About that BMJ Editorial…

Many thanks to anthropologist Aunchalee Palmquist for allowing me to re-blog this response to the BMJ editorial on human milk sharing.

Anthrolactology

A few days ago, the BMJ published an Editorial about the “Risks of the unregulated market in human breast milk.” In a matter of hours, this piece was trending across Facebook and Twitter. Al Jazeera even ran a story featuring this piece. The commodification of human milk is a hot topic, with the Medolac debacle in Detroit, athletes buying breast milk online to enhance their fitness, the New York times coverage of growing profit-driven interests in lactoengineering, and now this.

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The issue of skin-to-skin.

photo (3)Atul Gawande  is a general surgeon and researcher from North America. And he writes. And thinks.

I “discovered” him a couple of years ago when I read an article of his in The New Yorker on how medicine takes up new ideas into practice (see links below).

In part of the article he described the efforts of public health workers in India trying to instil the practice of immediate skin-to-skin contact for mothers and babies after birth. The proven power of skin-to-skin contact in reducing infant mortality means it should be a natural activity for birth workers to encourage. And it’s an easy thing to facilitate and encourage in the clinical setting. But still it took time for widespread taking-up of the practice.

Gawande’s conclusion was that people are key in creating change in clinical practice.

Health workers with some clinical skills were employed to visit health care facilities to educate on the importance of the practice and also to make connections with practitioners. Practice is a complicated thing. Clinicians go through many processes in order to change their practice. It is one thing to know what the “evidence” is. It’s another thing to incorporate that into what you do. There may be particular factors which prevent the practice from being carried out, and perhaps most importantly, there may be colleagues who don’t share your priorities.

In the case of skin-to-skin contact, I thought of a few obstructions that might occur in a typical Australian maternity setting:

– the need or expectation that other activities will occur following the birth, such as checking the woman’s perineum, delivering the placenta or checking the baby, which skin-to-skin contact may delay or prevent being carried out.

– the desire of family, friends or health workers to give the mother “a rest” from her baby after what may have been a long and difficult labour.

– the belief that the operating theatre environment is too cold for a newborn baby to be unwrapped.

– the belief that a mother having skin-to-skin contact with her baby on an operating table will interfere with the rest of the caesarean procedure.

– the pressure on labour rooms necessitating the transfer of women who have given birth to postnatal wards as soon as possible.  This might mean that administrative tasks take precedence in the activities following birth.

In fact, many of these obstructions were issues in Indian healthcare facilities too!

Gawande’s conclusion in the Indian situation was that this ongoing person- to- person contact was the most effective means of creating change in practice.  Why?

-It meant that the activity was perceived as a priority (why else have someone dedicated to the task of changing practice?)

-It allowed for the clinician to understand all the reasons for the new activity by discussing it with the health worker.

-It gave local clinicians the opportunity to “own” the activity because they could discuss the particularities of their place of workplace with someone else and adapt their practice in a way that suited their context.

-When the practice was increasingly adopted the results could also be observed by the clinician which then had a positive feedback effect…and so skin-to-skin would become a “standard” feature of post-birth care.

And we haven’t even started to talk about breastfeeding…

 

The New Yorker article: http://www.newyorker.com/magazine/2013/07/29/slow-ideas

Atul Gawande’s website: http://atulgawande.com

Breastfeeding in public. Build a bridge.

I’ve been a subscriber to google alerts for a couple of months now. The topics I am sent include “breastfeeding”, “bottle feeding”, “pregnancy” and “lactation consultants”. I get links to newspaper and magazine articles that the great google machine finds via its keyword searches.

Most days I skim them, some days I read a few and my midwife Facebook friends will know that I often post links that I think are discussion-worthy or particularly interesting.

The breastfeeding posts and links and articles have predominantly been focussed on two things: reported incidents of women breastfeeding who have been asked to cover up or leave the space they’re in. The other topic is how women are unfairly pressured to breastfeed by so-called breastfeeding nazis – a topic I have addressed in another post (More women doing it for longer).

