This is the 29th post in a series on Booby Traps, made possible by the generous support of Motherlove Herbal Company.

In my last post I wrote about cultural issues and breastfeeding support in the hospital.  Today I’m pleased to share a post asking the question:  Is there a racial Booby Trap?

You may know that there are significant disparities in breastfeeding rates among racial and ethnic groups in the U.S.  Probably the clearest example of this is the breastfeeding initiation rate of African American moms, which in 2007 was 60%, compared to the overall U.S. rate of 75%.

There are a number of reasons why the rates are different, and I explored some of them in this interview with Kathi Barber, founder of the African American Breastfeeding Alliance.

One reason we didn’t discuss, but which I’ve heard a number of times, is an assumption among health care providers that African American moms don’t plan on breastfeeding.  The result of this expectation is that moms sometimes get poor or no support in the hospital at getting breastfeeding off to a good start.

So, is there a “soft bigotry of low expectations” when it comes to breastfeeding support?  I certainly hear stories reflecting that, like this one in which a mother who is committed to breastfeeding gets no help (but plenty of formula samples) from her postpartum nurse, who “seemed surprised to find [her] breastfeeding.”

But I’ve been wondering whether any research might bear that out, so I spent some time looking at the limited literature on this topic, and I think the studies below add up to a “yes.”

Here’s what I found:

- One study examined racial disparities according to women’s self-report of advice received from health care providers during pregnancy about breast-feeding, among other topics.  It found that “the difference [in advice] between Blacks and Whites…approached significance for breast-feeding.”  Another study concluded that “the prenatal period may be a critical time to influence a prospective black mother’s decision to breastfeed.”

- One recent study of WIC breastfeeding support in North Carolina found that “those with higher African American populations were significantly less likely to offer clinic-based breastfeeding support services and trended toward fewer services in general” and found that “differences in the availability of breastfeeding support services were associated with the racial/ethnic composition of the catchment area.”

- A study using older data found that “being African American was associated with less likelihood of breastfeeding advice and greater likelihood of bottlefeeding advice from WIC nutrition counselors.”

- A small interview-based study of African American women and breastfeeding found that “support and advice about infant feeding from the health care system were uneven.”

Why is strong provider support important?  Because study after study has found that when African American women (and all women, for that matter) are given good advice and support, breastfeeding rates go up and up.

Take for example, Boston Medical Center, which became a Baby Friendly Hospital in 1999.  The rate of breastfeeding among African American women went from 34% in 1995 to 74% in 1999.

Another study found that Baby Friendly Hospitals, whether they serve high or low proportions of African American mothers, all had similarly high breastfeeding rates.  In other words: disparity, what disparity?

Is there good news to share on the disparity front?  Yes.  The gap between black and other mothers’ breastfeeding rates is closing at a strong rate, declining from a gap of 19% down to 15% in just seven years (2000-2007).

This is a real achievement, and something to celebrate.  But I would hope that continued progress occurs with the full support of our health care providers.

Do you think your race had any impact on your providers’ assumptions about whether you would breastfeed?  Have you experienced a Booby Trap based on your race?

Image credit:  Indiana Black Breastfeeding Coalition

This post is the 28th in a series on Booby Traps, made possible by the generous support of Motherlove Herbal Company.

I’ll be writing for a few weeks about a set of Booby Traps which are both seldom discussed and vitally important.  Cultural, language, and racial factors can have a tremendous impact on breastfeeding success, and the failure of providers to recognize this represents a significant Booby Trap for many mothers. I’ll begin today by talking about culture and breastfeeding in the hospital.

Culture

Once, a few years ago, I was asked to see a new mom in her hospital room.  The mother was of Indian background, and both the baby’s grandmother and an aunt were also in the room.

The mother asked me if there were any foods she should eat so that she would make enough milk.  Before thinking, I said what I always say, which is that it’s not necessary to eat or drink anything special; she would make enough milk on her own as long as she was feeding her baby frequently and effectively.

Off in the corner or my eye, I saw the grandmother and aunt exchange a look.  It was a specific look, recognizable across cultures and generations.  The look said, “this chick doesn’t know what she’s talking about.”

I suddenly realized that my answer, while technically correct, was really not the right response.

I had contradicted some influential people in the mother’s life and thousands of years of tradition.  Chances were, this mom wasn’t going to take much of anything else I said very seriously, and we’d barely started talking.

I mean, would you take Thanksgiving cooking advice from an “expert” who told you that, while serving turkey is an interesting and quaint tradition, there’s no scientific evidence that it’s the appropriate food for the occasion?

If I could go back, I would have returned the question with one of my own.  Something like, “what traditions do you have around eating foods to help with milk production?”  That would have 1) sparked an informative (especially to me) discussion, 2) made it more likely that my subsequent advice would be taken seriously, and 3) established some trust and mutual respect among us.

