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!” 



Infusing work-life balance in medicine: reflections from Katrina B. Mitchell, MD, IBCLC, PMH-C, FACS

— “…Breastfeeding isn’t about ‘success’ or ‘goals’ — it’s a human experience.” —
Mitchell’s son captures her on the job. Used with permission: https://www.instagram.com/p/CuN_G35Rc0h/

Katrina B. Mitchell, MD, IBCLC, PMH-C, FACS, a breast surgeon, lactation consultant, and perinatal mental health provider in Santa Barbara, Cali., went back to work at five weeks postpartum.

“Looking back…I have no idea how I did this,” she reflects.  “I know this is still far better than migrant workers on the central coast of California, who may not even have a week to recover.”

In part, Dr. Mitchell recognizes the support she received from a pediatrician; he counseled her on bed sharing during the time she was breastfeeding as a single parent in surgical training.

“This literally saved mine and my son’s physical and emotional health (as well as allowed me to exclusively breastfeed for six months and then onward for years),” Dr. Mitchell explains. “Sure, it was still terrible to have to pump milk in a bathroom by the OR and lug my pump all over the hospital, but I really believe I stayed on a postpartum high because I got to sleep and nurse my baby at night when I got home.”

She continues: “[Bedsharing] saved every possible complication we could have experienced with me being back at work operating 14 plus hours a day at that point in time…. I am forever grateful to this pediatrician…”

Dr. Mitchell captured these early experiences in a book she wrote for her son about being a surgeon mom.

In her practice today, Dr. Mitchell tells her patients who are going back to work that the ounces in a bottle during the day are not nearly as important as feeding baby at the breast when the dyad is together and feeding overnight on cue.

“Safe bedsharing is what facilitates this and results in continuation of breastfeeding far longer than separate surface bedsharing, sleep training, and feeding a pump rather than the baby,” she explains.

In particular, physicians have long struggled with “pouring from an empty cup” alongside being influenced by insidious industry tactics, mechanical culture and inadequate education. Nikki Lee and I wrote about these forces in Physicians as parents: How can one pour from an empty cup? and Physicians as breastfeeding supporters.

In New study calls for greater access, equity for breastfeeding surgeons author Hilary Brown reports on “A new vanguard of physicians… determined to make the field more hospitable to working mothers by establishing dedicated pumping spaces and allotting time for pumping without fear of retribution or punishment.”

Brown goes on, “… No one should be denied professional opportunities just for choosing to have a work-life balance. For too long, surgeons were lauded for not having families, or prioritizing their work over a personal life. To be a martyr to the field was considered the highest level of dedication. But ultimately, such devotion has proven to be a detriment. Excellent patient care, London-Bounds says, starts with self-care.”

Dr. Mitchell acknowledges that “..the surgical world is becoming more attune to this topic.”

In 2020, the Association of Women in Surgery released a position statement on supporting physicians and trainees who are breastfeeding.

In regard to lactation accommodations in the workplace though, Dr. Mitchell says she often thinks of something Kimberly Seals Allers pointed out many years ago when she said something along the lines of: “We are a pump nation — we shouldn’t be celebrating being gifted a pump from our medical insurance.  We should be demanding adequate paid maternity leave.”

“Accommodations should really be focusing on this governmental-level change,” Dr. Mitchell elucidates.  “Not only is it the right thing to do for human beings, but it reflects one of the fundamental principles of economics 101:  opportunity cost.  You lose some productivity up front by giving mom a longer maternity leave, but you exponentially recoup this cost when moms breastfeed rather than wean and have good mental and physical health when they return to work.”

In this landscape without paid leave, there can be a layer of tension that brews between colleagues.

“A  lot of the hostility towards lactation and lactating patients does stem from physician personal experience with lactation (which was unfortunately largely negative in the past, and can persist today no matter what accommodations we provide),” Dr. Mitchell begins.

“And these negative experiences are a direct result of the medical patriarchy, which provides little to no education on the breast and lactation in medical school, residency, or fellowship training.  Because of this, just like all other patients, physicians themselves are at risk for not receiving appropriate evidence-based support and education surrounding lactation and breastfeeding.”

She continues, “As we all know, the postpartum time period is one of great vulnerability, and a person’s experience with breastfeeding can play a central role in how they navigate early motherhood.”

Juxtaposing the way that we look at lactation and breast cancer care, Dr. Mitchell says that we would never tolerate breast cancer care as being reflective of personal experience, but this often happens with lactation.

“With breastfeeding, there’s the dismissive comments of ‘oh, it didn’t work for me, so it’s fine it doesn’t work for you.’  We would never say ‘that chemotherapy didn’t work for me, so it’s ok if it doesn’t work for you,’” she explains.

Clear to recognize that this is not the fault of the individual, Dr. Mitchell says it’s instead a reaction to “the fact that the patriarchy didn’t support them, either.”

And so, to influence real change, we have to start at a systems level in medical education, she says.

Training needs to include education about things like safe bedsharing, how formula feeding and breastfeeding are vastly different in terms of volume and infant behavior (e.g. the normal distraction of a breastfed infant at four months old versus a bottle fed infant taking a bottle on schedule), Dr. Mitchell explains.

