It’s Pride Month! Working to close the gaps in LGBTQ+ Care

Breastfeeding Family Friendly Communities of Durham (Breastfeed Durham) is a health equity advocacy group that formed in November 2018. 

Amber Crews, chair of LGBTQ+ Human Milk Feeding with Breastfeeding Family Friendly Communities of Durham (BFFC), started as a  “backseat” member of the team in the organization’s infancy while she parented her one-year-old. 

“From the beginning, I provided a voice as a lactating member of the LGBTQ+ community,” she explains. 

Then, a few months after the COVID-19 pandemic was recognized, Crews became chair of the equity committee.

“… I channeled some of my pent-up energy by chairing an official equity committee dedicated to representing the LGBTQ+ lens regarding human milk feeding,” she says.  

Crews explains that the committee’s early accomplishments included compiling resources in a user-friendly format so that LGBTQ+ folx and those supporting them could have a centralized platform to reach inclusive information and established/vetted providers who are affirming, LGBTQ+ friendly, and knowledgeable.

So far, the resource list includes the Directory of Local Support , National Lactation Support Resources for LGBTQ+ Families, and National Lactation Support Resources for Medical Providers  and they continue to welcome and research additions. 

“It was really cool to get some national inquiries/re-posting our resource lists shortly after publishing them on our website,” Crews highlights. “Even with all the advances in equity work right now, when it comes to a centralized resource list for chestfeeding/human milk that is truly inclusive to all the varied LGBTQ+ families out there, pickings are slim. The fact that our very small team of volunteers put together something that caught people’s attention in the wider-internet world is saying something. There is a need, and we have only begun to address it.”

In addition to Breastfeed Durham’s lactation support for LGBTQ+ families and medical providers, the organization created 10 steps that detail what it is to be a Breastfeeding Family Friendly community complete with a proclamation by the mayor supporting human milk feeding. Without diminishing these successes, there remains room for growth and improvement in regard to supporting LGBTQ families.  

For instance, Crews explains that “there is still so much work to be done in educating providers working with LGBTQ+ families, educating family members and other support people, and getting all the information that’s out there to individuals about the benefits of chest feeding, the possibilities for situations like induced lactating, all the different ways to give our babies human milk and how important it is.” 

In an effort to fill support voids, Crews held several months worth of virtual Milky Pride & Play gatherings and hopes to continue the meetups once more families feel safe convening in-person again.   

Breastfeed Durham held a  community-wide “Gaps in LGBTQ+ Care” meeting this month which started to explore just that– gaps in care for LGBTQ+ families.

“Among other things, having a more centralized place for LGBTQ+ families to meet and socialize seemed a priority,” Crews reports.

Crews completed her La Leche League Leader certification last year making her the only lesbian leader in her community. 

“I’m hoping with time and word of mouth, more and more lactating folx will learn that there are options for support that they can trust. . . and that Milky Pride & Play can become a peer-to-peer support group that more know about and attend,” she shares. 

Crews continues, “I’m excited to see this work grow and help more babies get more human milk!” 

The Institute of Family & Community Impact hosts event to boost paternal mental health

Photo by Humphrey Muleba on Unsplash

Several years ago, the American Psychological Association released a poignant video called Boys Don’t Cry  which briefly explores the negative impact of stereotypical expectations of masculinity.  

“There are so many things that shape each person’s idea of masculinity, from social norms to cultural influences,” as NICHQ Senior Project Director Kenn Harris explains in Promoting Fathers’ Mental Health During Children’s Early Childhood.

These forces have the potential to impact fathers’ mental health, and research shows that one in 10 fathers get Paternal Postpartum Depression (PPPD) and up to 16 percent of fathers suffer from an anxiety disorder during the perinatal period. 

Paternal mental health impacts their partners and their children and as NICHQ President and CEO Scott D. Berns, MD, MPH, FAAP points out, fathers can be powerful allies for maternal child health

In an effort to address paternal mental health, Healthy Children Project faculty Eira Yates in partnership with OhioGuidestone developed the Yates Paternal Depression Screening Tool for male fathers, a first of its kind measurement which we reported on last summer

 

Photo by Picsea on Unsplash

Father’s Feelings research activity, which uses the depression screening tool, was suspended due to the COVID-19 pandemic. 

