Taking Stock of Progress in Supporting, Protecting & Promoting Breastfeeding: The National Immunization Survey and the World Breastfeeding Trends Initiative

CindyBy Guest Blogger, Cindy Turner-Maffei, MA, ALC, IBCLC, Faculty, Healthy Children Project, Inc., Affiliated Faculty, Union Institute & University

(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. circle are taking up the blogger role.)

National Breastfeeding Data Updated

As World Breastfeeding Week (August 1-7) draws to a close, our celebration of National Breastfeeding Month continues.

This week marked the annual meeting of the United States Breastfeeding Committee (USBC) on August 4, followed by the Sixth National Breastfeeding Coalitions Conference, August 5-7, 2016.

At the USBC Annual Meeting, Carol MacGowan of the Centers for Disease Control & Prevention (CDC) noted that the National Immunization Survey (NIS) data for babies born in 2013 has been released on the CDC website[i]. The data indicates that 81.1% of US babies born in 2013 were breastfed immediately after birth, within striking distance of the Healthy People 2020 goal of 81.9%. Yay!

There have been incremental increases in breastfeeding duration and intensity (see table below).

The hard work of so many dedicated advocates, supporters, lactation care providers, health care providers, government partners, and others is having positive impact on breastfeeding success of new families. Yet, we are aware that much work lies ahead of us. There are still significant disparities in the rates of breastfeeding from one community to another, one from state to another, from one ethnic group to another.

This calls to mind a powerful finding the Baby-Friendly team at Boston Medical Center (BMC), one of our nation’s first Baby-Friendly birth facilities, reported as they examined the breastfeeding data collected over the years they strove to implement the Ten Steps to Successful Breastfeeding. At the beginning of their journey toward Baby-Friendly status, the BMC team found that women of color who were not born in the U.S. were twice as likely to breastfeed when compared with women of color who had been born in the U.S. As they implemented the Ten Steps, breastfeeding rates rose among all women, nearly doubling (34% to 74%) among the women of color born in the U.S., while breastfeeding among those born outside the U.S. increased in initiation from 78% to 96% after Baby-Friendly designation was achieved (Philipp et al., 2001).This indicates the powerful role that system factors play in supporting or eroding personal intentions and cultural traditions around infant feeding.

Boston Medical Center’s experience is echoed in recent findings of researchers from Centers for Disease Control & Prevention (2014), who examined the implementation of Baby-Friendly practices in nationwide hospitals:

The findings suggest that the implementation of maternity care practices supportive of breastfeeding vary based on the racial composition of the area, which means women living in areas with higher percentages of blacks might have less access to these services. Although the reasons for these disparities are unclear, the results might provide some insight into why there has been a persistent gap in breastfeeding initiation and duration rates between black and white infants in the United States. All facilities, regardless of the racial/ethnic composition of the populations they serve, can support the breastfeeding decisions of their patients by implementing evidence-based policies and practices shown to be critical for establishing breastfeeding, so that more infants are able to reap the numerous health benefits of breastfeeding. (p. 728)


Objective Healthy People 2020 Goal Rate among babies born in 2013 (NIS/CDC, 2016)
Ever breastfed 81.9% 81.1%
At 6 months 60.6 51.8
At 12 months 34.1 30.7
Exclusively through 4 months 46.2 44.4
Exclusively through 6 months 25.5 22.3


World Breastfeeding Trends Initiative

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Members of the Expert Panel announcing the WBTI launch at USBC, 8/4/16

At the end of the August 4 USBC annual meeting, a full day of progress reports on the progress of many initiatives underway through the USBC and its taskforces, or constellations, all attendees were invited to a celebration of the launch of the U.S.’s draft report to the World Breastfeeding Trend Initiative (WBTi). Many attended the launch, obtained copies of the draft report, and engaged in dialogue about its findings.

The WBTi was developed by International Baby Food Action Network (IBFAN) Asia in order to provide a platform for the assessment of achievement and progress toward the goals of the WHO/UNICEF Global Strategy for Infant and Young Child Feeding (“Global Strategy”). The process of engaging in the WBTi builds on the GLOPAR (Global Participatory Action) initiative of the 90’s in that it encourages careful self-assessment of the strengths and weaknesses of policies and programs toward the goal of “strengthening and stimulating breastfeeding action worldwide.”

Attendees of the WBTi Launch at USBC explore the report

Currently 107 countries have completed their WBTi assessment. Among these are many countries from Africa, Asia, and Latin America, but only 8 from Europe. The completed WBTi country reports allow immediate visual access to the status of breastfeeding in each participating country. A simple “traffic light” coding system (red/yellow/green) indicates level of achievement of each aspect of the Global Strategy.


