‘Words have energy and power’: exploring language in infant feeding and perinatal health Part One

Words evoke imagery. 

Co-Director of Kabbalah Centre International Yehuda Berg has written that “Words are singularly the most powerful force available to humanity.” 

“We can choose to use this force constructively with words of encouragement, or destructively using words of despair. Words have energy and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate and to humble…” he continues.

“What sets us apart from the animal kingdom is the use of symbolic language. Our ability to put our thoughts into words that symbolize objects allows us to communicate beyond the means of simple vocalization.” 

What do you think of when you see, say or hear the word breastfeeding? Is it a white woman with her white baby in flowing sheaths of gauzy fabric  feeding directly at the breast in a field of wildflowers? Is it a non-binary parent feeding their baby with a supplemental nursing system? Is it a parent feeding in public, covered by blankets so only the baby’s feet are visible? Is it a group of BIPOC women, holding their babies at their breasts looking fiercely at their audience? Is it pruned imagery of a baby’s mouth latched to a body on an informational pamphlet? 

Photo by William Fortunato : https://www.pexels.com/photo/mother-using-phone-while-breastfeeding-her-child-6392810/

During the United States Breastfeeding Committee’s (USBC) National Breastfeeding Conference & Convening 2022 session Decolonizing Language: Exploring Intent and Impact with Casey Rosen-Carole (she/her/s) of the Academy of Breastfeeding Medicine (ABM), Jordyn White, Deputy Director of Communities and Volunteer Relations at Human Rights Campaign, and Mari Villaluna, a lactating solo parent and doula, participants were asked to consider what breastfeeding looks like in our minds and how breastfeeding is perceived in society. 

Can we expand the images that come to mind when we use certain words? we were challenged.

“…Words have been streamlined to only pertain to certain types of people,” White began. “The visual connection to the word is always very strong. Words can be ostracizing even when they’re not intended to be. The goal in decolonizing language shouldn’t always be including new language, but also taking back the words that exist and reminding people that there are a myriad of ways that we can manifest.” 

Perhaps the words that we have were never intended to have a singular meaning, White went on to suggest. 

As we close out Pride Month, in two installments,  we’re exploring concepts around the language we use in infant feeding. This week, we explore some of those concepts which pertain specifically to the LGBTQI+ community. Stay tuned next week for others that are more generally applied. 

 

Language limitations and opportunities for inclusivity 

English is a language of colonization, and it has limitations. 

Photo by Kampus Production: https://www.pexels.com/photo/a-gay-couple-parenting-a-child-7983196/

Currently in our country, people sometimes grapple with the “newness” of being transgender when in reality, being transgender is not a trend. Trans people have been documented in ancient societies, and so there has been language to describe those experiences too. 

USBC conference participant Candi Cornelius writes: “A native American term for LGBTQ population is ‘Two spirited individual’. In history they were spiritual leaders with great strengths since they walk in both worlds (male and female). Each tribe has their own stories of two spirited individuals.”

Casey Rosen-Carole (she/her/s) discussed ABM’s Position Statement and Guideline: Infant Feeding and Lactation-Related Language and Gender which covers language considerations like legal, research, translation, scientific accuracy, and personal preference. All of these arenas bring up different intricacies and challenges. 

For instance, “Desexed or gender-inclusive terms may be confusing in languages other than English. Many languages assign gender to every noun, so that such terms cannot be gender-neutral. For example, in an attempt to be gender inclusive, the word ‘parent’ is often substituted for ‘mother,’ but in many languages, ‘parent’ is a masculine noun that could mean ‘father.’ Many languages have no gender-neutral equivalent for relevant words. For example, in many languages, the term for ‘breast milk/human milk’ is ‘mother’s milk.’”

Check out Breastfeeding: A Universal Language of Love for a list of translations. 

Rosen-Carole sums things up by asking “Who are we talking to?” In a one-on-one interaction with a family, their language preferences should always be respected. When scientific accuracy is necessary, using desexed language may not be appropriate. 

