Barbara wrote, ".. interesting findings was that nipple pain was almost
universal in the first week postpartum, but for most women rapidly resolved...
I wish that some of the non-US members (particularly those working with
indigenous populations would chime in with their perceptions about whether
this is an observed phenomenon other places.).."

Barbara, this is such an interesting question!  And very hard to answer.  I
work with mothers of all racial and ethnic groups in Zimbabwe, where
breastfeeding is heavily promoted. 99% of all mothers initiate
breastfeeding, exclusive breastfeeding rates are 39% at 4 months, and 26% of
toddlers at 20 - 23 months are still breastfeeding.   My impression is that
African (indigenous) mothers experience exactly the same kind and severity
of *all* breastfeeding problems as mothers of other races, including nipple
pain and damage.  I have seen the very worst cases of failure to thrive in
African breastfed babies - so severe, in fact, that I begin to wonder what
percentage of infant mortality in developing countries is due to
breastfeeding problems (some of which could probably have a nipple pain
component).  I do know too that the doctors, who have to work in the
government hospitals or rural clinics before they can practice privately in
the city, are extremely prompt about prescribing antibiotics at the first
sign of mastitis (which can follow nipple damage) because they are all too
familiar with breast abscess, and have many horror stories to tell from
their stints in the rural areas.  Certainly I have seen hundreds of African
mothers who have positioning and latching difficulties, and these too can
lead to nipple pain.  This always astonishes me because I too *expect* that
these moms know what to do, since they have grown up observing all babies
being breastfed everywhere.  Maybe living in a breastfeeding culture helps,
but clearly, it is still not enough to prevent all problems.

The reality is that I have seen too many African mothers with badly abraded
nipples, engorgement, mastitis, and yes, even abscess when all these
pre-conditions have been inadequately addressed.  To make a sweeping
generalization (always a dangerous thing to do!) I think the major
difference that I tend to see between the African mothers and the others
(Caucasians of all nationalities, Asians and others of mixed race) is that
the African mothers are just much, much more persistent through the
difficulties.  Not to breastfeed is hardly ever an option, economically for
the majority, and culturally for almost all.  So because they don't have any
other alternative to breastfeeding, and no-one is handing out any freebies,
these mothers just keep on keeping on, through the difficulties and through
the pain.  I think that this is one of the reasons, too, that when really
severe breastfeeding difficulties occur, and they are not addressed, they
can become the worst I have ever seen.

I suspect that we need to challenge the assumption that anything natural and
un-tainted by western technology is automatically without problems. Somehow
this has led to the belief that we only need to invest token effort into
supporting breastfeeding by healthworkers in Nairobi, or into providing
unmedicated deliveries and 24-hour rooming-in in New York, for breastfeeding
to work like clockwork.   This trivializes the importance of breastfeeding,
and fails to address its complexity.  Just as it is accepted that most women
can give birth with minimal intervention, but all deserve to have skilled
assistance, so too I think that most women can breastfeed with minimal
intervention, but they too, deserve skilled assistance to prevent and
resolve or work around the difficulties.

So, IMHO, I don't think that indigenous mothers have less pain with
breastfeeding - they just have no alternatives - and *that* is what makes
the difference.

Pamela Morrison IBCLC, Zimbabwe
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