“… A proper ringing toast soothes the savage beast,” Karen Krizanovich writes. “Taste has a sound and it’s the thing with the ding that is the ding an sich of the memorable toast.” We teach our little ones civility and celebration and merriment at a young age; the clunk of a sippy cup meets a mug of coffee, toasting the adventures of a toddler. One mother shares that her 15 month old decided to start “cheers-ing” her breasts together before she nurses.
Parenting is serious business, and those who support parents through their responsibilities undertake weighty duties too, but amidst the seriousness, there is hilarity and light.
In 2019, we published Cheap medicine: laughter, where you’ll find research on laughter as it relates to infants, development, breastfeeding, and prosocial behavior.
This week, we’ve compiled a collection of breastfeeding-related material to make you laugh. Interestingly, in our search for funnies, we found that many of these pieces are reactions to the absurdity of infant feeding culture in the U.S. For instance, there is a comic depicting a breastfeeding dyad in front of an ad of a buxom woman. Two men approach, shaming the dyad, “Nursing?! This is a shopping mall! We can’t allow women to brazenly display their breasts!” It makes you chuckle, but of course the undertone is depressing. Nikki Lee wrote commentary on the real-life manifestation of this absurdity. Find it here.
In another case, humor is used as a coping and healing mechanism as well as commentary on the Pinkwashing of the breast cancer epidemic. Poet and performer Christine Rathbun Ernst’s delivery will make you laugh and ask you to consider some really raw, hard topics. Find her work here.
During her second pregnancy, a mother tested positive for cytomegalovirus (CMV). The CMV virus can cross through the placenta and infect a developing fetus, potentially causing birth defects or other long-term health problems. This mother was contacted and presented with the opportunity to participate in a clinical trial where she would be infused with a drug that would potentially mitigate the risks of her child developing congenital CMV.
The mother reports that because her child was already at risk, she saw participating in the trial as something she could do to avoid the risk of potential health problems.
The process of participating was relatively simple considering her work-from-home arrangement and having reliable child care for her older child.
At last, her daughter was born healthy and continues to thrive.
This mother reports that, until recently, she hadn’t considered what she would have done if something had gone wrong as a consequence of participating in the trial. She said that she’s unsure what kind of compensation might make up for a hypothetical injury to her child who was unable to consent to the trial. She emphasized that parents dedicate themselves to making the right decisions for their children, so the stress of raising a child with special needs coupled with the guilt of having made the “wrong” decision, could be shattering.
The inclusion of pregnant and lactating people in clinical trials is part of an evolving national and international conversation.
Earlier this spring, the Committee on Developing a Framework to Address Legal, Ethical, Regulatory, and Policy Issues for Research Specific to Pregnant and Lactating Persons held a workshop to discuss how institutions make risk-benefit decisions regarding the inclusion and exclusion of pregnant and lactating persons in clinical research, and the role of liability, risk management, and trial insurance in those decisions as well as reviewed existing compensation schemes for research-related injuries and potential to scale these models to serve the needs of research participants.
Historically, pregnant and breastfeeding women have been excluded from clinical trials, due to concerns about the real or perceived potential risks to the fetus or child. [FDA Voices, 2021] Namely, the thalidomide crisis in the 1950s largely shaped the culture around risk aversion and clinical testing on the pregnant population.
“A 2011 study on all medications approved by the FDA from 1980 to 2010 found that 91 percent of the medications approved for use by adults did not have sufficient data on safety, efficacy and fetal risk of medication taken during pregnancy,” the authors of Fair inclusion of pregnant women in clinical trials: an integrated scientific and ethical approach write. “At the same time, the number of pregnant women who take medications, as well as the number of medications that these pregnant women take, has increased.”
Today, health advocates are pushing for the inclusion of this population in clinical research on the basis that patients should have solid evidence in order to make informed decisions about their health.
“Not having this evidence can result in unfairness in the distribution of benefits and burdens (injustice) and can curtail the autonomy in making informed choice,” Catriona Waitt writes in Clinical trials and pregnancy. “This may make it impossible to provide the best treatment, undermining the principle of beneficence, and risking increasing harm.”
Speakers at the workshop cited several roadblocks to the inclusion of pregnant and lactating people in clinical research.
