Dr. Newman,

I've worked both in private practice (US) and public health clinics (US and PR).
As an LC, the use of early Depo shots frightens me to no end as I do think
(despite the studies done I think in the US Army) that they do affect many
women's milk supply.

On the other hand as a nurse working with moms who delivered after not having
one prenatal visit and having many additional risk factors (drugs, alcohol,
etc.), I can understand the urgency the doctors feel to give the shot in
hospital before the mom is discharged - at least reducing the risk of pregnancy
for 3 months.  For a while, they were even inserting Norplants to increase that
protection for 5 years.

The reason for giving the early Depo or Norplant goes back to the concern of
early (sometimes within a week) return to sexual activity by many of the women
we worked with - and the concern for mom's and the next baby's as well as the
current baby's living situation in the short and long term if mom delivers
another baby before this one turns one.

Moms were being counseled related to the risks of the Depo or Norplant, but as
many weren't planning of breastfeeding (and the counselors weren't interested in
pressing the issue), the fact that this method of birth control may affect
breastfeeding was only lightly covered if at all.  Of course this means they
were not given "complete education in order that they can give informed
consent".

To tell the truth, "informed consent" is rarely completely "informed" unless
it's an MD receiving it - after all, I remember  translating the consent that
moms were supposed to read and sign before their babies were given each
vaccination.  Rarely did they read the whole thing - and their eyes glazed
through the middle of my translation - "Does that mean I shouldn't give it to my
baby?" was the questions I usually got from the moms who could speak no English.
What was I supposed to say?  What I usually said was that the studies related to
this particular vaccine demonstrated that the risk in giving it to the baby was
less than the risk of NOT giving it.  (Thank Heavens none of the babies whose
mothers I thus counseled ever reacted horribly.)

In Public Health there is often the paternalistic attitude that "we know what is
best for you" (vaccinations, prenatal and postpartum care, smoking, etc.).  The
problem lies in that we aren't making breastfeeding a Public Health issue
equivalent to those others - especially vaccinations and smoking. Can we make
breastfeeding a Public Health issue requiring that all moms need to have
information related to the risks of formula (just like smoking) and the benefits
of breastmilk (like vaccinations)?  Perhaps creating campaign equivalent to the
old "March of Dimes" (boy, am I showing my age!) or the current anti-smoking
one?

To tell the truth, in my small sample of moms, they _knew_  that breastfeeding
was best - they just didn't know how!  Dr. Parrilla has been working hard here
in Puerto Rico creating a breastfeeding education program to the MD's.  Still,
we're frustrated in that until moms begin _demanding_  knowledgeable health care
professionals (just as they demanded their husbands in the delivery room - which
forced change in hospitals and by the OB's) we don't see HCP's taking the issue
of breastfeeding seriously.  They go to some classes, but still stop bf with
colds, infections, jaundice, etc.  _Some_  change on their own - but they are
the minority.  Most continue on their old ways unless they face a mom (as one
from my support group) who refuses to stop breastfeeding due to jaundice.

The program we need to create includes changing our culture ("don't pick up the
baby - you'll spoil him"; "that baby is  just running your life - you need your
independence/freedom/time away") as well as our skills and knowledge.   Any
Sociologists in the Net want to help us tackle this?

Sorry - I have lots more questions than I have answers...

Jeanette Panchula BA-SW, LLLL, IBCLC, RN
Puerto Rico
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