Where are they now? Lessons from ruins with Carin Richter RN, MSN, APN-BC, IBCLC, CCBE

Photo by Aykut Eke on Unsplash

The peafowl is a bird known for attracting attention. Whether flaunting their colorful, unfurled plumage or delivering a resounding cry, peafowl are undoubtedly expressive, insistent creatures.

Occasionally, when Healthy Children Project’s Carin Richter, RN, MSN, APN-BC, IBCLC, CCBE hosts Lactation Counselor Training Course (LCTC) competencies from her Florida home, a curious peacock will poke its head into the frame of the video call demanding attention from her and the participants. 

“The big inquisitive bird insists on being part of the session on breastfeeding!” Richter exclaims.  

Since we featured her last, Richter has fully retired from her responsibilities at St. Anthony’s Medical Center in Rockford, Ill. and now helps facilitate the online LCTC once a week.

Our Milky Way caught up with Richter this winter as part of our Where are they now? series. 

Now 70 years old, Richter shares with a stirring of anger, worry and dismay in her tone: “Women’s health… We are in crisis mode. I’m personally struggling with any kind of optimism.”

She cites a few culprits: a political climate that tolerates division and disrespect, the marginalization of maternal child health issues, and the stripping of rights as marked by the reversal of Roe v. Wade. 

From these ruins, Richter has constructed several lessons. For one, she implores us to become politically involved. 

“Keep women’s issues right smack dab in the conversation,” she advises. “Look around. Search out areas where you can sit at that decision making table.” 

Political involvement, Richter suggests, can come in the form of participating on a shared governance board, community advisory boards, church councils, and rotary clubs. Engagement doesn’t need to look like shaking hands with the mayor. 

She continues, “My friends always say, ‘Oh Carin, you never have one conversation without the word breast coming through.’ We need to live that! Because if we don’t we’re going to lose what we have.”

Photo by Nicole Arango Lang on Unsplash

In other words, be a peafowl. Demand attention. 

Richter lays out what happens when we don’t. 

During her nursing career, Richter and her colleagues’ involvement with the Baby-Friendly Hospital Initiative (BFHI) eventually gave rise to seven hospitals in her area being designated by 2013. As of 2022, only one of those hospitals had retained their designation. 

“Because there was no one sitting at the decision making table speaking for the initiative,  administration lost sight of it and breastfeeding took a back seat or perhaps didn’t have a seat at all,” Richter reflects. “No one spoke of keeping breastfeeding issues in the forefront. It’s an experience that brings me to tears.”

Another insight she’s gained is the difficulty in beginning and sustaining a community-based lactation business. She watched friends with solid business plans, well-researched proposals, and passionate ambitions to help dyads get crushed by lack of insurance reimbursement, lack of mentorship and lack of collaboration.

“We need a lot of work on that front,” Richter comments. 

She suggests a reimagination of the way lactation services are viewed where insurances and companies recognize the importance of breastfeeding and elevate lactation support to a professional state. 

For instance, while working at the hospital, Richter brainstormed ways to give value to and justify the services of in-house lactation care providers. She found that postpartum breastfeeding support offered in-hospital  resulted in a marked increase in patient satisfaction scores. A creative solution suggested that  initial lactation and breast care be embedded in the room rate available for all patients, not billed as a separate line item, allowing for a higher reimbursement rate, Richter explains.  

Photo by Hannah Barata: https://www.pexels.com/photo/woman-having-skin-to-skin-contact-with-her-newborn-baby-19782322/

After retirement from the clinical setting, Richter cared for her aging parents. She says she felt the pinch many women of today experience as they juggle personal, familial and work responsibilities.

As she lived the struggle to find workable solutions for the care of her elder parents, she says she was surprised to find that barriers were similar to those she encountered while working for change in the community surrounding breastfeeding. For both, breastfeeding and elder care, resources are often limited, frequently expensive, and often inaccessible or unavailable.

Her focus now has broadened from maternal child health advocacy to the broader realm of family care issues. She finds herself
advocating for maternal child health and family care issues like pay equity and affordable child care.

“The struggle continues across the continuum, in arenas frequently dominated by women who bear the majority of responsibility,” Richter reflects. 

