Nurturing care is critical to improving health outcomes

Photo by Greta Hoffman

A friend recently told me, “I vowed to never use the word ‘diet’ in front of my daughter.” She explained how as she was growing up, her mother was fixated on dieting, and how that affected her relationship with food and her body image. I sympathized. My grandmother was a model, and I grew up in a ballet school, so body image was always at the forefront of my existence. My friend and I discussed the challenge of modeling healthy eating for our kids when we ourselves have been inflicted with such detrimental habits; things like eating in secrecy and restricting calories. 

Our conversation segued, soon chatting about convenience and ultra processed foods, what exactly are healthy choices?, and this incessant feeling of being rushed. We lamented about the after-school pace: hurry-up homework, hurry-up mealtime, hurry-up extra-curriculars, hurry-up bedtime.

Photo by August de Richelieu

The time to model healthy eating and the ability to engage socially over a meal is so condensed, families often forgo the art of dining and sharing meals entirely. Many of us have fallen to “the packet apocalypse”, propped bottles, hurled yogurt tubes to the back of the van, and scarfed- down burgers from the drive-thru.

Checking my email later this day, I was pleased to find Global Health Media’s recent announcement of their Nurturing Care Series.  While the 10-video collection is intended for health workers and not necessarily for direct family use, the resource felt like the perfect reminder of the importance of prioritizing responsive, nurturing and reciprocal interactions in all of our behavior, including meal time. 

Photo by Keira Burton

Global Health Media’s series is in partnership with USAID’s Responsive Care and Early Learning (RCEL) project which focuses on “good health, adequate nutrition, safety and security, responsive caregiving, and opportunities for early learning” as critical components to improving early childhood development (ECD) outcomes. 

“Integrating responsive care and early learning messages into existing nutrition counseling has significant potential to improve both nutrition and ECD outcomes,” the organization’s Advancing Nutrition page states. 

Over the years, Our Milky Way has produced quite a collection highlighting responsive feeding and interactive relationships. Stewed in a bit of irony, as I write to you from the glow of my computer, I’d like to spend this week resurfacing these pieces. 

 

 

 

  • Photo by Luiza Braun

    Mother and bab(ies) attend and respond to one another facilitating nourishment, the flow of hormones, immunity, learning and bonding, comfort, fun, an all-encompassing sensory experience that has generational impacts on social, emotional and physical health. Breastfeeding is collaborative covers the intimacy of the breastfeeding dyad up to breastfeeding as a collaborative global food security system. 

 

 

  • Cindy Turner-Maffei’s coverage of the “Nutrition and Nurture in Infancy and Childhood: Bio-Cultural Perspectives” conference… well, it’s really all in the title. 

 

  • Humans are carry mammals, not nest or cache animals. Baby-wearing facilities things like  the development of healthy physiological functions to providing a interactive social interactions for infants and young children, where they are included in the “action” rather than strapped into devices with little stimulation. Babywearing as a public health initiative  highlights Rebecca Morse’s work and further explores the importance of baby wearing.

 

 

  • Finally, we couldn’t close out without noting skin-to-skin, where connections are first fused outside of the womb. Find Our Milky Way’s collection on skin-to-skin and kangaroo mother care here and here

Changing the culture of mother baby separation in one Northeastern hospital

“I got to touch him once and they took him right away from me,” Northern Light Eastern Maine Medical Center labor and delivery nurse Jennifer Wickett says, remembering the birth of her first child 19 years ago.

Wickett desired non-medicated births, but her three children ended up being born via cesarean sections for various reasons. Wickett’s personal birth experiences coincided with her early professional life, working at a hospital in Massachusetts as a labor and delivery nurse.

At the time, she explains, the process was this: the baby was born,  taken to the warmer, vitals and weight were recorded. The baby was wrapped in a blanket and held next to mom’s face for five to ten minutes and then taken to the newborn nursery.

Skin-to-skin in the OR, Healthy Children Project

“I hated that for my patients and I hated that for me,” Wickett says.

So Wickett singularly started changing that culture of mother baby separation.
Now, at Northern Light Eastern Maine Medical Center, Wickett attends about 95 percent of the c-sections, and she says she was able to “take control.”

