I would love your input on this article- post to the blog so others can see your ideas... but last night I had a client have a wonderful VBAC and it made me think about what helps make a VBAC happen... here are a few ideas to ponder:
Choosing the right care provider. I put this first because I think it is paramount! Ask your doctor or midwife a few questions- how often do their previous cesarean patients choose to go for a VBAC? How many are successful? Do they enjoy working with moms who choose VBAC? Often times a care provider may say they are supportive but their numbers will show a lot. Often times they change their tone as you become more pregnant. Or they support it only if you birth by your due date- going over your due date is not acceptable. Some will help you into labor if you desire with breaking your water or low dose of pitocin. Others will only schedule another cesarean if you do not birth by your due date. Make sure they are really on board. Make sure you are a good candidate for a VBAC in their view before you proceed.
Choose a doula. It may be helpful to choose one with experience with VBAC but supporting a woman is universal- but having a doula there to help encourage you- to help remind you of your ideals- to help you in determining what may be considered in labor- these help. The studies show a doula reduces the chance of the initial cesarean but I think having one for a VBAC is essential for most couples. They are there to support the partner as well as the mom.
Take a preparation class for your VBAC. Read about how to help you achieve this. Learning techniques that help to align the baby properly- (www.spinningbabies.com), taking a yoga class or a mediation class that will help you get in touch with a mind body connection before hand will help. Take a class, especially if you did not take a childbirth preparation class the first time- techniques to help with pain will be beneficial. Also classes that help you process ideas and concerns- even fears that may be hidden will help.
Keep fit. If the reason your baby did not come out vaginally last time was due to the size- or at least the reason you were given- consider watching your diet closely to help you gain healthy weight- not bulk weight- and keeping your diet in check is good but so is keeping healthy and exercising to keep you fit.
Consider what worked last time and do it again- and consider what you felt hindered you last time and remove it. For instance if you had people with you last time that did not fully support you in the birth ideals you wanted... don't invite them back this time. If your partner was not on board last time with your choices- help him or her get on board this time in order to be the support you need. If you arrived too early last time to the birth location, consider staying home longer this time.
Work through your worries before you birth. Often times folks say they have no worries. The fear or worry may be hidden- but it comes out during labor. So, work through your thoughts. Think about how you want your labor to unfold. Consider what you can control from your previous birth this time. Consider how you will handle things differently this time. See yourself coping differently. There is so much fear around having a VBAC... some need to be addressed and some need to be researched to determine their veracity. Do the research so you will know what is true for you.
This type of preparation helps you achieve the birth you desire whether trying to achieve a VBAC or a vaginal birth anytime. Set yourself up to win.
VBACs don't usually just happen- they happen most often when women set themselves up to win!
I welcome comments from those who have VBAC'd and those who help women achieve this experience.
Friday, December 11, 2009
Thursday, December 10, 2009
"best laid plans always fail"
You know they say "best laid plans always fail"?
I had a "best laid plan" for the birth of Little Miracle. I hired a
doula, switched to a midwife that does water birth, had taken all the
classes, read all the books, and was ready for my HOSPITAL water birth
with my doula and midwife there.
I didn't get it.
I had a "best laid plan" for the birth of Little Miracle. I hired a
doula, switched to a midwife that does water birth, had taken all the
classes, read all the books, and was ready for my HOSPITAL water birth
with my doula and midwife there.
I didn't get it.
Monday, November 30, 2009
Epidural consent form
There was recent conversations regarding informed consent. Often times if a mom chooses to get an epidural it will be after she has been in a situation where she is hurting and it is hard to make a decision much less read the form- so here is a form from http://www.gentlebirth.org/archives/epdrlrsk.html for you to read now so you understand the risks involved.
Epidural Consent Form
Here's the consent form I mentioned a while back. The only thing I'd like to see added is increased c-section rate, which seems to finally be proven.
CONSENT TO EPIDURAL FOR LABOR PAIN CONTROL AND/OR CESAREAN SECTION
1. I authorize the performance upon _________ of the following
procedure ______________ performed under the direction of
______(physician's name).
2. I consent to the administration of local anesthetics, narcotics,
and/or other medications into the epidural space.
3. I understand that the following, among others, are possible
complications or risks of the procedure and that while they are
uncommon, they have been reported in the medical literature:
-Failure to relieve pain.
-Hypotension (low blood pressure).
-Postdural puncture (spinal) headache which may require
medical therapy.
-Persistent area of numbness and/or weakness of the lower
extremities.
-Temporary nausea and vomiting.
-Breakage of needles, catheters, etc. possibly requiring
surgery.
-Hematoma (blood clot) possibly requiring surgery.
-Infection.
-Rapid absorption of local anesthetics causing dizziness
and seizures.
-Temporary total spinal anesthesia (requiring life
support systems).
-Respiratory and/or cardiac arrest (requiring life
support systems).
-Back pain.
-Fetal distress resulting from one of the above complications.
4. I consent to the performance of procedures in addition to or
different from those now contemplated, whether or not arising from
presently unforeseen conditions, which the above named doctor or his
associates or assistants including residents, may consider necessary or
advisable in the course of the procedure.
5. The nature and purpose of the procedure, possible alternative
methods of treatments, the risks involved and the possibility of
complications have been fully explained to me. I understand that no
guarantee or assurance has been given by anyone as to the results that
may be obtained.
Notes from Midwifery Today tape on epidurals
After 7 hours on an epidural, the woman's temp is up 2.1 deg. F, which is considered a maternal fever, which requires a neonate septic workup.
Of 96 first-time moms, 0 w/o epidural had a c-sect., 25 w/ had a c-sect. Of those getting epidurals < 3 cm, 33% had c-sects, 3-4 cm, 26%, > 5 cm, 0% MORAL - try to wait until 5 cm before epidural.
Problems with epidurals: 5% got no pain relief; 5% got inadequate pain relief, often had windows of sensation, which are just as annoying as all over pain.
Epidurals require catheters, which can require antibiotics, which may interfere with nursing.
Another study of 11,000 women having epidurals showed that 18% of women had chronic backache within 6 months of birth, lasting > 3 months. Of those with chronic backache, only 10% didn't have an epidural.
Lactation consultants say that nipples don't get erect for 24 hours after end of epidural. Newborns can't get a good latch. (Ref: Dr. Edie? Laurence, "Measuring Effects of Breastfeeding Success and Epidurals", U. Rochester.)
Rare complications of epidurals: cardiac arrest, respiratory paralysis, convulsions (most often from high spinals or intravascular injection). Other complications, 9 had spinal headache for 6 weeks, 5 for a full year.
Ways to minimize risks: Choose attendant w/low -sect. rate. One study showed that 46% of primips have epidurals. 1% of "clinic" patients have c-sects. 20% or private patients. If you get an epidural, make sure the facility has emergency c-sect. available and full resuscitation team. For a first baby, posterior or VBAC, delay epidural until after active labor is well established.
Robbie Davis-Floyd says "Women's satisfaction with the birth experience is directly related to her sense of having mastered it."
You lose endorphins and euphoria.
Epidural Consent Form
Here's the consent form I mentioned a while back. The only thing I'd like to see added is increased c-section rate, which seems to finally be proven.
