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!” 



From Africa to Appalachia, improved relationships and communication through nutrition research

 From Africa to Appalachia, Stephanie L. Martin’s, PhD, CLC research on nutrition during pregnancy, lactation, and childhood, has gone beyond nutrition alone.

In a world where infant feeding is commonly reduced to input and output, “perfect” latches and weighted feeds, Martin’s work illuminates the added benefit of improved relationships and communication. 

In Zambia for instance, Martin and her colleagues have looked at how to engage family members to support nutrition in women living with HIV and their children. 

Twenty years ago, when antiretroviral therapy (ART) was less accessible, the risk of transmitting HIV through breastfeeding was high. Today though, with an increase in availability and access to ART, the World Health Organization (WHO) recommends the use of antiretroviral drugs as a safe way to prevent postnatal transmission of HIV through breastfeeding. 

Still, Martin has found that mothers talk about their fears of transmitting HIV to their infants the same way they did two decades ago. Mothers often use unfounded strategies like breastfeeding for shorter durations, breastfeeding less often or offering other liquids in an effort to limit the risk of transmission. So, Martin and her team have counseled mothers not to cut feedings short. Martin shares that her most recent Lactation Counselor Training has offered new insight.

“I’m going to change things in our counseling materials based on what we learned in the CLC training [in regard to] how we phrase things about breastfeeding for longer periods of time; if there is efficient milk transfer, we don’t need to focus on this longer length of time,” she explains.   

Additionally, in an effort to reduce caregivers offering infants under six months food or drink other than breastmilk, alternative soothing recommendations were offered. Martin remembers one mother who tried the suggestions to calm her crying baby. The mother reported that propping her infant onto a specific shoulder alleviated the baby’s discontent. “I don’t know what it was about that shoulder, but she stopped crying,” Martin quotes the mother, noting the importance of empowering mothers and caregivers through counseling. 

In Tanzania, Martin and partners at Kilimanjaro Christian Medical University College sought to identify  facilitators and barriers to exclusive breastfeeding among women working in the informal sector. And in Kenya, Martin and colleagues have worked to improve adolescent nutrition in informal settlements.

Martin pictured with colleagues from Kilimanjaro Christian Medical University College and Better Health for the African Mother and Child organization

Throughout all of her work in East and Southern Africa, Martin says they are reliant on community health workers to roll out their programs. 

“It’s so important to understand their experiences,” Martin says of hearing out the helpers. 

Through her research , Martin has explored the experiences of peer educators, community health workers, WIC breastfeeding peer counselors, health care providers, and program implementers.

Surveying global health professionals provides an opportunity to learn from their experiences and fill gaps in the peer-reviewed literature to strengthen intervention design and implementation as concluded in Martin, et al’s Experiences Engaging Family Members in Maternal, Child, and Adolescent Nutrition: A Survey of Global Health Professionals

Through Facilitators and Barriers to Providing Breastfeeding and Lactation Support to Families in Appalachia: A Mixed-Methods Study With Lactation Professionals and Supporters, Martin draws parallels in the challenges lactation care providers in Africa and Appalachia face, including compensation and availability of services. 

Specifically in Appalachia, the authors heard lactation care providers expressing the desire for additional training for providing support around mental health, chest feeding, drug use, etc. 

Martin says that she found the Lactation Counselor Training Course (LCTC) covered many of these topics. 

“[The course] seemed very intentional in all of the right ways,” she says. 

The Appalachian Breastfeeding Network (ABN) also offers an Advanced Current Concepts in Lactation Course which covers these desired topics with scholarship opportunities. 

When asked if she’s optimistic about the future of maternal child health, Martin answers with a slightly tense laugh: “I feel like I have to say yes.” Martin goes on to explain the inspiring work of ABN and all of the lactation care providers she’s interacted with.

“If they were in charge of the world, it would be such a better place,” she begins. 

“When I think about them, I feel optimistic. I’d like to see different laws that are supportive of women’s health and families. We have all the right people to make positive changes.”

Breastfeeding is food sovereignty. Breastfeeding is health equity. Breastfeeding is healing.

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

Breastfeeding is food sovereignty. Breastfeeding is health equity. Breastfeeding is healing.

Breastfeeding is a “weapon of mass construction”, a phrase coined by Camie Jae Goldhammer, MSW, LICSW, IBCLC, (Sisseton-Wahpeton).

In her Reclaiming the Tradition of Breastfeeding: the Foundation of a Nation webinar, Goldhammer describes how breastfeeding has the power to heal those suffering the effects of generational trauma, specifically through the release of oxytocin, subsequently allowing mothers and their babies to feel empowered and independent.

Photo by Luiza Braun

Kathleen Kendall Tackett’s work also illuminates how breastfeeding can heal trauma. Her videos, How Birth Trauma Affects Breastfeeding and Breastfeeding Can Heal Birth Trauma and Breastfeeding’s Healing Impact on Sexual Assault Trauma discuss the mechanisms behind why and how breastfeeding can be helpful for trauma survivors. Essentially, breastfeeding allows for the down regulation of stress responses, specifically adrenocorticotropic hormone (ACTH) and cortisol, and similar to exercise, improves maternal mood, decreases the risk of depression, decreases hostility, and improves the mother infant bond.

