Worksite program caters to nursing moms

A friend of mine shared this gorgeous poster of working mothers demanding the freedom to feed by Phoebe Wahl with me.

Working, nursing moms still have a lot to fight for, but the Health Care Reform requires employers to support nursing mothers in a couple of ways: Employers must provide reasonable break time to express breast milk for one year after her child’s birth each time she has the need; and a private place, other than a bathroom, for her to do so.

Mother-Friendly-Worksite-CertifiedTexas has been a shepherd in creating worksite legislation for nursing moms. The state established a health and safety code which includes the Mother-Friendly business designation nearly two decades ago.

Since then, the Mother-Friendly Worksite Program has designated 1120 businesses Mother-Friendly, says Texas State Breastfeeding Coordinator and Texas Mother-Friendly Worksite Program (TMFWP) administrator Julie Stagg, MSN, RN, IBCLC, RLC.

Becoming designated requires the following written into an employee worksite lactation support policy:

  • Flexible work schedules including scheduling breaks and work patterns to provide time for expression of milk,

  • Access to a private location(s) that is not a bathroom, for the purpose of milk expression,

  • Access to a nearby clean and safe water source and a sink for washing hands and rinsing out any breast pump equipment and

  • Access to hygienic storage options for mothers to safely store breastmilk. [Retrieved from: http://www.texasmotherfriendly.org/getting-designated]

Asking for basic breastfeeding support can be a difficult thing for working moms to do. Often times there is a communication gap between employers’ perception and employees’ reality.

Employers may not recognize worksite lactation support as significant because they are not familiar with the importance of exclusive breastfeeding.

“Sometimes they don’t understand how work plays an important role in a mother meeting her breastfeeding goals,” Stagg says.

Other times employers don’t think to create a worksite support system because it isn’t brought to their attention.

“Some moms have asked for support and had a horrible experience, but most are not talking at all because a lot of moms fear job security,” Stagg explains.

In the program’s infancy, TMFWP conducted focus groups with employers and employees as part of the development process.

One focus group found that 80 percent of people agreed or strongly agreed that supporting nursing employees was “the right thing to do.”

Another group of 30 employers with multiple worksites across Texas found that 75 percent of co-workers were supportive of a breastfeeding policy even though managers initially perceived a negative reaction from co-workers.

Stagg calls the opposition a “vocal minority.”

“They will always be there,” she says. “But that’s where the law really comes in handy. It’s not disputable.”

Stagg says employers often express concern about money and space. Often times though, businesses already meet the requirements before applying for designation.

And if not, “You just get creative and figure it out,” Stagg says.

A woman writes on TMFWP’s website: “My boss offered me an empty office to pump in. Unfortunately, the door didn’t lock, but my “MILKING IN PROGRESS” sign kept ‘em out!”

Stagg emphasizes the significance of return on investment because “businesses that proactively support breastfeeding see reduced health-care costs and lower turnover.” [Retrieved from: http://www.texasmotherfriendly.org/everyone-benefits]

In fact, Dr. Melissa Bartick and Arnold Reinhold state that businesses with worksite lactation programs experience up to a $3 return for every $1 invested in lactation support in The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis.

Stagg says that because nursing mothers spend less time at home with sick children, co-workers aren’t forced to cover extra hours which reduces their stress levels.

Becoming Mother-Friendly designated communicates a supportive environment overall which attracts qualified, loyal employees. Stagg says that’s most important.

When employers find their programs successful, they are given the option to add components to their policy which might include:

  • Extending program offerings to male employees and their partners

  • Bring-baby-to-work policies

  • Paid lactation breaks

  • Breastfeeding and/or parenting classes

TMFWP offers a Silver and Gold Mother-Friendly designation for employers who continue to add supportive components to their policies.

For other states looking to develop a similar program, Stagg suggests creating many partnerships to get people excited about the initiative.

“If you can help spread the word through existing programs, that’s a really great thing,” she says.

The program’s website offers businesses a step- by- step tool complete with downloadable PDFs to comfortably begin the designation process.

Texas families searching for breastfeeding information and support can visit http://breastmilkcounts.com/.

Where are the mother-friendly worksites in your state?

