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.”

Breastfeeding Latinas group offers scholarship for lactation training

Ileana Berrios, CLC is a mother, doula and Philadelphia WIC Breastfeeding Manager. Berrios praises Philadelphia as a breastfeeding-friendly city with Baby-Friendly Hospitals, organizations dedicated to maternal child health like Maternity Care Coalition, and a sisterhood among women of color.

“Women in the community are now breastfeeding openly in public, engage more on social media, serve as mentors for one another, and proudly promote breastfeeding,” she explains.

Still, Berrios recognizes racial disparities among lactation professionals in her area. She created the group Breastfeeding Latinas to address these disparities, call for culturally appropriate and culturally safe care, and to provide a resource to women of color in her community.

Inspired by the National First Food Racial Equity Cohort, Berrios, through her group, created a scholarship program that will award one person from a network of community doulas tuition to attend the Lactation Counselor Training Course.

Members of the community doula network have been provided with instructions on how to apply for the scholarship.  At present, a board of current CLCs is being established who will ultimately review the applications and choose a winner together. The scholarship recipient will be announced at The Global BIG Latch On in Philadelphia on August 5, 2017.

“[Members of] the Community Doula Network have expressed their excitement towards this opportunity,” Berrios says. “Many doulas have already shared their interest and desire to become a CLC or breastfeeding peer counselor. Doulas are beginning to see this opportunity as a way to engage with more women in the community.”

Next year, Breastfeeding Latinas will extend multiple scholarship opportunities to other networks of women who work with the mother baby dyad, Berrios reports.

Berrios completed the Lactation Counselor Training Course in 2013 while working with WIC.

“I was amazed at the amount of clinical information the CLC training provided,” she says. “I consider this training to be the necessary step towards any human lactation profession.”

Because the information was “entirely new” to her, Berrios admits feeling overwhelmed during her training. Not discouraged though, Berrios continues her journey as an IBCLC candidate.

Going forward, Berrios hopes to see the emergence of accessible, culturally appropriate maternity and lactation care and less restrictive insurance policies.

Healthy People 2020 has high expectations for breastfeeding rates and Breastfeeding Latinas wishes to add fuel to the fire when it comes to improving initiation and duration rates,” Berrios begins. “But we first must start by providing high-quality support which can be accessible to any woman of any color from all socioeconomic backgrounds.”

Finally, she sees the need for insurance companies to cover doula care and care provided by CLCs.
In her community, she has found that more CLCs provide support than IBCLCs, but only IBCLCs can bill insurance. It’s vital that the work of CLCs is recognized and rewarded for improving maternal child health outcomes, she says.

Happy thoughts

The following post is dedicated to those of you who crave restored hope in humanity! Too often, I find myself defeated by the state of maternal child health, but as I reviewed notes from this year’s International Breastfeeding Conference, I was reminded of the progress we’re making. Below, I am sharing unique findings,“big happenings,” and other highlights from the conference.

Little George and myself enjoying our time at the International Breastfeeding Conference.

Help us add to this list! Please share your “happy thoughts” in the comments below.

Growing a reputation

Downs Spradlin nurses her toddler at the Big Latch On.
Downs Spradlin nurses her toddler at the Big Latch On.

One of Danielle Downs Spradlin’s, CLC favorite parts of her job is seeing mothers exceed their infant feeding goals. Downs Spradlin is founder of Oasis Lactation Services in the suburbs of Atlanta. She’s tickled by dyads’ “hilarious” weaning stories, like the little boy she recalls who traded nursing for a toy truck.

“I remembered how voracious and committed he was [to nurse] from birth, that the truck seemed like hardly an equal trade,” Downs Spradlin says.

Initially inspired by mothers with little access to current postpartum health information and even more by women suffering from postpartum mood disorders, Downs Spradlin completed her Lactation Counselor Training in 2011.

Because the fear surrounding birth is great, people invest in childbirth classes, but the postpartum period gets ignored, Downs Spradlin observes.

