A story of lactation and breastfeeding as a ‘Tummy Mummy’

Apryl Yearout, a school psychologist in Washington state, uses her body in powerful ways. For one, Yearout, known as Ariel Pain on the roller derby track, competes as a full contact skater excelling as both a jammer and a blocker.

Used with permission.

Yearout was drawn to roller derby well over a decade ago because of the “incredible community” it offered her.

“I heard ‘I’m proud of you’ and ‘good job’ more than I ever had,” she reflects. “It’s physically demanding and makes you feel strong and capable.”

In another manifestation of her power, Yearout birthed and breastfed her two daughters. Yearout’s eager body produced so much milk that she was also able to donate about 1,000 ounces of milk to local families.

Beyond this, Yearout helped create a family as a gestational carrier, or “tummy mummy” as the intended parents refer to her.

The idea of surrogacy came to her as a few realities collided. She’d anticipated having many more children of her own, but she and her husband divorced when their youngest child was 18 months old. As her children grew and without a new partner, she didn’t feel she was in the position to “start over” again with a baby.

Yearout watched her sister struggle to carry a pregnancy to term for some time, but ultimately, she was able to birth her own baby, so Yearout pursued the services of an agency and matched with a couple in need.

In April 2023, Yearout gave birth to the couple’s son. The baby and her youngest daughter wound up sharing a birth date, fulfilling her daughter’s birthday wish.

As discussed during her pregnancy, Yearout breastfed her surrobaby on occasion, for a few days after the birth while spending time with the new family.

“Overall, it felt like the natural completion of the pregnancy,” she shares. She also predicts it’s why she recovered so well from pregnancy.

Though she and the indented parents had already discussed direct breastfeeding as their plan while possible, Yearout expressed colostrum in the event that the intended parents felt strongly about being the ones to feed their baby first.

Unlike some surrogates, Yearout didn’t struggle with the idea that breastfeeding would create an unhealthy bond with the surrobabe.

She shares: “I was already very connected to this baby. I approached the surrogacy with a mindset that I need to make sure I have the right couple, I need to fall in love with them becasue I know I’m going to fall in love with this baby… physically and emotionally…everything is tied up… he’s not mine, I never felt like he was my child but I still love him… For me, not nursing, not having any breastfeeding experiences would have felt a little incomplete. I think it also would have put a physical strain on my body that could have pulled on those emotions and made it harder. I didn’t like the idea of forcing my body to stop [producing milk].”

The intended parents were not interested in managing the shipment of her milk after they returned home, so Yearout sought out a local family to donate to.

“And I get to see that little one grow up,” she says.

Yearout completed pumping and donating her milk in the autumn of 2023.

“Pumping alone is really hard,” she reports. In contrast, Yearout after a workday pumping for her keepers, she would come home to breastfeed through the night, and her body responded to this interaction much differently.

“When I was just pumping, [production] tapered off a lot faster,” she shares.

Thinking back on her experience as a tummy mummy, Yearout articulates her discomfort with the perception that gestational carriers are compelled solely by financial compensation.

She says in a somewhat joking manner, “I feel like I could sell pictures of my feet for more money.” (Let us note that this is not to diminish the financial burden that surrogacy can cause for many couples looking to create a family.)

“The thing that always bothered me was that people assumed that I did this for the money,” she goes on. “I had other motivations. [The arrangement]  helped me take my kids on a trip we would have never gone on before, but it wasn’t my reason…Money wasn’t a primary motivator but it did come up so often [with others].”

Instead, Yearout sought and found connection.

She comments, “This is what my body is good at and I’m going to use it to benefit other people.”

Yearout and her mom recorded an interview with StoryCorps. Unrelated to surrogacy, it’s a conversation about Native American roots, racism, white privilege, and their relationships with their extended family, and it’s worth a listen. You can find it here.

Louisiana doula protects BIPOC women from abuse through birth work and beyond

Having endured the trauma of a lost pregnancy at the hands of her obstetrician during her teenagehood, Angelica Rideaux vowed that she would work to protect BIPOC women from emotional and physical abuse.

In 2021, she enrolled in Community Birth Companion, a non-profit doula training program serving those in Southwest Louisiana. 

