BOMB Doulas address disparities in care among BIPOC birthing people

When I first learned about the Birth Outcomes Made Better (BOMB) Doula Project, it was right around National Public Health Week and I thought, “Hooray! This could be a wonderful feature to celebrate public health!” 

I didn’t get in touch with the individuals heading up the Doula Project soon enough and Public Health Week came and went, but Black Maternal Health Week approached so I thought “Hooray! This will be a wonderful feature to celebrate Black Maternal Health!” 

Then that week came and went before I connected with the program managers.

Nicole Miles, MA, CD, CLC

While it’s sometimes nice to synchronize projects with events and holidays, it finally dawned on me that  this work is always relevant.  

Once we touched base, City of Milwaukee Health Department Maternal and Child Health Division Director Erica Olivier, BA, MS and City of Milwaukee Health Department BOMB Doula Program Manager Nicole Miles, MA, CD, CLC accommodated me for nearly an hour sharing what led them to maternal health, the details of their program and the challenges they’re working through.

Inspiration for this work 

Miles was 11 when her little sister was born, and she was involved in many of the aspects of her mother’s perinatal care. Having a natural inclination toward this work, Miles decided that she wanted to become an obstetrician. After being exposed to other care models during her undergraduate studies though, she pursued doula work and is currently a student midwife.  

Olivier spent much of her career working in social and human services. In this work she says the focus was typically reactionary.

“I’ve spent a long time seeing the worst case scenarios,” Olivier begins referring to substance abuse, infant and maternal death, etc. “How can we do a better job of preventing this from happening? There is something really important about pregnancy and birthing and going all the way into reproductive planning.”  

In her current position, Olivier is impassioned to mobilize preventative interventions. Having teamed up with Miles– who Olivier praises for having tenacity, passion, and insight (which was clearly evident in our interview)– they are excited to transform doula work from a grassroots operation, and something that has come to be seen as a “luxury reserved for wealthier white women”,  to a service that is simply normal, expected and accessible for all.  

BOMB Doulas  

To our knowledge, the BOMB Doula Program is one of the only city- and county- funded birth support initiatives.

The pilot program was approved in 2019, but the COVID-19 pandemic derailed some of their momentum, Olivier reports.  

“We took a pretty big hit,” she says. “But we made the best out of the circumstances.”  

Currently, the health department employs four doulas who serve the entire City of Milwaukee. In addition, the program is in the process of hiring doulas for community-based positions. These community-based doulas will serve 50 families in the 53206 zip code, an area with the highest infant and maternal mortality rates in the county. For scale, Wisconsin has the nation’s highest infant mortality gap between white and black babies, according to data compiled by the CDC 

There is a wealth of research showing the infant and maternal health benefits of having a doula present at any point in the perinatal period.  

When a client is enrolled into the BOMB Doula Program, they can expect access to wrap-around care services, thorough screenings like the Adverse Childhood Experiences (ACES), sensitive, respectful care, and weekly interactions with their doula up to 12 weeks postpartum. 

Miles notes that BOMB doulas have a unique setup working for the health department because they have access to resources that a private doula might not otherwise have, like Miles’s direct access to communication with other health care providers. 

What’s more, for generations, Black Indigenous People of Color (BIPOC) have been forced into silence and complacency which often affects the health care they receive. 

“A doula is going to put eyes on things that are happening,” Miles says, acknowledging the systemic racism embedded in health care and how that plays out into care provider/patient interactions. 

Doulas speak up for their clients, help guide patient questions, and sometimes even facilitate change of care when necessary. 

Olivier adds that doulas empower and advocate, creating safe spaces for patients to challenge the status quo. 

This isn’t to say that Olivier is encouraging confrontation; rather, doulas facilitate patient-driven care building the capacity for birthing people to become self-determined and aware of their rights to comprehensive, culturally-competent care. 

The BOMB Doulas also complete breastfeeding-specific continuing education and attend a monthly study group led by an IBCLC.  

The group currently celebrates a 100 percent breastfeeding initiation rate! 

Work to do 

There’s still so much room for racial equity improvement within all of the systems we find ourselves interacting.  

