can't" or it isn't worth the trouble. But these stories show that while some challenges just can't be overcome, some goals that seem impossible at first can be reached with support, belief, and perseverance. Many of the benefits babies receive from breastfeeding are particularly helpful for babies with Down syndrome, including better oral motor tone and immune protections for those with health issues.

If you or someone you know is looking for resources on breastfeeding a baby with Down syndrome, I suggest checking out Kellymom's resource page on Breastfeeding and Down syndrome.

Insomnia, radio silence, and links

2011-01-28T15:54:00.005-05:00

I haen't been posting lately for a few reasons. First the holidays, then general busy-ness, but also some really unpleasant and challenging sleep disruptions that have been wreaking some havoc with my life and schedule. Long story short, I have no trouble falling asleep and a lot of trouble staying asleep past 5-6 hours. I had this problem once before, when 3 night shifts were immediately followed by 2 doula calls. I was able to get over it fairly quickly. This newest sleep problem seems to have been provoked by a similar period of sleep deprivation, where my body just gets so out of joint that it doesn't seem to know how to stay asleep properly. I can function fine on 5-6 hours of sleep - hell, I can function on no sleep, that's one of the reasons I'm a good doula! But I can't do it night after night after night, never having the chance to catch up, without going a little crazy. And I couldn't seem to get over it. People kept telling me "You need to stop working nights" but it didn't matter what time I went to bed - in fact, when it started I was off for about 2 weeks for the holidays, and a regular evening bedtime did nothing to help (neither did going to bed later as if I was still working). I also had a fan for white noise, ordered new blackout curtains, had a sleep mask, took melatonin, drank warm milk, you name it. At that point I was so miserable that although I am not a fan of them, I took sleeping pills for several nights to try to get myself back into a normal sleep pattern, which helped somewhat. I also added more exercise to each day and started listening to relaxation/self-hypnosis for sleep CDs. None of those alone seems to have been the complete cure, but things do seem to be improving. (They seemed better a week ago than they do now which is discouraging.)

All of that has left me with lots of posts in process and very little energy and creativity to write them. I've been more in the zoned-out blog-reading-and-occasional-commenting zone. There are posts coming...I promise. In the meantime, if anyone has tips for waking-up-way-too-early insomnia (vs. not-being-able-to-fall-asleep insomnia which most people's suggestions seem to be based around) I would love it! Like I said, things are getting better but I would really like to kick this thing to the curb. (My former MCH classmates have suggested a weekend bender...it IS Friday.)

So while you're waiting (with bated breath, I'm sure!) on my posts, check out some good stuff elsewhere.

Molly at First the Egg reposted a really kickass take on some of the discourses around "natural" birth:

Many such comments also seem to imagine that, while women who prefer unmedicated vaginal births are merely “out for the experience,” women choosing epidural pain relief in hopes of a more pleasant birth are somehow exempt from this criticism (that it is selfish and “fucking self-indulgent” to want an enjoyable birth experience). But, in general, these choices spring from a single impulse: to make the birth experience as pleasant as possible, according to an individual woman’s definition of “pleasant,” whether that primarily means “pain-free,” “empowering,” “intense,” “calm,” or whatever (all ranking AFTER, of course, “safe for mother and baby”). And it is wise and good to seek the birth that will be safest given your own medical situation and most satisfying given your own personality and history.

Dou-la-la on When DNA isn't just DNA:

There's an incredible pressure that many adoptees feel to only express gratitude for their situation, with the implied belief that their birth parent was an undesirable person from whom you have been rescued (open adoption is changing that somewhat, in many cases). Expressing any feelings of grief or loss marks you as an ingrate, an "angry adoptee", as Fugitivus mentions, and is seen as questioning the benevolence of one's birth parents. Sometimes even curiosity is unacceptable. Identity is the very definition of multi-faceted: biology is certainly not the only thing, but it is a very real piece of it, and absence of its knowledge can be felt as a loss. Yet wondering about the biological piece of your identity is often viewed as a slap in the face to the adoptive parents. How dare you want to know about these other people? After all we've done for you. Nurture is the only thing that matters, nature plays no part. We're your REAL family now.

Banned from Baby Showers shares tips on exclusive pumping:

Doctors and nurses might tell you that you can try, but they will most likely tell you that you WON’T be successful at it, especially not long term. They will tell you that your body will not respond to a pump, that a baby is much more efficient than a pump, and, well, why bother when you can go straight to formula? Trust me, ladies, you don’t have to. You CAN exclusively pump. Long term, if you want to! I’ve been doing it for 2 years for my son . . . yes TWO!

Note: Not all mothers can be successful with exclusive pumping, but these are great tips for giving yourself the best chance for establishing and maintaining a full supply.

Defensive medicine and the c-section assembly line

2011-01-14T13:44:00.006-05:00

Apologies for the long posting silence. I have so many drafts in progress. In the meantime, I want to direct people to the excellent and thought-provoking posts and comments at the Unnecesarean's series Defending Ourselves Against Defensive Medicine.

