Physicians as parents: How can one pour from an empty cup?

A medical student once told Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500  about an obstetrician who loved to pump while she was catching babies because she collected more milk than usual. Lee theorizes that perhaps it was due to the high levels of oxytocin in the atmosphere during childbirth. 

It’s a fascinating concept, and quite unusual considering physicians often find themselves in a terrible paradox. As Lee puts it, they are supposed to take care of everybody else, and no one takes care of them. They’re expected to be experts on everything;  as childbirth educators and lactation care providers, we often disclaim “this information is not meant as a substitute for medical advice.”

In this two-part series, Lee and I set out to explore the forces that surround infant feeding, ones that physicians must muscle through as parents themselves and as professionals. We explore emerging themes inspired by the article Medical training taught this Philadelphia doctor about breast feeding. But the real lessons came from her twins. In Part One, we offer thoughts on physicians functioning as parents themselves. Part Two covers physicians as professionals trying to support breastfeeding most often with inadequate education and training.

Source: United States Breastfeeding Committee

With insufficient support in their personal infant feeding goals, physicians’ struggles sometimes seem to spur advocacy and a “do-better-for-my patients” attitude. Just the same, these experiences can lead individuals to harbor resentment, despair, resignation and defeat, and might unintentionally influence the breastfeeding support they are able to offer their patients. 

When physicians’ basic needs aren’t met, we can’t expect them to meet the needs of their patients. How can one pour from an empty cup?  Kathleen Kendall Tackett offers Burnout, Compassion Fatigue, and Self Care for Members of the Perinatal Team which presents insights on the effects of little institutional support and specific strategies for integrating self-care into care for others. 

Self-care is sustainable only when everyone can do it. 

Before physicians are done with their decade or more of training, they are challenged by inadequate support in their efforts to feed their own children. 

“In a survey of 412 medical trainees with children, more than 80% of women reported feeling stressed about breastfeeding, and one-third did not meet their breastfeeding goal,” Gaelen Dwyer points out in Pumping up support: Making breastfeeding easier for med students

What’s more, a  recent research letter, American Board of Medical Specialties Board Examination Lactation Accommodation, evaluates the American Board of Medical Specialties (ABMS) member boards’ lactation-specific board examination accommodation policies highlighting that a minority of female physicians (42%) achieve the recommendation that infants receive mother’s milk at least until age one. 

Source: United States Breastfeeding Committee

“Board examinations are a key aspect of medical training,” the authors begin. “With up to 22% of female trainees delivering a child during postgraduate training, and nearly 59, 000 female physicians in residency and fellowship in the US, there is a large group potentially affected by board examination lactation accommodations.”

About a decade ago, ​​in a landmark case that has implications for all testing organizations in Massachusetts, a unanimous Massachusetts Supreme Judicial Court ruled that breastfeeding mothers are entitled to special accommodations to allow them sufficient time to pump milk during lengthy testing for medical licensure. [https://www.wbur.org/news/2012/04/13/breastfeeding-doctor-ruling ] 

The elephant in the room is the issue of parental leave. Honestly, it’s hard to stomach that we are still arguing that there are medical and psychosocial benefits of protected parental leave for both parents and children. The U.S. is the only Organisation for Economic Co-operation and Development (OECD) member country—and one of only six countries in the world—without a national paid parental leave policy. The U.S. is also one of the few high-income countries without a national family caregiving or medical leave policy. [https://bipartisanpolicy.org/explainer/paid-family-leave-across-oecd-countries/

Women don’t breastfeed; societies do. The societal burden on the mother is magnified when the mother is a physician and is compelled to take care of everyone else, with no support for their own breastfeeding. Breastfeeding is blamed for being difficult, instead of us all getting furious that we don’t have paid maternity leave.

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. In short, the more RVUs a physician racks up, the more they’re paid. Often that leaves lactating physicians forgoing pumping to spend more time with patients. The Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act would close the loopholes that force physicians to choose income or feeding their babies. The PUMP Act advanced out of the Senate HELP Committee with unanimous bipartisan support in May 2021 and then passed with significant bipartisan support (267-149) in the House last October. Despite this strong bipartisan support, the bill has languished in the Senate for almost a year. Get updates on progress here

In February 2021, the American Academy of Pediatrics (AAP) issued a policy statement on Parental Leave for Residents and Pediatric Training Programs.