“That’s not a means of slander by any means,” Olivier clarifies. Instead, Olivier sees herself and the BOMB Doula Program situated to help care providers enhance their practices and shift their lenses. 

“Let me help you help them,” has become Olivier’s motto. 

The Foundation for Black Women’s Wellness recently published their work “Listening to Black Women” in the Wisconsin Medical Journal.   

Their report illuminates that “The present state of Black maternal and child health in Wisconsin is one of the most significant and urgent public health challenges we face. Turning the tide rests on our willingness to center, listen to, and position Black women and their communities as leaders and cocreators of the urgent changes we need.” 

Olivier comments that there is an unwritten power dynamic that a lot of providers don’t want to acknowledge. 

“It’s sad that we are at a state of accountability,” she says. 

Miles adds, “I should be in disbelief, but I’m not in disbelief,” when commenting on the way that BIPOC are too often dismissed and mistreated in their health care.  

She uses the example of procedures like epidurals being employed without the explanation of risks to the patient. 

 In her role, Miles has the capacity to document these recurring issues and provide feedback to the systems that need to be held accountable for best practice. 

Olivier notes that from a legislative standpoint, there is some movement around the awareness of doulas and support of healthy perinatal practices. She cites parts of the Black Maternal Health Momnibus Act of 2021 for instance. 

“We will see what this looks like and where this goes,” she comments. “It will take a lot of education, tough conversations and acknowledgement of a need for change to address the disparities in care to BIPOC birthing people; moreover invested stakeholders and change agents.”

Olivier continues, “We don’t want to lose the fidelity of what a doula is. [We need to] mobilize but also stay true to the work.”

“We are happy to see some progress, but we know there is a lot of work to be done still,” she concludes with cautious optimism.

Assessing the environmental impact of powdered baby formula sold in North America

Photo by Markus Spiske on Unsplash

My new favorite pastime is listening to this podcast about the climate crisis. Among the many things I appreciate about the show are the calls to action offered at the end of each episode. The hosts put together a digestible list of resources and doable actions that individuals can employ toward the broader goal of saving our planet, which in my case, otherwise feels like an insurmountable task.

Although not directly answering to the podcast’s calls to action, (this publication has been years in the making) authors of Powdered Baby Formula Sold in North America: Assessing the Environmental Impact are pushing forward systemic changes to our energy and food sectors by measuring the environmental impact of infant and toddler formulas sold in North America. 

“One of the things I’ve recognized for a long time is that we measure what we value,” co-author Dr. Cadwell begins. “When we were doing this project, we were trying to look at things in different directions, look at it with different lenses and different ways of imaging the numbers.”

Numbers through various lenses 

Photo by Aaron Katz on Unsplash

When analyzing data for their research, the authors computed that seventeen million tree seedlings grown for ten years would need to be planted in order to offset the greenhouse gas (GHG) emissions produced by powdered infant formula production and consumption in the United States each year. That’s equivalent to 778 acres of US forests. If, like me, you’re not mathematically inclined, these numbers are unfathomable. 

Through another lens, one might note that the U.S. government purchases 51 percent of all infant formula sold in the country, or one might look at the percentage of babies who receive formula in our country. 

More specifically, Dr. Cadwell points out findings from Powdered Baby Formula Sold in North America: Assessing the Environmental Impact. As noted in the Per Capita Analysis of Carbon Emissions (Table 5), Canada, Mexico and the U.S. share relatively close figures. Interestingly though, Canada’s total comes in higher than the North American total. 

“We can look at the sale in tons or look at the sale per capita and it’s going to give us a totally different idea of the usage,” Dr. Cadwell offers. 

No matter the perspective, the authors’ findings should be considered when developing and funding Infant and Young Child Feeding (IYCF) policies and supportive programs in order to contribute to The Intergovernmental Panel on Climate Change (IPCC) goal of decreasing GHG emissions by around 45 percent by 2030 and reach net zero in 2050.  

As Dr. Ayana Elizabeth Johnson points out in How to Save a Planet,  “Policy matters. You have to change the rules to keep up with the ecosystem.”

Dr. Cadwell and colleagues write that “Biofuels, solar, and wind energy are obvious choices for reduction of the 75% of emissions from the energy sector (including transportation), but making reductions in the remaining 25%, the food sector, is more of a challenge.” 

