Lamaze Certified Childbirth Educators and other professionals that work with expectant and new families often share information and resources on the topic of newborn and infant sleep. This subject always elicits lots of questions and discussion in my childbirth classes from the families. I always make sure to provide resources that clearly demonstrate what constitutes a safe sleep environment, some helpful strategies on getting “enough” sleep with a newborn and how families can reduce the risk of SUID/SID for their infant.
Lamaze International President Robin Elise Weiss, Ph.D recently participated in a Federal SUID/SID Workgroup forum and one of the outcomes of this forum was a Safe Infant Sleep Photo Repository. This collection of images reinforces the American Academy of Pediatrics safe sleep recommendations. All of the images are in the public domain, which means that you are free to use them for your blog posts, teaching presentations, classroom posters, websites and other needs as you like. There are plans to increase the diversity of families represented in the images in the near future, to include Native Americans and Native Alaskans.
First Candle’s Safe Sleep Image Guidelines is a useful resource if you are a photographer who takes your own images or you are looking to better understand what type of safe sleep image to use in your work with families. Additionally, if you see images in the media (magazines, websites, commercials, marketing materials, ads, etc.) that are using unsafe sleep images, you can contact First Candle and let them know, so they can contact the appropriate organization and have them replaced with images showing safe sleep environments.
Take a moment to review your teaching materials and resources on the topic of safe sleep for new families. Make sure your images model safe sleep practices. Check out the images in the Safe Sleep Image Repository and use them as you like in your classroom, your practice and as you work with families. What families learn from you about safe sleep can help to reduce the tragic death of an infant as a result of being placed in an unsafe sleep environment. How do you talk about safe sleep to your clients and students? Share your favorite resources and teaching ideas on the topic of safe sleep in the comments section below. Would you consider using some of the images available in the Safe Sleep Image Repository? Let us know.
By Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM
Kathleen Kendall-Tackett, Ph.D, author, IBCLC, researcher, internationally acclaimed speaker and occasional contributor to our blog, has written a new book – “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers,” that tries to lay to rest the myth that receiving help for a postpartum mood disorder and breastfeeding are not compatible. I asked Cynthia Good Mojab to share her expert review of the book to commemorate the end of Perinatal Mood Disorders Awareness Month. Cynthia is the perfect person for this task as she wears the hat of both a lactation consultant and a clinical counselor. As birth professionals who work with families throughout the childbearing year, we have a sincere responsibility to provide information and screening resources so that families can be evaluated and directed to receive help that continues to support the breastfeeding dyad if breastfeeding is the parent’s desire. Read Cynthia’s review and consider what you can do to increase awareness of perinatal mood disorders and offer your clients and students the best evidence based information available about how treatment options and breastfeeding are not mutually exclusive. – Sharon Muza, Community Manager, Science & Sensibility
Globally, the prevalence of postpartum depression is as high as 82.1% when measured using self-report questionnaires and as high as 26.3% when measured using structured clinical interviews (Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). These high rates mean that a significant proportion of families navigate breastfeeding in the context of postpartum depression.
As a perinatal mental health care provider and an IBCLC, I am frequently contacted by parents who found me after having been unable to access breastfeeding-compatible mental health care for postpartum depression (Good Mojab, 2014). They report feeling as though they are caught between a rock and a hard place: they’ve been diagnosed with postpartum depression and have been told by their primary care provider and/or their mental health care provider that they must wean in order to treat their depression. Sometimes they are even told that breastfeeding is causing their depression. Not only is that not true, but the relationship between infant feeding and postpartum depression is actually quite complex (Nonacs, 2014). While breastfeeding problems increase the risk of postpartum depression, breastfeeding itself is protective (Kendall-Tacket, n.d.). And research shows that infant-feeding intentions matter: breastfeeding mothers who are unable to accomplish their breastfeeding goals are two-and-a-half times more likely to develop postpartum depression (Borra et al., 2015). These research findings match what I see in my private practice: the partial or complete loss of a parent’s desired experience of breastfeeding can precipitate deep grief and worsen or precede the onset of postpartum depression.
