Science & Sensibility

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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 11^th, 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

• Prevention and Treatment of Traumatic Childbirth
• Midwifery Today
• Trauma and Birth Stress
• Posttraumatic Stress After Childbirth
• Birth Trauma Association

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, 2^nd Edition (2013, Civic Research Institute), Depression in New Mothers, 2^nd Edition (2010, Routledge), and Breastfeeding Made Simple, 2^nd Edition (co-authored with Nancy Mohrbacher, 2010).

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Breastfeeding Solutions; Quick Tips for the Most Common Nursing Challenges by Nancy Mohrbacher, IBCLC, FILCA is a recently published book, (April 2013) designed  for breastfeeding mothers.  This book is small and lightweight, measuring just 5 x 7 inches, with 202 pages, including appendices, which makes it practically pocket sized and easy to throw in a diaper bag or read while nursing a little one.  There is also an e-book version available as well.

The book is divided in to 7 chapters, and includes a short and concise resource list at the back, along with some brief citations referred to in the book.  The chapters have simple titles such as “Nipple Pain” or “Night Feedings” making it easy to find the information a mother might be looking for.  Each chapter is divided into the typical challenges that mothers might be dealing with under that particular topic.  With a clear, easy to read large font for each section,  the pages are well designed and simple, making it a breeze for a tired and sleep-deprived mother or partner to find exactly what information s/he needs. Occasional, basic, black and white line drawings reinforce the information provided in the text.  The language used throughout the book consists of common terms and is easy to read and understand. I really liked how Nancy reassures the reader with her writing style, that the while the mother or baby may be experiencing some struggles, that things can be fixed and will get better.   In many places throughout, the author lets us know that if things do not improve that the mother should seek out help from an appropriately skilled expert, with her first recommendation being an international board-certified lactation consultant (IBCLC).

Right from the start, Nancy encourages and explains laid back breastfeeding positions for the mother-baby dyad, sharing why these positions makes so much sense for the mother and baby who are just starting to breastfeed.  She even references and provides a link for a short video on this from Suzanne Colson. In several places in the text, Nancy encourages readers to refer to a linked video to reinforce the information provided in the book.

Nancy emphasizes throughout the book that mothers can follow their instincts and will know what to do, but problems can arise and that help is available. She uses some of the same vocabulary that I use when teaching breastfeeding classes, such as “breast sandwich” to help mothers understand getting a deep latch. When discussing weight gain in breastfed babies, Nancy references the WHO exclusively breastfed growth charts as the appropriate guide for how baby is doing.  This is good to know information when a mother will be discussing weight gain with the baby’s provider.

Important information is repeated throughout the book, so a mother who has opened the book to find specific information will not miss key points such as “drained breasts make milk faster, full breasts make milk slower” even if she never turns to the “Milk Supply Issues” chapter.

One of my favorite sections was Nancy’s accurate explanation of breastfeeding norms for the newborn.  Reassurance that cluster feedings, having night and day time mixed up, frequency and length of feedings in the first six weeks really go along way to reassure the new mother that her baby is normal and doing what normal newborns do.  She also shares information about the volume of milk a baby can expect to need as she grows. Every pregnant woman or new mom should read this section, so they don’t wonder if things are normal in their sleep-deprived state.

The old foremilk-hindmilk discussion is squashed as Nancy explains how fat molecules are released from the milk ducts as the feed progresses, but reassures mothers that this is not something to be concerned about.  When a mother feeds on demand and offers both breasts over the course of a day, the baby will be provided with adequate breastmilk that contains everything needed.

There is a great section on going back to work and maintaining supply, along with how to make a pumping session most effective. There are even tips on choosing the right pump for your pumping needs.  I loved the information and drawings included for making sure that your pump has the proper sized phalanges (or nipple tunnels as they are called in the book) for each woman’s nipples, as I frequently see women who have poor fitting phalanges, making pumping so much more uncomfortable.

Nancy shares several different strategies for solving the common problems, so women have many things to try and includes a section for each topic called “If these strategies don’t work” with even *more* information and other things to consider. There are also little sidebars with “Myth and Reality” nuggets scattered throughout the book.  Women are provided with current evidence based information for best breastfeeding practices.

