Our new look

Look up! Our Milky Way has a stunning new look. Canadian photographer Christian Sasse captured the featured image and the blog’s new backdrop of our galaxy seemingly spiraling through the dense, glittering night sky.

Sasse made the image…from a series of 30-second-long exposures, each taken 50 minutes apart, over 10 hours on April 28, Nadia Drake writes in National Geographic.

“He stacked those photographs using Startrails software, and then edited the final composite image using Photoshop,” Drake continues in her piece.

Our blog’s namesake– the beautiful, vast, Milky Way– has significance in the field of maternal child health.

While researching classical breastfeeding images for their Icons of Breastfeeding presentation, Healthy Children Project’s Cindy Turner-Maffei and Karin Cadwell came across art like Tintoretto’s The Origin of the Milky Way and Rubens’s Birth of the Milky Way.

“We were thrilled to find that the milk of a Goddess was thought by ancient peoples to be the source of our Galaxy,” Turner-Maffei begins. “This concurs with our view that breastfeeding is a core experience of human life.”

She and Cadwell retold the classic Milky Way story in their book Case Studies in Breastfeeding: Problem-Solving Skills & Strategies:

​[Jacopo Tintoretto’s beautiful painting, The Origin of the Milky Way, depicts] “the Greek God Zeus (Roman name Jupiter) bringing baby Herakles (Hercules) to suckle at the breast of the sleeping Goddess Hera (Juno), Zeus’s wife. Zeus wants Herakles to receive the milk of a goddess, because it bestows immortal life, and will make Herakles into a god. Zeus anticipates that Hera will not willingly provide her milk to his love child [born to mortal woman Alcmena]. Therefore, he tries to sneak up on her while she is sleeping. However, foreshadowing his adult strength, the baby Herakles attaches forceably to Hera’s breast, awakening her. Hera reacts by pushing the baby off her breast. Her milk spurts forth into the heavens, and creates the stars of what becomes our galaxy, the Milky Way.” (Cadwell & Turner-Maffei, 2004, p. xi)

Mario Livio tells a similar rendition in Our Home Galaxy: Myths and Facts.

We were thrilled when Healthy Children Project’s media guru Judy Blatchford secured licensing for the use of Sasse’s stellar image on Our Milky Way.

“​I am so grateful that [he] has given Healthy Children permission to use his amazing image of the Milky Way,” Turner-Maffei says.

One cannot view Sasse’s work without conjuring awe, wonder and appreciation.

Blatchford points out that his Milky Way image is a great example of what is known in design as the rule of the golden ratio.

“There is a real energy in the image, and perfection; it is a perfect universal creation, almost sacred,” Blatchford reflects. “For me, it also mimics a nautilus shell which symbolizes growth and renewal which I feel perfectly summarizes breastfeeding.”

She goes on, “I must admit, I am in awe when I view the image, not only because of the image itself, but also because Christian Sasse was able to capture this perfection.”

Turner-Maffei meditates on the image: “To me, [it] is a powerful reminder of the majesty, enormity, and mystery of the universe. Viewing it helps me to reframe daily human successes, tragedies, and challenges as a very small part of a vast, unending story.”

You can find out more about Sasse’s work on Facebook and Twitter.

Skin-to-skin in the operating room after cesarean birth

The term ‘operating theatre’ is synonymous with operating room. These terms are used interchangeably throughout the article.

When skin-to-skin (STS) started to be provided to mom and baby couplets in the recovery room after cesarean births at her hospital– a metropolitan public hospital in Sydney, Australia– midwife Jeni Stevens, RN, RN (Hon 1st), RM, IBCLC, PhD Candidate (Clinical Midwifery Consultant of Infant Feeding) noticed something different about the mothers.

“The women looked alive,” she says. “Their faces were bright.”

It was a stark contrast to the days without STS.

“Before, women shut down,” Stevens says. As a mother herself, she empathizes and imagines the trauma of having her baby taken from her.

That look on a new mother’s face, a seemingly small nuance that some might overlook, is something actually quite profound. It’s the gateway into intricate emotions, a presage to the everlasting imprint our birth stories hold.