“[Initially] I wasn’t tucking baby in skin-to-skin, but I was putting baby on top of mom with the support person helping hold the baby,” Wickett explains.
She deemed it the Wickett hold: baby placed chest down on mom with knees tucked under the left breast and baby’s head on the right breast.

Attending a Kangaroo Mother Care Conference in Cleveland galvanized her efforts: the evidence clearly supported skin-to-skin contact immediately after birth and beyond.  Fellow nurses, anesthesiologists and other team members were resistant, but Wickett and a few other fellow nurses who created the Kangaroo Care Committee kept at it, always leading with kindness and communication. Rather than approaching the process with an “I have to do this” agenda, Wickett involves and acknowledges all of the participants in the room.

For instance, to the mother, she asks permission while also explaining the importance of skin-to-skin contact.

“They’re in hook line and sinker when I explain that their body regulates their baby’s temperature,” Wickett explains. “They don’t want to give that baby up; they are not letting that baby go.”

To the anesthesiologist, she facilitates open communication. Wickett lets them know that she assumes responsibility for the baby. “Are you good?” she often checks in with the anesthesiologist, while minding their space to work safely and efficiently.

Wickett  makes certain to involve the partner in their baby’s care, asking them to keep a watchful eye over mom and baby.

Photo by Jonathan Borba

Just about half of the babies she sees begin breastfeeding in the OR, she reports. From the OR, babies are kept on their mothers’ chests as they’re transferred to the recovery room, continuing the opportunity to breastfeed. All in all, Wickett says that babies born by c-section at her hospital spend more time skin-to-skin than those who are born vaginally.

After a vaginal birth, eager nurses often disturb skin-to-skin contact to complete their screenings and documentation. Excited partners wanting to hold their baby tend to do the same.

In the OR though, Wickett says there are at least 30 minutes without these disruptions.  Once mother and baby are transferred to the PACU, mothers report decreased pain when skin-to-skin is practiced.

What’s more, Wickett reports hearing often “This baby is such a good breastfeeder!” because the babies have an opportunity to initiate breastfeeding within the first two hours of life.

The World Health Organization (WHO) recommends that immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 grams with experienced staff if assistance is needed), after all modes of birth. The recent Skin-to-skin contact after birth: Developing a research and practice guideline synthesizes the evidence. [Read more here.]

Skin-to-skin, Healthy Children Project

Wickett and seven other colleagues had the opportunity to complete the Lactation Counselor Training Course (LCTC) last year.
While she says she would have loved to have been able to take the course in-person, Wickett still found the material and resources “fabulous.”

For the past four years, there’s been a vacancy in the perinatal coordinator position at her hospital, so Wickett hopes that her new credentials will allow her to fill the need.  In the meantime, Northern Light Eastern Maine Medical Center offers outpatient lactation visits. The center’s breastfeeding support groups halted during the height of COVID and have yet to resume; Wickett reports that they are trying to bring those back virtually.

Additionally, Maine residents have access to the CradleME Program which
offers home-based services to anyone pregnant up to one year postpartum.
In partnership with the Mothers’ Milk Bank Northeast , Northern Light Eastern Maine Medical Center became the first milk depot in the Bangor area.

You can read more Our Milky Way coverage on skin-to-skin after cesarean birth in  Skin-to-skin in the operating room after cesarean birth , The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth , and Skin to skin in the OR.

Also check out Skin to Skin in the First Hour After Birth; Practical Advice for Staff after Vaginal and Cesarean Birth Skin to Skin.

Find some beautiful KMC imagery here.

Breastfeeding is eco-friendly.

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

Breastfeeding is eco-friendly.

Planetary protection has never been more crucial, and the undeniable relationship between planetary health and human health has never been more evident.

In November 2022, world leaders, policy-makers and delegates from nearly 200 countries attended the COP27 UN climate summit, held in Sharm El-Sheikh, Egypt.

Fabrication of Bodies Joined by a Molecule of Air(2022), by Invisible Flock and Jon Bausor, manufactured by MDM Props Limited in Lebanon, represented by Architect & Engineer Karim Attoui. ©Courtesy of Invisible Flock. https://invisibleflock.com/portfolio/bodies-joined/

Presenters made poignant remarks about the climate crisis we find ourselves in.

