By July Guest Blogger: Nikki Lee RN, BSN, MS, IBCLC, CCE, CIMI, ANLC, CKC
(Ed. Note: Our Milk Way blogger Jess Fedenia is on parental leave for the months of July, August, and September, 2016 to welcome a third child into the family. During Jess’s leave, members of the Healthy Children Project, Inc. faculty circle are taking up the blogger role.)
In June 1997, the Journal of Human Lactation published a paper; Observations based upon multiple telephone contacts with new breastfeeding mothers based on the work this author had done as the lactation consultant in a grant-funded program serving underserved mothers and babies in West Philadelphia for 6 years.
The paper reported some useful strategies that led to 86% of mothers breastfeeding for at least 1 month, 46% breastfeeding for at least 3 months, and 23% breastfeeding at least 5 months. A major finding in this descriptive paper was that about 94% of mothers would achieve sustained breastfeeding after receiving an average of 9 telephone calls over a period of 12.5 weeks. In other words, only about 6% of mothers would need a home visit for more intensive clinical care.
Today, the Certified Lactation Counselors (CLCs) and the Breastfeeding Champions of Maternity Care Coalition, are providing consistent and timely breastfeeding support to an underserved population in Philadelphia, and finding similar results and successes, with the majority of mothers doing well with basic breastfeeding support and only a few needing more intensive clinical care.
Maternity Care Coalition (MCC) is “a nonprofit organization with the mission to improve maternal and child health and well-being through the collaborative efforts of individuals, families, providers, and communities in Southeastern Pennsylvania”. Its programs serve pregnant women at 9 sites in a variety of programs that are funded by national and international organizations: W.K. Kellogg Foundation and Merck, to name but two. Most programs use a home visiting model.
Naima Black, CLC, has been the Coordinator of MCC’s North Philadelphia Breastfeeding and Community Doula Program since its very beginning in 2012, when the first Kellogg grant was awarded. Interested women from the community are given a free 20-session training to become doulas, and are matched with women delivering at local hospitals. In the past 4 years more than 680 pregnant mothers have been matched with a community doula and received some level of support. For those who had a community doula support them during labor and childbirth, the rates of cesarean section are 10% lower than the general hospital rates.
MCC has always employed healthcare workers who were passionate about breastfeeding; many took a peer-counseling course offered by the Philadelphia Department of Public Health; when more funding became available, many became CLCs. While the original intent was for all the Breastfeeding Champions to become CLCs, it is now difficult to offer the training to everyone who wants it. One problem is staff turnover. Some staff has left after being trained. While MCC pays for its staff to be trained, the hope is that there will be a commitment to the organization in return. However, the reality is that women move away, or seek higher education or leave to find better paying jobs. Unfortunately, community health workers are paid little as grants are stretched to the maximum to serve the most. Their workloads include providing support for follow-up care, Safe Sleep, and social issues; breastfeeding has become integrated into their caseloads.
Another problem is that grants have shrunk while the demand for credentialed lactation workers has increased because more women are leaving the hospital breastfeeding. This is because all 7 birthing hospitals in Philadelphia are working to implement best practices to promote and support breastfeeding; 2 hospitals have become Baby Friendly, 1 has become Keystone 10 designated, and 2 more are on the last leg of their Baby Friendly journey. (Keystone 10 is a similar program to the Texas 10 Step program, and is supported by the Pennsylvania Department of Health in partnership with the Pennsylvania Chapter of the AAP.)
Mothers find MCC and breastfeeding support by direct referral from other programs such as Centering Pregnancy (administered at one city hospital, and an outpatient clinic) and the ELECT Program (serving pregnant and/or parenting high school students). Word of mouth is a growing source of referrals, as the community doula model used in the North Philadelphia Breastfeeding and Community Doula Program is popular.
If pregnant mom says she doesn’t plan to breastfeed, the community health worker seeks to keep the door open using counseling techniques. Women are asked to, “Tell me more about that”. This is followed-up at next visit. “Would it be okay if I brought more information?”
The number of visits depends on the program. Some offer weekly visits throughout pregnancy, others offer monthly visits. The same is true for postpartum visits, which can be for 1, 2, or 3 years, depending on the program. Clients are also invited to seminars and trainings in addition to the visits.
The North Philadelphia Community Breastfeeding and Community Doula Program is the first and only one of its kind to use Microsoft Excel® to track data. In the home visiting programs, everything is tracked: feeding intention, initiation and 3-month duration; every contact (phone, text or visit) is documented, and the referent agency is kept in the loop.
The Breastfeeding Champion/CLC model is effective for most women; more challenging cases are referred to Naima, who will call in a community-based IBCLC with more experience. Not all mothers receive breastfeeding support from a Breastfeeding Champion or CLC; sometimes it is the community doula who provides the help. At other times, it is a community member who comes to a breastfeeding support group and needs a referral. Naima has not had to refer onward very often; only about 20-25 mothers (out of 680 cases) have required more intensive breastfeeding support.
Naima is a source of education and support for her staff, as well as doing the administrative tasks required by a grant-funded program. Senior CLCs are available for supervision and support and resources, with Naima as Coordinator being the clinical overseer to everyone.
Just as in 1997, when mothers were supported to breastfeed with regular contact and only a few needed a home visit for complex care, in 2016, most mothers enrolled in MCC programs are supported to breastfeed with regular contact, and only a few need more complex breastfeeding care. The Breastfeeding Champions/CLCs are doing a wonderful job for the majority of mothers, and the IBCLC is there when needed.
In 2014, the CDC cited both IBCLCs and CLCs as professional lactation supporters. Working together, Breastfeeding Champions, CLCs, and IBCLCs can provide a safety net of breastfeeding education and support to underserved mothers, illustrating how effectively a community of lactation care providers can work together in a successful model of practice.