“During the training, I was loved on by women who looked like me, and had the same purpose of ending racial bias in maternal child health care,” Rideaux recalls.

She now serves as a doula for BIPOC families around Louisiana  with the ultimate goal of becoming a Certified Professional Midwife (CPM). Currently, there are only three Black CPMs in Louisiana, according to Rideaux. In 2021 Baby Catcher Birth Center, the state’s first Black-owned, CABC accredited free-standing birth center opened.  

Most recently, Rideaux was accepted as a member of the Power Coalition for Equity and Justice’s She Leads: Community Activist Fellowship 2023 cohort: a “network of women activists who are disrupting the current power structures and realizing change in their communities.”

Rideaux’s accomplishments go on. She earned one of the most recent Accessing the Milky Way scholarships to support her completion of the Lactation Counselor Training Course (LCTC)

Because Rideaux is a hands-on learner, she reports the online format of the LCTC challenging. Even so, Rideaux says she likes challenges. 

“So I am going to push past that,” she states. 

She says she has found the office hours helpful; they make the experience of online learning feel less isolating. 

Working her way through the course, Rideaux has been surprised by how many myths have been put to rest. Specifically, she says it was “mind-blowing” to learn that water consumption is not solely responsible for milk production. She plans to share the knowledge she continues to gain among her colleagues and the families she supports.    

Rideaux sees the LCTC as an important piece in making her future in midwifery more well-rounded, effective and supportive. 

As Rideaux continues on her journey to know more to better serve her community, she reminds us of some important concepts to reflect on as we move through our own work to improve maternal child health outcomes. 

First is that discomfort is necessary for change, and sitting in discomfort, having those difficult  conversations is part of bringing an end to racial inequity.

Secondly, creating healthy environments for women and children, especially those in BIPOC communities,  is not a trend. Rideaux comments that while she wants everyone to be culturally aware and competent, she hopes that the impetus comes from “hearts to get the situation resolved” rather than for “the dollars” or for “the accolades” or for an illusion of doing good.  

In Equity is more than a buzzword, the author writes: “Those committed to equity should understand that the harm of racism cannot simply be ‘undone’. The ramifications of colonization, enslavement and segregation penetrate almost every aspect of our society, including our education systems. Merely boosting representation is not an effective way to increase equity in predominantly white institutions.”  (Paytner, 2023)

It’s a reminder that improving maternal child health outcomes for the BIPOC community is part of a revolution, as Rideaux describes it. 

A lot of us are on the ground getting this work done, never receiving any kind of media coverage,” she begins. “We are soldiers in this war, and the goal is to get everybody on the same path for equity and justice. We  want everybody to feel like they are humans because that’s what we are first and foremost.”  

Learn about ending obstetric racism by visiting Birthing Cultural Rigor, founded by Dr. Karen A. Scott, MD, MPH, FACOG. 

Respectful maternity care: the problem and suggested solutions

Guest  post by Donna Walls, RN, BSN, CLC, ANLC with intro by jess fedenia, clc

 

Donna Walls’s, RN, BSN, ICCE, IBCLC, ANLC unmedicated births were sort of a fluke.

“I remember being horribly afraid of someone sticking a needle in my back,” she recalls.

The “glorious” feelings of confidence and joy were unexpected consequences, but thinking back, Donna says, “Boy, I am sure glad I [gave birth that way.]”

In all other aspects of parenting, Walls credits growing up in the 1960s for becoming a self-described Granola Mom.

“When everything went ‘back to nature’, that was a big influencer for me,” she says.

As a nurse, Walls was always drawn to maternity care and supporting breastfeeding as the natural progression after giving birth.

It felt thorny to her when babies were taken to the transition nursery immediately after birth and later given back to their mothers.

This ritual sent the message that “We (as in the staff) can take better care of your baby than you (as in the mother) can.” That never sat right with Walls.

Then, one pivotal moment in particular, Walls on duty in the transition nursery, walked by a baby only a couple of hours old.

“He was frightened,” Walls begins. “His lip was quivering and he was splayed out underneath the warmer. He was so frightened. It just affected me.”

After that, Walls galvanized to change the culture in this hospital. She worked very hard alongside a physician colleague to open a birth center within the hospital. In 1995, Family Beginnings at Miami Valley Hospital in Dayton, Ohio was unveiled, offering families an option where birth wasn’t pathologized and where mothers and babies were honored as dyads. (Birthing at Family Beginnings remains an option for those in the Dayton area today.)

