A’nowa:ra Owira (Baby Turtle) Doulas serve Indigenous families at a uniquely situated point on the map

In a matrilineal society, ancestral descent is traced through maternal lines. Indigenous Full-Spectrum Doula Skaniehtiiohstha Kasokeo of A’nowa:ra Owira Doulas— serving those on the borderlands of Canada and the U.S.– points out that of the hundreds of Native American tribes across North America, many of them are matrilineal and this framework contributes to the interconnectedness of life.

Sign reads: “My Mom, Sisters, Aunties + Grandmas are Sacred” Photo by Dulcey Lima on Unsplash

But because of the devastation of colonization and forced assimilation, many of the birth and infant feeding traditions passed down through clans by mothers have been disturbed. Kasokeo and her colleagues are working to empower Indigenous families through birth, restoring these traditions. 

“A lot of things were taken,” Kasokeo says of the effects of colonization. “We all have bits and pieces of that big picture; we’re healing from historical trauma. We can use this time of birth to bring healing to [families].” 

She shares that an elder once told her that through the messages we tell our children, we send messages to our future. 

Skaniehtiiohstha Kasokeo

“I personally relate that back to the birth experience,”Kasokeo begins. “The messages we send about our bodies, our connection to each other and the strength of women, in my mind happens through breastfeeding. Especially in the first hours after birth, the first messages we relate are about our bodies and the connection to babies’ matrilineal line through breastfeeding.”

Kasokeo emphasizes that this path will look different for every person. 

“It doesn’t have to look a certain way,” she says. 

Another doula featured in Reclaiming Birthing Traditions: Indigenous Advocates Talk Maternal Health by Daisy Sprenger echoes this distinction. 

“There is a problematic tendency… to generalize within dialogues about Indigenous communities,” Sprenger writes. “It’s critical to remember that ‘Indigenous’ is a very broad term, and that each community has different practices and traditions. Within these communities …  each mother and family will have different outlooks, personal histories, and levels of comfort and desires.” 

Kasokeo and her colleagues embrace this approach with the overarching theme to give power to women, instilling in them the confidence that their bodies will help their babies to thrive.

Photo by Luiza Braun on Unsplash

The doulas in their group lean on one another, strengthening their collective as support people.  Kasokeo talks about how she, in part, pursued doula work in order to become what she needed.

When Kasokeo became pregnant at 19, she immediately sought out the very limited midwifery care where she was living in Saskatchewan (Treaty 6 Territory). With only 12 midwives in her entire province, she sent in her application as early as possible, but was denied due to the sheer number of parents seeking out midwifery care. 

Author Amanda Short details that “Jessica Bailey, President of the Midwives Association of Saskatchewan, said that her team of six at Saskatoon City Hospital turns away anywhere from 40 to 50 percent of people asking for care monthly. Across the province, it’s somewhere from 20 to 50 percent.” 

During this time though, she learned about doulas, connected with one in her area and says she “fell in love with everything about it.” 

As a survivor of sexual abuse, Kasokeo says it was important to her to know what procedures were going to be done to her perinatally and to be equipped with as much knowledge as possible. Having a doula by her side helped her achieve that.

Despite laboring for over 20 hours and ultimately deciding on pain medication not originally planned, Kasokeo reports having had an orgasmic birth. She says she thought, “Everybody should have this!” 

During her second birth, Kasokeo hemorrhaged and was later forced to navigate an unjust healthcare system with retained placental fragments eight weeks postpartum. 

Having endured the challenges she found herself in, Kasokeo says she sees herself as well-situated to meet other women where they’re at. 

In 2017, she and her colleagues formed A’nowa:ra Owira (Baby Turtle) Doulas serving those in Akwesasne, Canada and surrounding areas.

Akwesasne is a uniquely situated point on the map. Joshua Keating writes in The Nation That Sits Astride the U.S.-Canada Border: “This Mohawk community is home to around 13,000 people and sits astride the world’s longest border (three hours’ drive northeast of Syracuse or two hours’ travel southwest from Montreal), not quite a part of either country, but not quite independent either…The town has three different governments: one elected council recognized by Canada, one by the United States and a traditional government affiliated with the Iroquois Confederacy, of which the Mohawk are one of the six constituent nations, or tribes. All told, including the United States, Canada, the state of New York and the provinces of Quebec and Ontario, there are eight governments with some level of jurisdiction over a territory with an area of less than 40 square miles…” 

Kasokeo explains that this means not everyone has access to the same health care systems, so she and her colleagues work to fill in the voids that many families face when in need of maternal child health care. 