Source: United States Breastfeeding Committee

The policy reports that the Institutional Requirements of the Accreditation Council for Graduate Medical Education require training programs to provide written policies regarding leaves of absence, including parental leave, and these policies must comply with current legislation such as the Family Medical Leave Act (FMLA), but that the length of leave has considerable variability among residency programs. The statement outlines the challenges of parental leave policies in training programs and gives recommendations to protect trainees and their families. One challenge is that education calendars are set long before a person enters a medical program, but labor, delivery, and the establishment of breastfeeding don’t fit into a predetermined calendar. 

Despite this dismal landscape, the medical world is changing and there are stories and models to celebrate. 

Catherine Wagner, a cardiothoracic surgery resident at Michigan Medicine, managed to breastfeed and pump for a year during her residency with a network of support. 

A committee at the University of Michigan is calling on pediatricians to support their fellow physicians.  Pediatricians Advocating Breastfeeding: Let’s Start with Supporting our Fellow Pediatricians First describes the efforts to support lactation within the department. The committee collected university policies, state and federal laws, identified the needs of breastfeeding mothers and then created a policy to support lactating individuals as well as a handout to help supervisors and colleagues support lactating women in the healthcare setting. (Supplemental material; available at www.jpeds.com).

Got Milk? Design and Implementation of a Lactation Support Program for Surgeons describes an initiative where “Multiple faculty members offered to offload resident workload before starting cases to provide time for a lactating resident to express milk… The University of Wisconsin adopted a ‘cross-cover’ model encouraging lactating residents to have other residents assist in the operating room during non-critical portions of the case if the primary operating resident needed to express milk that has been very well received and easily implemented.”

Source: United States Breastfeeding Committee

There’s attention being paid to lactation accommodation information in urology residency programs too. 

In this study, “Of 145 urology residency programs, 72.4% included information about lactation accommodations anywhere on the institution’s website.” The authors conclude that “efforts to recruit and retain female urologists should include making [lactation accommodation]  information more easily accessible.”

Authors Annery G Garcia-Marcinkiewicz and Sarah S Titler call on  anesthesiology as a workforce and specialty, to support the unique need of lactating and breastfeeding anesthesiologists in Lactation and Anesthesiology

This study offers the first comprehensive scoping review of the literature on breastfeeding policies pertaining to surgical residents in Canada.

The authors write: “…We aim to use these data to advocate for breast feeding for surgical resident physicians through the creation and improvement of current breastfeeding policies as applicable. This work aims to help change surgical culture to be more inclusive, which is vital in creating a breast feeding-friendly environment. This would include leadership endorsement of the policy, a culture shift (for example, no repercussions to resident for coming back on a modified schedule or taking breaks for expressing milk), visible educational notices throughout the workplace (ie, ‘breast feeding-friendly workplace’ notices, common in Canadian public settings), and creation of a network of ‘new moms’ within the surgical resident programme to ensure there is support and mentorship for new moms returning back to work. ”

While we wait for policies to catch up to the needs of lactating physicians, wearable pumps are helping them reach their infant feeding goals.  The Impact of Wearable Breast Pumps on Physicians’ Breastfeeding Experience and Success found that “those who had used a wearable pump reported statistically significant shorter lactation breaks (p < 0.00001) and were more likely to be able to provide breast milk to their infants for their entire intended duration (p = 0.005) compared to the traditional pump group.” 

The support network Dr. MILK (Mothers Interested in Lactation Knowledge) has been successful at helping physicians mothers reach their infant feeding goals. 

Where else are you seeing physician parents being supported in their infant feeding journeys? Email us at info@ourmilkyway.org

Empathy in architecture

A friend of mine works in a healthcare building; her office, windowless. Stark white walls frame the shiny tiled floors in the also windowless laboratory that surrounds her office. Rectangular fluorescent lighting looms eerily overhead. Working in this space for the majority of her waking hours amounts to constant longing for sunshine and an overall agitated demeanor. I imagine the architect of this space wasn’t much of an empath.

Photo by Robert Katzki on Unsplash

This effect is being documented in a growing body of research demonstrating how color, texture and patterns affect human emotions.

Generally, humans are quite robot-like, performing our daily duties without a great deal of attention paid to the building structures, layouts or designs that we move through. 

