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Breastfeeding & Racial Disparities in Infant Mortality: Celebrating Successes & Overcoming Barriers

August 28th, 2014 by avatar
© mochamanual.com

© mochamanual.com

August has been designated as World Breastfeeding Month, and Science & Sensibility was happy to recognize this with a post earlier this month that included a fun quiz to test your knowledge of current breastfeeding information.  Today, we continue on this topic and celebrate Black Breastfeeding Week 2014 with a post from regular contributor, Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA sharing information about the increased breastfeeding rates rates among African American women.  Kathleen also discusses some of the areas where improvements can help this rate to continue to increase. 

Celebrating Successes

Many exciting changes occurred in 2013 in the breastfeeding world. One of the best trends was the increase in breastfeeding rates in the African American community. The CDC indicated that increased breastfeeding rate in African American women narrowed the gap in infant mortality rates.  As the CDC noted:

From 2000 to 2008, breastfeeding initiation increased…from 47.4% to 58.9% among blacks. Breastfeeding duration at 6 months increased from…16.9% to 30.1% among blacks. Breastfeeding duration at 12 months increased from… 6.3% to 12.5% among blacks.

Much of this wonderful increase in breastfeeding rates among African Americans has come from efforts within that community. In 2013, we saw the first Black Breastfeeding Week become part of World Breastfeeding Week in the U.S. Programs, such as A More Excellent Way, Reaching Our Sisters Everywhere (ROSE), and Free to Breastfeed, offer peer-counselor programs for African American women.


We can celebrate these successes. But there is still more to do. Although the rates of infant mortality have dropped, African Americans babies are still twice as likely to die. In addition, although rates of breastfeeding have increased among African Americans, they are still lower than they are other ethnic groups.

For each of the 2000–2008 birth years, breastfeeding initiation and duration prevalences were significantly lower among black infants compared with white and Hispanic infants. However, the gap between black and white breastfeeding initiation narrowed from 24.4 percentage points in 2000 to 16.3 percentage points in 2008.

Barriers to Overcome

In order to continue this wonderful upward trend in breastfeeding rates, we need to acknowledge possible barriers to breastfeeding among African American women. Here are a couple I’ve observed. They are not the only ones, surely. But they are ones I’ve consistently encountered. They will not be quick fixes, but they can be overcome if we recognize them and take appropriate action.

1) Pathways for IBCLCs of Color

In their book, Birth Ambassadors: Doulas and the Re-Emergence of Women-Supported Birth in America, Christine Morton and Elayne Clift highlight a problem in the doula world that also has relevance for the lactation world: most doulas (and IBCLCs) are white, middle-class women. And there is a very practical reason for this. This is the only demographic of women that can afford to become doulas (or IBCLCs). The low pay, or lack of job opportunities for IBCLCs who are not also nurses, means that there are limited opportunities for women without other sources of income to be in this profession. Also, as we limit tracks for peer-counselors to become IBCLCs, we also limit the opportunities for women of color to join our field. I recently met a young African American woman who told me that she would love to become an IBCLC, but couldn’t get the contact hours needed to sit for the exam. That’s a shame. (I did refer her to someone I knew could help.)

2) We need to have some dialogue about how we can bring along the next generation of IBCLCs. We need to recognize the structural barriers that make it difficult for young women of color to enter our field. ILCA has started this dialogue and held its first Lactation Summit in July to begin addressing these issues.

These discussions can start with you. Sherry Payne, in her recent webinar, Welcoming African American Women into Your Practice, recommends that professionals who work in communities of color find their replacement from the communities they serve.  Even if you only mentor one woman to become an IBCLC, you can have a tremendous impact in your community. If we all do the same, we can change the face of our field. (Note, here is a wonderful interview with Sherry as she discusses “Fighting Breastfeeding Disparities with Support.”)

3) Bedsharing and Breastfeeding

 This is an issue that I expect will become more heated over the next couple of years. But it is a reality. As we encourage more women to breastfeed, a higher percentage of women will bedshare. As recent studies have repeatedly found, bedsharing increases breastfeeding duration. This is particularly true for exclusive breastfeeding.

Bedsharing is a particular concern when we are talking about breastfeeding in the African American community. Of all ethnic groups studied, bedsharing is most common in African Americans. It is unrealistic to think that we are going to simultaneously increase breastfeeding rates while decreasing bedsharing rates in this community. The likely scenario is that breastfeeding would falter. It’s interesting that another recent CDC report, Public Health Approaches to Reducing U.S. Infant Mortality, talks quite a bit about safe-sleep messaging, with barely a mention of breastfeeding in decreasing infant mortality.  A more constructive approach might be to talk about being safe while bedsharing. But as long as the message is simply “never bedshare,” there is likely to be little progress, and it could potentially become a barrier to breastfeeding.