They continue that one solution is to change our diets to increase low-carbon food alternatives, like breastmilk feeding and breastfeeding for infants and young children. 

Mixed consumption 

Considered their foundational work, Dr. Cadwell and colleagues looked to BPNI’s 2012 report of the carbon footprint of formula milk in Asian Pacific countries as they embarked on their research.

The team quickly realized that infant formula ingredients are regionally and country specific, and because farming and agricultural practices differ, they pulled industry data from Euromonitor International which included the retail sales amount and the percent composition of the major ingredients for each of the classes of powdered formula sold at retail in North America. Then they used emissions data from US farming practices.

It is worth noting that their findings represent minimums as they represent only the macro processes to the farm gate and do not include the manufacturing, packaging, transportation, etc. 

Researchers found that in 2016, the North America Greenhouse Gas emissions (in tons of CO2 eq.) attributable to sales of powdered formula was:

  • 70,256 in Canada 
  • 435,820 in Mexico 
  • and 655,956 in the United States. 

The North American per capita emissions based on infants and toddlers from birth to 36 months of age in 2016 was, at a minimum, 59.06 kg of CO2 eq., the authors note. 

For comparison, the BPNI report revealed that in India, the total sale of milk formula led to 111,226 tons about a decade ago whereas China produced 2,249,287 tons around that same time.

Dr. Cadwell shares that she was struck by the consumption piece revealed in their work. 

“In Mexico, it’s mostly the growing up formulas that are being consumed,” she begins. “What the numbers seem to indicate is that Mexican babies are getting breastmilk for the initial feeding and then being weaned on to the growing up formulas.”

In the U.S. and Canada, this isn’t the case. These countries’ greatest impact is attributed to powdered infant formula. 

Dr. Cadwell notes that “special powder” touts a much lower GHG emission compared to the growing up concoctions. That’s because special powders are largely soy-based formulas whereas the growing up formulas are generally dairy-based. This comparison demonstrates the difference between plant-based and animal-based consumption on the climate. 

“The problem is that babies should be on a human-based diet,” Dr. Cadwell comments.

She says the first thing we can do is recognize that unless there are very special circumstances, babies do not need to be weaned from infant formula or breastmilk onto growing up formulas.

“There’s new research about the incredible amount of sugars in these formulas,” Dr. Cadwell explains. “Growing up formulas are not good for the health of children or for the environment.”

Consumerism is powerful though, to paraphrase Dr. Cadwell. It’s the power of what happens to us when we’re walking down the supermarket aisles. 

“If it’s there, I must need it,” goes our inner dialogue. 

1,000 solutions 

“Respect your Mother” Photo by Mika Baumeister on Unsplash

While it’s true that we all must take responsibility for the climate crisis, the burden cannot fall entirely on individuals. Instead of being fooled by a deceptive marketing campaign, “the carbon footprint sham”, systems must evolve. 

“[Our hope] is that policy makers will see [our work] and include breastfeeding in the wider idea of decreasing emissions,” Dr. Cadwell says. “We’re talking about mechanisms, our U.S. burden…” 

I like to think that once humans have healthy infant feeding figured out, where supportive policies are implemented and breastfeeding is as normal as breathing , that everything else falls into place: a state of kumbaya, a healthy planet, world peace. 

But restorative ocean farmer Bren Smith has warned that this “Wall Street perspective” where we look for the unicorn, is what we’re doing wrong. 

Smith has said, “Let’s bundle 1,000 solutions together… and move forward that way.”   

Mathematician leads healthy infant feeding efforts in Michigan

Behind Michigan’s growing breastfeeding-friendly culture is the Michigan Breastfeeding Network (MIBFN), a state-wide collaborative spurring action for education, advocacy, and coalition support. And behind MIBFN is Operations Manager Gi’Anna Cheairs, a mathematician with a glowing passion for maternal health advocacy and healthy infant feeding, “the wizard behind the curtain,” as she puts it.

Cheairs recently completed  the Lactation Counselor Training Course (LCTC) because she says she did not want to be limited to being the person behind the curtain. 