Institutional Review Boards (IRBs) are charged with keeping patients safe, so they often take a very conservative approach. [White, 2021] Elisa A. Hurley, PhD, executive director of Public Responsibility in Medicine and Research (PRIM&R) explained that the current framework does not encourage or assess the risk of not doing research on this population, and that the culture needs to shift from exclusion to inclusion as the default. Dr. Hurley cited the University of Washington where there’s been a shift to require justification to exclude pregnant and lactating populations.
Lorien Urban, Ph.D., Senior Medical Director Clinical Development at Ferring Pharmaceuticals pointed out that IRBs tend not to acknowledge a distinction between pregnancy and lactation when reviewing trials. In fact, while the placental barrier can be sensitive, there are very few drugs that pass through to mothers’ milk. [InfantRisk Center]
Metin Gülmezoğlu, M.D., Executive Director at the Concept Foundation argued that pregnant and lactating women should demand to be included in research, and that governments should react accordingly, assuming responsibility and taking action.
Gülmezoğlu’s project AIM responds to the created culture of risk aversion in the field. Gülmezoğlu said that risk aversion doesn’t get rid of risk; instead it shifts risk to another person: either the care provider or the pregnant person themself.
Risk is of primary concern for companies and organizations conducting research in these populations.
Sara E. Dyson, M.P.H., C.P.C.U.,Vice President of Underwriting Operations & Risk Management at Medmarc laid out the ways in which institutions can make their trials less risky and more attractive to underwriters:
demonstrate for the potential risk,
conduct significant bench testing,
conduct informed consent on video,
ensure compensation is reasonable and cannot be construed as coercion
consult with reputable IRB (multiple IRBs in some cases),
select a trial site (for instance an institution with specialty in high risk pregnancy)
Niranjan Bhat, M.D., M.H.S., Senior Medical Officer at PATH, shared that PATH’s global umbrella policy which covers any adverse event during participation of the study is a key research enabler.
Michelle Mello, J.D., Ph.D., Professor of Law and Health Policy at Stanford University and Renée J. Gentry, Esq., one of the leading experts on vaccine injury litigation in the National Vaccine Injury Compensation Program (NVICP), laid out the ways in which tort versus private compensation programs can be successful or unsuccessful in compensating injured clinical trial participants. In either case, proving causation tends to be the primary difficulty on the battleground for product liability.
The tort system is capacious enough to handle injury claims, Dr. Bello began. However, using Winston Churchill’s metaphor for democracy– “Democracy is the worst form of government – except for all the others that have been tried.”– it tends to favor the wealthy, is laborious in terms of time, and presents high volatility in terms of settled amounts.
Perhaps not a solid alternative, a system like NVICP, is at a “breaking point”, according to Gentry. The program started with eight special masters when it began in the 1980s; today this number remains. Set up to cover six vaccines, the program now covers 16 vaccines; as such the number of complaints have quadrupled in the past decade. People are waiting two to three years to have their trials scheduled. In fact, some seniors have died waiting for their trials.
Gentry advises that when considering the creation of a compensation system, there should be flexibility built in to include the modification of staffing levels and scheme.
In a private system, like the UW-Washington Human Subjects Compensation Program, this flexibility is a positive attribute; however, speakers pointed out that private systems do not address two major points:
A private system does not get around addressing causation difficulties.
A private system does not necessarily address equity and has the potential to lead to a patchwork of compensation of different solutions at different levels of generosity.
As health professionals, consumers and other individuals and organizations work to shape the legal, ethical and policy frameworks that affect research on the pregnant and lactating population, you might consider consulting the following readings and resources.
Breastfeeding is an opportunity to learn. Although breastfeeding is an ancient practice, there is still so much to learn about the lactating breast, breast function and the process of breastfeeding, especially as our modern lives continue to change.
“…Few studies have actively investigated the anatomy of the lactating breast despite the obvious importance a clear understanding of the lactating mammary gland has to both mother and infant,” Geddess writes. “Perhaps this lack of information is a part of the greater reason why many women continue to experience breastfeeding problems.”
Stroke is a growing global health problem. It is the third leading cause of disability adjusted–life years (DALYs) worldwide and the first leading cause of DALYs in China, Ren, et al point out. Stroke imposes a financial burden on patients, families, and society. The cohort study found that lactation duration significantly lowers the risk of stroke.