The book closes with a lovely chapter on weaning, sharing ideas on how to decide when the time is right and how to make it easy on both mother and child.  The entire book is non-judgmental, acknowledges that there can be challenges and offers encouragement and information in a non-biased manner and easy to read style that will provide support and answers to the most common concerns facing breastfeeding mothers today.  This book would be a great accompaniment to a breastfeeding class, and lactation consultants,  childbirth educators, doulas, midwives and doctors that work with breastfeeding families will want a few copies to put in their lending libraries for new moms to borrow.

About Nancy Mohrbacher

Nancy Mohrbacher, IBCLC, FILCA, is author of the books for breastfeeding specialists, Breastfeeding Answers Made Simple (BAMS) and its BAMS Pocket Guide Edition.  She is co-author (with Julie Stock) of all three editions of  The Breastfeeding Answer Book, a research-based counseling guide for lactation professionals, which has sold more than 130,000 copies worldwide. She is also co-author (with Kathleen Kendall-Tackett) of the popular book for parents, Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers.  Nancy has written for many publications and speaks at breastfeeding conferences around the world. Contact Nancy by email: nancymohrbacher@gmail.com

Sharon Muza Babies, Book Reviews, Breastfeeding, Childbirth Education, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, Newborns, Parenting an Infant, Uncategorized book review, breastfeeding, Childbirth Education, doulas, how to breastfeeding, lactation consultants, lactation support, midwives, Nancy Morhbacher, problems with breastfeeding, Sharon Muza

The topic of nutrition in pregnancy (and for breastfeeding moms) is an important one to cover, but may not get a lot of attention during your childbirth classes.  Women may also be “squeezing in” birth classes late in their third trimester, so the opportunity to make dietary changes during their pregnancy may not be feeling quite as “urgent” and they are very focused on preparing for labor and birth, as well as the postpartum period.  Hopefully, pregnant women are having an evidence based conversation about nutrition with their doctor or midwife during one of their early prenatals (or even better, during a preconception appointment, if they have had the opportunity to have one) at the start of their pregnancy.

Resources for Parents

Lamaze International’s “Giving Birth With Confidence” blog has several fantastic articles written by nutrition experts that you may want to review.  After reading these nutrition themed articles, you may very well want to consider sharing them with your class students as between class homework, highlighting them in a newsletter or just directing your students to the links.

Cara Terreri, the Community Manager at Giving Birth With Confidence states “Pregnant moms encounter so much conflicting advice on nutrition — from family, friends, doctors, the internet. First-time moms especially are known to stress over getting their nutrition just right. Educators can be an excellent resource to help moms find the most credible information.”

GBWC articles available include:

• Nutrition during Pregnancy
• Healthy Pregnancy Tips for Vegetarians and Vegans
• Good News about Pregnancy and Chocolate
• Top Ten Pregnancy Nutrition Blunders
• Don’t Let a Nutritious Pregnancy Diet Force You into March Madness

Choose My Plate

Additionally, the United States Department of Agriculture (USDA) has a very user-friendly, easy to read section on nutrition for pregnant and breastfeeding women in the “Choose My Plate” website.  Included in this section, is a “Daily Food Plan” personalized for each woman.  By creating a customized profile, using the SuperTracker tool,  a mother enters information, including her prepregnancy weight, her height and her due date.  The program creates a Daily Food Plan personalized for her pregnancy progress.  There is also a place to track foods eaten and the ability to produce reports to see how a mother is meeting suggested requirements.

I created a sample profile, as a pregnant woman, and found it very easy to move around and find useful information designed just for me. I suggest you take a few minutes to play around with it also, so you can share your experience with your classes.

Learning Activities

I teach nutrition in a variety of ways during my childbirth classes.  One of my favorite activities is to ask each family to bring in a food that is good for pregnant and breastfeeding women to eat.  We go around and have each family share what they brought, what nutrients, vitamins and benefits that item provides, how much makes up a single serving and finally I ask them to share their favorite way to eat it.

 I teaching method I use to share the nutritional needs of a pregnant or breastfeeding woman is to pass around my “lunch box” filled with laminated or plastic/fake food item.  Each family draws something from the lunch box and has a few minutes to look up information about that particular food, (see above) before sharing with the class.  I have some nutritional handouts and books in class and of course, the families all seem to have smart phones.

How do you teach nutrition?

Sharing nutritional information for pregnancy and breastfeeding is an important component of childbirth classes that often gets short shrift or overlooked all together.  If you are a childbirth educator, please share how YOU teach this important topic in your classes so that we all can create a diverse group of teaching tools to keep things lively for our students and ourselves.  If you are a provider, how do you talk about your client or patient’s nutritional needs during the childbearing year?  I look forward to reading your comments, suggestions and thoughts!  Thanks for participating.