Yates reports that thanks to a recent grant, the team will be able to expand its pilot program. 

Brittany Pope, M.S., Director of Applied Clinical Sciences and Research at OhioGuidestone shares that The Institute of Family & Community Impact has been able to move forward with some other exciting events too. 

Namely, DaddYoga, a free virtual yoga class for fathers and their children led by Judge William Dawson, a yoga instructor, motivational speaker, and municipal court judge in East Cleveland.

Photo by Devon Divine on Unsplash

Beyond the yoga instruction, Judge Dawson will offer insight and encouragement to fathers about healthy living and other life goals. 

Participants will also have the opportunity to interact with people from the world of professional sports. For instance, on June 13, Major League Baseball agent Josh Yates will join DaddYoga to discuss his experiences as a single father while navigating the high-powered world of professional sports.

The event provides fathers an opportunity to destress while engaging with their children which  aligns with UNICEF’s suggestions on how to build babies’ and children’s mental health. 

Information for the DaddYoga event can be found here.

Considering evolving language in perinatal care and beyond

In the 90s, Diane Wiessinger, MS, IBCLC wrote Watch Your Language, an iconic piece that got us thinking about how we talk about infant feeding simultaneously, warning us of the dangers of “inverting reality” as it relates to breastfeeding and artificial feeding methods. 

Wiessinger writes, “When we (and the artificial milk manufacturers) say that breastfeeding is the best possible way to feed babies because it provides their ideal food…the logical response is, ‘So what?’ Our own experience tells us that optimal is not necessary. Normal is fine, and implied in this language is the absolute normalcy–and thus safety and adequacy–of artificial feeding. The truth is, breastfeeding is nothing more than normal. Artificial feeding, which is neither the same nor superior, is therefore deficient, incomplete, and inferior. Those are difficult words, but they have an appropriate place in our vocabulary.”

Photo by Hanna Balan on Unsplash

“Health comparisons use a biological, not cultural, norm, whether the deviation is harmful or helpful…” she continues. “…We cannot expect to create a breastfeeding culture if we do not insist on a breastfeeding model of health in both our language and our literature.”

At present, infant feeding behavior has changed so greatly that the authors of The Meaning of “Breastfeeding” Is Changing and So Must Our Language About It  write “the term ‘breastfeeding’ is now so ambiguous that it is impossible to discuss contemporary breast milk feeding behaviors using this word.” 

To illustrate the diversity of infant feeding experiences, some of the ways infants and young children may receive milk include:

  • from their biological parent directly at the breast
  • human donor milk from a bottle or cup 
  • at the breast with a supplemental nursing system (SNS)
  • exclusively pumped milk via syringe 
  • wet nursing 
  • at the chest using an SNS with a combination of human donor milk and artificial milk 
  • feeding with purchased human milk 

Infant feeding is not black or white, nor one or the other. 

Given the multitude of ways that infants may be fed, the authors The Meaning of “Breastfeeding” Is Changing and So Must Our Language About It make several proposals for preferred language in order to develop clear communication around the feeding of breast milk to infants. 

They note:  “These terms are not intended to convey a value judgment about any of the behaviors described, but rather to provide an improved means of describing the wide variety of behaviors now encompassed by the word ‘breastfeeding.’” 

Language comes up often on Our Milky Way. We first explored it here, then went on to write about it here, featured transliteracy here and thought about language some more here and  here

This week, we’re adding to the ongoing discussion about terms that may be obsolete, using language to be more inclusive and evolving language to more accurately and positively describe certain behaviors and phenomena during the perinatal period and beyond. 

 

On-demand feeding or responsive feeding 

Photo by Nubelson Fernandes on Unsplash

Up first is the problematic term on-demand feeding

Caring for young humans is surely a massive responsibility, but to deem them demanding seems unfair and connotes negativity between the child and their caregiver.  

Instead, UNICEF suggests the term responsive feeding  which encourages relationship building through feeding responsively (regardless of feeding method) and recognition that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and caregiver. 

 

Sleep regression or sleep progression 

Many care providers have argued that the term sleep regression discredits what is actually happening: our babies’ brains are growing rapidly. 