CONSENT TO EPIDURAL FOR LABOR PAIN CONTROL AND/OR CESAREAN SECTION
1. I authorize the performance upon _________ of the following
procedure ______________ performed under the direction of
______(physician's name).
2. I consent to the administration of local anesthetics, narcotics,
and/or other medications into the epidural space.
3. I understand that the following, among others, are possible
complications or risks of the procedure and that while they are
uncommon, they have been reported in the medical literature:
-Failure to relieve pain.
-Hypotension (low blood pressure).
-Postdural puncture (spinal) headache which may require
medical therapy.
-Persistent area of numbness and/or weakness of the lower
extremities.
-Temporary nausea and vomiting.
-Breakage of needles, catheters, etc. possibly requiring
surgery.
-Hematoma (blood clot) possibly requiring surgery.
-Infection.
-Rapid absorption of local anesthetics causing dizziness
and seizures.
-Temporary total spinal anesthesia (requiring life
support systems).
-Respiratory and/or cardiac arrest (requiring life
support systems).
-Back pain.
-Fetal distress resulting from one of the above complications.
4. I consent to the performance of procedures in addition to or
different from those now contemplated, whether or not arising from
presently unforeseen conditions, which the above named doctor or his
associates or assistants including residents, may consider necessary or
advisable in the course of the procedure.
5. The nature and purpose of the procedure, possible alternative
methods of treatments, the risks involved and the possibility of
complications have been fully explained to me. I understand that no
guarantee or assurance has been given by anyone as to the results that
may be obtained.
Notes from Midwifery Today tape on epidurals
After 7 hours on an epidural, the woman's temp is up 2.1 deg. F, which is considered a maternal fever, which requires a neonate septic workup.
Of 96 first-time moms, 0 w/o epidural had a c-sect., 25 w/ had a c-sect. Of those getting epidurals < 3 cm, 33% had c-sects, 3-4 cm, 26%, > 5 cm, 0% MORAL - try to wait until 5 cm before epidural.
Problems with epidurals: 5% got no pain relief; 5% got inadequate pain relief, often had windows of sensation, which are just as annoying as all over pain.
Epidurals require catheters, which can require antibiotics, which may interfere with nursing.
Another study of 11,000 women having epidurals showed that 18% of women had chronic backache within 6 months of birth, lasting > 3 months. Of those with chronic backache, only 10% didn't have an epidural.
Lactation consultants say that nipples don't get erect for 24 hours after end of epidural. Newborns can't get a good latch. (Ref: Dr. Edie? Laurence, "Measuring Effects of Breastfeeding Success and Epidurals", U. Rochester.)
Rare complications of epidurals: cardiac arrest, respiratory paralysis, convulsions (most often from high spinals or intravascular injection). Other complications, 9 had spinal headache for 6 weeks, 5 for a full year.
Ways to minimize risks: Choose attendant w/low -sect. rate. One study showed that 46% of primips have epidurals. 1% of "clinic" patients have c-sects. 20% or private patients. If you get an epidural, make sure the facility has emergency c-sect. available and full resuscitation team. For a first baby, posterior or VBAC, delay epidural until after active labor is well established.
Robbie Davis-Floyd says "Women's satisfaction with the birth experience is directly related to her sense of having mastered it."
You lose endorphins and euphoria.
Wednesday, November 18, 2009
Doulas Being Advocates
Recently I received an email from a potential doula client that started like this, “I am looking for a doula to advocate for me and my husband's wishes in the hospital, and for the baby during labor.”
When I replied with a statement, “Why do you feel you will need an advocate to share your wishes in your labor? A doula will not speak for you- you can speak for yourself- if you can't then your partner will do so- we support you- we remind you of what you wanted- we help you find your questions to find your answers- but if you feel some need to be protected we need to discuss why that is- let's talk more about this.” She was taken a back and emailed me back this, “I think there has been a misunderstanding, I have no problem speaking up for myself; I don't know where that came from. I have a list of questions to help me find a doula. What I'm looking for is a good fit, the optimal organization, because I am assembling my team, and would like a doula present. And I don't know where this inference of needing to be "protected" came from? “
This made me think about the word advocate. Perhaps there was a misunderstanding of that word. When someone says initially something like they need an advocate to be with them- it sends up a red flag. My thesaurus lists these words: supporter, backer, promoter, believer, activist, campaigner, and sponsor. One who would support, encourage and be in favor of. I do think a doula can be these things. I do think there was a misunderstanding.
But this email came on the cusp of hearing from one of my doulas about a couple who had hired her. The father to be was initially one who was gun ho on having a very medicalized birth where all decisions were given over to their doctor. And then as they began to examine more of the birth journey- they had begun to explore options available to them and find out more about birth; he had changed quite a bit. The mother to be wanted a low intervention birth and was hoping to have a gentle vaginal birth in the least and was considering going natural.
Well after going a week past her due date and sharing how her care provider was not pressuring her to do anything to push this labor along, she went in for her 41 week prenatal appointment. After doing a non stress test and biophysical, it was determined that the amniotic fluid level was low- actually he admitted it was just what they expected it to be- well within the normal range- but lower than weeks earlier- but he suggested that they go straight to the hospital for an induction.
Her cervix was not ripe- but they could ripen it with cervidil. And after less than the suggested eight to twelve hours, it was removed and pitocin was started to bring on contractions although her cervix had not changed nor was it any more ripened than it had been the day before. The consideration of a second dose of cervidil was not discussed. And sometime in the night, her water had either been broken or had released due to the cervidil.
The pitocin was bringing on mild contractions initially since the couple had been requesting a slow start to the pitocin. But by mid morning, when the doctor made the decision to bring the pitocin up to normal management levels, the mom was struggling with the pain and the baby showed a few signs of also not being happy with the plan. The doctor had even said these contractions were like those of a mom who was close to pushing, but her cervix remained closed and unchanged. An epidural was placed and the doctor told them he would give them until 2pm to make some progress or she would have a surgical birth. I am unclear as to why this time was determined to be the magic hour of calling for the surgical birth- ACOG says a mom should have eighteen hours to be in active labor after her water was broken- perhaps he had broken her water at 8pm the night before.
Now mind you, they were in very little contact with their doula, and she was not with them- she was awaiting them inviting her to come be with them- whenever they needed her- she was ready- but they felt they did not need her yet. For inductions it can be tricky. Cervical ripenings is usually done while the mom sleeps. And the early onset of a pitocin induction can take hours before a mom even feels the first "real" contraction. So not having a doula present for the early parts of an induction is normal. But after several calls to them to help her know what might be occuring, she was finally able to find out at 3pm that they were going in at 4pm to have a surgical birth.
The doula was disappointed to have not been invited to be a part of this birth. What had happened? She was trying to be that supporter, believer, campaigner and encourager that they had wanted. But no phone calls had invited her to do so. And this care provider who was not going to push her into labor was now pushing her bed into the OR. But this was not the doulas's birth. These were not her choices to make. She could not make these decisions for them. But had they been adequate advocates for themselves in the midst of this situation?
It is hard to be an advocate if someone will not be their own advocate. A doula can not step in and throw herself over your bed and say no. She can not give you medical advice. She can not speak up when you fail to do so. She can not save you from the choices you make freely along the journey. And sometimes I think folks hire us to do just that. I was trying in this email to be clear about our role. The antonym to advocate is opponent and discourager. Sometimes we find the folks we choose to be with us may very well be those things- whether it is the care provider or a friend or family member.