As noted in the ABM protocol, “In clinical settings, health effects seen in mother–infant breastfeeding dyads cannot be generalized to other dyads due to lack of data and known or predictable differences with other dyads based on chromosomal, hormonal, and anatomic factors. Thus, substituting ‘parents’ for ‘mothers’ may be factually inaccurate.”

White made an important distinction for practitioners and researchers:  “The goal of this conversation and others like this is not to invalidate or undo any of the work that has been done because your research used the word ‘mother’ and ‘breastfeeding’. That’s not what’s happening here. We are evolving. The field is evolving.”

 

Reframing disparity and acting on inequity 

Equity has become a buzzword; in fact, one author brands the sentiment “Fakequity”. USBC presenters expressed their fatigue with the word. “We want to see action,” they said.

From Native Breastfeeding Coalition of Wisconsin: Oneida Nation

Director of the Urban Indian Health Institute and Executive Vice President of the Seattle Indian Health Board Abigail Echo-Hawk, MA (Pawnee) reframes the language we use when describing disparities and inequities. Echo-Hawk points out that it is not accurate to call out disparities within Indigenous communities; instead, Indigenous communities have disparities because of the systems that oppress them. 

Echo-Hawk and other USBC presenters asked participants to consider the implications of the term evidence-based. Historically and recently in the context of the COVID-19 pandemic, American Indian and Alaska Native populations have been left out of public health surveillance data, coined as Data Genocide. A parallel phenomenon is happening in API communities too.

Photo by RODNAE Productions: https://www.pexels.com/photo/man-love-woman-joy-8298421/

Alternatives suggested to evidence-based were community-based, people-informed and practice-based.  Another term to consider here is culturally rigorous science which is for and by the people.  

Hummingbird Indigenous Doula Services is a culturally responsive, full-spectrum, Indigenous doula program, proudly not rooted in “evidence”. Instead, it’s a community designed program and as Camie Jae Goldhammer,  MSW, LICSW, IBCLC, (Sisseton-Wahpeton) points out, it was specifically funded because “the outcomes are amazing” thanks to their people-based approaches. 

In the comments during these sessions, there were requests to do away with the word minority ASAP. 

Mr. Rashaad Lambert, Director Of Culture & Community @ Forbes/Founder of For(bes)TheCulture explains in There Is Nothing Minor About Us’: Why Forbes Won’t Use The Term Minority To Classify Black And Brown People, “…Non-whites are already a majority of the world’s population. Second, in my lifetime, people of color will compose a majority in America. Finally, as any Black or Brown person will tell you (and as echoed in the words of Prince), there is nothing minor about us.” 

Stay tuned next week for Part Two.

Facilitating the bond between children and fathers or male-identifying partners

 There’s quite a bit of literature on why it is important for fathers to support breastfeeding, and robust recommendations on how fathers can be good support people.

Photo by Anna Shvets: https://www.pexels.com/photo/a-man-in-blue-long-sleeves-playing-with-his-baby-11369399/

Specifically in Black communities though, there’s a “lack of resources for men to learn about and advocate for breastfeeding.”  George W. Bugg, Jr, et al. write in Breastfeeding Communities for Fatherhood: Laying the Groundwork for the Black Fatherhood, Brotherhood, and Manhood Movement  that “Black men deserve to be educated in culturally competent ways about prenatal and postpartum care to advocate for their partners. This is not happening in a systematic way in the Black community. In the Reproductive Justice space, Black men are basically being treated as if they are invisible.” 

As a whole, our nation lacks support for fathers and male identifying partners to bond with their babies. The father–infant relationship should be honored “in its own framework rather than as an alternative to mother–infant theory.” (Cheng 2011

Author Carolynn Darrell Cheng, et al points out in Supporting Fathering Through Infant Massage that “fathers may feel dissatisfied with their ability to form a close attachment with their infants in the early postpartum period, which, in turn, may increase their parent-related stress.”

