Foundation for Mother and Child Health India tackles malnutrition through community empowerment

In a small corner of the world, the Foundation for Mother and Child Health India (FMCH) is tackling malnutrition through community education and empowerment.

“To be able to be heard across continents is a really big deal for us,” FMCH CEO Piyasree Mukherjee, MSW says of being featured on Our Milky Way.

Mukherjee will present “Efficacy of Community Based First 1000 Days Initiative Across Two Urban Sites of Mumbai” at this week’s International Breastfeeding and MAINN Conference.

Mukherjee and her team found that the women they worked with managed to nourish their babies to a healthy state by breastfeeding over 70 percent of the time.

“The women we work with are phenomenal,” says Mukherjee.

The FMCH team recently celebrated the closure of their first initiative with the Dhobi Ghat community.

“The whole exit was kind of bittersweet,” Mukherjee shares. “As a non-profit there is a lot of fear saying we are going to close this program.”

But FMCH leaves the community well-equipped and empowered to thrive.

Community support group in Dhobi Ghat

“The community is strong,” Mukherjee confirms.

In fact, she reports that 92 percent of children in the Dhobi Ghat community are healthy under WHO guidelines;  whereas upon entry into the program, 82 percent of children were considered healthy.

“Here we have had the maximum impact on children with Moderate and Severe Acute Malnutrition,” Mukherjee comments.

Numbers aren’t everything to Mukherjee and her team though. Actually, Mukherjee admits that research analysis is not FMCH’s strong suit.

“We don’t understand numbers well,” she explains, and requests the help of other researchers who believe in this work.

Mukherjee and her team often measure success on an individual level.

“We say we have made an impact when we see a mother pick up a bunch of bananas over ramen noodles,” she explains.   

FMCH also places value on nutrition and the perception of health as part of communities’ conversations.

“It’s interesting that people still believe that you are sick only if you are bedridden,” Mukherjee comments.

FMCH community engagement event

FMCH calls on the Indian government to embrace nutrition as part of the national conversation, as well as focus on a preventative health model versus a reactive one that revolves around treatment.

Founded in 2006, FMCH launched its first intervention around 2008 with 200 children. To date, FMCH has worked with over 10,000 women and children in Mumbai and Thane districts of Maharashtra.

In 2015 FMCH had the opportunity to be part of the implementation group of Urban Nutrition Initiative, a first of its kind intervention designed specifically for urban slums by the Rajmata Jijau Nutrition Mission of Maharashtra. This was the first formal working relationship for FMCH with a Government system.

Prior to this connection, Mukherjee says FMCH was working “as a silo…. Not really a part of any existing system.”

“As we grew as an organization, we realized that you can’t really work as a silo especially in an urban setup,” Mukherjee begins. “You have to work within the system.”   

Today as a mandate to their model, FMCH works with the Integrated Child Development Scheme (ICDS) and the local Municipal Health Department.

Help spread the word about FMCH. Find them on social media @FMCHIndia.

Relactation success at National Children’s Hospital, Philippines

Joanne Datangel-Gallardo, MD, DPPS is a breastfeeding mother and pediatrician serving mostly poor patients at National Children’s Hospital, Philippines. She will present “Relactation Success Among Mothers of Formula-Fed Infants Who Received Lactation Education and Management at National Children’s Hospital, Philippines” at the upcoming International Breastfeeding and MAINN Conference.

In her presentation, Dr. Datangel-Gallardo will detail how proper lactation education, frequent follow-up, and management of individualized breastfeeding challenges have helped mothers to relactate despite months of exclusive bottle-feeding, without the need for any galactagogues. Dr. Datangel-Gallardo says that what once seemed like relactation anecdotes by  community breastfeeding support groups, has now been replicated and studied in her institution showing “promising results.”

Particularly, she recalls one mother-infant dyad under her study: The  baby was five months old and had been exclusively formula fed for three months. This baby was admitted for ileal stenosis and underwent surgery. After the surgery, Dr. Datangel-Gallardo remembers the mother begging to be included in the relactation study despite advice from their nutrition consultant to feed the baby commercially prepared milk. The mother refused. After two weeks of exclusively breastfeeding, the baby regained her original weight and  physical well-being, and this dyad continues to breastfeed at more than two years old.