I am coming to think that breastfeeding in public is a key issue for ongoing breastfeeding rates in Western countries. And it’s an issue of human rights…no,dammit, women’s rights.

If a woman is going to have the freedom to leave her home and surrounds with her breastfeeding infant she needs to know that she can feed her baby whenever and wherever she wants to, and more importantly, whenever, wherever and for however long it takes for her baby to feed. With no judgement whatsoever, and even with some encouragement – not a cheer squad, but maybe a nice place to sit and a drink of water.

Women who breastfeed in public are expected to look after the feelings of everyone else who enters that public space. It’s less of an issue that anyone can actually see anything (for example, areola or nipple) and more about the idea that this woman could be breastfeeding.

Breastfeeding women are often being asked to be discreet by the members of the public who see themselves as Reasonable People: “I don’t mind if women breastfeed, but they should be discreet about it”.  These people seem uninformed as to the realities of feeding a live, wriggling child.  And also to how rare sexual exhibitionism is amongst breastfeeding women.

Being a mother of a small baby and toddler can be an isolating experience. A lot of a mother’s time is spent in her own home with her children, attending to her childrens’ needs and running the household. Being able to get out, even if it’s to the shops, is what you need to do every day and sometimes it’s a downright lifeline (please take note shop keepers).

We all expect that when we enter the public sphere we can act as we please, within certain boundaries.

For a breastfeeding mother that means that she will very likely need to breastfeed her child at some point in public.She needs to do that so that she can leave her house, buy food, feel part of a community, stimulate her child, maybe even have a latte…in short, live her life.

Frankly, anyone else’s sensibilities will need to take a back seat if we can agree that, as a member of our society, she has the right to do those things. And breastfeed.

In Australia she has the inalienable legal right to do so.

I know that women’s bodies being displayed in public is a complicated issue in Western society. And breastfeeding is seen as a private activity that shouldn’t (?) be brought into the public sphere. What better way to cut through the hypocrisy around the objectification of women’s bodies than for a mother to carry out a beautiful, physiological activity of love and food with her child?you-can-do-it-breastfeeding

Maternal and Infant Nutrition and Nurture …oh my!

10 things I learnt and loved about #MAINN2014.

This conference is usually held each year in Grange-over-Sands in the UK, by the University of Central Lancashire. It is a conference dedicated to presenting and discussing research on infant feeding with an emphasis on alternative, contextual approaches to the subject. This year it was held at the University of Western Sydney in Parramatta. These are some of my personal highlights…in no particular order and with ruthless editing to make it digestible to others. Thanks to Virginia Schmied from UWS for making it happen.

1. Exploring the highs and lows of the Baby Friendly Initiative with Fiona Dykes from the UK and Danielle Groleau and Sonia Semenic from Canada. Good to know that there are people interested in the way that health professionals (midwives) live with the 10 steps and the culture of the accreditation.  Fiona spoke about the problems with a “top- down”approach with any behaviour change, but also about the promise of relationships in breastfeeding support.

Sonia spoke about the challenges of introducing the 10 steps into NICU units worldwide: there is a general pre-occupation with infant growth, calories and volume. There are also significant challenges associated with baby illness and feeding. It will be so exciting to see the progress with this work.

Danielle’s work looked at the varied impacts that BFI facilities seemed to have on women’s breastfeeding behaviour in the longer term. She highlighted the  need for more research into the impact of BFI on women from low income groups. She also spoke very clearly about the sociological theory that shines a light on the the problematic issues of breastfeeding cessation amongst women from low income backgrounds and breastfeeding in public. Symbolic capital…mmmm.

