Lactation professional contributes to New Hampshire’s breastfeeding success

lisa picI started the interview like this: Congratulations on being ranked number one for perinatal care for the fifth year in a row. I know a lot of the work you do contributes to great outcomes for moms and babies in New Hampshire.

She replied so seriously: How do you know that?

Not at all expecting that response, I stuttered; the words stumbled out of my mouth: Well, all the work you do with breastfeeding. That’s what really matters.

Lisa Lamadriz, RNC, IBCLC is one humble woman. Before our interview, I read and heard a lot about her, leading me to believe that she indeed does have a lot to do with NH’s great perinatal care.

Lamadriz works at Dartmouth Hitchcock Medical Center (DHMC), a Baby-Friendly tertiary care center where she heads the Baby-Friendly team. In 2007, she created lactation support programs for families with infants at Children’s Hospital at Dartmouth’s (CHaD) Intensive Care Nursery (ICN). She created a nutrition group that provides staff education. [Retrieved from:] She serves as New Hampshire Breastfeeding Taskforce’s co-chair. She contributes to CHaD’s breastfeeding episodes. And the list goes on.

During our chat, Lamadriz continued to prove that she and the collaboratives she’s a part of have a lot to do NH’s breastfeeding success.

As stated, back in April, the 2011 Maternity Practices in Infant Nutrition and Care (mPINC) Survey results from the Center for Disease Control and Prevention (CDC) showed New Hampshire as number one for the fifth straight year in perinatal care practices associated with breastfeeding success. The New Hampshire Department of Health and Human Services (DHHS) says the survey results are due largely to the efforts of the New Hampshire Ten Steps to Successful Breastfeeding Program, headed by Dartmouth-Hitchcock’s Bonny Whalen, MD. [Retrieved from:]

The Ten Steps program began as a hospital-based project but has grown into a state-wide initiative. DHMC’s journey to Baby-Friendly began about 15 years ago, but the facility recently revamped their efforts in 2009. The hospital was awarded designation in 2012. Read more about their efforts here:

Lamadriz tells me families have often told her they chose DHMC for their birthing experience specifically because of its Baby-Friendly designation; a great marketing tool as Baby-Friendly USA project manager Liz Westwater explains in Baby Friendly Hospitals decrease traumatic birth experiences, increase breastfeeding rates.

Getting DHMC staff excited about Baby-Friendly designation started with a large skin to skin campaign. Before the implementation of the Ten Steps began at the facility, Lamadriz admits that while they thought they were doing a great job getting babies skin to skin, they realized they could do a lot better (even with about a 30 percent population of high risk deliveries).

So bulletin boards showing evidence of the effectiveness of BFHI went up throughout the hospital. Staff champions mingled with resistant staff members.  Physician champions spread the word about breastfeeding.

Lamadriz names Dr. Whalen one of those physician champions. As a pediatrician, medical director of the Newborn Nursery and a certified lactation consultant, her positive influence on breastfeeding spreads far and wide. Even more, Lamadriz tells me she’s passionate about integrating breastfeeding education and support into young physicians’ curriculum.

Neonatologist Juliette Madan, MD, MS is equally encouraging about breastfeeding and breastmilk feeding. Her efforts allowed for an update of the ICN’s feeding guidelines. Mothers are now encouraged to provide colostrum for baby before any kind of supplementation is offered. Lamadriz says babies are never just automatically started on artificial baby milk.

“The gut is so fragile,” she explains. “It really needs that colostrum before we put anything else on it.”

The ICN’s support and patience with breastmilk feeding low birth weight babies has played a part in allowing the facility to significantly decrease the use of non-medically indicated formula supplementation. In fact, Lamadriz says their breastfeeding initiation rates are close to 98 percent. Any breastmilk feeding at time of discharge varies between 45 and 60 percent.

Because of the size of the facility, Lamadriz says it’s often difficult to engage everyone in the Baby-Friendly process, a common challenge facilities face when working toward designation.

However like many other successful Baby-Friendly facilities, DHMC formed a multidisciplinary quality improvement team comprised of clinicians including those from CHaD, the Prenatal Clinic, Birthing Pavilion, Newborn Nursery, INC, Pediatrics, Food and Nutrition Services, Finances and Purchasing to ensure every care provider a mother comes in contact with supports her breastfeeding goals. [Retrieved from:]

“Our biggest improvement was in the area of prenatal breastfeeding education in the clinic,” Lamadriz says in a DHMC news release. “We updated our patient education materials, and created a process with the staff in the prenatal clinic to provide small amounts of breastfeeding education at each prenatal visit.”

