Breastfeeding Support: Close to Mothers

I am creating this post in celebration of World Breastfeeding Week 2013. The theme is Breastfeeding Support: Close to Mothers. I will be continually adding to it over the week until I have a useful resource page. Check back frequently!

I am submitting this post to Mothering's "Blog About Breastfeeding" Event to celebrate International Breastfeeding Week. You can join in too by clicking the link above. From there you can post your own breastfeeding blog, share the page too, or both.

Below I am highlighting World Breastfeeding Week with information, including text, from the World Alliance for Breastfeeding Action. Below the WABA text provided in their World Breastfeeding Week resources are "Make or Break" comments provided by me. At the end there is an action item calling for your "Make or Break" stories. I'd love to hear your experiences with breastfeeding support in my Comments.

Breastfeeding Support: Close to Mothers

This year's World Breastfeeding Week (WBW) theme, 'BREASTFEEDING SUPPORT: CLOSE TO MOTHERS', highlights Breastfeeding Peer Counselling. Even when mothers are able to get off to a good start, all too often in the weeks or months after delivery there is a sharp decline in breastfeeding rates, and practices, particularly exclusive breastfeeding. The period when mothers do not visit a healthcare facility is the time when a community support system for mothers is essential. Continued support to sustain breastfeeding can be provided in a variety of ways. Traditionally, support is provided by the family. As societies change, however, in particular with urbanization, support for mothers from a wider circle is needed, whether it is provided by trained health workers, lactation consultants, community leaders, or from friends who are also mothers, and/or from fathers/partners.

The Peer Counselling Program is a cost effective and highly productive way to reach a larger number of mothers more frequently. Peer Counsellors can be anyone from the community who is trained to learn to support mothers. Trained Peer Counsellors, readily available in the community become the lifeline for mothers with breastfeeding questions and issues. "The key to best breastfeeding practices is continued day-to-day support for the breastfeeding mother within her home and community."

Reference: Saadeh RJ, editor with Miriam H. Labbok, Kristin A. Cooney, Peggy Koniz-Booher (1993), Breast-feeding: the Technical Basis and Recommendations for Action: Role of Mother Support Groups, Geneva, World Health Organization, 62-74. View Document Here

Five Circles of Support:

SUPPORT for breastfeeding illustrate the potential influences on a mother's decision to breastfeed and to have a positive breastfeeding experience. Previously featured during World Breastfeeding Week 2008, the Circles of Support continue to be a vital foundation for mothers to breastfeed their babies, and more. The CIRCLES OF SUPPORT are: Family and Social Network, Healthcare, Workplace and Employment, Government/ Legislation and Response to Crisis or Emergency, all surrounding women in the center circle.

I see The Five Circles of Support as the areas that can "make or break" breastfeeding. Below each Circle description provided by WABA, I have included my own comments. I describe how each area can "make" or "break" breastfeeding, and offer additional articles and posts for each Circle.

Women: The Center Circle:

Women are in the center because the presence or absence of support impacts them directly. Women also have an important role in securing support and in providing it to others. Within the Global Initiative for Mother Support (GIMS) for Breastfeeding Statement (2007) we noted, 'Mothers are considered active participants in the support dynamic, being both providers and recipients of information and support'.

Family and Social Networks:

Husbands/partners/fathers, family and friends compose the mother's immediate and continuous support network. Social support includes community support - at the market place, within a religious context, at a neighbourhood park, etc. Support during pregnancy reduces stress. Support during labour and birth empowers the mother. Societal support increases the mother's confidence in her ability to breastfeed beyond the early weeks and months.

Make:
Breastfeeding is natural. We are, after all, mammals. Yet it is a partially a learned skill, especially for mothers. Traditionally, breastfeeding was learned over a lifetime. Children grew up experiencing breastfeeding, first by nursing until they were old enough to remember it, and next by watching siblings, relatives, and neighbors nurse.
In our modern culture, with lower breastfeeding rates and social stigma around public nursing, family and social support is more important than ever. Mothers find they have an easier time nursing early on, and find themselves comfortable enough to continue longer, when they have good support from family and friends.