I can reassure you that will not be us- we will support the choices you make in your pregnancy and labor. We will remind you of what you desired. We will assist you in getting your questions answered and considering what your options are along the way. If you are desiring that, then we can be your advocates.
When I replied with a statement, “Why do you feel you will need an advocate to share your wishes in your labor? A doula will not speak for you- you can speak for yourself- if you can't then your partner will do so- we support you- we remind you of what you wanted- we help you find your questions to find your answers- but if you feel some need to be protected we need to discuss why that is- let's talk more about this.” She was taken a back and emailed me back this, “I think there has been a misunderstanding, I have no problem speaking up for myself; I don't know where that came from. I have a list of questions to help me find a doula. What I'm looking for is a good fit, the optimal organization, because I am assembling my team, and would like a doula present. And I don't know where this inference of needing to be "protected" came from? “
This made me think about the word advocate. Perhaps there was a misunderstanding of that word. When someone says initially something like they need an advocate to be with them- it sends up a red flag. My thesaurus lists these words: supporter, backer, promoter, believer, activist, campaigner, and sponsor. One who would support, encourage and be in favor of. I do think a doula can be these things. I do think there was a misunderstanding.
But this email came on the cusp of hearing from one of my doulas about a couple who had hired her. The father to be was initially one who was gun ho on having a very medicalized birth where all decisions were given over to their doctor. And then as they began to examine more of the birth journey- they had begun to explore options available to them and find out more about birth; he had changed quite a bit. The mother to be wanted a low intervention birth and was hoping to have a gentle vaginal birth in the least and was considering going natural.
Well after going a week past her due date and sharing how her care provider was not pressuring her to do anything to push this labor along, she went in for her 41 week prenatal appointment. After doing a non stress test and biophysical, it was determined that the amniotic fluid level was low- actually he admitted it was just what they expected it to be- well within the normal range- but lower than weeks earlier- but he suggested that they go straight to the hospital for an induction.
Her cervix was not ripe- but they could ripen it with cervidil. And after less than the suggested eight to twelve hours, it was removed and pitocin was started to bring on contractions although her cervix had not changed nor was it any more ripened than it had been the day before. The consideration of a second dose of cervidil was not discussed. And sometime in the night, her water had either been broken or had released due to the cervidil.
The pitocin was bringing on mild contractions initially since the couple had been requesting a slow start to the pitocin. But by mid morning, when the doctor made the decision to bring the pitocin up to normal management levels, the mom was struggling with the pain and the baby showed a few signs of also not being happy with the plan. The doctor had even said these contractions were like those of a mom who was close to pushing, but her cervix remained closed and unchanged. An epidural was placed and the doctor told them he would give them until 2pm to make some progress or she would have a surgical birth. I am unclear as to why this time was determined to be the magic hour of calling for the surgical birth- ACOG says a mom should have eighteen hours to be in active labor after her water was broken- perhaps he had broken her water at 8pm the night before.
Now mind you, they were in very little contact with their doula, and she was not with them- she was awaiting them inviting her to come be with them- whenever they needed her- she was ready- but they felt they did not need her yet. For inductions it can be tricky. Cervical ripenings is usually done while the mom sleeps. And the early onset of a pitocin induction can take hours before a mom even feels the first "real" contraction. So not having a doula present for the early parts of an induction is normal. But after several calls to them to help her know what might be occuring, she was finally able to find out at 3pm that they were going in at 4pm to have a surgical birth.
The doula was disappointed to have not been invited to be a part of this birth. What had happened? She was trying to be that supporter, believer, campaigner and encourager that they had wanted. But no phone calls had invited her to do so. And this care provider who was not going to push her into labor was now pushing her bed into the OR. But this was not the doulas's birth. These were not her choices to make. She could not make these decisions for them. But had they been adequate advocates for themselves in the midst of this situation?
It is hard to be an advocate if someone will not be their own advocate. A doula can not step in and throw herself over your bed and say no. She can not give you medical advice. She can not speak up when you fail to do so. She can not save you from the choices you make freely along the journey. And sometimes I think folks hire us to do just that. I was trying in this email to be clear about our role. The antonym to advocate is opponent and discourager. Sometimes we find the folks we choose to be with us may very well be those things- whether it is the care provider or a friend or family member.
I can reassure you that will not be us- we will support the choices you make in your pregnancy and labor. We will remind you of what you desired. We will assist you in getting your questions answered and considering what your options are along the way. If you are desiring that, then we can be your advocates.
Monday, November 2, 2009
Isabel's Birth Story
I was 39 weeks pregnant, feeling good physically and emotionally--better than I had for most of the pregnancy. Over the weekend, I started to get the feeling that something was going to happen soon. Isabel had changed the way she was moving inside of me. Instead of kicking, punching, and having "playtime" in there, it suddenly started to feel as though she was getting down to business. Her movements were more studied and intentional, like she was getting lined up for her big entrance into the world. She would move her little head back and forth, telling my body it was time to start opening up. She made little changes to her body position, making sure everything was just right for the big day.
Psychotropic Drug Use During Breastfeeding
Psychotropic Drug Use During Breastfeeding: A Review of the Evidence
Pediatrics 2009;124;e547-e556; originally published online Sep 7, 2009;
Filomena Fortinguerra, Antonio Clavenna and Maurizio Bonati
DOI: 10.1542/peds.2009-0326
OBJECTIVE: The objective of this study was to review the existing literature on the use of various classes of psychotropic medications during breastfeeding to provide information about infant exposure levels and reported adverse events in breastfed infants.
METHODS: A bibliographic search in the Medline (1967 through July 2008), Embase (1975 through July 2008), and PsycINFO (1967 through July 2008) databases was conducted for studies on breastfeeding and psychotropic medications for a total of 96 drugs. References of retrieved articles, reference books, and dedicated Web sites were also checked. The manufacturers were contacted for drugs without published information. Original articles and review articles that provide pharmacokinetic data on drug excretion in breast milk and infant safety data were considered, to estimate the “compatibility level” of each drug with breastfeeding.
RESULTS: A total of 183 original articles were eligible for analysis. Documentation was retrieved for 62 (65%) drugs. In all, 19 (31%) psychotropic drugs can be used during lactation according to an evidence based approach. For 28 drugs, the available data do not permit an evaluation of the drug’s safety profile during breastfeeding and, for an additional 15 drugs, the exposure dose or observed adverse effects make their use unsafe.
CONCLUSIONS: Although most drugs are considered safe during breastfeeding, compatibility with breastfeeding has not been established for all psychotropic drugs. There is a need for additional research and accumulation of experience to guarantee a more rational use of psychotropic drugs during breastfeeding. Pediatrics 2009;124:
e547–e556
AUTHORS: Filomena Fortinguerra, PharmD, Antonio Clavenna, MD, and Maurizio Bonati, MD
Laboratory for Mother and Child Health, Public Health Department, Mario Negri Institute for Pharmacological
Research, Milan, Italy
I love the way this article begins with this statement, “Breastfeeding is essential for the physical and psychological health of both mother and child, and its benefits are well documented.”