Infant feeding challenges abound

Dr. Datangel-Gallardo reports that “the permeation of the propaganda of milk companies, even to the poorest of the poor, have led many mothers to believe that breastfeeding only works with the fortunate few.”

Others believe that breastfeeding is only meant for those who cannot afford artificial baby milk.  

And because Filipinos live in an extended family setting and “filial respect predominates”, ill-informed family members often influence mothers’ infant feeding plans when they’re told “that their milk is not enough for their babies.”

“This problem is compounded with cultural beliefs such as transferring ‘sickness’, ‘tiredness’ or ‘bad emotions’ to the infant through breast milk during emotional situations, or breastmilk in the left breast being rice and breastmilk in the right breast being water,” Dr. Datangel-Gallardo goes on.  

Artificial feeding is not often sustainable due to its financial burden on families. Some families resort to diluting milk or using coffee creamers, Dr. Datangel-Gallardo says. Severe malnutrition results. Save the Children Foundation reports that 1 in 3 children under 5 years old is malnourished in the Philippines.

Dr. Datangel-Gallardo describes birth culture in the Philippines: In the general population especially in the rural poor, many still opt for home birth attended by a traditional birth attendant or midwife. However, due to erroneous practices and increased…deaths in the past, the government policy insisted on lying-in, health centers and hospital settings for birthing. Quezon City passed an Ordinance banning home birth. What may work in an urbanized community may not in isolated islands such as Busuanga, Palawan with 6,000 inhabitants and only one municipal doctor. Add to this dismal situation, the rising rate of teenage pregnancy and their inability to get sufficient prenatal support in local hospitals. In Metro Manila, some groups that support traditional home birth or water birth supported by a qualified doula and a well trained midwife have been gaining respect. These few progressive groups have formed Gentle Birth Philippines and Pinay Doulas Collective to support mothers who desire unmedicated birth.

Gradually improving health outcomes

The World Breastfeeding Trends Initiative (WBTi) Philippines report shows a significant improvement from 2009 to 2015 in its assessment. Dr. Datangel-Gallardo sheds light on the government’s efforts which have influenced these outcomes. For instance, The Department of Health led by the Family Health Division convened the Infant and Young Child Feeding (IYCF) Management Committee, as well as its Technical Working Group composed of individuals from government agencies, the Philippine Pediatric Society, some NGOs like UNICEF and KMI and some breastfeeding groups. This collaborative’s five year plan is making progress, says Dr. Datangel-Gallardo.

Moreover, a Presidential executive order has made August Breastfeeding Awareness Month which is celebrated nationally with “media mileage.”

“Providing lactation rooms and paid lactation breaks among working breastfeeding mothers and extending the coverage of the Milk Code from infancy to young children (approximately 36 months)… may have made an improvement on the Philippines breastfeeding rates,” suggests Dr. Datangel-Gallardo.

Of course the adoption of the International Code of Marketing of Breastmilk Substitutes in the Philippines has played a role in improving maternal infant health outcomes.

Dr. Datangel-Gallardo, with the help of Ines Avellana-Fernandez Director of Arugaan and IBFAN SEA Coordinator, explain: Executive order 51 was signed by the late Philippine President Cory Aquino in 1986 under her government after ousting the late Dictator President Ferdinand Marcos. The law–Philippine Code of Marketing of Breastmilk Substitutes, Breastmilk Supplements and Related Products (popularly known as the Milk Code)– took effect in 1987 with persistent action by NGO breastfeeding coalitions, people’s organizations, religious groups, medical and legal professionals. In 2007, The Pharmaceutical and Healthcare Association of the Philippines sued the health department over proposed regulations to strengthen the Milk Code. 

“Compared to most countries we could say that the Philippines have taken big steps in controlling the promotional activities of these big milk companies who try to reach out to mothers and health professionals,” Dr. Datangel-Gallardo and Avellana-Fernandez go on. But, the Food and Drug Administration (FDA)– the organization assigned to process complaints, monitor the Milk Code and facilitate the review of milk companies’ promotional activities– has done little to enforce the Code, they say.  

“Sanctions for violations are also deemed very minimal compared to the enormous profit from sales of a bottle company,” they continue. “If such challenges persist, the slowly growing breastfeeding culture may eventually backslide.”

Dr. Datangel-Gallardo tributes the bulk of infant feeding improvements in the Philippines to volunteers.