Even those without support from family or friends can find the support, information, and connections they need through breastfeeding support groups such as BACE-NMC and La Leche League.

Break:
Even mothers who desire to breastfeed can find themselves giving in to pressure and misinformation from family and friends. Fathers and partners may not have been breastfed and may harbor negative feelings and misconceptions about breastfeeding. Even well-meaning grandmothers eager to help may find that they are only comfortable giving bottlefeeding advice if they don't have experience with breastfeeding.



Friends often give well-meaning advice based on the way they parent, or even directly pressure a mother into not breastfeeding or weaning earlier than she wanted. Society, unfamiliar with the importance of breastfeeding, can isolate mothers by making children, especially infants, feel unwelcome in public. And breastfeeding in public can still be frowned upon.

After birth mothers, especially first-time mothers, are highly suggestible making them very vulnerable to pressure.

Articles on Support From Family and Social Networks:

The Importance of N.I.P. (Nursing In Public)

Tips: Preparing to Breastfeed

Health Care System

This includes a multitude of opportunities to support breast feeding. These opportunities range from mother friendly prenatal care and supportive labor and delivery services to postpartum and postnatal care that facilitates bonding and optimal infant feeding. Health workers trained in counseling skills support mothers before and after birth.

Make:
Never before has information, including medical information, been so widely available. More and more people are finding they need to be proactive about healthcare. Yet, we do still look to doctors and other healthcare providers for information and support. Providers who deliver accurate and useful information in the right way at the right time can be crucial for a mother's breastfeeding success.

More and more mothers are returning to natural, low to no intervention births. More are choosing birth centers and home birth. Midwives are increasing in popularity as birth attendants. Doulas provide important labor support. The Baby Friendly Hospital Initiative is increasing the number of hospitals providing breastfeeding friendly practices. All of these factors contribute to supporting breastfeeding success.

Recently, a new profession has emerged and Lactation Consultants are healthcare providers specializing in breastfeeding support. International Board Certified Lactation Consultants are the gold standard in lactation support and receive extensive medical training.

Break:
Doctors are trained to diagnose and treat diseases. Sometime and somehow we shifted to look to doctors for information, advice, and support on normal behavior. Unfortunately, for the most part, medical training did not keep up with this trend. Many mothers find it surprising that pediatric medical training does not include much information on breastfeeding, let alone the normal course of breastfeeding.

Workplace and Employment:

Employed women face challenges and need support to succeed at working and breastfeeding. The opportunities for mother support are as varied as the work women do, but usually involve facilitating mother-baby contact or expression and storage of breast milk.

Make:
Several years ago, I worked for an amazing store called Dance This Way. They were wonderful to me and threw me a baby shower towards the end of my pregnancy with my 6th child. But the most amazing thing about them is how they had me come back to work after Luke was born. I was able to bring Luke to work with me and nurse him as needed. I could ring the cash register, straighten the racks, and even fit shoes with him in the sling (often while he nursed!).

I had done it before, brought a baby to work, at my paint-your-own pottery studio. I wrote an article about it, linked below, called "Babies in a Family Business." Not being able to bring Luke to work at Dance This Way wouldn't have stopped me from breastfeeding, but it would have prevented me from working.

Break:
My experiences with working with my youngest 5 kids is contrasted with an experience with my oldest. When I was pregnant with him, I started working for a maternity and baby clothes store as an hourly manager. I worked until I went into labor at the store.

After he was born, I took a few weeks off and returned to work. In spite of being a maternity and baby clothes store, they were remarkably un-babyfriendly. There was no place to pump milk, aside from the unsanitary public bathroom and the smoke-filled back room with no privacy. When my parents or his dad brought him to me to nurse on break, I was often not allowed to take a break to do so.

I ended up resigning. Another person may have given up nursing, but I gave up my job instead. I continued to dance part-time with the ballet company I was a part of because I was allowed to bring him to rehearsals and classes. I waited to get another job until he was older.