While DHMC excels in its prenatal breastfeeding education, it still struggles with sustaining Baby-Friendly’s rooming-in model.

“Nurses feel like they are doing mom a favor if they take baby out for sleeping,” Lamadriz tells me, yet another common but not unconquerable challenge.

By improving prenatal education, Lamadriz says parents are better able to advocate for their families.

“They actually drive the practice,” she says. “They really take the initiative of keeping their baby with them.”

Postnatally, DHMC offers lactation support services including a Lactation Clinic and referrals to support groups like the Women’s Health Resource Center.  We know that continuity of care is essential when supporting moms’ breastfeeding goals, so DHMC lactation professionals make sure to communicate with mom and babys’ other health care providers.

Lamadriz says she and her co-workers connect with other maternal child health programs in NH through the state’s breastfeeding taskforce. Representatives from different organizations including WIC, universities, La Leche League and the Department of Health and Human Services (which heads the obesity prevention program) work toward a common goal to support breastfeeding throughout the community.

Members of the 10 Steps Collaborative including Lamadriz, Whalen, Joyce Kelly, RN, MPH and  Dr. Alison Holmes of Concord Hospital and Dartmouth-Hitchcock have educated staff at six  of the 20 birthing hospitals in NH about the 10 Steps program.

Through a survey, Lamadriz says they learned that one of hospitals’ biggest barriers to become Baby-Friendly is the cost of educating their staff. Lamadriz provides education and skills days to facilities in need.

“Hospitals are really working on the ten steps and trying to improve,” Lamadriz says. “I’m hoping that will increase our [breastfeeding] duration rates.”

According to the CDC’s 2012 breastfeeding report card, NH’s exclusive breastfeeding rates at six months came in just under 25 percent, about ten percentage points higher than the national average. While NH’s duration rate is one of the highest in the nation, 25 percent of babies breastfeeding at six months is still arguably a very dismal number.

The 10 Steps Collaborative provides education across the border to Maine’s Let’s Go! program, an initiative to reduce obesity that includes a breastfeeding component. Maine’s exclusive breastfeeding rates at six months come in just above 15 percent.

Despite the somewhat gloomy numbers, Lamadriz says she is very optimistic about future birth and breastfeeding outcomes in our country.

“I think we have a lot of work to do and I sometimes worry about the hightechness of everything,” she says. “But I am optimistic because I do see the younger mothers reading about breastfeeding and knowing a lot when they show up for their appointments.”

Lamadriz says it’s sometimes difficult to get people to slow down and recognize the importance of the biological and anthropological connection between mom and baby.

“It’s my generation’s responsibility to make sure young women are aware of how important this special time is.”

Lamadriz will take her responsibility to the next level this fall when she attends Boston University’s Master of Public Health: Maternal Child Health program. As a graduate of Union Institute and University’s Bachelor program in Maternal Child Health: Lactation Consulting, she says she gained a more global perspective on maternal child health issues. (The Healthy Children Project collaborates with UI&U to provide the lactation content of this degree program.)

“I became keenly aware of the horrible things happening to women and girls,” she says. “It flipped me upside down. Something inside of me said, ‘OK, now you know this so what are you going to do?’”

Celebrating dads with restructured breastfeeding support

Male nipples. What is their function? Well, if you are the parent of a breastfed baby, you have most likely had the experience of watching your infant try to latch or successfully latch onto dad’s chestly protrusions. For most parents, it’s a funny story to tell. But what if it’s more than that? My rudimentary research leaves me to believe that babies don’t seek their father’s nipples out of confusion or randomness. Instead, male nipples may serve as fleshy pacifiers and an important portal into father-baby bonding.

In honor of dads, this Father’s Day we decided to do something different on Our Milky Way; we take a glimpse into two fathers’ breastfeeding experiences.

The stories they share and their partner’s reflections prove that we need to modify the way we view dads’ roles and restructure the support we offer them.

Hope Elser, Union Institute and University Maternal Child Health student, WIC breastfeeding peer counselor and mother of two, and her husband Jason were kind enough to share their parenting journey with me. Hope and Jason are the parents of Kaitlyn, 6, and nursling Ryan, 18 months.