Baby Friendly Hospitals decrease traumatic birth experiences, increase breastfeeding rates

Early one humid August morning, I concentrated on the deep blue sky during my contractions on our way to the hospital. Nervous and excited for the arrival of my first baby, I watched a shooting star glisten across the velvety vastness.

Less than 10 hours later, I welcomed my exquisite daughter Willow into our world.

Despite my prenatal requests to have her laid upon my bare chest immediately after birth, I found myself struggling to simply see her curly red hair through the chaos of the delivery room. She was whisked from me for unnecessary examination.

Under glaring lights, gloved nurses poked and prodded my new baby. Loud requests for dad to take pictures filled the room.DSCF7809

Willow’s worried cry called above the commotion. I watched her arms flail as if reaching for me.

What felt like many moons later, a nurse handed my tightly bundled baby to me. She was frowning. I kissed her forehead; an apology for not protecting her from a traumatic birth experience.

Although Willow is happy and healthy (and nursing) 21 months later, I will always feel responsible for allowing her to be welcomed into this world in such an aggressive manner.

Guilt aside, typical hospital births have other significant consequences like unnecessary interventions and difficult breastfeeding initiation.

Nurturing early breastfeeding

But with the launch of the Baby-Friendly Hospital Initiative (BFHI) in the early 90s and its continued progress, less and less babies will suffer from traumatic births. Even more, moms and babies will be supported in the beginning of their breastfeeding journeys thanks to the program’s Ten Steps to Successful Breastfeeding which includes helping mothers initiate breastfeeding within one hour of birth (i.e. skin to skin) and allowing mothers and infants to remain together 24 hours a day.

mailLiz Westwater, MSM, CLC is project manager to Baby-Friendly USA. She became a Certified Lactation Counselor through Healthy Children Project nearly eight years ago and says the course helped her realize that common hospital practices do not support the 80 percent of women who initially desire to exclusively breastfeed.

Within a typical 48 hour stay, standard hospital practices like mother-baby separation and supplementation manage to severely impair a woman’s potential to breastfeed successfully.

Differently, BFHI applies evidence-based practices shown to increase breastfeeding success.

Growing quickly

“We are experiencing unprecedented growth and interest,” Westwater says of the initiative. “To feel that the whole country is changing direction in terms of perspective on importance of breastfeeding is really exciting.”

In fact, Westwater tells me that out of approximately 3,200 birthing facilities in the U.S., nearly 800 hospitals have been designated Baby Friendly or are currently working toward designation. Today, there are over 150 Baby Friendly birthing facilities in the U.S.

Part of the Healthy People 2020 breastfeeding objective includes increasing the proportion of births that occur in facilities that provide recommended care for lactating mothers and their babies to 8.1 percent. Currently, just under seven percent of births occur in Baby Friendly designated facilities.

Westwater says at this rate, she is confident we will surpass Healthy People’s goal before 2020. Celebrate!

“These are really exciting times,” she says. “For many, many years I’ve been involved in promoting breastfeeding and I never thought I’d see this day.”

Because government entities are taking a hard look at breastfeeding outcomes, BFHI has been acknowledged as a key component to improving mother-baby health.

For instance, Surgeon General Regina Benjamin recognizes BFHI’s benefits in her 2011 Call to Action to Support Breastfeeding.

The CDC also recently funded Best Fed Beginnings led by NICHQ, a program designed to increase the number of Baby Friendly facilities in the U.S.

The Joint Commission supports the mission to increase exclusive breastmilk feeding in all hospitals delivering more than 1,100 babies annually. Implementing BFHI’s 10 steps is an efficient way to increase exclusive breastfeeding.

Promoting collaboration

Achieving Baby Friendly status is certainly an earned accomplishment, but Westwater says the hard work is worth it.

“We think one of the most important things hospitals need to do first is to form a breastfeeding task force or committee,” she says.

Support should come from all areas; a multidisciplinary committee including administration members, nurses, physicians, lactation professionals, laboratory staff, etc. are all essential to achieving Baby Friendly status.