And then the comment that, “Despite the increased attention toward breastfeeding, however, information on breast milk drug excretion and knowledge of the adverse effects on the infant are often unavailable or still limited for many drugs that frequently are used by women of childbearing age, and misinformation abounds.” But the truth is it is not profitable for most pharmaceutical companies to research the small population of women breastfeeding to determine if a drug has an interaction with their baby’s breastmilk. It is easier to just determine that it is not okay for a mom to take most medications than to do the tests.
The article then makes this statement, “Worldwide, more than half of breastfeeding women take some type of drug and the concern about potential harm to the nursing infant from maternal medications is often cited as a reason to stop lactation,11 even if discontinuing breastfeeding is often the wrong decision. The Summary of Product Characteristics should not be considered a reliable source of breastfeeding information; it often indicates that a drug is not recommended during lactation, suggesting that it be avoided or that breastfeeding be interrupted. The warnings are not necessarily related to observed or reported adverse effects; they are often used as a defensive measure on the part of the manufacturer when the drug’s safety information is not available.”
What is astounding is how many women who could benefit from drugs are not getting them or not taking them or weaning their babies unnecessarily since no one is doing any real studies on drugs that could be helpful to them.
“It has been estimated that, each year, more than 500 000 pregnancies in the United States are complicated by psychiatric disorders such as depression, anxiety, and psychosis, which often develop, recur, and/or worsen during and after pregnancy. Furthermore, 13% of all psychiatric hospital admissions for women occur during the first postpartum year. Depression is the most frequent mental disorder in the perinatal period: 10% to 16% of pregnant women fulfill diagnostic criteria for major or minor depression, but up to 70% report symptoms of depression. Furthermore, 7% to 20% of women receive a diagnosis of postpartum depression in the first year after delivery. Untreated depression and anxiety can have a negative impact on pregnancy, and adverse short-term and long-term effects can have a negative impact on the developing infant and child.”
This article sited several studies to determine what is really known out there regarding drug interactions with breastfeeding infants from psychotropic drugs that their mothers were taking. They looked at several methods of determining how safe the drugs were- from dosage- to length of time the drugs were taken- to amount found in breastmilk to effect on babies in adverse ways. They looked at what may be compatible, what needed to be used very cautionary and what was contraindicated.
“A total of 19 (31%) psychotropic drugs can be used during lactation according to an evidence-based approach, whereas for 28 drugs, the available data do not allow an evaluation of their safety profile during breastfeeding.”
Antidepressants had been studied most. “In particular, among the antidepressants, sertraline, paroxetine, and fluvoxamine are the first-choice drugs for treatment of depression in breastfeeding mothers because they have the lowest degree of excretion into human breast milk.” “Antipsychotics are the class with the smallest number of studies concerning use during breastfeeding. The available data regarding the use of hypnotic and anxiolytic agents during breastfeeding are scant.”
I found it interesting that, “there have been no studies on infants’ long-term exposure to very low dosages of antidepressants.” It is as if the studies allows the mother to go on the drug but does not care once they determine it is okay what the long term effect on the infant could possibly be. Looking at long term effects seem the most important as that is what will cause the longer lasting issues.
The article stated, “The decision to prescribe psychotropic agents to breastfeeding mothers should depend on an individual risk/benefit analysis: the known benefits of breastfeeding and medication use for both mother and infant must be weighed against the risk of untreated maternal illness or the risk of infant exposure to medications through breast milk.”
But since so often physicians would rather just have the mom wean the baby and treat their patient without regard to the individual desires and needs of the nursing dyad, many moms wean unnecessarily. Or a mother who needs treatment will forgo the treatment at risk to herself and possibly her infant.
The conclusion of these authors was that more studies need to be done and the safety issue of many of these drugs is still unknown and quite controversial. So, this was their call to action report of sorts.
I attended a dinner that Dr Zachary Stowe, a renowned physician (Professor, Psychiatry & Behavioral Sciences Director, Women’s Mental Health Program Emory University School of Medicine in Atlanta, Georgia) presented information about psychotropic drugs and breastfeeding moms. He gave several ways to help a mom avoid depression, which included simple things like receiving postpartum help, going for walks outside in the sunshine and many others. But he stated that it is important in order to have a happy baby to have a happy mom. Getting moms the medication they need without unnecessarily weaning a baby is imperative. We know the benefits of breastfeeding on the baby and we need to stop throwing the proverbial baby out with the bath water. Research needs to be done more fervently and more physicians need to try to keep the baby and mother nursing dyad together. Mental illness needs to be treated like so many other diseases and illnesses- with avid research in order to be treated without putting the baby at risk- and that includes weaning the baby when we know the health benefits of nursing that are well documented.
Teresa Howard
Pediatrics 2009;124;e547-e556; originally published online Sep 7, 2009;
Filomena Fortinguerra, Antonio Clavenna and Maurizio Bonati
DOI: 10.1542/peds.2009-0326
OBJECTIVE: The objective of this study was to review the existing literature on the use of various classes of psychotropic medications during breastfeeding to provide information about infant exposure levels and reported adverse events in breastfed infants.
METHODS: A bibliographic search in the Medline (1967 through July 2008), Embase (1975 through July 2008), and PsycINFO (1967 through July 2008) databases was conducted for studies on breastfeeding and psychotropic medications for a total of 96 drugs. References of retrieved articles, reference books, and dedicated Web sites were also checked. The manufacturers were contacted for drugs without published information. Original articles and review articles that provide pharmacokinetic data on drug excretion in breast milk and infant safety data were considered, to estimate the “compatibility level” of each drug with breastfeeding.
RESULTS: A total of 183 original articles were eligible for analysis. Documentation was retrieved for 62 (65%) drugs. In all, 19 (31%) psychotropic drugs can be used during lactation according to an evidence based approach. For 28 drugs, the available data do not permit an evaluation of the drug’s safety profile during breastfeeding and, for an additional 15 drugs, the exposure dose or observed adverse effects make their use unsafe.
CONCLUSIONS: Although most drugs are considered safe during breastfeeding, compatibility with breastfeeding has not been established for all psychotropic drugs. There is a need for additional research and accumulation of experience to guarantee a more rational use of psychotropic drugs during breastfeeding. Pediatrics 2009;124:
e547–e556
AUTHORS: Filomena Fortinguerra, PharmD, Antonio Clavenna, MD, and Maurizio Bonati, MD
Laboratory for Mother and Child Health, Public Health Department, Mario Negri Institute for Pharmacological
Research, Milan, Italy
I love the way this article begins with this statement, “Breastfeeding is essential for the physical and psychological health of both mother and child, and its benefits are well documented.”
And then the comment that, “Despite the increased attention toward breastfeeding, however, information on breast milk drug excretion and knowledge of the adverse effects on the infant are often unavailable or still limited for many drugs that frequently are used by women of childbearing age, and misinformation abounds.” But the truth is it is not profitable for most pharmaceutical companies to research the small population of women breastfeeding to determine if a drug has an interaction with their baby’s breastmilk. It is easier to just determine that it is not okay for a mom to take most medications than to do the tests.
The article then makes this statement, “Worldwide, more than half of breastfeeding women take some type of drug and the concern about potential harm to the nursing infant from maternal medications is often cited as a reason to stop lactation,11 even if discontinuing breastfeeding is often the wrong decision. The Summary of Product Characteristics should not be considered a reliable source of breastfeeding information; it often indicates that a drug is not recommended during lactation, suggesting that it be avoided or that breastfeeding be interrupted. The warnings are not necessarily related to observed or reported adverse effects; they are often used as a defensive measure on the part of the manufacturer when the drug’s safety information is not available.”
