Among the many effects of the novel coronavirus, the pandemic has exposed our nation’s deficiencies: emergency unpreparedness, racial health disparities, our “highly polarized, fragmented, and individualistic society…” (I would add arrogant), and the failure of capitalism. In marginalized populations, poverty, health inequities, and other burdens are amplified during an outbreak or other emergency.
Long before the pandemic hit, individuals and advocacy organizations have been ringing the alarm, calling for better access to education, better healthcare, and equity and justice for all.
Of these trailblazers is Powerhouse Nikki Lee RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, CKC, RYT whose recent endeavor includes creating and implementing the 10 Steps to a Breastfeeding Friendly Shelter.
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.
Lee wrote the first draft of the 10 Steps to a Breastfeeding Friendly Shelter with policies like the Ten Steps to Successful Breastfeeding and Ten Steps to Breastfeeding-Friendly Child Care in mind.
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.