Articles on Workplace and Employment:

Babies in a Family Business

Pumping with Limited Privacy

Parenting in the Workplace Institute

Government Legislation

Women who plan to breastfeed or who are already breastfeeding benefit from the support of international documents, protections for optimal infant feeding, plus active and well funded national commissions. Legislation that combats aggressive marketing of breastmilk substitutes and enacts paid maternity leave also benefits breastfeeding women.

Make:
In an ideal society we wouldn't need laws pertaining to breastfeeding. There would be a common cultural understanding of the importance of breastfeeding. Nursing in public, at the workplace, and well into toddlerhood would be common occurrences. But right now, this isn't the case.

Breastfeeding, even breastfeeding in public, is not illegal in the United States. States that have laws pertaining to nursing in public aren't making breastfeeding in public legal. They are clarifying and protecting the right to nurse in public. Unfortunately, what most of these laws don't have is a way to punish those who violate the law. Still, just having the law can offer enough clout to change anti-breastfeeding behavior.

Laws related to breastfeeding which can have an impact on how a mother is supported to breastfeed include nursing in public, pumping at work, and restrictions on formula marketing and advertising.

In my opinion, the last one, restrictions on formula marketing and advertising, can have the biggest, most immediate, impact. It is also the area least touched by the law in the US.

One of the most effective steps we could take would be to make the World Health Organization's Code of Marketing of Breastmilk Substitutes an enforceable federal law. The WHO Code was adopted by the World Health Assembly in 1981, though the US voted against it. In 1994 the USA adopted the WHO Code at the WHA Resolution. Now every member of the WHA has endorsed the Code. Unfortunately, not all WHA members endorsing the Code have created laws to enforce it. In the US, we have taken no action to enforce the Code and all we can do is report Code violations to NABA, boycott code violators such as Nestle, and return unwanted formula samples back to manufacturers pointing out the violation.

Another step is to ban the give-away of formula marketing bags in hospitals and by healthcare providers. In 2006, I participated in Ban the Bags efforts in Massachusetts. If the WHO Code was a federal law there would be no need to Ban the Bags because the bag give-aways would be illegal.

Prior to my efforts and following of Ban the Bags, I was (minimally) involved and followed the efforts to pass what became, in 2009, An Act to Promote Breastfeeding in Massachusetts. It took years and years of effort by many dedicated people to "get it right." It would have passed years earlier but initial wording lacked protection for nursing older children and included wording requiring "discretion."

Laws can "make" breastfeeding by increasing breastfeeding rates. Laws can support mothers in following breastfeeding health guidelines set by all the major health organizations. Most importantly, breastfeeding laws can support a mother in fulfilling her own personal breastfeeding goals.

Break:
The lack of breastfeeding laws, or laws that are unclear, insufficient, or don't provide any recourse for breaking them, can all "break" breastfeeding.

Lack of breastfeeding laws can lower breastfeeding initiation and duration rates. Lack of breastfeeding/pumping regulations in the workplace can mean that a mother may choose not to breastfeed or may wean her baby early if she is unable or unwilling to find a more breastfeeding supportive job. And unless there are laws protecting breastfeeding babies in severe situations such as divorce or maternal incarceration, lack of breastfeeding laws can immediately "break" breastfeeding.

Resources on Government Legislation:

Breastfeeding Law

LLI: Breastfeeding and the Law

WHO Code

UNICEF

State of the Code by Country

IBFAN

National Alliance for Breastfeeding Advocacy

Ban the Bags

Response to Crisis or Emergency:

This CIRCLE OF SUPPORT represents the need for support IF a woman finds herself in an unexpected and / or serious situation, with little control. Situations that require special planning and support are: natural disasters, refugee camps, divorce proceedings, critical illness of mother or baby, or living in an area of high HIV/AIDS prevalence with no support for breastfeeding.

Make:
Breastfeeding is important, and even lifesaving, during normal conditions. In times of crisis, breastfeeding is more important than ever.