Sharon Muza Breastfeeding, Childbirth Education, Giving Birth with Confidence, Newborns, News about Pregnancy, Preconception Care breastfeeding, Childbirth Education, nutrition, nutrition in late pregnancy, Sharon Muza, teaching methods

Press time update: Over the course of my research on Monday 4/22/13, I noticed that by the end of the day, Milkscreen’s main website no longer shows links to the Breastfeeding Assesment Calculator. The Facebook page for this product has also been removed.  An email received from the company confirms that the product has been removed from the website and retailers have been instructed to pull the product from the shelves. I can only speculate that this is due to pressure from social media. ~ Deena

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© Deena Blumenfeld

I recently became aware of a new product, the Milkscreen Breastfeeding Assessment Calculator by Upspring Baby, designed to help new breastfeeding mothers be more confident in their breastfeeding abilities. This product tells them whether their milk supply is “low, normal or high” and how they can correct problems.  

This product assumes that many mothers are worried about having a low milk supply and therefore this product will reassure mothers that they are normal. To use this product, a mother must pump her milk. Additionally, this product assumes that pumping breastmilk will yield the same quantity as when a baby nurses.  We know: what a mother pumps is not indicative of what she may be producing to feed her baby. 

From the product description: 

“The Milkscreen Assessment home test determines daily breast milk supply. It was created to address the common concern many moms have: how much breast milk do I make and is that enough for my baby? Milkscreen Assessment gives mom confidence to keep breastfeeding by telling her how much breast milk she makes and how that relates to baby’s growth, identifying possible breastfeeding issues and providing recommendations on how to overcome these issues.”

This description may play directly into a mother’s fear that she isn’t making enough breastmilk for her baby. 

From the product box:

“Problem: About 50% of moms stop breastfeeding because they are concerned they don’t make enough milk for their baby. Solution: Milkscreen Calculator”

How do we know that this percentage is accurate? 

The company does not cite a source for this statement. Moms cease to breastfeed for many reasons, including, but not limited to; going back to work, pain while breastfeeding and personal preference. 

The real data on low milk supply

 An estimated 5% to 15% of all mothers experience either primary or secondary lactogenesis failure, with the actual numbers being unknown. 

Hypoplasia or Insufficient Glandular Tissue is a rare condition that some women may have. and it needs a clinical diagnosis to confirm. Many women with this condition supplement with donated breastmilk or formula while continuing to breastfeed.

I believe that the Milkscreen Calculator doesn’t help to eliminate low production worries, as advertised. I believe that it promotes this fear! 

How does Milkscreen test the breastmilk?

After scouring their website, I am not able to find any information on what nutrients they are testing for or what testing procedures they use because they don’t actually test the breastmilk! A mother doesn’t send the breastmilk to their lab for testing. A mother fills out a questionnaire and enters the amount of milk pumped in three pumping sessions, one hour apart. Milkscreen looks at a mother’s production level as “low, normal, or high” and gives her results and recommendations as to what to do if she’s having a problem, and then makes suggestions as to their other products she might like to purchase. 

From Milkscreen’s FAQ: 

How accurate is this test?

Milkscreen Assessment is modeled after a scientific paper, published in a peer-reviewed journal, and interpretation and recommendations provided in report are based on published scientific literature found in our list of references. However, each woman will respond differently to pumping breast milk. If a woman gets a result that shows low production, it’s possible that pumping was not as efficient for her as feeding at the breast.  In this case, the report will suggest to explore this possibility with a Lactation Consultant.

When I took a look through their references list, I was unable to find the paper they referred to.. They do offer useful citations and background information, but nothing supports the need or usefulness of this product.

From the video with breastfeeding expert Dr. Landers:

“This test is based on data that are normative. Hundreds of mothers have had very special calculations of daily milk supply. Our test takes an estimated amount of breastmilk supply over a shorter period of time and lets a mother know if she’s low, normal or high. Milkscreen calculator is an estimate of the day’s milk production, but in a scientifically studied, peer reviewed paper it’s actually a good approximation….. This test is an accurate estimate of daily milk supply…. It is the growth of the baby that is the most important thing. Gives mom an idea of whether baby’s weight gain is low, normal or high. (Uses the WHO growth chart)”

If the growth of the baby is “the most important thing” why don’t we weigh and measure the baby. That would tell us if the breastmilk supply is adequate.

