For new families, healthy, evidence-based infant feeding education and support can be hard to come by, but among this often barren landscape of support, the VA Maternity Care Coordinator (MCC) program provides an oasis for military Veteran mothers.
Retired USAF Lt Col Tammy Tenace BSN, MS, APRN-BC, now Women Veteran Education, Outreach and Research Coordinator for James A. Haley Veterans Hospital in Tampa, Fla. says that the VA understands that pregnancy and parenthood often requires specialized care.
About a decade ago, as care providers started to notice that lactation and breastfeeding support was severely limited in civilian communities, they established the MCC role. MCCs maintain contact with Veteran families throughout the perinatal period, facilitating care that meets their specific needs.
Because the VA does not provide obstetric care, the MCC acts as a liaison between the VA and the community obstetrical provider. MCCs follow Veterans through pregnancy and postpartum at one and six weeks postpartum. [https://link.springer.com/article/10.1007/s11606-019-04974-z] The VA supplies Veterans with lactation supplies like breast pumps, nursing bras, nursing pads, storage bags, etc.
The MCC role has been established at every VA medical center, and Tenace has served as MCC at her hospital since 2016.
Throughout the COVID-19 pandemic, what little perinatal support existed in civilian spaces, dwindled to almost nothing, Tenace points out.
Hospital breastfeeding support groups, while only meeting a couple of times a week, stopped meeting altogether. Women weren’t allowed support people or their partners at appointments, and they began to feel isolated.
“I realized I needed to do something; I couldn’t depend on the community,” Tenace says.
Working through the Office on Women’s Health as a subject matter expert, VA National Consultant for Lactation Ashley M. Lauria, MA, RD, LDN, IBCLC helps establish standards of care in lactation programs at VA facilities nationwide.
Tenace and Lauria both comment that among the hundreds of parents they have cared for, it is truly a rarity for an individual to express disinterest in lactation. Their experience reflects national numbers, where most dyads start out breastfeeding.
Women Veterans are the fastest growing group among the Veteran population. In fact, “by 2040, VA estimates they will comprise 18% of the Veteran population, versus just 4% in 2000,” according to a VA Pittsburgh press release.
In order to keep up with this demand, Tenace and her colleagues are in the process of curating a Certified Lactation Counselor (CLC) program. Made possible through funding from the Women’s Health Innovations and Staffing Enhancements (WHISE), ten of their staff members are completing the Lactation Counselor Training Course (LCTC), including Tenace, physicians, a health coach, advanced practice nurses, among others.
“The most up-to-date information is really important,” Tenace begins. “[We are all] unlearning the things we thought we knew. The course has been instrumental to helping us feel like we are actually helping women, instead of relying on the knowledge that we thought we had. The course is detailed and professional, yet practical. The practicalness is what’s to our advantage. It’s how we actually help women breastfeed.”
Tenace and Lauria go on to explain that their efforts are Veteran-led. That is, their facilities host quarterly focus groups where they can learn about Veterans’ requests.
“We want to know from women: what do they want?” Tenace comments.
Because Veteran women often prefer support groups comprised of other Veterans, Lauria offers virtual lactation support groups that also act as social circles and a place for comradery.
As James A. Haley Veterans’ Hospital designs new facilities, Tenace has been invited to offer input on the creation of lactation space for both employees and patients. Tenace applauds their leadership for focusing on improvement for the patient and employee experience. She also highlights that the newly designed main entrance will host a lactation pod.
“I can’t think of a better way to show commitment,” she adds.
Tenace and Lauria have embodied a passion for birth and lactation since their youth. Their work with the VA allows them to continue their mission to celebrate parents and their families and position themselves as life-long learners, evolving with the needs of Veteran mothers.
