No Rules in Relationship

By July Guest Blogger:

Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI, ANLC, CKC

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Nikki Lee: Mother of 2

(Ed. Note: Our Milk Way blogger Jess Fedenia is on parental leave for the months of July, August, and September, 2016 to welcome a third child into the family. During Jess’s leave, members of the Healthy Children Project, Inc. circle are taking up the blogger role. We extend our gratitude to Nikki for stepping up with such grace and panache!)

 

Yesterday, I saw a lovely mother and her 5-month-old baby. The mother requested a consultation because her baby wasn’t happy. Part of their history was that the baby would breastfeed very well at night, in bed with mamma, but wouldn’t feed more than twice during the day.

During a lovely long hike through a nearby park, through the woods, and along the stream, with the baby alert and interested in the baby carrier, the mother and I talked about everything: her work, her marriage, her labor and delivery, and her life.  I have found that conducting part of a consultation outdoors is very helpful. It relaxes the mother, and makes her feel safe to tell her story. This easy dialogue creates a connection between us. Working outdoors often dissipates tension; mothers benefit from a reminder that they are part of a bigger world.

After nearly 2 hours of chatty strolling, we got back to my office. The baby was ready to breastfeed. The mother got ready, opening her bra, holding her breast and her baby in a cross-cradle hold. The baby got fussy and the mother got worried; the baby didn’t attach, and they started a subtle battle with each other. The mother was insisting on a particular position and the baby wanted to do it herself.

At that point, it became obvious that the mother’s expectations and understanding were the barrier to easy, fun breastfeeding. She was working to breastfeed the way she had learned in the hospital, every 2 hours whether the baby wanted to feed or not, by holding her breast, pulling it into midline and guiding her baby’s head onto the nipple.

The daytime breastfeeding relationship for this dyad had been a battle for 5 months. She was tired of the struggles, and now was eager for new ideas. She was ready to let the baby teach her how to breastfeed.

When the baby found her own position on her mother’s lap, she showed just how well she could dive at the breast, attach herself, feed, let go and look around or smile at mamma, and then dive back and feed some more. The mother had no idea that her baby had any ability to feed on her own, and was delighted and surprised to see her baby’s skills.  This sweet baby played at the breast, sucking her thumb and mother’s nipple at the same time while resting her foot on the other nipple. The mother didn’t know that this was normal behavior for a 5-month old.

Their interaction was charming to watch. Breasts are babies’ first toys.

Breastfeeding is a relationship that must evolve to suit the mother and baby. Relationship can’t be taught. What can be taught is how to create the environment where the mother and baby can figure out their own way. The problem for this dyad was that they had never developed their own style of breastfeeding; the mother said that every interaction with her baby was a mission to accomplish something, that they had never hung out and discovered each other. Breastfeeding during the day had been about following rules; breastfeeding at night had been mindless. The baby had made her preference clear.

They left all happy, looking forward to a new chapter in their lives.

I love my work.

 

 

[This post originally appeared on Nikki Lee’s blog Morning Thoughts, on April 18, 2016. Thanks to Nikki for permission to repost.]

Celebrating the Breastfeeding Champions of North Philadelphia: An interview with Naima Black, CLC, Coordinator North Philadelphia Breastfeeding & Community Doula Program

By July Guest Blogger: Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI, ANLC, CKC

(Ed. Note: Our Milk Way blogger Jess Fedenia is on parental leave for the months of July, August, and September, 2016 to welcome a third child into the family. During Jess’s leave, members of the Healthy Children Project, Inc. faculty circle are taking up the blogger role.)

In June 1997, the Journal of Human Lactation published a paper; Observations based upon multiple telephone contacts with new breastfeeding mothers based on the work this author had done as the lactation consultant in a grant-funded program serving underserved mothers and babies in West Philadelphia for 6 years.

The paper reported some useful strategies that led to 86% of mothers breastfeeding for at least 1 month, 46% breastfeeding for at least 3 months, and 23% breastfeeding at least 5 months. A major finding in this descriptive paper was that about 94% of mothers would achieve sustained breastfeeding after receiving an average of 9 telephone calls over a period of 12.5 weeks. In other words, only about 6% of mothers would need a home visit for more intensive clinical care.

Today, the Certified Lactation Counselors (CLCs) and the Breastfeeding Champions of Maternity Care Coalition, are providing consistent and timely breastfeeding support to an underserved population in Philadelphia, and finding similar results and successes, with the majority of mothers doing well with basic breastfeeding support and only a few needing more intensive clinical care.

