Bridging the gap for skin-to-skin

It’s dangerous to think it’s up to mothers alone to successfully breastfeed. Support for breastfeeding moms in the home, in the community, and at the national level matters.  

Regina Hirt, RN, IBCLC and her team at Froedtert & the Medical College of Wisconsin Community Memorial Hospital in Menomonee Falls, Wis. are making sure breastfeeding dyads are protected and supported beyond their initial postpartum period in the hospital setting.

Last winter Hirt and her colleagues launched an initiative, Bridging the Gap for Skin-to-Skin, which educates and trains hospital staff and EMS providers in the community how to implement skin to skin contact between mother and baby. Skin to skin contact has seemingly endless benefits including increased breastfeeding success.

Hirt and her team started with hospital grand rounds in February 2016. When a mother comes to the hospital, even for a non-obstetrical related procedure, skin to skin with her baby is now offered as a standard of care.

Hirt and Johnston present their poster at the 2017 International Breastfeeding Conference.

Two months later, Hirt, EMS Liaison Julie Brady, Nurse Educator Pamela Johnston RNC, BSN, and the Medical OB Director collaborated to develop new training for EMS providers in the community. This piece was of particular importance because newborns admitted after precipitous births were arriving hypothermic and with delayed breastfeeding initiation. Training these providers how to implement skin to skin contact was the answer. The practice regulates babies’ body temperature better than any device on the market and allows baby direct access to its food source.

Skin-to-skin in the OR

Obstetrical emergency training was given too including how to safely assist with a precipitous birth in the field or in the ED, assist with initial skin to skin contact, safely assist with shoulder dystocia, and be able to identify cord prolapse and manage care until delivery.

The team extended the training to outlying EMS systems: a freestanding Emergency Department and local fire departments in Waukesha and Washington Counties.

“There was a lot of education that was needed,” Hirt says.

For instance, emergency responders were surprised to learn that the umbilical cord should be cut after baby is placed skin to skin on its mother.

One fire department claimed that transporting baby placed skin to skin on mother was against their policy; that baby must be placed in a separate restraint. Transporting baby and mother belted to the same restraint is indeed safer, Hirt explains. Training included showing personnel how to properly belt mother and baby to the restraint while implementing skin to skin contact. Hirt shared the case of the newborn baby who was severely burned by a foil blanket while transported separately from her mother after an unexpected birth as an example of how dangerous it can be to separate mother and baby.

Despite minor pushback from this department, Hirt and her team applaud 100 percent positive feedback from 150 staff and EMS personnel.

EMS personnel surveyed reported that is was “awesome education, new information was presented, and the hands on practice was great.”

In an effort to ensure changes are continuously and safely implemented and so new staff receive proper training, quarterly hospital-wide education is performed. Emergency department orientation occurs monthly, and Hirt’s team offers yearly education and site visits to the local fire departments, all of which have welcomed the opportunity.

Eventually, Hirt says they’d like to extend this training to Froedtert & the Medical College of Wisconsin in Milwaukee and the Milwaukee Fire Department.

“It’s a big undertaking,” Hirt states.

Compared to the smaller communities this program has been working in, the sheer size of a bigger city could present interesting challenges. Moreover, Milwaukee staffs their providers whereas some communities in Waukesha and Washington Counties typically also employ volunteers.

Father and his baby skin-to-skin

In the meantime, Hirt and her team look forward to their Birth Center Skills and Education Fair this Fall where there will be a continued emphasis on skin to skin as well as practical information about supporting pumping mothers and helping lactating mothers access sound information about pharmaceuticals.
Hirt is currently piloting equipment to launch virtual lactation and breastfeeding support. Virtual breastfeeding support could benefit mothers who have other children and can’t easily leave the home, or mothers who have undergone a c-section and cannot drive for instance. The virtual support will be offered free of charge to patients. Hirt hopes to eventually offer 24 hour lactation services.

CLCs bring diversity of experience to lactation field

Healthy Children Project has welcomed doulas, nurses, physicians, midwives, WIC counselors, social workers, occupational and speech language therapists, to name a few, to its Lactation Counselor Training Course. A pediatric practice dental assistant, state legislators, a bartender and a children’s consignment shop owner are also among those who have taken the course.