The two questions providers should ask themselves when encountering a tradition like this is, “is it harmless?” and “is it harmful?”  If it’s harmless, and especially if it could help the mother reach her goals, then by all means we should support it.  If it’s harmful to breastfeeding (for example, supplementing with formula without an understanding of its effect on milk supply, or not feeding colostrum because of a “colostrum taboo”), then there is cause for a discussion.

So when mothers of Chinese background have told me how important it is to eat a certain chicken dish, or mothers of Mexican descent say that they have to drink atole, should I say that there is no evidence that this has any effect on breastfeeding?  No, I should ask myself if these traditions are harmless or harmful, and get out of the way.  (Except maybe to ask for a taste?  These foods usually sound pretty good.)  That “look” taught me that important lesson.

Now that I’ve given you an example of what not to do, here’s an example of a cultural Booby Trap smashed to smithereens by some outstanding hospital staff:

In 2008, Cambodian American moms in Massachusetts had the lowest breastfeeding rates of any ethnic group in the state.  At one hospital, the rate for Cambodian moms was a dismal 17%, when the rate for non-Cambodian moms was 61%.

In Cambodian culture, as in many others, there are specific foods that are to be eaten postpartum.  And the staff recognized that “one barrier to breastfeeding is a lack of hospital foods that allow women to follow a traditional diet postpartum.”

So the forward thinking staff of the childbirth unit and food service department teamed up to offer a traditional Cambodian menu for moms in the postpartum period, and they studied the results.

Guess what happened?  The breastfeeding rate for Cambodian American moms jumped from 17% to 67%.

So, to follow the guidelines above, we ask:  Is serving traditional foods postpartum harmless?  Yes.  Is it helpful to breastfeeding?  Oh, yes!  And just look what can happen when you eliminate an easily overlooked cultural barrier.

To close this topic, I want to quote a wonderful article on this topic by Jan Riordan and Kathy Gill-Hopple, which sums up the issue beautifully:

Culturally sensitive care for breastfeeding women
begins with an honest and critical awareness of the differences
among cultural groups. By becoming aware of
these differences, we begin a process of partnership in
which all groups have something to contribute. Working
within the cultural constraints of the group to which the
mother belongs, the nurse can serve her client more
completely and is more likely to be viewed as a helper
rather than as one who “does not understand us.” Breastfeeding
families have the right to be treated in a nonjudgmental
manner that accepts their cultural diversity.
The study of traditions of a given culture is crucial to all
health care professionals who work with young families.

Were you Booby Trapped by a cultural issue in the hospital?  What cultural breastfeeding traditions do you follow?

This is the 27th in a series on Booby Traps, made possible by the generous support of Motherlove Herbal Company.

There are few topics that get me going more than the quality of help mothers get in the hospital getting their babies latched on comfortably and effectively.  So I hope you’ll forgive the frustration you’ll hear in this post.

Why do I get worked up about this?  Because CDC data show that one in three mothers who stop breastfeeding in the first month do so because “breastfeeding is too painful.”  37% percent of moms who stop in the first month report, “sore, cracked, or bleeding nipples.”  And because a good latch results in good milk transfer and the development of a full milk supply, and 50% of mothers report early weaning because “breastmilk alone didn’t satisfy my baby,” and another 50% report “I didn’t have enough milk.”

But most of all, I get upset because all of this could so easily be avoided.  When I hear mothers who have left the hospital with sore and bleeding nipples, say “they said the latch was fine” (an assessment made, in one case, from the doorway), I know that in the vast majority of cases their pain was avoidable.

Of course, not all pain with breastfeeding is a result of a poor latch.  Things like tongue ties, milk blisters, and thrush certainly cause pain.  But the vast majority of mothers I’ve seen who have left the hospital with pain have babies who are simply not latching on deeply.

For moms with ‘run of the mill’ latch problems, some good help can usually make breastfeeding significantly more comfortable in a matter of minutes.  In other words, it can go from “I’ve been crying through feedings,” or “This hurts more than labor did,” to “Oh my God, so this is what it’s supposed to feel like?” almost instantaneously.  How do I know?  Because I’ve helped moms get from here to there over, and over, and over.

Though I try not to show it, when moms thank me for helping them with the latch, I feel less gratified than angry.  I feel angry that the simple adjustments I made weren’t taught from the beginning.  I feel angry because, for many moms, this goes beyond “breastfeeding duration.”  It means that the early days of motherhood – a precious, irreplaceable time – are filled with pain, frustration, and doubt.  Most of all, I feel angry that all of that could be so easily avoided.

Is it too harsh a statement to say that moms are being robbed?  Robbed of peaceful early days with a new baby?  Robbed of good memories?  Robbed of the chance to fulfill their breastfeeding hopes and meet their goals?