As the world learns to manage life amidst a pandemic, she and her group are beginning to open up more meetings and social gatherings in hopes of reaching more birthing and lactating individuals. 

Recently, Kasokeo completed the online Lactation Counselor Training Course (LCTC)

“I loved the training!” she exclaims. The myth busting and the counseling skills were notable, and she says she appreciated the convenience of being able to simultaneously learn and stay at home with her children. 

Kasokeo admits that covering the counseling skills stalled her at times throughout the course; she says she felt guilty reflecting back on past clients and how she might have interacted with them differently and better served them.

Photo by Gustavo Cultivo on Unsplash

“I needed to find the confidence in myself,” she adds. “It was really scary for me, but the course has given me the tools to be confident in my ability to become a lactation care provider. Moving forward, the number one thing will be not making assumptions and asking people to clarify things.” 

Kasokeo’s fascination with and passion for maternal child health persist, and she says she would love to network with others. She is particularly interested in learning about how to nurture a homegrown organization with limited funds. You can reach Kasokeo directly at skasokeo@anowaraowiradoulas.org  or connect with A’nowa:ra Owira Doulas here and here.

Sudden Infant Death Syndrome (SIDS) Awareness Month: educating parents and caregivers about safe sleep environments

 A decade ago, an anti co-sleeping campaign aimed at reducing Milwaukee’s staggeringly high infant mortality rates, was launched. One of the campaign’s ads pictures an adorable, diapered baby sleeping amidst a cloud of fluffy bedding.  The baby snuggles up to a butcher knife strategically tucked under the pillow next to him. The text reads: Your baby sleeping with you can be just as dangerous.

The campaign sought to reduce the city’s infant mortality rate by 2017. Tragically, according to the Fetal Infant Mortality Review (FIMR), those numbers have risen.

Image courtesy of the Safe to Sleep® campaign, Eunice Kennedy Shriver National Institute of Child Health and Human Development, http://www.nichd.nih.gov/sids; Safe to Sleep® is a registered trademark of the U.S. Department of Health and Human Services.

In 2017, 120 infants born in the City of Milwaukee died before their first birthday. Over 15 percent of Milwaukee’s infant deaths are attributable to a combination of Sudden Infant Death Syndrome (SIDS) and Sudden Unexpected Death in Infancy (SUDI) and unsafe sleep.  Of these deaths, the majority died in an unsafe sleep environment. 

Nationally, there are about 3,400 infant sleep-related deaths each year. 

This month, we join maternal and child health advocates in recognizing Sudden Infant Death Syndrome (SIDS) Awareness Month– a time to educate parents and caregivers about creating safe sleep environments and reducing the risk of SIDS and other sleep-related illnesses alongside supporting breastfeeding/chestfeeding as the national norm.

Campaigns, like the one released in Milwaukee (no matter how controversial), are a good place to start in promoting healthy public health behavior. However, as noted in the series of learning modules, Building on Campaigns with Conversations: An Individualized Approach to Helping Families Embrace Safe Sleep & Breastfeeding developed by the National Center for Education in Maternal and Child Health (NCEMCH) while it operated the National Action Partnership to Promote Safe Sleep (NAPPSS, 2014-2017), true behavior change is only accomplished by two-way communication.

Image courtesy of the Safe to Sleep® campaign,  Eunice Kennedy Shriver National Institute of Child Health and Human Development, http://www.nichd.nih.gov/sids; Safe to Sleep® is a registered trademark of the U.S. Department of Health and Human Services.

The modules, designed for a range of health professionals, human service providers, community health workers, home visitors, and peer supporters who interact with families on topics of safe sleep and breastfeeding, urge care providers to “become listeners as much as talkers.”

Telling families what to implement based on expert knowledge is antithetical, the module argues. Instead, care providers must shift their standpoint from expert to resource, supporting families through their own informed decisions. When care providers position themselves as experts as opposed to resources, families often feel as though they cannot be honest about the realities of their experience. 