Despite a sometimes discouraging climate, Richter says she sees “little bright spots” here and there. 

“Not a week goes by that I don’t have a [medical professional] seeking lactation credentialing… I am thrilled with this,” she begins.  The practitioners seeking lactation credentials are not only specializing in women’s health; instead they’re an interdisciplinary group of folks, a sign that breastfeeding and lactation care is breaking free from siloed confines.  

“This is what keeps me excited,” Richter says. “More knowledgeable, eager voices speaking for mothers and babies.” 

Looking back, Richter remembers when it caused a fight to require lactation credentialing for OB nurses. 

“We got so much backlash not only from administration but from OB nurses themselves,”  Richter recounts. “Some OB nurses took no ownership of lactation. ‘That’s the lactation counselors’ job,’ they would claim.”

In this culture, Richter pointed out that trauma nurses are required to be trauma certified, oncology nurses  are required to be oncology certified; why were OB nurses not required to be certified in lactation when it’s such a large portion of their work?

“It was a bit of an eye opener,” Richter says. 

Retrieved from ALPP. Used with permission.

Now almost all hospital OB nurses need to be certified within the first one to two years of hire, and Richter says she’s encouraged by the ever-increasing number of OB nurses she speaks with weekly who are seeking breastfeeding certification and are supported by their department managers.

As for physicians certified in lactation, an already developed template existed. The state of Illinois had issued a Perinatal state wide initiative to mandate that all anesthesiologists caring  for pregnant patients were to be certified in Neonatal Resuscitation Program (NRP). All obstetricians soon followed. Richter says her wish would be that the template could extend to mandating lactation credentials to all professionals caring for pregnant and breastfeeding families.

Another bright spot Richter’s noticed are the larger, private sector industry and private employers in the Midwest offering adequate workplace lactation accommodations and services  that go beyond what is mandated by law. 

Moreover, Richter continues to be  impressed by the work that the United States Breastfeeding Committee (USBC) is doing, namely increasing momentum for workplace protections across the nation.

Though she adds, “The spirit is really strong, but the body is really weak. Getting the body to make the decisions and the policies is difficult.” 

Retrieved from ALPP. Used with permission.

Yet another area of encouragement is the inroad made into the recognition of perinatal mood disorders (PMD). Acknowledging that there is always room for improvement, Richter extols the improvements in detection, treatment and the lightened stigma around PMDs.  

Richter shares on a final note that while maternal child health issues have been largely well promoted and mostly supported in the last decade, she hopes to see more emphasis and energy put into the protection leg of the triad. That will require involvement in the work of policy change at the institution, community, state and national level. Policy development and change is the first stepping stone, she advises. 

“Do not be afraid of policies, because policies have power,” Richter states.  “Get involved and find your place at the decision making table.That’s your homework assignment for the year!” 



Brenda Hwang’s, MA, CCC-SLP, CLC, CDP light bulb moment: “My colostrum is in fact enough…”

[Photo by Andrea Piacquadio]
We consider ourselves life-long learners here at Healthy Children Project. Sometimes learning occurs gradually, and sometimes there are the ‘light bulb’ moments.

We put a call out to our followers to share “Aha!” moments with us. Maybe it was a myth busted during the Lactation Counselor Training Course (LCTC) or maybe it happened during a visit with a dyad.

We also called for stories about your babies’ and children’s ‘light bulb’ moments. When have you seen your little ones’ faces light up in discovery and understanding?

The call for stories is still open! Please send your reflections to info@ourmilkyway.org with “Light Bulb” in the subject line. 

This is Brenda L. Hwang’s, MA, CCC-SLP, CLC, CDP illuminating moment. 

******

Myth – You have to feed formula in the beginning until your milk “comes in.”

FACT – You do not have to feed formula if you do not want to and your colostrum IS ENOUGH. 

I had an incredible breastfeeding journey with my first born that lasted a little over two years. It was difficult for me to think about other moms not having a positive breastfeeding experience. 

That is when I decided to become a lactation counselor. During my training, I remember learning about helping mothers feel confident about their milk supply (when there are no medical reasons to be concerned about). I remember being fascinated with the Baby-Friendly Hospital Initiative and researching if there were any near me for when I deliver again or to recommend my patients to go to for the most pro-breastfeeding support. Unfortunately, there wasn’t one. 