What is astounding is how many women who could benefit from drugs are not getting them or not taking them or weaning their babies unnecessarily since no one is doing any real studies on drugs that could be helpful to them.
“It has been estimated that, each year, more than 500 000 pregnancies in the United States are complicated by psychiatric disorders such as depression, anxiety, and psychosis, which often develop, recur, and/or worsen during and after pregnancy. Furthermore, 13% of all psychiatric hospital admissions for women occur during the first postpartum year. Depression is the most frequent mental disorder in the perinatal period: 10% to 16% of pregnant women fulfill diagnostic criteria for major or minor depression, but up to 70% report symptoms of depression. Furthermore, 7% to 20% of women receive a diagnosis of postpartum depression in the first year after delivery. Untreated depression and anxiety can have a negative impact on pregnancy, and adverse short-term and long-term effects can have a negative impact on the developing infant and child.”
This article sited several studies to determine what is really known out there regarding drug interactions with breastfeeding infants from psychotropic drugs that their mothers were taking. They looked at several methods of determining how safe the drugs were- from dosage- to length of time the drugs were taken- to amount found in breastmilk to effect on babies in adverse ways. They looked at what may be compatible, what needed to be used very cautionary and what was contraindicated.
“A total of 19 (31%) psychotropic drugs can be used during lactation according to an evidence-based approach, whereas for 28 drugs, the available data do not allow an evaluation of their safety profile during breastfeeding.”
Antidepressants had been studied most. “In particular, among the antidepressants, sertraline, paroxetine, and fluvoxamine are the first-choice drugs for treatment of depression in breastfeeding mothers because they have the lowest degree of excretion into human breast milk.” “Antipsychotics are the class with the smallest number of studies concerning use during breastfeeding. The available data regarding the use of hypnotic and anxiolytic agents during breastfeeding are scant.”
I found it interesting that, “there have been no studies on infants’ long-term exposure to very low dosages of antidepressants.” It is as if the studies allows the mother to go on the drug but does not care once they determine it is okay what the long term effect on the infant could possibly be. Looking at long term effects seem the most important as that is what will cause the longer lasting issues.
The article stated, “The decision to prescribe psychotropic agents to breastfeeding mothers should depend on an individual risk/benefit analysis: the known benefits of breastfeeding and medication use for both mother and infant must be weighed against the risk of untreated maternal illness or the risk of infant exposure to medications through breast milk.”
But since so often physicians would rather just have the mom wean the baby and treat their patient without regard to the individual desires and needs of the nursing dyad, many moms wean unnecessarily. Or a mother who needs treatment will forgo the treatment at risk to herself and possibly her infant.
The conclusion of these authors was that more studies need to be done and the safety issue of many of these drugs is still unknown and quite controversial. So, this was their call to action report of sorts.
I attended a dinner that Dr Zachary Stowe, a renowned physician (Professor, Psychiatry & Behavioral Sciences Director, Women’s Mental Health Program Emory University School of Medicine in Atlanta, Georgia) presented information about psychotropic drugs and breastfeeding moms. He gave several ways to help a mom avoid depression, which included simple things like receiving postpartum help, going for walks outside in the sunshine and many others. But he stated that it is important in order to have a happy baby to have a happy mom. Getting moms the medication they need without unnecessarily weaning a baby is imperative. We know the benefits of breastfeeding on the baby and we need to stop throwing the proverbial baby out with the bath water. Research needs to be done more fervently and more physicians need to try to keep the baby and mother nursing dyad together. Mental illness needs to be treated like so many other diseases and illnesses- with avid research in order to be treated without putting the baby at risk- and that includes weaning the baby when we know the health benefits of nursing that are well documented.
Teresa Howard
Friday, October 16, 2009
Neriyah's Birth Story
Months of preparation finally became real on the morning of October 2, 2009. Nyokabi had a restful night and was ready for the day. After Morning Prayer with Jonathan, she decided to call Baby Depot to check on the special delivery of a hutch that she ordered for the nursery. After being on the phone with them for 15 minutes and not getting anywhere she started to get frustrated when she felt her first contraction. She knew right away that labor had started so she ran to tell Jonathan that her contracts had started at 10:56AM. After experiencing irregular contraction for about 30 minutes Jonathan calls Persis, their doula, to let her know today was possibly the day. Nyokabi told her that she saw part of the mucous plug and the contractions were not in any real pattern yet. However, 20 minutes later, Jonathan calls Persis again to let her know Nyokabi has a heavy show off blood. At this point Nyokabi starts to worry so Persis decides to come to the house just in case the labor was going fast.
Tuesday, October 13, 2009
Pediatricians- Not a Good Resource for Breastfeeding Information
Pediatricians’ Practices and Attitudes Regarding Breastfeeding Promotion
Richard J. Schanler, MD*; Karen G. O’Connor‡; and Ruth A. Lawrence, MD§
Pediatrics 1999;103;e35
ABSTRACT. Objective. Public awareness of the benefitsof breastfeeding is expected to increase during and after the national,federally funded Best Start BreastfeedingPromotion Campaign. It is anticipated that this will resultin more breastfeeding-based interactions between families and pediatricians. The American Academy of Pediatrics conducted a survey of its members to identify their educational needs regarding breastfeeding to assist in the design of appropriate information programs. Method. An eight-page, self-administered questionnaire was sent to 1602 active Fellows of the American Academy of Pediatrics. Results. The response rate was 71%. Breastfeeding, as the exclusive feeding practice for the first month after birth, was recommended by only 65% of responding pediatricians; only 37% recommended breastfeeding for 1 year. A majority of pediatricians agreed with or had a neutral opinion about the statement that breastfeeding and formula- feeding are equally acceptable methods for feeding infants. Reasons given for not recommending breastfeeding included medical conditions with known treatments that did not preclude breastfeeding. The majority of pediatricians (72%) were unfamiliar with the contents of the Baby-Friendly Hospital Initiative. The majority of pediatricians had not attended a presentation on breastfeeding management in the previous 3 years; most said they wanted more education on breastfeeding management. Conclusion. Pediatricians have significant educational needs in the area of breastfeeding management.
This study is one that is actually quite humorous to those of us who work with women who are nursing and have an issue that takes them to the average pediatrician. We understand not only the lack of information or education a pediatrician has regarding breastfeeding, but also the level of influence they still have on the breastfeeding relationship. Ironic that a non medical issue is one that parents still seek out medical opinions for.
This study cited that even though the big boy club of the AAP themselves promote breastfeeding as the best form of infant nutrition and encourage the infant to be fed that way, the very members of this association are failing miserably at conveying correct information to their patients parents. If the hospitals are not screwing up the relationship fairly quickly in the postpartum period, then the doctors then do their own lack of encouragement.
This study was timed to ascertain the physicians influence on breastfeeding as federally funded Best Start Breastfeeding Promotion Campaign was launched. “This campaign is targeted initially at 10 states to raise public awareness of breastfeeding through pre- and postnatal parent counseling and media promotion. Increased public awareness is expected to increase breastfeeding-related interactions between families and physicians.” They wanted to know how many of the doctors in the areas were going to be supportive of this endeavor and if they needed to do anything to help make this more likely.