I’ll share a personal example here. At our pediatric office, the computer screens illuminate with an image of an infant sleeping accompanied by text that reads: The ABCs of Sleep; Alone, on Back, in Crib. During the intake questioning at a visit with my first-born, the care provider asked, “Where is your baby sleeping?” I immediately started to sweat, nervous, because our sleeping arrangement looked nothing like what I was seeing on the screen. I timidly reported that my infant slept with me. I watched the care provider input the information, but then we moved onto the next topic. This was a missed opportunity to have a conversation about what safe sleep can look like and a missed opportunity to help create a plan that would support our family decisions. 

Time constraints are surely a challenge when supporting families. However, the Building on Campaigns with Conversations learning resource states: “… Research has reported that families are not likely to buy into the recommendations without some understanding of why they are made, [so] not sharing this information is actually wasting valuable time.”

Image Source: NICHQ-led NAPPSS Improvement and Innovation Network

It goes on to suggest,  “…The Conversations Approach is a two-way process, [so] you can ask families if they have any questions about why a recommendation is given and deal with that one or more. Also, there are two important themes that you can reference and relate to each recommendation: 1. Making sure the baby gets enough oxygen (keeping the baby’s airways open (nothing covering the face, not cut off by position of the chin on chest) and keeping the baby from rebreathing the carbon dioxide when face down; 2. Making sure the baby does not sleep so deeply that he/she doesn’t wake up if oxygen levels are getting too low. Breastfeeding, of course, has additional benefits.”

It’s essential to recognize that we have strangely unrealistic expectations for infants and infant sleep in our country. 

Parents of babies who are only weeks old are often asked if the baby is sleeping through the night. 

“Asking this question is like asking if the new baby is reading yet; it is not at all developmentally appropriate,” the module informs. 

Helping families reframe what is normal will help elicit healthy behavior and relationships. 

Care providers should also be aware that many parents and caregivers have extrapolated through the Back to Sleep campaign that “face up” positioning is as safe as “on back” , Michele Labotz, MD, FAAP explains in Out of the Container, and Onto the Floor. Labotz reports that babies spend almost six hours per day in containers like car seats, strollers, bouncy chairs, and other seating devices.

“Excessive time in these devices inhibits movement and places babies at higher risk for a variety of issues, such as plagiocephaly, decreased strength, and delayed motor milestones,” Labotz writes.

This SIDS Awareness Month, National Institute for Children’s Health Quality (NICHQ) offers many resources related to safe sleep including a short video quiz that can be used by health professionals to engage parents and caregivers in conversations about safe sleep and breastfeeding recommendations. 

NICHQ suggests using the quiz as an interactive, visual tool to prompt discussions around best-practices. It can also be shown in pediatric and obstetric waiting rooms, parenting group sessions, birthing classes, and breastfeeding classes. 

More Safe Sleep Resources:

Rafael Pérez-Escamilla, PhD Sofia Segura-Pérez, MS, RD and Megan Lott’s, MPH, RDN  Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach, offers sleep and physical activity considerations for infants and toddlers. (p 24-27)

La Leche League International’s Sleep Guide 

University of Notre Dame Mother-Baby Behavioral Sleep Laboratory

Safe to Sleep® Downloadable Media 

Our Milky Way’s coverage on Sleep Awareness Week 2021

Celebrating Elyse Blair, RN, BSN, ANLC, IBCLC and her career dedicated to special care babies

Elyse Blair, RN, BSN, ANLC, IBCLC , Healthy Children Project Faculty Emerita,  has spent most of her almost 50 year nursing career helping the smallest and most medically complex infants. Blair worked as a labor and delivery nurse for the first several years of her career, but she was always curious about the babies who spent time in the neonatal intensive care unit (NICU). After taking some time off after the birth of each of her sons, Blair returned to work with the same interest in the NICU setting.

“The curiosity was still really revved up about these babies,” Blair shares.

Eventually, that curiosity evolved into a passion that would lead her to play an integral role as a lactation care provider in a 100+ bed NICU at an Atlanta hospital.

Blair was instrumental in developing and implementing lactation programs at the special care nursery, starting conversations with neonatologists about human milk and breastfeeding. Up against a glaring deficit in lactation and breastfeeding education and training for medical students that still exists to this day, Blair was successful in advocating for human milk feedings for these medically complex babies. While feedings do not always occur directly at the breast, (although it’s been documented that a clinically stable preterm singleton infant initiated breastfeeding at 27.9 weeks postmenstrual age) once human milk feedings were established either by gavage, cup or spoon-feedings, Blair reports that their necrotizing enterocolitis (NEC) rates dropped markedly. NEC is common among very low birth weight (VLBW) infants and can lead to death. 