Oasis Lactation Services posted, noting that #languagematters: “Sleep regression? It’s a sign of development and brain growth! Sleep shift is a better way to describe it. Your baby is gaining skills, not regressing.”

 

At risk or underserved 

The way that we communicate about barriers, inequities and populations that have inadequate access to health care services matters. Advocates warn us to use caution when speaking about barriers to breastfeeding and other behaviors. For instance, the increased mortality rates experienced by Black Indigenous People of Color (BIPOC) are not biologically-based; instead the systems of power and the oppressors create the risk. 

 

Foremilk and hindmilk or simply milk  

The foremilk/ hindmilk myth comes up often in lactation professional networks. 

Nancy Mohrbacher writes that “There are not “‘two kinds of milk.’ … Despite this common belief, there is no ‘magic moment’ when foremilk becomes hindmilk. As the baby breastfeeds, the increase in fat content is gradual, with the milk becoming fattier and fattier over time as the breast drains more fully.”

In fact, the concept is even more complicated than this. While more fat is transferred when milk flows well, due to circadian rhythms, foremilk from one feeding may be higher in fat than hindmilk from another feeding, as Healthy Children Project’s Cindy Turner-Maffei details.  

Mohrbacher and others point out that research indicates there is no reason to worry about foremilk and hindmilk or to coax a baby to feed longer. 

 

Breastfeeding and chestfeeding and  human milk feeding and bodyfeeding and

Photo by Sergiu Vălenaș on Unsplash

Serena Kalish, PA-C, CLC got interested in the various terms used for feeding babies during her Lactation Counselor Training Course (LCTC). It was the first time she had heard the term chestfeeding and it got her wondering how many other care providers are unaware of the term chestfeeding as well as when and where the term is being utilized. 

Kalish created a poll on a social media page curious to learn what terms lactation care providers are using and prefer. The majority of the respondents replied with breastfeeding, followed by nursing, followed by breastfeeding & chestfeeding. Respondents added feeding, lactation/lactating parent/lactation journey, bodyfeeding and chestfeeding (as a standalone from breastfeeding) to the options.

The results of the poll didn’t necessarily surprise her, she reports, but she says she found the added options interesting. 

Photo by Nathan Dumlao on Unsplash

Kalish shares that for a medically-minded person like herself, the term nursing sounds archaic.  She wonders if by using the term nursing that we are perhaps adding to the stigma of breastfeeding by not using a term that specifically identifies anatomy. 

Many respondents noted that inclusivity matters to them in their practice, so the terminology that they use is determined by whatever their clients prefer. 

This sentiment reflects ABM’s Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients which states that “Although the terms introduced previously may be unfamiliar to some providers, recognizing and affirming patients’ names, pronouns, and family members are a cornerstone of providing affirming care for patients who identify as LGBTQ+…  Affirming health care, including using affirming names and pronouns, and recognizing individual patients’ families and communities, can help to mitigate the effects of stigma and improve health.” 

 

FTM or FTM 

Kalish goes on to present an interesting anecdote. As a participant in many “mommy groups” on social media, she became familiar with FTM to stand for “first time mom”. At one point, she noticed that some individuals were confused by a post that mentioned FTM because in LGBTQ circles, FTM stands for “female to male”. 

“It was an interesting perspective to learn that there are other contexts where certain terms and phrases and abbreviations are used,” Kalish comments. “It helps you realize that you have to be more sensitive sometimes and learn other terminology.” 

 

Language of inclusion and compassion  

Language comes in many forms. Hand Waves Birth Services’ Childbirth Educators and Full Spectrum Doulas Ally Balsley (she/her) and Brittany Noschese (she/her) touched base with us about non-verbal language and how to better serve individuals who are deaf or hard of hearing in a blog post from earlier this year.  

La Leche League International recently released a statement that announces the organization’s plan to increase audio and visual resources to better support those with vision or hearing impairment as well as those living in communities where we have not yet identified translators.

The statement also refers to their Cultural Sensitivity in Publications Policy, a trend that has been adopted by many companies and organizations as the national conversation about race amplifies.

Photo by Solen Feyissa on Unsplash

Finally, while many of us may have grown up on the playground chanting that bit about sticks and stones– stick and stones may break my bones, but words will never hurt me— it’s time we reckon with that falsehood. The words we chose when addressing birthing people and the conversations we have with them are impactful and can influence a lifetime. 