When I gave birth to my second born, I remember feeling overwhelmed by so many emotions following childbirth. I remember trying to remind myself that this was typical as our hormones are off the charts after experiencing what the amazing body just went through to bring new life into the world. I felt like there were so many things that I had little or no control over, but what I did have control over was advocating for immediate skin-to-skin and the opportunity to breastfeed my daughter. That made me feel grounded and confident. 

However, that night came and my daughter wouldn’t stop crying. The nurse would come in and out of our room always looking angry, telling me that my supply was not enough, and that I needed to give my daughter formula for her to stop crying. I kept advocating for myself and reminded my husband that –

  1. Formula was not what we planned for or want, 
  2. I have colostrum and,
  3. My colostrum is in fact enough and the best thing that we can give to our daughter right now. 

Although I knew this was true, the sad little cries broke my heart and the nurse’s comments and facial expressions made me feel uneasy. 

Even with the breastfeeding education that I had, she eventually made me believe that perhaps I was wrong and what I had was not enough for my daughter. I dozed off crying quietly to myself, feeling like a failure as a mom. This was my Ah-Ha moment. I thought, “Wow, that was terrible and unfortunately too common of an event that mothers often experience in the hospital.” I would never wish for any mom to feel that way – to feel like she is not enough, or a failure as a mom.

I am now dedicated to providing breastfeeding education during pregnancy… to help moms feel prepared for the first few moments after baby is born. I strive to find a role in the hospital in order to advocate for parents who wish to breastfeed and to provide timely interventions so that they too can have a positive breastfeeding experience. 

Thank you for reading my story.



Human milk banks around the world

Of all the known approaches to saving infant lives, human milk has the greatest potential impact on child survival. (PATH) When direct breastfeeding or mother’s expressed milk is not available, donor human milk is the next best option.

Photo by Samer Daboul

As such, the 2018 WHO/UNICEF implementation guidance on the Baby-friendly Hospital Initiative stated that “Infants who cannot be fed their mother’s own milk, or who need to be supplemented, especially low-birthweight infants, including those with very low birth weight and other vulnerable infants, should be fed donor human milk.” The American Academy of Pediatrics, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition, and other national and global policy groups also call for use of donor human milk as the feeding of choice, if mother’s own milk is insufficient, unavailable or contraindicated. (WHO)

Now, WHO is in the process of developing guidelines on donor human milk banking.

The ISRHML Trainee Interest Group recently presented A Global View of Human Milk Banking with Kimberly Mansen (PATH), Dr. Victoria Nakibuuka (Nsambya Hospital), Debbie Stone (Rogers Hixon Ontario Human Milk Bank), and Dr. Maryanne Perrin (The University of North Carolina Greensboro) which brought to light several, wonderful resources and is the inspiration for  this week’s post.

Let’s take a look at some human milk banks around the world.

This tableau map depicts publicly known human milk banks. If you know of a milk bank that is not shown on the map, you can fill out this form and/or email kamundson@path.org or humanmilkbankmap@gmail.com.

Brazil 

Donor milk banking thrives in countries such as Brazil, where there has been a concerted effort at the Health Ministry level to incorporate milk banks into health policy. (Arnold, 2006)

 

Uganda

In commemoration of World Prematurity Day, Uganda introduced its first human milk bank at Nsambya Hospital on the 26th of November 2021 at Pope Square. [More here.]

 

Canada 

The Rogers Hixon Ontario Human Milk Bank in Ontario has dispensed over 1 million ounces of human milk. The Rogers Hixon Ontario Human Milk Bank is a non-profit organization and a joint initiative of Mount Sinai Hospital, The Hospital for Sick Children (SickKids) and Sunnybrook Health Sciences Centre. It is a member of the Human Milk Banking Association of North America.

 

Ukraine 

The first and currently only Ukrainian Human Milk Bank was established in Kiev at the Perinatal Centre where approximately 80 percent of all premature babies in the city are born.

 

South Africa

The South African Breastmilk Reserve (SABR) has set up a total of 44 in-hospital human milk banks in public and private hospitals across South Africa.