“The babies were just not as ill,” she says. [For more on the effects of human milk on NEC, visit https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/infant-health-research/infant-health-research-necrotising-enterocolitis/  ] 

Determined to eliminate corporate pressure in her unit, Blair spurred a policy that prohibits formula company and breast pump company representatives from accessing care providers and families during their stay.

Photo by Sharon McCutcheon on Unsplash

Blair recalls an incident where she caught a formula company representative reading a patient’s chart on the postpartum unit. 

“The reps all know that breastmilk is the best thing,” Blair begins. “The reps wives all came to us for lactation consults. They’re just good at peddling a product. It’s just not ethical.”  

In order to normalize breastfeeding at her institution further, Blair advocated for language changes on pre-admission paperwork. Wording like “Do you plan to breast or bottle feed” was changed to “How long to do plan to breastfeed or provide breastmilk.” 

Blair started a program called the Mother’s Express, a two hour luncheon where parents from her NICU could interact with peers.  Their hospital provided the meal, and Blair brought in speakers like social workers and psychologists specializing in the preterm population and other professionals. She says this is one of her accomplishments she is most proud of. 

“Parents came in droves,” Blair remembers groups of 50 to 60 parents coming at a time, nodding to the importance of peer-to-peer support. “Parents made lasting relationships.” 

Blair also fondly remembers the yearly preemie birthday party her NICU hosted for the babies they cared for.

“It was amazing to see many of these children just thriving,” she says. 

The increasingly incredible outcomes of premature babies Blair notes, are often due to what she considers the most significant change she’s witnessed over the course of her career as it relates to care of infants in the NICU: surfactant. Surfactant is a substance that treats respiratory distress syndrome and some other respiratory conditions in underdeveloped neonatal lungs. Aerosolized surfactants have often decreased the need for intubation.

“There is a striking difference for parents when there are less tubes and wires all over their babies’ bodies,” Blair says. “Parents of fragile babies are often extremely cautious, but we want them to participate in their baby’s care.”

Source: United States Breastfeeding Committee
(Photo by Sara D. Davis)

Family-centered care can increase parental confidence and positively influence infant health outcomes; however, it is interesting to note a phenomenon that Dr. Renée Flacking reported on at the 2019 Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives conference.

Healthy Children Project’s Cindy Turner-Maffei, MA, ALC, IBCLC covered her presentation in a previous blog post: “Maintaining evidence-based is a never-ending process requiring not only ongoing uptake of new information, but also ongoing monitoring and evaluation of practice. Renée Flacking’s initial conference plenary focused on the decrease in exclusive breastfeeding that seems to be occurring in Swedish Neonatal Intensive Care Units (NICU), perhaps particularly in those that utilize single family care NICU rooms vs. open-bay NICU units. Dr. Flacking described how in earlier days parents were told that providing human milk was ‘the only thing’ they could do for their babies; today Swedish parents are welcomed to stay in the NICU with their babies, they know firsthand the importance of skin-to-skin contact, responsive parenting, etc.. Renée also discussed how when the parents are in charge of the baby, as in family care, the staff may tend to back off on strong messaging that is perceived as ‘pressure’ to breastfeed. Even in a country where breastfeeding is perceived as normal and breastfeeding support abounds, seemingly positive changes in policy and practice have the potential to create unintended negative side effects.” 

Maternal and Infant Assessment for Breastfeeding and Human Lactation: A Guide for the Practitioner, 3rd editionDedicated to evidence-based care, Blair actively taught for Healthy Children Project– evidence-based research, education and care being a pillar of the organization– for more than two decades.  Today, she continues to work with students completing the online Lactation Counselor Training Course (LCTC). She was a member of the Eisenhower Foundation Delegation on Breastfeeding and Human Lactation to Russia and Romania and has also traveled to Latvia, Egypt, and Germany, teaching and supporting new parents and their special care babies. She wrote the monograph A Guide to Breastfeeding Your Special Care Babies and co-authored the 2nd edition of Maternal and Infant Assessment for Breastfeeding and Human Lactation. Blair is the proud grandmother of her “heart lights” Millie (11), Charlotte (9), Goldie (5).

Beyond Blair’s work, Our Milky Way has covered special care babies extensively. 

