Yesterday our hospital celebrated getting certified as Baby-Friendly and the
head medical officer for the region spoke to us just before presenting the
plaques - two of them, one for the maternity ward and one for the NICU,
which was evaluated in a special process devised just for NICUs.

The medical officer has a lot of experience writing about health issues for
a lay public, and a strong public health orientation.  He entertained us
with an overhead showing the old 'Health information staircase' based on a
model I immediately recognized, but had completely forgotten since it has
been out of use for the past 15 years or so, at least here.

The steps on the staircase are labeled 'knowledge', 'attitude' and
'behavior'.  Until about 1990, it was assumed that if a person had knowledge
about the health effects of something, their attitude to that thing would
change, and this would result in behavioral change.  Much public health
information was presented with this underlying assumption and I'd be
surprised if the various creeps who profit off of our continued tendency to
engage in behavior that damages our health weren't involved in perpetuating
the notion that enough knowledge would eventually do the job.  

We know now that people do the things they do for a lot of other reasons
than the health effects involved, and our speaker even claimed that people
basically just stumble into their behavior patterns, and once they are
comfortable there, they tend to glom onto information that supports what
they do.  But it was kind of fun to sit there and admire the optimism and
innocence of health workers who honestly believed such a short time ago that
if you simply told people how harmful it is to smoke cigarettes, they would
develop negative attitudes to smoking and the smokers among them would just
quit.  I don't think many would argue with the idea that the real turning
point came when smoking was banned from one public arena after another and
it became such a bother to find a place to smoke, that people started
smoking less.

He said that the current strategy in public health circles is to weaken the
influences that are bad for us, and strengthen the factors that keep us
healthy.  Applied to breastfeeding, this would mean not concentrating on
informing the individual mother about how vital breastmilk is for children,
but rather on what it is that keeps women from breastfeeding.  Maybe they've
never known anyone who did it successfully.  Maybe there is no place they
can go outside their homes if they want to breastfeed.  Maybe they have too
little maternity leave, and/or no right to breastfeeding breaks.  Maybe the
communities where they live are still unable to provide support for the
everyday problems many women face at the start of breastfeeding.  None of
these things will be fixed most effectively by educating women about why
they ought to breastfeed.  

So, back to Heather's client who wished someone would just tell her it isn't
that big of a deal: empathy is the only tactic that will keep your dialogue
with her alive.  As Cathy G noted, she needs to learn ways to breastfeed
while resting.  Or to use the time her child sleeps to catch a nap herself.
I'd say 'Boy, you really are sleep deprived, when you want *me* to lie to
you about breastfeeding!  Let's see how you can get some rest, quick.'
There is nothing wrong with wishing things were different, and that wish is
expressing the conflict that mother is caught in, between doing what she
knows to be right, and wanting it to be less exhausting.  If she weren't
committed to breastfeeding, she wouldn't care whether anyone gave her an
out.  A really quick way to turn that mother into a formula customer is to
moralize about breastfeeding, or motherhood, or to fail to acknowledge her
need for rest.  Later, when she's gotten through that crisis, you can talk
to her calmly in the cold clear light of day about how much more actual work
is involved in artificial feeding.  Sure, someone else COULD do it, but is
there in fact a specific someone who WILL? 

Rachel Myr
Kristiansand, Norway

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