This product oversimplifies the issue of low milk supply. “Low, normal or high,” doesn’t give a mother any real data to go on.

How do others test* for nutritional quality of breastmilk?

The Mayo Clinic provides us with some insight as to how breastmilk is tested and what it is tested for. They use thin-layer chromatography (TLC)/colorimetry/spectrophotometry (SP)/other methodologies as appropriate. With their testing, they use samples that are 4-5ml of breastmilk.

From the Mayo Clinic:

“The nutritional content of breast milk changes considerably from day 1 to day 36 postpartum. Subsequent to that time the nutritional content is considered to be stable.

Measured nutritional components are glucose, lactose, triglyceride, and protein. Deficiency of any of the measured or calculated parameters is suggestive of decreased nutritional quality of human breast milk.”

Mayo Clinic, Breast Milk Nutritional Analysis

“Several different methods are used in the analysis of human breast milk. The sample is analyzed for triglycerides using an enzymatic method. One aliquot of breast milk is tested for total protein using biuret reagent and titration methodology and for measurement of glucose using a glucose oxidase method. A second aliquot of breast milk is pre-incubated with beta-galactosidase and glucose is measured. Lactose is calculated using results obtained by the methods listed above.”

*These tests are not FDA approved.

What is the rate of false positive / false negative results from the Milkscreen test?

An incorrect assessment can have a huge impact on the mother’s breastfeeding relationship. If a mother is led to believe falsely reassured that she is making enough milk, she may not seek appropriate help from a lactation consultant or other breastfeeding professional and her baby may suffer, Alternately, a mother may choose to supplement with formula when in fact, there was no issue or her supply could have been corrected with professional help.

Breastfeeding confidence 

In the video explaining the science behind Milkscreen, Dr. Landers states;  

“Anything we can do to help a new mom, especially a first time breastfeeding mom, to have confidence in her body’s ability to make milk and nourish her baby would be a huge, huge addition to our tools to help breastfeeding moms and babies. We know from clinical studies that moms stop breastfeeding because they think they don’t have enough breastmilk supply. It’s the mother’s perception of an inadequate supply and that she doesn’t know what she’s doing… Modern women don’t have confidence in that process (supply and demand). So one of the reasons this product is so important is that it is a huge confidence builder for the average mom.’

Phrases like  “they think they don’t have enough milk” and “mother’s perception of inadequate supply” or “doesn’t know what she is doing” reinforce the idea that women are not capable of being knowledgeable or confident about breastfeeding. 

© Deena Blumenfeld

Milkscreen Assessment also claims that if a mother has too much milk, she will likely have growth issues with her baby as well. They attribute this to the foremilk/hindmilk imbalance, including the problem of ‘loose stools’ with the infant.  Current research no longer supports the foremilk/hindmilk theory, and exclusively breastfed babies normally have loose, mustardy stool.  According to Kellymom.com, “Your breasts don’t “flip a switch” at some arbitrary point and start producing hindmilk instead of foremilk. Instead, think of the beginning of a nursing session as being like turning on a hot water faucet.” In other words, there is always fat in breastmilk but the quantity varies dependent upon how long baby nurses. Feeding from a relatively empty breast will yield a higher fat content in the milk. However, it’s the fat over the course of the day, not just in a single feeding which is important.

As educators and professionals, we know to refer a mother who is questioning her milk supply to seek help from a qualified lactation consultant or other breastfeeding professional.  Additionally, we can be sure that our breastfeeding and newborn care classes are evidence based, offer useful information and instill confidence in new mothers so they can start their breastfeeding relationship off on the right foot.  We also make sure that new mothers are aware of support groups and local resources that can help them if they run into problems and concerns. 

Lamaze’s Healthy Birth Practice #6: Keep Mother and Baby Together- It’s Best for Mother, Baby and Breastfeeding is a great resource for parents and includes a wonderful video for use in class. 

Resources and References:

 AAP Breastfeeding and the Use of Human Milk (2012) 

American Academy of Pediatrics, Adequacy of Milk Intake During Exclusive Breastfeeding: A Longitudinal Study, (2011)

Butte NF, Garza C, Smith EO, Nichols BL. Human milk intake and growth in exclusively breast-fed infants. J Pediatr. 1984 Feb;104(2):187-95.