Read about Bethany Gallagher’s, MS, CCC-SLP, CLC, CNT experience as a Senior Speech and Language Pathologist working in a level 2 NICU here

Noel Wier, BSN, RN, CLC and her colleagues at a level IV NICU in Colorado are helping moms with babies born with special challenges prove that they can and do breastfeed with proper support and determination. Read that story here

Angie Cordero, CLC breastfed her baby born with spina bifida. Read their story here

Jennifer Cloer’s, CLC premature births inspired her to donate milk to other babies in need. Read that story here.  

NICU nurse and lactation professional Donna Warr, RN, IBCLC works with families participating in Lee Memorial Health System’s Golisano Children’s Hospital of Southwest Florida NICU’s program called “Heart-to-Heart” Care which offers parents an opportunity to provide their babies with a sense of closeness while they are separated through sense of smell. Learn more here.

Source: United States Breastfeeding Committee.

Alongside Blair’s professional work, we would like to acknowledge Lois D. W. Arnold’s, PhD, MPH, ALC significant contribution to the use of human milk in NICUs, Ragnhild Maastrup’s RN, IBCLC, PhD work with preterm infants and their families and Renée Flacking’s, RN, PhD ongoing research.

Celebrating the final week of Hispanic Heritage Month

 ​​New Mexico Breastfeeding Task Force Deputy Director Monica Esparza, CLC and her 13-year-old daughter have started practicing Baile folklórico (Mexican folk dance) together to connect with their culture. The birth of Esparza’s daughter and subsequent WIC peer counselor position started her on her path to maternal child health advocacy. 

While searching for resources for her clients, Esparza networked with the New Mexico Breastfeeding Task Force (NMBTF), ultimately helping establish the Albuquerque chapter.  

An immigrant herself, Esparza’s experience navigating health systems inspired her to continue to help others face language barriers and other challenges to get the care they deserve.  

Identity erasure and revival  

From September 15 to October 15, we celebrate National Hispanic Heritage Month to honor the rich histories, cultural influences and contributions of Hispanics/Latinx in the United States.   Guest speaker Tecpaxochitl Mireya Gonzalez points out in the 2021 Nikki & Nikki LIVE: Celebrating Hispanic Heritage Month webinar that the term Hispanic is not accurate though and dismisses diversity. 

“What does it mean to be Hispanic?” Gonzalez poses. “There are a lot of nuances.”

Latinx are a diverse group with ancestry from 28 countries, USBC reports.

Photo by Elena Mozhvilo on Unsplash

To identify Spanish-speaking nations as the origin– an indicator of a colonized country– is to dismiss indigenous identities, “to dismiss all of our ancestry,” as Gonzalez puts it in the Nikki&Nikki discussion.  

It was breastfeeding/chestfeeding/bodyfeeding (the term Gonzalez uses) that allowed Indigenous People to be resilient through colonization, political injustices and other hardship.  

“We have these cultural practices that sustain us,” she says.  

Esparza says, “We are resilient, but we shouldn’t have to be.” 

“We are smart and we know how to solve our own problems,” she continues. “We need to make sure people listen and support us.”

Supporting diversity and cultural attachments 

In the webinar, Gonzalez details ways in which lactation care providers (LCPs) can best support a diverse group of people. 

First, questionnaires and intake forms should reflect diversity. Allow individuals to self identify.

Gonzalez explains that the CDC and the Census have allowed for the identification of Hispanic origin (which she acknowledges can be controversial because indigenous identity is not a subgroup; in fact, indigenous identity predates European invasion).

With this tweak in documentation, since 2009, there has been an 85 percent increase in the Native population, Gonzalez reports. There is dignity in this recognition, she says. 

LCPs can help individuals maintain their cultural attachments and build on their cultural values when identity is recognized. Birth, infant feeding and other cultural practices that were stolen, repackaged, and then resold back to Indigenous People can be restored. LCPs are uniquely situated to assist in this restoration of an entire food system and reclamation of health.  

This includes “re-indigenizing” agriculture– fueling pregnant bodies with pre colonial foods and feeding young children indigenous, complementary foods alongside breastfeeding.  

Secondly, Gonzalez urges trust-building. Create spaces where individuals feel seen and heard, ideally within the early prenatal period. Allow them to tell their stories, or help them to discover their stories. “Tell me about lactation in your lineage,” Gonzalez offers language for the LCP. Be aware that this transgenerational work can bring up trauma as birth and lactation often intersect with domestic abuse, sexual assault,  forced migration, etc. 