Photo by Caroline Hernandez on Unsplash

Infant massage is such a neglected modality, especially in the NICU, where it reduces both the risk of sepsis and bilirubin levels, and gets babies home sooner because their brains mature more quickly and they gain weight faster,” Nikki Lee points out. 

Beyond its benefits to infants, Cheng and colleagues have found that “infant massage appears to be a viable option for teaching fathers caregiving sensitivity.” Their work showed that “fathers were helped by increasing their feelings of competence, role acceptance, spousal support, attachment, and health and by decreasing feelings of isolation and depression. Although not all fathers saw the direct benefit of infant massage instruction, they did note they enjoyed participating in an activity that gave them special time with their infants and appreciated the opportunity to meet other fathers.” 

More broadly, skin-to-skin contact has a positive effect on paternal attachment.  

The results from Effects of Father-Neonate Skin-to-Skin Contact on Attachment: A Randomized Controlled Trial identified touching as the highest-scoring Father-Child Attachment Scale (FCAS) subscale. 

Ontario artist Lindsay Foster’s viral image of fathers BJ Barone and Frankie Nelson meeting Baby Milo captures perfectly the flood of oxytocin that skin-to-skin affords fathers and male-identifying parents.

Fathers BJ (left) and Frankie (right) embrace their seconds-old-newborn boy Milo. Milo’s umbilical cord is still attached to the surrogate in this image.
Photo by Ontario artist Lindsay Foster.
Formerly published in: http://www.ourmilkyway.org/skin-to-skin-image-goes-viral/

The World Alliance for Breastfeeding Action (WABA) identifies other ways in which fathers can be “empowered by a whole-of-society approach to fulfill their fathering capacity.” 

WABA suggests that fathers should be engaged and involved throughout the 1,000 days and health systems and care providers can provide knowledge on breastfeeding through antenatal visits, other breastfeeding classes and enabling their participation during labor and delivery and postnatally. 

Sufficient paternity or parental leave is vital to allow time to care for and bond with their new family. 

There is also “a need for greater vigilance against promotion and unethical marketing of breastmilk substitutes targeting fathers to ensure that they also get unbiased information.” [More here.] 

In our national sphere of advocacy, last month, Foundations of Fatherhood Summit hosted Wide World of Fathering  with a mission to advance fatherhood and families in Michigan communities and beyond. The speaker lineup was full of individuals passionate about fatherhood and working to shift the way we view males as parents. 

Presenter Reginald Day, CLC for instance, hosts a podcast called Get At Me Dad which reveals the true narrative of BIPOC fathers–”present, connected and raising strong families.”

Father-son duo Mark and Corey Perlman host another podcast called Nurturing Fathers based on the Nurturing Fathers Program

Last week, New Mexico Breastfeeding Task Force Board Member Francisco J. Ronquillo hosted a Hearing our Voices virtual roundtable for fathers and male-identifying partners. 

Reaching Our Brothers Everywhere (ROBE), an organization which seeks to educate, equip, and empower men to impact an increase in breastfeeding rates and a decrease in infant mortality rates within the African-American communities, hosts a monthly virtual call where males can discuss maternal child health related topics.   

In partnership with Reaching Our Sisters Everywhere (ROSE), ROBE will host the 11th Annual Breastfeeding and Equity Summit in New Orleans from August 25  to 27, 2022 where presentations center on equity in breastfeeding, maternal health, fathers and partners, and infant health initiatives.

 

Our Milky Way past coverage on fathers

Photo by PNW Production: https://www.pexels.com/photo/a-family-walking-together-on-a-boardwalk-8576210/

New CLC engages fathers, supports breastfeeding, heals communities

Fathers profoundly influence breastfeeding outcomes

Founder of Fathers’ Uplift adopted into breastfeeding movement

The Institute of Family & Community Impact hosts event to boost paternal mental health

Paternal mental health and engagement

Robert A. Lee, MA answers the call

A lasting bond 

Skin to skin image goes viral

Changing families demand changing policies

22 more actions in 2022

 In our third installment of 22 in 2022, we bring you 22 MORE Actions in 2022, because there is always work to do. 