The WBTi process has three phases:

  1. A National Assessment of the implementation of the Global Strategy. In this phase, multiple partners analyze and document the situation in their country and identify gaps according to 15 indicators.
  2. The scoring, rating grading and ranking of each country or region according to the findings of the national assessment.
  3. The repetition of the assessment after 3-5 years to analyze trends.
WBTI Workshop
Participants of the WBTi Assessment Workshop, April 2016

The National Assessment in the United States has been conducted according to the activities set forth by the WBTi Guide Book. Lois Arnold PhD and Linda Smith MPH (from the American Breastfeeding Institute), Karin Cadwell PhD, Kajsa Brimdyr PhD, and Cindy Turner-Maffei MA (from the Healthy Children Project) served as Assessment Coordinators.

Holly Hansen is the Assessment’s Editor. With funding from the Healthy Children Project, Inc., an Expert Panel with representatives from key sectors was convened and met for 5 days to collect information and draft a preliminary report. The report went through 3 rounds of editing resulting in the current draft (August 2016), and was circulated to the entire membership of the USBC and the attendees of the Breastfeeding Coalitions Conference for comment. Participating organizations are invited to include their logo on the cover of the final submission which is expected to be sent to IBFAN Asia on September 4, 2016.

Ultimately the addition of the U.S. data to the WBTi databank will provide other ways to examine and direct our efforts. Which aspects of support for optimal infant nutrition are well in place in our country? Which need some beefing up? And which are unimplemented, or unevenly implemented? How does our status compare with that of other countries? How can we learn from their experience, and apply lessons learned to improvements here? The inclusion of the U.S. National Report in the WBTi databank will allow us to explore the answers to these and other questions.




[i] Carol MacGowan reported that CDC’s 2016 Breastfeeding Report Card will be released soon, hopefully by September. This document reports on metrics including the NIS data but also data from the Maternity Practices in Infant Nutrition & Care (mPINC) survey as well as reporting on system factors in support of achievement of all of the HP2020 goals, including decreasing supplementation of breastfed newborns, increasing births in Baby-Friendly hospitals, increasing workplace support for breastfeeding. The 2014 Report Card also reported data on factors such as the number of lactation care providers, breastfeeding support groups, child care regulations in support of breastfeeding, etc. Report Card data is reported both in the aggregate as well as state by state.


Happy World Breastfeeding Week & National Breastfeeding Month!!

By Guest Blogger, Cindy Turner-Maffei, MA, ALC, IBCLC, Faculty, Healthy Children Project, Inc., Affiliated Faculty, Union Institute & University

(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. circle are taking up the blogger role.)

Happy WBW to You!

WBW Logo
Copyright © 2016 World Breastfeeding Week/WABA

Today marks the beginning of the World Alliance for Breastfeeding Action’s (WABA) World Breastfeeding Week (WBW) Celebration.

The WBW theme for this year, Breastfeeding: A Key to Sustainable Development, will be celebrated worldwide from August 1 through 7, 2016.

In 2011, the United States Breastfeeding Committee officially declared the month of August each year to be National Breastfeeding Month. Thus the U.S. celebrates WBW for an entire month!

World Breastfeeding Week, 2016

WABA’s Objectives for WBW 2016 are four-fold:

  1. Inform people about the Sustainable Development goals and how they relate to breastfeeding and Infant and young child feeding (IYCF)
  2. Firmly anchor breastfeeding and IYCF as a key component of sustainable development
  3. Galvanize actions at many levels to support breastfeeding and appropriate IYCF
  4. Engage and collaborate with a wider range of actors to around promotion, protection and support of appropriate IYC

The Sustainable Development Goals (SDG) were approved by the United Nations member states in 2015, to replace the Millennium Development Goals which were targeted for achievement in 2015. In the preamble of the full document, Transforming Our World: The 2030 Agenda for Sustainable Development, the SDGs are described as intended to stimulate action in areas critical to sustainable development, including People, Planet, Prosperity, Peace and Partnership. The vision statement of the document’s introduction is striking (recommended reading, p. 7). The scope and intent of the SDGs is broad, visionary, and monumental; it identifies 17 goals with 169 targets.

Of the 17 SDG goals, WABA’s WBW16 Poster identifies the following impact areas of IYCF:

  • Environment & Climate Change
  • Nutrition, Food Security and Poverty Reduction
  • Survival, Health & Wellbeing
  • Women’s Productivity & Employment
  • Sustainable Partnership and the Rule of Law

The ways in which infants and young children are fed do indeed have wide- and far-ranging impacts on survival, health, environment, productivity, and sustainability of life on earth.

This blog post focuses on the last bullet above: Sustainable Partnership.