“We are on a highway to climate hell with our foot on the accelerator,” António Guterres, Secretary-General of the United Nations said.

Sherry Rehman, Minister of Climate Change, Pakistan argued that  “The dystopia has already come to our doorstep …”

Mark Brown, Prime Minister of the Cook Islands, shared, “Our survival is being held to ransom at the cost of profit and an unwillingness to act despite the ability to do so.”

On Decarbonization Day of the summit, Dr. Abla Al Alfy convened a panel of speakers who presented on the importance of the 1,000 Golden Days and the relationship between the climate crisis and mother baby health. [You can access the United Nations Egypt’s recording here which starts at 19 minutes in.]

Dr. Nevein Dous, UNICEF health specialist, covered infant mortality rates, micronutrient deficiencies, mental health challenges, among other global health challenges and called for the integration of services rather than siloing health strategies.

WHO

Frederika Meijer with UNFPA Egypt highlighted UNFPA’s work confronting medical violence and reducing the country’s cesarean section rate which soars over 60 percent.

Meijer brought light to the need to create resilient health systems that will withstand the inevitable shocks of the climate crisis.  She noted the important role skilled midwives play in the reduction of unnecessary c-sections, giving way to the work of Dr. Kawther Mahmoud, President of the Nurses Syndicate, Assistant Undersecretary for Nursing and head of the Central Department for Nursing in Egypt, who helps lead the national plan for the midwife.

Many presenters emphasized the importance of family planning counseling and the environmental and health implications of pregnancy spacing.

Dr. Naeema Al-Gasseer’s remarks drew attention to a recent WHO report which states that “Almost the entire global population (99%) breathes air that exceeds WHO air quality limits, and threatens their health.”

Dr. Camilla Kingdon, President of the Royal College of Pediatrics and Child Health, further described that 26 percent of child deaths under 5 years of age have an element of environmental cause like heat waves, water scarcity, vector-borne diseases and flooding. UNICEF has identified that air pollution will be the leading cause of death for children by 2050, she shared. Additionally, there is a clear link between air pollution and miscarriage. Dr. Kingdon went on to describe the prevalence of visible air pollution particles on the placenta.

WHO

In connection to these harrowing accounts, Healthy Children Project’s Dr. Karin Cadwell presented research on the environmental impact of powdered baby formula milks in North America. Read about that work here.

Healthy Children Project’s Dr. Kajsa Brimdyr acknowledged the mess we are in and noted how many solutions that may contribute to planetary and population health are expensive and complex. Skin-to-skin contact (SSC) in the first hour after birth though, is simple and easy, inexpensive, is appropriate for all dyads, and touts priceless benefits.

Brimdyr noted just some of the benefits: SSC in the first hour after birth decreases infant mortality by 25 percent in low birth weight (LBW) infants, decreases transfers to the NICU,  decreases maternal stress and depression, improves paternal parental stress, and allows baby to self attach to the breast improving maternal confidence in breastfeeding and increasing breastfeeding rates overall.

The effects of SSC in the first hour extend far beyond the first hours, the first days and first weeks of life. Feldman et al. (2014) followed mothers and their premature infants who had been in SSC and control groups for 10 years. They found that children who had been in the SSC group had better cognitive development, better autonomic nervous system functioning, and mother–child interactions were more reciprocal 10 years later.

Photo credit: United States Breastfeeding Committee

Silke Mader of the European Foundation for the Care of Newborn Infants (EFCNI) and her colleagues are fighting for SSC and breastfeeding support for all dyads. Mader calls for a zero separation policy which is supported by evidence even in the context of the pandemic, she reported. Mader added that fathers and partners are not second-class citizens and should be included in the policies that help shape proper parent infant bonding.

As the climate emergency becomes more and more bleak, breastfeeding is a safeguard for infant and young child health. Read our coverage on infant and young child feeding in emergencies (IYCF-E)  in Prioritizing infant and young child feeding in emergencies during National Preparedness Month and beyond and National Preparedness Month: the U.S.’s deficit in Infant and Young Child Feeding preparedness during emergencies.

COP27 held the first-ever Youth-led Climate Forum ensuring that young people have a place in the conversation about the climate crisis. More on that here.