Daly SEJ, DiRosso A, Owens RA, Hartmann PE. Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk. Exp Physiol 1993;78:741-55.

Highlights of, and thoughts regarding the AAP’s Policy Statement “Breastfeeding and the Use of Human Milk”

Hurst, N (2007) Recognizing and Treating Delayed or Failed Lactogenesis II, Journal of Midwifery & Women’s Health

“Hypoplasia/Insufficient Glandular Tissue.” KellyMom RSS. N.p., n.d. Web. 22 Apr. 2013.

 World Health Organization on Breastfeeding

Deena Blumenfeld Babies, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Newborns, Social Media breastfeeding, breastmilk, Childbirth Education, Deena Blumenfeld, guest post, Healthy Birth Practices, power of social media, Social Media

by Jeanette McCulloch, IBCLC and Amber McCann, IBCLC

Jeanette McCulloch and Amber McCann recently presented a session at the 8th Breastfeeding and Feminism Symposium on March 21, 2013, speaking about the ways that social media can be used to support breastfeeding by protecting and promoting the WHO code.  They share their presentation today on Science & Sensibility to encourage all of us to be active participants in promoting action steps that help mothers and babies.  Sharon Muza, Community Manager, Science & Sensibility.

© http://flic.kr/p/e2E4Cu

Reaching breastfeeding women today means being savvy about the use of social media. While breastfeeding organizations – long without sufficient marketing resources – are stepping up to increase online efforts, formula companies are better funded and are developing sophisticated tools for reaching mothers using the Internet. Nestle, in particular, has launched a well funded social media center that has the effect of undermining women’s breastfeeding efforts. This “Formula Death Star,” though, is not going unchallenged. Using the unprecedented capacity of social media for advocates to educate and mobilize concerned consumers, a rag-tag group of rebel forces – online WHO code activists – are working to protect the WHO code and breastfeeding mothers everywhere. 

Meeting Women Where They Are At Means Using Social Media

Social media represents a revolution in communications that rivals the introduction of the printing press. Ninety-three percent^[1] of the “Millennial Generation” (those born after 1982, who have come of age in a time of dependence upon technology) are communicating online, and in the United States, for example, nearly 3 of 4 are using a social networking Website, such as Facebook, Twitter, or Pinterest.^[2]  Social media is widely accessed by women 18 – 29, regardless of race, ethnicity, or socio-economic status.

These changes are having a significant impact on how we talk about, learn about, and share information around birth and breastfeeding. More than half of all women responding to one survey expressed their intention to share their birth experience, as it happens, on social media.^[3] Moreover, time online increases after the birth—44% of US women spend more time online after a new baby is born—and the likelihood that a new mother will seek breastfeeding information and support online is high.^[4]

Women Are Seeking Information about Health Care – Including Breastfeeding – Online

Research tell us that health care providers continue to be the “first choice for most people with health concerns, but online resources, including advice from peers, are a significant source of health information in the United States.”^[5] Eighty percent of US Internet users have sought health care information online, and birth and related topics are an area of focus. Consumers using social media are not only seeking information online, but are sharing their knowledge with others. As connectivity soars through increased Internet access and the rise of the smartphone,^[6] so does altruistic sharing of what mothers learn online.^[7]

Formula marketers are fully aware of these changes. As advocates for breastfeeding mothers, we argue that it is our responsibility as advocates to understand these changes. We also can take advantage of unparalleled opportunities social media provides for advocacy organizations to engage in dialogues with mothers and affect change.

What is the WHO Code?

The International Code of Marketing of Breastmilk Substitutes (commonly called the WHO code) was written with the goal of reducing the impact of predatory marketing worldwide of formula and related products to new and expectant mothers.

The code was written and adopted in 1981 by the World Health Organization by a vote of 118 to 1 (United States was the lone dissenting vote). Thirty two countries have adopted the code as national law, with 76 others adopting portions of the code. Ethically and morally, the code should be considered worldwide, even where it has not yet been adopted as law.^[8]

Despite common misconceptions, the code does not limit access to or use of formula or related products. The code addresses marketing. And for good reason. When marketing spending on formula goes up, breastfeeding rates go down.^[9]

Formula Companies Are Making Significant Investments In Social Media

Savvy institutions understand what we’d teach you in any social media 101 presentation: social media is an unprecedented tool for listening to and engaging with an audience. Nestle has become a leading example of the use of social media both to reach consumers and to manage conflict and dissent.