Maternity Care Coalition (MCC) is “a nonprofit organization with the mission to improve maternal and child health and well-being through the collaborative efforts of individuals, families, providers, and communities in Southeastern Pennsylvania”. Its programs serve pregnant women at 9 sites in a variety of programs that are funded by national and international organizations: W.K. Kellogg Foundation and Merck, to name but two.  Most programs use a home visiting model.

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Naima Black (right) demonstrates comfort measures with a community doula trainee (left)

Naima Black, CLC, has been the Coordinator of MCC’s North Philadelphia Breastfeeding and Community Doula Program since its very beginning in 2012, when the first Kellogg grant was awarded. Interested women from the community are given a free 20-session training to become doulas, and are matched with women delivering at local hospitals. In the past 4 years more than 680 pregnant mothers have been matched with a community doula and received some level of support. For those who had a community doula support them during labor and childbirth, the rates of cesarean section are 10% lower than the general hospital rates.

 

MCC has always employed healthcare workers who were passionate about breastfeeding; many took a peer-counseling course offered by the Philadelphia Department of Public Health; when more funding became available, many became CLCs. While the original intent was for all the Breastfeeding Champions to become CLCs, it is now difficult to offer the training to everyone who wants it. One problem is staff turnover. Some staff has left after being trained. While MCC pays for its staff to be trained, the hope is that there will be a commitment to the organization in return. However, the reality is that women move away, or seek higher education or leave to find better paying jobs. Unfortunately, community health workers are paid little as grants are stretched to the maximum to serve the most.  Their workloads include providing support for follow-up care, Safe Sleep, and social issues; breastfeeding has become integrated into their caseloads.

Another problem is that grants have shrunk while the demand for credentialed lactation workers has increased because more women are leaving the hospital breastfeeding. This is because all 7 birthing hospitals in Philadelphia are working to implement best practices to promote and support breastfeeding; 2 hospitals have become Baby Friendly, 1 has become Keystone 10 designated, and 2 more are on the last leg of their Baby Friendly journey. (Keystone 10 is a similar program to the Texas 10 Step program, and is supported by the Pennsylvania Department of Health in partnership with the Pennsylvania Chapter of the AAP.)

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Practicing comfort measures with Community Doula trainees

Mothers find MCC and breastfeeding support by direct referral from other programs such as Centering Pregnancy (administered at one city hospital, and an outpatient clinic) and the ELECT Program (serving pregnant and/or parenting high school students). Word of mouth is a growing source of referrals, as the community doula model used in the North Philadelphia Breastfeeding and Community Doula Program is popular.

If pregnant mom says she doesn’t plan to breastfeed, the community health worker seeks to keep the door open using counseling techniques. Women are asked to, “Tell me more about that”. This is followed-up at next visit. “Would it be okay if I brought more information?”

The number of visits depends on the program. Some offer weekly visits throughout pregnancy, others offer monthly visits. The same is true for postpartum visits, which can be for 1, 2, or 3 years, depending on the program. Clients are also invited to seminars and trainings in addition to the visits.

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Sharing affirmations with one another during Community Doula training

The North Philadelphia Community Breastfeeding and Community Doula Program is the first and only one of its kind to use Microsoft Excel® to track data. In the home visiting programs, everything is tracked: feeding intention, initiation and 3-month duration; every contact (phone, text or visit) is documented, and the referent agency is kept in the loop.

The Breastfeeding Champion/CLC model is effective for most women; more challenging cases are referred to Naima, who will call in a community-based IBCLC with more experience. Not all mothers receive breastfeeding support from a Breastfeeding Champion or CLC; sometimes it is the community doula who provides the help. At other times, it is a community member who comes to a breastfeeding support group and needs a referral. Naima has not had to refer onward very often; only about 20-25 mothers (out of 680 cases) have required more intensive breastfeeding support.

Naima is a source of education and support for her staff, as well as doing the administrative tasks required by a grant-funded program. Senior CLCs are available for supervision and support and resources, with Naima as Coordinator being the clinical overseer to everyone.

Just as in 1997, when mothers were supported to breastfeed with regular contact and only a few needed a home visit for complex care, in 2016, most mothers enrolled in MCC programs are supported to breastfeed with regular contact, and only a few need more complex breastfeeding care. The Breastfeeding Champions/CLCs are doing a wonderful job for the majority of mothers, and the IBCLC is there when needed.