 

More resources to explore  

RCPCH Climate Change Working Group

Baby Milk Action’s coverage on COP27

Breastfeeding can help tackle climate crisis but it’s on governments, not mums to save the world

The climate crisis is a health crisis short video

 

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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, tell us: Where have you seen predatory marketing of breastmilk substitutes?

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.

To know is to do: retired nurse dedicates time to humanitarian aid in East Africa bringing awareness to the paradox of direness and vibrancy

Some days Susan Gold, RN, BSN, ACRN misses her ignorance. Since 2003, Gold has embarked on over 30 trips to various locations in East Africa where she teaches sexual and reproductive health and offers humanitarian aid.

Recalling one of her first visits to a clinic in Nairobi, Kenya, Gold describes a young mother, around 18-years-old, who arrived holding her severely malnourished infant against her breasts infected with such severe mastitis that her skin had split. This mother had been thrown out of her home for being HIV-positive and was breastfeeding and formula feeding her baby.

[Some background: Infant feeding has been complicated by the HIV epidemic. In the early 2000s, Gold explains that HIV-positive women were taught to formula feed to lower the risk of transmission to their babies, but with little to no access to clean water, babies were becoming severely ill. What’s more, in societies where breastfeeding is the norm, exclusive formula feeding is often an indication of one’s HIV status, which remains highly stigmatized. And formula is expensive, so many mothers choose mixed feeding, increasing the rate of HIV transmission, because formula irritates the GI system and gives the virus a pathway. By 2010, WHO issued new recommendations that stated that all mothers who tested positive should receive effective antiretroviral treatment (ART) which could lower risk of transmission during exclusive breastfeeding to virtually zero. In 2016, WHO extended the recommended duration of breastfeeding for HIV-positive mothers to 24 months. Effectiveness is dependent on consistency though, and Gold explains that mothers can develop resistance because there isn’t always access to ART.]

Gold was able to give the mother antibiotics, but the care that she and her infant required was beyond what Gold could offer. Considering the dyad’s condition and Gold’s limited resources, she says she’s certain that they died.

Reflecting on the suffering she witnessed and lives lost, that’s when Gold misses her ignorance most, but she says, “To know is to do.”

“For me it’s not a news story I can ignore, it’s names and faces,” she remarks.

In 2007, Gold received a Fulbright Grant to evaluate a reproductive health curriculum for HIV-positive adolescents. In 2017, she was awarded a Mandela Washington Fellowship Reciprocal Exchange Award to collaborate with Sicily Mburu, a Kenyan physician who co-founded AIDS No More. [Read more: https://ghi.wisc.edu/talking-health-out-loud-how-volunteering-led-to-life-saving-strategies-for-teens/]

Most recently, Gold spent several weeks in Dar es Salaam, Tanzania on a Nelson Mandela Fellowship Reciprocal Exchange Fellowship Grant where she partnered with Dr. Omari Mahiza, a pediatrician at Amana Regional Referral Hospital, focusing their efforts on combating pediatric malnutrition and education on family planning.

 

Shattering stereotypes 

Gold has found that most Americans hold a “shallow view” of the continent. Her frustration with the stereotypes associated with Africa runs deep.

“It’s either starving children or a safari,” she begins. “It’s so painful for me to see that displayed so many times. There is such a tendency [in America] to dehumanize people who are not like us… We set ourselves as the standard. Their culture is not a failed attempt to be our culture. Success doesn’t have to look like us or be measured against us.”

Alongside her humanitarian work, Gold hopes to shatter the stereotypes, to bring awareness to the paradox of direness and vibrancy in East Africa.

Gold reminisces: “I love the African sun on my face, the bright colors and motion, the culture that is built around the family and friends, that you’re never expected to do it alone, the  generosity of spirit,  the sounds and smells, the warm welcomes and the optimism.”

Acutely aware of “an inherent imbalance of power” and the concept of White Saviorism, Gold uses the Swahili term Tuko sawa, which means “We are all the same”, as the foundation of her work.

We all want healthy children and families and a future with opportunities to provide long, healthy, prosperous lives, she expounds.

Beyond this core belief, Gold says that she always develops relationships with the people she works with.