Aware of these intricacies, Stevens’ observations were the precursor to her research on STS contact after cesarean sections and her inspiration to do better for mothers.

STS is good for everyone

There’s a growing body of evidence that shows the benefits of STS.

STS increases maternal infant bonding, reduces postpartum hemorrhage, maintains infant temperature and heart rate, decreases the need for pain medication during surgery, reduces maternal infant stress, increases breastfeeding initiation, decreases admissions to NICU, reduces artificial supplementation, provides baby with healthy gut colonization.

What’s more, providing STS and allowing baby to self attach to the breast within the first hour or so after birth increases mothers’ confidence in their ability to breastfeed long-term, Stevens reports.

She has found that when the first breastfeed is missed, it is sometimes two to three days before a mother might directly breastfeed her baby because the baby is affected by medications post-surgery. It appears to affect their ability to suck at the breast.  In these cases, mothers express their milk until breastfeeding begins.

To avoid cases of supplementation, Stevens and her colleagues teach mothers to antenatally express their milk (which should occur under midwife/physician supervision) if there are anticipated challenges present that would interfere with breastfeeding. Even in the case of an emergency c-section, they encourage mothers to express their milk before going into theatre. Stevens’ anecdotal evidence shows that without antenatal expression, mothers typically express about .3 mLs of milk on the first day postpartum.

“With antenatal expression, it is not unusual to see one to two mLs on the first day,” she says.

Providing STS after c-sections is beneficial to the institution, too.

It’s proven economical to hospitals because it reduces admission to the NICU, (as per a new paper by Schneider, Crenshaw & Gilder, Skin-to- Skin Contact During Cesarean Surgery on Rate of Transfer of Newborn to NICU for Observation) decreases illness expenses related to not breastfeeding for both mom and baby and increases patient satisfaction.  

Cultural medicalization of birth challenges STS

Not surprisingly though, the benefits of STS are not met without challenges.

Stevens begins, when STS is taking place, it is generally not provided in the way that it is recommended by health organizations; that is immediately after birth, prolonged for over an hour and until baby has breastfed, and uninterrupted.

She has found that when asked if they’ve been provided the opportunity for STS, mothers say ‘yes and that it’s been done very well.’

“But in reality, it wasn’t,” Stevens refers to the immediate, prolonged, uninterrupted criteria.  

As detailed in A juxtaposition of birth and surgery: Providing skin-to-skin contact in the operating theatre and recovery, Stevens and colleagues show that many of the challenges of providing STS in the operating theatre have to do with the cultural medicalization of birth.

She points out that in no other instance are staff members responsible for multiple people in the operating room: mother, baby, and support person.   

“It’s a very complex situation for the staff to have to consider two other people,” Stevens comments.

Providing STS in the operating room challenges organizational staffing. Some staff members don’t feel competent enough to care for mother and baby, especially if they have never had neonatal training, Stevens explains.

She offers several solutions. We need to train staff to make them feel more comfortable.

While not part of her research, Stevens says that her hospital trained enrolled nurses on basic baby care, neonatal resuscitation, neonatal assessment and breastfeeding, so that they can supervise STS in recovery.

Other hospitals appoint student midwives responsible for the baby.

“Skin to skin is not that complex, but we have to make sure baby is safe,” Stevens says.

Time remains an issue when implementing STS in the operating room.  

Stevens points out that midwives want to be deemed efficient. They’re concerned about getting paperwork completed, so they interrupt STS to do things like weigh the baby, which is most often not of urgent medical concern.

“The thing that really alerted me is how much midwives do,” Stevens adds. “We can’t seem to let the mum and baby stay together without doing something.”

Medical providers must learn to simply observe, she offers. “We must learn to sit on our hands and find other things to distract us.”

Provision of STS is affected by individual knowledge of the matter.

“Some staff members really saw the value in skin-to-skin and knew the benefits, while others really didn’t know much about it, so they didn’t,” Stevens reports.

If staff members have personal knowledge or a personal experience with STS, it can make a big difference.

Still, even when hospital staff acknowledge the importance of STS, they often express difficulty envisioning how it might work in a medicalized environment.