“I could staunchly say that it was the efforts and spirit of volunteerism of the breastfeeding advocates and support groups outside the government health system who made a huge difference,” she begins. “Through the years, many breastfeeding support groups have been born in response to the needs of the society such as Arugaan, Breastfeeding Pinays (slang for Filipinas) and LATCH… Mothers from these support groups are volunteers and usually will give support without asking for anything in return.”

Connect with Dr. Datangel-Gallardo at the conference! Register here.

Placentophagy and its potential effects on breastfeeding: Guest post by Donna Walls, RN, BSN, IBCLC, ICCE, ANLC

We’re taking a brief break from International Breastfeeding and MAINN Conference introductions this week to bring to you a guest post by Master Herbalist, Certified Aromatherapist and Our Milky Way contributor Donna Walls, RN, BSN, IBCLC, ICCE, ANLC.

In many cultures, the placenta is regarded as a sacred, life-giving force even after the birth of the baby it helped sustain. Centuries-old traditions of ceremonial handling of the placenta like its burial, burning and consumption are practiced globally. It wasn’t until the 1970s and 80s that human placentophagy (consumption of the placenta) became increasingly popular in the U.S. for its perceived benefits like treatment of postpartum mood disorders and increased milk production.  Walls first encountered placentophagy in the form of placental encapsulation about eight years ago in her professional practice. She had some initial concerns.

“Does the progesterone interfere with early lactation?” she wondered.

Today, Walls and other maternal health care providers remain uncertain of the effects of placentophagy. Because it is “way far out of mainstream medicine,” there is scant research about the practice, Walls predicts.

The placenta acts as a “filter” during pregnancy; should we worry about maternal ingestion of toxins when consuming the placenta? Walls says this isn’t her biggest concern.

“I’m more worried about the lack of standards for preparation,” she says.

Moreover, Walls reports a connection between mothers who have low milk supply and ingestion of placenta in her practice.  This week, she shares with us her reflections and findings. With scarce evidence demonstrating either the safety or harm of placentophagy and a growing body of anecdotal evidence, Walls offers: “Nonjudgmental conversations are key.”

 

Placental Encapsulation: Friend or Foe of Postpartum Mothers?

In recent years a practice has appeared which involves the preparation of a woman’s placenta for ingestion. Preparation practices vary from dehydration to heat treatments. The dried and ground placenta is then placed in capsules for ingestion over the first days or weeks after birth.  Some recipes can be found for the use of the placenta for making soups, stews or smoothies to be eaten after the birth. This controversial practice has been cited as a common custom throughout history and often referred to as part of traditional medicinal systems. Many proponents of placental ingestion report the benefits of less postpartum mood disorders, enhanced breastmilk production, treatment of anemia and encouraging uterine involution.  Another rationale for ingestion points to the common mammalian practice of eating placentas immediately after the animal gives birth. Most authorities agree that this practice seems to be done for protection of the offspring by removing the smell of blood which can attract predators and not for nutritional needs. This immediate consumption also allows for the normal physiologic function of lactogenesis which occurs after the initial surge of ingested progesterone dissipates quickly over the first hours and days causing increasing levels of prolactin to begin early milk production.

Research supporting the safety and efficacy of placental ingestion, placentophagy, has been scarce as most information is anecdotal. Concerns include possible low milk supply issues and unregulated, unsafe preparation practices resulting in contamination and possible infections.  A case of neonatal group B Streptococcus sepsis was recently reported to the CDC. The Centers for Disease Control and Prevention then recommended that the intake of placenta capsules should be avoided owing to inadequate eradication of infectious pathogens during the encapsulation process The Association of Placenta Arts provides guidelines for patients and providers but at this time, there are no regulations for the safety in preparation or storage or standardization of amounts needed for therapeutic effects.

The low milk supply concerns can be explained by the physiology of early lactation. Placental progesterone fills and activates the receptor sites on the alveolar (milk making) cells during the pregnancy and is responsible for colostrum production in the last half of the pregnancy. At birth and with the expulsion of the placenta there is a dramatic, rapid drop in the progesterone allowing the receptor sites to empty of progesterone and fill with prolactin, the hormone responsible for milk production. Prolactin is released when the infant stimulates the nipple during feeding or nipple stimulation occurs with expression of milk.