Fortunately, there are many breastfeeding-compatible treatments for postpartum depression which health care providers and mental health care providers can use to effectively treat the vast majority of their clients. Dr. Kathleen Kendall-Tackett’s new book, “A Breastfeeding-Friendly Approach to Postpartum Depression: A Resource Guide for Health Care Providers,” presents an up-to-date overview of the related research in an outline format that is quick and easy to read. She presents a compelling case for ensuring that families coping with breastfeeding problems receive additional lactation support and that breastfeeding parents coping with postpartum depression have access to treatment that is compatible with the continuation of breastfeeding.
In the first chapter, Kendall-Tackett introduces the rationale for screening for, referring for, and treating postpartum depression: postpartum depression is common in new parents and untreated postpartum depression has significant, immediate, and long-term negative consequences for both parent and child. She then presents research showing that breastfeeding does not cause depression (as some health care providers falsely believe); rather, breastfeeding serves to protect the dyad from the deleterious consequences of postpartum depression via its dampening of the stress response and via its facilitation of ongoing engagement between parent and baby. (When we shift our culturally based reference frame in recognition that breastfeeding is the biological norm for humans, we can see that this research also shows that formula feeding increases the risk of deleterious consequences from postpartum depression through increasing the stress response and potentially lessening ongoing engagement between parent and baby.) The substantial evidence base for why the effective treatment of postpartum depression is so critical—briefly introduced in chapter 1—is presented in more detail in chapter 3. Psychological disorders that often co-occur with postpartum depression, such as posttraumatic stress disorder, bipolar disorder, eating disorders, and obsessive-compulsive disorder, are then described. Chapter 5 reviews the complex causes of postpartum depression, including inflammation, fatigue and sleep disturbance, pain, traumatic birth experiences, infant characteristics such as illness and prematurity, and maternal characteristics, life history, psychiatric history, and social context.
Chapter 6 emphasizes the importance of screening for postpartum depression. Kendall-Tackett wisely advocates that validated screening tools be used (rather than relying merely on casual observation) and that screening occur in a variety of care settings—prenatal, hospital, home, and pediatric office visits. The recommendation for prenatal screening is very important. Depression during pregnancy is common (11% to 23% of pregnant women experience depression), is a risk factor for adverse reproductive outcomes such as preterm delivery, and is among the strongest predictors of postpartum depression (Gaynes, et al., 2005; Yonkers, et al., 2009; Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). Kendall-Tackett describes three reliable screening tools—two of which (the Patient Health Questionnaire-2 and the Edinburgh Postnatal Depression Scale) are in the public domain. This excellent chapter would be improved further with information about how to implement perinatal mental health screening in various settings, including the need to build a breastfeeding-friendly referral network prior to initiating screening and the need to develop or obtain materials (e.g., brochures, handouts, posters, resource lists, referral lists) that provide anticipatory guidance and help parents more easily access information, support, and treatment for postpartum depression (Good Mojab, 2015).
In chapter 7, Kendall-Tackett presents the development of a breastfeeding-friendly treatment plan as being grounded in the facilitation of informed decision making—something perinatal care providers are ethically obligated to do. Informed decision making requires that parents be offered evidence-based information that will allow them to weigh the risks and benefits of a variety of treatment options. This final chapter presents such information in the form of a succinct review of the available research on treatments that have been shown to be effective in treating depression, including: 1) “alternative” treatments (i.e., long-chain omega-3 fatty acids, exercise, S-Adenosyl-L-Methionine, and bright light therapy), 2) psychotherapeutic treatments (i.e., cognitive behavioral therapy and interpersonal therapy), 3) herbal medications (i.e., St. John’s Wort); and 4) anti-depressant medications. The reader is referred to the Infant Risk Center for up-to-date information about the use of particular anti-depressant medications during breastfeeding. Additionally, Medications and Mothers’ Milk: A Manual of Lactational Pharmacology is listed among the references. The LactMed app, though not mentioned in the book, is another useful resource for facilitating informed decision making regarding the use of drugs and supplements during breastfeeding.
The appendices are helpful for readers who have not yet begun to screen for perinatal depression and are looking for appropriate screening tools. Included are the Postpartum Depression Predictors Inventory—which can be used to identify risk factors for postpartum depression—and the Edinburgh Postnatal Depression Scale—which is well-validated as a screening tool for perinatal depression in mothers, in many cultures and languages, and in fathers. (A gender/prenatal/postpartum inclusive version of the EPDS is available here.) Because postpartum depression often includes symptoms of anxiety and/or co-occurs with an anxiety disorder, the appendices would have been improved by including the well-validated Generalized Anxiety Disorder 7-item (GAD-7) Scale, which is also in the public domain.