Additionally, I formally interviewed my darling husband Addison. Our daughter Willow just turned 22 months. Like Hope and Ryan, we practice natural term breastfeeding. We’re also excited to announce that we’re expecting our second child in early

Hope, Jason and I engaged in very friendly conversation. We chuckled about our toddlers’ requests for milk from dad. Then, Hope made a profound observation: Children request breastmilk from the people they feel nurtured by- at least this has been our common experience.

Addison and Jason let me in on the ways they feel most effective in connecting with their children.

For Jason, bathtime and plenty of skin to skin contact are great ways for him to build a relationship with his kids.

Addison says reading and playing with Willow on her activity mat are important bonding opportunities.

“I never ever felt like I was taking something away from [Jason] by breastfeeding,” Hope explains. “I think he took a lot of pressure off of me because he just found other ways to bond with them.”

I wish I could say the same; after interviewing Addison, I do feel like I took something away from him.

Interestingly, Addison cites the bond that Willow and I share as the best and worst part of being the father of a breastfed child.

“Willow can be so upset sometimes and you just nurse and she is so happy,” Addison says.

photoBreastfeeding is also an extremely effective way for me to put Willow to sleep. Up until about a few weeks ago, Addison hadn’t been able to put her to sleep unless he drove around in the car with her.

To be honest, before our interview, I always felt like it was Addison’s fault that Willow generally prefers to come to me when she’s upset, hurt, scared or tired. I felt like if he would have put more effort into bonding with her in other ways beyond feeding, he would share the same relationship that she and I do. But I’m not so sure that theory is valid.

Looking back, I wonder if encouraging my husband to “nurse” Willow would have allowed him to experience what it’s like for me to be a breastfeeding mom.

Addison continually expresses interest in actively offering our next child bottles of breastmilk, a request I continually deny.

Yet, I am completely open to the idea of male nursing as a nurturing act. Addison makes clear that the thought of male nursing makes him very uncomfortable.

Writer and director Peter Templeman made a fascinating and provocative short film called Milk Men which explores male lactation and breastfeeding and is certainly worth watching if you’re interested in this model.

Hope tells me that as a lactation professional, she sees moms and babies all day long, every day but very rarely sees fathers coming in for support. When she asks mothers about their partner’s feelings, perceptions and concerns about breastfeeding, most of them reply that it doesn’t matter because he’s not a part of it- not necessarily that the fathers are absent all together, but they are uninvolved in the process of breastfeeding.

Hope argues that fathers should very much be a part of the process.

“You have to allow him to be,” she advises. In the same breath, “Moms don’t know how to integrate dads into the breastfeeding relationship anymore than dads do,” she says.

She’s spot on when it comes to my husband and I. Leaving my pride at being able to satisfy Willow aside, I hypothesize that it’s difficult for me to acknowledge the important role a dad can play because my father has been absent all of my life. I learned about parenting from my mother who fulfilled both responsibilities.

I pushed Addison away when I took on virtually every aspect of parenting beyond earning a living. I didn’t have a clue how to allow him to integrate himself into our nursing relationship and he didn’t know how to advocate for himself. I never learned from my mother how to consider a co-parent or partner. The breastfeeding education Addison and I did receive together was so moronic. Perhaps we are psychologically flawed in that we didn’t find a healthy balancing act on our own… But then again, how would new, first-time parents learn do to this without support and guidance?

What if we had been introduced to male nursing? Would this mutual engagement in such an intimate act with our infant have allowed us to better connect as parents?

Our nation is most certainly not ready for the promotion of male nursing; we can hardly handle images of mothers feeding their babies, let alone an infant suckling at its father’s breast. Gasp!!

A less controversial solution is to better include fathers in breastfeeding imagery in other ways.

Take a look at this screenshot of a Google Images breastfeeding search. The images are stunningly beautiful, but who is missing?googlebreast

I smell a problem here, especially when we consider Addison’s and Jason’s thoughts about breastfeeding before they expected their own children: they didn’t have any.

“I never really came across [breastfeeding] at all,” Addison says. “I didn’t have any knowledge about what good things can come of it or anything like that.”

He doesn’t recall any of his family members breastfeeding. Before Willow’s birth, he had never noticed a woman breastfeeding in public and says he can’t remember any times seeing breastfeeding in the media.

And before Hope decided that she wanted to breastfeed, Jason hadn’t thought about breastfeeding either.

The inclusion of partners in breastfeeding imagery might also allow mothers to acknowledge the part a father can play on the nursing team.

I firmly believe that the decision to breastfeed is ultimately that of the mother. Her body. Her choice. Simple.