The Practising Midwife Journal posted for Birth Trauma Awareness Week: “…What we say and how we say it – can make a woman’s birth experience either transforming or harrowing. We have that potential impact.”

CLC launches non-profit resource center

While much of the world came to a screeching halt when the COVID-19 pandemic was recognized, Danielle Villanueva, CLC took it as an opportunity to propel her work helping families.

Villanueva pictured with her daughter.

Villanueva completed the Lactation Counselor Training Course (LCTC) in February 2020 just before our lives started to change. 

Formerly a WIC peer counselor, she pursued the course in order to open a private practice and start her 501(c)(3) Latch & Love Lactation Support and Resource Center in Henderson, Texas. 

“There was so much unknown, it made me want to do it even more knowing the help was going to be needed even more,” she says of launching her non-profit during the pandemic. 

Latch & Love Lactation Support and Resource Center officially opened in January 2021 after taking the summer prior to fundraise. 

Latch & Love offers lactation services, home visits, classes, support groups, and a donation center for families in need in a town with no other local lactation and breastfeeding support beyond WIC services. 

“Whether it’s a single mom or dad, struggling family, foster or kinship placement, grandparents, etc., they are welcome here and we do whatever we can to help,” Villanueva explains.  

Villanueva’s daughter celebrates Latch & Love. 

Villanueva delved into this work after becoming unexpectedly pregnant at 18 with her daughter Esmè. Determined to breastfeed, she and her daughter were off to a solid start in the hospital.

“The second I got home, things started to go downhill,” Villanueva reports. 

The closest lactation care was 40 minutes away– back at the hospital she delivered in. 

“So there I was a young mom, postpartum still recovering from stitches and as you can imagine quite emotionally and physically exhausted,” Villanueva remembers. 

She second-guessed making the trek with her baby for help, but ultimately made the trip.

“My visit with [the lactation care provider] changed everything and after that I just knew that this was my true calling,” she says. 

Villanueva says Latch & Love is getting the conversation about healthy infant feeding started in her community.

“It’s really opened up a lot of people’s minds about [breastfeeding] and helped them to realize its importance,” she shares. 

Virtually, she hosts “Talk it Out Tuesday” on Facebook and offers a support group that generally meets during the lunch hour, so that working parents can pop in on their break. 

The local hospital now gives out Latch & Love’s information with their discharge information. 

Villaneuva sees about one to two moms per week through her private practice, although she reports helping others via phone and messaging very frequently. Latch & Love Donation Center serves roughly two to four families each week.

 

“I couldn’t imagine myself doing anything else and I can’t wait to further my education in this field…” Villanueva adds. “Latch & Love is making a big difference in our community and I would love for everyone to hear about it.” 

Celebrating the 40th Anniversary of the Code

The International Code of Marketing of Breast-milk Substitutes, now 40 years old, is as relevant as ever. 

Otherwise known as the Code, it was adopted by the 34th World Health Assembly (WHA) on May 21, 1981 in an effort to contribute to safe and adequate nutrition for infants by protecting breastfeeding and ensuring the proper use of breast-milk substitutes by restricting promotions that target the public, parents and health workers.

Formula milk companies– an industry worth 60 billion dollars and growing by about 10 percent annually– have done an incredibly successful job of positioning themselves as a trusted source for families, shaping infant feeding culture globally. They’ve achieved relationship-based marketing through digital avenues, shifted their target toward older children over the years, and used the COVID-19 pandemic to promote their brand undermining maternal child health. 

The baby food industry continues to use many of the promotional tactics they did in the 1970s but have become more sophisticated in pushing baby milk formulas through online social clubs, targeted ads, and hosting contests to be formula “influencers”.

This month, the United States Breastfeeding Committee (USBC) hosted its first webinar in its Unpacking Commercial Milk Formula Marketing: Communities, Contexts, and Impacts webinar series presented by World Health Organization (WHO) technical officer Laurence Grummer-Strawn, PhD and Senior Advisor Access to Nutrition Initiative (ATNI) Rachel Crossley, MSc.  