Esparza, too, emphasizes the value in building trust, listening and honoring stories and shares that these are the components that help her thrive as an LCP. 

Increasing representation in LCPs 

NMBTF offers a CLC scholarship program to those who self-identify as low income women of color throughout New Mexico in order to diversify the field of LCPs. The scholarship covers the online Lactation Counselor Training Course (LCTC) and the AALP exam. In its two years, the program has awarded 28 scholarships.

Photo by Laercio Cavalcanti on Unsplash

Since the LCTC has gone virtual, Esparza says that some of the participants have benefitted from the accessibility and self-paced nature of this platform; however, it has created barriers for some. In many rural areas in New Mexico, internet access is not always reliable. For those who speak English as a second language, a virtual platform requires a different learning process entirely, Esparza explains. 

With these challenges in mind, Esparza hosts two study groups a month which offer an opportunity to review the material and provide peer-to-peer encouragement. 

NMBTF recently started a virtual breastfeeding support group, and Esparza says that LCTC participants sometimes join these meetings to interact with real-life infant feeding challenges in their own language. 

Esparza shares that LA Publishing provides some of their lactation education materials in Spanish. Health Education Associates, Inc. offers many of their materials in Spanish as well. And this month, Lactation Education Resources (LER) announced that their 95-hour course is now offered in Spanish

Author Michelle Hackney and Illustrator Mia Ortiz-Gandara created Mamas Leche, a bilingual children’s picture book, told from the infant’s perspective. You can find a reading of the story here.  The second book in their series, Brave and Strong,  imagines a premature baby’s journey into the world.

Looking ahead  

Without diminishing the importance of Spanish- language materials, Gonzalez shared with Nikki&Nikki participants her hope to see lactation education developed into indigenous languages.  

Esparza emphasizes the need to include BIPOC communities when policies are being drafted and legislation is being written so that everyone’s voice is heard, considered and amplified.  

Esparza’s work through NMBTF has generated strong collaborations with organizations that interact with families at all stages. The coalition partners with the Indigenous Community Doula Association, W.K. Kellogg Foundation, birth and justice organizations, Family Friendly New Mexico, and health care providers among others.  NMBTF is in the process of creating a lactation curriculum for home visitors to best serve families. Learn more about NMBTF’s success and future plans in their 2020 Annual Report available in English and Spanish.

Plus-Size Mamas Can Breastfeed: Don’t Let Weight-Bias, Shaming and Poor Advice Derail Your Efforts. You’ve Got This!

By Kathleen Kendall-Tackett 
Illustrations by Ken Tackett

Bias against fat people remains the last socially acceptable prejudice. It’s in science, the world,  and in healthcare. Plus-size women encounter prejudice in almost every type of health  care setting, but for some reason, it seems particularly harsh in maternity care. Women are  bullied and shamed into doing things that are not healthy, such as a 15-pound weight gain  during their pregnancies or an unnecessary cesarean. What’s worse, many providers feel  justified when they act this way, claiming only to be concerned about the mother’s health.  When providers say, “It’s just not healthy,” they are often hiding baser feelings that have  little to do with the health of the mother and more to do with providers’ sense of aesthetics  (“it’s not attractive”), and even their sense of right or wrong (“fat = lazy, undisciplined, poor,  dumb, etc.”).  

The same thing happens in lactation care. Weight bias is rife. I’ve heard it in the way  providers talk about mothers and in conferences on “obese mothers.” Is it any surprise that  breastfeeding rates are lower among women with higher BMIs?  

You’ve most likely run into these judgments already. Don’t buy into it! That’s their problem,  not yours. Here are some of the myths you might run into. These myths are even in the  scientific literature.

Myths about Plus-Size Mothers and Breastfeeding 

Previous studies have found lower breastfeeding rates in plus-size mothers. The question is,  why? Weight-biased scientists have often hypothesized something like this; “If ‘obese mothers’ cannot breastfeed, it must be their fault.” Their “fatness” somehow made it impossible.  Research articles, published in generally decent journals, beat the tattoo of the fat-hating  culture. Although clinicians often repeat these myths, none of the problems they’ve identified have a shred of evidence to support them. Some of these would be funny if they weren’t  so poisonous. 

  1. Your nipple is too big.  

This one’s odd. Skinny women sometimes have larger nipples. Not a bit deal. Nipple size is  not related to weight.  