It can be effective to educate staff by asking parents who experienced STS to speak to hospital staff about their experiences.

“Then it’s not somebody telling them what to do,” Stevens explains. “Instead, it helps them realize how much it actually makes a difference when you are providing this care.”

Individuals make the difference. Stevens watched a midwife direct a student midwife to immediately place a baby STS on its mother during a cesarean. Stevens says she hopes that student saw the impact she made on the mother baby couplet. By boosting the mother’s confidence, Stevens hopes the student’s confidence in providing this care improved too.  

Continuity of care seems to have a positive effect on providing STS.

Stevens found that when midwives care for patients throughout their entire pregnancies and establish relationships, they tend to feel obliged to do what the mothers want. When there is no continuity of care, midwives report feeling obliged focus on their colleagues needs instead (e.g. going back to the ward to reduce their workload.) To align these would be to encourage all to value STS.

One mother in her research had continuity of obstetric care.  She was offered a maternal assisted c-section, where the mother helps pull the baby from her uterus and places the baby directly onto her chest.  This was the first maternal assisted c-section in the hospital where Stevens was conducting her research, and she had the privilege of filming it and using the footage as educational material for medical students and staff members.  

“This mom got to pull her baby out of her abdomen and put the baby directly to her chest,” Stevens explains. “Just seeing her lift that baby out and own that baby straight away was just amazing.”  

Following the birth, Stevens remembers the baby pooping and peeing all over the mother, and the mother thought it was “just the most amazing thing.”

In the operating theatre setting, one must consider the placement of equipment. Where will monitoring equipment go while mother and baby are STS? Where will the drape lay while surgery continues? Will the sphygmomanometer interfere? Are mothers’ gowns easily removed to expose the chest?

STS: A human right

Despite an array of challenges, STS contact can be successfully implemented in the operating theatre and recovery room with staff members input into adjustments to existing care, Stevens finds.

“I don’t even know why any of these [challenges] should be factors,” she reflects honestly on the challenges presented. “[Skin-to-skin] needs to be the norm, and then those factors won’t be an issue.”

In the meantime while we are still struggling to provide STS as the norm, it’s vital to encourage women to have a voice, she says.

“When women question things and want anything out of the norm, people quite often get surprised and don’t know how to cope with it,” Stevens observes.

She tells the story of a woman who felt defeated that she would require a c-section, but found comfort in that she would have the opportunity for immediate STS in the operating room. But, when the anesthetist could not get the morphine in her back, she required a general anesthetic. General anesthesia voided an opportunity for STS in this hospital, but this mother persisted with her rights. Stevens and her colleague advocated for her and agreed to place the baby STS after she began to wake up from the anesthesia. The mother’s wishes were simply documented, and they proceeded with them. Ultimately, the baby went STS with father first and then to the mother as soon as she became alert in the PACU.

While women’s stories of empowerment are the ultimate triumph of providing STS care, not providing STS has serious mental health consequences on mothers and babies.

Stevens’ recollection of a woman she chatted with in an elevator is arguably the most grim outcome of medicalized birth without compassion.

The woman shared that after one of her c-sections, she only saw her baby for a split second.

“She couldn’t even map the baby’s face,” Stevens recalls her story. “She couldn’t even visualize what that baby looked like.”

When this mother was moved to the postnatal ward, she talked about how medical staff gave her a baby, and she didn’t even know if it was hers.

Seven years later, she still doesn’t know if it’s her baby. Seven years later, she refers to her daughter as ‘it.’

Meditating on her story Stevens says, “Oh my god, what do we do to these poor women and these babies?”

Stevens also tells of one mother who cannot yet get herself to look at the photos of her mother in law holding her baby before she did, five years after her birth.

“I only spoke with a handful of women,” Stevens says of her research. “How many other people are feeling that devastated? We’ve got to start prioritizing this. It’s not an option.”

In fact,  Bashi Hazard, an Australian lawyer and board member of Human Rights in Childbirth, discussed with Stevens her argument that STS contact after birth is a human right.

Stevens says, “It is time to stand up for women and their babies, be their advocates and provide this essential care.”