I’ve thought a lot about the causes of this poor help, and here’s my list of contributing factors:

Poor training. As I’ve written before, preservice training for nurses, doctors, and other providers is generally cursory at best, and once on the job inservice training is not consistently done.  So some of the staff at hospitals just don’t know how help moms with latch.  And some dispense inaccurate information (i.e. “Your nipples with toughen up”).

Workload or low priority? Nurses, doctors, and other hospital staff are busy, and getting busier.  Helping with breastfeeding can take a while.  I’m sympathetic to the nurse who is running her behind off to keep up with her patients.  But I also know that organizations can make time for things they consider important.  So, what does it say about a hospital’s priorities that mothers are permitted to leave the hospital in such pain?

Changes in practice. To some extent, the target has been a moving one when it comes to teaching about latch and positioning.  Until maybe ten years ago, the state of the art advice on how to get a baby latched on was “line up the nipple with the baby’s mouth and ram her on she opens her mouth.”  Then research and clinical practice started to support the “asymmetrical latch,” in which the baby is lined up “nose to nipple” and the chin is touched to the underside of the breast, eliciting a wide gape (see this video for the best illustration).  When latched on this way, it looks like the baby has more of the breast in the chin side of the mouth than the nose side.  Newer research is supporting the use of reclined positions (“laid-back breastfeeding,” or “Biological Nurturing”) to elicit babies’ innate feeding instincts and ability to latch deeply.  At this point I think that hospital staff can be forgiven for not knowing about this latest trend, since the research is still fairly new.  But I would hope that in the next few years that will change.  For now, if you encounter a nurse who hasn’t heard the phrase “asymmetrical latch,” move on.

Deferring to lactation consultants.  I think I’m seeing a trend toward viewing basic breastfeeding support as the job of lactation consultants, rather than the job of the nurse.  It’s wonderful that more hospitals are employing lactation consultants, but unless a hospital intends for them to see every mother (and this is not common), it appropriately remains the job of nurses and others to get mothers going with breastfeeding, barring anything complicated.  I worry that mothers who just need basic help getting a good latch end up waiting to see a lactation consultant, who is appropriately busy with more complicated situations (prematurity, tongue tie, breast surgeries, and twins are a few that come to mind).  Meanwhile, many moms whose problems could be solved quite easily, wait for the cavalry which never comes.

Did you get good help with your baby’s latch when you were in the hospital?  Why do you think moms often get poor help with latch in hospitals?

This post is the 26th in a series on Booby Traps made possible by the generous support of Motherlove Herbal Company.

Following up on last week’s post on skin-to-skin after a cesarean, I’m very happy to share this interview with my friend and lactation consultant Joanna, who welcomed her second baby last year at a California hospital.  I trained to become a lactation consultant with Joanna, who now works as a lactation consultant in the San Francisco Bay Area.

Joanna, who had an unmedicated birth with her first son, was expecting to have a similar birth with her second baby.  Late in her pregnancy the baby’s position was breech, and after a version attempt resulted in the baby’s heart rate dropping, it became clear that she would have to birth by cesarean.

Joanna is well versed in the power of early skin-to-skin contact, and was able to arrange a period of skin-to-skin contact in the operating room.

1)  Why was it important to you to hold your baby skin-to-skin after your cesarean section?

When I met with my midwife and learned that we would need a cesarean, my emotions overwhelmed me.  After I was able to briefly compose myself I spouted, “I just want him to be a good feeder.”

Breastfeeding is really important to me, I’m a lactation consultant by day and enjoyed breastfeeding my first for almost two years.  I was very afraid that the cesarean would rob me of that experience.  I was also very afraid that I wouldn’t experience that same intimate time with my second baby that I enjoyed with my first through immediate and ongoing skin-to-skin time and lots of breastfeeding.

The midwife was awesome and added “skin-to-skin” to the problem list in my chart so the whole team knew it was really important to me.  Then at my pre-op appointment with the obstetrician I again expressed my deep concern/yearning over being able to do skin-to-skin.  She said she couldn’t make any promises because she wouldn’t be attending the delivery but would pass along how passionate I was and encouraged me to remind the team on the day of surgery my wishes.

On the day of the surgery as each provider talked to me in advance, they all said they had read in my chart that I wanted to do skin-to-skin.  They were more supportive than I expected.  I imagined I would be received with rolling eyes and that I would have to fight to get what I wanted, and likely be disappointed.  They all treated me like I had a reasonable request and it was no big deal to accommodate that request.  These positive conversations went on with my labor and delivery nurse, my OB, and the anesthesia team.

