Exploring mean behavior within the field of lactation

Be kind whenever possible. It is always possible. –Dalai Lama

I was four when I met Coleen and Rachelle, sisters and my childhood backdoor neighbors. The first time I saw them was through my mom’s bedroom window as I watched them glob mud pies in their unfinished yard. Instantly, I was crazy about them. I went on to spend the majority of my young childhood obsessively playing dolls with Coleen, and secretly idolizing Rachelle as a hip, maternal figure even though she’s only a handful of years older than me.

Funny how those memories seem just a trip-to-the-old-neighborhood-away. Coleen, Rachelle and I are all moms now, and it’s almost surreal to watch our children play together. Being a ‘real’ mom is not often like playing dolls, but eerily the same sometimes.

At one of our most recent visits, Coleen pumped during dinner and our conversation turned to lactation care providers (LCPs). Both Coleen and Rachelle told me they had unpleasant experiences initiating breastfeeding; they reported the LCPs were pushy and seemed to have an agenda.

I sympathized having had similar feelings about the “help” I received when my oldest was born. Learning of their experiences made me mournful too, because they’re my friends! And because I’m aware of the imprint health care providers make on women, especially postpartum. Sadly I wasn’t surprised, because it’s not the first time these feelings have been reported. In fact, there’s been damaging backlash as a result of “lactation professionals’ agenda,” which amounts to our implicit belief in opposites as Dr. Karin Cadwell broke down at the 2016 International Breastfeeding Conference. (Think The case against breastfeeding, Lactivism, Bottled Up, Guilt-free bottle feeding, Is breast best? to name a few.)

During our visit, we didn’t dwell on pushy LCPs, but the conversation certainly hasn’t left my mind. When a colleague shared Lions, and Bottles, and Teats, Oh My!—Legal Analysis: International-Code-Supportive Teaching About Bottle and Teat Use by Elizabeth C. Brooks and Kathleen Kendall-Tackett’s PhD, IBCLC, FAPA Clinical Lactation editorial Should Lactation Consultants Be Mean? Let’s Bring Civility, Kindness, and Professionalism Back Into Our Discourse, I thought mostly about Coleen and Rachelle. The material Brooks and Kendall-Tackett cover in their pieces is mostly in regard to behavior between professionals, but I wonder how much of that sentiment percolates from colleague to client.

I’m interested in sharing Coleen and Rachelle’s experiences, not to vilify any one credential of lactation professional or LCPs in general, but to expose the inappropriate, unhelpful and mean behavior of perhaps a select few who have the potential to tarnish the reputation of an entire profession and/or advocacy group.

Credibility problems

Kendall-Tackett puts it this way in her editorial: “A couple of years ago, a good friend of mine, who is high up in the doula world, told me that ‘lactation consultants are mean.’ Of course, I argued back. But in the end, I had to agree that at least some lactation consultants do behave quite meanly at times…I realize, as I write this, that I’m only talking about a few people in our field. Unfortunately, these few have created a toxic environment…Do we really want to be the mean profession? Doesn’t this create a serious credibility problem for us?”

More important than reputation though, are the mothers and babies who don’t reach their infant feeding goals and are left feeling deflated and defeated as a result of their interactions with someone who’s supposed to be there to help.

Learning of accounts of unlikeable behavior by LCPs gives us all a chance to reflect on the way we support and advocate for mothers.

Mothers’ desires 

As part of our interview, I asked Coleen and Rachelle to describe the ideal lactation professional.

“A woman who has personal experience breastfeeding. Someone who is positive, kind, patient, and helpful with the mom and baby through any breastfeeding challenges,” Coleen said.

Rachelle described someone similar: “The ideal lactation professional would be calming and offer help with whatever the mother is facing regarding breastfeeding. They would be positive and encouraging throughout the process. It would also be helpful to see constructive commentary and an empathetic outlook towards mothers that seem to be struggling with the process.”

Their responses align with the desires of other mothers too.

In The experience of nursing women with breastfeeding support: a qualitative inquiry by Kathleen H. Chaput, PhD, et al, the authors conclude, Nursing mothers want advice and support from people with the knowledge base to ensure resolution of problems, but it is critical that support be delivered without pressure and with emotional sensitivity to both mother and baby.” Not unreasonable.