But when fathers are not engaged in any kind of conversation about breastfeeding prenatally, we pose the risk of disengagement throughout parenthood.

Addison wasn’t involved in my decision to breastfeed Willow. It isn’t something either of us remember having a specific conversation about and it was never something Addison questioned (aside from his initial concerns with me breastfeeding in public.)

Like my husband and I, Hope and Jason don’t recall having a conversation about deciding how to feed their baby.

“I just knew that I was going to breastfeed and having support to do so was very encouraging, especially from a man,” Hope says of her first born. “That was a new experience having that kind of support in such an intimate way.”

I am impressed with Jason’s ability to offer support without direction, because he expresses feelings of unpreparedness. He says he wishes there had been breastfeeding education and support offered directly to him as the father.

In fact, research teams in Italy, Brazil, and Australia have evaluated the impact of training dads to support their breastfeeding partners. They’ve discovered that educating fathers about basic breastfeeding management increases the duration and/or exclusivity of breastfeeding.

“If I would have had a little bit of knowledge about the dad’s role, we may have understood what was wrong with Ryan and why he wouldn’t latch earlier,” he says of Ryan’s tongue tie.

Much the same, Willow and I initially had a tumultuous time perfecting our latch thanks to the infamous hospital birth with all of the booby traps perfectly in place.

Addison spent days and nights with me enticing Willow to open her tiny mouth so I could shove my bloody nipples into her face. Knowing what I know now, I cringe when I look back on those days.

“I fetched lanolin and nipple diapers,” Addison remembers of my sore but surprisingly leaky breasts.

“I could have called the specialist and had them come help,” he says in hindsight.

Breastfeeding advocates spend a lot of time sharing information about why dads should care about breastfeeding. For example, The Leaky Boob shares Breastfeeding- Good for Dads Too.

Similarly, we put a lot of energy into communicating how dads can effectively support their breastfeeding partner. For instance, Best For Babes recently came out with Listen Up, Dads! 10 Ways You Can Support Your Breastfeeding Partner. It’s a simple yet fabulous resource for new dads and I cannot deny that the support dad offers is a crucial part of building a successful breastfeeding relationship between mother and baby.

But what about support for the supporters? Tailored support for the dads like Addison and Jason.

The breastfeeding support we offer is so much more complicated than the pamphlets handed to new parents directing them to LLL meetings. And the general breastfeeding advice new parents stumble upon from Google searches doesn’t even scratch the surface of what needs to be available.

“I wanted to be involved in everything,” Addison says of birth and breastfeeding. “I didn’t really know what I was supposed to do.”

The biggest challenge for Jason as a father to breastfed children is the ridicule he gets from family members and in-laws, pressuring Hope to wean.

“I get it practically every time I talk to my dad,” he says.

Jason also admits missing having his wife’s breast to himself. This seems to be a common concern for fathers. It is fascinating and frightening what our culture has done to the female body. Why is it difficult for us to separate breasts’ primary function from sexual pleasure? After all, does the penis not excrete urine as well as serve a sexual function?

Creating dad-centered support groups or simply encouraging and accepting fathers into mother-centered support groups might generate more diverse conversation about the issues fathers of breastfed babies face. It may also lessen the pressure on dads and in turn, equip them with better support tools for their breastfeeding partners.

Jason adds that support or counseling groups “would get them hungry for different ways to be hands on and to be a part of the nursing team.”

Addison remembers that we didn’t have any proper lactation support aside from my occasional phone calls and incessant emails to our Boobie Guru Ms. Cindy Turner-Maffei, MA, ALC, IBCLC of Healthy Children Project.

Moreover, leaving young children to return to work is a reality for a lot of dads. Unfortunately, only 11 percent of families in the U.S. have access to paid family leave through their employers, Anayah Sangodele-Ayoka of reports in Celebrating Fathers Who ‘Leave’ to Be Home.

Jason was granted just two weeks family leave after Kaitlyn was born.

Then, when Kaitlyn was four months old, he was expected to leave for a tour in Korea and didn’t return until his daughter was 18 months old.

“That really pushed some levels of our relationship,” Jason admits. “And coming back from Korea it was kind of hard being around Kaitlyn because I kind of didn’t know her. We had to experience each other all over again.”

Jason expresses guilt in that he was unable to spend the time with his daughter at a young age like he has with his son now that he’s retired from the military.