“Doing the facts and figures, funding and budgeting, those things are all vitally important, but I wanted to be able to offer a service to the communities we are advocating for; I wanted to have that knowledge base,” Cheairs says. “It was just an amazing experience and a great training.”

Like so many maternal child health advocates, Cheairs’ inspiration to help others stems from her personal infant feeding story. Her intention to breastfeed her daughter for six months to a year was deflated by an uninformed pediatric care provider, ultimately cutting short their breastfeeding journey. 

“It really had an effect on me, my mental health and my confidence,” Cheairs explains. “I felt like I was failing my daughter.”  

Connected to MIBFN through a women’s leadership group several years later, Cheairs’ landed a part-time gig with the organization which quickly expanded to include all operations. It’s here where she channels her drive and fire to help others overcome the barriers to breastfeeding that have affected her so deeply. 

Cheairs shares that she is proud to be a part of MIBFN because the organization allows her to be her authentic self. She reports that her work culture is supportive of her expression, making space for her feelings without being labeled “the Angry Black Woman”. Cheairs notes that this is an important celebration for BIPOC. 

Working with MIBFN brings back all of the feelings Cheairs sifted through when her breastfeeding efforts were diminished, she says; now she’s determined to dismantle the disinformation for other families. 

And as a mathematician, advocacy comes naturally. 

“Being a person who has an affinity for math, I’m automatically inclined to be an analyst by nature,” she says. “I think and overthink all of the time…My mind is always going to look at the way systems are set up in this country. I can’t help but say, ‘This isn’t logical.  This is wrong,’” Cheairs says of the oppressive, racist institutional systems in our country. “The activism comes in when you do something about it.” 

In her role at MIBFN, Cheairs ensures that the mechanisms within and around MIBFN function smoothly and move forward. 

MIBFN’s network model brings together coalitions and other organizations across the state that may not have otherwise been bridged. MIBFN partners provide vital health services to community members and MIBFN  secures the funding so the organizations can operationalize. 

One of the important effects of these relationships is setting up continuity of care within communities. 

“It opens the door for individuals to know about these organizations that they might not otherwise have known about,” Cheairs explains. 

She goes on to explain that medical providers don’t often refer out for lactation and breastfeeding concerns. 

“They would refer to a cardiologist if you’re having a heart issue, but they won’t refer out for a breastfeeding problem.” 

MIBFN fills in these gaps, especially in disenfranchised communities, providing funding for things like specialists, home visits and consults to make sure that care providers can expand their reach. 

When the COVID-19 pandemic hit, Cheairs reports that MIBFN did a good job of pivoting. She says that MIBFN staff was allowed space to adapt to new environments and new challenges. They’ve  been working with funders in some situations to shift their approach too. In many cases, this means organizations changing over to virtual consultations and support groups and porch drop offs for supplies. 

MIBFN now provides video conferencing platforms for their partners in order to keep their connections strong. 

Recently, MIBFN hosted a  virtual community conversation that brought in families as subject matter experts. Cheairs says it was an amazing experience for MIBFN staff and families alike and created a space for Black, Indigenous, Families of Color to have their experiences heard and validated. 

“It was very, very powerful,” she says. 

Cheairs notes that Governor Gretchen Whitmer recently declared the week of April 11 to 17 Black Maternal Health Week, placing state-wide value and priority on women’s health issues like breastfeeding and birth support. The week is intended “to deepen the national conversation about Black maternal health in the United States; amplify community-driven policy, research, and care solutions; elevate the voices of Black mothers, women, families, and stakeholders; provide a national platform for efforts to address maternal health, birth, and reproductive justice; and enhance community efforts toward addressing Black maternal health.” 

For those interested in supporting MIBFN and its mission, Cheairs encourages us to sign up for their e-newsletter which keeps individuals up-to-date on the latest webinars offered, fundraisers and other events.

OTs can help new parents adopt new habits, skills and routines

When we think about Occupational Therapy (OT) for the nursing dyad, we often hear about the pediatric aspects of this care and benefits to the baby. Amanda Mack, OT, OTD, MS, OTR is an Instructor and Fieldwork Faculty in the Department of Occupational Therapy at MGH Institute of Health Professions in Boston, Mass. who specializes in adult OT and focuses on maternal aspects of feeding.