Often times, birthing facilities express concern about BFHI’s perceived financial commitment, namely purchasing artificial baby milk. The BFHI requires hospitals to pay fair market value for formula because it leads to greater objectivity without any ties to other commercial interest as BFUSA Executive Director Trish MacEnroe puts it in a MilkforThought interview.

Fortunately, MacEnroe says it’s not an insurmountable challenge.

“What we have found is that when hospitals get their exclusive breast milk feeding rates up to their highest possible levels, they are completely surprised by how much infant formula they actually need to purchase,” she continues in the MilkforThought interview.

Westwater cites resistant staff members as another challenge. However, this too is a very achievable task.

For example, Westwater says that observing skin to skin after birth will “make believers out of people.”

“I don’t see how you wouldn’t be moved by experiencing skin to skin,” she says.

Several hospitals even successfully implement skin to skin immediately after c-sections and less typical birth outcomes. Read more about skin to skin and c-sections here, here and here.

Continued benefits

Besides the obvious benefits of becoming Baby Friendly, the initiative offers hospitals less publicized rewards.

“We have anecdotal reports from hospitals using it as a marketing tool to increase patient population,” Westwater says.

When patients have positive birth experiences, they are more likely to return for other needs.

And because we know that breastfeeding offers an environmentally conscious infant feeding method, BFHI contributes to the protection of our planet by reducing artificial baby milk waste in its production, delivery and consumption. When mother becomes a heating and stabilizing source for baby after birth as opposed to expensive machinery, our environment also reaps the benefits.

Even more BFHI serves the entire family, not just the mother baby couplet.

“Families should know it helps with family bonding,” Westwater says of delivering at a Baby Friendly facility. “Their family relationships are going to be stronger; they’re going to be healthier.”

For more information about BFHI, please visit: http://www.babyfriendlyusa.org/.

Technology from a nurse’s perspective

I am currently adapting to life with a smart phone. I traded in my bulky, old-fashioned cell for a more fancy, streamlined iPhone. Yes, I am slowly but surely entering into the 21st century.

As I personalized my new gadget, I searched “breastfeeding” in the app store to see what it had to offer. I nearly dropped dead when this came up: Baby Nursing. The app’s description reads: Baby Nursing is a simple and intuitive app to help you keep track of your baby’s nursing progress and more! Our easy-to-use timer lets you track your nursing records real-time. Simply press “Start” and “Stop”!

Before I bash the program, I have a confession to make. During Willow’s first several weeks of life, I set my alarm every one to two hours during the night to offer her the breast. I was so concerned that I’d miss her feeding cues throughout my slumber and starve her. Talk about obsession!

All new moms worry about their infants in one way or another. An app like Baby Nursing serves to “subdue” those concerns by offering high-tech solutions. Here’s the problem: when we put gadgets before observation and instinct, we lose the very essence of motherhood. And while most technology is designed around practicality, when it comes to birth and breastfeeding, technology sometimes ends up doing more bad than good.

Even so, apps like Baby Nursing have rave reviews. “Definitely recommending this app to all new moms”…  “amazing”… “easy to use.”

Just how easy it is to juggle a device every time you go to nurse your baby, especially considering how often newborns feed. How long do moms remain attached to the program? For several weeks? Until baby weans? When mom relies on a tool like this, does she really get to know her baby’s language or is she consumed by tracking and counting and recording?

Technological reliance

CarinRHealthy Children faculty Carin Richter, RN, MSN, APN-BC, IBCLC, CCBE has been a women’s health nurse for 26 years. She currently works and teaches at St. Anthony’s Medical Center in Rockford, Ill.

“When we talk about breastfeeding and everything that needs to be done, we feel like we are churning the ocean,” she says. So why complicate things with potentially harmful technology?

Richter suggests creating a shift in U.S. culture in order to curb the use of unnecessary breastfeeding gadgets and intrusive technology in the hospital.

“Our culture is very much into let me do the fastest thing to get the job done,” she says.

Productivity can be a wonderful thing but not when mothers are staged with a false sense of assistance and efficiency.

In the United States, the majority of births occur in a hospital setting which means that most mothers receive (or don’t receive) infant feeding support from their nurses. Breastfeeding support is a core skill for nurses because infant feeding is of new mothers’ greatest concern, Richter explains.

