Breastfeeding in Appalachia

Carroll (left) pictured with ABN Vice President Mishelle Trescott (right).

You’ll often hear Healthy Children Project faculty say, “All roads lead to breastfeeding.” Time and time again, this sentiment rings true for Our Milky Way interviewees, like Appalachian Breastfeeding Network (ABN) President Stephanie Carroll, BS, IBCLC, CLS, CLC. With a degree in Communications, Carroll never anticipated she’d be doing the work she’s doing today. The experiences of birthing her two daughters though, led her to become the first peer hired as part of the Breastfeeding Peer Helper Program at her local WIC office in southeastern Ohio.

“I…owe a lot to the retired WIC director who first saw a light in me, Sandy Walker,” Carroll says. “…Sandy saw how passionate I was about feeding my baby breast milk. It is now that I realize that Sandy was the one true supporter I had in my own breastfeeding journey.”

Now, Carroll works as a Lactation Consultant at Holzer Health System where she revels in helping mothers transform.

“Breastfeeding changes you,” says Carroll. “And when you see that change in someone because of the help you provided, there’s no better satisfaction.”

She goes on, “This career field is one built of passion and drive, not on money and numbers. It’s the most satisfying when you duplicate that passion.”

Pamela Poe, left, receives an award for the first West Virginia Baby-Friendly hospital Mon Health System pictured with Carroll (right).

Carroll also works closely with the director of Women and Children’s Services and the physician/nurse team to introduce and build their Baby-Friendly Designation Program. She collaborates with Coffective and does freelance website work and writing.

Carroll volunteers her time to ABN, the Ohio Lactation Consultant Association, Ohio Breastfeeding Alliance, and other public Facebook pages working to normalize breastfeeding.

In 2011, she started her own Facebook page for her WIC clinic.

“It quickly grew into a huge support system for many women across the nation,” Carroll reports. “My page has grown to almost 10,000 likes.”

Carroll acknowledges the potential danger in using Facebook for “consultations” like HIPAA violations and lack of client history.

“Social media is instead used for promotion, links to information, news articles, and humor,” she explains.

In May 2016, Carroll and a few of her colleagues launched ABN, “dreaming that one day [Appalachian] parents would have the access to lactation care that they deserve.”

In just one year, the network grew to 11 states and 250 members. Today, ABN houses almost 400 members and continues to grow.  

“The growth was exponential!” Carroll exclaims.

She reports the network has over 1,000 likes on Facebook, an after-hours hotline that took 188 calls in 90 days, and an expected 200 people at their next conference in 2018.

“This growth was not expected, but also not surprising,” Carroll begins. “There was absolutely no organization that grouped Appalachia as a culture, together, to make an impact for change.”

ABN tracks its reach in various ways: through its after-hours hotline where they can measure ‘who, when, where, and why,’ through “insights” by social media outlets on their social media campaign Empower Mom Movement, and on a different scale by

educating nurses, physicians and other hospital staff through their Hospital Education Initiative.

Carroll says that, much like the barriers to breastfeeding in Appalachia, the network and their organizations face similar challenges of being rural and having limited funding.

“However, with modern technology, such as e-mail, conference calls, and social media, we are able to stay in contact and work with each other remotely,” she explains. “We also have other states starting up their own ABN meetings in person to work on initiatives separately, yet together.”

Carroll will present Barriers to Breastfeeding in Appalachia at the upcoming 24th Annual International Breastfeeding Conference & Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives which will focus on the sociocultural perspective of breastfeeding barriers in the region.

Her presentation will include anecdotal stories from Appalachian women, the history of breastfeeding in Appalachia, and current disparities and barriers.

“…While the presentation will focus on breastfeeding, many of these disparities can be applied to all of Appalachian healthcare,” Carroll says. “In order to create change, we must be aware of where we are doing our mothers and babies wrong, and how we can educate to induce change in the right direction. It’s all about normalizing a biological function, but changing a culture in the meantime.”

