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

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

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

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

Source: United States Breastfeeding Committee

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

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

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

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

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

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

Source: United States Breastfeeding Committee

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

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

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

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

In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans. In short, the more RVUs a physician racks up, the more they’re paid. Often that leaves lactating physicians forgoing pumping to spend more time with patients. The Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act would close the loopholes that force physicians to choose income or feeding their babies. The PUMP Act advanced out of the Senate HELP Committee with unanimous bipartisan support in May 2021 and then passed with significant bipartisan support (267-149) in the House last October. Despite this strong bipartisan support, the bill has languished in the Senate for almost a year. Get updates on progress here

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

Source: United States Breastfeeding Committee

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

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

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

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

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

Source: United States Breastfeeding Committee

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

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

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

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

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

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

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

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

Lactation counselor invents one-of-a-kind, hand expression education device

For as long as there have been humans, there has been human milk. As it happens, according to Greek mythology our entire galaxy originates from breastmilk. 

Although people have been breastfeeding for millennia, breastfeeding doesn’t necessarily come naturally, especially in our modern world where common birth practice, industry influence and cultural phenomena are at play. 

Adhering to a mentality where breastfeeding is viewed as completely natural, is one of the most “harmful and hurtful” beliefs because it assumes that lactating people don’t need support, Founder/CEO of Orolait Ana Rojas Bastidas, CLC explains. 

“The majority of women are not able to fulfill their [infant feeding] goals, and that’s unbelievably sad,” Rojas Bastidas says. 

“That’s where innovation comes in,” she continues. 

Rojas Bastidas’s company Orolait, is a breastfeeding apparel company at its core, but this summer she released a one-of-a-kind lactation education tool: the LactoPRO Trainer

The LactoPRO is an anatomically-correct, tissue-mimicking human breast used for demonstrating hand expression. The device features a realistically-sized areola, nipple, and six lactiferous ducts and effectively ejects a human milk-like or colostrum-like substance. The breast is available in various skin shades too. 

In April 2020, Rojas Bastidas shifted Orolait operations to help provide Personal Protective Equipment (PPEs) to a hospital in Haiti alongside a Houston-based company that creates surgical organs.  With Rojas Bastidas’s vision and entrepreneurship and the company’s patented technology, the LactoPRO Trainer came to fruition. 

Rojas Bastidas and the team are working to create a model with inverted nipples as well as fashioning a breast that can develop clogs and mastitis. 

Rojas Bastidas emphasizes that she is always working to make her contributions more affordable and accessible.

“Having great things that are not accessible to the community are not helpful to anyone,” she says. 

Through her movement PowerToPrevail and other projects,  Rojas Bastidas has been a force for body positivity, cultivating self worth and supporting modern motherhood. This work led her to complete the Lactation Counselor Training Course (LCTC) earlier this year. 

“As I was going through the course and tried to teach hand expression, I became frustrated by the lack of options to demonstrate it accurately and in a constructive way,” she reports. 

Evidence-based lactation care emphasizes a hands-off approach. Couple this with the idea that infant feeding is a learned behavior and in American culture we don’t grow up seeing lactating breasts and breastfeeding, hand expression is a terribly abstract practice to teach. 

The LactoPRO helps fill this void. 

“Innovation in the lactation space has been slow and overlooked, so this is really exciting for me,” Rojas Bastidas says. “I’ve created something for the private sector that’s going to push public perception.” 

She likens her invention to the evolution of professional lactation care services; maternal child health advocates took a stand and refused to let women suffer, she explains. Like lactation care, Rojas Bastidas has created something that validates people’s stories and experiences. 

Rojas Bastidas’s influence stems from her experience as a new mom and the way she viewed her evolving body. 

“I didn’t realize that the way I viewed my body was impacting so much of my life including my breastfeeding journey,” she says. 

So many parents sympathize with the conundrum of breastfeeding in public spaces for instance. To do so discreetly often means lifting your shirt and exposing the midsection.

It seems vain and trivial, Rojas Bastidas acknowledges but when you multiply it by the millions of moms who experience challenges like this, there’s got to be a solution.

“Don’t be afraid to tackle whatever problem you see,” Rojas Bastidas encourages. “Innovation is for anyone.” 

Rojas Bastidas’s apparel serves as functional fashion. Simultaneously, her pursuit celebrates the bodies that have been largely misrepresented and often altogether censored. 

“The absence of bodies sends a broader message that those bodies don’t exist,” she explains. 