At the beginning of the webinar, USBC Deputy Director Amelia Psymthe Seger reviews what has led USBC to create the shared learning journey around the Code. In 2019, USBC conducted a survey of the knowledge of the Code among member organizations, which demonstrated “a fractured understanding of the Code”.  In 2020, member organizations expressed interest in active engagement around the Code, leading to an incubation conversation, testing the will and capacity of the interested organizations to take action on the Code. That conversation led to the creation of this 3-part webinar series as a platform for mutual learning to determine future actions.

Responding to ‘old tricks, new opportunities’ 

The marketing of formula milks impact mothers’ infant feeding decisions on a personal level, but Grummer-Strawn reviews how marketing tactics have impacted society in general, embedding corporate influence on many levels.

(Image credit: Alive & Thrive)

Formula milk companies have infiltrated the networks mothers find themselves in controlling the advice that they receive from friends and relatives. Companies have influenced health care providers’ messaging by sponsoring scientific meetings. What’s more, they’ve molded a culture that claims infant feeding to be a personal choice making it easy for employers and legislators to ignore investing in policies that affect healthy maternal child health outcomes. 

Since the adoption of the Code, Grummer-Strawn lists subsequent clarifications that have addressed loopholes, unclear resolutions and the ever-changing contexts families find themselves in like modifications to how to monitor the Code in emergency situations, conflicts of interest, recommendations for the duration of exclusive breastfeeding, labels, follow-up formulas, health care provisions and cross promotion. 

Grummer-Strawn goes on to highlight some of the most recent work around the Code:

  • research that looks at mothers’ experiences with formula milk marketing in eight countries
  • Review of how the industry uses digital marketing  
  • Understanding breastfeeding within the context of human rights as well as the right of the industry through free speech 
  • Consideration of standardized formula milk packaging 
  • Analysis of how countries are implementing the Code 

Over the next 18 months, we can anticipate another Lancet series on maternal child nutrition and a global summit on the commercial determinants of child health. 

Highlighting positive outcomes  

Since its inception and moving forward, the Code calls on many actors to implement the code; from manufacturers and distributors to national governments, to UN agencies, NGOs and professional groups to health care workers, media and creative industries.

(Image credit: UNICEF)

Crossley’s work at ATNI around private sector accountability on nutrition has documented equally crushing and hopeful reports. For instance, ATNI’s 2018 US Access to Nutrition Index found that “overall America’s ten largest food and beverage manufacturers lack comprehensive strategies, policies and action to effectively address the nation’s high levels of obesity and diet-related diseases.”  

However, she reports that one major formula milk company has made a “substantial, unilateral, voluntary commitment through the call to action process” to extend its policy by the end of 2022 in alignment with the Code. 

“It’s really quite a big step forward,” Crossley says in the webinar. 

Some of ATNI’s newest work includes its Responsible Lobbying Framework which assesses how companies’ lobbying aligns with the Code.

One country’s journey with the Code

In Sweden, Kristin Svensson of Karolinska Institutet and Elisabeth Kylberg of the University of Skövde have witnessed the effects of the Code over several decades.

(Image credit: UNICEF)

In the 1970s while breastfeeding rates in Sweden were on the rise, the National Board of Health and Welfare initiated breastfeeding promotion throughout the country by establishing an expert group and publishing a book to help train professionals working with families from pregnancy and beyond. In 1973, The Breastfeeding Mothers Association (Amningshjälpen) was formed. 

“It was a positive climate to promote breastfeeding,” Svensson and Kylberg share in an email interview with Our Milky Way

In this climate, applying the Code in 1983 was “one step further in an ongoing process to protect breastfeeding.”  

At this time, Kylberg and Svensson remember formula milk advertisements disappearing from pediatric health centers. 

“It was an incredibly positive change,” they write.  

It wasn’t until 2013 that Sweden adopted the Code into law (SFS 2013:1054) following the EU-directive. 

(Image credit: UNICEF)

Kylberg and Svensson point out that there are limitations in the law. The baby food industry is permitted to advertise formulas in papers for professionals and bottles and teats have been omitted from the law. But they report that the Code is still used as an important tool to report violations. 

Because there is no national monitoring in place though, whistleblowing falls on non-governmental and professional organizations as well as individuals working in the health sector, they explain. 