And so my newfound obsession with male nursing continues. While it is unlikely that Kaitlyn would have immediately taken to Jason’s breast, could male nursing act as a bonding device for the fathers who spend much of their time away from home?

I’m so grateful that Addison’s job allows for an extremely flexible schedule and has never forced him overseas.

“I felt really comfortable leaving because I know how knowledgeable you are and I didn’t think you were going to need me,” he says. “I was very comfortable with you as a mother.”

He adds that he’s comfortable knowing that he’s needed to make a living.

While the challenges and sacrifices that fathers make are often overlooked, Addison and Jason reveal great appreciation for breastfeeding.

“We don’t have to make sure we have bottles packed,” Addison cites as a benefit. “We don’t have to get up in the middle of the night to go fix a bottle.”

“There’s something really special about [Hope] sitting in the chair holding her baby close to her and giving him exactly what his body needs, his heart needs and his spirit needs,” Jason says. “They seem so in tune with each other.”

The challenges Addison and Jason have faced allow them to offer valuable advice to new fathers.

“If your partner is struggling, you should seek the help of a lactation professional to help her because it will only make it easier,” Addison advises. “It doesn’t hurt to go get help if you think that there is something wrong.”

Jason suggests gathering as much breastfeeding information as possible because knowledge is power.

As he puts it: “Mortal Kombat said it the best.”

Let’s make a move and revolutionize the breastfeeding support we offer fathers so that we can continue to grow and strengthen support for our moms and babies.

Public education program focuses on African American breastfeeding disparities

The first several weeks after my daughter Willow’s birth were remarkable. I was full of the most incredible, indescribable love for my new infant. At the same time, I felt strangely alone.

As a fairly young mom, I didn’t belong to any kind of community of mothers going through experiences similar to mine, and I longed for those connections.

ION-bannerAbout two months ago, Surgeon General Regina M. Benjamin, MD, MBA announced the launch of the U.S. Department of Health and Human Services Office on Women’s Health’s project It’s Only Natural, a public education campaign aimed at increasing awareness among African American women of the importance of breastfeeding and providing helpful how-to tips.

Part of the campaign includes a My Breastfeeding Story component which provides new moms with inspiring personal stories from other mothers and even a new dad’s perspective on the journey of parenthood.

It’s Only Natural’s breastfeeding subject matter expert Ursuline Singleton, MPH, RD with the Office on Women’s Health at the U.S. Department of Health and Human Services reflects on the importance of storytelling and making connections.

“What stories do is they break down barriers,” she says and quotes Teddy Roosevelt: Nobody cares how much you know, until they know how much you care.

Which is why Singleton stresses the importance of lactation professionals truly understanding and embracing the reason for the It’s Only Natural campaign.

“Cultural sensitivity is a key factor in the success of this campaign,” Singleton explains.

Lactation care workers must listen to families’ concerns and must not make assumptions or judgements, she adds.

Responding to breastfeeding disparities

It’s Only Natural was developed in response to what Singleton refers to as unacceptable disparities in African American breastfeeding initiation and duration rates as addressed in the  CDC’s recent report on breastfeeding disparities.

With Surgeon General Regina M. Benjamin’s 2011 Call to Action to Support Breastfeeding in mind, the campaign responds with an action-based plan to squash breastfeeding barriers outlined by Benjamin.

Looking further back, It’s Only Natural is somewhat a continuation of the HHS Blueprint for Action on Breastfeeding released in 2000 by former Surgeon General David Satcher as well as HHS’s Babies Were Born to be Breastfed national campaign.

Extensive, formative research went into the creation of It’s Only Natural materials. Focus groups were initially conducted in three major cities: Montgomery, Ala., Washington D.C. and Chicago, Ill. Additional focus groups followed in New Orleans, La., Philadelphia, Pa., and Jackson, Miss.

Throughout the development of the project, contributors found that female family members have a very strong influence on a mother’s decision to breastfeed, especially in the African American community. In response, the campaign offers information on how to get your family on board with breastfeeding.

“We have a unique opportunity like never before to address breastfeeding rates through [this] campaign,” Singleton says.

Providing access to comprehensive materials

It’s not enough to acknowledge that breastfeeding barriers exist; action is needed to break them down.

It’s Only Natural offers comprehensive, action-based information for mothers including videos, storytelling, how-to advice and more. Moreover, the materials were specifically designed to reflect the experience of African American moms and families to better serve an underserved community.