Caesarean Doulas: Implications for Breastfeeding at 24th Annual International Breastfeeding Conference & Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives

Upcoming 24th Annual International Breastfeeding Conference & Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives presenter Emily Clark MA, CLC, CD (DONA), CPD says attendees won’t be surprised by her message: Women who birth their babies by surgery require just as much emotional and physical support as women who birth vaginally. Clark makes clear her presentation–Caesarean Doulas: Implications for Breastfeeding— is not a presentation about doulas being “magical.” The idea is that when women are empowered during the birth process, we are empowered in our postpartum experience.

“C-section birth can be empowering…when it’s treated as a birth experience and not a medical event,” Clark explains. She calls for the use of medical safety nets during these major surgeries without diminishing the pieces of the birth experience allow mothers empowerment, like breastfeeding for example.

Exploring and growing research

Current research clearly supports doula services. Doulas are a low cost intervention to some of the biggest problems, especially in minority and low-income groups. In her presentation, Clark will explore the reasons why the research shows the benefits of doula support, like how doulas can help facilitate early, continuous skin-to-skin contact.

“I really want to offer attendees solid pieces of information to bring back to their clients, clinics and hospitals,” she says.

Still, Clark acknowledges “huge gaps in maternal infant health research.” She’s eager to see more research surrounding doulas’ and labor support’s effect on breastfeeding outcomes. Clark celebrates the work of  Katy Kozhimannil, PhD, MPA  and Amy Gilliland,  Ph,D., BDT(DONA)  who have spearheaded birth empowerment research.

“I am hungry to get numbers out in the world,” Clark says.

Dissecting health outcomes

Switzerland’s c-section rate is similar to that of the United State’s, hovering around 32 percent;  yet Switzerland’s maternal infant mortality rate remains much lower.

Clark explains that Switzerland’s c-section rate is “probably a product of choice;” that is the highest c-section rates are at private clinics with elective surgeries accounting for 60 to 70 percent, she reports.

“In the U.S., I think there are a lot more layers, and it’s a bit more complicated,” Clark goes on.

First, there’s a culture of fear of litigation in the U.S. Additionally, most low risk births are attended by high risk specialists. There’s a connection between high intervention births and high maternal infant mortality rates. Often low income populations are subject to these high intervention births coupled with little or no access to perinatal support.

“This simply doesn’t happen in Switzerland,” Clark says.

In Switzerland, uncomplicated, vaginal births are attended by midwives; evidence shows mothers in the care of midwives experience better health outcomes. What’s more, the country’s universal health insurance covers all women with extensive perinatal care including six weeks worth of prearranged postpartum, home care from midwives and lactation specialists.

“It’s a tremendously supportive environment,” Clark says.

Reaching at-risk populations

Reflecting on her work as a private practice professional, Clark recognizes that she reaches women who have the means to hire her. Mindful of striking health disparities, she connected with Nurture Project International to reach underserved populations, specifically mothers and children in the refugee camps of Thessaloniki, Greece this summer.

“What struck me most was the incredible resilience of this population,” says Clark.

In a situation where families have lost everything and their futures unpredictable, Clark still witnessed women giving life.

“These women have had to rely heavily on others…When they can provide nutrition for their children… that is incredibly empowering,” she observes. “[It] gives them some joy and some power in this really awful situation.”

Clark emphasizes that the risks of infant formula in crises magnify. Infant feeding choice amounts to life and death.

“There are people everywhere who feel really cut off from support and don’t have access to [vital] kinds of services,” she says. She encourages health advocates to “look in their own backyard” for migrant and refugee populations in need of health services.

Connecting and collaborating

Looking ahead to the International Breastfeeding and MAINN Conference, Clark says she’s excited to connect personally with like-minded individuals with whom she’s only had email conversations with or seen their names on papers.

“And obviously I’m really excited about a lot of the [presenters’] topics,” she adds. “It’s exciting to see what we can do together.”

Join Clark and others at the upcoming conference. Click here for more information.

Social media enhances breastfeeding support: 24th Annual International Breastfeeding Conference & Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives sneak peek

Source: United States Breastfeeding Committee

Only a small percentage of mothers in the U.S. and globally achieve their breastfeeding goals. A myriad of factors contribute to this deficit, largely in part due to lack of access to proper breastfeeding support. Where there is a deficit for appropriate infant feeding support, there is a growing number of mothers turning to online social networking for breastfeeding support. With over half of the world’s population using the internet, including 75 percent of U.S. parents of whom turn to social media for parenting-related information and social support, maternal child health advocates need to be aware of this reality.

