Karleen is on to something when she notes that there is a difference between
disregarding a real problem or handling it inadequately on the one hand, as
in the case of mothers with insufficient glandular tissue who simply got the
standard advice for any woman with low supply, without regard to the
particulars of their case, and on the other hand having a policy of assuming
that breastfeeding will work, while being prepared to deal with virtually
any problem that can arise.  The first is a pretty good description of
malpractice; the latter is best-case scenario care.  If I were seeing a
pregnant woman who had undergone bilateral mastectomy at menarche and who
fully expected to bring in a full supply by day three post partum I would be
concerned that her expectations were at odds with the likely outcome - but I
would support her in breastfeeding while making sure there was a watertight
plan in place to make sure the baby didn't starve.  But I know women without
visible breasts except gumdrop nipples, who have breastfed all their
children exclusively.  I know so many women with hypothyroidism who have
breastfed exclusively that I have lost count, ditto women with PCOS, and
diabetes, and high body mass indices.  Most of the women we see nowadays who
have had breast surgery of any kind, are already convinced they will not be
able to breastfeed at all, so my biggest problem is bolstering their
confidence just to give it a go.

I'd like to add my few drops' worth to the discussion, on whether one would
prefer to know in advance of problems that might arise.  I'll grudgingly
admit to being a control freak, but for me, part of having control is being
able to admit that in fact, I don't control everything and it's really
better that way.  For example, I am very glad I did not know until he was
born that my son had an unusually large head.  I knew he was presenting by
the vertex, which bolstered my confidence, but I would not have been helped
by knowing his head circumference beforehand, nor by knowing how my labor
would proceed.  On the contrary, in fact.

I am also glad I did not know when I was 20, that both my parents would be
dead before I turned 30.   I am really glad I had no idea what it was like
to study midwifery as a new immigrant in a country with a language other
than my native one, while co-parenting two young children, because had I
known, I never would have attempted it.  But once I did it, I've never
regretted it.  I'm glad I didn't know about so many of the challenging,
gruelling experiences that lay in store for me, because I am the type to
fret and worry and defeat myself before I even get started, and had I known
about all of them I would probably just have curled up and read children's
fiction full time for the rest of my life.  I like to think the world is a
better place than it would have been if I had taken that route.  I'm now
actively, consciously thankful that I have no idea what the future holds for
me or those I love.

In all the adverse circumstances I have been in, I have been grateful for
getting the good help I have received.  I believe it was the help that got
me through them.  I won't waste time here on the people who made things
harder, just as I try not to let them occupy undeserved space in my life
now.  So rather than tell a woman 'you have such and such a condition and it
*may* be a barrier to the easy establishment of breastfeeding' I would say
'stay flexible and make sure you have access to excellent support'.  The
exception would be if I knew there was something she could do then and there
that would improve her chances, which of course I would let her know (seek
out a baby-friendly birth environment and abandon plans to give birth
somewhere renowned for its cozying up to formula reps, for example).  But I
would say the same thing to ANY woman embarking on parenthood, and any man
too, for that matter.  One of my colleagues, who struggled with milk supply,
and sore nipples complicated by Raynauds, said when her son was eight months
old and they had been breastfeeding happily and painlessly for two months
that she had been unprepared for how long it would take for the problem to
resolve.  She also said that had she known it would take so long, she might
have stopped at two weeks, and when we had this conversation she was
overflowing with gratitude for the richness of her relationship with her son
because they had kept on going, and she couldn't imagine stopping anytime
soon.

I reiterate what Karleen said: lying to women or giving them bad care in the
face of an obvious problem is NOT the same as refraining from describing
every possible complication that might arise with breastfeeding, or might
not.  Women do need to know how to recognize problems early on, and they
need to know where to get good help.  You don't need to be an IBCLC with a
special interest in BFAR or atypical breast development to know that a baby
who isn't happy or producing abundant used diapers or gaining weight despite
being well latched 22 hours of every 24, is a red flag.  I wonder how many
women who had serious obstacles to breastfeeding, as in the MOBI group,
would have been able to change the outcome by any means other than having
had better care in the first week of their childrens' lives, including
someone who made sure they got connected to other mothers in like
situations.

Teetering on the edge of my soapbox, so I'll step down now,
Rachel Myr
Kristiansand, Norway

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