The center was designed to look like a home. There was no nursery for babies to be separated from their parents. When mothers came in to labor, the staff would pop in bread to bake, a special touch of aromatherapy.

Freshly baked bread, though enticing, wasn’t the number one reason families signed up to birth here. Instead, they chose Family Beginnings because they didn’t want their babies taken away from them, Walls reports.

Walls has since retired from her work in the hospital, but respectful maternity care remains forward in her mind and in her advocacy.

She graces us with reflections on respectful maternity care in her guest post this week on Our Milky Way. Read on!

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As a nurse in maternity for over 40 years, I have too often witnessed what I refer to as the “empty vessel theory”. Women are regarded as merely a container for the fetus and care providers merely the technician to remove it, usually as quickly as possible. I have often been saddened when the emotions and spirituality of birthing are disregarded or even mocked. This miraculous process is a rite of passage with all the inherent pain, joy, lessons and connections needed to begin the journey into parenting. My hope is that through discussions and activism, we can reach a point where the birthing family is honored and all newborns are brought into the world with love and respect.

Photo by João Paulo de Souza Oliveira: https://www.pexels.com/photo/gray-scale-photo-of-a-pregnant-woman-3737150/

Respect is “showing regard for the feelings, wishes, rights or traditions of others”. Concerningly, there is an abundance of anecdotes from patients and caregivers that demonstrate how maternity care practices are often disrespectful, sometimes even abusive.

Disrespectful care encompasses racial inequity, lack of confidentiality, physical and/or emotional abuse, denial of care or provision of substandard care, lack of informed consent or coercion or condescending communications. This type of care occurs in all countries around the world, to all demographics of women and their families. Fortunately, disrespectful care has drawn the attention of many health organizations, including the World Health Organization, and steps are being taken to stop disrespectful, abusive care practices.

Examining the intersection of maternity care and human rights has been a recent topic in many maternal and infant care advocacy groups as well. We cannot assume that hospital admission for an appendectomy is equal to admission for the birth of a baby. This is because  the scope of the process of birthing impacts a person, a family, a community and a nation which is not so of a surgical procedure.

Most women and families expect they will receive safe, inclusive, compassionate care and trust their caregivers to provide prenatal, intrapartum and postnatal care with honest communication and respect for their needs and choices. Provision of safe care should look beyond the basics of preventing maternal, fetal or neonatal morbidity or mortality and consider how to support the family’s human rights– rights inherent to all people, without discrimination, regardless of age, nationality, place of residence, sex, national or ethnic origin, color, religion, language or any other status. (White Ribbon Alliance, 2020)

Photo by Dipu Shahin DS: https://www.pexels.com/photo/baby-in-pink-and-white-blanket-4050647/

The first stated right is to be free from harm and mistreatment, yet we find continuing cases of physically and emotionally abusive treatment of pregnant and birthing women. Secondly is the right to competent, culturally sensitive care for both mother and newborn.  Next is  the right to companionship and support, and lastly the right to meet the basic life-sustaining needs of the dyad, including breastfeeding support for the newborn.

The first step toward respectful care is choosing  healthcare providers who value open, honest communication and who will discuss options and listen to the family’s needs and concerns. WHO defines respectful communication as communication which  “aims to put women at the centre of care, enhancing their experience of pregnancy and ensuring that babies have the best possible start in life.” (WHO, 2018)

Other components of respectful communication include the use of positive body language, active listening, the use of non-judgmental language, assuring patient privacy and honoring physical and emotional needs.  Respectful communication can begin with simply referring to the person by the name they prefer. If it is not documented, ask.

Another important step is selecting the birthing place. (Niles, 2023) Most care providers practice at one to two hospitals or birth centers. Choosing the birthing environment is an important decision in creating a birth experience which is in line with the family’s expectations and goals. Research and discussions with childbirth educators, lactation care providers and other families can give insights into common or routine practices at that institution. Will the family’s requests be honored? Will questions be answered with open and honest informed consent? Will the birthing and breastfeeding practices support their goals? These are all questions that need to be answered before a birthing place decision is made.