Source: United States Breastfeeding Committee

22 in 2022 was inspired by Life Kit’s 22 Tips for 2022, and we hope it provides inspiration for you to forge forward with this important work.

  1. Learn about the Girls’ Bill of Rights. Empowered women start with empowered girls. 
  2. Watch a film centered around maternal child health like  A Doula Story, The Milky Way breastfeeding documentary, Chocolate Milk, Zero Weeks, Legacy Power Voice: Movements in Black Midwifery or register to play Factuality
  3. Identify and network with an individual or organization with a mission that intersects with maternal child health. This shouldn’t be a challenge… “All roads lead to breastfeeding!” (A popular adage at Healthy Children Project.)  Often, we find ourselves preaching to the choir, shouting in an echo chamber, whatever you want to call it. It’s time to reach beyond our normal audience. 
  4. Follow Dr. Magdelena Whoolery on social media to stay up to date on strategies that combat the multi-billion dollar artificial baby milk industry. 
  5. Sign on to USBC’s organizational letter in support of the DEMAND Act of 2022.
  6. Congratulate, encourage or simply smile at a mother. 
  7. Explore White Ribbon Alliance’s work around respectful care. You can start by watching this poignant webinar Healthcare Professionals Honoring Women’s Demands for Respectful Care
  8. Read The First Food System: The importance of breastfeeding in global food systems discussions.
  9. Read Lactation in quarantine: The (in)visibility of human milk feeding during the COVID-19 pandemic in the United States
  10. Sign this petition to stop unethical formula research on babies. 
  11. Check out the updated Center for WorkLife Law’s Winning New Rights for Lactating Workers: An Advocate’s Toolkit
  12. Register for a free PQI Innovation webinar.
  13. Read the revised Academy of Breastfeeding Medicine (ABM) Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads here
  14. Gear up for World Breastfeeding Week 2022 and National Breastfeeding Month. 
  15. Check out this NIH project Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project which seeks a deeper understanding of human milk biology to address ongoing and emerging questions about infant feeding practices.  
  16. Learn about the Melanated Mammary Atlas.
  17. Consider becoming a ROSE community transformer or share the opportunity with someone who may be interested. 
  18. Get familiar with WHO’s recent report How the marketing of formula milk influences our decisions on infant feeding and disseminate the corresponding infographics
  19. Sensitize journalists and the media to stimulate public debate on the links between breastfeeding and the climate crisis as suggested by the World Alliance for Breastfeeding Action (WABA).
  20. Get to know how breastfeeding and proper nutrition fits into the Sustainable Development Goals (SDGs)
  21. Access one of the National Institute for Children’s Health Quality’s (NICHQ) webinars on breastfeeding, infant health, early childhood or health equity here
  22. Engage with the PUMP Act Toolkit! This is crucial, time-sensitive work that will make a huge difference for families across our nation.

Read our original list of 22 Actions here and our celebration of unsung sheroes/heroes here

Physicians as breastfeeding supporters

Photo retrieved from: https://tobacco.stanford.edu/cigarette/img0079/

“More doctors smoke camels than any other cigarette,” claims the ad from 1950. Today, it’s preposterous to imagine that any physician would align themselves with the tobacco industry. Starting  in the 1920s and continuing well into the 1950s though, tobacco companies used doctors to help them sell their products. Stanford’s Research into the Impact of Tobacco Advertising has a collection of over 1,000 advertisements that feature doctors endorsing tobacco products. 

