Tuesday, June 28, 2011

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

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.

Friday, June 24, 2011

Where is your donor milk going?

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.

Saturday, June 18, 2011

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

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!

Friday, June 17, 2011

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

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!!

Thursday, June 16, 2011

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

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!

Wednesday, June 15, 2011

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

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.

Friday, June 10, 2011

How people find my blog, June edition

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".

Thursday, June 9, 2011

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

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?

Thursday, June 2, 2011

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

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?