Aggressive, condescending interactions

And yet, Coleen and Rachelle’s encounters with LCPs were unpleasant at best.

Coleen shares:

“My first interaction with a lactation professional was in the hospital the day after I had the baby. She came in briefly to help with feeding, perhaps 20 minutes or so in the beginning then she’d come in randomly to check on us. It may have just been her strong personality, but she came off very aggressive while trying to be overly nice in an exaggerated way. A nurse had helped with the first couple of feedings and had given me a nipple shield to use, however the LP wanted me to stop using it right away which I wasn’t a fan of as my nipples were cracked, bleeding and so sore!

She spoke to me in a condescending manner, but would add a smile with a cheery voice which irritated me more. I would have liked her to be more “gentle’ with me being a first time mom and not knowing what I was doing. I didn’t like how she pushed breast-is-best and would make me feel bad because it wasn’t “working’ for us.

The LP had scheduled a follow up appointment for me to come in a week after we went home, but I ended up cancelling the appointment because I didn’t want to meet with her again. I was going to go to a support group with a friend but decided not to after talking with the pediatrician. She said that it was ok if I wanted to pump and bottle feed more than breastfeed. [My husband] and I were already planning on doing that so he could help out with feedings, but it was reassuring hearing it from the pediatrician.” [bold text added]

Here’s Rachelle:

“I met with the lactations consultants at the hospital after each of the boys’ births. With Jaxon I met with the specialist the next morning after he was born. Jax was born at 4pm but he went straight to the NICU so I didn’t get to try to feed him until about 9pm that night. The nurse originally was the one that tried to help me feed him. They were very positive and encouraging. They had me try different positions and offered advice that had helped them in the past when they breastfed. The consultant came to my room the next morning and she was also pretty helpful. She gave me a nipple shield because she didn’t think my nipples protruded enough. She also provided me with gel pads and lanolin samples to help with the soreness I was feeling. She told me about breastfeeding classes/support groups that were offered through the hospital. I was also checked up on by another consultant while I was there to see if I was becoming any more comfortable with breastfeeding…I found her to be a little frustrating. When I expressed my concerns about the pain and discomfort I was feeling she basically blew me off and said that it wasn’t going to be easy and I needed to push through it. She also told me that I didn’t need to feed Jax for the half hour to forty minutes that I was trying to feed him. I didn’t really know what I was doing so it was a little deflating and she kind of made me feel stupid when she said that was way too long.

When Landon was born I again met with a lactation consultant. She tried to help me with the positioning and discomfort. I told her about my previous breastfeeding history with Jaxon and she said every kid/experience could be different. With Landon a nipple shield made the pain worse so they tried to offer alternative suggestions to make the process easier.

The lactation consultants in my opinion were minimally helpful. Of the three that I saw, the first one offered me the most help and comfort. The other ones just made me feel like I wasn’t really trying hard enough and they were kind of aggressive in how they tried to get the boys to latch on. Beyond the births I never sought any other professional help from any lactation consultants.”

The origin of mean behavior 

Most LCPs with evidence-based training could point out at least ten inappropriate suggestions or behaviors by the LCPs in Coleen and Rachelle’s accounts. Technicalities aside, and without making excuses for poor professionalism or devaluing Coleen’s, Rachelle’s, and other mothers’ experiences, I wonder why some LCPs’ behavior is graceless. Do some lactation specialists act mean because they’re stretched thin and burnt out? Does unlikeable behavior stem from lack of interpersonal skills?  

Brooks offers an explanation to part of the bullying problem between lactation specialists, which some might argue also affects their interactions with clients.

Brooks writes describing the Code, “There is no ultimate international legal authority empowered to enforce the model document as passed in 1981. In the absence of legislation or regulation within a country, and precedent-setting interpretation of such legal authority, Code supporters are left to interpret the Code’s language and intent on their own, with no sanction for failure to do so accurately.”

“The noble motives for the Code are undermined when skilled clinicians, who aim to respect a family’s need or desire to use a bottle-and-teat to offer a supplement (of any kind), fear (or are) being vilified in the name of the Code,” she continues in Lions, and Bottles, and Teats, Oh My!.