Bridges pictured with her children.

Ms. Nicole Bridges, B. Comm (Hons) is a lecturer in public relations and part time PhD candidate at Western Sydney University researching online social networking and breastfeeding support. Since 2000, Bridges has been a volunteer peer breastfeeding counsellor and community educator for the Australian Breastfeeding Association (ABA). Bridges was announced winner of the Mary Paton Research Award 2015. She’s published works like The faces of breastfeeding support: Experiences of mothers seeking breastfeeding support online. and Facebook as a Netnographic Research Tool.

Bridges looks forward to “catching up with a lovely… wonderful group of people” at the upcoming 24th Annual International Breastfeeding Conference & Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives presented by Healthy Children Project, Inc. and the University of Central Lancashire’s Maternal and Infant Nutrition and Nurture Unit (MAINN) where she will present Breastfeeding Peer Support on Social Networking Sites.

Contrary to popular concern, Bridges has found that online social media breastfeeding support complements face-to-face interaction.

“They work together in a lot of instances,” she says.

For instance, in-person support isn’t available 24/7; social media fills that gap. Of course this element is essential for mothers and babies struggling to breastfeed. Where breastfeeding helplines are available, like the one ABA offers, Bridges points out that many mothers are more likely to post their concern(s) on Facebook rather than call the helpline. What’s more, this space offers moms “access to the collective wisdom of the whole tribe,” as opposed to the perspective of one lactation professional.

“There is no one-size-fits-all approach,” says Bridges. Exposure to a range of experiences is important for mothers to make informed decisions that suit her  situation, she adds.

About a decade ago, when social media was relatively new, people were concerned about the deterioration of human interaction.

“A lot of people were afraid that people were going to turn into robots and never see the light of day,” Bridges begins.

In the realm of breastfeeding support, Bridges’ research shows that Facebook actually enables face-to-face interaction. Mothers looking for social interaction offline often post meet-up requests and connect this way.

“Mothers are getting out of the house as a result of [social media.]”

Social media offers the remote mother the opportunity to access support too.

As with any kind of online support, social media breastfeeding support has the potential to cause miscommunication largely in part due to the absence of body language and vocalization. Although Facebook provides some visuals like emojis, comments are sometimes misconstrued, Bridges says.

Certainly when it comes to ‘technical’ breastfeeding concerns, it is helpful for lactation support people to see the dyad breastfeeding. On Facebook, Bridges reports, the presumed limitations of online support can often be overcome by using tools like live feeds. In fact, ABA put forth a trial where mothers wore Google glasses while breastfeeding so that the breastfeeding counselor could see what the mother was seeing.

Bridges acknowledges that many mothers have too much access to their devices and social media which has been shown to affect our mental health. And while she appreciates the immediacy of social media, she informs mothers about these concerns.

Still, Bridges strongly encourages maternal child health advocates to embrace social media breastfeeding support.

“Don’t underestimate the effect that digital technologies can have on breastfeeding support.”

By assuming technologies are a bad idea, Bridges says we run the risk of missing out on “huge potential” for parenting support.

“Meet this current generation of mothers where they’re at,” Bridges advises. “We will not meet their needs if we’re not in their field. This is their playing field.”

To learn more about the upcoming International Breastfeeding and MAINN Conference, click here.

Internist, diabetologist reflects on infant feeding’s role in diabetes outcomes

November is National Diabetes Awareness Month.  Dana Dabelea, MD, PhD is  co-chair of the SEARCH for Diabetes in Youth study and currently the principal investigator on nine federally funded grants. She is also the director of the Center for Lifecourse Epidemiology of Adiposity and Diabetes (or LEAD) and an active educator for students and fellows. This week on Our Milky Way, she shares fascinating and valuable insight on how infant feeding plays a role in diabetes outcomes.

Q: How did you become interested in maternal child health?

