I have been keenly following the thread on medicalization of childbirth and
possibility of medicalization of breastfeeding. I had recently landed on Diane
Wiessinger website normalfed.com and found "What can she do for me?" give some
basic functions of what helps different members of maternity health care team do
for her given her circumstances and condition. Living in one of India's largest
city, I as a woman least knew that obstetrics care meant was "emergency care'
and not routine care which it is almost always. Here is where I believe that
Judith has articulated the medicalization of birth so eloquently and relate to
her thoughts to be true to birth in urban India. In the same breath I also see
from where Rachel's wisdom comes from when she mentions specialty breastfeeding
care required only in special cases.
While I am also part of birthindia NGO team working to educate women about
normal birthing practices and encouraging safe unmedicated births and possibly
encourage homebirth in the process in urban India; I realise this movement maybe
an exaggeration given that with a population of more than 1 billion people in
India, we recorded more than 40% of births in India with absolutely no antenatal
care and all of that as homebirths and maternal mortality rate at 300-500
maternal deaths in every 100,000 live births!! The highest in the world. We
certainly have a situation which I call lopsided nature of maternity care in
India. The Indian authorities are striving to ensure access to skilled
health professionals and institutional births for these
mothers foreseeing access to skilled obstetrics care to be the most important
strategy toward good maternal care. The Dais (traditional home birth attendants)
have been roped in with incentives to encourage them to take the pregnant women
to reach health institutes for better medical care. With all this the
breastfeeding rates stand at 46%.
This lopsidedness needs a careful balanced approach where we see underplaying
the rising medicalization in the urban cities of India and working on a war
footing to provide basic medical facilities for the women in rural India. With
the current trend of efforts I only forsee complete medicalization of birth such
as in developed countries in the next few decades. The most important missing
fulcrum in this imbalanced see-saw who can provide marriage of minds and clarity
to attain safe births and better breastfeeding rates is the IBCLCs &
breastfeeding specialists and breastfeeding advocates across health care system.
(This is where I resonate with what Rachel says IBCLCs as policy makers).
These are all important perspectives and I certainly agree with Judith and
Nikkie and believe preventive breastfeeding help is always better
than therapeutic breastfeeding help especially in urban highly medicalized
practices of birth and pick our battles appropriately. (Like Gini Baker said
once "Will we like to see a breast crawl always? 'YES' but will we see it often
'NO'.) So we need to pick our battles well.
Take Care
Yasmin
MA,HDSE,CLEC,LLLL
www.nourishandnurture.in
Mumbai, India
(Excited, thrilled and nervous about IBCLC exam just a fortnight away!)
----------------------------------------------------------------------------------------------------------------------------------------------
________________________________
From: Nikki Lee <[log in to unmask]>
To: [log in to unmask]
Sent: Sat, 9 July, 2011 3:32:35
Subject: always room to learn
Dear Lactnet Friends:
The discussion about IBCLCs and birth and hospital practices around the world
has been collegiate, professional and fabulous. Thank you to Judy Gutkowski and
Rachel Myr and others who have added their viewpoints.
Truly, birth in the US is technologically driven. In 2007, the CDC found that
the best score on its birth and hospital practices survey (mPINC) was 82 out of
100. This would be a B on a report card. My state has an average score of 61%
out of 100%; my city, 53% out of 100. As a nation, our mothers and babies are
having the crap beaten out of them. It is amazing that there is breastfeeding at
all.
At an urban hospital I know of, the cesarean section rate is nearly 50%; nurses
at that facility say "we have so many high-risk mothers." I don't know if this
is really true or if it is a reaction formation by women watching their sisters
be treated like raw materials on a factory line. If it is true, and nearly half
of all women are medically high-risk, I am worried.
I feel strongly that WHO has it right, and that all healthcare staff need to be
knowledgeable about breastfeeding. This means 20-hours of fundamental education.
One inner-city hospital (with a population of predominantly lower socio-economic
status women) has more labor and delivery staff putting babies skin to skin
after birth because more and more staff have received basic education about best
practice. Physicians tell me, when I make nursery rounds, that that more and
more women are breastfeeding as a result. This is despite the routine use of
technology and is very encouraging and exciting.