Insights about Sustaining Change: The 2016 ROSE Summit

This past week I had the joy of attending the powerful Reaching Our Sisters Everywhere (ROSE) Summit in New Orleans. This experience, combined with my study of the WBW 2016 topic, has led me to ponder what it takes to generate and sustain genuine change.

I was touched deeply by the energy, spirit and passion of the ROSE gathering of hundreds of breastfeeding advocates who are in the process of transforming breastfeeding promotion, protection and support for families of color.

The problems ROSE supporters tackle in their daily work are monumental: disparities in prenatal and breastfeeding care, disparities in infant mortality, disparities in breastfeeding outcomes, lifelong disparities in health.

The theme of the 2016 ROSE symposium was “The Rose That Grew From Concrete”, based on the poem by Tupac Shakur.

Although serious and heartrending information was shared in some parts of conference presentations, the overarching messages were affirming and positive.

Celebrating ROSE, New Orleans Style
Celebrating ROSE, New Orleans Style         ~Photo Courtesy of Andrea Serano

The amazing Kimarie Bugg and the ROSE team are experts at building and sustaining energy through music, laughter, connection and fun, as well as through deep, thought-provoking lectures and presentations. Where else does a conference begin and end with a procession led by a New Orleans jazz band? (Check out the videos posted here)


The ROSE Summit shared news of many inspired initiatives, such as those ongoing under ROSE’s umbrella as well as many others. Here I highlight just two initiatives of several featured at the summit:  the CHAMPS Initiative and Breastfeeding: Strengthening the Heart of the Community.

›♦ Communities and Hospitals Advancing Maternity Practices (CHAMPS) is working to implement the Ten Steps in many hospitals in the Mississippi Delta and other South Central areas with low breastfeeding rates. The initiative brings together community leaders and members, health care staff, and experts in breastfeeding and the Ten Steps to Successful Breastfeeding.

In describing lessons learned to date from the CHAMPS experience, Anne Merewood emphasized that effective and lasting change requires community involvement.

Event Poster

› ♦ Breastfeeding: Strengthening the Heart of the Community, Reclaiming the African American Tradition is an artistic collaboration of breastfeeding families, poets, and artists supported by the Ashé Cultural Arts Center, Healthy Start New Orleans, the New Orleans Health Department, and other local sponsors.

Several of the artists, poets, photographers, and mothers who created the multimedia breastfeeding exhibit at the Ashé Cultural Arts Center spoke of the power of collaboration, of individual artisans learning together from the experience of community members and from one another’s process.


These and other initiatives have great promise to foster not only breastfeeding outcomes, but also the achievement of many of the SDG focal areas. One can’t help but think that the type of collaboration necessary to create a welcoming atmosphere for breastfeeding families in a birth center, health center, workplace, or community is the same type of collaboration necessary to make other crucial social changes.


Sustaining Ourselves and Crucial Partnerships

Those of us fortunate enough to work as lactation support providers (LSPs) know the joy of working with babies and parents, and how their successes in achieving goals fuel us to continue the work.

As LSPs, we also face some very real forces that can erode our energy, ranging from giant commercial forces to the incessant need to improve policy and practice on many different levels.

It’s particularly painful to see so much energy drained by divisions among LSPs over issues such as licensure and reimbursement.

We all share interest, knowledge, skill, and passion to support breastfeeding families. Ideally we would merge our energies and resources, as CHAMPS and the group presented by the Ashé Cultural Arts Center did, to strengthen the network around our families, and to address the very real outside forces that threaten our shared work, and the future health of Americans.

I’d like to share the simple messages I have received from this week’s experiences:

  • Seek out and integrate new voices and new perspectives
  • Celebrate the successes of others, as well as of our own
  • Seek connection with all who influence new families (build those oxytocin levels together!)
  • Be aware that all do not share the same benefits, resources, and experiences; remain open to differences
  • Cultivate a spirit of gratitude for the roles all play in supporting new families
  • Whenever possible, Dance!


No Rules in Relationship

By July Guest Blogger:


Nikki Lee: Mother of 2

(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. circle are taking up the blogger role. We extend our gratitude to Nikki for stepping up with such grace and panache!)


Yesterday, I saw a lovely mother and her 5-month-old baby. The mother requested a consultation because her baby wasn’t happy. Part of their history was that the baby would breastfeed very well at night, in bed with mamma, but wouldn’t feed more than twice during the day.

During a lovely long hike through a nearby park, through the woods, and along the stream, with the baby alert and interested in the baby carrier, the mother and I talked about everything: her work, her marriage, her labor and delivery, and her life.  I have found that conducting part of a consultation outdoors is very helpful. It relaxes the mother, and makes her feel safe to tell her story. This easy dialogue creates a connection between us. Working outdoors often dissipates tension; mothers benefit from a reminder that they are part of a bigger world.