In 2014, the CDC cited both IBCLCs and CLCs as professional lactation supporters. Working together, Breastfeeding Champions, CLCs, and IBCLCs can provide a safety net of breastfeeding education and support to underserved mothers, illustrating how effectively a community of lactation care providers can work together in a successful model of practice.

A Reminder to Broaden the Focus: A comfortable breastfeeding relationship rests on much more than “proper latch”

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By July Guest Blogger:

Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI,        ANLC, CKC

 

 

(Ed. Note: Our Milk Way blogger Jess Fedenia is on parental leave for the months of July, August, and September, 2016 to welcome a third child into the family. During Jess’s leave, members of the Healthy Children Project, Inc. faculty circle are taking up the blogger role.)

I’ve been working with mothers and babies since 1975; I’ve been in private practice as a lactation therapist since 1989. These years have been full and wonderful and I look forward to many more.

Something is happening today in the language used by breastfeeding helpers that disturbs me and feels like fingernails scratching across a blackboard. This the focus on “the latch” instead of focusing on “breastfeeding.”

I’ve heard hospital colleagues say, “I was just latching a baby on when you called,” or “I latched on 24 babies today.” Current prenatal resources talk about the latch, “Getting your baby to latch”. “Your nurses in the hospital can help you and your baby learn to latch.” “Latch on, the key to successful breastfeeding.” “Breastfeeding: It’s Latching On.”

I’ve had clients tell me, “They told me the latch was perfect in the hospital, but it always hurt.”  These mothers are doubting themselves when the experts have told them something different to their own experience. Simply put, latch isn’t perfect if it always hurts. No one asks the mother if she is having fun with her baby, or if she knows when her baby wants to go to breast. It’s all about the latch. Mothers are calling the warm line or lactation professionals to “have the latch checked.”

I see clients controlling the relationship, focusing on getting the baby to latch, with little awareness of, or attention to, comfort or timing. No one seems to remember that healthy babies are born with all the reflexes and skills they need to breastfeed; certainly the mothers I see are always surprised to see what their baby can do when given the chance!

The focus of our work has become the latch, the narrow area where the baby’s mouth and the areola and nipple intersect. True, this component of breastfeeding has to be comfortable and effective. However, it is not the whole story. The whole story is about feelings and relationship, about observing, and about responding. Breastfeeding includes health, with functional anatomy and physiology. Breastfeeding includes environment, respect and timing. Breastfeeding encompasses fun, love, and pleasure.

Making the latch the focus of breastfeeding is like making penetration the focus of lovemaking. Today, it is as though the relationship has been distilled to directions for assembling a piece of furniture from IKEA. We all know that there is much more to intimacy than Part A accepting Part B comfortably and completely. We know that a baby is much more than the sum of its diapers, feeding frequency, and weight. We want to appreciate the emotional components of relationship that make breastfeeding something for mother and baby to enjoy.

Let’s remember the whole, and do what we can to promote relationship, while supporting all its elements.

 

[A version of this post appeared on the author’s blog, Morning Thoughts, in May of this year.]

On Becoming Transliterate: An Interview with Diana West, BA, IBCLC

By July Guest Blogger, Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI, ANLC, CKC

From dianawest.com

Diana West BA, IBCLC       From dianawest.com

Diana West BA, IBCLC, LLL, is a co-author of many important works, (the 8th edition ofthe Womanly Art of Breastfeeding, Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family,  Breastfeeding after Breast and Nipple Procedures, The Clinician’s  Breastfeeding Triage Tool, and The Breastfeeding Mother’s Guide to Making More Milk) , as well as the sole author of Defining your Own Success: Breastfeeding after Breast Reduction Surgery and editor of her father’s autobiography, In the Line of Duty.   In addition to her websites, she is well known as an educated, lively, and passionate public speaker. Our Milky Way blog is grateful for the chance to interview Diana about her research article, “Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study,” co-authored with Trevor MacDonald, Joy Noel-Weiss, Michelle Walks, MaryLynne Biener, Alanna Kibbe and Elizabeth Myler.

The universe works in wonderful and mysterious ways. Several years ago, Diana received an email from a would-be author asking her to read a book that he had written. There was something special about this letter that captured her attention. In it, Trevor MacDonald, a trans man wrote of reading her book Defining Your Own Success: Breastfeeding After Breast Reduction Surgery, and then of being inspired to chestfeed his own child.

