Maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine Alison Stuebe, MD, MSc recently wrote Breastfeeding and depression: It’s Complicated,  a fascinating post on the Academy of Breastfeeding Medicine’s blog. Her work is of such value because she recognizes that overstating the “benefits” of breastfeeding sometimes negates the reality of the experience for mother infant dyads.

Particularly intriguing is the story Stuebe tells of a mother who admits experiencing more concern about her milk production and her relationship with the pump than mothering her crying infant.

“When we emphasize breastmilk, we have completely misunderstood the biology of infant feeding,” Dr. Jack Newman replies in the post’s comment thread.

Stuebe fills me in on a theory that explains this woman’s (and other’s) obsession with milk production. Dr. Barbara L. Frederickson, Kenan Distinguished Professor of Psychology and Principal Investigator of the Positive Emotions and Psychophysiology Lab at the University of North Carolina, argues that obsessive passion comes from negative reinforcement.

“When we talk too much about the evil agents in formula, we risk creating obsessive passion,” Stuebe explains.

She describes obsessive passion this way: A fervid runner injures her ankle. Although continuing to run on that injury will decrease her chances of healing, she continues to do so. Her passion triumphs in an obsessive fashion and she ultimately risks destroying her ability to run all together.

On the contrary, a runner who exhibits harmonious passion will nurture her injury so not to risk the chance of never being able to run again.

Stuebe relates this analogy to the breastfeeding mother. If the risks of formula feeding are so ingrained in her mind, she may be motivated to neglect her child’s needs just as long as she never allows that baby to consume “rat poison”, or formula as Stuebe half-jokingly puts it.

Too often, breastfeeding advocates (including myself) become so hung up on the evils of formula that we leave mothers who do not successfully breastfeed in the dust with no other way to connect with their babies; hence the baby left to cry while mother squeezes out her last drop of milk.

Stuebe’s current research on breastfeeding and depression questions conventional thoughts about infant feeding and its relationship to the way mothers and infants connect.

If you look at a population of several hundred three-month-olds, you will find that more of the depressed mothers bottle feed, Stuebe explains.

However when longitudinal studies are considered, it’s hard to argue, “If she would just breastfeed, she wouldn’t be depressed,” Stuebe continues.

The study’s current results about oxytocin and depression are provoking.

“It could be that mothers who have lower oxytocin levels have trouble with breastfeeding and also feel more anxious and depressed,” Stuebe reflects in Breastfeeding and depression: It’s complicated. “Or it could be that, for mothers whose baseline oxytocin is lower, breastfeeding gives them a boost that’s essential for them to feel connected to their babies.”

She concludes, “The nuances of the biology suggest that doctors absolutely need to think about the effect of breastfeeding on a woman’s mood symptoms.”

Tackling a fragmented health care system

In fact, all health professionals caring for the mother infant dyad need to practice with this suggestion in mind.

Because of the nature of fragmented care in our nation, lactation professionals are often the only caregiver assessing the mother and baby as a couple.

“We’re that glue and we need to be watching really carefully,” Stuebe says.

She gives us simple advice and reminds us that the Edinburgh Postnatal Depression Scale or EPDS is a very easy test to administer to measure postpartum depression. It takes about five minutes and is translated into many languages.

Although there is sometimes a harmful disconnect between mother and baby providers, Stuebe says that there are breastfeeding medicine practices that serve to bridge the gap springing up around the country.

For instance, MilkWorks located in Lincoln, Neb. offers support from a variety of lacatation professionals including a medical doctor, lactation counselors and consultants, nurses, breastfeeding educators and dieticians.

In Chapel Hill, N.C., women have access to the Women’s Birth and Wellness Center which also offers lactation care within the community.

For the mother suffering from PPD, these centers offer an alternative to medication that might ultimately require her to stop breastfeeding.

While many communities are developing support centers for mother infant dyads, there is still a lot of scatter within our system. Stuebe says it would be ideal if these services were offered at YMCAs for instance, or if family physicians were able to provide a kind of “one-stop shopping” experience.

Stuebe says that pushing health care to be more woman-centered in general is a huge step in the right direction. To accomplish this, we need innovative ideas, new models, and new approaches.

Considering all of the science

“Those of us involved in breastfeeding advocacy need to be thoughtful about how we talk about the science,” Stuebe explains.

Getting people excited about breastfeeding research is a start, but it only goes so far. For the non-believers, the breastfeeding skeptics, getting a roomful of people fired up about breastfeeding makes them think, “This is a cult,” Stuebe half-heartedly chuckles.

(She makes clear that she is part of the cult, so she says that with love.)

It’s important for breastfeeding advocates to remain open about the research that doesn’t confirm what we already believe. Similarly, we should consider the studies that completely turn what we once believed upside down.