In an eerie parallel, WHO’s February 2022 report, How the marketing of formula milk influences our decisions on infant feeding, states that “Recommendations from health professionals are a key channel of formula milk marketing. Health professionals spoke of receiving commissions from sales, funding for research, promotional gifts, samples of infant and specialized formula milk products, or invitations to seminars, conferences and events.” (p. 7) 

Last week, Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500 and I shared our reflection on the forces that shape physicians’ personal infant feeding experiences. In this second installment, we explore how physicians as professionals can support breastfeeding despite being targeted by the breastmilk substitute (BMS) industry and despite generally being woefully equipped with proper lactation education, training and counseling skills. These predicaments can lead physicians to “explicitly or inadvertently, introduce doubts around the ability of women to breastfeed and the value and quality of their breast milk.” (WHO, p. 12) 

 

Pervasive industry influence for generations

Because “health professionals are among the most respected and trusted members of society…[their] advice…is highly influential for pregnant women and parents of infants and young children, including around infant feeding decisions.”  Formula milk companies exploit this relationship of trust. (WHO, p. 12)

Source: United States Breastfeeding Committee

BMS representatives target physicians “with a range of incentives, including funding for research, commissions from sales, ambassadorial roles, merchandise, gifts and all expenses paid promotional trips.” (WHO, p.13) 

The psychology behind gift-giving, both big and small is that “ it imposes…a sense of indebtedness…. The…rule of reciprocity imposes…an obligation to repay for favors, gifts and invitations…” (Katz 2003) Instead of supporting infant feeding purely through a health and wellness lens, physicians feel obliged to a company muddying their relationships with their patients. 

Interestingly, most physicians feel immune to marketing’s influence, despite clear evidence to the contrary, Frederick S. Sierles, MD lays out in The Gift-Giving Influence

Curious consumers can search their doctors’ names through ProPublica’s Dollars for Docs project to learn about gifts they have accepted. 

 

Mechanical culture 

Our culture fails to acknowledge the mother baby unit as a dyad, and this influences the way physicians can support breastfeeding too.

Source: United States Breastfeeding Committee (USBC)

“We are never taught, in our fragmented system, that the mother and baby are a unit,” Lee reiterates. “OB/GYN/midwife sees mama; peds sees babies. There are even different places for them in the hospital: nursery, postpartum unit. What a struggle we had with the BFHI to keep mother and baby together.” 

[As a side, Attorney Leah Margulies recently shared in Protecting Breastfeeding in the United States: Time for Action on The Code that formula companies provide architectural designs to maternity care facilities in a deliberate attempt to separate dyads.] 

The Alliance for Innovation on Maternal Health’s (AIM) Patient Safety Bundles offer models for how health professionals can use task force approaches that break down silos of care and open channels of communication. The strategies used in these bundles aim to ultimately shift from fractured care to continuity of care where the dyad is protected.  

We must also consider how physicians are compensated for their work. In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans, as we mentioned in our first installment. In short, the more RVUs a physician racks up, the more they’re paid. Breastfeeding counseling takes time.

 

Inadequate education 

How are physicians to spend time with their patients, educating and supporting breastfeeding when they’ve had little to no breastfeeding education invested in them? Dr. Nigel Campbell Rollins pointed out in WHO’s How the marketing of formula milk influences our decisions on infant feeding webinar that faculty in medical schools themselves sometimes believe that formula products are inevitable or necessary. 

A cross-sectional study in the UK suggests that UK medical schools are not adequately preparing students to support breastfeeding patients.  

Source: United States Breastfeeding Committee

Samantha A Chuisano and  Olivia S Anderson’s findings in Assessing Application-Based Breastfeeding Education for Physicians and Nurses: A Scoping Review “… align with existing literature in finding a dearth of high-quality studies assessing breastfeeding education among physicians and nurses. The variability in teaching and evaluation methods indicates a lack of standardization in breastfeeding education between institutions.”

Elizabeth Esselmont and colleagues’ piece Residents’ breastfeeding knowledge, comfort, practices, and perceptions: results of the Breastfeeding Resident Education Study (BRESt) concludes: “Pediatric residents in Canada recognize that they play an important role in supporting breastfeeding. Most residents lack the knowledge and training to manage breastfeeding difficulties but are motivated to learn more about breastfeeding. Pediatric program directors recognize the lack of breastfeeding education.” 