After my son was delivered he went to the baby warmer in the OR which I could see out of the corner of my eye.  They had him there probably less than 5 minutes; drying him, checking weight, doing a brief newborn exam.  Vaccines, eye drops, bath were on hold.

The nurse attending the baby asked if I was ready and I practically wanted to jump off the table!  Working inpatient lactation I’ve seen moms in the first few hours after c-sections and was prepared to feel awful and experience nausea and vomiting, among other side effects.  The anesthesia team was still by my head checking my vitals, etc.  Leads were all over my chest, and I couldn’t really feel my hands too well from the spinal.

They placed my baby on my chest with his feet almost on my left shoulder and his check on my right breast.  I placed my arms around him.  My husband sat at my left shoulder and also had a hand on the baby’s back for extra support.  We were able to stay skin-to-skin like this for about 10 minutes all the while the OB and team were closing the incision.

Out of nowhere I start feeling really yucky and very panicked. I told them I felt awful and somebody needed to take the baby.  Not seconds after they took him off my chest and had him back on the baby warmer did I throw up.  After that subsided, the baby nurse asked my permission to take the baby to the nursery with my husband and finish the newborn exam, and do the vaccines and eyedrops, with the bath on hold until later.  I consented, as I was still feeling awful and there was no way I could have him on me that point.

Shortly thereafter I was in the recovery room.  I was still feeling terrible, was really pale, had low blood pressure, and was shaking.  I was still feeling the effects quite heavily from the spinal.  My husband came in with the baby.  He was eager to get the first feeding going, anxiously looking at this watch because we were 1-2 hours since delivery.  The nurse was hesitant because I was still feeling and looking so awful.  I stayed in a semi-reclined position and my husband helped the baby get his first latch and then helped place him back skin-to-skin.

I was fortunate to know a lactation consultant where I delivered, and I offered to share my personal photos of us doing skin-to-skin in the OR for the hospital’s professional use.  She reported that within a month of when I delivered another c-section mom was able to do skin-to-skin and had subsequent great breastfeeding experience, and the baby had minimal weight loss.  That mom had had a horrible experience breastfeeding her first baby, who never latched.   She did skin-to-skin with her second child, who had a beautiful feeding at 90 minutes of age and was discharged exclusively breastfeeding with 4 percent weight loss!

She reports that they are still having resistance among providers to consistently have c-section moms do skin-to-skin in the OR.  When I last talked to her she said that they will be publishing my photos to be used in a campaign for skin-to-skin in OR.

I wrote thank you notes and sent to the managers of the labor and mother/baby units, thanking them for our experience.  If I can remember some of the details from my thank you note it was that I was treated with respect, and that nobody made me feel like I was asking for something unreasonable.  At a recent multidisciplinary meeting one of the managers read my thank you note aloud.  And, I’m told, one of the quality assurance team members was almost moved to tears.

I cherished that intimate time of getting to know my newborn through skin-to-skin.

This post is the 25th in a series on Booby Traps made possible by the generous support of Motherlove Herbal Company.

A little while back I wrote about the power of skin-to-skin contact and its relationship to breastfeeding and many other healthy outcomes for babies.

But one thing that kept nagging at me as I wrote it:  If one of three births (and perhaps as many as one in two, if current trends continue) is a cesarean, and if early skin-to-skin seems to be so important, what can be done to improve the chances that a baby born by cesarean has a good shot at this important experience?  A while back, Best for Babes linked to a wonderful video from Norway (shown above) showing skin-to-skin and breastfeeding in the operating room.  But is there evidence that this could work on a large scale here?

I’m very pleased to share a study, just published this fall, on one hospital’s experiment with making skin-to-skin in the operating room the standard of care after a cesarean for healthy, term babies.

So, on to this very exciting study:  A Baby Friendly San Francisco hospital recently initiated a quality improvement project in which skin-to-skin contact in the operating room and during recovery was used as a means of increasing breastfeeding success.  This intervention was prompted by reviewing data for a two week sample of healthy, term infants, which found the following problems:

Over 90% of [healthy, full term] infants born vaginally were exclusively breastfed during their hospital stay (11 out of 12) compared to only 50% of infants born by cesarean (5 out of 10). Furthermore, only 20% of the cesarean infants were [skin-to-skin] STS with their mothers within 90 minutes of birth, and 40% were not STS at all during the first 4 hours after birth. Of these infants who were not STS at all in the first 4 hours, 100% received formula supplementation while in the hospital.

So, the hospital embarked on an intervention to make skin-to-skin the standard practice in the operating room and in recovery.  Here were their findings:

During the first 3 months of our intervention, the rate of early STS among healthy babies born by cesarean increased from 20% to 68%. The rate of infants who did not get STS contact within 4 hours of birth decreased from 40% to 9%.  Nine months after the initiation of the intervention, 60% of healthy cesarean births utilized STS in the [operating room] OR, and 70% involved STS within 90 minutes of birth.