The campaign keeps the lactation professional in mind, too. Campaign developers created the Leader’s Guide which details how to host breastfeeding sessions right down to planning the event.  Posters and fact sheets and radio PSAs are also available for the public’s use.

While the campaign’s materials are amazingly complete, Singleton reminds leaders to always acknowledge how different audiences learn; How will a group of teenagers best retain the information presented? What is the optimal way to teach a group of expecting mothers, a diverse group of adults, family members or community members in general?

Reaching more mothers through The Village

Another portion of the It’s Only Natural vision includes bringing together diverse partners to better reach new mothers. As we know, collaboration is a key component to helping breastfeeding moms and babies.

“We use the phrase ‘It Takes a Village,’” Singleton says. “The thing about the village is that it’s not just a catchy phrase.”

The village includes an entire health care system as well as a community that conveys a culture of breastfeeding, she adds.

Relatives, employers, and other African American breastfeeding mothers are also part of the village and create a positive breastfeeding culture.

Unfortunately, health care professionals often don’t expect African American mothers to breastfeed, so they fail to provide them with information or proper breastfeeding support to help these mothers be successful with their healthy infant feeding choice, Singleton tells me.

Part of the problem may be, as outlined in the Surgeon General’s Call to Action, a shortage of health care providers who specialize in lactation. Even more, our nation lacks African American lactation professionals to serve African American women.

In response, the campaign offers several support sections including building your breastfeeding network.

Anticipating campaign outcomes

While still early in the program, Singleton says there is a lot of excitement about the campaign.

Program manager and co-founder of the African American Breastfeeding Network of Milwaukee Dalvery Blackwell, BA, IBCLC agrees.

“I’m eager to start using the materials to see the reaction of the people we serve,” she says.

Blackwell was drawn to the campaign by its access to printed materials like the breastfeeding fact sheets.

In order to keep track of the success of the campaign, Singleton says they are and will track the use of radio PSAs as well as receive reports through partner organizations.

Ultimately, the real success of the program will come when African American breastfeeding initiation and duration rates rise and when the ethnic gap closes.

The campaign would benefit from expanding its traditional and nontraditional partners, Singleton says.

She wants the public to embrace the campaign and to utilize the various resources presented, because when the whole community supports breastfeeding as the normal infant feeding choice, mothers will gain confidence to feed their babies.

Singleton also reminds us that if there is a problem, there is a solution. It’s Only Natural offers a National Breastfeeding hotline open Monday through Friday from 9 am to 6 pm EST. Call them at 800-994-9662.

Click here to explore the It’s Only Natural website.

How will you use the It’s Only Natural materials in your community? Share your comments below.

Who am I?

It’s Our Milky Way game time! Who am I?

  • When in my presence, laboring mothers undergo fewer cesarean sections, vacuum extraction and forceps deliveries.
  • When in my presence, laboring mothers experience shorter labors.
  • When in my presence, laboring mothers have less need for analgesia and oxytocin augmentation.
  • I increase breastfeeding initiation and duration rates.
  • I decrease the likelihood of postpartum depression.
  • My support results in a significantly more positive level of interaction between mother and infant two months after delivery.
  • Many consider my support an essential component of childbirth. [Clues retrieved from: and]

Ding, ding, ding! I am a doula.

In Doula Support and Attitudes of Intrapartum Nurses: A Qualitative Study from the Patient’s Perspective, authors Karla Papagni, BS and Ellen Buckner, DSN, RN summarize a doula’s role in seven objectives:

  1. To recognize birth as a key life experience that the mother will remember all of her life;

  2. To understand the physiology of birth and the emotional needs of a woman in labor;

  3. To assist the woman and her partner in preparing for and carrying out their plan for the birth;

  4. To stay by the side of the laboring woman throughout the entire labor;

  5. To provide emotional support, physical comfort measures, an objective viewpoint, and assistance to the woman in getting the information she needs to make good decisions;

  6. To facilitate communication between the laboring woman, her partner, and clinical care providers; and

  7. To perceive the doula’s role as one who nurtures and protects the woman’s memory of her birth experience.

Isn’t it fascinating that an ancient model of women helping women birth, also referred to as the social childbirth philosophy, has such positive, profound effects on mother and baby?

Tragically, in the early twentieth century in the U.S., “childbirth became a means of demonstrating new advances in technology and medicine” and the traditional birthing model was “practically abolished.” []

Today, the United State’s childbirth intervention rates and maternal mortality rates are shameful.