 

A collection of physicians’ stories 

Often, it is a physician’s own struggle to breastfeed that seems to spur advocacy and change. Our Milky Way’s repository includes a breadth of physicians’ stories of personal struggles that have inspired them to become breastfeeding champions for their patients and communities. 

Source: United States Breastfeeding Committee (Photo by Sara D. Davis)

Some of those stories are linked below: 

Sarah Jacobitz-Kizzier, MD, MS, in Resident physician advances breastfeeding support,  shares that her lactation education in medical school included a one hour lecture about the anatomy of the breast and a brief discussion in physiology about lactogenesis.

“There was no training about [breastfeeding] technique, no discussion about common problems before discharge, no training about clinical problems as far as in the first few months postpartum…when to introduce complementary food,” she continues.

Physician calls for peer breastfeeding support features the work of Colette Wiseman, MD, CLC. 

In Breastfeeding in the healthiest county in Virginia, Janine A. Rethy, MD, MPH, FAAP, FABM, IBCLC, a general pediatrician in Loudoun County, Va. describes her dedication to improving breastfeeding outcomes. In it, she shares a resource she and her colleagues created –the Breastfeeding Support Implementation Guide for the Outpatient Setting which includes information on how to bill insurance for lactation services.

Skin to skin in the OR showcases Rebecca Rudesill’s, MD, CLC quest for more breastfeeding education. 

Kristina Lehman’s, MD, CLC work is featured in Internist looks to augment breastfeeding education

James Thomas Dean III, DO and Assistant Professor of Pediatrics at the University of Texas San Antonio Dr. Perla N. Soni, MD share their perspectives in Lack of breastfeeding education in med school harms families

Alison Stuebe, MD, MSc tackles big topics in OB/GYN sheds light on breastfeeding culture.

We are honored to have been able to feature the work of the late Audrey Naylor in Commendable contributions to the field of lactation. ​​With a lifetime interest in illness prevention, Naylor said she was quickly convinced of the power of breastfeeding after only attending a few hours of a breastfeeding seminar in 1976.

“Neither medical school nor pediatric residency taught me anything about breastfeeding,” Naylor said.  

Elizabeth Sahlie’s, MD, FAAP and Jesanna Cooper’s, MD work is featured in Birmingham Mother-to-mother support helps moms reach feeding goals. Cooper says that before she became a mother, she had no idea that her medical training and education had been so lacking.

“It is easy to become frustrated with nurses and physicians who – often inadvertently sabotage breastfeeding mothers and babies, but I also sympathize,” she explains. “We are in a position where we are supposed to have answers, but no one has taught us the skills necessary to provide those answers.”

Other stories and models for care 

Lori Feldman-Winter’s, et al  Residency curriculum improves breastfeeding care showed that “a targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.

 As part of their work to build a cohort of breastfeeding-friendly pediatricians, the Georgia Chapter of the American Academy of Pediatrics and the Georgia Breastfeeding Coalition launched a “Breastfeeding-Friendly Pediatrician Interest Form.” Georgia pediatricians who are interested in becoming certified as a “Breastfeeding-Friendly Pediatrician” are invited to fill out the form.

 

Further reading and resources

Physicians, Formula Companies, and Advertising: A Historical Perspective

Inspire Health, CHAMPS,  and the University of Mississippi Medical Center’s Breastfeeding, Human Medicine,  Interprofessional Education training   

CDC Physician Breastfeeding Education  

What Every Physician Needs to Know About Breastfeeding from the W.K. Kellogg Foundation

The Institute for the Advancement of Breastfeeding & Lactation Education (IABLE) is a nonprofit membership organization whose mission is to optimize the promotion and support of breastfeeding for families in the outpatient sector. IABLE is dedicated to building Breastfeeding Knowledgeable Medical Systems and Communities. 

Academy of Breastfeeding Medicine (ABM) Breastfeeding-friendly Physicians protocol 

 

Physician group position papers and recommendations on breastfeeding 

American Academy of Pediatrics (AAP)

American Academy of Family Physicians (AAFP)

The American College of Obstetrics and Gynecology (ACOG) 

Physicians as parents: How can one pour from an empty cup?