For example, support for breastfeeding during a natural disaster can not only "make," or save, the breastfeeding relationship, but it can save lives. When excellent support is provided, breastfeeding can even help to save the lives of previously formula feeding babies through re-lactation and emergency wet nursing.

During Hurricane Katrina, there was a story of a mother stranded for 2 weeks with her newborn. She tried her best to bottle feed during these 2 weeks, but, in spite of her efforts, the baby later died in the hospital of malnutrition. Upon being rescued, the mother asked for medicine to dry up her milk because she was uncomfortably engorged. The emergency workers asked why she didn't nurse her baby. She responded that she didn't think she could. Even more astounding is that none of her extended family stranded with her thought she could either.

Breastfeeding support is crucial before, during, and after a crisis or emergency.

Break:
Without proper breastfeeding support certain crisis and emergency situations can "break" the breastfeeding relationship.

In natural disasters breastfeeding support should be available to provide accurate breastfeeding information and services. Formula donation and distribution, for example, can break the breastfeeding relationship. Safe areas should be provided in shelters so that a mother's letdown response isn't hindered by the stress of the situation. And breastfeeding counselors as first responders should be available to support breastfeeding, re-lactation, and emergency wet nursing.

During divorce proceedings the breastfeeding relationship can be broken if there is little understanding of the importance of breastfeeding, and little to no support of breastfeeding itself. When visitation rights are being determined maintaining the breastfeeding relationship is not always considered. And practices, such as nursing an older child, can unfairly be used against a mother.

When there is a critical illness of mother or baby, breastfeeding is vitally important. Even healthcare providers are often unaware of the importance of protecting the breastfeeding relationship, and have give little advice on breastfeeding safe medications. In some cases, inaccurate breastfeeding information is given regarding medications and medical procedures.

Articles on Response to Crisis or Emergency:

Feeding Babies in Emergency Situations


What are your experiences with The Five Circles of Support? What have your "Make" or "Break" situations been?

Feeding Babies in Emergency Situations

Nursing in a hotel room

In late October 2012 the historic hybrid storm, or "Frankenstorm," named Hurricane Sandy devastated the East Coast of the United States, especially New Jersey, New York, and Connecticut. When disasters such as this happen it conjures up all sorts of feelings, and people are especially compelled to help. But what happens when an act meant to be a good deed results in more death?

This is exactly what can happen when infant formula is donated and improperly distributed in disaster areas. It should also be noted that many relief organizations do not have first responders trained in proper infant feeding protocol and infant formula distribution.

I know it may be hard to wrap your head around why it is so dangerous to donate infant formula to donation drives or shelters. I know the feeling of urgency to help, especially the tiniest victims. And I know that it might feel like I am saying that formula fed babies should not be fed. Of course, formula fed babies need to be fed, but it needs to be done safely to prevent illness and death.

First, I will outline the dangers of formula distribution and improper feeding protocol in emergencies, and then I will offer alternatives and practical ways to make a difference.

Dangers of Infant Formula Distribution:

* The majority of the deaths of infants in emergencies are due to diarrhea from drinking formula mixed with contaminated water and/or unsanitary formula feeding conditions (ie. no way to sterilize equipment).

* It can be difficult or impossible to keep infant formula safe from spoiling if power goes out.

* There is often a disproportionate amount of infant formula donated. This leaves relief agencies with a lot more formula than they need, and/or the wrong type of formula (powdered should not be distributed). Surpluses mean that formula may have to be discarded or it will be handed out to breastfeeding mothers (which has a negative impact on breastmilk supply). Surpluses of any one item also take away from donations that are truly needed.

* Formula should not be distributed without the complementary supplies to make it safe. These supplies include things like bottled water, liquid soap, cups for cup feeding, storage container, paper towels, and a gas stove or other cooking stove for heating water if the formula is not ready-to-serve. Hand sanitizer can be useful, but be aware that it is harmful to children if accidentally swallowed.