The diversity of experience that CLCs bring to the lactation field benefits families and communities.

This week, the spotlight turns to Lucy Vest, CLC, an HR recruiter and former Program Director for Mom2Mom KMC (2012-2014.)

Vest assembles furniture for the new Lactation Room sponsored by M2M KMC at Landstuhl Regional Medical Center.

Mom2Mom Global Executive Director Amy Smolinski, MA, ALC, CLC calls Vest the “driving force” for Mom2Mom KMC.

“I still remember when we interviewed her for the newly-formed Mom2Mom KMC board,” Smolinski begins. “We were completely blown away that someone with her business acumen and managerial expertise would volunteer her time for our tiny little breastfeeding organization.”

Vest was drawn to Mom2Mom KMC because she’s a “busy, sociable, career-oriented person.”

“I can’t stand being at home with nothing to challenge my brain; that’s why I first applied to join M2M KMC’s Board of Directors,” she explains.  “I wanted something outside of just being a mom that would give me back my sense of self and achievement that I need.”

Military life can be hard, lonely and isolating too, Vest says.

She birthed her daughter while her husband was deployed. Her family lives in the UK.

“I had no mom friends and I had no reason to get out and about during the day so I looked up local mom and baby activities,” she says.

Vest announces prize winners at the Big Latch On 2014
Photo credit, Laura Karoline Photography

She says she felt Mom2Mom KMC might offer an experience where she’d immediately share common ground with others, so she attended a meeting. Her first experience wasn’t what she’d expected.

“I hated it because no one talked to me!” she recalls her first meeting.

Even so, Vest went on to become finance director and then program director for the organization.  

“Not only did [Lucy] prove herself a deeply compassionate and competent lactation counselor, but she brought her business skills to our grassroots support group and grew it into a thriving organization that revolutionized our community to the idea that breastfeeding is simply the normal way to feed babies,” Smolinski applauds her.

Vest first worked to smooth minor issues and concerns by implementing small, gentle changes with the help of the incumbent board.

“You can’t just take over an established organization and rip it to pieces expecting everyone to be on board and support you,” Vest explains.

They changed their meeting format from every other week table meetings to weekly breastfeeding cafes with sweet treats and hot drinks.

“Exactly what every breastfeeding mother wants!” Vest exclaims.

Most importantly, Vest encouraged board members to be welcoming and socialize with everyone in the room.

Photo credit, Laura Karoline Photography

“The team at large really focused on being…inclusive,” Vest explains. “Everything a vulnerable, nervous, first-time attendee needs when faced with an intimidating group of women.”

The organization’s formal Facebook page became a private group, which could reach the whole community, not just those who came to breastfeeding cafes.

During the time Vest began directing, Landstuhl Regional Medical Center (LRMC) hosted the Lactation Counselor Training Course.

“So we had a lot of newly qualified people in the community to support our team disseminating good, research-based evidence and information rather than old wives tales that are often thrown about freely in place of hard facts,” she says.

Vest and her team worked to develop relationships with other local parental support military programs and LRMC departments like the NICU.

“[We] raised our profile slowly but surely within the community,” she explains.

Vest’s interpersonal skills came of good use anytime the organization needed volunteers.  Smolinski shares this memory: “[Lucy] would take a clipboard around at breastfeeding cafes and ask people one on one to sign up to volunteer for our next activity.  No one could say no to her!”

Vest explains it this way: “No one tends to put their hand up and volunteer for anything, especially helping to man booths at the Big Latch On, or staff tables at membership drives so I’d go around with my clipboard and a list of duties and ask people face-to-face to help out. It’s an awful lot harder to say no to someone when they’re stood in front of you waiting for an answer.”

She goes on to explain that blanket posts on social media are routinely ignored, so a personal approach is always far more successful.

Vest instigated a simple budget for the organization: a monthly, quarterly and annual Profit and Loss management tool.

“We worked strategically; smarter, rather than harder, in our fundraising efforts,” Vest explains.  

Two years ago, Vest moved away from Kaiserslautern Military Community, so she’s no longer involved with M2M KMC. Still in Germany though, she became an admin on a local military, new baby Facebook group and provides home visits as a CLC,  mostly for friends and friends of friends.