Healthy infants born by cesarean who experienced STS in the OR had lower rates of formula supplementation in the hospital (33%), compared to infants who experienced STS within 90 minutes but not in the OR (42%), and those who did not experience STS in the first 90 minutes of life (74%).

And how did mothers react to having this early skin-to-skin contact?

We received positive feedback regarding mothers’ experience with STS in the OR. Mothers stated that they would like to have STS contact with their babies in the OR if they were to experience a cesarean again, and commonly concluded that STS in the OR made them feel happy.

One woman, when asked how she felt about having her baby STS with her in the OR, responded (translated from Spanish): I felt some pain at the end of the surgery because the effects of the anesthesia were wearing off, but when they put the baby in my arms I forgot about the pain because I was so happy to have him with me. She denied feeling worried about holding her baby STS in the OR and stated: With my last child they took her to the nursery right away [after the cesarean] and she never wanted to latch after that … but this baby latched right away and he nurses really well because I had him with me right away.

Another Spanish-speaking mother shared about her STS in the OR experience: It was nice, feeling her skin on me … She was looking at me with her eyes wide open … and I think we both could feel the attraction.

The authors write that some routines and staffing patterns had to be changed.  They also note that, while there was some initial resistance to change, “We received positive responses after staff received the in-service education on benefits of STS and understood the need for improvement.”

The authors conclude: “We concluded that STS contact was feasible after cesarean and could be provided for healthy mothers and infants immediately after cesarean birth. Perinatal and neonatal nurses should be leaders in changing practice to incorporate early STS contact into routine care after cesarean birth.”

It may be a while before skin-to-skin in the operating room is embraced as the standard of care, but this account of one hospital’s successful experience and the evidence it provides that the practice supports breastfeeding, gives me hope!

Next week I’ll share an interview with a friend and fellow lactation consultant who had skin-to-skin contact in the operating room after her second son was born by cesarean.

This post is the 24th in a series on Booby Traps made possible by the generous support of Motherlove Herbal Company.

For several years I taught breastfeeding classes at area hospitals.  At one class, in addition to about ten expecting couples, there was a nurse from the childbirth center in attendance.  This was part of an effort to try to make our messages about breastfeeding consistent from prenatal class through postpartum care.

When I got to the issue of pacifiers I explained, “Pacifiers can cause breastfeeding problems, particularly in the early days when a baby is learning now to suck.  The American Academy of Pediatrics recommends:  For breastfed infants, delay pacifier introduction until breastfeeding has been firmly established, usually by 3 to 4 weeks of age.’”*

As I finished explaining this, I saw the nurse’s hand go up.  I was surprised, since the idea was that she was there to observe, not to participate.  But I called on her to speak.

She said, “You know what I find is really helpful?  Using a pacifier that first night after a baby is born.  It really seems to calm them down and keep them happier, and it allows the moms to get some sleep.  I’d really recommend that.”

Needless to say, I was disturbed by this comment, both because it completely contradicted what I had just said, and because it was the opposite of what the evidence has shown.  So I said, “I’m sorry, but I’m going to have to disagree with you.”  I then explained the ways in which the early introduction of a pacifier can harm breastfeeding.  As I did so, I heard a dad in the class say, “Oooooooh.”  I suddenly felt like I was back in seventh grade.

Thinking back on that moment, I think that this experience probably gave the families a realistic picture of the contradictions they were about to encounter on this and other issues related to breastfeeding.  One person says pacifiers are bad, another says they’re great.  Chances are this wasn’t the only confusing message they were going to receive.

National data confirm that pacifiers are still a commonly used item in our hospitals.  The CDC reports that only 30% of hospitals limit the use of pacifiers so that less than 10% of healthy full-term breastfed infants are given pacifiers by maternity care staff members.  This, despite the fact that “giving no artificial teats or pacifiers to breastfeeding infants” is one of the evidence-based Ten Steps to Successful Breastfeeding, and the AAP in their breastfeeding policy, says: “Pacifier use is best avoided during the initiation of breastfeeding and used only after breastfeeding is well established.”

Some of this pacifier use is driven by uninformed views like the one voiced by the nurse sitting in on my class, but some is undoubtedly a result of maternal request.  Here again, as we’ve discussed before on the issues of early elective birth and formula supplements in the hospital, health care providers have a responsibility to explain to mothers that pacifier use can get in the way of their goal of breastfeeding.  Not explaining this deprives moms of their informed consent.

I recently heard of one way in which some hospitals which are working toward Baby Friendly status deal with the pacifier issue:  they inform moms prenatally that the hospital where they are going to deliver simply does not stock pacifiers.  Think that sparks a discussion about pacifiers and breastfeeding?  I’m sure it does!