“I educate myself on the origins and current status of their culture. I don’t tell people what to do, I share my experiences and expertise. I always learn from them.”

 

Doing more with less 

Ingenuity is something she’s gathered from working alongside East Africans.

For instance, Gold was struck by the engineering of incubators for very sick babies at  St. Joseph’s Hospital in Moshi, Tanzania.

If there is electricity, she explains, the heat is controlled by the number of light bulbs lit. The wood absorbs the heat, the aluminum components absorb and reflect heat, the mattress absorbs heat but also protects the baby, and the lid retains the heat but allows for monitoring of the baby. Mosquito netting is fashioned around the system.

Gold notes that Kangaroo Mother Care (KMC) is practiced for almost all premature babies, but it’s not common among sick babies. [Read about skin-to-skin efforts just north of Tanzania here:  https://www.ourmilkyway.org/skin-skin-gulu-uganda/]

 

Hunger: hidden and stark 

A recent Lancet Global Health Publication, Revealing the prevalence of “hidden hunger”, released estimates of two billion people worldwide with one or more micronutrient deficiencies, noting that this is a gross underestimate. The hunger and deficiencies that Gold and her colleagues witness are rarely hidden and often quite obvious.

A severely malnourished child holds onto one of the toy cars that Gold collects and brings for the children at the clinics.

Breastfeeding is important in the prevention of different forms of childhood malnutrition, including wasting, stunting, over/underweight and micronutrient deficiencies. Tanzania scores quite high in the World Breastfeeding Trends Initiative (WBTi) World Ranking.

Gold observes that all of the women breastfeed in the low-income neighborhoods she visits.

The struggle, she says, is getting enough nutrition for the women to sustain milk production and have energy to feed their babies. During her most recent visit, Gold reports that almost none of the 35 families had food in the home.

Reporters of the new estimates for micronutrient malnutrition point out that processed fortified foods and micronutrient powders can be an easy answer to hunger, but they don’t create sustainability of local and indigenous foods and create conflict of interest issues with industry.

Gold adds that low income community members can’t afford to buy industry developed foods consistently. Lack of access to clean water is also a barrier.

“And you can’t depend on outside groups to sustain you,” she continues.

“We didn’t see any processed food at all because there is no market for it,” Gold says of visiting seven different neighborhoods in the low income region of Dar es Salaam. Instead, small markets with locally-grown fruits and vegetables prevail, but access to protein is a challenge.

As medically indicated, ready-to-use therapeutic food (RUTF) packets of fortified peanut butter issued by UNICEF are given out through health clinics. But Gold notes that sometimes parents sell these packets for money.

 

A challenge but not insurmountable 

North of Dar es Salaam, in Moshi, Gold brings a portable printer that doesn’t require Wifi to the small hospital where she volunteers. She gifts each postpartum mother a printed 4×6 photo of herself and her baby.

“You don’t know how many of these babies are going to survive due to the high infant mortality rate.”

There’s a long moment of silence between us on the video call.

Then Gold expresses her frustration and anger,  “The world can fix this, but chooses not to.”

She urges us to educate ourselves and others. Vote for people who have a vision of the world as one world, she says.

Last month, the President signed into law H.R. 4693, the “Global Malnutrition Prevention and Treatment Act of 2021,” which authorizes the United States Agency for International Development to undertake efforts to prevent and treat malnutrition globally.

For those interested in making financial contributions or donations like baby clothes, children’s  books, or toy cars, email Gold at talkinghealthoutloud@gmail.com.

Follow Gold’s organization Talking Health Out Loud on Facebook here.

For an interesting discussion on Numeracy Bias, check out this episode of Hidden Brain. Numeracy bias is described this way: “…When you see one person suffering, you feel like, ‘Oh, I can do something for that person.’ But when you hear that a whole country has a refugee crisis, you tend not to get involved because you feel like, ‘Well, this is overwhelming. I don’t think I can do anything about this, so I’m not going to engage.’…It turns out that people who have experienced a high level of lifetime adversity are immune to this bias.”

 

Other resources

Micronutrient Deficiencies

UNICEF Child Food Poverty

UNICEF No Time to Waste

UNICEF Fed to Fail