Mack became interested in maternal child health after the birth of her first daughter and the  breastfeeding struggles she surmounted. While attending a local breastfeeding support group, she realized that OT and therapists’ skill sets could be extremely valuable to new parents. 

For instance, she heard mothers describe wrist pain and difficulty positioning their babies to nurse. She heard concerns about how to comfortably breastfeed while out to eat and others about how to manage pumping schedules. There were questions about mental health, self-care, infant care, and more. 

“All of these things, OT helps address,” Mack says. “We are professional problem solvers.” 

Mack goes on to describe OT as “a bit of an enigma.”

“Occupational therapy is a profession that helps people across the lifespan to do the things they want and need to do,” she clarifies. “We focus on helping people participate in their meaningful daily activities, which we call occupations. Breastfeeding and infant feeding, as well as parenting, are very meaningful occupations.”  

Mack explains that much of parenting is learning new habits, skills and routines and  learning how to cope with the loss of previously established habits and routines. 

OTs have training in physiology, mental health, child development, sensory processing, and even feeding which all converge in order to best support new parents.

“We can look at the different aspects involved in infant feeding: the ergonomics, the baby and their development, the mom’s needs, the demands on the mom’s time and body, and many, many other aspects,” Mack explains.  “By considering all these different things, we can help deliver holistic care to new moms.” 

She uses the example of assessing both mom and baby’s positioning for a comfortable latch at the breast, whereas oftentimes care providers zoom in to just a small piece of the puzzle and examine the baby’s mouth at the breast. 

“Another great example is a return to work,” Mack continues. “I’m looking at helping the mom figure out a routine that works; teaching her how to manage the pump and supplies; even educating on her rights and teaching her how to advocate for the breaks and time she needs.” 

She adds, “But the place where occupational therapy really shines is when there is another variable making these already difficult things even more difficult. Especially people who may have physical or mental disabilities or illness, we can really use our expertise to help people participate in this very meaningful ‘occupation’ despite the barriers they may be facing.”

Before a mother gives birth, there may be implications for breastfeeding outcomes when and if OT is integrated into prenatal care, but Mack says that this is an emerging area of practice and there’s a need for more research. 

 She points out that there is some work in Brazil with OTs being part of the prenatal team, an OT at NYU doing work with new and expecting mothers, and some therapists in Australia looking at this topic. But while there are therapists doing the work, there isn’t high-quality research on the outcomes yet, she reports. 

Mack adds that she and her colleagues hope to collaborate with local OB-GYNs, midwives, and other care team members to be able to provide these services and collect more data on this in the coming years.

In her primary role as a faculty member at MGH Institute of Health Professions, Mack teaches entry-level occupational therapy doctoral students. Here, she is heavily involved in the IMPACT practice center— an education center where healthcare students provide free care to the community.

Their new parent and infant feeding support group launched in January, which runs every week on Thursday afternoons. They also collaborate with nursing colleagues to provide 1:1 support to expecting and new moms in order to supplement their existing medical care. 

Macks says there has been great interest from her students and it helps to broaden their learning experiences. 

“Wow, there’s a lot I don’t know yet,” Mack recalls some of her students’ remarks.

She also reports that it helps students see the need for this kind of care; it has drummed up a lot of student advocacy for equitable maternal child care. 

“It’s encouraging because they’ll all be practitioners one day,” Mack says. 

In the future, Mack and her colleagues hope to complete research on the efficacy of their services and the impacts of other conditions like tongue ties.

What’s more, the team is committed to making sure that underserved communities and Communities of Color have equal access to their services. 

“Along with my doctoral students, we have hopes to expand our offerings to include peer support and alternative meeting formats to help expand our reach,” Mack says.

In this light, OTs are overwhelmingly white and female. Mack reports that MGH is committed to inclusion and diversity and is working toward diversifying the field. 

Most recently, Mack completed the Lactation Counselor Training Course (LCTC) in order to gain a more comprehensive understanding of breastfeeding and how to counsel parents. 

“I’ve really enjoyed learning more about what we know about breastfeeding from the literature,” Mack shares. “Much of what I’ve learned about breastfeeding previously is the ‘how’ – but learning the ‘why’ behind it has been really exciting and eye-opening for me! I’ve definitely learned more tricks and tips to bring into my practice.” 