In response to Brooks’s and Kendall-Tackett’s pieces on bullying, Cindy Turner-Maffei, MA, ALC, IBCLC ponders, “I wonder how much of this is just a sidetrack created by our very human resistance to the hard work ahead of us in leveling the structural racism behind disparities in infant and maternal experiences, tackling parental leave legislation and the other very real ‘Booby Traps’.”

Woman-centered, not breastfeeding-centered

If breastfeeding self-efficacy and the avoidance of breastmilk substitutes are public health imperatives, we cannot afford any behavior that might compel women to give up on breastfeeding.

At last year’s International Breastfeeding Conference, Dr. Cadwell asked a roomful of breastfeeding advocates, Are we acting as sales reps or customer service reps?

She suggested we leave sales up to the formula companies and focus on individualized maternal care. Forget about being breastfeeding-centered; the support we offer must be woman-centered, she said.  

In The impact of attitudes on infant feeding decisions, Mary E. Losch, et al point out that, in the profiles of women who decided not to breastfeed, one of the most consistent findings was that “women who decide to formula feed are not so much embracing this method of infant feeding as rejecting breastfeeding.”

 

Exploring the world of exclusive pumping: Guest post by Fiona Jardine, MA, LLM, MLS, CLC

Fiona Jardine, MA, LLM, MLS, CLC is a PhD candidate at the University of Maryland’s iSchool conducting research on the experiences and information behavior of those who exclusively pump breast milk. This week on Our Milky Way, she shares preliminary findings from her research, her motivations, and how she hopes to contribute to maternal child health. We look forward to hearing her conclusions as there is much to learn about exclusive pumping. 

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My PhD research topic came to me completely by surprise, given both the circumstances surrounding it and the incredibly circuitous route my life had taken up to that point. I don’t think anyone—including myself—thought that an undergraduate and master’s degree in law from the Universities of Cambridge and San Francisco respectively together with a Master’s of Library Science (interspersed with me opening and running a café and practicing law) would lead me to study exclusive pumping of human milk.

Given this unorthodox background, it’s not surprising that my research is a result of my own experience. I had a beautiful baby girl in April 2016 and unfortunately, due to a variety of obstacles and little to no professional support, my baby and I were not able to establish a direct nursing relationship. I was devastated that we would never have the “gold standard” of baby nutrition, bonding, and comfort, but was still determined to give her my milk any way I could. I knew vaguely how to express milk with a breast pump, but little clue how to do it as the sole means of extraction, despite having taken a breastfeeding class, spoken at length about breastfeeding with our doula, and done a great deal of online research on the topic. After doing more online research, I discovered the term “exclusive pumping” (EP, EPing, EPer) at about two weeks postpartum. Through social media, specifically Facebook groups, I learned how to sustainably EP, received answers to specific questions, and felt understanding and support for my situation.

We all know that human milk is seen by mothers, healthcare providers, and public health organizations as optimal nutrition for infants and, perhaps more importantly, most mothers want to breastfeed. We also all know that a variety of external barriers to breastfeeding exist, such as problems establishing a latch, getting milk to flow, or poor infant weight gain. Internal barriers, such as a perception that human milk alone is not sufficient and a desire for caregivers to be involved in infant feeding, are also responsible for breastfeeding cessation. EPing, defined as only expressing milk and not directly nursing at the breast, can—and successfully does—provide the solution to many of these barriers while still providing the benefits of feeding human milk.

However, research on EPing is scant and often limited to secondary analysis of existing data (such as the Infant Feeding Practices Survey II), content analysis of expressed milk, or mothers of infants in the NICU. I have not been able to find (and I would LOVE to be proved wrong) any published research documenting the experiences of EPers themselves, including why they EP, where they find information, what support they get, how they feel, and problems they have. The field of my PhD—Information Studies—provides me with enough latitude to ask all of these questions (and more).

