> I had talked with her on the phone a few times before I went there, but I didn't really know what was going on until I saw it for myself.
> I learned something that day.

I discovered this years ago when I first went into private practice as
an LC (1985). By default (I had no office in which to see women), I did
exclusive home visits. Immediately, I uncovered "reasons" that
interfered with breastfeeding that would never or rarely have shown up
in an office setting. In an office with ideal BFing furniture, moms can
be "successful" but cannot replicate the furniture or posture at home
and so "fails" once she returns to her own environment. Also, the office
visit focuses on BFing rather exclusively in a controlled setting.
Observing family interactions is often more telling than not. So, I
decided to opt for an exclusively home-visit based LC practice, which is
what I still do. Not only can I get a truly complete picture, but the
business overhead is incredibly low!!

In any case, I have discovered, among other things:

* inappropriate furniture for breastfeeding (no chairs with arms, etc.)
* furniture that interferes with BFing ("I have to wean because I can't
nurse in bed" - it was a waterbed of the old big-bag type for a large
woman and a 5 pounder - ne'er the twain did meet on that bed!!)
* homes with no furniture other than the TV and a mattress in the corner
* psychological ambivalence (Observed interaction with the adopted first
child made me question her emotional situation. She was able to
articulate her fears that she was providing her own-born with something
"extra" not provided to her dearly-beloved adopted child. She needed to
resolve this dilemma of perceived favoritism in a way that made sense
for her and ultimately chose to wean. Her choice was made from a power
decision and not guilt - so then I taught her how to bottle-feed
"correctly")
* counter-productive (expensive) "baby nurses" and nannies ("Let me
bottle-feed at night so you can sleep")
* "smother-in law" interference (in many cultures here in Los Angeles,
the grandmother is "in charge"; the grandmother usually does not come in
for the office visits, yet she is the woman who needs the BFing teaching
- easy to incorporate her during a home visit)
* lack of spousal/family support (more difficult to work with, but
possible)
* lack of financial resources (lack of food, etc. Then I make
appropriate referrals to community agencies - there are too many women
who do not qualify for government assistance who are in marginal living
standards. I keep a file of local food banks, Meals on Wheels, Jewish
Family Services, Lutheran Social Services, call their own church/temple,
etc. This also becomes a "pro bono" visit in many cases)
* child/wife endangerment (with proper notification and further
assistance to the woman and baby)

This last is definitely not fun, and makes home visits NOT for cowards!
In fact, there was just enough alluded to in the original posting that
concerned me about spousal abuse. Perhaps in the case cited, the LLLL
should suggest to mom to call the Social Services dept of the hospital
of delivery, or tell her you will make the call for her; there may well
be some services for which she is eligible. If you make that call, you
can also voice concerns over what you saw with the spouse so that the
Social Worker can make appropriate follow-up.

Good work! You are "Right On"!

Katharine West, BSN, MPH, IBCLC (exp)
Sherman Oaks, CA