Breastfeeding in Emergencies:

Breastfeeding is important under the best of circumstances, but during an emergency it is lifesaving. Breastmilk is clean, full of antibodies, requires no special equipment to deliver, and adjusts to meet the baby's needs (contains more water when it is hot outside and more hydration is needed, for example). The act of nursing is calming for both mother and child. During nursing the mother's breasts will change temperature to either warm or cool the baby, as needed.

But breastfeeding can be undermined in emergencies by well meaning, but uninformed, volunteers. There are many myths that even nursing mothers themselves might believe.

Myths include that breastmilk will "dry up" when a mother is under stress, that a malnourished mother can't breastfeed or will make inadequate milk, and that breastfeeding mothers are safer with some formula "just in case."

In reality, breastmilk supply is not impacted by stress, however the milk ejection response, also known as "letdown," which makes the milk available for the baby to swallow can be impacted when a mother isn't relaxed. Once the baby starts nursing and MER happens, both mother and baby will become more relaxed. The solution is not to discourage nursing or offer formula, but simply to provide an environment where the mother can relax.

Unless a mother is severely and catastrophically malnourished, she will make adequate breastmilk. Her body will protect her baby's nutrition first.

The dangers of formula samples for breastfeeding mothers are magnified in times of crisis. Having formula on hand for "just in case," especially if handed out by someone perceived as an expert (relief worker, shelter volunteer, nurse, etc) can impact breastfeeding, even if the sample is never used. It sends the message that breastfeeding and breastmilk supply are fragile and prone to failure.

Parents of breastfed babies can put together an emergency kit, especially if there is advanced warning of a disaster. Some things to include are diapering or EC supplies, instructions for building milk supply, tips on nursing in an emergency, a baby carrier, and contact information for breastfeeding counselors.

During and after a disaster, there are a few things you can do to preserve breastfeeding. Breastfeed frequently to maintain or increase your supply, as well as keep both mother and baby calm. Nurse while your baby is in a baby carrier so that you are able to have hands free for other things, to make it easier to nurse frequently, and to feel more comfortable nursing in crowded areas.

Infant Formula Feeding in Emergencies:

Extra care needs to be taken to formula feed safely in emergency situations. The first thing that can be done by families is to prepare in advance. An emergency kit for formula feeding can include a 1 week supply of ready-to-serve formula in individual serving sizes, a knife or scissors to open the formula packages, sanitary wipes, bottled water, bottles/nipples or cups, paper towels, and a storage container.

You may want to learn how to cup feed your baby and use disposable cups instead of bottles and nipples. You may be in a situation where it is impossible to clean or sterilize feeding equipment.

Put formula preparation and storage guidelines in your emergency kit. Under times of stress you may not be able to think clearly and it can help to have them written out. It can also be helpful if you get into a situation where someone else needs to prepare the formula.

Consider inducing lactation or relactating, especially with younger babies or babies who have nursed at some point. Put an induced lactation/relactaion instruction sheet with breastfeeding counselor contact information in your emergency kit. You may also want to put some milk inducing herbs in your emergency kit.

Wet nursing, if available, should be offered to and accepted by formula feeding parents. If you have any breastfeeding friends close by make sure to have their contact information in your emergency kit. In emergency situations, wet nursing can be safer than formula feeding.

Mixed Feeding and Breastmilk Expression in Emergencies:

If you have warning prior to an emergency, begin to increase time nursing to build supply. If you lose power, have limited water, or need to evacuate you may need to switch to full time nursing. Put instructions for building milk supply in your emergency kit. You may want to start taking milk inducing herbs, or put them in your emergency kit. All the Breastfeeding in Emergencies tips will also apply.

If you express milk using an electric or manual pump, learn how to express milk by hand. Put instructions in your emergency kit.

Consider how you will protect your frozen supply of breastmilk during a power outage. Consider purchasing a back-up generator in case of loss of power. A deep freezer will keep cold longer than an upright freezer. Move milk to the center of your freezer, but away from any frozen meat. Fill empty spaces with containers of frozen water, "blue ice," or even newspaper.