Stuebe explains that it’s too easy to dismiss new research on the grounds that someone involved in the process received money from a formula company. Instead, we should look at the findings critically.

Stuebe’s breastfeeding wisdom doesn’t end here.

Saving nipples two ears at a time

She suggests we remain receptive with clients as well.

“Communication starts with listening,” she says.

Lori B. Feldman-Winter, MD, MPH, Head of the Adolescent Medicine Division at Cooper University Hospital and National Faculty Chair of the Best Fed Beginnings project once offered Stuebe this analogy to consider: A doctor asks a pregnant woman if she plans to breastfeed. The woman replies that she’s apprehensive because she’s uncertain she wants to have her nipples pierced. The doctor explains that the holes for breastfeeding are already in place. “Well in that case, of course I’ll breastfeed,” the woman responds.

Feldman-Winter suggests always starting conversation with a parent by asking what he or she has heard about breastfeeding. Listening saves nipples!

Creating conversation in the workplace

Conversation is crucial among lactation professionals’ colleagues as well. Fittingly, Stuebe tells me about a book called Crucial Conversations: Tools for Talking When Stakes are High which discusses how to establish mutual purpose and mutual respect.

Establishing collaborative relationships within the workplace can be especially valuable in the hierarchical field of medicine.

Perhaps a misinformed doctor gives a patient incorrect breastfeeding advice. Stuebe suggests lactation professionals respectfully question the physician’s information privately. She advises resisting the urge to shout, “You stupid fool!”

“Feeling stupid in front of the patient doesn’t feel particularly good,” she explains.

When physicians are the least knowledgeable about breastfeeding, it can either motivate them to learn, or it can turn them off completely; they may decide that breastfeeding isn’t their problem, Stuebe tells me.

She adds that unfortunately there is no culture in place that dictates offering proper breastfeeding support is the physician’s responsibility.

Considering the breastfeeding OB/GYN

As a mother of three boys, Stuebe is able to speak not only to the physician’s experience but also to that of the breastfeeding OB/GYN.

The training process is generally unfriendly to nursing mothers, she tells me. Demanding schedules often don’t allow time for pumping. And when there is time, co-residents sometimes see a mother’s need to pump as an excuse to dump her work on someone else.

Sadly, when nursing OB/GYNS aren’t supported in their breastfeeding journeys, their guilt and anger can sublimates into their general perception of breastfeeding. The same might happen if an OB/GYN’s partner had a difficult time nursing.

Fortunately, Stuebe reports being blessed with a supply that withstood extended spans between pumping.

She started her internship the first day her son turned three months old and recalls “walking down Brookline Avenue to Brigham and Women’s Hospital with a Pump-in-Style slung on [her] back and a vague determination to breastfeed.” [Retrieved from: https://bfmed.wordpress.com/2012/11/16/building-a-breastfeeding-culture/]

Her decision to breastfeed was hardly influenced by medical school as breastfeeding was “not really in the mix at all.” Most of her initial breastfeeding education as a mother was self-sought; reading So That’s What They’re For and observing her sisters’ breastfeeding adventures. Stuebe says that breastfeeding eventually defined her as a mother.

“Breastfeeding became the one thing they couldn’t take from me,” she says of her time interning. “They could take my soul, sanity and sleep, but they would not keep me from nursing my baby.”

In Building a breastfeeding culture, Stuebe further explains what motivated her to nurse her children.

Sharing her stories

Perhaps it is Stuebe’s willingness to share her personal experience that makes her contributions to the field of lactation so extraordinary. She is so human, so humble yet so outstanding.

Take her Twitter description for example: High risk obstetrician, aspiring midwife, Breastfeeding researcher and advocate, mom of three. Aspiring midwife catches my eye.

“I love low risk birth,” she explains. “I believe in physiology, but I think that even in the sickest patients I’ve taken care of, I try to remember that this is still a life event for them.”

She recalls a mother with severe cardiac arrhythmia who birthed her baby in “low lights and lovely ambiance” with the cardiac intensive care unit outside the door. Her baby went skin to skin immediately after birth and latched within the first four minutes! Stuebe remembers the image of the baby’s small hand resting on its mother’s defibrillator pad.

Stuebe has worked closely with the Massachusetts Breastfeeding Coalition, helping with web design and a variety of educational initiatives. She’s currently involved with the Carolina Global Breastfeeding Institute at UNC where she serves as an institute-associated faculty member.

In her pre-medical life, Stuebe worked as a journalist which she says has significantly influenced her ability to communicate with the public and her patients.

To read more about Stuebe’s work, visit the Breastfeeding Medicine blog here and her compilation of articles at the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM) here.