Jennie Toland, BSN, RN, CLC offers commentary on the role lactation care providers play in offering trauma-informed care in this piece.

This Invisibila episode, Therapy Ghostbusters, shares the incredible story of how a Cambodian practitioner worked to help heal an entire community from generational trauma. It took him over a year to simply earn individuals’ trust.

“…That’s pretty unique,” the podcast hosts point out and offers insight into how our nation approaches care for individuals with specific mental health needs and cultural considerations.

Goldhammer quotes Round Rock elder Annie Kahn:  “When a mother nurses her baby, she is giving that child her name, her story and her life’s song. A nursed baby will grow to be strong in body, mind and spirit.”

This connection to the past that Kahn refers to, also offers a form of healing. Breastfeeding is an example of Indigenous food sovereignty, “a part of living culture” and facilitates the revitalization of traditional knowledge. (Cidro, et al 2018)

The revitalization of breastfeeding spans the Black Indigenous People of Color (BIPOC) experience and is a channel to champion equity.

Ifeyinwa V. Asiodu,  Kimarie Bugg,  and Aunchalee E.L. Palmquist write in Achieving Breastfeeding Equity and Justice in Black Communities: Past, Present, and Future:

“Breastfeeding is an especially important public health issue in Black communities, particularly given that Black families and communities continue to experience the highest burden related to poor maternal and infant health outcomes, including higher incidence of preterm birth, low birth weight, maternal mortality and morbidity, infant mortality, and lower breastfeeding rates. Owing to lifetime exposure of racism, bias, and stress, Black women experience higher rates of cardiovascular disease, type 2 diabetes, and aggressive breast cancer. Given that cardiovascular disease and postpartum hemorrhage are leading causes of maternal mortality and morbidity, increasing breastfeeding rates among Black women can potentially save lives.”

Photo by Emily Finch

More specifically, studies show that the experience of racial discrimination accelerates the shortening of telomeres (the repetitive sequences of DNA at the ends of chromosomes that protect the cell) and ultimately contributes to an increase in people’s risks of developing diseases.

It has been found that higher anxiety scores and inflammation are associated with shorter telomere length.

Because physical and psychological stressors trigger the inflammatory response system, one way to counter this reaction is by supporting ongoing breastfeeding relationships; when breastfeeding is going well, it protects mothers from stress. (Kendall-Tackett, 2007)

Another study found that early exclusive breastfeeding is associated with longer telomeres in children.

Photo by Luiza Braun

The authors of Achieving Breastfeeding Equity and Justice in Black Communities: Past, Present, and Future continue, “Yet breastfeeding is rarely seen as a women’s health, reproductive health, or a public health strategy to address or reduce maternal mortality and morbidity in the U.S. Inequities in lactation support and breastfeeding education exacerbate health inequities experienced by Black women, specifically maternal mortality and morbidity, and thus a greater investment in perinatal lactation and breastfeeding education and resources is warranted. Breastfeeding is an essential part of women’s reproductive health.”

Journalist and maternal child health advocate Kimberly Seals Allers’ approach is one “For Black people, from Black people.”

“…The call to revive, restore and reclaim Black breastfeeding is an internal call to action,” Kimberly Seals Allers begins in Black Breastfeeding Is a Racial Equity Issue.  “… Breastfeeding is our social justice movement as we declare the health and vitality of our infants as critical to the health and vitality of our communities.”

Specifically through her work with Narrative Nation, Seals Allers and colleagues are promoting health equity “by democratizing how the story of health disparities is told,” centering BIPOC voices. Additionally, through her Birthright podcast, KSA uplifts stories of  joy and healing in Black birth.

Especially after the deaths of George Floyd, Breonna Taylor and Ahmaud Arbery, organizations made statements about their commitments to dismantling structural racism and focusing efforts on equity.

Equity has become a buzzword; in fact, one author brands the sentiment “Fakequity”. This year, United States Breastfeeding Committee (USBC) National Conference and Convening presenters expressed their fatigue with the word.

“We want to see action,” they said.

Nikki & Nikki LIVE offer their Allies, Advocates and Activists Equity in Lactation webinar which covers the meaning of equitable in lactation care, how to show up for the marginalized and how to make a lasting impact.

In other efforts, the CDC has identified breastfeeding as a priority area to address health inequities.

Photo by Luiza Braun

NICHQ’s Achieving Breastfeeding Equity campaign also focuses on closing breastfeeding disparity gaps, viewing their efforts through an equity lens.

Director of policy and partnerships at the National Women’s Health Network Denys Symonette Mitchell offers commentary on a way forward with key policies that will ensure investment in breastfeeding to ultimately advance health equity.

Watch Racism and the Colonial Roots of Gendered Language in Public Health and Biomedicine with Dr. Aunchalee Palmquist, PhD, IBCLC for more on these issues.  

 

——–

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 about how you are contributing to working toward healthy equity.

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