System-based approach reduces racial disparities in breastfeeding

Despite efforts to reduce racial disparities in maternal child heath care, Black women die during pregnancy, childbirth, and the first year postpartum at nearly four times the rate of White women. Black babies are more than twice as likely as White babies to die before they turn one. And breastfeeding rates among Black women are lower than those in White.

Since 2014, the CHAMPS (Communities and Hospitals Advancing Maternity Practices) initiative has been doing something about that.

The W.K. Kellogg Foundation awarded Boston Medical Center (BMC) a $2,125,000 three-year grant for the program which improves maternal child health outcomes through the promotion of Baby-Friendly practices in Mississippi, New Orleans, Texas, and Southern Tennessee. In 2017, CHAMPS secured three more years of funding from the Kellogg Foundation and the Bower Foundation to increase the number of Baby-Friendly hospitals in Mississippi.

CHAMPS Project Director Anne Merewood, PhD, MPH, IBCLC worked mainly as a researcher in breastfeeding for 15 years.

“Eventually, I got fed up doing one more research project to prove that breastfeeding is good for babies,” she says. Instead, she now focuses on “action and implementation.”

In 2017, Dr. Merewood launched CHEER, the Center for Health Equity, Education and Research at BMC which oversees the Baby-Friendly projects as well as a growing body of work in Indian Country.

Dr. Merewood points out that it takes an average of 17 years before research integrates into policy and practice. CHAMPS has made tremendous progress around reducing racial inequities in just three years.

Breastfeeding initiation in the U.S. rose from 80% to 81% between 2012 and 2013, but Mississippi’s rate fell from 59% to 52%, Dr. Merewood notes in her 2016 American Public Health Association (APHA) Annual Meeting presentation CHAMPS Initiative and Improved Compliance with the Ten Steps to Successful Breastfeeding in the South.

In 2013, Mississippi had the lowest breastfeeding rates in the nation, the lowest mPINC score and ranked last on the CDC’s breastfeeding report card.

Also in CHAMPS Initiative and Improved Compliance with the Ten Steps to Successful Breastfeeding in the South, Dr. Merewood reports that prior to CHAMPS enrollment, none of the hospitals reported data by race or correctly defined or charted skin-to-skin or rooming-in.

But between January and December 2015, twenty five of 31 CHAMPS hospitals in Mississippi, Louisiana, Texas, and Tennessee collected and submitted data. The results:

  •         “Average breastfeeding initiation rose from 64% to 72% (all races), and from 50% to 61% (blacks).
  •         Exclusive breastfeeding rose from 32% to 36% (all) and from 10% to 23% (blacks).
  •         Skin-to-skin rose from 42% to 50% in vaginal births, and from 8% to 35% post-cesarean.
  •         In Mississippi CHAMPS-enrolled hospitals, breastfeeding initiation rates rose from 49% to 62%; from 69% to 77% among white individuals, and from 33% to 45% among black individuals.”

Rigorous data collection has allowed institutions to recognize and address racism, although there’s still a lot of progress to be made.

“There’s an awful lot of institutional racism and it needs to be figured out,” says Dr. Merewood.

All this activity has led to tremendous momentum in Mississippi; now 80% of Mississippi’s 43 birthing hospitals are on the Baby-Friendly Hospital Initiative’s 4D pathway to designation.

In December 2015, Mississippi’s first Baby-Friendly Hospital was designated. That same month, Mississippi opened a human milk bank. In February 2016, the first Lactation Counselor Training Course in the state took place. In April 2016, the first Baby Café opened. Since its infancy, CHAMPS has trained over 40 Reaching Our Sisters Everywhere (ROSE) Community Transformers.

CHAMPS also works in Indian Country where hospitals are generally severely under resourced; they lack federal funding, they suffer from remoteness and high staff turnover and they serve high-risk populations. Dr. Merewood served as Baby-Friendly consultant to the Indian Health Service (IHS), and 100% of federally funded IHS birthing hospitals are now Baby-Friendly designated.

IHS accomplishments are “an example for the nation,” Dr. Merewood states in a WKKF article.