Reason to Hope

BBW-Logo-AugustDates3Even with these barriers, and others I haven’t listed, Baby-Friendly Hospitals are having a positive effect. When hospitals have Baby-Friendly policies in place, racial disparities in breastfeeding rates seem to disappear. For example, a study of 32 U.S. Baby-Friendly hospitals revealed breastfeeding initiation rates of 83.8% compared to the national average of 69.5%. In-hospital exclusive breastfeeding rates were 78.4% compared with a national rate of 46.3%. Rates were similar even for hospitals with high proportions of black or low-income patients (Merewood, Mehta, Chamberlain, Phillipp, & Bauchner, 2005). This is a very hopeful sign, especially as more hospitals in the U.S. go Baby-Friendly.

http://kcur.org/post/kc-group-fights-breast-feeding-disparities-education-support

In summary, we have made significant strides in reducing the high rates of infant mortality, particularly among African Americans. I am encouraged by the large interest in this topic and the number of different groups working towards this goal. Keep up the good work. I think we are reaching critical mass.

Additional resource: Office of Women’s Health, U.S. Department of Health & Human Services Breastfeeding Campaign for African American families.

References

Merewood, A., Mehta, S. D., Chamberlain, L. B., Phillipp, B. L., & Bauchner, H. (2005). Breastfeeding rates in U.S. Baby-Friendly hospitals: Results of a national survey. Pediatrics, 116(3), 628-634.

Reprinted with permission from Clinical Lactation, Vol. 5-1. http://dx.doi.org/10.1891/2158-0782.5.1.7

About Kathleen Kendall-Tackett

kendall-tackett 2014-smallKathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist, International Board Certified Lactation Consultant and Fellow of the American Psychologial Association in both the divisions of Health and Trauma Psychology. Dr. Kendall-Tackett is President-Elect of the Division of Trauma Psychology, Editor-in-Chief of Clinical Lactation, clinical associate professor of pediatrics at Texas Tech University Health Sciences Center, and Owner/Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett has authored more than 310 articles or chapters and is the author or editor of 22 books on women’s health, maternal depression, family violence and breastfeeding. Dr. Kendall-Tackett and Dr. Tom Hale received the 2011 John Kennell and Marshall Klaus Award for Research Excellence from DONA International. You can find more from her at Uppity Science Chick

 

Babies, Breastfeeding, Childbirth Education, Guest Posts , , , , , , , ,

Why Hospital Policies Matter: Study of California Hospitals Finds Birth Practices Impact Exclusive Breastfeeding Rates

August 1st, 2013 by avatar

Science & Sensibility, Lamaze International and our contributors are proud to support  World Breastfeeding Week 2013, running August 1-7.  The Sixth Healthy Birth Practice- “Keep mother and baby together- It’s best for mother, baby and breastfeeding” stresses the importance of getting breastfeeding off to a good start.  In honor of WBW, our next several posts will look at some of the recent research around breastfeeding.  Today, Kathleen Kendall-Tackett shares research on how the place of birth impacts breastfeeding rates.  - Sharon Muza, Community Manager, Science & Sensibility

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A recent study in California found that exclusive breastfeeding rates vary tremendously from hospital to hospital. If a mother is planning to breastfeed, where she gives birth makes a difference.  For example, the rate of exclusive breastfeeding may be 90% in one hospital, while only 10% in another. (Maternity Care Matters:Overcoming Barriers to Breastfeeding, 2012)

Unfortunately, hospitals with the lowest exclusive breastfeeding rates are often those that serve low-income and ethnic minority women. For many years, policy makers assumed that low rates of breastfeeding in ethnic-minority populations were due to “cultural differences.” We have since learned that this is not the case.  

Breastfeeding Policies Make a Difference

In 2010, the Joint Commission included exclusive breastfeeding as part of its core perinatal measures. To increase exclusive breastfeeding rates, hospitals need policies that ensure that women have access to skilled breastfeeding support. In addition, breastfeeding policies need to stipulate that staff avoid separating mothers and babies, delaying first feeding, and supplementing with formula unless there is a medical reason.  But many hospitals are falling far short of this standard. According to the 2009 mPINC (Maternity Practices in Infant Nutrition and Care) national survey, 91% of hospitals were providing breastfeeding education, and 88% were providing breastfeeding advice and counseling. However, only 31% of hospitals offered postpartum support and 21% had a written breastfeeding policy. In addition, 78% were regularly using formula. (Maternity Care Matters:Overcoming Barriers to Breastfeeding, 2012)

Birthing Practices Also Impact Breastfeeding

Birthing practices, such as cesarean sections or elective inductions, can also lower rates of exclusive breastfeeding. At some hospitals, these procedures are rare. At others, they are commonplace. For example, the Maternity Care Matters report compared two hospitals in California, and found that one hospital had 10 times the rate of early elective inductions as the other.

Cesarean sections are another birth practice that can impact breastfeeding. From 1998 to 2008, cesarean births in California increased by 50%. These rates also varied by hospital, ranging from 9% at one hospital to more than 50% at another.

Early elective delivery of infants (37 to 38 weeks gestation) also rose in California by 47% from 1990 to 2006. This practice contributes to a number of serious health problems for infants. In fact, this type of birth is so high risk that the California Maternal Quality Care Collaborative, in partnership with the March of Dimes, has developed a tool kit to help administrators curb this dangerous practice. 