2.Renee Flacking reporting on her ethnographic study of four NISC units: 2 in Sweden, 2 in UK. eleven months of fieldwork (phew!).  Her comparison of the different models of care was effective in demonstrating the many benefits of the “womb” model: continuous skin to skin with mother (and/or partner), a separate, private space that allowed families to “focus within”, with the baby as the context.  Interactions between mother and baby “effortless”. Importantly, parents can “be who they are”. Her description of the “standard” nursery care with one uncomfortable chair for mama highlighted the culture in many nurseries of parents being expected to stay an hour or three, but not for longer.

3. Investigations of the impact of peer support for breastfeeding in the UK with Gill Thomson.

Nursing Mothers and the Australian Breastfeeding Association have done this en masse in Australia over the past 50 years. Yup, we reckon it works. Kate Mortensen from ABA is investigating breastfeeding peer support globally and the RUBY study  (Ringing Up about Breastfeeding) will examine the impact of telephone peer support for breastfeeding mums in Melbourne, as presented by Heather Grimes from La Trobe University… it’s already under way.

4. Shanti Raman’s ethnographic study of families in Bangalore,India: “nothing special, everything is normal”. How pregnancy and childbirth is part of the discourse of everyday life in India, and how it is woven into the rich repertoire of celebration and ritual. This resonated with my own experience of providing care for Indian families in Australia… somehow enviable in our culture where pregnancy and childbirth seems so “other”.

5. Gold star to Charlene Thornton for making me like stats!  Her “normal woman” enables effective comparison between care models. Some juicy details: C/S rates, inductions and episiotomy in  private compared to public.

6. Deborah Lupton – renowned health, food and  now digital sociologist.  Enjoyed her quick summary of her own work and directions over the past 20 or so years, with some emphasis on the sociology of risk: “The precious foetus” and more. Mothers place so much pressure on themselves to perform as guardians of their children. Children are both beloved and reviled in our society. Food for thought …

7. Examination of the breast pump discourse: Helene Johns, Kath Ryan and Athena Sheehan. Soft touch indeed. The impact of advertising culture on breastfeeding culture: when breastfeeding comes to equal breastmilk.

8. Talking at meal breaks.  To anyone and everyone – so friendly! What is it about people who do research into breastfeeding and birth? I’d like to think we are uncorrupted by wealth or status!

9. Meeting strangers at dinner. Actually, turned out to be new friends.  This was the kind of conference where, no matter who you spoke to, they were interested and involved in breastfeeding research  and/or clinical practice. Often both. I found out a great deal about what breastfeeding support looks like in Queensland. I also was delighted to share my own plans for research (thanks guys!).

10. Being at UWS in Parramatta. Home of the Whitlam Institute. The campus is an oasis from the traffic and noise of the bustling city.  It’s also a stunning combination of old architecture and new as well as useable and attractive open spaces.  An amazingly culturally diverse community in Parramatta and a calm and beautiful walk each day along the beautiful Parramatta river. Harbour? Who needs a harbour?!

 

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speech made on leaving the best job ever…

WitchesIt’s almost a year since I left work to start full-time study as a PhD student. So ended ten years of part-time and casual work as a midwife in a major metropolitan maternity teaching hospital.

I hosted an afternoon tea in the postnatal ward – and I made a little speech, because I grew up in a family where making a speech was a way of marking an occasion… and because it all felt like a big thing to be doing.

This month I have started doing a few shifts back there … just to remind myself of the realities of clinical work and to catch up with friends and colleagues. It feels ok.

Jen’s end of work speech. 2/1/2014  

I have loved working here – although some days are better than others! I have great colleagues who care about the women they provide care for. I have met so many inspiring, interesting women and families and had the privilege of sharing what is a life-changing event with them. They personify what I think this place is all about – the highs and lows of human existence. And they let us experience this with them!
Our work as midwives is so important.