In an eerie parallel, WHO’s February 2022 report, How the marketing of formula milk influences our decisions on infant feeding, states that “Recommendations from health professionals are a key channel of formula milk marketing. Health professionals spoke of receiving commissions from sales, funding for research, promotional gifts, samples of infant and specialized formula milk products, or invitations to seminars, conferences and events.” (p. 7)
Last week, Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500 and I shared our reflection on the forces that shape physicians’ personal infant feeding experiences. In this second installment, we explore how physicians as professionals can support breastfeeding despite being targeted by the breastmilk substitute (BMS) industry and despite generally being woefully equipped with proper lactation education, training and counseling skills. These predicaments can lead physicians to “explicitly or inadvertently, introduce doubts around the ability of women to breastfeed and the value and quality of their breast milk.” (WHO, p. 12)
Pervasive industry influence for generations
Because “health professionals are among the most respected and trusted members of society…[their] advice…is highly influential for pregnant women and parents of infants and young children, including around infant feeding decisions.” Formula milk companies exploit this relationship of trust. (WHO, p. 12)
BMS representatives target physicians “with a range of incentives, including funding for research, commissions from sales, ambassadorial roles, merchandise, gifts and all expenses paid promotional trips.” (WHO, p.13)
The psychology behind gift-giving, both big and small is that “ it imposes…a sense of indebtedness…. The…rule of reciprocity imposes…an obligation to repay for favors, gifts and invitations…” (Katz 2003) Instead of supporting infant feeding purely through a health and wellness lens, physicians feel obliged to a company muddying their relationships with their patients.
Interestingly, most physicians feel immune to marketing’s influence, despite clear evidence to the contrary, Frederick S. Sierles, MD lays out in The Gift-Giving Influence.
Our culture fails to acknowledge the mother baby unit as a dyad, and this influences the way physicians can support breastfeeding too.
“We are never taught, in our fragmented system, that the mother and baby are a unit,” Lee reiterates. “OB/GYN/midwife sees mama; peds sees babies. There are even different places for them in the hospital: nursery, postpartum unit. What a struggle we had with the BFHI to keep mother and baby together.”
The Alliance for Innovation on Maternal Health’s (AIM) Patient Safety Bundles offer models for how health professionals can use task force approaches that break down silos of care and open channels of communication. The strategies used in these bundles aim to ultimately shift from fractured care to continuity of care where the dyad is protected.
We must also consider how physicians are compensated for their work. In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans, as we mentioned in our first installment. In short, the more RVUs a physician racks up, the more they’re paid. Breastfeeding counseling takes time.
How are physicians to spend time with their patients, educating and supporting breastfeeding when they’ve had little to no breastfeeding education invested in them? Dr. Nigel Campbell Rollinspointed out in WHO’s How the marketing of formula milk influences our decisions on infant feeding webinar that faculty in medical schools themselves sometimes believe that formula products are inevitable or necessary.
Often, it is a physician’s own struggle to breastfeed that seems to spur advocacy and change. Our Milky Way’s repository includes a breadth of physicians’ stories of personal struggles that have inspired them to become breastfeeding champions for their patients and communities.
“There was no training about [breastfeeding] technique, no discussion about common problems before discharge, no training about clinical problems as far as in the first few months postpartum…when to introduce complementary food,” she continues.
We are honored to have been able to feature the work of the late Audrey Naylor in Commendable contributions to the field of lactation. With a lifetime interest in illness prevention, Naylor said she was quickly convinced of the power of breastfeeding after only attending a few hours of a breastfeeding seminar in 1976.
“Neither medical school nor pediatric residency taught me anything about breastfeeding,” Naylor said.
“It is easy to become frustrated with nurses and physicians who – often inadvertently sabotage breastfeeding mothers and babies, but I also sympathize,” she explains. “We are in a position where we are supposed to have answers, but no one has taught us the skills necessary to provide those answers.”
Other stories and models for care
Lori Feldman-Winter’s, et al Residency curriculum improves breastfeeding care showed that “a targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.
As part of their work to build a cohort of breastfeeding-friendly pediatricians, the Georgia Chapter of the American Academy of Pediatrics and the Georgia Breastfeeding Coalition launched a “Breastfeeding-Friendly Pediatrician Interest Form.” Georgia pediatricians who are interested in becoming certified as a “Breastfeeding-Friendly Pediatrician” are invited to fill out the form.