For many mothers, a high-intervention birth, combined with inadequate breastfeeding support, compromises breastfeeding in the early days of life. In summary, the California WIC Association and the UC Davis Human Lactation Center note that many birthing practices, which some hospitals consider routine, are not necessary and do not meet current standards of care. (Maternity Care Matters:Overcoming Barriers to Breastfeeding, 2012

Hospital policies and practices—from elective procedures to formula supplementation—that do not directly support the health of mothers and babies are not only outdated, but they fail to reflect what is now considered standard, high-quality care.

So what can hospitals do to increase the rate of exclusive breastfeeding, thereby improving the health of both mother and baby?

Recommendations

 1.     Have Written Breastfeeding Policies and Train Staff

The WIC/UC Davis Report recommended several specific policy changes to increase exclusive breastfeeding. These policy recommendations include monitoring hospitals that have high rates of supplementation and low rates of exclusive breastfeeding, with an eye towards improving their maternity practices. The Report strongly encourages hospitals to have written breastfeeding policies, and train their staff in breastfeeding support, consistent with the first two steps of the Baby-Friendly Hospital Initiative(BFHI).

© http://flic.kr/p/5f29EK

 

The BFHI also includes prenatal education about breastfeeding, initiating breastfeeding in the first hour after birth, showing mothers how to breastfeed or maintain lactation when separated from their infants, avoiding supplementation unless medically necessary, rooming in, unrestricted breastfeeding, no artificial teats/nipples, and community breastfeeding support. Research has demonstrated that these recommendations increase exclusive breastfeeding, even in groups designated as “high risk.” (Merewood, 2005)

A study from Boston Medical Center, which became a Baby-Friendly Hospital in 1999, demonstrated the impact of the BFHI on breastfeeding rates for African American women: 34% in 1995, 74% in 1999. (Philipp, 2001)  Another  study found that, “Among a predominantly low-income and black population giving birth at a U.S. Baby-Friendly hospital, breastfeeding rates at 6 months were comparable to the overall U.S. population.” (Merewood, 2007)

2.     Avoid Unnecessary Interventions During Labor

Hospitals vary widely in the percentages of cesareans, elective inductions, and elective early deliveries. All of these interventions increase women’s risk of PTSD following birth (Kendall-Tackett, 2013) and can potentially have a negative impact on breastfeeding.  Some of these procedures may be medically necessary. But many are not, and are done for doctor or patient convenience.

If our maternal outcomes were good, perhaps we could conclude that these practices are saving mothers’ lives.  But our maternal mortality rates are not good, and in fact have nearly doubled since 1987. Moreover, there is a huge racial disparity in maternal mortality: the rate for African American mothers is triple the rate for whites. (Huffington Post, 2012)

The WIC/UC Davis report explicitly states that “poor maternity care means poor breastfeeding outcomes.” If we want to increase our breastfeeding rates, we must address birth. In fact, we need to ensure that birth is not only baby friendly; it needs to also be mother friendly.

In conclusion, the World Health Organization and American Academy of Pediatrics recommend exclusive breastfeeding for the first six months of life. Unfortunately, many babies in American hospitals receive formula supplements during their time in the hospital. Early supplementation, combined with lack of community support, means that many mothers fall far short of their breastfeeding goals. High-intervention birthing practices can also undermine breastfeeding, particularly when mothers do not receive skilled breastfeeding support in the hospital or in their communities. Fortunately, hospitals can turn this around by implementing policies that are good for both mothers and babies. Maternity Care Matters summarizes it as follows: Breastfeeding support is an essential part of high-quality maternity care.

And to be truly effective, breastfeeding support needs to start before birth.

References

California WIC Association and UC Davis Human Lactation Center. Maternity Care Matters: Overcoming Barriers to Breastfeeding; 2012 Annual California Fact Sheet. http://calwic.org/storage/restricted/hospitalreport/Maternity%20Care%20Matters_2012.pdf

Fact Of The Day #26: Maternal Mortality Rate Rising Despite Expensive Care (INFOGRAPHIC). (2012, August 24). Retrieved July 30, 2013, from http://www.huffingtonpost.com/2012/08/24/maternal-mortality-rate-infographic_n_1827427.html

Kendall-Tackett, K. (2013, June). Science & Sensibility » Childbirth-Related Psychological Trauma: It’s Finally on the Radar and It Affects Breastfeeding. Retrieved July 2013, from http://www.scienceandsensibility.org/?p=6821

Merewood, A., Mehta, S. D., Chamberlain, L. B., Philipp, B. L., & Bauchner, H. (2005). Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics116(3), 628-634.

Merewood, A., Patel, B., Newton, K. N., MacAuley, L. P., Chamberlain, L. B., Francisco, P., & Mehta, S. D. (2007). Breastfeeding duration rates and factors affecting continued breastfeeding among infants born at an inner-city US Baby-Friendly hospital. Journal of Human Lactation23(2), 157-164.

Philipp, B. L., Merewood, A., Miller, L. W., Chawla, N., Murphy-Smith, M. M., Gomes, J. S., Cimo, S., & Cook, J. T. (2001). Baby-friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics,108(3), 677-681.