“When it comes to breastfeeding,  we have to remember that the relationship you have with a mother is extremely important especially in the first two weeks,” Richter says.

She tells me that  nurses tend to rely on technology (i.e. breast pumps, shields, supplemental devices) before they use alternative problem solving (i.e. latch assessment, skin to skin implementation, simple encouragement.)

“They are always looking for a quick fix so technology is frequently something they employ,” she says.

During my hospital stay with Willow, I received such inadequate breastfeeding support I still get angry about it 20 months later. I rarely had anyone by my side cheering me on and when I did, it was a hurried. At one point, a nurse forcefully attempted to shove my entire areola into my newborn’s tiny mouth. Unless she was equipped with a shrinking machine, this was never going to happen.

Until I spoke with Ms. Richter, I hadn’t considered why my lactation support was so awful; I simply thought I was dealt a bad hand of nurses.

Pressed for time

Postpartum hospital stays are generally very short, making it difficult for nurses to establish relationships with mother and baby, Richter explains.

Not only that, nurses have other time-consuming demands to satisfy like clinical documentation including mandatory assessments, documentation of daily care plans, documentation of patient learning, documentation of resources, and the list goes on. Electronic documentation makes things even more complicated.

Also consider the nurse who is responsible for four to five mother baby couplets. That’s eight to ten patients relying on one provider.

In a Medical News Today article, one nurse describes her experience: “I didn’t become a nurse to be chained to documentation.”

Electronic programs can take a long time to learn and to integrate into practice.

“Documentation takes up so much of [nurses’] time, it cuts into their ability to set up a relationship with their patient,” Richter explains.

Even so, Richter tells me that nurses really do want to help moms with breastfeeding, they just sometimes feel trapped.

She adds that some nurses take on physician’s work when the physicians themselves are not familiar with new systems.

Still, nurses have a tendency to cling to technology simply because health care in the hospital has become so technology based.

“When we ask them to just do the natural, which is what giving birth and breastfeeding are all about, they don’t feel empowered,” Richter explains.

She says that if nurses don’t have tools at their beck and call, it’s difficult for them to remain hands off. A hands off approach is often the best method when it comes to moms and babies, especially when you consider skin to skin contact.

Effectively implementing skin to skin contact between mother and baby involves no intervention. Richter says this is the number one thing that will lessen nurses’ workloads.

That’s because when baby’s nine stages are allowed to progress organically, breastfeeding problems are often averted.

Because the Baby-Friendly Hospital Initiative nurtures early skin to skin contact and baby-led breastfeeding, nurses’ workloads are potentially lessened when mothers need less technical assistance with infant feeding.

Implementing breastfeeding education

In order to better prepare nursing students for their OB rotations, Richter is working diligently to integrate skin to skin and breastfeeding training into their curriculum.

“It is imperative that nursing students get a good foundation in the fundamentals of breastfeeding,” Richter says.

Ideally, Richter says a lactation professional should teach the breastfeeding portion of the curriculum.

Along with curriculum changes, Richter suggests implementing breastfeeding training with a lactation professional during nursing orientation.

“We have to start before the problems are even developed,” she says.

When nurses aren’t properly trained to support mothers in their feeding choices, lactation consultants become hot commodities. Most hospitals have a severe lack of lactation professionals and that insufficiency presents yet another barrier to breastfeeding.

Richter says she would love for all nurses to be trained as Certified Lactation Counselors (CLC).

When nurses are trained to properly support and assist mothers with breastfeeding, we become that much closer to securing normal feeding goals.

Even more, the CLC training is a valuable way to build nurses’ confidence in their own ability to provide breastfeeding education and support.

“When organizations require a certification such as the CLC, that really bolsters a nurses’ ability to assess and teach [breastfeeding] effectively and efficiently,” Richter explains.

But do nurses express interest in receiving breastfeeding education, or do supplemental certifications overwhelm?

“I believe that any nurse in whatever specialty she is in has a professional obligation to have a thirst for the newest knowledge that improves the care she gives to her patient,” Richter explains. “What I do find with obstetric nurses is that some of them do not see breastfeeding education and support to be within the scope of their practice.”