Did your hospital push pacifiers?  Discourage them?

* The AAP encourages the use of pacifiers as a means of preventing Sudden Infant Death Syndrome (SIDS) once breastfeeding is established.

This post is the 23rd in a series on Booby Traps made possible by the generous support of Motherlove Herbal Company.

To borrow a phrase, if there were a drug that could do the following things for premature and/or term infants, would it be ethical not to use it?

• Better survival rates in preterm babies
• Better oxygenation
• Better heart rate*
• Better temperature
• Opportunity to self attach to the breast
• Lower stress hormones
• Less crying
• Better blood sugars
• Better immunity, even six months later
• Lowered risk of infection
• Lowered risk of necrotizing enterocolitis
• Increased maternal attachment
• Increased breast milk supply
• Increased maternal confidence in ability to care for babies
• Increased maternal confidence that their babies are well cared for
• Increased maternal sense of control
• Better rates of breastfeeding, even many months later**

The ‘drug’ is your skin, in contact with your baby’s skin.  All of these things occur when your baby is held in skin-to-skin contact with you. 

Research has even shown that our chest temperature automatically increases right after birth – a built in “warmer” for our babies.  And since I have your attention, I’m going to take this opportunity to share my favorite trivia about skin-to-skin:

1) If you graph a baby’s temperature in an incubator, which uses a sensor to gauge a baby’s temperature and raise or lower the warmth, the graph will show the baby’s temperature in a wave-like pattern because there is a delay as the incubator responds to the baby’s temperature.  Compare that to a baby on its mom’s chest.  What does the graph look like?  A straight line.  The mother’s chest raises and lowers the temperature instantaneously.  Beat that, machine.

2)  If you place twins on their mother’s chest, one on each breast, each breast will raise and lower its temperature independently to meet the warmth need of each baby.

Though it’s logical to assume that this has been practiced for ages by mothers, research demonstrating the benefits of keeping babies in their natural habitat (mothers’ bodies) dates to 1979, when two doctors in Bogota, Columbia stumbled upon a dramatic finding.

Drs. Rey and Martinez were trying to care for preterm infants in an extremely resource-poor environment.  There was a shortage of warmers.  The mortality rate of premature infants there was about 70%.  Then, they began recommending that mothers hold their babies, skin-to-skin between their breasts as much as possible, and breastfeed on cue.

A miraculous thing happened:  the mortality rate of their patients wasn’t 70%.  It was 30%.

This practice became known as Kangaroo Care, and subsequent research in many other developing countries confirmed their findings.

The next question that needed to be answered was whether there was any benefit to full term babies.  And the answer, established by this review of 18 studies, is a resounding yes.  The World Health Organization fully supports it for all babies, declaring: “Almost two decades of implementation and research have made it clear that KMC is more than an alternative to incubator care. It has been shown to be effective for thermal control, breastfeeding and bonding in all newborn infants, irrespective of setting, weight, gestational age, and clinical conditions.”

So, are hospitals fully supportive and encouraging of Kangaroo Care and skin-to-skin?  I think that it’s safe to say that things are moving in that direction, but there is a lot of work yet to be done.

The most obvious place to look for progress is in the nation’s NICUs, since evidence for Kangaroo Care has been around the longest for preterm babies.  A national survey in 2002 found that 82% of NICUs were practice kangaroo care, and I would imagine that that number has increased in the ten years since.  But barriers exist, even there, and one of the key reasons is staff education and motivation.

The survey found that the practice of Kangaroo Care was more strongly influenced by perceptions than evidence.  As summarized in this article, it found that “Staff reluctance seemed particularly focused on the misconception that kangaroo care would require extra work on their part.” Another study published in 2011 which looked into barriers to kangaroo care found, “Key institutional factors were education and motivation of staff.”

While I couldn’t find any national data on the use of skin-to-skin in full term babies, I can say that I’ve heard similar objections to routine skin-to-skin care.  There is a perception that encouraging moms to hold their babies skin-to-skin will create more work for hospital staff, when in fact the opposite appears to be true.  Babies held skin-to-skin cry less, feed better, and need less care generally because they are in a much more stable state.  Moms are happier, too, and isn’t it possible that this results in fewer call buttons being pushed?

Culture change is hard, and takes time, but the evidence in favor of Kangaroo Care and skin-to-skin makes encouragement of these practices an imperative.

Did your hospital encourage skin-to-skin (or kangaroo care, if you had a preemie)?

* As with breastfeeding, we could discuss these outcomes in terms of the risks of not holding a baby skin-to-skin, rather than “better” rates associated with holding a baby skin-to-skin.  For example, we could say “When a baby is separated from its mother, its heart rate slows to an abnormally low rate as part of a “protest- despair” response.   A return to skin-to-skin contact with the mother restores a normal heart rate.”  Another example:  “A baby removed from its mother is at higher risk for hypothermia than a baby in its normal state – held skin-to-skin with its mother.”