 

 

Babies, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, Maternal Quality Improvement, Maternity Care, Newborns, Uncategorized , , , , ,

Childbirth-Related Psychological Trauma: It’s Finally on the Radar and It Affects Breastfeeding

 

© http://flic.kr/p/6hqwdF

I first became interested in childbirth-related psychological trauma in 1990.  Twenty-three years ago, it was not something researchers were interested in studying.  I found only one study, and it reported that there was no relation between women’s birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births.  I was convinced that the researchers got it wrong,

To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley’s classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is “sudden, dangerous, and overwhelming.” That was a perfect framework for me to begin to understand women’s experiences of birth. It focused on women’s subjective reactions, and I used it to describe birth trauma in my first book, Postpartum depression (1992, Sage).

Since writing Postpartum Depression, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing: high numbers of American women, as well as women in other countries, have posttraumatic stress symptoms (PTS) after birth. Some even meet full criteria for posttraumatic stress disorder. For example, Childbirth Connection’s Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that “the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic” (Beck, et al., 2011).

If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).

Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.

In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt “invisible and out of control” (Elmir, Schmied, Wilkes, & Jackson, 2010).  The women used phrases, such as “barbaric,” “inhumane,” “intrusive,” “horrific,” and “degrading” to describe the mistreatment they received from healthcare professionals. 

“Isn’t that just birth?,” you might ask. “Birth is hard.” Yes, it certainly can be.

But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009).  Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011).  Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.

How Does this Influence Breastfeeding?

Breastfeeding can be adversely impacted by traumatic birth experiences,  as these mothers in Beck and Watson’s study (Beck & Watson, 2008) describe:

  • I hated breastfeeding because it hurt to try and sit to do it. I couldn’t seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.
  • The first five months of my baby’s life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.
  • Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.
  • Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.
  • My body’s ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.

What You Can Do to Help

There are many things that nurses, doulas, childbirth educators, and lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. You really can make a difference for these mothers.

  • Recognize symptoms.

Although it is not within many of our scope of practice to diagnose PTSD, you can listen to a mother’s story. That, by itself, can be healing. If you believe she has PTS or PTSD, or other sequelae of trauma, such as depression or anxiety, you can refer her to specialists or provide information about resources that are available (see below). Trauma survivors often believe that they are going “crazy.” Knowing that posttraumatic symptoms are both predictable and quite treatable can reassure them. 

  • Refer her to resources for diagnosis and treatment.

There are a number of short-term treatments for trauma that are effective and widely available. EMDR, is a highly effective type of psychotherapy and is considered a frontline treatment for PTSD. Journaling about a traumatic experience is also helpful. The National Center for PTSD has many resources including a PTSD 101 course for providers and even a free app for patients called the PTSD Coach.

The site HelpGuide.org also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.

  • Anticipate possible breastfeeding problems mothers might encounter.

Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.

  •  Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers’ boundaries.

Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able handle it. But if she can’t, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin to skin, babywearing or infant massage.

  •  Partner with other groups and organizations who want to reform birth in the U.S.

Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection, are working to reform birth in the U.S.  

2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria were released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.

There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices.

I would also like to see our hospitals implementing practices recommended by the Mother-friendly Childbirth Initiative.

There is also a major push to among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions.

And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers are care providers stand together, and say that the high rate of traumatic birth is not acceptable, and it’s time that we do something about it. Amy Romano describes it this way.

 As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates

There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.

This article originally appeared as an editorial in the journal Clinical Lactation: Kendall-Tackett, K.A. (2013). Childbirth-related psychological trauma: An issue whose time has come. Clinical Lactation, 4(1), 9-11

References

Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two-stage U.S. national survey. Birth, 38(3), 216-227.

Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding. Nursing Research, 57(4), 228-236.

Elmir, R., Schmied, V., Wilkes, L., & Jackson, D. (2010). Women’s perceptions and experiences of a traumatic birth: A meta-ethnography. Journal of Advanced Nursing, 66(10), 2142-2153.

Galea, S., Vlahov, D., Resnick, H., Ahern, J., Susser, E., Gold, J., . . . Kilpatrick, D. (2003). Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of  Epidemiology, 158, 514-524.

Grajeda, R., & Perez-Escamilla, R. (2002). Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women. Journal of Nutrition, 132, 3055-3060.

Soderquist, I., Wijma, B., Thorbert, G., & Wijma, K. (2009). Risk factors in pregnancy for post-traumatic stress and depression after childbirth. British Journal of Obstetrics & Gynecology, 116, 672-680.

Stramrood, C. A., Paarlberg, K. M., Huis in ‘T Veld, E. M., Berger, L. W. A. R., Vingerhoets, A. J. J. M., Schultz, W. C. M. W., & Van Pampus, M. G. (2011). Posttraumatic stress following childbirth in homelike- and hospital settings. Journal of Psychosomatic Obstetrics & Gynecology, 32(2), 88-97.

Reports from Childbirth Connection on Important Issues Regarding Birth in the U.S.