Didn’t catch that? I’ll say it again – our work is so important.
From the booking visit in clinic to the last home visit …. Sure we have expertise: we know plenty of stuff about normal pregnancy and birth. But we’re more than that – we’re another woman, we like having a chat, we care about the whole woman and we meet women where they are.
So then we write the dicky little sentences in the antenatal record about holidays planned, sickness in the family, concerns about another child, how last time’s experience is effecting this pregnancy…
And sometimes we are one of the very few people who have taken the time to listen, to care about what’s happening to this woman in her life. We may well be the only positive educational experience she has had. We can be part of a life-changing time for her – diet, exercise, relationships, doing something amazing for herself and her family by bringing a baby into the world.
So I’m leaving being a midwife because I love being a midwife so much! And people have asked me: “why are you leaving and doing this?”
The project I will do about Lactation Consultants is a means of learning how to do research. The masters sparked it for me – I realised there was so much research out there that can help our clinical practice, answer our questions, help us ask more and help us to live with the doubt.
Anyway, so that’s what I’m going to do. And maybe I’ll come back to help you guys do some research too.
Just one thing to finish with … I don’t think we’re very good at letting each other know how fabulous we are. Do me a favour – tell your colleagues – don’t just thank them for their help, but tell them how you admire their practice, their attitude to women, their commitment to caring, their ability to help a woman birth her baby.

And enjoy your work. Thanks

Scientific Motherhood

ModernPriscilla1929-03When I was studying midwifery, approximately 100 years ago, I decided to write an essay on parenting advice.

It was probably a pretty crappy piece of work.

The internet was not really something you surfed back then. Research was all about library books on shelves and some midwifery journals (paper ones, in the library).

None of which seemed to have anything to say about this topic.

I can’t remember the major texts I cited back then, but I do remember coming to the conclusion that parents should be encouraged to trust their own instincts with regard to parenting.

Controversial stuff for a student midwife with no experience of parenting at all. Partly, I think I was overwhelmed with the prospect of teaching new parents about something I knew nothing about. Hand it over to them, sister. It made sense.

Turns out maybe I wasn’t so wrong.

The last hundred years or so in the industrialised world has seen a bunch of people termed “parenting experts” telling parents how to raise their children. Given that not so long before that children were usually seen as economic units: mini- adults suited to working in confined areas, like chimneys and sweat shops, I guess it was nice at least that someone took an interest in whether they lived or died.

Mothers were also seen to be solely in charge of child raising (see my post on the Cult of the Mother). Sounds good, but unfortunately they ended up caught in a trap: when concerns arose over infant mortality rates in urban areas in the US, mothers took the lionshare of the blame. Mothers were collectively blamed for poor hygiene, poor diet, not breastfeeding or breastfeeding poorly.

Germ theory made a few things clear, but it took years for the message to get out: babies got ill because of exposure to viruses and bacteria, viruses and bacteria thrived in dirty drinking water, poor people often had to rely on contaminated drinking water…should do something about that dirty drinking water.

The new profession of paediatrics leapt into the task of developing formula for babies whose mothers were unable to breastfeed them.  This was much needed, when so many babies died before their first birthday.  This unfortunately turned into a way to feed babies when women were having problems with breastfeeding, and then, into just a different way to feed your baby. Formula feeding was, initially at least, managed by the medical profession. Paediatricians’ main work was largely in infant feeding plans.

Parenting books started to be written in the 1920’s, but Dr Spock was the breakthrough text in 1946 with his Baby and Child Care. 

The book was predicated on the idea that parents “know more than they think”. There was gentle encouragement for parents to “trust their instincts”. Unfortunately most of the information in the book related to bottle fed baby behaviour. Again parents were gently encouraged to breastfeed, but if it proved difficult, there was always bottle-feeding.

And there were regular reminders to consult with your doctor to check that your instincts were indeed right.

Today there are approximately one gazillion people who write and blog and speak about parenting. Some of these instruct  inflexible and routinised methods to make absolutely sure babies will sleep for long periods.

The good ones let parents know about normal baby and infant behaviour to help them adjust their expectations of what “normal” is (it’s a cycle on the washing machine last time I checked).

Then gentle encouragement to go for that elusive goal: “what works for you”.