 

Vietnam

The first human milk bank in Vietnam was officially opened on February 17, 2017, at the Danang Hospital for Women and Children. This facility is supported by the Vietnam Ministry of Health and the Danang Provincial Department of Health, and is the first human milk bank in Vietnam to be operated within the public health system and to international standards. (PATH)

Take a virtual tour of the bank here.

Also consult:

Efforts to curtail dubious marketing practices of commercial milk formula industry

The commercial milk formula (CMF) industry uses marketing tactics similar to those of the tobacco, alcohol, and ultra-processed food industries.

Photo Credit: Boston Public Library
Date: ca. 1870–1900 https://ark.digitalcommonwealth.org/ark:/50959/3b591d51p Please visit Digital Commonwealth to view more images: https://www.digitalcommonwealth.org.

Earlier this winter, the Lancet published a three-paper series outlining the multifaceted and highly effective strategies used by commercial formula manufacturers to target parents, health-care professionals, and policy-makers.

“The industry’s dubious marketing practices—in breach of the breastfeeding Code—are compounded by lobbying of governments, often covertly via trade associations and front groups, against strengthening breastfeeding protection laws and challenging food standard regulations,” the Lancet summarizes.

Two new publications corroborate WHO findings on the digital marketing of commercial milk formulas in Mexico:

In another recent publication, Pediatricians’ Reports of Interaction with Infant Formula Companies, the authors found that: “Of 200 participants, the majority reported a formula company representative visit to their clinic (85.5%) and receiving free formula samples (90%). Representatives were more likely to visit areas with higher-income patients (median = $100K versus $60K, p < 0.001). They tended to visit and sponsor meals for pediatricians at private practices and in suburban areas. Most of the reported conferences attended (64%) were formula company-sponsored.”

The authors write that “Seventy percent of countries follow the World Health Organization International Code of Marketing Breast Milk Substitutes that prohibits infant formula companies (IFC) from providing free products to health care facilities, providing gifts to health care staff, or sponsoring meetings. The United States rejects this code, which may impact breastfeeding rates in certain areas.”

The Lancet series authors provide recommendations to restrict the marketing of CMF to protect the health and wellness of mothers and babies, and ultimately society and the planet.

  • Curtail the power and political activities of the CMF industry
  • End state practices that do not uphold, or that violate, the rights of women and children
  • Recognise, resource, and redistribute women’s care work burdens in support of breastfeeding
  •  Address structural deficiencies and commercial conflicts of interest in health systems
  •  Increase public finance and correct the misalignment between private and public interests
  • Mobilise and resource advocacy coalitions to generate political commitment for breastfeeding

In Mexico, UNICEF and Instituto Nacional de Salud Pública have designed infographics for policymakers as well as parents and caregivers to educate on the impact of digital marketing.

The partners are also working on proposed modifications to current Mexican regulations that involve commercial formula milk and ultra processed food marketing to infants and young children. Further, development is underway for a mobile app tool for monitoring the Code in Mexico.

Legislation in El Salvador was recently passed–“Love Converted into Food Law, for the Promotion, Protection, and Support of Breastfeeding.”

PAHO is monitoring the implementation of the Baby-friendly Hospital Initiative in the Americas BFHI requires full compliance with the Code and subsequent WHA resolutions.

In other efforts to protect parents and babies, Breastfeeding Advocacy Australia released a video on how the organization monitors predatory marketing. Find it here. You can find their Facebook group here.

Also read:

Follow IBFAN’s coverage of the 43rd Codex Nutrition Session of the Committee on Nutrition and Foods for Special Dietary Uses here.

Breastfeeding is part of a continuum. 

–This post is part of our 10-year anniversary series “Breastfeeding is…”

Breastfeeding is part of a continuum.

It has been hypothesized that starting around nine weeks of fetal development, the pattern and sequence of intrauterine movements of the fetus seem to be a survival mechanism, which is implemented by the newborn’s patterns of movement during the first hour after birth  (described as the 9 stages)  when skin-to-skin with the mother to facilitate breastfeeding.

Photo credit United States Breastfeeding Committee

This very behavior refutes the idea that breastfeeding is “an adjunct to birth” as it is generally viewed in maternity care settings in America.