“It makes every battle so much harder, but that’s what keeps driving me. I  should have just closed up shop because this is so hard, but  I’m going to make as many people as uncomfortable as humanly possible,” Rojas Bastidas says of being a female innovator in health and wellness advocacy. 

She adds that by showing the public what bodies actually look like, it frees us, elevates us and empowers us. 

“Lactating individuals deserve to be seen, heard and helped.”

Rojas Bastidas has a lot to offer on her website including her shop, lactation counseling services, a member forum and blog. Check it out here

Follow her on social media @orolaitofficial and @powertoprevail

A call to reinvigorate the International Code Of Marketing Of Breastmilk Substitutes

Last month marked the 39th anniversary of the World Health Organization (WHO) International Code Of Marketing Of Breastmilk Substitutes. As the World Alliance for Breastfeeding Action (WABA) reminds us,  “Following the adoption of the Code in 1981, governments have been called upon by the World Health Assembly to give effect to the provisions in the Code through national legislation. So far, UNICEF/ World Health Organization (WHO)/ #IBFAN have identified 136 countries as having Code regulations in place.”

Photo by Andre Adjahoe on Unsplash

You might know that the U.S. is not one of these nations. 

In a timely offering– when formula companies use the crises of the pandemic to prey on mothers and babies– The Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly Resolutions (#NetCode) has developed a toolkit to reinvigorate and reinforce ongoing monitoring and periodic assessment of the Code and national laws. The toolkit offers health advocates an opportunity to connect with governments to establish a sustainable system that will monitor, detect and report violations of national laws. Find it here: https://waba.org.my/netcode-toolkit-for-ongoing-monitoring-and-periodic-assessment-of-the-code/?fbclid=IwAR2PzeROMctrsCJ3ZiG8gah07IXQMhI-3eSn6EqLDhV3-TdGhhmk-IxDzt4

“Formula manufacturers are exploiting the panic and fears of contagion to intensify their aggressive marketing practices,” Patti Rundall writes in the Baby Milk Action policy blog. “In this context, government action to regulate the marketing of breast-milk substitutes has never been greater.”

On May 28, the World Health Organization (WHO), UNICEF, and the International Baby Food Action Network (IBFAN) launched the virtual 2020 Status Report which highlights which countries have implemented measures required by the Code. [The official launch event can be viewed here.]

Photo by Kelly Sikkema on Unsplash

“Given the important role of health workers in protecting pregnant women, mothers and their infants from inappropriate promotion of breast-milk substitutes, the 2020 report provides an extensive analysis of legal measures taken to prohibit promotion to health workers and in health facilities,” Thahira Shireen Mustafa, Department of Nutrition and Food Safety, writes. 

In the U.S. in late March, Baby-Friendly USA released a statement detailing access to adequate nutrition for babies born during the Covid-19 crisis with an announcement explaining that BFUSA  would relax one standard regarding the provision of small quantities of formula upon discharge to formula feeding families in communities experiencing shortages in retail outlets. 

“We did so to ensure that formula feeding families receive essential support during this global emergency,” BFUSA CEO Trish MacEnroe writes. “We did NOT loosen restrictions on interactions with formula companies.”

MacEnroe goes on to write, “Regrettably, some formula companies have interpreted our statement as a window of opportunity to reengage their aggressive marketing tactics with Baby-Friendly designated hospitals… 

“We at BFUSA are appalled that these companies would use the pandemic as an ‘opportunity’ to advance their business interests under the guise of an intent to support facilities during this difficult time.

So, please let us be perfectly clear: Our standards are still our standards. We have not ‘loosened’ our guidelines and we still expect Baby-Friendly designated facilities to shield health care workers, mothers and families from commercial influence, as outlined in the International Code of Marketing Breast-Milk Substitutes.”

Photo by Luiza Braun on Unsplash

In other parts of the world too, companies exploit the Covid-19 crisis. Baby Milk Action documents how one company violates Indian Law with their YouTube channel. Keep scrolling and scrolling and scrolling on Baby Milk Action’s page and you’ll find offense after offense after offense documented in multiple countries. 

In response, there are several documents cited offering guidance on how to navigate avoiding partnerships with these corporations.  Find them here

On an individual level, this is a great time to remind Certified Lactation Counselors (CLCs) of our Code of Ethics which states we must “Abide by the International Code of Marketing of Breast-Milk Substitutes and subsequent resolutions which pertain to health workers.”