Dear all:

After NOT reading the new pacifier study and watching the Tale of Two Births:  Baby Friendly and didn't bother to read the study on pacifiers and I think both of these together are causing me to think a tiny bit like the Tea Party. 

There was a previous study on pacifiers that I think really hit the nail on the head.  Mothers grab for pacifiers when breastfeeding is NOT going well.  If breastfeeding is going well, they don't need to use the pacifiers. Basically this is an issue of the pacifier being blamed for what really is an underlying issue which is a breastfeeding problem.  I certainly find this to be the case in Manhattan.  There are the rare moms who really don't put in the effort, but for the most part mothers try.  The problem then is that they try, don't get the help they need and often others think they didn't try. So I absolutely agree that moms don't simply use pacifier to stuff their mouths shut. And this to me seems to be part of the problem.  We often just think if we could get rid of the gadgets or even formula list would return to some blissful normal that I don't really think ever existed. It dawned on me that in Niger where they had no formula, they routinely gave fermented camel's milk and millet to babies when they feared that had insufficient milk.  

I've contemplating the fact that if only 5% of births are in baby friendly hospitals in the United States that means 95% of births are in baby unfriendly hospitals. I'm not sure what the percentage of HOME birthed babies is, but given that home births weren't mentioned at all I'm assuming that the percentage is negligible.  

La Leche League, as far as I'm concerned has done the peer counseling thing better than anyone.  I know that there are now rifts at the higher levels because they have done what private corporations try to do to OWN what the individuals actually create -- by trying to keep La Leche League Leaders from having other peer counseling certificates.  But at the grass roots levels the structure is still incredibly sound. The La Leche League Leaders here in Manhattan are fantastic and I haven't seen a 5 or 10 or 20 day course lead to counselors that even come close to the leaders I know here.  Which is why I love the fact that the Intern Coordinator for NYLCA really pushes them to attend La Leche League meetings regardless of any training that they paid for.  

Now, if all we needed was peer counseling and support and telling moms how wonderful breastfeeding is, I would say that it would have happened under La Leche League.  I think the proliferation of paid courses and certificates for counseling and women now charging for counseling (which can be as high as $300 per visit here in Manhattan) -- taking La Leche League from volunteer to "vocational" is appropriate in an era where volunteerism is no longer possible for many poor and middle class families that struggle with two incomes.  BUT I do not believe that this is going to increase breastfeeding duration rates, particularly in Manhattan. 

I think the reason why this is not going to occur:

a) women who are struggling want MORE than just counseling, they want concrete solutions
b) more and more women have done their homework on the internet and/or with their friends and already know many of the potential solutions and have tried them, so they don't just want a repetition of the basic solutions
c) women need someone to sit with them and listen to their own unique situations and help them develop the customized strategy 
d) 95% of women are not birthing under baby friendly circumstances -- and while counseling can be exceedingly helpful for NORMAL situations, we are NOT dealing with normal and we DO need more sophisticated care to improve the duration of breastfeeding

So, in thinking of the next tier that has been proposed, improving the training of health care professionals which seems logical on the surface, I don't think it will work either.  I think the United States is different than many of the developing countries where I have worked that have Ministries of Health.  Here, the emphasis has increasingly been on fee for service.  This has led to a DECREASE in time spent with patients and counseling.  Additionally, if what I read on the American Academy of Pediatrics is correct and I'm interpreting it properly, a breastfeeding curriculum was only implemented in 2010.  It takes a long time to develop an effective curriculum. It takes decades to integrate new research into the curriculum.  I still see that research I read in the 1980s in nutritional sciences has not yet made it into the curriculum of dieticians, speech and occupational therapists and pediatrics.  And even when the curriculum is up and running pediatricians are never going to have the time to sit with a woman for 2-3 hours to really get to the bottom of her unique needs. Furthermore, the takeover of medicine in the United States by a for-profit health insurance industry that has as its mission to find ways to maximize profits over outcome, has led to many pediatricians to team up in big groups and standardize their care. So, advice about breastfeeding is only going to get more "cookie cutter" in such settings. And every single obstetrician I have talked to in Manhattan that I have seen as a client told me that had NO training in breastfeeding. Anything they have learned they did on their own and since most babies are delivered by obstetricians, we cannot expect them to be the solution either. They probably have LESS time to sit and talk with mothers after they emerge from baby unfriendly hospitals.

And while it is exceedingly important that mothers have support in the hospital -- the amount of time spent in the hospital is 0.45 of the recommended duration of breastfeeding.  We MUST have support out of the hospital. 

So far from armies of more counselors I think we need the equivalent of charter schools.  I confess my son goes to a good solid public school.  I myself do feel that too much money is being put into charter schools and is detracting from having better schools available for more children.  So I am now realizing my own hypocracy.  There is an advantage to economies of scale when it comes to certain public services -- and YET -- true innovation comes from small scale projects.   These projects do often fail - but they can sometimes percolate paradigm shifts in thinking that revolutionize how problems are approached.  Big institutions are NOT great at innovation.  When big institutions are run effectively they have great reach and standardized products.  I've seen in developing areas that some tiny projects have developed truly innovative ways of solving problems. These tiny projects then benefit when they are coupled with larger institutional support to scale up and adapt these creative solutions WHEN the larger institutions are effective.  

A BALANCE needs to be made between developing innovative solutions and accessibility to the kind of care that will address the 95%. Right now we have NO balance. There is only a tiny tiny percentage of private practice IBCLCs and this is a shame.  They have spent huge amounts of time and effort to deepen their understanding of how to help women.  They do NOT scorn acquiring more experience before they set out to work with women.  They do not believe that problems have cookie cutter solutions.  And, most of the creative and innovative solutions to breastfeeding problems that I read about on Lactnet come from these private practice IBCLCs.  They can do this because they work individually with women and are not restricted by policies that stifle creative solutions.  Some may fail in their approaches and some will develop wonderfully creative innovations.  That is the process by which innovation occurs.  To lose this valuable resource in the interests of spreading armies of counselors around the globe would be particularly damaging in the areas where birth has become most baby unfriendly.  We have had spectacular counselors already thanks to La Leche League and they have done a MARVELOUS job.  We need to ADD to their work by recognizing that MOTHERS really do deserve specialized care when they encounter complex and complicated problems.  Anything less is serving up platitudes and patronizing to women who are actually really quite sophisticated at researching the basic general advice about breastfeeding.   

Sincerely, 

Susan E. Burger, MHS, PhD, IBCLC

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