Their work is supported by a grant through the Tri-County Health Department. Westover has been working alongside Susan Howk, a breastfeeding policy specialist, to create their policies and lactation spaces through a six-point plan which includes policy, staff and provider training, patient education, environment, evaluation and sustainability, and continuity of care.
The grant has funded things like a chair, end tables, a hospital-grade multi user breast pump and kits, a stuffed animal nursing dog with her puppies for siblings to play with, and a lactation scale for weighted feeds.
Their lactation space started in one of their smallest exam rooms, but has recently graduated to one of their larger exam rooms, which is now near the end of its renovation. Westover notes that the space also functions for newborn and young baby visits.
Westover reports that CRP owners since November 2021 Drs. Anderson and Bouchillon have been highly supportive of the breastfeeding-friendly changes.
Prior to the implementation of their lactation policies, Westover says their office “was not lactation friendly at all.” She describes stacks of formula in plain view.
“It gave the impression that we were promoting formula,” she comments.
Gift bags for patients were also riddled with formula-promotions, so the team phased out the branded materials and replaced them for non-branded, breastfeeding-friendly items.
Now, Westover and her colleague Sydney Gruenhaupt RN-BSN, CLC see breastfeeding dyads weekly for office visits; whereas they once had to refer out. Of mothers’ main concerns are poor weight gain and uncomfortable or painful latch.
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.
For as long as there have been humans, there has been human milk. As it happens, according to Greek mythology our entire galaxy originates from breastmilk.
Although people have been breastfeeding for millennia, breastfeeding doesn’t necessarily come naturally, especially in our modern world where common birth practice, industry influence and cultural phenomena are at play.
“The majority of women are not able to fulfill their [infant feeding] goals, and that’s unbelievably sad,” Rojas Bastidas says.
“That’s where innovation comes in,” she continues.
Rojas Bastidas’s company Orolait, is a breastfeeding apparel company at its core, but this summer she released a one-of-a-kind lactation education tool: the LactoPRO Trainer.
The LactoPRO is an anatomically-correct, tissue-mimicking human breast used for demonstrating hand expression. The device features a realistically-sized areola, nipple, and six lactiferous ducts and effectively ejects a human milk-like or colostrum-like substance. The breast is available in various skin shades too.
In April 2020, Rojas Bastidas shifted Orolait operations to help provide Personal Protective Equipment (PPEs) to a hospital in Haiti alongside a Houston-based company that creates surgical organs. With Rojas Bastidas’s vision and entrepreneurship and the company’s patented technology, the LactoPRO Trainer came to fruition.
Rojas Bastidas and the team are working to create a model with inverted nipples as well as fashioning a breast that can develop clogs and mastitis.
Rojas Bastidas emphasizes that she is always working to make her contributions more affordable and accessible.
“Having great things that are not accessible to the community are not helpful to anyone,” she says.
“As I was going through the course and tried to teach hand expression, I became frustrated by the lack of options to demonstrate it accurately and in a constructive way,” she reports.
Evidence-based lactation care emphasizes a hands-off approach. Couple this with the idea that infant feeding is a learned behavior and in American culture we don’t grow up seeing lactating breasts and breastfeeding, hand expression is a terribly abstract practice to teach.
The LactoPRO helps fill this void.
“Innovation in the lactation space has been slow and overlooked, so this is really exciting for me,” Rojas Bastidas says. “I’ve created something for the private sector that’s going to push public perception.”
She likens her invention to the evolution of professional lactation care services; maternal child health advocates took a stand and refused to let women suffer, she explains. Like lactation care, Rojas Bastidas has created something that validates people’s stories and experiences.
Rojas Bastidas’s influence stems from her experience as a new mom and the way she viewed her evolving body.
“I didn’t realize that the way I viewed my body was impacting so much of my life including my breastfeeding journey,” she says.
So many parents sympathize with the conundrum of breastfeeding in public spaces for instance. To do so discreetly often means lifting your shirt and exposing the midsection.
It seems vain and trivial, Rojas Bastidas acknowledges but when you multiply it by the millions of moms who experience challenges like this, there’s got to be a solution.
“Don’t be afraid to tackle whatever problem you see,” Rojas Bastidas encourages. “Innovation is for anyone.”
Rojas Bastidas’s apparel serves as functional fashion. Simultaneously, her pursuit celebrates the bodies that have been largely misrepresented and often altogether censored.
“The absence of bodies sends a broader message that those bodies don’t exist,” she explains.
“It makes every battle so much harder, but that’s what keeps driving me. I should have just closed up shop because this is so hard, but I’m going to make as many people as uncomfortable as humanly possible,” Rojas Bastidas says of being a female innovator in health and wellness advocacy.
She adds that by showing the public what bodies actually look like, it frees us, elevates us and empowers us.
“Lactating individuals deserve to be seen, heard and helped.”
Rojas Bastidas has a lot to offer on her website including her shop, lactation counseling services, a member forum and blog. Check it out here.
“I had a very adventurous time with those guys in the NICU,” Boyd remembers. “It changed the way I thought about breastfeeding.”