What you can do:

* Donate money instead of formula so that relief agencies can buy the amount and type of formula that can be used. Excess formula ends up being wasted or given to breastfeeding or mixed feeding babies.

It is best to donate money above anything, not just infant formula, because there are often not enough volunteers to sort donations and money can buy exactly what is needed in the correct amounts. Here is what FEMA says about donations:

Cash Contributions
Cash donations are very useful in situations where supplies must be acquired quickly. This is the most efficient way to make an impact with your donations. If you need help in determining who to give to, the National Voluntary Organizations Active in Disaster website has a list of major nonprofits that are active in disaster work or you can make your offer through the National Donations Management Network.


Don't Send Unsolicited Donations
One of the biggest issues around disasters is the amount of unsolicited item donations that start to come in immediately. It's better to wait until communities assess and confirm their needs before you start to send things in. At that time, you can make your donations through non-profits in the National Donations Management Network.

* Donate your time. Contact a relief agency or local shelter and find out how you can donate your time. Often, this is needed more than donations. FEMA offers great tips and resources for helping in a disaster. This is the page specifically on Hurricane Sandy.

* If you are a breastfeeding counselor or lactation consultant, donate your time and expertise in disaster areas. If you have breastfeeding experience, become a breastfeeding counselor or lactation consultant so that you can volunteer if a disaster strikes.

* Shelters and food distribution centers should have the contact information for local and regional breastfeeding support including lactation consultants, breastfeeding counselors (such as through La Leche League or BACE-NMC), WIC breastfeeding counselors, midwives, and postpartum doulas.

These volunteers can offer help with proper breastfeeding support and information, relactating and building milk supply, teaching mothers to hand express, supporting emergency wet nursing, information on protecting expressed milk stashes, information on proper storage and handling of both expressed breastmilk and infant formula, supporting the emotional needs of all mothers.

* If you are a breastfeeding mother it may be appropriate for you to act as an emergency wet nurse. If you have recently weaned a child, you may be able to relactate.

* Donate complementary items to help infants such as diapers, diaper wipes, sanitary wipes, hand sanitizer, and bottled water. Even baby slings and carriers can be crucial in devastated areas. They can help keep infants and toddlers safely attached to parents, keep children calm, provide a buffer between baby and a stangers' potential germs, and offer a way for breastfeeding mothers to feel more comfortable even in crowded areas.

* Contact relief agencies about the importance of having breastfeeding counselors included in front line responders, and having emergencies workers trained in the proper protocol of infant feeding in disasters.

* Donate blood. When an emergency happens, the need for blood may increase. As a result of Hurricane Sandy, many blood drives across the East Coast were cancelled. Blood products, especially platelets, have a short shelf life.

* Donate breastmilk to a HMBANA milk bank. Milk banks are currently facing critical shortages. Do not donate to Prolacta or National Milk Bank because they are for profit companies rather than non-for-profit.

Resources for Infant Feeding in Emergencies:

World Health Organization:
        Breastfeeding: A vital emergency response. Are you ready?

        Guidelines for the safe preparation, storage, and handling of powdered infant formula

UNICEF:
        Breastfeeding a crucial priority for child survival in emergencies

International Medical Corps

United States Breastfeeding Committee

International Breastfeeding Journal (includes detailed information on formula feeding in emergencies)

La Leche League:
        La Leche League Resources

        Infant Feeding in Emergency Situations

        Relactation

Kellymom

Breastfeeding USA

Relief Organizations and Volunteering:

UNICEF
Experts in proper infant feeding protocol, including breastfeeding, in emergencies

Save the Children
Have set up safe breastfeeding areas in Hurricane Sandy shelters

The American Red Cross
Accept blood donations. Volunteers may or may not understand proper infant feeding protocol in emergencies.

Salvation Army
Accepts donations and volunteers

FEMA
FEMA has updates on coordinated relief efforts and great tips on how to help.

National Donations Management Network
This is a great page to go to if you want to donate cash or supplies, or donate your time.