Through its American Indian and Alaska Native Communities and Hospitals Advancing Maternity Practices (AI/AN CHAMPS) project, the group has helped four out of five tribally run birthing hospitals become Baby-Friendly designated and is now working with all Alaska Native hospitals to implement the Ten Steps.

“We found a winning solution with CHAMPS and the same with Indian Country,” Dr. Merewood says. “The way to go is regional. Once you get momentum going, everyone gets on board and things move much more quickly.”

A geographic or system-based focus has proven effective along with the formation of partnerships. CHAMPS team members and participants have collaborated with state health departments, WIC, the Mississippi Perinatal Quality Collaborative and Blue Cross & Blue Shield of Mississippi for example.

In fact, Blue Cross Blue Shield’s Quality Model requires all delivering network hospitals across Mississippi to gain Baby-Friendly designation as part of criteria for achieving Blue Distinction for maternity care. [More here: https://www.bcbsms.com/2015-healthy-mothers.html]

With the launch of CHEER, the team is now working on a broad range of projects: drug abuse prevention, Community Health Assessments in tribal communities, enhancement of prenatal care, domestic violence prevention, suicide prevention and technical assistance especially in tribal communities. CHEER partners with the Indian Health Service (Billings area), the Rocky Mountain Tribal Epidemiology Center in Billings, Montana and the Blackfeet, Northern Cheyenne and Chippewa Cree tribes.

Learn more at www.cheerequity.org.

Non-profit Julia’s Way proves babies with Down syndrome can breastfeed

Against the backdrop of a misty ocean and watercolor sky, ten mother baby couplets and their families gathered for a photoshoot to prove that babies with Down syndrome can indeed breastfeed, a truth not widely accepted especially among medical professions.  

The photoshoot is part of phase one of a breastfeeding project by Ella Gray Cullen, founder of the non-profit Julia’s Way, after her daughter Julia Grace. Nicole Starr Photography captured the celebratory nature of Cullen’s overall mission to “reimagine life with Down syndrome.”

The darling stars of the Julia’s Way photoshoot– Julia Grace, Emily, Mae, Oliver, Lewis, Harper, Rian, Cate, Rory, and Cayden– have been shared widely on social media pages including La Leche League, Occupy Breastfeeding and Nationwide Nurse-In Facebook pages as well as Love What Matters Facebook page which has seven million followers.

Making it known that breastfeeding is possible for babies with Down syndrome is ever important as the negative effects of not providing human milk and breastfeeding on babies born with Down syndrome are robust. Even so, Cullen reports that 20 to 30 percent of women are told that their babies with this diagnosis are not as capable of breastfeeding as other children.

Nicole Starr Photography

Her research comes from an infant feeding survey she conducted of over 500 mothers of children with Down syndrome, which will eventually be converted into an academic paper. Cullen anticipates the paper will help identify what helps mothers of babies with Down syndrome achieve their infant feeding goals.

Next on Cullen’s schedule is the release of a video which will feature the infant feeding stories of the mothers who participated in the photoshoot. The video is set for release during World Breastfeeding Week. Currently, Cullen features the “Breastfeeding Superstars’” stories on the Julia’s Way blog.

A book and accompanying website that will serve as a comprehensive resource for new mothers seeking information on how to help their babies with Down syndrome breastfeed successfully is also part of phase one. The book will be available as a free download and a print version will be available for a nominal fee to cover printing costs and shipping.

Julia’s Way is currently working to establish a database of lactation professionals who specialize in working with babies with Down syndrome.

The second phase of the project focuses on developing resources for medical professionals so they may properly support women to breastfeed their babies with Down syndrome. Last week on Our Milky Way, we featured the story of Ashley Albright, a mother of a child with Down syndrome, which exposes the dangerous deficit of infant feeding support to those with children who are medically complex.

Cullen’s breastfeeding advocacy dates back to before Julia Grace was born while Cullen worked in the medical field.

“I have been a huge proponent of breastfeeding for years,” she writes on her blog. “As a former labor and delivery nurse and a one-time midwifery student I believe the benefits cannot be overstated and have always encouraged people to consider it. I find it comical how little understanding I had of breastfeeding when I was instructing my patients and now that I have personal experience I understand how challenging it can be in those early weeks and how much persistence it can take.”