Not only are human babies hardwired to progress through 9 stages and self attach to the breast, mammalian bodies are hardwired to produce milk too.

Around 16 weeks of pregnancy, the body starts to prepare for breastfeeding. This phase, called Lactogenesis I is when colostrum begins to be created. During Lactogenesis II, the secretion of copious milk follows the hormonal shift triggered by birth and the placenta delivery. After this phase, milk production must be maintained through a supply-and-demand-like system. [Neville 2001]

Even before a pregnancy is achieved, individuals are being influenced by the infant feeding culture that surrounds them, consciously or subconsciously laying a foundation for how they feel about feeding their own babies.

Pat Hoddinott’s, et al study found that women who had seen successful breastfeeding regularly and perceived this as a positive experience were more likely to initiate breastfeeding.

Exposure to prenatal breastfeeding education also affects breastfeeding outcomes. Irene M. Rosen and colleagues found that women who attended prenatal breastfeeding classes had significantly increased breastfeeding at 6 months when compared to controls.

Photo by Luiza Brain

Mode of birth and birth experiences influence infant feeding too, for both members of the dyad.

A growing body of evidence shows that birth by cesarean section is associated with early breastfeeding cessation.

Intrapartum exposure to the drugs fentanyl and synOT is associated with altered newborn infant behavior, including suckling, while in skin-to-skin contact with mother during the first hour after birth. [Brimdyr, et al 2019]

What’s more, the authors of Intrapartum Administration of Synthetic Oxytocin and Downstream Effects on Breastfeeding: Elucidating Physiologic Pathways found “No positive relationships between the administration of synthetic oxytocin and breastfeeding.” They comment, “Practices that could diminish the nearly ubiquitous practice of inducing and accelerating labor with the use of synthetic oxytocin should be considered when evaluating interventions that affect breastfeeding outcomes.”

Photo by Olivia Anne Snyder on Unsplash

In Transdisciplinary breastfeeding support: Creating program and policy synergy across the reproductive continuum, author Miriam Labbok takes a detailed look at “the power and potential of synergy between and among organizations and individuals supporting breastfeeding, the mother-child dyad, and reproductive health to increase sustainable breastfeeding support.”

Labbok points out that a paradigm shift on the issues in the reproductive continuum – family planning, pregnancy and birthing and breastfeeding– is needed.

“These are issues that are intimately, biologically, gender linked in women’s lives, and yet ones that are generally divided up to be addressed by a variety of different professional disciplines,” Labbok begins.  “Despite the impact of child spacing on birthing success, of birthing practices on breastfeeding success, and of breastfeeding on child spacing, we are offered family planning services by a gynecologist, birth attendance by an obstetrician or midwife, and baby care by a pediatrician. Having these ‘silos’ of care, each with its own paradigm and priorities, may lead to conflicting messages, and hence, may undermine the search for mutuality in goals, and collaboration.”

One such initiative looking to deconstruct siloed care is the Baby-Friendly Hospital Initiative which includes standards and goals for birthing practices, for breastfeeding-friendly communities, and guidance for birth spacing, in addition to reconfirming the original Ten Steps to Successful Breastfeeding, in recognition that breastfeeding occurs along a continuum.

Source: United States Breastfeeding Committee

1,000 Days emphasizes how breastfeeding fits within the global picture as a crucial part of a whole.

In the U.S. context, the 1,000 Days initiative recognizes comprehensive health coverage, comprehensive guidelines on nutrition during pregnancy, lactation, and early childhood for women in the first 1,000 days, paid family  and medical leave policy for all workers, and investments to ensure parents and caregivers can access good nutrition as solutions to a well nation and a well world.

 

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As part of our celebration, we are giving away an online learning module with contact hours each week. Here’s how to enter into the drawings:

Email info@ourmilkyway.org with your name and “OMW is 10” in the subject line.

This week, in the body of the email, please share with us some or all of your birth stor(ies).

Subsequent weeks will have a different prompt in the blog post.

We will conduct a new drawing each week over the 10-week period.  Please email separately each week to be entered in the drawing. You may only win once. If your name is drawn, we will email a link with access to the learning module. The winner of the final week will score a grand finale swag bag.