The good news is this study was to “to assess breastfeeding attitudes, knowledge, and management skills of pediatricians, as well as awareness of their hospitals’ breastfeeding promotion activities. Results from this survey are expected to help in the design of appropriate breastfeeding education programs for physicians.” The bad news is the majority of the doctors definitely need more education in this area!
The conducted this study by first giving a survey to the physicians- mostly located in urban areas. The solo and group practices had better breastfeeding initiation and continuation than the clinic physicians. Tragically, only 65% of the pediatricians’ recommended exclusive breastfeeding to new parents during the early weeks of their infants’ births. 13% recommended formula supplementation while actually 2% said formula feeding was ideal. Although the AAP takes a stand on duration of exclusive breastfeeding being recommended for at least six months only 63% made any recommendation regarding duration. And only 31% made the recommendation that AAP suggested. But to be commended are the 61% who suggested the ideal time of at least one year.
Establishing breastfeeding and bonding time with the infant in the early hours after birth is a known factor in helping to increase breastfeeding success. Yet the doctors varied in their initial recommendation to do so. Only 44% recommended that the mom initiate breastfeeding in the first half hour after the birth. Only 59% suggested that demand feeding be established. Almost a quarter of the physicians were not opposed to formula or water be given to the breastfed infant. And keeping the mom and baby together by rooming in was equally divided in the study.
The use of pacifiers was only discouraged by a fourth of the doctors until breastfeeding was established. And the introduction of solids was not at the AAP recommendation either. Many recommended solids at a much younger age than 6 months. As this study states, “These infant feeding practices are known to impede successful breastfeeding and may be unnecessary.”
It was no surprise that in an office several people could be called on for phone consultations to assist new parents with breastfeeding questions. Only 76% of the time it was the doctors- who have proven they were not following suggested guidelines. Fewer than a quarter actually had lactation consultants. And few even knew how or if the staff that supplied information had ever been trained in the area of breastfeeding. Is it no wonder that misinformation was being handed out?
Only 58% of the actual physicians themselves had ever had any education regarding breastfeeding. The younger physicians (under 45 years of age) were more likely than the older physicians. And the female physicians had more training than their male counterparts. And yet although they mostly said they wanted to learn more and had not had sufficient training, 77% said they felt competent to manage common breastfeeding problems. Based on their lack of training or education in the area, it makes you wonder other areas they feel competent managing where they may also lack training and expertise.
It is no wonder that only 60% of the pediatricians had children of their own who were breastfed! Those with no personal experience were more likely to not recommend breastfeeding if the moms had common problems like breast or nipple problems- this was at 37%!
It is also no wonder that few hospitals are meeting the standard of Baby-Friendly Hospital Initiative since 72% of the doctors were unfamiliar with this initiative as well as the Ten Steps to Successful Breastfeeding statement. How can they be supportive and help promote these ideals if they are unaware of what they recommend? More then half of the doctors were unsure if there was a written policy regarding breastfeeding and if there was one what was stated within it.
The study stated, “These data suggest that the lack of clear recommendations may lead to confusion when parents question physicians about breastfeeding.” I find this an understatement. It also uncovered that very few pediatricians were even seeing their patients’ parents prenatally- where good information regarding breastfeeding could be conveyed.
The study was effective in uncovering the strong need to get the pediatricians on board with promoting breastfeeding. Helping parents prepare, initiate, be successful and continue to breastfeed is certainly an area where pediatricians can make a huge difference. But we need to get them up to speed on how to do this and it begins with more education.
Teresa Howard, CD (DONA), CLD, CLE, CCCE (CAPPA), CHBE
Richard J. Schanler, MD*; Karen G. O’Connor‡; and Ruth A. Lawrence, MD§
Pediatrics 1999;103;e35
ABSTRACT. Objective. Public awareness of the benefitsof breastfeeding is expected to increase during and after the national,federally funded Best Start BreastfeedingPromotion Campaign. It is anticipated that this will resultin more breastfeeding-based interactions between families and pediatricians. The American Academy of Pediatrics conducted a survey of its members to identify their educational needs regarding breastfeeding to assist in the design of appropriate information programs. Method. An eight-page, self-administered questionnaire was sent to 1602 active Fellows of the American Academy of Pediatrics. Results. The response rate was 71%. Breastfeeding, as the exclusive feeding practice for the first month after birth, was recommended by only 65% of responding pediatricians; only 37% recommended breastfeeding for 1 year. A majority of pediatricians agreed with or had a neutral opinion about the statement that breastfeeding and formula- feeding are equally acceptable methods for feeding infants. Reasons given for not recommending breastfeeding included medical conditions with known treatments that did not preclude breastfeeding. The majority of pediatricians (72%) were unfamiliar with the contents of the Baby-Friendly Hospital Initiative. The majority of pediatricians had not attended a presentation on breastfeeding management in the previous 3 years; most said they wanted more education on breastfeeding management. Conclusion. Pediatricians have significant educational needs in the area of breastfeeding management.
This study is one that is actually quite humorous to those of us who work with women who are nursing and have an issue that takes them to the average pediatrician. We understand not only the lack of information or education a pediatrician has regarding breastfeeding, but also the level of influence they still have on the breastfeeding relationship. Ironic that a non medical issue is one that parents still seek out medical opinions for.
This study cited that even though the big boy club of the AAP themselves promote breastfeeding as the best form of infant nutrition and encourage the infant to be fed that way, the very members of this association are failing miserably at conveying correct information to their patients parents. If the hospitals are not screwing up the relationship fairly quickly in the postpartum period, then the doctors then do their own lack of encouragement.
This study was timed to ascertain the physicians influence on breastfeeding as federally funded Best Start Breastfeeding Promotion Campaign was launched. “This campaign is targeted initially at 10 states to raise public awareness of breastfeeding through pre- and postnatal parent counseling and media promotion. Increased public awareness is expected to increase breastfeeding-related interactions between families and physicians.” They wanted to know how many of the doctors in the areas were going to be supportive of this endeavor and if they needed to do anything to help make this more likely.
The good news is this study was to “to assess breastfeeding attitudes, knowledge, and management skills of pediatricians, as well as awareness of their hospitals’ breastfeeding promotion activities. Results from this survey are expected to help in the design of appropriate breastfeeding education programs for physicians.” The bad news is the majority of the doctors definitely need more education in this area!
The conducted this study by first giving a survey to the physicians- mostly located in urban areas. The solo and group practices had better breastfeeding initiation and continuation than the clinic physicians. Tragically, only 65% of the pediatricians’ recommended exclusive breastfeeding to new parents during the early weeks of their infants’ births. 13% recommended formula supplementation while actually 2% said formula feeding was ideal. Although the AAP takes a stand on duration of exclusive breastfeeding being recommended for at least six months only 63% made any recommendation regarding duration. And only 31% made the recommendation that AAP suggested. But to be commended are the 61% who suggested the ideal time of at least one year.
Establishing breastfeeding and bonding time with the infant in the early hours after birth is a known factor in helping to increase breastfeeding success. Yet the doctors varied in their initial recommendation to do so. Only 44% recommended that the mom initiate breastfeeding in the first half hour after the birth. Only 59% suggested that demand feeding be established. Almost a quarter of the physicians were not opposed to formula or water be given to the breastfed infant. And keeping the mom and baby together by rooming in was equally divided in the study.