At the same time, it makes sense to have more breastfeeding
specialists available at hospitals where more technology is used; the IBCLC is
that designated specialist.
warmly,
Nikki Lee RN, BSN, Mother of 2, MS, IBCLC, CCE, CIMI, ANLC, CKC
craniosacral therapy practitioner
www.breastfeedingalwaysbest.com
________________________________
From: Ruth Piatak <[log in to unmask]>
To: [log in to unmask]
Sent: Fri, 8 July, 2011 17:42:30
Subject: Judith Gutowski on lactation in the U.S.
Hear, Hear, Judith -- I am grieved that you are precisely right, and
relieved to have the summary handy where some of us might plagiarize it for
grant applications! Which grieves me again, that in large part our efforts
to have babies fed and families off to a normal start are due to "donations"
and "appropriations" rather than consistent policy.
To use Catherine's language from Chapter 1 of "Supporting Sucking Skills",
La Leche League and lactation consulting evolved in the U. S. as
COMPENSATORY STRATEGIES for the dysfunctional start moms and babies get
here. We can struggle with FACILITATIVE strategies as we try to eliminate
the "booby traps". Meanwhile we will stay tuned and will join you, Judith
(in any way we can, in whatever setting is available to us) in helping each
family we encounter to get on track as soon as possible with the
breastfeeding they deserve.
--
Ruth Piatak, BA, MS
La Leche League Leader
WIC Breastfeeding Peer Counselor
Tulsa, Oklahoma
214-886-1218 (cell)
918-585-9114 (home)
[log in to unmask]
Judith wrote:
Date: Thu, 7 Jul 2011 20:01:24 -0400
From: "Judith L. Gutowski" <[log in to unmask]>
Subject: weight loss in newborn babies in first week
I am replying to Rachel's post where she states, "At the risk of undermining
my own IBCLC credential I'm going to disagree, respectfully, with Judith
Gutowski on the need for an IBCLC to see every baby."
Thank you for sharing your wise opinion with us Rachel as always. I
certainly agree with and admire your vision, especially the part about
IBCLCs being in policy making positions. I should have qualified my thoughts
as pertaining to infants born in the United States rather than just saying
"Where I practice". In the US most babies are born in the hospital and
newborn care happens in a medical setting where they are followed by a
general practice or pediatric physician once discharged. As we both agree,
birth is medicalized here and needs improvement or completely overhauled,
but that is a separate battle altogether. While I personally had midwife
births and understand this and advocate for it, I am more concerned with
caring for the families presented to me now and what I can do to help these
mothers and babies in spite of the birth circumstances which have passed. I
am one of the roughly 20% of US based IBCLCs who works in the out patient
setting and this is the environment from which I speak. I have 15 years
working on a breastfeeding helpline and in private practice and 5 years in
pediatric practices. Though I know how inadequate telephone helping can be,
I have supported hundreds, of women as best as I could via telephone because
no other option was available to them. As evidence for my desire to make
breastfeeding support easy to access and integral to health care in the US,
I cite the poor breastfeeding duration rates that can be found on the CDC
website as well as the work of Ruowei Li, Sara B. Fein, Jian Chen and
Laurence M. Grummer-Strawn, During the First Year Why Mothers Stop
Breastfeeding: Mothers' Self-reported Reasons for Stopping Pediatrics
2008;122;S69-S76. 75% of US mothers attempt to breastfeed, but few are able
to continue to their desired goals.
I rarely see an infant that was born without anesthesia, without pitocin
exposure, without separation from the mother or other troublesome
interventions. The difference in feeding instincts and ability of mother and
baby are profound for those who manage to avoid intervention and be born
naturally. These rare few really don't need an IBCLC to do anything to help
them feed. However, even with an ideal birth, they live in a culture that
generally does not trust the process of breastfeeding and will receive lots
of negative messages about breastfeeding and plain wrong information from
the people who surround them. Many normal newborn behaviors will be
mistakenly interpreted as breastfeeding problems. Many need anticipatory
guidance about use of hormonal birth control or medications or returning to
work. There are many cultural breastfeeding practices in the US that mothers
accept without a second thought that can undermine breastfeeding. Most will
not seek out, or find, any type of lay breastfeeding support. Because I am
available to them in the health professional setting, I have credibility,
even though I might say the same thing at a La Leche League meeting in my
role as a lay volunteer, the perception of the information is different. So,
I believe that an IBCLC in the primary care practice can give families
correct information, and more importantly, the confidence to continue to
breastfeed.