** Skin-to-skin is great for all babies, whether breastfeeding or not.

This is the 22nd in a series of posts on the Booby Traps, made possible by the generous support of Motherlove Herbal Company.

It’s postpartum day one for 29 nursing mothers and babies in an Ohio hospital who have agreed to participate in a study.

From 8:00 am to 8:00 pm, research assistants sit outside each room, counting the number of times the door is door is opened and someone enters – nurses, doctors, family, friends, food service, housekeeping, and anyone else – and keeping track of the duration of these interruptions as well as time spent alone.  Research assistants count the number of phone calls the mother makes and receives as well.  Each visitor is counted an an separate interruption, and partners are also counted when they entered the room.

Want to guess the average number of times mothers were interrupted by phone or in person?  54.

And what was the most common duration of time the mothers had alone with their babies? 1 minute.

The mothers were alone with their babies for an average of 24 times in the 12 hour period, and half of these episodes were 9 minutes or less.  The average duration of a breastfeeding session was 20 minutes.  This included a number of sessions that lasted zero minutes when a visitor entered and the baby was immediately removed from the breast.

Who were the people entering the room most frequently?  The majority of the visits were from nurses and other care personnel, followed by the father and other visitors.

At the end of the day mothers were asked about their experiences (summarized by this La Leche League article):

1. How do you feel about the interaction and breastfeeding experiences with your baby today?

Typical responses: “They [breastfeeding sessions] were good, but it was hard having visitors; probably would have done it [breastfeeding] more. Tried to squeeze it in when visitors left.” “Not too many visitors, but the phone calls did make it harder to concentrate on the baby. The nurses’ visits helped because they showed me different techniques.”

2. Did you and your baby have enough quiet/uninterrupted time together?

Typical responses: “I had a very busy day and though I do feel I gave a lot of time and spent a lot of time together, I did feel very pressured.” “Wish we had more [alone time]. Both baby and myself were tired and I wanted to sleep with her. But every time I tried, we got interrupted.” “I felt like someone was constantly interrupting us and when we were able to breastfeed I felt rushed and worried that someone else would be coming in soon.”

Of course, I am not suggesting that all interruptions are bad for breastfeeding.  Some are clearly helpful to breastfeeding, like a visit from a lactation consultant, and having a partner and other supportive family and friends around can help, too.

But look what happened in a 2010 study when a simple intervention was tried:  hanging a “do not disturb” sign on the door when a mother was feeding her baby (one example of such a sign is above, from ILCA).

The number of interruptions to was significantly less in the ‘sign’ group than in the ‘no sign’ group.   And 95% of the ‘sign’ mothers strongly agreed with the statement, “My breastfeeding sessions were successful, vs. 67% of the mothers who had no sign on the door.  No difference was noted regarding the number of breastfeeding sessions, total minutes of breastfeeding sessions, or percentage of infant weight loss at day 2 of life.

Another interesting example comes from a number of Boston-area hospitals which, in the course of working toward becoming Baby Friendly, have are trying to “bundle” education about different topics together so that the number of interruptions is decreased.  They’ve also tried to stop taking vital signs at midnight and at other times when the mother or aby is sleeping.  This requires cultural and logistical changes, but it can be done.

Again, I am not saying that mothers shouldn’t have visitors or that hospital staff who have important business in the rooms should be banned from entering.  I also want to acknowledge that there are interesting cultural questions here – among some families having lots of family around all the time is the normal and expected thing, and restricting visitation might actually make breastfeeding more challenging.

What I am saying is that the near constant stream of interruptions can make getting started with breastfeeding difficult, and that some thought should be given to prioritizing some privacy if mothers need it to make breastfeeding work.  Yes, it might mean some inconvenience to hospital staff at first, but the same could be said about a lot of things which are now the standard of care, and which result in better breastfeeding outcomes.

For now, you may want to write in a request for privacy while feeding into your birth plan, talk with your partner about politely escorting family to the cafeteria at times, and maybe even making your own privacy sign.

Was your hospital room more like Grand Central Station?  Did it have any impact on your breastfeeding experience in the hospital?

This is the 21st in a series of posts on Booby Traps, made possible by the generous support of Motherlove Herbal Company.

My doula once attended a training in which the presenter shoved a giant bulb syringe in the faces of the participants, and then asked, “feel like eating?”  Her point, if it isn’t obvious:  It’s not fun to be suctioned right after birth, and it can interfere with your desire to eat.