There is no clear answer to the question of how much of the active hormone remains after the preparation process is completed. If the hormone is degraded, there may not be a negative effect on early milk production. If progesterone remains physiologically active there is a concern.  Only one study (Young et al, 2016) found that hormones did remain active and in levels high enough to cause a physiologic response.

In my professional practice, I have found a connection between mothers who have low milk supply and ingestion of placenta. Many of these mothers complained that they never really felt the initial filling, and when they expressed their milk, rarely pumped adequate milk to meet their infant’s needs.  They struggled with supply, even after adding extra feedings or expression sessions and often began supplementing when there was poor weight gain in the newborn period. There were enough cases noted that I added a routine question about the practice of placental ingestion to my history when working with mothers who have milk supply concerns. I have also found, within days, there was a filling of the breast and an increase in supply when the placental ingestion was discontinued.

So, how can we respond to patient questions? Should we be adding placental encapsulation education in our consults or prenatal breastfeeding classes? There seems to be enough research to be aware of some concerns regarding milk supply issues. We need to ask, nonjudgmentally, about the possible ingestion of placenta when there are low milk supply concerns. If education is provided either prenatally or post birth, it is helpful to supply all information and research to help our families reach an informed decision and then support their lactation needs with accurate, evidence-based techniques.

References

Beacock M. Does eating placenta offer postpartum health benefits? Br J Midwif 2012; 20(7):464–469. 10.12968/bjom.2012.20.7.464

Buser GL, Mató S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the Field: Late-Onset Infant Group B Streptococcus Infection Associated with Maternal Consumption of Capsules Containing Dehydrated Placenta – Oregon, 2016. MMWR Morb Mortal Wkly Rep. 2017 Jun 30;66(25):677–8.

Coyle CW, Hulse KE, Wisner KL, Driscoll KE, Clark CT. Placentophagy: therapeutic miracle or myth? Arch Womens Ment Health. 2015 Oct;18(5):673–80. 10.1007/s00737-015-0538-8

Daley MC. Eating the placenta after birth carries no health benefits, new study finds [Internet]. [cited 2017 Oct 16]. (Research Developments). Available from: https://www.nichd.nih.gov/news/releases/Pages/062615-podcast-placenta-consumption.aspx

Farr A, Chervenak FA, McCullough LB, Baergen RN, Grünebaum A. Human placentophagy: a review. Am J Obstet Gynecol. 2017 Aug 30; pii: S0002-9378(17)30963-8. doi: 10.1016/j.ajog.2017.08.016.

Gryder LK, Young SM, Zava D, Norris W, Cross CL, Benyshek DC. Effects of Human Maternal Placentophagy on Maternal Postpartum Iron Status: A Randomized, Double-Blind, Placebo-Controlled Pilot Study. J Midwifery Womens Health. 2017 Jan;62(1):68–79. 10.1111/jmwh.12549

Hammett F. The effect of the maternal ingestion of dessicated placenta upon the rate of growth of breast-fed infants. Journal of Biological Chemistry. 1918;(36):569–73.

Hayes EH. Consumption of the Placenta in the Postpartum Period. J Obstet Gynecol Neonatal Nurs. 2016 Feb;45(1):78–89. doi:10.1016/j.jogn.2015.10.008. Epub 2015 Nov 25. 10.1016/j.nwh.2016.08.005

Joseph R, Giovinazzo M, Brown M. A Literature Review on the Practice of Placentophagia. Nurs Womens Health. 2016 Nov;20(5):476–83. 10.1016/j.nwh.2016.08.005

Kristal MB, DiPirro JM, Thompson AC. Placentophagia in humans and nonhuman mammals: causes and consequences. Ecol Food Nutr 2012; 51(3):177–197. DOI: 10.1080/03670244.2012.661325

Marraccini ME, Gorman KS. Exploring Placentophagy in Humans: Problems and Recommendations. J Midwifery Womens Health. 2015 Aug;60(4):371–9. 10.1111/jmwh.12309

Young SM, Gryder LK, David WB, Teng Y, Gerstenberger S, Benyshek DC. Human placenta processed for encapsulation contains modest concentrations of 14 trace minerals and elements. Nutr Res. 2016 Aug;36(8):872–8. 10.1016/j.nutres.2016.04.005

Young SM, Gryder LK, Zava D, Kimball DW, Benyshek DC. Presence and concentration of 17 hormones in human placenta processed for encapsulation and consumption. Placenta. 2016 Jul;43:86–9. 10.1016/j.placenta.2016.05.005

‘Translating Maternal and Infant Community Health Needs Into Evidence-Based, Patient-Centered Care’

It’s hard to believe that the 24th International Breastfeeding and MAINN Conference is just a few weeks away. It’s just as hard to imagine that the upcoming conference could get any better than years’ past, but something tells me this one could be the best of all!