And ask I did. In March 2017 (and after receiving IRB approval), I started collecting data through an online survey containing 170 open– and closed–ended questions (although almost no one answered all 170 questions, given respondents were routed based on their individual situations). Below is a flowchart containing the topics covered in this initial survey. In addition, women currently EPing were given the option to participate in follow-up surveys every two months until they ceased EPing. So far, the initial survey has been taken by over 2,300 current and former EPers, and follow-up surveys sent out in May and July 2017 have received 372 and 159 responses respectively (recruitment was limited to 500 for the May survey; only those that participated in May’s survey could participate in July’s). 

 

I am overwhelmed by the response to my research. The number of survey responses in itself is an indication of how passionately these women want their voices to be heard: this survey is long and has a fair amount of open-ended questions, yet women took their time (often over an hour) to share their experiences at length (consequently, I have a huge amount of qualitative data to analyze). However, it has been the support and messages I have received that have truly touched me and made me realize both the critical need for EPing research and that my research as already made a difference. Some women have shared with me that they experienced profound catharsis as they finally got to share their breastfeeding/postpartum/EPing journey; others have expressed joy and gratitude that someone is finally taking EPing seriously, getting the word out there, or trying to create a world where the women that come after them won’t face as many challenges or negative reactions as they did.

So, what am I doing with all this (and more—the initial survey is still open) data? As part of a department-required PhD milestone, I analyzed a small selection of the data focusing on prenatal information behavior (that is, the information needs, seeking methods, and use) of women who EPed postpartum. My findings were interesting and stress the need for more information about EPing to be provided prenatally. It was a little disheartening, however, to produce this word cloud, which represents the feelings of EPers about EPing. I am currently preparing a paper about these findings for journal submission. 

 

As I am working on my dissertation, I will be analyzing more of the data collected: next on my list is galactagogue use and how effective EPers perceive various popular ones to be, since this is a constant topic of conversation within various EPing discussion groups. To me, though, the most important findings from my research will be those that can make women’s experiences of EPing more positive. Anecdotally, I have discovered that a frightening number (read: vast majority) of EPers get no or bad advice from their healthcare providers, including but certainly not limited to lactation care providers of all kinds. This advice doesn’t usually come out of ill intention, but simply ignorance: giving an EPer the same advice about pumping as a nursing mother is usually going to result in failure for the EPer. As EPing grows in popularity as breast pumps sit on every new mother’s side table and continue to offer more technologically advanced features, it is the responsibility of lactation care providers to have the correct information to provide. One of my goals through this research is to discover and disseminate this correct information.

Finally, I want to make sure that those of you that have made it this far aren’t left with the wrong impression of what I am trying to achieve with my work. Just as no lactation care provider should force a woman to nurse against her wish, I don’t think that EPing should replace nursing for those that want to and are successful. In fact, I obtained my CLC qualification (and plan to become an ALC later this year) to help as many women be successful at nursing as possible. Nevertheless, there are some EPers who have or could have chosen to nurse successfully, but felt that EPing was the right choice for them. There are far more EPers, however, that tried to nurse and, for a variety of reasons (that shall be illuminated by my data), failed and resorted to the frustrating, challenging, but devoted path of EPing so they could still feed their babies their milk. It is for all EPers that I do this research, but especially those that felt, as I did, the double letdown of nursing failure together with little to no competent professional support for or advice about the only alternative that allowed them to feed their own milk to their babies.

Celebrating World Breastfeeding Week in Milwaukee, Wis.

During this year’s World Breastfeeding Week (and always,) WABA called on us to forge purposeful partnerships to “attract political support, media attention, participation of young people and widen our pool of celebrants and supporters” in an effort to achieve the Sustainable Development Goals (SDG) by 2030.

Logo designed by Ammar Khalifa and commissioned by WABA which owns the copyright.

This year’s WBW celebrated the enormity of breastfeeding; the way it affects all aspects of our existence, and how the way we exist affects breastfeeding. It celebrated the strides we take when we form partnerships and work together.

Milwaukee County Breastfeeding Coalition’s (MCBC) annual community breastfeeding walk and Big Latch On to celebrate WBW exemplified how we come together to promote and sustain breastfeeding, healthy families and healthy communities.

Long-time MCBC partner Alice’s Garden– a two-acre spring of bounty on Milwaukee’s Northside– received the roughly 50 walk participants who proudly paraded informative breastfeeding signs on a short jaunt to Fondy Farmers Market, another long-time partner.