She’s also back in her old career field, something she waited six years for.
“I truly am thrilled to be doing the day-job again, but I hugely attribute the maintenance and expansion of my business skill-set to my time with M2M KMC,” Vest says.

Babywearing as a public health initiative

Picture this: A Detroit mother with five children under the age of seven has no car and needs to go to the corner store for groceries. She must either choose to lug her infant in the hospital-provided car seat while she walks to the store and only purchase half of the groceries she needs so that she can manage carrying her load; or leave the infant at home with its older siblings. If she leaves her baby at home, she knows it could be unsafe, but she’d be doing it for her family’s survival.

Access to a baby carrier changes all of that, explains Rebecca Morse CLC, CBE, CPST, CKC recalling one of her client’s realities that strongly influenced her.

“The first picture I get on my phone when I wake up the day after leaving her house is her [wearing] her baby and holding all the groceries,” Morse remembers.

Morse is an infant care and breastfeeding instructor at St. Joseph’s Hospital in Ann Arbor, Michigan. Most recently, she started conducting postpartum discharge surveys as St. Joe’s works toward Baby-Friendly designation​.

Through her private practice, ​Close at Hand Baby Service​, Morse provides infant care education and home-visiting services with a focus on breastfeeding and baby carrier use and safety. The clients featured on her blog include many sets of multiples, and families on journeys with various, unique challenges.

Fellow Lactation Counselor Training Course participant and head of the Wayne County Fatherhood Initiative, wears another participant’s daughter at lunch break study group. More about the initiative here:

She’s also founder of Baby Carriers Provided (BCP)​, an organization that seeks to​ create access to baby carriers for caregivers enrolled in the ​WIC program​ as well as other family service organizations, hospitals, and family/legal interfacing systems.

It was after completing the ​Lactation Counselor Training Course​ this February that Morse “kicked into high gear” writing and creating the website for BCP with help from her team.

“I…gained a massive amount of inspiration,” she says.”I thought to myself, My​ dreams of growing an organization with a large reach and impact could be real.”

Babywearing as a public health initiative

The function of baby carriers in public health are many, Morse says.

Baby Carriers Provided (BCP) Staff

It keeps babies in their natural habitats (close to their caregivers) and simultaneously allows caregivers to integrate into and participate in modern society.

Morse addresses babywearing as a public health intervention through BCP​, in that​ the practice increases breastfeeding success, decreases child abuse, increases​ general safety and health of the family unit and potentially lowers maternal/infant mortality.

In her private lactation practice, Morse says ​Kangaroo Care​– carrying or holding baby while skin to skin– is her number one breastfeeding tool.

But Kangaroo Care and babywearing aren’t only for the breastfeeding dyad.

“When we breastfeed, we get natural oxytocin shots,” Morse explains. “We also get fairly good sized natural oxytocin shots during Kangaroo Care. Kangaroo Care does scientifically replace some of those hormones when the breastfeeding relationship is lost.”

One of Morse’s clients wearing her twins. She started wearing her babies around the time they turned five months old. Babywearing “lifted her mood,” Morse reports.

Morse theorizes that the connection between Kangaroo Care and baby carrier use is strong pointing out that “babywearing is just kangaroo care while walking around.”

She says she hopes to show this through the work of BCP.

Baby carriers can play an integral role in child abuse prevention too. Morse reports that 89 to 94 percent (range based on variation of data state to state) of parents who abused their babies did so because the baby wouldn’t stop crying.

“Baby carriers reduce crying,” Morse points out., referring to research published in Pediatrics..

It’s why baby carriers could also be an important tool for incarcerated mothers and pregnant women or families going through the Child Protective Services system.

Morse’s husband teaches at a Nurse Family Partnership event.

“The facilitation of attachment and the transfer of infant parenting skills by providing baby carriers in these systems could be effective in improving family preservation rates,” Morse explains.

Babywearing to prevent accidents

Babywearing has the potential to prevent infant-related accidents too.

Upright, on-body infant carriers have one of the lowest incident profiles of all baby products on the market. Infant bucket-seat/car-seat carriers on the other hand are often used outside of automobiles​, like on top of shopping carts, which can cause serious injury and death.

In fact, a 2010 AAP study​ found that about 10,000 infants​ in the U.S. are injured each year in their infant car seats while using the seat outside of an automobile.