A thing I say when talking to parents-to-be in antenatal clinic: “we midwives know a bunch of stuff about lots of babies, but not about your baby …. pretty soon you’ll be the expert there.”

Here are some links to good baby stuff:

http://www.pinkymckay.com

http://raisingchildren.net.au

https://www.breastfeeding.asn.au

 

 

More women doing it for longer.

There has been some talk lately about the pressure placed on women to breastfeed their babies.

Ninety-six percent of women in Australian initiate breastfeeding when their baby is born (Australian National Infant Feeding Survey, 2011), which is a cracking good statistic by world standards. It’s definitely up with the leading leaders in Northern Europe.

The well-worn promotional phrase “breast is best” may well be at least partly responsible for this excellent initiation rate, although breastfeeding advocates are well aware of a more pressing problem – that of keeping women breastfeeding.

In the first week after birth, many, many women who had planned to breastfeed either give their babies infant formula or stop breastfeeding completely. This is despite the best efforts to promote the World Health Organisation’s (and Australia’s National Health and Medical Research Council’s) recommendations that advise there are specific health benefits to babies when they receive ONLY breastmilk in the first six months of life.

The latest figures state that 15 percent of Australian babies are receiving only breastmilk just as they turn six months old.

The question of why this is happening is certainly of interest to breastfeeding advocates and researchers. There is every reason to believe that women who start to breastfeed plan to continue doing so, but as for many health behaviours, the reasons why women enact and sustain breastfeeding are extremely complex, and, I would say, intimately related to the context of their lives. This means that messages like “breast is best” have some power in people’s decision-making, but may not sustain their health behaviours over time.

More influential in the medium term for women breastfeeding their babies might be things like how much time off work a woman has after her baby is born, how supportive and knowledgeable about breastfeeding her friends, partner and family are, how much timely support she gets from health professionals if/when she has difficulties, how comfortable she is breastfeeding in public or even in front of other family members in her own home, and how much she actually enjoys the activity of breastfeeding.

Madeleine Morris’ new book, Guilt-free bottle feeding argues that women have too much pressure placed on them to breastfeed. Earlier, I assumed that 96 percent of Australian women were breastfeeding because they wanted to. It is unsurprising then, that when 96 percent of Australian women start off breastfeeding, our health system is somewhat geared towards supporting them to continue. The known health benefits to mother, baby and community of women breastfeeding might also explain the enthusiasm with which that support is offered.

As for individual guilt, it is generally unhelpful to blame those who helped you try to achieve the goals you set for yourself. Better to protest about the values of a society that purports to like the idea of breastfeeding, but doesn’t provide sufficient affordable, skilled support and education to those trying to do it.

Morris argues that there is really very little difference between breastmilk and baby formula, despite regularly stating throughout the book that of course breastmilk is the best and first choice for feeding a baby. Also confusing is her argument that women want to breastfeed because it is an activity that is inextricably linked in our society to the ideal of a good mother. Rather, the evidence we have suggests that women start and continue to breastfeed because of the health benefits it confers to babies.

There are also many women who struggle to breastfeed in public, whether because of overt comments or because they are worried about the possibility of comments being made. This situation is not likely to be reflective of a society head over heels in love with breastfeeding mothers.

The bigger question remains: if most women start off breastfeeding, why do so many start giving formula as well or stop completely?

To be honest, we don’t know enough about how best to support women to breastfeed. The Cochrane Collaboration’s review paper on support for breastfeeding women particularly mentions the lack of research examining women’s satisfaction with breastfeeding support. My doctoral research will ask women about their experience of care with lactation consultants. I will also observe lactation consultants in practice and talk to them about their work. I am excited by this opportunity to learn about women’s experiences of getting help to breastfeed. It will also be great to observe and talk with the health professionals who support women to breastfeed every day.

There is a happy ending to this story: the Cochrane review also notes that any form of breastfeeding support is most effective in populations with high breastfeeding initiation rates.images-6