Workaround: Sometimes, a nipple can be too big in the early days, especially if your baby  was born small or a bit early. If your baby is having trouble, you may need to express for a few  days to give her a chance to catch up. Keep offering and keep expressing milk to establish  your milk production. Try some different positions. If it hurts, stop, and give it a bit longer.  It will happen. 

  1. Your areola is too big.  

So what? Your baby doesn’t need to get the whole areola in her mouth. She only needs to  take enough in to get a deep latch, one that doesn’t hurt you and helps her transfer milk well. 

Workaround: While you  don’t need to worry about  “big areolas,” you do  need to pay attention to  whether your baby has a  deep latch. If your nipples  are sore and/or you don’t  hear audible swallowing,  have a lactation specialist  take a look. Many times, it  can be quite easily sorted  with skilled help. But it’s  better to get that help  sooner rather than later. 

  1. Your breasts will “crush” your infant.  

This is a particularly hateful myth. New mothers are already sensitive enough. Saying that  they will harm their infants with their bodies is the worst kind of fat-shaming, and it’s not  even close to true. 

Workaround: You’ve been handling your breasts since puberty. I’m sure you can figure  out a comfortable way for you and your baby to sit while nursing. Some mothers find that  a rolled-up washcloth under their breast takes some of the weight off the baby. The truth is  that many different positions can work. Feel free to experiment.  

Remember, this is your body and your baby. You don’t have to do it like anyone else. The  “right” position is the one that works. 

  1. You have no lap, so you won’t be able to use all the standard  positions. The no-lap argument is laughable. Lap  size depends on people’s height and body  shape. You can’t make a blanket statement  that supposedly includes all plus-size  women. For example, short women may  not use much space for the baby to be. Are  we going to say they can’t breastfeed? Or  course not! You also do not need to use all  the standard positions. That’s just silly. And since when do mothers breastfeed  from their laps?  

    Workaround: Biological Nurturing (laid back breastfeeding) is your friend here. By using it, you increase the ventral space area  where your baby can lie. Here’s a quick overview. 

    a) Sit comfortably and pretend like you are watching TV. It can be any angle you like.

b) Put your baby at what Dr. Suzanne Colson calls the “right address.” Your baby should  be face down on your body, letting gravity do the work to hold her in place. Scoot  the baby up so that your baby’s cheek is on your breast. From that position, you  should comfortably be able to see your baby’s face. 

c) Hang out and enjoy being close to your baby. When your baby gets hungry, she  will start bobbing her head towards your breast. Feel free to support your baby’s  movements and adjust yourself, your breasts, and your baby as needed. From this  position, babies tend to latch well and feed efficiently.  

d) Try different positions. Don’t feel like you have to do it the way that anyone else  does. Here is a link to her site so you can see this in action.


You can also purchase her book here. PraeclarusPress.com 

    1. “Obese women” have less of a prolactin response to suckling.

This myth is insidious  because it sounds  so scientific and so  sure, and it comes  from a particular  study (Rasmussen  & Kjolhede, 2004).  This study has gained  importance because  everyone cites it and  uses it for evidence  about why plus size women can’t  breastfeed. It’s even  on the exam we take  to become IBCLCs.  But here’s the thing:  this belief was a  hypothesis. The study  included only 17 mothers (some of whom were “overweight,” not “obese”). Tiny  sample. It’s interesting, but you can’t conclude much from it. Strike one. 

The researchers hypothesized that progesterone in adipose (fat) tissue suppress es prolactin, the hormone necessary for milk production. That wouldn’t be a good  thing. (Progesterone is another hormone that helps sustain pregnancy and drops to  low levels after birth.)  

Unfortunately, the data did not support their hypothesis. They only found the effect  of suppressed prolactin on day one but not on day two (so it could be anything, really, including a measurement error). Further, progesterone appeared to have no role  in this process whatsoever.  

So what does this mean? It means that this theory, in all its fat-shaming glory, was  not supported by the findings. What do you need to do about it? Absolutely nothing!  But do be aware that some of your providers may harbor this belief—mainly because  most have not read the actual study. 