Additionally, it is not the norm for the hospitals in the US
to have adequate breastfeeding support available for their patients. There
are rarely enough IBCLCs to attend to the number of birthing women because
the US the health care system is based on third party reimbursement. In
hospital settings, third party reimbursement is not given for IBCLC services
so this care is rolled into the total cost of maternity care. For the sake
of the bottom line, hospitals will often cut lactation care which is seen as
a non-necessity. For more information about these inherent problems see the
documents on the USLCA homepage <http://www.uslcaonline.org/>
www.uslcaonline.org; Containing Health Care Costs Help in Plain Sight, IBCLC
Staffing Statement, and Five Steps to Improving Job Security. Due to these
reasons, many mothers have not received even good basic breastfeeding
support and information as part of maternity care. They are usually at home
before the milk comes in and that is when the problems become apparent.
www.BestforBabes.org is a good website to help those who live outside of the
US understand the unique challenges, and the "booby traps" women face here.
Lactnet also had a recent link to stories on blogs that would give insight
into the problems women face which in my opinion are heart wrenching.
http://temerity-jane.com/life/was-almost-stirred-to-something-kind-of-resemb
ling-a-bleached-out-version-of-mild-righteous-outrage/#comments
Once mothers are at home with their infants, they encounter problems
diagnosed in the medical setting where they receive routine care such as
weight loss, jaundice, breast / nipple pain, engorgement, low milk supply,
infant fussiness and so on. All of these are blamed on breastfeeding and
without breastfeeding support the baby is weaned to formula. Many of these
problems do require professional IBCLC support, some do not. But mothers
also cannot wait for the next monthly La Leche League meeting or the next
weekly WIC appointment to see a peer counselor to have the problem
addressed, even when that support would be sufficient to fix the underlying
problem. Lastly, Rachel says "But I would settle for just knowing that all
staff will refer to the next level of specialized care without delay". This
is unfortunately uncommon in the US unless a mother happens to live where
there are IBCLCs in private practice, knows how to find them, AND she can
afford to pay for their services out of her own pocket. Hospital referrals
systems consist of a list somewhere in the bag of formula and papers a
mother brings home with her. If she has remembered to look among this
"stuff", she then has to make phone calls to find help and figure out how to
pay for services. The available lactation consultant may be many miles away.
It is hard for mothers to take their babies on long rides to get needed
support. Additionally, our public health programs that promote
breastfeeding rarely provide necessary IBCLC services for mothers who
encounter difficulties. One study cited 30% of mothers as having significant
problems that would require these services.
I see the IBCLC in the out-patient primary care setting as a
preventive health care provider. I would rather see the few mothers and
babies who absolutely don't need any IBCLC services have an unnecessary
visit, than have many not get care they do need. I know that there are
fewer, and less severe, breastfeeding problems presenting to me on a regular
basis now that I am working with mothers routinely within the first 1-2
newborn visits. Previously, I worked in private practice where the mothers
didn't find me until the problems had been ongoing for two or more weeks. By
that time milk supplies that could have been normal are low due to poor
breast stimulation and babies have no energy due to weight loss and their
feeding skills have declined due to supplementing, and so on. The longer a
breastfeeding problem is not recognized and managed the harder it is to
normalize. Additionally, problems crop up later in lactation; biting,
oversupplies, allergies to proteins in mother's milk, nursing strikes, low
milk supply and so on. Because I am known to the mothers and accessible to
them in the familiar and local setting, the mothers contact me so these
problems can be overcome with support and correct information.
In the long run, providing effective breastfeeding support as
preventive health care will save billions of dollars in health care costs
for infants and mothers, much suffering that goes along with these illnesses
and lives of both as well. If that wasn't enough, mothers with this kind of
support have less anxiety over feeding and caring for their infants during
this important threshold in their lives. Maybe they will have less
postpartum depression too? Do I have data to support this opinion? No,
unfortunately not. But I have the cards, emails, phone calls, smiles and
tears of relief from many mothers, fathers, grandparents and even fellow
health care providers that prove to me the value of being available in their
time of need. I don't need numbers, but I hope to some day have the
opportunity to do the research to prove what I believe. Stay tuned.
Judy
Judith L. Gutowski, BA, IBCLC, RLC
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