Our current health care system also presents flaws in its continuity of care, or lack thereof. Because birth experience strongly influences breastfeeding outcomes, interruptions in maternal infant health care can be everlasting.

2010-11 075Co-author of The Doula Guide to Birth: Secrets Every Pregnant Woman Should Know and doula Ananda Lowe, CLC explains a doula’s influence on continuity of care like this:

As a doula, I am likely to be the only person in a mother’s life who witnesses her birth as well as her early days at home learning to breastfeed.  She knows and trusts me, and we have already established our ability to communicate well with each other.  I can respond to her breastfeeding issues without delay in the postpartum period.  I am aware that there is a debate about the effect of birth interventions on breastfeeding, and my lactation colleagues as well as my medical colleagues offer conflicting evidence on this topic.  Aside from the issue of birth interventions, I feel that the lack of continuity of care is problematic for the majority of mothers; with the exception of those who have doulas, women don’t have a plan for who they will turn to with lactation questions in their first days home alone, and this is when floundering and cessation of breastfeeding often occurs.

(Visit to learn about the risks of not breastfeeding.)

As a certified lactation counselor (CLC), Lowe offers her clients an even higher standard of  care.

In a recent The Doula Guide blog post, Lowe cites using skin to skin as one of her favorite pieces of advice for families.

“Specifically regarding skin-to-skin, I encourage mothers to utilize it at every feeding for at least the first 48 hours of life, not just in the hour after birth, because babies need the sensory input that skin to skin provides to help them finesse their latching abilities,” she tells me.

Lowe is also excited about the advice she learned in her CLC training: follow the angle of the dangle.

“That is, different breasts and nipples point in different directions – straight ahead, upward, downward, or slightly to the sides,” she explains.  “There is no one breastfeeding position that can work for all mothers and babies, because everyone’s anatomy is slightly different.  A mother needs to hold her baby in alignment with her specific anatomy, which may be different than the way another woman would hold a baby.”

Lowe says that she learned this on a personal level when she initially had a difficult time nursing her daughter using the football hold.

“Mothers should be encouraged to listen closely to their instincts as they learn to position their babies, not to only rely on (even a well-meaning) nurse or lactation specialist who is positioning the baby for them,” she says.

While we know the support of a doula is beneficial to mom, baby and family, the doula profession can often be difficult within a landscape that does not adequately support normal birth.

“ It can…be stressful to do work that promotes change and best practices, when you may be surrounded by protocols and cultural views that undermine normal birth and breastfeeding,” as Lowe puts it.

She suggests that there needs to be a revolution in support for parents and doulas alike. Organizations have been formed in numerous states with the name “[State] Friends of Midwives,” but nothing similar exists for friends of doulas, Lowe explains.

“I believe we need to shift the paradigm of the doula working in solo practice and attempting to provide superhuman support to families by herself,” she says.  “The doula movement evolved around that model, we are attached to it and even afraid to change it, but it is not sustainable.  In some areas, such as the San Francisco Bay area, it is becoming more common for doulas to work in pairs.  We have a high level of burnout as a profession, but this one change would make a big difference.”

In What I Learned from 17 Years as a Freelance Doula, Lowe also reflects on doulas’ struggles including “society’s devaluing of women’s work, and our own shaky professional self-esteem”.

She offers a comprehensive list of advice for the “freelance soul.”

Occasionally warding off burnout, Lowe tells me she finds inspiration from Gretchen Rubin, author of The Happiness Project.

“In the book, she describes how she gave herself the assignment to “be Gretchen” (or to be herself) as much as she possibly could, in order to find happiness and best contribute to society,” Lowe explains. “I now frequently remind myself to ‘be Ananda’ when I need to make decisions about my Maternal Child Health career or other aspects of my life, and I really do feel that it helps lead me in more satisfying and appropriate directions!”

Despite the pressures Lowe and other doulas often assume, Lowe says she is optimistic about future breastfeeding outcomes in our nation. She cites our changing national healthcare reform and The Joint Commission perinatal policies as positive forces.

“It is a long, complicated process to change attitudes and protocols, and some mothers and babies lose out along the way which is very unfortunate,” she says.  “But more resources are available every day to protect, promote and support successful lactation outcomes.”

Lowe doesn’t express the same kind of optimism about our nation’s birth outcomes.