Helping refugees – Baby Carriers and Breastfeeding in Displaced Populations

In June and November of last year, Morse traveled to Greece on a pair of refugee​ relief trips with ​Carry the Future​, a grassroots effort dedicated to delivering baby​ carriers, baby beds, and diapers and other needed supplies to refugee camps.

Carry the Future provides training and resources to volunteers without babywearing credentials to ensure families are properly and safely fitted.

One of Morse’s clients, Jennifer Canvasser, M.S.W., founder of NEC Society pictured with her son Micah.
“If I can help people connect and feel physically close with their babies no matter what the journey, it can be a source of healing and strength,” Morse says. “[Jennifer’s] story drives me.”
More here:
During her travels, Morse also encountered volunteers from Nurture​ Project International, an organization that sets up breastfeeding tents and supports​ refugee mothers and babies.

Morse says she believes it is a “perfect place” for CLCs to consider volunteering their time and expertise to the Syrian humanitarian crises.

“This is real good we can do with the knowledge we have,” she says.

You can read more about Morse’s experience with Carry the Future on her blog​.

Learn more about babywearing as a public health intervention here​. Connect with BCP on Facebook here.

Additional reading about babywearing:

Natural Parenting ― Back to Basics in Infant Care

Does infant carrying promote attachment? An experimental study of the effects of increased physical contact on the development of attachment

Babywearing: The Benefits and Beauty of this Ancient Tradition



Breastfeeding in the healthiest county in Virginia

Janine A. Rethy, MD, MPH, FAAP, FABM, IBCLC is a general pediatrician in Loudoun County, Va. dedicated to improving breastfeeding outcomes in her community. She currently leads the Obesity and Chronic Disease Prevention team at the Loudoun County Health Department where she and her colleagues focus on a community-based approach to reduce disparities in obesity and chronic disease, with a focus on breastfeeding and healthy food access. 

Dr. Rethy also serves as the American Academy of Pediatrics’ Childhood Obesity Advisor for Continuing Health and says she’s pleased to have been appointed as Virginia Chapter of the American Academy of Pediatrics’ Co-Chair for Breastfeeding.  She also serves on the Virginia Breastfeeding Advisory Committee, as the physician advisor on the Loudoun County Head Start Health and Mental Health Advisory Committee and on the Loudoun County Public Schools Wellness Policy Committee.

In February, The Loudoun County Health Department hosted The Lactation Counselor Training Course as part of an effort to increase knowledge about best practice in their community.

“The training was successful by every measure,” Dr. Rethy says.

Of the 65 participants, present were six out of seven Loudoun WIC staff, nineteen other Virginia WIC staff, physician assistants, nurses, occupational therapists and doulas from around the region, and a participant who came in from a US military base in Japan, Dr. Rethy reports.

“After the course, many people from our community attended our quarterly Loudoun Breastfeeding Coalition meeting with additional pride at their accomplishment and increased knowledge,” she says.  

With an understanding that our medical system often strips mothers’ confidence to feed their own babies, she says she finds it most rewarding to demystify breastfeeding and help mothers feel confident.

“My favorite stories are the ones where we can peel away the complications we have often created on the mother-baby feeding process, and go back to the basics of skin-to-skin, mother and baby enjoying each other and often just facilitating and reassuring the re-emergence of the feeding instincts of the dyad,” she explains.

Below, Dr. Rethy shares fascinating insights into the state of breastfeeding in her community including results from a summer 2016 WIC survey, and the pivotal work she and her colleagues are doing to ensure healthy outcomes for all families.

Q: Loudoun County ranks highest in mean household income in the U.S. How does this affect maternal child health outcomes in your community? What else is unique about Loudoun county? 

A: Loudoun County does have the highest mean income in the US and is the healthiest county in Virginia.  What those numbers do not reveal is the more difficult situations for our lower-income families:  We have seen more than a four-fold increase in immigrants over the last 15 years and we have significant pockets of poverty in the county.  These communities are particularly struggling because the cost of living is very high and the infrastructure for services is less available since the demographic change happened so fast.  We have seen the pediatric obesity rates in our community health center, which serves the lower income community double that of the rest of the county.  In our recent WIC study, we found very high rates of early introduction of formula and poor access to lactation services.