She encourages all lactation care providers to connect with OTs in their area or someone they can connect their clients with via telehealth. 

“Breastfeeding support takes a village, and OT brings a unique view and lens to supporting new parents.”

Anyone interested in learning more may reach out directly to Mack at amack@mghihp.edu.

Doctoral student researches lived experiences of Black women after pregnancies complicated by gestational diabetes, breastfeeding, and later risk of Type 2 Diabetes

 Marked by a devastating entry into parenthood, Indiana State University doctoral student Teirra Riggs has turned tragedy into triumph,  manifesting a pay-it-forward attitude.

Riggs’ first pregnancy resulted in an unexplained stillbirth of her daughter at 20 weeks gestation. Days after the birth, Riggs remembers breastmilk leaking onto her computer while doing her doctoral work. 

“I didn’t have any education about what to do next,” Riggs says. “…Coming home with breasts full of milk and no baby, it was a very tumultuous time for me.” 

Even so, through the mental health upset and distress,  she remained committed to her doctoral program. 

Two years later, Riggs became pregnant again. At six weeks pregnant, she learned through an employer health program screening that her blood sugar level was dangerously high, resulting in a diagnosis of gestational diabetes.  

Riggs gave birth to her son at 37 weeks. Although her baby was born full term, over the next six months he would be diagnosed with failure to thrive– a set of words that became quite triggering for Riggs. 

“I knew I wanted to breastfeed,” she begins. “But I didn’t know what that would look like as a diabetic.” 

With the goal of increasing her baby’s weight, Riggs worked tirelessly with lactation care providers, all the while, the words “failure to thrive” playing over and over in her mind. She and her son went on to nurse for nine months. 

In many ways, Riggs felt the void of lactation and breastfeeding support as a Black woman, but she had some cheerleaders along the way. She and her dissertation committee chair Dr. Darleesa Doss were expecting their first babies at the same time and Riggs says she found comfort in that peer support.

“She was an immense support for me,” Riggs says. 

The department’s secretary, Ms. Susan Crist, would sometimes look after Riggs’ sleeping baby while she taught class. And when space wasn’t available for Riggs to pump, they made space for her in the women’s volleyball locker room. 

“Academia can be male-centered and male-led, so it was nice to have that nurturing support,” Riggs says. “It was an immeasurable experience.” 

The personal experiences of birthing and parenting as a diabetic quickly became inspiration and a vested interest in her professional life. 

Riggs currently serves as the Diabetes Prevention Coordinator at the Indiana State Department of Health. In this role, she works with employers encouraging them to adopt the CDC’s National Diabetes Prevention Network (DPP) Platform — a yearlong lifestyle training course for those at risk for diabetes. The platform is now offered on a virtual platform called Inspire Health. 

“Research has shown through this implementation, it works to get people off of their medication when they are aware of healthier lifestyles,” Riggs begins. “Prevention works. Promotion works.”  

Over the next nine months, Riggs’ doctoral research will look more specifically at the lived experiences of Black women after pregnancies complicated by gestational diabetes, breastfeeding, and later risk of Type 2 Diabetes. Although Black women are not most at risk for gestational diabetes, they have a 56 percent higher rate of developing Type 2 Diabetes five to seven years after delivery, Riggs explains. 

She says she hopes to explore and understand what happens during this time period: What are  Black women’s perception of risk of developing diabetes after a complicated pregnancy? What does access to care look like for Black women who receive this diagnosis? What are the psychological impacts on Black women during this time? 

Riggs also hopes to shed light on the importance of breastfeeding’s potential to mitigate the challenges of maternal diabetes and affect babies’ health outcomes

Most recently, Riggs completed the Lactation Counselor Training Course (LCTC) after learning about the course through the Indiana Black Breastfeeding Coalition

“[The class] was a great fit for my research endeavors,” Riggs explains. “[The LCTC] will help me pay it forward after working with the lactation care providers that embraced me.” 

She adds, “Even if you are diagnosed with a condition, breastfeeding is still possible when you have the right support system around. I want to change the narrative showing that Black women breastfeed.” 

 

In the future, Riggs hopes to present her experiences and findings through a TED Talk.