“When we don’t notice the built environment, it’s silently affirming our right to be there, our value to society. When we do, too often it is because it’s telling us we don’t belong. Those messages can be so subtle that we don’t recognize them for what they are,” Kim Tingley writes, later quoting architect Joel Sanders: “‘We sleepwalk our way through the world…Unless a building interior is strikingly different or lavish or unusual, we are unaware of it.’” 

The first time I saw a lactation pod at an airport– unusual at the time– I had mixed emotions. Part of me became excited that this was an option for traveling, lactating, pumping, and breastfeeding people, but most of me scoffed, annoyed, thinking something along the lines of: “Of course breastfeeding moms would be given this messaging to go hide themselves away from the public eye.” 

What Tingley wrote, that our built environment affirms our right to be in a space, affirms our value to society, is certainly a powerful concept. 

The COVID pandemic has forced us to think more about the built spaces we move through, adding layers to this idea of how and what and who we value.  

In a recent episode of Uniquely Milwaukee Salam Fatayer of 88Nine Radio Milwaukee poses the question: “What could our city, neighborhoods and community spaces look like if they were created based on people’s emotional, psychological and social needs?”

Photo by Coasted Media on Unsplash

Local architects and scholars answer with ideas about how they’re supporting the users of the spaces they create, with the goal of making sure people feel safe, at peace and nurtured by those built environments. 

On Our Milky Way, we’ve had the honor of highlighting the work of those thinking about how built spaces affect birth, lactation and beyond. 

For example, in conjunction with the Institute of Patient-Centered Design, Inc., The MomFriendly Network created The Lactation Design program which consists of research and outreach projects to enable the Institute to contribute design resources that  improve accommodations to support breastfeeding. Read more about this project here: https://www.ourmilkyway.org/physical-environment-influences-breastfeeding-outcomes/ 

Renée Flacking and her colleagues’ work, Closeness and separation in neonatal intensive care, explores how architecture influences outcomes in neonatal units. Single-family room designs are increasingly replacing traditional open-bay units for reasons documented in their paper.

Source: United States Breastfeeding Committee (USBC)

“This architectural structure provides the family with an opportunity to be with their child in the neonatal intensive care unit day and night providing facilities for parents’ basic needs including the need for privacy. This design has been suggested to be associated with a lower rate of hospital-acquired infections, similar to single patient rooms in adult intensive care (48), earlier full enteral nutrition, higher breastfeeding rates and a more soothing environment with, for example, lower ambient sound levels (49). As this design has been shown to reduce the length of stay in hospital significantly, for example, by 10 days in preterm infant below 30 weeks of gestation in a Swedish study (50), it shortens the time of separation for the infant from the home and family. Parents have reported that they felt that a single family room design in a NICU facilitated their presence with their infant (51), but the increase in parent–infant closeness gained by a single family room model during hospital care is not well documented in scientific literature.”

Read Our Milky Way’s coverage on this concept here

In stark contrast, attorney Leah Margulies recently shared in Protecting Breastfeeding in the United States: Time for Action on The Code that formula companies provide architectural designs to maternity care facilities in a deliberate attempt to separate dyads, making bonding and breastfeeding difficult and consequently,  families more likely to become reliant on their artificial products. It’s a sickening example of how the industry saturates our systems, down to the skeletons of our buildings.

Photo credit: Henrico County Public Library

Venturing beyond the very early postpartum period, it’s exciting to explore how community spaces are supporting young families. The Henrico County Public Library – Fairfield Area Library is accommodating families with their Computer Work + Play Stations which were conceptualized by library staff and materialized by architects at Quinn Evans and TMC Furniture staff. Read more about that inspiration and process here

Supporting lactation and breastfeeding in the workplace is a vital part of ensuring that lactating individuals feel valued. Setting up lactation spaces sometimes calls for innovation and creativity. You can explore our collection of stories about workplace accommodations in the stories below: 

CLC advances breastfeeding protection and support in the workplace

Workplace supports breastfeeding mother of triplets

Making Breastfeeding the Norm through The Breastfeeding Family-Friendly Community Designation (BFCD)

Alameda sergeant improves lactation space and support in county

Artist celebrates working mothers with ‘Liquid Gold’ project

Worksite program caters to nursing moms

Photo credit: Meredith W. Gonçalves

 

Pulling back the lens further, the architecture of communities themselves influences well-being too. One of the effects of redlining is poor health outcomes. Part of this equation involves the placement of industrial buildings and factories. Vann R. Newkirk II points out in Trump’s EPA Concludes Environmental Racism Is Real that The National Center for Environmental Assessment released a study indicating that BIPOC are much more likely to live near polluters and breathe polluted air. “Specifically, the study finds that people in poverty are exposed to more fine particulate matter than people living above poverty,” he writes.  