Nestle is the world’s largest food company and also one of the world’s most controversial.^[10] Nestle was founded on the formulation of artificial infant milk, made of cow’s milk, wheat flour and sugar.^[11]

But they are not alone in their use of social media to reach parents. Research conducted in 2011 – before Nestle doubled their social media budget – found that 10 out 11 brands commonly available in the US have a social media presence. Examples of their use included Facebook pages, Twitter accounts, YouTube channels, mobile apps, sponsored reviews on blogs, and interactive web sites.^[12]

How Do the TOP Breastfeeding Profiles Stack Up?

Nestle and other formula companies have built these audiences using significant budgets. While overall marketing budgets are not generally available, at least $50 million was spent on formula advertising in 2004^[13]  and Nestle has been quoted saying they have doubled their social media spending in recent years.^[14] Compare this to the resources of top breastfeeding organizations, groups like La Leche League International, which is by far the best resourced breastfeeding organization in the US. In 2011, LLL International had total revenues of $1.5 million and spent a little over $115,000 on “public relations, external relations, and advocacy.”^[15]

Other organizations, like KellyMom, BestforBabes, and the relatively new Breastfeeding USA have small budgets and rely largely on volunteer efforts. The result? Although all of these organizations make a significant impact on the women they reach, compare the total number of all of their followers on Facebook – about 145,000 as of this writing – to that of Nestle Good Start at five million followers.^[16] 

Rebel Forces vs the Death Star

Nestle has combined its significant financial resources with social media experts and tools that have made it a shining example of how corporations should handle social media. Nestle’s “Digital Acceleration Team” has a trained staff monitoring each and every mention of Nestle’s brands. Team members identify negative “emerging issues” based on the volume of mentions and respond to those with a high level of engagement using a scripted playbook for team members.^[17]

The Formula Death Star, as it has become known to WHO code activists, can feel overwhelming, both because it limits our capacity to reach families and because it can feel impossible to influence change at the world’s largest food company.

However, Nestle developed these tools in response to their inability to manage an onslaught of angry advocates and consumers on social media. In 2010, Greenpeace activists were able to secure significant changes in how Nestle sources palm oil, all thanks to a YouTube video spoof that garnered over 1.5 million views, along with a resulting social media campaign that netted more than 200,000 e-mail complaints.^[18] Policy change at Nestle based on calls from consumers is possible.

Examples of Efforts to Support the WHO code Online

Although Nestle may have the Death Star, rebel forces are pulling together to provide much needed social media support for the WHO code.

A recent campaign demonstrates the power of using social media tools to organize individuals, even without an official organizing body like Greenpeace. A blog post^[19] exposing that Pan American Health Office – the regional representative in the Americas for the World Health Organization – accepted more than $150,000 in donations from Nestle sparked outrage among activists concerned that the fox was helping to buy the hen house. Within days, a private Facebook group experienced rapid growth to 400 members, now at 900 members as of this writing. Each day, members were given specific action steps, including suggested scripts for tweets directed at PAHO and WHO.^[20] Members provided impromptu trainings on Twitter use and etiquette, researched the money trail, and quickly developed strategy, including a decision to target WHO and call for a rejection of the Nestle funding.

The result: A relatively small group of consumers and advocates – through the use of Facebook and Twitter alone – were able to force the World Health Organization to respond. But more importantly, advocates began to organize and mobilize a group of motivated individuals, who will come to the next battle more organized and prepared to engage. 

How The Rebel Forces Can Defeat The Death Star

As the Greenpeace example shows, social media provides advocates with a unique opportunity to influence how companies do business. With ongoing support to the rebel forces, much-needed pressure can be put on Nestle to change their policies. But this will not come without significant work. Some areas that need support:

• Ongoing consumer support and education around the WHO code. In our anecdotal experience, mothers generally are unaware of the WHO code, or if they are aware, think that it limits access to formula (rather than limiting marketing of breastmilk substitutes). The importance of the WHO code needs to be distilled into social media friendly images and infographics to build awareness and support for future efforts.
• Ongoing education of maternal health advocates. The WHO code impacts more than just breastfeeding. Anyone concerned with infant and maternal health should be aware of and providing support for the adoptions and enforcement of the WHO code worldwide.
• Bring even more social media savvy to the table. After Nestle’s run in with Greenpeace, they brought in a top notch social media strategist to revamp their approach and provide training for the digital engagement team. Nestle uses sophisticated tools to monitor and respond to issues. The Friends of the WHO Code – and any group hoping to use social media for impact – needs people on hand who are savvy in the use of social media and the funding for at least some basic tools to help make the job collaborative.
•  Keep doing what we know best. One the greatest impacts of the PAHO/WHO crisis was to bring together the community that will need to continue to take action. This and other groups need to use traditional community organizing strategies, with social media as the tools they use to create a more level playing field.