Q: Please tell us more about the 2016 WIC survey you conducted with Dr. Sina Gallo of George Mason University.

A: This study was conducted at our two WIC clinics in Loudoun County in the summer of 2016.  The study looked at infant feeding patterns, Vitamin D, healthy food access, and utilization of assistance programs and community resources.  The study was funded as a part of a National WIC Association and the Centers for Disease Control Community Partnerships for Healthy Mothers and Children (CPHMC) grant we received at the Loudoun County Health Department. The grants larger goals are to develop policy, system and environmental changes to decrease obesity and promote health.

In regards to the breastfeeding piece of our study, we found fairly high rates of breastfeeding compared to HP2020 goals and recent US and Virginia scorecards with 84% ever breastfed and 58% still breastfeeding at 6 months.  However, looking more closely, 91% of mothers gave formula at some time. It turns out that 43% gave formula before they ever left the hospital, 17% at the first feed!  This tells us a lot of things and opens the door for some positive solutions.  Half of women intended to breastfeed exclusively, and only 9% never gave formula.  We as a health care system and community can do better to help women reach their goals and protect their infants from the harm that early introduction of formula can do.  We know that exposure to exclusive breastmilk in the first few days of life is critical for immune priming and development as well as intestinal maturation, the effects of which last a lifetime. Not to mention the improved chances of for successful lactogenesis 2 and overall success at reaching breastfeeding goals.  Interestingly we saw an increase in exclusive breastfeeding at 6 months compared to 3 months which corresponds with the time that the WIC package is greatly expanded for mother and infant if they are exclusively breastfeeding.   Our results lead us to believe that the non-exclusive breastfeeding we are seeing is likely modifiable with good counseling, especially in the prenatal period and right after birth.

Another result worth mentioning is the low rate of Vitamin D – only 27% of infants ever received Vitamin D, only 14% of exclusively breastfed infants received daily Vitamin D as recommended.  We found that less than half of mothers knew about the recommendations, those who did not give Vitamin D cited the fact that their pediatrician had not recommended Vitamin D as the primary reason they didn’t give it. Only 39% said that a pediatrician had recommended Vitamin D.  In response to this, we created a Vitamin D educational handout targeted in language and content to both the families and the physicians.  This document was recently approved and accepted by Virginia WIC to be distributed to all WIC offices in the Virginia.

Q: You and your colleagues have produced many amazing breastfeeding resources like the Breastfeeding Friendly Workplace document and the Breastfeeding Support Implementation Guide for the Outpatient Setting (which includes information on how to bill insurance for lactation services.) Please tell us more about these documents.

A: The Breastfeeding Support Implementation Guide for the Outpatient Setting was created in response to a study we did in 2015 of primary care providers in our county.  We looked at knowledge, attitude and practice in the area of infant feeding and found several gaps we wanted to address.  The Breastfeeding Friendly Workplace toolkit we created as a local adaptation of the HHS Business Case for Breastfeeding. We presented the toolkit at local Chamber of Commerce and Society for Human Resources events.  We worked with several businesses and agencies to take them through the process of implementing a Lactation Support Program.  Our biggest success was the Loudoun County Government, which has about 3,000 employees.  We worked with their HR department and health insurance company (Cigna) and helped them develop a comprehensive employee policy, HR systems and training to create a process for mothers returning to work, and educational materials including how to access support and equipment benefits afforded under the ACA. We also helped them open two permanent breastfeeding rooms.   We have recently expanded our toolkit to include information on the Virginia law which protects breastfeeding in public.

Q: What’s next?

A: We are currently partnered with the Loudoun County Chamber of Commerce (LCCC) and the Virginia Department of Health (VDH) to recognize businesses as Breastfeeding Friendly Businesses.  We have incorporated elements of breastfeeding friendly businesses into the annual LCCC Healthy Business Challenge.  Those businesses that complete all the elements, including educating employees on the recent Virginia law protecting breastfeeding in public, will receive a Breastfeeding Welcome Here decal for their businesses.

Dr. Gallo and I would like to continue our work at WIC and have recently applied for a grant to conduct a randomized controlled study looking at the effect of shared-decision making prenatal counseling on the early introduction of formula in the WIC population.