Up until now, most research has focused on the association between lactation and cardiovascular diseases (CVDs), but this piece lays out the association between lactation and stroke subtypes.
Specifically, the study found that parous postmenopausal women with lifetime lactation duration of at least 7 months had lower risks of ischemic stroke and intracerebral hemorrhage (ICH) compared with women who never lactated. For subarachnoid hemorrhage (SAH) though, such associations were found only in participants with lifetime lactation duration of longer than 24 months. In addition, the authors found that those with an average lactation duration per child or lactation duration for the first child of at least 7 months were less likely to develop stroke and its subtypes.
The systematic review and meta-analysis demonstrated higher rates of low birth weight (<2500 g) and small for gestational age (<fifth percentile), lower mean birth weight, preterm delivery (<37 weeks’ gestation), higher rate of admission to the neonatal intensive care unit, poorer Apgar scores at 1 minute, and smaller head circumference in those exposed to marijuana.
The prevalence of marijuana use during pregnancy is significant, and many people cite the belief that marijuana use is relatively safe during
pregnancy. This work may help to raise awareness and be used to educate patients about adverse outcomes with the hope of improving neonatal health.
More on cannabis during the perinatal period here.
The authors of Childhood Obesity and Breastfeeding Rates in Pennsylvania Counties-Spatial Analysis of the Lactation Support Landscape examined the relationship between childhood obesity and breastfeeding rates in Pennsylvania (PA) counties, the relationship between geographic access to professional lactation support providers (LSPs) in PA counties and breastfeeding rates, and the relationship between geographic access to professional LSPs and childhood obesity in PA counties. They found a significant, inverse relationship between breastfeeding rates and childhood obesity prevalence at the county level and a significant, inverse relationship between the number of CLCs and the number of all professional LSPs and childhood obesity rates at the county level. Thus, the authors conclude, the availability of breastfeeding support is significantly related to breastfeeding rates and inversely related to childhood obesity rates across Pennsylvania.
More specifically, the algorithm provides a tool to help reduce delays or decrease interruptions during skin-to-skin contact (SSC). The authors note, “Not suckling in the first hour after birth places newborns at higher risk for neonatal morbidities and mortality. Examining patterns and developing strategies for change optimizes patient outcomes.”
Acknowledging the social determinants of health
Pregnancy and the origins of illness(2022) by Anne Drapkin Lyerly begins by acknowledging that the COVID-19 pandemic has induced a collective trauma that is expected to be felt for generations after the virus is contained. The study of epigenetics has shown that children gestated or born during times of great tragedy, carry a genetically coded and inherited imprint of their mother’s experience with lifelong consequences to their health.
Recognizing the “maternal-fetal interface” as the “nexus of inter-generational trauma” raises the question of how we should think about this implication of maternal bodies, especially in light of the current pandemic.
The author explores the growing field of developmental origins of health and disease (DOHaD) and its use of epigenetics. Thinking about the tools of history, philosophy, and gender studies of science, the author advises we proceed with caution as we consider maternal effect science which raises several concerns that can impact practice and the well-being of mothers and consequently their children.
Namely, there may be a tendency to ascribe blame on pregnant people for the health outcomes of their offspring that are well beyond their control. This approach doesn’t adequately weigh the effects of paternal, postanal, and other social and environmental factors that also influence the long-term health of children.
Analyzing epigenetics can eventually contribute to the erasure of the mother as a person, and further, characterizing the maternal body as an environment may excuse women from being appropriately considered in public health policies, clinical care and health research.
The author considers DOHaD research a corrective approach to near-sighted fetal origins science and urges that we expand our understanding of the gestational environment from not simply the womb, but to the broader environment in which a person gestates, marking the importance of acknowledging the social determinants of health. To best direct our efforts during the current pandemic, the author suggests shifting the focus off of maternal behavior and choices and instead focus on limiting the harm of climate change, racism, and other structural inequities.
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 email@example.com with your name and “OMW is 10” in the subject line.
This week, in the body of the email, tell us: What fascinates you about breastfeeding and/or what do you wonder about breastfeeding?
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.