A medical student once told Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500  about an obstetrician who loved to pump while she was catching babies because she collected more milk than usual. Lee theorizes that perhaps it was due to the high levels of oxytocin in the atmosphere during childbirth. 

It’s a fascinating concept, and quite unusual considering physicians often find themselves in a terrible paradox. As Lee puts it, they are supposed to take care of everybody else, and no one takes care of them. They’re expected to be experts on everything;  as childbirth educators and lactation care providers, we often disclaim “this information is not meant as a substitute for medical advice.”

In this two-part series, Lee and I set out to explore the forces that surround infant feeding, ones that physicians must muscle through as parents themselves and as professionals. We explore emerging themes inspired by the article Medical training taught this Philadelphia doctor about breast feeding. But the real lessons came from her twins. In Part One, we offer thoughts on physicians functioning as parents themselves. Part Two covers physicians as professionals trying to support breastfeeding most often with inadequate education and training.

Source: United States Breastfeeding Committee

With insufficient support in their personal infant feeding goals, physicians’ struggles sometimes seem to spur advocacy and a “do-better-for-my patients” attitude. Just the same, these experiences can lead individuals to harbor resentment, despair, resignation and defeat, and might unintentionally influence the breastfeeding support they are able to offer their patients. 

When physicians’ basic needs aren’t met, we can’t expect them to meet the needs of their patients. How can one pour from an empty cup?  Kathleen Kendall Tackett offers Burnout, Compassion Fatigue, and Self Care for Members of the Perinatal Team which presents insights on the effects of little institutional support and specific strategies for integrating self-care into care for others. 

Self-care is sustainable only when everyone can do it. 

Before physicians are done with their decade or more of training, they are challenged by inadequate support in their efforts to feed their own children. 

“In a survey of 412 medical trainees with children, more than 80% of women reported feeling stressed about breastfeeding, and one-third did not meet their breastfeeding goal,” Gaelen Dwyer points out in Pumping up support: Making breastfeeding easier for med students

What’s more, a  recent research letter, American Board of Medical Specialties Board Examination Lactation Accommodation, evaluates the American Board of Medical Specialties (ABMS) member boards’ lactation-specific board examination accommodation policies highlighting that a minority of female physicians (42%) achieve the recommendation that infants receive mother’s milk at least until age one. 

Source: United States Breastfeeding Committee

“Board examinations are a key aspect of medical training,” the authors begin. “With up to 22% of female trainees delivering a child during postgraduate training, and nearly 59, 000 female physicians in residency and fellowship in the US, there is a large group potentially affected by board examination lactation accommodations.”

About a decade ago, ​​in a landmark case that has implications for all testing organizations in Massachusetts, a unanimous Massachusetts Supreme Judicial Court ruled that breastfeeding mothers are entitled to special accommodations to allow them sufficient time to pump milk during lengthy testing for medical licensure. [https://www.wbur.org/news/2012/04/13/breastfeeding-doctor-ruling ] 

The elephant in the room is the issue of parental leave. Honestly, it’s hard to stomach that we are still arguing that there are medical and psychosocial benefits of protected parental leave for both parents and children. The U.S. is the only Organisation for Economic Co-operation and Development (OECD) member country—and one of only six countries in the world—without a national paid parental leave policy. The U.S. is also one of the few high-income countries without a national family caregiving or medical leave policy. [https://bipartisanpolicy.org/explainer/paid-family-leave-across-oecd-countries/

Women don’t breastfeed; societies do. The societal burden on the mother is magnified when the mother is a physician and is compelled to take care of everyone else, with no support for their own breastfeeding. Breastfeeding is blamed for being difficult, instead of us all getting furious that we don’t have paid maternity leave.