“My feeling is that clinicians themselves, OBs, nurses, even some of our midwives, have a deeper investment in all their years of training to perform their jobs in a certain way, as well as being saddled with heavy malpractice fears,” she says. “Mothers are becoming more outspoken and they are the roots of change, but they have a lot to fight against.”

Challenges aside, Lowe acknowledges the movement to change birth outcomes as crucial.

“Doulas are a key element of this, and I am proud to have helped create the doula movement over the last 18 years.”

Are you optimistic about birth and breastfeeding outcomes in our nation? Share your thoughts in the comment thread below.

Worksite program caters to nursing moms

A friend of mine shared this gorgeous poster of working mothers demanding the freedom to feed by Phoebe Wahl with me.

Working, nursing moms still have a lot to fight for, but the Health Care Reform requires employers to support nursing mothers in a couple of ways: Employers must provide reasonable break time to express breast milk for one year after her child’s birth each time she has the need; and a private place, other than a bathroom, for her to do so.

Mother-Friendly-Worksite-CertifiedTexas has been a shepherd in creating worksite legislation for nursing moms. The state established a health and safety code which includes the Mother-Friendly business designation nearly two decades ago.

Since then, the Mother-Friendly Worksite Program has designated 1120 businesses Mother-Friendly, says Texas State Breastfeeding Coordinator and Texas Mother-Friendly Worksite Program (TMFWP) administrator Julie Stagg, MSN, RN, IBCLC, RLC.

Becoming designated requires the following written into an employee worksite lactation support policy:

  • Flexible work schedules including scheduling breaks and work patterns to provide time for expression of milk,

  • Access to a private location(s) that is not a bathroom, for the purpose of milk expression,

  • Access to a nearby clean and safe water source and a sink for washing hands and rinsing out any breast pump equipment and

  • Access to hygienic storage options for mothers to safely store breastmilk. [Retrieved from:]

Asking for basic breastfeeding support can be a difficult thing for working moms to do. Often times there is a communication gap between employers’ perception and employees’ reality.

Employers may not recognize worksite lactation support as significant because they are not familiar with the importance of exclusive breastfeeding.

“Sometimes they don’t understand how work plays an important role in a mother meeting her breastfeeding goals,” Stagg says.

Other times employers don’t think to create a worksite support system because it isn’t brought to their attention.

“Some moms have asked for support and had a horrible experience, but most are not talking at all because a lot of moms fear job security,” Stagg explains.

In the program’s infancy, TMFWP conducted focus groups with employers and employees as part of the development process.

One focus group found that 80 percent of people agreed or strongly agreed that supporting nursing employees was “the right thing to do.”

Another group of 30 employers with multiple worksites across Texas found that 75 percent of co-workers were supportive of a breastfeeding policy even though managers initially perceived a negative reaction from co-workers.

Stagg calls the opposition a “vocal minority.”

“They will always be there,” she says. “But that’s where the law really comes in handy. It’s not disputable.”

Stagg says employers often express concern about money and space. Often times though, businesses already meet the requirements before applying for designation.

And if not, “You just get creative and figure it out,” Stagg says.

A woman writes on TMFWP’s website: “My boss offered me an empty office to pump in. Unfortunately, the door didn’t lock, but my “MILKING IN PROGRESS” sign kept ’em out!”

Stagg emphasizes the significance of return on investment because “businesses that proactively support breastfeeding see reduced health-care costs and lower turnover.” [Retrieved from:]

In fact, Dr. Melissa Bartick and Arnold Reinhold state that businesses with worksite lactation programs experience up to a $3 return for every $1 invested in lactation support in The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis.

Stagg says that because nursing mothers spend less time at home with sick children, co-workers aren’t forced to cover extra hours which reduces their stress levels.

Becoming Mother-Friendly designated communicates a supportive environment overall which attracts qualified, loyal employees. Stagg says that’s most important.

When employers find their programs successful, they are given the option to add components to their policy which might include:

  • Extending program offerings to male employees and their partners

  • Bring-baby-to-work policies

  • Paid lactation breaks

  • Breastfeeding and/or parenting classes

TMFWP offers a Silver and Gold Mother-Friendly designation for employers who continue to add supportive components to their policies.

For other states looking to develop a similar program, Stagg suggests creating many partnerships to get people excited about the initiative.

“If you can help spread the word through existing programs, that’s a really great thing,” she says.

The program’s website offers businesses a step- by- step tool complete with downloadable PDFs to comfortably begin the designation process.

Texas families searching for breastfeeding information and support can visit

Where are the mother-friendly worksites in your state?