NICHQ hosts a webinar The Residual Impact of Historical Structural Inequities: Connecting Residential Segregation and Mortgage Discrimination to Current Infant Mortality and Breastfeeding Rates where maternal child health experts including speakers Jaye Clement, MPH, MPP, Brittney Francis, MPH, Kiddada Green, MAT, Arthur James, MD and Jessica Roach, LPN, BA, MPH share examples for supporting efforts to reduce infant mortality and improve maternal and infant health. 

Circling back to Tingley’s piece, the article raises the concern that although we’re equipped with knowledge about how under-resourced populations are being affected by current structures and practices,  “funding earmarked for expanding inclusivity [may] be diverted toward making existing facilities safer for those they already privilege.” 

Drawing on Sanders’ work, Tingley writes,  “Throughout history… the built environment has reflected and reinforced inequality by physically separating one group from another, often in the presumed interests of health or safety. Women-only bathrooms, so designated by men, supposedly preserved their innocence and chastity; white-only bathrooms separated their users from supposedly less ‘clean’ black people. It’s no coincidence that Covid-19 has disproportionately sickened and killed members of demographic groups — people who are black, Indigenous and Latino; who are homeless; who are immigrants — that have been targets of systemic segregation that increased their vulnerability. It’s also not hard to imagine the pandemic, and a person’s relative risk of infection, being used to justify new versions of these discriminatory practices.”

Art by Liz Richter, Photo by Leslie Rodriguez
Find more of Richter’s art here: https://www.lizrichterart.com/public-art

In this vein, Glenn Gamboa details where some funding gets funneled in a piece published this spring. 

“Twelve national environmental grant makers awarded $1.34 billion to organizations in the Gulf and Midwest regions in 2016 and 2017, according to a 2020 study by The New School’s Tishman Environment and Design Center. But only about 1% of it — roughly $18 million — was awarded to groups that are dedicated to environmental justice.” 

The climate crisis is an accelerating threat that is both affected by and affects architecture. 

“Architecture has to mediate between the perceived needs of the moment versus the unknowable needs of the future; between the immediate needs of our bodies and the desire to create something that will outlast generations,” Tingley goes on to write. 

Across the globe, architects push to be “mindful of their projects’ environmental impacts and resilience, including an emphasis on upcycling, the use of solar power, better building practices, and, of course, structural longevity,” Alyssa Giacobbe writes.  [More on ecological design here.] 

Alongside resilience and sustainability, there must be a focus on design that specifically serves mothers and their children. Mothers are too often left out, unseen, underserved despite there being about two billion of us worldwide, with an increasing likelihood of women becoming mothers

Photo by Dimitry Anikin on Unsplash

Lisa Wong Macabasco puts it this way: “Although the experience of human reproduction touches all of us at least once in our lives, its effects remain taboo, under-researched and excluded from exhibitions and publications covering architecture and design history and practice. In these spheres, maternity is treated furtively or as unimportant, even as it defines the everyday experiences of many – some 6 million Americans are pregnant at any given time.” 

It isn’t surprising that “design for children, design for healthy spaces, design for those with disabilities, care of and for their colleagues – these discussions and follow through are happening largely through female-led firms and initiatives,”  Julia Gamolina comments in The Unspoken Burden on Women in Architecture

In an exciting development, Wong Macabasco describes design historians Amber Winick and Michelle Millar Fisher’s Designing Motherhood, “a first-of-its-kind exploration of the arc of human reproduction through the lens of design. Their endeavor encompasses a book, a series of exhibitions and public programs in Philadelphia, and a design curriculum taught at the University of Pennsylvania.” 

This is exciting, and it’s progress. But as Wong Macabasco quotes Juliana Rowen Barton– architecture and design historian and curator who also helped organize Designing Motherhood– “Progress is not the fact that this show happened – progress is these conversations continuing to happen.” 

Designing Motherhood is on view at the Mutter Museum in Philadelphia through this month of May 2022.