“No one told these women what to expect; that they would be wet and sticky, that feeding their babies might be hard, that unsolicited and incorrect advice would be easier to come by than truth or help, that it’s okay to think your baby is ugly, that asking for help isn’t a sign of weakness, or that it’s okay to not have it all together within three days,” she says.

Downs Spradlin finds too much focus on the baby with very little support for the mother.

“Telling moms that breastmilk is best for the baby isn’t helpful,” she explains. “We have to make breastfeeding beneficial for moms and convenient for all adults in the baby’s life.”

Downs Spradlin supports social change which makes maternal health a priority, particularly in communities of color where women and babies are most vulnerable.

Originally, Downs Spradlin planned to use her lactation training to develop a curriculum for families about how to make their feeding goals fit into a culture that doesn’t honor the postpartum period.

10013506_220604331482013_3172665187043410705_nNow, her practice partners with two pediatric offices and a chiropractic office. Downs Spradlin is also co-founder of a pregnancy through pediatric health professionals network, North Fulton Wellness Alliance (NFWA). The network seeks to improve continuity of care over disciplines including obstetricians, midwives, pediatric ENTs, chiropractors, postpartum therapists, doulas, etc.

Members of NFWA attend a monthly dinner to stay connected with one another. They also host community events and birth and baby expos.

Downs Spradlin believes strongly in WIC’s mission.

“The WIC program is critical for women in my state and directly impacts my practice and my community,” she says. “The community resources for breastfeeding support are extremely variable and some are unintentionally exclusive to upper-income families.”

She reports that Georgia ranks in the top ten largest WIC programs in the nation and says that the expansion of breastfeeding support within WIC is a public health imperative.  

Downs Spradlin reflects on the growth of Oasis Lactation Services:

“When I started my practice I knew not to expect instant customers,”  she says.

Instead, she networked with childbirth educators and doulas, got involved with her local La Leche League and birth and breastfeeding Meet Up groups.

“I met everyone I could,” she says.

Mostly, she provided a lot of volunteer hours teaching free group classes and hosting free support groups.

“My reputation in the community grew first; my practice grew second,” she says.

Downs Spradlin writes: "I got swaddled at #breastcon17 and it was awful! Swaddling has NO benefits. Swaddling increases SIDS risk, decreases breastfeeding, and obstructs skin to skin."
Downs Spradlin writes: “I got swaddled at #breastcon17 and it was awful! Swaddling has NO benefits. Swaddling increases SIDS risk, decreases breastfeeding, and obstructs skin to skin.”

In the first two years of her practice she broke even, seeing enough clients to cover the cost of her continuing education conferences, equipment and gas.

“By my third year, I had grown a lot,” Downs Spradlin reports. She was able to hire two other CLCs and add a postpartum doula to her team.

Downs Spradlin notices that scope of practice gets brought up a lot in her work.

“My practice focuses on providing evidence based choices to parents,” she explains. “I never tell a client what to do, always stressing that the family is the best judge of what is best for their situation.”

As a lactation counselor, it’s her job to explain the safety and efficacy of their choices so they can make fully informed decisions, she goes on.

Recalling her lactation training, Downs Spradlin says the amount of research that Healthy Children Project supports struck her.

“Culturally, Americans seem to believe research is unique to universities or pharmaceutical companies,” she begins. “We are information saturated, but most people are untrained in reading and interpreting research. Research from ‘trusted sources’ seems harder and harder to come by as pseudoscience is normalized on social media. Healthy Children Project has a unique place as a trustworthy source of feeding information because of the non-profit status and international reputation.”

And while Downs Spradlin uses evidence-based practice as her foundation, she says that helping families to get to know their babies is a much more valuable tool than any research she can provide.

Learn more about Oasis Lactation Services here and North Fulton Wellness Alliance here.

You can also Like Oasis Lactation Services on Facebook and follow them on Instagram.