Helpful Links to Share with Mothers

About Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA

Kathleen Kendall-Tackett is a health psychologist and an International Board Certified Lactation Consultant. She is the Owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett is a Fellow of the American Psychological Association in both the Divisions of Health and Trauma Psychology, Editor-in-Chief of U.S. Lactation Consultant Association’s journal, Clinical Lactation, and is President-Elect of the American Psychological Association’s Division of Trauma Psychology. Dr. Kendall-Tackett is author of more than 320 journal articles, book chapters and other publications, and author or editor of 22 books in the fields of trauma, women’s health, depression, and breastfeeding, including Treating the Lifetime Health Effects of Childhood Victimization, 2nd Edition (2013, Civic Research Institute), Depression in New Mothers, 2nd Edition (2010, Routledge), and Breastfeeding Made Simple, 2nd Edition (co-authored with Nancy Mohrbacher, 2010).

 

Babies, Breastfeeding, Childbirth Education, Depression, EMDR, Guest Posts, Infant Attachment, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Trauma work , , , , , , , , ,

The Quiet Underground is Quiet No More. Extended Breastfeeding is Officially Out of the Closet.

November 27th, 2012 by avatar

My first reaction to the now-infamous Time magazine cover was to groan out loud. Like many of you, I was horrified by that cover’s mean-spirited tone. If we didn’t get the message from the picture, there was also the antagonistic caption: “Are you mom enough?” It wasn’t until later that I recognized that this cover, and the controversy that followed, actually reflected a positive shift. Many things had changed since I first became aware of this topic more than 20 years ago.

In 1992, I was just finishing my post-doctoral fellowship at the University of New Hampshire and was expecting my second baby.  My first experience had gone not particularly well, so I spent months educating myself about birth, breastfeeding, and postpartum. During this time, I became friends with Dr. Muriel Sugarman. We were both on the board of a local child abuse organization in Massachusetts. Muriel was a child psychiatrist at Harvard’s Massachusetts General Hospital and an amazing ally to the breastfeeding community. She was interested in long-term breastfeeding and had collected some data. (“Long-term” was operationally defined for that study as “six months or longer.”)  We started working on it together, and bit by bit, had some findings to report.

We submitted one of our first articles on weaning ages to [a well-known journal in pediatrics].  Consistent with studies in other parts of the world, when weaning was child led, it tended to occur at ages 2.5 to 3. So far, so good.

But then there were our outliers….the babies who weaned at age 5…and a couple of babies were even older. The reviewers, all women we later learned, went completely nuts. If it had been up to them, we would have been both rejected…and flogged. (Eighteen years later, these are still the worst reviews I’ve ever received.) They hated us, our study, and mostly definitely our “weird” mothers.

I wasn’t sure what to do next, until a colleague handed me an article called, “Darwin takes on mainstream medicine.” It described how extended breastfeeding, babywearing, and cosleeping  conferred a survival advantage for moms and babies, and was presented at the American Association for the Advancement of Science meetings. That was radical stuff in the mid-1990s. I sacked our introduction and rewrote it using this framework.

The next question was where to send the revised manuscript. I called a pediatric researcher I knew in Philadelphia. He said, “Oh, I never send articles to [well-known pediatric journal]. They’re mean!” That had certainly been my experience. He recommended Clinical Pediatrics, where we got a much more positive reception. The article came out. We were happy. End of story….or so we thought.

In 1997, AAP Statement on Breastfeeding was released. Controversy swirled around that statement for months about one bit in particular: that women breastfeed for at least 12 months and “as long thereafter as is mutually desired.” I was going about my business, blithely unaware that Muriel and I were smack in the middle of the controversy. What reference did the AAP cite to support “as long thereafter as is mutually desired”? You’ve got it: Sugarman and Kendall-Tackett (1995)!

That paper taught me a lot. Ten years later, when I applied for APA Fellow, I identified it as one of the most important in my career. I learned firsthand about the intense negative stigma surrounding extended breastfeeding. I was equally amazed to discover a quiet underground of women who were defying cultural norms and nursing their older babies right under the radar of family, friends, and healthcare providers. Avery described this phenomenon as “closet nursing,” and noted that extended breastfeeding had a lot in common with revealing sexual orientation. Brave souls who chose to be up front faced marginalization—or worse.

Through much of the decade that followed publication of our article, Muriel and I, along with Liz Baldwin and Kathy Dettwyler, frequently had to write letters to courts and child protection agencies on behalf of mothers who were being investigated for child abuse. Their crime? Extended breastfeeding.

Which brings us up to the present time. Yes, the Time magazine article said mean things. But look at it this way: extended breastfeeding is being discussed in a mainstream publication. In addition, thanks to social media, the “quiet underground” is quiet no more. I’ve been amazed at outpouring of support from both celebrities—and ordinary moms—speaking opening and positively about extended breastfeeding. It was something I couldn’t even imagine in 1995. I think it’s safe to say that extended breastfeeding is officially out of the closet.

In closing, I’d like to suggest that we all owe a debt of gratitude to Drs. Ruth Lawrence and Larry Gartner, and the other brave members of the 1997 AAP Committee on Breastfeeding. Their statement did much to move extended breastfeeding out of the margins and into the public square (and Muriel and I were happy to have a small part in that). We still have a ways to go. But let’s take a moment and savor this small victory.