Joyea Marshall-Crowley, CBS, Protect Yourself, Protect Your Baby Program Coordinator with the Kansas Breastfeeding Coalition (KBC) and coalition coordinator at the Wichita Black Breastfeeding Coalition (WBBC) had a wonderful perinatal experience in Dayton, Ohio. She shared her pregnancy and labor and delivery stories on social media, specifically advocating for midwifery care, sparking curiosities and starting conversations among her friends.
When she moved back to her hometown of Wichita, Kansas though, she realized that the health options available were lacking.
“Those options were not offered, spoken about, or supported,” Marshall-Crowley begins. “Since then, I pride myself on letting women know they have choices and are in control of their maternal healthcare.”
Marshall-Crowley’s management of “Protect Yourself, Protect Your Baby” helps provide pregnant and breastfeeding mothers of color with accurate information about the COVID-19 vaccine. The focus of this project is to create a safe space to talk about vaccine hesitancies. The project includes healthcare experts of color who understand that these hesitancies come from trauma and historical incidents within the healthcare system, Marshall-Crowley explains. You can find more information here: https://ksbreastfeeding.org/covid-19-vaccine-awareness/
WBBC formed relatively early on in the pandemic. With everything shut down, Marshall-Crowley noticed that people were in a state of being still and listening. On top of that, more babies were being born, and mothers were interested in finding ways to keep their babies safe from COVID which led them to research and take more interest in breastfeeding.
Marshall-Crowley and other supporters uplift mothers with lactation and breastfeeding information and supplies.
“We are most proud of being a representation for women of color regarding breastfeeding support,” Marshall-Crowley shares.
WBBC has engaged in many community events this summer like The Rudy Love Music Festival, Fiesta Mexicana of Topeka, Rock the Block, and Juneteenth celebrations just to name a few.
Marshall-Crowley shares that they have received excellent feedback from the community and have been thanked many times for doing this work for the black and brown communities.
She goes on, “Since the pandemic, social media has highlighted maternal healthcare for black and brown women, and breastfeeding has entered into those conversations. The culture is undoubtedly changing and starting to include breastfeeding as a first choice for infant feeding. For Wichita specifically, there have been changes like the formation of the coalition and the creation of the “Wichita Birth Justice Society,” which highlights maternal healthcare in a full circle. As a result, women of color in our community are feeling more supported and interested in owning their own maternal health experiences.”
When WBBC started, there were no credentials in lactation within the group, Marshall-Crowley reports. Since spring though, they’ve added two certified breastfeeding specialists (CBS) working towards their IBCLC, three doula-trained workers, three Chocolate Milk Café trained facilitators, and two in the works of getting their midwifery license.
“Our vision is to become the resource and information where Black women can seek help from the coalition, people who look like them and do not have to be outsourced because of ‘credentials,’” Marshall-Crowley stated in the coalition’s HealthConnect One feature.
Eight years ago, Dennis Gaynor Jr.’s son Samuel was born at 28 weeks gestation weighing 1 lb. 6 oz. Mr. Gaynor was encouraged to hold his baby skin-to-skin during their hospital stay to help improve his baby’s blood oxygen levels, sleep, temperature, breastfeeding and weight gain. Kangaroo Care was a new concept for Mr. Gaynor.
“[I] didn’t realize that this is such a great way to bond with Sam. But I did it with no hesitation and I’m enjoying every minute, second, and hour,” Mr. Gaynor shared. “The thought of my heart beat going into my sons’ ears brings a melody to my heart.”
Samuel’s mother also held him skin-to-skin and provided her milk which helped them endure several surgeries throughout his first few years of life.
Mr. Gaynor says that he continued to hold Sam skin-to-skin after they were discharged from the hospital. “He was so small, I was scared to hold him, but that was the only other method,” he explains. “To this day, he lays on my chest; everyone else gives me a normal hug, but this is what we’ve always done.”
Mr. Gaynor and his wife run a 501(C)3 nonprofit organization called Young Men on a Mission: YMOM (pronounced why mom) established in the inner city of Milwaukee, Wis. Their programming includes mentoring, sports and work training intended to help young men “gain hope in themselves to create goals that extend beyond their daily existence; retain hope when it appears that the odds are stacked against them; and dare to be somebody.” Find out more about YMOM here: https://www.youngmenonamission.org/about-us
Check out Healthy Children Project’s Kajsa Brimdyr’s The 9 Stages of Premature Infants film which shows the nine stages demonstrated by premature infants. Find more here.
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