A: I was trained as an internist and diabetologist in Romania and worked primarily with adults, though I did see youth with type 1 diabetes. I later became a fellow at the Epidemiology and Field Studies Branch of the National Institutes of Health in Phoenix, Arizona.  There, we noticed that young American Indian children were developing diabetes that used to be seen only in adults – namely Type 2 diabetes. Since they were young (some as young as age 5) it seemed logical that something was happening very early in life that set them on this trajectory. We began to study the effect of having diabetes during pregnancy – called gestational diabetes or GDM – on the offspring of those pregnancies. It turned out that the recent rise in youth onset type 2 we had been seeing was almost completely explained by the increase in GDM among mothers. The realization that early life events had later consequences was what really got me started in this area.

Q: To date, what is your most fascinating discovery?

A: After our studies in Arizona, we showed in Denver that the effect of GDM was very similar among non-American Indian youth. That and other studies led us to ask what GDM does to the offspring to increase the risk of diabetes and obesity – we knew from Arizona studies that while genetics plays a small role, something was very specific to pregnancy. So I began a study of pregnant mothers and their offspring called Healthy Start that collects information from the mothers and children as well as biologic samples to study this question. We began studying fuels that fed the growing baby – such as fats of various types and sugars- all of which come through the placenta and umbilical cord to nourish the fetus. It turns out that fatter babies (measured with an instrument called the PedPod®) had mothers with higher glucose levels during pregnancy, even if these levels were still considered in the “normal” range. We followed the offspring and looked at what influence postnatal feeding had as well. It turns out that breast-feeding for at least 6 months largely reverses the effects of GDM on fatness in children.  I think this was exciting, since it meant that there are things that can be done very early in life that can reduce the later risk of obesity and diabetes. We continue to look for others. But there is one additional thing of great interest – in studies of stem cells grown from the umbilical cords of these babies by my basic science colleagues, they have shown that obese mothers unknowingly ‘program’ these stem cells to be more likely to turn into fat cells than muscle or bone cells – some of the first human evidence of a possible pathway that changes how an infant responds to their environment. This too is very fascinating!

Q: The SEARCH for Diabetes in Youth study has shown diabetes to disproportionately affect minority children. Can you please briefly discuss this health disparity?

A: You are correct for type 2 diabetes – that used to be called adult onset diabetes. Type 1 diabetes (juvenile diabetes) is actually most common among non-Hispanic white youth, although recently we are seeing increasing trends in minority group, especially Hispanics. There are several factors at work in type 2 diabetes, but we don’t yet know all of the story. First, a higher proportion of minority youth are overweight or obese, which is the major risk factor for later diabetes. Second, many of these are children are offspring of mothers who themselves have diabetes, GDM, or even just obesity as they enter pregnancy. Such women pass to their babies an increased susceptibility for obesity and diabetes, a phenomenon called the “vicious cycle” – where the risk of obesity and diabetes are passed to the next generation without involving genetics. Lack of breastfeeding, or only a short duration of breastfeeding likely also plays a role, since it appears that breastfeeding reduces both obesity and diabetes among offspring. There is likely also increased genetic among minorities, which is actively under study.

Q: It’s been found that research takes about 17 years before it’s integrated into policy and practice. Are you concerned about this phenomenon as it relates to the diabetes epidemic among youth in the U.S.?

A: It would be great if we could move more quickly from basic and epidemiologic research into public health and clinical action – and there has been progress in this area. Fueled by a National Institutes of Health funding strategy called “Clinical Translational Sciences Awards” to many institutions across the country, these awards specifically target moving science from the “bench” to “bedside” (clinical action) to the community (public health action). A factor that still affects the time to answers and action is that our epidemiologic studies of mother-child populations need to follow participants as they grow up to see what is happening. Thus, we may have a good guess (hypothesis) about what is happening, but it may take several years of follow-up to learn if we were right. This is also true of prevention efforts aimed at obesity and diabetes. Recent data suggest that the obesity epidemic may be leveling off, but whether this will last, or even reduce diabetes, remains unknown. So there is an inherent delay while the studies are being completed.