And to the members of the 1997 AAP Committee, I say this: We, the quiet underground, salute you!

The two articles published from that data set are:

Kendall-Tackett, K.A., & Sugarman, M. (1995). The social consequences of long-term breastfeeding.  Journal of Human Lactation, 11, 179-183.

Sugarman, M., & Kendall-Tackett, K.A. (1995). Weaning ages in a sample of American women who practice extended nursing. Clinical Pediatrics, 34(12), 642-647.

 About Kathleen Kendall-Tackett

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press, a new small press specializing in women’s health. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. www.KathleenKendall-Tackett.com

 

American Academy of Pediatrics, Breastfeeding, Guest Posts, Research , , , , , , , ,

Recent Study Finds that Controlled-Crying Causes No Apparent Long-term Harm: Should We Recommend This Practice to Parents?

October 30th, 2012 by avatar

 

 

“Crying it out” and sleep issues have always been a “hot” topic amongst parents and many of today’s parents look to childbirth educators and others for information on how best to prepare for and deal with their infant’s sleep habits.  Talking about infants and sleep can be as flammable a topic as talking politics.   Today’s post is by regular contributor Kathleen Kendall-Tackett takes a look at recent study on the long-term effects of controlled crying and shares her thoughts on the validity of the study and examines the potential shortcomings and limitations.  How do you speak about sleep and infants in your classes or with your clients and patients?  Do you have information that parents have found particularly helpful? Let us know in the comments section of today’s post.- SM

Image credit: Fotolia stock photo

A recent article in Pediatrics (Price, Wake, Ukoumunne, & Hiscock, 2012) reported on the long-term effects of a controlled-crying intervention for parents of infants 8 to 10 months old. The children were assessed five years post-intervention and showed no apparent harm. The media response to these findings has been overwhelming. Could this be the answer that weary parents have been waiting for? The authors certainly thought so. In fact, they concluded that practitioners could “confidently” recommend this approach.

Before we recommend this approach to parents, let’s step back for a moment and consider whether this recommendation is warranted. We must critically evaluate both the current study and where it fits within the larger literature in maternal-child health. In my view, there are a number of serious limitations to this study that call into question whether we should recommend this practice to parents.

Study Design

In the Price et al. (2012) study, the researchers randomly assigned parents to either intervention or control groups. In the intervention group, parents received instruction in controlled crying, i.e., to wait an increasing amount of time before responding to their infants’ cries, or “camping out,” which involved staying with their infants until the infants fell asleep on their own. The parents in the control group received “usual care,” which meant no specific recommendation regarding infant sleep. At earlier time points, the authors found that the controlled-crying intervention prevented depression in mothers and improved babies’ sleep.

At the five-year follow-up with 225 families (69% of the original sample), the researchers found that the intervention did not adversely affect the parent-child bond, the mother’s depression level, the child’s level of adjustment, or their cortisol levels. Indeed, they noted, that there were no adverse effects. However, there were also no long-term benefits. Still, the authors concluded that practitioners could recommend this technique to prevent postpartum depression and improve infant sleep.

Study Limitations

There were a number of limitations to this study. Below is a brief synopsis.

The Impact of Context: The Cumulative Effect of Childhood Adversities 

Context is an important consideration when evaluating potential harm caused by a parenting technique. In other words, how many parental missteps does it take for children to show evidence of lasting harm? Fortunately, children are resilient and don’t require perfect parenting.  However, chronic bad parenting does harm children and the effects are cumulative (Shonkoff, Boyce, & McEwen, 2009). Chronic bad parenting has also been described as childhood adversity in such major research studies as the Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2010) and New Zealand’s Dunedin Multidisciplinary Health and Development Study (Danese et al., 2009).

So does controlled crying cause infant harm? If it occurs in families with generally warm, responsive, and loving parents, probably not. Because children are resilient, they can endure a lot. Family strengths can buffer any potential negative effects.

I am more concerned about the impact of controlled crying when it takes place in high-risk families. This is a key limitation in Price et al. study. A full 31% of their original sample was lost to follow-up. Most of these families were identified as “high disadvantage.” In other words, the group most likely to be negatively affected by controlled crying was not in the follow-up study.

Assessing “Dose”: The Chronicity and Severity of the Experience

When assessing potential harm of a practice, it’s also important to consider chronicity and severity. In terms of infant sleep, we need to know how often controlled crying was used in an average week, how many weeks or months that the parents employed these techniques, and in an average episode how many minutes elapsed before the parents responded to their babies. I would expect more long-term negative effects if parents did not respond to their babies’ cries for long periods of time (such as 45 minutes or longer), and that they used this technique for months on end. In contrast, if parents used this technique a few times and for a few minutes, there probably wouldn’t be any negative effects.

Chronicity and severity is basically a way of factoring in “dose” of the intervention. This important nuance was totally absent from the Price et al. study. From their article, we know little about what the parents actually did. A full range of practices was grouped together in the “intervention group.” Indeed, we also don’t know what the “control” group did. These parents could have easily implemented a controlled-crying program for themselves using one of the myriad of books for parents on sleep training. Given the wide range of practices that likely occurred in both the “intervention” and “control” groups, I am again not surprised to see no significant difference.

