Laurie asked some questions about positioning and in particular if this is
such a big deal in other cultures where BF is taken for granted.

I can't comment on other countries of course, but in Zimbabwe we have what
could be called a "breastfeeding culture" - just about 100% of the
indigenous population breastfeed.  As a private practice LC I mostly -
although not exclusively - work with the non-indigenous population (in the
private healthcare system) who often believe that "Africans" all find
breastfeeding so easy, never have problems with latching, never get sore
nipples, never have concerns about "enough milk" etc.  Because "they" all
breastfeed this is a logical assumption, but it is not based on fact.

During my times going round the large government hospital doing the clinical
portions of the BFHI training and assessments, and from my (fewer) African
clients in the private hospitals it has been fascinating to me (I am a
product of my own culture too!) to see that African mothers, as a group,
have *exactly* the same problems as every other mother on the planet.  It
has struck me as ironic that I, who come from a bottle-feeding culture,
should assist women who traditionally breastfeed, with positioning problems.
Some of the grannies and visiting extended family really look at me sideways
too!  But these moms can have the same sore nipples, the same domino-effect
of lactation failure from poor positioning = inadequate drainage = eventual
failure to thrive. Some of the mothers have inverted nipples, some have
perfect nipples but seem very inept, some of the babies suck their tongues,
or slip off the breast, and I have even assisted with latching a frustrated
baby during a BFHI Assessment.

Laurie asked whether the baby instinctively latches well most of the time?
Yes, this happens - most of the time - just as it does with moms from a
non-breastfeeding culture, assuming a lack of medications during labour and
lots of mother-baby contact.  But sometimes the positioning is appalling -
baby flat on mother's lap, tummy up, mother bending right over the baby,
scissors to support the nipple, mother being very rough to jiggle the baby
into submission. Sometimes you see the baby learning *in spite* of what the
mother is doing, not *because* of what the mother is doing.

In our government hospitals there are no pillows, no pumps, no aids of any
kind, and no I don't see babies latching "instinctively" any more than I do
in the private hospitals where (sometimes, at least) the mom has extra
pillows but has to obtain her own gadgets and devices (and LC!) if she wants
them.  I think the difficulties that we all see with newborns from any
culture is that each mother needs time and practice to learn about *this*
baby in her arms.

What I *do* observe as one glaring difference between "us" and "them" is
that African mothers are just very, very persistent about working with their
babies until whatever-the-problem-is comes right.  With positioning or
latching difficulties they will just patiently and steadily keep trying to
feed the baby until the baby *does* learn what to do. Most African mothers
have learned about breastfeeding as they grew up, by watching all the other
babies being breastfed, and sometimes the grandmother or "tete" (mother's
mother's sister, almost like a godmother) takes her under her wing and
teaches her what to do.  The stark truth is that breastfeeding *has* to work
or the baby will starve so the mothers just don't give up. Mothers of
healthy babies are not asked whether they want to breastfeed in the
hospital. There are no handouts of free formula unless the circumstances are
truly exceptional (orphans, triplets). When they go home one tin of L*******
(which might last the baby four days) can cost 12% of the husband's minimum
wage - this month, anyway!  So they are highly motivated, but it doesn't
*always* work.

Are LCs or Doulas really needed?  My opinion is that we are. Even in a
breastfeeding culture an LC can provide a short-cut to a latching difficulty
and "fix" in minutes what it might take the mom two days to work out for
herself.  We also need to provide a *lot* of education to the health-care
staff (many of whom were trained "overseas") and to mothers themselves,
because each culture has its different (and sometimes unphysiological) myths
about how and what babies should be fed (e g only 16% of babies in Zimbabwe
were exclusively breastfed during the first 4 - 6 months at the last count
and babies are weaned overnight when the mother discovers a subsequent
pregnancy).  We have high rates of malnutrition and stunting even in this
sunny breastfeeding climate.  Furthermore there is an urgent responsibility
to preserve the breastfeeding part of the culture.  I have worked with
affluent African moms who themselves were bottle-fed and been amazed to hear
them voice exactly the same questions and concerns about "not enough milk"
that the European and Indian moms express.

Sometimes the medicalization and other contraptions can be useful (we need
your knowledge and technology) and they are not *always* the cause of all
breastfeeding difficulties.  Each culture has good things it can teach the
others.

Pamela Morrison IBCLC, Zimbabwe