As a young Black mother, Boyd says she feels fortunate to have had support from hospital staff to feed her twins (which she went on to do for three years), acknowledging that this is not often the case for BIPOC families.
“That support in turn gave me the desire to help other mommies,” she says.
Boyd’s passion lies in uplifting underserved communities, particularly families living in the rural regions of the Southeast U.S. where she lived for nearly 20 years.
Now located in Florida, Boyd’s newly released podcast,The Early Postpartum Period, offers a way to stay connected and reach underserved mothers with basic, relevant breastfeeding information.
Boyd admits that the technology was something new to her and it required much patience to bring the project to fruition. Still, she says, it’s something that she wants to commit to for a long time to come, connecting with families especially in the time after they’ve left the hospital. Boyd hopes to soon host focus groups to get a better understanding of what kind of information families would like her to cover in the episodes.
In the meantime, she plans to release more episodes over the summer. Her practice emphasizes the importance of organization, so she’s planning a podcast featuring organizational skills and time management tips.
“There is a lot of lactation education out there and I don’t want to be repetitive,” Boyd begins. “I want to hit areas that will really be relevant and give [parents] something they can use, not just something they can listen to.”
Boyd explains that learning organizational skills can bring a sense of calmness which allows parents the energy to move forward with daily tasks, rather than getting engulfed by an often chaotic world. She suggests things like preparation, avoiding procrastination and working up endurance through taking a breath and stepping away when necessary.
Especially as our country examines our foundations and current events have brought race to the forefront, Boyd emphasizes the urgency to address high Black maternal mortality rates.
The pandemic has illuminated ways in which to address these rates, Boyd explains, like out of hospital birth and doula support.
“We have to move forward,” Boyd encourages.
You can connect with Boyd on Twitter here and find her website here.
In her role at the City of Philadelphia Department of Public Health, Lee noticed the challenges breastfeeding people face in shelters.
The barriers are a result of our cultural attitude toward lactating people and misunderstandings about their bodies and needs.
Lee talks about issues of privacy and ‘fairness’ in a shelter. Organizational dress codes often require residents to dress modestly, so when a person exposes their breasts to feed a baby, other residents can wonder why they’re not allowed to wear short shorts. Parents can express concern about the teenage boys in their families seeing breasts while a baby is being fed.
There’s the concern over safe milk storage and the mythology around reimbursement through the Child and Adult Care Food Program. Shelter staff may believe that if a mother breastfeeds, the facility will lose money to buy food because the allotted amount for infant formula isn’t getting used. Lee clarifies that if a mother breastfeeds, the institution will have more money to spend on food.
Just like in the rest of the US, there tends to be a push for formula feeding because the baby’s intake is easily measured, and staff are more comfortable with what is familiar, i.e. bottle-feeding
Lee continues, “There is a genuine honesty from people who don’t understand anything about breastfeeding, ‘Why are we breastfeeding?’ ‘Why are we bothering?’” Staff in hospitals have been educated about breastfeeding over the past few decades; staff in shelters have not.
So when she conducts trainings, she starts at the rudimentary level of ‘what are mammals?’
“All the worst mythology that you can imagine is in the shelter,” Lee says. “All the worst in how society treats mothers and babies gets magnified in shelters.”
With the problem identified, Lee says she started “from scratch in a way,” looking for a written policy to support breastfeeding people. Early on in her search, she followed up on a news story featuring a homeless mother in Hawaii. She posted inquiries on Lactnet, CDC listserv, international online forums, Facebook groups, and reached out to shelters at random wondering if they had breastfeeding policies .
“Nothing,” Lee reports. “There is probably a shelter somewhere that has a policy, but after two years of a global search, I wasn’t able to find it.”
In all her search, Lee found one published document— a Canadian study looking at the factors that influence breastfeeding practices of mothers living in a maternity shelter– that could be helpful.
She sent it out to colleagues at CHOP’s Homeless Health Initiative for feedback, and for quite a while, there was none. Lee’s colleague Melissa Berrios Johnson, MSW, a social work trainer with HHI, and the convenor of its breastfeeding workgroup subcommittee, helped to make the policy reality.
Partner agency Philadelphia Health Management Corporation (PHMC) received a grant that funded research which took the policy to four different shelters for staff and resident feedback.
“Everyone, residents and staff alike, felt this policy was important and feasible,” Lee says.
PHMC’s next step was to identify a shelter staff member to become a breastfeeding champion. This champion would be provided with free breastfeeding training, and receive an honorarium.
As program oversight changed though, “breastfeeding champion” became a job, with a list of responsibilities. So far, Lee says they’ve only found four people out of 10 shelters who are willing to take on the task.
“There are some folks in shelters working hard to make things better,” Lee says. “They are those champions, most of whom have breastfed themselves.”
Currently, Lee and colleagues are in the process of developing training for staff members and ironing out how to help staff implement the policy.
Lee’s and co-authors Alexandra Ernst MPH, and Vanesa Karamanian MD, MPH landmark paper about the 10 Steps to a Breastfeeding Friendly Shelter has been submitted to the Journal of Human Lactation (JHL).
At present, COVID has put all of this work on hold.