After nearly 2 hours of chatty strolling, we got back to my office. The baby was ready to breastfeed. The mother got ready, opening her bra, holding her breast and her baby in a cross-cradle hold. The baby got fussy and the mother got worried; the baby didn’t attach, and they started a subtle battle with each other. The mother was insisting on a particular position and the baby wanted to do it herself.

At that point, it became obvious that the mother’s expectations and understanding were the barrier to easy, fun breastfeeding. She was working to breastfeed the way she had learned in the hospital, every 2 hours whether the baby wanted to feed or not, by holding her breast, pulling it into midline and guiding her baby’s head onto the nipple.

The daytime breastfeeding relationship for this dyad had been a battle for 5 months. She was tired of the struggles, and now was eager for new ideas. She was ready to let the baby teach her how to breastfeed.

When the baby found her own position on her mother’s lap, she showed just how well she could dive at the breast, attach herself, feed, let go and look around or smile at mamma, and then dive back and feed some more. The mother had no idea that her baby had any ability to feed on her own, and was delighted and surprised to see her baby’s skills.  This sweet baby played at the breast, sucking her thumb and mother’s nipple at the same time while resting her foot on the other nipple. The mother didn’t know that this was normal behavior for a 5-month old.

Their interaction was charming to watch. Breasts are babies’ first toys.

Breastfeeding is a relationship that must evolve to suit the mother and baby. Relationship can’t be taught. What can be taught is how to create the environment where the mother and baby can figure out their own way. The problem for this dyad was that they had never developed their own style of breastfeeding; the mother said that every interaction with her baby was a mission to accomplish something, that they had never hung out and discovered each other. Breastfeeding during the day had been about following rules; breastfeeding at night had been mindless. The baby had made her preference clear.

They left all happy, looking forward to a new chapter in their lives.

I love my work.



[This post originally appeared on Nikki Lee’s blog Morning Thoughts, on April 18, 2016. Thanks to Nikki for permission to repost.]

Celebrating the Breastfeeding Champions of North Philadelphia: An interview with Naima Black, CLC, Coordinator North Philadelphia Breastfeeding & Community Doula Program

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 (right) demonstrates comfort measures with a community doula trainee (left)

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.)

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Practicing comfort measures with Community Doula trainees

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.

Sharing affirmations with one another during Community Doula training

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.

A Reminder to Broaden the Focus: A comfortable breastfeeding relationship rests on much more than “proper latch”


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.)

I’ve been working with mothers and babies since 1975; I’ve been in private practice as a lactation therapist since 1989. These years have been full and wonderful and I look forward to many more.

Something is happening today in the language used by breastfeeding helpers that disturbs me and feels like fingernails scratching across a blackboard. This the focus on “the latch” instead of focusing on “breastfeeding.”

I’ve heard hospital colleagues say, “I was just latching a baby on when you called,” or “I latched on 24 babies today.” Current prenatal resources talk about the latch, “Getting your baby to latch”. “Your nurses in the hospital can help you and your baby learn to latch.” “Latch on, the key to successful breastfeeding.” “Breastfeeding: It’s Latching On.”

I’ve had clients tell me, “They told me the latch was perfect in the hospital, but it always hurt.”  These mothers are doubting themselves when the experts have told them something different to their own experience. Simply put, latch isn’t perfect if it always hurts. No one asks the mother if she is having fun with her baby, or if she knows when her baby wants to go to breast. It’s all about the latch. Mothers are calling the warm line or lactation professionals to “have the latch checked.”

I see clients controlling the relationship, focusing on getting the baby to latch, with little awareness of, or attention to, comfort or timing. No one seems to remember that healthy babies are born with all the reflexes and skills they need to breastfeed; certainly the mothers I see are always surprised to see what their baby can do when given the chance!

The focus of our work has become the latch, the narrow area where the baby’s mouth and the areola and nipple intersect. True, this component of breastfeeding has to be comfortable and effective. However, it is not the whole story. The whole story is about feelings and relationship, about observing, and about responding. Breastfeeding includes health, with functional anatomy and physiology. Breastfeeding includes environment, respect and timing. Breastfeeding encompasses fun, love, and pleasure.

Making the latch the focus of breastfeeding is like making penetration the focus of lovemaking. Today, it is as though the relationship has been distilled to directions for assembling a piece of furniture from IKEA. We all know that there is much more to intimacy than Part A accepting Part B comfortably and completely. We know that a baby is much more than the sum of its diapers, feeding frequency, and weight. We want to appreciate the emotional components of relationship that make breastfeeding something for mother and baby to enjoy.

Let’s remember the whole, and do what we can to promote relationship, while supporting all its elements.


[A version of this post appeared on the author’s blog, Morning Thoughts, in May of this year.]