Creating an environment of respectful care in the birthing place is foundational. It is care that assures women and their families will be regarded as capable of making decisions. Making decisions which respect the values and unique needs of the birthing woman can only be made when patient autonomy– the right of patients to make decisions about their medical care without their health care provider trying to influence the decision–  is recognized.

Photo by Rebekah Vos on Unsplash

Individuals often comment on birthing in the hospital as a time when you lose all modesty; however, it is possible to follow protocols that set a standard for assuring privacy and modesty which can positively impact the birth experience. Simple steps like not discussing patient history or current conditions in front of others (without the patient’s permission), being mindful of covering intimate body parts (or culturally sensitive covering) whenever possible, asking permission before touching or knocking (and waiting for a response) before entering the room are a huge part of maintaining patient dignity. It cannot be overstated that any cultural requirements for modesty must be respected at all times.

More on respect in health care on Our Milky Way here, here and here.

Other recommended resources 

The International MotherBaby Childbirth Initiative (IMBCI) A Human Rights Approach to Optimal Maternity Care

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.

Exploring Evidence for Disrespect and Abuse in Facility‐based Childbirth: Report of a Landscape Analysis

 

Centers for Disease Control and Prevention (CDC) changes their breastfeeding policy for HIV-infected mothers

Without major announcement, in February 2023,  the Centers for Disease Control and Prevention (CDC) changed their breastfeeding policy for HIV-infected mothers and no longer recommend advising against breastfeeding.

Photo by Paul Hanaoka

The new recommendation gets closer to the updated 2010 World Health Organization (WHO) guideline on HIV and infant feeding. Before 2010, “WHO guidance on HIV and infant feeding (UNICEF et al., 2003; WHO et al., 2006) recommended an individualized approach in which women living with HIV would be counselled on feeding options according to their household circumstances.”

The new CDC guideline acknowledges that, “For mothers on antiretroviral therapy (ART) with a sustained undetectable HIV viral load during pregnancy, the risk of transmission through breastfeeding is less than 1%, but not zero,” as determined in the PROMISE Study.

The guideline goes on to recommend “patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.” Read the full document here.

Organizations like the National Institute of Health Office of AIDS Research, the Infectious Disease Society of America and National Association of County and City Health Officials announced the new guidance, but it has gone largely unacknowledged in the field of lactation.

“This change in HIV policy serves as a reminder to always check sources. New research findings and policy reconsiderations make it imperative that the most up-to-date information is available to the families we serve,” Healthy Children Project’s Karin Cadwell PhD, RN, FAAN, IBCLC, ANLC comments.

Photo by Wren Meinberg

In the U.S., HIV diagnoses among women have declined in recent years; still, nearly 7,000 women received an HIV diagnosis in 2019. (The CDC has commented on the effect of the COVID-19 pandemic: “Data for 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state and local jurisdictions. While 2020 data on HIV diagnoses and prevention and care outcomes are available, we are not updating this web content with data from these reports.”)

How does the U.S. compare in their recommendations to other high-income countries?

The British HIV Assocation’s 2018 guidelines for the management of HIV in pregnancy and postpartum states that “Women who are virologically suppressed on cART with good adherence and who choose to breastfeed should be supported to do so, but should be informed about the low risk of transmission of HIV through breastfeeding in this situation and the requirement for extra maternal and infant clinical monitoring” among other recommendations for helping manage lactation in HIV-positive mothers.

Photo by Laura Garcia

A National Health Service (NHS) Greater Glasgow and Clyde document Management of infants born to HIV positive mothers reads: “There is now evidence from developing countries that breast feeding while mum’s viral load is fully suppressed is safe, and BHIVA/CHIVA no longer regard a decision to breast feed as grounds for referral to child protection services. For HIV positive women who choose to breast feed, maternal HAART should be carefully monitored and continued until one week after all breastfeeding has ceased. The mother’s viral load should be tested monthly to ensure that HIV virus remains undetectable; this testing will be undertaken by the obstetric/ID team. It is recommended that breastfeeding be exclusive, and completed by the end of 6 months.”

You can learn more about Canada’s approach here and Switzerland’s here.

For more, check out  Lacted’s Clinical Question and the CDC’s Preventing Perinatal HIV Transmission.