Was the Intervention Actually Effective, Even in the Short Term? Accounting for the Hawthorne Effect

Another problematic aspect of this study has to do with the research design’s inability to account for the Hawthorne Effect. The Hawthorne Effect was first noted by industrial psychologists who were testing the impact of minute changes in illumination on productivity in factory workers. When they raised the level, employees reported that it was “better” and productivity increased. When they lowered the level, it was also “better” and productivity increased.  In other words, any intervention was described as helpful. It’s basically a placebo effect for behavioral interventions.

The Hawthorne Effect could also be behind the positive results for the controlled-crying intervention. Earlier papers from this same research sample found lower rates of depression and better sleep among the mothers in the intervention group. Yet these results do not demonstrate that it was the controlled-crying technique per se that actually caused the effect. Perhaps it was simply a matter of the mothers appreciating that someone was listening to their concerns. Controlled crying was compared to “usual care.” A better test for the effectiveness of this technique would have been to compare it with another intervention (such as educating mothers about the developmental normality of infant waking at 8 to 10 months, and brainstorming about ways the mothers could get more rest and cope with fatigue). Given that the authors are actually recommending this technique, this standard of evidence is a minimum.

Does Controlled Crying Cause Long-term Change to Cortisol Levels? 

One concern that critics of controlled crying raise is that this technique changes infant physiology and alters the production of the stress hormone cortisol. To address this concern, the authors assessed cortisol levels of the children at two different points during a single day at age 6. They found no significant differences in cortisol levels at age 6 between the intervention and control groups, which further reassured them that their techniques were not harmful.

Unfortunately, these findings alone do not mean lack of physiological harm. To demonstrate lack of harm, the authors needed to measure cortisol levels during infancy: before, during, and after the intervention. Did controlled-crying elevate cortisol levels? How high were those levels and how long did they remain elevated? The authors did not measure this.

The question we need to ask is what happens to babies when their mothers do not respond to their cues? One way this has been studied is by examining the impact of maternal depression on infants. Maternal depression impairs mothers’ ability to respond to their infants’ cues. Infants whose mothers do not respond to their cues  tend to have elevated cortisol levels (Feldman et al., 2009). Even when non-response is temporary, babies still find it stressful. In the still-faced mother paradigm, mothers are asked to not respond to their infants’ cues in a laboratory setting. This research is designed to mimic the effects of maternal depression. The still-faced-mother experiments increase babies’ cortisol levels (Grant et al., 2009). And the effect of chronic maternal non-response can last long past infancy (Douglas & Harmer, 2011; Luijk et al., 2010; Murray, Halligan, Goodyer, & Herbert, 2010).

So why the concern about cortisol? Mainly, it’s this: cortisol is quite toxic to brain cells. If cortisol is elevated for short time, it likely causes no damage. But if cortisol levels are repeatedly elevated because the infants are experiencing long and repeated incidents of being ignored when they cry, it can be a problem. The brain is at its most vulnerable in the first five years, so soaking the developing brain in cortisol is not a good idea (Buss et al., 2012).

The authors of the current study claimed no effect of cortisol just because there was no difference between the groups at age 6. In my opinion, the lack of difference between the groups does not mean lack of harm. For some of these children, the effects of elevated cortisol in infancy could be more subtle. Cortisol levels likely returned to normal in the intervening five years, unless there was ongoing adversity. Unfortunately, cortisol that was elevated in infancy could have still affected vulnerable brain cells, even if current levels are normal. The measures Price et al. used were not particularly sensitive. And these effects would likely not show up without more sensitive measures.

What About Breastfeeding?

The final limitation of this study is rather stunning. Price et al. did not measure the effect of infant feeding method on sleep or maternal depression. Yet feeding method has a direct effect on both maternal sleep and postpartum depression, which are the two main factors the authors claim to address with their sleep intervention. This omission is particularly surprising given that Australia, the authors’ home country, has one of the highest rates of breastfeeding in the world. It is far from a marginal issue.

Recent studies have demonstrated that exclusively breastfeeding mothers get more sleep and are less likely to be depressed than their mixed- or formula-feeding counterparts. They take fewer minutes to fall asleep, sleep longer over the course of a night, and report more daytime energy and better physical health than their mixed- or formula-feeding counterparts (Doan, Gardiner, Gay, & Lee, 2007; Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009a, 2009b; Kendall-Tackett, Cong, & Hale, 2011).

Given these findings, isn’t it strange that breastfeeding was not even enquired about, let alone controlled for? If the study was conducted in a country with low breastfeeding rates, this omission would be somewhat understandable. But it makes no sense from a study conducted in a country with one of the highest breastfeeding rates in the world.

Conclusion

So what can we take away from the Price et al. study? Should we recommend the controlled-crying technique to parents? Based on the limitations of this study, I do not recommend this approach. The sample size is small, the follow-up sample is missing the children most likely to be negatively affected, their assessment of their intervention did not account for the Hawthorne/placebo effect, they have not measured dose of the intervention, nor have they accounted for feeding method, which recent research has soundly demonstrated as being related to both variables that are of key interest: maternal fatigue and postpartum depression.