“…This should be standard education for all of us.”

Physicians from less traditional backgrounds have great power to drive change too, Dr. Mitchell suggests, sharing her personal experience:  “I am the only person in my generation on one side of my family to go to college, much less medical school.  Three quarters of medical school matriculants come from the top two household-income quintiles — I was not one of them.  Since I was a teenager, I worked my way through school.  I had a liberal arts background and undergraduate degree, and I think all of this made me see things from a different perspective than other medical students and physicians.  I was also lucky that my mom pushed back against the tide of formula feeding in the late 1970s, and I was a breastfeed infant myself because of this.”

In a powerful Instagram post, a photo snapped by her seven-year-old son is captioned “I love this moment because it’s the ultimate rebellion against corporate medicine. No one can take away the power of human connection.”

The post is commentary on a simpler, more connected way of caring for patients.

“Instead of a patient having to login to the EMR or deal with a centralized scheduling call center to make an appointment, [the post] reflected the way we used to care for people in medicine and what I try to preserve as much as possible:  a patient needing help, contacting me directly on a weekend, us all going in with casual clothes and me just doing my job as a doctor,” Dr. Mitchell explains. “ No electronic medical record, no ‘15 minutes with each patient’ corporate mandates, no ‘you can’t do this or that’ by the administration.”

Ironically, Dr. Mitchell continues, she’s noticed that corporate medicine has made certain aspects of lactation accommodations better.

“The one positive aspect …is oversight and standardization and human resource departments,” she says.   “If there’s a law for accommodations, there is someone enforcing them (along with all the other not-so-helpful ‘enforcements’ like clicking through countless screens in the EMR simply to write a quick note on a patient).”

During the 2020 COVID-19 pandemic, Dr. Mitchell created the Physician Guide to Breastfeeding, a hub where she’s committed to sharing openly and advocating for improvements in broader maternal child health education. You can explore her collection here.

Boston Public School teacher works to extend support to other lactating educators

Porshai Z. is a third grade teacher in the Boston Public School system, currently on maternity leave with her three-month-old son who cooed during our phone call on an early October morning.

Photo courtesy of Porshai Z.

“I absolutely love it,” Porshai says of teaching. “My [students] are at the most tender age where they’re still aiming to please adults, but they have a little sass and personality.” 

After the birth of her first son, Porshai returned to work just four months postpartum, and she says it’s one of her biggest regrets. For one, it took away from her role as a teacher. She found herself pumping in a bathroom,  stressing each and every time she needed to leave her full-of-personality third graders. Returning to work so soon after the birth of her baby also took away from the joy of feeding her first son, Porshai shares. 

Though Porshai poured herself into research about unmedicated birth and how to breastfeed as soon as she became pregnant, she found herself unprepared for the physical demand of feeding her little human. There was one evening in particular where she felt enticed to open the commercial milk formula package sent by the formula company, but she ultimately persevered. 

“I don’t know what quieted that voice,” Porshai reflects. Perhaps it was the investment she made learning and preparing for this relationship and her realization even through the challenge: “Wow, this is really special.”  

This time, Porshai will remain at home with her new baby for a year. Simultaneously, she is completing the Lactation Counselor Training Course (LCTC). Porshai earned one of the most recent rounds of the Accessing the Milky Way Scholarships

“I have really been enjoying [the course],” Porshai shares. “ There is so much I wish I knew the first time I was nursing.” 

She says she appreciates that the course grounds breastfeeding as a public health issue and that she was surprised to learn about the composition of human milk. Learning about milk’s dynamic nature has allowed her to better understand her own infant’s behavior. More generally, she was fascinated to consider how our society has adopted nesting caregiving behavior though we are truly carriers.  

“This is mind-blowing,” she says. “So many more women need to hear that.” 

As a highschooler, Porshai was always fascinated by reproductive health. She’d watch documentaries on birth and her favorite science museum exhibit was one that depicted the stages of life. It wasn’t until later that she became aware of the option to become a lactation care provider. 

Through Boston Medical Center’s Curbside Care for Moms and Babies, a mobile unit that provides “comprehensive mother-infant dyadic care during the first six weeks of life”– Porshai met her first duo of Certified Lactation Counselors (CLCs). 

“I really do think the power of that training is what allowed me to continue [breastfeeding]  in the first place,” Porshai reflects. 

This wrap-around care was particularly influential as it ‘met her where she was at.’ 

Porshai goes on to say, “I hope to work in that way as well. I hope to be that visibility.” 

More specifically, Porshai says she has been thinking a lot about how elementary education is a female-dominated industry; with many friends and colleagues growing their families, Porshai hopes to be a resource and support for them as they learn to feed their babies. She plans to create a network of breastfeeding mothers within the Boston Public Schools so that there is a designated space for parents navigating infant feeding and the unique challenges of teaching. 

In addition, Porshai is considering becoming a postpartum nurse. 

“[The LCTC] could very well be the thing that catapults me to go back to school.” 

For more on teaching and lactation, check out this article. The PUMP Act now extends federal lactation rights and protections to all employees in K-12 schools.

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