If you’re still considering registering, let me give you another reason to attend. Her name is Elizabeth Crabtree, PhD, MPH, Director of Clinical Integration and Evidence-Based Practice at Oregon Health and Science University (OHSU). Dr. Crabtree will present “Translating Maternal and Infant Community Health Needs Into Evidence-Based, Patient-Centered Care”.

Her presentation details how a highly engaged, multidisciplinary group of stakeholders addressed community health needs within a health system through the creation of a guideline that incorporates patient values and preferences, clinical expertise, and best available evidence in an effort to maximize patient outcomes.

Maternal child health has always been an interest of Dr. Crabtree’s.

“…Healthy moms and babies seem to be elemental components of a healthy community,” she begins. “I think it’s natural for anyone interested in health promotion to care deeply about maternal child health as there’s so much research that shows the importance of and connections between the mother/child relationship and the quality of interactions a child has in the first few years of life, to success and well-being in later years.”

During a graduate school internship at a safety net hospital’s emergency room, Dr. Crabtree surveyed women for mental health and intimate partner violence concerns.

“It was clear to see how a lack of needed resources and care in the perinatal period and early childhood resulted in poor health outcomes for both moms and children,” she reflects.

Dr. Crabtree has a two-year-old daughter, and she says the “privilege and challenges of motherhood” have made her even more invested in maternal/child health promotion.

Prior to joining OHSU, Dr. Crabtree worked at the Medical University of South Carolina (MUSC) and Texas Children’s Hospital. At MUSC, Dr. Crabtree worked with College of Medicine faculty to offer a project-based evidence-based practice course to second-year medical students. Small teams of medical students partnered with interprofessional clinical teams at MUSC’s hospital to engage students in conducting evidence reviews that informed practice guidelines and the development of clinical decision support tools.

For nearly a decade, Dr. Crabtree has led interprofessional clinical teams to develop and implement evidence-based plans of care. Collaboration has proven an essential element.

“It’s been remarkable to see the collaboration and advancements made in care standardization and coordination just by giving clinicians the opportunity to sit at the same table,” she says. “We also provide free lunch, which certainly helps get people to the table!”

A partnership of multidisciplinary teams of clinicians and patient representatives develop guidelines at OHSU; any discipline or specialty that will have interaction with a patient is represented on the guideline development team, Dr. Crabtree explains.

What evidence do Dr. Crabtree and her team consider? She defines evidence as published literature in peer-reviewed journals, acknowledging that just because something is published doesn’t mean it’s good evidence or reliable.

Moreover, she goes on, retrieval and review of primary literature can be burdensome for busy, practicing clinicians.

“The value of clinical practice guidelines and systematic reviews is that, if done well, they attend to quality concerns, and in a systematic and critical way appraise and synthesize studies to guide clinicians in their decision-making,” Dr. Crabtree explains.

She makes clear that clinicians shouldn’t be directed by evidence alone. Instead, evidence-based practice is about care that’s based on best available evidence, while remaining mindful of biases and expertise, and patients’ values and preferences.

“Delivering evidence-based care is the art of determining how to apply a given best practice or recommendation to the patient sitting in front of you in the exam room,” she says.

Dr. Crabtree reports that evidence-based guidelines can markedly shorten the time it takes for the translation of research to policy and practice to occur, from 17 to 7 years.

“There’s been a paucity of research assessing how to effectively implement best practices, and health systems often aren’t structured in such a way to successfully support and engage clinicians in these efforts,” Dr. Crabtree explains.

These insufficiencies highlight the importance of designing systems of care that support integrating best research into practice.

At the local health system level, Dr. Crabtree and colleagues at OHSU provide the opportunity for clinicians to build consensus around guideline development and how care should be delivered, and help to design workflows that make it easier for clinicians to “do the right thing.”