As the right of all people to their own identity is one of her core values, Diana entered into a relationship with Mr. MacDonald, first as a mentor guiding him towards publication, and then as a friend, sharing a room with him at an ILCA conference, and then as a collaborator, working together.

He was appreciative of and patient with her respectful approach; he taught about this new world, where an untold number of people struggle without help, staying underground as they fear the judgments of the helping professions.

They thought of publishing a case study but changed their minds to do a research study instead. While they initially envisioned a quantitative study, after consulting with others, including Canadian Professor Joy Noel-Weiss, they decided to do a qualitative study.  Dr. Noel-Weiss helped them to see that the data in a qualitative study would be richer, giving insight into the motivations behind lived experience; this would be far more valuable than evaluating numbers.

After developing research questions and obtaining clearance from an ethics committee, the merry band applied for a modest CHID (the Canadian version of the US’s National Institutes of Health) grant.  In an amazing affirmation of the value of this research, they received $100,000, far more than they had requested, because the agency was so impressed with the topic!

The 3 goals of their study were: to understand the lived experience of the transgender men who chose to birth and to chestfeed, to understand the barriers they encounter, and to provide guidance to healthcare providers.

Many breastfeeding helpers came of age and into their avocations in the 1970s, when women were fighting for autonomy and rights to freedom in birth and breastfeeding. Today, some feel that trans men are encroaching on women and their feminist perspectives. This is why trans women were banned from a women’s festival in Michigan. Instead of saying, “These are more women who have been denied dignity” they were seen as men who were encroaching on a woman’s needs for equality of choice. However, gender identity is not binary, i.e., only male or female.

A cisgender person, one who identifies as the gender manifested by their genitalia may not be absolutely and always female or male.  Gender identity is fluid. We may feel more male on some days, more female on others, and there are days when we feel neuter. There are mutational variations of hormones that create variations on gender. Babies are born with ambiguous genitalia. There are cultures where people can be recognized as 2-spirited. Gender, identity, and sexual preference are complex traits, there is a wide range of variation, and consequently, people don’t all fit into a neat “either/or” category.

Thirty-three years ago, I met a great fiddler named Gary. Gary was the most crass and obnoxious man that I ever met. It was impossible to have a conversation with him without his making some gross joke or sexually slanted comment. I didn’t like to be with him, because he was such a cad. He lived in the South; I lived in the North and didn’t have contact with him very often.

Fast-forward 25 years, when I run into Gary at a fiddler’s convention. Only now Gary has breasts, is wearing a dress, earrings and make-up and wants to be known as Marie. We had an amazingly open discussion, where I got to ask all the questions I wanted to ask and she answered them all. She told me that all the deeply difficult work, all the family disruption (before transitioning, she had married and had 2 children), and all the medical and surgical interventions were worth it, as now she felt complete and comfortable in her own skin for the first time in her life.  All was well except for one thing, family and friends continued to use the wrong pronoun; myself included. I got annoyed with her for being annoyed with me when I kept using male pronouns; I said to her, “Gary, I’ve known you for 33 years as a male and it is hard for me to switch gears quickly enough for you.”

After hearing this story, Diana gently suggested,

 “Oh yes you can, and here is why. For a trans person to come out to the world as someone who is a different sex than the world has known them before, is one of the most difficult situations imaginable. It is difficult to be brave enough to be one’s true self out in the world. Acceptance is what is craved, in order to have dignity. When we who are cisgender do not recognize that change, we are denying that person their dignity. We can make the effort to honor the pronoun they choose.  Everybody has the right to the pronoun of their choice. It is simply a matter of respectfully asking them what pronoun they prefer.” (This means adding new terms, understanding, and words to our vocabulary.)

Diana goes on to say, “We don’t know people’s paths, and we don’t know their hurts. When we accept people choosing the path that meets their needs, we recognize their right to be who they are. “

She paraphrases Mr. MacDonald in saying that many people find the concept of being transgender disturbing because they picture themselves having to act and dress differently than their true selves. But really, it is the trans folks that have had to act differently to who they really are until they transition. Putting it another way, was there a day that you consciously chose to be cisgender? Or, do your feelings about your gender identity flow from a place inside you, where the truth of who you are has always lived?

Society is presently a challenge, as there is anger about trans gender.  Some people believe that sexuality is a choice and manifest their fear in attacks that fill our feeds and screens. The rudeness and brutality of the Internet and the rhetoric of today’s political debates is painful to those struggling for recognition.  It behooves us all to post and tweet with courtesy and respect.