The use of pacifiers was only discouraged by a fourth of the doctors until breastfeeding was established. And the introduction of solids was not at the AAP recommendation either. Many recommended solids at a much younger age than 6 months. As this study states, “These infant feeding practices are known to impede successful breastfeeding and may be unnecessary.”
It was no surprise that in an office several people could be called on for phone consultations to assist new parents with breastfeeding questions. Only 76% of the time it was the doctors- who have proven they were not following suggested guidelines. Fewer than a quarter actually had lactation consultants. And few even knew how or if the staff that supplied information had ever been trained in the area of breastfeeding. Is it no wonder that misinformation was being handed out?
Only 58% of the actual physicians themselves had ever had any education regarding breastfeeding. The younger physicians (under 45 years of age) were more likely than the older physicians. And the female physicians had more training than their male counterparts. And yet although they mostly said they wanted to learn more and had not had sufficient training, 77% said they felt competent to manage common breastfeeding problems. Based on their lack of training or education in the area, it makes you wonder other areas they feel competent managing where they may also lack training and expertise.
It is no wonder that only 60% of the pediatricians had children of their own who were breastfed! Those with no personal experience were more likely to not recommend breastfeeding if the moms had common problems like breast or nipple problems- this was at 37%!
It is also no wonder that few hospitals are meeting the standard of Baby-Friendly Hospital Initiative since 72% of the doctors were unfamiliar with this initiative as well as the Ten Steps to Successful Breastfeeding statement. How can they be supportive and help promote these ideals if they are unaware of what they recommend? More then half of the doctors were unsure if there was a written policy regarding breastfeeding and if there was one what was stated within it.
The study stated, “These data suggest that the lack of clear recommendations may lead to confusion when parents question physicians about breastfeeding.” I find this an understatement. It also uncovered that very few pediatricians were even seeing their patients’ parents prenatally- where good information regarding breastfeeding could be conveyed.
The study was effective in uncovering the strong need to get the pediatricians on board with promoting breastfeeding. Helping parents prepare, initiate, be successful and continue to breastfeed is certainly an area where pediatricians can make a huge difference. But we need to get them up to speed on how to do this and it begins with more education.
Teresa Howard, CD (DONA), CLD, CLE, CCCE (CAPPA), CHBE
Does Income Affect Breastfeeding.... Does a Mom's BMI?
Maternal Variables Influencing Duration of Breastfeeding Among Low-Income Mothers
Anne Chevalier McKechnie, RN, IBCLC, RLC, Audrey Tluczek, PhD, RN, and Jeffrey B. Henriques, PhD
ICAN: Infant, Child, & Adolescent Nutrition June 2009
This is my review of their study….
Who breastfeeds longer? The study was performed on low income moms. The lack of long term breastfeeding is highest in this group. What the findings showed was that moms who had a high body mass index also fed for a shorter period of time. And the moms who fed longer were also moms who breastfed more exclusively. Younger moms did not nurse as long as the older moms in this study as well.
The study was done in hopes to figure out how to improve the outcomes for breastfeeding moms to nurse for a longer period of time. It stated, “US Department of Health and Human Services established the following goals for breastfeeding by the year 2010: a 75% rate of initiation, a 50% rate of breastfeeding for 6 months, and a 25% rate of breastfeeding for 12 months.“ They set a goal to lengthen the duration of breastfeeding and to help moms exclusively breastfeed.
So, let’s look at this study. It makes sense that if you begin weaning- and weaning meaning putting anything in the baby’s mouth besides the breasts- that the breastfeeding duration will be shortened. Many mothers do not realize that sucking needs are normal and should be met at the breasts as often as possible as to increase milk supply. Instead they begin using a pacifier too quickly and too often and wonder why their milk supply dwindles. They also think that just one bottle will not make any difference to their breastfeeding relationship. It does. One bottle quickly becomes more and soon others are feeding the baby and we are trying to pump to keep our supply going when nursing would automatically do that.
Poor women are more susceptible, I suspect, since often they are forced into the work environment to survive and our government assistance offers them free formula in order to feed their baby instead of a stipend to stay home and nurse. When my own daughter qualified for the WIC program I was amazed out how often she was encouraged to take the formula they offered and start supplements sooner. So, I was not surprised to find this study also showed, “Many mothers in low-income populations participate in Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs, and numerous studies have shown that these mothers are less likely to breastfeed as compared with nonparticipants of WIC programs.”
I believe these women are also often encouraged to start solids sooner. The concern I am sure may be that the women themselves have poor nutrition, thus breast milk is compromised. But instead of providing the mom with better nutritional guidelines, the suggestion is made that she offer her infant something that is less nutritious than nursing her baby. This study indeed showed how, “the highest risk for poor health, tend to have the lowest breastfeeding rates.”
The other part of this study looked at how the B.M.I. of women affected their breastfeeding relationship with their babies. “Obesity may also adversely affect breastfeeding in several ways. First, mothers with a BMI at or above 30 kg/m2 may experience hormonal patterns that interfere with milk production.30-32 Second, the infants of obese and overweight mothers may have physical difficulty latching onto the breast.31 Finally, an elevated BMI may indirectly interfere with the initiation and duration of breastfeeding because obesity is also associated with complications of pregnancy and delivery, cesarean delivery, poor maternal self-esteem, maternal depression, and low socioeconomic status. A recent study34 found that mothers with a BMI ≥25 kg/m2 were more likely to have discontinued breastfeeding before 6 months than normal-weight mothers.”
I tried to think about how this factored into the relationships of moms and babies I had worked with over the years. Indeed I saw more women who were considered overweight having complications with their pregnancies. These complications did lead to more surgical births as well as inductions and the edema that inductions sometimes caused in the moms causing latch issues initially. I have not seen the hormonal shift issues but certainly can see where an out of balance hormonal issue can cause milk production issues as well. But recently I had a client who is obese have real issues with her third baby. She found herself unable to successfully breastfeed outside of her own home environment due to how she had to work to latch her daughter onto the breast. It was not something she could do easily or even the least bit discretely.
New moms are concerned with body image as their breasts are larger but their bellies are still on the post pregnancy form- and therefore they want to hide their bulges and are learning to manage the new larger breasts. This makes them uncomfortable initiating breastfeeding in many situations outside of their home. Part of this is how we make women feel about their bodies in general in the USA and how we make breastfeeding a sexual act instead of a natural one. But certainly not feeling good about our bodies makes us not feel good about some of the natural body functions we may have as well. Our environmental support systems are certainly lacking in regards to support for breastfeeding.
This study had a hypothesis of, “Mothers within a low-income population who chose exclusive breastfeeding would likely (a) continue breastfeeding longer than mothers, who chose partial breastfeeding, (b) be of an older age than mothers who chose partial breastfeeding, and (c) have a lower BMI than mothers who chose partial breastfeeding.”
The other factor that was mentioned in this study was age. The younger moms seemed to lack the support of their community in breastfeeding and therefore initiated breastfeeding less as well as length of time of breastfeeding was limited.
The study concluded with this statement, “Breastfeeding is a complex issue with lifelong consequences for both mother and infant. This study found that factors, such as exclusive breastfeeding, older maternal age, and lower BMI, were associated with longer breastfeeding duration. These findings move us closer to understanding the unique needs of low-income, WIC, breastfeeding mothers and support the notion that maternal readiness and capacity for breastfeeding are influenced by dynamic biopsychosocial processes.”