Q: Anything else you’d like to highlight about the work you’re doing? 
A: The Loudoun Breastfeeding Coalition was founded in 2012 and includes active participation from WIC, our local hospital system, La Leche League, doulas, and local health care providers.  It has become an important referral and information sharing network both for providers and for people in the community through the Facebook page.  We have also created and regularly  update a printed resources guide for our community. We were accepted to be represented on the Virginia Breastfeeding Advisory Committee, a body which advises the VDH.

Standing up as an ally

When I found out that my midwife Erin O’Day, CPM, LM was traveling to Oceti Sakowin Camp, a camp close by Standing Rock Indian Reservation, I thought I’d indulge in her tremendous birth stories, the birth junkie I am. Instead, upon her return, there were no birth stories; our conversation turned to Race. Simultaneously, I worked on a piece about what I had learned about Race at the International Breastfeeding Conference, and where I fit in the movement toward equity. Speaking with Erin helped me to process the complexities surrounding Race. She sets an example of what it’s like to be an ally to People of Color.

Erin traveled to the camp for about two weeks in the middle of December 2016 shortly after the water cannon incidence.   

“Things were relatively tense,” she recalls.

There wasn’t any particular connection that drew Erin to Standing Rock except that she said it was something she thinks is “right.” She felt the need to “stand in solidarity with Indigenous People for a fight that could potentially affect all of us.”

At the same time, it’s a fight that doesn’t necessarily affect us all, but the people who have been oppressed for more than 500 years, Erin reminds us.

She’s dedicated to owning her role in ending racism, even if it’s uncomfortable.

“We need to feel the guilt, the weight, the stuff that’s uncomfortable, so that we can do everything we can to step back and allow other cultures in our country to step forward and take the lead…” she said.

In this light, while Erin offered her midwifery services she makes clear her trip was not a volunteer mission and that she didn’t arrive with a rescue mentality. Instead, she went as someone humbled; someone ready to follow the leadership of the Indigenous People.

Erin’s main role during her stay was to simply stoke the fire in the midwife yurt. She and other women’s health advocates handed out yeast infection and UTI treatment, condoms and pregnancy tests. While she did provide some perinatal counseling, she says most of the women at the camp preferred care from the Indigenous Midwife.

“There was a lot of tea pouring, warming people up, and inviting people to sit and process whatever they needed to process through,” Erin remembers.

As an ally, that’s where she felt she fit in: creating and holding safe spaces for others.

Erin also collected and delivered winter camping supplies including a face cord of kiln dried firewood, a four season tent with wood stove, about 40 long john underlayers, bulk food items like beans, rice, honey and coffee and hand and foot warmers.

It was evident to Erin that most other visitors were ill-equipped to withstand the sub-zero conditions at the reservation. This is what struck her most, that people arrived with a “Burning Man” mentality of which Erin’s experience was nothing like.

“It’s a war zone,” she said. “You are subjecting yourself to potential trauma.”

What’s more, sometimes helping hurts; perceived help was more a burden in that Standing Rock leadership became responsible for the well-being of their guests.

Erin’s stay overlapped with that of about 2,000 U.S. military veterans which pushed the total population at the camp to about 10,000.

“Port-o-potties were overflowing, almost to a crises point,” Erin said.

Not long after, a snowstorm hit and many people left. Erin called the “ebb and flow” of protesters “interesting”; perhaps an illustration of taking on the ally role when conditions are convenient and walking away when they’re not.

During her stay, an Indigenous friend Erin met at the camp had a disagreeable encounter with a visiting man. The encounter amounted to this man declaring that “He doesn’t see Race” which further upset her friend.  

Erin wondered how she could help and offered to talk to the man. Unsure of the result, her friend ultimately accepted reporting that no one has ever offered to do that.

Erin approached the man and explained that his intention meant nothing, it was his impact that mattered.

She reflects on this encounter:
“The example it sets in my mind is that we all have the power to speak out if we see racism happening. We all have the power to show we are capable of shifting perspective and standing in a place that educates each other versus the constant need of education coming from people of color, letting us know what it is that offends them. We should know already. We should be changing our rhetoric and recognizing what it is that we say that has a negative impact. We should allow that uncomfortable feeling to set in to give us perspective and admit when we are wrong in our choice of words… It’s a story of what it looks like to speak out as an ally.”