Cullen’s infant feeding story is atypical in that she received feeding support during their hospital stay and at home.

While Cullen says she was internally determined to breastfeed, she writes on her blog: “I know I would not have had the ability to be successful without [lactation professionals] and am grateful that they believed in me and in Julia Grace’s ability to nurse eventually.”

Julia Grace breastfed directly for the first time at 11 weeks. That meant that Cullen pumped exclusively for those 11 weeks, ten to 12 times each day which amounted to at least 40 hours per week of the pumping routine (cleaning equipment and bottles, storing, etc.)

“It was exhausting and tough,” Cullen remembers.

Her experience allows her to remain realistic about the challenges of providing milk for a medically complex child. She includes this project “disclaimer:”

“Our project has always been about supporting mamas who want to and can pump or breastfeed. We understand that babies with Down syndrome can have medical complexities that may be overwhelming at times and there may be other priorities for the family and the medical team. Our intention is not to add a layer of difficulty to what can be a stressful time. However, no mama should ever be told that she shouldn’t even bother to breastfeed her baby just because of a diagnosis of Down syndrome and for those mamas who want to attempt breastfeeding but just need support or encouragement, we are here for them.”

Cullen will attend this year’s Down Syndrome Diagnosis Network – DSDN Rockin’ Moms Retreat in Chicago where she will woman a table to share her vision for reimagining life with Down syndrome.

Get involved with Cullen’s mission:

  • Share your stories.
  • Share your professional infant feeding photographs to be included in her upcoming book.
  • Donate to the cause. There are several ways to support Julia’s Way which can be found on the Julia’s Way Facebook page.

You can get in touch with Cullen here.

Turning regret into advocacy

When Ashley Albright’s baby Marcus Jr. (MJ) was diagnosed with Down syndrome, she was “crushed.”

I felt what I thought was my heart shattering. I could not believe it,” she writes on her blog Just the Albrights.

It was her husband who helped change her perspective. After a conversation with him, she no longer felt defeated by the diagnosis; she felt hopeful and enthusiastic about her son’s future.

While Albright has embraced the diagnosis, she still has regrets about her infant feeding story.

We had a very rocky breastfeeding journey and stopping at three months is still one of my biggest regrets!” she exclaims.

Although Albright planned to exclusively breastfeed, she reports that the hospital offered “absolutely no support.” During her son’s eight-day stay in the NICU, no one encouraged her to provide breastmilk for her baby; actually, no one had a conversation with her about breastfeeding at all. Still, determined Albright pumped milk for MJ.

“I grew tired of pumping though…Because of his Down syndrome, we were terribly busy with doctor appointments, therapy sessions, [and so on.]”

Albright has since had another son and a daughter. She breastfed her second child for 34 months and continues to exclusively breastfeed her eight month old daughter.  She points out that she birthed her daughter at a different hospital than her sons and acknowledges that the breastfeeding support was “out of this world amazing.” She also utilized the Tennessee Breastfeeding Hotline, staffed by CLCs and IBCLCs.

“Out of all of my children, MJ needed [my milk] the most,” Albright says. “I regret that I did not supply him with the best.”

“Months later, I would pump whenever I was engorged with my second son,” she goes on.  “I would offer that milk to MJ, but he would refuse it.”

Now that Albright has several years of breastfeeding experience, she says that friends, family and co-workers come to her for breastfeeding advice.

“Plus, I absolutely love breastfeeding” she adds. “I want to be there to encourage and educate other moms.”

Accordingly, Albright recently completed The Lactation Counselor Training Course.  

“I loved the course…I learned so much,” she says. “If I had money to dispose of, I’d take the class again because it was so fun and interesting!”

Albright plans to volunteer her new skills at the Down Syndrome Association of Memphis and the Mid South.

“[People] need to know the endless benefits that they can offer their children through breastmilk,” she says.

Albright also practices her breastfeeding advocacy through breastfeeding groups on Facebook, by creating breastfeeding videos on her YouTube channel and offering breastfeeding encouragement through Instagram.