Science and technology have made possibilities real that were hitherto unimaginable. Think of the suffering that has gone on for millennia, where differently gendered folk could only dream of the pharmacy and the surgery that would enable them to have their physical bodies match their inside spirits. Today, these dreams can come true; now, everyone in society needs new skills and new understanding to catch up to the new reality.

Another barrier is the public attitude about children who are being parented by trans men.  Diana responds,

Children raised with love and respect and healthy growing environments, have the best chance to be wonderful adults. We don’t have to be perfect parents; the only ideal for a parent is deeply loving a child and taking care of them.  There is NOTHING about being transgender that precludes them from being a good parent. In fact, they may have more understanding to teach about the importance of treating everyone with dignity.”

Most trans people are not activists as they are too busy living their lives. The trans experience is really about self-actualization, a concept younger folks may not yet appreciate.

So far, what is most helpful is social support from family and friends. (This is true for breastfeeding too!) The people who donated a lot of the milk that Mr MacDonald used to chestfeed were Mennonites and Mormons. Although they knew who he was, their priority was on feeding the child human milk, and they didn’t judge him nor withheld their gift.

As healthcare professionals, we need to become transliterate, so that we can be helpful and respectful to anyone that we care for. This means educating ourselves so that our clients don’t have to explain everything over and over again with each one of us. The new research article has great information about how healthcare professionals can help transgender clients more effectively.  Diana also has a FAQ on her website to aid the transgender person in finding the help they need for birth and breastfeeding, and for healthcare professionals to educate themselves.

Ask about preferred pronouns and “what would you like your child to call you?” There is no need to apologize for what we don’t know; “I want to be helpful, how can I help?” is a lovely way to start a discussion.  People make mistakes; those who are transgender understand this. Our responsibility is not to be stuck on our mistakes, and to make the transition to helping and not to impose our own struggles.  We also want to avoid overcompensating to prove how cool and current we are.

If transgender issues aren’t comfortable for you, remember that as healthcare professionals, we are ethically bound to take care of people that we may not like. We have an obligation to provide best care; this requires only an intention of respect. We need to treat people in a humane way, as we should be treating ourselves.

Grammar is another stumbling block, as language locks old societal attitudes into our unconscious, where they are negative influence on our interactions with others.  Diana says, “ ‘They’ has been a plural noun; we have to let go of old grammar rules and use ‘they’ as a singular noun.”  (Facebook is doing this.) This will get rid of the gender binary view, and bring us forward into the 21st century. Language is a dynamic, changing thing; language change fuels our intention and is manifested in our actions.

A mistake that I made in this interview was to talk about the “transgendered” This noun is similar to the term “colored”, it is a subtle way of expressing the terrible attitudes towards “those people who are different to and inferior than us.”  Diana encourages the use of the word “transgender”.

Diana reminds us that of the need for acceptance, dialogue and welcoming all points of view; she is collaborating with transgender speakers to introduce her talks on that topic. Her goal is to be a cisgender Ally; the capital ‘A’ is intentional and reflects the importance of a new social advocacy role in supporting human rights. Her dream is for all people to become self-actualized and lead the best and healthiest lives possible.

We applaud Diana for breaching this barrier, and educating us about human rights. We can use this information in our own communities, and together, build an inclusive and respectful world.

Introducing July’s guest blogger: Nikki Lee

mail1Nikki Lee, joining us as an Our Milky Way guest blogger during my maternity leave, has an excellent line up for you to indulge in this month.

The first time I met Nikki was at my first International Breastfeeding Conference. She warmly approached me and asked, “So what do you do?”

“I’m just a stay-at-home mom,” I replied.

“What do you mean just a stay-at-home mom?” she asked.  

During that simple exchange was the first time I felt validated as just a mom, and that validation never left my side. During that simple exchange, Nikki made me feel important which has had a huge impact on my confidence as a mother.

I have no doubt Nikki’s contribution to the blog will make an impact on your work.

In one post, she comments on a language change in the field.

“Folks don’t talk about breastfeeding any more,” she says. “They talk about latching the baby on. This makes me sad; it is like talking about the penetration instead of love making.”

In another post, she interviews Diana West about her co-authorship of the article Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study.

“The blog is about … what breastfeeding helpers need to do to best serve all clients,” Nikki reports.

She tells me another is about a model of practice exemplified in a local organization where doulas and CLCs saw about 450 mothers and about 20 to 25 of those needed referral to an IBCLC.
Stay tuned! In the meantime, you can visit Nikki’s website here.