“Any effort to bring humanity back to all things natural is something I want to be a part of,” Venice Williams, executive director of Alice’s Garden said.

At Fondy, participants mingled amidst the jovial beats of Lucky Diop’s drum circle.

Seven mother child couplets (including George and myself) gathered for The Global BIG Latch On. Globally, over 50,000 people attended registered Latch On locations. MCBC volunteers and participants visited and enjoyed tea infused with herbs from Alice’s Garden.

Nancy Castro, program manager of City of Milwaukee WIC  handed out coloring books and crayons, copies of the magazine Chop Chop and other farmers’ market information.

“Only positive things can come from breastfeeding,” she said. Castro expressed disappointment that there weren’t more event attendees.

County supervisor Sheldon Wasserman, MD, FACOG and his wife Wendy Wasserman attended the celebration; and like Castro, Dr. Wasserman announced that he wished there were more walk participants in attendance.

During his address, Dr. Wasserman remembered Wisconsin women who were arrested for indecency while publicly breastfeeding before a 2010 state statute was passed which gives women the legal right to breastfeed in public in our state.

He told attendees that we’ve come far from that terrible time, acknowledging the progress we’ve made protecting and supporting breastfeeding families.

Still, Hunger Task Force ACCESS Program Manager Martha Collins pointed out that Milwaukee is known for many disparities; maternal child health one of them.

Hunger Task Force is an organization working to prevent hunger and malnutrition by providing food to people in need and promoting social policies.

Last month the CDC released Racial and Geographic Differences in Breastfeeding in the U.S. from 2011-2015 which shows that Wisconsin suffers the highest percentage point difference between white and black infants in exclusive breastfeeding through 6 months, at 17.8 percent. That’s compared to a low of 4.2 percent in Rhode Island.

In a newsletter honoring WBW, Kimberly Seals Allers wonders if breastfeeding has the capacity to endure as women continue to face complex structural, cultural and societal barriers. She draws special attention to racial disparities in health. Does breastfeeding have the capacity to endure here in Milwaukee? 

MCBC Board Member Lindsay Kohut, MS, RDN, CD, CLC says ‘yes.’

“Breastfeeding stats are trending upwards as moms encounter positive breastfeeding messages in a wider variety of settings,” Kohut begins. “No longer simply recommended at the OB’s office, breastfeeding is a being supported in the community through the WIC program and organizations like 9 to 5 Wisconsin and the African American Breastfeeding Network.  Continuing to work towards making breastfeeding support pervasive through the community is something that I see as key to normalizing breastfeeding.”

Seals Allers continues in regard to this year’s WBW theme: “Ultimately sustainability is a complex balancing act, a dynamic process of maintaining the good (like the improvement in overall initiation rates) and continuing to aggressively and intentionally eradicate the bad.  Ultimately, in order for breastfeeding to be sustained,  it must be transformed–on a policy, cultural, community and individual level. Only with radical transformation can we achieve a breastfeeding experience for all that is truly worth sustaining.”

While the walk and Big Latch On attendance was comparatively low, it seemed that we were part of something big, something with traction, something with the potential to sustain the good.

MCBC volunteer Sally Callan pointed out that the celebration at Fondy “offers us all a chance to connect.”

She directed our attention to the voting registration table; policy and legislation are vital to our breastfeeding success. Mothers need access to healthy food so that we can provide for our families; Fondy participates in Wisconsin’s FoodShare benefits. Callan supplied appropriate receptacles for landfill, recycle and compost at the event; we have an obligation to care for the planet we rely upon.

Small details surrounding the event amount to potentially big implications, especially in a city with deplorable health disparities.

According to the 2015-2016 City of Milwaukee Community Health Assessment, even though “…Milwaukee has Wisconsin’s most concentrated health resources, health disparities are also the most pronounced.”

The report goes on, “Milwaukee has higher than state average rates of infant mortality, sexually transmitted diseases, cancer (breast, cervical, lung, and prostate), violence, teen pregnancy, childhood lead poisoning, and mortality due to unintentional injuries. The Milwaukee [Metropolitan Statistical Area] MSA is also the most racially segregated MSA in the nation.”

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.”