I thought I would tell a little story to go with it. My last CenteringPregnancy group had their reunion today. The midwife organizes it so that the reunion takes place at the meeting of a group who is about to have their babies. Then the new moms can share their experiences of birth, breastfeeding, and baby care with the moms-to-be.

One of the reunion moms had quite the story. She had 3 days of labor and was finally at the hospital making very slow progress with a posterior baby. The midwife who facilitated the group was working with her and the doctor came in to tell the midwife that the woman should have a c-section.

The midwife took him out into the hallway to discuss it. Turns out he had a morbidly obese patient who was also going to need a c-section, and would need the OR and a number of staff for a significant amount of time. The doctor's take was, "Let's get this one out of the way, then we'll do the more complicated surgery." The midwife went to bat and said "No. Mom is fine and baby is fine. I know my patient is stalled, but you do this longer surgery and THEN, if she's still not progressed, you can take her to the OR." They argued and (thankfully!) the midwife won. She went back in and put mom in a knee chest position (keep in mind this was a mom who had an epidural! these positions are possible under many circumstances!) The baby rotated to OA, and after that labor progressed and baby was born easily.

Thank goodness for guardian midwives in the face of not just defensive but assembly-line medicine.

Is breastmilk "just food"?

2011-01-04T14:26:00.003-05:00

An LC friend of mine sent me this story from the journal Nature, "Mother's milk: a rich opportunity". The article summarizes a lot of recent research on the ingredients and biological specificity of breastmilk. A few of the things mentioned:

- The discovery of human milk oligosaccharides, which are carbs that nourish not the baby but friendly bacteria in the baby's gut
- Differences in milk consumed by male and female infants (I had never heard of this before!)
- New research on how breastmilk influences infant gene expression

I liked the way the author framed these discoveries at the end:

The diverse ingredients of an infant's first meal have an impact on its development, and no matter how much we tinker with the composition of formula milk it will always lack many of the trace constituents of human milk. As research identifies these substances, it increasingly seems they serve a role beyond direct nutritional benefit: that of communicating information to the infant about the environment and even the social structure around the mother...

It is easy to see breastmilk as "just food" and anything we use to replace it as just a different kind of food. I attended an excellent lecture a while back where the speaker spent 15-20 minutes discussing breastfeeding's immunological properties, effects on gene expression, effects on maternal health and child spacing, etc. and at the end said "Oh yeah - and it provides calories". When we think about it this way, breastmilk is not "just food" - it is a way of preparing and adapting the baby to its environment (and in the case of its effects on maternal hormones, health, and fertility, the biological changes of breastfeeding are adapting the mother to the baby).

I would take a little farther and say that when we think about the act of breastfeeding more broadly in a social context, we also communicate to babies (and children, and adults!) important things about their environment. This happens both on the individual level - the time a breastfeeding mother spends skin-to-skin, holding her baby, talking and interacting with her baby - as well as on a larger scale. When what society has deemed the "optimal" method of infant feeding is supposed to take place in a public restroom lest it offend, we communicate important things about the value of parenting and of young children. When mothers are extensively supported and nurtured in how they've chosen to feed their babies, we again communicate important things about how we value those mothers' mental and physical health. As breastmilk is not "just food", the act of breastfeeding is not just transferring food into a baby, but a way to see how we see mothers, mothering, and infant care.

Attachment parenting the baby Jesus

2011-01-03T16:56:00.006-05:00

When I visited my grandmother over Christmas she had a sweet story to tell me. Every year since I can remember she has set out a small nativity. It's pretty standard: wise men, shepherds, goats, Mary and Joseph all gathered around the baby Jesus in his manger, their arms spread wide - in worship or awe, I suppose. Every year since I can remember, the manger is empty until Christmas Eve, when my grandmother places the baby into his little cradle. This year, though, my youngest cousin (age 2) came to visit a couple weeks before Christmas. My grandmother wanted to show her the baby, so she put him in early. This cousin was breastfed until she was about 18 months and still often co-sleeps with her mom - not for any kind of deep attachment parenting philosophy as far as I know, but just because that's what works for them.

The day after my cousin's family left, my grandmother realized the manger was empty. She wondered if she had managed to keep track of the little baby figurine all these years only to lose it. Maybe the little girl had done something with him or hidden him somewhere? My grandmother looked all around the house, but when she finally found the baby, he had never left the nativity: my little cousin had taken him out of the manger and placed him back in Mary's arms. It was a bit of an awkward fit - she kind of had to hook him over one of the arms, legs dangling, in a feat of fine motor skills I was surprised she was capable of. All the more impressive that she was so determined that Mary hold him!

My grandmother hadn't touched it since - I so wish I had gotten a picture. It was a sweet reminder of how children can model what they're used to seeing - in this case, a mom hugging her baby.

When and how to give formula to the developing world

2010-12-23T08:10:00.004-05:00

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

2010-12-17T22:05:00.003-05:00

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

2010-12-16T16:14:00.004-05:00

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

2010-12-15T01:11:00.004-05:00

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

2010-12-14T16:48:00.003-05:00

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

2010-12-07T17:51:00.003-05:00

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!

2010-12-03T22:45:00.000-05:00

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?