Obviously, suctioning is sometimes necessary – for resuscitation in the most extreme example.  Linda Smith, in The Impact of Birthing Practices on Breastfeeding, notes that “babies born by cesarean section usually require considerable suctioning, because the oropharyngeal mucus is not squeezed out as it is during vaginal birth.”*

But suctioning an otherwise healthy, vigorous newborn?  Research shows that 1) there are no demonstrated benefits to routine suctioning (randomized controlled trials have shown no difference), and 2) routine suctioning can cause breastfeeding problems.

Linda Smith cites research showing several ways in which this causes problems for breastfeeding:

Mispatterned tongue movement: “The tongue muscle group can be mispatterned by early superstimuli such as deep or repeated suctioning.”

Defensive tongue position: “Physical irritation of the posterior palate creates a reflex guarding of the airway by the tongue…This is exactly the opposite of the anterior-to-posterior tongue peristaltis needed for breastfeeding.”

Pain, possibly leading to aversion to feeding:  “Suctioning a vigorous newborn (except as needed for resuscitation) can cause physical damage to the oropharynx, causing pain during feeding attempts.”

The evidence is strong enough that the American Academy of Pediatrics makes a point of discouraging suctioning in its breastfeeding policy, recommending that physicians: “avoid procedures that may interfere with breastfeeding or that may traumatize the infant, including unnecessary, excessive, and over-vigorous suctioning of the oral cavity, esophagus, and airways to avoid oropharyngeal mucosal injury that may lead to aversive feeding behavior.”

Nevertheless, suctioning healthy, vigorous newborns appears to be very common.  If you do not want your healthy, vigorous baby suctioned, we encourage you to discuss this with your care providers before your birth.

Was your baby suctioned?  For good reason or because it’s just “what they do?”  Do you think it had any impact on your breastfeeding experience?

* One study challenges the utility of this practice.

This is the 20th post in a series on Booby Traps made possible by the generous support of Motherlove Herbal Company.

Keeping mothers and babies together as much as possible right after birth has long been recognized as important for breastfeeding.  But for years the standard practice has been to remove the baby from the mother’s arms in order to perform a variety of newborn procedures, including weighing and measuring, eye prophylaxis, bathing, and needle sticks.

This tradition of yanking the baby away can be so strong that a nurse midwife once told me she resorted to a kind of guerrilla move to keep moms and babies together:  “When I delivered at hospitals where I knew they liked to separate the mom and baby right after the birth,” she said, “I’d just ‘forget’ to cut the cord for as long as I could.”

Sadly, mothers’ reported experiences bear this out.  In the 2006 Listening to Mothers survey, 66% of mothers reported not having their babies in their arms in the first hour.

When it comes to the timing of newborn procedures, delay is a good thing.  According to Linda Smith in The Impact of Birthing Practices on Breastfeeding, the evidence supporting continuous contact between moms and babies after birth is “overwhelmingly strong.”  This uninterrupted contact allows the natural, programmed behaviors of the infant – including instinctual breastfeeding behaviors – to unfold.  Research has shown that during this sensitive period, separation of the baby from the mother disrupt babies’ instinct to crawl and attach to the breast.   Bathing is particularly disruptive to breastfeeding, since some of breastfeeding at this stage is based on smell.  Linda Smith concludes, “Separating the baby for any reason other than resuscitation is unjustified and harmful.”

It’s not just breastfeeding advocates who believe that delay is best.  The 2005 the American Academy of Pediatrics statement, “Breastfeeding and the Use of Human Milk,” instructs providers to:

Dry the infant, assign Apgar scores, and perform the initial physical assessment while the infant is with the mother. The mother is an optimal heat source for the infant. Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed. Infants affected by maternal medications may require assistance for effective latch-on. Except under unusual circumstances, the newborn infant should remain with the mother throughout the recovery period. [my emphasis added]

What can you do if you’re expecting a baby and are concerned that your baby might be taken away for these newborn procedures?

One thing you can do is include this statement in your birth plan:  “I would like all newborn procedures, including weighing, measuring, bathing, needle-sticks, and eye prophylaxis,* delayed until after the first feeding.  After the feeding, I would like these procedures done with the baby lying on me or being held by me.”

If you think you’ll need some justification for this change in procedure at your hospital, you could cite the AAP policy above.  And if you really need to push for this, you can give your providers a copy of the AAP’s model hospital breastfeeding policy, which states the same thing.

For the one in three babies who are born by cesarean section, this kind of delay may not be feasible, but I’m holding out hope that one day all healthy babies born by cesarean will have the chance at some skin-to-skin time and even the opportunity to feed immediately after birth.  It is certainly worth discussing your desires with your providers and requesting that you get skin-to-skin contact with your baby as early and as much as you are physically capable of having.

Did you have newborn procedures delayed until after the first feeding?  Did you have to fight for this?

*Modify based on the procedures you’re planning to have done.