We can still recommend and test best practices as we know them today, even with incomplete knowledge. For example, we conducted a pilot randomized controlled trial of obesity prevention among American Indian children aged 7 to 10, called Tribal Turning Point. We found that a combination of parent-child sessions aimed at behavioral motivation for change, along with a toolbox of community activities, cooking classes and fun things for kids to do, resulted in lower weight gain among the group that got the intervention. We are expanding this study to both urban and rural American Indians with a larger sample size to see if we can replicate the results. This kind of work is aimed at helping stem the tide of the epidemic in the highest risk group – American Indians. But counter forces are strong – an abundance of calories, often of poor quality, the ease with which we can live without much physical activity and potential environmental factors such as air pollution and endocrine disrupting chemicals, are all promoting dangerous levels of obesity.

Q: Can you please explain the term transgenerational prevention strategy? How does infant feeding fit into this dialogue?

A: I mentioned the “vicious cycle” of transgenerational obesity and diabetes above. Let me explain this in terms of prevention. We know that mother’s obesity prior to pregnancy, her amount of weight gain during pregnancy, and whether or not she develops diabetes during pregnancy, all increase the risk of obesity in the next generation – her offspring. There is even data suggesting that this risk may be partially transmitted to her grandchildren as well. So any preventive intervention aimed at reducing maternal obesity, weight gain or GDM during pregnancy all have the potential to be trans-generationally preventive.

Infant breastfeeding is one important component of this strategy. As I mentioned previously, we found that breastfeeding greatly reduced the risk of obesity in the offspring, brought about from the mother developing GDM. One caveat – this is from observational data, and it really needs to be tested in a clinical trial before saying that we really know this works.

Q: You have found that “breastfeeding ameliorates increased adiposity of offspring born to mothers with gestational diabetes.” Is this due to the act of breastfeeding itself or the components of human milk? Both?

A: These are good questions. While I suspect that it is largely due to breastmilk components, there is limited data on this as it relates to obesity and diabetes prevention. The reason I suspect this is that banked breast milk appears to provide similar benefits. But again, this is largely my opinion at this point in time.

Q: Does the duration of breastfeeding seem to have an effect on diabetes prevention? How about exclusivity?

A: I think both are important. In our studies we calculate “breast-milk-months’. If a woman breastfeeds exclusively for three months, then breastfeeds about one-half time for the next six months, we call that six breast-milk months, since (exclusive X 3) + (1/2 time X 6) = (3 + 3) = 6 breast milk months. There are other combinations that also produce six or more breast-milk months. I think this helps mothers who have trouble continuing breast feeding exclusively on return to work or for other reasons, but continuing for longer at part-time appears to provide at least many of the benefits as they relate to obesity

Q: How does the introduction of complementary feeding affect diabetes outcomes?

A: A number of studies of the timing of introduction of cereals, cow’s milk, formula, and other solid foods, have been conducted in children at genetically high risk of developing type 1 diabetes. Summarized simply, since this is a complex set of studies, it appears that introduction of cereals or any solid food before 4 months increases the risk of type 1, and similarly introduction at six months or after of either of these also appears to increase risk. Importantly, introduction of cereals at or after six months while breastfeeding actually reduces risk. It is important to remember that these studies were done among children who are at high genetic risk for type 1, and it is not clear that these findings are true among most children who are not already at increased risk.

I am not aware of studies that have rigorously tested this for type 2 diabetes. However, early introduction of solid foods (before six months) have been associated with increased fatness and obesity in children.

Q: The U.S. has the worst maternal mortality rate in the developed world, and our infant mortality rate is deplorable too. What’s more, lactation and breastfeeding education, promotion, protection and support are severely lacking. Even so, are there noteworthy efforts you’d like to highlight that aim to resolve these tragic outcomes?