Promisingly, an initiative in the region of Skåne upholds the Code and urges all staff working in primary health care to follow it.

At the national level, a collaborative of different national agencies is working to find a solution on how to organize a holistic approach on breastfeeding and to revitalize the BFHI which now includes the Code, the duo shares. 

They add that the Code is now even more important in light of the COVID-19 pandemic.  

“We think that to monitor the Code is [continuous work] and to push the national agencies to do what they should do,” Svensson and Kylberg share. “That is the best honor of the Code.”

[This figure depicts the prevalence of exclusive breastfeeding in Sweden from 1964 until 2016. Note: no breastfeeding data collection occurred between 1975 and 1985. The upper line depicts breastfeeding at 2 months of age, middle at 4 months and the lower at 6 months.]

Onward 

Advancing the mission of the Code is an uphill battle, as Grummer-Strawn puts it.  

He details the many ways we can contribute to the cause.

(Image credit: UNICEF)

First, he encourages education. There are plenty of online opportunities offered including a health professinals’ guide from UNICEF, IBFAN’s resource page, as well as USBC’s upcoming webinars as part of their series Unpacking Commercial Milk Formula Marketing: Communities, Contexts, and Impacts. Up next is “Commercial Milk Formula Marketing: Communities and Emergencies” on Wednesday, June 2 from 2 to 3:30 p.m. ET. 

Documenting and publicizing the problem is paramount. 

“If we aren’t making noise so people understand what the problem is, it’s going to be very hard to get any action on it,” Grummer-Strawn explains during the webinar. 

For this piece, there are tools like the NetCode Toolkit and IBFAN’s Code Monitoring Toolkit.  

Crossley suggests writing directly to the entities at fault. You can report compliance concerns to one major company here. While some companies have a direct page to report complaints, you may be surprised to find the trail others lead you down. For example, in the U.S. one company takes you from here to here to here, making the whistleblowing process much more convoluted and distracting. 

(Image credit: UNICEF)

USBC webinar presenters emphasized the importance of lifting up the good actors, celebrating and amplifying the companies that are doing good things rather than solely focusing on companies’ wrongdoings. 

Honoring the Code, especially in the U.S., has to be a long term strategy, Grummer-Strawn says. Executing an incremental approach ultimately adds up to the goal of full Code implementation. 

In this light, Grummer-Strawn touches on U.S.-specific circumstances to consider: 

  • We have a shared understanding of the harms of tobacco and can restrict tobacco companies’ speech, but we don’t have that same understanding with formula milk.
  • Modifying procurement standards within organizations like WIC may improve the way infant formula is distributed in the U.S. For example, would it be feasible to use Code compliance as a factor used to determine how states, territories, and tribal organizations choose formula vendors for WIC contracts?
  • Addressing conflicts of interest between healthcare providers and pharmaceutical companies is a huge movement in healthcare; conflicts of interest with formula companies are in this same vein and voluntary action against this conflict should be taken. 
  • Educating and engaging retailers may be instrumental in changing the industry. 
  • Pressure from consumers and investors drives competition among companies to work ethically. 

Our nation’s health and global health are so deeply intertwined with the saturation of baby food industry’s influence. Without vilifying the use of baby milk formulas, companies must be held accountable for their exploitation of maternal child health outcomes.  The Global Breastfeeding Collective and its partners call on all governments and their actors to protect mothers and babies from commercial exploitation by enacting and enforcing strong national legislation. Put #BabiesBeforeProfits.

(Image credit: Alive & Thrive)

The 40th Anniversary of the #BMSCode is a powerful reminder of what happens when the world comes together to protect the youngest lives. This #NutritionYearOfAction, Governments can once again pledge to safeguard children’s lives by #ProtectingBreastfeeding + putting #BabiesBeforeBusiness. 

A recording of the Global Breastfeeding Collective’s celebration of the Code is available here in several languages. 

Additional resources and links from Global Breastfeeding Collective 

Event Landing page

The BMS Code resources from the Global Breastfeeding Collective

Capitalizing on fears, companies promote breastmilk substitutes during the pandemic | Alive & ThriveCode FAQs 

Marketing of breast milk substitutes: national implementation of the international code, status report 2020

https://www.llli.org/quick-guide-international-code-2/