Scattered throughout the book are links to video clips that provide information on topics such as how breastfeeding protects maternal mental health and how breastfeeding ameliorates the negative effects of sexual assault. Readers with an auditory learning style will especially appreciate this access to online interviews and mini-presentations. Unfortunately, the dark gray links on a light gray background can sometimes be hard to read, leaving the reader to wonder “is that character a capital I, a lowercase L, or a numeric 1?” But, the video resources are worth the trial and error needed to open a couple of the links. Those with access to a smartphone with a QR code reader or barcode scanner can simply scan the code for each video clip to open the links, which greatly simplifies the process.
While the title of the book, “A Breastfeeding-Friendly Approach to Postpartum Depression,” is gender neutral, readers should know that the book is focused on cisgender mothers and uses cisnormative language. Certainly, there is a dearth of research on transgender and gender non-conforming parents which makes it difficult to write an evidence-based book addressing their needs in the context of breastfeeding/chestfeeding and postpartum depression. Nonetheless, we can infer that the high rate of clinical depression (44.1%) among transgender individuals means that transgender parents are at high risk for postpartum depression. And, the fact that transgender individuals experience “gender insensitivity, displays of discomfort, denied services, substandard care, verbal abuse, and forced care” in health care settings (Bockting, et al., 2013) means that transgender parents are also at high risk of being unable to access effective mental health care, much less breastfeeding/chestfeeding-compatible mental health care. Perinatal care providers need to be aware of these higher risks and learn how to bring their services into compliance with the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (Bockting, et al., 2011). The lactation-friendly treatment options for postpartum depression that are reviewed in the book are likely to also be effective for transgender and gender non-conforming parents who breastfeed, chestfeed, or feed their expressed milk to their babies. The effective treatment of breastfeeding/chestfeeding parents with postpartum depression will also need to include responding to whether and how they are experiencing gender dysphoria during lactation.
Although written for health care providers, “A Breastfeeding-Friendly Approach to Postpartum Depression” will also be useful for childbirth educators, doulas, lay supporters, lactation specialists, and perinatal mental health care providers as they strive to do their part to offer families evidence-based anticipatory guidance about postpartum depression and its treatment options, advocate for more lactation support for families coping with breastfeeding difficulties, screen for postpartum depression, refer to and effectively collaborate with other breastfeeding-friendly perinatal care providers, and provide services that avoid iatrogenically increasing the risk of negative health, developmental, and mental health consequences for parents and babies through the unnecessary undermining of breastfeeding. The more widely Dr. Kendall-Tackett’s powerful little book is read and applied in practice, the more breastfeeding families will have access to breastfeeding-compatible treatment that truly meets their needs in the context of postpartum depression.
Norhayati, M., Nik Hazlina, N., Asrenee, A., & Wan Emilin, W. (2014). Magnitude and risk factors for postpartum symptoms: A literature review. Journal of Affective Disorders, 175C, 34-52.
Yonkers, K. Wisner, K., Stewart, D. Oberlander, T., Dell, D., Stotland, N., Ramin, S., et al. (2009). The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 114(3):703–713. Accessed: May 28, 2015. Url: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094693/pdf/nihms293837.pdf
About Cynthia Good Mojab
Cynthia Good Mojab, MS Clinical Psychology, is a Clinical Counselor, International Board Certified Lactation Consultant, author, award-winning researcher, and internationally recognized speaker. She is the Director of LifeCircle Counseling and Consulting, LLC where she specializes in providing perinatal mental health care, including breastfeeding-compatible treatment for postpartum depression. Cynthia is Certified in Acute Traumatic Stress Management and is a member of the American Academy of Experts in Traumatic Stress and the National Center for Crisis Management. Her areas of focus include perinatal loss, grief, depression, anxiety, and trauma; lactational psychology; cultural competence; and social justice. She has authored, contributed to, and provided editorial review of numerous publications. Cynthia can be reached through her website.
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.
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.
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
Even 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.
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.
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/10.1891/2158-07220.127.116.11
About Kathleen Kendall-Tackett
Kathleen 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
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
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?
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).
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.
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. Pediatrics, 116(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 Lactation, 23(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.
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.
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.
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.
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
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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.
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).