A: I think the most notable efforts started with Dr. David Olds here at the University of Colorado. A number of years ago his team began the Nurse-Family Partnership (also called the Nurse Home Visiting Program) where a nurse visits high risk pregnant mothers who may lack access to pregnancy care, may suffer from poverty, teen pregnancy, and other risk factors, and works with the mother (and father, if available) to teach them about healthy pregnancies and how to nurture their infant after birth, including breastfeeding assistance. This intervention has been tested in rigorous clinical trials in several US and international settings and has shown marked improvements in infant outcomes over many years. Today, Nurse-Family Partnership serves low-income, first-time moms and their babies in 42 states, the U.S. Virgin Islands and six Tribal communities. I believe the widespread utilization of this approach would go a long way toward improving both maternal and infant mortality and would increase breastfeeding.

Lactation counselor training changes PA’s life

Credit: Wrought Iron Photography

Tia L. Oliveri, MMS, PA-C, CLC maintains a long and admirable list of accomplishments: first generation college graduate, mother of two, committed volunteer, bilingual, former member of the Wake Forest University Cultural Diversity Committee, former Guilford County Health Department Maternity Services care provider and Catawba County Health Department Women’s health provider, to name a few.

Most recently, Oliveri completed The Lactation Counselor Training Course after what might be considered a twist of fate due to time and money constraints. Completing the CLC course ultimately helped her land her newest position as a physician’s assistant in San Antonio.

“Becoming a lactation professional is changing my life,” Oliveri says.

During a time of transition, Oliveri networked with Brian the Birth Guy who encouraged her to pursue The Lactation Counselor Training Course and connected her to the practice she’s with today. Oliveri’s approach is patient-centered.

“I want patients to know their experience is all about them,” she says.

Oliveri’s passions for maternal child health “kind of happened by accident,” she says.

“I worked in the ER…and men wouldn’t deal with the female issues,” Oliveri recalls a chauvinistic environment. Eventually, she was asked to work as a contractor for a health department in a poor town where she was the only health care provider. Oliveri remembers seeing 36 patients a day without a doctor.

It was an “exhausting” experience for Oliveri, and there are things she says she “can’t unsee,” like female circumcision.

Oliveri saw it her mission to serve the underserved; she sat at the hospital with a Patient of Color so that she was certain a provider would see her.

“I was thrown into [the work] and didn’t have a lot of help,” Oliveri says. Later, a midwife mentored Oliveri.

Especially while serving a refugee population, the CenteringPregnancy model proved to be an effective method in her practice. Oliveri points out that CenteringPregnancy offers a tribe to those who don’t otherwise have a support system and allows women to ask relevant questions. She notes that in this population, many of the women had never seen a doctor, so breastfeeding became ever-important as it increased their own and their babies’ survival rates. CenteringPregnancy offered a space for the expectant mothers to ask questions about breastfeeding as well as milk sharing and wet nursing, practices often present in refugee populations.

In her personal life, Oliveri endured breastfeeding challenges due to lack of proper support after the birth of her first child.

“I had a job that told me to pump in the bathroom,” Oliveri recalls. Her breastfeeding relationship with her son ended when he was six weeks old.

“I was super depressed,” Oliveri says.

When her daughter was born years later, “she breastfed like a champ and gained a lot of weight.”

At only two weeks old though, her daughter contracted severe bronchiolitis, a lung infection that causes inflammation and congestion in the bronchioles of the lung. The congestion made it challenging for her daughter to breastfeed.

Oliveri feeds her daughter her expressed milk during their hospital stay.
Credit: Wrought Iron Photography

At one point, “she turned blue at home,” Oliveri says. They rushed to the hospital where she found herself, two weeks postpartum, forced into the health care provider role. Oliveri fashioned maxi pads from baby diapers. During her daughter’s hospital stay, Oliveri dedicated to pumping. Despite the severity of her daughter’s illness, the doctor was impressed with her resolve and attributed her resilience to Oliveri’s milk. Today, her daughter is a thriving one-year-old.

Credit: Jamilla Walker of the Labor Ladies

Although Oliveri weaned her daughter months ago, she reports relactating during her recent CLC training.

“I felt a let down during the videos,” she says. Later, she says she discovered the mature milk. Oliveri not only found herself relactating during her CLC course, she led a belly dance to the “When you counsel” song in a 1950s Lucille Ball inspired dress. It is this effervescent energy, confidence and unwavering wherewithal that is sure to score Oliveri more on her list of accomplishments.