In actuality, obstetric nurses like all health care providers, play a crucial role in implementing breastfeeding. OB nurses have a special opportunity to allow immediate skin to skin contact between mom and baby to occur.

Fortunately, when nurses have the opportunity to learn about the significance of skin to skin, they’re excited to apply it.

“I see this every time I teach,” Richter says of the CLC course. “Nurses will come up to me after the week and say, ‘If I only would have known about the Magical Hour and its importance, my practice would have been different.’”

I nearly drop dead again when Richter tells me that because of our litigation culture, nurses are encouraged to become certified in advanced fetal monitoring. The lactation counselor certification isn’t promoted nearly as much.

Why is a certification for a hospital practice that heightens the likelihood of c-sections promoted over a certification that has only positive results for mom and baby?

Richter says she believes breastfeeding education and fetal monitoring competence are equally as important.

Encouraging breast over bottle

The evidence is clear that breastfeeding is more beneficial than breast milk feeding. (For instance, babies fed from a bottle are less likely to self-regulate milk intake.) But because of our culture’s obsession with technology, moms also become caught up in the use of unnecessary devices.

Patients then potentially become barriers to nurses’ ability to provide breastfeeding education, Richter says. It’s sometimes difficult for well-educated providers to explain the possible dangers of introducing technology to a breastfeeding relationship if a mother is insistent on a “quick fix”.

Trainings like the CLC course offer professionals effective, gentle and respectful communication tools when presented situations like these.

Perhaps the most common device requested is the breast pump. Pumps can be vital to maintaining a breastfeeding relationship especially when and if mom must return to work.

However breast pumps should not be offered before a breastfeeding relationship is established. Mom’s milk production generally will not respond to a mechanical device the same way it will to her warm newborn. Mom might also become discouraged to see healthy but small amounts of colostrum.

“In reality, moms don’t know how much work pumping really is,” Richter explains. No one is claiming that breastfeeding is effortless, but it is certainly the most efficient infant feeding choice.

Richter says normalizing skin to skin will help get babies to breast versus to breastmilk bottle because moms will continually desire baby at breast.

“There is so much else going on with breastfeeding that a pump can’t replace,” Richter explains. “It’s a sacred time that no one else can duplicate.”

When technology triumphs

Technology is the antithesis of breastfeeding, as Richter puts it.

“What we need to do now is look at any kind of technology to use for the promotion and support of breastfeeding.”

Once mom and baby have established a comfortable breastfeeding relationship, technology can be used to offer continued support. For instance, emailing and text messages offer quick responses when moms need instant answers.

“This is a really big frontier that we need to explore,” Richter says of text messaging. “There is evidence that using the cell phone will be very important in maintaining that relationship.”

(Read more about text messaging and breastfeeding support at: http://lactationmatters.org/2012/01/31/supporting-breastfeeding-with-new-technologies/)

Online breastfeeding communities may also be helpful in extending support. They allow mother to connect any time of day and encourage relationships between mothers in similar situations.

Still, these communities present the risk of rapid spread of misinformation.

“I want to make sure online communities are monitored so that correct information is given,” Richter expresses concern.

She says mothers need to be cautioned about the information they act on. However providing mothers with reliable resources will better suit them to make informed choices.

Even though Kangaroo Mother Care is an effective way to promote breastfeeding in low birth weight babies, technology can play an important role when mother must be separated from her baby.

For instance, Richter encourages mothers to pump until she becomes reunited with her child.

She says it gives mom something to focus on when she feels helpless and alone.

“Pumping helps empower her so she knows that she can do something for her fragile child.”

Following Dr. Koop’s footsteps

One day while traveling, an elderly woman holding a suitcase turned and said to a fully uniformed government employee, “Put this up for me, will ya Sonny?” The uniformed man gladly did.

Shortly after while checking into a Holiday Inn, the government employee was asked for identification although still adorned in uniform. He handed the woman ID proving his status. She picked it up with two fingers, slapped it back and said almost disgustedly, ”Don’t you have a driver’s license?”

Healthy Children Project’s Karin Cadwell, PhD, RN, FAAN, ANLC, IBCLC remembers these illustrations of former Surgeon General Charles Everett Koop (1982 to 1989.) Cadwell first knew Dr. Koop as a pediatric surgeon at Children’s Hospital of Philadelphia where she also worked.