“I really believe it’s the duty of health systems to create the appropriate systems of care that support clinicians in integrating best research evidence and delivering evidence-based care in a consistent manner,” she notes. “It’s not realistic to expect an individual clinician to evaluate and translate all existing relevant literature on her own. Health system leaders and administrators need to make it easier through system design.”

Breastfeeding in Appalachia

Carroll (left) pictured with ABN Vice President Mishelle Trescott (right).

You’ll often hear Healthy Children Project faculty say, “All roads lead to breastfeeding.” Time and time again, this sentiment rings true for Our Milky Way interviewees, like Appalachian Breastfeeding Network (ABN) President Stephanie Carroll, BS, IBCLC, CLS, CLC. With a degree in Communications, Carroll never anticipated she’d be doing the work she’s doing today. The experiences of birthing her two daughters though, led her to become the first peer hired as part of the Breastfeeding Peer Helper Program at her local WIC office in southeastern Ohio.

“I…owe a lot to the retired WIC director who first saw a light in me, Sandy Walker,” Carroll says. “…Sandy saw how passionate I was about feeding my baby breast milk. It is now that I realize that Sandy was the one true supporter I had in my own breastfeeding journey.”

Now, Carroll works as a Lactation Consultant at Holzer Health System where she revels in helping mothers transform.

“Breastfeeding changes you,” says Carroll. “And when you see that change in someone because of the help you provided, there’s no better satisfaction.”

She goes on, “This career field is one built of passion and drive, not on money and numbers. It’s the most satisfying when you duplicate that passion.”

Pamela Poe, left, receives an award for the first West Virginia Baby-Friendly hospital Mon Health System pictured with Carroll (right).

Carroll also works closely with the director of Women and Children’s Services and the physician/nurse team to introduce and build their Baby-Friendly Designation Program. She collaborates with Coffective and does freelance website work and writing.

Carroll volunteers her time to ABN, the Ohio Lactation Consultant Association, Ohio Breastfeeding Alliance, and other public Facebook pages working to normalize breastfeeding.

In 2011, she started her own Facebook page for her WIC clinic.

“It quickly grew into a huge support system for many women across the nation,” Carroll reports. “My page has grown to almost 10,000 likes.”

Carroll acknowledges the potential danger in using Facebook for “consultations” like HIPAA violations and lack of client history.

“Social media is instead used for promotion, links to information, news articles, and humor,” she explains.

In May 2016, Carroll and a few of her colleagues launched ABN, “dreaming that one day [Appalachian] parents would have the access to lactation care that they deserve.”

In just one year, the network grew to 11 states and 250 members. Today, ABN houses almost 400 members and continues to grow.  

“The growth was exponential!” Carroll exclaims.

She reports the network has over 1,000 likes on Facebook, an after-hours hotline that took 188 calls in 90 days, and an expected 200 people at their next conference in 2018.

“This growth was not expected, but also not surprising,” Carroll begins. “There was absolutely no organization that grouped Appalachia as a culture, together, to make an impact for change.”

ABN tracks its reach in various ways: through its after-hours hotline where they can measure ‘who, when, where, and why,’ through “insights” by social media outlets on their social media campaign Empower Mom Movement, and on a different scale by

educating nurses, physicians and other hospital staff through their Hospital Education Initiative.

Carroll says that, much like the barriers to breastfeeding in Appalachia, the network and their organizations face similar challenges of being rural and having limited funding.

“However, with modern technology, such as e-mail, conference calls, and social media, we are able to stay in contact and work with each other remotely,” she explains. “We also have other states starting up their own ABN meetings in person to work on initiatives separately, yet together.”

Carroll will present Barriers to Breastfeeding in Appalachia at the upcoming 24th Annual International Breastfeeding Conference & Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives which will focus on the sociocultural perspective of breastfeeding barriers in the region.

Her presentation will include anecdotal stories from Appalachian women, the history of breastfeeding in Appalachia, and current disparities and barriers.

“…While the presentation will focus on breastfeeding, many of these disparities can be applied to all of Appalachian healthcare,” Carroll says. “In order to create change, we must be aware of where we are doing our mothers and babies wrong, and how we can educate to induce change in the right direction. It’s all about normalizing a biological function, but changing a culture in the meantime.”