My objections to this approach are not new. When I first encountered the Price et al. study, I remembered a study this same group of researchers published 10 years ago in the British Medical Journal demonstrating that controlled crying lessened the risk of postpartum depression (Hiscock & Wake, 2002). I was specifically struck by this response to it from a German physician (Perl, 2002).

As a German, I am unhappy to find fairly undiluted ideas of militaristic Nazi infant care uncritically repeated by these Australian care providers. The Nazis understood very well the crucial effect of letting young babies cry on their future development and made this a central theme in their child care. As a scientist, I find it hard to believe that all of the results of mother-infant sleep research of the 1990s completely escaped the authors’ notice.

In closing their article, Price et al. stated that organizations, such as the Australian Breastfeeding Association, were unduly negative towards controlled-crying techniques and based their positions on research that had not been “updated since the mid-2000s.”

Thus, there is a pressing need to deliver evidence-based information to parents and health care providers, which could be achieved, in part, by updating position statements, policy documents, and training curricula to reflect our current findings that behavioral sleep techniques are both effective in the short- and medium-term and safe to use in the long-term (p. 8).

Given recent findings in neuroscience, childhood trauma and adversity, and breastfeeding and maternal sleep, which are not accounted for in the Price et  al. study, I’d respectfully advise the authors to do the same. I’d further urge healthcare providers who are considering recommending these techniques to consider the limitations to the current study and to consider alternative approaches that can meet the needs of both mother and baby.

References

Buss, C., Davis, E. P., Shahbaba, B., Pruessner, J. C., Head, K., & Sandman, C. A. (2012). Maternal cortisol over the course of pregnancy and subsequent child amygdala and hippocampus volumes and affecive problems. Proceedings of the National Academy of Sciences USA, 109(20), E1312-E1319.

Centers for Disease Control and Prevention. (2010). Adverse childhood experiences: Major findings  Retrieved May 16, 2011, from http://www.cdc.gov/ace/findings.htm

Danese, A., Moffitt, T. E., Harrington, H., Milne, B. J., Polanczyk, G., Pariante, C. M., & Caspi, A. (2009). Adverse childhood experiences and adult risk factors for age-related disease: Depression, inflammation, and clustering of metabolic risk factors. Archives of Pediatric and Adolescent Medicine, 163(12), 1135-1143.

Doan, T., Gardiner, A., Gay, C. L., & Lee, K. A. (2007). Breastfeeding increases sleep duration of new parents. Journal of Perinatal & Neonatal Nursing, 21(3), 200-206.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009a). Sleep and depression in postpartum women: A population-based study. Sleep, 32(7), 847-855.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009b). Subjective and objective sleep among depressed and non-depressed postnatal women. Acta Psychiatrica Scandinavia, 119, 128-136.

Douglas, J.-L., & Harmer, C.-J. (2011). Early morning cortisol response and emotional processing in adults exposed to postnatal depression in infancy. European Psychiatry, 26, 479-481.

Feldman, R., Granat, A., Pariente, C., Kanety, H., Kuint, J., & Gilboa-Schechtman, E. (2009). Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 48(9), 919-927.

Grant, K.-A., McMahon, C., Austin, M.-P., Reilly, N., Leader, L., & Ali, S. (2009). Maternal prenatal anxiety, postnatal caregiving and infants’ cortisol responss to the still-face procedure. Developmental Psychobiology, 51, 625-637.

Hiscock, H., & Wake, M. (2002). Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. British Medical Journal, 324(7345), 1062-1065.

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2011). The effect of feeding method on sleep duration, maternal well-being, and postpartum depression. Clinical Lactation, 2(2), 22-26.

Luijk, M. P. C. M., Saridjan, N., Tharner, A., Van Ijzendoorn, M., Bakermans-Kranenburg, M. J., Jaddoe, V. V. W., . . . Tiemeier, H. (2010). Attachment, depression, and cortisol: Deviant patterns in insecure-resistant and disorganized infants. Developmental Psychobiology, 52, 441-452.

Murray, L., Halligan, S. L., Goodyer, I., & Herbert, J. (2010). Disturbances in early parenting of depresssed mothers and cortisol secretion in offspring: A preliminary study. Journal of Affective Disorders, 122, 218-223.

Perl, F. M. (2002). Infant sleep intervention or Nazi drill? Rapid response to Hiscock & Wake. British Medical Journal. Retrieved from http://www.bmj.com/content/324/7345/1062?tab=responses

Price, A. M. H., Wake, M., Ukoumunne, O. G., & Hiscock, H. (2012). Five-year follow-up of harms and benefits of behavioral infant sleep intervention: Randomized trial. Pediatrics, 130(4). Retrieved from www.pediatrics.org/cgi/doi/10.1542/peds.2011-3467

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA, 301(21), 2252-2259. doi: 301/21/2252 [pii] 10.1001/jama.2009.754

About Kathleen Kendall- Tackett

Kathleen Kendall-Tackett, Ph.D., IBCLC

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press, a new small press specializing in women’s health. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. www.KathleenKendall-Tackett.com

 

Babies, Breastfeeding, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Parenting an Infant, Research , , , , , ,