Photo courtesy of Geisel School of Medicine at Dartmouth. http://geiselmed.dartmouth.edu/news/2013/02/25_koop/

Photo courtesy of Geisel School of Medicine at Dartmouth.
http://geiselmed.dartmouth.edu/news/2013/02/25_koop/

Cadwell remembers Dr. Koop as “amazingly human,” hoisting luggage and harrassed for second forms of ID.

“He had a wonderful sense of humor,” she says. Although he held great status, he recognized that he was also an ordinary person.

Breastfeeding champion Dr. Ruth Lawrence attributes our government’s interest in infant nutrition to Dr. Koop’s initial work with breastfeeding, a not-so-ordinary accomplishment.

In 1984, Dr. Koop convened the first Workshop on Breastfeeding and Human Lactation. The workshop resulted in several important recommendations including:

As a result of the workshop, two follow-up reports describing breastfeeding promotion activities were released. You can read them here and here.

Dr. Koop established the first neonatal intensive care unit in the United States in the mid 50s. He also focused much of his work on infants born with congenital anomalies.

He recognized the importance of breastfeeding into toddlerhood and young childhood.

“It is the lucky child who still breastfeeds past two years old,” Dr. Koop is quoted on Best for Babes’ Facebook page.

Cadwell reaffirms that he cared passionately about babies and children.

“I think his religious beliefs influenced his passion for breastfeeding and wanting the best for mother and baby.”

Referring to him as a servant leader, Cadwell tells me she always felt that Dr. Koop’s work was in god’s service.

“You just knew that he had charisma,” she says. “There was something very noble about him. He was kind and powerful.”

While many refer to Dr. Koop as “America’s family doctor,” Cadwell says she thought of him more of an old fashioned practitioner.

“You could imagine him as a member of the community getting in his horse and buggy and sitting with a laboring woman or a dying person.”

Dr. Koop served under the Reagan administration in a politically conservative climate. But Dr. Koop’s agenda was less than conservative; he issued The Health Consequences of Smoking: Cancer: A Report of the Surgeon General, an account telling the dangers of tobacco use.

Later, he focused on creating dialogue around HIV/AIDS which “once again…upset the applecart by rejecting ideas such as quarantine and insisting that AIDS be treated as a medical and not a moral issue,” according to Geoff Watts of The Lancet.

While Cadwell doesn’t believe the political landscape directly affected the work Dr. Koop did around breastfeeding, she does describe some political barriers he was up against.

In his breastfeeding workshop, Dr. Koop managed to include enactments of the World Health Organization’s (WHO) International Code of Marketing Breast-milk Substitutes, which Cadwell says was “very political.”

She tells me President Reagan refused to sign the legislation after speaking with highly influential formula companies.

“Reagan’s point of view was to not regulate things,” she explains.

It wasn’t until 1994 President Clinton delegation voted for the World Health Assembly Resolution, “which reaffirmed the 1981 WHO Code and called for an end to free and subsidized breastmilk substitutes in all parts of the health care system,” according to the New Hampshire Department of Health and Human Service’s and the New Hampshire Breastfeeding Task Force’s New Hampshire Breastfeeding Resource Guide.

Furthermore, when the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) began, breastfeeding support wasn’t included in its financial plans. In the 1970s during the  initial writing of WIC, all of the funding was based on artificial baby milk provision.

Cadwell explains that the program was primarily created to combat anemia; with the amount of people using homemade baby formula, their children weren’t getting enough iron.

It wasn’t until nearly two decades later when a separate line item for breastfeeding was added to the program. Cadwell attributes this accomplishment to Dr. Koop bringing breastfeeding “into the light.”

“Unfortunately, Dr. Koop didn’t see the immediate results of his work,” she says. “But we have the benefit of the foundation he laid.”

Dr. Koop’s belief that we can make change and progress if we go about it in a thoughtful and caring way is something all lactation professionals can commit to.

Cadwell says she is inspired by his engagement of the entire community in the process of moving breastfeeding forward.

“It’s not something to be legislated or mandated,” she says. “You have to bring people along.”