^[1] Howe N, Strauss W, Matson RJ. Millennials Rising: The Next Great Generation. New York, NY: Vintage Books; 2000.

^[2] Lenhart A, Purcell K, Smith A, Zickuhr K. Social media and mobile Internet use among teens and young adults. Pew Internet and the American Life Project. http://web.pewinternet.org/~/ media/Files/Reports/2010/PIP_Social_Media_and_Young_ Adults_Report_Final_with_toplines.pdf. February 3, 2010.

^[3] Social media giving birth to new generation of parents-to- be. Chicago Tribune Website. http://connect.mayoclinic.org/ news-articles/863-social-media-giving-birth-to-new- generation-of-parents-to-be/portal.

^[4] Bartholomew M, Schoppe-Sullivan S, Glassman M, Kamp Dush C, Sullivan J. New parents’ Facebook use at the transition to parenthood. Fam Relat. 2012;61:455-469.

^[5] Fox S. The social life of health information. Pew Internet and American Life Project. http://www.pewinternet.org/~/media// Files/Reports/2009/PIP_Health_2009.pdf. May 12, 2011.

^[6] Smith A. Cell Internet use 2012. Pew Internet and Ameri- can Life Project. http://www.pewinternet.org/~/media//Files/ Reports/2012/PIP_Cell_Phone_Internet_Access.pdf. June 26, 2012.

^[7] Kibbe D, Kvedar J. Building a research agenda for participatory medicine. J Particip Med. 2009;1:16.

^[8] http://lactationmatters.org/2013/03/12/the-international-code-part-1/

^[9] http://www.bestforbabes.org/what-is-the-who-code

^[10] http://www.corp-research.org/nestle

^[11] http://www.nestle.com/AboutUs/History

^[12] J Hum Lact. 2012 Aug;28(3):400-6. doi: 10.1177/0890334412447080. Epub 2012 Jun 6. Milk and social media: online communities and the International Code of Marketing of Breast-milk Substitutes. Abrahams SW.

^[13] http://www.bestforbabes.org/what-is-the-who-code

^[14] http://uk.reuters.com/article/2012/10/26/uk-nestle-online-water-idUKBRE89P07Q20121026

^[15] La Leche League Annual Report: http://www.llli.org/docs/00000000000000001AnnualReport/llli_ar2011_final.pdf

^[16] www.facebook.com/Gerber

^[17] https://www.youtube.com/watch?v=ktsMa8hfgY0

^[18] http://mashable.com/2010/05/17/nestle-social-media-fallout/

^[19] http://lactationmatters.org/2012/11/08/if-you-dont-advocate-for-mothers-babies-who-will/

^[20] http://lactationmatters.org/2012/11/14/world-wide-impact-in-10-minutes-or-less-using-social-media-for-powerful-change-2/

About Jeanette McCulloch and Amber McCann

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, has been combining communications work and women’s health advocacy for more than 20 years. She is a co-founder of BirthSwell, which is working to improve infant and maternal health – and the way we talk about birth and breastfeeding – by making social media accessible for birth and breastfeeding professionals. She is a board member of Citizens for Midwifery, and is active in local, statewide, and national birth and breastfeeding advocacy projects.

© Amber McCann

Amber McCann, IBCLC is a  board certified lactation consultant with the Breastfeeding Center of Pittsburgh. She is particularly interested in connecting with mothers through social media channels and teaching others in her profession to do the same. In addition to her work as the co-editor of Lactation Matters, the International Lactation Consultant Association’s official blog, she has written for a number of other breastfeeding support blogs including for Hygeia, The Leaky Boob, and Best for Babes and is a regular contributor to The Boob Group, a weekly online radio program for breastfeeding moms. Amber is particularly interested in the impact of the WHO Code and has worked on grass-roots campaigns to support its efforts online.

Sharon Muza Babies, Breastfeeding, Continuing Education, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, Newborns, Social Media, Uncategorized Amber McCann, breastfeeding, Jeanette McCulloch, power of social media, Social Media, WHO, World Health Organization