I wonder if we had more pictures of younger moms nursing their babies in ads, women who overweight were nursing their babies, and moms in general nursing in more public areas in ads and government promotional materials, if we would increase these numbers for both initiating breastfeeding as well as duration of nursing exclusively. I wonder if we increased awareness to the communities of the benefits of breastfeeding if we would see the support change in the communities to support all women and babies in breastfeeding.
When as a lactation educator I am still counteracting the negative and detrimental things that are being done in the hospitals to sabotage breastfeeding, in the WIC offices to undermine the moms and in the communities that still want to banish women and their nursling to the bathrooms to nurse, if BMI and socioeconomic conditions are just a drop in the bucket as to why breastfeeding numbers are dwindling in the US.
Teresa Howard, CD (DONA), CLD, CLE, CCCE (CAPPA), CHBE
Anne Chevalier McKechnie, RN, IBCLC, RLC, Audrey Tluczek, PhD, RN, and Jeffrey B. Henriques, PhD
ICAN: Infant, Child, & Adolescent Nutrition June 2009
This is my review of their study….
Who breastfeeds longer? The study was performed on low income moms. The lack of long term breastfeeding is highest in this group. What the findings showed was that moms who had a high body mass index also fed for a shorter period of time. And the moms who fed longer were also moms who breastfed more exclusively. Younger moms did not nurse as long as the older moms in this study as well.
The study was done in hopes to figure out how to improve the outcomes for breastfeeding moms to nurse for a longer period of time. It stated, “US Department of Health and Human Services established the following goals for breastfeeding by the year 2010: a 75% rate of initiation, a 50% rate of breastfeeding for 6 months, and a 25% rate of breastfeeding for 12 months.“ They set a goal to lengthen the duration of breastfeeding and to help moms exclusively breastfeed.
So, let’s look at this study. It makes sense that if you begin weaning- and weaning meaning putting anything in the baby’s mouth besides the breasts- that the breastfeeding duration will be shortened. Many mothers do not realize that sucking needs are normal and should be met at the breasts as often as possible as to increase milk supply. Instead they begin using a pacifier too quickly and too often and wonder why their milk supply dwindles. They also think that just one bottle will not make any difference to their breastfeeding relationship. It does. One bottle quickly becomes more and soon others are feeding the baby and we are trying to pump to keep our supply going when nursing would automatically do that.
Poor women are more susceptible, I suspect, since often they are forced into the work environment to survive and our government assistance offers them free formula in order to feed their baby instead of a stipend to stay home and nurse. When my own daughter qualified for the WIC program I was amazed out how often she was encouraged to take the formula they offered and start supplements sooner. So, I was not surprised to find this study also showed, “Many mothers in low-income populations participate in Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs, and numerous studies have shown that these mothers are less likely to breastfeed as compared with nonparticipants of WIC programs.”
I believe these women are also often encouraged to start solids sooner. The concern I am sure may be that the women themselves have poor nutrition, thus breast milk is compromised. But instead of providing the mom with better nutritional guidelines, the suggestion is made that she offer her infant something that is less nutritious than nursing her baby. This study indeed showed how, “the highest risk for poor health, tend to have the lowest breastfeeding rates.”
The other part of this study looked at how the B.M.I. of women affected their breastfeeding relationship with their babies. “Obesity may also adversely affect breastfeeding in several ways. First, mothers with a BMI at or above 30 kg/m2 may experience hormonal patterns that interfere with milk production.30-32 Second, the infants of obese and overweight mothers may have physical difficulty latching onto the breast.31 Finally, an elevated BMI may indirectly interfere with the initiation and duration of breastfeeding because obesity is also associated with complications of pregnancy and delivery, cesarean delivery, poor maternal self-esteem, maternal depression, and low socioeconomic status. A recent study34 found that mothers with a BMI ≥25 kg/m2 were more likely to have discontinued breastfeeding before 6 months than normal-weight mothers.”
I tried to think about how this factored into the relationships of moms and babies I had worked with over the years. Indeed I saw more women who were considered overweight having complications with their pregnancies. These complications did lead to more surgical births as well as inductions and the edema that inductions sometimes caused in the moms causing latch issues initially. I have not seen the hormonal shift issues but certainly can see where an out of balance hormonal issue can cause milk production issues as well. But recently I had a client who is obese have real issues with her third baby. She found herself unable to successfully breastfeed outside of her own home environment due to how she had to work to latch her daughter onto the breast. It was not something she could do easily or even the least bit discretely.
New moms are concerned with body image as their breasts are larger but their bellies are still on the post pregnancy form- and therefore they want to hide their bulges and are learning to manage the new larger breasts. This makes them uncomfortable initiating breastfeeding in many situations outside of their home. Part of this is how we make women feel about their bodies in general in the USA and how we make breastfeeding a sexual act instead of a natural one. But certainly not feeling good about our bodies makes us not feel good about some of the natural body functions we may have as well. Our environmental support systems are certainly lacking in regards to support for breastfeeding.
This study had a hypothesis of, “Mothers within a low-income population who chose exclusive breastfeeding would likely (a) continue breastfeeding longer than mothers, who chose partial breastfeeding, (b) be of an older age than mothers who chose partial breastfeeding, and (c) have a lower BMI than mothers who chose partial breastfeeding.”
The other factor that was mentioned in this study was age. The younger moms seemed to lack the support of their community in breastfeeding and therefore initiated breastfeeding less as well as length of time of breastfeeding was limited.
The study concluded with this statement, “Breastfeeding is a complex issue with lifelong consequences for both mother and infant. This study found that factors, such as exclusive breastfeeding, older maternal age, and lower BMI, were associated with longer breastfeeding duration. These findings move us closer to understanding the unique needs of low-income, WIC, breastfeeding mothers and support the notion that maternal readiness and capacity for breastfeeding are influenced by dynamic biopsychosocial processes.”
I wonder if we had more pictures of younger moms nursing their babies in ads, women who overweight were nursing their babies, and moms in general nursing in more public areas in ads and government promotional materials, if we would increase these numbers for both initiating breastfeeding as well as duration of nursing exclusively. I wonder if we increased awareness to the communities of the benefits of breastfeeding if we would see the support change in the communities to support all women and babies in breastfeeding.
When as a lactation educator I am still counteracting the negative and detrimental things that are being done in the hospitals to sabotage breastfeeding, in the WIC offices to undermine the moms and in the communities that still want to banish women and their nursling to the bathrooms to nurse, if BMI and socioeconomic conditions are just a drop in the bucket as to why breastfeeding numbers are dwindling in the US.
Teresa Howard, CD (DONA), CLD, CLE, CCCE (CAPPA), CHBE
Saturday, October 10, 2009
Melia Gives Birth
Melia had her first baby using pain medication- I can't remember the details- hopefully she will share them in the comments... She then took my childbirth class and hired one of the LOL doulas and had a home birth. This time she hired a local doula- an excellent one I might add- and took the Birthing Again classes that I teach. They chose to give birth at Athens Regional using the wonderful midwifery group that supports women there. I read her birth story and asked if we could please post it here to share with you. She happily agreed!
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