The Real Reason for Lower Breastfeeding Rates  in Plus-Size Mothers 

Let’s go back to our original question.  Why do plus-size women breastfeed at  lower rates than women with lower BMIs?  The answer is one you might suspect. A  study of more than 19,000 women in the  U.S. found that plus-size mothers were significantly less likely to get the support that  we know they need to successfully breast feed (Kair & Colaizy, 2016). They were  less likely to have their babies with them  in the first hour, less likely to have skin to  skin time, and less likely to be instructed  on cue-based breastfeeding. Further, their  babies were less likely to room in and were  more likely to use pacifiers. They were  even less likely to get a handout listing breastfeeding resources in the community.  

There is no excuse for this. We (as a field) have spent years looking for ridiculous hormonal  explanations or looking at the mothers’ characteristics. While we have been pointing fingers at you, we should have noticed that three fingers are pointing back at us. 

Things to Watch For 

While you don’t have to believe the myths, there are a couple of things that may be related  to BMI, so they are important to watch for. 

  1. You may have more edema. 

This isn’t always true, but it can be, especially if you’ve had a lot of fluids during your delivery.  

Workaround: If you have engorgement or your breasts feel so full that your baby can’t  latch, use reverse-pressure softening to push some of the fluid away from your nipple and  areola. It’s important to breastfeed as much as you can during this time. Here’s a link to  show you how. 

http://www.breastfeedingonline.com/rps.shtml#sthash.XplY2f Ke.dpbs 

Engorgement is caused by your milk “coming to volume,” but also excess blood and fluid.  It’s important for you to address for your own comfort and because it can influence your  milk production. Breastfeed or express your milk frequently. Use some cool compresses  to comfort. You might also try some very gentle breast massage. The best expert on this is  lactation consultant Maya Bolman. You don’t need a deep massage. The lymph nodes are  near the skin. You just need enough so that they can help move excess fluid. Here’s a link for her site below. The first half is on hand expression, and the second part is on breast massage. https://player.vimeo.com/video/65196007 

  1. Watch out for the effects of insulin resistance. 

If you have a condition related to insulin resistance (e.g., polycystic ovarian syndrome  (PCOS) or type II diabetes), it’s important to keep it under good control. Excessive insulin  can affect the hormones necessary for lactation. If you are on medication to control excessive insulin, don’t stop. Exercise is your friend here. It’s good to have some gentle exercise  every day if you can. Put your baby in a sling or stroller and take a walk. If you’ve had a particularly carby meal, go take a walk. It will help a lot. 

Exercise will make it easier for you to breastfeed. The goal is not weight loss; it’s to use exercise as a way to control insulin. You may lose some weight too, but you will get major health  benefits even if you are not smaller. 


If you are a breastfeeding mother, or want to be, what do you need to do? First, know that  you may not get the support you need from your providers. I wish that it was different, but  it’s important to acknowledge the landscape. Fortunately, knowledge is power. If you know  what you might run into, you can gather what you need for yourself. Find people you connect with and who will help you. I’m sorry that you will have to do it this way. You deserve  better. But you can make it work. 

Breastfeeding is your right.  Don’t let anyone tell you differently.  You’ll be amazing. 


Kathleen Kendall-Tackett, PhD, IBCLC, FAPA, is a health psychologist and international  board-certified lactation consultant. She lectures extensively across the U.S. and Canada, and  in 15 countries outside of North America. She became interested in the topic of weight bias in  maternity care after attending several conferences in a  row on the topic of “obese mothers.” They made her mad.  After being bumped off of a plane, she wrote a particularly  snarky piece for the Science and Sensibility blog called  “Weighing in on Obesity and Breastfeeding,” which lead  to many opportunities to speak on the topic. She served  on the U.S. Office of Women’s Health’s Taskforce on  Obesity and Trauma, and lectures frequently on the topic  of weight/BMI, trauma, and bias in healthcare providers.  Dr. Kendall-Tackett is the founding editor for Clinical  Lactation and served as Editor-in-Chief for 11 years.  She is also Editor-in-Chief of Psychological Trauma  and is currently serving her second term. She continues to  advocate for plus-size women in every setting that she is in.   You can find out more at www.kathleenkendall-tackett.com. 


Kair, L. R., & Colaizy, T. T. (2016). Obese mothers have lower odds of experiencing  pro-breastfeeding hospital practices than mothers of normal weight: CDC Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2008. Maternal &  Child Health Journal, 20(3), 593-601.  

Rasmussen, K. M., & Kjolhede, C. L. (2004). Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics, 113,  e465-e471.  

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Questions: ken@praeclaruspress.com