In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans. In short, the more RVUs a physician racks up, the more they’re paid. Often that leaves lactating physicians forgoing pumping to spend more time with patients. The Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act would close the loopholes that force physicians to choose income or feeding their babies. The PUMP Act advanced out of the Senate HELP Committee with unanimous bipartisan support in May 2021 and then passed with significant bipartisan support (267-149) in the House last October. Despite this strong bipartisan support, the bill has languished in the Senate for almost a year. Get updates on progress here

In February 2021, the American Academy of Pediatrics (AAP) issued a policy statement on Parental Leave for Residents and Pediatric Training Programs.

Source: United States Breastfeeding Committee

The policy reports that the Institutional Requirements of the Accreditation Council for Graduate Medical Education require training programs to provide written policies regarding leaves of absence, including parental leave, and these policies must comply with current legislation such as the Family Medical Leave Act (FMLA), but that the length of leave has considerable variability among residency programs. The statement outlines the challenges of parental leave policies in training programs and gives recommendations to protect trainees and their families. One challenge is that education calendars are set long before a person enters a medical program, but labor, delivery, and the establishment of breastfeeding don’t fit into a predetermined calendar. 

Despite this dismal landscape, the medical world is changing and there are stories and models to celebrate. 

Catherine Wagner, a cardiothoracic surgery resident at Michigan Medicine, managed to breastfeed and pump for a year during her residency with a network of support. 

A committee at the University of Michigan is calling on pediatricians to support their fellow physicians.  Pediatricians Advocating Breastfeeding: Let’s Start with Supporting our Fellow Pediatricians First describes the efforts to support lactation within the department. The committee collected university policies, state and federal laws, identified the needs of breastfeeding mothers and then created a policy to support lactating individuals as well as a handout to help supervisors and colleagues support lactating women in the healthcare setting. (Supplemental material; available at www.jpeds.com).

Got Milk? Design and Implementation of a Lactation Support Program for Surgeons describes an initiative where “Multiple faculty members offered to offload resident workload before starting cases to provide time for a lactating resident to express milk… The University of Wisconsin adopted a ‘cross-cover’ model encouraging lactating residents to have other residents assist in the operating room during non-critical portions of the case if the primary operating resident needed to express milk that has been very well received and easily implemented.”

Source: United States Breastfeeding Committee

There’s attention being paid to lactation accommodation information in urology residency programs too. 

In this study, “Of 145 urology residency programs, 72.4% included information about lactation accommodations anywhere on the institution’s website.” The authors conclude that “efforts to recruit and retain female urologists should include making [lactation accommodation]  information more easily accessible.”

Authors Annery G Garcia-Marcinkiewicz and Sarah S Titler call on  anesthesiology as a workforce and specialty, to support the unique need of lactating and breastfeeding anesthesiologists in Lactation and Anesthesiology

This study offers the first comprehensive scoping review of the literature on breastfeeding policies pertaining to surgical residents in Canada.

The authors write: “…We aim to use these data to advocate for breast feeding for surgical resident physicians through the creation and improvement of current breastfeeding policies as applicable. This work aims to help change surgical culture to be more inclusive, which is vital in creating a breast feeding-friendly environment. This would include leadership endorsement of the policy, a culture shift (for example, no repercussions to resident for coming back on a modified schedule or taking breaks for expressing milk), visible educational notices throughout the workplace (ie, ‘breast feeding-friendly workplace’ notices, common in Canadian public settings), and creation of a network of ‘new moms’ within the surgical resident programme to ensure there is support and mentorship for new moms returning back to work. ”

While we wait for policies to catch up to the needs of lactating physicians, wearable pumps are helping them reach their infant feeding goals.  The Impact of Wearable Breast Pumps on Physicians’ Breastfeeding Experience and Success found that “those who had used a wearable pump reported statistically significant shorter lactation breaks (p < 0.00001) and were more likely to be able to provide breast milk to their infants for their entire intended duration (p = 0.005) compared to the traditional pump group.” 

The support network Dr. MILK (Mothers Interested in Lactation Knowledge) has been successful at helping physicians mothers reach their infant feeding goals. 

Where else are you seeing physician parents being supported in their infant feeding journeys? Email us at info@ourmilkyway.org